[Two cases of mitral stenosis associated with ball thrombus in the left atrium].

Two patients (55-year-old female and 77-year-old female) were operated on for mitral stenosis associated with left atrial ball thrombus. The first case had the episode of cerebral infarction and second case had syncopal attack. Both of them presented with systemic arterial embolism. After confirmation of the diagnosis by echocardiography, removal of ball thrombi, OMC and MVR were carried out urgently. Considering high risk of "hole in one sudden death" and multiple-episodes of systemic embolization, ball thrombus should be removed as urgent following confirmation of diagnosis.

Aneurysm of a branch of the subclavian artery with multiple arteriovenous fistulae.

A rare case is reported of an 83-year-old woman with an aneurysm of a branch of the subclavian artery with multiple arteriovenous fistulae. The patient was admitted to our hospital with a pulsatile mass in the supraclavicular space and a prominent continuous murmur which radiated to the anterior chest, right forearm and right neck. She first noticed a pulsatile 2 cm mass in 1972, 1 year following a subtotal gastrectomy. At that time, she had intravenous therapy through a right neck vein. In 1993, the mass became larger, and she developed a shunt murmur. Digital subtraction angiography (DSA) demonstrated an aneurysm of the right subclavian artery and an arteriovenous fistula between the right subclavian artery and vein. The right common carotid artery and right subclavian artery arose from the aortic arch separately. The aneurysm arose from a branch of the subclavian artery which may be the costocervical trunk. The 5 x 4 cm aneurysm was resected and the arteriovenous fistula was divided. On postoperative day 5, a new murmur was ausculated. A repeat DSA detected a new fistula between the axillary artery and vein. Reoperation was performed to ligate and divide the fistula. Pathological examination revealed an atherosclerotic aneurysm.

[Obstruction of the true lumen by retrograde perfusion during repair of DeBakey type I aortic dissection: a case report].

Retrograde femoral perfusion is often used during the repair of DeBakey type I aortic dissections, however, it may cause serious ischemic damage of vital organs even though the arterial cannula is properly placed. A 58-year-old woman with chest pain was admitted to our hospital. She was operated on urgently because chest computed tomograms revealed that she suffered from a DeBakey type I aortic dissection. A ringed graft, 22 mm in diameter, was implanted into the ascending aorta using retrograde perfusion through the right femoral artery. Following the removal of the aortic cross-clamp and rewarming, the prosthetic graft remained flaccid and the heart failed to resume beating. We speculated that retrograde femoral perfusion caused the true lumen obstruction while distending the false lumen. This resulted in blocking reperfusion of the coronary arteries. After antegrade perfusion was initiated through an 8 mm Dacron graft which was anastmosed to the ringed graft, the heart soon resumed beating. During the repair of DeBakey type I aortic dissections, this serious complication should be anticipated. If it occurs, retrograde femoral perfusion must be exchanged for antegrade aortic perfusion before irreversible changes occur.

[Operative removal of esophageal leiomyosarcoma: a case report].

This is a case report of 56-year-old man complaining of dysphasia. Upon admission, his chest X-ray film revealed medium amount of fluid accumulation in the right pleural space. Cytological examination of the aspirated fluid revealed nothing particular. Preoperative radiological examination including esophagogram, CT and MRI demonstrated cystic appearance of mass lesion, measuring approximately 5 cm in size located in posterior aspect of the lower portion of the mediastinum. Upon operation, it was found that a tumor with pedunculated connection to the esophageal muscle layer, suspecting diagnosis of leiomyoma of the esophagus. Then, tumor was removed together with the part of esophageal muscle. Postoperative pathology reported leiomyosarcoma of the esophagus with low grade malignancy. We added no esophagectomy. He made uneventful recovery without no sign of recurrence of the malignancy, 4 years after the surgery.

[Surgical management of coronary artery fistula with tricuspid stenosis in a three-month-old infant].

This is a case report of a 3-month-old infant who had been suffering from progression of cardiac failure. Two dimensional echo-cardiography revealed a fistula between the right coronary artery to the right heart. He was operated upon using extracorporeal circulation. Symbas procedure was carried out to close the fistula. Upon opening the right atrium, there noted tricuspid stenosis (TS). Then, ASD was created to reduce the right atrial pressure to prevent right heart failure secondary to TS. He is doing well postoperatively.

[Mitral valve replacement and closure of atrial septal defect in the case associated with Marfan syndrome].

This is a case report of 8-years-old boy, who was diagnosed mitral regurgitation, secundum type of atrial septal defect and annulo-aortic ectasia in association with Marfan syndrome. His diagnosis was confirmed at the age of 6 years when cardiac catheterization was carried out. Atrial septal defect was closed using PTFE patch (0.2 mm in thickness). His diseased mitral valve was replaced with CarboMedics prosthesis 27 mm in diameter. Because of intact aortic valvular function, we left the ectatic aorta alone at present time for future procedure. His postoperative course was uneventful. He is active and doing well at present and has been followed-up at the outpatient clinic routinely. He might be having to require AVR and graft implantation for ectatic ascending aorta.

[Endoscopic closure of the postoperative bronchopleural fistula].

A case of successful endoscopic closure of a bronchopleural fistula with fibrin glue was reported. Fifty-eight-year-old man underwent right lower lobectomy for lung carcinoma. On the 21st postoperative day, he suffered from high fever and diagnosed as right side pyothorax. Then tube thoracotomy was done under UCG-guide. As a fistula in the right lower bronchial stump was found tiny by BFS, we tried to close the fistula bronchoscopically with fibrin glue. The fibrin glue was injected into the fistula via the ERCP tube, which was passed through the bronchoscope. This procedure was performed twice for two weeks interval. The fistula was completely closed about a month after the trial. This method is useful to close postoperative small bronchopleural fistula without surgical intervention.

[A case report of surgical treatment of acute aortic dissection (DeBakey III B) in association with thoracic aortic aneurysm].

This is a case report of 63-year-old man suffering from DeBakey III B acute dissection in association with thoracic aortic aneurysm. He had been following up for hypertension and thoracic aortic aneurysm. He was brought to the hospital by city ambulance complaining of sudden onset of severe back pain. Emergency operation was carried out. It revealed aneurysm of 90 mm in diameter located just distal to the aortic arch and an intimal tear or entry of the dissection located distal to the left subclavian artery. A low porosity Dacron graft was interposed between the distal aortic arch and middle portion of the thoracic descending aorta using inclusion technique. Systemic circulation was bypassing external iliac vein to artery using pump-oxygenator during aortic clamping. His postoperative course was uneventful. In review of the literature, association of the atherosclerotic aneurysm and acute dissection occurred approximately 5% in the cases of aortic dissection with increasing risk of aneurysmal rupture.

[A case report of emergency surgical repair of traumatic transection of thoracic descending aorta].

The injury to the thoracic aorta caused by blunt chest trauma is often fatal. This case is 22-year-old male suffering from transection of the thoracic descending aorta caused by traffic accident. He was transported to our emergency room by an ambulance 15 minutes after the accident. Hundred fifty minutes after arrival to the hospital, we were rush to bring him to the operation theater suspecting serious injury of the thoracic organs in association with left hemothorax. The left standard thoracotomy disclosed the injury of the thoracic descending aorta. Simple cross clamp was applied to the thoracic descending aorta distal to the left subclavian artery for 20 minutes. Completely transected aorta was reapproximated using monofilament 3-0 polypropylene sutures with running manner. He tolerated the procedure well without any complication. His postoperative course was uneventful. He was followed up at the orthopedic department for associated hip fracture thereafter.

[Surgical repair of postinfarction cardiac rupture in three cases].

Operative managements and results of postinfarction left ventricular (LV) rupture in 2 patients and right atrial (RA) rupture in one patient are reviewed. Two patients showed both subacute onset of LV rupture in association with cardiac tamponade. The site of infarction was inferior wall in one and anterior wall in the other. Both patients underwent infarctectomy with closure of the defect using a Dacron felt patch. Endocardial site of the Dacron patches were covered with own pericardium to avoid bleeding from the patch and postoperative complication of endocardial clot formation. The case with extended inferior wall infarction was succumbed to cardiac failure and acute renal failure at the twelfth postoperative day. The other case was uneventful postoperatively and shows excellent long-term result. Left ventriculography and coronary angiographic studies were carried out 3 months after the surgery. It demonstrated 43% of LVEF. Multiple stenotic lesions were also noted in left coronary artery. The third patient was rupture of the RA in association with cardiac tamponade. Direct suture closure of the rupture was carried out under extracorporeal circulatory support. Patient tolerated the procedure well. Postoperatively, he suffered from exacerbation of renal insufficiency necessitating hemodialysis for a month. He discharged from hospital and now in the good condition. Postoperative RI study and coronary angiography demonstrated no compatible finding of right atrial infarction. However, pathological specimen revealed definite diagnosis of the infarction at the RA appendage.

[Supravalvular aortic stenosis syndrome with advanced mitral regurgitation requiring extended aortoplasty and mitral valve replacement: a case report].

This is a case report of a 28-year-old male, suffering from supravalvular aortic stenosis (systolic pressure gradient 60 mmHg) and severe mitral regurgitation associated with elfin face and mental retardation. Severely prolapsed mitral valve with elongated chordae tendineae was replaced with Björk-Shiley mitral valve prosthesis. Simultaneously, extended aortoplasty was carried out using Doty's method. His postoperative course was uneventful. Catheterization study, carried on one month after surgery, revealed complete disappearance of supravalvular aortic stenosis and mitral regurgitation. In review of the literature, as far as we know, report of successful combined correction for supravalvular aortic stenosis and mitral regurgitation is extremely rare.