A 76-year-old woman, with a history of secundum atrial septal defect (ASD) patch closure 11 years earlier, presented with loss of appetite and dyspnea. She was treated for heart failure due to aortic regurgitation (AR), mitral regurgitation (MR), tricuspid regurgitation (TR), and atrial fibrillation (Af). Upon transfer to our department, she went into shock, leading to the introduction of V-A ECMO and IABP. Emergency surgeries, including aortic valve replacement (AVR), mitral valve replacement (MVR), tricuspid valve annuloplasty (TAP), and left atrial appendage closure, were performed. A second surgery for hemostasis was necessary, and V-A ECMO was removed on the second postoperative day. Transesophageal echocardiography revealed mitral bioprosthetic valve thrombosis. The patient was treated with heparin and warfarin, resulting in improved pressure gradients and removal of IABP by the seventh day. The sternum was closed on the seventeenth day, and she was transferred to the general ward on the thirty-ninth day. This case demonstrates the effective use of anticoagulant therapy for early valve thrombosis after mitral valve replacement under V-A ECMO.

Loeys-Dietz syndrome (LDS) is a rare genetic disorder characterized by systemic connective tissue abnormalities. Among its subtypes, LDS type 3 is associated with SMAD3 gene mutations and often presents with vascular and skeletal abnormalities. Narrow chest is a relative contraindication for minimally invasive cardiac surgery (MICS), yet this approach can be advantageous in connective tissue disorders where repeated surgeries may be anticipated. A 63-year-old woman with a previously unreported SMAD3 variant was diagnosed with LDS type 3. She presented with severe mitral regurgitation due to A2-3 prolapse. Her skeletal features included a narrow chest (anteroposterior diameter: 5 cm), scoliosis, and pectus excavatum. Totally endoscopic 3D mitral valve plasty was performed via a right minithoracotomy using a 2-port, 1-window approach. Mitral repair was successfully completed using artificial chordae and ring annuloplasty. Adequate exposure was achieved despite the narrow chest by retracting the pericardium and displacing the aorta using gauze packing. The mitral valve was clearly visualized using the 3D endoscopic camera, allowing safe repair of the A2-3 prolapse with four artificial chordae and a 29-mm Tailor ring. The patient was extubated 3.5 hours postoperatively and had an uneventful recovery except for transient atrial fibrillation. She was discharged on postoperative day 13 in sinus rhythm. Totally endoscopic MICS-MVP is feasible and beneficial even in patients with challenging thoracic anatomy due to connective tissue disease. It enables chest wall preservation and minimizes surgical trauma, which is particularly advantageous for LDS patients with lifelong surgical risk.

Pharyngeal perforation is a rare but crucial complication of transesophageal echocardiography during cardiac surgery. We herein report the case of a 72-year-old man with infective endocarditis in the aortic valve, who had a poor performance status due to congestive heart failure and brain infarction. The echo probe of the transesophageal echocardiography was detected in the anterior mediastinum after median sternotomy. Pharyngeal repair after aortic valve replacement with bioprosthetic valve, following omental wrapping was performed simultaneously. The operative course was relatively good, and the patient moved to the general ward 32 days after the surgery.

A 75-year old woman in whom a left ventricular tumor had been detected by echocardiography 2 years before referral to our hospital, presented with blurry vison for one month. Acute cerebral infarction was diagnosed. We suspected that the infarction was occurred by an embolus from the intraventricular tumor, and resected it through left atrial incision. The resected tumor was 10 mm in size and it resembled a sea anemone. The tumor was pathologically diagnosed as papillary fibroelastoma. The postoperative course was good, with no recurrence for the last 18 months.

The optimal strategy for shaggy aorta syndrome has not been established, however, several case reports are published with the increase of the aged population. We report two men with shaggy aorta syndrome. The one was 75 years old with acute limb ischemia at the left popliteal artery due to the macroembolism from infrarenal Shaggy Aorta. The other was 76 years old with kidney dialysis, who had suffered from blue toe syndrome due to microembolism from the mobile plaque adhering to the infrarenal aortic wall. We successfully performed graft replacement of the abdominal aorta in order to prevent the recurrence of atheromatous embolization from the Shaggy Aorta. They have been free from any embolic event for the last 1 year. The ultrasonogram was useful for preoperative diagnosis and intraoperative management.