This study reviewed the operative results in patients who underwent elective isolated coronary artery bypass grafting (CABG) from 1991 to 1997 and the long-term outcome in patients who received an internal thoracic artery (ITA) to left anterior descending artery graft from 1984 to 1995. The morbidity rates were as follows: low output syndrome (LOS), 19 (2.6%); perioperative myocardial infarction (PMI), 14 (1.9%); IABP required, 9 (1.2%); respiratory insufficiency, 32 (4.4%); acute renal failure, 28 (3.8%); mediastinitis, 9 (1.2%); stroke, 13 (1.8%); and reoperation for bleeding, 9 (1.2%). Operative mortality was 0.7%. Patients with moderate or severe impairment of left ventricular function (ejection fraction≤40) or chronic renal failure had high incidences of arrthythmia and respiratory insufficiency; those who were 75 or older at operation had a higher incidence of arrhythmia than those who were 50 or under (p=0.033). Patients who received four or five grafts needed a longer duration of hospitalization than those who received a single graft (p=0.0147). The 10-year actuarial survival rate, cardiac death-free rate and cardiac event-free rate in the entire series were 89.4%, 96.7%, and 80.9%, respectively. Among patients who underwent complete revascularization, the 10-year cardiac event-free rate and catheter intervention-free rate were 82.7% and 91.7%, respectively, compared with 77.5% and 84.2% in patients who underwent incomplete revascularization (p=0.0428, 0.0343). Since this study demonstrated that CABG with cardiopulmonary bypass contributed to favorable operative and long-term results, the indications for minimally invasive direct coronary artery bypass (MIDCAB) and off-pump CABG should be considered carefully and perhaps limited to elderly patients and/or those with major co-morbidities, until the long-term benefits have been clarified.

A case of 38-year-old woman with corrected transposition of great arteries is reported. She was admitted for acute cardiac failure caused by not only the left-side atrioventricular regurgitation for the ruptured chordae tendineae, but also the right-side one. We have to perform double valve replacement emergently due to the progression of biventricular failure. Very few reports have described a surgical repair of the right-sided valve replacement. The postoperative course was favorable.

We report a rare case of a protruding tumor from the right atrial free wall into the cardiac sac. A cardiac tumor was incidentally detected in the right atrium of a 64-year-old man by transthoracic echocardiography. The tumor was located in the right atrial anterior free wall, infiltrating the right artrial appendage near the tricuspid valve annulus. It had an irregular surface, did not have a tumor stalk, and was considerably mobile. We resected the tumor and performed cryosurgical ablation of the remnant tissue to reduce the risk of local recurrence. Histopathologic examination confirmed the tumor to be metastatic malignant fibrous histiocytoma (MFH). The postoperative course was uneventful, and the patient was discharged 11 days after surgery. Follow-up computed tomographic scans and transthoracic echocardiography did not reveal any evidence of local cardiac recurrence or distant metastasis.

Surgical treatment of two abdominal and two thoracic aneurysms in hemodialysis patients were performed from 1991 to 1993. Two elective cases survived, but two emergency cases died. The causes of death were PMI and respiratory failure. Ruptured aneurysms are critical and probably result in higher mortality and morbidity than elective replacement of aneurysms. In view of the documented risk of rupture and current operative risk, we believe that elective surgical treatment of aneurysm is a much better treatment than following the aneurysms until they produce symptoms or significantly enlarge.

Coronary artery bypass surgery in a 54-year-old female with severe calcified ascending aorta was performed with aortic no touch technique, Extracorporeal circulation with femoral cannulation was performed, and bilateral internal thoracic acteries and gastroepiploic artery were used as grafts under ventricular fibrillation and hypothermia without aortic cross-clamping. No neurological complication was observed and postoperative course was uneventful. We think the aortic no touch technique is safe and reliable in the coronary revascularization with severe calcified aorta.

Although left anterior descending coronary artery (LAD) grafting with a left internal thoracic artery (ITA) on a beating heart via a small left anterior thoracotomy (LAST) has become widely accepted, significant limitations exist due to the limited surgeon experience, smallness of exposure, thus making harvesting of the ITA, visualization of the surgical field and anastomosis quite difficult. Patients often have significant pain and wound complications postoperatively. A lower mini-sternotomy approach in 4 patients was performed from December 1998 through January 1999. Results: The length of mini-sternotomy incision is 7 to 14cm. These operations were accomplished without morbidity or mortality. No patients required intraoperative conversion to conventional bypass. Postoperative angiography showed patency of graft without stenosis of the anastomosis in all 4 patients. The patients did not complain of significant pain and their postoperative hospital stay was 5 to 11 days. The lower mini-sternotomy approach or“xyphoid” approach proposed by Benetti seems to be an excellent novel approach giving the freedom of extension of the incision if needed with satisfactory exposure for left ITA harvest and access to LAD as well as the distal RCA, and causes less postoperative incisional pain.