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Background: Ventricular septal rupture (VSR) is an infrequent but life-threatening situation. Although outcomes have improved with the introduction of infarction exclusion, we have experienced difficulty in determining the optimal patch size and shape for obtaining good outcomes. Therefore, we modified the infarction exclusion technique. Herein, we review our experience on the basis of early closure of VSR with and without use of the infarction exclusion technique. Methods: We retrospectively analyzed the hospital records of 33 patients who underwent surgical treatment for VSR. We employed Dagget's method from 1982 to 1995, and then introduced the infarction exclusion technique in 1995. We have developed two modifications: the two-sheet single-patch technique and the three-sheet double-patch technique. Results: Overall hospital mortality was 41.9% and that of the infarction exclusion group was significantly lower than the hospital mortality rate of the noninfarction exclusion group (21% and 63%, respectively, p = 0.0266). Late mortality of survivors was low in all groups during the observation period. The three-sheet double-patch group showed no residual shunt. This difference in outcomes between the single-patch and double-patch groups was statistically significant (p = 0.0174). Conclusions: The two-sheet method facilitates the restoration of ventricular geometry. A double-patch using the three-sheet method may be useful for reducing residual shunt. (J Card Surg 2012;27:34–38)

SummaryA 49-year-old woman was admitted to the hospital because of cardiac tamponade. The hemorrhagic pericardial effusion was cytologically negative for malignant cells. Cardiac magnetic resonance imaging showed two masses in the anterior and lateral right atrium; however, positron emission tomography (PET) image using 18F-fluorodeoxyglucose revealed strong uptake in the anterior right atrium, without other tumors or metastasis. Intraoperatively, the lateral mass was confirmed as a thrombus, whereas the anterior mass was removed surgically and was diagnosed as an angiosarcoma with histopathological examination. However, she was re-admitted to the hospital 1 month after the operation because of cerebral hemorrhage, suspicious of distant metastasis. PET is useful for the detection of cardiac angiosarcoma.

a University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan b Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan c Department of Pain and Palliative Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan d Department of Medical Engineering, the University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan e Department of Cardiovascular Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan f Precursory Research for Embryonic Science and Technology (PRESTO), Japan Science and Technology Agency (JST), Research Division Gobancho Building, 7, Gobancho, Chiyodaku, Tokyo 102-0076, Japan g Translational Systems Biology and Medicine Initiative, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan h Department of Cardiovascular Surgery, Kinki University School of Medicine, 377-2 Onohigashi, Osakasayama, Osaka 589-8511, Japan

Port-access cardiac surgery has been developed to minimize skin incision and improve cosmetic outcomes. Using this method, a skin incision is generally made just above where the thoracotomy will be placed, horizontally along the intercostal space at the anterolateral submammary position. However, this type of incision can affect the frontal view and shape of the breast. Here, we report our experience with minimally invasive cardiac surgery using a port-access approach via a small vertical right infra-axillary incision and a moving window method. Twenty patients underwent surgical procedures with this approach from December 2010 to January 2012. Thirteen patients underwent mitral valvuloplasty, four mitral valve replacement, one mitral and tricuspid valve replacement and atrial septal defect closure and two atrial septal defect closure. All surgical procedures were completed using this minimally invasive method. All patients had an uneventful recovery and indicated that they were satisfied with the cosmetic results during the follow-up. Our experience suggests that this technique can effectively minimize skin incision and improve cosmetic outcomes.

We report a case of late mediastinal false aneurysm originating from disruption of the suture line between synthetic vascular grafts for aortic root and total aortic arch replacements. This aneurysm developed without any infection in a patient with Marfan's syndrome. To our knowledge, this event has never been reported before. The only possible cause of this disruption was that the monofilament suture was broken by continuous friction between the pointed anastomotic line and the sternum since the operation. The treatment options for this unusual event after extended synthetic graft replacement are discussed.

A 38-year-old man was diagnosed with acute type A aortic dissection and severe aortic regurgitation, and taken immediately to the operating room for repair of the ascending aorta using the Bentall procedure. The presence of the anomalous right coronary artery was revealed at the time of the procedure, and was repaired with single coronary button technique. Some case reports have described anomalous coronary artery in association with acute myocardiac infarction or angina pectoris. This report describes a case of anomalous coronary artery diagnosed during an emergency operation for aortic dissection.

Acquired coarctation due to coral reefs is a rare and unique entity characterized by extensively calcified thrombus of the entire aorta. There are few reports of coral reef aorta resulting in severely congestive heart failure in the literature. We describe a 60-year-old female with acute heart failure. Computed tomography (CT)-scan and magnetic resonance imaging (MRI) revealed that the cause of the heart failure was cardiac after-load mismatch due to serious stenosis of the aorta. In order to prevent cardio-respiratory failure, an axillofemoral bypass was performed to release the cardiac after-load mismatch. This diminished the pressure gradient between upper and lower blood pressure that caused cardiac dysfunction.

A 38-year-old man was hospitalized complaining of an episode of syncope. He was diagnosed with acute infective endocarditis (IE) of the aortic and the mitral valves with mobile and large vegetations, complicated with mycotic cerebral emboli related to the left anterior and the middle cerebral arteries. Double valve replacement with mechanical prosthesis was performed within 24 hours after cerebral accident occurred. On the 36 postoperative day, emergency cerebrovascular surgery was done due to rupture of a mycotic intracranial aneurysm. He was discharged on foot without any neurological abnormal finding. The optimum treatment of IE complicated with cerebral embolism is a controversial theme. Management should be considered carefully in individual cases.

In adults, coarctation of the aorta is usually accompanied by dilatation of the aorta at a site distal to the coarctation, and graft replacement of the aorta is therefore usually performed. Pathological study of coarctation has revealed that median necrosis of the aorta and aortic injury may occur as a result of crossclamping a portion of the aorta to the site of coarctation. Herein, we report a successful surgical repair of coarctation of the aorta by graft replacement using open anastomosis technique under the condition of deep-hypothermic circulatory arrest and a central cannulation technique. These techniques appear to be safe, and we recommend that they be used as a standard procedure for surgical repair of coarctation of the aorta in adults.

Cerebral malperfusion due to expansion of a false lumen can occur acutely during aortic repair when retrograde femoral perfusion is initiated. We detected this catastrophe by a rapid decrease in regional cerebral oxygenation and successfully treated it by immediate isolation of the cerebral circulation from the systemic circulation. The surgical management, including the above technique, for this rare event is described.

Introduction: Cardiac pacing for small children has been performed using a myocardial lead. Intravenous pacemaker lead implantation has a lot of advantages such as lower frequency of exit block and better pacing threshold compering to myocardial lead. However, intravenous pacemaker lead implantation has not been aggressively performed, because this approach for small children requires consideration of future growth, an appropriate entry site to avoid venous obstruction, and selection of lead. Patient and Method: The patient is a 4-year-old male underwent total correction of pulmonary atresia with ventricular septal defect following a lot of previous palliative surgery. Use of a myocardial lead was initially considered to treat sick sinus syndrome after total correction. However, it seemed difficult to attach a myocardial lead to the best place in the right atrium for AAI pacing, due to previous thoracotomies and cardiac surgery. Screw-in type lead was attached to the free wall of the right atrium and excess loop was left to adapt his growth. During the 16-year follow-up period, no adverse phenomenon such as an exit block, sensing failure, or free-floating of the lead were observed. Conclusion: The selection of a small size endocardial lead and an appropriate entry vein make implantation of an endocardial lead for small children easier and safety.

Background: Although pacemaker infection is a rare, but life-threatening complication, the optimal treatment is poorly defined. Methods: We describe 8 cases (7 patients), treated for an infected pacemaker at our institute between 2008 and 2011. The pacemaker pockets were fenestrated and treated with vacuum-assisted wound closure (VAC). Results: Infection was eradicated in seven cases without the need for aggressive surgery or removal of the intra-vascular lead. Fenestrated wounds in two cases were re-sutured without replacement of the entire pacemaker system. The others were implanted with new pacemakers in the contra-lateral side after removing the infected generator. However, in only a case, who had been operated for pacemaker implantation before 42 days, VAC did not lead to eradicate the infection, and intra-vascular lead was removed using traction. A pacemaker became infected again in one patient nine months later. The VAC therapy was repeated and the infection was eradicated by removing the pacemaker generator but not the intra-vascular lead. The mean durations of VAC were 30.3 days, respectively. There is no evidence of recurrent infection for 14–38 months after discharge. Conclusions: Although complete removal of an infected pacemaker system is essential, less invasive VAC might serve as the first option for treating pacemaker infection when the risk of total system explantation is high.