We present a rare case of a 59-year-old-man with a diagnosis of hypertrophic cardiomyopathy (HCM) complicated with left ventricular thrombus. He was admitted to our hospital because of acute re-occlusion of the right brachial artery. Thrombectomy was performed and reperfusion was obtained. Anti-coagulation therapy was started from that day. Four days after surgery, echocardiography revealed mobile thrombus in left ventricular apical aneurysm that was not detected on admission. An emergency thrombectomy and left ventriculoplasty was performed. The patient was discharged 22 days after surgery in good condition.

We report 2 cases of successful proximal reoperations after acute type A dissection. Case 1 : A 53-year-old man underwent ascending aorta and aortic arch replacement and aortic valve re-suspension for acute type A dissection with aortic valve regurgitation in 1992. Thirteen years after the first operation, computed tomography demonstrated a Valsalva aneurysm (74 mm) and Doppler echocardiography showed moderate aortic valve regurgitation. Therefore, we performed an operation. We could not locate the dissection in the Valsalva sinus, and the aortic valve cusps had organic change. A David procedure was performed. The postoperative course was uneventful and he was discharged on the 19th postoperative day. Case 2 : A 65-year-old woman underwent ascending aorta replacement and aortic valve resuspension for acute type A dissection with aortic valve regurgitation in 1997, but 11 years after the first operation, computed tomography demonstrated a Valsalva aneurysm (55 mm) and arch aneurysm (65 mm) with stenosis of the innominate vein and she had facial and left arm edema. Doppler echocardiography showed moderate aortic valve regurgitation. We could not find the location of dissection in the Valsalva sinus or aortic arch, and aortic valve cusps had no organic change. A Bentall procedure and total arch replacement were performed and her postoperative course was uneventful.

We describe Takotsubo syndrome, which developed after elective mitral valve repair and tricuspid annuloplasty in a 76-year-old woman. A preoperative echocardiogram confirmed severe mitral regurgitation due to posterior leaflet prolapse, moderate tricuspid regurgitation, and normal left ventricular function. Mitral valve repair and tricuspid annuloplasty were performed. After uneventful weaning off cardiopulmonary bypass, intraoperative transesophageal echocardiography revealed adequate mitral leaflet function and normal left ventricular contractions. After being transferred to the intensive care unit, the patient's hemodynamic parameters progressively deteriorated. Transthoracic echocardiography showed akinesis and ballooning of the apex and hyperkinesis of the base, and the ejection fraction was 20% on postoperative day 1. The serum aminotransferase and CPK-MB levels increased on postoperative day 2. The left ventricular function did not improve despite supportive therapy with vasopressors. She developed cardiogenic cerebral infarction due to obstruction of the right middle cerebral artery on postoperative day 8. Endovascular thrombectomy was performed within 2 h of the onset of cerebral infarction. Thereafter, the patient gradually recovered and was discharged without any sequelae on postoperative day 31. The ejection fraction was 65% with normal left ventricular motion at discharge. An electrocardiogram revealed a deep negative T wave in II, III, aVF, and V3-V6. After 2 months, the electrocardiogram findings were normalized. Coronary lesions were not observed on pre- or postoperative coronary angiographies; therefore, we diagnosed Takotsubo cardiomyopathy after mitral valve repair. Takotsubo cardiomyopathy should be considered as a possible complication of cardiac surgery, especially after mitral valve surgery.