Aortic dissection in an elderly patient with atrial septal defect.

We report a case of acute aortic dissection that occurred in the late course of surgically untreated atrial septal defect. A 60-year-old man with acute aortic dissection and atrial septal defect was operated on successfully, and we discuss the causal relationship between these two unusual conditions.

[A case of CABG under the cardiac arrest induced by a short acting beta-blocker without clamping the aorta].

A seventy one year old woman had a coronary artery bypass grafting. No touch technique to her ascending aorta was applied due to the severely atherosclerotic aorta. Cardiac arrest was induced by a large dose of short acting beta-blocker (Esmolol) without cross-clamping the aorta under the normothermic cardio-pulmonary bypass. The heart was flaccid and rotated easily while the coronary anastomoses were performed. Both of the internal thoracic arteries were grafted individually to the anterior descending artery and to the circumflex artery. The cardiac beats were resumed with the ordinary inotropic support and then the cardio-pulmonary bypass was weaned off. Her postoperative course was uneventful and the cardiac enzyme level was not elevated. Both of the grafts were revealed patent by the postoperative angiography. Esmolol had played an important roll to perform excellent anastomoses and to protect the myocardium. It was concluded that this technique could be one of the suitable modality for patients with diseased aorta and further studies should be pursued concerning Esmolol as an alternative to the conventional cardioplegia.

[Two cases of annulo-aortic ectasia with type A aortic dissection reconstructed by reimplantation of the aortic valve].

We performed aortic valve sparing operation in two cases of annulo-aortic ectasia combined with Type A aortic dissection. Marfan syndrome was found in one case and the dissection was acutely evolving in another case. The aortic valves were observed as normal configuration in both cases and then reimplanted within the synthetic grafts along with the David's procedure. No aortic regurgitation was found in the acute case but slight regurgitation was checked out in the Marfan case at the discharge. The aortic valve preserving operation for annulo-aortic ectasia was considered much effective in cases with aortic dissection in order to expect the thrombolization in the pseudo lumen.

[A successful repair of ventricular septal defect and patient ductus arteriosus associated with pulmonary hypertension in an infant with left lung agenesis].

We report the first case of successful repair of ventricular septal defect (VSD) and patent ductus arteriosus (PDA) associated with pulmonary hypertension in an infant with left lung agenesis. A 70-days-old infant was referred to our hospital with the diagnosis of congenital heart disease and abnormalities of the left lung. Two-dimensional echocardiogram showed ventricular septal defect and patent ductus arteriosus associated with pulmonary hypertension. Computed tomogram of the chest and bronchogram confirmed agenesis of the left lung. The operation was performed at age 114 days with the body weight 4333 g. VSD was closed with the patch and PDA was ligated under cardiopulmonary bypass. Postoperative course was uneventful. Cardiac catheterization, 50 days after operation, revealed normal pulmonary arterial pressure and good cardiac function. Agenesis of the lung is a rare condition and often associated with congenital abnormalities of the skeletal, gastrointestinal, genitourinary and cardiovascular system. As the prognosis is poor especially in those with congenital heart disease, the cardiac surgery is mandatory for the patient to survive.

[Subdural hematoma complicated after open heart surgery: a report of two cases with successful treatment].

Two cases of subdural hematoma complicated after open heart surgery were successfully treated during thirty years history of the department. A 45 year-old woman underwent tricuspid valve replacement due to isolated congenital tricuspid insufficiency. On the 27th postoperative day, she was suddenly attacked by headache, and disturbance of consciousness was recognized with gradual deterioration. Brain CT scan showed a subdural hematoma on the right frontal region. Immediate irrigation of the hematoma was performed. Postoperative course was uneventful, and she was discharged without any complications. A 59 year-old woman underwent mitral valve replacement due to mitral re-stenosis. On the 3rd postoperative day, disturbance of consciousness was seen suddenly. Brain CT scan showed a subdural hematoma in the bilateral posterior cranial fossa. Immediate GL-YCEOL drip infusion was started. On the next day consciousness returned without operation and she was discharged without any neurological complications. Both patients did not have head trauma during pre and post operative period. It was important to consider the possibility of a intracranial hematoma, when the disturbance of consciousness was recognized after open heart surgery and/or during anticoagulant therapy.

[Pseudoaneurysm of the left ventricle after mitral valve replacement: report of two cases without surgical repair].

We report two non-surgical cases of pseudoaneurysm of the left ventricle after mitral valve replacement. Two patients underwent uncomplicated mitral valve replacement with Ionescu-Shiley and Carpentier-Edwards bioprosthesis respectively, and both had good early postoperative course with no symptoms. Left ventriculogram one month after operation showed subvalvular pseudoaneurysm of the left ventricle in both patients. Two patients were in New York Heart Association Functional Class I with digitalis and diuretics and have left ventriculogram had done five years postoperatively. Pseudoaneurysm of the left ventricle without a surgical repair disappeared in one patient, and revealed no enlargement in the other. There still remain controversies regarding the treatment of pseudoaneurysm of the left ventricle following mitral valve replacement.

[A case report of poststernotomy mediastinitis treated with the pectoralis major muscle flap after protracted wound irrigation].

A 8-year-old boy developed mediastinitis after direct closure of atrial septal defect. Methicillin-resistant Staphylococcus aureus (MRSA) was detected from the wound. Intermittent wound irrigation with povidone-iodine solution and vancomycin solution was protracted for two months. After the remission of MRSA infection, implantation of pectoralis major muscle flap was performed. Without recurrence of infection the wound was healed completely. Although pectoralis major muscle flap is an effective method of choice for mediastinitis, an appropriate timing of enforcing this method should be investigated hereafter.

[A case of acute postinfarction mitral insufficiency and cardiogenic shock caused by total rupture of a papillary muscle].

A 61-year-old male in cardiogenic shock was transferred to our hospital with an intra-aortic balloon pumping (IABP). He had had acute posterior myocardial infarction previous day. He had developed progressively increasing dyspnea and physical signs of severe congestive failure. On admission, his blood pressure was 60 mmHg even with IABP. He was anuric with a high blood urea nitrogen and serum creatinine level. An echocardiogram demonstrated a rupture of a posterior papillary muscle and massive mitral insufficiency. His deteriorating condition did not allow us to perform cardiac catheterization. He underwent an emergency operation. Total rupture of a posterior papillary muscle was confirmed. Mitral valve replacement with a SJM prosthetic valve was performed. A postoperative course was uneventful.

[Fatal delayed hemolytic transfusion reaction in a postoperative case of traumatic aortic rupture].

A 52-year-old woman with traumatic rupture of the thoracic descending aorta had a history of previous blood transfusion 23 years ago. This time, she received 4,600 ml of blood transfusion during the replacement procedure of thoracic aorta. On the 12th postoperative day, she had acutely progressive severe jaundice, anemia and hepatosplenomegaly. All transfused blood was compatible by bromelin method before operation. Serological studies revealed a secondary response of hemolytic transfusion reaction due to anti E and anti c antibodies. She fell into severe bilirubinemia (66 mg/dl) and anuria, and died on 19th day after operation. A positive Coombs test in a patient who has been transfused recently must be interpreted with great caution. The "coated" cells may be incompatible donor cells in a patient who has antibodies from a prior transfusion. The incompatibility occasionally leads to delayed transfusion reaction that may stimulate "autoimmune" hemolytic anemia.