Efficacy of modified less invasive quick replacement using mild hypothermic arrest and partial retrograde cerebral perfusion for type A acute aortic dissection.

OBJECTIVE: We previously reported a unique technique called "less invasive quick replacement (LIQR)" for treating type A acute aortic dissection with moderate hypothermic arrest (28 °C). This study examines the modified LIQR using mild hypothermic arrest (30 °C) with partial retrograde cerebral perfusion (RCP). METHODS: 187 patients were divided into 2 groups: group L consisted of 130 patients underwent LIQR without any cerebral perfusion; group M consisted of 57 patients who were treated with modified LIQR. In modified LIQR, circulatory arrest was commenced under the 30 °C for open distal aortic stamp fixation. RCP was used during final half anastomosis of the prosthesis and then rapid re-warming was initiated. RESULTS: The incidence of additional valve or coronary surgeries was significantly higher in group M (28.1%) than in group L (9.2%). The average rectal temperature was significantly higher in group M (29.5 °C) than in group L (27.4 °C). The durations of brain ischemia (M 7.7 min; L 18.6 min), cardiopulmonary bypass (M 82.0 min; L 93.3 min), and overall operation (M 145.2 min; L 154.2 min) were significantly shorter in group M. The incidence of postoperative brain damage was 6 patients (4.6%) in group L, but none in group M. The hospital mortality rate was 3 patients in group L (2.3%). All group M patients were discharged from the hospital without any complications. CONCLUSION: Modified LIQR is safe and effective. It makes the surgery much quicker and is a less invasive procedure. The surgical outcome was also favorable.

Efficacy of a newly modified technique for distal limited open stenting in octogenarians with aortic arch aneurysm.

OBJECTIVE: We assessed the efficacy of distal limited open stenting procedure in octogenarians with distal aortic arch aneurysm. METHODS: During the last 5 years, 24 patients underwent distal limited open stenting. Mean patient age was 81.6 ± 2.5 years, ranging from 80 to 90 years. The hemicircumference of the anterior surface of the arch around the left common carotid artery was obliquely incised, and a J-Graft Open Stent (Japan Lifeline Co, Ltd, Tokyo, Japan) was inserted into the descending aorta. During open stenting, circulatory arrest was induced at a rectal temperature of 28°C without any cerebral perfusion. As soon as the proximal side of the stent graft and aortic incision were concomitantly sutured, rapid rewarming was initiated through heated blood perfusion. RESULTS: The durations of circulatory arrest, aortic crossclamping, cardiopulmonary bypass, the overall operation, postoperative mechanical ventilation, and hospital stay were 17.0 minutes, 27.8 minutes, 106.1 minutes, 167.6 minutes, 11.0 hours, and 13.9 days, respectively. The in-hospital mortality was 0%. There were no incidences of brain damage, renal failure, or respiratory failure. At the time of this study, 21 patients were doing well and visiting the outpatient clinic, and 19 scored more than 20 points on the Mini-Mental State Examination, indicating no development of dementia. The actuarial survival at 5 years was 82.4%. CONCLUSIONS: This unique technique is safe and effective. It is a very attractive procedure that can contribute to maintaining a good long-term quality of life for octogenarians with distal aortic arch aneurysm.

Limited Distal Arch Open Stenting for Type B Aortic Dissection with an Enlarged Ulcer-Like Projection, Complicated by Abdominal Aortic Occlusion.

A 79-year-old man underwent bifurcated graft replacement for abdominal aortic aneurysm, but the graft was totally occluded owing to an acute type B aortic dissection. We could not have access to the root for performing endovascular stenting for dissecting aneurysm. Furthermore, it was difficult to remove the aneurysm via a left thoracotomy because it was impossible to perfuse the lower body with blood from the femoral artery and also a left axillary arterial cannulation was unusable. Herein, we report a patient who was successfully treated with open surgical aortic stenting for an enlarged ulcer-like projection complicated by a type B aortic dissection.

Efficacy of limited proximal arch replacement for type A acute aortic dissection with critical complications.

OBJECTIVE: We assessed the efficacy of limited proximal arch replacement for type A acute aortic dissection (AAD) with critical complications. METHODS: Sixty-four patients with average age of 64.5 ± 13.0 years, who were intubated prior to arriving at hospital due to cardiopulmonary arrest, cardiac tamponade, or vital organ mal-perfusion, were divided into two groups: group PA consisted of 52 patients undergoing proximal arch repair with mild hypothermic circulatory arrest; group TA consisted of 12 patients who underwent total arch replacement with moderate hypothermia and selective cerebral perfusion. RESULTS: The intimal tear on the distal side of the left subclavian artery was not excised in 11 patients (21.2 %) of group PA. The intimal tear was excised in all patients in group TA. The durations of cerebral protection (PA, 18.7; TA, 70.3 min), cardiopulmonary bypass (PA, 121.5; TA, 206 min), and overall operation (PA, 181.8; TA, 403.8 min) were significantly shorter in group PA. The incidence of postoperative brain damage was significantly lower in group PA (9.6 %) than in group TA (33.3 %). The mortality rate was significantly lower in group PA (5.8 %) than in group TA (58.3 %). Distal arch to descending aortic replacement was required in four patients of group PA during follow-up period. There were no complications or mortality during the reoperation. The actuarial survival rate at 10 years was significantly better in group PA (66.5 %) than in group TA (25 %). CONCLUSION: Limited proximal arch repair is suitable for high-risk patients with AAD, despite no excision of the intimal tear.

Less Invasive Quick Open Stenting using a J Graft Open Stent for Distal Arch Aneurysms.

A new device of aortic stent graft made in Japan has been available since July 2014. Here, we describe a novel, unique surgical technique named "less invasive quick open stenting" at a rectal temperature of 28°C without any cerebral perfusion for treating distal arch aneurysms. All 12 patients were discharged from the intensive care unit within 24 hours after surgery without any complications. This technique aids in the exclusion of atherosclerotic plaques on the aortic wall and shortens the duration of circulatory arrest; moreover, it represents a very attractive option to prevent recurrent nerve injury.

Complete occlusion of the left main trunk coronary artery by a cardiac papillary fibroelastoma in a hemodynamically unstable patient.

Papillary fibroelastomas are benign cardiac tumors with high embolic potential. The majority of cases of complete obstruction of the left main trunk (LMT) of the coronary artery are diagnosed via autopsy following sudden death; survival is rare in this setting. We present the case of a 60-year-old woman who underwent stent placement in the LMT three years prior to developing chest pain and cold sweats. On coronary arteriography, the catheter could not be advanced into the LMT due to resistance in the ostium. Insertion of the catheter was achieved after the resolution of resistance via catheterization of the LMT by means of an intra-aortic balloon pump drive system. The LMT was normal, and the patient's circulatory failure improved. The cause of the LMT embolism was a cardiac papillary fibroelastoma. Primary surgical excision is the recommended therapy for symptomatic cardiac papillary fibroelastoma. If the patient is hemodynamically stable, it may be possible to delay surgery. However, the patient in question developed cardiogenic shock secondary to two-vessel obstruction by the tumor. Therefore, even if the tumor had been removed using an intra-aortic balloon pump, the patient may not have survived until surgery. .

Outcomes of Open Surgical Repair for Type B Dissecting Aortic Aneurysm With Alternative Methods in the Endovascular Stent Era.

We assessed the midterm outcomes of 2 types of open surgical repair for type B dissecting aortic aneurysm (BDA). During the last 4 years, 86 patients with BDA (mean age, 68.5 ± 9.8 years; range: 41-87 years) underwent open repair. The average duration between the dissection onset and surgery was 51.5 ± 31.3 months. If the BDA was of open type with patent false lumen or the aneurysm extended for a long segment, descending or thoracoabdominal aortic repair was performed with left thoracotomy. If the BDA was of the closed type with thrombosed false lumen and the aneurysm was located around the distal arch, open stent implantation was performed with our unique technique using circulatory arrest with a rectal temperature of 28 °C without any cerebral perfusion. Left thoracotomy was performed in 68 patients. The durations of aortic clamping and cardiopulmonary bypass were 65.2 ± 16.9 and 78.5 ± 34.6 minutes, respectively. Open stent implantation was performed in 18 patients. The durations of circulatory arrest and cardiopulmonary bypass were 19.1 ± 5.1 and 86.2 ± 17.8 minutes, respectively. In the present study, 4 patients (4.7%) required reexploration for bleeding and 1 patient (1.2%) had a stroke, but none suffered paraplegia. The hospital mortality rate was 1.2% (1 patient), resulting from retrograde type A dissection. The actuarial aortic event-free survival rate, including operative death, was 96.4% at 3 years. Both open surgical procedures for BDA were relatively safe, with favorable early and midterm outcomes, and may be superior for avoiding neurologic complications.

Incidence of drug interaction when using proton pump inhibitor and warfarin according to cytochrome P450 2C19 (CYP2C19) genotype in Japanese.

OBJECTIVES: The US Food and Drug Administration has suggested that proton pump inhibitors (PPIs) increase the international normalized ratio (INR) when used concomitantly with warfarin (WF) because of being metabolized by cytochrome P450 2C19 (CYP2C19). We assessed whether CYP2C19 genotypes and type of PPI accentuated the drug interaction. METHODS AND RESULTS: The study group was 82 patients who needed WF after surgery and had their CYP2C19 genotypes analyzed in advance. We randomly divided them into two groups: group I (n = 41) included patients who had lansoprazole 15 mg/day and group II (n = 41) included patients who had rabeprazole 10 mg/day. The dose of WF was controlled by the doctor in charge as a target INR of 1.6 to 2.6 during the 2 months after surgery. The maximum INR was significantly higher in group I (3.36 ± 0.98) than in group II (2.29 ± 0.55, p < 0.0001). The incidence of over-INR (> 3.5) was significantly higher in group I (15 cases) than in group II (2 cases, p = 0.0001). Several bleeding events complicated 10 patients in group I, but none in group II (p = 0.015). Logistic regression analysis revealed that over-INR (odds ratio [OR] 3.58, 95% confidence interval [CI]: 3.48-368.25, p < 0.0001), and pair of lansoprazole and CYP2C19 intermediate metabolizer (OR 2.39, 95% CI: 1.108-29.491, p = 0.0009) were independent predictors of bleeding events. CONCLUSION: If a patient has had the intermediate metabolizer CYP2C19 genotype and concomitant use of WF and a PPI after open heart surgery, lansoprazole intensifies the effects of WF and is associated with bleeding events.

RARGE II: an integrated phenotype database of Arabidopsis mutant traits using a controlled vocabulary.

Arabidopsis thaliana is one of the most popular experimental plants. However, only 40% of its genes have at least one experimental Gene Ontology (GO) annotation assigned. Systematic observation of mutant phenotypes is an important technique for elucidating gene functions. Indeed, several large-scale phenotypic analyses have been performed and have generated phenotypic data sets from many Arabidopsis mutant lines and overexpressing lines, which are freely available online. Since each Arabidopsis mutant line database uses individual phenotype expression, the differences in the structured term sets used by each database make it difficult to compare data sets and make it impossible to search across databases. Therefore, we obtained publicly available information for a total of 66,209 Arabidopsis mutant lines, including loss-of-function (RATM and TARAPPER) and gain-of-function (AtFOX and OsFOX) lines, and integrated the phenotype data by mapping the descriptions onto Plant Ontology (PO) and Phenotypic Quality Ontology (PATO) terms. This approach made it possible to manage the four different phenotype databases as one large data set. Here, we report a publicly accessible web-based database, the RIKEN Arabidopsis Genome Encyclopedia II (RARGE II; http://rarge-v2.psc.riken.jp/), in which all of the data described in this study are included. Using the database, we demonstrated consistency (in terms of protein function) with a previous study and identified the presumed function of an unknown gene. We provide examples of AT1G21600, which is a subunit in the plastid-encoded RNA polymerase complex, and AT5G56980, which is related to the jasmonic acid signaling pathway.

Case of sudden death from retrograde type A dissection two days after surgery for a type B dissecting aneurysm.

A 64-year-old man underwent a descending aortic replacement for a chronic type B dissecting aneurysm with left thoracotomy. The patient was weaned from the mechanical ventilator immediately after surgery without any neurological complications. However, on the second post-operative day, he suddenly suffered from cardiopulmonary arrest when talking with his family. Despite 6 hours of cardiopulmonary resuscitation, the patient died. The postmortem examination revealed a 1000 mL blood volume and huge hematoma in the pericardium owing to a retrograde type A dissection, which descended from an intimal laceration between the common carotid and left subclavian arteries that corresponded with aortic cross clamping. We here report a rare case of iatrogenic retrograde type A dissection caused by surgical clamping on the aortic arch 2 days post-surgery.

Screening and management for ischemic heart disease in patients undergoing emergency surgery for a type A acute aortic dissection.

PURPOSE: We assessed the incidence of coronary artery disease (CAD) during hospitalization after emergency surgery for a type A acute aortic dissection. METHODS: A total of 123 patients underwent multi-slice computed tomography (MSCT) scans during an early stage after surgery. The patients were divided into two groups: group I consisted of 14 patients (11.4%) who had coronary artery stenosis of more than 75% on MSCT, and group II consisted of 109 patients (88.6%) who had no coronary lesions. RESULTS: The prevalence of diabetes, dyslipidemia and a smoking history was significantly higher in group I. Although the serum low-density lipoprotein cholesterol levels were similar, the high-density lipoprotein cholesterol (HDL) level was significantly lower in group I (36.4 ± 7.9 mg/dl) than in group II (49.6 ± 13.5 mg/dl, P = 0.0005). The maximum carotid intima-media thickness (IMT) was significantly thicker in group I (1.17 ± 0.37 mm) compared to group II (0.96 ± 0.33 mm, P = 0.0297). The logistic regression analysis detected that a carotid IMT over 1.1 mm (odds ratio 4.35, P = 0.0371) and HDL less than 40 mg/dl (odds ratio 3.90, P = 0.0482) were predictors for CAD. CONCLUSIONS: CAD screening should be recommended for patients with aortic dissection who have several atherosclerosis risk factors, even after emergency surgery.

Genome-wide discovery and information resource development of DNA polymorphisms in cassava.

Cassava (Manihot esculenta Crantz) is an important crop that provides food security and income generation in many tropical countries, and is known for its adaptability to various environmental conditions. Its draft genome sequence and many expressed sequence tags are now publicly available, allowing the development of cassava polymorphism information. Here, we describe the genome-wide discovery of cassava DNA polymorphisms. Using the alignment of predicted transcribed sequences from the cassava draft genome sequence and ESTs from GenBank, we discovered 10,546 single-nucleotide polymorphisms and 647 insertions and deletions. To facilitate molecular marker development for cassava, we designed 9,316 PCR primer pairs to amplify the genomic region around each DNA polymorphism. Of the discovered SNPs, 62.7% occurred in protein-coding regions. Disease-resistance genes were found to have a significantly higher ratio of nonsynonymous-to-synonymous substitutions. We identified 24 read-through (changes of a stop codon to a coding codon) and 38 premature stop (changes of a coding codon to a stop codon) single-nucleotide polymorphisms, and found that the 5 gene ontology terms in biological process were significantly different in genes with read-through single-nucleotide polymorphisms compared with all cassava genes. All data on the discovered DNA polymorphisms were organized into the Cassava Online Archive database, which is available at http://cassava.psc.riken.jp/.

PRIMe Update: innovative content for plant metabolomics and integration of gene expression and metabolite accumulation.

PRIMe (http://prime.psc.riken.jp/), the Platform for RIKEN Metabolomics, is a website that was designed and implemented to support research and analyses ranging from metabolomics to transcriptomics. To achieve functional genomics and annotation of unknown metabolites, we established the following PRIMe contents: MS2T, a library comprising >1 million entries of untargeted tandem mass spectrometry (MS/MS) data of plant metabolites; AtMetExpress LC-MS, a database of transcriptomics and metabolomics approaches in Arabidopsis developmental stages (AtMetExpress Development LC-MS) and a data set of the composition of secondary metabolites among 20 Arabidopsis ecotypes (AtMetExpress 20 ecotypes LC-MS); and ReSpect, hybrid reference MS/MS data resources (acquisitions and literature). PRIMeLink is a new web application that allows access to the innovative data resources of PRIMe. The MS2T library was generated from a set of MS/MS spectra acquired using the automatic data acquisition function of mass spectrometry. To increase the understanding of mechanisms driving variations in metabolic profiles among plant tissues, we further provided the AtMetExpress Development LC-MS database in PRIMe, facilitating the investigation of relationships between gene expression and metabolite accumulation. This information platform therefore provides an integrative analysis resource by linking Arabidopsis transcriptome and metabolome data. Moreover, we developed the ReSpect database, a plant-specific MS/MS data resource, which allows users to identify candidate structures from the suite of complex phytochemical structures. Finally, we integrated the three databases into PRIMeLink and established a walk-through link between transcriptome and metabolome information. PRIMeLink offers a bi-directional searchable function, from the gene and the metabolite perspective, to search for targets seamlessly and effectively.

UniVIO: a multiple omics database with hormonome and transcriptome data from rice.

Plant hormones play important roles as signaling molecules in the regulation of growth and development by controlling the expression of downstream genes. Since the hormone signaling system represents a complex network involving functional cross-talk through the mutual regulation of signaling and metabolism, a comprehensive and integrative analysis of plant hormone concentrations and gene expression is important for a deeper understanding of hormone actions. We have developed a database named Uniformed Viewer for Integrated Omics (UniVIO: http://univio.psc.riken.jp/), which displays hormone-metabolome (hormonome) and transcriptome data in a single formatted (uniformed) heat map. At the present time, hormonome and transcriptome data obtained from 14 organ parts of rice plants at the reproductive stage and seedling shoots of three gibberellin signaling mutants are included in the database. The hormone concentration and gene expression data can be searched by substance name, probe ID, gene locus ID or gene description. A correlation search function has been implemented to enable users to obtain information of correlated substance accumulation and gene expression. In the correlation search, calculation method, range of correlation coefficient and plant samples can be selected freely.

Does warfarin help prevent ischemic stroke in patients presenting with post coronary bypass paroxysmal atrial fibrillation?

PURPOSE: This study examines the efficacy of warfarin in preventing ischemic stroke due to paroxysmal atrial fibrillation (PAF) after coronary artery bypass grafting (CABG). METHODS: Postoperative PAF occurred in 151(33.5%) of 447 patients undergoing conventional CABG. The patients were divided into two groups: group I consisting of 93 patients administered two types of antiplatelet agents and group II consisting of 58 patients treated with a single antiplatelet agent and warfarin. We compared the two groups in terms of CHADS2 score, incidence of ischemic stroke, and independent risk for stroke associated with post-CABG PAF. RESULTS: The group I CHADS2 score (2.24 ±1.67) was significantly lower than the group II score (2.64 ± 1.22), p = 0.0452. However, 12 patients in group I (12.9%) suffered postoperative ischemic stroke, a rate significantly higher than that of group II (1 patient, 1.7%; p = 0.0173). Any recurrence of PAF or atrial fibrillation with bradycardia was assessed at the time of stroke onset. Logistic regression analysis showed that the absence of warfarin therapy constituted a risk factor for post-CABG stroke associated with PAF (Odds 13.04, p = 0.027). CONCLUSION: Warfarin therapy administered concomitantly with an antiplatelet agent dramatically reduced the incidence of ischemic stroke associated with postoperative PAF.

Early and midterm outcomes of quick proximal arch replacement with mild hypothermia and rapid rewarming for type A acute aortic dissection.

OBJECTIVE: We assessed the efficacy of our unique procedure with mild hypothermic circulatory arrest and rapid rewarming during emergency surgery for type A acute aortic dissection. METHODS: During the last 6 years, 91 patients with acute aortic dissection and an average age of 66.2 ± 14.1 years underwent our newly modified quick hemiarch replacement. Eighteen patients (19.8%) had independent predictors for surgical mortality, such as preoperative cardiopulmonary arrest or malperfusion of vital organs. During open distal anastomosis with a rectal temperature of 28°C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass circuit was warmed to 40°C, accompanied by warming of the patient's body using a heating mat. As soon as distal anastomosis was completed, rapid rewarming was initiated by 40°C blood perfusion. RESULTS: Circulatory arrest, cardiopulmonary bypass, and overall operation times were 19.1 ± 5.1, 86.2 ± 17.8, and 150.1 ± 25.2 minutes, respectively. Five patients (5.5%) required reexploration for bleeding, and 4 patients (4.4%) had strokes, but none had acute renal failure. The hospital mortality rate was 3.3% (3 patients), and the postoperative hospital stay was 10.6 ± 4.7 days. Five patients required replacement of the distal arch or descending aorta at a later stage. Eight patients died during follow-up. A postoperative midterm computed tomography scan revealed a closed distal arch in more than 80% of patients and partial abdominal open false lumen in 45% of patients. Echocardiograms showed mild aortic valve regurgitation in 8 patients. The freedom from reoperation rate at 5 years was 90.0%. Actuarial survival including operative death was 82.7% at 5 years. CONCLUSIONS: Our original technique is a safe and less-invasive procedure that enables a quicker surgery. The midterm outcome also was favorable.

The Chloroplast Function Database II: a comprehensive collection of homozygous mutants and their phenotypic/genotypic traits for nuclear-encoded chloroplast proteins.

The Chloroplast Function Database has so far offered phenotype information on mutants of the nuclear-encoded chloroplast proteins in Arabidopsis that pertains to >200 phenotypic data sets that were obtained from 1,722 transposon- or T-DNA-tagged lines. Here, we present the development of the second version of the database, which is named the Chloroplast Function Database II and was redesigned to increase the number of mutant characters and new user-friendly tools for data mining and integration. The upgraded database offers information on genome-wide mutant screens for any visible phenotype against 2,495 tagged lines to create a comprehensive homozygous mutant collection. The collection consists of 147 lines with seedling phenotypes and 185 lines for which we could not obtain homozygotes, as well as 1,740 homozygotes with wild-type phenotypes. Besides providing basic information about primer lists that were used for the PCR genotyping of T-DNA-tagged lines and explanations about the preparation of homozygous mutants and phenotype screening, the database includes access to a link between the gene locus and existing publicly available databases. This gives users access to a combined pool of data, enabling them to gain valuable insights into biological processes. In addition, high-resolution images of plastid morphologies of mutants with seedling-specific chloroplast defects as observed with transmission electron microscopy (TEM) are available in the current database. This database is used to compare the phenotypes of visually identifiable mutants with their plastid ultrastructures and to evaluate their potential significance from characteristic patterns of plastid morphology in vivo. Thus, the Chloroplast Function Database II is a useful and comprehensive information resource that can help researchers to connect individual Arabidopsis genes to plastid functions on the basis of phenotype analysis of our tagged mutant collection. It can be freely accessed at http://rarge.psc.riken.jp/chloroplast/.

Rapid aortic enlargement requiring surgery in patients with chronic type B aortic dissection.

We report the relationship between rapid aortic enlargement of chronic type B aortic dissection and sleep disorder due to anxiety after Tohoku disaster. Five patients underwent surgical procedures due to rapid aortic enlargement after the earthquake disaster. They reported that their morning blood pressure increased to approximately 190 mm Hg after the disaster. They were troubled with severe insomnia due to anxiety about the continuing aftershocks. In primary care for patients with mental stress after a big disaster, it is important to keep a careful monitoring of blood pressure besides assessment of anxiety and sleep.

RIKEN tandem mass spectral database (ReSpect) for phytochemicals: a plant-specific MS/MS-based data resource and database.

The fragment pattern analysis of tandem mass spectrometry (MS/MS) has long been used for the structural characterization of metabolites. The construction of a plant-specific MS/MS data resource and database will enable complex phytochemical structures to be narrowed down to candidate structures. Therefore, a web-based database of MS/MS data pertaining to phytochemicals was developed and named ReSpect (RIKEN tandem mass spectral database). Of the 3595 metabolites in ReSpect, 76% were derived from 163 literature reports, whereas the rest was obtained from authentic standards. As a main web application of ReSpect, a fragment search was established based on only the m/z values of query data and records. The confidence levels of the annotations were managed using the MS/MS fragmentation association rule, which is an algorithm for discovering common fragmentations in MS/MS data. Using this data resource and database, a case study was conducted for the annotation of untargeted MS/MS data that were selected after quantitative trait locus analysis of the accessions (Gifu and Miyakojima) of a model legume Lotus japonicus. In the case study, unknown metabolites were successfully narrowed down to putative structures in the website.

Concomitant aortic valve and ascending aorta replacement with moderate hypothermic circulatory arrest to treat an aortic bicuspid valve with post-stenotic dilatation.

We recommend concomitant surgery for aortic valve replacement (AVR) and ascending aortic replacement using moderate hypothermic circulatory arrest (CA) for post-stenotic dilatation complicated by an aortic bicuspid valve. Cardiopulmonary bypass (CPB) was established from the right atrium to the dilated ascending aorta. As soon as the rectal temperature decreased to 28 °C, CA was commenced and the open distal anastomosis of a polyester prosthesis, without any cerebral perfusion, was completed. AVR was then carried out during rapid re-warming with CPB using a side arm of the prosthesis. This procedure exhibited safe and satisfactory results. There are many benefits of carrying out the procedure in this way; it avoids the requirement for cannulation to a calcified aortic arch, provides a good operative field, for an easier distal anastomosis and suturing at the valve site, and reduces the risk of further dilatation or dissection of the residual ascending aorta in the later phase.