The onset mechanism of takotsubo cardiomyopathy is unkown. The reported cases of takotsubo cardiomyopathy that happened after cardiac surgical operation were very few. We describe one case of takotsubo cardiomyopathy with left ventricular outflow tract obstruction (LVOTO) that occurred after having undergone mitral valve replacement (MVR) for combined valvular disease. The patient was an 82-year-old woman who was hospitalized with congestive heart failure in our hospital. She had diagnosis of rheumatic valvular disease (i.e. severe mitral regurgitation and mild mitral stenosis, secondary tricuspid regurgitation), atrial fibrillation and pulmonary hypertension. She had a sigmoid septum pointed out by cardiac ultrasonography. Preoperative coronary angiography was normal. After general anesthesia induction, bradycardia and hypotension developed. Therefore epinephrine and norepinephrine were administered. The rheumatic mitral valve was replaced using a 27 mm-size mitral pericardial bioprosthesis, preserving the posterior mitral leaflet. DeVega tricuspid annuloplasty and maze surgery were also performed at the same time. We did not recognize wall motion abnormalities by the transesophageal echocardiographic examination during the operation. On postoperative day 1, she was extubated and became hypotensive immediately. Takotsubo cardiomyopathy was diagnosed from characteristic views (an apical ballooning and a preserved basal contraction of the left ventricle) by transthoracic echocardiography (TTE). This echocardiogram showed also LVOTO of pressure gradient 38 mmHg. Blood transfusion and discontinuation of epinephrine infusion improved LVOTO. TTE showed a gradual recovery of the left ventricle to normal systolic function, on postoperative day 34. The postoperative coronary angiogram was normal. We presumed that LVOTO was important in the onset and severity of takotsubo cardiomyopathy. In this report, we showed also the pathological significance of the sigmoid septum.

We report a case of an 85-year-old woman with severe aortic insufficiency caused by structural valve deterioration (SVD) of Medtronic Freestyle stentless aortic bioprosthesis (Freestyle valve) complicated by rheumatic multivalvular heart disease. The patient received an aortic valve replacement by using the modified sub-coronary method with a 21 mm Freestyle stentless porcine valve (Medtronic Inc., Minneapolis, MN, USA), for severe aortic valve stenosis at of the age of 71. The patient developed severe heart failure 14.5 years after the surgery. She was admitted for severe aortic insufficiency caused by a leaflet injury (tear) of the Freestyle valve. She also had had rheumatic mitral stenosis and secondary tricuspid insufficiency with severe pulmonary hypertension. Therefore, treating her heart failure was difficult, but surgery was performed. The leaflets of the stentless bioprosthesis were resected. The insertion of the needle suture into the annulus of the stentless valve was difficult because of calcification of the tissue. An aortic root enlargement procedure was performed using a bovine pericardial patch, enabling the insertion of the needle suture into the Dacron cloth at the bottom of the stentless valve, with 2-0 Ethibond threads and single sutures. We successfully performed an aortic valve re-replacement using an Open Pivot Mechanical Heart Valve (OPHV) 16 mm AP (Medtronic, Minneapolis, MN, USA), which was implanted by using the partial valve-in-valve technique. Simultaneously, mitral valve commissurotomy and tricuspid annuloplasty were performed. The patient had an uneventful postoperative recovery.

A 69-year-old woman suffered from postprandial abdominal pain and hematochezia. Colonoscopy suggested ischemic colitis, and intestinal angina was diagnosed by multirow-detector computed tomography (CT), which showed occlusion of the superior mesenteric artery (SMA). On enhanced CT, there was extensive calcification on the aortic wall and aortic expansion and several mural thrombi in the thoracoabdominal and abdominal aorta, as well as severe stenoses in the bilateral common iliac arteries. A bypass from the right renal artery, which was the only artery without significant stenosis of the major branches of the abdominal artery, to the SMA, was created using a saphenous vein graft. Postoperatively, the postprandial abdominal pain disappeared, and the patient was discharged after a good postoperative course.

A 65-year-old woman suffered from left-side paralysis and dysarthria after sudden chest pain, and we diagnosed cerebral infarction caused by type A acute aortic dissection in the Stanford classification. At that time, the aberrant right subclavian artery with Kommerell's diverticulum was found on enhanced computed tomography. The acute aortic dissection with closed false lumen was treated conservatively. Because the ulcer-like projection (ULP) expanded during the course, we performed surgery. Ascending aorta and arch replacement, patch closure of Kommerell's diverticulum and reconstruction of right subclavian artery were performed simultaneously. The postoperative course was good.

We present here a rare case of coronary artery bypass grafting through a left thoracotomy after substernal gastric interposition for esophageal cancer. A 58-year-old man, who had undergone esophagectomy and substernal gastric interposition 11 years previously, was admitted for cerebral infarction from which he made a good recovery without any complication. At this time, the patient was diagnosed as having coronary artery disease on electrocardiogram. Cardiac catheterization revealed triple vessel disease. Coronary artery bypass grafting to the left anterior descending artery and obtuse marginal branch through a left thoracotomy was performed using a radial artery Y-graft under femorofemoral bypass. The aorta was cross-clamped and the heart was arrested with antegrade cold cardioplegic solution for the distal anastomosis of the left anterior descending artery and the obtuse marginal branch which was embedded within the myocardium. The postoperative angiography showed good coronary flow. Left thoracotomy approach provides a good exposure of the left coronary artery. This approach, therefore, is advocated as an alternative method for cases requiring coronary artery bypass but in which median sternotomy is difficult, such as the present case. The appropriate procedure for the site of thoracotomy, supporting methods, choice of graft, and the site of graft anastomosis should be selected in each patient.

A 68-year-old woman received aortic valve replacement (AVR) with a Freestyle stentless valve using a subcoronary technique for aortic stenosis and regurgitation in September 2000. She complained of chest pain, had low grade fever and findings of inflammation and was admitted to our hospital with a diagnosis of acute myocardial infarction in December 2000. She suffered from repetitive or recurrent myocardial infarction. Transesophageal echocardiogram revealed no abnormal findings of the Freestyle stentless valve, but her blood culture was positive for methicillin-resistant coagulase negative Staphylococcus aureus (MRCNS) and she underwent an emergency operation. The Freestyle stentless valve was removed and replaced with a mechanical valve. The patient's intraoperative tissue grew MRCNS and parenteral antibiotics were administered for 8 weeks after surgery. Her condition was complicated with multiple cerebral infarction, however she was discharged on the 113th postoperative day and is doing well without recurrence of infection 12 months after the operation.

We report a 25-year-old man with ventricular septal perforation due to blunt chest trauma. He was transferred by ambulance to our hospital following a traffic accident. On admission, he had no cardiac murmur. Two days later, a pansystolic murmur appeared over the left lower sternal border. Doppler echocardiogram revealed a large left-to-right shunt through a ventricular septal perforation. We postponed surgical treatment as long as possible because he also exhibited bronchial bleeding due to a lung contusion. Surgical repair of the ruptured ventricular septum was performed 8 days after the chest trauma, because the pulmonary to systemic flow ratio was elevated to 4.6 and cardiac function had deteriorated. During the operation, the site of the septal perforation was easily detected by epicardial echocardiography. A 4-cm tear in the muscular septum was closed through a right ventriculotomy using a pericardial patch reinforced with a Dacron patch. Postoperative recovery was uneventful with the exception of transient right ventricular failure. There was no residual shunt.

Primary cardiac undifferentiated pleomorphic sarcoma is rare and is associated with very poor survival. We report a case of a 45-year-old female who presented with dyspnea on effort, in whom an echocardiographic exam showed a large mass in the left atrium and the tumor resection was performed. The pathological diagnosis of the resected tumor was undifferentiated pleomorphic sarcoma which subsequently recurred. The patient needed four re-surgeries, and chemotherapy with Pazopanib was performed. A long-term survival of 5 years after the initial surgery was achieved.

Primary cardiac malignant tumor is rare and is associated with very poor survival. We report a case of a 45-year-old female who presented with dyspnea and general edema due to severe congestive heart failure, in whom an echocardiographic exam showed a large mass in the left atrium, mitral valve regurgitation and tricuspid valve regurgitation and the tumor resection, mitral valve repair and tricuspid annuloplasty were performed under semi-emergency. The pathological diagnosis of the resected tumor was cardiac intimal sarcoma which recurred; the patient needed re-surgery after 1 year and 5 months, and chemotherapy by pazopanib was performed. She died due to widespread metastasis. A relatively long-term survival of two years and 1 month after the initial surgery was achieved.

Introduction: Research was carried out using a mixed method approach in order to evaluate the educational effects of medical students' visit of an elderly home.Methods: Focus group interviews were conducted with 5 medical students and 5 elderlies. All interviewees had experienced the visitation program more than three times. Self-administrative questionnaires were built based on the results of the focus group interview. The questionnaire was then distributed to medical students and elderlies who participated in the program.Results: A total of 84 medical students and 30 elderlies provided informed consent to participate in the study and returned the questionnaire. Nearly 70 percent of the students answered that they had gotten to know about the life of elderly people and sixty percent of the elderlies answered they had experienced some favorable changes after joining the program. While ninety percent of the elderly were satisfied with the program, only half of the students showed positive comments toward it.Discussion: To help all students participate in this program more actively, more organized planning is necessary so that students can have more chances to build communication skills and clarify their own objectives when visiting the elderly.