A 79-year-old woman, who had undergone mitral valve replacement with a Björk-Shiley valve 16 years previously, was transferred to our institute due to active prosthetic valve infection associated with severe heart failure on respirator. On admission, her white blood cells and c-reactive protein (CRP) were elevated to 15,700/µl and 7.29 mg/dl, respectively, and she had anemia (hemoglobine 8.1 g/dl), thrombocytopenia (platelets 75,000/µl), and renal dysfunction (blood urea nitrogen 57 mg/dl, creatinine 1.8 mg/dl, estimated glomerular filtration rate 21.5 ml/min/1.73 m²). Her brain natriuretic peptide was elevated to 456.7 pg/dl. Blood culture revealed bacteremia with Streptococcus agalactiae. Though CT scan revealed cerebellum infarction, we decided to perform emergency surgery because of uncontrollable infection and heart failure, even with massive infusion of catecholamine and respiratory support. At surgery, huge vegetation proliferated over the prosthetic valve. The prosthetic valve was detached from approximately two-thirds of the annulus due to an annular abscess. The infected annulus was resected aggressively. Mitral annulus was reconstructed and reinforced with a bovine pericardial patch, and the bioprosthetic valve of 23 mm in size was implanted in an intra-annular position. In the postoperative phase, antibiotics (ampicillin, gentamicin) was given, and CRP became negative 47 days postoperatively, and the patient discharged from the hospital 56 days after the operation.

Objective : To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. Methods : Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. Results : The median age of the patients was 15.5 years (range : 9-38 years). The patients had a mean body surface area of 1.48±0.3 m² (range : 1.00-1.92 m²). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3 (modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months (range : 1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0 mmHg preoperatively to 27.9±7.7/14.8±4.7 mmHg postoperatively and to 28.3±11.1/14.1±7.0 mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4 g preoperatively to 179.7±61.1 g postoperatively and to 100.4±76.3 g at intermediate-term follow-up, respectively. Conclusions : Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.

A 76-year-old woman presented because of bilateral lower-extremity edema and dyspnea. Transthoracic echocardiography revealed a mobile mass in the right atrium. A right atrial mass associated with heart failure was diagnosed. Surgery was performed. Intraoperative transesophageal echocardiography showed that the mass was contiguous with the inferior vena cava. However, the primary lesion was unclear. Therefore, only the intracardiac mass was resected. The margins of the residual tumor were marked with clips. Computed tomography performed immediately after surgery revealed a clip in structures contiguous with the region from a uterine myoma to the inferior vena cava. Intravenous leiomyomatosis was diagnosed on histopathological examination of the resected specimens. Computed tomography 6 months after surgery showed that the clip had moved from the inferior vena cava to a vein contiguous with the uterus. The tumor regressed slightly. Close follow-up is required.

The patient was a 39 -year-old woman. Malignant rheumatoid arthritis was diagnosed when she was 32 years old, and the patient was treated with oral steroids. She presented at our center with sudden precordial pain. Coronary angiography revealed severe stenosis of the left main coronary artery (segment 5, 99%). Acute myocardial infarction and pulmonary edema were diagnosed. The patient underwent off-pump coronary-artery bypass grafting, with anastomosis of the left internal thoracic artery to the left anterior descending artery. One year 3 months later, the patient was readmitted to the hospital because of recurrent angina pectoris and heart failure. Coronary angiography showed patency of the left internal thoracic artery and severe stenoses of the left main coronary artery(segment 5, 100%), circumflex artery (segment 11, 99%), and right coronary artery (segment 1, 90%), suggesting angiitis. On-pump coronary-artery bypass grafting was done, with anastomosis of the right internal thoracic artery to the right coronary artery (segment 2) and the gastro-omental artery to the obtuse marginal branch (segment 12). The patient is being followed up on an outpatient basis. There are few reports describing patients with rheumatoid arthritis who underwent coronary artery bypass surgery. However, the most common cause of death in patients with rheumatoid arthritis is coronary-artery disease. Although the patient was still young, coronary-artery disease progressed rapidly. Such rapid progression was attributed to difficulty in controlling the inflammatory response after initial surgery, as well as to changes in vascular endothelial cells caused directly by treatment with steroids. Possible adverse effects of such treatment should be carefully considered.

A 83-year-old woman suffered pulseless-electrical-activity (PEA) because of cardiac tamponade after acute myocardial infarction with blow-out type cardiac rupture. Immediately median sternotomy was performed and active bleeding from the postero-lateral wall was found. It was impossible to stop bleeding only by putting pressure on the aperture of the myocardium with a piece of TachoComb coated with gelatin-resorcinol-formaldehyde (GRF) glue, however, the chemical action of GRF glue made the delicate myocardium after acute infarction stronger and we managed to stop that bleeding with mattress sutures that had initially seemed to be impossible. She was discharged on POD 103 uneventfully. We think this is a useful and safe operation procedure for blow-out type cardiac rupture.

A 74-year-old woman presented with shortness of breath. Cardiac ultrasonography showed that left-ventricular-wall motion was good (left ventricular ejection fraction, 70.2%). The left atrium and ventricle were enlarged (left anterior dimension, 53.4mm; left ventricular enddiastolic dimension, 58.5mm). The posterior cusp of the mitral valve was thickened; the flexibility was decreased. Color Doppler ultrasonography revealed a regurgitant jet toward the posterior cusp of the left atrium. However, there was no deviation of the anterior cusp. Severe mitral-valve insufficiency was diagnosed, and surgery was performed. The second heart sound (P2) of the posterior cusp was shortened because of localized calcification of the posterior mitral annulus. This site may have caused the regurgitation. Mitral annuloplasty with rectangular resection of the valve cusps and annulorrhaphy was performed. The patient had an uneventful recovery after surgery. Postoperative cardiac ultrasonography showed that mitral-valve insufficiency had improved and was regarded as trivial. Mitral annuloplasty is generally considered unsuitable for mitral-valve insufficiency with calcification of the valve annulus. In patients such as the present case who have localized calcification, however, mitral annuloplasty can be performed by resection of the valve cusps with annulorrhaphy.

A 61-year-old man admitted to another hospital because of cerebral infarction had fever (about 39°C). Computed tomographic scanning revealed a pseudoaneurysm of the brachiocephalic artery, accompanied by pericardial fluid. The patient was transferred to our hospital. Culture studies of a sample of pericardial fluid revealed Staphylococcus aureus. A mycotic pseudoaneu-rysm of the brachiocephalic artery was diagnosed. Antibiotics were given for about 2 weeks after transfer to our hospital. Surgery was performed after the inflammation subsided. The pseudoaneurysm was incised during circulatory arrest. A hole measuring 2cm in diameter was found at the origin of the brachiocephalic artery. The hole was sealed with an autologous arterial patch, made from a 3-cm section of the right axillary artery. The axillary artery was reconstructed by end-to-end anastomosis. After surgery, infection was controlled by means of systemic antibiotics and closed mediastinal lavage. The patient was discharged from the hospital in good condition 160 days after surgery. To date, there has been no flare-up of infection.

A 76-year-old woman with Stanford type A acute aortic dissection underwent replacement of the ascending aorta with the use of gelatin-resorcin-formalin glue. The patient suffered sudden cardiogenic shock at home 15 months after surgery and was admitted to the Emergency Center of our hospital. A series of examinations revealed an aortic-root pseudoaneurysm associated with anastomotic disruption. Cardiogenic shock caused by obstruction of the ascending aortic graft due to anastomotic disruption was diagnosed. An intraaortic balloon pump (IABP) was inserted, and the patient's circulatory status improved. On the following day, reanastomosis of the aortic root graft was performed. On day 32 after surgery, the patient was discharged from the hospital in good condition. IABP can stabilize circulatory status and improve cardiogenic shock in the short term in patients with an aortic-root pseudoaneurysm caused by narrowing of the graft lumen, as in the present patient. IABP may thus be a useful ancillary measure before radical operation.

In the postoperative treatment of ruptured abdominal aortic aneurysm surgery, the relationship between intra-abdominal pressure (IAP) and the clinical course is not been clearly understood. From April 2000 to January 2003, we treated 109 cases of abdominal aortic aneurysm surgery (non-rupture 71 cases, rupture 38 cases) and measured intra-abdominal pressure in 30 of the ruptured cases which we analyzed in this study. The patients were divided into 2 groups. The H-group included 12 patients with maximum IAP equal to or higher than 20mmHg, and the L-group included 18 patients with a maximum IAP less than 20mmHg. Clinical characteristics were compared between the 2 groups. The mean age was 79.3±7.6yr in the H-group and 70.7±10.1yr in the L-group (p=0.019). Preoperative shock was diagnosed in 83.3% of the H-group patients, and 61.1% of the L-group patients the (p=0.26). Postoperative maximum values of intra-abdominal pressure were 22.3±2.0mmHg in the H-group, and 15.4±2.4mmHg in the L-group. Duration of intubation was 87.7±110.0h in the H-group, and 25.1±29.2h in the L-group (p=0.04). Food intake was started 14.4±11.2d after surgery in the H-group, and 8.5±4.8d after surgery in the L-group (p=0.094). The length of ICU stay was 6.7±6.5d in the H-group, and 2.9±2.1d in the L-group (p=0.033). Length of hospital stay after surgery was 54.1±25.8d in the H-group, and 25.2±6.8d in the L-group (p=0.001). Complications occurred in 8 cases out of 11 surviving cases (73%) in the H-group, and in 3 cases out of 17 surviving cases (18%) in the L-group (p=0.0024). Complication in the H-group included acute renal failure, paralytic ileus, respiratory failure, abdominal wall dehiscence, and acute arterial occlusion, and that in the L-group included acute renal failure, upper limb paresis, and lower limb paresis. Monitoring of intra-abdominal pressure was considered beneficial to recognize complication and decide therapeutic strategy after ruptured aortic aneurysm surgery.

Fourteen patients with 22 solitary aneurysms of the iliac artery were operated in a 16-year period (1983 to 1999). Patients were divided into two groups. The non-ruptured group consisted of 6 patients who underwent surgical intervention before aneurysm rupture, and their mean age was 78.5 years. The ruptured group consisted of 8 patients who underwent surgical intervention for aneurysm rupture, with a mean age of 68.5 years. Although seven patients underwent emergency surgery for aneurysm rupture, less than half of them were operated upon within 24hr after the onset of aneurysm rupture. The average size of aneurysms was similar in the two groups (common iliac artery aneurysms: non-ruptured 47mm vs. ruptured 44mm in diameter, internal iliac artery aneurysms: non-ruptured 55mm vs. ruptured 55mm). Two patients died in the ruptured group, in which the operative mortality rate was 25%. Six patients (75%) of the ruptured group had hypovolemic shock, and two of them died during surgical repair. Of the patients with shock, two patients had intestinal ischemia after operation. Intestinal ischemia was one of the serious complications of ruptured iliac aneurysms. These results suggest that in patients with shock from ruptured iliac artery aneurysms, strategy for treatment is an important determinant of the outcome.