A 61-year-old woman developed shock during transportation to our hospital in an ambulance under a diagnosis of acute myocardial infarction, Emergency coronary angiography showed left anterior interventricular descending branch #6 to be completely occluded. At the same time, ultrasonic cardiography showed pericardial effusion. Therefore we diagnosed left ventricular free wall rupture, and performed emergency surgery to repair the rupture site. After pericardiotomy massive hemorrhage occurred and we diagnosed blow-out type left ventricular free wall rupture. We immediately established extracorporeal circulation via the femoral artery and vein, and cross clamped the ascending aorta, then achieved cardiac arrest. Because the area of myocardial infarction was extensive, we applied the David-Komeda method to avoid bleeding due to left ventricular systolic pressure, left ventricular aneurysm or ventricular septal rupture. The postoperative course was good; the patient was weaned from PCPS on the 3rd day postoperatively, IABP on the 5th day postoperatively and from the respirator on the 8th day postoperatively. She was discharged on postoperative day 40. Currently she has no cardiac complains, no left ventricular aneurysm and no neurological problems. Left ventricular free wall rupture can remain a fatal complication after acute myocardial infarction. We consider the David-Komeda method useful for repairing left ventricular free wall rupture (blow-out type) after acute myocardial infarction as well as ventricular septal rupture without a risk of left ventricular aneurysm, bleeding or ventricular septal wall rupture.

A 22-year-old woman without any serious distincted symptoms was found to have hypertension on a health examination. On further examinations, involving echocardiography and chest enhanced CT, showed dilatation of the ascending aorta, aortic coarctation, well-developed intercostal arteries and other collateral arteries. She was only 137 cm tall and weighed 52 kg. Besides, she had not had menstruation for the past two years. Chromosomal studies revealed Turner syndrome. Left lateral thoracotomy was thought to have the risk of heavy bleeding from collateral arteries, therefore we chose ascending-to-descending aorta bypass grafting through median sternotomy. She had an uncomplicated postoperative course. Here we report about operation in a adult case of coarctation of the aorta and discuss the usefulness of extraanatomical bypass grafting.

We report a successfully treated case of infectious endocarditis with ventricular septal defect (VSD) and double-chambered right ventricle. A 41-year-old man complained of dyspnea. Echocardiography showed his tricuspid valve, aortic valve, and pulmonary valve had vegetation and severe regurgitation. He received treatment with antibiotics but it was not effective. He underwent TVR, AVR, pulmonary valve resection, VSD patch closure and RV abnormal muscle resection. Pathological findings of resected valves showed infectious endocarditis. He recovered uneventfully and resumed his original social activities.

We describe the case of a 60-year-old woman with severe aortic stenosis and severe calcification of the thoracic aorta, who underwent an apico-aortic conduit bypass using an aortic valved graft. Because of stenosis of the annulus of the aortic valve and severe calcification of the thoracic aorta (porcelain aorta), we did not perform ordinary aortic valve replacement. Instead, apico-aortic conduit bypass surgery was performed using a St. Jude Medical Aortic Valved Graft (19-20 mm : St. Jude Medical, St. Paul, MN, USA) and cardiopulmonary bypass (CPB) surgery was performed using descending aortic perfusion and left pulmonary artery drainage, while the subject was in the right decubitus position. The descending aorta was clamped and a 20-mm graft (Hemashield Platinum ; Boston Scientific/Medi-tech, Natick, MA, USA) was sutured to it. Under ventricular fibrillation, the left ventricular apex was circularly resected using a puncher with a diameter identical to that of the 20-mm graft, in order to create a new outflow for the conduit bypass. The graft was sutured to the outflow, and a torus-shaped equine pericardial sheet was used to reinforce the suture line. After recovery of the heartbeat, the aortic valved graft was first sutured to the graft at the outflow and then to the graft at the descending aorta. The CPB time was 285 min and ventricular fibrillation time was 36 min. Therefore, the benefits of using an aortic valved conduit for apico-aortic conduit bypass are reduced operation time, since there is no need to prepare a handmade valve conduit, and easy management of the grafts which are made of the same material.

A 66-year-old man with an unknown medical history developed chest pain and a diagnosis of acute myocardial infarction (AMI) was given by his physician. Percutaneous coronary intervention was performed in the left anterior descending artery. Echocardiography revealed ventricular septal perforation (VSP) ; therefore, the patient was transferred to our hospital. After admission, his platelet count dropped rapidly during heparin administration, and left ventricular thrombosis and deep vein thrombosis were noted, raising a suspicion of heparin-induced thrombocytopenia (HIT). To establish cardiopulmonary bypass, argatroban alone was insufficient to prolong the Powered by Editorial Manager^® and ProduXion Manager^® from the Aries Systems Corporation activated clotting time (ACT) ; thus, nafamostat mesilate was also used for coronary artery bypass grafting and surgical repair of VSP. It took many hours to normalize the ACT, requiring re-exploration for excessive bleeding. On the 37th postoperative day, the patient was transferred to another hospital. We performed cardiac surgical procedures using argatroban in a patient who developed HIT during the course of VSP following AMI ; however, we had difficulty in controlling the ACT. Since, to the best of our knowledge, there are no previous studies reporting surgical case of VSP complicated by HIT, we present this case with a review of the relevant literature.

An 88-year-old woman presented at a local hospital with a left femoral pulsatile mass. CT revealed saccular aneurysms with irregular intima in the descending thoracic aorta, the right common femoral artery and the left superficial femoral artery. They were 60 mm, 30 mm, and 25 mm in diameter, respectively. After referral to our hospital, multiple inflammatory aneurysms were strongly suspected by detailed examinations. Endovascular treatment including thoracic endovascular aortic repair and surgical replacement were performed by two-stage operations. After steroid therapy was started postoperatively, her c-reactive protein (CRP) value decreased. Nevertheless, the thoracic aortic aneurysm enlarged and she died due to hemorrhage. Multiple inflammatory aneurysms are extremely rare. We consider that appropriate steroid therapy and close follow-up are most important.

An 80-year-old man presented with a history of retrosternal gastric tube reconstruction for esophageal cancer. He experienced sudden chest pain, and temporarily lost consciousness, before being transferred to our hospital. Contrast-enhanced computed tomography revealed acute Stanford type A aortic dissection and a retrosternal gastric tube. We performed emergency operation using a median sternotomy approach. Before median sternotomy, we detected the gastric tube in the subxiphoid and suprasternal spaces. The anterior and right sides of the gastric tube were dissected bluntly from the posterior surface of the sternum and median sternotomy was performed. The gastric tube was mobilized to the left side and we were able to obtain the usual operative view for ascending aorta graft replacement. Intraoperatively, the gastric tube remained intact and uninjured. The patient was transferred to another hospital for rehabilitation on postoperative day 34.

The use of the radial artery (RA) for coronary artery bypass grafting (CABG) is increasing. This study describes mid-term results of the use of RA for CABG. Between March 1996 and March 1999, we performed 134 CABGs using RA or saphenous vein graft (SVG) for the left circumflex branch area or diagonal branch area. The mean age was 62.6±9.6 years in the RA group and 65.0±7.8 years in the SVG group. The average number of anastomoses was 2.7per patient. RA was anastomosed with the postero-lateral branch (PL) in 69 cases, with the obtuse marginal branch (OM) in 29 cases and with the diagonal branch (DB) in 10 cases. SVG was anastomosed with PL in 26 cases, with OM in 14 cases and with DB in 2 cases. The proximal anastomosis was made with the ascending aorta in all cases. No sequential bypass anastomosis was used in any case. The early patency rate of the grafts was 97.9% (93/95) in RA and 91.7% (33/36) in SVG. The clinically negative rate in the treadmill test (TMT) performed later was 99.0% (102/103) in RA and 90.9% (30/33) in SVG. The late patency rate of the grafts was 92.9% (13/14) in RA and 50.0% (3/6) in SVG. Perioperative death occurred in 5 cases. Late cardiac death occurred in 2 cases (0.02%) of the RA group and 1 case (0.03%) of the SVG group. The 3 year-survival rate free of cardiac events was 92.8% in the RA group and 80.9% in the SVG group. The use of RA for CABGs is not only effective for myocardial revascularization, but also can be expected to bring about good patency as a late result.

Primary malignant tumors of the heart are rare and are associated with very poor survival. We retrospectively analyzed early and late results for five primary malignant tumors of the heart. There were two operative deaths and two late deaths, and the mean survival of patients who survived operation was 18.3 months. No operative survivors had symptoms of congestive heart failure during follow up period. One patient who underwent histologic biopsy received postoperative chemotherapy and is alive without recurrence 36 months after operation. The operative mortality of primary malignant tumors of the heart was high and unsatisfactory, however, surgical treatment prevented congestive heart failure during follow up and contributed to the selection of postopeative therapeutic options, with or without complete resection of the tumors.

We report a successfully treated case of double valve replacement for mucopolysaccharosis in a 27-year-old woman. Mucopolysaccharosis had been suspected since she was aged 11. Symptoms of heart failure and chest pain suggested valvular disease and she was referred to us. Echocardiography, aortography and cardioangiography showed aortic regurgitation (grade IV/IV) and mitral regurgitation (grade III/IV). She received double valve replacement and was discharged on the 38th postoperative day with symptom improvement. Although urinalysis was positive for heparan-sulfate, this case could not be diagnosed definitively as mucopolysaccharosis due to normal lymphocytic enzyme-activity. However, large amounts of mucopolysaccharoid deposits were present in her removed aortic and mitral valve leaflets, and her clinical picture corresponded with mucopolysaccharosis. Thus, it was considered that her ultimate diagnosis was combined cardiac valvular disease due to mucopolysaccharosis.