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Bacteria can adhere to cardiac endothelium damaged by regurgitation or a shunt jet; however, healthy cardiac endothelium is supposedly resistant to bacterial adhesion. A 22-year-old man presented to our emergency department with fever. Physical examination revealed no obvious cardiac murmur, but there was evidence of splinter hemorrhages and Janeway lesions. Transthoracic echocardiography did not reveal vegetative lesions, but a 15 × 7-mm vegetation was identified on the surface of the left ventricular muscle just below the anterolateral commissure of the mitral valve without regurgitation or a shunt jet by means of transesophageal echocardiography. Surgery was performed on the seventh day, but the patient's postoperative course was unstable. Some complications occurred because the vegetation existed in a unique location. Although the patient continued to have an uncontrollable infection over the subsequent course, he was discharged on the 94(th) hospital day. We present a case of a vegetation in a unique location without exposure to regurgitation or a shunt jet. This case indicates that vegetative lesions may develop even in the absence of regurgitation and shunt jets. In case of infective endocarditis where a vegetation exists in a unique location, comprehensive testing or strategy are required to treat this condition.

We describe a patient with typical manifestations of 9p monosomy syndrome, including trigonocephaly and sex reversal. Array comparative genomic hybridization (CGH) revealed a 9p terminal deletion of approximately 9 Mb with the breakpoint at 9p23. We compared the deleted segments of 9p associated with reported cases of 9p monosomy syndrome with trigonocephaly. We did not identify a region that was shared by all patients; however, when only pure terminal or interstitial deletions that did not involve material from any other chromosome were compared, we identified a segment from D9S912 to RP11-439I6 of approximately 1 Mb that was deleted in every patient. We propose that this 1-Mb segment might be the critical region for 9p monosomy syndrome with trigonocephaly.

A 68-year-old woman exhibited an increasingly protruding mass on the left heart border on chest X-ray. Transthoracic echocardiography revealed an echo-free mass in the anterior pericardial space. Transesophageal echocardiography revealed blood flow from the proximal left anterior descending coronary into a large coronary artery aneurysm measuring 61 mm × 51 mm in diameter and a quadricuspid aortic valve with a small cusp between the left and right coronary cusps. Coronary angiography demonstrated the presence of a coronary aneurysm connected to the proximal left coronary anterior descending artery. A giant coronary artery aneurysm and pulmonary artery fistulas extending from the left and right coronary arteries were confirmed by surgeons and successfully treated with surgery.

43歳，女性．健診で縦隔腫瘍を疑われ当院受診，胸部CT，血液生化学的諸検査などが施行された．CA19-9の高値（108U/ml），前縦隔に約3×4cmの隔壁を有する嚢胞性病変が認められ，手術が施行された．腫瘍は左前縦隔に存在し，胸腺左葉と連続しており，左上葉，左縦隔胸膜とも強固に癒着していた．左上葉の部分切除と癒着した縦隔胸膜とを一塊にして胸腺摘出術を施行した．病理診断は膵組織を伴う成熟型奇形腫であった．術前上昇していたCA19-9は術後正常化し，腫瘍内産生が示唆された．成熟型奇形腫は診断時に無症状であっても周囲組織と強固な炎症性癒着を起こし，合併切除が必要になることがあり，注意を要すると考えられた．

症例は54歳女性．2005年6月会社の健診にて胸部異常陰影を指摘され当院呼吸器内科に紹介となった．胸部CT検査で右中葉胸膜直下に辺縁不整な10mm大の結節影を認められたがPET検査は陰性であったため経過観察されていた．しかし2006年1月のCT検査で肺癌の可能性も否定できず確定診断，治療目的で当科に紹介となり胸腔鏡下手術を施行した．迅速病理検査で血管腫と診断され，病理組織学的検査で毛細血管腫（capillary hemangioma）と最終診断された．術後経過良好で合併症もなく軽快退院となった．肺の孤立性の毛細血管腫についての報告は極めて稀であり文献的考察を加えて報告する．

症例は55歳，女性．意識消失発作にて，精査が施行された．頭蓋内病変は認められず，24時間ホルター心電図にて2:1高度房室ブロックが認められた．そのため，意識消失はAdams-Stokes発作と診断され，ペースメーカー（Pacemaker:PM）植込み術の予定となった．しかし，金属アレルギーの既往があったため，外来にて金属パッチテストを施行した．PMに使用されている金属にアレルギーは認められなかったが，予防的にPM本体をpolytetrafluoroethylene（PTFE）シート（ゴアテックスシート®）にて被覆し，植込み術を行った．植込み後12カ月が経過したが，PM植込み部のトラブルは生じていない．PMアレルギーのためPM植込み部の皮膚炎を繰り返す症例に対し，PTFEシートを使用した報告はいくつかある．今回われわれは，予防的PTFEシート被覆にてPM植込み部トラブルを回避した，金属アレルギーの1症例を経験したため，報告する．

ObjectivePredicting the risk factors for late aortic events in patients with type B acute aortic dissection without complications may help to determine a therapeutic strategy for this disorder. We investigated whether late aortic events in type B acute aortic dissection can be predicted accurately by an index that expresses the degree of fusiform dilatation of the proximal descending aorta during the acute phase; this index can be calculated as follows: (maximum diameter of the proximal descending aorta)/(diameter of the distal aortic arch + diameter of the descending aorta at the pulmonary artery level).MethodsPatients with type B acute aortic dissection without complications (n = 141) were retrospectively analyzed to determine the predictors of late aortic events; these include aortic dilatation, rupture, refractory pain, organ ischemia, rapid aortic enlargement, and rapid enlargement of ulcer-like projections.ResultsThe fusiform index in patients with late aortic events (0.59) was higher than that in patients without late aortic events (0.53, P < .01). Patients with a higher fusiform index exhibited aortic dilatation earlier than those with a lower fusiform index. By multivariate analysis, we conclude that the predominant independent predictors of late aortic events were a maximum aortic diameter of 40 mm or more, a patent false lumen, and a fusiform index of 0.64 or more (hazard ratios, 3.18, 2.64, and 2.73, respectively). The values of actuarial freedom from aortic events for patients with all 3 predictors at 1, 5, and 10 years were 22%, 17%, and 8%, respectively, whereas the values in those without these predictors were 97%, 94%, and 90%, respectively.ConclusionsThe degree of fusiform dilatation of the proximal descending aorta, a patent false lumen, and a large aortic diameter can be predominant predictors of late aortic events in patients with type B acute aortic dissection. Patients with these predictors should be recommended to undergo early interventions (surgery or stent-graft implantation) or at least be closely followed up during the chronic phase before such events develop.

Context: Natriuretic peptide receptor-B (NPR-B, GC-B in rodents; gene name NPR2) is a guanylyl cyclase-coupled receptor that mediates the effect of C-type natriuretic peptide. Homozygous mutations in human NPR-B cause acromesomelic dysplasia, type Maroteaux (OMIM 602875), an autosomal recessive skeletal dysplasia. NPR-B has an intracellular kinase homology domain (KHD), which has no kinase activity, and its functional significance in vivo is currently unknown.Objective: We examined the functional significance of a novel NPR-B KHD mutation in humans.Patients and Methods: A 28-yr-old Japanese male presented with marked short stature (118.5 cm, −9.3 sd). His limbs showed marked shortening in the middle and distal segments. His parents had relatively short stature with height z-scores of −2.75 and −0.98 (his father and mother, respectively). Direct sequencing of coding region of the NPR2 gene of the family was performed. The mutant receptor activity was investigated by saturation binding assay and cGMP measurement. Additionally, interaction between the mutant and wild type allele was investigated by the titration experiments.Results: We identified a novel missense mutation L658F in KHD of NPR-B in homozygous and heterozygous states in the patient and his parents, respectively. The mutation conferred normal binding affinity for C-type natriuretic peptide but no discernible ligand-induced cGMP production. Furthermore, L658F mutant impaired wild-type NPR-B-mediated cGMP production in a dose-dependent manner, suggesting that short stature found in L658F heterozygote can be caused by its dominant-negative effect.Conclusions: This study provides the first evidence that intact KHD of NPR-B is essential for skeletal development.

症例は55歳の男性. 平成17年10月中旬に胸部不快感のため近医受診し, 発作性上室性頻拍と診断され内科的に加療されるも心房細動に移行したため当院循環器内科に紹介となった. EPSにてKENT束を持つ潜在性WPW症候群と診断されたが, 心臓超音波検査で僧帽弁後尖に付着する腫瘍を認められ, 手術目的で当科紹介となった. 準緊急的に腫瘍切除, 僧帽弁形成術および副伝導路切断術を施行した. 病理組織学的検査で乳頭状弾性線維腫と診断された. 術後は洞調律で経過し, EPSにてKENT束の離断を確認した. 現在, 不整脈や腫瘍の再発を認めず, 同時手術は有用であった.

大動脈四尖弁は発生頻度が非常に低く,大動脈弁閉鎖不全に対する手術例の報告も少ない.今回われわれは,経食道および経胸壁心エコーにて術前に大動脈四尖弁による閉鎖不全症と診断し,弁置換術を施行した症例を経験したので報告する.症例は37歳男性で,左胸部違和感を主訴に来院した.経食道および経胸壁心エコーを施行したところ,大動脈四尖弁による閉鎖不全症と診断された.心臓カテーテル検査にて大動脈閉鎖不全(AR) III度と診断され,手術適応として当科紹介となった.術中所見では左右冠尖が同大で,無冠尖と過剰弁は同大であるが他の2つに比してやや小さかった.手術は人工弁にて弁置換術を行い,経過は良好であった.

肩・鎖骨などの整形外科的手術で固定に用いる鋼線の術後の移動・迷入はまれな合併症であると言われているが我々は2例の胸腔内迷入症例を経験したので報告する.症例1は34年前に左胸鎖関節脱臼のため固定術を受けた56歳男性で, 他病で入院した際の胸部X線検査にて縦隔内に存在する金属性異物を指摘された.胸部CTでは前縦隔内大動脈弓部の前方に位置していたため, 胸腔鏡下摘出術を行った.症例2は右鎖骨骨折に対して経皮的整復固定術を受けた71歳女性で, 3ヵ月後に発熱のため撮影した胸部X線写真にて, キルシュナー鋼線 (2本) の移動を認めた.先端がそれぞれ肺実質内と縦隔内の血管の間に達していたため右開胸にて除去した.心血管系の損傷を起こして死亡した症例の報告もあり, 固定用鋼線の移動・迷入が確認された場合には症状の有無にかかわらず早期の摘出術が必要である.

症例は79歳男性.腹部大動脈瘤手術後9年目に間歌性下血を呈し精査中に, Y型人工血管置換部中枢側に約6cmの腹部大動脈瘤の再発を認めた.下血症状は消失し, I型人工血管術を施行した.腹部大動脈と腸管との間に瘻孔はなかったが,術後4日目に再度間欺性の下血症状が出現し,術後8日目には大量下血によるショック症状を呈し緊急開腹手術となった.骨盤腔内の癒着した小腸を剥離すると,Y型人工血管左脚の吻合部から約2cm離れた部位に外腸骨動脈瘤腸管瘻があり,手術にて救命できた.動脈瘤腸管瘻は下血の原因としては稀であるが,術前診断が困難であるだけでなく,手術時期が遅れると致死的となる.腹部大動脈瘤術後9年目に間歌性下血で発症したことで,診断に苦慮したが,早期診断のためには本疾患も念頭に置き精査する必要があると思われる.

症例は58歳女性.検診で胸部X線写真で異常陰影を指摘され当院受診した.胸部CT検査, MRI検査で巨大な心膜嚢腫を疑われた.胸腔鏡下に嚢胞内貯留液を吸引することで容易に巨大嚢腫を切除できた.嚢腫は心膜と連結していたが交通はなく,病理組織学的診断は心膜嚢腫であった.心膜嚢腫は比較的稀な疾患であるが,本症例の如く嚢胞液中の腫瘍マーカー (CA19-9, CA125) が異常高値を示した巨大な心膜嚢腫を胸腔鏡下に切除した症例の報告はない.心膜嚢腫は悪性化の報告もあり,積極的な外科的切除が望ましいと考えているが,胸腔鏡下手術は術中の病理学的検査で確定診断が得られ,嚢腫内容液の吸引することで容易に心膜から剥離切除でき理想的な治療法と考える.

1993年1月より1998年5月までに当院にて経験した胸部大動脈瘤に起因する大動脈気管支肺瘻 (Aortobronchopulmonary fistula, ABPF) 12例を対象とした. 男性7名, 女性5名, 年齢は30～85歳 (平均67.4歳) であった. 非感染性の真性瘤 (4例) によるABPFでは, 手術で肺と癒着している動脈壁との血流を隔離することにより良好な結果を得た. 胸部動脈瘤術後の感染性仮性瘤によるABPF (4例) は, 手術施行, 非施行症例とも全例急性期または遠隔期に再喀血で死亡した. 大動脈解離に合併したもの (1例) は肺との癒着が広範囲であり, 血栓化した偽腔を貫通して複数のABPFが形成されたため術後も喀血が持続し死亡した. 手術非施行となった3症例は全例喀血で死亡した. 感染合併例では確実な感染コントロールが困難で, 予後不良であった. 感染性4症例は無症状にABPFが形成され突然の喀血により死亡したため, 厳密な経過観察が必要である.

症例は52歳, 男性. 40歳ころより労作時の息切れを生じるようになり, 最近, 呼吸困難, 下腿浮腫が出現するようになった. 精査の結果, 高度の三尖弁閉鎖不全を認め, Carpentier-Edwards ring (34mm) にて三尖弁輪縫縮術を施行した. 術中所見では三尖弁輪の異常拡大を認めたが, 各弁尖は軽度菲薄化しているのみであり, 他の合併心奇形も認めなかったため孤立性三尖弁閉鎖不全と診断した. 術後経過は良好で, 抗凝固療法も必要とせず現在社会復帰している.

われわれは,大動脈弁原発の乳頭状弾性線維腫の1例を経験したので報告する.症例は71歳,女性.畑仕事中に倒れ当院へ緊急搬送され脳梗塞の診断で入院加療されていたが,心エコーにて大動脈弁左冠尖に3×10mm大の疣贅エコーあり,当科紹介となった.全身状態の改善を待ち手術を施行.人工心肺下に手術を行った.左冠尖弁尖に約10mm大の茎を有するイソギンキャク様の腫瘍を認めた.腫瘍切除のみ行い大動脈は温存した.病理組織学的に乳頭状弾性線維腫と診断された.術後は合併症なく順調に経過した.心臓原発の腫瘍は稀であり,その7割は良性腫瘍である.しかし乳頭状弾性線維腫は脳梗塞や心筋梗塞といった重大な合併症をきたしうるため,発見次第早期に摘出をすることが推奨されている.

右鎖骨下動脈起始異常を伴う偽性大動脈縮窄に合併した遠位弓部大動脈瘤の1手術例を経験した. 症例は22歳女性, 一卵性双生児の姉で, 心室中隔欠損自然閉鎖の既往歴がある. 健康診断の際, 胸部X線写真にて左上縦隔の拡大を指摘され, 精査にて偽性大動脈縮窄に合併した遠位弓部大動脈瘤および右鎖骨下動脈起始異常と診新された. 選択的脳分離体外循環下にて遠位弓部人工血管置換術および左鎖骨下動脈再建術を施行し良好な結果を得た. 偽性大動脈縮窄に合併した動脈瘤は, 壁が脆弱で破裂の危険性が高いため早期手術が必要と思われた. また一卵性双生児の妹には偽性大動脈縮窄を伴っておらず, 同疾患の成因は遺伝的素因でなく大動脈弓の発生異常であるとする説を支持していると思われた.

We report here a patient with features of Down syndrome and tetralogy of Fallot who had a 21q22 duplication. The extent of the duplication was defined using fluorescent hybridization probes that map to the critical region on chromosome 21. Included within the interval was the cell adhesion molecule DSCAM but not the collagen COL6A1. The present case provides further support to the concept that there exists Down syndrome-associated congenital heart disease gene(s) on chromosome 21q22 and that over-expression of DSCAM may contribute to the cardiac defects of Down syndrome.

高位腹部大動脈閉塞を伴った2枝梗塞の59歳男性に対して, 左内胸動脈 (LITA), 右胃大網動脈 (RGEA) の動脈グラフトのみを用いた冠状動脈バイパス術と腹部大動脈-大腿動脈バイパス術を同時に施行した. IABPが必要となった際の挿入経路, 体外循環中の下肢灌流, LITAが左下肢動脈への側副血行路, 動脈グラフトのみを使用することを考慮して, 本症例では体外循環に先駆けてYグラフトによる血行再建術を行い, 引き続き冠状動脈バイパス術を行った. 体外循環時間の短縮, 下肢虚血防止に効果があり, 良好な結果を得た.

We report the successful surgical treatment of a rare case of chronic expanding hematoma in the pericardial cavity that developed into a very large mass over a long period. The patient, who had a history of cardiac surgery for a double-outlet right ventricle 14 years previously and for tricuspid regurgitation 8 years ago, noticed a slowly growing mass near the left atrium and ventricle 5 years ago. The mass, which confirmed a diagnosis of chronic expanding hematoma, was resected by left thoracotomy.

Tracheal disruption due to blunt chest trauma is relatively rare but often fetal. Further improvement in life-saving strategy is expected. Here two cases of tracheal disruption due to a traffic accident with different clinical course are reported on. Case I: A 35-year-old woman manifested tension pneumothorax immediately after the injury to develop dyspnea. Emergency operation was carried out within 4 hours after the injury. Tracheoplastic procedure was able to save the patient's life. Case II: A 58-year-old man had a completed atelectasis of the left lung due to encapsulated tracheal disruption three weeks after a traffic accident and was also successfully treated by tracheoplastic procedure. It should be emphasized that early diagnosis and primary repair are important in the treatment of tracheal distruption due to blunt chest trauma.

We have operated upon 18 cases of true arch aneurysm, including 2 cases of rupture, in a recent 6 years and 3 months. Seventeen aneurysms were arteriosclerotic and one was syphilitic. Operative adjuncts during aortic cross clamping were left heart bypass with a centrifugal pump (LHB, 4 cases), retrograde cerebral perfusion (RCP, 5 cases) and selective cerebral perfusion (SCP, 9 cases). LHB was applied to localized aneurysm apart from the left subclabina artery. It was safely conducted during operation, but cerebral embolism happened in 2 cases by aortic cross clamping, leading to one hospital death. RCP was carried for emergency cases by rupture or inpending rupture. Recent three cases was operated on by left thoracotomy under RCP. SCP was conducted in 9 cases of large aneurysm, including 6 cases of total arch replacement. There was two operative deaths, but minimum complications in the survivors. Operative adjunct was selected by condition of true arch aneurysm, but we have thought that SCP was safely applied among these adjuncts.

Our ventricular assist device uses a valveless volumetric pump operating on the Maillard-Wankel rotary principle. It is driven by an electric motor and provides a semi pulsatile flow. At each cycle, blood is actively aspirated into the device, and overpumping results in collapse at the pump inlet. To prevent overpumping, it is necessary to ensure that pump intake does not exceed venous return. Poor long-term reliability rules out the use of current implantable pressure sensors for this purpose. To resolve this problem, we have developed a method of control based on monitoring of the intensity of electric current consumed by the motor. The method consists of real time monitoring of current intensity at the beginning of each pump cycle. A sudden change in intensity indicates underfilling, and motor speed is reduced to prevent collapse. The current consumed by the motor also depends on the afterload, but the form of the signal remains the same when afterload changes. After demonstrating the feasibility of this technique in a simulator, we are now testing it in animals. We were able to detect and prevent collapse due to overpumping by the cardiac assist device. This system also enables us to know the maximum possible assistance and to thus adapt assistance to the user.

We report a relatively rare surgical treatment for two cases of inflammatory pseudotumors of the lung. In case 1, a 52-year-old male with a history of left chest pain was admitted to our hospital for an abnormal nodule with an irregular margin that was detected in the left upper lung field. The nodule, measuring 15 mm in diameter, was larger than the one observed six months earlier, which had been removed by a thoracoscopic resection. In case 2, a 64-year-old female with a history of chronic cough and hemoptysis was admitted to our hospital, and an abnormal nodule with pleural indentation was detected in the lower left lung field. The nodule, measuring 8 mm in diameter, was also removed by a thoracoscopic resection. In both cases, the histologic examination enabled us to diagnose the lesion as an inflammatory pseudotumor. In general, it is very difficult to differentiate inflammatory pseudotumors from malignant tumors of the lung. The best treatment for inflammatory pseudotumors is usually early and complete surgical resection, since it can lead to improved survival. Therefore, we consider thoracoscopy-aided surgery to be less invasive and more useful than other surgical methods in the diagnosis and treatment of inflammatory pseudotumor of the lung.

A study was undertaken to evaluate the validity and efficacy of video-assisted thoracic surgery (VATS) for the diagnosis of indeterminate pulmonary nodules.Between April 2001 and November 2004, 57 adult patients (31 males, 26 females) with a clinical diagnosis of pulmonary nodules by preoperative chest computed tomographic (CT) scanning were included in this study.A definitive tissue diagnosis was obtained in all 57 patients. The mean age of the patients was 66+/-9.8 yrs. The mean size of the tumor was 1.76+/-0.67 cm. 38 patients (67%) had malignant disease. Twenty eight patients (49%) had primary lung cancer and 10 patients (18%) had metastatic lung cancer from an extrathoracic primary neoplasm. The rate of malignancy was 65% in the tumor sizes equal to or less than 2 cm. Among primary lung cancer, most patients had primary adenocarcinoma (24 cases)(86%). Pathologic staging showed T1N0 (stage IA) in 18 cases (69%), T2N0 (stage IB) in 4 cases (15%), T2N1 (stage IIB) in 1 case (4%), and T1N2 (stage IIIA) in 3 cases (12%). In 10 patients (18%) who required preoperative placement of a localization hookwire with a string near the nodule, the rate of malignancy was 70%. In 7 patients with positive positron emission tomography (PET) imaging with F-18 fluorodeoxyglucose (FDG), the rate of malignancy was 57% and proved to be falsely positive in 3 cases (43%). There was no operative mortality and no significant morbidity in all cases.We proposed that VATS, which is safe and offers virtually 100% sensitivity and specificity, should be performed for most small (3 cm in diameter) and all indeterminate pulmonary lesions on the basis of these results.

We report on the rare and surgical treatment of a case of primary mediastinal liposarcoma. A 64-year-old male complained of hoarseness for one month and was admitted to our hospital because of an abnormal shadow, which was postulated to be an anterior mediastinal tumor on a chest computed tomography (CT) scan. Horizontal T1-weighted magnetic resonance imaging (MRI) showed an anterior mediastinal round mass with a signal intensity similar to that of subcutaneous fat, which was 6.5 cm in diameter. An operation similar to extended thymectomy was perfomed through a median sternotomy. Histological examination of the resected specimen revealed that the tumor was composed of well-differentiated liposarcoma and pleomorphic malignant fibrous histiocytoma and the tumor was diagnosed as a de-differentiated liposarcoma. We discuss it with reference to a collective review of the Japanese literature for surgical cases of primary liposarcoma of the mediastinum.

We report on the rare and surgical treatment of a senile patient of infected intralobar pulmonary sequestration. A 56-year-old male who had complained of headache, vomiting, cough, sputum production, and high fever was admitted to our hospital. Chest computed tomography (CT) showed an infected intralobar pulmonary sequestration as an 8x6 cm cystic mass with multiple air-fluid cavities in the left lower basal segment and severe pneumonia in the left upper and lower lobes around the mass. A 3-D CT showed an aberrant artery entering the consolidation from the descending aorta. A standard lower lobectomy was performed with a ligation of the aberrant artery with a diameter of 1 cm supplying the posterior segment of the left lower lobe. A histological examination of the lung revealed acute and chronic broncho-bronchiolitis with cystic dilatation consistent with intralobar pulmonary sequestration. We discuss the characters of senile patients compared with juvenile patients, with reference to a collective review of patients older than 50 reported in the literature.

We report on the rare and successful surgical treatment of a case of spontaneous rupture of the ascending thoracic aorta resulting in a mimicking pseudoaneurysm. A 72-year-old male who had complained of sudden onset of severe chest pain was admitted to our hospital. Initially, acute type A closing aortic dissection was suspected because computed tomography (CT) showed a small ulcer-like projection (ULP) in the posterior aspect of the ascending aortic wall, but it also revealed no intimal flap, false lumen or aortic aneurysm. CT and magnetic resonance imaging (MRI) indicated a change in the radiographic aspect of the ULP and revealed a mimicking saccular-type pseudoaneurysm and gradual increasing size of the pseudoaneurysm. Surgery was performed after considering the risk of pseudoaneurysmal rupture. We replaced the ascending aorta and diagnosed it as a spontaneous aortic rupture by histological examination of the rupture site after failing to observe an aneurysm or dissection. We discuss these results with reference to the literature, including our pathological and radiographical findings.

A 61-year-old male had complained of cough and dyspnea on effort, with right pleural effusion. Computed tomography demonstrated a calcific pericardium surrounding the entire heart, with thickening of 10 mm. Cardiac catheterization showed no coronary disease, but a dip-and-plateau of the pressure curve of both ventricles. We diagnosed congestive heart failure due to chronic constrictive pericarditis, and performed a subtotal pericardiectomy, using an Ultrasonic Scalpel through a median sternotomy combined with anterior left thoracotomy at the level of the fifth rib, without cardiopulmonary bypass (CPB). After the subtotal pericardiectomy, his postoperative recovery was uneventful and his functional status improved. We consider that our surgical technique is a useful method for treatment of chronic constrictive pericarditis, and advocate the use of the Ultrasonic Scalpel for a safe and easy pericardiectomy.

We report a 58-year-old man who underwent surgical treatment of primary lung cancer arising from the wall of a giant bulla. Chest roentgenography and computed tomography revealed multiple emphysematous bullae in the bilateral upper lobes, and a right upper giant bulla with a mass measuring 6 cm arising on the bulla wall. Right upper lobectomy was performed, the postoperative pathological diagnosis was large cell carcinoma arising from the wall of a giant bulla. Although the postoperative course was uneventful and he was discharged, he underwent partial resection of the jejunum for recurrence of carcinoma in the jejunum, and postoperative chemotherapy, and he was alive 20 months after that operation. In general, patients with both pulmonary bullous disease and primary lung cancer have a very poor prognosis, because they receive treatment when the tumor is at an advanced stage. On the basis of our review of the literature, we recommend that middle-age male patients with a giant bulla who smoke should have annual chest roentgenography and/or chest computed tomography to screen for lung cancer arising in or close to the bullous disease, and that a giant bulla should be resected in patients older than 50 years because of the high incidence of coexisting cancer and bulla, to improve the prognosis of this disease.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.

The performance of cardiac surgical procedures via median sternotomy in a patient with a tracheostomy can result in difficult problems, such as mediastinitis, stoma necrosis or inadequate operative exposure. We present a case of successful treatment for aortic valve regurgitation in a patient with a tracheostomy using a T-shaped sternotomy instead of a usual median sternotomy. This approach permitted adequate surgical exposure for cardiopulmonary bypass and aortic valve replacement. After surgery, the patient had a good clinical course without any complications and he was discharged on the 65th postoperative day. We consider this procedure to be applicable in consideration of the favorable results obtained.

We report a very rare case of primary malignant lymphoma arising in the pleura with no history of persistent pyothorax. A 72-year-old male was hospitalized with dyspnea on effort and chest CT demonstrated a mass along the right chest wall. Right thoracotomy with complete en bloc resection of the pleural tumor was performed. Immunohistochemical examination of the pleural tumor showed that the histology was marginal zone B-cell malignant lymphoma. We considered that this tumor had originated from the soft tissue in the chest wall based on radiographical and surgical findings. As diagnosis and treatment of pleural malignant lymphoma seems to have been difficult in most cases reported in the literature, it is thought that early active and accurate biopsy with large-bore needles, or, if possible, surgical incision for early diagnosis and aggressive surgery to achieve complete resection combined with radiation therapy and/or chemotherapy would be very important for a good prognosis.

We report a 58-year-old male treated with surgical drainage by mediansternotomy using a pedicled omental flap for descending necrotizing mediastinitis (DNM). The patient recovered from DNM after five months of mechanical respiratory support. In deciding upon the most appropriate surgical approach for mediastinal drainage, the level of infection is a good landmark and should be investigated by CT scan. We also review the 43 cases of successful surgical treatment of DNM reported since 1989 in Japan, including our own patient, who were diagnosed with DNM by CT scan according to the classification proposed by Endo et al., and discuss the most appropriate surgical approach for mediastinitis based on the literature. In the treatment of DNM localized to the upper mediastinal space above the carina, a transcervical approach may be appropriate. In diffuse DNM extending into the lower anterior mediastinum, a mediansternotomy or a thoracotomy may be useful, and in diffuse DNM extending into both the anterior and posterior lower mediastinum, a thoracotomy may be the best approach for debridement of the lower posterior mediastinum, in addition to early complete debridement of the entire cervical area.

We report a rare successful surgical repair of a common atrium (CA) with mild tricuspid valve (TV) regurgitation due to valvular annulus enlargement in a 39-year-old man, who had a complete atrial septum defect (ASD) without the characteristic of an endocardial cushion defect. The left-to-right shunt ratio was 85 percent and the Qp/Qs was 6.7 due to the CA. Left ventriculogram revealed no evidence of typical goose-neck deformity and no mitral valve regurgitation. The operation consisted of making a new atrial septum with an autologous pericardial patch and tricuspid annuloplasty (DeVega) using extracorporeal circulation. There was no evidence of a cleft on the anterior leaflet of the mitral valve or the septal leaflet of the TV. The postoperative echocardiogram showed no residual shunt flow through a new atrial septum and no TV regurgitation, and atrioventricular (AV) dissociation did not occur. We consider this procedure to be widely applicable in consideration of the favorable results obtained after surgical treatment.

A 53-year-old man crashed his motorcycle into a vehicle and was transported to our hospital by ambulance after about 30 min. Echocardiography revealed cardiac tamponade. Pericardiocentesis was immediately performed using a 5 Fr catheter via the subxiphoid approach and the results suggested cardiac injury. Surgery was commenced via median sternotomy about 2.5 hours after the accident. Patients with cardiac rupture who reach hospital alive can be saved by rapid transport, early detection, and early surgery. In particular, rapid echocardiography and pericardiocentesis via the subxiphoid approach under ultrasonic guidance are easy and helpful methods of making a diagnosis and achieving hemodynamic improvement prior to surgical intervention.

A 42-year-old man was admitted to another hospital complaining of acute abdominal pain that was induced by eating. Abdominal computed tomography and selective angiography revealed an intimal flap separating true and false lumens that was located 3 cm from the origin of the superior mesenteric artery (SMA). Emergency surgery was performed because of the sudden recurrence of diffuse abdominal pain after eating and abdominal aorta-SMA bypass grafting was done using a radial artery graft. Postoperative angiography revealed that the graft showed good patency. The postoperative course was uneventful and abdominal pain no longer occurred after eating. This excellent result was achieved by early diagnosis using CT scanning and angiography plus an aggressive surgical repair with a radial artery bypass graft for isolated dissection of the superior mesenteric artery.

Spontaneous and isolated dissection of the limb arteries without involvement of the aorta is extremely rare. We present a 36-year-old male who has 95% tapering stenosis and dissection of the left external iliac artery with abrupt onset with total thrombosis in the false lumen until the level of the inguinal ligament. We also suggest that endovascular stent graft placement is a useful treatment for isolated arterial dissections prior to operation in consideration of the technical ease and safety of guiding intravascular ultrasound like in this case.

In most of the previously reported cases of isolated tricuspid regurgitation, both tricuspid leaflets and subvalvar tissue have been absent, hypoplastic, or fused. For this reason, tricuspid valvoplasty was difficult and valve replacement was adopted in many cases. In the present case of a 52-year-old man, however, the tricuspid valve showed no abnormalities other than a severely dilated tricuspid annulus. Ring annuloplasty was performed, and this resulted in a subsequent satisfactory course without anticoagulant therapy.

Background —In the treatment of type B acute aortic dissection without complications, better results are obtained if surgery is performed before enlargement of the aorta in patients who are predicted to show aortic enlargement and if drug-based treatment is continued for patients who are predicted to show no enlargement. The purpose of this study was to predict the acute-phase factors that may affect chronic-phase aortic enlargement by studying chronic-phase enlargement of dissections in patients without complications during the acute phase. Methods and Results —In 101 patients with type B acute dissection who had no complications, univariate and multivariate factor analyses were performed to determine the predictors for chronic-phase enlargement (≥60 mm) of the dissected aorta. The independent predominant predictors for aortic enlargement in the chronic phase were a maximum aortic diameter of ≥40 mm and a patent false lumen during the acute phase. The values of actuarial freedom from aortic enlargement for the patients with a maximum aortic diameter of 40 mm and a patent false lumen at 1, 5, and 10 years were 43%, 33%, and 22%, respectively, whereas in patients with a maximum aortic diameter of Conclusions —These results suggest that patients with type B acute aortic dissection who show a maximum aortic diameter of ≥40 mm and a patent false lumen should undergo surgery earlier during the chronic phase before enlargement of aorta, whereas patients with a maximum aortic diameter of