A 72-year-old woman had undergone a right upper lobectomy and thoracoplasty in 1954 and an aortic valve replacement in December 2001. She suffered from dysphagia in June 2002. X-ray film and CT-scan revealed a sternal partial nonunion. The treatment was resection of the clavicle, because of the adhesion behind the sternum and the sternal partial nonunion. The postoperative course was uneventful and she was discharged. However, she was transferred to our hospital because of hematoma and bleeding at the right clavicle 1 month after the operation. Emergency operation was performed because of injury of the ramus of artery subscapularis. We ligated the ruptured portion and additionally resected the clavicle. Her postoperative course was good. Resection of the clavicle is one choice for sternal partial nonunion after open heart surgery. However, when we resect the clavicle, we should consider preservation of the ligament, reconstruction of the ligament, and the clavicular excision range.

We report a case of surgical treatment of iatrogenic cardiac trauma. A patient with cardiac tamponade was treated by pericardiocentesis. During pericardiocentesis both right and left ventricles were perforated. These perforations were repaired in the beating heart state using 20 monofilament mattress sutures reinforced by felt pledgets. Iatrogenic cardiac trauma is rare. Fatal complications might arise when proper procedures are not followed during the placement of a catheter for pericardiocentesis. Here we present successfull surgical treatment of cardiac penetrations induced by pericardiocentesis.

A 79-year-old man was admitted for thoracoabdominal aortic aneurysm repair. He had already twice undergone coronary artery bypass grafting, 19 and 2 years previously. The value of the ejection fraction of the left ventricle was 36%, measured by ventriculography; and transthoracic echocardiography revealed moderate aortic valve regurgitation. In the presence of aortic valve regurgitation or coronary artery disease, myocardial perfusion under hypothermic fibrillatory arrest may be significantly impaired. Therefore, to maintain a beating heart we used separate perfusions of the upper and lower body that enabled individual temperature control of each organ. The femoral and axillary arteries were cannulated, and a long cannula was inserted into the right common femoral vein and positioned in the right atrium. Cardiopulmonary bypass was established, and the upper body was mildly cooled until the pharyngeal temperature was 33°C, while the lower body was cooled until the bladder temperature reached 20°C. Mild hypothermia of the upper body maintained the beating heart, and deep hypothermia in the lower body provided adequate protection to the spinal cord. Furthermore, in a case of aortic valve regurgitation and low left ventricular function, left ventricular venting is essential for the heart. However, it was difficult to insert the venting tube through the apex of the left ventricle or through the left inferior pulmonary vein; therefore, we selected the left main pulmonary artery for left ventricular venting, and maintained a non-working beating heart. After cardiopulmonary bypass was discontinued, cardiac function was good although a bleeding tendency became apparent. Postoperatively, the maximum dose of dopamine we needed was only 3γ. There were no remarkable complications and the patient was discharged on postoperative day 30. This experience suggests that pulmonary artery venting and separate perfusion of the upper and lower body to individually control organ temperatures is a useful procedure for thoracoabdominal aortic aneurysm repair in patients with low left ventricular function.

A 74-year-old man who had received graft replacement of ruptured abdominal aortic aneurysm 6 years previously was admitted to our hospital because of hematemesis. Gastroduodenoscopy revealed no bleeding site in the stomach or the first and second portions of the duodenum. Preoperative CT scan demonstrated an adhesion of the aorta-duodenum at the proximal anastomosis of the prosthetic graft. Preoperative angiography demonstrated no leak of contrast material at the proximal anastomosis of the prosthetic graft. Therefore, we performed an emergency operation under a diagnosis of an aortoduodenal fistula. Operative reconstruction was performed with in situ grafting using a new prosthetic graft, and the greater omentum was used to fill defects surrounding the anastomotic site. We report a case of surgical treatment for an anastomotic aneurysm associated with a graft-duodenal fistula after abdominal aortic aneurysm repair.

We report the Lampshade Technique : a new technique using Carbo-Seal Valsalva (Sorin Biomedica, Saluggia, Italy) to facilitate preparation of a composite graft. A Bentall operation and an ascending aorta replacement were performed with a composite graft using a Carbo-Seal Valsalva. This new technique can be considered useful as it can reduce the time required for preparing a composite graft, and create a skirt portion for continuous suturing to prevent bleeding.

Primary cardiac malignant tumors are relatively rare, and their prognosis is poor. We report a patient with sarcoma causing severe mitral regurgitation and stenosis due to rapid and specific infiltration into the mitral valve.

A 59-year-old man had been treated at another institution for bacterial meningitis (Streptococcus pneumoniae). He had severe back pain and lumbago. Computed tomographic (CT) scanning of the chest and abdomen demonstrated saccular aneurysms at the diaphragm in the descending thoracic aorta and the infrarenal abdominal aorta. An extended left posterolateral retroperitoneal incision was performed for resection of the thoracoabdominal aneurysm and replacement of an in situ dacron graft with rifampicin using cardiopulmonary bypass. The abdominal aneurysm was resected and replaced by an in situ dacron graft with rifampicin. The grafts were covered with a pedicled omental flap. The tissue culture was negative. After subsequent intravenous antibiotic therapy for 2 months, the patient was discharged without any evidence of remaining infection.

Reflux hypersensitivity (RH) is one of the phenotypes of gastroesophageal reflux disease. The latest Rome IV defines RH as a condition with typical reflux symptoms and positive reflux-symptom association despite normal acid exposure. Subsequently, the Lyon consensus proposed detailed cutoff values for the criteria on the basis of experts’ consensus. Rome IV brought a clear-cut perspective into the pathophysiology of gastroesophageal reflux disease and the importance of esophageal hypersensitivity. This perspective can be supported by the fact that other functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia often overlap with RH. Although several possible pathophysiological mechanisms of esophageal hypersensitivity have been identified, there is still unmet medical needs in terms of treatment for this condition. This review summarizes the current knowledge regarding RH.

A 50-year-old man with an extensive thoracic aortic aneurysm underwent staged surgery which consisted of preceding total aortic arch replacement with the frozen elephant trunk technique using J Graft Open Stent Graft^®, followed by open thoracoabdominal aortic aneurysm repair. During the second operation, the descending aorta was cross clamped along with the preexisting stent graft, and Dacron graft was anastomosed directly to the stent graft using a running 4-0 monofilament suture. The anastomosis site was then covered with a short piece of Dacron graft identical with the stent graft in size to secure hemostasis. We herein discuss our approach in this complex case, focusing on prevention of inadvertent events such as deformation of the preexisting stent graft and unexpected bleeding.

Entrapment of an intravascular ultrasonography (IVUS) catheter is an infrequent but serious complication associated with percutaneous coronary intervention (PCI). We report a case of successful surgical treatment of an IVUS catheter entrapped in a coronary stent after PCI. An-80-year-old man was admitted to a hospital with sudden anterior chest pain. He underwent PCI to left circumflex branch (Cx) and left anterior descending artery (LAD), followed by IVUS to ascertain stent expansion of the LAD stent. The IVUS catheter became entangled in the stent and could not be withdrawn from the outside. The patient was transferred to our hospital for its surgical removal. For the emergent surgery, we opened the stent region in the LAD and directly removed the IVUS catheter with the twisted stent. The opened place in the LAD was directly closed. Additional coronary bypass grafting involving two vessels was performed. The postoperative course was uneventful with no graft occlusion.