A 73-year-old woman was due to undergo elective AVR and aortoplasty because of aortic stenosis (AS) and an ascending aortic aneurysm. During the operation, after the start of cardiopulmonary bypass, the ascending aorta was found to be dilated and discolored. A diagnosis of type A dissection was made by transesophageal echocardiography. Replacement of the ascending aorta and AVR were performed under deep hypothermic circulatory arrest. After the operation, VTR revealed that the ascending aorta was dissected from the cardioplegia injection site. The postoperative course was good and she was discharged on postoperative day 28. Intraoperative aortic dissection is a rare but lethal complication, so it is important to recognize it rapidly and manage it appropriately.

A 74-year-old woman was given a diagnosis of mitral regurgitation (MR) and tricuspid regurgitaton (TR) underwent mitral valve replacement (MVR) and tricuspid annuloplasty (TAP). Pacemaker implantation was necessary because of postoperative atrial fibrillation (Af) followed by bradycardia on the postoperative day 14. Five months later, she was again admitted to our hospital because of fever. A blood culture revealed Streptococcus sangius. Symptoms improved with the administration of antibiotics. Twenty days after discharge, she suffered back pain and fever. A CT scan showed destructive changes in the thoracic vertebrae and echocardiography revealed mitral vegetations. A blood culture revealed Streptococcus agalactiae. Symptoms subsided with the administration of antibiotics. However, new mitral regurgitation was recognized so the patient underwent redo MVR. The patient's recovery was uncomplicated after surgery, and she was discharged on the 104th post-operative day.

A 68-year-old man underwent percutaneous transluminal coronary angioplasty (PTCA) to left anterior descending artery (LAD) seg 7 after acute anteroseptal myocardial infarction 8 years previously. He was admitted because of syncope attack due to sustained ventricular tachycardia and subsequent fibrillation. He was treated medically in the ICU after cardiopulmonary resuscitation. Medical treatment with amiodarone and lidocaine was not successful and he was transferred to our hospital for surgical treatment of malignant ventricular tachycardia (VT) associated with left ventricular aneurysm and acute cholecystitis that occurred during admission. Left ventriculogram showed left ventricular aneurysm (ejection fraction: 35%) without any significant coronary lesions. The patient successfully underwent a Dor operation (left ventriculoplasty), double encircling endocardial cryoablation without endocardial resection, and preoperative and intraoperative endocardial mapping. Cholecystectomy was simultaneously performed after complete closure of the median chest incision. The recurrence of VT was never recognized clinically or electrophysiologically. The extended encircling endocardial cryoablation without endocardial resection and preoperative and intraoperative electrophysiological study, was a simple and effective method for ventricular tachycardia.

This study was designed to evaluate the perioperative outcome of dialysis patients undergoing cardiac surgery, who were managed with our perioperative dialysis program. Between April 1994 and August 1999, 11 patients (7 men and 4 women with a mean age of 57.3±10.3 (36-73)) with hemodialysis (HD, n=8) and peritoneal dialysis (PD, n=3) underwent cardiac surgery. The duration of dialysis was 5.6±4.3 years. Operation included mitral valve replacement (n=1) and isolated coronary artery bypass grafting (n=10). Patients with HD had single hemodialysis on the day before operation. Patients with PD were maintained on PD in the usual manner until the day before surgery. Intraoperative hemofiltration during extra-corporeal circulation and normokalemic non-depolarizing cardioplegic solution were used in all patients to avoid post-operative hyperkalemia. All HD patients had dialysis on the first post-operative day (POD 1), and then every other day. PD patients had PD soon after arriving at the ICU. Levels of serum creatinine, urea nitrogen, acid-base balance were successfully controlled within acceptable ranges. No patients required emergency HD or any post-operative managements for hyperkalemia in the ICU. Six of 8 HD patients required an increase in vasopressor because of a tendency toward hypotension and 4 of 8 patients suffered from atrial fibrillation during the initial HD on POD 1. Eight of 11 patients could be extubated on the first POD. No hospital death occurred. The use of normokalemic cardioplegic solution was useful to avoid post-operative hyperkalemia. Our perioperative dialysis programme successfully managed the perioperative clinical course of dialysed patients undergoing cardiac surgery.

A 59-year-old man who had been treated medically for aortic stenosis and angina pectoris was hospitalized due to a high fever. He was treated immediately by intravenous infusion of antibiotics. Blood culture was positive for α-streptococcus. Echocardiography revealed severe aortic stenosis with vegetation on the aortic valve and minimal aortic regurgitation. The peak aortic pressure gradient was 80mmHg. The patient developed chest pain at rest and showed ischemic ST-segment depression on the electrocardiogram obtained after admission. Coronary angiography (CAG) was performed to assess the extent of coronary artery disease, and it showed 90% stenosis of the right coronary artery (RCA) and 75% stenosis of the circumflex branch (Cx). Both fever and angina pectoris were so resistant to maximal medical treatment that the patient was referred to our hospital for urgent surgical treatment. During surgery, a large vegetation was noted on the aortic valve, which was calcified, and a destructive ring abscess was observed around the coronary cusp. Aortic valve replacement (SJM-19mm) was performed after complete debridement of the abscess and repair of the resulting aortoventricular discontinuity. Double coronary bypass saphenous vein grafting to RCA and Cx was performed. The patient recovered without incident and was discharged 4 weeks after surgery.