A 79-year-old woman with degenerative mitral regurgitation and secondary tricuspid regurgitation underwent mitral and tricuspid repair. Massive and intractable endobronchial hemorrhage occurred during weaning from cardiopulmonary bypass (CPB). Bronchoscopic examination during CPB revealed that the right distal bronchus was the probable bleeding point. We then performed a double-lumen endotracheal tube and a bronchial blocker in the distal portion of the right main bronchus. In addition, extracorporeal membrane oxygenation (ECMO) with a heparin-coating system was performed for 11 h, without extra heparinization because of severe hypoxia. The bronchial blocker was removed 14 h later, and the patient was weaned from ECMO 19 h after admission into ICU. Postoperative computed tomography (CT) revealed a pseudoaneurysm of the right pulmonary artery (A⁵b) corresponding with the probable site of bronchial bleeding (B⁵). We speculate that a pulmonary artery catheter induced this endobronchial hemorrhage. At 3 months after surgery the patient was doing well with no symptoms of airway bleeding, and her abnormal CT findings had disappeared.

A 55-year old man was admitted to our hospital owing to endograft collapse after TEVAR. He had undergone total arch replacement for acute aortic type A dissection at age 39, and undergone thoracic endovascular aortic repair (TEVAR) for chronic aortic type B dissection at age 54. TEVAR was successfully performed and the false lumen was shrunk. However, one year after TEVAR, computed tomography showed endograft collapse. Technical success was not achieved by the balloon technique to treat endograft collapse, so we performed additional TEVAR. After this procedure, endograft collapse was repaired. The postoperative course was uneventful.

A 49-year-old man was admitted to another hospital because of exertional dyspnea. He had run an entire 20-km race 33 days before admission. Echocardiograms, MRI and CT scans, and cineangiograms showed a right ventricular tumor arising from the tricuspid valve, which occupied the area from the right ventricular outflow tract (RVOT) to the pulmonary trunk and extended to the bilateral pulmonary arteries. MRI scans suggested that the tumor had not invaded the normal cardiac structure. The patient was transferred to our hospital for surgery. An operation was performed on the same day, since the tumor could have caused pulmonary embolisms. Under cardiopulmonary bypass, a right atriotomy, pulmonary arteriotomy and incision in the RVOT were made. The tumor had adhered to the chordae of the tricuspid valve, myocardium of the RVOT, and pulmonary valve. It was completely resected macroscopically. The postoperative course was uneventful and the patient was discharged on the 18th postoperative day. The size of the tumor was 2.0×2.0×10.0cm and the histological diagnosis was angiosarcoma. The patient died 4 months after the operation due to brain metastasis and local recurrence. This appeared to be a case of rapidly progressive cardiac angiosarcoma with an unusual noninvasive growth pattern.

Five patients with isolated stenosis of the left main coronary artery or stenotic ostial lesions underwent direct coronary artery surgery. These surgical approaches included vein patch angioplasty in 2 cases, punch out endarterectomy in 1 case, and resection of the thickened aortic wall and transaortic endarterectomy in 2 cases. Early results were satisfactory, except for one case who died due to severe LOS and MOF. In the late postoperative period, one case of vein patch angioplasty died due to cerebral bleeding, and in the other case, stenosis existed in position of distal patch anastomosis. Since direct coronary artery surgery was successful in both early and late postoperative fidings, it is believed to be useful and safe technique if the candidates are selected properly.

A minimally invasive approach to coronary artery revascularization without cardiopulmonary bypass has been performed recently and its feasibility and effectiveness have been proved. However, occlusion of the coronary artery during anastomosis in the beating heart is liable to cause myocardial ischemia or infarction. To prevent these and to perform minimally invasive coronary artery bypass on the beating heart safely, intra-coronary shunt was developed and applied in animal experiments. Materials and methods: The left internal mammary artery was harvested endoscopically and anastomosed to the left anterior descending coronary artery in the beating heart without cardiopulmonary bypass in seven pigs. Three of them utilized intracoronary shunt tubes (group S) and the other did not (group C). Results: Use of an intracoronary shunt tube facilitated non-blood exposure of the coronary artery during anastomosis. In group C, three pigs out of four had ventricular fibrillation during occlusion for the anastomosis. In group S the anastomosis was accomplished without change of ECG except one case and without any elevation of CPK-MB and Troponin T during and after the anastomosis. Conclusion: These results showed that an intra-coronary shunt can prevent myocardial ischemia and may be very useful especially to those who do not develop collateral branches from other coronary arteries.

A 43-year-old man visited another hospital because of dry cough and dyspnea in a supine position after having experienced chest pain about 1 month prior to his visit. He had undergone open aortic commissurotomy and ligation of the ductus arteriosus due to congenital bicuspid valve aortic stenosis and patent ductus arteriosus at age 13. CT scan showed a dissected giant aortic aneurysm (12.0cm in diameter) of the DeBakey Type II which compressed surrounding organs, such as his trachea, bilateral main bronchus, superior vena cava, and right main pulmonary artery. Echocardiograms revealed severe aortic stenosis and a dissecting ascending aortic aneurysm. The patient was admitted to our hospital and an urgent operation was performed. Under cardiopulmonary bypass with selective cerebral perfusion, a replacement of the aortic root and the ascending-arch aorta with the inclusion technique was performed. Postoperatively, the patient suffered from ventilatory disturbance under mechanical ventilation. CT scan showed a giant aneurysmal sac containing a hematoma in the perigraft space and the false lumen of the aneurysmal wall and remaining tracheobronchial compression. A reoperation was performed for removal of the hematoma and placation of the aneurysmal sac. The subsequent postoperative course was good. The patient was weaned from mechanical ventilation at 12 days and discharged at 67 days after the initial operation. Histologically, the resected aortic wall showed cystic medial necrosis.

A 56-year-old man had aneurysms of the right subclavian artery and cerebral artery in association with congenital absence of the right internal carotid artery. The aneurysm of the subclavian artery was successfully surgically repaired through a partial sternotomy. Congenital absence of the internal carotid artery is rare vascular anomaly. This anomaly contributes to the occurrence of intracranial aneurysms. However, aneurysm of subclavian artery associated with congenital absence of the internal artery is very rare. This is the 3rd case reported in the literature.

To estimate the blood compatibility during extracorporeal circulation, we designed mock circulation system consisted of a membrane oxygenator and vinyl circuit with roller pump. Primed with 200ml Ringer's acetate and 200ml of fresh whole human blood, mock circulation was worked at flow rate 0.5l/min for 6hr. Heparin was not primed, oxygenator did not fill any gases and circulation was keeping at 37°C. The thrombin-antthrombin complex and fibrinopeptide-A showed progressive increase and fibrinogen correspondingly decrease. Nevertheless, the plasmin α2 plasmin inhibitor complex and D-dimer showed minimal changes within normal range in spite of increasing fibrinopeptide B β 15-42. We can not find any signs of secondary fibrinolytic activity. On the other hand, the platelet was persistently activated as shown statistically significant increase in β-thrombogloblin and platelet factor IV. Significant elevations of complement 3a and 4a were seen with increase of complement 5a and activated oxygen productivity by neutrophilic leucocytes. In conclusion, moderate and limited blood alterations occurred in mock cardiopulmonary bypass circuit.

Though preoperative autologous donation is not acceptable for all cases partly because some are preoperatively in a severe condition, intraoperative predonation is possible in almost all cases. We retrospectively evaluated the major factors related to the prevention of homologous blood transfusion by intraoperative predonation in 25 cases following valvular surgery without preoperative autologous donation. Homologous blood was not transfused in 18 cases {Group-(-)} but in 7 cases only after CPB {Group-(+)}. The male/female ratio, type of operation, body weight, CPB dilution, CPB duration, and perioperative change in hematocrit were comparable in the 2 groups. However, the autologous blood pooled before CPB in Group-(-) was significantly more than in Group-(+) (11.3±2.5 vs 7.3±1.8ml/kg, p<0.001). In conclusion, homologous blood transfusion may be prevented by appropriate intraoperative predonation during surgery for valvular disease.

A 36-year-old man underwent direct closure of an atrial septal defect through median sternotomy at the age of 14. He also underwent a mitral valve replacement with tricuspid annuloplasty using the same approach at the age of 18. The patient also presented with pretibial edema and congestive liver disease at the age of 27 and the pretibial edema progressed at the age of 35. Hypoalbuminemia (TP ; 3.6 g/dl, Alb ; 1.6 g/dl) was also observed. Further examinations were performed, which revealed that the right ventricular pressure curve presented a dip and plateau pattern by cardiac catheterization. Computed tomography of the chest additionally revealed thickened and calcified pericardium in the left ventricle. Abdominal scintigraphy showed tracer accumulation in the transverse colon hepatic flexure 4 h after intravenous administration of technetium-99m-labelled human serum albumin. The patient was diagnosed with a protein-losing gastroenteropathy caused by constrictive pericarditis. He underwent pericardiectomy via left anterior thoracotomy without cardiopulmonary bypass. No complications were present after the surgery, and he was discharged after 46 postoperative days. Following his discharge from the hospital, the pretibial edema disappeared, and serum albumin levels gradually increased and normalized within 3 months after the surgery (TP 7.1 g/dl, Alb 4.2 g/dl).