Perivalvular leakage (PVL) is one of the serious complications of mitral valve replacement. Between 1991 and 2006, 9 patients with mitral PVL underwent reoperation. All of them had severe hemolytic anemia before surgery. The serum lactate dehydrogenase (LDH) level decreased from 2,366±780 IU/l to 599±426 IU/l after surgery. The site of PVL was accurately defined in 7 patients by echocardiography. PVL occurred around the posterior annulus in 3 patients, anterior annulus in 2, anterolateral commissure in 1, and posteromedial commissure in 1. The most frequent cause of PVL was annular calcification in 5 patients. Infection was only noted in 1 patient. In 4 patients, the prosthesis was replaced, while the leak was repaired in 5 patients. There was one operative death, due to multiple organ failure, and 4 late deaths. The cause of late death was cerebral infarction in 1 patient, subarachnoid hemorrhage in 1, sudden death in 1, and congestive heart failure (due to persistent PVL) in 1. Reoperation for PVL due to extensive annular calcification is associated with a high mortality rate and high recurrence rate, making this procedure both challenging and frustrating for surgeons.

We present a case of Marfan's syndrome with acute aortic dissection during the trimester of her pregnancy, who underwent a Bentall operation 2 days after emergency cesarean section. A 24-year-old woman during the 31st week of pregnancy visited our emergency room due to sudden onset of chest and back pain, though she had no abnormality until this event. Because of her tall height, spider fingers, positive wrist sign, visual disorder and scoliosis, she was given a diagnosis of Marfan's syndrome. Enhanced CT and cardiac ultrasonography revealed that she was suffering from acute aortic dissection with annulo-aortic ectasia. Since it was difficult for her to continue with her pregnancy, she underwent emergency cesarean section and gave birth to a male baby weighted 1, 706g. Although there was little likelifood of early thrombus formation in the false lumen or significant aortic regurgitation indicating an emergency operation, fear of massive bleeding from her uterus and the exfoliated surface of the placenta after cesarean section required an observation period of 2 days. We performed a Bentall operation successfully after careful sedation, ventilation and blood pressure control for 2 days.

A 38-year-old woman was referred to our hospital for treatment of infective endocarditis associated with abscesses in the brain and the left lower limb. A causative organism had not been detected by serial blood cultures. Preoperative brain CT revealed mycotic aneurysms and echocardiography showed a mobile vegetation (8mm in size) on the anterior leaflet of the mitral valve. We performed resection of the vegetation together with a small triangle of the anterior leaflet, after which the margins of the defect were approximated. Then bilateral Kay procedures and reinforcement with autologous pericardium were done to obtain proper coaptation. The patient's fever, left lower limb pain, and intracerebral mycotic aneurysms resolved after surgery. The brain abscess also became smaller. Mitral valve plasty should sometimes be considered in the active phase of endocarditis, even in patients with cerebral complications and without congestive heart failure.

Protein C (PC) deficiency is an inherited thrombotic disorder with a prevalence of 0.19% among the general population. PC deficiency is associated with an increased risk of thrombosis when other risk factors are present, such as trauma, surgery, or infection, and is an important cause of mechanical valve thrombosis. We performed tricuspid valve replacement with a 29mm Carpentier-Edwards Perimount valve in a 20-year-old man with PC deficiency. The patient had corrected transposition of the great vessels with severe tricuspid insufficiency, as well as a history of cerebral infarction. In the perioperative period, we used only heparin sodium as the anticoagulant. When we restarted administration of warfarin, changing over from heparin, transient increases of serum plasmin inhibitor-plasmin complex (PIC) and thrombin antithrombin complex (TAT) levels were observed. Despite an increased dose of heparin, an appropriate activated partial thromboplastin time (APTT) was not obtained. This suggested a hypercoagulatory state, but the postoperative course was uneventful. Management of perioperative anticoagulation, prevention of late thrombotic events, and prosthetic valve selection in this particular situation are discussed.

The purpose of this study was to analyze the relationship between activity pattern and temporal changes in the oxygen dynamics of human femoral medial vastus muscles. Oxygen dynamics were evaluated from the surface of the body by near-infrared spectroscopy (NIRS) . Arterial occlusion tests were performed in the femoral region at a cuff pressure of 300 mmHg. Exercise type and speed were controlled by CYBEX 6000. The exercise types examined were concentric contraction (CON) and eccentric contraction (ECC) . The 3 angular velocities of 90, 120 and 180 degrees were used as the exercise speeds. Exercise was performed continuously 60 times at maximum effort. The subjects were 7 healthy males with a mean age of 19.6±0.5 years. A transient decrease in oxygen concentration was observed during circulatory occlusion ; and rapid hyperemia occurred immediately after the removal of pressure. Oxygen concentration peaked above the control level and then returned to the initial level. In the CON exercise, the initial decrease in oxygen concentration was the largest at CON 90, and a gradual increase in oxygen concentration was clearly observed during exercise. In the recovery stage, after exercise at CON 90, 120 and 180, oxygen concentration exceeded the control level before exercise, then peaked and returned to the initial level. In the ECC exercise, an initial decrease in oxygen concentration was similar to that in the CON exercise, but a gradual increase in oxygen concentration was not observed during the exercise ; nor did oxygen concentration exceed the control level in the recovery stage after the exercise.
These results indicate that an increase in oxygen level after the removal of arterial occlusion, during and after the CON exercise was much higher than the control level before the exercise, sug-gesting the involvement of reactive hyperemia and exercise hyperemia.

A study was conducted to evaluate the clinical and hemodynamic performance of the 19-mm Medtronic Mosaic Valve (MMV) in the aortic position, which is a third-generation stented porcine bioprosthesis. Between 2003 and 2006, 9 patients underwent AVR using the 19-mm MMV. None of the patients were suitable for a 19-mm Perimount bioprosthetic valve due to having a small annulus and sinotubular junction. The patients included 3 men and 6 women with a mean age of 73.2±4.97 years and mean body surface area of 1.35±0.11m². Preoperatively, 8 patients were in New York Heart Association class II and 1 was in class III. The reason for surgery was aortic stenosis in 8 patients and aortic regurgitation due to infective endocarditis in 1 patient. Four patients had chronic renal failure and were on hemodialysis, while 1 patient had Crohn's disease. Concomitant coronary artery bypass grafting was performed in 3 patients, and tricuspid valve annuloplasty was done in 1 patient. The follow-up period was 12.0±7.71 months. No deaths occurred, but there was 1 cerebral infarction. Postoperatively, the peak pressure gradient decreased from 81.3±32.7 to 40.3±16.3mmHg (p<0.01). The mean pressure gradient also decreased significantly from 48.8±11.6mmHg to 23.9±9.32mmHg (p<0.01). Left ventricular end-diastolic diameter was 47.9±3.82mm preoperatively and 45.1±7.53mm postoperatively, showing no significant change. The left ventricular mass index also improved from 217.3±46.9 to 160±54.9g/m² (p<0.05). The ejection fraction was 72.0±8.93% preoperatively and 67.6±6.37% postoperatively, showing no difference. Although the postoperative indexed effective orifice area (EOAI) was 0.90±0.11cm²/m², mild patient-prosthesis mismatch (EOAI 0.77cm²/m²) was noted in 1 patient. In conclusion, the early clinical and hemodynamic performance of the 19-mm MMV in small elderly patients was acceptable.

Total anomalous pulmonary venous connection (TAPVC) is rarely associated with remarkably small left heart structures. In these types of cases, the hemodynamics resembles that of hypoplastic left heart syndrome, and the treatment strategy is controversial. We present the case of a 1-day-old girl with infracardiac TAPVC, small left heart structures (hypoplastic left heart complex), bilateral superior vena cava, and aberrant origin of the right subclavian artery. We performed a semi-emergent first-stage open palliation for repair of TAPVC, because of pulmonary venous obstruction. We concomitantly performed atrial septal defect (ASD) enlargement and bilateral pulmonary artery banding (BPAB). The postoperative course was uneventful and the left heart structures did not grow, so we performed the Norwood procedure and placed a right ventricle-pulmonary artery shunt with a 5.0 mm artificial graft. Subsequently, the left heart structures were not suitable for biventricular repair, so we chose univentricular repair. The patient underwent a bilateral bidirectional Glenn operation and Fontan completion at 6 and 23 months of age, respectively. TAPVC repair, BPAB, and ASD enlargement are reasonable surgical options for a patient with borderline small left heart structures and TAPVC, as they enable us to wait for growth in the left heart structures and to determine whether univentricular or biventricular repair is suitable.

Objective : The aim of this study is to describe a series of patients undergoing reoperation due to hemolytic anemia after mitral valve surgery and assess the mechanisms and surgical outcomes. Methods : Between 2009 and 2014, we performed redo mitral valve surgery in 11 patients who had refractory hemolytic anemia after mitral valve surgery at Kyoto University Hospital. The mean age of the patients was 72.2±6.8 years old, and there were 5 men. Results : Preoperative echocardiography demonstrated that only 3 patients had ≥ grade 3 mitral regurgitation (MR), the rest of the patients had only mild to moderate MR. The mechanisms of severe hemolysis included paravalvular leakage (PVL) after mitral valve replacement (MVR) in 8 patients, structural valve deterioration (SVD) after MVR using a bioprosthesis in one, and residual/recurrent mitral regurgitation after mitral valve plasty (MVP) in two. All the patients except one (re-MVP) underwent MVR. The mean interval between previous operation and current operation was 14.1±9.4 years in post-MVR cases, and 2.0±1.9 years in post-MVP cases. There were three late deaths, one of which was due to cardiac death (exacerbation of heart failure due to pneumonia). There was one patient who required re-MVR for recurrent hemolysis due to PVL after MVR. Conclusion : Although hemolytic anemia after mitral valve surgery is rare, it often requires reoperation regardless of the degree of MR at late follow-up period. Thus, patients after mitral valve surgery should be carefully followed-up.

A 56-year-old woman suffering from mitral stenosis had underwent PTMC (percutaneous transvenous mitral commissurotomy) at age 46. After she developed congestive heart failure, mitral valve replacement (MVR) with Carbomedics 29M and tricuspid annuloplasty (TAP) was carried out. Four hours after admission to the ICU, massive bleeding was noticed. Cardiopulmonary bypass was restarted in the operating room. Laceration and hematoma were found at the posterolateral wall of the left ventricle. Under cardiac arrest with removal of the prosthetic valve, an internal tear was detected about 2cm below the anterolateral commissure (Miller Type III). The tear was covered with a horse pericardial patch (2×3cm) using 6-0 running sutures with reinforcement with gelatin-resorcine-formaline (GRF) glue between the laceration and the patch. MVR sutures in the annulus above the ventricular tear were first passed through the annulus, the pericardial patch and then the prosthetic cuff. Additionally, an epicardial tear was covered and reinforced with the fibrin sheet, GRF glue and pericardial patch in turn. Cardiopulmonary bypass was weaned easily without bleeding. The patient was intentionally on respiratory support with sedation for 3 days. The subsequent postoperative course was uneventful.

Infected aortic aneurysm is very difficult to treat and is associated with a high mortality rate. A 78-year-old man had been scheduled to undergo selective endovascular repair for distal aortic arch aneurysm. While standby, however, he was admitted to our emergency room because of hemoptysis. Rapid dilatation of the aneurysm shown on serial CT and elevated of inflammatory reactions yielded a diagnosis of infected aortic aneurysm. Because the aneurysm had ruptured into the left lung, emergency surgery was performed. Six days after the first operation, critical bleeding due to anastomotic disruption of the distal aorta caused by infection and subsequent cardiac arrest occurred. We immediately started open chest massage and controlled the bleeding manually in the ICU, while an operating room was prepared. In the redo operation, anastomotic disruption was repaired using the visceral pleura under deep hypothermic circulatory arrest. Anastomotic bleeding is a potentially life-threatening condition, therefore extremely prompt measures are vital. Appropriate management based on the assumption of anastomotic bleeding was very important in the postoperative course of this case of infectious aortic aneurysm.