A female in her 60 s with a mobile cardiac tumor in the left atrium was referred to our hospital. The tumor was diagnosed as myxoma by echocardiography, CT scan, and MRI. Under cardiac arrest using cardiopulmonary bypass, we resected the tumor through the superior trans-septal approach. We resected two tumors (tumor 1 and 2) with adequate rims of the interatrial septum to avoid recurrence. Although the tumor had a broad base and extended to near the mitral annulus, mitral valve repair was not necessary. Tumor 1 was gelatinous and seemed to be a myxoma ; tumor 2 had a lot of papillary structures attached to the solid mass and presented with the figure of a sea anemone when it was put in saline, which is typical for papillary fibroelastomas. The defect of the interatrial septum was closed with the autologous pericardium. The postoperative course was uneventful. Unexpectedly, both tumor 1 and 2 were diagnosed as myxomas on pathological examination. Tumor 2 (papillary lesion) included a few tumor cells with positive staining of calretinin typical for myxoma and was diagnosed as a “villous-type myxoma”. Because it is difficult to distinguish myxoma from papillary fibroelastoma by pre- and intraoperative findings, it would be recommended to resect tumors with an adequate margin to prevent recurrence.

Anomalous origin of the coronary artery from the pulmonary artery (ACAPA) is a rare congenital heart disease. A woman in her 60s was diagnosed as ARCAPA during examination for angina. A magnetic resonance image showed myocardial ischemia in a small area of the right coronary artery (RCA) and left anterior descending artery. Reimplantation of the RCA to the ascending aorta and patch plasty of the pulmonary artery were performed. Repositioning of the RCA orientation was necessary for relief of the kinking. The postoperative course was uneventful. She is now free from angina 15 months after surgery.

Background : Persistent endoleak is a major cause of aneurysmal enlargement or rupture after endovascular aneurysm repair (EVAR). Although several reports have described ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy as useful strategies, treatment for type II endoleak after EVAR is controversial. Objectives : We investigated the early results in 5 patients who underwent ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy for type II endoleak. Methods : A>10 mm increase in aneurysm diameter after primary EVAR or a maximum diameter>65 mm serve as indications for intervention for type II endoleak. Under general anesthesia, following transperitoneal exposure of the abdominal aorta, the infrarenal aorta was banded using a tape at the proximal landing zone. After the aorta was opened without clamping, the lumbar arteries were ligated, and a stent graft-conserving aneurysmorrhaphy was performed. Results : The mean interval from the primary EVAR was 47±17 months. The mean operation time was 215±76 min. Blood transfusion was necessary in 4 patients (estimated blood loss 1,260±710 ml). No in-hospital deaths were observed, and the mean postoperative hospital stay was 26±20 days. One patient developed aspiration pneumonia and 1 developed surgical site infection post-surgery. The diameter of the aneurysm changed from 68±8 to 47±5 mm during hospitalization and decreased further to 36±7 mm at the last follow-up. Conclusions : The early results of ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy were favorable. Although this strategy could be useful for aneurysmal dilatation secondary to persistent type II endoleak after EVAR, the indications for this approach should be determined following careful evaluation of the patient's status considering the invasiveness of the procedure.

Surgical cases for pulmonary artery aneurysm after palliative operation for congenital heart disease are rare. A man in his 40s underwent Waterston operation (side-side anastomosis of the ascending aorta and right pulmonary artery) for pulmonary atresia and ventricular septal defect at the age of one. Medical follow-up was continued at a local clinic without definitive repair. He had complained of exertional dyspnea and cough for one month. CT scan on admission showed a large right pulmonary artery aneurysm and atelectasis of the right lung. An urgent operation was planned for the huge pulmonary artery aneurysm. Under cardiac arrest, the proximal end-to-side anastomosis to the aorta was conducted using a Y-shaped vascular prosthesis at the previous Waterston anastomosis. The peripheral pulmonary arteries were reconstructed by inclusion technique. Percutaneous cardiopulmonary support was necessary for one day after operation due to unstable hemodynamics. He was extubated on postoperative day (POD) 4 and transferred to our general ward on POD 5. He was discharged home on POD 38. He is now free from heart failure symptoms and recurrence of aneurysm one year after surgery. Careful follow-up is necessary for the dilatation of the pulmonary artery and aortic root. A definitive operation—Rastelli and closure of the ventricular septal defect—may be considered in the future if the pulmonary artery resistance is suitable for the repair.

Introduction : Right atrial (RA) and right ventricular (RV) dilatation that are associated with severe tricuspid regurgitation, and severe high RV pressure that is associated with pulmonary atresia and intact ventricular septum cause left ventricular (LV) dysfunction and hypoplastic lung. We have applied a modified RV obliteration technique that excludes non-functional enlarged RV for these diseases. Objectives : To evaluate the efficacy of our procedure. Methods and Results : Five patients (six operations) underwent the procedure without complications. Cardiothoracic ratio significantly decreased from 71±10% to 61±5% (p=0.017), and fractional shortening ended to increase from 27±17% to 37±5% (p=0.071). All of them achieved Fontan completion finally. One patient who underwent this procedure as a neonate experienced RV re-dilation 19 months later. He additionally received the same procedure in a Fontan operation, and then RV reduced again and good LV function was maintained. Conclusion : The application of modified RV obliteration technique is effective for Fontan candidates with nonfunctional RV.

Congenital coronary artery-pulmonary artery fistula is rare and occurs concomitantly with various disease conditions, including myocardial ischemia symptoms and aneurisms. Such a fistula complicated by continuity to a systemic blood vessel is even rarer. The patient was a healthy 75-year-old man who had lost consciousness for several tens of seconds at home. An examination performed at a nearby neurosurgical clinic showed no abnormalities, and he was referred to our cardiovascular department for detailed examination for suspected cardiogenic syncope. Sick sinus syndrome was diagnosed based on Holter monitoring. Pulmonary artery-bilateral coronary artery fistula with coronary artery stenosis was diagnosed on coronary arteriography. It was difficult to determine whether coronary bypass surgery was indicated because of the presence of a fistula. Based on the overall evaluation of coronary fractional flow reserve, coronary artery ultrasound, and stress myocardial scintigraphy in addition to usual coronary arteriography, triple-vessel bypass surgery was indicated. Preoperative CT angiography showed a left common carotid artery/bronchial artery-pulmonary artery fistula, with a communication at a bilateral coronary artery-pulmonary artery fistula. Coronary artery bypass surgery was performed in addition to coronary artery-pulmonary artery fistula ligation, left common carotid artery-pulmonary artery fistula closure, bronchial artery-pulmonary artery fistula closure, and pacemaker implantation. Preoperative CT angiography and perioperative surface echocardiography were useful for locating fistula openings. The abnormal blood vessels that allowed blood flow from the left common carotid and bronchial arteries, and into the fistula vessel opening were ligated previously. When cardioplegic solution was injected, the fistula opening was directly pressed, which facilitated the solution to spread over the cardiac muscle, contributing to full cardiac arrest. Postoperative CT angiography showed disappearance of the pulmonary artery-bilateral coronary artery fistula and left common carotid artery/bronchial artery-pulmonary artery fistula. To our knowledge, there are no reports describing the surgical treatment of left common carotid artery/bronchial artery-pulmonary artery fistula and bilateral coronary artery-pulmonary artery fistula. Here we report this rare case with a review of the relevant literature.

A 52 year-old man was admitted to our institution with sudden onset of severe chest and back pain. The electrocardiogram showed ST segment depression in leads I, II, aVL, aVF, V3-6. Emergent coronary angiogram was performed, but the catheter did not reach to the coronary ostia, and it only performed false lumen aortogram. Computed tomography showed acute Stanford A aortic dissection. Ultrasound echocardiography also showed aortic regurgitation 3/4 degree. We decided to perform an emergency operation. During anesthesia induction, systemic blood pressure fell below 80 mmHg during systolic period, and pulmonary pressure raised to 60 mmHg. Transesophageal echography showed the movements of dissection flap intermittently obstructed the coronary blood flow and aortic valve annuls. Those flap movements, so called ‘flap suffocation’ was thought to be the cause of cardiac failure. Intra-operative findings of the ascending aorta showed an entry of dissection just above the left coronary ostia, and the entire detachment of intima to aortic wall. We performed ascending aorta replacement with aortic valve resuspension and fixation of coronary ostia. The postoperative course was uneventful, and he was discharged on the 25th postoperative day. For the precise treatment of acute Stanford A aortic dissection with such coronary ischemia, quick diagnosis and operative correction is essential.

Introduction : Although there are various diagnostic tools like computed tomography, magnetic resonance imaging, and positron emission tomography, it is sometimes difficult to precisely diagnose cardiac tumors. Early pathological diagnosis is crucial for possible chemotherapy and/or radiation therapy in cardiac malignant lymphoma. Objectives : To assess the diagnostic value of pericardial excisional biopsy and cytology of pericardial effusion for the pathological diagnosis of cardiac lymphoma. Methods : Five patients had a clinical diagnosis of cardiac tumor with no pathological diagnosis. The pericardial biopsy and pericardial effusion were obtained without sternotomy through the subxyphoid by a small incision under local anesthesia. Results : All procedures were completed without complications. In 3 cases, the cytology of pericardial effusion yielded a diagnosis of malignant lymphoma. One patient who had a negative cytology result in whom surgical resection was performed for definitive diagnosis and tumor volume reduction was found to have malignant lymphoma. The remaining patient underwent tumor biopsy via a cardiac catheter and benign lymphoma was diagnosed. There were no specific findings in the pericardial excisional biopsy in 3 cases. Conclusion : The analysis of cytology of pericardial effusion obtained through the subxyphoid may be useful for the diagnosis of cardiac malignant lymphoma. Pericardial excisional biopsy may not be necessary for the diagnosis of cardiac malignant lymphoma.

We report the surgical correction of an incomplete atrioventricular septal defect (AVSD) associated with pulmonary stenosis in a 72-year-old woman. She was given a diagnosis of atrial septal defect at the age of 19, but at that time surgery was not indicated. She had an uneventful pregnancy at age 28. She had received medical treatment for congestive heart failure since the age of 67. Four years later, she was admitted to another hospital due to edema of the leg and retention of massive ascites. After careful and precise evaluation, AVSD was diagnosed, associated with bilateral atrioventricular (AV) valve regurgitation, pulmonary stenosis, atrial fibrillation and significant stenosis of the left anterior descending (LAD) coronary artery. She was referred to our hospital for surgery, and intracardiac repair was determined to be necessary after clinical assessment. Prior to surgery, she underwent percutaneous coronary intervention with a bare-metal stent for an LAD lesion. Under antegrade cold blood cardioplegia and mild hypothermia, we performed closure of the ostium primum atrial septal defect using a heterologous pericardial patch with expanded polytetrafluoroethylene strip, and right side atrioventricular (AV) valvuloplasty and pulmonary valvotomy. The postoperative course was uneventful. The patient has been designated NYHA class I for 2 years since surgery, and has had mild regurgitation of both AV valves, but neither have affected her quality of life. Surgical correction should be considered in elderly patients with incomplete AVSD, even in those aged 70 and over.

Cardiac papillary fibroelastoma (CPFE) is a rare tumor, and is usually located in the atrioventricular or ventriculoarterial valves. It is occasionally identified by echocardiography or surgery. It can also be an unexpected finding at autopsy. As this tumor often occurs in left-sided cardiac chambers, early aggressive surgical resection is required in order to prevent severe systemic embolic complications. However, the operative indications of tumors on the right cardiac chamber are controversial. The patient was a 73 year-old man. He had had cerebral infarction at age 58. Before the currently reported operation, we found CPFE on the tricuspid valve but we could not find a patent foramen ovale (PFO) by the usual examinations. During surgery, we found a CPFE on the tricuspid valve that had a short stalk and PFO. We cut the short stalk of the CPFE easily, and closed the PFO directly. This patient did not need complicated valve repair. We speculated that this cerebral infarction was caused by a CPFE on the tricuspid valve and patent foramen ovale. Echocardiography is very useful in diagnosing CPFE. However, we should not neglect the possibility of PFO before surgery. The postoperative course was uneventful. We concluded that early surgical resection of CPFE, even in right-sided cardiac chambers, should be performed in order to prevent severe embolic complications, even without PFO diagnosis.