In cases complicated with immune thrombocytopenic purpura (ITP), the perioperative period in which cardiopulmonary bypass is used may pose a problem due to a rapid decrease in platelet count. In this case, we performed myxoma resection and a Maze procedure on a patient with a left atrial myxoma and atrial fibrillation who was receiving eltrombopag therapy under an ITP diagnosis. Initially, because the cardiology department suspected a left atrial thrombus caused by atrial fibrillation, eltrombopag administration was discontinued and anticoagulation therapy initiated; however, an episode occurred in which the platelet count precipitously fell from 192,000/μl to 71,000/μl over six days. Therefore, a plan was devised preoperatively to ensure stable continuation of ITP treatment, which involved administering a high-dose infusion of intravenous immunoglobulin (IVIG) preoperatively and using subcutaneous injection of romiplostim on the day of surgery. Due to the potential for excessive platelet elevation depending on the timing of eltrombopag reinitiation, the drug was restarted and adjusted at the point when a postoperative decline in platelet count was observed. The operation and postoperative course proceeded with good control and without significant bleeding. Although the patient had a history of sick sinus syndrome noted during preoperative internal medicine admission, postoperative bradycardia persisted; as a result, the patient underwent pacemaker implantation on postoperative day 23. The patient was unaffectedly discharged on postoperative day 34.

A 49-year-old man presented with subclavian steal phenomenon and severe stenosis of LMT. His SSP was composed of severe stenosis of the innominate artery, and the greater part of the blood supply to the right subclavian artery was through the collateral circuit of the vertebral arteries and the internal thoracic arteries. We performed replacement of the innominate artery with a prosthetic graft and coronary artery bypass using LITA in one-stage surgery.

Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by thrombocytosis and malfunction of platelets. Both thrombosis and bleeding due to thrombocytosis may occur. An 81-year-old female patient complicated with ET underwent mitral valve replacement using a bioprosthetic valve due to severe mitral regurgitation. She had been diagnosed and treated with the hydroxycarbamide for ET. The hydroxycarbamide had been interrupted 14 days before the surgery, to prevent infection and delayed wound healing. At hospitalization for surgery, her platelet count rose to 1,290,000/μl from 790,000/μl. Readministration of a half dose of the hydroxycarbamide lowered the platelets to her original level. During the operation, more heparin was necessary to control activated coagulation time for cardiopulmonary bypass. She was discharged unaffectedly on 25 POD.

A 71-year-old man with double vessel disease (left anterior descending artery and right coronary artery) was surgically treated by off-pump coronary artery bypass grafting. He had undergone pre-sternal subcutaneous gastric tube reconstruction and mediastinal radiation therapy 19 years previously due to esophageal cancer. The gastric tube prevented the median sternotomy that is commonly necessary for cardiac surgery. In cases with difficulties of median sternotomy, left anterolateral thoracotomy and the use of the subclavian artery as inflow root for bypass grafting are available. Both radial arteries were harvested as graft conduit, because of prospective severe adhesion of left internal thoracic artery due to previous radiation. The radial artery was anastomosed on the back side of the left subclavian artery with side-to-end fashion. Y-shaped composite graft was made with the other arterial graft. Both ends were anastomosed to the left anterior descending artery and the right posterior descending branch on the beating heart status without cardiopulmonary bypass. Intra-operative SPY images showed good patency of both bypass grafts. The post-operative course was eventful. The catheter angiography revealed all graft patency 5 years after the surgery.