A 62-year-old man had suffered from massive pedal edema, dyspnea and sinus bradycardia for 10 days. He had been heavy drinker for over 20 years. He was transferred to our hospital with severe heart failure. Echocardiography showed severe diffuse hypokinesis of left ventricular wall motion (EF20%) with dyssynchrony, and thrombus in the left ventricular apex. Under a diagnosis of LV thrombus due to severe heart failure, we made a plan for an emergency open heart surgery, but it could not be performed because of initial cardiogenic embolic stroke. Therefore, we waited for 2 weeks while performing anticoagulation therapy. The removal of LV thrombus and atrio-biventricular pacing for heart failure due to dyssynchrony were performed 2 weeks later. The pathological specimen of myocardium showed marked fibrous and hypertrophic change, which were similar to idiopathic dilated cardiomyopathy. Alcoholic cardiomyopathy due to alcohol intake for many years is similar to a clinical image of dilated cardiomyopathy, but its clinical prognosis by abstinence is not bad. In this case we performed an urgent open heart surgery due to cardiogenic embolic stroke, but must be essentially performed as an emergency operation. Postoperative course was uneventful and he was discharged 21 days after open heart surgery without any complications.

We report a rare case of a 70-year old woman who suffered right ventricular failure and shock with a comparatively rapid course due to a huge primary right atrial malignant lymphoma occupying the right atrium. She had undergone mitral valve replacement and tricuspid valve annuloplasty due to combined valvular disease 12 years previously, and she had been treated for liver cirrhosis due to hepatitis C. The transthoracic echocardiography and the computed tomography scan revealed a huge tumor occupying the right atrial cavity and incarceration into the tricuspid valve ring. We performed an emergency operation to resect the heart tumor. As the tumor strongly adhered to the free wall of the right atrium and the tricuspid valve ring, we performed complete resection of the right atrial free wall and tricuspid valve. Therefore, we performed tricuspid valve replacement with a bioprosthesis, and reconstruction of the right free wall with an EPTFE sheet. The pathological examination of the tumor was consistent with malignant lymphoma of B-cell origin. These surgical procedures were effective to reduce acute right heart failure due to severe tricuspid valve regurgitation, but she died 3 months after surgery because of liver failure due to cirrhosis. Even though the operation was not curative, it might have been effective for preventing sudden death and acute right ventricular heart failure due to incarceration into the tricuspid valve ring of the huge right atrial tumor.

A 78-year-old man underwent replacement of a descending thoracic aorta in 1980 using a Cooley double velour knitted Dacron (CDVKD) following a diagnosis of DeBakey type III b aortic dissection. He had back pain and bloody sputum from around January 2012, and so the patient was referred to our department. Upon multi-detector computed tomography (MDCT), we diagnosed a graft aneurysm caused by the prosthetic graft carried out 32 years previously that had expanded to a maximum of greater than 80 mm. An emergency operation was considered due to the continuing back pain and bloody sputum. As a strategy for treatment, low invasive treatment by thoracic endovascular aortic repair (TEVAR) was initially planned. However, due to the large size of the aneurysm relative to the surrounding vessels and severe aortic calcification of the landing zone, complications of endoleak and migration were considered possible upon TEVAR. Instead, we selected total aortic arch replacement with extracorporeal circulation upon median sternotomy, even though this required increased surgical invasion. Postoperative prognosis was good and the patient was discharged from hospital 5 weeks following surgery. There are few reports on the failure of a prosthetic graft causing a graft aneurysm, particularly involving an aging CDVKD graft, but it is possible that deterioration of a prosthetic graft may cause a graft aneurysm. Therefore, postoperative follow-up must be carried out with care.

A 39-year-old man was admitted to our hospital with symptoms of anterior chest pain and slightly dyspnea. At that time, he had chest discomfort, hypertension, and with enlargement of mediastinal shadow on chest X ray. Medical treatment rapidly improved the hypertension and the other symptoms. Transthoracic echocardiography (TTE) and enhanced chest CT revealed aortic root dilation, and trivial aortic valve regurgitation, but these examinations could not identify the cause of such as typical Stanford type A dissection. Transesophageal echocardiography (TEE) and chest MD-CT were undertaken on 7 days after the admission revealed a localized aortic dissection, intimal flap, and enlargement of sinotubular junction (STJ). An Urgent operation was performed. During the operation, a localized aortic dissection appeared to be above the left coronary cusp through the right coronary cusp of the aortic valve, but the valve findings were normal, so we decided to perform a aortic valve remodeling operation. The aortic sinuses were excised leaving 4 mm of arterial wall attached to the aortic annulus and around the coronary arteries. A Woven Dacron graft of diameter equal to the diameter of the STJ was tailored to recreate three aortic sinuses. The three commissures were suspended into the tailored graft and the neo-aortic sinuses were sutured to the aortic annulus and remnants of arterial wall. The coronary arteries were reimplanted into their respective neo-aortic sinuses and the graft anastomosed to the distal aorta. The postoperative course was uneventful. We concluded that this procedure is useful for a localized aortic dissection around the coronary orifice.

A 15-year-old boy who had been treated for TOF (tetralogy of Fallot) at 3 years of age was admitted with dysphagia due to esophageal stenosis. He also suffered from malrotation of the intestine. The esophageal stenosis was caused by recurrent cyclic vomiting and subsequent esophagitis. Three years earlier, he had received an implantation of a totally implantable central venous access device via the right cephalic vein. Echocardiography revealed a floating mass in his right atrium, which was assumed to be a thrombus at the catheter tip of the central venous access device. We suspected that the cause of atrial thrombus in this case was complicated by the long-term (3 years) use of the venous central port. He was suspected to have a pulmonary embolism. A perfusion lung scan (99mTc-MAA) revealed multiple diminished uptake in both lungs. The thrombus was removed successfully under partial cardiopulmonary bypass. The postoperative course was uneventful.

The internal thoracic artery is a useful conduit for coronary artery bypass grafting (CABG). Recently we have developed a method for increasing blood flow by directly injecting a phosphodiesterase III (PDE III) inhibitor into the left internal thoracic artery (LITA) to inflate the artery and prevent its contraction. In the present study we compared the reactivity of the LITA to three drugs: PDE III inhibitor, papaverine hydrochloride and isosorbide dinitrate (ISDN). Forty-two patients with a mean age of 66.8±11.5 years old who were undergoing primary CABG were enrolled in this study and were randomly separated into one of three groups based on the vasodilating drug administered. Each drug was used in 14 cases. Graft free flow (GFF) and systemic blood pressure were measured before and one minute after drug administration to calculate blood vessel resistance (R). All the drugs significantly increased GFF, and reduced both R and blood pressure. A comparison of the change rate of blood pressure did not differ significantly among the three drug groups. The PDE III inhibitor significantly increased change rates of both GFF and R, compared with the other drugs. These results indicate that PDE III inhibitor is most effective for increasing the blood flow of LITA grafts for CABG.

A 53-year-old woman was admitted because of cardiac failure caused by mitral valve stenosis and regurgitation. She had been treated by an aortic valve replacement with a Björk-Shiley convexo-concave valve (21mm) 22 years previously in our institute. Her clinical symptoms and the histological findings of the lung specimen from the operation led to a diagnosis of Swyer-James syndrome. The diagnosis was confirmed by pulmonary blood flow scintigraphy on the present admission. With her informed consent, we treated her cardiac disease by mitral valve replacement and a second aortic valve replacement was carried out because of the structural brittleness of the Björk-Shiley convexo-concave valve. She was discharged from our institute after the operation without any complications.

Horseshoe kidney is an unusual abnormality occurring in 0.25% of the population. In surgery for AAA with horseshoe kidney, reconstruction of aberrant renal and preservation of renal isthmus is important. We report 3 cases of AAA with horseshoe kidney treated successfully without division of the isthmus.

We have long advocated the usefulness, accuracy and safety of carbon dioxide angiogrphy for patients with iodine allergy and renal dysfunction. In addition to its utility, no specialized apparatus is necessary for carbon dioxide angiography. Carbon dioxide as a contrast material has been adopted by consensus for use in endovascular revascularization. Here we report 4 cases of endovascular revascularization using carbon dioxide angiography. Two of the four patients had an iodine allergy, one had renal dysfunction, and the remaining one was complicated by diabetes mellitus. All patients exhibited intermittent claudication and were treated for iliac arterial stenotic lesions with percutaneous angioplasty and sequential endovascular stenting using carbon dioxide gas as a negative contrast material. All cases demonstrated improvement of the chief complaint. There were no direct or indirect complications of carbon dioxide angiography and endovascular intervention after the procedures. All 4 patients were discharged without event within 1 week after the endovascular intervention. Carbon dioxide is useful not only as an angiographic contrast material but also for endovascular intervention in patients with iodine allergy or renal dysfunction.

We experienced the usefulness of the superficial femoral vein as an autogenous graft replacement of an infected prosthetic graft. Case 1: A 75-year-old man complained of right leg intermittent claudication due to arteriosclerosis. Prosthetic femoro-femoral crossover bypass was performed. Three months after the operation, prosthetic bypass graft infection was diagnosed. Case 2: A 72-year-old man underwent an aortobifemoral graft surgery for an abdominal aortic aneurysm (5cm in diameter) . Ten days after the operation, the patient suddenly had a high fever and bacterial culture of the blood demonstrated Gram-negative bacilli. Prosthetic bypass graft infection was diagnosed. Both cases were resistant to conservative therapies including antibiotics. The infected prosthetic grafts were removed and autogenous reconstructions were performed extra-anatomically using the superficial femoral vein: in Case 1, with femoro-femoral crossover bypass, and in Case 2, with axillo-unifemoral bypass with anastomosis of bilateral common iliac arteries. Both infections eventually resolved. Since the deep femoral vein had been preserved during harvesting of the superficial femoral vein, no problems, such as venous congestion of the leg, occurred in either of the two cases. Their postoperative courses were uneventful and the patients were given ambulatory their own feet. We reviewed the literature about the utility of superficial femoral veins as arterial substitutes.