Multiple Giant Coronary Artery Aneurysms with Coronary-Pulmonary Artery Fistula / 日本心臓血管外科学会雑誌

Giant coronary artery aneurysms are relatively rare and are usually associated with Kawasaki disease, atherosclerosis, congenital disease, or trauma. Although a coronary-pulmonary artery fistula is a known complication, clear guidelines for treatment of this condition remain unavailable. We report a case of multiple giant coronary artery aneurysms associated with a coronary-pulmonary artery fistula in a patient who underwent fistulotomy, aneurysmectomy, and coronary artery bypass graft surgery. A 66-year-old woman was initially evaluated by her primary care physician following right breast cancer surgery. She denied any specific symptoms; however, she was referred to our hospital for evaluation of an abnormal shadow detected on chest radiography. Contrast-enhanced computed tomography (CT) performed at our hospital revealed multiple giant coronary artery aneurysms(approximately 45 mm in size), as well as right and left coronary-pulmonary artery fistulas. We performed simultaneous aneurysmectomy, fistula resection, and coronary artery bypass grafting for management of the giant coronary artery aneurysms concomitant with coronary-pulmonary artery fistulas. Threedimensional CT was useful for accurate imaging of the location of the coronary artery aneurysms, fistula vessels, and the left anterior descending, and left circumflex arteries. It is essential to accurately delineate the boundary between the aneurysms and healthy coronary arteries and fistula vessels, and coronary artery bypass graft surgery should be performed if necessary. We report a rare case of the aforementioned clinical condition, together with a literature review.

A Case of Prosthetic Infective Endocarditis with Acute Myocardial Infarction due to Septic Embolism / 日本心臓血管外科学会雑誌

The patient was a 68-year-old man. In January 2017, he underwent aortic valve replacement (Carpentier-Edwards Perimount Magna, 25 mm, Edwards Lifescience Corporation, Irvine, USA) for aortic stenosis and coronary bypass surgery with two saphenous vein grafts (SVG-#7 and SVG-4PD) for asymptomatic myocardial ischemia. He was treated as an outpatient by a local physician for at least a week during November 2017, with a principal complaint of mild fever, but no other significant symptoms. Transthoracic echocardiography suggested prosthetic valve endocarditis, so he was referred to the author's hospital. The day after admission, he had symptoms of thoracic discomfort, and emergency cardiac catheter examination showed a lesion thought to be due to a thrombus in the left main coronary trunk ; so, thrombus aspiration was carried out. However, no improvement in blood flow was achieved, so balloon angioplasty was carried out, with the aim of improving blood flow in the left circumflex artery, where coronary artery bypass grafting had not been performed. Improvement in blood flow was achieved, and a culture was carried out using the aspirated thrombus. Streptococcus pasteurianus was detected in the culture.

A Rare Case of Intracardiac Angiomyolipoma / 日本心臓血管外科学会雑誌

A 34-year-old woman was admitted with a history of syncope and a mass was detected in the right atrium (RA) by transthoracic echocardiography (TTE). Preoperative chest computed tomography (CT) also demonstrated an RA tumor measuring 4×3 cm. We performed resection of the RA tumor under cardiopulmonary bypass. Histopathological findings showed that the tumor was an angiomyolipoma. It is well known that angiomyolipomas are most frequently found in the kidney and are associated with tuberous scleroses. There was no evidence of tuberous sclerosis in this case. Primary tumors of the heart are rare. However, there have been a few intracardiac angiomyolipomas reported previously.

Syncope on Exertion due to Congenital Hypoplasia of the Left Main Coronary Artery / 日本心臓血管外科学会雑誌

A 13-year-old girl was admitted to our hospital with a history of syncope after exercise. Neither left ventricular (LV) function nor hypertrophy was detected by transthoracic echocardiography. However, 24-h Holter electrocardiogram demonstrated ST segment depression with increasing heartbeat. Exercise ²⁰¹Tl myocardial scintigram also demonstrated ischemia of the anterior LV wall. Multi-slice coronary computed tomography (CT) demonstrated hypoplasia of the left main coronary artery. The syncope on exertion was ascribed to myocardial ischemia due to hypoplasia of the left main coronary artery. We performed off-pump coronary artery bypass graft (CABG) (left internal thoracic artery-left descending artery). The postoperative course was uneventful and postoperative stress ²⁰¹Tl myocardial scintigram demonstrated the absence of myocardial ischemia. Coronary CT demonstrated good graft patency. To date, there has not been any recurrence of syncope on exertion. We herein report a successful off-pump CABG for a patient with syncope due to hypoplasia of the left main coronary artery. Syncope on exertion due to hypoplasia of the left main coronary artery is very rare. However, certain forms of congenital coronary anomalies are associated with adverse cardiac events, including sudden cardiac death. The diagnosis, therefore, can be important and CABG is indicated, especially when there is repetitive syncope due to myocardial ischemia.

A Case of Metastatic Left Ventricular Tumor Causing Acute Lower Limb Embolisms / 日本心臓血管外科学会雑誌

A 76-year-old man was admitted complaining of sudden right lower limb pain. Echocardiography showed occlusion of the right femoral artery. He underwent thrombectomy and regained his lower limb circulation. Two days after the operation, the patient suffered cardiopulmonary arrest. He was resuscitated and immediately after the resuscitation, echocardiography revealed a left ventricular mass that almost fell into the left ventricular out-flow tract. Emergency surgery was performed to remove the mass. Pathological testing showed that the mass was a metastatic transitional carcinoma. Fourteen days after the open-heart surgery, the patient suddenly developed left lower limb pain. We performed an emergency thrombectomy so that limb perfusion could recover quickly. The pathological diagnosis was embolism from a tumor of the left ventricle. His postoperative progress was rapid and he died 23 days after the open-heart surgery.

A Case of Tetralogy of Fallot with Endocardial Cushion Defect of the Intact Primary Septum / 日本心臓血管外科学会雑誌

The patient was a 15-month-old girl with Down's syndrome. She had a heart murmur on the first day after birth. The echocardiogram revealed that she had the tetralogy of Fallot (TOF) and mitral insufficiency (MI). She was observed because she had no heart failure or cyanosis. However, she developed heart failure with progressive MI. Then, she was admitted to our medical center for surgical treatment. During the operation, it was confirmed that the primary septum was intact and a large ventricular septal defect was located at the inlet to outlet portion with anterior malalignment. Each leaflet of the atrioventricular valve were attached to the same level and the ventricular septum was scooped out. TOF with endocardial cushion defect (ECD) without primary septal defect was diagnosed based on the operative findings. Surgical repair was performed through the right atrium and pulmonary artery. She was discharged 17 days after operation without any complications. This was a very rare combination of TOF with ECD without a primary septal defect. We discussed this rare condition with a review of the literature.

Successful Conversion of Atriopulmonary Anastomosis to Total Cavopulmonary Connection Using Autologous Atrial Flap / 日本心臓血管外科学会雑誌

We report a successful conversion of atriopulmonary anastomosis to total cavopulmonary connection using an autologous atrial flap. A 28-year-old man after atriopulmonary anastomosis with a valve conduit performed under a diagnosis of double inlet left ventricle (DILV), d-TGA, was admitted with moderate cyanosis and atrial fibliration which he had suffered since age 25. Cardiac catheterization and ultrasonic cardiography revealed regurgitation at the site of tricuspid patch closure, and atrial dilatation. We excised the regurgitated patch, closed tricuspid valve leaflets, and made an atrial lateral tunnel using an autologous atrial flap. In particular we took care of crista terminalis, sinus node arteries, and sinus node at the operation. He recovered his sinus rhythm on the first operative day, but secondary atrial fibrillation developed. Four months later, catheterization showed good hemodynamics with low central venous pressure, and no obstruction of the atrial tunnel.

Postoperative Aortic Regurgitation Probably due to Use of Gelatin-Resorcin-Formalin Glue for Acute Aortic Dissection / 日本心臓血管外科学会雑誌

A 45-year-old man presented with cough and dyspnea. He had undergone reconstruction of the ascending aorta for acute aortic dissection (DeBakey type I) 5 months previously, at which time we used the gelatin-resorcin-formalin glue (GRF glue) for reconstruction of the wall layer. Preoperative transesophageal echocardiography and aortography revealed aortic regurgitation due to redissection of the aortic root. Intraoperatively, dehiscence was noted between the right coronary sinus including the coronary ostia and the non-coronary sinus. These intraoperative findings suggested that the pathology leading to the redissection was related to the previous use of GRF glue. The redissected segment appeared to be necrotic on macroscopic examination intraoperatively, however histological examination revealed only degenerative changes, and there was no evidence of the glue. He was treated by the modified Bentall method and had a good postoperative course after discharge. In this case, it is also conceivable that tissue necrosis resulted from the use of too much formalin.