A 22-year-old woman with pseudocoarctation of the aorta as a complication of disal arch aortic aneurysm and aberrant right subclavian artery was successfully treated. She was the elder of identical twins, with a past history of spontaneous closure of the ventricular septal defect. Preoperative angiograms suggested pseudocoarctation of the aorta complicated by distal arch aortic aneurysm with aberrant right subclavian artery. At operation, the distal arch was replaced with a 14mm woven dacron graft and the left subclavian artery was reconstructed by interposition of 6mm IMPRA graft between the vessel and ascending aorta. The postoperative angiograms indicated successful reconstructions. Contrast-enhanced CT scans of the younger identical twin showed no anomaly of the thoracic aorta.

Isolated tricuspid regurgitation is extremely rare, and in most of the previously reported cases, both tricuspid leaflets and subvalvar tissue have been absent, hypoplastic or fused. For this reason, tricuspid valvoplasty was difficult and valve replacement was adopted in many cases. In the present case, a 52-year-old man, however, the tricuspid valve showed no abnormalities other than a severely dilated tricuspid annulus. Ring annuloplasty was performed, and this resulted in a subsequent satisfactory course.

For treatment of Stanford type A aortic dissection, we have operated only on the ascending aorta out of consideration of operative invasions and complications. However, if only the ascending aorta is replaced, the residual distal false lumen and its dilatation become problematic. We examined the risks of postoperative dilatation of the distal false lumen in terms of the following three factors (1) patency of the distal false lumen, (2) Marfan's syndrome, (3) aortic medial degeneration. Between 1984 and 1993, 55 cases of acute and chronic type A aortic dissection were treated surgically at our hospital, and a total of 33 survivors were subsequently followed up. The mean follow-up period was 92 months. None of the survivors died of late aortic complications. Five patients (15%) had Marfan's syndrome. As a result, all 18 patients (55%) with a closed distal false lumen did not show late distal dilatation or late deaths. Marfan patients had a high incidence of distal dilatation of the aorta and required additional aortic operations. Aortic medial degeneration was a high risk factor for younger onset (>40 years old) of aortic dissection, patent false lumen, and late dilatation, not only for Marfan patients but for non-Marfan patients. Non-Marfan patients with onset of aortic dissection under 40 years of age, showed significantly high incidence of medial degeneration. In conclusion, patent false lumen and medial degeneration of non-Marfan patients is a high risk factor of late dilatation as well as those of Marfan patients. On the other hand, patent false lumen is not a risk factor of late dilatation for non-Marfan patients without medial degeneration. Therefore, in both Marfan and non-Marfan patients with onset under 40 years of age, concomitant aortic arch repair should be performed because the rate of reoperation is significantly high.

Aortobronchopulmonary fistula (ABPF) caused by thoracic aortic aneurysm is uniformly fatal if not treated surgically. Here we report 12 cases, and discuss the cause, surgical treatment, and results. Between 1993 and 1998, we encountered 12 cases of ABPF. ABPFs were complicated by (A) true aneurysms without infection (n=4), (B) aortic dissection (n=1), and (C) infective pseudoaneurysms occurring after thoracic aortic surgery (n=4). Three patients refused surgery. The ABPFs were located in the ascending aorta to the trachea (n=1), the distal arch to the upper lobe of the left lung (n=6), and the descending aorta to the lower lobe (n=5). They were repaired by graft replacement or patch closure. All four patients in group A have shown an uneventful course 10 patient-years after surgery. One patient in group B died of mediastinitis. The other three patients in group B were discharged from hospital, but died of sudden recurrent hemoptysis at their homes. A patient with aortic dissection underwent patch closure of an ABPF located at the distal arch, however he died of recurrent hemoptysis due to bleeding from another ABPF at the descending aorta. All of the three patients who refused surgery died of hemoptysis at various times after diagnosis. The surgical results in the non-infection group (A) were satisfactory. The group with infection (C) showed poor results after surgery and died due to recurrence of hemoptysis caused by new ABPFs arising from infected pseudoaneurysms. ABPF caused by aortic dissection (B) is difficult to repair because of severe adhesions to the lung and the unclear location of the fistula. ABPF infection is difficult to control after thoracic surgery and it is the reason for the fatal outcomes, due mainly to sudden hemoptysis. Early diagnosis and prompt surgical intervention are important for patients with ABPF.

We report a case of left internal iliac aneurysm that ruptured into the left common iliac vein and formed an arteriovenous fistula. A 79-year-old man who had general fatigue was admitted to our hospital with a diagnosis of left internal iliac artery aneurysm, left hydronephrosis, dehydration and low renal function. After dehydration and low renal function resolved rapidly by medical treatment, an enhanced computed tomography was performed. This demonstrated a 69 by 67 mm diameter left internal iliac artery aneurysm with an arteriovenous fistula. During the operation, left common iliac artery and left external iliac artery were resected and the stumps sutured. External iliac-external iliac artery bypass was performed. An occlusive balloon catheter was inserted from the left femoral vein and the balloon was dilated to patch the fistula before opening the aneurysm. After clamping the proximal artery the aneurysm was opened. Bleeding from the fistula was controlled by this maneuver and digital compression of the left common iliac vein where was proximal side of fistula. An arteriovenous fistula with a 18 by 3 mm orifice was found between the left internal iliac artery and left common iliac vein. The fistula was closed from the inside of the aneurysm. His postoperative course was uneventful.

Postoperative infections should be comprehensively controlled in the context of infection control, rather than as activities of individual surgeons. We started a surgical site infection (SSI) surveillance program in 2009 in which prophylactic measures for preventing SSIs were applied. These measures were as follows : 1) screening for nasal carriage of methicillin-resistant Staphylococcus aureus ; 2) dental checks and oral screening ; 3) antibiotic prophylaxis in the intra- and postoperative period ; 4) control of glucose levels to ≤160 mg/dl in the immediate postoperative period ; and 5) early removal of surgical drain. After the introduction of prophylactic measures, we reexamined SSI surveillance and added the following prophylactic measures at the beginning of 2011 : 6) data concerning SSI and compliance with prophylactic measures for all surgical and ward staff were published monthly, and the Infection Control Team (ICT) and surgeons performed weekly ward visits to assess SSIs ; 7) recommendations were made for wearing two pairs of gloves and surgical hoods to cover the hair, scalp, ears and neck ; and 8) collaboration with diabetologists was implemented to control glucose levels in diabetics. We compared incidences of SSI in cardiovascular surgery from the periods before (469 cases, Group B) and after (118 cases, Group A) introduction of the additional prophylactic measures. Clinical characteristics of patients in each group did not differ significantly. Operative time was significantly shorter in Group A (400±116 min) than in Group B (434±145 min). Compliance with antibiotic prophylaxis in the intraoperative period improved progressively from 93% in Group B to 99% in Group A. Compliance with control of glucose levels to ≤160 mg/dl on postoperative day 1 improved progressively from 71% in Group B to 81% in Group A. Duration of drain placement was significantly shorter in Group A (2.9±1.8 days) than in Group B (3.6±2.9 days). Incidence of SSI decreased significantly from 6.0% in Group B to 0.8% in Group A. Revision of preventive measures based on the results of surveillance and enhancement of cooperation between the ICT and surgeons could help to decrease the incidence of SSI.

A 84-year-old woman underwent aortic root replacement with stentless bioprosthesis and coronary artery bypass grafting. Four years later, she presented with dyspnea. Transthoracic echocardiography revealed aortic regurgitation, dilation and dissection of the sinus of Valsalva. A Bentall operation was performed by using prosthetic graft and bioprosthetic valve. Intimal tear caused the aortic wall dissection and aneurysm of the Freestyle valve.

We report a case of re-repair mitral valve replacement (MVR) for paravalvular leaks that were unsuitable for catheter treatment. Three years ago, a 67-year-old woman, who had undergone MVR for rheumatic mitral valve replacement at the age of 33 years and undergone re-MVR at the age of 47 years, was admitted with hemolytic anemia. We performed paravalvular leak (PVL) repair directly with 5-0 polypropylene sutures because of calcifications in the annulus. Three years after the operation, she presented with dyspnea on exertion, and transthoracic echocardiography revealed several paravalvular leaks. We consulted with cardiologists in our and other institutions, and these leaks were determined to be unsuitable for catheter treatment. We removed the artificial valve, and found the calcifications and residual cuffs from the first or second artificial valves. These residual cuffs were removed with Cusa® and Harmonic Synergy®. We performed re-repair MVR without reconstruction of the annulus. She was discharged on postoperative day 39 with no complications and did not experience any recurrence of PVL for 2 years. Residual cuffs from the artificial valve may cause PVLs, and Cusa® and Harmonic Synergy® are useful for removing residual cuffs and calcifications.

Vascular Ehlers-Danlos Syndrome (EDS) causes fragility of the blood vessels, skin, and hollow organs, and the most common clinical feature is vascular rupture. We report a surgical case of a spontaneous ruptured dissection of the left common iliac artery (CIA) in a patient with vascular EDS. A 27-year-old man with documented vascular EDS with a mutation of the collagen type III alpha-1 [COL3A1] gene, presented with acute left lower abdominal pain. The enhanced computed tomography (CT) scan revealed a ruptured dissection of the left CIA with extravasation, and left iliopsoas hematoma. The enhanced CT performed 1 month previously showed no arterial aneurysm. The left CIA was anastomosed end-to-end using a 7 mm heparin-bonded polytetrafluorethylene (PTFE) graft (Fusion, MAQUET Cardiovascular LLC, USA). A PTFE graft was anastmosed end-to-side to the left external iliac artery (EIA). The distal side of the CIA was closed. The postoperative enhanced CT showed aneurysmal formation in the right inferior gluteal artery. The follow-up CT showed enlargement of the left EIA (from 7.5 to 12 mm in a diameter), and aneurysm formation in the proper hepatic artery. Therefore, a close follow-up based on noninvasive imagings is mandatory to detect life-threatening vascular complecations in patients with vascular EDS.

A 76-year-old man with ischemic cardiomyopathy and functional severe mitral regurgitation, suffered from profound dyspnea. He displayed a very low ejection fraction (12%) and was diagnosed with cardiogenic shock. Initially, we inserted the IMPELLA 5.0 heart pump into the patient's left ventricle and began an optimal medical therapy regimen. Once hemodynamic stability was acquired, we performed left ventricular reconstruction, mitral valve replacement, and tricuspid annuloplasty. The patient was supported postoperatively with IMPELLA 5.0 and venoarterial extracorporeal membrane oxygenation. The patient was discharged on POD100. Overall, IMPELLA 5.0 may be a useful tool for perioperative support against cardiogenic shock.