[Elderly patient with acute type A aortic dissection; report of a case].

A 93-year-old woman complained of severe back pain. Computed tomography (CT) and echocardiography revealed acute type A aortic dissection with enlargement of the ascending aorta, moderate aortic regurgitation and cardiac tamponade. Despite her age, the patient was able to support herself, and she and her family desired to have a surgical treatment. Therefore she was referred to our hospital immediately and underwent an emergent ascending aortic replacement using a 28mm woven Dacron graft under deep hypothermic circulatory arrest. Postoperative course was uneventful, and the patient was discharged from our hospital on the 34 th postoperative day in good condition.

[A case of paraffinoma after plombage with spinal paralysis].

A 55-year-old woman was presented with large left-sided chest wall mass and spinal paralysis. She had undergone pleural plombage using paraffin for pulmonary tuberculosis at age 40 years. Thoracotomy was performed and all paraffin was removed. Paraffin provoked granulomatous change (paraffinoma) and invaded to vertebral canal. She remains well at 16 months postoperatively without spinal paralysis.

[MIDCAB in the patient with ischemic heart disease and chronic renal failure].

Our case is a 50-year-old man with angina and chronic renal failure. He underwent double vessel MIDCAB (LITA-LAD and GEA-SVG-RCA). Postoperative course was uneventful and postoperative angiography revealed patent grafts. MIDCAB is thought to be effective for patients who have chronic renal failure, because they are able to resume hemodialysis in early postoperative period for controlling water and electolyte.

[A case of mediastinal myelolipoma].

Myelolipoma is a benign tumor composed of mature adipose tissue and hematopoietic tissue. It was mainly found in the adrenal grand, but there have been reports of extra-adrenal locations. Only 7 cases of mediastinal myelolipoma have been reported ever. We have experienced a case of mediastinal myelolipoma surgically resected from a 55-year-old-man. He has visited our department because of chest pain. Chest X-ray showed typical pneumothorax, but abnormal mediastinal shadow was remarked. Chest CT showed a well circumscribed mass with fat and soft-tissue attenuation in posterior mediastinum. Lung bullectomy and mediastinal tumor resection under VATS was performed. A blue-red tumor 4 cm in diameter was resected en bloc. Pathological examination showed its composition of mature adipose tissue and hematopoietic tissue. Diagnosis was extra-adrenal myelolipoma. No recurrent nor abnormality was found in 8 months since surgery.

Alternative to reconstruction of the pulmonary outflow tract in the Ross procedure.

We report our experience with 2 cases in which we used the native ascending aorta and a porcine valve to reconstruct the right ventricular outflow tract in the Ross procedure. Unfortunately, in many parts of the world, the lack of homografts for reconstruction of the right ventricular outflow tract limits the use of the Ross procedure. The technique described herein can be an alternative to a cryopreserved pulmonary homograft replacement for adult patients.

Surgical removal of a stent entrapped in the left main coronary artery.

A stent entrapped in the coronary artery, which can not be removed by a trans-catheter approach, is extremely rare but is the biggest problem cardiologists face. Surgical retrieval appears to be the only possible treatment to avoid sudden death due to stent thrombosis. We experienced with a New Parmaz-Schatz stent entrapped in the left main coronary artery (LMT) of a 65-year-old man. He underwent surgical removal of the stent with ascending aorta incision and double coronary artery bypass grafting (CABG) using saphenous veins. We believe that a stent entrapped in the LMT must be removed as rapidly as possible to avoid sudden death. Furthermore, in order to avoid the risk of peripheral thrombosis, retrieval is also the case in patients whose distal coronary flow can be maintained with CABG.

Is atrial fibrillation resulting from rheumatic mitral valve disease a proper indication for the maze procedure?

BACKGROUND: There are a few patients without detectable atrial contraction despite restoration of atrial rhythm after the maze procedure for atrial fibrillation (AF) associated with mitral valve disease. METHODS: From January 1995 to March 1997, 29 consecutive patients with AF associated with mitral valve disease underwent our modified maze procedure combined with mitral or other valve operations. The causes of mitral valve disease were rheumatic mitral stenosis (n = 22) and nonrheumatic mitral regurgitation (n = 7). The 17 patients with postoperative atrial rhythm were divided into group I with rheumatic mitral stenosis (n = 10), and group II with mitral regurgitation of nonrheumatic origins (n = 7). RESULTS: Seventeen patients regained atrial rhythm, 2 patients had junctional rhythm, and another 10 remained in AF. Between the group of patients with restoration of atrial rhythm and that of patients remaining in AF, significant differences were found in the percentage with rheumatic disease, history of AF, and maximum f-wave voltage. The postoperative peak velocity of the atrial filling wave to peak velocity of early filling wave ratio for the left atrium measured using Doppler echocardiography was 0.25 in group I, which was significantly lower than that (0.42) in group II. CONCLUSIONS: Reconsideration of the indications for the maze procedure for AF associated with rheumatic mitral stenosis may thus be reasonable, particularly for cases in which replacement using a prosthetic valve is necessary, but we believe that patients with nonrheumatic mitral valve disease, especially those able to undergo reconstructive operations, are the best candidates for the maze procedure.

A surgical method for selecting appropriate size of graft in aortic root remodeling.

We describe a surgical technique for selecting the appropriate size of a tube graft in aortic root remodeling procedures. As the technique has a geometric basis, we believe that our method is more accurate in determining the graft size than others.

[Removal of the left atrial myxoma combined with coronary artery bypass grafting in an elderly patient].

The case of simultaneous coronary artery bypass grafting with resection of the leat atrial myxoma is rarely reported. We surgically treated a 81-year-old woman who had been diagnosed as left atrial myxoma and unstable angina. At surgery we performed coronary artery bypass grafting prior to resection left atrial myxoma, because we thought it is the most important to protect myocardium by antegrade cardioplegia in the consequence of CABG. Postoperative course was excellent and uneventful. The patient is doing well now.

[Surgical treatment for endocardial cushion defect in an elderly patient with pulmonary hypertension].

We performed surgery for a partial endocardial cushion defect (ECD) in a 67-year-old female patient with pulmonary hypertension. The patient had grade 2 tricuspid regurgitation and pulmonary hypertension (Pp/Ps = 0.58, Rp = 8.4 Um2). The operative procedure involved patch closure of the ostium primum and tricuspid annuloplasty with a Carpentier ring. The postoperative course was uneventful and the pulmonary hypertension improved (Pp/Ps = 0.33). Surgery for partial ECD should be recommended even for elderly patients.

[Concomitant composite graft replacement of the aortic root and the aortic arch for type A aortic dissection].

Successful surgical treatment of type A aortic dissection with annuloaortic ectasia (AAE) and severely destroyed aortic root was reported. Between April 1991 and April 1996, 26 patients with type A aortic dissection underwent the surgical treatment in our institute. Among those cases, 4 cases (15%) needed the total aortic root replacement with composite graft. Two cases had Marfan syndrome and AAE and aortic regurgitation. Other two cases had severely destroyed aortic root because of the extension and advancement of the dissection to the aortic root. One was the case of disrupted right coronary ostia. And another was the case of frank rupture and massive bleeding from the aortic root during the operation. Cases of AAE were treated successfully by the routine composite graft that was made before the operation. However, the reconstruction of the aortic root for the cases who had destroyed aortic root with normal relation and size of the aortic root was cumbersome because of non displaced coronary artery ostia and the relatively narrow aortic root. For these cases, composite graft was fixed just below the aortic valve annulus by the sutures enforced with Teflon felt strip from the outside of the aorta and it made the reimplantation of the coronary ostia easier. As for the technique of the reimplantation of the coronary ostia, Carrel patch technique was used because good coaptation and fixation of the suture line around the coronary ostia could be obtained with this technique which prevent the complication such as the pseudoaneurysm or the periostial aneurysm formation around the coronary artery in the long term period. Concomitant procedures were aortic arch replacement in all cases, total arch replacement with four vessels graft in 3 cases and hemiarch replacement in 1 case. Each operations were performed with the aid of selective cerebral perfusion and open distal anastomosis.

[Abdominal aortic surgery in Stanford type B chronic dissecting aortic aneurysm].

Three cases of a chronic type B dissecting aneurysm which required abdominal aortic reconstruction are presented. Constriction of the iliac artery due to dissection was found in case 1, in case 2 the left subclavian artery originated from a giant false lumen, and arteriosclerosis obliterans was observed in case 3. The left renal artery originated from a false lumen in all cases. Each patient underwent preliminary graft replacement of the abdominal aorta because using the femoral artery for extracorporeal circulation had a higher risk factor. The distal arch and descending aorta were then replaced with woven dacron graft. In a chronic type B dissecting aneurysm, the surgical procedure is sometimes complex because of the narrowing of the true lumen and the enlargement of the false lumen or arteries originating from the false lumen to major organs. It is necessary to consider preliminary abdominal reconstruction in cases of 1) dilatation of abdominal aneurysm, 2) obstruction, stenosis or thrombus below the abdominal aorta, or 3) presence of a giant false lumen.

[A case of successful surgical treatment of recurrent Stanford type A thrombosed aortic dissection].

A 70-year-old female was hospitalized with a complaint of anterior chest pain. Enhanced CT scan demonstrated acute type A aortic dissection with the clotted false lumen. Aortography showed ulcer-like projection in the ascending aorta. The patient received the conservative medical treatment and had been followed up medically at outpatient clinic. One year later, she was admitted with the general malaise, chest discomfort and the enlargement of the mediastinum on the chest X-ray. Aortography revealed recrudescent enlarged false lumen. Graft replacement of the ascending aorta was successfully performed. Careful medical follow up should be necessary for the thrombosed Stanford type A aortic dissections.

[A case of localized pleural mesothelioma].

Localized pleural mesothelioma is reported. A 62-year-old male had been observed as a patient with old tuberculosis of the left lung for a few decades. For detailed examination of fever of unknown cause and abnormal shadow on the chest X-ray, the patient was introduced to our hospital. By percutaneous cytodiagnosis, the illness was diagnosed as pleural mesothelioma, and the patient underwent surgery. Since adhesion of the tumor to the lower lobe of the lung was extremely tight, the tumor and the left lower lobe were resected as a mass. The tumor was about 15 cm in diameter, weighed 1,300 g and a slight pleural effusion was observed. The tumor was diagnosed as malignant localized pleural mesothelioma pathologically. Localized pleural mesothelioma should be subjected to surgery in the early stage, in principle. Even in cases difficult to diagnose, operation should not be delayed by repeating easy-going needle-biopsy or a long-term treatment with antitubercular drugs. The postoperative course of this case has been good, and no recurrence nor metastasis has been detected.

[A case of tricuspid valve endocarditis in a non-addicted adult person without underlying cardiac disease].

A very rare case of tricuspid valve endocarditis which developed in a healthy adult was observed. An 18-year-old man with no history of heart disease nor use of stimulant drugs was diagnosed as having cardiac tumor, introduced to this hospital and admitted. Before the operation, symptoms characteristic to infective endocarditis such as high fever and embolism were not observed, but the tumor was detected in the right ventricle by echocardiography. The patient underwent cardiotomy. The thrombus was removed and annuloplasty was performed by Kay's method, and good results were obtained. Pathologically the disease was diagnosed as infective endocarditis accompanied by thrombus. The postoperative course has been good. When the injury of the valve is slight, the surgical method preserving patient's own valve such as excision of localized vegetation and annuloplasty appears to be useful.

[A case of total arch graft replacement for distal aortic arch aneurysm developed around the site of graft patch aortoplasty].

A 65-year-old male underwent graft patch aortoplasty for a sacciform aneurysm of the distal aortic arch. Three years later an aneurysm developed around the site of the graft patch aortoplasty, therefore total arch graft replacement was required. The operation was performed through median sternotomy and left supraclavicular incision. The ascending aorta was selected for the aortic perfusion site, avoiding thromboembolism. Selective cerebral perfusion (SCP) was employed to protect the brain. Open distal anastomosis with circulatory arrest offered the optimal operating field despite re-operation. Graft replacement or graft patch aortoplasty has been proposed for the treatment of sacciform aneurysm. However, there is a possibility of aneurysmal change around the site of resected aneurysm. Furthermore because of the development of surgical skill and extracorporeal circulation technique, total arch graft replacement should be considered for the surgical treatment of distal aortic arch aneurysm.