Between December 1994 and December 2002, surgical repair of aneurysm of the abdominal aorta (AAA) was performed in 139 patients, 32 of whom had ruptured AAA. Thirty-nine patients were 80 years old or older (O) and 100 patients were younger (Y) than 80. The ratio between ruptured and unruptured AAA was significantly higher among older patients (O: 41.0% versus Y: 16.0%, p=0.002). Surgical mortality was identical in those receiving elective repair (O: 0% versus Y: 0%) and similar in those receiving repair following rupture (O: 13.3% versus Y: 28.5%, p=0.314). A diagnosis of AAA had been made before rupture in only 10 patients, whose survival rate was relatively higher (100%) than that of patients without known AAA (66.7%). Ten patients died of ruptured AAA without surgery. Four of them had intractable cardiopulmonary arrest despite attempts at resuscitation. Four other patients were debilitated due to other disease even before rupture of AAA. Another 2 patients were diagnosed as ruptured AAA at autopsy. In conclusion, elective surgical repair is safe in elderly patients with AAA. The survival rate of elderly patients following rupture of AAA is comparable to that of younger patients. Some patients, however, should be excluded from aggressive treatment because of associated conditions such as marked debilitation prior to rupture or uncorrectable cardiopulmonary arrest on arrival. Patient selection is a sensitive but important issue in the era of society being composed of many elderly people.

A 68-year-old man underwent percutaneous transluminal coronary angioplasty (PTCA) to left anterior descending artery (LAD) seg 7 after acute anteroseptal myocardial infarction 8 years previously. He was admitted because of syncope attack due to sustained ventricular tachycardia and subsequent fibrillation. He was treated medically in the ICU after cardiopulmonary resuscitation. Medical treatment with amiodarone and lidocaine was not successful and he was transferred to our hospital for surgical treatment of malignant ventricular tachycardia (VT) associated with left ventricular aneurysm and acute cholecystitis that occurred during admission. Left ventriculogram showed left ventricular aneurysm (ejection fraction: 35%) without any significant coronary lesions. The patient successfully underwent a Dor operation (left ventriculoplasty), double encircling endocardial cryoablation without endocardial resection, and preoperative and intraoperative endocardial mapping. Cholecystectomy was simultaneously performed after complete closure of the median chest incision. The recurrence of VT was never recognized clinically or electrophysiologically. The extended encircling endocardial cryoablation without endocardial resection and preoperative and intraoperative electrophysiological study, was a simple and effective method for ventricular tachycardia.

A 78-year-old man presented with back pain 20 years after aortic root replacement using a homograft and was admitted with a diagnosis of pyogenic spondylitis. The patient had a history of prosthetic valve infective endocarditis (PVE) 9 months after aortic valve replacement (AVR) at 57 years of age at another hospital, and had undergone aortic root replacement using a homograft. Streptococcus anginosus was detected in blood culture, and antibiotic therapy was commenced according to the treatment of PVE. During the course of the treatment, the diagnosis of PVE was confirmed due to worsening aortic regurgitation (AR) and a finding of suspected vegetation attachment to the right coronary cusp. Since there were no embolic symptoms or heart failure, antibiotic therapy was preceded by surgery on the 33rd day. Intraoperatively, the homograft showed a highly calcified sinus of Valsalva and each valve leaflet was very fragile. The aortic valve had a vegetation adherent to the tip of the right coronary leaflet, but the infection was localized and did not extend to the annulus. Although aortic root replacement had been considered, the patient was elderly and had impaired activities of daily living, so AVR was performed in order to reduce the invasiveness of the procedure. The annulus was so hard that the needle could not be passed through. It was possible to thread the annulus by inserting the needle through the autologous tissue below the suture line on the proximal side of the homograft at the previous surgery. A bovine pericardial patch was used to close the aortotomy line of sclerotic homograft. There was no recurrence of infection, and the patient was transferred to the hospital for rehabilitation on postoperative day 37. The optimal surgical technique should be considered according to the degree of calcification and the patient's background in each case, as grafts are often highly calcified in cases of reoperation after homograft replacement.