We performed transatrial repair of postinfarction posterior ventricular septal defect (VSP) in a 69-year-old man who was transferred to our hospital with a diagnosis of posterior acute myocardial infarction and VSP. Coronary angiogram revealed total occlusion of the right coronary artery at #3 and 75% stenosis of the left circumflex artery at #13. UCG revealed the ventricular septal defect on the posterior ventricular septum without LV wall motion abnormality. Surgical repair was planned around 3-4 weeks later because his hemodynamic state was stable without inotropes nor IABP support upon arrival. Under general anesthesia, standard median sternotomy was performed and cardiopulmonary bypass was established with the ascending aorta and bicaval cannulation. Cardiac arrest was achieved with antegrade cold crystalloid cardioplegic solution and an oblique right atrial incision was made. The VSP was visualized via the tricuspid valve. The location of VSP was confirmed with saline injection from the LA vent line. VSP was closed with two patches, consist of a Teflon felt and a bovine pericardial patch, from the left and right ventricle side with six 4-0 polypropylene mattress sutures. Also coronary artery bypass for LCx was performed with a saphenous vein graft. The postoperative course was uneventful. There was no residual ventricular septal shunt and LV function was normal by UCG. Right atrial approach for surgical repair seemed to be useful for posterior VSP.

A 81-year old woman had hypertensive heart failure. She had a history of intermittent claudication for 5 years. Her ankle brachial pressure index (ABI) was 0.53 on the right and 0.58 on the left side. Coarctation of the descending aorta with severe calcification was found by a whole body CT. After medical therapy for heart failure, axillo-bifemoral artery bypass using an 8 mm ringed expanded polytetrafluoroethylene (ePTFE) graft was performed. Postoperatively, ABI improved to 0.83 on the right and 0.87 on the left side. The patient is doing well without any signs of heart failure or intermittent claudication. Although it is a palliative operation, axillo-bifemoral artery bypass is an effective and less-invasive procedure and appropriate for elderly patients.

We encountered a case of aortic root replacement of a prosthesis-patient mismatch (PPM) after performing aortic valve replacement (AVR) with the Björk-Shiley Monostrut (BSM) valve. The patient was a 55-year-old female. She underwent AVR with a bioprosthesis for the treatment of congenital aortic stenosis at 20 years of age ; AVR was performed again using the BSM valve at 28 years of age. Congestive heart failure gradually worsened, and she was referred to our hospital at 55 years of age, where she was diagnosed with PPM after AVR. Under general anesthesia, standard median resternotomy was performed, and cardiopulmonary bypass was established with right femoral artery and right femoral vein cannulation. Cardiac arrest was achieved with the antegrade application of a cold, crystalloid, cardioplegic solution. The BSM valve was removed, and her annulus was extremely small, measuring less than 19 mm. We performed an aortic root replacement with a 21 mm mechanical valve composite graft because aortic root enlargement was difficult owing to the fragility of her annulus and very severe adhesion surrounding the ascending aorta. The postoperative course was uneventful. Postoperative ultrasonic echocardiography showed reduced transvalvular mean gradients. Although the BSM valve is durable, non-structural valvular deterioration surrounding the implanted BSM valve may occur and should be monitored.