Combined surgery for left Subclavian artery revascularization and CABG was performed in a 74-year-old man with diabetes mellitus. The preoperative coronary angiogram showed critical stenoses in all three major branches, and arteriography revealed obstruction at the left proximal subclavian artery. Severe atherosclerotic calcification was acknowledged circumferentially in the ascending aorta and in the aortic arch. For this patient axillo-axillary crossover bypass grafting was performed first using and expanded PTFE graft, followed subsequently by off-pump CABG using all in situ grafts (right internal thoracic artery-left anterior descending artery (RITA-LAD), left internal thoracic artery-diagonal branch (LITA-diagonal branch), gastroepiploic artery-right coronary artery (GEA-RCA)). Postoperative recovery was smooth, with disappearance of significant pressure difference between both arms (preoperatively, 46mmHg). An angiogram on the 7th postoperative day showed a widely patent axillo-axillary bypass graft along with good flow of all three coronary grafts, in which LITA was visualized well through the axillo-axillary bypass graft. For complex atherosclerotic disease of the proximal aorta and incipient portion of neck vessels associated with severe coronary sclerosis, this technique is a suitable option.

To assess the indications and clinical outcome of minimally invasive coronary artery bypass grafting with mini-sternotomy and cardiopulmonary bypass (MICS-CABG) for patients with multiple coronary artery disease, left main trunk stenosis and/or concomitant heart diseases, we examined results in 17 patients (mean age 62.5 years) who underwent MICS-CABG. The average number of distal anastomoses was 2.2 anastomoses/patient. The category of the coronary lesions was the left main trunk in 6 patients, triple vessel disease in 7, double vessel disease in 3, and left anterior descending artery stenosis with aortic regurgitation in 1 patient. Each operative procedure through the mini-sternotomy was easily and completely performed in all patients. By means of postoperative coronary angiography, full patency without stenosis in all grafts was recognized in 95.0%. Immediately after the MICS-CABG, all patients showed quick recovery of respiration, and postoperative admission duration significantly decreased compared with standard CABG with full sternotomy. The above results suggest that MICS-CABG is one of the procedures of choice for patients with multiple coronary artery disease, left main trunk stenosis and/or concomitant heart diseases.

Two cases who underwent emergency operation for papillary muscle rupture complicating acute myocardial infarction were presented. The first case was a 75-year-old female who had suffered myocardial infarction 26 days previously. Operation was performed on the 2nd day after onset of mitral insufficiency. The posterior papillary muscle was partially ruptured and the mitral valve was replaced with a mechanical prosthesis (SJM 25mm). The second case was a 76-year-old female who had suffered myocardial infarction 10 days previously. Emergency operation was performed on the 4th day after onset of mitral insufficiency. The posterior papillary muscle was completely ruptured. Mitral valve replacement with a mechanical prosthesis (Omnicarbon 25mm) was performed. In both cases, recovery from cardiogenic shock was not possible preoperatively even with pharmacologic and circulatory support, but the postoperative courses were uneventful in both cases. We recommend immediate surgical intervention for mitral insufficiency in patients with severe grade regurgitation and cardiogenic shock following acute myocardial infarction.