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This report documents the sudden onset of aortic regurgitation (AR) by an exceptional cause. A 68-year-old woman suddenly experienced general fatigue, and AR was diagnosed. One year later, we performed aortic valve replacement. At surgery, three aortic cusps with a larger noncoronary cusp had prolapsed along with a free-floating fibrous band that had previously anchored the cusp to the aortic wall. Its rupture had induced the sudden onset of AR. There was no sign of infectious endocarditis. We performed successful aortic valve replacement.

eft ventricular (LV) thrombus following acute myocardial infarction (AMI) is a common complication and is associated with the risk of systemic embolism. There is an especially high risk of systemic embolism if the thrombus has a ball-like shape. In the early period after the onset of AMI, surgery is potentially dangerous due to the fragile LV wall and risk of pump failure. We report a rare case of thrombectomy in the acute phase of AMI. Case ReportA 61-year-old man without a contributory family history, but with a history of slight diabetes and hypertension, experienced chest discomfort and was admitted to a local hospital. He had persistent chest pain, dyspnea and elevated creatine kinase (CK) at 1,800 IU/L 7 days after the onset of angina and was transferred to our hospital for AMI.On admission, he was in profound shock with orthopnea. Electrocardiography showed ST-segment elevation in leads V1-4, suggesting antero-septal AMI. He was managed using intubation and intra-aortic balloon pumping (IABP). Emergency coronary angiography demonstrated the occlusion of the proximal left anterior descending coronary artery (LAD), 90% stenosis in the proximal right coronary artery (RCA) and 90% stenosis in the posterior descending circumflex artery (Cx). The thrombus in the LAD was aspirated with an aspiration catheter (Nipro, Osaka, Japan) in the LAD, but there was 75% residual stenosis. Additional left ventriculography showed that LV wall motion was hypokinetic with an ejection fraction of 34% and that there was a mobile Circulation Journal Vol.72, September 2008ball-like thrombus in the apex (Fig 1). Although in such a situation the thrombus carries a risk of embolization, we considered coronary artery bypass grafting (CABG) and thrombectomy on the same day would be more risky due to profound shock and severe congestive heart failure. On the third hospital day (3 days after the onset of AMI), the patient had recovered slightly from congestive heart failure and we estimated that the embolization risk of the ball-like thrombus significantly surpassed the surgical risks during the acute phase of AMI, and scheduled the patient for surgical thrombectomy and CABG.Open heart surgery was conducted using a standard cardiopulmonary bypass via median sternotomy. Cold blood cardioplegia was delivered in both an initial antegrade and continuous retrograde fashion. There was a large area showing edematous and fragile change due to AMI in the anterior wall of LV. First distal anastomosis of the saphenous vein to the RCA was performed, and an incision measuring about 8 cm was made from the apex to the base of the left ventricle parallel to the LAD through the center of the transmural infarction. The fragile ball-like thrombus, which was approximately 2 cm in diameter, was found attached in the apex to the trabeculae of the ventricular wall, and was carefully removed without causing scattering. We also found severely fragile change due to AMI in the septal wall and therefore repaired the left ventricle using the infarction exclusion tec...

Twenty-four patients with cardiac myxomas consisting of 22 left and 2 right atrial myxomas were operated on. All myxomas were removed with an excision of the attachment walls using a cardiopulmonary bypass. Two myxomas required a partial cardiopulmonary bypass from the femoral vein to the artery prior to operation because they were on the verge of becoming stuck in the atrioventricular valves and potentially causing shock. For embolic complications of myxoma, the embolus of the external carotid artery was extirpated before undergoing cardiac surgery. In a patient with pulmonary infarction, the infarcted lung was resected simultaneously. Another patient with a cerebral infarction received a clipping of an aneurysm which later appeared in the infarcted area. For associated cardiac lesions, two patients underwent a coronary artery bypass graft and one mitral valve replacement with tricuspid annuloplasty. In the former two cases, the myxoma was removed prior to coronary artery bypass grafting because the use of retrograde coronary perfusion was considered to be sufficient to protect the heart. In the latter case, the removal of the myxoma first disclosed a significant mitral lesion which had been masked by the huge myxoma. All patients but one, who died of pneumonia, showed a good recovery. In this series, the problems of surgical treatment for cardiac myxoma and associated lesions are also discussed.