胸部外科

A severely calcified ascending aorta increases the risk of perioperative cerebral damage in cardiac surgery. Conventional aortic valve replacement using an external aortic cross clamp may be dangerous in patients with this morbidity. We used an intra-aortic balloon occlusion catheter（IABOC）to minimize risks of aortic valve replacement（AVR） in an 81-year-old man with severe aortic stenosis combined with a severely calcified aorta. IABOC was introduced to the ascending aorta via the right femoral artery by esophageal echocardiography. The precise site of the inflated balloon was confirmed by the pressure of the right radial artery and was secured by 2 tourniquets around the ascending aorta. The postoperative course was uneventful. Our technique can contribute to prevention of embolic complications in some patients with a severely calcified ascending aorta.

We report a case of bronchial artery aneurysm （BAA） successfully treated with a combination of transcatheter embolization and stent graft. A 50-year-old woman was referred to our hospital for further examination of a hemispherical bulging lesion on the middle esophagus detected by gastroscopy. Computed tomography （CT） revealed BAA with a 15 mm-diameter arising from the descending aorta on the left side of the esophagus. We performed transcatheter embolization combined with a stent graft because of a short neck. Postoperative course was uneventful. Follow-up CT showed complete isolation of the blood flow into the BAA. BAA is rare and often found incidentally by diagnostic imaging as shown in our case. Prompt treatment with complete isolation of blood inflow is required because the rupture of BAA is life-threatening.

Coronary artery aneurysm is rare disease, usually asymptomatic and is often found by chance by echocardiography, computed tomography（CT） and coronary angiography. However, its rupture or thrombotic obstruction to the periphery of the coronary artery leads to cardiac tamponade, angina pectoris, or myocardial infarction. We describe 2 cases of giant coronary artery aneurysm presented as acute coronary syndrome. Surgical resection of the aneurysm and coronary artery bypass grafting were successfully carried out under cardiopulmonary bypass. Postoperative courses of both cases were uneventful, and the patients were free of symptoms.

Pulmonary mucosa-associated lymphoid tissue （MALT） lymphoma is associated with pre-existing infections or autoimmune disorders. We report a case of lung cancer initially suspected of MALT lymphoma. The patient was a 73-year-old woman. Complete screening examinations identified a tumor in the right middle lobe. Transbronchial lung biopsy revealed the infiltration of CD20＋/CD79a＋ lymphocytes invading the structure of the alveolus. MALT lymphoma was suspected, and the middle lobe was resected. The tumor was primarily invasive mucinous carcinoma, and lymphocytic infiltration was observed around the tumor. The monoclonal expansion of B cells and genetic and chromosomal abnormalities which are criteria for the diagnosis of MALT lymphoma were not demonstrated and the lesion was diagnosed as reactive lymphoid infiltrates. Marked lymphocytic infiltration regardless of neoplastic or reactive may suggest the presence of latent lesions.

Idiopathic subglottic stenosis （ISS） is defined as the narrowing of the upper airway without any known cause. A 40-year-old female was referred to our hospital with the complaint of exacerbation of dyspnea causing difficulty in going out. Chest computed tomography （CT） scan and bronchoscopy revealed subglottic tracheal stenosis with a luminal diameter of 5 mm at the narrowest part. Tracheal mucosa of the stenotic lesion was smooth, and the patient had no previous medical history. Subglottic tracheal resection of the stenotic lesion and reconstruction were performed. The postoperative course was good, and the symptom of dyspnea improved significantly. Recently, some reports have suggested conservative treatments such as laser and balloon dilation for ISS, but the recurrence rate after these treatments is still high. Surgery is recommended rather than conservative treatments for patients with less severe inflammation of tracheal mucosa and other comorbidities like present case.

A 69-year-old man was hospitalized urgently to the department of cardiology, with the progressive general malaise. On admission, his blood pressure was 80/42 mmHg, his white cell count 13,700/μl, and C-reactive protein 25.55 mg/dl suggesting existence of aggressive infection with impaired circulation. Massive pericardial effusion was detected in echocardiography. Pericardial drainage was undergone promptly. There was drainage of 700 ml and the property was purulent. Pneumococcus was detected by the culture test of the pericardial fluid. Antibiotic administration was started by a diagnosis of the purulent pericarditis. His general condition was improved. However, a rapidly expanding saccular aneurysm was found in a descending thoracic aorta by computed tomography（ CT）. As an infected thoracic aortic aneurysm secondary to the purulent pericarditis, we performed thoracic endovascular aneurysm repair （TEVAR）. The intravenous administration of antibiotics was continued for 2 weeks after TEVAR, which was followed by oral antibiotic administration for 1 year. The aneurysm completely disappeared by CT, 10 months after TEVAR. In case with an infected thoracic aortic aneurysm, TEVAR can be a 1st choice of treatment, depending on a causative organism and the morphology of the aneurysm.

A 40-year-old man presented to our hospital with fever and slight palpitation. The echocardiogram revealed bicuspid aortic valve, massive aortic regurgitation, and aneurysm of Valsalva sinus. Operative findings showed an aortic root pseudoaneurysm originating just below the avulsion of the right to left commissure. The orifice was closed with a part of a woven vascular graft, and the aortic valve was replaced with a mechanical valve. There was no sign of marked inflammation, although pathophysiologic findings indicated infective endocarditis. His postoperative course was uneventful.

A 62-year-old female with Moyamoya disease （MMD） had cardiomegaly pointed out by chest X-ray and was admitted to our hospital. Chest computed tomography （CT） scan and echocardiography revealed a large dissecting ascending aortic aneurysm 78 mm in diameter combined with severe aortic regurgitation and mild mitral regurgitation. She had a history of intracranial hemorrhage related with MMD twice. Considering her relatively young age and risk of intracranial hemorrhage, valve-sparing aortic root replacement was planned to avoid anticoagulant therapy. Operation was performed keeping intra-operative blood pressure, perfusion pressure, Paco2 and activating clotting time in appropriate ranges. The postoperative course was uneventful without cerebral complication. No clinical symptom related with MMD was observed in 4 years after the operation.

Coronary artery aneurysm is a rare disease and its surgical indication is still controversial. We present a 63-year-old male having left main coronary artery aneurysm with 6 mm in diameter and symptomatic severe triple vessel disease. It was saccular and expanding into the myocardium. The patient successfully underwent off-pump quadruple coronary artery bypass and suture ligation of the aneurysmal neck. We believe that this technique is effective and less invasive to manage small or medium-sized coronary artery aneurysm in case aneurysmal shape, size, and location should be fitting for it.