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Thrombin generation is considered unavoidable during cardiac surgery using cardiopulmonary bypass (CPB). We compared the effects of open and closed circuits on coagulation and fibrinolysis under identical conditions of priming volume, heparin-coating, and anticoagulation and transfusion protocols. Thirty coronary surgery patients were randomized to surgery using open circuits with open reservoirs and cardiotomy suction (open group, n=15) or closed circuits without either (closed group, n=15). In the closed group, a cell-saving device was used instead of cardiotomy suction. Blood samples were collected at eight time points from before the operation to the first postoperative morning. Thrombin-antithrombin III (TAT), fibrinogen degradation products, and D-dimer were not elevated during CPB in the closed group, but were significantly increased in the open group (P<0.0001 for all markers). The peak TAT value at the termination of CPB in the open group was significantly correlated with CPB time (r(2)=0.879, P=0.037) and the simultaneous peak D-dimer value (r(2)=0.640, P=0.040). In conclusion, the use of closed circuits maximally suppressed thrombin generation and coagulofibrinolytic activation during coronary artery bypass grafting. The respective contribution of open reservoirs and cardiotomy suction to the perioperative thrombin generation remains to be elucidated.

I report a hemorrhagic complication due to disseminated intravascular coagulation after thoracic endovascular aortic repair for a dissecting aortic aneurysm. A 74-year-old man underwent thoracic endovascular aortic repair and carotidcarotid artery bypass to close the primary entry site of the dissecting aortic aneurysm. Postoperatively, he developed a gradually expanding cervical hematoma. Laboratory data showed disseminated intravascular coagulation. He could not extubated until postoperative day 6 because of the risk of airway obstruction. He was treated with transfusion to replenish the coagulation factor. Disseminated intravascular coagulation may occur secondary to thrombus formation in the false lumen after thoracic endovascular aortic repair.Keywords: disseminated intravascular coagulation, aortic aneurysm, blood vessel prosthesis but had not been followed up. Computed tomographic angioglaphy showed a Stanford type B chronic aortic dissection extending from the distal aortic arch to the abdominal aorta, with the false lumen entirely patent (Fig. 1a). The primary entry site was 20 mm distal to the origin of the left subclavian artery (Fig. 1b), and the re-entry site was at the origin of the left renal artery. The maximum diameter of the distal aortic arch was 72 mm, and the diameter of the descending aorta was 65 mm. The celiac axis, superior mesenteric artery and right renal artery originated from the true lumen. Laboratory data showed mild coagulopathy: fibrinogen 262 mg/dl, prothrombin time international normalized ratio 1.39, activated partial thromboplastin time 34.5. Liver function test was within normal limits. It would have been difficult to perform conventional replacement of the descending aorta via left thoracotomy because the patient had been bedridden for a long time and could not even stretch the left arm and could not be placed in the left lateral position due to joint contracture. To avoid the risk associated with conventional open surgery, I decided to perform TEVAR to close the primary entry site.The procedure was performed under general anesthesia using the Zenith TX2 TAA Endovascular Graft (Cook Medical, Bloomington, Ind). To ensure enough length of the healthy aorta at the proximal neck, the stent graft was positioned so that it covered the origins of the left common carotid artery and left subclavian arteries after carotidcarotid artery bypass (Fig. 2a). The left subclavian artery was not revascularized because preoperative magnetic resonance imaging showed communication between the right and left vertical arteries. The origin of the left subclavian artery was embolized with metallic coils to prevent a type 2 endoleak. The primary entry site in the distal aortic arch was covered with the stent graft, and postoperative angiography did not show contrast medium in the false lumen of the thoracic aorta (Fig. 2b). The re-entry site at the origin of the left renal artery was not closed. The operation time was 276 min and no blood transfusion was needed.After surgery, the patient was transfe...

Although there are several mitral valve aneurysm reports, studies on aortic valve aneurysm are extremely rare. This paper describes an uncommon case of a large saccular aortic valve aneurysm associated with infective endocarditis. A 37-year-old man was hospitalized in our hospital with fever and dyspnea. Echocardiography found severe aortic regurgitation and aortic valve aneurysm of the non-coronary cusp going in and out of the left ventricular chamber. Blood cultures grew Streptococcus viridance. Therefore, the patient underwent aortic valve replacement. During the operation, we observed a 30 × 20 mm ruptured aneurysm that arose from the non-coronary cusp. The aortic valve containing the aneurysm was resected and replaced with a mechanical heart valve. Histopathological examination of the aortic valve aneurysm showed active inflammatory changes. Infective endocarditis was considered to be the cause of this aortic valve aneurysm.