We assessed the mid-term and long-term results of the coronary artery bypass grafting (CABG) for 121 patients with left main disease and complex coronary artery disease and compared with the 5-year results of the SYNTAX trial. Off-pump CABG (OPCAB) was performed in 108 patients (89.3%). The number of the distal anastomoses was 3.7 grafts, and the internal thoracic artery was used for the left anterior descending artery in 117 patients (96.7%). The mean number of arterial grafts used in each patient was 1.8 grafts. Although the rate of cerebrovascular events in CABG group of the SYNTAX trial was 2.7% in the first year, there was no perioperative cerebrovascular event in our patients, but the rate was increased to 4.2% during the 5-year follow-up, which was similar to the results of the SYNTAX trial. The rate of myocardial infarction (5.0%) was similar to the results of the SYNTAX trial. The rate of repeat revascularization, major adverse cardiac and cerebral events (MACCE), and cardiac death was 6.3%, 12.8%, and 2.9%, respectively, which were much lower than those of the SYNTAX trial. The results suggests that the strategy of complete revascularization by OPCAB can be the first choice for patients with left main and complex coronary artery disease and provide the excellent mid-term and long-term outcome.

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Preventing reoccurrence of ischemic heart disease needs to control coronary risk factors through improving lifestyle by patients themselves with environmental assistance from their family and health care providers. We ought to clarify the effectiveness of in-hospital education with re-readable pamphlets on patients underwent percutaneous coronary intervention (PCI). Forty-three consecutive patients were randomly assigned either to receive lifestyle guidance with pamphlets, or not to receive any guidance. Patient backgrounds, vital signs and blood test results were compared between the groups at discharge and their office visits on 1 and 3 months later. As results, systolic blood pressure at 1 month was significantly lower (115±18 vs. 127±19 mmHg, p=0.045), and negative change of body weight between discharge and 1-month visit was significantly larger (−0.58±1.7 vs. +0.60±1.9 kg, p=0.041) in the educated group. However, these favorable effects disappeared at 3-month visit. It suggests that nurse-leading education may have improved lifestyle of patients performed PCI, yet further needed continual assistance for long-term improvement.

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Post-operative atrial fibrillation is a common complication after coronary artery bypass grafting. It is associated with increased risk of stroke and mortality, and duration of hospitalization. In 264 patients undergoing elective isolated off-pump coronary artery bypass grafting, preoperative clinical and echocardiographic data were compared between patients with and without post-operative atrial fibrillation. Diastolic dysfunction was defined as E/e’>8 (E: Peak early mitral pulsed-wave Doppler flow, e’: mitral lateral annular early velocities). In this study, diastolic dysfunction and age were the independent risk factors of post-operative atrial fibrillation. The evaluation of preoperative diastolic dysfunction might be useful in identification of high risk patient of post-operative atrial fibrillation.

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Background: The presence of low platelet response to antiplatelet therapies is associated with worse clinical outcomes in coronary artery disease patients. Chronic kidney disease (CKD) has been reported associated with reduced response to antiplatelet therapies. Objective: To assess the impact of renal function on platelet activity in Japanese patients with coronary artery disease on dual-antiplatelet therapy. Methods: The subjects consisted of 198 patients with coronary artery disease who were taking aspirin and clopidogrel (75 mg/day) for more than 30 days. Patients were categorized into 3 groups according to renal function, a control group, with estimated glomerular filtration rate (eGFR)≥60 ml/min/1.73m² (n=118) and a moderate CKD group, with eGFR 30–60 ml/min/1.73m² (n=65), a severe CKD group, with eGFR <30 ml/min/1.73m² (n=15). Platelet aggregatory threshold index (PATI) was measured by platelet function test (light transmittance aggregometry) and compared among the three groups. Results; Mean eGFR was 77.2±14.2 ml/min/1.73m² in the control group, 48.3±8.5 ml/min/1.73m² in the moderate CKD group and 9.9±7.8 ml/min/1.73m² in the severe CKD group. Adenosine diphosphate induced PATI was significantly lower in the moderate CKD (3.28±0.99 μM) and severe CKD (3.03±1.32 μM) than in the control group (3. 66±0. 73 μM) (p<0. 05). Conclusion: The efficacy of clopidogrel and inhibition of platelet aggregation are reduced in moderate/severe CKD patients taking maintenance dual antiplatelet therapy. For the management of coronary artery disease patients with CKD, we should take care the case of low platelet response to clopidogrel.

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A 60-year-old male implanted drug-eluting stent at proximal left anterior descending artery with acute myocardial infarction 17 days ago was admitted to our hospital with prolonged chest discomfort. Coronary angiography (CAG) revealed complete occlusion of stent implanted site. We successfully implanted DES under intra aortic balloon pumping (IABP) support. Two hours later, refractory ventricular fibrillation (VF) occurred, therefore percutaneous cardiopulmonary support (PCPS) was initiated. We began infusion of amiodarone. After the procedure, he received cardiac rehabilitation and seceded from hemodynamic supports. However, 19 days after hospital admission, he had unexpectedly VF again with hemodynamic collapse and emergent CAG showed total occlusion of BES implanted lesion once more. Under IABP support, bare metal stent was implanted with acceptable coronary flow. After the procedure, refractory VF recurred and we restarted PCPS. Two days later, we discontinued PCPS and IABP. He discharged from our institute without sequelae after ICD implantation for secondary prevention. In the case of subacute stent thrombosis (SAT), we should have reconsidered an appropriate anti-platelet therapy and device selection. We experienced a case of recurrent SAT after ACS which required PCPS twice due to refractory ventricular arrhythmias.

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The patient was a 66-year-old woman. She first became aware of exertional chest pain at the age of 40 years. Because of a positive exercise tolerance test result at the age of 44 years, she underwent coronary angiography (CAG). The CAG results showed 75% stenosis in the ostium of the left main trunk. At that time, she presented with few coronary risk factors and was thus considered to have an isolated coronary ostial stenosis of unknown origin. Owing to drug therapy resistance, coronary bypass surgery was performed (the left internal thoracic artery graft was anastomosed with the left descending artery, and the saphenous vein graft was anastomosed with the left circumflex artery). She did not have any symptoms after the surgery. However, at the age of 66 years, she experienced a relapse of the exertional chest pain and underwent CAG. The results showed that the stenosis in the left main trunk had progressed to 90%. The bypass grafts also showed severe stenosis. Revascularization was deemed necessary; percutaneous coronary intervention was performed on the left main trunk, and her symptoms improved. This is a case of an isolated coronary ostial stenosis that required revascularization by coronary bypass surgery and percutaneous coronary intervention with long-term follow-up.

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We report a case of systemic amyloidosis that was diagnosed shortly after coronary artery bypass surgery. The patient was a 76-year-old male who was transported to our hospital by ambulance due to severe dyspnea. A few months prior to his emergency admission, purpuric spots were found around his eyes, neck, and within the oral cavity. Many decubitus ulcers were detected, and his nutritional status was poor. On close examination, he was diagnosed with congestive heart failure. On the night following admission, ventricular fibrillation/tachycardia occurred frequently. Coronary arteriography revealed double-vessel disease, and emergency coronary bypass surgery was performed. After the surgery, he had melena, and a colonoscopy revealed a hemorrhagic area mainly around the sigmoid colon. A biopsy revealed the definitive diagnosis of intestinal amyloidosis. Cardiac magnetic resonance imaging also indicated a high possibility of cardiac amyloidosis. During our attempts to classify the disease, he died of sudden atrioventricular block 43 days after the surgery.

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Congenital coronary arteriovenous fistula (CAVF) is a rare type of congenital heart disease. Because of variation in the age, symptoms, and associated pathologies of the patients, precise diagnosis is important before surgery. Although operative techniques are comparatively easy, detailed treatment planning for abnormal pathology is mandatory. For this purpose, multidetector CT (MDCT) has recently become a key diagnostic modality for visualizing and understanding the origin, course, and drainage of CAVFs. We report 3 patients who required surgery for CAVF as their main cardiac problem. At operation, detection of abnormalities was obvious and easy, because the MDCT information was quite accurate and identical to the actual heart. Closure of the CAVF was performed in all 3 patients, with addition of tricuspid annuloplasty and coronary bypass surgery in one patient and pulmonary vein isolation in one patient. The results were satisfactory.

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