A 50-year-old man was referred to our hospital with a tumor in the left ventricle. He had suffered from rheumatic fever when 14 years old. He had shown signs of chronic heart failure due to atrial fibrillation and rheumatic valves (ASr, MSr) for 10 years. There was a history of unaccountable fever and rash, so infective endocarditis was suspected and echocardiography was performed. It showed a homogeneous mass with a diameter of approximately 10mm, fixed directly to the left ventricular septum 20mm below the aortic valvular ring. At operation, the tumor was excised together with endocardium and a part of the muscular coat. The rheumatic aortic and mitral valves were replaced with a 21mm SJM AHP and a 27mm SJM MTK mitral valve, respectively. Tricuspid annuloplasty (TAP) (De Vega 29mm) was also performed. Histopathological examination of the tumor revealed benign papillary fibroelastoma. It suggested that the tumors were secondary to mechanical wear and tear, and represent a degenerative process due to rheumatic valve disease.

The use of the internal mammary artery (IMA) is now routine in most coronary artery bypass grafting (CABG) because of its improved long-term patency and survival. A small but important percentage of these patients will require valve surgery and thoracic aortic aneurysm repair following CABG. These operations present a challenging problem for the cardiac surgeon because of difficulties regarding approach, dissection around the IMA and optimal myocardial protection. We investigated surgical results and the effectiveness of various methods of myocardial protection in 8 patients who underwent reoperations between December 1983 and June 2005. The mortality was 13%. There were 2 perioperative myocardial infarctions (25%), 6 cases of prolonged ventilation (75%), 3 cases of low output syndrome (38%), 1 case of acute renal failure (13%) and 1 case of sepsis (13%). We carried out resternotomy for 6 patients without any hospital death or perioperative myocardial infarction. Our reoperation approach had acceptable risk control with resternotomy, avoidance of dissecting the IMA and hypothermic perfusion.

Although sequential bypass with in situ arterial conduits (the left and right internal thoracic arteries; LITA and RITA, the right gastroepiploic artery; GEA) in coronary artery bypass grafting (CABG) is technically demanding, it is one of the most important procedures using a limited number of in situ arterial conduits to revascularize a wide area. In this report, we retrospectively investigated the clinical outcome of CABG with 4 or more distal anastomoses using only in situ arterial conduits. From December 1990 to May 1999, 62 patients underwent CABG with in situ arterial conduits, with at least one sequential bypass. There were 59 men and 3 women patients with mean age of 59.6 years (41 to 82 years). Mean postoperative follow-up period was 32 months (1 to 101 months). The total number of distal anastomoses was 4 (1 sequential bypass) in 54 patients, 4 (2 sequential bypasses) in 6 patients, 5 (1 sequential bypass) in 1 patient and 6 (3 sequential bypasses) in 1 patient. There were 5 emergency operations (8%), 37 patients (60%) had a history of myocardial infarction, 30 patients (48%) had diabetes mellitus and 6 patients (10%) had chronic renal failure and were on hemodialysis. Left ventricular ejection fraction was 40% or less in 15 patients (24%). There were no early deaths. Angiographic patency was satisfactory for each graft (sequential: individual, LITA 96.7%: 100%, RITA 100%: 100%, GEA 89.5%: 97.4%). Patency of a distal anastomoses of GEA was rather poorer than that of proximal (p=0.03). Three patients died during the follow-up period (all of them due to malignancy). The 5-year actuarial survival and cardiac event-free rate was 94.6% and 87.2%, respectively. In conclusion, although an indication of GEA sequential grafting needs further study, in situ arterial grafting with at least one sequential arterial conduit was associated with excellent results and achieved more complete revascularization with exclusive use of in situ arterial conduits in patients with diffuse coronary artery disease.

A 71-year-old man was given a diagnosis of saccular aneurysm of the aortic arch (maximum 48mm in diameter) at the age of 68. When he was 69 years old, he began to take steroids for autoimmune hepatitis (AIH). The following year, the aneurysm was enlarged to 52mm. Further examinations showed the aneurysm to extend to the ostium of the left subclavian artery. Since he had transient ischemic attacks, ultrasonography of the carotid arteries was performed. Bilateral internal carotid stenoses were detected, however, cold Xe CT showed an almost normal pattern of cerebral blood flow. We decided that operation was feasible using retrograde cerebral perfusion (RCP). Liver dysfunction due to AIH improved, and his steroid dosage was tapered. Using RCP, the no-touch technique and the elephant trunk procedure, he underwent the replacement of ascending aorta and aortic arch and was discharged without major complications. RCP and the no-touch technique might enable safer operations on patients with carotid stenoses.

Background : The improvement in surgical results for congenital heart disease has resulted in an increase in the number of adult congenital heart disease (ACHD) cases. Some ACHD patients are known to develop thoracic aortic aneurysm (TAA) at a young age, so we examined TAA in ACHD patients presenting at our institute over a 10-year interval. Methods : From 2002 to 2011, we performed 32 cases of surgery for TAA in ACHD patients. We excluded 5 cases of adult bicuspid aortic valve, 2 of TAA with untreated congenital heart disease (CHD), 1 of Marfan syndrome with CHD, and 9 of coarctation of the aorta (CoA) repair for the same site ; 15 patients were included. Results : The male/female ratio was 13/2, and the age of reoperation was 33.3±10.8 years. The 15 ACHD patients included 5 cases of the tetralogy of Fallot (TOF), 4 of congenital aortic stenosis (AS), 3 of ventricular septal defect (VSD), and 1 of each CoA complex, polysplenia/double outlet right ventricle (DORV), and polysplenia/corrected transposition of the great arteries (cTGA). Twelve cases of root dilatation and 2 of ascending aortic aneurysm were observed and 10 cases were concomitant with moderate to severe aortic regurgitation. Thirteen cases underwent elective surgery and the other two cases were emergency surgeries : a Bentall procedure for type 2 acute aortic dissection of polysplenia/DORV, and a Bentall and right ventricular outflow reconstruction (RVOTR) for ascending aorta/right ventricle rupture due to Konno patch detachment in congenital AS. The 13 elective cases included 11 cases of Bentall procedure, 1 of ascending aorta/hemi arch replacement, and 1 of ascending aorta replacement. Concomitant procedures were 1 case of aortic valve replacement, 1 of mitral valve replacement, 1 of subaortic stenosis release, and 2 of RVOTR. Operation time was 572.8+/-101.4 min, cardiopulmonary bypass time was 295.8+/-100.2 min, and aorta clamp time was 188.1+/-58.8 min. One hospital death was observed in 1 emergency case due to methicillin-resistant Staphylococcus aureus (MRSA) sepsis, but no 30-day mortality was observed. Intensive care unit (ICU) stay was 9.4+/-10.1 days and hospital stay was 34.4+/-18.2 days. Conclusion : The most common ACHD found during TAA surgery in our institute was Tetralogy of Fallot. ACHD had various complications and restrictions for surgery but TAA surgery in ACHD patients was safe and feasible.