Two patients of chronic mediastinitis after cardiac surgery were treated by omental transfer. Their previous cardiac operations were open mitral commissurotomy and aortic valve replacement. They underwent radical surgical therapy for mediastinitis 8 to 9 years after the first cardiac surgery. In both cases, the infection resulted from Dacron felt on the ascending aorta. Under the cardiopulmonary bypass, the Dacron felt and infected tissue were resected. And omental transfer was done to prevent recurrent infection. The patients have been follwed up for 10 to 14 months. And they have no symptoms of their mediastinitis during these periods. From these experience, we consider that omental transfer is very helpful to treat infectious complications after cardiac surgery.

From January, 1975 to December, 1989, 231 Björk-Shiley prostheses have been implanted in our hospital. During this period, we have experienced thrombosed valves in 0.69%/pt-yr for the aortic and 1.2%/pt-yr for the mitral position. Ten patients, four in the aortic and six in the mitral, have had thrombotic obstruction of a prosthetic valve. Seven cases of them had insufficient warfarin control. Clinical signs of thrombosed valves were dyspnea, thromboembolism and abnormal cardiac sound. Cineradiography was the most useful diagnostic method. Two cases underwent thrombolytic therapy, but one case died of cerebral complication and another needed an emergency cardiac operation 24 hours after the onset. Six survived among the eight surgical cases. We concluded that thrombosed valves mainly resulted from an insufficient anticoagulant therapy and an urgent surgical intervention would better be performed.

In this report, we describe our surgical experience with seven cases of acute type A aortic dissection which resulted from retrograde propagation from tears in the proximal descending arota. As an emergency procedure, we used a ringed intraluminal prosthesis in six patients and five of these survived. All survivors underwent follow up CT scanning during a period ranging from 4 months to 5.6 years after surgery, especially to evaluate the fate of the false lumen on the residual aorta. In four patients, the arch dissection has been completely occluded by thrombosis, however, it remained patent in one patient 2.3 years postoperatively in whom reentry was found in the arch vessel at the time of operation. Enlargement of the false lumen beyond the descending aorta was found in two patients. On the other hand, the results have been excellent in the most recent patient who underwent complete graft replacement of both the ascending aorta and aortic arch including the primary tear. The authors believe, therefore, that the complete graft replacement of the ascending aorta to the aortic arch should be considered as the procedure of choice in these particular patients. Only such procedures enable the complete healing of both the ascending and arch dissection, and reoperation can be confined to the area distal to the descending aorta, if necessary.

A typical feature of mid-ventricular obstructive hypertrophic cardiomyopathy (MVO-HCM), is obvious hypertrophy of the mid-ventricular muscle and ventricle with transformation into the shape of an hourglass. We report a 60-year-old woman who had been given a diagnosis of apical type hypertrophic cardiomyopathy 12 years previously, but it changed to MVO-HCM with apical left ventricular aneurysm. We considered the impending rupture of the aneurysm because its wall was thin and pericardial effusion was detected by UCG (ultrasonic cardiograph). Urgent surgery was performed consisting of ventricular aneurysmectomy and patch reconstruction. After the surgery, a pseudoaneurysm was found in cardiac apex, so we performed surgery again. A residual shunt in the trabeculation caused the pseudoaneurysm, but its origin was not clear. She has been fine for 18 months without complications such as recurrence of aneurysm, ventricular arrhythmia or left ventricular dysfunction since the last surgery.

Between January 1994 and October 2004, 87 patients underwent emergency thoracic aortic surgery. Of these, 11 patients were more than 80 years old (O-group) and 76 were less than 80 years old (Y-group). A total of 58 patients (6 in O-group and 52 in Y-group) were treated for acute type-A aortic dissection, 5 (0 in O-group and 5 in Y-group) for acute type-B aortic dissection and 21 (4 in O-group and 17 in Y-group) for the involved rupture of a thoracic aortic aneurysm. The operative procedures consisted of the replacement of either the ascending, or the ascending and transverse aorta in 71 patients (8 in O-group and 63 in Y-group), and the replacement of the distal descending aorta in 15 patients (3 in O-group and 12 in Y-group). The operative mortality rates were 27.2% (3 patients) and 19.7% (15 patients) in the O- and Y-groups, respectively, with no significant difference between the groups. The rate of early complications, including circulatory failure, respiratory failure and cerebral infarction, did not statistically differ between the 2 groups. The overall 2-year survival rates of the patients who survived the operation were 83.3% in the O-group and 95.1% in the Y-group. Moreorer, 75% of the patients (6 of 8) who survived the surgery regained normal activities of daily life after the surgery, at a level similar to before the surgery. The present data indicates that emergency thoracic aortic surgery can be justified in selected in octogenarian patients.

Immune heparin-induced thrombocytopenia (HIT) is a crucial side effect of heparin therapy. We report the case of a 52-year-old man who was strongly suspected of having HIT after urgent descending aorta replacement. This case required continuous hemodiafiltration (CHDF) anticoagulated with unfractionated heparin (UFH) for acute renal failure after the operation. The patient developed thrombocytopenia and thrombus emphraxis in the circuit on the seventh day and was suspected of having HIT. UFH was ceased and replaced with argatroban. After then, thrombus emphraxis was not seen in the circuit and the platelet count was recovered promptly. He tested positive in an enzyme-linked immunosorbent assay for anti-platelet factor 4/heparin antibodies (anti-PF4/H Abs). Six months later, we found, an expanding thoracoabdominal aortic aneurysm and performed thoracoabdominal aorta replacement. We selected heparin anticoagulation for cardiopulmonary bypass because anti-PF4/H Abs were negative at that time. Thrombus emphraxis was not found during the operation. The patient developed neither thrombocytopenia nor thrombosis in the perioperative period.

We report a case of a 72-year-old woman, who had an anastomotic pseudoaneurysm in the ascending aorta, successfully treated by endovascular aortic repair with vascular embolic devise and stent-graft. It seemed to be high risk to achieve conventional surgery with extracorporeal circulation, therefore we selected endovascular treatment because she had a bleeding tendency which derived from disseminated intravascular coagulation. Then, we adopted stent-grafting with a vascular embolic device, because the distal side of pseudoaneurysm had too short a landing zone to cover the stent-graft only. The patient well tolerated this procedure and her postoperative course was uneventful. The pseudoaneurysm shrank at 6th months after operation.

A 12-year-old girl had relative graft stenosis following the reconstruction of type A interrupted aortic arch. At 25 days after birth she underwent ascending aorta-descending aorta bypass with a 7mm knitted Dacron graft, ligation of the patent ductus arteriosus and pulmonary artery banding. She had patch closure of a ventricular septal defect (VSD) as well at 20 months of age. At age 12 catheterization was carried out, because she had headache and dizziness on exertion. The pressure of the ascending aorta was 163/79mmHg and the pressure gradient between the ascending and the descending aorta was 65mmHg. Aortography revealed severe stenosis of the graft, which might have occurred according to her growth. An extra-anatomic bypass was placed between the right axillary and the right common iliac artery through the intrapleural and preperitoneal route with a 10mm Dacron graft. Six months later, the blood pressure was 108/63mmHg in the upper extremities, the pressure gradient between the upper and lower extremities was reduced to 18mmHg, and headache and dizziness had disappeared.

A 81-year-old man underwent CABG for angina pectoris. The grafts were all patent in postoperative coronary angiography and he was discharged on postoperative day 24. Pericardial and pleural effusion appeared in 1 month after surgery. After pericardial and pleural effusion drainage, we started steroid therapy. However, his symptoms did not improve. We performed pericardiectomy under the diagnosis of constrictive pericarditis. Diastolic dysfunction improved after the surgery, and he was discharged on postoperative day 117.