Papillary fibroelastoma (PFE) is a rare primary cardiac tumor that usually involves an aortic or mitral heart valve. We encountered a case of a 32-year-old woman, who presented with syncope and was found to have multiple PFEs involving all four heart valves during surgery. The echocardiography was performed and showed two mobile masses near the tricuspid and mitral valves. Moreover, the enhanced computed tomography (CT) showed thickened aortic cusps, which may indicate the possibility of heart tumor. Intraoperatively, we first found multiple tumors at each cusp of the aortic valve, ranging in size from 5 to 10 mm which were excised without injury of aortic cusps themselves. These showed a sea anemone-like appearance and were suspected to represent PFE. We then observed the tricuspid and mitral valves, and both valves showed tumors of similar appearance in each cusp. Furthermore, we found a tumor at the pulmonary valve, even though there had been no evidence of its presence on echocardiography or CT. We confirmed that these masses were PFEs by histological study after the operation. We should keep in mind that PFE can develop in multiple valves. To the best of our knowledge, this is the first description of multiple PFEs involving all four heart valves.

We report a case of reoperation for proximal pseudoaneurysmal formation of the ascending aorta and distal enlargement of the dissecting arch and descending aorta after ascending aorta replacement for acute type A aortic dissection. The patient was a 47-year-old man who had undergone ascending aorta replacement and aortic valve replacement for acute type A aortic dissection three months previously. Pseudoaneurysm of the ascending aorta and enlargement of the dissecting arch and descending aorta were revealed by computed tomography. Therefore, we performed extensive replacement of the aortic root, arch and descending aorta. Median re-sternotomy with left anterolateral thoracotomy the (“Door open method”) was applied as the surgical approach. After reconstructing the aortic root using the modified Bentall procedure, we replaced the arch and descending aorta using antegrade continuous coronary perfusion with systemic blood through the composite graft of the aortic root under non-cardioplegic arrest. Despite the long duration of extracorporeal circulation, the duration of cardioplegic arrest was relatively short, and the postoperative cardiac function was not deteriorated at all. The patient is currently doing well with no problems at 1.5 years after the surgery. The Door open method was a useful approach providing good operative exposure in this case requiring extensive replacement of the thoracic aorta. Antegrade continuous blood coronary perfusion was useful for performing the arch and descending aortic replacement under non-cardioplegic arrest, and it was a reliable strategy for ensuring myocardial protection and avoiding prolonged duration of cardiac ischemia.

An echocardiogram revealed a mobile mass attached to the left coronary cusp of the aortic valve in an 81-year-old woman. The tumor was surgically removed without valve replacement. The tumor was whitish in color, with a sea anemone-like appearance, and it measured 10 mm in maximum dimension. It was histopathologically defined as papillary fibroelastoma (PFE), and the postoperative course was uneventful. Primary cardiac tumors are rare, and the majority are myxomas. However recent advances in noninvasive examination and surgery may increase the detection of PFE, which occurs most frequently on the endocardial surface of the cardiac valve. We report a case of cardiac PFE with a review of the pertinent literature.

We describe two repeated operations to treat ascending aortic pseudoaneurysms. The first was emergency patch closure of the ascending aorta due to impending rupture 8 years after an operation for type I aortic dissection under hypothermic circulatory arrest. The second was endovascular repair using a fenestrated stent graft 7 years after coronary artery bypass grafting. No specific guidelines have been established regarding optimal management for such patients. We believe that individualized management is safer, especially for repeated operations.

Use of the internal thoracic artery for myocardial revascularization has regained general acceptance because it offers better long-term results than do venous conduits. However, according to angiographic studies, it has been reported that atherosclerotic changes in the internal thoracic artery occurred in 1-5% of patients with coronary artery disease, although, generally, it is considered that atherosclerotic changes in internal thoracic artery are rare. From January 1998 to August 2001, of the 274 patients who underwent coronary artery bypass grafting, it was estimated that the left internal thoracic artery could not be used for coronary revascularization by preoperative angiography in 7 patients (7/262=2.7%). Two hundred sixty-two patients underwent preoperative angiography to evaluate the grafts for coronary revascularization. All were men and age at the time of operation ranged from 62 to 81 years (mean, 68.6 years). The reason for the left internal thoracic artery being useless were occlusion or stenosis of the subclavian artery in 4 and stenosis or occlusion of the left internal thoracic artery in 3. One patient needed an emergency operation. Four patients had a history of myocardial infarction, 3 patients had hypertension, 2 patients had diabetes mellitus, 4 patients had hyperlipidemia, 1 patient had aortitis and 3 patients had a history of percutaneous transluminal coronary angioplasty. There were 4 patients with peripheral vascular disease. Four right internal thoracic arteries, 9 radial arteries and 6 gastroepiploic arteries were used for coronary revascularization. A composite Y graft (right internal thoracic artery-radial artery) was used in 3 patients, and sequential bypass was performed in the other 3 patients. The total number of distal anastomoses was 2.7±1.0/patient. The angiographic patency of the distal anastmoses was 94.7% (18/19). One patient required intra-aortic balloon pumping postoperatively for perioperative myocardial infarction (Max CK-MB 200IU/l). All other patients had an uneventful postoperative course. In conclusion, although the internal thoracic artery is a protective vessel, there is a certain extent of atherosclerosis, which correlates with known risk factors. Our observations should not preclude use of the internal thoracic artery, but they should be considered for patients who are at risk for atherosclerotic changes of the internal thoracic artery. We considered that it is important to evaluate condition of in situ arterial grafts for patients with coronary artery disease preoperatively. Although further studies are required, in situ arterial grafting with sequential arterial conduit and composite arterial graft were associated with excellent results and achieved complete revascularization.

Patients with myelodysplastic syndrome (MDS) most commonly have refractory anemia accompanied by various degrees of granulocytopenia and thrombocytopenia. At the time of cardiac surgery, both major infections and bleeding are severe complications in patients with pancytopenia due to MDS. However, there were very few patients with MDS who had undergone open-heart surgery. We reported a case of mitral valve replacement in a patient with MDS. A 68-year-old man with valvular heart disease and MDS, with a platelet count of 1.9×10⁴/mm³, underwent successful mitral valve replacement. The mitral valve was replaced by an SJM 25 A prosthesis after resection of left atrial thrombosis using cardiopulmonary bypass. Platelets were transfused after the bypass. Perioperative hemorrhage was moderate and postoperative course was uneventful. We evaluated platelet function by Sonoclot coagulation and a platelet function analyzer. We did not need a large amount of transfusion of red blood cells and platelets, and prevented major bleeding and severe wound infections in the acute postoperative state.

We present a rare case of tuberculous thoracic aneurysm which ruptured into the lung. A 66-year-old woman who has been treated for lung tuberculosis and spondylocace was referred to our hospital for treatment of a descending thoracic aneurym confirmed by enhanced CT scan. On the 6th hospital day, she had massive hemoptysis and her systolic pressure dropped to 70mmHg. Emergency operation was performed under an F-F bypass. The saccular aneurysm was excised and surrounding infected tissue was debrided. UBE graft was inserted in situ and totally covered with omentum. The pathological diagnosis of the specimen was tuberculous aortic aneurysm. The postoperative course was uneventful. Good reconstruction and omental vessels around the replaced graft were revealed by postoperative angiogram. Two years later she is well. The omental covering of the replaced graft was a useful method for preventing graft infection.

Primary abdominal aortic dissection occurs infrequently. We experienced aortic dissection originating at the level of the right renal artery, for which graft replacement and reconstruction of the aorta and also the celiac, superior mesenteric and both renal arteries were performed. A 44-year-old woman with severe back pain was admitted to our hospital. CT and aortogram revealed primary abdominal aortic dissection. The abdominal aorta was replaced with a trunk prosthetic graft, to which were connected smaller grafts for the four abdominal visceral and also lumbar arteries. The intercostal artery was preserved by a diagonal trasection at the upper end of the graft site. To prevent ischemia of the visceral organs, we used a selective perfusion technique to the superior mesenteric artery and both renal arteries. The postoperative course was uneventful. The postoperative aortogram demonstrated good patency and function of the trunk graft and reconstructed visceral arteries

A 47-year-old woman complained of dyspnea on exertion. Ultrasonic cardiography revealed coronary sinus type atrial septal defect. At operation, the drainage veins to the left atrium from the coronary arteries were observed but no anomalies of the vena cave or any other veins were observed. The defect was closed with a pericardial patch under cardiopulmonary bypass. The post-operative course was uneventful. Coronary arteriography performed on the 14th post operative day confirmed that the coronary veins drained individually into the corresponding atria. Unroofed coronary sinus is rare and difficult to diagnose prior to operation. Ultrasonic cardiography and coronary arteriography are considered useful for preoperative diagnosis.

A case of ruptured dissecting aortic aneurysm (DeBakey IIIa) involving a right-sided aortic arch is reported. A 54-year-old man was admitted to our hospital with a complaint of severe back pain. Roentgenogram and enhanced computed tomography of the chest revealed a right-sided aortic arch, right descending thoracic aorta and right pleural effusion. Thoracocentesis of the right thoracic cavity revealed bloody fluid. The ruptured dissecting aortic aneurysm was suspected. The enhanced CT of the chest revealed leakage of the contrast medium at the level of the bifurcation of the trachea so aortography wasn't performed. There was a 2cm intimal tear in the descending aorta. Resection and grafting of the aneurysm via right thoracotomy was performed. The patient made an uneventful recovery and was discharged 4 weeks later. It is pointed out that the operative method and/or decision of the method of approach for the aneurysm involving a right arch are difficult because of the aberrant left subclavian artery and/or tortuous descending thoracic aorta. Impeccable judgement is needed for emergency operation of ruptured dissecting aneurysms like the present case.