A 59-year-old man presented with sporadic febrile illness. Echocardiography showed multiple vegetations on the mitral valve. Blood culture yielded Viridans streptococci. Mitral valve replacement was performed, and a high dose of penicillin G sodium (24 million U/day) was administrated for 4 weeks postoperatively. On the 28th postoperative day, the patient developed severe back pain and bloody sputum. Chest CT showed a false aneurysm of the distal aortic arch (5.5cm). The patient was placed on cardiopulmonary bypass with the arterial return in the mid-aortic arch. The aneurysm was resected and replaced with a Dacron tube during deep hypothermic circulatory arrest. The aortic wall was interspersed with mobile nodules that appeared to be colonized. The aorto-pulmonary fistula was directly closed. The whole procedure was carried out through the 4th intercostal space. The tissue culture was negative but histopathology suggested a persistent inflammatory process. Excavating aortic sepsis may occur following active endocarditis. Even if cardiac infection is controlled, continuous search should be undertaken for possible dilatation in remote parts of the arterial system.

Background. In recent years, aortic valve stenosis in the elderly is increasing. To determine the treatment of aortic stenosis in the elderly, we retrospectively evaluated the patients who underwent aortic valve replacement. Method. Between 1992 and 1997, 22 patients older than 70 years underwent aortic valve replacement for aortic stenosis. There were 15 women and 7 men, with a mean age of 73.0±4.0 years. Seven patients underwent concomitant procedures: 5 patients required coronary artery bypass grafts, 1 mitral valve plasty and 1 aortic root plasty. SJM prosthetic valves of sizes 19mm, 21mm and 23mm were used in 11, 8 and 3 patients respectively. Nobody underwent aortic annuloenlargement. Three patients underwent supraannular aortic valve replacement. All patients had New York Heart Association (NYHA) class III or IV symptoms. Results. There was no operative or hospital death. Five patients had atrial fibrillation after operation. There was only one late death, due to a traffic accident, and there was no significant complication during the follow up period. Of the 22, 21 patients improved to NYHA class I or II after operation. There were significant differences between patients who were 70 years or more and those under 70. BSA in these two groups were 1.495 and 1.615m²; p<0.01, and the amounts of blood transfusion were 918±702 and 408±428ml, p<0.01. However, there was no significant difference between these two groups in terms of ACC time (56.8 and 59.9min), CPB time (88.7 and 92.1min), ICU stay (4.0 and 3.3 days) and hospital stay (29.5 and 25.5 days). Conclusion. The results of aortic valve replacement in patients aged 70 years or more, were satisfactory. If the aortic annulus being small, a small mechanical valve prosthesis is suitable, and supraannular positioning yielded good results.

We evaluated the surgical strategy for thoracic aortic aneurysm associated with abdominal aortic aneurysm. From January 1982 to March 1999, 24 consecutive patients underwent surgical treatment for thoracic aortic aneurysm with abdominal aortic aneurysm. Staged operation was performed if one was only slightly dilated, but extensive operation was needed if the size of both aneurysms was greater than 6cm. In cases of thoracic aortic aneurysm with abdominal aortic aneurysm up to 4cm in size, surgical treatment was performed only for the thoracic aortic aneurysm. Circulatory support during operation was established from the ascending aorta, and circulatory arrest with deep hypothermia and retrograde cerebral perfusion were used for brain protection during surgery for thoracic aortic arch aneurysm. Hospital mortality was 12.5% (3/24 cases). The causes of death were cerebral infarction and respiratory failure. Antegrade systemic perfusion and aortic no-touch technique were an effective method of surgery for thoracic aortic aneurysm with abdominal aortic aneurysm to avoid perioperative embolism and major complications. We successfully performed staged operation, but regular radiographic follow-up was needed.