Total replacement of the aortic root in patients with anomalous origin of the coronary arteries has not been reported. We report a 63-year-old male with anomalous origin of the right coronary artery from the left sinus of Valsalva in whom aortic root replacement was performed to correct a 60mm aortic root aneurysm and a grade 4/4 aortic regurgitation. In this operation with a composite graft (a 24mm Gelseal graft with a 23mm St. Jude Medical prosthesis), modified reconstruction of the coronary arteries was necessary not only because both coronary ostia were in close proximity but also because the proximal portion of the right coronary artery was intramural. We used a modification of Piehler's technique in which both coronary ostia were simultaneously anastomosed to a beveled 10mm Gelseal graft. In this anastomosis, a small piece of the autologous pericardium was interposed between the graft and the aortic wall surrounding the ostium of the right coronary artery to protect the intramural artery from injury. This modification in reconstructing the coronary arteries was technically easy and effective in the special setting of the anomalous origin of the coronary arteries.

Left ventricular noncompaction (LVNC) is believed to represent an arrest in the normal process of myocardial compaction, resulting in persistence of both hyper-trabeculation and intratrabecular recess within the left ventricle. High mortality is the important clinical feature of this disease. LVNC in adult cases has been rarely, but occasionally, reported, however, LVNC with insufficiency of both the aortic and mitral valves has not been reported to our knowledge. Herein, we describe a 62-year-old man with LVNC and the severe insufficiency of the aortic and mitral valves, who was successfully operated upon with aortic and mitral valve replacement using mechanical valves. Although the postoperative course was uneventful, careful attention is mandatory for the possible left ventricular dysfunction due to LVNC.

Primary cardiac malignant lymphoma (PCL), which is defined as an extra-nodal malignant lymphoma involving only the heart and/or pericardium, is extremely rare. Its prognosis is reported to be very poor because the PCL grows rapidly and frequently causes fatal heart failure or arrhythmias. We report a 65-year-old woman with PCL accompanied with superior vena cava (SVC) syndrome 6 weeks following a pacemaker implantation for complete atrio-ventricular block. She underwent a partial resection of the tumor to release the SVC syndrome and subsequent systemic chemotherapy. This combined therapy successfully induced complete remission, and improvement of the atrio-ventricular conduction disturbance was also observed.

A-75-year-old man had refractory late cardiac tamponade after an off-pump coronary artery bypass grafting. He was initially treated by pericardiocentesis with oral nonsteroidal anti-inflammatory drugs, but the treatment failed. Pericardial fenestration was conducted twice for refractory pericardial effusion during his hospitalization. He presented again with recurrence of cardiac tamponade 2 months after the last pericardial fenestration. Therefore, a pleuroperitoneal shunt system was implanted. He recovered well and was discharged without reaccumulation of pericardial effusion.

We reviewed twenty patients with mechanical prosthetic heart valves who underwent noncardiac operations which were performed in the presence of continual anticoagulant therapy. Prosthetic valves used were the SJM valve in nineteen patients and the Björk-Shiley valve in one. Twenty dental extractions in ten patients were performed with no reduction of warfarin, or the mean thrombotest value of 16%. Seven nonlaparotomy operations (polypectomy of the vocal cord in one patient, total hip joint replacement in one, insertion of a CAPD tube in one, pacemaker implantation in one, cataract operation in two and repair of tibial fracture in one) and three laparotomy operations (partial gastrectomy in two and hysterectomy in one) were performed under the thrombotest value of around 40% with partial reduction of warfarin. There was no difficulty in hemostasis during these operations. The only hemorrhagic complication in this series was bleeding from the abdominal wound in one patient two days after the gastrectomy when subcutaneous injections of heparin prolonged the ACT over 200sec. There were no thromboembolic complications. We conclude that dental extractions in patients with prosthetic heart valves can be safely performed with no reduction of warfarin and that the coagulability of thrombotest value of 40% is sufficient for hemostasis even in laparotomy operations.

In coronary artery bypass grafting (CABG), a portable suction unit was used in the superior mediastinum to evaluate whether it is effective in decreasing the amount of mediastinal hematoma and the incidence of hematoma-related postoperative complications. Out of 179 consecutive patients who underwent CABG at the Matsuyama Red Cross Hospital, in 97 patients (Group 1), two drainage tubes were placed as usual in the inferior mediastinum, while in 82 patients (Group 2), a small drainage tube of the portable suction unit was additionally placed in the superior mediastinum. The total amount of postoperative drainage in Group 2 was larger than that in Group 1 but there was no statistically significant difference. The postoperative mediastinothoracic ratio expressed in comparison with the preoperative value was 134±22% in Group 1 and 123±15% in Group 2 on the first postoperative day (POD), and 133±20% and 122±14%, respectively on the seventh POD (p<0.001). Regarding postoperative complications, there were two cases of mediastinitis and five cases of late cardiac tamponade in Group 1 but none in Group 2. The difference in the incidence of these complications between the two groups was statistically significant (p<0.02). We conclude that the portable suction unit effectively decreased the amount of mediastinal hematomas and the incidence of mediastinitis and cardiac tamponade following CABG.

A 76-year-old man received implantation of sirolimus-eluting stent for total occlusion of the left circumflex artery causing an acute myocardial infarction of posterolateral wall on May 21st, 2005. Off-pump coronary artery bypass grafting was performed on June 9th for a residual 90% stenosis on the proximal segment of his left anterior descending artery. Ticlopidine and aspirin were discontinued 7 days and 2 days before the operation, respectively. Continuous intravenous drip of heparin had been given for 5 days until just prior to the operation. Though the left internal thoracic artery was successfully grafted onto the left anterior descending artery, he developed an acute myocardial infarction after the operation. An emergency angiography, performed on the 1st postoperative day showed thrombotic occlusion of the sirolimus-eluting stent in the circumflex artery and patent internal thoracic artery to the left anterior descending artery. Percutaneous catheter intervention restored the stent patency. Antiplatelet therapy including ticlopidine or clopidogrel is mandatory to prevent subacute thrombosis in drug-eluting stent. Hemorrhagic complication or major surgery may hinder continuing antiplatelet regimens and trigger acute thrombosis. Alternative antiplatelet and/or anticoagulant therapy is essential to prevent acute stent occlusion in such clinical settings.