Since January 1981, we have performed bypass surgery between the inferior vena cava and the right atrium (IVC-RA bypass) using ring-reenforced expanded polytetrafluoroethylene (EPTFE) graft in five cases of Budd-Chiari syndrome in which at least one or more hepatic veins or accessory hepatic veins connected with the inferior vena cava. IVC-RA bypass cases include two men and three women aged 33 to 61 years old. The EPTFE graft was cut just outside of the ring and anastomosed to the inferior vena cava and the right atrium. The ring was utilized to keep the anastomosed orifice circular. EPTFE grafts (14 to 16mm in diameter and 24 to 27cm in length) were placed through the route alongside the second portion of the duodenum behind the transverse colon and anterior to the liver. Warfarin was given as an anticoagulant for at least several months to several years postoperatively in 4 cases with life-long time in one case. The cases have been followed up for 4 to 24 years. Three patients showed good graft patency for 20 years or more after the operation. Two cases died of rupture of esophageal varices 12 and 23 years after the bypass surgery, respectively. IVC-RA bypass using ring-reenforced EPTFE graft for Budd-Chiari syndrome is expected to have good long term patency without long term anticoagulant therapy, but its effect on preventing the progress of liver cirrhosis and esophageal varices is limited. Therefore IVC-RA bypass is a choice, when direct reconstruction of the hepatic vein and the inferior vena cava is impossible.

When coronary artery bypass grafting (CABG) is to be done, we use the internal thoracic artery (ITA) as a graft conduit in order to obtain longer patency. When the ITA acts as a good collateral to the lower extremities, blood flow to the extremities may decrease after CABG with ITA. Simultaneous open heart surgery and laparotomy may cause pulmonary complication. We made an algorithm of treatment for patients with coronary artery disease (CAD) and aortoiliac occlusive disease including these problems. From July 1991 to March 1992, 6 patients were operated and reviewed. Four patients were operated on for CAD and AIOD simultaneously. Two patients were operated on for CAD or AIOD at first and for the other secondarily. All 6 cases were discharged without any complications and are now free from angina and intermittent claudication. When the therapeutic plan for the patients with CAD and AIOD is made, it is very important that coronary revascularization is planned at first with careful evaluation of the blood flow to the lower extremities in cases with AIOD.

There is disagreement regarding the indications of surgery for cases of severe aortic stenosis (AS) with a decrease in left ventricular ejection fraction (EF) and a low aortic pressure gradient (PG), since there is a high perioperative risk associated with this condition. Hence, we investigated the surgical outcome of AS cases with impaired left ventricular function. Our department performed 144 aortic valve replacements (AVRs) for cases of AS and AS-dominant mild regurgitation (ASr) between January 2000 and September 2005. Among these cases, 9 patients had an EF under 35%, and these patients were selected as subjects and compared with a control group with an EF of more than 35%. Patients with accompanying coronary artery diseases that required treatment were excluded to avoid confounding effects on cardiac function. The mean age of the 9 subjects (4 men and 5 women) was 67.8±10.8 years old, with a range from 53 to 80 years old, and the subjects had the following mean background data: EF, 34.4±0.5%; left ventricular end-diastolic dimension (LVDd), 57.3±5.8mm; left ventricular end-systolic dimension (LVDs), 49.3±5.7mm; interventricular septum thickness (IVSth), 11.9±1.9mm; and left ventricular posterior wall thickness (LVPWth), 11.1±2.6mm. Characteristics such as left ventricular dilatation and thinning of the left ventricle myocardium were noted in these data. The cases were classified as severe AS because the mean aortic valve area (AVA) was 0.58±0.2cm², but the peak aortic pressure gradient (peak PG) (65.2±32.7mmHg) in the 9 subjects was lower than that of the control group (97.0±65.2mmHg). All 9 subjects underwent aortic valve replacements (AVRs), with simultaneous mitral annuloplasty (MAP) in 3 cases, mitral valve replacement (MVR) in 1 case and performance of a Maze procedure in 1 case. No deaths occurred while the patients were in hospital. Postoperative complications included 2 cases of transient atrial fibrillation and 1 case of postoperative bleeding requiring rethoracotomy for hemostasis. The EF in the late postoperative period showed improvement in 8 cases and was unchanged in the remaining case; the mean postoperative EF was 56.9% for the 9 subjects. All cases were rated as improved based on the NYHA classification of cardiac performance, and the significant improvement in EF in 8 of the 9 cases suggests that surgery is safe and can improve prognosis for patients with advanced AS with myocardium thinning and decreased EF.