We experienced 2 rare cases of acute myocardial infarction (AMI) complicated by ventricular septal perforation (VSP) and right ventricular free wall rupture. Case 1 was a 70-year-old woman who developed VSP and cardiac rupture after percutaneous coronary artery thrombolytic therapy for AMI (total occlusion of left anterior descending branch (LAD) # 6) and died of cardiac tamponade. Postmortem examination showed right ventricular free wall rupture. Case 2 was a 76-year-old woman. She developed VSP 6 days after percutaneous coronary artery intervention (stenting) for AMI (total occlusion of LAD # 8). VSP was closed by the double patch repair technique. During operation, right ventricular free wall rupture (oozing type) was found, so hemostasis with fibrinogen was added. She was discharged in a satisfactory condition 4 weeks after surgery. Right ventricular rupture after AMI of the LAD region is rare. VSP may be associated with right ventricular free wall rupture complicated by AMI of LAD region because all of our cases were accompanied by VSP.

The cause of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is not clear yet. Speculating that the extension of pulmonary vein (PV) would induce AF after CABG, we analyzed 39 cases in which a Swan-Ganz catheter was inserted at the onset of AF. The cardiac index (CI), systolic pulmonary artery pressure (sPA), diastolic pulmonary artery pressure (dPA) were measured continuously after operation. The “occupation index” was defined as “(value just before the AF onset-minimum value)/(maximum value-minimum value) × 100%.” The mean values of the occupation index for CI, sPA and dPA were 16±30%, 77±36%, 76±38% (mean±SD) respectively. Furthermore, cases in which CI just before the AF onset showed a minimum value in all the collected data consisted of 27 of the 39 cases (69%), and sPA/dPA just before the AF onset showed a maximum value in all the collected data in 26/25 of the 39 cases (67%, 64%). About two-thirds of AF cases occurred in the descending phase of CI, and in the ascending phase of sPA/dPA. We considered these conditions to be equivalent to the extension condition of PV and surmised that PV extension might be one of the causes of AF after CABG.

We encountered a case of cerebral oncotic aneurysms and intracerebral hemorrhage after resection of a left atrial myxoma. A 67-year-old woman underwent resection of the left atrial myxoma. She was followed by ultrasound cardiography on an ambulatory basis. About one and a half years later, she was hospitalized because of neural symptoms. Multiple cerebral aneurysms and intracerebral hematoma were found, and the hematoma was removed. With the neural symptoms recurring repeatedly thereafter, however, she eventually died due to pneumonia. The pathological examination of the intracerebral hematoma removed at operation and cerebral aneurysms at autopsy revealed myxoma cells causing embolisms in the artery and invading the atrial wall with some hemorrhage. It is known that cardiac myxoma occasionally causes a cerebral lesion. The lesion is presumed to be caused by embolism as in our case. So it is nessesary to evaluate morphologic characteristics of cardiac myxoma before operation and to pay attention to the occurrence of embolism during operation. Making a rigorous follow-up of the general progress by computed tomography after operation is also considered important.

For aortic root replacement in annuloaortic ectasia (AAE), an artificial prosthesis is commonly sutured to the aortic annulus (hemodynamic ventriculoaortic junction). We consecutively had 6 cases of aortic root replacement using anatomic ventriculoaortic junction suture. This anatomic ventriculoaortic junction suture is a simplified and practical method for aortic root replacement in the same way as using stentless bioprostheses or homografts.

The patient was a 37 year-old man. We diagnosed Loeys-Dietz syndrome based on his physical characteristics that were widely spaced eyes and brachycephaly etc. Since he developed De Bakey III b aortic dissection 3 months later, he needed surgical repair for saccular-shaped distal arch aortic aneurysm. We performed total aortic arch replacement for the aneurysm and valve-sparing aortic root reconstruction for dilatation of the Valsalva sinus. Furthermore we performed the frozen elephant trunk technique for residual aortic dissection at the same time. After 18 months from the operation, we were able to recognize by computed tomography that the false lumen of the aorta next to the stent graft was thrombosed and absorbed and finally disappeared. The stent graft treatment for patients with connective tissue disease might be an effective method and deserves more attention.

A 79-year-old woman had received implantation of a pace maker for sick sinus syndrome at age 64 and tricuspid valve annuloplasty and Maze at age 68. Furthermore, she underwent tricuspid valve and mitral valve replacement with a bioprosthesis because of tricuspid valve and mitral valve regurgitation at age 73. She was referred to our institution for congestive heart failure in November 2005, because her bioprostheses at the mitral and tricuspid positions had shown significant regurgitation due to the degeneration of the prostheses, which required rereplacement. Because 1) surgical treatment of the heart had been performed twice in the past, 2) the general condition was not good owing to cirrhosis and hypothyroidism and 3) the durability of bioprostheses is short, we performed mitral valve re-replacement by using the “valve-on-valve” technique for reducing the invasion of surgical therapy. She had a satisfactory postoperative course. The “valve-on-valve” technique is a useful option for the re-replacement of bioprosthesis because it obviates the need for removing the sewing ring of the previous bioprosthesis.

A 69-year-old woman was admitted with fever and dyspnea. We diagnosed the congestive heart failure due to infective endocarditis (IE) with mitral valve regurgitation and stenosis. We immediately started medical therapy in order to control both the heart failure and the infection. However, we had to semi-emergency mitral valve replacement additionally perform a days after the initial hospitalized due to a progression of the heart failure. The operative findings showed an area of vegetation to be incarcerated in the mitral orifice. In cases of IE which are associated with mitral stenosis, we therefore should consider the possibility that vegetation may be present in the mitral orifice and closely follow such patients by echocardiography.

We presented here 2 cases of rare nonvascular tumor involving the aorta. Case 1: A 69-year-old woman. She presented leg edema and dyspnea on admission. Computed tomography revealed abdominal aortic aneurysm perforating left common iliac vein. Abdominal aortic aneurysm replacement and fistula closure were done on an emergency basis. Immunohistologic examination revealed that malignant mesothelioma invaded the aortic wall. Case 2: A 47-year-old woman presented with dyspnea. Enhanced computed tomography revealed rupture of the descending aortic aneurysm (saccular type). Aortic replacement was done on an emergency basis. One year after the operation, computed tomography revealed a giant mass (160×70mm) surrounding the descending thoracic aorta. On biopsy, malignant schwannoma was found to invade the descending aorta. Sometimes nonvascular tumors form aneurysms. So we should be careful in diagnosis before operation.