A 69 year old man who was admitted with hoarseness and diagnosed as aneurysm of the diverticulum of the ductus arteriosus was reported. Operation was performed through a median sternotomy under partial cardiopulmonary bypass. Saccular form aneurysm, had a stalk attaching to left pulmonary artery, was repaired using Dacron patch prosthesis. His postoperative course was uneventful except transient left pleural effusion. Because of fragirity of aneurysm in the adult, early surgical intervention is recommended. To our knowledge, this is 11th surgically treated case to be reported in the literature in Japan.

One hundred and thirty cases of closed mitral commissurotomy were followed for up to 25 years and 10 months. There was no operative death, but 31 cases died during the follow-up period. Eight cases died suddenly of unknown cause, 7 due to heart failure, 5 due to thromboembolism, 4 on reoperation, and 6 due to other reasons. In the 7 cases who died of heart failure late after commissurotomy, 3 cases refused reoperation. Each of the remaising 4 cases were not operated on because of associated severe liver dysfunction, left ventricular dysfunction plus pulmonary hypertension, respiratory failure due to bronchial asthma, and unknown reasons, respectively. The actuarial survival rate was 93.6% 10 years after surgery, and 72.2% 20 years after surgery. Forty-two cases had reoperation with a mean interval of 12 years and 6 months. Reoperation-free survival rate was 88.7% 10 years after the first operation and 42.8% 20 years after the first operation. Incidence of major thromboembolism was 1.25%/patient-year. Thromboembolism and sudden death of unknown cause constituted the leading cause of late death and played a key role in long term results. Cardiac event-free survival rate was 65.7% 10 years after surgery and 32.6% 20 years after surgery. From these results it was concluded that the clinical limitations of the effectiveness of closed mitral commissurotomy was around ten years after surgery. We believe that these findings provide useful information for percutaneous transvenous mitral ommissurotomy.

Emergency coronary artery bypass grafting (CABG) for the treatment of acute coronary syndrome is still associated with increased operative risk and postoperative morbidity. Thirty-five patients underwent CABG for the treatment of medically refractory unstable angina (UAP), 42 patients for acute myocardial infarction (AMI) and 7 patients for post-infarction angina (PIA). The UAP patients received 2.8 distal anastomoses on average. Five patients (14%) died postoperatively, 3 of them due to perioperative myocardial infarction (PMI). In the AMI patient group, 29 patients were in shock and 3 patients were in cardiac pulmonary arrest (CPA) preoperatively. They received an average of 2.8 distal anastomoses. Fourteen patients (33%) died postoperatively. Ten of them died of postoperative myocardial failure. The operative mortality was extremely high in the shock state patient group (41%) and CPA state patients group (100%). Poor operative results were anticipated in those patients whose infarct-related artery was not recanalized preoperatively. All patients survived the CABG in the PIA group. It was concluded that reduction in mortality in the group of patients undergoing emergency CABG required highly refined myocardial preservation techniques to prevent PMI and to limit intraoperative myocardial damage, as well as powerful mechanical assist systems to provide support in cases of the postoperative myocardial failure.

In 1984, a 67-year-old man had aortic valve replacement surgery for aortic regurgitation; he returned with chest pain on May 15, 2003. Emergency coronary angiography was performed because electrocardiogram revealed ST segment depression in leads V₄ to V₆. However, coronary angiography, echocardiogram and chest computed tomography finding were normal. Therefore the patient was discharged the following day. However, he was re-admitted for chest pain, followed by loss of consciousness 4 days after his initial release. Echocardiogram and chest computed tomography revealed perforation in the lateral wall of his left ventricle (LV) and a “blow-out” type rupture was diagnosed. The patient fell into cardiogenetic shock in the emergency room, and emergency left ventricular free wall rupture (LVFWR) surgical repair was performed under percutaneous cardiopulmonary support (PCPS). A round perforation measuring about 10mm in diameter was observed in the lateral LV wall along the course of LCx # 12. The perforation was closed using Teflon strip reinforced mattress sutures. The hemostasis was reinforced with fibrin glue sheet (TachoComb) and polyglygolic acid surgical mesh (Dexon Mesh), with fibrin glue extensively applied. He was discharged on July 17, 2003 without major complications. In this case, the precise cause that led to LVFWR was unknown. Emergency PCPS insertion enabled the LVFWR surgical repair and extensive adhesion due to the previous AVR prevented the massive bleeding to pericardial cavity and the catastrophic hemodynamic deterioration: both factors positively contributed to patient recovery.