A 51-year-old woman suffered from a sudden onset of anterior chest pain and was referred to our hospital on the suspicion of an anginal attack. The exercise ECG showed findings of an anterior lesion and ischemia. Coronary angiography also revealed left anterior descending branch fistula and circumflex branch fistula connecting to the main pulmonary artery trunk. Direct closure was performed for both intra-pulmonary openings under cardiopulmonary bypass. The postoperative course was uneventful and the patient did not show any precordial pain. Coronary angiography showed no coronary organic narrowing, but contrast medium remained in the fistulae although there was no left to right shunt. Ligation of the fistulae had to be performed simultaneously to confirm complete obstruction of the coronary-pulmonary arterial fistulae. The antiplatlet agent is administered to the patient to prevent occurring myocardial infarction caused by thrombus which might be formed in fistulae.

Carcinoma arising from the remnant of branchial epithelium or branchial cleft cyst is known as branchiogenic carcinoma. It is very rare, and its existence is a matter of controversy. We report a case of cystic carcinoma of the upper neck that fully met Martin's criteria for branchiogenic carcinoma. A 53-year-old male visited Tsurumi University Dental Hospital with a swelling on the left side of the neck. Three tumors were excised from the neck, and histopathology revealed squamous cell carcinoma in a cystic lesion. As metastatic carcinoma of the cervical lymph nodes was suspected, the appropriate clinical tests and imaging were performed to determine the possible presence of a primary tumor. However, no primary carcinoma was found. These findings suggest that this was a case of branchiogenic carcinoma. The patient was treated with radiotherapy and followed up over an 8-year period. No evidence of recurrence was found.

Between May in 1988 and October in 1990, simultaneous coronary artery bypass grafting (CABG) and valve surgery was performed in 14 patients. Nine patients received arterial graft conduit for CABG (AG group) and only saphenous vein graft (SVG) was used in 5 patients (SVG group). In AG group, mean age was 63.3 years and the number of distal anastomosis was 2.2/patient. In valve operation, valve replacement was performed in 5 and valve plasty was in 4, and the mean aortic cross clamping time was 116min. As AG, internal thoracic artery (ITA) was used in 8 and right gastroepiploic artery (RGEA) was in 4. Among them concomitant use of ITA and RGEA was in 3, and the use of SVG was in 5. In two patients, the AG pedicle did not reach to either left anterior descending or obtuse marginal artery and the SVG was used as a graft conduit. Between AG group and SVG group, there were no significances in the age and aortic cross clamping time. However, postoperative use of cathecholamin was in three (33%) in AG group and three (60%) in SVG group and there were significant differences between them. In AG group, there were no operative deaths and the late NYHA improved to class I in 4 and class II in 5. In simultaneous CABG with AG and valve surgery, the improvement of symptom was good and stable operative result was obtained, however, the length of the pedicled graft should be carefully considered for coronary anastomosis.

The operative results in case of aortic coarctation (CoA) were studied. Between June 1980 and June 1995, 37 children with CoA underwent surgical intervention during their first year of life in our institute. The aortic lesion was repaired by the subclavian flap (SCF) method in 27, direct anastomosis (DA) method in 7, grafting or other methods in 3 children, respectively. The mean follow up period was 7.4±5.3 years (6 months-13 years). Rate of re-stenosis of the aorta was 10% (2 in 20 children) after SCF method, 0% (0 in 7 children) after DA method. The stenotic lesion was successfully dilated by the percutaneous balloon reconstruction in one child. Perioperative mortality was 25% (1/4) in one-stage repair, while one-stage repair was successfully performed in the last three cases and 16.6% (3/18) in two-stage repair for CoA associated with ventricular septal defect (VSD). The mortality was 60% (6/10) of CoA associated with other complex anomalies. In conclusion, one-stage repair seems to be recommendable for the operation of CoA with VSD, and two-stage repair seems to be safe for CoA with complex anomalies.

This paper describes a very rare case of both ventricular septal defect (VSD) and atrial septal defect (ASD) associated with pulmonary hypertension (PH) successfully repaired via a right thoracotomy in infant with right lung aplasia. A 4-month old infant was admitted to our hospital because of congenital heart disease and right lung abnormalities. Roentogenograms revealed complete opacity of the right hemithorax, with a shift of the mediastinum and the heart to the right. Computed tomography of the chest showed the absence of the right lung and a right bronchus remnant. Therefore, a dignosis of aplasia of the right lung was made at this point. Echocardiogram confirmed VSD and ASD, both of which were 5-mm in diameter, and associated with PH. At the age of 1 year and 7 months, cardiac catheterization was performed, showing pulmonary hypertension with a systolic pulmonary-to-systemic pressure ratio (P_p/P_s) of 0.66. Tolazoline hydrochloride decreased pulmonary vascular resistance (R_p) from 6.92 units·m² to 3.11 units·m². The operation, under cardiopulmonary bypass, was performed via a right thoracotomy approach, because of severe counterclockwise rotation of the heart. VSD and ASD were closed by primary suturing. This approach offered excellent exposure of the intracardiac anatomy in our case. An intraoperative pressure study showed normal pulmonary arterial pressure, the P_p/P_s decreased to 0.33. The postoperative course was uneventful.

Postoperative cardiac function, changes of LV wall motion and exercise tolerance test were studied in 49 patients who received coronary artery bypass grafting (CABG) using antegrade intermittent warm blood cardioplegia (IWBC) and had postoperative left ventriculography (LVG). The mean aortic cross clamp (ACC) time was 68.2±22.8 minutes, and the coronary perfusion time during ACC was 12.6±6.9 minutes (18.2±7.1% of total ACC time). Spontaneous return of normal sinus rhythm was seen in 45 patients (92%). Perioperative myocardial infarction occurred in only one patient and one patient required inotropic support>5μg/kg/min after operation. The mean cardiac index measured by Swan-Ganz catheter improved postoperatively, and the postoperative LVG revealed improvement of the LV wall motion in comparison with that of preoperative LVG, and no local asynergy due to inadequate distribution of IWBC was seen in the early postoperative period. The mean postoperative exercise tolerance performed in 24 patients was 6.6 METS (metabolic equivalents), and no patient revealed myocardial ischemia at exercise. In conclusion, the IWBC is considered to be an easy and safe technique for distal anastomoses of CABG with no influence upon the postoperative cardiac function and LV wall motion.

We studied possible factors to cause left ventricular rupture after mitral valve replacement and the prevention in eight patients of 1, 046 receiving mitral valve replacement between September, 1965 and August, 1991. The age at operation ranged from 43 to 67 years old (average 58 years old), and there were one man and seven women. According to the Treasure and Miller's classification, the type of rupture was type I in 5, type II in 2, and type III in 3. The onset time of rupture was immediately after cardiopulmonary bypass in 3 and at the time of chest closure in one. In four patients it occurred 11 hours, 14 hours, 18 hours and 25 hours after operation, respectively. In 8 patients, repair was performed with external closure under heart beating and in five patients with both internal and external closure during cardiac arrest under cardiopulmonary bypass. Two patients under cardiopulmonary bypass were successful for hemostasis, however, they died with low cardiac output syndrome, following to multiple organ failure 2 or 44 days after operation, respectively. The repair was not successful in 6 patients. In four patients the left ventricular rupture occurred immediately after hypertension and pathological findings showed severe myocardial degeneration of left ventricular muscle in all of them. These findings may suggest that hypertension after the operation is one of major factors to cause left ventricular rupture and thus the careful management of the systemic blood pressure after mitral valve replacement is effective to prevent the left ventricular rupture.

Objective: Combination therapy with glecaprevir and pibrentasvir (G/P) has been shown to provide a sustained virologic response (SVR) rate of >97% in patients with chronic hepatitis C virus (HCV) infection in the first published real-world Japanese data. However, a recently published study showed that the treatment was often discontinued in patients ≥75 years old, resulting in low SVR in intention-to-treat (ITT) analysis. Thus, our aim was to evaluate real-world data for G/P therapy in patients ≥75 years of age, the population density of which is high in “rural” regions.Patients and Methods: We conducted a multicenter study to assess the efficacy and safety of G/P therapy for chronic HCV infection, in the North Kanto area in Japan.Results: Of the 308 patients enrolled, 294 (95.5%) completed the treatment according to the protocol. In ITT and per-protocol analyses, the overall SVR12 rate was 97.1% and 99.7%, respectively. The old-aged patients group consisted of 59 participants, 56 of whom (94.9%) completed the scheduled protocol. Although old-aged patients tended to have non-SVR factors such as liver cirrhosis, history of HCC, and prior DAA therapies, the SVR12 rates in old-aged patients were 98.3% and 100% in the ITT and PP analyses, respectively. Of 308 patients enrolled, adverse events were observed in 74 patients (24.0%), with grade ≥3 events in 8 patients (2.6%). There was no significant difference in any grade and grade ≥3 adverse events between the old-aged group and the rest of the study participants. Only one patient discontinued the treatment because of adverse events.Conclusion: G/P therapy is effective and safe for old-aged patients.