We report a case of a 52-year-old man with situs inversus totalis who underwent repair of tetralogy of Fallot in his childhood. He also experienced cerebral embolism at the age of 50 years, and recovered with no sequela after endovascular thrombectomy. Two years later, he was admitted to our hospital due to progressing orthopnea. He was diagnosed with congestive heart failure caused by severe aortic regurgitation with moderate tricuspid regurgitation and pulmonary hypertension. Three-dimensional computed tomography also showed aortic root dilation, single coronary artery, and inverse persistent left superior vena cava (PLSVC) draining into the left atrium, which was assumed to be associated with the previous stroke. A Bentall operation, tricuspid annuloplasty, and concomitant ligation of the PLSVC were performed.

Calcified amorphous tumor (CAT) is a non-neoplastic mass characterized by calcified nodules that was first reported in 1997. It is often associated with dialysis or mitral annular calcification (MAC). CAT is considered a risk factor for systemic embolism, but there has been no report of CAT damaging the native valve tissue and leading to valvular disease. An 81-year-old woman had shortness of breath on exertion starting 1 year previously, and was referred to our hospital with cardiac murmur detected on physical examination. Echocardiography showed evidence of severe mitral valve regurgitation with ruptured chordae tendineae of the posterior leaflet and a poorly mobile club-shaped structure protruding into the left ventricle and appearing to be continuous with MAC. She underwent elective mitral valve repair. A club-shaped calcification originating from MAC was found under the P2 segment, with ruptured P2 chordae tendineae immediately above it and mitral perforation in the contralateral A2 segment, which were likely to have resulted from direct damage by the hard structure. Mitral valve repair was successful with mass resection, triangular resection of the posterior leaflet P2 segment, and closure of the perforation. Histopathological findings of the mass were consistent with CAT, with no evidence of infection or malignancy. CAT may not only cause embolism but also grow while damaging the native valve tissue. It is important to closely follow-up and perform surgery in proper timing.

Objective : To investigate the surgical outcomes of left ventricular free wall rupture (LVFWR) and ventricular septal perforation (VSP) in terms of mechanical complications following acute myocardial infarction (AMI). Methods : Subjects comprised 26 patients (male : 12, female : 14, mean age : 74 years) who underwent surgery between 2001 and 2012. The LVFWR type was blowout in 2 cases and oozing in 5 cases. Immediately after diagnosis, 4 cases underwent intra-aortic balloon pumping (IABP) and 2 cases received extracorporeal membrane oxygenation (ECMO). LVFWR was repaired by suture and patch closure in 5 patients and by TachoComb in 2 patients. VSP was caused by anterior infarction in 15 cases and inferior infarction in 5 cases. IABP was inserted in 16 cases. VSP was repaired by the infarct exclusion technique in 17 patients, while 2 patients underwent suture or patch closure. Results : The operative mortality rate was 14.3% for LVFWR and 15.8% for VSP. The cause of operative death in 1 patient with blowout type LVFWR who was in a state of cardiopulmonary arrest on arrival, was low cardiac output syndrome (LOS). The causes of operative death in VSP included 2 patients with LOS and 1 patient who died suddenly 8 days postoperatively due to ventricular fibrillation. Two VSP patients underwent repeat surgery for residual shunt. The five-year Kaplan-Meier survival rates were 85% for LVFWR and 62% for VSP. Of 20 patients who received IABP preoperatively, the time from confirming LVFWR or VSP diagnosis after admission to IABP initiation was 103±45 (48-120) min in the survival group (n=17) and 259±174 (122-455) min in the operative mortality group (n=3). A significant difference was observed between the two groups (p=0.04). Conclusion : Therapeutic strategies including rapid diagnosis after admission, early insertion of IABP, and prompt surgery could improve the prognosis for patients with LVFWR and VSP following AMI.

A 24-year-old woman, under the treatment for atypical depression, visited our emergency room on foot with a chief complaint that she stabbed herself in the chest with a sewing needle. Chest X-ray and plain CT showed the needle penetrating the chest into the heart. There was no sign of pneumothorax or cardiac tamponade. She was hemodynamically stable. Echocardiography revealed atrial septal defect (ASD) by chance. We performed urgent surgery for needle removal and ASD closure through median sternotomy. The needle was easily recognized near the right ventricle apex. The right atrium was opened, but the needle was not seen through the tricuspid valve because of trabecular formation. After the needle was removed, ASD was closed using the direct suture method. The needle was 35 mm long. She was transferred to the psychiatry department on postoperative day 4 and had a good postoperative course.

A 76-year-old woman with abdominal aortic aneurysm coexisting horseshoe kidney and pelvic arteriovenous malformation (AVM) is reported. Operation was performed by a transperitoneal approach via typical median laparotomy. The aneurysm was successfully replaced by a bifurcated prosthetic graft without division of the renal isthmus. Cold lactated Ringer solution was injected into an aberrant renal artery at the time of aortic cross-clamping. This was useful not only to protect the kidney against ischemic injury, but also to know the perfusion area of the vessel. The aberrant renal artery was attached to the prosthetic graft following the aortic proximal anastomosis. Though a part of the asymptomatic AVM, which involved the left ureter, ovary, and uterus, was located anterior to the left iliac arteries, distal anastomoses at the internal and external iliac arteries were done smoothly. No surgical intervention was applied to the AVM in the operation. The post-operative course was uneventful.

We report a rare case of brachiocephalic arterial aneurysm associated with rapid tracheal obstruction. A 68-year-old woman visited our hospital because of progressive dyspnea. She developed acute respiratory failure and emergency incubation was performed. CT revealed a large brachiocephalic arterial aneurysm causing severe tracheal stenosis by compression. Angiography revealed a saccular aneurysm behind the brachiocephalic artery. It also demonstrated a common trunk of the brachiocephalic and the left common carotid artery. Aneurysmectomy with arterial reconstruction using an 8-mm prosthetic graft was performed while monitoring of regional cerebral oxygen saturation without extracorporeal circulation. The postoperative course was uneventful and there was no postoperative neurological deficit.

We report the use of endovascular stent-graft treatment for a case of traumatic thoracic aortic dissecting aneurysm complicated with multiple injuries. A 65-year-old man who had fallen from a 6m high roof was admitted to our hospital with severe circulatory failure and deep coma. Examination showed right hemopneumothorax, hematoma around the thoracic descending aorta and abdominal cavity, and bone fractures of all right ribs, skull, right clavicle, pelvis and lumbar vertebra. The patient recovered without major neurological deficit, but a dissecting aortic aneurysm approximately 6.5cm in diameter occurred at the proximal portion of the descending aorta. Since we considered that conventional aortic repair would be difficult with high operative risks based on the complicated thoracic and head injuries, we performed an endovascular stent-graft treatment. The postoperative course was uneventful and the aneurysmal diameter has been decreasing to date.

We evaluated long-term survival and morbidity of 191 patients (161 non-ruptured and 30 ruptured) undergoing abdominal aortic aneurysm repair between 1980 and 1997. Thirty-day mortality rates of non-ruptured and ruptured aneurysms were 1.2% and 36.6%, respectively. Hospital death occurred in 3.1% of patients with non-ruptured aneurysms and 53.3% of those with ruptured aneurysms. Cumulative survival rates after successful AAA repair at 5 and 10 years were 76.3% and 42.3%, respectively. These were lower than survival rates in the age- and gender-matched general population. The most frequent cause of late death was cardiac problems (28.8%) including myocardial infarction. Other causes included stroke (19.2%), malignant neoplasm (17.3%), and ruptured recurrent aneurysms at or above the proximal anastomosis (9.6%) including aorto-enteric fistulas. Regarding late vascular complications, recurrent aneurysms at or above the proximal anastomosis were found in 10% of patients, including 3.5% of true aneurysms, 4.7% of anastomotic aneurysms, and 1.8% of aorto-enteric fistulas. Thoracic aortic aneurysms were found in 3.7% and aortic dissection in 4.2%. Cumulative graft patency rates at 10 and 15 years were 97.4% and 90.9%, respectively. Suppressive treatment for arteriosclerosis and continuous careful follow-up with an aggressive diagnostic approach may reduce morbidity and mortality from recurrent aneurysms or coronary artery disease, thereby improving late survival after AAA surgery.

We evaluated long-term results of 126 consecutive bypass surgeries for chronic limb ischemia including 54 aorto-femoral (AF), 26 femoro-femoral crossover (FF), 7 axillo-femoral (AxF), and 39 femoro-above the knee popliteal (FP) bypasses. Patients who had undergone FF bypasses were significantly older than those who received AF bypasses (p<0.01). Preoperative ankle brachial pressure indices (ABI) of the AxF and FF patients were significantly lower than those of AF patients (p<0.05). Compared with AF patients, the AxF and FF groups included significantly higher percentages of Fontaine III and IV limbs treated by limb salvage surgery (p<0.05). The cumulative graft patency rates 5 years after AF, FF, and FP bypasses were 94.7%, 91.3%, and 64.3%, respectively. In the FP group, patients with intermittent claudication before surgery showed a 5-year graft patency rate of 82.5%, while that in patients who underwent surgery for limb salvage was 43.3%. The secondary graft patency rates 5 years after AF, FF, and FP bypasses were 94.6%, 91.3%, and 83.3%, respectively. All patients whose bypass grafts were occluded were male and were smokers. Poor run-off and insufficient anticoagulation therapies were also associated with graft occlusion. Two of the 12 patients who developed graft occlusion underwent limb amputation.

A 63-year-old man was admitted because of sudden hematemesis and melena. Seven years previously, he had had a woven Dacron aorto-biiliac graft inserted for abdominal aortic aneurysm. Aorto-enteric fistula was diagnosed based on the clinical findings and enhanced computed tomography. It was not clear whether the insected Y graft was infected. We first reconstructed the axillo-bifemoral bypass and then removed the Y graft. Good result can be obtained with prompt surgical intervention.