We report a rare case of primary cardiac undifferentiated pleomorphic sarcoma with invasion to the posterior mediastinum, for which partial resection of the tumor in the left atrium had already been carried out twice. After remission for about three years, recurrence in the atrial wall involving the mitral valve posterior leaflet required a third surgical resection following mitral valve replacement.

Eight patients with multiple aortic aneurysms of both the thoracic and abdominal aortae treated surgically from 1991 to 1995 were evaluated clinically. The patients consisted of six men and two women, with an average age of 65.6 years ranging from 50 to 73. The incidence of multiple aortic aneurysms was about 10% of all cases of aortic aneurysms. The entire aorta should be examined in all patients with aortic aneurysms. Among the five patients who underwent a two-staged operation, the thoracic operation preceded the abdominal one in one case, and the abdominal operation preceded the other in four cases. No aneurysm rupture occurred in the two-staged cases. In conclusion we should first replace the aneurysm with the higher risk of rupture. However, when such a judgement is difficult, it is improtant to consider the possibility of a rupture of the second aneurysm or a brain infarction caused by a thrombosis moving from the abdominal aneurysm. The order of operation should be decided according to the location and the size of the thoracic aneurysm.

A 42-year-old female suffered annulo-aortic ectasia (AAE) and mitral regurgitation associated with Marfan's syndrome was successfully treated by a modified Bentall procedure combined with mitral valve replacement (MVR) under continuous warm blood cardioplegia (CWBC). With the patient under total cardiopulmonary bypass and myocardial protection with CWBC, MVR with 27 mm mechanical valve was first done, followed by the total replacement of the aortic root with a composite graft made of vascular graft and an aortic mechanical valve. Anastomosis of the composite graft to the aortic valve annulus was made to guarantee a watertight closure using numerous interrupted mattress sutures and three pieces of Teflon felt strips to the annulus. Both coronary arteries were reconstructed by means of the “Interposition Graft Method” which interposes two short grafts between the composite graft and both coronary ostia. In spite of long time aortic cross clamp (235 min), cardiac function was recovered excellenthy and a peak CK-MB value was very low (23 IU/L) in the early postoperative period. Thus, CWBC provided a satisfactory myocardial protective effect. It was suggested that the modified Bentall procedure combined with MVR using CWBC was an effective therapy for a patient with AAE and mitral regurgitation associated with Marfan's syndrome.

A 50-year-old man was admitted to our hospital due to chest pain. He had a history of chronic pancreatitis associated with a pancreatic pseudocyst. Coronary angiography revealed stenotic lesions in left main trunk and right coronary artery coronary artery bypass grafting (RITA-LAD, LITA-OM, SVG-#4PD) were performed. The postoperative course was uneventful without any complications, and he was discharged on the 9th day after surgery. A week later, fatigue and dyspnea appeared. Echocardiography showed a large mount of pericardial fluid and echo-guided pericardiocentesis was performed. One week after the procedure the pericardial fluid reaccumulated. Pericardial drainage resulted in continuous drainage of pericardial fluid. A 7 French plastic stent was placed in the pancreatic pseudocyst, which decompressed the pancreatic pseudocyst, which led to the disappearance of pericardial effusion accumulation. The possible relation between a recurrent pericardial fluid accumulation and a pancreatic pseudocyst was suspected.

An 82-year-old woman was transferred to our hospital due to an abrupt back pain. She exhibited a cardiac tamponade and her CT angiography revealed Stanford type-A acute aortic dissection without abdominal extension. Emergent surgery for partial arch replacement was performed. After a few days of stable postoperative course, she suffered 38 degrees fever with an elevated inflammatory response and complained of a slight abdominal pain. Her CT scan revealed an intra-abdominal abscess with a small intestine necrosis. Emergent surgery for partial small intestine resection was performed. Her postoperative course was stable and she was discharged to a rehabilitation hospital 52 days after the first operation.

Anti-inflammatory therapy is generally considered to be prior to surgery for Takayasu disease to achieve better outcomes. We report two Takayasu arteritis patients with thoracic aneurysm. Case 1 was a 19-year-old woman who presented acute trachyphonia for one month. CT revealed aortic arch aneurysm of which maximal diameter was 64 mm with partial cystic protrusion. We performed urgent total arch replacement before anti-inflammation therapy was induced. Postoperative course was uneventful and the patient discharged on steroid therapy. Case 2 was a 35-year-old woman who complained chest pain for two weeks. CT revealed a Valsalva aneurysm with maximal diameter 54 mm and the aortic wall of the arch including its branches was surrounded by thick low density area. As the FDG-PET confirmed inflammatory arteritis, initial steroid therapy was planned. However, one day before admission, the patient presented acute aortic dissection and did not respond to any resuscitation. We conclude that the right time of surgery or the initial induction of anti-inflammatory therapy for anuerysmal dilation by Takayasu arteritis is to be determined based not only on the inflammation level but also on aneurysmal size and the patient's severity of complaints.

Today, syphilitic aortic aneurysm is rarely diagnosed due to widespread use of penicillin for early syphilis. Large aneurysms can be symptomatic by compressing on adjacent organs. We report a case of a huge syphilitic aneurysm of the thoracic aorta complicated with airway obstruction and superior vena cava syndrome. A 62-year-old man presented with acute severe dyspnea and distention of superficial veins. Contrast-enhanced computed tomography revealed an aneurysm of the ascending aorta extending to the transverse arch the diameter of which was 90 mm. The aneurysm compressed the bilateral main bronchi and superior vena cava. We performed an emergency operation because respiratory failure persisted despite the support of a ventilator. Since the aneurysm eroded the sternum, median sternotomy was performed under hypothermic circulatory arrest. Dissecting the aneurysm was complicated due to dense adhesion. Ascending aorta and partial arch replacement with reconstruction of the brachiocephalic trunk was successfully performed with antegrade cerebral perfusion. Postoperative computed tomography demonstrated that compression of the bilateral main bronchi was released. The result of preoperative syphilitic serologic test was strongly positive, and pathological findings of the aneurysm wall specimen was compatible with syphilitic aneurysm. Following treatment with benzyl penicillin for 14 days, the patient was discharged on the 19th postoperative day without specific complications.

Surgical stress is closely associated with the activity of the thyroid hormone. Although many patients undergoing cardiac surgery revealed markedly low triiodothyronine (T3), few patients showed symptomatic hypothyroidism. This condition is generally recognized as “non thyroidal illness (NTI) ” which is characterized by a low T3 level, despite the normal function of hypothalamus-pituitary-thyroid system. NTI is generally considered as one of the biological defense mechanisms rather than a pathological condition, eliminating the requirement of medical intervention. Even if low T3 is observed in blood biochemical examination after open heart surgery, a cautious interpretation is required. We report an elderly case presenting severe fatigue and mild disorientation accompanied by significantly low thyroid hormone after aortic valve replacement. The morbidity was remarkably improved with medical treatment, suggesting hypothyroidism after cardiac surgery.

Non-occlusive mesenteric ischemia (NOMI) after cardiovascular surgery is a disease with a poor prognosis that is difficult to diagnose and treat. We report a case of NOMI diagnosed and treated immediately after open heart surgery. A 77-year-old man was admitted to our hospital due to heart failure. Echocardiography showed the diagnosis of severe aortic stenosis. He underwent surgery for the replacement of the aortic valve. After surgery, the hemodynamics became unstable and lactate continued to rise. Contrast abdominal computed tomography revealed a smaller SMV sign and ischemic area in the intestinal wall. We suspected NOMI, and continuous intravenous administration of prostaglandin was started. Angiography revealed scattered vascular stenosis in the superior and inferior mesenteric arteries, which led to the diagnosis of NOMI, and selective infusion of papaverine hydrochloride was started. Thereafter, hemodynamic improvement was observed and the patient was able to survive. To facilitate early diagnosis and treatment of NOMI, it is important to establish a protocol at the time of onset of illness to ensure smooth treatment.