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Absence of the pericardium is generally asymptomatic rare congenital disorder. However, it may be life-threatening problem due to cardiac deviation or herniation after the pulmonary resection. We described a case of complete defect of the pericardium found at surgery for metastatic lung cancer. Since the left lower lobectomy was necessary, the pericardium was reconstructed with an ePTFE sheet. Postoperative course was uneventful without any symptoms at two years post-surgery.

A 66-year-old male with hypertension was referred for evaluation of abnormal find chest X-ray. A computed tomography (CT) scan revealed a solitary pericardial mass with a diameter of 5 cm, located in the left atrioventricular groove. It showed solid but unevenly enhanced contents suggesting a well vascularized tumor originating in either a part of the left heart or the pericardium. As magnetic resonance imaging showed a clear boundary between the tumor and the pericardium, cardiac origin was suspected. Surgical removal of the tumor was performed via median sternotomy. The tumor originated from the lateral aspect of the left atrial appendage, having a base of 10 mm in diameter. The tumor was fully excised with an associated left atrial cuff under cardiopulmonary bypass. The postoperative course was uneventful. The tumor was histopathologically diagnosed as cavernous hemangioma originating in the left atrial wall. There has been no sign of recurrence for four years following surgery.

A 79-year-old man had undergone endoscopic colorectal resection for colon cancer and partial resection of right S2 for lung cancer in 2007. Two years later, enlargement of a small nodule in the right S10 detected by chest computed tomography was noted. Partial lung resection was performed in April 2009, and the pathological diagnosis was localized nodular pulmonary amyloidosis.

Quadricuspid aortic valve is a rare congenital disease. We experienced 3 surgical cases of quadricuspid aortic valve. Patient 1 was a 72-year-old man who was noted to have a quadricuspid aortic valve associated with aortic regurgitation and an ascending aortic aneurysm(51 mm in diameter). He underwent replacement of the aortic valve and the ascending aorta. Patient 2 was a 71-year-old man with severe aortic stenosis, regurgitation, and coronary triple vessel disease. He underwent aortic valve replacement and coronary artery bypass grafting. Preoperative echocardiography revealed no abnormalities in the number of valve leaflets, but quadricuspid aortic valve was identified during surgery. Patient 3 was a 79-year-old man with severe aortic regurgitation, who underwent aortic valve replacement. In all patients, the 4 valve cusps were approximately of the same size. Multi-detector computed tomography is useful for evaluation of valve morphology. Indication of prophylactic ascending aorta replacement in patients with aortic dilatation requires further study.

A 77-year-old man, who had been under medical treatment for myasthenia gravis without thymoma, was diagnosed with aortic arch aneurysm. He underwent total aortic arch replacement and total resection of the thymus through median sternotomy. His symptoms relating to myasthenia gravis dramatically disappeared after the surgery. The serum anti-acetyl chorine receptor antibody decreased from 2.7 to 0.7 nmol/l (N<0.2) with the reduction of oral predonisolone from 12.5 to 5 mg/day at 4 years after the surgery. The concomitant operations significantly improved his quality of life.

A 42-year-old woman was admitted with chest pain. Coronary angiography did not reveal any significant stenosis, but left ventriculography showed akinesis and ballooning of the apex with a hyperkinetic basal segment indicating Takotsubo cardiomyopathy. Cerebral embolism occurred after one and a half years because of a left ventricular thrombus. The apical akinesis had worsened to a left ventricular aneurysm (maximum diameter 43 mm). The left ventricle was reconstructed to avoid repeated thrombus formation and cerebral infarction despite anticoagulant therapy. A pathological assessment revealed a fibrotic myocardium, but the cause of the cardiac aneurysm remained unknown. Although the outcome of Takotsubo cardiomyopathy is relatively good, careful observation and appropriate treatment are needed considering the possibility of aggravation.

Polyarteritis nodosa (PN) is vasculitis of small- to medium-sized arteries. A 57-year-old woman with PN developed aortic valve regurgitation. Aortic valve replacement (AVR) was performed. We found inflammatory change of the ascending aorta which was rarely involved in PN. Abnormal thickness of the aortic wall was recognized during operation, which had not been detected by preoperative computed tomography. Perioperative course was uneventful, and the patient underwent anti-inflammatory therapy after the operation. No perivalvular leakage has been detected for 3 years since AVR. We should consider the possibility of aortitis, when cardiovascular operations are performed in patients with vasculitis for small- to medium-sized arteries.

We experienced 2 patients who died early after emergency cardiac operation because of malignant diseases. In one case, we operated on a 67-year-old woman for infective endocarditis and performed aortic valve replacement, but she died of terminal pancreatic cancer on the 26 postoperative day. In the other case, a 53-year-old woman underwent emergency operation for cardiac tumor of the left atrium. However, the tumor was diagnosed as cardiac sarcoma during the operation, and it could not be completely resected. The sarcoma recurred after 2 months and she passed away. An emergency cardiac operation without enough preoperative examinations sometimes causes a poor prognosis.

We report a successful arterial switch operation for complete transposition of great arteries with atrial and visceral situs inversus totalis and mirror image dextrocardia in a 12-day-old infant girl. The aorta was located left side-by-side to the pulmonary trunk with a single coronary artery (mirror image of 1RLCx). After French maneuver, the posterior circumference of the neo-aorta was reconstructed. Then the coronary button was transplanted into the neo-aorta with a trap door technique carefully avoiding any twist and over-stretch. The neo-pulmonary trunk was reconstructed with an autologous pericardial patch and sutured to the longitudinal incision made into the left central pulmonary artery. The baby was discharged from hospital and has been doing well without any morbidity relating myocardial ischemia.

Dexmedetomidine hydrochloride (DEX) is a newly developed alpha-2 adrenergic agonist sedative and has been shown to be effective in post-surgical patients, providing not only unique sedation but also stabilization of hemodynamic and respiratory function. We investigated the hemodynamic and respiratory effects and efficacy of DEX in 84 consecutive patients (age <6 months: 18, 6-12 months: 13, 1-3 years: 29, 4-9 years: 18, >10 years: 5, male:female = 44:40) who were sedated by DEX in combination with a small dose of midazolam and morphine. DEX was commenced at an initial dose of 0.7 microg/kg/hr during surgery, approximately 1 hour prior to transfer to the intensive care unit (ICU). DEX infusion was maintained at a rate of 0.2-0.7 microg/kg/hr after ICU admission throughout weaning from mechanical ventilation and extubation. The dose of the sedatives was optimized by scoring on Ramsay's sedative scale. There were no undesirable hemodynamic changes throughout the DEX infusion. Respiration was maintained and all patients were extubated uneventfully. Optimal level of sedation was achieved in all patients. There were no adverse events related to DEX administration. Moreover, junctional ectopic tachycardia (JET) and severe pulmonary hypertension (PH) leading to clinical deterioration, which are the major causes of postoperative morbidity in pediatric cardiac surgery, occurred at a low incidence in this series. Our DEX protocol provided 1) satisfactory postoperative sedation without compromising hemodynamics and respiration, and 2) prevention and amelioration of postoperative morbidity caused by sympathomimetic stimulation, in pediatric cardiac surgery.

Two episode of junctional ectopic tachycardia (JET) caused hemodynamic deterioration early after tetralogy of Fallot repair in an 8-month-old infant. Sinus rhythm resumed in each of the episodes immediately after intravenous administration of nifekalant hydrochloride (NIF), a newly developed Vaughan-Williams class III antiarrhythmic drug in Japan. Although QT interval was modestly prolonged with NIF, no life-threatening ventricular arrhythmia (i.e., torsades de pointes) occurred. NIF might be an effective alternative in the treatment of postoperative JET in congenital cardiac surgery.

St. Jude Medical Hemodynamic plus bileaflet valve prosthesis (HP) was employed in 7 cases undergoing aortic valve replacement since December 1993. Echocardiographic evaluation of left ventricular dimension and transvalvular pressure gradient was performed in 5 cases with 19 HP before and after operation. Each data was compared with those of 21 cases having undergone aortic valve replacement with 19 mm Standard model (19 SD). There was no significant postoperative change in left ventricular end-diastolic dimension (50 +/- 4 mm to 44 +/- 8 mm; p = NS) and left ventricular end-systolic dimension (34 +/- 4 mm to 34 +/- 9 mm; p = NS) in 19 HP cases. However, left ventricular end-diastolic dimension (51 +/- 11 mm to 41 +/- 8 mm; p < 0.05) and left ventricular end-systolic dimension (35 +/- 12 mm to 28 +/- 9 mm; p < 0.05) decreased in 19 SD cases. Transvalvular systolic peak pressure gradient was reduced significantly in both groups (19 HP: 94 +/- 38 mmHg to 43 +/- 19 mmHg; p < 0.05, 19 SD: 73 +/- 49 mmHg to 33 +/- 14 mmHg; p < 0.05). Poor reduction of left ventricular volume and high residual systolic pressure gradient in patients with 19 HP might be due to relatively high incidence of stenotic lesion in original aortic valve disease. In some cases with these critical aortic stenosis, radical annular enlargement procedure would provide more fundamental release of left ventricular outflow tract stenosis rather than one size increase of effective orifice area by employing HPs. Structural examination demonstrated that 19 HP had the same outer diameter of sewing flange with identical orifice ring as 21 SD (24 mm) did, and 17 HP had that of 19 SD (22 mm). Therefore, precise attention is needed for application of SJM-19 HP in patients with small aortic annuli.

Newly-developed procedure for aortic annular enlargement was geometrically examined on its optimal annular augmentation. Valve prosthesis is accommodated by anterior annular split extending into aortopulmonary and infundibular septum and, eventually, protrudes into pulmonary valvular orifice in this procedure. Relationship between residual pulmonary valvular area (PVA) and aortic annular incremental radius (x) is given by: PVA = (r+x)2 [pi - 2 pi x/(r+x) + sin (2 pi x/(r+x))], where r is original aortic annular radius. Optimal aortic annular augmentation maximizing PVA and saving original PVA is 1.33 times and 1.70 times of original diameter respectively. Animal experiments employing six mongrel dogs demonstrated no significant increase of systolic peak pressure gradient in right ventricular outflow tract after the procedure standardized by this geometrical idea. Our procedure would bear radical enlargement of small aortic annulus.

Newly-developed catheter for the intraaortic balloon counterpulsation with cardio-renal assist was examined on animal model. The catheter consists of two balloon segments between which the celiac trunk, the superior mesenteric artery and the renal artery are to be placed. Statistical comparison on each hemodynamic element was carried out between the catheter (DBC), conventional single balloon catheter (SBC) of the same balloon volume as DBC and no assist (None) groups. There were no significant changes between SBC and DBC in cardiac output, femoral arterial flow and central venous pressure. Renal arterial flow and urinary output were significantly increased in DBC (None 14.4 +/- 3.9, SBC 22.6 +/- 5.6, DBC 31.0 +/- 6.9 ml/min in renal arterial flow, None 33 +/- 9, SBC 64 +/- 14, DBC 78 +/- 20 ml/h in urinary output, p < or = 0.05). After the remodeling adjust to the human stature, a clinical application would be considered.

A 60-year-old male, who had been hospitalized with a Stanford type B acute aortic dissection 3 years ago, was admitted with severe disquiet caused by discomfort of the chest and the neck. Enhanced CT scans demonstrated the ascending aorta compressed by non-opacified false lumen, so-called "thrombosed dissection" or "closing aortic dissection", and normal descending aorta. Aortography showed no intimal tear in the ascending aorta and aortic arch. "Hibernation therapy" with pentobarbital was performed to be sedated over during 13 days. 29 days later follow-up CT scans showed reopacified false lumen and enlargement of the ascending aorta, although he had no complaints during the medical therapy. Large intimal tear just under the brachiocephalic artery and giant false lumen without reentry occupying the ascending aorta was found by the repeat aortography. Graft replacement of the ascending aorta was successfully performed. This case suggested that thrombosed dissection might have the risk of recanalization of clotted false lumen asymptomatically, and it would be important to take care of radiographic changes during the medical therapy even if the patient had no symptoms.

We carried out combined operation of coronary artery bypass grafting using the right gastro-epiploic artery (GEA) and other abdominal operation in four patients. The abdominal operation were one total gastrectomy for double early gastric cancer, one bypass with Y-shaped graft for arteriosclerosis obliterans in iliac region and two peritoneal dialysis for chronic renal failure. There were no early death. The postoperative course was uneventful without any mediastinitis or other infectious events. Doing careful maneuver, we can use the GEA for grafts in such cases.

A 55-year-old woman eighteen years after mitral valvular replacement with Delrin disc Björk-Shiley valve prosthesis underwent a reoperation of prosthetic valve replacement for the prosthetic malfunction due to disc defacement. The patient suffered from faintness and vertigo at rest. An echocardiographic examination showed a moderate mitral insufficiency with a normal disc movement. Precise examination on the removed prosthesis revealed accelerated defacement of disc margin which made the ring-disc clearance up to 0.35 mm and strut-shaped groove formation on the inlet surface of the disc occluder. These findings suggested a pronouncedly earlier disc wear than predicted by Björk and co-workers. We concluded, therefore, that a patient undergone a valve replacement with Delrin disc Björk-Shiley valve should be examined periodically by echocardiography even though being without any symptoms.

A 46-year-old female who had undergone single CABG for BWG syndrome 11 years ago was referred to our hospital for paroxysmal atrial fibrillation. The roentgenogram showed slightly cardiomegaly and the enlargement of LA. Ischemic changes of ECG appeared at I, aVL, V5, V6, as inverted T wave, and low voltage R wave at V1-V4, but non Q wave. The thallium-201 emission computed tomogram at exercise revealed poor perfusion at apical region without redistribution pattern. Catheterization showed mitral regurgitation (grade III), big right coronary artery (RCA) arising from aorta, rich collateral to poor left coronary artery (LCA), and bypass graft was obstructed. The proximal end of LCA was closed, and didn't arise from both pulmonary artery and ascending aorta. In this cases, MVR only without re-CABG to LCA was selected and performed. Postoperative course was uneventful. The result of this case suggested that MVR was an effective surgical procedure for MR of BWG syndrome in the adult case and it was better to add CABG to LCA as much as possible if the ischemic region was large.

A new catheter was developed for the cardio-renal assist during intra-aortic balloon counterpulsation. The catheter consists of both a large balloon of conventional IAB (TMP balloon) located at the distal end of the catheter and an additional small balloon 10 cm distant from the large balloon with common lumen and single shaft. Experimental study was carried out in the mock circulatory system simulating the descending aorta employing a conventional IAB catheter as a control. It was demonstrated that the flow in the mid portion between both balloons could be increased maximally by as much as 28% of that of the control under the continuous flow and 214% under the pulsatile flow. The double balloon catheter was considered to improve the renal perfusion as well as the coronary perfusion.

Graft patency after coronary bypass surgery (CABG) was evaluated with stress 201-thallium scintigraphy (stress 201Tl) in 26 cases, including 13 cases using the left internal thoracic artery (LITA group) in situ and 13 cases with saphenous vein graft (SVG group). All of them had effort or unstable angina caused by LAD lesion without apparent infarction. Stress 201Tl using a symptom-limited, graded bicycle exercise test was performed before CABG and 1 month, 6 months to 1 year, 1 year to 1.5 years after surgery. Five tomographic images including the apical side of the area fed by the bypass anastomosed to LAD in short axial sections were picked out and piled up. Fan-shaped ROI was made on this area and % Tl uptake was calculated using the following formula. 201Tl counts in ROI--Background counts/Maximum counts--Background counts x 100 (%) The normal % Tl uptake calculated in the control group (n = 11) in this ROI was 68.2 +/- 4.8%. Preoperative % Tl uptake showed 49.3 +/- 0.2% in the LITA group and 54.3 +/- 13.2% in the SVG group. % Tl uptake of the SVG group 1 month after CABG was slightly higher than that of the LITA group, (62.0 +/- 7.0% vs. 56.3 +/- 7.6%). However 6 months to 1 year after, % Tl uptake of the LITA group increased to 60.8 +/- 6.4%, inspite of a tendency on the decrease of that in the SVG group, (59.0 +/- 8.5%), and further more, 1 year to 1.5 years after CABG, increased to 62.3 +/- 5.1% near the normal % Tl uptake of the control group and the SVG group decreased to 58.8 +/- 6.8%. This result suggested that arterial in situ bypass graft might have an auto-regulation and "growing property" corresponding to flow demand, and this helps the excellent long-term patency of arterial bypass grafts.

A 70-year-old female with partial atrioventricular septal defect underwent a total correction of the anomaly. The patient was in NYHA functional class II. Preoperative cardiac catheterization demonstrated a primum-type atrial septal defect through which 33% of left to right shunt occurred and a cleft of mitral valve causing moderate regurgitation. The operative procedure as our routine for this anomaly consisted of suture of mitral septal commissure and closure of atrial septal defect with autologous pericardial patch. Postoperative examination showed satisfactory competence of mitral valve and improved functional capacity. A successful correction for the case aged more than 66 with this anomaly has not been reported so far in Japanese literature. We conclude that surgical treatment should be basically considered for this anomaly in spite of senility.

Four dialysis patients received aorto-coronary bypass grafting (CABG) at Fukuyama cardiovascular hospital from April 1989 to March 1992. We employed continuous ambulatory peritoneal dialysis (CAPD) in two cases, hemodialysis with extracorporeal ultrafiltration method (ECUM + HD) in one case and hemodiafiltration with continuous veno-venous hemofiltration (CVVHF + HDF) in one case for perioperative management. In each cases, intermittent HD was undergone during 4 days before operation. Intraoperatively, HD was used together with extracorporeal circulation. Blood pressure in the postoperative course changed more frequently in CAPD cases than ECUM + HD or CVVHF + HDF case. Especially, CVVHF + HDF stabilized the movement of circulation and kept balance of serum BUN, Cr after the operation (BUN; 27.2 +/- 6.3, Cr; 5.0 +/- 0.6). We concluded that CVVHF + HDF would be the most favorable method to maintain the fluid balance stably for the uremic patients after CABG.

CABG with all arterial grafts using both the internal thoracic artery (RITA, LITA), the right gastroepiploic artery (GEA) and the inferior epigastric artery (IEA) was performed in 26 patients from July 1989 to August 1991. There were no early and late deaths. Early postoperative coronary angiography in all patients revealed that the best choice of anastomosis was RITA to LAD, LITA to LCX or DIA, and GEA to RCA (type A). All arterial grafts CABG is safe and feasible, but the saphenus vein graft must be used to avoid the anastomosis from small GEA to small LCX.

We have performed a mitral valve reconstruction on a 31-year-old man who suffered from infective endocarditis four years ago. Severe mitral regurgitation and posterior commissural chordal rupture were noted. The mitral valve was repaired by Carpentier's sliding commissuroplasty and ring annuloplasty. The postoperative course was uneventful, and mitral regurgitation completely disappeared. It appears that Carpentier's sliding commissuroplasty is a superior new reconstructive technique for mitral regurgitation due to commissural chordal rupture.

It has been reported that the incidence of mitral valve prolapse was remarkably increased in patients with Klinefelter's syndrome. Some cases which have been previously reported were associated with hemodynamically significant transvalvular regurgitation, however, none of them underwent a surgical treatment such as valvular replacement. Here we report a case of Klinefelter's syndrome which underwent MVR for mitral regurgitation caused by idiopathic chordal rupture. Pathological microscopic examination showed topical and minor myxomatous changes on the free edge of the leaflet and no inflammatory changes such as in infectious endocarditis. It is, therefore, suggested that an echocardiographic follow-up should be carried out in case of Klinefelter's syndrome during its life and also in the case treated by a prophylactic therapy for endocarditis with antibiotics. And when, unfortunately, surgical treatment is required, valve replacement would be preferable to valvuloplasty because of a fragility of leaflet.

A new procedure of "intra-arterial aorto-infundibuloplasty" for the narrowed aortic annulus is described. Aortic valve replacement can be performed through the aorto-pulmonary and infundibular septal incision which is eventually enlarged by a single patch.

Aneurysms of the inferior left ventricular wall represent only a small fraction of all aneurysms that have been reported in surgical series. And in comparison to anterior left ventricular aneurysms, a comparatively higher percentage of reported inferior wall aneurysms was classified as false. A 73-year-old male was admitted for acute inferior myocardial infarction. Three weeks after admission, cardiac catheterization was carried out. Coronary arteriography revealed triple vessel disease and left ventriculography showed an aneurysm of the inferior left ventricular wall, whose feature near the mitral annulus was multiple fenestrations. Left ventricular aneurysmectomy and aortocoronary bypass grafting to the left anterior descending artery were simultaneously performed under cardiopulmonary bypass with moderate hypothermia. The pathological feature was a true aneurysm. The postoperative course was uneventful.

Two cases of iatrogenic left main coronary artery stenosis (ICOS) following aortic valve replacement (AVR) are documented. The first patient began to have chest pain due to myocardial ischemia 7 months after AVR. Angiographically, the ostium of her left coronary artery was severely stenotic. She refused coronary bypass grafting. She died of myocardial infarction due to ICOS, 23 months after AVR. Histologically, a loose cellular connective tissue was found around the stenotic coronary arterial lumen. The other patient had chest pain 4 months after aortic and mitral valve replacement. The ICOS was diagnosed angiographically. After she had coronary bypass grafting, she was free from myocardial ischemic symptoms. The onset of myocardial ischemic symptoms in the first six months after AVR is highly suggestive of ICOS, and urgent coronary angiography is recommended and, if proximal stenosis of the coronary arteries is diagnosed, coronary bypass grafting should be performed.