We report 4 cases of aortic graft replacement for Kommerell diverticulum (KD) and the aberrant subclavian artery (ASA). In two patients who had a right-sided aortic arch, KD and the left ASA, we performed descending aorta replacement and in-situ reconstruction of the left ASA via a right lateral thoracotomy. Third patient had a left-sided aortic arch, KD and the right ASA, in whom we performed descending aorta graft replacement via a left lateral thoracotomy with ostial closure of the right ASA. Fourth patient had a left-sided aortic arch, KD and the right ASA, and complicated by acute type A aortic dissection. We performed a total arch repair with frozen elephant trunk procedure via a median sternotomy. All 4 patients survived operations and discharged from the hospital with symptom relief. The choice of approach, a thoracotomy or a median sternotomy, should be based on patient-specific anatomy and extent of graft replacement.

We present herein a case of disc fracture of a Björk-Shiley valve prosthesis in the mitral position. A 69-year-old woman was admitted to our hospital with a sudden onset of dyspnea followed by deep shock. An echocardiography showed a severe degree of mitral regurgitation and moderate degree of tricuspid regurgitation. Forty-three years previously she had undergone a mitral valve replacement (MVR) for stenosis with the original version of a Björk-Shiley valve prosthesis in another institute. Emergency redo MVR was performed with a bioprosthesis and tricuspid annuloplasty with a semirigid ring. The disc of the extracted Björk-Shiley valve was found to have escaped from the metal housing with two intact struts. Although Björk-Shiley valve dysfunction due to Delrin disk abration has been rarely reported, complete disk fracuture is extremely rare. The important role of regular echocardiographic follow-up should be emphasized to prevent fatal valve fracture.

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.

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 49-year-old woman with systemic lupus erythematosus (SLE) underwent grafting for abdominal aortic aneurysm. She had been receiving steroid therapy for 23 years. The abdominal aneurysm was a saccular type, 7cm in width. It had thick mural thrombi with focal calcification, however, no inflammatory findings were recognized around it. Replacement with 16mm Dacron tube graft was performed. The postoperative course was uneventful. Pathological examination showed only atherosclerotic change with no specific inflammation in the aneurysmal wall. It is rare that SLE patients have aortic aneurysm. However, SLE patients should be carefully followed because of their premature atherosclerotis.

Total aortic arch repair was performed simultaneously with the aortic root replacement using Cabrol's method in a 61-year-old man with recurrent aortic dissection. Two months prior to admission the patient had undergone a separate replacement of the aortic valve and ascending aorta for acute type A dissection with aortic regurgitation due to a bicuspid valve. He developed a suture line disruption caused by recurrent dissection in the aortic root which had been reinforced with GRF glue on the first operation. During the second operative procedure the dilated aortic arch with the remnant false lumen was found to be extensively injured. Therefore total arch replacement was required in addition to aortic root reconstruction preserving the previously placed mechanical valve.

A 62-year-old woman was admitted suffering from chest tightness and palpitations. Coronary angiography revealed slight stenosis of the coronary artery requiring medical treatment. At that time right renal artery aneurysm was found accidentally. In addition abdominal echogram showed gallbladder stone. She underwent aneurysmectomy with reconstruction of the right renal artery and cholecystectomy. Postoperative course was uneventful and renal arteriography one month after operation depicted the patent right renal artery. Surgical indications for renal artery aneurysm should be carefully considered.

Clinical evaluation of perioperative IABP use in valvular heart surgery was studied. There were 4 preoperative, 18 intraoperative and 20 postoperative applications of IABP. The indications of IABP were LOS in 19 patients, failed weaning from bypass in 11, life threatening arrhythmia in 11, and congestive heart failure in 1. Sixteen out of 26 patients with successful weaning from IABP support could be discharged. Ten died after removal of IABP. Longer duration of cardiopulmonary bypass and aortic clamp, lower value of cardiac index 24 hours after introduction of IABP support were implicated in unsuccessful IABP support. The causes of death were due to LOS in 8 patients, MOF in 12, GVHD in 2, others in 3. The outcome of IABP for patients with valvular heart surgery was not satisfactory. However, the results of IABP support in valvular surgery will be improved by reducing the incidence of postoperative complications, especially LOS, followed by MOF.

From 1978 through 1992, 103 patients (mean age: 69 years) underwent elective repair of abdominal aortic aneurysm (eAAA) at our institute. One or more postoperative complications occurred in 30 patients (29%), with mortality rate of 1.9%. Factors significantly associated with postoperative complications by univariate analysis included male sex (p=0.0082), operation time (p=0.0006), size of aneurysm (p=0.0045), blood loss during operation (p=0.0037), decreased pulmonary function (p=0.0155), and the number of platelet counts (p=0.0468). Simple linear regression analysis showed that there was a significant correlation among AAA size, operation time and blood loss. Age at operation, however, did not have any influence on morbidity and mortality. Complete survival information was obtained in 96 (follow up rate of 95%) patients, and the influence of preoperative risk factors on late survival was also examined by the Kaplan-Meier method. Factors influencing long-term survival were renal dysfunction and age at time of operation.

Elective resection of abdominal aortic aneurysms is now a safe operation, though mortality related to ruptured abdominal aortic aneurysm (rAAA) remains high. To evaluate factors affecting survival after rAAA, 26 consecutive cases were studied. The operative mortality was 58% (15/26) compared with 1.8% for 110 elective AAA patients. Factors associated with poor prognosis were blood pressure of less than 90mmHg and profound acidosis of the arterial blood on admission, size of the aneurysm, and massive transfusion. The high mortality and morbidity rate for the rAAA patient emphasize the need for early and aggressive treatment of AAA in elective cases at high risk. In a follow-up study, however, the survival rate of rAAA, excluding hospital mortality, was 71% at five years and there was no significant difference in quality of life as compared with those patients who had elective AAA resection during the same time interval.