Mid-ventricular obstructive hypertrophic cardiomyopathy is rare and often complicated by apical ventricular aneurysm, which can cause life-threatening ventricular arrhythmias. A 76-year-old male patient came to our hospital because of an electrocardiogram abnormality (giant T-wave inversion). Transthoracic echocardiography showed myocardial hypertrophy at the level of the papillary muscles, apical thinning, and aneurysm formation. The patient was diagnosed with mid-ventricular obstructive hypertrophic cardiomyopathy with apical ventricular aneurysm. During follow-up, the patient developed exertional dyspnea, and nonsustained ventricular tachycardia was noted on Holter monitoring. Therefore, we opted for surgical treatment. The patient was placed on cardiopulmonary bypass and treated with apical aneurysmectomy, followed by myectomy with a trans-apical approach. Postoperative echocardiography showed an increased left ventricular end-diastolic volume. The patient no longer had difficulty breathing and did not develop postoperative ventricular arrythmia. He has been uneventful six months after surgery. We considered surgical treatment was effective in treating arrhythmias and heart failure.

We report 3 cases of ascending aorta-abdominal aorta bypass for atypical coarctation with Takayasu's aortitis. We performed an extra-anatomical bypass from the ascending aorta to the terminal abdominal aorta. The graft was arranged to pass through the diaphragm from the pericardium, behind the left lobe of the liver and the stomach, to the front side of the pancreas to the terminal abdominal aorta. Although the graft was exposed in the abdominal cavity in part behind the stomach, it was completely covered with the great omentum thus avoiding direct contact between the graft the abdominal organs. Decrease in the pressure gradient between the ascending aorta and the abdominal aorta was achieved using a large prosthetic graft 14-16 mm in diameter. There are several advantages with this technique. (1) Positional change during surgery can be avoided. (2) Anastomosis can be performed in non-diseased vessels. (3) This bypass graft can be branched off to visceral arteries if necessary. Reduction of the after load on the left ventricle and long-term graft patency by using a large diameter prosthetic graft were anticipated. The postoperative courses of all cases were satisfactory. Case 1 died of another disease 11 years and 11 months postoperatively, but the graft to was still patent.

An 18-year-old man underwent a Ross operation for the treatment of prosthetic aortic valve endocarditis with extensive perivalvular tissue destruction. Postoperatively, he developed poststernotomy methicillin-resistant Staphylococcus aureus mediastinitis, which was treated with one-staged irrigation, debridement and omental transfer. After 3 years of follow-up, he is doing well without any sign of infection or a graft failure.

Endovascular grafting via the aortic arch, a novel alternative method for aortic aneurysm repair, was performed in 18 patients with aortic arch or distal arch aneurysms. For cerebral protection, selective or retrograde cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy. Selective cerebral perfusion was performed through both cerebral arteries and the left subclavian artery. Throughout this procedure, the aorta was filled with carbon dioxide to prevent the spinal arteries from air embolism. Two patients were lost, one due to myocardial infarction and one due to pneumonia. Endoluminal leakage was found in 2 patients, for which reoperation was required. However, no cerebral or spinal complications were observed in this series. Thus we conclude that endovascular stent grafting via the aortic arch is an acceptable alternative for the aortic arch or distal arch aneurysm repair with little risk of cerebral or spinal complications.

A combined aortic and mitral valve replacement was performed in a 50-year-old man who had undergone living-related renal transplantation one year previously. The oral administration of tacrolimus was continued perioperatively while monitoring blood tacrolimus level. The postoperative administration of human atrial natriuretic peptide (hANP) was effective to maintain urine output was performed in addition to frosemide, mannitol, dopamin and prostaglandin E₁ infusions. He was discharged on the 37th postoperative day without rejection, infection or renal dysfunction. This is the first report in Japan describing successful combined aortic and mitral valve replacement after renal transplantation.

We performed a video-assisted thoracoscopic surgery (VATS) to clip the patent ductus arteriosus (PDA), which was 5mm in internal diameter, in an 11-year-old girl, who first underwent a coil embolization ending in failure. Under general anesthesia with one-lung ventilation in a right lateral decubitus position, four thoracostomies were made in the left hemithorax. The PDA was clipped by two titanium clips, the length of which is 11mm at closing. Transesophageal echocardiography confirmed the location of the PDA and the absence of a residual shunt. The patient showed neither left recurrent laryngeal nerve dysfunction nor hemorrhage after operation, and was discharged on the 9th postoperative day. The clipping of the PDA by VATS can be applied for PDA without calcification if the external diameter is up to 7mm. This technique was minimally invasive and reliable. It was excellent in terms of the high quality of life achieved by the patient.

The internal mammary artery (IMA) has been widely used in CABG due to the excellent long-term results. However, the extensive use of bilateral IMA grafting has been believed to increase operative morbidity and mortality. This study was designed to determine if bilateral IMA grafting in diabetic patients increased the likelihood of mediastinitis. We analyzed the data of 386 consecutive patients who underwent isolated CABG in 1992 to 1996. The definitions of sternal wound complications are as follows, (1) mediastinal dehiscence and (2) mediastinal wound infection. Subtypes include superficial wound infection and deep wound infection (mediastinitis). Among these patients 97 received unilateral IMA grafts and 289 did bilateral IMA grafts. mediastinitis did not occur in any subjects. The occurrence rate of mediastinal dehiscence and superficial wound infection was 7.2% (7/97) for bilateral IMA grafting, 7.3% (21/289) for unilateral IMA grafting. No patients died of wound complications. The occurrence rate of mediastinal dehiscence and superficial wound infections were 12.0% (4/33) for bilateral IMA grafting in diabetic patients, 12.0% (14/117) for unilateral IMA grafting in diabetic patients. That of this complications was 4.7% (3/64) for bilateral IMA grafting in non-diabetic patients, 4.1% (7/172) for unilateral IMA grafting in diabetic patients, without significant differences in wound complication. Bilateral IMA grafting in diabetic patients carried no great risk of mediastinitis, but diabetes mellitus itself was a great risk for mediastinitis.

Malignant hyperthermia (MH) and antithrombin III (AT III) deficiency are both rare, but once they occur, the patient's prognosis is very poor. A 67-year-old man was referred to our hospital with a diagnosis of unstable angina. A coronary angiography revealed stenosis of LMT and triple vessels. The patient was considered a candidate for CABG. He had been prescribed 50mg/day of dantrolene for frequent muscular convulsions of the lower extremities. He had had a high CK level for a few years. Therefore he was considered to be at high risk for malignant hyperthermia (MH). He underwent CABG (×4). Dantrolene was administered orally at a dose of 25mg and then 160mg intravenously before anesthesia and modified NLA was performed in order to avoid probable MH. During the operation, AT III deficiency was suspected because the reaction of ACT after heparinization was poor. AT III preparation (1, 500 units) was used and CABG under cardiopulmonary bypass was completed without any events. It was proved after the surgery that the AT III volume had been almost normal but its activity had decreased. His postoperative course was good. For possibly fatal MH and AT III deficiency, it is necessary and important to predict, prevent and diagnose as early as possible.

There have been many reports radial artery grafts (RA) are useful in CABG, but there were very few reports about hand grasping power (GP), edema and sensory disturbance after surgery. From January to April, 1999, RA were used for 14 patients (R group) and were not in 16 patients (C group) among a total of 30 coronary artery bypass grafting procedures. The patients in the two groups were statistically similar. RA were anastomosed to #12 in 9 patients and #14 in 5. GP and the circumference of forearms were examined and sensory disturbance was also checked preoperatively and at 1, 2 and 4 weeks postoperatively. In both groups, left GP decreased slightly after surgery but gradually recovered. Four weeks after surgery, it was 26.2±9.6kg in the R group and 26.2±7.5kg in the C group (NS). The difference between left and right circumference of forearms, which indicates the degree of edema, was significantly larger in the R group than in the C group (3.5±3.6mm vs. -0.5±3.8mm, 1 week postoperatively, p<0.05). However, it gradually improved in the R group (2.1±2.6mm at 2 weeks and 1.9±2.6mm at 4 weeks postoperatively). No sensory disturbance was seen at any time. Therefore we conclude that using RA in CABG is not only useful but is also safe and does not increase postoperative risk.

A 57-year-old man underwent subtotal graft replacement of the thoracic aorta for aneurysms of both the ascending and descending aorta. On the 20th post-operative day, pus was found to be draining from the sternotomy wound. The wound was opened and irrigated with 2% Povidoneiodine solution for a total of 3 months. Culture of the pus from the irrigation revealed Staphylococcus epidermidis. When there were no clinical indications of infection and wound cultures were negative, the necrotic sternum and surrounding tissue were debrided and an omental graft was placed in the cavity. Upon follow-up examination, the patient is doing well 10 months after the initial surgery.