Clinical outcomes of CABG for elderly patients have dramatically changed during the last decade. Data from the clinical registries revealed the decrease of in-hospital mortality rate of CABG for elderly patients. Several large-scale comparative studies reported the advantage of CABG to improve long-term outcomes in elderly patients compared with PCI or medical therapy. These findings suggested the need to reconsider our approach to treat ischemic heart disease in the elderly. Hence, this study tries to overview the recent studies investigating the clinical outcomes of CABG for elderly patients.

A 47-year-old man was referred to our hospital with acute congestive heart failure. Echocardiography and computed tomography revealed a left atrial tumor obstructing blood flow. An emergency operation was performed to relieve the obstruction. The tumor deeply invaded the posterior wall of the left atrium. We did not completely resect the tumor. The patient was discharged 10 days after surgery without complications. The tumor was diagnosed as pleomorphic rhabdomyosarcoma histopathologically. Adjuvant chemotherapy (cyclophosphamide, vincristine, adriamycin and dacarbazine) was started 23 days after surgery. Although partial remission was achieved, the tumor started to grow after chemotherapy was discontinued because of severe adverse effects. The patient died 11 months after surgery. In this patient, even though complete resection was not done, emergency palliative surgery was effective to treat acute heart failure and to establish a pathologic diagnosis of the tumor. We report this rare case and discuss the therapeutic strategy for primary cardiac sarcomas.

Eight patients with multiple aortic aneurysms of both the thoracic and abdominal aortae treated surgically from 1991 to 1995 were evaluated clinically. The patients consisted of six men and two women, with an average age of 65.6 years ranging from 50 to 73. The incidence of multiple aortic aneurysms was about 10% of all cases of aortic aneurysms. The entire aorta should be examined in all patients with aortic aneurysms. Among the five patients who underwent a two-staged operation, the thoracic operation preceded the abdominal one in one case, and the abdominal operation preceded the other in four cases. No aneurysm rupture occurred in the two-staged cases. In conclusion we should first replace the aneurysm with the higher risk of rupture. However, when such a judgement is difficult, it is improtant to consider the possibility of a rupture of the second aneurysm or a brain infarction caused by a thrombosis moving from the abdominal aneurysm. The order of operation should be decided according to the location and the size of the thoracic aneurysm.

A 34-year-old woman who was suffering from aortitis syndrome with annuloaortic ectasia (AAE) and severe aortic regurgitation (AR) from 18 years of age was admitted for an aortic root replacement. She has been on 5mg predonine daily. Aortography, CT and echocardiography examinations revealed dilated aortic annulus (D=30mm) and valsalva sinuses (D=43mm) and overstretched aortic valve leaflets. The ascending aorta was aneurysmal (D=50mm). Because of the patient's strong desire to have children, a Freestyle bioprosthesis was chosen for replacement. A collagen impregnated tube graft was interposed between the Freestyle and the proximal end of the transverse aorta. In order to reconstruct the coronary arteries, the Cabrol technique was utilized because of severe inflammatory adhesion of the aortic root. The patient had an uneventful postoperative course. This case shows that an aortic root replacement with Freestyle bioprosthesis offers a great benefit to those patients who are not suitable to receive postoperative anti-coagulation therapy to enable future pregnancy and child delivery.

A 76-years-old woman was admitted with a left ventricular tumor that was accidentally found by a transthoracic echocardiogram. The tumor was located in the papillary muscle near the apex, had an irregular surface, and was well mobile. The urgent operation was planned because the tumor might have caused of embolism. A cardiopulmonary bypass was established with distal ascending aortic cannulation and bicaval venous cannulations. The resection of the tumor was performed by a transaortic approach. Pathological examination confirmed the tumor as primary papillary fibroelastoma. During the operation, a thoracoscope was used to assist the resection of the tumor. It was useful for a good visualization in the left ventricle. In this case report we describe a rare case of primary papillary fibroelastoma in the left ventricle and a technique of resection using a transaortic approach with an assistance of a thoracoscope.

This study was designed to evaluate the perioperative outcome of dialysis patients undergoing cardiac surgery, who were managed with our perioperative dialysis program. Between April 1994 and August 1999, 11 patients (7 men and 4 women with a mean age of 57.3±10.3 (36-73)) with hemodialysis (HD, n=8) and peritoneal dialysis (PD, n=3) underwent cardiac surgery. The duration of dialysis was 5.6±4.3 years. Operation included mitral valve replacement (n=1) and isolated coronary artery bypass grafting (n=10). Patients with HD had single hemodialysis on the day before operation. Patients with PD were maintained on PD in the usual manner until the day before surgery. Intraoperative hemofiltration during extra-corporeal circulation and normokalemic non-depolarizing cardioplegic solution were used in all patients to avoid post-operative hyperkalemia. All HD patients had dialysis on the first post-operative day (POD 1), and then every other day. PD patients had PD soon after arriving at the ICU. Levels of serum creatinine, urea nitrogen, acid-base balance were successfully controlled within acceptable ranges. No patients required emergency HD or any post-operative managements for hyperkalemia in the ICU. Six of 8 HD patients required an increase in vasopressor because of a tendency toward hypotension and 4 of 8 patients suffered from atrial fibrillation during the initial HD on POD 1. Eight of 11 patients could be extubated on the first POD. No hospital death occurred. The use of normokalemic cardioplegic solution was useful to avoid post-operative hyperkalemia. Our perioperative dialysis programme successfully managed the perioperative clinical course of dialysed patients undergoing cardiac surgery.

This study was designed to evaluate the optimal surgical treatment strategy for abdominal aortic aneurysm (AAA) coexisting with coronary artery disease (CAD). Twenty-six patients (21 men and 5 women with a mean age of 72.6±3.7 years old) who required surgical treatment of both conditions were examined. Eleven patients underwent a one-stage operation. Four of them had on-pump CABG and 7, including 3 high-risk-patients, underwent off-pump CABG. There were no operative mortalities, but 3 patients had severe morbidity (respiratory failure, acute renal failure, pneumonia). Fifteen patients underwent a two-stage operation. None of them had rupture of the AAA during the interval between the two operations, but 2 patients with large AAA (more than 6cm in diameter) required emergency operation due to impending rupture of the AAA. There was no operative mortality, but one patient suffered acute renal failure. One-stage operation for low-risk patients seems to be a safe and reasonable strategy. One-stage operation for high-risk patients should be performed cautiously, and off-pump CABG is especially useful in such patients.

A 49-year-old man who had no history of cardiac disease or intravenous drug abuse was referred to our hospital complaining of fever despite antibiotic chemotherapy. Blood culture was positive for Streptococcus agalactiae, and transesophageal echocardiography revealed vegetation attached to the tricuspid valve and moderate tricuspid regurgitation. Two-thirds of the anterior leaflet and a part of the posterior leaflet of the tricuspid valve were excised with the vegetation, and the remaining anterior leaflet was sutured to the posterior leaflet after annular plication. DeVega's annuloplasty was added to a diameter of two fingers. Following this procedure tricuspid regurgitation was minimal.

An 84-year-old man visited a local doctor, complaining of general fatigue for the last 2 months and dyspnea at rest since the last few days. His echocardiogram revealed a defect hole measuring 1.5 cm at the base of the ventricular septum and left-to-right shunt blood flow. The diagnosis of ventricular septal perforation due to subacute myocardial infarction was confirmed, and an emergency surgery was performed. A right atrial oblique incision revealed a perforation just below the tricuspid valve septal apex. The perforation site was closed using the sandwich patch technique with two bovine pericardial membrane patches. The patient was transferred to the hospital for rehabilitation on day 18 postoperatively.

Case 1: Sixty-seven-year-old male. Presented with exertional dyspnea, raising suspicion for constrictive pericarditis. His condition rapidly progressed to a state of shock, necessitating emergency surgery under percutaneous cardiopulmonary support. Pericardiectomy using the waffle procedure was performed. However, there was limited improvement in hemodynamics, and he died on the 17th postoperative day. Postoperative pathological examination diagnosed epithelioid malignant pericardial mesothelioma. Case 2: Sixty-nine-year-old female. Presented with exertional dyspnea, raising suspicion for constrictive pericarditis. While being transported for surgical intervention, she went into shock, followed by cardiopulmonary resuscitation and initiation of percutaneous cardiopulmonary support. Waiting for the improvement of multiple organ failure, pericardiectomy using the waffle procedure was conducted. However, there was limited improvement in hemodynamics, and she died on the 2nd postoperative day. Postoperative pathological examination diagnosed sarcomatoid malignant pericardial mesothelioma.