A 71-year-old man with early-stage esophageal cancer underwent off-pump coronary artery bypass grafting (CABG) through left thoracotomy to avoid sternotomy to allow subsequent esophageal surgery. The patient had severe double vessel coronary artery disease (the left anterior descending artery and the right coronary artery). Esophageal pull-out resection and reconstruction with the transverse colon over the sternum were planned after recovery from CABG. Therefore, we performed off-pump CABG via left thoracotomy using a saphenous vein Y-graft. Proximal anastomosis was placed in the descending aorta, and the distal anastomoses were completed with a stabilizer and an apical retraction device. Postoperative angiograms showed both grafts were patent and had suitable layout for subsequent esophageal surgery. In conclusion, off-pump CABG via left thoracotomy is an appropriate option for myocardial revascularization, if median sternotomy is contraindicated.

Lambl's excrescences are the fibrous structures which are attached to the heart valve, and usually the presence of Lambl's excrescences alone is not an indication of operation. The operative indications of isolated Lambl's excrescence is still controversial, because some reports indicated cross relationship between Lambl's excrescences and cerebral embolism. Based on these facts, we discussed our 3 cases of Lambl's excrescences. Two of the cases had been complicated with severe mitral regurgitation and Lambl's excrescences were resected at the time of mitral valve plasty. In another case, Lambl's excrescence was found with echocardiography during chronic heart failure therapy. This patient had a past history of cerebral infarction, but no relationship of cerebral infarction was suggested. In this case, cardiac surgery was not required, so we followed isolated Lambl's excrescence without resection in this case. One operated case, which had infective endocarditis was suspected by echocardiography, had slighted inflammatory reaction but blood culture was negative. Diagnosis of Lambl's excrescence was made by histopathological examination. One report suggested that the cause of the cerebral infarction is not Lambl's excrescence itself but the thrombi around Lambl's excrescence. However, we hesitate to operate on isolated Lambl's excrescence. Based on some reports, it is useful to resect Lambl's excrescence when a concurrent cardiac operation is carried out to avoid cerebral embolic events.

The case was a 70-year-old man. Nine years after VVI pacemaker implantation with a screw-in electrode, the battery was replaced. One year later, a new electrode was added due to pacing failure, and the old electrode was left in the pocket with silicone cap. Two months later, he was admitted due to fever. Although no infection was recognized, an increase in pericardial effusion was observed and the patient, with a past history of interstitial pneumonia, was positive for anti-ARS antibodies. Therefore, colchicine and aspirin were administered as nonspecific pericarditis, and the pericardial effusion disappeared in 2 weeks. When the dose of aspirin was reduced two months later, the inflammatory reaction flared-up. CT scan showed an abscess between the liver and the right ventricular wall. The electrode, penetrated the right ventricle, was continuous into the abscess cavity. During open heart surgery, it was observed the old electrode firmly adhered to the superior vena cava, right atrium, tricuspid valve, and anterior papillary muscle and successfully dissected and removed without bleeding. The chest was closed after aggressive lavage of the abscess cavity and the pocket. Fluid retention was observed in the pocket, the old electrode internal lumen, and the abscess cavity. Cutibacterium was detected in all of them. It was thought that Cutibacterium pocket infection was transmitted through the internal lumen of the screw-in electrode that penetrated the right ventricular wall and caused intrapericardial abscess. There were no reports about infection transmitted route as in this case.

A 77-year-old woman was admitted to our hospital with a decreased level of consciousness and left hemiplegia. Contrast-enhanced CT showed acute type A aortic dissection and right common carotid artery occlusion. Electrocardiogram findings showed ST segment elevation in the anterolateral wall. The results suggested that the aortic dissection had extended to the left main trunk and caused acute myocardial infarction. Percutaneous coronary intervention (PCI) was performed preoperatively to improve myocardial ischemia reperfusion. After a successful PCI, the patient underwent ascending aorta replacement immediately. In cases of acute aortic dissection involving the left main artery, preoperative PCI prevents extensive myocardial damage and serves as a bridge to surgery.