The purpose of this study was to evaluate the efficacy of early rehabilitation starting on the day after cardiac surgery. In the early rehabilitation program, introduced from November 2006, we adopted an original video program about hospitalization and daily multi-specialist conference in the ICU. We divided 179 patients who underwent elective cardiac operation from June 2004 to September 2007 (mean age 65.4 years old, 51 women, 91 CABG, 53 valve procedures and 35 other procedure) into group A (the initial rehabilitation group : n=73) and group B (the early rehabilitation group : n=106). There were no significant differences in patient profile (age, gender, operation time etc.) between the two groups. The mean postoperative day of starting cardiac rehabilitation was 4.3+/-1.6 days in group A and 1.5+/-1.0 days in group B (p<0.01). The mean achievement period of all walking distances in group B was significantly shorter than in group A as follows, 50 m : group A 5.4+/-2.2 vs. group B 3.1+/-1.5 days (p<0.01), 100 m : group A 6.9+/-3.1 vs. group B 4.9+/-2.2 days (p<0.01), 200 m : group A 8.5+/-3.9 vs. group B 6.5+/-2.5 days (p<0.01), 300 m : group A 10.2+/-3.9 vs. group B 8.1+/-2.9 days (p<0.01), 500 m : group A 14.5+/-6.1 vs. group B 11.9+/-3.8 days (p<0.05). Approximately 90 per cent of patients in group B could walk by themselves on leaving the ICU. There were no major complications throughout rehabilitation. The mean hospital stay was 31.0+/-11.2 days for group A and 25.9+/-7.4 days for the group B, with a statistically significant difference (p=0.03). In a questionnaire survey at discharge, 91.0 per cent of patients in group B answered that early rehabilitation was most gratifying. In conclusion, early rehabilitation after cardiac surgery is effective for early recovery of ADL and leads to shorter hospital stay. We think both preoperative education and daily conferences are indispensable for safe and effective early rehabilitation programs.

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A 47-year-old man was found to have a thoracic aortic aneurysm. When the patient was 20 years old, he underwent aortic correction with Dacron graft for coarctation of the descending aorta. CT showed an enhanced true aneurysm and a pseudolumen in the proximal anastomotic site of the graft of the distal arch and an aneurysm in the left subclavian artery bifurcation. The operation was performed. Because we anticipated severe adhesion due to the preceding left thoracotomy, we approached by median sternotomy and the transmediastinal replacement method (pull-through method). Before cardio pulmonary bypass was started, an 8-mm Dacron graft was anastomosed to the left subclavian artery via a subclavian incision. The patient was given heparin and we cannulated the ascending aorta via the right femoral artery. A venous cannula was placed in the superior and inferior vena cava and patent left superior vena cava confirmed during operation. Antegrade cardioplegia was initially administered. During deep hypotheremic circulatory arrest antegrade cerebral perfusion was employed. The heart was retracted and the descending aorta was exposed through the posterior pericardium. The old graft was excised and a new Dacron graft was pulled down into the descending aorta from the distal arch. The graft was anastomosed to the descending aorta. After we repaired the other aortic arch branch and ascending aorta, the left subclavian graft and graft branch were anastomosed. There was no bleeding or other complication and the patient was discharged. The pull-through method should be considered for such descending aortic aneurysm cases.

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We report a case of surgical treatment for pseudoaneurysm 4 years after Patch-and-Glue Repair of left ventricle free wall rupture (LVFWR) due to acute myocardial infarction (AMI) in 2004 in a 74-year-old woman, she had been followed in our hospital. And 2 years later, echocardiography and MRI showed a pseudoaneurysm at the repair spot which was growing very slowly. Since we found a thrombus in the pseudoaneurysm, a redo operation was performed in 2008. The pseudoaneurysm was successfully extirpated, under cardiopulmonary bypass. The infracted area had degenerated to scar tissue and we could suture tightly without worrying about a fissure in the wall. We can use Patch-and-Glue Repair to rescue the LVFWR patients due to AMI in the acute stage because it is possible to remove the pseudoaneurysm in the future, on pseudoaneurysm excision in a firmly infarcted area is possible in the chronic stage.

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We report a case of ulcerative colitis (UC) after mitral valve replacement (MVR) surgery due to infective endocarditis (IE). A 59-year-old woman underwent MVR for mitral regurgitation due to IE. Six days after the surgery, melena was observed suddenly, and she received a blood transfusion. Ulcer and erosion were observed in the rectum 5 to 10 cm from the anal ring by endoscopy. We changed her antibiotic treatment and stopped warfarin potassium. Heparin sodium was started 2 days after melena. We diagnosed ulcerative colitis from the finding of the rectal lesion and biopsy. We gave mesalazine and betamethasone as treatment for UC. The patient's condition improved and her general condition stabilized. She was discharged 36 days after surgery.

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A 22-year-old woman had been treated with a Ross operation for aortic root aneurysm and aortic regurgitation 10 years previously. In the initial Ross operation, a handmade tri-leaflet conduit was used for the right ventricle outflow tract (RVOT) reconstruction. The conduit was prepared preoperatively, by sewing a folded 0.1 mm expanded polytetrafluoroethylene (ePTFE) membrane onto the luminal cavity of the 24 mm woven double velour vascular graft, thereby creating a tri-leaflet valve. During ambulatory follow up after discharge, dilation of the pulmonary autograft had been observed, and its maximal diameter reached 60 mm. Furthermore, preoperative a pressure study revealed a 25 mmHg pressure gradient between the right ventricle and the pulmonary artery. At the time of reoperation, we performed an aortic root replacement combined with RVOT conduit replacement. A 24-mm woven double velour vascular graft integrating a 21-mm On-X mechanical prosthesis was used for aortic root replacement. A handmade ePTFE tri-leaflet conduit, 26 mm in size, was used to replace the previous RVOT conduit. The operation was successful, and the postoperative course was uneventful. The explanted conduit was sent for microscopic examination, which revealed that the graft was covered by a fibrocollagenous membrane. On the contrary, no surface membrane was found on the ePTFE valve. Moreover the microscopic examination showed cystic medionecrosis of the pulmonary autograft. Both dilatation of the pulmonary autograft and RVOT conduit failure were successfully treated at the second operation. However this young patient will require follow-up of the mechanical prosthesis and RVOT conduit for the rest of her life.

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A 64-year-old woman who had been followed for complete right bundle branch block at another hospital was found to have heart failure due to cardiac sarcoidosis. She was admitted because of progressive thinning of the ventricular septum and septal aneurysm which protruded into the right ventricle. On echocardiogram, her left ventricular ejection fraction had decreased to 40%. We decided to perform an operation because the patients's heart failure was thought to be due to dyskinesia of the ventricular septum with bulging of the septum into the right ventricle during systole, which consequently decreased cardiac output. The scarred ventricular septum, which was observed through right atrial, right ventricular and aortic incisions, was incised along the marginal normal interventricular myocardium. A tailored 4×3 cm oval Dacron patch was secured over this opening. A DDD pacemaker was implanted for complete atrio-ventricular block and, to synchronize both ventricles, ventricular leads were fixed on the right and left ventricular epicardium. Her postoperative course was uneventful. A postoperative pathologic study revealed a noncaseating granuloma on the border of the normal myocardium. We report a rare surgically treated case of cardiac sarcoidosis.

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A 27-year-old woman was given a diagnosis of infectious endocarditis with severe tricuspid regurgitation. Despite adequate antibiotics therapy, her general condition did not improve, and moreover multiple pulmonary abscesses were detected by computed tomography. Therefore surgery was indicated. Surgery consisted of removal of vegetation and tricuspid valve plasty with autologous pericardial patch augmentation of the anterior leaflet. Tricuspid valve plasty was carried out without prosthetic materials. Her postoperative course was uneventful with only mild tricuspid regurgitation. One year after surgery, neither recurrence of infection nor worsening of tricuspid regurgitation was noted. This method could be a useful technique for young patients with severe infection.

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A 72-year-old man presented with low back pain, intermittent claudication, atrophy of the muscle of the lower extremities, and impotence. Laboratory tests revealed inflammation, and computed tomography showed an abdominal aortic aneurysm with severe stenosis of the terminal aorta. Consequently, we diagnosed an infected aortic aneurysm and antibiotics were administered intravenously. Bacterial culture of the blood on admission demonstrated Listeria monocytogenes. On day 27 after admission, in situ replacement with a rifampicin-soaked vascular prosthesis and omentopexy were performed. After the surgery, intermittent claudication, atrophy of the muscles of the lower extremities, and impotence improved dramatically. The postoperative course was uneventful. Antibiotics were administered for a long period, and the C-reactive protein levels decreased to a normal range. For 18 months thereafter, the patient has been doing well without any sign of infection.

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We report a case of aneurysm located at the right sinus of Valsalva with mild aortic regurgitation (AR). The patient was a 55-year-old man with hypertension. When he consulted a local doctor complaining of back pain, aneurysm of right sinus of Valsalva was unexpectedly diagnosed by detailed examinations. He was transferred to our hospital for surgery. An echocardiogram showed mild aortic regurgitation and enlargement of the right sinus of Valsalva. Computed tomography demonstrated an unruptured and extracardiac aneurysm of the right sinus of Valsalva (diameter, 45 mm) and a right coronary artery (RCA) that originated from just above the ostium of the aneurysm. He underwent a partial aortic root remodeling procedure with trimmed Hemashield graft and the RCA was anastomosed to the Hemashield graft by the Carrel patch technique. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. Postoperative angiography revealed that aneurysm of the right sinus of Valsalva was not enhanced and the RCA was patent. This procedure preserve the patient's own aortic valve and normal sinus of Valsalva and enabled him to have more physiologic hemodynamics than patch closure, although progression of the AR requires careful follow-up.

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