A 46 year-old man underwent double valve replacement for valve insufficiency due to infective endocarditis. Upon withdrawal from extracorporeal circulation and administration of 8 units of fresh frozen plasma, a large amount of yellow serous secretion was aspirated from the trachea, and rapid and exacerbated oxygenation was observed. We determined that the patient was not congested, based on his hemodynamics; instead, he appeared to have acquired transfusion-related acute lung injury (TRALI). The patient was given a steroid infusion. By the time the patient returned to the intensive care unit, his oxygenation capacity improved and the secretions from his trachea decreased. The patient was weaned off the ventilator on the second post-operative day. Inhaled nitric oxide was very effective in improving oxygenation. We conjectured that TRALI should be recognized as a differential diagnosis for poor oxygenation after withdrawal from extracorporeal circulation.

The frozen elephant trunk technique (FET) for the treatment of acute aortic dissection is associated with more favorable remodeling in the descending aorta compared to those patients without FET, but it may also be associated with postoperative spinal cord injury (SCI) and actually,some postoperative SCI cases after FET are reported. Several risk factors for SCI are known and one of them is due to the occlusion of intercostal arteries from false lumen. A 71-year-old woman underwent total arch replacement with FET, but after surgery, she noticed decreased movement in both lower extremities and was suspected of postoperative paraplegia. She went through cerebrospinal fluid drainage but didn't get better at all. According to the preoperative contrast computed tomography images, seven out of ten intercostal arteries were originating from the false lumen and six of them were occluded after surgery. When most of intercostal arteries are originating from the false lumen and there is no entry inside the descending and abdominal aorta, the intercostal arteries may be occluded due to thrombosis of the false lumen and it may cause spinal cord ischemia after surgery.

Anomalous aortic origin of a coronary artery is a rare congenital anomaly that can cause myocardial ischemia and ventricular arrhythmia. This disease initially manifests as cardiac arrest in half of patients. The indications and surgical strategy remain unclear, especially in patients who are asymptomatic and have poor ischemic findings. We report a surgical strategy to treat anomalous aortic origin of the right coronary artery. A 47-year-old man with a chief complaint of chest tightness was diagnosed with anomalous aortic origin of the right coronary artery, which branches from the left sinus of Valsalva and runs an inter-arterial course. Although no objective myocardial ischemia was identified with blood tests, electrocardiography, or cardiac catheterization, we suspected that the cause of the thoracic symptoms was sharp branching of the right coronary artery, which was compressed between the ascending aorta and the pulmonary artery. To reduce the risk of sudden death in the future, we performed reimplantation of the right coronary artery. Good imaging results were obtained, and the patient is currently undergoing outpatient follow up and has not experienced recurrence of chest symptoms. We conclude that our surgical strategy to treat anomalous aortic origin of a coronary artery may be useful in the clinic.

A 51-year-old woman presented with a high fever and weakness and was diagnosed with mitral valve infective endocarditis. Medical treatment was unsuccessful, and the patient developed disseminated intravascular coagulation syndrome, multiple cerebral infarctions, and massive cerebral hemorrhage. She was transferred to our hospital for surgical treatment. On admission, she had motor aphasia and right-sided hemiplegia. Echocardiography showed mild mitral regurgitation with a huge mobile vegetation measuring greater than 20 mm on the anterior leaflets. Head CT showed a huge cerebral hemorrhage in the left frontal lobe. Chest radiography revealed severe pulmonary congestion, and laboratory data showed disseminated intravascular coagulation syndrome. Despite medical treatment, the pulmonary congestion worsened. There were concerns that a fatal cerebral infarction would develop, and so urgent open-heart surgery was performed. On the day after the cerebral hemorrhage had occurred, hematoma removal and decompressive craniotomy were performed to reduce the risks associated with cardiopulmonary bypass. Four days after the craniotomy, mitral valve plasty was performed following the complete excision of the infected tissue. Heparin was administered at our normal dosage as an anticoagulant during cardiopulmonary bypass. Postoperative head CT showed no aggravation of the preoperative cerebral lesion. The patient still had symptomatic epilepsy and difficulty performing exact movements with her right hand, but she was able to walk unaided after 1 year of rehabilitation. Generally, early surgery for infective endocarditis is not recommended if the patient has concomitant cerebral hemorrhage ; our strategy may be the safest option for patients in such a serious condition.

Hypertrophic cardiomyopathy with apical aneurysm is known to have high risk of a sudden death due to ventricular arrhythmias or thromboembolisms. We report a surgical case of surgical case of this disease. A 67-year-old man was found to have abnormality in an electrocardiogram during his checkup, and subsequent careful examinations revealed his disease. He had no symptoms and the pressure gradient at the obstruction was about 30 mmHg, but there was thrombus in the apical aneurysm. After anticoagulant therapy, the thrombus dissolved. We scheduled an operation on him because he was judged to have high risk of a sudden death. In the operation, excision of the apical aneurysm, and hypertrophic midventricular myocardium were performed, concomitant with cryoablation to the border between the aneurysm and normal myocardium. Although complete atrioventricular block occurred postoperatively and he needed permanent pacemaker implantation, he was discharged from the hospital 21 days postoperatively without any other complications. He is doing well at two years and six months, postoperatively.

We report a case of type A acute aortic dissection in an elderly woman with immune thrombocytopenia (ITP) who underwent replacement of the ascending aorta and aortic arch and later required aortic root replacement for redissection of the aortic root one month after her initial surgery. She was an 86-year-old woman with severe mitral regurgitation, and surgery was contraindicated because of her age and ITP. In October 2014, the patient presented with back pain. Computed tomography confirmed the diagnosis of her condition as type A acute aortic dissection, and she was immediately transferred to our hospital. Because echocardiography showed severe aortic regurgitation, severe mitral regurgitation, and moderate tricuspid regurgitation, we performed replacement of the ascending aorta and aortic arch, mitral valve repair, and tricuspid annuloplasty. We used Bioglue to fuse the false lumen of the type A acute aortic dissection and used a Teflon felt sandwich for the proximal anastomosis technique. Respiratory support was discontinued 91 h after her first operation ; however, 30 days after surgery, she developed a to-and-fro murmur-a sign of the progression of heart failure. Echocardiography showed aggravation of aortic regurgitation, and computed tomography showed aortic root redissection ; therefore, 39 days after the initial surgery, we performed aortic root replacement. During the operation, we found the entry under the proximal anastomosis with an almost semicircle form at the right coronary cusp to the noncoronary cusp, and the dissection extended close to the right coronary artery ; thus, we performed bypass to the right coronary artery. Pathologic findings did not establish a causal association between the redissection and Bioglue, and we believed the fragility of the tissue and the selection of the surgical procedure to be the cause of redissection. The patient was transferred to another hospital when she was able to walk and eat, which was 121 days after her first operation. The patient required 50 units of platelet transfusion during her first and second operations, but her bleeding was easily controlled during surgery. She needed two procedures of pericardium drainage for pericardiac effusion and cardiac tamponade, which may relate to ITP. The diagnosis of redissection of the aortic root was made 30 days after the patient's first operation, on the basis of exacerbation of the to-and-fro murmur. Here, we emphasize the clinical importance of basic observations over time, such as auscultation, that are liable to be overlooked in the intensive care unit.

Cardiac papillary fibroelastomas are rare but are still the second most common benign cardiac tumor ; after myxoma. While cardiac papillary fibroelastomas are benign, there is the potential for severe complications related to embolism. Consequently, a surgical treatment approach is generally recommended. Nevertheless, from the risk of the recurrence of tumor and the valve insufficiency, the excision range is still controversial, particularly with tumors arising from the valve. We report the case of a 66-year-old woman who underwent resection of cardiac papillary fibroelastomas arising from three leaflets of the aortic valves. We performed simple excision without valve surgery and obtained an uneventful prognosis. At 18 months after surgery, no recurrence of tumors was recognized. We consider that it is possible to resect cardiac papillary fibroelastomas without performing valve repair or replacement if they are removed carefully even if the tumors arise from three leaflets of an aortic valve.

The patient was a 74-year-old woman who had undergone mitral valve replacement with a mechanical valve for rheumatic mitral valve stenosis at age 60. She was scheduled for aortic valve replacement for severe aortic stenosis. However, she had significantly worsening anemia before the operation. Capsule endoscopy showed angiodysplasia with bleeding in her small intestine, which was considered the cause of the anemia. Because of progressive anemia, we tried embolization under angiography. However, there was no evidence of extravasation. Neither melena nor exacerbation of anemia was observed, and she underwent aortic valve replacement. She was discharged on postoperative day 22 without gastrointestinal bleeding. Heyde syndrome is aortic valve stenosis associated with gastrointestinal bleeding induced by von Willebrand disease and angiodysplasia in small intestine. Molecular multimeric analysis of von Willebrand factor and the existence of angiodysplasia with hemorrhage of the digestive tract are important for definitive diagnosis. Capsule endoscopy, which is a general examination, is more useful for diagnosis than molecular multimeric analysis of von Willebrand factor. Aortic valve replacement is the only therapeutic option for Heyde syndrome. It is important to decide the appropriate timing of AVR with cardiopulmonary bypass.

A 31-year-old man fell into syncope caused by compression by a machine in his factory. He was taken to the nearest hospital at once for treatment. His chest X-ray seemed normal and his general condition improved. He received no medical treatment and was allowed to return home. Two days later, he went to the hospital for further investigation, and contrast-enhanced chest computed tomography (CT) was performed. Chest CT showed aortic dissection from the ascending aorta to the aortic arch. Therefore, he was admitted for bed rest with antihypertensive therapy. He was discharged on the 35th day after the accident. However, the diameter of the ascending aorta was found to have become dilated, and so he underwent ascending aorta and hemiarch replacement at our hospital. His postoperative course was uneventful, and he was discharged on the 16th postoperative day. We report a rare case of an acute aortic dissection caused by blunt chest trauma.

An 8 year-old boy had a cardiac murmur pointed out on day three after birth and was given a diagnosis of ventricular septal defect (VSD). He underwent VSD patch closure at two months after birth. He was also found the having Loeys-Dietz syndrome on the basis of mutation of TGFBR2 and physical examination at the age of 2 years. He had been followed up at pediatrics clinic of our hospital since then, and was hospitalized for a 46.5-mm extension of valsalva sinus diameter and moderate aortic insufficiency. The aortic valve was three-cusped and had no abnormality. We performed valve-sparing aortic root replacement. He was discharged on day 18 after the operation without any problems in the postoperative course. Use of an artificial heart valve for the surgery of the aortic root lesion in childhood will probably cause reoperation in the future and difficulty in Warfarin anticoagulation control. A careful decision is needed in the choice of an operation method. Valve-sparing aortic root replacement is a useful operation for patients without aortic valve abnormality.