A 40-year old man with chest pain was admitted to our hospital. A three-dimensional CT revealed an unruptured left coronary sinus of Valsalva aneurysm and mild stenosis of the left main trunk. An echocardiogram revealed severe aortic regurgitation. He was operated on with an aortic root replacement procedure. Though the procedure was itself uneventful, he could not be weaned from cardiopulmonary bypass because of unexpected coronary events ; relative stenosis of the RCA and stretched LMT due to a huge aneurysm of the sinus of Valsalva. Additional CABG with LITA to LAD and SVG to RCA led to weaning from cardiopulmonary bypass. Left coronary sinus of Valsalva aneurysm is rare, and it requires early surgical intervention for an increase in the diameter of the aneurysm together with myocardial ischemia due to compression of the coronary artery.

A 62-year-old woman was admitted to our hospital because of dextrocardia on her chest X-ray film. She had been in good health though the X-ray abnormality had been pointed out from her childhood. Echocardiogram, magnetic resonance imaging, and cardiac catheterization revealed situs inversus, congenitally corrected transposition of the great arteries, and severe tricuspid valve (systemic atrioventricular valve) regurgitation with mild systemic ventricular dysfunction. The surgeon stood on the patient's left side during the operation. On cardiopulmonary bypass, the tricuspid valve, facing almost dorsally, was exposed through a superior transseptal approach. Tricuspid valve replacement with a mechanical valve was performed with leaflet preservation. Systemic ventricular function is preserved at one year after operation.

The purpose of this study was to estimate the postoperative growth of untreated segments of the dissected aorta with non-thrombotic communicating false lumen, and also to evaluate the clinical outcome in relation to the aortic enlargement after surgery. Nineteen patients who underwent surgical treatment of aortic dissection were studied with enhanced CT scans and angiograms during the postoperative follow-up period. In Stanford type A patients, mean aortic dilatation rate calculated at the segment showing maximal dilatation was 5.1mm/year during 13-82 months (average, 41 months) after surgery, as a sequela of enlargement of the false lumen. Differences in the aortic dilatation rates between the different segments of the aorta were observed and these were per annum 4.8mm in the ascending aorta, 5.4mm in the transverse aortic arch, 4.3mm in the proximal descending aorta, 2.7mm in the distal descending aorta and 2.4mm in the abdominal aorta. In all patients, major communications were detected at the perianastomotic sites on angiography. In Stanford type B patients, false lumens with small communications were observed to show gradual thrombotic occlusion, but no significant aortic dilatation was detected during the follow-up period (13-70 months, average: 44 months), except three cases of sudden death who had major communications. Nine late events related to dissection, consisting of 4 sudden deaths suspected to be due to aortic rupture, 2 intestinal necroses and 3 cerebral infarctions, occured in 6 patients (32%), among which three patients had undergone arterial fenestration, one of whom had double barrel anastomosis. In the remaining two, major leakages were recognized at distal aortic anastomotic sites on postoperative angiography. The results of this study, we stress the importance of periodic check-ups using enhanced CT scan and if necessary, angiography after surgery of the patients having communicating false lumen. Early detection of progressive aneurysm formation and timely surgical reintervention can yield a good prognosis.

A 64-year-old man was admitted with intermittent high fever of 4 months duration and with three episodes of arterial embolism in the previous 2 months. Several investigations revealed evidence that those episodes involving bilateral popliteal arteries and the left external iliac artery originated from mycotic emboli. Severe mitral insufficiency due to infective endocarditis was also recognized. The ischemic symptoms improved after medical treatment. Despite antibiotic therapy for 4 weeks, inflammatory signs did not subside. Since aneurysm formation of the left external iliac artery at the embolized portion was detected on CT, mitral valve replacement and aneurysmectomy with femoro-femoral grafting were done concomitantly. Inflammatory signs disappeared immediately after the operation. Pathological findings indicated organization of the mitral vegetation and evidence of active infection in the aneurysm wall. Though aneurysmal change of a symptomatic embolized site is not common, the preoperative evaluation of possible associated mycotic aneurysm is important to decide on surgical strategy for infective endocarditis complicated by embolism.

A 16-year-old high school boy experienced intermittent claudication of his left lower limb during boxing training. Physical examination revealed a cold left foot and diminished pulse. A 64-row multi-slice CT (MSCT) demonstrated lateral shift and severe stenosis of the left popliteal artery due to malposition of the medial head of the gastrocnemius muscle. A diagnosis of popliteal artery entrapment syndrome (Delaney type II) was established and a surgical correction was planned. During surgery, since the artery was found to be compressed but not occluded, we simply released the popliteal artery by division of the medial head of the gastrocnemius and abnormal flips of muscle. The postoperative ankle brachial pressure index rose from “not measurable” to 1.22. MSCT was useful to characterize this anomaly by expressing the precise anatomical relation of muscle, bone and artery, which was a good guide for an appropriate surgical intervention.

A 71-year-old man had sudden onset of left lower limb swelling and consulted an orthopedic surgeon 14 days later. Venous echography demonstrated compression of the left iliac vein and the thrombus of the common iliac vein. After emergency admission, conservative therapy was given for 7 days, but the symptoms did not sufficiently diminish and a thrombus was also present. We therefore performed femoro-iliac cross-over vein bypass using a 10mm ringed ePTFE graft. Symptoms were completely improved and the graft was shown to be patent by echography after 3 months.

A 62-year old man was referred to our hospital with endocarditis. Although the infection was improved by antibiotic therapy, he underwent surgery because of severe aortic and mitral valve regurgitation. Preoperative computed tomography revealed a pseudoaneurysm of 20 mm in diameter at the posterior wall of the ascending aorta. The non-coronary cusp was infected and there was a punched-out pseudoaneurysm at the ascending aorta adjacent to the sino-tubular junction. After resection of the aortic wall and the aortic valve, a modified Bentall operation with a composite graft and mitral valve plasty was performed. Postoperative whole body computed tomography revealed no other pseudoaneurysms. In case of endocarditis, we have to consider the possibility of aneurysm formation throughout the body.

The patient was a 68-year-old woman with chief complaints of severe lumbago, left lateral abdominal pain and high fever. Computer tomography (CT) at a local hospital showed a left psoas abscess and a low density area around the terminal aorta. Blood tests indicated a high inflammatory response and MSSA was detected in a blood culture. Control of the infection was first attempted with antibiotics, but CT showed a pseudoaneurysm at the terminal aorta, and therefore she was transferred to our hospital. We diagnosed infected abdominal aortic and left common iliac aneurysms complicated by an MSSA psoas abscess, and performed extra-anatomic reconstruction with axillo-bifemoral bypass, aneurysmectomy and omentopexy in the psoas abscess cavity. Because of massive intestinal edema and mesentery, we attempted temporary abdominal closure with the vacuum-assisted closure (VAC) technique, and finally succeeded in closing without abdominal infection in the 6th operation, 42 days after the first operation. Infected abdominal aortic aneurysm complicated by psoas abscess is extremely rare and life threatening. The VAC technique is very effective not only in avoiding abdominal compartment syndrome but also in avoiding abdominal infection.

Emergency coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS) is still associated with high mortality and morbidity, and early outcome is poor compared with outcome in patients with stable angina. The purpose of this study was to examine the clinical results of on-pump beating heart CABG vs. off-pump coronary artery bypass (OPCAB) for ACS patients. From a total of 432 CABG patients, we retrospectively analyzed 72 (16.7%) patients who underwent emergency CABG between 2004 and 2008. Emergency CABG cases were divided into 2 operative groups : an on-pump beating-heart CABG group (on, n=31) and an OPCAB group (off, n=41). A preoperative history of acute myocardial infarction (AMI), detection of troponin T, preoperative creatine phosphokinase (CPK) value, low ejection fraction, presence of mitral regurgitation (MR) (>II) and cardiomegaly were markedly higher in the on group. There were no statistically significant differences in intraoperative factors. In-hospital mortality was 3.2% (1 patient) in the on group and 7.3% (3 patients) in the off group. Furthermore, statistically significant differences were found between the 2 groups in incidence of all-cause morbidity (on=71.0% : off=41.5%, p=0.01), respiratory failure (on=58.1% : off=29.3%, p=0.01), ICU stay (on=6.5±4.6 days : off=4.1±3.2 days, p=0.01), and necessary inotropic support (on=51.6% : off=17.1%, p=0.02). Multivariate regression analysis of preoperative and intraoperative factors was performed to identify independent factors for in-hospital mortality and morbidity. On multivariate analysis of preoperative factors, only the pre-CPK value reached statistical significance as an independent factor for in-hospital mortality and morbidity.

This study evaluated factors influencing residual aortic regurgitation (AR) after valve re-suspension surgery for acute type A aortic dissection. From January 1996 through December 2002, 63 patients were treated for acute type A dissection at our institution. Among these 63 patients, pre-and postoperative echocardiograms were available in 38 patients who underwent surgery combined with native aortic valve re-suspension. These 38 patients were divided into 2 groups according to the postoperative AR grade, i. e.: AR group: AR grade≥II (n=6), no-AR group: AR grade≤I (n=32). The severity of pre and postoperative AR was assessed by transthoracic or transesophageal echocardiography. The preoperative diameters of mid ascending aorta and sinotubular junction, and the percentage of the circumference of the dissection at the sinotubular junction level was measured by enhanced CT scan. Preoperative patient backgrounds were similar in both groups. The preoperative AR grade in the AR group was significantly greater than that of the no-AR group (2.25±1.17: 0.69±0.91, p<0.001). The tear was more frequently located in the ascending aorta in the AR group than in the no-AR group (66.7%: 37.5%, p<0.05). The percentage of circumference of the dissection at the sinotubular junction level did not affect the preoperative AR grade, but it did show a tendency to influence the severity of postoperative AR, though the difference was not significant. Three patients (7.9%) had AR grade III at the time of discharge, but did not clinically require further surgical intervention. Preoperative significant AR and the location of the tear in the ascending aorta are associated with postoperative residual AR after aortic valve re-suspension. The percentage of circumference of the dissection at the sinotubular junction level might influence the severity of postoperative AR.