A 71-year-old man who had undergone repair of a ruptured abdominal aortic aneurysm with a tube graft 3 months ago was transferred from another hospital with an Aortoenteric Fistula (AEF) for surgical treatment. Computed tomographic (CT) angiography revealed pseudoaneurysm formation at the proximal anastomotic site. Waiting for the elective operation, he developed massive hematemesis with shock. Endovascular stent-graft repair was emergently performed because of high risk for conventional open surgery. Gastrointestinal bleeding was successfully controlled. The psuedoaneurysm disappeared, which was confirmed by postoperative CT angiography. At 1-year follow-up, he has shown no clinical and radiographic evidence of recurrent infection or bleeding. For the case with shock, Endovascular repair could be a bridge to open surgery because it is fast and minimally invasive. Endovascular repair of AEF is technically feasible and may be the definitive treatment in selected patients without signs of infection and gastrointestinal bleeding.

We reported a 74-year-old female complicated by ostial obstruction of the left main trunk after aortic valve replacement for severe aortic stenosis. At surgery, the length from the orifice of the left main trunk to the aortic annulus was 3 mm. After a 19 mm Carpentier-Edwards PERIMOUNT MAGNA was implanted in supra-annular position, the orifice of left main trunk was concealed by a sewing cuff of the bioprosthesis. Before aortic declamping, saphenous vein graft was bypassed to the left anterior descending artery. The postoperative course was uneventful. Computed tomography demonstrated the ostial obstruction of the left main trunk by the bioprosthesis.

A 65-year-old-man was admitted with congestive heart failure and septic shock associated with suspected mitral valve infective endocarditis. An echocardiogram revealed vegetation attached to the chordae, high density lesions in both papillary muscles, and severe mitral regurgitation. An emergency operation was performed. Vegetation was been attached to the chordae. Multiple myocardial abscesses were noted in both papillary muscles and surrounding myocardium. However, there were few noticeable lesions on mitral valve leaflets and annulus. The anterior mitral leaflet was resected together with the chordae and the papillary muscles containing the myocardial abscesses. Mitral valve replacement was performed using a 27mm SJM valve after the other myocardial abscesses were drained. Klebsiella pneumoniae was cultured from the vegetation and the myocardial abscesses. Cases of myocardial abscess associated with infective endocarditis at the site of the papillary muscles and in the areas of the myocardium are very rare. It was assumed that the myocardial abscesses were probably due to the septic state from infective endocarditis, since myocardial abscesses was recognized in multiple sites and at a distance from the valve leaflets and annulus.

An 81-year-old woman developed abdominal pain after off-pump CABG (OPCAB) for unstable angina pectoris. X-ray film and CT scan showed paralytic ileus the day after surgery. A presumptive diagnosis of mesenteric ischemia was made and exploratory laparotomy was performed. During surgery, however, there was no sign of mesenteric ischemia. The patient still complained of abdominal pain after the laparotomy, so selective angiography of the mesenteric artery was performed. The angiography showed remarkable vasospasm of the superior mesenteric artery (SMA) and diagnosis of nonocclusive mesenteric ischemia (NOMI) was made and continuous intra-arterial perfusion of papaverine into the SMA was started. Control angiography during papaverine perfusion showed a clear reduction of vasospasm. Thereafter, the patient developed diffuse peritonitis due to intestinal gangrene on postoperative day 12 and was compelled to undergo extensive resection of the intestine and sigmoidectomy. She could not be weaned from the ventilator due to respiratory insufficiency and died of multiple organ failure about 5 months after OPCAB. NOMI can develop even in OPCAB, in which cardiopulmonary bypass is not required. Therefore maintenance of stable hemodynamics intraoperatively, careful management of the postoperative state and early diagnosis and therapy are essential to prevent NOMI.

A 70-year-old-woman was admmitted to receive an operation for aortic arch aneurysm. Total arch replacement was carried out under deep hypothermic circuratory arrest with selective cerebral perfusion. During sternal closure, her blood pressure dropped to 60/30mmHg suddenly, and massive venous bleeding started from the substernal space which turned out to be hemorrhage from the laceration of the pulmonary trunk. Controlling the bleeding by finger compression, rapid introduction of cardiopulmonary bypass was carried out and the laceration was closed by a pericardial patch. The postoperative course was uneventful. In this case, compression of the pulmonary trunk by the aortic arch aneurysm may have caused the fistula formation between them, and decompression of the aneurysm probably induced the rupture of the pulmonary trunk. If the preoperative computed tomogram had showed the compression of the pulmonary artery by the aneurysm, a careful exploration of the main pulmonary artery and a removal of the thrombus should have been performed, even when the preoperative diagnostic evaluation failed to reveal aortopulmonary fistula.

A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO₂, low level of PaO₂ and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/l and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.

Destructive aortic valve endocarditis or poor controlled aortitis cause the development of left ventricular-aortic discontinuity. We reported our experience with aortic root replacement for cases of severe aortic annular destruction. Between 1999 and 2006, 9 patients with severe aortic annular destruction underwent aortic root replacement at our institute. There were 8 men and one women with a mean age of 55 years. Seven patients were in New York Heart Association functional class III. Four of 9 patients had native valve endocarditis, 4 had prosthetic valve endocarditis (previous aortic valve replacements in 2, aortic root replacements in 2) and one had active aortitis with a detached mechanical valve. Radical debridement of the infected cavity and necrotic tissue was performed in all cases, followed by reconstruction of the aortic annulus using autologous or xenogenic pericardium in 3 cases. Antibiotic-saturated fibrin glue was applied to the cavity. Aortic root replacement was achieved with a pulmonary autograft (Ross procedure) in 4 and stentless aortic root xenograft in 4. One patient who had advanced liver cirrhosis underwent aortic valve replacement with a stentless xenograft by subcoronary implantation method. No mortality was observed during hospitalization and follow-up. Reoperation within 5 years was not necessary in 66.7% of the patients. Excellent outcome can be achieved by radical exclusion of the abscess cavity and viable pulmonary autograft or stentless aortic root xenograft in patients with severe aortic annular destruction.