Japanese Journal of Cardiovascular Surgery Vol.42, No.3

Preface

• K. Hashimoto

Invited Review

• Cost Accounting in Cardiovascular Surgery T. Misumi.…173

Case Reports

• Septal Myectomy and Mitral Valve Replacement for Hypertrophic Obstructive Cardiomyopathy Accompanied by Severe Mitral Regurgitation H. Seta et al.…175
  Septal Myectomy and Mitral Valve Replacement for Hypertrophic Obstructive Cardiomyopathy Accompanied by Severe Mitral Regurgitation

  （Department of Cardiovascular Surgery, National Hospital Organization Yokohama Medical Center, Yokohama, Japan）

  Hiroyoshi Seta	Yukihiro Bonkohara	Masafumi Higashidate

  Septal myectomy and mitral valve surgery are performed for the treatment of hypertrophic obstructive cardiomyopathy（HOCM）; however, there is a debate as to which is the better option. In this paper, we report on the eventless postoperative course of a patient who underwent septal myectomy and mitral valve replacement simultaneously to treat HOCM accompanied by severe mitral regurgitation. A 75-year-old woman was referred to our department for severe mitral regurgitation accompanied by exertional dyspnea; we observed systolic anterior motion of the anterior mitral leaflet and a left ventricular outflow tract pressure gradient of 130 mmHg that was not decreased by DDD pacing. A 15×6×15-mm rectangular parallele pipe-shaped section of the hypertrophied basal septum was resected via a transaortic approach. In addition, mitral valve replacement with a 25-mm SJM was performed during the same procedure, as lesions were observed in the mitral valve. After surgery, the left ventricular outflow tract pressure gradient decreased by 12.5mmHg. Necessary and sufficient resection of the hypertrophied basal septum, after careful preoperative and intraoperative evaluation of the extent of myocardial resection and mitral valve lesions is important for improving left ventricular outflow tract pressure gradient in HOCM. Mitral valve replacement should also be performed, if necessary, to treat mitral valve lesions.　
    Jpn. J. Cardiovasc. Surg. 42:175-178（2013）
  
  Keywords：hypertrophic obstructive cardiomyopathy, septal myectomy, systolic anterior motion, mitral valve replacement
• An Operative Case of Traumatic Aortic Regurgitation S. Okuma et al.…179
  An Operative Case of Traumatic Aortic Regurgitation

  （Department of Cardiovascular surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan）

  Shinnosuke Okuma	Takahiko Misumi	Tsutomu Itou
  Akihiro Yoshitake	Osamu Ishida	Akinori Hirano

  Case reports of traumatic aortic regurgitation are rare. We report a case of a 62-year-old man injured by falling from a paraglider. After recovering from multiple injuries and discharge, he began to suffer from dyspnea. Severe aortic regurgitation and pseudoaneurysm of the sinus of Valsalva were diagnosed by ultrasound cardio graphy（UCG）and multi-detector-row computer tomography（MDCT). After cardiac failure was controlled, we operated. The commissure between the left and the right coronary cusps was detached from the aortic wall, and a modified Bentall operation was performed. The patient recovered well and was discharged uneventfully.
    Jpn. J. Cardiovasc. Surg. 42:179-182（2013）
  
  Keywords：thoracic injury, traumatic aortic regurgitation, Bentall operation, aortic pseudoaneurysm
• Valvuloplasty of Persistent Truncus Arteriosus with Pentacuspid Truncal Valve Insufficiency T. Abe et al.…183
  Valvuloplasty of Persistent Truncus Arteriosus with Pentacuspid Truncal Valve Insufficiency

  （Department of Cardiovascular Surgery, Saitama Children’s Medical Center, Saitama, Japan）

  Takayuki Abe	Koji Nomura	Katsushi Kinouchi
  Ko Yoshihiro

  A neonate, presenting with cyanosis, received the diagnosis of persistent truncus arteriosus with truncal valve stenosis with insufficiency. Her disease was classified as persistent truncus arteriosus Van Praagh type A1, or Collett and Edwards type I. At the age of 2 months, she underwent a modified Blalock-Taussig shunt, and her operative team was waiting for adequate body weight gain before performing further surgery. At the age of 1 year, however, she began to have repeated episodes of congestive heart failure due to severe tricuspid valve regurgitation and truncal valve insufficiency. When she reached 18 months of age, she underwent a definitive operation including a truncal valve plasty, VSD patch closure, and a right ventricular outflow tract reconstruction. Postoperative echocardiography 6 months after surgery showed a good truncal valve function with minimal regurgitaion. Truncal valve surgery is a challenging operation;we report a successfully treated case, though the patient will require extensive follow-up.
    Jpn. J. Cardiovasc. Surg. 42:183-185（2013）
  
  Keywords：persistent truncus arteriosus, truncal valve, pentacuspid, valvuloplasty
• A Case of Ascending Aorta-Abdominal Aorta Bypass with Reconstruction of the Visceral Arteries for Atypical Coarctation H. Harada and M. Suzuki…186
  A Case of Ascending Aorta-Abdominal Aorta Bypass with Reconstruction of the Visceral Arteries for Atypical Coarctation

  （Department of Cardiovascular Surgery, Kushiro Kojinkai Memorial Hospital, Kushiro, Japan）

  Hideyuki Harada	Masao Suzuki

  A 51-year-old man was referred to us because of upper extremity hypertension and vascular claudication of the lower extremities. He underwent extraanatomic ascending aorta-abdominal aorta bypass with vascular graft under a median sternotomy and a midline laparotomy incision without cardiopulmonary bypass. The postoperative course was uneventful. Upper extremity hypertension and vascular claudication were completely resolved. Although the patient has done well in the three years since his operation, we continue to observe him closely. The etiology of atypical coarctation may be related to Takayasu arteritis because of the angiographic findings and positive specific alleles such as HLA-B5201 and DRB1 1502.
    Jpn. J. Cardiovasc. Surg. 42:186-189（2013）
  
  Keywords：atypical coarctation, reconstruction of the visceral arteries, ascending aorta-abdominal aorta bypass, Takayasu arteritis
• Quadricuspid Aortic Valve Associated with Mitral Regurgitation and Tricuspid Regurgitation M. Hayakawa et al.…190
  Quadricuspid Aortic Valve Associated with Mitral Regurgitation and Tricuspid Regurgitation

  （Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Japan）

  Masato Hayakawa	Takeshi Kinoshita	Shiho Naito
  Noriyuki Takashima	Satoshi Kuroyanagi	Hiromitsu Nota
  Tomoaki Suzuki	Tohru Asai

  Congenital quadricuspid aortic valve is a very rare malformation. Most cases have been discovered as an incidental finding at aortic valve surgery or at autopsy. It frequently evolves to aortic regurgitation, which can manifest in adulthood and may require surgical treatment. A 66-year-old man was admitted because of dysprea. Echocardiogram revealed aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. We performed aortic valve replacement, mitral annuloplasty, and tricuspid annuloplasty successfully. The aortic valve showed one large, two intermediate and one smaller cusp, which were classified as type d by Hurwitz’s classification. An accessory cusp was situated between the right and left coronary cusps. No coronary abnormality was involved. The postoperative course was uneventful and he is doing well 6 months after operation.
    Jpn. J. Cardiovasc. Surg. 42:190-192（2013）
  
  Keywords：quadricuspid aortic valve, aortic regurgitation, aortic valve replacement, mitral regurgitation, tricuspid regurgitation
• Successful Management in the Case of Mesenteric Ischemia Following EVAR for Ruptured Abdominal Aortic Aneurysm K. Ishikawa et al.…193
  Successful Management in the Case of Mesenteric Ischemia Following EVAR for Ruptured Abdominal Aortic Aneurysm

  （Department of Cardiovascular Surgery, National Hospital Organization Mito Medical Center, Ibaraki, Japan, and Department of Cardiovascular Surgery, Cardiovascular Center, Sendai Kousei Hospital＊, Sendai, Japan）

  Kazunori Ishikawa	Azumi Hamasaki＊	Kazuo Abe＊
  Kazuo Abe＊

  We report a case of successfully treated mesenteric ischemia following emergency endovascular aortic repair（EVAR）for ruptured abdominal aortic aneurysm（r-AAA). A 79-year-old man, who had received hemodialysis for 5 years for diabetic nephropathy, presented with sudden onset abdominal pain. Contrast-enhanced computed tomography revealed an rAAA with a 60-mm diameter in the infrarenal abdominal aorta. Emergency EVAR was performed. After completion of stent graft placement, intraoperative angiogram revealed serious imaging delay of the superior mesenteric artery. An emergency saphenous vein bypass was performed from the right external iliac artery to the ileocolic artery. The postoperative course was uneventful, and there has been no evidence of endoleak or enlargement of aneurysm diameter during the follow-up period of 2 years.
    Jpn. J. Cardiovasc. Surg. 42:193-196（2013）
  
  Keywords：ruptured abdominal aortic aneurysm, stent graft, EVAR, mesenteric artery, bypass
• A Pseudoaneurysm of Abdominal Aorta after Intravesical bacillus Calmette-Guerin Therapy F. Asami et al.…197
  A Pseudoaneurysm of Abdominal Aorta after Intravesical bacillus Calmette-Guerin Therapy

  （Department of Cardiovascular Surgery, New-Tokyo Hospital, Matsudo, Japan）

  Fuyuki Asami	Hiroki Yamaguchi	Tatsuya Nakao
  Yu Oshima	Noriyuki Tokunaga	Hiromasa Nakamura
  Takaaki Itohara	Tasuku Kadowaki	Masatoshi Sunada
  Kyohei Ueno

  We report a patient who underwent an operation for an infectious abdominal aortic aneurysm 10 months after intravesical bacillus Calmette-Guerin therapy. A 68-year-old man had previous gastrectomy for early gastric cancer and intravesical BCG therapy for early stage urinary bladder cancer. His follow up CT scan revealed an abdominal aorta pseudoaneurysm. We performed aneurysmectomy, omentopexy and bilateral axillo-femoral bypass. The culture of an abscess in the aneurysm identified Mycobacterium bovis. The patients improved clinically with antituberculosis agents after operation. Intravesical bacillus Calmette-Guerin therapy is effective in the treatment of early stage urinary bladder cancer. Although this treatment is generally considered safe, serious complications including vascular complications have been reported.
    Jpn. J. Cardiovasc. Surg. 42:197-199（2013）
  
  Keywords：BCG, pseudoaneurysm, Mycobacterium bovis
• A Case of Aortic Valve Remodeling Operation for Aortic Localized Dissection S. Sakamoto et al.…200
  A Case of Aortic Valve Remodeling Operation for Aortic Localized Dissection

  （Department of Cardiovascular Surgery, Himi Municipal Hospital, Kanazawa Medical University, Himi, Japan）

  Shigeru Sakamoto

  Jun Kiyosawa

  Hideaki Nishimoriz

  A 39-year-old man was admitted to our hospital with symptoms of anterior chest pain and slightly dyspnea. At that time, he had chest discomfort, hypertension, and with enlargement of mediastinal shadow on chest X ray. Medical treatment rapidly improved the hypertension and the other symptoms. Transthoracic echocardiography（TTE）and enhanced chest CT revealed aortic root dilation, and trivial aortic valve regurgitation, but these examinations could not identify the cause of such as typical Stanford type A dissection. Transesophageal echocardiography（TEE）and chest MD-CT were undertaken on 7 days after the admission revealed a localized aortic dissection, intimal flap, and enlargement of sinotubular junction（STJ). An Urgent operation was performed. During the operation, a localized aortic dissection appeared to be above the left coronary cusp through the right coronary cusp of the aortic valve, but the valve findings were normal, so we decided to perform a aortic valve remodeling operation. The aortic sinuses were excised leaving 4mm of arterial wall attached to the aortic annulus and around the coronary arteries. A Woven Dacron graft of diameter equal to the diameter of the STJ was tailored to recreate three aortic sinuses. The three commissures were suspended into the tailored graft and the neo-aortic sinuses were sutured to the aortic annulus and remnants of arterial wall. The coronary arteries were reimplanted into their respective neo-aortic sinuses and the graft anastomosed to the distal aorta. The postoperative course was uneventful. We concluded that this procedure is useful for a localized aortic dissection around the coronary orifice.　
    Jpn. J. Cardiovasc. Surg. 42:200-203（2013）
  
  Keywords：aortic valve remodeling operation, aortic localized dissection, intimal flap, MD-CT
• Spontaneous Thrombosis of a Ruptured Deep Femoral Artery Aneurysm K. Iyori et al.…204
  Spontaneous Thrombosis of a Ruptured Deep Femoral Artery Aneurysm

  （Department of Cardiovascular Surgery, Yamanashi Kosei Hospital, Yamanashi, Japan）

  Keiji Iyori	Yoshitaka Mitsumori	Kenji Ariizumi
  Ryoichi Hashimoto

  We report a rare case of spontaneous thrombosis of a ruptured deep femoral artery aneurysm. An 85-year-old man presented two days after onset of acute swelling and pain in the left groin. Computed tomography demonstrated rupture of a deep femoral artery aneurysm and thrombosis of the aneurysm. After 1 month of observation, surgical intervention was performed as the local pain persisted. Opening of the aneurysm sac confirmed that thrombosis was complete. Simple ligation and drainage of the aneurysmal sac was performed. His postoperative course was uneventful.
    Jpn. J. Cardiovasc. Surg. 42:204-206（2013）
  
  Keywords：deep femoral artery aneurysm, aneurysm rupture
• An Aortic Arch Aneurysm Developing Late after a Non-anatomical Bypass Surgery for an Aortic Coarctation in Adulthood R. Shimada et al.…207

  （Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan）

  Ryo Shimada	Hayato Konishi	Yoshikazu Motohashi
  Shinji Fukuhara	Hiroaki Uchida	Mari Kakita
  Takahiro Katsumata

  A 48-year-old man underwent an non-anatomical bypass surgery for aortic coarctation when he was 38 years old, when a bypass laid between the left subclavian artery and the descending aorta with a prosthesis（10mm, internal diameter). Four years after the first surgery, aortic aneurysms at the proximal and distal sites of the coarctation were detected. Six years from then, we decided to perform another surgery when the maximum diameters of the proximal and distal sites exceeded 60 and 47mm, respectively. We performed the aortic replacement from the proximal left subclavian artery to the descending aorta at eighth thoracic vertebra. The approach to the aortic aneurysm was through the extended left thoracotomy with the transection of the sternum. The cardiopulmonary bypass was established with an antegrade aortic perfusion（from the ascending aorta）and drainage from the right atrium. The circulatory arrest was obtained under deep hypothermia at 20℃ measured by deep body temperature. After the surgery, the pressure differences between upper and lower extremities decreased to 10mmHg, which had been 40mmHg before surgery. Macroscopic observation showed the coarctation site was completely obstructed by an old thrombus. From this observation, we surmise that one of the reasons for the aneurysmal formation at the proximal site of coarctation might be an insufficient depressurization by the non-anatomical bypass grafting from the left subclavian artery to the descending aorta at the first surgery. We consider that a severe coarctation might become thrombotic sooner or later after a non-anatomical bypass surgery due to a change of blood flow, and a radical anatomical surgery would be recommended for adult coarctation cases.
    Jpn. J. Cardiovasc. Surg. 42:207-210（2013）
  
  Keywords：coarctation, aortic aneurysm
• A Juvenile Case of Folding Plasty for Mitral Active Infectious Endocarditis
  A Juvenile Case of Folding Plasty for Mitral Active Infectious Endocarditis

  （Department of Cardiovascular Surgery, Okazaki City Hospital, Okazaki, Japan, and Department of Cardiovascular Surgery, Chukyo Hospital＊, Nagoya, Japan）

  Takeshi Yuasa	Kazutaka Horiuchi	Takafumi Terada＊
  Shunsuke Nakata	Masahiko Hasegawa	Kenzo Yasuura

  We report a case of mitral active infectious endocarditis in a 15-year-old boy successfully managed by folding plasty without any prosthetic devices. He was admitted to our hospital because of high fever and general fatigue. Echocardiography revealed a vegetation of 15×18mm attached to the anterior commissure area of the mitral valve with severe mitral regurgitation. Brain MRI showed acute brain infarction without symptoms, and enhanced computed tomography also showed multiple infarctions of the spleen and the left kidney. Staphylococcus aureus was identified in the venous blood culture. We diagnosed active mitral infectious endocarditis with multiple systemic embolization and disseminated intravascular coagulation. After antibiotic therapy for 9 days, mitral valve surgery was performed with cardiopulmonary bypass and cold blood cardioplegia through a median sternotomy and a left atriotomy. A giant vegetation was attached to the damaged mitral leaflet of the AC to A1 and P1. The vegetation and damaged leaflet were removed by an ultrasonic aspirator and resected. Removal of the superficial vegetation with the aspiration method enabled preservation of more than half of the A1 and half of the P1 for valve repair. The anterior commissure annulus without a leaflet was reconstructed by compression suture. Furthermore, in a procedure similar to folding plasty, leaflet A1 was folded down and sutured to annulus P1, and a simple suture technique was involved to the left cut edges of leaflet A1 and P1. The postoperative course was uneventful. Two years after surgery, the patient was well with no recurrence of infection and trivial mitral regurgitation on echocardiography.
    Jpn. J. Cardiovasc. Surg. 42:211-214（2013）
  
  Keywords：active infectious endocarditis, mitral valve plasty, folding plasty, commissural leaflet disease
• Successful Endovascular Treatment of an Intrathoracic Left Subclavian Artery Aneurysm with TEVAR and Coil Embolism H. Akagi et al.…215
  Successful Endovascular Treatment of an Intrathoracic Left Subclavian Artery Aneurysm with TEVAR and Coil Embolism

  （Department of Cardiovascular Surgery, Yao Tokushukai General Hospital, Osaka, Japan, and Department of Radiology, Matsubara Tokushukai Hospital＊, Osaka, Japan）

  Haruhiko Akagi	Hiroshi Irie	Yoshihisa Nakao
  Kei Sakai	Shoji Sakaguchi＊

  A 77-year-old man with an abdominal aortic aneurysm, detected by abdominal ultrasonography, was referred to our hospital. Multi-detector computed tomography（MDCT）revealed an intrathoracic left subclavian artery aneurysm 30mm in diameter and a small distal arch aortic aneurysm as well as an abdominal aortic aneurysm 40mm in diameter. Surgery was indicated for the subclavian artery aneurysm considering the risks of rupture and distal embolism. Our choice for treatment was endovascular repair;thoracic endovascular aortic repair（TEVAR）and coil embolism. The operation was performed successfully. Orifices of the left subclavian artery and the distal arch aneurysm were covered with a stent graft and the left subclavian artery was occluded with coils distal to the aneurysm. The operation time was 1 h and 44 min. He was extubated in the operation theater. A follow-up CT scan performed at 1 week showed the correct position of the TEVAR device, patency of the common trunk of the brachiocephalic and right common carotid arteries, and complete exclusion of the aneurysms. He was discharged on the 12th postoperative day without complication. Subclavian artery aneurysms, in particular in the intrathoracic location, are rare. Conventional surgery for this entity tends to require arch replacement to be unreasonably invasive as a therapy for peripheral artery disease. We believe this endovascular therapy can be a useful, less-invasive alternative to conventional open surgery.
    Jpn. J. Cardiovasc. Surg. 42:215-218（2013）
  
  Keywords：intra thoracic subclavian artery aneurysm, TEVAR, coil embolism
• A Perivalvular Leakage 25 Years after Mitral Valve Replacement by the Omnicarbon Valve Prosthesis M. Yoshida et al.…219
  A Perivalvular Leakage 25 Years after Mitral Valve Replacement by the Omnicarbon Valve Prosthesis

  （Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan）

  Minoru Yoshida	Shunji Uchita	Yoshiharu Nishimura
  Yoichi Hisada	Kentarou Honda	Takashi Miura
  Seiji Matsukuma	Mizuki Sumi	Yoshitaka Okamura
  Kiyoyuki Eishi

  A 79-year-old woman had undergone mitral valve replacement（Omnicarbon（OC）valve:31mm）due to rheumatic mitral stenosis with regurgitation and tricuspid annuloplasty at the age of 54. The patient developed anemia and congestive heart failure with pleural effusion and an elevated LDH level in 25 years late up without any valve-related cardiac event. Echocardiography revealed perivalvular leakage near the anterolateral commissure. The patient received re-mitral valve replacement（CEP valve:25mm）and a tricuspid valve ring annuloplasty（MC3 Tricuspid ring:28mm). The annulus was covered with marked calcification and fibrosis with a partial deficit at the anterior part of antero-lateral commissure. Despite the thorough pathological examination, we could not clarify the etiology of sudden onset of hemolysis.The patient was discharged uneventfully on the 28th day after operation. In general, the OC valve can work without serious complications for a long time. We report a rare case of perivalvular leakage 25 years after mitral valve replacement with hemolysis and congestive heart failure.　
    Jpn. J. Cardiovasc. Surg. 42:219-222（2013）
  
  Keywords：Omnicarbon valve, re-mitral valve replacement, perivalvular leakage, hemolytic anemia
• Specific Treatment Technique of Perivalvular Aortic Regurgitation in a Patient with Takayasu Arteritis S. Yasuda et al.…223
  Specific Treatment Technique of Perivalvular Aortic Regurgitation in a Patient with Takayasu Arteritis

  （Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan, and Department of Surgery, Yokohama City University Hospital＊, Yokohama, Japan）

  Shota Yasuda	Shigehiko Tokunaga	Daisuke Machida
  Yukinao Isomatsu＊	Munetaka Masuda＊

  We describe our experience of surgical treatment in a patient with Takayasu’s arteritis who required aortic root replacement because of perivalvular aortic regurgitation, developing 2 years after aortic valve replacement. A 65-year-old man underwent aortic valve replacement with a mechanical valve 3 years previously because of serious aortic insufficiency associated with Takayasu’s arteritis. No steroids were given postoperatively. Three years after surgery, perivalvular aortic regurgitation developed. Reoperation was scheduled because of increased regurgitation and valve dehiscence. The sinus of Valsalva and the ascending aorta were enlarged, and a false aneurysm was found at the suture line of the aortotomy. Moderate mitral insufficiency was also present. The patient underwent aortic root replacement with a mechanical valve（J-graft Shield®:, 24mm;and SJM Regent®, 21mm), hemiarch replacement（J-graft Shield®:, 24mm), and mitral annuloplasty（IMR ET Logix®: ring, 28mm). Intraoperative examination showed very severe adhesion around the ascending aorta and marked wall thickening extending from the aortic root to the ascending aorta. The annulus was recognized to be very fragile after the mechanical valve was removed. The annulus was reinforced with autologous pericardium patch, furthermore, the subannulus was reinforced with a shortly cut artificial vessel graft. Aortic root replacement was then performed. After surgery, the patient received steroids. Inflammation was improved by steroids and the patient is being followed up on an outpatient basis. In patients with a fragile annulus and severe inflammation associated with aortitis, tissue reinforcement and postoperative management of inflammation are essential.
    Jpn. J. Cardiovasc. Surg. 42:223-227（2013）
  
  Keywords：Takayasu’s arteritis, perivalvular leakage, Bentall’s operation
• A Successfully Treated Case of Crawford Type I Thoracoabdominal Aortic Aneurysm with Supra-renal Abdominal Aorta Occulusion by Endovascular Repair and Debranching Visceral Arteries I. Katayama et al.…228
  A Successfully Treated Case of Crawford Type I Thoracoabdominal Aortic Aneurysm with Supra-renal Abdominal Aorta Occulusion by Endovascular Repair and Debranching Visceral Arteries

  （Department of Cardiovascular Surgery, and Department of Vascular Surgery＊, Shonan Kamakura General Hospital, Kamakura, Japan）

  Ikuo Katayama	Masashi Tanaka	Hidemitsu Ogino＊
  Satoshi Ito	Tadahiro Shimada	Kazunori Hashimoto
  Yoshikazu Ooshiro	Miyo Shirouzu

  A 64-year-old man under dialysis was referred for surgical treatment of Crawford type I thoracoabdominal aortic aneurysm. He had a history of idiopathic portal hypertension and chronic total occulusion of supra-renal abdominal aorta and appeared to have massive development of collateral arteries and veins in the abdomen. We chose endovascular repair with debranching of visceral arteries and bypass grafting to bilateral superficial femoral artery considering bleeding from collateral arteries and veins by conventional open surgery. Postoperative CT scan revealed no endoleak and all debranched and bypass grafts were patent. He was discharged with no postoperative complications including paraplegia.
    Jpn. J. Cardiovasc. Surg. 42:228-231（2013）
  
  Keywords：thoracoabdominal aortic aneurysm, debranching, collateral artery and veins
• Removal of a Left Ventricular Thrombus Associated with Acute Myocarditis via Left Ventriculotomy K. Imai et al.…232
  Removal of a Left Ventricular Thrombus Associated with Acute Myocarditis via Left Ventriculotomy

  （Department of Cardiovascular Surgery, Heart Center, Amagasaki Hospital, Hyogo, Japan）

  Kenta Imai	Nobuhisa Ohno	Ayano Futsuki
  Mamoru Hamuro	Kosuke Yoshizawa	Eiji Yoshikawa
  Keiichi Fujiwara

  A 41-year-old man was referred to our hospital suffering from pyrexia. Echocardiogram showed diffuse severe hypokinesis of the left ventricle. The patient was treated medically under a diagnosis of acute myocarditis and anticoagulation therapy had been started. However a large mobile thrombus and multiple small thrombi were detected in the left ventricle 2 days after admission. Because of the deterioration of his left ventricular function（LVEF 14%), he was treated medically with careful monitoring of the thrombi by echocardiogram. His left ventricular function started to improve 3 days after admission（LVEF 27%), and then surgical removal of the thrombi was performed through left ventriculotomy. His postoperative course was uneventful. LVEF was improved to 60% at discharge. He is doing well without any signs of embolic event at 2 years postoperatively. Left ventriculotomy is one of the useful methods for removal of left ventricular thrombus associated with acute myocarditis, if the procedure is performed during the recovery phase.
    Jpn. J. Cardiovasc. Surg. 42:232-235（2013）
  
  Keywords：acute myocarditis, left ventricular thrombus, left venticulotomy
• Aortic Valve-Sparing Operation in a 8 Years Old Boy with Loeys-Dietz Syndrome with Annuloaortic Ectasia T. Kono et al.…236
  Aortic Valve-Sparing Operation in a 8 Years Old Boy with Loeys-Dietz Syndrome with Annuloaortic Ectasia

  （Department of Surgery, Kurume University Hospital, Kurume, Japan）

  Takanori Kono	Koji Akasu	Hiroyuki Saisho
  Yuichiro Hirata	Kazuyoshi Takagi	Tomokazu Kosuga
  Hiroshi Tomoeda	Koichi Arinaga	Hidetoshi Akashi
  Hiroyuki Tanaka

  An 8 year-old boy had a cardiac murmur pointed out on day three after birth and was given a diagnosis of ventricular septal defect（VSD). He underwent VSD patch closure at two months after birth. He was also found the having Loeys-Dietz syndrome on the basis of mutation of TGFBR2 and physical examination at the age of 2 years. He had been followed up at pediatrics clinic of our hospital since then, and was hospitalized for a 46.5-mm extension of valsalva sinus diameter and moderate aortic insufficiency. The aortic valve was three-cusped and had no abnormality. We performed valve-sparing aortic root replacement. He was discharged on day 18 after the operation without any problems in the postoperative course. Use of an artificial heart valve for the surgery of the aortic root lesion in childhood will probably cause reoperation in the future and difficulty in Warfarin anticoagulation control. A careful decision is needed in the choice of an operation method. Valve-sparing aortic root replacement is a useful operation for patients without aortic valve abnormality.
    Jpn. J. Cardiovasc. Surg. 42:236-240（2013）
  
  Keywords：Loeys-Dietz syndrome, valve-sparing aortic root replacement, child, David operation
• Rupture of Free Wall of the Left Ventricular and Ventricular Septum（Double Rupture）after Acute Myocardial Infarction D. Onohara et al.…241
  Rupture of Free Wall of the Left Ventricular and Ventricular Septum（Double Rupture）after Acute Myocardial Infarction

  （Department of Cardiovascular Surgery, Oita Prefectural Hospital, Oita, Japan）

  Daisuke Onohara

  Kazuki Hisatomi

  Takahumi Yamada

  Cardiac ruptures are life-threatening complications after acute myocardial infarction. Types of rupture include left ventricle free-wall rupture, ventricular septal rupture, and papillary muscle rupture. Double rupture is defined as the coexistence of two of the above-mentioned forms of rupture. It complicates approximately 0.3% of acute myocardial infarction with the most frequent combination being free-wall rupture and ventricular septal rupture. We present the case of a 74-year-old man whose recent acute myocardial infarction was complicated by a combination of free-wall rupture and ventricular septal rupture. The patient underwent successful surgical treatment of the double myocardial rupture along with bypass grafting.
    Jpn. J. Cardiovasc. Surg. 42:241-245（2013）
  
  Keywords：ventricular septal rupture, free-wall rupture, double rupture, patch closure
• A Small Ruptured Splenic Artery Aneurysm Presenting as Anemia and Melena after Graft Replacement of an Abdominal Aortic Aneurysm T. Akimoto et al.…246
  A Small Ruptured Splenic Artery Aneurysm Presenting as Anemia and Melena after Graft Replacement of an Abdominal Aortic Aneurysm

  （Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan）

  Takehide Akimoto

  Mitsuru Kitano

  Hiroo Teranishi

  The splenic artery is a common site of intraabdominal aneurysms. Very few patients present with symptoms before a splenic artery aneurysm ruptures. However, the symptoms vary depending on the type of aneurysm. Some patients present with hemodynamic shock, while others develop mild lumbago, anemia, or syncope. Thus, it is sometimes difficult to diagnose and treat ruptured splenic aneurysms. We report a rare case of rupture of a small splenic artery aneurysm, which remained undetected for 3 months after the appearance of the first symptoms, i.e., anemia and melena, despite conducting different examinations at our hospital. A 74-year-old man who underwent a graft replacement of an abdominal aortic aneurysm in 2006 complained of melena in May 2011. He was severely anemic, but presented with no other symptoms. A 16-mm-diameter splenic aneurysm was detected during a previous operation. The splenic artery aneurysm, as seen on computer tomography（CT）scans, showed no significant change in diameter for 5 years. The patient underwent upper and lower gastrointestinal endoscopy, capsule endoscopy, and enhanced CT at the Department of Gastroenterology to determine the site of the bleeding. However, the source of the bleeding was unclear. Finally, a diagnosis by elimination was made and the cause of the melena was identified as a ruptured splenic aneurysm. The splenic artery aneurysm was treated with coil embolization, and the patient’s anemia was cured. The splenic artery aneurysm ruptured and bled into the pancreatic duct. The findings of this case suggest that a small splenic artery aneurysm rupture might not cause major symptoms like hemodynamic shock or large hematomas that can be identified on CT scans, but they may bleed into visceral organs. Therefore, interventions for the treatment of a non-symptomatic abdominal visceral artery aneurysm should be carried out promptly.
    Jpn. J. Cardiovasc. Surg. 42:246-248（2013）
  
  Keywords：ruptured splenic artery aneurysm, small visceral artery aneurysm, melena, acute abdomen, pitfall

Letter to Editor

• S. Tokunaga

Editor's Postscript

• Y. Saeki