Three patients with subclavian artery obstruction caused by arteriosclerosis underwent surgical reconstruction based on their specific anatomic characteristics. Subclavian artery transposition was performed in a patient with a short segmental occlusion of the proximal subclavian artery. The patient with a long segmental occlusion, from the origin of the internal thoracic artery to the origin of the thoracoacrominal artery, underwent bypass-grafting between common carotid artery and axillary artery. The graft was passed lateral to the anatomical tract to prevent compression by the scalenus and subclavian muscles. Because the branchial plexus also can be compressed in the thoracic outlet, the scalenus muscles were detached at the first rib in both methods. It is important to consider the specific cause of subclavian artery occlusion when planning corrective surgery. Ischemic and neurologic symptoms improved using both techniques.

We performed several arterial reconstruction methods for five patients with buttock claudication due to ischemia of the hypogastric artery, and their symptoms improved remarkably. They had complained of severe buttock pain, although every patients' ankle brachial pressure index had almost been within the normal range. Angiography had showed not only hypogastric arterial stenosis but extensive sclerotic changes of pelvic arteries. Two cases had had contralateral iliac stenosis. We placed stress on reconstruction for the main trunks to supply the lower extremities with sufficient blood flow, and occasionally reconstructed the hypogastric artery in addition. Aorto-femoral bypass, ilio-femoral bypass, Y-graft replacement, atherectomy were performed, among other procedures. The buttock pain was eliminated. Buttock claudication, caused by critical hypogastric circulation, occurs only when blood flow through the pelvic collateral vessels is compromised. In particular, the principal etiology seems to be blood flow steal to the ischemic legs on exercise. In such cases, arterial reconstruction of the lower extremities is very effective.

A 71-year-old man with early-stage esophageal cancer underwent off-pump coronary artery bypass grafting (CABG) through left thoracotomy to avoid sternotomy to allow subsequent esophageal surgery. The patient had severe double vessel coronary artery disease (the left anterior descending artery and the right coronary artery). Esophageal pull-out resection and reconstruction with the transverse colon over the sternum were planned after recovery from CABG. Therefore, we performed off-pump CABG via left thoracotomy using a saphenous vein Y-graft. Proximal anastomosis was placed in the descending aorta, and the distal anastomoses were completed with a stabilizer and an apical retraction device. Postoperative angiograms showed both grafts were patent and had suitable layout for subsequent esophageal surgery. In conclusion, off-pump CABG via left thoracotomy is an appropriate option for myocardial revascularization, if median sternotomy is contraindicated.

A 81-year old woman had hypertensive heart failure. She had a history of intermittent claudication for 5 years. Her ankle brachial pressure index (ABI) was 0.53 on the right and 0.58 on the left side. Coarctation of the descending aorta with severe calcification was found by a whole body CT. After medical therapy for heart failure, axillo-bifemoral artery bypass using an 8 mm ringed expanded polytetrafluoroethylene (ePTFE) graft was performed. Postoperatively, ABI improved to 0.83 on the right and 0.87 on the left side. The patient is doing well without any signs of heart failure or intermittent claudication. Although it is a palliative operation, axillo-bifemoral artery bypass is an effective and less-invasive procedure and appropriate for elderly patients.

A 54-year-old woman complained of prolonged fever. Echocardiography showed severe mitral regurgitation with vegetation, and computed tomography showed right coronary artery (RCA) fistula to the coronary sinus (CS). Blood culture revealed Strep. viridans, thus a diagnosis of active infective endocarditis was established. The patient underwent urgent surgery. Surgical findings showed that vegetation was located in A3 to P3 of the mitral valve. The patient underwent mitral valve repair using a glutalualdehyde-treated autologous pericardial patch and artificial chordea. Epicardial ligation for fistula was performed. Her postoperative course was uneventful.

A recent study evaluated the effect of pleurotomy for harvesting internal thoracic arteries (ITAs) on pulmonary complications after coronary artery bypass grafting (CABG). Fifty consecutive patients with pleurotomy (group I) were studied retrospectively and compared with a control group of fifty patients undergoing CABG without pleurotomy during ITA harvest (group II). Group I was divided into two groups; forty patients using left ITAs with left open pleurotomy (group Ia), and ten patients using bilateral ITAs with bilateral open pleurotomy (group Ib). On the other hand, group II includes 22 patients without pleurotomy (group IIa) and 28 patients with closed pleurotomy (group IIb). In group I, ITAs were dissected from the chest wall with mediastinal pleura and then isolated from the pleura by pleurotomy. Before sternal closure, an L-shaped pleural tube was inserted into the deep costophrenic sinus and the pleurotomy remained open. In group II, ITAs were simultaneously dissected from the chest wall and mediastinal pleura, and if the pleura was damaged, the pleurotomy was approximated before sternal closure. There was no significance in the number of bypass grafts, aortic crossclamp time, cardiopulmonary bypass time and temperature. ITA harvest time with open pleurotomy was shorter than that of closed pleura (15min versus 25min). Postoperatively, the ventilation time and duration of chest drainage also showed no significance, however group Ia and Ib showed significantly more fluid accumulation removed by chest drainage (Ia, 288±193ml; Ib, 285±198ml, versus IIb, 169±98ml). On postoperative day 30 no pleural effusion was observed in group I but it was seen in one case in group IIb which had diaphragm paralysis. In conclusion, open pleurotomy results in minimal pulmonary complications with optimal chest drainage and offers significant advantages for harvesting ITAs.

Between February 1999 and November 1999, 33 patients (age 67.0±7.6 years old) underwent off-pump CABG using coronary shunt tubes. The number of graft anastomoses per patient was 2.8±0.8. The operative mortality was 0%. There was no incidence of on-pump conversion, low cardiac output syndrome, IABP insertion, mediastinitis or stroke. The maximum CPK-MB during the perioperative period was 25.9±18.8IU/l. One patient had perioperative myocardial infarction probably due to native coronary artery spasm. In patients with off-pump CABG, the intubation time, the ICU stay and the hospital stay were shorter. The number of patients who were extubated in the operating room was higher and the cost was lower than those with on-pump CABG. An early phase study revealed patency ratios of 85% (the previous term) and 97% (the latter term). Off-pump CABG is a safe and effective means of revascularization with no mortality, minimal morbidity and good short-term patency.

A 44-year-old man with a history of remittent fever for 6 months was given a diagnosis of inf ective endocarditis of the aortic valve related to a congenital ventricular septal defect (VSD), although no bacterial growth was obtained by blood culture. After one week of antibiotic treatment, aortic valve replacement (AVR) and patch closure of the VSD were performed after debridement of infected tissue and vegetations involving the aortic root, pulmonary and tricuspid valves, and myocardium surrounding the VSD. Antibiotic treatment was continued postoper-atively, but elevation of C-reactive protein (CRP) persisted. Blood culture disclosed Candida albicans in the blood 3 months after AVR. Fungal prosthetic valve endocarditis (PVE) was suspected, therefore, aortic root replacement with a Free Style bioprosthesis and VSD re-closure were performed followed by continued systemic antifungal treatment. Five months after reoperation, the patient was readmitted with a high fever. A pseudoaneurysm of the left common iliac artery and complete obstruction of the external iliac artery were shown by contrast-enhanced computed tomography (CT). The aneurysm was resected without revascular-ization. This case presentation concludes that long-term whole body study with contrast-enhanced CT might be necessary even though complete eradication of the infected foci of the heart has been established.

SOLO SMART is a stentless bioprosthesis that comprises a larger effective orifice area and reduced pressure gradient, exhibiting a better hemodynamic profile than a stented bioprostheses. Currently, SOLO SMART finds application in patients with aortic valve diseases. However, patients with bicuspid aortic valve disease may present Valsalva sinus asymmetry. Recently, some studies have considered SOLO bioprosthesis as contraindicated in patients with a bicuspid aortic valve. Here, we report the case of a 79-year-old female with bicuspid aortic stenosis and Valsalva sinus asymmetry. We preoperatively assessed the aortic root of the patient using a novel 3D workstation that creates virtual reality (VR) images from cardiac CT data. After creating three symmetric commissures at the wall of the Valsalva sinus, we evaluated the distance from the coronary orifices. We determined the appropriate suture line of bioprosthesis avoid coronary orifice occlusion. Aortic valve replacement with SOLO SMART was successful, and the postoperative clinical course was uneventful. Hence, preoperative evaluation of the aortic root using VR images could be a precise and useful method for the assessment of the operative indication for SOLO SMART.

Ascites is a rare sign of aortic valve disease. Here, we report two cases of refractory ascites that had resulted from aortic stenosis and insufficiency and consequently improved after aortic valve replacement. The first case was a 44-year-old female who had undergone aortic valve repair for aortic stenosis 15 years earlier. She complained of dyspnea and severe abdominal distension due to unimproved massive ascites despite medical therapy. She was diagnosed with aortic stenosis and insufficiency and functional tricuspid insufficiency as well as complete atrioventricular block. She underwent mechanical aortic valve replacement, tricuspid annuloplasty and DDD pacemaker implantation. The second case was a 61-year-old man with a history of alcoholic liver disease who had been hospitalized for massive ascites, progressing rapidly in spite of aggressive medical therapy. Echocardiography revealed severe aortic stenosis and insufficiency; thus, he underwent bioprosthetic aortic valve replacement. Both patients were completely free from ascites about 6 months after surgery.