Case 1 presented congestive heart failure with atrial fibrillation. Echocardiography and cardiac catheterization demonstrated mitral regurgitation and communications between the right and left coronary arteries and pulmonary artery (PA). The fistula orifice was directly closed and mitral annuloplasty was done at the same time. Case 2 had a history of open mitral commissurotomy for mitral atenosis (MS), and was diagnosed as to be re-MS. Selective coronary angiography (CAG) newly documented an aberrant artery originating from the left coronary artery and draining into the distal right PA. At operation, the origin of the aberrant artery was successfully ligated, and mitral valve was replaced with a prosthetic one. This paper presented relatively rare types of coronary artery fistulae, focusing on the importance of routine CAG before open heart surgery and of consideration on the association of this anomaly in respect to perioperative myocardial protection.

To investigate the efficacy of human superoxide dismutase (h-SOD) in myocardial ischemia and reperfusion with difference of administration of h-SOD, twenty four dogs were subjected to 120min ischemia by the cross clamping of the ascending aorta, and followed by 60min reperfusion, The dogs were randomly assigned to three groups: group G, h-SOD (8mg/kg) was injected into the cardiopulmonary bypass (CPB) circuit 5min prior to reperfusion; group L, h-SOD (3mg/kg) was administered by bolus injection through the aortic root into the coronary artery 1min prior to reperfusion; group C, nothing was administered. The values of creatinine phosphate MB isozyme (CPK-MB) and a-hydroxydehydrogenase (HBD) in coronary effluent, and lipid peroxides (LPO) in coronary artery and sinus blood, were measured during CPB. Cardiac function was evaluated by cardiac index (C. I.) and LV max d_p/d_t, and it was expressed as a percent recovery of pre-CPB state. Myocardial water contents as myocardial edema were measured after CPB. Effluents of CPK-MB and HBD at 60min after reperfusion were less in group L than group G, C. Generations of LPO (A-Cs difference) were less at 5min after reperfusion in group G, L than group C and there were significant differences between group G, L and group C. The percent recovery of C. I. and LV max d_p/d_t at 60min after reperfusion was superior in group G, L than group C and there were significant difference between group G, L and group C. Myocardial water contents at 60min after reperfusion were less in group G, L than group C and there were significant difference between group G, L and group C. In the lipid peroxides generation, cardiac function and myocardial edema except effluents of cardiac enzymes, group G was as well as group L. These data suggest that the injection of h-SOD into the CPB circuit just before reperfusion is effective to prevent the reperfusion injury as well as the administration through the aortic root.

A 53-year-old man underwent aortic and mitral valve replacement, but postoperative cardioangiograms unexpectedly demonstrated aneurysms that had developed right-anteriorly and exactly anteriorly to the ascending aorta. They were initially thought to be pseudoaneurysms formed at the sites of aortotomy for valve replacement and of the aortic hole made by the needle puncture for air-venting. Operative findings, however, strongly suggested that it was a DeBakey type II dissecting aneurysm with two entries at the same sites as described. It was found that almost all distal parts of the aneurysmal cavity, probably a pseudolumen, had been occluded with clots, leaving two round cavities at the entries, which were preoperatively observed as pseudoaneurysms. The entries were successfully closed with approximation of the aortic walls using cardiopulmonary bypass, and the patient survived the operation.

We performed the thromboexclusion procedure with reconstruction by an axillo-bifemoral bypass for unresectable abdominal aortic aneurysm combined with chronic renal faliure, and obtained satisfactory postoperative result. The patient was a 68-year-old male who suffered from a huge abdominal aortic aneurysm (AAA) and had a history of hypertension and chronic renal failure. The AAA was accompanied with a saccular portion 10cm in diameter which compressed and eroded the vertebral body. Aortic cross-clamping above the bilateral renal arteries was inevitable for resection in spite of the renal dysfunction. We decided that direct manipulation of the aneurysm was impossible despite it being on the verge of rupture, considering the high operative mortality. We employed the exclusion-bypass method to stabilize the aneurysm, that is, we constructed axillo-bifemoral bypass using a knitted Dacron T-graft 8mm in diameter and then intercepted the bilateral common iliac arteries by suture closure. Postoperative intraaneurysmal thrombosis progressed rapidly from the distal side, then it halted just below the bilateral renal arteries on the 12th postoperative day. Renal arterial flow was maintained and renal function improved. Bleeding from the operative wound occurred suddenly on the 5th postoperative day. Although this appeared to be disseminated intravascular coagulation initially, it had resulted from augmentation of fibrinolysis due do acceleration of coagulation. The markers of fibrinolysis for example α₂ plasmin inhibitor (α₂PI) and plasmin-α₂ plasmin inhibitor complex (PIC) were useful for diagnosis, and tranexam acid and aprotinin were effective for therapy. Although the exclusion-bypass method is technically less invasive and useful for high-risk AAA, the postoperative management is not easy because of the acceleration of the coagulation-fibrinolysis system.