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Extravasation of prosthetic grafts is rare. Various anatomical problems after graft replacement might make standard endovascular treatment difficult. Use of a commercially available main body requires an adequate distance of the flow divider. An 86-year-old man developed extravasation of a graft that had been implanted in the infrarenal abdominal aorta 24 years previously. Endovascular repair with upside-down and kissing stent graft techniques using the contralateral leg was successfully performed., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Transit-time flow measurement (TTFM) allows intraoperative functional assessment of grafts in coronary artery bypass grafting (CABG). The major limitation of this technique is a low positive predictive value (PPV) that could lead to unnecessary graft revisions. A combined approach with high-resolution epicardial ultrasonography (HR-ECUS) and TTFM was evaluated for the first time in terms of diagnostic accuracy. The aim of this study is to evaluate the added value of intraoperative HR-ECUS for an improved graft patency verification., Methods: From November 2009 to September 2012, 333 patients underwent isolated CABG. A total number of 717 grafts were performed; all grafts were intraoperatively verified by means of both TTFM and HR-ECUS., Results: Among 678 grafts considered functioning at TTFM, 3 (0.4%) were failing at HR-ECUS and promptly redone (2 bilateral internal mammary artery-Y-grafts and 1 left internal mammary artery to left anterior descending (LIMA-LAD)). These were confirmed as true positive at graft revision due to technical error. HR-ECUS confirmed the good functioning of the remaining 675 grafts already demonstrated by TTFM; among them, 8 showed high troponin I release (clinical false negative), whereas the remaining 667 had no high TnI release (clinical true negative). In 2 of 39 grafts malfunctioning at TTFM, HR-ECUS confirmed the graft failure; surgical inspection of the anastomosis during redo procedure (in both cases LIMA-to-LAD graft) showed a technical error leading to define those 2 grafts as 'true positive' on the basis of either direct vision and improved post-redo TTFM parameters. Finally, in 35 cases, HR-ECUS did not confirm TTFM diagnosis demonstrating a full patency of the anastomosis; these grafts had an uneventful clinical course (true negative). The main result of this study is the increase of PPV from 10% with TTFM to almost 100% of TTFM + HR-ECUS, avoiding many unnecessary graft revisions., Conclusions: HR-ECUS should be considered complimentary to TTFM. Simultaneous use of the two methods during CABG provides morphological and functional information improving considerably diagnostic accuracy of intraoperative graft verification procedure close to 100%.

Objective: Saline injection test performed during mitral valvuloplasty is popular; however, discrepancies are sometimes noticed between the 'naked eye' findings of regurgitation during the saline injection test and the echocardiographic findings after surgery. These discrepancies may arise due to the geometric differences in the mitral valve-left ventricular complex between the saline-injected left ventricle (LV) and the beating LV. Therefore, to elucidate these differences, we compared the three-dimensional geometries between these two conditions., Methods: Sonomicrometry crystal markers were implanted in seven mongrel dogs at the mitral annulus, edge of the mitral leaflets between scallops, tips of papillary muscles, and LV apex under cardiopulmonary bypass. Geometric data of the LV were acquired during the saline injection test and in the beating heart., Results: The commissural width was greater and the annular height was lesser during the saline injection test than in the beating heart (20.5+/-5.1mm vs 17.2+/-2.2mm, p<0.01 and 5.5+/-1.8mm vs 7.3+/-2.2mm, p<0.05, respectively), indicating that the saddle-shaped mitral annulus was flattened during the test. Additionally, the middle scallop width and the distance between the papillary tips were greater during the test (14.0+/-4.2mm vs 11.3+/-3.6mm, p<0.05 and 22.9+/-5.9mm vs 11.6+/-5.0mm, p<0.01, respectively), implying that the middle scallop was stretched by the traction of the chordae. The distance between the papillary tips and the mitral annular plane remained constant in both the conditions (19.3+/-2.6mm vs 18.6+/-6.2mm, not significant)., Conclusions: The saline injection test could aid in determining the length of the reconstructed chordae. However, the test may provide inaccurate data of the mitral-LV dimensions due to the flattened annulus and overstretched leaflets.