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Early stage lung cancers which localized in the middle layer or the center of the lung become indications for anatomical segmentectomy. As a method of intraoperative identifying the intra-segmental plane, 2 different techniques utilizing indocyanine green (ICG) fluorescence has been clinically applied. The one is a method of systemically intravenous administration of ICG after ligating the objective segmental pulmonary artery. The other is a method of insufflate the diluted ICG into the objective segmental bronchus under the bronchoscope. The segmental alveoli were visualized with a ICG fluorescence thoracoscope. Both methods visualize inter-segmental plane. Both advantages and disadvantages were discussed. These methods may help the repertoire of atypical segmentectomy getting wider. Also, ICG fluorescence imaging is incorporated into a robotic surgery. ICG fluorescence imaging is expected to be applied to various applications of thoracic surgery.

Transesophageal echocardiography (TEE) provides real-time information on both morphology and hemodynamics without radiation exposure or contrast media, interruption of surgical procedures, or need for transferring the patient to other division, and thus can be used as intraoperative monitoring as well as diagnostic imaging. TEE is helpful for confirming the adequacy of routine surgical procedures, ruling out an occurrence of unexpected adverse events, or even navigating the manipulations of cannulae and catheters. In mitral valve repair, TEE assessment is essential for secure success and making a decision of 2nd pump run with a strategy for re-repair. In acute aortic dissection, TEE is often the only information source for making treatment strategy or detecting unexpected events. TEE provides unique information on properties of tissues, thrombus, or blood, which cannot be identified even with fluoroscopy, thus TEE is to be used efficiently in the hybrid operating room (OR). In thoracic surgery, TEE is helpful for assessing an invasion of tumor to the adjacent structures including the aorta or heart. With all these capabilities of TEE, it should be fully utilized to optimize the outcomes of thoracic and cardiovascular surgeries.

We report a case of ascending aortic thrombus with acute arterial occlusion of the brachial artery. A 49-year-old woman had sudden pain in her right arm due to acute occlusion of the right brachial artery. Contrast-enhanced computed tomography and echocardiography revealed a large mobile thrombus in the ascending aorta, which prompted surgical intervention. The thrombi were removed via aortotomy under circulatory arrest. Trans-esophageal echocardiography was useful for watching a potential detachment of the thrombus in the aorta during surgical manipulations or systemic perfusion. Despite no evidence of either inherited or acquired thrombotic predisposition, thrombosis in the right atrium and deep veins of the lower extremities was found postoperatively. Since antiplatelet and anticoagulant therapy was started, she has suffered from no thrombotic event.

In aortic arch surgery, we reconstruct branches before opening the arch to avoid cerebral embolism of the debris derived from the aortic wall. We made a trifurcated graft for branch reconstruction using 10 mm and 8 mm polyester grafts. Cardiopulmonary bypass started under right axillary perfusion and venous drainage through the right atrium. While cooling, the left subclavian artery was clamped and anastomosed to the end of the trifurcated graft. Then the ascending aorta was cross-clamped and cardioplegic solution was infused. At 25 degrees centigrade of the tympanic temperature, the left carotid artery is clamped and anastomosed to the branch of the trifurcated graft with or without perfusion into the left carotid artery. Subsequently the brachiocephalic artery was reconstructed in the same manner. After antegrade cerebral perfusion was established through the trifurcated graft via right axillary perfusion, distal anastomosis of the aortic arch was done with the open distal technique. Graft-graft anastomosis was followed to reperfuse the lower half of the body. Finally proximal anastomosis was performed to complete total arch replacement. Forty-four patients underwent total arch replacement in this technique. In-hospital mortality was 4.5%. Cerebral infarction occurred in 4.5% of the patients probably due to embolization of the debris derived from the branches of the aortic arch.

In the treatment for pacemaker infection, removal of infected devices and intensive antibiotics therapy are in principle and new devices should be implanted apart from the infected site. However, there are some problems in the case of children:it is not easy to remove infected devices because epicardial leads are often used for them. If endocardial leads are chosen as a new system, extension of the lead would be concerned with their growth. We report a pediatric case of infection of pacemaker using epicardial leads. It was difficult to cure infection by repeated local treatment leaving epicardial leads and antibiotics therapy was obliged to continue for 9 years to keep infection under control. After growing up, we implanted endocardial leads for her and removed infected devices to cure infection completely.

We have devised a simple and cost-free mitral valve model using "right hand", which is placed on the median portion of anterior chest and supinated by 30 degrees. The palm is used to resemble the mitral valve:the thenar eminence, its margin wrinkle, and adjacent palm as the anterior leaflet, coaptation line, and the posterior leaflet, respectively. As the thumb and its origin is assumed as the ascending aorta and aortic valve, this model represents the mitral and aortic valves as viewed from the left atrium. This model is anatomically accurate and facilitates comprehending image orientation in transesophageal echocardiographic probe manipulations.