An 80-year-old man was admitted to our hospital with a diagnosis of distal aortic arch aneurysm. A preoperative chest CT demonstrated a 54 mm in diameter distal aortic arch and coronary angiography revealed stenosis of LAD and the diagonal branch. We planned a thoracic endovascular repair after total arch replacement with a coronary artery bypass graft. A ZTEG-2P-30-200-JP was deployed at the proximal side of the elephant trunk, and a ZTEG-2P-34-152-JP was deployed. About 10 months later, a chest CT demonstrated a 90 mm in diameter distal native aortic arch, and anemia had increased to Hb 7.7 g/dl. A CT and angiography revealed a type II endoleak and so we tried to close the endoleak through a left thoracotomy approach. Twenty-eight months after the TEVAR, the patient had esophageal perforation and stent graft infection. At first, we resected the esophagus and reconstructed it with a gastric tube. Secondly, a descending thoracic aorta replacement was performed. The patient suffered from a cerebral infarction. However, infection was controlled successfully and he was transferred to another hospital for rehabilitation 69 days after the descending aorta replacement.

A 64-year-old woman was admitted to our hospital with sudden chest and back pain. Computed tomography showed acute type A aortic dissection complicated with malperfusion of the left main coronary artery (LMT). Immediately after the CT, the patient went into sudden shock. Electrocardiogram showed ventricular tachycardia and ventricular fibrillation. Percutaneous cardio-pulmonary support was administered and coronary arteriogram (CAG) was performed. CAG revealed LMT stenosis and intravascular ultrasound showed mobile intimal flap at the LMT. Percutaneous coronary intervention of the LMT was performed. The patient recovered from shock and was treated with ascending aorta replacement with CABG. The patient was discharged from the hospital without any major complication.

We report a case of successful anatomical reconstruction with omentopexy of an infected abdominal aortic aneurysm (AAA) in a patient with a previous history of coronary artery bypass grafting with the right gastroepiploic artery. A 60-year-old man was referred to our institute because of fever and abdominal pain during hemodialysis for chronic renal failure. Antibiotic therapy was started after computed tomography revealed an infected abdominal aortic aneurysm. After infection control, surgical treatment was scheduled. At surgery, left axillo-bifemoral bypass was performed first, because it was unclear whether the omentum was large enough for omentopexy. At laparotomy, adequate omentum and infective AAA were confirmed. AAA repair using a rifampicin-soaked graft, and omentopexy were performed. Enterobacter aerogenes was detected from the resected aortic wall. After the operation, intravenous antibiotic was used for 25 days until CRP was normalized. One year follow-up showed no sign of re-infection.

We describe a case of ruptured coronary artery aneurysm with a coronary artery to a pulmonary artery fistula. An 89-year-old woman with general fatigue and dyspnea was admitted. At the visit she went into shock and was restored by rehydration therapy. Enhanced computed tomography shows a coronary aneurysm (maximum diameter of 50 mm) at the left side of pulmonary artery and mild pericardial effusions. She was scheduled for an emergency operation due to the ruptured coronary artery aneurysm with a coronary artery to pulmonary artery fistula. We performed aneurysmectomy and ligation of the coronary artery to the pulmonary artery fistula under cardiopulmonary bypass. We also reviewed 23 cases of ruptured coronary artery aneurysm with coronary artery extending to a pulmonary artery fistula in Japan. The disease is a rare clinical state and regarded as an indication for emergency surgery.

Balloon aortic valvuloplasty (BAV) is a treatment for high risk patients with severe aortic valve stenosis (AS). Rapid pacing is needed to reduce cardiac output when dilating the balloon, but it may cause cardiac ischemia or lethal arrhythmia. In this case report, percutaneous cardiopulmonary support (PCPS) was used to prevent these complications with BAV. We achieved adequate blood pressure and cardiac output during BAV without using rapid pacing by drawing a certain amount of blood into the reservoir equipped with the PCPS circuit. When performing BAV, PCPS may be a useful option for the patients who have high risks of circulatory failure.

We encountered left main coronary artery hypoplasia in a 14-year-old boy. He had a history of syncope after exercise. Computed tomography revealed hypoplasia of the left main coronary artery and the syncope on exertion was diagnosed as due to myocardial ischemia. We performed off-pump coronary artery bypass (OPCAB) graft using the left internal thoracic artery. The postoperative course was uneventful and chest symptoms were not recognized in daily life. Left main coronary artery hypoplasia is rare, but is associated with adverse cardiac events, including sudden cardiac death. In cases like this, coronary artery bypass graft is indicated.

Objective : The aim of this study is to describe a series of patients undergoing reoperation due to hemolytic anemia after mitral valve surgery and assess the mechanisms and surgical outcomes. Methods : Between 2009 and 2014, we performed redo mitral valve surgery in 11 patients who had refractory hemolytic anemia after mitral valve surgery at Kyoto University Hospital. The mean age of the patients was 72.2±6.8 years old, and there were 5 men. Results : Preoperative echocardiography demonstrated that only 3 patients had ≥ grade 3 mitral regurgitation (MR), the rest of the patients had only mild to moderate MR. The mechanisms of severe hemolysis included paravalvular leakage (PVL) after mitral valve replacement (MVR) in 8 patients, structural valve deterioration (SVD) after MVR using a bioprosthesis in one, and residual/recurrent mitral regurgitation after mitral valve plasty (MVP) in two. All the patients except one (re-MVP) underwent MVR. The mean interval between previous operation and current operation was 14.1±9.4 years in post-MVR cases, and 2.0±1.9 years in post-MVP cases. There were three late deaths, one of which was due to cardiac death (exacerbation of heart failure due to pneumonia). There was one patient who required re-MVR for recurrent hemolysis due to PVL after MVR. Conclusion : Although hemolytic anemia after mitral valve surgery is rare, it often requires reoperation regardless of the degree of MR at late follow-up period. Thus, patients after mitral valve surgery should be carefully followed-up.

Primary cardiac malignant tumors are relatively rare, and their prognosis is poor. We report a patient with sarcoma causing severe mitral regurgitation and stenosis due to rapid and specific infiltration into the mitral valve.

Background : Endovascular treatment of the thoracic aorta (TEVAR) for type B aortic dissection is reported to be effective if the interval between the onset and the procedure is relatively short. However, the optimal timing for TEVAR is still controversial. Method : From December 2008 to April 2015, we experienced 46 TEVARs for type B aortic dissection. The interval between onset and TEVAR was within 3 months in 15 cases (Group A), from 3 months to 1 year in 10 cases (Group B), and more than 1 year in 21 cases (Group C). Result : Primary success was obtained in all cases, and no new intimal tear was formed during the procedure. There was no hospital death. At the time of discharge, disappearance of ULP or thrombosed thoracic false lumen occurred significantly more frequently in Group A (93%) than in Group B (50%) and Group C (43%) (p<0.05). At 6 months, the rate of the patients with reduced aneurysm diameter more than 5 mm was significantly higher in Group A (87%) and Group B (70%) than in Group C (19%) (p<0.05). Three cases of Group C had enlargement of the aneurysm despite of TEVAR, and graft replacement of thoracoabdominal aorta was performed in one of the cases. Conclusion : For type B aortic dissection, TEVAR is more effective if performed within 3 months from the onset.

We report a case of percutaneous transluminal angioplasty (PTA) treatment for low cardiac output syndrome due to superior vena cava (SVC) stenosis with venous return anomaly. A 69-year-old man was referred to our hospital for surgical treatment of tricuspid valve infective endocarditis due to infected pacemaker leads, which had been implanted for sick sinus syndrome. Preoperative computed tomography indicated polysplenia syndrome-related absence of the hepatic segment of the inferior vena cava (IVC). Preoperative coronary angiography showed a 99% stenosis in the left anterior descending artery and a total occlusion in the right coronary artery. We therefore performed pacemaker system removal, tricuspid valve plasty, coronary artery bypass surgery, and a new pacemaker implantation (epicardial leads). However, over the postoperative course we noted low cardiac output syndrome due to SVC syndrome, which appeared to be aggravated by venous return anomaly from the patient's absent IVC hepatic segment. Eight days after the surgery we conducted PTA for SVC syndrome, which notably improved the patient's hemodynamics. The patient recovered and was transferred to a rehabilitation facility 34 days after the surgery.