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Intrathoracic tracheal disruption by blunt trauma is rare and potentially life threatening. Here report 3 cases of intrathoracic tracheal disruption due to blunt trauma. Two cases, each 43 year old, involved an unrestrained male driver who suffered a head-on crash, while the other, 63 year old, involved a male who suffered compression. Chest roentgenograms on admission showed remarkable deep cervical and mediastinal emphysema in Cases 1 and 2 and mediastinal emphysema alone in Case 3. Bronchoscopy revealed disruption in the trachea. Primary repair was performed through a right posterolateral thoracotomy in Cases 1 and 3 and through a median sternotomy in Case 2. In all cases the postoperative course was uneventful.

Objective: The effect of terminal warm blood cardioplegia was analyzed in 191 patients undergoing either coronary artery bypass grafting (CABG) or prosthetic heart valve replacement between Jan. 1990 and Dec. 1995., Methods: Patients were subdivided into 3 historical cohorts based on the method of myocardial protection: Group A (n = 106), multidose cold crystalloid glucose-potassium cardioplegia, alone; Group B (n = 37), cold crystalloid glucose-potassium cardioplegia plus terminal warm blood cardioplegia, Group C (n = 48), cardioplegia induction with cold crystalloid glucose-potassium cardioplegia, maintenance with multidose cold blood cardioplegia, and terminal warm blood cardioplegia., Results: Of patients undergoing CABG, 5.6% of group A, 70.4% of group B, and 86.7% of group C spontaneously resumed sinus rhythm after aortic declamping, as did 9.1% of group A, 60.0% of group B, and 55.6% of group C of patients undergoing prosthetic heart valve replacement. The incidence of spontaneous recovery was significantly better in groups B and C than in group A (p < 0.05). Over 90% of patients without terminal warm blood cardioplegia developed ventricular fibrillation or tachycardia requiring electrical cardioversion (p < 0.05). Postoperatively, patients without terminal warm blood cardioplegia required temporary epicardial pacing more frequently than those with terminal warm blood cardioplegia (p < 0.05). In patients undergoing prosthetic heart valve replacement, groups B and C, the incidence of postoperative atrial fibrillation was significantly lower than in group A., Conclusion: Terminal warm blood cardioplegia thus promoted better postoperative electrophysiological cardiac recovery.

A 55-year-old man was operated on urgently for aortic valve endocarditis complicated by an annular abscess at the base of the non-coronary leaflet extending down to the left ventricle. Rapidly progressive heart failure and presence of a friable-appearing vegetation on echocardiography were the indications for urgent operation. Preoperative electrocardiogram showed first degree A-V block. At operation the aortic valve was generally thickened with mild calcification about the commissures. Non-coronary cusp was severely deformed and was nearly detached at its base due to annular abscess formation. Native valve was completely excised and the abscess was debrided. A club or a tongue-shaped pedicled aortic wall flap was prepared to the left of the oblique aortotomy incision with its free end to the distal side of the aorta. The flap was folded inward at its pedicle about 1 cm above the non-coronary annulus and was used to patch the abscess cavity. The aortic valve was replaced with a SJM 23 mm aortic valve prosthesis. The remaining defect of the aortic wall was repaired with a patch of woven-dacron vascular prosthesis. Post-operative hemodynamics of the patient was uneventful and he was given a 6-week course of parenteral antibiotics. He developed complete A-V block during the operation, and a permanent pacemaker was implanted on the 6th postoperative day. One year after operation he has not had recurrent infection and is leading a normal life. When used in the repair of ventriculo-aortic discontinuity created by infective endocarditis, the pedicled aortic wall flap has several advantages. It is easily obtainable and can cover abscesses of almost any shape and size. Unlike aortic root homograft, there is no problem of availability. Technically it is relatively simple to prepare a flap, bring it down through the non-coronary sinus and suture over the abscess. Aortic wall has just appropriate thickness and strength to reinforce the weakened periannular area, and if the debrided cavity is deep, the flap can be folded to obtain double thickness. By using this flap, potentially infected cavity is covered and packed by autologous tissue alone, and the synthetic patch to repair the aortic wall defect is placed well away from the site of possible contamination. In addition to the use in infective endocarditis, the aortic wall flap can predictably be used in the repair of aortic annular defect created by over-zealous removal of calcium in the surgery of calcific aortic stenosis, and in intracardiac patching in aortic annular enlargement operation such as Manouguian operation. To our knowledge, the use of pedicled aortic wall flap for aortic annular reconstruction has not been reported in the literature.

The current treatment of pure pulmonary atresia consists of early initiation of prostaglandins followed by a combination of surgical procedures according to the right ventricular morphology. Major right ventricular sinusoidal-coronary artery communications (SCAC) occasionally present in patients with hypoplastic right ventricle may remain as coronary artery-right ventricular fistulae after right ventricular decompression, which may in turn be the cause for poor surgical results after pulmonary valvotomy in neonates with the SCAC. Herein, a case of this anomaly is reported with a review of literature. A 2-month-old infant underwent an aorto-pulmonary artery shunt operation using Gore-Tex graft for an emergency treatment of pure pulmonary atresia with major SCAC. The catheterization and ventriculography performed 6 months later disclosed suprasystemic right ventricular pressure and more extended SCAC. Then, right ventricular outflow tract was constructed utilizing Gore-Tex patch across the pulmonary valve under cardiopulmonary bypass. The aortico-pulmonary artery shunt was left functioning. After another 6 months, cardiac catheterization and ventriculography were repeated. Right ventricular pressure decreased to the systemic level, right ventricular ejection fraction improved, and the SCAC was not visualized by ventriculography. The decreased inter-ventricular pressure difference and improved right ventricular emptying after the second operation may have played a role in the disappearance of the SCAC. For the neonates with pure pulmonary atresia and sinusoidal-coronary artery communications, we still advocate systemic-pulmonary shunt procedure with concomitant or slightly delayed pulmonary valvotomy as the initial procedure. Unless the tricuspid valve is critically small or stenotic, there may still be a chance for the growth of the right ventricle even in this type of case.