We report a 71-year-old man who was successfully treated with simultaneous coronary artery bypass grafting (CABG) and abdominal aortic repair. The patient presented with a combination of long segmental stenosis of the left anterior descending coronary artery and large infrarenal abdominal aortic aneurysm (diameter in 7.8 cm). Because both lesions were serious, one-stage operation of coronary artery and abdominal aorta was carried out. First, CABG was performed under the beating heart without cardiopulmonary bypass. After completion of CABG, the median sternotomy incision was extended down to the pubic symphisis, and abdominal aortic replacement was performed using a standard technique with a gelatin-coated bifurcated graft (Gelseal). The operation was uneventfully finished in 6hr 18min without requiring the use of homologous blood products. Postoperative course was uneventful and he was discharged 15 days after the operation. CABG without cardiopulmonary bypass is a safe and effective method not only in patients with left ventricular dysfunction or calcified aorta, but also in patients requiring a one-stage approach for both myocardial ischemia and abdominal aortic aneurysm.

A 45-year-old man was hospitalized with sudden-onset chest pain. He was in cardiogenic shock with a systolic pressure of 68 mmHg. His electrocardiogram (ECG) showed ST segment elevation in leads I, aVL, and V2-5. An emergency coronary angiogram (CAG) showed that the true lumens of bilateral coronary arteries were compressed, showing acute Stanford type A aortic dissection involving bilateral coronary artery. A bare metal stent was promptly implanted in the left main trunk (LMT) to restore coronary blood flow because of his hemodynamic instability. Soon afterwards, the ischemic changes on ECG disappeared and he was transferred to the operating room in a stable hemodynamic condition. We performed emergency graft replacement of the ascending aorta and coronary artery bypass grafting. The postoperative CAG showed patent bypass grafts. Implantation of LMT stent, as a bridge to surgery, should be the treatment of choice for acute type A dissection involving LMT.

We report a case of type A acute aortic dissection in a patient with situs inversus totalis. A 51-year-old man was hospitalized with sudden-onset back pain. Contrast-enhanced computed tomography revealed Stanford type A acute aortic dissection and situs inversus totalis. Total arch replacement using selective cerebral perfusion and mild hypothermic circulatory arrest was successfully performed. He was discharged home 23 days after the operation.

Treatment of acute pulmonary thromboembolism (APTE) in patients with hemodynamic instability still remains controversial. We analyzed the outcome and validity of surgical pulmonary embolectomy for APTE. Between January of 2004 to December of 2010, 15 patients underwent emergency surgical pulmonary embolectomy using cardiopulmonary bypass with beating heart. Our operative indications were ; within 7 days from onset, hemodynamic instability, bilateral pulmonary artery obstruction or unilateral obstruction with central clot and right ventricular dysfunction. Ten patients presented in cardiogenic shock, two of whom showed cardiac arrest and required cardiopulmonary resuscitation before operation. One patient required percutaneous cardiopulmonary support. Median follow up period is 33 months (range 3 to 86 months). All patients survived the operation, but 3 patients died in the hospital on post operative day 11 (massive cerebral infarction), day 18 (brain hypoxia) and day 25 (multiorgan failure). Two of them had cardiac arrest and received cardiopulmonary resuscitation before operation. Hospital mortality was 20%. And all patients left the hospital on foot except one patient who had been bedridden by myotonic dystrophy before operation. No patients died or showed symptoms of pulmonary hypertension after discharge. Prompt diagnosis and surgical pulmonary embolectomy before threatening fatal condition improves the outcome of embolectomy.

To reduce surgical invasion, we recently used a limited incision through a retroperitoneal approach in the abdominal aortic surgery. Between May 2001 and March 2002, 18 patients who had infrarenal aortic aneurysm, iliac aneurysm, or aortoiliac occlusive disease were surgically treated using a new approach at Dokkyo University Koshigaya Hospital. Although 1 patient with a short aortic neck had to be converted to conventional surgical incision, the remaining 17 patients were successfully treated with the limited incision (range, 6-10cm). Operative time and intraoperative blood loss were 275.2±62.9min and 968.5±473.8ml, respectively. None of these patients required homologous blood transfusion in the perioperative period. All patients were extubated in the operation room. Oral feeding and mobilization started on day 1.6±0.5 and 1.4±0.9, respectively. Furthermore, all patients were discharged home without serious complications such as postoperative ileus and perioperative death. These results show that the limited incision through a retroperitoneal approach is safe and effective in the abdominal aortic surgery. This technique maintains quality outcome while reducing surgical invasion.

A 24-year-old woman with an abdominal aortic aneurysm (AAA) caused by mucoid medial degeneration of the aortic wall in the absence of Marfan syndrome is reported. She required a Y-shaped graft replacement of the abdominal aorta through a minimal incision and recovered successfully.

We encountered a case of ascending aorta pseudoaneurysm due to a Freestyle-valve free-wall fistula after a modified Bentall procedure with the button technique. A 60-year-old man with Marfan's syndrome who contracted annuloaortic ectasia presented with the onset of Stanford A type acute aortic dissection 3 years ago. The patient underwent aortic root replacement with a Freestyle-valve and ascending and hemi-arch aortic replacement. Thirty-seven months after this operation the patient was re-operated because of pseudo-ascending aorta aneurysm. The cause of the pseudo-aneurysm was a fistula of the Freestyle-valve free-wall and the left coronary artety (LCA) ostial reconstruction component. The fistula was repaired by direct closure with pledgets. The patient was discharged from the hospital 24 days after the operation.

A conventional reoperation via full sternotomy approach is associated with a higher risk of heart injury compared with first time operations. We employ a minimally invasive cardiac surgery (MICS) for valve reoperations in order to minimize dissection of sternal adhesions. We evaluated MICS for mitral reoperation in this report. We retrospectively analyzed 20 patients (group P) who underwent mitral reoperation via partial lower hemisternotomy (PLH) from July 1997 through March 2002, and 13 patients (group F) who underwent mitral reoperation via full sternotomy from April 1990 through June 1997. All patients received mitral valve replacement in both groups. Concomitant Maze procedures were significantly more frequent in group P (group P: n=8, group F: n=1). Aortic cross clamp times were significantly longer in group P (group P: 110±5min, group F:87±11min). The blood loss during operations was significantly less in group P (group P: 666±100ml, group F: 2, 405±947ml). Postoperative ventilation time and the length of intensive care unit stay were significantly shorter in group P. In group P and F the occurrence of a heart injury associated with sternotomy was 0/20 (0%), 2/13 (15%) respectively. Hospital mortality was 0/20 (0%), 2/13 (15%) respectively. There were neither any hospital deaths nor any postoperative major complications in group P. We conclude that PLH for mitral reoperations could be performed safely and is an alternative approach for mitral reoperations.

A 65-year-old man who had been taking warfarin for a mitral mechanical valve, was transported to our hospital for acute heart failure 3 months after switching to edoxaban. The fluoroscopy revealed restriction of the mechanical valve opening, and the catheterization showed an increased pressure gradient of the mechanical valve. The patient was diagnosed with valve thrombosis, and emergency redo mitral valve replacement was performed. The patient recovered well without complication. In cases with mechanical heart valves, sufficient explanation and education about warfarin administration is mandatory for patients' home doctors as well as patients and their families.