A 79-year-old woman with aortic stenosis due to a calcified small aortic root and severe coronary stenosis (at the left anterior descending artery) underwent aortic valve replacement with a 19mm CarboMedics “Top Hat” supra-annular aortic valve and coronary artery bypass grafting. The postoperative course was uneventful. It was found that by using the CarboMedics supra-annular aortic valve, at least one more large sized valve could be implanted compared to the standard aortic valve. This valve is useful in difficult cases to enlarge the narrow aortic annulus, such as in patients with a severe calcified small aortic root, left ventricular dysfunction or elderly cases. In addition, the operative risk may be decreased and operative time shortened using this valve.

We report two operated cases of papillary fibroelastoma of the aortic valve. Case 1: A 56-year-old man was referred to our hospital with hyperlipidemia. On echocardiogram, he was found to have a mobile mass attached to the NCC of the aortic valve. At operation, a sea anemone-like tumor was found attached to the free edge of the RCC and resection of the tumor was performed without valve replacement. Case 2: A 75-year-old woman was referred with heart murmur, and echocardiogram showed a tumor of the NCC of the aortic valve. At operation, the tumor was attached to the NCC and resection of the tumor was performed. On each case, microscopic examinations showed typical findings of PFE. The patients' postoperative courses were unremarkable.

Seven patients underwent surgical repair of the distal aortic arch aneurysm from January 1990 to October 1997. They were 5 men and 2 women ranging from 63 to 78 years of age (mean, 72.7 years). All patients were operated with a median sternotomy only. There was one operative death, which was ruptured case. However, there were no major complications in non-ruptured cases. This retrospective study suggests that it is possible to repair the distal aortic arch aneurysm through a median sternotomy approach alone, when 1) descending aorta originates with normal size just distal to sacciform aneurysm, 2) the maximum diameter of the aneurysm is over 70mm and 3) distal involvement of the aneurysm does not extend beyond the bifurcation of the trachea. It is useful to retract descending aorta proximally by three threads with pledget for distal anastomosis in inclusion technique.

Patient 1 was a 62-year-old woman who had been treated for hypertension for three years. Stanford A type acute aortic dissection occurred accompanied by right coronary ischemia. CABG and graft replacement of the ascending aorta were performed 8 hours after the onset of coronary ischemia, but after cardiopulmonary bypass the patient could not be weaned from the RVAD because of right ventricular infarction. On the 8th day after operation, she died due to right heart failure. Patient 2 was a 72-year-old male. Stanford A acute aortic dissection occurred and right coronary ischemia appeared during UCG examination in the ICU. CABG and graft replacement of the ascending aorta and the aortic arch were carried out less than 1 hour from the onset of coronary ischemia. The postoperative course was satisfactory and uncomplicated. If the dissection extends to the aortic root, it is important to monitor the ECG carefully to detect myocardial ischemic changes. In cases with coronary ischemia, early operation and CABG are mandatory.

A 47-year-old woman complained of dyspnea on exertion. Ultrasonic cardiography revealed coronary sinus type atrial septal defect. At operation, the drainage veins to the left atrium from the coronary arteries were observed but no anomalies of the vena cave or any other veins were observed. The defect was closed with a pericardial patch under cardiopulmonary bypass. The post-operative course was uneventful. Coronary arteriography performed on the 14th post operative day confirmed that the coronary veins drained individually into the corresponding atria. Unroofed coronary sinus is rare and difficult to diagnose prior to operation. Ultrasonic cardiography and coronary arteriography are considered useful for preoperative diagnosis.