[Intraoperative Pulmonary Artery Rupture Induced by a Pulmonary Artery Catheter].

We herein present a case of massive intratracheal hemorrhage due to pulmonary artery catheter (PAC) use during triple valve surgery. A 75-year-old woman underwent biological aortic valve replacement along with mitral and tricuspid valve annuloplasty. Operative procedures were uneventful. Shortly after weaning from cardiopulmonary bypass, massive blood and froth filled the endotracheal tube. As her blood pressure and arterial oxygen saturation dropped, extracorporeal membrane oxygenation(ECMO) support through the right femoral artery and vein was promptly initiated. After the tip of the PAC was identified in the right pulmonary artery by chest Xray, an endobronchial blocker was used to protect the opposite lung. After clinical stability was achieved, she underwent pulmonary artery angiography and subsequent successful transcatheter embolization. Right heart unloading using ECMO and transcatheter embolization might have played key roles in the management of intraoperative pulmonary artery rupture.

[True Ascending Aortic Aneurysm Late after Total Arch Replacement].

An aortic aneurysm was incidentally diagnosed in a 75-year-old woman during a thorough examination for other diseases. She had a history of total arch replacement( TAR) for aortic arch aneurysm 17 years previously. Contrast-enhanced computed tomography( CT) revealed a proximal aortic aneurysm with a maximum diameter of 67 mm protruding to the lateral side. She was treated by elective ascending aortic replacement. The resected aneurysm was not a pseudoaneurysm, but a true aneurysm. The etiology of this aneurysm might be long-term hemodynamic stress from the left ventricle and inadequate blood pressure control in addition to the anatomical position of the proximal residual aorta after first surgery. Therefore, to prevent aneurysm formation, it is important to replace the ascending aorta as proximally as possible at first surgery and to continue strict postoperative blood pressure control.

[Hybrid Coronary Revascularization of Minimally Invasive Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in a Patient with Left Main Coronary Stenosis].

We report a successful case of hybrid coronary revascularization of minimally invasive coronary artery bypass grafting( MICS-CABG) and percutaneous coronary intervention(PCI). The patient was a 78-year-old man with angina pectoris due to left main trunk (LMT) lesion, and had a history of repeated PCI to the left anterior descending artery (LAD) and the left circumflex artery (LCX) for angina pectoris. He presented with a chest pain on effort in June, 2015. A coronary angiogram showed a severe stenosis in the LMT extending to LAD and LCX. We performed hybrid therapy of CABG to LAD, and PCI to LMT and the proximal portion of LCX because the lesion was technically and suitable for PCI. CABG to LAD was performed via left mini thoracotomy using the left inter mammary artery (LIMA). LIMA was harvested under 3-dimentional endoscope. On the 5th post-operative day, PCI was performed to LMT and LCX. The postoperative course was uneventful and he was discharged on the 11th post-operative day. This case suggests that hybrid coronary revascularization is less invasive and feasible for selected patients with multi-vessel disease.

[Suspended Ventricular Septal Defect Closure Due to Heparin Resistance;Report of a Case].

We present a case of heparin resistance whereby open heart surgery was discontinued. A 53-year-old woman who was diagnosed with ventricular septal defect and atrial septal defect was scheduled for intracardiac repair. However, after intravenous heparin (400 U kg-1) supplementation, the activated clotting time (ACT) increased only to seconds. The operation was discontinued because the addition of heparin( 200 U kg-1) did not show sufficient prolongation of ACT, fully indicative of heparin resistance. Additional antithrombin III concentrate was also ineffective. Postoperative study of the administration of heparin in vitro to the patient's serum showed the probability of transient heparin resistance arising from the stress of surgery.

[Full root replacement with a Freestyle bioprosthesis for prosthetic valve endocarditis complicated by aortic-root pseudoaneurysm after subcoronary technique; report of a case].

We report a surgical case of prosthetic valve endocarditis( PVE) after aortic valve replacement with a Freestyle stentless bioprosthesis, which was successfully treated with full root replacement using a Freestyle valve. A 80-year-old man underwent aortic valve replacement with a Freestyle stentless bioprosthesis, using subcoronary technique for aortic stenosis in 2004. Three years later he had late PVE, and we found the aortic-root pseudoaneurysm. Although homografts are the optimal for cases of severe aortic annular destruction, availability of these are limited in Japan. We chose a Freestyle valve with full root technique, which fitted well to the destroyed annulus. The postoperative course was uneventful. Freestyle stentless bioprosthesis can be useful option for PVE, meanwhile care should be taken to dead cavity between prosthesis and aortic wall in the subcoronary technique.

[On pump beating heart mitral and tricuspid valve annuloplasty via right mini thoracotomy approach in a patient who had undergone cardiac surgery 3 times].

The patient was an 84-year-old man. He had a history of 3-time median sternotomy with a functioning coronary bypass graft. Because of his dependence on inotropic agents caused by a progressing mitral and tricuspid valve insufficiency, we decided to perform surgery. To avoid heart damage and injury to the bypass graft by adhesiotomy, we performed on-pump beating heart mitral and tricuspid valve annuloplasty via right mini-thoracotomy approach. He was discharged 16 days after surgery. The on-pump beating heart valve repair via right mini-thoracotomy approach was useful in a selected case with multiple surgeries.