A 55-year-old female with silent myocardial ischemia was admitted to our hospital for CABG. Her postoperative course was uneventful. However, after the initiation of oral nutrient intake on the first postoperative day, drainage from the anterior mediastinum increased to 600ml/day. The character of the fluid was milky and biochemical examination revealed that it had a high triglyceride content (925mg/dl). The patient was placed on a medium-chain triglyceride diet and intravenous hyperalimentation without success. On the sixth postoperative day, the mediastinum of the patient was re-explored. The fistula was located in the left side of the anterior mediastinum where the thymic tissue is located. The fistula was ligated and the chylorrhea ceased. The incidence of chylothorax after cardiac procedures through median sternotomy is rare. We recommend early surgical ligation of the fistula if the postoperative hemodynamic state of the patient is stable.

We report an alternative way to preserve autologous blood with the aid of erythropoietin for a patient with anemia combined with irregular antibody who need the CABG operation. A 62-year-old woman was given a diagnosis of angina pectoris due to three-vessel coronary artery disease. All blood reserved for the coronary operation was incompatible on the crossmatch test and an irregular antibody was suspected. Antibody screening tests revealed anti-drug antibody and anti-P1 antibody. The operation was postponed because she had anemia. After 800ml of autologous blood was collected with administration of erythropoietin and iron for a month, the operation was performed. Two saphenous vein grafts were anastomosed to the left anterior descending artery and circumflex branch respectively. Total blood loss was 580g. Her postoperative course was uneventful and hemoglobin level was ranged from 7 to 10g/dl without any homologous blood transfusion.

A 42-year-old female was admitted complaining of a pulsating mass of her left upper arm for two years. As she had played volleyball, she hit a ball with her upper arm accidentally for many times. The arteriogram showed a 30×35mm sized brachial artery aneurysm. Replacement of brachial aneurysm with saphanous vein graft was performed. Histologically, the aneurysmal wall consisted of three layers of arterial wall and had multiple breaks in continuity of the elastic layer. We diagnosed it was a true traumatic aneurysm caused by repetitive blunt injury. The causes and etiology of the brachial artery aneurysms were discussed.

A 65-year-old man was referred to our service complaining of intermittent claudication of his left leg. During preoperative examinations, he was found to have bilateral isolated internal iliac artery aneurysms. As it was strongly suspected that ischemic colitis or gluteal ischemia would be caused if his bilateral internal iliac arteries were ligated during aneurysm surgery, his right internal iliac artery was reconstructed using a prosthetic graft. His postoperative course was uneventful. As aneurysm of the internal iliac artery is rare, there are few reports about reconstruction of the internal iliac artery. Technical details and pitfalls of internal iliac artery aneurysm surgery were discussed.

The sudden development of cyanotic lesions on the foot and toes may be a result of atheroembolic disease referred to as “blue toe syndrome”. During the last 7 years, 10 patients, consisting of 7 men and 3 women, were treated for ischemia of the toes of varied severity. The patients' ages ranged from 58 to 85 years (mean 73 years). Five patients had lesions on both legs and 5 on one leg. Contrast-enhanced abdominal CT scan revealed atherosclerotic changes of the abdominal aorta concomitant with intramural thrombus in every examined case. Four patients were treated medically and 4 underwent surgery consisting of replacement of the abdominal aorta in 3 and minor amputation of the toes in the other case. Two other patients developed acute renal failure within two months after the diagnosis of blue toe syndrome and succumbed to either heart failure or bleeding peptic ulcer. Contrast-enhanced CT scan is important for the diagnosis of blue toe syndrome. Though the prognosis of patients with blue toe syndrome is good in most cases, multiple microembolization to the viscera may cause renal failure and the prognosis of those patients is less favorable. Surgical intervention should be considered if the blue toe syndrome patient has an abdominal aortic aneurysm or history of multiple embolic episodes.

A 70-year-old man with a diagnosis of unstable angina pectoris (UAP) and arteriosclerosis obliterans (ASO) was admitted to our hospital with chest pain and intermittent claudication of both lower extremities. Coronary artery bypass grafting (CABG) was performed prior to peripheral arterial reconstruction due to UAP. He was in good condition after CABG, but he had sharp pain in both lower extremities suddenly on the 2nd postoperative day and the creatinine phosphokinase level increased to 17, 560IU/l. On the 3rd postoperative day axillo-bifemoral bypass was performed. However 5 hours after the revascularization, respiratory arrest and ventricular fibrillation occurred and he died in spite of attempted cardiopulmonary resuscitation.

We report a 69-year-old woman with transient mitral valve regurgitation and hemolysis following mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis. She had a history of congestive heart failure caused by mitral valve regurgitation so we performed mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis (Model 6900). Three days after surgery, a systolic murmur became clearly audible and the serum LDH level reached a maximum of 2, 018IU/l on postoperative day 10. Echocardiography showed regurgitant flow through the center of the bioprosthetic valve. It was thought that stent distortion of the implanted pericardial bioprosthesis had occurred and re-operation would be necessary, but the regurgitant flow disappeared suddenly on postoperative day 12. If mitral valve regurgitation occurs following mitral valve replacement with a pericardial bioprosthesis, stent distortion should be taken into consideration.

Persistent sciatic artery is an embryonic blood vessel that continues to feed the lower extremity after fulfilling an important role in lower limb development during early gestation. It is so rare that only 20 cases have been reported in Japan. This paper describes a case of acute occlusion of a persistent sciatic artey. A 78-year-old woman was admitted to hospital because of sudden onset of severe pain in her left leg. Angiography showed bilateral persistant sciatic arteries (complete type) with occlusion of the left artery and a small aneurysm on the right side. Left femoro-popliteal bypass was performed and postoperative angiography showed that the graft was patent.

Mitral regurgitation caused by papillary muscle rupture has a poor prognosis and should be operated on soon after onset. We recently encountered a patient who was operated on 8 months after the onset of mitral regurgitation caused by rupture of the posterior papillary muscle. The patient was a 72-year-old man who was admitted as an emergency case for acute left heart failure due to severe mitral regurgitation. As medical treatment was effective, he refused to have mitral valve surgery. Six months later, he was admitted to our hospital complaining of nocturnal orthopnea and underwent surgical treatment. Severe mitral regurgitation with postero-medial papillary muscle rupture was revealed by transesophageal echocardiography. Coronary angiography showed 90% stenosis of the proximal left circumflex artery. At 8 months after the onset of mitral regurgitation, the patient underwent successful scheduled mitral valve replacement together with coronary artery bypass grafting. There are few reports of mitral valve surgery being performed successfully for papillary muscle rupture due to coronary artery disease in the chronic stage.

The purpose of this study was to evaluate the efficacy of early rehabilitation starting on the day after cardiac surgery. In the early rehabilitation program, introduced from November 2006, we adopted an original video program about hospitalization and daily multi-specialist conference in the ICU. We divided 179 patients who underwent elective cardiac operation from June 2004 to September 2007 (mean age 65.4 years old, 51 women, 91 CABG, 53 valve procedures and 35 other procedure) into group A (the initial rehabilitation group : n=73) and group B (the early rehabilitation group : n=106). There were no significant differences in patient profile (age, gender, operation time etc.) between the two groups. The mean postoperative day of starting cardiac rehabilitation was 4.3+/-1.6 days in group A and 1.5+/-1.0 days in group B (p<0.01). The mean achievement period of all walking distances in group B was significantly shorter than in group A as follows, 50 m : group A 5.4+/-2.2 vs. group B 3.1+/-1.5 days (p<0.01), 100 m : group A 6.9+/-3.1 vs. group B 4.9+/-2.2 days (p<0.01), 200 m : group A 8.5+/-3.9 vs. group B 6.5+/-2.5 days (p<0.01), 300 m : group A 10.2+/-3.9 vs. group B 8.1+/-2.9 days (p<0.01), 500 m : group A 14.5+/-6.1 vs. group B 11.9+/-3.8 days (p<0.05). Approximately 90 per cent of patients in group B could walk by themselves on leaving the ICU. There were no major complications throughout rehabilitation. The mean hospital stay was 31.0+/-11.2 days for group A and 25.9+/-7.4 days for the group B, with a statistically significant difference (p=0.03). In a questionnaire survey at discharge, 91.0 per cent of patients in group B answered that early rehabilitation was most gratifying. In conclusion, early rehabilitation after cardiac surgery is effective for early recovery of ADL and leads to shorter hospital stay. We think both preoperative education and daily conferences are indispensable for safe and effective early rehabilitation programs.