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A 64-year-old woman was admitted due to back pain and dyspnea. She was suffering from fever of unknown origin for a few weeks without aortic aneurysm by enhanced chest computed tomography (CT). Chest CT taken 1 month later revealed rupture of aortic arch aneurysm. Total arch replacement was performed with in situ grafting under selective cerebral perfusion combined with deep hypothermic circulatory arrest. Rifampicin (RFP) was sprinkled on the graft at operation and omentopexy was done 5 days after the 1st operation. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated on the culture of the aneurysmal wall, therefore, polymyxin B immobilized fiber with direct hemoperfusion (PMX-DHP) was also conducted with antibiotic therapy. Her clinical course after the 2nd operation was uneventful with no infective complication. We report a successful case of ruptured aneurysm of aortic arch infected with MRSA and review our strategy as one of feasible options without using homograft or preparative RFP-bonded vascular prosthesis.

Atrial rupture by blunt trauma is lethal and one of controversial problems for cardiovascular surgeons, because of complexed conditions due to multiple organ injuries. Some papers recommend strategy of early diagnosis and treatment at an acute phase for better clinical course, but high mortality rate has not been improved yet, especially that of left atrial rupture. Three patients were reffered to our hospital by blunt chest trauma, one of whom died due to hemorrhagic shock before receiving surgical or interventional treatment. The remaining 2 patients had surgical operations at an early phase and were discharged without severe complications. We review our strategy of atrial rupture of blunt chest trauma. At an acute phase, atrial rupture alone should be repaired urgently unless use of cardiopulmonary bypass is contraindicated by severe hemorrhage of the other organs.

A total of fourteen patients with combined operation of coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) for coronary artery disease (CAD) and aortic stenosis (AS) were reviewed to evaluate the indication of the combined operation. Preoperative pressure gradient across the valve and effective orifice area were 21-89 mmHg (mean 64 mmHg), 0.5-1.9 cm2 (mean 0.92 cm2), respectively. The extent of CAD was 1-3 (mean 2.0). Fractional shortening (%FS) ranged from 13% to 43% with mean value of 28%. All patients underwent CABG and AVR. The number of grafts was 1-4 (mean 2.3) with internal thoracic artery used in 7 cases. Mechanical valves were employed for all patients except 1 case with cerebral aneurysm. There was no operative death, although low output syndrome developed in 2 cases. One had poor left ventricular function preoperatively, and the other was emergency case. Fractional shortening improved postoperatively even in two cases with preoperative %FS less than 20%, and all grafts were patent on postoperative coronary angiography. The event-free survival was 100% during 32 months of mean follow-up. Combined AVR with CABG is recommended to avoid risky secondary operation in patients of CAD and AS, even if one of which is relatively mild, because of the fact that operative and late results of the combined surgery are satisfactory.

Twenty-six patients with moderate and severe ischemic mitral regurgitation due to papillary muscle dysfunction underwent mitral valve replacement (MVR) or mitral annuloplasty (MAP) using modified Kay method. Emergent operation was performed in 12 patients of whom 11 had severe congestive heart failure even under IABP, 5 had cardiogenic shock and 9 needed respiratory care with intubation preoperatively. Elective operation was performed in 14 patients of whom 6 had history of congestive heart failure and 1 had episodes of ventricular tachycardia. As intraoperative findings of mitral valve, mural annular dilatation in 84.6%, prolapse of anterior leaflet in 23.1%, papillary muscle scar in 15.4%, chordal elongation in 15.4% and chordal rupture in 3.8% were seen separately or in combination. In 22 patients MAP using modified Kay method and CABG were performed, but in 4 patients MVR was needed because of the prominent prolapse of the anterior leaflet. Fourteen patients who underwent MAP with CABG and one MVR with CABG survived. Hospital mortality was higher in emergent (58.5%) than elective operation (28.6%). In the 15 survivors, mitral regurgitation decreased below Sellers 2, pulmonary wedge pressure decreased significantly (p < 0.01) and NYHA functional class improved to I or II postoperatively. During the follow up period of 15-100 (mean 38.7 +/- 21.6) months, 2 MAP+CABG patients died suddenly, but the remaining 13 patients were in NYHA class I or II and no progression of MR was seen. These results indicated that MAP+CABG is recommendable in the treatment of ischemic mitral regurgitation due to papillary muscle dysfunction, in order to preserve cardiac function and to reduce valve related complications.

A case of acute aortic dissection (Stanford Type A) with severe aortic regurgitation successfully treated by postoperative ECMO was reported. The patient was 41-year-old man in shock condition and was transferred to Kobe University Hospital. Chest CT scan and echocardiogram revealed acute aortic dissection with severe aortic regurgitation. An emergent operation by Collins' method and resuspension of aortic valve were carefully performed. Consequent ECMO was necessitated because of postoperative left ventricular and respiratory failure. Thereby, ECMO using heparin-coated CBAS-MAXIMA membrane oxygenator, centrifugal pump, and tubes was established by arterial cannulation via the anastomotic site of the ascending aorta to prevent the obstruction of the aortic true lumen by the false lumen which may be enlarged by retrograde perfusion via the femoral artery. Left ventricular function and pulmonary function were improved after 6 hours and 20 minutes, thus ECMO was successfully weaned without any complications.

A technique for closure of patent ductus arteriosus in the elderly cases is described. We have operated on eleven adult cases of patent ductus arteriosus cases in 10 years. In five cases cardiopulmonary bypass used and in the other six cases it was not used. The cardiopulmonary bypass was used especially for the patients with pulmonary hypertension (pulmonary artery mean pressure greater than 40 mmHg), or high aged (older than 40 years) patients. No operative death have occurred in both groups, and no complication from air embolism or hemorrhage have been encountered. The technique embodies the profound hypothermia, low flow, and direct suture of the pulmonary end of the ductus arterious through a pulmonary arteriotomy. The ductus has been obstructed by using a Hegar's dilator before core cooling was started. Hegar's dilator is useful for establishing profound hypothermia and satisfactory visualization of the operative field.