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Hepatic abscesses are divided into bacterial and amoebic types. Although the prognosis of bacterial liver abscesses has improved owing to progress in drainage techniques and antimicrobial agents, poor outcomes remain common. While there have been some reports of amoebic liver abscesses complicated by thrombosis, bacterial liver abscesses and subsequent thrombus in the right atrium are very rare. We herein report the case of an 82-year-old man. He had suffered acute obstructive suppurative cholangitis 10 months previously, and bile culture yielded Enterococcus faecalis. In the present case, a right atrial thrombus caused by a bacterial liver abscess was observed and the causative organism was thought to be Enterococcus faecalis, for which was detected in a blood culture was positive. The patient was successfully treated with hepatic abscess drainage and surgical right atrial thrombectomy under cardiopulmonary bypass with a beating heart.

A 60-year-old woman was admitted to our hospital for dyspnea. Contrast-enhanced computed tomography( CT) revealed acute pulmonary artery thromboembolism. An echocardiogram showed a movable structure in the right atrium. Emergency surgery was performed under general anesthesia. The movable structure in the right atrium looked like a Chiari network with a diameter of over 5 cm, and no obvious thrombus was found. The patient had a good postoperative course and was discharged home on postoperative day 17. The Chiari network is a remnant structure of the fetal venous sinus valve, and its diagnosis was important for determining the appropriate treatment plan for this case.

The patient was a 74-year-old male who had undergone intravesical Bacillus Calmette-Guérin(BCG) instillation therapy for bladder cancer. He visited our hospital with chief complaints of fever and abdominal pain. Abdominal aortic aneurysmal rupture and iliopsoas muscle abscess were confirmed by computed tomography( CT). We performed semi-emergency surgery, including replacement of the abdominal aorta with a synthetic graft, iliopsoas abscess debridement, and omentopexy. A rifampicin-bonded synthetic graft was used because of the possibility of tuberculous involvement after BCG instillation therapy. Examination of the tissues collected during surgery were positive for tuberculosis deoxyribonucleic acid (DNA) in a polymerase chain reaction (PCR), and showed multiple giant cell granulomas with caseous necrosis, which both strongly suggested involvement of tuberculosis. Therefore, 4 types of antituberculous drugs were administered for 40 days. This case shows that an infective aneurysm should be suspected when fever and abdominal pain develop after intravesical BCG instillation therapy.

A 71-year-old male was admitted to our hospital for treatment of complete atrioventricular block. By cardiac catheterization, chronic occlusion was confirmed in the right coronary artery and circumflex branch, and coronary artery bypass grafting was planned. Although atrioventricular block disappeared by discontinuance of β-blocker, paroxysmal atrial flutter had been confirmed before surgery. After an incision into the pericardium, changes in the color of the right atrial appendage were observed, and a thrombus was detected at the site by epicardial echography. The right atrial appendage was removed together with the thrombus, and coronary artery bypass grafting was performed as scheduled. Pathological findings suggested myocardial tissues with ischemic changes and an organized thrombus exhibiting granulomatous changes. This case suggested the need to observe the right atrial appendage carefully during cardiac surgery in patients with risk factors for atrial thrombus.

Myxomas are account for approximately half of primary cardiac tumors, 75% of which originate in the left atrium. We report a case of a right atrial myxoma complicated with bilateral pulmonary embolism. A 54-year-old woman was admitted to the hospital with a complaint of dyspnea. Echocardiography and computed tomography angiography showed a right atrial tumor and bilateral pulmonary embolism. We performed an emergency surgery to remove both the right atrial tumor and the pulmonary emboli. Histopathologically, the tumor was revealed to be myxoma. The postoperative course was uneventful. She is now doing well without any symptoms.

A 55-year-old man was admitted with severe back pain and saccular aneurysm of the descending aorta on computed tomography. Laboratory examinations showed elevated serum C-reactive protein of 16.98 mg/dl. Graft replacement of the descending thoracic aorta was performed on an emergency basis, and a latissimus dorsi muscle flap was wrapped around the implanted graft. Because Streptococcus pneumoniae was detected in the resected tissue, proper antibiotic therapy was administrated. The patient recovered uneventfully, without any sign of infection.

We report a 73-year-old man with myelodysplastic syndrome (MDS) who developed Sweet's disease after off-pump coronary artery bypass grafting (OPCAB). Coronary angiography showed severe 3 vessel disease. We conducted OPCAB on triple vessels using bilateral internal thoracic artery and saphenous vein grafts. He had a high fever and rubor around the median skin incision on 5 postoperative day. Skin biopsy demonstrated acute febrile neutrophilic dermatitis (Sweet's disease). The cutaneous lesions improved gradually by corticosteroids. A careful attention should be paid postoperatively in a patient with hematological disorders such as MDS, aplastic anemia, and malignancy.

We report a case of a 76-year-old man with traumatic aortic dissection complicated with cardiac herniation due to traumatic pericardial rupture. He was involved in an automobile crush and was transferred to our hospital. His vital signs were stable except for atrial fibrillation. Enhanced computed tomography (CT) showed aortic dissection on the descending aorta, multiple left rib fractures, substernal hematoma and shift of the heart toward the left chest cavity. We performed emergency operation. Through left thoracotomy, pericardial rupture was observed. Dacron graft replacement of the descending aorta and pericardial patch plasty were performed. He was discharged on the 24th postoperative day. Careful attention should be paid to aortic injury and pericardial rupture in the patient with severe blunt chest trauma.

We report our method for delineating the Adamkiewicz artery using multidetector row computed tomography (MDCT) with selective perfusion using a distal perfusion cannula that is clinically available for off-pump coronary artery bypass (OPCAB). The tip of a distal perfusion catheter (Medtronic Quickflow, Minneapolis) designed for OPCAB was applicable for selective perfusion of the segmental arteries. The femoro-femoral venoarterial bypass was branched off into selective perfusion of the segmental arteries, using an independent roller pump and heat exchanger. Our method of visualization of the Adamkiewicz artery was MDCT scanning with injection of contrast medium directly into the proximal descending aorta: namely, "CT during aortography". Lower descending aorta to abdominal aorta (the range involving the aneurysm) was scanned in a cephalad-to-caudal direction using a detector collimation of 4 x 1.25 mm with a table speed of 9.4 mm/sec, pitch of 6, and image thickness of 1.25 mm. All images were reviewed on a workstation to investigate the continuity between the Adamkiewicz artery and its proximal segmental artery with paging, mulitplanar reformation and curved planar reformation. Distal perfusion cannulae of 2.0 mm in diameter were inserted into the respective intercostal arteries. 4-0 polyethylene sutures were placed to tourniquet the catheters. Segmental arteries were perfused with total flow of approximately 80 ml/min at a circuit pressure of 120 mmHg. Reattachment of the ninth intercostal arteries related to the Adamkiewicz artery was carried out. A total of 6 consecutive 6 patients with thoracoabdominal aortic aneurysm (TAAA) have undergone graft replacement by the methods described, since April 2002. All patients survived surgery without any neurological complications. This method is expected to minimize the ischemic time of the spinal cord and attenuate the reperfusion injury.

The purpose of this study was to evaluate the feasibility of using CT during aortography with multidetector-row CT (MDCT) to depict the continuity of the Adamkiewicz artery and its origin. We performed CT during aortography in 4 patients with thoracoabdominal or descending aortic aneurysm, using multi-detector-row CT and portable DSA. The continuity of the Adamkiewicz artery and its origin were evaluated on multiplanar and curved planar reformation images and on cine-mode displays. In all patients, the Adamkiewicz artery was clearly visualized. The continuity of the Adamkiewicz artery and its origin were clearly visualized in 3 of 4 patients. In our preliminary study, CT during aortography with MDCT seemed to provide useful information about the Adamkiewicz artery and its origin for surgical candidates.

Patients with angina undergoing carotid endarterectomy have a high mortality. A 74-yaer-old man who has severe carotid stenosis was performed combined carotid endarterectomy and off-pump coronary artery bypass grafting successfully. At first, carotid endarterectomy was performed with Jamieson's specially designed dissector, which allow simultaneous dissection and removal blood from the surgical field. Secondly, then off-pump CABG was performed. Skeletonized internal mammary artery was harvested with ultrasound dissector. The advantage of that the dissected artery is not only long and greater blood flow, but also less damage to sternal blood flow which prevent infection and complications. Then internal mammary artery was anastomosed to left anterior discending artery with Octopus II stabilizer. After the operation, he recovered uneventfully without neurological complication. Combined single staged carotid endarterectomy and off-pump CABG appears to be a safe method.

A 73-year-old man was admitted for sudden onset of dyspnea with cardiogenic shock. Chest X-P showed bilateral severe pulmonary edema. Echocardiogram demonstrated diffuse severe hypokinesis of left ventricle. Emergency coronary angiography showed 99% stenosis of left main trunk with delay. After insertion of intraaortic balloon pump (IABP) and percutaneous cardiopulmonary support system (PCPS), vital signs and consciousness were improved. Emergency coronary artery bypass grafting (CABG) was performed, LIMA to left anterior descending artery, saphenous vein grafts to circumflex and right coronary artery. Left ventricular wall motion was improved after bypass grafting and cardiopulmonary bypass was weaned with catecholamine and IABP support. The patient was discharged from hospital 60 days after the operation with good cardiac function. We emphasized a usefulness of combined use of IABP and PCPS to provide systemic organ perfusion and reduce myocardial infarct size and ischemic damages after re-vascularization for coronary insufficiency with profound shock.

Four cases of aortic operations using open proximal anastomosis (OPA) under the hypothermic circulatory arrest (HCA) and left lateral approach (LLA) are reported. Three of 4 cases had extensive aortic disease from distal arch to descending thoracic aorta (Stanford type B chronic aortic dissection, double false aneurysms, and double true aneurysms). Another one case had ruptured aneurysm of thoracic aorta. LLA should have been selected in all cases, however, aortic proximal cross-clamp was impossible in them, because of giant pseudolumen, diseased lesion of aortic arch, hemothorax followed rupture of aneurysm. Therefore OPA under the HCA was performed. There were no complication associated with HCA, bleeding, neurological deficiency and respiratory dysfunction. We conclude that, although the HCA may have some problems, if there is the proper indication, OPA under the HCA is useful method at aortic operation for difficult aortic disease.

We report a 65-year-old female who had a extensive thoracic aneurysm from ascending aorta to descending thoracic aorta. The patient underwent a graft replacement of ascending aorta and aortic arch using modified elephant trunk method. The surgery was carried out through median sternotomy with profound hypothermia and selective cerebral perfusion. Postoperatively, the patient was recovered without any complications except bronchial asthma. Postoperative chest computed tomography showed that the surrounding space of the elephant trunk vascular graft inserted into distal arch and descending aneurysm was mostly occupied with thrombus. Therefore, we considered that the second operation on the descending aorta is not necessary at this point and careful attention to the size and shape of the descending aneurysm should be paid.

Objective of this study is to evaluate influence of acute aortic dissection on long-term results of aortic root reconstruction in patients with Marfan's syndrome. 19 patients who underwent consecutive aortic root reconstruction between 1985 May to 1998 February were retrospectively reviewed. Patients who associated acute aortic dissection at the time of operation (group D, n = 7) were compared long-term results with those who did not (group non-D, n = 12). Mean follow-up period was 5.1 +/- 3.2 years and longest follow-up term was 12.5 years. In each group early postoperative death was found in one patient. In-hospital mortality in each group were respectively; 14.2% and 8.3%. Late deaths were found in four patients who all belonged to group D, respectively caused by; rupture of thoracoabdominal aneurysm, DIC after subsequent thoracoabdominal surgery, sepsis due to prosthetic valve endocarditis, and sudden death. Actuarial overall survival rate including operative death in D and non-D group were respectively; 0.0 +/- 0% at 6.6 years and 91.1 +/- 8.0% at 12 years. Overall cumulative survival rate was 56.6 +/- 14.0%. Freedom from cardiovascular events, in D and non-D group were respectively; 0.0 +/- 0% at 6.6 years and 60.0 +/- 25.3%, and freedom free form dilatation of residual aorta were respectively; 0.0 +/- 0% at 6.6 years and 100.0 +/- 0% at 12 years. Freedom from subsequent cardiovascular surgery in group D, group non-D and over-all patients were respectively; 0.0 +/- 0% at 6.6 years, 60.0 +/- 25.3% at 12 years and 42.6 +/- 20.2%. In this study, acute aortic dissection in Marfan's syndrome significantly increased late cardiovascular events including dilatation of residual aorta, subsequent aortic surgery and late mortality. On the other hand, excellent long-term results after aortic root reconstruction were found in non-dissection Marfan's syndrome. Considering high incidence of late dilatation of residual aorta, simultaneous total arch replacement with aortic root reconstruction is recommended in acute dissecting Marfan's syndrome. Whereas, preventive simultaneous arch replacement is not required in non-dissecting Marfan's syndrome because of less postoperative vascular events.

Impending rupture of the true aneurysm of the thoraco-abdominal aorta induced by acute aortic dissection (Stanford type A) is very rare, and decision making of the therapeutic plain is difficult. A 88-year-old woman manifested severe back pain with hypotension. Chest computed tomographic examination revealed a true aneurysm of the thoraco-abdominal aorta and acute thrombosed-type aortic dissection (Stanford type A) with cardiac tamponade. Under the diagnosis of impending rupture of the thoraco-abdominal aortic aneurysm induced by acute aortic dissection (Stanford type A), graft replacement of the thoraco-abdominal aortic aneurysm and pericardial drainage were successfully performed. Two months later, computed tomographic examination revealed disappearance of the thrombosed false lumen in the ascending aorta.

We report a case of a broad prolapse in the posterior leaflet successfully treated by a mitral valve repair by the sliding leaflet technique. The mitral valve regurgitation was caused by a rupture and elongation in the chordae supporting the middle scallop. First 3 cm of the leaflet was quadrangularly resected, then the posterior leaflet was detached from the annulus. Suture annuloplasty of that portion was performed and then the posterior leaflet was reattached to the annulus. Finally a Carpentier-Edwards annuloplasty ring was sutured in position. A postoperative study revealed no regurgitation. The sliding leaflet technique seemed to be effective to reduce tension in the isovolumic stress area caused by covering the broad gap left by the resected leaflet. When mitral valve repair by the sliding leaflet technique is performed, we recommend the use of an annuloplasty ring to decrease the stress on the suture line, to remodel the annular configuration and to prevent annular dilatation.

Two cases of traumatic diaphragmatic hernia (TDH) which occurred at the same traffic accident, are reported. The first case, a plain chest X-P was diagnostic of TDH. With thoracotomy and additional laparotomy, lacerated diaphragm was repaired. The second case, continual observation on plain chest X-P was useful to suspect TDH, and thoracoscopy was diagnostic. With thoracotomy diaphragm was repaired. Two patients recovered well. It has not been reported that two cases of TDH occurred at same trauma. For diagnosis of TDH, chest X-P is useful for suspicion, and thoracoscopy is useful for correct diagnosis. Surgical approach should be decided in consideration of phase, location, and complicated injuries.

We report a case of Budd-Chiari syndrome in which, radical operation was successfully performed. A 60-year-old male was admitted to our hospital for evaluation of liver dysfunction. Caval venography demonstrated caval obstruction with an extensive collateral circulation passing through the azygos veins. At the operation, intraoperative Doppler echography revealed complete obstruction with thrombus of the IVC. We performed endovenectomy and patch dilatation under circulatory assist with femorofemoral bypass. After this procedures, doppler echography demonstrated excellent flow with no residual stenosis. AKBR was immediately recovered from the abnormal states compared with other laboratory data. The patient has been doing well after 3 years postoperatively.

Emergency coronary artery bypass grafting (CABG) was performed on a 48-year-old male with a long-term hemodialysis history. Following the operation, the patient developed acute elevation of potassium. We applied hemodialysis and obtained beneficial beneficial results. No remarkable change on hemodynamics and coagulant system was observed. Hemodialysis should be recommended on an acute phase for the patients of good cardiac function with less bleeding during the operation.

We report a case of rare congenital anomaly of quadricuspid aortic valve and coexisting right coronary displacement. A 70-year-old man was admitted to our hospital for heart murmur and ECG abnormality. The trans-esophageal echocardiography and aortography showed moderate aortic stenosis and regurgitation. At the operation, a quadricuspid aortic valve with three equal cusps and one smaller cusp that showed marked calcification and displacement of right coronary orifice were noted. Successful aortic valve replacement and coronary artery bypass grafting were performed and postoperative course was uneventful.

We report a case of syphilitic coronary ostial obstruction and aortic regurgitation associated with advanced gastric cancer for which subtotal curative gastrectomy and AVR with CABG was successfully performed in a two-stage operation. A 65-year-old male was admitted complaining of tarry stool and angina. A serological test for syphilis was strongly positive and angiography demonstrated a left coronary ostial obstruction accompanied by moderate aortic regurgitation. An endoscopic examination of the stomach revealed a Borrmann type II advanced gastric cancer with active bleeding. In the first stage, a subtotal gastrectomy with wide margin was performed, under hemodynamic monitoring because of the active tumoral bleeding. After the second-stage AVR, the postoperative course was uneventful.

This is a case report of infective endocarditis with idiopathic thrombocytopenic purpura (ITP). Open heart surgery to the patient with ITP has a problem of perioperative hemorrhage. Usually, treatment for ITP is performed before operation, and platelet transfusion is provided for hemorrhage. However, in our patient, we had to perform emergency operation because of progressive heart failure without treatment of ITP. Emergency operation should be performed without treatment of ITP, not to delay operative timing in such a case of progressive heart failure from active infective endocarditis.