We reported a rare case of aorto-left ventricular fistula with the unruptured aneurysm of the Valsalva sinus due to the infective endocarditis. Preoperatively trans-echocardiographic examination revealed the ruptured left sinus of Valsalva aneurysm protruded toward the left ventricule. Aorto-left ventricular fistula contiguous to the unruptured aneurysm of the right valsalva sinus, however, was detected at operation. Granulation tissue resembling healed infective vegetation was detected in the margin among the orifices of this fistula and Valsalva aneurysm. Pathological examination showed excessive accumulation of white blood cells, which suggested infective endocarditis.

Treatment of acute pulmonary thromboembolism (APTE) in patients with hemodynamic instability still remains controversial. We analyzed the outcome and validity of surgical pulmonary embolectomy for APTE. Between January of 2004 to December of 2010, 15 patients underwent emergency surgical pulmonary embolectomy using cardiopulmonary bypass with beating heart. Our operative indications were ; within 7 days from onset, hemodynamic instability, bilateral pulmonary artery obstruction or unilateral obstruction with central clot and right ventricular dysfunction. Ten patients presented in cardiogenic shock, two of whom showed cardiac arrest and required cardiopulmonary resuscitation before operation. One patient required percutaneous cardiopulmonary support. Median follow up period is 33 months (range 3 to 86 months). All patients survived the operation, but 3 patients died in the hospital on post operative day 11 (massive cerebral infarction), day 18 (brain hypoxia) and day 25 (multiorgan failure). Two of them had cardiac arrest and received cardiopulmonary resuscitation before operation. Hospital mortality was 20%. And all patients left the hospital on foot except one patient who had been bedridden by myotonic dystrophy before operation. No patients died or showed symptoms of pulmonary hypertension after discharge. Prompt diagnosis and surgical pulmonary embolectomy before threatening fatal condition improves the outcome of embolectomy.

A 45-year-old man was hospitalized with sudden-onset chest pain. He was in cardiogenic shock with a systolic pressure of 68 mmHg. His electrocardiogram (ECG) showed ST segment elevation in leads I, aVL, and V2-5. An emergency coronary angiogram (CAG) showed that the true lumens of bilateral coronary arteries were compressed, showing acute Stanford type A aortic dissection involving bilateral coronary artery. A bare metal stent was promptly implanted in the left main trunk (LMT) to restore coronary blood flow because of his hemodynamic instability. Soon afterwards, the ischemic changes on ECG disappeared and he was transferred to the operating room in a stable hemodynamic condition. We performed emergency graft replacement of the ascending aorta and coronary artery bypass grafting. The postoperative CAG showed patent bypass grafts. Implantation of LMT stent, as a bridge to surgery, should be the treatment of choice for acute type A dissection involving LMT.

We report a case of type A acute aortic dissection in a patient with situs inversus totalis. A 51-year-old man was hospitalized with sudden-onset back pain. Contrast-enhanced computed tomography revealed Stanford type A acute aortic dissection and situs inversus totalis. Total arch replacement using selective cerebral perfusion and mild hypothermic circulatory arrest was successfully performed. He was discharged home 23 days after the operation.

A 62-year-old woman was admitted to a regional hospital for acute myocardial infarction. Emergency coronary angiography revealed occlusion of the first diagonal branch, and transesophageal echocardiography showed severe mitral regurgitation due to anterior papillary muscle rupture. She was transferred to our hospital in a state of cardiogenic shock despite the use of high-dose catecholamine and intra-aortic balloon pumping. We immediately performed mitral valve replacement. The patient's postoperative course was uneventful and she was ambulatory when transferred to another hospital on foot on postoperative day 19. Physicians should be aware that fatal anterior papillary muscle rupture may be caused by isolated occlusion of the diagonal branch.

A 58-year old man without Marfan syndrome was referred to our hospital for congestive heart failure due to severe mitral regurgitation. He had undergone sternal turnover with a rectus muscular pedicle for pectus excavatum 36 years previously. We were able to perform mitral valve repair via median sternotomy using a usual sternal retractor. There was no adhesion in the pericardium and the exposure of the mitral valve was excellent. We closed the chest in ordinary fashion without any problems in the fixation of the sternum or costal cartilage. There were no complications such as flail chest or respiratory failure.

Infectious endocarditis (IE) concomitant with patent ductus arteriosus (PDA) is now considered rare because the early treatment of PDA in infancy has become standard. We report a case of PDA with IE diagnosed by computed tomography (CT). A 51-year-old man complained of arthralgia and numbness of the left extremities. He had fever of 39°C and left hemiplegia, and was referred to our hospital. A chest X-ray film showed infiltration in both lungs. CT revealed a mass lesion in the main pulmonary artery and a tubular connection between the main pulmonary artery and the aortic arch. Multiple small infarctions were also found in the brain, lungs, kidneys and spleen. Ultrasonic cardiography revealed a bi-leaflet aortic valve, and vegetations on the aortic and mitral valves. Staphylococcus aureus was detected by culture of an intravenous catheter tip. These findings suggested IE concomitant with PDA, and we started intravenous administration of antibiotics. However, congestive heart failure occurred due to severe aortic and mitral regurgitation 2 days after hospital admission, and therefore, we performed emergency surgery. The main pulmonary artery was incised after cardiopulmonary bypass was initiated. A 20-mm length of vegetation was found on the orifice of the PDA. The vegetation was removed and the PDA directly closed. Aortic and mitral valve replacement was then performed. The post-operative course was uneventful and his neurological symptoms did not exacerbate. No sign of IE recurrence was observed 2 years after the surgery. CT clearly showed PDA and vegetation in the main pulmonary artery, although ultrasonic cardiography did not. CT was useful to make a diagnosis of PDA with IE in the present case.

This study compared the hemodynamic performance of the Carpentier-Edwards PERIMOUNT Magna bioprosthesis (Magna) with the Carpentier-Edwards PERIMOUNT bioprosthesis (CEP) for aortic valve stenosis (AS). Between January 2005 and May 2010, 164 patients underwent aortic valve replacement for AS with either the Magna (n=68) or the CEP (n=96) at our institute. Patients undergoing a concomitant mitral valve procedure were excluded from this study. The 21-mm Magna and CEP prostheses were the most frequently used during this period. Transthoracic echocardiography was postoperatively performed within 2 weeks. The peak velocity (PV) of the Magna was significantly lower than that of the CEP (2.59±0.36 vs. 2.75±0.47 m/s ; p=0.022). The mean pressure gradient (PG) was not significantly different. For the 19-mm prostheses, the mean PG and PV of the Magna were significantly lower than those of the CEP [16.4±4.5 vs. 19.7±6.4 mmHg ; p=0.034 (PG) and 2.70±0.36 vs. 3.03±0.49 m/s ; p=0.008 (PV)]. The effective orifice area (EOA) of the Magna was larger than that of the CEP [19 mm : 1.29±0.18 vs. 1.11±0.24 cm² (p=0.007) ; 21 mm : 1.46±0.23 vs. 1.42±0.18 cm² (p=0.370) ; and 23 mm : 1.70±0.34 vs. 1.52±0.25 cm² (p=0.134)]. In this study, the EOA of the Magna was approximately 80% of that described in the manufacture's description. Patient-prosthesis mismatch (PPM ; EOA index≤0.85 cm²/m²) was seen in 26.8% of patients with the Magna and in 47.2% of patients with the CEP (p=0.018). Severe PPM (EOA index≤0.65 cm²/m²) was not seen in any patients with the Magna. The EOA of the 19-mm Magna was significantly larger and the mean PG was lower than those of the 19-mm CEP. Compared with the CEP, the Magna significantly reduced the incidence of PPM, and had superior hemodynamic performance.