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Objectives: We investigated the validity of the surgical strategy for aortic arch aneurysm depending on the patient's condition., Methods: Between 2014 and 2019, 70 patients underwent total arch replacement (TAR) and 14 patients underwent fenestrated thoracic endovascular aortic repair( fTEVAR) for aortic arch aneurysm. We selected the surgical strategy on the basis of the patient's condition with or without frailty and if surgical risks including cancer or a respiratory condition precluded open surgery., Results: The preoperative average ages were 73.3±7.8 years in the TAR group and 73.9±6.1 years in the fTEVAR group (p=0.93). EuroSCORE Ⅱ was 4.3±3.6 in the TAR group and 6.0±3.3 in the fTEVAR group (p=0.03). Frailty was observed in 11 patients (15.7%) in the TAR group and fivepatients (35.7%) in the fTEVAR group (p=0.08). In the fTEVAR group, there were three patients (21.4%) with cancer and three patients (21.4%) with a respiratory condition that precluded open surgery. The overall 30-day mortality rate was 0% for both groups, and the in-hospital mortality rate was 2.9% in the TAR group and 0% in the fTEVAR group (p=0.52). The incidence of stroke was 2.9% (two patients) in the TAR group and 7.1%( one patient) in the fTEVAR group( p=0.43). However, all stroke patients were able to walk at discharge. The cumulative survival rate was 88.9% and 83.5% in the TAR group and 85.1% and 68.1% in the fTEVAR group at two and five years, respectively (p=0.173). There were both 98.1% of patients in the TAR group and 85.7% and 75.0% of patients in the fTEVAR group who were free from reoperations at two and five years, respectively( p<0.01)., Conclusions: Our surgical strategy and outcomes for aortic arch aneurysm were generally appropriate. It is important to select open surgery or TEVAR depending on the patient's condition.

Surgical results were compared between 18 patients (group A) who underwent preoperative anatomic characterization of the Adamkiewicz artery by magnetic resonance angiography (MRA) and 38 patients (group B) without such imaging. In group A, intercostal or lumbar arteries related to the aneurysm were reattached to the graft only when they represented the origin of the Adamkiewicz artery. In group B, reconstruction from the Th 7 intercostal and the L2 lumbar arteries was performed whenever possible. In-hospital mortality was 16.7% in group A and 15.8% in group B. Total aortic clamp time and operating time were only 84 and 437 min in group A, compared with 134 and 589 min in group B. Three patients showed postoperative paraplegia in group B. No spinal cord injury occurred in patients whose artery had been detected preoperatively. Preoperative anatomic delineation of the Adamkiewicz artery by MRA can reduce risk of ischemic injury to the spinal cord and decrease operating time required for repair of thoracoabdominal aortic aneurysms.

One hundred eighty two patients with thoracic aortic aneurysms or dissections who required total arch replacement (TAR) were operated on with separated graft technique and selective cerebral perfusion (SCP) between 1991 and 2000. These patients were divided into 4 groups according to the pathology as follows: group 1; acute type A dissection, group 2; chronic type A dissection, group 3; distal arch aneurysm and group 4; proximal arch aneurysm. For SCP, both the innominate artery and the left common carotid artery were cannulated when the patient was cooled to a rectal temperature of 22 degrees C. Hospital mortalities were 27% in group 1, 14% in group 2, 19% in group 3, and 8% in group 4. Independent predictors of hospital mortality were shock, visceral, and leg ischemia in group 1, and circulatory arrest time of the lower half body to be more than 1 hour and cardiopulmonary bypass time to be more than 5 hours in group 3. Permanent neurological complication occurred in 3% in group 1 and 8% in group 3. Hospital mortality was affected by the type of aneurysms and dissections. It is necessary to give careful consideration to the indication of TAR with SCP, especially in acute type A dissection and distal arch aneurysm.

A 53-year-old woman, who had undergone MVR and TAP 2 months ago at other hospital, was referred because of PVE caused by MRSA, mediastinitis and remaining AR. Emergency operation was performed, and it was found that mitral mechanical valve was detached and massive vegetation was present around prosthetic valve suture ring. MRSA was cultured from mechanical valve. Thorough debridement for mediastinitis and mitral annulus were performed. Diagnosis and timing of surgical intervention for mechanical PVE were discussed.

Selective cerebral perfusion (SCP) has been widely used as the method for cerebral protection during aortic arch repair in the treatment of aortic arch aneurysms in our institution. Recently, we modified our technique of aortic arch reconstruction and SCP in order to reduce the neurological complication. Following institution of SCP into both innominate and left common carotid arteries at 22 degrees C, the distal graft anastomosis and left subclavian reconstruction were performed while the descending aorta was left opened. Then the antegrade perfusion with rewarming was started via the fourth limbs attached to the main graft instead of the femoral artery. The aortic arch was completely replaced with the graft with three limbs for arch vessels. During one-year period from December 1993 to November 1994, 30 patients were operated on for aortic arch aneurysms using this technique. The etiology of aneurysms was true aneurysms in 16 patients, and aortic dissection in 14 including 8 cases of acute dissection. The concomitant procedures included descending graft replacement in 11 patients, composite graft replacement in 5, CABG in 3, and AVR in 1. The hospital mortality was 3.3% (1 of the 30 patients). There was no neurological complication. We conclude that the present techniques are useful methods for preventing the neurological complication in the treatment of aortic arch aneurysms.

In the past 7 years, 9 emergent or urgent coronary artery bypass operations after failed percutaneous transluminal angioplasty (PTCA) were performed among 947 (PTCA). Since the introduction of coronary perfusion catheter system for the support of coronary perfusion during PTCA we could reduce the number of emergent cases and these patients could be operated on semi-emergently and securely without endangering co-medical staffs in a hurry. It is also unnecessary to be on standby all the time when the PTCA is being undertaken. Two acute myocardial infarction cases died in the early phase of this study (operative mortality 22%) and none after the introduction of coronary perfusion system during PTCA.

We analyzed surgical results of 91 patients who underwent re-mitral valve replacement (reMVR) for valve morbidity between January 1981 and March 1994 in an attempt to draw some therapeutic guidelines. The study population consisted of 38 men and 53 women, ages 32-73 (mean 52 +/- 10) years. The causes of valve morbidity were structural deterioration in 71 patients, nonstructural dysfunction manifested by paravalvular leakage in 5 valve thrombosis in 7 and prosthetic valve endocarditis in 8. Twelve of ninety-one patients (13.2%) died postoperatively in the hospital. All the patients were divided into the survivors (n = 12) and the nonsurvivors (n = 79). Mean right atrial pressure, extracorporeal circulation time, concomitant coronary artery bypass grafting, and application of intra-aortic balloon pumping were significantly different between the groups. Twenty preoperative and intraoperative variables were analyzed by means of univariate and multivariate analysis. By univariate analysis, male gender, NYHA IV, history of congestive heart failure, renal insufficiency and prosthetic valve stenosis were related to a higher incidence of hospital death. Multivariate analysis revealed that male gender and NYHA IV were risk factors in reMVR, and indicated no differences in intraoperative parameters between survivors and deaths. It is recommended to examine patients with bioprostheses thoroughly and to perform early elective reMVR before a patient develops NYHA IV.

A 61-year-old man was operated on an emergent basis because of abrupt closure of left anterior descending coronary artery (LAD) following failed coronary angioplasty. At once abrupt closure occurred, Stack autoperfusion balloon catheter was placed across the coronary lesion to reestablish blood flow to the ischemic myocardial area with intraaortic balloon counterpulsation. Despite a longtime of 12 hours to cardiopulmonary bypass, the patient had been managed with excellent resolution of symptoms and ST elevation. Under a stable hemodynamic state, saphenous vein grafting to LAD was performed with minimal myocardial infarction. Stack catheter made it possible to perform the subsequent coronary bypass operation as a controlled, optimal revascularization procedure because of its passive autoperfusion effect.