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A 56-year-old man had left nephrectomy and resection of a cavoatrial tumor thrombus under a cardiopulmonary bypass assist for left renal cell carcinoma. An intraoperative bipolar temporary epicardial atrial pacing wire was removed on postoperative day 8. The patient collapsed on postoperative day 15. Emergent transthoracic echocardiography and computed tomography scanning with contrast media detected cardiac tamponade. The three-dimensional volume-rendering images from the multislice computed tomography scan demonstrated bleeding from the aortic root. Upon emergency operation, active arterial bleeding from the aortic root distal to the sites of cannulation and cardioplegia was confirmed, and hemostasis with sutures was completed. It is well known that the intraoperative temporary epicardial pacing wire can cause bleeding or arrhythmia, especially when the wire is being removed. However, bleeding usually occurs from the inserted epicardial point of the pacing wire soon after removal of the wire. To our knowledge, this late bleeding complication of the pacing wire is a previously unreported serious iatrogenic complication after cardiac surgery.Keywords: temporary pacing complications, bleeding, cardiac tamponade, aorta Removal of these pacing wires has been associated with life-threatening complications, such as atrial and ventricular lacerations, and also injuries to saphenous vein grafts, resulting in bleeding and cardiac tamponade. 3,4) We describe a very rare but serious case of late cardiac tamponade caused by bleeding from the aortic root due to the injury from the atrial epicardial temporary pacing wire. Case ReportA 56-year-old man suffering from left renal cell carcinoma with cavoatrial tumor thrombus was referred to our department for surgical resection. Upon operation, the left nephrectomy was initially performed through midline laparotomy. Through median sternotomy extended from laparotomy, the liver was mobilized and rotated to expose the intrahepatic portion of the inferior vena cava. Then, cardiopulmonary bypass was established by means of ascending aortic cannulation and two venous cannulations, one from the superior vena cava and the other from the

A 60-year-old woman who underwent ventricular septal defect (VSD) closure, mitral valve repair, and tricuspid annuloplasty 10 years earlier, presented with congestive heart failure. Her previous postoperative echocardiogram demonstrated a residual VSD leak and moderate mitral regurgitation. Transesophageal echocardiography (Figure 1) showed moderate mitral regurgitation, severe tricuspid regurgitation, a large atrial septal defect, and a fistulous communication from the sinus of Valsalva to the right ventricle, which was confirmed by multi-slice computed tomography (Figure 2). Surgery revealed a prolapsed right coronary cusp with a 3-mm perforation at the lower end of the prolapsed leaflet, adhering to the edge of the VSD patch. The fistula was closed with autologous right coronary valvular leaflet, and concomitant aortic and mitral valve replacement was performed with repeat tricuspid annuloplasty and patch closure of the atrial septal defect that was caused by dehiscence of the previous interatrial septum atriotomy.