A 41-years-old man with Marfan syndrome developed acute aortic dissection Stanford Type B. A new entry was located at the distal aortic arch. Medical treatment was given for a month, but the proximal descending aorta expanded to 50 mm. Because he had undergone partial arch replacement at the age of 36, thoracic endovascular aortic repair (TEVAR) using the synthetic graft as proximal landing zone was performed to close the entry. Six months after TEVAR, the false lumen around the stent graft disappeared. Distal stent graft-induced new entry (d-SINE) did not occur after TEVAR. Three years after TEVAR, we performed thoracoabdominal aortic replacement because of expansion of the residual false lumen without any complication. Endovascular therapy could be useful option for extensive aortic lesion even in Marfan syndrome.

We report the case of a patient with severe tricuspid regurgitation and severe liver dysfunction who was successfully treated by tricuspid valve repair with spiral suspension and perioperative management of high cardiac output. The patient was a 77-year-old woman who presented with chronic atrial fibrillation with bradycardia (heart rate approximately 50 bpm). She had been diagnosed with severe tricuspid valve and mitral valve regurgitation at the age of 74. As her heart failure and hepatic failure grew worse, and hepatic encephalopathy also occurred, she was admitted to the hospital. Her Child-Pugh score for liver disease was Grade C at the preoperative assessment, suggesting that she was in the high-risk category for open heart surgery. Therefore, further medical treatment was required before selecting the surgical treatment. After the implantation of a pacemaker (VVI mode, 80 bpm), the cardiac output increased with a cardiac index of 5.17 L/min/m2 compared with 2.97 L/min/m2 prior to pacemaker implantation. Furthermore, the symptoms of heart failure improved and total bilirubin decreased from 3.9 mg/dl to 1.7 mg/dl, and surgery was performed. Tricuspid regurgitation was treated with spiral suspension, and mitral regurgitation due to annular dilation was treated with annuloplasty. Following the surgery, the cardiac index was maintained from 4.3 L/min/m2 to 5.8 L/min/m2 with central venous pressure below 10 mmHg by the assistance of intra-aortic balloon pumping. The patient was extubated 30 h after surgery, and was discharged on postoperative day 54. At the time of discharge, total bilirubin was 1.5 mg/dl. At 1.5 post-operative years, the patient is New York Heart Association functional Class II and tricuspid valve regurgitation is mild.

Case 1 of stuck valve was an 84 year old man, 25 years after mitral valve replacement (MVR) using a mechanical valve. Case 2 was a 67 year old woman, 18 years after the previous operation. These patients underwent re-do replacement of the prosthesis with a minimally invasive right thoracotomy approach using a microscope. Re-do cardiac surgery is commonly regarded high risk on account of difficulty in peeling the adhension, risk of injury to the heart, lung or large vessels, longer operation time, greater amount of transfusion, higher invasion and longer admission. In both cases however, because of microscope-assist and right thoracotomy MICS technique, we safely and successfully completed the operation without any unplanned troubles. We finally had a good course with a short admission, no perioperative transfusion or no perioperative complication.

A 24-year-old man was admitted to another hospital due to fever and chest and back pain. Enhanced chest computed tomography showed an aneurysm between the distal aortic arch and left pulmonary artery. The patient was transferred to our hospital for surgery. Because of suspicion of an infectious ductus arteriosus aneurysm, antibiotic therapy was started. Urgent graft replacement of the descending aorta was performed on the third day due to the enlargement of the aneurysm. All blood cultures including the preoperative examination, and the aneurysmal culture were negative. The histopathological study showed non-specific inflammatory response with plasma cell, T lymphocyte, and B lymphocyte infiltrations. There was no evidence of infection. Eventually we diagnosed this patient as having a ductus arteriosus aneurysm with non-specific inflammation. The antibiotic therapy was terminated on postoperative day 10, and the postoperative course was uneventful.

An 82-year-old man was referred to our hospital for heart failure due to severe mitral regurgitation and severe tricuspid regurgitation. We performed mitral annuloplasty and tricuspid annuloplasty (TAP). Three weeks after surgery, he developed hemolytic anemia (HA). Transesophageal echocardiography revealed a defect in the left ventricular outflow tract that communicated directly with right atrium, and the jet was striking with the TAP prosthetic ring. HA was not controlled, so we performed re-operation. The defect was found in the atrioventricular membranous septum. The defect was closed and TAP was performed using an autologous pericardial roll again. We report a rare case of acquired left ventricular to right atrium communication after TAP.

We report a case of percutaneous transluminal angioplasty (PTA) treatment for low cardiac output syndrome due to superior vena cava (SVC) stenosis with venous return anomaly. A 69-year-old man was referred to our hospital for surgical treatment of tricuspid valve infective endocarditis due to infected pacemaker leads, which had been implanted for sick sinus syndrome. Preoperative computed tomography indicated polysplenia syndrome-related absence of the hepatic segment of the inferior vena cava (IVC). Preoperative coronary angiography showed a 99% stenosis in the left anterior descending artery and a total occlusion in the right coronary artery. We therefore performed pacemaker system removal, tricuspid valve plasty, coronary artery bypass surgery, and a new pacemaker implantation (epicardial leads). However, over the postoperative course we noted low cardiac output syndrome due to SVC syndrome, which appeared to be aggravated by venous return anomaly from the patient's absent IVC hepatic segment. Eight days after the surgery we conducted PTA for SVC syndrome, which notably improved the patient's hemodynamics. The patient recovered and was transferred to a rehabilitation facility 34 days after the surgery.

Prosthetic valve dysfunction due to pannus formation is an infrequent but serious complication of tricuspid valve replacement. An 87-year-old woman underwent tricuspid valve re-replacement for severe prosthetic valve stenosis and regurgitation. On removal, thick fibrous pannus and chordal attachments were observed on the ventricular side of the cusp, which corresponded to the septal leaflet of the native valve. Microscopic examination revealed inflammatory cell infiltration accompanied with severe fibrosis and scarring had compromised and broken the prosthetic valve cusp under the pannus. The elastic fiber, which was detected in the base of the pannus, suggested it was a remnant of the native tricuspid valve leaflet. Prevention of native tissue attachment to the prosthetic valve cusp, which may cause severe pannus formation, appears to be extremely important for the long-term outcome and valve durability. The choice of prosthesis for the tricuspid position remains controversial. We should especially consider the height of stent posts and the continuity between the cusp and suture ring in the choice of the bioprosthetic valve for tricuspid position.

We report an extremely rare case of renal cell carcinoma (RCC) extending into the left atrium through the pulmonary vein next to lung metastasis. The patient was a 76-year-old man. Extirpation of the RCC in the right kidney was carried out. Metastasis to the lungs, mediastinal lymph nodes and the pubis were diagnosed and 4 years later, a myxoma-like tumor was formed in the left atrium by echocardiography. We extirpated of the tumor. During surgery, continuity with the metastatic lesion in the right lung, right inferior pulmonary vein and the left atrium was suggested. Histopathologic examination showed the same histopathology as seen in the RCC.

A 16-year-old boy had a motorcycle accident and was given a diagnosis of blunt aortic injury (BAI) by contrast computed tomography (CT), complicated by diffuse brain injury, lung contusions and blunt liver injury. Despite conservative treatment his anemia worsened and further CT images revealed mediastinal hematoma. It was difficult to perform cardiopulmonary bypass with systemic heparinization because of his multiple injuries and therefore decided to perform endovascular stentgrafting. Aortography revealed that the proximal stent-graft landing zone to be very small, and therefore it was necessary to the cover left common carotid artery. Before stentgrafting, we performed a right subclavian artery-left common carotid artery bypass to attain a sufficient proximal landing zone, and stentgrafting was successful. We concluded that endovascular stentgrafting is an effective initial treatment for BAI complicated with multiple injuries. However, endovascular stentgrafting for BAI has some limitations because of the morphologic and anatomical characteristics of the thoracic aorta in cases of BAI. It is therefore important to perform endovascular stentgrafting for BAI on a case-by-case basis.

A 71-year-old man with obstruction of the left anterior descending branch (#7) suffered an acute myocardial infarction. A ventricular septal perforation (VSP) and a widespread left ventricular aneurysm were detected in the anteroseptal region by both cardiac ultrasonography and cardiac catheterization. Surgery was performed at week 7 after onset. After establishing extracorporeal circulation, the left ventricular aneurysm was longitudinally excised from the left side of the left anterior descending branch while the patient was maintained in a state of cardiac arrest. A septal anterior ventricular exclusion (SAVE) operation was performed using oblong equine pericardial patches to exclude the left ventricular aneurysm and the VSP portion. The VSP was directly closed with sutures because the surrounding tissues were relatively strong at week 7 after the onset of the myocardial infarction and the portion was excluded with an equine pericardial patch. At the same time, CABG (LITA-LAD) was also performed. After surgery, left ventriculography found no residual shunts and we were able to obtain both a good morphology and satisfactory functioning of the left ventricle. The present method is thus considered to be an effective surgical method that excludes both the VSP portion and the infracted portion, while improving the morphology of the left ventricle for VSP with a left ventricular aneurysm.