Health Information Exchange (HIE) is the most prevelant patient information sharing technology currently in use. Although a number of regional healthcare information systems exist in Japan, little is known about the effectiveness of the systems or how effectiveness should be measured. As an approach to this issue, we developed a framework for measuring effectiveness of HIE using the dimensions for health indicators from ISO/TS 21667:2004 "Health Indicators Conceptual Framework". Three phases for measuring HIE are defined: Phase I: the static aspects of a system; Phase II: the use of the system; Phase III: the outcomes of the use of the system. Complex factors involved in HIE are organized and objectives of evaluation are made clear. The domains to which measures are applied and categories of measures are defined. Sample measures extracted from publications and co-authors' studies are discussed. This work is the first step towards the systematic development of a framework of measures of the effectiveness of HIE.

We describe here an initial successful case of valve-sparing surgery using reimplantation technique in a 24-year-old male with aortic root dilatation with truncal valve insufficiency after common arterial trunk repair. Concomitant right ventricular outflow tract reconstruction with expanded polytetrafluoroethylene was also successfully performed. He was discharged home on postoperative day 10 without stenosis or regurgitation of repaired valves. He is in New York Heart Association class I condition without any anticoagulant agents 6 months after operation. Of course, careful follow-up will be needed though our early result is acceptable. (C) 2014 by The Society of Thoracic Surgeons

A 61-year-old asymptomatic woman was referred for echocardiography to evaluate recently detected systolic murmur. Transthoracic echocardiography revealed an echodense obstructive mass in the left ventricular outflow tract of unclear origin. Subsequent transesophageal echo suggested an intracardiac calcified tumor and recommended surgical excision. Contrast-enhanced cardiac computed tomography (CT) confirmed a well-defined lobulated mass adherent to the anterior mitral valve leaflet, the non-enhanced scout view revealed marked hyper-attenuation confirming diffuse calcification. Caseous calcification was diagnosed and surgery was deferred. Caseous calcification is typically benign and most commonly involves the posterior mitral annulus. Our patient displayed an atypical location of exuberant mitral annular calcification.

A 20-year-old man with fever and chest pain was referred to our hospital, where purulent pericarditis was confirmed by various examinations. Hemodynamic collapse and acute pulmonary edema occurred 1 week later, caused by acute severe aortic valvular regurgitation (AR). Emergency surgery revealed that the AR had been caused by avulsion of the aortic valvular commissure, which seemed to have resulted from penetration of the pericardial inflammatory process to the aortic root. We report this case because purulent pericarditis is now relatively uncommon and resultant aortic commissure avulsion is even rarer.

A 43-year-old man with congenital double-outlet right ventricle and pulmonary atresia was referred to our institution for his respiratory discomfort. He had undergone ventricular septal defect closure, ligation of patent ductus arteriosus (PDA), and a Rastelli procedure at the age of 7. Transthoracic echocardiography revealed pulmonary artery stenosis caused by calcification of the prosthetic valve with a peak transvalvular pressure gradient of 116 mm Hg and residual atrial septal defect. Heartbeat-synchronized multi-detector computed tomography (MDCT) revealed recanalized PDA, collateral arteries from the descending thoracic aorta to bilateral pulmonary arteries, and coronary artery aberrancy. His coronary system consisted of three isolated coronary arteries, the origin of which arose from each sinus of Valsalva (Fig 1A) : main right coronary artery (RCA) from anatomic noncoronary sinus (Fig 1B), independent right ventricular (RV) coronary branch from the original right coronary sinus (Fig 1B), and left coronary artery (LCA) from the left coronary sinus (Fig 1C). Furthermore, whereas the left circumflex artery (LCX) appeared normal, the left anterior descending artery (LAD) was dilated and directly drained into the posterior left ventricle (LV), forming a coronary-to-ventricular fistula. For these conditions, we performed transcatheter coil embolization of the aorta-to-pulmonary collaterals, surgical ligation of the PDA, patch closure of the atrial septal defect, and reformation of a valved conduit between the RV and main pulmonary trunk. Considering the minor shunt of the LAD to the LV, the fistula was not closed, leaving the possibility of requiring transcatheter coil embolization in the future. The postoperative course was uneventful. MDCT proved useful in precise understanding of the three-dimensional structure of the heart, including the coronary system. Based on the information provided, we could successfully avoid injury to the coronary arteries and the RV on reentry of the densely adhesed mediastinum (Fig 2).Fig 2View Large Image Figure ViewerDownload (PPT)

Recently, several new anticoagulants have been used instead of warfarin for preventing thromboembolism. In the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial, the direct thrombin inhibitor dabigatran etexilate was as an effective and safe as dose-adjusted warfarin for prevention of stroke in high-risk patients with atrial fibrillation. However, the safety and efficacy of thromboprophylaxis after mechanical valve replacement is uncertain. We report a 57-year-old man with a mechanical heart valve who experienced acute upper limb thromboembolism during dabigatran intake. Dabigatran might be inadequate for thromboprophylaxis after mechanical valve replacement. (C) 2013 by The Society of Thoracic Surgeons

A 74-year-old man who had undergone implantation of a biventricular pacing apparatus for his ventricular contractile dyssynchrony resulting from dilatated cardiomyopathy (DCM) 5 years previously was referred to our hospital for congestive heart failure. Transthoracic echocardiography showed severe mitral regurgitation, which seemed to result from significant dilatation of the mitral annulus along with downward tethering of the valve. Additionally, moderate aortic stenosis was seen. Three-dimensional transesophageal echocardiography (TEE) showed moderate sclerotic changes in the right and noncoronary cusps, consisting of an almost bicuspid configuration, with a rudimentary left coronary cusp, which had a hole 5 mm in diameter (Fig 1). For this patient, we performed a combined procedure of mitral annuloplasty using Carpentier-Edwards Physio II Annuloplasty Ring (30 mm; Edwards Lifesciences, Irvine, CA) and aortic valvular replacement with Carpentier-Edwards PERIMOUNT Aortic Heart Valve (25 mm; Edwards Lifesciences. A rudimentary left coronary cusp with a 5-mm hole had adhered to the aortic wall at the supravalvular level, so we were not able to look at the ostium of the left trunk directly, and 2 other large cusps were moderately sclerotic (Fig 2). The postoperative course was uneventful.Fig 2View Large Image Figure ViewerDownload (PPT) A rudimentary cusp of the aortic valve is a congenital deformity. Although echocardiographic findings of unequal proportions of the 3 cusps may be diagnostic, it is sometimes difficult to define precisely. In this respect, the 3-dimensional TEE may be helpful, as in this case. There are several reports that a rudimentary cusp that covers the coronary ostium can cause ischemic heart attack. In our patient, thanks to the fenestration in the cusp, flow to the left coronary orifice was thought to be sufficient in preventing the occurrence of myocardial ischemia.

We describe the case of a 17-year-old boy with bicuspid aortic valve with two raphae, for whom subvalvular circular annuloplasty and adjustable cusp suspension procedures successfully terminated severe regurgitation.

We report two cases of non-obstructive mesenteric ischemia (NOMI), a rare but potentially lethal complication after cardiovascular surgery, which was successfully managed. In both cases (a 74-year-old chronic hemodialysis patient who underwent emergency aortic valve replacement and coronary artery bypass graft (CABG), and a 74-year-old patient who underwent emergency abdominal aortic aneurysm operation), NOMI occurred early postoperatively (on day 8 and 22, respectively). They suffered from severe abdominal pain, confusion, and metabolic acidosis. Contrast-enhanced multi-detector CT (MDCT) scan and subsequent selective mesenteric angiography revealed characteristic signs of NOMI, for which selective papaverine infusion through the angiography catheter was performed. It was effective in both cases to halt progressive bowel ischemia and bided our time to perform a hemicolectomy of the necrotic segment. Contrast-enhanced MDCT scan and subsequent selective angiography are vital for diagnosis. If the condition does not improve after selective papaverine infusion, exploratory laparotomy and resection of necrotic intestinal segment should be performed immediately.

Septal hyper-contractility is thought to be the principal cause of significant left ventricular outflow tract obstruction (LVOT) and systolic anterior motion (SAM) of the mitral valve by making the distance between the mitral valve and papillary muscle shorter. A seven-year-old patient with severe hypertrophic obstructive cardiomyopathy underwent direct interventricular septal myectomy/myotomy using the resection/crush method to modify hyper-contractility. The procedure successfully reduced the pressure gradient from 180 mmHg to 7.6 mmHg, and systolic anterior movement of the mitral leaflet disappeared. Mitral regurgitation improved from grade 2 to grade 0. Postoperative echocardiographic vector velocity imaging (VVI) study revealed a reduced twist angle, depicting attenuated ventricular contraction power from a maximum twist 17.9° to 7.9°. Perioperative VVI revealed that interventricular septal myectomy/myotomy is useful, not only in reducing LVOT obstruction, but also in reducing hyper-contractility, which increases the distance from the mitral valve to the papillary muscle and relieves SAM.

For a 75 year-old man with extensive aortic aneurysm, who had undergone a previous infra-renal abdominal Y-graft, a staged replacement of remaining segments was performed. A hybrid procedure of open-laparotomy debranching of visceral branches and endovascular stentgraft insertion in the thoracoabdominal aorta was performed first, followed by subsequent direct replacement between the proximal ascending and distal arch using cardiopulmonary bypass. Three months thereafter dissection of enlarged proximal descending aorta occurred, for which we performed an emergent endovascular stentgraft deployment which bridged "elephant trunk" of the arch graft and the previous stentgraft. Consequently total aortic replacement was successfully accomplished without any neurological sequela.

The proper management of a patient with active infective endocarditis (IE) remains to be determined, especially when his or her condition is complicated with intracranial mycotic aneurysm. Here we present a 46-year-old company employee hospitalized with a subarachnoid hemorrhage caused by a ruptured mycotic aneurysm. Cardiac echography showed a verruca on the posterior mitral cusp and leaflet destruction, resulting in severe valvular regurgitation (determined pathogen was α-streptococcus). High-dose antibiotic infusion and restriction of physical activity to prevent heart failure were combined with emergency craniotomy drainage and coiling of the necks of two cerebral mycotic aneurysms. After 2 months of conservative therapy for IE, he suddenly collapsed with hypotension and bradycardia because of embolic occlusion of the proximal right coronary artery (RCA). An emergent operation was carried out to remove the emboli in the RCA and to replace the mitral valve with a mechanical prosthesis. The postoperative course was uneventful. Although disturbances of spatial recognition and manual dexterity remained, he was able to walk and talk. After postoperative sufficient-duration antibiotic therapy, which lasted 20 days, he was transferred to a rehabilitation center.

From Jul/1997 to Jun/2007 65 patients (mean age 61; 31 to 87 years) underwent emergency graft replacement of the proximal aorta for acute Stanford A dissection. Operative Method: Unless intimal tear was present in the arch, ascending aortic replacement was performed. As regards Valsalva sinus, we made effort as much as we could to appose intima and adventitia using GRF glue to reconstruct the structure and subsequently anastomose a tube graft to the transected proximal stump at the level just above the sino-tubular junction. Consequently, operative procedures in these 65 patients were: ascending replacement, 36; ascending to hemiarch, 7; valve-sparing root replacement, 2; Bentall, 11; total arch, 9. Results: There were 2 operative deaths due to LMT occlusion (3.1%), and 2 other late hospital deaths. The remaining 61 were followed up with a mean period of 41 months. Survival rate of these patients at 10 years was 86%. There were 9 second operations (14.8%). Bentall procedure was done in 5, total arch replacement in 4, Bentall plus total arch in 1. Operative mortality in redo surgery was 1 in 9 (11.1%). Conclusions: Emergency grafting for acute D/A could be performed with low operative mortality and satisfactory long-term survival rate.

症例は70歳男性．大動脈弁閉鎖不全症（AR）にて外来経過観察を受けていたが，その増悪のため手術適応と判断された．心エコー図にて右冠尖の逸脱による高度ARが認められ，CTにて上行基部大動脈の約50 mmまでの拡大が見られた．さらに冠動脈造影検査（CAG）で右冠動脈（RCA)#2の90%の狭窄が認められた．手術はaortic root remodeling および subvalvular circular annuloplasty と逸脱したRCCに対する leaflet suspension を用いた大動脈弁形成術を施行した．RCA#2の狭窄に対しては冠動脈バイパス術を併用した．術後経過は良好で無輸血管理で第10病日に独歩退院となった．

A new apparatus has been built that annexes a normal electrocardiograph, ECG, with the aim to enhance its capacity. It adds the normal ECG power to superpose multiple records of ECG altogether and averages out them and, further, makes sophisticated analysis, such as normalizing the peak heights, evaluating the half-line widths of the peaks, or that of the standard deviations of measurements like the inter peak distances. The results of the said calculations have not been obtainable using the former instruments, and are expected to be useful for clinicians.

A 46-year-old female was admitted to our hospital complaining of dizziness. Echocardiography and magnetic resonance imaging showed a pedicled tumor in the right ventricular outflow tract (RVOT), causing severe obstruction during systole. Resection was performed under cardiopulmonary bypass. Postoperative course was uneventful, with complete disappearance of major symptoms. Histological examination revealed the nature of the tumor to be a benign hemangioma. As reports of cardiac hemangioma causing severe RVOT obstruction are extremely rare, this case warrants attention.

症例は74歳,男性.息切れを主訴に来院し,心電図上変化を認めたため,カテーテル検査を施行したところ,3枝病変を認め,大動脈造影では左鎖骨下動脈閉塞を認めた.また術前の胸部CTで上行大動脈石灰化を認めたため,手術は一期的にaxillo-axillary crossover bypass graftingとin situ graftによるoff-pump冠動脈バイパス術(CABG)を施行した.術中axillo-axillary crossover bypass grafting後の左内胸動脈(LITA)のfree flowは良好であり,術後造影ではaxillo-axillary bypassを経由してLITAが良好に造影された.術後経過は順調で術後12日目に退院した.上行大動脈高度石灰化を伴う症例に対しては,in situ graftの選択が望ましいと考えられるが,鎖骨下動脈閉塞を合併する症例でも適切な血行再建術後の内胸動脈(ITA)のflowが良好な場合は,ITAはin situ graftとして十分に使用可能であると考えられた.