A 58-year-old woman admitted for further examination of the proximal descending thoracic aortic aneurysm (TAA) combined with atypical coarctation and aortic regurgitation (AR). The chest CT and aortography confirmed these diagnoses, and revealed a pressure gradient of 40mmHg at the descending thoracic aorta with a severe calcification of the aortic wall, and severe AR. We scheduled a one-stage operation for this patient. First, we performed aortic valve replacement. Then we made a graft replacement from the aortic arch to the descending aorta using a stent graft via the aortic arch. Finally we did a reconstruction for lower limb perfusion using an aorto-iliac (extra-anatomical) bypass. The patient is now doing well 3 years after the surgery without any endoleak and without any difference of blood pressure between upper and lower limbs.

A 65-year-old man, who had undergone the aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis (CEP 25 mm) 18 years previously (at age 48), was admitted to our hospital with a diagnosis of acute heart failure due to acute aortic regurgitation. Redo surgery was performed. The ascending aorta was cross clamped, and cardiac arrest was induced, and aortotomy was done. One of the leaflets of the CEP was entirely collapsed and dislocated to the LV side, which caused acute aortic regurgitation. Although there was no evidence of endocarditis, the other two leaflets of CEP were severely calcified. Aortic valve replacement was performed with a CEP 23 mm. He was discharged in good condition on the 16th post-operative day.

An 89-year-old woman had undergone a medical examination and treatment due to exertional dyspnea symptom and cardiac enlargement, but her symptoms had not improved. According to images from a computed tomography scan, a huge intrapercardial mass excluding the heart was detected, and the patient was referred to our department for surgical treatment. Because of cardiac failure due to the mass excluding the heart, we planned to excise the tumor for cure and also for diagnosis. We did not distinguish the tumor before operation as is often the case with cardiac tumor. The tumor arose from the epicardium of the left ventricular (LV) anterior wall, and was attached to the LV wall with a broad stalk (approximately 3×10 cm) along the left anterior descending coronary artery (LAD). We had to operate under cardiopulmonary bypass and cardiac arrest, since the tumor involved the LAD, so we underwent resection of a part of the LAD. The patient was discharged uneventfully on postoperative day 37. On histopathology, the tumor was diagnosed as a solitary fibrous tumor (SFT) of the epicardium. Cardiac SFTs are rare. Above all, SFTs arising from LV epicardium are very rare. We report this case with some literature review.

Endovascular grafting via the aortic arch, a novel alternative method for aortic aneurysm repair, was performed in 18 patients with aortic arch or distal arch aneurysms. For cerebral protection, selective or retrograde cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy. Selective cerebral perfusion was performed through both cerebral arteries and the left subclavian artery. Throughout this procedure, the aorta was filled with carbon dioxide to prevent the spinal arteries from air embolism. Two patients were lost, one due to myocardial infarction and one due to pneumonia. Endoluminal leakage was found in 2 patients, for which reoperation was required. However, no cerebral or spinal complications were observed in this series. Thus we conclude that endovascular stent grafting via the aortic arch is an acceptable alternative for the aortic arch or distal arch aneurysm repair with little risk of cerebral or spinal complications.

We performed a video-assisted thoracoscopic surgery (VATS) to clip the patent ductus arteriosus (PDA), which was 5mm in internal diameter, in an 11-year-old girl, who first underwent a coil embolization ending in failure. Under general anesthesia with one-lung ventilation in a right lateral decubitus position, four thoracostomies were made in the left hemithorax. The PDA was clipped by two titanium clips, the length of which is 11mm at closing. Transesophageal echocardiography confirmed the location of the PDA and the absence of a residual shunt. The patient showed neither left recurrent laryngeal nerve dysfunction nor hemorrhage after operation, and was discharged on the 9th postoperative day. The clipping of the PDA by VATS can be applied for PDA without calcification if the external diameter is up to 7mm. This technique was minimally invasive and reliable. It was excellent in terms of the high quality of life achieved by the patient.

Malignant hyperthermia (MH) and antithrombin III (AT III) deficiency are both rare, but once they occur, the patient's prognosis is very poor. A 67-year-old man was referred to our hospital with a diagnosis of unstable angina. A coronary angiography revealed stenosis of LMT and triple vessels. The patient was considered a candidate for CABG. He had been prescribed 50mg/day of dantrolene for frequent muscular convulsions of the lower extremities. He had had a high CK level for a few years. Therefore he was considered to be at high risk for malignant hyperthermia (MH). He underwent CABG (×4). Dantrolene was administered orally at a dose of 25mg and then 160mg intravenously before anesthesia and modified NLA was performed in order to avoid probable MH. During the operation, AT III deficiency was suspected because the reaction of ACT after heparinization was poor. AT III preparation (1, 500 units) was used and CABG under cardiopulmonary bypass was completed without any events. It was proved after the surgery that the AT III volume had been almost normal but its activity had decreased. His postoperative course was good. For possibly fatal MH and AT III deficiency, it is necessary and important to predict, prevent and diagnose as early as possible.

There have been many reports radial artery grafts (RA) are useful in CABG, but there were very few reports about hand grasping power (GP), edema and sensory disturbance after surgery. From January to April, 1999, RA were used for 14 patients (R group) and were not in 16 patients (C group) among a total of 30 coronary artery bypass grafting procedures. The patients in the two groups were statistically similar. RA were anastomosed to #12 in 9 patients and #14 in 5. GP and the circumference of forearms were examined and sensory disturbance was also checked preoperatively and at 1, 2 and 4 weeks postoperatively. In both groups, left GP decreased slightly after surgery but gradually recovered. Four weeks after surgery, it was 26.2±9.6kg in the R group and 26.2±7.5kg in the C group (NS). The difference between left and right circumference of forearms, which indicates the degree of edema, was significantly larger in the R group than in the C group (3.5±3.6mm vs. -0.5±3.8mm, 1 week postoperatively, p<0.05). However, it gradually improved in the R group (2.1±2.6mm at 2 weeks and 1.9±2.6mm at 4 weeks postoperatively). No sensory disturbance was seen at any time. Therefore we conclude that using RA in CABG is not only useful but is also safe and does not increase postoperative risk.