A 77-year-old woman with previous aortic grafting for abdominal aortic and iliac artery aneurysms developed a blue toe in her left foot. Enhanced CT showed a high density area around the vascular graft of the left iliac artery, which partially protruded into the graft. Because of the elevated β-D glucan level, fungal infection of the vascular graft was strongly suspected. Her general condition precluded the graft removal. Instead, thrombectomy was performed. Microbial examination of the removed clot revealed infection by Aspergillus fumigatus. Voriconazole was administered for 3 months. The β-D glucan level was normalized. Only thrombectomy and Voriconazole administration can be an alternative in case with vascular graft infection by Aspergillus.

A 70-year-old man was given emergency admission with severe back pain. Computer tomography revealed type-B acute aortic dissection with a distal aortic arch aneurysm which was 69mm in diameter. The dissection extended from the distal portion of the aneurysm to right external iliac artery, and the false lumen was patent. The right renal artery arose from the false lumen. He was treated conservatively according to the guidelines of AHA, and later we performed total arch replacement electively for the aortic arch aneurysm. Distal anastomosis was applied using the elephant trunk method for reconstruction of only the true lumen. Postoperative computer tomography showed the false lumen was closed in the descending thoracic aorta, but patent below the level of the celiac artery. He was discharged without any complications. Cases of acute aortic dissection coexisting with atherosclerotic thoracic aortic aneurysm are rare. However, with the increase of the elderly population, vascular diseases will become more complicated. Strategy for therapy and operation should be considered carefully especially in such cases with multiple vascular diseases.

A 60-year-old man, who had undergone mitral valve repair with quadrangular resection of the posterior mitral leaflet and ring annuloplasty with a Cosgrove-Edwards ring, developed severe mechanical hemolytic anemia. Doppler echocardiography showed only mild residual mitral regurgitation, but turbulent jet was directed toward the annuloplasty ring. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent replacement of the mitral valve with a St. Jude Medical valve. Inspection of the annuloplasty ring at operation showed no evidence of dehiscence, but the area of the annuloplasty ring adjacent to the posteromedial commissure showed no endothelization. After the reoperation, the hemolysis and general condition immediately improved. This experience made us realize the possibility that a high-velocity regurgitant jet toward the cloth-covered annuloplasty ring, even if it mild, can cause severe hemolysis.

Aortic dissection is a rare but potentially fatal complication of cardiac surgery. We report 3 cases of acute aortic dissection complicating open heart surgery. The incidence of complications was 0.18% of cardiac operation during 10 years at our institute (3/1, 647). The dissection is most frequently observed to originate in the ascending aorta, and can occur during operation. In our series, however, two of the three had their dissection entry in the descending aorta and another in the left subclavian artery. Their dissection mainly extended to the distal site of the aorta. Two of the cases were found by postoperative examinations (CT, US) and had had no symptoms or complications, and they were treated conservatively with antihypertensive therapy. One case died due to intrathoracic bleeding and a cerebrovascular event just after the onset of the complication on the 10 postoperative-day. We have to pay attention to this as one of the possible complications after open heart surgery, and intraoperative transesophageal echocardiography or postoperative examinations such as CT were useful for detecting them. We should also take care of hypertension after cardiac surgery in cases in which this is a potential factor such as Marfan's syndrome.

A 22-year-old man with dilated cardiomyopathy (DCM), who was a practicing Jehovah's Witness, was transferred to our hospital for surgical treatment of medically uncontrollable mitral regurgitation (MR). Our original mitral complex reconstruction procedure and permanent pacemaker implantation for biventricular pacing were successfully performed without transfusion of blood products. Blood conservation strategy included: 1) preoperative treatment with erythropoietin, 2) utilization of a shortened extracorporeal circuit and assisted venous drainage system, 3) the use of ultrafiltration to save the residual autoblood in the extracorporeal circuit. The preoperative hemoglobin level was 17.1g/dl and the postoperative lowest level was 9.5g/dl. MR decreased from grade III to none, and NYHA functional class improved from class II to class I postoperatively. He was moved to a cardiology ward on the 13th postoperative day without complications. Transfusion-free surgery for DCM should be performed before DCM advances and requires left ventriculoplasty at risk for major blood loss. A careful follow-up is needed to examine the long-term results of the operative procedure during his expected long survival.

A 39-year-old man was found to have left iliac artery rupture, and was transferred to our department. Emergency surgical repair was done, however, his intra- and postoperative condition precluded primary abdominal closure. On the 8th postoperative day, temporary abdominal closure (TAC) was performed using Composix Mesh TM and negative pressure wound therapy (NPWT). On the 19th day after the first surgery, an emergency reoperation was needed because of the rupture of the common hepatic artery aneurysm, of which there was no finding on admission. After the reoperation of the hepatic artery aneurysm, TAC was again performed using new Composix Mesh. On the 43rd day after the first surgery, the abdominal wall reconstruction without Composix Mesh was done using components separation and the anterior rectus abdominis sheath turnover flap method. On the 106th day after the first surgery, he had recovered well and was discharged. The genetic testing revealed COL3A1 mutation, which is specific for vascular type Ehlers-Danlos syndrome. When long-term open abdominal management is necessary after the abdominal aortic surgery, TAC with Composix Mesh and NPWT may be a useful alternative. Artery rupture in young people is a finding that should be considered suspicious for vascular type Ehlers-Danlos syndrome, which is difficult to treat.

A 68-year-old man suffered a pain in his right groin and was diagnosed with deep vein thrombosis at a previous medical clinic, two months earlier. He was referred to our hospital to treat deep vein thrombosis. However, adventitial cystic disease of the femoral vein was suspected from findings of preoperative contrast CT and ultrasonography. Under general anesthesia, the operation was performed. The venous wall was resected including an adventitial cyst, which was followed by the venous reconstruction using an autologous vein patch. Anticoagulant therapy was continued after the operation for one year. He was followed for 18 months after the surgery without a recurrence of the adventitial cystic disease. Venous adventitial cystic disease is extremely rare and may be misdiagnosed as deep vein thrombosis. Careful follow-up is mandatory, because the postoperative recurrence rate is reported to be substantially high.