The case report by Sicim et al. is the placement of extra-anatomical bypasses in bilateral common carotid arteries. The similar previous reports of the extra-anatomical bypass usually indicate unilateral bypass. Whether or not the Willis' circle is incomplete is difficult to judge during emergency surgery, and the authors' judgment seems to have been correct in the sense that it could maintain cerebral perfusion reliably and quickly. The direct perfusion and extraanatomical bypass of carotid artery is a reasonable strategy in patients with cerebral malperfusion.

A 63-year-old woman was diagnosed with a giant atrial septal aneurysm (ASA) protruding into the right atrium and thrombus attached to the left side of the ASA pouch. We surgically resected the ASA, and the resection site was closed with pericardial patch. The postoperative course was uneventful.

A 40-year-old male with Becker muscular dystrophy presented with severe mitral regurgitation and underwent mitral valve repair. Following the surgery, the patient became tachycardic, and developed a continuous high grade-fever and hyperbilirubinemia. The patient's condition worsened and we eventually tested his thyroid levels and discovered abnormally high thyroid levels. After diagnosing a severe thyroid storm, the patient was treated with oral administration of Lugol's iodine and thiamazole, as well as an intravenous steroid, which led to an immediate improvement of symptoms. The incidence of thyroid storm after open-heart surgery is extremely rare but highly life-threatening if unrecognized.

Cryoglobulinemia is a cold-reactive autoimmune disease. A 64-year-old man with active cryoglobulinemia presented Stanford type A acute aortic dissection. He had been treated with immunosuppressive drugs and plasma exchange (PE) at our hospital; subsequently, qualitative analysis of cryogobulin (CG) was negative. He underwent emergency ascending aorta replacement using cardiopulmonary bypass (CPB) under deep hypothermia circulatory arrest with selective cerebral perfusion. The total CPB time, aortic cross clamp time, and selective cerebral perfusion time were 255, 153, 56 minutes, respectively, and the minimal nasopharyngeal temperature was 17.3°C. Our patient had no significant perioperative complications. Hence, if PE is performed appropriately and CG is negative, patients with cryoglobulinemia who exhibit severe preoperative symptoms can safely undergo surgery with deep hypothermia.

A 63-year-old woman presented with chest discomfort. Coronary angiography revealed vasospastic angina. Cardiac multi detector computed tomography and cardiac magnetic resonance imaging showed a 30 × 30-mm atrial septal aneurysm (ASA) protruding into the right atrium and thrombus attached to the left side of the ASA pouch. We surgically resected the ASA because the patient was at risk for systemic thrombosis. The resection site was closed with pericardial patch through a median sternotomy under a cardiopulmonary bypass. The postoperative course was uneventful, and the patient was discharged on postoperative day 26.