Backgrounds: Previously, we routinely removed pacemaker wires (PW) one week after heart valve surgery, however, we have changed to remove PW on the second postoperative day in order to prevent retrograde infection. The purpose of this study was to clarify the clinical benefits of earlier PW removal. Subjects/Methods: Overall 133 patients were reviewed and a comparative study was conducted between the two groups; late group (n=48) and early group (n=85). Results: There were no significant differences in age, gender, body physique, diabetes, preoperative dialysis, operation time, cardiopulmonary bypass time, or cross-clamp time between the two groups. C-reactive protein was significantly lower in the early group at both 1 and 2 weeks postoperatively, Leukocyte was also significantly lower in the early group at 2 weeks, and the frequency of fever of 38 degrees Celsius or higher, frequency of additional antibiotic treatment, and the frequency of diagnosis of postoperative infection were also significantly lower in the early group. Platelet counts on the day of removal were significantly lower in the early group, however PT-INR was significantly lower in the early group, and the frequency of pericardial drainage tended to be lower in the early group. Among the cases in the early removal whose PW were removed on the second day, only one patient required pacing for transient complete atrioventricular block during hospitalization. Conclusions: After valve surgery, in patients who did not require pacing by the second postoperative day, removing the pacemaker wires on the second day might prevent postoperative infection, without increasing the need for pericardial drainage or a temporary pacing catheter. It was considered appropriate to remove the lead on the second postoperative day in cases where pacing was not required until the second postoperative day.

A 72-year-old woman with multiple comorbidities was diagnosed with severe aortic stenosis (AS) and mitral stenosis (MS). Contrast-enhanced computed tomography revealed remarkable calcification of the annulus from the posterior leaflet to the posterior commissure. Considering the potentially fatal complications associated with excising the calcification, chimney mitral valve replacement (MVR) was performed. Furthermore, aortic valve replacement was performed for severe AS. Transthoracic echocardiography 14 months after surgery revealed normal valve motion and no perivalvular regurgitation. Thus, chimney MVR was deemed useful for MS with severe mitral annular calcification, as in this case.

The patient was a 78-year-old man who presented with dyspnea and decreased SpO₂ in the sitting and standing positions. Transthoracic echocardiography revealed a patent foramen ovale (PFO), and a microbubble test showed Grade 1 in the supine position and Grade 4 in the sitting position, suggesting an increase in shunt volume when seated. Chest CT revealed age-related kyphosis and right atrial compression by the ascending aorta. The patient was diagnosed with platypnea-orthodeoxia syndrome (POS) due to PFO, and a PFO closure was performed using minimally invasive cardiac surgery (MICS). The postoperative course was favorable, and the patient was discharged on the 20th postoperative day. Although percutaneous device closure is generally performed for PFO closure, MICS was useful in this case due to the anatomical unsuitability caused by an atrial septal aneurysm.

The patient was a 59-year-old man who had undergone aortic valve replacement with a mechanical valve for aortic stenosis eight years ago. Six months ago, he developed complete atrioventricular block and underwent pacemaker implantation. One day before admission, he presented to a local clinic with complaints of dyspnea and chest pain. Suspecting acute myocardial infarction, he was referred to our hospital for further evaluation and was subsequently admitted. On admission, he exhibited fever and elevated inflammatory markers. Transthoracic echocardiography and computed tomography revealed vegetations on the prosthetic valve and an annular abscess with aneurysmal dilatation of the sinus of Valsalva. Based on these findings, prosthetic valve endocarditis was diagnosed, and semi-urgent surgery was performed. Intraoperatively, numerous vegetations were found attached to the prosthetic valve annulus, and the annular abscess had extensively invaded the myocardium circumferentially. Aneurysmal dilatation of the sinus of Valsalva was observed, especially around the left and right commissures. After debridement of the abscess cavity, it was determined that Bentall procedure was not feasible due to extensive annular destruction and fragility of the surrounding myocardial tissue. Therefore, we opted for a root reconstruction using the “graft insertion technique” as described by Nakamura et al. A 5-cm length of tube graft was inverted and inserted from the aortic root into the left ventricular outflow tract (LVOT). Nine mattress sutures using 3-0 polypropylene with pledgets were placed from inside the graft through the LVOT, with external reinforcement using a Teflon felt strip, followed by continuous suturing for added security. The intraventricular portion of the graft was pulled out through the LVOT and trimmed. A preconstructed composite graft was then anastomosed to the trimmed end. The right coronary artery was reimplanted using the button technique. The left coronary artery was injured during dissection of adhesion and could not be reimplanted; therefore, a bypass from the great saphenous vein to the left anterior descending artery was performed. Despite the loss of healthy annular tissue due to complete debridement of the infected valve and myocardial abscess, the reconstruction of the aortic root was successful without the need for additional hemostatic sutures. The “graft insertion technique，” though not yet widely established, offers a valuable approach for reconstructing severely damaged and fragile aortic roots in the setting of prosthetic valve endocarditis. It allows for safe and reliable surgical repair even in challenging anatomical conditions.

In cases complicated with immune thrombocytopenic purpura (ITP), the perioperative period in which cardiopulmonary bypass is used may pose a problem due to a rapid decrease in platelet count. In this case, we performed myxoma resection and a Maze procedure on a patient with a left atrial myxoma and atrial fibrillation who was receiving eltrombopag therapy under an ITP diagnosis. Initially, because the cardiology department suspected a left atrial thrombus caused by atrial fibrillation, eltrombopag administration was discontinued and anticoagulation therapy initiated; however, an episode occurred in which the platelet count precipitously fell from 192,000/μl to 71,000/μl over six days. Therefore, a plan was devised preoperatively to ensure stable continuation of ITP treatment, which involved administering a high-dose infusion of intravenous immunoglobulin (IVIG) preoperatively and using subcutaneous injection of romiplostim on the day of surgery. Due to the potential for excessive platelet elevation depending on the timing of eltrombopag reinitiation, the drug was restarted and adjusted at the point when a postoperative decline in platelet count was observed. The operation and postoperative course proceeded with good control and without significant bleeding. Although the patient had a history of sick sinus syndrome noted during preoperative internal medicine admission, postoperative bradycardia persisted; as a result, the patient underwent pacemaker implantation on postoperative day 23. The patient was unaffectedly discharged on postoperative day 34.

The patient is a 15-year-old female who initially presented to our hospital at the age of 6 with complaints of tachycardia. However, no significant abnormalities were identified, and she was subsequently placed under observation. At the age of 7, the patient developed symptoms including headache, chest pain, and absent pulses, accompanied by a pronounced inflammatory response. A thorough diagnostic evaluation was performed, which led to the diagnosis of Takayasu’s arteritis. At that time, computed tomography (CT) imaging revealed a fusiform aortic aneurysm with a maximum short axis diameter of 34 mm, extending from the ascending aorta to the proximal aortic arch. Under vigilant monitoring, by the age of 15, the maximum short diameter had increased to 45 mm, demonstrating progressive enlargement over time. Following a multidisciplinary discussion of treatment options in a heart team conference, it was determined that surgical intervention was warranted. Given that the patient was receiving maintenance therapy for a relapse of arteritis, the dose of prednisolone was reduced to 4 mg prior to performing an ascending partial arch aortic replacement. The postoperative course was uneventful, and the patient was discharged on postoperative day 13. She continues to receive maintenance therapy and undergoes regular CT scans at the outpatient clinic. Childhood-onset Takayasu’s arteritis is exceedingly rare, but with timely surgical intervention and sustained disease management, an improved long-term prognosis can be anticipated.

Currently, thoracic endovascular aortic repair (TEVAR) is recommended for type B aortic dissection to reduce long-term aneurysmal progression and lethal aortic events, however, preoperative risk and managements are still unclear. In this report, we present a case of recurrent embolic cerebral infarction associated with stent graft-induced new entry tear (SINE), which required additional surgical treatment. The patient was a 61-year-old male who underwent Zone 3 TEVAR 34 days after the onset of acute type B dissection. Over the course of approximately 1.5 years, he experienced six episodes of recurrent embolic cerebral infarction. A follow-up contrast-enhanced CT scan revealed migration of the stent graft to the distal side and a SINE (stent-induced new entry) in the left subclavian artery distal to the major curvature. Furthermore, a 4D-MRI showed retrograde blood flow from the proximal end of the stent graft extending to the brachiocephalic artery. Therefore, the patient underwent ascending aortic arch replacement with an open stent graft technique. False lumen thrombus caused by SINE in the distal aortic arch has potential risk of repeat cerebral infarction. Early and precise diagnosis, as well as preventive treatment strategies are warranted.

A 78-year-old male was referred to our facility due to persistent fever and arthralgia. Transesophageal echocardiography revealed fragile vegetations measuring 26 mm in length attached to the mitral valve (MV), along with severe mitral regurgitation. Magnetic resonance imaging showed multiple cerebral infarctions. He also had an abscess at his left sternoclavicular joint caused by Streptococcus agalactiae, which was identical to the strain identified in his blood culture. He was diagnosed with active infective endocarditis due to Streptococcus agalactiae and severe mitral regurgitation. To prevent postoperative mediastinitis, which could be a complication of median sternotomy in the presence of a left sternoclavicular joint abscess, he underwent urgent minimally invasive mitral valve surgery. Intraoperative Findings: The MV exhibited massive vegetation and partial valve destruction on the medial side of P2 and throughout P3, along with an annular abscess. The MV and annular abscess were debrided down to the left ventricular muscular layer. Mitral valve replacement was performed with reconstruction of the mitral posterior annulus using a bovine pericardial patch. The postoperative course was uneventful, and the left sternoclavicular joint abscess diminished with intravenous antibiotic therapy. He was discharged on the 36th day after surgery, and no relapse has been observed.