A 75-year-old woman required aortic valve replacement for aortic stenosis. She had undergone radical mastectomy and irradiation for left breast cancer 25 years previously, and had chest wall infection secondary to osteoradionecrosis. In spite of preoperative infection controls including surgical debridement, the chest wall was not healed well and colonized with MRSA. However, she was too ill with severe heart failure to wait until the chest wound was negative for MRSA for a valve operation. With the infection remaining, the aortic valve was approached through a right parasternal incision, to exclude the infected sternum from the surgical site, and successfully replaced with a mechanical valve. An internal mammary retractor was useful to avoid fractures of the infected sternum and provided excellent exposure of the aortic root. No mediastinitis or prosthetic valve infection was encountered postoperatively.

A case is described of the staged surgical repair of thoracic aortic aneurysm after revascularization of single functioning ischemic kidney of a 68 year old man. A hitological evaluation of renal function was obtained before renal revascularization, which encouraging us to perform the repair of thoracic aortic aneurysm with less risk of post-surgical acute renal failure. In case of single ischemic kidney, renal revascularization should be preceded to other major surgeries in order to prevent renal shut down.

Between 1970 and October, 1992, 120 cases of abdominal aortic aneurysms (AAA) were treated for surgical repair. Thirteen of these cases (11%) were performed with simultaneous repair for coexistent visceral vascular diseases and other intestinal organ diseases. Another 9 patients (7.5%) were treated with coronary revascularization for combined ischemic heart disease. Six of these cases received both operations during the same hospital stay. Our surgical strategy for coexistent AAA and ischemic coronary artery disease is basically a staged operation. Coronary revascularization should precede AAA repair. Operative mortality was 1.1 percent for elective AAA repair. Long-term survival was 78% for elective surgery with a mean follow-up of 51 months, and 52% for emergency surgery with a mean follow-up of 46 months. Major risks for late death were malignant neoplasms and ischemic coronary artery disease. Survival rate of the 9 patients with successful concomitant coronary revascularization and AAA repair was 89% after 51 months of mean follow-up. We conclude that re-evaluation for coexistent ischemic heart disease is the most important point for management before and after AAA repair.

Among the 203 cases of aortic valvular surgery, we experienced 8 cases of acute coronary insufficiency during the early postsurgical period. Five cases suffered from right coronary insufficiency. The other 2 cases had left coronary failure, and the remaining case had both. The main symptom of right coronary failure was right ventricular dysfunction, resulting in inability to wean from cardiopulmonary bypass in 3 cases, and left ventricular dysfunction due to inferior myocardial infarction in 2 cases. On the other hand, the main symptom of left coronary insufficiency was acute left ventricular pump failure with a broad anteroseptal infarction, and cardiac arrest occurred in the other 2. All patients receiving an emergency coronary artery bypass graft survived. Two cases expired due to thromboembolism in the interposed graft to the left coronary ostium in Cabrol's or Piehler's procedures. In the 6 survivors we could not detect any recent coronary lesions by postsurgical coronary cineangiography. We suggest that the pathophysiology of this phenomenon was coronary artery spasm and a lack of coronary reserve capacity in severe left ventricular hypertrophy of aortic valvular disease combined with diastolic dysfunction. Prompt coronary artery bypass grafting and a careful myocardial protection using retrograde cardioplegic solutions might save patients in this critical condition and an appropriate decision on the surgical indications for aortic valvular surgery is necessary before the occurrence of left ventricular diastolic dysfunction and demand ischemia.