A 44-year-old man underwent implantation of a DDD pacemaker for third degree heart block at age 20. The cutaneous pocket for the pulse generator was situated in the left pectoral region. He visited our hospital because of skin ulcer over the pacemaker without any other complaint such as fever or pain. The patient received a new DDD pacemaker system in the right pectoral region and old pacing leads were translocated under the pectoral muscle. However, right pectoral skin ulcer appeared 1 month later. Patch tests revealed a positive reaction to silicon. Wrapping of the pacemaker with a polytetrafluoroethylene (PTFE) sheet proved to be effective.

We report 4 cases of delayed hypersensitivity reaction to Vancomycin (VCM) after cardiac surgery. Case 1: A patient developed sepsis and mediastinitis after aortic valve replacement (AVR) for aortic valve insufficiency. Case 2: A patient developed mediastinitis after coronary artery bypass grafting (CABG) for effort angina pectoris. Case 3: A patient developed pneumonia after AVR for aortic valve infective endocarditis. Case 4: A patient developed sepsis after CABG for acute myocardial infarction. All of them received VCM intravenously and their infections improved. However, sudden high fever, skin rush and eosinophilia occurred 12 or 13 days after the initiation of therapy. These symptoms resolved after halting VCM administration. We need to take examine eosinophils when considering further administration of VCM.

A 62-year-old man suddenly felt severe back pain. An enhanced computed tomography (CT) demonstrated an acute Stanford type B dissection and the true lumen was severely compressed by the false lumen. We started conservative therapy because there was no sign of organ ischemia. A 23 days from onset, he developed bilateral limb ischemia and renal failure because the compression of the true lumen increased. After bilateral axillo-femoral bypass the organ ischemia disappeared. Four months later, CT showed the dilatation of the true lumen and occlusion of the bilateral grafts. In spite of graft occlusion, there was no sign of organ ischemia.

A 56-year-old man was admitted with fever of unknown origin and congestive heart failure. Blood cultures grew Streptococcus gordonii. An echocardiographic examination showed vegetation attached to the bicuspid aortic valve and severe aortic regurgitation. Despite the aggressive therapy, an emergency operation had to be performed because it was otherwise impossible to control heart failure. Vegetation was attached to the aortic valve leaflets. There was no noticeable lesion on the aortic annulus, but a myocardial abscess was noted in the left atrial wall. Aortic valve replacement was performed after the myocardial abscess was drained. It was assumed that the myocardial abscess was due to the septic state from Infective endocarditis because it was recognized at a distant zone from the active valvular infection.

A 64-year-old man who underwent aortic valve replacement with a 25mm Bjork-Shiley valve in 1993 began to have severe anemia and required repeated transfusions by November 2003. Doppler echocardiography showed only mild aortic regurgitation, but revealed turbulent flow around the mechanical valve. Autoimmune hemolytic anemia (AIHA) was diagnosed and he was treated with prednisolone (PSL) starting May 2004. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent rereplacement of the aortic valve with a 25-mm Freestyle valve. His hemolysis and general condition immediately improved. This case suggests the possibility that mild regurgitant jet and turbulent jet stress can cause severe hemolysis when AIHA develops.

An 80-year-old man was transferred to our hospital because of blunt traumatic aortic arch injury caused by a fall. Computed tomography (CT) revealed a pseudoaneurysm and mediastinal hematoma around the aortic arch, right hemothorax, left hemopneumothorax, lung contusion and spine fractures. His hemodynamic condition was stable but he required mechanical ventilation because of severe hypoxemia. Surgery was postponed until twelve days after the injury, when his lung function improved and active bleeding decreased. During surgery we found that the intimal disruption extended to half of the circumference of the aortic arch, and thus performed total arch replacement under deep hypothermic circulatory arrest and selective cerebral perfusion. The patient suffered respiratory failure and pneumonia postoperatively as well as multiple cerebral infarctions. He was referred to a rehabilitation center on postoperative day 130.