A 44-year-old woman received pacemaker implantation (PMI) at age 43 because of complete atrioventricular block. One year after PMI, she suffered palpitations and fainting. Cardiac examination revealed aneurysm of the sinus of Valsalva dissecting into the interventricular septum and severe aortic regurgitation. Patch closure of the aneurysm of the sinus of Valsalva and aortic valve replacement were carried out under complete cardiopulmonary bypass. The endocardial leads were removed and epicardial leads were implanted for the pacemaker. This is a very rare case. The first symptom could have developed from conduction disturbance, such a complete atrioventricular block. The patch closure of the aneurysm and aortic valve replacement was considered effective for this disease.

A new technique of left atrial plication (LAP) for giant left atrium (GLA) resulting from mitral regurgitation (MR) is reported. A 66-year-old man was found to have NYHA class III resulting from severe MR, mild TR and GLA with a left atrial diameter (LAD) of 107mm on echocardiogram. Chest X-ray showed the cardiothoracic ratio (CTR) to be 92%, and the right side CTR was 88.4%. Surgery was performed under general anesthesia with endotracheal intubation. Under cardiac arrest established by antegrade and retrograde cardioplegia, mitral repair was performed first through a superior transseptal approach. Left atrial resection was continued paralell to the mitral posterior annulus and to the right side wall of the left atrium, following the right side resection. Simultaneously the left atrial wall was incised 3 to 4cm in width all the way along the resection line and it was closed by a running suture of 3-0 prolene. The continuous line of the left atrial plication formed a spiral shape. A prominent portion of the atrial septum resulted from the LAP and the right atrial wall was also resected and plicated. The postoperative course was uneventful, and the postoperative CTR reduced to 71% with a right side CTR of 54.4% with reduction of LAD to 67mm on ultrasound cardiogram (UCG). This spiral LAP was considered more effective to reduce all dimensions of the giant left atrium dilated in all directions in comparison with other LAP methods previously reported.

A 71-year-old female, who had diabetes mellitus and chronic renal failure on dialysis, had undergone mitral valve repair and tricuspid valve annuloplasty. Five months after the operation, she suffered from infectious endocarditis and underwent mitral valve replacement. Postoperatively, a total fluid volume of 300 to 600 ml/day was drained from the pericardial tube, and its appearance became milky after the start of oral intake of food. She was diagnosed with chylomediastinum. Despite fasting and total parenteral nutrition for 2 weeks and subcutaneous octreotide administration, the volume of fluid drainage was not reduced. Therefore, we planned lymphangiography treatment with Lipiodol on postoperative day 37. On operation, under local anesthesia, the left inguinal lymph node was punctured under ultrasound guidance, and Lipiodol was injected at a rate of 12 ml/h for 1h. On the next day, the volume of fluid drainage was reduced, and the pericardial tube could be removed 9 days after lymphangiography.