A 60-year-old man with impending rupture of abdominal aortic aneurysm was transferred to our hospital. The patient entered a state of shock because of rupture during a CT scan examination. Emergency in site reconstruction with a dacron Y-graft was performed. There was massive intraperitoneal bleeding but no apparent abscess formation around the aneurysm. No drain was placed. A subcutaneous abscess that developed postoperatively was cured by open drainage and local antibiotic administration. Culture from both the aortic wall and the subcutaneous abscess revealed Salmonella infection. After subsequent intravenous antibiotic therapy for 45 days, the patient was discharged without any evidence of remaining infection.

A 27-year-old female with Marfan's syndrome underwent successful emergency surgery for rupture of an abdominal aortic aneurysm. Annulo-aortic ectasia with a saccular aneurysm of the aortic arch was revealed by angiography after the initial operation. Cabrol's operation with replacement of the aortic arch was performed. Because bleeding from the distal anastomotic portion was uncontrollable, the segment was ligated and an extra-anatomical bypass was performed from the ascending aortic graft to the bilateral femoral arteries. Intra-graft balloon pumping was carried out in the extra-anatomical bypass graft while the patient was in low cardiac output condition after the second operation. This was considered to be an effective circulatory assist procedure.

A 59-year-old man was admitted to our hospital with severe mitral incompetence. Mitral valve repair, tricuspid annuloplasty and the Maze procedure were performed. After weaning from cardiopulmonary bypass, his systolic blood pressure (SBP) dropped to 40 mmHg. Immediate administration of catecholamines markedly increased SBP but his continuing low blood pressure required additional treatment with vasopressin and hydrocortisone. On postoperative day 12 in the general ward, he suddenly lapsed into an intractable hypoglycemic coma. Endocrine function tests revealed adrenocorticotropic hormone deficiency. Since the time of writing has been doing well with 20 mg of hydrocortisone.

A 62-year-old woman was admitted for chest and back pains. She was found to have thrombosed type A aortic dissection by enhanced computed tomography. Since she had no clinical symptoms after her admission, she was discharged. Forty days after the admission, she returned with acute renal failure and ischemia of both lower extremities. Occlusion of the abdominal aorta was diagnosed and emergency axillobifemoral bypass was performed. Her renal function and the ischemia of both lower extremities improved dramatically and she was discharged 30 days after the operation. Axillobifemoral bypass is one of the most effective and least invasive operations in such cases.

A 39-year-old man received Bentall's operation for annuloaortic ectasia in July 1985. He was admitted with a high fever in July 1998. On the 2nd day of his admission, he suddenly suffered from headache and dizziness. Head computed tomography showed multiple low density areas in the right cerebrum and cerebellum. A transesophageal echocardiogram revealed massive vegetation around the prosthetic valve. The patient underwent emergency operation using cardiopulmonary bypass. The left ventricle outflow was almost occluded by thrombi. The prosthetic valve and graft were removed completely and replaced with a 24mm Gelseal^® graft and a 23mm St. Jude Medical^® valve. The right coronary ostium was reimplanted directly on the prosthesis, and the left coronary ostium was reinserted using a 10mm graft. The patient's intraoperative tissues grew S. aureus and parenteral antibiotics were administered for 5 weeks after surgery. The patient was discharged on the 45th postoperative day and is doing well 9 months after the operation.

A 70-year-old woman who was bedridden because of right hemiplegia attributable to a history of cerebral hemorrhage underwent surgical thrombectomy for pulmonary embolism four years previously. Symptoms of heart failure appeared one year previously, and she was diagnosed with constrictive pericarditis and had been treated with medication by a previous doctor. In the current situation, she visited the previous doctor with the chief complaint of fever, and pericardial effusion was observed on echocardiography. Cardiac tamponade was suspected and she was transferred to our hospital. She was then diagnosed with purulent pericarditis because purulent fluid was observed during pericardiocentesis drainage. Bacteroides fragilis was isolated from the culture of the abscess. The abscess was resistant to conservative antibiotic therapy ; therefore, we performed a pericardiotomy with a left small thoracotomy. The pleural effusion was found to be negative for culture and the patient exhibited a good postoperative course. Purulent pericarditis is refractory with poor prognosis. An appropriate surgical procedure must be chosen considering the patient's activities of daily living. Here, we report a surgical case wherein we chose the left thoracotomy approach and achieved positive results.

The first case was a 67-year-old woman. She had been given a diagnosis of fulminant myocarditis and received a biventricular assist device as a bridge to recovery. A Nipro ventricular assist device (VAD) was implanted into her left heart. She was also found to have moderate aortic insufficiency before the operation, so she received aortic valve replacement (AVR) with a bioprosthetic valve (CEP Magna Ease 21 mm) at the same time. Her cardiac function recovered gradually. Therefore, a weaning operation was scheduled for three months after the VAD implantation. However, her left ventricle motion was very poor when she was taken off of the extracorporeal circulation after removing the VAD, and transesophageal echocardiography (TEE) revealed severe bioprosthetic valve stenosis. When her heart was stopped again and the bioprosthetic valve was observed, the leaflets of the bioprosthetic valve were fused. Commissural fusion of bioprosthetic valve was able to be released using forceps, and the punnus extending under the leaflet was removed. In this way, the function of the bioprosthetic valve was restored. Her cardiac motion became good, and removal from extracorporeal circulation was easily achieved. She left the hospital 100 days after weaning from the VAD. The second case was a 68-year-old woman. She also had fulminant myocarditis. She underwent biventricular assist device implantation and AVR (CEP Magna Ease 19 mm). Her cardiac function recovered, and a weaning operation was scheduled on the 73rd-postoperative day. Preoperative TEE before the weaning of VAD showed severe bioprosthetic valve stenosis. The commissural fusion of the bioprosthetic valve was released and the punnus extending under the leaflet removed at the same time as the VAD was removed. Re-valve replacement was not required. We should therefore consider the possibility of bioprosthetic valve stenosis when VAD implantation and AVR with a bioprosthetic valve are performed at the same time in patients with an extremely reduced cardiac function.