During the last 15 years, isolated aortic valve replacement was performed in 122 patients, 12 of whom had severe elevated pulmonary systolic pressure (PAS) of 50mmHg or over. A comparative study of preoperative and postoperative data was done between two groups; group I (n=12), with a pulmonary systolic pressure 50mmHg or over, and group II, with a value of under 50 mmHg (n=45). On preoperative evaluation, cardiomegaly and constrictive pulmonary dysfunction were found in group I and also PAWP, mean pressure of PA, PAS, LVEDP and RVEDP were of a higher value in group I than group II. The LVEDP was high in group I and correlated well with PAS preoperatively, suggesting that pulmonary hypertension was a consequence of severe LV dysfunction. There was no difference in the operative mortality and postoperative complication between these two groups. CTR, PAWP, mPA and PAS decreased to within the normal range postoperatively. It was concluded that pulmonary hypertension does not adversely effect the operative mortality and postoperaive complications of AVR, and the cause of the elevated pulmonary pressure was thought to be due to the impaired LV function.

A 59-year-old female case with cardiac tamponade due to rupture of the coronary arteriovenous fistula is described. Preoperative coronary arteriography showed bilateral coronary-pulmonary fistulae not associated with significant atherosclerotic stenosis. On opening the pericardium after establishing F-F bypass, the pericardial sac contained 300 grams of partially clotted blood. There was subepicardial hematoma along the area of the left anterior descending artery and the left circumflex artery without any other abnormal findings of the heart. The operation consisted of hemostasis with several mattress sutures along the left anterior descending artery and the left circumflex artery, closure of multiple fistulous openings from within the pulmonary artery, and ligation of abnormal dilated vessels originating from bilateral coronary arteries. The coronary arterio-venous fistula with aneurysmal dilatation should be operated on aggressively, whether symptomatic or asymptomatic, to prevent the rupture of fistulae.

A case of ruptured dissecting aortic aneurysm (DeBakey IIIa) involving a right-sided aortic arch is reported. A 54-year-old man was admitted to our hospital with a complaint of severe back pain. Roentgenogram and enhanced computed tomography of the chest revealed a right-sided aortic arch, right descending thoracic aorta and right pleural effusion. Thoracocentesis of the right thoracic cavity revealed bloody fluid. The ruptured dissecting aortic aneurysm was suspected. The enhanced CT of the chest revealed leakage of the contrast medium at the level of the bifurcation of the trachea so aortography wasn't performed. There was a 2cm intimal tear in the descending aorta. Resection and grafting of the aneurysm via right thoracotomy was performed. The patient made an uneventful recovery and was discharged 4 weeks later. It is pointed out that the operative method and/or decision of the method of approach for the aneurysm involving a right arch are difficult because of the aberrant left subclavian artery and/or tortuous descending thoracic aorta. Impeccable judgement is needed for emergency operation of ruptured dissecting aneurysms like the present case.

A 78-year-old woman with abnormal shadows on computed tomography (CT) was given a diagnosis of right-sided aortic arch and Kommerell diverticulum (KD), accompanied by aberrant left subclavian artery. Although no symptoms were observed, the maximum diameter of the aneurysm was 63 mm, and surgical intervention was chosen because of the possibility of rupture. At first, a 4-branched blood vessel prosthesis with a side branch was anastomosed to the ascending aorta. Next, after reconstructing the cervical branches, a Conformable GORE® TAG® (W.L. Gore and Associates, 34 mm×200 mm) was inserted from the side branch and expanded in the range of Zones 0 to Th 7. Finally, ALSA coil embolization was performed. She was discharged on postoperative day 36, and at her 2-year follow-up, she was doing well, with shrinkage of Kommerell diverticulum.