The purpose of this study was to review our experience in the treatment of active endocarditis and identify determinants of early outcome. Sixty-nine patients (mean age 47.3 years, range 5 months to 88 years) underwent surgery for active endocarditis. Native valve endocarditis was present in 59 (85.5%) and prosthetic valve endocarditis in 10 (14.9%). The aortic valve was infected in 26 (37.7%), the mitral valve in 24 (34.8%), both aortic and mitral valves in 13 (18.8%), and the tricuspid in 3 (4.3%). Paravalvular abscess was identified in 22 (31.9%). Streptococci (27.5%) and Staphylococci (23.3%) were the most common pathogens, but the pathogen was not identified in 36.2%. Hospital death occurred in 13 (18.8%), and causes of deaths included cardiac failure in 6 and sepsis in 5. There were 2 late deaths, and the causes of death were cerebral infarction and renal dysfunction. Univariate analysis indicated that older age (p=0.02), New York Heart Association class III or IV (p=0.02), a preoperatively unidentified pathogen (p=0.02) and concomitant operation for abscess and fistula (p=0.04) were significant risk factors in hospital mortality. Prosthetic valve infection was a relative risk factor in hospita mortality (p=0.11). Multivariate analysis revealed that NYHA III-IV(p=0.02, odds ratio=18.1, 95% CI=1.49-220.1) and a preoperatively unidentified pathogen (p=0.02, odds ratio=7.45, 95% CI=1.44-38.5) were independent predictors of hospital mortality. To reduce hospital mortality in active endocarditis, early surgical intervention is recommended before the involvement of heart failure, particularly when the pathogen is not identified.

Higher incidence of spinal cord injury has been reported in total aortic arch replacement using a stented elephant trunk compared with the conventional one, perhaps due to embolism of atheromatous plaque to the spinal cord arteries. We report a case with delayed-onset lower spinal cord injury after replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. A 69-year-old man who had a history of abdominal aortic aneurysm repair using a Y-graft and untreated Crawford's type II thoracoabdominal aortic aneurysm underwent replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. He developed weakness of the lower extremities 4 days after the operation. Since a preoperative computed tomography demonstrated thrombus and atheroma in the aneurysm, atheromatous plaque that can cause embolization of the spinal cord arteries was suspected to be responsible for spinal cord injury. As this technique is mostly applied to patients with severe atheromatous aortic disease, embolization of the intercostal arteries or other main branches caused by manipulation of a stent graft must be avoided.

We report a case with Crawford type III thoracoabdominal aortic aneurysm associated with occlusion/stenosis of the visceral and the iliac arteries necessitating surgical repair. The patient was a 54-year-old man. His visceral arteries were obstructed except the left renal artery which was stenotic. His iliac arterial system was also completely occluded except the patent left common and internal iliac arteries. The blood flow of his visceral organs and lower extremities depended on the collateral vessels from the left internal iliac artery. We successfully performed thoracoabdominal aortic aneurysm repair concomitant with reconstruction of the visceral arteries and the femoral arteries using partial cardiopulmonary bypass between the left internal iliac artery and the left femoral vein. It is important to select appropriate adjuncts and surgical options for patients with thoracoabdominal aortic aneurysms that involve visceral/iliac arteries.

A 20-year-old woman had intermittent fever frequently since dental therapy one year previously. Two months previously Takayasu's arteritis had been diagnosed and she had been given 30mg/day prednisolone. She then developed subarachnoid hemorrhage, left arm pain/cataplexy, purpura, sight disturbance, and sepsis caused by Serratia. Finally she felt chest pain and a left Subclavian artery pseudoaneurysm was detected out. Therefore she was transferred to our service for emergency surgery. Preoperative angiography demonstrated post-stenosis aneurysm in the right common carotid artery, left common carotid artery aneurysm, and saccular pseudoaneurysm in the left subclavian artery that suggested impending rupture. The operation was performed through a left upper partial sternotomy extended to the left supraclavicular space. The left subclavian artery was ligated proximal to the aneurysm and distal portion was also ligated through a subclavicular approach. The postoperative course was uneventful. No ischemic sign has been seen in her left arm one year after operation and left/right brachial artery pressure index has improved to 0.80. The patient currently takes steroids and remains healthy without signs of expansion of bilateral carotid artery aneurysms.

We reported a successful emergency operation for ruptured juxtarenal abdominal aortic aneurysm via an extended retroperitoneal approach. A 70-year-old man with a history of distal gastrectomy and pancreatoduodenectomy complained of epigastric pain and was transferred to our emergency room in a state of shock. Computed tomograpy demonstrated a ruptured juxtarenal abdominal aortic aneurysm and massive intraperitoneal hematoma. We performed emergency graft replacement through an extended retroperitoneal approach in order to control the aorta quickly, safely, and reliably. This approach is a useful option in the emergency treatment of ruptured juxtarenal abdominal aortic aneurysm.

A 77-year-old man, who had undergone total cystectomy, was transferred to our hospital because of repeated arterial bleeding from the left cutaneous urostomy on urostomy catheter exchange. Abdominal CT scan revealed infrarenal aortic and bilateral common iliac aneurysms. Multidrug-resistant Pseudomonas was detected from preoperative urine culture. A fistula between the left iliac artery and the left ureter was strongly suspected and an operation was performed. Aneurysmectomy and graft replacement with a bifurcated graft was conducted. Both limbs of the Y-graft were anastomosed to the right internal and external iliac artery. The left lower extremity was revascularized using femorofemoral bypass. After left nephrostomy, the graft was wrapped around with an omental flap. The postoperative course was uneventful, without infective complications.

A 58-year old man without Marfan syndrome was referred to our hospital for congestive heart failure due to severe mitral regurgitation. He had undergone sternal turnover with a rectus muscular pedicle for pectus excavatum 36 years previously. We were able to perform mitral valve repair via median sternotomy using a usual sternal retractor. There was no adhesion in the pericardium and the exposure of the mitral valve was excellent. We closed the chest in ordinary fashion without any problems in the fixation of the sternum or costal cartilage. There were no complications such as flail chest or respiratory failure.