In patients with acute type A aortic dissections, it is possible to perform extensive primary repair of the thoracic aorta with relative safety by using a synthetic graft with a self-expanding stent, and this method might reduce the necessity of further operations not only for the distal descending aorta but also for the thoracoabdominal aorta.

Trifecta is a stented bioprosthetic heart valve with a bovine pericardial sheet externally mounted on a titanium stent. This valve is applied only for aortic valve replacement (AVR), providing excellent hemodynamics and extremely low incidence of structural valve deterioration (SVD). A 76-year-old woman presented with dyspnea on effort 24 months after AVR with a 21-mm Trifecta valve. Echocardiography revealed severe aortic regurgitation with prolapse of a cusp of Trifecta valve, which suggested that she developed acute heart failure due to early SVD. In the operation, Trifecta valve had a cusp tear near the commissure with circumferential fibrous pannus ingrowth only at the inflow side. There was neither calcification nor infection. The Trifecta valve was successfully replaced with a new porcine bioprosthesis.

Objective: We report our current treatment strategy for acute type A aortic dissection with organ ischemia as well as notable findings in our experience. Materials and Methods: Among 101 cases of acute type A aortic dissection, 25 had organ ischemia. Malperfusion was assessed at the aorta, proximal portion of the branch, organ parenchyma, and organ function by means of multiple modalities, including transesophageal echocardiography (TEE), near-infrared spectroscopy, and physical examinations. It was assessed every time the perfusion status was altered. Results: There were three operative deaths and one late hospital death. Uncertainty of symptoms and inadequate preoperative assessment in an emergent situation indicated the necessity of an overall checkup of organ ischemia in the operating room on a routine basis. Multi-modality assessment including TEE was helpful for this purpose. Two cases indicated that recovery of a true lumen could be inadequate despite true lumen perfusion including central cannulation. Thrombus in the false lumen appeared to be responsible. Conclusions:To solve practical problems in treating acute type A dissection with organ ischemia, realtime information on organ perfusion is important for detecting the presence of malperfusion, making an appropriate strategy, and immediately assuring the efficacy of the means taken.

A 65-year-old man presenting with visceral malperfusion complicating acute type A aortic dissection underwent emergent surgery. Bypass grafting from the right common iliac artery to the superior mesenteric artery was performed prior to central aortic repair because intestinal ischemia caused hemodynamic instability. Subsequently, the ascending aorta was replaced with a Dacron graft under a condition of circulatory arrest with selective cerebral perfusion. Endotoxin adsorption was carried out intraoperatively in parallel with cardiopulmonary bypass to prevent postoperative end-organ failure. The patient recovered uneventfully and was discharged from our hospital 31 days after surgery.

A 42-year-old man suffering from massive aortic valve regurgitation with mild stenosis because of a bicuspid valve underwent surgery in May 2007. The surgical procedure was performed through a right anterolateral thoracotomy using the peripheral cannulation method. Cardiac arrest was achieved by direct aortic cross-clamping and selective cardioplegia delivery. The aortic valve was replaced with a bioprosthesis. The operation and aortic cross-clamping periods were 265 and 117 min, respectively. The patient's recovery was uneventful, and he was discharged from hospital 8 days after surgery.