Background Coarctation of the aorta is a relatively common congenital heart defect. Various operative techniques have been proposed for aortic coarctation repair, which are tailored to individual patient circumstances. However, regardless of the chosen surgical approach, some patients may develop late thoracic pseudoaneurysms. Repeated surgery with a left thoracotomy increases the risk of lung injury and bleeding due to adhesions and rich collateral blood circulation. Case presentation The patient underwent subclavian artery descending aortic bypass surgery for coarctation of the aorta at the age of 22 years and developed a pseudoaneurysm 30 years after bypass surgery. From the available surgical options for this condition, we selected total arch replacement using a frozen elephant trunk. The outcomes were excellent. Conclusions Depending on each patient’s circumstances, revision surgery using the frozen elephant trunk technique can be a viable option.

BackgroundCalcified amorphous tumor of the heart is a rare non-neoplastic cardiac mass composed of calcified nodules over amorphous fibrous tissue with degeneration and some chronic inflammation. Calcified amorphous tumor is often associated with mitral annular calcification in patients with end-stage renal disease on dialysis. However, the exact etiology of calcified amorphous tumors remains uncertain.Case presentationA 77-year-old female with lung cancer showed a tumor with large mobility in the left ventricular outflow tract on transthoracic echocardiography. She had mitral annular calcification, although her renal function was normal. The tumor was excised surgically. Pathologically, the extracted specimen consisted of a calcified lesion without tumor tissue and was diagnosed as a calcified amorphous tumor.ConclusionsAs the patient had no other risk factors for calcified amorphous tumor except mitral annular calcification, we considered the association of blood coagulation abnormalities due to cancer-related thrombosis. This case suggests that calcified amorphous tumors may be associated with malignant tumors.

Abstract We describe a case of successful fenestrated endovascular aneurysm repair (EVAR) for a living kidney transplantation donor. A 79-year-old male visited our hospital for the treatment of a 40-mm diameter left common iliac artery aneurysm. He was a living kidney transplant donor to his son. Because left nephrectomy was planned using retroperitoneoscopy, EVAR was chosen to avoid dissection of the adhesions for organ retrieval. Preoperative computed tomography (CT) revealed a double renal artery in the right kidney, with the lower branch originating from the lower position of the abdominal aorta. We performed surgeon-modified fenestrated endografting to preserve the right lower accessory renal artery and maintain the right renal function after the left nephrectomy. A postoperative CT scan showed no endoleaks, and the blood flow of the right lower accessory renal artery was maintained. In our case, fenestrated EVAR is feasible for preservation of lower originated accessory renal artery, and contributes to maintaining the postoperative renal function of the donor.

気管切開後の合併症である気管腕頭動脈瘻は重篤な病態である．予防的に腕頭動脈離断術を施行した5例について検討した．平均年齢は16歳で，全例に精神発達遅滞があり，気管切開後で気管カニューレが留置されていた．術前の胸部CTで胸郭の著明な変形と脊椎の側弯があり，腕頭動脈が気管前面を走行して気管の圧迫と狭窄があった．頭部CT，MRIでWillis動脈輪の交通を確認した．右上肢と，左上肢または下肢に動脈ラインを確保した．前頚部横切開を行い，胸骨は切開しなかった．腕頭動脈を一時的に遮断後の右上肢の血圧は平均83 mmHgで，右上肢／体血圧の血圧の比は，0.77だった．腕頭動脈を離断し，右総頸動脈と右鎖骨下動脈との連続性を維持するよう断端を閉鎖した．人工血管によるバイパスは行わなかった．術後の経過は良好であった．予防的腕頭動脈離断術は気管腕頭動脈瘻の危険が高い症例を適応とすることは妥当である．

Background: Coronary artery bypass grafting in situs inversus totalis patients has been seldom reported in the literature. Case presentation: A 76-year-old woman visited our hospital for chest pain and dyspnea that had started about 5 years earlier. Coronary angiography revealed triple-vessel disease, and computed tomography showed situs inversus totalis. Coronary artery bypass grafting was performed. In this case, the main operating surgeon stood on the right side of the patient until cardiopulmonary bypass was established and then switched positions to the left side of the patient for anastomosis.Conclusion: CABG was successfully completed in a patient with situs inversus totalis. The position shift helped improve the safety and ease of the surgery.

症例は85歳女性．突然の胸背部痛を主訴に救急搬送され，解離性大動脈瘤と診断し，保存的加療を行った．入院直後に内頚静脈から中心静脈カテーテル（central venous catheter: CVC）を挿入した際に，ヘパリン加生理食塩水（ヘパリン生食）をルート内にフラッシュした．第5病日に再解離したため，緊急上行大動脈置換術を行った．ところが，術後3日目に左片麻痺が出現し，CT検査で広範脳梗塞を認めた．術後4日目には，血小板が顕著に減少し，ヘパリン起因性血小板減少症（heparin-induced thrombocytopenia: HIT）を疑った．精密検査でHITと診断し，アルガトロバンの投与を開始し，新しい塞栓は認めなかった．第49病日，リハビリ病院へ転院した．ヘパリン暴露から血小板減少までの期間を考えると，CVC挿入によるヘパリンフラッシュがHITの契機となったと考えられた．

A 69-year-old male had catheter-based ablation for atrial fibrillation. He was admitted with high fever and had neurological disorder; he was diagnosed with atrioesophageal fistula by CT scan. Intraoperative findings showed that the fistula existed adjacent to the left lower pulmonary vein with a vegetation. The esophageal fistula was repaired, and the left atrial fistula was closed. A nasogastric tube tip was placed in the esophagus for decompression and advanced into the stomach for nutritional support. After vomiting, the patient showed loss of consciousness and left hemiplegia. CT scan revealed a micro-air embolism to the brain. The nasogastric tube tip was pulled back into the esophagus. Gastrointestinal fiberscopy showed a pinhole at the fistula, and a percutaneous endoscopic gastrostomy was made. After conservative treatment, the esophageal fistula was closed and mediastinitis was improved. He was discharged with a little neurological deficit.

症例は66歳，男性．慢性腎不全のため30年前より血液透析を受けていた．5年前に大動脈弁狭窄症と診断され経過観察されていた．2年前に発熱と呼吸困難を主訴に当院に救急搬送され，精査の結果，感染性心内膜炎infective endocarditis（IE）に伴う僧帽弁閉鎖不全症，および完全房室ブロックと診断された．大動脈弁および僧帽弁の二弁置換術double valve replacement（DVR）とペースメーカー移植術を準緊急で行った．感染による炎症は僧帽弁前尖の後交連から僧帽弁輪を超えて房室中隔，右房に波及する広範なものだった．術後，抗生剤の投与により感染は鎮静化した．術後3カ月目に行った経過観察の経胸壁心エコーで僧帽弁輪直下から右房内へ突出する径30 mm大の瘤状構造物を指摘され，IE術後の左室仮性瘤と診断された．その後の心エコーで瘤の拡大を認めたため，前回手術から2年後に今回の手術となった．心停止後に右房を切開すると，コッホの三角部を中心に左室仮性瘤を認め，僧帽弁輪部膿瘍が原因と考えられた．瘤壁を切開すると開口部は径約20 mmだった．径35 mmのポリエステルパッチで開口部を閉鎖した．術後の心エコーでは，瘤内は血栓化し血流はなかった．瘤壁の病理組織所見では心筋細胞は認めず，線維化した組織のみだった．IEに対するDVR後の左室仮性瘤に対して，パッチ閉鎖術を施行した稀な1例を経験したので報告する．

Occlusion of an internal iliac artery or its branches is sometimes required prior to abdominal endovascular aneurysm repair. The Amplatzer vascular plug (AVP) is a useful device for this purpose, but it requires a large lumen catheter or guiding sheath to place it in the intended artery. We propose an anchor balloon technique for advancing this guiding sheath/catheter through a tortuous or angulated iliac artery for AVP placement.

症例は55歳男性．労作時呼吸困難の精査で紹介され，不完全型房室中隔欠損症，僧帽弁閉鎖不全症，卵円孔開存，心房細動，漏斗胸と診断された．漏斗胸を合併した心臓・大血管手術では，術中の良好な視野と術後の安定した血行動態を得るために，心疾患に対する根治術とともに胸郭形成術を一期的に行うことが望ましいとされている．本症例では，自己心膜パッチによる房室中隔欠損孔閉鎖術，クレフト縫合による僧帽弁形成術，卵円孔の直接縫合閉鎖，メイズ手術変法を行った後，閉胸時にRavitch変法による胸骨挙上術を施行した．術後は人工呼吸器による長期の呼吸管理を要したが，徐々に呼吸状態は安定し，術後17日目に抜管した．長期挿管に伴う嚥下障害を併発したが，嚥下リハビリテーションにより嚥下機能は改善し，その後の経過は順調で術後59日目に退院した．本症例では，皮下剥離範囲の広さ，出血量増大のリスク，胸骨肋軟骨複合体の血流維持や感染リスク等の問題を考慮し，胸郭形成には胸骨翻転術ではなくRavitch変法による胸骨挙上術を選択した．心疾患を合併した漏斗胸に対して，胸骨挙上術を併施することで，良好な術野と術後の安定した循環動態が得られると考えられた．

Aortocaval fistula (ACF) is a well-known but uncommon complication of ruptured abdominal aortic aneurysm (AAA). Even with attentive care, oversight of ACFs may occur in emergency cases. Because mortality due to ACF is high, a rapid multidirectional analysis of the preoperative state leading to a correct diagnosis is essential. Here, we report the case of an 82-year-old man with a ruptured AAA and ACF. He presented with multiple organ failure that was initially attributed to congestive heart failure. He underwent emergent surgery and was diagnosed intraoperatively as having an AAA with ACF. He left the hospital 1 month after the operation without complications.

BACKGROUND CONTEXT: Reports of Gorham disease of the lumbar spine complicated by abdominal aortic aneurysms are rare.PURPOSE: We herein report the case of a patient with Gorham disease of the lumber spine involving an abdominal aortic aneurysm (AAA).STUDY DESIGN: Case report.METHODS: A 49-year-old man had a 1-month history of right leg pain and severe low back pain. Plain lumbar radiography revealed an osteolytic lesion in the L4 vertebral body. Computed tomography images demonstrated the presence of an extensive osteolytic lesion in the L4 vertebral body and an AAA in front of the L4 vertebral body.RESULTS: The patient underwent mass resection, spinal reconstruction, and blood vessel prosthesis implantation. During surgery, it was found that the wall of the aorta had completely disappeared and was shielded by the tumor mass; therefore, we speculated that the mass in the lumbar spine had directly invaded the aorta.CONCLUSIONS: The patient was able to walk without right leg or low back pain 1 year after undergoing surgery. No recurrence was demonstrated in the magnetic resonance images taken 1 year and 10 months after surgery. (C) 2014 Elsevier Inc. All rights reserved.

Papillary fibroelastoma (PFE) is a well-known primary cardiac tumor, but multiple PFEs are rare. We report an interesting case with multiple PFEs that were clearly demonstrated and evaluated with real time three-dimensional (RT3D) transesophageal echocardiography (TEE). A 77-year-old woman was referred to our institution with a diagnosis of osteoarthritis of the hip. Transthoracic echocardiography showed an abnormal structure on the aortic valve. Although two-dimensional TEE revealed typical characteristics of multiple PFE, RT3D TEE clearly demonstrated their number and location on the right and non-coronary cusp of the aortic valve. These results were subsequently confirmed by surgery and pathological findings. RT3D TEE is an exceptionally useful tool for pre-surgical evaluation of PFE.

A 68-year-old woman experienced frequent episodes of intermittent abdominal pain 6 months before admission. Because of increasing abdominal pain, she was admitted to our hospital. A computed tomography (CT) scan of the chest and abdomen revealed an enlarged and saccular-shaped thoracoabdominal aorta of 5.3 cm in diameter. No abnormality was seen in the lung aside from the periaortic mass. Laboratory studies revealed a white blood cell count of 7000/μl and a C-reactive protein level of 5.36 mg/dl (normal laboratory range <0.1). The suspected diagnosis was an infected thoracoabdominal aortic aneurysm. All blood bacteriological cultures were negative. The patient was treated conservatively by administration of analgesics, antihypertensive drugs, antibiotics, and heparin. Nevertheless, 3 months after admission, the diameter of the thoracoabdominal aorta reached 6.3 cm (Figure 1). As the patient experienced three attacks of thromboembolism of the legs, an emergency thrombectomy was performed. A pathological examination revealed no malignant cells in the removed thrombus. Subsequently, the patient was transferred to another hospital and underwent a surgical resection with an allograft replacement of the thoracoabdominal aorta, the celiac artery, the superior mesenterial artery, and the bilateral renal artery. A partial resection of the lower lobe of the left lung was also performed because a portion of the tumor was localized in the left lung. Macroscopically, the mass surrounding the resected aorta was solid, and there was no bleeding into the mass. Histopathology finally revealed a mass surrounding the aorta and that the intrapulmonary tumor was a pulmonary large cell carcinoma. The tumor had invaded the wall of the aorta, and tumor cells were found in the mural thrombus of the resected aorta. The tumor had also caused intravascular obstruction and stenosis of branches of the resected abdominal aorta. It was also revealed that the resected margin of the aorta was positive for tumor cells. The chest CT findings of pulmonary large cell carcinomas are frequently a single, peripheral mass or nodule with an irregular shape and margins with signs of lobulation.1Stojsic J Stevic R Kontic M et al.Large cell lung carcinoma with unusual imaging feature, immunophenotype and genetic finding.Pathol Oncol Res. 2011; 17: 175-179Crossref PubMed Scopus (7) Google Scholar In our case, the tumor existed in an atypical location and extended into the mediastinum and surrounded the aorta mimicking an infected thoracoabdominal aortic aneurysm. The tumor possessed some CT features specific to an infected aortic aneurysm, such as an atypically located saccular-shaped mass, rapid progression, and lack of athelosclerotic signs.2Azizi L Henon A Belkacem A et al.Infected aortic aneurysms: CT features.Abdom Imaging. 2004; 29: 716-720Crossref PubMed Scopus (20) Google Scholar Furthermore, the patient had repeated attacks of thromboembolism, probably because tumor cells were migrating into the mural thrombus in the aorta. This pattern of the tumor presentation is extremely rare,3Margolis JA Cohn RA Griffin JP et al.Oat cell carcinoma presenting as a pseudoaneurysm.South Med J. 1980; 73: 1087-1089Crossref PubMed Scopus (5) Google Scholar and symptoms and images obtained before surgery led to the diagnosis of an infected aortic aneurysm. An infected aortic aneurysm is an uncommon disease2Azizi L Henon A Belkacem A et al.Infected aortic aneurysms: CT features.Abdom Imaging. 2004; 29: 716-720Crossref PubMed Scopus (20) Google Scholar; however, the imaging characteristics overlap with those of tumors, such as a rapidly expanding mass with heterogeneous enhancement. Thus, if a thoracoabdominal aortic mass is encountered that mimics an infected thoracoabdominal aortic aneurysm, cancers originating from organs surrounding the aorta, particularly lung cancer, should be included in the differential diagnosis. The pathological evaluation revealed a residual tumor in the patient, but no obvious distant metastasis was found immediately after the surgery. The patient was treated with best supportive care because of the existence of the allograft beside the residual tumor and her poor performance status.

It has previously been reported that cardiac troponin I (cTnI) is useful in predicting the postoperative course after cardiac surgery, and that elevated serum cTnI levels are associated with increased in-hospital mortality. However, these findings have been reported in heterogeneous groups of cardiac surgical procedures. In the current study, the usefulness of postoperative cTnI measurements for the prediction of patient outcomes in a specific group of cardiac surgical procedures was determined, with the analysis limited to patients undergoing mitral valve surgery. The results of cTnI measurements were compared with postoperative creatine kinase-myocardial band fraction (CK-MB) levels.A total of 24 patients who underwent mitral valve surgery from July 2004 to April 2009 were retrospectively studied. Serum cTnI and CK-MB levels were measured on postoperative day (POD) 0 (immediately after surgery), and on POD 1, 2, and 3. The relationship between serum cTnI and CK-MB levels, cardiopulmonary bypass (CPB) time, aorta cross-clamping (AoC) time, and the length of ICU stay and postoperative hospital stay (POHS) were evaluated.CPB and AoC time influenced postoperative cTnI and CK-MB levels. Values of cTnI on POD 1 and POD 2 were significantly correlated with the length of ICU stay, whereas only the CK-MB level on POD 2 was significantly correlated with the length of ICU stay. In addition, the cTnI levels on POD 1 and POD 2 were significantly correlated with POHS, however, there was no relationship between postoperative CK-MB levels and POHS. Postoperative cTnI measurements are more useful than CK-MB measurements in predicting the postoperative course of a patient following mitral valve surgery.

先天性第X因子欠乏症に合併した腹部大動脈瘤に対して，凝固因子製剤の投与下で人工血管置換術を施行したので報告する．症例は84歳男性．平成7年4月に前立腺癌の疑いで前立腺針生検を予定されていたが，術前検査で凝固異常を認め，先天性第X因子欠乏症と診断された．平成19年1月，CTで瘤径60mmの腹部大動脈瘤を発見された．術前に複合型凝固因子製剤PPSB®-HTによる凝固因子の試験投与を行い，周術期の至適投与量を決定した．手術はPPSB®-HT投与下に人工血管置換術を施行した．第4病日までPPSB®-HTを補充し投与を終了したが，その後も異常出血はなかった．術前に凝固因子製剤を用いた試験投与を行い，周術期の至適投与量を決定することで，ヘパリン投与を必要とする心臓血管外科手術においても，周術期に異常出血等の合併なく手術を施行することができた．

骨髄異形成症候群を合併した開心術は出血や感染症のリスクが高く，また周術期治療の明確なガイドラインはない．われわれは周術期の蛋白同化ステロイド，活性型ビタミンD3，ビタミンK2の投与による薬物療法と，輸血による補助療法により，骨髄異形成症候群を合併した大動脈弁狭窄症に対し，大動脈弁置換術を安全に施行できた1例を経験した．症例は73歳，女性．骨髄異形成症候群（不応性貧血）の経過観察中に，胸痛の精査で大動脈-左室間圧較差140mmHg，大動脈弁口面積0.67cm2の重症大動脈弁狭窄症と診断された．術前から薬物療法を行い汎血球減少の改善を図った．周術期に血小板数が3.0×104/μl，好中球数が2,000/μlを維持するよう補助療法を行い，大動脈弁置換術を施行した．周術期に出血性の合併症や感染症は認めず，術後経過は良好であった．

We present a case of a 61-year-old man who underwent aortic valve replacement for aortic regurgitation complicated with left ventricular noncompaction. The pathogenesis of this condition remains unknown. In advanced form, left ventricular noncompaction produces marked disability and carries a poor prognosis. We underscore that familiarity with this disease entity will help to stimulate early diagnosis and timely treatment when necessary.