A 67-year-old woman suffering from chronic atrial fibrillation and cadiomyopathy was transferred to our hospital for treatment of a left atrial thrombus. Echocardiography demonstrated the thrombus attached to the left atrial appendage, left ventricular dilatation and low ejectior fraction. Removal of the thrombus and radiofrequency Maze ablation were performed simultaneously under beating heart cardiopulmonary bypass. The patient showed no impairment of lefl ventricular function perioperatively and regained normal sinus rhythm.

The decision of which surgical approach to use for the treatment of a multifocal craniofacial abscess is still a controversial matter. A failure to control disease progress in the craniofacial region can potentially put the patient's life at risk. Therefore, understanding the various ways to approach the craniofacial region helps surgeons to obtain satisfactory results in such cases. In this report, we describe a patient who visited the emergency department with a large swelling in his right cheek. A blood test and computed tomography revealed odontogenic maxillary sinusitis. The patient developed sepsis due to a progressive multifocal abscess. An abscess was seen in the temporal muscle, infratemporal fossa, and interorbital region. To control this multifocal abscess, we used the facial dismasking flap (FDF) approach. After debridement using the FDF approach, we succeeded in obtaining sufficient drainage of the abscess, and the patient recovered from sepsis. The advantages of the FDF approach are that it provides a wide surgical field, extending from the parietal region to the mid-facial region, and that it leaves no aesthetically displeasing scars on the face. The FDF approach may be one of the best options to approach multifocal abscesses in the craniofacial region.
Abscess* ; Cheek ; Cicatrix ; Debridement ; Drainage ; Emergency Service, Hospital ; Facial Bones ; Hematologic Tests ; Humans ; Maxillary Sinus ; Maxillary Sinusitis ; Orbit ; Parietal Lobe ; Sepsis ; Surgeons ; Temporal Muscle

Six cases without aortic reconstruction for 48 hours were encountered among 22 cases of Stanford type A acute aortic dissection from April, 1990 to July, 1996. They were one man and five women, with a mean age of 60.3 years old (from 52 to 82 years old). According to Hagiwara's definition, acute thrombotic aortic dissection (ATAD) was observed in four and acute opacified aortic dissection (AOAD) in two of six cases of Stanford type A acute aortic dissection without aortic reconstruction. One of the four ATAD cases was well-controlled by medical therapy, but the others could not be controlled and underwent aortic root reconstruction within 1 month. Two AOAD patients died due to rupture within 1 month. It is said in general that the patients with acute thrombotic aortic dissection can be treated medically, but we consider that they should be treated surgically because of the frequency of late rupture.

A 66-year-old man was under observation as an outpatient for moderate aortic regurgitation and distal aortic arch aneurysm since 2005. He underwent surgery for gradual expansion of the distal aortic arch aneurysm. Preoperative enhanced computed tomography (CT) revealed a fusiform-type aortic aneurysm with a maximum short diameter of 63 mm. The aneurysm extended from the left subclavian artery to the descending aorta, 67 mm ahead. Based on the preoperative CT, a 150-mm open stent graft (OSG) was selected because of an adequate landing zone when inserted from the proximal site of the left subclavian artery. A 33-mm diameter graft was selected with a diameter 10% larger than that of the aorta at the landing zone. Moreover, the preoperative rapid plasma reagin (RPR) test was positive at 5.5 RU, and the fixed Treponema pallidum latex agglutination (TPLA) test was positive at 4,670 TU. He had undergone treatment for syphilis, and we concluded that the patient harbored antibodies after syphilis treatment. In the operating room, median sternotomy was performed. Cardiopulmonary bypass (CPB) was instated with bilateral axillary artery return, and superior vena cave (SVC) -inferior vena cave (IVC) venous drainage was placed. The aortic wall was strongly adherent to the surrounding tissue, similar to that observed in the aortitis syndrome. We performed aortic valve replacement during the systemic cooling. Under hypothermic circulatory arrest at 25°C with selective cerebral perfusion, the aorta was cut between the left common carotid artery and left subclavian artery. From this site, OSG was inserted to the level of the aortic valve. Total arch replacement was performed with a 30-mm bypass graft. Pathological findings indicated infiltration of lymphocytes and plasma cells around the feeding artery in the aortic aneurysm wall, and the aortic media wall showed fibrillation. Based on the intraoperative and postoperative pathologic findings, we diagnosed the patient with syphilitic aortic aneurysm, and started oral administration of amoxicillin 1,500 mg per day for 3 months. He was discharged on the 13th postoperative day without paraplegia, vocal cord paralysis, or other complications. Although syphilitic aortic aneurysm is rarely seen, it must always be considered as one of the causes of aortic aneurysm.

An 81-year-old man who visited a local physician for evaluation of hoarseness was admitted to our hospital for management of a thoracic aortic aneurysm. Careful examination revealed a thoracic aortic aneurysm, aortic regurgitation, and left ventricular aneurysm. We performed total arch replacement using a frozen elephant trunk prosthesis (combined right axillary artery bypass and coil embolization), aortic valve replacement, papillary muscle approximation, and a septal anterior ventricular exclusion operation. The patient's postoperative course was uneventful, and he was discharged on the 25th postoperative day. A Kommerell diverticulum is located at the origin of an aberrant subclavian artery, and subclavian artery reconstruction via thoracotomy is challenging in such cases. Although increasing numbers of thoracic endovascular aortic repairs have been performed in recent years, the procedure is associated with complications such as endoleak and aortic esophageal fistula, and the surgical risk-benefit ratio should be carefully determined. We report a case of safe non-anatomical subclavian artery reconstruction and coil embolization.

Takayasu Arteritis causes annuloaortic ectasia and coronary ostial stenosis, which may necessitate open heart surgery. However, pseudoaneurysms are sometimes observed postoperatively, making subsequent treatment difficult. We report thoracic endovascular aortic repair of a pseudoaneurysm of the ascending aorta with an anastomosis of the great saphenous vein in a 61-year-old female with a history of multiple open-heart procedures. Thirty years earlier, she underwent aortic valve replacement and coronary artery bypass surgery for aortic regurgitation, and right coronary ostial stenosis. Eleven years after surgery, an ascending aortic aneurysm was found and Bentall's surgery was performed. Multiple open thoracotomies were subsequently performed. Postoperatively, a pseudoaneurysm was found at the anastomosis between the ascending aorta and the great saphenous vein. The patient was transferred to the emergency room owing to hemoptysis and was diagnosed with a ruptured pseudoaneurysm at the anastomosis of the ascending aorta and the great saphenous vein. By inserting a stent graft into the ascending aorta, we avoided further complications and her prognosis was good. She was discharged on postoperative day 18 and did not experience any end leak for a year. Thoracic endovascular aortic repair in the ascending aorta is a minimally invasive procedure that may be useful for high-risk patients.