We report a case of minimally invasive cardiac surgery treated by small right intercostal thoracotomy for left atrial myxoma after substernal reconstruction of the esophagus using gastric interposition. This technique could not only alleviated risk at the second median sternotomy, but was also minimally invasive. A 63-year old man was admitted to our hospital for complaints of right upper limb asthenia and slight fever. Computed tomography showed cerebral infarction. Moreover, cardiac ultrasonography showed a giant myxoma in the left atrium. We thought that it was impossible to reperform median sternotomy, because there was high risk of injury to the reconstructed esophagus using a gastric duct behind the sternum. The patient underwent excision of the myxoma by the right intercostal thoracotomy approach, and did well. He was discharged from the hospital without any complications.

A 51-year-old woman with a 12-year history of chronic hemodialysis and secondary hyperparathyroidism suffered dyspnea induced by massive mitral regurgitation due to severe circular mitral annular calcification. Her anterior mitral leaflet was resected and successfully replaced with a 25mm SJM valve in the supra-annular position. The posterior leaflet was heavily calcified and adhered to the left ventricle. The flangeless prosthesis was directly implanted into the left atrial wall on the calcified annulus. Postoperative cine fluoroscopy and echocardiography showed good hemodynamic performance of the prosthesis without perivalvular leakage. In cases of mitral annular calcification due to chronic renal failure, the SJM valve is a more suitable valve prosthesis for replacement of the mitral valve in the supra-annular position. Supra-annular mitral valve replacement without a flange may give superior valve-performance compared to valves with a flange considering thrombogenicity and left ventricular function. However, we may still have to consider the indication of a supra-annular mitral valve replacement with a flange in cases with wide mitral annular calcification in the giant left atrium.

A 68-year-old male was admitted as an emergency case because of two severe back pain episodes in one week. Chest X-ray showed a marked prominence of the aortic knob. A remarkable bulging of the distal aortic arch and a crescentic low density area along the descending aorta on enhanced chest CT suggested a closing aortic dissection. Operation revealed extensive collapse of the very fragile intima of the aneurysmal wall and extraluminal hematoma along the descending aorta due to bleeding from the ruptured site. The ruptured aneurysm of this type should be accurately differentiated from the DeBakey type III closing aortic dissection which can be followed up medically.

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.