The“elephant trunk”operation, first described by Borst and associates, is a multistage operation for diffuse aneurysmal disease. We report a 59-year-old man complaining of hoarseness, who had a diffuse aneurysm extending from the ascending aorta to the upper abdominal aorta with occlusive disease in the neck branches. His aorta was replaced in two stages using the“elephant trunk”operation. The first stage operation, replacement of the ascending aorta and transverse aortic arch, was performed through a median sternotomy under selective cerebral perfusion. The second stage operation, replacement of the descending thoracic and upper abdominal aorta, was performed under F-F bypass. He had occlusive disease on bilateral carotid arteries with a history of brain infarction, had lost his left lower limb because of arteriosclerosis, and had undergone replacement of the infrarenal abdominal aorta because of an aneurysm. Despite a complicated preoperative general condition, the postoperative course was uneventful. The“elephant trunk” operation facilitates staged operation for diffuse aneurysmal disease as presented here, and thereby improves opeative result by reducing surgical stress.

A 60-year-old man, who had undergone mitral valve repair with quadrangular resection of the posterior mitral leaflet and ring annuloplasty with a Cosgrove-Edwards ring, developed severe mechanical hemolytic anemia. Doppler echocardiography showed only mild residual mitral regurgitation, but turbulent jet was directed toward the annuloplasty ring. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent replacement of the mitral valve with a St. Jude Medical valve. Inspection of the annuloplasty ring at operation showed no evidence of dehiscence, but the area of the annuloplasty ring adjacent to the posteromedial commissure showed no endothelization. After the reoperation, the hemolysis and general condition immediately improved. This experience made us realize the possibility that a high-velocity regurgitant jet toward the cloth-covered annuloplasty ring, even if it mild, can cause severe hemolysis.

Left ventricular overlapping operation was applied to a woman with cardiac sarcoidosis who presented with cardiopulmonary arrest. She did not have any particular history, with minimal risk factors for atherosclerosis. By-stander cardiopulmonary resuscitation delivered by her husband saved her life. Acute coronary syndrome was denied by emergency coronary arteriography. However, left vetriculography revealed broad dyskinetic area inconsistent with coronary distribution. Those findings raised a high suspicion of cardiac sarcoidosis, although this was unconfirmed. Broad ventricular aneurysm and a history of cardiac arrest and congestive heart failure prompted us to operate on her. Left ventricular overlapping operation was applied followed by ICD implantation and steroid induction. The pathologic examination of the ventricular wall showed noncaseous epithelioid granulomas and polynuclear giant cells, which are consistent with cardiac sarcoidosis. She has been leading a healthy daily life without signs of heart failure for one and a half years after discharge. Lesions of cardiac sarcoidosis have a broad spectrum from narrow localized to wide generalized aneurysm. Appropriate surgical strategy should be performed according to the location and the extent of the lesion. Left ventricular overlapping operation is among the alternatives.