A 70-year-old woman who was bedridden because of right hemiplegia attributable to a history of cerebral hemorrhage underwent surgical thrombectomy for pulmonary embolism four years previously. Symptoms of heart failure appeared one year previously, and she was diagnosed with constrictive pericarditis and had been treated with medication by a previous doctor. In the current situation, she visited the previous doctor with the chief complaint of fever, and pericardial effusion was observed on echocardiography. Cardiac tamponade was suspected and she was transferred to our hospital. She was then diagnosed with purulent pericarditis because purulent fluid was observed during pericardiocentesis drainage. Bacteroides fragilis was isolated from the culture of the abscess. The abscess was resistant to conservative antibiotic therapy ; therefore, we performed a pericardiotomy with a left small thoracotomy. The pleural effusion was found to be negative for culture and the patient exhibited a good postoperative course. Purulent pericarditis is refractory with poor prognosis. An appropriate surgical procedure must be chosen considering the patient's activities of daily living. Here, we report a surgical case wherein we chose the left thoracotomy approach and achieved positive results.

A 65-year-old man with a history of severe aortic valve regurgitation had undergone aortic valve replacement (AVR) via partial upper hemisternotomy at the age of 50 years. At that time, bioprosthetic valve was implanted. Fifteen years after the valve implantation, he presented with palpitations and chest tightness. Examination revealed bioprosthetic valve failure with consequent severe aortic valve regurgitation. Redo AVR via right anterior mini-thoracotomy was decided as the treatment strategy, and the procedure was successfully completed without complications. The patient underwent extubation on the day of the operation. His postoperative course was unremarkable, and he was discharged 13 days postoperatively. In this case, the patient had previously undergone partial upper hemisternotomy (classified as a minimally invasive cardiac surgery [MICS]) and showed only few adhesions in the pericardium, suggesting that MICS could be beneficial in cases involving re-operation.

A 73-year-old woman presented with epigastric discomfort and lightheadedness. She was admitted to another hospital with congestive heart failure due to severe aortic and mitral regurgitation. However, her heart failure was refractory to medical treatment, necessitating transfer to our hospital for surgical treatment. Emergency surgery was performed for worsening heart failure after admission to our hospital. Intraoperative findings showed aneurysms of the ascending aorta and aortic root and avulsion of the aortic valve commissure between the right coronary and non-coronary cusps. Replacement of the ascending aorta and aortic root replacement using the Florida sleeve method as well as double valve replacement (mitral and aortic) were performed with a favorable outcome. Histopathological examination showed myxomatous degeneration, which suggested that it could have contributed to avulsion of the aortic valve commissure.

The first case was a 67-year-old woman. She had been given a diagnosis of fulminant myocarditis and received a biventricular assist device as a bridge to recovery. A Nipro ventricular assist device (VAD) was implanted into her left heart. She was also found to have moderate aortic insufficiency before the operation, so she received aortic valve replacement (AVR) with a bioprosthetic valve (CEP Magna Ease 21 mm) at the same time. Her cardiac function recovered gradually. Therefore, a weaning operation was scheduled for three months after the VAD implantation. However, her left ventricle motion was very poor when she was taken off of the extracorporeal circulation after removing the VAD, and transesophageal echocardiography (TEE) revealed severe bioprosthetic valve stenosis. When her heart was stopped again and the bioprosthetic valve was observed, the leaflets of the bioprosthetic valve were fused. Commissural fusion of bioprosthetic valve was able to be released using forceps, and the punnus extending under the leaflet was removed. In this way, the function of the bioprosthetic valve was restored. Her cardiac motion became good, and removal from extracorporeal circulation was easily achieved. She left the hospital 100 days after weaning from the VAD. The second case was a 68-year-old woman. She also had fulminant myocarditis. She underwent biventricular assist device implantation and AVR (CEP Magna Ease 19 mm). Her cardiac function recovered, and a weaning operation was scheduled on the 73rd-postoperative day. Preoperative TEE before the weaning of VAD showed severe bioprosthetic valve stenosis. The commissural fusion of the bioprosthetic valve was released and the punnus extending under the leaflet removed at the same time as the VAD was removed. Re-valve replacement was not required. We should therefore consider the possibility of bioprosthetic valve stenosis when VAD implantation and AVR with a bioprosthetic valve are performed at the same time in patients with an extremely reduced cardiac function.

We evaluated body constituent patterns of 130 consecutive patients with symptomatic acute cerebral infarction. They comprise lacunar infarction (n = 47), atherothrombotic infarction (n = 70), cardiogenic embolism (n = 11), and other type of infarction (n = 2). We compared body constituent patterns between them and 93 consecutive patients with other neurological diseases of the same age. We used qi-ketsu-sui scores to evaluate body constituent patterns in all cases. Qi-ketsu-sui scores measure six factors : qi deficiency (kikyo), qi stagnation (kiutsu), qi counterflow (kigyaku), blood deficiency (kekkyo), blood stasis (oketsu), and fluid retention (suitai). As a result of multivariate model analysis, symptomatic acute cerebral infarction had the largest weight of blood stasis and an adjusted odds ratio (95% confidence interval) was 4.6 (2.45-8.91). Even when gender as a confounding factor was adjusted by stratified analysis, adjusted odds ratios of blood stasis (95% confidence interval) were 7.46 (3.02-20.25) for males and 2.63 (1.02-7.11) for females, and those were maximum. The point (median, interquartile range) of blood stasis was more severe in acute cerebral infarction (24 points, 18-33 points) than other neurological diseases (16 points, 9-23 points). We examined relationships between body constituent patterns and clinical disease type, severity at hospitalization, and sex in patients with symptomatic acute cerebral infarction. Ratio of blood stasis was the largest in any clinical disease type, severity and sex. Blood stasis seemed to be the most important factor in symptomatic acute cerebral infarction.

Objective：To elucidate factors associated with physical function and clarify the actual condition of functional deterioration in patients with knee osteoarthritis (OA) prior to total knee arthroplasty (TKA)．

Methods：We enrolled 467 patients with severe knee OA and preoperatively assessed the following parameters：background factors (sex, age, BMI, K-L grade, and pain) and physical function (muscle strength of knee extensors and flexors, and knee joint angles). A multiple regression analysis was performed to determine the relationship between the independent background factors and dependent physical functions. The median of preoperative function based on selected factors of physical function was calculated.

Results：Based on the multiple regression analysis, sex, BMI, K-L grade, and pain statistically significantly correlated with muscle strength of knee extensors and flexors. Sex and BMI statistically significantly correlated with knee joint flexion angle. K-L grade statistically significantly correlated with knee joint extension angle. The median of muscle strength for knee extension was 0.98/0.92 Nm/kg (Grade 3/Grade 4) for males and 0.70/0.59 Nm/kg for females. The median of muscle strength for knee flexion was 0.53/0.45 Nm/kg for males, 0.36/0.30 Nm/kg for females. The median for knee joint flexion angle was 130° for males and 120° for females. The median for knee joint extension angle was -5°/-10° (Grade 3/Grade 4)．

Conclusion：We clarified the degree of muscle strength and range of motion before TKA in patients with knee OA. We believe that the findings obtained in this study will contribute to explaining the functional deterioration of patients with knee OA.

Left ventricular thrombus is a complication of left ventricular dysfunction, including acute myocardial infarction, cardiomyopathy, and severe valvular heart disease. Surgical removal should be considered when a thrombus is mobile, when thromboembolism occurs, and when cardiac function has the potential to improve. Two patients with left ventricular thrombus underwent totally thoracoscopic transatrial thrombectomy. A thrombus developed in the apex of the left ventricle after acute myocardial infarction in one patient (Case 1) and during treatment for congestive heart failure in the other (Case 2). The minimally-invasive transatrial approach requires no sternotomy or left ventriculotomy and is thus particularly beneficial for treating left ventricular dysfunction. Moreover, totally endoscopic surgery confers the advantage of a deep and narrow visual field. Therefore, we consider that this strategy is highly effective for treating left ventricular thrombus.