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INTRODUCTION: Postmortem heart specimens are essential for education and research on the anatomy, morphology, and pathology of congenital heart defects. However, such specimens are rarely obtained these days, and the specimens stored in formalin are inexorably deteriorating. This study aimed to develop methods to archive three-dimensional data of rare human heart specimens and to publish the data. METHODS: All wax-infiltrated human postmortem heart specimens stored in the Cardiac Registry, Boston Children's Hospital were scanned using microfocus computed tomography (X-Tek HMXST225, Nikon Metrology, Inc.), and reproduced using a three-dimensional printer (Form 3B, Formlabs Inc.). The digital models were published as an interactive three-dimensional online atlas. The resolution of the three-dimensional data was evaluated. RESULTS: The primary diagnoses in the 88 specimens included in the study include normal cardiac anatomy (11 cases), transposition of the great arteries {S,D,D} (11 cases), ventricular septal defect (10 cases), double-outlet right ventricle (9 cases), hypoplastic left heart syndrome (9 cases), and common atrioventricular canal (7 cases). Twenty-five cases (28%) underwent previous surgical or percutaneous interventions to the heart, including Mustard procedure (1 case), Senning procedure (2 cases, one was performed on a postmortem heart specimen). The median voxel size of the three-dimensional data was 40.5 um (IQR, 32.8-64.2). All intracardiac structures were precisely reproduced as digital and physical three-dimensional models. CONCLUSIONS: The methods and resultant models were considered useful for archiving and furthering the utilization of these invaluable specimens. The atlas is available at https://www.sketchfab.com/heartmodels/collections.
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Ductus venosus stenting via a transumbilical approach for pulmonary venous obstruction in infracardiac total anomalous pulmonary venous connection has been described. In a 902-gram infant who was diagnosed with asplenia syndrome and infracardiac total anomalous pulmonary venous connection, ductus venosus stenting was attempted by a transumbilical approach. However, ductus venosus stenting was discontinued due to bleeding from the portal vein. The bleeding subsided in time spontaneously, and total anomalous pulmonary venous connection repair with pulmonary artery banding was performed on 21â¯days after birth. To our knowledge, this is the first report that describes total anomalous pulmonary venous connection repair in a neonate under 1000â¯g body weight. Learning objective: Ductus venosus stenting is an effective palliative option, especially in the presence of high surgical risk, such as heterotaxy syndrome and a low birth weight. However, ductus venosus stenting should carefully be evaluated by assessment of anatomical configuration of umbilical vein and ductus venosus. If ductus venosus stenting is anatomically difficult, primary surgical repair may be an option even in an extremely low birth weight infant.
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Various surgical approaches address complex heart disease with arch anomalies. Bilateral pulmonary artery banding (bPAB) is a strategy for critically ill patients with complex arch anomalies. Some reports argued the potential effect of bPAB on the growth of the left ventricular outflow tract (LVOT) during inter-stage after bPAB. This study aimed to analyze the LVOT growth for biventricular repair candidates with arch anomaly and systemic ventricular outflow tract (SVOT) for univentricular repair candidates with arch anomaly. This retrospective study analyzed 17 patients undergoing initial bPAB followed by arch repair. The Z-scores of LVOT and SVOT were compared between pre-bPAB and pre-arch repair. Patient characteristics, transthoracic echocardiogram data, and PAB circumferences were reviewed. The diameter of the minimum LVOT for biventricular repair (BVR) candidates, the pulmonary valve (neo-aortic valve, neo-AoV) and the pulmonary trunk (the neo-ascending aorta, neo-AAo) for univentricular repair (UVR) candidates, and the degree of aortic or neo-aortic insufficiency in each candidate was statistically analyzed. 17 patients were divided into the UVR candidates (group U) with 9 patients and the BVR candidates (group B) with 8 patients. In group B, the median value of the Z-score of the minimum LVOT increased from -3.2 (range: - 4.1 ~ - 1.0) at pre-PAB to -2.8 (range: - 3.6 ~ - 0.3) at pre-arch repair with a significant difference (p = 0.012). In group U, the median value of the Z-score of the neo-AoV increased from 0.5 (range: - 1.0 ~ 1.7) at pre-bPAB to 1.2 (range: 0.2 ~ 1.9) at pre-arch repair with a significant difference (p < 0.01). The median value of the Z-score of the neo-AAo was also increased from 3.1 (range: 1.5 ~ 4.6) to 4.3 (range: 3.1 ~ 5.9) with a significant difference (p = 0.028). The growth of the LVOT for BVR candidates and SVOT for UVR candidates during the inter-stage between bPAB and arch repair was observed. These results suggest the potential advantage of bPAB in surgical strategies. Further research is needed to validate these findings and refine surgical approaches.
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Aorta Torácica , Procedimientos Quirúrgicos Cardíacos , Ventrículos Cardíacos , Arteria Pulmonar , Humanos , Estudios Retrospectivos , Masculino , Arteria Pulmonar/cirugía , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/anomalías , Femenino , Aorta Torácica/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/anomalías , Procedimientos Quirúrgicos Cardíacos/métodos , Lactante , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/anomalías , Ventrículos Cardíacos/cirugía , Ventrículos Cardíacos/fisiopatología , Resultado del Tratamiento , Ecocardiografía , Preescolar , Cardiopatías Congénitas/cirugía , Cardiopatías Congénitas/fisiopatología , Cardiopatías Congénitas/diagnóstico , Corazón Univentricular/cirugía , Corazón Univentricular/fisiopatología , Niño , Recién NacidoRESUMEN
BACKGROUND: Total anomalous pulmonary venous connection accompanied by unilateral lung agenesis and Goldenhar syndrome is extremely rare. CASE PRESENTATION: We present a case of total anomalous pulmonary venous connection accompanied by unilateral lung agenesis and Goldenhar syndrome in a patient who was diagnosed based on transthoracic echocardiography and computed tomography. We observed complete absence of the lung, the bronchial tree, and vascular structures on the right side, with abnormal drainage of the left pulmonary veins into the innominate vein. The patient showed clear clinical evidence of pulmonary venous obstruction and underwent surgery 3 days after birth. The pulmonary venous chamber containing the vertical vein was anastomosed to the left atrium using 7-0 PDS running sutures via a median sternotomy. Echocardiography and computed tomography performed 1 year postoperatively revealed no pulmonary venous obstruction. CONCLUSION: We report a rare case of total anomalous pulmonary venous connection accompanied by unilateral lung agenesis and Goldenhar syndrome, which was successfully repaired 3 days after birth. A median sternotomy is a safe and effective approach for surgical repair of congenital heart disease with unilateral lung agenesis. Repair of the supra cardiac total anomalous pulmonary connection using the vertical vein is feasible in patients with a small pulmonary venous chamber.
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Síndrome de Goldenhar , Enfermedades Pulmonares , Venas Pulmonares , Anomalías Múltiples , Atrios Cardíacos , Humanos , Recién Nacido , Pulmón/anomalías , Pulmón/diagnóstico por imagen , Pulmón/cirugía , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/cirugíaRESUMEN
A rare case of a patient with a large type IV aortico-left ventricular tunnel who underwent successful repair at 1 day after birth was described. To the best of our knowledge, no such cases that aortic opening was over 10 mm have been reported in the English literature. Our case demonstrated no leak or significant aortic regurgitation by a two-patch repair.
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Insuficiencia de la Válvula Aórtica , Túnel Aórtico-Ventricular , Cardiopatías Congénitas , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , HumanosRESUMEN
The neo-aortic insufficiency in patients with hypoplastic left heart syndrome is an important sequela. We assessed the risks of the neo-aortic valve deterioration by the difference of initial palliations: Group I underwent primary Norwood (Nw) with systemic-to-pulmonary artery shunt (SPS), Group II underwent bilateral pulmonary artery banding (bPAB) and subsequent Nw with SPS (bPAB-Nw/SPS), Group III underwent bPAB and subsequent Nw with bidirectional Glenn (BDG) procedure (bPAB-Nw/BDG). The neo-aortic valve z score changes over time did not reach statistical significance in all groups (p = 0.43 for Group I, 0.20 for Group II, and 0.30 for Group III). The degree of neo-aortic valve insufficiency did not change significantly over time during this period except for Group III (p = 0.34 for Group I, 0.20 for Group II, and 0.02 for Group III). On the other hand, dimensions of the neo-aortic annulus and degrees of neo-aortic insufficiency did not differ significantly among the 3 groups at any pre-determined time. The presence or absence of incision into the sino-tubular junction at Nw did not affect the late neo-aortic valve z score or insufficiency. These data indicate that the difference of initial palliative procedures does not affect late neo-aortic valve insufficiency in Nw survivors. Because valve failure may develop in longer follow-up, further observation should be conducted.
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Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Síndrome del Corazón Izquierdo Hipoplásico/cirugía , Insuficiencia de la Válvula Aórtica/patología , Ecocardiografía , Femenino , Procedimiento de Fontan/efectos adversos , Humanos , Lactante , Recién Nacido , Masculino , Procedimientos de Norwood/efectos adversos , Arteria Pulmonar/cirugía , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
We report a case of Fontan completion for a tricuspid atresia (TA) patient with left ventricular non-compaction (LVNC). The patient was diagnosed with TA (Ia) with LVNC by fetal echocardiography. Because the unfavourable prognosis of LVNC was anticipated, Imidapril as well as Carvedilol were administered to improve cardiac function, from the early stages of infancy. Staged Fontan completion with fenestration was successfully achieved with improvement of LV function.
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Procedimiento de Fontan , Cardiopatías Congénitas/cirugía , Atresia Tricúspide/cirugía , Antagonistas Adrenérgicos beta , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/fisiopatología , Humanos , Recién Nacido , Masculino , Recuperación de la Función , Resultado del Tratamiento , Atresia Tricúspide/diagnóstico , Atresia Tricúspide/fisiopatología , Ultrasonografía Prenatal , Función Ventricular IzquierdaRESUMEN
Aortic arch thrombosis (AAT) of the neonate is rare but life-threatening by fatal compromise associated with thrombotic obstruction of the ascending aorta. We report a neonate with AAT who demonstrated a severe coarctation of the aorta and cerebral hypo-perfusion immediately after birth. Echocardiography confirmed the diagnosis of AAT on the findings of a large thrombus located on the transverse arch and blocking the cervical arterial branches. Low-molecular-weight heparin reduced the size of the thrombus and improved the hemodynamics of coarctation and cerebral perfusion. Echocardiography is a powerful tool to make a diagnosis and to monitor the size and regression of AAT.
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We report a 3-day-old boy with double outlet of the right ventricle and interruption of the aortic arch who developed spontaneous dissection of the arterial duct (DA) despite use of continuous infusion of lipo-prostaglandin E1 (PGE1). Transthoracic echocardiography demonstrated the spontaneous dissecting aneurysm of DA, which was confirmed by histology at the modified Norwood procedure done at age of 18 days. This is the first report of spontaneous dissection of DA in a neonate receiving PGE1, suggesting a new closing mechanism of DA.
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We report a successfully treated case of unilateral absence of a pulmonary artery, associated with an atrial septal defect and chronic lung disease with severe pulmonary hypertension. Because this severe pulmonary hypertension could jeopardize postoperative hemodynamic, the ingenuity of surgical strategy was required. The atrial septal defect was left open as a safety "pop-off" valve, and prosthetic graft was chosen as a reconstructive material to avoid excessive dilatation from exposure to unpredictable postoperative pulmonary hypertension.
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Anomalías Múltiples , Implantación de Prótesis Vascular , Hipertensión Pulmonar/cirugía , Arteria Pulmonar/cirugía , Malformaciones Vasculares/cirugía , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Cateterismo Cardíaco , Femenino , Defectos del Tabique Interatrial/complicaciones , Hemodinámica , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/fisiopatología , Lactante , Imagen de Perfusión , Diseño de Prótesis , Arteria Pulmonar/anomalías , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/fisiopatología , Circulación Pulmonar , Radiografía , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Malformaciones Vasculares/complicaciones , Malformaciones Vasculares/diagnóstico por imagen , Malformaciones Vasculares/fisiopatologíaRESUMEN
OBJECTIVES: We ranked the haemodynamics and pulmonary artery (PA) configurations of Norwood with bidirectional Glenn shunt (NW-G) patients among the other staged Fontan completion (conventional) patients in this study. METHODS: Between August 2001 and April 2010, 91 consecutive patients completed staged Fontan operations. Among them, NW-G was performed in 11. RESULTS: There was no operative or late death except in one case which resulted from a reoperation after Fontan completion. Although the age at bidirectional Glenn (BDG) and Fontan completion was younger in NW-G (4.2 vs. 10.9 months, P < 0.01, and 2.3 vs. 3.3 years, P < 0.01), the interval between BDG and Fontan completion was not significantly different in these groups (23.6 vs. 28.0 months, P = 0.71). On Fontan completion, the extracardiac conduit size was significantly different (16.4 vs. 17.7 mm, P < 0.01). However, the pulmonary artery size (PA index) and the PA pressure were not significantly different (165.4 vs. 205.1 mm(2)/m(2), P = 0.23, and 13.4 vs. 11.0 mmHg, P = 0.08). Particularly in hypoplastic left heart syndrome patients, the PA index was not significantly different between these groups (165.4 vs. 174.9 mm(2)/m(2), P = 0.59). CONCLUSIONS: The NW-G patients could have a subsequent Fontan completion with good results. There was no significant difference with respect to Fontan completion.
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Procedimiento de Fontan , Cardiopatías Congénitas/cirugía , Hemodinámica , Procedimientos de Norwood , Arteria Pulmonar/cirugía , Presión Sanguínea , Procedimiento de Fontan/efectos adversos , Procedimiento de Fontan/mortalidad , Cardiopatías Congénitas/mortalidad , Cardiopatías Congénitas/fisiopatología , Humanos , Lactante , Recién Nacido , Japón , Procedimientos de Norwood/efectos adversos , Procedimientos de Norwood/mortalidad , Cuidados Paliativos , Arteria Pulmonar/fisiopatología , Reoperación , Estudios Retrospectivos , Volumen Sistólico , Factores de Tiempo , Resultado del TratamientoRESUMEN
Persistent 5th aortic arch (PFA) is a rare congenital cardiac anomaly that was firstly reported by Van Praagh et al, in 1969. A 3-month-old boy was referred to us with no symptom but heart murmur. Cardiac echocardiography and the following 3-dimensional computed tomography (3D-CT) scan revealed PFA with coarctation of aorta. There was pressure gradient of 50 mmHg between upper and lower limbs. He was carefully observed at the outpatient clinic because of no afterload mismatch. At the age of 9 months, coarctectomy and end-to-end anastomosis was performed between the PFA and distal arch below left vertebral artery. A histological examination of resected tissue revealed the thickened intima and rough elastic fiber that is absolutely different from normal aorta. Careful observation is necessary with the possibility of future aneurysmal change or re-coarctation, although the postoperative course has been so far uneventful.
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Aorta Torácica/anomalías , Coartación Aórtica/complicaciones , Aorta Torácica/cirugía , Coartación Aórtica/cirugía , Humanos , Lactante , MasculinoRESUMEN
OBJECTIVE: The left superior vena cava (LSVC) is often complicated with congenital heart defect. Although we simply clamp LSVC during cardio-pulmonary bypass (CPB), appropriateness of this technique has not been clarified. We noninvasively evaluate cerebral tissue oxygenation while the clamping of LSVC under CPB by near-infrared spectroscopy (NIRS). METHODS: Six children (3 male and 3 female; aged 1.0 +/- 0.6 year) undergoing open heart surgery were studied. The NIRO 300 was incorporated into an established multimodal monitoring system. Tissue oxygenation index (TOI), oxyhemoglobin (O2Hb), and deoxyhemoglobin (HHb) changes were assessed and compared with LSVC pressure. RESULTS: There were no significant changes in cerebral oxygen delivery after LSVC clamp. LSVC pressure increased from 7.3 +/- 1.8 mmHg to 20.1 +/- 2.6 just after LSVC clamp, but gradually decreased without any maneuver. CONCLUSION: These data demonstrated that LSVC could be safely clamped when LSVC pressure was under 30 mmHg.
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Circulación Cerebrovascular/fisiología , Vena Cava Superior/fisiología , Constricción , Femenino , Cardiopatías Congénitas , Humanos , Lactante , Masculino , Oxígeno/sangre , Espectroscopía Infrarroja CortaRESUMEN
BACKGROUND: The choice of appropriate treatment in children with aortic valvular lesions remains controversial. The purpose of this study is to assess early and late outcomes of aortic valve replacement with annular enlargement in children. METHODS: A retrospective study was conducted in 16 consecutive patients aged 0.26 to 15.9 years operated on between 1993 and 2008. Thirteen children underwent aortic valve replacement with Konno procedure (mechanical valve: 12, homograft: 1), 2 children underwent Ross procedure, and the last child underwent Nicks procedure with mechanical valve replacement. All patients undergoing mechanical valve replacement were given warfarin with a monthly international normalized ratio (INR) control. RESULTS: Overall early mortality was 12.5% (2 cases). Emergency operation was performed in these cases because of infectious endocarditis and acute cardiac failure. However, cardiopulmonary bypass (CPB) weaning could not be obtained. There was 1 late death 5 months after mechanical valve replacement. The patient developed methicillin-resistant Staphylococcus aureus (MRSA) sepsis after cleft palate repair. Reoperation was needed in 1 case. CONCLUSION: We conclude that mechanical valve replacement with aortic annular enlargement is an acceptable treatment in children. It is associated with acceptable mortality and low incidence of late events, and provides long-term survival.
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Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Adolescente , Procedimientos Quirúrgicos Cardíacos/métodos , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Trasplante Homólogo , Resultado del TratamientoRESUMEN
BACKGROUND: Interrupted aortic arch (IAA) is associated with a multitude of lesions ranging from isolated ventricular septal defect to hypoplastic left ventricle or severe subaortic stenosis (SAS). Left ventricular outflow obstruction such as SAS continues to be an important factor for deciding the surgical procedure between univentricular and biventricular repairs. METHODS: A retrospective study was conducted in 8 consecutive infants aged 14 to 117 days and operated on between 2004 and 2009. Seven patients had undergone bilateral pulmonary artery banding for pulmonary high flow regulation. All patients underwent Norwood-type operation (4 with systemic to pulmonary artery shunt, 3 with right ventricle to pulmonary artery shunt, and 1 with bidirectional Glenn shunt). RESULTS: One patient died 2 months after surgery due to respiratory failure. The others were discharged in a good condition. One patient underwent Rastelli-type operation and biventricular circulation was achieved. The other 6 patients were all Fontan candidates. CONCLUSION: Satisfactory initial palliation can be achieved by Norwood-type operation for IAA with severe SAS or hypoplastic left ventricular-aortic complex.
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Aorta Torácica/anomalías , Procedimientos de Norwood , Aorta Torácica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Toma de Decisiones , Femenino , Humanos , Síndrome del Corazón Izquierdo Hipoplásico/complicaciones , Lactante , Recién Nacido , Masculino , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
We report a female infant with acute coronary syndrome after Aubert-Imai modification for transposition of the great arteries. Two months postoperatively, she visited the emergency room because of perspiration and tachypnea. She was diagnosed with acute coronary syndrome by blood chemistry examination. Cardiac catheterization revealed Aubert route stenosis, and emergency operation was performed. The lumen around the aortopulmonary window was almost totally occluded by fibrous tissue extending from the equine pericardial patch. This fibrous tissue was completely resected and the aortopulmonary window was deepened to enlarge the coronary ostium. We recommend a close follow-up including angiography after these procedures.
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Síndrome Coronario Agudo/cirugía , Transposición de los Grandes Vasos/cirugía , Síndrome Coronario Agudo/etiología , Vasos Coronarios/cirugía , Femenino , Humanos , Lactante , Complicaciones Posoperatorias , ReoperaciónRESUMEN
Operative correction of tetralogy of Fallot has been performed for more than 50 years and well established. To date, the literature on reoperation has focused and indications and the long-term outcome have not been well defined. We herein report a case of pulmonary valve replacement due to ectopic ossification on expanded polytetrafluoroethylene (ePTFE) cusp in a female child who had undergone right ventricular outflow tract reconstruction for tetralogy of Fallot with pulmonary atresia. Because of severe right ventricular dilatation with end diastolic volume of 186 ml/m2 on cardiac catheterization, redo operation was planned for functional recovery of the right ventricle. Previous transannlar patch was removed and pulmonary valve replacement was performed using CEP 23 mm. A hard calcification was observed around the cusp of transannular patch. Pathological findings revealed ectopic ossification with osteoblast colonization around the ePTFE cusp. This is the 1st report of ectopic ossification on ePTFE.
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Osificación Heterotópica/patología , Complicaciones Posoperatorias , Insuficiencia de la Válvula Pulmonar/etiología , Válvula Pulmonar/cirugía , Tetralogía de Fallot/cirugía , Niño , Femenino , Prótesis Valvulares Cardíacas , Humanos , Politetrafluoroetileno , ReoperaciónRESUMEN
Background. The purpose of this study was to evaluate the surgical outcomes and pulmonary artery (PA) development associated with a new strategy wherein the modified Norwood (N) procedure is performed at 1-2 months after bilateral pulmonary artery banding (PAB). Methods. Between January 2008 and February 2010, 16 patients underwent Norwood-type operation after previous bilateral PAB. For analysis, patients were divided into two groups. Group I (n = 11) underwent modified Norwood procedure with either right modified Blalock Taussig (RMBT) shunt (n = 4) or right ventricle to pulmonary artery (RV-PA) conduit (n = 7). Group II (n = 5) underwent Norwood procedure plus bidirectional Glenn anastomosis. Diagnoses were hypoplastic left heart syndrome in 6 and its variants in 10. Results. There was no surgical death and no late death. Pulmonary artery interventions were performed at the time of the Norwood procedure in 27% in Group I and in 100% in Group II (p < 0.05). Additional PA interventions were performed during the period of follow-up in 4 cases in Group I (36.4%), and in 4 cases in Group II (80.0%). Additional Blalock Taussig shunts were performed in 7 patients, resulting in significant increase in PA index. In all, four patients have reached total cavopulmonary connection, and one has undergone biventricular repair. Eight patients in Group I and one patient in II Group reached bidirectional Glenn anastomosis. In Gp II, two patients showed LPA narrowing or obstruction with PA index of 80 ± 12 mm(2)/m(2). Conclusions. Regarding the second-stage palliation after bilateral PAB, modified Norwood procedure with either RMBT or RV-PA conduit has some advantages compared with Norwood plus BDG with respect to subsequent pulmonary artery development. Additional BT shunt may contribute to PA development, even in the patients with Norwood procedure with RV-PA conduit.
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Aortico-left ventricular tunnel (ALVT) is a rare congenital heart disease presenting as congestive heart failure in the neonatal or early infantile period due to severe aortic regurgitation (AR). We presented a 1-month-old boy with ALVT, originally diagnosed by two-dimensional echocardiography; however, the detailed anatomical features were not ascertained. Real-time three-dimensional echocardiography (RT3DE) could provide clear images of the three-dimensional structures of ALVT, just the same as those of surgical findings. ALVT originated from the left coronary cusp and ran an oblique path to the subvalvular orifice, having a narrow segment in the middle. RT3DE is a clinically useful diagnostic tool to clarify the detailed anatomy of ALVT.
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We report a rare case of a 65-year-old woman who underwent an emergent lifesaving heart operation for an undiagnosed right coronary artery aneurysm with a coronary arteriovenous fistula complicated by active infective endocarditis, which affected the aortic valve, mitral valve, and coronary sinus. We performed direct closure of the coronary arteriovenous fistula, ligation of the right coronary artery aneurysm, double coronary artery bypass grafting, and double valvular replacement. Five years after the operation, she had no sign of congestive heart failure or infection, and was not receiving antibiotics.