The patient was placed on anticoagulant therapy with warfarin after aortic valve replacement. Although it was initially possible to stabilize the international normalized ratio (INR=2.90), the prothrombin time was significantly prolonged (INR=31.39) after intravenous infusion of miconazole for 9 days at a dose of 200mg/day to treat lichen planus. Warfarin therapy was discontinued until the INR decreased to within the acceptable range, which required 14 days, and then warfarin was resumed. A stable INR value was achieved approximately 50 days later. Treatment with miconazole results in significant promotion of the anticoagulant effect of warfarin and a long period was required before normalization of the INR could be achieved in this patient. Accordingly, miconazole therapy should only be indicated in patients receiving treatment with warfarin when administration is essential. Caution should be employed when using this drug in combination with warfarin, and careful monitoring of the bleeding time is necessary.

Cardiac surgery using heparin was performed in a patient in whom AST and ALT had been increased due to continuous drip infusion of heparin sodium. Here, we report postoperative changes in AST and ALT in the patient. The patient was a 59-year-old man with a past medical history of left internal carotid artery constriction and right cerebral infarction. Because of his previous medical history, continuous drip infusion of heparin was initiated upon discontinuation of preoperative antithrombotic agents. AST and ALT increased, but returned to normal levels when heparin was discontinued. Heparin was used to avoid aggravation of the symptoms, and bypass of 3 branches was performed with pulsation. Postoperative respiration and circulatory dynamics were stable, and the courses of AST and ALT were similar to those after general surgery, without abnormally high levels. Although the cause of heparin-induced increases in AST and ALT is unknown, the absence of postoperative increases may have been due to transient use at a high dose and neutralization by protamine.

This report documents two rare cases we encountered in which paraplegia developed as a postoperative complication following elective operations for an unruptured abdominal aortic aneurysm (AAA). Case1: A 80-year-old man receiving dialysis therapy was found to have 75% occlusion of the left anterior descending branch by preoperative coronary arteriography but, as the cardiac function was satisfactory, replacement of the aneurysm with a tube graft was performed through a retroperitoneal approach for treatment of the AAA. Symptoms of paraplegia developed immediately following the operation and a diagnosis of anterior spinal artery syndrome was made based on the postoperative MRI findings. Case 2: A 62-year-old man underwent a coronary artery bypass operation (3 sites in 2 branches) using the bilateral internal thoracic artery with the breast beating prior to elective surgery for an unruptured AAA, and subsequently underwent an aneurysm replacement with a Y-graft through a midline incision. At the same time, the celiac artery and superior mesenteric artery cure found to be stenotic at their roots were also bypassed via vascular prostheses to the right arm of the Y-graft. Paraplegia was evident after emerging from anesthesia. In both cases, there were complicating coronary arterial lesions and significant atherosclerotic changes in the thoracic descending aorta. A CT scan demonstrated an artery coursing from the iliolumbar artery, a branch of the internal iliac artery, to the spinal cord in Case 2, indicating that intraoperative clamping of the internal iliac artery might have caused the paraplegia. In patients with marked arteriosclerosis of the thoracic descending aorta, there is the possibility of occlusion of spinal root arteries originating from that affected region. Blood supply to the spinal cord via a collateral vascular route is important in such cases.

We report surgically treated case of tricuspid valve endocarditis in a non-drug addict. A 35-year-old man with no history of cardiac disease was admitted to our institution for persistent fever. His blood culture was positive for methicillin-sensitive Staphylococcus aureus (MSSA). Echocardiography showed friable vegetations attached to the tricuspid valve with moderate tricuspid regurgitation. No other valves were affected. Chest computed tomography revealed multiple septic pulmonary emboli in both lungs. The infection was uncontrollable, so despite 6 weeks' of appropriate intravenous antibiotics therapy, he required surgery. Infected lesions had extended to parts of the septal leaflet and the posterior leaflet of the tricuspid valve. Valve repair with the resection-suture technique was performed. Half of the septal leaflet and a part of the posterior leaflet were excised with the vegetations, and the remaining septal leaflet was sutured to the posterior leaflet after annular plication without implanting an artificial ring. The postoperative course was uneventful, without further tricuspid regurgitation or stenosis. He was discharged after additional antibiotic administration for 4 weeks postoperatively, and he has remained free from endocarditis for over 1 year.

A 64-year-old woman, with no findings of Marfan's syndrome, was addmited with dyspnea on exsertion. She had a family history of thoracic aortic disease. Moderate aortic regurgitation was diagnosed due to mild annulo-aortic ectasia (AAE) limited in the sinuses of Valsalva with moderately impaired left ventricular function. The aortography showed that the diameters of the ascending aorta, the aortic root, and the aortic ring were 38mm, 48mm, and 23.5mm. We planned aortic valve replacement, as the AAE was small and was limited in the sinuses of Valsalva, but she sufferd from A type acute dissection combined with AAE, while waiting for operation. As she fell into deep shock and cardiac arrest caused by cardiac tamponade, an emergency operation was done. The intimal tear was found in the ascending aorta, but no organic change was seen on the three cusps of the aortic valve. Total aortic root replacement with Cabrol's procedure was performed successfully. We recommend that AR with AAE should be performed with aortic root reconstruction in such cases because AAE is often combined with aortic root dissection, even if the aortic root size is small.

From July 1984 to June 1998, 159 patients with infrarenal abdominal aortic aneurysms (AAA) were surgically treated in our hospital by the extended retroperitoneal (ERP) approach described by Williams et al. There were 132 men and 27 women, with a mean age of 69.3 years. Of the 159 patients, 82 (52%) had hypertension, 62 (39%) had coronary artery disease, of which 20 cases had previously received coronary artery bypass grafting, 17 (11%) had diabetes, 16 (10%) had thoracic aortic disease, 15 (9.4%) had cerebrovascular disease, and 14 (8.8%) had chronic renal dysfunction, including 6 cases on hemodialysis. Among these patients treated with this approach, 67 cases underwent tube grafting and 92 received Y-grafting. Patent inferior mesenteric arteries were ligated in all cases except one. Postoperative morbidity was observed in 54 cases (34%); lower extremity ischemia including microembolism or acute graft occlusion in 13, abdominal complication including paralytic ileus, liver dysfunction, or gastrointestinal hemorrhage in 11, wound complication in 9, pulmonary in 7, cardiac in 6, cerebral in 4, and the others in 4. No patient suffered ischemic colitis. There was hospital mortality in 4 cases (2.5%). Two patients died because of myonephropathic metabolic syndrome on second postoperative day. Two patients with combinations of several co-existing diseases died because of respiratory failure or multi-organ failure on the 48th and 141st postoperative day. Oral feeding was restarted at a mean of 2.7 days after the operation, and 64% of the cases did not require blood products. The mean postoperative hospital stay of survivors was 16.9 days (range, 7-63 days). Based on our clinical experience, we believe that the ERP approach is a safe and useful procedure for elective surgery for AAA to enable fast recovery and short hospital stay, especially in older and high-risk patients.

A 59-year-old man, who had received graft replacement for the “inflammatory” abdominal aortic aneurysm two years previously was admitted to our hospital because of preshock caused by intermittent intestinal hemorrhage. Gastrointestinal endoscopy revealed an ulcer at the 3rd portion of the duodenum. As aortoenteric fistula was diagnosed and he underwent an emergency operation. After initial axillo-bifemoral bypass grafting, the aortic graft was removed and the aortic stump was closed directly. The duodenal rent was closed by Albert-Lembert suture, He survived the operation and was discharged. We suggest that extra-anatomic bypass is safer than in situ graft replacement in patients with secondary aortoenteric fistula after operation for “inflammatory” abdominal aortic aneurysm, because adjacent organs adhere firmly to the proximal suture line in such cases.