The survival of adult patients with total anomalous pulmonary venous return (TAPVR) is rare without surgery. A 38-year-old man was referred to us on emergency basis because of congestive heart failure. Cardiac catheterization and angiogram demonstrated TAPVR (Darling type Ia) with a Qp/Qs of 3.4, Pp/Ps of 0.17 and Rp/Rs of 0.03. Operative procedures consisted of a large anastomosis between the left atrium and the common pulmonary vein using a superior approach, closure of the atrial septal defect, and ligation of the vertical vein. Repeated catheterization three months after surgery showed normal hemodynamics and pulmonary vascular resistance. We consider that the strongest determinant factor affecting long-term survival is normal or only slightly elevated pulmonary vascular resistance, and that the superior approach is useful in adult patients for repair of supracardiac type TAPVR, because it offers an excellent operative field and the risk of postoperative atrial arrhythmia was thought to be minimal.

A 52-year-old man had a saccular non-trauma-induced aneurysm of the left internal thoracic artery (ITA) with ischemic heart disease. Right ITA-to-LAD anastomosis was performed for one-vessel disease under CPB. The left ITA aneurysmectomy was performed and reconstructed by end-to-end anastomosis. The resected specimen showed the features of atherosclerotic changes. This is the eighth reported case of this entity in the international and Japanese literature. The previous 7 cases are reviewed. The association with von Recklinghausen's disease and Kawasaki disease are discussed. Also summarized are the symptomatology, diagnosis, and management of this very rare condition.

A 52-year-old male with unstable angina after acute myocardial infarction, and Leriche's syndrome was referred to our hospital for intensive care. He had a history of diabetes. Coronary angiography demonstrated a 75% stenosis of the LMT in association with a 90% stenosis of the LAD, 75% stenosis of the LCX and 99% stenosis of the RCA. Aortography revealed an arterial occlusion extending from the infrarenal aorta to both common iliac bifurcations. Both internal thoracic arteries were well developed as collateral pathways to external iliac arteries. With concomitant Y graft replacement of the abdominal aorta, two large internal thoracic arterial conduits and the right gastroepiploic artery were grafted to the coronary artery. This procedure was useful for protection of limb ischemia, in addition to producing a route for insertion of an intraaortic balloon pumping catheter.

Pseudoaneurysm of the ascending aorta is a rare but potentially fatal complication of cardiovascular surgery. Two cases are described in which a pseudoaneurysm of the ascending aorta developed and caused profuse intermittent bleeding through the MRSA infection of the sternotomy wound. One was a 29-year-old man who had undergone a mitral valve replacement five months previously. The aneurysm was successfully repaired with a prosthetic graft patch under deep hypothermia and circulatory arrest, when a bloodless field was obtained using a handmade double-balloon catheter. The other patient was a 79-year-old man who had undergone a graft replacement of the distal aortic arch four months previously. The possibility of surgical correction was also considered but was thought to carry too high a risk. Embolization of the aneurysm was therefore regarded as the only realistic alternative, but failed, and he died due to aneurysmal rupture. The importance of the diagnosis process and surgical and intervascular treatment of pseudoaneurysm of the ascending aneurysm is described.

We reviewed the results of 14 patients who underwent the operation of thoracic aneurysms using a centrifugal pump. Nine patients had atherosclerotic aneurysms and 5 had aortic dissections. The autotransfusion system (ATS) was used to keep hemodynamic stability by rapid transfusion. The ATS consisted of a roller pump, a 2, 000ml reservoir and a heat exchanger. Two mg/kg of heparin was given to the patients to keep ACT over 400 seconds. All patients survived. Body temperature increased 0.08±0.59°C during bypass with the ATS, and no patients showed hemodynamic instability after aneurysmotomy under the help of the ATS. We conclude that 1) the centrifugal pump is a useful and safe assisting means for the surgery of thoracic aneurysms, 2) the autotransfusion system has advantages as follows: keeping stable circulation and preventing loss of body temperature during bypass.