Early detachment of prosthetic aortic valve one year after replacement for severe aortic regurgitation due to perforated aortic valve aneurysm; a case of suspected HLA-B52 positive Behçet's disease.

Herein, we report a case of 61-year-old male with congestive heart failure (HF) due to severe aortic regurgitation (AR) caused by ruptured aortic valve aneurysm (VA). Aortic valve replacement (AVR) was performed after improvement of HF symptoms. Pathological examination of resected aortic VA showed neutrophil infiltration. Although he did not have typical clinical features associated with infective endocarditis (IE) such as fever, leukocytosis, or positive blood culture, we misdiagnosed this case as "concealed IE". However, we reconsidered the etiology because prosthetic aortic valve detachment occurred only one year after AVR. When considering causes except IE for perforated aortic VA and early prosthetic valve detachment, Behçet's disease (BD) was more likely based on the clinical course, echocardiography, and pathological findings in this case. The inflammatory process of BD is associated with aortic valvulitis/aortitis, leading to a possible cause of aortic regurgitation due to aortic VA or early prosthetic valve detachment. The diagnosis of BD was challenging in this case because he did not have predominant clinical findings, including recurrent oral ulcer which is a mandatory criterion for the diagnosis by the International Study Group, however, cardiac involvement may have been the initial presentation of BD. .

Ductus Aneurysm Ruptured Into the Esophagus With Massive Bleeding.

We report a patient with life-threatening hematemesis caused by the rupture of a ductus aneurysm into the esophagus, which was successfully treated by coil embolism for the esophageal fistula through the aorta and subsequent thoracic endovascular aortic replacement. Second-stage therapy was performed surgically after proactive antibiotic treatment and in consideration of the patient's improved general condition. This included debridement with drainage, aortic encasement with remnant aneurysmal wall, omentopexy, and jejunostomy. The esophagus was preserved, and satisfactory healing and natural closure of the fistula were achieved. Although repeated aspirations were later required for pleural fluid, such inflammatory complications finally subsided.

Use of stent-grafts for the ductus arteriosus and its related lesions.

Five cases of ductal lesions with various anatomies have been successfully treated by thoracic endovascular aortic replacement in recent years; 4 using mainly fenestrated stent-grafts, and one using a non-fenestrated stent-graft. Considering the invasive nature of open surgery and the anatomical limitations of the catheter technique for occluding a patent ductus in many adult cases, thoracic endovascular aortic replacement should be the first option because of its broad applicability for ductal lesions.

Plural large floating thrombi in the ascending aorta.

Floating thrombi in the ascending aorta are a very rare finding in non-aneurysmal, mildly atherosclerotic or normal aortas. We report a case of floating thrombi in a 66-year-old man who was admitted to the hospital with acute chest pain and dyspnea. Enhanced computed tomography showed two large floating thrombi in the ascending aorta, type B aortic dissection, deep venous thrombosis, and pulmonary embolism. A temporary inferior vena cava filter was inserted and the subject underwent an emergency surgical intervention to remove both masses. His postoperative course was uneventful; the etiology of the thrombi is unknown. Lifelong anticoagulation therapy was started and the subject has been stable without recurrence for the last 2 years.

Massive hematuria and shock caused by ilio-ureteral fistula in a patient with an isolated internal iliac artery aneurysm.

An emergent operation was performed on a 73-year-old woman with massive hematuria and serious shock. A computed tomography (CT) revealed that the cause of the shock was hemorrhage from an aneurysm into the ureter, with resultant massive hematuria. During surgery, we observed that the ureter was encased into the wall of the aneurysm, with exposure of the pre-positioned ureteric stent inside the aneurysmal space. Reconstruction of the ureter was performed by wrapping the tissues with the ureteric stent inside. Postoperative recovery was uneventful, and CT angiography showed complete exclusion of the right internal iliac artery with the in situ ureteric stent.

Left atrial papillary fibroelastoma accidentally diagnosed with gastric cancer.

Papillary fibroelastoma is a rare but benign cardiac tumor and usually originates from the cardiac valve. We describe a 78-year-old woman who was initially diagnosed with gastric cancer, and was incidentally found to have a mass in the free wall of her left atrium between the left atrial appendage and the left superior pulmonary vein. An excision was performed through the left atrial appendage under cardiopulmonary bypass. The histopathologic examination of the resected tissue revealed a papillary fibroelastoma. The unusual localization of this papillary fibroelastoma was discussed.

Perfect and least invasive sealing technique on the lesser curvature of the aortic arch: application of a novel stent graft to an aneurysm developing on a postoperative ductus arteriosus.

A 78-year-old woman who underwent an operation for a patent ductus arteriosus (PDA) about thirty years ago developed an aneurysm on the aortic side of the remnant ductal tissue. To avoid risky, open surgery, we performed endovascular aortic therapy using a novel stent graft (SG), which was pre-curved, fenestrated and custom-made type. This graft was designed to configure to the patient's whole aortic arch anatomy, and was capable of accurately adjusting its fenestrations to the arch branch orifices during the procedure. The operation was successful, and the patient was discharged uneventfully on 16th postoperative day. The advantage of this fenestrated SG is close sealing, especially over the lesser curvature of the arch. This device could be a simple and effective option to deal with an otherwise normal aortic arch with such a ductus-related localized lesion.

Mesenteric artery fenestration for type B dissection with visceral ischemia.

We describe a successful case of direct superior mesenteric artery fenestration for an acute type B dissection complicated by bowel necrosis in a 68-year-old man. At 11 days after the onset, computed tomography showed superior mesenteric artery obstruction. We fenestrated and connected the true lumen to the false lumen of the superior mesenteric artery, and performed thrombectomy in both lumens. A bowel resection was carried out immediately. The patient was discharged uneventfully after recovery.

An innovative exclusion technique for ductus arteriosus with a novel stent graft.

A 72-year-old woman who had a patent ductus arteriosus that was anatomically unsuitable for catheter coiling was treated with a pre-curved fenestrated stent graft. This graft was custom-made to configure the patient's whole aortic arch, and was capable of accurately adjusting its fenestrations to the arch branch orifices. The advantage of this fenestrated stent graft is close sealing, especially on the lesser curvature of the arch. This device could be an excellent option to treat an otherwise normal aortic arch with such a localized lesion.

Acute cardiac tamponade caused by the extension of multiple hepatic actinomycotic abscesses.

A 60-year-old man was diagnosed as multiple hepatic abscesses. Failure in the first empiric therapy led to extension into the pericardium, causing acute cardiac tamponade. Actinomyces species were not cultured from the pericardial effusion. The definitive diagnosis was acquired by ultrasound guided needle biopsy.

Aortic valve-sparing operation and a total arch replacement by an elephant trunk method for Marfan's syndrome with aortic regurgitation and a DeBakey type IIIb dissection.

A 35 year-old male with Marfan's syndrome was referred with a fortuitous echographic finding of an abdominal aorta flap. Transthoracic echocardiography showed moderate aortic regurgitation and an aneurysm in the sinus of Valsalva. Computed tomography demonstrated an aneurysm in the sinus of Valsalva 60 mm in size and a DeBakey type IIIb dissection extending from the left subclavian artery to the right common iliac artery. An aortic valve-sparing operation (reimplantation), total aortic arch replacement and the elephant trunk method were used in this patient. An aortic valve-sparing operation is preferable because the patient is young, and has no need for anticoagulant therapy after surgery. The extent of the aortic reconstruction, including the intact aortic arch, was appropriate to prohibit future dilatation of the aortic arch and retrograde dissection from a DeBakey type IIIb dissection.

Surgical treatment of giant left atrium using a combined superior-transseptal approach.

We report on the usefulness of a combined superior-transseptal approach for the surgical treatment of giant left atrium. The posteroinferior wall and the roof of the left atrium were easily plicated and the mitral valve procedure was simple.

Surgical removal of an accufix pacing lead with a protruding J wire.

We report a patient with a fractured J wire protruding through the outer polyurethane sheath of an Accufix electrode in the subclavian vein and right atrium. The wire within the subclavian vein was removed transvenously, while the tip of the lead within the right atrium was removed surgically via a median sternotomy.