A secondary aorto-enteric fistula can directly communicate with the gastroduodenal tract, colonic tract and the aorta in patients undergoing major surgery on the aorta, and this phenomenon is observed particularly often in patients who have undergone abdominal aortic graft replacement. We encountered a case of secondary aortoduodenal fistula and colonic fistula. The patient was a 60-year-old man who had previously undergone a graft replacement for an infra-renal abdominal aortic aneurysm. His present admission was due to episodes of gastro-intestinal hemorrhaging and he had also undergone an abdominal aortic graft replacement 2 months previously. The patient's bleeding was managed conservatively. A scar was observed in the duodenum based on the endoscopic findings. At 10 days after admission, abdominal computed tomography (CT) showed active bleeding from the graft in the third portion of the duodenum. We therefore diagnosed secondary aorto-duodenal fistula. Since this pathogenic state may lead to serious massive gastroduodenal hemorrhaging, both an accurate diagnosis and emergency operation are therefore essential to successful treatment. We immediately inserted an intra-aortic occlusion balloon catheter (IABO). Thereafter, another aorto colonic fistula was detected after laparotomy, for the first time. First, the old graft was removed and the direct closure of the duodenum was performed, followed by omentopexy, colostomy, colostoma and then the extra-anatomical revascularization between the left axillary and bilateral femoral arteries was carried out. Finally, an intestinal feeding tube was inserted. The patient fell into a state of cardiac arrest during the operation due to the uncontrolled active bleeding in spite of the presence of IABO. An emergency thoracotomy was thus performed in the left 4th intercostal region. The descending aorta was clamped, and then all of the planned procedures were performed in order. The postoperative course was eventful, however, the patient's lower thigh eventually had to be amputated due to ischemia of the clamped descending aorta. We encountered a case of graft duodenal and colonic fistula with cardio pulmonary arrest due to delayed diagnosis based on the endoscopic findings after abdominal aortic graft replacement. This case was successfully treated despite various difficulties in making a timely and accurate diagnosis.

　　Case 1: A woman in her 70s was carried into emergency department of our hospital. Apparently she had dyspnea. Acute pulmonary heart was suspected. Electrocardiography S I Q III T III-pattern. The patient was diagnosed with popliteal vein vascular aneurysm by ultrasonography. Case 2: A man in his 60s, was referred to our hospital for treatment of lower extremity swelling and pain. Like Case 1, the male patient was suspected of having deep vein thrombosis and femoral artery aneurysms by ultrasound inspection and also diagnosed with pulmonary thromboembolism based on CT findings. We were able to rescue these two patients by rapid medical cooperation. Ultrasonography was particularly useful for diagnosis and morphological evaluation of blood vessels.

We report an 81-year-old woman with giant left atrial myxoma who had been admitted with congestive heart failure. Diagnosis was established by echocardiography and a moderate degree of tricuspid valve regurgitation was also found. The tumor was extensively attached to the atrial septum, and was excised completely including endocardium. She had concomitant tricuspid annuloplasty. Atrial fibrillation occurred on postoperative day 10, but conversion to a sinus rhythm was seen on postoperative day 19. She was discharged in good condition on postoperative day 36. Even in a patient over 80 years old with congestive heart failure, aggressive surgical treatment of left atrial myxoma should be performed.

We report a 66-year-old woman with circulatory collapse due to acute pulmonary thromboembolism, in whom a left nephrectomy for a renal tumor was scheduled. Following preoperative renal angiography. The patient suffered sudden shock resulting from pulmonary thromboembolism (PTE) following release of compression of the puncture site. The patient was transported to the ICU, and percutaneous cardiopulmonary support (PCPS) was instituted immediately for resuscitation. Hemodynamics were stabilized by PCPS and percutaneous thrombectomy was attempted. However, perforation by a catheter inverted to the extracardiac space occurred, which neccesitated emergency surgical hemostasis. PCPS was converted to cardiopulmonary bypass (CPB). The injured right ventricle and right atrial walls were repaired, and pulmonary thrombectomy was performed via the pulmonary trunk. CPB was easily terminated and her postoperative course was uneventful with anticoagulant therapy. Left nephrectomy was performed two months later. PTE recurred due to the interruption of anticoagulation for surgical treatment of a renal tumor. Percutaneous pulmonary thrombectomy and thrombolysis therapy were effective and a Greenfield filter was inserted into the inferior vena cava to prevent recurrence.

A 36-year-old previously healthy woman with cardiomegaly on a routine chest X-ray was given a diagnosis of primary chylopericardium after pericardial puncture revealed milky effusion. Endoscopy-assisted ligation of the thoracic duct and creation of a pericardial window was performed. The operation was greatly facilitated by the preoperative three-dimensional CT scan with lymphangiography that precisely demonstrated the distribution of the thoracic duct and other lymphatic ducts.

Objectives : We sought to present data relative to valvular heart surgeries from the Japan Cardiovascular Surgery Database in 2017 and 2018 to show current status and trend in Japan. Methods : We extracted data relative to cardiac valve surgeries performed in 2017 and 2018 from the Japan Cardiovascular Surgery Database. We obtained total number of aortic valve replacement procedures and showed trend for these 6 years from 2013 to 2018. The operative mortality rates were shown for representative valve procedures stratified by age group with the aim of showing a bench mark of Japan. Data regarding minimally invasive procedures and transcatheter aortic valve implantation which the Japan Cardiovascular Surgery Database can provide were also presented. Results : Despite dramatic increase of number of transcatheter aortic valve implantation in 2017 and 2018 compared to in 2015 and 2016, surgical aortic valve replacement also increased from 26,054 to 28,202. Regarding the operative mortality of first time valve procedures, it was 1.8% in isolated aortic valve replacement, 0.9% in isolated mitral valve repair, 8.2% in mitral valve replacement with biological prostheses, and 4.6% with mechanical prostheses. For first time valve procedures with concomitant coronary artery bypass, the operative mortality was 5.2% in aortic valve replacement, 4.9% in mitral valve repair. Regarding prosthetic valve selection, 72.6% of patients had biological prosthesis for aortic valve replacement procedures in their 60's, showing trend of increasing percentages of biological valve choice. Regarding minimally invasive procedure, 31.8% of first time isolated mitral valve plasty were performed via right thoracotomy. Though patients who underwent surgery via right thoracotomy had better clinical outcomes, it was also apparent that the patients who underwent surgery via right thoracotomy had lower operative risk profile. Aortic clamp time and cardiopulmonary bypass time were longer in the right thoracotomy patients. 6.3% of the patients who had isolated aortic valve replacement underwent surgery via right thoracotomy. The right thoracotomy aortic valve replacement patients had better clinical outcomes and had more percentage of lower risk profile. The overall mortality of transcatheter aortic valve implantation and surgical aortic valve replacement were 1.5% and 1.8%, respectively. Conclusion : We reported data related to heart valve surgery in 2017 and 2018 from the Japan Cardiovascular Surgery Database.

Objectives : Data of valvular heart surgeries from the Japan Cardiovascular Surgery Database in 2015 and 2016 were analyzed to demonstrate the associated mortality and morbidity rates and choice of surgical procedures. Methods : We used the Japan Cardiovascular Surgery Database to extract data of cardiac valve replacement procedures performed in 2015 and 2016. The cases were further evaluated depending upon the type of procedure, and prosthesis used at each site. The rate of bio-prosthesis usage was derived for each valve position and age groups. The rates of operative mortality and morbidity were calculated for each valve position and type of procedures. Results : In total, 26,054 aortic valve replacements were performed in 2015 and 2016, showing a slight increase in number since the last report(2013-2014). A total of 3,305 transcatheter aortic valve replacements, 5,652 mitral valve replacements, and 12,024 mitral valve repair procedures were performed. The rate of bio-prosthesis usage in aortic valve replacement was 96.5%, 92.7% and 63.5% for patients in their 80s, 70s and 60s, respectively, demonstrating an increase in usage since 2013-2014. Mechanical valves were preferred in patients on chronic hemodialysis. The mortality rates of aortic valve replacement, mitral valve replacement, mitral valve repair, and tricuspid valve replacement procedures were 4.1%, 7.1%, 2.2%, and 10.5%, respectively. Conclusion : We evaluated recent trends in valvular heart surgery in Japan with respect to the type of procedure and prosthesis preferred and the postoperative outcomes. We found that bio-prosthesis usage was the most common.