A 71-year-old woman underwent repair of a ventricular septal perforation due to myocardial infarction by the extended sandwich patch technique 5 years ago. She was discharged from the hospital without complications. During the follow-up period, a ventricular apical aneurysm was found on contrast-enhanced computed tomography and transthoracic echocardiography. Since the aneurysm had enlarged gradually and a thrombus was found in it, repairing surgery was indicated. The patient was initiated on cardiopulmonary bypass after dissection of the adhesions of the previous surgery, and a longitudinal incision was made on the left side of the left anterior descending artery under cardiac arrest to remove the aneurysm. A large amount of thrombus was found inside the aneurysm. The thrombus was removed, Dor surgery was performed with a circular Hemashield patch. Reports of ventricular apical aneurysm after myocardial infarction in a remote period are rare. It is necessary to perform surgical intervention as soon as possible to prevent free wall rupture as well as cerebral infarction.

A 47-year-old man was admitted to our hospital complaining of chest and back pain. Enhanced CT scan revealed Stanford type A acute aortic dissection. The celiac artery (CA) was not enhanced and the superior mesenteric artery (SMA) appeared on the delayed phase. There was a small amount of pericardial effusion. Blood gas analysis showed metabolic acidosis. To treat mesenteric malperfusion, we initially performed thoracic endovascular aortic repair (TEVAR) by the PETTICOAT technique and stenting to CA and SMA. The acidosis gradually normalized after TEVAR. We then performed surgical central repair (total arch replacement). He temporarily showed paraplegia after the operation but soon recovered by treatment for spinal ischemia. He was discharged 68 days post operatively without any complication. Surgical central repair is not always effective for treating organ ischemia, so endovascular repair before surgical operation is sometimes taken into consideration.

Distal anastomosis during total arch replacement (TAR) for thoracic aortic aneurysm (TAA) is often difficult to perform because of the limited surgical view. The most common methods available are direct anastomosis of a 4-branched graft to the distal aorta, or stepwise anastomosis with the elephant trunk procedure. However, the stepwise technique requires graft-to-graft anastomosis, which is often associated with bleeding. In the present study, we developed a new approach, which we have termed the “Branched Graft Inversion technique”, which does not require anastomosis between grafts, and facilitates anastomosis with a view equal to that in the stepwise technique. A 65-year-old man with a diagnosis of saccular-type thoracic aortic aneurysm was admitted. Cardiopulmonary bypass was established by cannulating the ascending aorta and femoral artery via a median sternotomy. We performed distal anastomosis under selective cerebral perfusion during hypothermic circulatory arrest (25°C). An inverted branched graft was inserted into the descending aorta and anastomosed using mattress and running sutures together with outer reinforcement with a Teflon felt strip. The distal end of the inverted branched graft was then extracted, and reconstruction of the neck vessels and proximal anastomosis were performed. Our newly developed Branched Graft Inversion technique was useful during TAR for TAA.

A 62-year-old man had been given a diagnosis of atrial septal defect (ASD) 20 years previously, but the condition was left untreated. A heart murmur was detected on a routine health examination, so he visited our institution where a diagnosis of type II ASD and moderate tricuspid regurgitation was given. Cardiac catheterization revealed a pulmonary to systemic flow ratio (Qp/Qs) of 2.9, pulmonary vascular resistance of 3.1 units, and systolic pulmonary artery pressure of 90 mmHg. The patient underwent open surgery consisting of a patch closure of the ASD, and tricuspid annuloplasty. His pulmonary arterial pressure rose and his blood pressure dropped, and left cardiac failure developed on postoperative day (POD) 2. The administration of catecholamines and a phosphodiesterase (PDE) III inhibitor failed to correct the left cardiac failure. We performed intra-aortic balloon pumping (IABP) immediately, and his hemodynamic condition stabilized. The IABP catheter was removed on POD 10. The postoperative development of circulatory failure suggested that it was almost too late for surgery for ASD. It has been believed that surgery for ASD is relatively safe. However, it seems that, the considering the possible occurrence of postoperative cardiac failure in elderly patients with accompanying pulmonary hypertension, careful postoperative management is necessary.

A 51-year-old man admitted to our hospital because of an ECG abnormality pointed out by his local doctor. He had been hospitalized for scarlet fever at age 10. A coronary artery CT scan showed coronary artery aneurysm of the left main trunk (LMT), and coronary angiography showed 3-vessel disease including a chronic total occlusion of the right coronary artery (RCA). We performed conventional coronary artery bypass grafting (CABG) using an arterial graft and aneurysmectomy. The patency of the graft was confirmed by coronary angiography postoperatively. The pathological diagnosis of the coronary aneurysm was Kawasaki disease. CABG is a standard procedure for coronary artery aneurysms with Kawasaki disease. However, there are no established treatment guidelines on whether to perform aneurysmectomy. We chose CABG with aneurysmectomy because of the possibility of intra-aneurysmal thrombosis leading to peripheral occlusion, and the cause of the coronary artery aneurysm could not be determined. However, even if additional treatment by percutaneous coronary intervention (PCI) is not possible, it is important to avoid occlusion of the graft.

Cardiac papillary fibroelastoma (CPF) is a rare benign cardiac tumor. It commonly arises from the left side heart valve. We present two rare cases of CPF that originating from the right side of the heart confirmed by surgical resection. Case 1 : A 67-year-old man was admitted for surgical resection of a cardiac tumor located in the right atrium. Transesophageal echocardiography revealed a mobile mass attached on the anterior leaflet of the tricuspid valve. The tumor was resected by open heart surgery. Histopathologic examination confirmed the tumor to be a CPF. Case 2 : A 68-year-old man was admitted for surgical resection of a tumor occurred from the tricuspid valve. Transthoracic echocardiography revealed a tumor attached to the medial leaflet. The tumor was resected. Histopathologic examination confirmed it to be a calcified mass. However, the surface of tumor had many papillary projections macroscopically. We redo the histopathologic examination, and confirmed the tumor as a CPF finally. In both cases, postoperative courses were uneventful.

In Japan, few surveys have evaluated the structure and clinical process of cardiovascular surgery programs. We mailed a questionnaire to all 149 facilities participating in the Japan Adult Cardiovascular Database as of April 1st 2007. We received responses from 129 facilities (response rate 86.6%). For CABG surgery, many facilities regard “IMA use (95.3%) ” and “off-pump surgery” is the first choice as a facility and recommend “discharge antiplatelets (89.9%) ” and “discharge antilipid (47.3%) ”. On the other hand most facilities did not made any recommendation regarding “preoperative beta blockers (72.9%) ” and “discharge beta blockers (60.5%) ”. The usage rates of preoperative beta blockers and discharge beta blockers were very low in Japan though their usage rates were relatively high in the United States.

A 67-year-old man had angina pectoris due to left main trunk stenosis of coronary artery was transferred to our hospital. Anticoagulation was achieved with a continuous intravenous infusion of 625IU/h heparin. Sixteen days after admission, his platelet count decreased to 14×10⁴/μl, and further decreased to 9.1×10⁴/μl 4 days later. Since we suspected HIT, heparin administration was immediately discontinued, and was substituted with argatroban. A definitive diagnosis of type II HIT was made by a serologic test confirming positive antibodies to the heparin-platelet factor 4 (PF4) complexes. After the platelet count recovered, we performed off-pump CABG (OPCAB) using argatroban. The postoperative course was uneventful and platelet counts was normal. The patient was discharged on the 13th postoperative day. Heparin-induced thrombocytopenia, which causes thrombosis, is a serious side effect of heparin therapy. It is not rare, and in such case argatroban can be useful as an anticoagulant during OPCAB.

We report a rare case of concomitant coronary artery disease, abdominal aortic aneurysm, and bile duct cancer. A 65-year-old man, who had been recognized to have jaundice in late November 2005, was found to have bile duct cancer, an abdominal aortic aneurysm with a diameter of 70mm, and coronary artery disease (with two severely diseased branches). To avoid extended operation, a two-stage operation was performed; at the first operation, off-pump coronary artery bypass surgery (LITA to LAD and Ao-SVG to 4 PD) and replacement of the abdominal aortic aneurysm by an artificial blood vessel with minimal incision were implemented. In 21 days after the cardiovascular surgery, the patient underwent pylorus-preserving pancreatoduodenectomy (modified Child method) in the second operation. After the two-stage operation, the patient showed a favorable outcome without any major complications. On the basis of the outcome of two-stage operation we successfully applied, we discuss the strategy for treatment of patients having both cardiovascular and abdominal malignant diseases, with reference to the literature.

A 24-year-old woman with an abdominal aortic aneurysm (AAA) caused by mucoid medial degeneration of the aortic wall in the absence of Marfan syndrome is reported. She required a Y-shaped graft replacement of the abdominal aorta through a minimal incision and recovered successfully.