We report a rare case of a 73-year-old man with abdominal and thoracic aortic aneurysms complicated with Buerger's disease. He complained of abdominal pain, nausea and an abdominal pulsatile mass. Computed tomography and angiography revealed an abdominal aortic aneurysm (58mm in diameter) and a thoracic aortic aneurysm (47mm in diameter). Y graft replacement was performed for abdominal aortic aneurysm. The size of the thoracic aortic aneurysm increased from 47mm to 60mm in 3 years, and hoarseness appeared. We then performed graft replacement of the thoracic aorta. In cases of Buerger's disease, we have to consider perfusion of the extremities when we need extracorporeal circulation, and we must shorten ischemic interval.

The patient was a 70-year-old woman with severe aortic stenosis and familial hyperlipidemia which was diagnosed in 1994. The patient was admitted as an emergency case due to syncope in 2002. According to ultrasound cardiography (UCG), the pressure gradient of the aortic valve was 120.7mmHg, and the diameter of the aortic valve annulus was 16.7mm. Computed tomography showed porcelain aorta from the annulus of aortic valve to the ascending aorta. On cardiac catheterization, the pressure gradient was 96mmHg, AVA was 0.4cm², and the ejection fraction was 38.7%. Since these findings suggested that conventional AVR was difficult, thoracotomy was performed at the left 5th intercostal level, and apicoaortic valved conduit (valved graft: SJM19HP, Intergard 22mm+Medtronic apical LV connector) was implanted. Postoperative cine MRI showed that most of the cardiac output (87%, 3.29l/min) flowed through the conduit, with the flow via the aortic valve accounting for 13%, 0.51l/min. This surgical procedure can be an effective alternative when conventional AVR is difficult.

Emergency coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS) is still associated with high mortality and morbidity, and early outcome is poor compared with outcome in patients with stable angina. The purpose of this study was to examine the clinical results of on-pump beating heart CABG vs. off-pump coronary artery bypass (OPCAB) for ACS patients. From a total of 432 CABG patients, we retrospectively analyzed 72 (16.7%) patients who underwent emergency CABG between 2004 and 2008. Emergency CABG cases were divided into 2 operative groups : an on-pump beating-heart CABG group (on, n=31) and an OPCAB group (off, n=41). A preoperative history of acute myocardial infarction (AMI), detection of troponin T, preoperative creatine phosphokinase (CPK) value, low ejection fraction, presence of mitral regurgitation (MR) (>II) and cardiomegaly were markedly higher in the on group. There were no statistically significant differences in intraoperative factors. In-hospital mortality was 3.2% (1 patient) in the on group and 7.3% (3 patients) in the off group. Furthermore, statistically significant differences were found between the 2 groups in incidence of all-cause morbidity (on=71.0% : off=41.5%, p=0.01), respiratory failure (on=58.1% : off=29.3%, p=0.01), ICU stay (on=6.5±4.6 days : off=4.1±3.2 days, p=0.01), and necessary inotropic support (on=51.6% : off=17.1%, p=0.02). Multivariate regression analysis of preoperative and intraoperative factors was performed to identify independent factors for in-hospital mortality and morbidity. On multivariate analysis of preoperative factors, only the pre-CPK value reached statistical significance as an independent factor for in-hospital mortality and morbidity.

We performed aortic remodeling using a tailored Dacron graft (Yacoub's procedure) in two cases of root aneurysm combined with aortic regurgitation. The cases were 20-year-old and 45-year-old women. The leaflets did not coapt at a central portion, but the lack of coaptation did not produce significant prolapse. No organic change was found, so we attributed aortic regurgitation to sinotubular junction. Remodeling of the root was selected as the operative procedure because degeneration in the annulus was unlikely in these two cases. All three sinuses were excised, with 3mm of the arterial wall left above the aortic annulus and a small button of the aortic wall around the ostia of the coronary arteries. Then each commissure was pulled up and the height of the commissure was measured. The proximal end of the graft was then tailored to a scallop shape, so that the top of the scallop matched the commissure level. The graft was then sutured to the aortic rim with continuous 5-0 polypropylene sutures. Both coronary arteries were reimplanted utilizing the Carrel patch method and the distal graft anastomosis was completed. The aortic crossclamp times were 147 minutes and 163 minutes and the total pump times were 166 minutes and 189 minutes. One patient has mild or 1+ aortic regurgitation on postoperative echocardiogram and aortography, but she has no activity restrictions, and no evidence of congestive symptoms. Yacoub's remodeling procedure which spares the aortic valve, requires no anticoagulant therapy in the post-operative period. Aortic valve-sparing replacement of the aortic root is an excellent procedure for any patient with an ascending aneurysm and an anatomically salvageable valve. Although further long-term follow-up is required, we believe that preserving the native aortic valve is useful for preventing complications associated with mechanical valves.

During the past 7 years from January 1991 through October 1997, we treated 30 cases of aortic root reconstruction by the Carrel patch method. The cases included annulo-aortic ectasia (AAE), root aneurysm with aortic regurgitation (AR), aortic dissection with AR, and true aneurysm (ascending and arch) with AR. The surgical treatment consisted of 28 modified Bentall operations and 2 aortic root remodelings, similar to the Yacoub operation. The aortic root and valve were resected, the coronary arteries were dissected free, mobilized, and then implanted into the composite graft. Coronary anastomosis was performed by mattress suture reinforced by Teflon felt strips. In 5 cases it was necessary to undergo coronary artery bypass grafting for myocardial ischemia. Blood transfusion was unnecessary in 11 cases. Post operative death was seen in only one patient who underwent an emergency operation for cardiac tamponade due to aortic dissection on the 25th postoperative day. The operative mortality rate was 3.3%. The complications of anastomosis, for example leakage and dilatation of the coronary ostia, were not seen in our experience. Reoperation and late death were not observed during the follow-up period (average 23 months). Cerebral hemorrhage occurred in only one case, at 5 years after the operation, and all other patients had an uneventful postoperative course. The event-free rate is 75% (n=1) at 6 years. The operative procedure is considered feasible in any anatomic variation of aortic root diseases, even if dislocation of the coronary ostia is minimal, and this method holds hope for the prevention of anastomotic pseudoaneurysm formation and long-term survival. Although further long-term follow-up study is necessary, our experience suggests that the Carrel patch procedure has few late term complications.

A 75-year-old woman underwent endovascular stent-grafting for a descending thoracic aortic aneurysm, followed by video-assisted thoracoscopic right upper lobectomy for concomitant lung cancer in a later procedure. Two custom-made endovascular spiral Z stents covered with woven Dacron (DuPont Co., Wilmington, DE, USA) were delivered via the femoral artery under local anesthesia using pull-through technique. Intraoperative angiograms showed successful exclusion of the aneurysm without any endoleakage. Conventional surgical treatments for both diseases in this patient would have required bilateral thoracotomy either in a simultaneous or staged fashion and entail risks of postoperative pulmonary dysfunction and progression of the cancer. Endovascular stent-grafting offered potential superior operative results and quality of postoperative life in this patient with concomitant descending thoracic aortic aneurysm and cancer of the right lung.

This study evaluated factors influencing residual aortic regurgitation (AR) after valve re-suspension surgery for acute type A aortic dissection. From January 1996 through December 2002, 63 patients were treated for acute type A dissection at our institution. Among these 63 patients, pre-and postoperative echocardiograms were available in 38 patients who underwent surgery combined with native aortic valve re-suspension. These 38 patients were divided into 2 groups according to the postoperative AR grade, i. e.: AR group: AR grade≥II (n=6), no-AR group: AR grade≤I (n=32). The severity of pre and postoperative AR was assessed by transthoracic or transesophageal echocardiography. The preoperative diameters of mid ascending aorta and sinotubular junction, and the percentage of the circumference of the dissection at the sinotubular junction level was measured by enhanced CT scan. Preoperative patient backgrounds were similar in both groups. The preoperative AR grade in the AR group was significantly greater than that of the no-AR group (2.25±1.17: 0.69±0.91, p<0.001). The tear was more frequently located in the ascending aorta in the AR group than in the no-AR group (66.7%: 37.5%, p<0.05). The percentage of circumference of the dissection at the sinotubular junction level did not affect the preoperative AR grade, but it did show a tendency to influence the severity of postoperative AR, though the difference was not significant. Three patients (7.9%) had AR grade III at the time of discharge, but did not clinically require further surgical intervention. Preoperative significant AR and the location of the tear in the ascending aorta are associated with postoperative residual AR after aortic valve re-suspension. The percentage of circumference of the dissection at the sinotubular junction level might influence the severity of postoperative AR.

A survey was conducted by sending questionnaires to 466 doctors working at nine hospitals affiliated with the Aichi Prefectural Federation of Agricultural Cooperatives for Health and Welfare (Kohseiren).
The survey found that the length of service was under 5 years in 60% of the respondents and that many of them identified themselves strongly with the department of the teaching hospital where they were trained.
They were found to be little intersted in the present situation of the agricultural cooperatives and Japanese agriculture. However, they said they were satisfied with the present working conditions, because they could show their skills. Most approved of organ transplants after brain death but disapproved of human cloning. They showed a positive attitude toward the allowing of each patient to give access to his or her clinical records and standardization of medical treatment. Some 67% of the doctors admitted they had made medical mistakes and keenly realized the necessity of risk management.
While feeling uneasy about the recent upsurge of lawsuits brought by patients about medical treatment, they said they are endeavoring to provide safe and high quality medical service. Their recent concerns were rearrangement of dispensaries based on the subspecialty, reinforcement of postgraduate courses in medical schools and the postgraduate training system which will be a legal obligation from 2005. They suported the reform plans for the national medical service for aged patients and recognized the necessity of joining hands with local agricultural cooperatives in providing nursing care services. They said they wish to continue their career as a physican at the Kohseiren hospital.

Lately, there has been a trend towards integration among cardiovascular surgery institutions. However, local institutions continue to play a crucial role in community-based medicine, given the emergent nature of cardiovascular diseases and the challenges involved in transporting patients with such conditions over long distances. We present the results of a questionnaire survey we conducted to examine the current status and issues faced by cardiovascular surgery institutions in community-based medicine.