Interactive CardioVascular and Thoracic Surgery current issue

[Work in progress report - Valves] Transcranial Doppler and acoustic pressure fluctuations for the assessment of cavitation and thromboembolism in patients with mechanical heart valves

Rodriguez, R. A., Ruel, M., Labrosse, M., Mesana, T. — 2008-04-01

The formation and collapse of vapor-filled bubbles near a mechanical heart valve is called cavitation. Such microbubbles are suspected to have strong pro-coagulant effects. Therefore, cavitation may be a contributing factor to the pro-thrombotic effects of mechanical valves. Herein, we systematically review the available evidence linking cavitation and thrombosis. We also critically appraise the potential usefulness of transcranial Doppler and other new non-invasive diagnostic methods to study cavitation and cerebral embolism in mechanical valve patients. Experimental studies indicate that cavitation microbubbles cause platelet aggregation, complement-activation, fibrinolysis, release of tissue-factor, and endothelial damage. Administration of 100% oxygen to mechanical valve patients during transcranial Doppler examination can transiently decrease the counts of Doppler-detected cerebral microemboli compared with room air. This is associated with removal of most circulating gaseous emboli from cavitation. This method may therefore be applied to the study of cavitation and thromboembolism. Additionally, the analysis of high-frequency acoustic-pressure fluctuations detected from the implosion of cavitation bubbles is a promising method for assessment of cavitation in vivo; however, this requires further development. A better understanding of cavitation is important in order to adequately investigate its role in the overall pro-thrombotic effects in mechanical valve patients. Such studies may allow establishing guidelines for new valve designs.

[Work in progress report - Congenital] Propranolol: a new indication for an old drug in preventing postoperative junctional ectopic tachycardia after surgical repair of tetralogy of Fallot

Mahmoud, A.-B. S., Tantawy, A. E., Kouatli, A. A., Baslaim, G. M. — 2008-04-01

Junctional ectopic tachycardia (JET) is a major cause of postoperative morbidity after complete repair of tetralogy of Fallot (TOF). Propranolol is a known medication used in patients with TOF to prevent and control hypercyanotic spells. Despite this, there is little information regarding the relation between preoperative use of propranolol and the incidence of postoperative JET. The aim of this study was to examine the effect of preoperative use of propranolol on the incidence of postoperative JET after full surgical repair of TOF. A retrospective analysis of 109 patients in whom 57 patients received preoperative propranolol (propranolol group) was compared with 52 patients who did not receive propranolol preoperatively (control group). The incidence of postoperative JET was significantly higher in the control group (38%) than the propranolol group (21%) P=0.042. The propranolol group had significantly less mechanical ventilation time, less ICU stay and less total hospital stay than the control group (P<0.05). Our findings suggest that the preoperative use of propranolol may decrease the incidence of JET after full surgical repair of TOF. A prospective randomized study may help to elucidate the exact relationship between the preoperative use of propranolol and the incidence of postoperative JET.

[Work in progress report - Coronary] Pre-operative long saphenous vein mapping predicts vein anatomy and quality leading to improved post-operative leg morbidity

Luckraz, H., Lowe, J., Pugh, N., Azzu, A. A. — 2008-04-01

Long saphenous vein harvesting for coronary bypass surgery is associated with significant morbidity. Furthermore, vein quality is often variable sometimes requiring incisions in both legs. This prospective randomised control study assessed the usefulness of pre-operative long saphenous vein mapping in terms of conduit quality and location, incision lengths and post-operative morbidity. The long saphenous vein was assessed and mapped pre-operatively (n=31) by venous Doppler ultrasound or not (n=30). The size and anatomical distribution of the long saphenous vein was well predicted by the ultrasound study (correlation coefficient=0.87). Intra-operatively, the mean length of leg wound incision per vein graft performed was significantly less in the mapped group [16.8 (4.0) vs. 24.1 (10.4) cm, P=0.005]. This translated in a shorter operative time for vein harvesting per length of vein graft needed [36 (13) vs. 47 (17) min, P=0.04]. Post-operatively there was a tendency to less leg wound complications in the mapped group (P=0.08) and earlier hospital discharge (median length of stay 6.5 days vs. 8.0 days, P=0.05). Thus, long saphenous vein mapping pre-operatively predicted the size and anatomy of the vein appropriately. This led to a selective leg wound incision and reduced operative time with the benefit of reduced leg complication post-operatively.

[eComment] eComment: Long saphenous vein harvesting and recurrences

Hudorovic, N. — 2008-04-01

[Work in progress report - Congenital] Systemic venous segments interposition for pulmonary artery to aorta connection

Napoleone, C. P., Oppido, G., Angeli, E., Gargiulo, G. — 2008-04-01

Two patients with pulmonary atresia and ventricular septal defect underwent implantation of the diminutive pulmonary arteries on the ascending aorta by interposition of short segment of azygos and innominate veins. The very thin structure of the systemic veins' wall matched perfectly the fragile pulmonary arterial wall. The anastomosis were perfectly patent and no aneurism dilatation was evident after three and four months, respectively.

[eComment] eComment: The anastomosis between aorta and extension conduit of the pulmonary artery

Tireli, E., Ugurlucan, M., Banach, M. — 2008-04-01

[Work in progress report - Valves] Evaluation of biological aortic valve prostheses by dual source computer tomography and anatomic measurements for potential transapical valve-in-valve procedure

Grunenfelder, J., Plass, A., Alkadhi, H., Genoni, M. — 2008-04-01

Transapical aortic valve replacement has been introduced into clinical practice from which also patients with failing biological valves might profit: valve-in-valve procedure. The aim of the study was to determine the fate of biological valves in long-term follow-up (FU) and to evaluate topography and dimensions for transapical access via dual-source CT scan (DSCT). Fifty patients (mean age 76±13 years, range 38–87 years) underwent DSCT whereas the patients were followed for up to 13 years after porcine aortic valve replacement. Measurements of valve prosthesis and illustration of chest topography were done. Out of 46 evaluable patients, 34 showed no leaflet calcification and 12 minimally calcified. Seventeen valves (37%) showed no, 24 valves (52%) mild and 5 (11%) moderate-to-severe ring calcification. Three patients had moderate aortic stenosis, two patients showed mild insufficiency. The angle from the 4th ICS to apex to aortic valve annulus measured 80.3±11.1° compared to the angle from the 5th ICS which measured 101.6±7.2° (P<0.0001). Biological valves show good long-term results with minimal failure rate and limited calcification. Leaflet calcification might be problematic if unevenly distributed which can endanger the very close LCO. These measurements represent a prerequisite for preoperative planning and increase the awareness to detect potential procedural problems of the valve-in-valve concept.

[Institutional report - Arrhythmia] Medium-term outcome of different surgical methods to cure atrial fibrillation: is less worse?

2008-04-01

Different lesion sets and ablation techniques have been performed. We compared these outcomes in search of the best method. We performed a retrospective analysis of patients who have undergone AF surgery different from the maze III. The surgical lesion sets were pulmonary vein isolation (PVI) alone, left atrial maze (LAM) and bi-atrial maze (BAM) and were made with different ablation techniques. During surgery one patient died due to bleeding of a pulmonary vein. The number of patients in the PVI-, LAM-, BAM-groups was 12, 28 and 26, respectively, with freedom from AF at latest follow-up [22.0±15.6 (3.1–81.2) months] of 33%, 59% and 60%, respectively. Atrial flutter occurred less in the BAM-group (4%) than in the left-sided procedures (15.4%) (P=0.231). Multivariate analysis demonstrated a higher recurrence of AF for PVI alone (OR 4.42, CL 0.95–20.6, P=0.0583) and a lower recurrence for the ‘cut-and-sew’ technique (OR 0.13, CL 0.030–0.60, P=0.0084). Left- and bi-atrial maze procedures are equally effective in the suppression of AF, whereas omission of right-sided lesions results in a higher prevalence of atrial flutter. The ‘cut-and-sew’ technique is superior in terms of freedom from AF compared to bipolar and unipolar radiofrequency.

[eComment] eComment: Bilateral atrial appendage excision should be performed routinely in the surgical treatment of atrial fibrillation

Oumeiri, B. E., Astarci, P., Lacroix, V. — 2008-04-01

[Institutional report - Cardiopulmonary bypass] Delayed recovery of human leukocyte antigen-DR expression after cardiac surgery with early non-lethal postoperative complications: only an epiphenomenon?

Franke, A., Lante, W., Zoeller, L. G., Kurig, E., Weinhold, C., Markewitz, A. — 2008-04-01

HLA-DR expression on peripheral blood monocytes is reduced after cardiac surgery. Little is known about the reconstitution of HLA-DR expression on peripheral blood monocytes in patients suffering from early non-fatal perioperative complications. We conducted a prospective study to prove whether these complications adversely affect the recovery of HLA-DR expression. Before surgery (d0), on the first (d1), third (d3), fifth (5th) postoperative days, blood samples were collected from 90 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB). HLA-DR expression was analysed flow cytometrically. Eleven patients experienced postoperative complications [mechanical ventilation of 24–48 h (n=6); reinstitution of CPB (n=2) intraoperatively; laparotomy (n=1), re-thoracotomy (n=1), re-intubation (n=1) within the first 24 h after surgery]. All patients showed a reduced HLA-DR expression after surgery with nadirs at d1 and d3. Whereas the values increased from d3 to d5 in patients with an uneventful clinical course, HLA-DR expression remained suppressed in patients with complications. HLA-DR expression is reduced after cardiac surgery with CPB. A delayed recovery of HLA-DR expression is seen in patients with early perioperative complications. These non-fatal complications appear to represent a ‘second hit’ resulting in a prolonged deficiency of the innate immune system. This might predispose to further infectious and septic complications.

[Institutional report - Thoracic general] Is thoracoscopic surgery justified to treat pulmonary metastasis from colorectal cancer?

Nakajima, J., Murakawa, T., Fukami, T., Takamoto, S. — 2008-04-01

We retrospectively analyzed 143 consecutive patients undergoing pulmonary resection for metastasis from colorectal cancer, either through thoracotomy or thoracoscopy from 1987 to 2005. Patients with incomplete resection were excluded. Patients were divided into two groups, based on whether or not they underwent thoracoscopy (n=72) or open thoracotomy (n=71) at the first pulmonary metastasectomy. Two patients undergoing thoracoscopy died postoperatively (one from pulmonary thromboembolism and one from gastrointestinal bleeding). Factors influencing postoperative recurrence-free or overall survival were multiple pulmonary metastasis and history of liver metastasis by univariate analysis, and multiple pulmonary metastasis, hilar or mediastinal nodal metastasis, larger diameter of the pulmonary metastasis, and surgery by wedge resection by multivariate analysis. Five-year recurrence-free rates after the first pulmonary metastasectomy were 34.4% in thoracoscopy and 21.1% in thoracotomy, respectively (P=0.047). Overall 5-year survival rates were 49.3% in thoracoscopy and 39.5% in thoracotomy, respectively (not significant). We found no significant difference in the survival rates between the thoracotomy and thoracoscopy groups, even with elimination of the patients with multiple pulmonary metastases in both groups. We suggest that thoracoscopic surgery for pulmonary metastasectomy from colorectal cancer may be justified if the surgical treatment is indicated.

[Institutional report - Coronary] Early and mid-term results of off-pump coronary artery bypass grafting in patients with end stage renal disease: surgical outcomes after achievement of complete revascularization

Horai, T., Fukui, T., Tabata, M., Takanashi, S. — 2008-04-01

End stage renal disease is a risk factor for mortality after coronary artery bypass grafting. We conducted a retrospective review of 37 consecutive dialysis-dependent patients who underwent off-pump coronary artery bypass grafting between April 2001 and July 2004. Complete revascularization was successfully performed in all patients. The mean number of anastomoses was 3.7, and early graft patency was 98.8%. Thirty-day mortality was 2.7%. In-hospital mortality was 8.1%. At a mean follow-up of 26 months, there were six late deaths including one cardiac death, and five cardiac events. Actuarial survival rate at one and three years was 88.8% and 77.0%, respectively. Cardiac event free rate at one and three years was 85.9% and 72.6%, respectively. Multivariate analysis revealed that preoperative left ventricular ejection fraction (P=0.003) and smoking history (P=0.026) were significant predictors for mid-term mortality, and co-existing peripheral vascular disease was a significant predictor for cardiac events (P=0.033). Early and mid-term outcomes after off-pump coronary artery bypass grafting in patients with end stage renal disease have acceptable mortality rate with excellent early graft patency, while low ejection fraction and smoking history were significant risk factors for mid-term survival, and co-existing peripheral vascular disease was a significant predictor for cardiac events.

[Institutional report - Cardiac general] Cardiac surgery in type-1-myotonic muscular dystrophy (Steinert syndrome) associated to Barlow disease

2008-04-01

No data exist in the English-language literature about patients with Barlow disease associated to Steinert syndrome and little is known about the employment of hypothermic cardiopulmonary bypass (CPB) and hyperkalemic cardioplegia in these patients. We present our experience with six patients affected by myxomatous degeneration associated to Steinert disease undergoing complex mitral valve repair. In all patients we employed mild hypothermic CPB (31 °C) and myocardial protection was achieved, in the entire cohort, by the use of blood hyperkalemic cold cardioplegia. The postoperative course was uneventful in all patients and neither shivering nor generalized muscle contraction were observed. Furthermore, all patients have remained well on an outpatient basis. Hypothermic CPB and hyperkalemic cardioplegia can be safely employed in patients with Steinert syndrome requiring complex cardiac surgery. Further large studies are necessary to confirm our findings.

[Institutional report - Thoracic general] Single-staged laryngotracheal resection and reconstruction for benign strictures in adults

2008-04-01

Laryngotracheal stenosis (LTS) is a challenging problem, and its management is complex. This study evaluated both short- and long-term outcomes following laryngotracheal resection and anastomosis. Between 1994 and 2006, 37 patients underwent surgery for LTS. The cause of stenosis was post-intubation or post-tracheostomy injury in 28 cases and idiopathic in nine. Pearson's technique was used for anterolateral cricotracheal resection (n=23), and Grillo's technique of providing a posterior membranous tracheal flap was used in cases of circumferential stenosis (n=14). Since 1998, we have modified the techniques in 21 cases, using a continuous 4/0 polydioxanone suture for the posterior part of the anastomosis. No peri-operative mortality was recorded. Three (8.1%) patients developed major complications (two fistulae and one early stenosis) that required a second surgical look. We had 16 minor complications in 14 (37.8%) patients. The long-term results were excellent to satisfactory in 36 patients (97.3%) and unsatisfactory in one (2.7%). Single-staged laryngotracheal resection is a demanding operation, but can be performed successfully with acceptable morbidity in specialized centers. The continuous suture in the posterior part of the anastomosis simplifies the procedure without causing technique-related complications. In our experience, this procedure guaranteed excellent to satisfactory results in more than 90% of patients.

[Institutional report - Cardiac general] Secondary prevention following coronary artery bypass grafting has improved but remains sub-optimal: the need for targeted follow-up

2008-04-01

A focused review of secondary preventive medication following revascularisation provides an opportunity to ensure optimal use of these agents. A retrospective analysis of our in-house cardiothoracic surgical database was performed to identify patients undergoing non-emergency, elective surgical revascularisation discharged on four secondary preventive medications: aspirin; beta-blockers; ACE-inhibitors and statins. Of 2749 patients studied, 2302 underwent isolated coronary artery bypass grafting (CABG), mean age 65.5 years (S.D. 9.15). Overall, 2536 (92%) patients were prescribed aspirin. Beta-blockers were prescribed in 2171 (79%) patients overall, in 1096/1360 (81%) of patients with a history of myocardial infarction and in 465/619 (75%) of patients with left ventricular systolic dysfunction (LVSD). Overall, 1518 (55%) patients were prescribed an ACE-inhibitor and 179 (6.5%) an angiotensin receptor blocker (ARB); one of these agents was prescribed in 446/619 (72%) patients with LVSD and 915/1360 (67%) patients with a history of previous myocardial infarction. Overall, 2518 (92%) patients were prescribed a statin. Secondary preventive therapies are prescribed more commonly on discharge after CABG than in previous studies, but there is a continuing under-utilisation of ACE-inhibitors. To maximise the potential benefits of these agents, further study is required to understand why they are not prescribed.

[Institutional report - Vascular general] The influence of levosimendan and iloprost on renal ischemia-reperfusion: an experimental study

2008-04-01

The effects of iloprost on ischemia–reperfusion injury have been studied on the skeletal, muscle, liver, myocardium, kidney, and spinal cord. However, no sufficient data exist about effects of levosimendan on renal ischemia–reperfusion injury. The purpose of this experimental study was to investigate and compare effectiveness of levosimendan and iloprost on renal injury induced by ischemia and reperfusion. Fifty rabbits were divided into five groups. Levosimendan was continuously infused starting half an hour before the cross-clamp. Cross-clamp time was one hour. After one hour ischemia, levosimendan was continued for 4 h in Group A whereas Group B took iloprost in the same protocol. Group C was the control group which did not receive any medication. Group D was sham group and Group E was medicated both iloprost and levosimendan. Renal tissues were histologically and biochemically evaluated. The histological scores were obtained according to presence of tubuler necrosis and atrophy, regenerative atypia, hydropic degeneration (Group A vs. Group C<0.001, Group B vs. Group C<0.001, Group D vs. Group C<0.01, Group E vs. Group C<0.001). Mean malondialdehyde levels were 114±12 nmol/g tissue; in Group A 121±13 nmol/g tissue, in Group B 134±13 nmol/g tissue, in Group E 130±11 nmol/g tissue, in Group D 134±11 nmol/g tissue (Group A vs. Group B; P=0.003, Group B vs. Group D; P=0.132, Group A vs. Group E; P=0.132). Malondialdehyde levels and histologic scores of all of the groups were significantly different from the control group. Iloprost and pentoxyfillin reduced renal ischemia–reperfusion injury in rabbit model. There was no significant difference between these two medications.

[Institutional report - Thoracic general] Systemic mediastinal lymph node dissection of right lung cancer: surgical quality control and analysis of mediastinal lymph node metastatic patterns

Wu, N., Lv, C., Yan, S., Duan, H., Zheng, Q., Wang, J., Xiong, H., Yang, Y. — 2008-04-01

Standardization of systemic mediastinal lymph node dissection (SMLD) of lung cancer requires further investigation. A consecutive 124 right lung cancer patients were recruited for pulmonary resection plus SMLD. Three mediastinal lymph node compartments, (i) the upper compartment (station 1–4), (ii) the middle compartment (station 7–8) and (iii) the lower compartment (station 9), were en bloc collected to achieve surgical quality control and to analyze mediastinal lymph node metastatic patterns. The number of total harvested lymph nodes, N1 nodes and N2 nodes were 21.9±8.7, 9.2±4.7 and 12.8±6.7, respectively. Tumor location (peripheral or central) (P=0.023) and status of blood vessel invasion (P=0.002) were identified as risk factors for nodal involvement. Right upper lobe (RUL) cancer with N2 disease primarily metastasized to the upper compartment (27.3%) (P=0.001). For right lower lobe (RLL) cancer, lymph node metastasis most commonly detected in the middle compartment (48.8%) (P=0.001). Single mediastinal compartment metastasis occurred in 64.7% (11/17) of adenocarcinomas from RUL and RML, whereas multiple compartments metastasis occurred in all adenocarcinoma cases (12/12) from RLL (P=0.001). SMLD needs to standardize the extent of lymphadenectomy and number of removed lymph nodes for surgical quality control. Simplifying mediastinal lymph node stations to three compartments may benefit surgical excision.

[Institutional report - Vascular thoracic] A study of aortic dimension in type B aortic dissection

2008-04-01

Difference between arch diameter and true lumen diameter in the descending aorta was studied in patients with type B aortic dissection. The diameters of the aortic arch (Proximal ) and mid-descending aorta (Distal ) were measured on computer tomography angiography (CTA) in 20 healthy adults. Forty-two patients with type B aortic dissection who underwent endovascular repair were divided into two groups: an acute group (23 patients) and a chronic group (19 patients). The diameters of the arch (Proximal ) and the true lumen of the mid-descending aorta (Distal ) were measured on digital subtraction angiography (DSA) and CTA. The taper ratio was defined as (Proximal –Distal )/(Proximal )x100%. In the control group, the taper ratio was 13.0±4.7% on CTA. In the acute patients group, the taper ratio was 23.6±11.3% on DSA and 21.9±12.1% on CTA. In the chronic patients group, the taper ratio was 31.5±13.6% on DSA and 30.1±11.4% on CTA. In both acute and chronic type B aortic dissection, the aorta tapers significantly from arch to true lumen in the descending aorta. Stent-graft with tapered design may be a viable treatment option for endovascular repair of type B aortic dissection.

[ESCVS article - Experimental] Neoangiogenesis after combined transplantation of skeletal myoblasts and angiopoietic progenitors leads to increased cell engraftment and lower apoptosis rates in ischemic heart failure

2008-04-01

Objectives: We previously reported that combined transplantation of skeletal myoblasts and AC-133+ cells leads to improved left ventricular function, reduced infarct size and myocardial apoptosis in a model of chronic ischemia. The aim of this study is to elucidate on the possible mechanisms and to assess new implications in increasing cell therapy efficacy in chronic ischemia. Methods: Heart failure was induced by LAD-ligation in nude rats. (a) Homologous skeletal myoblasts (SM), (b) human derived AC-133+ cells (SC), (c) combination of both cells (Comb) and (d) culture medium (CM) were injected in the infarct and peri-infarct area, respectively, four weeks after infarction. Cell engraftment was detected by fluorescence microscopy and confirmed by immunohistochemical techniques. Cardiac gene expression levels of VEFG-A, cardiac troponin, ACTA2, SDF-1, TGF-beta-1, were assessed by RT-PCR. Results: Both cell types were detected in the injection areas four weeks after cell transplantation. Double cell therapy led to increased cell engraftment (SM: 52±13/mm², SC: 45±8 in the combination group vs. SM: 31±9 and 23±7 in the monotherapy groups, P=0.007). This effect was confirmed using PCR. Apoptotic index among engrafted cells was significantly lower in the Comb group (Comb: 0.53±0.12 for myoblasts and 0.34±0.09 for SC, vs. SM: 0.76±0.19 and SC: 0.63±0.16, P=0.013). Expression of cardiac troponin was higher in the combination group in the peri-infarct area. Evaluation of capillary density revealed increased angiogenesis in the combination group (Comb: 12.3±2.3, SM: 5.2±1.2, SC: 8.3±1.8, P=0.002). Neoangiogenesis was associated with higher levels of VEGF-A and TGF-beta in the injection areas as detected by RT-PCR. The higher SDF-1 expression in the injected areas implies an increased secretion of chemoattractants by the injected cells, which suggests that the effect of combined cell transplantation is mainly associated with paracrine mechanisms. Conclusions: The mechanism of functional improvement after combined transplantation of skeletal myoblasts and AC-133+ progenitors in ischemic heart failure is mainly associated with increased angiogenesis based on paracrine factors, which leads to improved survival and lower apoptosis rates of the injected cells.

[ESCVS article - Cardiac general] Surgical treatment of postinfarction anterior left ventricular aneurysms: linear vs. patch plasty repair

Mukaddirov, M., Frapier, J.-M., Demaria, R. G., Albat, B. — 2008-04-01

Background: The patch plasty repair is increasingly advocated over linear closure in the surgical treatment of postinfarction anterior left ventricular aneurysm (LVA). A comparative estimate of the clinical results of these two techniques seemed in order. Methods: Between 1985 and 2004, 53 patients (mean age of 64.2±8.3 years) underwent repair of anterior LVA. Twenty-seven patients underwent linear repair (group 1) and 26 patients patch plasty (group 2). The mean left ventricular ejection fraction was 33.9±8.2% in group 1 vs. 29.7±10.2% in group 2 (P=0.118). Preoperatively 85.2% of patients in group 1 were in NYHA functional class III or IV vs. 88.5% in group 2 (P=0.71). All patients had preoperative recurrent ventricular tachycardia (VT) and non-guided encircling cryoablation for treatment of VT was performed in all patients. Coronary revascularization was performed in 29.6% of patients in group 1 and 42.3% in group 2 (P=0.398). Results: The overall in-hospital mortality was 1.9% as one patient died of low cardiac output (LCO). LCO was the most frequent early postoperative complication and was observed in 66.7% of patients in group 1 vs. 65.4% in group 2 (P=1.000). LCO was related to right coronary artery disease on multivariate analysis (odds ratio 6.9, P=0.0097). Mean follow-up was 6.4±4.8 years (range 1 day–17.5 years). Overall survival at 10 years was 65.5% of patients in group 1 vs. 60.6% in group 2 (P=0.395). At 10 years, 91.5% of patients were free from VT or sudden death in group 1 vs. 81% in group 2 (P=0.269). At follow-up the patients' functional status improved and among survivors 76.9% in group 1 were in NYHA functional class I–II vs. 62.5% in group 2 (P=0.432). Deaths from congestive heart failure (CHF) occurred in 38.5% of patients in group 1 vs. 55.6% in group 2 (P=0.632). On multivariate analysis a preoperative left ventricular end-diastolic pressure above 20 mmHg was a predictor of mortality from CHF (odds ratio 9.6, P=0.038). Conclusions: Our study did not reveal significant differences between linear closure and patch plasty repair in the short- and long-term. The choice of repair technique should be adapted to each patient's anatomical and physiological characteristics.

[ESCVS article - Experimental] Changes in cerebrospinal fluid and blood lactate concentrations after stent-graft implantation at critical aortic segment: a preliminary study,

2008-04-01

Objectives: Obstruction of blood flow through the arteria radicularis magna (ARM) has been linked with ischemic spinal cord injury after conventional thoracic aortic repair. Whether or not endoluminal stent-grafts, deliberately positioned against this artery can cause similar damage to the spinal cord has not been comprehensively investigated. The purpose of this study was to assess the blood and cerebrospinal fluid (CSF) concentrations of lactate – a well-known biochemical marker of ischemic neurological injury, before and after stent-graft implantation against the ARM. Materials and methods: Endoluminal stent-grafting was performed in ten mongrel dogs. In five animals (experimental group), stent-grafts covered the fourth and fifth lumbar segmental arteries – which have been described as the canine equivalents to the ARM in humans. In the remaining five animals (control group), devices of similar length were placed in the lower thoracic aorta. CSF was obtained by cisternal puncture technique at the following time points; before stent-grafting, and 15, 30 and 60 min after stent-grafting. Parallel arterial blood samples were also obtained using a heparinized syringe. All samples were centrifuged and the supernatant analysed for lactate. Results: The mean preprocedural lactate concentration in the CSF was 1.7±0.3 mmol/l. Mean postprocedural levels in the experimental group at 15, 30 and 60 min were 3.1±1.9, 3.9±1.1 and 11.9±2.5 mmol/l, respectively (control values; 2.1±1.9, 2.7±1.1 and 1.9±1.5 mmol/l, respectively). Mean preprocedural blood lactate level was 1.8±0.6 mmol/l, while the mean postprocedural concentrations in the experimental group at 15, 30 and 60 min were 2.9±1.2, 3.4±1.7 and 3.9±2.0 mmol/l, respectively. Two out of the five animals in the experimental group suffered mild to moderate hind limb weakness. Conclusion: Selective placement of stent-grafts against the ARM in dogs resulted in a conspicuous increase in CSF and blood lactate concentrations 60 min after the procedure with or without physical signs of neurological deficits. Although the small sample size of this preliminary study does not allow any definitive conclusion, it may be worthwhile to confirm the findings in appropriately controlled larger studies.

[Proposal for bail-out procedures - Thoracic general] Tuberculous tracheobronchial stricture causing post-pneumonectomy-like syndrome corrected by insertion of a bespoke Dumon stent

King, J. E., Lau, R. W.T., Wan, I. Y.P., Yim, A. P.C. — 2008-04-01

Post-pneumonectomy syndrome is a well-recognised but uncommon late complication of pneumonectomy. Usually occurring after right-sided surgery, the mediastinal contents are rotated and displaced into the right hemithorax, producing airways or oesophageal compression. We report a case in which the radiological features and symptoms of post-pneumonectomy syndrome appeared to be precipitated by the development of a complex tuberculous tracheobronchial stenosis that resolved after the insertion of a bespoke Dumon stent.

[Proposal for bail-out procedures - Vascular thoracic] Use of the right brachio-femoral wire approach to manage a thoracic aortic aneurysm in an extremely angulated and tortuous aorta with an endoluminal stent graft

Kpodonu, J., Rodriguez-Lopez, J. A., Ramaiah, V. G., Diethrich, E. B. — 2008-04-01

The presence of a tortuous, elongated thoracic aorta and an angulated arch poses a technical challenge for the delivery of an endoluminal graft to the target site to exclude management of a thoracic aortic aneurysm. Despite the availability of a flexible delivery sheath system, adjunct techniques are necessary to deal with extremely tortuous thoracic aortas. The use of a brachio-femoral wire with tension applied at both ends is a useful technique to deliver an endoluminal graft in an angulated thoracic arch. We describe the use of a right brachio-femoral wire approach to treat a thoracic aortic aneurysm in a 75-year-old man with an elongated, tortuous and angulated arch aorta.

[Proposal for bail-out procedures - Cardiac general] Novel adjunct to surgery for end-stage cardiomyopathy receiving hemodialysis

Toda, K., Taniguchi, K., Matsue, H., Yoshida, K. — 2008-04-01

Surgical management of heart failure patients receiving hemodialysis (HD) is a challenge to surgeons and reports are limited. Five patients receiving HD underwent a mitral annuloplasty with or without restoration of the left ventricle because of class III or IV heart failure due to mitral regurgitation and poor ventricular functions. Of those, three fully recovered to NYHA class I after the cardiac procedure, however, two patients remained symptomatic and required an adjunctive procedure. For that, we converted the arteriovenous dialysis shunt to an inter-arterial bypass by dividing the venous side of the shunt and anastomosing it to the proximal radial artery (RA), followed by ligation of the RA between the two anastomoses so that the RA was bypassed by the cephalic vein. Following this procedure, left ventricular end-diastolic pressure and volume were reduced, and heart failure symptoms diminished. This simple procedure was able to reduce the cardiac overload, while keeping the vascular access intact and may be a relevant adjunct to surgical reverse remodeling in end-stage heart failure patients receiving HD.

[Proposal for bail-out procedures - Cardiac general] Entirely polytetrafluoroethylene coating for pacemaker system contact dermatitis

Tamenishi, A., Usui, A., Oshima, H., Ueda, Y. — 2008-04-01

A 63-year-old man underwent pacemaker implantation for complete atrio-ventricular block. The patient repeated admissions for skin necrosis, and generator or pacemaker system was re-implanted each time. The patient was admitted with skin necrosis of the generator pocket three years after re-implantation. A skin patch test was positive on almost all components of the pacemaker system. The patient underwent pacemaker system removal and re-implantation of polytetrafluoroethylene (PTFE) sheets coating pericardium leads and generator. There has been no recurrence. PTFE sheet coating is effective to treat pacemaker system contact dermatitis.

[eComment] eComment: Foreign body reaction to polytetrafluoroethylene

Ozeren, M. — 2008-04-01

[Proposal for bail-out procedures - Congenital] Fontan operation through a right lateral thoracotomy to treat Cantrell syndrome with severe ectopia cordis

Okamoto, Y., Harada, Y., Uchita, S. — 2008-04-01

A median sternotomy would be very difficult for Cantrell syndrome with severe ectopia cordis. For Cantrell syndrome and tricuspid atresia after left modified Blalock-Taussig shunt with severe ectopia cordis, defect in the middle and inferior portion of the sternum, and the closing of ventriculo-peritoneal shunt, we performed extracardiac total cavopulmonary connection through a right lateral thoracotomy after establishing right modified Blalock-Taussig shunt and performing coil embolization of left modified Blalock-Taussig shunt by cardiologists.

[Negative results - Cardiac general] Bronchopericardial fistula, an unusual complication of oxytetracycline sclerosis therapy

Grbolar, A., Qaradaghi, L., Imren, Y., Tasoglu, I., Coskun, E., Avci, T. — 2008-04-01

Here we report a rare case of bronchopericardial fistula following intrapericardial instillation of oxytetracycline. A 63-year-old female patient was admitted for management of malignant pericardial effusion secondary to right-sided bronchogenic carcinoma. Medical therapy and recurrent percutaneous catheter drainage failed in resolving the problem, so subxiphoid pericardiostomy and drainage tube insertion was performed. There was no decrease in the drainage so we decided to perform pericardial sclerosis by intrapericardial tetracycline instillation. After the second time oxytetracycline instillation, the patient developed respiratory arrest with hemodynamic instability. A huge amount of yellow frothy secretion aspirated through the endotracheal tube. The presence of tetracycline in the bronchial secretion was proved by microbiological methods. The hemodynamic status of the patient deteriorated rapidly and despite all resuscitation measures we lost the patient within a few hours.

[Negative results - Congenital] Hybrid palliation for right atrial isomerism associated with obstructive total anomalous pulmonary venous drainage

Jhang, W.-K., Chang, Y.-J., Park, C.-S., Oh, Y.-M., Kim, Y.-H., Yun, T.-J. — 2008-04-01

A twenty-four-day-old girl, who was prematurely born at 36 weeks of gestation, and weighed 2.2 kg, and diagnosed with right atrial isomerism, functionally single ventricle, bilateral superior vena cava (SVC) and obstructive supracardiac total anomalous pulmonary venous drainage (TAPVD) draining to the junction between the right SVC and the right atrium, underwent a hybrid procedure in the operating room, which consisted of pulmonary artery banding, ductus ligation and stenting of the draining vein of TAPVD. Obstruction at the drainage site of TAPVD was initially relieved after stenting, but, one month after the procedure, the distal end of the stent became stenotic and she received bilateral sutureless repair of TAPVD. At postoperative seven months, she underwent bidirectional cavopulmonary shunt uneventfully, and she has been followed-up for two months in a stable state without any problem in the pulmonary venous pathway.

[Negative results - Aortic and aneurysmal] Preoperative hepatic insufficiency and type III endoleak: a confirmed potential fatal association following endovascular treatment

Pesteil, F., Labrousse, L., Chevreuil, C., Laskar, M. — 2008-04-01

Consumptive coagulopathy is known to occur in patients with aneurysm, especially in the thoracic localization. Compared to open chest surgery, the endovascular treatment leaves in place a large thrombosed aneurysmal sac, which might induce and/or exacerbate the coagulopathy. Although exceptional, some recent reports have raised the potential disastrous issue related to this complication. We report the case of a 74-year-old patient treated for an asymptomatic thoracic aorta aneurysm by endoprosthesis who developed a fatal disseminated intravascular coagulopathy. This complication has been related to a type III endoleak associated with a preoperative hepatic insufficiency.

[Negative results - Vascular thoracic] Acute intraoperative aortic dissection following axillary artery cannulation

Rokkas, C. K., Angouras, D., Chamogeorgakis, T., Anagnostopoulos, C. E. — 2008-04-01

We describe a 75-year-old woman who underwent right axillary artery cannulation in preparation for reconstruction of the aortic arch and the proximal descending aorta for athesosclerotic aortic aneurysm via a ‘clamshell’ incision. As soon as cardiopulmonary bypass was established, the ascending aorta and the aortic arch was dissected. The innominate artery was dissected including one-third of its circumferance anteriorly. Arterial perfusion was stopped immediately and the left femoral artery was cannulated to resume CPB. We proceeded with replacement of the ascending aorta, the aortic arch and the proximal descending thoracic aorta with a Dacron branched aortic graft. The patient recovered uneventfully. Arterial blood pressure was equal bilaterally.

[eComment] eComment: TEE- and guidewire-guided axillary artery cannulation. An option?

Demertzis, S. — 2008-04-01

[Negative results - Thoracic general] Spontaneous rupture of a normal spleen following bronchoplastic left lung lower lobectomy

Stupnik, T., Vidmar, S., Hari, P. — 2008-04-01

Rupture of the spleen is a common event associated with trauma, infectious diseases, neoplasia and many systemic disorders affecting the reticuloendothelial system. A rare subtype of rupture occurring spontaneously and arising from a normal spleen was recognized as a distinct clinicopathologic entity. It has been reported in association with trivial insults such as vomiting and coughing. We report a case of a patient with spontaneous rupture of a normal spleen observed after severe coughing on the 3rd postoperative day following bronchoplastic left lung lower lobectomy combined with S4, S5 segmentectomy.

[Follow-up papers - Pulmonary] Do the benefits of shorter hospital stay associated with the use of fleece-bound sealing outweigh the cost of the materials?

Anegg, U., Rychlik, R., Smolle-Juttner, F. — 2008-04-01

Objective: To compare the cost of materials and hospitalization for standard techniques (suturing, stapling and electrocautery) for sealing the lung after pulmonary resection with those for a fleece-bound sealing procedure. Methods: This cost comparison analysis uses as its basis a prospective randomised clinical trial involving 152 patients with pulmonary lobectomy/segmentectomy (standard technique group: 77 patients; fleece-bound sealing group: 75 patients). The cost comparison was performed from the economic perspective of Austrian and German hospitals, taking into consideration the cost of materials for the two alternatives as well as the mean time to hospital discharge. Results: The clinical study found significantly smaller postoperative air leaks in the fleece-bound sealing group. The mean times to chest drain removal and to hospital discharge were also significantly reduced after application of fleece-bound sealing [5.1 vs. 6.3 days (P=0.022) and 6.2 vs. 7.7 days (P=0.01), respectively]. The cost of materials for sealing air leaks amounted to 47 per patient in the standard technique group and 410 per patient in the fleece-bound sealing group. The 1.5-day reduction in the length of hospital stay associated with fleece-bound sealing represents a saving of 462 per patient. Conclusions: There was an overall saving of 99 for the fleece-bound sealing procedure compared to standard techniques for sealing the lung following pulmonary resection.

[Best evidence topic - Thoracic general] Is incentive spirometry effective following thoracic surgery?

Agostini, P., Calvert, R., Subramanian, H., Naidu, B. — 2008-04-01

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether incentive spirometry is a useful intervention for patients after thoracic surgery. Altogether 255 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that incentive spirometry is a relatively good measure of lung function and may be used to assess respiratory recovery in the days after thoracic surgery. Physiotherapy either with or without incentive spirometry reduces the incidence of postoperative complications and improves lung function but there is currently no evidence that incentive spirometry in itself could either replace or significantly augment the work of the physiotherapists. Clinicians should be aware that while incentive spirometry can provide an assessment of lung recovery, well-organised and regular physiotherapy remains the most effective mechanism to augment their patient's recovery and avoid postoperative complications.

[Best evidence topic - Valves] Is it ever worth contemplating an aortic valve replacement on patients with low gradient severe aortic stenosis but poor left ventricular function with no contractile reserve?

Subramanian, H., Kunadian, B., Dunning, J. — 2008-04-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is worth performing aortic valve replacement in patients with severe aortic stenosis and poor left ventricular function but no contractile reserve on dobutamine stress testing. Altogether 251 papers were identified using the below mentioned search and all major international guidelines were included. Fourteen presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that patients with severe aortic stenosis and a contractile reserve of <20% improvement in stroke volume on dobutamine stress testing have a very poor prognosis of only 10–20% at two years. Heart transplant would offer the best chance of survival to those eligible but for those not eligible, a surgical option should not be discounted for selected patients. The American Heart Association guidelines state that prognosis is very poor for either medical or surgical treatment, but the European Society of Cardiology guidelines state that surgery can be performed in these patients but should take into account the clinical condition of the patient. The operative mortality is around 30% and the French Multicentre study on low gradient aortic stenosis has shown that if the patient survives there is likely to be an improvement in symptoms and ejection fraction. Thus, absence of contractile reserve on stress testing does not exclude myocardial recovery after surgery, although it is a strong predictor for operative mortality. It should be noted that surgery has only been reported in very few of these patients to date. B-natriuretic peptide has also been suggested as a further marker of better prognosis in these high-risk patients in one small study.

[Best evidence topic - Coronary] For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass grafting the better option?

Malvindi, P. G., Dunning, J., Vitale, N. — 2008-04-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The topic addressed was to identify the patients with left main stem disease for which percutaneous intervention would be a better option than coronary artery bypass grafting. Altogether 665 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. We conclude that if a bare metal stent is used for left main stenting the mortality at one year may be from 3% to over 28% in reported series. The restenosis rate of the bare metal stent in the left main position is around 20% at one year. There are some early series and randomized studies of drug eluting stents for left main stem lesions and the restenosis rate is reported to be around 10%. The European Society of Cardiology in their 2005 percutaneous intervention guidelines state that coronary bypass grafting is the procedure of choice for left main stem disease and only patients with a prohibitively high surgical risk should be considered. We consider that with such high restenosis rates, and with short-term follow-up in such low numbers and short periods compared to coronary artery bypass grafting, left main stenting should only be used as a last resort in patients turned down for coronary artery bypass grafting after full assessment by a cardiac surgeon due to prohibitive co-morbidities.

[Brief communication - Cardiac general] Simultaneous multi-vessel coronary artery bypass grafting, ischemic mitral regurgitation repair and descending aortic aneurysm replacement: analysis of technical points

Malyshev, M., Safuanov, A., Borovikov, D., Malyshev, A. — 2008-04-01

The combination of coronary artery disease and its complications (ischemic mitral regurgitation etc.) with the aneurysm of the descending thoracic aorta is not a rare case. The single-stage correction of coronary/intracardiac/aortic lesions may be considered as a way of managing the combined patients. Simultaneous multi-vessel coronary artery bypass grafting, suture mitral annuloplasty and descending aortic aneurysm replacement with synthetic prosthesis is described. The operation was performed through the left thoracotomy with cardiopulmonary bypass established by the cannulation of the ascending aorta and of the right atrial appendage. Ventricular fibrillation and no clamping of the ascending aorta were used. The circulatory arrest was induced for the construction of the proximal anastomosis between the descending aorta and the synthetic prosthesis. No complications related to the operation were diagnosed for the 14-month follow-up. Several technical points seem optimal for the combined procedure: (1) Minimization of manipulations on the ascending aorta (using of pedicled left internal thoracic artery; construction of the proximal anastomoses with synthetic aortic prosthesis; unclamped ascending aorta). (2) Revascularization of all coronary areas and correction of intracardiac lesions through the left thoracotomy. Individual planning of the procedural technical points for every patient may provide a safe feasibility of the combined procedure.

[Brief communication - Vascular thoracic] Perforation of the ascending aorta with a hematoma extending into the left-side upper extrapleural cavity

Kadohama, T., Akasaka, N., Goh, K., Sasajima, T. — 2008-04-01

We herein present an extremely rare case of a perforation of the ascending aorta with a hematoma extending into the left-side upper extrapleural cavity. A 62-year-old male with a sudden onset of severe chest pain was referred to our institution because of an abnormal shadow in the left-side upper lung field. Computed tomography revealed a small fusiform aortic arch aneurysm and a hematoma extending to the left-side upper extrapleural cavity. We diagnosed the patient to have acute aortic syndrome and urgent surgery was thus performed. Major bleeding which might be caused by a progression of the perforation was seen during a dissection of the aorta. The aortic arch was transected and a total arch replacement was performed with a 26 mm Dacron graft. No findings of a rupture of the aortic arch aneurysm or dissection were observed. The histopathology of the aorta revealed a severe atheromatous lesion with calcification and thinning disarrayed elastic fibers. The postoperative course was essentially good except for the development of pericardial effusion which required drainage.

[Brief Communication - Cardiac general] Resection of left ventricular papillary fibroelastoma through thoracoscopic-assisted minithoracotomy

Je, H. G., Kim, Y. S., Jung, S.-H., Lee, J. W. — 2008-04-01

Although a mobile papillary fibroelastoma in the left ventricle should be excised to prevent systemic embolism, difficulties in surgical exposure of a left ventricular mass are not uncommon. Herein, we report a minimally invasive approach for resecting left ventricular papillary fibroelastoma using thoracoscopic assistance.

[Case report - Vascular thoracic] Successful one-stage operation of aortoesophageal fistula from thoracic aneurysm using a rifampicin-soaked synthetic graft

Inoue, T., Nishino, T., Peng, Y.-F., Saga, T. — 2008-04-01

Aortoesophageal fistula secondary to thoracic aneurysm is rare, but is usually lethal, and few survivors have been reported. We report successful surgery for aortoesophageal fistula in a one-stage operation. Repair involved in situ replacement of the thoracic aneurysm using a rifampicin-soaked graft, primary repair of the esophagus, omental wrap and tube jejunostomy. This is the original report of the surgical repair of aortoesophageal fistula using a rifampicin-soaked graft.

[Case report - Cardiac general] Papillary muscle sling and overlapping cardiac volume reduction with aortic valve replacement for valvular cardiomyopathy

Yamamoto, K., Ito, H., Hiraiwa, T. — 2008-04-01

A 63-year-old male was admitted to our hospital because of severe aortic regurgitation. The left ventricle was extremely dilated and mild functional mitral regurgitation was detected because of outward displacement of papillary muscles. We used a papillary muscle sling with aortic valve replacement to correct the widened distance between the papillary muscles. A papillary muscle sling when used for reducing tethering at the mitral valve also reduces the posterior left ventricular volume. As well, a transmural longitudinal incision along the left anterior descending artery in the left ventricular free wall was sutured by an overlapping method to reduce the anterior left ventricular volume. The combination of papillary muscle sling and the overlapping method does not need any resection of the cardiac muscle and so would be beneficial for end-stage valvular cardiomyopathy.

[Case report - Congenital] Pulmonary artery growth after Norwood and bidirectional Glenn procedure

Takabayashi, S., Mitani, Y., Yokoyama, K., Shimpo, H. — 2008-04-01

A 19-day-old boy diagnosed with hypoplastic left heart syndrome underwent stage I bilateral pulmonary artery banding and main pulmonary artery-to-descending aorta shunt. A restrictive atrial septal defect existing before stage I recurred after balloon atrioseptostomy. After stage II Norwood and bidirectional Glenn procedure at age nine months, the Nakata index decreased to 73 mm²/m² (pulmonary artery mean pressure: 15 mmHg) and multiple systemic venous collaterals developed. Thus, we instituted oral sildenafil medication, and undertook surgical chest subcutaneous venous ligation and coil embolizations. Three years later, the Nakata index had increased to 117 mm²/m² (pulmonary artery mean pressure: 13 mmHg) and a Fontan procedure was successfully performed.

[Case report - Cardiac general] Successful aortic valve replacement using dilutional ultrafiltration during cardiopulmonary bypass in a patient with Child-Pugh class C cirrhosis

Iino, K., Tomita, S., Yamaguchi, S., Watanabe, G. — 2008-04-01

Open-heart surgery is a relatively high-risk procedure when performed in patients with Child-Pugh class C cirrhosis. Even though they can tolerate cardiac surgery with cardiopulmonary bypass (CPB), most of them suffer major postoperative complications and prolonged hospital stay. The present report describes a case of a patient with Child-Pugh class C cirrhosis who developed severe heart failure secondary to aortic valve stenosis. The patient underwent successful aortic valve replacement with the use of dilutional ultrafiltration during CPB to reduce adverse effects of CPB. He recovered smoothly after the operation without major postoperative complications. Thus, the use of dilutional ultrafiltration (DUF) during CPB appears to produce beneficial effects for improving outcomes in patients with decompensated cirrhosis who require open-heart surgery.

[Case report - Cardiac general] Surgical removal of a left ventricular thrombus associated with cardiac sarcoidosis

Kanemitsu, S., Miyake, Y., Okabe, M. — 2008-04-01

We report successful surgical management of a 31-year-old man with a left ventricular thrombus following heart failure due to cardiac sarcoidosis. Preoperative echocardiography showed diffuse hypokinesis and a mobile ball-like thrombus in the left ventricle. Computed tomography revealed a left ventricular tumor and bilateral hilar lymphadenopathy, while MRI of the brain showed small infarctions in the occipital lobe. Postoperative pathologic examination of a specimen from the left ventricular free wall and a mediastinal lymph node revealed non-caseating granulomas consistent with cardiac sarcoidosis. The patient was referred to a cardiologist for further treatment with prednisolone. This is a rare case of surgical removal of a left ventricular ball-like thrombus in a patient with cardiac sarcoidosis.

[Case report - Thoracic general] Mediastinal fibrosis in a patient with idiopathic retroperitoneal fibrosis

Bahler, C., Hammoud, Z., Sundaram, C. — 2008-04-01

Combined idiopathic retroperitoneal-mediastinal fibrosis is rare. We report a case of mediastinal fibrosis that followed the onset of retroperitoneal fibrosis by six years. A 61-year-old asymptomatic woman was diagnosed with idiopathic mediastinal fibrosis in December of 2006 after discovering a 1.4 cm thick prevascular mass encasing the aortic arch. In August of 2001 the patient had been diagnosed with retroperitoneal fibrosis, which was successfully treated surgically. An axillary thoracotomy found dense adhesions that fixed the arch of the aorta to the adjacent lung. Mediastinal biopsies were consistent with idiopathic fibrosis. We describe the imaging of this case and briefly review the literature.

[Case report - Vascular thoracic] Successful management of a combined ruptured Stanford type B aortic dissection and malperfusion syndrome with an endoluminal graft

Kpodonu, J., Ramaiah, V. G., Diethrich, E. B. — 2008-04-01

Thoracic endografting has been recently approved in the USA for the treatment of thoracic aortic aneurysms. The application of endoluminal graft therapy to treat acute type B dissection has been shown to be effective but is still not considered standard of care. We describe the use of an endoluminal graft to treat a patient with an acute type B dissection associated with malperfusion and thoracic aortic rupture.

[eComment] eComment: Can we use endovascular graft stenting in all type B dissections?

Ates, M., Yekeler, I. — 2008-04-01

[Case report - Valves] Percutaneous cardioplegia delivery using the miniport in minimally invasive mitral valve surgery

Chiu, K.-M., Lin, T.-Y., Chen, J.-S., Chu, S.-H. — 2008-04-01

Minimally invasive cardiac surgery involves limited exposure of cardiac structures. Extracorporeal circulation is usually conducted by peripheral cannulation. Cross-clamp can be achieved by remote ways of either balloon endoclamp or transthoracic clamp. Effective delivery of cardioplegic solution is somewhat more difficult than those abovementioned tasks. In order to prevent additional expenses, we sought to deliver cardioplegic solution in a simple, reproducible, and cost-effective way. The miniport is used for this application. The procedures are reported in detail.

[Case report - Congenital] Total cavo-pulmonary connection without foreign material for asplenic heart associated with partial anomalous pulmonary venous connection

Agematsu, K., Naito, Y., Aoki, M., Fujiwara, T. — 2008-04-01

The presented case was a 3-year-old boy diagnosed with asplenia (SLL), double outlet right ventricle, pulmonary stenosis, atrioventricular septal defect, hypoplastic left ventricle and partial anomalous pulmonary venous connection to the superior vena cava. Partial anomalous pulmonary venous connection was repaired by translocation of pulmonary artery to avoid pulmonary venous obstruction when Glenn anastomosis was performed. Total cavo-pulmonary connection was established by re-routing the inferior vena cava to pulmonary artery using the atrial septal remnant and the left atrium free wall flap.

[Case report - Thoracic general] Thymoma accompanied by lichen planus

Hayashi, A., Shiono, H., Okumura, M. — 2008-04-01

Thymomas are associated at a high frequency with paraneoplastic autoimmune diseases. We treated a 64-year-old male with a thymoma, who also had lichen planus. The tumor was resected and diagnosed as thymoma, however, the symptoms associated with lichen planus did not subside and persisted. A preoperative examination showed an elevated serum level of squamous cell carcinoma antigen, which gradually decreased to normal after surgery. The findings of this case are interesting for understanding the correlation between a thymoma and autoimmune abnormalities.

[Case report - Thoracic general] Pulmonary intestinal-type adenocarcinoma

Maeda, R., Isowa, N., Onuma, H., Miura, H. — 2008-04-01

We report a rare case of pulmonary intestinal-type adenocarcinoma in a 69-year-old man. A computed tomographic scan of the chest and positron emission tomography revealed a well-defined nodule measuring 2.5 cmx2.5 cm in the right lower lobe with high ¹⁸F-fluorodeoxyglucose accumulation. Furthermore, sputum cytology tested positive for adenocarcinoma. Right lower lobectomy and systemic lymph node dissection were performed by video-assisted thoracic surgery (VATS). Histopathologically, the tumor was composed mainly of tall columnar cells with similarity to intestinal epithelia and colorectal carcinoma. Immunohistochemical staining was positive for cytokeratin 7 (CK7) and thyroid transcription factor-1 (TTF-1), whereas staining for cytokeratin 20 (CK20) was negative. The final diagnosis was primary pulmonary intestinal-type adenocarcinoma.

[Case report - Thoracic general] Thoracoscopic apico-posterior transmediastinal approach for bilateral spontaneous pneumothorax

Cho, D. G., Do Cho, K., Kang, C. U., Seop Jo, M. — 2008-04-01

Thoracotomic, trans-sternal or thoracoscopic approaches through transmediastinal access for contralateral lung are operative alternatives for bilateral pulmonary lesions. Video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax (PTX) is now considered as a standard approach. Herein, we report a novel method of apico-posterior transmediastinal ipsilateral approach using VATS to perform simultaneous bilateral bullectomy in two young men with simultaneous bilateral spontaneous PTX. This new VATS access is technically feasible and may mitigate postoperative pain and avoid a secondary thoracic incision.

[Case report - Coronary] A new form of coronary subclavian steal syndrome: 'the spinning wheels' syndrome

Fayad, G., Modine, T., Beregi, J.-P., Koussa, M. — 2008-04-01

Coronary subclavian steal syndrome refers to decreased or reversed internal mammary artery flow, which causes angina related to severe subclavian steno-occlusive disease in patients with in situ internal mammary-to-coronary artery graft. We report a case, the first in the literature, of a right internal mammary artery-coronary-subclavian unidirectional steal syndrome. Clinical features, pathophysiology, and diagnostic and therapeutic strategies of this unusual adverse event are discussed.

[Case report - Cardiac general] Cardiac tumor masquerading as obstructive sleep apnea syndrome

Thung, K.-h., Wan, I. Y.P., Yip, G., Underwood, M. J. — 2008-04-01

We report a case of a large right atrial hemangioma masquerading as a clinical presentation of obstructive sleep apnea syndrome (OSAS) in a 57-year-old man, who was wrongfully treated with nocturnal continuous positive airway pressure (CPAP) prior to surgical consultation. The exact diagnosis was made during the investigation for his cardiac arrhythmia. A large right atrial tumor obstructing the tricuspid valve intermittently was noted on cardiac echocardiography. His symptoms became worse when the patient was lying flat. Tumor excision under cardiopulmonary bypass was carried out, which confirmed the preoperative finding of cardiac hemangioma. The patient underwent uneventful recovery postoperatively and the symptoms of OSAS settled after surgery. To our knowledge, this is the first reported case of right atrial tumor masquerading as a clinical presentation of OSAS.

[Case report - Coronary] Congenital bilateral coronary artery to pulmonary artery fistulas associated with left main trunk stenosis

Levy Praschker, B. G., Rama, A., Gandjbakhch, I., Pavie, A. — 2008-04-01

A rare case of a 57-year-old patient who presented with an acute coronary syndrome with incidental discovery of bilateral coronary arteriovenous fistulas originating from both coronary arteries to the pulmonary artery trunk and coronary artery atherosclerosis.