Healing of the intimal dissection of the internal thoracic artery graft

We report healing of the intimal dissection of an internal thoracic artery graft. Triple coronary artery bypass grafting was performed using left internal thoracic artery and saphenous vein grafts. One month after operation, the intimal dissection of the internal thoracic artery graft was clearly visible by coronary angiography; however, after 1 year of only medical treatment consisting of warfarin, ticlopidine, and nitrate, the intimal dissection was undetectable by coronary angiography.

[Coronary artery bypass grafting technique to minimize the usage of metallic materials]

Some metallic materials are widely used for coronary artery bypass surgery. There is no problem using the metallic materials themselves. However, metallic artifact interferes with the interpretation and reduces the sensitivity of the MRI. To minimize the utilization of metallic materials, we applied absorbable nonmetallic clips and used an ultrasonically activated scalpel to harvest the arterial grafts. We also applied polyester suture instead of the stainless steel sternal wire. We believe this technique will allow increased MRI usage for patients who undergo coronary artery bypass surgery.

Basic fibroblast growth factor induction of neuronal ion channel expression in ascidian ectodermal blastomeres

1. Cleavage-arrested anterior animal (a4-2) blastomeres isolated from eight-cell embryos of Halocynthia aurantium differentiated into neuronal type cells expressing neuron-specific ion channels when they were treated with basic fibroblast growth factor (bFGF). This induction process was very similar to that when a4-2 blastomeres were cultured in contact with anterior vegetal (A4-1) blastomeres from the same embryos or when treated with subtilisin, a serine protease. 2. Other growth factors, transforming growth factor (TGF) beta1, activin A, epidermal growth factor (EGF) and nerve growth factor (NGF), had no effect on the default epidermal differentiation of cleavage-arrested a4-2 blastomeres. 3. Messenger RNA of the ascidian neuronal Na+ channel, TuNa I, was detected using RT-PCR in a4-2-derived partial embryos of Halocynthia aurantium as well as in the cleavage-arrested a4-2 blastomeres treated with bFGF, confirming the neural inducer activity of bFGF during ascidian embryogenesis. 4. bFGF was effective at concentrations as low as 1 ng ml-1 in inducing neuronal ion channels in cleavage-arrested a4-2 blastomeres. EC50 for neuronal differentiation was estimated to be around 8 ng ml-1, and the maximum effect of 90 % neuronalization was obtained with above 100 ng ml-1. 5. For induction of neuronal differentiation, bFGF was required to be continuously present 8 to 14 h after fertilization. A similar time window was required for cell-contact induction, but it was considerably shorter for subtilisin induction. 6. We discuss whether activation of receptor tyrosine kinase is a common pathway for neural induction by bFGF, subtilisin, and cell-contact with A4-1 blastomeres.

Interleukin-6 and "complex" cardiac myxoma

A rare case of "complex" cardiac myxoma is reported. Complex cardiac myxoma manifests with more constitutional signs than the sporadic type. These constitutional signs are known to be associated with the overproduction of interleukin-6 by cardiac myxomas. In our study, immunohistochemical staining of the myxoma for interleukin-6 was strongly positive. The serum interleukin-6 level decreased after surgical removal of the tumor and has remained undetectable for the past 2 years.

Formation of superoxide anion in the hepatic sinusoid after lipopolysaccharide challenge

Using the cytochrome c method, superoxide anion that is released into the hepatic sinusoid was measured after a lipopolysaccharide challenge in a liver perfusion system. Moreover, damages of epithelial cells of the hepatic sinusoid were estimated with scanning electron microscopic analysis and levels of purine nucleoside phosphorylase/GPT ratio. Lipopolysaccharide administration increased the conversion of oxidized cytochrome c into reduced cytochrome c in the perfusate, indicating that superoxide anion was formed in the hepatic sinusoid. This change was associated with increase in levels of portal tumor necrosis factor-alpha and attenuated by the simultaneous administration of superoxide dismutase. Scanning electron microscope analysis revealed that diameters of sinusoidal fenestrae increased in rats treated with lipopolysaccharide, compared with controls. Moreover, levels of purine nucleoside phosphorylase/GPT ratio was significantly increased in the liver perfusate in lipopolysaccharide-treated rats, compared with controls. Superoxide anion in hepatic sinusoid may be one of the pathogenic factors behind damages of epithelial cells of the hepatic sinusoid caused by lipopolysaccharide.

Effect of chronic ethanol feeding on endotoxin-induced hepatic injury: role of adhesion molecules on leukocytes and hepatic sinusoid

Endotoxin is postulated to be an important aggravating factor for alcoholic liver disease. We have previously reported that rats fed ethanol are more vulnerable to endotoxin-induced liver damage, and hepatic microcirculatory disturbance plays an important role for this liver damage by observation with an intravital microscopy. In this study, we have investigated the role of adhesion molecules in endotoxin-induced microcirculatory disturbance in chronic ethanol-fed rats. Male Wistar rats were pair-fed with ethanol liquid diet (ethanol group) or an isocaloric control diet (control group) for 6 weeks. Leukocyte adherence to the hepatic sinusoid by stimulation with lipopolysaccharides (1 mg/kg of body weight) was observed by an inverted fluorescence microscopy equipped with a silicon-intensified target camera and was found to be enhanced in ethanol-fed rats. Tumor necrosis factor-alpha and GRO/CINC-1 (rat counterpart of interleukin-8) was increased in the blood in these animals. Subsequent expression of adhesion molecules, LFA-1 beta-chain on leukocytes were demonstrated by flow cytometry, which suggests a possible involvement of leukocyte adherence to the hepatic damage in ethanol-fed animals. Preadministration of anti-rat LFA-1 beta-chain monoclonal antibody effectively suppressed leukocyte adherence to the hepatic sinusoid. These results suggest that the enhanced sequestration of neutrophils to the liver with these adhesion molecules may play a significant role in the pathogenesis of alcoholic liver disease.

[A case report of recurrent self inserted needle in heart]

A 17-year-old female who had, on two occasions, inserted a total of 7 needles into her heart and chest wall, resulting in autolesion on both occasions, was examined. On the first occasion, because the needle end was recognizably protruding from the right ventricle, we successfully removed the needle without using ECC. No complications arose prior to discharge, after which she regularly visited the psychiatric department for treatment. Two months after discharge, she again inserted needles into her chest wall and was admitted to hospital. At that time, five needles were evident in the chest wall. During preparation for removal of the needles under local anesthetic, she escaped from the room. When found in a ward several hours later, six needles were embedded in her chest wall, the sixth, most recently inserted needle was an injection needle. Due to the depth to which the needle had been inserted in the heart, neither the point nor end were visible, and thus the needle had to be removed using ECC and fluoroscopy.

[A case of MIDCAB to the left circumflex via the left posterolateral thoracotomy]

There have been many reports of MIDCAB to left anterior descending artery via a small dissection utilizing the left anterolateral thoracotomy. We report here a case of CABG reoperation to the circumflex artery by MIDCAB via the left posterolateral thoracotomy. A 66-year-old male patient had received a 3 branch bypass graft on the LITA-LAD and the SVG-OM-4 PD at another institution. Postoperative angiography revealed a SVG occlusion. Since repeated intervention was unsuccessful, reoperation was necessary. To preserve the patency of the LITA, the 4th left intercostal posterolateral thoracotomy was selected. We utilized a commercially available rib retractor for MIDCAB, as well as a stabilizer and a CO2 blower to obtain a nearly perfect bloodless stabilized view. A new SVG was used to connect the left circumflex artery. The operation was successful without any postoperative complications or need for transfusion. After a two week hospital stay, the graft patency was confirmed and the patient was discharged.

Ion channels and early development of neural cells

In this review we underscore the merits of using voltage-dependent ion channels as markers for neuronal differentiation from the early stages of uncommitted embryonic blastomeres. Furthermore, a fairly large part of the review is devoted to the descriptions of the establishment of a simple model system for neural induction derived from the cleavage-arrested eight-cell ascidian embryo by pairing a single ectodermal with a single vegetal blastomere as a competent and an inducer cell, respectively. The descriptions are focused particularly on the early developmental processes of various ion channels in neuronal and other excitable membranes observed in this extraordinarily simple system, and we compare these results with those in other significant and definable systems for neural differentiation. It is stressed that this simple system, for which most of the electronic and optical methods and various injection experiments are applicable, may be useful for future molecular physiological studies on the intracellular process of differentiation of the early embryonic cells. We have also highlighted the importance of suppressive mechanisms for cellular differentiation from the experimental results, such as epidermal commitment of the cleavage-arrested one-cell Halocynthia embryos or suppression of epidermal-specific transcription of inward rectifier channels by neural induction signals. It was suggested that reciprocal suppressive mechanisms at the transcriptional level may be one of the key processes for cellular differentiation, by which exclusivity of cell types is maintained.

[A case report of thoracic outlet syndrome with acute arterial obstruction caused by abnormal first rib]

A 33-year-old male was transferred to our hospital because of coldness, numbness and pain in his right arm. Chest X-ray showed abnormal first ribs on both sides that were attached to the second ribs below the clavicles. Angiogram revealed an aneurysm of right subclavian artery, thrombus in the aneurysm and embolism to the brachial artery. Thrombectomy using a Fogarty catheter was done and the radial pulse recovered. Surgical resection of the abnormal first rib and thrombectomy was performed, because ischemic symptoms recurred in spite of anticoagulation and antiplatelet therapy. Acute arterial occlusion in patients with thoracic outlet syndrome is rare. The literature on arterial complications of thoracic outlet syndrome is reviewed.

[A case of impending rupture of coronary aneurysm after rapid growth within a month]

A case of successful surgery for a rapidly growing aneurysm is described. The patient, a 47-year-old woman, had suffered from recurrent aphtous and genital ulcers for 17 years and hyperthyroidism for two years. One month after myocardial infarction, follow-up coronary angiography showed total obstruction at the distal part of the aneurysm in the left anterior descending artery with rapid dilation to 37 mm. Echocardiography revealed gradually increasing pericardial effusion. Urgent surgery was performed on January 11, 1995. Because Behçet's disease was suspected and since the vascular wall was suspected to have become fragile, surgery was performed using the aortic-no-touch technique. Under ventricular fibrillation, the proximal and distal part of the left anterior descending artery of the coronary aneurysm was ligated and bypass grafting was achieved at the distal part of the left anterior descending artery with the left internal thoracic artery. Low dose steroid treatment was started from nine days after surgery. The post operative course was satisfactory and coronary angiography during the first month showed no abnormal signs.

Distinct neuronal lineages of the ascidian embryo revealed by expression of a sodium channel gene

The ascidian larva contains tubular neural tissue, one of the prominent anatomical features of the chordates. The cell-cleavage pattern and cell maps of the nervous system have been described in the ascidian larva in great detail. Cell types in the neural tube, however, have not yet been defined due to the lack of a suitable molecular marker. In the present work, we identified neuronal cells in the caudal neural tube of the Halocynthia embryo by utilizing a voltage-gated Na+ channel gene, TuNa I, as a molecular marker. Microinjection of a lineage tracer revealed that TuNa I-positive neurons in the brain and in the trunk epidermis are derived from the a-line of the eight-cell embryo, which includes cell fates to epidermal and neural tissue. On the other hand, TuNa I-positive cells in the more caudal part of the neural tissue were not stained by microinjection into the a-line. These neurons are derived from the A-line, which contains fates of notochord and muscle, but not of epidermis. Electron microscopic observation confirmed that A-line-derived neurons consist of motor neurons innervating the dorsal and ventral muscle cells. Isolated A-line blastomeres have active membrane excitability distinct from those of the a-line-derived neuronal cells after culture under cleavage arrest, suggesting that the A-line gives rise to a neuronal cell distinct from that of the a-lineage. TuNa I expression in the a-line requires signals from another cell lineage, whereas that in the A-line occurs without tight cell contact. Thus, there are at least two distinct neuronal lineages with distinct cellular behaviors in the ascidian larva: the a-line gives rise to numerous neuronal cells, including sensory cells, controlled by a mechanism similar to vertebrate neural induction, whereas A-line cells give rise to motor neurons and ependymal cells in the caudal neural tube that develop in close association with the notochord or muscle lineage, but not with the epidermal lineage.

[A case of aortic valve replacement 3 years after coronary artery bypass grafting]

A rare case of aortic valve replacement (AVR) with poor left ventricular function, following coronary artery bypass grafting, was reported. The patient was 57-year-old man who received urgent CABG with 2 saphenous vein grafts 3 years ago. At that time, aortic regurgitation (AR) was grade 2. He suffered acute myocardial infarction 1 year after CABG because of the occlusion the saphenous vein graft to the obtuse marginal branch. Percutaneous transluminal angioplasty was successfully performed for occluded graft. Since then, however, AR increased gradually and the left ventricular function decreased. Three years after the initial operation, he was admitted again with congestive heart failure. Heart catheterization revealed grade 3 AR and 17% left ventricular ejection faction (LVEF). AVR was performed through a median sternotomy and 2 saphenous vein grafts were preserved. He showed uneventful postoperative recovery and is now very well with 40% LVEF.

[A case of thymic epidermoid carcinoma recurred in the pericardial cavity]

A 61-year-old woman with cough and sputum and right scapular pain was referred to our hospital with a suspected anterior mediastinal tumor by Chest X-rays and CT-scan. The tumor was diagnosed as thymic cancer cytologically by fine needle biopsy. At the the thoracotomy via median sternotomy, the tumor adhered to left brachial vein, superior vena cava and pericardium and it was dissected by maneuver. It was diagnosed as moderately differentiated epidermoid carcinoma by histology of the surgical specimen and involvement of the pericardium was histologically presumed. The patient received postoperative radiation therapy. A year after operation, the tumor recurred in the pericardial cavity. Inspite of resection of the recurred tumor and an anticancer chemotherapy, the patient died of cardiac failure due to the proliferated tumor around the heart. There are some reports that epidermoid carcinoma of the thymus may have different responses to radiation therapy according to histologic tumor differentiations. At resection of epidermoid carcinoma of thymus, therefore, intraoperative pathologic examination of the adhesive part of excised specimen and additional resection were essential to resect thymic cancer radically.

Monoclonal antibodies against pig ovarian follicular granulosa cells induce apoptotic cell death in cultured granulosa cells

Two monoclonal antibodies capable of inducing granulosa cell apoptosis were produced against granulosa cells prepared from antral follicles of pig ovaries. The healthy follicles, 4-5 mm in diameter, were dissected from the ovaries of gilts, and then granulosa cells were isolated. BALB/c female mice were immunized with the isolated granulosa cells. Antibodies against the granulosa cells were detected by immunofluorescent staining using frozen ovarian sections. The isolated spleen cells prepared from immunized mice producing antibodies against the granulosa cells were fused with Sp2/O-Ag 14 mouse myeloma cells by standard hybridization techniques. Two hybridoma clones, PFG-1 and PFG-2, which produced specific IgM antibodies against granulosa cells were selected. Western blotting analysis revealed that PFG-1 and PFG-2 antibodies specifically recognized cell-membrane proteins with molecular weights of 55 and 70 kD and isoelectric points of 5.9 and 5.4, respectively. The monoclonal antibodies immunohistochemically reacted with granulosa cells of healthy follicles. When the isolated granulosa cells prepared from healthy follicles were cultured in medium containing 0.1 or 10 micrograms/m/PFG-1 or PFG-2 antibodies, respectively, the cells underwent apoptosis as determined by nuclear morphology, DNA electrophoresis and flow cytometric analysis. In conclusion, these two monoclonal antibodies against granulosa cells have cell-killing activity in cultured granulosa cells.

[Coronary bypass surgery in the elderly: characteristics and quality of life]

From November 1991 to December 1996, 66 patients aged 70 years or more underwent coronary artery bypass grafting (CABG). They were compared with a group of 200 consecutive patients aged less than 70 years of age who underwent CABG during the same period. The elderly patients had a higher incidence of female gender, smaller body structure, left main trunk disease, calcification of ascending aorta and emergency operation. However, there were no significant differences between two groups in hospital mortality, IABP insertion or length of stay in intensive care unit. Quality of life (QOL) of the elderly patients was evaluated for all the 58 survivors by means of Specific Activity Scale Questionnaires. Forty of the 58 patients (69%) had functional capacity of 5 METs or more. All the 43 patients who worked before CABG were able return to work, although some patients reduced their workload. We conclude that CABG in elderly patients can be performed with mortality and morbidity similar to those in younger patients. QOL is generally maintained.

[Urgent coronary reoperation under the beating heart via the left thoracotomy]

An 80-year-old female, who had received coronary artery bypass grafting (CABG) 12 years ago was admitted to our hospital because of unstable angina. The vein grafts to the left anterior descending artery (LAD) and circumflex artery (Cx) were both occluded. Chest computerized tomography showed a severely calcified aorta. An intra-aortic balloon pump was inserted and an urgent reoperation was performed. The patient was positioned for an anterolateral left thoracotomy. The chest was entered through the forth intercostal space. The pericardium was opened parallel to the phrenic nerve. Femorofemoral bypass was instituted. Anastomosis of the saphenous vein graft and the diagonal branch and anastomosis of a second saphenous vein to the old SVG just proximal to the anastomotic site of Cx were performed under a beating heart. Proximal anastomosis of the two saphenous veins and the left subclavian artery was then performed. The patient had an uncomplicated postoperative recovery. A postoperative angiogram showed that the new SVG anastomosed to the diagonal branch was patent while the other new SVG anastomosed to the old SVG/Cx was occluded. The patient was discharged and is now free from angina.

[Evaluation of coronary artery bypass grafts with magnetic resonance imaging]

Currently, the efficacy of magnetic resonance imaging (MRI) for evaluating coronary artery disease has been reported. In this study, we have evaluated the usefulness and the problems of MRI for evaluating the patency of coronary artery bypass grafts. Thirty-five patients who received coronary artery bypass grafting (CABG) were evaluated by using MRI for determining the graft patency compared with conventional coronary angiography. There were 30 men and 5 women. The mean age was 61.2 years (range 45 to 75). The 35 patients had a total of 92 grafts (28 internal thoracic artery, 7 gastroeploic artery and 57 saphenous vein grafts). Magnetic resonance coronary angiogram (MRCA) was performed with SIGNA HORIZON 1.5 T (GE Inc.) by using 2D-FASTCARD sequence. All patients underwent imaging in the transverse and coronal planes, most had imaging in the sagittal plane, and a few had in the oblique plane. By using MRCA, 82 of 90 grafts were diagnosed correctly as patent, and 1 of 2 grafts were diagnosed correctly as occluded. Thirty-four of 40 LAD grafts (85%), 20 of 22 RCA grafts (91%) and 29 of 30 Cx grafts (97%) were correctly evaluated. The efficacy of MRCA for evaluating the patency of coronary artery bypass grafts was recognized. But the sternal wire (stainless steel) and hemoclip interfere with the interpretation and reduce the sensitivity. Higher sensitivity may be obtained by changing the material of the sternal wires and hemoclips at coronary surgery.

[Beneficial effects of continuous hemodiafiltration after cardiac surgery in patients with chronic renal failure]

From December 1993 to June 1996, fourteen patients with chronic renal failure (CRF) were underwent cardiac surgery. Thirteen of them had coronary artery bypass grafting (CABG) and one patient had aortic valve replacement. We employed continuous hemodiafiltration (CHDF) with or without peritoneal dialysis in eleven cases in the early postoperative course of open heart surgery. In these cases, the usefulness of CHDF were examined. CHDF was started after 16.9 +/- 13.7 hours of surgery, and continued for 31.9 +/- 18.0 hours. We adjusted blood flow as 80 ml/min, perfusate flow of hemofilter as 500 ml/hr, and the activated clotting time (ACT) as 150-200 seconds with heparin or nafamostat mesilate. No hemorrhagic tendency was observed. Mean serum creatinine level before and after 24 hours of CHDF was 5.6 +/- 2.2 and 5.6 +/- 2.1 mg/dl respectively, and it was not elevated. The average removal volume was 2,223 +/- 1,256 ml for the first 24 hours, and pulmonary wedge pressure was decreased from 9.0 +/- 2.3 to 6.4 +/- 3.0 mmHg (p < 0.05). However, there was no significant change at cardiac output before and after CHDF. Total dose of dopamine and dobutamine were unchanged. No significant change were noted at systemic vascular resistance and pulmonary vascular resistance. We conclude that CHDF allows an adequate removal of fluid and waste products without deleterious effects on hemodynamics even in patients after cardiac surgery. CHDF is a safe and effective alternative in patients with CRF after cardiac surgery.

Studies on the metabolism and disposition of the new retinoid 4-[(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-naphthyl)carbamoyl]benzoic acid. 5th communication: factors affecting percutaneous absorption in rats

4-[(5,6,7,8-Tetrahydro-5,5,8,8-tetramethyl-2-naphthyl)carbamoyl] benzoic acid (CAS 94497-51-5, Am-80) is a new synthetic retinoid which has been shown to have a potent topical antipsoriatic activity. Factors affecting the percutaneous absorption of Am-80 were studied with the intention of obtaining information for toxicity and clinical investigations. The percutaneous absorption of radioactivity was compared after topical application of 0.1% 14C-Am-80 ointment to female rats by simple application (SA), occlusive dressing technique (ODT), and application using lint (AUL). After single topical application to normal skin female rats, the percutaneous absorption of radioactivity was very low with no significant differences in the extent of absorption among the three application methods. In the stripped skin female rats, a distinct increase of the percutaneous absorption was observed indicating that it was markedly affected by the lack of the stratum corneum. Compared with the single dosing, a considerable increase of percutaneous absorption was observed following repetitive topical application once daily for 4 or 7 days to the normal skin female rats. The extent of increase was highest in ODT rats followed by SA rats, but was relatively low in AUL rats. The effects of concentration, dose and application area of 14C-Am-80 ointment on the percutaneous absorption of radioactivity were studied following topical application of 0.002%-0.008% 14C-Am-80 ointment to normal skin male rats by ODT to areas of 72 cm2/kg-360 cm2/kg (5%-25% of the body surface area) at ointment doses of 2g/kg-8 g/kg. When the application area and the amount of ointment applied were fixed at 144 cm2/kg (10% of the body surface area) and 2 g/kg, respectively, the amount of radioactivity absorbed increased in proportion to the 14C-Am-80 concentration in the ointment, whereas the rate of percutaneous absorption, expressed as the percent of dose, was nearly constant. When the 14C-Am-80 concentration in the ointment and the amount of ointment applied were fixed at 0.08% and 2 g/kg, respectively, both the amount of radioactivity absorbed and the rate of percutaneous absorption markedly increased with an increase in the application area. When the concentration of 14C-Am-80 in the ointment was set at 0.008% and the application area at 72 cm2/kg, 144 cm2/kg or 288 cm2/kg (5%, 10% or 20% of the body surface area), the amount of radioactivity absorbed increased as the amount of ointment applied increased for areas of the same, though the rate of percutaneous absorption remained almost constant. When the 14C-Am-80 concentration in the ointment was fixed at 0.008%, the amount of radioactivity absorbed increased markedly about 20-fold with 4-fold simultaneous increases in both the application area (from 72 cm2/kg to 288 cm2/kg) and the amount of ointment applied (from 2 g/kg to 8 g/kg).

Regulation of voltage-gated ion channels during ascidian embryogenesis

In the proto-chordate Halocynthia roretzi, a voltage-activated sodium current undergoes a change in kinetics within 48 h of fertilization. Molecular cloning and microinjection of antisense DNA into single cells suggest that the kinetic changes are due to the increased expression of a neural-specific sodium channel gene, TuNa I. TuNa I gene transcription is first induced in late-stage gastrulae, preceding the appearance of the rapidly inactivating sodium current unique to alpha 4-2 derived neural cells. In cleavage-arrested and intact embryos, cell interactions between specific animal and vegetal blastomeres are required for induction of TuNa I gene expression. By contrast, another sodium channel gene, TuNa II, is mainly expressed in neural cells of the alpha 4-1 lineage. In this lineage, cells of endoderm, notochord and muscle develop. TuNa II gene transcription occurs in isolated alpha 4-1 blastomeres without interacting with other lineage cells. Thus, there are two distinct neural cell lineages in the ascidian tadpole: one is similar to the ectoderm-derived neural tissue controlled by a mechanism reminiscent of the neural induction in the vertebrate, the other is the lineage of posterior neural tube in which motor neurons develop in close association with the notochord or muscle lineage.

[Coronary artery bypass grafting under the beating heart in a patient with insufficient cardiopulmonary bypass]

Coronary artery bypass grafting in a 64-year-old male with a severe calcified ascending aorta was performed under the beating heart, because of insufficient cardiopulmonary bypass. The patient suffered inferior and anterolateral myocardial infarction with moderate mitral regurgitation. Computerized tomography showed a severely calcified ascending aorta. During the operation, cardiopulmonary bypass was conducted with femoral arterial cannulation and bicaval cannulation. Adequate perfusion flow, however, could not be achieved. Anastomoses of left internal thoracic artery-left anterior descending artery and right gastroepiploic artery-right coronary artery were performed under a beating heart supported by cardiopulmonary bypass. The patient made an uneventful recovery and postoperative angiography revealed patent grafts. Mitral regurgitation remained unchanged, but the postoperative lifestyle has been stable for the last 15 months.