Background and Aim: Mesenteric malperfusion is a complication with a higher risk of inhospital mortality because diagnosing mesenteric ischemia before necrotic change is difficult, and when it occurs, the patient's condition has worsened. Although it contradicts the previous consensus on central repair-first strategy, the revascularization-first strategy was found to be significantly associated with lower mortality rates. This study aimed to present our revascularization-first strategy and the postoperative results for acute aortic dissection involving mesenteric malperfusion. Methods: Among 58 patients with acute type A aortic dissection at our hospital between January 2017 and December 2019, mesenteric malperfusion was noted in six. Four hemodynamically stable patients underwent mesenteric revascularization with endovascular intervention in a hybrid operation room before central repair, and two hemodynamically unstable patients underwent central repair before mesenteric revascularization. Results: No in-hospital mortality was recorded. All four patients with mesenteric revascularization-first strategy recovered with no symptoms related to mesenteric ischemia. Two patients with central repair-first strategy developed paralytic ileus for 1 week; one of them needed exploratory laparotomy, but no patients needed colon resection. Conclusion: No in-hospital mortality was recorded. All four patients with mesenteric revascularization-first strategy recovered with no symptoms related to mesenteric ischemia. Two patients with central repair-first strategy developed paralytic ileus for 1 week; one of them needed exploratory laparotomy, but no patients needed colon resection.

Objectives Acute type A aortic dissection complicated with brain ischemia is associated with significantly higher mortality risks. Even if rescued with central aortic repair, some patients develop permanent postoperative neurological deficiency postoperatively. We recently introduced direct common carotid artery perfusion for acute type A aortic dissection involving the common carotid artery. This study introduced this technique to prevent postoperative neurological deficiency by comparing brain protection strategies. Methods Among 91 acute type A aortic dissection patients treated at our hospital during August 2015-October 2020, the common carotid artery was involved in 19 (21%), which had > 90% stenosis in either of the carotid arteries on preoperative contrast-enhanced computed tomography. Twelve patients underwent conventional selective cerebral perfusion during August 2015-December 2018 and seven patients underwent direct carotid artery perfusion during January 2019-October 2020. We assessed patient characteristics, surgical courses, clinical outcomes, and neurological outcomes. Results The mean age was 69 (range 39-84) years; 17 patients were male (89%). Eight patients (42%) had neurological symptoms. Concomitant procedures, postoperative neurological symptoms, and late mortality were significantly associated with conventional selective cerebral perfusion. Five selective cerebral perfusion patients experienced worsened neurological symptoms and two died of broad cerebral ischemia. No direct carotid artery perfusion patient died during hospitalization or experienced worsened neurological outcomes. Conclusions Direct carotid artery perfusion may be useful in aortic dissection with brain ischemia because it does not aggravate neurological symptoms and is not associated with intraoperative cerebral infarction. However, it may be ineffective when cerebral infarction has already developed.

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Postinfarction ventricular septal defect has been a challenge to cardiac surgeons. Recently, a number of reports have recommended ventricular septal defect closure through the right ventricle. However, when inferior myocardial infarction widely extends to the left ventricle, it is necessary to modify a patch-closure technique due to extensive fragile necrotic myocardium. We describe a simplified surgical technique via a right ventricular incision.

We report the successful repair in a 29-year-old man who experienced penetration of the ascending aorta and bronchus by a crossbow bolt. Imaging studies revealed the arrow penetrating the sternum, right lung, ascending aorta and right bronchus, with mediastinal emphysema. The top of the arrow (8 mm in diameter) was deeply embedded in the body of the thoracic vertebra. The arrow was successfully removed while maintaining a stable respiratory condition by performing differential lung ventilation. There was no need for cardiopulmonary bypass. To our knowledge, this is the first case of a through-and-through penetrating ascending aorta injury.