Papillary fibroelastoma (PFE) is a benign tumor accounting for approximately 8% of cardiac tumors. We report a 64-year-old woman with pulmonary valve PFE associated with atrial septal defect. It was detected by a transesophageal echocardiography as a fluttering mass clinging to the pulmonary valve, and was simply removed concomitantly with a patch closure of atrial septal defect. In a review of the past literature, 43 surgical cases of PFE have been reported in Japan, and aortic valve, mitral valve and left ventricle PFE was commonly encountered in 81%. Pulmonary PFE is very rare, and only one case has been reported apart from the present one.

Objective : Blunt aortic injury often accompanies other organ injuries, and therefore requires an appropriate lifesaving surgical strategy. Patients : During the past 8 years, blunt aortic injury was reviewed, based on 5 lifesaving cases experienced in our hospital. There were 3 men and 2 women (aged 57-70, average 64.2). The Injury Severity Scores were 13-25 (an average of 17.2). Intervention : Regarding our strategy, stabilization of vital signs should be at first aimed by intensive primary care, concomitantly with diagnostic procedures. When stabilization of vital signs is obtained, a delayed operation would be considered after damage control resuscitation. As for 3 of these 5 cases, an emergency surgery was performed because of distinct aortic hemorrhage with instability of vital signs, and stent graft repair was applied based on anatomical indication in two cases. In the other 2 cases, primary diagnosis suggested aortic injury by the bone fracture pieces. Damage control was conducted following stabilization of vital signs, and delayed surgery was done with removal of the bone fracture pieces and repair of aortic injury, which improved activities of daily living. Results : All cases recovered with no particular complication, and were discharged on 9-32 days average postoperatively. Conclusion : Blunt aortic injury is often fatal, but the appropriate diagnosis and treatment can play an important role in obtaining the good results.

To evaluate peripheral occlusive diseases quantitatively, we performed color duplex sonography. Between July 1996 and July 1998, we examined 68 limbs of 40 patients using color duplex sonography in addition to intraarterial digital subtraction angiography for evaluation of peripheral arterial occlusive disease. We classified the wave form of blood flow into four types (Type I-IV). Furthermore we measured the systolic velocities of the dorsal pedial and the posterior tibial arteries as well as the brachial artery. We also calculated the flow volume, and the ratio of systolic velocities and flow volume of lower to upper extremity (AVI, AFI). The waveform was significantly higher in Fontaine class III and IV, and showed remarkable improvement after arterial reconstruction. The value of AVI as well as AFI showed lower in Fontaine class I, II, III, and IV in order. In four limbs classified as Fontaine class II or more with normal ankle pressure index, the values of AVI were rather lower. On the other hand, three limbs with normal values of peak AVI (>0.9) and lower API (<0.75) were in Fontaine class I. The types of waveform correlated with clinical symptoms, and showed a remarkable regression after arterial reconstruction. The new AVI and AFI values had better correlation with clinical symptoms than API.

In two cases of thromboangitis obliterans (TAO) a popliteal-posterior tibial-peroneal artery sequential bypass was attempted through a median approach. The 1st case underwent the operation successfully with non-reversed saphenous vein graft. However, only popliteal-peroneal bypass was carried out in the 2nd patient because the posterior tibial artery was severely affected. In surgery of TAO patients, careful assessment of preoperative angiographic findings is important to select the site of distal anastomosis. We found that the posterior tibial artery and the peroneal artery are easily accessible through the medial route in the proximal half of the lower leg and that peroneal artery revascularization was effective for limb salvage.

A 67-year-old man suffered acute arterial occlusion caused by emboli from aneurysms in a right axillo-bifemoral graft using Cooley double velour knitted Dacron, which was inplanted 10 years and 10 months before the admission. The patient underwent urgent redo surgery; left axillobifemoral bypass with 6mm ringed PTFE graft and right femoropopliteal bypass with in situ saphenous vein were performed successfully. Several clinical experiences by others demonstrated that Cooley double velour knitted Dacron graft, manufactured before June, 1981, might have possible aneurysmogenic factors, therefore cases in which it has been employed should be followed up carefully.

We reviewed the results of 14 patients who underwent the operation of thoracic aneurysms using a centrifugal pump. Nine patients had atherosclerotic aneurysms and 5 had aortic dissections. The autotransfusion system (ATS) was used to keep hemodynamic stability by rapid transfusion. The ATS consisted of a roller pump, a 2, 000ml reservoir and a heat exchanger. Two mg/kg of heparin was given to the patients to keep ACT over 400 seconds. All patients survived. Body temperature increased 0.08±0.59°C during bypass with the ATS, and no patients showed hemodynamic instability after aneurysmotomy under the help of the ATS. We conclude that 1) the centrifugal pump is a useful and safe assisting means for the surgery of thoracic aneurysms, 2) the autotransfusion system has advantages as follows: keeping stable circulation and preventing loss of body temperature during bypass.

Caseous calcification of mitral annulus (CCMA) is rare variant of mitral annular calcification (MAC). There is no clear consensus on the optimal management for CCMA. However, patients with CCMA have high risk of embolic strokes. We performed drainage and debridement in 3-cases of CCMA. All patients had a history of chronic kidney disease (CKD), and two of the three patients were undergoing hemodialysis. If a calcified mass at the mitral valve annulus is observed, especially in hemodialysis patients, CCMA should be recognized.