Surgical treatment of two abdominal and two thoracic aneurysms in hemodialysis patients were performed from 1991 to 1993. Two elective cases survived, but two emergency cases died. The causes of death were PMI and respiratory failure. Ruptured aneurysms are critical and probably result in higher mortality and morbidity than elective replacement of aneurysms. In view of the documented risk of rupture and current operative risk, we believe that elective surgical treatment of aneurysm is a much better treatment than following the aneurysms until they produce symptoms or significantly enlarge.

A 54-year-old male with sudden back pain was diagnosed as having acute aortic dissection of Stanford type A. He underwent an aortic arch replacement under the deep hypothermic circulatory arrest and retrograde cerebral perfusion. During retrograde cerebral perfusion, the central venous pressure was maintained at 20mmHg, the perfusion flow rate was 400ml/min and the lowest rectal temperature was 19°C. The duration of retrograde cerebral perfusion was 135 min, but the patient recovered successfully without any evidence of neurological complications. This report suggests that retrograde cerebral perfusion associated with deep hypothermic circulatory arrest has the possibility to prolong the safety time limit of antegrade cerebral circulatory arrest up to 135min.

We present a case of aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer. A 84-year-old man with a history of esophageal resection with retrosternal reconstruction by gastric tube for esophageal cancer required aortic valve replacement for aortic stenosis. The aortic valve was approached through an 8-cm right parasternal incision over the third and fourth costal cartilages. Cardiopulmonary bypass was initiated through cannulas in the ascending aorta and the right atrium and the aortic valve was replaced with a bioprosthetic valve. The postoperative course was uneventful. In the literature, there are only 7 reports on such cases so far, in which aortic valve relplacement was performed through left thoracotomy, right parasternal approach or median sternotomy. We recommend the right parasternal approach in cases of aortic valve replacement in patients with retrosternal gastric tube, because it does not only avoids injury of gastric tube, but also offers an excellent operative view.

Though the number of reoperative coronary artery bypass grafting procedures (re-CABG) is increasing, the operative results are still inferior to primary CABG. In the present study, we analyzed results of our two different procedures for re-CABG and estimated predominance of the LAST-MIDCAB (off-pump left anterior small thoracotomy minimally invasive direct coronary artery bypass) procedure in selected patients. From 1999 to 2001, 25 patients underwent re-CABG. The age of patients ranged from 56 to 82 years (mean 70 years). Re-CABG was performed due to the occlusion of existing grafts in 14 cases, progressive disease of previously ungrafted vessels in 6 and anastomotic stenosis of previously grafted vessels in 5. We performed off-pump LAST-MIDCAB in 15 patients, on-pump CABG via a median sternotomy in 9 and on-pump LAST-CABG in 1 which was converted due to RV injury during a re-sternotomy. In the LAST-MIDCAB group, the left internal thoracic artery was chosen as a graft to the LAD in 10 patients, the right gastroepiploic artery in 4 and the saphenous vein in 1. The operation time of the LAST-MIDCAB group was significantly shorter than that of the on-pump CABG group. Blood transfusion was necessary for only one patient in the LAST-MIDCAB group. Although many postoperative complications occurred in the on-pump CABG group, no major postoperative complication was seen in the LAST-MIDCAB group except one patient who sufferred from lung fibrosis, which led to shortness of the postoperative hospital stay. We conclude that LAST-MIDCAB is an alternative way to reduce operative morbidity in selected re-CABG cases.

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.

A 10-year-old girl with heart murmur immediately after birth was found to have a ventricular septal defect (VSD). Although she had been followed up for an insignificant shunt, funnel chest became apparent and was referred to our hostpital at the age of 10. She was 133 cm in height, 25.7 kg in weight with a body surface area of 0.99 m². The VSD was the muscular outflow type with a Qp/Qs of 1.1, defect of 2.5 mm in diameter, and pulmonary artery pressure of 24/10/15 mmHg. Pectus excavatum was apparent with a CT index of 2.99. The preceding surgery for one was likely to interfere with the subsequent surgery for the other. Therefore we decided on concomitant surgery for both. Under median sternotomy, cardiopulmonary bypass was established and the VSD was closed with a patch. After the pericardium was sutured and closed, a tape was carefully passed through the chest wall under the guidance of direct vision and digital palpation. A metal bar was inserted guided by the tape, reversed with a rotator, appropriately shaped with a hand bender, and was fixed to the chest wall with the stabilizer bars at both ends. The sternum was sutured with 1-0 polyester sutures and two sternum pins made of particulate hydroxyapatite and poly-L lactide. The postoperative course was uneventful. After 2 years, the excavatum was adequately corrected and the bar was successfully removed under general anesthesia. Although the comorbidity of VSD and funnel chest is rare, concomitant surgery for both can be safely carried out and may be considered as an option for treatment.