Fifteen patients were operated on infective endocarditis (IE). We studied indication for operation, operative methods and results. There were 13 male and 2 female patients and the mean age of these patients was 48.5 years. 8 cases were inactive IE and 3 of them were prosthetic valve endocarditis (PVE). The patients consisted of 4 cases of aortic valve regurgetation, 2 cases of mitral valve regurgetation, 3 cases of PVE and 3 cases of VSD. Casual bacteria were positive for blood culture in 5 cases. The following bacteria findings were found: Streptcoccus viridans in 3 patients, gram-negative bacteria and Staphylococcus each in one case. Valve cultures were positive in 3 cases: There were gram-positive bacteria in 2 patients and Enterococcus in one case. Vegetations were present in all native valves and the echocardiogram was useful for these findings. There were 3 perioperative deaths (20%) and 2 of those patients were active PVE. All patients with IE who develop progressive congestive heart failure and cerebral emboli should have prompt valve relacement. In paticular active PVE still has high mortality rate.

The patient was a 43-year-old male who presented with heart murmur. Echocardiography, chest CT, and cardiac catheterization data showed extracardiac extension of an aneurysm of the noncoronary sinus, compressing the right atrium, right ventricular outflow tract, and superior vena cava. Severe aortic regurgitation was also recognized. The aneurysm was incised under extracorporeal circulation. The orifice of the aneurysm was closed, and the elongated annulus of the noncoronary sinus was corrected with woven Dacron patch. Mild aortic regurgitation was shown on postoperative aortogram, and the case is being carefully followed up.

Two cases that were surgically treated with atherosclerotic aortic aneurysm, followed by innominate artery aneurysm are reported. The causes of these aneurysms were determined to be arteriosclerosis and idiopathic inflammation. Blood flow reconstruction surgery using grafts was performed on these two patients. In one case, we also employed an internal shunt technique to prevent brain ischemia. It was speculated that this type of aneurysm develops not only in cases of inflammation, but also in multifocal arteriosclerotic vascular diseases. This type of aneurysm will probably increase in the future.

A 61-year-old man admitted to another hospital because of cerebral infarction had fever (about 39°C). Computed tomographic scanning revealed a pseudoaneurysm of the brachiocephalic artery, accompanied by pericardial fluid. The patient was transferred to our hospital. Culture studies of a sample of pericardial fluid revealed Staphylococcus aureus. A mycotic pseudoaneu-rysm of the brachiocephalic artery was diagnosed. Antibiotics were given for about 2 weeks after transfer to our hospital. Surgery was performed after the inflammation subsided. The pseudoaneurysm was incised during circulatory arrest. A hole measuring 2cm in diameter was found at the origin of the brachiocephalic artery. The hole was sealed with an autologous arterial patch, made from a 3-cm section of the right axillary artery. The axillary artery was reconstructed by end-to-end anastomosis. After surgery, infection was controlled by means of systemic antibiotics and closed mediastinal lavage. The patient was discharged from the hospital in good condition 160 days after surgery. To date, there has been no flare-up of infection.

Objective : To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. Methods : Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. Results : The median age of the patients was 15.5 years (range : 9-38 years). The patients had a mean body surface area of 1.48±0.3 m² (range : 1.00-1.92 m²). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3 (modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months (range : 1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0 mmHg preoperatively to 27.9±7.7/14.8±4.7 mmHg postoperatively and to 28.3±11.1/14.1±7.0 mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4 g preoperatively to 179.7±61.1 g postoperatively and to 100.4±76.3 g at intermediate-term follow-up, respectively. Conclusions : Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.

Between Nov. 1981 and Dec. 1990, seventy-seven patients underwent surgical repair for abdominal aortic aneurysm (56, non-ruptured and 21, ruptured). There were no operative and hospital deaths in the non-ruptured group and 4 deaths (19%) in the ruptured group. To improve operative results by means of decreasing hemorrhagic blood loss and operative time, we have ameliolated some points of the technical procedures as follows. Dissection of the perianeurysmal tissue was limited to only the neck and anterior peritoneal surface of the aneurysm. Taping to keep the aorta and distal iliac artery was not applied and vascular clamps were placed without dissection of the posterior walls of the aorta and distal arteries. Proximal anastomosis of the Y-vascular prostheses were performed by the inclusion technique. The end-to-side method was used in distal anastomosis to the external iliac arteries routing behind the ureter. Even when aneurysmal dilatation involved the common iliac arteries, the orifices of the common iliac arteries were closed by continuous sutures bilaterally. In ruptured cases too, this standard technique was used without application of special means for proximal cross-clamping. Postoperative arteriography or enhanced computed tomography reveald thrombosis and reduction in size of residual aneurysm of the common iliac artery. By these improved surgical techniques, 25 cases (45%) of the 56 non-ruptured group had surgical correction of the abdominal aortic aneurysm without using homologous blood transfusion. Cumulative 5-year survival rate by Kaplan-Meier method of non-ruptured and ruptured group was 87% and 49% respectively.

A Case of abdominal aortic occlusion caused by acute aortic dissection (DeBakey's type III b) is reported. A 59-year-old woman was admitted with sudden onset back pain and sensory disturbance of bilateral lower extremities. The pulsations of bilateral femoral arteries were absent. CT and aortogram revealed dissection of the thoracic descending aorta and infrarenal aortic occlusion. Since ischemic change had progressed, bilateral axillofemoral bypass was performed for limb salvage, and the symptoms improved rapidly. Axillofemoral bypass is an easy and safe procedure even in the acute phase of aortic dissection. It provides fast reperfusion, and so is considered to be useful to preventing myonephrotic metabolic syndrome MNMS.

In the postoperative treatment of ruptured abdominal aortic aneurysm surgery, the relationship between intra-abdominal pressure (IAP) and the clinical course is not been clearly understood. From April 2000 to January 2003, we treated 109 cases of abdominal aortic aneurysm surgery (non-rupture 71 cases, rupture 38 cases) and measured intra-abdominal pressure in 30 of the ruptured cases which we analyzed in this study. The patients were divided into 2 groups. The H-group included 12 patients with maximum IAP equal to or higher than 20mmHg, and the L-group included 18 patients with a maximum IAP less than 20mmHg. Clinical characteristics were compared between the 2 groups. The mean age was 79.3±7.6yr in the H-group and 70.7±10.1yr in the L-group (p=0.019). Preoperative shock was diagnosed in 83.3% of the H-group patients, and 61.1% of the L-group patients the (p=0.26). Postoperative maximum values of intra-abdominal pressure were 22.3±2.0mmHg in the H-group, and 15.4±2.4mmHg in the L-group. Duration of intubation was 87.7±110.0h in the H-group, and 25.1±29.2h in the L-group (p=0.04). Food intake was started 14.4±11.2d after surgery in the H-group, and 8.5±4.8d after surgery in the L-group (p=0.094). The length of ICU stay was 6.7±6.5d in the H-group, and 2.9±2.1d in the L-group (p=0.033). Length of hospital stay after surgery was 54.1±25.8d in the H-group, and 25.2±6.8d in the L-group (p=0.001). Complications occurred in 8 cases out of 11 surviving cases (73%) in the H-group, and in 3 cases out of 17 surviving cases (18%) in the L-group (p=0.0024). Complication in the H-group included acute renal failure, paralytic ileus, respiratory failure, abdominal wall dehiscence, and acute arterial occlusion, and that in the L-group included acute renal failure, upper limb paresis, and lower limb paresis. Monitoring of intra-abdominal pressure was considered beneficial to recognize complication and decide therapeutic strategy after ruptured aortic aneurysm surgery.

A 76-year-old woman with Stanford type A acute aortic dissection underwent replacement of the ascending aorta with the use of gelatin-resorcin-formalin glue. The patient suffered sudden cardiogenic shock at home 15 months after surgery and was admitted to the Emergency Center of our hospital. A series of examinations revealed an aortic-root pseudoaneurysm associated with anastomotic disruption. Cardiogenic shock caused by obstruction of the ascending aortic graft due to anastomotic disruption was diagnosed. An intraaortic balloon pump (IABP) was inserted, and the patient's circulatory status improved. On the following day, reanastomosis of the aortic root graft was performed. On day 32 after surgery, the patient was discharged from the hospital in good condition. IABP can stabilize circulatory status and improve cardiogenic shock in the short term in patients with an aortic-root pseudoaneurysm caused by narrowing of the graft lumen, as in the present patient. IABP may thus be a useful ancillary measure before radical operation.

A 83-year-old woman suffered pulseless-electrical-activity (PEA) because of cardiac tamponade after acute myocardial infarction with blow-out type cardiac rupture. Immediately median sternotomy was performed and active bleeding from the postero-lateral wall was found. It was impossible to stop bleeding only by putting pressure on the aperture of the myocardium with a piece of TachoComb coated with gelatin-resorcinol-formaldehyde (GRF) glue, however, the chemical action of GRF glue made the delicate myocardium after acute infarction stronger and we managed to stop that bleeding with mattress sutures that had initially seemed to be impossible. She was discharged on POD 103 uneventfully. We think this is a useful and safe operation procedure for blow-out type cardiac rupture.