[Infective Endocarditis Caused by Abiotrophia defectiva Required Double-valve Replacement Using the Manouguian Procedure].

A 39-year-old man was presented with infective endocarditis caused by Abiotrophia defectiva. Transesophageal echocardiography revealed extensive vegetation and destruction extending from the aortic valve to the aortic-mitral curtain and mitral valve accompanied by severe regurgitation of the aortic and mitral valves. After removal of vegetation, double-valve replacement were performed with double patch and mechanical prosthesis using the manouguian procedure.

[Longitudinal Direct Closure of Mitral Anterior Leaflet Large Perforation for Infective Endocarditis:Report of a Case].

A 65-year-old man was presented with infective endocarditis of mitral valve. Echocardiography revealed severe mitral regurgitation and moderate aortic regurgitation. The aortic regurgitant jet directed toward the mitral anterior leaflet, so thickening and perforation of the anterior leaflet of the mitral valve were observed. In addition, Staphylococcus epidermidis was detected in blood culture. After infection control, aortic valve replacement and mitral valve repair was performed. A 17 mm diam-eter perforation of the anterior mitral leaflet were closed directly and longitudinally with 5-0 prolene polypropylene suture and mitral valve regurgitation was controlled. Primary closure was simple and effective for anterior mitral leaflet perforation.

[Transthoracic Endovascular Aortic Repair for Malperfusion after Ascending Aortic Replacement for Stanford Type A Acute Aortic Dissection;Report of a Case].

A 53-year-old man was presented with Stanford type A acute aortic dissection. We first performed emergency ascending aortic replacement under selective cerebral perfusion with moderate hypothermia. He developed abdominal pain after the surgery. Six days after the 1st surgery, computed tomography revealed that the new entries were located in the distal anastomosis site and the distal aortic arch, and the true lumen of the aorta was obstructed by the false lumen and stenosis. Visceral malperfusion was diagnosed and emergent total debranching thoracic endovascular aortic repair (TEVAR) was planned. One proximal covered stentgraft and 2 distal bare stents were deployed.

A Case of Cardiogenic Stroke After Thoracoscopic Left Atrial Appendectomy.

Thoracoscopic left atrial appendectomy is a minimally invasive procedure for left atrial appendage occlusion in patients with non-valvular atrial fibrillation, particularly those at a great risk for both stroke and bleeding despite appropriate oral anticoagulant therapy. It serves as an alternative strategy for stroke risk reduction. Moreover, the oral anticoagulant therapy can be discontinued after the operation. However, we encountered a 74-year old male patient who developed cardiogenic stroke after thoracoscopic left atrial appendectomy. We report this case to introduce how we evaluate the risk of postoperative cardiogenic stroke by means of contrast-enhanced cardiac computed tomography (CT), and how we formulate the postoperative patient management strategy including short-term oral anticoagulation therapy by using results of cardiac CT.

[Relapse of Mitral Regurgitation Due to Tethering after Valve Plasty with Edge-to-edge Repair;Report of a Case].

A 75-year-old woman with severe mitral regurgitation (MR) successfully underwent mitral valve plasty with edge-to-edge plasty and commissural annuloplasty. Three days after the operation, she was found to have moderate MR caused by tethering of the valve. Functional MR occurring as a complication of mitral edge-to-edge plasty could be treated conservatively.

[Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair;Report of a Case].

A 72-year-old man presented with aneurysms of the distal aortic arch and the distal descending aorta due to chronic type B aortic dissection. We first performed thoracic endovascular aortic repair (TEVAR) in the distal descending aorta, and the aneurysm was successfully excluded using a Gore Tag stentgraft. Seven days after TEVAR, computed tomography revealed retrograde type A aortic dissection occurring from the ascending aorta to the distal aortic arch. In emergency surgery, ascending aorta and total arch replacement were performed under selective cerebral perfusion with moderate hypothermia, and after coming off cardiopulmonary bypass, the distal aortic arch aneurysm was excluded using a Gore Tag stentgraft.

[Thoracoscopic Left Atrial Appendectomy for a Patient with Thrombus in the Left Atrial Appendage after Anticoagulation Therapy;Report of a Case].

Thoracoscopic left atrial appendectomy for patients with non-valvular atrial fibrillation has been suggested as a new approach for preventing cardiogenic thromboembolism. While this procedure is effective in patients who suffer from thromboembolism even with anticoagulation therapy, it is contraindicated in patients with an existing left atrial appendage thrombus. We herein report a case of 61-yearold female with atrial fibrillation and recurrent cardiogenic thromboembolism. Left atrial appendage thrombus had been detected even under anticoagulation therapy. We decided to strengthen anticoagulation therapy and successfully resolved the left atrial appendage thrombus. Thus, thoracoscopic left atrial appendectomy was performed safely, and thromboembolism has never occurred since the operation.

A rare case of axillobifemoral bypass graft infection caused by Helicobacter cinaedi.

Helicobacter cinaedi infection is rarely encountered in nonimmunocompromised patients. We report the case of an 85-year-old man who presented with axillobifemoral bypass graft infection caused by Helicobacter cinaedi. The patient was not immunocompromised. We successfully treated him by iliac stenting of the native iliac artery, with near-total removal of the infected graft. At present, 48 months later, the patient is doing well at home, with no evidence of infection. To the best of our knowledge, this is the first report of infection of a prosthetic graft caused by Helicobacter cinaedi.

[Combined Open and Endovascular Repair of Multiple Aortic Aneurysms due to Syphilitic Aortitis].

The patient was a 69-year-old man who presented with low-grade fever and appetite loss. Thoracoabdominal computed tomography revealed multiple aneurysms in the distal arch and descending thoracic and infrarenal aortic regions combined with a right common iliac artery aneurysm. After endovascular stent grafting for a right iliac artery aneurysm, he underwent total arch replacement and open stent grafting for the descending thoracic aneurysms. Pathological microscopic examination revealed an inflammatory infiltrate within the adventitia and destruction of the elastic fibers in the media, which are classical features of syphilitic aortitis. Endovascular aneurysm repair is contraindicated in mycotic infected aneurysms. However, endovascular repair is useful for treating mycotic infected aneurysm, if multiple aneurysms have the possibility of rupture and a high risk of surgery.

[DeBakey type 2 Aortic Dissection Failed to Diagnose by Enhanced Computed Tomography;Report of a Case].

An 81-year-old woman presented with dyspnea and chest pain. A plain chest X-ray revealed widening of the mediastinum and a contrast-enhanced chest computed tomography showed dilatation of the ascending aorta without any specific findings of aortic dissection. Transesophageal echocardiography revealed severe aortic regurgitation (AR). We planned an aortic valve replacement on the 34th day after admission because of the severe AR. During the operation, we found an entry in the intima of the ascending aorta 5 mm above the aortic valve and she was diagnosed with DeBakey type II aortic dissection. Therefore, we decided to perform Bentall's operation and the operation was successful.

[Vacuum-assisted Closure (VAC) Treatment for Sternal Infection in a Patient after Cardiovascular Surgery; Report of a Case].

One year ago, a 42-year-old woman underwent aortic root replacement because of a pseudoaneurysm that developed at the site of an anastomosis after ascending aortic replacement for acute aortic dissection. Six months later, she complained of fever and cough. A computed tomography revealed recurrence of the peudoaneurysm at the proximal anastomosis of the aortic root replacement. After emergency re-do aortic root replacement, she was admitted to intensive care unit (ICU) without sternal closure because of mediastinitis. The mediastinitis was managed by debridement and lavage drainage, followed by vacuum-assisted closure (VAC) treatment. The VAC treatment facilitated wound healing and active rehabilitation using a portable device. Finally, the wound was closed completely using a skin graft. VAC treatment is considered very useful in a case of post-sternotomy madiastinitis.

Conservative therapy as a primary treatment for spontaneous isolated dissection of the superior mesenteric artery.

BACKGROUND: Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare and potentially fatal disease. Several therapeutic options are available, including conservative therapy, endovascular repair, and open surgery. Herein, we report our experiences in the treatment of SIDSMA. METHODS: Between February 2009 and June 2013, 17 patients were diagnosed as having SIDSMA. We retrospectively reviewed and analyzed their clinical characteristics, medical history, risk factors, symptoms, diagnostic imaging modality, treatment, and outcome. The lesions were categorized according to the modified Sakamoto's classification. If no evidence of bowel necrosis or arterial rupture was present in the patients with symptomatic SIDSMA, we first performed conservative therapy, even if the patients had abdominal pain. RESULTS: The subjects included 15 men and 2 women, with a median age of 62.8 years. Eight patients were symptomatic and 9 were asymptomatic. Conservative therapy included the use of antithrombotic agents in 3 patients but not in 5 patients. During the follow-up period (mean, 21.1 months), all the patients were discharged without any significant complications, and none of the patients showed the progression of the dissection on follow-up computed tomography angiography examinations. CONCLUSIONS: Conservative therapy without antithrombotic agents should be the primary treatment for SIDSMA. Endovascular repair for SIDSMA is associated with several risks, thus the procedure might occasionally be useful and necessary.

Early heparin administration attenuates tissue factor-mediated thrombin generation during simulated cardiopulmonary bypass.

BACKGROUND: We tested the hypothesis that heparin administration prior to the emergence of tissue factor (TF) would increase plasma TF pathway inhibitor (TFPI) and attenuate TF-mediated thrombin generation during simulated cardiopulmonary bypass (CPB). METHODS: Human blood was recirculated for 120 minutes using an oxygenator and roller pump. Four groups were examined: control group (heparin 3.75 U/mL, in donor blood, n = 7), rTF group (heparin + recombinant TF 1000 pg/mL, in donor blood, n = 7), TFPI boost group (heparin, in preheparinized donor blood, n = 8), and rTF + TFPI boost group (heparin + rTF, in preheparinized blood, n = 7). In the two TFPI boost groups, 50 U/kg of heparin was given to the donors intravenously five minutes before donation to boost plasma TFPI levels. Total plasma TFPI, thrombin-antithrombin complex, and prothrombin fragment F1+2 levels were measured before and during CPB. RESULTS: Preheparinization increased total plasma TFPI levels by a factor of 8.0. Administration of rTF significantly enhanced the generation of F1+2 (p = 0.0002). The heparin-induced TFPI elevation reduced both thrombin-antithrombin complex and F1+2 to control levels in rTF + TFPI boost group (p = 0.0158 for thrombin-antithrombin complex, p < 0.0001 for F1+2 ). F1+2 levels were at all times lower than control levels in TFPI boost group (p < 0.0001). CONCLUSIONS: Heparin-induced TFPI elevation attenuates TF-mediated thrombin generation. Early heparin administration prior to the emergence of plasma TF may represent a novel strategy for controlling thrombin generation by the extrinsic coagulation pathway during CPB.

[Endovascular stent-grafting for rupture of descending aorta with a patient with severe arterial occlusive disease; report of a case].

A patient was a 63-year-old woman with poor cardiac function and systemic arterial occlusive disease, who complained of severe back pain. Computed tomography (CT) revealed a rupture of the descending aorta. Initially, abdominal aortic approach through open laparotomy was attempted, but a guide wire caused local aortic dissection. Then, after median sternotomy, endovascular stent was successfully deployed through the ascending aorta. Postoperative course was uneventful. Follow-up CT showed no endoleak. A less invasive endovascular repair would be an alternative treatment for high risk patients such as this case, but several access routes should be considered, especially in a patient with systemic arterial occlusive disease.

[Bridge to recovery with ventricular assist device support for eosinophilic myocarditis].

A 39-year-old man initially presented with cough, fever, and shortness of breath. His symptom got worse gradually, and he was admitted to a nearby hospital. Echocardiography revealed a dilated left ventricle and severe left ventricular dysfunction. Despite inotropic and intra-aortic balloon pumping (IABP) support, the patient developed cardiogenic shock with fever of unknown origin, followed by multi-organ failure. A left-ventricular assist device (LVAD) was implanted. Pathologic evaluation showed an extensive eosinophil-rich inflammatory infiltrate, and consistent with the diagnosis of eosinophilic myocarditis. After high-dose steroid administration, the cardiac function improved and explantation of the LVAD was successfully performed. The patient was discharged and remains well at the 24-month follow-up.

Paradoxical restoration from complete and persistent atrioventricular block after surgical aortic valve replacement: a case report.

Background: One of the most important and relatively frequent complications of aortic valve replacement is atrioventricular block. It typically occurs by direct injury of the infranodal conduction system due to intra-operative manipulation and persists post-operatively, necessitating permanent pacemaker implantation in many cases. Case summary: A 66-year-old man presented to our hospital after experiencing syncope while walking after drinking. He had experienced two episodes of alcohol-induced syncope several years earlier. His electrocardiogram (ECG) and transthoracic echocardiogram revealed complete atrioventricular block and severe aortic stenosis, respectively. He received a temporary pacemaker on the day of admission and underwent surgical aortic valve replacement on hospital Day 9. The native aortic valve was bicuspid. Unexpectedly, the ECG immediately after aortic valve replacement showed complete restoration of atrioventricular conduction during temporary atrial pacing. The atrioventricular block did not recur, and he was discharged to home on post-operative Day 13. Discussion: This remarkably rare clinical course, complete restoration from complete and persistent atrioventricular block after surgical aortic valve replacement, can be explained by multifactorial mechanisms: (i) surgical removal of the aortic annulus calcification directly hindering the infranodal conduction system; (ii) relief from the ventricular pressure overload stressing the conduction system within the septum; and (iii) improvement of substantial autonomic dysregulation as manifested by alcohol-sensitive syncope in the present patient, which was a result of unloading of the intraventricular pressure affecting the left ventricular mechanoreceptor.

[Concomitant off-pump coronary artery bypass and left lower lobectomy for lung cancer;report of a case].

A 58-year-old man had an abnormal shadow in the left lower lobe on his computed tomography, and also had stenosis of the coronary arteries. Preoperative coronary angiography revealed severe stenosis of right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex branch(LCx). The diagnosis of lung cancer was made by transbronchial lung biopsy. Initially, we scheduled to undergo surgery of both the heart and lung in 2stage operation. However, before surgery, the infection of cavity was caused by tumor growing, so we performed the surgery in 1stage operation. Off-pump coronary artery bypass and left lower lobectomy with lymph node dissection was concomitantly performed. The postoperative course was uneventful. He was discharged after confirming the patent bypass grafting on the 13th postoperative day. Histopathological diagnosis was squamous cell carcinoma without lymph node metastasis. Lung cancer and ischemic heart disease can be surgically treated simultaneously, benefitting selected patients.

Experience of a patient with an extracorporeal ventricular assist system who participated in a sleepover program.

A 19-year-old woman suffered fulminant myocarditis owing to a mycoplasma infection and was inserted with an intra-aortic balloon pump and a percutaneous cardiopulmonary support. Antibiotics and gamma globulin were administered, however, the patient's cardiac function did not recover, and the TOYOBO ventricular assist device (VAD) was implanted. She had rehabilitation training such as maintaining a standing position at the bedside and walking in the hospital, and a hospital outing program to a family restaurant was conducted two times with the VAD. The patient wished to attend the coming-of-age ceremony in Tachikawa city, which is 3 h away from our hospital by car. Therefore, we planned the program including a night stay at her home. The patient and her family fully understood the risks and wished to participate in the sleepover program. In preparing for the sleepover, the patient and her family learned to operate the VAD, and she was able to move to the lavatory and through the house with the help of only her family. A physician and a clinical engineer stayed at her house for infusion of antibiotics and management of sudden changes. There was no adverse event. In Japan, the community support of patients with VAD is not yet established, and we hope that our experience becomes a help to support return to society for patients with VAD.

[Support for temporary homecoming of a patient with ventricular assist device].

A 19-year-old woman suffered from fulminant myocarditis by Mycoplasma infection, and intra-aortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were initiated. As the cardiac function was not recovered, the ventricular assist device (VAS) was implanted. Rehabilitation training was started such as maintaining standing position at the bedside, and walking. The preparatory training program for homecoming was conducted twice with VAS. She strongly hoped for participation of coming-of-age ceremony in Tachikawa City that is 3 hours' drive from our hospital. The patient stayed 1 night at home with a doctor and a medical engineer. There was no adverse event. In Japan, the community support of patients with VAS is not yet established and we hope that our experience will be of some help in supporting the homecoming of patients with VAS.