A 59-year-old woman has presented symptoms of fatigue since January 1996. Atypical coarctation due to aortitis syndrome had been diagnosed 8 years earlier. Her upper-limb blood pressure was 200mmHg and antihypertensive drugs were administered. An aortogram showed severe stenoses of the aorta at the level of the diaphragm and renal artery. A computed tomogram showed extensive calcification of the aorta below the origin of the left subclavian artery. She underwent a bypass operation with a 16-mm-diameter prosthetic graft from the ascending aorta to the infrarenal abdominal aorta. She has progressed well after the bypass and her upper-limb blood pressure is almost normal.

An 8-year-old girl had been found to have a congenital ventricular septal defect (VSD), based on the presence of a cardiac murmur from birth. She had a history of infective endocarditis and lung abscess when she was 2 years old. Mild aortic regurgitation was revealed by an echocardiogram in August 2004. Right-heart catherization revealed a step up in the oxygen saturation of the right ventricle, aortography showed a deformity of the noncoronary cusp and mild aortic regurgitation, and Doppler color-flow echocardiography detected progression of aortic regurgitation. The patient underwent surgical repair of the VSD with a cardiopulmonary bypass. Following direct suturing combined with pledgets for perimembranous VSD, infusion of cardioplegia revealed the aneurysmal sac extruding from the wall of the right atrium. The final diagnosis was an aneurysm of the sinus of Valsalva from the noncoronary aortic sinus into the right atrium (type IV of Konno). The aneurysm was sutured by polyethylene strings with pledgets. The postoperative course was uneventful, and echocardiography performed before discharge showed no deformity of the sinus of Valsalva and trivial aortic regurgitation which was less than before surgery. She was discharged on the 7th postoperative day.

Background/Aims: The safety of gastric endoscopic submucosal dissection (ESD) in users of a P2Y12 receptor antagonist (P2Y12RA) under current guidelines has not been verified. Methods: Patients treated by gastric ESD at Okayama University Hospital between January 2013 and December 2020 were registered. The postoperative bleeding rates of patients (group A) who did not receive any antithrombotic drugs; patients (group B) receiving aspirin or cilostazol monotherapy; and P2Y12RA users (group C) those on including monotherapy or dual antiplatelet therapy were compared. The risk factors for post-ESD bleeding were examined in a multivariate analysis of patient background, tumor factors, and antithrombotic drug management. Results: Ultimately, 1,036 lesions (847 patients) were enrolled. The bleeding rates of group B and C were significantly higher than that of group A (p=0.012 and p<0.001, respectively), but there was no significant difference between group B and C (p=0.11). The postoperative bleeding rate was significantly higher in dual antiplatelet therapy than in P2Y12RA monotherapy (p=0.014). In multivariate analysis, tumor diameter ≥12 mm (odds ratio [OR], 4.30; 95% confidence interval [CI], 1.99 to 9.31), anticoagulant use (OR, 4.03; 95% CI, 1.64 to 9.86), and P2Y12RA use (OR, 3.40; 95% CI, 1.07 to 10.70) were significant risk factors for postoperative bleeding. Conclusions P2Y12RA use is a risk factor for postoperative bleeding in patients who undergo ESD even if receiving drug management according to guidelines. Dual antiplatelet therapy carries a higher risk of bleeding than monotherapy.