A 40-year-old woman presented with Salmonella enteritidis endocarditis involving the mitral valve. A severe degree of congestive heart failure developed despite appropriate medical and antibiotic treatment, and resulted in urgent surgical intervention in the active phase of the infection. She underwent successful mitral valve replacement with a mechanical valve, followed by additional antibiotic infusion with adequate distribution to the biliary system to prevent late reactivation of the organism. Although antibiotic therapy is fairly effective for patients with Salmonella enteritidis, early rather than procrastinated surgical treatment is recommended to minimize damage to the valve and surrounding structures.

A 77-year-old woman was referred to our hospital for treatment of a ruptured thoracoabdominal aortic aneurysm (TAAA) with a maximum diameter of 7cm. Considering her age and level of daily activity, the placement of an endovascular stent graft was performed as an emergency rescue procedure. For termination of the endoleak from the distal portion of the stent graft detected by CT the next day, another stent graft placement was added after establishment of blood supply to the superior mesenteric and celiac arteries by placing a Y-shaped graft from the abdominal aorta to each artery with success. The patient was discharged from our hospital 25days after surgery with disappearance of endoleak and good graft patency. A hybrid technique with grafting to abdominal branches, followed by placement of stent graft, can be an alternative treatment for such high-risk patients with ruptured TAAA.

To evaluate a comparison for endovascular repair (EVAR) versus open repair (OR) for the treatment of abdominal aortic aneurysm (AAA). Data of all patients with infrarenal AAA treated electively, both with OR (107 cases) and EVAR (24 cases), at our institute between January 1999 and March 2004 were retrospectively reviewed. No difference was found between the 2 groups for sex, age, and AAA size. Cases of chronic obstructive pulmonary disease (20.8% vs 6.5%, p<0.04) and frequencies of laparotomy (25% vs 2.8%, p<0.001) were significantly more in the EVAR group than the OR group. In the initial results, deployment of the stent grafts was successful in all cases and complete thrombosis of the aneurysm was achieved in 21 cases (87.5%). One graft occlusion and a wound infection occurred in the EVAR group. OR was successfully performed in all cases. These were 6 cases of paralytic ileus, 1 of re-operation for hemorrhage, 1 of respiratory failure, and 1 of ischemic colitis in the OR group. One hospital death occurred in each group. Mean blood transfusion (0ml vs 238±345ml) and operation time (131±53min vs 250±76min) were significantly less in the EVAR group than the OR group. In the long term results, the cumulative survival rate was 88.0±6.5% at 1 and 2 years, 80.6±9.2% at 3 years in the EVAR group; 99.0±0.9% at 1 year, 94.1±2.6% at 2 years, 87.7±3.9% at 3 years in the OR group, with no difference between the 2 groups regarding survival rate. Four new endoleak and 3 graft infections were encountered in the EVAR group. Freedom from stent graft-related complications was 81.3±8.5% at 1 year, 61.4±11.9% at 2 years, 47.8±12.6% at 3 years in the EVAR group, but 100% at 1, 2 and 3 years in the OR group. Freedom from procedure-related complications in the EVAR group was significantly lower than that in OR group. In the long term results, EVAR was associated with more procedure-related complications. This finding may justify reappraisal of currently accepted EVAR for AAA management strategies.

There is disagreement regarding the indications of surgery for cases of severe aortic stenosis (AS) with a decrease in left ventricular ejection fraction (EF) and a low aortic pressure gradient (PG), since there is a high perioperative risk associated with this condition. Hence, we investigated the surgical outcome of AS cases with impaired left ventricular function. Our department performed 144 aortic valve replacements (AVRs) for cases of AS and AS-dominant mild regurgitation (ASr) between January 2000 and September 2005. Among these cases, 9 patients had an EF under 35%, and these patients were selected as subjects and compared with a control group with an EF of more than 35%. Patients with accompanying coronary artery diseases that required treatment were excluded to avoid confounding effects on cardiac function. The mean age of the 9 subjects (4 men and 5 women) was 67.8±10.8 years old, with a range from 53 to 80 years old, and the subjects had the following mean background data: EF, 34.4±0.5%; left ventricular end-diastolic dimension (LVDd), 57.3±5.8mm; left ventricular end-systolic dimension (LVDs), 49.3±5.7mm; interventricular septum thickness (IVSth), 11.9±1.9mm; and left ventricular posterior wall thickness (LVPWth), 11.1±2.6mm. Characteristics such as left ventricular dilatation and thinning of the left ventricle myocardium were noted in these data. The cases were classified as severe AS because the mean aortic valve area (AVA) was 0.58±0.2cm², but the peak aortic pressure gradient (peak PG) (65.2±32.7mmHg) in the 9 subjects was lower than that of the control group (97.0±65.2mmHg). All 9 subjects underwent aortic valve replacements (AVRs), with simultaneous mitral annuloplasty (MAP) in 3 cases, mitral valve replacement (MVR) in 1 case and performance of a Maze procedure in 1 case. No deaths occurred while the patients were in hospital. Postoperative complications included 2 cases of transient atrial fibrillation and 1 case of postoperative bleeding requiring rethoracotomy for hemostasis. The EF in the late postoperative period showed improvement in 8 cases and was unchanged in the remaining case; the mean postoperative EF was 56.9% for the 9 subjects. All cases were rated as improved based on the NYHA classification of cardiac performance, and the significant improvement in EF in 8 of the 9 cases suggests that surgery is safe and can improve prognosis for patients with advanced AS with myocardium thinning and decreased EF.

Surface induced hypothermia was introduced in six cases with low cardiac output syndrome after open heart surgery to reduce oxgen consumption. The patients were consisted of two ACBG, two LV rupture after MVR, MVR with ACBG and AVR with poor LV function. Hemodynamic changes such as heart rate, mean arterial pressure, cardiac index, systemic vascular resistance, pulmonary artery wedge pressure, were measured every 3-4 hours throughout the course of hypothermia. Acid-base balance, mixed venous oxgen saturation and oxygen consumption were also monitored. Hypothermia was induced using a blanket and ice-beutels. Temperature in hypothermia was maintained at about 33°C. We are intended to increase SVO₂ up to the level of 50% and to improve anerobic condition. Hypothermia was continued for 45 hours in the shortest and 148 hours in the longest case with a mean of 78 hours. Arrythmia was not seen. Hemodynamic and acid-base balance were in significantly changed in comparison of the control values. However, SVO₂ and VO₂ changed significantly after introduction of hypothermia. They increased from 47.8±7.5% to 58.7±7.9% and reduced from 231±29.7 to 188±31.3ml O₂/min respectively. Hemodynamic condition was improved and IABP was successfully weaned in all cases. We suggest that the use of hypothermia is one of the effective modality in the management of low cardiac output syndrome after open heart surgery.

A 74-year-old man undergone mitral valve plasty. After cessation of cardiopulmonary bypass, bleeding persisted from the cardioplegia injection site and dilatation of the ascending aorta with discoloration was observed. The diagnosis of type A aortic dissection extending to the descending aorta was made by transesophageal echocardiogram. Replacement of the ascending aorta was performed under deep hypothermic circulatory arrest. The postoperative course was uneventful. The false lumen of the aortic arch and descending aorta was thrombosed completely on postoperative computed tomography. Intraoperative aortic dissection is a rare but fatal complication of cardiopulmonary bypass. Prompt recognition and appropriate surgical management are of prime importance.