We describe two repeated operations to treat ascending aortic pseudoaneurysms. The first was emergency patch closure of the ascending aorta due to impending rupture 8 years after an operation for type I aortic dissection under hypothermic circulatory arrest. The second was endovascular repair using a fenestrated stent graft 7 years after coronary artery bypass grafting. No specific guidelines have been established regarding optimal management for such patients. We believe that individualized management is safer, especially for repeated operations.

We performed aortic remodeling using a tailored Dacron graft (Yacoub's procedure) in two cases of root aneurysm combined with aortic regurgitation. The cases were 20-year-old and 45-year-old women. The leaflets did not coapt at a central portion, but the lack of coaptation did not produce significant prolapse. No organic change was found, so we attributed aortic regurgitation to sinotubular junction. Remodeling of the root was selected as the operative procedure because degeneration in the annulus was unlikely in these two cases. All three sinuses were excised, with 3mm of the arterial wall left above the aortic annulus and a small button of the aortic wall around the ostia of the coronary arteries. Then each commissure was pulled up and the height of the commissure was measured. The proximal end of the graft was then tailored to a scallop shape, so that the top of the scallop matched the commissure level. The graft was then sutured to the aortic rim with continuous 5-0 polypropylene sutures. Both coronary arteries were reimplanted utilizing the Carrel patch method and the distal graft anastomosis was completed. The aortic crossclamp times were 147 minutes and 163 minutes and the total pump times were 166 minutes and 189 minutes. One patient has mild or 1+ aortic regurgitation on postoperative echocardiogram and aortography, but she has no activity restrictions, and no evidence of congestive symptoms. Yacoub's remodeling procedure which spares the aortic valve, requires no anticoagulant therapy in the post-operative period. Aortic valve-sparing replacement of the aortic root is an excellent procedure for any patient with an ascending aneurysm and an anatomically salvageable valve. Although further long-term follow-up is required, we believe that preserving the native aortic valve is useful for preventing complications associated with mechanical valves.

During the past 7 years from January 1991 through October 1997, we treated 30 cases of aortic root reconstruction by the Carrel patch method. The cases included annulo-aortic ectasia (AAE), root aneurysm with aortic regurgitation (AR), aortic dissection with AR, and true aneurysm (ascending and arch) with AR. The surgical treatment consisted of 28 modified Bentall operations and 2 aortic root remodelings, similar to the Yacoub operation. The aortic root and valve were resected, the coronary arteries were dissected free, mobilized, and then implanted into the composite graft. Coronary anastomosis was performed by mattress suture reinforced by Teflon felt strips. In 5 cases it was necessary to undergo coronary artery bypass grafting for myocardial ischemia. Blood transfusion was unnecessary in 11 cases. Post operative death was seen in only one patient who underwent an emergency operation for cardiac tamponade due to aortic dissection on the 25th postoperative day. The operative mortality rate was 3.3%. The complications of anastomosis, for example leakage and dilatation of the coronary ostia, were not seen in our experience. Reoperation and late death were not observed during the follow-up period (average 23 months). Cerebral hemorrhage occurred in only one case, at 5 years after the operation, and all other patients had an uneventful postoperative course. The event-free rate is 75% (n=1) at 6 years. The operative procedure is considered feasible in any anatomic variation of aortic root diseases, even if dislocation of the coronary ostia is minimal, and this method holds hope for the prevention of anastomotic pseudoaneurysm formation and long-term survival. Although further long-term follow-up study is necessary, our experience suggests that the Carrel patch procedure has few late term complications.

Use of the internal thoracic artery for myocardial revascularization has regained general acceptance because it offers better long-term results than do venous conduits. However, according to angiographic studies, it has been reported that atherosclerotic changes in the internal thoracic artery occurred in 1-5% of patients with coronary artery disease, although, generally, it is considered that atherosclerotic changes in internal thoracic artery are rare. From January 1998 to August 2001, of the 274 patients who underwent coronary artery bypass grafting, it was estimated that the left internal thoracic artery could not be used for coronary revascularization by preoperative angiography in 7 patients (7/262=2.7%). Two hundred sixty-two patients underwent preoperative angiography to evaluate the grafts for coronary revascularization. All were men and age at the time of operation ranged from 62 to 81 years (mean, 68.6 years). The reason for the left internal thoracic artery being useless were occlusion or stenosis of the subclavian artery in 4 and stenosis or occlusion of the left internal thoracic artery in 3. One patient needed an emergency operation. Four patients had a history of myocardial infarction, 3 patients had hypertension, 2 patients had diabetes mellitus, 4 patients had hyperlipidemia, 1 patient had aortitis and 3 patients had a history of percutaneous transluminal coronary angioplasty. There were 4 patients with peripheral vascular disease. Four right internal thoracic arteries, 9 radial arteries and 6 gastroepiploic arteries were used for coronary revascularization. A composite Y graft (right internal thoracic artery-radial artery) was used in 3 patients, and sequential bypass was performed in the other 3 patients. The total number of distal anastomoses was 2.7±1.0/patient. The angiographic patency of the distal anastmoses was 94.7% (18/19). One patient required intra-aortic balloon pumping postoperatively for perioperative myocardial infarction (Max CK-MB 200IU/l). All other patients had an uneventful postoperative course. In conclusion, although the internal thoracic artery is a protective vessel, there is a certain extent of atherosclerosis, which correlates with known risk factors. Our observations should not preclude use of the internal thoracic artery, but they should be considered for patients who are at risk for atherosclerotic changes of the internal thoracic artery. We considered that it is important to evaluate condition of in situ arterial grafts for patients with coronary artery disease preoperatively. Although further studies are required, in situ arterial grafting with sequential arterial conduit and composite arterial graft were associated with excellent results and achieved complete revascularization.

An echocardiogram revealed a mobile mass attached to the left coronary cusp of the aortic valve in an 81-year-old woman. The tumor was surgically removed without valve replacement. The tumor was whitish in color, with a sea anemone-like appearance, and it measured 10 mm in maximum dimension. It was histopathologically defined as papillary fibroelastoma (PFE), and the postoperative course was uneventful. Primary cardiac tumors are rare, and the majority are myxomas. However recent advances in noninvasive examination and surgery may increase the detection of PFE, which occurs most frequently on the endocardial surface of the cardiac valve. We report a case of cardiac PFE with a review of the pertinent literature.

Patients with myelodysplastic syndrome (MDS) most commonly have refractory anemia accompanied by various degrees of granulocytopenia and thrombocytopenia. At the time of cardiac surgery, both major infections and bleeding are severe complications in patients with pancytopenia due to MDS. However, there were very few patients with MDS who had undergone open-heart surgery. We reported a case of mitral valve replacement in a patient with MDS. A 68-year-old man with valvular heart disease and MDS, with a platelet count of 1.9×10⁴/mm³, underwent successful mitral valve replacement. The mitral valve was replaced by an SJM 25 A prosthesis after resection of left atrial thrombosis using cardiopulmonary bypass. Platelets were transfused after the bypass. Perioperative hemorrhage was moderate and postoperative course was uneventful. We evaluated platelet function by Sonoclot coagulation and a platelet function analyzer. We did not need a large amount of transfusion of red blood cells and platelets, and prevented major bleeding and severe wound infections in the acute postoperative state.

Papillary fibroelastoma (PFE) is a rare primary cardiac tumor that usually involves an aortic or mitral heart valve. We encountered a case of a 32-year-old woman, who presented with syncope and was found to have multiple PFEs involving all four heart valves during surgery. The echocardiography was performed and showed two mobile masses near the tricuspid and mitral valves. Moreover, the enhanced computed tomography (CT) showed thickened aortic cusps, which may indicate the possibility of heart tumor. Intraoperatively, we first found multiple tumors at each cusp of the aortic valve, ranging in size from 5 to 10 mm which were excised without injury of aortic cusps themselves. These showed a sea anemone-like appearance and were suspected to represent PFE. We then observed the tricuspid and mitral valves, and both valves showed tumors of similar appearance in each cusp. Furthermore, we found a tumor at the pulmonary valve, even though there had been no evidence of its presence on echocardiography or CT. We confirmed that these masses were PFEs by histological study after the operation. We should keep in mind that PFE can develop in multiple valves. To the best of our knowledge, this is the first description of multiple PFEs involving all four heart valves.