Objective: A few cases of an aseptic abscess after thoracic aortic surgery have been reported. However, it sometimes requires surgical treatment because the rapid growth of perigraft fluid collection results in exposure towards the body surface. We discuss the results of our treatment of these cases. Methods: This study was a retrospective analysis. Four of 341 cases who underwent thoracic aortic surgery between April 2013 and March 2020 were included. These cases presented with a bulge of the body surface 10.3 (range, 3-27) months after surgery. Results: Although the fluids looked purulent in all cases, no bacteria were detected. We diagnosed them as aseptic abscess, for which omental implantation was performed. No signs of recurrence have been found in any cases even after 5.4 (range, 1-8.5) years. Conclusions: Omental implantation was effective for controlling aseptic abscess for long-term periods.

A 47-year-old man had severe mitral regurgitation after severe skin eruption, so mitral valve replacement was electively performed 8 months later. A median sternal wound opened spontaneously and had purulent exudate on the 5th postoperative day (5 POD). We had suspicion of bacterial mediastinitis, so we drained the anterior mediastinum and tried antibiotic treatment. However, the microbiological stains and culture were negative, and adipose tissue was extremely melted with pustules around the wound. Considering other diseases without infection, we consulted to a dermatologist and tried highdose steroid therapy as pyoderma gangrenosum (PG) appeared on the 8 POD. Meanwhile, the sternum was left open and apllied a negative pressure dressing applied with Negative Pressure Wound Therapy (NPWT). The wound responded remarkably to steroid therapy, so we closed the sternum on the 10 POD, and sutured the sternal wound on the 19 POD. We tapered off steroids after the suture. PG can be caused by the trauma of surgery, so we have to make a decision on whether to use high dose steroid therapy in the postoperative period. We report this case as one of the differential diseases that the surgeons must know.

A 44-year-old man was injured by concreate boards falling on the left side of his body, and he was transferred to our hospital on suspicion of a blunt traumatic aortic injury. The contrast-enhanced CT axial scan showed the abnormal alignment of the brachiocephalic artery and a mediastinal hematoma. However, a 3D-CT image showed a pseudoaneurysm in the aortic arch between the brachiocephalic and left common carotid arteries. Immediately, partial arch replacement was performed. A 20 mm disruption was detected on the intimal surface of the arch aorta between the brachiocephalic and left common carotid arteries. This case was a very rare condition of blunt traumatic aortic injury.

We report a case of a 64-year-old woman with a history of radiation therapy for breast cancer 27 years ago who developed malignant pericardial mesothelioma. Since 3 years ago, the recurrent bloody pericardial effusion was getting worse, which caused general edema and nocturnal dyspnea. She had a thickened pericardium and the right ventricular pressure curve showed a dip-and-plateau pattern. We diagnosed constrictive pericarditis and performed a pericardiectomy and waffle procedure on the thickened epicardium without cardiopulmonary bypass. The post-operative histology confirmed malignant pericardial mesothelioma and she died on the 17th postoperative day. Pericardial malignant mesothelioma is a rare disorder but very aggressive. This fatal disease may be considered in a patient with recurrent bloody pericardial effusion who has a history of thoracic radiation therapy.

We report the case of a 55-year-old man who received a hard blow to his chest from a liquid nitrogen hose that caused traumatic aortic dissection (Stanford type A, DeBakey type II). He did not have any other hemorrhagic injury ; therefore, we decided to perform an emergency surgery. The postoperative course was uneventful, and he was discharged on postoperative day 19. Pathological findings were compatible with traumatic aortic dissection. Blunt thoracic aortic injury is a potentially life-threatening injury ; therefore, it is worth remembering that relatively low-energy blunt trauma can cause aortic injury in patients with severe atherosclerosis. The optimal timing of intervention should be individualized in traumatic aortic injury with consideration of associated injuries.

A 75-year-old man, who had undergone aortic valve and ascending aorta replacement at the age of 73 years, was admitted to our hospital with one week of fever. Blood culture showed growth of Streptococcus bovis and echocardiography showed vegetation on the prosthetic valve. Although antibiotic treatment was commenced, he complained of abdominal pain, and computed tomography showed a superior mesenteric artery embolism. The abdominal pain improved with fasting, but echocardiography showed another vegetation, and re-aortic valve replacement was performed to prevent embolism recurrence. When he resumed eating postoperatively, he again complained of abdominal pain and computed tomography showed mesenteric ischemia. The necrotic intestine was extensively resected and he recovered successfully. A superior mesenteric artery should be revascularized to 2/11 prevent perioperative mesenteric ischemia when cardiac surgery complicated by acute superior mesenteric artery embolism is performed.

A 79-year-old man, who had undergone aortic valve replacement due to severe aortic stenosis 2.5 years previously and permanent pacemaker implantation for sick sinus syndrome 2 months after aortic valve replacement, was admitted for congestive heart failure and suspicion of prosthetic valve endocarditis. However, he had a fever in spite of medical therapy, and transthoracic echocardiography revealed a 20 mm vegetation on the posterior mitral valve leaflet. He underwent emergency surgery on a diagnosis of infective endocarditis. The intraoperative examination showed annular abscess on the calcified mitral annulus, and a part of abscess had disintegrated, from which the vegetation arose. We performed maximal possible debridement of the infected tissue and mitral annulus reconstruction with a bovine pericardium. Subsequently, mitral valve replacement and annulus reinforcement with a prosthetic valve collared with a bovine pericardium were performed to prevent perivalvular leakage. The patient showed no recurrence of infection and perivalvular leakage at 1.5 years of follow-up.

Patients with an aortic root pseudoaneurysm communicating to the right atrium are rare. A 67-year-old woman underwent ascending aorta and total aortic arch replacement for acute type A aortic dissection at our institute 9 years prior to the current presentation. She was transported to our emergency department with complaints of chest pain, palpitations, and cold sensation. A continuous murmur was heard at the right sternal margin. Contrast-enhanced computed tomography (CT) and ultrasonic cardiography showed a huge pseudoaneurysm at the proximal anastomotic site and an aorto-right atrial fistula. Ascending aortic replacement with concomitant direct closure of the fistula was successfully performed. The patient was discharged in good condition on the 14th postoperative day. Careful follow-up with CT is important after acute type A aortic dissection repair.

Homozygous familial hypercholesterolemia is a rare metabolic disorder with characteristic clinical presentations, such as tendon xanthomas, hypercholesterolemia, and significant cardiovascular disease including premature coronary artery disease. We describe a case of a 56-year-old woman with homozygous familial hypercholesterolemia. She had been treated with low-density lipoprotein apheresis for 23 years. Preoperative echocardiography and coronary angiography showed severe aortic valve stenosis and right coronary artery stenosis. Aortic valve replacement with patch enlargement of the aortic valve annulus, and coronary artery bypass grafting were successfully performed. She was discharged uneventfully.

We describe a case of cardiac surgery for a patient with CD36 deficiency. A 56-year old man had progressive dyspnea on effort for 1 year. On admission, echocardiography revealed severe aortic valve regurgitation. He required medical treatment for heart failure, and subsequently elective aortic valve replacement was planned. Pre-operative cardiac scintigraphy (¹²³I-BMIPP) showed total defect of myocardial uptake. CD 36 deficiency was diagnosed based on the characteristic findings. CD 36 deficiency could cause transfusion related complication by donor blood transfusion. We prepared 1,200 ml autologous blood preoperatively in a two week period. The operation was performed successfully without donor blood transfusion. He was discharged uneventfully.