A 60-year-old man with impending rupture of abdominal aortic aneurysm was transferred to our hospital. The patient entered a state of shock because of rupture during a CT scan examination. Emergency in site reconstruction with a dacron Y-graft was performed. There was massive intraperitoneal bleeding but no apparent abscess formation around the aneurysm. No drain was placed. A subcutaneous abscess that developed postoperatively was cured by open drainage and local antibiotic administration. Culture from both the aortic wall and the subcutaneous abscess revealed Salmonella infection. After subsequent intravenous antibiotic therapy for 45 days, the patient was discharged without any evidence of remaining infection.

A free-floating ball thrombus in the left atrium is a rare occurrence. Few patients who developed a ball thrombus after mitral valve replacement have been reported. Our patient was a 58-year-old man who had undergone mitral valve replacement in 1981. Since bleeding gastric cancer had been diagnosed anticoagulant therapy had been 4 days before admission. On admission, echocardiography revealed a large thrombus in the left appendage. First, he underwent total gastrectomy for gastric cancer. After the operation, he developed aspiration pneumonia, and was intubated. We observed that a large thrombus had moved from the left appendage to the left atrium. Emergency operation was successfull.

A 62-year-old woman was admitted for chest and back pains. She was found to have thrombosed type A aortic dissection by enhanced computed tomography. Since she had no clinical symptoms after her admission, she was discharged. Forty days after the admission, she returned with acute renal failure and ischemia of both lower extremities. Occlusion of the abdominal aorta was diagnosed and emergency axillobifemoral bypass was performed. Her renal function and the ischemia of both lower extremities improved dramatically and she was discharged 30 days after the operation. Axillobifemoral bypass is one of the most effective and least invasive operations in such cases.

A 39-year-old man received Bentall's operation for annuloaortic ectasia in July 1985. He was admitted with a high fever in July 1998. On the 2nd day of his admission, he suddenly suffered from headache and dizziness. Head computed tomography showed multiple low density areas in the right cerebrum and cerebellum. A transesophageal echocardiogram revealed massive vegetation around the prosthetic valve. The patient underwent emergency operation using cardiopulmonary bypass. The left ventricle outflow was almost occluded by thrombi. The prosthetic valve and graft were removed completely and replaced with a 24mm Gelseal^® graft and a 23mm St. Jude Medical^® valve. The right coronary ostium was reimplanted directly on the prosthesis, and the left coronary ostium was reinserted using a 10mm graft. The patient's intraoperative tissues grew S. aureus and parenteral antibiotics were administered for 5 weeks after surgery. The patient was discharged on the 45th postoperative day and is doing well 9 months after the operation.

An 81-year-old woman with severe chest pain was admitted to our hospital. Computed tomography showed aortic dilation and a non-enhanced crescentic area in the ascending aortic wall, indicating a DeBakey type-II aortic dissection with thrombus. The ascending aorta was replaced with an impregnated knitted Dacron graft. Fresh clotted hematoma was found in the dissected ascending aortic wall, and the intimal surface was involved with a local atherosclerotic ulcer penetrating the media. Operative findings were compatible with intramural hematoma due to penetrating atherosclerotic ulcer described by Stanson et al. In the literature most penetrating atherosclerotic ulcers are located in the descending aorta, thus this case is rare.

We present a rare case of mitral stenosis with bilateral pulmonary arteriovenous fistulae (PAVF). A 55-year-old female who complained of dyspnea did not have pulmonary hypertension. She underwent successfully mitral valve replacement with an artificial valve 2 months after transcatheter coil embolization for PAVF. The combination with mitral valve replacement and transcatheter embolization is regarded as a useful procedure for mitral valve disease associated with PAVF.

Between 1984 and 1994, 58 patients underwent operations for type A aortic dissection. A sutureless ringed intraluminal graft was used in 9 of the 58 cases. The patients ranged from 47 to 74 years old (mean, 60.4 years). Six patients were discharged from the hospital and three patients died. The operative mortality rate for the 9 patients was 33.3% and for the other 49 patients it was 20.4%. Post-operative aortograms revealed a remaining false lumen in 5 of the 6 discharged patients. The result of the operation with the sutureless ringed intraluminal graft was not satisfactory. Therefore, we prefer to resect and replace the dissected aorta using the prosthetic graft rather than repair with the sutureless ringed intraluminal graft.

The diagnosis of ruptured dissecting limited abdominal aortic aneurysm was made in four cases. The sex ratio (M/F) was 1/3, and mean age was 63.5 years (from 53 to 78yr). Only one of these cases die due to intraoperative bleeding. Other three cases were discharged from our hospital. Intraluminal proximal anastomosis after fixed dissected aortic wall due to mattress suture and end to end anastomosis with reinforcement by Teflon felt were good results. The one case who was anastomosed simple intraluminal method has pseudoaneurysm in the proximal portion. It is important to diagnose preoperatively dissection and to make end to end anastomosis with Teflon felt.

We experienced a 51-year-old male case of CABG whose graftography one month after CABG revealed a 0.5cm venous bypass graft aneurysm. Anginal pain recurred in the eighth month after CABG. Re-graftography showed enlargement of the aneurysm and stenosis of the graft at the same site. Re-CABG was carried out successfully and his postoperative course was good. Venous graft aneurysm is a comparatively rare complication, and that of the present case was considered to be most ascribable to the fragility of the graft, caused by mediastinitis secondary to the first CABG. Thrombus formation was noted in the aneurysm, with a risk of causing rupture or myocardial infarction. Therefore, such graft aneurysms should be treated by re-CABG as soon as possible after detection.

A 27-year-old female with Marfan's syndrome underwent successful emergency surgery for rupture of an abdominal aortic aneurysm. Annulo-aortic ectasia with a saccular aneurysm of the aortic arch was revealed by angiography after the initial operation. Cabrol's operation with replacement of the aortic arch was performed. Because bleeding from the distal anastomotic portion was uncontrollable, the segment was ligated and an extra-anatomical bypass was performed from the ascending aortic graft to the bilateral femoral arteries. Intra-graft balloon pumping was carried out in the extra-anatomical bypass graft while the patient was in low cardiac output condition after the second operation. This was considered to be an effective circulatory assist procedure.