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.

The aim of this study was to evaluate the Enclose II anastomosis device (Novare Surgical System, Inc., Cupertino, CA). A retrospective record review was conducted of all cases which underwent off-pump coronary artery bypass surgery (OPCAB) at our general hospital between January 2002 and December 2006. We identified 91 patients (a mean age of 71.0 years, the average number of distal anastomoses 2.5/patient) underwent OPCAB. The proximal anastomoses were constructed with the Enclose II (group E, 40 patients), aorta side-clamp technique (group S, 17 patients), and aorta no touch (group N, 34 patients). Group E had more grafts than group N (E:N=2.7:1.7/patient, p<0.0001), while Group E (3.1/patient) had more distal anastomoses than group S (2.6/patient, p=0.0486) and N (1.8/patient, p<0.0001). There was no difference of graft patency in each group (early; E:S:N=99.1%:97.8%:98.0%, 1-year; E:S:N=95.8%:91.3%:95.2%). There was no patient with sustained permanent neurologic deficits after OPCAB. The Novare Enclose II proximal anastomotic device appears to be a safe and effective tool during OPCAB.

Acute respiratory failure after cardiopulmonary bypass is a severe postoperative complication. We evaluated the effects of a specific neutrophil elastase inhibitor, sivelestat sodium hydrate (Ono Pharma Co. Ltd., Osaka, Japan), on postoperative respiratory failure due to acute aortic dissection (type A, AAD). A retrospective review of clinical records was conducted for all cases of emergency surgery for AAD at Ome Municipal General Hospital between June 2001 and August 2006. We identified 16 patients (median age, 64.9 years old; male: female ratio, 4:12) who had an initial postoperative PaO₂/FIO₂ of less than 300mmHg. Among these patients, 11 treated with sivelestat were compared with 5 (the control group) who did not receive sivelestat. There were no significant differences in age, body weight, sex, operating time, cardiopulmonary time, blood transfusion, initial WBC and CRP between the two groups. At arrival in the ICU, the patients in the sivelestat group had a worse respiratory condition based on parameters such as PaO₂/FiO₂ (sivelestat vs. control, 74.1 vs. 181.1mmHg, p=0.0007), A-aDO₂ (sivelestat vs. control, 620.3 vs. 556.7mmHg, p=0.0003), and respiratory index (sivelestat vs. control, 9.29 vs. 4.92, p=0.0002). However, the patients in the sivelestat group showed a greater improvement in these parameters and CRP over a 3-day observation period, compared to those in the control group. We conclude that sivelestat may attenuate postoperative respiratory complications in patients with AAD.

A 68-year-old woman with a chief complaint of dyspnea was admitted in March, 2007. She had undergone percutaneous angioplasty of the right coronary artery in 2002. Elective surgery was advised because echocardiography, left ventricular cineangiography and 64-multidetector-row CT (64MDCT) had revealed a left ventricular aneurysm (LVA), a ventricular septal perforation (VSP) through the aneurysm, and three diseased coronary arteries. The aneurysm wall was located on the inferior wall, and this was incised longitudinally. The VSP was directly sutured using 4-0 polypropylene, and the aneurysm was closed with large patches, and pledgetted mattress and running sutures. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. It is rare for LVA and VSP to be diagnosed simultaneously, but the risk of pseudo-false aneurysm of the left ventricle is high because of free wall rupture and septal wall perforation, and therefore surgical repair is recommended.

A 73-year-old woman was due to undergo elective AVR and aortoplasty because of aortic stenosis (AS) and an ascending aortic aneurysm. During the operation, after the start of cardiopulmonary bypass, the ascending aorta was found to be dilated and discolored. A diagnosis of type A dissection was made by transesophageal echocardiography. Replacement of the ascending aorta and AVR were performed under deep hypothermic circulatory arrest. After the operation, VTR revealed that the ascending aorta was dissected from the cardioplegia injection site. The postoperative course was good and she was discharged on postoperative day 28. Intraoperative aortic dissection is a rare but lethal complication, so it is important to recognize it rapidly and manage it appropriately.

A 74-year-old woman was given a diagnosis of mitral regurgitation (MR) and tricuspid regurgitaton (TR) underwent mitral valve replacement (MVR) and tricuspid annuloplasty (TAP). Pacemaker implantation was necessary because of postoperative atrial fibrillation (Af) followed by bradycardia on the postoperative day 14. Five months later, she was again admitted to our hospital because of fever. A blood culture revealed Streptococcus sangius. Symptoms improved with the administration of antibiotics. Twenty days after discharge, she suffered back pain and fever. A CT scan showed destructive changes in the thoracic vertebrae and echocardiography revealed mitral vegetations. A blood culture revealed Streptococcus agalactiae. Symptoms subsided with the administration of antibiotics. However, new mitral regurgitation was recognized so the patient underwent redo MVR. The patient's recovery was uncomplicated after surgery, and she was discharged on the 104th post-operative day.

Vertebral osteomyelitis (VO) is a relatively rare, but lethal, complication of infective endocarditis (IE). We report two cases who had been given a diagnosis of IE during conservative therapy for VO. A 60-year-old and a 52-year-old men each suffered onset of severe back pain. Magnetic resonance imaging demonstrated osteomyelitis in the lumbar spine. IE was revealed from congestive heart failure and persistent fever, as an unusual complication of VO. A series of echocardiograms demonstrated the progression of valvular lesions and vegetation, despite treatment with antibiotics. We therefore performed surgery. One underwent aortic and mitral valve replacement, and the other underwent aortic valve replacement. VO was treated with long-term antibiotics and good responses were achieved in both patients. The possibility of VO in the lumbar spine should be considered in patients with IE complaining of severe back pain. Appropriate antibiotic therapy over a prolonged period is recommended.

A 68-year-old man underwent percutaneous transluminal coronary angioplasty (PTCA) to left anterior descending artery (LAD) seg 7 after acute anteroseptal myocardial infarction 8 years previously. He was admitted because of syncope attack due to sustained ventricular tachycardia and subsequent fibrillation. He was treated medically in the ICU after cardiopulmonary resuscitation. Medical treatment with amiodarone and lidocaine was not successful and he was transferred to our hospital for surgical treatment of malignant ventricular tachycardia (VT) associated with left ventricular aneurysm and acute cholecystitis that occurred during admission. Left ventriculogram showed left ventricular aneurysm (ejection fraction: 35%) without any significant coronary lesions. The patient successfully underwent a Dor operation (left ventriculoplasty), double encircling endocardial cryoablation without endocardial resection, and preoperative and intraoperative endocardial mapping. Cholecystectomy was simultaneously performed after complete closure of the median chest incision. The recurrence of VT was never recognized clinically or electrophysiologically. The extended encircling endocardial cryoablation without endocardial resection and preoperative and intraoperative electrophysiological study, was a simple and effective method for ventricular tachycardia.

This study was designed to evaluate the perioperative outcome of dialysis patients undergoing cardiac surgery, who were managed with our perioperative dialysis program. Between April 1994 and August 1999, 11 patients (7 men and 4 women with a mean age of 57.3±10.3 (36-73)) with hemodialysis (HD, n=8) and peritoneal dialysis (PD, n=3) underwent cardiac surgery. The duration of dialysis was 5.6±4.3 years. Operation included mitral valve replacement (n=1) and isolated coronary artery bypass grafting (n=10). Patients with HD had single hemodialysis on the day before operation. Patients with PD were maintained on PD in the usual manner until the day before surgery. Intraoperative hemofiltration during extra-corporeal circulation and normokalemic non-depolarizing cardioplegic solution were used in all patients to avoid post-operative hyperkalemia. All HD patients had dialysis on the first post-operative day (POD 1), and then every other day. PD patients had PD soon after arriving at the ICU. Levels of serum creatinine, urea nitrogen, acid-base balance were successfully controlled within acceptable ranges. No patients required emergency HD or any post-operative managements for hyperkalemia in the ICU. Six of 8 HD patients required an increase in vasopressor because of a tendency toward hypotension and 4 of 8 patients suffered from atrial fibrillation during the initial HD on POD 1. Eight of 11 patients could be extubated on the first POD. No hospital death occurred. The use of normokalemic cardioplegic solution was useful to avoid post-operative hyperkalemia. Our perioperative dialysis programme successfully managed the perioperative clinical course of dialysed patients undergoing cardiac surgery.