We report a case of surgical ostial angioplasty with fresh autologous pericardium concomitant with aortic valve replacement for ostial stenosis of the left main coronary artery (LMT) with aortic valve insufficiency due to syphilitic aortitis (SA). A 50-year-old man with chronic atrial fibrillation and a history of multiple cerebral infarctions was found to have a 90% ostial stenosis of the LMT with an intact distal coronary artery tree. On preoperative echocardiography, severe aortic valve insufficiency and left atrial thrombus were noted. A chest CT showed no thickening or dilatation of the ascending aorta and no calcification of the aortic root and LMT. As a serological syphilitic test, the treponema pallidum hemagglutination test was positive in 1:10, 387 dilution with a positive rapid plasma reagin method. He had no chest pain or fever. At surgery, gross thickening and fibrosis of the ascending aortic wall extending from the aortic root was noted, suggesting aortitis such as Takayasu aortitis and SA. The aortic valve was replaced with a mechanical valve and the LMT was successfully enlarged with a fresh autologous pericardial patch, confirmed by postoperative coronary angiography. Pathological findings of the aortic wall and the valve were consistent with SA, where treponema pallidum was found immunohistologically. He had an uneventful postoperative course and was treated with a 3.5-month course of amoxicillin (750mg/day) for cardiovascular syphilis. Although SA is rarely seen nowadays, we should consider the possibility of this disease if there is a combination of coronary ostial stenosis and aortic valve insufficiency. Since surgical coronary ostial angioplasty has never been applied for SA, a careful observation is required.

A female in her 60 s with a mobile cardiac tumor in the left atrium was referred to our hospital. The tumor was diagnosed as myxoma by echocardiography, CT scan, and MRI. Under cardiac arrest using cardiopulmonary bypass, we resected the tumor through the superior trans-septal approach. We resected two tumors (tumor 1 and 2) with adequate rims of the interatrial septum to avoid recurrence. Although the tumor had a broad base and extended to near the mitral annulus, mitral valve repair was not necessary. Tumor 1 was gelatinous and seemed to be a myxoma ; tumor 2 had a lot of papillary structures attached to the solid mass and presented with the figure of a sea anemone when it was put in saline, which is typical for papillary fibroelastomas. The defect of the interatrial septum was closed with the autologous pericardium. The postoperative course was uneventful. Unexpectedly, both tumor 1 and 2 were diagnosed as myxomas on pathological examination. Tumor 2 (papillary lesion) included a few tumor cells with positive staining of calretinin typical for myxoma and was diagnosed as a “villous-type myxoma”. Because it is difficult to distinguish myxoma from papillary fibroelastoma by pre- and intraoperative findings, it would be recommended to resect tumors with an adequate margin to prevent recurrence.

Anomalous origin of the coronary artery from the pulmonary artery (ACAPA) is a rare congenital heart disease. A woman in her 60s was diagnosed as ARCAPA during examination for angina. A magnetic resonance image showed myocardial ischemia in a small area of the right coronary artery (RCA) and left anterior descending artery. Reimplantation of the RCA to the ascending aorta and patch plasty of the pulmonary artery were performed. Repositioning of the RCA orientation was necessary for relief of the kinking. The postoperative course was uneventful. She is now free from angina 15 months after surgery.

Background : Persistent endoleak is a major cause of aneurysmal enlargement or rupture after endovascular aneurysm repair (EVAR). Although several reports have described ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy as useful strategies, treatment for type II endoleak after EVAR is controversial. Objectives : We investigated the early results in 5 patients who underwent ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy for type II endoleak. Methods : A>10 mm increase in aneurysm diameter after primary EVAR or a maximum diameter>65 mm serve as indications for intervention for type II endoleak. Under general anesthesia, following transperitoneal exposure of the abdominal aorta, the infrarenal aorta was banded using a tape at the proximal landing zone. After the aorta was opened without clamping, the lumbar arteries were ligated, and a stent graft-conserving aneurysmorrhaphy was performed. Results : The mean interval from the primary EVAR was 47±17 months. The mean operation time was 215±76 min. Blood transfusion was necessary in 4 patients (estimated blood loss 1,260±710 ml). No in-hospital deaths were observed, and the mean postoperative hospital stay was 26±20 days. One patient developed aspiration pneumonia and 1 developed surgical site infection post-surgery. The diameter of the aneurysm changed from 68±8 to 47±5 mm during hospitalization and decreased further to 36±7 mm at the last follow-up. Conclusions : The early results of ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy were favorable. Although this strategy could be useful for aneurysmal dilatation secondary to persistent type II endoleak after EVAR, the indications for this approach should be determined following careful evaluation of the patient's status considering the invasiveness of the procedure.

Surgical cases for pulmonary artery aneurysm after palliative operation for congenital heart disease are rare. A man in his 40s underwent Waterston operation (side-side anastomosis of the ascending aorta and right pulmonary artery) for pulmonary atresia and ventricular septal defect at the age of one. Medical follow-up was continued at a local clinic without definitive repair. He had complained of exertional dyspnea and cough for one month. CT scan on admission showed a large right pulmonary artery aneurysm and atelectasis of the right lung. An urgent operation was planned for the huge pulmonary artery aneurysm. Under cardiac arrest, the proximal end-to-side anastomosis to the aorta was conducted using a Y-shaped vascular prosthesis at the previous Waterston anastomosis. The peripheral pulmonary arteries were reconstructed by inclusion technique. Percutaneous cardiopulmonary support was necessary for one day after operation due to unstable hemodynamics. He was extubated on postoperative day (POD) 4 and transferred to our general ward on POD 5. He was discharged home on POD 38. He is now free from heart failure symptoms and recurrence of aneurysm one year after surgery. Careful follow-up is necessary for the dilatation of the pulmonary artery and aortic root. A definitive operation—Rastelli and closure of the ventricular septal defect—may be considered in the future if the pulmonary artery resistance is suitable for the repair.