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A 49-year-old woman visited our clinic on July 12th, 2006, complaining of discomfort in fingers of both hands, edema of both lower limbs, and pain in the right shoulder and chest. Chest X-ray examination showed an infiltrative shadow with pleural effusion and loss of lung volume in the left lower lung field. She was treated with CTRX, but it was ineffective, and she was therefore admitted to Kurume University Hospital on July 21st, 2006. Chest CT demonstrated pyothorax and loss of lung volume in the left lung. Culture of a sample obtained by thoracentesis yielded Nocardia asteroides. The pulmonary nocardiosis improved after oral administration of trimethoprim-sulfamethoxazole, and the patient was discharged on August 25th 2006. No immunological impairment was observed, and the serum levels of ACHT and cortisol were normal. In February 2007, however, she developed facial acne, facial edema ("moon" face), centripetal obesity, and weight gain. Cushing syndrome was diagnosed on the basis of tests including a low-dose dexamethasone suppression test. To the best of our knowledge, there has been no previous report of pulmonary nocardiosis with pyothorax in a patient with Cushing syndrome. We assume that the present patient had pre-(sub-) clinical Cushing syndrome when she presented with pulmonary nocardiosis and pyothorax.

A 52-year-old woman was admitted to Yame General Hospital because of persistent cough, wheeze, and shortness of breath at age 48. Chest X-ray and computed tomography (CT) showed bilateral centrilobular shadows. Pulmonary function test revealed obstructive dysfunction. She also had chronic sinusitis. Initially, diffuse panbronchiolitis was diagnosed and she was given macrolides, but no improvement was observed. Thus video-assisted thoracoscopic lung biopsy (VATS) was performed in order to establish a definitive diagnosis. Histopathological findings were compatible with a diagnosis of follicular bronchiolitis. Treatment with corticosteroid (oral prednisolone, 50 mg/day) improved her condition. However, on reducing the steroid doze, her symptoms and chest X-ray film/CT findings became exacerbated. In addition, polyarthritis appeared. Further investigations revealed a diagnosis of rheumatoid arthritis. Only 2 cases of follicular bronchiolitis preceding rheumatoid arthritis have been reported in Japan.

We herein report a case of aortic root replacement using cryopreserved allograft. A 52-year-old man received aortic valve replacement using a mechanical prosthesis for aortic stenosis. He was complicated by postoperative methicillin-resistant staphylococcus aureus mediastinitis involving the ascending aorta. Surgical therapy including debridement, omental transposition, patch closure using pericardium had not achieved satisfied result. Aortic root replacement using cryopreserved allograft was mandatory for refractory aortic infection. He had an uneventful postoperative course. The cryopreserved allograft was effective for a patient with refractory aortic root infection due to postoperative mediastinitis.

Four patients underwent a pulmonary embolectomy using cardiopulmonary bypass for acute pulmonary embolism which had occurred after various operations. In two cases, dehydration due to either diabetes insipidus or ileus had existed. In two cases, pulmonary embolism suddenly occurred in our hospital. In the remainder, the disease occurred in the previous hospitals and its diagnosis was established on the 6th and 7th postoperative days, respectively. In massive pulmonary embolism, echocardiography and/or enhanced chest CT are useful for prompt and noninvasive diagnosis. Thrombolytic therapy was performed in only one case before surgical embolectomy, which was not effective. Three patients were discharged without any postoperative complications, but one requiring preoperative external cardiac massage died of multiple organ failure 9 days after operation. Acute pulmonary embolism is one of the fatal postoperative complications. Recognition of this entity, and prompt diagnosis and treatment are essential for managing the fatal disease. Even in the early postoperative period, embolectomy using cardiopulmonary bypass is a safe and effective treatment.

Between January 1990 and December 1999, 20 patients underwent the valve surgery concomitant with coronary artery bypass grafting. There were 16 males and 4 females, their mean age was 66.5 years. Of the 20 patients, aortic stenosis was noted in 7, aortic regurgitation in 3, mitral stenosis in one, and mitral regurgitation in 9 patients. The cause of mitral regurgitation was considered to be an ischemic change in six patients, including ruptured papillary muscle due to myocardial infarction in two patients. On the contrary, LMT lesion was recognized in 5, LAD lesion in 17, LCX in 16, and RCA in 12 patients. Seven patients had preoperative myocardial infarction, three patients were required preoperative IABP support. AVR was performed in 10, MVR in 5, and MAP in 5 patients. The number of bypass was 1.9 +/- 0.85. Four patients died of LOS and MOF. The remaining 16 patients have been doing well. The significant difference between the survived and the not survived patients was recognized in the factor of emergency, preoperative IABP, papillary muscle rupture due to myocardial infarction, history of PTCA, LAD lesion, and the time of CPB. The factors regarding coronary artery had the influence on the outcome of a patients of valve surgery concomitant with CABG. Therefore, an appropriate myocardial protection and perioperative management for ischemia were mandatory.

A 45-year-old man was admitted to our hospital complaining of mild chest pain. The stab wound on the chest was very small and the nail had been completely buried under the skin. Emergency operation was mandatory for cardiac tamponade by the nail stabbing. Contused right ventricular wall was repaired using Teflon felt under cardiopulmonary bypass. It was important to have a suspicion as cardiac tamponade, when the patient showed uncertain hypotension.

77 cases of acute type A dissection underwent emergency operation during 5 years were studied. There were 37 men and 40 women, and 58 cases in type I, 19 cases in type II on DeBakey type. The grafting for the aorta including the tear was basically performed under selective brain perfusion and deep hypothermic circulatory arrest. The overall hospital mortality rate was 24.7%. However, it was 14% after using GRF glue. The overall actuarial survival rate for 58 patients who survived operation was 87% at 5 years after surgery. Late remnant false lumen-related complications were recognized in four patients (6.9%). For two of them, subsequent operations were performed. Another two patients died of rupture of remnant false lumen during observation. Aortic valve regurgitation was recognized preoperatively in 13 patients. None of them required subsequent operation in late phase. Results and countermeasure for late remnant false lumen-related and aortic valve-related complications were investigated.

A 46-year-old woman was hospitalized for aortic valve stenosis (AS) associated with systemic lupus erythematosus (SLE) on April 12, 1996. She had a syncopal episode six months before admission. She was found to have thrombocytopenia, and was diagnosed with SLE by further examination. Irregular genital bleeding was also seen on admission while her SLE was being controlled with steroid therapy. Aortic valve replacement was performed after the steroids had been reduced to avoid excessive bleeding. The aortic valve was the bicuspid with raphe. There was much calcification on the cusps and the annulus, but there were no degenerative changes. The postoperative course was uneventful, and her SLE has been in remission two years after the operation. The management of steroid therapy for SLE patients complicated with cardiovascular disease is discussed.

A 66-year-old woman was operated on aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty. Retrieval of remaining Swan-Ganz Thermodilution catheter in the superior vena cava and the right atrium for 15 years was also made. Fortunately, contamination and embolism have not occurred for 15 years. Extracted catheter showed to be stiff due to the degradation. It was suggested that the cause of remaining was the thread for closing the left atrium on the previous operation. The explanation to patient and one's recognition are most important. We recommend that retrieval of remaining catheter for a long time and/or after open heart surgery should be made under extracorporeal circulation because that remaining catheter may be involved with the intima, and preventing from bleeding.

We performed the modified Bentall procedure for annuloaortic ectasia in a 41-year-old man with Marfan's syndrome. Approximately 15 minutes after initiation of cardiopulmonary bypass with an arterial delivery via the left common femoral artery, perfusion volume gradually decreased and the abdomen of the patient was distended. Retrograde dissection was strongly suggested. Perforation and localized dissection of the left common iliac artery were recognized. Following repair of the lesion, the modified Bentall operation was carried out. Postoperative course was uneventful. The patient has been well for 22 months after the operation.

A 32-year-old woman developed heart failure. She had received Glenn operation 26 years ago and Fontan operation using valved conduit (Björk-Shiley: 21 mm) seven years ago for tricuspid atresia type 1b. She underwent extirpation of the struck prosthetic valve. Neither graft stenosis nor pressure gradient between the right atrium and the pulmonary artery were observed on postoperative right arteriography. Sternotomy on redo Fontan operation should be carefully performed for preventing breaking down the implanted valved conduit. Though the prosthetic valve was not necessary on redo Fontan operation, anticoagulation after operation should be done.

A 61-year-old woman of ASD complicated with SLE was operated on. We used a heparin coating Carmeda BioActive Surface (CBS) in cardiopulmonary bypass circuit for the purpose to prevent the postoperative complications due to the reduced complement activation by SLE. This system could prevent the decline of the reduced complement activation during cardiopulmonary bypass and after operation. The management of steroid therapy for SLE patient, usefulness of heparin coating CBS system for hypocomplement disease were discussed.

We evaluated the 80 cases of porcine valve replacement, accomplished between April 1975 and December 1980. There were 48 males and 32 females aged between 16 and 60 years old with a mean of 37.4 +/- 11.4. Ten patients underwent aortic valve replacement (AVR), 63 mitral valve (MVR), and 7 AVR plus MVR. Twenty-seven Hancock valves (H) were implanted in aortic (3) and mitral (24) position and 61 Carpentier-Edwards valves (CE) were used in aortic (14), mitral (46), and tricuspid (1) position. The mean duration of follow-up was 9.3 years (0.2-19.2 years) and cumulative follow-up was 747.2 patient years (py). The late mortality was 3.3%/py (25 patients). Actuarial survival rates for all patients at 10 and 15 years were 67%, and 49% respectively. The linearized rates (LR) of structural valve deterioration (SVD) was 7.0%/py. The freedom from SVD for all patients at 10, and 15 years were 47.1%, and 12.4% respectively. There were no differences of free rates of SVD between H and CE. between valve sites implated, and among age at operation. The incidence of occurrence of SVD was gradually increased 6 years after operation. The LR of thromboembolism (TE), anticoagulant-related hemorrhage (ACH), prosthetic valve endocarditis (PVE), nonfunctional valve dysfunction (NVD), and reoperation (RO) were 0.7%/py, 0.1%/py, 0.3%/py, 0.1%/py and 7.4%/py, respectively. The freedom from TE, ACH, PVE, NVD, and RO for all patients at 15 years were 91.3%, 98.1%, 95.6%, 80%, and 6.5%, respectively. The surgical results of glutaraldehyde-preserved porcine bioprostheses was excellent during the first 5 years after operation. A high incidence of SVD has been occurred thereafter. According the indication for valve replacement with bioprotheses is now strictly limited for elderly, child bearing female case, contraindition for therapy of anticoagulants, and some social condition.

We evaluated the Björk-Shiley tilting-disc (BS) valve replacement up to the longest duration for about 12 years. The study was started in November 1982 and ended in September 1991. There were total number of 206 with 117 males and 89 females aged between 18 and 71 with a mean of 51.6. Eighty three patients had isolated aortic valve replacement (AVR), 92 had isolated mitral valve replacement (MVR), and 31 had AVR plus MVR. One hundred and fourteen spherical-disc valves were replaced in the aortic, 112 spherical and 11 monostrut in the mitral position. The mean duration of follow up was 6.5 years for a total of 1330.6 patient years (PY). Forty-one patients (3.8%/PY) died later, and 14 out of 41 died of valve-related complications. Actuarial survival rates for all, AVR, MVR and DVR at 10 years after operation were 71.2%, 73.5%, 73.9% and 55.4%, respectively. The linearized rates of thromboembolism (TE), thrombosed valve (TV), anticoagulant-related hemorrhage (ACH), prosthetic valve endocarditis (PVE), hemolysis (H), and reoperation (RO) were 1.2%/PY, 0.2%/PY, 0.7%/PY, 0.2%/PY, 0.1%/PY, and 0.2%/PY, respectively. The rates of freedom from TE, TV, ACH, PVE, H, and RO and 10 years after operation were 83.5%, 98.5%, 94.0%, 98.4%, 99.0% and 95.6%, respectively. The major causes of postoperative mortality and morbidity were TE, TV, and ACH. One hundred and fifty-six out of 161 patients showed an improvement in NYHA functional class post operatively. The surgical results of valve replacement with the BS valve was excellent and acceptable one. Intensive management with a special reference of anticoagulant therapy is necessary for a long-term management of the patients with mechanical valve replacement.

A 68-year-old man had prosthetic valve replacement for aortic stenosis. Unfortunately, sternal dehiscence with osteomyelitis occurred on the fifth postoperative day. Implantation of the pedicled omentum to the wound was carried out three days later. The result was excellent. This is the worthy method to try to such wound of infected sternum with dehiscence. From the point of view of anatomy and physiology, the omentum has a great benefit to repair the infected space and promote the wound healing process.

From January 1986 to June 1993, twenty one patients aged 70 years or older with valvular heart disease underwent open heart surgery. There were 12 males and 9 females with a mean age of 71.2 years (range 70 to 76). Eight patients were in NYHA class III, and 4 in class IV preoperatively. AVR was performed in 10 patients, MVR, MVR with TAP, OMC, AVR with MAP, DVR with TAP in 4, 4, 1, 1, and 1, respectively. Mechanical and bioprosthetic valves were replaced in 11, and 9 patients respectively. There were 6 early death (4 operative, 2 hospital). Longer duration of cardiopulmonary bypass (p < 0.05) and aortic crossclamp time (p < 0.05) were the risk factors independently for early mortality. Follow-up of 15 hospital survivors was 100% (8 months-7.7 years, mean: 3.2 years) and cumulative follow-up was 47.6 patients years (PY). There was one late death, and one prosthetic valve endocarditis (2.1%/PY). No other valve-related complications was occurred. Actuarial survival rate and freedom from valve-related morbidity at seven years were 83.3%, and 93.3%, respectively. These results show that operative mortality of valvular disease in elderly patients remains high, but the late results is acceptable one. Valve surgery for these elderly patients is reasonably acceptable.

The operation for the isolated secundum type of atrial septal defect (ASD) is usually conducted electively in the older age. Small number of cases, however, inevitably require surgical treatment for the reason of intractable heart failure. We have experienced such two infants with the isolated secundum type of ASD, whose conservative treatment was ineffective.