Resting angina due to papillary fibroelastoma of the right coronary cusp.

A 63-year-old man with chest pain at rest was referred to our hospital. Transthoracic echocardiography showed a mobile ball-like mass at the top of the right coronary cusp. Subsequently, transesophageal echocardiography also showed a mobile mass at the right coronary cusp. Aortic valve replacement with a mechanical valve was performed under general anesthesia. We diagnosed this condition as papillary fibroelastoma based upon the pathological findings with hematoxylin and eosin staining, and Elastica van Gieson staining. Coronary angiography revealed no organic lesions. The operation was successful, and the patient remains asymptomatic. We speculate that the resting chest pain was induced by transient occlusion of the right coronary orifice by the tumor. We describe this rare case in detail including a review of the literature.

Use of the Konno procedure in an 80-year-old woman with aortic stenosis, a narrow left ventricular outflow tract, and a small aortic annulus.

This report describes a technique for repairing an aortic stenosis in an elderly patient with a small aortic annulus and a narrow left ventricular outflow tract. Preoperative echocardiography in an 80-year-old woman showed severe aortic stenosis with a narrow outflow tract: the aortic valve area was 0.48 cm(2), the aortic annular diameter was 14 mm, and the left ventricular outflow tract diameter was 14 mm. The Konno procedure was used to enlarge both the small aortic annulus and the left ventricular outflow tract, and a 19-mm Carpentier-Edwards bioprosthetic valve was implanted. The patient's postoperative course was uneventful. The left ventricular mass decreased from a preoperative value of 236 g to 96 g, 3 years after surgery. Only a few reports have described the use of the Konno operation in adult patients. In the present case, the Konno operation was demonstrated to be a good option for aortic stenosis accompanied by a small aortic annulus and a narrow left ventricular outflow tract, even in an elderly patient.

An autopsy case of the rupture of a giant aneurysm in a saphenous vein graft: 18 years after CABG.

The saphenous vein is a widely used blood vessel for arterial bypass procedures. Failures of saphenous vein aortocoronary bypass grafts are predominantly the result of subsequent vein graft atherosclerotic disease. Rarely saphenous vein grafts undergo aneurysmal degeneration. This report describes a case of a ruptured aneurysm in a saphenous vein graft that occurred in an 82-year-old female who underwent a coronary artery bypass operation 18 years previously. We could not resuscitate her, but describe the autopsy findings in detail.

Primary cardiac lymphoma: computed tomography and magnetic resonance imaging features.

Primary cardiac lymphoma is a rare, extremely aggressive malignancy. Early diagnosis and treatment is important for patient survival. We present a case of a 76-year-old woman admitted for worsening dyspnea caused by a large tumor in the right atrium. Magnetic resonance imaging and computed tomography clearly depicted the primary cardiac tumor, and histopathological study of the surgical specimen confirmed the diagnosis of diffuse large B-cell lymphoma.

Four characteristics of vascular echo suggesting arterial thromboembolism: differentiation from aggravation of atherosclerotic peripheral artery disease.

BACKGROUND: Arterial thromboembolism (ATE) leading to acute arterial occlusion can involve life-threatening complications, including limb loss and death, without prompt thrombectomy. Several ATEs are hard to differentiate from acute aggravation of atherosclerotic peripheral artery disease (PAD). We determined four characteristics of vascular echos suggesting ATE for the differentiation from PAD and validated their use. METHODS AND RESULTS: Twenty patients (11 men and 9 women; mean age, 74 years) with ATE confirmed by therapeutic findings and 19 patients with PAD including occlusive lesions (14 men and 5 women; mean age, 78 years) were enrolled. Four hallmarks of vascular echo suggesting ATE were defined as the manifestation of the intima-media complex next to the adventitia (M1), mild to moderate echolucency of the intravascular structure (M2), mobility of the intravascular structure (M3), and the pulsatile movement of the arterial wall (M4) in occlusive arterial lesions. In the ATE group, 6 patients had three positive items, and 14 patients had four positive items. In the PAD group, ten patients had no positive items, and nine patients had one positive item. Using a cutoff score of more than 3 for ATE, the sensitivity was 100%, the specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 100%. CONCLUSIONS: The presented characteristics of vascular echo suggesting ATE could be useful for making the differential diagnosis against PAD.

Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection.

BACKGROUND: Although type B aortic dissection has been treated with beta blockers to lower the arterial blood pressure (BP), there has been little evidences about reduction in heart rate (HR). We assessed whether tight HR control improved the outcome of medical treatment in patients with aortic dissection. METHODS AND RESULTS: From 1997 to 2005, 171 patients with acute aortic dissection medically treated and controlled to lower BP under 120 mm Hg were enrolled. Based on the average HR at 3, 5, and 7 days after the onset, patients were divided into tight HR (<60 beat per minute) control group (32 patients; mean HR of 56.6+/-3.1 beat per minute) and conventional HR (>/=60 beat per minute) control group (139 patients; mean HR of 71.7+/-8.2 beat per minute). We compared the frequency of aortic events including late organ or limb ischemia, aortic rupture, recurrent dissection, and aortic expansion of >5 mm, and surgical requirement between two groups. During a median follow-up of 27.0 months, late organ or limb ischemia, aortic rupture, recurrent dissection, pathological aortic expansion, and aortic surgery occurred in 0, 8, 14, 39, and 26 patients, respectively. Reduction in aortic events was observed in tight HR control group (12.5%) compared to conventional HR control group (36.0%), (Odds ratio: 0.25, C.I.: 0.08 to 0.77, P<0.01). CONCLUSIONS: The present study demonstrated that tight heart rate control improved the outcome of medical treatment in patients with aortic dissection.

Radical excision of thymic adenocarcinoma with selective cerebral perfusion.

Most cases of thymic carcinoma have some invasion to neighboring organs when diagnosed, and it is generally difficult to completely remove. We adopted selective cerebral perfusion as a cerebral protection and successfully performed resection of a thymic adenocarcinoma that involved the superior vena cava, left brachiocephalic vein, right brachiocephalic artery and vein, and left common carotid artery in a 47-year-old woman. Even if multiple great vessels were involved by mediastinal malignant tumor, complete resection with selective cerebral perfusion could be safely performed.

Malignant fibrous histiocytoma arising from the aortic wall mimicking a pseudoaneurysm with ulceration.

Malignant fibrous histiocytoma of the thoracic aorta associated with ulcer-like projection has not been reported previously. The hypovascular tumor of the thoracic aorta involved the mural layer, which showed intra- and extra-mural growth patterns and no significant filling defect within the aortic lumen, and mimicked ulcer-like projection with secondary pseudoaneurysm formation. Aortic tumor, although rare, should be included among the causes of an ulcer-like projection.