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This study evaluates the effectiveness and potential complications of stent-grafting for the treatment of distal arch aneurysms using profound hypothermia and circulatory arrest with retrograde cerebral perfusion. Between December 1998 and December 2001, 9 consecutive patients with a distal arch aneurysm (6 men and 3 women, mean age 71 years) underwent surgical repair using a stent-graft. Profound hypothermic circulatory arrest and retrograde cerebral perfusion were performed in all patients. Endovascular leakage was screened postoperatively using three-dimensional computerized tomography. The mean follow-up period was 27.4 months. Thirty day mortality was 0%. One patient died 3 months after stent-grafting due to proximal leakage into her aneurysm. The mean postoperative extubation period was 2.1 days. No patients suffered cerebral infarction or paraplegia. Although preliminary outcomes using this technique were good, endovascular leakage is a concern. We suggest that, if major proximal leakage is recognized postoperatively, re-intervention should be performed as soon as possible. Endovascular stent-grafting appears to be a good alternative treatment for distal arch aneurysms, although longer follow-up is necessary to more comprehensively evaluate this procedure.

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.

Objectives: Many interventional physiological assessments for retrograde cerebral perfusion (RCP) have been explored. However, the appropriate arterial gas management of carbon dioxide (CO 2 ) remains controversial. The aim of this study is to determine whether alpha-stat or pH-stat could be used for effective brain protection under RCP in terms of cortical cerebral blood flow (CBF), cerebral metabolic rate for oxygen (CMRO 2 ) and distribution of regional cerebral blood flow. Methods: Fifteen anesthetized dogs (25.1 ± 1.1 kg) on cardiopulmonary bypass (CPB) were cooled to 18°C under alpha-stat management and had RCP for 90 min under: (1), alpha-stat; (2), pH-stat: or (3), deep hypothermic (18°C) antegrade CPB (antegrade). RCP flow was regulated for a sagittal sinus pressure of around 25 mmHg. CBF was monitored by a laser tissue flowmeter. Serial analyses of blood gas were made. The regional cerebral blood flow was measured with colored microspheres before discontinuation of RCP. CBF and CMRO 2 were evaluated as the percentage of the baseline level (%CBF, %CMRO 2 ). Results: The oxygen content of arterial inflow and oxygen extraction was not significantly different between the RCP groups. The %CBF and %CMRO 2 were significantly higher for pH-stat RCP than for alpha-stat RCP. The regional cerebral blood flow, measured with colored microspheres, tended to be higher for pH-stat RCP than for alpha-stat RCP, at every site in the brain. Irrespective of CO 2 management, regional differences were not significant among any site in the brain. Conclusions: CO 2 management is crucial for brain protection under deep hypothermic RCP. This study revealed that pH-stat was considered to be better than alpha-stat in terms of CBF and oxygen metabolism in the brain. The regional blood flow distribution was considered to be unchanged irrespective of CO 2 management.

Objective: The purpose of this study is to evaluate the possibility of identifying critical segmental arteries (CSAs) based on Doppler ultrasonographic hemodynamics. Methods: In 18 mongrel dogs, the descending aorta was scanned directly with a 5-MHz linear probe through left thoracotomies and the flow velocities in segmental arteries were measured by pulsed Doppler. The aorta was cross-clamped between Th13 and L1, and flow velocity changes were recorded. According to flow increases, segmental arteries were divided into three groups: arteries with the largest flow increase (L-arteries), arteries with the smallest increase (S-arteries) and other arteries (O-arteries). Animals were divided into three groups. One aortic segment including an L-artery or an S-artery was perfused via a temporary shunt during 30-min aortic cross-clamping distal to the left subclavian artery (Group L or Group S) and neurological outcomes were compared with those of animals without shunting (Group N) after 24 and 48 h. Results: L-arteries had significantly larger flow increases than S- and O-arteries (74.3 ^ 33.8, 20.4 ^ 9.8 and 33.3 ^ 17.8 cm/s, P , 0.01). In Group N, five of the six animals were completely paraplegic (Tarlov Grade 0) and the other was Grade 1. In Group S, four animals were Grade 4 and two were Grade 0 after 24 h. However, two animals showed delayed paraplegia. Therefore, four animals were Grade 0 and two were Grade 4 after 48 h. All animals in Group L were neurologically normal (Grade 4) at both after 24 h (vs. Group N, Pa 0:0013) and 48 h (vs. Group N, Pa 0:0013; vs. Group S, Pa 0:019). Conclusions: Flow responses to aortic cross-clamping differed among segmental arteries and selective perfusion of L-arteries completely prevented paraplegia. Therefore, L-arteries were considered to be CSAs. Hemodynamic measurement of segmental arterial flow using Doppler ultrasonography could be clinically useful for spinal cord protection during thoracoabdominal aortic surgery. q 2001 Elsevier Science B.V. All rights reserved.

Background: Visualization of the left circumflex arteries during off-pump coronary artery bypass grafting (CABG) causes hemodynamic disturbance. We investigated whether right heart mini-pump bypass (RHB), using a centrifugal pump, improved the safety of this procedure by studying the influences of different heart displacement positions, the Trendelenburg maneuver and RHB on hemodynamics. Method: Hemodynamic parameters in eight mongrel dogs (15.5‐20 kg) were continuously monitored at a fixed heart rate of 80 beats/min through a conventional median sternotomy. The posterior descending artery (PDA) and left circumflex artery (LCX) were exposed using an Octopus tissue stabilizer. After evaluating the influence of the Trendelenburg maneuver on hemodynamics, a heparin-coated centrifugal pump without an oxygenator was introduced and the impact of different pump flow volumes was investigated during RHB. Results: LCX exposure caused significant decreases in aortic flow (to 35.1 ^ 12.8%) and arterial mean pressure (to 66.1 ^ 9.3%) compared with baseline (P , 0:001). In contrast to PDA exposure, values remained significantly decreased during the Trendelenburg maneuver. On the contrary, RHB significantly improved the hemodynamic impairments caused by both heart displacement procedures, especially LCX exposure, although 100% pump flow significantly increased left atrial pressure to 131.3 ^ 19.5% (P , 0:01). Conclusion: Exposure of the LCX caused severe hemodynamic deterioration, which was not fully reversed by the Trendelenburg maneuver. In contrast, RHB significantly improved hemodynamics, and therefore this technique can be beneficial for CABG of LCX in the limited cases. q 2000 Elsevier Science B.V. All rights reserved.

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.

Objective: The transseptal superior approach can offer an excellent view of the mitral valve but the incision almost always transects the sinus node artery. The purpose of this study was to evaluate the sinus node function after mitral operation by this approach. Patients and Methods: We reviewed the electrocardiograms of 76 patients who underwent mitral valve operations either via transseptal superior approach or via right lateral atriotomy. Nine patients who maintained the sinus rhythm for more than one year after surgery via the transseptal superior approach were selected for electrophysiological study to evaluate the sinus node function. Results and Conclusions: Postoperative electrocardiographic and electrophysiological studies revealed that the sinus node function after the transseptal superior approach was relatively well maintained for more than one year after the operation. The influence of the transseptal superior approach on the sinus node function in the mid-term postoperative period was apparently mild and did not cause a serious problem. However, some of the patients did show abnormal data in terms of sino-atrial conduction time and intrinsic heart rate. Therefore, further follow-up of the sinus node function is necessary in patients who underwent mitral surgery through the transseptal superior approach.

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.

The approach to the heart for open heart surgery in patients with a tracheostoma requires careful consideration. The presence of a tracheostoma interferes with the standard sternotomy and increases the risk of mediastinitis. We have successfully performed coronary artery bypass grafting in two patients with a tracheostoma using the limited median sternotomy and describe the surgical procedure used in these patients.

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.

Objective: Retrograde cerebral perfusion (RCP) is used as an adjunctive method to hypothermic circulatory arrest to enhance cerebral protection in patients undergoing thoracic aortic surgery. It remains unclear whether RCP provides improved neurological and neuropsychological outcome. Methods: Forty-six patients undergoing thoracic aortic surgery using RCP, and 28 undergoing coronary artery bypass grafting (CABG; nZ28) with CPB, were enrolled in the study. Patients receiving RCP were subdivided into two groups, those with less than 60 min of RCP (S-RCP; nZ27) and with 60 min or more (L-RCP; nZ19). The patients’ neurocognitive state was assessed by the revised Wechsler Adult Intelligence Scale a few days before operation, at 2–3 weeks and 4–6 months after operation. Results: There were no stroke, seizure, and hospital mortality in either group. Significant decline between baseline and early scores were seen in three subtests (digit span, arithmetic, and picture completion) for S-RCP and four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP. Significant decline between baseline and late scores were seen in one subtest (arithmetic) for S-RCP, four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP, and one (object assembly) for CABG. The mean change of scores for one late test (digit symbol) was significantly lower in S-RCP than in CABG. The mean change of scores for three early tests (digit span, vocabulary, and picture arrangement) and four late tests (information, digit span, picture completion, and picture arrangement) were significantly lower in L-RCP than in CABG. Stepwise logistic regression analysis disclosed that, after considering the other variables, significant difference in test score changes were observed between CABG and L-RCP for two early tests (picture completion and digit symbol) as well as for three late tests (digit span, similarities, and picture completion). None of test score changes showed significant difference between CABG and S-RCP. Conclusions: The neurocognitive outcome in patients undergoing RCP less than 60 min were comparable with patients undergoing CABG without circulatory arrest. Prolonged RCP of 60 min or more in patients undergoing surgery of the thoracic aorta was associated with postoperative neurocognitive impairment.

Clinical Summary A 52-year-old man had undergone, in another hospital, a graft replacement of the ascending aorta and coronary bypass grafting (saphenous vein to the right coronary artery) for acute type A aortic dissection. Gelatin-resorcinol-formaldehyde tissue glue had been used in reinforcement of the dissected aorta in both ends. Nine months after that operation, the patient had dyspnea and mild fever. Computed tomographic (CT) scan showed pseudoaneurysm of the ascending aorta, and he was referred to us. Physical findings included a continuous murmur maximal at the second right intercostal space. Chest radiography showed mild cardiomegaly and enhancement of the right pulmonary vasculature. Transesophageal echocardiography and a new CT scan (Figure 1) revealed a pseudoaneurysm of the ascending aorta, with fistulization to the right pulmonary artery arising from the proximal anastomosis. Aortography confirmed complete occlusion of the vein graft as well as the presence of the aortopulmonary fistula. Right heart catheterization revealed right-sided pressure elevation. When the left ventricular pressure was 74/20 mm Hg, the right atrial pressure was 17 mm Hg, the right ventricular was 34/18 mm Hg, and the pulmonary arterial pressure was 35/16 mm Hg. An oxygen saturation step-up was observed in the pulmonary artery, with 59.8% in the main pulmonary artery and 91.8% in the right pulmonary artery. Because of the risks of repeated median sternotomy, we chose a right thoracotomy to approach the aortic root. We prepared a cryopreserved aortic valve allograft in case of infection. The right fourth intercostal space was opened, and sternal transection and left thoracotomy were included. The femoral artery and the superior and inferior venae cavae were cannulated for cardiopulmonary bypass. An occlusion balloon was inserted into the distal part of the pseudoaneurysm to reduce the degree of aortopulmonary shunting. After systemic cooling, retrograde cardioplegia, and deep hypothermic circulatory arrest, the pseudoaneurysm was incised, and dissection proceeded until the distal part of the aortic graft was crossclamped and systemic circulation was resumed. The defect of the right pulmonary artery wall was 14 mm in diameter; it was closed with the anterior mitral leaflet taken from the aortic allograft. We found dehiscence in the anterior part of the proximal anastomosis, blackened aortic edge, and fragile aortic wall with dissection almost reaching the annulus. There were no findings indicating infection. The left coronary ostium was resected as a button. A Dacron polyester fabric tube composite graft with a mechanical valve was inserted into the aortic root, and the left coronary button was reattached to the graft. During rewarming, the right internal thoracic artery was anastomosed to the right coronary artery (Figure 2). The patient’s postoperative course included pneumonia, which improved with antibiotics, and he was discharged 47 days after operation. Histologic examination of the media of the dissected aorta revealed a homogeneous eosinophilic substance that seemed to be composed of glue, severe calcification, and fibrous tissue with hemosiderin deposition.

This report describes a 60-year-old male patient who developed early valvular obliteration of a cryopreserved aortic valve allograft with associated severe valvular leakage. The patient had previously undergone two operations for aortic valve insufficiency resulting from infective endocarditis, and prosthetic valve endocarditis: aortic valve replacement with a mechanical prosthesis was done 4 years ago, and two years later aortic root replacement with a cryopreserved allograft was performed. Perforation through the non-coronary cusp of the aortic allograft was found, and valve replacement was achieved using a mechanical prosthesis. The intraoperative findings, histological, immunological, and bacteriological studies of the resected cusps demonstrated negative for infection and rejection, therefore, the valvular perforation might have been caused by an injury or degeneration during management of the homologous graft. The patient showed neither aortic regurgitation on echocardiography nor recurrence of endocarditis 10 months after surgery.

We report a case of left coronary artery ostial stenosis and bilateral pulmonary artery (PA) stenosis in a 22-year-old woman with Wegener granulomatosis (WG). Complicating periaortitis and obstruction of the internal thoracic arteries hampered conventional coronary artery bypass grafting and in situ PA reconstruction. Successful treatment was achieved by restoration of right ventricular outflow tract (RVOT) to bilateral PA continuities with reinforced polytetrafluoroethylene (PTFE) grafts and coronary-coronary bypass.

We report a case of ruptured aortic aneurysm of the distal aortic arch. This aneurysm was fusiform and only 4.0 cm in maximum diameter: Emergency total aortic arch replacement was successful. Rupture of a thoracic aortic aneurysm of this shape and size is possible but extremely rare.

Since Haissagere and colleagues [1] reported that a rapid firing focus in or close to the pulmonary veins could be the cause of atrial fibrillation, a transcutaneous catheter technique directed at isolating these foci has been developed. How should patients with nonvalvular atrial fibrillation who require cardiac operation be managed? We developed an epicardial technique that uses cryoablation to isolate the left atrial posterior wall and pulmonary veins and used it to treat a patient. Because cryoablation is achieved epicardially, the technique does not require atriotomy and does not prolong aortic cross-clamp time. Isolation of the left atrium was confirmed by electrophyscologic studies, and the patient remains in sinus rhythm 16 months after operation. This concomitant procedure allows treatment of patients with nonvalvular atrial fibrillation.

Left atrial dissection, a rare complication occurring mainly after mitral repair, is reported after double valve replacement in a patient with a connective tissue disease. A 63-year-old woman with systemic sclerosis underwent double valve replacement. Laceration of the tissue between the two mechanical prostheses and dissection of the left atrial wall emerged postoperatively and regurgitation through the dissection caused heart failure, which later improved without surgery. The possible causes of the dissection were thought to be shear forces against the tissue between the two prostheses and tissue fragility due to systemic sclerosis and corticosteroid therapy.

The aim of this study was to determine whether alpha- or pH-stat protects the brain during deep hypothermic retrograde cerebral perfusion. Fifteen anesthetized dogs on cardiopulmonary bypass were cooled to 18°C under alpha-stat and underwent retrograde cerebral perfusion for 90 minutes under alpha-stat or pH-stat, or underwent antegrade cardiopulmonary bypass under alpha-stat as the control. Cerebral blood flow of the cortex was monitored and serial analyses of blood gases and total nitric oxide oxidation products made. Cerebral blood flow and cerebral metabolic rate for oxygen were significantly higher and plasma levels of nitric oxide oxidation products in the outflow from the brain were significantly lower in retrograde cerebral perfusion under pH-stat than under alpha-stat. This study shows that reduced levels of nitric oxide oxidation products may protect against neuronal damage induced by nitric oxide and that increased cerebral blood flow under pH-stat may lead to a reduction of nitric oxide oxidation products. Under retrograde cerebral perfusion, pH-stat is thus better than alpha-stat for protecting the brain.

Open surgery using the endovascular stent-graft is a novel technique that lessens the invasiveness of surgery for the aortic arch. However, the outcome of this procedure remains uncertain.Between November 1996 and July 2000, a total of 19 patients underwent open surgery using an endovascular stent-graft for thoracic aortic aneurysms. There were 15 men (78.9%) and 4 women (21.1%). Patient age ranged from 29 to 82 years (mean 69.3 years, median 74 years). Atherosclerotic thoracic aortic aneurysms were present in 17 patients (89.4%) and aortic dissection in 2 patients (10.5%).Two patients (10.5%) died in the hospital and 4 patients (21.1%) presented with paraplegia postoperatively. Among the 4 patients with postoperative paraplegia, 1 case was complicated with intraoperative aortic dissection. The other 3 patients with paraplegia had spinal cord ischemic time of more than 60 minutes and intraoperative body weight gain of more than 4 kg. Of these 3 patients, hemodynamic instability after cardiopulmonary bypass was observed in 1 patient and cholesterin embolus in the anterior spinal artery was found at autopsy in another. On univariate analysis, age greater than 75 years was the only risk factor associated with paraplegia (p0.05). Autopsy findings for the 2 patients showed that the Adamkiewicz arteries were not blocked by the stent-graft in either patient.Intraoperative aortic dissection, embolization of the intercostal arteries, long ischemic time of the spinal cord, and excessive weight gain during operation may have been associated with the high incidence of paraplegia after open surgery using the endovascular stent-graft.

Conventional graft replacement of the ascending aorta and surgically endovascular stent-grafting of the proximal descending aorta were performed concomitantly in a 82-year-old woman with an acute DeBakey type II aortic dissection and a chronic DeBakey type IIIb aortic dissection. Postoperative computed tomography and angiography showed the adequately replaced ascending-aortic prosthesis, the well-expanded stent-graft, and the thrombosed false lumen in the descending aorta.

Background . The effectiveness of blood conservation measures for thoracic aortic operations with deep hypothermic circulatory arrest has not yet been documented. Methods . From July 1997 to December 2000, 148 thoracic aortic operations were performed in our department. Sixty-one cases involving patients who underwent elective thoracic aortic operation with deep hypothermic circulatory arrest were reviewed retrospectively. Results . Seventeen patients did not meet the criteria for the blood conservation program and were excluded from the present study. Therefore, 44 patients were analyzed in this study. Overall, 50% of patients did not require operative homologous blood transfusion (HBT) and 43% did not require in-hospital HBT. Smaller amounts of autologous donation, greater blood loss, and a longer operation time were independent risk factors for HBT requirement. Among 16 patients who had made an autologous donation of 1,600 mL or greater, 75% did not require intraoperative HBT and 69% did not require in-hospital HBT. The overall perioperative mortality rate was 4.5%. As for postoperative complications, prolonged intubation and postoperative infection were significantly more frequent among patients who required in-hospital HBT. Conclusions . Our combined blood conservation measures were effective in avoiding HBT during major thoracic aortic operations with deep hypothermic circulatory arrest and may have reduced postoperative complications. The amount of the autologous donation was a strong predictor for avoiding HBT.

Atrial and ventricular dysrhythmias developing after cardiac operation further reduce cardiac output, posing a serious problem for postoperative management. We have developed a "bio-mini-paddle" electrode designed to be attached directly to the myocardium for atrial or ventricular defibrillation and pacing for intraoperative and postoperative cardiac management. We use fibrin glue for the paddle, which is biodegradable. The characteristics of this unique paddle were examined using mongrel dogs.

This communication describes our clinical experience with the hybrid method, a video-assisted anterior minithoracotomy approach developed for minimally invasive limited pericardiectomy to treat 8 patients with massive pericardial effusion. The average operating time was 37.2 minutes, and there was no procedure-related morbidity or mortality. The mean follow-up period was 5.6 months, and there have been no recurrences. The hybrid approach can be accomplished irrespective of pleural adhesions. It eliminates the need for hemipulmonary collapse, making it more advantageous than the totally port-access thoracoscopic approach.

Background . In the surgical treatment of acute aortic dissection, intractable hemorrhage often occurs. We performed an animal study to test the hypothesis that a new sealant, AdvaSeal (Ethicon Inc, Johnson & Johnson Medical KK, Somerville, NJ), can close the false channel of aortic dissection. Methods . Acute descending aortic dissection was created surgically in 12 mongrel dogs. In 7 of these (treated group), AdvaSeal was applied to the false cavity for reinforcing and fusing the dissected layers and also to the suture line. The other 5 dogs (control) were left untreated. Specimens were harvested 2 weeks after surgery. Results . The sealant could be used in wet conditions. In the treated group, hemostasis was easily achieved during surgery. All false cavities were perfectly thrombosed, causing no deleterious effects related to the sealant. In the control group, all false lumina remained patent. Conclusions . The advantage of AdvaSeal was its effectiveness on wet tissue and its adhesiveness, allowing good hemostasis and closure of the false lumen. The sealant can be an easy and efficacious sealant in treatment for acute aortic dissection.

A 3-year-old boy underwent mitral valve repair for congenital mitral stenosis through combined superior-septal atriotomy and apical left ventriculotomy. The operation was performed safely with excellent exposure of the subvalvular apparatus by the ventricular approach, while sufficient visualization of the valvular lesion was obtained by the atrial approach. Postoperative echocardiography demonstrated normal left-ventricular motion and no residual mitral stenosis.

Tuberculous pseudoaneurysm has been reported to be a fatal, but rare complication of tuberculosis. We report a case of a 68-year-old man who underwent successful surgical treatment for a tuberculous pseudoaneurysm of the thoracic aorta with bronchial communication, and review previous reports of patients who also underwent operation for similar lesions, focusing especially on the pathway of infection to the aorta.

Since 1986, a rotation-advancement flap method has been used in 11 patients with partial anomalous pulmonary venous drainage into the superior vena cava. This method consists of atrial partitioning, enlargement of the superior vena cava, and protection of the sinus node. The midterm postoperative sinus node function and hemodynamic changes were examined in this study. Postoperative angiograms showed normal pulmonary venous pathway and no stenosis in the superior vena cava. Cardiac rhythm was normal and no clinical symptoms appeared. (J Thorac Cardiovasc Surg 1996;112:1-7)

During operations on patients with extracardiac conduits, sternal reapproximation occasionally results in critical compression of the conduit and serious deterioration in hemodynamic function. Permanent splinting of the sternum with a methyl methacrylate resinous plate provides an adequate substernal space for the extracardiac conduit.

Renal cell carcinoma occasionally invades the inferior vena cava and rarely extends to the right atrium. However, despite the frequency of venous extension, it is unusual to recognize patients with massive pulmonary tumor embolus clinically. We describe a 60-year-old man who underwent pulmonary tumor embolectomy using cardiopulmonary bypass combined with profound hypothermia and intermittent low-flow perfusion. The patient is currently alive and well without implantation metastasis 6 months after the operation.

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.

Gastric varices formed in a patient who had undergone a total cavopulmonary shunt operation 7 years previously. The varices were found to be due to development of collaterals from high-pressure systemic vein to low-pressure portal vein. Bleeding gastric varix can be a late complication of total cavopulmonary shunt.

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.