This case highlights that rapid diagnosis and emergency surgical repair for catastrophic Stanford Type A acute aortic dissection may preserve the opportunity for successful lung donation even when neurological recovery is impossible. Transthoracic echocardiography played a critical role in establishing the diagnosis when computed tomography could not be performed.

BACKGROUND:Prosthetic valve endocarditis (PVE) is a life-threatening complication following valve replacement and is often challenging to diagnose in the early postoperative period. Coronary embolization is a rare manifestation of infective endocarditis, and PVE presenting as acute coronary syndrome is exceptionally uncommon. CASE PRESENTATION:A 73-year-old man underwent surgical aortic valve replacement with a 21-mm bioprosthetic valve. His postoperative course was uneventful, and he was discharged without anticoagulation therapy. One month later, he developed exertional dyspnea, gastrointestinal symptoms, and intermittent chest pain, which progressed to cardiogenic shock with severe bradycardia. Emergent coronary angiography revealed acute occlusion of the right coronary artery, and percutaneous coronary intervention was performed. Intravascular ultrasound and contrast-enhanced computed tomography revealed a low-echoic, low-attenuation lesion at the right coronary ostium, initially interpreted as thrombotic material. Despite successful revascularization, profound circulatory instability persisted. Subsequent echocardiography revealed prosthetic valve dehiscence with an annular abscess, confirming early PVE. Emergent surgery included annular reconstruction with a bovine pericardial patch, aortic root replacement, removal of the coronary stent, and coronary artery bypass grafting. Intraoperative hemodynamics remained unstable, necessitating postoperative veno-arterial extracorporeal membrane oxygenation support. The patient ultimately succumbed to non-occlusive mesenteric ischemia on postoperative day 10. CONCLUSIONS:This case illustrates a rare and complex presentation of early PVE manifesting as acute right coronary artery occlusion. Coronary imaging alone may be insufficient to differentiate infected vegetation from thrombus. Early valve-focused echocardiographic evaluation is essential in patients with recent valve surgery presenting with acute coronary events.

OBJECTIVE:At our institution, open surgical repair (OS) is the first-line treatment for ruptured abdominal aortic aneurysms (rAAA). This study aimed to evaluate in-hospital and long-term outcomes of rAAA treatment in a community hospital setting and to assess temporal changes in management, including operative delay (time to surgery), and survival. METHODS:We retrospectively analyzed 58 patients (mean age: 74 ± 9 years; male: n = 47) who underwent emergency surgery for rAAA between November 2012 and March 2025. OS was performed as the primary treatment strategy in 51 cases, whereas EVAR was selectively performed in seven hemodynamically stable patients with suitable anatomy when an appropriate stent-graft device was available. RESULTS:In-hospital mortality rate was 13/58 (22.4%), all in the OS group. Deaths were due to multiple organ failure (n = 6), sepsis (n = 3), bowel necrosis (n = 2), and hemorrhage (n = 2). Mortality rate decreased from 37.9% (11/29) in the early group to 6.9% (2/29) in the late group, with shorter time to surgery (median: 109 vs. 217 minutes; p = 0.01). The five-year survival rate was 58% ± 7%. CONCLUSION:A shorter time to surgery contributed to improved outcomes in patients with rAAA. Even when OS is adopted as the primary strategy, rapid surgical intervention can lead to favorable outcomes.

Protamine has a more difficult side-effect profile. Circulatory collapse has been reported as a result of acute pulmonary artery spasm caused by complement cascade activation by large heparin–protamine complexes. A 79-year-old male underwent endovascular aneurysm repair 11 years ago for a ruptured abdominal aortic aneurysm. A saccular aneurysm (maximum diameter: 57 mm) appeared at the proximal end of the stent graft. Thoracoabdominal aortic replacement was performed under partial cardiopulmonary bypass. The cardiopulmonary bypass was removed, and 15 min after protamine initiation, circulatory collapse emerged with pulmonary hypertension. Extracorporeal membrane oxygenation was then initiated. Unfortunately, the patient developed coagulopathy, followed by severe pulmonary hemorrhage occurred, leading to death. Pulmonary artery spasm should always be considered as a differential diagnosis for hypotension after protamine administration, and prompt intervention is crucial.

The graft insertion technique is an effective choice for redo aortic root reconstruction in cases with extensive annular destruction. Nevertheless, its impact on postoperative left ventricular outflow tract (LVOT) geometry and flow dynamics has not been investigated in detail. A 69-year-old woman who underwent aortic valve replacement for infective endocarditis developed prosthetic valve dehiscence with paravalvular leakage and a large aortic root pseudoaneurysm after 4 months. Because the native annulus was completely destroyed, redo aortic root replacement using the Bentall procedure with the graft insertion technique was performed. Intraoperative examination revealed no macroscopic evidence of active infection but raised concerns regarding potential LVOT narrowing after the insertion of the inverted graft. Postoperative contrast-enhanced computed tomography demonstrated significant LVOT narrowing, with a minimal diameter of 14 mm, despite the implantation of a 19-mm bioprosthetic valve. Moreover, four-dimensional flow (4D-flow) magnetic resonance imaging (MRI) revealed accelerated systolic flow at the narrowed LVOT, indicating functional LVOT stenosis. This case emphasizes an important pitfall of the graft insertion technique—postoperative LVOT narrowing caused by the intraventricular portion of the inverted graft. Postoperative morphological and hemodynamic evaluation using advanced imaging modalities, including 4D-flow MRI, may be required to ensure the safety of this technique in complex aortic root reconstruction.

A 76-year-old male patient, who had undergone right axillary artery bypass and arch replacement surgery for retrograde type A aortic dissection after thoracic endovascular aortic repair 2 years ago, was referred to our department with complaints of swelling and pain in the right subclavian region. A computed tomography scan suspected an abscess around the bypass graft; however, the culture was negative. Pathological examination indicated a diffuse large B-cell lymphoma (DLBCL) diagnosis. Chemotherapy was not indicated due to the patient's condition, and he passed away after 3 months. DLBCL originating around a graft is extremely rare but crucial for differential diagnosis.

A 79-year-old man was admitted for transurethral resection of a bladder cancer. He had a history of thoracic endovascular aortic repair for Stanford type B acute aortic dissection and thoracic aortic aneurysm performed 2 years prior. During hospitalization, computed tomography scan findings raised suspicion of a stent-graft infection. Blood cultures confirmed the presence of Streptococcus gallolyticus ssp. pasteurianus. Gallium scintigraphy supported the diagnosis of a stent-graft infection. A subsequent lower gastrointestinal endoscopy revealed a colorectal cancer in the lower rectum. We then performed surgery for the stent-graft infection.

OBJECTIVES:Postoperative mediastinitis after cardiovascular surgery remains a significant concern because it leads to prolonged hospitalization and increased mortality. Recently, continuous local antibiotic perfusion (CLAP) has been widely used as a new route of antimicrobial administration in orthopedic surgery. We herein report the outcomes of applying CLAP to mediastinitis after cardiovascular surgery.  Methods: Seven patients (mean age, 52±22 years) who underwent CLAP for mediastinitis after cardiovascular surgery at our hospital from May 2020 to December 2024 were enrolled and retrospectively analyzed. Pathogenic bacteria identified included methicillin-resistant Staphylococcus aureus in five patients and Pseudomonas in two patients. The wounds were closed with 18-24 Fr Salem sump tubes placed in the wound after appropriate debridement. A negative pressure continuous therapy device was connected to the main sump tube to maintain a negative pressure of 60 mmHg, with gentamicin at a concentration of 1.2 mg/mL perfused at a rate of 2 mL/h through the subroute. RESULTS:No hospital mortality occurred. All patients achieved sternal closure without severe adverse events. One patient underwent closure with an omentum flap in the early stages of CLAP implementation. The median length of CLAP was 14 (5-24) days. The mean duration of respiratory support and the duration until oral feeding were 2.5 and 3.3 days after CLAP initiation, respectively. No gentamicin-induced adverse events were observed. The three-year survival rate was 75%, whereas the reinfection-free rate was 100%. CONCLUSION:CLAP can be easily introduced to facilitate early extubation, early ambulation, and early resumption of oral intake, which are beneficial for infection control.

Various methods for reconstructing the left subclavian artery and approaches to treat aortic aneurysms associated with Kommerell’s diverticulum and an aberrant left subclavian artery arising from a right-sided aortic arch have been reported. The case involved a 69-year-old woman, in whom a right-sided aortic arch with Kommerell’s diverticulum and a left subclavian artery originating from the diverticulum were incidentally observed. Severe stenosis was noted on the origin of the left subclavian artery, and the diameter of Kommerell’s diverticulum had expanded to 64 mm, resulting in dysphagia. Therefore, a total arch replacement was performed via median sternotomy. For reconstruction, the left subclavian artery was anastomosed to the left common carotid artery. Kommerell’s diverticulum was successfully resected through a median sternotomy. The postoperative course was uneventful, and the patient was discharged home without complications. Translocation of the aberrant left subclavian artery is a simple procedure and is effective during total arch replacement via a median sternotomy.

Objective: To evaluate the long-term outcomes of heart valve replacement with mechanical prosthesis (MP) versus bioprosthesis (BP) in patients on dialysis. Methods: A retrospective review was performed at 7 hospitals. Patients on dialysis who underwent valve replacement were included. Survival, reoperation, bleeding, and embolic events were compared across the MP and BP groups. Results: Between April 2000 and April 2016, 312 patients on dialysis were enrolled in our study (MP: 94 patients [30.1%], BP: 218 patients [69.9%]) Mean follow-up was 3.4 +/- 3.6 years. Five-year and 10-year survival rates were similar in both groups (MP: 57.4 +/- 5.5% at 5 years and 46.3 +/- 6.4% at 10 years, BP: 50.2 +/- 4.1% at 5 years and 38.8 +/- 4.5% at 10 years, P = .305). Multivariate Cox hazard analysis demonstrated that diabetic nephropathy (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.31-2.73, P < .001), New York Heart Association functional classification >= III (HR, 2.16; 95% CI, 1.37-3.35, P = .001), and mitral valve replacement (HR, 2.36; 95% CI, 1.58-3.49, P < .001) were significant risk factors for late death. Valve selection was not a significant risk factor. Freedom from valve-related embolic event at 5 years was significantly lower in the MP group (MP: 88.3 +/- 4.3% at 5 years, BP: 97.2 +/- 1.6% at 5 years, P = .007). Freedom from valve-related reoperation or hemorrhagic events was similar across both groups. Conclusions: Valve selection was not associated with late survival outcomes in patients on dialysis. However, BP may have an advantage in preventing embolic events without increasing the incidence of valve-related reoperation when compared with MP.

症例は76歳，男性．Type B急性大動脈解離（偽腔閉塞型）に対して保存的加療が導入された．発症後18日目に背部痛が出現し，CTにて偽腔の再開通と逆行性type A大動脈解離が認められたため，緊急手術を行った．オープンステントグラフト（JOSG）をfrozen elephant trunkとして用いた上行弓部全置換術を施行した．術後，下肢圧が体血圧の70%程度に低下しており，精査したところJOSGの中枢側の非ステント部の高度狭窄，およびそれに連続するステント部中枢側の狭窄と診断された．術2日目に狭窄部解除目的に胸部ステントグラフト内挿術（TEVAR）を施行した．術後速やかに下肢圧の上昇が認められ翌日に人工呼吸器を離脱した．脳神経学的合併症を起こすことなく順調に経過している．JOSGを使用する場合には留置部位の解剖学的特徴を詳細に検討し非ステント部長を短くするなど合併症予防のための配慮が必要である．JOSG狭窄に対してTEVARは有効な治療手段であると考える．

非交通性の左上大静脈遺残を伴った急性A型大動脈解離に対する手術の報告は少ない．症例は71歳，女性．右頸部痛と気分不良を主訴に受診，急性A型大動脈解離と診断され，当科紹介となった．CTで非交通性の左上大静脈遺残を伴っていることが判明した．緊急で上行弓部大動脈部分置換術を施行した．右大腿動脈送血，右上大静脈，下大静脈にて人工心肺を確立した後に，左上大静脈にも心嚢内から直接L型脱血管を挿入し，計三本脱血とした．中心冷却後に上行大動脈を遮断，右房切開をおき，逆行性心筋保護で心停止を得た．直腸温28℃で循環停止とし，左右の上大静脈からの逆行性脳灌流を施行し，脳保護をおいた．術後経過は良好であった．非交通性の左上大静脈遺残を伴った急性A型大動脈解離の手術に際し，LSVCに直接カニューレを挿入し，逆行性心筋保護や逆行性脳灌流を確実に施行することで定型的な上行弓部部分人工血管置換を施行することが可能であった．

2000年1月から2003年12月までの4年間に当院で施行した80歳以上の大動脈弁置換術(AVR)症例29例を高齢者群とし,その手術成績ならびに中期成績について検討した.使用した弁は,全例,生体弁(Carpentier-Edwards PERIMOUNT)であった.また,同時期に施行された75歳以下の生体弁によるAVR症例36例を対照群として,2群間で比較検討を行った.平均年齢は高齢者群で82.9歳,対照群で71.6歳であり,病変は高齢者群では大動脈弁狭窄(AS)症例が79%と対照群の53%に比較して有意に多く,ASの程度も高度であった.術前合併症としては,高齢者群では糖尿病と腎機能障害(Cr≧1.5)の頻度が有意に高く,緊急手術例も高齢者群24%,対照群6%と高齢者群で緊急手術の頻度が有意に高かった.術後合併症は,48時間以上の長期の人工呼吸器管理を要した症例と一時的にCHDFを必要とするような腎機能障害をきたした症例の頻度が高齢者群で有意に高かったが,病院死亡は高齢者群6.9%,対照群5.6%と差はなく,3年生存率も高齢者群89%,対照群78%と差は認めなかった.80歳以上の超高齢者に対するAVR症例では術前の重症度が高かったが,その手術成績ならびに遠隔成績は良好であり,外科的治療を積極的に考慮すべきであると考えられた.

Pulmonary thromboendarterectomy was performed on a patient with chronic pulmonary thromboembolism showing thrombophilia. The patient was a 56-year-old female with the above condition complicated by congenital protein C deficiency. She was admitted to our hospital with severe dyspnea accompanied by right ventricular failure. A pulmonary arteriogram showed occlusion and stenosis from lobar to segmental arteries Cardiac catheterization showed marked pulmonary hypertension. A lung perfusion scintigram revealed multiple defects in the right and left lungs. After the insertion of an inferior vena cava filter, she was operated on Following a median sternotomy, thromboendarterectomy of the bilateral pulmonary arteries was performed using deep hypothermia and intermittent circulatory arrest. Circulatory arrest was employed in three periods totaling up to 36 minutes. After surgery, she had improvements in pulmonary hypertension and pulmonary vascular resistance. She maintained improved lung functions, and remained in the New York Heart Association functional class I for more than two years and eight months after surgery.

Objectives: Coronary artery disease (CAD) and abdominal aortic aneurysms (AAA) commonly coexist. However, each disease treatment complicates the management of the other. In this study, we evaluate whether a simultaneous operation of AAA repair and off pump coronary artery bypass (OPCAB) would be safe and acceptable, compared with either procedure alone. Subjects and Methods: We retrospectively reviewed all patients who underwent simultaneous AAA repair and OPCAB (AAA/OPCAB, n=18), compared AAA repair alone (AAA, n=239) and OPCAB alone (OPCAB, n=137) from June 1999 to December 2003. There were no significant differences with regard to age or gender, but the AAA/OPCAB group had significantly larger aneurysms (60.6 vs. 53.2 mm) and significantly lower ejection fractions (EF) (54.9 vs. 60.3%). Results: The patients in the AAA/OPCAB group underwent a significantly longer operative time than AAA, OPCAB (403 vs. 360,296 minutes, respectively), there was significantly greater blood loss (726 vs. 426, 462 ml), and more transfusion required (8.13 vs. 1.69, 2.8 units). The number of bypass grafts in AAA/OPCAB group (1–5 per patients) was significantly smaller (1.78 vs. 2.93). The AAA/OPCAB patients had a significantly longer hospital stay than the AAA (38 vs. 22 days), but was not significantly longer than the OPCAB. There were no significant differences with regard to the morbidity and mortality rate among the three groups. Conclusion: This study suggests that the simultaneous operation of AAA and OPCAB can be done with the same morbidity and mortality as independent surgical procedures. Key words: coronary artery bypass grafting, abdominal aortic aneurysm, off pump coronary artery bypass, simultaneous operation