[Anastomotic Pseudoaneurysms after Graft Replacement for IgG4-related Thoracic Aortic Aneurysm].

We report a case of pseudoaneurysms at the anastomotic sites after prosthetic graft replacement for Immunogloblin G4 (IgG4)-related thoracic aortic aneurysm. A 69-year-old male patient underwent ascending and aortic arch replacement and open stent graft insertion. Five months after the surgery, pseudoaneurysms at the anastomosis to the brachiocephalic artery and to the left common carotid artery developed, and urgency surgery was performed. The right common carotid artery, the right subclavian artery, and the left common carotid artery were individually reconstructed with grafts, and the anastomoses were wrapped with grafts. In IgG4-related aneurysms, complete resection of the diseased tissue and reinforcement of the anastomosis, such as anastomotic wrapping, are important to prevent anastomotic site failure. While serum IgG4 had normalized after the first surgery, C-reactive protein (CRP) remained elevated until the reoperation. Thus, CRP is considered one of the biomarkers for disease activity in IgG4-related vascular disease.

[Mitral Valve Repair under Ventricular Fibrillation for Acute Mitral Valve Regurgitation in a Patient with Aortitis Syndrome].

A 73-year-old woman with a history of aortitis syndrome was referred to our hospital presenting with congestive heart failure caused by acute severe mitral regurgitation due to posterior leaflet prolapse. Upon admission, the patient fell into shock state while undergoing an examination. Medical treatment including mechanical ventilation could not alleviate circulatory collapse, so emergency surgery was performed on the day of admission. Severe calcification of the ascending aorta and severe stenosis or occlusion of the aortic arch vessels resulted from the patient's aortitis syndrome precluded aortic cannulation and aortic clamp. Therefore, mitral valve repair was performed under ventricular fibrillation at moderate hypothermia. Surgery was successful, and the patient recovered well without any cerebral complications after the surgery.

Papillary fibroelastoma causing severe aortic stenosis.

Herein, we present a rare case of papillary fibroelastoma of the aortic valve, which caused severe aortic stenosis. The papillary fibroelastoma developed on the left ventricular side of the non-coronary cusp, immobilizing the cusp motion and obstructing the left ventricular outflow tract, resulting in severe aortic stenosis that brought on acute heart failure. The patient underwent an urgent surgical treatment, which resulted in a successful outcome. To the best of our knowledge, this is the first case of papillary fibroelastoma in which aortic stenosis was so severe as to cause congestive heart failure. Learning objective: Papillary fibroelastoma (PFE) is the most commonly observed primary cardiac tumor in adults that commonly involves left heart chambers. While PFEs often cause embolisms, they rarely cause valvular dysfunction. In a case presented herein, a PFE developed on the left ventricular side of the non-coronary cusp, immobilizing the cusp motion and obstructing the left ventricular outflow tract, resulting in severe aortic stenosis that brought on acute heart failure.

[Ventricular Pseudoaneurysm after Sutureless Repair of Postinfarction Free Wall Rupture of the Left Ventricle:Report of a Case].

We herein report a case of a left ventricular pseudoaneurysm following sutureless repair for left ventricular free wall rupture. A 78-year-old woman underwent emergency sutureless repair for left ventricular free wall rupture following acute myocardial infarction. Three months later, echocardiography revealed an aneurysm in the postero-lateral wall of the left ventricle. The ventricular aneurysm was incised during reoperation, and defect in the left ventricular wall was closed with a bovine pericardial patch. Histopathologically, the aneurysm wall did not contain any myocardium, confirming the diagnosis of pseudoaneurysm. Although sutureless repair is a simple and highly effective method for oozing-type left ventricular free wall rupture, post-procedural pseudoaneurysm can develop both in acute and chronic phases. Consequently, long-term follow-up is mandatory.

[Rupture of Left Ventricular Pseudo-false Aneurysm after Myocardial Infarction].

We herein present a case of ruptured left ventriclular pseudo-false aneurysm. A 73-year-old female had acute myocardial infarction due to occlusion of the left circumflex artery, and subsequently underwent percutaneous coronary intervention. Three weeks later, however, the patient suddenly fell into a state of shock. Contrast-enhanced computed tomography (CT) revealed rupture of left ventricular aneurysm, and emergency surgery was performed. A ruptured aneurysm was observed in the posterior wall, and as the wall of the aneurysm was fragile, it was repaired using double-patch technique. Histopathological examination revealed myocardial cells in the aneurysm wall, confirming diagnosis of pseudo-false aneurysm. Pseudo-false aneurysm is a rare type of left ventricular aneurysm. In cases of rupture in acute or subacute phase of myocardial infarction, when the aneurysm wall is fragile, double-patch repair technique effectively ensures hemostasis and prevents future aneurysm formation.

[Total Arch Replacement due to Tracheal Compression by Brachiocephalic Artery with Bovine Aortic Arch:Report of a Case].

A 78-year-old female presented to our institution with a dry cough and dyspnea. Chest computed tomography( CT) revealed tracheal stenosis caused by compression from a brachiocephalic artery with a bovine aortic arch. Subsequently, surgery was performed in which the brachiocephalic artery was resected, and a total arch replacement using a four-branched graft was completed. We paid particular attention to the graft branches, making sure to avoid contact with the trachea. Both the patient's cough and dyspnea dissipated after the surgery, and a CT revealed the tracheal stenosis had been completely relieved. The patient has remained in good condition for the past three years since the surgery showing no respiratory symptoms or thoracic aortic disease. Because the bovine aortic arch is a known risk factor for thoracic aortic disease, rather than simply reconstructing the brachiocephalic artery, we chose a more aggressive surgical treatment to prevent any possible future thoracic aortic disease.

[Fatal Cerebral Hemorrhage after Mitral Valve Repair for Active Infective Endocarditis:Report of a Case].

Cerebral hemorrhage is a known complication of infective endocarditis (IE) and is associated with a high mortality rate. We herein present a case of fatal cerebral hemorrhage occurring after successful mitral valve repair in a patient in active phase of IE. A 58-year-old male with active IE underwent an urgent mitral valve repair due to systemic embolisms and a massive mobile vegetation on the mitral valve. During the surgery, a rolled autologous pericardium was fixed onto the annulus, therefore we initiated anticoagulation therapy with warfarin. A follow-up brain MRI on the 18th postoperative day showed several cerebral micro bleedings, and on the next day, the patient suffered massive and fatal cerebral hemorrhage. As cerebral hemorrhage can be fatal especially in patients taking anticoagulants, we believe that anticoagulation therapy should be avoided after mitral valve repair in patients who have cerebral micro bleeding in active phase of IE.

[Primary Pericardial Dedifferentiated Liposarcoma Detected by Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography;Report of a Case].

We herein present a rare case of dedifferentiated liposarcoma originating from the pericardium. A 79-year-old female was referred to our hospital with a pericardial tumor detected by fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). The tumor, 80×48 mm in size, showed increased uptake of fluorodeoxyglucose on the FDG-PET/CT without any evidence of metastasis. The tumor was resected with the pericardium, and a histopathological examination confirmed the diagnosis of dedifferentiated liposarcoma. Additional chemotherapy, radiation therapy, or a combination of both were offered but refused by the patient. Although the patient was discharged without any complications, the tumor recurred locally 2 months after the surgery, and the patient succumbed 15 months later. The FDG-PET/CT was useful not only in detecting this malignant tumor but also in diagnosing its malignant nature.

[Bronchial Occlusion with Endobronchial Watanabe Spigot for Massive Pulmonary Hemorrhage during Heart Surgery;Report of a Case].

Massive pulmonary hemorrhage, although rare, is a potentially life-threatening complications during heart surgery. We herein present 1 such case successfully treated by selective bronchial occlusion using an Endobronchial Watanabe Spigot (EWS). The 82-year-old female underwent mitral valve replacement, tricuspid annuloplasty, and maze procedure. An hour and a half after cessation of cardiopulmonary bypass, the patient suffered a massive pulmonary hemorrhage. A subsequent bronchoscopy identified the hemorrhage site at the right middle lobe bronchus (B5b), and an EWS was then selectively deployed into this bronchus to block the hemorrhage. The following day, bronchial arterial embolization was performed, enabling the removal of the spigot on the next day. The patient's respiratory condition gradually improved, allowing for extubation on the 21st postoperative day. By preventing bleeding into neighboring bronchi, which, in turn, avoids the risk of exacerbating hypoxia, bronchial occlusion with EWSs is highly effective in managing massive pulmonary hemorrhage during heart surgery.

[Endovascular Treatment Using the Fenestrated Stent Graft for Distal Aortic Arch Aneurysm with Aortic Arch Vessel Anomalies;Report of a Case].

We herein present a case of distal aortic arch aneurysm associated with the bovine arch and the isolated left vertebral artery (ILVA). Incorporating 2 fenestrations, we successfully performed an endovascular repair using the commercially available Najuta fenestrated stent graft system. During surgery, the Najuta was deployed in the aorta so as to allow for the proximal fenestration to be aligned with the orifice of the 1 branch of the aortic arch, and the distal fenestration with the orifice of the ILVA and that of left subclavian artery. Postoperatively, the patient's recovery went well without any cerebral complications, and in a subsequent computed tomography (CT), the patency of all aortic arch vessels and absence of endoleaks was confirmed. For cases of distal aortic arch aneurysm associated with arch anomalies, the endovascular treatment using the Najuta system is not only simple but also reliable in preserving blood flow to the brain and upper extremities.

[Papillary Fibroelastoma of the Pulmonary Valve;Report of a Case].

We herein present a rare case of a papillary fibroelastoma on the pulmonary valve. A 66-year-old female underwent a graft replacement of the ascending aorta and an aortic valve replacement. Subsequent biannual checks have been performed as a follow up to surgery. An echocardiography, 3 years post surgery, revealed a growing mass, 13 mm in diameter, which was attached to the pulmonary valve. Upon surgery, the mass, which lacked a stalk, was found attached to the right semilunar cusp of the pulmonary valve. The cusp was resected with the mass in order to ensure a complete resection, and as we were unable to repair the pulmonary valve, it needed to be replaced with a mechanical valve. The pathological examination of the resected mass resulted in our diagnosis of a papillary fibroelastoma. The patient is now doing well 2 years after the surgery without any recurrence of the tumor.

[Total Arch Replacement for Distal Arch Aneurysm with Isolated Left Vertebral Artery;Report of a Case].

We herein present a case of distal aortic arch aneurysm with an isolated left vertebral artery(LVA). In surgery, after establishing cardiopulmonary bypass, the LVA was anastomosed to the left common carotid artery (LCCA) while under moderate hypothermia. Selective cerebral perfusion (SCP) was then initiated by inserting catheters into the brachiocephalic artery( BCA), the LCCA and the left subclavian artery (LSA). The aorta was transected between the BCA and the LCCA, and an open stent graft was deployed into the descending aorta during circulatory arrest. After reconstructing the LSA, LCCA and BCA, the ascending aorta was replaced with a graft. The patient recovered well without any cerebral complications, and computed tomography confirmed the patency of the reconstructed LVA. Regarding the surgical treatment of an aortic arch aneurysm with an isolated LVA, reconstructing the isolated LVA before SCP makes the establishment of SCP straightforward, thereby helping protect the brain from ischemia.

[Tricuspid Valve Replacement without Removing Transvenous Pacemaker Lead].

Transvenous pacemaker lead occasionally impairs tricuspid valve coaptation because of the direct injury like a perforation, the direct interference with the valve, or the adhesion between the pacemaker leads and the valve leaflets, resulting in severe tricuspid regurgitation. In these situation, tricuspid valve replacement (TVR) is selected after the exchange from transvenous lead to epicardial lead. However this procedure has some problems such as poor threshold of the endcardial lead, the injury and the difficulty in transvenous lead removal. We performed successful TVR without removing transvenous pacemaker lead after the fixation to the annulus of posterior leaflet in tricuspid valve. This technique is useful in a patient with tricuspid regurgitation due to the influence of the pacemaker lead.

[Dual Left Anterior Descending Coronary Artery;Report of a Case].

A 77-year-old male presented with angina pectoris. On coronary angiography, the left anterior descending artery(LAD) was obstructed after branching the second septal branch. Three-dimensional (3D) images constructed with 64-slice computed tomography (CT) showed type I dual LAD. The short LAD, which had been erroneously recognized as a septal branch on coronary angiography, ran on the anterior interventricular sulcus (AIVS) where it then terminated. The long LAD, which was obstructed at its origin, ran on the left ventricular side of the AIVS, and entered the distal part of the AIVS. Coronary artery bypass grafting including a bypass to the long LAD was successfully performed. Recognition of the dual LAD, a rare coronary artery anomaly regarding its origin and course, is import ant in performing successful myocardial revascularization procedures. The 3D-CT images are extremely useful in demonstrating dual LAD, especially in cases where there is occlusion of the LAD.

Tricuspid Valve Replacement Preserving Endocardial Pacemaker Lead.

We describe a simple and reliable technique to replace the tricuspid valve preserving a permanent endocardial pacemaker lead. This technique avoids any direct contact between the pacemaker lead and the prosthetic valve, which protects the pacemaker lead from the mechanical stress of the valve prosthesis and preserves the prosthetic valve's function. doi: 10.1111/jocs.12747 (J Card Surg 2016;31:311-314).

Surgical treatment of valvular and supravalvular aortic stenosis in homozygous familial hypercholesterolemia.

A 61-year-old male with homozygous familial hypercholesterolemia presented with dyspnea and syncope. He had been treated with low-density lipoprotein apheresis for 26 years. Echocardiography and computed tomography showed severe valvular and supravalvular aortic stenosis. Computed tomography and cardiac catheterization revealed a severely calcified narrowed aortic root and an occlusion in the proximal right coronary artery. During surgery, the ascending aorta was replaced under deep hypothermic circulatory arrest without aortic cross-clamping. After that, the aortic root from the annulus to the sino-tubular junction was enlarged with a two-ply bovine pericardial patch. An aortic valve replacement with a 17 mm mechanical valve and coronary artery bypass grafting to the right coronary artery were performed. The patient recovered from the surgery without any cerebrovascular complications.