We report a successful case of aortic valve-sparing root replacement for dilated aortic root after a Ross procedure. A 29-year-old male underwent a Ross procedure when he was 11 years old for congenital aortic bicuspid valve. The right ventricular outflow tract was reconstructed using an autologous pericardium as a single leaflet valve. Aortic root dilatation and moderate aortic valve regurgitation were noted. Further investigation with enhanced computed tomography and ultrasonic cardiography revealed good quality of leaflets and sufficient geometric height, and aortic valve-sparing root replacement was performed. In addition, we performed pulmonary valve replacement with a biological valve. The post-operative course was uneventful and the patient was discharged after 8 days with a completely controlled aortic valve regurgitation. No recurrence of aortic valve regurgitation was observed 1 year later. Because surgical outcomes of congenital heart diseases have improved and more patients have an increasing life expectancy, several other problems were revealed, such as the occurrence of aortic root dilatation after a Ross procedure. Aortic roots may dilate due to arterial pressure; however, valve-sparing procedures may be performed if the volume of the leaflets is sufficient.

Cardiac metastasis from cervical cancer is rare. We herein present a case involving a 54-year-old woman with cervical cancer who was undergoing radiotherapy for left supraclavicular lymph node metastasis. The patient was admitted to the hospital because of shortness of breath. Transthoracic echocardiography showed a large mass in the right ventricle. To rescue the patient from circulatory collapse, we surgically resected the intracardiac mass via a right ventricular incision parallel to the posterior descending artery and left anterior descending artery. This approach prevented right ventricular outflow tract obstruction and perioperative pulmonary embolization, which could have led to death. The intracardiac mass was diagnosed as squamous cell carcinoma. After hospital discharge, the patient underwent chemotherapy. An echocardiography performed 3 months postoperatively showed recurrence of the cardiac metastasis, and the patient died 5 months later. Cardiac metastasis in the right ventricle can present as pulmonary embolization. Although rare, most cases of metastasis from cervical carcinoma to the heart have an extremely poor prognosis.

A 71-year-old woman was diagnosed with antiphospholipid antibody syndrome following an acute myocardial infarction and had been taking anticoagulants ever since. Three years later, she was hospitalized with high fever and substantial fatigue. She was diagnosed with infective endocarditis because the blood culture was positive, and scattered cerebral infarction was seen on magnetic resonance imaging, along with an iliopsoas muscle abscess and purulent discitis. She was treated with antibiotics, and her blood culture became negative; however, she was referred to our hospital for surgical treatment because of severe mitral regurgitation due to the progressive valve destruction. She also had aortic regurgitation and underwent mitral and aortic valve replacement. The mitral valve exhibited strong thickening of both leaflets, including the subvalvular tissue, and perforation was observed in the posterior leaflet, P2. The operation time was 4 h and 2 min, and the aortic clamp time was 92 min. The culture of the mitral valve leaflet was negative. She had antiphospholipid antibody syndrome and intraoperative activated clotting time (ACT) management was difficult; therefore, her heparin blood levels were measured and managed using HMS PLUS. The target heparin blood concentration during cardiopulmonary bypass was set at 3 mg/kg and controlled; no thrombotic tendency or increase in circuit pressure was observed during the operation, and the procedure was completed without any problem. She resumed heparin administration 6 h after the operation and continued oral anticoagulant therapy. She recovered without problems and was discharged 12 days after the operation. Management using HMS PLUS may be useful in patients with antiphospholipid syndrome undergoing cardiovascular surgery.

The patient was a 68-year-old woman. She was diagnosed with uterine cancer after experiencing irregular genital bleeding. Contrast-enhanced computed tomography showed a 30 mm left ventricular mass and splenic infarction, and head MRI showed multiple cerebral infarctions. The patient was suffering from systemic embolism caused by the cardiac mass, and we decided to perform cardiac mass removal prior to uterine cancer treatment. A yellowish-white thrombus-like mass attached to the mitral valve, subvalvular tissue, and left ventricular endocardium was removed by a trans-septal approach under cardiopulmonary bypass. Pathological examination revealed that the mass was a fibrin-based thrombus with almost no inflammatory findings, we diagnosised non-bacterial thrombotic endocarditis (NBTE). Postoperatively, the patient developed Takotsubo cardiomyopathy, and treatment for uterine cancer, was delayed. Hypercoagulability was not controlled well, and she developed recurrence of left ventricle vegitation, acute arterial occlusion of the lower extremities and inferior vena cava thrombosis, making active intervention for uterine cancer difficult. The patient was treated palliatively and died on POD 36. NBTE tends to be characterized by multiple small growths, but giant vegetation may also occur as in this case. Unless the primary disease causing the hypercoagulability is treated, recurrence of NBTE is possible, and prompt treatment of the primary disease is required.

We herein report a case of cardiac tumor resection through a right mini-thoracotomy. A 48-year-old man exhibited no symptoms. A mass was detected incidentally in the right atrium on computed tomography. We performed resection under cardiopulmonary bypass through a right mini-thoracotomy. Histopathological examination confirmed that this tumor was a lipoma. The patient's postoperative recovery was uneventful. He was discharged on postoperative day 6. As cardiac tumor resection through right mini-thoracotomy is minimally invasive, this approach may be useful for surgery in cases of benign cardiac tumors.

After a MitraClip was implanted for mitral regurgitation (MR), we experienced a case in which mitral valve replacement was performed for recurrent severe MR because of a detached MitraClip. The case was an 82-year-old woman. The MitraClip was implanted for severe MR and regurgitation was controlled to a mild level, but one month after the operation, symptoms of heart failure appeared, and single leaflet device attachment (SLDA) with severe MR was observed on the echocardiogram. As the heart failure symptoms recurred, surgical mitral valve replacement was performed. Because of severe kyphosis, the left atrial approach with a midline sternum incision made it difficult to achieve a good operative field and this was changed intraoperatively to a transseptal approach. The MitraClip was firmly fused with the anterior leaflet A2, so it was judged that removal of the clip was difficult and valve repair was impossible ; it was thus decided to replace the valve. The mark of the MitraClip could be observed on the posterior leaflet, and it appeared to have been inserted for only about 1-2 mm. A bioprosthetic valve was implanted, preserving the posterior leaflet. There were no problems in weaning the patient from cardiopulmonary bypass. The postoperative course was uneventful, and she was discharged on the 14th day after the operation. Valve repair is difficult in a case with a merged SLDA after insertion of a MitraClip, and valve replacement needs to be performed, so it is important to pay attention to the attachment of the MitraClip.

We report a case of mycotic aneurysm treated with endovascular aneurysm repair (EVAR). An 80-year-old man was admitted to a local hospital with high fever and lower back pain. Pyogenic spondylitis and psoas muscle abscess were diagnosed. Klebsiella pneumoniae was confirmed by blood culture. Treatment with intravenous antibiotics was not effective and contrast computed tomography (CT) scan showed an enlargement of the abscess and an abdominal aortic rupture. The patient was immediately transferred to our hospital. Laboratory tests showed an elevated C-reactive protein (12.3 mg/dl) and WBC (10,400/μl). Mycotic abdominal aneurysm rupture was diagnosed by CT scan. He underwent an emergency EVAR with an Excluder® (aorta extender). Intraoperative angiography showed a ruptured abdominal aorta. After operation, he was treated with intravenous minocycline and ampicillin, and the size of the abscess reduced without any endoleak on enhanced CT imaging. After intravenous antibiotics therapy for 4 weeks, we switched to oral antibiotics (minocycline and ciprofloxacin) and continued them for 6 months. As of 2 years after the surgery, there are no signs of infection or recurrence.

A 66-year-old man was referred to our hospital for the treatment of a right subclavian artery aneurysm. Computed tomography showed a 35-mm aneurysm in the right subclavian artery, and occlusion of the right internal carotid artery. A surgical approach with maintenance of intracranial blood flow was required. During anastomosis of the graft to the native vessel, we clamped the distal and proximal portions of the right subclavian artery, to maintain the blood flow of the right common carotid artery. The INVOS® cerebral oximeter (Somanetics Corp., Troy, MI, USA) was useful in determining the clamping site and surgical strategy. The procedure was completed without complications, and the patient was discharged from the hospital on postoperative day 8 following a good clinical course.

A 71-year-old man with Behçet's disease was admitted to our hospital for treatment of a thoracic aortic aneurysm. On admission, there was marked inflammatory response, but blood culture was negative and there was no significant accumulation of gallium scintigraphy. The aorta was shaggy and there were two aneurysms in the descending aorta. We performed endovascular aortic repair for this aneurysm in consideration of the inflammatory aortic aneurysm. After treatment, the patient had paraparesis, however he underwent physical rehabilitation to regain function. He was followed up for 1 year and remains in good clinical condition without anastomotic aneurysm, dilatation or aneurysm at another site.

We encountered left main coronary artery hypoplasia in a 14-year-old boy. He had a history of syncope after exercise. Computed tomography revealed hypoplasia of the left main coronary artery and the syncope on exertion was diagnosed as due to myocardial ischemia. We performed off-pump coronary artery bypass (OPCAB) graft using the left internal thoracic artery. The postoperative course was uneventful and chest symptoms were not recognized in daily life. Left main coronary artery hypoplasia is rare, but is associated with adverse cardiac events, including sudden cardiac death. In cases like this, coronary artery bypass graft is indicated.