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We present a 57-year-old woman with severe aortic stenosis. She was diagnosed with acute myocardial infarction by electrocardiography and the detection of elevated creatine phosphokinase in another hospital. Soon after transfer to our hospital, this patient developed cardiac arrest. Percutaneous cardiopulmonary support (PCPS) was established, and subsequently performed coronary angiography revealed normal coronary arteries. However echocardiography revealed severe aortic stenosis. Emergency aortic valve replacement (AVR) was performed, and the patient was discharged from hospital 30 days after surgery in good health. Prompt establishment of PCPS maintained her systemic circulation, and allowed us to conduct investigations for diagnosis. In patients with critical aortic stenosis, emergency AVR should be performed as early as possible following diagnosis.

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.

We experienced a rare case of the mitral regurgitation due to papillary muscle rupture after percutaneous transvenous mitral commissurotomy (PTMC). This case was a seventy years old female who underwent PTMC. The cardiac tamponade and mitral regurgitation occurred after PTMC. Pericardial drainage was done immediately, and the next day the emergency operation was required. Rupture of the posterior papillary muscle was found at the operation, and mitral valve replacement was performed. Her postoperative course was uneventful and she discharged on the 26th day after the operation. We should take the papillary muscle rupture into consideration if there are severe sub-valvular lesion and shorting of the chorda.

To evaluate the effect of retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) on brain protection, changes of cerebrovascular oxygen saturation (rSO2) were studied in 14 patients with aortic arch reconstruction during the procedure. The rSO2 was monitored with spectroscopy instrument (Invos 3100, Somanetics). The mean value of rSO2 measured just before cardiopulmonary bypass was 65.9 +/- 6.2% in 7 patients with RCP, and was 64.9 +/- 4.7% in 7 patients with SCP. The value of rSO2 during core cooling of cardiopulmonary bypass was increased step by step. Although RCP time with a mean of 38.9 +/- 9.7 min was statistically shorter than SCP time (80.7 +/- 45.1 min), the mean value of rSO2 during cerebral protection in RCP group was decreased from 80.3 +/- 8.1% to 63.4 +/- 10.2%, lowest 46% with a ratio of 21.1%. In contrast, the mean value of rSO2 in SCP group was well maintained from 79.9 +/- 6.5 to 75.6 +/- 6.8%, lowest 63% with a ratio of 5.4%. Although no neurological deficits were recognized after operation in both groups, rSO2 in SCP group was sustained above the control value (65% just before cardiopulmonary bypass) but rSO2 in RCP group was decreased below the control value after 35 min. So we conclude that with regard to brain protection assessed from rSO2 measured by Invos 3100 cerebral oximeter, there is no time limitation of SCP during the procedure but RCP had a limit of the duration.

Two cases of acute aortic dissection which developed compression of the true lumen due to retrograde perfusion during cardiopulmonary bypass were reported. In the first case, coronary reperfusion could not be achieved when the aortic cross-clamping was removed after Collins' method of aortic dissection. There was no blood flow from the true lumen through the aortic root while the false lumen was distended by the retrograde perfusion. After completion of antegrade perfusion through the arterial cannula inserted into the anastomosed site of the ascending aorta, coronary reperfusion was established and the heart beating could be thereby obtained. In the second case, the false lumen was gradually expanded, and the true lumen was completely obstructed by it. Reexpansion of the true lumen was achieved by initiation of antegrade perfusion through the cannula inserted into the graft replaced in the ascending aorta. Fortunately cerebral and cardiac complications were not found in both cases postoperatively. Compression of the true lumen is rare, but fatal complication that may occur during retrograde perfusion in surgical repair for aortic dissection of Stanford type A. Therefore, it is very important to replace the perfusion cannula in the true lumen of the reconstructed aorta for preventing insufficiency of coronary and cerebral circulation.

Sixty-seven patients subjected to this study composed of 32 patients treated surgically, 15 patients treated medically and 20 patients examined by autopsy for the past 8 years. Out of 32 surgical cases, 16 were operated on in an acute stage, within 2 weeks after onset and 9 out of these 16 acute cases belonged to DeBakey type I or II and 11 out of 15 autopsy cases belonged to type I or II either. Contrarily most of the medical cases were type III. Both causes of death in the acute autopsy group and operative indications in the acute surgical group were cardiac tamponade, heart failure due to aortic insufficiency, myocardial infarction and aortic rupture. Operative mortality rate was 12.5% in the acute cases and 19% in the chronic cases, late mortality rate was 19% in the acute cases and 0% in the chronic cases. Two cases of operative death had massive bleeding due to aortic rupture and massive myocardial infarction. These were the most dangerous complications of acute aortic dissections. We conclude that all patients with type I or II dissections should be operated on before fatal complications occur.