SummaryThis study was conducted to evaluate the safety and efficacy of tolvaptan following open heart surgery. We retrospectively reviewed 109 patients who were administered tolvaptan following open heart surgery between August 2011 and July 2014. We divided the patients according to their urine output index (amount of urine output/body surface area) into tertiles as follows: T1 (low responders; n = 36), T2 (intermediate responders; n = 36), and T3 (high responders; n = 37). No fatal adverse events were observed following tolvaptan administration. The factors that showed a significant difference among the 3 groups were body surface area (BSA) and preoperative body weight. Body weight rapidly decreased and a greater increase in the serum sodium level was observed on day 1 in the T3 group than in the other 2 groups. No decrease in blood pressure and no significant differences in the occurrence of atrial fibrillation were observed among the 3 groups during tolvaptan administration.Tolvaptan can be safely and effectively administered to increase the urine output without adversely affecting the cardiovascular system or renal function following open heart surgery. However, careful attention is required regarding the possibility of a rapid increase in the serum sodium level so it is important to monitor changes in serum Na levels. ( open heart surgery in recent years, volume control is one of the most important factors in the perioperative management of open heart surgery. Tolvaptan, a vasopressin V2-receptor antagonist, is available as a diuretic drug that can be used in the treatment of fluid accumulation in heart failure. Several studies have reported the efficacy of tolvaptan in patients with chronic congestive heart failure and acute heart failure. [1][2][3][4][5] According to previous reports, the use of tolvaptan for acute heart failure at an early stage of hospitalization prevents exacerbation of acute kidney injury, improves patient prognosis, 6) is superior to carperitide in terms of treatment cost of acute heart failure, 7) and is effective for correcting hyponatremia. [8][9][10] Although there are case reports indicating the efficacy of tolvaptan after open heart surgery, the number of patients reported is small. [11][12][13][14] Open heart surgery using cardiopulmonary bypass is often followed by symptoms such as circulatory inflammatory response, capillary hyperpermeability due to low body temperature, decreased intravascular colloid oncotic pressure due to hemodilution, and stromal edema as a result of decreased lymph flow.15) Blood vasopressin concentration also increases after cardiac surgery because of hypotension during cardiopulmonary bypass and sympathetic nerve activation caused by operative stress.16) Therefore, it is believed that reabsorption of water in the collecting tubules is excessive following open heart surgery. Because the diuretic effect of tolvaptan reduces the accumulation of intercellular fluid through an increase in the serum Na level or a difference in osmotic pressure, tolvaptan ...

Diagnosis of vascular graft prosthesis infection is crucial, but not straightforward. Here we report two cases in which [18 F] fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18 F-FDG PET/CT) was very useful in the diagnosis of aortic graft infection. Case 1: A 77-year-old Japanese man, two months status post aortic arch graft surgery, suffered from repeated fevers. Blood cultures revealed bacteremia. 18 F-FDG-PET/CT ruled out graft infection and diagnosed lumbar pyogenic spondylitis, which was treated with antibiotics, sparing the patient a possible reoperation. Case 2: A 53-year-old Japanese man, seven years status post replacement of the aortic root and ascending aorta, had been suffering from an ostensibly aseptic fistula for over a year and a half. Although repeated CT findings had been negative, 18 F-FDG-PET/CT clearly demonstrated communication between the fistula and the ascending aortic graft. He was treated with repeat ascending aortic replacement, omentopexy, and antibiotics. Our experience supports 18 F-FDG-PET/CT as a promising modality in cases of suspected vascular graft infection.

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We report an 84-year-old woman who presented with right ventricular perforation 4 days after pacemaker implantation for syncope due to sick sinus syndrome. Median sternotomy revealed no pericardial effusion, but the pacing lead had penetrated the right ventricle and pericardium. When the pleura was opened, the tip of the lead was seen in the visceral pleura. The lead was cut in the pericardial cavity and extracted from the left subclavian wound together with the generator. The right ventricular perforation was sutured and a temporary pacing lead was placed on the right ventricular wall intraoperatively. Ten days after the surgery, a new pacemaker lead was placed in the ventricular septum via the right axillary vein. Right ventricular perforation is a rare complication after pacemaker implantation. Typically, it occurs at the time of implantation or within 24 hours after implantation. In the present case, the perforation of the right ventricle which needed urgent surgery occurred 4 days after implanting the pacing lead at the right ventricular apex. Great care should have been taken not to overlook this life-threatening complication even more than 24 hours after pacemaker implantation.

Metal allergy is an uncommon but crucial problem during surgery, which can lead to complicated skin diseases, such as palmoplantar pustulosis (PPP). 1) Among metal allergies, titanium allergy is said to be rare. 2) Here, we describe the rare case of a woman with titanium allergy and PPP who underwent coronary artery bypass grafting (CABG) under cardiopulmonary bypass (CPB) Remission of Palmoplantar Pustulosis after On-Pump Coronary Artery Bypass Grafting in a Patient with Titanium AllergyTakanori Kono, MD, PhD, 1 Takeshi Oda, MD, PhD, 1 Keiichi Akaiwa, MD, PhD, 1 Katsuhiko Nakamura, MD, 1 Kenya Sasaoka, MD, 2 and Hiroyuki Tanaka, MD, PhD 3Metal allergy is an uncommon problem during surgery. Among them, titanium allergy is said to be rare, but can lead to serious complications, such as palmoplantar pustulosis (PPP). A 69-year-old woman was admitted to our hospital with a chief complaint of chest pain. Coronary angiography showed severe coronary artery disease that required coronary artery bypass grafting (CABG). The patient had a history of orthopedic surgery for left distal radius fracture 2 years previously, which resulted in inflammation on the left arm and PPP. We suspected titanium allergy based on results of skin patch tests and use of titanium alloy in the previous orthopedic operation. The patient underwent CABG without use of permanent metallic material. As a result, her PPP disappeared. In this rare case, it is difficult to identify the exact cause of the improvement in PPP; thus, further studies are required to clarify the mechanism of remission.

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Osteopetrosis is a rare hereditary bone development disorder caused by osteoclast dysfunction, which increases bone density. Although few studies have investigated cardiovascular disease in osteopetrosis, sternotomy outcomes in this condition are unclear. We report the case of a patient with osteopetrosis and severe mitral regurgitation. A 63-year-old woman with exertional dyspnea had regurgitant systolic murmur audible at the apex. Transthoracic echocardiography showed severe mitral regurgitation due to posterior leaflet prolapse on the anterolateral side. Radiological findings revealed increased bone density (consistent with osteopetrosis). Considering risks in median sternotomy, we performed minimally invasive cardiac surgery through right minithoracotomy for mitral regurgitation. Preoperative imaging showed sclerotic rib changes; nevertheless, sufficient surgical views obtained involved the intercostal space. No residual mitral regurgitation was observed, and the postoperative course was good. To the best of our knowledge, this is the first case report on minimally invasive cardiac surgery for mitral regurgitation with osteopetrosis. K E Y W O R D S minimally invasive cardiac surgery, mitral regurgitation, osteopetrosis How to cite this article: Kono T, Takagi K, Tayama E. Minimally invasive cardiac surgery in a patient with osteopetrosis and symptomatic mitral regurgitation.