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From June 2003 to November 2006, transapical aortic cannulation was performed in 73 patients (41 men and 32 women, mean age 63 years, 64 hemiarch repair and 9 total arch replacement) with acute type A aortic dissection. A 1-cm incision was made in the apex of the left ventricle, and a 7-mm soft and flexible cannula was passed through the apex and across the aortic valve until positioned in the ascending aorta under guidance by transesophageal echocardiography. In all cases, cardiopulmonary bypass flow was sufficient. There were no malperfusion events. Our results showed that transapical aortic cannulation was secure and useful for repair of acute type A aortic dissection.

A 50-year-old man was admitted to our hospital because of dyspnea. His chest X-ray and computed tomography (CT) showed right pneumothorax and multiple bullae. His pneumothorax was drained with a chest tube, however, because of a persistent air leak, bullectomy was performed 18 days after the occurrence of pneumothorax. Intraoperatively, we found a palpable tumor in the bulla approximately 10 mm in diameter and resected it with the bullae. Histologically, the tumor was diagnosed as a large cell carcinoma.

A 28-year-old woman who had been diagnosed as schizophrenia was admitted to our hospital, complaining of chest pain. Her chest X-ray demonstrated 9 foreign bodies in the pericardium, lung and others. Her chest computed tomography (CT) confirmed needle-like shadows in the pericardium and lung. They were diagnosed as aberrant needles, and surgically removed. The intrapulmonary aberrant needle was removed with video-assisted thoracoscopic surgery. Aberrant needle in pericardium or lung should be removed surgically, because it is very dangerous. Intraoperative chest X-ray is always necessary before closing the wound to avoid leaving the residual fragments.

We experienced a case of operation for acute type A aortic dissection using transapical aortic cannulation (TAC). A 62-year-old male with chest and back pain admitted to our hospital. The chest computed tomography (CT) showed the dissection of total aorta. Hemiarch repair (circulatory arrest time: 64 min, pump time: 152 min) was performed by cardiopulmonary bypass (CPB) established with bicaval cannulation and TAC in this case. The reason why we use TAC is that retrograde perfusion by femoral artery has a high-risk of malperfusion and cerebral embolism because of atheromatous change in aorta, and the use of the axillary artery can be troublesome because of the vessel's small diameter. We considered that in cases of acute aortic dissection, TAC is much safer and simpler than femoral or axillary cannulation.

We report 2 cases of aortic disease with Marfan syndrome underwent surgery. Case 1 was 38-years-old man and case 2 was 36-years-old woman. They were brothers and they had 8 times operation for 13 years. Surgical procedure included aortic root reconstruction, descending aortic aneurysm repair and abdominal aortic aneurysm repair. Patients with Marfan syndrome sometimes require repeated surgical repair of aortic disease.

We report a case of mediastinal esophago-bronchogenic cyst in a patient with a high serum level of CA 19-9. A 49-year-old man presented with a complaint of dysphagia. Chest X-ray, CT, and MRI showed posterior mediastinal cystic shadow which was diagnosed preoperatively. The serum level of CA 19-9 was 158 U/ml. We underwent extirpation of the cyst through video-assisted thoracoscopic surgery (VATS) and confirmed to be a bronchogenic cyst histologically. The serum level of CA 19-9 returned to normal after the operation.

The case was a 76-year-old male. After thoracoscopic left upper lobectomy against primary lung cancer with poor risks such as complication of systemic lupus erythematosus (SLE) and pulmonary emphysema, oral steroid treatment, heavy smoker, decreased renal function, the patient was complicated with intractable pulmonary fistula and MRSA pyothorax. Intracavitary administration of albumin preparation and fibrin glue (Beriplast P) was effective against pulmonary fistula though it was not helpful in the pleurodesis which was conducted 7 times. Teicoplanin (Targosid) was effective against MRSA pyothorax and maintained the renal function.

This study was undertaken to assess optimum anticoagulation control after bileaflet mechanical valve replacement by using the international normalized ratio of prothrombin time (PT-INR). From January to December 1995, 261 patients (pts) underwent mechanical valve replacement in the aortic (n = 95), mitral (n = 126), aortomitral (n = 39) or isolated tricuspid (n = 1) valve position in 8 medical centers in Tokyo, Japan. The St. Jude Medical valves were implanted in 184 pts and the Carbomedics valves in 77. There were 17 valve-related events as follows: 11 thromboembolic events (3.62%/pt-yr) including 10 transient ischemic attacks. 5 non-fatal bleeding events (1.65%/pt-yr), 2 reoperations (0.66%/pt-yr). At 18 postoperative months, free rates from all deaths (actuarial survival) thromboembolism, reoperation and all valve-related events were 95.3%, 95.7%, 98.7% and 88.9%, respectively. Under anticoagulant therapy, thrombin-antithrombin III complex and D-dimmer remained in high levels at 1 month after operation, and both values decreased to the control level at 6 months. In patients with thromboembolic events, PT-INR tended to be less than 2.0. The patients with bleeding events showed some increase of PT-INP or received anti-platelet agents. The 5 to 95 percentile of PT-INR at 6 months was 1.2 to 3.0 in the patients without valve-related events. These results suggested that optimum range of PT-INR might be between 1.2 and 3.0 after bileaflet mechanical valve replacement in patients without high risk of thromboembolism and between 2.0 and 3.0 in patients with the high risk.

Thirty-five-year female had taken video assisted thoraco-surgery (VATS) and resected her localized fibrous tumor of parietal pleura. She suspected chest tumor with annual X-ray survey for lung disease four years ago. She complained of left side back pain recently. Her chest CT revealed that the tumor enlarged than before. She was performed video assisted thoraco-surgery. The tumor was solid hard and connected to the parietal pleura with pedicle, which was resected easily from her pleural cavity. Histrogical examination detected that her tumor was localized fibrous tumor of parietal pleura. CD 34 and Vimentin were positive and cytokeratin was negative in this case. Four year and two examinations of the chest CT later, we could determine the doubling time (800.7 days) of localized fibrous tumor in this case.

A 72-year-old male was admitted to our clinic for the treatment of early stomach cancer. A chest X-ray film on admission showed a mass in the right lung field. CT scan and transbronchoscopic lung biopsy revealed lung cancer (C-T2N2M0-stage IIIA). Histologically it was poorly differentiated adenocarcinoma, which was different from stomach cancer. We underwent synchronous resection of this double cancer through median sternotomy and abdominal incision. We conducted lobectomy, bilateral mediastinal lymph node dissection, and wedge resection of stomach. Postoperative diagnosis was early lung cancer (p-T2N0M0-stage I) and advanced stomach cancer (A-IIc+IIa advanced t2 (mp) n1H0P0M0-stage II). Postoperative course was stable and the patient was healthy at present. As such, this case report suggests that synchronous double cancers involving the lung and stomach, if both cancer are early stage, should be resected synchronously.

A 28-year-old male received a redo aortic valve replacement (AVR) with a 19 mm St. Jude Medical mechanical valve 3 months after the initial AVR because of recurrent valve detachment. We re-operated on this patient by aortic root replacement using a fresh aortic homograft. The donor of the homograft was a 59-year-old female who died of a traffic accident. The aortic root and valve was harvested aseptically and stored in a nutrient medium including antibiotics at 4 degrees C for 4 days. At the 3rd operation, aortico-ventricular discontinuity and an annular-abcess-like cavity were found. After debridement, the cavity was closed with a homograft aortic wall and then aortic root replacement was performed using a fresh aortic homograft. At first, prosthetic valve detachment seemed to be caused by infective endocarditis on the basis of his clinical history. However, causative organisms had never been recovered from the blood or the specimens obtained at the time of operation and reoperation. Post-operative HLA examination revealed No. 51 on HLA-B locus and thus we suspected that valve detachment might have been due to inflammation of the aortic wall caused by a subtype of Behçet disease. The early post-operative course was uneventful with a low dose of predonine. Post-operative aortography showed no aortic regurgitation and normal coronary anastomosis. Unfortunately however, he died suddenly 8 months after the operation. Autopsy demonstrated the presence of aortic wall necrosis with massive infiltration of macrophages and leucocytes resulting in dehiscence of the coronary anastomotic site. The cause of homograft detachment could not be determined for sure but might be recurrent infective endocarditis, although causative organisms were never identified, or infective endocarditis in combination with Behçet vasculopathy.

Pericardial cyst and diverticulum are commonly found in areas of cardiophrenic angles. In this article, we reported on two operated cases (54-year-old female, 43-year-old male) with pericardial diverticula in upper mediastinum. On their chest CT films, well circumscribed cystic lesions were seen in the right (case 1) and left (case 2) upper mediastinum. Based on findings of imaging modalities such as CT, MRI and transesophageal ultrasonography, the lesions were suspected of benign cystic tumors such as bronchogenic cyst, lymphatic cyst, esophageal cyst and pericardial cyst. However, definite diagnoses were made by thoracotomy. Even though the cystic lesion is recognized in the upper mediastinum, pericardial diverticulum should be considered as its diagnosis as well as bronchogenic cyst, lymphatic cyst, esophageal cyst.

A 30-year-old man was admitted to the hospital because of type A aortic dissection associated with annuloaortic ectasia (AAE). A magnetic resonance image (MRI), computed tomography of the aorta demonstrated aortic enlargement with dissection, but revealed no evidence of dissection of the aortic arch. A transesophageal echocardiography demonstrated dissection of the aortic arch. A graft replacement of the total aortic root were performed using hypothermic circulatory arrest with retrograde cerebral perfusion and open distal anastomosis. We reconstructed coronary ostiums with carrel patch, and discontinued the operation without major bleeding. No neurological deficit was found postoperatively.

The effect of diltiazem and nicardipine cardioplegia on A-V conduction system was analyzed in 75 patients undergoing coronary bypass operation. The dose of these drugs into the crystalloid cardioplegia was 10 micrograms/kg in nicardipine group (n = 29) and 100 micrograms/kg in diltiazem group (n = 46). Among these patients, there was no operative death and no patient required IABP after surgery and there was no difference on the post operative CK-MB level, on the cardiac index and on the pulmonary pressure between two groups. The number of patients who had complete A-V block after release of aortic cross clamping was significantly smaller in nicardipine group than in diltiazem group: 45.7% in diltiazem group vs. 6.9% in nicardipine group at 30 minutes and 21.7% vs. 6.9% at 60 minutes. We conclude that the suppressive effect on A-V conduction system was significantly lower in nicardipine cardioplegia than in diltiazem cardioplegia in the patients undergoing coronary bypass operation.

The indication in revascularization surgery is quite complicated, as the manifestation of the anatomical disease in the major three coronary arterial trees are innumerable and different as the face of each patient. Even though it is simply grouped into three categories as single, double and triple vessel disease, the combination of the degree and position of the obstructive lesions and the status of left ventricular function is varied in each instance. Adding further the patient's specific variables and risk factors to the anatomical variance, the situation becomes more complex. During the first decade of revascularization surgery, several large scale clinical studies were carried out in the United States and Europe to define the subsets of patients who were more benefited by revascularization surgery than medical treatment. The technique of aorto-coronary bypass graft (CABG) surgery also rapidly developed during this period and more complete revascularization using more durable conduits such as the internal mammary artery grafts with less surgical morbidity and mortality has been attained in the second decade. The appearance of PTCA (percutaneous transluminal coronary angioplasty) as a new invasive modality of treatment by the cardiologist towards the end of 1970's further complicated the indication of CABG. The comparative benefit of PTCA & CABG should be searched by the objective prospective randomized studies but such studies may be very difficult to be conducted in large scale, and meantime the number of PTCA will continue to increase. Based on the ACC/AHA Task Force Report, "Guideline and Indication for Coronary Artery Bypass Graft Surgery.": JACC Vol. 17, No. 3 March 1, 1991: 543-89, some of the subjects in surgical treatment of coronary artery disease were discussed in this paper.