Modified composite-graft technique for aortic root replacement.

This report describes a novel modification of a self-assembled composite graft to replace the aortic root and left ventricular outflow tract (LVOT). This technique enables the implantation of a larger valve than conventional ways and simultaneous reconstruction of LVOT. This technique comprises Inspiris Resilia aortic valve and Gelweave Valsalva graft. By placing the valve in the sinus portion of the graft, the bioprosthesis that is 1 mm smaller than the graft can be accommodated, providing a proper length of the collar for LVOT reconstruction. This technique is useful for patients who require redo-aortic root replacement and have restricted LVOT.

Sex differences in continuous-flow ventricular assist device therapy for advanced heart failure.

OBJECTIVE: The effect of patient sex in continuous-flow ventricular assist device (c-VAD) therapy has not been well described. We investigated sex-specific differences in clinical outcomes related to c-VAD therapy for Japanese patients. METHODS: We retrospectively analyzed 153 patients, including 41 (27%) female patients who underwent c-VAD implantation over the last 13 years in our institution for a mean follow-up of 766 ± 446 days. Clinical outcomes were compared between male and female patients RESULTS: There was no significant difference in mortality, cerebral vascular accidents, the severity of heart failure, or driveline infection in patients who underwent c-VAD implantation, regardless of sex. While male patients tended to have more bleeding at the time of surgery, female patients had significantly higher rates of non-surgical bleeding during subsequent c-VAD therapy, mainly from gynecological origins. CONCLUSIONS: Female patients treated with c-VAD had a significantly higher incidence of non-surgical bleeding events. Careful attention to gynecological complications and sex-specific care is required in female patients with c-VAD.

Multimodality imaging and three-dimensional printed model in patients with left ventricular outflow tract obstruction.

Surgical treatment is an effective therapy and the gold standard for patients with left ventricular outflow tract obstruction (LVOTO) and drug-refractory symptoms. However, it is difficult to arrange a concrete surgical plan due to the heterogenous and complex cardiac anatomy. Three-dimensional (3D) printing is an emerging technology that is able to reproduce complex cardiac anatomy. Here, we present two patients with LVOTO in whom we created 3D printed models. In these two patients, we compared the 3D printed model and the intraoperative findings and confirmed that the 3D printed model we created could reproduce the complex cardiac anatomy including the interventricular septum, papillary muscles, and abnormally thickened chordae. By using 3D printed models, cardiologists and surgeons can comprehend the complex 3D cardiac structure and spatial positional relationship preoperatively and perform surgical rehearsal. 3D printing could be a valuable tool for the management of patients with LVOTO.

Robotic minimally invasive direct coronary artery bypass for Kawasaki disease.

Case 1: 17-year-old boy developed severe stenosis at the proximal site of the coronary aneurysm in the left anterior descending artery (LAD). Case 2: 16-year-old boy developed severe stenosis at the proximal site of the coronary aneurysm in the LAD. Case 3: 30-year-old woman developed severe stenosis of the distal portion of the coronary aneurysm in the LAD. Minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal thoracic artery harvest was successfully performed without cardiopulmonary bypass in these three young patients with Kawasaki disease. This is the first case report of robot-assisted MIDCAB for Kawasaki disease.

Experience of the use of octreotide for refractory gastrointestinal bleeding in a patient with Jarvik2000® left ventricular assist device.

Gastrointestinal bleeding (GIB) is among the major complications affecting implantable continuous-flow left ventricular assist device (iLVAD) recipients and is the major cause of re-hospitalization. GIB in iLVAD recipients is sometimes critical, and controlling bleeding using conventional approaches is difficult. A 35-year-old woman developed refractory GIB from multiple gastric polyps and de novo angiodysplasia after Jarvik2000® iLVAD implantation. Discontinuation of anticoagulation and antiplatelet therapies had little effect on GIB; thus, multiple endoscopic hemostatic therapies were performed. However, bleeding recurred several times, and red blood cell (RBC) transfusion in large volumes was required for progressive anemia. Furthermore, the von Willebrand factor (VWF) multimer analysis revealed loss of the high-molecular weight multimer, which may have resulted from the high-speed rotation of the axial-flow LVAD pump. To supplement VWF, cryoprecipitate was administered, but it was effective for only several days. Finally, the patient was treated with octreotide, a somatostatin analog, on post-operative day 58. After starting octreotide, tarry stool gradually decreased, and progression of anemia slowed down within the first 14 days of treatment; thus, the total RBC transfusion volume was reduced without additional hemostatic interventions, including cryoprecipitate administration. The patient developed mediastinitis on post-operative day 68 and died of sepsis on post-operative day 72. There was no adverse effect associated with octreotide use. Although the observation period was short, octreotide appears to be useful for resolving recurrent GIB after iLVAD implantation and reducing blood transfusions.

Type and Size of Implanted Bioprosthetic Valve Rather Than Intraoperative Peak Transprosthetic Valvular Velocity Predict Postoperative Midterm Prosthesis-Patient Mismatch in Patients Undergoing Surgical Aortic Valve Replacement.

OBJECTIVES: High transprosthetic valvular peak velocity (PV) is indicative of prosthesis-patient mismatch (PPM), which exacerbates mortality and morbidity after surgical aortic valve replacement (AVR). During surgical AVR, a high intraoperative PV sometimes is detected, but whether it affects mortality and morbidity is unknown. The aims of this study were to determine whether intraoperative and postoperative PV were correlated and what factors predicted postoperative PPM. DESIGN: Retrospective, observational, cohort study. SETTING: Tertiary medical center. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study comprised 556 patients who underwent AVR with a bioprosthetic valve. PV was measured intraoperatively, 1 month after surgery, and 1 year after surgery. The occurrence of PPM was defined as an effective orifice area index of less than 0.85 cm2/m2. The associations between PV values at the aforementioned 3 time points were analyzed using a multivariable nonlinear regression model. A multivariable logistic regression model was used to identify the predictors of PPM at 1 year. There was no significant association between intraoperative PV and PV at 1 month (p = 0.419) or 1 year (p = 0.115). The implanted valve type (p < 0.001) and size (p < 0.001), but not intraoperative PV (p = 0.503), were independent predictors of PPM. CONCLUSIONS: There was no significant association between intraoperative and postoperative PV values. Implanted valve type and size, but not intraoperative PV, predicted postoperative PPM.

Multiple Coronary Artery Bypass Grafting for Kawasaki Disease-Associated Coronary Artery Disease.

BACKGROUND: Although coronary artery bypass grafting (CABG) is the preferred choice for advanced Kawasaki disease (KD)-associated coronary artery disease, graft design such as number of grafts or type of conduits has not been fully established. We reviewed a series of patients who underwent single or multiple CABG for coronary artery disease of KD sequelae to investigate the optimum revascularization strategy. METHODS: We enrolled a consecutive series of 102 CABG surgeries in 92 patients during the last 36 years. Mean patient age at CABG was 14.9 ± 10.4 years. Internal thoracic artery, radial artery, and gastroepiploic artery were used in 100 (98%), 18 (15%), and 4 (4%) cases, respectively. Patients were divided into 2 groups by single (n = 53) or multiple (n = 49) CABG. RESULTS: Actuarial survival was 93% in single CABG and 91% in multiple CABG at 30 years (P = .71). There was no in-hospital mortality, but 6 deaths occurred long term, with no significant difference between the groups. Freedom from cardiac events was 45.2% in single CABG and 68.5% in multiple CABG at 25 years (P = .228), and reintervention to the left anterior descending (LAD) artery territory was the most common event. Graft patency of the internal thoracic artery-LAD artery graft was 81% in single CABG and 85% in multiple CABG at 25 years. Patency of the radial artery in the non-LAD artery territories was significantly greater than that of the saphenous vein graft at 10 years (91% vs 46%, P = .013). CONCLUSIONS: Multiple CABG using arterial conduits is feasible, safe, and therapeutically effective long term for patients with advanced KD-associated coronary artery disease.

Contemporary outcomes of the concomitant CryoMaze procedure.

OBJECTIVES: As an institutional strategy, the CryoMaze procedure has been established for treating atrial fibrillation (AF) since 2001. In this study, we aimed to analyse the contemporary outcomes of the CryoMaze procedure and to examine the predictive factors of successful sinus rhythm conversion. METHODS: Between January 2009 and March 2018, we performed 352 CryoMaze procedures. The contemporary outcomes of the CryoMaze procedure concomitant with other cardiac procedures were analysed by the Kaplan-Meier method. The logistic regression model was used to predict risk factors for recurrent AF. RESULTS: There were no 30-day or in-hospital deaths and all of the patients were discharged. The 1- and 5-year survival rates were 99.0% and 94.6%, respectively. The rates of freedom from permanent pacemaker implantation and cerebrovascular accidents were 92.6% at 1 year and 86.9% at 5 years, and 99.1% at 1 year and 97.9% at 5 years, respectively. The rates of freedom from recurrent permanent AF were 91.9% at 1 year and 86.1% at 5 years. The multivariable analysis showed that the independent predictive factors for recurrent permanent AF included an F-wave grade in lead V1 (P < 0.001), the preoperative duration of persistent AF (P = 0.031), a non-mitral procedure (P = 0.019) and a preoperative tricuspid regurgitation grade (P = 0.034). CONCLUSIONS: Preoperative voltage of the F wave in V1 lead is strongly associated with the sinus rhythm restoration after the CryoMaze procedure.

De novo malignancy in heart transplant recipients: A single center experience in Japan.

BACKGROUND: Because of aggressive immunosuppression, heart transplant recipients have a high risk of de novo malignancy, which is a major cause of death and worse prognosis, regardless of the type. However, the impact of de novo malignancy on Japanese heart transplant recipients is unknown. METHODS: We analyzed 103 Japanese heart transplant recipients over 18-years-old at the time of transplantation between April 1999 and April 2017. Patient characteristics and prognosis were compared between heart transplant recipients with or without de novo malignancy after heart transplantation (HTx). Additionally, univariate and multivariate analyses for the risk factors of de novo malignancy after HTx were performed. RESULTS: De novo malignancy developed in 7 patients (6.8%; post-transplant lymphoproliferative disorders, n=3; Bowen's disease, n=1; colon cancer, n=2; bladder cancer, n=1). Follow-up time and previous antibody mediated rejection (AMR)≥grade 1 were risk factors of de novo malignancy after HTx in multivariate analysis (OR: 1.19, 95% CI: 1.00-1.42, p=0.043; and OR: 10.7, 95% CI: 1.37-83.68, p=0.038, respectively). History of malignancy was a potential risk factor, albeit not significant (OR: 23.05, 95% CI: 0.99-534.53, p=0.071). The survival rates in patients with de novo malignancy was significantly lower than in those without de novo malignancy (3-year survival rate: 100% versus 67%, p=0.0025). CONCLUSIONS: Long follow-up time and previous AMR≥grade 1 were risk factors of de novo malignancy after HTx. Japanese heart transplant recipients with de novo malignancy have worse prognosis; therefore, screening examinations are important for early diagnosis.

Benefit and Risk of Minimally Invasive Mitral Valve Repair for Type II Dysfunction　- Propensity Score-Matched Comparison.

BACKGROUND: Despite the cosmetic benefits of the minimally invasive approach for mitral disease, the clinical benefit and risk are not fully known. We investigated the benefit and risk of minimally invasive mitral valve (MV) repair for type II dysfunction using propensity score-matched analysis. Methods and Results: Since 2001, 602 patients have undergone MV repair for type II dysfunction (464 with conventional median sternotomy and 138 with the minimally invasive approach). One-to-one matched analysis using the estimated propensity score based on 23 factors resulted in 93 well-matched patient pairs. There was no in-hospital death in both groups. The operation time was significantly shorter (P=0.002), blood transfusion was less frequent (P=0.04), extubation at the day of surgery was more frequently performed (P=0.017), and the length of hospital stay was significantly shorter in the minimally invasive group than in the sternotomy group (P<0.0001). On postoperative (P=0.02) and 1-year echocardiography (P=0.04), ejection fraction was lower in the minimally invasive group than in the sternotomy group. There were no significant differences in postoperative cerebral infarction, aortic dissection, deep sternal infection, or mid-term outcome between the groups. CONCLUSIONS: Standard sternotomy and the minimally invasive approach provide similar good quality of MV repair for type II dysfunction. The minimally invasive approach is more likely to contribute to fast-track perioperative treatment than the standard sternotomy approach.

[Outpatient Care for Implantable Left Ventricular Assist Device Patients].

From 2005, 124 patients have received implantable left ventricular assist device (iVAD) in our institute, including HeartMate II (84), EVAHEART (17), Jarvik2000 (13), DuraHeart (9), HVAD (1). At February 2018, 60 patients were waiting for heart transplant with iVAD support. Multi-specialist team consisted of clinical engineer, VAD management specialist, nurse, transplant coordinator for recipient and physicians provide patients care. Thirty one percents returned to their social activity after iVAD implantation. 73% patients required rehospitalization for more than 1 time. Overall frequency of rehospitalization was 1.43 events per patient-year. Driveline infection was the most frequent reason and tended to repeat, accounted for 41% of overall rehospitalization. To reduce skin trouble around the driveline exit site causing driveline infection, we made a skin care outpatient clinic, cooperating with a certified nurse in wound, ostomy, and continence nursing (WOC). Besides, we utilize smartphones for remote advising system for patients to facilitate early diagnosis and precise care for driveline infection. A self-anticoagulation management device( Coag-check XS personal) enable us to give adequate anticoagulation therapy and to minimize bleeding and thromboembolic event. Additionally, establishment of psychosocial care promote patient's recovery of social status. With those strategies in outpatient care, we are trying to achieve successful quality of life of iVAD patients.

Efficacy of regional saturation of oxygen monitor using near-infrared spectroscopy for lower limb ischemia during minimally invasive cardiac surgery.

Lower limb ischemia with an occlusive cannula is a potential complication of minimally invasive cardiac surgery (MICS). We evaluated intraoperative local oxygen supply-demand balance by monitoring regional saturation of oxygen (rSO2) using near-infrared spectroscopy (NIRS), and analyzed the correlation between cannula size and fluctuation range of rSO2. Fifty-four patients undergoing MICS surgery using femoral artery cannulation from April 2015 to August 2016 were enrolled. The rSO2 of both the cannulated and uncannulated lower limbs were measured using NIRS. The association between the decline of rSO2 from baseline (delta-rSO2) and the ratio of the cannula diameter to the femoral artery diameter (Cd/FAd) was analyzed. Of the 54 patients, 16 (30%) (Group 1) showed values over 0.65 for Cd/FAd, and the remaining 38 (70%) (Group 2) showed values under 0.65. No patient developed postoperative lower limb ischemia. No patient was treated with an ipsilateral distal perfusion cannula. There were significant differences between Group 1 and Group 2 in the decrease of rSO2 at the point of cannulation on the cannulated limb. In the lower limb on the cannulated side, delta-rSO2 showed a significant decrease in Group 1 compared to Group 2 (Group 1 vs Group 2: 19.9 vs 11.0%; p < 0.001). Delta-rSO2 was significantly correlated with body surface aera (BSA), but not with gender or age. Decreasing rSO2 correlates with the Cd/FAd index. Low BSA, Cd/Fad > 0.65 is considered as the risk factor for decline of rSO2 in cannulated limb in MICS.

Intracranial mycotic aneurysm is associated with cerebral bleeding post-valve surgery for infective endocarditis.

OBJECTIVES: The presence of cerebral haemorrhage (CH) preoperatively is a risk factor of in-hospital cerebrovascular complications post-valve surgery for acute infective endocarditis. However, factors related to cerebrovascular complications in the long term are poorly understood. We reviewed a series of these patients to investigate risk factors of in-hospital and long-term outcomes. METHODS: An institutional series of 148 patients who underwent valve surgery for active infective endocarditis between 2000 and 2016 were enrolled. Patients were divided into 2 groups based on the presence of preoperative CH:CH group (n = 25) and non-CH group (n = 123). Of them, 14 (10%) patients were preoperatively diagnosed with mycotic aneurysm (MA). RESULTS: The 30-day mortality was 5% with no difference between the 2 groups. The 5-year survival rate was 92% in the CH group and 77% in the non-CH group. Freedom from CH at 5 years was 92% in the CH group and 97% in the non-CH group. There was no difference in the postoperative haemorrhage rate between patients who had surgery within 14 days from the onset of CH and those who had surgery after 14 days. Freedom from CH at 5 years was 99% in patients without MA and 71% in those with MA. The presence of MA preoperatively was the only independent risk factor of postoperative CH (P = 0.002). CONCLUSIONS: Valve surgery for acute infective endocarditis is safe, even in patients with CH preoperatively, regardless of the timing of surgery. Patients with intracranial MA are associated with postoperative CH in the hospital and long term.

Functional mitral stenosis after mitral valve repair for Type II dysfunction: determinants and impacts on long-term outcome.

OBJECTIVES: This study was performed to analyse the impacts of functional mitral stenosis (MS) following mitral valve (MV) repair on late cardiac function and new onset of atrial fibrillation or survival. METHODS: We retrospectively reviewed 602 patients with mitral regurgitation who underwent MV repair for Type II dysfunction from 2001. Functional MS was diagnosed when the mean transmitral pressure gradient (MTPG) was ≥5 mmHg on postoperative echocardiography. We analysed preoperative and surgical risk factors for functional MS (MS group). We then compared long-term outcomes and late cardiac function over time between patients in the MS and no-MS groups using a mixed-effects model with repeated measures. RESULTS: On postoperative echocardiography, 51 patients had an MTPG of ≥5 mmHg (MS group) and 551 had an MTPG of <5 mmHg (no-MS group). Only the ring size was an independent predictor of MS (28.8 ± 2.1 mm in the no-MS group vs 28.0 ± 1.9 mm in the MS group, P = 0.004). During follow-up, increases in the tricuspid regurgitation (TR) pressure gradient (PRV-RA) and TR severity over time were significantly greater in the MS group than in the no-MS group (PRV-RA: 0.72 ± 0.16 vs 0.35 ± 0.17 mmHg per year, respectively, P = 0.03; TR severity: 0.072 ± 0.014 vs 0.034 ± 0.015 per year, respectively, P = 0.0113). Moreover, the 10-year rate of new onset of atrial fibrillation was significantly lower in the MS group than in the no-MS group (37.5% vs 16.9%, respectively; log-rank P = 0.003). CONCLUSIONS: Annuloplasty using a small-sized ring in MV repair caused a postoperative high MTPG, which induced an elevation in the pulmonary artery pressure and residual TR grade and causing new onset of atrial fibrillation despite a competent MV.

Two Cases of Surgical Management of Supravalvular Aortic Stenosis in Familial Hypercholesterolemia.

Homozygous familial hypercholesterolemia is a rare autosomal dominant disorder caused by gene mutations of the low-density lipoprotein receptor, generally characterized by three major signs-hyper low-density lipoprotein cholesterolemia, tendon/skin xanthomas, and premature atherosclerosis disease-beginning in childhood and including supravalvular aortic stenosis. To the best of our knowledge, only a few successful surgical cases for supravalvular aortic stenosis in these patients have been reported. We report two cases of homozygous familial hypercholesterolemia with severe supravalvular aortic stenosis and coronary artery disease associated with very small aortic root, managed by aortic root replacement concomitant with coronary artery bypass graft surgery, which resulted in excellent postoperative outcomes.

Impact of mitral valve intervention with left ventricular assist device implantation on postoperative outcomes and morphologic change.

Although mitral regurgitation (MR) is prevalent in patients with end-stage heart failure, the impact of mitral valve (MV) surgery on outcomes after left ventricular assist device (LVAD) implantation and morphologic changes of MV remains unclear. We retrospectively reviewed 74 patients who underwent LVAD implantation as a bridge to transplant. Of these, 11 (15%) underwent MV repair concomitant with or prior to LVAD implantation, while 27 patients with preoperative significant (moderate or greater) MR did not undergo concomitant MV surgery. The mean interval between LVAD implantation and the last echocardiographic examination was 913 days. Irrespective of MV surgery, significant LV reverse remodeling including decreased LV and left atrial dimension and improved MR severity was observed in all patients except for patients with prior MV surgery. Histopathological examination of explanted hearts removed at heart transplantation (n = 69) or autopsy (n = 5) revealed that the MV annulus was still dilated (mean perimeter 11.7 cm) in the patients with preoperative significant MR and no concomitant MV surgery. Concomitant MV surgery at the time of LVAD implantation for significant MR might not be always necessary for bridge to transplant or destination therapy cases. However, it might be required in patients having potential for cardiac recovery or patients with severe pulmonary hypertension and depressed right ventricle.

Irrigation Device Successfully Tests Valve Competence During Minimally Invasive Mitral Valve Repair.

Minimally invasive mitral valve repair has become standard. We hypothesized that reproducible water testing with less air contaminations may help achieve successful repair and prevent air embolism. We used a long shaft irrigation device connected to an infuser pump to water test mitral valve repair in 104 consecutive patients with severe mitral regurgitation due to type II mitral valve dysfunction. All patients underwent mitral valve repair via small right thoracotomy. Water testing was performed by simultaneously monitoring root pressure to confirm valve competence and adequate leaflet coaptation with suitable pressure. Irrigation was stopped when root pressure reached 60 mm Hg. Simultaneous transesophageal echocardiography showed a negligible amount of air introduction. Predischarge echocardiography revealed residual mitral regurgitation of less than or equal to 1 in all patients, and no patient experienced any major adverse event such as stroke or perioperative myocardial infarction. This novel water test allowed us to correctly check mitral valve competence and reduce air contamination.

Long-Term Outcomes of Suture vs. Ring Tricuspid Annuloplasty for Functional Tricuspid Regurgitation.

BACKGROUND: Whether there is a significant difference in the long-term surgical outcomes between suture annuloplasty and ring annuloplasty for the treatment of functional tricuspid regurgitation (TR) is still controversial. We compared the long-term outcomes of tricuspid annuloplasty (TAP) with and without an annuloplasty ring.Methods and Results:From January 1996 to December 2015, we consecutively enrolled 684 patients (mean age, 65.5 years; 60% women) undergoing TAP for functional TR: 312 underwent conventional suture annuloplasty (Group S) and 372 underwent ring annuloplasty (Group R). Baseline characteristics were comparable between the 2 groups, except for age and the prevalence of prior cardiac surgery. The mean follow-up period was 7.3 years (range, 0.3-20.3 years).There was no significant difference in overall survival, freedom from major adverse cardiac and cerebrovascular events, and freedom from recurrent moderate to severe TR between Groups S and R, although postoperative mean TR grade and sPAP were significantly lower in Group R. Multivariate analysis revealed that age, prior cardiac surgery, and preoperative severe TR were independent predictors of recurrent moderate or greater TR. CONCLUSIONS: There was no significant difference in the long-term surgical outcomes between ring and suture TAP, although postoperative mean TR grade was lower in the ring annuloplasty group.

Long-term outcome of isolated off-pump coronary artery bypass grafting in patients with coronary artery disease and mild to moderate aortic stenosis.

BACKGROUND: The best management strategy for patients with coronary disease and mild to moderate AS requires the clinician to consider the operative risks of isolated coronary artery bypass grafting (CABG) against the risks of untreated aortic stenosis (AS). METHODS: Between 2000 and 2014, isolated off-pump CABG (OPCAB) was performed in 2023 patients. Of these patients, 103 presented with mild or moderate AS (mean age 72.7±6.3 years; 23 females), 96 (93.2%) presented with mild AS and seven (6.8%) presented with moderate AS. We compared the long-term outcome of these 103 patients undergoing isolated OPCAB with 13 patients who presented with moderate AS and coronary artery disease (CAD) and underwent concomitant aortic valve replacement (AVR) and CABG during the same period. RESULTS: Mean number of distal anastomoses was 3.7±0.9 per patient, and early graft patency was 98.9% (365 of 369 grafts). No patient required on-pump CABG or concomitant AVR. There were two in-hospital deaths (1.9%). Cumulative 5- and 10-year survival rates were 78.3% and 56.6%, respectively. The respective 5- and 10-year rates of freedom from severe AS were 38.1% and 0.0% in patients with moderate AS, and 73.2% and 65.4% in patients with mild AS (log-rank test, p<0.01). Twelve patients required subsequent AVR, including eight who underwent transcatheter AVR. There were no significant differences between patients undergoing isolated OPCAB and patients undergoing concomitant AVR and CABG according to cumulative survival rate (log rank test, p=0.78) and freedom from major adverse cardiac and cerebrovascular events (log rank test, p=0.59). CONCLUSIONS: Isolated OPCAB is a reasonable staged strategy in coronary disease with mild AS, as the less invasive option of transcatheter AVR is available later if required.

Simultaneous transcatheter aortic valve implantation and off-pump coronary artery bypass grafting for Takayasu arteritis.

We report a patient who underwent simultaneous transcatheter aortic valve implantation and off-pump coronary artery bypass grafting for Takayasu arteritis with diffuse porcelain aorta. The patient was a 59-year-old female with severe aortic stenosis and regurgitation, as well as both coronary ostial stenosis and porcelain aorta. Bilateral internal thoracic arteries were unavailable due to Takayasu arteritis. Therefore, composite radial artery with in-situ gastroepiploic artery was used as graft material. Radial artery was anastomosed to left anterior descending artery and posterior descending artery sequentially. Surgical procedures were successfully accomplished and major perioperative complications did not occur. .