We encountered 3 cases of protein S deficiency accompanied by coronary artery disease (CAD). None of the patients had been given diagnoses of congenital protein S deficiency prior to referral to our department. Our examination revealed three-vessel CAD with distal lesions. CAD was of early onset in two patients in their 40 s. In 2 of the 3 patients, off-pump coronary artery bypass was performed, and continuous heparin infusion was postoperatively changed to oral warfarin. These patients had a favorable postoperative course and graft patency was maintained. In the third patient, who underwent repeated percutaneous coronary revascularization, in whom coronary artery bypass was contraindicated, oral warfarin alleviated the symptoms of CAD. No disease progression was observed in coronary angiography performed at the one-year follow-up examination.

The purpose of this study was to review our experience in the treatment of active endocarditis and identify determinants of early outcome. Sixty-nine patients (mean age 47.3 years, range 5 months to 88 years) underwent surgery for active endocarditis. Native valve endocarditis was present in 59 (85.5%) and prosthetic valve endocarditis in 10 (14.9%). The aortic valve was infected in 26 (37.7%), the mitral valve in 24 (34.8%), both aortic and mitral valves in 13 (18.8%), and the tricuspid in 3 (4.3%). Paravalvular abscess was identified in 22 (31.9%). Streptococci (27.5%) and Staphylococci (23.3%) were the most common pathogens, but the pathogen was not identified in 36.2%. Hospital death occurred in 13 (18.8%), and causes of deaths included cardiac failure in 6 and sepsis in 5. There were 2 late deaths, and the causes of death were cerebral infarction and renal dysfunction. Univariate analysis indicated that older age (p=0.02), New York Heart Association class III or IV (p=0.02), a preoperatively unidentified pathogen (p=0.02) and concomitant operation for abscess and fistula (p=0.04) were significant risk factors in hospital mortality. Prosthetic valve infection was a relative risk factor in hospita mortality (p=0.11). Multivariate analysis revealed that NYHA III-IV(p=0.02, odds ratio=18.1, 95% CI=1.49-220.1) and a preoperatively unidentified pathogen (p=0.02, odds ratio=7.45, 95% CI=1.44-38.5) were independent predictors of hospital mortality. To reduce hospital mortality in active endocarditis, early surgical intervention is recommended before the involvement of heart failure, particularly when the pathogen is not identified.

Cardiovascular manifestations of acromegaly include cardiomegaly and very often hypertension, coronary atherosclerosis, and diabetes. Primary valvular disease is less commonly observed. A 62-year-old woman had acromegaly associated with mitral regurgitation (MR) resulting from prolapse of the posterior mitral leaflet, which was successfully repaired. At the age of 57 years, the patient was admitted due to heart failure without valvular disease. Acromegaly was diagnosed and a pituitary tumor was removed surgically. At the age of 62, a heart murmur was found, and moderate to severe MR was diagnosed. MR was successfully corrected by quadrangular resection of the posterior leaflet, including the prolapsed portion, and prosthetic ring annuloplasty. Histological examination showed myxomatous degeneration. The patient recovered uneventfully. During the last 2 decades, only 21 surgical cases of valvular disease associated with acromegaly were reported in the literature; mitral valve lesions in 10 patients (all with regurgitation), aortic valve lesions in 10 patients (7 with regurgitation and 3 with stenosis), and one with combined lesions of mitral and aortic valves. Since histology did not show specific changes in many reports, it is still unclear whether valve lesions are caused by a high GH hormone level. Although mitral valve replacement was recommended in the 1990s due to the fragility of valvular rings and their apparatus, mitral repair was performed in 5 recent cases and no recurrence has been reported.

A computed tomography (CT) scan was performed for a man in his 60s to investigate a continuous murmur. An 18-mm coronary aneurysm with a fistula with the pulmonary artery was found on the anterior aspect of the main pulmonary artery (MPA),and a 10-mm coronary aneurysm was found on the lateral aspect. Abnormal inflow vessels originating from the right sinus of Valsalva and the left anterior descending artery (LAD) formed a complicated network around the MPA. Although the patient was asymptomatic, the aneurysms were saccular and considered to be an indication for surgery to prevent rupture. In addition, heart failure, embolism, and myocardial ischemia could be prevented by treatment. We planned a hybrid therapy of open surgery and percutaneous coil embolization. Surgical repair was performed through a median sternotomy. The abnormal vessel originating from the right sinus of Valsalva was ligated under cardiopulmonary bypass. After cardiac arrest, the 18-mm aneurysm located on the anterior surface of the MPA was incised and the orifice of the fistula and inflow vessels were closed from the inside of the aneurysm. The anomalous vessels originating from the LAD and the 10-mm aneurysm on the lateral aspect of the MPA were located near the LAD; therefore, we avoided surgical repair of these lesions. An additional percutaneous coil embolization was performed postoperatively for the remaining lesions. A post-embolization CT scan showed no residual aneurysms or fistula. A hybrid treatment may be a useful method to reduce the risk of complications of each therapy for reliable closures of fistula and aneurysms.

During aortic arch replacement in response to an aortic arch aneurysm sealed rupture, we experienced a case in which weaning from cardio-pulmonary bypass (CPB) became difficult, and pulmonary artery stenosis developed due to expanded hematoma. A 77-year-old man was raced to our hospital due to subjective symptom of chest/back pain. With a recognition of aortic arch aneurysm and hematoma around the aneurysm, it was diagnosed as an aortic arch aneurysm sealed rupture. Even though an elective aortic arch replacement was implemented using an open stent graft, reduction in blood pressure and poor oxygenation was observed at the process of CPB weaning. As a result of intraoperative pulmonary arteriography, severe stenosis was revealed on both left and right pulmonary arteries. With placement of a self-expanding stent, weaning from CPB was successfully completed. Being transferred to other hospital on day 60 after the surgery in order to continue rehabilitation, the man visits our hospital as an outpatient on his own as of now. As it is considered to be a rare case that weaning from CPB was successfully performed by pulmonary stenting in response to progressed intraoperative pulmonary artery stenosis caused by expanded hematoma after heparin administration, the details are reported here.