A Case of Primary Myxofibrosarcoma of the Heart Recurring 7 Months after the First Cardiac Operation / 日本心臓血管外科学会雑誌

Primary cardiac myxofibrosarcoma is an extremely rare malignant tumor of the heart, which can be difficult to diagnose. We report such a case, which recurred 7 months after the initial heart surgery. A 63-year-old woman with progressive dyspnea was seen by a physician. A transthoracic echocardiography revealed a large mobile mass in the left atrium, causing severe mitral stenosis. The patient was referred to our hospital for an operation. The tumor, which arose from the anterior mitral annulus, was resected, and mitral and tricuspid annuloplasty were performed. The histopathological diagnosis was myxoma. The postoperative course was uneventful. Seven months later, the patient reported suffering from dyspnea and leg edema. The echocardiography showed multiple recurrences of tumor in the left atrium. A second operation was performed to reduce the mass volume as a palliative treatment because some large fragile tumors occupied the left atrium. The patient died 5 months after the second operation due to metastasis. The final diagnosis by histopathology was myxofibrosarcoma.

Emergency Reoperation for Vein Graft Rupture Caused by PCI Failure / 日本心臓血管外科学会雑誌

A 68-year-old woman on chronic hemodialysis was admitted to our hospital for further evaluation because of recurrent angina 14 months after coronary bypass surgery (left internal thoracic artery-left anterior descending artery (LITA-LAD), gastro-epiploic artery-4 posterior descending artery (GEA-4PD), saphenous vein graft-#9-#14 sequential (SVG-#9-#14 sequential)). On coronary angiography, a localized 90% stenosis of the vein graft was present at the anastomosis with the diagonal branch of the native coronary artery. Although the lesion was relieved with a 5mm balloon catheter inflated to 14 atmospheres, contrast injection demonstrated extravasation of dye into the pericardial space, indicating vein graft rupture. Repositioning the inflated balloon across the rupture site for hemostasis was unsuccessful, and the patient was transferred to the operating room. Emergency reoperation was accomplished through a left lateral thoracotomy without cardiopulmonary bypass. Although hemorrhage was not noted at the rupture site, the vein graft was ligated at the proximal and distal portions of the rupture, followed by a new vein graft bypass. Postoperative cardiac catheterization clearly demonstrated the patent graft. Although localized hypokinesis was observed in the lateral wall on postoperative echocardiography, the left ventricular ejection fraction was 67%, her activity level was good, and she had no angina.

Aortic Valve Replacement Following Infectious Endocarditis Requiring Re-Operation Three Times / 日本心臓血管外科学会雑誌

A 47-year-old man with active aortic valve endocarditis underwent direct closure of a paraannular abscess and valve replacement. Methicillin-resistant <i>Staphylococcus aureus</i> was isolated from his blood culture preoperatively. Because of a postoperative paravalvular leak (PVL) and an echo-free space suggesting a residual cavity, he was reoperated for patch closure of the aneurysm and prosthetic valve replacement. However, the PVL and paraannular cavity were still observed after the 2nd surgery. At the 3rd operation, prosthetic valve detachment along one fourth of its circumference was confirmed, and the cavity was fully opened. A patch was used to cover the pseudoaneurysm and was placed under the orifice of the left coronary artery. This patch repair of the cavity was accomplished, followed by prosthetic valve replacement <i>in situ</i>. Trivial PVL was identified after the operation, and a diagnosis of intravascular mechanical hemolysis was made. Clinical examination revealed partial detachment of the prosthetic valve resulting in a significant PVL and paraannular pseudoaneurysm. Because of unremitting hemolysis and the increased PVL, the patient underwent a 4th repair. Inspection showed that the prosthetic valve was partially detached and the defect was opened at the upper edge. The orifice of the aneurysmal was covered, and valve replacement was performed in the supraannular position using 3 U-stays, which were passed through both the aortic wall and the patch, followed by ascending aortic graft replacement. In the case of aortic valve endocarditis with paraannular involvement, radical debridement and complete reconstruction of the left ventriculoaortic discontinuity without tension are required.

Surgical Treatment for Congenital Venous Malformations in the Lower Limb / 日本心臓血管外科学会雑誌

Four patients, 13 to 53 years old, with congenital venous malformation including Klippel-Trenaunay syndrome underwent surgical treatment followed by sclerotherapy. They developed marked dilatation of varicose veins with spots, and complained of pain, dullness, and bleeding. Two patients also had hypertrophy of the diseased leg. Phlebography and color Doppler ultrasonography were performed in all patients to precisely determine the abnormal vein and incompetent communicating veins which were then resected and/or ligated with minimal skin incision. In two patients, additional ligation of incompetent communicating veins was necessary. One to two weeks after surgical therapy, sclerotherapy was performed with 1-2% polidocanol. Symptoms improved after treatment, even in a patient with claudication before operation. Surgical therapy for congenital venous malformation was feasible and satisfactory, with the aid of meticulous identification of abnormal veins and communicating veins by not only phlebography but color Doppler ultrasonography.