A 44-year-old woman with dyspnea on effort was admitted. Aortic stenosis and mitral stenosis and pulmonary hypertension were diagnosed. She underwent surgical treatment for her aortic valve and mitral valve by enlarging the aortic and mitral valve ring and replacing them by modified coupling valve methods. The postoperative course was uneventful and she was discharged on the 21st postoperative day.

Long-term hemodialysis remains a major risk factor for coronary artery bypass grafting (CABG). In our institution, a surgical strategy for these high risk patients is the complete coronary revascularization with off-pump CABG (OPCAB) using an arterial graft. However in cases of advanced functional disorder, we choose hybrid strategy or reduction strategy, namely the target of surgical intervention is just the key vessel. Aggressive usage of continuous hemodiafiltration (CHDF) to control water and electrolytic balance intra- and post-operatively is an alternative. This study aimed to elucidate whether our strategy is appropriate for hemodialysis patients. We enrolled 608 consecutive patients who underwent CABG between August 1999 and December 2006. Among them, 25 (4.1%) had received regular hemodialysis. As a control group, 100 patients were selected randomly among 583 patients excluding 25 hemodialysis patients. All patients had at least one major complication, and 13 had several major complications. The number of preoperative complications in hemodialysis patients is significantly higher than that of control group. Mean patient age was 66.3±8.7 years. The mean number of diseased vessels was 2.32±0.7, and that of anastomosis per patient was 2.4±1.2. All patients completed the procedure without cardiopulmonary bypass (CPB) as a result. Complete revascularization was performed in 22 (88%). The causes of non-completion were a hybrid strategy with PCI in one patient in the early period and a reduction strategy in 2 on account of social indications. Perioperative mortality was 0%, while the major complication was extended pleural effusion in 3 patients and slowly progressive sternal osteomyelitis in one. Mid-term results showed 2 cardiac deaths. The surgical outcome was equivalent in the hemodialysis group and the control group, though each preoperative state was not equal. Our strategy for patients undergoing chronic hemodialysis attained excellent perioperative and mid-term outcomes. We consider OPCAB produced better outcomes. CHDF is an important tool for use in surgical intervention in these patients.

Left ventricular reconstruction methods (LVR) consisting of the Dor procedure or septal anterior ventricular exclusion (SAVE) have been advocated for left ventricular dysfunction due to ischemic cardiomyopathy (ICM). This study reports early results achieved with LVR in patients with ICM. Between April 2001 and August 2004, 9 patients with ICM underwent LVR and coronary artery bypass grafting (CABG). Their age was 62±11 years, and 7 were men. The Dor procedure was performed in 8 patients and 1 patient underwent SAVE. CABG was performed in all patients. Two patients with grade 3 mitral regurgitation (MR) preoperatively had mitral valve annuloplasty (MAP). The mean left ventricular ejection fraction (LVEF) improved from 31.6±7.2% to 47.8±9.4%. The mean left ventricular end diastolic volume index (LVEDVI) decreased from 166.7±50.4ml/m² to 102.6±23.0ml/m². The mean left ventricular end systolic volume index (LVESVI) decreased from 114.4±34.7ml/m² to 52.4±16.6ml/m². The mean coaptation depth decreased from 9.3±3.1mm to 4.5±1.4mm. The mean MR, with or without MAP, improved from grade 1.7±1.1 to grade 0.2±0.4. There were no hospital deaths. Seven of 9 patients were categorized as New York Heart Association functional class I at discharge. We conclude that LVR is an effective treatment for ICM with severe left ventricular dysfunction.

The purpose of this study was to analyze our results of mitral valve repair with a rigid annuloplasty ring (Carpentier-Edwards ring; Baxer-Edwards CVS Laboratories; Lrvine, Calif) in terms of its efficacy and safety. We have examined postoperative mitral regurgitation (MR) and left ventricular diastolic dimension (LVDd) in 63 cases of mitral valvoplasty during a period of 5 years. The operative methods were 20 cases of tendon reconstruction, 42 cases of quadrangular resection, and 15 cases of annuloplasty alone. Operative mortality and freedom from complications were examined at the mean 41.2 months after the operation. There were no operative deaths, and no case with severe MR postoperatively. From echocardiographic findings, the grade of MR changed from 3.13 to 0.28 postoperatively, and LVDd changed from 58.4±6.71 to 48.7±6.3ml postoperatively. Reoperation was performed in 2 cases (3.2%) several years after the first operation. The rate of midterm mortality was 4.8%. The postoperative mitral valve area was 2.85cm² in size of 26mm ring, 2.95cm² in size of 28mm, 3.09cm² in size of 30mm, which were measured from PHT (pressure half time) of the Doppler echocardiography. In conclusion, mitral valve repair with rigid annuloplasty ring (CE ring) provided good results for MR at midterm follow-up.

Coronary artery bypass grafting (CABG) using in situ skeletonized arterial conduits with an off-pump technique is a high quality and minimally invasive procedure. The internal thoracic artery (ITA) is the most reliable conduit as grafting the left anterior descending artery and circumflex arteries with bilateral ITAs leads to better long-term patient outcomes. In this study, we demonstrated the feasibility and usefulness of off-pump coronary artery bypass grafting surgery using bilateral ITAs. A total of 217 consecutive CABG cases using skeletonized ITA grafts were studied and they were divided into 2 groups are using unilateral ITA (UITA, n=104) and the other using bilateral ITA (BITA, n=113). OPCAB was completed in 94% (98/104) in the UITA group and in 99% (112/113) in the BITA group. The mean number of distal anastomoses per patient was 3.02 in the UITA group and 3.63 in the BITA group. The ITAs were used in situ in 100% (104 ITAs) in the UITA group and in 96% (217 ITAs) in the BITA group. One patient in the UITA group suffered from mediastinitis and one patient in the BITA group died due to intestinal ischemia 3 days after operation. Postoperative angiography was performed before discharge in 101 patients in UITA and 99 in BITA. The patency rate was 98.7% in the UITA group and 99.4% in the BITA group. OPCAB with bilateral skeltonized ITAs is a feasible and safe technique with excellent early clinical results and graft patency. OPCAB using in situ skeletonized artery conduits can become a standard surgical treatment for ischemic heart disease.

Between January 1999 and August 2002, 13 patients with mitral regurgitation resulting from native valve endocarditis underwent surgery. The age of these patients was 54±13.8 years (range, 27 to 74 years); 8 patients were men. Five patients were categorized as New York Heart Association functional class III or IV. Endocarditis was active in 3 patients. Emergency or urgent surgery was required in 4 patients. Twelve patients underwent repair, and one had a valve replacement. Following the removal of all infected or nonviable tissue, a decision was made as to the possibility of repair. Repair was attemped in 13 patients and was successful in 12 patients. Most patients received ring annuloplasty with a Carpentier-Edward ring. Six patients had chordae ruptures, 5 patients had vegetations, and 2 patients had elongated chordae. Twelve patients were categorized as New York Heart Association functional class I, and one was categorized as class II at discharge. There were no hospital deaths. The mean follow-up of the 13 survivors was 24±14 months (range from 3 to 43 months). There were no late deaths, reoperations, recurrent endocarditis, thromboembolic events, or other valve-related morbidities. We conclude that mitral valve repair is an effective treatment for inective endocarditis with mitral regurgitation.

“Cardiac Cycle: The First Step, ” which discretely, non-ambiguously, and accurately presents basic essential information on the cardiac cycle, was compared with conventional material in terms of educational efficiency. Twenty-six first-year medical students were randomly assigned to either material. The conventional group was presented with a standard textbook with a typical figure and text. The students were blinded as to the origin of the materials. After self-study, the same quiz (30 two-item choice questions asking basic essential information) was given to both groups and was scored by a blinded rater. The number of correct answers was 25.7±3.7 (mean±SD) in the conventional group and 29.4±1.1 in the ‘first-step group’(p<0.01).

We report the results of aortic arch replacement in 32 patients (20 males, 12 females) with aortic arch aneurysm, including 9 emergency cases. The etiology of aneurysm was atherosclerotic aneurysm in 18 patients, pseudoaneurysm in 1 patient, and aortic dissection in 13 patients. Selective cerebral perfusion (SCP) and retrograde cerebral perfusion (RCP), which are used for brain protection during aortic arch reconstruction, were both employed in this study according to our institutional policy. RCP was started at the moment of circulatory arrest after which the aneurysm was opened. In the case of 1-branch reconstruction or hemiarch replacement, we only employed RCP. If 2-branch reconstruction or total arch replacement was needed, we switched to SCP. After the distal graft anastomosis was performed, antegrade systemic perfusion was started via the 4th branch of the graft. Subsequently, 3 arch vessels was reconstructed with rewarming to shorten the SCP time, and finally proximal graft anastomosis was performed. Distal graft anastomosis with a new technique was applied in the 10 most recent cases. The “cuff” was made at the distal anastomosis site of the graft beforehand and this “cuff” was sutured to the aortic wall in an elephant-trunk fashion. This technique was a simple approach to repairing the distal lesion and allowed easy addition of stitches in case's of bleeding. The in-hospital mortality rate was 6.3% (2 of 32 patients) and the rate of cerebrovascular accident was 6.3% (2 of 32 patients). This technique for aortic arch repair is a useful method that results in low rates of in-hospital mortality and morbidity.

Minimally invasive direct coronary artery bypass grafting (MIDCAB) has been performed in some institutions and mid-term results have been reported. However, because of its technical difficulty, the procedure has not been gaining acceptance among cardiovascular surgeons. We report the clinical results of our MIDCAB series and describe the effect and role of the MIDCAB in the therapy of ischemic heart disease. From May 1999 through May 2002, 65 patients (age 29 to 90 years) underwent MIDCAB via a small left thoracotomy. Postoperative angiography was performed before discharge in all patients. No conversions to sternotomy were necessary. There were no operative, hospital or mid-term mortalities, nor were these any major complications, including myocardial infarction, stroke, respiratory failure, and other organ failure. Wound infection occurred in 1 patient. No graft occlusion was seen. Graft stenosis was seen in only 1 patient. The graft patency rate was 98.5% (66/67). Postoperative cardiac events included 2 incidents of angina, and 4 of atrial fibrillation. There were no incidents of congestive heart failure. MIDCAB is a safe and less-invasive operation. According to our clinical results, MIDCAB is an alternative to conventional coronary artery bypass grafting for selected patients, especially for those at high risk.

A digital teaching material on the cardiac cycle, which discretely illustrates only the left heart system, not the right, and shows the pressure of each section clearly with an illustration of a water pipe pressure gauge, as proposed by G. Doman et al., was presented to medical students, who had not previously learned circulatory physiology. Many formative questions were also provided to promote active learning. After learning the material, the students were given an anonymous questionnaire comparing the present material with a standard textbook of physiology as the control. When asked the overall impression, 86% of the students supported the present material.