[Aortoesophageal Fistula due to Aortic Aneurysm;Report of a Case].

A 77-year-old woman presented with general fatigue, was found to have anemia, and was referred to our hospital. Upper gastrointestinal endoscopy revealed a submucosal elevated lesion with a bleeding site and debris at the middle thoracic esophagus. Enhanced computed tomography demonstrated a thoracic aortic aneurysm compressing the esophagus. She was diagnosed with an aorto-esophageal fistula due to the thoracic aortic aneurysm. Graft replacement was performed under partial extracorporeal circulation. Because the perforation of the esophagus was small, omental flap transposition was performed without esophagectomy. Her post-operative course was uneventful, and she has been doing well without any infective episodes over 3 years after surgery.

[Corrected Transposition of the Great Arteries, Ventricular Septal Defect, Tricuspid Regurgitation and Pulmonary Hypertension Operated at Middle Age: Report of a Case].

A 45-year-old male with corrected transposition of great arteries and the ventricular septal defect (VSD) was considered to have no indication for the total repair because of severe pulmonary hypertension in his young age. He was suffered from heart failure with absence at the age of 44. Detail examinations revealed the severe tricuspid valve regurgitation with VSD. We reevaluated him for the operative indication by the aspect of pulmonary hypertension. His pulmonary vascular resistance decreased with the administration of 100% oxygen, and no pulmonary vascular obstructions were detected in the lung specimen. As a result, he underwent VSD patch closure and tricuspid valve replacement. His postoperative course was uneventful and he was discharged from our hospital at day 16 postoperatively. Our data suggested that reevaluation including lung biopsy should be important to determine operative indication for adult congenital heart disease.

Giant coronary artery aneurysm occluded completely by a thrombus.

A coronary artery aneurysm is an uncommon vascular disorder, and it can be a life-threatening disease when associated with rupture or an embolism. A 52-year-old man was found to have a 50-mm coronary artery aneurysm at the right coronary artery, and the aneurysm was completely occluded by a thrombus. He had no symptoms after arriving at our hospital, and his hemodynamics was stable. Therefore, initially, we administered anticoagulation therapy involving heparin. After therapy, the distal coronary artery was detected when the thrombus dissolved, and elective surgery was planned. Coronary artery bypass grafting, ligation of the inflow and outflow vessels, and resection of the aneurysm were performed. Early anticoagulation therapy and surgical aneurysm resection were effective for treating the completely occluded coronary artery aneurysm. We herein report this rare case of a giant coronary artery aneurysm occluded completely by a thrombus and treated successfully by anticoagulation therapy and surgical aneurysm resection.

[A case with Stanford type A acute aortic dissection that presented with consciousness disturbance and hemiparesis].

The patient was a 63-year-old female who had a past history of hypertension. She suddenly complained of agonizing pain and became comatose soon thereafter. Upon admission, she was in a state of shock, with upper airway obstruction and a coma. The pupils were dilated on both sides. The laboratory data showed that D-dimer was >80µg/mL. Brain CT scan and diffusion weighted MRI of the brain showed no abnormality. On brain 2D-CT angiography, the visualization of the right internal carotid artery and the right vertebral artery was poor. She eventually was able to nod her head in response to verbal commands, but her left extremities were completely hemiplegic. Cerebral angiography showed occlusion of the right vertebral artery at the branching point from the brachiocephalic artery, and was visualized in a retrograde fashion through the left vertebral artery. The brachiocephalic artery was severely stenotic in aortography. During angiography, she became able to speak and complained of back pain. Chest CT just after angiography showed a dissection in the aortic arch. Therefore, she was directed to the cardiovascular surgeon for immediate consultation. During the operation, the aortic dissection was revealed to be Stanford type A. Laceration of the intima was found in the ascending aorta and cardiac tamponade was also found. Total arch replacement was performed. The pathological examination showed that the arterial dissection occurred in the layer of elastic fiber, and the minimum arterial thickness of the medial layer was 0.2mm. The patient improved after the operation and her neurological deficits disappeared completely 13 days after operation. Brain and spinal MRI 15 days after the operation showed no abnormality.

[Left atrial posterior wall flap method for II a type of the isolated total anomalous pulmonary venous drainage].

We address the left atrial posterior wall flap (LAPF) method for the isolated total anomalous pulmonary venous drainage( TAPVD) II a. The postoperative pulmonary venous obstruction( PVO) is a serious complication and is not rare after repair of the isolated TAPVD II a by the conventional surgical techniques. The LAPF method contains superiorities to prevent PVO to the conventional surgical techniques by wider left atrium(LA) - pulmonary vein(PV) communication, less risk of turbulence and no need of a prosthetic patch or an autologous pericardial patch. Furthermore, from a hemodynamic point of view, it makes LA-PV communication a functional preloading chamber which leads the postoperative hemodynamics stable. So, we think that the LAPF method is able to be a standard operative technique for the isolated TAPVD II a.

[Acute type a aortic dissection operated in childhood; report of a case].

A 12-year-old boy without any previous history and risk factors of cardiovascular disease presented to the emergency room with persisting general fatigue, bilateral shoulder pain and facial pallor. He was diagnosed as acute type A aortic dissection with cardiac tamponade by ultrasonic cardiogram (UCG) and computed tomography (CT) imaging, and the emergency surgery was indicated. He underwent hemiarch replacement because his aorta diameter was quite small but grafting as a large vascular prosthesis as possible was necessary in consideration of the growth. His postoperative course was uneventful and good, and he was discharged from our hospital in day 21 postoperatively. Acute aortic dissection in childhood is very rare but life-threatening. We should consider the particularity of children and make early diagnosis and treatment appropriately.

An adult case of giant congenital left atrial wall aneurysm.

Congenital left atrial wall aneurysm is a rare disorder that occurs in a wide range of age groups from infancy to adulthood. Here, we present a case of a congenital left atrial wall aneurysm that was detected in a 19-year-old man who was surgically treated. Although the patient was asymptomatic without any pre-existing conditions, chest radiography performed as part of a routine health examination detected abnormalities in the heart. Contrast-enhanced computed tomography revealed a giant aneurysm measuring 72 mm × 56 mm that extended from the posteroinferior wall of the left atrium to the posterior surface of the left ventricle. Transthoracic echocardiography revealed mild mitral regurgitation. The patient was diagnosed as having a congenital left atrial wall aneurysm associated with mild mitral regurgitation. The aneurysm was resected through median sternotomy under cardiopulmonary bypass with cardioplegic arrest. During surgery, no structural abnormalities were noted in the mitral valve. After surgery, the patient was discharged without complications. Neither recurrence of the aneurysm nor exacerbation of mitral regurgitation was observed at 1 year postoperatively. Learning objective: A congenital left atrial wall aneurysm is a rare disorder. Rupture of the aneurysm is rare. However, when they are left untreated, there are concerns regarding arrhythmias, heart failure, and systemic embolism. Thus, surgical treatment is recommended. Aneurysms are resected under cardiopulmonary bypass. In cases of aneurysms complicated by moderate or severer mitral regurgitation, mitral valve repair is necessary. The prognosis following surgical treatment is favorable.

Giant biatrial myxoma with two different gross findings.

We experienced a giant biatrial myxoma concomitant with hepatocellular carcinoma. Most of myxomas originate from the left atrium, and biatrial myxomas are extremely rare. Excision of the giant cardiac tumor was performed to avoid risks of life-threatening complications. The resected mass was grossly composed of two parts with the border of interatrial septum and with the shape of peanut shell. Although microscopic examinations revealed enlarged vessels, hemorrhages and hemosiderosis in the left part and high cellularity with chronic inflammation in the right part, spindle-shaped cells in a loose myxoid stroma were observed in both parts of the tumor, consistent with the diagnosis of myxoma. His second operation for hepatic cancer was successfully performed following 1 month after the first operation. Surgical treatment should be considered for giant atrium tumor which has risk of life-threatening complications even if patients have another cancer.