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We report a male patient who underwent successful redo cardiac surgery in 2014; tricuspid valve repair and redo mitral valve replacement of a Starr–Edwards mitral valve implanted 48 years previously. Six years after the redo operation, the patient remains well and therefore has an impressive over 54 years of survival following mitral valve replacement surgery.

Postoperative deep sternal wound infection (DSWI) is a serious complication in cardiac surgery (1–5% of patients) with high mortality and morbidity rates. Vacuum-assisted closure (VAC) therapy has shown promising results in terms of wound healing process, postoperative hospital length of stay and lower in-hospital costs. The aim of our retrospective study is to report the outcome of patients with DSWI treated with VAC therapy and to assess the effect of contributory risk factors. Data of 52 patients who have been treated with VAC therapy in a single institution (study period: September 2003–March 2012) were collected electronically through PAtient Tracking System PATS and statistically analysed using SPSS version 20. Of the 52 patients (35 M: 17 F), 88·5% (n = 46) were solely treated with VAC therapy and 11·5% (n = 6) had additional plastic surgical intervention. Follow-up was complete (mean 33·8 months) with an overall mortality rate of 26·9% (n = 14) of whom 50% (n = 7) died in hospital. No death was related to VAC complications. Patient outcomes were affected by pre-operative, intra-operative and postoperative risk factors. Logistic EUROscore, postoperative hospital length of stay, advanced age, chronic obstructive pulmonary disease (COPD) and long-term corticosteroid treatment appear to be significant contributing factors in the long-term survival of patients treated with VAC therapy.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was in osteogenesis imperfecta (OI) patients with valve disease undergoing valve replacement which type of valve (bioprosthetic or mechanical) is most appropriate in terms of safety, complications and survival. Altogether more than 77 papers were found as a result of the reported search, of which 43 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Previous review articles have presented case reports up to 2009. As all published data are based on case reports, we conducted a more detailed analysis that included the aforementioned series, reports that were missed prior to 2009 and all published data from 2009 to October 2013. Our analysis identified 43 OI patients. Mechanical valves were used in the majority of cases (31 patients), bioprosthetic valves in 10 patients and homografts in 2 patients. We conclude that based on the best available evidence, it appears that bioprosthetic valves have had better outcomes (mortality rate 10%) and a lower valve-related complication rate (0%) compared with mechanical valves (mortality rate 16.1%, complication rate 16.1%), even though differences were not statistically significant. Although the existing evidence is solely based on case reports of a relatively small number, we would suggest the use of bioprosthetic valves in OI patients with valve disease, as they appear to be safer according to our analysis. Moreover, considering the surgical difficulties related to the friability and weakness of the tissues in terms of suture lines and implantation of the valve as well as the high risk of perioperative bleeding which can be related to tissue friability, capillary fragility and platelet dysfunction followed by the risk of major traumatic fractures and a possible risk of aortic dissection in the future, the bioprosthetic valves seem to be safer taking into account the avoidance of lifelong anticoagulation and its secondary bleeding complications.

Osteogenesis imperfecta (OI) is a heritable disorder of the connective tissue. Cardiovascular involvement is rare, related mainly to aortic valve regurgitation. Open-heart surgery in these patients is associated with increased morbidity and mortality rates as a result of tissue friability and bone brittleness as well as platelet dysfunction. We present a patient with OI who underwent successful aortic valve replacement with a mini-sternotomy approach.

Objective: Prospective randomised study comparing patients with atrial fibrillation (AF) of more than 6 months duration after mitral valve surgery plus biatrial modified radiofrequency Maze procedure using Medtronic Cardioblate System (Cardioblate group, n = 24) vs mitral valve surgery plus intensive rhythm control strategy (control group, n = 25). Methods: Patients were blinded to randomisation. Preoperatively, at discharge, and at 3-month and 1 -year follow-up, echocardiography, quality of life assessments and ECGs were done. In both groups, sinus rhythm (SR) restoration was attempted by intra- and postoperative DC cardioversion and class III antiarrhythmic medication. All patients received warfarin. Amiodarone and warfarin was considered for discontinuation after 3 months in SR, 24-h Holter or event monitor excluding AF. Results: Both groups underwent mitral valve replacement or repair (Cardioblate vs control: 16:8 vs 10:15), had similar gender (male: 33% vs 56%), age (66 ± 8 years vs 68 ± 9 years), additional aortic valve replacement (7 vs 6 patients), tricuspid annuloplasty (13 vs 13 patients), and CABG (10 vs 16 patients). There was 0% operative mortality, 0% postoperative cerebrovascular accidents, but 2 late deaths in the control group. At discharge, 3-and 12-month follow-up, more patients in the Cardioblate group returned to normal SR compared to control (29%, 57% and 75% vs 20%, 43% and 39%; p = 0.030). Return of functional atrial contraction in patients in SR at 1 year was comparable between groups (63% vs 89%, NS), and more likely in non-rheumatic pathology and preoperative AF of shorter duration. The effectiveness of atrial contraction was 36 ± 14% vs 43 ± 18% of transmitral flow and there was no difference between groups. Amiodarone treatment decreased more in Cardioblate group over time (92%, 55% and 29% vs 52%, 52% and 21%; p = 0.003), whereas warfarin decrease was comparable (100%, 100% and 71% vs 100%, 95% and 82%; NS). Conclusions: Radiofrequency Maze ablation additional to mitral valve surgery resulted in a higher SR conversion rate (75%), despite control group treatment with intensive rhythm control strategy having a higher SR conversion rate (39%) compared to literature (∼25%). Maze ablation resulted in normalisation of atrial function in 63% of patients converted to SR.

Coronary cameral fistula, a rare acyanotic congenital or acquired anomaly that involves a large communication between one of the coronary arteries and a cardiac chamber, is the most important hemodynamically significant coronary artery abnormality. This case report is the first description of the combination of double coronary artery cameral fistulas associated with pulmonary hypertension and congestive heart failure and complicated by mitral and tricuspid regurgitation, patent foramen ovale, and chronic atrial fibrillation.

We retrospectively reviewed the surgical treatment of 12 patients (nine female, mean age 16.1+/-8.7 years) with sub-mitral aneurysms managed in our institution between 1991 and 2002. We identified three groups of patients in accordance with the degree of posterior mitral annular involvement by the aneurysm. A single aneurysm neck was found in seven patients, multiple necks in two and involvement of the entire posterior mitral annulus in three patients. Involvement of the entire posterior annulus by the aneurysmal process has not been previously described. The mean age of this latter group 29+/-5.1 years was significantly older than the former (P=0.001), suggesting a possible progressive nature of sub-mitral aneurysms. An intracardiac surgical approach was used in six patients and a combined intra and extracardiac approach in the remainder. There was no operative mortality. The mitral valve was initially repaired in eight patients. Failure of closure of the aneurysm necessitating reoperation occurred in four patients (33.3%). An understanding of the inter-relationship between the aneurysm and mitral valve is essential for successful surgical repair. Histology of the aneurysm tissue showed rheumatic heart disease in two patients and tuberculosis in two patients. Hence, although sub-valvar aneurysms are thought to be congenital, a third of our patients had evidence of co-existent rheumatic heart disease or tuberculosis.

We present the successful management of an interesting case of a single-stage combined mitral valve repair plus repair of the pectus excavatum with a Nuss bar.

Objective: This report describes the early and midterm results after intraoperative radiofrequency ablation of atrial fibrillation for patients with isolated chronic atrial fibrillation or atrial fibrillation in combination with additional valvular and nonvalvular cardiac diseases. Methods: From August 1998 to March 2001, a total of 234 patients with chronic atrial fibrillation underwent isolated intraoperative radiofrequency ablation alone (n = 74, 31.6%) or in combination with other cardiac procedures, such as mitral valve reconstruction (n = 57, 24.4%), mitral valve replacement (n = 38, 16.2%), aortic valve replacement (n = 11, 5.1%), coronary artery bypass grafting (n = 8, 5.0%), or a combination of the last with other cardiac procedures (n = 46, 19.7%). In all cases anatomic reentrant circuits confined within the left atrium were eliminated by placing contiguous lesion lines involving the mitral anulus and the orifices of the pulmonary veins through the use of radiofrequency energy application (exposure time, 20 seconds). A median sternotomy was used in 101 cases (43.2%), and video assistance through a right lateral minithoracotomy was used in 133 cases (56.8%). Results: A total of 188 patients (83.9%) were discharged in sinus rhythm, 17 patients (7.6%) had atrial fibrillation, and 19 patients (8.5%) had atypical flutter. Pacemakers were implanted in 23 patients (9.8%). There were 10 in-hospital deaths (4.2%), and 30-day mortality was 5 patients (2.1%). In 3 cases (1.3%) an atrioesophageal fistula developed, necessitating surgical repair. Six months' follow-up was complete for 122 (61.0%) of 200 patients, with 99 patients still in stable sinus rhythm (81.1%, 95% confidence interval 73.1%-89.9%). Twelve months' follow-up was complete for 80 (90.9%) of 88 patients, with 58 patients still in sinus rhythm (72.5%, 95% confidence interval 61.3%-83.2%). Conclusions: Intraoperative radiofrequency ablation is a curative procedure for chronic atrial fibrillation. It is technically less challenging than the maze procedure and can be applied through a minimally invasive approach. Protection of the esophagus seems mandatory to avoid the deleterious complication of a left atrioesophageal fistula, such as was observed in 3 cases. J Thorac Cardiovasc Surg 2002;123:919-27

The primary objective of mitral valve repair for secondary mitral regurgitation is to obtain a competent mitral valve. The secondary objective, by removing the ventricular volume overload is to prevent further deterioration of left ventricular function, and possibly improve left ventricular function by reverse remodelling. Patients with secondary mitral regurgitation, in contrast to degenerative mitral valve disease, have a higher risk of recurrent mitral regurgitation after initially successful mitral valve surgery. Hence, assessment and follow up of the mitral valve repair relies on more frequent routine echocardiography examinations (2D, 3D) including mitral valve parameters to detect mitral regurgitation recurrence, as well as left and right ventricle function and pulmonary hypertension. Post operative management includes anticoagulation to reduce thrombo-embolic risks, optimal medical therapy for heart failure including ACE inhibitors, beta blockers, spirinolactone and diuretics when indicated. Reoperation, ventricular assist devices or heart transplantation may need to be considered after mitral valve repair in patients who have continued symptoms of heart failure despite optimal medical and non-pharmacological therapy such as cardiac resynchronisation therapy.

OBJECTIVE The efficacy of the left atrial radiofrequency ablation procedure, for the curative treatment of atrial fibrillation, is dependent upon obtaining a confluent transmural line of hyperthermic cellular death. We compare the in vitro effectiveness of obtaining transmural hyperthermic cellular death (>55 degrees C) of both the Osypka single electrode and Boston Scientific Thermaline multi-electrode radiofrequency systems. METHODS Isolated cadaver porcine hearts were used to measure epicardial temperatures either 'central' or at the 'edge' in relation to an endocardial applied radiofrequency electrode. Reference set point was 70 degrees C, and 4-6-mm thick atrial tissue was used for all applications. 'Edge' temperatures with the Boston Scientific unit were measured whilst activating both adjacent electrodes. RESULTS Boston Scientific: Probe temperature closely approximated the set point. 'Central' epicardial temperature was lower than probe temperature until after 40 s application (P

Pulmonary artery sarcoma is a known but rare tumor with poor prognosis. It is a challenging diagnostic dilemma, as the main complaint of these patients is progressive dyspnea. Dyspnea is a common symptom in cardiorespiratory disease and therefore a high index of suspicion is necessary to make the diagnosis early and proceed with surgery and radiotherapy and/or chemotherapy. We report a case of primary pulmonary artery sarcoma that presented initially with weight loss, shortness of breath, palpitations, and dysphagia.

Background. Over the past decade the incidence of pulmonary disease due to drug-resistant strains of Mycobacterium tuberculosis has increased worldwide. We reviewed our local experience to clarify the benefits and risks of pulmonary resection in the management of drug-resistant strains of Mycobacterium tuberculosis . Methods. A retrospective review was performed of 62 patients undergoing pulmonary resection for drugresistant strains of Mycobacterium tuberculosis between January 1990 and November 1995. Results. Fifty-three percent were men and 47% women with an average age of 34 years (range, 16 to 72 years). There was one postoperative death, for a perioperative (30-day) mortality of 1.6%. Sixteen complications occurred in 14 patients for an overall morbidity of 23%. Eighteen of 24 patients (75%) who were persistently sputum positive at the time of operation immediately converted to a negative sputum smear and culture. For all patients who were sputum negative after operation 80% remain relapse-free by actuarial analysis. Conclusions. We believe that operation plays an important ancillary role in the treatment of drug-resistant strains of Mycobacterium tuberculosis . The operation can be performed with acceptable morbidity and mortality and must be combined with appropriate and well-monitored pre- and postoperative antituberculous drug therapy.

Purpose: Forty-one months after we performed bilateral implantation of in vitro endothelialized femoropopliteal bypass grafts in a 69-year-old patient, we obtained a central graft segment for histologic and ultrastructural investigation. Methods: Before implantation the grafts were confluently lined with autologous first passage mass cultures of pure cephalic vein endothelial cells. The precoating of the expanded polytetrafluoroethylene prosthesis was done with fibrinolytically inhibited fibrin glue. Reoperation became necessary because of symptomatic unilateral atherosclerotic lesions located in the center of one of the two in vitro lined grafts. A 21 cm long graft segment was removed and replaced by a new in vitro endothelialized expanded polytetrafluoroethylene graft. Results: On scanning electron microscopy a confluently covering mature endothelium was found throughout the whole length of the removed prosthesis. The endothelial identity was confirmed by a positive immunohistochemical CD 34, von Willebrand factorstaining, and the ultrastructural demonstration of Weibel Pallade bodies. The endothelium rested on a collagen IV positive basement membrane. Histologic cross sections revealed uniformly developed subintimal tissue of 1.21 ± 0.19 mm thickness, which was separated from the intima by a distinct internal elastic membrane. The cells of this cell-rich matrix stained strongly positive for actin. Ultrastructurally, this matrix was dominated by highly contractile myofibroblasts loaded with peripherally located well-developed actin fillaments. A number of these cells also showed signs of secretory cells with a distinct endoplasmic reticulum and a Golgi complex. In areas of atherosclerotic lesions the subendothelial matrix was partially exposed, and the internal elastic membrane had to a certain extent disintegrated. Only in these areas KP-1 and MG-Ml positive foamy macrophages and CD 34 positive capillaries were found. The myofibroblasts of this diseased part of the subintimal tissue contained large lipid vacuoles. Conclusions: We conclude that the confluent in vitro lining of synthetic vascular grafts with pure autologous endothelial cells facilitates graft healing, which may result in a hybrid structure with features of a native vessel.

Coronary artery perforation is a known complication of percutaneous coronary intervention and potentially life threatening. Normally, these perforations are small and localized. We report the successful surgical management of a coronary artery perforation following stent insertion with extrusion of an 8-cm endarterectomy length of the circumflex coronary artery with a brief review of the recent literature.

We read with great interest the best evidence topic by Yap et al. regarding the best bioprosthesis for aortic valve replacement [1]. We would like to present the results of our relative prospective multicentre randomized study. The aim of the study was to compare the haemodynamic performance and the sizing characteristics of the Medtronic Mosaic Ultra porcine and Carpentier-Edwards Perimount Magna bovine pericardial bioprosthetic stented aortic valve in relation to the patient's true aortic annulus size [2]. After the aortic valve excision, the annulus was measured by blinded sizers prior to the randomization of 141 patients (Ultra, n = 72; Magna, n = 69) [2]. The median patient age was 75 years, and 89% of the patients had aortic valve stenosis. A good left ventricular function was present in 75% of patients, and the EuroSCORE-predicted mortality was equal to 9%. Concomitant procedures (coronary artery bypass grafting, mitral/tricuspid valve repair, septal myectomy, modified maze procedure with radiofrequency) were performed in 61% of patients. The in-hospital mortality was 3%, and at six months postoperatively, 96% of the patients were in NYHA class I/II, with no inter-group differences. The mean 'true aortic annulus' size was 23.0 ± 1.4 mm for the Ultra valve, and 22.6 ± 1.8 mm for the Magna valve (P = not significant). The implanted labeled valve size was > or = 23 mm for 83% of Ultra valves, and for 52% of Magna valves (P 70 years [2,4]. The results of in vitro studies have also suggested that the Perimount Magna ThermaFix anticalcification treatment may be inferior to the Mosaic Ultra anti-calcification, and would result in an earlier reversal of the initially favorable Magna gradients [5]. Conflict of interest: none declared

We read with great interest the manuscript by Yano et al. regarding the surgical treartment of a mycotic aneurysm of ascending aorta [1]. We agree with the authors that the surgical repair of mycotic aortic aneurysms (extensive debridement of infected tissues, irrigation of the operative field with saline solution or antiseptic fluid and in situ reconstruction of the aorta) combined with wrapping of the prosthetic graft with pedicled omentum and administration of long-term antibiotics for prevention of the recurrence of infection is an acceptable mode of treatment [1]. Rifampicin-bonded prosthetic grafts can offer very good mid-term results. Uchida et al., in their retrospective study of 23 patients with mycotic aneurysms (6in thoracic aorta, 8 in thoracoabdominal aorta and 9 in abdominal aorta), who treated with in situ replacement of aorta with these grafts (plus omental pedicle grafts) found out that the overall survival at 5 years and freedom from aortic events was 95% and 86%, respectively. One patient died in the hospital due to recurrence of infection and another one required reoperation in another site of the aorta [2]. In addition, cryopreserved arterial homografts can be considered the treatment of choice and is our preferred option. Vogt et al., in their retrospective study of 19 patients with mycotic aneurysms (9/19) or infected grafts (10/19), in the thoracic (7/19) or abdominal aorta (12/19), apart from 16.2% mortality (1 early and 2 late deaths) didn't report on any recurrence of infection, homograft problems or anastomotic aneurysms in a mean follow-up period of 18.6 ± 13 months [3]. Silver-coated Dacron grafts compared to cryopreserved arterial homografts are reportable safe and present no significant difference in the treatment of infected abdominal aorta (in early mortality and mid-term survival) [4]. During the last years there is an increased use of thoracic endovascular stents and this modality of treatment has to be considered in the management of the complex cases, but with a higher incidence of recurrent infection. Patel et al., in their retrospective study of 20 patients with endovascular stenting of infected aortic pathological cases including 4 with infected grafts (10 aortobronchial fistulae, 2 aorto-oesophageal fistulae, 1 aortocutaneous fistula and 7 mycotic aneurysms) had an in-hospital mortality of 15%. Arch repair was needed in 8 patients, total descending, in 6 patients. Three patients underwent hybrid thoracic endovascular repair or debranching procedures. Mean Kaplan-Meier survival was 39.0 months. Late mortality was seen in 13 patients (history of immunosuppression and concurrent malignancy in 4 and 5 patients respectively) with 3 related to recurrent infection of thoracic aorta [tendency for recurrence when endovascular stent was performed in an infected graft (p = 0.08)]. At last imaging follow-up, 14 patients had a healed aorta [5]. In conclusion, conventional surgical treatment (with cryopreserved homografts or mycotic resistant prosthetic grafts or omental wrapping) is still the treatment of choice. However, knowing and understanding its limitations, the consideration of endovascular treatment in challenging, high-risk patients may offer acceptable results. Conflict of interest: none declared

The study aim was to compare the sizing characteristics and hemodynamics of the Medtronic Mosaic Ultra porcine and Carpentier-Edwards PERIMOUNT Magna bovine pericardial bioprosthetic stented aortic valves in relation to the patient's true aortic annulus size.In this prospective multicenter randomized study, data acquired perioperatively and at six months postoperatively were collected. Following aortic valve excision and debridement, the annulus was measured by blinded sizers prior to the randomization of 141 patients (Ultra, n=72; Magna, n=69).The median patient age was 75 years, and 89% of the patients had aortic stenosis. A good left ventricular function was present in 75% of patients, and the EuroSCORE-predicted mortality was 9%. Concomitant procedures (coronary artery bypass grafting, mitral/tricuspid repair, septal myectomy, modified Maze) were performed in 61% of patients. The in-hospital mortality was 3%, and at six months postoperatively 96% of the patients were NYHA class I or II, with no intergroup differences. The mean 'true aortic annulus' size was 23.0 +/- 1.4 mm for the Ultra valve, and 22.6 +/- 1.8 mm for the Magna valve (p = NS). The implanted labeled valve size wasor = 23 mm for 83% of Ultra valves, and for 52% of Magna valves (p0.01), and smaller than the measured true aortic diameter (44% Magna versus 33% Ultra). The mean echo gradients were lower with Magna valves (11 +/- 6 mmHg) than with Ultra (17 +/- 6 mmHg; p0.01), while the effective orifice area (EOA) was higher with Magna than with Ultra (1.6 +/- 0.4 versus 1.4 +/- 0.4 ; p0.01). Both groups showed a similar left ventricular mass regression (Ultra -48 +/- 83 g; Magna -42 +/- 70 g). Trivial to moderate regurgitation was noted in 24% of Ultra valves compared to 48% of Magna valves (p0.01).Selection of the Ultra bioprosthetic valve allowed the implantation of larger valve sizes. However, when compared to the 'true aortic annulus', the Magna was associated with lower transprosthetic gradients and larger EOAs. The longer term significance of these observations remains inconclusive in terms of bioprosthesis selection, however.

We read with interest the article by Andreetti et al. regarding the treatment of post-pneumonectomy bronchopleural fistula (PPBPF) by self-expandable stent and we agree that this modality can be in the armamentarium of cardiothoracic surgeons [1]. PPBPF is one of the most serious and lethal complications in thoracic surgery. There are well-known predisposing factors related to this devastating postoperative complication such as extensive bronchial devascularization, right-sided pneumonectomy, long residual bronchial stump, neoadjuvant or adjuvant chemotherapy, regional radiotherapy, diabetes mellitus, steroid therapy, prolonged mechanical ventilation, history of smoking, pre-existing empyema, incomplete resection of cancer at the bronchial margins, decreased albumin levels (less than 3.5 mg/dL), male gender, and technique of bronchial stump closure [2, 3]. From the beginning of thoracic surgery, many different methods have been used to prevent the development of PPBPF [2, 3]. Pedicled pericardial flap or pericardial fat pad, pleura, intercostal muscle, diaphragm, and azygos vein (for right pneumonectomy) have been used as an additional coverage of bronchial stub wound with very good results [2, 3]. Brewer et al. in 1953 were the first ones who reported on their experimental and clinical work on the use of pedicled pericardial fat graft for reinforcement of bronchial closure in patients with pulmonary resection [4]. Taghavi et al. in 2005, in their retrospective study of 96 patients who underwent pneumonectomy (89.2% for primary lung cancer) and had covered bronchial stump with a pedicled pericardial flap, did not notice any evidence of PPBPF during the perioperative and postoperative period (mean follow up 15 ± 21.2 months) [2]. Sfyridis et al. in 2007, in their prospective randomised trial of 70 patients with diabetes mellitus who underwent pneumonectomy and were randomised to have their bronchial stump covered with an intercostal muscle flap or not; found that the group with the covered bronchial stump had a lower incidence of PPBPF (0% versus 8.8%; p = 0.02) and of empyema (0% versus 7.4%; p = 0.05) compared with the group not covered, at a mean follow-up of 18 ± 9.2 months [3]. Endobronchial valves have also been used to good effect in patients with persistent pulmonary air leaks (refractory to other therapy) secondary to alveolopleural fistula and to bronchopleural fistula as well [5]. In conclusion, in high risk patients the consideration of an effective method for covered bronchial stump for the prevention of the development of PPBLF is very important. Therefore, the multidisciplinary approach for the ideal treatment of patients with PBPF should be on an individual basis and is of paramount importance. Conflict of Interest: None declared

Bhagwat and colleagues have reported on the successful surgical treatment of a patient with primary pulmonary artery sarcoma [1]. We would like to share our experience relating to a 62 year female and to add a brief comment as well [2]. We reported on a patient with primary pulmonary artery sarcoma presenting initially with weight loss, shortness of breath, palpitations, and dysphagia. The diagnostic approach consisted of echocardiography, CT scan, MRI and coronary angiogram, and the differential diagnosis included pulmonary emboli, chronic thromboembolic disease and pulmonary artery tumour. The patient underwent exploratory median sternotomy under cardiopulmonary bypass (CPB), logistic EuroSCORE 6%, and the entire tumour was resected with an extensive tumour endarterectomy. However, as a fibrotic area in the right ventricle was left, this was considered to be a palliative procedure and the patient was referred for chemotherapy and radiotherapy [2]. Pulmonary artery sarcoma presents a diagnostic challenge, as the main presenting complaint of patients is progressive dyspnoea. Dyspnoea is a quite common symptom in diseases of the heart and lungs and therefore a high index of suspicion is necessary to make the diagnosis early, and to proceed with surgery and radiotherapy and/or chemotherapy [2]. Since 1923, when the first case was described, until 2006, no more than 210-220 cases have been reported [2]. Pulmonary artery sarcomas arise from pluripotent intimal cells. They are most frequently located within the pulmonary trunk, spreading into the proximal and distal pulmonary arteries. Typical onset age is 45-55 years, with reported age ranging from 13 to 86 years and a female to male ratio equal to 2:1. Due to the rarity of these tumours, they are often initially misdiagnosed as chronic thromboembolic disease leading to unnecessary anticoagulation of affected patients [2]. Preoperative histological diagnosis is generally not possible although, rarely, biopsy may be obtained via CT-guided transthoracic aspiration or, alternatively, via transvenous catheter suction biopsy with pulmonary angioscopy, as well as by transbronchial biopsy [2]. Endarterectomy via median sternotomy and CPB, with dissection of the intima and most of the media, may result in complete tumour removal and is the most commonly used and widely acceptable surgical strategy. Although in unilateral disease it is possible to attempt a pneumonectomy, in bilateral disease it seems to be of limited value [2]. Alternative surgical methods include total excision of pulmonary trunk with reconstruction, and heart and lung transplantation for unresectable tumours [3,4]. Palliative treatment includes debulking of the tumour, endovascular stent or bypass procedure [2,5]. The prognosis is poor: without surgery survival is 1.5 months. The median survival has been significantly improved with radical surgical resection and multimodality treatment [1,2]. Surgical treatment remains the cornerstone of management, offering definite diagnosis, improvement of symptoms and the best outcome. However, if curative resection is not possible, palliative resection still provides good symptom relief and can improve survival [2]. A high index of suspicion for early diagnosis is the key to successful treatment and prolonged survival for these patients presenting with no specific symptoms. Conflict of Interest: None declared

A metaanalysis of articles concerning the surgical management of acute traumatic rupture of the descending thoracic aorta published in the English-language literature between 1972 and July 1992 was performed. The overall mortality of 1,742 patients who arrived at the hospital alive was 32.0%, one-third died before surgical repair was started. Paraplegia was noted preoperatively in 2.6% of these hospitalized patients, and paraplegia complicated the surgical repair in 9.9% of 1,492 patients who reached the operating room in a relatively stable condition. Patients then were analyzed according to the surgical intervention used. Simple aortic cross-clamping (n = 443) was associated with a hospital mortality of 16.0% and incidence of paraplegia of 19.2%, despite lower average mean cross-clamp times (32 minutes; p < 0.01 versus passive or active methods of providing distal perfusion). In a subset of 290 patients in whom individual data were available, the cumulative risk of paraplegia was shown to increase substantially if the duration of aortic cross-clamping exceeded 30 minutes, but only when distal perfusion was not augmented (p < 0.00001). "Passive" perfusion shunts (n = 424) were associated with a mortality of 12.3%, and the incidence of paraplegia decreased to 11.1% (p < 0.001). However, shunts inserted from the apex of the left ventricle had a contradictory high 26.1% incidence of paraplegia compared with shunts from the ascending aorta (8.2%; p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

A 31-year-old woman who had undergone left pneumonectomy for a tuberculosis-destroyed left lung 3 years previously presented in respiratory distress after a pregnancy complicated by preeclampsia and aspiration pneumonia. Investigation revealed a large aortic arch aneurysm as well as a filling defect in the descending thoracic aortic lumen. Emergency aortic arch reconstruction was performed for a massive pseudoaneurysm or contained rupture filling the entire postpneumonectomy space. Pathologic and microbiological examination demonstrated Aspergillus fumigatus and active inflammation.

Part of the complexity of mitral valve chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures is determining the correct replacement chordal length and knotting the ePTFE suture without sliding the knot. We describe a technique of measuring the required chordal length and making a "premeasured" Gore-Tex chordal loop that abolishes problems of inadvertently altering chordal length during fixation. This improves the reproducibility of chordal replacement surgery, and can be used both via conventional and minimally invasive approaches.

The hypothesis tested is that shifts in pH, induced when a cardioplegic solution is oxygenated, can be detrimental. We added either 100% nitrogen, 95% nitrogen and 5% carbon dioxide, 100% oxygen, or 95% oxygen and 5% carbon dioxide to the cardioplegic solution (St Thomas’ Hospital No. 2 plus glucose 11 mmol/L), and determined postischemic recovery of isolated rat hearts after 3 hours of 10° C cardioplegic protected ischemia. Hearts were arrested and reinfused every 30 minutes throughout the ischemic period with cardioplegic solution. When 5% carbon dioxide was added to nitrogen, the pH of the cardioplegic solution decreased from 9.1 (100% nitrogen) to 7.0 (95% nitrogen : 5% carbon dioxide), a change associated with improved postischemic functional recovery. Aortic output improved from 52.3% ± 2.7% to 63.9% ± 2.8%, p

The cultivation of autologous endothelial cells on the blood surface of artificial hearts might prevent their detrimental thromboembolic complications. To investigate the growth characteristics of endothelial cells on theoretically suitable biomaterials, we compared three polyurethanes (Pellethane, Biomer, Enka) and three silicone rubbers (Elastosil, 3145 RTV, Medical Adhesive). All synthetic surfaces were precoated with an extracellular matrix (group 1), fibronectin (group 2), or a glutaraldehyde-preserved cellular matrix (group 3). After the seeding of 2.5 x 10(4)/cm2 human endothelial cells into the various surfaces, primary adherence, growth kinetics, and maintenance of monolayer integrity were studied for 13 days. On the three polyurethanes all precoating procedures resulted in endothelial cell proliferation and the formation of persistent monolayers. In contrast, on silicone rubbers a persistent coverage with a confluent endothelium could be achieved only on the glutaraldehyde-preserved cellular matrix. When endothelial cell growth was quantitatively assessed on all precoating substrates, the glutaraldehyde-preserved cellular matrix proved to be far superior on each of the synthetics (p less than 0.001). These results demonstrate the theoretical feasibility of endothelialization of artificial hearts in vitro. Provided such an endothelium can withstand the mechanical forces within an artificial heart, in vitro endothelialization might contribute to a regained attractiveness of the elective long-term implantation of artificial hearts.

The early effect of allogenic in vitro endothelialization was assessed in small- diameter vascular prostheses. Cryopreserved and pooled venous endothelial cells (ECs) from 13 baboons of similar blood group were used for confluent in vitro endothelialization of fibrin glue-coated polytetrafluoroethylene vascular grafts. Bilateral femoral interpositions (12 cm) of experimental and control grafts were subsequently implanted into a separate group of 18 male baboons with the same blood group as that of the pooled cells. After sixteen days of implantation the patency rate of grafts of the endothelialized group was similar to that of the control group (55.6% vs 61.1%, p>0.1). Scanning electron microscopy revealed that 44.4% of experimental grafts were completly free of endothelium, while the remaining grafts showed a moderate mean EC coverage of 34.4 17.1%. These remaining ECs were found mainly as small islands densely covered by leukocytes. The majority of these white cells resembled granulocytes, although adherent lymphocytes were also regularly observed. Since surface morphology does not explain the mechanism of EC loss, further experiments must elucidate this question. If rejection is found to be the primary cause for this cell loss, the use of major histocompatibility complex (MHC) matched EC subpools might be considered.

Surgical repair of tetralogy of Fallot is recognized as one of the most successful palliative cardiac surgical procedures. We report a patient in whom cystic medial necrosis developed 50 years after tetralogy of Fallot repair that caused a pathologic ascending aortic aneurysm requiring operative repair. Thus, long-term clinical follow-up along with echocardiography, when indicated, is mandatory in patients undergoing tetralogy of Fallot repair.

We present a rare case of bacterial endocarditis of the aortic valve complicated by intracranial haemorrhage, splenic and renal infarcts. Aortic valve replacement was complicated by delayed splenic rupture. The successful surgical management of this case is described as well as a review of the literature.

Noonan's syndrome is one of the commonest hereditary syndromes with cardiac involvement. We report a rare presentation of this syndrome, associated with giant aneurysms of the left and non-coronary sinuses of Valsalva, resulting in symptomatic aortic valve regurgitation. The patient's clinical investigations and operative management are presented. Histological examination of aortic tissues offers insight into the pathogenesis of these complications.

We read with great interest the article by Almdahl et al., regarding the cardiac surgical outcome of patients with complications of percutaneous coronary intervention (PCI) [1]. Complications of PCI include perforation (of the coronary artery or ventricle), retained wires, dissection, bleeding (subepicardial or not), tamponade and myocardial ischaemia or infarction [1, 2]. There is an angiographic classification of three types of coronary artery perforation post PCI according to Ellis et al. [3]. In Type I, the angiographic findings are consistent with extraluminal crater with no contrast extravasation. In Type II the contrast extravasation is limited to ‘blushing’ in the myocardial or epicardial fat. In Type III there is a contrast extravasation through frank (>1 mm) perforations or Type III ‘cavity spilling’ extravasation into either the left ventricle, the coronary sinus, any of the cardiac chambers, or the pericardium [3]. This classification is quite important as a useful tool for the diagnosis, management and prognosis of this potentially severe complication. Type I perforations are associated with the lowest incidence of tamponade (8%) with no reported incidence of myocardial infarction or mortality. As a result, the vast majority (85%) of Type I are treated conservatively. Type II perforations show a higher incidence of tamponade and myocardial infarction (13% and 14%, respectively) with no reported mortality, and conservative treatment is successful in 90% of cases. In contrast, Type III perforations have a high morbidity with a much higher incidence of tamponade and myocardial infarction (63% and 50%, respectively) and conservative treatment has been reported to be successful in only 44% of cases, with a mortality independent of treatment in 19% of cases [2, 3]. Shimony et al., in their recent systematic review and meta-analysis (16 studies, 197 061 PCIs), reported that the incidence of PCI complications was 0.43%. Furthermore, the tamponade rates were 0.4%, 3.3% and 45.7% for patients with Ellis classes I to III coronary artery perforations, respectively [4]. It is important to take into consideration the fact that currently (to the best of our knowledge), no established protocol guidelines exist regarding management strategies for PCI complications [2–4]. According to the suggested algorithm of Shimony et al., which is consistent with our department's practice as well, all these patients should be under continuous monitoring and assessment (sequential echocardiography studies). In the case of haemodynamic instability (mainly Ellis class III), the patient is either initially treated conservatively under the care of the cardiologists [pericardiocentesis (definitive or bridging treatment for open surgical intervention), heparin reversal, discontinuation of IIb/IIIa inhibitors/bivalirudin, prolonged balloon inflation for 5 to 15 minutes, embolization, polytetrafluoroethylene-covered stent etc], or surgically by the cardiac surgeons [4]. Surgical management is not standardized and depends on the surgical anatomy, patient co-morbidities and clinical condition. Surgical reports include simple suturing of the perforation, ligation of bleeding vessels, pericardial patch application, surgical glues, CABG (on or off CBP) with and without endarterectomy, stent removal, or vein patch [1–5]. Conflict of interest: none declared

The case is presented of dynamic left ventricular mid-cavitary obstruction that complicated the postoperative course following aortic valve replacement and coronary artery bypass grafting. The condition resolved with appropriate medical management, without further surgical intervention. It is hypothesized that this was due to both concentric left ventricular hypertrophy and direct diastolic ventricular interaction.

We read with interest the best evidence topic article by Shin and Abah regarding routine stress ulcer prophylaxis in cardiac surgery [1]. We agree with their recommendation of routine acid suppression therapy for the prevention of gastrointestinal (GI) complications in patients undergoing cardiac surgery. Major GI complications following cardiac surgery consist mainly of upper GI bleeding and GI ischaemia followed by peptic ulcer disease, diverticulitis, pancreatitis and cholecystitis [2, 3, 4]. We have audited our practice with regards to major GI complications in patients undergoing cardiac surgery [2]. We found out that after routine introduction of acid suppression therapy, there was a significant reduction in GI complications related to upper GI bleeding. Therefore, there was no single practice in various cardiothoracic units in the United Kingdom [2]. In their retrospective study of 51 patients with GI complications (in total of 4819 patients), Filsulfi et al. listed the following as independent predictive factors of GI complications in cardiac surgery: age, myocardial infarction, congestive heart failure, haemodynamic instability, cardiopulmonary bypass time (over 120 min), peripheral vascular disease, and renal and hepatic failure [3]. The overall hospital mortality among patients with GI complications was higher and the long-term survival was significantly decreased in these patients compared with the control group [3]. In addition, Mangi et al. performed a retrospective analysis of 46 patients (out of 8709 patients) with GI complications and found the following to be preoperative predictor factors: prior cerebrovascular accident, chronic obstructive pulmonary disease, type II heparin-induced thrombocytopenia, atrial fibrillation, prior myocardial infarction, renal insufficiency, hypertension, and need for intra-aortic balloon counterpulsation [4]. Univariate predictors of increased mortality rate in patients with GI complications included New York Heart Association class III and IV, smoking, direct bilirubin over 2.4 mg/dl, pH less than 7.30, syncope at time of presentation, chronic obstructive pulmonary disease, aspartate transaminase over 600 mg/dl and the need for two or more pressors [4]. The National Institute of Clinical Excellence has recommended the treatment with acid suppression therapy (H2-receptor antagonists or proton pump inhibitors) in all acutely ill patients (admitted to intensive care or high dependency units) for primary prevention of upper GI bleeding. Therefore, depending on the patient, the oral form of acid suppression therapy is preferable [5]. The need of acid suppression therapy should be reviewed after the discharge of the patient from the intensive care or high dependency units on an individual basis and during their recovery process [5]. Acid suppression therapy can reduce the risk of acute upper GI bleeding and blood transfusion requirements. However, it does not significantly affect the mortality rate. The adverse events of ventilation-associated pneumonia and of Clostridium difficile-associated diarrhoea do not appear to be increased significantly after the introduction of acid suppression therapy [5]. In conclusion, GI complications in patients undergoing cardiac surgery remain rare but devastating. The early identification of predictive factors and the application of all the preventive measures are of paramount importance for the better outcome of these patients.

Objectives: To review 26 consecutive patients with sustained monomorphic ventricular tachycardia (VT) of left ventricular origin, who underwent direct VT surgery. Methods: Economic factors precluded the use of an implantable cardioverter defibrillator (ICD) in the majority of these patients, and the indication for surgery in 81% of patients was for failed medical drug therapy and 27% of patients had frequent or incessant life-threatening VT. The principles of direct VT surgery included intraoperative mapping, extended endocardial resection, cryoablation, left ventricular aneurysm repair by left ventricular remodelling and endoaneurysmorrhaphy, as well as coronary artery bypass grafting. Results: Two patients with non-ischaemic VT were significantly younger (37.7 ^ 19.4 years, P ¼ 0:03), had lower preoperative New York Heart Association class (P ¼ 0:03), and had better left ventricular ejection fractions of 59.5 ^ 2.1% (P ¼ 0:001) than the 24 ischaemic patients. No operative mortality or recurrence of VT occurred in this group. Ischaemic VT patients had an operative mortality of 8.3%; risk factors were concomitant valve surgery (P ¼ 0:02), and perioperative intra-aortic balloon pump (P ¼ 0:02). Surgery improved the left ventricular ejection fraction from 28.4 ^ 9.8% to 43.2 ^ 8.2% (P ¼ 0:0001). Freedom from recurrence or inducibility of VT in operative survivors was 78.8 ^ 9.6% at 10 years; risk factors were arrhythmic focus remote to the left ventricular aneurysm (P ¼ 0:015), and simple cryoablation or endocardial resection alone and not in combination (P ¼ 0:003). Survival was 54.1 ^ 11.6% and 43.3 ^ 13.4% at 5 and 10 years, respectively, and there were no arrhythmic or sudden cardiac deaths. Patients with immediately life-threatening VT unsuitable for ICD implantation requiring urgent or emergent VT surgery had a 10-year survival of 22.2 ^ 13.9% compared to the more elective surgical group with a rate of 73.3 ^ 13.9% (P ¼ 0:08). Conclusions: Direct VT surgery should remain an objective for symptomatic drug refractory VT of left ventricular origin. q 2002 Elsevier Science B.V. All rights reserved.

The chemical glue, gelatin, resorcin and formaldehyde (GRF) is widely used to obliterate the false lumen of acute dissected aortic wall tissue.A retrospective review of 41 consecutive patients operated upon for ascending aortic dissection between 1993 and 2000 was conducted. This study focused on 19 patients with acute aortic dissection in whom the aortic valve was resuspended and GRF glue used in the proximal aortic sinuses. These patients were compared with ascending aortic dissection patients in whom the aortic valve was not resuspended. In total, nine acute and 13 chronic dissections were performed in which aortic valve replacement, valve-sparing root reconstruction (without GRF glue), or no aortic valve surgery was carried out.The operative mortality for ascending aortic dissections was 24.4%; identified risk factors included the specific surgeon involved. Third-degree heart block occurred only in patients in whom GRF glue was used in the proximal aortic sinus (15% incidence). Operative survivors in whom the aortic valve was resuspended and GRF glue used in the proximal aortic sinus, had a 64% incidence of late recurrent aortic regurgitation requiring reoperation due to recurrent aortic sinus aneurysm formation with or without recurrent proximal aortic dissection. No recurrence of aortic regurgitation or proximal disease occurred in the other two groups (p0.01). Actuarial survival of patients in whom the aortic valve was resuspended with GRF glue was 52.1+/-11.6% at five years and 27.8+/-14.3% at eight years, compared with 55.6+/-16.6% at five years if the aortic valve was not resuspended using GRF glue.The use of GRF glue to repair acute dissected aortic sinuses combined with the resuspension of the aortic valve is associated with an unacceptable incidence of failure of aortic valve repair and recurrence of aortic regurgitation. It may be more appropriate to resect all acute dissected aortic sinus tissue.

Fixation at high glutaraldehyde (GA) concentrations mitigated bioprosthetic calcification in the rat model. The present study intended to verify this observation in the circulatory sheep model.Porcine aortic roots were either fixed in 0.2%, 1.0%, or 3.0% GA. Eight roots per group were implanted in the distal aortic arch of sheep. After six weeks and six months calcification and inflammation were quantitatively and qualitatively assessed.By increasing the GA concentration from 0.2% to 3.0%, aortic wall calcification could be reduced by 38% after 6 weeks and 34% after 6 months of implantation (p0.01). Mineralization coincided with the presence of elastin although calcium was predominantly found in cell nuclei and membranes. Leaflet calcification was absent in all groups after 6 weeks but in a few leaflets presented as heterogeneous, nodular spongiosa deposits after 6 months. Overall, differences between 0.2%-, 1.0%-, and 3.0%-fixed tissue were quantitative but not qualitative regarding distribution patterns. There was no significant difference in inflammatory host reaction between all groups.We have shown in the circulatory sheep model that the anticalcific effect of better cross-linking seems to outweigh the intrinsic pro-calcific effect of GA accumulation in bioprosthetic aortic wall tissue.

Aortoesophageal fistulas due to atherosclerotic thoracic aneurysms are usually fatal, with few reported survivors. We report an aortoesophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. Immediate esophageal reconstruction was attained using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft.

Coronary arterio-venous fistulae are congenital or acquired cardiac anomalies whereby blood bypasses the myocardial capillary network. Involvement of all three coronary arteries is rare. There is a wide variation in the clinical presentation and the actual morphological malformations. The mainstay of treatment is either surgical or coil embolisation. Associated congenital malformations can be dealt with during the same surgical setting if required. We present a case of coronary arterio-venous fistula involving all three coronary arteries with associated atrial septal defect and acquired aortic regurgitation, all of which were dealt with surgically with good surgical outcome.

Background. Innominate artery stab wounds are rarely encountered, and the optimal management of this injury is different from that of blunt innominate injury in that permanent bypass shunting should not be necessary. Methods. The records of 19 patients with stab wounds of the innominate artery who were treated by our department from January 1982 to June 1995 were reviewed. Results. Eighteen patients (95%) sustained zone 1 neck stabs, with a similar proportion having only a single stab wound. Seventeen (89%) of the 18 patients having chest roentgenograms had mediastinal widening. Thirteen patients (68%) were hemodynamically stable at admission; the remainder were unstable (26%) or moribund (5%). Fourteen patients (74%) underwent angiography, with no false-negative studies for arterial injury. Associated injuries to thoracic viscera occurred in 4 patients (21%). All injuries were repaired with either direct suture (18 of 19) or prosthetic interposition grafting (1 of 19). One patient required cardiopulmonary bypass to repair complex injuries. The overall mortality rate was 5% (1 of 19), and complications occurred in 2 patients (11%). Conclusions. Innominate artery stab wounds can be managed successfully without permanent bypass shunting and with a low mortality rate.

Background. Isolated thoracic duct injuries as a result of penetrating chest trauma without any major vascular or tracheoesophageal injury seldom are seen. Methods. A retrospective 13-year review identified 8 patients with this injury. Results. Seven had supraclavicular or suprascapular knife stabs, and the eighth had a low-velocity gunshot injury entering the mid-lateral right chest wall. All 7 stab victims presented with left-sided chylothoraces, and the site of injury of the thoracic duct was within Poirier's triangle, the borders of which are the arch of aorta, the left subclavian artery, and the vertebral column as seen from a lateral approach. Five patients initially were treated conservatively for 13.4 ± 4.4 days without success. Surgical intervention thus was necessary and was successful in all 8 patients. The thoracic duct injury was controlled successfully through a left posterolateral thoracotomy in 6 patients. A supraclavicular repair was attempted in 1 patient but failed to control the leak and required reexploration via the supraclavicular approach. The right chylothorax from the gunshot injury was explored via a right posterolateral thoracotomy; the leak into the pleura was identified and obliterated. Conclusions. As conservative management was uniformly unsuccessful, we advocate early operative management through a thoracotomy on the side of the chylothorax for this relatively rare injury.