A 76-year-old woman required aortic valve replacement due to severe aortic stenosis. She had a huge thyroid cancer, which invaded the innominate and left internal jugular veins. We planned a two-stage operation : the first involved aortic valve replacement ; and the second involved operation of the thyroid cancer. To avoid median sternotomy, we adopted the right parasternal approach. A 7-cm right parasternal skin incision was made. The third and fourth costal cartilages were cut and bent into the right thoracic cavity, without removal of the ribs. The postoperative course was uneventful, and second operation was performed via the median sternotomy approach on postoperative day 53. The right parasternal approach can be used as an alternative when sternotomy is unsuitable in cases of aortic valve replacement.

Anomalous origin of the coronary artery is rare. Various complications have been reported in patients with this anomaly undergoing heart valve surgery. We describe a case of aortic valve stenosis combined with an anomalous origin of the left coronary artery. An 84-year-old man with exertional dyspnea was referred for surgical treatment of severe aortic valve stenosis. Coronary angiography and computed tomography of the coronary artery revealed a coronary arterial anomaly : the left anterior descending coronary artery originated as a branch of the right coronary artery, and the left circumflex artery separately originated from the right coronary sinus and extended behind the aortic annulus. To prevent injury to the anomalous circumflex artery during surgery, the artery was separated from the fatty tissue around the aortic annulus and dissected free from the aortic wall before the performance of transverse aortotomy. The coronary artery exhibited a single orifice that was significantly enlarged. Whether antegrade infusion of the cardioplegic solution could be achieved was difficult to determine. To perform the retrograde infusion, the catheter tip was inserted directly into the coronary sinus from the epicardium because the orifice in the right atrium was lattice-like. Aortic valve replacement was successfully performed with supra-annular prosthesis insertion using a 19-mm Mosaic porcine valve (Medtronic, Minneapolis, MN, USA). The postoperative course was uneventful. When aortic valve replacement is performed for patients with an anomalous coronary artery, careful performance of operative procedures and postoperative observation are considered important for the prevention of specific perioperative complications, such as intraoperative coronary injury or postoperative myocardial ischemic events in patients with an anomalous left circumflex artery.

We report a rare case of primary cardiac lymphoma in the right atrium. An 85-year-old woman with severe heart failure was referred to our hospital. The echocardiography revealed a huge tumor occupying the right atrial cavity. We conducted an emergency operation to resect the tumor. However, as the tumor strongly adhered to the wall of the right atrium and tricuspid valve, we performed partial resection of the tumor to improve hemodynamics. The pathological examination of the tumor was consistent with malignant lymphoma of B-cell origin. Although the postoperative chemotherapy was effective to reduce a volume of the tumor, the patient died because of the adverse reaction to medication.

A 16-year-old female who complained of hoarseness and left back pain. An abnormal shadow in the left superior mediastinum was observed in chest X-ray films. Thoracic aortogram revealed elongations of the aortic arch and two sacculated aneurysms located in the minor curvature of the arch. She was operated by median sternotomy and left collar incision. The left vagal nerve laid between the two aneurysms. The proximal aneurysmal wall seemed to be of normal thickness, but the distal aneurysmal wall was so thin that the intraluminal blood stream was visible. Aneurysmectomy and insertion of a Dacron patch were successfully performed under cardio-pulmonary bypass with selective cereberal perfusion. The postoperative course was uneventful.

A 66-year-old man with an abdominal aortic aneurysm and coexisting horseshoe kidney is reported. The aneurysm was successfully replaced by a prosthetic graft without resection of the renal isthmus. Because of renal blood supply and location of renal isthmus, aortic reconstruction presents a significant technical problem. Preservation of multiple renal arteries may be facilitated by preoperative aortography, and retraction of the renal isthmus offers good operative exposure.

A 61-year-old man, who had previously undergone quadruple coronary artery bypass graft surgery, was successfully treated for proximal descending aortic aneurysm using hypothermic circulatory arrest via a left thoracotomy. Preoperative angiograms revealed that the left internal thoracic artery bypass graft to the LAD was patent, and that the aneurysm was located at the descending aorta just distal to the left subclavian artery. Operative procedures were as follows. A left thoracotomy incision was made through the 4th intercostal space. The common femoral artery and vein were cannulated, and the venous cannula was positioned in the right atrium. The patient was cooled by partial cardiopulmonary bypass until the EEG was isoelectric (24°C rectal temperature), and then circulation was arrested. Left ventricular decompression was not performed. After opening of the aneurysm, proximal anastomosis was performed first at the aorta just distal to the left subclavian artery. Another arterial cannula, connected to the Y-shaped arterial line, was inserted into the graft, and perfusion to the brain was restored through this cannula. Distal anastomosis was then completed, and routine cardiopulmonary bypass was reestablished. After the heart was defibrillated, the patient was rewarmed to 34°C before discontinuing the bypass. Circulatory arrest time and total cardiopulmonary bypass time were 17 minutes and 139 minutes, respectively. Postoperative recovery was uneventful.

We studied 73 patients, 70 years of age or older, who underwent aortic valve replacement for aortic stenosis between October, 1990 and October, 2004. There were 31 men and 42 women with a mean age of 75.7±3.6 years. Mechanical valves were implanted in 37 patients, and bioprostheses in 36 patients. Operative mortality was 1 of 73 (1.4%) and the New York Heart Association functional class improved to class I or class II in all of the hospital survivors. Follow-up (100%) extended from 0.3 to 11.6 years (mean 3.7 years). There were 16 late deaths (5.9% per patient-year), including valve-related deaths in 6 patients. The overall survival rates at 5 and 10 years was 74.2% and 44.3%, respectively. The freedom from valve-related events at 5 and 10 years was 78.8% and 78.8%, respectively. The 10-year survival rates and freedom from valve-related events were not different between the patients with mechanical valves and those with bioprostheses. The size of the implanted valve did not influence the late survival or freedom from valve-related events. The outcome after aortic valve replacement in the elderly (70 years and older) was excellent with low operative mortality, and acceptable late mortality and morbidity. Thus, aortic valve replacement for elderly patients should have the same indications as for younger patients. Bioprostheses showed good long-term results with no structural valve deterioration, thromboembolism, or bleeding events. Mechanical valves, which required the maintenance of an anticoagulant therapy, were also useful with acceptable late morbidity. The long-term results with small valves (≤19mm) were comparable to the results with large valves (>19mm) in the elderly. Thus, the use of these small valves in this particular age group seems to be acceptable.

A case of abdominal aortic aneurysm associated with systemic lupus erythematosus (SLE) is described. SLE is rarely associated with aneurysm of great arteries. Histological investigation revealed marked infiltration of inflammatory cells in the aneurysmal aortic wall. Immunocytochemical analysis using anti-factor VIII-related antigen antibody showed a marked increase of the vasa vasorum with luminal narrowing due to intimal thickning. In this case the major etiology of aortic aneurysm is considered to be non-specific inflammation of the abdominal aorta, not arteriosclerosis.

We report a 25-year-old man with ventricular septal perforation due to blunt chest trauma. He was transferred by ambulance to our hospital following a traffic accident. On admission, he had no cardiac murmur. Two days later, a pansystolic murmur appeared over the left lower sternal border. Doppler echocardiogram revealed a large left-to-right shunt through a ventricular septal perforation. We postponed surgical treatment as long as possible because he also exhibited bronchial bleeding due to a lung contusion. Surgical repair of the ruptured ventricular septum was performed 8 days after the chest trauma, because the pulmonary to systemic flow ratio was elevated to 4.6 and cardiac function had deteriorated. During the operation, the site of the septal perforation was easily detected by epicardial echocardiography. A 4-cm tear in the muscular septum was closed through a right ventriculotomy using a pericardial patch reinforced with a Dacron patch. Postoperative recovery was uneventful with the exception of transient right ventricular failure. There was no residual shunt.

Essential thrombocythemia is considered one of the chronic myeloproliferative disorders resulting in arterial thromboembolism, venous thrombosis, and bleeding tendency. We report a case of left ventricular aneurysm with successful treatment of the complications of this disease. A 66-year-old man who suddenly experienced right upper limb paralysis was carried to a nearby hospital. Computed tomography revealed multiple cerebral infarctions. An electrocardiogram confirmed findings of old myocardial infarctions in the anteroseptal wall. Echocardiography indicated a left ventricular aneurysm with mobile thrombus. The blood tests showed an abnormally high platelet count of 120×104/μl. His left ventricular thrombus showed an increasing tendency regardless of heparin administration ; thus, he was transferred to our hospital. The resection of the aneurysm and left ventricular restoration was performed emergently to avoid re-embolism. There was a soft thrombus inside the aneurysm at its apex. During cardiopulmonary bypass, the activated clotting time was not prolonged easily. We gave additional heparin and antithrombin III. The patient had no problem with hemostasis or postoperative bleeding. We started low-molecular-weight heparin from the second postoperative day and he was diagnosed with essential thrombocythemia by bone marrow biopsy. We started warfarin and aspirin on the fifth day after surgery. The number of platelets increased to 183×104/μl on the 8th day ; thus, oral administration of hydroxycarbamide was started. His platelet count fell to less than 100×104/μl around 3 weeks after surgery and he was discharged on the 34th day without new embolisms.