A 71-year-old female, who had diabetes mellitus and chronic renal failure on dialysis, had undergone mitral valve repair and tricuspid valve annuloplasty. Five months after the operation, she suffered from infectious endocarditis and underwent mitral valve replacement. Postoperatively, a total fluid volume of 300 to 600 ml/day was drained from the pericardial tube, and its appearance became milky after the start of oral intake of food. She was diagnosed with chylomediastinum. Despite fasting and total parenteral nutrition for 2 weeks and subcutaneous octreotide administration, the volume of fluid drainage was not reduced. Therefore, we planned lymphangiography treatment with Lipiodol on postoperative day 37. On operation, under local anesthesia, the left inguinal lymph node was punctured under ultrasound guidance, and Lipiodol was injected at a rate of 12 ml/h for 1h. On the next day, the volume of fluid drainage was reduced, and the pericardial tube could be removed 9 days after lymphangiography.

A 76-year-old female was admitted with complaints of dyspnea on exertion and lower leg edema. She had undergone an aortic valve replacement thirty-nine years before and a redo aortic valve replacement and mitral valve replacement twenty-eight years before. She also had hemolytic anemia with jaundice. Echocardiography showed severe paravalvular leakage in the aortic and mitral valves, and a blood flow in the aortic annulus that flows from the aortic side into the left atrium. We diagnosed heart failure and hemolytic anemia due to paravalvular leakage and decided to perform a double-valve replacement for the third time. On operation, after removing the aortic valve through aortotomy, aorto- mitral fibrous continuity was extensively calcified and perforated, and its strength was not enough to sew the prosthetic valve to it. Therefore, we decided to perform the Commando procedure. Aortotomy was extended between the noncoronary aortic sinus and the left coronary aortic sinus until it reached the dome of the left atrium. After the prosthetic mitral valve was excised, annuloplasty of the posterior mitral annulus was performed using a bovine pericardial patch, and the new prosthesis mitral valve was implanted. The anterior part of the annulus corresponding to the aorto-mitral fibrous continuity was reconstructed by sewing the base of a two-tongued triangular bovine pericardial patch to the sewing cuff of the mitral prosthesis. After closing the left atrial ceiling with the posterior patch, the aortic prosthesis was secured to the aortic annulus and the pericardial patch. The anterior patch was used to close the right side of the aortotomy. The postoperative course was uneventful, and postoperative echocardiography revealed no paravalvular leakage.