A 76-year-old female was admitted with complaints of dyspnea on exertion and lower leg edema. She had undergone an aortic valve replacement thirty-nine years before and a redo aortic valve replacement and mitral valve replacement twenty-eight years before. She also had hemolytic anemia with jaundice. Echocardiography showed severe paravalvular leakage in the aortic and mitral valves, and a blood flow in the aortic annulus that flows from the aortic side into the left atrium. We diagnosed heart failure and hemolytic anemia due to paravalvular leakage and decided to perform a double-valve replacement for the third time. On operation, after removing the aortic valve through aortotomy, aorto- mitral fibrous continuity was extensively calcified and perforated, and its strength was not enough to sew the prosthetic valve to it. Therefore, we decided to perform the Commando procedure. Aortotomy was extended between the noncoronary aortic sinus and the left coronary aortic sinus until it reached the dome of the left atrium. After the prosthetic mitral valve was excised, annuloplasty of the posterior mitral annulus was performed using a bovine pericardial patch, and the new prosthesis mitral valve was implanted. The anterior part of the annulus corresponding to the aorto-mitral fibrous continuity was reconstructed by sewing the base of a two-tongued triangular bovine pericardial patch to the sewing cuff of the mitral prosthesis. After closing the left atrial ceiling with the posterior patch, the aortic prosthesis was secured to the aortic annulus and the pericardial patch. The anterior patch was used to close the right side of the aortotomy. The postoperative course was uneventful, and postoperative echocardiography revealed no paravalvular leakage.

The patient is a 39-year-old-man who had rheumatic heart disease and had undergone mitral and aortic valve replacements with mechanical St. Jude prostheses as well as tricuspid valve repair and a MAZE procedure 17 years previously. He was admitted with ventricular tachycardia (VT) and an implantable cardioverter-defibrillator (ICD) was implanted. Four months later, he was admitted again with VT, and attempts to manage the VT with drugs were not successful. We performed electro-anatomical mapping and ablation for VT by re-median sternotomy. His postoperative course was uneventful. At 15 months after surgery, no recurrence of VT was recognized.

A 71-year-old female, who had diabetes mellitus and chronic renal failure on dialysis, had undergone mitral valve repair and tricuspid valve annuloplasty. Five months after the operation, she suffered from infectious endocarditis and underwent mitral valve replacement. Postoperatively, a total fluid volume of 300 to 600 ml/day was drained from the pericardial tube, and its appearance became milky after the start of oral intake of food. She was diagnosed with chylomediastinum. Despite fasting and total parenteral nutrition for 2 weeks and subcutaneous octreotide administration, the volume of fluid drainage was not reduced. Therefore, we planned lymphangiography treatment with Lipiodol on postoperative day 37. On operation, under local anesthesia, the left inguinal lymph node was punctured under ultrasound guidance, and Lipiodol was injected at a rate of 12 ml/h for 1h. On the next day, the volume of fluid drainage was reduced, and the pericardial tube could be removed 9 days after lymphangiography.

Methods: We retrospectively evaluated 54 hands of 40 girls with AIS who visited Nara Medical University Hospital from 2000 to 2015 using previously collected radiographs. The examiners included a spine surgeon and a pediatric orthopedic surgeon, each with over 10 years of experience. The reliability of the DRU and sTW3 was evaluated using the kappa coefficient. Results: The left-hand radiographs of 40 female patients with AIS (mean age, 13.9±1.7 years; N=54 hands) were evaluated by two blinded examiners using the sTW3 and DRU methods. The highest inter-observer and intra-observer reliabilities (kappa, 0.64 and 0.62, respectively) for radius evaluation were determined. Radius evaluation by the DRU showed the highest agreement rate and smallest error between the inter- and intra-observer examinations. Conclusions The DRU was the most reliable assessment tool, and it has the potential to be useful for precisely determining the stage of skeletal maturity in outpatient clinics.

A 71-year-old man who had undergone repair of a ruptured abdominal aortic aneurysm with a tube graft 3 months ago was transferred from another hospital with an Aortoenteric Fistula (AEF) for surgical treatment. Computed tomographic (CT) angiography revealed pseudoaneurysm formation at the proximal anastomotic site. Waiting for the elective operation, he developed massive hematemesis with shock. Endovascular stent-graft repair was emergently performed because of high risk for conventional open surgery. Gastrointestinal bleeding was successfully controlled. The psuedoaneurysm disappeared, which was confirmed by postoperative CT angiography. At 1-year follow-up, he has shown no clinical and radiographic evidence of recurrent infection or bleeding. For the case with shock, Endovascular repair could be a bridge to open surgery because it is fast and minimally invasive. Endovascular repair of AEF is technically feasible and may be the definitive treatment in selected patients without signs of infection and gastrointestinal bleeding.

We reported a 74-year-old female complicated by ostial obstruction of the left main trunk after aortic valve replacement for severe aortic stenosis. At surgery, the length from the orifice of the left main trunk to the aortic annulus was 3 mm. After a 19 mm Carpentier-Edwards PERIMOUNT MAGNA was implanted in supra-annular position, the orifice of left main trunk was concealed by a sewing cuff of the bioprosthesis. Before aortic declamping, saphenous vein graft was bypassed to the left anterior descending artery. The postoperative course was uneventful. Computed tomography demonstrated the ostial obstruction of the left main trunk by the bioprosthesis.

A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO₂, low level of PaO₂ and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/l and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.

A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. Klebsiella pneumoniae was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus.

An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.

A 70-year-old-woman was admmitted to receive an operation for aortic arch aneurysm. Total arch replacement was carried out under deep hypothermic circuratory arrest with selective cerebral perfusion. During sternal closure, her blood pressure dropped to 60/30mmHg suddenly, and massive venous bleeding started from the substernal space which turned out to be hemorrhage from the laceration of the pulmonary trunk. Controlling the bleeding by finger compression, rapid introduction of cardiopulmonary bypass was carried out and the laceration was closed by a pericardial patch. The postoperative course was uneventful. In this case, compression of the pulmonary trunk by the aortic arch aneurysm may have caused the fistula formation between them, and decompression of the aneurysm probably induced the rupture of the pulmonary trunk. If the preoperative computed tomogram had showed the compression of the pulmonary artery by the aneurysm, a careful exploration of the main pulmonary artery and a removal of the thrombus should have been performed, even when the preoperative diagnostic evaluation failed to reveal aortopulmonary fistula.