A 69-year-old woman, who had undergone a right nephrectomy for renal tuberculosis in her teens, was admitted with a low grade fever, anorexia and progressive dyspnea. Transthoracic echocardiography showed cardiac tamponade and chest CT revealed an enlarged ascending aorta. She was treated with pericardiocentesis. Specimens of pericardial effusion failed to demonstrate any acid-fast bacilli, but they did reveal a high level of adnosine deaminase (72 IU/l). A diagnosis of tuberculous pericarditis was considered, and antituberculous chemotherapy was started. However, he presented with severe back pain 32 days later and CT revealed type A acute aortic dissection. We therefore replaced the ascending aorta and aortic root. A histopathological examination of the ascending aorta revealed evidence of a granulomatous inflammatory reaction with Langhans giant cells. She thereafter received antituberculous chemotherapy with 4 drugs for 2 months, with continued rifampicin and isoniazid treatment. There was no evidence of any graft infection after 70 days.

We report the case of a 55-year-old woman with aortitis syndrome. She was admitted to our hospital because of repeated chest pain and syncope. An electrocardiogram and the laboratory data suggested acute myocardial infarction, and coronary angiography showed severe bilateral coronary ostial stenosis. No valvular disease was observed. Aortitis syndrome was suspected because of the stenosis of the brachiocephalic artery in addition to the bilateral coronary ostial stenosis, while the patient did not have elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Coronary artery bypass grafting was performed, and the patient's postoperative course was uneventful. However, she again experienced chest pain 9 months after surgery due to aortic regurgitation (AR) and diffuse narrowing change of the left internal thoracic artery graft. Aortic valve replacement and Re-CABG was performed, and the patient was treated with steroid therapy postoperatively. The postoperative course was uneventful, but the patient thereafter died due to bleeding of a malignant adrenal tumor at 21 months after the second surgery.

A sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of it with an anomalous origin of the coronary artery are scarce. A 35-year-old male was admitted to our department with fatigue and cough. Multi-detector-row computer tomography (MDCT) revealed an isolated extracardiac right sinus of Valsalva aneurysm with an anomalous origin of the left circumflex artery (LCX) and total occlusion of the right coronary artery (RCA). Its diameter was about 70 mm. We performed a partial aortic root remodeling procedure with a trimmed J-graft because he had neither aortic regurgitation (AR) nor annuloaortic ectasia (AAE). Concomitantly, coronary artery bypass grafting to the RCA (Seg. 3) using a saphenous vein, and reconstruction of the LCX by Piehler's technique using a saphenous vein were added. The patient's postoperative course was uneventful, and he was discharged on the 28th postoperative day. Postoperative MDCT revealed that the aneurysm of the right sinus of Valsalva was not enhanced, and the RCA and LCX were patent. This procedure preserved the patient's own normal aortic valve and sinus of Valsalva and enables him to have more physiologically normal hemodynamics than aortic root reconstruction using a composite graft, e.g. Bentall procedure, Cabrol procedure, although the potential progression of the AR requires careful follow-up.

A 59-year-old woman with a history of pulmonary and cardiac sarcoidosis was admitted to our hospital because of acute femoral artery occlusive diseases. Preoperative echocardiography showed diffuse hypokinesis and biventricular tumors. Transesophageal echocardiography revaealed mobile biventricular tumors. The tumors which consisted of organized thrombi were successfully excised. She was discharged 23 days after surgery. This suggested that hypokinesis accompanying cardiac sarcoidosis caused the biventricular thrombi.

Total aortic arch repair was performed simultaneously with the aortic root replacement using Cabrol's method in a 61-year-old man with recurrent aortic dissection. Two months prior to admission the patient had undergone a separate replacement of the aortic valve and ascending aorta for acute type A dissection with aortic regurgitation due to a bicuspid valve. He developed a suture line disruption caused by recurrent dissection in the aortic root which had been reinforced with GRF glue on the first operation. During the second operative procedure the dilated aortic arch with the remnant false lumen was found to be extensively injured. Therefore total arch replacement was required in addition to aortic root reconstruction preserving the previously placed mechanical valve.

A 62-year-old woman was admitted suffering from chest tightness and palpitations. Coronary angiography revealed slight stenosis of the coronary artery requiring medical treatment. At that time right renal artery aneurysm was found accidentally. In addition abdominal echogram showed gallbladder stone. She underwent aneurysmectomy with reconstruction of the right renal artery and cholecystectomy. Postoperative course was uneventful and renal arteriography one month after operation depicted the patent right renal artery. Surgical indications for renal artery aneurysm should be carefully considered.

Clinical evaluation of perioperative IABP use in valvular heart surgery was studied. There were 4 preoperative, 18 intraoperative and 20 postoperative applications of IABP. The indications of IABP were LOS in 19 patients, failed weaning from bypass in 11, life threatening arrhythmia in 11, and congestive heart failure in 1. Sixteen out of 26 patients with successful weaning from IABP support could be discharged. Ten died after removal of IABP. Longer duration of cardiopulmonary bypass and aortic clamp, lower value of cardiac index 24 hours after introduction of IABP support were implicated in unsuccessful IABP support. The causes of death were due to LOS in 8 patients, MOF in 12, GVHD in 2, others in 3. The outcome of IABP for patients with valvular heart surgery was not satisfactory. However, the results of IABP support in valvular surgery will be improved by reducing the incidence of postoperative complications, especially LOS, followed by MOF.

A 70-year-old woman was admitted with precordial pain. Two-dimensional echocardiography revealed a right atrial tumor. CT scan also showed a high density tumor in the right atrium. Right atriography demonstrated a mobile tumor with a stalk arising from the vicinity of the Eustachian valve. On open heart surgery the stalk of the tumor seen to be attached to the Eustachian valve. The tumor was very hard because of massive calcification. Removal of the tumor was accomplished in the standard fashion, excising the Eustachian valve together with surrounding endocardium to prevent recurrence. The weight of the tumor was 20g and the size was 6×3×2cm. Histologic examination of the tumor revealed myxoma. Thirty five cases of right atrial myxoma have been reported in Japan. There was only one previous report which reported a case originating from an Eustachian valve.

From 1978 through 1992, 103 patients (mean age: 69 years) underwent elective repair of abdominal aortic aneurysm (eAAA) at our institute. One or more postoperative complications occurred in 30 patients (29%), with mortality rate of 1.9%. Factors significantly associated with postoperative complications by univariate analysis included male sex (p=0.0082), operation time (p=0.0006), size of aneurysm (p=0.0045), blood loss during operation (p=0.0037), decreased pulmonary function (p=0.0155), and the number of platelet counts (p=0.0468). Simple linear regression analysis showed that there was a significant correlation among AAA size, operation time and blood loss. Age at operation, however, did not have any influence on morbidity and mortality. Complete survival information was obtained in 96 (follow up rate of 95%) patients, and the influence of preoperative risk factors on late survival was also examined by the Kaplan-Meier method. Factors influencing long-term survival were renal dysfunction and age at time of operation.

Elective resection of abdominal aortic aneurysms is now a safe operation, though mortality related to ruptured abdominal aortic aneurysm (rAAA) remains high. To evaluate factors affecting survival after rAAA, 26 consecutive cases were studied. The operative mortality was 58% (15/26) compared with 1.8% for 110 elective AAA patients. Factors associated with poor prognosis were blood pressure of less than 90mmHg and profound acidosis of the arterial blood on admission, size of the aneurysm, and massive transfusion. The high mortality and morbidity rate for the rAAA patient emphasize the need for early and aggressive treatment of AAA in elective cases at high risk. In a follow-up study, however, the survival rate of rAAA, excluding hospital mortality, was 71% at five years and there was no significant difference in quality of life as compared with those patients who had elective AAA resection during the same time interval.