Congenital coronary artery-pulmonary artery fistula is rare and occurs concomitantly with various disease conditions, including myocardial ischemia symptoms and aneurisms. Such a fistula complicated by continuity to a systemic blood vessel is even rarer. The patient was a healthy 75-year-old man who had lost consciousness for several tens of seconds at home. An examination performed at a nearby neurosurgical clinic showed no abnormalities, and he was referred to our cardiovascular department for detailed examination for suspected cardiogenic syncope. Sick sinus syndrome was diagnosed based on Holter monitoring. Pulmonary artery-bilateral coronary artery fistula with coronary artery stenosis was diagnosed on coronary arteriography. It was difficult to determine whether coronary bypass surgery was indicated because of the presence of a fistula. Based on the overall evaluation of coronary fractional flow reserve, coronary artery ultrasound, and stress myocardial scintigraphy in addition to usual coronary arteriography, triple-vessel bypass surgery was indicated. Preoperative CT angiography showed a left common carotid artery/bronchial artery-pulmonary artery fistula, with a communication at a bilateral coronary artery-pulmonary artery fistula. Coronary artery bypass surgery was performed in addition to coronary artery-pulmonary artery fistula ligation, left common carotid artery-pulmonary artery fistula closure, bronchial artery-pulmonary artery fistula closure, and pacemaker implantation. Preoperative CT angiography and perioperative surface echocardiography were useful for locating fistula openings. The abnormal blood vessels that allowed blood flow from the left common carotid and bronchial arteries, and into the fistula vessel opening were ligated previously. When cardioplegic solution was injected, the fistula opening was directly pressed, which facilitated the solution to spread over the cardiac muscle, contributing to full cardiac arrest. Postoperative CT angiography showed disappearance of the pulmonary artery-bilateral coronary artery fistula and left common carotid artery/bronchial artery-pulmonary artery fistula. To our knowledge, there are no reports describing the surgical treatment of left common carotid artery/bronchial artery-pulmonary artery fistula and bilateral coronary artery-pulmonary artery fistula. Here we report this rare case with a review of the relevant literature.

Introduction : Although there are various diagnostic tools like computed tomography, magnetic resonance imaging, and positron emission tomography, it is sometimes difficult to precisely diagnose cardiac tumors. Early pathological diagnosis is crucial for possible chemotherapy and/or radiation therapy in cardiac malignant lymphoma. Objectives : To assess the diagnostic value of pericardial excisional biopsy and cytology of pericardial effusion for the pathological diagnosis of cardiac lymphoma. Methods : Five patients had a clinical diagnosis of cardiac tumor with no pathological diagnosis. The pericardial biopsy and pericardial effusion were obtained without sternotomy through the subxyphoid by a small incision under local anesthesia. Results : All procedures were completed without complications. In 3 cases, the cytology of pericardial effusion yielded a diagnosis of malignant lymphoma. One patient who had a negative cytology result in whom surgical resection was performed for definitive diagnosis and tumor volume reduction was found to have malignant lymphoma. The remaining patient underwent tumor biopsy via a cardiac catheter and benign lymphoma was diagnosed. There were no specific findings in the pericardial excisional biopsy in 3 cases. Conclusion : The analysis of cytology of pericardial effusion obtained through the subxyphoid may be useful for the diagnosis of cardiac malignant lymphoma. Pericardial excisional biopsy may not be necessary for the diagnosis of cardiac malignant lymphoma.

Introduction : Right atrial (RA) and right ventricular (RV) dilatation that are associated with severe tricuspid regurgitation, and severe high RV pressure that is associated with pulmonary atresia and intact ventricular septum cause left ventricular (LV) dysfunction and hypoplastic lung. We have applied a modified RV obliteration technique that excludes non-functional enlarged RV for these diseases. Objectives : To evaluate the efficacy of our procedure. Methods and Results : Five patients (six operations) underwent the procedure without complications. Cardiothoracic ratio significantly decreased from 71±10% to 61±5% (p=0.017), and fractional shortening ended to increase from 27±17% to 37±5% (p=0.071). All of them achieved Fontan completion finally. One patient who underwent this procedure as a neonate experienced RV re-dilation 19 months later. He additionally received the same procedure in a Fontan operation, and then RV reduced again and good LV function was maintained. Conclusion : The application of modified RV obliteration technique is effective for Fontan candidates with nonfunctional RV.

A 41-year-old man who had a history of suicide attempt by self-stabbing of the chest at the age of 15 and surgical repair of the stab wound of the heart was transferred to a neurosurgical hospital suffering from right hemiparesis. Stroke was diagnosed and he successfully underwent endovascular thrombectomy but postoperative computed tomography revealed left ventricular aneurysm and intracavitary thrombus that could have caused the embolic stroke. He was transferred to our hospital for cardiac surgery to prevent another embolization. Although an emergency operation had been attempted for the large and mobile thrombus, the patient was carefully observed for 4 weeks prior to surgery because of acute and huge stroke with a high risk of perioperative intracranial hemorrhage. After a fortunately uneventful observation, thrombectomy with left ventriculoplasty was performed successfully and the postoperative course was uneventful without neurological impairment. To prevent a fatal embolic event, postoperative follow-up after successful repair of cardiac injury is mandatory.

We report a case of multiple papillary fibroelastoma (PFE) on the aortic valve. A healthy woman in her 60 s was referred to a nearby doctor with the chief complaint of palpitation and was admitted to our hospital for detailed examination. A mobile tumor was found by transthoracic echo, and she was introduced to us. We undertook excision surgery for her. Initially, it was thought to be a single tumor, and a pedunculated tumor adhering to the central aortic side of the left coronary cusp with a length of 7 mm was removed. After closing the aorta, we recognized a remaining mobile tumor by transesophageal echo. We decided to perform cardiac arrest again, and we recognized one tumor with 6 mm long string-like mobile mass on the right and non-coronary commissure of cardiac side, and a thorn-like mass of about 1.5 mm on the non-coronary cusp of the cardiac side. We removed both tumors from the aortic valve using shaving resection and preserved the aortic valve. All of these were found to be PFE pathologically as if they were three tumors that followed the developmental stage of PFE. After surgery, PFE recurrence is extremely rare. In the case of a pedunculated tumor, it is possible to remove the tumor and preserve the valve. However, as in this case, if both sides of the valve were not carefully inspected, it can be overlooked. In addition, small tumor resection could avoid the risk of new cerebral infarction and myocardial infarction due to recurrence and could avoid reoperation.

Popliteal venous aneurysm (PVA) is recognized as source of fatal pulmonary embolism ; surgical treatment is indicated. A 79-year-old woman presented with acute shortness of breath. A cardiac ultrasound echography showed right heart overload and pulmonary hypertension. A contrast enhanced CT revealed multiple pulmonary artery emboli and right popliteal venous aneurysm. She was immediately started anticoagulation therapy with oral factor Xa inhibitor and her dyspnea improved. As thrombus in venous aneurysm was considered the cause of the pulmonary embolism, we recommended surgical treatment. Tangential aneurysmectomy with lateral venorrhaphy for the saccular venous aneurysm was performed. Postoperative contrast enhanced CT showed good morphology and she was discharged without complication. Surgical treatment of symptomatic popliteal venous aneurysm is considered useful strategy.

We report a new risk stratification of invasive stage papillary thyroid carcinomas (PTCs) by combining invasive status, using extrathyroid invasion (Ex) status, and tumor growth speed using the Ki-67 labeling index (LI). Methods: We examined tumor recurrence in 167 patients with PTC who were surgically treated at the Kindai University Nara Hospital between 2010 and 2022. The patients were classified according to the degree of invasion [negative (Ex0) or positive (Ex1, Ex2, and Ex3)] and tumor growth speed expressed with Ki-67 LI, as low (<5%) or high (>5%). This study confirmed previous findings that the disease-free survival (DFS) rate in PTCs significantly differed between patients with a high and low Ki-67 index. Results: When combining Ex status (negative or positive) and Ki-67 proliferation status (low or high), the DFS rate of invasion in the negative, low Ki-67 LI group was only 1.1%, while that of invasion in the positive, high Ki-67 LI was 44.1%. This study reports for the first time that recurrence risks can be stratified accurately when combining carcinoma’s essential two features of extrathyroid invasion status and tumor growth speed. Conclusions: We believe the evidence for low tumor recurrence risk may contribute to use of more conservative treatment options for invasive-stage PTCs and help alleviate patient anxiety about tumor recurrence and death.

We report a new risk stratification of invasive stage papillary thyroid carcinomas (PTCs) by combining invasive status, using extrathyroid invasion (Ex) status, and tumor growth speed using the Ki-67 labeling index (LI). Methods: We examined tumor recurrence in 167 patients with PTC who were surgically treated at the Kindai University Nara Hospital between 2010 and 2022. The patients were classified according to the degree of invasion [negative (Ex0) or positive (Ex1, Ex2, and Ex3)] and tumor growth speed expressed with Ki-67 LI, as low (<5%) or high (>5%). This study confirmed previous findings that the disease-free survival (DFS) rate in PTCs significantly differed between patients with a high and low Ki-67 index. Results: When combining Ex status (negative or positive) and Ki-67 proliferation status (low or high), the DFS rate of invasion in the negative, low Ki-67 LI group was only 1.1%, while that of invasion in the positive, high Ki-67 LI was 44.1%. This study reports for the first time that recurrence risks can be stratified accurately when combining carcinoma’s essential two features of extrathyroid invasion status and tumor growth speed. Conclusions: We believe the evidence for low tumor recurrence risk may contribute to use of more conservative treatment options for invasive-stage PTCs and help alleviate patient anxiety about tumor recurrence and death.