A 63-year-old woman presented with pseudoaneurysm formation due to rupture of the porcine aortic wall of the stentless bioprosthesis. She had undergone aortic root replacement using the full root technique with the 25-mm Prima Plus bioprosthesis for annuloaortic ectasia. Congestive heart failure, appearing 65 months after the first surgery, progressed rapidly. Multidetector computed tomography (CT) showed a pseudoaneurysm of the aortic root, and echocardiography revealed severe mitral regurgitation. At reoperation, a large pseudoaneurysm with a 20-mm horizontal tear was seen in the non-coronary sinus of the Prima Plus valve. A repeat aortic root replacement and mitral valve replacement with two mechanical valves were performed. The patient had an uneventful recovery. Histologic examination of the explanted porcine aortic root showed host mononuclear cells and macrophages between the well-stained and poorly stained areas, suggesting that the torn tissue had undergone host-mediated degeneration to some extent. Porcine aortic roots have excellent hemodynamic features, but ruptures in the aortic sinuses of the porcine aortic root have been reported in some cases. Careful follow up with CT or echocardiography is therefore needed after aortic root replacement with stentless bioprostheses.

Anomalous aortic origin of a coronary artery (AAOCA) can cause sudden death, especially in young athletes. AAOCA does not have any clinical cardiovascular manifestations and sudden death is often the first manifestation ; hence, it is difficult to diagnose AAOCA before a major episode occurs. We report the case of a 58-year old woman with a right coronary artery arising from the left sinus and passing between the aorta and the pulmonary artery. Although the results of the exercise treadmill test and various other tests were normal, this patient underwent coronary artery bypass, surgery using the right internal thoracic artery to preventing sudden death. Two years after the operation, she is asymptomatic and has normal results on the exercise treadmill test.

A 48-year-old man with Buerger disease and intractable finger ulcers underwent successful transplantation of autologous peripheral blood-derived mononuclear cells pretreated with erythropoietin and blood donation to activate bone marrow function. Clinical symptoms on his finger ulcers improved significantly within 1 month after mononuclear cell transplantation, however, one of the intractable ulcers reappeared 2 months later. In total three transplantations were performed. Every cell transplantation revealed similar effectiveness 1 month later, and the interval of the subsequent disappearance of finger ulcers ranged from 3–6 months. There were no adverse effects based on this new therapy. These findings suggest that autologous peripheral mononuclear cell transplantation pretreated with erythropoietin and blood donation might be a non-invasive and safe alternatives for patients with Buerger disease and intractable finger ulcers.

A 69-year-old woman had syncope and aphasia. Magnetic resonance imaging showed multiple cerebral infarctions in both hemispheres. Cardiogenic embolisms were suspected, but no arrhythmic causes were shown. Transesophageal echocardiography revealed a highly calcified mitral annulus (MAC) with a rough intraluminal surface and mild mitral regurgitation, but no thrombus or tumor in the left heart system. However, recurrent multiple cerebral embolisms occurred in spite of strict anticoagulation therapy. We speculated that spontaneous rupture of the MAC was the cause of the scattered cerebral embolisms, and we therefore planned to remove the MAC as safely as possible and to endothelialize the deficit of MAC with autologous pericardium. Operative findings revealed that the MAC in P2-P3 had ruptured longitudinally and the ostium of the left atrium was connected to the ostium of the left ventricle as an inter-atrioventricular tunnel beneath the posterior mitral annulus with a fragile calcified wall. The finding suggested that calcified particles that had peeled away from the MAC by normal heart beating resulted in the cerebral infarctions. Therefore, she underwent resection of the MAC and mitral valve replacement with reinforcement of the decalcified posterior mitral annulus between the posterior left ventricular wall and the left atrial wall using autologous pericardium, which enabled both appropriate insertion of a mechanical prosthetic valve and endothelial continuity covering the surface of the residual MAC. No systemic embolism has occurred for two and a half years after surgery. This is the first case report of cerebral embolism caused by a spontaneously ruptured MAC.