A 55-year-old man was brought to our hospital with a knife penetrating his left anterior chest wall following a suicide attempt. Massive left hemothorax was identified on echocardiography ; however, there was no evidence of cardiac tamponade. After draining blood from the left thorax, computed tomography (CT) revealed that the tip of the knife had penetrated the left lung and reached the left pulmonary vein. In preparation for cardiopulmonary bypass, an emergency thoracotomy was scheduled with a plan to access the left lung and left pulmonary vein. The patient was transferred to the operating room, and the procedure was started with the patient in the supine position. During dissection of the femoral vessels, the patient suddenly developed hypotension. After surgical access to the heart was achieved via median sternotomy, a pericardiotomy was performed and cardiopulmonary bypass was established. A 50-mm stab wound was identified at the lateral wall of the left ventricle. The knife was removed, and the left ventricular wound was repaired. The lingular segment of the left lung was partially resected. The patient had no postoperative complications and was transferred to the referral hospital on postoperative day 25. This case report emphasizes the importance of taking appropriate measures for thoracotomy and cardiopulmonary bypass in patients with penetrating thoracic trauma with massive hemothorax, even in the absence of cardiac tamponade on imaging. We were able to successfully manage a life-threatening condition by taking appropriate measures.

Hydrophilic polymer embolism (HPE) associated with endovascular therapy has steadily gained attention. We report a case of a 70-year-old man who had undergone one-debranched TEVAR. He had a history of distal arch replacement for dissecting aortic aneurysm 14 years earlier. Pseudoaneurysm at the proximal site of graft anastomosis was found on computed tomography (CT) angiogram during the follow-up. 1 debranching TEVAR was performed using the pull-through technique. Fourth days after the procedure, a skin rash appeared in the right lower extremity around the access site. Skin biopsy with pathological examination revealed HPE. We decided to observe a patient because there was no symptom of limb ischemia. Skin lesions improved and he was discharged on the 27th postoperative day. Hydrophilic polymers are widely used in the endovascular devices and there is an urgent need to better understand the complication of HPE.

A 92 year-old-female with melena was admitted to our hospital. She underwent Y-graft replacement of the abdominal aorta at the age of 65. Gastroduodenal fiberscopic examination and computed tomography (CT) confirmed the diagnosis of aortoduodenal fistula. The fistula in the proximal anastomotic site was occluded with a suture ligature and omentopexy was performed. On the 15th post-operative day she developed high-grade fever. CT revealed a pseudoaneurysm formation at the proximal anastomosis site. She underwent emergency endovascular aneurysmal repair (EVAR). Her postoperative course was uneventful. She is doing well without symptoms of recurrent infection.

Cor triatriatum is a rare congenital cardiac anomaly in which the accessory chamber is separated from the left atrium by an anomalous septum. We report a rare case of cor triatriatum with severe mitral regurgitation and atrial fibrillation in an adult. The patient was a 65-year old woman who developed congestive heart failure 3 years previously, and received medical follow-up with mitral regurgitation, atrial fibrillation and cor triatriatum since then. She developed congestive heart failure again and was referred to our hospital for operation for progressed mitral regurgitation, tricuspid regurgitation and atrial fibrillation. Mitral valve plasty (Physio ring II 28 mm, cleft closure, edge to edge repair for PMC), tricuspid annuloplasty (Physio tricuspid ring 28 mm), resection of the anomalous septum and maze procedure was performed. All of the pulmonary veins were connected to the accessory chamber. There was only one hole on the anomalous septum, and the hole was large, about 3.0 cm in diameter. The patient regained sinus rhythm without mitral and tricuspid regurgitation after the operation. Even though the duration of atrial fibrillation was long and left atrium diameter was large, complete excision of the anomalous septum and maze procedure were effective for the patient diagnosed cor triatriatum.

A 60-year-old man on chronic hemodialysis was found to have severe aortic stenosis causing refractory atrial fibrillation elected to undergo aortic valve replacement. However, chest CT scan revealed a severely calcified ascending aorta which prevented safe aortic cross-clamping. At operation, arterial cannulation of the systemic circulation was performed to a graft anastomosed to the right axillary artery and venous cannulation to the right atrium. Cardiopulmonary bypass was started and the body was cooled. When a rectal temperature of 25°C was achieved, cardioplegic solution was administered retrogradely to achieve cardiac arrest and circulatory arrest was performed. Immediately, brachiocephalic artery was clamped and a single selective cerebral perfusion (SCP) was started with right axillary perfusion. In addition, a selective cerebral perfusion was added via the left common carotid artery to maintain adequate flow. After anastomosing the tube graft to the distal ascending aorta, cardiopulmonary bypass was restarted, a clamp was placed on the tube graft, and the patient was rewarmed. The aortic valve was excised and a 21-mm SJM-Regent valve was placed in the intra-annular position. The systemic circulatory arrest time was 18 min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without complications. The ascending aorta replacement described here for the treatment of aortic valve disease in a patient with a severely calcified aorta is safer than deep hypothermic circulatory arrest alone, allowing a shorter circulatory arrest period. In addition, selective cerebral perfusion by right axillary artery anastomosed graft is advantageous in that we can start selective cerebral perfusion promptly by clamping the brachiocephalic artery.

We report a case of aneurysm located at the right sinus of Valsalva with mild aortic regurgitation (AR). The patient was a 55-year-old man with hypertension. When he consulted a local doctor complaining of back pain, aneurysm of right sinus of Valsalva was unexpectedly diagnosed by detailed examinations. He was transferred to our hospital for surgery. An echocardiogram showed mild aortic regurgitation and enlargement of the right sinus of Valsalva. Computed tomography demonstrated an unruptured and extracardiac aneurysm of the right sinus of Valsalva (diameter, 45 mm) and a right coronary artery (RCA) that originated from just above the ostium of the aneurysm. He underwent a partial aortic root remodeling procedure with trimmed Hemashield graft and the RCA was anastomosed to the Hemashield graft by the Carrel patch technique. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. Postoperative angiography revealed that aneurysm of the right sinus of Valsalva was not enhanced and the RCA was patent. This procedure preserve the patient's own aortic valve and normal sinus of Valsalva and enabled him to have more physiologic hemodynamics than patch closure, although progression of the AR requires careful follow-up.

A 75-year-old man was admitted to our hospital with a pulsatile mass in the bilateral groin. He had received placement of a Y-shaped Cooley double velour knitted Dacron graft 20 years previously for arteriosclerosis obliterans. Computed tomography demonstrated an aneurysm near the distal anastomosis of the graft. Based on a clinical diagnosis of a non-anastomotic aneurysm, an operation was performed. When the right aneurysm was incised, it was found that the anastomosis of the graft to the common femoral artery was intact and that the graft itself had a defect, 1.5 cm in size near the distal anastomosis of the graft. The final diagnosis of the right groin aneurysm was a non-anastomotic false aneurysm due to prosthetic graft failure. The left groin aneurysm was a true aneurysm due to arteriosclerosis. After resection of the bilateral aneurysm, graft interposition with an expanded polytetrafluoroethylene (ePTFE) graft was successfully performed. Generally, arterial grafts below the groin are subject to high levels of mechanical stress, and graft failure is not uncommon. Vascular surgeons should keep in mind that graft failure is not rare in patients with long-standing prosthetic graft.

We report a case of successful surgical treatment for acute aortic dissection in a patient with late pregnancy with Marfan syndrome. The patient was a 32-year-old primipara. She experienced sudden precordial pain and visited on other hospital at 29 weeks' gestation. She was given a diagnosis of acute type A aortic dissection on computed tomography (CT), and was referred to our hospital for surgery. The earliest possible operation was required, but, in view of the risk of massive bleeding following placental separation due to heparin administration for cardiopulmonary bypass, Caesarian section and abdominal total hysterectomy were initially performed, followed 2 days later by the Bentall procedure plus prosthetic graft replacement of the ascending aorta and aortic arch in a two-stage operation. The postoperative course of the mother and infant was uneventful. The treatment strategy for Marfan syndrome complicated by aortic dissection in late pregnancy is very important. We were able to safely perform surgery and perioperative management using a two-stage operation, that is, by performing Caesarian section first, then strictly controlling circulatory dynamics under sedation and artificial ventilation in the ICU, and subsequently performing repair of the heart and aorta after the subsidence of obstetric hemorrhage.

We report a case of surgical treatment for pseudoaneurysm 19 years after aortic root replacement. The patient was a 57-year-old female who had undergone aortic root replacement (Piehler procedure) in another hospital due to acute Stanford A type aortic dissection in 1988, and was then followed up at another hospital. However, a low density area around the artificial graft was pointed out on computed tomography (CT) in 2001, which increased to 60mm in size by November, 2006. She was then referred to our hospital for a redo operation. Pseudoaneurysm of the anastomosis and mitral regurgitation (MR) was diagnosed by the examination of the CT, angiography, etc., and we performed ascending aorta and aortic arch replacement, and mitral valve replacement (MVR) in April, 2007. A slight hemorrhage were found at the anastomosis of the artificial graft-artificial graft. Deterioration of the artificial graft or deterioration of the suture was suspected as the cause of the slight hemorrhage from the anastomosis a long period after the operation. In this case, loosening of the suture string was revealed, so the latter was more strongly suspected.

A 56-year-old man was admitted to our institution with sudden onset of severe chest pain and ischemia of the lower extremities on February 24, 2007. An enhanced computed tomography scan showed acute Stanford type A aortic dissection. Electrocardiography showed ST segment elevation in leads V_1-4 and a transthoracic echocardiogram revealed antero-septal wall akinesis. The patient was given a diagnosis of acute myocardial infarction (AMI) caused by left main trunk dissection (LMT) due to acute aortic dissection. Coronary angiography (CAG) showed severe stenosis in the LMT with poor distal run-off. For this reason, after we implanted a stent in the left main coronary trunk to maintain coronary blood flow, we performed total aortic arch replacement, coronary artery bypass grafting (SVG-LAD #8), and F-F cross-over bypass. Removal of the implanted stent from the LMT during the operation was simple. Postoperative CAG showed a patent SVG and intact LMT. Because preoperative PCI is still controversial for acute aortic dissection with AMI, either more immediate surgery or preoperative PCI (bridge stent to surgery) in the left main coronary artery is mandatory. Implantation of an LMT stent, as a bridge to surgery, is an effective strategy for acute type A aortic dissection with LMT occlusion before surgical repair.