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We evaluated the early outcome of surgical treatment of thoracic aortic disease combined with coronary artery bypass grafting (CABG). Between January 2001 and December 2007, a total of 22 patients underwent thoracic aortic surgery with CABG. Four patients had an emergency operation performed for acute type A aortic dissection (group D). Three patients with a dissection of the right coronary artery (RCA) and 1 patient with cardiac ischemia during operation underwent CABG. One of the 18 patients with non-dissecting aneurysm (group N) underwent CABG due to injury of RCA. A comparative study was made between the study groups and a control group of 68 patients (group S) who underwent thoracic aortic replacement without CABG. Hospital mortality was 4.5% (1/22 patients) due to low output syndrome. There were significant differences in operation time, total cardiopulmonary bypass time and cardiac arrest time between groups D and N, and between groups N and S. There was also a significant difference in ventilation time and the duration of stay in the intensive care unit between groups D and N. However, there were no significant differences in postoperative complications among all the groups. This operation provides satisfactory early clinical outcomes. Thoracic aortic surgery combined with CABG can be carried out safely in elderly patients.

We report a case of 44-year-old male with aortitis syndrome who suffered a prosthetic aortic valve detachment and recurrent aneurysm of sinus of Valsalva 5 years after aortic valve replacement and patch closure of non-coronary sinus of Valsalva. Preoperative computed tomography (CT) and angiography revealed severe aortic regurgitation and complicated aneurysm formation of sinus of Valsalva due to prosthetic valve and prosthetic patch dehiscence. Aortic root replacement was performed successfully after induction of steroid therapy to control inflammation. His postoperative course has been uneventful for 18 months.

An 85-year-old woman was admitted to the hospital for a lumbar compression fracture. Her white blood cells and C-reactive protein (CRP) were elevated to 20,400/microl and 30.58 mg/dl, respectively. Chest and back pain occurred suddenly, 16 days after admission. Computed tomography revealed aortic arch aneurysm and bleeding. Rupture of the aortic arch aneurysm was diagnosed and she was transferred to our hospital for an emergency operation. The aneurysm was treated by debridement of the infected aortic tissue, and total aortic arch replacement was performed. Bacterial culture of the aneurysmal wall demonstrated methicillin sensitive Staphylococcus aureus (MSSA). Her postoperative course was uneventful. After surgery, antibiotics were administered for 2 weeks intravenously and orally. However oral antibiotics were administered again for about 2 months because wound infection occurred on the day 37 and 60 postoperatively. CRP normalized during her course of antibiotic therapy. Thereafter, the patient remained well without any sign of wound infection or mediastinitis.

A 64-year-old man with a history of hypertension was admitted to another hospital, presenting with sudden chest pain. Although his symptoms resolved after admission, chest computed tomography (CT) revealed acute type A aortic dissection, and he was referred to our hospital for surgery. On arrival, his hemodynamic status was stable. Electrogram showed no ST-T change, and transthoracic echocardiography demonstrated pericardial effusion, mild aortic regurgitation and good left ventricular wall motion. We immediately decided on an emergency operation. Commencing a median sternotomy, the pericardial cavity was found to be filled with old blood. Standard cardiopulmonary bypass was instituted with right atrial drainage and right femoral arterial return, and with right upper pulmonary venous venting. When antegrade cold blood cardioplegia was selectively administered, we noticed the partial disruption of the upper aspect of the right coronary ostium. The right coronary sinus was resected in a scallop shape. Partial aortic root remodeling using a trimmed tube graft and coronary artery bypass grafting to the right coronary artery with saphenous vein were performed under deep hypothermic circulatory arrest. Weaning from cardiopulmonary bypass was not difficult. The postoperative course was uneventful.

A 65-year-old man and a 51-year-old man underwent mitral valve repair for commissural prolapse due to infective endocarditis. On the occasion of repairing, folding plasty technique was employed to avoid relatively large annular plication after leaflet resection. Postoperative echocardiography showed no residual regurgitation and sufficient orifice area of the mitral valve. Folding plasty technique appeared to be simple and useful for repairing commissural prolapse due to infective endocarditis.

We report a case of 63-year-old male who suffered from aortic dissection associated with pseudoaneurysm 21 years after aortic valve replacement. Preoperative computed tomography (CT) scan and aortography revealed DeBakey type I dissecting aneurysm with maximum diameter of 70 mm on ascending aorta and calcified pseudoaneurysm at previous aortotomy. He underwent modified Bentall procedure preserving previous mechanical valve and total aortic arch replacement with elephant trunk technique. Postoperative course was uneventful.

A 63-year-old woman had undergone graft replacement for abdominal aortic aneurysm in 1992, and coronary artery bypass grafting (CABG) using saphenous vein grafts in 1995. At that time arch aneurysm (4.7 cm) was pointed out. Chest computed tomography (CT) showed dilated arch aneurysm (7 cm) in 2000. We performed an operation for arch aneurysm. As the bypass graft to obtuse marginal branch was close to aneurysm, aortic closs clamp was impossible. So we injected potassium chloride to aortic root and cardiac arrest was obtained. Total arch replacement for arch aneurysm was performed and postoperative course was uneventful.

We report a case of 62-year-old male who suffered from a distal aortic arch aneurysm developed 5 years after coronary artery bypass grafting (CABG). Preoperative angiography revealed a distal arch aneurysm and a patent left internal mammary artery (LIMA) graft. Graft replacement of the total aortic arch was performed using a 4 branched graft. After the re-median sternotomy, cardiopulmonary bypass was established with ascending aortic perfusion and right atrium (RA) drainage. Myocardial protection was achieved with root cold blood cardioplegia and LIMA continuous cold blood perfusion. Distal anastomosis was performed under selective cerebral perfusion and during deep hypothermic circulatory arrest. Postoperative course was satisfactory and the patient was discharged without complications.

Management of severe tricuspid regurgitation late after left heart valve operation is controversial. There has been reluctance to the operation due to the high risk of repeat operation, coexistent right ventricular dysfunction and pulmonary hypertension. We investigated 6 cases of isolated tricuspid valve surgery (tricuspid valve replacement: 2, tricuspid valve plasty: 4) late after left heart valve operation. Before operation, these patients showed poor general condition (4 cases were NYHA III or IV) but good left ventricular function [mean ejection fraction (EF) 66 +/- 9.6%]. Hospital mortality was 0% and the mean mid-term actual event-free survival over 2 +/- 1.8 years was 80%. Most of patients demonstrated NYHA I and improvement of hepatomegaly after operation. There were many complications in 2 cases that had been performed previous operation more than 20 years before. In summary, the patient who complained symptoms due to right heart ventricular failure and showed good left ventricular function after left heart valve surgery should be considered to undergo tricuspid valve operation before the occurrence of other complications.

A 39-year-old man has complained of palpitation and dyspnea since 8 months ago. With aortic regurgitation pointed out in another hospital, he was referred to our hospital for examination. Preoperative ultracardiography (UCG) showed a dilated noncoronary sinus of Valsalva and aortic regurgitation. A daughter aneurysm was found by aortography. There were 2 perforations and 1 pouch at the noncoronary sinus cusp (NCC). The noncoronary sinus of Valsalva was dilated and the orifice to the daughter aneurysm was noticed. The noncoronary sinus of Valsalva was obliterated by suturing a dacron patch on the orifice. The aortic valve was replaced with ATS 23 mm valve. Postoperative computed tomography (CT) showed clot formation outside the patch.

A 74-year-old woman was pointed out distal arch aneurysm 4 years ago in another hospital. As the diameter has gradually increased, the operation was considered. At first a pig tail catheter was inserted from the right femoral artery to aortic arch in the cardiac catheterization laboratory. In the operating room, stent-graft was inserted using pig tail catheter. Post operative CT showed clot formation outside the stent-graft. This procedure was thought to be less invasive and safe.

A 10 month-old infant with Down syndrome having ventricular septal defect and pulmonary hypertension performed cardiac catheterization, which resulted in a slight increase in the pulmonary vascular resistance from 10.8 to 11.3 unit.m2. Lung biopsy findings showed at most an early grade 2 Heath-Edwards classification, and an index of pulmonary vascular disease of 1.1, both of which indicated operability for total correction. He underwent surgical correction and the pulmonary arterial pressure significantly decrease. Although he suffered chylothorax in 5th postoperative day, he did not developed pulmonary hypertension crisis.

We experienced two surgical cases of MR associated with extensive calcification of the mitral valve annulus. For two cases we performed MVP which consisted of valve repair and annular remodeling. Annular remodeling was performed only on the annulus without calcification using 3 mm Gore-tex graft, because calcified annulus did not contribute to annular dilatation and would not dilate in the future. Both patients recovered uneventfully. Postoperative echocardiography revealed no MR in both cases.

A 67-year-old man with a twenty-year history of effort angina was referred to our hospital. He underwent successful PTCA for the right coronary artery and diagonal branch. However, his angina recurred three months after PTCA due to restenosis and he was recommended to undergo CABG. Because he had concomitant bilateral internal carotid artery stenosis and aneurysm of the brachiocephalic artery, we chose two-staged operation strategy to avoid cerebrovascular complication during CABG. First, he underwent bilateral carotid endarterectomy (CEA), and then he underwent concomitant CABG and grafting of brachiocephalic artery 12 days after CEA. After these operations he recovered uneventfully without neurological complication.

We evaluated a method of mitral valve plasty (MVP) for ischemic mitral regurgitation (IMR) by examining the morphological changes of the mitral valve. From November 1992 to May 1998, 8 patients (M : F = 4/4, age 44-79 years, mean age 65.1 years) with IMR underwent surgical repair. Preoperative mitral regurgitation (MR) was grade III of Sellers classification in 7 patients and grade IV in 1 patient. The cause of MR was mitral valve annular dilatation in 4 patients, mitral valve prolapse due to papillary muscle elongation in 2 patients, and partial papillary muscle rupture (PMR) in 2 patients. Cardiac surgery consisted of CABG + MVP in 7 patients and MVP in 1 patient. Mitral valve repair was separated into three types. Repair for annular dilatation consisted of commissuroplasty in 3 patients (2 patients Kay method, 1 patient Reed method) and ring annuloplasty using a Carpentier-Edwards ring (C-E ring) in 1 patient. Repair for papillary muscle elongation consisted of papillary muscle shortening and ring annuloplasty using a C-E ring. Repair for partial PMR consisted of papillary muscle implantation and ring annuloplasty for anterior leaflet prolapse in 1 patient, and quadrangular resection, posterior leaflet plasty (McGoon method) and ring annuloplasty in 1 patient. There was no hospital death. Postoperative outcome was 6 patients with no MR and 2 patients with grade II MR, but they were well-controlled with medication. Based on the morphological changes of the mitral valve, it is considered that MVP for IMR is an effective and recommended procedure.

We experienced a 42-year-old patient who underwent aortic valve replacement and a 63-year-old patient who underwent coronary artery bypass grafting with mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA). They were successfully treated with the intermittent mass-irrigation technique. The irrigation device consistent of a irrigation tube which placed in upper half of mediastinum and three suction tubes which placed in lower half. We dripped the wash composed of 0.03-0.05% of Povidone-Iodine with 1,000 ml of physiological saline, for 3 to 5 times a day by condition. After each wash, we cross clamped the drainage tubes and filled mediastinum with 0.5 grams of vancomycin hydrochloride dissolved in 100 ml of physiological saline, dripped from irrigation tube, for 30 minutes. After 9-day irrigation in the former case and 16-day irrigation in the latter case, the culture of drainage turned negative. We presumed that this new method is effective for mediastinitis after cardiovascular surgery.

A 41-year-old woman was referred to our hospital due to dyspnea and cyanosis. Echocardiography revealed a right atrial tumor with right to left shunt through PFO. There was no evidence of pulmonary embolism from the tumor. The tumor was removed under cardiopulmonary bypass and PFO was closed. The patient is doing well now.

A 63-year-old woman with atrial septal defect, mitral regurgitation, and tricuspid regurgitation underwent mitral valvuloplasty with 30 mm Carpentier ring, patch closure of atrial septal defect and tricuspid annuloplasty with 36 mm Carpentier ring. She was doing well now. In this case, preoperative catheterization showed left-to-right shunt ratio of 32% and right-to-left shunt ratio of 51%. The existence of right-to-left shunt was considered to be related to the grade of tricuspid regurgitation. It is concluded that in these cases, surgical repair should be recommended before the onset of severe progressive heart failure.

A 69-year-old man was referred to us with the diagnosis of abdominal aortic aneurysm (7 cm in diameter). Additionally his coronary arteriogram showed severe stenosis (LMT 75% and #6 99% delay). Because his ascending aorta was calcified severely, double CABG (LITA to LAD and RGEA to PL) was carried out in hypothermic ventricular fibrillation. Abdominal aortic aneurysm was replaced thereafter while the patient was still on cardiopulmonary bypass. His postoperative courses was satisfactory. In cases requiring early operation for both myocardial ischemia and abdominal aortic aneurysm, one stage operation was recommended. When atherosclerotic changes in the ascending aorta were severe, in situ arterial bypass grafting for ischemic heart disease under hypothermic ventricular fibrillation was useful.

Valve replacement for aortic regurgitation in patient with rheumatoid arthritis was rare in Japan. We report a successful case in which aortic regurgitation necessitated aortic valve replacement. A 62-year-old woman was admitted for shortness of breath, chest pain and progressive edema. She had been treated for rheumatoid arthritis for more than ten years using steroids. The aortic valve was successfully replaced by a prosthetic mechanical valve. The histopathological examination of the excised aortic valve demonstrated rheumatic nodules in the right- and non-coronary cusp. It was supported that these changes caused shrinkage of cusp and resulted in aortic regurgitation. This patient was discharged on the 20th postoperative day. There was no evidence of detachment of the prosthetic valve.

A 67-year-old female patient underwent a left ventricular aneurysmectomy and mitral valve replacement for ischemic cardiomyopathy. The replacement was done through left ventricle rather than left atrium. She had heart failure of NYHA class IV despite aggressive medical therapy. Preoperative examination revealed a left ventricular aneurysm and mitral regurgitation of grade II with markedly reduced ventricular function (LVEF 17%). Mitral valve replacement through left ventricle preserving chorda of the mitral valve is a promising method to eliminate regurgitation and shorten the cardiac ischemic time.

The etiology of the papillary muscle rupture includes myocardial infarction, trauma, hypertension, myxomatous degeneration, endocarditis etc. We report a case of partial papillary muscle rupture whose etiology was unknown, in a 77-year-old woman. The preoperative catheterization and coronary angiography showed severe mitral regurgitation and no significant coronary stenosis. And we recognized the mass waving into the left atrium in systole with the echocardiogram. At surgery, we repaired the mitral valve by resecting quadrangular areas of the posterior leaflet including the attachment of the torn papillary muscle. Additionally a number 28 Carpentier-Edwards mitral annuloplasty ring was sewn in place. In pathologic specimen, there were focal fibrosis, necrotic muscle, lymphocytes, and no vegetation.

A case of a 42-year-old man with ruptured aneurysm of the sinus Valsalva resulted in tricuspid valve endocarditis was reported. The aneurysm originating from the right sinus Valsalva ruptured into the right atrium, which caused tricuspid valve endocarditis. The aneurysm was closed through right atrial approach. A part of the septal leaflet of tricuspid valve including vegetation was resected and repaired.

A 67-year-old female patient underwent mitral valvuloplasty for mitral regurgitation due to the chordal rupture at the posterior commissure. Sliding commissuroplasty was made to avoid large annular plication. Carpentier's prosthetic ring (30 mm) was sutured to remodel the annulus and to reinforce repair. Postoperative Left ventriculogram revealed no regurgitation. Sliding commissuroplasty is effective for mitral regurgitation due to commissural chordal rupture.

A 63-year-old male patient with both coronary artery disease and leg ischemia was successfully treated with a combined procedure. Coronary arteries were bypassed with the saphenous vein graft and in situ left internal mammary artery, and bilateral femoral arteries were bypassed with expanded polytetrafluoroethylene grafts descended from the ascending aorta through the preperitoneal abdominal wall tunnel. After this procedure he experienced neither angina nor claudication.

Survival to seventh decade with tetralogy of Fallot is uncommon. Herein we report a successful repair of tetralogy of Fallot combined with aortic valve replacement for concomitant aortic valve regurgitation in a 65-year-old woman. She had been in severe congestive heart failure and respiratory failure, and also showed liver and renal dysfunction preoperatively. Postoperative course has been good but ventricular arrhythmia of Lown grade II persisted.

A 68-year-old male patient with a left atrial myxoma, mitral regurgitation, ischemic heart disease and abdominal aortic aneurysm underwent resection of the myxoma, mitral valve replacement, 4 coronary artery bypass grafting and replacement of the aneurysm simultaneously. The aneurysm was replaced under partial cardiopulmonary bypass. Combined cardiac and abdominal aortic operation is useful in selected patients who require IABP support postoperatively or whose cardiac function is poor.

A case of right atrial rupture with cardiac tamponade due to a traffic accident is reported. By thoracic CT, we diagnosed this condition and successfully repaired the ruptured site five hours after injury. Early diagnosis of cardiac rupture is always very difficult, but at any time in nonpenetrating injury, we must treat patient under suspicion of this disease.

A simple method to wrap the graft in repair of acute aortic dissection was described. The diseased ascending aorta was excised and both ends of the aorta were trimmed with application of a Teflon felt inside and a preserved equine pericardium outside. The graft was anastomosed to the trimmed ends and the equine pericardiums were turned and sutured around the graft. Two additional sutures were tied around the equine pericardium to reinforce oppression. This simple technique is very useful to control oozing from the suture lines.

A 57-year-old male patient with aortic regurgitation and aneurysm of the ascending aorta and the aortic arch underwent aortic valve replacement and graft replacement from the ascending aorta to the aortic arch. The operation was done using cardio-pulmonary bypass and selective cerebral perfusion with deep hypothermia. Postoperative DSA revealed no dilatation of the sinus Valsalva and a good configuration of the anastomosis. It seems that selective cerebral perfusion with deep hypothermia is a safe method to prevent cerebral damage in a case of arch aneurysm.