Use of the internal thoracic artery for myocardial revascularization has regained general acceptance because it offers better long-term results than do venous conduits. However, according to angiographic studies, it has been reported that atherosclerotic changes in the internal thoracic artery occurred in 1-5% of patients with coronary artery disease, although, generally, it is considered that atherosclerotic changes in internal thoracic artery are rare. From January 1998 to August 2001, of the 274 patients who underwent coronary artery bypass grafting, it was estimated that the left internal thoracic artery could not be used for coronary revascularization by preoperative angiography in 7 patients (7/262=2.7%). Two hundred sixty-two patients underwent preoperative angiography to evaluate the grafts for coronary revascularization. All were men and age at the time of operation ranged from 62 to 81 years (mean, 68.6 years). The reason for the left internal thoracic artery being useless were occlusion or stenosis of the subclavian artery in 4 and stenosis or occlusion of the left internal thoracic artery in 3. One patient needed an emergency operation. Four patients had a history of myocardial infarction, 3 patients had hypertension, 2 patients had diabetes mellitus, 4 patients had hyperlipidemia, 1 patient had aortitis and 3 patients had a history of percutaneous transluminal coronary angioplasty. There were 4 patients with peripheral vascular disease. Four right internal thoracic arteries, 9 radial arteries and 6 gastroepiploic arteries were used for coronary revascularization. A composite Y graft (right internal thoracic artery-radial artery) was used in 3 patients, and sequential bypass was performed in the other 3 patients. The total number of distal anastomoses was 2.7±1.0/patient. The angiographic patency of the distal anastmoses was 94.7% (18/19). One patient required intra-aortic balloon pumping postoperatively for perioperative myocardial infarction (Max CK-MB 200IU/l). All other patients had an uneventful postoperative course. In conclusion, although the internal thoracic artery is a protective vessel, there is a certain extent of atherosclerosis, which correlates with known risk factors. Our observations should not preclude use of the internal thoracic artery, but they should be considered for patients who are at risk for atherosclerotic changes of the internal thoracic artery. We considered that it is important to evaluate condition of in situ arterial grafts for patients with coronary artery disease preoperatively. Although further studies are required, in situ arterial grafting with sequential arterial conduit and composite arterial graft were associated with excellent results and achieved complete revascularization.

Patients with myelodysplastic syndrome (MDS) most commonly have refractory anemia accompanied by various degrees of granulocytopenia and thrombocytopenia. At the time of cardiac surgery, both major infections and bleeding are severe complications in patients with pancytopenia due to MDS. However, there were very few patients with MDS who had undergone open-heart surgery. We reported a case of mitral valve replacement in a patient with MDS. A 68-year-old man with valvular heart disease and MDS, with a platelet count of 1.9×10⁴/mm³, underwent successful mitral valve replacement. The mitral valve was replaced by an SJM 25 A prosthesis after resection of left atrial thrombosis using cardiopulmonary bypass. Platelets were transfused after the bypass. Perioperative hemorrhage was moderate and postoperative course was uneventful. We evaluated platelet function by Sonoclot coagulation and a platelet function analyzer. We did not need a large amount of transfusion of red blood cells and platelets, and prevented major bleeding and severe wound infections in the acute postoperative state.