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Background: Limited surgical options are available for patients with extensive mitral annular calcification. Several reports have shown the feasibility of surgical mitral valve replacement (MVR) using a transcatheter aortic valve in the mitral position (MVR-TAVR). This study reviewed 30-day and 1-year outcomes of a minimally invasive approach for MVR-TAVR., Methods: Between 2017 and 2019, 16 patients underwent MVR-TAVR under direct vision. Primary end points included overall survival, technical success, and effectiveness. Secondary end points included valve and cardiac hemodynamics postoperatively and during follow up., Results: The 16 patients (69% female) were 53 to 88 years of age (average, 77 ± 9 years). Comorbidities on presentation were as follows: 31% (5 of 16) were reoperative procedures; 13% (3 of 16) of patients had right ventricular dysfunction, 31% (5 of 16) had severe pulmonary hypertension, and 20% (3 of 16) had chronic kidney disease. Isolated MVR-TAVR was performed on 69% (11 of 16) of patients, with a cross-clamp (58%; 7 of 12) or on a fibrillating heart (42%; 5 of 12), whereas concomitant MVR-TAVR was performed in 31% (5 of 16) of patients with a cross-clamp. At follow-up, the estimated 30-day mortality rate was 12.5%, and the 1-year mortality rate was 36.2%. A moderate postoperative paravalvular leak (PVL) was evident immediately in 1 patient, and a severe PVL was noted after 30-day follow-up in another. In addition, 1 patient had mild left ventricular outflow tract obstruction, and another had moderate mitral valve stenosis. At 1-year follow-up, there were no changes in the mild PVL and moderate stenosis identified postoperatively., Conclusions: Minithoracotomy MVR-TAVR is an acceptable alternative to conventional and transcatheter MVR in patients with mitral valve disease and extensive mitral annular calcification., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Severe mitral annulus calcifications significantly hinder surgical repair and replacement of the dysfunctional mitral valve. Herein, we present a novel surgical technique where we created an intra-atrial neomitral ring using a vascular Dacron graft in which a prosthetic valve was implanted. This approach is a simple alternative technique that can be used when anatomic prosthetic valve implantation is not feasible. Major assets of this approach are evasion of extensive debridement, implantation of an adequately sized prosthesis, and prosthetic material availability., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Traditionally, quantification of aortic valve calcium (AVC) has been performed with noncontrast computed tomography (NCCT) using the Agatston method. This study sought to derive and validate a systematic method enabling AVC quantification using computed tomographic angiography (CTA) in patients with aortic stenosis (AS)., Methods: The study included 134 consecutive patients with AS who underwent both NCCT and CTA and were subdivided into derivation (n = 71) and validation cohorts (n = 63). AVC on NCCT (AVC NCCT ) was quantified using the Agatston method using the software developed for semiautomatic assessment of coronary calcium. On CTA, the mean contrast attenuation of the aorta in Hounsfield units (Aorta HU ) and SD was measured in the region of interest at the level of the sinotubular junction., Results: Using an adjusted calcium detection threshold of Aorta HU  + 2 SD, we calculated AVC on CTA (AVC CTA ) using the same software without modifying other variables. Correlation between AVC NCCT and AVC CTA in the derivation cohort was excellent (r = 0.9679; P < .001). We used a linear regression model to derive a formula for predicting AVC CTA that enabled conversion of AVC CTA to AVC Derived (AVC Derived  = 1.821 × AVC CTA ). Applying this formula in validation cohort, we calculated AVC Derived , which showed excellent agreement with AVC NCCT (intraclass correlation coefficient, 0.9648; 95% confidence interval, 0.9427-0.9782). Excellent correlation was also found between categorized AVC NCCT and AVC Derived scores (κ = 0.9044; 95% confidence interval, 0.7989-1.0000), with 95.24% (60 of 63) of scores falling within the same severity category., Conclusions: AVC quantification on CTA is feasible with high accuracy and reliability and shows excellent agreement with the standard AVC NCCT score. With the systematic approach using "dynamic thresholds" being largely independent of the scan acquisition protocol, AVC Derived can potentially replace AVC NCCT , eliminating the need for separate NCCT acquisition solely for AVC quantification., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Mitral annular calcification (MAC) increases technical complexity for surgeons during mitral valve (MV) procedures. This study assesses the risks conferred by the presence of MAC in patients undergoing MV replacement (MVR) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database., Methods: A total of 52,816 MVR procedures were performed between 2011 and June 2017. Individuals with concomitant tricuspid procedures were included, but those from institutions that reported < 1 MAC case/y were excluded. Operative mortality and in-hospital complications in MAC patients were compared with controls from the same institution. The contribution of hospital MV procedure volume (stratified by mean procedures per year during) to adjusted operative mortality was also assessed., Results: Overall, 9551 MVR cases were classified as MAC (18.1%). Observed operative mortality was 5.8% for MAC and 4.4% for non-MAC patients (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.19-1.38). Although postoperative stroke and reoperation rates were similar, MAC was associated with increased risk of acute kidney injury (relative risk, 1.15) and reintubation (relative risk, 1.26) (all P < .001). After risk adjustment, MAC remained a risk factor for operative mortality (OR, 1.24; 95% CI, 1.08-1.42). Centers with less than 50 MV procedures/y were also associated with increased operative mortality (OR, 1.21; 95% CI, 1.08-1.37; observed-to-expected mortality among MAC patients 1.09 vs 0.82 in centers with ≥ 50 MV procedures; P = .001) CONCLUSIONS: The presence of MAC alone, regardless of severity, was independently associated with increased operative mortality and adverse postoperative outcomes. Even after adjusting for attendant cardiovascular and metabolic comorbidities, centers with low MV case volumes were found to have worse outcomes after MVR., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Cardiac pseudoaneurysms of noninfectious or nonischemic etiology are rare. This case report illustrates the surgical management of a patient with a large postsurgical calcified pseudoaneurysm located in the base of the heart that was disrupting the continuity between the aortic and mitral annulus., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Mitral annular calcification (MAC) is associated with worse outcomes after mitral valve replacement (MVR). With limited data available on long-term outcomes, we reviewed our experience of MVR in presence of MAC., Methods: A retrospective review of 1,710 consecutive patients who underwent MVR between January 2000 and December 2015 was performed. Patients with isolated primary MVR (n = 496) were included, whereas patients with concomitant cardiac surgery (n = 1,068), previous MVR (n = 110), and mitral valve (MV) endocarditis (n = 36) were excluded. MV calcification was classified as MAC present in anterior/posterior annulus and vertically at the level of leaflets/subvalvular apparatus. A conservative approach towards annular debridement was followed., Results: Our sample's mean age was 64.4 ± 14.1 years, and included 279 (56%) women. MV calcification was observed in 169 (34%) patients with MAC in 115 (23%). Older age, higher ejection fraction, peripheral vascular disease, diabetes, dialysis, and previous aortic valve surgery were associated with increased prevalence of MAC. Patients with MV calcification had higher stroke rate (p = 0.040), patients with anterior leaflet and commissural calcification had higher pacemaker implantation (p = 0.010, p = 0.001, respectively), and patients with circumferential MAC had higher postoperative dialysis (p = 0.006). Operative mortality was not significantly different (p = 0.466) between MAC (n = 1, 1%) and non-MAC (n = 9, 2%) patients. MAC was associated with late mortality (unadjusted hazard ratio, 1.62; 95% confidence interval, 1.20 to 2.18), though on multivariable analysis age, diabetes, dialysis, hypertension, previous aortic valve surgery, previous coronary artery bypass grafting, and MVR with a bioprosthetic valve were found to be independent risk factors for mortality whereas MAC was not., Conclusions: A conservative approach to treat MAC achieves satisfactory results. Patients with MAC have significant comorbidities contributing to a worse survival, though MAC in itself is not a risk factor for mortality., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Mitral valve replacement is technically challenging in the context of mitral annular calcification. A new surgical strategy is described that was used in a 71-year-old obese patient, where intraatrial prosthesis insertion and valve fixation into native uncalcified structures were performed without calcium debridement., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification; it can manifest with conduction abnormalities or systemic embolization. It typically involves the posterior mitral annulus, and surgery is indicated for severe mitral valve dysfunction, for embolic complications or when the diagnosis is not certain. We describe a structured approach to the surgical management of CCMA using bovine pericardium to repair the defect., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We describe an improvised technique during open surgery of inserting a transcatheter heart valve in the mitral position under very challenging circumstances. This is the first described use of the "extended collar" technique, which allowed implantation of a transcatheter heart valve in severe mitral valve annular calcification, into which a surgical valve could not safely be implanted. We believe that this technique is reproducible and may be helpful to other surgeons when faced with similar difficult circumstances., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Transcatheter valve implantation in the mitral position with severe calcific mitral stenosis has been described in patients who are at an increased risk for conventional mitral valve surgical procedures. We report the direct deployment of the Sapien 3 valve in the mitral position with severe mitral annular calcification through a sternotomy in an arrested heart in two cases., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Substantial aortic calcification is known to be associated with aortic stiffening and subsequent left ventricular (LV) hypertrophy. This study examined whether the thoracic aorta calcium score (TACS) is related to LV hypertrophy and whether it leads to an adverse prognosis in patients with severe aortic stenosis (AS) after aortic valve replacement (AVR)., Methods: We retrospectively reviewed 47 patients (mean age, 64 ± 11 years) with isolated severe AS who underwent noncontrast computed tomography of the entire thoracic aorta and who received AVR. TACS was quantified using the volume method with values becoming log transformed ( log [TACS+1]). Transthoracic echocardiography was performed before and 1 year after the operation., Results: Preoperative LV mass index (LVMI) displayed significant positive correlations with male gender (r = 0.430, p = 0.010) and log (TACS+1) (r = 0.556, p = 0.003). In multivariate linear regression analysis, only log (TACS+1) was independently associated with LVMI, even after adjusting for age, gender, transaortic mean pressure gradient, and coronary or valve calcium score. Independent determinants for postoperative LVMI included log (TACS+1) and preoperative LVMI after 1 year of follow-up echocardiography, adjusting for age, gender, indexed effective orifice area, and coronary or valve calcium score. During a median follow-up period of 54 months after AVR, there were 10 events (21%), which included 4 deaths from all-causes, 3 strokes, 2 inpatient admissions for heart failure, and 1 myocardial infarction. The event-free survival rate was significantly lower for patients with TACS of 2,257 mm 3 or higher compared with those whose TACS was lower than 2,257 mm 3 (log-rank p < 0.001)., Conclusions: High TACS was associated with increased LVMI among patients with severe AS. Further, high TACS usefully predicted less regression of LVMI and poor clinical outcomes after AVR. TACS may serve as a useful proxy for predicting LV remodeling and adverse prognosis in patients with severe AS undergoing AVR., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Mitral annular calcification (MAC) is a chronic degenerative process at the fibrous base of the mitral valve. It is a feared diagnosis in the context of mitral valve operations because of the risk of severe adverse events such as atrioventricular disruption, injury to the circumflex artery during debridement, and difficult placement of annular sutures. We report a series of 3 consecutive female patients with severe circular MAC who underwent successful mitral valve replacement through a lateral minithoracotomy with use of an inverted transcatheter aortic valve., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Anastomotic leakage is associated with increased morbidity and mortality after esophagectomy. Calcification of the arteries supplying the gastric tube has been identified as a risk factor for leakage of the cervical anastomosis, but its potential contribution to the risk of intrathoracic anastomotic leakage has not been elucidated. This study evaluated the relationship between calcification and the occurrence of leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy., Methods: Consecutive patients who underwent minimally invasive esophagectomy for cancer at 2 institutions were analyzed. Diagnostic computed tomography images were used to detect calcification of the arteries supplying the gastric tube (eg, aorta, celiac axis). Multivariable logistic regression analysis was used to determine the relationship between vascular calcification and anastomotic leakage., Results: Of 167 included patients, anastomotic leakage occurred in 40 (24%). In univariable analysis, leakage was most frequently observed in patients with calcification of the aorta (major calcification: 37% leakage [16 of 43]; minor calcification: 32% [18 of 56]; no calcification: 9% [6 of 70], p < 0.001). Calcification of other studied arteries was not significantly associated with leakage. A significant association with leakage remained for minor (odds ratio, 5.4; 95% confidence interval, 1.7 to 16.5) and major (odds ratio, 7.0; 95% confidence interval, 1.9 to 26.4) aortic calcifications in multivariable analysis., Conclusions: Atherosclerotic calcification of the aorta is an independent risk factor for leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy for cancer. The calcification scoring system may aid in patient selection and lead to earlier diagnosis of this potentially fatal complication., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Among cardiac calcified amorphous tumors, the mitral annular calcification-related calcified amorphous tumor is extremely rare. We herein describe 3 surgical cases of swinging calcified amorphous tumor with related mitral annular calcification. The clinical, echocardiographic, and pathophysiologic features are reported here together with a brief review of the literature., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Mitral valve surgery in patients with severe mitral annular calcification can be challenging. We investigated surgical outcomes of mitral valve surgery with complete annular decalcification and reconstruction., Methods: Between January 2004 and December 2013, 2,104 patients underwent mitral valve surgery at our institution. Of these, 61 patients (mean age 70 years) with severe mitral annular calcification were reviewed. Valve lesions were stenosis in 20 patients (32.8%), regurgitation in 16 (26.2%), mixed in 19 (31.1%), and prosthetic valve dehiscence in 6 (9.8%). Calcified annulus was resected completely and reconstructed with equine pericardium in 48 patients (78.7%), autologous pericardium in 10 (16.4%), and polytetrafluoroethylene felt pledgets in 3 (4.9%). Mitral valve repair was attempted in 4 patients (6.6%) and mitral valve replacement in 57 (93.4%). One patient (1.6%) had conversion from repair to replacement due to cardiac rupture. Concomitant procedures included aortic valve replacement in 36 patients (56.3%), tricuspid valve surgery in 28 (43.8%), and coronary artery bypass graft surgery in 18 (28.1%). Mean follow-up was 3.5 ± 2.5 years., Results: There was no 30-day hospital death. Early complications were left ventricular pseudoaneurysm in 1 patient, pericardial patch dehiscence in 1, severe arrhythmia in 6, and stroke in 2. At 5 years, rates of survival and freedom from cardiac death and major adverse valve-related events were 75.6%, 79.7%, and 72.7%, respectively. Multivariate analysis indicated coronary artery disease as an independent predictor of cardiac death., Conclusions: In patients with severe mitral annular calcification undergoing mitral valve surgery, complete annular decalcification and reconstruction yields favorable outcomes., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 42-year-old woman presented with a 6-month history of palpitations and progressive dyspnea on exertion. She had undergone aortic and mitral valve repair using glutaraldehyde-treated autologous pericardium for active infective endocarditis 5 years prior. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification of the glutaraldehyde-treated pericardial patch on the anterior mitral leaflet was observed. Double valve replacement was performed with pulmonary vein isolation. Pathologic examination showed calcification of the glutaraldehyde-treated autologous pericardium. The patient was discharged on postoperative day 11 with oral anticoagulant therapy., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 59-year-old man was referred to our department for evaluation of an asymptomatic abnormal mediastinal shadow detected on chest roentgenogram. Computed tomography (CT) of the chest showed an anterior mediastinal tumor with ring calcification. Thymectomy through a median sternotomy was performed. Pathologic examination showed an encapsulated type B2 thymoma with ring calcification. Microscopically, the calcified layer was within the fibrous capsule layer. A part of the fibrous capsule was thought to become calcified like a ring. Although focal calcification is sometimes found in thymomas, ring calcification is rare., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We report a very rare case of a calcified amorphous tumor presenting atypically as a mobile left ventricular outflow tract mass in a 69-year-old female who was admitted for shortness of breath., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Calcific aortic valve disease (CAVD) is the most common cause of acquired valve disease. Initial phases of CAVD include thickening of the cusps, whereas advanced stages are associated with biomineralization and reduction of the aortic valve area. These conditions are known as aortic valve sclerosis (AVSc) and aortic valve stenosis (AVS), respectively. Because of its asymptomatic presentation, little is known about the molecular determinants of AVSc. The aim of this study was to correlate plasma and tissue osteopontin (OPN) levels with echocardiographic evaluation for the identification of asymptomatic patients at risk for CAVD. In addition, our aim was to analyze the differential expression and biological function of OPN splicing variants as biomarkers of early and late stages of CAVD., Methods: From January 2010 to February 2011, 310 patients were enrolled in the study. Patients were divided into 3 groups based on transesophageal echocardiographic (TEE) evaluation: controls (56 patients), AVSc (90 patients), and AVS (164 patients). Plasma and tissue OPN levels were measured by immunohistochemical evaluation, enzyme-linked immunosorbent assay (ELISA), and real-time quantitative polymerase chain reaction (qPCR)., Results: Patients with AVSc and AVS have higher OPN levels compared with controls. OPN levels are elevated in asymptomatic patients with AVSc with no appearance of calcification during TEE evaluation. OPN splicing variants OPN-a, OPN-b, and OPN-c are differentially expressed during CAVD progression and are able to inhibit biomineralization in a cell-based biomineralization assay., Conclusions: The analysis of the differential expression of OPN splicing variants during CAVD may help in developing diagnostic and risk stratification tools to follow the progression of asymptomatic aortic valve degeneration., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Calcifying fibrous pseudotumor is a rare benign lesion composed mostly of dense hyalinized colagen with multiple dystrophic or psammomatous calcifications and variable lymphoplasmacytic infiltrate. Children and young adults are most commonly affected by this tumor of uncertain pathogenesis. This is a case of an asymptomatic young woman with calcifying fibrous pseudotumor of the pericardium compressing heart cavities. Partial resection and marsupialization of the mass was performed., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We present a case of a giant right coronary artery pseudoaneurysm that presented as a right atrial intracardiac mass. Preoperatively, a two-dimensional echocardiogram, a computed tomographic scan, a magnetic resonance image, and cardiac catheterization were performed to diagnose and assess the origins of the mass., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We describe the treatment of a 16-year-old girl with calcific aortic stenosis, porcelain aorta, and calcific mitral stenosis with insufficiency using a valved apicoaortic conduit and mitral valve prosthesis. Both valve replacements were porcine bioprostheses, and the apicoaortic conduit was implanted without the use of cardiopulmonary bypass. In cases in which the degree of aortic calcification pre-empts manipulation of the coronary ostia, an apicoaortic conduit may offer a viable solution to improve left ventricular outflow obstruction.

Constrictive pericarditis is an infrequent disorder. We report the case of a 52-year-old man with constrictive pericarditis with an uncommon anterior associated pericardial mass. Upon diagnosis of constrictive pericarditis, the patient underwent pericardectomy and resection of the mass. He is well 6 months postoperatively, with complete resolution of his heart failure symptoms.

Myelolipoma is a rare mesenchymal tumor composed of an admixture of fat and bone marrow-derived hematopoietic cells. It is typically an adrenal lesion, and mediastinal location is extremely unusual. We describe a 56-year-old man with nonspecific symptoms of cough and dyspnea and no underlying disease whose chest computed tomography showed a huge (25 x 15 cm) mediastinal tumor containing calcification. Surgical removal and subsequent pathologic examination of the tumor revealed myelolipoma. Primary myelolipoma should be considered in the differential diagnosis of large posterior mediastinal tumors containing calcification.

Background: We assessed the hemodynamic performance and calcification potential of a new design of bovine pericardial valve, the Trilogy valve (Arbor Surgical Technologies Inc, Irvine, CA). We compared this new valve with the Perimount valve (Edwards Lifesciences, Irvine, CA) in a randomized prospective study in adolescent sheep., Methods: Nine Trilogy valves (size 21) and six Perimount valves (size 23 or 25) were implanted in the mitral position in adolescent sheep and studied during five months. Hemodynamic measurements were performed at one week, three months, and five months using transthoracic echocardiography. Valve calcification was assessed by X-ray and calcium content was measured by atomic absorption spectrometry after five months implantation in sheep. Tissues were also evaluated histologically (Von Kossa staining)., Results: The nine Trilogy valves had lower peak velocity, peak gradient, and mean gradient compared with the six Perimount valves. These 21-mm Trilogy valves had similar deceleration time and effective orifice area compared with the 23- and 25-mm Perimount valves. Calcification of the Trilogy valves was significantly lower than Perimount valves (p < 0.01), particularly in the commissural (p < 0.01) and free margin regions (p < 0.03). In all parameters assessed, the Trilogy valves exhibited less variation valve-to-valve compared with Perimount valves., Conclusions: These findings demonstrate that a valve designed to reduce stress in the tissue, improve leaflet kinematics, with advanced antimineralization treatment, can exhibit superior calcification resistance in the mitral position of adolescent sheep. The trilobal geometry and independent leaflet suspension design, combined with an advanced tissue treatment, appears to be a promising breakthrough in the effort to develop a more durable and hemodynamically efficient bioprosthetic valve.

We describe the recognition and management of two patients who developed intraoperative fracture of the right coronary artery (RCA). Both patients had a calcified RCA without a hemodynamically significant stenosis. Compression of the right atrioventricular groove during the surgical procedure resulted in fracture of the RCA, leading to ventricular arrhythmias and hemodynamic instability. Coronary bypass grafting without cardioplegic arrest was used for definitive diagnosis and treatment. Both patients made a rapid and uneventful recovery.

A giant coronary pseudoaneurysm of uncertain cause, arising from Vieussens' arterial ring, was preoperatively diagnosed in an oligosymptomatic female patient. Successful off-pump surgical excision without additional bypass grafting was performed. Difficulties in diagnostic algorithm, as well as possible cause and extremely rare localization were discussed.

We report 2 patients with ostial stenoses of coronary arteries and heavy aortic calcification caused by Takayasu's disease in which severe angina was successfully relieved by off-pump coronary artery bypass grafting. In one case, visceral arteries such as the right gastroepiploic artery, the superior mesenteric artery, and the splenic artery were used as proximal blood sources of saphenous vein grafts. In another case, an aortic connector system was employed for proximal anastomoses of saphenous vein grafts. The use of off-pump coronary artery bypass grafting techniques should be considered in surgical coronary revascularization in patients with Takayasu's disease, thus leading to wide-spreading indication for the surgery.

We describe the use of a microoscillating saw on the heart to remove calcific pericardium. This microoscillating saw proved indispensable to achieve a safe pericardiectomy in a 55-year-old woman with thick, severe idiopathic calcific constrictive pericarditis.

This report describes a 61-year-old patient on chronic hemodialysis with multiple, left-sided, intracardiac masses causing intermittent coronary obstruction. Mitral valve replacement was performed. Massive deposition of calcium pyrophosphate crystals in and around the valve cusps led to the diagnosis of tophaceous pseudogout (tumoral calcinosis) of the mitral valve.

This report concerns the finding of a clinically benign 4-cm mass in the anterior thorax of a 12-year-old girl. The tumor was inseparable from the chest wall. A wide excision was performed. Microscopic examination proved it to be a rare but distinctive lesion recently entitled "calcifying fibrous pseudotumor" primarily involving the chest wall. Wide excision is thought necessary to preclude local recurrence.

For many years, valvulitis in systemic lupus erythematosus has been known to occur. Our patient was a 17-year-old girl who presented with severe mitral incompetence and renal insufficiency due to lupus valvulitis. The patient was first treated by mitral valve repair, but follow-up disclosed precocious calcification of the valve, necessitating mitral valve replacement with a cryopreserved homograft. At follow-up after 1 year, echocardiography has shown the valve to be functioning normally. A reconstructive mitral valve operation would seem to be preferable. However, a conservative operation does not alter the natural history of the disease and the progression of valve thickening and calcification.

Lung transplantation has been successfully used in the treatment of patients with end-stage pulmonary disease and adequate cardiac function. We report about a 32-year-old man with pulmonary alveolar microlithiasis who underwent sequential bilateral lung transplantation. Preoperative hemodynamic studies revealed severe pulmonary hypertension; the right ventricular ejection fraction was 0.27. Eighteen months postoperatively, he continues to do well with normalized pulmonary and cardiac function and without clinical or histopathologic signs of graft rejection.

Calcification of the ascending aorta and transverse arch significantly increases morbidity and may compromise the completeness of cardiac surgical procedures. Several stratagems have been suggested to reduce the risk, but for some patients this finding is still associated with a devastating outcome, irrespective of the technique employed. Thirteen patients (7 men and 6 women with a mean age of 66 years) with extensive calcification in the ascending aorta and transverse arch underwent cardiopulmonary bypass (CPB). The presence of calcification was known prior to CPB in 12 patients and noted after cross-clamping of the aorta in 1 patient. Special techniques for cannulation of the ascending aorta or arch were undertaken in 12 patients; 1 patient required groin cannulation. In 12 patients CPB with gradual core cooling to 18 degrees C was done, during which time no manipulation of the aorta was allowed. Circulatory arrest was then initiated for 3.5 to 12 minutes. The aorta was opened widely during this time to remove ulcerated plaques and friable debris, and to locate a safe place for aortic occlusion. All patients recovered without neurological complications. In 1 patient, in whom occipital lobe infarcts developed, calcification was discovered after the aorta had been cross-clamped and necessitated subsequent endarterectomy of the ascending aorta and transverse arch.(ABSTRACT TRUNCATED AT 250 WORDS)