A 58-year old man without Marfan syndrome was referred to our hospital for congestive heart failure due to severe mitral regurgitation. He had undergone sternal turnover with a rectus muscular pedicle for pectus excavatum 36 years previously. We were able to perform mitral valve repair via median sternotomy using a usual sternal retractor. There was no adhesion in the pericardium and the exposure of the mitral valve was excellent. We closed the chest in ordinary fashion without any problems in the fixation of the sternum or costal cartilage. There were no complications such as flail chest or respiratory failure.

A 72-year-old man presented with a thoracoabdominal aortic aneurysm which had been diagnosed six years earlier. Surgical intervention was planned due to aortic diameter enlargement up to 57 mm and back pain. Although he had a shaggy aorta, a preoperative work-up revealed pulmonary dysfunction, which made open repair via thoracotomy challenging. Therefore, a decision was made to proceed with two-stage thoracic endovascular aortic repair (TEVAR) with debranching and functional brain isolation. In the first operation, iliofemoral bypass with debranching of four abdominal vessels was performed via median laparotomy to secure the access route and distal landing zone. In the second operation, two debranching TEVAR was performed. The functional brain isolation technique was employed using cardiopulmonary bypass and balloon occlusion of the left subclavian artery to prevent an embolic stroke from the shaggy aorta during the stent graft deployment. In addition, embolic protection of abdominal branches and lower extremities was established using a balloon occlusion and a sheath in the iliac arteries. The postoperative course was uneventful with no embolic complications. Although the shaggy aorta is not evaluated in Japan SCORE or Euro SCORE, it is a risk factor for perioperative stroke. Those patients would benefit from a tailored approach to prevent embolic complications.