We recorded a case of a 58-year-old man who presented with swelling of the right neck after sudden chest pain. He was diagnosed with Stanford type A aortic dissection. Computed tomography revealed an aneurysm in the innominate artery surrounded by a hematoma. We therefore suspected a rupture of the innominate artery. In addition, the right common carotid artery was almost completely obstructed due to dissection. An emergency partial arch replacement was performed. Cardiopulmonary bypass (CPB) was established with two blood supplies : the right axillary and left common femoral arteries. When CPB was started, the innominate artery ruptured and could no longer be used for cerebral perfusion or as an anastomotic site. The right side of the neck was opened, and a synthetic graft was anastomosed to the right common carotid artery for cerebral perfusion. Finally, the graft was anastomosed with a branch of the main trunk. The right subclavian artery was also reconstructed using a graft that was anastomosed to the axillary artery for blood supply. The postoperative course was favorable, and no cerebral complications were observed.

A 70-year-old woman who was bedridden because of right hemiplegia attributable to a history of cerebral hemorrhage underwent surgical thrombectomy for pulmonary embolism four years previously. Symptoms of heart failure appeared one year previously, and she was diagnosed with constrictive pericarditis and had been treated with medication by a previous doctor. In the current situation, she visited the previous doctor with the chief complaint of fever, and pericardial effusion was observed on echocardiography. Cardiac tamponade was suspected and she was transferred to our hospital. She was then diagnosed with purulent pericarditis because purulent fluid was observed during pericardiocentesis drainage. Bacteroides fragilis was isolated from the culture of the abscess. The abscess was resistant to conservative antibiotic therapy ; therefore, we performed a pericardiotomy with a left small thoracotomy. The pleural effusion was found to be negative for culture and the patient exhibited a good postoperative course. Purulent pericarditis is refractory with poor prognosis. An appropriate surgical procedure must be chosen considering the patient's activities of daily living. Here, we report a surgical case wherein we chose the left thoracotomy approach and achieved positive results.

The first case was a 67-year-old woman. She had been given a diagnosis of fulminant myocarditis and received a biventricular assist device as a bridge to recovery. A Nipro ventricular assist device (VAD) was implanted into her left heart. She was also found to have moderate aortic insufficiency before the operation, so she received aortic valve replacement (AVR) with a bioprosthetic valve (CEP Magna Ease 21 mm) at the same time. Her cardiac function recovered gradually. Therefore, a weaning operation was scheduled for three months after the VAD implantation. However, her left ventricle motion was very poor when she was taken off of the extracorporeal circulation after removing the VAD, and transesophageal echocardiography (TEE) revealed severe bioprosthetic valve stenosis. When her heart was stopped again and the bioprosthetic valve was observed, the leaflets of the bioprosthetic valve were fused. Commissural fusion of bioprosthetic valve was able to be released using forceps, and the punnus extending under the leaflet was removed. In this way, the function of the bioprosthetic valve was restored. Her cardiac motion became good, and removal from extracorporeal circulation was easily achieved. She left the hospital 100 days after weaning from the VAD. The second case was a 68-year-old woman. She also had fulminant myocarditis. She underwent biventricular assist device implantation and AVR (CEP Magna Ease 19 mm). Her cardiac function recovered, and a weaning operation was scheduled on the 73rd-postoperative day. Preoperative TEE before the weaning of VAD showed severe bioprosthetic valve stenosis. The commissural fusion of the bioprosthetic valve was released and the punnus extending under the leaflet removed at the same time as the VAD was removed. Re-valve replacement was not required. We should therefore consider the possibility of bioprosthetic valve stenosis when VAD implantation and AVR with a bioprosthetic valve are performed at the same time in patients with an extremely reduced cardiac function.