Thirty-nine patients underwent emergency coronary bypass surgery for acute myocardial infarction, Patients were divided into two age groups; 10 patients aged 75 years or older and 29 patients under the age of 75 years. In addition, we compared these two groups and another 23 patients aged 75 years and older who recieved reperfusion therapy alone. The rate of mortality was 30% in the patients 75 years or older, 31% in the patients under 75 years and 52% in the patients with reperfusion therapy alone. There were no significant differences between the three groups. The majority of two groups of surgical patients died of low cardiac output after the operation. Fifty percents of the patients who recieved reperfusion therapy alone died of extension of myocardial infarction or reinfarction. However, no surgical patients died of reinfarction. There were no significant differences in Killip's class, preoperative hemodynamics and the number of diseased vessels between two surgical groups. In the patients of 75 years or older, the post-operative cardiac output did not increase in comparison with the patients under the age of 75 years. They required a longer period for oral uptake and a longer recovery period after the surgery. Therefore, emergency coronary bypass surgery for acute myocardial infarction was effective in the elderly population aged 75 years or older, although it still carried a high operative mortality.

A 29-year-old female with aortic regurgitation associated with aortitis syndrome and severe stenosis of bilateral carotid arteries was reported. She had no symptom of brain ischemia, although an aortogram revealed complete occlusion of the left common carotid artery and the left subclavian artery, and severe stenosis of the right common carotid artery. The intracranial major arteries were perfused totally by the right vertebral artery via collaterals. The transcranial Doppler method and perfusion cintigraphy revealed normal cerebral perfusion. Therefore, we performed conventional aortic valve replacement without reconstruction of carotid arteries. During cardiopulmonary bypass, the mean systemic blood pressure was kept higher than 60mmHg under moderate-hypothermic (tympanic temperature: 25°C) pulsatile perfusion with monitoring of the left middle cerebral artery flow velocity. The patient did not develop any cerebral complications during or after the operation.

Four patients with multiple dissecting aortic aneurysms treated surgically from 1960 to 1996 were evaluated clinically. The incidence of multiple dissecting aortic aneurysms was 3.2% of all surgically treated cases of aortic dissection. Only one case suffered from Marfan's syndrome. Morphologically, all cases showed chronic DeBakey II+III type dissection. Case 1 was treated by Bentall's operation for DeBakey II type dissection and the residual aortic aneurysm was not treated surgically. Case 2 underwent a two-staged operation: Bentall's operation first, followed by entry closure with plication of the DeBakey III type aneurysm. Case 3 underwent a two-staged operation: graft replacement of the ascending aorta combined with coronary artery bypass grafting in the first operation and graft replacement of descending and abdominal aorta in the second. Case 4 was treated by graft replacement of the hemiarch, resuspension of the aortic valve and entry closure of the DeBakey III type dissection. Among them, two cases (Cases 1 and 2) whose aneurysms were treated incompletely showed a rapid growth and rupture of residual DeBakey III type aneurysm. In conclusion, one-staged aggressive and complete operation should be done for the patients with multiple dissecting aortic aneurysms. When a two-staged operation is selected, more intensive follow-up of the residual aortic aneurysm is needed.

It is reported that myasthenia gravis (MG) with thymoma occupy 20% of all MG and extended thymectomy is recommended. After having operation, it is rare, but cases of recurrence of thymoma and, what is worse, thymic cancer from residual thymus tissue are reported. A 69-year-old man came to our hospital to have his dyspnea level examined. He had a past history of MG with thymoma and he had undergone extended thymectomy 17 years previously. Enhanced CT showed pericardial thickening and many tumors in the epicardium. Catheterization study showed dip and plateau pattern of left ventricular pressure. We therefore diagnosed constrictive pericarditis (CP). We performed pericardiectomy under cardiopulmonary bypass. He was discharged ambulatorily on postoperative day 24. Histological findings of the tumor and the pericardium showed that they were dissemination of thymic cancer. It was considered that thymic cancer caused CP and it was an extremely rare case. We think this is the first report to the best of our knowledge.

A 64-year old man was admitted to our hospital with a diagnosis of aortic stenosis. Pre-operative chest CT revealed pseudocoarctation of the aorta with a hypoplastic aortic arch, elongation and kinking of the aortic arch and proximal descending aorta. There was also a large aneurysm from the distal arch to descending aorta. We performed a single-stage repair of the aortic lesion from the ascending to the descending aorta with aortic valve replacement. For the surgical approach, transverse clamshell incision was applied safely. Concomitant aortic valve replacement in surgical repair of pseudocoarctation and thoracic aneurysm was rare, and clamshell incision seemed beneficial in such single-stage repair from the aortic root to the descending aorta.

A 31-day-old infant with total anomalous pulmonary venous drainage (type I-A) suffered from severs left-sided heart failure unable to be weaned from cardiopulmonary bypass (CPB) after total repair. By reopening the vertical vein, the CPB was successfully terminated and the sternum was closed primarily. Percutaneous delayed closure of the vertical vein by lifting up the string which had been encircled the vertical vein at the time of repair was performed 3 days after repair. Systemic arterial pressure and left atrial pressure were unchanged after closure of the vertical vein. Postoperative cardiac study revealed satisfactory result and no left-to-right shunt through the vertical vein.

We experienced a very rare case in a 26-year-old man who underwent surgery for bilateral atrial myxomas. Moreover, his initial symptoms were due to acute myocardial infarction, which strongly suggested coronary artery embolization. Transesophageal echocardiography revealed not only left atrial myxoma at posterior wall, but also right atrial myxoma at the fossa ovalis which had not been detected by transthoracic echocardiography. At surgery, both left and right atriotomy was performed and bilateral atrial myxomas were completely removed. We emphasized that transesophageal echocardiography was very useful in detecting the location of myxomas, and that surgical exploration of the right atrium would have been necessary even if left atrial myxomas had not existed at the atrial septum.

We developed a percutaneous left ventricular assist system (PLVAS) using a centrifugal pump. PLVAS is the transseptal left atrial-femoral artery bypass to unload the left ventricle using a centrifugal pump. This PLVAS can be implanted through the inguinal vessels under fluoroscopy and also in 2 cases additional transesophageal echocardiogram guiding was performed. This PLVAS was applied to 6 patients with profound heart failure and refractory cardiogenic shock. The implantation of PLVAS required 30-60 minutes. The PLVAS assist flow was maintained at 3.0-4.0l/min. One patient with acute myocardial infarction survived and has been doing well for more than 1 year. The complications directly related to this procedure were minimal. PLVAS appears to be useful for patients with severe heart failure and may be useful as a short-time support or bridge to other more aggressive forms of life support.

Four patients with DeBakey type 1 aortic dissection underwent primary repair operations: resection of intimal tear with complete aortic transection, circumferential suture line reinforced with Teflon felt strips, and end-to-end anastomosis. There was one hospital death due to pneumonia, and the other three survived. Postoperative CT revealed excellent thrombogenesis in the residual false lumen in three patients. In one case with Marfan's syndrome thrombus formation was not identified in the false lumen.

We encountered a case of aortic valvuloplasty for aortic regurgitation due to congenital bicuspid valve. A 31-year-old man was found to have aortic regurgitation due to prolapse of a leaflet of the bicuspid valve by echocardiography. Under cardiopulmonary bypass, the right and left coronary cusps were conjoined and that conjoined cusp was larger than that of the opposing leaflet and had a longer free edge. A raphe was present in the conjoined leaflet. At first, we shortened the elongated free edge of the prolapsing leaflet by means of a triangular resection, and placed horizontal mattress sutures at each commissure. Furthermore, we performed subcommissular annuloplasty at each commissure, resulting in good coaptation of cusps. The patient survived and has shown an uneventful recovery. It is likely that this method of aortic valvuloplasty can be used for aortic regurgitation due to congenital bicuspid valve.