We report a case of multiple papillary fibroelastoma (PFE) on the aortic valve. A healthy woman in her 60 s was referred to a nearby doctor with the chief complaint of palpitation and was admitted to our hospital for detailed examination. A mobile tumor was found by transthoracic echo, and she was introduced to us. We undertook excision surgery for her. Initially, it was thought to be a single tumor, and a pedunculated tumor adhering to the central aortic side of the left coronary cusp with a length of 7 mm was removed. After closing the aorta, we recognized a remaining mobile tumor by transesophageal echo. We decided to perform cardiac arrest again, and we recognized one tumor with 6 mm long string-like mobile mass on the right and non-coronary commissure of cardiac side, and a thorn-like mass of about 1.5 mm on the non-coronary cusp of the cardiac side. We removed both tumors from the aortic valve using shaving resection and preserved the aortic valve. All of these were found to be PFE pathologically as if they were three tumors that followed the developmental stage of PFE. After surgery, PFE recurrence is extremely rare. In the case of a pedunculated tumor, it is possible to remove the tumor and preserve the valve. However, as in this case, if both sides of the valve were not carefully inspected, it can be overlooked. In addition, small tumor resection could avoid the risk of new cerebral infarction and myocardial infarction due to recurrence and could avoid reoperation.
A 41-year-old man who had a history of suicide attempt by self-stabbing of the chest at the age of 15 and surgical repair of the stab wound of the heart was transferred to a neurosurgical hospital suffering from right hemiparesis. Stroke was diagnosed and he successfully underwent endovascular thrombectomy but postoperative computed tomography revealed left ventricular aneurysm and intracavitary thrombus that could have caused the embolic stroke. He was transferred to our hospital for cardiac surgery to prevent another embolization. Although an emergency operation had been attempted for the large and mobile thrombus, the patient was carefully observed for 4 weeks prior to surgery because of acute and huge stroke with a high risk of perioperative intracranial hemorrhage. After a fortunately uneventful observation, thrombectomy with left ventriculoplasty was performed successfully and the postoperative course was uneventful without neurological impairment. To prevent a fatal embolic event, postoperative follow-up after successful repair of cardiac injury is mandatory.
A female in her 60 s with a mobile cardiac tumor in the left atrium was referred to our hospital. The tumor was diagnosed as myxoma by echocardiography, CT scan, and MRI. Under cardiac arrest using cardiopulmonary bypass, we resected the tumor through the superior trans-septal approach. We resected two tumors (tumor 1 and 2) with adequate rims of the interatrial septum to avoid recurrence. Although the tumor had a broad base and extended to near the mitral annulus, mitral valve repair was not necessary. Tumor 1 was gelatinous and seemed to be a myxoma ; tumor 2 had a lot of papillary structures attached to the solid mass and presented with the figure of a sea anemone when it was put in saline, which is typical for papillary fibroelastomas. The defect of the interatrial septum was closed with the autologous pericardium. The postoperative course was uneventful. Unexpectedly, both tumor 1 and 2 were diagnosed as myxomas on pathological examination. Tumor 2 (papillary lesion) included a few tumor cells with positive staining of calretinin typical for myxoma and was diagnosed as a "villous-type myxoma". Because it is difficult to distinguish myxoma from papillary fibroelastoma by pre- and intraoperative findings, it would be recommended to resect tumors with an adequate margin to prevent recurrence.
Surgical cases for pulmonary artery aneurysm after palliative operation for congenital heart disease are rare. A man in his 40s underwent Waterston operation (side-side anastomosis of the ascending aorta and right pulmonary artery) for pulmonary atresia and ventricular septal defect at the age of one. Medical follow-up was continued at a local clinic without definitive repair. He had complained of exertional dyspnea and cough for one month. CT scan on admission showed a large right pulmonary artery aneurysm and atelectasis of the right lung. An urgent operation was planned for the huge pulmonary artery aneurysm. Under cardiac arrest, the proximal end-to-side anastomosis to the aorta was conducted using a Y-shaped vascular prosthesis at the previous Waterston anastomosis. The peripheral pulmonary arteries were reconstructed by inclusion technique. Percutaneous cardiopulmonary support was necessary for one day after operation due to unstable hemodynamics. He was extubated on postoperative day (POD) 4 and transferred to our general ward on POD 5. He was discharged home on POD 38. He is now free from heart failure symptoms and recurrence of aneurysm one year after surgery. Careful follow-up is necessary for the dilatation of the pulmonary artery and aortic root. A definitive operation—Rastelli and closure of the ventricular septal defect—may be considered in the future if the pulmonary artery resistance is suitable for the repair.
Background : Persistent endoleak is a major cause of aneurysmal enlargement or rupture after endovascular aneurysm repair (EVAR). Although several reports have described ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy as useful strategies, treatment for type II endoleak after EVAR is controversial. Objectives : We investigated the early results in 5 patients who underwent ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy for type II endoleak. Methods : A>10 mm increase in aneurysm diameter after primary EVAR or a maximum diameter>65 mm serve as indications for intervention for type II endoleak. Under general anesthesia, following transperitoneal exposure of the abdominal aorta, the infrarenal aorta was banded using a tape at the proximal landing zone. After the aorta was opened without clamping, the lumbar arteries were ligated, and a stent graft-conserving aneurysmorrhaphy was performed. Results : The mean interval from the primary EVAR was 47±17 months. The mean operation time was 215±76 min. Blood transfusion was necessary in 4 patients (estimated blood loss 1,260±710 ml). No in-hospital deaths were observed, and the mean postoperative hospital stay was 26±20 days. One patient developed aspiration pneumonia and 1 developed surgical site infection post-surgery. The diameter of the aneurysm changed from 68±8 to 47±5 mm during hospitalization and decreased further to 36±7 mm at the last follow-up. Conclusions : The early results of ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy were favorable. Although this strategy could be useful for aneurysmal dilatation secondary to persistent type II endoleak after EVAR, the indications for this approach should be determined following careful evaluation of the patient's status considering the invasiveness of the procedure.
活動期感染性心内膜炎(infective endocarditis:IE)に対する外科治療は,心不全や感染の制御,塞栓症の予防の観点から,適応,手術時期を判断し,感染組織の可及的切除により再感染を予防する.また,脳合併症を呈する場合には,梗塞後出血や新規発症のリスクを考慮に入れたうえで適切な手術時期を決定すべきである.大動脈弁位では弁周囲膿瘍が起こりやすく,周囲組織との解剖学的関係を十分理解し,郭清,再建を行う.僧帽弁位では弁形成の可能性を常に考慮すべきである.
Congenital coronary artery-pulmonary artery fistula is rare and occurs concomitantly with various disease conditions, including myocardial ischemia symptoms and aneurisms. Such a fistula complicated by continuity to a systemic blood vessel is even rarer. The patient was a healthy 75-year-old man who had lost consciousness for several tens of seconds at home. An examination performed at a nearby neurosurgical clinic showed no abnormalities, and he was referred to our cardiovascular department for detailed examination for suspected cardiogenic syncope. Sick sinus syndrome was diagnosed based on Holter monitoring. Pulmonary artery-bilateral coronary artery fistula with coronary artery stenosis was diagnosed on coronary arteriography. It was difficult to determine whether coronary bypass surgery was indicated because of the presence of a fistula. Based on the overall evaluation of coronary fractional flow reserve, coronary artery ultrasound, and stress myocardial scintigraphy in addition to usual coronary arteriography, triple-vessel bypass surgery was indicated. Preoperative CT angiography showed a left common carotid artery/bronchial artery-pulmonary artery fistula, with a communication at a bilateral coronary artery-pulmonary artery fistula. Coronary artery bypass surgery was performed in addition to coronary artery-pulmonary artery fistula ligation, left common carotid artery-pulmonary artery fistula closure, bronchial artery-pulmonary artery fistula closure, and pacemaker implantation. Preoperative CT angiography and perioperative surface echocardiography were useful for locating fistula openings. The abnormal blood vessels that allowed blood flow from the left common carotid and bronchial arteries, and into the fistula vessel opening were ligated previously. When cardioplegic solution was injected, the fistula opening was directly pressed, which facilitated the solution to spread over the cardiac muscle, contributing to full cardiac arrest. Postoperative CT angiography showed disappearance of the pulmonary artery-bilateral coronary artery fistula and left common carotid artery/bronchial artery-pulmonary artery fistula. To our knowledge, there are no reports describing the surgical treatment of left common carotid artery/bronchial artery-pulmonary artery fistula and bilateral coronary artery-pulmonary artery fistula. Here we report this rare case with a review of the relevant literature.