A 66-year-old man underwent percutaneous transcatheter ablation of the myocardium to treat chronic atrial fibrillation. Fifteen days after the procedure, he visited our hospital with a chief complaint of hematemesis. At that time, upper gastrointestinal endoscopy led to a diagnosis of esophageal ulcer. Oral food intake was suspended for approximately 1 month. Subsequently, 4 days after resumption of oral intake, he developed multiple cerebral infarcts. Moreover, massive hematemesis occurred, with resultant shock and cardiopulmonary arrest. At this point, a definitive diagnosis of left atrio-esophageal fistula resulting from the injury relating to the transcatheter ablation was made. Cardiopulmonary resuscitation was carried out, followed by emergency surgery. The operation was performed via median sternotomy and was done under cardiac arrest using complete extracorporeal bypass, and the fistula in the posterior left atrial wall and the middle esophagus were directly sutured for closure. Unfortunately, 3 days after this open heart surgery, the patient died from low cardiac output syndrome and multiple organ failure. Although rare, this complication may be fatal when it develops then its prevention is important. Once atrio-esophageal fistula develops after percutaneous transcatheter ablation, immediate surgical intervention seems essential.

A 65-year-old man presented to our hospital with a chief complaint of hoarseness. Chest radiography and computed tomography detected a right subclavian artery aneurysm. The aneurysm had a maximum diameter of 85 mm, and was associated with a mural thrombus and displacement of the trachea to the left, which led to airway stenosis. In case ventilatory insufficiency developed during anesthesia induction, an extracorporeal membrane oxygenator was prepared, followed by administration of anesthesia. Careful administration of anesthesia allowed for anesthesia management without the extracorporeal membrane oxygenator. We approached the periphery and the proximal portion of the aneurysm through a right subclavicular incision and partial median sternotomy, respectively. After excision of the aneurysm, we performed EPTFE prosthesis implantation. The patient's postoperative course was uneventful, which led to postoperative improvement of the airway stenosis. The combination of a right subclavicular incision and partial median sternotomy is useful for the surgical treatment of large subclavian artery aneurysms such as the one in this case. Moreover, careful anesthesia management after close consultation with anesthesiologists is important for patients who exhibit preoperative airway stenosis.

Aortic valve allografts have been used extensively for aortic valve replacement, aortic root replacement and relief of right ventricular outflow tract obstruction. Some investigators consider that the degree of cellular viability is important in determining allograft durability. In order to evaluate cell viability and histological changes of cryopreserved aortic valve allograft in a pig model, porcine aortic and pulmonary valves are subjected to cryopreservation. Porcine aortic valves were obtained from a slaughterhouse in a non-sterile condition. The dissected valves together with vascular walls were kept in a solution of antibiotics (CFX, IPM/CS, PCG, SM) for 6hr, at 37°C. After sterilization, no growth of aerobic and anaerobic bacteria, as well as fungi was seen in pieces of valves. For cryopreservation, the program freezing method (control freezing at a rate of -1°C/min) and the rapid freezing method (simple immersion in liquid nitrogen), with and without 10% dimethylsulfoxide (DMSO) for cryoprotective agents, were tested. Cell viability was assesed by cell growth from pieces of valves and vascular walls. Histological changes and cell viability were evaluated after storage periods of 1 week, 1 month and 3 months. By the program freezing method with 10% DMSO, cell viability was well preserved and no histological change was detected after 3 months storage. By the rapid freezing method with 10% DMSO, cell viability of valves and vascular walls, except for aorta, were preserved and histological changes were slight. The valves and vascular walls cryopreserved without DMSO showed no cell growth after storage of 1 week. The result suggests that the program freezing method with 10% DMSO is applicable in a clinical use.

A76-year-old man was transferred to our hospital for evaluation of continuous abdominal pain with systemic inflammation. Clinical examinations suggested the pressure of an adynamic ileus due to diverculitis and an infrarenal abdominal aortic aneurysm. Thirty-eight millimeter in diameter despite the commencement of antibiotic therapy, the symptoms progressively worsened and repeated CT scan demonstrated a rupture of the aneurysm without any enlargement in diameter. An emergency operation was done, and the patient was discharged on the 77th postoperative day. Blood culture and histological findings disclosed an infected aortic aneurysm due to Listeria monocytogenes. The possibility of aortic infection should be considered in patients showing a sudden rupture of an aortic aneurysm.

Between January and December 1991, six patients aged 80 years or older underwent coronary artery bypass grafting (CABG). Five cases were female, the mean age was 83 years, and the oldest was 90 years of age. Of these patients, five were of 3 vessels disease, three of whom had left main trunk lesions as well. Five cases were classified as NYHA-IV, four of whom required inotropic support, and two needed IABP support preoperatively. Emergency CABG was performed in five patients. As a result, all patients needed extensive postoperative care and extended hospital stays. However, five cases survived, and there was one hospital death due to severe left ventricular dysfunction (hospital mortality; 16.7%). We conclude that CABG in patients 80 years or older, although associated with longer ICU and hospital stay, can give good operative results and that patients should not be denied CABG because of age alone.

We report a 70 year old female patient who underwent three successful surgical repairs for the following postinfarction mechanical complications: left ventricular free wall rupture (LVFWR), ventricular septal perforation (VSP) and left ventricular pseudoaneurysm (LVPA). The patient had an oozing type LVFWR following PTCA and t-PA therapy for acute broad-anterior myocardial infarction. Initially, treatment of the LVFWR consisted of emergency pericardial wrapping over the infarcted myocardial area. However, on the second postoperative day the patient developed VSP, which necessitated patch closure of the VSP and patch plasty of the left ventricle. An LVPA, which was detected by UCG examination 38 days after the second procedure, was repaired successfully through a left antero-lateral thoracotomy and with femoro-femoral bypass. The patient made a full recovery and was discharged on the 200th postoperative day. In conclusion, UCG is an effective diagnostic method for postinfarction mechanical complications and pericardial wrapping over an infarcted area is a safe and useful method for an oozing type LVFWR. In addition, it is important that appropriate surgical repairs for postinfarction mechanical complications should be performed without delay.

Pulmonary stenosis is the most frequent problem after arterial switch operation for TGA. We experienced four cases of late severe pulmonary stenosis out of twelve patients. All four had supravalvular stenosis either at anastomotic site or at previously banded segment. One patient had associated valvular stenosis and another had bilateral branch stenosis. It is possible that valvular stenosis was due to retraction of equine pericardial patch and branch stenosis was due to overdistension. All four cases were successfully reoperated on 13∼39 months after switch operation. To prevent late pulmonary stenosis, we now alter technique of switch operation in two points. First, the great arteries are anastomosed with interrupted U-shaped sutures from outside of the vessels in whole circumference. Second, both coronary arteries are transferred with punched-out method to save tissue of Valsalva sinus, and the defects are closed with autologous pericardial patch.

Obstruction of right ventricle-pulmonary artery bioprosthetic valved conduits can result from valvular degeneration and calcification or neointimal peel formation. From 1968 through 1989, 38 patients underwent repair of congenital heart malformation with a porcine xenograft extracardiac valved conduits from right ventricle to pulmonary artery. Of 27 patients who survived after initial repair, 14 patients (8 males and 6 females) were reoperated for conduit obstructions. Ages of patients at the reoperation ranged 5 to 20yr (mean age 11.8±3.6yr) and the interval between initial repair and reoperation ranged 3 to 9yr (mean 6.6±1.7yr). The obstructed conduits were replaced with mechanical valved conduits (4 patients), nonvalved conduits (7 patients) or outflow patches (3 patients). In a half of patients, obstructions occured at multiple levels within the conduits. Obstructions mainly resulted from valvular degeneration, neointimal peel formation and anastomotic narrowings. There was no operative death but one late death due to the infective endocarditis. The systolic pressure ratio of right ventricle to left ventricle (or aorta) decreased from 0.81±0.13 preoperatively to 0.48±0.10 postoperatively. From our experience, it is recommended to use adequate sized bioprosthetic valued conduits for patients' body weight at the initial repair and replace obstructed conduits to the large sized nonvalved conduit at reoperation if possible.