Endovascular aneurysm repair (EVAR) of pararenal abdominal aortic aneurysm (pararenal AAA) includes fenestrated or branched endografts, and the chimney technique. However, fenestrated and branched endografts are not currently available. An 82-year-old man, who underwent EVAR two years previously, was admitted to our hospital because of pararenal AAA measuring 56 mm. He underwent endovascular treatment with the chimney technique for bilateral renal arteries. We used a self-expanding and balloon-expandable uncovered-stent in renal arteries. Postoperatively he had slight renal dysfunction and acute pancreatitis, but was discharged 14 days after surgery. EVAR with the chimney technique for bilateral renal arteries was thought to be useful in high risk patients with pararenal AAA.

A 75-year-old man was admitted to our hospital due to sudden onset of chest pain. Computerized tomography showed penetrating atherosclerotic ulcer at the distal arch and hematoma around the aortic arch, therefore we diagnosed spontaneous rupture of the aortic arch. He had a history of previous CABG and multiple cerebral infarction with diffuse cerebral arteries. Open surgery under deep hypothermia, circulatory arrest and cerebral perfusion was considered to be difficult and too invasive, therefore we performed debranching TEVAR. Postoperative cerebellar infarction occurred, but he was discharged 29 days after surgery. TEVAR is especially useful for treatment of spontaneous rupture of the aorta in high-risk patients.

Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a severe complication after coronary artery bypass grafting (CABG). Vacuum-Assisted Closure (VAC) therapy is a technical innovation in wound care. The advantage of VAC is the application of negative pressure to sternal wounds. A 73-year-old man was admitted to our hospital because of operation for triple vessel disease including left main coronary artery lesion. Off-pump CABG was performed using the bilateral internal thoracic arteries and right gastroepiploic artery. The postoperative course was uneventful. However, purulent discharge from a median sternostomy wound appeared on the 11th postoperative day. MRSA was identified by the culture of the wound exudate. On operation, the necrotic tissue was removed, and continuous irrigation and drainage were performed. Conventional technique was not effective. VAC therapy was applied on the 35th postoperative day. During VAC therapy, the wound became smaller and granulation tissue proliferated. VAC therapy was discontinued on the 208th postoperative day. Finally, the wound was naturally closed. He was discharged in good condition on the 213th postoperative day. VAC therapy was an effective treatment for MRSA mediastinitis after cardiac surgery.

The current technique of retrograde coronary sinus perfusion (RCSP) has been provided double cannulation of the vanae cavae and isolation of these vessels, and right atriotomy. Most aortic valve and coronary artery bypass surgery are performed with single venous cannulation. We used a new RCSP catheter, Retroplegia (Research Medical Co.), and performed Cabrol procedure safely with single venous cannulation. This catheter can be cannulated to the coronary sinus through a right atrial purse-string suture without opening the right atrium. The occlusion balloon is inflated spontaneously by infusing the cardioplegic solution and occlude the coronary sinus adequately and nicely. This catheter has double lumen, one is for infusion of the cardioplegic solution, the other is for measurement of the coronary sinus pressure. We believe that this catheter is useful for RCSP of the cardiac surgery using single venous cannulation.

The 37-year-old woman underwent mitral valve replacement (MVR) with a Carpentier-Edwards bioprosthesis for hypertrophic obstructive cardiomyopathy (HOCM) 14 years previously. Since the 10th postoperative year, progressive right heart failure due to tricuspid valve regurgitation was recognized. Therefore, reoperation was recommended. At the time of reoperation in the 14th postoperative year, the cavity of the left ventricle was markedly diminished. In particular, deformitiy of the right ventricle was found. This was considered to be the effect of progressive septal hypertrophy. The mitral valve was replaced with a 25mm Carpentier-Edwards and the tricuspid valve with a 31mm Carpentier-Edwards bioprosthesis. Although the weaning from the cardiopulmonary bypass was uneventful, postoperative right heart failure occured with hyperbilirubinemia followed by multiple organ failure. She died on the 47th postoperative day. At autopsy, the intraventricular septal thickness was 24mm and the cavities of left and right ventricle were almost occluded by septal hypertrophy. This is considered to be a rare case of long-term survival after MVR in a patient with HOCM.

Although sequential bypass with in situ arterial conduits (the left and right internal thoracic arteries; LITA and RITA, the right gastroepiploic artery; GEA) in coronary artery bypass grafting (CABG) is technically demanding, it is one of the most important procedures using a limited number of in situ arterial conduits to revascularize a wide area. In this report, we retrospectively investigated the clinical outcome of CABG with 4 or more distal anastomoses using only in situ arterial conduits. From December 1990 to May 1999, 62 patients underwent CABG with in situ arterial conduits, with at least one sequential bypass. There were 59 men and 3 women patients with mean age of 59.6 years (41 to 82 years). Mean postoperative follow-up period was 32 months (1 to 101 months). The total number of distal anastomoses was 4 (1 sequential bypass) in 54 patients, 4 (2 sequential bypasses) in 6 patients, 5 (1 sequential bypass) in 1 patient and 6 (3 sequential bypasses) in 1 patient. There were 5 emergency operations (8%), 37 patients (60%) had a history of myocardial infarction, 30 patients (48%) had diabetes mellitus and 6 patients (10%) had chronic renal failure and were on hemodialysis. Left ventricular ejection fraction was 40% or less in 15 patients (24%). There were no early deaths. Angiographic patency was satisfactory for each graft (sequential: individual, LITA 96.7%: 100%, RITA 100%: 100%, GEA 89.5%: 97.4%). Patency of a distal anastomoses of GEA was rather poorer than that of proximal (p=0.03). Three patients died during the follow-up period (all of them due to malignancy). The 5-year actuarial survival and cardiac event-free rate was 94.6% and 87.2%, respectively. In conclusion, although an indication of GEA sequential grafting needs further study, in situ arterial grafting with at least one sequential arterial conduit was associated with excellent results and achieved more complete revascularization with exclusive use of in situ arterial conduits in patients with diffuse coronary artery disease.

Rheumatic tricuspid stenosis has become rare recently. A 54-year-old woman had undergone mitral valve replacement with a Carpentier-Edwards bioprosthesis for mitral stenosis 22 years previously and had undergone repeat mitral valve replacement for prosthetic valve failure 10 years later. She was admitted with severe leg edema. Cardiac catheterization revealed pulmonary hypertension and tricuspid stenosis with a diastolic pressure gradient of 6mmHg across the tricuspid valve. Tricuspid valve replacement was performed with a Hancock bioprosthesis. The postoperative course was uneventful and her edema improved markedly. This case suggested that careful follow-up to detect progression of tricuspid stenosis is necessary in patients with rheumatic valve disease and pulmonary hypertension.