A 44-year-old woman with heart murmur was admitted for cardiac examination. Echocardiography and cardiac catheterization including coronary angiography demonstrated atrial septal defect (ASD) and left coronary artery-main pulmonary artery fistula. At operation, the ASD was directly closed, and the proximal portion of coronary fistula was successfully ligated from the epicardial side and the fistula orifice was directly closed from inside the pulmonary trunk under the cardiopulmonary bypass. We report a relatively rare case of adult ASD with coronary-pulmonary artery fistula, with particular emphasis on the importance of consideration of the association of this anomaly in diagnosing congenital heart disease.

We performed the thromboexclusion procedure with reconstruction by an axillo-bifemoral bypass for unresectable abdominal aortic aneurysm combined with chronic renal faliure, and obtained satisfactory postoperative result. The patient was a 68-year-old male who suffered from a huge abdominal aortic aneurysm (AAA) and had a history of hypertension and chronic renal failure. The AAA was accompanied with a saccular portion 10cm in diameter which compressed and eroded the vertebral body. Aortic cross-clamping above the bilateral renal arteries was inevitable for resection in spite of the renal dysfunction. We decided that direct manipulation of the aneurysm was impossible despite it being on the verge of rupture, considering the high operative mortality. We employed the exclusion-bypass method to stabilize the aneurysm, that is, we constructed axillo-bifemoral bypass using a knitted Dacron T-graft 8mm in diameter and then intercepted the bilateral common iliac arteries by suture closure. Postoperative intraaneurysmal thrombosis progressed rapidly from the distal side, then it halted just below the bilateral renal arteries on the 12th postoperative day. Renal arterial flow was maintained and renal function improved. Bleeding from the operative wound occurred suddenly on the 5th postoperative day. Although this appeared to be disseminated intravascular coagulation initially, it had resulted from augmentation of fibrinolysis due do acceleration of coagulation. The markers of fibrinolysis for example α₂ plasmin inhibitor (α₂PI) and plasmin-α₂ plasmin inhibitor complex (PIC) were useful for diagnosis, and tranexam acid and aprotinin were effective for therapy. Although the exclusion-bypass method is technically less invasive and useful for high-risk AAA, the postoperative management is not easy because of the acceleration of the coagulation-fibrinolysis system.

Between February 1999 and November 1999, 33 patients (age 67.0±7.6 years old) underwent off-pump CABG using coronary shunt tubes. The number of graft anastomoses per patient was 2.8±0.8. The operative mortality was 0%. There was no incidence of on-pump conversion, low cardiac output syndrome, IABP insertion, mediastinitis or stroke. The maximum CPK-MB during the perioperative period was 25.9±18.8IU/l. One patient had perioperative myocardial infarction probably due to native coronary artery spasm. In patients with off-pump CABG, the intubation time, the ICU stay and the hospital stay were shorter. The number of patients who were extubated in the operating room was higher and the cost was lower than those with on-pump CABG. An early phase study revealed patency ratios of 85% (the previous term) and 97% (the latter term). Off-pump CABG is a safe and effective means of revascularization with no mortality, minimal morbidity and good short-term patency.