Papillary fibroelastoma is a rare benign cardiac tumor generally arising from the valvular endocardium. We describe the successful surgical management of a patient who had a papillary fibroelastoma attached to a false tendon of the left ventricle. A 71-year old man was admitted with a left ventricular tumor. Routine transthoracic echocardiography revealed a mobile, 6×8 mm mass, which was attached to a false tendon in the apical area of the left ventricle. Continuous intravenous heparin was commenced to avoid the embolism, and then an urgent operation was performed, consisting of left ventriculotomy following establishment of a standard cardiopulmonary bypass. A mobile gelatinous mass with a short stalk, 7 mm in diameter, was attached to the false tendon. The mass was excised including a part of the false tendon. The excised tumor changed its shape in saline to a sea-anemone like tumor. The histopathological findings were consistent with the diagnosis of papillary fibroelastoma. The patient made an uneventful recovery and was discharged from the hospital on postoperative day 12.

Our strategy for treatment of thoracic aortic aneurysms with severely stenotic or occluded cerebral vessels is as follows. 1) The status of cerebral vessels and brain is assessed in detail by a team of neurologists and neurosurgeons, 2) cerebral surgical treatment is performed prior to aortic arch surgery, and 3) reconstruction of the total arch is performed using the arch-first technique through a median sternotomy. We successfully performed artificial graft replacement of the total aortic arch in two patients with old cerebral infarcts and severely stenotic cerebral vessels. In both cases, the operation was performed through median sternotomy under circulatory arrest by feeding the blood to the ascending aorta and draining it from the right atrium. Cerebral protection during reconstruction of the aortic arch was provided by profound hypothermia and retrograde cerebral perfusion (RCP). Prior to the incision of the aneurysm, cerebral branches were dissected to avoid escape of debris into cerebral vessels. The graft replacement was completed in 4 steps: 1) anastomosis of each of the 3 arch vessels, 2) distal anastomosis of another graft for the elephant trunk procedure, 3) anastomosis of the arch graft and the graft for the elephant trunk, and 4) proximal anastomosis. Just after cerebral branches were anastomosed to the 3 branches of the graft, the blood was supplied to the brain through the side branch of the graft instead of RCP. No signs of neurological deficit occurred postoperatively. The above protocol provided protection of high-risk patients with old cerebral infarcts from possible postoperative brain damage.

Patients on chronic hemodialysis, undergoing coronary artery bypass grafting (CABG) have high perioperative mortality and morbidity. In order to reduce the perioperative risks, we performed intraoperative hemodiafiltration (HDF) during off-pump CABG (OPCAB). A 62 year-old-man, who had been on dialysis for 2 years, was admitted with a sensation of chest compression. A coronary angiography revealed 75% stenosis with severe calcification in the left anterior descending artery and 90% stenosis in the second diagonal branch. During the operation, veno-venous HDF was started, using a double lumen catheter that was introduced into the femoral vein at the same time that a skin incision was made. During the exposure of the diagonal branch by rotating the heart, the blood flow of HDF was decreased and dehydration was halted to avoid hemodynamic deterioration. The patient was extubated 1.5h after the operation and did not require continuous hemodiafiltration (CHDF) in the intensive care unit (ICU). Routine hemodialysis was restarted on the 3rd postoperative day. The postoperative course was uneventful, and the patient was discharged to home on the 11th postoperative day. HDF during OPCAB for this chronic dialysis patient was observed to be effective and yielded an excellent postoperative recovery without CHDF in the ICU.

An 81-year-old man who had a saccular abdominal aortic aneurysm (AAA) with a narrow terminal aorta underwent endovascular aortic aneurysm repair (EVAR) with the Medtronic Endurant^® stent graft system. After 4 days, computed tomography (CT) showed stenosis of the stent graft left limb, which was pressed flat against the right limb at the narrow terminal aorta. We performed re-intervention to dilate the narrow terminal aorta and bilateral limbs with kissing stenting using Express Vascular LD^® (Boston Scientific). After operation his ankle brachial pressure index rose from 0.88 to 0.99 and there was no evidence of stenotic limbs at CT image. We need to be careful about the stenotic limb after EVAR with Medtronic Endurant stentgraft system for AAA with a narrow terminal aorta.

We developed a new double-lumen balloon catheter for retrograde cerebral perfusion (RCP) via jugular vein cannulation. Between November 1996 and September 2000, 34 of 73 patients treated with surgical procedures for thoracic aortic aneurysms underwent RCP using the new catheter during circulatory arrest under deep hypothermia. Nine patients underwent a median sternotomy, and 25 underwent a left thoracotomy. In all cases, the new catheter installation under fluoroscopy was easy, and it took about 15min. The mean RCP time, pressure, and flow rate were 26.8min, 20.0mmHg, and 202.6ml/min, respectively. Our procedure using the new catheter was safe and easy in RCP during circulatory arrest in aortic arch replacement regardless of surgical approaches such as a left thoracotomy or median sternotomy.

An 89-year-old man complained of pulsatile masses in his right groin. Computed tomography (CT) scans revealed an aneurysm of the right deep femoral artery. He was admitted to our hospital with a diagnosis of deep femoral artery aneurysm (DFAA). The clinical frailty scale score was 6 (moderately frail), and he also suffered chronic obstructive pulmonary disease (COPD). Considering his complicated frail and impaired pulmonary function, conventional graft replacement and aneurysmectomy were thought to be quite a high risk. Thus, we selected endovascular treatment. It was not possible to secure a sufficient proximal landing zone for measurement, we did not select a stent-graft treatment. Therefore, we performed hybrid therapy with proximal neck ligation and distal outflow coil embolization. The postoperative course was uneventful, and CT disclosed complete occlusion of the aneurysm.