Ten patients with distal aortic arch aneurysm underwent prosthetic graft replacement using moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion via antero-axillary thoracotomy. Central cannulation was performed in the ascending aorta and venous drainage from the right femoral vein. The mean patient age was 74 years and the mean surgical duration was 5h and 12min. One patient died of multiple cerebral embolisms. Nine patients survived without major complications. Anastomosis between the vascular graft and the distal aorta can be easily achieved via left thoracotomy. Moderate hypothermia provides less coagulopathy and is less invasive. The rate of cerebral complications was acceptable. This technique is preferable for surgical treatment of the distal aortic arch.

Elective resection of abdominal aortic aneurysms is now a safe operation, but mortality related to ruptured abdominal aortic aneurysm (rAAA) remains high. In many reports, there has been much discussion about the factors that affect the mortality rate of patients who had rAAA repair. Preoperative shock is the most frequently cited prognostic factor related to survival. At the induction of anesthesia in these patients it is not rare for hypotension to cause deep shock. To prevent these deep shock states, we make a mid-abdominal skin incision simultaneously at the induction of general anesthesia just after preparation. Forty-four cases of rAAA underwent emergency surgery with this technique between April 1993 and December 1999. We also reviewed medical records of these 44 consecutive patients to evaluate clinical factors in mortality after rAAA resection. The overall hospital mortality rate was 18.2% (8/44) in our series. Factors associated with poor prognosis were the duration of preoperative shock state (p=0.031), an episode of cardiac arrest (p=0.015), an episode of loss of consciousness (p=0.018), systolic blood pressure of less than 60mmHg at the induction of anesthesia (p=0.019), intraperitoneal rupture (p=0.010) and intraoperative massive blood transfusion (p=0.043). These findings suggest that these factors may be reflections of preoperative shock and intraoperative technical errors. The surgical results of rAAA have improved significantly due to the prevention of hypotension which may cause a state of deep shock at induction of anesthesia. Although the patient's outcome after rupture of AAA is partly determined before intervention by the surgeon, efforts for rapid diagnosis and prompt flawless surgery can increase survival.

Between January and December 1991, six patients aged 80 years or older underwent coronary artery bypass grafting (CABG). Five cases were female, the mean age was 83 years, and the oldest was 90 years of age. Of these patients, five were of 3 vessels disease, three of whom had left main trunk lesions as well. Five cases were classified as NYHA-IV, four of whom required inotropic support, and two needed IABP support preoperatively. Emergency CABG was performed in five patients. As a result, all patients needed extensive postoperative care and extended hospital stays. However, five cases survived, and there was one hospital death due to severe left ventricular dysfunction (hospital mortality; 16.7%). We conclude that CABG in patients 80 years or older, although associated with longer ICU and hospital stay, can give good operative results and that patients should not be denied CABG because of age alone.

We report a 70 year old female patient who underwent three successful surgical repairs for the following postinfarction mechanical complications: left ventricular free wall rupture (LVFWR), ventricular septal perforation (VSP) and left ventricular pseudoaneurysm (LVPA). The patient had an oozing type LVFWR following PTCA and t-PA therapy for acute broad-anterior myocardial infarction. Initially, treatment of the LVFWR consisted of emergency pericardial wrapping over the infarcted myocardial area. However, on the second postoperative day the patient developed VSP, which necessitated patch closure of the VSP and patch plasty of the left ventricle. An LVPA, which was detected by UCG examination 38 days after the second procedure, was repaired successfully through a left antero-lateral thoracotomy and with femoro-femoral bypass. The patient made a full recovery and was discharged on the 200th postoperative day. In conclusion, UCG is an effective diagnostic method for postinfarction mechanical complications and pericardial wrapping over an infarcted area is a safe and useful method for an oozing type LVFWR. In addition, it is important that appropriate surgical repairs for postinfarction mechanical complications should be performed without delay.