Median sternotomy is the most common approach used for repeated cardiac surgery, but it is associated with potential risks such as cardiac injury. Patients with valvular heart disease may be especially prone to these complications because of severe cardiomegaly and adherence of the heart to the posterior sternum. To avoid these risks, we began using a right thoracotomy approach, performed through a right parasternal vertical incision, which is better than the traditional right anterolateral thoracotomy, in selected patients. A 50-year-old woman who had undergone 3 previous cardiac operations at another hospital presented with remarkable cardiomegaly. We performed successful tricuspid valve replacement for tricuspid stenosis, through a right parasternal vertical incision. This approach provides excellent exposure of the tricuspid valve with minimal need for dissection. The right parasternal vertical incision has 3 main advantages over right anterolateral thoracotomy; first, it provides an excellent view of the right atrium underneath the wound; second, it allows for easy cannulation because of the position of the spine; and third, the skin incision is smaller. In conclusion, we think that the parasternal vertical incision is a better approach for repeated cardiac surgery than anterolateral thoracotomy because it provides a better operative view and an easier maneuver.

Quantitative histochemical analysis of the internal thoracic artery (ITA) and right gastroepiploic artery (GEA) was performed using microspectrophotometry. Arterial specimens from eight patients who underwent coronary bypass grafting using both ITA and GEA grafts were examined. There were seven men and one woman with a mean age of 60 years; ranging from 36 to 73 years. Concerning risk factors, 4 patients had hypertension, 3 had hypercholesterolemia and 2 had diabetes mellitus. The degree of intimal hyperplasia was calculated as follows; Intimal hyperplasia (%)=(I/I+M)×100 (I: area of intima, M: area of media). Quantitative histochemical analysis (smooth muscle cells, elastin, collagen and mucopolysaccaride) of arterial graft was measured by means of microspectrophotometry. Pieces of both the ITA and GEA grafts were obtained immediately before grafting. Each sample was stained with Azocarmin G, Weigert, van Gieson and Alcian Blue stains to identify smooth muscle cells, elastin, collagen and mucopolysaccaride, respectively. Intimal hyperplasia was significantly greater in GEA than ITA grafts (25.3 ±8.7% versus 6.8±3.5%, respectively; p<0.01). In quantitative histochemical analysis of the arterial grafts, the volume of smooth muscle cells was also significantly higher in GEA than ITA at both the intima (ITA; 38.8±7.9%E, GEA; 52.5±7.6%E, p<0.01) and media (ITA; 49.6±6. 5%E, GEA; 59.5±8.2%E, p<0.05). No significant differences in elastin, collagen or mucopolysaccaride content were observed. The greater amount of smooth muscle in GEA grafts may be one reason why the magnitude of intimal hyperplasia was greater in GEA than ITA grafts. Long-term follow-up is necessary to determine the course of atherosclerotic change in arterial grafts.

We used the Fogarty 2Fr IMAG Kit^® on 14 patients who underwent aorto-coronary bypass grafting. The free flow of the left internal thoracic artery (LITA) after dilatation using Fogarty balloon catheter was 7.4 times greater than before dilatation. There was no statistical differences in catecholamines used postoperatively and postoperative cardiac output in the groups of cases with and without dilatation. String sign was appeared in 4 patients with dilatation of LITA. Fogarty balloon catheter save effective dilatation of LITA in certain selected cases.

A 47-year-old male complaining of dyspnea and fever was admitted to our hospital and regurgitation of the aortic and mitral valves with mitral valve aneurysm due to infective endcarditis was diagnosed. The non-coronary and the right coronary cusps of the aortic valve had amount of vegetations, and also the anterior leaflet of the mitral valve had an aneurysm with vegetations. Both aortic and mitral valve replacement were performed. The postoperative clinical course was uneventful.

Case 1 was a 42-year-old woman who was admitted because of infective endocarditis. Pulmonary embolism occurred during medical treatment for infective endocarditis. Despite the acute infectious phase, surgical treatment was successfully performed. Case 2 was a 50-year-old man who was admitted because of infective endocarditis. Cardiac catheterization showed ventricular septal defect and atrial septal defect. Surgical treatment was performed successfuly. In both cases, and the postoperative courses were unventful.

From April 1990 to December 1993, 13 patients (8 males and 5 females; mean age, 62 years) who underwent surgery for DeBakey type I aortic dissection, were studied to determine pre- and postoperative complications due to original dissection and residual dissection. Ascending aortic replacement had been performed in 9 patients and replacement of the ascending aorta and aortic arch in 4. Preoperative complications were aortic regurgitation (AR) in 3 cases, shock in 4, cardiac tamponade in 5, myocardial ischemia in 2 and spinal cord ischemia in 1. Postoperative complications were visceral and limb ischemia in 1 case, left leg ischemia in 1, spinal ischemia in 2 and worsening AR in 1. The postoperative 30-day survival rate was 85% (11/13). Two patients who underwent urgent ascending aortic replacement with simultaneous coronary artery bypass grafting died within 30 days after surgery. One patient with visceral and limb ischemia died in the hospital. Two patients with spinal ischemia survived but became paraplegic. Cardiac, visceral or spinal ischemia was a common problem in this series. All four patients who underwent ascending aortic replacement with simultaneous aortic arch replacement were alive for 30 days after surgery. The incidence of residual dissection may be reduced by replacing the ascending aorta concomitantly with the aortic arch rather than replacing the ascending aorta only. If a patient with DeBakey type I aortic dissection is in fair preoperative condition and elective surgery is possible, replacement of the ascending aorta and the aortic arch should be considered.

From April 1990 to August 1995, 44 consecutive patients (25 males and 19 females; mean age, 63 years) who underwent surgery for Stanford type A aortic dissection, were studied to examine surgical results and postoperative quality of life (QOL). Ascending aortic replacement was performed in 22 patients and simultaneous replacement of the ascending aorta and the aortic arch in 22. The postoperative 30-day survival rate was 84% (37/44). Univariate analysis revealed that operation time (p<0.01), postoperative cardiac failure (p<0.02), respiratory failure (p<0.01), severe brain damage (p<0.01), and intestinal ischemia (p<0.02) were significant factors in increased operative mortality risk. Additional operative procedure was also a significant factor (p<0.05) all 3 patients with coronary artery bypass grafting died, while all 5 patients with the Bentall or Cabrol procedure lived. The factors which influenced postoperative QOL were preoperative renal damage (p<0.05), history of cerebral vascular disease (p<0.02), shock (p<0.02), postoperative renal failure (p<0.02), paraplegia (p<0.02), and residual dissection (p<0.02). The operation method, which was replacement of the ascending aorta or simultaneous replacement of the ascending aorta and the aortic arch, had no influence on postoperative QOL. Five of 22 patients receiving ascending aorta replacement had dissection only in the ascending aorta (localized type). The other 17 patients receiving ascending aorta replacement had dissections extending to the arch or descending aorta. The incidence of complications due to residual dissection was 5/17 (29%) in cases of replacement of the ascending aorta for type A aortic dissection, while it was 1/22 (5%) in cases of replacement of the ascending aorta and the aortic arch (p=0.0684). Simultaneous replacement of the ascending aorta and the aortic arch did not negatively affect the surgical results and postoperative QOL more than replacement of the ascending aorta, and there was lower incidence of postoperative complications due to residual dissection. If Stanford type A aortic dissection extends to the arch, simultaneous replacement of the ascending aorta and the aortic arch is recommended.