A mismatch between SVG diameter and RCA diameter has an impact on the patency rate of the SVG. Evaluation of the saphenous vein before surgery and selection of a graft to minimize mismatch should improve SVG patency.
Pseudocoarctation of the aorta is a rare anomaly and considered a benign condition. Pseudocoarctation of the aorta has been associated with aneurysm formation in the thoracic aorta, which may cause sudden rupture or dissection. Thus, the presence of an aneurysm in combination with pseudocoarctation of the aorta is thought to be an indication for surgery. We present a case of pseudocoarctation of the aorta associated with thoracic aortic aneurysm and severe aortic valve stenosis with a bicuspid aortic valve. In our case, single-stage repair was performed through a median sternotomy using our "pleural-window approach." Keywords: coarctation, aneurysm, aortic valve elevation of the brain natriuretic peptide (1577 pg/ml). A chest X-ray showed pulmonary congestion, cardiac enlargement and widening of the superior mediastinum. The results of transthoracic echocardiography showed an ejection fraction of 30%, a peak gradient across the aortic valve of 93 mmHg and an effective orifice area of 0.55 cm 2 . Enhanced computed tomography (CT) performed subsequently revealed kinking in the distal aortic arch with stenosis (Fig. 1A), poststenotic dilatation of the descending aorta (45 mm), a left subclavian artery aneurysm (30 mm) and no significant collateral vessels (Fig. 1B). There was no systolic pressure gradient between the upper and lower extremities. As descending aorta tended to expand, we thought that the aneurysm was needed for resection. After treatment of CHF, we performed single-stage surgery through a median sternotomy (Fig. 1C). Total cardiopulmonary bypass was initiated by cannulating the ascending aorta. The common femoral artery was isolated and cannulated with an 18 Fr cannula. After the ascending aorta was clamped and cardiac arrest was obtained, the ascending aorta was opened. We found a bicuspid aortic valve and performed aortic valve replacement (AVR) with a 21-mm bovine pericardial bioprosthetic aortic valve. A wide incision of the left pleura was made from the aortic arch to the diaphragm. The left lung was mobilized to the right side and the narrowed segment and descending aortic aneurysm were clearly visible when the heart with the pleura and pericardium were retracted. After the patient was cooled to 28°C and the descending aorta was clamped, antegrade cerebral perfusion and femoral artery perfusion were initiated (Fig. 2A). The aneurysm wall was thinned and diameter of the narrowed segment was 9 mm (Fig. 2B). The distal aortic anastomosis was completed with a fourbranched woven Dacron graft. After antegrade flow to the lower body was established through a side branch of the graft, the ascending aorta, brachiocephalic and carotid arteries were anastomosed. The third graft limb was anastomosed to the left axillal artery through the pleural cavity and the left subclavian artery aneurysm was resected and
We describe an alternative technique through median sternotomy to perform total arch replacement for an extended distal arch aneurysm. After initiating cardiopulmonary bypass, the left pleura is opened widely from the aortic arch to the diaphragm and the left lung is mobilized to the right side with the heart. The descending aorta is visible through the window of the pleural incision. This technique provides excellent exposure, facilitating aneurysm resection, control of the descending aorta and successful completion of the distal anastomosis. In our experience of 26 cases who had distal aortic arch aneurysm with downstream extension, total arch replacement was achieved through a median sternotomy without the need for left anterolateral thoracotomy. This procedure reduced perioperative bleeding and resulted in satisfactory clinical outcomes.
Single coronary artery (SCA) in the absence of other major congenital cardiovascular anomalies is rare. We report an extremely rare case of acute aortic dissection in an octogenarian who had a single left coronary artery with the right coronary artery originating from the distal circumflex. A single ostium was incidentally detected by visual inspection during an operation. We diagnosed the anomaly in detail by postoperative 64-slice multi-detector computed tomography. As we performed an emergency operation, it was difficult to recognize SCA preoperatively. In this situation, it is very important to establish adequate myocardial protection and careful dissection is necessary to avoid iatrogenic injury.
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