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Seventeen patients treated for infected grafts (11/17) or aneurysms (6/17) of the aorta between 1998 and 2003 were reviewed to evaluate our experience with aortic infection. The causative organisms were identified in 12 patients (71%), with 5 (29%) having methicillin-resistant Staphylococcus aureus. A periaortic abscess occurred in eight patients, and all of them were associated with infected grafts. Surgical treatment included cryopreserved allograft replacement in eight patients, prosthetic graft replacement in four patients, and drainage with or without omental wrapping in five patients. One patient was still hospitalized at the end of the study period. Five patients with infected grafts died after the operation during the initial hospitalization. No early mortality occurred in the aneurysm group. The early mortality rate was 31% for all patients, 50% for the graft group, and 63% for patients with a periaortie abscess. Another patient with an infected aneurysm died of arrhythmia after discharge from the initial hospitalization, Ten patients are still alive without evidence of reinfection. The early mortality rate for patients with infected aortic grafts is higher than that for those with infected aneurysms, especially when a periaortic abscess accompanies them. However, the late outcome is favorable, with no reinfection or late treatment-related deaths.

1240 The Journal of Thoracic and Cardiovascular Surgery • December 2001 O pen surgery with an endovascular stent graft is a novel therapeutic technique for aortic aneurysm that is especially useful for aneurysms of the distal arch. In this report we describe the clinical course and autopsy findings of 2 patients who had paraplegia after undergoing this procedure and died during the hospital stay.

Background . The hemodynamic effects of carbon dioxide insufflation under single-lung ventilation were studied in 22 consecutive thoracoscopic harvests of the left internal mammary artery, which was used for minimally invasive coronary artery bypass grafting. Methods . An electrocardiograph, arterial catheter, Swan-Ganz catheter, and transesophageal echocardiograph were used to monitor seven hemodynamic variables. Baseline data were obtained during ventilation of both lungs and the measurements were repeated after the left lung was collapsed and at 5 and 30 minutes after hemithorax insufflation with low-flow (2 to 3 L/minute) carbon dioxide gas was begun. The intrapleural pressure was maintained at 8 to 10 mm Hg. Results . Thoracoscopic harvest of the internal mammary artery was completed in all cases with a mean insufflation time of 44 ± 12 minutes. There were no significant changes in the mean arterial pressure, heart rate, cardiac index, and left ventricular ejection fraction throughout the procedure, whereas the central venous pressure, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure ( p Conclusions . Low-flow carbon dioxide insufflation into the left hemithorax with an intrapleural pressure of 8 to 10 mm Hg under selective right-lung ventilation does not compromise the human heart with normal to moderately depressed function and can be an efficacious adjunct in specific thoracoscopic procedures.

Background . Paravalvular leakage is one of the most serious complications of aortic valve replacement in patients with aortitis syndrome. The purpose of this study was to compare the effectiveness of the intravalvular implantation technique in preventing paravalvular leakage with that of the conventional technique. Methods . Since 1982, 14 patients with aortic regurgitation caused by aortitis syndrome have undergone aortic valve replacement at our institute. An intravalvular implantation technique was applied in 7 of the 14 patients. The technique consists of suturing a prosthetic valve to the aortic annulus and sandwiching the leaflets between exogenous felt pledgets and the inflamed aortic annulus. Results . Paravalvular leakage occurred in 3 of 7 patients in the conventionally treated group and in none of 7 in the intravalvular implantation group. Conclusions . The intravalvular implantation technique is effective in preventing paravalvular leakage in patients with aortitis syndrome.

Background . The purpose of this study was to develop a method of atrial ablation. In the IRK-151 infrared coagulator, light from a tungsten-halogen lamp is focused into a quartz rod. The distal exit plane is connected to a tip made of sapphire to allow linear ablation. Methods . Thirty-six lesions were created in 9 mongrel dogs. The beating ventricular myocardium was ablated from the epicardium. In each dog, 4 lesions were created by using the following durations of application: 3, 9, 15, and 21 seconds. After the ablation, the myocardium was fixed and stained. A linear lesion on the beating right atrial free wall was created. Before and after the ablation, epicardial plaque–electrode mapping was performed. Three months after ablation, remapping was performed. Results . The ablated myocardium had well-demarcated necrosis without carbonization or vaporization. The maximum depth was 10.3 ± 0.8 mm. The conducting pathway was blocked. The block, once made, continued for 3 months. Conclusions . The IRK-151 produces well-demarcated lesions that were deep enough for atrial ablation to block the conducting pathway.

We report an unusual case of aortobronchial fistula late after transverse arch replacement caused by the remnant of a temporary bypass near the ascending aorta. In reconstructive surgery of the ascending aorta, antegrade perfusion is preferably performed through a side branch after completion of the distal anastomosis by some surgeons. This report suggests possible risk of a serious late complication unless the side branch is placed and tailored properly.

Endovascular covered stents were successfully applied to temporarily halt hemoptysis and postpone surgical intervention in a 69-year-old man with a ruptured anastomotic false aneurysm of the distal aortic arch. Surgical graft implantation was performed successfully by the elephant trunk technique 14 days after the endovascular stent-grafting, at which time aspiration pneumonia had subsided.

The Journal of Thoracic and Cardiovascular Surgery • Volume 123, Number 2 371 I ntimal injury is a probable complication after stent-graft implantation. It is generally believed to occur more frequently during the perioperative rather than the late postoperative period and in cases of acute rather than chronic aortic dissections. We, however, encountered a case in which intimal injury occurred about 1 year after stent-graft implantation for chronic aortic dissection, and a surprisingly high incidence of such cases has recently been reported. We report this case as a word of caution.

We have been using three-dimensional computed tomography (3-D CT) in reoperative coronary artery bypass grafting performed by using a minimally invasive approach. Preoperative 3-D CT scanning can provide beneficial anatomical information about old patent grafts as well as the internal thoracic artery. Thus a mini-thoracotomy can be created at an optimal site, leaving the old graft untouched, and the length of the harvested internal thoracic artery, necessary for the bypass, can be assessed using this new modality.