[Successful Open Surgical Repair of Asymptomatic Coronary Artery Fistula with Giant Aneurysm: Report of a Case].

Coronary artery fistula is an uncommon congenital anomaly of the coronary arteries, and there are lots of variations. We present a-46-year-old male patient with abnormal cardiac silhouette on chest X-ray. Coronary computed tomography (CT) angiography showed coronary artery (left anterior descending artery)-to-pulmonary artery fistula with a giant aneurysm( 55 mm). Considering the risk of rupture, surgery was indicated. The patient underwent surgical repair through median sternotomy under cardiopulmorary bypass and cardiac arrest antegrade myocardial protection. Fistulas were dissected and ligated proximally and distally, then the aneuysm was resected. By flushing bloody cardioplegic solution, we confirmed that there was no residual blood inflow to the aneurysm. Post-operative course was unevenful without evidence of myocardial injury. The patient discharged home on 10th postoperative day.

Successful surgical repair of traumatic aortic dissection utilizing the Najuta stent graft in a patient with pre-existing situs inversus and anomalous neck vessels.

We report the case of a 39-year-old man who underwent surgical repair for traumatic Stanford type B acute aortic dissection. He was involved in a traffic accident, resulting in multiple rib fractures and a sternum fracture. On investigation, he was also found to have anatomical anomalies, namely, situs inversus and abnormality in the aortic arch and neck vessels. Thoracic endovascular aortic repair was performed as it is a less invasive procedure, thus recommended in such cases. A fenestrated thoracic endovascular aortic repair using the Najuta stent graft was found to be effective in this case where the anomalous anatomy was pre-existing.

Nonbacterial thrombotic endocarditis involving all four cardiac valves.

This report describes a case of nonbacterial thrombotic endocarditis caused by Waldenström macroglobulinemia, with diffuse endocardial lesions and involvement of all 4 cardiac valves. A 77-year-old man presented with heart failure due to severe regurgitation of all 4 cardiac valves; surgical repair using bioprosthetic valves was indicated. A pathological study revealed fibrin-triggered thrombus formation that confirmed the diagnosis of nonbacterial thrombotic endocarditis. In cases of nonbacterial thrombotic endocarditis, the underlying cause should be investigated.

Extra-Adrenal Retroperitoneal Paraganglioma with Extensive Duodenal Invasion and Inferior Vena Cava Tumor Thrombus.

We report a case of extra-adrenal retroperitoneal paraganglioma (RP) with extensive duodenal invasion and tumor thromboses both in the right testicular vein and in the inferior vena cava (IVC). Because there was rigid adherence between the RP and the abdominal aorta, pancreatoduodenectomy with replacement of the IVC and aorta was performed for complete surgical resection. In the present case, both the mode of progression of the RP and the surgical approach were extremely rare.

Granulomatosis with Polyangiitis (Wegener's Granulomatosis) Complicated with Ruptured Posteromedial Papillary Muscle in the Absence of Coronary Angiographic Findings.

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis, associated with antineutrophil cytoplasmic autoantibody-associated systemic vasculitis, and it can affect many organ systems via the inflammation of small-to-medium-sized vessels. Cardiac involvements in GPA are relatively rare. We report a 75-year-old woman who was diagnosed with GPA and rapid progressive glomerulonephritis that resulted in a partial posteromedial papillary muscle rupture, but with no coronary angiographic findings. The surgical and pathological findings with regard to the ruptured papillary muscle revealed necrotic muscle and acute ischemic change. The mechanism of papillary muscle rupture in GPA is coronary vasculitis leading to myocardial infarction. The ischemic change is not always detected on coronary angiography, so assessment using an echocardiogram is important.

[Mitral valve replacement for a severely calcified mitral annulus].

An 80-year-old woman was referred to our institution because of acute heart failure due to moderate mitral stenosis and severe regurgitation. After medical treatment of heart failure, she underwent mitral valve surgery. Intraoperatively severe calcification of the posterior mitral annulus was revealed. We excised only the anterior mitral leaflet and preserved the posterior mitral leaflet to prevent a fatal complication such as left ventricular rupture, injury of the coronary artery or embolism. Partial resection of the calcified annulus was performed using Ultrasonic Surgical System (SonoSurg), after 2-0 polyester mattress sutures were placed through the anterior and posterior annuli from the left ventricle to the left atrium. Then, mitral valve replacement was performed using a St. Jude Medical mechanical heart valve at the supra-annular position. The postoperative course was uneventful. We concluded that partial resection of a severely calcified posterior mitral annulus by the ultrasonic device was a safe and simple procedure.

Effects of right atrial pacing preference in prevention of paroxysmal atrial fibrillation: Atrial Pacing Preference study (APP study).

BACKGROUND: Several preliminary studies have indicated that atrial pacing can prevent atrial tachyarrhythmias. The suggested mechanisms by which pacing may be effective include suppression of premature atrial beats. METHODS AND RESULTS: The Atrial Pacing Preference (APP; Guidant, St Paul, MN, USA) algorithm allows the pacemaker to maintain a pacing rate slightly higher than the sinus rate. The preventive effects of APP on paroxysmal atrial fibrillation (AF) were studied in 51 patients (70+/-11 years). Nine patients did not complete the protocol. The pacemaker was programmed in random order to APP off and APP on at 3 different settings (ie, 8, 16 and 32 cycles) for 4 weeks each, using a cross-over design. Percentage atrial pacing was lower in APP off than at the other settings. Premature beat counts were greater in APP off than at the other settings. There was a significant difference in mode switch episode counts between APP off and the most effective setting (3,818+/-15,356 vs 596+/-1,719; p<0.01). CONCLUSIONS: The APP algorithm is a promising method for preventing atrial tachyarrhythmia in patients with an implanted pacemaker and AF. Optimizing the setting of the APP algorithm is an important issue in the prevention of AF.

Review of coronary artery disease in patients with infrarenal abdominal aortic aneurysm.

In the process of establishing a less invasive assessment strategy for coronary artery disease (CAD) in patients with infrarenal abdominal aortic aneurysm (AAA), the incidence of CAD and the surgical and mid-term outcomes were reviewed. From January 1994 through September 2001, 94 elective surgical repairs of AAA were carried out. Preoperative coronary angiography showed 43 patients (45.7%) had CAD: 29 (67.4%) were asymptomatic, 23 had single-vessel disease (1VD), 12 had 2VD and 8 had 3VD. Of the 43 patients with CAD, 19 (44.2%) underwent coronary interventional therapy before aortic surgery (11 percutaneous transluminal coronary angioplasty (PTCA), 8 coronary artery bypass grafting). Eight asymptomatic patients underwent coronary interventional therapy. None of the patients died of cardiac causes or experienced a postoperative cardiac event. During the follow-up period, 10 late deaths occurred: 7 patients with CAD, and 3 cerebrovascular or cardiac deaths. There was no statistical difference in the survival rate between the groups with and without CAD. Two patients with CAD underwent PTCA during the follow-up period. The findings confirm the need for a less invasive assessment strategy of CAD that does not overlook asymptomatic myocardial ischemia, because the incidence of CAD in patients with AAA is high.

Obstruçäo da via de saída de ventrículo esquerdo por prótese mitral: apresentaçäo de seis casos / Obstruction of the left ventricle outlet by mitral valve prosthesis: report of 6 cases

De janeiro de 1982 a março de 1984, foram implantadas 170 biopróteses de pericárdio bovino e alto perfil, no Instituto do Coraçao do Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, com mortalidade hospitalar de 7,1 por cento. Através do estudo anatomopatológico, foram identificados cinco casos em que ocorreu obstruçao da via de saída do ventrícuio esquerdo após substituiçao da valva mitral. Com base nessa experiência, a indicaçao de estudo hemodinâmico no 1( dia de pós-operatório em paciente em baixo débito, sem explicaçao, possibilitou identificar obstruçao da via de saída do ventrículo esquerdo, com retroca valvar e boa evoluçao. Neste trabalho, sao relatados detalhadamente os seis casos e discutidas as causas da obstruçao da via de saída na substituiçao mitral.

Tratamento cirúrgico da endocardite em prótese valvular cardíaca / Surgical treatment of endocarditis in heart valve prosthesis

No período de janeiro de 1983 a março de 1988, 1.512 pacientes foram submetidos a substituiçao valvar, no Instituto do Coraçao, sendo 28 (1,85 por cento) deles por endocardite em prótese valvular. Dezessete doentes eram do sexo masculino e a idade variou de 18 a 67 anos, com média e desvio padrao de 36,7 + 12,9. A avaliaçao da classe funcional (C.F.) revelou 11 pacientes em C.F. IV, 12 em C.F. III e 5 em C.F. II. Oito (28,5 por cento) pacientes foram operados em condiçoes de emergência. Um paciente era portador e válvula mecânica e 27, de válvula biológica. As hemoculturas foram positivas em 14 (50 por cento) pacientes; o agente mais encontrado foi o Streptococcus viridans em 5 casos. O ecocardiograma realizado no pré-operatório em 27 pacientes mostrou correlaçao com os achados cirúrgicos em 26 (96,2 por cento). Na cirurgia, 17 doentes apresentavam vegetaçao na prótese e 11, abscesso no anel. Na retroca, foram utilizadas biopróteses em 27 (96,4 por cento) pacientes. A mortalidade imediata foi de 28,5 por cento (8 doentes), ocorrendo 1 óbito tardio. A análise da associaçao óbito e tempo de aparecimento da endocardite, condiçao cirúrgica e resultado da cultura foi feita pelo teste de Qui-Quadrado (X(2)). Podemos concluir que as condiçoes clínicas pré-operatórias interferem, decisivamente, no resultado cirúrgico; a cirurgia de emergência tem resultados piores, devido às condiçoes mais críticas dos doentes; as endocardites mais precoces sao mais graves; a manipulaçao de focos infecciosos em pacientes com prótese valvular deve ser cuidadosa e precedida de antibioticoterapia e, nos doentes sobreviventes à operaçao, a evoluçao a longo prazo apresenta melhora significativa da classe funcional.