A computed tomography (CT) scan was performed for a man in his 60s to investigate a continuous murmur. An 18-mm coronary aneurysm with a fistula with the pulmonary artery was found on the anterior aspect of the main pulmonary artery (MPA),and a 10-mm coronary aneurysm was found on the lateral aspect. Abnormal inflow vessels originating from the right sinus of Valsalva and the left anterior descending artery (LAD) formed a complicated network around the MPA. Although the patient was asymptomatic, the aneurysms were saccular and considered to be an indication for surgery to prevent rupture. In addition, heart failure, embolism, and myocardial ischemia could be prevented by treatment. We planned a hybrid therapy of open surgery and percutaneous coil embolization. Surgical repair was performed through a median sternotomy. The abnormal vessel originating from the right sinus of Valsalva was ligated under cardiopulmonary bypass. After cardiac arrest, the 18-mm aneurysm located on the anterior surface of the MPA was incised and the orifice of the fistula and inflow vessels were closed from the inside of the aneurysm. The anomalous vessels originating from the LAD and the 10-mm aneurysm on the lateral aspect of the MPA were located near the LAD; therefore, we avoided surgical repair of these lesions. An additional percutaneous coil embolization was performed postoperatively for the remaining lesions. A post-embolization CT scan showed no residual aneurysms or fistula. A hybrid treatment may be a useful method to reduce the risk of complications of each therapy for reliable closures of fistula and aneurysms.

A 76-year-old female was admitted with complaints of dyspnea on exertion and lower leg edema. She had undergone an aortic valve replacement thirty-nine years before and a redo aortic valve replacement and mitral valve replacement twenty-eight years before. She also had hemolytic anemia with jaundice. Echocardiography showed severe paravalvular leakage in the aortic and mitral valves, and a blood flow in the aortic annulus that flows from the aortic side into the left atrium. We diagnosed heart failure and hemolytic anemia due to paravalvular leakage and decided to perform a double-valve replacement for the third time. On operation, after removing the aortic valve through aortotomy, aorto- mitral fibrous continuity was extensively calcified and perforated, and its strength was not enough to sew the prosthetic valve to it. Therefore, we decided to perform the Commando procedure. Aortotomy was extended between the noncoronary aortic sinus and the left coronary aortic sinus until it reached the dome of the left atrium. After the prosthetic mitral valve was excised, annuloplasty of the posterior mitral annulus was performed using a bovine pericardial patch, and the new prosthesis mitral valve was implanted. The anterior part of the annulus corresponding to the aorto-mitral fibrous continuity was reconstructed by sewing the base of a two-tongued triangular bovine pericardial patch to the sewing cuff of the mitral prosthesis. After closing the left atrial ceiling with the posterior patch, the aortic prosthesis was secured to the aortic annulus and the pericardial patch. The anterior patch was used to close the right side of the aortotomy. The postoperative course was uneventful, and postoperative echocardiography revealed no paravalvular leakage.