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An 84-year-old woman with a history of surgery for cholangiocarcinoma presented to Akita University Hospital with severe right lower abdominal pain, respiratory distress, and hypotension. Computed tomography scanning revealed a ruptured right common iliac artery aneurysm with a massive right retroperitoneal hematoma and a right internal iliac artery aneurysm. Under the bilateral retroperitoneal approach, we preformed an in-situ repair of an aneurysm rupture from the aorta to the left common and right external iliac arteries using a bifurcated knitted Dacron graft, and then we ligated the right internal iliac artery. The postoperative course of the patient was uneventful. The patient was discharged from hospital 52 days after surgery. In conclusion, a bilateral retroperitoneal approach may be a safe and useful strategy for in-situ repair of a right iliac artery aneurysm rupture in patients with peritoneal adhesions after transperitoneal abdominal surgery.

We report a reoperative case in which a Valsalva graft was utilized on a 64-year-old woman who had previously undergone emergency repair of a DeBakey type I acute aortic dissection. On follow-up computed tomography (CT), she was found to have pseudoaneurysms of both proximal and distal anastomoses. We performed valve-sparing aortic root replacement (VSRR) with the reimplantation technique and total arch replacement, since we felt that a graft with pseudosinuses helps to prevent torsion of the coronary arteries. The postoperative course was uneventful, and postoperative echocardiography revealed no significant aortic valve regurgitation. The pathology results raised the hypothesis that pseudoaneurysm formation might have been related to the use of gelatin-resorcinol-formaldehyde (GRF) glue at the time of the initial intervention.

We verified the significance of 3-dimensional (3D) spectral mapping during atrial fibrillation (AFIB) using a 64-channel magnetocardiogram (MCG). The study consisted of 16 patients with valvular heart disease who had chronic AFIB. All 16 patients had surgical pulmonary vein (PV) isolation followed by valvular repair. We performed spectral mapping by fast Fourier transform analysis in nonaveraged 64-channel MCG data. The 3D spectral map was superimposed on a 3D heart polygon. At 1 year after surgical PV isolation for AFIB, followed by valve repair, 7 patients had restoration to sinus rhythm, and 9 patients remained in persistent AFIB. The preoperative mean 3D frequency of AFIB was 6.1 +/- 0.9 Hz in patients with restored sinus rhythm and 7.2 +/- 0.7 Hz in patients with sustained AFIB after PV isolation (P = .02). In addition, the preoperative 3D spectrum was distributed on the right side of the heart in patients with persistent AFIB. In conclusion, 3D spectral mapping using 64-channel MCG may represent a meaningful noninvasive strategy for patients with AFIB who receive an interventional procedure.

Objectives: Vitamin K epoxide reductase (VKORC1) is the drug target for inhibition by coumarin-based anticoagulant drugs such as warfarin. Warfarin therapy has been reported as a leading cause of drug-related hospitalization and there is therefore an urgent need to develop tests for better warfarin prescription. We report here the distribution of the intron 1 -136 T>C (1173 T>C intron) polymorphism of VKORC1, previously reported to be associated with warfarin maintenance dose in Caucasians and Japanese, in several ethnic populations from Japan and Israel, and describe its significance for warfarin dosage in Japanese cardiovascular surgery patients., Methods: Subjects consisted of 132 Japanese individuals and 341 Israeli individuals from four Jewish ethnic groups (86 Ashkenazi Jews, 95 Yemenite Jews, 73 Moroccan Jews and 87 Libyan Jews). In addition, 31 Japanese patients receiving warfarin therapy after cardiovascular surgery, maintained with a target International Normalized Ratio, were studied. The genotyping for the 1173 T>C intron polymorphism of VKORC1 was determined using rapid real-time PCR., Results: The allele frequency of the combined VKORC1 1173 CT and CC genotypes varied among the four Israeli ethnic groups and was, on average, much higher in the Israeli (0.728) than in the Japanese population (0.152). For the Japanese cardiovascular surgery patients, the maintenance dose of warfarin was significantly larger in the combined VKORC1 1173 TC and CC genotype group than in the 1173 TT genotype group (3.6 +/- 0.5 mg vs 2.8 +/- 0.7 mg, respectively; p = 0.02)., Conclusion: The frequencies of the intron 1 VKORC1 1173 T>C SNP show significant differences between ethnic groups and are associated with warfarin dose requirements for achieving a recommended International Normalized Ratio range in Japanese cardiovascular surgery patients. This study supports the example of warfarin as an appropriate model for applying personalized medicine for anticoagulant drugs, and highlights the importance of ethnicity in pharmacogenetics.

Background: QT dispersion reveals heterogeneities in the repolarization time in the three-dimensional (3D) structure of the ventricular myocardium. In this study, we report on a 3D function map of recovery time (RT) dispersions as measured by 64-channel magnetocardiography (MCG)., Methods: MCG were simultaneously recorded in 29 controls and 21 patients with previous myocardial infarction (MI). The 3D current density was calculated from 64-channel MCG data in the Bz component using a space filter. The heart outline, reconstructed from the integrated the current density, revealed both the atrium and ventricle. The RT for the intervals between QRS onset and the time of the maximum dT/dt of T wave, and the peak to the end of the T wave (T(peak)-negative dT/dt) were automatically measured by means of a computer from 3D MCG data. The corrected RT (RTc) and corrected T(peak)-negative dT/dt were then calculated using Bazett's formula. The 3D RTc and the corrected T(peak)-negative dT/dt dispersion map were superimposed on the heart outline generated by MCG., Results: The RTc was significantly longer for the MI group than in the control group (67+/-25 ms1/2 vs. 16+/-6 ms1/2) (p<0.0001). The corrected T(peak)-negative dT/dt dispersions in each patient was also significantly longer for the MI group than in the control group (35+/-27 ms1/2 vs. 10+/-5 ms1/2) (p<0.0001). Furthermore, the 3D RTc and T(peak)-negative dT/dt dispersion maps corresponded with the space location of MI, as defined by Tc-99m tetrofosmin myocardial imaging, Conclusions: 3D RTc and T(peak)-negative dT/dt dispersion maps in the ST segment, obtained by 64-channel MCG may be used demonstrate the location of a myocardial injury and heterogeneities of repolarization.

Population of elderly people is increasing and aortic valve disease due to degeneration with aging process, especially aortic stenosis (AS) is increasing in elderly patients. With development and great use of non-invasive diagnostic techniques, particularly echocardiography, the diagnosis and evaluation of aortic valve disease are even safer in these patients. Aortic valve replacement (AVR) is effective treatment for symptomatic AS, however, generally has a higher risk in elderly patients, especially 80 years and over patients. Several reports demonstrated acceptable operative mortality and morbidity in elderly patients. We performed AVR or AVR with other cardiac surgical procedures in 16 cases of 80 years and over patients from 1998 to 2004, and there were no operative or hospital death. Therefore, AVR in 80 years and over patients could be acceptable surgical treatment and age alone is not contraindication.

A 59-year-old women was referred to our hospital due to severe dyspnea and shock status 12 days after intracranial hematoma evacuation for the hypertensive right putaminal hemorrhage. Transthoracic echocardiography revealed right ventricular dilatation and floating structures in the right atrium. Transesophageal echocardiography demonstrated a large, snake-like structure crossing her foramen ovale of the interatrial septum, and impending paradoxical embolism was diagnosed. She did not receive any anticoagulation and surgery due to recent cerebral hemorrhage. Follow-up TEE showed complete disappearance of the thrombus in the atrium two weeks after the onset. Phlebogram of deep vein demonstrated several thrombus in her leg. She underwent placement of inferior vena cava filter and was discharged from our hospital without any symptom of paradoxical embolism.

In this study, we analyzed the extent and pattern of regression of left ventricular (LV) hypertrophy after aortic valve replacement in patients with aortic stenosis (AS) and compared the results with those of another group of patients with aortic regurgitation (AR). Seventy patients who underwent isolated aortic valve replacement were divided into 2 groups. Group 1 was comprised of 29 patients who underwent aortic valve replacement for aortic stenosis, and Group 2 of 41 patients who underwent aortic valve replacement for aortic regurgitation. A third group of 10 healthy subjects served as a healthy control group. Echocardiographic studies were done before the operation and 5 years postoperatively. At follow-up, a significant reduction in the left ventricular mass was found in both groups, but it remained significantly greater than in the healthy control group. The ratio of LV wall thickness to radius (th/r) in Group 1 decreased significantly, and at follow-up it was within the normal value. In Group 2, the th/r ratio increased, and at follow-up it was within the normal value. After aortic valve replacement, the wall thickness remained significantly greater than normal for patients with AS, and the chamber radius remained significantly greater than normal for patients with AR. For these reasons, LV hypertrophy still existed in both groups at postoperative follow-up. The actuarial survival rate was 85.3% at 16 years for Group 1 and 83.4% at 18 years for Group 2. There was no significant difference in the long-term survival rates between the 2 groups. Actuarial freedom from valve-related events was 91.9% at 16 years for Group 1 and 82% at 18 years for Group 2. There was no significant difference in the valve-related event free curves between groups. After 5 years of follow-up, th/r reached normal for both groups, indicating remodeling of the LV geometry after aortic valve replacement.

The purpose of this report is to describe the clinical characteristics and surgical technique for splanchnic artery aneurysms. Over the past 10 years we have surgically resected 8 cases of splanchnic artery aneurysms including 2 cases involving the superior mesenteric artery, 3 involving the renal artery, 1 involving the hepatic artery and 2 involving the splenic artery. Diagnosis was established preoperatively in all patients by splanchnic angiography. Surgical treatment for splanchnic artery aneurysms is indicated in any symptomatic patient, in all symptomatic patients with suspected renal aneurysmal expansion and in patients who have renal aneurysms occurring with functionally important renal stenosis, usually associated with hypertension, in all patients with surgical accessible hepatic artery aneurysms, in all patients who have superior mesenteric artery aneurysms having a high tendency to rupture, and in all patients with an asymptomatic splenic artery aneurysms 1.5 cm or larger in diameter. Although splanchnic artery aneurysms are uncommon and asymptomatic, we recommend that splanchnic arteries should be treated surgically because of their tendency to rupture or organ failure.

Ruptured fusiform descending thoracic aortic aneurysms due to aortitis syndrome are rare. A 29-year-old woman was readmitted to our hospital with a chief complaint of back pain and shock, and diagnosed as having rupture of a descending thoracic aortic aneurysm. She had a past history of aortitis syndrome beginning eight years ago. On chest CT examination earlier a year, the descending thoracic aortic aneurysm was 4.5 cm in diameter, and calcification we observed in the aortic wall. An inflammatory reaction had been controlled by steroid therapy and her blood pressure had been controlled by vasodilator drugs. Emergent graft replacement of a descending aortic aneurysm was successfully performed under a femoro-femoral bypass using a centrifugal pump and membrane oxygenerator, and Cell Sver. Although in the literature surgical treatment is indicated only if there is a symptomatic or enlarging aneurysm especially of saccular type and no operation is justified for an aortic aneurysm showing marked calcification, we concluded that aggressive surgical treatment was necessary for this fusiform aneurysm due to aortitis syndrome.

A 48-year-old man was readmitted to our hospital with a chief complaint of left anterior chest mass. He had a past history of thymo-thymomectomy six years earlier. On chest CT examination, multiple tumor shadows were noted within the left thoracic cavity. All visible tumors were resected. His postoperative course was favorable, and no signs of recurrence have been recognized on CT to date (three years and six months postoperatively). However, in view of the possible recurrence of the present disease after a long period, strict observation of the course of the disease is necessary.

During a 20-year period, 364 patients underwent coronary artery bypass grafting (CABG) for the treatment of ischemic heart disease. Among these patients, 28 underwent emergency surgery. The reasons for performing emergency CABG were unstable angina in 15 patients, impending myocardial infarction in 12 patients, and congestive heart failure in 1 patient. Eleven patients died postoperatively. Eight variables were examined by univariate analysis for their influence on the occurrence of a hospital death. IABP and acute coronary occlusion were found to be predictors of hospital death and previous myocardial infarction was a predictor of hospital survival. Seventeen patients were followed up for 12 years. There was no cardiac death and actuarial survival at 12 years was 63%. The 14 survivors are now in NYHA functional class I or II. Although the operative mortality rate is high after emergency CABG, the patient's prognosis is good.

Underlying cardiac lesions in 39 adult cases with infective endocarditis were studied. 18 cases (46%) of the patients had no evidence of preexisting cardiac disease and infection frequently involved aortic valve. The patients without preexisting cardiac disease and 4 patients with an intracardiac substitute including pacemaker lead and aortic valve prosthesis required a surgery during an active infective endocarditis. All cases of active infective endocarditis accompanied with rheumatic valvular disease underwent surgery after a suppression of active inflammation by medical treatment.

We experienced a case of 47-year-old man who suffered swallowed fish bone-induced esophageal perforation with purulent mediastinitis and underwent direct suture closure of the perforation and reinforcement with a pedicled parietal pleura four days after the onset. Postoperative esophageal suture insufficiency was occured and reoperation was performed two months after the first operation. The esophageal fistula was plugged with a pedicled omental graft successfully. The postoperative course of the patient was uneventful and he discharged 45 days after the second operation. A reinforcement by pedicled omental graft for esophageal rupture accompanied with mediastinitis was considered to be a useful procedure.

Total anomalous pulmonary venous drainage (TAPVD) is a rare congenital cardiac anomaly. It occurs in only 1.5% of children born with congenital heart defects. But, it is one of the most common lesions necessitating intracardiac operation in the neonatal period. We have experienced a 33-year-old man with supracardiac type TAPVD who was operated upon successfully. Cardiac catheterization showed 0.35 in Pp/Ps, 3.33 in Qp/Qs and 0.11 in Rp/Rs. The left to right shunt ratio was 77%, while the right to left shunt ratio was 23%. The operation was composed of anastomosis between the left atrium and the common pulmonary vein, patch closure of the atrial septal defect, ligation of the vertical vein and tricuspid annuloplasty. The posterior approach was adopted in anastomosis between the left atrium and the common pulmonary vein. The association of a normal pulmonary vascular resistance, a large interatrial communication and absence of a pulmonary venous obstruction was considered as factors of a favorable result.

A totally implantable motor-driven left ventricular assist device (LVAD) has been developed and tested. The performance of this LVAD was tested in a mock circulatory system. This pump provided 8 L/min of output against a mean afterload of 120 mm Hg with a filling pressure of 20 mm Hg when the pump was operated in the fill/empty mode. The right and left pumps were tested in a mock loop. The right pump afterload was kept in the range from 23-32 mm Hg. With increase in the left pump afterload, the pump power output varied from 1.64 to 2.37 W. The instantaneous motor power input varied from 22.6 to 30.6 W with the total system efficiency ranging from 6.7 to 9.4%. To date, 4 in vivo studies have been conducted for up to 12 h. Two animals survived 12 and 10 h, respectively. Termination was due to bleeding in 1 animal, vent tube obstruction in 1, and respiratory failure in 2. All animals died of technical failure. Another experiment is to be undertaken, and a newly designed cannula is now being manufactured.

Although the protective effects of the calcium antagonists on ischemic and reperfused myocardium have been investigated, there have been only a few reports regarding their efficacy in relation to the degree of ischemic myocardium. This study was undertaken to investigate the efficacy of diltiazem, a calcium antagonist, in relation to the degree of ischemic myocardial injury in an isolated working rat heart. Three different models of ischemic injury were designed; Group A: 30 min global ischemia with a single dose infusion of St. Thomas' cardioplegic solution (STS), Group B: 60 min global ischemia with multidose infusion (every 30 min) of STS and Group C: 60 min global ischemia with multidose infusion (every 15 min) of STS. These groups received only STS, while Groups A-D, B-D and C-D (the treated groups) received the same solution with diltiazem (0.5 mumol/l). The recovery of post-ischemic cardiac function and the CPK leakage during reperfusion were evaluated, and the two groups were compared. For 30 min global ischemia, the addition of diltiazem to STS significantly improved the percentage recovery ratio of aortic flow (63.2 +/- 8.6% vs 79.9 +/- 5.9%, control vs. diltiazem, p < 0.01) and reduced CPK leakage during reperfusion (87.5 +/- 35.8 IU/20 min/g dry wt vs. 41.7 +/- 14.5 IU/20 min/g dry wt, control vs. diltiazem, p < 0.05). However, no differences in the post-ischemic functional recovery and CPK leakage were noted between the groups for 60 min global ischemia. In conclusion, for myocardial preservation, the addition of diltizaem to St. Thomas' cardioplegic solution was less effective for the 60 min global ischemia. Regarding severe myocardial ischemia, it was suggested that, inhibitation or suppression of calcium channel by diltizaem might insufficient to obtain additional protection of the St. Thomas' cardioplegic solution. Therefore, it would be necessary to control calcium entry through another pathway during ischemia and reperfusion.

A case of rare thymic squamous cell carcinoma was reported. A 46-year-old female was admitted to our hospital because of an abnormal shadow on chest X-ray. Chest CT showed anterior mediastinal tumor and histological diagnosis of squamous cell carcinoma was made by needle biopsy under CT guide. Esophagus and lung were no abnormal findings, we thought the primary region was thymus. On mid-sternotomy, anterior mediastinal tumor was resected with thymus, right phrenic nerve and pericardium, however it was not direct invasion to heart, great vessels, lung and chest wall. Resection of peripheral fatty tissue and dissection of mediastinal lymph nodes as much as possible, it was not capsular invasion and mediastinal lymph nodes metastasis and complete curative resection was able to perform. Additional radiation therapy was done, post-operative course was uneventful.

A 20-year-old man was admitted to our hospital because of an abnormal shadow on chest X-ray Laboratory data revealed a high serum alpha-fetoprotein (AFP) and LDH level. Percutaneous needle biopsy of the tumor suggested primary mediastinal germ cell tumor. Curative resection was performed after three courses of combination chemotherapy (cis-platinum, VP-16, bleomycin and adriamycin). A post-operative histological examination of the mass revealed total necrosis. Post-operative course was uneventful, and he has been free of recurrence for the last six months.

Between 1975 and 1993, 16 of 95 patients who received open mitral commissurotomy for mitral stenosis required reoperation for recurrent mitral lesions with a mean duration of 11 years after the initial operation at Kawasaki Medical School Hospital. The mitral lesions necessitating reoperation involved restenosis in eight, stenoinsufficiency in six and regurgitation in two. In 13 patients, mitral commissure was well separated, and the mitral restenosis and regurgitation were caused by progressions of valvular and subvalvular lesions. Significant tricuspid valve regurgitation was also seen in nine patients, and in seven out of eight patients who were in NYHA functional class III or IV, tricuspid regurgitation of grade 3 was observed. The combined tricuspid regurgitation aggravated the patient's symptoms and became a major risk factor of the reoperation after open mitral commissurotomy.

The case of a 56-year-old man who underwent mitral valve replacement due to HOCM complicated by IE and MR is reported. Preoperative 2D echocardiographic assessment of the mitral valve revealed systole anterior motion (SAM) and vegetation, and color flow Doppler echocardiographic examination revealed severe mitral regurgitation. The left ventricular out-flow tract gradient decreased from 140 mmHg preoperatively to 60 mmHg postoperatively. Mitral valve replacement should be considered in patients with associated IE and severe MR.

A 54-year-old man with an acute retrograde type I dissecting aneurysm of the aorta underwent three operations for four years. The first operation was by the Collins method, the second was a graft replacement of the descending aorta, and the third involved a graft replacement of the ascending aorta and aortic arch, revascularization of the aortic branches and replacement of the aortic valve. In operations on acute retrograde type I dissecting aneurysms of the aorta, the methods of Koster or Collins are in appropriate in cases where sufficient entry treatment is impossible, and graft replacement of the ascending aorta at least is considered to be necessary.

An adult case of anomalous origin of left coronary artery from pulmonary trunk was reported. The catheterization studies revealed significant amount of left to right shunt in the pulmonary trunk and anomalous origin of left coronary artery from pulmonary artery with well developed and marked tortuously dilated collaterals from the right coronary artery. During surgery, blood flow waveforms of the LAD was measured using pulsed Doppler velocimeter. After temporary closing of the origin of left coronary artery, blood flow of the LAD markedly decreased. A-C bypass grafting to LAD was performed successfully using saphenous vein and graft flow rate was 220 ml/min. These findings suggest that the coronary blood flow through the tortuously dilated collaterals after ligation of the origin of left coronary artery was insufficient to perfuse the left coronary artery.

Between January 1975 and July 1992, coronary artery reoperation was performed in 16 of 333 patients who had undergone primary bypass grafting. The interval between the operations ranged from 2 to 147 months. Reoperation was done within one year in two patients, within one to five years in five patients and after more than five years in nine patients. The mean number of bypass grafts was 2.31 per patient in the first operation and 1.75 in the reoperation. The main reasons for the reoperation were an occlusion of the graft in 12 cases and both graft occlusion and new coronary artery disease in 3 cases. In one other case, an emergency right coronary bypass graft done for an acute occlusion during PTCA to an area of right coronary artery stenosis 13 months after two bypass graftings to the LAD and circumflex coronary artery. Fourteen cases had vein graft disease bypassed to the LAD or new coronary artery disease in the LAD and required reoperations of the LAD. In the case with a recurrence of myocardial ischemia after coronary bypass surgery and with bypass grafts to the LAD that were patent, there were no cases requiring reoperation. These findings demonstrate that patency of the grafts to the LAD is an important factor for reoperation after myocardial revascularization surgery.

Three patients with spasm of internal mammary arteries and gastroepiploic artery immediately after coronary bypass surgery were reported. On completion of the revascularization, all patients could not be weaned from cardiopulmonary bypass. The flow velocity waveforms of the arterial grafts measured by pulsed Doppler velocimeter showed only small systolic component without diastolic flow and the palpation revealed profound spasm partially in the arterial conduits. Although all patients could be weaned from cardiopulmonary bypass only after insertion of a saphenous vein graft, two of them died on the next day. In all patients, free flow measured prior bypass was considered to be sufficient and a technically satisfactory anastomosis was felt to be performed. If a profound hemodynamic instability as a result of intractable spasm of arterial conduit occurred after completion of coronary bypass surgery, an additional saphenous vein graft should be placed before discontinuation of cardiopulmonary bypass.

Since 1987, arterial conduits have been used in 78 of 130 cases receiving coronary bypass surgery, including 25 treated by arterial conduits alone. The use of arterial conduits was mainly indicated to the anterior descending coronary artery (LAD), but the saphenous vein had to be used in 39 percent, 47 of 120 cases receiving bypass grafting to the LAD for various reasons including a combination of multiple obstructive arteriosclerosis, multiple bypass graftings in the aged, unstable angina, emergency operation and no suitable artery for a conduit as indicated by preoperative angiography. Hereafter, arterial conduits for coronary bypass grafting to LAD should be used in many more cases to the best possible advantage.

Four surgically treated cases of aortic valve regurgitation associated with the aortitis syndrome were reported. All patients were female and ranged in age from 38 to 51 years. In two cases, obstructive lesions of the aortic arch branch were seen in aortograms. Three patients had no inflammatory findings at the operation and one was operated on after improvement of inflammatory findings by steroid therapy. Aortic regurgitation was caused by annuloaortic ectasia, and aortic valve replacement was performed by the everting mattress suture method in all cases. One patient with stenosis of the left carotid artery, occlusion of the left subclavian artery, and hypertension died of extended cerebral damage due to suspected low flow cerebral perfusion during cardiopulmonary bypass. The other three patients are doing well 4 months to 11 years after surgery without paravalvular leakage. In cardiac surgery for the aortitis syndrome with an obstructive lesion of the aortic arch branch, deep hypothermic and high flow cardiopulmonary perfusion is required to prevent ischemic brain complications during surgery.

To clarify the causative factors responsible for the development of effort angina in aortic stenosis, the influence of an increase in heart rate by atrial pacing and isoproterenol infusion on the phasic left coronary flow velocity waveforms were studied using a pulsed Doppler velocimeter during cardiac surgery. Coronary flow velocity waveforms in aortic stenosis was characterized by a slowly increased diastolic inflow and an elongation of the time from the onset of diastole to the diastolic peak velocity. An increase in heart rate by pacing brought about a marked decrease in diastolic coronary flow since the slowly increasing diastolic flow was cut with the onset of following systole. On the contrary, after an increase in heart rate by infusion of isoproterenol, diastolic increasing rate in the coronary flow waveform accelerated and diastolic peak velocity markedly increased. As the results, isoproterenol produced a significant increase in diastolic coronary inflow.

Between 1981 and 1989, ten patients underwent replacement of the ascending aorta and aortic valve by a composite graft for an aneurysm of the ascending aorta with aortic regurgitation. The first two cases using an SJM aortic valve prosthesis and Teflon felt-pledgeted mattress sutures for the proximal anastomoses required a coronary bypass graft from the tube graft to the anterior descending coronary artery because of difficulty in completing the graft-left coronary ostial anastomoses. In the subsequent seven cases, an SJM mitral valve prosthesis with a large, soft cuff for a valved conduit was sewn in reverse and a thin wall Teflon roll was used for the Teflon felt of the pledgeted mattress suture in the proximal anastomoses. As a result, anastomoses between the tube graft and coronary ostia were performed easily and successfully in eight patients. One case with Marfan syndrome required reoperation nine years after the first operation for recurrence of the aneurysm of the aortic arch. Thus, the need for careful and continued follow-up is important in the Marfan syndrome.