Objective : The ascending aortic cannulation (Ao-C) is the routine procedure for cardiopulmonary bypass (CPB) in our hospital. However, for patients with diseased ascending aorta, such as severely calcified aorta, dissected or aneurysmal aorta, we used brachiocephalic artery (BCA) cannulation. The effectiveness and simplicity of BCA cannulation was evaluated. Methods : For patients with diseased ascending aorta, BCA was cannulated when the diameter of BCA is larger than 10 mm and is free from calcification, since January 2013. There were 62 patients who underwent aortic valve replacement (AVR) for aortic valve stenosis and BCA cannulation was applied for 11 patients. Standard Ao-C was used for remaining 51 patients. There were 44 patients with dissected or aneurysmal ascending aorta and BCA cannulation was applied for 7 patients, axillary artery perfusion was used for 15 patients and standard Ao-C was used for 22 patients. Consciousness level at the time of awaking from general anesthesia and any complication related with BCA cannulation was evaluated for the effectiveness. Simplicity was evaluated by the time required to establish CPB after skin incision. Results : In AVR patients, there was 1 patient with delayed consciousness level recovery with BCA cannulation and this patient was found to have cerebral infarction by CT. Intraoperative aortic dissection, probably due to BCA cannulation was observed in 1 patient, very old fragile and long period steroid user. In diseased ascending aorta patients, no patient suffered neurological accident nor any complication due to cannulation. In AVR patients, the time required to establish CPB after skin incision was 51+/-9 min in BCA cannulation and 47+/-10 min in Ao-C patients (p=0.34). In diseased ascending aorta patients, the time required to establish CPB after skin incision was 49+/-49 min in BCA cannulation and 51+/-16 min (p=0.82). Conclusion : BCA cannulation is a very simple and safe technique to establish CPB for patients with diseased ascending aorta. However great care should be taken, and BCA cannulation should be avoided for the long term steroid users or patients with connective tissue disease.

We performed transatrial repair of postinfarction posterior ventricular septal defect (VSP) in a 69-year-old man who was transferred to our hospital with a diagnosis of posterior acute myocardial infarction and VSP. Coronary angiogram revealed total occlusion of the right coronary artery at #3 and 75% stenosis of the left circumflex artery at #13. UCG revealed the ventricular septal defect on the posterior ventricular septum without LV wall motion abnormality. Surgical repair was planned around 3-4 weeks later because his hemodynamic state was stable without inotropes nor IABP support upon arrival. Under general anesthesia, standard median sternotomy was performed and cardiopulmonary bypass was established with the ascending aorta and bicaval cannulation. Cardiac arrest was achieved with antegrade cold crystalloid cardioplegic solution and an oblique right atrial incision was made. The VSP was visualized via the tricuspid valve. The location of VSP was confirmed with saline injection from the LA vent line. VSP was closed with two patches, consist of a Teflon felt and a bovine pericardial patch, from the left and right ventricle side with six 4-0 polypropylene mattress sutures. Also coronary artery bypass for LCx was performed with a saphenous vein graft. The postoperative course was uneventful. There was no residual ventricular septal shunt and LV function was normal by UCG. Right atrial approach for surgical repair seemed to be useful for posterior VSP.

A 81-year old woman had hypertensive heart failure. She had a history of intermittent claudication for 5 years. Her ankle brachial pressure index (ABI) was 0.53 on the right and 0.58 on the left side. Coarctation of the descending aorta with severe calcification was found by a whole body CT. After medical therapy for heart failure, axillo-bifemoral artery bypass using an 8 mm ringed expanded polytetrafluoroethylene (ePTFE) graft was performed. Postoperatively, ABI improved to 0.83 on the right and 0.87 on the left side. The patient is doing well without any signs of heart failure or intermittent claudication. Although it is a palliative operation, axillo-bifemoral artery bypass is an effective and less-invasive procedure and appropriate for elderly patients.

Between 1987 and 2002, 22 internal iliac artery aneurysms in 14 patients were repaired. In 13 we performed aneurysm excision or reconstruction. There were 3 cases in which simple proximal ligation of the internal iliac artery was performed; in 2 of these CT scans confirmed that the reduction of the internal iliac artery aneurysms was not recognized, but blood flow was not shown in the aneurysm. However, 6 years postoperatively 1 patient was confirmed with an expansion of the aneurysm, and blood flow was seen on a CT scan. In the 2 latest patients, the blood pressure of the internal iliac artery was measured before and after proximal clamping of the internal iliac artery, but the blood pressure of aneurysms could not be fully lowered by proximal ligation of the internal iliac artery. Therefore, endoaneurysmorrhaphy seemed to be the operative method of choice for treatment of the internal iliac artery aneurysms.

The extremely rare occurrence of a case of spontaneous rupture of the aortic arch is reported. The patient was a 55-year-old woman who underwent a medical examination at a hospital following a sudden onset of chest pain. After a diagnosis of having cardiac tamponade was established, she was transferred to our hospital. She was in a state of shock with systolic blood pressure recorded at 70mmHg. Computerized tomographic findings indicated cardiac tamponade and hematoma around the ascending aortic arch but no aortic dissection. She was diagnosed as having a ruptured aortic arch and an emergency operation was performed. Apertures were observed on the anterior arch and were closed by a suture under halted circulation. Transesophageal echography was used to correctly identify the aperture on the rupture during the operation. Pathologic findings also indicated only extramural hematoma on the ascending aortic arch without the dissection. The patient's postoperative progress was satisfactory, and she was discharged after spending 16 days in the hospital. Spontaneous rupture of the thoracic aorta is extremely rare; it cannot be accurately diagnosed and leads to poor prognosis. Even in a case without trauma and aortic aneurysm, this disease should be diagnosed through rapid and detailed examination using computed tomography, and aggressive surgical treatment should be performed.

A 67-year-old woman had left lateral chest pain. CT scan and digital subtraction angiography revealed coarctation of the abdominal aorta just distal from the renal artery and a fusiform aneurysm of the descending thoracic aorta with a maximum diameter of 60mm. The meandering mesenteric artery was significantly dilated as a collateral vessel from the superior mesenteric artery to the inferior mesenteric artery. Aortitis syndrome was suspected from the angiographic findings although inflammatory changes in laboratory data were not observed. She underwent aneurysmectomy followed by prosthetic graft replacement of the descending thoracic aorta under femoro-femoral bypass and an extraanatomical bypass grafting from the replaced graft to the abdominal aorta proximal to the aortic bifurcation via the retroperitoneal space. She was discharged on the 42nd day after operation without any complications and in the past year has returned to her usual daily life without any anastomotic site trouble.

A 44-year-old man with a history of remittent fever for 6 months was given a diagnosis of inf ective endocarditis of the aortic valve related to a congenital ventricular septal defect (VSD), although no bacterial growth was obtained by blood culture. After one week of antibiotic treatment, aortic valve replacement (AVR) and patch closure of the VSD were performed after debridement of infected tissue and vegetations involving the aortic root, pulmonary and tricuspid valves, and myocardium surrounding the VSD. Antibiotic treatment was continued postoper-atively, but elevation of C-reactive protein (CRP) persisted. Blood culture disclosed Candida albicans in the blood 3 months after AVR. Fungal prosthetic valve endocarditis (PVE) was suspected, therefore, aortic root replacement with a Free Style bioprosthesis and VSD re-closure were performed followed by continued systemic antifungal treatment. Five months after reoperation, the patient was readmitted with a high fever. A pseudoaneurysm of the left common iliac artery and complete obstruction of the external iliac artery were shown by contrast-enhanced computed tomography (CT). The aneurysm was resected without revascular-ization. This case presentation concludes that long-term whole body study with contrast-enhanced CT might be necessary even though complete eradication of the infected foci of the heart has been established.

Background : Post-operative fluid management after cardiac valvular surgery is very important. In our institute, carperitide 0.0125 γ was started during surgery and oral furosemide 20-40 mg/day and spironolactone 25 mg/day were started at post-operative day (POD) 1 as the standard therapy. Tolvaptan, vasopressin V2 receptor antagonist, was started when fluid retention such as pleural effusion occurred. With this strategy, the frequency of pleural drainage was more than 40%. Therefore we changed our standard therapy in February 2018. In this new standard therapy, carperitide (0.0125 γ) was started and maintained until oral intake became possible and tolvaptan 7.5 mg was started with furosemide 20 mg and spironolactone 25 mg as oral medicine usually at POD 1. In this study, whether tolvaptan prevents pleural effusion or not after cardiac surgery was examined. Subjects and Methods : Sixty-four patients were operated during February 2017 and December 2018 were included in this study. Thirty-two patients operated in the period until January 2018 served as control group and were compared with 32 patients for whom tolvaptan was started on POD 1 (tolvaptan group). Results : There was no significant difference between two groups for background, operative procedure, operation time, cardiopulmonary bypass time, aortic cross clamp time and fluid balance during procedure. Tolvaptan was given to all patients in the tolvaptan group and in 22% of patients in the control group. Oral furosemide dose (tolvaptan group 21±5 mg/day, control group 31±20 mg/day, p＝0.0112), and the frequency of patients with intravenous furosemide administration (tolvaptan group 9%, control group 44%, p＝0.0038) were significantly less in tolvaptan group. In the tolvaptan group, intravenous furosemide administrated only once in all patients, whereas the frequency of intravenous furosemide administration was 1-32 times, average 6.6 times in control group. Tolvaptan was stopped within 1 week because of too much urination in two patients and the elevation of liver enzyme in two patients without any adverse effects. Post-operative urination volume until POD 5 did not differ. In both groups, body weight increased at POD 1 and 2 and returned to pre-operative weight at POD 3. Pleural effusion was significantly less in the tolvaptan group at POD 3 (tolvaptan group : none 66%, small amount 22%, moderate amount 3%, drain tube inserted 9%, control group : none 16%, small amount 34%, moderate amount 13%, drain tube inserted 38%, p＝0.0003), at POD 7 (tolvaptan group : none 72%, small amount 28%, vs., control group : none 47%, small amount 19%, moderate amount 22%, drain tube inserted 13%, p＝0.0041) and at discharge (tolvaptan group : none 94%, small amount 6%, vs., control group : none 69%, small amount 22%, moderate amount 9%, p＝0.0301). The frequency of pleural drainage was also less in the tolvaptan group (tolvaptan group 9.4%, control group 44%, p＝0.0038). Conclusion : After cardiac valvular surgery, tolvaptan started at POD 1 is very effective to reduce the frequency of pleural effusion and pleural drainage, and careful checking for too much urination and the elevation of liver enzymes is mandatory.

Purpose : Easy and safe implantability, good post-operative valve function and good long-term durability are required for any bioprosthetic valve implanted in aortic position. The Carpentier Edwards Perimount Magna valve (Magna) was introduced in 2009 and the St. Jude Medical Trifecta valve (Trifecta) was introduced in 2012 to our institution. In this study, we compared implantability, early post-operative valve function and structural valve deterioration (SVD) between these two valves. Patients and Methods : Between January 2009 and December 2019, Magna or Trifecta were electively implanted for 254 patients (Magna 151 patients and Trifecta 103 patients) and these patients were included in this study. Implantability was evaluated by occurrence of intraoperative valve dysfunction. Early post-operative valve function was evaluated by mean pressure gradient (m-PG) and indexed aortic valve area (AVAI) by ultrasonography performed 10 days after surgery. The relationship between indexed bioprosthetic valve orifice area calculated from internal diameter (GOAI) and AVAI was evaluated. If there was a significant relationship between GOAI and AVAI, maximum body surface area (BSA) to obtain AVAI≥0.85 cm2/m2 was estimated from 99% reliable interval of regression line. Results : Age, gender, and BSA did not differ between the two groups. There was no intraoperative valve dysfunction in Magna ; however we experienced one patient with severe aortic regurgitation due to stent distortion by the aortic wall during surgery with the 25 mm Trifecta valve. For this patient, Trifecta was replaced with Magna intra-operatively. In the 19 mm valve, AVAI was significantly larger (1.12±0.27 cm2/m2 vs. 0.88±0.21 cm2/m2, p<0.001) and m-PG was significantly lower (8.7±2.7 mmHg vs. 17.2±6.3 mmHg, p<0.001) in Trifecta. The frequency of AVAI<0.85 cm2/m2 (24% vs. 49%, p=0.036) and the frequency of m-PG≥20 mmHg (0% vs. 26%, p=0.006) were significantly less in Trifecta. There was significant relationship between GOAI and AVAI in both valves. Maximum BSA to obtain AVAI ≥0.85 cm2/m2 was estimated as 1.35 m2 in Magna and 1.50 m2 in Trifecta. In the 21 mm valve, AVAI was significantly larger (1.14±0.23 cm2/m2 vs. 0.92±0.22 cm2/m2, p<0.001) and m-PG was significantly lower (7.8±3.2 mmHg vs. 14.6±4.7 mmHg, p<0.001) in Trifecta. The frequency of AVAI<0.85 cm2/m2 was significantly less in Trifecta (11% vs. 42%, p=0.002) ; however, the frequency of m-PG≥20 mmHg did not differ significantly. There was a significant relationship between GOAI and AVAI in Magna and Trifecta. Maximum BSA to obtain AVAI ≥0.85 cm2/m2 was estimated as 1.49 m2 in Magna and 1.70 m2 in Trifecta. In the 23 and 25 mm valves, AVAI was significantly larger and m-PG was significantly lower in Trifecta. However neither the frequency of AVAI<0.85 cm2/m2 nor m-PG≥20 mmHg differed between the two valves. There was one early (27 months after surgery) SVD due to leaflet tear in Trifecta and two SVDs due to leaflet calcification more than 10 years after surgery in Magna. Conclusion : For Trifecta implantation, valve size selection seemed to be important and larger valves should be avoided with narrow ST junctions. Selection of 19 and 21 mm Magna valves should be limited for the patient with a BSA less than 1.35 and 1.49 m2 respectively. In Trifecta, early SVD might occur and careful follow-up is necessary.