Inflammatory Myofibroblastic Tumor of the Lung: A Case Report.

Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumor classified as an intermediate malignancy that rarely metastasizes. The most common site for IMTs is the lung, though they can develop in various other anatomical locations. Pulmonary IMTs are more common in children and adolescents and are infrequently diagnosed in adults. This case report describes a 49-year-old woman with a history of breast cancer previously treated with subtotal mastectomy and chemotherapy who developed an IMT in the lung. This case emphasizes the rarity of the disease and the associated clinical challenges when managing such cases.

Hemodynamic effects of combination therapy with inhaled nitric oxide and iloprost in patients with pulmonary hypertension and right ventricular dysfunction after high-risk cardiac surgery.

OBJECTIVE: The purpose of this study was to evaluate the hemodynamic effects of inhaled nitric oxide (NO) plus aerosolized iloprost in patients with pulmonary hypertension/right ventricular dysfunction after cardiac surgery. DESIGN: A retrospective study. SETTING: A single center. PARTICIPANTS: Eight consecutive patients with valve disease and postextracorporeal circulation (ECC) pulmonary hypertension/right ventricular dysfunction. INTERVENTION: The continuous inhalation of nitric oxide (10 ppm) and iloprost, 10 µg, in repeated doses. MEASUREMENTS AND MAIN RESULTS: The hemodynamic profile was obtained before inhalation, during the administration of inhaled NO alone (prior and after iloprost), and after the first 2 doses of iloprost. Tricuspid annular velocity and tricuspid annular plane systolic excursion were estimated at baseline and before and after adding iloprost. At the end of the protocol, there were significant decreases in pulmonary vascular resistance (p < 0.001), the mean pulmonary arterial pressure (p < 0.001), and the mean pulmonary artery pressure/mean arterial pressure ratio (p = 0.006). Both tricuspid annular velocity (p < 0.001) and tricuspid annular plane systolic excursion (p < 0.001) increased. The cardiac index (p < 0.001) and venous blood oxygen saturation (p = 0.001) increased throughout the evaluation period. Each iloprost dose was associated with further decreases in pulmonary vascular resistances/pressure. By comparing data at the beginning of inhaled NO with those after the second dose of iloprost, the authors noticed decreases in pulmonary vascular resistances (p = 0.004) and the mean pulmonary artery pressure (p = 0.017) and rises in tricuspid annular velocity (p < 0.001) and tricuspid annular systolic plane systolic excursion (p < 0.001). CONCLUSIONS: Inhaled NO and iloprost significantly reduced pulmonary hypertension and contributed to the improvement in right ventricular function. Inhaled NO and iloprost have additive effects on pulmonary vasculature.

Surgical Repair of Spontaneous Lung Herniation Induced by Vigorous Coughing: A Case Report and Literature Review.

Lung herniation is a rare clinical entity defined by extrathoracic protrusion of the lung or lung tissue due to a weakness in the thoracic wall. We present here a case of a 72-year-old male who presented with a spontaneous lung herniation, which occurred as a result of a ventral luxation of the third rib from the sternocostal joint due to vigorous coughing. The defect was repaired through anterolateral thoracotomy, reposition of the lung and approximating the ribs using heavy sutures. The postoperative course of the patient was uncomplicated. A brief review of the literature is also provided.

Bronchopleural Fistula Management With an Amplatzer Duct Occluder: A Comprehensive Case Report and Literature Review.

Bronchial stump insufficiency (BSI), also reported as bronchopleural fistula, following pneumonectomy is a rare but potentially devastating complication that can result in substantial morbidity and mortality. Despite advances in thoracic surgical techniques and perioperative care, bronchial stump dehiscence remains a challenging clinical scenario, especially when associated with severe infections and compromised patient conditions. Traditional surgical re-intervention to address this complication may carry significant risks and might be contraindicated in certain patients. As a result, innovative interventions are necessary to address these challenging cases effectively. In this report, we present an interventional endoscopic technique using an Amplatzer Duct occluder for the successful management of BSI in a 55-year-old male patient with a complex medical history.

A critical appraisal of open- and closed-chest models of experimental myocardial ischemia.

Myocardial ischemia is one of the most extensively studied topics in modern cardiovascular research. Early investigators first reported experimental myocardial ischemia (EMI) in 1862. The open-chest (surgical) approach is a well-developed model of EMI that enables researchers to directly access and observe the heart. With this approach, EMI is generally induced by surgical ligation of a coronary artery. A drawback of the open-chest model is the need for major surgery, which can result in local and systemic side effects. Alternative closed-chest models of EMI have been developed; most of these models involve endovascular catheterization with coronary artery embolization or thrombosis. Closed-chest techniques eliminate the need for invasive surgery, and the resultant model is more physiologically similar to clinical myocardial ischemia than is EMI produced by artery ligation. The authors present a review of open- and closed-chest models of EMI and discuss the advantages and disadvantages of each approach.

The π-Circuit Technique in Coronary Surgery: Analysis of 1359 Consecutive Cases.

Coronary artery bypass surgery still has its unique role in the treatment of coronary artery disease. It faces, however, the continuous challenge of becoming even less invasive and more effective as cases become more complex. We here present the results of 1359 cases treated with the π-circuit technique which consists of an off-pump total myocardial revascularization using composite arterial grafts. The results demonstrate that it is a safe technique providing low mortality, stroke, renal failure, wound infection, and other complication rates. We suggest the application of this technique, as well as of other similar techniques regarding similar principles, especially in high-risk patients.

Antegrade versus retrograde cerebral perfusion in relation to postoperative complications following aortic arch surgery for acute aortic dissection type A.

BACKGROUND: Aortic arch surgery is impossible without the temporary interruption of brain perfusion and therefore is associated with high incidence of neurologic injury. The deep hypothermic circulatory arrest (HCA), in combination with antegrade or retrograde cerebral perfusion (RCP), is a well-established method of brain protection in aortic arch surgery. In this retrospective study, we compare the two methods of brain perfusion. MATERIALS AND METHODS: From 1998 to 2006, 48 consecutive patients were urgently operated for acute type A aortic dissection and underwent arch replacement under deep hypothermic circulatory arrest (DHCA). All distal anastomoses were performed with open aorta, and the arch was replaced totally in 15 cases and partially in the remaining 33 cases. Our patient cohort is divided into those protected with antegrade cerebral perfusion (ACP) (group A, n = 23) and those protected with RCP (group B, n = 25). RESULTS: No significant difference was found between groups A and B with respect to cardiopulmonary bypass-time, brain-ischemia time, cerebral-perfusion time, permanent neurologic dysfunction, and mortality. The incidence of temporary neurologic dysfunction was 16.0% for group A and 43.50% for group B (p = 0.04). The mean extubation time was 3.39 +/- 1.40 days for group A and 4.96 +/- 1.83 days for group B (p = 0.0018). The mean ICU-stay was 4.4 +/- 2.3 days for group A and 6.9 +/- 2.84 days for group B (p = 0.0017). The hospital-stay was 14.38 +/- 4.06 days for group A and 19.65 +/- 6.91 days for group B (p = 0.0026). CONCLUSION: The antegrade perfusion seems to be related with significantly lower incidence of temporary neurological complications, earlier extubation, shorter ICU-stay, and hospitalization, and hence lower total cost.

Simultaneous off-pump coronary artery bypass graft and nephrectomy.

We report the one-stage surgical management of a 68-year-old patient with renal cell carcinoma and serious hematuria combined with coronary artery disease and unstable angina. After the accomplishment of coronary revascularization without cardiopulmonary bypass, we proceeded to nephrectomy and resection of the renal tumor at the same time. The patient's postoperative course was uneventful, and at 17 months of follow-up, the patient showed no signs of recurrence. To the best of our knowledge, such a case has never been reported before in the literature.

In vitro evaluation for potential calcification of biomaterials used for staple line reinforcement in lung surgery.

Bovine pericardium (BPC) and polytetrafluoroethylene (PTFE) have been widely used to reinforce staple lines in lung resection. Since limited information regarding the calcification of these biomaterials is available, we undertook an in vitro study to evaluate their calcification potential. Commercially available BPC and PTFE biomaterials were evaluated and compared with custom-prepared BPC tissue. In vitro calcification was performed via submersion in supersaturated solution in a double-walled glass reactor at 37.0 degrees C +/- 0.1 degrees C, pH 7.4 +/- 0.1, mimicking most ion concentrations of human blood plasma. In processing of calcification, the pH decrease of the solution simulated the addition of consumed H(+), Ca(2+), and PO(4)(3-) ions from titrant solutions, the concentrations of which were based on the stoichiometry of octacalcium phosphate. The molar ion addition with time was recorded, and the initial slope of the curve was computed for each experiment. The rate of calcification developed (molar calcium phosphate ion addition rate per time and total surface area) (R) was computed after that with respect to the relative supersaturation (sigma) used in each experiment. R for custom-prepared BPC tissues was found to be in the range of 0.19 +/- 0.08 to 0.52 +/- 0.19 (n = 17) in sigma range of 0.72 to 1.42. Commercial BPC was found to be 0.016 to 0.052 (n = 4), and PTFE was 0.005 to 0.05 (n = 8) in the same sigma range. Both clinically applied biomaterials, BPC and PTFE, seemed to be calcified with rates of at least one order of magnitude lower than the custom-prepared BPC tissue. This data suggested that BPC and PTFE biomaterials showed a similar, relatively very low tendency for calcification compared with custom-prepared BPC tissue. Although further studies are necessary, staple line reinforcement by these two biomaterials should be considered safe from the calcification point of view.

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment.

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

Intramyocardial thrombin promotes angiogenesis and improves cardiac function in an experimental rabbit model of acute myocardial infarction.

OBJECTIVE: Thrombin has been reported to play a pivotal role in the initiation of angiogenesis by indirectly regulating and organizing a network of angiogenic molecules. On the basis of these reports, we investigated the angiogenic action of thrombin in a rabbit model of acute myocardial infarction. METHODS: A rabbit model of acute myocardial infarction was established by ligation of the left anterior descending coronary branch. Subjects were then divided into 2 groups and treated with intramyocardial administration of thrombin (2500 IU; n = 13) or an equal volume of normal saline (n = 13). Four weeks later, animals were euthanized and histopathologic analysis, immunohistochemical staining for endothelial markers CD31 and vascular endothelial growth factor-A, and electron microscopy examination were performed on excised hearts. Electrocardiography, cardiac enzymes, and assessment of cardiac function by measuring left ventricular end-diastolic pressure and ejection fraction were recorded before and after myocardial infarction, and both left ventricular end-diastolic pressure and ejection fraction were further measured on the day of euthanasia (n = 5-8 in each case). RESULTS: Increased levels of troponin, ST elevation, and histopathologically confirmed myocardial infarction were observed in all animals. A significant increase of microvessel density at the infarct border zone, as evaluated by CD31 immunohistochemistry, was observed in the thrombin-treated group compared with the control group (30.3 ± 12.8 vs 12.6 ± 4.8, P = .0065). A significantly higher number of vascular endothelial growth factor-A-positive vessels at the infarct border zone was observed in the thrombin-treated animals compared with the control group (21.8 ± 8.9 vs 5.6 ± 4.4; P = .0009). The thrombin-treated animals showed a statistically significant reduction in left ventricular end-diastolic pressure values (6.9 ± 1.8 mm Hg vs 12.7 ± 2.2 mm Hg, P = .0002) and significant improvement in left ventricular ejection fraction (59.8% ± 3.1% vs 42.2% ± 6.14%, P = .002) on the day of euthanasia compared with the post-infarct day, reflecting significantly improved cardiac function compared with control subjects that showed no significant change. CONCLUSIONS: Intramyocardial administration of thrombin seems to promote angiogenesis and improve cardiac function of the ischemic myocardium, which may provide a new therapeutic approach in patients with myocardial ischemia.

Tc-99m depreotide SPECT/CT for lymph node staging of non-small-cell lung cancer.

OBJECTIVE: To investigate the potential role of Tc-99m depreotide (Tc-DEPR) in the preoperative lymph node (N) staging of non-small-cell lung cancer (NSCLC). METHODS: Sixty-one patients with NSCLC at the potentially operable stage were enrolled and underwent scintigraphy before surgery (n=56) or mediastinoscopy (n=5). Imaging was performed with a hybrid single photon emission computed tomography/computed tomography (SPECT/CT) system. Depreotide uptake in N stations was evaluated visually and semi-quantitatively and compared to histology. Quantification was carried out in attenuation-corrected SPECT slices. Different sites of normal uptake were used as a reference for comparison with lesional uptake. Receiver operating characteristic analysis was employed to identify the most preferable reference area and the cut-off best discriminating disease-free from disease-involved lymph nodes. RESULTS: With reference to 53 Ν1 hilar and 147 Ν2/Ν3 sampled stations, sensitivity of scintigraphy by visual interpretation was 100 and 94%, specificity 43 and 59% and accuracy 55 and 67%, respectively. No patient was down-staged, but 52% were incorrectly up-staged and 44% were misclassified as inoperable. Compared to scintigraphy, preoperative contrast-enhanced diagnostic CT demonstrated lower sensitivity (36% for hilar and 73% for N2/N3 stations), higher specificity (79 and 75%) and similar accuracy (70 and 75%). Regarding the ultimate N-stage and the prediction of surgical disease, diagnostic CT was wrong in 51 and 34% of cases. Dichotomy of quantitative scintigraphic data by the use of certain N-to-spine ratio cut-offs resulted in a significant increase of specificity (76% for hilar and 89% for N2/N3 stations), while sensitivity remained high (82% in both circumstances) and accuracy for Ν2/Ν3 stations was substantially improved (88%). By this quantitative approach, misclassifications as to the N-stage and patient operability (25 and 16%) were considerably less than that of visual Tc-DEPR and diagnostic CT interpretations. CONCLUSION: Tc-99m depreotide SPECT/CT seems to have a role in the N-staging of NSCLC, mainly because of its high sensitivity and negative predictive value. Quantification of uptake can improve specificity, at a low cost of sensitivity. If F-18 fluoro-deoxyglucose positron emission tomography is not available, this method may be used as a surrogate to conventional staging modalities.

Inhaled nitric oxide plus iloprost in the setting of post-left assist device right heart dysfunction.

BACKGROUND: Pulmonary hypertension and right ventricular (RV) dysfunction may complicate the implantation of a left ventricular assist device (LVAD). We examined whether inhaled vasodilators can sufficiently reduce RV afterload, avoiding the need for temporary RV mechanical support. METHODS: The study includes 7 patients with RV dysfunction after LVAD insertion. Treatment consisted of inotropes, inhaled nitric oxide (10 ppm), and iloprost (10 µg) in repeated doses. Full hemodynamic profile was obtained before inhalation, during administration of inhaled NO alone (before and after iloprost), as well as after the first two doses of inhaled iloprost. Tricuspid annular velocity was estimated at baseline and before and after adding iloprost. RESULTS: There was a statistically significant reduction in pulmonary vascular resistance (PVR), mean pulmonary artery pressure (MPAP), RV systolic pressure, and pulmonary capillary wedge pressure, and a considerable increase in LVAD flow, LV flow rate index, and tricuspid annular velocity at all points of evaluation versus baseline. By the end of the protocol, MPAP/mean systemic arterial pressure, and PVR/systemic vascular resistance ratios were reduced by 0.17±0.03 (95% confidence interval, 0.10 to 0.25, p=0.001) and 0.12±0.025 (95% confidence interval, 0.06 to 0.18; p=0.003), respectively. The tricuspid annular velocity increased by 2.3±0.18 cm/s (95% confidence interval, 1.83 to 2.73 cm/s; p<0.001). Pairwise comparisons before and after iloprost showed an important decrease in PVR (p=0.022), MPAP (p=0.001), pulmonary capillary wedge pressure (p=0.002), and RV systolic pressure (p<0.001), and a rise in tricuspid annular velocity (p=0.008). CONCLUSIONS: Inhaled vasodilators mainly affected the pulmonary vasculature. Combination treatment with inhaled NO and iloprost sufficiently decreased PVR and MPAP on the basis of an additive effect, improved RV function, and avoided the need for RV assist device.

Prognostic factors of atrial fibrillation following elective coronary artery bypass grafting: the impact of quantified intraoperative myocardial ischemia.

BACKGROUND: Atrial fibrillation (AF) occurs in 28-33% of the patients undergoing coronary artery revascularization (CABG). This study focuses on both pre- and peri-operative factors that may affect the occurrence of AF. The aim is to identify those patients at higher risk to develop AF after CABG. PATIENTS AND METHODS: Two patient cohorts undergoing CABG were retrospectively studied. The first group (group A) consisted of 157 patients presenting AF after elective CABG. The second group (group B) consisted of 191 patients without AF postoperatively. RESULTS: Preoperative factors presenting significant correlation with the incidence of post-operative AF included: 1) age > 65 years (p = 0.029), 2) history of AF (p = 0.022), 3) chronic obstructive pulmonary disease (p = 0.008), 4) left ventricular dysfunction with ejection fraction < 40% (p = 0.015) and 5) proximal lesion of the right coronary artery (p = 0.023). The intraoperative factors that appeared to have significant correlation with the occurrence of postoperative AF were: 1) CPB-time > 120 minutes (p = 0.011), 2) myocardial ischemia index < 0.27 ml.m2/Kg.min (p = 0.011), 3) total positive fluid-balance during ICU-stay (p < 0.001), 4) FiO2/PO2 > 0, 4 after extubation and during the ICU-stay (p = 0.021), 5) inotropic support with doses 15-30 µg/Kg/min (p = 0.016), 6) long ICU-stay recovery for any reason (p < 0.001) and perioperative myocardial infarction (p < 0.001). CONCLUSIONS: Our results suggest that the incidence of post-CABG atrial fibrillation can be predicted by specific preoperative and intraoperative measures. The intraoperative myocardial ischemia can be sufficiently quantified by the myocardial ischemia index. For those patients at risk we would suggest an early postoperative precautionary anti-arrhythmic treatment.

Transternal repair of a giant Morgagni hernia causing cardiac tamponade in a patient with coexisting severe aortic valve stenosis.

BACKGROUND: Foramen of Morgagni hernias have traditionally been repaired by laparotomy, laparoscopy or even thoracoscopy. However, the trans-sternal approach should be used when these rare hernias coexist with other cardiac surgical diseases. CASE PRESENTATION: We present the case of a 74 year-old symptomatic male with severe aortic valve stenosis and global respiratory failure due to a giant Morgagni hernia causing additionally cardiac tamponade. The patient underwent simultaneous repair of the hernia defect and aortic valve replacement under cardiopulmonary bypass. The hernia was repaired through the sternotomy approach, without opening of its content and during cardiopulmonary reperfusion. CONCLUSIONS: Morgagni hernia can rarely accompany cardiac surgical pathologies. The trans-sternal approach for its management is as effective as other popular reconstructive procedures, unless viscera strangulation and necrosis are suspected. If severe compressive effects to the heart dominate the patient's clinical presentation correction during the cardiopulmonary reperfusion period is mandatory.

Surgical or interventional revascularization in diabetic patients with coronary artery disease?

The combination of diabetes mellitus and coronary artery disease (CAD) constitutes an aggressive disease characterized biologically by chronic inflammatory, proliferative and pro-thrombotic situation. In the "diabetic patient" the increased frequency and gravity of simultaneous myocardial infarction and the deterioration of congestive heart failure contribute to the inevitable unfavourable final result. Diabetes accelerates the natural course of atherosclerosis and involves a great number of coronary vessels with more diffuse atherosclerotic lesions. Moreover, the risks of plaque ulceration and thrombosis have been shown to be considerably higher in diabetic patients. The treatment should be also aggressive and be based on the combined treatment of CAD and the effective regulation of glucose levels. The decision of revascularization in the diabetic patient should be posed relatively earlier. The surgical choice of revascularization seems to be advantageous over the interventional, with better early and late results.

Strategies to prevent intraoperative lung injury during cardiopulmonary bypass.

During open heart surgery the influence of a series of factors such as cardiopulmonary bypass (CPB), hypothermia, operation and anaesthesia, as well as medication and transfusion can cause a diffuse trauma in the lungs. This injury leads mostly to a postoperative interstitial pulmonary oedema and abnormal gas exchange. Substantial improvements in all of the above mentioned factors may lead to a better lung function postoperatively. By avoiding CPB, reducing its time, or by minimizing the extracorporeal surface area with the use of miniaturized circuits of CPB, beneficial effects on lung function are reported. In addition, replacement of circuit surface with biocompatible surfaces like heparin-coated, and material-independent sources of blood activation, a better postoperative lung function is observed. Meticulous myocardial protection by using hypothermia and cardioplegia methods during ischemia and reperfusion remain one of the cornerstones of postoperative lung function. The partial restoration of pulmonary artery perfusion during CPB possibly contributes to prevent pulmonary ischemia and lung dysfunction. Using medication such as corticosteroids and aprotinin, which protect the lungs during CPB, and leukocyte depletion filters for operations expected to exceed 90 minutes in CPB-time appear to be protective against the toxic impact of CPB in the lungs. The newer methods of ultrafiltration used to scavenge pro-inflammatory factors seem to be protective for the lung function. In a similar way, reducing the use of cardiotomy suction device, as well as the contact-time between free blood and pericardium, it is expected that the postoperative lung function will be improved.

Superior vena cava syndrome in a patient with previous cardiac surgery: what else should we suspect?

BACKGROUND: Although mediastinal tumors compressing or invading the superior vena cava represent the major causes of the superior vena cava syndrome, benign processes may also be involved in the pathogenesis of this medical emergency. One of the rarest benign causes is a pseudoaneurysm developing in patients previously having heart surgery. CASE REPORT: We present the case of a large pseudoaneurysm of the ascending aorta, five years after primary surgery, with a significant compression of the right mediastinal venous system causing superior vena cava syndrome, detected at chest CT angiography. Perioperative findings showed two rush out points both coming from the distal aortic suture line which was performed five years ago. The patient underwent reoperation under circulatory arrest facilitating safe exploration and repair of the distal anastomotic leaks CONCLUSION: Enhanced chest CT should be always undertaken in all patients with superior vena cava syndrome, especially in those previously having cardiac or aortic surgery to correctly evaluate the presence of a pseudoaneurysm. Mass effect to the superior vena cava makes necessary an open surgical treatment of the pseudoaneurysm so as to concurrently resolve the right mediastinal venous system's compression. Surgery should be performed in terms of safe approach to avoid exsanguination and cerebral malperfusion.

Current role of surgery in small cell lung carcinoma.

Small cell lung carcinoma represents 15-20% of lung cancer. Is is characterized by rapid growth and early disseminated disease with poor outcome. For many years surgery was considered a contraindication in Small Cell Lung Cancer (SCLC) since radiotherapy and chemoradiotherapy were found to be more efficient in the management of these patients. Never the less some surgeons continue to be in favor of surgery as part of a combined modality treatment in patients with SCLC. The reevaluation of the role of surgery in this group of patients is based on clinical data indicating a much better prognosis in selected patients with limited disease (T1-2, N0, M0), the high rate of local recurrence after chemoradiotherapy with surgery considered eventually more efficient in the local control of the disease and the fact that surgery is the most accurate tool to access the response to chemotherapy, identify carcinoids misdiagnosed as SCLC and treat the Non Small Cell Lung Cancer component of mixed tumors. Performing surgery for local disease SCLC requires a complete preoperative assessment to exclude the presence of nodal involvement. In stage I surgery must always be followed by adjuvant chemotherapy, while in stage II and III surgery must be planned only in the context of clinical trials and after a pathologic response to induction chemoradiotherapy has been confirmed. Prophylactic cranial irradiation should be used to reduce the incidence of brain metastasis.

Primary aortoesophageal fistula due to thoracic aortic aneurysm: successful surgical treatment.

Aortoesophageal fistula is a rare emergency that presents a real challenge for cardiothoracic surgeons. There have been few reports of survivors. We present the case of a 70-year-old man with aortoesophageal fistula, mediastinal abscess, and severe septicemia consequent to esophageal erosion and rupture of a chronic degenerative descending thoracic aortic aneurysm. The patient underwent successful surgical treatment by aorto-aortic bypass and bipolar esophageal exclusion in conjunction with a cervical esophagostomy and a feeding gastrostomy. The pleural cavity was copiously irrigated and drained. Three months later, a retrosternal gastric bypass operation was performed successfully. The patient's 6-month follow-up examination revealed no problems.