We assessed the change in intraoperative cerebral oxygen metabolism during coronary artery bypass grafting (CABG) in patients with cerebrovascular desease (CVD) identified by preoperative computed tomography or magnetic resonance imaging. The study population consisted of 36 patients who underwent consecutive CABG and were divided into two groups on the basis of preoperative CVD. With near-infrared spectroscopy, the change in oxygenated hemoglobin/total hemoglobin ratio (%Oxy-Hb), which was regarded as regional tissue oxygenation, was obtained. In addition, jugular venous bulb oxygen saturation (SjO₂) was measured simultaneously. Moreover, the influence of intraoperative parameters on cerebral oxygenation was assessed by regression analysis. Thirteen patients (36%) were given a diagnosis of CVD preoperatively (group A) and were compared with the remaining 23 patients as controls (group B). All of group A were asymptomatic cerebral infarction. The average %Oxy-Hb was 51.2±4.1% in group A and 62.0±12.1% in group B (p=0.04), and SjO₂ was 63.5±8.6%in group A and 68.1±7.7% in group B (p=0.12). In serial changes, %Oxy-Hb during the late phase of cardiopulmonary bypass (CPB) and SjO₂ during the early phase of CPB were significantly lower in group A. The positive correlation between perfusion pressure and SjO₂ was demonstrated in groupA (r=0.699, p<0.0001) while no correlation was observed in group B. It is concluded that patiens with silent cerebral infarctions had poorer intraoperative cerebral oxygen metabolism during CABG. It is necessary to keep a higher perfusion pressure in these patients during CPB because cerebral autoregulation may be impaired.

A 60-year-old man with impending rupture of abdominal aortic aneurysm was transferred to our hospital. The patient entered a state of shock because of rupture during a CT scan examination. Emergency in site reconstruction with a dacron Y-graft was performed. There was massive intraperitoneal bleeding but no apparent abscess formation around the aneurysm. No drain was placed. A subcutaneous abscess that developed postoperatively was cured by open drainage and local antibiotic administration. Culture from both the aortic wall and the subcutaneous abscess revealed Salmonella infection. After subsequent intravenous antibiotic therapy for 45 days, the patient was discharged without any evidence of remaining infection.

A free-floating ball thrombus in the left atrium is a rare occurrence. Few patients who developed a ball thrombus after mitral valve replacement have been reported. Our patient was a 58-year-old man who had undergone mitral valve replacement in 1981. Since bleeding gastric cancer had been diagnosed anticoagulant therapy had been 4 days before admission. On admission, echocardiography revealed a large thrombus in the left appendage. First, he underwent total gastrectomy for gastric cancer. After the operation, he developed aspiration pneumonia, and was intubated. We observed that a large thrombus had moved from the left appendage to the left atrium. Emergency operation was successfull.

Postsplenectomy patients are susceptible to severe infections due to encapsulated bacteria such as Streptococcus pneumoniae and Haemophilus influenzae and this condition is widely known as Overwhelming Postsplenectomy Infection (OPSI). OPSI is relatively rare in conditions with rapid progression and high mortality rates. There are very few reports of infective endocarditis from OPSI. A 40-year-old man who underwent splenectomy 20 years before was transported to the emergency room. He had severe heart failure and multiple cerebral embolisms. The echocardiography showed vegetation on the aortic valve and severe regurgitation due to perforation of the non-coronary cusp. We performed aortic valve replacement on an emergent basis. In infected patients after splenectomy, early diagnosis and prompt treatment are desired because of the possibility of rapid progression of sepsis in encapsulated bacteria and poor prognosis.

A 59-year-old man was admitted to our hospital with severe mitral incompetence. Mitral valve repair, tricuspid annuloplasty and the Maze procedure were performed. After weaning from cardiopulmonary bypass, his systolic blood pressure (SBP) dropped to 40 mmHg. Immediate administration of catecholamines markedly increased SBP but his continuing low blood pressure required additional treatment with vasopressin and hydrocortisone. On postoperative day 12 in the general ward, he suddenly lapsed into an intractable hypoglycemic coma. Endocrine function tests revealed adrenocorticotropic hormone deficiency. Since the time of writing has been doing well with 20 mg of hydrocortisone.