The patient was a 74-year-old man with a history of previous aorto-coronary bypass grafting 14 years previously. Echocardiography showed severe aortic valve stenosis. Computed tomography showed severe circumferential aortic calcification of the whole aorta, including the aortic root. Coronary cineangiography showed patency of the endoric graft. Avoiding graft injury and aortic cross clamping, we performed apicoaortic conduit. His postoperative course was uneventful, he was discharged very much improved on the 11th postoperative day. This procedure is useful in high risk patients with aortic valve stenosis.

A 60-year-old man, who underwent repair of ventricular septal defect (VSD) 40 years previously, presented with dyspnea on effort and leg edema. Further examination showed residual VSD, mitral and tricuspid valve insufficiency, atrial flutter and pulmonary hypertension. We performed repair of the residual VSD, mitral valve replacement, tricuspid valve annuloplasty, and the Maze procedure. After surgery, systolic pulmonary arterial pressure decreased from 70 to 39 mmHg. On the 4th postoperative day, his hemodynamic state was stable and he weaned from ventilator. He showed hypoxia with sticky excretions, and reintubation was done 10 h after extubation. After intubation, pulmonary hypertension continued, nitroglycerine administration was not effective but inhaleted nitric oxide (NO) improved pulmonary hypertension. On the 15th postoperative day, sildenafil administration from nasogastric tube was started the day before extubation. On postoperative echocardiogram on the 35th postoperative day, the systolic pulmonary arterial pressure was 30-40 mmHg and left ventricular function was severely impaired because of the paradoxical movement of the ventricular septum after repair VSD. Sildenafil was safely used for the patient with heart failure and secondary pulmonary hypertension associated with congenital heart disease.

Although left anterior descending coronary artery (LAD) grafting with a left internal thoracic artery (ITA) on a beating heart via a small left anterior thoracotomy (LAST) has become widely accepted, significant limitations exist due to the limited surgeon experience, smallness of exposure, thus making harvesting of the ITA, visualization of the surgical field and anastomosis quite difficult. Patients often have significant pain and wound complications postoperatively. A lower mini-sternotomy approach in 4 patients was performed from December 1998 through January 1999. Results: The length of mini-sternotomy incision is 7 to 14cm. These operations were accomplished without morbidity or mortality. No patients required intraoperative conversion to conventional bypass. Postoperative angiography showed patency of graft without stenosis of the anastomosis in all 4 patients. The patients did not complain of significant pain and their postoperative hospital stay was 5 to 11 days. The lower mini-sternotomy approach or“xyphoid” approach proposed by Benetti seems to be an excellent novel approach giving the freedom of extension of the incision if needed with satisfactory exposure for left ITA harvest and access to LAD as well as the distal RCA, and causes less postoperative incisional pain.