A 58-year-old man was admitted with pulsatile abdominal mass with fever and dull pain. Abdominal aortic aneurysm with left hydronephrosis due to obstruction of the left ureter was diagnosed by CT scanning. Aortic valve replacement was performed ten years previously for aortic regurgitation and recently his cardiac function deteriorated. On the 5th day after admission he suddenly suffered from hemorrhagic shock with massive melena. Emergency laparotomy was performed and ruptured abdominal aortic aneurysm was observed penetrating to the sigmoid colon with perianeurysmal abscess. The abdominal aorta was excluded and closed using two-layer sutures just below the renal artery, and bilateral common iliac arteries were also closed. The aneurysmal sac and the sigmoid colon were removed as a whole, and colostomy was made according to Hartmann's procedure. Permanent right axillo-bifemoral bypass graftiny was made to avoid infectious complications of the vascular graft. A successful vascular reconstruction was done without any complication of graft infection, however he died of cardiac failure due to dilated cardiomyopathy after 4 months postoperatively. We reported a successfully treated abdominal aortic aneurysm extending to the sigmoid colon with hemorrhagic schok.

A 60-year-old man with impending rupture of abdominal aortic aneurysm was transferred to our hospital. The patient entered a state of shock because of rupture during a CT scan examination. Emergency in site reconstruction with a dacron Y-graft was performed. There was massive intraperitoneal bleeding but no apparent abscess formation around the aneurysm. No drain was placed. A subcutaneous abscess that developed postoperatively was cured by open drainage and local antibiotic administration. Culture from both the aortic wall and the subcutaneous abscess revealed Salmonella infection. After subsequent intravenous antibiotic therapy for 45 days, the patient was discharged without any evidence of remaining infection.

A free-floating ball thrombus in the left atrium is a rare occurrence. Few patients who developed a ball thrombus after mitral valve replacement have been reported. Our patient was a 58-year-old man who had undergone mitral valve replacement in 1981. Since bleeding gastric cancer had been diagnosed anticoagulant therapy had been 4 days before admission. On admission, echocardiography revealed a large thrombus in the left appendage. First, he underwent total gastrectomy for gastric cancer. After the operation, he developed aspiration pneumonia, and was intubated. We observed that a large thrombus had moved from the left appendage to the left atrium. Emergency operation was successfull.

Left ventricular thrombus is a complication of left ventricular dysfunction, including acute myocardial infarction, cardiomyopathy, and severe valvular heart disease. Surgical removal should be considered when a thrombus is mobile, when thromboembolism occurs, and when cardiac function has the potential to improve. Two patients with left ventricular thrombus underwent totally thoracoscopic transatrial thrombectomy. A thrombus developed in the apex of the left ventricle after acute myocardial infarction in one patient (Case 1) and during treatment for congestive heart failure in the other (Case 2). The minimally-invasive transatrial approach requires no sternotomy or left ventriculotomy and is thus particularly beneficial for treating left ventricular dysfunction. Moreover, totally endoscopic surgery confers the advantage of a deep and narrow visual field. Therefore, we consider that this strategy is highly effective for treating left ventricular thrombus.

A 59-year-old man was admitted to our hospital with severe mitral incompetence. Mitral valve repair, tricuspid annuloplasty and the Maze procedure were performed. After weaning from cardiopulmonary bypass, his systolic blood pressure (SBP) dropped to 40 mmHg. Immediate administration of catecholamines markedly increased SBP but his continuing low blood pressure required additional treatment with vasopressin and hydrocortisone. On postoperative day 12 in the general ward, he suddenly lapsed into an intractable hypoglycemic coma. Endocrine function tests revealed adrenocorticotropic hormone deficiency. Since the time of writing has been doing well with 20 mg of hydrocortisone.

A 54-year-old man developed cardiogenic shock after acute myocardial infarction. Urgent coronary angiogram revealed complete occlusion at proximal portion of the right coronary artery and severe stenosis at just proximal site of the left anterior descending branch. Following thrombolytic therapy was not successful and he was sent to the operating room for coronary artery bypass surgery under external cardiac massage after 6hr from the onset. Three aorto-coronary bypasses were made to left anterior descending branch, first diagonal branch and right coronary artery using saphenous vein grafts by aortic cross-clamping of 67min. He fell into severe low cardiac output syndrome and could not be weaned from the cardiopulmonary bypass even by catecholamine infusions and IABP support. Veno-arterial bypass consisted of centrifugal pump and membranous artificial oxygenator was instituted. Venous blood was drained from the right atrium using percutaneous cannula via the right femoral vein and oxygenated blood was returned to the right subclavian artery. Hemodynamics recovered dramatically and after 71hr of this assisted circulation he was weaned from veno-arterial bypass. Activated coagulation time was maintained within 180-200sec. During this period, the centrifugal pump and oxygenator was not necessary to change and no clot was seen in the bypass system. He discharged from our hospital after 2 mo, postoperatively and now he is doing well as NYHA class-II 8 mo. postoperatively.

We experienced a 51-year-old male case of CABG whose graftography one month after CABG revealed a 0.5cm venous bypass graft aneurysm. Anginal pain recurred in the eighth month after CABG. Re-graftography showed enlargement of the aneurysm and stenosis of the graft at the same site. Re-CABG was carried out successfully and his postoperative course was good. Venous graft aneurysm is a comparatively rare complication, and that of the present case was considered to be most ascribable to the fragility of the graft, caused by mediastinitis secondary to the first CABG. Thrombus formation was noted in the aneurysm, with a risk of causing rupture or myocardial infarction. Therefore, such graft aneurysms should be treated by re-CABG as soon as possible after detection.

A 27-year-old female with Marfan's syndrome underwent successful emergency surgery for rupture of an abdominal aortic aneurysm. Annulo-aortic ectasia with a saccular aneurysm of the aortic arch was revealed by angiography after the initial operation. Cabrol's operation with replacement of the aortic arch was performed. Because bleeding from the distal anastomotic portion was uncontrollable, the segment was ligated and an extra-anatomical bypass was performed from the ascending aortic graft to the bilateral femoral arteries. Intra-graft balloon pumping was carried out in the extra-anatomical bypass graft while the patient was in low cardiac output condition after the second operation. This was considered to be an effective circulatory assist procedure.

We present a rare case of mitral stenosis with bilateral pulmonary arteriovenous fistulae (PAVF). A 55-year-old female who complained of dyspnea did not have pulmonary hypertension. She underwent successfully mitral valve replacement with an artificial valve 2 months after transcatheter coil embolization for PAVF. The combination with mitral valve replacement and transcatheter embolization is regarded as a useful procedure for mitral valve disease associated with PAVF.

Between 1984 and 1994, 58 patients underwent operations for type A aortic dissection. A sutureless ringed intraluminal graft was used in 9 of the 58 cases. The patients ranged from 47 to 74 years old (mean, 60.4 years). Six patients were discharged from the hospital and three patients died. The operative mortality rate for the 9 patients was 33.3% and for the other 49 patients it was 20.4%. Post-operative aortograms revealed a remaining false lumen in 5 of the 6 discharged patients. The result of the operation with the sutureless ringed intraluminal graft was not satisfactory. Therefore, we prefer to resect and replace the dissected aorta using the prosthetic graft rather than repair with the sutureless ringed intraluminal graft.