A 63-year-old man with unstable angina and idiopathic thrombocytopenic purpura (ITP) underwent off-pump coronary artery bypass grafting after being admitted to our hospital because of angina pectoris. Coronary angiography performed on admission showed 90% stenosis of the left main coronary artery. High dose transvenous γ globulin therapy was performed for 3 days before surgery. The number of platelets, which was 2.3×10⁴/mm³ on admission increased to 4.1×10⁴/mm³ before surgery. Ten units of platelets were transfused intraoperatively, with little perioperative hemorrhage and no increased incidence of bleeding complications. The postoperative course was uneventful. High dose transvenous γ globulin therapy and operation without cardiopulmonary bypass were useful in facilitating the treatment of this ITP coronary artery bypass patient.

It is well known that patients with abdominal aortic aneurysms (AAA) have a high incidence of coronary artery disease (CAD), and that the major cause of death in patients undergoing aneurysmectomy is acute myocardial infarction. A total of 53 patients (mean age, 71 years) underwent elective repair of AAA between January 1991 and November 1999. In an attempt to reduce early and late mortality caused by myocardial infarction, coronary angiography (CAG) was performed in all cases. Significant CAD was found in 23 patients (43%), with triple vessel disease in 1 patient (2%), double vessel disease in 5 patients (9%), single vessel disease in 16 patients (30%) and left main in 1 patient (2%). Ten patients (19%) in whom CAD was detected by CAG had no history of CAD and displayed no ischemic findings on ECG. In 4 patients (8%), AAA repair was performed 2 (mean) months after coronary artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 8 patients (23%) 19 days (mean) prior to AAA surgery. No patient had a perioperative myocardial infarction either following coronary revascularization (CABG and PTCA) or AAA resection. Moreover, there was only one operative death after abdominal aneurysmectomy (2%), in a patient who was 70 years old with chronic hemodialysis and who died due to multiple organ failure caused by uncontrollable adhesional ileus. The results of this study emphasize the importance of preoperative routine coronary angiography following coronary artery revascularization to enhance the operative outcome of AAA repair.

The use of transapical aortic cannulation for arterial inflow during surgical repair of type A acute aortic dissection was evaluated. Thirty-six patients who underwent repair of type A aortic dissection were divided into 2 groups: those who underwent repair with transapical aortic cannulation (group A; 19 patients) and those who underwent repair with axillary and/or femoral artery cannulation (group C; 17 patients). Preoperative condition, estimated blood loss, transfusion requirements, and duration of the tube drainage and postoperative hospital stay did not differ in the 2 groups. Cannulations were successful in all patients, and none of the attempted inflow sites required moving to alternate sites in either group. The time to initiation of extracorporeal circulation (74.2±16.2min versus 88.8±12.5min, p=0.005) and the extracorporeal circulation time (175.2±55.5min versus 216.6±58.1min, p=0.036) was shorter in group A than in group C. However, the total operation time did not differ between the groups (309.3±112.5min in group A versus 363.4±130.9min in group C, p=0.198). All patients survived the operation, and there were no complications directly related to transapical aortic cannulation. Postoperative stroke tended to be lower in group A than in group C (5.3% versus 29.4%; p=0.081). There was 1 operative death in group A (5.3%) and 4 operative deaths in group C (23.5%) (p=0.167). These data demonstrate that the use of transapical aortic cannulation yielded more favorable results than other cannulation techniques for induction of extracorporeal circulation and for minimization of extracorporeal circulation time and postoperative morbidity. We conclude that transapical aortic cannulation represents a safe, effective and less invasive means of providing arterial inflow during cardiopulmonary bypass for patients undergoing surgical correction of type A aortic dissection.

A 47-year-old man was referred to our hospital for multiple rib fractures and pneumohemothorax due to a traffic accident. After admission, tricuspid valve regurgitation and hypoxemia were also diagnosed. Although fixation of the fractured ribs with plates and removal of hematoma in the pleural cavity were performed, hypoxemia did not improve. He was discharged on home oxygen therapy. Ten months and 3 years after the traffic accident, pulmonary perfusion scintigraphy suggested a right-to-left shunt. Transesophageal echocardiography demonstrated an opening of the foramen ovale and a right-to-left interatrial shunt. Direct closure of the patent foramen ovale and tricuspid valve replacement with the Carpentier-Edwards bioprosthesis were performed and hypoxemia disappeared after the second operation. Traumatic tricuspid valve regurgitation with cyanosis is extremely rare. However, it is important to take the possibility of patent foramen ovale into consideration in patients with traumatic tricuspid valve regurgitation and cyanosis.

An 82-year-old man was taken to a local clinic following the occurrence of syncope. Chest roentgenography and computed tomography (CT) findings led to a suspicion of a ruptured aortic aneurysm, and the patient was immediately transferred to our hospital. Upon admission, his consciousness was clear and blood pressure was 74/47mmHg. Enhanced chest CT images demonstrated pericardial effusion and a saccular aneurysm with a maximum diameter of 5cm, which was associated with a thrombus in the distal aortic arch. An emergency operation was performed under a diagnosis of a ruptured distal aortic arch aneurysm and hemorrhagic cardiac tamponade. During the procedure, a hole was found in the lesser curvature of the aneurysm, which had directly ruptured into the pericardial space, and a graft replacement of the aortic arch was performed using selective cerebral perfusion. The patient was discharged 19 days after surgery without any postoperative complications.

Rheumatic tricuspid stenosis has become rare recently. A 54-year-old woman had undergone mitral valve replacement with a Carpentier-Edwards bioprosthesis for mitral stenosis 22 years previously and had undergone repeat mitral valve replacement for prosthetic valve failure 10 years later. She was admitted with severe leg edema. Cardiac catheterization revealed pulmonary hypertension and tricuspid stenosis with a diastolic pressure gradient of 6mmHg across the tricuspid valve. Tricuspid valve replacement was performed with a Hancock bioprosthesis. The postoperative course was uneventful and her edema improved markedly. This case suggested that careful follow-up to detect progression of tricuspid stenosis is necessary in patients with rheumatic valve disease and pulmonary hypertension.