We report a rare case of aorto-right ventricular fistula and vegetation in the right ventricle after aortic valve replacement. A 74-year-old woman with a history of aortic valve replacement with a Carpentier-Edwards Perimount pericardial bioprosthesis 7 months earlier was admitted with fever. Methicillin-sensitive Staphylococcus aureus was detected from her blood culture. Transthoracic echocardiography showed an aorto-right ventricular fistula and vegetation in the right ventricle. Under a diagnosis of infective endocarditis, surgery was performed. The operative findings showed a fistula from the previous aortic suture line to the right ventricle, and substantial vegetation in the right ventricular outflow tract. No infective change was observed in the previously inserted prosthetic or pulmonary valves. The vegetation was removed and the fistula was closed directly with a single pledgeted 4-0 prolene mattress suture. The right ventricular outflow tract was reconstructed with a heterogeneous pericardial patch. The patient was discharged in good health on the 59th postoperative day without any infective complications.

A 67-year-old man with aortic insufficiency underwent aortic valve replacement (AVR) with a Freestyle^TM valve (Medtronic Inc.), using the complete subcoronary technique. Although a trivial aortic insufficiency remained on postoperative echocardiography, he continued without chest symptoms. A cardiac murmur developed and dyspnea on effort appeared five months postoperatively. Echocardiography and aortography showed severe aortic insufficiency, and a re-do AVR was performed seven months after the first procedure. Examination of the Freestyle valve revealed that two loops of the suture line on the inflow side of the valve had become detached from the muscular tissue. It is most important to keep the geometry of the Freestyle valve at the time of the implantation using the subcoronary technique, and an unsuitable implantation can cause consequent perivalvular leakage.

A 33-year-old woman underwent aortic root replacement for aortic regurgitation and an aneurysm of the ascending aorta due to annuloaortic ectasia. Ehlers-Danlos syndrome was diagnosed by skin biopsy when she was 23 years old. At operation, to avoid mechanical stress to the residual aorta, cardiopulmonary bypass was established via cannulation of the left femoral artery and we used the open distal anastomosis method under hypothermic circulatory arrest with selective cerebral perfusion. Moreover, the sutures of the aortic annulus were reinforced sewing the aortic wall together. Her postoperative course was uneventful. Despite the fragility of the cardiovascular tissues in Ehlers-Danlos syndrome, cardiac surgery could be performed safely with appropriate surgical procedures.

We report a rare case of lipoma arising from the right ventricle. A 66-year-old woman was admitted to our hospital for exertional chest pain and fatigability. She was diagnosed of mild aortic stenosis and regurgitation (ASR), mild mitral regurgitation (MR), and asymptomatic cardiac tumor in the right ventricle about two years previously, for which she had been followed up at other local hospital. A recheck transthoracic echocardiography revealed moderate MR. No evidence of deterioration of ASR and cardiac lipoma were detected. The patient underwent mitral annuloplasty and replacement of aortic valve, plus resection of the right ventricle tumor through the tricuspid valve. Pathological examination of the resected tumor showed mature adipose tissue infiltrated into normal cardiac muscle without atypical cells, which suggested intramyocardial lipoma. Postoperative course was uneventful. Fourteen months after the operation, the patient remains asymptomatic and regular echocardiographic checkup demonstrates no tumor recurrence or residual MR.

It is well known that patients with abdominal aortic aneurysms (AAA) have a high incidence of coronary artery disease (CAD), and that the major cause of death in patients undergoing aneurysmectomy is acute myocardial infarction. A total of 53 patients (mean age, 71 years) underwent elective repair of AAA between January 1991 and November 1999. In an attempt to reduce early and late mortality caused by myocardial infarction, coronary angiography (CAG) was performed in all cases. Significant CAD was found in 23 patients (43%), with triple vessel disease in 1 patient (2%), double vessel disease in 5 patients (9%), single vessel disease in 16 patients (30%) and left main in 1 patient (2%). Ten patients (19%) in whom CAD was detected by CAG had no history of CAD and displayed no ischemic findings on ECG. In 4 patients (8%), AAA repair was performed 2 (mean) months after coronary artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 8 patients (23%) 19 days (mean) prior to AAA surgery. No patient had a perioperative myocardial infarction either following coronary revascularization (CABG and PTCA) or AAA resection. Moreover, there was only one operative death after abdominal aneurysmectomy (2%), in a patient who was 70 years old with chronic hemodialysis and who died due to multiple organ failure caused by uncontrollable adhesional ileus. The results of this study emphasize the importance of preoperative routine coronary angiography following coronary artery revascularization to enhance the operative outcome of AAA repair.

Rheumatic tricuspid stenosis has become rare recently. A 54-year-old woman had undergone mitral valve replacement with a Carpentier-Edwards bioprosthesis for mitral stenosis 22 years previously and had undergone repeat mitral valve replacement for prosthetic valve failure 10 years later. She was admitted with severe leg edema. Cardiac catheterization revealed pulmonary hypertension and tricuspid stenosis with a diastolic pressure gradient of 6mmHg across the tricuspid valve. Tricuspid valve replacement was performed with a Hancock bioprosthesis. The postoperative course was uneventful and her edema improved markedly. This case suggested that careful follow-up to detect progression of tricuspid stenosis is necessary in patients with rheumatic valve disease and pulmonary hypertension.