A 78-year-old woman who had undergone triple coronary bypass grafting with the right internal thoracic artery (RITA) to the left anterior descending artery 8 years previously was referred to our hospital because of heart failure due to progressive aortic valve stenosis. Coronary angiography showed that all of the coronary grafts were patent, and multidetector-row computed tomography demonstrated the functional RITA graft located close to the posterior of the sternum at the level of the second costal cartilage. To prevent injury of the RITA graft, we initially performed an inverted-L-shaped partial sternotomy extended to the right second intercostal space. After institution of peripheral cardiopulmonary bypass, we performed careful removal of adhesions along the posterior of the sternum under decompressed conditions and accomplished resternotomy safely. The patent internal thoracic artery grafts were never dissected and the patient was cooled to a rectal temperature of 22°C. After aortic crossclamping, myocardial arrest was obtained with systemic hyperkalemia by instilling 40 mEq of potassium chloride into the cardiopulmonary bypass circuit and we successfully performed aortic valve replacement. This method is an alternative approach for re-do cardiac surgery after previous bypass grafting in patients with a functional RITA graft located close to the posterior of the sternum.

Ebstein's anomaly is a rare congenital heart disease. A 51-year-old man was hospitalized due to Ebstein's anomaly with severe congestive heart failure. He underwent Hetzer's procedure for tricuspid valve incompetence and right atrial isolation technique to restore the sinus rhythm. The postoperative course was uneventful, he was discharged from the hospital on the 21st day after the operation. The cardiothoracic ratio reduced from 74% before the operation to 60%. And his New York Heart Association functional class also improved from III to I after discharge. Hetzer's procedure for tricuspid valve repair in Ebstein's anomaly restructures the valve mechanism at the level of the true tricuspid annulus by using the most mobile leaflet for valve closure without placation of the atrialized chamber. We thus conclude that Hetzer's procedure, with anatomical evaluation of the malformed tricuspid valves before or during the operation, is beneficial as a simple and reproducible method for the repair of certain cases of Ebstein's anomaly.

DeBakey IIIb aortic dissection associated with thoracic aneurysm was successfully operated upon in a 59-year-old man. The patient had sudden onset of severe back pain and pain in the left lower extremity and dissection associated with thoracic aneurysm was diagnosed. During the operation, we used partial cardiopulmonary bypass support with cannulation of the pulmonary and femoral artery. The entry of the dissection was in a true aneurysm of the descending aorta, and it was replaced with a 22mm Hemashield prosthetic graft. Aortic dissection, with entry in the true aneurysm is rare and is of high risk for rupture.

We describe a case of an intracardiac foreign body that was treated by surgery. A 27-year-old man sustained a neck injury by a nail fired from a pneumatic nail gun, and was admitted to a hospital. Chest radiography did not show any abnormality, and his injury healed after 1week. A radiography performed during a routine medical checkup after 2 months indicated that a nail was located within the heart. He was subsequently admitted to our hospital for further examinations. Chest computed tomography (CT) revealed the presence of a nail-like foreign body in the right ventricle. We diagnosed the patient with an intracardiac foreign body that was related to the injury sustained 2 months previously, although the underlying mechanism was unknown. He underwent emergency surgery, and the foreign body was removed under cardiopulmonary bypass without any complications. When a rigid substance impacts the body at high speeds, we should consider that some fragments could remain embedded in the body. CT scans are very useful for the diagnosis and identification of foreign bodies.

We evaluated the efficacy of evoked spinal potential (ESP) monitoring during thoracoabdominal aortic replacement to prevent intra-operative spinal ischemia. Nine patients underwent intraoperative ESP monitoring. The ESP was unchanged in 5 patients and decreased in 4 patients. However, ESP recovered in 2 of them by the following techniques: (1) perfusion of intercostal arteries, (2) elevation of distal bypass perfusion pressure, (3) slight hypothermia. Postoperative paraplegia occurred only 1 patient of the 2 whose ESP was not restored. The sensitivity and specificity of the efficacy of ESP monitoring were 100% and 87.5%, respectively. We concluded that ESP is the most useful monitoring for prevention of operative spinal ischemia during thoracoabdominal aortic replacement.