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We reported our long-term results of valve sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation( AR) were satisfactory. Three hundred twenty-seven patients had VSRR, and 164 patients of them had aortic cusp repair for prolapse. At 10 years after the operation, the overall survival was 91.5%, the freedom from more than mild recurrent AR was 71.2%, and the freedom from aortic valve reoperation was 82.0%. As for the aortic cusp repair technique, there was no significant difference in the mid-term results of the recurrent AR and reoperation for the aortic valve between the central plication technique and the resuspension technique (two layers of continuous mattress sutures placed the entire length of the free margin of the aortic cusp). The resuspension technique might be useful for repairing the aortic cusp with prolapse. Furthermore, among the patients with acute aortic dissection, connective tissue disease, or aortitis, the long-term results of VSRR and aortic cusp repair were also satisfactory.

The patient is a 56-year-old man. He fell while playing golf and sustained a contusion on his right chest. He fell into hemorrhagic shock during surgery for a right clavicle fracture at a nearby hospital and required cardiac resuscitation. Computed tomography( CT) scan revealed left pneumothorax and right hemothorax, and a contrast-enhanced CT scan revealed a pseudoaneurysm at the brachiocephalic artery origin. He underwent surgery three weeks later. Surgery was performed through a median sternotomy and partial arch replacement (zone 2) with antegrade cerebral perfusion under moderate hypothermia. He was discharged on postoperative day 10 without significant complications.

Annular fixation has an important role aortic valve repair for aortic regurgitation. We have used the reimplantation procedure as annular fixation combined with cusp repair rechniques for aortic valve repair even in small aortic root( <50 mm) since 2010. Freedom from aortic valve reoperation was 93% at 5 years and 79% at 8 years. Freedom from greater than moderate aortic regurgitation was 80% at 5 years and 71% at 8 years. Although the outcomes were not satisfactory and should be improved, this technique would be one of choices in selected patients, considering durability of bioprostheses and anticoagulation-related events in mechanical valves.

Objective: We report our current surgical management and early and late outcomes of total arch replacement., Method: From October 1999 to December 2012, 372 consecutive patients (mean age 71.8±12.0) underwent total arch replacement through a median sternotomy at our institute. Mean Japan score (predicted 30 day mortality) was 8.0±9.2( median 4.4). Our current surgical approach included the following:(1) meticulous selection of arterial cannulation site and type of arterial cannula;(2) circulatory arrest at tympanic temperature (below 23 °C) and rectal temperature (below 30 °C);(3) antegrade selective cerebral perfusion and cerebral monitoring of regional cerebral saturation;(4) early rewarming just after distal anastomosis;(5)maintaining fluid balance below 1,000 ml during cardiopulmonary bypass., Results: Overall 30 day and in-hospital mortality was 1.6%( 6/372) and 3.8%( 14/372), and was 1.0%(3/308)and 2.6% (8/308) in elective cases. Permanent neurologic deficit occurred in 2.2%(8/372) of patients. The mean follow up period were46±39months(range2~165 months). Survival at 5 and 10 years after surgery was 75.8±2.8% and 66.0±3.8%, respectively. During follow up period, there was only one total arch replacement related problem (proximal anastomosis aneurysm). Freedom from additional aortic surgery and aortic related event at 5 and 10 years was 90.8 ±2.2% and 86.1±3.4%,respectively., Conclusion: Our current approach for total aortic arch replacement was associated with low hospital mortality and morbidities and with favorable long-term outcome.

Descending necrotizing mediastinitis( DNM) is often a lethal condition resulting from odontogenic or cervical infection, with a previously reported mortality rate of 25 to 40%, which is known to accompany occasional pericardial effusion. Here, we report a case of diffuse DNM with cardiac tamponade.

Our experiences of secondary aortic root replacement after proximal aortic operation and their technical details are presented. Between November 1999 and February 2013, 50 patients underwent reoperative aortic root replacement(34 male, mean age 59.6±13.1 years). The mode of previous operation was ascending and arch replacement in 21, aortic valve replacement (AVR) in 19, and aortic root replacement in 10. Indications for reoperation included root dilation( n=13), aortic root abscess( n=13), residual proximal dissection (n=12), formation of pseudoaneurysm (n=5)and graft infection (n=3), and non-structural valve dysfunction (n=4). Mean interval from 1st operation was 84.3±85.2 months (range, 0.8 month~11.8 years). At reoperation, 29(58.0%)patients had Bentall operation, 11(22.0%)had valve sparing root replacement, 5(10.0%)had prosthetic valve preserved root replacement and 5(10.0%)had partial replacement of Valsalva sinus without reimplantation of coronaries. In-hospital mortality was 8.0%(4 of 50). The cause of mortality was sepsis in 2, low-output syndrome in 1 and hemorrhagic stroke in 1. During follow-up, 2 patients had a 3rd-time root replacement for pseudoaneurysm formation and infective endocarditis. Other 2 patients needed coronary artery bypass grafting(CABG) and AVR for structural valve deterioration. Freedom from 3rd-time aortic root related operation was 90.2±4.7% at 10 years. Actuarial survival after reoperation was 84.6±6.3% at 10 years. In conclusion, reoperative aortic root replacement can be performed with acceptable outcomes even in patients with complicated aortic pathologies.

Thoracoabdominal aortic aneurysm (TAAA) repair is the most invasive aortic surgery, requiring wide aortic exposure and reconstruction of branches of vital organs. Spinal cord ischemic injury( SCII) remains the most devastating complication. There has been a significant improvement in operative mortality and the incidence of SCII during past 2 decades in the treatment of TAAA repair. A number of adjuncts have been successfully used intraoperatively and postoperatively to minimize the risk of SCII. However, TAAA repair is a still surgical challenge for many cardiothoracic surgeons because there is no definite method to prevent SCII. As the cause of SCII has been considered to be multifactorial from many experimental and clinical studies, multidisciplinary approach is essential in the surgical treatment of TAAA. This review describes the recent advances and operative management of TAAA repair in the current era.

Background: The purpose of this study is to compare mitral valve replacement (MVR) to anuloplasty (MAP) in patients with severe functional mitral regurgitation (FMR)., Methods: Data of 43 patients with significant chronic FMR who underwent mitral valve operations from November 1999 through May 2011 were retrospectively analyzed. This reference group included patients who underwent MVR (n = 18) and MAP (undersized restrictive annuloplasty, n = 25). The mitral valve is replaced sparing the continuity between mitral valve and subvalvular apparatus. All patients had severe FMR, and 71.4% had New York Heart Association (NYHA) III or IV symptoms of heart failure, and 20% had preoperative intraaortic balloon pumping (IABP) insertion. The MVR group had significantly higher risk patients with complex jet and advanced coaptation depth (13.3 +/- 2.1 versus 11.1 +/- 2.3 mm, p = 0.04)., Results: Hospital mortality was 9.3%. No statistical difference was found between the 2 groups in term of intraoperative data. Kaplan-Meier survival estimates at 1, 5 years was 82.6, 72.3% in MVR group, and 77.8, 69.7% in MAP group (p = 0.98). Freedom from Cardiac-related event at 5 years was 62.7% for MVR compared to 56.8 % for MAP (p = 0.75). At the last follow-up, recurrence of MR II or greater was present in 4 (14.8%) patients in the MAP group and only one patient required re-operation because of worsening heart failure. In multivariable analysis, independent predictor of increased cardiac-related event was associated with residual pulmonary hypertension (HR, 3.0: p = 0.021)., Conclusions: In high-risk patients with severe FMR. MVR seems to be a reasonable option.

Background: Outcome of the patients who underwent aortic root replacement with valve sparing procedure concomitant with cusp repair was evaluated., Methods: Between October 1999 and April 2009, valve sparing aortic root replacement were performed in 62 patients. Isolated valve sparing procedure was performed in 38 patients (control) and concomitant cusp repair was performed in 24 patients (aortic valve plasty: AVP). Cusp prolapse was corrected by plication of Arantius body (n = 13), cusp perforations were closed by pericardial patch (n = 6) or reinforcement of free margin (n = 6)., Results: No patient died during the hospital stay and no thromboembolic events occurred in the follow up. Pre-operative grade of aortic insufficiency was 3.0 +/- 0.9 in AVP group vs. 2.5 +/- 1.3 in control (NS). There was no significant difference between both groups regarding age, cardiac function and preoperative aortic root diameter. However, eccentric jet by preoperative transesophageal echocardiography (TEE) was more often in group AVP than in control (p<0.01). Five patients underwent reoperation because of recurrent aortic regurgitation (AR) or hemolysis. Postoperative AR grade were similar in both groups (0.9 +/- 0.5 vs 0.5 +/- 0.6). During follow up, the 5 year freedom from re-operation (aortic valve replacement: AVR) was 85.1+/- 8.2% in AVP and 94.0 +/- 4.1% in control (NS). 5-year-survival was 100% and 95.0 +/- 4.9% (NS), respectively., Conclusions: Valve sparing aortic root replacement with concomitant cusp repair provided satisfactory midterm result.

Thoracic aortic surgery still involves a significant risk of neurological complications including stroke and paraplegia, associated with high morbidity and mortality. Intraoperative monitoring of the brain and the spinal cord ischemia, such as 4-channel cerebral In Vivo Optical Spectroscopy (INVOS) and myogenic transcranial motor evoked potentials (MEP), may enable us to prevent the devastating complications by prompt and proper intraoperative management. This review describes our standard methods for these procedures during thoracic aortic surgery.

Perioperative management in emergency cardiac operation is challenging because general condition of the patient is often poor and only little preoperative information is available. In order to obtain an optimal surgical outcome, careful assessment of preoperative problems and prevention and detection of complications must be done without any delay. Preoperative carotid duplex scan should be performed in every case to assess the steno-occlusive lesion or unstable plaque, which affect the surgical strategy (eg. selection of arterial cannulation site and cerebral protection). Regional cerebral oxygen saturation (rSO2) must be monitored in all the operation. If intraoperative drop in rSO2 is detected, administration of inotropic agents and increase in cardiopulmonary bypass flow is needed to maintain the mean blood pressure at higher level. Intraaortic balloon pumping (IABP) insertion should be considered when rSO2 cannot be recovered with those procedures. We have to keep in mind that many of the patients undergoing emergency surgery are at high risk for coronary artery disease. If one cannot be weaned from cardiopulmonary bypass, coronary artery bypass grafting to a major branch may be performed. Coronary angiography should be performed immediately when ST-T changes in electrocardiogram (ECG) or chest symptoms appear in the postoperative period. Hesitation in making a decision will only jeopardize the situation.

The number of patients with thoracic aortic aneurysm has been increasing in Japan. The annual report by the Japanese Association for Thoracic Surgery 2001 demonstrated that 4,133 patients underwent surgery for thoracic aortic aneurysm. Among them, ruptured cases consisted of 11% (460 patients) and its early mortality was 32%. At the emergency room, initial accurate diagnosis, using echocardiography and computed tomography (CT), is mandatory for the next step and catastrophic shock status should be corrected if possible, such as pericardiocentesis or transfusion. For patients with ruptured descending or thoracoabdominal aortic aneurysms, the endovascular stent-grafting should be first choice of treatment. Otherwise, patients should be sent for the operation room as quickly as possible for initialing cardiopulmonary bypass and for controlling bleeding. Special attention should be paid for not injuring the left lung after left thoracotomy. Mycotic false aneurysms, including the aorto-esophageal fistula and prosthetic graft infection, remained as one of challenging entities in aortic emergency. The standard treatment for this fatal disease resection of the infected both aneurysm and esophagus, and has been reconstruction with an extra-anatomical bypass, however, recent advancement of technologies, including allograft and tissue engineering might enable to have in situ reconstruction of the aorta.

Spinal cord injury such as paraparesis and paraplegia remains one of the major concerns in surgery on the thoracoabdominal aortic aneurysm (TAAA). We utilize spinal cord protection including cerebrospinal fluid drainage (CSFD), adjuncts of aortic distal perfusion, reconstruction of the intercostal or lumbar arteries and deep hypothermia in TAAA repair. This report describes the results of surgical treatment for TAAA including postoperative neurological outcome. Between October 1999 and January 2004, 33 patients (mean age 66 years; range 26 to 81) underwent TAAA repair. Adamkiewicz artery could be detected using magnetic resonance angiography in 9 patients. CSFD was done in 20 patients. TAAA repair was achieved using adjuncts of aortic distal perfusion in 31 patients (partial cardiopulmonary bypass: 19, deep hypothermia: 9, left heart bypass: 3). We tried to reconstruct the intercostal or lumbar arteries which were located between Th8 and L2 as possible. Twenty-five patients underwent reconstruction of the intercostal or lumbar arteries. There were 6 hospital deaths. Postoperative spinal cord injury occurred in 4 patients (paraparesis: 1, paraplegia: 3). This clinical experience demonstrates that current technical strategies enable patients to undergo TAAA repair with acceptable early survival. However, despite aggressive spinal cord protection, few patients suffered from postoperative spinal cord injury. Future research should focus on spinal cord protection in patients with TAAA.

In patients with Marfan syndrome, pregnancy is associated with a potential higher risk of aortic dissection. To determine the incidence and characteristics of aortic dissection in pregnancy, clinical courses of 8 patients with Marfan syndrome were reviewed. Aortic dissection occurred in 3 patients, one of whom had developed rapid dilatation of the ascending aorta during pregnancy. The patient underwent Bentall operation subsequent to cesarean section and simple hysterectomy. All patients tolerated pregnancy well, with favorable maternal and fetal outcomes. Follow-up echocardiography showed no apparent worsening of cardiovascular status attributable to pregnancy such as aortic dilatation and aortic regurgitation except for one patient. Dilatation of the ascending aorta during pregnancy is considered to be an important predictor for aortic dissection. Close observation should be mandatory in such patients. In patients with serious cardiovascular involvement such as acute aortic dissection, cesarean section is preferable for delivery. To prevent hemorrhagic complications under systemic heparinization, simultaneous hysterectomy should be considered as one option.

One-hundred-one surgeries for aortic arch aneurysm were divided into 2 groups: 52 aortic dissection cases (AD) and 49 non-dissecting aneurysm (TA). In group AD, 30 cases were operated in acute phase (acute AD) and 22 were in chronic phase (chronic AD). Preoperative shock were observed in 21 cases (15 in acute AD mostly due to cardiac tamponade, 1 in chronic AD and 5 in TA due to rupture). Through median sternotomy, 59 total arch replacement and 25 hemi-arch replacement were carried out under deep hypothermia (16 degrees C:DH) and retrograde (RCP) or selective (SCP) cerebral perfusion or arch-first technique. Through thoracotomy, distal arch replacement were carried out with DH + RCP in 8 cases and with partial bypass in 9. Early mortality were observed in 7 patients (6.9%) and 24 months survival rates (Kaplan-Meier) were 86.1% overall, 76.1% in acute AD, 95.5% in chronic AD, 87.8% in TA. The survival rates in patients with preoperative shock was 61.2%, however, without shock, 92.9% in acute AD, 95.2% in chronic AD, and 91.4% in TA. Other than mortality, 4 re-operations for aortic arch, 4 operations for descending to abdominal aorta and 1 late hemiplegia were observed. Aortic event free ratio at 24 months was 55.4% in acute AD, 94.4% in chronic AD, and 75.7% in TA. For the further improvement of aortic arch surgery, early mortality and residual false lumen in acute aortic dissection and atherosclerotic aneurysm in descending to abdominal aorta are focused.

We report a successful surgical case of 78-year-old woman with aortoesophageal fistula subsequent to the operation for sealed rupture of thoracic aortic aneurysm. She underwent one-stage operation consisted of esophagectomy, transmediastinal interposition of the stomach and esophagogastroanastomosis, to re-establish the gastrointestinal tract. The patient recovered well postoperatively without infection.

From 1978 to July 1997, 140 patients with extended Stanford type A aortic dissection underwent surgical treatment. There were 77 acute and 63 chronic aortic dissections. The follow-up period of the 61 surviving patients in acute aortic dissection ranged from 2 to 164 months (mean, 56 months). During follow-up periods, 6 patients died of no dissection-related causes. The actuarial survival ratios in 77 patients were 77.2% at 3 years, 72.2% at 5 years and 62.6% at 10 years, respectively. There was no significant difference between acute aortic dissection and chronic aortic dissection in actuarial survival ratio. The ratio of the clotted false lumen in the distal aorta was lower and subsequent surgery was more frequent in patients with Marfan syndrome than those with non-Marfan syndrome. In extended type A aortic dissection, the observation of the residual false lumen using body CT scan was very important after surgery, especially in Marfan syndrome. If the false lumen is dilated, a subsequent surgery is needed to get good late results.

Between 1987 to 1990, six patients underwent replacement of the ascending aorta and aortic valve with a composite graft which was not wrapped with aneurysmal aortic wall; annuloaortic ectasia in 4, aortitis with acute onset of aortic regurgitation in 1, and acute aortic dissection with aortic regurgitation in 1. In 2 patients, "open aortic anastomosis" under deep hypothermic systemic circulatory arrest and retrograde cerebral perfusion was utilized for distal anastomosis of the graft to the resected aortic arch. Three patients required no transfusion. One patient with annuloaortic ectasia and severely dilated left ventricle died from ventricular fibrillation in ICU. One patient with aortitis died from stroke due to occlusion of bilateral carotid arteries 3 years postoperatively. The other 4 patients are alive and favorable. It is our belief that this technique still maintains simplicity and facilitates the secured anastomosis and minimized bleeding.

A 5-year-old girl presented infected tricuspid valve related to a residual ventricular septal defect. Antibiotic therapy produced a satisfactory initial improvement. However, subsequent deterioration with uncontrolled infection, in spite of alterations of the antibiotic regime, necessitated surgical intervention. Because the lesion was localized to the anterior leaflet of the tricuspid valve, partial excision of this leaflet and patch was undergone with a sustained clinical improvement with minimum residual valvular incompetence. This experience supports the concept that tricuspid valvuloplasty is the method of choice in the treatment of patient with regional right-sided infective endocarditis.

A case of delayed hemolytic transfusion reaction (DHTR) caused by blood transfusions after open heart surgery was reported in a 61-year-old woman. She had undergone mitral annuloplasty 8 years before. She underwent the 2nd mitral and tricuspid annuloplasty for recurrent mitral and tricuspid regurgitation in 1988. After the reoperation, she developed severe hemolytic anemia with fever. The anti-Jka antibody was detected in her serum by the blood antibody screening test. She was diagnosed to have a DHTR. She was treated conservatively and recovered.

A rare case of left atrial myxoma associated with ruptured chordae tendineae is presented. The patient was 70-year-old woman, and was diagnosed to have a left atrial myxoma. The myxoma was extirpated together with the atrial septum from which tumor developed. After removal of the myxoma, a ruptured strut chordae tendineae of anterior leaflet was also detected and resutured to the original papillary muscle. The cause of the torn chordae is presumed to be so-called "wrecking ball effect", and to be myxomatous degeneration of the valve.

An 8-month-old girl of anomalous origin of the left coronary artery from the pulmonary artery associated with severe mitral regurgitation underwent radical operation. She had been in serious cardiac and respiratory failure. Aorto-left coronary arterial continuity was established by intrapulmonary arterial tunnel using Takeuchi's technique. Mitral annulus was plicated by modified Kay's technique. Post-operative course was uneventful.

An atypical huge patent ductus arteriosus (PDA) associated with extreme pulmonary hypertension in a 6-month old female infant was reported. The left 3rd intercostal thoracotomy revealed huge PDA which has an appearance of pulmonary-ductus-descending aorta-trunk (PDDT) on the left side. The right side of the ductus continued to the aortic arch without demarcation between the ductus and the aorta. The median sternotomy clarified the ascending aorta, normal aortic arch, and main pulmonary artery. However, the top of the main pulmonary artery seemed to be fused with the aortic arch. The diagnosis of distal type of aortopulmonary window with wide communication was made and the total circulatory arrest with deep hypothermia and the intracavitary patching for separation of systemic and pulmonary blood flow seemed to be required for the complete repair. Total repair was decided to be postponed one week later and the chest was closed. The patient died of multi-organ failure originating from acute respiratory failure 23 days after exploratory thoracotomy without being repaired. Postmortem examination revealed a huge PDA freely communicating with the ascending aorta and the aortic arch. This is a report of an atypical huge PDA rarely seen and the conventional division or ligation is unfeasible. The circulatory arrest with deep hypothermia and intracavitary patching are obligatory for the surgical repair.