A 63-year-old woman, had been referred to our hospital on diagnoses of mitral restenosis (MS) and tricuspid regurgitation (TR) 8 years after on percutaneous transvenous mitral commissurotomy (PTMC). Echocardiography revealed an additional finding of residual atrial septal perforation (ASP). Mitral valve replacement, tricuspid valve annuloplasty and direct closure of the ASP was performed. Though ASP is major complication of PTMC, few cases of ASP remain patent for such a long time. Since the patients with MS and residual ASP after PTMC present hemodynamics such as Lutembacher syndrome, there is a possibility of biventricular failure in an early phase along with progression of secondary TR. In a patient with residual ASP after PTMC, careful observation by echocardiography is mandatory, particularly regarding occurrence of regurgitation, restenosis, or both.

A 71-year-old man who had mitral and tricuspid regurgitations with severely calcified aorta had been called off an elective operation 4 years ago, because cardiopulmonary bypass (CPB) could not be established intraoperatively operation. This time, mitral valve replacement and tricuspid annuloplasty was performed by left axillary arterial cannulation and moderate hypothermic ventricular fibrillation after resternotomy. Calcification of the aorta is sometimes more severe than detected by preoperative CT scan, as in the present case. Therefore, it is necessary and recommended for cases of calcified ascending aorta to be fully examined and, based on the results decided alternative modalities.

In patients with so-called porcelain aorta characterized by calcification of the total aorta, manipulation of the ascending aorta can cause cerebral infarction and other conditions due to aortic dissection or rupture and calcified debris. In the present case with ischemic cardiomyopathy and porcelain aorta, an occlusion balloon catheter was inserted into the ascending aorta to avoid its clamping, followed by Dor operation and CABG under cardiac arrest with normothermic extracorporeal circulation. Techniques such as deep hypothermic circulatory arrest and surgery while the heart is beating are often currently used as auxiliary methods to avoid aortic clamp. However, the present case with insufficient left ventricular function required a left ventriculotomy, and thus the technique presented here is useful for shortening the surgical time and ensuring a reliable outcome of the operation.

Some cases of atrial fibrillation and bradycardia show improvement in slow ventricular response after valvular surgery. However, there is still no established view regarding the indications of pacemaker implantation for the bradyarrhythmia with valvular disease. In 24 cases (permanent pacing group: 15, non-pacing group: 9) of those with bradyarrhythmia who were fitted with a myocardial pacing lead at the time of valvular surgery, we examined predictions of pacemaker implantation and the role of valvular surgery for the bradyarrhythmia. The permanent pacing group showed much larger values than the non-pacing group in regard to preoperative NYHA, right and left atrial pressure, and duration of atrial fibrillation. After valvular surgery, many cases that had significantly decreased left atrial pressure after operation improved with regard to bradycardia. We should judge the indication of pacemaker implantation after valvular surgery from the evaluation of preoperative hemodynamics and early postoperative cardiac function. Because atrial fibrillation tends to accompany bradycardia due to chronic atrial load, we must make an effort to promote the rapid recovery of cardiac function by doing valvular surgery as early as possible.

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.

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.

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.

A 71-year-old woman underwent VVI pacemaker implantation for complete atrioventricular block 38 years ago at the cardiovascular department of another hospital. In the course of observation, she developed atrial fibrillation. One year ago, she was admitted to hospital for aggravated congestive heart failure and was subsequently treated by a cardiovascular practitioner. She had persistent shortness of breath and lower leg edema, which were treated with increasing doses of oral diuretics. Due to poor treatment outcomes, she was referred to our hospital. Her echocardiography results suggested severe tricuspid regurgitation (TR) and moderate mitral regurgitation. She was also found to have impaired renal function and liver cirrhosis (Stage A of the Child classification), and was admitted. In addition, she had undernutrition with suspected cardiac cachexia. She was first treated by inotrope infusion and central venous hyperalimentation before tricuspid annuloplasty and mitral valvuloplasty were performed. Even though her postoperative management was complicated, she was discharged from our hospital. The conservative treatment with the increased dose of the diuretic for TR-associated right heart failure was prolonged in this patient, leading to severe right heart failure and aggravation of impaired renal function or congestive liver-associated hepatic disorders. Eventually, the patient required operative intervention; however, postoperative management is usually complex, and the operation result may be poor in such patients. We suggest that, from the time when right heart failure can be managed with relatively small doses of diuretics, surgeons should be involved in the care of patients with severe TR who do not require left heart valvular surgery, and should discuss the necessity of surgery earlier than the relevant guidelines suggest, depending on the patient's condition.

Background : Risk factors for surgical site infection (SSI) are thought to include poorly controlled diabetes mellitus, dialysis, and a long operating time, but patients without risk factors can also develop infection. Therefore, it is possible that SSI could be prevented by routinely using the precautions against SSI developed for high-risk patients. We investigated the route and pathogenetic mechanism of mediastinitis, which is the most frequent SSI after cardiac surgery. We hypothesized that mediastinitis occurred when the deep sternal marrow was contaminated by skin bacteria. Based on this hypothesis, we investigated the efficacy of various intraoperative prophylactic methods for preventing mediastinitis. Methods : We evaluated 658 patients undergoing cardiac surgery at our institution between April 2011 and July 2016. They were classified into two groups. Group C comprised 406 patients who received standard insertion of a sternal retractor after sternotomy. Group S was 252 patients in whom a retractor was inserted after covering the sternal marrow with oxidized cellulose hemostats and belt-like thin towels, with surplus parts of the towels being used to fill subcutaneous dead space at the superior and inferior margins of the midline wound. We investigated the following 10 risk factors for mediastinitis: diabetes (HbA1c≥7.5), renal failure (Cr≥2), smoking, obesity (BMI≥30), reoperation, urgent/emergency operation, intubation in the preoperative period, long operating time (≥8 h), reopening the chest for hemostasis, and coronary artery bypass grafting (CABG). Factors associated with mediastinitis were determined using univariate modeling analysis followed by multi-variate logistic regression analysis. Results : Mediastinitis occurred in 13 patients (2.0%). The significant risk factor for mediastinitis were urgent/emergency operation and CABG, but 1 patient had no risk factors. A univariate analysis showed statistical significance in CABG, presence of maneuver covering the sternal marrow, JapanSCORE-II in mortality and deep sternum infection (DSI). Reopening the chest for hemostasis, CABG, aortic aneurysm, plural risk factors, and JapanSCORE-II in DSI were identified as a risk factor by multiple logistic regression, not all factors showed a significant difference. Mediastinitis only occurred in group C, and it was significantly less frequent in group S with additional precautions against infection including propensity score matching analysis (p<0.05). Conclusion : When the bone marrow of the transected sternum was covered tightly to protect it from contamination by skin bacteria during cardiac surgery, the frequency of postoperative mediastinitis was significantly reduced.