We report a patient with Leriche syndrome who had ileal conduit and a right lower quadrant stoma. A 47-year-old man with a history of bladder cancer had undergone radical total cystectomy with formation of an ileal conduit and right lower quadrant stoma 2 years previously. CT scanning revealed total occlusion of the distal aorta. He experienced right lower leg pain after 30 m of walking. Through a repeat midline laparotomy incision, the abdominal aorta was dissected with a transperitoneal approach. To avoid dissection around the ileal conduit, the retroperitoneum was incised (open) at the right of the ascending colon and at the left of the sigmoid colon. A prosthetic graft (Interguard 14×7 mm) was pulled bilaterally through these incisions, to the external iliac arteries. Abdominal aorto-bilateral external iliac artery bypass grafting was performed and the patient was discharged without complications on the 15th postoperative day.

Ankylosing spondylitis is chronic, progressive, inflammatory disease involving the spine, peripheral joints, and periarticular structures. Cardiac abnormalities associated with ankylosing spondylitis are well recognized, but a case with DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for aortic regurgitation has not been previously reported. We report a case of a 66-year-old man with ankylosing spondylitis who was successfully treated by DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for severe aortic regurgitation.

This study aimed to clarify whether continuous hemodiafiltration (CHDF) or hemodialysis (HD) was more effective after open heart surgery in dialysis patients. We evaluated 48 consecutive hemodialysis patients (28 men and 20 women, mean age : 68±10 years) who underwent coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) between January 2003 and December 2008. The patients were divided into 2 groups according to their postoperative dialysis treatment either continuous hemodiafiltration (CHDF) (CHDF group, n=36) or hemodialysis (HD) (HD group, n=12). Surgery in the CHDF group included 13 concomitant operations, 16 CABGs and 7 AVRs. There was only 1 concomitant surgery in the HD group, and there were 6 CABGs and 5 AVRs. There was no difference between the 2 groups regarding operation time, aortic clamp time, cardiopulmonary bypass time or intraoperative volume balance. CHDF was started significantly earlier than HD (8.0±5.8 vs. 21.0±1.0 h, p <0.01), which resulted in the removal of a greater volume of body fluid, during the first postoperative 24 h in the CHDF group (1,200±110 vs. 550±50 ml, p <0.01). However, there was no difference between the 2 groups regarding the amount of postoperative chest drainage. There were 6 hospital deaths in the CHDF group (17% ; 3 heart failures, and 1 each of pneumonia, arrhythmia and massive intestinal necrosis). There was also 1 hospital death in the HD group (8.3% ; heart failure). Most of the hospital deaths occurred after concomitant operations (6/7, 86%). It is beneficial to start CHDF soon after open heart surgery in hemodialysis patients.

Bicuspid aortic valve (BAV) is one of the more common congenital anomalies. It is well known that the ascending aorta and aortic root sometimes dilate in patients with BAV, even when the valve function is normal. We examined the morphological type and histological features of the dilated ascending aorta in patients with BAV. Of 276 patients who underwent aortic valve replacement (including coronary artery bypass grafting) from 2004 onwards, 60 (21.5%) with BAV were included in this study. The type of BAV was defined according to the Sievers classification. Type 1 BAV was the most common, and enlargement of the ascending aorta (≥45 mm) was the most common in the L/R type of BAV (48%). The morphology of the dilated ascending aortic wall was evaluated using three-dimensional CT angiography. The majority of dilations were asymmetric, but dilation was symmetric in the patient with dilation of the aortic root. Histological examination graded cystic medial necrosis of the ascending aortic walls using the aortic wall score. All patients with BAV had degeneration of the aortic wall, even when there was no dilation. The aortic walls of patients with dilated aortic roots showed advanced degeneration compared with the aortic walls of other patients. Therefore, aggressive root replacement may be appropriate, when the root is mildly dilated in patient with BAV.

We successfully performed aortic root replacement in an asymptomatic 52 year-old man with dilatation of the Valsalva sinuses (75 mm). The patient had previously undergone a radical operation for the tetralogy of Fallot at 13 years of age and AVR at 46 years of age. Massive bleeding occurred in the lungs after weaning from CPB. Emergency bronchoscopy revealed that the bleeding came from the right middle and lower lobes. The bleeding was stopped conservatively on POD 3 ; however, V-V ECMO was started on POD 5 because of severe hypoxia. ECMO was successfully weaned on POD 11 and he discharged on POD 59. The presence of developed bronchial collaterals and barotrauma during the operation were speculated the causes of the bleeding from the right lung.