We report a case of reoperation for proximal and distal pseudoaneurysmal formations of the ascending aorta with aortic regurgitation (AR) after an ascending aorta replacement for acute type A aortic dissection. The patient was a 69-year-old woman who had undergone ascending aorta replacement for acute type A aortic dissection six years previously. Subsequent development of pseudoaneurysms of the ascending aorta and aortic regurgitation were revealed by computed tomography and echocardiography respectively. We chose debranch Thoracic Endovascular Aortic Repair (TEVAR) with a staged approach. First, aortic valve replacement, patch closure of proximal pseudoaneurysmal formation, coronary artery bypass, and ascending aorta-axillary artery bypass were performed. Two weeks later, debranching and TEVAR were performed. Cardiac reoperation for proximal and distal pseudoaneurysmal formations of the ascending aorta with aortic regurgitation after an ascending aorta replacement is known to be high risk. Nevertheless we performed the operation safely in two-stage surgery.

Here, we report a patient who underwent surgery for acute aortic regurgitation (AR) due to rupture of an aortic valve commissure. The patient was a 51-year-old man who had undergone ascending aorta replacement for acute type A aortic dissection 6 years previously. He presented with a 2-day-history of headache and insomnia. Echocardiography showed only AR initially. However, 2 days later, a vegetation-like mass was noted at the aortic valve commissure on transesophageal echocardiography. We diagnosed AR associated with infective endocarditis, and decided to perform aortic valve replacement immediately. During surgery, we found that the cause of AR was rupture of the aortic valve commissure without infection. The cause of rupture in this case was suspected to be traumatic or myxomatous degeneration.

Background : Fungal mycotic aneurysm is rare ; however, special care and treatment are required for the deep fungal infection itself. Case : The patient was a 69-year-old man with a history of sepsis due to Candida albicans. He suffered from back pain and moderate fever. CT revealed saccular-form aneurysm at the infrarenal abdominal aorta. After emergent in situ bifurcated graft replacement of the infected aneurysm, antifungal treatment was attempted in reference to the antifungal drug sensitivity of C. albicans from intraoperative cultures and findings of fungal endophthalmitis in an ophthalmic examination. After an uneventful acute course, follow up CT images after 12 months postoperatively revealed pseudoaneurysm formation proximal to the site of graft anastomosis. Reoperation was planned with a trans-thoracic and transabdominal approach because of concerns about thoracoabdominal aortic infection. However, the reoperation displayed only inflammatory tissue around the graft and aortic tissue. Removal of the previous graft and reconstruction of the bilateral renal artery, and the pararenal abdominal aorta to the bilateral common iliac artery was performed. Intraoperative tissue cultures revealed no evidence of microorganisms. He returned home with oral antifungal treatment and is doing well at 8 months after the reoperation. Conclusions : Management of fungal mycotic aneurysms requires both surgical treatment and antifungal treatment. Antifungal agents should be selected based on the results of a susceptibility test and after examinations for metastatic comorbidities.

Paroxysmal atrial fibrillation (pAf) is an arrhythmia that often occurs in the elderly. The quality of life often declines due to severe palpitations caused by pAf. We present a case of recurrent pAf that occurred on postoperative day 2 of coronary artery bypass grafting and pulmonary vein isolation for unstable angina pectoris and pAf. The patient was a 62-year-old man who complained of palpitations, which was consistent with pAf on the monitor ECG. During hospitalization, the patient was constantly wearing an ECG monitor. During pAf, the heart rate was around 120 bpm, and pAf could continue for up to and beyond 24 hours. Paroxysmal atrial fibrillation with strong palpitations was observed every day, even after starting beta-blockers and anticoagulants. After discharge, a Japanese Kampo medicine called shakanzoto was taken for a month, but there was no improvement. After that, it was changed to another Japanese Kampo medicine called saikokaryukotsuboreito, because abdominal examination revealed kyokyokuman (hypochondriac discomfort and distension (resistance)) and saiboki (brisk pulsation in the para-umbilical region). Palpitations quickly improved dramatically. It was speculated that not only palpitations but also pAf had been improved.