A 61-year-old man who had hypertension and renal dysfunction (serum creatinine : 1.5-2.0 mg/dl) was referred to our hospital for an abnormal shadow on chest roentgenogram. Chest CT scan with contrast revealed a distal aortic arch aneurysm (maximum diameter 52 mm) and left subclavian artery aneurysm (maximum diameter 30 mm). For the surgical treatment of the aneurysms, left hemi-collar incision and left subclavian incision followed by median sternotomy were performed. After the left subclavian artery was secured distal to the aneurysm, a ringed dacron graft was anastomosed with the distal left subclavian artery. Cardiopulmonary bypass was commenced, and selective cerebral perfusion was instituted at 25°C. The aorta was transected at the origin of the left common carotid artery. A 30 mm stent graft (length 13 cm) was inserted and was fixed on the transected aorta using 4-0 Prolene continuous suture. Then a branched dacron graft was sewn onto the transected aorta and the stent graft. The left common carotid artery and the brachiocephalic artery were anastomosed onto side branches of the graft. The left subclavian artery was reconstructed by anastomosing the ringed bypass graft onto one of the side branches. The left subclavian artery was ligated between the aneurysm and the origin of the vertebral artery, thereby interposing the subclavian artery aneurysm. After proximal anastomosis was done and the heart was reperfused, the patient was weaned from cardiopulmonary bypass. The patient was discharged without any major complication. Two years after the operation, the patient is doing well and there is no evidence of aneurysmal dilatation or endoleak. In conclusion, frozen elephant trunk technique provides an alternative to conventional graft replacement, resulting in complete exclusion of these aneurysms in a single stage. However, long-term follow up is warranted in order to ensure the durability of the stent graft.

Mitral valve reoperation through a median sternotomy is technically challenging and carries higher postoperative morbidity and mortality than the primary operation, especially for a patient with patent coronary bypass grafts. We here present 3 cases of mitral valve reoperation using the beating heart technique under normothermic cardiopulmonary bypass via a mini-thoracotomy. The reasons that precluded sternal reentry were as follows : previous coronary bypass and patent internal mammary artery grafts in 2 cases, and a history of mediastinal wound infection at the initial operation in 1 case. All cases were carried out via right mini-thoracotomy and cardiopulmonary bypass using arterial cannulation via the ascending aorta or the femoral artery, and venous cannulation via the femoral vein and the superior vena cava. Mitral valve repair was performed for 1 case, and valve replacement for 2 cases. Transfusion was not necessary, except for 1 case that had anemia due to hemolysis preoperatively. All patients were discharged without major complications. This technique is a safe and feasible option for a mitral valve reoperation that excludes re-sternotomy, extensive pericardial dissection and aortic clamping, thereby minimizing risks of bleeding, graft injury and myocardial damage.

We encountered a case of aortic valvuloplasty for aortic regurgitation due to congenital bicuspid valve. A 31-year-old man was found to have aortic regurgitation due to prolapse of a leaflet of the bicuspid valve by echocardiography. Under cardiopulmonary bypass, the right and left coronary cusps were conjoined and that conjoined cusp was larger than that of the opposing leaflet and had a longer free edge. A raphe was present in the conjoined leaflet. At first, we shortened the elongated free edge of the prolapsing leaflet by means of a triangular resection, and placed horizontal mattress sutures at each commissure. Furthermore, we performed subcommissular annuloplasty at each commissure, resulting in good coaptation of cusps. The patient survived and has shown an uneventful recovery. It is likely that this method of aortic valvuloplasty can be used for aortic regurgitation due to congenital bicuspid valve.

We have experienced 3 successful repair surgeries for insufficient bicuspid aortic valve. The operative procedure consisted of combinations of suture placation, raphe triangular resection, commisural annuloplasty, and patch closure of perforation due to infectious endocarditis. The postoperative course was uneventful and postoperative echocardiography showed residual regurgitation as only trivial or mild. Retrospective study done on 19 previous cases with insufficient bicuspid aortic valve demonstrated that this operative procedure could have been applied in 15 (79%) of the cases. These results showed that repair surgery for insufficient bicuspid aortic valve is useful and has a wide application.

A 49-year-old man who had had severe tripple vessel coronary disease and low left ventricular function (EF=29%) underwent coronary artery bypass grafting. Following the procedure he could not be weaned from cardiopulmonary bypass (CPB) even with an intra-aortic balloon pumping (IABP). Left ventricular assist using a centrifugal pump (CFP) together with IABP was then utilized with a dramatic recovery from profound postcardiotomy cardiogenic shock, and the CPB was successfully terminated. The left ventricular function recovered gradually from intraoperative myocardial damage. The CFP was successfully removed at 86 LHB hour and the IABP at 9th postoperative day. At present 12 months after LHB, he reveals no angina. Settting up the left ventricular support using a CFP is simple and not-time-consuming, so this system with IABP is of practical use in the case of unpredicted postcardiotomy cardiogenic shock.

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