Introduction : Prevention of embolic stroke is the key issue to perform aortic arch replacement in patients with a shaggy aorta. The aim of this study is to report the utility of the isolation technique for total arch replacement in patients with a shaggy aorta. Methods : Clinical results of seven patients (71.7 years old, all men) with a shaggy aorta who underwent total arch replacement between January 2017 and November 2018 were retrospectively reviewed. The operative indications were a distal arch or proximal descending aortic aneurysm in 6 patients and a thrombus inside brachiocephalic artery in one. A cerebral perfusion was established by inserting a cannula directly into all supra-aortic branches before starting systemic perfusion. Result : Utilizing the isolation technique with clamping of all branches in 4 patients and the functional isolation technique with clamping of two branches in 3, total arch replacement was performed in all patients (operation time : 513 min, selective cerebral perfusion time : 162 min). No operative death was observed and no newly developed stroke was encountered. Conclusion : The isolation technique is a useful method to prevent stroke during total arch replacement in patients with a shaggy aorta.

A 35-year-old man was referred to our hospital for surgical repair of grade IV/IV aortic regurgitation secondary to a congenital unicuspid aortic valve accompanied by aneurysm of the ascending aorta. The aortic valve was the unicuspid unicommissural type and a fully developed commissure was located in the left lateral position (left coronary/right coronary). The anterior (non-coronary/right coronary) and posterior (non-coronary/left coronary) borders were rudimentary with calcified raphe. We performed aortic valve repair in combination with valve sparing root replacement (reimplantation) and partial arch replacement. We converted the unicuspid into a bicuspid aortic valve by preserving his own free margin tissue and creating a neocommissure to the 180 degrees opposite side of the left lateral commissure at the same height by enlarging the cusp with a glutaraldehyde-treated autologous pericardium patch to the cusp belly. The patient was discharged on the 17th postoperative day with trace aortic regurgitation. We successfully repaired the unicuspid aortic valve by augmenting the cusp size using a pericardium patch in order to preserve the free margin of the cusp.

A 42-year-old woman with Turner syndrome was admitted to our hospital due to severe aortic stenosis. Transthoracic echocardiography demonstrated severe aortic stenosis with a bicuspid aortic valve. Enhanced computed tomography revealed that the left upper pulmonary vein connected to the innominate vein, and the ascending aorta was enlarged (maximum diameter of 41 mm). Surgical intervention was performed though median sternotomy with cardiopulmonary bypass. After achieving cardiac arrest by antegrade cardioplegia, we performed an anastomosis to connect the left upper pulmonary vein to the left atrial appendage. Then, aortic valve replacement was performed with an oblique aortotomy in the anterior segment of the ascending aorta. The aortic valve was a unicaspid aortic valve. Following completion of aortic valve replacement with a mechanical valve, reduction aortoplasty was performed on the ascending aorta. The postoperative course was uneventful.

We report a successful case of fulminant myocarditis treated with central ECMO with a transapical left ventricular vent (TLVV). A 33-year-old man was diagnosed with fulminant myocarditis with acute biventricular failure. Using a cardio-pulmonary bypass, we introduced central ECMO with ascending aortic perfusion, right atrial venous drainage and TLVV. After ancillary circulation, his cardiac function gradually improved. The endotracheal tube was removed 5 days after the surgery (POD 5), and he was weaned from ECMO on POD 7 and discharged on POD 38. Although there are many cases in which peripheral veno-arterial ECMO (VA-ECMO) is used for fulminant myocarditis, there is a drawback to VA-ECMO : left ventricle (LV) unloading may be incomplete. Insufficient LV unloading may cause pulmonary congestion or disadvantage in myocardial recovery. TLVV can be used as a solution to unload the left ventricle. Central ECMO with TLVV should be useful therapy for fulminant myocarditis.

An unconscious 79-year-old woman was admitted. Echocardiography showed cardiac tamponade with pericardial effusion. Enhanced computed tomography revealed pericardial effusion and a coronary artery aneurysm (maximum diameter of 16 mm) on the left side of the main pulmonary artery. Emergency coronary angiography confirmed the aneurysm, which originated from a branch of the left anterior descending artery. Emergency surgery was performed through median sternotomy with cardiopulmonary bypass. After cardiac arrest by antegrade cardioplegia, the aneurysm was opened and two orifices of the arteries were observed. The orifices were ligated, and the remaining aneurysmal wall was closed with a continuous suture. A pathological examination of the aneurysmal wall demonstrated an atherosclerotic true aneurysm.

A 53-year old female was noted to have an enlarged heart on a medical checkup. A multislice computed tomography study demonstrated a giant coronary artery aneurysm measuring 10 cm in diameter and a coronary arteriovenous fistula, both located below the left atrium. Resection of the aneurysm and ligation of the feeding arteries and arteriovenous fistula were performed under cardiopulmonary bypass. As the native coronary sinus was occluded, we reconstructed the vessels draining from the aneurysm into the right atrium with an autologous pericardial patch to preserve the coronary venous blood flow. To our knowledge this is the first report of an autologous pericardial patch being successfully used to reconstruct the coronary venous flow during surgical treatment of a giant coronary artery aneurysm with a coronary arteriovenous fistula.

After a MitraClip was implanted for mitral regurgitation (MR), we experienced a case in which mitral valve replacement was performed for recurrent severe MR because of a detached MitraClip. The case was an 82-year-old woman. The MitraClip was implanted for severe MR and regurgitation was controlled to a mild level, but one month after the operation, symptoms of heart failure appeared, and single leaflet device attachment (SLDA) with severe MR was observed on the echocardiogram. As the heart failure symptoms recurred, surgical mitral valve replacement was performed. Because of severe kyphosis, the left atrial approach with a midline sternum incision made it difficult to achieve a good operative field and this was changed intraoperatively to a transseptal approach. The MitraClip was firmly fused with the anterior leaflet A2, so it was judged that removal of the clip was difficult and valve repair was impossible ; it was thus decided to replace the valve. The mark of the MitraClip could be observed on the posterior leaflet, and it appeared to have been inserted for only about 1-2 mm. A bioprosthetic valve was implanted, preserving the posterior leaflet. There were no problems in weaning the patient from cardiopulmonary bypass. The postoperative course was uneventful, and she was discharged on the 14th day after the operation. Valve repair is difficult in a case with a merged SLDA after insertion of a MitraClip, and valve replacement needs to be performed, so it is important to pay attention to the attachment of the MitraClip.

A 62-year-old woman with severe breathlessness was admitted to the emergency department. Computed tomography revealed nearly complete airway obstruction by a giant thoracic aortic aneurysm, measuring 90 mm in diameter. Previously, she had undergone hemiarch replacement for acute aortic dissection and was not attending follow-up consultations for personal reasons. Owing to the excessive adhesion of the aorta, the aorta and aneurysm could not be detected. We decided to remove the hematoma inside the aneurysm and perform aortic patch repair instead of total arch replacement. After cardiopulmonary bypass and deep hypothermic circulatory arrest with antegrade selective cerebral perfusion, a hall of 30 mm diameter through the intimal wall was found at the aortic distal arch. The hall was a neck of the aneurysm. A dacron patch was attached to the intimal wall covering the hall after removal of the hematoma to reduce the volume of the aneurysm. After surgery, her airway was not completely relived yet owing to the remaining hematoma. Subsequently, bronchial stenting was performed. Bronchial compression was successfully resolved. She underwent tracheotomy and safely withdrew from the respirator. Aortic patch reconstruction is an alternative technique for thoracic aortic disease in the case of incapability of graft replacement or endovascular therapy. Additionally, although bronchial compression from an aortic aneurysm is not common, it could be life threatening. Endobronchial stenting is indicated not only for unresectable malignancy but also for benign lesions like an aortic aneurysm.

The case concerns a seventy-one-year old male patient on maintenance dialysis. He experienced chest discomfort and called for emergency conveyance. He was diagnosed with acute Stanford type A aortic dissection with open false lumen and expanded hematoma around the aorta using computed tomography (CT). The patient was referred to our hospital for emergent surgical intervention. At the time of admission to our hospital, cerebral hemorrhage in the left thalamus and right head of caudate nucleus was revealed on a CT head scan. On neurologic examination, a slight drop in exercise ability was demonstrated in the right arm. We shared the images offline with a neurosurgeon in a neighboring hospital. After the consultation, surgery for the acute aortic dissociation was canceled due to concerns about cerebral hemorrhage aggravation with the use of an intraoperative anticoagulant. Although there was no indication for surgical intervention for the cerebral hemorrhage at that point, he was placed under careful observation. Hemodialysis using nafamostat mesilate was restarted ; fortunately, there was no exacerbation in the cerebral hemorrhage. However, a CT scan revealed expansion of the false cavity of the ascending aorta on the fifth day post-diagnosis. After confirming no exacerbation of cerebral hemorrhage on CT on the fifth, sixth, and seventh days, graft replacement of the ascending aorta and concomitant aortic valve replacement for aortic valve stenosis were performed on the eighth day. He was extubated on the first postoperative day. He left the ICU on the sixth postoperative day. Neither increase of hematoma on the postoperative CT, nor any exacerbation of the neurologic symptoms was observed. On the forty-seventh postoperative day, he was shifted back to the referring hospital for rehabilitation.Acute aortic dissection with simultaneous onset of cerebral hemorrhage is very rare. Though both conditions are critical, there are no guidelines for treatment, and decisions on the treatment strategy are unclear. In this case of acute Stanford type A aortic dissection, there was a concern about the exacerbation of cerebral hemorrhage with the use of an intraoperative anticoagulant. We report the successful surgical repair of acute aortic dissection one week after onset as a viable therapeutic option in cases where emergency intervention is not possible due to associated complications.

A 48-year-old woman was admitted to our hospital with exertional dyspnea and lower leg edema since 2 months previously. Echocardiogram presented dilation of Valsalva sinus, severe AR (aortic regurgitation) and a supra-annular flap. Enhanced cardiac cycle-gated computed tomography revealed Stanford type A aortic dissection. Primary entry was found just above the aortic valve, the right coronary artery branched from the false lumen, and the commissure between the right and non-coronary cusps was detached. The left coronary artery branched from the true lumen. The false lumen was all patent to the bilateral bifurcations of the common iliac artery. We performed valve sparing partial root remodeling, right coronary artery bypass and total arch replacement after the heart failure management. The operation, cardiopulmonary bypass, aortic cross clamp and selective cerebral perfusion times were 402, 234, 167 and 109 min, respectively. The postoperative course was uneventful, and the patient was discharged 12 days after the operation without any complication. Postoperative CT revealed a well-shaped Valsalva and complete thrombosis of the false lumen on the thoracic aorta. Aortic regurgitation completely disappeared according to a postoperative echocardiogram.

We conducted a questionnaire survey on shift and on-call system targeting under-forty cardiovascular surgeons and obtained responses from 35 surgeons. We report the questionnaire results.