Postoperative hemodynamic performance after aortic valvular replacement using the Carpentier-Edwards pericardial valve of 19-mm (group A, 10 cases) or 21-mm (group B, 5 cases) was compared with that using the 19-mm St. Jude Medical hemodynamic plus (group C, 13 cases). We evaluated hemodynamic performance by measuring the peak pressure gradient via aortic valve using Doppler echocardiography. Preoperative peak pressure gradients were 80±18.5mmHg in A, 81.6±17.5mmHg in B and 87±36.3mmHg in C. Valvular replacement obviously improved the hemodynamic performance by decreasing the postoperative peak pressure gradient to 24.2±7.3mmHg in A, 14.2±6.2mmHg in B and 26.7±19.0mmHg in C, though no statistically significant difference was present among the three groups. We also applied the dobutamine stress test for 5 cases in group A, 4 in B and 4 in C, who could receive the additional examination. The amount of dobutamine given was 8.2±1.6μg/kg/min in A, 7.2±2.0μg/kg/min in B and 7.7±1.5μg/kg/min in C. Before administration of dobutamine, the peak pressure gradient was 18.1±4.3mmHg in A, 14.2±6.2mmHg in B and 20.9±5.7mmHg in C. Although administration of dobutamine increased the peak pressure gradient to 41.1±15.0mmHg in A, 32.2±9.8mmHg in B and 46.8±14.4mmHg in C, there was no significant difference among the groups. The Carpentier-Edwards pericardial valve of 19-mm and 21-mm thus provided satisfactory valvular function compared with the 19-mm St. Jude Medical in terms of hemodynamics. Therefore, it is concluded that the Carpentier-Edward pericardial valve is a reliable alternative for elderly patients.

The total arch replacement protocol using the open-style stent-graft placement is frequently performed for type A aortic dissection to obtain complete closure of entry sites. However the open-style stent-graft placement must be carefully planned when the entry site is in the descending aorta and extends beyond the level of the tracheal bifurcation, because spinal cord ischemia can be caused due to occlusion of lower thoracic intercostal arteries. We report an alternative to total arch replacement for type A aortic dissection with entry in the ascending aorta and aneurysmal re-entry in the descending aorta, beyond the level of the tracheal bifurcation. We inserted a guide-wire from the dissected area of the aortic arch towards the normal region beyond the re-entry in the descending aorta, with confirmation by direct ultrasonography and already incised half, introduced a graft into the descending aorta using the wire as a guide and performed anastomosis at the level of the transverse aortotomy in the inclusion method. This operation has the advantage of preventing spinal cord ischemia because the re-entry site in the descending aorta is confirmed by direct ultrasonography and the distal anastomosis does not reach the lower thoracic intercostal arteries. In this method, by which the prosthesis is introduced through the descending aorta and anastomosed in the inclusion method, is not needed troublesome treatment in the descending aorta and less invasive than conventional single-stage total arch replacement and applicable with the great safe for aortic dissection that had shown difficulty in application of open-style stent-graft placement.

A 63-year-old woman was admitted to our hospital for combined valvular disease with tricuspid valve stenosis. Aortic and mitral valves were replaced with artificial valves and tricuspid valve were replaced with a biological valve. We chose artificial valves for the aortic and mitral valves because the patient was younger than 70, while a biological valve was used for the tricuspid valve to avoid possible thromboembolism. The postoperative course was excellent. We propose that it is better to use a biological valve for the tricuspid valve, even if artificial valves are used in other sites.

A 37-year-old man who had suffered right chest pain while mowing weeds was transferred to our hospital. A chest roentgenogram revealed a needle-like foreign body overlying the cardiac silhouette and chest CT confirmed an intracardiac foreign body. The patient underwent emergency operation, and a foreign body was removed under cardiopulmonary bypass and performed cardiac repair. A foreign body penetrated right lung and reached it in the left atrial cavity. The patient recovered uneventfully without any symptoms of infections.

There are few reports on the long term efficacy of surgery for endocardial cushion defect (ECD) in elderly patients. We report a case with a successful course after ECD operation. A 70-year-old man was admitted with incomplete ECD, grade III mitral and tricuspid regurgitation, pulmonary hypertension and atrial fibrillation. The operative procedures included direct closure of the mitral cleft, pericardial patch closure for the ostium primum defect, direct closure of the tricuspid cleft and tricuspid annuloplasty. Pulmonary hypertension was improved after the operation, and he was discharged on the 41st day after the operation. Now, 3 years and 6 months after the operation, he has maintained an improved quality of life (QOL) with an uneventful postoperative course. The present report may suggest one solution for the long term effective treatment by operation for elderly patients who suffer from ECD, especially to achieve better QOL.

We evaluated the efficacy of evoked spinal potential (ESP) monitoring during thoracoabdominal aortic replacement to prevent intra-operative spinal ischemia. Nine patients underwent intraoperative ESP monitoring. The ESP was unchanged in 5 patients and decreased in 4 patients. However, ESP recovered in 2 of them by the following techniques: (1) perfusion of intercostal arteries, (2) elevation of distal bypass perfusion pressure, (3) slight hypothermia. Postoperative paraplegia occurred only 1 patient of the 2 whose ESP was not restored. The sensitivity and specificity of the efficacy of ESP monitoring were 100% and 87.5%, respectively. We concluded that ESP is the most useful monitoring for prevention of operative spinal ischemia during thoracoabdominal aortic replacement.