A sinus of Valsalva aneurysm is a comparatively rare disease, and it has almost no symptoms unless this is rupture, whereas aortic insufficiency, myocardial ischemia and heart failure might be associated with un-ruptured aneurysm of the sinus of Valsalva. We encountered 2 elderly patients (71 years old and 83 years old) with huge un-ruptured aneurysm of the sinus of Valsalva which causes right ventricular outflow tract obstruction. The orifice of the aneurysm of the sinus of Valsalva was closed using ePTFE patches in the both cases. Plication of aneurysm was attempted in both cases, but it failed in case 1 due to undetermined border of the aneurysm on the right side of the heart. Case 2 was required concomitant aortic valve replacement with a bioprosthesis due to associated aortic regurgitation. The repair of un-ruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract obstruction can be performed safely and effectively even in elderly patients.

A 56-year-old man, who underwent aortic valve replacement with a stentless artificial valve for aortic valve endocarditis at age 52, found to have left ventricular outflow pseudoaneurysm by transthorasic echocardiography, transesophageal echocardiography and enhanced computed tomography. We repaired the pseudoaneurysm, combined with valve re-replacement. Left ventricular outflow pseudoaneurysm is a rare disease, and is often associated with active endocarditis. Transesophageal echocardiography and CT scan are useful to diagnose this disease, especially to rule out annular abscess. Operative indication is recommended soon after the diagnosis was made to prevent rupture of pseudoaneurysm, or development of either mitral regurgitation or coronary ischemia due to compression from the pseudoaneurysm. Combined aortic valve replacement, with or without mitral valve replacement is necessary to repair the pseudoaneurysm.

Intracardiac repair for cardiac anomalies associated with a transposed aorta from the right ventricle is a technically demanding operation. We present two cases of left ventricular outflow tract (LVOT) obstruction after the use of an ePTFE flat patch to reconstruct the LVOT. Case 1 : A 10-year-old boy had undergone the Rastelli operation, VSD enlargement, and intraventricular re-routing using an ePTFE flat patch for repair of the DORV with noncommitted VSD and pulmonary stenosis at the age of 5. Five years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using a part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. Case 2 : A 13-year-old girl had undergone a double-switch operation (Senning operation, the Rastelli operation, and intraventricular re-routing by the use of an ePTFE flat patch) for the repair of corrected TGA, PA and VSD at the age of 7. Six years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. We consider that the use of a flat patch for reconstruction of a left ventricular out flow tract in cases with transposition of the aorta from the right ventricle involves a risk of future development of LVOT obstruction.

The patient was a 39 -year-old woman. Malignant rheumatoid arthritis was diagnosed when she was 32 years old, and the patient was treated with oral steroids. She presented at our center with sudden precordial pain. Coronary angiography revealed severe stenosis of the left main coronary artery (segment 5, 99%). Acute myocardial infarction and pulmonary edema were diagnosed. The patient underwent off-pump coronary-artery bypass grafting, with anastomosis of the left internal thoracic artery to the left anterior descending artery. One year 3 months later, the patient was readmitted to the hospital because of recurrent angina pectoris and heart failure. Coronary angiography showed patency of the left internal thoracic artery and severe stenoses of the left main coronary artery(segment 5, 100%), circumflex artery (segment 11, 99%), and right coronary artery (segment 1, 90%), suggesting angiitis. On-pump coronary-artery bypass grafting was done, with anastomosis of the right internal thoracic artery to the right coronary artery (segment 2) and the gastro-omental artery to the obtuse marginal branch (segment 12). The patient is being followed up on an outpatient basis. There are few reports describing patients with rheumatoid arthritis who underwent coronary artery bypass surgery. However, the most common cause of death in patients with rheumatoid arthritis is coronary-artery disease. Although the patient was still young, coronary-artery disease progressed rapidly. Such rapid progression was attributed to difficulty in controlling the inflammatory response after initial surgery, as well as to changes in vascular endothelial cells caused directly by treatment with steroids. Possible adverse effects of such treatment should be carefully considered.