A 22-year-old man shot himself with a nail gun. He was admitted to a local hospital with chest pain. Chest x-ray film and chest computed tomography showed 5 nails penetrating the left thorax and some of these nails were considered to reach the pericardium. He was transferred to our hospital for intervention. Left thoracotomy was performed. Three nails reached the left ventricle and one nail was embedded the left lung. The last nail was found by transesophageal echocardiography to be completely buried in the left ventricle wall. All nails were removed and the left ventricular wounds were repaired with felt 4-0 surgipro mattress sutures. He made an uneventful postoperative recovery with a normal postoperative echocardiography and he was discharged on postoperative day 12 in good condition.

We report a case of total aortic arch replacement for ruptured aortic arch aneurysm in an oldest-old person. The patient was a 92-year-old woman with hypertension, who had normal daily activity. She consulted another hospital because of hemoptysis. A chest roentgen exam showed an outpouching of the first left arch. In our hospital, chest computed tomography revealed a saccular thoracic aortic aneurysm, 43mm in maximum diameter, which seemed to be the cause of hemoptysis. The patient and her family wanted to have operation. While waiting for the operation, she coughed up a large amount of blood and suffered respiratory failure, requiring a mechanical respirator. Two days later, in the operation room, she coughed up a large amount of blood again and suffered long term hypoxygenation. Though she underwent total aortic arch replacement, she developed septic shock with MRSA pneumonia. However, she was weaned from ventilatory support on the 24th postoperative day. On the 86th postoperative day, ambulatory was possible. She had no ischemic cerebral damage. In extensively elderly patients, careful attention must be paid to decide an the indications for highly invasive surgery such as total aortic arch replacement.

We performed redo off-pump coronary artery bypass (OPCAB) through a left thoracotomy using a PAS·Port system for proximal vein graft anastomoses for a patient with symptomatic ischemia in the left circumflex system. A 60-year-old man underwent OPCAB (LITA-LAD, RA-4PD) 7 years previously. Coronary angiography revealed a remarkable lesion in the left circumflex system, but the left internal thoracic artery graft (ITAG) and the radial artery graft (RAG) were patent. OPCAB was performed through a left thoracotomy to avoid injury to the patent grafts. With the heart beating, a saphenous vein graft (SVG) was anastomosed sequentially from the descending aorta to the first and second obtuse marginary arteries. Avoiding descending aortic clamping, a proximal anastomosis was made using the PAS·Port system and the SVG was routed anterior to the pulmonary hilum. The postoperative course was uneventful and he was discharged on the 22nd postoperative day. Cardiac CT showed patent SVG and adequate proximal anastomosis. In this case OPCAB through left thoracotomy was effective. The selection of the graft inflow source and bypass routes according to the individual patient is essential for the success of the procedure.

The patient was a 37 year-old man. We diagnosed Loeys-Dietz syndrome based on his physical characteristics that were widely spaced eyes and brachycephaly etc. Since he developed De Bakey III b aortic dissection 3 months later, he needed surgical repair for saccular-shaped distal arch aortic aneurysm. We performed total aortic arch replacement for the aneurysm and valve-sparing aortic root reconstruction for dilatation of the Valsalva sinus. Furthermore we performed the frozen elephant trunk technique for residual aortic dissection at the same time. After 18 months from the operation, we were able to recognize by computed tomography that the false lumen of the aorta next to the stent graft was thrombosed and absorbed and finally disappeared. The stent graft treatment for patients with connective tissue disease might be an effective method and deserves more attention.