The long-term efficacy of various treatments for intermittent claudication was studied to determine which regimen should be selected. Two hundred and nineteen patients with arteriosclerosis obliterans (ASO) and intermittent claudication of the extremities were divided into two groups based upon the type of treatment: 1) 170 patients who underwent arterial reconstruction and 2) 49 receiving conservative treatment. Fifty-five patients with Buerger's disease (TAO) with intermittent claudication were divided into three groups: 1) 17 patients who underwent arterial reconstruction, 2) 15 with lumbar sympathectomy, and 3) 23 receiving conservative treatment. The background factors of both disease groups were analyzed, and the changes in claudication, the quality of life, and the survival rate were followed up. Among ASO patients, the improvement of intermittent claudication was significantly better in the arterial reconstruction group (p<0.001) than in the conservative treatment group. The quality of life and 5-year surival rate were also superior in the arterial reconstruction group (p<0.01), and they were closely related to the improvement of intermittent claudication. On the other hand, there was no significant difference in any of these parameters between the three groups of TAO patients. This discrepancy in outcome was concluded to be due to differences in the background factors of the two diseases. Accordingly, the treatment for intermittent claudication should be discussed making a clear distinction between ASO and TAO. In conclusion, the treatment of choice for intermittent claudication is arterial reconstruction in ASO patients, whereas surgical treatment should only be considered for TAO patients when conservative therapy is ineffective.

Loeys-Dietz syndrome (LDS) is characterized by vascular findings (aortic aneurysms and dissections) and skeletal manifestations. Since aortic dissection occurs at smaller aortic diameters than observed in Marfan syndrome, early and aggressive surgery is recommended for patients with LDS. A 45-year-old man who underwent aortic valve replacement for aortic regurgitation at the age of 33 was transferred to our hospital with the diagnosis of acute aortic dissection. We performed emergeny ascending aortic replacement, and suspected LDS because of his specific physical characteristics after surgery. His postoperative course was uneventful, however, computed tomography (CT) performed at 2 weeks after operation showed the new entry at the distal anastomotic site, patent false lumen of the descending aorta and rapid enlargement of the distal aortic arch. Therefore, we performed total arch replacement with the elephant trunk method at 3 weeks after the emergency operation. Mutation of the TGFBR2 gene was found and we finally diagnosed LDS. One year after, complete thrombosis of the false lumen of the descending aorta and decrease in size of the distal aortic arch was observed by CT.

We report a case of aortic valve replacement using a bioprosthesis after coronary artery stenting in the left coronary main trunk of a 76-year-old man with symptoms of heart failure. Pre-operation studies revealed severe aortic valve regurgitation and that the left main coronary stent protruded into the aorta. Cardiac arrest was obtained with retrograde cardioplegia. Careful observation was made to avoid injury to the aortic bioprosthesis. The postoperative course was uneventful and cardiac echo graphy showed good function of the aortic valve.

NIPPV provides positive pressure ventilation through a face mask without intubation. We performed NIPPV for 2 patients with acute respiratory failure following cardiovascular surgery. (Case 1) A 63-year-old man, who had had COPD (Hugh-Jones class III), underwent replacement of the aortic arch. He was extubated after 5 days. However, he was re-intubated under controlled ventilation because of deterioration of his respiratory condition. The patient had NIPPV after extubation on postoperative day 14 because he was alert and had no cardiovascular compromise. On the 18th postoperative day he was weaned from NIPPV. (Case 2) A 67-year-old man underwent coronary artery bypass surgery. On the next day he was extubated, but he suffered from hypoxemia due to impaired respiratory condition on postoperative day 3. The patient underwent NIPPV instead of conventional mechanical ventilation because his condition was stable except for respiration. Respiratory condition improved quickly and he was weaned from NIPPV on the 7th postoperative day. NIPPV is an effective method for managing patients with acute respiratory failure after cardiovascular surgery.

The relationship between coldness of the hands and feet (“Hiesho”) and Blood Stagnation (“Oketsu”), a disorder description unique to Oriental Medicine, was examined using the Oketsu score of five Hiesho cases based on the Terasawa Oketsu Diagnostic Criteria. The effects of acupuncture treatment were studied by evaluating Oketsu symptoms and accompanying complaints, the Visual Analogue Scale (VAS) and subjective evaluation of coldness of the hands and feet.
The results were as follows:
1) 100% of the five females with Hiesho were also positive for the Oketsu factor.
2) The Oketsu score showed a significant decrease (P<0.05) upon treatment with acupuncture.
3) An improvement in subjective Hiesho symptoms (VAS) was seen in three of the five cases upon acupuncture treatment.
4) It was suggested that the subjective improvement in Hiesho symptoms, i. e., coldness of the hands and feet, was related to the disappearance of the resistance and pain upon pressure in the ileocecal region that is characteristic of Oketsu, and the improvement in menstrual disorders.

A 69-year-old woman was admitted with fever and dyspnea. We diagnosed the congestive heart failure due to infective endocarditis (IE) with mitral valve regurgitation and stenosis. We immediately started medical therapy in order to control both the heart failure and the infection. However, we had to semi-emergency mitral valve replacement additionally perform a days after the initial hospitalized due to a progression of the heart failure. The operative findings showed an area of vegetation to be incarcerated in the mitral orifice. In cases of IE which are associated with mitral stenosis, we therefore should consider the possibility that vegetation may be present in the mitral orifice and closely follow such patients by echocardiography.

A 20-year-old male was referred to our hospital to undergo operative treatment due to aortic valve insufficiency which had gradually worsened. The patient's chief complaint was a loss of breath upon effort which had progressively worsened after undergoing aortic valve plasty (AVP) for aortic valve insufficiency with infective endocarditis at another institution. AVP by the cusp extension method had been performed because of the patient's youth and there had been no change in the morbid state, except for the presence of a non-coronary cusp. In addition, the aortic valve insufficiency was controlable and postoperative course was also excellent. The cusp extension method was therefore considered to be an appropriate procedure for this case since it would allow the patient to return it to a state with a more normal heart, since the valve organization after this procedure would be able to reach a maximum level.

We performed redo coronary artery bypass grafting (CABG) using lateral MIDCAB for 3 patients with severe symptomatic ischemia in the left circumflex system alone. When the descending thoracic aorta had no atherosclerotic lesions on chest CT, it was selected as the inflow of the bypass. According to the location of the target artery, we undertook sequential or T-composite off-pump bypass using the radial artery through a left lateral thoracotomy. On the other hand, when the descending aorta was diseased, the left axillary artery was chosen as the inflow of the bypass. We selected the saphenous vein as a conduit to obtain sufficient graft length. A proximal anastomosis was made through a left infraclavicular incision, and then a distal anastomosis was done through a left lateral thoracotomy without cardiopulmonary bypass. Moreover, care was taken not to kink the grafts. The postoperative course was uneventful in all patients. Lateral MIDCAB technique was useful for redo revascularization to the circumflex system. We believe that selection of bypass conduits, routes, and bypass inflow according to the individual patient is essential for the procedure.

We presented here 2 cases of rare nonvascular tumor involving the aorta. Case 1: A 69-year-old woman. She presented leg edema and dyspnea on admission. Computed tomography revealed abdominal aortic aneurysm perforating left common iliac vein. Abdominal aortic aneurysm replacement and fistula closure were done on an emergency basis. Immunohistologic examination revealed that malignant mesothelioma invaded the aortic wall. Case 2: A 47-year-old woman presented with dyspnea. Enhanced computed tomography revealed rupture of the descending aortic aneurysm (saccular type). Aortic replacement was done on an emergency basis. One year after the operation, computed tomography revealed a giant mass (160×70mm) surrounding the descending thoracic aorta. On biopsy, malignant schwannoma was found to invade the descending aorta. Sometimes nonvascular tumors form aneurysms. So we should be careful in diagnosis before operation.

A 59-year-old man was admitted to our hospital with severe mitral incompetence. Mitral valve repair, tricuspid annuloplasty and the Maze procedure were performed. After weaning from cardiopulmonary bypass, his systolic blood pressure (SBP) dropped to 40 mmHg. Immediate administration of catecholamines markedly increased SBP but his continuing low blood pressure required additional treatment with vasopressin and hydrocortisone. On postoperative day 12 in the general ward, he suddenly lapsed into an intractable hypoglycemic coma. Endocrine function tests revealed adrenocorticotropic hormone deficiency. Since the time of writing has been doing well with 20 mg of hydrocortisone.