We describe successful surgical treatment of blow-out type left ventricular free wall rupture (LVFWR) that suddenly occurred in a 66-year-old man 6 days after antero-lateral acute myocardial infarction. Immediate use of a percutaneous cardiopulmonary support system (PCPS) and intra-aortic balloon pumping (IABP) successfully resuscitated the patient, followed by emergency operation for the beating heart under PCPS and IABP. The actively bleeding site, located at the antero-lateral wall, was gently approximated by large bites of mattress suture with pledgets to close the rupture site, and the site was then additionally covered with oxycel and fibrin glue. The infarct area was finally widely covered with a large patch of equine pericardium. This simple surgical method for the beating heart under PCPS and IABP can provide a prompt and less invasive surgical cure for critically ill patients with blow-out type LVFWR.

A 69-year-old man developed abdominal aortic aneurysm (AAA) during treatment for chronic renal failure at another hospital. On admission, CT revealed infrarenal AAA associated with horseshoe kidney. The aneurysm was exposed through a transperitoneal approach, and aortoiliac reconstruction was performed preserving the renal isthmus. Two accessory renal arteries were reconstructed. Postoperatively, both reconstructed arteries were patent on angiography, and postoperative renal function was not impaired. In surgery for AAA with horseshoe kidney, preservation or reconstruction of renal feeding arteries is important to maintain renal function.

A 70-year-old woman was admitted to our hospital complaining of upper abdominal pain. Computed tomography revealed a 6-cm tumor next to the inferior vena cava (IVC). Venography revealed obstruction of the IVC, and venous return was via collateral circulations. Right nephrectomy and tumor resection of the middle part of the IVC was performed. The left renal vein, which was invaded by tumor, was divided without venous reconstruction. Pathological diagnosis was leiomyosarcoma. Postoperatively hemodialysis was needed for a month, but maintenance hemodialysis was avoided. Leiomyosarcoma of the middle part of the IVC sometimes invades bilateral kidneys, and sometimes it is not possible to reconstruct the renal vein. It is important to recognize collateral circulation by preoperative angiography, and to protect such circulation during operation.

We present a case of successful mitral valve repair in a 38-year-old woman with Marfan's syndrome. Prolapse in a redundant billowing posterior mitral leaflet caused severe mitral valve regurgitation. Only slight dilatation of the sinus Valsalva and grade I aortic regurgitation were recognized. At operation, prolapsed portions seen on both sides of the middle scallop were quadrangularly resected. The sliding leaflet technique reduced the height of the posterior mitral leaflet to prevent systolic anterior motion of the mitral valve, which could be expected to occur after the operation. The anterior extremities of the Carpentier-Edwards annuloplasty ring were bent upward to accommodate the shape of the anterior mitral leaflet. Mitral valve regurgitation disappeared postoperatively, and she is now doing well 3 years after the operation. In general, isolated mitral valve regurgitation appears in relatively young patients with Marfan's syndrome, and these patients are at high risk of developing aortic dissection and aortic regurgitation. Therefore, mitral valve repair should be performed to improve the quality of life after the operation, and to reduce the risk of bleeding, which may be a lethal complication in aortic surgery.

Constrictive pericarditis after open heart surgery is a rare entity that is difficult to diagnose. There are various approaches in the surgical treatment of pericarditis. We performed a pericardiectomy on cardiopulmonary bypass via a median approach with good results. A 67-year-old man underwent mitral valve repair in 2005. He began to experience easy fatigability as well as leg edema beginning in January 2010 for which he was treated medically. The fatigability worsened in July 2012. Echocardiography at that time was unremarkable. However, CT and MRI showed pericardial thickening adjacent to the anterior, posterior, inferior, and left lateral wall of the left ventricle. Bilateral heart catheterization revealed dip and plateau and deep X, Y waves as well as end-diastolic pressure of both chambers approximately equal to the respiratory time. He was diagnosed with constrictive pericarditis and taken to surgery. The chest was entered via median sternotomy and cardiopulmonary bypass was initiated to facilitate complete resection of the pericardium. The left phrenic nerve was visualized and care was taken to avoid damage to the structure. A part of the pericardium was strongly adherent to the epicardium. We elected to perform the waffle procedure. After pericardial resection, cardiac index improved from 1.5 l/min/m² to 2.7 l/min/m², and central venous pressure improved from 17 to 10 mmHg. Postoperatively, dip and plateau disappeared as measured via bilateral heart catheterization and diastolic failure improved. In the treatment of constrictive pericarditis, we should resect as much of the pericardium as possible. Depending on the case, this can be facilitated by median sternotomy and cardiopulmonary bypass.

Early surgical resection for cardiac myxoma is necessary because it may frequently cause cerebral infarction. However the optimal surgical timing for the disease is controversial because the acute phase of infarction may induce intracranial hemorrhage. An 82-year-old woman referred to our hospital because of unconsciousness and right hemiparesis. MRI showed infarction in the left middle cerebral artery area and UCG revealed a left atrial mass. The fourth day after the onset, brain CT showed hemorrhagic infarction and MRI showed new infarction. There was no enlargement of the hemorrhagic focus on brain CT and the patient underwent surgery on the fifth day after the onset. The postoperative course was uneventful. Despite the existence of hemorrhagic infarction, open heart surgery may save patients with cerebrovascular event.

A 72-year-old man was admitted with an abnormal shadow on chest X-ray. Chest CT and aortography showed double saccular aneurysms at the aortic arch and the descending thoracic aorta. Three-dimensional CT was useful to detect the association between the arch aneurysm and neck vessels. Graft replacement, from the distal arch to the descending thoracic aorta, was performed by the lateral approach with hypothermic arrest and open proximal method. The aorta had severe atherosclerotic changes and the intima was absent at the orifices of the aneurysms. Pathological examination showed the aneurysmal wall to be composed of fibrous tissue without medial components. These macroscopic and pathological findings of aneurysms corresponded with double pseudo-aneurysms originating from the penetrating atherosclerotic ulcer.

A 61-year-old man underwent percutaneous coronary intervention (PCI) for the right coronary artery. However, he had an acute onset of right neck pain and swelling after PCI. Contrast enhanced computed tomography (CT) revealed extravasation into the mediastinum and aberrant right subclavian artery. After transfer to our hospital, we performed emergency endovascular repair for iatrogenic arterial injury. His postoperative course was uneventful.

Central diabetes insipidus (CDI) is a disease that caused by insufficient or no anti-diuretic hormone (ADH) secretion from the posterior pituitary, which results in an increase in urine volume. CDI is controlled with ADH supplementation thereby reducing urine output and correcting electrolyte imbalance. However, reports on perioperative management for CDI patient are scarce, especially for patients who underwent cardiac surgery. We herein report our experience of the management of a CDI patient who underwent surgery for valvular heart disease.

The case is a 72-year-old woman who developed secondary CDI after pituitary tumor removal. She had been controlled with orally administered desmopressin acetate hydrochloride. She underwent aortic valve replacement and mitral valve repair for severe aortic, and moderate mitral regurgitation. Immediately after surgery, we started vasopressin div, which yielded good urine volume control. However, once we started to switch vasopressin to oral desmopressin administration, the control became worse. We thus made a sliding scale for subcutaneous injection of vasopressin every 8 h according to the amount of urine output, which resulted in good control. Overlapping administration of vasopressin and oral desmopressin between postoperative day 12 and 17 resulted in successful transition. The patient was discharged with oral desmopressin administration. Management with sliding scale for vasopressin subcutaneous injection after surgery was useful in controlling a CDI patient who underwent major cardiac surgery.

We report a case of a 53-year-old woman, who was transported as an emergency case to our institution because of type A acute aortic dissection. Total arch replacement and coronary artery bypass grafting (CABG) with open stent graft was performed. After the operation, during rehabilitation for discharge (33 and 38 days after the surgery), she developed acute arterial occlusion of the right lower limb, and we performed thrombectomy. Both thrombi extracted from the right common femoral artery were organized clots. No perioperative arrhythmia was observed, and no obvious left atrial appendage thrombus was observed on CT. We performed angiography to diagnose the cause of the spread of organized clots, and an entry was detected at the distal tip of the open stent graft, and antegrade blood flow in a false lumen was observed. We considered that the thrombus was caused by the antegrade blood flow in a false lumen, TEVAR (c-TAG) was performed to seal the entry 48 days after the surgery. Embolism did not occur afterward, and the patient was discharged for rehabilitation.