Objective : To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. Methods : Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. Results : The median age of the patients was 15.5 years (range : 9-38 years). The patients had a mean body surface area of 1.48±0.3 m² (range : 1.00-1.92 m²). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3 (modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months (range : 1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0 mmHg preoperatively to 27.9±7.7/14.8±4.7 mmHg postoperatively and to 28.3±11.1/14.1±7.0 mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4 g preoperatively to 179.7±61.1 g postoperatively and to 100.4±76.3 g at intermediate-term follow-up, respectively. Conclusions : Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.

This report documents a case of three-channeled aortic dissection. The diagnosis of dissecting aneurysm was made by chest X-P and CT to 70-year-old man, with a chief complaint of back pain. Aortogram showed aortic aneurysm (DeBakey type IIIb), which had an entry at distal of the beginning of the left subclavian artery. Though we had given a pressure control therapy, the patient died on the 5th day of the admission. At autopsy, a new dissection was found in the chronic dissecting outer wall, forming three channeled dissection and rupture was there. Three-channeled dissection is very rare, only 8 cases including ours have been reported so far. From this case, we learned it very difficult to diagnose and treat it.

We report a relatively rare case of syphilitic aortic aneurysm that was treated by reconstruction with interposition of a prosthesis. The patient was a 72-year-old woman who presented with an abnormal shadow on chest radiograph and an abdominal pulsatile tumor. Aortography revealed double aneurysms in the descending thoracic and infrarenal abdominal regions, combined with a left common iliac artery aneurysm. Microscopic examination revealed an inflammatory infiltrate within the adventitia and destruction of the elastic fibers in the media, classical features of syphilitic aortitis. The incidence of double aortic aneurysm is expected to increase in the future, and one of the many problems involved in the management of this disorder is the correct timing for safe surgery. We prefer simultaneous surgery to secondary surgery, since this rules out the possibility of rupture of the remaining aneurysm. In order to perform this operation safely, it is necessary to treat the patient's general condition with regard to the surgical procedure and possible adjevant therapy.

Fourteen patients with 22 solitary aneurysms of the iliac artery were operated in a 16-year period (1983 to 1999). Patients were divided into two groups. The non-ruptured group consisted of 6 patients who underwent surgical intervention before aneurysm rupture, and their mean age was 78.5 years. The ruptured group consisted of 8 patients who underwent surgical intervention for aneurysm rupture, with a mean age of 68.5 years. Although seven patients underwent emergency surgery for aneurysm rupture, less than half of them were operated upon within 24hr after the onset of aneurysm rupture. The average size of aneurysms was similar in the two groups (common iliac artery aneurysms: non-ruptured 47mm vs. ruptured 44mm in diameter, internal iliac artery aneurysms: non-ruptured 55mm vs. ruptured 55mm). Two patients died in the ruptured group, in which the operative mortality rate was 25%. Six patients (75%) of the ruptured group had hypovolemic shock, and two of them died during surgical repair. Of the patients with shock, two patients had intestinal ischemia after operation. Intestinal ischemia was one of the serious complications of ruptured iliac aneurysms. These results suggest that in patients with shock from ruptured iliac artery aneurysms, strategy for treatment is an important determinant of the outcome.

A 61-year-old man admitted to another hospital because of cerebral infarction had fever (about 39°C). Computed tomographic scanning revealed a pseudoaneurysm of the brachiocephalic artery, accompanied by pericardial fluid. The patient was transferred to our hospital. Culture studies of a sample of pericardial fluid revealed Staphylococcus aureus. A mycotic pseudoaneu-rysm of the brachiocephalic artery was diagnosed. Antibiotics were given for about 2 weeks after transfer to our hospital. Surgery was performed after the inflammation subsided. The pseudoaneurysm was incised during circulatory arrest. A hole measuring 2cm in diameter was found at the origin of the brachiocephalic artery. The hole was sealed with an autologous arterial patch, made from a 3-cm section of the right axillary artery. The axillary artery was reconstructed by end-to-end anastomosis. After surgery, infection was controlled by means of systemic antibiotics and closed mediastinal lavage. The patient was discharged from the hospital in good condition 160 days after surgery. To date, there has been no flare-up of infection.

A 49-year-old man who had no history of cardiac disease or intravenous drug abuse was referred to our hospital complaining of fever despite antibiotic chemotherapy. Blood culture was positive for Streptococcus agalactiae, and transesophageal echocardiography revealed vegetation attached to the tricuspid valve and moderate tricuspid regurgitation. Two-thirds of the anterior leaflet and a part of the posterior leaflet of the tricuspid valve were excised with the vegetation, and the remaining anterior leaflet was sutured to the posterior leaflet after annular plication. DeVega's annuloplasty was added to a diameter of two fingers. Following this procedure tricuspid regurgitation was minimal.

A 51-year-old man underwent arch replacement for a thoracic aortic succular aneurysm in December 1996. The pathological examination indicated aortitis to be the cause of the aneurysm. At that time we did not surgically treat the abdominal aortic aneurysm (AAA) which was only 32mm in diameter. Sixteen months after the first operation, he complained of a pulsatile tumor in his left leg. Angiography revealed an aneurysm of the left superficial femoral artery. The artery distal to the aneurysm was occluded, and the left popliteal artery received collateral blood flow from the deep femoral artery. The size of the AAA increased to 48mm, an indication of repair. Aneurysmectomy of the left superficial femoral artery and replacement of the abdominal aorta were performed simultaneously. The operative findings showed that the aneurysm of the left superficial femoral artery had been ruptured and formed a pseudoaneurysm. The pathological findings demonstrated both aneurysm aortitis. After the second operation, he was given steroid therapy to control the inflammatory reaction and he has been well for one year.

In the postoperative treatment of ruptured abdominal aortic aneurysm surgery, the relationship between intra-abdominal pressure (IAP) and the clinical course is not been clearly understood. From April 2000 to January 2003, we treated 109 cases of abdominal aortic aneurysm surgery (non-rupture 71 cases, rupture 38 cases) and measured intra-abdominal pressure in 30 of the ruptured cases which we analyzed in this study. The patients were divided into 2 groups. The H-group included 12 patients with maximum IAP equal to or higher than 20mmHg, and the L-group included 18 patients with a maximum IAP less than 20mmHg. Clinical characteristics were compared between the 2 groups. The mean age was 79.3±7.6yr in the H-group and 70.7±10.1yr in the L-group (p=0.019). Preoperative shock was diagnosed in 83.3% of the H-group patients, and 61.1% of the L-group patients the (p=0.26). Postoperative maximum values of intra-abdominal pressure were 22.3±2.0mmHg in the H-group, and 15.4±2.4mmHg in the L-group. Duration of intubation was 87.7±110.0h in the H-group, and 25.1±29.2h in the L-group (p=0.04). Food intake was started 14.4±11.2d after surgery in the H-group, and 8.5±4.8d after surgery in the L-group (p=0.094). The length of ICU stay was 6.7±6.5d in the H-group, and 2.9±2.1d in the L-group (p=0.033). Length of hospital stay after surgery was 54.1±25.8d in the H-group, and 25.2±6.8d in the L-group (p=0.001). Complications occurred in 8 cases out of 11 surviving cases (73%) in the H-group, and in 3 cases out of 17 surviving cases (18%) in the L-group (p=0.0024). Complication in the H-group included acute renal failure, paralytic ileus, respiratory failure, abdominal wall dehiscence, and acute arterial occlusion, and that in the L-group included acute renal failure, upper limb paresis, and lower limb paresis. Monitoring of intra-abdominal pressure was considered beneficial to recognize complication and decide therapeutic strategy after ruptured aortic aneurysm surgery.

A 76-year-old woman with Stanford type A acute aortic dissection underwent replacement of the ascending aorta with the use of gelatin-resorcin-formalin glue. The patient suffered sudden cardiogenic shock at home 15 months after surgery and was admitted to the Emergency Center of our hospital. A series of examinations revealed an aortic-root pseudoaneurysm associated with anastomotic disruption. Cardiogenic shock caused by obstruction of the ascending aortic graft due to anastomotic disruption was diagnosed. An intraaortic balloon pump (IABP) was inserted, and the patient's circulatory status improved. On the following day, reanastomosis of the aortic root graft was performed. On day 32 after surgery, the patient was discharged from the hospital in good condition. IABP can stabilize circulatory status and improve cardiogenic shock in the short term in patients with an aortic-root pseudoaneurysm caused by narrowing of the graft lumen, as in the present patient. IABP may thus be a useful ancillary measure before radical operation.

A 83-year-old woman suffered pulseless-electrical-activity (PEA) because of cardiac tamponade after acute myocardial infarction with blow-out type cardiac rupture. Immediately median sternotomy was performed and active bleeding from the postero-lateral wall was found. It was impossible to stop bleeding only by putting pressure on the aperture of the myocardium with a piece of TachoComb coated with gelatin-resorcinol-formaldehyde (GRF) glue, however, the chemical action of GRF glue made the delicate myocardium after acute infarction stronger and we managed to stop that bleeding with mattress sutures that had initially seemed to be impossible. She was discharged on POD 103 uneventfully. We think this is a useful and safe operation procedure for blow-out type cardiac rupture.