A 51-year-old woman was referred to our hospital for investigation of an abnormal ECG. Transesophageal echocardiogram revealed a round mass which originated from the right coronary cusp of the aortic valve. The tumor was successfully excised from the aortic valve, and the postoperative echocardiogram showed normal aortic valve function. Pathological examination demonstrated papillary fibroelastoma.

Between October, 1992 and April, 2002, 40 patients underwent thoracic aorta surgery using antegrade selective cerebral perfusion. There were 29 men and 11 women, with a mean age of 67.2±8.1 years (range 45 to 79 years). Twenty-one patients were emergency (emergency group), and 19 were elective procedures (elective group). We compared preoperative, intraoperative and postoperative factors between the emergency group and elective group. In the emergency group, 15 patients underwent an ascending aortic replacement, 5 patients underwent a total arch replacement, 1 patient underwent a partial arch replacement. In the elective group, 2 patients underwent an ascending aortic replacement, 17 patients underwent a total arch replacement. Hospital mortality occurred in 5 patients in the emergency group (23.8%) and 1 in the elective group (5.2%). A permanent neurologic defect occurred in 1 patient in the emergency group (4.7%) and 1 in the elective group (5.2%). The results of surgical treatment of aortic surgery using antegrade selective cerebral perfusion were satisfactory.

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.

Three surgical cases of postinfarction left ventricular free wall rupture (LVFWR) are described. Patient 1, a 76-year-old woman, developed LVFWR of the posterior wall after acute myocardial infarction (AMI). Coronary arteriography (CAG) revealed total occlusion of left circumflex artery (Cx) (#11). Direct closure of the myocardial tear was performed using cardiopulmonary bypass (CPB) and cardiac arrest. Patient 2, a 67-year-old man, developed LVFWR of the anterior wall after AMI. CAG revealed total occlusion of left anterior descending artery (LAD) (#7). He was placed on a percutaneous cardiopulmonary support system (POPS) prior to the operation and direct closure of the myocardial tear was performed with the heart beating. Patient 3, a 57-year-old man, developed LVFWR of the posterior wall after AMI. CAG revealed total occlusion of Cx (#13). He was placed on PCPS prior to the operation and direct closure of the myocardial tear was performed using CPB and cardiac arrest. Patients 2 and 3 who were placed on PCPS prior to the operation successfully underwent emergency operations. In all cases, 2-0 Prolene horizontal mattress sutures with Teflon felt strips were used through the infarcted area in order to close the myocardial tear.

Sixteen consecutively seen patients underwent surgical repair for complications following acute myocardial infarction. There were two cases with acute mitral regurgitation due to posterior papillary muscle rupture, who underwent mitral valve replacement with a prosthetic valve. There were three cases of postinfarction left ventricular free wall rupture. In all cases, horizontal mattress suture with Teflon felt strip was used in order to close the myocardial tear. The two out of three who survived had been placed on percutaneous cardiopulmonary support prior to the operation. There were 11 cases of postinfarction ventricular septal perforation. The surgical procedures consisted of simple patch closure (Daggett's method) in 7 cases, direct closure in one case, apical amputation in one case and endocardial patch repair with infarct exclusion (Komeda-David method) in the most recent two cases. Six out of eleven survived. Early diagnosis and surgical treatment are mandatory to save these patients. Intraaortic balloon pumping and percutaneous cardiopulmonary support prior to the operation have been used to advantage in some patients.

A 72-year-old man suffering from postinfarction angina and atrial septal defect (ASD) underwent a combined operation of four bypass graftings and direct closure of ASD. The great saphenous vein was harvested with the use of a bipolar Nd-YAG laser dissector without scissors or threads. Nd-YAG laser (wavelength: 1.064um) was irradiated to the branches of the saphenous vein through the ceramic tips of the dissector. After about five minutes exposure, the branch was dissected and bleeding from the dissected edge was not seen. Postoperative angiogram six months after grafting showed all grafts were patent, and morphological abnormalities such as reginoal shrinkage, diffuse narrowing and aneurysmal dilation were not observed. We conclude that laser graft harvesting using the bipolar dissector is safe and effective in saving time.

Although the results of surgical treatment for acute type A dissection have improved because of progress in surgical techniques, the prognosis is still very poor and optimal therapeutic approach is still not clearly established for cases of acute dissection complicated with malperfusion. Of 134 patients who presented with acute aortic dissection between January 1986 and June 1999, 57 had acute type A dissection and 10 had acute type A dissection with malperfusion. Patient age ranged from 53 to 78 (average, 64.6) years. There were 6 men and 4 women. There was accompanying cerebral ischemia in 3 cases, coronary ischemia in 1, visceral ischemia in 5, renal ischemia in 2, ischemia of the extremities in 7, and multiple organ ischemia in 5. One patient died before surgery, and another patient died after sternotomy due to aortic rupture. The other 8 patients underwent surgical operations. The following surgical procedures were performed: bypass grafting to the superior mesenteric artery was performed in 1 patient, stent implantation to the right coronary artery followed by ascending aortic replacement (19th day after onset) was performed in 1, and aortic repair (5 ascending aortic replacements and 1 hemiarch replacement) in the acute phase was performed in 6. The mortality rates were 66.7% (2/3) in patients with cerebral ischemia, 0% (0/1) in the patient with coronary ischemia, 80% (4/5) in those with visceral ischemia, 100% (2/2) in those with renal ischemia, 42.9% (3/7) in those with ischemia of the extremities, 80% (4/5) in those with multiple organ ischemia, and 50% (5/10) in all cases. All patients whose base excess (B.E.) was less than -10mEq/l on admission died (4/4). We conclude that in order to improve surgical results in patients with acute type A dissection with malperfusion, different approaches may be required for each patient. The combination of aortic repair and percutaneous reperfusion are important. Arterial blood gas analyses were simple, and the values of B. E. at admission were useful to determine the surgical strategy in these patients and to predict their prognosis.

Since arteriosclerosis is a general progressive disease, an aneurysm of the thoracic aorta is not infrequently complicated by ischemic heart disease. Therefore, assessment of indications of surgical treatment and selection of the surgical procedure and auxiliary procedures on the basis of accurate preoperative evaluation of ischemic heart disease are considered to be very important for improving the results of operations for thoracic aortic aneurysm. Recently. we successfully operated on a 64-year-old patient with a left ventricular aneurysm and a descending aortic aneurysm. One-stage operation was performed by a left thoracotomy approach and partial left heart bypass by draining the pulmonary artery into the femoral artery with mild hypothermia. The approach and the auxiliary procedures employed in this patient are considered to be a useful combination applicable also to one-stage operation for descending aortic aneurysm and coronary artery bypass grafting.

A 60-year-old woman underwent surgical treatment of postinfarction ventricular septal perforation (VSP) in the early phase after receiving total cardiopulmonary bypass without aortic occlusion. VSP developed four days after anterior myocardial infarction. On admission, inraaortic balloon pumping was used to obtain hemodynamic stabilization. On the day of admission, emergency total cardiopulmonary bypass was performed. VSP was closed with a Dacron felt patch positioned on the left side of the septum. The anterior wall of the left ventricle was closed with Dacron felt strips and reinforced using a Gore-Tex sheet. Postoperative hemodynamics improved significantly. Although the operation while the heart was beating was difficult technically, the total cardiopulmonary bypass time of this method was not longer than that of operations under cardioplegic arrest. Further more, the area of infarction was easily distinguished by color and bleeding. The surgery during normothermic heart beat was effective in preventing further ischemia of the myocardium. The surgical treatment of VSP in the early phase during normothermic heart beat under total cardiopulmonary bypass was considered to be more effective and safer than operations under cardioplegic arrest.