Background : Perioperative care in congenital heart surgery has evolved in recent years, and it was considered a contributive factor to improve surgical outcome and prognosis. Objective : To extract perioperative clinical protocols that have been applied in our hospital, then assess their usefulness for better clinical outcome. Methods : We retrospectively reviewed our patients' records to analyze representative perioperative protocols that might have contributed to surgical outcome, such as intraoperative transesophageal echocardiography (ITEE), extubation in the operating room on patients of atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), Glenn procedure and Fontan procedure. We also assessed clinical pathway of ASD and VSD, and each protocol was individually explored to calculate achievement ratio in order to show its adequacy. Results : This study included 482 of on-pump surgery patients and 146 of off-pump surgery patients from June 2007 to June 2014. ITEE was performed in 474 of on-pump surgery patients and 102 of off-pump surgery patients. No case had a residual lesion immediately after operation. Extubation in the operating room was performed in cases without severe pulmonary hypertension (PH). The extubation ratio was 94.7% (ASD repair), 60.0% (VSD repair), 50.0% (TOF repair), 42.5% (Glenn procedure), and 45.2% (Fontan procedure), respectively. Clinical pathways of ASD and VSD included patients without severe PH. Achievement ratio of the clinical pathway was 98.2% in ASD and 94.2% in VSD patients, respectively. Four patients were excluded because of high c-reactive protein (CRP), and one patient because of familial circumstance. Conclusion : ITEE was useful in evaluation of cardiac function, residual issue and residual air at weaning of cardiopulmonary bypass. Reintubation did not occur in any clinical course of extubation in the operating room, but the extubation rate was not high because of safety concerns. Achievement ratio of the clinical pathways of both ASD and VSD was more than 90%, therefore, application of the clinical pathway was considered appropriate.

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Tamponade occurring several years after open-heart surgery is rare ; the decision to surgically intervention for tamponade is a difficult one. We present our experience with a case of tamponade that occurred 4 years after open heart surgery. The patient was a 70-year-old man who underwent aortic valve replacement (Carbomedics^TM 27 mm), pulmonary vein isolation, right atrium maze operation, and ligation of the left atrial appendage. Four years after the surgery, he was admitted to our hospital because of dyspnea on exertion and leg edema. Echocardiography and computed tomographic (CT) scan revealed a hematoma in the intrapericardial cavity, which was pressing on the posterior wall of the left ventricle, for which surgery was indicated. After the hematoma was removed, there was bleeding from the left atrial appendage. Hemostasis was performed with one mattress suture. A postoperative CT scan demonstrated that the left ventricle deformity had disappeared and the cardiac hemodynamics were normalized. During the follow-up period, no recurrent hematoma was observed. This evidence suggests that tamponade occurred because of re-bleeding from the left atrial appendage where the bleeding was stopped by the pressure of the hematoma.

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Inferior mesenteric artery aneurysm (IMAA) is a rare disease among visceral aneurysms. We encountered an open repair of IMAA in association with arteriosclerosis obliterans (ASO). The case was 74-year-old man who had progressive intermittent claudication for 10 years. Preoperative enhanced CT demonstrated IMAA and ASO due to the occlusion of right common iliac artery, the coil embolization was initially considered as a therapeutic option. However, since CT also revealed the occlusion of superior mesenteric artery, the open repair of the aneurysmal resection and subsequent IMA reconstruction were performed in order to avoid mesenteric necrosis. During the procedure, we confirmed bilateral arterial flow of the lower extremities and the good color of the small intestine before closing the abdomen. The patient was started on food intake on postoperative day (POD) 3, and CT showed intact arterial flow of the inferior mesentery. Postoperative course was uneventful and the patient was discharged on POD 16.

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A 79-year-old woman, who had undergone mitral valve replacement with a Björk-Shiley valve 16 years previously, was transferred to our institute due to active prosthetic valve infection associated with severe heart failure on respirator. On admission, her white blood cells and c-reactive protein (CRP) were elevated to 15,700/µl and 7.29 mg/dl, respectively, and she had anemia (hemoglobine 8.1 g/dl), thrombocytopenia (platelets 75,000/µl), and renal dysfunction (blood urea nitrogen 57 mg/dl, creatinine 1.8 mg/dl, estimated glomerular filtration rate 21.5 ml/min/1.73 m²). Her brain natriuretic peptide was elevated to 456.7 pg/dl. Blood culture revealed bacteremia with Streptococcus agalactiae. Though CT scan revealed cerebellum infarction, we decided to perform emergency surgery because of uncontrollable infection and heart failure, even with massive infusion of catecholamine and respiratory support. At surgery, huge vegetation proliferated over the prosthetic valve. The prosthetic valve was detached from approximately two-thirds of the annulus due to an annular abscess. The infected annulus was resected aggressively. Mitral annulus was reconstructed and reinforced with a bovine pericardial patch, and the bioprosthetic valve of 23 mm in size was implanted in an intra-annular position. In the postoperative phase, antibiotics (ampicillin, gentamicin) was given, and CRP became negative 47 days postoperatively, and the patient discharged from the hospital 56 days after the operation.

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We report a rare case of double outlet right ventricle (DORV) with sub-pulmonary type ventricular septal defect (VSD). The great arteries were almost side-by-side, and the ascending aorta was located slightly posterior to the right of the pulmonary artery. We performed complete repair at the age of 25 days. Intra-cardiac rerouting (VSD closure) was carried out through the tricuspid valve. Arterial switch procedure was performed without the Lecompte maneuver. His postoperative course was uneventful and he was discharged 19 days after the operation without any complications.

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A 1-year-old girl with patent ductus arteriosus (PDA) was admitted for cardiac catheter examination which identified a 7.8 mm Krichenko D type PDA. An Amplatzer duct occluder (ADO) was used but fluoroscopy showed the device at an oblique angle and residual shunt. The girl underwent surgical removal of the device 2 days after deployment because of progression of residual PDA shunt and left pulmonary artery encroachment, suggesting device dislodgement. Median sternotomy was performed, cardiopulmonary bypass was established and dissection was carried out around the PDA. Marked protrusion of the PDA wall made by the ADO retention disc was noted. The main pulmonary artery was incised under cardioplegic arrest. The device was incarcerated in PDA and attempts to remove the device failed. Therefore delivery cable through sheath was reconnected to the device by its microscrew, and the pulmonary end of the device was recaptured into sheath. The incarceration was dissolved and the device was removed. PDA was ligated.

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A 37-year-old man who fell from a truck had chest pain and we diagnosed blunt chest trauma. A chest computed-tomography displayed a traumatic cardiac tamponade. The patient was transported to our hospital for emergency surgery. After median sternotomy, there was no injury of heart and great vessels in the pericardial sac but a rupture of the pericardium. Bleeding and hematoma were found in the anterior mediastinal space. The cardiac tamponade was caused by the bleeding from anterior mediastinal space. Usually, blunt cardiac tamponade was caused by the bleeding from cardiovascular organs, however, we encountered a very rare cardiac tamponade due to the bleeding from the anterior mediastinal space.

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An 80-year-old woman underwent lower and middle lobe resections of right lung in 1990 and 1998 because of lung cancers. There was no recurrence. In 2009, she presented with exertional dyspnea, and echocardiography showed grade III mitral regurgitation (MR). We diagnosed with congestive heart failure caused by MR. Her chest CT showed her mediastinum was shifted to the right and her heart was in the right thoracic cavity. We performed mitral valve plasty via right 7th intercostal thoracotomy. Post-operative respiratory condition was stable and she was extubated on the first postoperative day. Post-operative UCG showed trivial MR. She was discharged on the 14th day.

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A 75-year-old man was admitted to our hospital due to sudden onset of chest pain. Computerized tomography showed penetrating atherosclerotic ulcer at the distal arch and hematoma around the aortic arch, therefore we diagnosed spontaneous rupture of the aortic arch. He had a history of previous CABG and multiple cerebral infarction with diffuse cerebral arteries. Open surgery under deep hypothermia, circulatory arrest and cerebral perfusion was considered to be difficult and too invasive, therefore we performed debranching TEVAR. Postoperative cerebellar infarction occurred, but he was discharged 29 days after surgery. TEVAR is especially useful for treatment of spontaneous rupture of the aorta in high-risk patients.

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A 28-year-old man visited the emergency department of our hospital with a chief complaint of palpitation and chest pain. The patient had undergone 4 operations at other hospitals for tetralogy of Fallot (TOF), left pulmonary atresia, an aberrant right coronary artery, and a right aortic arch. As a result of thorough investigations, we suspected that the cause of the patient's symptoms was an excess of the right ventricular pressure over the left ventricular pressure, which was caused by right ventricular compression resulted from an abnormal mass on the anterior surface of the right ventricle, and by pulmonary stenosis (PS) associated with right ventricular outflow tract stenosis (RVOTS). Excision of the mass, right ventricular outflow restoration (RVOTR), and pulmonary valve replacement (PVR) were indicated. The mass on the anterior surface of the right ventricular was found to have been caused by retention of serous fluid in the interstice formed by a folded expanded polytetrafluoroethylene (ePTFE) pericardial sheet. An ePTFE pericardial sheet, which is used to supplement the pericardium, has been reported to have advantages with respect to prevention of adhesion, denaturation of pericardial substitutes, and inflammatory thickening and adhesion of the epicardium, compared with other materials used as pericardial substitutes. However, epicardial thickening has been noted with the use of ePTFE pericardial sheets, and hence, its use is currently avoided in many cases. This case presents an extremely rare pathology in which the inflammatory reaction of the epicardium caused by an ePTFE pericardial sheet is suspected to have caused serous components to become tightly encapsulated in the interstice formed by the folded patch ; no definite cause was identified. Thus far, no other such case has been reported, and ePTFE pericardial sheets should be used with caution.

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Interest in aortic valve repair has been growing for more than a decade. Since ross and associates 1) first introduced single cusp enlargement, cusp extension or replacement of aortic valve insufficiency has been used with rheumatic and congenital aortic valve disease. There is more interest on the effectiveness and durability of the leaflet extension technique with autologous pericardium and long-term clinical results. A 29-year-old woman had suffered from aortic valve insufficiency after congenital heart disease operation. Echocardiography and computed tomography showed right cusp shortening with severe aortic valve regurgitation. We perfomed right cusp extension with bovine pericardium and central plication. According to some reports, the stability of autologous pericardium being better than bovine pericardium, but this case could not use a autologous pericardium because of a previous operation. The patient had an uneventful postoperative course and pregnancy became possible.

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We report a case of surgical repair of acquired left ventricular-right atrial communication resulting from infective endocarditis. A 70-year-old man with aortic regurgitation due to infective endocarditis was referred to our hospital because of congestive heart failure. Preoperative transthoracic echocardiography showed severe aortic regurgitation and left ventricular-right atrial shunt flow. He underwent surgery following intensive antibiotic therapy. The fistula was located at the atrioventricular membranous septum. The communication site from the left ventricular view it was below the commissure between the left and the non-coronary cusps, and from the right atrial view it was above the tricuspid annulus of the septal leaflet. The fistula was closed with autologous pericardial patch from the aortotomy and a mattress suture from the right atriotomy. Aortic valve replacement was performed simultaneously. The postoperative course was uneventful. He was in sinus rhythm all the time. It is important to discuss surgical procedure preoperatively with precise echocardiographic examination.

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Objective : Blunt aortic injury often accompanies other organ injuries, and therefore requires an appropriate lifesaving surgical strategy. Patients : During the past 8 years, blunt aortic injury was reviewed, based on 5 lifesaving cases experienced in our hospital. There were 3 men and 2 women (aged 57-70, average 64.2). The Injury Severity Scores were 13-25 (an average of 17.2). Intervention : Regarding our strategy, stabilization of vital signs should be at first aimed by intensive primary care, concomitantly with diagnostic procedures. When stabilization of vital signs is obtained, a delayed operation would be considered after damage control resuscitation. As for 3 of these 5 cases, an emergency surgery was performed because of distinct aortic hemorrhage with instability of vital signs, and stent graft repair was applied based on anatomical indication in two cases. In the other 2 cases, primary diagnosis suggested aortic injury by the bone fracture pieces. Damage control was conducted following stabilization of vital signs, and delayed surgery was done with removal of the bone fracture pieces and repair of aortic injury, which improved activities of daily living. Results : All cases recovered with no particular complication, and were discharged on 9-32 days average postoperatively. Conclusion : Blunt aortic injury is often fatal, but the appropriate diagnosis and treatment can play an important role in obtaining the good results.

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Patients with an aortic root pseudoaneurysm communicating to the right atrium are rare. A 67-year-old woman underwent ascending aorta and total aortic arch replacement for acute type A aortic dissection at our institute 9 years prior to the current presentation. She was transported to our emergency department with complaints of chest pain, palpitations, and cold sensation. A continuous murmur was heard at the right sternal margin. Contrast-enhanced computed tomography (CT) and ultrasonic cardiography showed a huge pseudoaneurysm at the proximal anastomotic site and an aorto-right atrial fistula. Ascending aortic replacement with concomitant direct closure of the fistula was successfully performed. The patient was discharged in good condition on the 14th postoperative day. Careful follow-up with CT is important after acute type A aortic dissection repair.

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We herein report a 79-year-old man who developed anaphylactoid purpura after thoracic endovascular aortic repair, which he underwent for a distal aortic arch aneurysm of saccular type. On the third postoperative day he had purpura over his lower legs and abdomen accompanied by intermittent fever. His serum C-reactive protein concentration reached a maximum of 12 mg/dl, and remained at around 4 mg/dl thereafter. A dermatologist diagnosed anaphylactoid purpura ; this gradually improved with topical steroid and the nature and dosage of the oral medication. We suspected the presence of malignancy ; however, appropriate investigations failed to identify a cause for the purpura. During 6 months of outpatient follow up he has been free of recurrence. Anaphylactoid purpura occurs most frequently in childhood, often after an upper respiratory tract infection, whereas this condition is rare in adults. Triggers for anaphylactoid purpura include surgery, infection, certain medications, chronic lung, liver, or renal failure, and malignancy. We believe that the stress of undergoing thoracic endovascular aortic repair was the trigger in this case. Anaphylactoid purpura may be complicated by arthritis, gastrointestinal involvement and renal manifestations. There were no such complications in this case.

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