A 74-year-old man with very severe chronic obstructive pulmonary disease (COPD) was scheduled for elective total arch replacement for a distal arch saccular aneurysm. Postoperative respiratory failure was anticipated because of a marked reduction in forced expiratory volume in one second (FEV_1.0 - less than 0.5l). Through median sternotomy, total arch replacement using selective cerebral perfusion was completed uneventfully. Postoperative respiratory condition was stable. Therefore, the patient was extubated on postoperative day 2 (POD2). However, as the respiratory condition started getting worse, respiratory therapy external (RTX) was introduced to assist ventilation. Additionally, non-invasive positive pressure ventilation (NPPV) with BiPAP was used on POD3 and management with both RTX and NPPV was continued during the remainder of the intensive care unit stay. As a result, we were able to avoid re-intubation. In conclusion, assisted ventilation supplemented by RTX and NPPV was useful for the prevention of postoperative respiratory failure in a patient with very severe COPD undergoing total arch replacement.

We describe the case of a 59-year-old man who developed constrictive epicarditis 2 months after an episode of acute pericarditis. Magnetic resonance imaging demonstrated parietal pericarditis and epicarditis. Through a median sternotomy, a markedly thickened parietal epicardium was noted which was removed where possible. After this procedure, however, no improvement of the hemodynamic parameters was observed. We attempted removal of the epicardium, but the procedure had to be abandoned due to myocardial injuries and bleeding. Multiple longitudinal and transverse incisions were carefully performed on the thickened epicardium, following which relief of constriction along with a remarkable improvement of the hemodynamic status was achived. Although the dip and plateau pattern was persisted, cardiac index increased from 2.2 to 2.9 l/min/m² and the pulmonary capillary wedge pressure decreased from 20 to 13 mmHg. Patient's postoperative course was uneventful and he was discharged on postoperative day 22.

Pulmonary artery (PA) aneurysm is rare, but its true incidence is unclear, because most cases remain asymptomatic. The need for surgical treatment is controversial. We report two cases of surgical treatment of PA aneurysm associated with pulmonary valve (PV) disease in adults. Case1: A 54-year-old woman. She underwent pulmonary valvotomy for pulmonary stenosis (PS) at age 22. She had suffered from palpitations and dyspnea on effort recently. Then progressive changes of pulmonary stenosis-regurgitation (PSR) occurred. After further examinations, she was diagnosed as having PA aneurysm and right ventricular dysfunction with PSR, tricuspid regurgitation and paroxysmal atrial fibrillation. We performed PV replacement, PA aneurysmo-plasty, tricuspid annuloplasty, cryo-MAZE procedure. Case2: A 70-year-old man sufferd recently from dyspnea on effort. The dilatation of the pulmonary artery was pointed out on chest X-ray. PA aneurysm and PS with ventricular arrhythmia were diagnosed. We performed PV commissurotomy and PA aneurysmo-plasty. There were no significant findings of high PA pressure in either case. PA with pulmonary valve disease in the presence of low pulmonary pressure have low risk of rupture and dissection. Surgical treatments are recommended when right ventricular dysfunction or ventricular arrhythmia secondary to pulmonary valve disease is present.

A 58-year old man without Marfan syndrome was referred to our hospital for congestive heart failure due to severe mitral regurgitation. He had undergone sternal turnover with a rectus muscular pedicle for pectus excavatum 36 years previously. We were able to perform mitral valve repair via median sternotomy using a usual sternal retractor. There was no adhesion in the pericardium and the exposure of the mitral valve was excellent. We closed the chest in ordinary fashion without any problems in the fixation of the sternum or costal cartilage. There were no complications such as flail chest or respiratory failure.

A 62-year-old woman was admitted to a regional hospital for acute myocardial infarction. Emergency coronary angiography revealed occlusion of the first diagonal branch, and transesophageal echocardiography showed severe mitral regurgitation due to anterior papillary muscle rupture. She was transferred to our hospital in a state of cardiogenic shock despite the use of high-dose catecholamine and intra-aortic balloon pumping. We immediately performed mitral valve replacement. The patient's postoperative course was uneventful and she was ambulatory when transferred to another hospital on foot on postoperative day 19. Physicians should be aware that fatal anterior papillary muscle rupture may be caused by isolated occlusion of the diagonal branch.

The patient was a 50-year-old man who had undergone ascending aortic replacement and coronary artery bypass grafting at another hospital for acute type A aortic dissection 4 years before. He was diagnosed with hemolytic anemia 1 year after surgery for his progressive anemia and high serum lactate dehydrogenase level. He was referred to our hospital because frequent transfusion was required. A computed tomography showed severe kinking of the graft (110°), which we considered to be the cause of hemolysis. Peak pressure gradient was 60 mmHg. To remove the cause of hemolysis and to precipitate thrombosis of the residual false lumen, we performed re-ascending aortic replacement and total arch replacement with a frozen elephant trunk. The postoperative course was uneventful and hemolysis resolved soon after the operation. Surgeons should be aware that severe kinking of a Dacron graft can be a cause of hemolysis.