A Case of Quadricuspid Aortic Valve with Multiple Fenestrations / 日本心臓血管外科学会雑誌

A 73-year-old man diagnosed with severe aortic regurgitation by transthoracic echocardiography was referred to our hospital. Quadricuspid aortic valve was diagnosed on preoperative transesophageal echocardiography. We performed aortic valve replacement with a bioprosthetic valve. In the operation, the accessory cusp was found to be located between the right coronary and noncoronary cusps, and the cusps had multiple fenestrations near the commissures.

A Case of Spontaneous Ascending Aortic Rupture Which Was Difficult to Distinguish from Stanford Type A Acute Aortic Dissection / 日本心臓血管外科学会雑誌

A 77-year-old man was admitted to our hospital with sudden anterior chest pain followed by shock. An echocardiography showed enlargement of the sinus of Valsalva, severe aortic regurgitation and pericardial effusion. A chest CT scan showed a crescent sign in the ascending aorta. The preoperative diagnosis was a ruptured Stanford type A acute aortic dissection and an emergency operation was performed. In the operative findings, a bloody pericardial effusion, a hematoma around the ascending aorta and a tear (less than 2 cm) of the ascending aorta just distal area of the sinotubular junction were observed. In this case, since the enlargement of the sinus of Valsalva and the severe aortic regurgitation were observed, we performed a replacement of the ascending aorta including the aortic root with an artificial vascular graft (J graft 28 mm) and a biological valve (Magna EASE 25 mm). The pathologic examinations revealed a rupture of ascending aorta in all layers and a hematoma outside the adventitia. The pathologic diagnosis showed a spontaneous aortic rupture. The postoperative course was good and he was discharged 1 month after the surgery. A spontaneous aortic rupture is defined as an aortic rupture without a trauma, an aneurysm or a dissection. It is rare but fatal and it is said that surgical treatment is necessary. We report a successful surgical case of the spontaneous aortic rupture which was difficult to distinguish from a Stanford A type acute aortic dissection.

Mitral Valve Repair via a Right Mini Thoracotomy in a Patient with Aplastic Anemia / 日本心臓血管外科学会雑誌

Aplastic anemia is a syndrome characterized by pancytopenia, and performing an open heart operation for patients with this syndrome may be associated with an increased surgical risk for both bleeding and post-surgical infection. We report a case of mitral regurgitation complicated with aplastic anemia that underwent a mitral valve repair via a right lateral minithoracotomy. The patient was a 70-year-old woman who presented with shortness of breath on exertion. She was found to have aplastic anemia based on pancytopenia (WBC 2,150/µl, Hgb 8.8 g/dl, PLT 5.0×10⁴/µl) and the results of a bone marrow biopsy. Echocardiography showed severe mitral valve insufficiency at the same time, and the patient was referred for surgery. To deal with the decrease in white blood cells and platelets, prior to surgery, a granulocyte colony-stimulating factor was administered, 30 units of platelet concentrate were transfused during the operation, and mitral valve repair via a right lateral minithoracotomy was performed. After surgery, there were no complications due to infection or bleeding, and the subsequent course was favorable. Several studies have reported the advantages in right minithoracotomy of less intraoperative bleeding and a lower infection rate compared with full sternotomy. In cases of this kind, in which there is a tendency toward bleeding and ease of infection, we believe that right lateral minithoracotomy may be a useful option to consider.

An Inflammatory Pseudotumor Arising from the Mitral Valve / 日本心臓血管外科学会雑誌

We herein report a rare case of an inflammatory pseudotumor arising from the mitral valve. A 58-year-old man who was undergoing maintenance dialysis was referred to us due to the presence of a tumor mass attached to the mitral valve. It was asymptomatic and had been coincidentally found by echocardiography. The tumor mass was a sphere measuring about 1 cm in size, and it arose from the posterior mitral leaflet. A myxoma of the left atrium was suspected, and the tumor mass was resected along with part of the posterior leaflet by means of a right minithoracotomy (MICS). The tumor was postoperatively diagnosed to be an inflammatory pseudotumor based on the findings of a histopathological examination. During the follow-up period of 1 year and 2 months after surgery, there was no recurrence. An inflammatory pseudotumor is a tumorous lesion characterized by the infiltration of inflammatory cells and the growth of myofibroblasts. This tumor occurs most frequently in the lung, and the greatest number of intracardiac cases have been reported in small children. There are few reports of inflammatory pseudotumors occurring in adults, and only 4 cases originating in the mitral valve has so far been reported, which means that such tumors are extremely rare. For this reason, we reported the findings of this case, while adding a bibliographical survey.

A Case of Late Acute Type A Aortic Dissection after Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

Late acute type A aortic dissection after coronary artery bypass grafting (CABG) is rare, and only a few cases have been published in the literature. It is important to treat cases of living graft during reoperation. We report a successful surgical treatment in a case of late acute type A aortic dissection after CABG. A 68-year-old man underwent a triple CABG (to the left anterior descending artery with left internal thoracic artery, to the left circumflex artery with left radial artery, and to the right coronary artery with right gastroepiploic artery) beating heart procedure using a centrifugal pump and pulmonary assist with closed circuit due to unstable angina pectoris in December 2007 and had presented with sudden anterior chest pain, and was found to have an ascending aortic dissection (type A) on enhanced computed tomography in May, 2009. We performed ascending artery replacement, paying special attention to the living graft performed through a median sternotomy. The postoperative course was uneventful and he was discharged on the 22nd postoperative day.

A Case Report of Aortic Root Replacement, Mitral Valve Replacement and Extended Thoracic Aorta Replacement for a Patient with Marfan's Syndrome / 日本心臓血管外科学会雑誌

A 39-year-old woman with Marfan's syndrome was referred with a symptom of exertional dyspnea, had mitral valve regurgitation, annuloaortic ectasia with aortic valve regurgitation and Stanford B type chronic aortic dissection. She was successfully treated with a one-stage operation, consisting of aortic root replacement with the Carrel patch method, mitral valve replacement and extended replacement of the thoracic aorta (ascending, arch and thoracic descending aorta), through median sternotomy and left antero-axillary thoracotomy. This operation was performed under hypothermic circulatory arrest with continuous retrograde cerebral perfusion. The postoperative course was uneventful. Although the operation may include complicated procedures, it is important to perform a sufficient operation corresponding to the patient's condition and lesions, employing the most advanced surgical techniques, such as circulatory arrest, myocardial protection and so on.