Primary cardiac malignant tumor is rare and is associated with very poor survival. We report a case of a 45-year-old female who presented with dyspnea and general edema due to severe congestive heart failure, in whom an echocardiographic exam showed a large mass in the left atrium, mitral valve regurgitation and tricuspid valve regurgitation and the tumor resection, mitral valve repair and tricuspid annuloplasty were performed under semi-emergency. The pathological diagnosis of the resected tumor was cardiac intimal sarcoma which recurred; the patient needed re-surgery after 1 year and 5 months, and chemotherapy by pazopanib was performed. She died due to widespread metastasis. A relatively long-term survival of two years and 1 month after the initial surgery was achieved.

Primary cardiac undifferentiated pleomorphic sarcoma is rare and is associated with very poor survival. We report a case of a 45-year-old female who presented with dyspnea on effort, in whom an echocardiographic exam showed a large mass in the left atrium and the tumor resection was performed. The pathological diagnosis of the resected tumor was undifferentiated pleomorphic sarcoma which subsequently recurred. The patient needed four re-surgeries, and chemotherapy with Pazopanib was performed. A long-term survival of 5 years after the initial surgery was achieved.

We report a case of an 85-year-old woman with severe aortic insufficiency caused by structural valve deterioration (SVD) of Medtronic Freestyle stentless aortic bioprosthesis (Freestyle valve) complicated by rheumatic multivalvular heart disease. The patient received an aortic valve replacement by using the modified sub-coronary method with a 21 mm Freestyle stentless porcine valve (Medtronic Inc., Minneapolis, MN, USA), for severe aortic valve stenosis at of the age of 71. The patient developed severe heart failure 14.5 years after the surgery. She was admitted for severe aortic insufficiency caused by a leaflet injury (tear) of the Freestyle valve. She also had had rheumatic mitral stenosis and secondary tricuspid insufficiency with severe pulmonary hypertension. Therefore, treating her heart failure was difficult, but surgery was performed. The leaflets of the stentless bioprosthesis were resected. The insertion of the needle suture into the annulus of the stentless valve was difficult because of calcification of the tissue. An aortic root enlargement procedure was performed using a bovine pericardial patch, enabling the insertion of the needle suture into the Dacron cloth at the bottom of the stentless valve, with 2-0 Ethibond threads and single sutures. We successfully performed an aortic valve re-replacement using an Open Pivot Mechanical Heart Valve (OPHV) 16 mm AP (Medtronic, Minneapolis, MN, USA), which was implanted by using the partial valve-in-valve technique. Simultaneously, mitral valve commissurotomy and tricuspid annuloplasty were performed. The patient had an uneventful postoperative recovery.

The onset mechanism of takotsubo cardiomyopathy is unkown. The reported cases of takotsubo cardiomyopathy that happened after cardiac surgical operation were very few. We describe one case of takotsubo cardiomyopathy with left ventricular outflow tract obstruction (LVOTO) that occurred after having undergone mitral valve replacement (MVR) for combined valvular disease. The patient was an 82-year-old woman who was hospitalized with congestive heart failure in our hospital. She had diagnosis of rheumatic valvular disease (i.e. severe mitral regurgitation and mild mitral stenosis, secondary tricuspid regurgitation), atrial fibrillation and pulmonary hypertension. She had a sigmoid septum pointed out by cardiac ultrasonography. Preoperative coronary angiography was normal. After general anesthesia induction, bradycardia and hypotension developed. Therefore epinephrine and norepinephrine were administered. The rheumatic mitral valve was replaced using a 27 mm-size mitral pericardial bioprosthesis, preserving the posterior mitral leaflet. DeVega tricuspid annuloplasty and maze surgery were also performed at the same time. We did not recognize wall motion abnormalities by the transesophageal echocardiographic examination during the operation. On postoperative day 1, she was extubated and became hypotensive immediately. Takotsubo cardiomyopathy was diagnosed from characteristic views (an apical ballooning and a preserved basal contraction of the left ventricle) by transthoracic echocardiography (TTE). This echocardiogram showed also LVOTO of pressure gradient 38 mmHg. Blood transfusion and discontinuation of epinephrine infusion improved LVOTO. TTE showed a gradual recovery of the left ventricle to normal systolic function, on postoperative day 34. The postoperative coronary angiogram was normal. We presumed that LVOTO was important in the onset and severity of takotsubo cardiomyopathy. In this report, we showed also the pathological significance of the sigmoid septum.

A 69-year-old woman suffered from postprandial abdominal pain and hematochezia. Colonoscopy suggested ischemic colitis, and intestinal angina was diagnosed by multirow-detector computed tomography (CT), which showed occlusion of the superior mesenteric artery (SMA). On enhanced CT, there was extensive calcification on the aortic wall and aortic expansion and several mural thrombi in the thoracoabdominal and abdominal aorta, as well as severe stenoses in the bilateral common iliac arteries. A bypass from the right renal artery, which was the only artery without significant stenosis of the major branches of the abdominal artery, to the SMA, was created using a saphenous vein graft. Postoperatively, the postprandial abdominal pain disappeared, and the patient was discharged after a good postoperative course.

A 65-year-old woman suffered from left-side paralysis and dysarthria after sudden chest pain, and we diagnosed cerebral infarction caused by type A acute aortic dissection in the Stanford classification. At that time, the aberrant right subclavian artery with Kommerell's diverticulum was found on enhanced computed tomography. The acute aortic dissection with closed false lumen was treated conservatively. Because the ulcer-like projection (ULP) expanded during the course, we performed surgery. Ascending aorta and arch replacement, patch closure of Kommerell's diverticulum and reconstruction of right subclavian artery were performed simultaneously. The postoperative course was good.

We present here a rare case of coronary artery bypass grafting through a left thoracotomy after substernal gastric interposition for esophageal cancer. A 58-year-old man, who had undergone esophagectomy and substernal gastric interposition 11 years previously, was admitted for cerebral infarction from which he made a good recovery without any complication. At this time, the patient was diagnosed as having coronary artery disease on electrocardiogram. Cardiac catheterization revealed triple vessel disease. Coronary artery bypass grafting to the left anterior descending artery and obtuse marginal branch through a left thoracotomy was performed using a radial artery Y-graft under femorofemoral bypass. The aorta was cross-clamped and the heart was arrested with antegrade cold cardioplegic solution for the distal anastomosis of the left anterior descending artery and the obtuse marginal branch which was embedded within the myocardium. The postoperative angiography showed good coronary flow. Left thoracotomy approach provides a good exposure of the left coronary artery. This approach, therefore, is advocated as an alternative method for cases requiring coronary artery bypass but in which median sternotomy is difficult, such as the present case. The appropriate procedure for the site of thoracotomy, supporting methods, choice of graft, and the site of graft anastomosis should be selected in each patient.

Between March 1976 and February 1996, 17 patients underwent surgical treatment for cardiac myxomas. There were 5 men and 12 women with a mean age of 55 years (range: 22 to 78 years). The location was the left atrium in 13, right atrium in 2, right ventricle in 1 and multiple locations in 1. Since 1978 the standard operative method to treat left atrial myxoma has been a biatrial approach with complete removal of cardiac myxoma and partial resection of the atrial septum. There were no perioperative deaths, but 1 patient had a permanent pace-maker implantation, 2 had transient atrial fibrillation during the early postoperative period, and 1 had acute pulmonary edema after resection of a right ventricular myxoma. There were two late deaths, not related to cardiac event and one recurrence with multiple myxomas. Overall with long term follow-up, the actual survival rate at 10 years was 75% (n=6), with a mean follow-up of 7.1 years, with a 100% follow-up ratio (17 patients). We conclude that the biatrial approach with complete removal of the left atrial myxomas and partial resection of the atrial septum is one of the best procedures for surgical treatment.

A 31-year-old woman complained of dizziness. Preoperative aortogram revealed a saccular type of aneurysm of the aortic arch and abnormal origin of the left subclavian artery. She underwent reconstruction of the aortic arch through 4th intercostal thoracotomy on August 10th, 1996. The aneurysm originated distally to the left common carotid artery and its wall was very thin. Aortic arch replacement with woven Dacron prosthesis was performed between the left common carotid artery and the left subclavian artery using the inclusion method under hypothermic circulatory arrest. The post operative course was uneventful. Cystic medial necrosis of the aneurysmal wall, and normal arterial findings of the left femoral artery were recognized by the pathohistological examinations. Kinking of the aorta is a congenital disease due to abnormal embryonal development. The aortic arch elongates between the left common carotid artery and the left subclavian artery, and arch aneurysm originates in this portion, because the aneurysmal wall is very thin and fragile when accompanied with cystic medial necrosis. Therefore, it is important that the left subclavian artery originating distally to the arch aneurysm in this category of the aortic arch aneurysm be recognized. There are 11 cases which were successfully operated for aortic arch aneurysm associated with congenital kinking of the aorta in Japan.

We report a case of a 16-year-old boy with Marfan's syndrome who underwent Bentall's procedure on a diagnosis of acute aortic dissection (DeBakey type II). He was readmitted with pyrexia 5 months after the initial operation. Methicillin-resistant Staphylococcus epidermidis (MRSE) was detected by blood culture and transesophageal echocardiography revealed a vegetation adherent to the entry of a remaining false lumen just distal to the distal anastomosis. Although antimicrobial therapy was employed, an arterial embolism developed in the right popliteal artery. CT scan revealed dilatation of the false lumen, and consequently, emergency surgery was performed. The intima of the distal aortic end was partially out of the suture line and the vegetation adhered at that point. Re-replacement of the ascending aorta, omental transposition, and embolectomy of the right femoral artery were performed and resulted in a satisfactory course.