A 60-year-old man was referred to our hospital for surgical treatment of sinus of Valsalva aneurysm and aortic regurgitation. He had suffered from palpitation and leg edema since a month before. Echocardiography revealed right sinus of Valsalva aneurysm dissecting into interventricular septum complicated with aortic and mitral regurgitation. He successfully underwent patch closure of aneurysm, aortic valve replacement and ring annuloplasty of mitral and tricuspid valve. His postoperative course was uneventful.

We encountered 6 cases of descending or thoracoabdominal aortic aneurysm operation with reversed elephant trunk (R-ET). R-ET was originally developed by Dr. Carrel in order to circumvent the dissection of the proximal anastomotic site from surrounding organs such as the lung, recurrent nerve, phrenic nerve, and esophagus in the future proximal aortic replacement. Three of 6 patients underwent a 2nd operation (total arch replacement). Distal anastomosis was easy and safe. One patient had multiple cerebral infarction and died after the second operation, but no patient suffered from complications derived from injury to the lung, esophagus, recurrent nerve or phrenic nerve. During outpatient follow-up, 1 patient who had suffered from paraparesis after the 1st operation died of repture of an arch aneurysm before the 2nd operation could be. Thrombosis was found between the inside and outside grafts of R-ET in 2 patients, who had been implanted with Gelweave prosthesis. There were no negative events caused by the thrombus. One patient with the thrombus underwent total arch replacement. We removed the fibrin-like thrombus from the R-ET prosthesis under endoscopic visualization without any complication. R-ET is a very easy and useful technique, but one should exert care about the thrombus formation around the R-ET.

Papillary muscle rupture after acute myocardial infarction (AMI) is an infrequent but fatal complication. We report a case of mitral valve repair performed in a patient with partial papillary muscle rupture after AMI. An 85-year-old man was admitted to our hospital for AMI with cardiac shock. Emergency coronary angiography revealed triple-vessel disease, and percutaneous coronary intervention for the culprit lesion of the left circumflex artery was successfully performed. Eleven days after the onset of the AMI, the pulmonary artery pressure abruptly increased to 60 mmHg and a pansystolic murmur was detected. Transesophageal echocardiography showed severe mitral regurgitation (MR) with flail in the A1—A2 region of the anterior mitral leaflet. We demonstrated erratic motion of the ruptured anterior head in the left ventricle, and this was diagnosed as partial rupture of the posterior papillary muscle. Intra-aortic balloon pumping (IABP) was performed to maintain the systemic circulation. Four days after the onset of acute MR (15 days following AMI), we performed mitral valve repair with coronary artery bypass grafting. We reattached the ruptured head to the viable posterior head with pledget sutures and performed annuloplasty using Carpentier-Edwards classical ring M28. Postoperative echocardiography showed no MR, and the patient was uneventfully discharged on the 45th postoperative day.

A 79-year-old man developed congestive heart failure. He was given a diagnosis of severe mitral regurgitation with calcification of the posterior mitral annulus and secondary tricuspid regurgitation. He had a history of esophageal resection with retrosternal gastric tube reconstruction about 20 years previously. We replaced the mitral valve with a mechanical prosthesis and performed tricuspid ring annuloplasty through a right parasternal approach. We did not risk resecting the calcified annulus, but fixed the prosthesis and annulus with the equine pericardium in between as a cushion and collar, to prevent perivalvular leakage. The postoperative course was uneventful.

We report a case of successful saphenous vein bypass grafting for superior mesenteric artery stenosis. A 50-year-old man complained of abdominal pain which was not induced by either eating or defecation. He was admitted to our hospital and examinations of the gastrointestinal tract revealed no abnormality. Angiography showed stenosis of the superior mesenteric artery (SMA), but not of the celiac artery (CA) or inferior mesenteric artery (IMA). We speculated that his symptom was due to SMA stenosis and poor collateral circulations from the CA, IMA and internal iliac arteries. Saphenous vein bypass grafting for SMA was undertaken successfully and abdominal pain disappeared completely.

An increase of aortic valvular disease associated with congenital bicuspid aortic valve is observed due to the relative decrease of rheumatic valvular diseases. A total of 24 patients with aortic valvular disease associated with congenital bicuspid aortic valve underwent surgical treatment at our institution during the period from January, 1997 to December, 1999. These 24 patients constituted 46.2% (24/52) of all cases of surgical operations for aortic valvular disease. The age of the patients ranged from 17 to 83 years (mean 62 years). They consisted of 16 men (66.7%) and 8 women. Two patients had infective endocarditis. The classification of congenital bicuspid aortic valve was right-left cusp type in 15 patients (raphe+: 11), anterior-posterior cusp type in 9 patients (raphe+: 9). We performed aortic valve replacement in 22 patients, aortic root replacement in 1 patient and aortic root remodeling in 1 patient in combination with mitral valve plasty in 3 patients, coronary artery bypass grafting in 3 patients and closure of the atrial septal defect (ASD) in 1 patient. We detected ASD in 1 patient, ventricular septal defect in 1 patient and high-posterior take-off right coronary artery in 1 patient. Patients with stenosis often have a small aortic annulus and severe post-stenotic aortic dilation. Preoperative and intraoperative evaluation is important in cases of aortic valvular disease associated with congenital bicuspid aortic valve.

A 50-year-old man with an extensive thoracic aortic aneurysm underwent staged surgery which consisted of preceding total aortic arch replacement with the frozen elephant trunk technique using J Graft Open Stent Graft^®, followed by open thoracoabdominal aortic aneurysm repair. During the second operation, the descending aorta was cross clamped along with the preexisting stent graft, and Dacron graft was anastomosed directly to the stent graft using a running 4-0 monofilament suture. The anastomosis site was then covered with a short piece of Dacron graft identical with the stent graft in size to secure hemostasis. We herein discuss our approach in this complex case, focusing on prevention of inadvertent events such as deformation of the preexisting stent graft and unexpected bleeding.

We report a case of Takotsubo cardiomyopathy that developed after elective coronary artery bypass grafting (CABG) in an 80-year-old woman. She had been given a diagnosis of unstable angina complicated with mild hypertrophic obstructive cardiomyopathy (HOCM). Her cardiac index began to fall 7 h postoperatively, and we needed to infuse fluids and increase dopamine dose (up to 5 µg/kg/min) to maintain cardiac index and blood pressure. CPK-MB level increased up to 140 IU/l at 12 h postoperatively. Transthoracic echocardiography showed akinesis and ballooning of the apex and hyperkinesis of the base with accelerated left ventricular outflow tract (LVOT) flow and increased mitral regurgitation (MR). Emergency coronary artery angiography showed good patency of all bypass grafts and no new coronary lesion. We diagnosed Takotsubo cardiomyopathy. To improve the hemodynamic status, we started intra-aortic balloon pumping (IABP) instead of adding catecholamines. Blood pressure and cardiac index had improved temporarily, but became unstable again because of increased LVOT pressure gradient and moderate-to-severe MR. LV wall motion gradually improved, but the hemodynamic status stayed unstable, but improved after removal of IABP. In general, the prognosis of Takotsubo cardiomyopathy is favorable with supportive care. However, when it is associated with LVOT stenosis and significant MR, low cardiac output syndrome can become intractable, thus we should manage critical conditions with extreme caution.

We report a case of septal branch aneurysm. A 61-year-old woman was referred to our hospital because of heart murmur. Septal branch aneurysm (25×15 mm) was diagnosed by echocardiography and coronary angiography, and followed up annually with multi-detector row computed tomography (MDCT). Nine years later, another aneurysm proximal to the known aneurysm, which protruded above the epicardium, has rapidly dilated from 5 to 11 mm. We therefore performed closure of the orifice of the septal branch concomitant with bypass grafting ; left internal mammary artery to distal LAD. After the procedure, the aneurysm in the septum had completely collapsed. Her postoperative course was uneventful.

We report a case of re-expansion pulmonary edema (REPE), which complicated mitral valve plasy via right small thoracotomy. A 56-years old man underwent mitral valve plasty for severe mitral regurgitation caused by P2 prolapse. After separation from heart-lung machine, massive yellow foamy secretion has begun to spout from the right side endotracheal tube and hypoxemia has ensued. Differential ventilation with high airway pressure and steroid pulse therapy could not counteract the exacerbation of hypoxemia. Echocardiography showed severe diffuse hypokinesis of left ventricular wall. Intra-aortic balloon pumping and percutaneous cardiopulmonary support (PCPS) were introduced, and they were very effective. After five-days' support, PCPS was successfully weaned. The patient recovered well. REPE complicated by mini-thoracotomy approach cardiac surgery, is rare, but can be fatal.