The survival of adult patients with total anomalous pulmonary venous return (TAPVR) is rare without surgery. A 38-year-old man was referred to us on emergency basis because of congestive heart failure. Cardiac catheterization and angiogram demonstrated TAPVR (Darling type Ia) with a Qp/Qs of 3.4, Pp/Ps of 0.17 and Rp/Rs of 0.03. Operative procedures consisted of a large anastomosis between the left atrium and the common pulmonary vein using a superior approach, closure of the atrial septal defect, and ligation of the vertical vein. Repeated catheterization three months after surgery showed normal hemodynamics and pulmonary vascular resistance. We consider that the strongest determinant factor affecting long-term survival is normal or only slightly elevated pulmonary vascular resistance, and that the superior approach is useful in adult patients for repair of supracardiac type TAPVR, because it offers an excellent operative field and the risk of postoperative atrial arrhythmia was thought to be minimal.

A 52-year-old man had a saccular non-trauma-induced aneurysm of the left internal thoracic artery (ITA) with ischemic heart disease. Right ITA-to-LAD anastomosis was performed for one-vessel disease under CPB. The left ITA aneurysmectomy was performed and reconstructed by end-to-end anastomosis. The resected specimen showed the features of atherosclerotic changes. This is the eighth reported case of this entity in the international and Japanese literature. The previous 7 cases are reviewed. The association with von Recklinghausen's disease and Kawasaki disease are discussed. Also summarized are the symptomatology, diagnosis, and management of this very rare condition.

A 52-year-old male with unstable angina after acute myocardial infarction, and Leriche's syndrome was referred to our hospital for intensive care. He had a history of diabetes. Coronary angiography demonstrated a 75% stenosis of the LMT in association with a 90% stenosis of the LAD, 75% stenosis of the LCX and 99% stenosis of the RCA. Aortography revealed an arterial occlusion extending from the infrarenal aorta to both common iliac bifurcations. Both internal thoracic arteries were well developed as collateral pathways to external iliac arteries. With concomitant Y graft replacement of the abdominal aorta, two large internal thoracic arterial conduits and the right gastroepiploic artery were grafted to the coronary artery. This procedure was useful for protection of limb ischemia, in addition to producing a route for insertion of an intraaortic balloon pumping catheter.

Pseudoaneurysm of the ascending aorta is a rare but potentially fatal complication of cardiovascular surgery. Two cases are described in which a pseudoaneurysm of the ascending aorta developed and caused profuse intermittent bleeding through the MRSA infection of the sternotomy wound. One was a 29-year-old man who had undergone a mitral valve replacement five months previously. The aneurysm was successfully repaired with a prosthetic graft patch under deep hypothermia and circulatory arrest, when a bloodless field was obtained using a handmade double-balloon catheter. The other patient was a 79-year-old man who had undergone a graft replacement of the distal aortic arch four months previously. The possibility of surgical correction was also considered but was thought to carry too high a risk. Embolization of the aneurysm was therefore regarded as the only realistic alternative, but failed, and he died due to aneurysmal rupture. The importance of the diagnosis process and surgical and intervascular treatment of pseudoaneurysm of the ascending aneurysm is described.

Intrapericardial teratomas are unusual tumors that often cause cardiorespiratory distress and might be lethal in the newborn. We described a case of neonate who was successfully treated by emergency surgery. A 5-day-old female infant was referred for further evaluation of a fever and progressive cardiorespiratory distress. Chest X-ray showed a widened central silhouette. Echocardiogram and chest CT scanning demonstrated a 59×40mm mediastinal mass and the mass effect or massive pericardial effusion cause cardiac tamponade. After sternotomy, the tumor was found to have arisen from the anterior surface of the aortic root and 30ml of serosanguinous fluid were aspirated. The tumor was completely removed without any difficulty with cardiopulmonary bypass standby. The postoperative course was uneventful. Histologically, this tumor appeared to be a mature teratoma. The surgical resection was lifesaving.

Cardiac surgery in patients aged 90 years or older is not common. We report 2 successful cases in nonagenarians. A 90-year-old man underwent the Bentall operation for aortic root aneurysm with moderate aortic valve regurgitation. A 91-year-old man underwent aortic valve replacement and single CABG (LITA to LCX) for severe aortic valve stenosis with single coronary artery disease. Their postoperative courses were uneventful. We emphasize that cardiac surgery in nonagenarians should not be withheld on the basis of age alone, but should be based on careful assessments of the relative medical risks and benefits, as well as the wishes of the patient and family.

We present a rare case of cardiac surgery for coronary artery single vessel disease and aortic valve stenosis after substernal gastric interposition for gastric cancer. An 80-year-old man, who had undergone esophagectomy and substernal gastric interposition 7 years previously, was referred to our institute for surgical treatment of coronary artery disease and aortic valve stenosis. Through a median sternotomy with cardiopulmonary bypass, we performed aortic valve replacement and coronary artery bypass grafting to the right coronary artery without injury to the gastric tube. Postoperatively, the patient was on respirator care and catecholeamine support for several days. Although urinary tract infection occurred, he recovered with antibiotic therapy. Finally, he was discharged on postoperative day 40. For cardiac surgery after substernal gastric interposition for esophageal cancer, even though the substernal gastric tube may preclude the usual median approach, median sternotomy is an appropriate alternative with close preoperative examination and careful dissection of substernal gastric tube.

During the last 15 years, isolated aortic valve replacement was performed in 122 patients, 12 of whom had severe elevated pulmonary systolic pressure (PAS) of 50mmHg or over. A comparative study of preoperative and postoperative data was done between two groups; group I (n=12), with a pulmonary systolic pressure 50mmHg or over, and group II, with a value of under 50 mmHg (n=45). On preoperative evaluation, cardiomegaly and constrictive pulmonary dysfunction were found in group I and also PAWP, mean pressure of PA, PAS, LVEDP and RVEDP were of a higher value in group I than group II. The LVEDP was high in group I and correlated well with PAS preoperatively, suggesting that pulmonary hypertension was a consequence of severe LV dysfunction. There was no difference in the operative mortality and postoperative complication between these two groups. CTR, PAWP, mPA and PAS decreased to within the normal range postoperatively. It was concluded that pulmonary hypertension does not adversely effect the operative mortality and postoperaive complications of AVR, and the cause of the elevated pulmonary pressure was thought to be due to the impaired LV function.

A 59-year-old female case with cardiac tamponade due to rupture of the coronary arteriovenous fistula is described. Preoperative coronary arteriography showed bilateral coronary-pulmonary fistulae not associated with significant atherosclerotic stenosis. On opening the pericardium after establishing F-F bypass, the pericardial sac contained 300 grams of partially clotted blood. There was subepicardial hematoma along the area of the left anterior descending artery and the left circumflex artery without any other abnormal findings of the heart. The operation consisted of hemostasis with several mattress sutures along the left anterior descending artery and the left circumflex artery, closure of multiple fistulous openings from within the pulmonary artery, and ligation of abnormal dilated vessels originating from bilateral coronary arteries. The coronary arterio-venous fistula with aneurysmal dilatation should be operated on aggressively, whether symptomatic or asymptomatic, to prevent the rupture of fistulae.