We assessed the late aortic reoperation after surgery for type A acute aortic dissection (AAAD). Subjects were 108 consecutive patients with AAAD who underwent surgery by routine aortic arch replacement using geratin-resorcin-formalin-glutaraldehyde (GRF) glue between January 1996 and December 2010. Seven of the 94 patients who were discharged after the initial repair of AAAD required reoperation for the residual aorta. Reoperations included 4 procedures on the distal aorta and 3 procedures on the proximal aorta (aortic root or ascending aorta) at a mean interval of 6.1±3.5 (0.9∼13.7) years after initial surgery. There were no hospital reoperation-related deaths. Freedom from reoperation was 96% and 89% at 5 and 10 years. In conclusion, the use of GRF glue may influence the risk of reoperation after surgery for AAAD, but our results showed that there were very few of such cases. Furthermore, routine aortic arch replacement for AAAD may reduce late aortic reoperations after surgery by eliminating possible risks of residual tear at the transverse arch.

We report two cases of patch reconstruction for distal arch aneurysms. Supportive measures during operation included selective cerebral perfusion for brain protection and cardioplegic arrest for heart protection. During operation the whole body except for the heart was cooled down to 25°C, and only the heart was perfused at 36°C and kept beating. Both aneurysms were saccular, and after the resection of the aneurysm the defect of the aortic wall was reconstructed with woven double velour patches. The relationship between the pressure and the flow during coronary perfusion is not clear, but we thought the above measures should be taken when operating on distal arch aneurysm.

A 70-year-old man was found to have aortic regurgitation and underwent aortic valve replacement. About 10 minutes after disconnection from the cardiopulmonary bypass, cardiac arrest occurred suddenly and the bypass was immediately resumed. At this point, a Stanford type A aortic dissection was detected by transesophageal echocardiography, and the orifice of the left coronary artery was considered to be occluded by invasion of a hematoma. Although ascending aortic replacement with a prosthesis was performed under hypothermic circulatory arrest with selective cerebral perfusion, the heart did not resume vigorous beating. Therefore, saphenous vain graftings to the left anterior descending artery and the right coronary artery were performed. Finally, the patient could be weaned from the cardiopulmonary bypass. On postoperative digital subtraction angiography, neither occlusion nor stenosis in both coronary arteries was observed. We conclude that it would be considered to perform coronary artery bypass graftings in this particular condition.

A 61 y. o. male was admitted as a diagnosis of Stanford type A dissecting aortic aneurysm 6 day after the occurrence. An urgent operation was performed next day and the ascending aorta was replaced. Oral intake was initiated after uneventful postoperative 6 day-period. However, paralytic ileus became obvious associated with spiked fever over 38°C. Second trial after the suspension of oral intake also failed in the same result and turned out sepsis caused by Enterococcus faecium. The angiogram revealed the intact celiac axis and superior mesenteric artery (SMA), and the remarkably narrowed true lumen of the aorta. Although the clinical symptom was not typical, we thought that the ileus was induced by abdominal angina. At 78th postoperative day the fenestration of the abdominal aorta and the bypass grafting with saphenous vein between SMA and the abdominal aorta were performed. The symptom and sign of ileus subsided after the operation.

A 76-year-old man developed dysphagia and esophageal stenosis was diagnosed. A computed tomographic scan of the chest demonstrated a large aneurysm of the distal aortic arch. The patient had undergone left thoracoplasty 45 years previously for the treatment of lung tuberculosis, then the aortic arch with the aneurysm was displaced backward because of the narrowed upper thoracic cavity and the esophagus was sandwiched between the aortic arch and the spine. The patient was thought to be in danger of developing an aortoesophageal fistula, so an emergency operation was performed in spite of his age and general condition. He was successfully treated with graft replacement including reconstruction of three arch vessels and his severe dysphagia improved.

A 69-year-old woman, who had undergone mitral valve replacement, developed acute congestive heart failure and was transferred to our institution. Cineradiography demonstrated that two leaflets of the St. Jude Medical valve were stuck in a closed position. Emergency redo mitral valve replacement was performed with a CarboMedics valve. Postoperative hematological studies yielded a diagnosis of antiphospholipid syndrome. Although postoperative anticoagulant therapy was performed more carefully than usual, the prosthesis became stuck again. Therefore, a third operation was performed using a tissue prosthesis. We concluded that mitral valve plasty should be a first option for patients with antiphospholipid syndrome undergoing mitral valve surgery. Should prosthetic valve replacement be required, a tissue prosthesis would be best.

A 63-year-old man developed acute congestive heart failure with orthopnea and was transferred to our institution. Aortography and transesophageal echocardiography demonstrated that the aortic valve was congenitally quadricuspid. In preoperative coronary angiography, the left anterior descending artery and the circumflex artery arose from the same orifice of the right coronary artery. So far as we know, quadricuspid aortic valve associated with a single coronary ostium is an extremely rare congenital cardiac anomaly combination. During aortic valve replacement for this particular case, antegrade cardioplegia including a selective coronary perfusion was considered unreliable, thus continuous retrograde blood cardioplegia was employed for intraoperative myocardial protection.

Endoventricular circular patch plasty was performed in a 42-year-old man, with a postinfarction akinetic aneurysm. The case was complicated with severe congestive heart failure, marked pulmonary hypertension (70% of systemic pressure) and sustained ventricular tachycardia. Cardiac catheterization data revealed low ejection fraction (20%), high pulmonary capillary wedge pressure (33mmHg) and high pulmonary arterial pressure (70/33mmHg), associated with enlarged end diastolic volume index (142ml/m²). After the operation, contractile and volumetric improvements were observed, however the severe pulmonary hypertension remained without any improvement. Disappearance of life-threatening arrhythmia allowed his discharge from the hospital, but unsatisfactory hemodynamic data, except for improved ejection fraction to 49%, turned our attention to patient selection and alternative treatment (cardiac transplantation) for such a severe case.

Sixteen patients with congenitally corrected transposition of the great arteries (CTGA) underwent operative closure of ventricular septal defects (VSD). Ages of the patients ranged from 10 months to 25 years. Three different approaches were employed to access to the defect: through right ventriculotomy 3, through left ventriculotomy 5, and de Leval's maneuver 8. Here, right or left ventricle refers to its anatomic morphology. Early postoperative death occurred in a patient who concomitantly underwent extracardiac couduit repair between left ventricle and pulmonary trunk. Late death occourred in 5 (left ventriculotomy in 1 and righ ventriculotomy in 4), among whom 2 expired suddenly of unknown cause (one in each of the right and left ventriculotomy), and 1 expired of pneumonia. Two other deaths were related to their reoperations for replacement of the incompetent left atrioventricular (AV) valve. Another patient who had been repaired by de Leval's maneuver also underwent replacement of the left AV valve and survived. Two patients who had undergone left ventriculotomy developed com-plete heart block leading to implantation of permanent pacemaker. Postoperative complete heart block was temporarily noted in a patient who had been repaired by de Leval's maneuver but returned to sinus rhythm on the 10th postoperative day. Late postoperative function of the systemic ventricle was assessed in 8 by gated radionuclide ventriculography. Calculated ejection fractions in each of the methods were the followings. Left ventriculotomy: 0.38, 0.47. Right ventriculotomy: 0.13. de Leval's maneuver: 0.29, 0.54, 0.66, 0.47, 0.36. These results draw us to the following conclusions that either ventriculotomy holds its drawbacks, that is, left ventriculotomy is apt to develop complete heart block and right ventriculotomy can predispose incompetent left AV valve ultimately leading to the fatal congestive heart failure. de Leval's maneuver, however, is rare to be complicated by the above morbidity and is considered to be the best operative method currently available.

Here we present a long-term follow-up of 50 operative survivors, who underwent surgery between December 1975 and March 1994 for the placement of an extracardiac conduit. Twenty-six patients received conduits with various valves (VC group). The valves used were the Hancock valve in 9 patients, the St. Jude Medical valve in 5, and a valved roll made of equine pericardium in 10. Twenty-four patients received valveless Dacron conduits (NVC group). Another group of patients, also with discontinuity between the right ventricle and the pulmonary artery, who were operated on without the use of a conduit, is presented here for comparison (NCR group: 16 patients). The follow-up period for the NCR group was shorter than for the other groups. There were a total of 4 late deaths in the conduit groups, and none in the NCR group. Freedom from reoperation due to conduit stenosis was analyzed by the Kaplan-Meier method. In the VC group, freedom from reoperation at 5, 10, and 15 years, was 87.8%, 50.8%, and 31.2% respectively. In the NVC group, freedom from reoperation at 5, 10, and 15 years was 100%, 95.7%, and 60.4%. There were statistically significant differences between the values in these 2 groups. In the NCR group, only one patient (6.25%) underwent reoperation due to stenosis in the right ventricular outflow tract. Although the rate of freedom from reoperation was lower in the valveless conduit group than in the valved conduit group, the majority of patients who receive a conduit between the right ventricle and the pulmonary artery will eventually require reoperation. Avoiding the use of an extracardiac conduit, and creating continuity between the right ventricle and pulmonary artery with autologous tissue is a useful alternative and may reduce the need for reoperation.