A 53-year-old male patient was admitted with back pain. A diagnosis of DeBakey IIIb type dissecting aortic aneurysm was made based on the results of examinations such as CT-scan and MRI. The right renal artery bifurcated from the pseudolumen. The right iliac artery and left renal artery showed severe stenosis due to aortic dissection. Y-graft replacement of the abdominal aorta was carried out to save the right iliac artery and left renal artery. At the same time, a fenestration operation was carried out to maintain the blood flow of the right renal artery which bifurcated from the pseudolumen. Secondarily, replacement of the descending aorta was carried out with successful thrombotic obstruction of the pseudolumen.

This report describes the surgical technique for partial left ventriculectomy (PLV) and perioperative management. We have performed PLV to treat end-stage non-ischemic cardiomyopathy in 6 patients (4 men and 2 women, mean age: 59 years) since February 1998. Preoperative New York Heart Association (NYHA) functional class was III or more in all patients. On echocardiography, the mean left ventricular diastolic dimension was 75mm, and the mean ejection fraction was 29%. One patient was operated on with cardiogenic shock, and 5 were elective cases. A wedge of the left ventricular muscle was removed from the apex to the base of the two papillary muscles. Associated surgical procedures were as follows; mitral valve reconstruction in 5 patients (4 replacements and 1 annuloplasty), tricuspid annuloplasty in three, and aortic valve replacement in one. Five elective patients were successfully weaned from cardiopulmonary bypass, but one emergency surgery case required intraaortic balloon pumping. Two patients died in the hospital: one elective case was due to multiple organ failure, and one emergency case due to low output syndrome. Three of 4 survivors returned to NYHA functional class I-II, and 1 remained in class III. We are very cautious to ensure that extended PLV does not to lead to serious diastolic dysfunction. The complete reconstruction of the mitral valve and the preservation of annular-chordal-papillary muscle continuity result in the maintenance of left ventricular function and geometry. The practical principles in the post-PLV period are to maintain adequate preload and to avoid excessive afterload. Further studies are required to further enhance outcome.

A 36-year-old man underwent partial left ventriculectomy (PLV) to treat end-stage dilated hypertrophic cardiomyopathy. Mitral valve replacement and tricuspid valve annuloplasty were performed to correct the mitral and tricuspid valve insufficiency. The patient suffered ventricular tachycardia and ventricular fibrillation (VT/VF) soon after surgery, but antiarrhythmic-drug therapy was sufficiently effective to treat the VT/VF. On the third postoperative day, an implantable cardioverter-defibrillator (ICD) was implanted to prevent these arrhythmias. Two months later after his discharge from the hospital, recurrent VT/VF appeared and was supposedly associated with renal failure. Continuous hemodialysis was efficacious to ameliorate the systemic circulation, and ventricular arrhythmias disappeared. He survived due to 18 ICD shocks. In appropriately selected patients, ICDs have been recognized as one of the cost-effective therapeutic options. ICDs might be recommended for patients in the postoperative period of PLV who have potentially lethal ventricular arrhythmias resistant to antiarrhythmic-drug therapy.

It is a common notion that the right gastroepiploic artery (RGEA) tends to exhibit more hardening than the internal thoracic artery (ITA) and that it shows varied development among patients, since RGEAs are structurally rich in musculature. Therefore, a preoperative examination should be conducted to determine whether or not they are appropriate for grafting. In general, catheter-angiography is widely employed for such examinations. Our recent research on the availability of CT-angiography as an alternative has revealed that CT-angiography is a minimally-invasive, simple way of testing, and provides very clear and detailed angiographical pictures. We therefore concluded that it was a highly effective method in deciding the appropriateness of RGEA for graft.

We report a case of total aortic arch replacement for ruptured aortic arch aneurysm in an oldest-old person. The patient was a 92-year-old woman with hypertension, who had normal daily activity. She consulted another hospital because of hemoptysis. A chest roentgen exam showed an outpouching of the first left arch. In our hospital, chest computed tomography revealed a saccular thoracic aortic aneurysm, 43mm in maximum diameter, which seemed to be the cause of hemoptysis. The patient and her family wanted to have operation. While waiting for the operation, she coughed up a large amount of blood and suffered respiratory failure, requiring a mechanical respirator. Two days later, in the operation room, she coughed up a large amount of blood again and suffered long term hypoxygenation. Though she underwent total aortic arch replacement, she developed septic shock with MRSA pneumonia. However, she was weaned from ventilatory support on the 24th postoperative day. On the 86th postoperative day, ambulatory was possible. She had no ischemic cerebral damage. In extensively elderly patients, careful attention must be paid to decide an the indications for highly invasive surgery such as total aortic arch replacement.

We performed redo off-pump coronary artery bypass (OPCAB) through a left thoracotomy using a PAS·Port system for proximal vein graft anastomoses for a patient with symptomatic ischemia in the left circumflex system. A 60-year-old man underwent OPCAB (LITA-LAD, RA-4PD) 7 years previously. Coronary angiography revealed a remarkable lesion in the left circumflex system, but the left internal thoracic artery graft (ITAG) and the radial artery graft (RAG) were patent. OPCAB was performed through a left thoracotomy to avoid injury to the patent grafts. With the heart beating, a saphenous vein graft (SVG) was anastomosed sequentially from the descending aorta to the first and second obtuse marginary arteries. Avoiding descending aortic clamping, a proximal anastomosis was made using the PAS·Port system and the SVG was routed anterior to the pulmonary hilum. The postoperative course was uneventful and he was discharged on the 22nd postoperative day. Cardiac CT showed patent SVG and adequate proximal anastomosis. In this case OPCAB through left thoracotomy was effective. The selection of the graft inflow source and bypass routes according to the individual patient is essential for the success of the procedure.

We have operated upon 17 cases of distal arch aneurysm, including 3 cases of rupture, during the past 6 years. Operative adjuncts during aortic cross clamping were left heart bypass with a centrifugal pump (LHB, 6 cases), retrograde cerebral perfusion (RCP, 5 cases) and selective cerebral perfusion (SCP, 6 cases). LHB was applied to localized, the aneurysm apart from the left subclavian artery. It was safely performed during operation, but cerebral embolism happened in 2 cases with aortic cross clamping. RCP was performed in emergency cases of rupture or impending rupture. Recently 3 cases were operated by left thoracotomy under RCP. One case, an 85-year-old female, was perfused for 100min by RCP, became unconsciousness and died by multiple organ failure. Although this method was simple and easy to prepare, the efficacy of cerebral perfusion is unclear and a perfusion time of less than 90min is thought to be safe. SCP was performed in 6 cases of large aneurysm, including four cases of total arch replacement. There was one operative death, but minimum complications in the survivors. Distal arch aneurysm varies in shape, location and size. Operative adjunct must be selected based on the condition of the aneurysm.