The loop technique via median sternotomy to treat posterior, anterior and, especially, bileaflet prolapse provided satisfactory mid-term outcomes.

neurysmal circumflex coronary artery (Cx) with fistulous connection to the coronary sinus is a rare clinical condition, 1 and usually remains asymptomatic until later in life. 2 The therapeutic strategy, including the timing of surgical treatment, is not well defined, especially in asymptomatic patients, and surgical repair is quite challenging. 3 Regarding surgical intervention, whether to leave or exclude a diffusely aneurysmal Cx, in addition to ligation of the fistula, is a big issue, considering the risk of later rupture when leaving the aneurysm and sacrifice of the native coronary circulation when excluding the aneurysm. 1 We report a case of an aneurysmal Cx, which finally ruptured into the left atrium after surgical ligation of its fistulous connection to the coronary sinus. Case ReportIn 2001, an asymptomatic 59-year-old man with a continuous heart murmur underwent cardiac catheterization, which revealed an aneurysmal Cx with fistulous connection to the coronary sinus. The pulmonic-to-systemic flow ratio (Qp/Qs) was 2.05 with an anomalous oxygen step-up at the right atrium. However, he rejected any intervention, because of the lack of symptoms. In 2006, he started to feel worsening dyspnea on exertion, and his Qp/Qs became 4.1. The aneurysmal Cx was grossly dilated from its origin and its maximum diameter was 2.5 cm. It pursued a tortuous course along the left posterior atrioventricular groove (Fig 1). In another institution, he underwent external ligation of the fistula and closure of its distal opening into the coronary sinus under cardiopulmonary bypass. He became symptom-free with an equal Qp/Qs and was discharged without any additional dilatation of the aneurysmal Cx in early angiographs.However, at 6 weeks after the operation, he complained of severe, abrupt chest and back pain and was transferred to our institution as an emergency case. On arrival, his blood pressure was 70 mmHg with ST depression in all leads of the electrocardiogram. Several cardioversions were needed to treat the ventricular tachycardias. He was emergently intubated and required intra-aortic balloon pump support, followed by establishment of percutaneous cardiopulmonary support. Echocardiography revealed akinetic inferior and posterolateral left ventricular walls with generalized hypokinesis and an anomalous penetrated shunt from the aneurysmal Cx to the left atrium. Emergency cardiac repair was undertaken under cardiac arrest using cardiopulmonary bypass. The aneurysmal Cx was opened after transection of the pulmonary trunk (Fig 2). The dilated Cx contained a massive adherent thrombus. Saphenous vein grafts were individually bypassed to the left anterior descending coronary artery and a posterolateral branch of the Cx. A right-side left atriotomy clearly showed perforation of the aneurysmal Cx into the left atrium with a 3×4-cm fragile-ended foramen, which was successfully closed using a bovine pericardial patch. After ensuring that there was no bleeding from the excluded portion, the operation Circ J 2007; 71: 1996 -1998 ...

No abstract

Atheromatous degeneration of the aorta is considered to be a risk factor for postoperative embolic complications after endovascular treatment, and is associated with a high incidence of vascular events in the long term. We devised a method to quantify the shagginess of the aorta using contrast-enhanced computed tomography (CT) images. This study examined the method's validity and prognostic usefulness in patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR).We retrospectively investigated 427 patients who underwent elective EVAR between 2007 and 2013. Preoperative contrast-enhanced CT images with a slice thickness of 1 mm were analyzed using a workstation, and the degree of aortic luminal irregularity from the level of the left subclavian artery ostium to that of the celiac artery ostium was quantified by computing a shagginess score. We compared the computed scores with subjective visual assessments of aortic shagginess. Subsequently, we evaluated the relationship between the computed scores and postoperative prognosis.The shagginess scores were significantly correlated with the visual assessments of the aortic lumen, which were performed by 5 experienced vascular surgeons (rho ranged from 0.564–0.654, all P < 0.001). Multiple logistic regression analysis demonstrated that the shagginess score was independently associated with the development of renal impairment within a month after EVAR (odds ratio, 2.78; 95% confidence interval [CI], 1.83–4.22, P < 0.001). The shagginess score was significantly higher in patients who suffered postoperative intestinal and peripheral ischemic complications, as compared with those who did not (P < 0.001). The mean postoperative follow-up period was 1207 ± 641 days. Cox proportional hazards regression showed that the shagginess score was a significant independent predictor of all-cause and cardiovascular mortality (hazard ratio [HR], 1.37; 95% CI, 1.09–1.72, P = 0.007, and HR, 1.51; 95% CI, 1.04–2.18, P = 0.030, respectively).The results suggest that the shagginess score provides a quantitative reflection of aortic luminal irregularity. It may serve as a useful predictive factor for postoperative renal function deterioration, embolic complications, and long-term mortality after elective EVAR.