Reoperations were performed due to infection(n＝10), after valve surgery (n＝16), after coronary surgery(n＝9), due to Marfan syndrome(n＝3), after aortic surgery(n＝7), after congenital surgery(n＝4), and for other reasons. In the reoperations, the same surgical site was exposed in 65%, the femoral vessels were exposed before re-sternotomy in 77%, the inflow was on the ascending aorta in 35%, and cardiopulmonary bypass was initiated before re-sternotomy in 37%. Systemic cooling was needed in 4 patients and some maneuvers for patent internal thoracic artery grafts in 6 patients. The operation time of 9.6±2.5 h and the cardiopulmonary bypass time of 295±111 min, respectively. We experienced intraoperative injuries in 16 patients(31%). Platelet transfusion was needed in 90% and a second CPB in 15%. Postoperative complications included hemorrhage(14%), infection(13%), stroke(4%), respiratory failure(44%), and renal failure(1%). The hospital mortality was 7.7%(4/52)due to uncontrolled infection, liver failure, pulmonary hemorrhage, and left ventricular rapture. The 2-year survival rate was 83.1% with the mean follow-up of 24±18 months. In conclusion, although the risk of injuries at re-sternotomy was not high, limited surgical field due to adhesions resulted in fatal injuries and in the cardiac reoperations we experienced. We need to improve our strategies for further reduction in mortality and morbidities in reoperations. Jpn. J. Cardiovasc. Surg.

A 60-year-old man with type 2 diabetes mellitus and severe obesity(height 170 cm, weight 160 kg, BMI 55)was admitted to our hospital because of acute inferior wall myocardial infarction due to acute thromboembolism of the right coronary artery(RCA). Because of three-vessel coronary diseases, we planned coronary artery bypass grafting after the medical therapy. The patient was intubated, then suffered congestive heart failure and pneumonia, and had a tracheotomy because of obesity hypoventilation syndrome. When his general condition improved after 14 months of medical therapy, we performed the operation. At that time, his weight had decreased to 107.5 kg, and BMI decreased to 37.2. We decided that tracheotomy was necessary to avoid respiratory complications. We chose a thoracoabdominal spiral incision for 2 reasons. Firstly we needed to avoid wound contamination by the tracheotomy stoma. Secondly we decided that the left internal thoracic artery(LITA)and the right gastroepiploic artery(RGEA)were sufficient for bypass grafts to the left anterior descending artery (LAD), the diagonal branches(D1), the posterolateral artery(PL)and the posterior descending artery(PD). Before the operation, epidural anesthesia was performed for postoperative analgesia to prevent respiratory dysfunction. In the right semi-lateral position at 30°, a 4th intercostal space thoracotomy was performed, and the LITA was harvested. The skin incision was extended to the midline of the abdomen and the RGEA was harvested. The end of the LITA was anastomosed with the free RGEA as I composite and the composite was anastomosed to the LAD, the D1, the 14 PL and the 4 PL without cardiopulmonary bypass. Without any perioperative blood transfusion, the patient was discharged with no perioperative complication, including mediastinitis. With this incision, we achieved secure prevention of wound contamination by the tracheotomy stoma, harvesting of a sufficient length of the LITA and

A 58-year-old man underwent aortic root replacement for annuloaortic ectasia (AAE) and aortic regurgitation (AR). The patient was readmitted because of chest discomfort 3 months after the first operation. Computed tomography showed a pseudoaneurysm of the ascending aorta. Re-aortic root replacement was done on an emergency basis. However, 16 days after the second operation, a pseudoaneurysm was revealed by computed tomography. The third operation was successfully performed using a rif ampicin-bonded gelatin-sealed Dacron graft (GELSEAL(R); Sulzer Vascutek, Glasgow, UK). The postoperative course was uneventful.

A 72 year-old man presented with aortic pseudoaneurysm and aortopulmonary fistula, due to dehiscence of the both coronary button anastomosis, at 15 years after aortic root replacement with Carrel patch procedure for annuloaortic ectacia. At reoperation, a fistula was found on the pulmonary trunk. The pulmonary artery defect was closed with interrupted 3-0 polypropylene sutures placed through strips of Teflon felt. The left and right coronary button had completely detached from the graft. The coronary ostial hole of composite valve graft was closed using a new prosthetic patch. Two coronary artery bypass were placed on LAD and RCA using saphenous vein grafts.Coronary pseudoaneurysm with fistulization to the pulmonary artery after a modified Bentall operation is a rare complication, only a few cases has been previously reported.