Asian Cardiovascular and Thoracic Annals recent issues

[ELECTRONIC CASE STUDIES] Correction of Anomalous Drainage of Right Superior Vena Cava to Left Atrium

Sajja, Koneti, Mannam, Sundaram — 2008-07-31

A 2-year-old boy with cyanosis was found to have normal situs and looping with anomalous drainage of a right-sided superior vena cava to the left atrium, and intact interatrial septum in association with anomalous drainage of the left pulmonary veins to the right superior vena cava. He underwent successful surgical repair of this rare congenital malformation.

[ELECTRONIC CASE STUDIES] Right Atrial Thrombus Masquerading as Intracardiac Cyst: a Case Report

Singh, Walsh, Birdi — 2008-07-31

Intracardiac cystic lesions are rare. Hydatid disease, blood cysts and bronchogenic cysts in various chambers of the heart have been reported. Right atrial thrombus presenting as a cystic lesion on echocardiogram has not been reported. We describe a patient with mitral regurgitation in atrial fibrillation with a right atrial cyst, which was found to be a cavitating thrombus.

[ELECTRONIC CASE STUDIES] Right Cervical Aortic Arch with Aberrant Left Subclavian Artery

Tjang, Aramendi, Crespo, Hamzeh, Voces, Rodriguez — 2008-07-31

The combination of right cervical aortic arch, aberrant retroesophageal left subclavian artery originating from a Kommerell’s diverticulum, and a ligamentum arteriosum, constitutes a rare form of vascular ring. Two patients aged 21 days and 54 years, who were diagnosed by multislice 3-dimensional computed tomography and magnetic resonance imaging, underwent surgical division of a vascular ring. The adult required resection of a Kommerell’s aneurysm and subclavian artery reimplantation.

[EDITORIAL] Surgical Ventricular Restoration and the STICH Trial

Di Donato, Menicanti, Suma — 2008-07-31

[EDITORIAL] Endovascular Management of Complicated Acute Type B Aortic Dissection

Chan, Cheng — 2008-07-31

[ORIGINAL CONTRIBUTIONS] Arterial Switch Operation: Troponin T Does Not Predict Ventilation Requirements

Maddali, Valliattu, al Delamie, Zacharias, Ahmed, Ganguly — 2008-07-31

The aim of this study was to assess whether postoperative cardiac troponin T levels could predict ventilation requirements in infants undergoing the arterial switch operation. Cardiac troponin T was measured 6 hours after aortic cross clamping and prior to tracheal extubation in 20 consecutive patients; 10 had simple and 10 had complex (with ventricular septal defect) transposition of the great arteries. The mean plasma troponin T level prior to extubation did not differ significantly in patients who were re-intubated and those who were successfully extubated. The initial cardiac troponin T levels in the complex defect group was significantly higher than in the simple transposition group. There was no correlation between initial cardiac troponin T levels and the duration of mechanical ventilation. There was no difference in mean duration of ventilation between the 2 groups. It was concluded that the postoperative cardiac troponin T level is not a predictor of successful extubation or prolonged artificial ventilation in this subset.

[ORIGINAL CONTRIBUTIONS] Hemodynamic Evaluation of Aortic Regurgitation by Magnetic Resonance Imaging

Wittlinger, Dzemali, Bakhtiary, Moritz, Kleine — 2008-07-31

Magnetic resonance imaging was compared with echocardiography and angiography in determining the regurgitant volume in patients with aortic regurgitation. Forty patients were examined at 1.5 T. The regurgitant jet was located using a gradient-echo sequence. Cine measurements were performed to calculate left ventricular function. For flow evaluation, a velocity-encoded breath-hold phase-difference magnetic resonance sequence was used. The degree of aortic regurgitation assessed by magnetic resonance imaging agreed with that of angiography in 28 of 40 (70%) patients, and with the echocardiography result in 80%. Correlation between calculated stroke volume by magnetic resonance cine and flow measurements was very good (r > 0.9). Magnetic resonance imaging enables quick and reliable quantitative assessment of aortic regurgitant volume, and it might be the optimal technique for multiple follow-up studies and assessment of left ventricular function, leading to better evaluation of disease severity and optimization of the timing of valve surgery.

[ORIGINAL CONTRIBUTIONS] Cardiac Troponin T in Acute Coronary Syndrome with Renal Insufficiency

Chew — 2008-07-31

Cardiac troponin levels are frequently elevated in patients with chronic renal failure, hence diagnosis of myocardial necrosis is difficult. The prevalence of elevated serum troponin T was determined and its diagnostic value in acute coronary syndrome was assessed in patients with chronic renal insufficiency. A retrospective cross-sectional analysis was performed in 227 patients with chronic renal insufficiency and a diagnosis of unstable angina, non-ST or ST-segment elevation myocardial infarction. All patients had baseline serum troponin T levels measured at previous visits; the baseline troponin T level was raised in 53.3%. Cardiac troponin T levels did not correlate with creatinine levels, and were not affected by dialysis. Mortality after an acute coronary event was high (46.3%). Because of the elevated baseline cardiac troponin T levels, detection of acute coronary syndrome in patients with chronic renal failure requires evaluation of serial cardiac enzyme measurements and serial 12-lead electrocardiograms. Early and definitive cardiac interventions may contribute towards decreasing the mortality rate in this group of patients.

[ORIGINAL CONTRIBUTIONS] Esophageal Stethoscope in Thoracoscopic Interruption of Patent Ductus Arteriosus

Kahrom, Kahrom — 2008-07-31

There is a significant rate of residual or recurrent ductal patency after video-assisted thoracoscopic closure of patent ductus arteriosus. Between February 2000 and October 2004, this procedure was carried out on 145 consecutive patients in whom heart sounds were monitored intraoperatively with an esophageal stethoscope. Changes in continuous cardiac murmurs were recorded after placing the 1^st and 2^nd vascular clips. There was no ductal flow after clipping twice in 138 (95%) patients; in the other 7, residual flow was abolished at the 3^rd attempt. All patients left the operating room with no residual ductal patency on echocardiography. After 6 months, there was no incidence of residual patency. Intraoperative esophageal stethoscopy provides remarkably loud and clear heart sounds for direct monitoring and reliable evaluation of the entire course of thoracoscopic patent ductus arteriosus closure, without interrupting the surgical procedure, thus avoiding re-intervention and complications associated with residual ductal flow.

[ORIGINAL CONTRIBUTIONS] Predictors of Sinus Rhythm after Radiofrequency Maze and Mitral Valve Surgery

Chaiyaroj, Ngarmukos, Lertsithichai — 2008-07-31

The prevalence and predictors of postoperative sinus rhythm in patients undergoing a radiofrequency ablation maze operation and mitral valve surgery were assessed in 63 patients of whom 54 (86%) were in permanent atrial fibrillation. Operative mortality was 3.17%. At a median follow-up of 18 months, 54 (88.5%) patients were in sinus rhythm and 7 (11.5%) were in atrial fibrillation. The probability of sinus rhythm at 30 months was 92%. Left atrial diameter was the most significant prognostic factor for sinus rhythm on multivariate proportional-hazard regression analysis. The cutoff value of preoperative left atrial diameter for predicting persistent atrial fibrillation at 6 months was 6 cm (100% sensitivity and 73.6% specificity). The radiofrequency ablation maze operation can be performed in addition to mitral surgery with a high rate of successful conversion to sinus rhythm. Preoperative left atrial diameter < 6 cm is an important prognostic factor for sinus rhythm conversion.

[ORIGINAL CONTRIBUTIONS] Esophageal Injuries Due to Aluminum Phosphide Tablet Poisoning in India

Darbari, Tandon, Chaudhary, Bharadwaj, Kumar, Singh — 2008-07-31

Aluminum phosphide is a lethal systemic poison with 80%–90% mortality. Survivors have taken either a very small amount or the tablet had been exposed to air, rendering it less toxic, but often causing severe esophageal injuries. The presentation and treatment of 11 cases of esophageal injury due to aluminum phosphide are described. Ten patients had esophageal stricture, and 1 had tracheoesophageal fistula with stricture. Endoscopic bougie dilatation was sufficient in 7 patients, and surgical intervention was required in 4 who underwent definitive repair via gastric tube or feeding jejunostomy with a 2^nd stage repair planned in 2. There was no mortality but significant morbidity. Mortality and morbidity might be prevented by withdrawing this pesticide from the market, making its sale difficult, or modifying the packaging.

[ORIGINAL CONTRIBUTIONS] Mortality in Open Heart Surgery with Intraaortic Balloon Pump Support

Karimi, Movahedi, Salehiomran, Marzban, Hesameddin Abbasi, Yazdanifard — 2008-07-31

Mechanical circulatory assistance is frequently needed to support the failing heart. The aim of this study was to determine perioperative prognostic factors for hospital mortality in patients undergoing open heart surgery who required intraaortic balloon pump support. Between January 2002 and September 2006, 475 patients received an intraaortic balloon pump perioperatively. Hospital mortality was 21.89%. Risk factors for hospital death identified by multivariate logistic regression analysis were peripheral vascular disease, left main coronary artery disease, postoperative renal failure, postoperative cardiac arrest, and prolonged hospital stay. Minor and major intraaortic balloon pump-related complications were not significant in univariate and multivariate analysis; the incidence was 5.05%. It is suggested that the threshold for using balloon pump support is decreased in high-risk patients undergoing cardiac surgery.

[ORIGINAL CONTRIBUTIONS] Anomalous Origin of Right Coronary Artery From Left Coronary Sinus

Hamzeh, Crespo, Estaran, Rodriguez, Voces, Aramendi — 2008-07-31

Anomalous aortic origin of the coronary arteries is uncommon but clinically significant. Manifestations vary from asymptomatic patients to those who present with angina pectoris, myocardial infarction, heart failure, syncope, arrhythmias, and sudden death. We describe 4 patients, aged 34 to 59 years, who were diagnosed with right coronary artery arising from the left sinus of Valsalva, confirmed by coronary angiography, which was surgically repaired. Three patients presented dyspnea and angina, and one with acute myocardial infarction. At operation, the right coronary artery was dissected at the take-off from the intramural course, and reimplanted into the right sinus of Valsalva. There was no mortality. One patient had associated coronary artery disease that required stent placement postoperatively. This reimplantation technique provides a good physiological and anatomical repair, eliminates a slit-like ostium, avoids compression of the coronary artery between the aorta and the pulmonary artery, and gives superior results to coronary artery bypass grafting or the unroofing technique.

[ORIGINAL CONTRIBUTIONS] Novel Anti-Adhesive Pericardial Substitute for Multistage Cardiac Surgery

Matsumura, Shin'oka, Ikada, Sakamoto, Kurosawa — 2008-07-31

Dense adhesions in the retrosternal space make reoperations difficult in the field of cardiovascular surgery. Several substitutes for pericardium have been employed to prevent dense adhesions forming, but they have been unsatisfactory because of peel formation, calcification, and infection. To overcome these drawbacks, a novel biodegradable pericardial substitute was developed from gelatin obtained from specific-pathogen-free porcine skin and a bioabsorbable polyester mesh, which persists while the adhesion reaction occurs in the retrosternal space. A clinical pilot study of this gelatin sheet was carried out in patients scheduled to receive multistage cardiac surgery. From February 2003 to July 2004, the material was used in 5 patients aged 0.4 to 3.0 years. There were no complications related to the gelatin sheet. The effectiveness of the material was evaluated when the sternum was reopened 1.4 ± 0.5 years later. It took 24.5 ± 6.0 min for the resternotomy, and all surgeons who participated in the surgery rated the effectiveness of the gelatin sheet as "good". This anti-adhesive sheet prevented dense adhesions, suggesting that this material may be useful as a pericardial substitute for multistage pediatric cardiac surgery.

[ORIGINAL CONTRIBUTIONS] Mammary Artery Patch Reconstruction of Left Anterior Descending Coronary Artery

Prabhu, Thazhkuni, Rajendran, Thamaran, Vellachamy, Vettath — 2008-07-31

Most patients with diffuse coronary disease require endarterectomy for revascularization. In view of the high morbidity and mortality associated with coronary endarterectomy, patch angioplasty and reconstruction of the coronary artery was developed. We retrospectively evaluated 104 patients who underwent mammary artery patch angioplasty of the left anterior descending coronary artery. The procedure consisted of laying open the entire diseased segment of the coronary artery and patching it with an in-situ left internal mammary artery onlay patch, without endarterectomy, in an off-pump procedure. One (0.9%) patient died, 2 (1.8%) suffered perioperative myocardial infarction, and an intraaortic balloon pump was used in 2. The mean blood loss was 224 mL. Intensive care unit stay was 2.5 days, and hospital stay was 7.8 days. At 1-year follow-up, most patients were in New York Heart Association functional class I. Follow-up angiography was carried out in 16 patients and showed good patency of all anastomoses. Arterial patch reconstruction of the left anterior descending coronary artery can be performed safely and effectively in an off-pump procedure, with excellent early and intermediate results.

[CASE STUDIES] Early Repair of Acquired Tracheoesophageal Fistula

Yeh, Chou — 2008-07-31

We report early direct repair of a cuff-related tracheoesophageal fistula in a 30-year-old alcoholic man with diabetic ketoacidosis who fell unconscious and was ventilated via an endotracheal tube. He was successfully weaned from the ventilator 1 week after the operation.

[CASE STUDIES] Retrieval of Broken Paravertebral Catheter by Video-Assisted Thoracic Surgery

Sihoe, Das, Ling, Cheng — 2008-07-31

A paravertebral catheter was placed in a 34-year-old man to provide analgesia after a right upper lobectomy. On removal, the catheter broke within the chest wall. Although bedside exploration and computed tomography scanning failed to locate it, the 13-cm long retained fragment was easily retrieved by video-assisted thoracic surgery, using a single-port technique.

[CASE STUDIES] Anomalous Left Coronary Artery from Non-facing Pulmonary Sinus

Hirota, Kawada, Ishino, Sano — 2008-07-31

A case of anomalous left coronary artery originating from the non-facing pulmonary sinus, located at the most distal position from the aorta, is described. An intrapulmonary tunnel was created without causing undue stenosis or kinking. The Takeuchi procedure is considered to be a useful surgical technique when the origin of the anomalous left coronary artery is far from the aorta.

[CASE STUDIES] Simultaneous Bilateral Carotid Endarterectomy Under Local Anesthesia

Portinos, Kefaloyannis, Philippakis, Dountsis, Zisis, Bellenis — 2008-07-31

A 75-year-old man with bilateral carotid stenosis and severe coronary artery disease underwent successful simultaneous bilateral carotid endarterectomy under local anesthesia. A few days later, coronary artery bypass grafting was performed with no complications.

[HOW TO DO IT] A Simple Method of Inspection of Proximal Bleeding in Bentall Procedure

Song, Tokuda, Nakayama, Hattori — 2008-07-31

A simple method of checking for bleeding from the proximal anastomosis site in Bentall operations is described. After suturing a Carbo-Seal prosthesis to the aortic annulus, using a folding-over technique, the left ventricle is filled with cardioplegic solution through the prosthetic valve, and the heart is massaged to visualize possible leaks at the level of the suture.

[REVIEW PAPER] Pathophysiology of Aortocoronary Saphenous Vein Bypass Graft Disease

Hassantash, Bikdeli, Kalantarian, Sadeghian, Afshar — 2008-07-31

Aortocoronary saphenous vein bypass grafting relieves anginal pain in patients with coronary artery disease. However, its effectiveness is limited due to graft failure; the 10-year patency rate is 50%–60%. Early, 1-year and late graft failure may be due to thrombosis, fibrointimal hyperplasia and atherosclerosis, respectively. There is general agreement that vein graft atherosclerosis differs from arterial lesions in terms of temporal and histological changes. Vein graft atherosclerosis is more rapid, with diffuse concentric changes and a less noticeable fibrous cap, making venous plaques more vulnerable to rupture and subsequent thrombus formation. Despite progress in understanding the pathophysiology, some aspects of vein graft atherosclerosis need to be clarified. This review focuses on the pathophysiologic aspects of this widespread, costly and disabling disease, with emphasis on late graft occlusion and distinctions between arterial and venous atherosclerosis in terms of histology, pathophysiology and risk factors.

[REVIEW PAPER] Endovascular Repair of Traumatic Thoracic Aortic Injuries: a Critical Appraisal

Lin, Huynh, Kougias, Wall, Coselli, Mattox — 2008-07-31

Blunt trauma to the thoracic aorta is life-threatening, with instant fatality in at least 75% of victims. If left untreated, nearly half of those who survive the initial injury will die within the first 24 hours. Surgical repair has been the standard treatment of blunt aortic injury, but immediate operative intervention is frequently difficult due to concomitant injuries. Although endovascular treatment of traumatic aortic disruption is less invasive than conventional repair via thoracotomy, this strategy remains controversial in young patients due to anatomical considerations and device limitations. This article reviews the likely advantages of endovascular interventions for blunt thoracic aortic injuries. Potential limitations and clinical outcomes of this minimally invasive technique are also discussed.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Left Upper Limb Shortening Following Reverse Flap Subclavian Artery Angioplasty

Maddali, Menon, Valliattu, Maimouna — 2008-07-31

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] A Rare Cause of Pericardial Tamponade

Nanjappan, RajagopalaReddy, Velayutham, Rajagopal, DoraiRajan — 2008-07-31

[LETTER TO EDITOR] NEONATAL SHUNT OPERATIONS

Erer, Banach, Ugurlucan — 2008-07-31

[ERRATUM] ERRATUM

2008-06-18

[ELECTRONIC CASE STUDIES] Pyogenic Vertebral Osteomyelitis after Surgery for Rupture of the Aortic Arch

Nogami, Isoda, Shimizu, Kimura, Suzuki, Maehara — 2008-05-30

Vertebral osteomyelitis is a very rare and intractable complication after vascular surgery. We describe a case of pyogenic vertebral osteomyelitis induced by methicillin-resistant Staphylococcus Aureus sepsis following surgery for traumatic rupture of the aortic arch, successfully managed with long-term antibiotic therapy for 75 weeks.

[ELECTRONIC CASE STUDIES] Cavernous Hemangioma of The Rib: A Case Report

Ceberut, Aksoy, Savas, Muslehiddinoglu — 2008-05-30

Cavernous hemangioma of the bone is an uncommon benign vascular tumor, generally occurring in the spine or skull but extremely rare in the rib. We report the case cavernous hemangioma of the rib treated by surgical resection after CT and MR findings.

[ELECTRONIC CASE STUDIES] Abdominal Aortic Aneurysm Associated with Horseshoe Kidney

Kawanishi, Tanaka, Nakagiri, Yamashita, Okada, Okita — 2008-05-30

The optimal approach to abdominal aortic aneurysm with horseshoe kidney is still debated. We describe a successful abdominal aortic aneurysm repair through a left retroperitoneal approach in a 77-year-old woman with a horseshoe kidney.

[ELECTRONIC CASE STUDIES] Reversal of Myocardial Dysfunction Due to Brain Injury

Wippermann, Bennink, Wittwer, Madershahian, Ortmann, Wahlers — 2008-05-30

Severe myocardial dysfunction after blunt head injury is a rare but potentially lethal complication. We describe remarkable myocardial recovery after severe hemodynamic deterioration in a young man with brain injury, due to extracorporeal membrane oxygenation support. Because of the severity of brain damage, the patient succumbed after diagnosis of brain death. Postmortem histopathological examination of the heart showed severe myocardial necrosis.

[EDITORIAL] Fast Track in Thoracic Surgery

Freixinet, Rodriguez — 2008-05-30

[ORIGINAL CONTRIBUTIONS] Bicuspidized Pulmonary Homograft for Truncus Arteriosus Repair

Benjacholamas, Namchaisiri, Khongphatthanayothin, Lertsapcharoen — 2008-05-30

Primary repair is preferable to palliation in infants with truncus arteriosus. At our institute, an appropriately small homograft valved conduit is not available for every patient; a bicuspidized pulmonary valve homograft is an alternative. Between December 1996 and August 2005, 24 patients aged 28 days to 21 months with truncus arteriosus underwent primary repair with a homograft valved conduit; bicuspidized homografts were used in 15 of them. In the 18 (75%) patients who survived to hospital discharge, 5-year survival was 94% (75% for tricuspid homografts and 100% for bicuspidized homografts, which was not significantly different). Freedom from reoperation or balloon angioplasty in all 18 survivors was 89% at 5 years. Freedom from reoperation in tricuspid and bicuspidized homograft groups at 5 years was 67% and 100%, respectively; the difference was not statistically significant. Bicuspidized homografts worked as well as tricuspid conduits in the intermediate term. The remodeled homografts showed excellent hemodynamic characteristics and appear to be a reasonable alternative when an appropriate size of valved homograft is unavailable.

[ORIGINAL CONTRIBUTIONS] Catheter Ablation of Left Atrial Ganglionated Plexi for Atrial Fibrillation

Pokushalov, Turov, Shugayev, Artyomenko, Romanov, Shirokova — 2008-05-30

Radiofrequency ablation of pulmonary vein ostia does not provide complete and long-term elimination of atrial fibrillation. Combining this procedure with local radiofrequency application on sites with strong vagal reflexes results in partial parasympathetic denervation and increases the antiarrhythmic effect. A novel catheter-ablation technique to modify ganglionated plexi in the left atrium was assessed in 58 patients (mean age, 52.1 ± 1.9 years, 67% male) with drug-refractory atrial fibrillation, which was chronic in 21 (36%; mean duration, 14.3 ± 2.9 months; range, 5–39 months). The mean left atrial volume was 93.1 ± 6.1 mL. The patients underwent ablation of 4 areas of ganglionated plexi in the left atrium, with no circumferential ablation of the pulmonary veins; atrial fibrillation ceased immediately in 94.1% of them. Transient vagal bradycardia was seen in 93% of patients. For 7.2 ± 0.4 months after the procedure, 86.2% of them were free from arrhythmias, and no antiarrhythmic drugs were administered. Ganglionated plexi ablation is an efficient treatment for atrial fibrillation.

[ORIGINAL CONTRIBUTIONS] Effect of Completion of Cardiac Rehabilitation on Heart Rate Recovery

Soleimani, Salarifar, Kasaian, Sadeghian, Nejatian, Abbasi — 2008-05-30

To evaluate the effects of a cardiac rehabilitation program on heart rate recovery after percutaneous transluminal coronary angioplasty, a historical cohort study was performed on 436 patients of whom 285 were grouped on completion of 5, 10, or 24 training sessions. All 3 groups showed significant improvements in heart rate recovery, peak heart rate during treadmill testing, and end-training heart rate, from baseline to follow-up. Heart rate recovery on follow-up correlated significantly with the number of completed exercise sessions. The number of sessions, baseline ejection fraction, and age were independent predictors of mean post-training heart rate recovery. The cardiac rehabilitation program had a significant effect on peak heart rate and heart rate recovery, regardless of the underlying characteristics of the patients.

[ORIGINAL CONTRIBUTIONS] Echocardiographic Follow-Up after Implanting 17-mm Regent Mechanical Prostheses

Casali, Luzi, Vicchio, Lilla della Monica, Minardi, Musumeci — 2008-05-30

The aim of this study was to evaluate midterm echocardiographic results and changes in quality of life after aortic valve replacement with 17-mm St. Jude Medical Regent mechanical prostheses in patients with aortic valve stenosis. The study population was 34 women and 2 men, aged 31–83 years. Echocardiographic follow-up was 100% complete at 4.1 ± 1.8 years. Hospital mortality was 5.6%. Actuarial 5-year survival was 88.5% ± 0.067%. Postoperative echocardiography showed significant regression of left ventricular mass index and significant reductions of peak gradient, mean gradient and mean effective orifice area index. All survivors were interviewed using the 36-item Short Form Health Survey questionnaire. Scores obtained in 7 of the 8 domains of the test were significantly higher than preoperative values. In our experience, implantation of this prosthesis allowed regression of left ventricular mass index and improved the perceived quality of life.

[ORIGINAL CONTRIBUTIONS] Management of Extremity Vascular Trauma: Jammu Experience

Kohli, Singh — 2008-05-30

Experience in 111 patients treated for extremity vascular trauma between 1995 and 2004 is described. Only 40 (36%) patients presented within 6 hours of sustaining the injury. Penetrating injuries due to stabbing and gunshots were the causes in 65 patients, and blunt trauma in 46. There were associated bone fractures in 73 patients. The brachial artery was the most commonly injured upper limb vessel, whereas the femoral vessels were most often damaged in the lower limb. Surgical procedures consisted of end-to-end anastomosis in 50 patients, an interposition graft in 32, lateral arteriorrhaphy in 14, ligation in 6 and venous patch plasty in 5. Concomitant artery and vein repair was carried out in 12 patients, 6 underwent embolectomy and fasciotomy was performed in 16. Three (2.7%) patients died postoperatively. Good blood flow was obtained after repair in 69 (62%) patients, 29 (26%) had collateral compensation, 5 underwent primary amputation and 5 required secondary amputation. Most vascular injuries due to limb trauma can be managed successfully unless associated with severe damage to bones, nerves or soft tissues.

[ORIGINAL CONTRIBUTIONS] Postinfarction Ventricular Septal Defect: Patch Repair with Infarct Exclusion

Sajja, Mannam, Gutti, Goli, Sompalli, Penumatsa — 2008-05-30

Postinfarction rupture of the interventricular septum is usually fatal without prompt surgical intervention. Repair of postinfarction ventricular septal rupture by an endocardial patch technique with infarct exclusion is associated with less morbidity and mortality. The results of this repair in 22 consecutive patients were analyzed retrospectively. After myocardial infarction, 16 patients were operated on within 7 days, 3 at 8–21 days, and 3 at 3–6 weeks. 2D-echocardiography, color Doppler studies and coronary angiography were performed in all patients prior to surgery. The mean age of the patients was 57.46 ± 5.31 years and 20 were male; 15 were in cardiogenic shock or congestive heart failure at the time of operation. There were 5 (22.7%) operative deaths. Postoperative complications included low cardiac output, renal failure and respiratory failure. Preoperative cardiogenic shock, severe right ventricular dysfunction, residual ventricular septal defect, and preoperative renal failure were predictors of operative mortality. There were 2 late deaths. A rapid diagnosis, aggressive medical management and prompt surgical intervention are required to optimize survival and recovery in patients who present with septal rupture complicating myocardial infarction

[ORIGINAL CONTRIBUTIONS] Estimation of Pulmonary Vascular Resistance with Doppler Diastolic Gradients

Atiq, Tasneem, Aziz — 2008-05-30

This study was undertaken to determine the diastolic Doppler echocardiographic correlates of pulmonary vascular resistance calculated on cardiac catheterization in patients with secondary pulmonary arterial hypertension. Thirty-eight consecutive patients with congenital heart disease, pulmonary artery hypertension and pulmonary regurgitation were studied. Continuous-wave Doppler-derived pulmonary artery diastolic gradients were measured at 3 points on the pulmonary regurgitant diastolic velocity slope: peak diastolic, end-diastolic (at the R wave on the electrocardiogram), and mid-diastolic (midway between the peak and end-diastolic points). Catheterization data included oximetry, measurements of pressure in the cardiac chambers and great arteries, and calculation of pulmonary vascular resistance index. Doppler-derived peak, mid, and end-diastolic pulmonary regurgitation gradients correlated best with catheterization-measured pulmonary artery systolic, mean and diastolic pressures, respectively. The best Doppler correlate of pulmonary vascular resistance index was the pulmonary artery end-diastolic gradient. Clinically useful information can be obtained from Doppler pulmonary artery diastolic gradients measured on the pulmonary regurgitant diastolic velocity slope, which can estimate the pulmonary arterial pressure as well as pulmonary vascular resistance obtained on cardiac catheterization.

[ORIGINAL CONTRIBUTIONS] Predictors of Emergency Conversion to On-Pump During Off-Pump Coronary Surgery

Hovakimyan, Manukyan, Ghazaryan, Saghatelyan, Abrahamyan, Hovaguimian — 2008-05-30

The purpose of this study was to determine predictors and evaluate outcomes of emergency conversion to cardiopulmonary bypass during planned off-pump coronary artery bypass grafting. From January 2001 to November 2005, of 467 consecutive patients aged ≥ 60 years who underwent off-pump coronary surgery, 17 (3.6%) were converted to cardiopulmonary bypass. Those converted to an on-pump technique had significantly higher rates of postoperative cerebrovascular accident (17.6% vs 1.1%), intraaortic balloon pumping (5.9% vs 0%), and red blood cell transfusion (82.4% vs 57.3%), as well as prolonged intensive care unit stay (52.9% vs 25.2%), ventilation time (25% vs 5.3%) and hospital stay (64.7% vs 31.3%) compared to patients whose operation was completed off-pump. Multivariable logistic regression identified left ventricular ejection and left main stenosis as significantly associated with conversion. The rate of emergency conversion to cardiopulmonary bypass during planned off-pump coronary surgery was acceptable, but patients who required conversion had less favorable early outcomes than those who remained off-pump.

[ORIGINAL CONTRIBUTIONS] Gender Influence on Hospital Mortality after Coronary Artery Bypass Surgery

Mandegar, Marzban, Lebaschi, Ghaboussi, Alamooti, Ardalan — 2008-05-30

There is still controversy about the influence of gender on hospital mortality after coronary artery bypass grafting. We analyzed various risk factors in 1,258 patients undergoing isolated on-pump coronary artery bypass, of whom 19 (1.5%) died in hospital. There were 937 men (74.5%) and 321 women (25.5%). Compared to men, women were older with a higher mean body mass index, twice as many were hypertensive and diabetic, and they had higher serum cholesterol and triglycerides. Men smoked more, had lower ejection fractions, more myocardial infarctions and poorer functional status. Female sex, congestive heart failure, low ejection fraction, diabetes, previous percutaneous interventions and chronic lung disease were more prevalent among the patients who died. These factors were used to form a logistic regression model in which sex did not have an independent influence on hospital mortality. The difference between men and women can be explained by differences in risk factor profile.

[ORIGINAL CONTRIBUTIONS] Selection of Monitoring Site and Outcome after Neonatal Coarctation Repair

Maddali, Valliattu, al Delamie, Zacharias — 2008-05-30

To assess whether simultaneous invasive arterial pressure monitoring of right upper and lower limbs in neonatal aortic coarctation with or without arch hypoplasia has an impact on surgical decision-making and outcome, data of 140 newborns who underwent emergency surgical repair over 15 years were analyzed retrospectively. The 36 who had simultaneous right arm and lower limb arterial pressure monitored intraoperatively were assigned to group 1. The other 104 who had blood pressure monitored invasively at a single site (either upper or lower limb) were allocated to group 2. In group 1, a residual gradient across the repaired segment was detected intraoperatively in 13% of patients, and corrected at the same sitting. In group 2, 6% needed subsequent balloon angioplasty. In all babies with arch hypoplasia in group 1, the proximal aortic cross clamp was readjusted at least once to avoid compromise of carotid blood flow. Simultaneous right upper and lower limb invasive pressure monitoring has an impact on the overall outcome in these sick neonates.

[CASE STUDIES] Life-Threatening Vomiting Caused by Large Morgagni Hernia in an Octogenarian

Turut, Demirpolat, Bulbuloglu, Yuksel — 2008-05-30

An 84-year-old woman presented with frequent severe vomiting, dyspnea and generalized muscle weakness associated with diaphragmatic hernia. Her poor general condition and muscle weakness resembling cranial pathology were considered to be due to severe vomiting caused by a Morgagni hernia. An urgent subcostal laparotomy confirmed the diagnosis. The critical role of urgent surgery, even in advanced age, is emphasized.

[CASE STUDIES] Fracture Embolization of an Edwards-Duromedics Valve with Asymmetrical Closure

Yamazaki, Nishimura, Iwakura, Uehara, Okada, Sugita — 2008-05-30

We report a case of sudden leaflet fracture of an Edwards-Duromedics mitral valve 17-years after its implantation. The patient had a history of an asymmetrical motion of the valve, five months earlier. A computed tomography scan showed two fragments that had embolized to the right brachiocephalic artery and left common iliac artery. An emergency mitral replacement surgery was successfully performed. Asymmetrical closure of the valve leaflet may have contributed to valve fracture.

[CASE STUDIES] Extralobar Pulmonary Sequestration in the Hilum

Chen, Zheng — 2008-05-30

Extralobar pulmonary sequestration usually occurs between the left lower lobe and the diaphragm; occurrence in the hilum has not been reported previously. An unusual case of extralobar pulmonary sequestration, presenting initially as a hilar bronchogenic cyst in a 43-year-old female, is described.

[HOW TO DO IT] Entry Closure and Aortic Tailoring for Chronic Type B Aortic Dissection

Matsuyama, Narita, Usui, Akita, Oshima, Ueda — 2008-05-30

Although graft replacement for chronic type B dissection is the standard operation, this operation is invasive to some extent, and the mortality and morbidity remain high. We describe a simple and less invasive technique using initial entry closure and aortic tailoring of the dissected lumen.

[HOW TO DO IT] Repair of Anomalous Left Coronary Artery from the Right Pulmonary Artery

Modi, Chen, Murphy, Pawade — 2008-05-30

Surgical correction of anomalous left coronary artery from the right pulmonary artery is achieved by either direct implantation of the left coronary artery into the aorta or creation of a conduit between the two. We modified a technique originally described by Tashiro for the main pulmonary artery, by using a circumferential section of right pulmonary artery wall to create a conduit with a side-to-side anastomosis onto the aorta.

[HOW TO DO IT] Ascending Aortic Transection: Useful Adjunct in Pulmonary Artery Reconstruction

Singh, Krishnan, Agarwal, Dave, Cherian — 2008-05-30

Pulmonary artery reconstruction is frequently needed during surgery for congenital heart disease. Exposure of the main pulmonary artery and its branches is difficult if they are hypoplastic with a large anteriorly placed aorta. In redo operations, adhesions make this not only technically difficult, but also prone to bleeding. We electively transected the ascending aorta in 36 patients to facilitate pulmonary artery exposure, without complications or significant prolongation of cross clamp time.

[REVIEW PAPER] Cardioprotection with Volatile Anesthetics in Cardiac Surgery

Lorsomradee, Cromheecke, Lorsomradee, De Hert — 2008-05-30

Myocardial ischemia during the perioperative period is a major cause of morbidity and mortality after surgery. Experimental data indicate that clinical concentrations of volatile anesthetics protect the myocardium from ischemia and reperfusion injury, as shown by decreased infarct size and more rapid postoperative recovery of contractile function. These anesthetics may also mediate protective effects in other organs, such as the brain and kidney. A number of recent reports have indicated that these experimentally observed protective effects might also be present in the clinical setting. Implementation of such cardioprotection during surgery may provide an additional tool in the treatment and prevention of ischemic cardiac dysfunction in the perioperative period. This review discusses the clinical studies that have focused on the potential cardioprotective effects of volatile anesthetic agents.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Cardiac Fibroma on Chest X-Ray

Alotti, Rashed, Kecskes, Sipos — 2008-05-30

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Unicuspid Aortic Valve and Aortic Arch Aneurysm in a Patient with Turner Syndrome

Bansal, Arora, Traub, Haybron — 2008-05-30

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Tracheal Rupture in A Spontaneous Breathing Patient after A Blunt Chest Trauma

Knobloch, Simon, Haverich — 2008-05-30

[ELECTRONIC CASE STUDIES] Intimal Sarcoma of Aortic Arch Treated with Proton Therapy Following Surgery

Ishigami, Suzuki, Takahashi, Neyatani, Bashar, Kazui — 2008-04-01

Management of a rare case of intimal sarcoma of the aortic arch is reported, which was diagnosed unexpectedly after total arch replacement for pseudoaneurysm. The prognosis for this condition is poor, with death usually within a few months from diagnosis. The newly developed proton-beam radiation therapy was applied to treat a local recurrence of the sarcoma following surgery. Positron-emission tomography/computed tomography revealed complete remission of the lesion.

[ELECTRONIC CASE STUDIES] Mycotic Pseudoaneurysm of the Ascending Aorta at Site of Aortic Cannulation

Gabbieri, Dohmen, Linneweber, Lembcke, von Heymann, Konertz — 2008-04-01

Reoperation for pseudoaneurysm of the ascending aorta presents a surgical challenge. Instituting femorofemoral bypass and establishing hypothermic circulatory arrest is a well-known strategy, although not free from complications. We report a case of mycotic pseudoaneurysm after coronary artery bypass in a 53-year-old man, at the site of previous aortic cannulation, and review the surgical strategies proposed to manage this pathologic entity.

[ELECTRONIC CASE STUDIES] Double Outlet Right Ventricle with Anomalous Left Pulmonary Artery

Bockeria, Makhachev, Sobolev, Plakhova, Gorbachevsky, Zaets — 2008-04-01

We describe a rare case of anomalous origin of the left pulmonary artery from the ascending aorta with concomitant double-outlet right ventricle in a 2-year-old boy. He underwent successful 2-stage surgical treatment with transluminal balloon pulmonary valvuloplasty, followed by complete repair. A follow-up examination at 4 years after the operation showed good results.

[ELECTRONIC CASE STUDIES] Chylous Pericardial Effusion after Aortic Valve Replacement

Chaloob, Brown, Stuklis — 2008-04-01

Chylous pericardial effusion after open-heart surgery is a rare complication. We report a case of chylous pericardial effusion following aortic valve replacement, which presented as cardiac tamponade, and its subsequent management.

[EDITORIAL] From Vision to Mission in Myocardial Restoration

Kofidis, Lee — 2008-04-01

[ORIGINAL CONTRIBUTIONS] Procedural Outcome and Midterm Result of Carotid Stenting in High-Risk Patients

Kojuri, Ostovan, Zamiri, Zolghadr Asli, Bani Hashemi, Borhani Haghighi — 2008-04-01

Carotid endarterectomy is the standard treatment for carotid stenosis, but carotid artery stenting has emerged as a potential alternative. Elective carotid artery stenting was performed in 42 patients aged 42 to 79 years (mean, 67.05 ± 8.67 years) after ultrasonography, computed tomography, magnetic resonance angiography and a neurological evaluation. There was bilateral carotid stenosis in 23 patients (55%), with > 90% stenosis in 18 vessels. All patients had significant associated coronary lesions. An emboli protection device and self-expanding stents were used. One year later, the patients were evaluated by Doppler sonography and selective angiography. Technical success was achieved in all procedures. During follow-up, 1 (2.4%) patient died from myocardial infarction, 1 underwent coronary artery bypass and 14 (40%) had minor complaints including occasional dizziness. No other neurological events were noted. Restenosis was found in one case, but selective angiography ruled out a significant lesion. One patient suffered embolization, but recovered completely within 24 hours. In 7 (17%) patients with type C arch interruption and a tortuous carotid course, stenting was successful and they had no embolization or restenosis. Carotid artery stenting is recommended in high-risk patients.

[ORIGINAL CONTRIBUTIONS] Cardiac Troponin I vs EuroSCORE: Myocardial Infarction and Hospital Mortality

Simon, Capuano, Roscitano, Benedetto, Comito, Sinatra — 2008-04-01

Perioperative myocardial infarction is the most common cause of morbidity and mortality in cardiac surgery. It occurs in 8% to 35% of patients. The primary aim of this prospective study was to determine the level of cardiac troponin I that indicates perioperative myocardial infarction in patients undergoing coronary artery bypass. A secondary goal was to establish the best independent predictor of hospital death. There were 180 consecutive patients undergoing isolated coronary artery bypass surgery enrolled in this study. Values of cardiac troponin I > 12.9 ng·mL^–1 at 8 hours postoperatively predicted perioperative myocardial infarction with a sensitivity of 100% and a specificity of 93.2%. Compared to patients who survived, those who suffered hospital death were significantly older (74 ± 7 vs 63 ± 10 years), had significantly higher levels of cardiac troponin I at 24 hours (9 ± 17 vs 27.3 ± 16 ng·mL^–1) and 48 hours (6.9 ± 19 vs 30.3 ± 24 ng·mL^–1) postoperatively, and a significantly higher EuroSCORE (9 ± 2 vs 4 ± 3). At 8 hours postoperatively, cardiac troponin I led to an earlier diagnosis of perioperative myocardial infarction, while EuroSCORE was the strongest independent predictor of hospital death.

[ORIGINAL CONTRIBUTIONS] Differentiation of Ischemic and Dilated Cardiomyopathy on Electrocardiograms

Aghasadeghi, Aslani — 2008-04-01

Differentiating coronary artery disease with left ventricular dysfunction from dilated cardiomyopathy is important prognostically and therapeutically. To provide a diagnostic algorithm to distinguish these conditions using a standard 12-lead electrocardiogram, all 105 patients with left ventricular ejection fraction < 50% who underwent angiography between January 2004 and December 2006 were studied prospectively. Coronary artery disease was defined as ≥ 50% stenosis of the left main coronary artery or ≥ 70% stenosis of 1 or more of the 3 major epicardial arteries. Normal coronary angiography findings with left ventricular ejection fraction < 50% was defined as dilated cardiomyopathy. The most specific finding for differentiation of these diseases was pathologic Q waves in lead II, aVF, V3 or V4. The most sensitive parameter was a ratio ≥ 5 of R-wave amplitudes in lead V6 and lead III (94% sensitive). The 12-lead electrocardiogram provides a useful noninvasive method for differentiation of dilated cardiomyopathy from coronary artery disease with left ventricular systolic dysfunction.

[ORIGINAL CONTRIBUTIONS] Valvuloplasty in the Treatment of Rheumatic Tricuspid Disease

Pande, Agarwal, Majumdar, Kapoor, Kale, Kundu — 2008-04-01

Organic involvement of the tricuspid valve is uncommon. Valve repair is preferred over replacement as it results in a low gradient across the valve and obviates the risk of prosthesis-related complications. From October 2002 to October 2004, 37 patients who required tricuspid valve repair for organic involvement were included in this study. They were divided into 2 groups depending on the surgical procedure for valve repair: 20 patients in group 1 had tricuspid commissurotomy and De Vega annuloplasty; 17 in group 2 had tricuspid commissurotomy only. There were significant reductions in peak and mean tricuspid gradients and right ventricular systolic pressure in both groups. Annular shortening was similar in both groups (median, 23% in group 1, 21% in group 2), but the ratio of the tricuspid regurgitation jet area to right atrial area was greater in group 2 (median, 0.40 in group 2, 0.19 in group 1). There was no postoperative death. We recommend supporting the tricuspid annulus with annuloplasty in patients with organic tricuspid valve disease and no dilatation of the annulus, if annular shortening is < 30%.

[ORIGINAL CONTRIBUTIONS] Abscess of Residual Lobe After Pulmonary Resection for Lung Cancer

Ligabue, Voltolini, Ghiribelli, Luzzi, Rapicetta, Gotti — 2008-04-01

Abscess of the residual lobe after lobectomy is a rare but potentially lethal complication. Between January 1975 and December 2006, 1,460 patients underwent elective pulmonary lobectomy for non-small-cell lung cancer at our institution. Abscess of the residual lung parenchyma occurred in 5 (0.3%) cases (4 bilobectomies and 1 lobectomy). Postoperative chest radiography showed incomplete expansion and consolidation of residual lung parenchyma. Flexible bronchoscopy revealed persistent bronchial occlusion from purulent secretions and/or bronchial collapse. Computed tomography in 3 patients demonstrated lung abscess foci. Surgical treatment included completion right pneumonectomy in 3 patients and a middle lobectomy in one. Complications after repeat thoracotomy comprised contralateral pneumonia and sepsis in 1 patient. Residual lobar abscess after lobectomy should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy and bronchoscopy. Computed tomography is mandatory for early diagnosis. Surgical resection of the affected lobe is recommended.

[ORIGINAL CONTRIBUTIONS] Survival after Surgery with Cardiopulmonary Bypass in Low Weight Patients

Miyamoto, Sinzobahamvya, Photiadis, Brecher, Asfour — 2008-04-01

To evaluate risk factors for hospital death in patients weighing < 2.5 kg undergoing open-heart surgery, records of 34 consecutive low-weight patients operated on between December 1997 and November 2004 were reviewed. Mean weight was 2.152 ± 0.237 kg (range, 1.600 to 2.460 kg). Biventricular repair was achieved in 28 patients. The most frequent procedures were the arterial switch operation in 9 children, ventricular septal defect closure in 6, repair of total anomalous pulmonary venous connection in 5 and truncus arteriosus repair in 5. There were 8 early deaths. Mortality was strongly associated with the Comprehensive Aristotle Complexity Score: mortality was low (2/27; 7.4%) with a score < 19, and high (6/7; 85.7%) with a score ≥ 19. Higher mortality was encountered after univentricular repair (4/6; 67%). Hyperlactatemia at the end of cardiopulmonary bypass was also associated with poor survival. A Comprehensive Aristotle score < 19 was the strongest predictor of survival in low-weight patients undergoing open-heart surgery. Biventricular repair, when feasible, should be promoted to improve outcome.

[ORIGINAL CONTRIBUTIONS] Management of Malignant Pleural Effusion Associated with Trapped Lung Syndrome

Qureshi, Collinson, Powell, Froeschle, Berrisford — 2008-04-01

Management of recurrent malignant pleural effusion associated with trapped lung syndrome remains problematic. An alternative treatment using a pleural catheter has been advocated. Between August 1999 and August 2002, 127 patients underwent thoracoscopy for malignant pleural effusion. Of these, 52 (41%) with trapped lung were managed by insertion of a pleural catheter. Mean age was 66 years (range, 42–89 years). The most frequent diagnosis was breast cancer. Spontaneous pleurodesis (drainage < 10 mL) occurred in 25 (48%) patients whose catheter was removed after 30 to 255 days (mean, 93.8 days). Symptomatic relief was achieved in 49 (94%) patients. Mean dyspnea score improved significantly from 3.0 to 1.9. Complications comprised catheter blockage, surgical emphysema, cellulitis, and loculated effusion in 2 patients each. Mean length of hospital stay was 3 days (range, 1–16 days). Median survival was 126 days (range, 10–175 days). We conclude that long-term placement of a pleural catheter provides effective palliation for malignant pleural effusion associated with trapped lung syndrome.

[ORIGINAL CONTRIBUTIONS] Potential Role of Adipocytokine Leptin in Acute Coronary Syndrome

Dubey, Zeng, Wang, Liu — 2008-04-01

By activating immune cells or a direct action on the vascular wall, leptin may affect the initiation and progression of atherosclerosis. We investigated whether plasma leptin concentration is associated with coronary artery disease, with particular focus on the relationship between plasma leptin and the development of an acute coronary syndrome. Plasma leptin, interleukin-6 and high-sensitivity C-reactive protein were measured in 34 patients with acute coronary syndrome and 21 with stable angina. Their results were compared with those of 21 normal controls. Plasma leptin levels were significantly higher in the acute coronary syndrome group (13.36 ± 5.02 ng·mL^–1) compared to the stable angina group (8.97 ± 4.06 ng·mL^–1) or normal controls (5.14 ± 2.75 ng·mL^–1). Interleukin-6 and high-sensitivity C-reactive protein were also higher in the acute coronary syndrome group, and leptin correlated positively with interleukin-6 and high-sensitivity C-reactive protein. These findings suggest that plasma leptin levels may be a useful marker of systemic inflammation, and measurement of plasma leptin may be helpful in assessing the risk of developing coronary heart disease.

[ORIGINAL CONTRIBUTIONS] Valve Repair in Rheumatic Heart Disease in Pediatric Age Group

Reddy, Dharmapuram, Swain, Ramdoss, Raghavan, Murthy — 2008-04-01

Valve repair in children is technically demanding but more desirable than valve replacement. From April 2004 to September 2005, 1 boy and 8 girls with rheumatic heart disease, aged 2–13 years (median, 9 years), underwent valve repair for isolated mitral regurgitation in 5, combined mitral and aortic regurgitation in 2, mitral stenosis in 1, and mitral regurgitation associated with atrial septal defect in 1. Chordal shortening in 7, annular plication in 6, commissurotomy in 1, reconstruction of commissural leaflets in 7 were performed for mitral valve disease. Plication and reattachment of the aortic cusps was carried out in 2 patients. Annuloplasty rings were not used. All patients survived the operation, 8 had trivial or mild residual mitral regurgitation, and 1 had trivial aortic regurgitation. Mean left atrial pressure decreased from 14 to 7 mm Hg postoperatively. During follow-up of 3–18 months, all children were asymptomatic and enjoyed normal activity. None required reoperation. In addition to chordal shortening and annular plication, reconstruction of the commissural leaflets is considered the most important aspect of valve repair. It can be achieved without annuloplasty rings, giving good early and midterm results.

[ORIGINAL CONTRIBUTIONS] Endoscopic vs Conventional Vein Harvesting: a Prospective Analysis

Vaidyanathan, Sankar, Cherian — 2008-04-01

Minimally invasive vein harvesting is associated with better leg wound healing and a lower incidence of wound infections. We analyzed our experience in 2 prospectively enrolled groups of non-randomized patients undergoing elective coronary artery bypass grafting. Group 1 was 81 patients who had endoscopic vein harvesting; group 2 was 80 who had conventional open vein harvesting. The time taken for endoscopic harvest (skin incision to skin closure) was significantly less than that for open harvest (51.07 vs 75.94 min). The number of cases to reach a plateau on the learning curve for endoscopic vein harvest was 20 for 2 lengths of vein and 35 for 3 lengths of vein. Significantly more suture repairs per vein were required in group 1 (1.32) than group 2 (0.38). The incidence of wound infection was 1.2% in group 1 vs 8.8% in group 2. Endoscopic vein harvesting is not difficult to learn and it should be preferred over open vein harvest, given its benefits in wound healing.

[ORIGINAL CONTRIBUTIONS] Solitary Benign Fibrous Tumors of the Pleura

Regal, Al Rubaish, Al Ghoneimy, Hammad — 2008-04-01

Solitary benign fibrous tumors of the pleura are very rare. Seven patients (mean age, 52 years) who presented between 1995 and 2005 were studied retrospectively. They had nonspecific chest symptoms and no history of asbestos exposure or smoking. Chest radiography showed a large opacity occupying most of the affected hemithorax, with clear costophrenic angles. Computed tomography of the chest showed a large well-delineated heterogeneous mass directly related to the lateral chest wall. Needle biopsy suggested the benign nature of the lesion. Surgery was performed through a posterolateral thoracotomy. Five tumors arose from visceral pleura, and 2 from parietal pleura. The mean tumor diameter was 7.5 cm (range, 8–14 cm). Complete surgical excision was carried out in all cases. Histopathology and immunohistochemical staining confirmed the benign nature of the tumors. There was no mortality or major complication. The mean follow-up period was 4 years (range, 1–10 years). All patients remained tumor-free during follow-up. Wide local excision, including pulmonary and pleural resection, is recommended as the best therapeutic option.

[ORIGINAL CONTRIBUTIONS] Intramyocardial Angiogenic Cell Precursor Injection for Cardiomyopathy

Arom, Ruengsakulrach, Jotisakulratana — 2008-04-01

Stem cell therapy for heart failure is a rapidly progressing field. The objective of this study was to assess the safety, and short-term results of thoracoscopic direct injection of angiogenic cell precursors into patients with endstage cardiomyopathy. Cells were obtained from the patient’s own blood, avoiding immunological concerns. The number of cells prior to injection was 29.1 ± 18.9 x10⁶. Forty-one patients with cardiomyopathy (mean age, 58.5 ± 14.3 years) underwent stem cell injection; 21 had dilated cardiomyopathy and 20 had ischemic cardiomyopathy. Overall ejection fraction improved significantly by 4.8% ± 7.5% at 149 ± 98 days postoperatively. It increased from 25.9% ± 8.6% to 28.7% ± 9.8% in dilated cardiomyopathy, and from 26.6% ± 5.8% to 33.6% ± 7.8% in ischemic cardiomyopathy. New York Heart Association functional class was significantly better at 2 months in both groups. It was concluded that thoracoscopic intramyocardial angiogenic cell precursor injection is feasible and safe in patients with cardiomyopathy. The early results are good, and phase II trials are in progress.

[CASE STUDIES] Late Presentation of Cor Triatriatum with Persistent Levoatrial Cardinal Vein

Feltri, Crawley, Peart, Pozzi, Corno — 2008-04-01

An asymptomatic 10-year-old boy presented with reduced exercise tolerance and an echocardiographic diagnosis of cor triatriatum. Transthoracic and transesophageal echocardiography failed to reveal the persistent levoatrial cardinal vein discovered at surgery. In patients with late presentation of cor triatriatum with severe mitral inflow obstruction and a small patent foramen ovale, an alternative communication between the posterior collecting chamber and the systemic venous circulation should be sought with alternative imaging techniques.

[CASE STUDIES] Fibrin Sealant for Left Ventricular Rupture after Mitral Valve Replacement

Garcia-Villarreal, Casillas-Covarrubias — 2008-04-01

Despite safer surgical procedures, left ventricular rupture remains a rare but potentially lethal complication of mitral valve replacement. The use of fibrin sealant has substantially improved the outcome of many difficult bleeding episodes after cardiac surgery. We describe a case of left ventricular rupture successfully treated with fibrin sealant combined with external Teflon-pledgeted sutures.

[CASE STUDIES] Angiosarcoma Presenting as Syncope

Nayar, Nayar, Cherian — 2008-04-01

A 31-year-old lady presented with anemia and syncope. Echocardiography revealed massive pericardial effusion with a right atrial mass. Transesophageal echocardiography, computed tomography and magnetic resonance imaging scans confirmed presence of a right atrial mass. Histopathology revealed a high grade angiosarcoma. Complete resection was done and the patient was referred to an oncology unit for further management. After three months the patient had extensive metastasis and succumbed to the disease. This case report highlights the clinical presentation, rapid and aggressive course of cardiac angiosarcomas.

[CASE STUDIES] Hancock Valve Deterioration in Tricuspid Position for Ebstein's Anomaly

Sughimoto, Nakano, Gomi, Nakatani, Nakamura, Sato — 2008-04-01

A 65-year-old woman with a Hancock valve implanted 25 years earlier for Ebstein’s anomaly underwent a successful second tricuspid valve replacement with a Mosaic valve because of significant tricuspid regurgitation. At surgery, it was found that the Hancock valve had a cylinder-shaped hole and had lost its entire structure. Tricuspid valve dysfunction may be tolerated for a long time before surgery is contemplated.

[HOW TO DO IT] Left Heart Pump-Assisted Beating Heart Coronary Surgery in High-Risk Patients

Pepino, Oliviero, Petteruti, di Tommaso, Monaco, Stassano — 2008-04-01

A simple technique of left ventricular assistance, offering the advantages of both cardiopulmonary bypass and off-pump revascularization, was adopted for high-risk patients. It was used in 56 patients with critical left main stenosis and occluded right coronary artery, severely reduced ejection fraction and/or unstable angina. All patients underwent complete and successful myocardial revascularization (3.4 grafts per patient). Weaning from the pump was uncomplicated, and none required conversion to full cardiopulmonary bypass.

[HOW TO DO IT] Easy Technique for Placing Anchoring Sutures for Aortic Root Reimplantation

Ogino, Minatoya, Matsuda, Sasaki — 2008-04-01

In the aortic valve-sparing reimplantation technique, insertion of the anchoring sutures beneath the valve is a crucial but difficult step because the spared aortic cusps obscure the field of view. We present a novel and easy method of placing these anchoring stitches with good exposure of the subvalvular tissue.

[REVIEW PAPER] Current Status of Off-pump Coronary Artery Bypass Surgery

Raja, Dreyfus — 2008-04-01

The expanding indications for angioplasty coupled with the successful short and mid-term results of randomized controlled trials of drug-eluting stents have already had an unquestionable impact on the practice of coronary revascularization operations. However, coronary artery bypass grafting remains a major mode of therapy for coronary artery disease. It is likely that surgery will continue to be preferred for more complex subsets and that surgeons will have to continue to maintain good results in patients with more complex problems. Concerns regarding morbidity associated with conventional surgical myocardial revascularization on cardiopulmonary bypass have led to a resurgence of interest in off-pump bypass surgery during the last decade, with the expectation that it would be safer if cardiopulmonary bypass could be avoided. This review summarizes the impact of off-pump bypass surgery in reducing the morbidity and mortality associated with conventional coronary artery bypass on cardiopulmonary bypass by evaluating the current best-available evidence from randomized controlled trials and meta-analyses comparing off-pump surgery with conventional bypass grafting.