Dabigatran is a new/direct oral anticoagulant drug unlike warfarin. It is being increasingly used to prevent thromboembolism in patients with nonvalvular atrial fibrillation. We present the case of a 77-year-old woman with a giant left atrial thrombus in spite of anticoagulation therapy with dabigatran 300 mg/day. She had developed a cerebral infarction 18 months previously and was switched from warfarin to dabigatran. However, magnetic resonance imaging showed multiple new cerebral infarcts, and computed tomography scan and echocardiogram revealed a giant thrombus measuring 37×29 mm in the left atrium. Thrombectomy and left atrial appendage closure were urgently performed. Dabigatran was changed to warfarin again after the operation. She has had no recurrent thromboembolic event since then.

A 72-year-old man was referred to our hospital for coronary artery bypass grafting (CABG) due to asymptomatic severe coronary artery disease. A preoperative CT revealed 99% stenosis of the aberrant right subclavian artery, 90% stenosis at the origin of right common carotid artery, and 75% stenosis at the origin of the left subclavian artery. As he had high risk of a perioperative cerebral ischemic event for CABG, it was difficult to perform a carotid artery stent. We performed a total aortic arch replacement combined with CABG. The postoperative course was uneventful, and he was discharged on the 12th postoperative day.

Most renal artery aneurysms are asymptomatic and the indication of surgery for renal artery aneurysm is controversial. We encountered 3 cases of renal artery aneurysms that were found incidentally during imaging studies. We used urological approach to undergo renal or adrenal surgery and we injected renal protection solution into the kidney after clamping the renal artery, later we underwent renal artery aneurysmectomy. In all cases, we got good operative field, and they went an uneventful postoperative course without deterioration of renal function. In surgical treatment of renal artery aneurysm, this approach method, reconstructive procedure, and renal protection are satisfied enough.

We report a case of Takotsubo cardiomyopathy that developed after elective coronary artery bypass grafting (CABG) in an 80-year-old woman. She had been given a diagnosis of unstable angina complicated with mild hypertrophic obstructive cardiomyopathy (HOCM). Her cardiac index began to fall 7 h postoperatively, and we needed to infuse fluids and increase dopamine dose (up to 5 µg/kg/min) to maintain cardiac index and blood pressure. CPK-MB level increased up to 140 IU/l at 12 h postoperatively. Transthoracic echocardiography showed akinesis and ballooning of the apex and hyperkinesis of the base with accelerated left ventricular outflow tract (LVOT) flow and increased mitral regurgitation (MR). Emergency coronary artery angiography showed good patency of all bypass grafts and no new coronary lesion. We diagnosed Takotsubo cardiomyopathy. To improve the hemodynamic status, we started intra-aortic balloon pumping (IABP) instead of adding catecholamines. Blood pressure and cardiac index had improved temporarily, but became unstable again because of increased LVOT pressure gradient and moderate-to-severe MR. LV wall motion gradually improved, but the hemodynamic status stayed unstable, but improved after removal of IABP. In general, the prognosis of Takotsubo cardiomyopathy is favorable with supportive care. However, when it is associated with LVOT stenosis and significant MR, low cardiac output syndrome can become intractable, thus we should manage critical conditions with extreme caution.

We report a case of septal branch aneurysm. A 61-year-old woman was referred to our hospital because of heart murmur. Septal branch aneurysm (25×15 mm) was diagnosed by echocardiography and coronary angiography, and followed up annually with multi-detector row computed tomography (MDCT). Nine years later, another aneurysm proximal to the known aneurysm, which protruded above the epicardium, has rapidly dilated from 5 to 11 mm. We therefore performed closure of the orifice of the septal branch concomitant with bypass grafting ; left internal mammary artery to distal LAD. After the procedure, the aneurysm in the septum had completely collapsed. Her postoperative course was uneventful.

We report a case of re-expansion pulmonary edema (REPE), which complicated mitral valve plasy via right small thoracotomy. A 56-years old man underwent mitral valve plasty for severe mitral regurgitation caused by P2 prolapse. After separation from heart-lung machine, massive yellow foamy secretion has begun to spout from the right side endotracheal tube and hypoxemia has ensued. Differential ventilation with high airway pressure and steroid pulse therapy could not counteract the exacerbation of hypoxemia. Echocardiography showed severe diffuse hypokinesis of left ventricular wall. Intra-aortic balloon pumping and percutaneous cardiopulmonary support (PCPS) were introduced, and they were very effective. After five-days' support, PCPS was successfully weaned. The patient recovered well. REPE complicated by mini-thoracotomy approach cardiac surgery, is rare, but can be fatal.

A 11-year-old boy was admitted to our hospital with a diagnosis of the progressive residual coarctation of the aorta, severe left ventricular hypertrophy and dilatation of the ascending aorta. He had previously undergone 3 operations for coarctation of the aorta. We performed ascending-to-descending aortic bypass through a median sternotomy for residual coarctation of the aorta. Partial cardiopulmonary bypass (CPB) was established via the right femoral artery and right atrium. A cephalad retraction of the heart with a heart positioner and a longitudinal pericardial incision over the descending aorta allowed excellent exposure of the aorta through the posterior pericardium. The graft was anastomosed to the ascending aorta and descending aorta. The graft was brought around the right lateral aspect of the right atrium and through to the anterior aspect of right pulmonary veins and inferior vena cava. The bypass graft size was 14 mm in diameter. The CPB time was 134 min, and operation time was 232 min. The postoperative course was uneventful, and he did not suffer from paraplegia. His blood pressure postoperatively normalized without medication. He was discharged 20 days after surgery. The ascending-descending aortic bypass through a posterior pericardium approach is a safe and effective option for relieving residual coarctation and improving hypertension, for patients who have complex coarctation requiring surgical correction. However, because of his young age (II) it is necessary to follow him up carefully.

A 63-year-old man had undergone patch repair of a chronic dissecting thoracoabdominal aortic aneurysm 8 years previously. Postoperative course was uneventful during 8 years after the first operation. However follow-up CT scan 8 years after demonstrated pseudoaneurysm of thoracoabdominal aorta at the anastomotic side. Reoperation for pseudoaneurysm was performed through left thoracotomy under partial cardiopulmonary bypass. Pseudoaneurysm was revealed at the proximal anastomotic side. Graft replacement for thoracoabdominal aorta and reconstruction of two pairs of intercostal arteries and the celiac artery was performed under SEP and MEP monitoring. His postoperative course was uneventful. He was discharged from our hospital 12 days after surgery. Follow-up CT scan demonstrates no recurrence of pseudoaneurysm for 1 year after surgery.

A 6-year-old girl who had undergone repair of an endocardial cushion defect 4.5 years previously, developed discrete subaortic stenosis requiring surgical intervention. On two-dimensional echocardiography a membrane was visualized below the aortic valve. A pressure gradient of 97mmHg was recorded across the left ventricular outflow tract by cardiac catheterization. Operative findings showed a fibrous ring tissue just below the aortic valve, which was peeled away by sharp dissection. Postoperative cardiac catheterization revealed a 25mmHg pressure gradient across the left ventricular outflow tract. Two years later, she continues to do well and the pressure gradient remains unchanged on Doppler echocardiography.

We present a case of solitary arteriosclerotic aneurysm of the profunda femoris artery (PFA), which is very rare among peripheral aneurysms and a reviewed the 19 cases reported in the Japanese literature. A 78-year-old man had a chief complaint of a painful pulsatile mass in the left thigh. Enhanced CT showed the ruptured solitary aneurysm of the PFA. The aneurysm was 6.8cm in diameter. It was removed after ligation of the the PFA. In the Japanese literature, the mean age of patients with solitary arteriosclerotic aneurysm of the PFA was 73 (64-84), all patients were males, the rate of rupture of PFA aneurysm was 47%, and the mean diameter was 8.9cm. In our case, we simply ligated the aneurysm because the patient did not have any evidence of peripheral artery occlusive disease and the distal artery of the aneurysm was very small. However, there is a need to reconstruct the PFA whenever possible because the surgical importance of PFA in occlusive arterial disease has been recognized.