Patient is a 58-year-old man who had a thoracoabdominal aortic aneurysm with abdominal angina due to the occlusion of celiac artery with mural thrombus in the aneurysm. He had a recurring abdominal pain for half a year, and relapsing elevation of serum transaminase levels. Graft displacement was performed, followed by reattachment of visceral vessels, celiac artery and superior mesenteric artery, using partial extracorporeal circulation. Abdominal angina due to thoracoabdominal aortic aneurysm has been seldom reported. It has been said that complete revascularization is not required as surgical therapy, and single vessel revascularization is sufficient to reduce symptoms. Preoperative angiography will reveal which vessels supply dominant blood flow to visceral organs, therefore, angiographic examination should be performed essentially prior to surgery.

During a twelve-year period (1982-1993), 15 axillo-femoral bypass surgeries have been performed for aortoiliac occlusive disease. All patients were men, with an average age of 71.2 years. Axillo-bifemoral bypass was performed in 10 cases, and axillo-unifemoral bypass in 5 cases. In Additional femoro-popliteal bypass was required 3 cases. All cases had some accompanying disease, so they were considered to be high risk cases for anatomic bypass surgery. In the 12 elective cases, 2 hospital deaths (16.7%) occured due to the accompaning disease (atrial fibrillation and lung canser). At discharged leg symptoms had improved in 10 patients. In the long term postoperative phase, 4 patients died due to accompanying disease, and one was lost to follow up. Excluding these patients, the long term patency in the 5 surviving patients was 100%. In this series, we encountered a case of perigraft seroma, which is rare. The intractable perigraft seroma disappeared after the reoperation with another material graft. Axillo-femoral bypass is preferable for high risk patients with aortoiliac occlusive disease. In cases of severe respiratory dysfunction, it can be performed under epidural and local anesthesia.

Three cases of isolated iliac aneurysms were reported. The first case was a 28-year-old man who was transferred to our hospital in shock. The ruptured left iliac aneurysm was replaced with a prosthetic graft. It was assumed to be a rupture of a false aneurysm. The second case was a 60-year-old man who complained swelling of his right leg and dyspnea on exertion. Angiography revealed tht those symptoms were due to right iliac aneurysm with AV fistula. The aneurysm was replaced with a bifurcating graft and the AV fistula was closed concurrently. The third case was a 55-year-old man who had no symptoms. He had been followed up for hepatitis type C with periodical echogram. The echogram showed dilatation of his bilateral iliac arteries. On a diagnosis of bilateral iliac aneurysms, bifurcating graft replacement was performed. All of these three cases recovered successfully and were discharged. Because the greater part of the cases of isolated iliac aneurysms have few symptoms, many cases were first diagnosed through the event of its rupture. The number of cases of isolated iliac aneurysm with no symptoms will increase with advanced availability of abdominal echogram and CT scanning.

A 67-year-old man had ischemic cardiomyopathy. He had New York Heart Association class III heart failure with pleural effusion. Further examinations revealed an enlarged left ventricle with markedly reduced ejection fraction (6.2%) and 3-vessel coronary disease. He underwent single coronary bypass grafting, using the gastroepiploic artery (GEA) to RCA without cardiopulmonary bypass. He showed a remarkable improvement of cardiac function. He was discharged from our hospital (NYHA class I) on the 40th postoperative day and lives an almost normal life now. Coronary artery bypass grafting without cardiopulmonary bypass is one of the useful surgical techniques for patients with ischemic severe left ventricular dysfunction.

Because of the improved safety of cardiovascular surgical techniques, the small incision approach, called minimally invasive cardiac surgery (MICS), has recently been employed. In some cases of MICS, however, prolonged extracorporeal circulation time is required, and it is not minimally invasive in some aspects. It has been reported that the most prominent advantages of MICS is reducing the adverse consequences of conventional full-sternotomy, such as pain, bleeding and risk of mediastinitis, therefore it is helpful to reduce the period of hospitalization and costs. The small incision and cosmetic advantage is one of the objective advantages of MICS, so we interviewed 139 patients who underwent cardiac surgeries, to find out how they think of their operation scar. Most (61.9%) of the patients were not bothered by their scar, and the presence of keloid lesions mattered move than the size of their wound. What the patients considered to be most important were less pain after operation and shorter hospital stay, not to mention good results of the operation. The size and place of the wound ranked low in importance. It is important to be aware of the difference in thinking between the operative wound by patients and by the healthy medical staff. Furthermore it is important to recognize the difference between minimaly invasiveness and small incisions in cardiac surgery.

Two cases of bilateral phrenic nerve paralysis were reported. The first case was a 51-year-old male who underwent mitral valve replacement for mitral valve regurgitation. Upon extubation he was noted to have the paradoxical breathing pattern associated with bilateral phrenic nerve paralysis. He was treated conservatively, keeping him in a sitting position without reintubation or tracheostomy. The patient recovered from the paradoxical breathing pattern by the tenth post-operative day. The second patient was a 66-year-old male who underwent mitral valve replacement and CABG for mitral valve regurgitation and angina pectoris. Upon extubation this patient was also noted to have a paradoxical breathing pattern. Conservative treatment was initiated. This patient suffered from sudden apneic episode followed by cardiac arrest on 17th post-operative day. Cardio-pulmonary resuscitation was successful, however, the patient was noted to have extensive ischemic brain damage after resuscitation. The patient died approximately one year later from respiratory failure. Generally speaking, the cause of phrenic nerve paralysis after cardiac surgery is cold injury from ice slush used for topical cardiac cooling. However, direct mechanical injury to the right phrenic nerve might result from the proximity of the right phrenic nerve to the left atrial suture line of a mitral valve replacement.

A 53-year-old woman was admitted with cardiac failure due to aortic regurgitation (AR) and pseudocoarctation of the aorta associated with Takayasu's aortitis. It was revealed that her hypertension of upper extremities was based on Takayasu's aortitis at her 37-year-old age. But at that time there was no sign of inflammation, only drug therapy for hypertension had been employed. She started to complaint of dyspnea on exertion and palpitation when 47 years old, ultrasonic echocardiography and cardiac catheterization revealed that her symptoms were based on pseudocoarctation and AR. Despite of drug therapy, her symptoms progressed and reached NYHA class III. Detailed examination showed progressed AR and occurrence of mitral regurgitation (MR). Surgical treatment, ascending aorto-terminal aortic bypass, aortic valve replacement (AVR), and mitral valvuloplasty was performed at the age of 53 years old. In instituting the extracorporeal circulation, an arterial cannula was placed in the graft that anastomosed to the terminal aorta, in addition to the arterial cannula to the ascending aorta, to prevent low perfusion of the organs distal to the pseudocoarctation. The postoperative course was uneventful. Special attention should be paid to prevent low perfusion of the organs in such case with presence of pressure gradient in the aorta.

A 22-year-old woman was admitted to our hospital with high fever and lumbar pain. Echocardiography revealed mitral regurgitation due to prolapse of the anterior mitral leaflet. On admission, her white blood cell count was high and results for C-reactive protein were positive. The blood culture was positive for hemolytic streptococcus. After the white blood cell count and C-reactive protein level were normalized, and the blood culture had become negative following treatment by multiple antibiotics, she underwent valvular surgery. Because the infectious lesion was limited to the mitral leaflet and chordae, mitral valvuloplasty was performed with a satisfactory postoperative result. The operative technique consisted of resection of the infected valvular tissue, implantation of artificial chordae with e-PTFE, and suture annuloplasty. To conclude, mitral valvuloplasty should be the operative method of choice in patients with infective endocarditis, especially in young women with the potential of future pregnancy and labor.

Abnormalities of the skeleton and joint as well as ophthalmic symptoms and cardiovascular abnormalities are found in Marfan's syndrome, one of the connective tissue diseases associated with autosomal dominant inheritance. A 34-year-old man was operated on for Stanford type A acute aortic dissection that developed 13 years after sternal turnover surgery for funnel chest. After approaching by median incision made on the sternum, composite graft replacement and aortic arch replacement were performed. After surgery, the sternum at the site of reflections became unsteady, causing flail chest, which required internal fixation with an artificial respirator for 15 days. A patient with Marfan's syndrome may undergo cardiovascular operation twice or more throughout his lifetime. Where a longitudinal incision is made on the sternum after operation on the funnel chest, care should be exercised even if it is a long time after surgery. In this sense, minimal invasive surgery with a steel bar inserted percutaneously, a surgical technique that has come to be used recently, should be useful.

A 62-year-old man was admitted to our hospital because of acute aortic dissection (DeBakey type III b). Inflammatory findings were detected and methicillin-resistant staphylococcus aureus (MRSA) was detected by blood culture. Appropriate antibiotic therapy was begun but was ineffective. Repeated CT scans revealed dilation of the false lumen with thrombus and perianeurysmal inflammatory change in the lung. A diagnosis of infected aortic dissection was made. The patient was treated by resection of the descending aorta and placement of an in situ Dacron graft covered with a pedicled omental flap. An infected thrombus in the false lumen was confirmed by a positive MRSA culture. Computed tomography was found to be more sensitive in the diagnosis of infected aortic dissection. When the infection is not controlled with antibiotics, prompt surgical treatment should be performed.