A 74-year-old man had a right common iliac aneurysm perforating into his inferior vena cava. He showed a pulsating abdominal mass, claudication of the right leg and swelling of both legs. The fistula was preoperatively diagnosed by aortography. The fistula was closed with two interrupted 3-0 monofilament sutures with pledgets within the aneurysm, by clamping all vessels communicating to it. The aneurysm was replaced with a Y-shaped Dacron graft. The postoperative course was uneventful and the patient was discharged on the 17th postoperative day without any leg claudication or swelling of the legs. This complication is rare, with only 7 such reports in Japan. It should be surgically managed as soon as the diagnosis is confirmed. Clamping all vessels communicating to the fistula in closing it is a safe and reliable approach.

We report a case of successful saphenous vein bypass grafting for superior mesenteric artery stenosis. A 50-year-old man complained of abdominal pain which was not induced by either eating or defecation. He was admitted to our hospital and examinations of the gastrointestinal tract revealed no abnormality. Angiography showed stenosis of the superior mesenteric artery (SMA), but not of the celiac artery (CA) or inferior mesenteric artery (IMA). We speculated that his symptom was due to SMA stenosis and poor collateral circulations from the CA, IMA and internal iliac arteries. Saphenous vein bypass grafting for SMA was undertaken successfully and abdominal pain disappeared completely.

An increase of aortic valvular disease associated with congenital bicuspid aortic valve is observed due to the relative decrease of rheumatic valvular diseases. A total of 24 patients with aortic valvular disease associated with congenital bicuspid aortic valve underwent surgical treatment at our institution during the period from January, 1997 to December, 1999. These 24 patients constituted 46.2% (24/52) of all cases of surgical operations for aortic valvular disease. The age of the patients ranged from 17 to 83 years (mean 62 years). They consisted of 16 men (66.7%) and 8 women. Two patients had infective endocarditis. The classification of congenital bicuspid aortic valve was right-left cusp type in 15 patients (raphe+: 11), anterior-posterior cusp type in 9 patients (raphe+: 9). We performed aortic valve replacement in 22 patients, aortic root replacement in 1 patient and aortic root remodeling in 1 patient in combination with mitral valve plasty in 3 patients, coronary artery bypass grafting in 3 patients and closure of the atrial septal defect (ASD) in 1 patient. We detected ASD in 1 patient, ventricular septal defect in 1 patient and high-posterior take-off right coronary artery in 1 patient. Patients with stenosis often have a small aortic annulus and severe post-stenotic aortic dilation. Preoperative and intraoperative evaluation is important in cases of aortic valvular disease associated with congenital bicuspid aortic valve.

We report the results of aortic arch replacement in 32 patients (20 males, 12 females) with aortic arch aneurysm, including 9 emergency cases. The etiology of aneurysm was atherosclerotic aneurysm in 18 patients, pseudoaneurysm in 1 patient, and aortic dissection in 13 patients. Selective cerebral perfusion (SCP) and retrograde cerebral perfusion (RCP), which are used for brain protection during aortic arch reconstruction, were both employed in this study according to our institutional policy. RCP was started at the moment of circulatory arrest after which the aneurysm was opened. In the case of 1-branch reconstruction or hemiarch replacement, we only employed RCP. If 2-branch reconstruction or total arch replacement was needed, we switched to SCP. After the distal graft anastomosis was performed, antegrade systemic perfusion was started via the 4th branch of the graft. Subsequently, 3 arch vessels was reconstructed with rewarming to shorten the SCP time, and finally proximal graft anastomosis was performed. Distal graft anastomosis with a new technique was applied in the 10 most recent cases. The “cuff” was made at the distal anastomosis site of the graft beforehand and this “cuff” was sutured to the aortic wall in an elephant-trunk fashion. This technique was a simple approach to repairing the distal lesion and allowed easy addition of stitches in case's of bleeding. The in-hospital mortality rate was 6.3% (2 of 32 patients) and the rate of cerebrovascular accident was 6.3% (2 of 32 patients). This technique for aortic arch repair is a useful method that results in low rates of in-hospital mortality and morbidity.

Coronary artery bypass grafting (CABG) using in situ skeletonized arterial conduits with an off-pump technique is a high quality and minimally invasive procedure. The internal thoracic artery (ITA) is the most reliable conduit as grafting the left anterior descending artery and circumflex arteries with bilateral ITAs leads to better long-term patient outcomes. In this study, we demonstrated the feasibility and usefulness of off-pump coronary artery bypass grafting surgery using bilateral ITAs. A total of 217 consecutive CABG cases using skeletonized ITA grafts were studied and they were divided into 2 groups are using unilateral ITA (UITA, n=104) and the other using bilateral ITA (BITA, n=113). OPCAB was completed in 94% (98/104) in the UITA group and in 99% (112/113) in the BITA group. The mean number of distal anastomoses per patient was 3.02 in the UITA group and 3.63 in the BITA group. The ITAs were used in situ in 100% (104 ITAs) in the UITA group and in 96% (217 ITAs) in the BITA group. One patient in the UITA group suffered from mediastinitis and one patient in the BITA group died due to intestinal ischemia 3 days after operation. Postoperative angiography was performed before discharge in 101 patients in UITA and 99 in BITA. The patency rate was 98.7% in the UITA group and 99.4% in the BITA group. OPCAB with bilateral skeltonized ITAs is a feasible and safe technique with excellent early clinical results and graft patency. OPCAB using in situ skeletonized artery conduits can become a standard surgical treatment for ischemic heart disease.

A digital teaching material on the cardiac cycle, which discretely illustrates only the left heart system, not the right, and shows the pressure of each section clearly with an illustration of a water pipe pressure gauge, as proposed by G. Doman et al., was presented to medical students, who had not previously learned circulatory physiology. Many formative questions were also provided to promote active learning. After learning the material, the students were given an anonymous questionnaire comparing the present material with a standard textbook of physiology as the control. When asked the overall impression, 86% of the students supported the present material.

A digital teaching material on the cardiac cycle, which discretely illustrates only the left heart system, not the right, and shows the pressure of each section clearly with an illustration of a water pipe pressure gauge, as proposed by G. Doman et al., was presented to medical students, who had not previously learned circulatory physiology. Many formative questions were also provided to promote active learning. After learning the material, the students were given an anonymous questionnaire comparing the present material with a standard textbook of physiology as the control. When asked the overall impression, 86% of the students supported the present material.

A digital teaching material on the cardiac cycle, which discretely illustrates only the left heart system, not the right, and shows the pressure of each section clearly with an illustration of a water pipe pressure gauge, as proposed by G. Doman et al., was presented to medical students, who had not previously learned circulatory physiology. Many formative questions were also provided to promote active learning. After learning the material, the students were given an anonymous questionnaire comparing the present material with a standard textbook of physiology as the control. When asked the overall impression, 86% of the students supported the present material.

Long-term hemodialysis remains a major risk factor for coronary artery bypass grafting (CABG). In our institution, a surgical strategy for these high risk patients is the complete coronary revascularization with off-pump CABG (OPCAB) using an arterial graft. However in cases of advanced functional disorder, we choose hybrid strategy or reduction strategy, namely the target of surgical intervention is just the key vessel. Aggressive usage of continuous hemodiafiltration (CHDF) to control water and electrolytic balance intra- and post-operatively is an alternative. This study aimed to elucidate whether our strategy is appropriate for hemodialysis patients. We enrolled 608 consecutive patients who underwent CABG between August 1999 and December 2006. Among them, 25 (4.1%) had received regular hemodialysis. As a control group, 100 patients were selected randomly among 583 patients excluding 25 hemodialysis patients. All patients had at least one major complication, and 13 had several major complications. The number of preoperative complications in hemodialysis patients is significantly higher than that of control group. Mean patient age was 66.3±8.7 years. The mean number of diseased vessels was 2.32±0.7, and that of anastomosis per patient was 2.4±1.2. All patients completed the procedure without cardiopulmonary bypass (CPB) as a result. Complete revascularization was performed in 22 (88%). The causes of non-completion were a hybrid strategy with PCI in one patient in the early period and a reduction strategy in 2 on account of social indications. Perioperative mortality was 0%, while the major complication was extended pleural effusion in 3 patients and slowly progressive sternal osteomyelitis in one. Mid-term results showed 2 cardiac deaths. The surgical outcome was equivalent in the hemodialysis group and the control group, though each preoperative state was not equal. Our strategy for patients undergoing chronic hemodialysis attained excellent perioperative and mid-term outcomes. We consider OPCAB produced better outcomes. CHDF is an important tool for use in surgical intervention in these patients.

A 44-year-old woman with dyspnea on effort was admitted. Aortic stenosis and mitral stenosis and pulmonary hypertension were diagnosed. She underwent surgical treatment for her aortic valve and mitral valve by enlarging the aortic and mitral valve ring and replacing them by modified coupling valve methods. The postoperative course was uneventful and she was discharged on the 21st postoperative day.