[Surgical Treatment for Giant Coronary Aneurysm Complicated by Acute Myocardial Infarction and Cardiopulmonary Arrest:Report of a Case].

Giant coronary aneurysm is rare, but a life-threatening disease. We report a 67-year-old man with 39 mm coronary aneurysm. He was presented to our facility with acute coronary syndrome complicated by cardiogenic shock. Angiography demonstrated giant coronary aneurysm and occlusion of the right coronary artery. After cardiopulmonary resuscitation and cardiopulmonary support (PCPS), emergent excision of aneurysm and coronary artery bypass grafting was performed. The postoperative course was good without complications. Most giant coronary artery aneurysms are asymptomatic but some patients present with angina pectoris, sudden death, fistula formation, pericardial tamponade, compression of surrounding structures, or congestive heart failure. But once complications, such as thrombosis, distal embolization, fistula formation or rupture occurred, it is difficult to save life without aggressive surgery. At present, there are no specific guidelines for the treatment of giant coronary aneurysm. Surgical correction is a preferred approach for the treatment of giant coronary artery aneurysms.

[Total Arch Replacement Using Isolation Technique for Giant Thrombus in Ascending Aorta and Aortic Arch:Report of a Case].

We report a case of giant thrombus in the ascending aorta and the aortic arch, and our successful treatment. A 52-year-old man was referred to our department for coldness and numbness of the right upper arm and hand for several days. Contrast enhanced computed tomography revealed thrombosis of the right brachial artery and a giant thrombus in the ascending aorta and the aortic arch. Three days after the revascularization of the right upper limb by thrombectomy, we performed total arch replacement with frozen elephant trunk using "isolation technique" which is reported to be useful to prevent embolic stroke during total arch replacement in patients with shaggy aorta. In this technique brain circulation was isolated by establishing selective cerebral perfusion before starting systemic perfusion. Postoperative course was uneventful and no recurrent thrombosis has been observed for a year with anticoagulant therapy. We advocate that this technique is also useful in the presence of thrombus in the ascending aorta and the aortic arch.

Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians.

OBJECTIVE: The number of older patients with acute aortic dissection type A (AAD [A]) is increasing as the population ages. We evaluated clinical outcomes for octogenarians with AAD (A) treated surgically at our hospital. Whenever possible, we limited the replacement site of the ascending aorta to the supracoronary and hemiarch. METHODS: Of 436 patients with AAD (A) seen in our hospital emergency room between April 2001 and August 2015, 90 were octogenarians. Surgery was performed using a simple cardiopulmonary bypass established through the right femoral artery and venous cannulation, and distal anastomosis was performed under deep hypothermic circulatory arrest at 20°C. RESULTS: Of the 90 octogenarians with AAD (A), 11 required cardiopulmonary resuscitation, 9 of whom died. Four patients with stable hemodynamics refused surgery. Thus, 77 were treated surgically. Of these 77 patients, isolated replacement of the ascending aorta or hemiarch was performed in 73 (94.8%), and total arch replacement in 4 (5.2%). Five patients (6.5%) died within 30 days, and 5 (6.5%) died in the hospital more than 30 days after surgery. Seven (9.1%) had a new stroke, 5 (6.5%) had pneumonia, and 4 (5.2%) had mediastinitis. Forty-four (57.1%) patients were discharged to their homes and 23 (30%) to rehabilitation hospitals. Three patients later required endovascular stent graft repair, which was successful in each case. The overall postoperative survival was 82%, 70%, and 62% at 1, 3, and 5 years, respectively. CONCLUSIONS: Our results suggest that our limited replacement protocol for emergency AAD (A) surgery has early and midterm survival benefits for octogenarians.

[Cardiac tamponade due to ruptured coronary artery aneurysm associated with coronary-pulmonary artery fistula; report of a case].

We report a successful operative treatment of ruptured coronary artery aneurysm associated with coronary-pulmonary artery fistula. A 67-year-old woman was diagnosed with coronary artery fistula previously but observed without any treatment. She had medical examination at a previous hospital because of sudden onset of dyspnea, and transported to our institution with a diagnosis of cardiac tamponade. Multi-detector computed tomography (MDCT) showed massive pericardial effusion, coronary-pulmonary artery fistula and giant coronary artery aneurysm. We performed emergency operation. Under cardiopulmonary bypass, coronary artery fistula and aneurysm was resected. Postoperative MDCT showed almost complete exclusion of coronary artery fistula. Postoperative course was uneventful.

Emergency rescue endovascular stent grafting of ascending aorta to relieve life-threatening coronary obstruction in a case of acute aortic dissection.

Myocardial ischemia associated with acute aortic dissection is frequently a fatal complication, and the emergent management still remains a challenge. We report a patient with life-threatening myocardial ischemia due to acute aortic dissection managed by rescue stent grafting of the ascending aorta. Coronary blood flow improved immediately with this endovascular procedure, hemodynamic status was ameliorated dramatically, followed by uneventful open repair.