Penetrating cardiac injury caused by multiple rib fractures following high-energy trauma: Usefulness of the exploratory video-assisted thoracoscopic surgery.

Background: Penetrating cardiac injuries are usually fatal and associated with poor survival rates. Case Presentation: A 69-year-old man was injured in a motor vehicle accident and suffered from left hemothorax and multiple rib fractures near the heart. A comprehensive assessment raised suspicions of lacerated pericardium and myocardial injury. Consequently, a thoracoscopy was performed 9 h after injury. A penetrating cardiac injury was detected and surgically treated via video-assisted thoracoscopic surgery. The patient recovered uneventfully and was discharged on postoperative day 16. Conclusion: Exploratory video-assisted thoracoscopic surgery may play a key role in the primary diagnosis of patients with high-energy chest traumas with cardiac injury and simultaneously allow for the appropriate surgical interventions.

Totally endoscopic concomitant aortic and mitral valve surgery in junctional epidermolysis bullosa: a case report.

BACKGROUND: Junctional epidermolysis bullosa is a rare skin and mucosal disorder characterized by blister formation in response to minor trauma and extracutaneous manifestations. There have been no reports of cardiac surgery and prognostication in patients with epidermolysis bullosa due to skin and mucosal fragility. CASE PRESENTATION: A 55-year-old man presented with congenital junctional epidermolysis bullosa, hypertension, and vasospastic angina. He complained of dyspnea on exertion, and transthoracic echocardiography revealed severe aortic valve regurgitation, moderate aortic valve stenosis (tricuspid valve), and severe mitral valve regurgitation. Considering that the skin condition in the right chest wall was relatively healthy, the right thoracotomy approach was preferred and totally endoscopic concomitant mitral valve repair and aortic valve replacement were performed using a sutureless bioprosthetic valve (Perceval™ (Corcym, Group, Milan, Italy)). Polyurethane and silicon dressing foams were used to protect the skin at the site of contact with the bag valve mask, arterial pressure catheter, intravenous catheter, and the tracheal intubation tube. Vertical mattress sutures were used for the skin sutures. The postoperative course was uneventful, and the patient was discharged nine days after the operation. There was no indication for reoperation until three years follow-up period. CONCLUSIONS: The totally endoscopic concomitant aortic and mitral valve surgery using Perceval™ prosthesis can be performed safely in patients with junctional epidermolysis bullosa by adequate protection of the skin and mucosa.

Left-sided primary cardiac lymphoma diagnosed by needle biopsy with total endoscopic anterolateral mini-thoracotomy: a case report.

Background: Primary cardiac lymphoma (PCL) is an extremely rare tumour that typically affects the right heart chamber. It is a life-threatening tumour presenting with rapid growth; therefore, early diagnosis and treatment are crucial for improving the prognosis of patients with PCL. Case summary: An 81-year-old female with a history of dermatomyositis and interstitial pneumonia was referred to the cardiology department for cardiomegaly detected on chest radiography and computed tomography (CT). She experienced shortness of breath on exertion. Electrocardiography revealed negative T-waves in various leads. Transthoracic and transoesophageal echocardiography revealed a large mass on the epicardial free wall of the left atrium and ventricle. Coronary CT angiography showed feeding vessels from the left circumflex artery and the posterolateral branch of the right coronary artery. Positron emission tomography showed elevated mass uptake and no systemic metastasis. Needle biopsy with total endoscopic anterolateral mini-thoracotomy was performed. Histopathological examination revealed diffuse large B-cell lymphoma. She received systemic chemotherapy and achieved a complete metabolic response. Discussion: Herein, we report an extremely rare case of PCL located on the left side of the heart. Owing to the location of the tumour, percutaneous or transcatheter biopsy could not be performed. Early diagnosis with needle biopsy via anterolateral mini-thoracotomy and systemic chemotherapy resulted in good outcomes.

Multicenter Study of Surgical Ablation for Atrial Fibrillation in Aortic Valve Replacement.

There is controversy regarding appropriate surgical ablation procedures concomitant with nonmitral valve surgery. We retrospectively investigated the impact of surgical ablation for atrial fibrillation during aortic valve replacement between 2010 and 2015 in 16 institutions registered through the Japanese Society for Arrhythmia Surgery. Clinical data of 171 patients with paroxysmal and nonparoxysmal atrial fibrillation undergoing aortic valve replacement were collected and classified into full maze operation (n = 79), pulmonary vein isolation (PVI) (n = 56), and no surgical ablation (n = 36) groups. All patients were followed up and electrocardiograms were recorded in 68% at 2 years. The myocardial ischemia time was significantly longer in the maze group than the others during isolated aortic valve replacement (p ≤ 0.01), but there were no significant differences in 30-day or 2-year mortality rates between groups. The ratios of sinus rhythm at 2 years in paroxysmal and nonparoxysmal atrial fibrillation in the maze group versus PVI group were 87% versus 97%, respectively (p = 0.24) and 53% versus 42%, respectively (p = 0.47). No patients with nonparoxysmal atrial fibrillation in the no surgical ablation group maintained sinus rhythm at 2 years. In conclusion, both maze and PVI during aortic valve replacement are valuable strategies to restore sinus rhythm at 2 years and result in favorable early and midterm survival rates.

Surgical repair of a right coronary artery fistula to the left ventricle.

A 17-year-old male complained of exertional dyspnea and was referred to our hospital after he was diagnosed with a right coronary artery fistula into the left ventricle. Surgical repair was considered to improve the symptoms. We identified the distal end of the right coronary artery entering the left ventricle under cardiopulmonary bypass with cardiac arrest. The fistula was transected at the distal end of the right coronary artery and closed at both ends without incision of the left ventricle. Coronary angiography revealed the patency of the right coronary artery and the peripheral branches four months after surgery. The coronary computed tomography four years and four months after operation showed no pseudoaneurysm formation, no thrombosis, and subsequent regression of the dilated right coronary artery. Learning objective: The coronary artery fistula is a rare congenital anomaly, and the treatment strategies of the coronary fistula are controversial. We performed ligation of the coronary fistula under cardiac arrest on cardiopulmonary bypass without incision of the left ventricle. This strategy may contribute to the accurate identification and ligation of the fistula without pseudoaneurysm formation.

Posterior Reversible Encephalopathy Syndrome After Thoraco-Abdominal Aortic Replacement.

Introduction: Induced hypertension, administered peri-operatively during thoraco-abdominal aortic intervention, is one of the most effective methods to maintain spinal cord perfusion pressure. Posterior reversible encephalopathy syndrome or reversible cerebral vasoconstriction syndrome is a rare encephalopathy, possibly caused by excessive hypertension, usually encountered in the obstetric or cerebrovascular department. Report: A 61 year old man underwent open surgery for repair of an extent II dissecting thoraco-abdominal aneurysm. Several attempts at spinal drainage tube insertion one day prior to surgery failed. The Adamkiewicz artery was anastomosed by bypass, and transcranial motor evoked potentials were generally stable. Initially, no apparent neurological abnormality was observed after surgery; however, paraplegia occurred on post-operative day 1. The patient's mean arterial pressure increased from > 85 mmHg to > 95 mmHg. His systolic blood pressure occasionally exceeded 170 mmHg. On post-operative day 3 he became blind. A serial imaging test revealed cerebral oedema of both posterior lobes and segmental constriction of the vertebral and basilar arteries. Posterior reversible encephalopathy syndrome with reversible cerebral vasoconstriction syndrome was diagnosed from the clinical context and imaging tests. Despite treatment with magnesium and calcium channel blockers, the patient's visual acuity remained poor. Discussion: Excessive induced hypertension for spinal cord protection could rarely lead to cerebral vascular dysfunction, resulting in irreversible neurological damage. Awareness of this rare but devastating complication may help in early diagnosis, potentially mitigating permanent sequelae.

[Staged Hybrid Repair of Extensive Thoracic Aortic Aneurysm with Right Aortic Arch and Isolated Left Subclavian Artery:Report of a Case].

A 69-year-old male was referred to our hospital due to extensive thoracic aortic aneurysm with right aortic arch and isolated left subclavian artery. We chose staged hybrid repair to avoid the risk of spinal cord injury and bilateral recurrent nerve paralysis. First, ascending aorta replacement with elephant trunk and reconstruction of the cervical branches were underwent. Second, we performed the thoracic endovascular aortic repair for aortic arch and descending aortic aneurysm. The postoperative course was satisfactory and, computed tomography (CT) showed successful aortic repair without any type of endoleak. He was discharged on the ninth day after the second operation. To our knowledge, this is the first report of surgical repair for an aortic aneurysm with right aortic arch and isolated subclavian artery.

Life Expectancy of Patients With Severe Aortic Stenosis in Relation to Age and Surgical Risk Score.

BACKGROUND: There is a paucity of data regarding shorter life expectancy after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). METHODS: Among 3815 patients with severe AS enrolled in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry, there were 1469 patients (initial AVR: n = 647; conservative strategy: n = 822) with low surgical risk, 1642 patients (initial AVR: n = 433; conservative strategy: n = 1209) with intermediate surgical risk, and 704 patients (initial AVR: n = 117; conservative strategy: n = 587) with high surgical risk. Among 1163 patients who actually underwent surgical AVR as the initial strategy, patients were divided into 4 groups according to age <65 years (n = 185), 65 to 74 (n = 394), 75 to 80 (n = 345), and >80 (n = 239). The expected survival of the general Japanese population was obtained from the Statistics Bureau of Japan. The surgical risk was estimated using The Society of Thoracic Surgery (STS) score. RESULTS: The median follow-up was 3.7 years. The cumulative incidences of all-cause death were significantly lower in the initial AVR strategy than in the initial conservative strategy across the 3 STS groups. Shorter life expectancy after surgical AVR was seen especially in younger patients. The observed mortality in low-risk patients was comparable to the expected mortality across all the age-groups, while intermediate-risk patients aged <75 years, and high-risk patients across all age-groups had higher mortality compared with the expected mortality. CONCLUSIONS: The risk stratification according to age and STS score might be useful to estimate shorter life expectancy after AVR, and these findings have implications for decision making in the choice of surgical or transcatheter AVR.

Surgical resection and epicardial lead implantation for primary cardiac lymphoma with a complete atrioventricular block: a case report.

Background: Primary cardiac lymphoma (PCL) is a rare cardiac tumour with various presentations, which might cause a complete atrioventricular (AV) block, which can, in turn, cause heart failure symptoms. Case summary: We report a case of a 55-year-old woman with a chief complaint of exertional dyspnoea. Her vital signs showed bradycardia, and electrocardiography revealed a complete AV block. Transthoracic echocardiography revealed a large intra-cardiac mass in the right atrium. Full-body positron emission tomography showed an elevated fluorodeoxyglucose uptake in the right atrial mass, interatrial septum, and wall of the left atrium. Since the tumour could obstruct the tricuspid valve, urgent tumour debulking surgery and epicardial lead implantation were performed. Histopathological examination results were consistent with diffuse large B-cell lymphoma. After several courses of chemotherapy, we kept her in complete remission of the tumour for 2 years. Discussion: Primary cardiac lymphoma was complicated by a complete AV block and diagnosed by using the samples that we obtained in the surgery. A surgical resection of the tumour and epicardial lead implantation, combined with chemotherapy, can be an option, especially in patients who require cardiac surgery.

Long-Term Clinical Outcomes in Patients With Severe Tricuspid Regurgitation.

Background The natural history and optimal interventional timing in patients with isolated severe tricuspid regurgitation (TR) have not been well studied. This study aimed to investigate long-term clinical outcomes and risk factors associated with poor prognosis in patients with isolated severe TR. Methods and Results Consecutive transthoracic echocardiographic examinations in 2877 patients with isolated severe TR were retrospectively reviewed. Patients with significant left-sided valve disease or repeated examinations were excluded. Primary outcome was defined as a composite of all-cause death and hospitalization for heart failure. Among the 613 enrolled patients (mean age, 74±13 years; men, 38%), 141 died, and 62 were hospitalized for heart failure during the median follow-up period of 26.5 (interquartile range, 6.0-57.9) months. The 5-year event-free rate was 60.1%. TR pressure gradient (adjusted hazard ratio [HR], 1.03 [95% CI, 1.01-1.04]), blood urea nitrogen (adjusted HR, 1.02 [95% CI, 1.01-1.04]), left atrial volume index (adjusted HR, 1.01 [95% CI, 1.002-1.02]), and serum albumin (adjusted HR, 0.56 [95% CI, 0.36-0.95]) were identified as independent predictors of adverse events. A risk model based on the 4 clinical factors that included pulmonary hypertension (TR pressure gradient >40 mm Hg), elevated blood urea nitrogen levels (>25 mg/dL), decreased albumin levels (<3.7 g/dL), and left atrial enlargement (left atrial volume index <34 mL/m2) revealed a graded increase in the risk of adverse events (P<0.001). Conclusions The prognosis of isolated severe TR is not always favorable. Careful attention should be paid to patients with concomitant risk factors, such as pulmonary hypertension, elevated blood urea nitrogen levels, decreased albumin levels, and left atrial enlargement.

Effects of Low-Dose Tolvaptan for Fluid Management After Cardiovascular Surgery.

Background: Perioperative management of body fluid levels after cardiovascular surgery with cardiopulmonary bypass is essential. Fluid management using tolvaptan with conventional diuretics is effective in maintaining urine output without worsening renal function. This study aimed to improve the in-out balance in the early perioperative phase using low-dose tolvaptan (3.75 mg/day). Methods and Results: This prospective, single-center, randomized, open-label study included 199 patients who underwent cardiovascular surgery with cardiopulmonary bypass in Kobe City Medical Center General Hospital between September 2018 and December 2020. Treatment with tolvaptan and loop diuretics (tolvaptan group; 99 patients) was compared with treatment with loop diuretics alone (control group; 100 patients) to evaluate achievement of preoperative body weight as the primary outcome. Secondary outcomes were urine volume, the incidence of worsening renal function (WRF), and postoperative paroxysmal atrial fibrillation (POAF). There was no significant difference between groups in the return to preoperative body weight on postoperative Day 6. The tolvaptan group had significantly increased urine volume (2,530 vs. 2,150 mL/day) and decreased total furosemide dose (24 vs. 32 mg) compared with the control group. No significant differences were observed in the development of WRF and POAF between the 2 groups. Conclusions: Although low-dose tolvaptan administration did not shorten the time to achieving preoperative body weight, it did significantly increase urine volume without WRF and POAF.

Thoracic endovascular aortic repair for traction-induced aortic avulsion injury in neurofibromatosis type 1.

Rupture of intercostal artery aneurysms has been reported in patients with neurofibromatosis type 1. Many reports have demonstrated the efficacy of endovascular interventions. Herein, we present a case of successful treatment with thoracic endovascular aortic repair for traction-induced avulsion injury of the previously embolized intercostal artery. We further report the potential postoperative risk of rapid aneurysmal enlargement, possibly owing to changes in the thoracic arterial regional network. Even after successful treatment, vascular surgeons should pay attention to other aneurysmal events in the acute phase and avulsion injuries in the chronic phase. Close follow-up is essential.

Impact of postoperative patient-prosthesis mismatch as a risk factor for early structural valve deterioration after aortic valve replacement with Trifecta bioprosthesis.

BACKGROUND: Several studies have reported high rates of structural valve deterioration (SVD) in the Trifecta valves. Herein, we analyzed the midterm results of the Trifecta valve and risk factors for early SVD. METHODS: We retrospectively reviewed the records of 110 patients who had undergone Trifecta implantation between January 2012 and December 2017. RESULTS: We encountered seven cases of Trifecta valve failure. We performed a redo aortic valve replacement in five patients and a transcatheter aortic valve replacement in two patients. The SVD rate was 4.8% at 5 years and 6.6% at 7 years. The mean pressure gradient and peak velocity on the first postoperative echocardiogram in patients with SVD were higher than those in patients without SVD. The SVD rates with and without patient-prosthesis mismatch (PPM) were 2.8% and 12.6% at 5 years and 2.8% and 20.0% at 7 years. PPM is a risk factor for SVD. Noncoronary cusp tears were observed in all patients who had undergone redo surgery. CONCLUSIONS: The most common cause of SVD was noncoronary cusp tear. Patients with PPM are at high risk of developing SVD.

Staged graft replacement with thoracic endovascular aneurysm repair for an extensive thoracoabdominal aortic aneurysm after total arch replacement.

BACKGROUND: Open surgery for thoracoabdominal aortic aneurysm is highly invasive. Staged repair for extensive TAAA is effective because it has low morbidity and mortality, and preserves spinal cord perfusion. An initial total arch replacement can create a proximal landing zone for thoracic endovascular aneurysm repair. CASE PRESENTATION: We performed a staged hybrid thoracoabdominal aortic aneurysm repair after total arch replacement, which consisted of a primary open repair procedure as Crawford Extent III and IV thoracoabdominal aortic aneurysms, and a secondary thoracic endovascular aneurysm repair for the residual lesions for four patients. No spinal cord injury was observed. In one patient, the residual descending aortic aneurysm ruptured six months after the primary open surgery. CONCLUSIONS: Overall, staged hybrid repair is effective and shows low morbidity and mortality. Secondary thoracic endovascular aneurysm repair should be performed as soon as possible to reduce the risk of residual aneurysm rupture.

Long-Term Outcomes of the Mosaic Mitral Porcine Bioprosthesis in Japan　- Results From the Japan Mosaic Valve Long-Term Multicenter Study.

BACKGROUND: This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic mitral porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:The medical records of 390 patients who underwent mitral valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014) were reviewed. Patient data were collected using the Research Electronic Data Capture software. Patient survival was determined using the Kaplan-Meier method. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined using actuarial methods. The median (interquartile range [IQR]) age of the cohort was 73 (69-77) years. The median (IQR) follow-up period was 4.83 (1.84-8.26) years. The longest follow-up period was 15.8 years. The 30-day mortality rate was 5.4%. The 12-year actuarial survival rate was 54.1±4.5%, and the freedom from valve-related death was 85.3±3.4%. The freedom from reoperation at 12 years was 74.3±5.7%. The freedom from SVD at 12 years was 81.4±6.6% for patients aged ≥65 years and 71.6±11.1% for those aged <65 years. The median (IQR) mean pressure gradient was 4.1 (3.0-6.0) and 5.6 (4.0-6.7) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.7 (1.4-2.0) and 1.4 (1.2-1.6) cm2at 1 and 10 years, respectively. CONCLUSIONS: The Mosaic porcine bioprosthesis offered satisfactory long-term outcomes for up to 12 years.

Short- and mid-term outcomes of the frozen elephant-trunk procedure for degenerative aortic arch aneurysm.

PURPOSE: The frozen elephant-trunk (FET) procedure is used widely in total aortic arch replacement (TAR) surgery; however, its safety, effectiveness, and long-term outcomes compared with those of the conventional elephant trunk (cET) procedure for degenerative aneurysms are unclear. METHODS: Between July, 2011 and August, 2019, 126 patients underwent elective total aortic arch replacement at our institution. We compared the short- and mid-term outcomes of 60 patients who underwent the FET procedure (FET group) with those of 66 patients who underwent cET (cET group). RESULTS: The in-hospital mortality rate tended to be lower in the FET group than in the cET group (p = 0.12). There were two cases of paraplegia (3.3%) in the FET group and in none in the cET group. The all-cause mortality at the 3-year follow-up did not differ significantly between the groups (p = 0.31). The FET group required more unexpected interventions at the surgical site in the mid-term period. CONCLUSIONS: FET was associated with a shorter operative time and lower surgical mortality than cET. Although the mid-term total aortic arch replacement outcomes of FET were acceptable, careful imaging observation is necessary because reinterventions were required more frequently.

Coronary Revascularization in the Past Two Decades in Japan (From the CREDO-Kyoto PCI/CABG Registries Cohort-1, -2, and -3).

The treatment of coronary artery disease has substantially changed over the past two decades. However, it is unknown whether and how much these changes have contributed to the improvement of long-term outcomes after coronary revascularization. We assessed trends in the demographics, practice patterns and long-term outcomes in 24,951 patients who underwent their first percutaneous coronary intervention (PCI) (n = 20,106), or isolated coronary artery bypass grafting (CABG) (n = 4,845) using the data in a series of the CREDO-Kyoto PCI/CABG Registries (Cohort-1 [2000 to 2002]: n = 7,435, Cohort-2 [2005 to 2007]: n = 8,435, and Cohort-3 [2011 to 2013]: n = 9,081). From Cohort-1 to Cohort-3, the patients got progressively older across subsequent cohorts (67.0 ± 10.0, 68.4 ± 9.9, and 69.8 ± 10.2 years, ptrend < 0.001). There was increased use of PCI over CABG (73.5%, 81.9%, and 85.2%, ptrend < 0.001) and increased prevalence of evidence-based medications use over time. The cumulative 3-year incidence of all-cause death was similar across the 3 cohorts (9.0%, 9.0%, and 9.3%, p = 0.74), while cardiovascular death decreased over time (5.7%, 5.1%, and 4.8%, p = 0.03). The adjusted risk for all-cause death and for cardiovascular death progressively decreased from Cohort-1 to Cohort-2 (HR:0.89, 95%CI:0.80 to 0.99, p = 0.03, and HR:0.80, 95%CI:0.70 to 0.92, p = 0.002, respectively), and from Cohort-2 to Cohort-3 (HR:0.86, 95%CI:0.78 to 0.95, p = 0.004, and HR:0.77, 95%CI:0.67-0.89, p < 0.001, respectively). The risks for stroke and repeated coronary revascularization also improved over time. In conclusions, we found a progressive and substantial reduction of adjusted risk for all-cause death, cardiovascular death, stroke, and repeated coronary revascularization over the past two decades in Japan.

Effect of Heart Failure on Long-Term Clinical Outcomes After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Severe Coronary Artery Disease.

Background Heart failure might be an important determinant in choosing coronary revascularization modalities. There was no previous study evaluating the effect of heart failure on long-term clinical outcomes after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG). Methods and Results Among 14 867 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013 in the CREDO-Kyoto PCI/CABG registry Cohort-3, we identified the current study population of 3380 patients with three-vessel or left main coronary artery disease, and compared clinical outcomes between PCI and CABG stratified by the subgroup based on the status of heart failure. There were 827 patients with heart failure (PCI: N=511, and CABG: N=316), and 2553 patients without heart failure (PCI: N=1619, and CABG: N=934). In patients with heart failure, the PCI group compared with the CABG group more often had advanced age, severe frailty, acute and severe heart failure, and elevated inflammatory markers. During a median 5.9 years of follow-up, there was a significant interaction between heart failure and the mortality risk of PCI relative to CABG (interaction P=0.009), with excess mortality risk of PCI relative to CABG in patients with heart failure (HR, 1.75; 95% CI, 1.28-2.42; P<0.001) and no excess mortality risk in patients without heart failure (HR, 1.04; 95% CI, 0.80-1.34; P=0.77). Conclusions There was a significant interaction between heart failure and the mortality risk of PCI relative to CABG with excess risk in patients with heart failure and neutral risk in patients without heart failure.

[Surgical Excision of Calcified Amorphous Tumors on Mitral and Aortic Valves:Report of a Case].

Calcified amorphous tumor (CAT) is a nonneoplastic cardiac tumor that can be located in any of the four cardiac chambers, but is predominantly detected on the mitral valve. We report a rare case of CAT originating from the mitral and aortic valves. A 69-year-old woman with end-stage renal disease, hypertension, and diabetes mellitus was referred to our hospital for the evaluation of cardiac masses found incidentally on screening transthoracic echocardiography. She had no symptoms, including fever and neurological deficits, and her blood cultures were negative. Echocardiography revealed mobile masses arising from the mitral and aortic valves. We performed surgical excision and histopathologically diagnosed the masses with cardiac CATs. Mobile and pedunculated CAT frequently causes systemic embolization, and thus, complete surgical excision is recommended in such a case.

[Superior Mesenteric Artery Bypass Grafting from the Ascending Aorta Using a Saphenous Vein Graft for Treatment of Acute Aortic Dissection with Abdominal Malperfusion:Report of a Case].

A 50-year-old man presented with abdominal pain and numbness in the right leg. He was diagnosed with type A acute aortic dissection with malperfusion of the superior mesenteric artery(SMA) and the right external iliac artery. Before median sternotomy, we made median celiotomy and anastomosed a saphenous vein graft to SMA. After cardio-pulmonary bypass was instituted, perfusion to the saphenous vein graft was started. After the central repair, we selected the vascular graft of the ascending aorta as the inflow of SMA bypass because leading the vein graft to the external iliac artery was difficult due to obesity and intestinal edema. The graft flow was favorable with 100 ml/minute. He was discharged on postoperative day 56 without any abdominal complications. Some reports suggested that early reperfusion improved the outcomes of surgery for acute aortic dissection with mesenteric ischemia. The ascending aorta may be a viable alternative as an inflow of SMA bypass when the iliac artery is inappropriate.