Thromboembolic events after cardiac surgery, including ischemic strokes, can be devastating complications, however only a few studies manifest the platelet activation and coagulation state after off-pump coronary artery bypass (OPCAB). Platelet-derived microparticles (PMP) are observed as released vesicles from platelets following platelet activation, and are believed to play a role in some clinical diseases because of their procoagulant activity. The aim of the present study was to evaluate the hypercoagulant state after OPCAB using PMP and other indices. Data were obtained from 15 patients (aged 69±7 years; only men) undergoing elective OPCAB surgery. One hundred milligrams of aspirin were used as postoperative antiplatelet drugs. Preoperative risk factors, operation time, postoperative hospital stay, transfusion and blood samples of CBC, PMP, βTG, PF 4, platelet aggregation, FDP, D-dimer and TAT of pre- and postoperative days (POD) 3 and 7 were studied. There was no difference between the PMP level with or without risk factor. The PMP levels of POD 3 and 7 were significantly higher compared to the preoperative levels (pre-op, POD 3, 7:9.1±5.1, 15.2±10.3, 28.4±24.5/10⁴plt respectively, p<0.05). The levels of FDP, D-dimer and TAT rose significantly on POD 3 and 7 and significantly correlated with the PMP levels. Beta TG, PF 4 and platelet aggregation did not change after OPCAB surgery, and no correlation was found with the PMP levels. Elevated levels of PMP, TAT, FDP and D-dimer persisted until POD 7 and suggested not only platelet activation, but also activation of the coagulation and fibrinolytic system. The findings suggest that 100mg of aspirin may not be adequate for the inhibition of platelet activation after OPCAB surgery.

A 52 year-old man was admitted to our institution with sudden onset of severe chest and back pain. The electrocardiogram showed ST segment depression in leads I, II, aVL, aVF, V3-6. Emergent coronary angiogram was performed, but the catheter did not reach to the coronary ostia, and it only performed false lumen aortogram. Computed tomography showed acute Stanford A aortic dissection. Ultrasound echocardiography also showed aortic regurgitation 3/4 degree. We decided to perform an emergency operation. During anesthesia induction, systemic blood pressure fell below 80 mmHg during systolic period, and pulmonary pressure raised to 60 mmHg. Transesophageal echography showed the movements of dissection flap intermittently obstructed the coronary blood flow and aortic valve annuls. Those flap movements, so called ‘flap suffocation’ was thought to be the cause of cardiac failure. Intra-operative findings of the ascending aorta showed an entry of dissection just above the left coronary ostia, and the entire detachment of intima to aortic wall. We performed ascending aorta replacement with aortic valve resuspension and fixation of coronary ostia. The postoperative course was uneventful, and he was discharged on the 25th postoperative day. For the precise treatment of acute Stanford A aortic dissection with such coronary ischemia, quick diagnosis and operative correction is essential.

We experienced 2 cases of accessory mitral valve tissue (AMVT). Case 1 : A 56-year-old man was admitted with aortic regurgitation. Transthoracic and transesophageal echocardiography revealed AMVT with no left ventricular outflow tract obstruction. The patient underwent a successful aortic valvuloplasty. AMVT was carefully excised, because we suspected AMVT might be the cause of recurrent aortic regurgitation and left ventricular outflow tract obstruction with aging. Case 2 : A 63-year-old woman was admitted with mitral regurgitation due to infective endocarditis. During medical treatment, transthoracic and transesophageal echocardiography revealed membranous structure in the left atrium uneffected by antibiotics. Mitral valvuloplasty and resection of membranous structure was performed. The membranous structure was not vegetation and had no relationship to mitral regurgitation. Pathological examination proved AMVT. To our knowledge, this is the first report of AMVT in left atrium in an adult.

A 64-year-old woman who had been followed for complete right bundle branch block at another hospital was found to have heart failure due to cardiac sarcoidosis. She was admitted because of progressive thinning of the ventricular septum and septal aneurysm which protruded into the right ventricle. On echocardiogram, her left ventricular ejection fraction had decreased to 40%. We decided to perform an operation because the patients's heart failure was thought to be due to dyskinesia of the ventricular septum with bulging of the septum into the right ventricle during systole, which consequently decreased cardiac output. The scarred ventricular septum, which was observed through right atrial, right ventricular and aortic incisions, was incised along the marginal normal interventricular myocardium. A tailored 4×3 cm oval Dacron patch was secured over this opening. A DDD pacemaker was implanted for complete atrio-ventricular block and, to synchronize both ventricles, ventricular leads were fixed on the right and left ventricular epicardium. Her postoperative course was uneventful. A postoperative pathologic study revealed a noncaseating granuloma on the border of the normal myocardium. We report a rare surgically treated case of cardiac sarcoidosis.

Cardiac papillary fibroelastoma (CPFE) is a rare tumor, and is usually located in the atrioventricular or ventriculoarterial valves. It is occasionally identified by echocardiography or surgery. It can also be an unexpected finding at autopsy. As this tumor often occurs in left-sided cardiac chambers, early aggressive surgical resection is required in order to prevent severe systemic embolic complications. However, the operative indications of tumors on the right cardiac chamber are controversial. The patient was a 73 year-old man. He had had cerebral infarction at age 58. Before the currently reported operation, we found CPFE on the tricuspid valve but we could not find a patent foramen ovale (PFO) by the usual examinations. During surgery, we found a CPFE on the tricuspid valve that had a short stalk and PFO. We cut the short stalk of the CPFE easily, and closed the PFO directly. This patient did not need complicated valve repair. We speculated that this cerebral infarction was caused by a CPFE on the tricuspid valve and patent foramen ovale. Echocardiography is very useful in diagnosing CPFE. However, we should not neglect the possibility of PFO before surgery. The postoperative course was uneventful. We concluded that early surgical resection of CPFE, even in right-sided cardiac chambers, should be performed in order to prevent severe embolic complications, even without PFO diagnosis.

We report the surgical correction of an incomplete atrioventricular septal defect (AVSD) associated with pulmonary stenosis in a 72-year-old woman. She was given a diagnosis of atrial septal defect at the age of 19, but at that time surgery was not indicated. She had an uneventful pregnancy at age 28. She had received medical treatment for congestive heart failure since the age of 67. Four years later, she was admitted to another hospital due to edema of the leg and retention of massive ascites. After careful and precise evaluation, AVSD was diagnosed, associated with bilateral atrioventricular (AV) valve regurgitation, pulmonary stenosis, atrial fibrillation and significant stenosis of the left anterior descending (LAD) coronary artery. She was referred to our hospital for surgery, and intracardiac repair was determined to be necessary after clinical assessment. Prior to surgery, she underwent percutaneous coronary intervention with a bare-metal stent for an LAD lesion. Under antegrade cold blood cardioplegia and mild hypothermia, we performed closure of the ostium primum atrial septal defect using a heterologous pericardial patch with expanded polytetrafluoroethylene strip, and right side atrioventricular (AV) valvuloplasty and pulmonary valvotomy. The postoperative course was uneventful. The patient has been designated NYHA class I for 2 years since surgery, and has had mild regurgitation of both AV valves, but neither have affected her quality of life. Surgical correction should be considered in elderly patients with incomplete AVSD, even in those aged 70 and over.

A 71-year-old man was admitted complaining of abdominal pain. Contrast enhanced CT scan showed bilateral inflammatory common iliac artery aneurysms and encasement of bilateral ureters with perianeurysmal fibrosis. Drip infusion pyelography (DIP) showed bilateral hydronephrosis. After insertion of ureteral stents, Y-graft replacement and bilateral ureterolysis were performed successfully in spite of adhesion of the ureters to the aneurysmal wall. Postoperative DIP showed good passage in ureters and improvement of hydronephrosis. We would like to emphasize the usefulness of preoperative ureteral stenting for identification and mobilization of ureters.

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 : 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 22-year-old man with dilated cardiomyopathy (DCM), who was a practicing Jehovah's Witness, was transferred to our hospital for surgical treatment of medically uncontrollable mitral regurgitation (MR). Our original mitral complex reconstruction procedure and permanent pacemaker implantation for biventricular pacing were successfully performed without transfusion of blood products. Blood conservation strategy included: 1) preoperative treatment with erythropoietin, 2) utilization of a shortened extracorporeal circuit and assisted venous drainage system, 3) the use of ultrafiltration to save the residual autoblood in the extracorporeal circuit. The preoperative hemoglobin level was 17.1g/dl and the postoperative lowest level was 9.5g/dl. MR decreased from grade III to none, and NYHA functional class improved from class II to class I postoperatively. He was moved to a cardiology ward on the 13th postoperative day without complications. Transfusion-free surgery for DCM should be performed before DCM advances and requires left ventriculoplasty at risk for major blood loss. A careful follow-up is needed to examine the long-term results of the operative procedure during his expected long survival.