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The authors present the case of an 81-year-old patient with severe aortic stenosis who experienced left ventricular embolization of an aortic bioprosthesis during transapical aortic valve implantation. The authors discuss reasons for prosthesis embolization and reinforce the attention to technical details and the widespread use of multimodality imaging techniques. In this context, transesophageal echocardiography appears indispensable in the detection and management of procedure-related complications., (Crown Copyright © 2010. Published by Mosby, Inc. All rights reserved.)

Objective: The 3f Enable aortic bioprosthesis (ATS Medical, Inc, Minneapolis, Minn) represents a new generation of equine pericardial self-expanding valve designed for sutureless implantation. This study evaluated technical aspects of implantation and safety and effectiveness of the valve in the short term., Methods: In an outcome analysis of a consecutive series of 28 patients who underwent aortic valve replacement for aortic stenosis with the 3f Enable during an 18-month period, mean age was 75.7 +/- 6.6 years, 18 patients were female (64.2%), and mean EuroSCORE was 7.1% +/- 1.7%., Results: Most implanted valves were 23 mm in diameter (19-27 mm). Mean aortic crossclamp time was 39 +/- 15 minutes (29-103 minutes), mean cardiopulmonary bypass time was 58 +/- 20 minutes (41-127 minutes), mean hospital stay was 11 days (7-22 days), and 30-day mortality was 3.5%. Mean and peak intraoperative transvalvular pressure gradients were 6.1 +/- 2.6 and 18 +/- 5 mm Hg, respectively. Trivial and mild paravalvular leaks were observed in 1 patient each. One patient underwent reoperative aortic valve replacement 4 months after initial surgery for severe valve-unrelated paravalvular leakage. Five patients (18.5%) required permanent pacemakers. No patients were unavailable for follow-up. One-year survival was 86.2%., Conclusions: The 3-f Enable aortic bioprosthesis can be implanted safely with favorable early hemodynamics. The self-expanding stent allows sutureless implantation with a large valve area. The procedure was fast, although not as fast as expected. This experience has led to continued design and procedural enhancements to facilitate and accelerate future implantation., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Cardiac myxomas originating from the left ventricular free wall are extremely rare. A 32-year-old Swiss male was found to have a 5 x 3 x 3 cm myxoma originating from the left ventricular free wall using transthoracic echocardiography. The tumour was successfully treated by surgical excision but the mitral valve could not be preserved because of an untypical interference of the myxoma with the subvalvular apparatus.

Objective: The Ross operation remains a controversially discussed procedure, because concern exists regarding late dilatation of the neoaortic root and progressive regurgitation of the autograft valve. We present our early experience with an external reinforcement of the autograft, which is inserted into a prosthetic Dacron graft with an artificial aortic root configuration. This detail should help to prevent neoaortic root dilatation., Patients and Methods: Between 2006 and 2007, 12 patients (mean age 16 +/- 38 years; range 15-38 years) underwent a Ross procedure by this technique. Indications were aortic regurgitation (n = 2), aortic stenosis (n = 5), and combined aortic stenosis and insufficiency (n = 5). A bicuspid aortic valve was present in 9 patients. Balloon valvuloplasty had been performed in 7 patients. Follow-up was performed by clinical and echocardiographic examinations., Results: No early or late deaths occurred in this small series, and freedom from reoperation is 100%. Echocardiographic follow-up confirmed absence of aortic insufficiency in 11 patients after a mean of 11 months (range 2-30 months). In 1 patient, a small asymmetric regurgitation jet was already observed at discharge echocardiography. As expected, no neoaortic root dilatation was observed during follow-up. All patients are in New York Heart Association class I., Conclusions: The present technique is a simple and reproducible technical step that does not require significant additional time. Inclusion of the autograft within a root prosthesis may be especially indicated in situations known for late autograft dilatation, namely, bicuspid aortic valve, predominant aortic insufficiency, and ascending aortic enlargement.

Objective: Treatment of central and paracentral pulmonary embolism in patients with hemodynamic compromise remains a subject of debate, and no consensus exists regarding the best method: thrombolytic agents, catheter-based thrombus aspiration or fragmentation, or surgical embolectomy. We reviewed our experience with emergency surgical pulmonary embolectomy., Methods: Between January of 2000 and March of 2007, 25 patients (17 male, mean age 60 years) underwent emergency open embolectomy for central and paracentral pulmonary embolism. Eighteen patients presented in cardiogenic shock, 8 of whom had cardiac arrest and required cardiopulmonary resuscitation. All patients underwent operation with mild hypothermic cardiopulmonary bypass. Concomitant procedures were performed in 8 patients (3 coronary artery bypass grafts, 2 patent foramen ovale closures, 4 ligations of the left atrial appendage, 3 removals of a right atrial thrombus). Follow-up is 96% complete with a median of 2 years (range, 2 months to 6 years)., Results: All patients survived the procedure, but 2 patients died in the hospital on postoperative days 1 (intracerebral bleeding) and 11 (multiorgan failure), accounting for a 30-day mortality of 8% (95% confidence interval: 0.98-0.26). Four patients died later because of their underlying disease. Pre- and postoperative echocardiographic pressure measurements demonstrated the reduction of the pulmonary hypertension to half of the systemic pressure values or less., Conclusion: Surgical pulmonary embolectomy is an excellent option for patients with major pulmonary embolism and can be performed with minimal mortality and morbidity. Even patients who present with cardiac arrest and require preoperative cardiopulmonary resuscitation show satisfying results. Immediate surgical desobstruction favorably influences the pulmonary pressure and the recovery of right ventricular function, and remains the treatment of choice for patients with massive central and paracentral embolism with hemodynamic and respiratory compromise.

Complete correction of Tetralogy of Fallot, the most common cyanotic congenital heart defect, has now become routine. However, late residual lesions, primarily chronic pulmonary valve insufficiency, may have a negative impact on right-ventricular function, leading to the need for reoperation to insert a competent valve at the right-ventricular outflow. The diagnostic modalities pertaining to the failing right ventricle, the timing for eventual reintervention and the various surgical reconstruction possibilities of the right-ventricular outflow tract are still controversial and evolving, and are reviewed with a brief overview on current trends and future outlooks.

A 3-year-old boy underwent interventional closure of an atrial septal defect using an Amplatzer septal occluder. After 4 weeks, an aortic sinus-to-left atrial fistula was detected by echocardiography in an asymptomatic child. The device was surgically explanted with fistula and atrial septal defect closure. Follow-up was uneventful., (Copyright 2005 Wiley-Liss, Inc.)

Objectives: We sought to evaluate the safety of a right axillary incision, a cosmetically superior approach than anterolateral thoracotomy, to repair various congenital heart defects., Methods: All the patients who were approached with this incision between March 2001 and October 2004 were included in the study. There were 80 patients (median age, 4 years) with atrial septal defect closure (38 patients), repair of partial abnormal pulmonary venous return (14 patients), partial atrioventricular canal (16 patients), and perimembranous ventricular septal defect (12 patients). The surgical technique involved peripheral and central cannulation for institution of cardiopulmonary bypass. Electrically induced ventricular fibrillation was used for defects located in front of the atrioventricular valves, and cardioplegic arrest was used for those located at the level or behind these valves., Results: The repair was possible without need for conversion to another approach. One patient sustained a transient neurologic deficit. The patients were all in excellent condition after a mean follow-up of 14 months. The cardiac defect was repaired with no residual defect in 75 patients and with trivial residual defect in 5 patients (3 with mitral valve regurgitation, 1 with atrial septal defect, and 1 with ventricular septal defect). The incision healed properly in all, and the thorax showed no deformity., Conclusion: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because it lies more laterally and is hidden by the resting arm, it provides superior cosmetic results compared with conventional incisions, including the anterolateral thoracotomy. Finally, the incision is unlikely to interfere with subsequent development of the breast.

Objective: The objective of this study was to assess the safety of directly closing the septum primum during the correction of atrioventricular canal defects., Methods: We performed a retrospective analysis of our experience with direct closure of the septum primum during the repair of atrioventricular canal defect. The series consisted of 28 consecutive patients presenting with a partial (15 patients) and complete (13 patients) atrioventricular canal defect. The cleft in the atrioventricular valve was closed completely in 25 patients and partially in 3 patients (those with a small left lateral leaflet). In complete atrioventricular canal, the ventricular septum defect was closed with a patch of polytetrafluoroethylene (Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) or xenopericardium. Follow-up was complete and ranged from 3 to 21 months (median 11 months)., Results: There were no early or late deaths and no surgical complications. The septum primum defect was closed completely in all patients as assessed by echocardiography. All the patients were in sinus rhythmus, and none had even a temporary complete atrioventricular block. The surgical result and heart rhythm have remained stable over time., Conclusions: Direct closure of the septum primum is an easy, quick, and safe procedure during repair of atrioventricular defects.

Background: Reducing the negative side effects associated with extracorporeal circulation is the major advantage of off-pump revascularization. However, side clamping of a calcified aorta for proximal anastomoses can cause emboli, resulting in neurologic damage. This problem has been addressed by introducing a mechanical anastomosis device (Symmetry, St Jude Medical) that allows vein-to-aorta anastomosis without manipulating the aorta. This report describes our experience with this device., Methods: Between June 2001 and April 2002, 77 connectors (1.3 per patient) were deployed in 61 patients (51 men and 10 women; mean age, 68 +/- 8.6 years) undergoing off-pump coronary artery bypass grafting or beating-heart revascularization. Intraoperative quality assessment included transit-time flow measurement (Medistim) and indocyanine green-based angiography (Spy, Novadaq)., Results: The surgeons were meticulously trained in loading of the device. No postoperative neurologic deficits were detected. Fifty-three patients had an uneventful course. However, 8 (13.1%) patients with 12 implanted connectors were symptomatic within 8 months (1 day to 8 months). Angiography revealed significant (95%) stenosis or even occlusion of the proximal vein-to-aorta anastomosis at the level of all connectors. Four patients underwent reoperation (2 dilated-stented and 2 treated with drugs)., Conclusion: On the basis of these observations, the routine use of the connector was halted at our institution. At the moment, the use of this therapy is reserved for patients with severely calcified aortas with no technical alternative. Further investigations appear necessary to evaluate the clinical patterns of this otherwise promising technology.

Objective: To study the early function of the bovine jugular vein (BJV) when used for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure., Methods: Seventeen consecutive patients (median age, 12 years; range, 30 days to 40 years) who had undergone a Ross procedure with RVOT reconstruction using a BJV were reviewed. Nine patients had prior balloon valvotomy (n = 6) and/or surgical aortic valvotomy (n = 4). Additional procedures included a reduction-plasty of the ascending aorta (5 patients), a Konno procedure (2 patients), a mitral valve repair/replacement (2 patients), and others (3 patients). The size of the BJV ranged from 12 to 22 mm (median, 20 mm)., Results: There were no early or late deaths. None of the patients encountered any significant postoperative complications. The neo-aortic valve showed good function in all patients with no more than trivial insufficiency. At a median follow-up period of 11 months, the frequency of freedom from BJV graft dysfunction/reintervention/reoperation was 100%. One patient had moderate insufficiency of the BJV in a perioperative examination that regressed to mild insufficiency during follow-up. Overall, none of the patients had more than mild insufficiency at follow-up. Four patients showed a flow acceleration of more than 250 cm/s (equivalent to a gradient of 25 mm Hg) across the BJV, and the remaining patients had lower gradients., Conclusions: The BJV, when used to replace the pulmonary valve in the Ross procedure, showed excellent function in the early phase. The large size range and easy availability of this valved conduit are particularly attractive. Further followup is needed to determine the long-term results of its use.