Asian Cardiovascular and Thoracic Annals recent issues

[EDITORIAL] Use of a Biodegradable Annuloplasty Ring for Mitral Valve Repair in Children

Christenson, Kalangos — 2009-06-10

[ORIGINAL ARTICLE] Folic Acid-Based Intervention in Non-ST Elevation Acute Coronary Syndromes

Imasa, Gomez, Nevado — 2009-06-10

Homocysteinemia is a risk factor for cardiovascular diseases. Folic acid combined with vitamins B₆ and B₁₂ is effective in lowering homocysteine levels. This randomized placebo-controlled study was designed to determine the effect of a folic acid-based supplement on secondary prevention of clinical events in non-ST-segment elevation acute coronary syndromes. The study comprised 240 patients with either unstable angina or non-ST-elevation myocardial infarction in the previous 2 weeks who were randomized to a folate group (n =116) or a placebo group (n =124). The folate group received 1 mg folic acid, 400 µg vitamin B₁₂, and 10 mg vitamin B₆ daily. Clinical outcomes within 6 months were assessed. The composite endpoint of death, nonfatal acute coronary syndrome, and serious re-hospitalization was significantly higher in the folate group; serious re-hospitalization alone was significantly higher in this group. Advanced age and diabetes increased susceptibility to the composite outcome. Folic acid-based supplementation is not beneficial and may even be harmful in the secondary prevention of cardiovascular events in patients with unstable angina and non-ST-elevation myocardial infarction. Further studies on the safety of such supplements are suggested. Controlled Clinical Trials Registry no. ISRCTN30249553.

[ORIGINAL ARTICLE] Valve-Sparing Aortic Root Stabilization in Acute Type A Aortic Dissection

Shrestha, Khaladj, Hagl, Haverich — 2009-06-10

Composite replacement is the standard approach for repair of acute type A aortic dissection involving the aortic root. Reimplantation or remodeling procedures have become valve-sparing alternatives. We developed a new and simple technique to stabilize the aortic root. A Dacron graft is attached outside the native aortic cylinder, and incised twice vertically to create openings corresponding to the right and left coronary ostia. Thus the entire graft covers the native aortic root cylinder from the outside, and the native aortic valve and coronary ostia do not need to be reimplanted. From 2002 to 2007, this technique was applied in 14 patients (8 male) with a mean age of 71 years (range, 34–83 years). Four patients died within 30 days; 3 had been hemodynamically unstable with ventilator and inotropic support preoperatively. Echocardiography showed normal function of the preserved aortic valve, without regurgitation, in all patients. This technique is an alternative valve-sparing method for stabilization of the aortic root in patients with acute type A aortic dissection.

[ORIGINAL ARTICLE] Seasonal Variation in Thrombogenicity of Blood: a Word of Caution

Narang, Banerjee, Satsangi, Geelani — 2009-06-10

Thrombogenicity of blood is known to have seasonal variations. The clinical implications of seasonal variations in the anticoagulation profile of patients with mechanical valves was assessed. Data of patients implanted with a mechanical heart valve for more than 3 months were collected at follow-up or on presentation to the emergency department. The mean time from the previous follow-up examination was 3.6 ± 0.3 months. The number of patients with an international normalized ratio >3.5 and the incidence of hemorrhagic events peaked in hottest part of the year (June–July), with 128 cases of prolonged clotting and 43 hemorrhagic events in this period. The number of patients with rapid clotting and the incidence of embolic events peaked in coldest part of the year (December–January), with 120 cases of international normalized ratio <1.5 and 37 embolic events in this period. There was a significant correlation between temperature and thrombogenicity in patients with prosthetic heart valves on long-term anticoagulation.

[ORIGINAL ARTICLE] Outcomes of Mitral Valve Repair for Chronic Ischemic Mitral Regurgitation

Sajja, Mannam, Dandu, Pathuri, Sompalli, Anjaneyulu — 2009-06-10

Mitral regurgitation is a frequent complication of ischemic heart disease. A retrospective study was performed on 127 patients with significant ischemic mitral regurgitation (regurgitant jet area ≥6.0 cm² and/or vena contracta width ≥0.70 cm) who underwent elective mitral valve repair between January 2001 and October 2007. Concomitant myocardial revascularization was carried out in all except one patient, and left ventricular restoration in 8. All patients had ring annuloplasty, with release of posterior mitral leaflet tethering in 21, leaflet resection in 7, chordal transfer in 3, and chordal shortening in 2. There were 4 (3.1%) hospital deaths. Two patients underwent successful mitral valve replacement for repair failure in the immediate postoperative period, and one had an unsuccessful valve replacement at 3 months. During a mean follow-up of 19.65 ± 13.21 months in 121 patients, 111 had trivial or no residual regurgitation, and 10 had mild regurgitation. Mitral valve repair for chronic ischemic mitral regurgitation is a reproducible technique with satisfactory early and mid-term outcomes and freedom from valve-related complications.

[ORIGINAL ARTICLE] Quality of Life After Mechanical vs. Biological Aortic Valve Replacement

Aboud, Breuer, Bossert, Gummert — 2009-06-10

To assess the quality of life after biological and mechanical aortic valve replacement, data of 136 patients were assessed retrospectively after 2 years of follow-up. Bioprostheses were implanted in 53 patients with a mean age of 74 years, and mechanical prostheses were used in 83 with a mean age of 64 years; there were 47 women and 89 men. Quality of life was evaluated using the Short Form 36-Item Health Survey questionnaire. Physical function scores were significantly better in patients with a mechanical prosthesis. Mental health indices were identical in both groups. Younger patients with mechanical valves and older patients with biological valves had significantly better item scores. In all age groups, men tended to have better scores than women, but a significant difference was noted only in the physical functioning index. The quality of life in patients with mechanical and biological valves was similar at 2 years postoperatively.

[ORIGINAL ARTICLE] Exercise Tolerance in Extracardiac Total Cavopulmonary Connection

Yin, Wang, Zhu, Zhang, Wang, Li — 2009-06-10

Cardiopulmonary adaptation during exercise was compared in patients with an extracardiac total cavopulmonary connection and controls with biventricular repair of Fallot’s tetralogy. Heart rate, blood pressure, respiratory frequency, and transcutaneous oxygen saturation increased with treadmill exercise intensity below grade 3 in patients who had undergone extracardiac total cavopulmonary connection. When exercise intensity exceeded grade 4, blood pressure and oxygen saturation decreased continuously, respiratory rate kept increasing, and heart rate showed no significant change. In cases of fenestrated cavopulmonary connection, heart rate peaked at grade 5 exercise intensity, and blood pressure at grade 4; but both peaked at grade 3 in non-fenestrated patients. During all exercise testing, fenestrated patients had a higher respiratory rate but lower oxygen saturation than those without fenestration. Exercise tolerance was below normal after a cavopulmonary connection, but patients still adapted to exercise below grade 3 with appropriate increases in heart rate and respiratory rate. Due to insufficient right heart systems, patients with a cavopulmonary connection showed obvious exercise limitation at exercise intensity grade 3 or more. Total exclusion of the right heart system may also have adverse effects on the sinoatrial node, leading to impaired heart rate regulation.

[INVITED COMMENTARY] Exercise Tolerance in Extracardiac Total Cavopulmonary Connection

Corno — 2009-06-10

[ORIGINAL ARTICLE] Effect of Central Venous Pressure on Spinal Cord Oxygenation

Ulus, Hellberg, Ulus, Karacagil — 2009-06-10

To analyze the effect of central venous pressure on cerebrospinal fluid oxygen tension and intrathecal pressure, multiparameter sensors were introduced into the intrathecal space for continuous monitoring of cerebrospinal fluid Po₂, Pco₂, and intrathecal pressure in 15 pigs. After 20 min of aortic clamping, hypervolemia was established for 20 min, followed by normovolemia. The animals were divided into 3 groups: in group 1, cerebrospinal fluid Po₂ = 0% at some time during crossclamping; in group 2, cerebrospinal fluid Po₂ was <50%; and in group 3, cerebrospinal fluid Po₂ remained ≥ 50%. Mean decreases in cerebrospinal fluid Po₂ during the initial 20 min of crossclamping were 82%, 57%, and 15% in groups 1, 2, and 3, respectively. Following induction of hypervolemia, central venous and cerebrospinal fluid pressures increased simultaneously; this caused a significant decrease in cerebrospinal fluid Po₂ in group 2 only. In this model, aortic clamping did not increase cerebrospinal fluid pressure if central venous pressure was not elevated. The detrimental effect of elevated intrathecal pressure on cerebrospinal fluid oxygenation was seen only in animals with an intermediate degree of spinal cord ischemia. This might have important implications for the prevention of paraplegia during thoracoabdominal aortic replacement.

[ORIGINAL ARTICLE] Off-Pump Coronary Artery Bypass in Severe Left Ventricular Dysfunction

Pande, Agarwal, Kundu, Kale, Chaudhary, Dhir — 2009-06-10

The outcome of multivessel off-pump coronary artery bypass grafting in cases of severe left ventricular dysfunction was studied in 58 consecutive patients with ejection fraction ≤35% who were followed up for a median of 15 months. Patients with ejection fractions ≤25% (group 1) had the largest left ventricular dimensions preoperatively, with gradual increases during follow-up; those with ejection fractions of 26%–35% (group 2) had smaller preoperative ventricular dimensions, with left ventricular regression postoperatively. There was more improvement in ejection fraction in group 2 than group 1 (33% vs. 10%). Mitral regurgitation improved from moderate to mild in group 2; whereas in group 1, mild mitral regurgitation progressed to moderate or severe during follow-up. Ejection fraction was a predictor of more frequent use of intraaortic balloon pumping, longer duration of inotropic use, a higher mean pulmonary artery-to-systemic arterial pressure ratio, and increased postoperative drainage.

[ORIGINAL ARTICLE] Hospital Outcome of Coronary Artery Bypass Grafting and Coronary Endarterectomy

Abid, Farogh, Naqshband, Akhtar, Khan — 2009-06-10

To compare hospital mortality and postoperative complications in patients with severe coronary artery disease undergoing coronary artery bypass grafting with or without coronary endarterectomy, 100 consecutive patients were divided into 2 groups of 50 patients each. Group 1 had coronary endarterectomy, and group 2 had no coronary endarterectomy. There were 87 men and 13 women, with a mean age of 54.79 ±7.8 years; 48% had stable angina. The right coronary artery was endarterectomized in 22 patients, the left anterior descending artery in 21, and the left circumflex in 7. There were no significant differences in outcomes. There was 1 hospital death in each group. Perioperative myocardial infarction occurred in 2 patients in group 1 and 1 in group 2. Endarterectomy is a suitable option to achieve complete revascularization in patients with refractory angina and severe diffuse disease.

[CASE STUDIES] Bilateral Giant Pulmonary Bronchogenic Cysts

Liu, Pan, Wei — 2009-06-10

Bilateral giant tension bronchogenic cysts were detected by computed tomography in a 13-year-old girl who presented with fever and severe cough. One was located in the right upper lobe, the other in the left lower lobe. The cysts, both measuring 10 cm in diameter, were removed in 2 operations 2 months apart.

[CASE STUDIES] Massive Cerebral Air Embolism after Bronchoscopy and Central Line Manipulation

Seeburger, Borger, Merk, Doll, Bittner, Mohr — 2009-06-10

A 50-year-old woman who underwent double-lung transplantation suffered a massive cerebral air embolism with severe neurological impairment and temporary hemodynamic deterioration after surveillance bronchoscopy and central line removal. We hypothesize that this was due to microscopic pulmonary parenchymal injury during bronchoscopy as well as air entrainment during removal of the central venous line, with subsequent transpulmonary passage into the cerebral vessels.

[CASE STUDIES] Diaphragmatic Fenestrations in Catamenial Pneumothorax: a Management Strategy

Rafay, El-Bawab, Kurdi, Al Kattan — 2009-06-10

Video-assisted thoracoscopic exploration of the right hemithorax in a 37-year-old woman with recurrent catamenial pneumothorax revealed multiple diaphragmatic fenestrations. She underwent successful plication of the diaphragm, with no recurrence of pneumothorax after 4 years of follow-up.

[CASE STUDIES] Syncope and Facial Blushing Due to Giant Intrapulmonary Bronchogenic Cyst

Ramos-Izquierdo, Escobar-Campuzano, Llatjos-Sanuy, Moya-Amoros — 2009-06-10

A 43-year-old man presented with dizziness, head instability, and facial reddening, always in relation to body posture and without fever or systemic manifestations. Chest radiography revealed a large cavity with an air-fluid level in the right upper hemithorax. A right upper lobectomy was performed to remove a large bronchogenic cyst. The presentation with cardiac but no respiratory symptoms is uncommon but should be considered in the differential diagnosis of patients with intrathoracic cysts.

[CASE STUDIES] Coarctation of Right Aortic Arch with Left Descending Aorta in an Adult

Hirota, Ishino, Kawada, Sano — 2009-06-10

We report an adult case of right aortic arch coarctation with a left descending aorta. Associated anomalies included dextrocardia, situs inversus, polysplenia, bilateral superior vena cava, and absent inferior vena cava with azygos connection. Extensive mobilization of the azygos vein was needed to obtain a good surgical field, including the left descending aorta via a right thoracotomy, and the lesion was anatomically repaired by resection and end-to-end anastomosis.

[CASE STUDIES] Self-Expanding Bifurcation Stent for Malignant Esophagotracheobronchial Fistula

Lindenmann, Neuboeck, Anegg, Matzi, Maier, Smolle-Juettner — 2009-06-10

A 60-year-old man with esophageal carcinoma in the upper 3rd underwent palliative treatment including photodynamic therapy, brachytherapy, external beam irradiation, and esophageal stenting. He developed a symptomatic malignant esophagotracheo-bronchial fistula that could not be closed by telescope-stenting in the esophagus. Implantation of a self-expanding, covered metal, tracheal bifurcation stent by flexible bronchoscopy resulted in immediate closure of the fistula with an uneventful recovery.

[CASE STUDIES] Left Anterior Descending Coronary Aneurysm

Lloyd, Weiss, Vricella — 2009-06-10

A 19-year-old man presented with gradual onset of retrosternal chest pain and hemodynamic instability. Echocardiography and computed tomography showed substantial anterior and posterior pericardial effusion with tamponade. At surgery, a 3-cm ruptured aneurysm of the left anterior descending coronary artery was identified. It was successfully bypassed using a saphenous vein graft anastomosed to the ascending aorta.

[CASE STUDIES] Pulmonary Angiosarcoma Presenting as Spontaneous Recurrent Hemothorax

Campione, Forte, Luzzi, Comino, Gorla, Terzi — 2009-06-10

An incidental diagnosis of pulmonary angiosarcoma was made after surgical exploration for repeated episodes of bleeding in an 85-year-old woman. Spontaneous hemothorax is uncommon and deserves detailed investigation.

[HOW TO DO IT] Modified Muscle-Sparing High Approach to the Thoracoabdominal Aorta

Belov, Stepanenko, Gens, Savichev, Komarov — 2009-06-10

A modified muscle-sparing high approach to the thoracoabdominal aorta is described, which improves surgical access for thoracoabdominal aortic aneurysm repair. Since 2000, 16 patients with type I and II thoracoabdominal aortic aneurysms have undergone aortic graft replacement using this approach via the 3^rd intercostal space. There were no hospital deaths. Three (18.8%) patients had severe postoperative pain requiring prolonged analgesia. This approach is a good alternative to the standard approach via the 6^th intercostal space.

[INVITED REVIEW] Cellular Cardiomyoplasty: What Have We Learned?

Kao, Browder, Li — 2009-06-10

Restoring blood flow, improving perfusion, reducing clinical symptoms, and augmenting ventricular function are the goals after acute myocardial infarction. Other than cardiac transplantation, no standard clinical procedure is available to restore damaged myocardium. Since we first reported cellular cardiomyoplasty in 1989, successful outcomes have been confirmed by experimental and clinical studies, but definitive long-term efficacy requires large-scale placebo-controlled double-blind randomized trials. On meta-analysis, stem cell-treated groups had significantly improved left ventricular ejection fraction, reduced infarct scar size, and decreased left ventricular end-systolic volume. Fewer myocardial infarctions, deaths, readmissions for heart failure, and repeat revascularizations were additional benefits. Encouraging clinical findings have been reported using satellite or bone marrow stem cells, but understanding of the benefit mechanisms demands additional studies. Adult mammalian ventricular myocardium lacks adequate regeneration capability, and cellular cardiomyoplasty offers a new way to overcome this; the poor retention and engraftment rate and high apoptotic rate of the implanted stem cells limit outcomes. The ideal type and number of cells, optimal timing of cell therapy, and ideal cell delivery method depend on determining the beneficial mechanisms. Cellular cardiomyoplasty has progressed rapidly in the last decade. A critical review may help us to better plan the future direction.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Constrictive Pericarditis with Constrictive Epicarditis

Lindblom, Nyman, Vedin — 2009-06-10

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Left Anomalous Pulmonary Vein Connection: the Role of Magnetic Resonance Imaging

Contrafouris, Chatzis, Giannopoulos, Danias, Sarris — 2009-06-10

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Spontaneous Resolution of Mediastinal Mass of Uncertain Etiology

Narayan, Thomas, Rajnish, Kornaszewska — 2009-06-10

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Computed Tomography Finding Mimicking Aortic Dissection After Cabrol Procedure

Kruser, Osaki, Kohmoto, Chopra — 2009-06-10

[LETTER TO THE EDITOR] The Issue of Entry Closure and Aortic Tailoring in Type B Aortic Dissection

Belov, Stepanenko, Gens, Savichev — 2009-06-10

[LETTER TO THE EDITOR] Bicuspidized Pulmonary Homograft: an Old Technique but Still a Valuable Option

Santini, Telesca, Faggian, Mazzucco — 2009-06-10

[LETTER TO THE EDITOR] The Nephroscope Used for Emergency Therapeutic Bronchoscopy

Chakravarthy, Krishnamoorthy, Rangarajan, Rajeev, Belur — 2009-06-10

[ELECTRONIC CASE STUDIES] Endotracheal Tube Ignition During the Intratracheal Laser Treatment

Komatsu, Kaji, Okazaki, Miyawaki, Ishihara, Takahashi — 2008-11-04

We experienced the combustion of the endotracheal tube during a bronchoscopic potassium titanyl phosphate laser resection of an intratracheal metastatic tumor. Some preventive precautions have been reported, however, none of them are absolutely perfect. We report the rare occurrence of tracheal tube ignition, preventive measures and treatment strategies for the resultant airway burn.

[ELECTRONIC CASE STUDIES] Operative Timing for Absent Pulmonary Valve with Obstructive Sleep Apnea

Hayashi, Barron, Almeida — 2008-11-04

Congenital absence of the pulmonary valve appears to have a prolonged fate, despite substantial regurgitation, thus the optimal timing of surgical correction remains unclear. A 53-year-old man with isolated pulmonary regurgitation accompanied by obstructive sleep apnea developed progressive heart failure after reopening of the foramen ovale. Closure of the interatrial shunt and pulmonary valve replacement with a 25-mm mechanical prosthesis relieved his refractory left heart failure.

[ELECTRONIC CASE STUDIES] Chronic Contained Rupture of Abdominal Aortic Aneurysm

Yokomuro, Ichikawa, Kajiwara — 2008-11-04

Computed tomography in a 74-year-old man with intermittent claudication revealed an abdominal aortic aneurysm, retroperitoneal hematoma, vertebral erosion, and total aortic occlusion. Surgery was delayed for 9 months after definitive diagnosis of contained rupture of the aortic aneurysm to allow treatment for ischemic heart disease and cardiac failure. After interposing a Y-shaped woven Dacron graft, the intermittent claudication was alleviated. The postoperative course was uneventful.

[ELECTRONIC CASE STUDIES] Graft Replacement for Massive Mobile Embolic Source in Brachiocephalic Artery

Oishi, Hirahara, Takaseya, Kawara, Yasaka, Morita — 2008-11-04

A 76-year-old woman presented with multiple brain infarctions in the right middle cerebral artery and vertebral artery area. Carotid sonography revealed a large mobile pedunculated mass in the brachiocephalic artery, which showed rapid growth despite treatment with heparin and aspirin. Graft replacement of the brachiocephalic artery was performed under selective cerebral perfusion with deep hypothermia. Histology of the resected specimen revealed aortic atherosclerotic plaque.

[EDITORIAL] Full Root Replacement with Stentless Valves Should Be More Frequently Performed

Loisance — 2008-11-04

[ORIGINAL CONTRIBUTIONS] Current Incidence of Peripheral Arterial Embolism and Role of Echocardiography

Mohammadi Tofigh, Karvandi, Coscas — 2008-11-04

We reviewed the incidence and outcome of all cases of upper and lower limb embolism surgically treated in our vascular unit, from January 2001 to June 2006, to assess the role of transthoracic and transesophageal echocardiography in defining the source of the embolus. Transthoracic echocardiography was carried out postoperatively, and patients in whom the embolic source was not found underwent transesophageal echocardiography. There were 85 patients (mean age, 69 years) who underwent embolectomy: 58 for lower and 27 for upper limb ischemia. The source or potential source of thrombus was demonstrated in 17 (20%) patients after transthoracic echocardiography. Fifty-three patients had transesophageal echocardiography, the source of embolism was found in 85%, and the subsequent management was changed in 47% of them. Arterial limb emboli are still prevalent in developing countries. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source of peripheral embolism, with transesophageal echocardiography being reserved for specific indications.

[ORIGINAL CONTRIBUTIONS] Can 64-Row Computed Tomography Replace Angiography After Coronary Bypass?

Doi, Koshima, Suzuki, Takahashi, Yokoyama, Yoshida — 2008-11-04

Multi-detector (64-row) computed tomography has become an alternative to coronary angiography to diagnose graft occlusion and stenosis after coronary artery bypass. We compared the power of evaluation of multi-detector computed tomography with that of conventional coronary angiography in 60 patients who underwent coronary artery bypass with 135 grafts and 210 graft anastomoses. The diagnostic power of multi-detector computed tomography for graft occlusion was: 100% (2/2) sensitivity, 98.5% (131/133) specificity, 50% (2/4) positive predictive value, and 100% (133/133) negative predictive value; there were no significant differences in rates of occlusion among the different types of graft. The diagnostic power of multi-detector computed tomography for stenosis of the graft anastomosis was: 100% (2/2) sensitivity, 95.1% (194/204) specificity, 16.6% (2/12) positive predictive value, and 100% (194/194) negative predictive value, with no significant differences among grafts. Multi-detector computed tomography permits evaluation of bypass grafts and is much less invasive for the patients.

[ORIGINAL CONTRIBUTIONS] Fibrin Glue Administration to Support Bronchial Stump Line

Gursoy, Yapucu, Ucvet, Yazgan, Basok, Ermete — 2008-11-04

Bronchopleural fistula is an important cause of mortality and morbidity after pulmonary resection. The use of fibrin glue to reduce the tension and number of sutures in the bronchial stump was assessed in this prospective study of 20 patients between June 2002 and May 2003. They all had a high risk of bronchopleural fistula development because of bronchiectasis, tuberculosis, lung abscess, diabetes mellitus, preoperative neoadjuvant radiotherapy, or residual tumor at the surgical margin. After pulmonary resection, the bronchial stump was closed with separate nonabsorbable sutures supported with fibrin glue. Bronchopleural fistula was observed in only 1 (5%) patient during 6.45 ± 3.09 months of follow-up. There was no postoperative mortality. Closing the bronchial stump with an appropriate technique and supporting it with fibrin glue were considered effective in preventing bronchopleural fistula development after pulmonary resection in high-risk patients.

[ORIGINAL CONTRIBUTIONS] Experience with Paclitaxel-Eluting Infinnium Coronary Stents

Ostovan, Mollazadeh, Kojuri, Mirabadi — 2008-11-04

To investigate the safety and efficacy of the Infinnium Paclitaxel-eluting stents in the treatment of coronary artery lesions, 196 patients with symptomatic coronary disease who received 202 stents at our center from January 2004 to November 2005 were studied prospectively. The primary study endpoint was the incidence of abnormalities on exercise electrocardiograms or cardiac single-photon emission tomography at 6 months, as a noninvasive index of stent reocclusion. Secondary endpoints were the rates of major adverse cardiac events at 1, 3, 6, 9, and 12 months. Stent deployment was successful in 98% of patients. Cumulative major adverse cardiac event rates at the end of 12 months were: cardiac death 1%, myocardial infarction 5% (Q-wave 2.5%, non-Q-wave 2.5%), and repeat revascularization of the stented lesion 3%. The overall major adverse cardiac event rate was 8.1%. There were 6 (3%) stent thromboses; all occurred late after the procedure. In patients with symptomatic ischemic heart disease, the low-cost Infinnium stent proved both effective and safe, with an acceptably low major adverse cardiac event rate.

[ORIGINAL CONTRIBUTIONS] Minimally Invasive Thoracoscope-Assisted Heller Myotomy for Achalasia

Ma, Zhong, Ye, Shan, Zhang, Mei — 2008-11-04

Forty-five patients (20 men and 25 women) with a median age of 46.5 years, who were diagnosed with esophageal achalasia by clinical history, esophagoscopy, and barium esophagogram, underwent thoracoscope-assisted Heller myotomy with a minimal incision. Esophageal pressure and pH were monitored. Two patients were excluded because of mucosal perforation during the operation, requiring conversion to an open procedure. There was no postoperative esophageal leakage or hospital death. All patients resumed a normal diet as soon as gastrointestinal function recovered, and their symptoms disappeared completely. The mean operative time was 1.2 hours (range, 0.5–3.8 hours). After 2.1 years of follow-up, the outcome was rated excellent in 33 (77%) patients, good in 7 (16%), and fair in 3 (7%). Esophageal dilation was required in 3 patients because of relapsing dysphagia within 3 months after the operation. Four (9%) patients had some regurgitation but no further surgical or medical treatment was needed. Esophageal pressure and pH correlated with the clinical manifestations. Our modified Heller myotomy with the assistance of thoracoscopy is effective for achalasia.

[ORIGINAL CONTRIBUTIONS] Effect of Body Mass Index on Perioperative Complications in Thoracic Surgery

Suemitsu, Sakoguchi, Morikawa, Yamaguchi, Tanaka, Takeo — 2008-11-04

Obesity is perceived as a risk factor in general thoracic surgery. We conducted a single-center retrospective evaluation of perioperative complications in 822 patients who underwent thoracic surgery between 2000 and 2005. According to body mass index, 82 were underweight (< 18.5 kg·m^–2), 568 were normal (18.5–24.9 kg·m^–2), 155 were overweight (25.0–29.9 kg·m^–2), and 17 were obese (≥30 kg·m^–2). A significant increase in preoperative comorbidity (hypertension and ischemic heart disease) was observed with increasing body mass index. There was no significant difference in operation time or length of stay in the operating room, but extubation time was significantly different among the 4 groups. Of the intraoperative complications, alveolar-arterial oxygen difference increased significantly with increasing obesity, and hypoxia was least common in the normal group. Postoperatively, there was more pulmonary leakage in the underweight group and less pneumonia in the normal group. Both the underweight and the obese are at increased risk of perioperative complications and need to be carefully observed and managed intraoperatively and postoperatively.

[ORIGINAL CONTRIBUTIONS] Renal Outcome Following On- and Off-Pump Coronary Artery Bypass Graft Surgery

Ooi, Abdul Rahman, Shah, Dimon — 2008-11-04

A prospective study was carried out to compare the outcomes of patients with preexisting non-dialysis-dependent renal dysfunction who underwent coronary artery bypass grafting with or without cardiopulmonary bypass. Elective off-pump coronary artery bypass was performed in 29 patients with renal dysfunction. Their results were compared with those of a similar group of 35 patients who underwent the conventional on-pump coronary artery grafting. There was a significant deterioration in creatinine clearance in the on-pump group on days 1, 2, and 4 after surgery, while creatinine clearance in the off-pump group remained close to the baseline level. Both groups had improved to the preoperative creatinine clearance values on follow-up at 4 weeks. It was concluded that off-pump surgery provided better renal protection than the conventional on-pump technique in patients with preexisting non-dialysis-dependent renal dysfunction.

[ORIGINAL CONTRIBUTIONS] Off-Pump Coronary Revascularization for Left Main Coronary Artery Stenosis

Mannam, Sajja, Dandu, Pathuri, Saikiran, Sompalli — 2008-11-04

Experience of on- and off-pump coronary artery bypass in 379 patients with significant left main coronary artery stenosis was retrospectively reviewed. Beating-heart operations were performed on 219 patients between January 2001 and October 2007. Their results were compared with 160 who underwent revascularization under cardiopulmonary bypass during the same period. All patients had multivessel grafting via a median sternotomy. Both groups were comparable demographically. Off-pump patients received significantly fewer grafts per patient (3.21 ± 0.86 vs 3.74 ± 0.82). The use of moderate or high doses of inotropics (> 5 µ g · kg^–1 · min^–1) was more frequent in the on-pump group (44% vs 26%). Postoperative blood transfusion requirement was lower in off-pump patients, and fewer of them experienced worsening of preexisting renal insufficiency. There were 2 operative deaths in the on-pump group and 1 in the off-pump group. The off-pump procedure is safe and effective in patients with left main coronary artery disease.

[ORIGINAL CONTRIBUTIONS] Cardiac Surgery and Sickle Cell Disease

Al-Ebrahim — 2008-11-04

Three patients with homozygous sickle cell disease underwent successful open heart surgery for multivalvular lesions. Details of the surgical technique and the necessary precautions are described. Exchange transfusion was implemented in all cases. Crucial issues in cardiac surgical management to avoid or at least minimize vasoocclusive crisis and associated complications are discussed.

[ORIGINAL CONTRIBUTIONS] Aprotinin for Patients Exposed to Clopidogrel Before Off-Pump Coronary Bypass

Nurozler, Kutlu, Kucuk — 2008-11-04

To verify whether low-dose aprotinin reduces blood loss and blood product usage in patients with clopidogrel exposure within 5 days before off-pump coronary artery bypass, 51 patients with clopidogrel exposure were randomized in a double-blind fashion to receive low-dose aprotinin (25 patients), or placebo (26 patients). The baseline characteristics and number of distal anastomoses in the patients in each group were comparable. Time between the last dose of clopidogrel and start of the operation was similar in both groups, as was mean left ventricular ejection fraction. Chest tube drainage, blood product usage, and reoperation rate were significantly higher in the placebo group. In patients with unstable angina and recent clopidogrel exposure who are undergoing off-pump coronary artery bypass, intraoperative administration of low-dose aprotinin is recommended to reduce blood loss and transfusion requirements.

[CASE STUDIES] Mitral Valve Replacement in Calcified Annulus Following Ring Annuloplasty

Messer, Saxena, Mickelburgh, Jalali, Konstantinov — 2008-11-04

We present a patient with persistent severe hemolysis following mitral valve repair which resolved after valve replacement with bioprosthesis. The posterior portion of the annuloplasty ring was retained due to severe calcifications of the posterior mitral valve annulus. All chordae were preserved to avoid disruption of the mitral annulus.

[CASE STUDIES] Primary Right Atrial Angiosarcoma

Santo, Dandekar — 2008-11-04

A rare case of right atrial angiosarcoma is described in a 55-year-old man who was admitted with acute chest pain. Electrocardiography, cardiac enzymes, and chest radiography were negative. His pain settled and he was discharged, but readmitted 15 days later with clinical features of cardiac tamponade. Computed tomography demonstrated a large pericardial effusion. Emergency surgery was performed to excise a right atrial tumor, which histology confirmed to be an angiosarcoma.

[CASE STUDIES] Unusual Venacaval Anomalies in a Patient with Atrial Septal Defect

Oruganti, Jariwala, Taggarse, Mishra — 2008-11-04

An unusual systemic venous drainage pattern was found in a 30-year-old man with ostium secundum atrial septal defect and pulmonary stenosis. He had the rare association of absent right superior vena cava, persistent left superior vena cava draining into the coronary sinus, and a left-sided inferior vena cava draining into a left superior vena cava through the hemiazygous vein.

[HOW TO DO IT] Simple Suture Mitral Annuloplasty with Left Ventriculotomy

Mandegar, Yousefnia, Roshanali — 2008-11-04

Surgical treatment of mitral regurgitation, especially when compounded by ventricular aneurysm, remains a challenge. Several procedures have been developed to repair the mitral valve and reduce regurgitation. We describe a technique of intraventricular annuloplasty which is much less time-consuming than mitral valve repair through a left atriotomy. This procedure is considered technically easy and useful.

[REVIEW PAPER] Surgical Anatomy of Atrioventricular Septal Defect

Adachi, Uemura, McCarthy, Ho — 2008-11-04

This review aims to describe the anatomic spectrum of hearts classified with the collective term atrioventricular septal defect. Despite their anatomical variety, hearts with the stigmata of atrioventricular septal defect share the characteristic feature of a common atrioventricular junction guarded by a 5-leaflet valve. The lack of normal atrioventricular septation makes the aorta un-wedged, resulting in an elongated outlet length on the left ventricular surface (known as inlet-outlet disproportion). The major determinant of anatomic variations is the relationship of the bridging leaflets to the septal structures. This important relationship determines not only the level of intracardiac shunting (interatrial only, interventricular only, or both) but also the propensity for left ventricular outflow tract obstruction. Furthermore, the location of the atrioventricular node, which is posteroinferiorly displaced from the tip of the triangle of Koch, is also affected by this relationship. Understanding the cardiac anatomy in this malformation is an absolute prerequisite for successful surgery, and should be facilitated by recognizing the fundamental nature of the morphology.

[REVIEW PAPER] Pulmonary Protection During Cardiac Surgery: Systematic Literature Review

Carvalho, Gabriel, Salerno — 2008-11-04

Ischemia-reperfusion injury occurs during heart surgery in which cardiopulmonary bypass is used. Current knowledge of the factors contributing to postoperative pulmonary dysfunction and the measures to avoid it are reviewed.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Pediatric Bronchial Rupture: Diagnosis and Treatment

Toker, Ziyade, Eroglu, Tanju, Dilege — 2008-11-04

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Transaortic Video-assisted Excision of a Left Ventricular Mass

Kawamoto, Ishibashi, Shibukawa, Izutani — 2008-11-04

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Post-infarction Left Ventricular False Aneurysm

Garcia-Valentin, Mestres, Cartana, Fernandez-Gallego, Bernabeu, Josa — 2008-11-04

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Rare Presentation of Bilateral Femoral Arteriovenous Fistula

Kohli, Singh, Sharma — 2008-11-04

[LETTERS TO THE EDITOR] PEDIATRIC MITRAL VALVE REPAIR WITH THE NOVEL ANNULOPLASTY RING: KALANGOS-BIORING(R)

Cikirikcioglu, Pektok, Myers, Christenson, Kalangos — 2008-11-04

[ELECTRONIC CASE STUDIES] Congenital Quadricuspid Aortic Valve Associated With Severe Regurgitation

Kawanishi, Tanaka, Nakagiri, Yamashita, Okada, Okita — 2008-09-22

A 56-year-old man was referred because of severe aortic regurgitation. He had a quadricuspid aortic valve with a small accessory cusp between the right coronary and noncoronary cusps. The ostium of the right coronary artery was deviated toward the accessory cusp commissure. Aortic valve replacement was performed with a bioprosthesis. The resected cusps showed fibrotic thickening with calcification and fenestration.

[ELECTRONIC CASE STUDIES] A Rare Cause of Dyspnea in Adult: a Right Bochdalek's Hernia-containing Colon

Terzi, Tedeschi, Lonardoni, Furia, Benato, Calabro — 2008-09-22

Symptomatic cases of Bochdalek’s hernia (BH) are uncommon in adults; symptoms arise only due to complications. Most of symptomatic cases are related to a left-sided hernia. Right colon herniation in adults has never been reported. We present a case of a 70-year-old woman with right BH-containing colon. The patient was successfully treated by combined laparoscopic and thoracoscopic approach.

[ELECTRONIC CASE STUDIES] Vacuum-Assisted Closure for Mediastinitis after Pediatric Cardiac Surgery

Hiramatsu, Okamura, Komori, Nishimura, Suzuki, Takeuchi — 2008-09-22

Two children, aged 1 and 14 years with methicillin-resistant Staphylococcus aureus mediastinitis after pediatric open-heart surgery, were fitted with a vacuum-assisted closure system. Complete healing was achieved in both cases, and primary wound closure could be carried out without an omental flap after 6 and 16 days.

[ELECTRONIC CASE STUDIES] Mature Cardiac Myocyte Hamartoma in the Right Atrium

Movahedi, Boroumand, Sotoudeh Anvari, Yazdanifard — 2008-09-22

During coronary artery bypass grafting in a 58-year-old man, a mass was discovered incidentally in the right atrium, measuring 1.5 x 1 x 0.5 cm. It was composed of disorganized hypertrophic mature cardiac myocytes, and associated with focal fibrosis, mature adipocytes, and mild lymphocytic infiltration in peripheral areas, indicative of cardiac hamartoma. This type of hamartoma has been rarely reported as an isolated mass in the right atrium.

[EDITORIAL] STER Science and Cardiothoracic Surgery: an Asian Perspective

Chiu — 2008-09-22

[EDITORIAL] The Use of PET and PET/CT Scanning in Lung Cancer

Woolley, Rajesh — 2008-09-22

[ORIGINAL CONTRIBUTIONS] Subcoronary Implantation of a Stentless Valve in Patients with Aortic Aneurysms

John, Al-Hariri, Ackemann, El-Mehsen, Roethemeyer, Warnecke — 2008-09-22

Experience with a new operation for patients with aortic valve disease and aneurysm or dissection of the ascending aorta is described. Twenty-four patients aged 66 87 years were operated on using a subcoronary implantation technique with a stentless aortic valve bioprosthesis and an extension using a vascular tube prosthesis. No major adverse cardiac events were observed in the postoperative period. This operation offers a safe alternative to the technically more demanding procedures of composite bioprosthetic ascending aortic replacement or full root replacement.

[ORIGINAL CONTRIBUTIONS] Surgery for Sinus of Valsalva Aneurysm: 27-Year Experience with 100 Patients

Yan, Huo, Qiao, Murat, Ma — 2008-09-22

Sinus of Valsalva aneurysm is a rare anomaly. This study was designed to assess the long-term outcome of surgical repair of sinus of Valsalva aneurysm and factors influencing the prognosis. From August 1980 to August sinus of Valsalva aneurysm repair. Ventricular septal defect (42) and aortic regurgitation (34) were the most frequent coexisting anomalies. An approach via the involved chamber was used in 60 patients, aortotomy in 5, and a combined approach in 35. Either direct (43) or patch (57) closure was used to repair the defect. Aortic valve replacement was required in 14 patients, and 8 needed valvuloplasty. Eighty patients were followed up for 15.6 ± 3.9 years. There were 3 hospital deaths and 2 late deaths. New York Heart Association functional class improved significantly after surgery. Actuarial survival was 94% at 10 years, and 90% at 15 years. Surgical treatment of sinus of Valsalva aneurysm is safe and effective, but late progressive aortic regurgitation is still a risk during long-term follow-up, and early aggressive measures are recommended.

[ORIGINAL CONTRIBUTIONS] Harmonic Scalpel in Video-Assisted Thoracoscopic Thymic Resections

Soon, Agasthian — 2008-09-22

Video-assisted thoracoscopic thymectomy is safe, but the efficacy of this technique in thymomectomy is unproved. Data of 103 consecutive patients who had thoracoscopic thymectomy and thymomectomy between 1998 and 2006 were retrospectively reviewed. Conventional monopolar diathermy and endoscopic Liga clips were used in the first 50 patients, and the Harmonic Scalpel was employed in the next 53. Only mean tumor size differed between groups (56.6 ± 18.2 vs 40.0 ± 20.8 mm in Harmonic Scalpel group). A similar number of patients had myasthenia gravis in the first group (72%) and Harmonic Scalpel group (83%). There were 49 thymomas (22 in first group, 27 in Harmonic Scalpel group). Of the earlier patients, 2 were re-explored for excessive chest tube drainage, 1 had ipsilateral phrenic nerve injury, and 2 had left phrenic nerves sacrificed intraoperatively due to thymoma invasion, but there was no significant difference in complications between groups. At a mean follow-up of 3.40 ± 2.38 years (range, 0.04–8.52 years), there was 1 thymoma recurrence in the first group. Use of the Harmonic Scalpel in video-assisted thoracoscopic thymic resection is safe and confers some advantages over conventional methods of dissection.

[ORIGINAL CONTRIBUTIONS] Interpleural Morphine vs Bupivacaine for Postthoracotomy Pain Relief

Dabir, Parsa, Radpay, Padyab — 2008-09-22

This prospective randomized double-blind trial was designed to compare the analgesic effects of interpleural bupivacaine and interpleural morphine for postthoracotomy pain management. Thirty-six American Society of Anesthesiologists class I and II patients undergoing an elective posterolateral thoracotomy were randomly divided into 2 groups of 18 each. Before chest closure, an interpleural catheter was inserted under direct vision. At the end of the operation and every 4 hours thereafter, they received either 0.25% bupivacaine with epinephrine or 0.2 mg·kg^–1 morphine sulfate interpleurally for 24 hours. The chest tubes were clamped during injection and for 15 min afterwards. Supplementary doses of intravenous morphine were given on request. The pain severity was evaluated at rest and on coughing before and 30 min after each interpleural injection, using an 11-point visual analog scale. Supplemental analgesic consumption and side effects were recorded. Both interpleural morphine and bupivacaine significantly reduced pain scores 30 min after each injection. However, pain scores and supplementary analgesic requirements were significantly lower in the interpleural morphine group. No serious side effects were detected in either group. Interpleural morphine provides better pain control than interpleural bupivacaine after a posterolateral thoracotomy.

[ORIGINAL CONTRIBUTIONS] Prognostic Variability in Completely Resected pN1 Non-Small-Cell Lung Cancer

Gonfiotti, Crocetti, Lopes Pegna, Paci, Janni — 2008-09-22

We used the Tuscan Cancer Registry archives to retrieve records of 2,896 patients with a histological diagnosis of lung tumor from January 1996 to December 2000. Of 2,410 patients with non-small-cell lung cancer, 767 (31.8%) underwent complete resection. The following variables were analyzed for their influence on survival in the 157 patients with pathologic N1 status: sex, age, cell type, pathologic tumor status, number and level of involved lymph nodes, tumor grade, and type of surgery. Overall 5-year survival rates were 43.9% for 417 patients with pN0 disease, 10.8% for 176 with pN2 disease, and 31.6% for those with pN1 disease. In pN1 disease, the overall 5-year survival rates for patients with hilar and non-hilar lymph node involvement were 27.4% and 39.6%, respectively. Univariate analysis demonstrated that pathological T status and level of N1 involvement weresignificant prognostic factors. Cox proportional hazards analysis indicated that hilar lymph node involvement was an independent prognostic factor. N1 lymph node status was identified as an independent prognostic factor in a combination of subgroups with different prognoses.

[ORIGINAL CONTRIBUTIONS] Factors Influencing Survival in Patients After Bidirectional Glenn Shunt

Silvilairat, Pongprot, Sittiwangkul, Woragidpoonpol, Chuaratanaphong, Nawarawong — 2008-09-22

Clinical characteristics, echocardiographic values, and catheterization data of 45 patients with a functional univentricular heart who had a bidirectional Glenn shunt instituted between November 1994 and October 2006 were retrospectively reviewed. Median age at operation was 20 months (range, 9 months to 19 years). Median follow-up time after the bidirectional Glenn operation was 4 years (range, 1 day to 11 years). The early mortality rate was 4/45 (8.9%); overall mortality was 24.4%. Actuarial survival after a bidirectional Glenn shunt was 73% ± 8% at 5 years and 55% ± 17% at 10 years. In multivariate Cox proportional hazards analysis, heterotaxy syndrome and systemic right ventricle were independent predictors of mortality after the bidirectional Glenn shunt. Age at operation, oxygen saturation, previous surgery, a pulsatile Glenn shunt, cardiopulmonary bypass, postoperative pulmonary artery pressure, bilateral superior venae cavae, and Nakata index were not predictive of mortality. The presence of heterotaxy syndrome and systemic right ventricle in patients with a functional univentricular heart should lead to aggressive investigation and management strategies.

[ORIGINAL CONTRIBUTIONS] Clinical Characteristics and Surgery of Primary Lung Cancer in Younger Patients

Funakoshi, Takeda, Kadota, Kusu, Maeda — 2008-09-22

Controversy exists regarding the clinical characteristics, pathological findings, and prognosis of patients < 50 years of age with primary lung cancer. The medical records of 4,556 patients diagnosed with primary lung cancer between 1980 and 2004 were reviewed; of these, 305 were < 50 years old. Of 1,335 patients who were surgically treated, 122 were < 50 years old. Females were over-represented in the younger group. Younger patients had a significantly higher incidence of adenocarcinoma and large cell carcinoma, and a lower incidence of squamous cell carcinoma. The resectable rate in younger patients was significantly higher. Overall and among surgically treated patients, the survival rates of younger patients with stage 0-I disease were significantly better than those of older patients. Younger patients with early-stage primary lung cancer had a significantly better prognosis than older patients, although survival in the advanced stages was not significantly different.

[ORIGINAL CONTRIBUTIONS] One-Stage Procedure for Lung and Liver Hydatid Cysts

Aghajanzadeh, Safarpoor, Amani, Alavi — 2008-09-22

Concomitant pulmonary and liver hydatid cysts occur in 4% 25% of patients with echinococcosis. To evaluate the safety of a single-stage operation, experience with this procedure between 1992 and 2005 was reviewed. Of 152 patients who underwent surgery for pulmonary hydatid cyst, 30 had an additional hepatic cyst that was located on the upper dome of the liver in all cases. Pulmonary cysts were excised first via a posterolateral thoracotomy. After phrenotomy, the hepatic hydatid cyst was evacuated without capitonnage, and a Folly catheter was left in the cavity. Postoperative complications in the 30 patients with cysts in both locations included empyema in 2, bronchopleural fistula in 1, excessive biliary discharge in 3 and hemorrhage in 1. Hepatic hydatid cysts recurred in 2 patients. There was no hospital death. A single-stage posterolateral thoracotomy for extraction of pulmonary and liver hydatid cyst is an effective and safe surgical technique with few complications.

[ORIGINAL CONTRIBUTIONS] Verapamil and Nitroglycerin Improves the Patency Rate of Radial Artery Grafts

Yoshizaki, Tabuchi, Toyama — 2008-09-22

The best way to prevent spasm of the radial artery is still under investigation. We retrospectively compared the effectiveness of topical verapamil-nitroglycerin with papaverine in preventing graft spasm in 215 patients who underwent isolated conventional coronary artery bypass using a radial artery. Postoperative angiographic data were successfully collected in 116 patients. Perioperative radial artery graft spasm was observed in 2 patients in the papaverine group and 1 in the verapamil-nitroglycerin group; this difference was not considered significant. Complete or functional occlusion was detected by postoperative angiography in 13 grafts (10 in the papaverine group and 3 in the verapamil-nitroglycerin group). Multivariate regression analysis revealed that topical papaverine and grafting to the right coronary artery significantly increased the rate of occlusion of radial artery grafts. Although further studies are needed, our data support the view that topical verapamil-nitroglycerin reduces the incidence of radial artery graft occlusion.

[ORIGINAL CONTRIBUTIONS] Ventricular Restoration by Linear Endoventricular Patchplasty and Linear Repair

Parachuri, Adhyapak, Kumar, Setty, Rathod, Shetty — 2008-09-22

Surgical ventricular restoration improves cardiac function in patients with large left ventricular aneurysms. Aneurysm repair techniques have evolved to geometric repair by exclusion of the aneurysmal area with a circular patch. But even circular endoventricular patchplasty may result in a less elliptical ventricle. We modified the techniques of both linear and geometric repair. The early and intermediate outcomes in 102 patients with post-infarction left ventricular aneurysm, treated between 2001 and 2004, were analyzed. Concomitant procedures included coronary artery bypass grafting in 73 patients, mitral valve repair in 29, cryoablation in 3, and post-infarction ventricular septal rupture repair in 3. Overall mortality was 12.7%. Left ventricular ejection fraction increased significantly postoperatively, from 31.5% ± 6.5% to 34.2% ± 5.9%. There were significant decreases in end-diastolic volumes from 140.3 ± 38.3 to 100.8 ± 33.5 mL, and end-systolic volumes from 95.1 ± 26.1 to 66.0 ± 21.7 mL. These benefits continued at the 12- to 52-month follow-up. Our modified technique restores a near physiological left ventricular geometry and has a favorable clinical outcome.

[CASE STUDIES] Postinfarction Heart Rupture of Posterior Wall Repaired by Covering Patch

Kimura, Yamaguchi, Tanaka, Okamura, Adachi, Ino — 2008-09-22

A 46-year-old man underwent emergency surgery for heart rupture after acute infarction of the posterior wall. Echocardiography revealed limited myocardial thinning, so rather than sutureless repair, a covering patch was used in view of the risk of recurrent rupture. Postoperative echocardiography showed the myocardial thinning had progressed to a wide defect, and computed tomography demonstrated that the covering patch had prevented a repeat rupture.

[CASE STUDIES] Pure Yolk-Sac Tumor of the Lung

Basoglu, Sengul, Buyukkarabacak, Yetim, Yildiz — 2008-09-22

Primary germ cell tumors of the chest often localize in the anterior mediastinal compartment. Such tumors originating from lungs and pleura are rare. Chest tomography revealed a mass in the middle lobe of the right lung in a 25-year-old man. A middle lobe medial segmentectomy was performed, and chemotherapy was applied postoperatively.

[CASE STUDIES] Surgical Palliation for Taussig-Bing Anomaly with Multiple Lesions

Agematsu, Aoki, Naito, Fujiwara — 2008-09-22

A successful surgical palliative procedure, consisting of an arterial switch operation, pulmonary artery banding, and arch repair, was performed in a neonate with Taussig-Bing anomaly and aortic arch interruption, subaortic stenosis, and multiple muscular ventricular septal defects. Such anatomical complexity made treatment difficult. This palliative procedure allows future biventricular repair.

[HOW TO DO IT] Two Easy Ways to Ensure Safe Sternotomy and Sternal Closure

De Cicco, Fucci, Lorusso — 2008-09-22

Appropriate sternotomy and sternal closure are the most important factors in mechanical stability of the sternum and prevention of several postoperative complications. Easy techniques for identifying the sternal midline to facilitate opening and for obtaining reinforced closure are described. These techniques require minimal additional time. They are particularly indicated in patients at risk of sternotomy-related complications, and helpful to young surgeons in training.

[HOW TO DO IT] Simple and Reliable Distal Anastomosis for Total Aortic Arch Replacement

Ohkado, Tanaka, Yamada, Inoue, Wakita — 2008-09-22

In total aortic arch replacement, distal aortic anastomosis is often remarkably difficult because of the deep operative field. Once bleeding from the anastomotic area occurs, it is intractable not only because of technical problems but also decreased coagulability due to deep hypothermia and the fragility of the aortic wall. We describe a simple but reliable strategy for distal anastomosis, which is unique with regard to the approach to the anastomotic area and the anastomotic method.

[REVIEW PAPER] Mechanical Circulatory Support: a Clinical Reality

Loisance — 2008-09-22

Mechanical circulatory support is becoming an alternative therapeutic option for patients in cardiogenic shock or advanced cardiac failure who cannot be improved by maximal medical therapy. More than 30 years of engineering development and clinical research have led to a level of efficacy and reliability of ventricular assist devices, which allows promotion of this approach for the most difficult patients. Uses include a gaining-time strategy as a bridge to cardiac transplantation or recovery of native cardiac function, as well as permanent support with the device. The large variety of devices permits every cardiac surgical unit, even those not used to cardiac transplantation, to propose this option to the patient. Recent experience with small silent implantable pumps suggests that the pioneering period of mechanical circulatory support is probably over, and the time has come for precise prospective trials to optimize both patient selection and the timing for utilization. In countries where cardiac transplantation has not developed, there is now an easily accessible technique for management of patients with cardiac failure.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Chronic Constrictive Calcific Pericarditis

Singh, Swami, Singh, Sharma, Mehta, Dhaliwal — 2008-09-22

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Spontaneous Pneumomediastinum Involving Carotid Artery Neurovascular Pedicle

Koletsis, Kalogeropoulou, Katsanos, Apostolakis, Dougenis — 2008-09-22