Ten-year experience of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair.

BACKGROUND: Mitral valve repair is the procedure of choice to correct mitral regurgitation (MR). Although chordal replacement with expanded polytetrafluoroethylene (ePTFE) has been widely accepted to repair anterior mitral prolapse and other difficult situations, the long-term results of the repair and the fate of ePTFE have not been delineated. METHODS AND RESULTS: From July 1988 to April 1999, 74 patients (49 males, 25 females) aged 17 to 77 years (mean age 55. 3+/-14.8 years) underwent mitral valve repair with chordal replacement with ePTFE. The follow-up period was from 6 months to 11. 3 years (mean 4.6+/-3.2 years). The causes of MR were degenerative in 65 patients (88%) and infective in 9 (12%). Three patients had active infective endocarditis. Valve lesions were anterior in 35 patients, posterior in 10, and both anterior and posterior in 29. Various procedures for plasty of leaflets were necessary in 37 patients (50%). Atrial fibrillation was associated in 38 patients (51%), and the maze procedure has been performed in a selected group of 30 patients (41%) since July 1992. There was 1 in-hospital death (1.4%) and 3 late cardiac deaths (4.1%). More than moderate MR developed in 12 patients (17%) during the follow-up period. Three of these patients required early reoperation within 1 year due to hemolysis. Two patients underwent mitral valve replacement at 6 and 8 years after repair, respectively. The actuarial reoperation-free rates at 5 and 10 years were 94.3+/-2.8% and 81.7+/-9.1%, respectively. Sinus rhythm was restored in 21 patients (70%) with the maze procedure. There was only 1 thromboembolic episode (0. 3%/patient-y) in a patient with atrial fibrillation who did not undergo the maze procedure. Event-free survival rates as assessed by the freedom from cardiac death, thromboembolism, reoperation, and anticoagulation-related hemorrhage at 5 and 10 years were 91.3+/-3. 4% and 71.6+/-9.7%, respectively. There was no relationship between recurrent MR and the change of ePTFE. Structural analysis of the ePTFE resected during reoperation revealed no calcification and showed remaining flexibility and pliability. Protein infiltration was observed in the ePTFE, and collagenous proliferation was recognized at the site of fixation to the valve leaflet and the papillary muscle. The surface of the ePTFE was completely endothelialized, which may induce antithrombogenicity. CONCLUSIONS: The long-term durability and biological adaptation of ePTFE as artificial chordae for mitral valve repair of MR were proved for >10 years.

Cryopreserved homograft valves in the pulmonary position: risk analysis for intermediate-term failure.

OBJECTIVE: The purpose of this study was to examine the durability of cryopreserved homografts used to replace the "pulmonary" valve and to identify factors associated with their late deterioration. METHODS: We reviewed our entire experience (1985-1997) with 331 survivors in whom cryopreserved homograft valves (pulmonary, n = 304; aortic, n = 27) were used to reconstruct the pulmonary outflow tract. Median age was 14 years (range, 2 days-62 years). Operations included Ross operation (n = 259), tetralogy of Fallot (n = 41), truncus arteriosus (n = 14), Rastelli operation (n = 11), and others (n = 6). Median follow-up was 3.8 years (range, 0.2-11.2 years); late echographic follow-up was complete for 97% of patients. Homograft failure was defined as the need for explantation and valve-related death; homograft dysfunction was defined as a pulmonary insufficiency grade 3/4 or greater and a transvalvular gradient of 40 mm Hg or greater. RESULTS: Homograft failure occurred in 9% (30 of 331 patients; Kaplan-Meier); freedom from failure was 82% +/- 4% at 8 years. Homograft dysfunction occurred in 12% (39 of 331 patients), although freedom from dysfunction was 76% +/- 4% at 8 years. For aortic homografts, this was 56% +/- 11%, compared to 80% +/- 4% for pulmonary homografts (P =.003). For patients aged less than 3 years (n = 38), this was 51% +/- 12%, compared with 87% +/- 4% for older patients (P =.0001). By multivariable analysis, younger age of homograft donors, non-Ross operation, and later year of operation were associated with homograft failure; younger age of homograft donors, later year of operation, and use of an aortic homograft were associated with homograft dysfunction. CONCLUSIONS: Homograft valves function satisfactorily in the pulmonary position at mid-term follow-up. The pulmonary homograft valve appears to be more durable than the aortic homograft valve in the pulmonary position.

Preservation of myocardial function and metabolism at subzero nonfreezing temperature storage of the heart.

BACKGROUND: The hypothermic simple immersion technique has been widely used to preserve the donor heart for transplantation. However, there is still controversy as to which temperature provides the best protection against prolonged ischemia. The low molecular weight solutes within cells depress the freezing point to -0.6 degree C. In practice, however, most cells do not freeze internally unless they are cooled below -10 degrees C. We investigated the effects of subzero nonfreezing storage at -1 degree C on the preservation of myocardial metabolism and function. METHODS: Isolated Wistar rat hearts were subjected to 6 hours of preservation with the intracellular type University of Wisconsin solution; the hearts of the subzero group were preserved at subzero nonfreezing (-1 degree C) temperature, and the hearts of the control group were at 4 degrees C. Recovery of cardiac function, myocardial adenine nucleotides content, and myocardial water content were evaluated after preservation. RESULTS: Subzero group resulted in significantly better aortic flow, cardiac output, and aortic systolic pressure than in the control group. Myocardial adenosine triphosphate, adenosine diphosphate, and total adenine nucleotides at end-storage were significantly better preserved in subzero group when compared with the control group. Myocardial water content at reperfusion significantly increased in the control group compared with the subzero group. CONCLUSIONS: Storage in the intracellular type solution at subzero nonfreezing (-1 degree C) temperature as compared with 4 degrees C appears to prolong myocardial preservation with respect to the enhancement of postischemic functional recovery, preservation of myocardial adenine nucleotides during ischemia, and prevention of myocardial edema at reperfusion.

Ex vivo gene transfer into myocardium using replication-defective retrovirus.

Heart transplantation is the most effective therapy for chronic severe heart failure, but there is an extreme shortage of hearts available. We examined the possibility that cardiomyocytes can be modified genetically prior to being grafted to the heart. We used a replication-defective retrovirus carrying the beta-galactosidase (beta-gal) reporter gene. The beta-gal gene was transduced into murine fetal cardiac myocytes by culturing a recombinant retrovirus-producing cell line in a Transwell plate hung into the primary cardiomyocyte culture. The cultured cells were stained with the di-beta-D-galactopyranoside (FDG) and were sorted by fluorescence-activated cell sorting (FACS). FACS analysis showed that 25.5 +/- 4.3% of the cardiomyocytes in a primary culture were positive for beta-gal activity. These cells were transplanted into the hearts of syngeneic adult mice. Expression of the beta-gal gene in the grafted cells was demonstrated by staining with 5-bromo-4-chloro-3-indoyl-beta-D-galactoside (X-gal). Gene expression was recognized as long as 6 mo after cell transplantation. Histologic analysis showed neither inflammation nor fibrous scar tissue on the host myocardium. This study demonstrated that genetically modified cardiac cells were transplantable to the heart.

Effect of warm ischemia and cryopreservation on cell viability of human allograft valves.

Fibroblast viability of the allograft valve leaflet has been suggested to affect clinical durability. Warm ischemic time is thought to be one of the critical determinants of cell viability. We assessed cell viability of allograft valves by flow cytometry, using a fluorescein diacetate-propidium iodide stain to characterize the effects of warm ischemia and cryopreservation on viability. Twelve human pulmonary valves with harvest-related warm ischemic times (range, 70 to 520 minutes; mean +/- standard deviation, 225 +/- 157 minutes) were studied by flow cytometry. We assessed cell viability of the allograft valve leaflets before and 30 days after storage. A significant negative correlation was found between warm ischemic time (x minutes) and cell viability (y%) before (y = -0.024x + 96.7; r2 = 0.62; p = 0.002) and after 30 days of storage (y = -0.036x + 94.0; r2 = 0.86; p = 0.001). Cell viability of the cryopreserved allograft valves was well preserved (> 70%) with a warm ischemic time less than 520 minutes (8.7 hours).

Gene transfer into the donor heart during cold preservation for heart transplantation.

BACKGROUND: Ex vivo gene transfer to heart grafts may hold promise as a means of changing alloreactivity or xenoreactivity after transplantation. However, it remains to be determined how effectively gene transfer can be accomplished within a short time in cold-stored grafts that are ready to be transplanted. METHODS: We performed an experimental study using a replication-defective adenovirus (Adex1CALacZ) encoding the Escherichia coli beta-galactosidase (beta-gal) gene to perform gene transfer to heart grafts awaiting transplantation. Thirty hearts of Wistar rats were removed and their coronary arteries were perfused with University of Wisconsin solution containing 1 x 10(9), 1 x 10(10), or 1 x 10(11) plaque-forming units of the recombinant adenovirus at 4 degrees C for 60 minutes. As a control, other hearts were perfused with University of Wisconsin solution with an adenoviral vector that did not contain the beta-gal gene (Adex1w1) for the same period. After perfusion, the grafts were implanted in the necks of syngeneic adult rats. The grafts were removed each week after transplantation and their expression of beta-gal was assessed by 5-bromo-4-chloro-3-indoyl-beta-D-galactoside staining. RESULTS: Successful gene transfer and expression of the beta-gal gene were demonstrated in adenovirus-perfused hearts. Gene transfer occurred preferentially in the cardiomyocytes over the endothelial cells and smooth muscle cells of the coronary vessels. In hearts perfused with 1 x 10(9) plaque-forming units of the adenovirus, gene expression persisted for 4 weeks after transfer, but it diminished gradually and was minimal by day 28. Histologic analyses revealed slight inflammatory reactions in the myocardium. In hearts perfused with 1 x 10(10) and 1 x 10(11) plaque-forming units of the adenovirus, beta-gal diminished 3 weeks after transplantation and a prominent infiltration of leukocytes was recognized in the myocardium. CONCLUSIONS: This study demonstrated that the cardiomyocytes of heart grafts express an exogenous gene product after adenovirus-mediated gene transfer under hypothermic preservation conditions. However, immune or inflammatory reactions to recombinant adenoviruses must be taken into account when a large number of adenoviruses are injected into the coronary arteries.

Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis.

BACKGROUND: There are advantages to using homografts and autografts as aortic valve replacements, particularly in patients with infective endocarditis. To better define these advantages, we reviewed our 13-year experience with the surgical management of infective endocarditis involving the aortic valve and root. METHODS: From 1986 through 1998, 81 adults with aortic valve endocarditis underwent valve replacement (AVR). The mean age of the 65 men and 16 women was 44 +/- 14 years. Sixty-three (78%) patients had active endocarditis at the time of operation. Non-native valve endocarditis was present in 29 (36%) patients, in 9 of whom the infection was a recurrence. Aortic valve replacements were performed with 46 homografts (homo-AVR), 25 autografts (Ross-AVR), and 10 prosthetic valves (prosth-AVR). Among Ross-AVR and homo-AVR patients, 11 required mitral valve replacement or repair (homo-Ross DVR). Follow-up was 90% complete within 2 years of the end of the study with a mean of 3.7 +/- 3.4 years. RESULTS: Early mortality was 16% (13 of 81 patients). This was 12% (3 of 25 patients) for Ross-AVR, 17% (8 of 46 patients) for homo-AVR, and 20% (2 of 10 patients) for prosth-AVR. Overall late mortality was 10% (7 of 68 patients) with a valve-related late mortality of 7% (5 of 68 patients). Actuarial survival at 5 years was 88% +/- 9% in Ross-AVR, 69% +/- 11% in homo-AVR, and 29% +/- 22% in prosth-AVR (p = 0.03). Endocarditis recurred in 12.5% (1 of 8 patients) with prosth-AVR and 3% (2 of 60 patients) in homo-Ross AVR. CONCLUSIONS: Valve replacement in the presence of native and prosthetic endocarditis remains a formidable challenge. Autografts and homografts are the preferred replacement aortic valves for these patients even if concomitant mitral valve replacement is required, and risk of valve-related death or recurrent endocarditis is low at medium-term follow-up.

Tracheal replacement with cryopreserved tracheal allograft: experiment in dogs.

BACKGROUND: It has been difficult to perform tracheal allotransplantation without immunosuppression. To determine whether cryopreserved trachea can be used in tracheal replacement, we evaluated the viability of cryopreserved tracheal allografts in a canine model of immunosuppressant-free transplantation. METHODS: Cryopreserved tracheal allografts, which had been frozen to -80 degrees C in a programmed freezer and then stored in liquid nitrogen (-196 degrees C) (group 1, n = 6), fresh tracheal autografts (group 2, n = 5), and fresh tracheal allografts (group 3, n = 4) were transplanted into the thoracic segment of the trachea using an omental flap without immunosuppressive agents. RESULTS: All dogs in groups 1 and 2 survived, but in group 3, all 4 died of airway obstruction between 1 month and 2 months after operation. Histologically, the cryopreserved allografts displayed normal epithelium and cartilage, but the fresh allografts showed chronic inflammatory changes, no epithelium, and no cartilage. CONCLUSIONS: Cryopreserved tracheal allografts maintain their structural integrity after transplantation. The cryopreservation process seems to reduce the allogenic response of the trachea in canine models. Therefore, we believe the cryopreserved tracheal allograft is an excellent choice for tracheal replacement.

Comparative rest and exercise hemodynamics of allograft and prosthetic valves in the aortic position.

BACKGROUND: Allograft aortic valve replacement has gained widespread acceptance. However, there is little information about in vivo allograft valve function at rest and during exercise. METHODS: Cardiac catheterization was performed to measure hemodynamic variables at rest and during supine bicycle exercise in 44 patients who had had aortic valve replacement using allograft valves or Bicer or St. Jude Medical prosthetic valves 19 to 27 mm in diameter. Sixteen patients received an allograft valve; 17, a Bicer valve; and 11, a St. Jude Medical valve. There were no significant differences between the three groups in age, body surface area, left ventricular end-systolic and end-diastolic volume indices, exercise cardiac index, exercise heart rate, or work load achieved. Left ventricular and ascending aortic pressures were measured simultaneously according to the transseptal method. RESULTS: The mean pressure gradient was generally higher for the Bicer and St. Jude Medical valves than for the allograft valves, both at rest and during exercise. Significant differences were obtained in patients with small-sized valves (21 and 23 mm); pressure gradients were higher in the prosthetic valve groups. In patients with large-sized prosthetic valves (25 mm), there were no significant differences between the three groups at rest and during exercise. However, there was no pressure gradient at all for allograft valves. CONCLUSIONS: Exercise cardiac catheterization confirms that the allograft aortic valve is an ideal substitute from the hemodynamic aspect, particularly in patients with a small aortic root and in those who perform strenuous exercise.

Normalization of left ventricular dimensions after Ross operation with aortic annular reduction.

BACKGROUND: Fifty-seven patients (August 1995 to November 1998) with a dysplastic dilated aortic root, a relative contraindication to the Ross operation, received an extended Ross operation with aortic annulus reduction and external cuff fixation (age 14-54 years). To assess the efficacy of these operations, echocardiographic assessment of autograft valve function and left ventricular function and dimensions were reviewed. METHODS: Preoperative and postoperative assessment of 27 patients with aortic insufficiency (AI group) and 30 patients with aortic stenosis (>20 mm Hg peak gradient) and aortic insufficiency (AS group) were compared. Aortic annulus size, valvular gradient, valve insufficiency, left ventricular dimensions at end-systole and end-diastole, left ventricular fractional shortening, and left ventricular mass were assessed. RESULTS: There was one late death. Aortic annulus size, degree of AI, left ventricular internal dimensions, and left ventricular mass were all significantly reduced (p<0.05) postoperatively in the AI group. Mean peak pressure gradients for this group were 6.8+/-6.7 mm Hg before operation and 8.7+/-6.4 mm Hg at 1 year after operation. Peak pressure gradient, aortic annulus size, degree of AI, left ventricular internal dimensions, and left ventricular mass were significantly reduced (p<0.05) in the AS group. Mean fractional shortening was within normal limits pre- and postoperatively for both groups. CONCLUSIONS: Regression of left ventricular dilatation and hypertrophy, excellent autograft valve function, and survival suggest that this modification of the Ross operation may be offered to patients with a dysplastic aortic root requiring aortic valve replacement.

Efficacy and limitation of a left ventricular assist system in a patient with dilated cardiomyopathy accompanying multi-organ dysfunction.

A left ventricular assist system (LVAS, Toyobo CO., LTD., Japan) was used to provide life support for 190 days in a 44-year-old male patient with end-stage dilated cardiomyopathy. Before LVAS implantation, heart failure and cardiogenic shock with multi-organ dysfunction progressed despite the use of intra-aortic balloon pumping (18 days), mechanical ventilatory support (15 days), continuous veno-venous hemofiltration (two days) and intravenous administration of catecholamines. Before LVAS implantation, the patient had marked hepatic and renal dysfunction (total bilirubin 6.1, BUN 73 and serum creatinine 3.1 mg/dl). Those functions returned to normal (total bilirubin 1.2, BUN 11 and serum creatinine 0.6 mg/dl) one month after implantation. He was complicated by multiple cerebral embolisms occurring on the 9th, 57th and 175th postoperative days and died 190 days after surgery. Autopsy showed thrombi attaching to the diaphragm of the blood pump and multiple embolisms in the kidney and the spleen. By scanning electron microscopic examination, initial thrombi with attached erythrocytes were seen on the diaphragm surface without intimal lining formation. In conclusion, LVAS support can be useful for patients with end-stage heart disease complicated by multi-organ dysfunction. However, the LVAS may cause thromboembolic complications over the prolonged use.

Long-term benefits of internal thoracic artery-coronary artery bypass in Japanese patients.

OBJECTIVES: This study sought to determine the effects of grafting the internal thoracic artery (ITA) to the left anterior descending coronary artery (LAD) on long-term (10-year) survival, the cardiac death-free rate, and on the cardiac event-free rate in Japanese patients. BACKGROUND: The use of ITA grafts has been reported to enhance postoperative survival and to decrease the occurrence of cardiac events in the Western literature. However, the survival benefits in Japanese patients, who may have different prognoses with coronary artery disease and a different fate of a saphenous vein graft, have not yet been determined. SUBJECTS AND METHODS: A total of 954 consecutive patients who underwent coronary artery bypass graft operations (CABG) during the last 12 years at the Nara Medical University were followed and evaluated. Of these, 713 patients underwent ITA-CABG to at least the LAD (ITA group), and 241 patients received a saphenous vein graft (SVG) to the LAD (SVG group). At the time of operation, no significant difference was found between these two groups in age, sex ratio left ventricular ejection fraction, left ventricular end-diastolic pressure, cardiac index, incidence of unstable angina, or in the necessity for an emergency operation. However, those patients who received ITA-CABG had significantly higher incidences of diabetes mellitus, hyperlipidemia, and left main coronary artery disease. RESULTS: The 10-year cumulative graft patency rate for the LAD was 23% higher in the ITA group (90.3%) compared to the SVG group (67.0%), (p < .0001). Despite increased preoperative risk factors, patients in the ITA group showed significant improvements in their 5- and 10-year cumulative survival rates as well as in their cardiac death-free and event-free rates. Furthermore, this study demonstrated that ITA grafts improved the prognoses of patients with diabetes mellitus or left ventricular dysfunction and lowered both the long-term postoperative cardiac-death rate and the cardiac-event rate. CONCLUSIONS: The use of ITA grafts was effective in improving both the postoperative survival and cardiac event-free rates, and should be recommended in patients with diabetes mellitus or left ventricular dysfunction. ITA grafting to the LAD should be a routine operation in almost all categories of such patients.

[Effect of blood conservation in open-heart surgery: a comparison of 3 different methods].

Conventional blood conservation techniques have been insufficient to decrease blood transfusion requirement in open-heart surgery. Blood conservation and erythropoietin administration were performed to avoid homologous blood transfusion. Intraoperative autotransfusion has been routinely used in cardiac operations with cardiopulmonary bypass in our hospital. To evaluate the effect of conservation techniques, 286 patients were divided into four groups. In group I (23 patients), autologous whole blood was drawn and saved one to two weeks before operation. In group II (50 patients), erythropoietin preparation was given subcutaneously once a week and autologous blood conservation was also performed in the same manner as group I. In group III (48 patients), intra-operative hemodilutional autologous blood transfusion was performed. In group IV, as a control group (165 patients), only intra-operative autotransfusion was used. Homologous blood transfusion was avoided in 83% of group I patients, in 90% of group II, in 82% of group III, and 29% of group IV. In addition, in group II the hemoglobin value at the time of discharge was significantly higher than those of other groups (p < 0.05-0.01). Thus, conventional blood conservation techniques plus subcutaneous administration of erythropoietin was very effective to increase the rate of "non-blood" open-heart surgery.

[A case report of aortic root replacement with fresh aortic homograft for valve detachment due infective endocarditis].

A 28-year-old male received a redo aortic valve replacement (AVR) with a 19 mm St. Jude Medical mechanical valve 3 months after the initial AVR because of recurrent valve detachment. We re-operated on this patient by aortic root replacement using a fresh aortic homograft. The donor of the homograft was a 59-year-old female who died of a traffic accident. The aortic root and valve was harvested aseptically and stored in a nutrient medium including antibiotics at 4 degrees C for 4 days. At the 3rd operation, aortico-ventricular discontinuity and an annular-abcess-like cavity were found. After debridement, the cavity was closed with a homograft aortic wall and then aortic root replacement was performed using a fresh aortic homograft. At first, prosthetic valve detachment seemed to be caused by infective endocarditis on the basis of his clinical history. However, causative organisms had never been recovered from the blood or the specimens obtained at the time of operation and reoperation. Post-operative HLA examination revealed No. 51 on HLA-B locus and thus we suspected that valve detachment might have been due to inflammation of the aortic wall caused by a subtype of Behçet disease. The early post-operative course was uneventful with a low dose of predonine. Post-operative aortography showed no aortic regurgitation and normal coronary anastomosis. Unfortunately however, he died suddenly 8 months after the operation. Autopsy demonstrated the presence of aortic wall necrosis with massive infiltration of macrophages and leucocytes resulting in dehiscence of the coronary anastomotic site. The cause of homograft detachment could not be determined for sure but might be recurrent infective endocarditis, although causative organisms were never identified, or infective endocarditis in combination with Behçet vasculopathy.

[Coronary artery bypass grafting in patients over 70 years old].

We examined the outcome of CABG in 157 patients aged over 70 years. The average age was 72.7 +/- 2.4 years: the number of the diseased vessels, 2.5 +/- 0.7/pt; the mean preoperative LVEF, 0.55 +/- 0.17 and the number of patients with left main trunk disease, 40 (26%). The mean number of bypass grafts was 2.8 +/- 0.8/pt. In 131 patients (83.4), left internal thoracic artery (LITA) was used to bypass the left anterior descending artery (LAD). The postoperative hospital mortality rate was 6.4%. After 10 years of follow-up, the actuarial survival rate and cardiac event-free rate were 73.6% and 88.9%, respectively calculated by the Kaplan-Meier method. A comparison of the long-term results of CABG with and without ITA grafting, showed no statistical difference with respect to actuarial survival rate. However, the cardiac event-free rate was improved by using an ITA graft (92.4% with an ITA vs 77.3% without an ITA, p = 0.047). This result suggested that the use of ITA in patients over 70 years old reduced the incidence of postoperative cardiac events without increasing the operative risk.

[An experience with the Ross operation utilizing cryopreserved pulmonary homografts procured by and stored in our homograft valve bank].

Eight patients, 4 males and 4 females ranging in age from 10 to 54 years (mean 27 +/- 13 years) underwent the Ross operation using a cryopreserved pulmonary homograft harvested by and cryopreserved in our institutional "Tissue Bank". Seven patients had a congenital bicuspid aortic valve and 3 patients had had healed infective endocarditis of the aortic valve. Four young female patients wanted to have a baby after operation. The Ross procedure was carried out utilizing aortic root replacement techniques in all patients. All patients survived and are currently in NYHA class 1, but 2 cardiac events occurred in 2 patients during the mean follow-up term of 29 +/- 19 months. The one was the anastomic stenosis between the homograft and distal pulmonary artery treated by balloon dilatation and the other was ventricular tachycardia eventually managed by the insertion of an ICD. Pulmonary autograft valve regurgitation is present in 3 patients, but it is not progressive up to the present time. Pulmonary homograft valves function well in all patients. The Ross operation for adolescents and young adults should become more popular along with more easy availability of homograft valves based upon the establishment of the "Homograft Valve Bank" system in Japan.

[Reoperative coronary artery bypass grafting in patients with patent internal thoracic artery grafts].

The incidence of reoperative coronary artery bypass grafting (reCABG) is recently increasing. However, there has been no report of reCABG in patients with patent internal thoracic artery (ITA) grafts in Japan. We performed reCABG in three such patients with patent ITA grafts. The first patient was a 49-year-old male who had undergone a 2 CABG (left ITA-LAD, SVG-DX 1), 8 years and 7 months prior to the 2nd operation, he received a re 2 CABG (GEA-RCA, RITA-SVG-DX 1) with a patent prior LITA-LAD graft. The second patient was a 65-year-old female who had undergone CABG in which the LITA had been erroneously anastomosed to the DX 2 in place of the LAD. Three year later, the reCABG (RITA-LAD) was performed with a patent prior LITA-DX 2 graft. The third patient was a 51-year-old male who had undergone 3-CABG (RITA-LAD, LITA-DX, SVG-RCA). The RITA was closed most probably due to technical errors and his angina recurred. Tree year after the first operation, he received a re 3-CABG (GEA-LAD, SVG-RCA, SVG-OM) with a patent prior LITA-DX graft. In each patient, PTCA had been tried twice, twice and once prior to redo operations. Their post-redo courses were uneventful, and they were discharged free from angina. In such cases it is important to manage with care the patent ITA grafts at reoperation. Biplane ITA angiograms are quite helpful to evaluate the course of grafts in relation to the sternum. To cover the ITA graft with a GORE-TEX membrane may also be useful for easy identification of the graft at redo operations.