We report a rare case of acute type A aortic dissection in a patient with rheumatoid arthritis (RA) being treated with tacrolimus. The patient was a 77-year-old woman, who had received implantation of 6 artificial joints and was treated with 3 mg/day of tacrolimus and 10 mg/day of prednisolone. Tacrolimus, one of the immunosuppressive drugs for severe RA, had been applied to her to reduce the amount of prednisolone. An emergency surgery was performed successfully and 20 mg/day of prednisolone was administered for RA instead of her preoperative regimen. Such simplification of RA medication was actually useful to us for managing her difficult postoperative care. Respiratory insufficiency with persistent preural effusion was regulated by non-invasive positive pressure ventilation (NPPV) and pleural drainage. Disuse syndrome was treated with enteral nutrition and rehabilitation. Such care was also useful for her recovery.

Sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of its origin among in the left sinus are scarce. This report describes a 38-year-old man with an isolated extracardiac unruptured aneurysm of the left sinus of Valsalva. The patient presented with chest pain due to compression of the main trunk of the left coronary artery by the aneurysm. The aneurysm was resected, and the aortic root was reconstructed using the Bentall procedure. Concomitantly, coronary artery bypass grafting (LITA-LAD) was added. Postoperative native coronary flow was fully restored, and his anginal symptoms disappeared despite occlusion of the additional LITA-LAD anastomosis. This type of case would be considered to not require concomitant CABG, since the cause of the coronary artery stricture was compression by an aneurysm in the left sinus of Valsalva.

A 61-year-old man was referred to our hospital for treatment of hemolytic anemia after ascending aortic replacement aortic dissection. Cine mode magnetic resonance imaging (MRI) showed stenosis at the proximal anastomostic site of a Teflon strip. We diagnosed hemolytic anemia induced by collision of red blood cells on the inverted felt strip. Conservative therapy with Sarpogrelate and β-blockers was effective to treat his hemolytic anemia. However, 7 years later he was re-admitted because of infective endocarditis at the aortic valve, and underwent aortic root replacement. Intraoperative findings showed a stiff and inverted Teflon felt strip causing stenosis of the proximal anastomosis. Hemolytic anemia should be considered a rare complication of using a Teflon felt strip to reinforce anastomosis for acute aortic dissection.

There is an impression among cardiothoracic surgeons that the technique of profound hypothermic circulatory arrest (PHCA) is associated with an increased bleeding tendency compared to conventional bypass surgery. In addition to the recognized factors contributing to the hemorrhagic tendency seen in moderate hypothermic cardiopulmonary bypass (CPB), it is likely that the lower temperature utilized in PHCA may exacerbate platelet dysfunction. In this report, platelet counts and functions at the same cardiopulmonary bypass time were compared in human PHCA surgery (hypothermia group, n=16) and moderate hypothermic cardiopulmonary bypass surgery (control group, n=20). Mean platelet count corrected by hematocrit in the hypothermia group at 2h of CPB was significantly lower than in the control group (3.7×10⁴μl vs. 11.4×10⁴/μl, p<0.0001). In the hypothermia group, there were significant increases in the percentage of GMP-140 (P-selectin)-positive platelets (11.8% vs. 8.3%, p=0.0091) at 1h of CPB, and also in microparticles (24.8% vs. 10.5%, p<0.0001) and aggregated platelets (3.4% vs. 1.4%, p=0.0058) at 2h of CPB. Profound hypothermic circulatory arrest used in surgery for aortic arch aneurysm or dissection may cause irreversible platelet dysfunction and contribute to hemorrhagic tendency during the surgery. To minimize platelet dysfunction during CPB, the lowest blood temperature should be maintained above 15°C.

A 72-year-old woman was admitted as an emergency case to our hospital because of chest oppression. She had a history of admission due to the same symptoms about 9 months previously. Her chest computed tomography showed a dissection of the ascending aorta (DeBakey type II). We suspected an acute aortic dissection and an emergency operation with CPB was performed. The ascending aorta was markedly enlarged, but the dissected adventitia did not appear weakened. Moreover, there was no bloody pericardial effusion which is specific to acute aortic dissection. When the pseudo-lumen was exposed, a firm intimal flap and single entry hole were recognized. The chronic phase of aortic dissection was finally diagnosed. Then the dissected adventitia and intimal flap were removed and a patch graft aortoplasty with a tailored 26mm gelatin-impregnated knitted Dacron vascular graft was employed because the residual aortic wall was normal in size and consisting. Her postoperative course was uneventful and there was no evidence of recurrence of aortic dissection or enlargement 2 years after the operation. We conclude that patch aortoplasty for repair of chronic aortic dissection can be effective when the range of dissection is restricted and to residual aortic wall is normal.

Lung hemorrhage associated with pulmonary reperfusion injury is a rare but lethal condition. We presented a case salvaged by non-heparinized extracorporeal life support for massive lung hemorrhage after pulmonary thromboembolectomy. Sub-acute pulmonary thromboembolism with a floating right atrial thrombus was diagnosed in 63-year-old woman by computed tomography and echocardiography. An emergency pulmonary thromboembolectomy was performed using cardiopulmonary bypass and moderate hypothermia. Immediately after reperfusion, extraordinary lung hemorrhage occurred and continued. We decided to take over the standard cardiopulmonary bypass with a non-heparinized extracorporeal life support system. Fortunately, hemostasis of the lung hemorrhage was completely secured within 12h, and the extracorporeal life support was terminated at 20h after the surgery. The patient was extubated at 48h after the surgery, and was discharged after the insertion of an inferior vena cava filter for a floating deep venous thrombus. Although the necessity, efficacy and risk of the non-heparinized extracorporeal life support should be clarified, we conclude that it could be the treatment of choice for life threatening lung hemorrhage associated with pulmonary reperfusion injury.

A 22-year-old man was hospitalized due to severe back pain having being diagnosed as Stanford type A aortic dissection, AAE, mitral regurgitation and pectus excavatum associated with Marfan's syndrome. A single staged operation including ascending aortic replacement, mitral valve replacement and sternal turnover with a rectus muscle pedicle was carried out in order to keep the blood supply to the plastron to reduce the risk of infection during such a long operation. By this approach, it was found that the operative field was excellent and postoperative hemodynamics were stable. However, frail plastron occurred because of difficulties in keeping the patient stabilized because of severe pain thus re-fixation was required. The necessity of strong pain control after such an operation was also recognized.

A 72-year-old man presented with chief complaints of back pain. Medical workup discovered infrarenal abdominal aortic aneurysm (AAA) with Stanford type B acute aortic dissection on CT. The dissection originated distal to the left subclavian artery and extended to the right commom iliac artery. All visceral arteries branched from the false lumen. The maximum diameter of the thoracic aneurysm was 4.8cm and that of the abdominal aneurysm was 6.5cm. Multiple renal infarcts were noted and the right kidney function was decreased. Initial surgery was performed 3 months after presentation using a graft technique. Advanced atherosclerosis and dissection were noted in the aneurysm making the arterial wall quite vulnerable. Hemorrhage was extensive and hemostasis difficult in the defective arterial wall. The patient became unstable so the aneurysm was closed and the surgical procedure was changed to right axillo-bifemoral bypass rather than the original surgical plan of anatomic reconstruction of the AAA. The patient tolerated the procedure well. We report a rare case of acute aortic dissection which extended through the AAA.

The incidence of ventricular subepicardial aneurysm following myocardial infarction is quite low. We report a case of subepicardial aneurysm that was diagnosed on postoperative pathohistologic examination. A 69-year-old man was admitted to our hospital because of left ventricular aneurysm following myocardial infarction. The patient had left main trunk disease, triple-vessel coronary artery desease and low output syndrome. Under cardiopulmonary bypass with the heart arrested, the aneurysm was resected and the defect was closed. The suture line was reinforced using Teflon felt and GRF glue. A saphenous vein graft was anastmosed to the left anterior descending artery. On pathohistologic examination, the wall of the aneurysm was found to be composed of fibrotic tissue, myocardial fibers, medium-sized pericardial arteries, epicardium and fibrin thrombi. We diagnosed this as subepicardial aneurysm.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.