A 53-year-old woman with von Recklinghausen's disease was admitted with severe pain and acute right leg swelling. The physical examination revealed neurofibromas and café-au-lait spots, typical of patients with von Recklinghausen's disease. Computed tomography and ultrasonography showed a rupture of a posterior tibial artery pseudoaneurysm. Since her complaint of pain was severe and because of the rapid progression of pseudoaneurysm, we performed an emergency operation. Under general anesthesia with the pneumatic tourniquet technique, both of the proximal and distal sides of the posterior tibial artery were ligated, and the pseudoaneurysm was resected. The postoperative course was uneventful. She was given an ambulatory discharge 26 days after operation. Histological examination revealed spindle-shaped cells infiltrating the aneurysmal wall. We diagnosed this is a vascular lesion of von Recklinghausen's disease.

We report a case of left internal iliac aneurysm that ruptured into the left common iliac vein and formed an arteriovenous fistula. A 79-year-old man who had general fatigue was admitted to our hospital with a diagnosis of left internal iliac artery aneurysm, left hydronephrosis, dehydration and low renal function. After dehydration and low renal function resolved rapidly by medical treatment, an enhanced computed tomography was performed. This demonstrated a 69 by 67 mm diameter left internal iliac artery aneurysm with an arteriovenous fistula. During the operation, left common iliac artery and left external iliac artery were resected and the stumps sutured. External iliac-external iliac artery bypass was performed. An occlusive balloon catheter was inserted from the left femoral vein and the balloon was dilated to patch the fistula before opening the aneurysm. After clamping the proximal artery the aneurysm was opened. Bleeding from the fistula was controlled by this maneuver and digital compression of the left common iliac vein where was proximal side of fistula. An arteriovenous fistula with a 18 by 3 mm orifice was found between the left internal iliac artery and left common iliac vein. The fistula was closed from the inside of the aneurysm. His postoperative course was uneventful.

A 66-year-old woman who had percutaneous mitral valve commissurotomy 12 years before was admitted complaining of dyspnea on effort. Echocardiography showed severe mitral stenosis and regurgitation, and moderate tricuspid regurgitation associated with atrial fibrillation. Based on her past history we suspected allergy to metal, and skin patch tests showed a positive reaction to zinc, manganese, nickel, cobalt, dichromate, stainless steel, titanium alloys, and nickel-chromium-cobalt alloys. We selected an artificial organ which would not cause an allergic reaction. The St. Jude Medical standard cuff mechanical valve was the only compatible prosthetic valve. Anterolateral right thoracotomy, instead of median sternotomy, was selected. Mitral valve replacement with a 27-mm St. Jude Medical standard cuff mechanical valve and tricuspid valve annuloplasty with a 27-mm Duran flexible band were performed. Her postoperative course was uneventful. She is doing well without any allergic symptom 18 months after the surgery.

In a 73-year-old man, ventricular septal rupture and tricuspid papillary muscle rupture were complicated with inferior acute myocardial infarction (AMI). Twenty-five days after AMI, radical operation was performed. VSR was found 1.5cm diameter at the inferior septum and directly closed using teflon felt strip. Infarctectomized inferior LV free wall was closed with woven Dacron patch which was cut from Cooley low porosity aortic tube graft and sutured with bovine pericardium facing to LV cavity. A part of anterior tricuspid papillary muscle was found to be ruptured. Tricuspid valve replacement was performed with Carpentier-Edwards valve. One and half year postoperatively, the patient has been doing well without heart failure. To our knowledge, this is the first case of VSR complicated with tricuspid papillary muscle rupture following AMI.

A case of idiopathic enlargement of the right atrium (IERA) is described. A 28-year-old woman was admitted to our hospital because of cardiomegaly and a mass in the right atrium. She had had cardiomegaly for at least 8 years. Echocardiography showed an enlarged right atrium and a large mass. Cardiac catheterization demonstrated normal hemodynamic data. Based on these findings, we diagnosed this case as IERA and the right atrial mass was suspected to be myxoma. At operation, a markedly enlarged right atrium was found. The right atrial wall was paper-thin. Through right atriotomy, a giant round thrombus (5×4×4cm) was found. The tricuspid valve showed a normal configuration. After extirpation of the thrombus, the right atrial wall was excised and plicated. The postoperative course was uneventful. IERA is extremely rare and heart failure and sudden death have been reported. Therefore, symptomatic or complicated cases should be treated surgically.

We present an unusual case of a delayed right ventricular perforation by a single standard-caliber implantable cardioverter-defibrillator lead, which manifested 14 days after implantation. Multidetector computed tomography could clearly display the lead perforation, and allow for identification of the associated sequelae such as pericardial effusion and planning the lead extraction strategy.
Defibrillators, Implantable ; Multidetector Computed Tomography ; Pericardial Effusion

Postoperative infections should be comprehensively controlled in the context of infection control, rather than as activities of individual surgeons. We started a surgical site infection (SSI) surveillance program in 2009 in which prophylactic measures for preventing SSIs were applied. These measures were as follows : 1) screening for nasal carriage of methicillin-resistant Staphylococcus aureus ; 2) dental checks and oral screening ; 3) antibiotic prophylaxis in the intra- and postoperative period ; 4) control of glucose levels to ≤160 mg/dl in the immediate postoperative period ; and 5) early removal of surgical drain. After the introduction of prophylactic measures, we reexamined SSI surveillance and added the following prophylactic measures at the beginning of 2011 : 6) data concerning SSI and compliance with prophylactic measures for all surgical and ward staff were published monthly, and the Infection Control Team (ICT) and surgeons performed weekly ward visits to assess SSIs ; 7) recommendations were made for wearing two pairs of gloves and surgical hoods to cover the hair, scalp, ears and neck ; and 8) collaboration with diabetologists was implemented to control glucose levels in diabetics. We compared incidences of SSI in cardiovascular surgery from the periods before (469 cases, Group B) and after (118 cases, Group A) introduction of the additional prophylactic measures. Clinical characteristics of patients in each group did not differ significantly. Operative time was significantly shorter in Group A (400±116 min) than in Group B (434±145 min). Compliance with antibiotic prophylaxis in the intraoperative period improved progressively from 93% in Group B to 99% in Group A. Compliance with control of glucose levels to ≤160 mg/dl on postoperative day 1 improved progressively from 71% in Group B to 81% in Group A. Duration of drain placement was significantly shorter in Group A (2.9±1.8 days) than in Group B (3.6±2.9 days). Incidence of SSI decreased significantly from 6.0% in Group B to 0.8% in Group A. Revision of preventive measures based on the results of surveillance and enhancement of cooperation between the ICT and surgeons could help to decrease the incidence of SSI.

We report a case of extracardiac rupture of the left Valsalva sinus aneurysm, which is an extremely rare and fatal lesion. The three drugs, clindamycin, ethambutol and rifampicin, had been administered for eleven years because of lung mycobacterium infection. An emergency surgery was performed because of cardiac tamponade. The left Valsalva sinus was entirely enlarged without an aneurysmal neck. The other Valsalva sinuses seemed to be almost normal. The aneurysmal wall adhered the pulmonary artery and the left atrium. The left descending and circumflex arteries independently originated from the aneurysmal wall. The left main trunk seemed to become a part of the aneurysmal wall. Additionally the intraoperative transesophageal echocardiography showed severe aortic regurgitation. The Bio-Bentall procedure was performed. The right coronary artery was reconstructed with the Carrel patch method and the saphenous vein grafts were anastomosed to the proximal portions of the left anterior descending and circumflex arteries, individually. On the thirty-third postoperative day, the patient was discharged uneventfully expect for the delayed sternal closure on the second postoperative day. Five and half years after surgy, the patient is living a normal life and rifampicin has been administered without any anticoagulation drugs.