We experienced 2 rare cases of acute myocardial infarction (AMI) complicated by ventricular septal perforation (VSP) and right ventricular free wall rupture. Case 1 was a 70-year-old woman who developed VSP and cardiac rupture after percutaneous coronary artery thrombolytic therapy for AMI (total occlusion of left anterior descending branch (LAD) # 6) and died of cardiac tamponade. Postmortem examination showed right ventricular free wall rupture. Case 2 was a 76-year-old woman. She developed VSP 6 days after percutaneous coronary artery intervention (stenting) for AMI (total occlusion of LAD # 8). VSP was closed by the double patch repair technique. During operation, right ventricular free wall rupture (oozing type) was found, so hemostasis with fibrinogen was added. She was discharged in a satisfactory condition 4 weeks after surgery. Right ventricular rupture after AMI of the LAD region is rare. VSP may be associated with right ventricular free wall rupture complicated by AMI of LAD region because all of our cases were accompanied by VSP.

The cause of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is not clear yet. Speculating that the extension of pulmonary vein (PV) would induce AF after CABG, we analyzed 39 cases in which a Swan-Ganz catheter was inserted at the onset of AF. The cardiac index (CI), systolic pulmonary artery pressure (sPA), diastolic pulmonary artery pressure (dPA) were measured continuously after operation. The “occupation index” was defined as “(value just before the AF onset-minimum value)/(maximum value-minimum value) × 100%.” The mean values of the occupation index for CI, sPA and dPA were 16±30%, 77±36%, 76±38% (mean±SD) respectively. Furthermore, cases in which CI just before the AF onset showed a minimum value in all the collected data consisted of 27 of the 39 cases (69%), and sPA/dPA just before the AF onset showed a maximum value in all the collected data in 26/25 of the 39 cases (67%, 64%). About two-thirds of AF cases occurred in the descending phase of CI, and in the ascending phase of sPA/dPA. We considered these conditions to be equivalent to the extension condition of PV and surmised that PV extension might be one of the causes of AF after CABG.

We encountered a case of cerebral oncotic aneurysms and intracerebral hemorrhage after resection of a left atrial myxoma. A 67-year-old woman underwent resection of the left atrial myxoma. She was followed by ultrasound cardiography on an ambulatory basis. About one and a half years later, she was hospitalized because of neural symptoms. Multiple cerebral aneurysms and intracerebral hematoma were found, and the hematoma was removed. With the neural symptoms recurring repeatedly thereafter, however, she eventually died due to pneumonia. The pathological examination of the intracerebral hematoma removed at operation and cerebral aneurysms at autopsy revealed myxoma cells causing embolisms in the artery and invading the atrial wall with some hemorrhage. It is known that cardiac myxoma occasionally causes a cerebral lesion. The lesion is presumed to be caused by embolism as in our case. So it is nessesary to evaluate morphologic characteristics of cardiac myxoma before operation and to pay attention to the occurrence of embolism during operation. Making a rigorous follow-up of the general progress by computed tomography after operation is also considered important.

For aortic root replacement in annuloaortic ectasia (AAE), an artificial prosthesis is commonly sutured to the aortic annulus (hemodynamic ventriculoaortic junction). We consecutively had 6 cases of aortic root replacement using anatomic ventriculoaortic junction suture. This anatomic ventriculoaortic junction suture is a simplified and practical method for aortic root replacement in the same way as using stentless bioprostheses or homografts.

Methylprednisolone (MP) has anti-inflammatory properties. We evaluated the influence of MP on systemic inflammatory response syndrome (SIRS) in a conventional coronary artery bypass grafting (CABG) operation. We compared three groups: (1) the HD-MP group (high-dose MP group): injecting 30mg/kg MP before extracorporeal circulation, (2) the LD-MP group (low-dose MP group): injecting 5mg/kg MP, (3) the N-MP group (non-MP group): no MP injected. Postoperative SIRS duration was shorter in the HD-MP and LD-MP groups than in the N-MP group, although low-dose MP had a shortening effect on the duration of SIRS. Interleukin 6 (IL-6) and interleukin 8 (IL-8) showed lower values in the HD-MP and LD-MP groups than in the N-MP group, although low-dose MP had an inhibitory effect on the production of interleukin. However, there were no differences between the three groups in the organ protective action of MP, such as total dose of catecholamine (as an index of cardiac dysfunction), intubation period (pulmonary dysfunction), GPT/D-Bil abnormality (liver dysfunction), or BUN/Cr abnormality (renal dysfunction). The maximum value of the postoperative white blood cell count showed a higher value in the HD-MP group than in the N-MP group. In conclusion, the usage of low dose (5mg/kg) MP in a conventional CABG operation is able to shorten SIRS duration and inhibit the production of IL-6 and IL-8 without increasing the risk of infection.

For aortic root replacement in annuloaortic ectasia (AAE), an artificial prosthesis is commonly sutured to the aortic annuls (hemodynamic ventriculoaortic junction). In this case report, suturing was conducted using the anatomic ventriculoaortic junction along with full-thickness-suturing. The first case was a 28-year-old man and the second, his 31-year-old brother. The former showed AAE (maximum diameter, 120mm) with 4°AR and the latter, AAE (maximum diameter, 54mm) without AR. The present method is simple due to the flat suture line and is quite reliable owing to full-thickness-suturing.

Clinical cases of normothermic extracorporeal circulation (ECC) are increasing, but the possibility of brain damage is not clear.In emergencies, the brain protective effects of mild (33-34°C) hypothermic therapy have been clearly confirmed. Natural Temperature decrease ECC was conducted in this study, hoping to obtain the advantages of both normothermic ECC and brain protection by mild hypothermia. These were 12 cases at high risk of brain damage (10 cases of brain infarction and 2 cases of severe carotid artery stenosis). In all cases, coronary artery bypass grafting operation with natural temperature decrease ECC was performed. The average laryngeal temperature dropped to 33.0±0.3°C. There was no brain infarction or ICU syndrome. Evaluation of post-operative brain condition by the patients themselves and their families was good. The possibility of natural temperature decrease ECC for high risk cases of brain damage was demonstrated.

A 62-year-old man was diagnosed as having atrial septal defect (ASD) and atrial fibrillation (Af) upon admission to our hospital with acute myocardial infarction. He was placed on medication for 3 years but surgery was considered necessary because of the further complication of angina pectoris. Coronary arterial bypass grafting, ASD closure and right atrial separation procedure which was a modification of the right-sided maze operation, were performed simultaneously. Although chronic Af disappeared immediately after surgery, it reappeared on the 8th postoperative day, and medicinal and electrical defibrillation had no effect. We considered that the main cause of Af accompanied by ASD had existed in the right atrium before surgery. Also, as the right atrial separation procedure was less invasive than the Cox/maze procedure for such complications in patients with ischemic heart disease, we chose this method. In our patient, postoperative left ventricular loading was considered to have been the cause of Af recurrence. Therefore the indications for this procedure should be decided carefully in patients with preoperative left ventricular hypofunction or left atrial dilatation.

The patient was a 71-year-old man with intermittent claudication. Angiography indicated severe stenosis of the right common iliac artery. The right femoral artery was anastomosed to an artificial graft by conventional hand-sewn suturing and the left femoral artery by the Vascular Closure Staples (VCS). Postoperatively, the patient had an uneventful recovery and was discharged. This new procedure minimizes trauma to the vascular intima since the arcuate legged clip is non-penetrating. Suturing with VCS is more extensive than by the conventional method. VCS has been applied by the authors to treat arteriosclerosis obliterans lesions.

A 65-year-old woman presented with coughing and dyspnea. Giant left atrial myxoma was found by echocardiography. The tumor size was 7×5×4cm and its weight was 70g. The biatrial approach was chosen over left atriotomy or the transseptal approach. However, it may not be possible to decide on the correct incision line in cases of giant tumor. Intraoperative trans-esophageal echocardiogaphy was useful for evaluation of the mitral valve.