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apillary fibroelastomas, which are generally found on the valvular endocardium, are relatively uncommon benign tumors and the next most common of the primary cardiac tumors after myxomas and lipomas. 1,2 However, they can cause lethal embolisms resulting in myocardial infarction, cerebral infarction and pulmonary embolism. 2 The number of patients diagnosed with papillary fibroelastomas has increased since the advent of echocardiography, but cases of recurrence have not been reported and multiple occurrence is rare. [3][4][5][6][7][8][9][10][11] We present a case of double papillary fibroelastoma of the aortic valve with aortic regurgitation and mitral periprosthetic leakage occurring 4 years after resection of an initial left ventricular papillary fibroelastoma with mitral and tricuspid valvular disease. Case ReportIn 1997, a 52-year-old man presented to hospital with dyspnea and a medical history that included atrial fibrillation in 1993. Cardiac catheterization revealed mild pulmonary hypertension of 45/22 mmHg, elevated wedge pressure of 22 mmHg, and obstruction of the posterior descending artery. Transthoracic echocardiography confirmed the presence of a left ventricular tumor (Fig 1A), and revealed moderate mitral stenosis and regurgitation, tricuspid regurgitation and trivial aortic regurgitation. Mitral valve replacement (29 mm Carbomedics Valve), tricuspid annuloplasty (32 mm Carpentier Ring) and tumor excision without blood transfusion were performed. The tumor, found on the anterior wall of the left ventricle near the apex of the heart, was pale yellow and 7 mm in maximum length. It was excised through the mitral valve (Fig 2A). Pathology showed papillary growth with myxoid stroma and the

Continuous hemofiltration was very easily set up with less interference to the hemodynamics. Using an arterial graft with off-pump bypass, an aortic no-touch technique and water control with conventional hemodialysis were possible.

The objective of this study was to investigate the difference between the closed circuit system and the open circuit system in clinical heparin-coated cardiopulmonary bypass (CPB) circuits with a centrifugal pump. We evaluated the coagulation, fibrinolysis, and inflammatory response in valvular heart surgery. Nineteen patients were assigned at random to a group for the closed circuit system or the open circuit system. This is the first report on the effect of a closed circuit in valvular surgery. We measured the platelet count, white blood cell count, plasma fibrinogen concentration, thrombin-antithrombin III complex, plasmin-Alpha2 plasmin inhibitor complex, D-dimer, interleukin-6, polymorphic neutrophil-elastase, and the plasma free hemoglobin. Blood samples were collected before the start of perfusion, 15 and 60 min after the start of perfusion, 60 min after the administration of protamine, and 1 day after the operation. During the perfusion, coagulation, fibrinolysis, and inflammatory responses were activated; however, no significant differences between the two groups were noted. In this clinical investigation with suction and the cell saving system, the closed circuit was not found to be superior to the open circuit with regard to biocompatibility.

We performed modified aortic root replacement using a composite graft in seven patients over a 7-year-period. Six patients underwent emergency surgery for acute aortic dissection and one patient underwent elective surgery for an aortic aneurysm. To make the composite graft, we chose an artificial valve that was 1 mm larger than the graft, and when performing the proximal anastomosis, we sutured only the graft edge using the horizontal mattress suture technique, applying an additional running suture for reinforcement. The button technique was routinely used for coronary reattachment. To assess hemostasis of the aortic proximal and coronary suture line, cardioplegia was injected via the left atrial vent, which enabled us to confirm hemostasis before performing the distal anastomosis. Blood loss and the need for blood transfusion were minimized by this modified technique. None of the six survivors has required reoperation during 7-year period. Our technique of aortic root replacement based on a composite graft with some operative modifications seems to be safe and reliable, resulting in a satisfactory outcome.

The presence of a horseshoe kidney associated with aortoiliac vascular disease poses technical difficulties in terms of vascular reconstruction. The renal isthmus, position of the renal pelvis and ureters, and variable blood supply to the horseshoe kidney can complicate aortoiliac reconstruction. The left retroperitoneal approach provides excellent exposure of the abdominal aorta in patients with a horseshoe kidney without dividing the renal isthmus and avoids the risk of injury to a ureter in an anomalous position. We herein report the case of a patient with a horseshoe kidney who underwent a successful reconstruction of aortoiliac vascular disease using the left retroperitoneal approach.

The patients with highly damaged renal functions following extracorporeal circulation (ECC) were reviewed. Markers such as serum and urine creatinine (SCr, UCr), blood urea nitrogen (BUN), alpha 1-microglobulin in urine (as a marker of renal tubular function, abbreviated as U alpha 1-m), microalbumin in urine (as a marker of renal glomerular function, abbreviated as UA1b) were measured in each cases. Twenty patients were selected with the maximum value of U alpha 1-mover 60 micrograms/dl during or after ECC. The patients were classified into three groups according to preoperative value of alpha 1-m index (alpha 1-m index (I) = U alpha 1-m/UCr x 100 mg/g Cr), and Albumin index (Albumin index (I) = UA1b/UCr x 100 mg/g Cr). Group I (n = 13); alpha 1-m I > 10 and, Alb I > or = 50 (abnormal value of tubular and glomerular function), Group II (n = 3); alpha 1-m I < or = 10, Alb I > or = 50 (abnormal value of glomerular function), Group III (n = 4); alpha 1-m I < or = 10, Alb I < 50 (normal value of tubular and glomerular function). Six patients in Group I required postoperative hemodialysis (HD) and one patient in Group II. No one required HD in Group III. These facts suggest that preoperative damage of tubular and glomerular functions may become prolonged or irreversible damages may occur after operation. HD is required frequently in patients with alpha 1-m I level over 500 mg/g Cr, especially continuous HD may be needed in patient with alpha 1-m I level over 1000 mg/g Cr.

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