Herein, we report a rare case of a pseudoaneurysm at the anastomotic site of the bicarotid trunk after thoracic aortic graft replacement. A 53-year-old man with Marfan syndrome underwent a three-stage operation involving aortic root reimplantation and ascending aortic replacement ; aortic valve replacement and total arch replacement ; and descending aortic replacement performed for type A dissection combined with an aberrant right subclavian artery. Two years after total arch replacement, the patient presented with hoarseness and a computed tomography scan revealed an anastomotic pseudoaneurysm of the common trunk of the left and right carotid arteries. A right axillary artery-common carotid artery bypass was performed, with simultaneous insertion of a vascular stent graft from the left common carotid artery to the anastomotic site. Cervical bypass and stent implantation were both performed without shunting. He was discharged home without any neurological complications.

Cardiac leiomyosarcoma and atrial intramural hematoma are extremely rare. Here, we present the case of a 52-year-old woman with dyspnea. Echocardiography showed a large mass in the left atrium. Tumor resection was performed. A pathological diagnosis of intramural hematoma was made. Ten months later, she presented to our hospital again with dyspnea. Echocardiography and computed tomography showed recurrence of the left atrial tumor. Another tumor resection operation was performed. The tumor originated from the inferior wall of the left atrium, and it was surrounded by atrial wall thickening. Complete resection was not possible. Although postoperative chemotherapy was prescribed, the patient died of heart failure nine months after the second operation.

We report 4 cases of aortic graft replacement for Kommerell diverticulum (KD) and the aberrant subclavian artery (ASA). In two patients who had a right-sided aortic arch, KD and the left ASA, we performed descending aorta replacement and in-situ reconstruction of the left ASA via a right lateral thoracotomy. Third patient had a left-sided aortic arch, KD and the right ASA, in whom we performed descending aorta graft replacement via a left lateral thoracotomy with ostial closure of the right ASA. Fourth patient had a left-sided aortic arch, KD and the right ASA, and complicated by acute type A aortic dissection. We performed a total arch repair with frozen elephant trunk procedure via a median sternotomy. All 4 patients survived operations and discharged from the hospital with symptom relief. The choice of approach, a thoracotomy or a median sternotomy, should be based on patient-specific anatomy and extent of graft replacement.

We present herein a case of disc fracture of a Björk-Shiley valve prosthesis in the mitral position. A 69-year-old woman was admitted to our hospital with a sudden onset of dyspnea followed by deep shock. An echocardiography showed a severe degree of mitral regurgitation and moderate degree of tricuspid regurgitation. Forty-three years previously she had undergone a mitral valve replacement (MVR) for stenosis with the original version of a Björk-Shiley valve prosthesis in another institute. Emergency redo MVR was performed with a bioprosthesis and tricuspid annuloplasty with a semirigid ring. The disc of the extracted Björk-Shiley valve was found to have escaped from the metal housing with two intact struts. Although Björk-Shiley valve dysfunction due to Delrin disk abration has been rarely reported, complete disk fracuture is extremely rare. The important role of regular echocardiographic follow-up should be emphasized to prevent fatal valve fracture.

A 69-year-old woman, who had undergone a right nephrectomy for renal tuberculosis in her teens, was admitted with a low grade fever, anorexia and progressive dyspnea. Transthoracic echocardiography showed cardiac tamponade and chest CT revealed an enlarged ascending aorta. She was treated with pericardiocentesis. Specimens of pericardial effusion failed to demonstrate any acid-fast bacilli, but they did reveal a high level of adnosine deaminase (72 IU/l). A diagnosis of tuberculous pericarditis was considered, and antituberculous chemotherapy was started. However, he presented with severe back pain 32 days later and CT revealed type A acute aortic dissection. We therefore replaced the ascending aorta and aortic root. A histopathological examination of the ascending aorta revealed evidence of a granulomatous inflammatory reaction with Langhans giant cells. She thereafter received antituberculous chemotherapy with 4 drugs for 2 months, with continued rifampicin and isoniazid treatment. There was no evidence of any graft infection after 70 days.

We report the case of a 55-year-old woman with aortitis syndrome. She was admitted to our hospital because of repeated chest pain and syncope. An electrocardiogram and the laboratory data suggested acute myocardial infarction, and coronary angiography showed severe bilateral coronary ostial stenosis. No valvular disease was observed. Aortitis syndrome was suspected because of the stenosis of the brachiocephalic artery in addition to the bilateral coronary ostial stenosis, while the patient did not have elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Coronary artery bypass grafting was performed, and the patient's postoperative course was uneventful. However, she again experienced chest pain 9 months after surgery due to aortic regurgitation (AR) and diffuse narrowing change of the left internal thoracic artery graft. Aortic valve replacement and Re-CABG was performed, and the patient was treated with steroid therapy postoperatively. The postoperative course was uneventful, but the patient thereafter died due to bleeding of a malignant adrenal tumor at 21 months after the second surgery.

A sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of it with an anomalous origin of the coronary artery are scarce. A 35-year-old male was admitted to our department with fatigue and cough. Multi-detector-row computer tomography (MDCT) revealed an isolated extracardiac right sinus of Valsalva aneurysm with an anomalous origin of the left circumflex artery (LCX) and total occlusion of the right coronary artery (RCA). Its diameter was about 70 mm. We performed a partial aortic root remodeling procedure with a trimmed J-graft because he had neither aortic regurgitation (AR) nor annuloaortic ectasia (AAE). Concomitantly, coronary artery bypass grafting to the RCA (Seg. 3) using a saphenous vein, and reconstruction of the LCX by Piehler's technique using a saphenous vein were added. The patient's postoperative course was uneventful, and he was discharged on the 28th postoperative day. Postoperative MDCT revealed that the aneurysm of the right sinus of Valsalva was not enhanced, and the RCA and LCX were patent. This procedure preserved the patient's own normal aortic valve and sinus of Valsalva and enables him to have more physiologically normal hemodynamics than aortic root reconstruction using a composite graft, e.g. Bentall procedure, Cabrol procedure, although the potential progression of the AR requires careful follow-up.

A 59-year-old woman with a history of pulmonary and cardiac sarcoidosis was admitted to our hospital because of acute femoral artery occlusive diseases. Preoperative echocardiography showed diffuse hypokinesis and biventricular tumors. Transesophageal echocardiography revaealed mobile biventricular tumors. The tumors which consisted of organized thrombi were successfully excised. She was discharged 23 days after surgery. This suggested that hypokinesis accompanying cardiac sarcoidosis caused the biventricular thrombi.

There is disagreement regarding the indications of surgery for cases of severe aortic stenosis (AS) with a decrease in left ventricular ejection fraction (EF) and a low aortic pressure gradient (PG), since there is a high perioperative risk associated with this condition. Hence, we investigated the surgical outcome of AS cases with impaired left ventricular function. Our department performed 144 aortic valve replacements (AVRs) for cases of AS and AS-dominant mild regurgitation (ASr) between January 2000 and September 2005. Among these cases, 9 patients had an EF under 35%, and these patients were selected as subjects and compared with a control group with an EF of more than 35%. Patients with accompanying coronary artery diseases that required treatment were excluded to avoid confounding effects on cardiac function. The mean age of the 9 subjects (4 men and 5 women) was 67.8±10.8 years old, with a range from 53 to 80 years old, and the subjects had the following mean background data: EF, 34.4±0.5%; left ventricular end-diastolic dimension (LVDd), 57.3±5.8mm; left ventricular end-systolic dimension (LVDs), 49.3±5.7mm; interventricular septum thickness (IVSth), 11.9±1.9mm; and left ventricular posterior wall thickness (LVPWth), 11.1±2.6mm. Characteristics such as left ventricular dilatation and thinning of the left ventricle myocardium were noted in these data. The cases were classified as severe AS because the mean aortic valve area (AVA) was 0.58±0.2cm², but the peak aortic pressure gradient (peak PG) (65.2±32.7mmHg) in the 9 subjects was lower than that of the control group (97.0±65.2mmHg). All 9 subjects underwent aortic valve replacements (AVRs), with simultaneous mitral annuloplasty (MAP) in 3 cases, mitral valve replacement (MVR) in 1 case and performance of a Maze procedure in 1 case. No deaths occurred while the patients were in hospital. Postoperative complications included 2 cases of transient atrial fibrillation and 1 case of postoperative bleeding requiring rethoracotomy for hemostasis. The EF in the late postoperative period showed improvement in 8 cases and was unchanged in the remaining case; the mean postoperative EF was 56.9% for the 9 subjects. All cases were rated as improved based on the NYHA classification of cardiac performance, and the significant improvement in EF in 8 of the 9 cases suggests that surgery is safe and can improve prognosis for patients with advanced AS with myocardium thinning and decreased EF.

A 37-year-old woman had a permanent transvenous cardiac pacemaker inserted previously in the left subclavian region to treat complete atrioventricular heart block. As infection occurred in the left subclavian subcutaneous pacemaker pocket after generator replacement, the generator was removed and a new permanent transvenous cardiac pacemaker was inserted in the right subclavian region. After two months, she developed fever and productive cough, and was admitted to our hospital. Echocardiography showed vegetation on the pacemaker electrodes and the tricuspid valve. Chest-computed tomography showed scattered bilateral peripheral nodules with various degrees of cavitation. We diagnosed right-sided infective endocarditis (IE) with septic pulmonary emboli (SPE) and performed cardiac surgery. We observed vegetation on the pacemaker electrodes and the tricuspid valve. The vegetation, the electrodes, and the generator were all removed and a permanent epicardial pacemaker was inserted subcutaneously in the left subcostal region. Methicillin sensitive Staphylococcus aureus (MSSA) was isolated from cultures of vegetation. Postoperative antibiotic therapy was performed and SPE was completely cured. We removed the pacemaker and the electrodes, and performed postoperative antibiotic therapy.