Seven patients underwent surgical repair of the distal aortic arch aneurysm from January 1990 to October 1997. They were 5 men and 2 women ranging from 63 to 78 years of age (mean, 72.7 years). All patients were operated with a median sternotomy only. There was one operative death, which was ruptured case. However, there were no major complications in non-ruptured cases. This retrospective study suggests that it is possible to repair the distal aortic arch aneurysm through a median sternotomy approach alone, when 1) descending aorta originates with normal size just distal to sacciform aneurysm, 2) the maximum diameter of the aneurysm is over 70mm and 3) distal involvement of the aneurysm does not extend beyond the bifurcation of the trachea. It is useful to retract descending aorta proximally by three threads with pledget for distal anastomosis in inclusion technique.

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We evaluated 13 patients (4 men & 9 women, mean age: 61 years-old) who required steroid treatment for more than 1 month before open heart surgery. The subjects included 3 patients with collagen diseases, 3 with dermatopathy, 2 with bronchial asthma, one each with Takayasu's disease, autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, brain tumor and post-renal transplantation. Surgical procedures were performed with an AC bypass in 9 cases, one each with AVR, MVR, reMVR and ASD patch closure. The steroid treatment before open heart surgery had been continued for a mean of 4 years and 11 months at a mean dose of 9.4mg/day equivalent of prednisolone. We evaluated the adrenocortical function on the rapid ACTH test and found hypoadrenalism in 5 of 8 cases (63%). In these cases we gave either 100mg of hydrocortisone or 1, 000mg of methylprednisolone before open heart surgery. The total perioperative dosage of steroid was a mean of 2, 488mg equivalent of prednisolone, including 4mg/kg of betamethasone during the extra corporeal circulation. Postoperatively we lost one case due to ventricular rupture after MVR. Other major complications were seen in one case each, cardiac tamponade, temporary clamp, wound infection and lumbar vertebral fracture. For steroid treated patients, it is important to select the patient who really need steroid by the rapid ACTH test, and to use the minimum dosage of steroids in open heart surgery.

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Ventricular Septal Defect (VSD) is the most frequent cardiovascular anomaly. VSD causes pulmonary hypertension through stenotic changes in the pulmonary vasculature, and this progress depends on the size of defect and associated cardiovascular anomalies. Since surgical repair has been performed in childhood for patients without a tendency toward spontaneous closure of VSD, operations in elderly patients, especially those aged over 40, are rare. We report an elderly patient with VSD complicated with severe pulmonary hypertension who underwent surgical repair. A 66-year-old man was admitted to our hospital because of general fatigue, chest oppression and palpitations. The pulmonary to systemic pressure ratio was 0.66. The oxygen saturation stepped up at the right ventricle level. The pulmonary to systemic blood flow ratio was 2.9, shunt ratio was 71% and resistance ratio was 0.12. The VSD was 18mm in diameter at the perimembranous trabecula and was closed with a Dacron patch through a right atrium incision. The lung biopsy specimen revealed little occlusive pulmonary vascular disease, Grade I according to the Heath-Edwards criteria. The patient had an uneventful recovery.

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This study reviewed the operative results in patients who underwent elective isolated coronary artery bypass grafting (CABG) from 1991 to 1997 and the long-term outcome in patients who received an internal thoracic artery (ITA) to left anterior descending artery graft from 1984 to 1995. The morbidity rates were as follows: low output syndrome (LOS), 19 (2.6%); perioperative myocardial infarction (PMI), 14 (1.9%); IABP required, 9 (1.2%); respiratory insufficiency, 32 (4.4%); acute renal failure, 28 (3.8%); mediastinitis, 9 (1.2%); stroke, 13 (1.8%); and reoperation for bleeding, 9 (1.2%). Operative mortality was 0.7%. Patients with moderate or severe impairment of left ventricular function (ejection fraction≤40) or chronic renal failure had high incidences of arrthythmia and respiratory insufficiency; those who were 75 or older at operation had a higher incidence of arrhythmia than those who were 50 or under (p=0.033). Patients who received four or five grafts needed a longer duration of hospitalization than those who received a single graft (p=0.0147). The 10-year actuarial survival rate, cardiac death-free rate and cardiac event-free rate in the entire series were 89.4%, 96.7%, and 80.9%, respectively. Among patients who underwent complete revascularization, the 10-year cardiac event-free rate and catheter intervention-free rate were 82.7% and 91.7%, respectively, compared with 77.5% and 84.2% in patients who underwent incomplete revascularization (p=0.0428, 0.0343). Since this study demonstrated that CABG with cardiopulmonary bypass contributed to favorable operative and long-term results, the indications for minimally invasive direct coronary artery bypass (MIDCAB) and off-pump CABG should be considered carefully and perhaps limited to elderly patients and/or those with major co-morbidities, until the long-term benefits have been clarified.

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The internal thoracic artery (ITA) has been established as the preferred conduit for myocardial revascularization. Several reported improved late results of coronary artery bypass grafting (CABG) with bilateral internal thoracic arteries (BITAs). In our institute, BITAs have been used for CABG from 1993. Since 1995, the indications for use of BITAs were extended to high risk patients. Between January 1995 and December 1997, 119 patients received BITAs for coronary artery revascularization. Right ITAs were anastomosed to the left anterior descending arteries (65%), the diagonal branches (7%), the left circumflex arteries (12%) and the right coronary arteries (10%). In 8 patients (7%), free right ITAs were used to bypass between proximal and distal portions of the right coronary artery. The hospital mortality rate was 4.2%. Regarding hospital morbidity, there were 2 patients with sternal infection and 2 patients with LOS postoperatively. There was no reoperation for bleeding. No significant difference was observed in the rate of wound infection or rate of operation without blood transfusion between the patients having BITAs grafting and those having unilateral ITA or saphenous vein grafting only, during the same period. Diabetes mellitus, older age, feminine gender, reduced ejection fraction and urgent operation are known risk factors for CABG. Among patients with these factors, no significant difference was observed in hospital mortality rate between patients with BITAs grafting and those with unilateral ITA grafting. The operative results of CABG using BITAs were considered to be satisfactory.

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Infective endocarditis with apical abscess is very rare. A 49-year-old man was admitted in a diabetic coma. The next day, he suddenly developed chest pain and headache. Echocardiogram revealed mitral valve vegetations and mitral regurgitation, and brain CT showed multiple cerebral hemorrhage that was thought to be due to cerebral embolism. Surgery was performed on the 10th hospital day for progressive heart failure. During surgery, an abscess was noted at the apex, but the abscess cavity was not connected to the cardiac cavity. The mitral valve was replaced, and the abscess cavity was resected. The defect of the ventricle was repaired with an 8×5cm Goretex sheet. Cultures of blood, vegetation, and the abscess were negative. It was thought that the abscess formation in the apex was caused by infectious coronary embolism, since cerebral embolism and chest pain happened simultaneously, and the abscess cavity was isolated and not in communication with the cardiac cavity.

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An unusual case of a 71-year-old man with massive sinuses of Valsalva presenting with coronary insufficiency was reported. Primarily, he had undergone aortic valve replacement (AVR) with a diagnosis of severe aortic regurgitation (AR) and annulo-aortic ectasia (AAE). Four years after the primary operation, he came to our hospital as an emergency admission complaining of chest pain. Electrocardiography showed sinus rhythm with ST wave elevation in limb leads of II, III and aVF and a diagnosis of acute myocardial infarction was made. Coronary angiography revealed right coronary insufficiency and aortography showed massive sinuses of Valsalva (diameter 8.5cm) with minimal functional AR. At the second operation, the right coronary artery was severely stretched and attenuated over the surface of the right coronary sinus. The ostium was found to be free of atherosclerosis. A composite reconstruction of the aortic root with a new valved conduit and reimplantation of coronary arteries were performed. The postoperative course was uneventful. Aneurysmal change of the sinus of Valsalva is rare, and it is reported that the mean maximal diameter is 5.4cm in this type of AAE. In our case, the unusual dilation of the sinuses of Valsalva resulted in right coronary insufficiency. This case reminded us that aortic root replacement must be applied in patients with AAE as the initial treatment of choice.

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We present a rare case of tuberculous thoracic aneurysm which ruptured into the lung. A 66-year-old woman who has been treated for lung tuberculosis and spondylocace was referred to our hospital for treatment of a descending thoracic aneurym confirmed by enhanced CT scan. On the 6th hospital day, she had massive hemoptysis and her systolic pressure dropped to 70mmHg. Emergency operation was performed under an F-F bypass. The saccular aneurysm was excised and surrounding infected tissue was debrided. UBE graft was inserted in situ and totally covered with omentum. The pathological diagnosis of the specimen was tuberculous aortic aneurysm. The postoperative course was uneventful. Good reconstruction and omental vessels around the replaced graft were revealed by postoperative angiogram. Two years later she is well. The omental covering of the replaced graft was a useful method for preventing graft infection.

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A 53-year-old woman was admitted with cardiac failure due to aortic regurgitation (AR) and pseudocoarctation of the aorta associated with Takayasu's aortitis. It was revealed that her hypertension of upper extremities was based on Takayasu's aortitis at her 37-year-old age. But at that time there was no sign of inflammation, only drug therapy for hypertension had been employed. She started to complaint of dyspnea on exertion and palpitation when 47 years old, ultrasonic echocardiography and cardiac catheterization revealed that her symptoms were based on pseudocoarctation and AR. Despite of drug therapy, her symptoms progressed and reached NYHA class III. Detailed examination showed progressed AR and occurrence of mitral regurgitation (MR). Surgical treatment, ascending aorto-terminal aortic bypass, aortic valve replacement (AVR), and mitral valvuloplasty was performed at the age of 53 years old. In instituting the extracorporeal circulation, an arterial cannula was placed in the graft that anastomosed to the terminal aorta, in addition to the arterial cannula to the ascending aorta, to prevent low perfusion of the organs distal to the pseudocoarctation. The postoperative course was uneventful. Special attention should be paid to prevent low perfusion of the organs in such case with presence of pressure gradient in the aorta.

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Three-channeled aortic dissection of the ascending aorta is rare. A 38-year-old man was given a diagnosis of DeBakey type I aortic dissection with three-channel at the ascending aorta on a chest CT scan. Right axillar and left femoral artery and two-stage right atrial cannulas were used to institute cardiopulmonary bypass. Hemiarch replacement was performed. The open proximal anastomosis technique was used under deep hypothermic circulatory arrest and selective cerebral perfusion. This three-channeled aortic dissection was thought to be produced by DeBakey type II dissection first followed by a retrograde dissection of DeBakey type III b. Since obstruction of the brachiocephalic artery due to the expansion of the pseudolumen was found during rewarming, reconstruction of the brachiocephalic artery was necessary. The present case was treated successfully by right axillary artery perfusion and subsequent reconstruction of the brachiocephalic artery.

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We encountered two cases of infected aortic abdominal aneurysm with spondylodiskitis. Both cases were diagnosed on the basis of fever, back pain and pulsatile abdominal mass. A 69-year-old man, case 1, underwent in situ reconstruction 1 year from the onset, because the infection was controllable by antibiotics and he had diabetes mellitus. A 68-year-old man, case 2, underwent operation while his infection was still active, because of paralysis of the bilateral lower extremities, aggravated by invasion of the vertebrae by the abscess. To prevent artificial graft infection, he underwent axillo-femoral bypass, which was extra-anatomical reconstruction, after the infected aneurysm and vertebrae were removed during aortic clamping above the aneurysm and bilateral common iliac arteries. Each stump was sutured and anterior fixation of the vertebrae was performed using an iliac bone graft. The postoperative course of both patients was successful. These cases suggest that the timing and procedure of the operation for infected aortic abdominal aneurysm with spondylodiskitis should be decided depending on the activity of infection, complications, age and activity of daily life of patients.

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An 80-year-old woman who had been suffering from atrial fibrillation and recurrent cerebral infarction was admitted to our hospital. Transesophageal echocardiography revealed a giant mobile thrombus in the left atrial appendage. The patient underwent thrombectomy and left atrial appendage obliteration under cardiopulmonary bypass. Her postoperative course was uneventful. The patient showed no recurrence of the left atrial thrombus nor thromboenbolism postoperatively. Based on the present results, we recommend cardiac thrombus be investigated by transesophageal echocardiography in cases of atrial fibrillation accompanied by recurrent thromboembolism. This should be followed by thrombectomy under cardiopulmonary bypass, even in the elderly.

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Metastasis to the heart is not so rare, but it is not diagnosed easily during patient's lifetime because clinical symptoms are not related to the nature of the tumor. We present a rare case of resection of cardiac metastasis of liposarcoma. A 37-year-old man suffered from dyspnea on effort was given a diagnosis of heart failure. He had already suffered from primary liposarcomas of the right heel which had been resected at age 28 and 32. Echocardiography revealed pericardial effusion and a tumor exiting from the apex. The mass grew rapidly and was excised using a cardiopulmonary bypass. The pathophysiological diagnosis was metastatic liposarcoma to the heart. The surgical margins of tumor were positive and cancer cells were exposed on the epicardial surfaces on some places. Adjuvant chemotherapy was therefore performed for 6 months. The patient was discharged after a good post-operative course and has been in good health for 40 months since the operation. Despite the generally poor prognosis of metastatic liposarcoma to the heart, combination of surgical treatment and chemotherapy yield a long period of survival in this case. It is important not only to establish the therapeutic strategy for metastatic tumor to the heart but also to detect it at an early stage.

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Subclavian arterial aneurysms are relatively rare compared to aortic aneurysms. The common causes of subclavian arterial aneurysms are arteriosclerosis, non-specific inflammation, thoracic outlet syndrome, and trauma. A case of a subclavian arterial aneurysm is reported. The patient was a 57-year-old woman. She had no previous history of hypertension, infection and trauma. She underwent complete resection of the aneurysm and reconstruction of right subclavian artery. Exploration of the aneurysmal wall revealed circumferential ridge which caused stenosis of the right subclavian artery at the orifice of the aneurysm. It has been suggested that a subclavian arterial aneurysm developed as a result of abnormal development of the embryologic right fourth and distal sixth aortic arches.

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An 60-year-old man who initially presented with ventricular tachycardia was suspected of cardiac tumor because of localised hypertrophy of the right ventricle. Although the localized region detected by an echocardiography suggested malignancy, percutaneous transcatheter myocardial biopsy failed to obtain a histological diagnosis. Six months later, a permanent pace maker was implanted due to complete AV block. Two years after the first admission, echocardiogram and computed tomography demonstrated a cardiac tumor in the right ventricle. To obtain a histological diagnosis, open biopsy was performed under median sternotomy and showed malignant lymphoma. Antemortem diagnosis of cardiac malignancy is usually very difficult. Median sternotomy is an established procedure for cardiovascular surgeons. Open biopsy can be an acceptable technique to obtain histological diagnosis of the neoplastic region in terms of safety and simplicity, and has good sampling accuracy compared with other diagnostic modalities. We recommend early stage surgical exploration when cardiac malignancy is a diagnostic possibility.

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