A 69-year-old man in whom two stents had been implanted on segments 6 and 7 was admitted to our hospital with acute myocardial infarction (AMI). Coronary angiography suggested a total occlusion of the left anterior descending (LAD) between two stents. Percutaneous transluminal coronary angioplasty (PTCA) was performed, but it made an acute coronary occlusion due to a dissection of left main trunk (LMT). As cardiogenic shock occurred, he was put on percutaneous cardioplumonary support (PCPS), and a perfusion catheter was introduced to the LAD and a guide wire to the circumflex (Cx). Emergency coronary artery bypass grafting (CABG) was performed on cardioplumonary bypass (CPB). First, an SVG was grafted to the LAD on ventricular fibrillation, and the other SVG was grafted to segment 13 on cardiac arrest after the perfusion catheter and guide wire was removed. This method allowed this operation to be performed with suitable myocardial protection.

Seven patients underwent surgical repair of the distal aortic arch aneurysm from January 1990 to October 1997. They were 5 men and 2 women ranging from 63 to 78 years of age (mean, 72.7 years). All patients were operated with a median sternotomy only. There was one operative death, which was ruptured case. However, there were no major complications in non-ruptured cases. This retrospective study suggests that it is possible to repair the distal aortic arch aneurysm through a median sternotomy approach alone, when 1) descending aorta originates with normal size just distal to sacciform aneurysm, 2) the maximum diameter of the aneurysm is over 70mm and 3) distal involvement of the aneurysm does not extend beyond the bifurcation of the trachea. It is useful to retract descending aorta proximally by three threads with pledget for distal anastomosis in inclusion technique.

Patient 1 was a 62-year-old woman who had been treated for hypertension for three years. Stanford A type acute aortic dissection occurred accompanied by right coronary ischemia. CABG and graft replacement of the ascending aorta were performed 8 hours after the onset of coronary ischemia, but after cardiopulmonary bypass the patient could not be weaned from the RVAD because of right ventricular infarction. On the 8th day after operation, she died due to right heart failure. Patient 2 was a 72-year-old male. Stanford A acute aortic dissection occurred and right coronary ischemia appeared during UCG examination in the ICU. CABG and graft replacement of the ascending aorta and the aortic arch were carried out less than 1 hour from the onset of coronary ischemia. The postoperative course was satisfactory and uncomplicated. If the dissection extends to the aortic root, it is important to monitor the ECG carefully to detect myocardial ischemic changes. In cases with coronary ischemia, early operation and CABG are mandatory.

A 47-year-old woman complained of dyspnea on exertion. Ultrasonic cardiography revealed coronary sinus type atrial septal defect. At operation, the drainage veins to the left atrium from the coronary arteries were observed but no anomalies of the vena cave or any other veins were observed. The defect was closed with a pericardial patch under cardiopulmonary bypass. The post-operative course was uneventful. Coronary arteriography performed on the 14th post operative day confirmed that the coronary veins drained individually into the corresponding atria. Unroofed coronary sinus is rare and difficult to diagnose prior to operation. Ultrasonic cardiography and coronary arteriography are considered useful for preoperative diagnosis.