A 22-year-old man was referred to our medical center with an impending rupture of an aneurysm of the descending thoracic aorta. Blood pressure was 180/110mmHg in the right arm but 110/60mmHg in the right foot. The diagnosis was confirmed by chest Xray, enchanced computed tomography and aortogram. Five days later, the chest Xray showed massive effusion in the left pleural cavity. Surgery was immediately performed via a left thoracotomy. Five hundred ml of bloody fluid was found in the pleural cavity but the site of bleeding could not be identified. The aneurysm was 7×10cm in size. Under percutaneous cardio pulmonary support, the aneurysm was replaced by a 22mm Gel-Seal Dacron vascular graft. The intima and the media of the aneurysm were lacerated longitudinally at the region receiving jet flow from isthmus, There was blood coagula between the media and adventitia. During replacement, activated clotting time was maintained at 200∼300sec. As a result, bleeding was limited to 200ml. The postoperative course was uneventful with little difference in pressure between the right arm and right foot.

It is well known that patients with abdominal aortic aneurysms (AAA) have a high incidence of coronary artery disease (CAD), and that the major cause of death in patients undergoing aneurysmectomy is acute myocardial infarction. A total of 53 patients (mean age, 71 years) underwent elective repair of AAA between January 1991 and November 1999. In an attempt to reduce early and late mortality caused by myocardial infarction, coronary angiography (CAG) was performed in all cases. Significant CAD was found in 23 patients (43%), with triple vessel disease in 1 patient (2%), double vessel disease in 5 patients (9%), single vessel disease in 16 patients (30%) and left main in 1 patient (2%). Ten patients (19%) in whom CAD was detected by CAG had no history of CAD and displayed no ischemic findings on ECG. In 4 patients (8%), AAA repair was performed 2 (mean) months after coronary artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 8 patients (23%) 19 days (mean) prior to AAA surgery. No patient had a perioperative myocardial infarction either following coronary revascularization (CABG and PTCA) or AAA resection. Moreover, there was only one operative death after abdominal aneurysmectomy (2%), in a patient who was 70 years old with chronic hemodialysis and who died due to multiple organ failure caused by uncontrollable adhesional ileus. The results of this study emphasize the importance of preoperative routine coronary angiography following coronary artery revascularization to enhance the operative outcome of AAA repair.

We report a case of successful surgical treatment for an aortic anastomotic false aneurysm associated with a graft-duodenal fistula after abdominal aortic aneurysm repair. A 63-year-old man was admitted with melena and an aortic anastomotic false aneurysm after prosthetic graft replacement 8 years previously. CT scan demonstrated an aneurysm with a maximum diameter of 70mm at the proximal anastomotis of the prosthetic graft. Gastroduodenoscopy revealed no bleeding site in the stomach or the first and second portions of the duodenum. Therefore, we performed an emergency operation under a diagnosis of an aortic anastomotic false aneurysm associated with a graft-duodenal fistula. The aneurysm was replaced with interposition of a new prosthetic graft via a thoracoabdominal approach. The fistula was repaired by covering the duodenum with the jejunum through a left pararectal laparotomy. The postoperative course was uneventful, and there was no evidence of graft infection at 14 months after the operation.

A 68-year-old woman received aortic valve replacement (AVR) with a Freestyle stentless valve using a subcoronary technique for aortic stenosis and regurgitation in September 2000. She complained of chest pain, had low grade fever and findings of inflammation and was admitted to our hospital with a diagnosis of acute myocardial infarction in December 2000. She suffered from repetitive or recurrent myocardial infarction. Transesophageal echocardiogram revealed no abnormal findings of the Freestyle stentless valve, but her blood culture was positive for methicillin-resistant coagulase negative Staphylococcus aureus (MRCNS) and she underwent an emergency operation. The Freestyle stentless valve was removed and replaced with a mechanical valve. The patient's intraoperative tissue grew MRCNS and parenteral antibiotics were administered for 8 weeks after surgery. Her condition was complicated with multiple cerebral infarction, however she was discharged on the 113th postoperative day and is doing well without recurrence of infection 12 months after the operation.

A 69-year-old woman underwent aortic valve replacement (AVR) for prosthetic valve (Freestyle^TM stentless valve) endocarditis (PVE) in April 2001. The patient was admitted to our hospital with diarrhea and tarry stools in January 2002 and was treated with intravenous hyperalimentation. She had fever and inflammatory findings at 1 week after admission, and was given intravenous antibiotics. Symptoms and laboratory findings improved gradually, but transesophageal echocardiography revealed a mobile mass in the ascending aorta near the noncoronary sinus of Valsalva. The serum β_-D glucan level was elevated and blood culture was positive for Candida parapsilosis. These findings suggested fungal endocarditis of the ascending aorta, so the patient underwent surgery. Vegetation was attached to the aortic wall near the noncoronary sinus of Valsalva. It was removed with part of the ascending aorta, followed by reconstruction with a gusset xenograft. In addition, aortic valve replacement was performed with a mechanical valve. The resected tissue grew C. parapsilosis, so parenteral anti-fungal drugs were administered intravenously for 8 weeks after surgery. Although cerebral infarction occurred, she was discharged on the 133rd postoperative day. There was no recurrence of infection and she remained on oral anti-fungal medication for 24 months postoperatively.

Between January 1981 and December 1996, we performed valve replacement in 281 patients using bileaflet prosthetic valves in mitral and/or tricuspid positions. Thrombosed valve were seen in 10 patients (7 in mitral, 3 in tricuspid positions). In 5 patients, coumadin had been stopped for several reasons (pacemaker implantation, melena, drug allergy), but in the other 5 patients, anticoagulation was within the therapeutic range at the time of presentation. For thrombolytic therapy urokinase or tissue plasminogen activator were used. The treatment was successful in 5 patients (4 mitral, 1 tricuspid), and unsuccessful in 5 patients (3 mitral, 2 tricuspid). Three of the 5 unsuccessful patients were treated surgically (3 with re-mitral valve replacement, 1 with thrombectomy). Prompt surgical treatment can be used as the first line of therapy for thrombosed valves. Thrombolytic therapy may be useful in some cases of bileaflet valve thrombosis without critical hemodynamic collapse. Doppler echocardiographic assessment of increasing peak velocity and pressure half time is useful for detecting thrombosed valves.