Introduction: To date, totally 3D-endoscopy has primarily been employed in mitral, tricuspid, and aortic valve surgeries. Herein, we describe the first case of a pulmonary valve surgery using totally 3D-endoscopy. To the best of our knowledge, this is the first case of a totally endoscopic pulmonary valve surgery. Case report: A 56-year-old woman was provisionally diagnosed with a tumor arising from the left cusp of the pulmonary valve. Totally 3D-endoscopy was planned for tumor resection. The patient was placed in a modified right lateral decubitus position and underwent mild hypothermic cardiopulmonary bypass using the left femoral artery, right jugular vein, and right femoral vein. An on-pump beating-heart technique was used during this surgery. Trocars for the 3D-endoscopic system and surgical instruments were inserted through the third and fourth intercostal spaces. Upon incision of the pulmonary artery, the suspected tumor was revealed to be a hyperplastic left pulmonary cusp; therefore surgical resection was abandoned. The patient was discharged without any complications. Conclusion: This case demonstrates that a totally 3D-endoscopic approach may provide optimal views of the pulmonary valve. Moreover, this procedure would be a novelty in MICS.

A 65-year-old man with a history of severe aortic valve regurgitation had undergone aortic valve replacement (AVR) via partial upper hemisternotomy at the age of 50 years. At that time, bioprosthetic valve was implanted. Fifteen years after the valve implantation, he presented with palpitations and chest tightness. Examination revealed bioprosthetic valve failure with consequent severe aortic valve regurgitation. Redo AVR via right anterior mini-thoracotomy was decided as the treatment strategy, and the procedure was successfully completed without complications. The patient underwent extubation on the day of the operation. His postoperative course was unremarkable, and he was discharged 13 days postoperatively. In this case, the patient had previously undergone partial upper hemisternotomy (classified as a minimally invasive cardiac surgery [MICS]) and showed only few adhesions in the pericardium, suggesting that MICS could be beneficial in cases involving re-operation.

A 73-year-old woman presented with epigastric discomfort and lightheadedness. She was admitted to another hospital with congestive heart failure due to severe aortic and mitral regurgitation. However, her heart failure was refractory to medical treatment, necessitating transfer to our hospital for surgical treatment. Emergency surgery was performed for worsening heart failure after admission to our hospital. Intraoperative findings showed aneurysms of the ascending aorta and aortic root and avulsion of the aortic valve commissure between the right coronary and non-coronary cusps. Replacement of the ascending aorta and aortic root replacement using the Florida sleeve method as well as double valve replacement (mitral and aortic) were performed with a favorable outcome. Histopathological examination showed myxomatous degeneration, which suggested that it could have contributed to avulsion of the aortic valve commissure.

Left ventricular thrombus is a complication of left ventricular dysfunction, including acute myocardial infarction, cardiomyopathy, and severe valvular heart disease. Surgical removal should be considered when a thrombus is mobile, when thromboembolism occurs, and when cardiac function has the potential to improve. Two patients with left ventricular thrombus underwent totally thoracoscopic transatrial thrombectomy. A thrombus developed in the apex of the left ventricle after acute myocardial infarction in one patient (Case 1) and during treatment for congestive heart failure in the other (Case 2). The minimally-invasive transatrial approach requires no sternotomy or left ventriculotomy and is thus particularly beneficial for treating left ventricular dysfunction. Moreover, totally endoscopic surgery confers the advantage of a deep and narrow visual field. Therefore, we consider that this strategy is highly effective for treating left ventricular thrombus.

The patient was a 61-year-old woman. In April 2005, she suffered a cerebral infarction and became paralyzed on the right side. In June 2005, a stent graft was placed to treat significant stenosis of the right coronary artery. Computed tomography (CT) in October 2006 revealed widespread patent aortic dissection in both the true and false lumens, extending from the origin of the ascending aorta to the three arch branches and both femoral arteries. Preoperative coronary angiography also showed occlusion of the left anterior descending branch. As a result of these findings, widespread Stanford type A chronic aortic dissection with coronary artery disease was diagnosed, and surgery was performed in February 2007. Brachiocephalic artery dissection and severe stenosis of the right subclavian artery were present, and the left common carotid artery and left subclavian artery were also dissected distally. In addition, both the true and false lumens were patent distal to the aortic arch, with the major abdominal branch bifurcating from both lumens and the dissection extending to the femoral artery, requiring cannulation of both lumens. During surgery, extracorporeal circulation was established by means of blood removal from the right atrium, transapical aortic cannulation, and cannulation of both luminens of the left femoral artery, in an effort to prevent malperfusion due to hypothermia. For revascularization, a Y-shaped artificial blood vessel was used to reconstruct the three arch branches first (the arch-first technique), after which an I-shaped artificial blood vessel was used to form anastomoses distally with both lumens, ensuring perfusion to the false lumen. The proximal anastomosis was then formed, and finally, a single coronary artery bypass graft (CABG) branch was performed using a great saphenous vein graft. No postoperative complications were encountered, and CT showed good blood flow through both luminens below the graft and aortic arch. The patient was discharged from hospital and returned home in an anbulatory condition independently 18 days postoperatively. In this case of widespread type A chronic aortic dissection, the cannulation site was selected and the order of reconstruction and methods of anastomosis were carefully chosen to avoid cardiac malperfusion during arch replacement, resulting in a good outcome.

A 60-year-old man with impending rupture of abdominal aortic aneurysm was transferred to our hospital. The patient entered a state of shock because of rupture during a CT scan examination. Emergency in site reconstruction with a dacron Y-graft was performed. There was massive intraperitoneal bleeding but no apparent abscess formation around the aneurysm. No drain was placed. A subcutaneous abscess that developed postoperatively was cured by open drainage and local antibiotic administration. Culture from both the aortic wall and the subcutaneous abscess revealed Salmonella infection. After subsequent intravenous antibiotic therapy for 45 days, the patient was discharged without any evidence of remaining infection.

A free-floating ball thrombus in the left atrium is a rare occurrence. Few patients who developed a ball thrombus after mitral valve replacement have been reported. Our patient was a 58-year-old man who had undergone mitral valve replacement in 1981. Since bleeding gastric cancer had been diagnosed anticoagulant therapy had been 4 days before admission. On admission, echocardiography revealed a large thrombus in the left appendage. First, he underwent total gastrectomy for gastric cancer. After the operation, he developed aspiration pneumonia, and was intubated. We observed that a large thrombus had moved from the left appendage to the left atrium. Emergency operation was successfull.

A 62-year-old woman was admitted for chest and back pains. She was found to have thrombosed type A aortic dissection by enhanced computed tomography. Since she had no clinical symptoms after her admission, she was discharged. Forty days after the admission, she returned with acute renal failure and ischemia of both lower extremities. Occlusion of the abdominal aorta was diagnosed and emergency axillobifemoral bypass was performed. Her renal function and the ischemia of both lower extremities improved dramatically and she was discharged 30 days after the operation. Axillobifemoral bypass is one of the most effective and least invasive operations in such cases.

A 39-year-old man received Bentall's operation for annuloaortic ectasia in July 1985. He was admitted with a high fever in July 1998. On the 2nd day of his admission, he suddenly suffered from headache and dizziness. Head computed tomography showed multiple low density areas in the right cerebrum and cerebellum. A transesophageal echocardiogram revealed massive vegetation around the prosthetic valve. The patient underwent emergency operation using cardiopulmonary bypass. The left ventricle outflow was almost occluded by thrombi. The prosthetic valve and graft were removed completely and replaced with a 24mm Gelseal^® graft and a 23mm St. Jude Medical^® valve. The right coronary ostium was reimplanted directly on the prosthesis, and the left coronary ostium was reinserted using a 10mm graft. The patient's intraoperative tissues grew S. aureus and parenteral antibiotics were administered for 5 weeks after surgery. The patient was discharged on the 45th postoperative day and is doing well 9 months after the operation.

An 81-year-old woman with severe chest pain was admitted to our hospital. Computed tomography showed aortic dilation and a non-enhanced crescentic area in the ascending aortic wall, indicating a DeBakey type-II aortic dissection with thrombus. The ascending aorta was replaced with an impregnated knitted Dacron graft. Fresh clotted hematoma was found in the dissected ascending aortic wall, and the intimal surface was involved with a local atherosclerotic ulcer penetrating the media. Operative findings were compatible with intramural hematoma due to penetrating atherosclerotic ulcer described by Stanson et al. In the literature most penetrating atherosclerotic ulcers are located in the descending aorta, thus this case is rare.