A 71-year-old man with obstruction of the left anterior descending branch (#7) suffered an acute myocardial infarction. A ventricular septal perforation (VSP) and a widespread left ventricular aneurysm were detected in the anteroseptal region by both cardiac ultrasonography and cardiac catheterization. Surgery was performed at week 7 after onset. After establishing extracorporeal circulation, the left ventricular aneurysm was longitudinally excised from the left side of the left anterior descending branch while the patient was maintained in a state of cardiac arrest. A septal anterior ventricular exclusion (SAVE) operation was performed using oblong equine pericardial patches to exclude the left ventricular aneurysm and the VSP portion. The VSP was directly closed with sutures because the surrounding tissues were relatively strong at week 7 after the onset of the myocardial infarction and the portion was excluded with an equine pericardial patch. At the same time, CABG (LITA-LAD) was also performed. After surgery, left ventriculography found no residual shunts and we were able to obtain both a good morphology and satisfactory functioning of the left ventricle. The present method is thus considered to be an effective surgical method that excludes both the VSP portion and the infracted portion, while improving the morphology of the left ventricle for VSP with a left ventricular aneurysm.

We present a successful case of ruptured abdominal aortic aneurysm with left-sided inferior vena cava (IVC). A 74-year-old man, with complaints of abdominal pain and loss of consciousness, was referred to our hospital. Computed tomography revealed a ruptured aneurysm of the abdominal aorta, and the operation was performed immediately. At the operation, left-sided IVC was recognized to cross anteriorly over the abdominal aorta at the usual level of the left renal vein. Proximal anastomosis was safely performed with careful mobilization of the IVC in the appropriate direction. The patient was in acute renal failure after this procedure, with 9 days of continuous hemodiafiltration, but he recovered to discharge on the 46th postoperative day with normal renal function. The cardiovascular surgeon should be familiar with anomalies of the IVC in performing procedures of the abdominal aorta, especially in emergency operations, even if they are rare.

We report a case of percutaneous transluminal angioplasty (PTA) treatment for low cardiac output syndrome due to superior vena cava (SVC) stenosis with venous return anomaly. A 69-year-old man was referred to our hospital for surgical treatment of tricuspid valve infective endocarditis due to infected pacemaker leads, which had been implanted for sick sinus syndrome. Preoperative computed tomography indicated polysplenia syndrome-related absence of the hepatic segment of the inferior vena cava (IVC). Preoperative coronary angiography showed a 99% stenosis in the left anterior descending artery and a total occlusion in the right coronary artery. We therefore performed pacemaker system removal, tricuspid valve plasty, coronary artery bypass surgery, and a new pacemaker implantation (epicardial leads). However, over the postoperative course we noted low cardiac output syndrome due to SVC syndrome, which appeared to be aggravated by venous return anomaly from the patient's absent IVC hepatic segment. Eight days after the surgery we conducted PTA for SVC syndrome, which notably improved the patient's hemodynamics. The patient recovered and was transferred to a rehabilitation facility 34 days after the surgery.

An 82-year-old man was referred to our hospital for heart failure due to severe mitral regurgitation and severe tricuspid regurgitation. We performed mitral annuloplasty and tricuspid annuloplasty (TAP). Three weeks after surgery, he developed hemolytic anemia (HA). Transesophageal echocardiography revealed a defect in the left ventricular outflow tract that communicated directly with right atrium, and the jet was striking with the TAP prosthetic ring. HA was not controlled, so we performed re-operation. The defect was found in the atrioventricular membranous septum. The defect was closed and TAP was performed using an autologous pericardial roll again. We report a rare case of acquired left ventricular to right atrium communication after TAP.

Prosthetic valve dysfunction due to pannus formation is an infrequent but serious complication of tricuspid valve replacement. An 87-year-old woman underwent tricuspid valve re-replacement for severe prosthetic valve stenosis and regurgitation. On removal, thick fibrous pannus and chordal attachments were observed on the ventricular side of the cusp, which corresponded to the septal leaflet of the native valve. Microscopic examination revealed inflammatory cell infiltration accompanied with severe fibrosis and scarring had compromised and broken the prosthetic valve cusp under the pannus. The elastic fiber, which was detected in the base of the pannus, suggested it was a remnant of the native tricuspid valve leaflet. Prevention of native tissue attachment to the prosthetic valve cusp, which may cause severe pannus formation, appears to be extremely important for the long-term outcome and valve durability. The choice of prosthesis for the tricuspid position remains controversial. We should especially consider the height of stent posts and the continuity between the cusp and suture ring in the choice of the bioprosthetic valve for tricuspid position.

When performing aortic valve replacement (AVR) in patients with a past history of coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA), the patent ITA graft needs to be detached from the surrounding tissue and occluded to properly protect the myocardium. However, detaching the ITA graft from the surrounding tissue takes time, and caution must be exercised to avoid damaging the graft. Two patients with a past history of CABG using the ITA were scheduled to undergo AVR. To simplify AVR, a balloon was placed preoperatively, and was inflated during aortic occlusion to occlude the ITA graft. The myocardium was adequately protected in this manner. Furthermore, since adhesion detachment was limited to around the ascending aorta, operative duration was short and bleeding volume was low. Balloon occlusion of the ITA graft appears to be useful in reducing the invasiveness of AVR in patients with a past history of CABG.

A 63-year-old man had been receiving medical treatment for hypertrophic cardiomyopathy (HCM) for 20 years. Sustained ventricular tachycardia (VT) had often occurred over the previous 2 years in spite of the administration of antiarrhythmic drugs. He therefore received an implantable cardioverter defibrillator (ICD). However, his symptoms did not improve thus dilated-phase HCM was diagnosed. Because sustained VT often occurred subsequently, the ICD had to be frequently used. An electrophysiological study (EPS) using the CARTO electroanatomical mapping system revealed the earliest activation site to be in the posterolateral wall of the left ventricle (LV). VT did not stop despite 2 endocardial catheter ablation procedures. Therefore, the VT foci was thought to be a reentry circuit on the epicardial side of the posterolateral LV wall. A part of the posterolateral LV wall that involved the reentry circuit was therefore resected. Since undergoing this surgical procedure, the patient has experienced no recurrence of VT during a follow-up period of 14 months.

A 16-year-old boy had a motorcycle accident and was given a diagnosis of blunt aortic injury (BAI) by contrast computed tomography (CT), complicated by diffuse brain injury, lung contusions and blunt liver injury. Despite conservative treatment his anemia worsened and further CT images revealed mediastinal hematoma. It was difficult to perform cardiopulmonary bypass with systemic heparinization because of his multiple injuries and therefore decided to perform endovascular stentgrafting. Aortography revealed that the proximal stent-graft landing zone to be very small, and therefore it was necessary to the cover left common carotid artery. Before stentgrafting, we performed a right subclavian artery-left common carotid artery bypass to attain a sufficient proximal landing zone, and stentgrafting was successful. We concluded that endovascular stentgrafting is an effective initial treatment for BAI complicated with multiple injuries. However, endovascular stentgrafting for BAI has some limitations because of the morphologic and anatomical characteristics of the thoracic aorta in cases of BAI. It is therefore important to perform endovascular stentgrafting for BAI on a case-by-case basis.

We report an extremely rare case of renal cell carcinoma (RCC) extending into the left atrium through the pulmonary vein next to lung metastasis. The patient was a 76-year-old man. Extirpation of the RCC in the right kidney was carried out. Metastasis to the lungs, mediastinal lymph nodes and the pubis were diagnosed and 4 years later, a myxoma-like tumor was formed in the left atrium by echocardiography. We extirpated of the tumor. During surgery, continuity with the metastatic lesion in the right lung, right inferior pulmonary vein and the left atrium was suggested. Histopathologic examination showed the same histopathology as seen in the RCC.

We present a successfully treated case of re-operation for aortic valvular stenosis caused by implantation of a stentless prosthesis using oversizing sub-coronary insertion in a young woman. The 17-year-old Japanese woman received aortic valve replacement (AVR) with a 21mm Freestyle stentless porcine valve (Medtronic Inc.), using the oversizing modified sub-coronary insertion because of infectious endocarditis 12 years previously at another hospital. Just after the operation, she suffered severe heart failure. At 16 years old, since a cardiac murmur and dyspnea on effort appeared, and she presented severe heart failure due to significant aortic valvular stenosis with a mean aortic valve gradient 115mmHg, we performed aortic valve re-replacement (ATS AP 18mm) with an aortic root enlargement procedure. Intraoperative findings suggested that the oversizing technique was related to aortic valvular stenosis. The postoperative course has been uneventful.