A sinus of Valsalva aneurysm is a comparatively rare disease, and it has almost no symptoms unless this is rupture, whereas aortic insufficiency, myocardial ischemia and heart failure might be associated with un-ruptured aneurysm of the sinus of Valsalva. We encountered 2 elderly patients (71 years old and 83 years old) with huge un-ruptured aneurysm of the sinus of Valsalva which causes right ventricular outflow tract obstruction. The orifice of the aneurysm of the sinus of Valsalva was closed using ePTFE patches in the both cases. Plication of aneurysm was attempted in both cases, but it failed in case 1 due to undetermined border of the aneurysm on the right side of the heart. Case 2 was required concomitant aortic valve replacement with a bioprosthesis due to associated aortic regurgitation. The repair of un-ruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract obstruction can be performed safely and effectively even in elderly patients.

We report a case of endovascular surgery in a patient of common iliac artery aneurysm with arteriovenous (A-V) fistula. A 60-year-old woman was admitted because of dyspnea. She had a clinical history of lumbar disk surgery at age of 40. On physical examination, we detected a pulsatile mass and pansystolic murmurs in her left lower abdomen. A chest X-ray film demonstrated severe cardiomegaly with 70% of cardiothoracic ratio. Contrast-enhanced CT revealed left common artery aneurysm with A-V fistula between the left common iliac artery and the left common iliac vein. Three-dimensional CT showed hyper-vascularity in the region from the pelvic vein to IVC. We considered that she had high risk of intraoperative massive bleeding for open abdominal surgery. We conducted endovascular repair for this iliac artery aneurysm with A-V fistula by the GORE EXCLUDER C3^® stent graft system. Postoperative contrast-enhanced CT showed complete exclusion of both left common iliac artery aneurysm and A-V fistula. After surgery, her symptoms improved significantly.

We report a rare case of aortic root replacement after arterial switch operation (ASO). Ten years after undergoing ASO, a 10-year-old boy underwent a Bentall operation because of progressive aortic valve regurgitation and aortic root dilation. The operation was performed under the division of the right pulmonary artery. This view made it easy and safe to dissect the coronary arteries and to perform aortic root surgery.

A 56-year-old man, who underwent aortic valve replacement with a stentless artificial valve for aortic valve endocarditis at age 52, found to have left ventricular outflow pseudoaneurysm by transthorasic echocardiography, transesophageal echocardiography and enhanced computed tomography. We repaired the pseudoaneurysm, combined with valve re-replacement. Left ventricular outflow pseudoaneurysm is a rare disease, and is often associated with active endocarditis. Transesophageal echocardiography and CT scan are useful to diagnose this disease, especially to rule out annular abscess. Operative indication is recommended soon after the diagnosis was made to prevent rupture of pseudoaneurysm, or development of either mitral regurgitation or coronary ischemia due to compression from the pseudoaneurysm. Combined aortic valve replacement, with or without mitral valve replacement is necessary to repair the pseudoaneurysm.

Intracardiac repair for cardiac anomalies associated with a transposed aorta from the right ventricle is a technically demanding operation. We present two cases of left ventricular outflow tract (LVOT) obstruction after the use of an ePTFE flat patch to reconstruct the LVOT. Case 1 : A 10-year-old boy had undergone the Rastelli operation, VSD enlargement, and intraventricular re-routing using an ePTFE flat patch for repair of the DORV with noncommitted VSD and pulmonary stenosis at the age of 5. Five years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using a part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. Case 2 : A 13-year-old girl had undergone a double-switch operation (Senning operation, the Rastelli operation, and intraventricular re-routing by the use of an ePTFE flat patch) for the repair of corrected TGA, PA and VSD at the age of 7. Six years later, catheter examination revealed severe LVOT obstruction. Intraventricular re-routing using part of the ePTFE graft concomitant with re-replacement of an extracardiac conduit was successfully performed. We consider that the use of a flat patch for reconstruction of a left ventricular out flow tract in cases with transposition of the aorta from the right ventricle involves a risk of future development of LVOT obstruction.

We report a rare case of isolated intracavitary metastatic esophageal cancer of the right atrium and ventricle. A 67-year old woman had been treated for esophageal carcinoma for three years. Combined radiotherapy and chemotherapy had been performed, and partial remission had been achieved. Recent follow up computed tomography of the chest revealed intracavitary cardiac mass in her right atrium and right ventricle. On echocardiography a mobile, irregularly shaped large mass was detected in her right atrium. She was admitted for emergency operation. We resected the mass under cardiopulmonary bypass. The pathological examination revealed intracavitary metastasis of squamous cell carcinoma of the esophagus. She was discharged on the 29th postoperative day. Six months later, she died from multiple metastases of squamous cell carcinoma. Even though the operation was not curative, it might have been effective for preventing tumor embolism to the lung and elongating life expectancy.

Objective : To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. Methods : Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. Results : The median age of the patients was 15.5 years (range : 9-38 years). The patients had a mean body surface area of 1.48±0.3 m² (range : 1.00-1.92 m²). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3 (modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months (range : 1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0 mmHg preoperatively to 27.9±7.7/14.8±4.7 mmHg postoperatively and to 28.3±11.1/14.1±7.0 mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4 g preoperatively to 179.7±61.1 g postoperatively and to 100.4±76.3 g at intermediate-term follow-up, respectively. Conclusions : Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.

A 74-year-old woman presented with shortness of breath. Cardiac ultrasonography showed that left-ventricular-wall motion was good (left ventricular ejection fraction, 70.2%). The left atrium and ventricle were enlarged (left anterior dimension, 53.4mm; left ventricular enddiastolic dimension, 58.5mm). The posterior cusp of the mitral valve was thickened; the flexibility was decreased. Color Doppler ultrasonography revealed a regurgitant jet toward the posterior cusp of the left atrium. However, there was no deviation of the anterior cusp. Severe mitral-valve insufficiency was diagnosed, and surgery was performed. The second heart sound (P2) of the posterior cusp was shortened because of localized calcification of the posterior mitral annulus. This site may have caused the regurgitation. Mitral annuloplasty with rectangular resection of the valve cusps and annulorrhaphy was performed. The patient had an uneventful recovery after surgery. Postoperative cardiac ultrasonography showed that mitral-valve insufficiency had improved and was regarded as trivial. Mitral annuloplasty is generally considered unsuitable for mitral-valve insufficiency with calcification of the valve annulus. In patients such as the present case who have localized calcification, however, mitral annuloplasty can be performed by resection of the valve cusps with annulorrhaphy.

The patient was a 39 -year-old woman. Malignant rheumatoid arthritis was diagnosed when she was 32 years old, and the patient was treated with oral steroids. She presented at our center with sudden precordial pain. Coronary angiography revealed severe stenosis of the left main coronary artery (segment 5, 99%). Acute myocardial infarction and pulmonary edema were diagnosed. The patient underwent off-pump coronary-artery bypass grafting, with anastomosis of the left internal thoracic artery to the left anterior descending artery. One year 3 months later, the patient was readmitted to the hospital because of recurrent angina pectoris and heart failure. Coronary angiography showed patency of the left internal thoracic artery and severe stenoses of the left main coronary artery(segment 5, 100%), circumflex artery (segment 11, 99%), and right coronary artery (segment 1, 90%), suggesting angiitis. On-pump coronary-artery bypass grafting was done, with anastomosis of the right internal thoracic artery to the right coronary artery (segment 2) and the gastro-omental artery to the obtuse marginal branch (segment 12). The patient is being followed up on an outpatient basis. There are few reports describing patients with rheumatoid arthritis who underwent coronary artery bypass surgery. However, the most common cause of death in patients with rheumatoid arthritis is coronary-artery disease. Although the patient was still young, coronary-artery disease progressed rapidly. Such rapid progression was attributed to difficulty in controlling the inflammatory response after initial surgery, as well as to changes in vascular endothelial cells caused directly by treatment with steroids. Possible adverse effects of such treatment should be carefully considered.

A 79-year-old woman, who had undergone mitral valve replacement with a Björk-Shiley valve 16 years previously, was transferred to our institute due to active prosthetic valve infection associated with severe heart failure on respirator. On admission, her white blood cells and c-reactive protein (CRP) were elevated to 15,700/µl and 7.29 mg/dl, respectively, and she had anemia (hemoglobine 8.1 g/dl), thrombocytopenia (platelets 75,000/µl), and renal dysfunction (blood urea nitrogen 57 mg/dl, creatinine 1.8 mg/dl, estimated glomerular filtration rate 21.5 ml/min/1.73 m²). Her brain natriuretic peptide was elevated to 456.7 pg/dl. Blood culture revealed bacteremia with Streptococcus agalactiae. Though CT scan revealed cerebellum infarction, we decided to perform emergency surgery because of uncontrollable infection and heart failure, even with massive infusion of catecholamine and respiratory support. At surgery, huge vegetation proliferated over the prosthetic valve. The prosthetic valve was detached from approximately two-thirds of the annulus due to an annular abscess. The infected annulus was resected aggressively. Mitral annulus was reconstructed and reinforced with a bovine pericardial patch, and the bioprosthetic valve of 23 mm in size was implanted in an intra-annular position. In the postoperative phase, antibiotics (ampicillin, gentamicin) was given, and CRP became negative 47 days postoperatively, and the patient discharged from the hospital 56 days after the operation.