A 73-year-old man who underwent redo aortic valve replacement due to dysfunction of tissue heart valve developed hypoxemia with bilateral infiltrates on frontal chest radiograph and hypotension shortly after his operation. Due to the presence of progressive hypotension and hypoxemia, we inserted an intra-aortic balloon pump and, furthermore, provided percutaneous cardiopulmonary support. We ruled out cardiogenic pulmonary edema based on information from various examinations, including echocardiography, and subsequently diagnosed possible transfusion-related acute lung injury (possible TRALI). The patient was treated by mechanical ventilation and circulatory support under close supervision, showing a trend of improvement from postoperative day 2 and discontinuing mechanical ventilation on postoperative day 11. The patient made an uneventful recovery and was discharged on postoperative day 50. Cardiac surgery patients are at particular risk for TRALI, so physicians should consider TRALI whenever a patient develops hypoxemia during or shortly after transfusion. Rapid diagnosis and appropriate treatment of TRALI are especially important in cardiac surgery patients.

We clinically reviewed 4 cases of redo cardiac surgery after previous CABG with functioning internal thoracic artery grafts. The patients consisted of 1 man and 3 women (76.8±8.3 years old). Internal thoracic artery (ITA) grafts were used in all patients. Furthermore, 2 mitral valve replacements, 1 aortic valve replacement and 1 replacement of the ascending aorta were performed as redo cardiac surgery. The heart was approached via a anterolateral right thoracotomy in 3 cases. Femoral artery cannulation was used for cardiopulmonary bypass, and the right superior pulmonary vein was exposed to vent the left ventricle in all patients. The functioning ITA grafts were not dissected and were clamped in all cases of the 4 patients, 2 underwent cardioplegic arrest under moderate hypothermia. We could not achieve cardioplegic arrest in 1 patient, and therefore we also performed deep hypothermic fibrillatory arrest. Another patient underwent deep hypothermic circulatory arrest. Serum CK-MB values were elevated in all cases (111.7±89.0 IU/l). However, these elevations did not correlate with intraoperative arrest duration or type of operative procedure performed. Operative mortality was 0%, and all patients were discharged with out any evidence of sequelae. Hypothermic fibrillatory arrest had an effective additional cardioprotective effect for incomplete cardioplegia in these 4 cases. Functioning ITA grafting was not necessary in dissection and clamping for cardioprotection. An anterolateral right thoracotomy provided a safe approach to the heart, avoiding functioning ITA graft injury.

Renal function, hemolysis and hematologic parameters after transfusion using a cell-separation (CS) device were retrospectively evaluated during abdominal aortic aneurysm repair. Fifty-eight patients were divided into two groups, that is, the CS group (n=39) who received autologous retransfusion using the CS device and the non-CS group (n=19) who were operated before 1989, when we started to use CS device in our operating theater. Hematologic parameters and levels of GOT, GPT, LDH, BUN and creatinine were assessed before and 1, 2, 3, 4 and 7 days after the operation. Mean transfused homologous blood was 1.3±1.8 units in the CS groups and 4.9±3.1 units in the non-CS group (p<0.05). Peak levels of LDH and GPT were significantly higher in the CS group than the non-CS group (p<0.05) after the operation (GOT, CS group: 60.4±29.1IU/l vs non-CS group: 34.8±12.3IU/l, LDH, CS group: 643±324IU/l vs non-CS group: 446±108IU/l). There was no significant difference in the levels of BUN and creatinine levels between the two groups. Hemoglobin levels decreased gradually after the operation in CS group patients who did not receive a homologous blood transfusion. These data suggested that mild hemolysis occurred after retransfusion of autologous blood, but that the hemolysis due to the CS device had no effect on the renal function of the patients.

A 37-year-old man who fell from a truck had chest pain and we diagnosed blunt chest trauma. A chest computed-tomography displayed a traumatic cardiac tamponade. The patient was transported to our hospital for emergency surgery. After median sternotomy, there was no injury of heart and great vessels in the pericardial sac but a rupture of the pericardium. Bleeding and hematoma were found in the anterior mediastinal space. The cardiac tamponade was caused by the bleeding from anterior mediastinal space. Usually, blunt cardiac tamponade was caused by the bleeding from cardiovascular organs, however, we encountered a very rare cardiac tamponade due to the bleeding from the anterior mediastinal space.

We successfully performed one-stage definitive repair for 3 infants weighing 4.2, 6.1 and 5.2kg with complex coarctation without homologous blood transfusion. The priming volume of the bypass circuits was 195ml, and their lower hematocrit values during cardiopulmonary bypass were 15, 16 and 13%, respectively. In order to diminish the aortic cross clamp time, the aortic arch was repaired with the heart beating, using isolated cerebral and myocardial perfusion methods. The base excess in each patient decreased to -9.4, -8.0 and -4.9mEq/l during the rewarming phase, however, their postoperative hemodynamic and respiratory conditions were satisfactory. They have grown without any sequelae for at least 2 months.

Postoperative hemodynamic performance after aortic valvular replacement using the Carpentier-Edwards pericardial valve of 19-mm (group A, 10 cases) or 21-mm (group B, 5 cases) was compared with that using the 19-mm St. Jude Medical hemodynamic plus (group C, 13 cases). We evaluated hemodynamic performance by measuring the peak pressure gradient via aortic valve using Doppler echocardiography. Preoperative peak pressure gradients were 80±18.5mmHg in A, 81.6±17.5mmHg in B and 87±36.3mmHg in C. Valvular replacement obviously improved the hemodynamic performance by decreasing the postoperative peak pressure gradient to 24.2±7.3mmHg in A, 14.2±6.2mmHg in B and 26.7±19.0mmHg in C, though no statistically significant difference was present among the three groups. We also applied the dobutamine stress test for 5 cases in group A, 4 in B and 4 in C, who could receive the additional examination. The amount of dobutamine given was 8.2±1.6μg/kg/min in A, 7.2±2.0μg/kg/min in B and 7.7±1.5μg/kg/min in C. Before administration of dobutamine, the peak pressure gradient was 18.1±4.3mmHg in A, 14.2±6.2mmHg in B and 20.9±5.7mmHg in C. Although administration of dobutamine increased the peak pressure gradient to 41.1±15.0mmHg in A, 32.2±9.8mmHg in B and 46.8±14.4mmHg in C, there was no significant difference among the groups. The Carpentier-Edwards pericardial valve of 19-mm and 21-mm thus provided satisfactory valvular function compared with the 19-mm St. Jude Medical in terms of hemodynamics. Therefore, it is concluded that the Carpentier-Edward pericardial valve is a reliable alternative for elderly patients.

The total arch replacement protocol using the open-style stent-graft placement is frequently performed for type A aortic dissection to obtain complete closure of entry sites. However the open-style stent-graft placement must be carefully planned when the entry site is in the descending aorta and extends beyond the level of the tracheal bifurcation, because spinal cord ischemia can be caused due to occlusion of lower thoracic intercostal arteries. We report an alternative to total arch replacement for type A aortic dissection with entry in the ascending aorta and aneurysmal re-entry in the descending aorta, beyond the level of the tracheal bifurcation. We inserted a guide-wire from the dissected area of the aortic arch towards the normal region beyond the re-entry in the descending aorta, with confirmation by direct ultrasonography and already incised half, introduced a graft into the descending aorta using the wire as a guide and performed anastomosis at the level of the transverse aortotomy in the inclusion method. This operation has the advantage of preventing spinal cord ischemia because the re-entry site in the descending aorta is confirmed by direct ultrasonography and the distal anastomosis does not reach the lower thoracic intercostal arteries. In this method, by which the prosthesis is introduced through the descending aorta and anastomosed in the inclusion method, is not needed troublesome treatment in the descending aorta and less invasive than conventional single-stage total arch replacement and applicable with the great safe for aortic dissection that had shown difficulty in application of open-style stent-graft placement.

A 63-year-old woman was admitted to our hospital for combined valvular disease with tricuspid valve stenosis. Aortic and mitral valves were replaced with artificial valves and tricuspid valve were replaced with a biological valve. We chose artificial valves for the aortic and mitral valves because the patient was younger than 70, while a biological valve was used for the tricuspid valve to avoid possible thromboembolism. The postoperative course was excellent. We propose that it is better to use a biological valve for the tricuspid valve, even if artificial valves are used in other sites.

We describe a case of an intracardiac foreign body that was treated by surgery. A 27-year-old man sustained a neck injury by a nail fired from a pneumatic nail gun, and was admitted to a hospital. Chest radiography did not show any abnormality, and his injury healed after 1week. A radiography performed during a routine medical checkup after 2 months indicated that a nail was located within the heart. He was subsequently admitted to our hospital for further examinations. Chest computed tomography (CT) revealed the presence of a nail-like foreign body in the right ventricle. We diagnosed the patient with an intracardiac foreign body that was related to the injury sustained 2 months previously, although the underlying mechanism was unknown. He underwent emergency surgery, and the foreign body was removed under cardiopulmonary bypass without any complications. When a rigid substance impacts the body at high speeds, we should consider that some fragments could remain embedded in the body. CT scans are very useful for the diagnosis and identification of foreign bodies.

We describe a case of ruptured coronary artery aneurysm with a coronary artery to a pulmonary artery fistula. An 89-year-old woman with general fatigue and dyspnea was admitted. At the visit she went into shock and was restored by rehydration therapy. Enhanced computed tomography shows a coronary aneurysm (maximum diameter of 50 mm) at the left side of pulmonary artery and mild pericardial effusions. She was scheduled for an emergency operation due to the ruptured coronary artery aneurysm with a coronary artery to pulmonary artery fistula. We performed aneurysmectomy and ligation of the coronary artery to the pulmonary artery fistula under cardiopulmonary bypass. We also reviewed 23 cases of ruptured coronary artery aneurysm with coronary artery extending to a pulmonary artery fistula in Japan. The disease is a rare clinical state and regarded as an indication for emergency surgery.