A 61-year-old woman was admitted to our hospital because of acute heart failure. The angiogram showed an enlarged aortic root and aortic incompetence which indicated annulo-aortic ectasia. An aortic valve-sparing operation was impossible because of severe prolapse of the aortic valve and the patient hesitated to have anti-coagulation therapy. Thus we performed aortic root replacement with the Freestyle™ stentless porcine valve (Medtronic Inc.). We plicated each original commissure in order to narrow the enlarged annulus and attach the Freestyle valve to the annulus directly by continuous suture. There was no significant difference in surgical technique and aortic cross-clamping time, compared to conventional operation. Aortic root replacement with the Freestyle valve seems an attractive option especially for elderly patients or cases in which of contraindicated for anti-coagulation therapy.

We report a rare case of aorto-right ventricular fistula and vegetation in the right ventricle after aortic valve replacement. A 74-year-old woman with a history of aortic valve replacement with a Carpentier-Edwards Perimount pericardial bioprosthesis 7 months earlier was admitted with fever. Methicillin-sensitive Staphylococcus aureus was detected from her blood culture. Transthoracic echocardiography showed an aorto-right ventricular fistula and vegetation in the right ventricle. Under a diagnosis of infective endocarditis, surgery was performed. The operative findings showed a fistula from the previous aortic suture line to the right ventricle, and substantial vegetation in the right ventricular outflow tract. No infective change was observed in the previously inserted prosthetic or pulmonary valves. The vegetation was removed and the fistula was closed directly with a single pledgeted 4-0 prolene mattress suture. The right ventricular outflow tract was reconstructed with a heterogeneous pericardial patch. The patient was discharged in good health on the 59th postoperative day without any infective complications.

In 46-year-old man who had had general fatigue due to hypertension for about 20 years, only hypertension of the upper part of the body had been pointed out; the blood pressure of the upper limbs was 190mmHg and that of the lower limbs was 80mmHg. Computed tomography showed severe aortic stenosis with advanced calcification from the proximal descending thoracic aorta to the infra-renal abdominal aorta, the minimum caliber of the aorta being only 5mm. Hypertension was not controlled in spite of administration of 5 anti-hypertensive agents. Because renal factors were not related to hypertension, we chose a minimally invasive procedure: axillo-bifemoral artery bypass. After operation, the difference of blood pressure between upper and lower limbs reduced and symptoms disappeared. There are many case reports of aorto-aortic bypass for atypical coarctation, but we think that the less invasive axillo-bifemoral artery bypass is also an alternative procedure.

A 67-year-old man with aortic insufficiency underwent aortic valve replacement (AVR) with a Freestyle^TM valve (Medtronic Inc.), using the complete subcoronary technique. Although a trivial aortic insufficiency remained on postoperative echocardiography, he continued without chest symptoms. A cardiac murmur developed and dyspnea on effort appeared five months postoperatively. Echocardiography and aortography showed severe aortic insufficiency, and a re-do AVR was performed seven months after the first procedure. Examination of the Freestyle valve revealed that two loops of the suture line on the inflow side of the valve had become detached from the muscular tissue. It is most important to keep the geometry of the Freestyle valve at the time of the implantation using the subcoronary technique, and an unsuitable implantation can cause consequent perivalvular leakage.

A 60 year-old female underwent mitral valve replacement with a Duromedics valve. She was in good condition during weaning from cardiopulumonary bypass. However, rupture of the left ventricle was manifested by massive bleeding just after dis-contination of cardiopulmonary bypass. A large hematoma accompanied by bleeding was observed in the posterior atrio-ventricular groove. The patient was quickly put back on total cardiopulmonary bypass. A slight laceration was suspected in the membranous portion of the ventricular septum just below the mitral annulus. Re-valve replacement was performed by reinforcing the mitral annulus with a Dacron patch. This patient was removed from cardiopulmonary bypass, but died of multiple organ failure in 7 days after operation. At autopsy, the left ventricular rapture was identified just below annuls in the area of the atrioventricular groove. Furthermore, extensive hematoma was noted in the posterior atrioventricular groove.

A 33-year-old woman underwent aortic root replacement for aortic regurgitation and an aneurysm of the ascending aorta due to annuloaortic ectasia. Ehlers-Danlos syndrome was diagnosed by skin biopsy when she was 23 years old. At operation, to avoid mechanical stress to the residual aorta, cardiopulmonary bypass was established via cannulation of the left femoral artery and we used the open distal anastomosis method under hypothermic circulatory arrest with selective cerebral perfusion. Moreover, the sutures of the aortic annulus were reinforced sewing the aortic wall together. Her postoperative course was uneventful. Despite the fragility of the cardiovascular tissues in Ehlers-Danlos syndrome, cardiac surgery could be performed safely with appropriate surgical procedures.

We report a rare case of lipoma arising from the right ventricle. A 66-year-old woman was admitted to our hospital for exertional chest pain and fatigability. She was diagnosed of mild aortic stenosis and regurgitation (ASR), mild mitral regurgitation (MR), and asymptomatic cardiac tumor in the right ventricle about two years previously, for which she had been followed up at other local hospital. A recheck transthoracic echocardiography revealed moderate MR. No evidence of deterioration of ASR and cardiac lipoma were detected. The patient underwent mitral annuloplasty and replacement of aortic valve, plus resection of the right ventricle tumor through the tricuspid valve. Pathological examination of the resected tumor showed mature adipose tissue infiltrated into normal cardiac muscle without atypical cells, which suggested intramyocardial lipoma. Postoperative course was uneventful. Fourteen months after the operation, the patient remains asymptomatic and regular echocardiographic checkup demonstrates no tumor recurrence or residual MR.

Myxoma of the left ventricle is exceedingly rare and to the best of our knowledge not a single case of its recurrence has been reported in Japan. We have recently experienced a case in which a myxomatous tumor of the left ventricle recurred at the same site as the primary lesion 2.5 years after operation and was treated by surgical excision. The patient was a 28-year-old female who, under the diagnosis of myxoma of the left ventricle, underwent surgical removal of the tumor and mitral valve replacement at her age of 25 years. Although her postoperative course was uneventful, she was noticed, at her age of 28 years, of her inaudible prosthetic valve clicks on auscultation at the outpatient service. Echocardiography revealed a tumor mass in the left ventricle, which tended to grow with the elapse of time. Echocardiography on rehospitalization disclosed a mobile cystic tumor on the posterior wall of the left ventricle, while pulmonary arteriography also revealed a movable tumor in the left ventricle. Intraoperatively, there was noted a solid tumor, composed partly of cystic structure, on the posterior wall of the left ventricle and quick pathology led to a suspected diagnosis of myxoma. Since the tumor was found to have involved the ventricular septum and myocardial tissue of the posterior wall of the left ventricle, its complete surgical excision was impossible. The tumor, with its growth pattern and morphology, was diagnosed as a malignant clinical behavior one, although histopathological evidence indicates its benignancy.

The current technique of retrograde coronary sinus perfusion (RCSP) has been provided double cannulation of the vanae cavae and isolation of these vessels, and right atriotomy. Most aortic valve and coronary artery bypass surgery are performed with single venous cannulation. We used a new RCSP catheter, Retroplegia (Research Medical Co.), and performed Cabrol procedure safely with single venous cannulation. This catheter can be cannulated to the coronary sinus through a right atrial purse-string suture without opening the right atrium. The occlusion balloon is inflated spontaneously by infusing the cardioplegic solution and occlude the coronary sinus adequately and nicely. This catheter has double lumen, one is for infusion of the cardioplegic solution, the other is for measurement of the coronary sinus pressure. We believe that this catheter is useful for RCSP of the cardiac surgery using single venous cannulation.

The 37-year-old woman underwent mitral valve replacement (MVR) with a Carpentier-Edwards bioprosthesis for hypertrophic obstructive cardiomyopathy (HOCM) 14 years previously. Since the 10th postoperative year, progressive right heart failure due to tricuspid valve regurgitation was recognized. Therefore, reoperation was recommended. At the time of reoperation in the 14th postoperative year, the cavity of the left ventricle was markedly diminished. In particular, deformitiy of the right ventricle was found. This was considered to be the effect of progressive septal hypertrophy. The mitral valve was replaced with a 25mm Carpentier-Edwards and the tricuspid valve with a 31mm Carpentier-Edwards bioprosthesis. Although the weaning from the cardiopulmonary bypass was uneventful, postoperative right heart failure occured with hyperbilirubinemia followed by multiple organ failure. She died on the 47th postoperative day. At autopsy, the intraventricular septal thickness was 24mm and the cavities of left and right ventricle were almost occluded by septal hypertrophy. This is considered to be a rare case of long-term survival after MVR in a patient with HOCM.