A 28-year-old man visited the emergency department of our hospital with a chief complaint of palpitation and chest pain. The patient had undergone 4 operations at other hospitals for tetralogy of Fallot (TOF), left pulmonary atresia, an aberrant right coronary artery, and a right aortic arch. As a result of thorough investigations, we suspected that the cause of the patient's symptoms was an excess of the right ventricular pressure over the left ventricular pressure, which was caused by right ventricular compression resulted from an abnormal mass on the anterior surface of the right ventricle, and by pulmonary stenosis (PS) associated with right ventricular outflow tract stenosis (RVOTS). Excision of the mass, right ventricular outflow restoration (RVOTR), and pulmonary valve replacement (PVR) were indicated. The mass on the anterior surface of the right ventricular was found to have been caused by retention of serous fluid in the interstice formed by a folded expanded polytetrafluoroethylene (ePTFE) pericardial sheet. An ePTFE pericardial sheet, which is used to supplement the pericardium, has been reported to have advantages with respect to prevention of adhesion, denaturation of pericardial substitutes, and inflammatory thickening and adhesion of the epicardium, compared with other materials used as pericardial substitutes. However, epicardial thickening has been noted with the use of ePTFE pericardial sheets, and hence, its use is currently avoided in many cases. This case presents an extremely rare pathology in which the inflammatory reaction of the epicardium caused by an ePTFE pericardial sheet is suspected to have caused serous components to become tightly encapsulated in the interstice formed by the folded patch ; no definite cause was identified. Thus far, no other such case has been reported, and ePTFE pericardial sheets should be used with caution.

Postoperative infections should be comprehensively controlled in the context of infection control, rather than as activities of individual surgeons. We started a surgical site infection (SSI) surveillance program in 2009 in which prophylactic measures for preventing SSIs were applied. These measures were as follows : 1) screening for nasal carriage of methicillin-resistant Staphylococcus aureus ; 2) dental checks and oral screening ; 3) antibiotic prophylaxis in the intra- and postoperative period ; 4) control of glucose levels to ≤160 mg/dl in the immediate postoperative period ; and 5) early removal of surgical drain. After the introduction of prophylactic measures, we reexamined SSI surveillance and added the following prophylactic measures at the beginning of 2011 : 6) data concerning SSI and compliance with prophylactic measures for all surgical and ward staff were published monthly, and the Infection Control Team (ICT) and surgeons performed weekly ward visits to assess SSIs ; 7) recommendations were made for wearing two pairs of gloves and surgical hoods to cover the hair, scalp, ears and neck ; and 8) collaboration with diabetologists was implemented to control glucose levels in diabetics. We compared incidences of SSI in cardiovascular surgery from the periods before (469 cases, Group B) and after (118 cases, Group A) introduction of the additional prophylactic measures. Clinical characteristics of patients in each group did not differ significantly. Operative time was significantly shorter in Group A (400±116 min) than in Group B (434±145 min). Compliance with antibiotic prophylaxis in the intraoperative period improved progressively from 93% in Group B to 99% in Group A. Compliance with control of glucose levels to ≤160 mg/dl on postoperative day 1 improved progressively from 71% in Group B to 81% in Group A. Duration of drain placement was significantly shorter in Group A (2.9±1.8 days) than in Group B (3.6±2.9 days). Incidence of SSI decreased significantly from 6.0% in Group B to 0.8% in Group A. Revision of preventive measures based on the results of surveillance and enhancement of cooperation between the ICT and surgeons could help to decrease the incidence of SSI.

A 77-year-old woman was admitted to our hospital with a decreased level of consciousness and left hemiplegia. Contrast-enhanced CT showed acute type A aortic dissection and right common carotid artery occlusion. Electrocardiogram findings showed ST segment elevation in the anterolateral wall. The results suggested that the aortic dissection had extended to the left main trunk and caused acute myocardial infarction. Percutaneous coronary intervention (PCI) was performed preoperatively to improve myocardial ischemia reperfusion. After a successful PCI, the patient underwent ascending aorta replacement immediately. In cases of acute aortic dissection involving the left main artery, preoperative PCI prevents extensive myocardial damage and serves as a bridge to surgery.

A 73-year-old woman presented at our hospital with dyspnea. Echocardiography showed severe aortic stenosis and a coronary angiography revealed right coronary artery disease. Therefore, we performed aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) surgery. Proximal anastomosis was initially attempted to the ascending aorta. However, the ascending aorta was thin and weak, we decided to anastomose to the side of the aortic arch. Proximal anastomosis was performed with an anastomotic device. Postoperative coronary computed tomography (CT) showed that the graft was patent.

A 67-year-old man with dyspnea at rest was diagnosed with acute heart failure and admitted to our hospital. Echocardiogram showed severe AR, and CT implied an ascending aortic aneurysm and abnormal space in the aortic root. The patient underwent emergent surgery for suspected acute aortic dissection. Intraoperative findings showed the dehiscence of commissure of the aortic valve, and more, the abnormal space in the aortic root was not due to acute aortic dissection but an aortic subannular left ventricular aneurysm. The aneurysm was sutured and closed, and after that, aortic valve replacement and ascending aortic replacement were performed. Although subannular left ventricular aneurysm is a rare disease, it is important to carry out the preoperative evaluation considering the existence of such diseases.