A 59-year-old man with myocardial infarction underwent 4-vessel coronary artery bypass grafting. After operation, on the 9th hospital day, fever, dehiscence of the median wound, and pus discharge were observed. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the wound, and median wound curettage and removal of the sternal bone wire were performed. The infection also involved the substernal area and anterior mediastinum, and a diagnosis of mediastinitis was made. After wound cleansing and antibiotic (vancomycin) administration, inflammatory reactions decreased, and MRSA disappeared from the wound. The wound spontaneously closed, and complete closure required 60 days. On the 75th hospital day, pain from the right shoulder to the neck and numbness in the upper limbs suddenly developed. MRI revealed vertebral body destruction at C5-6, and a diagnosis of cervical osteomyelitis was made. The spinal cord was compressed, and there was a risk of spinal cord injury below the cervical spine. After consultation with orthopedic surgeons, cervical anteroposterior fixation was performed, he improved, and was discharged. We report a patient with MRSA mediastinitis complicated by cervical osteomyelitis who required emergency surgery.

Emergency coronary artery bypass grafting (CABG) for the treatment of acute coronary syndrome is still associated with increased operative risk and postoperative morbidity. Thirty-five patients underwent CABG for the treatment of medically refractory unstable angina (UAP), 42 patients for acute myocardial infarction (AMI) and 7 patients for post-infarction angina (PIA). The UAP patients received 2.8 distal anastomoses on average. Five patients (14%) died postoperatively, 3 of them due to perioperative myocardial infarction (PMI). In the AMI patient group, 29 patients were in shock and 3 patients were in cardiac pulmonary arrest (CPA) preoperatively. They received an average of 2.8 distal anastomoses. Fourteen patients (33%) died postoperatively. Ten of them died of postoperative myocardial failure. The operative mortality was extremely high in the shock state patient group (41%) and CPA state patients group (100%). Poor operative results were anticipated in those patients whose infarct-related artery was not recanalized preoperatively. All patients survived the CABG in the PIA group. It was concluded that reduction in mortality in the group of patients undergoing emergency CABG required highly refined myocardial preservation techniques to prevent PMI and to limit intraoperative myocardial damage, as well as powerful mechanical assist systems to provide support in cases of the postoperative myocardial failure.

Myonephropathic metabolic syndrome (MNMS) is a fatal complication following open-heart or aortic surgery. We evaluated 7 cases of MNMS following cardiac or aortic surgery. The patient's ages ranged from 43 to 81 years old. Of the 7 patients, four presented with myocardial infarction, which required coronary artery bypass grafting (CABG), and three presented with acute aortic dissection. Two patients with Stanford type A underwent total arch replacement and CABG and 1 patient with Stanford type B underwent a left axillo-femoral bypass. MNMS was caused by acute arterial occlusion due to intra-aortic balloon pumping (IABP) or percutaneous cardio-pulmonary support (PCPS) in patients who experienced myocardial infarction and acute lower limb ischemia in patients who experienced aortic dissection. The ratio of MNMS caused by IABP and PCPS, and acute aortic dissection was 1.4% and 4.2%, respectively. Four patients died; 3 had undergone CABG and 1 had undergone an aortic operation 18.5h after acute dissection. Both IABP and PCPS were removed early in possible cases. Limb wash-out was performed in 1 patient, and 5 were treated with hemodiafiltration. IABP and PCPS should be introduced via a prosthetic graft if limb ischemia is noticed. MNMS should be recognized as a disastrous complication of aortic dissection, and early bypass graft or limb amputation may become the treatment of choice. We emphasize that hemodiafiltration should begin as soon as MNMS is diagnosed.

We encountered a case of Dor's operation for left ventricular aneurysm with cardiac failure 19 years after operation for post-infarction ventricular septal perforation. A 70-year-old man, who had undergone patch closure for ventricular septum perforation due to acute anteroseptal myocardial infarction, was admitted for congestive heart failure. Preoperative left ventriculography (LVG) revealed large anteroseptal and ventricular septal aneurysm. The left ventricular ejection fraction (LVEF) was 39%, and the left ventricular end diastolic volume (LVEDV) was 200ml. Dor's operation and coronary artery bypass grafting to the left circumflex branch was performed. The postoperative course was uneventful and the patient was discharged 33 days after the operation. Postoperative LVG revealed improved left ventricular function and showed that LVEF was 45% and LVEDV was 171ml. The large akinetic aneurysm was formed 19 years after operation following the linear closure method. LVG after Dor's operation showed remarkable improvement for left ventricular function. These findings indicated that Dor's operation is superior to the linear method.

In 1984, a 67-year-old man had aortic valve replacement surgery for aortic regurgitation; he returned with chest pain on May 15, 2003. Emergency coronary angiography was performed because electrocardiogram revealed ST segment depression in leads V₄ to V₆. However, coronary angiography, echocardiogram and chest computed tomography finding were normal. Therefore the patient was discharged the following day. However, he was re-admitted for chest pain, followed by loss of consciousness 4 days after his initial release. Echocardiogram and chest computed tomography revealed perforation in the lateral wall of his left ventricle (LV) and a “blow-out” type rupture was diagnosed. The patient fell into cardiogenetic shock in the emergency room, and emergency left ventricular free wall rupture (LVFWR) surgical repair was performed under percutaneous cardiopulmonary support (PCPS). A round perforation measuring about 10mm in diameter was observed in the lateral LV wall along the course of LCx # 12. The perforation was closed using Teflon strip reinforced mattress sutures. The hemostasis was reinforced with fibrin glue sheet (TachoComb) and polyglygolic acid surgical mesh (Dexon Mesh), with fibrin glue extensively applied. He was discharged on July 17, 2003 without major complications. In this case, the precise cause that led to LVFWR was unknown. Emergency PCPS insertion enabled the LVFWR surgical repair and extensive adhesion due to the previous AVR prevented the massive bleeding to pericardial cavity and the catastrophic hemodynamic deterioration: both factors positively contributed to patient recovery.