To evaluate a comparison for endovascular repair (EVAR) versus open repair (OR) for the treatment of abdominal aortic aneurysm (AAA). Data of all patients with infrarenal AAA treated electively, both with OR (107 cases) and EVAR (24 cases), at our institute between January 1999 and March 2004 were retrospectively reviewed. No difference was found between the 2 groups for sex, age, and AAA size. Cases of chronic obstructive pulmonary disease (20.8% vs 6.5%, p<0.04) and frequencies of laparotomy (25% vs 2.8%, p<0.001) were significantly more in the EVAR group than the OR group. In the initial results, deployment of the stent grafts was successful in all cases and complete thrombosis of the aneurysm was achieved in 21 cases (87.5%). One graft occlusion and a wound infection occurred in the EVAR group. OR was successfully performed in all cases. These were 6 cases of paralytic ileus, 1 of re-operation for hemorrhage, 1 of respiratory failure, and 1 of ischemic colitis in the OR group. One hospital death occurred in each group. Mean blood transfusion (0ml vs 238±345ml) and operation time (131±53min vs 250±76min) were significantly less in the EVAR group than the OR group. In the long term results, the cumulative survival rate was 88.0±6.5% at 1 and 2 years, 80.6±9.2% at 3 years in the EVAR group; 99.0±0.9% at 1 year, 94.1±2.6% at 2 years, 87.7±3.9% at 3 years in the OR group, with no difference between the 2 groups regarding survival rate. Four new endoleak and 3 graft infections were encountered in the EVAR group. Freedom from stent graft-related complications was 81.3±8.5% at 1 year, 61.4±11.9% at 2 years, 47.8±12.6% at 3 years in the EVAR group, but 100% at 1, 2 and 3 years in the OR group. Freedom from procedure-related complications in the EVAR group was significantly lower than that in OR group. In the long term results, EVAR was associated with more procedure-related complications. This finding may justify reappraisal of currently accepted EVAR for AAA management strategies.

A 68-year-old woman with a diagnosis of atrial septal defect (ASD) presented with dyspnea. Chest radiography demonstrated cardiomegaly and infiltration in both lungs, suggestive of cardiac decompensation due to ASD. Detailed evaluation with transthoracic echocardiography revealed a mobile tumor on the aortic valve. Intraoperatively, tumors were identified on all aortic cusps. Preservation of the aortic valve was difficult. We therefore performed aortic valve replacement and patch closure of the ASD. The existing literature suggests that mobile papillary fibroelastoma should be excised irrespective of size, to prevent the risk of embolism. Excision of the tumor alone is usually sufficient. However, the present case showed clustered tumors on the aortic valve, so preservation of the cusps could not be achieved in this case.

In coronary artery bypass grafting (CABG), a portable suction unit was used in the superior mediastinum to evaluate whether it is effective in decreasing the amount of mediastinal hematoma and the incidence of hematoma-related postoperative complications. Out of 179 consecutive patients who underwent CABG at the Matsuyama Red Cross Hospital, in 97 patients (Group 1), two drainage tubes were placed as usual in the inferior mediastinum, while in 82 patients (Group 2), a small drainage tube of the portable suction unit was additionally placed in the superior mediastinum. The total amount of postoperative drainage in Group 2 was larger than that in Group 1 but there was no statistically significant difference. The postoperative mediastinothoracic ratio expressed in comparison with the preoperative value was 134±22% in Group 1 and 123±15% in Group 2 on the first postoperative day (POD), and 133±20% and 122±14%, respectively on the seventh POD (p<0.001). Regarding postoperative complications, there were two cases of mediastinitis and five cases of late cardiac tamponade in Group 1 but none in Group 2. The difference in the incidence of these complications between the two groups was statistically significant (p<0.02). We conclude that the portable suction unit effectively decreased the amount of mediastinal hematomas and the incidence of mediastinitis and cardiac tamponade following CABG.

Background. In recent years, aortic valve stenosis in the elderly is increasing. To determine the treatment of aortic stenosis in the elderly, we retrospectively evaluated the patients who underwent aortic valve replacement. Method. Between 1992 and 1997, 22 patients older than 70 years underwent aortic valve replacement for aortic stenosis. There were 15 women and 7 men, with a mean age of 73.0±4.0 years. Seven patients underwent concomitant procedures: 5 patients required coronary artery bypass grafts, 1 mitral valve plasty and 1 aortic root plasty. SJM prosthetic valves of sizes 19mm, 21mm and 23mm were used in 11, 8 and 3 patients respectively. Nobody underwent aortic annuloenlargement. Three patients underwent supraannular aortic valve replacement. All patients had New York Heart Association (NYHA) class III or IV symptoms. Results. There was no operative or hospital death. Five patients had atrial fibrillation after operation. There was only one late death, due to a traffic accident, and there was no significant complication during the follow up period. Of the 22, 21 patients improved to NYHA class I or II after operation. There were significant differences between patients who were 70 years or more and those under 70. BSA in these two groups were 1.495 and 1.615m²; p<0.01, and the amounts of blood transfusion were 918±702 and 408±428ml, p<0.01. However, there was no significant difference between these two groups in terms of ACC time (56.8 and 59.9min), CPB time (88.7 and 92.1min), ICU stay (4.0 and 3.3 days) and hospital stay (29.5 and 25.5 days). Conclusion. The results of aortic valve replacement in patients aged 70 years or more, were satisfactory. If the aortic annulus being small, a small mechanical valve prosthesis is suitable, and supraannular positioning yielded good results.

Background: Operative blood loss during open-heart surgery has been decreasing recently. We have stopped predonated autologous blood transfusions to reduce hospital stay and cost. Material and methods: In 70 consecutive elective open-heart cases, we used intraoperative hemodilutional autologous transfusions and intraoperative autotransfusions to avoid homologous blood transfusion. Predonated autologous blood transfusion was not used. All patients received an infusion of high-dose tranexamic acid prior to and after cardiopulmonary bypass (CPB). Results: Homologous blood transfusion was not required in 77.1% of patients who underwent open-heart surgery. When further classified, 84.5% of patients who underwent primary open-heart surgery, 41.7% of patients who underwent a reoperation, and 33.3% of patients who were preoperatively anemic did not require homologous blood transfusion. In patients who undergo reoperation and who are preoperatively anemic, the rate of homologous blood transfusion is high. Therefore, during the reoperation, intraoperative autologous blood transfusion should be used before starting CPB, and iron should be given to anemic patients prior to reoperation. Conclusion: Our strategy of blood conservation consists of intraoperative hemodilutional autologous transfusion, intraoperative autotransfusion, infusion of high-dose tranexamic acid prior to and after CPB and, avoiding predonated autologous blood transfusion. Based on our experience, predonated autologous blood transfusion is usually unnecessary for cases who undergo surgery for the first time and are not anemic. Predonated autologous blood transfusion should be reserved only for high risk patients with anemia and reoperation cases. For further blood conservation, we need to study the safety limits of non-transfusion in open-heart surgery.

A 69-year-old woman was given a diagnosis of moderate aortic stenosis (AS) associated with congenital bicuspid valve in 2011. In 2014, surgery was indicated because of progression of AS and dilatation of the sinus of Valsalva and ascending aorta. Preoperative contrast-enhanced CT and echocardiography showed the saccular space (2×2 cm) located at the left ventricular outflow tract just below the aortic annulus. At surgery, the saccular aneurysm was located just below the aortic annulus of the noncoronary cusp. We resected the aneurysm and closed the orifice with interrupted sutures from the inside of the LV and the outside. Aortic subannular left ventricular aneurysm is a very rare malformation with only 25 reported cases and its natural course is largely unknown. Rupture of aneurysms, infection, thrombus formation, arrhythmia, and heart failure etc. has been reported as complications. We reported a case of aortic subannular left ventricular aneurysm with bicuspid aortic valve stenosis with a literature review.