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From 1987 to 1994, 116 patients received replacement of the ascending and/or aortic arch using selective cerebral perfusion. They were 82 male and 34 female, with average age of 64 years. There were 63 dissecting and 53 true aneurysms. Extent of replacement was: ascending aorta in 13, aortic root in 2, aortic arch in 93, and aortic root and complete arch in 8. Aortic arch replacements were composed of: 29 partial proximal aortic arch replacements, 44 complete aortic arch replacements, and 20 partial distal aortic arch replacements. Nineteen (16.4%) hospital deaths occurred. Univariate testing of pre-, intra-, and post-operative variables followed by stepwise logistic regression analyses identified elderly, ischemic heart disease, postoperative neurologic complication, cardiac dysfunction, renal failure, and massive bleeding as factors having independent association with hospital mortality. Neurologic complication was found in 10 patients (8.6%), and risk factor for this complication was preoperative peripheral vascular disease. Follow-up of hospital survivors documented an overall cumulative 5-year survive rate of 69%. There was no significant difference between dissection and true aneurysms in 5-year survive ratios, which were 63% and 82%, respectively. During follow-up periods, 18 patients died. Half of these cases were vascular deaths, caused by rupture, sudden death and secondary operation. Univariate analyses followed by stepwise Cox testing indicated that chronic obstructive pulmonary disease and a history of postoperative massive bleeding were associated with decreased later survival. Our experience suggests that selective cerebral perfusion is a safe technique for the repair of ascending aorta and/or aortic arch problems. High-risk subgroups of patients with these aortic problems can be identified by risk factors. Aggressive and careful management is necessary for such subgroups to improve early and late survival rates.

A 58-year-old man, who had been submitted to an indication of mitral valvuloplasty (MVP) because of severe mitral regurgitation, was diagnosed as idiopathic thrombocytopenic purpura (ITP). In order to diminish the peri-operative blood loss, splenectomy and high-dose bolus administration of gamma-globulin (400 mg/kg/day) were performed at the time of two weeks and during last five days respectively, prior to MVP surgery. In early post-operative stage, anticoagulant therapy was held down considering ITP, and we were not troubled with bleeding throughout the peri-operative period. On the fourteenth post-operative day, however, mural thrombi in the left atrium were pointed out by transesophageal echocardiography (TEE). Then anticoagulant therapy was reinforced by increasing the warfarin dose. When TEE was restudied on 36th, post-operative day, mural thrombi had almost disappeared. Although it is commonly known that mitral valvuloplasty has low risk of thrombosis and less necessity of anticoagulation, hyper coagulability may be feasible in the early post-operative period of our case whose ITP is meticulously treated prior to surgery. Suitable anticoagulation should have been performed regardless of ITP immediately after MVP.

Elephant trunk prosthesis was devised for treatment of multiple aortic aneurysm. But it has applied to type A aortic dissection. Because residual false lumen often dilates gradually and come to have the risk of rupture. Two patients who were diagnosed as type A aortic dissection were performed total aortic arch replacement with Elephant trunk prosthesis on distal anastmosis. Postoperative diagnostic images showed that residual false lumen of proximal descending aorta were thrombosed. Now it is not necessary to perform next extensive aortic replacement. Complication which is threatened in using Elephant trunk prosthesis, paraplegia, thromboembolism, kinking of prosthesis could have been avoided by setting suitable length and diameter of the prosthesis.

We studied the mid-term results in 191 patients (including emergent operation in 27 patients) who have performed coronary artery bypass grafting (CABG) using the right gastroepiploic artery (REGA) for 74 months (mean follow up period was 37 months). We evaluated the postoperative results in terms of 1. mortality and survival rate, 2. graft angiography, 3. cardiac event free rate and 4. abdominal complications. We had operative death in 6 patients (3.1%) including 3 patients of emergent operations. Late deaths were found in 11 patients (5.9%): 2 patients were cardiac death and 9 were non-cardiac. The actual survival rates were 94.2% at one year, 90.0% at three years and 85.9% at five years. Early patency rate of the RGEA was 98.9% (n = 178). However flow competition between the RGEA and native coronary artery was seen in 42 patients (24.0%). Mid-term patency rate was 96.4% (n = 28). According to mid-term graft angiography, 1 patient improved and 5 patients got worse in comparison with early control. Cardiac event free rates were 98.2% at 1 year, 94.8% at 3 years and 92.7% at 5 years. Abdominal complications were observed in 5 patients (1 patient of bleeding from the RGEA, 1 of gastric perforation, 2 of bleeding from gastric ulcer and 1 of pyloric stenosis) at early period and in 7 patients (2 patients of incisional hernia and 5 of gastric cancer) at long-term period. Early and mid-term results of CABG using the RGEA were quite good. However, the RGEA had a tendency of flow competition against native coronary artery and a problem of gastric cancer after the operation.

Coronary artery bypass grafting using bilateral internal thoracic arteries and inferior epigastric arteries was performed in a 72-year-old man with multiple coronary artery disease who had a history of gastrectomy 25 years before. He postoperatively suffered from ischemic necrosis on anterior chest wall and mediastinitis caused by methicillin resistant staphylococcus aureus and aortic rupture. He got over by drainage at twice, hemostasis of aortic rupture and long-term irrigation using vancomycin. We must not perform coronary artery bypass grafting using bilateral internal thoracic arteries and inferior epigastric arteries at same time.

A 13-year-old girl performed two coronary artery bypass grafting with only left internal thoracic artery. She had no symptoms but was pointed out the abnormality in ECG (ST depression of V4 and V5) at junior high school. According to a coronary angiogram, she was diagnosed as double coronary vessels disease (a total occlusion on the proximal left anterior descending and a stenosis of 90% on the left high lateral artery). She performed sequential coronary artery bypass grafting to the left anterior descending artery and high lateral artery with only left internal thoracic artery. The anastomotic site on the left anterior descending artery showed slight thickness of the internal lumina and chronic inflammation. However they could not detect the pathological diagnosis. The postoperative course was uneventful. The postoperative angiographic control demonstrated a good patency with much blood flow of the left internal thoracic artery graft sequentially anastomosed to the left anterior descending artery and high lateral artery. The postoperative electrocardiogram became normal. She discharged on the 19th postoperative day. The sequential coronary artery bypass grafting with the left internal thoracic artery was effective for infantile ischemic heart disease.

We evaluated inferior epigastric artery (IEA) from the aspect of preoperative and postoperative grafts angiography. Between January 1994 and february 1995, we could perform preoperative and postoperative graft-angiography for 12 patients in 27 patients who were undergone CABG using IEA graft. They were 7 males and 5 females. The age ranged from 56 to 76 years (mean, 66.2 years). We used 12 IEAs, 8 LITAs, 7 RGEAs and 2 RITAs as artrial grafts. We measured the diameter of arterial grafts in each angiography. The preoperative diameter of IEA was measured at three points; the proximal part (Prox), center (Cent) and bifurcation (Bif). The postoperative diameter of IEA was measured at two points; the proximal part of composite graft (Prox) and the distal part (Dist). The preoperative grafts diameters were IEA-Prox = 2.01 +/- 0.40 mm, IEA-Cent = 1.75 +/- 0.39 mm, IEA-Bif = 1.32 +/- 0.29 mm, LITA-Prox = 2.40 +/- 0.25 mm, LITA-Cent = 2.00 +/- 0.24 mm, LITA-Bif = 1.64 +/- 0.22 mm, RGEA-Prox = 2.72 +/- 0.49 mm, and RGEA-Cent = 2.29 +/- 0.34 mm. RGEA was the largest, the second was RITA, the third was LITA and IEA was the smallest of the four. The diameter of IEA-Prox was almost equal to LITA-Cent. The postoperative grafts diameter were IEA-Prox = 1.85 +/- 0.37 mm, IEA-Dist = 1.67 +/- 0.38 mm, LITA-Prox 2.57 +/- 0.11 mm, LITA-before Y = 2.01 +/- 0.22 mm, LITA-after Y = 1.83 +/- 0.14 mm, RGEA-Prox = 2.70 +/- 0.55 mm and RGEA-Dist = 0.53 mm. RGEA was the largest and RGEA-Dist = 2.34 +/- 0.53 mm. RGEA was the largest and IEA was the smallest. The diameter of LITA was not significantly different between before-Y and after-Y. We conclude in view of the graft diameter, LITA-IEA Y composite graft is the best method for CABG using IEA but IEA graft should be used only to myocardial revascularization to the coronary lesion that does not require high blood flow.

We studied the effects of Calafiore technique that is intermittent (every 15 minutes) antegrade warm blood cardioplegia oxygenated and included high potassium solution with normothermic cardiopulmonary bypass. From September 1994 to February 1995, 20 patients having continuously elective coronary artery bypass grafting with arterial conduits alone were randomized to traditional intermittent cold crystalloid cardioplegia and slight hypothermic cardiopulmonary bypass (cold group) or warm heart surgery by Calafiore technique (warm group). Preoperative variables were similar to both groups, as were the intraoperative variables of number of coronary grafts, aortic cross-clamp time, and cardiopulmonary bypass time. Warm group had more rapidly spontaneous defibrillation at cross-clamp removal than cold group. CK on one postoperative day was lower than cold group. Warm group had good results as concern postoperative blood loss volume, intubated time, and change of base excess. Events of PMI (cold, 2 and warm, 0) and need of an intraaortic balloon pump (cold, 2 and warm, 0) were significantly lower in the warm group. We suspected the possibility of vasospasm was lower in the warm group. We concluded warm heart surgery (Calafiore technique) was a best technique for CABG with arterial conduits.

A 70-year-old man underwent replacement of the distal aortic arch which contained a huge aneurysm using a ringed graft. He died suddenly of hemoptysis 54 months following the operation. An autopsy revealed dislodgement of the spool on the posterior aspect of the aorta. Histologic examination of the dislodged portion of the ring showed complete disruption of the intima and elastic fibers of the media. There were minimal histologic changes in the anterior portion of the anastomotic site. It is postulated that the long, kinked graft might have caused the late ring dislodgement.

We discussed upper abdominal complications after 161 coronary artery bypass graftings using right gastroepiploic artery (RGEA). We had one case of bleeding from RGEA branches (1), one case of pyrolus stenosis because of anterior stomach pressed by RGEA (2), three cases of gastric ulcer (3) (three cases with a past history of gastric ulcer, two case with IABP) and one case of gastric perforation (4) as early postoperative complications. As long-term postoperative complications, we had two cases of abdominal hernia (5) and two cases of gastric cancer (6). The cases of number 1, 2 and 3 are solvable because these are technical problem. As concerns gastric mucosal ischemic complications (3.4), long-term antiulcerative medication was required for the patients with gastric ulcer as a past history or with IAPB, RGEA should not be used in case of bad general condition. And as far as gastric cancer is concerned, frequent gastric fiberscopic examinations are necessary after CABG using RGEA for the purpose of finding out early gastric cancer until we can perform culative gastrectomy without cutting RGEA.

We experienced a surgical case of aortic dissection (Stanford type A) with annuloaortic ectasia in Marfan Syndrome. A 45-year-old female who had been diagnosed as Marfan Syndrome three years age was emergently admitted to our hospital with sudden chest pain. We diagnosed this case as aortic dissection of Stanford type A by ultrasonic cardiogram and thoracic CT. The ascending aorta was replaced with composite graft by modified Bentall procedure, right coronary artery was bypass to segment 2 using vein graft and left coronary artery was interposed by Dacron graft. During operation we utilized retrograde cold blood cardioplegia for cardiac arrest (180 min.) and retrograde cerebral perfusion accompanied with total circulatory arrest (45 min.). No complication such as cardiac damage and cerebral damage was found postoperatively. We discussed surgical method for aortic dissection with anuloaortic ectasia in particular reconstruction of coronary artery, cardioplegia and cerebral protection.