Late acute type A aortic dissection after coronary artery bypass grafting (CABG) is rare, and only a few cases have been published in the literature. It is important to treat cases of living graft during reoperation. We report a successful surgical treatment in a case of late acute type A aortic dissection after CABG. A 68-year-old man underwent a triple CABG (to the left anterior descending artery with left internal thoracic artery, to the left circumflex artery with left radial artery, and to the right coronary artery with right gastroepiploic artery) beating heart procedure using a centrifugal pump and pulmonary assist with closed circuit due to unstable angina pectoris in December 2007 and had presented with sudden anterior chest pain, and was found to have an ascending aortic dissection (type A) on enhanced computed tomography in May, 2009. We performed ascending artery replacement, paying special attention to the living graft performed through a median sternotomy. The postoperative course was uneventful and he was discharged on the 22nd postoperative day.

We herein report a rare case of an inflammatory pseudotumor arising from the mitral valve. A 58-year-old man who was undergoing maintenance dialysis was referred to us due to the presence of a tumor mass attached to the mitral valve. It was asymptomatic and had been coincidentally found by echocardiography. The tumor mass was a sphere measuring about 1 cm in size, and it arose from the posterior mitral leaflet. A myxoma of the left atrium was suspected, and the tumor mass was resected along with part of the posterior leaflet by means of a right minithoracotomy (MICS). The tumor was postoperatively diagnosed to be an inflammatory pseudotumor based on the findings of a histopathological examination. During the follow-up period of 1 year and 2 months after surgery, there was no recurrence. An inflammatory pseudotumor is a tumorous lesion characterized by the infiltration of inflammatory cells and the growth of myofibroblasts. This tumor occurs most frequently in the lung, and the greatest number of intracardiac cases have been reported in small children. There are few reports of inflammatory pseudotumors occurring in adults, and only 4 cases originating in the mitral valve has so far been reported, which means that such tumors are extremely rare. For this reason, we reported the findings of this case, while adding a bibliographical survey.

Aplastic anemia is a syndrome characterized by pancytopenia, and performing an open heart operation for patients with this syndrome may be associated with an increased surgical risk for both bleeding and post-surgical infection. We report a case of mitral regurgitation complicated with aplastic anemia that underwent a mitral valve repair via a right lateral minithoracotomy. The patient was a 70-year-old woman who presented with shortness of breath on exertion. She was found to have aplastic anemia based on pancytopenia (WBC 2,150/µl, Hgb 8.8 g/dl, PLT 5.0×10⁴/µl) and the results of a bone marrow biopsy. Echocardiography showed severe mitral valve insufficiency at the same time, and the patient was referred for surgery. To deal with the decrease in white blood cells and platelets, prior to surgery, a granulocyte colony-stimulating factor was administered, 30 units of platelet concentrate were transfused during the operation, and mitral valve repair via a right lateral minithoracotomy was performed. After surgery, there were no complications due to infection or bleeding, and the subsequent course was favorable. Several studies have reported the advantages in right minithoracotomy of less intraoperative bleeding and a lower infection rate compared with full sternotomy. In cases of this kind, in which there is a tendency toward bleeding and ease of infection, we believe that right lateral minithoracotomy may be a useful option to consider.

We experienced two rare cases of acute aortic dissection with leg ischemia after Y graft repair of the abdominal aortic aneurysma. Case 1 was a 63-year-old woman who had received Y graft repair at age 55, and case 2 was a 28-year-old man with Marfan's syndrome who received a Y graft repair at age 21. Both patients sustained DeBakey type I dissections terminating at the suture line of the Y graft and had symptoms of acute arterial occlusion of bilateral lower extremities. Emergency operation was performed 8 hours after onset in case 1 and 6 hours after in case 2. Case 1 could not be weaned from cardiopulmonary bypass because of intraoperative rupture and acute heart failure, but case 2 underwent successfully aortic root replacement and total arch replacement under selective cerebral perfusion.

We experienced a rare case of a patient who had a bicuspid aortic valve associated with acute aortic dissection limited to the sinus of Valsalva involving the left main coronary artery and acute coronary syndrome. The patient was a 36-year-old male who was identified as having a congenital bicuspid aortic valve. He visited our emergency room with a chief complaint of acute chest/back pain. He was diagnosed with acute coronary syndrome based on ECG findings and underwent an emergency coronary angiography. This test revealed filling defects at the entrance of the left main coronary artery, with aortic dissection limited to the sinus of Valsalva suspected. Emergency chest contrast-enhanced CT (ECG gated) led to his being diagnosed as having an acute aortic dissection limited to the sinus of Valsalva. After an intra-aortic balloon pump was inserted in order to maintain the coronary blood flow by surgery, emergency coronary artery bypass surgery and a modified Bentall procedure (the Carrel patch method) were carried out. His postoperative course was good and he was discharged home on the 19th disease day.

The patient, a female in her 60s, was under anticoagulant therapy with direct oral anticoagulant (DOAC) for persistent atrial fibrillation. She suddenly presented with chest pain, prompting her emergency admission to our medical facility. Subsequently, she received a diagnosis of acute aortic dissection (Stanford A) and was referred to our department for urgent surgical intervention. The administration of Andexanet Alfa was initiated in the emergency department due to the markedly elevated risk of life-threatening hemorrhage associated with DOAC medications. Surgery was approached through a median sternotomy, and 20,000 units of unfractionated heparin were administered intravenously during cardiopulmonary bypass (CPB) preparation. However, the activated clotting time (ACT) exhibited suboptimal extension at 181 s (pre-heparin ACT: 124 s), necessitating supplementary heparin infusion. This resulted in the cumulative administration of 80,000 U of heparin before achieving an ACT exceeding 400 s. Suspecting heparin resistance, we maintained an ACT greater than 400 s during CPB through the continuous administration of nafamostat within the CPB circuit. Subsequently, we performed graft replacement of the ascending aorta, weaning from the CPB was smooth, hemostasis was good, and the operation was completed. The patient's postoperative recovery remained uneventful, leading to her discharge on the 11th day following the surgery. Notably, there were no instances of major bleeding or thromboembolic events during her hospitalization. Preoperative oral DOAC therapy presents a critical and potentially life-threatening concern due to its association with heightened intraoperative and postoperative bleeding risks. Currently, a Factor Xa inhibitor reversal agent, Andexanet Alfa (Ondexa®)，is available and expected to contribute to the treatment of critical bleeding in patients taking DOAC. However, further research is warranted to accumulate knowledge regarding its efficacy and optimal utilization. In this case, we present an instance of acute aortic dissection with heparin resistance following the preoperative administration of a DOAC antagonist, contributing to the existing literature on this matter.

Congenital mitral regurgitation (MR) occurs infrequently and the number of reported adult surgical cases is small. A 77-year-old man presented with an exacerbation of congestive heart failure. He had a 19-year history of receiving medical treatment for MR and atrial fibriration. Transthoracic and transesophageal echo cardiograms revealed severe MR due to the restriction of the posterior mitral leaflet with very short chorda tendanea attached beneath the posterior leaflet preoperatively. We diagnosed this case to have congenital MR (Carpentier type III) in an adult based on the specific findings of echocardiography and mitral valve plasty was thus performed. All the dysplastic chordae of the P2 and P3 in the immovable leaflet region were cut and the reconstructed by the fifth artificial chordae. These procedures successfully allowed the posterior mitral leaflet to recover its normal shape and movability. Postoperative echocardiography showed no further mitral regurgitation and normal leaflet motion.