To examine the effectiveness of fibrin-glue (FG) in fatal left ventricular (LV) free wall rupture (LVFWR), acute myocardial infarction (AMI) in the LV anterior wall was produced in 18 mongrel dogs (weighting 6.8-14.4kg) by coronary ligation under general anesthesia. A punched-out hole made in the center of the AMI area using a Scanlan aortic-punch (E.D.=5.5mm) was closed immediately with a 3-0 polypropylene stitch and a heating electrode. Hemodynamic stability was obtained within 30 minutes after closure of the pericardium and thoracotomy. Then the stitch was cut by heating the electrode with an electric power of 0.45 Watt and LVFWR was induced. Hemodynamic parameters were assessed until cardiac arrest in 12 dogs (controls), and FG therapy was performed on 6 dogs (FG group) at 20min after the rupture with pericardial centesis and drainage, and infusion of 1 unit FG into the pericardial space. FG was composed by Solution A (5, 000 units of Thrombin-Green Cross+50, 000 units of Trasyrol+10ml of Carcicol) and Solution B (1g of Fibrinogen HT-Green Cross+20ml of Saline). The administered dose of Solution A was 1ml/kg and that of Solution B was 0.7ml/kg. All dogs of the control group died within 50min, however, 4 of 6 dogs of the FG group survived. The blood pressure in the control group was 108±28mmHg before the rupture and 48±41mmHg at 20min after the rupture, but no significant blood pressure was observed at 40min after the rupture. On the other hand the average blood pressure of the 4 surviving dogs in FG group was 93±12mmHg at 40min after the rupture and 90±15mmHg at 80min after the rupture and the level of blood pressure was maintained until the end of the experiment. In conclusion, FG therapy may be a promising therapy for LVFWR instead of surgical repair, which has a extremely high mortality.

We encountered a patient with platypnea-orthodeoxia syndrome. This rare syndrome is characterized by right-to-left shunt, which appears in the upright position. A 76-year-old woman with symptomatic hypoxemia was referred for evaluation and treatment. She did not complain of dyspnea while in a supine position, but experienced dyspnea with severe hypoxemia in a sitting or standing position. She did not have any pulmonary diseases that can be cause of dyspnea. Echocardiography revealed a patent foramen ovale and mild left-to-right shunt when the patient was supine. However in an upright position, right-to-left shunt appeared and the arterial oxygen saturation dropped from 95% to 80% with dyspnea. Cardiac catheterization revealed normal pulmonary artery pressure and right-to-left shunt through the patent foramen ovale in the sitting position. We then diagnosed platypnea-orthodeoxia syndrome. The chest CT showed deformity of the right atrium caused by compression of the elongated ascending aorta. The patent foramen ovale was closed and the ascending aorta was shortened by open heart surgery. Her dyspnea and hypoxemia in the upright position was completely resolved after surgery.

We report successful operative treatment of a ruptured coronary artery saccular aneurysm associated with a coronary-pulmonary artery fistula. A 66-year-old woman experienced sudden onset of unconsciousness due to cardiac tamponade. Echocardiogram and chest CT on admission showed pericardial effusion and a 50-mm diameter saccular coronary artery aneurysm. Coronary angiogram revealed coronary artery aneurysm which arose on the conus branch of the right coronary artery. The connection between the aneurysm and the pulmonary artery was not clarified. Cardiac tamponade due to rupture of the saccular coronary artery aneurysm was suspected and emergency operation was performed. Operative findings revealed coronary-pulmonary artery fistula. Closure of the orifice of the draining artery to the pulmonary artery, and aneurysmorrhaphy were performed. Postoperative coronary angiogram and chest CT showed no residual fistula, and the postoperative course was uneventful.

Case 1 is a 70-year-old male. He has a history of cholelithiasis and left inguinal hernia. A preoperative examination of the inguinal hernia showed the enlargement of the mediastinal shadow, and he was referred to our department. A close examination revealed a right-sided aortic arch, a right descending aorta, and a descending aortic diverticulum. No subjective symptoms, intracardiac malformations, or other cardiovascular diseases were observed. The surgery was scheduled for descending aorta replacement including a diverticulum with right posterior lateral 4th intercostal thoracotomy and lower body partial extracorporeal circulation. However, due to aortic intima injury at the proximal end, hypothermic cerebral circulatory arrest and proximal anastomosis were performed by the open proximal method. There was no problem with the postoperative course, and he was discharged 19 days after surgery. Case 2 is a 51-year-old female. Born in China, she has lived in Japan for 15 years. No notable history. An abnormal shadow was shown on chest Xp performed in a medical examination, and aortic malformation was suspected on chest CT. She was referred to our department. The diagnosis was right-sided aortic arch, right descending aorta, aberrant left subclavian artery, and Kommerell diverticulum. There were no subjective symptoms and no intracardiac malformations. The operation was a two-stage operation. As the initial surgery, median sternotomy was performed, total arch replacement with intrathoracic reconstruction of the left subclavian artery, and open stent graft insertion, and the Kommerell diverticulum was covered with an open stent graft. We did not treat the diverticulum because it was located on the dorsal side. At 15 days after surgery, we performed embolization of the origin of the left subclavian artery from the Kommerell diverticulum. There was no problem with the postoperative course, and she was discharged 19 days after the initial surgery.