The use of transapical aortic cannulation for arterial inflow during surgical repair of type A acute aortic dissection was evaluated. Thirty-six patients who underwent repair of type A aortic dissection were divided into 2 groups: those who underwent repair with transapical aortic cannulation (group A; 19 patients) and those who underwent repair with axillary and/or femoral artery cannulation (group C; 17 patients). Preoperative condition, estimated blood loss, transfusion requirements, and duration of the tube drainage and postoperative hospital stay did not differ in the 2 groups. Cannulations were successful in all patients, and none of the attempted inflow sites required moving to alternate sites in either group. The time to initiation of extracorporeal circulation (74.2±16.2min versus 88.8±12.5min, p=0.005) and the extracorporeal circulation time (175.2±55.5min versus 216.6±58.1min, p=0.036) was shorter in group A than in group C. However, the total operation time did not differ between the groups (309.3±112.5min in group A versus 363.4±130.9min in group C, p=0.198). All patients survived the operation, and there were no complications directly related to transapical aortic cannulation. Postoperative stroke tended to be lower in group A than in group C (5.3% versus 29.4%; p=0.081). There was 1 operative death in group A (5.3%) and 4 operative deaths in group C (23.5%) (p=0.167). These data demonstrate that the use of transapical aortic cannulation yielded more favorable results than other cannulation techniques for induction of extracorporeal circulation and for minimization of extracorporeal circulation time and postoperative morbidity. We conclude that transapical aortic cannulation represents a safe, effective and less invasive means of providing arterial inflow during cardiopulmonary bypass for patients undergoing surgical correction of type A aortic dissection.

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Coronary artery bypass grafting (CABG) in elderly patients has been increasing in recent years. Between June 1981, and February 2004, 32 patients aged 80 years or older (mean 81.8) underwent CABG in our hospital. Twenty one patients (67%) were in New York Heart Association class III or IV. Incidence of emergency surgery in the elderly (17 of 32, 53%) was significantly (p<0.0001) higher than that in younger patients (131 of 969, 13.5%). Total hospital deaths were 19% (6 of 32, emergency procedures 5, elective 1). The hospital deaths in patients with an ejection fraction (EF) of 45% or more (5 of 12, 42%) were significantly (p<0.05) higher than those in patients with an EF of more than 45% (1 of 20, 5%). The main features of CABG in octogenarians was the high rate of emergency surgery and high mortality. Thus CABG in octogenarians should be performed early, before the cardiac function deteriorates, in order that treatment not be denied because of age alone.

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A 60-year-old male who had a history of Buerger's disease was admitted due to chest pain on exertion. Coronary angiography showed severe double vessel disease (the left anterior descending artery and the right coronary artery). Carotid angiography showed severe stenosis of the left internal carotid artery associated with brain ischemia. In addition, angiography of the lower extremities showed segmental occlusion and collateral arteries resembly a “corkscrew” appearance. We implanted a stent in the carotid artery followed by revascularization surgery of the left lower leg and simultaneous coronary artery bypass surgery. The postoperative course was excellent.

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Papillary fibroelastoma (PFE) is a benign tumor accounting for approximately 8% of cardiac tumors. We report a 64-year-old woman with pulmonary valve PFE associated with atrial septal defect. It was detected by a transesophageal echocardiography as a fluttering mass clinging to the pulmonary valve, and was simply removed concomitantly with a patch closure of atrial septal defect. In a review of the past literature, 43 surgical cases of PFE have been reported in Japan, and aortic valve, mitral valve and left ventricle PFE was commonly encountered in 81%. Pulmonary PFE is very rare, and only one case has been reported apart from the present one.

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A 68-year-old man who had undergone previous coronary artery bypass grafting was admitted with cardiac failure because of aortic valve stenosis and severe mitral valve regurgitation. Preoperative cardiac catheterization showed a patent left internal thoracic artery (LITA) and a stenotic saphenous vein graft. We performed aortic valve replacement, mitral valve repair, and coronary artery bypass grafting with repeat sternotomy, moderate hypothermia (29.3°C), aortic cross-clamping, retrograde cardioplegia and proximal occlusion of the LITA graft using a soft bulldog clamp. The proximal LITA was occluded through a supraclavicular incision without intrathoracic dissection. Although cardiopulmonary bypass (CPB) time and aortic cross-clamp time were prolonged, the patient was taken off CPB without any problem. The postoperative course was uneventful. We believe that this technique is safe and effective for establishing myocardial protection without deep hypothermia and risk of LITA injury.

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We encountered a case of cerebral oncotic aneurysms and intracerebral hemorrhage after resection of a left atrial myxoma. A 67-year-old woman underwent resection of the left atrial myxoma. She was followed by ultrasound cardiography on an ambulatory basis. About one and a half years later, she was hospitalized because of neural symptoms. Multiple cerebral aneurysms and intracerebral hematoma were found, and the hematoma was removed. With the neural symptoms recurring repeatedly thereafter, however, she eventually died due to pneumonia. The pathological examination of the intracerebral hematoma removed at operation and cerebral aneurysms at autopsy revealed myxoma cells causing embolisms in the artery and invading the atrial wall with some hemorrhage. It is known that cardiac myxoma occasionally causes a cerebral lesion. The lesion is presumed to be caused by embolism as in our case. So it is nessesary to evaluate morphologic characteristics of cardiac myxoma before operation and to pay attention to the occurrence of embolism during operation. Making a rigorous follow-up of the general progress by computed tomography after operation is also considered important.

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For aortic root replacement in annuloaortic ectasia (AAE), an artificial prosthesis is commonly sutured to the aortic annulus (hemodynamic ventriculoaortic junction). We consecutively had 6 cases of aortic root replacement using anatomic ventriculoaortic junction suture. This anatomic ventriculoaortic junction suture is a simplified and practical method for aortic root replacement in the same way as using stentless bioprostheses or homografts.

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We report a case of localized abdominal aortic dissecting aneurysm, diagnosed in association with an intractable ulcer on the right leg. The patient, a 62-year-old man, with a history of hypertension and hyperlipidemia, was admitted to another hospital for hematemesis and phlegmon of the left lower leg. He subsequently needed intensive care, including mechanical ventilation, because of loss of consciousness and extreme leucocytosis caused by meningitis. The skin ulcer that developed on his right leg leaked gabexate mesilate, which had been administered to treat disseminated intravascular coagulation. The ulcer was resistant to several surgical treatments, including skin graft implantation. As he complained of intermittent claudication, ischemia of the right lower limb was suspected. Angiography and computed tomography revealed infrarenal abdominal aortic dissecting aneurysm and occlusion of the right common iliac artery. He was referred to us for surgery. After performing a median laparotomy, we resected the aneurysm and implanted a Y-shaped prosthetic graft. The postoperative course was uneventful, and the patient was discharged 4 weeks after operation. The surgical indications of infrarenal abdominal aortic dissecting aneurysm are the same as those for abdominal aortic aneurysm.

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We performed the Senning operation and pulmonary valvotomy in an 11-month-old baby with transposition of the great arteries (TGA) with an intact ventricular septum (IVS), and bicuspid pulmonary valvular stenosis associated with pulmonary hypertension (PH). Preoperative catheterization showed a pressure gradient (PG) between the left ventricle (LV) and main pulmonary artery (MPA) of 35mmHg, mean pulmonary artery pressure (MPAP) of 56mmHg, and pulmonary vascular resistance (PVR) of 11.2unit·m². The pure oxygen inhalation test showed a decrease in MPAP from 56 to 38mmHg, and a decrease in PVR from 11.2 to 5.5 unit·m². We could not perform lung biopsy to determine the surgical indications in terms of PH due to preoperative progressive congestive heart failure in this patient. Postoperative catheterization (28 days after the Senning operation) showed a decrease in PG between the LV and MPA to 8mmHg, and MPAP also decreased to 17mmHg. Two radical operations were possible in this patient. One was the arterial switch operation (ASO), and the other was the atrial switch operation, i. e. the Senning or the Mustard operation. We selected the Senning operation because there was the possibility that the new aortic valve might develop persistent stenosis and regurgitation after ASO and pulmonary valvotomy. The Senning operation may be an alternative in selected patients with TGA with IVS and pulmonary valvular stenosis.

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A case of successful surgical revascularization for mid-aortic syndrome is reported, with discussion of the operative method. A 10-year-old boy with headache and vomiting was admitted to our hospital for excessive hypertension. A diagnosis of mid-aortic syndrome with severe stenosis of abdominal aorta and stenosis or occlusion of bilateral renal arteries was made. His hypertension did not respond to conservative treatment. Therefore we performed aorto-aorta bypass using a prosthetic graft and revascularization of the bilateral renal arteries. The preoperative symptoms disappeared, his blood pressure became controllable, and he was discharged on the 21st day after surgery. At present, he attends school and has a normal blood pressure without hypotensive medication.

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A typical feature of mid-ventricular obstructive hypertrophic cardiomyopathy (MVO-HCM), is obvious hypertrophy of the mid-ventricular muscle and ventricle with transformation into the shape of an hourglass. We report a 60-year-old woman who had been given a diagnosis of apical type hypertrophic cardiomyopathy 12 years previously, but it changed to MVO-HCM with apical left ventricular aneurysm. We considered the impending rupture of the aneurysm because its wall was thin and pericardial effusion was detected by UCG (ultrasonic cardiograph). Urgent surgery was performed consisting of ventricular aneurysmectomy and patch reconstruction. After the surgery, a pseudoaneurysm was found in cardiac apex, so we performed surgery again. A residual shunt in the trabeculation caused the pseudoaneurysm, but its origin was not clear. She has been fine for 18 months without complications such as recurrence of aneurysm, ventricular arrhythmia or left ventricular dysfunction since the last surgery.

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A 9-year-old boy with multisaccular thoracic aortic aneurysm associated with coarctation of the aorta underwent definitive repair under partial cardiopulmonary bypass. The operation consisted of resection of the aneurysm and reconstruction of the descending aorta. Aortic reconstruction was done without an artificial graft, and extended end-to-end anastomosis was performed successfully. He has been doing well and there was no significant restenosis at the repair site 5 years after the operation. Some authors reported that untreated coarctation of the aorta frequently developed aneerysm, which usually has multisaccular lesions. Surgical strategy of aortic reconstruction for coarctation of the aorta in boyhood should be decided prudently to avoid postoperative complications.

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An 87-year-old man who had a history of aortic valve replacement (Carbomedics n 23) due to severe aortic valve regurgitation 3 years previously was admitted to our hospital suffering from syncope. The ascending aorta was 40mm in diameter at the time. At the time of admission, the patient's ECG showed elevation of the ST segments in leads V₁-V₃ and depression in leads V₅, V₆, II, III and _aV_F. Emergency coronary angiography performed for suspected acute myocardial infarction showed a type A acute aortic dissection extending to the ostium of the left coronary artery. However, because of his age and stable condition without cardiac tamponade, we treated this patient with conservative therapy including antihypertensive medication. He experienced no major complication and was discharged 31 days after admission. It is concluded that the occurrence of acute aortic dissection after aortic valve replacement is not common, but for a patient with a dilated aortic root at the time of aortic valve replacement, strict postoperative care is necessary. An operation is the first choice of treatment for acute type A aortic dissection, but in this case the patient's overall condition had to be considered.

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We describe our surgical experience of localized thoracoabdominal aneurysm in a 60-year-old woman with hypertension and hyperlipidemia. She was admitted for severe nausea associated with uremia. The initial CT scan revealed bilateral hydronephrosis, retroperitoneal fibrosis, inflammatory abdominal aneurysm, and localized thoracoabdominal aneurysm. To resolve the bilateral urinary tract obstruction, bilateral ureteral stents were inserted. After the renal function improved, the thoracoabdominal aneurysm was removed and replaced with an 18-mm woven-Dacron graft under partial cardiopulmonary bypass. The inflammation and fibrosis along the abdominal aorta did not extend to the thoracoabdominal aneurysm. Following the case presentation, we discussed the pathophysiologic aspects of this patient.

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Primary cardiac angiosarcoma is very rare and its prognosis was reported to be very poor (average survival period 7 months). A 46-year-old woman with angiosarcoma was admitted for recurrent symptoms of cardiac tamponade. Surgical excision of the tumor was performed 5 months after initial presentation and irradiation therapy was added. Thereafter, immunotherapy, and transcatheter arterial embolization were performed for liver metastasis. Despite this multidisciplinary therapy, she passed away 355 days after surgery. In our report, we described our multidisciplinary approach to this highly malignant tumor and the treatment strategy was discussed.

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Fatal intestinal necrosis developed following off-pump CABG and implantation of a bifurcated vascular prosthesis in a 70-year-old man with unstable angina pectoris and abdominal aortic aneurysm. A CT scan with three-dimensional reconstruction (3D-CT), showed no narrowing or obstruction of the SMA. The patient was scheduled to undergo an extensive resection of the intestine on the 23rd postoperative day. The pathological diagnosis was nonocclusive mesenteric ischemia (NOMI). He died of multiple organ failure on the 38th postoperative day. Early diagnosis of NOMI is essential to lower mortality and postoperative morbidity. Invasive angiography is the gold standard in diagnosis. 3D-CT, a non-invasive method, is an increasingly useful technique, which may allow identification of vascular anatomy and pathology with sufficient detail for diagnosis. Several other causes of acute abdomen, other than mesenteric ischemia, can be ruled out. Therefore, 3D-CT might be useful in screening for NOMI.

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