We report a case of redo aortic valve replacement by right minithoracotomy approach for aortic stenosis after coronary artery bypass grafting (CABG). An 81-year-old man was followed-up once a year for 9 years after CABG. He complained of increasing respiratory distress, showed narrowing of the aortic valve area, elevation of the aortic valve pressure gradient, and tricuspid valve regurgitation by echocardiography. He was admitted for surgery. We considered minimally invasive operation would be better for him and performed aortic valve replacement (Carpentier-Edwards Perimaunt valve 19 mm) by a right minithoracotomy approach because graft injury could occur by median sternotomy after CABG, and he had the risks of advanced age, low activities of daily living, and mild dementia. His postoperative course was uneventful. On echocardiography performed at postoperative days 9, the ejection fraction recovered to 75% from 53% before surgery and the mean aortic valve pressure gradient was 8 mmHg. He was discharged on postoperative day 12. Right minithoracotomy approach with port access is a good option for redo operation for aortic valve stenosis after CABG.

A 53-year-old woman was admitted with cardiac failure due to aortic regurgitation (AR) and pseudocoarctation of the aorta associated with Takayasu's aortitis. It was revealed that her hypertension of upper extremities was based on Takayasu's aortitis at her 37-year-old age. But at that time there was no sign of inflammation, only drug therapy for hypertension had been employed. She started to complaint of dyspnea on exertion and palpitation when 47 years old, ultrasonic echocardiography and cardiac catheterization revealed that her symptoms were based on pseudocoarctation and AR. Despite of drug therapy, her symptoms progressed and reached NYHA class III. Detailed examination showed progressed AR and occurrence of mitral regurgitation (MR). Surgical treatment, ascending aorto-terminal aortic bypass, aortic valve replacement (AVR), and mitral valvuloplasty was performed at the age of 53 years old. In instituting the extracorporeal circulation, an arterial cannula was placed in the graft that anastomosed to the terminal aorta, in addition to the arterial cannula to the ascending aorta, to prevent low perfusion of the organs distal to the pseudocoarctation. The postoperative course was uneventful. Special attention should be paid to prevent low perfusion of the organs in such case with presence of pressure gradient in the aorta.

A 22-year-old woman was admitted to our hospital with high fever and lumbar pain. Echocardiography revealed mitral regurgitation due to prolapse of the anterior mitral leaflet. On admission, her white blood cell count was high and results for C-reactive protein were positive. The blood culture was positive for hemolytic streptococcus. After the white blood cell count and C-reactive protein level were normalized, and the blood culture had become negative following treatment by multiple antibiotics, she underwent valvular surgery. Because the infectious lesion was limited to the mitral leaflet and chordae, mitral valvuloplasty was performed with a satisfactory postoperative result. The operative technique consisted of resection of the infected valvular tissue, implantation of artificial chordae with e-PTFE, and suture annuloplasty. To conclude, mitral valvuloplasty should be the operative method of choice in patients with infective endocarditis, especially in young women with the potential of future pregnancy and labor.

A 70-year-old man with dextrocardia with situs inversus, presented to our hospital complaining of chest pain. ECG showed ST elevations in leads II, III and _aV_f , and ST depressions in leads V3 through V6. Blood tests showed creatinine kinase elevation. He underwent coronary angiography, which revealed obstruction of the anatomical right coronary artery and we diagnosed acute inferior myocardial infarction. However, the anatomical left coronary artery was not clearly identifiable because of its anomalous origin. He was transferred to our intensive care unit and intra-aortic balloon pumping was initiated. Coronary 3D-CT was then performed to obtain an anatomical overview of the coronary artery system. This enabled a second coronary angiography which showed obstruction of the left anterior descending artery and stenosis of the left main trunk in the first diagonal branch and the ramus intermedius branch. Coronary artery bypass grafting surgery (CABG) was indicated. He underwent conventional quintuple CABG using the right internal thoracic artery and saphenous vein grafts. Preoperatively we made digital mirror images of the original coronary angiographic images to clarify his coronary artery anatomy. During surgery, the main surgeon continuously stood on the patient's left side except when opening and closing the chest, which enabled us to perform CABG. The postoperative course was uneventful. CABG in a patient with situs inversus totalis is very rare. We present this case with a review of the relevant literature.

Edaravone is an agent developed as a free radical scavenger, and is useful in functional recovery of the brain after cerebral infarction. However, to the best of our knowledge no experimental studies have been made regarding the effect of edaravone on cerebral protection during aortic arch surgery. We investigated the pharmacological effect of edaravone experimentally, through selective cerebral perfusion under deep hypothermia. Twelve adult dogs (body weight 14.8±2.0 kg) were used, and selective cerebral perfusion was performed under hypothermic circulatory arrest of 20°C for 120 min at 5 mg/kg/min, which was half the usual flow volume of cerebral perfusion. Group E (n=6) received 3 mg/kg edaravone for 30 min at the start of both selective cerebral perfusion and rewarming of the body, while Group C (n=6) received no drugs. Somatosensory evoked potential (SEP) was measured, and so were blood pressure, body temperature, pH level, oxygen partial pressure, and blood flow in the cerebral tissue. Histopathological investigations were also performed. In Group E, complete SEP recovery was observed in all dogs, while in Group C, complete SEP recovery was observed in only 2 dogs (33%) (p=0.014). A statistically significant difference was also observed in cerebral tissue pressure (p=0.014), but not in pH level, oxygen partial pressure, or cerebral tissue blood flow. On histopathological investigation, Group C demonstrated reduced staining of Nissl granules in neurons of the cerebral cortex, and many of them presented the appearance of acute circulatory impairment while Group E demonstrated no reduction in staining of Nissl granules. In the present experimental study of selective cerebral perfusion under deep hypothermia below the safety threshold flow, edaravone was effective in cerebral protection.

A 76-year-old woman required aortic valve replacement due to severe aortic stenosis. She had a huge thyroid cancer, which invaded the innominate and left internal jugular veins. We planned a two-stage operation : the first involved aortic valve replacement ; and the second involved operation of the thyroid cancer. To avoid median sternotomy, we adopted the right parasternal approach. A 7-cm right parasternal skin incision was made. The third and fourth costal cartilages were cut and bent into the right thoracic cavity, without removal of the ribs. The postoperative course was uneventful, and second operation was performed via the median sternotomy approach on postoperative day 53. The right parasternal approach can be used as an alternative when sternotomy is unsuitable in cases of aortic valve replacement.

One hundred and thirty cases of closed mitral commissurotomy were followed for up to 25 years and 10 months. There was no operative death, but 31 cases died during the follow-up period. Eight cases died suddenly of unknown cause, 7 due to heart failure, 5 due to thromboembolism, 4 on reoperation, and 6 due to other reasons. In the 7 cases who died of heart failure late after commissurotomy, 3 cases refused reoperation. Each of the remaising 4 cases were not operated on because of associated severe liver dysfunction, left ventricular dysfunction plus pulmonary hypertension, respiratory failure due to bronchial asthma, and unknown reasons, respectively. The actuarial survival rate was 93.6% 10 years after surgery, and 72.2% 20 years after surgery. Forty-two cases had reoperation with a mean interval of 12 years and 6 months. Reoperation-free survival rate was 88.7% 10 years after the first operation and 42.8% 20 years after the first operation. Incidence of major thromboembolism was 1.25%/patient-year. Thromboembolism and sudden death of unknown cause constituted the leading cause of late death and played a key role in long term results. Cardiac event-free survival rate was 65.7% 10 years after surgery and 32.6% 20 years after surgery. From these results it was concluded that the clinical limitations of the effectiveness of closed mitral commissurotomy was around ten years after surgery. We believe that these findings provide useful information for percutaneous transvenous mitral ommissurotomy.

We experienced a surgically treated case of chronic contained rupture of a common iliac artery aneurysm. A large number of cases of chronic contained ruptures of the abdominal aorta have been reported; however, that of the common iliac artery is very rare. A 66-year-old man was injured in a bicycle accident. Three months later, the patient felt a dull abdominal pain and noticed a tumor in the left lower abdomen. On presenting computed tomography (CT) scan revealed an aneurysm of the left common iliac artery. After further examinations, a contained rupture of the left common iliac artery aneurysm was diagnosed. At operation, the main aneurysm, 7.5×6.5cm in size, was seen in the left common iliac artery, extending to the right common iliac artery and the infrarenal abdominal aorta. A 5.0×3.0cm tear, was found oil the posterior wall of the left common iliac aneurysm, surrounded by a huge hematoma. The aneurysm was resected and the abdominal aorta and the common iliac arteries were replaced with a Bard Albumin-coated DeBakey vascular bifurcated graft (16×8mm). The postoperative course was uneventful.

Abnormalities of the skeleton and joint as well as ophthalmic symptoms and cardiovascular abnormalities are found in Marfan's syndrome, one of the connective tissue diseases associated with autosomal dominant inheritance. A 34-year-old man was operated on for Stanford type A acute aortic dissection that developed 13 years after sternal turnover surgery for funnel chest. After approaching by median incision made on the sternum, composite graft replacement and aortic arch replacement were performed. After surgery, the sternum at the site of reflections became unsteady, causing flail chest, which required internal fixation with an artificial respirator for 15 days. A patient with Marfan's syndrome may undergo cardiovascular operation twice or more throughout his lifetime. Where a longitudinal incision is made on the sternum after operation on the funnel chest, care should be exercised even if it is a long time after surgery. In this sense, minimal invasive surgery with a steel bar inserted percutaneously, a surgical technique that has come to be used recently, should be useful.

A regular check-up in a 69-year-old man showed normal blood chemistry values, except for elevated value of liver enzymes and inflammatory reactions. A computed tomography scan (CT) of the abdomen revealed a normal appearance of the liver, pancreas and spleen, but incidentally showed a tumor in the right atrium. The tumor (a blood cyst which contained white thrombus) was successfully excised. Blood cysts of the heart are extremely rare in adults. These tumors are incidently found at autopsy on cardiac valves in approximately 50% of infants under 2 months of age. The blood cyst in this case arose from the right atrial wall, which is also quite rare.