[Mitral valve plasty for infective endocarditis associated with vertebral osteomyelitis].

Infective endocarditis (IE) associated with vertebral osteomyelitis (VO) is relatively rare, but needs long and careful therapy. We report a case of the patient who was incidentally diagnosed as having IE during therapy for VO. A 77-year-old man was hospitalized with a complaint of high fever and back pain. Because magnetic resonance imaging demonstrated osteomyelitis, antibiotic therapy was started. Persistent infectious signs and congestive heart failure indicated the diagnosis of infective endocarditis. Echocardiogram demonstrated sever mitral regurgitation due to perforation of anterior mitral leaflet but no vegetation. Surgery revealed perforation of the valvular aneurysm of the anterior mitral leaflet, which was successfully repaired with deberidement and patch closure. Antibiotic therapy was continued for 4 months postoperatively. In the case of VO, it is often necessary to consider an association of IE, although it is hardly possible to determine which the preceding infection is.

Primary embryonal carcinoma of heart with SVC syndrome.

We present a case report of a 25-year-old man with embryonal carcinoma of right atrium and multiple lung metastases featuring SVC syndrome. We resected the cardiac tumor which occupied the right atrium and performed left upper lobectomy. No tumor mass or vestige was detected in the testes. Cis-platinum based combination chemotherapy was performed for residual lung tumors, which leads to the complete remission.

Surgical treatment of an aneurysm in the right aortic arch with aberrant left subclavian artery.

A saccular aneurysm in the right-sided aortic arch with aberrant left subclavian artery is an uncommon disease, and surgical treatment is complicated. Three patients with Edwards type III-B right aortic arch and enlargement of the Kommerell's diverticulum underwent operations. Right thoracotomy was the preferred approach for this lesion and partial cardiopulmonary bypass is a safe and simple procedure when the aortic arch has mild atherosclerosis.

Impending rupture in an aortic arch aneurysm by Candida infection.

A 68-year-old man was hospitalized with the complaints of left back pain and fever. He had a history of using steroids to treat uveitis for about thirty years. Computed tomography on the chest demonstrated an impending rupture in an aortic arch aneurysm, which was consequently surgically excised. Candida albicans was identified in the wall of the aneurysm, so fluconazole and itraconazole were administered. The patient was discharged at 120 days after surgery without recrudescence of the candida. To our knowledge, this is the fifteenth case of a successfully treated aneurysm caused by candida infection.

Primary osteosarcoma of heart with severe congestive heart failure.

We present a case report on a 54-year-old woman with extraskeletal osteosarcoma of the left atrium featuring severe congestive heart failure. We resected the tumor, which occupied the left atrium and had widely infiltrated the atrial wall, but the patients died of the tumor 9 months after surgery. This is to our knowledge the 32nd case of cardiac osteosarcoma ever reported.

[Combined CABG and valve operation].

We presented 20 patients, who were underwent combined valve and coronary artery bypass surgery in our institute from September 1995 to December 1999. They were 13 male and 7 female, ages ranged from 54 to 79 (mean 67.5 years). Previous cardiac operation was done in 2 cases. The patients carried out a combination of CABG with aortic valve replacement (n = 9), mitral valve replacement (n = 4), mitral valve plasty (n = 6), double valve replacement (n = 1). Emergency operation was performed in 2 cases. The hospital mortality was 5%. One patient who was underwent mitral valve repair and CABG died due to severe heart failure 2 week post operatively. The perioperative complications were found in 2 patients, one was acute renal failure with HD, the other was cerebral infarction. There are no patient with perioperative myocardial infarction. The combined operation of valvular surgery and CABG for the patients with coexisting disease might be safety and reliable methods, even in older one.

[Predonation and transfusion in open heart surgery].

The efficacy of predonation of autologous blood in reducing the use homologous blood during open heart surgery was investigated. Between January 1997, and February 1998, predonation and transfusion was studied in 100 consecutive open heart operations (CABG, 77; valve surgery, 17; ASD, 5; myxoma, 1). The guidelines for autologous predonation were as follows: an age < 70 years, a weight > 40 kg and a hemoglobin > 12 g/dl. Patients in NYHA class IV or undergoing emergency operation were excluded. The blood loss during operation ranged from 195 to 1,850 ml (mean; 670 ml), being from 305 to 1,850 ml (723 ml) for CABG, from 260 to 1,020 ml (493.5 ml) for valve surgery and from 195 to 570 ml (342 ml) for ASD. The blood loss was not significantly dependent on sex or age and did not differ elective and emergent operations. Only 36.6% of patients with autologous predonation needed homologous transfusion versus 63.4% of those without predonation. Homologous transfusion was done in only 5% of the those with predonation of 800 ml versus 69% at 400 ml and 71% at 200 ml. In conclusion, autologous blood transfusion is effective for reducing the homologous blood requirement. It also seems that predonation of 800 ml may be sufficient to allow open heart surgery without blood transfusion.

Mitral valve replacement in a patient with an extensively calcified mitral anulus: report of a case.

We report herein the case of a patient with chronic renal failure in whom mitral valve stenosis with extensive mitral anular calcification involving the entire anulus and leaflets was successfully treated surgically. Excision of both leaflets and partial resection of the anular calcification enabled the insertion of a 23-mm St. Jude Medical prosthetic valve. The technical difficulties involved with inserting the appropriate-sized prosthetic valve in a narrowed mitral anulus with heavy calcification are discussed following this case report.

[CarboMedics "Top Hat" supraannular prosthesis in the small aortic root with severe calcification: a case report].

A 71-year-old man with aortic stenosis due to calcification successfully underwent aortic valve replacement with a 21-mm CarboMedics "Top Hat" supraannular prosthesis. We were able to implant a "Top Hat" valve one size larger than would have been possible using a standard bileaflet valve. The postoperative recovery was uneventful, and echocardiography showed a peak gradient of 23 mmHg for this prosthesis. The CarboMedics supraannular valve allowed a gain in size over standard prostheses, resulting in favorable hemodynamics. This valve may be useful in difficult or unsuitable cases to enlarge the narrow aortic valve ring, such as patients with severe calcification of aortic root, elderly patients with less activity, or patients who can tolerate only short cardiopulmonary bypass time due to cardiac dysfunction.

[Uretero-external iliac artery fistula: a case report].

We report a case of uretero-external iliac artery fistula. A 60-year-old female was referred to our hospital complaining of intermittent gross macrohematuria. She had undergone radical hysterectomy, radiation therapy and chemotherapy for advanced cervical cancer 2 years ago. The patient had a 7 Fr ureteral double-J stent for left hydronephrosis. Retrograde urography showed a filling defect (8 mm in diameter) of the left ureter. A contrast-enhanced computed tomographic scan showed left hydronephrosis and hydroureter but no evidence of fistula formation or extravasation. A pelvic arteriography revealed a pseudoaneurysm of the left external iliac artery at the crosspoint between the left ureter and the iliac artery. Surgical repair of the left uretero-external arterial fistula was successfully performed as well as left nephroureterectomy. The possibility of fistula formation between ureter and artery should be kept in mind in patients with long-term indwelling ureteral stents and history of radiation therapy.

[Cardiac operation for aged patients (aged 75 years and over): results of surgical intervention].

We evaluate the results of cardiac operation for 41 elderly patients (aged 75 years and over, mean, 77.5 years old). The overall hospital mortality was 12.2% (5/41) with mortality of 8.3% (2/24) in cases of elective operation and mortality of 17.6% (3/17) in cases of emergency operation. Causes of hospital death in emergency cases were congestive heart failure and left ventricular rupture (two cases) due to acute myocardial infarction. Patients who died in elective operation had been performed reoperation for bleeding and unstable sternum. These complications which need a reoperation seemed to be a potential risk for elderly patients. Because of poorer results of the emergency case, it is advocate to operate on these aged patients with an elective basis, if there is no absolute contraindications.

[A case report of an infective endocarditis caused by methicillin-resistant Staphylococcus aureus with successful mitral valve replacement].

We report a case of successful mitral valve replacement performed on the patient who is an infective endocarditis due to MRSA. She was 27-year-old female and treated by antibiotics medication because of remittent fever two years ago. On August 1995, cerebral infarction occurred and she was pointed out endocarditis. After high fever continued, blood cultures demonstrated MRSA. Furthermore, echocardiography showed vegetation on posterior mitral valve leaflet and moderate mitral regurgitation so, mitral valve replacement with a S.J.M. 25 mm performed to control MRSA sepsis condition. During operation, we used VCM 2 g into the extracorporeal circulation and after operation 0.5 g intravenously every 6 hours. Two weeks later we changed antibiotics to FOM, Viccillin and ABK according to the result of minimum inhibitory concentration (MIC) obtained through blood culture. The patient was discharged on the 44 th postoperative day because of her uneventful postoperative course.

[Rupture of the aneurysm of the sinus valsalva: thirteen years after the initial diagnosis].

We report a case of an unruptured aneurysm of the sinus Valsalva (URASV) which was followed thirteen years without surgery. A 47-year-old female had a heart murmur detected at age 34 during pregnancy. Though an URASV was diagnosed, because the aneurysm was less than 1 cm in size, no surgery was advised at that time. Thirteen years later, she gradually noticed of increased heart beats and also dyspnea on exertion. Echocardiogram showed an aneurysm of the sinus Valsalva ruptured to the RV cavity. In June 1994, resection of the aneurysm was performed. One year later, the patient was asymptomatic. This may be the second longest long-term follow-up report of the patient with an unruptured aneurysm of the sinus Valsalva.

[A case of mitral valvuloplasty with concomitant CABG in an aged patient].

A 79-year-old man was referred to our hospital complaining of the manifestation of mild heart failure. Echo cardiography and LV gram showed sever mitral regurgitation by the prolapse of posterior leaflet. CAG revealed coronary artery disease affected two vessels (LAD and RCA) without symptoms. Quadrangular resection of posterior leaflet (McGoon's method) without annuloplasty and concomitant single CABG to the LAD using a saphenous vein were performed. Postoperative course was satisfactory and the manifestation of heart failure was diminished. Mitral valvuloplasty with concomitant CABG may be a safe and effective procedure in the treatment of aged patients.

[Simultaneous operations for both the repair of the aortic arch aneurysm and repeated CABG].

A 73-year-old female complaining of left thoracic pain was referred to our hospital. In 1988, she had the first CABG of the left circumflex coronary artery (CX) and right coronary artery. On admission in April 1994, chest X-ray and CT scan revealed a saccular aortic aneurysm, 5 x 5 cm in size, extending to the distal to the left subclavian artery. Coronary arteriography showed a patency of the CX graft, but 99% stenosis of the proximal left anterior descending branch (LAD) with delayed opacification. After the repeated median sternotomy, cardiac arrest was achieved with the aortic cross clamping and St. Thomas Hospital solution infusion. CABG to the LAD branch using a saphenous vein was accomplished. Following this, the replacement of the aortic aneurysmal lesion with a prosthetic graft was performed under the selective cerebral perfusion with deep hypothermia. Proximal anastomosis of the vein graft was completed during a rewarming period. The operation was performed without complications. Postoperative course was satisfactory except a few minor transient complications such as athelectasis of the left upper lobe and the intra-thoracic hematoma. After one month's hospitalization, she was discharged, and currently (six months postoperative) remains asymptomatic.

[A case of left atrial ball thrombus].

A 76-year-old man admitted to one hospital complaining of transient left hemiparesis. Because of arrhythmia, he was examined by an echocardiogram and found to have an oval free-floating thrombus in his left atrium concomitant with mitral stenosis. He was transferred to our hospital for emergency surgery. On operation, a 3 x 4 cm ball thrombus was removed and diseased mitral valve was replaced with a SJM prosthetic valve. His postoperative course was relatively uneventful. Though left atrial ball thrombus is rarely found among the patients with mitral valve disease, when left atrial ball thrombus is found, immediate surgical intervention is recommended to avoid sudden death.