A 47-year-old man was found to have a thoracic aortic aneurysm. When the patient was 20 years old, he underwent aortic correction with Dacron graft for coarctation of the descending aorta. CT showed an enhanced true aneurysm and a pseudolumen in the proximal anastomotic site of the graft of the distal arch and an aneurysm in the left subclavian artery bifurcation. The operation was performed. Because we anticipated severe adhesion due to the preceding left thoracotomy, we approached by median sternotomy and the transmediastinal replacement method (pull-through method). Before cardio pulmonary bypass was started, an 8-mm Dacron graft was anastomosed to the left subclavian artery via a subclavian incision. The patient was given heparin and we cannulated the ascending aorta via the right femoral artery. A venous cannula was placed in the superior and inferior vena cava and patent left superior vena cava confirmed during operation. Antegrade cardioplegia was initially administered. During deep hypotheremic circulatory arrest antegrade cerebral perfusion was employed. The heart was retracted and the descending aorta was exposed through the posterior pericardium. The old graft was excised and a new Dacron graft was pulled down into the descending aorta from the distal arch. The graft was anastomosed to the descending aorta. After we repaired the other aortic arch branch and ascending aorta, the left subclavian graft and graft branch were anastomosed. There was no bleeding or other complication and the patient was discharged. The pull-through method should be considered for such descending aortic aneurysm cases.

In a 73-year-old man, ventricular septal rupture and tricuspid papillary muscle rupture were complicated with inferior acute myocardial infarction (AMI). Twenty-five days after AMI, radical operation was performed. VSR was found 1.5cm diameter at the inferior septum and directly closed using teflon felt strip. Infarctectomized inferior LV free wall was closed with woven Dacron patch which was cut from Cooley low porosity aortic tube graft and sutured with bovine pericardium facing to LV cavity. A part of anterior tricuspid papillary muscle was found to be ruptured. Tricuspid valve replacement was performed with Carpentier-Edwards valve. One and half year postoperatively, the patient has been doing well without heart failure. To our knowledge, this is the first case of VSR complicated with tricuspid papillary muscle rupture following AMI.