[Resection of a Myxoma Orginating from the Coumadin Ridge with Superior Transseptal Approach:Report of a Case].

A 70-year-old man with a history of lacunar stroke about a year before was incidentally found to have primary cardiac tumor during the work up for orthopedic surgery. It uniquely originated from the coumadin ridge between the left upper pulmonary vein and the left atrial appendage. He underwent tumor resection under cardiopulmonary bypass with superior transseptal approach. It allowed enough surgical exposure for en-bloc resection of the tumor with minimal risk of tumor embolisms. The pathological report confirmed that the tumor was a cardiac myxoma. The postoperative course was uneventful with no stroke nor embolism complications. We experienced a rare myxoma orginating from the coumadin ridge and successfully resected it with superior septal approach.

[Early Clinical Outcomes of Robotic Mitral Valve Repair;Initial Twenty Cases].

We report the early results of our initial 20 consecutive robotic-assisted mitral valve repairs at our institution. A total of 20 patients (aged 55±10 years, 15 males) underwent robotic assisted mitral repairs by using da Vinci system. Successful mitral valve repairs were done in all cases. All patients received an annuloplasty band. Triangular resection were done in 2 cases and artificial chordae were used in 18 cases. There was no conversion to sternotomy intraoperatively. Three cases needed recross-clamping because of mitral regurgitation, mitral stenosis and the problem of venous canula. Cardiopulmonary bypass time and aortic cross-clamp time were 272±56 minutes, 153±41 minutes. There were no hospital mortality and major complications. Post-pump echocardiograms showed no/trivial mitral regurgitation in all cases. Robotic-assisted mitral valve repairs were done safely and the early results were acceptable in our series.

[Surgical Treatment of Acute Infective Endocarditis after Transcatheter Aortic Valve Replacement].

Infective endocarditis (IE) after transcatheter aortic valve replacement (TAVR) is a rare complication, but has a high mortality. An 86-year-old female with symptomatic severe aortic stenosis underwent TAVR at our hospital and she was discharged without complication after 10 days. She was readmitted with high fever and acute heart failure 1 month later. Blood culture revealed Staphylococcus, and echocardiography showed vegetation on the septal cusp of the tricuspid valve and perforation at the membranous ventricular septum. We decided to perform emergency operation due to active infection and intracardiac complication despite appropriate antibiotic treatment. The infected valve was replaced with a bioprosthetic valve and the right ventricular (RV)-left ventricular (LV) communication was closed with a bovine pericardial patch. The patient received the antibiotics for 6 week and was transferred to the previous facility.

Intraprocedural left ventricular free wall rupture diagnosed by left ventriculogram in a patient with infero-posterior myocardial infarction and severe aortic stenosis.

BACKGROUND: Left ventricular wall rupture remains a major lethal complication of acute myocardial infarction and hypertension is a well-known predisposing factor of cardiac rupture after myocardial infarction. CASE PRESENTATION: An 87-year-old man was admitted to our hospital, diagnosed as acute myocardial infarction (AMI). The echocardiogram showed 0.67-cm(2) aortic valve, consistent with severe aortic stenosis (AS). A coronary angiography showed a chronic occlusion of the proximal left circumflex artery and a 99 % stenosis and thrombus in the mid right coronary artery. During percutaneous angioplasty of the latter, transient hypotension and bradycardia developed at the time of balloon inflation, and low doses of noradrenaline and etilefrine were intravenously administered as needed. The patient suddenly lost consciousness and developed electro-mechanical dissociation. Cardio-pulmonary resuscitation followed by insertion of an intra-aortic balloon pump (IABP) and percutaneous cardiopulmonary support were initiated. The echocardiogram revealed moderate pericardial effusion, though the site of free wall rupture was not distinctly visible. A left ventriculogram clearly showed an infero-posterior apical wall rupture. Surgical treatment was withheld because of the interim development of brain death. CONCLUSIONS: In this patient, who presented with severe AS, the administration of catecholamine to stabilize the blood pressure probably increased the intraventricular pressures considerably despite apparently normal measurements of the central aortic pressure. IABP, temporary pacemaker, or both are recommended instead of intravenous catecholamines for patients with AMI complicated with significant AS to stabilize hemodynamic function during angioplasty.

[Mitral valve replacement after previous coronary artery bypass grafting with functioning left internal thoracic artery graft: effectiveness of the method using a direct vision retrosternal approach; report of a case].

Performing a redo-sternotomy when a mammary artery graft is patent can be rather difficult. We previously reported a redo-sternotomy technique involving direct visualization with a retrosternal dissection (DR) method using a Kent's retractor. The DR method in detail is as follows: 1) A midline skin incision is extended to the abdomen about 5 cm. 2) The bilateral costal arches are divided from the rectal muscle. 3). A pair of retractors is placed under the costal arch. 4) A stainless steel wire is applied to the previous sternal wire at the center of the sternum. 5) The retractor and sternal wire are lifted up using the Kent's retractor to widen the retrosternal space. 6) The sternum and sub-sternal tissue are carefully divided using an electronic scalpel or metal retractor with an entirely sternal length. 7) Routine sternotomy is performed using a Stryker. Herein, we report a patient who had undergone cardiac surgery, coronary artery bypass grafting (CABG), using a left internal mammary artery and mitral annuloplasty 2 years previously, and then developed mitral regurgitation caused by infectious endocarditis. He successfully underwent redo-sternotomy and mitral valve replacement using the DR method. In a patient with a patent internal mammary artery, the DR method greatly reduces the risk of graft injury.

[Usefulness of the axillary artery perfusion in open heart surgery in a patient with severe ascending aortic calcification].

Because of high-aging Japanese society, high-risk patients with multiple co-morbidities have been increasing in regular open-heart surgery. Especially, extensive aortic atherosclerosis with severe calcification that involves the ascending aorta can complicate the choice of sites of cannulations and aortic cross-clamping for cardiopulmonary bypass. To date, the standard peripheral arterial cannulation site in such cases has been the common femoral artery;however, this approach carries the risk of atheroembolism due to retrograde aortic perfusion, or it is undesirable in case of severe iliofemoral disease. Recently, it has been reported that arterial perfusion through the axillary artery provides sufficient antegrade aortic flow associated with fewer atheroembolic complications. In this paper, we report 3 successful cases of valvular surgeries in which axillary artery cannulation was used to avoid complications of brain. In cases of extensive aortic atherosclerosis with severe calcification, arterial perfusion through the axillary artery is a safe and effective method to provide sufficient arterial inflow during cardiopulmonary bypass, and is an excellent alternative to femoral artery cannulation.

Delayed closure of postinfarction ventricular septal rupture.

We present the case of a patient with postinfarction ventricular septal rupture (VSR) who underwent delayed repair using a modified infarction exclusion technique. The patient was taken to the operating room 21 days after the first incidence of acute myocardial infarction because the intra-aortic balloon pump maintained a stable circulatory condition without cardiogenic shock. In our procedure, a Dacron patch was sutured to the healthy endocardium to exclude the infarcted septum, and the VSR was subsequently closed with another Dacron patch. After three years of postoperation, the patient's condition remains normal with good ventricular kinesis and no residual shunt. We describe herein a novel procedure for repairing postinfarction VSR by using two Dacron patches.

[Anesthetic management in ten cases for tracheobronchial Dumon stent placement].

BACKGROUND: To determine perioperative complications, we evaluate herein 10 cases of anesthetic management for placement of Dumon stent in patient with tracheal or bronchial stenosis due to invasion of esophageal or lung cancer. METHODS: After sufficient oxygenation, anesthesia was induced with propofol and fentanyl. Since muscle relaxant has been considered safe for central-type air way stenosis except for cases involving large anterior mediastinal masses, we administered vecuronium for all cases to facilitate insertion of rigid bronchoscope and for surgical procedures. Anesthesia was maintained with continuous infusion of propofol, and ventilation was performed via a side-port of a rigid bronchoscope with 100% oxygen. Extra corporeal circulation was instituted in 2 cases. RESULTS: In 5 of the 10 cases, stent placement was uneventful. However, in the other 5 cases, respiratory failure (SpO2 < 90% and/or PaCO2 > 80 mmHg: 4 cases) or severe hypotension (systolic blood pressure < 60 mmHg: 3 cases) developed. Severe hypotension was attributed to relatively higher dose of anesthetic agents for cachexic status, or reduction in venous return following over-inflation of the lungs. Acute reduction in blood carbon dioxide levels due to extracorporeal circulation (case 4), and loss of consciousness after administration of anesthetic agents (case 2) could also have been involved in 2 cases. CONCLUSIONS: Circulatory status must be closely monitored during anesthetic management for Dumon stent placement.

[Brachial plexus neuropathy following open-heart surgery].

A 64-year-old woman underwent open-heart surgery for repair of atrial septal defect (ASD) and tricuspid valve regurgitation. Preoperative complications included rheumatoid arthritis with pain in both wrists treated with methotrexate. Following smooth endotrachial intubation, a pulmonary arterial (PA) catheter was inserted into the right jugular vein after several attempts. She was placed in a supine position with abduction of the shoulders to approximately 90 degrees and of the elbows to 60 degrees. Operation was performed through sternum splitting to second intercostal space, and the 4-h intraoperative course was uneventful. On the first postoperative day, she complained of inability to raise her right arm. Neurological examination revealed marked weakness of the deltoid and biceps brachialis muscles, and decreased sensitivity around the right shoulder. Iatrogenic brachial plexus injury was diagnosed. Administration of vitamin B12 and physical therapy were instituted. Symptoms improved gradually and had disappeared by 3 months postoperatively. Neuropathy might be attributed to stretch and compression of the brachial plexus caused by traction of the pectoralis minor muscle enhanced by sternotomy and/or malposition of the upper extremity, or direct injury due to cannulation of the PA catheter into the internal jugular vein.

[The history of Yunosawa village and the policy of leprosy of Japan. IV].

There was a village which was called Yunosawa, lots of leprosy patients lived, existed from 1887 to 1941, Kusatu town, Gunnma Prefecture, Japan. It was the only place continued securing self-government to the last as area was free from the isolation policy of State in prewar days there. The aim of this study will make clear the dynamism of "The protection from the tension of the society of leprosy patient currently persecuted" to "The defense of the society from the leprosy patient who is a source of infection". In this study, explained the factor of confusion to a National Leprosarium Kuryu Rakusen-en during World War II and considered relation between patient movement and residents of Yunosawa village at the postwar period.

[The history of Yunosawa village and the policy of leprosy of Japan III].

There was a village which was called Yunosawa, lots of leprosy patients lived, existed from 1887 to 1941, Kusatu town, Gunnma Prefecture, Japan. It was the only place continued securing self-government to the last as area was free from the isolation policy of State in prewar days there. The aim of this study will make clear the dynamism of "The protection from the tension of the society of leprosy patient currently persecuted" to "The defense of the society from the leprosy patient who is a source of infection". In this study, explained the history of the Yunosawa village and the shift of the policy of leprosy by State had relation to the village. In addition, showed worth of free medical-treatment area here.

[The history of Yunosawa village and the policy of leprosy of Japan. I].

There was a village which was called Yunosawa, lots of leprosy patients lived, existed from 1887 to 1941, Kusatu town, Gunma Prefecture, Japan. It was the only place continued securing self-government to the last as area was free from the isolation policy of State in prewar days there. The aim of this study will make clear the dynamism of "The protection from the tension of the society of leprosy patient currently persecuted" to "The defense of the society from the leprosy patient who is a source of infection". In this study, it outlined what community of Yunosawa village. This seen here was not an image called the illness person's group but the advanced community, and was equipped fully with an autonomous system, institution, etc.

[The history of Yunosawa village and the policy of leprosy of Japan. II].

There was a village which was called Yunosawa, lots of leprosy patients lived, existed from 1887 to 1941, Kusatu town, Gunma Prefecture, Japan. It was the only place continued securing self-government to the last as area was free from the isolation policy of State in prewar days there. The aim of this study will make clear the dynamism of "The protection from the tension of the society of leprosy patient currently persecuted" to "The defense of the society from the leprosy patient who is a source of infection". In this study, explained the history of the Yunosawa village and the shift of the policy of leprosy by State had relation to the village. In addition, the effort of residents and Christianity persons' activity are drawn in this paper. Moreover also drew what is desired how it is going to live under adverse circumstances, and showed worth of free medical-treatment area here.