A 62-year-old man with ischemic heart disease suffered from a poststernotomy wound trouble after coronary artery bypass grafting. We performed vacuum-assisted closure (VAC), minimally invasive treatment for difficult wounds, because he had severe heart failure and depressive disorder. This therapy assists in wound healing by applying localized negative pressure to the surface of the wound, and its effectiveness for poststernotomy mediastinitis has already been reported in several countries. It is, however, very difficult for us to obtain a manufactured device, the V. A. C.® system (KCI, San Antonio, Texas), which is not available in Japan yet. Therefore, we had to make a self-made system which combined RetractorPad® polyvinyl alcohol hydrofoam (Mondomed NV, Harmont, Belgium) and J-VAC® closed wound drainage system (Johnson & Johnson, Tokyo, Japan). This self-made system, without a vacuum pump machine, was small and light enough to be carried by the patient even in the early postoperative period. In this case, VAC resulted in complete healing of the wound in about 3 weeks with little pain, stress, effort and time, and with reasonable cost in comparison to conventional treatment. This is a useful and hopeful option in the treatment of not only sternum dehiscence but also mediastinitis after cardiac surgery, especially for high-risk patients.

Sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of its origin among in the left sinus are scarce. This report describes a 38-year-old man with an isolated extracardiac unruptured aneurysm of the left sinus of Valsalva. The patient presented with chest pain due to compression of the main trunk of the left coronary artery by the aneurysm. The aneurysm was resected, and the aortic root was reconstructed using the Bentall procedure. Concomitantly, coronary artery bypass grafting (LITA-LAD) was added. Postoperative native coronary flow was fully restored, and his anginal symptoms disappeared despite occlusion of the additional LITA-LAD anastomosis. This type of case would be considered to not require concomitant CABG, since the cause of the coronary artery stricture was compression by an aneurysm in the left sinus of Valsalva.

We report a rare case of acute type A aortic dissection in a patient with rheumatoid arthritis (RA) being treated with tacrolimus. The patient was a 77-year-old woman, who had received implantation of 6 artificial joints and was treated with 3 mg/day of tacrolimus and 10 mg/day of prednisolone. Tacrolimus, one of the immunosuppressive drugs for severe RA, had been applied to her to reduce the amount of prednisolone. An emergency surgery was performed successfully and 20 mg/day of prednisolone was administered for RA instead of her preoperative regimen. Such simplification of RA medication was actually useful to us for managing her difficult postoperative care. Respiratory insufficiency with persistent preural effusion was regulated by non-invasive positive pressure ventilation (NPPV) and pleural drainage. Disuse syndrome was treated with enteral nutrition and rehabilitation. Such care was also useful for her recovery.

A 75-year-oldm an with an aortocaval fistula as a complication of aortoiliac aneurysm visited our hospital. He complained of shortness of breath and melena. Physical examination revealed a pulsating abdominal mass with thrill and continuous murmur. Chest X ray showed cardiomegaly with pulmonary congestion. CT scan showed infrarenal aortoiliac aneurysm and echo Doppler scan revealed aortocaval communication at the inferior caval bifurcation. Aortoiliac bifurcated graft and patch reconstruction of IVC were performed. The postoperative course was uneventful, and his congestive heart failure and hepatorenal dysfunction immediately improved.