Both aortic dissection and aortic aneurysm are complicated with disseminated intravascular coagulation (DIC) at the rate of four percent. DIC is said to be caused by the imbalance between coagulation and fibrinolysis and is classified into three types : suppressed fibrinolysis, balanced fibrinolysis, and enhanced fibrinolysis. Tranexamic acid has effects on suppressing the fibrinolytic system by inhibiting the mechanism by which plasmin decomposes fibrin. It is generally considered that the use of tranexamic acid for DIC is contraindicated. However, some reports show its effectiveness for non-infective chronic DIC. We illustrate two cases of DIC with enhanced fibrinolysis which are complicated with aortic dissection or aortic aneurysm that were successfully treated with tranexamic acid.

A 37-year-old man who fell from a truck had chest pain and we diagnosed blunt chest trauma. A chest computed-tomography displayed a traumatic cardiac tamponade. The patient was transported to our hospital for emergency surgery. After median sternotomy, there was no injury of heart and great vessels in the pericardial sac but a rupture of the pericardium. Bleeding and hematoma were found in the anterior mediastinal space. The cardiac tamponade was caused by the bleeding from anterior mediastinal space. Usually, blunt cardiac tamponade was caused by the bleeding from cardiovascular organs, however, we encountered a very rare cardiac tamponade due to the bleeding from the anterior mediastinal space.

We describe a case of an intracardiac foreign body that was treated by surgery. A 27-year-old man sustained a neck injury by a nail fired from a pneumatic nail gun, and was admitted to a hospital. Chest radiography did not show any abnormality, and his injury healed after 1week. A radiography performed during a routine medical checkup after 2 months indicated that a nail was located within the heart. He was subsequently admitted to our hospital for further examinations. Chest computed tomography (CT) revealed the presence of a nail-like foreign body in the right ventricle. We diagnosed the patient with an intracardiac foreign body that was related to the injury sustained 2 months previously, although the underlying mechanism was unknown. He underwent emergency surgery, and the foreign body was removed under cardiopulmonary bypass without any complications. When a rigid substance impacts the body at high speeds, we should consider that some fragments could remain embedded in the body. CT scans are very useful for the diagnosis and identification of foreign bodies.

We clinically reviewed 4 cases of redo cardiac surgery after previous CABG with functioning internal thoracic artery grafts. The patients consisted of 1 man and 3 women (76.8±8.3 years old). Internal thoracic artery (ITA) grafts were used in all patients. Furthermore, 2 mitral valve replacements, 1 aortic valve replacement and 1 replacement of the ascending aorta were performed as redo cardiac surgery. The heart was approached via a anterolateral right thoracotomy in 3 cases. Femoral artery cannulation was used for cardiopulmonary bypass, and the right superior pulmonary vein was exposed to vent the left ventricle in all patients. The functioning ITA grafts were not dissected and were clamped in all cases of the 4 patients, 2 underwent cardioplegic arrest under moderate hypothermia. We could not achieve cardioplegic arrest in 1 patient, and therefore we also performed deep hypothermic fibrillatory arrest. Another patient underwent deep hypothermic circulatory arrest. Serum CK-MB values were elevated in all cases (111.7±89.0 IU/l). However, these elevations did not correlate with intraoperative arrest duration or type of operative procedure performed. Operative mortality was 0%, and all patients were discharged with out any evidence of sequelae. Hypothermic fibrillatory arrest had an effective additional cardioprotective effect for incomplete cardioplegia in these 4 cases. Functioning ITA grafting was not necessary in dissection and clamping for cardioprotection. An anterolateral right thoracotomy provided a safe approach to the heart, avoiding functioning ITA graft injury.

A 37-year-old man who had suffered right chest pain while mowing weeds was transferred to our hospital. A chest roentgenogram revealed a needle-like foreign body overlying the cardiac silhouette and chest CT confirmed an intracardiac foreign body. The patient underwent emergency operation, and a foreign body was removed under cardiopulmonary bypass and performed cardiac repair. A foreign body penetrated right lung and reached it in the left atrial cavity. The patient recovered uneventfully without any symptoms of infections.

Although the pressure gradient (PG) and the effective orifice area (EOA) have been used as indices of prosthetic valve function, these values show correctly neither energy loss, nor increased workload. This study aimed to evaluate the prosthetic valve function using echocardiography and PG, EOA and energy loss index, a new index advocated by Garcia et al. These were calculated for 40 patients with aortic prosthetic valve replacement by SJM valve (19HP, 6 cases; 21mm, 16 cases; 23mm, 14 cases; 25mm, 4 cases). Preoperative and postoperative echocardiographic measurements and their variations were analyzed and compared according to the size of implanted valve. In the comparison before and after aortic valve replacement, left ventricular mass (383±151g vs 288±113g, p<0.01), SV1+RV5 on ECG (5.07±1.73mV vs 3.83±1.5mV, p<0.01), and diastolic left ventricular posterior wall thickness (14.4±3.7mm vs 12.9±2.8mm, p<0.05) decreased significantly after the operation. However, there was no significant difference according to the size of the prosthetic valve in these reduction rates caluculated by (preoperative value-postoperative value)/preoperative value. Small size prosthetic valves were used for patients with small diameter of left ventricular outflow tract (LVOT) (19HP, 18±2mm; 21mm, 21±2mm; 23mm, 23±4mm; 25mm, 27±3mm; p<0.01) and small body surface area (19HP, 1.5±0.2m²; 21mm, 1.5±0.2m²; 23mm, 1.7±0.1m²; 25mm, 1.8±0.1m²; p<0.01) in our study. There was a signifcant difference in EOA (19HP, 1.2±0.4cm²; 21mm, 1.9±0.7cm²; 23mm, 2.2±0.9cm²; 25mm, 3.5±1.1cm²; p<0.01), but not in ELI (19HP, 1.01±0.41cm²/m²; 21mm, 1.87±1.03cm²/m²; 23mm, 1.83±1.09cm²/m²; 25mm, 3.08±1.21cm²/m²; p=0.055) according to the size of the prosthetic valve. Small size prosthetic valves had small EOA, but showed satisfactory valve function in decreasing left ventricular hypertrophy and reducing LVM and ELI of small size was similar to that of large size.

A 65-year-old man had undergone coronary artery bypass grafting (CABG) using a left internal mammary artery graft 3 years and 5 months previously. Anginal pains recurred due to an occlusion of the left subclavian artery. A subclavian-subclavian artery bypass was performed using 8mm e-PTFE graft with rings and the results were excellent. This grafting procedure appears to be a safe and satisfactory reperfusion technique, and therefore we recommend its use in patients requiring CABG.

A 47-year-old man was admitted with symptoms of angina pectoris. After evaluating the patient, coronary artery bypass grafting (CABG) was performed. First, the left internal thoracic artery (LITA) was grafted to the obtuse marginal branch (OM), and then the right gastroepiploic artery (RGEA) was grafted to the posterior descending branch (PD). Just after completing anastomosis, we performed intraoperative thermal coronary angiography. The RGEA-PD was patent. However, the LITA-OM was not patent on thermal coronary angiography. After a re-anastomosis was done at the LITA-OM, thermal coronary angiography was again performed and the LITA-OM was found to be patent. The postoperative course was uneventful, and all grafts were patent on postoperative angiography. In conclusion, intraoperative thermal coronary angiography was found to be useful for CABG.

A 45-year-old woman with an 8-year history of systemic lupus erythematosus (SLE) was admitted with complaints of sudden onset of chest and back pain and syncopal attack. Aortography showed DeBakey type I acute aortic dissection. She has been maintained on a small dose of corticosteroids (prednisone 5mg/day). After antihypertensive drug treatment, a replacement of the total aortic arch and arch vessels was successfully performed. The postoperative course was uneventful and she has had no relapse of SLE.

We herein review the early results of minimally invasive coronary artery bypass (MIDCAB). From April 1994 to November 1998, 23 patients underwent MIDCAB, and 12 patients underwent coronary artery bypass grafting with cardiopulmonary bypass (CABG). We compared and analyzed the findings of these two groups. Regarding preoperative factors, the MIDCAB group included elderly patients, while the CABG group consisted of younger patients. However, the frequency of hemodialysis, respiratory disorders and cerebral vascular accidents did not differ significantly between the 2 groups. Regarding perioperative factors, the MIDCAB group needed a shorter operation time, and also had a lower bleeding volume, and a low incidence of blood transfusion. Regarding the postoperative course, the MIDCAB group needed a shorter artificial respiration time, and a shorter postoperative hospital stay, and no mortality was observed. The graft patency of the MIDCAB group was lower (88%) than the CABG group (100%). However, the graft patency of the MIDCAB group reached 94% after we used a stabilizer in the operation. In conclusion, the operation results of the MIDCAB group were comparatively better than those of the CABG group. Thanks to recent technological advances, the results of MIDCAB continue to improve. Though MIDCAB remains an invaluable operative modality for the treatment of one-vessel disease, surgeons must be careful to select appropriate candidates for this operative method.