A 72-year-old man was referred to our hospital for coronary artery bypass grafting (CABG) due to asymptomatic severe coronary artery disease. A preoperative CT revealed 99% stenosis of the aberrant right subclavian artery, 90% stenosis at the origin of right common carotid artery, and 75% stenosis at the origin of the left subclavian artery. As he had high risk of a perioperative cerebral ischemic event for CABG, it was difficult to perform a carotid artery stent. We performed a total aortic arch replacement combined with CABG. The postoperative course was uneventful, and he was discharged on the 12th postoperative day.

A 78-year-old woman was referred to our hospital because of progressive exertional dyspnea due to nonrheumatic severe aortic valve stenosis and moderate mitral valve stenosis with mitral annular calcification. We subsequently performed aortic valve replacement and mitral anterior leaflet decalcification. During surgery, we found that the cause of mitral valve stenosis was calcification of A2 aortic curtain-medial trigon through aortic valve annulus and resected calcification with SONOPET. The postoperative echocardiography revealed good mitral valve motion with mild mitral valve stenosis.

A 76-year-old man with a complaint of dyspnea was diagnosed with acute severe mitral regurgitation due to ruptured chordae tendineae. For improvement of pulmonary congestion, we introduced IMPELLA 5.0^® and extra-corporeal membrane oxygenation before valve surgery. After two-days' IMPELLA 5.0^® support, mitral valve replacement surgery with a bioprosthetic valve was performed and IMPELLA 5.0^® was withdrawn. We report a successful case of a bridge to surgery using IMPELLA 5.0^® with mitral valve regurgitation accompanied by acute left heart failure with severe respiratory failure.

Radiation-induced heart disease includes various types of cardiac disorders that occur after thoracic irradiation therapy. The coronary artery has been known to be affected in this kind of pathological condition. A 37-year-old man diagnosed with acute coronary syndrome was referred to our institution. He had received irradiation therapy for mediastinal malignant lymphoma at the age of 10 and 11 years. An extended thymectomy for a thymoma via median sternotomy was performed at 18 years old. He also underwent thoracoscopic pericardial fenestration for a pericardial effusion at 26 years old. Coronary angiography revealed severe stenosis of the left and right coronary ostia. Considering the patient's characteristics, including a history of thoracic irradiation therapy, radiation induced heart disease was suspected as a pathogenesis for severe ostial stenosis of the coronary arteries. He underwent conventional on-pump beating coronary artery bypass grafting (CABG) on an urgent basis. Neither internal thoracic artery was suitable for bypass conduit because of dense adhesion. Therefore, the radial artery and great saphenous vein were used as free grafts for coronary revascularization. Furthermore, partial clamping of the ascending aorta seemed to be difficult and inappropriate owing to severe adhesion, so proximal anastomosis devices were used without a side biting clamp. The postoperative course was uneventful and both bypass grafts were patent. Now, he is doing well 10 years after the CABG without any other cardiac event.

Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by thrombocytosis and malfunction of platelets. Both thrombosis and bleeding due to thrombocytosis may occur. An 81-year-old female patient complicated with ET underwent mitral valve replacement using a bioprosthetic valve due to severe mitral regurgitation. She had been diagnosed and treated with the hydroxycarbamide for ET. The hydroxycarbamide had been interrupted 14 days before the surgery, to prevent infection and delayed wound healing. At hospitalization for surgery, her platelet count rose to 1,290,000/μl from 790,000/μl. Readministration of a half dose of the hydroxycarbamide lowered the platelets to her original level. During the operation, more heparin was necessary to control activated coagulation time for cardiopulmonary bypass. She was discharged unaffectedly on 25 POD.

A female in her 60 s with a mobile cardiac tumor in the left atrium was referred to our hospital. The tumor was diagnosed as myxoma by echocardiography, CT scan, and MRI. Under cardiac arrest using cardiopulmonary bypass, we resected the tumor through the superior trans-septal approach. We resected two tumors (tumor 1 and 2) with adequate rims of the interatrial septum to avoid recurrence. Although the tumor had a broad base and extended to near the mitral annulus, mitral valve repair was not necessary. Tumor 1 was gelatinous and seemed to be a myxoma ; tumor 2 had a lot of papillary structures attached to the solid mass and presented with the figure of a sea anemone when it was put in saline, which is typical for papillary fibroelastomas. The defect of the interatrial septum was closed with the autologous pericardium. The postoperative course was uneventful. Unexpectedly, both tumor 1 and 2 were diagnosed as myxomas on pathological examination. Tumor 2 (papillary lesion) included a few tumor cells with positive staining of calretinin typical for myxoma and was diagnosed as a “villous-type myxoma”. Because it is difficult to distinguish myxoma from papillary fibroelastoma by pre- and intraoperative findings, it would be recommended to resect tumors with an adequate margin to prevent recurrence.

Aortoiliac occlusive disease (AIOD) can be difficult to treat. We performed aorto-uni-iliac (AUI) stent-grafting with external-iliac artery crossover bypass in 3 cases of extensive AIOD (mean age 69 years). Lesions were TASC II type D in 2 and D+A in 1. Mean ankle-brachial index of diseased side was 0.52. Bare stent placement for iliac stenosis was also done in 2 cases. All cases were a technical success with no complications. Mean operation time was 123 min and mean hospital stay was 11 days. We have been keeping good patency. We consider it an effective treatment option for AIOD.

A 66-year-old man was under observation as an outpatient for moderate aortic regurgitation and distal aortic arch aneurysm since 2005. He underwent surgery for gradual expansion of the distal aortic arch aneurysm. Preoperative enhanced computed tomography (CT) revealed a fusiform-type aortic aneurysm with a maximum short diameter of 63 mm. The aneurysm extended from the left subclavian artery to the descending aorta, 67 mm ahead. Based on the preoperative CT, a 150-mm open stent graft (OSG) was selected because of an adequate landing zone when inserted from the proximal site of the left subclavian artery. A 33-mm diameter graft was selected with a diameter 10% larger than that of the aorta at the landing zone. Moreover, the preoperative rapid plasma reagin (RPR) test was positive at 5.5 RU, and the fixed Treponema pallidum latex agglutination (TPLA) test was positive at 4,670 TU. He had undergone treatment for syphilis, and we concluded that the patient harbored antibodies after syphilis treatment. In the operating room, median sternotomy was performed. Cardiopulmonary bypass (CPB) was instated with bilateral axillary artery return, and superior vena cave (SVC) -inferior vena cave (IVC) venous drainage was placed. The aortic wall was strongly adherent to the surrounding tissue, similar to that observed in the aortitis syndrome. We performed aortic valve replacement during the systemic cooling. Under hypothermic circulatory arrest at 25°C with selective cerebral perfusion, the aorta was cut between the left common carotid artery and left subclavian artery. From this site, OSG was inserted to the level of the aortic valve. Total arch replacement was performed with a 30-mm bypass graft. Pathological findings indicated infiltration of lymphocytes and plasma cells around the feeding artery in the aortic aneurysm wall, and the aortic media wall showed fibrillation. Based on the intraoperative and postoperative pathologic findings, we diagnosed the patient with syphilitic aortic aneurysm, and started oral administration of amoxicillin 1,500 mg per day for 3 months. He was discharged on the 13th postoperative day without paraplegia, vocal cord paralysis, or other complications. Although syphilitic aortic aneurysm is rarely seen, it must always be considered as one of the causes of aortic aneurysm.

A 76-year-old man who suffered from consistent back pain was admitted for anti-hypertensive therapy to strictly manage the early thrombosed acute type A aortic dissection (AAAD). On admission, his blood pressure could not be controlled well ; soon he complained of recurrent severe back pain. The second thoracoabdominal enhanced computed tomography revealed the progression of AAAD from DeBakey type II to type I with thrombosed pseudolumen at the descending thoracic aorta ; therefore, emergent surgical intervention by primary central repair was conducted. Paraplegia was diagnosed eight hours after surgery, then cerebrospinal fluid drainage and intravenous administration of Naloxone were started immediately followed by keeping the systemic blood pressure more than 120 mmHg. However, paraplegia had never improved and been persistent with neurological deficit of the lower extremities. We herein report a complicated surgical case of an AAAD patient with paraplegia and review the complex clinical settings.

A 34-year-old female with a gestational age of 38 weeks developed acute type A aortic dissection. Appearance of this patient was typical for Marfan's syndrome, and echocardiography revealed annulo-aortic ectasia with mild aortic regurgitation, but pericardial effusion was absent. As her hemodynamic condition was stable, an emergency Caesarean section was carried out first. After careful observation in the ICU for half a day, she successfully underwent aortic valve reimplantation and replacement of the ascending aorta under deep hypothermic circulatory arrest. Intraoperative heparin use minimally impacted uterine bleeding. Both the mother and the neonate were discharged home 16 days later. We believe a two-stage strategy should be adopted whenever possible.

Hydrophilic polymer embolism (HPE) associated with endovascular therapy has steadily gained attention. We report a case of a 70-year-old man who had undergone one-debranched TEVAR. He had a history of distal arch replacement for dissecting aortic aneurysm 14 years earlier. Pseudoaneurysm at the proximal site of graft anastomosis was found on computed tomography (CT) angiogram during the follow-up. 1 debranching TEVAR was performed using the pull-through technique. Fourth days after the procedure, a skin rash appeared in the right lower extremity around the access site. Skin biopsy with pathological examination revealed HPE. We decided to observe a patient because there was no symptom of limb ischemia. Skin lesions improved and he was discharged on the 27th postoperative day. Hydrophilic polymers are widely used in the endovascular devices and there is an urgent need to better understand the complication of HPE.

A 66-year-old man was referred to our hospital for the treatment of a right subclavian artery aneurysm. Computed tomography showed a 35-mm aneurysm in the right subclavian artery, and occlusion of the right internal carotid artery. A surgical approach with maintenance of intracranial blood flow was required. During anastomosis of the graft to the native vessel, we clamped the distal and proximal portions of the right subclavian artery, to maintain the blood flow of the right common carotid artery. The INVOS^® cerebral oximeter (Somanetics Corp., Troy, MI, USA) was useful in determining the clamping site and surgical strategy. The procedure was completed without complications, and the patient was discharged from the hospital on postoperative day 8 following a good clinical course.

Cardiovascular surgeons have strong preferences regarding basic surgical skills. However, those basic skills have never been discussed great detail. The aim of this study is to survey the approach methods for axillary and subclavian artery targeting cardiovascular surgeons in Japan aged under 40, and to share the results of those basic skills.