Objective Anomalous aortic origin of a coronary artery is the congenital heart defect that consists of an abnormal origin and course of a coronary artery. The most common variation is the anomalous origin from the opposite Sinus of Valsalva (SoV), and it can refer either to the left main, the circumflex or the right coronary artery (RCA). In the last case, RCA has an acute angle take-off and an interarterial course between the aorta and the pulmonary artery, which can lead to myocardial infarction, arrhythmia, or sudden cardiac death because of the compromised coronary blood flow. The unroofing procedure includes the excision of the shared wall between the coronary artery and the aorta, eliminating the malignant course, and the creation of a widened neo-ostium. In the current case report, we present two patients with anomalous origin of the RCA from the left SoV, where unroofing was performed and the immediate improvement in coronary blood flow was able to be shown intraoperatively with the usage of transesophageal echocardiography (TOE). Design and method A 50yr and a 65yr old male patients were admitted to our hospital with chest pain on exertion and syncopal attacks respectively. After a CT and a classic angiography, they were both proved to have anomalous origin of the RCA from the left SoV with a simultaneous interarterial course between the aorta and the pulmonary artery, which was the cause of their provocative ischemia. Both of them were scheduled for a surgical repair with the unroofing procedure. Intraoperatively and before the repair, we were able to illustrate with TOE both the anomalous origin and the route of the RCA and the reduced coronary flow with the colour Doppler. Following the administration of cardioplegia and a partial aortotomy, the left and right coronary ostia were identified and probed. The RCA ostium was slit-like and positioned in the left SoV. Unroofing was performed by transecting the endothelium from the current ostium along and to the extent of the intramural course of the artery, creating a wider neo-ostium in the correct SoV. Finally, the neo-ostium was marsupialized with interrupted sutures to prevent local dissection.Following the release of the cross clamp, as soon as the coronary blood flow was restored and the heart was normally beating, the surgical result was reassessed with TOE. Results and conclusions The unroofing procedure increased the coronary blood flow of the RCA in both patients; this depended both on the the widened neo-ostium on the 2D images and the enriched coloured flow inside the RCA on the colour Doppler images. Also, we were able to depict the neo-ostium with 3D imaging. In this way, there was no need for a postoperative CT angiographic examination.In conclusion, the current case report underlines that anomalies regarding the origin and the route of the coronary arteries are able to be recognised with intraoperative TOE. Furthermore, the coronary ostia and the coronary flow are able to be evaluated with TOE and should always be assessed intraoperatively whenever surgical interventions are being performed on them.

Introduction The-double chambered right ventricle (DCRV) is a rare distinctive anatomic entity with both congenital and acquired components, wherein abnormally located or hypertrophied muscular bands divide the right ventricle into a proximal high-pressure and a distal lower pressure chambers - even to the point of mid-ventricular obstruction. As the DCRV is very often associated with other congenital cardiac defects, such as a perimembranous ventricular septal defect (PM-VSD), it is usually diagnosed in infancy and childhood. However, it may remained unrecognised until adulthood, when the patient presents with atypical symptoms mimicking common acquired cardiac diseases. In the current case report, we present an adult patient with DCRV that underwent a complex cardiac surgery, not only for the primary defect, but also for the coexisting cardiac pathologies. Methods A 63yr old female patient, with a known medical history of an uncorrected VSD, presented to our hospital with intense chest discomfort and dyspnea on minimal exertion (NYHA III). The laboratory exams showed mild troponin increase, whilst the TTE verified the presence of a VSD, but also revealed the existence of a DCRV with normal function and dimensions, a severely stenosed aortic valve, a severely regurgitant mitral valve and a left ventricle with preserved EF. After performing a coronary angiography that showed right coronary artery disease and common origin of the left and right coronary arteries from a single ostium, the patient was scheduled for surgery. Intraoperatively, the TOE examination showed a normally functioning hypertrophied RV, with abnormal muscular bands (AMB) that cross its cavity and cause nearly total RVOT obstruction and turbulent flow. The usage of a Swan-Ganz catheter verified the existence of two separate chambers with a pressure gradient of almost 100mmHg inside the RV and set the diagnosis of a DCRV. Furthermore, the known VSD was more specifically a PM-VSD with left to right flow between the LVOT and the proximal supra-systematic chamber of the RV, because of the simultaneous severe aortic valve stenosis. Results The patient underwent excision of the AMB through a small right ventriculotomy, mitral valve repair with an Alfieri stitch transaortically and aortic valve replacement with root enlargement. No graft was placed to the RCA because of the poor distal target. Despite the successful excision of the AMB and the release of the intracavitary obstruction, the separation from the CPB was very difficult due to biventricular, but mostly RV dysfunction. The patient was placed on V-A ECMO and transferred to the CICU. Discussion In this case report, we showed that a rare congenital cardiac disease (DCRV) can remain masked until adulthood, when the patient becomes finally symptomatic but with atypical symptoms. Definitive treatment is surgery and generally has an excellent prognosis. However, we should be very careful before attempting to derange the balances that the RV has set to itself until then.

Introduction The Pulmonary Artery Catheter (PAC) Swan-Ganz, despite the widespread rumours regarding the possible complications that correlate with its insertion, such as the pulmonary artery rupture, is still - in the experienced hands - an essential tool of hemodynamic monitoring in cardiac surgery. In combination with Transoesophageal Echocardiography (TOE) though, they offer to the Anaesthesiologist an integrated profile of pressure, volume, flow velocity and anatomical information. However, there can still be occasions where the above mentioned hemodynamic and non-hemodynamic data are not enough to guide the surgical decision-making process intraoperatively. In this case report, we present the contribution of the difficulty in advancing the PAC into the Right Atrium (RA), as an indication of Superior Vena Cava (SVC) stenosis, and the need to return to CardioPulmonary Bypass (CPB) to repair it, during a surgery of totally endoscopic Atrial Septal Defect (ASD) closure. Methods A 40yr old female patient is undergoing totally endoscopic cardiac surgery with CPB for the closure of a Superior Sinus Venosus ASD with simultaneous anomalous drainage of the Right Upper Pulmonary Vein (RUPV) into the SVC. The anaesthetic monitoring includes arterial line, PAC and TOE, which confirms the preoperative findings (Figure 1,2,3), while for the needs of the operation the Anaesthesiologist inserts also a CPB cannula in the Right Internal Jugular Vein. Later on, during the phase that the surgeon is advancing the second venous CPB cannula through the femoral vein and the Inferior Vena Cava (IVC) into the RA, the PAC is being withdrawn from its wedge position and is left high inside the SVC, showing the Central Venous Pressure (CVP). Results After the closure of the ASD and the flow diversion of the RUPV into the Left Atrium with a bovine pericardial patch, deairing is taking place, the restoration of the ASD is being confirmed with the TOE and successful CPB weaning occurs. A subsequent TOE scan shows turbulence inside the SVC with the colour Doppler (Figure 4), indicative of stenosis, while the CVP is 15mmHg, and the dilemma that is coming up is if the stenosis is clinically significant or not. However, at the same time it is impossible to readvance the PAC into the RA, an indication of severe SVC stenosis, and the team decides to return to CPB to repair it. After the placement of a second pericardial patch that widens the RA-SVC junction on a beating heart, laminar flow is being depicted inside the SVC (Figure 5), the PAC is being seamlessly floated into the RA (Figure 6) until its wedge position, and the CVP is 8mmHg. The short and the long-term postoperative periods were uncomplicated. Discussion The intraoperative use of the PAC in the current case report, and the difficulty in readvancing it more specifically, proved to be crucial in making an undoubtedly critical decision towards repairing a stenosis that could have been overlooked, if we had simply relied on the CVP, and become even fatal in case of delayed diagnosis. The mechanical contribution of the PAC has been underlined.

The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2017.11.009] on http://www.annalsthoracicsurgery.org.A 60-year-old woman was admitted to the hospital because of dyspnea, acute kidney failure, and elevated hepatic enzymes. Her medical history revealed an operation for brain oligodendroglioma 1 month previously. After that operation, she was transferred to a recovery unit with left hemiparesis. Fifteen days after being admitted to the recovery unit, she was again transferred to our hospital, and acute pulmonary embolism was diagnosed. Transthoracic echocardiography showed a mass extending from the right atrium across the patent foramen ovale (PFO) by the left atrium and the mitral valve (Fig 1A, Videos 1–5). The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2017.11.009] on http://www.annalsthoracicsurgery.org. Computed tomography angiography of the pulmonary tree showed multiple intraluminal filling defects of right atrium through a PFO and left atrium, that looked like the Greek capital letter lambda (Λ), which was a saddle-shaped thrombus (Fig 1B [red arrows], Fig 1C). There were also extensive intraluminal filling defects of the right and left pulmonary artery (Video 6). An emergent operation confirmed the existence of a large serpentine mobile mass in the right atrium extending to the left atrium through a PFO and also thrombi in bilateral pulmonary arteries. All thrombi from both pulmonary arteries were removed under 7 minutes of circulatory arrest. Thrombi from right and left atrium were also removed, and the PFO was closed (Fig 1D). The patient was transferred to the intensive care unit. Unfortunately, she died of multiple organ failure 5 days later. The identification of a thrombus “caught in the act” crossing a PFO is rare [1Pierre-Justin G. Pierard L.A. Management of mobile right heart thrombi: a prospective series.Int J Cardiol. 2005; 99: 381-388Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2ZDc4OGE2NzY0MjlkYjY4YjEwODBiMjRjNzM4YjI3NCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MTgwMTk4fQ.nfe63G4GGFzoI6LfPkMkr7zfyi9UeSoleYJanyMU0vPMR_RJYD8aiBJ1Wdv1nu6SGZ0z5shuubUPdwg_KwI2U2QE6VFLgJ--dZ0ozX5B_8PEuFVyzf6TjpFcuSgoeJE6jRVT1Z-le58DwkNpbZCZJkcFUVeERI-t5rRClfXNIks_3YLQLANjP8RNNY5fmXNxWCvsLGxbMtkBNPOZht_ld0-mDBINlUNYXHqMMwZa8yccFbJIcgODPTm1pKlzdhHLpWDLYyKsWDMBf0cS6YvtpHO_Xy5CKPpdHPuo0tuM_Jus8ZHbINQ7wMKac558fy6zYihOGZK8JYK9GIMS6Oty9A Download .mp4 (0.63 MB) Help with .mp4 files Video 1eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5MGFkZjVkNjlkZTU1N2IzMjVhN2YzMjliY2YyYTYyNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MTgwMTk4fQ.BnaPRzZLm3S9n-Dq_vhKJh0Tz8wExx4vEzPttLswUVfEJ1oglklm-GK0JOAj0shANaDtFi3dmjvJhhCTYIzF1ENbXccKTeBtHed1ORZFfPcy94P2fq6N7D1QoGav2nCKIMl8pVVR0O_aE97Ra12QGRfGAXmgKpFDk-ogg6PaltUnPlUSkd208IongUvKDhap2xt8NZKe_gBkUn1pM_RlkAz-pSD5c54uA-WYGGTToSzAfjs5QNW7kA-LBmdM3LGVGobf2fspwhl5RIMCju1nOhNmT0e7NeZ0LS5rKS3mYIBjQkdMTFGw1kA5om3QeQ80MjHn8AQDE_Pq7SwN6_dfQA Download .mp4 (0.64 MB) Help with .mp4 files Video 2eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2YmVlZjQxMDk1MzIxYmQwMWRkOTNkZjQxYzcwMjRlYiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MTgwMTk4fQ.erIRm-Tprr7qIx4Uj0QG02Cb6dlqGu-Dw6lKtgbT1RJNQ1RwCVaUkbmc0ktoJ06Q9Dn_QCCjFFk9BMadkD3Z3Ew6xEFy33r7c4oUiaPiPFwl-iQJgFV1tEpWlc_1e0umMWDobxWsNd1wOz51704FvdsSvuFbjLPR0YZOk_wYHk6s4f1ETLcBVs40XIDNI6IyFsOes6hbgG2rtXS_AHrORnA9bjEOTz35ii8ARpVZOiJ79Hzt_feyMylR6Z9t7x7sMFLDbdoBZ2Tvrtdm7SI6oUU9P-Z-fsbRedLlkrWoT_2rYZhEyMza774e3mHElb3sUGJiPyHbKFywY0m3VpJ-0w Download .mp4 (0.64 MB) Help with .mp4 files Video 3eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzZDA3OTQzNzljMmY5ZDg5NzFiNGM4NTI0NWZmOGEyMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MTgwMTk4fQ.ZAM_uz18HwIq11mAo1yRSZr36mpE9fwz1qG7tWfc-UFcmD43HTlHg16xAJMJppg15kpceashcqaCWsgG8uiN6ehtukY7L9ME7R85Wfj-AHlv_3W73HXSClfOjoUXrK40WzjyK46Vl10eyLoze617Ymy_8wF8ZP96ch3Y2XiFPok-3DgfQ2oO6M6QZqSe4HSobAxgg2qBEDfPBJx2p4pzeKAXA8-xUW-85YW_l9Oi0-Mnin6imvo5avFAkQBfiRiiELcbs2kX9uCIrFnBPmzXzWhN2GDcfVCXmqZ36ireTnyGeumvIDkB_ixln8-UIlBE6t8S1YzUFO1HoUH1TOTLEw Download .mp4 (0.65 MB) Help with .mp4 files Video 4eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzMTRjNmNhMTQxMTg4MGFlYTViNzMwZjY4MWFhMDljNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MTgwMTk4fQ.e_Mxm-SZhLSvRtd2Hda6x2nU-NKIIdH4Zz2-ACmZKKFCjmXoxTyl1JxXoj6SsT-JM5ebpeWIY-SVJzgklJYX5kiJug7kKWs03ZRexeKpbrxcAjRTBUBKfk7W46SKrKWyvdPLrDKkESZmC1oxo8YzSBu7QgRUxWDAvdE5eIuJfPpWZj0Gvm3WjRbHQ26j8vTUYWmZM-Fuf0SLUT8b9QRndrmc4Zzhd2wOUTjSUUwvVXykwNK4mkbDynDecrdjx_ocywkIGfQq9iTYYYL8G2A8TqISsk15FVeGfxlpxeKxvQvMbpOzBud-Or6csOJeCUABx1U0-pl1cIk0mQkJ57IOEQ Download .mp4 (0.67 MB) Help with .mp4 files Video 5eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2MGQwOGUzNDk5YjY5NDRhYjdjZTI5ODRiMjFiMzVkOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MTgwMTk4fQ.QxN8rAg6h6k9lmFLCEwKAhI7iS2yi_bFEklwGs5MCFsV-xvqQH1Pg_HOCfx3PcUlgznAfOgAsXFE6RiDbqhqgx36HYU51-CJJeOD2yBY1dJ_3FmZK5azWAo6RUritVhBxL18aS9JasFEkpxgFZmatY0Dfz9AP52u9D3X3UfTcLOz0s4xYJr3DuHYyG5mxVgBuA0AlU9CyuG-u3648ZHHvq9R3a2KM7SJqpQcjRQTKYH-9KlU_BlwcmHaxChyUUeN27ga3hGNlp9Nql0_5SpxMNY0K46NjMevazNCVOQg4HslRYk2Q3OhV9cV_Sl_taTzPWdvEvGh8dTxr7G6sHv_5Q Download .mp4 (0.98 MB) Help with .mp4 files Video 6

Primary cardiac neoplasms are rare, and the estimated prevalence in autopsy series is 0.001%-0.03%.1Burke A. Virmani R. Tumors of the heart and great vessels.in: Atlas of Tumor Pathology. 3rd series, fascicle 16. Armed Forces Institute of Pathology, Washington, DC1996: 171-177Google Scholar The majority (75%) of primary cardiac tumors are benign and arise from any layer of the heart.2Silber E.N. Heart Disease.2nd ed. Macmillan, New York1987: 1427-1448Google Scholar Cardiac hemangiomas are benign vascular tumors and account for 5%-10% of benign cardiac tumors. They are discovered incidentally.1Burke A. Virmani R. Tumors of the heart and great vessels.in: Atlas of Tumor Pathology. 3rd series, fascicle 16. Armed Forces Institute of Pathology, Washington, DC1996: 171-177Google Scholar A 67-year-old man presented with chest pain and exertional dyspnea. The physical examination and chest x-ray revealed nothing. The electrocardiogram showed sinus rhythm. Transthoracic echocardiography showed a mobile mass in the left ventricle (10 mm × 10 mm) that was attached to the lower part of the interventricular septum (Figure). Coronary angiography revealed that the left main coronary artery had a 50% stenosis and the right coronary artery had a 100% stenosis proximally. Septal branches of the left anterior descending artery created a capillary-like vascular net, and a mobile, pediculated mass was observed inside the left ventricle (Figure). Cardiac magnetic resonance imaging revealed the tumor's tissue type and its relationship to other cardiac structures. On steady-state free precession short-axis cine a pedunculated small mobile lesion was revealed, and this mass was attached to the interventricular septum (Figure). On T2 inversion recovery magnitude short-axis view the lesion appeared with heterogeneous high signal (Figure).Figure(A) Transthoracic echocardiography showed a mobile mass in the left ventricle (10 mm × 10 mm) that was attached to the lower part of the interventricular septum. (B) A mobile, pediculated mass was observed inside the left ventricle. Septal branches of the left anterior descending artery created a capillary-like vascular net. (C) A pedunculated small mobile lesion was attached to the interventricular septum, as shown by steady-state free precession short-axis cine. (D) A lesion was seen with heterogeneous high signal by T2 inversion recovery magnitude short-axis. (E) A lesion with a rapid, progressive contrast uptake was detected during the early and late perfusion sequence. (F) The strong enhancement of the lesion was detected during the late gad phase sensitive inversion recovery short-axis sequence. (G) Macroscopic appearance of the tumor. (H) Immunohistochemically, a thin internal layer of cells with endothelial origin without atypia was shown. It is a capillary-type hemangioma.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During the early and late perfusion sequence a rapid, progressive contrast uptake of the lesion was detected (Figure); and during the late gadolinium phase sensitive inversion recovery short-axis sequence, strong enhancement of the lesion was detected (Figure). The tumor was excised surgically (Figure), and 2 bypasses were performed. Histopathologic evaluation revealed small and medium-sized capillary-type vessels with anomalous configuration. Immunohistochemically, a thin internal layer of cells with endothelial origin without atypia was seen, and all these findings were consistent with the diagnosis of capillary-type hemangioma (Figure). The patient had an uneventful recovery. Cardiac hemangiomas are usually solitary, but they have also been associated with extracardiac hemangiomas, including cutaneous sites (port-wine stain of the face) or visceral sites (hemangiomas of the gastrointestinal tract).3Tabry I.F. Nassar V.H. Rizk G. Touma A. Dagher I.K. Cavernous hemangioma of the heart: case report and review of the literature.J Thorac Cardiovasc Surg. 1975; 69: 415-420PubMed Google Scholar Cardiac hemangiomas are classified as capillary, cavernous, or arteriovenous. Endocardial hemangiomas are usually capillary or mixed cavernous–capillary. Intramural hemangiomas might be capillary, cavernous, or arteriovenous.1Burke A. Virmani R. Tumors of the heart and great vessels.in: Atlas of Tumor Pathology. 3rd series, fascicle 16. Armed Forces Institute of Pathology, Washington, DC1996: 171-177Google Scholar Cardiac hemangiomas can occur in any chamber. They may be predominantly intramural or endocardial. Cardiac hemangiomas are seen as hyperechoic lesions at echocardiography and are intensely enhanced on computed tomography with contrast. These tumors typically demonstrate intermediate signal intensity on T1-weighted images and become hyperintense on T2-weighted images.4Brizard C. Latremouille C. Jebara V.A. et al.Cardiac hemangiomas.Ann Thorac Surg. 1993; 56: 390-394Abstract Full Text PDF PubMed Scopus (133) Google Scholar Coronary arteriography demonstrates the blood supply to the tumor, which is characterized by a "vascular blush," particularly in the capillary and arteriovenous types of hemangiomas, which exhibit rapid blood flow. This characteristic sign is observed in 80% of cases.4Brizard C. Latremouille C. Jebara V.A. et al.Cardiac hemangiomas.Ann Thorac Surg. 1993; 56: 390-394Abstract Full Text PDF PubMed Scopus (133) Google Scholar Surgical resection is the treatment of choice for symptomatic lesions or if the diagnosis is in question. The long-term outcome of patients with surgically treated symptomatic lesions is excellent.4Brizard C. Latremouille C. Jebara V.A. et al.Cardiac hemangiomas.Ann Thorac Surg. 1993; 56: 390-394Abstract Full Text PDF PubMed Scopus (133) Google Scholar Spontaneous regression of a cardiac hemangioma has been reported.5Palmer T.E. Tresch D.D. Bonchek L.I. Spontaneous resolution of a large cavernous hemangioma of the heart.Am J Cardiol. 1986; 58: 184-185Abstract Full Text PDF PubMed Scopus (75) Google Scholar Surgery might not always be necessary, particularly for extensive and asymptomatic hemangiomas that would require complex and potentially hazardous excision.

A 61-year-old man with a history of alkaptonuria presented with severe aortic valve stenosis for aortic valve replacement. His aortic valve stenosis had been discovered 3 years previously. He had been operated on for replacement of the right hip 30 years previously, and he underwent replacement of the left hip 3 years later. At that point, the brown-black pigmentation of his joint was discovered, and the diagnosis of alkaptonuria was established. Later, bilateral knee replacement was done because of ochronotic arthropathy. During the operation for aortic valve replacement, the intima of the ascending aorta, the aortic root, the aortic valve leaflets, and the left ventricular outflow tract were heavily brown-black pigmented (Fig 1). The aortic valve leaflets were calcified, thickened, and pigmented (Fig 2). A mechanical valve (On-X 25 mm; On-X Life Technologies, Austin, TX) was used. The patient had an uneventful recovery. Alkaptonuria is a rare inherited disorder of the metabolism of tyrosine and results in a concentration of homogentisic acid in the connective tissues (ochronosis), which is characterized by degenerative arthropathy, skin pigmentation, and discoloration of the urine [1Hannoush H. Introne W. Chen M. et al.Aortic stenosis and vascular calcifications in alkaptonuria.Mol Genet Metab. 2012; 105: 198-202Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. Cardiovascular involvement is a rare adverse event and is manifested by pigment deposition at locations that are influenced by intravascular pressure and turbulence, usually observed at the valve cusp or at the base of the leaflet and then extending into the annulus of the valve [2Thakur S. Markman P. Cullen H. Choice of valve prosthesis in a rare clinical condition: aortic stenosis due to alkaptonuria.Heart Lung Circ. 2013; 22: 870-872Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar].Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Completion angiography confirmed complete thrombosis and no blood flow in the false lumen of the BCA.The patient's postoperative course was uneventful, and no evidence of neurological impairment was present at discharge.Postoperative computed tomography immediately after the procedure demonstrated complete thrombosis of the false lumen.Computed tomography 15 months postoperatively revealed no residual dissection and shrinkage of the false lumen (Fig. 1A-C).

We report a 71-year-old male who underwent successful minimally invasive transapical aortic valve implantation to treat severe aortic stenosis, with simultaneous pulmonary resection for the treatment of lung cancer. At five-year follow-up the patient remains free of symptoms (NYHA I) and recurrence. doi: 10.1111/jocs.12223 (J Card Surg 2013;28:660–662)

7 P. Sindika St. 546 43 Thessaloniki, Greece e-mail: tkelpis@gmail.com

Congenital left ventricular (LV) diverticula are rare findings, particularly when first diagnosed in adulthood. We describe successful surgical repair of an isolated congenital apical LV diverticulum associated with an abnormal submitral apparatus in a young adult who received his diagnosis following a peripheral embolism. We intraoperatively identified an abnormally originating belly of the posteromedial papillary muscle, which arose from the interventricular septum, causing partition of the LV cavity and forming an apical aneurysmal communicating chamber. This anatomy of abnormal papillary muscle bifurcation was possibly the mechanism for the development of the apical diverticulum and to the best of our knowledge has not previously been described. Reattachment of the abnormal belly to its normal position preserved mitral valve competence, and an endoventricular patch repair restored LV volume and geometry.