An unusual case of a 71-year-old man with massive sinuses of Valsalva presenting with coronary insufficiency was reported. Primarily, he had undergone aortic valve replacement (AVR) with a diagnosis of severe aortic regurgitation (AR) and annulo-aortic ectasia (AAE). Four years after the primary operation, he came to our hospital as an emergency admission complaining of chest pain. Electrocardiography showed sinus rhythm with ST wave elevation in limb leads of II, III and aVF and a diagnosis of acute myocardial infarction was made. Coronary angiography revealed right coronary insufficiency and aortography showed massive sinuses of Valsalva (diameter 8.5cm) with minimal functional AR. At the second operation, the right coronary artery was severely stretched and attenuated over the surface of the right coronary sinus. The ostium was found to be free of atherosclerosis. A composite reconstruction of the aortic root with a new valved conduit and reimplantation of coronary arteries were performed. The postoperative course was uneventful. Aneurysmal change of the sinus of Valsalva is rare, and it is reported that the mean maximal diameter is 5.4cm in this type of AAE. In our case, the unusual dilation of the sinuses of Valsalva resulted in right coronary insufficiency. This case reminded us that aortic root replacement must be applied in patients with AAE as the initial treatment of choice.

Between January, 1975 and June, 1990, 67 patients underwent surgical treatment for infective endocarditis at our hospital. Of 67 patients, 27 patients showed active endocarditis at the time of operation. In these 27 patients, 20 had active endocarditis of the native valve (NVE), and the seven had active prosthetic valve endocarditis (PVE). The interval between onset of infective endocarditis and operation ranged from 7 to 252 days (mean, 36 days). In the operative results, 3 of 20 patients (15%) with NVE and 2 of 5 patients (40.0%) with PVE died before discharge from the hospital. According to analysis of preoperative hemodynamic state and bacteriological data, the determinant factors of operative mortality and morbidity were preoperative NYHA functional classification, the interval between onset of infection and operation, and annular destruction (annular abscess). Patient's age, preoperative renal function, positive blood culture, the site of infection, and positive culture or stain of the surgically excised valve did not play an important role to determine operative mortality and morbidity. It is our conclusion that all patients with infective endocarditis who develop progressive congestive heart failure and echocardigraphical extravalvular infection despite medical treatment, should have prompt valve replacement.

We experienced 26 cases of free internal mammary artery (IMA) grafting for coronary artery bypass (CABG) during past 44 months. There were 3, 6 distal anastomoses per patient and 1.6 distal anastomoses per patient were performed with free IMA. The early mortality rate (within 1 month after surgery) was 3.8%. The surgical complications were 0 in mediastintis requiring operation, 0 in reoperation for bleeding and 1; phrenic nerve paralysis with respiratory dysfunction, the patency rate at 1 month after surgery were 97.2% in free IMA and were 96.1% in in-situ IMA. Conclusion was as followed that the use of free IMA for CABG provided excellent result in early period and we would anticipate to expand the use of IMA.

A rare case of secundum type atrial septal defect associated with cleft of the anterior mitral leaflet in 63-year-old man is reported. The electrocardiogram showed right bandle branch block and indeterminate QRS axis. Preoperative cardiac catheterization revealed left to right shunt at the atrial level and moderate mitral regurgitation due to a cleft in the anterior mitral leaflet. Marked tricuspid regurgitation due to a dilated annulus concomitantly existed. The valve deficiencies were repaired and the atrial septal defect was closed at operation. Forty cases of secundum type atrial septal defect associated with cleft mitral valve were discussed about their electrocardiograms and operative indications.

Left ventricular hypertrophy in patients with aortic valve disease has long been recognized as a significant risk factor for aortic valve replacement. Higher operative mortality in such patients has been attributed to poor myocardial preservation. In these patients improvement of left ventricular subendocardial blood flow during reperfusion seems to be mandatory to avoid subendocardial injury. Therefore, we attempted to increase subendocardial blood flow during reperfusion by terminal warm blood cardioplegia (TWBCP) followed by controlled aortic root reperfusion (CARR) in patients requiring isolated aortic valve replacement. The patients with TWBCP and CARR had a tendency towards severe left ventricular hypertrophy and more advanced NYHA function class compared to those with hypothermic cardioplegia alone. Nevertheless, the patients with TWBCP and CARR showed significantly better recovery of left ventricular function, i.e., spontaneous recovery of beating and higher cardiac index as well as left ventricular stroke work index, despite significantly less catecholamine support. These resuls suggest that TWBCP followed by CARR may offer significant benefits over unmodified reperfusion during aortic valve replacement for patients with severe left ventricular hypertrophy.

A case of 41-year-old man with large candidal vegetation on the tricuspid valve was reported. He was presented with high fever and newly developed heart murmur. Four months before admission, he had suffered from head trauma which required intravenous hyperalimentation and injection of multiple antibiotics through catheter indwelling the superior vena cava. On admission, echocardiogram showed large vegetation on the tricuspid valve, although blood cultures were sterile. At operation, tricuspid valve was replaced with St. Jude Medical prosthesis because large vegetation developed from the anterior tricuspid leaflet was confirmed. Candida albicans was detected by microscopic examination of the vegetation. The total of 1500mg of Amphotericine-B were administered intravenously after operation. His postoperative course was uneventful. We discussed about the availability of echocardiogram for diagnosis and the effectiveness of a combination of chemotherapy and valve replacement for treament of fungal endocarditis.

Cor triatriatum is one of the rare congenital cardiac malformations and once the diagnosis is correctly established, this is amenable to surgical correction. We reported a case of 25-year-old male of cor triatriatum, who had symptomes of easy fatiguability. The diagnosis of cor triatriatum was suspected preoperatively by two-dimensional echocardiogram at first, detecting abnormal diaphragm in the left atrium, and it was confirmed by color Doppler echocardiogram and transesophageal two-dimensional echocardiogram. Cardiac catheterization revealed high pulmonary capillary wedge pressure and the abnormal diaphragm in the left atrium was showed by the pulmonary arteriography. On the operation, the abnormal diaphragm was excised by the trans-septal approach, which had a small fenestration of 8mm in diameter at posterolateral site. Some considerations for clinical diagnosis and surgical treatment are discussed.

A 53 year-old male with mitral valve aneurysm was presented. This patient, who had no episodes of rheumatic fever, was admitted with complaints of general fatigue, dyspnea and continuing high fever. Echocardiographic examination showed an abnormal echo behind the anterior leaflet of mitral valve, protruding into the left atrium during systole. Angiogram showed the same abnormal change of mitral valve and mitral regurgitation (MR) and aortic regurgitation (AR). We diagnosed as mitral valve aneurysm with MR and AR due to infective endocarditis. At operation, it was revealed that the aortic valve was destroyed, resulting in severe AR, and the anterior leaflet of mitral valve was a large aneurysm itself. Both valves were replaced with St. Jude Medical valve prosthesis. Postoperative course was good and with no complications. In Japan, 21 cases of mitral valve aneurysm were reported. We discussed the clinical course and the operative procedure for mitral valve aneurysm in this report.

Experimental autoimmune uveitis (EAU) is an animal model of human autoimmune uveitis that is characterized by the infiltration of autoimmune T cells with concurrent increases in pro-inflammatory cytokines and reactive oxygen species. This study aimed to assess whether betaine regulates the progression of EAU in Lewis rats. EAU was induced via immunization with the interphotoreceptor retinoid-binding protein (IRBP) and oral administration of either a vehicle or betaine (100 mg/kg) for 9 consecutive days. Spleens, blood, and retinas were sampled from the experimental rats at the time of sacrifice and used for the T cell proliferation assay, serological analysis, real-time polymerase chain reaction, and immunohistochemistry. The T cell proliferation assay revealed that betaine had little effect on the proliferation of splenic T cells against the IRBP antigen in an in vitro assay on day 9 post-immunization. The serological analysis showed that the level of serum superoxide dismutase increased in the betainetreated group compared with that in the vehicle-treated group. The anti-inflammatory effect of betaine was confirmed by the downregulation of pro-inflammation-related molecules, including vascular cell adhesion molecule 1 and interleukin-1β in the retinas of rats with EAU. The histopathological findings agreed with those of ionized calcium-binding adaptor molecule 1 immunohistochemistry, further verifying that inflammation in the retina and ciliary bodies was significantly suppressed in the betaine-treated group compared with the vehicle-treated group. Results of the present study suggest that betaine is involved in mitigating EAU through anti-oxidation and anti-inflammatory activities.

Experimental autoimmune uveitis (EAU) is an animal model of human autoimmune uveitis that is characterized by the infiltration of autoimmune T cells with concurrent increases in pro-inflammatory cytokines and reactive oxygen species. This study aimed to assess whether betaine regulates the progression of EAU in Lewis rats. EAU was induced via immunization with the interphotoreceptor retinoid-binding protein (IRBP) and oral administration of either a vehicle or betaine (100 mg/kg) for 9 consecutive days. Spleens, blood, and retinas were sampled from the experimental rats at the time of sacrifice and used for the T cell proliferation assay, serological analysis, real-time polymerase chain reaction, and immunohistochemistry. The T cell proliferation assay revealed that betaine had little effect on the proliferation of splenic T cells against the IRBP antigen in an in vitro assay on day 9 post-immunization. The serological analysis showed that the level of serum superoxide dismutase increased in the betainetreated group compared with that in the vehicle-treated group. The anti-inflammatory effect of betaine was confirmed by the downregulation of pro-inflammation-related molecules, including vascular cell adhesion molecule 1 and interleukin-1β in the retinas of rats with EAU. The histopathological findings agreed with those of ionized calcium-binding adaptor molecule 1 immunohistochemistry, further verifying that inflammation in the retina and ciliary bodies was significantly suppressed in the betaine-treated group compared with the vehicle-treated group. Results of the present study suggest that betaine is involved in mitigating EAU through anti-oxidation and anti-inflammatory activities.