Cardiovascular surgery in situs inversus totalis (SIT) is unusual. We report a case of coronary artery bypass grafting (CABG) in SIT. A 67-year-old man with unstable angina pectoris was admitted to our hospital. Coronary arteriography demonstrated three-vessel disease in the mirror-image heart. CABG with 4 distal anastomosis was carried out with conventional methods. Careful observation based on complete understanding for preoperative images could minimize operative difficulties caused by mirror-image heart.

We report a case of graft infection long after femorofemoral crossover bypas grafting (FFBG), first presenting as septic distal emboli without any infective signs in the groin. A 71-year-old man who had undergone FFBG visited our hospital because of sudden pain in his right foot. No infective signs were found in the graft route from physical examination. However, computed tomography demonstrated perigraft fluid and graft thrombi. Graft excision and extra-anatomic revascularization were successfully done. Light micrography showed Staphylococcus aureus extensively infiltrating in the expanded polytetrafluoroethylene graft wall.

We report a case of a dissecting brachiocephalic artery aneurysm that developed at the anastomotic site following surgery for acute aortic dissection ; and which was successfully treated by stent grafting. The patient, a 62-year-old man, had undergone total arch replacement for an acute Stanford type A aortic dissection that accompanied dissection of the brachiocephalic artery. In the early postoperative period, he complained of dull pain in the right arm and fatigue on exertion. The blood pressure in the patient's right arm was found to be significantly lower than in the left. Enhanced computed tomography (CT) performed 1 month postoperatively revealed leakage at the anastomotic site of the brachiocephalic artery, leading to the formation of a false lumen and the creation of a dissecting aneurysm with a maximum short diameter of 30 mm. No re-entry was seen, and the greatly expanded false lumen was exerting pressure on the true lumen, causing ischemia of the arm. Enhanced CT performed 3 months postoperatively showed that the maximum short diameter of the aneurysm had increased to 35 mm. Because ischemic symptoms of the arm were also present, surgery was considered to be indicated, and stent grafting was performed. A stent graft was inserted via the right axillary artery and positioned to close the entry to the false lumen of the dissecting aneurysm. Symptoms resolved without any complications, and the patient was discharged 7 days after the surgery. The false lumen of the dissecting aneurysm completely disappeared, and no complications have developed during the 3-year interval since stent grafting. In this patient, stent grafting enabled minimally invasive closure of the entry to the dissecting aneurysm that had developed at the anastomosis site. We conclude that stent grafting is very useful for treating dissecting aneurysms caused by anastomotic leakage and without re-entry, as seen in this case.

Simultaneous pulmonary trunk and ascending aortic aneurysms are very rare, and the role of surgery in this entity is not well defined. We report a rare case of aneurysm of both the pulmonary trunk and the ascending aorta, associated with pulmonary and aortic valve insufficiency in a 17-year-old boy. Cardiac disease had been diagnosed at the age of 5, and at that time, pulmonary and aortic valve insufficiency were found by ultrasound cardiography (UCG). At regular follow-up, both cardiac valve regurgitation and the dilatation of the aneurysm gradually increased. A recent computed tomographic scan revealed that the ascending aortic aneurysm was 55 mm and the pulmonary trunk aneurysm was 60 mm. A UCG also showed severe aortic valve regurgitation and moderate pulmonary valve regurgitation with no pulmonary hypertension. Surgical repair was performed successfully. The aortic valve was replaced with a mechanical valve. The dilated ascending aortic aneurysm was excised and replaced with a Dacron graft. The pulmonary trunk aneurysm was incised longitudinally. The pulmonary valve was tricuspid, and no organic leaflets change was observed. Pulmonary valvuloplasty by commissure plication of the prolapsed cusps was performed. A large portion of the anterior pulmonary aneurysm wall was excised and plicated to reduce the radius diameter. The pathology of the aneurysm wall showed infiltration of inflammatory cells in the tunica media, fragmentation and decrease of elastic fiber, loss of muscular tissue, and increase in collagen fibers. No cystic medial necrosis was observed in the pathologic specimen. The postoperative course was uneventful, and there were no adverse events or complications at 2 years follow-up. The following image study revealed the normal size of the great vessels.

Five patients with isolated stenosis of the left main coronary artery or stenotic ostial lesions underwent direct coronary artery surgery. These surgical approaches included vein patch angioplasty in 2 cases, punch out endarterectomy in 1 case, and resection of the thickened aortic wall and transaortic endarterectomy in 2 cases. Early results were satisfactory, except for one case who died due to severe LOS and MOF. In the late postoperative period, one case of vein patch angioplasty died due to cerebral bleeding, and in the other case, stenosis existed in position of distal patch anastomosis. Since direct coronary artery surgery was successful in both early and late postoperative fidings, it is believed to be useful and safe technique if the candidates are selected properly.

Ascending aorta-infrarenal abdominal aorta bypass was performed in 8 patients: 4 patients with dissecting aortic aneurysm, 3 patients with thoracic aneurysm and 1 patient with stenosis of the thoracic aorta after grafting for congenital thoracic aneurysm. Four patients who had aortic dissection underwent the thromboexclusion method, but thromboexclusion of the thoracic aorta occured in only one patient after additional clamp to the distal thoracic aorta. He is the only long-term survival in this series. The thromboexclusion method was also performed in two patients with infectious thoracic aortic aneurysm, but they died of aneurysmal rupture within 13 months after operation. One patient who undewent resection of a thoracic aneurysm with extra-anatomic bypass, developed respiratory insufficiency and paraplegia, and died of pneumonia. The patient with thoracic aortic stenosis is alive and well 11 years after operation. The indications of the thromboexclusion method for thoracic aneurysm should be limited only to very poor-risk patients who seem to be inaccessible to a direct approach. Ascending aorta-abdominal aorta bypass is recommended in cases of thoracic aortic stenosis.

Among the 203 cases of aortic valvular surgery, we experienced 8 cases of acute coronary insufficiency during the early postsurgical period. Five cases suffered from right coronary insufficiency. The other 2 cases had left coronary failure, and the remaining case had both. The main symptom of right coronary failure was right ventricular dysfunction, resulting in inability to wean from cardiopulmonary bypass in 3 cases, and left ventricular dysfunction due to inferior myocardial infarction in 2 cases. On the other hand, the main symptom of left coronary insufficiency was acute left ventricular pump failure with a broad anteroseptal infarction, and cardiac arrest occurred in the other 2. All patients receiving an emergency coronary artery bypass graft survived. Two cases expired due to thromboembolism in the interposed graft to the left coronary ostium in Cabrol's or Piehler's procedures. In the 6 survivors we could not detect any recent coronary lesions by postsurgical coronary cineangiography. We suggest that the pathophysiology of this phenomenon was coronary artery spasm and a lack of coronary reserve capacity in severe left ventricular hypertrophy of aortic valvular disease combined with diastolic dysfunction. Prompt coronary artery bypass grafting and a careful myocardial protection using retrograde cardioplegic solutions might save patients in this critical condition and an appropriate decision on the surgical indications for aortic valvular surgery is necessary before the occurrence of left ventricular diastolic dysfunction and demand ischemia.

A 55-year-old man was admitted with a thoracic aortic aneurysm causing wheezing. Computed tomography and angiography revealed a large distal aortic saccular aneurysm, occupying the retrotracheal space and compressing the trachea. There has been only one report of this type of aneurysm. This patient needed emergency intubation because of severe dyspnea caused by premedication for surgery. Replacement of the distal arch was performed via left posterolateral thoracotomy. Profound hypothermia was used during open proximal anastomosis, which helped to make this procedure safe and simple. This patient recovered uneventfully.