The Novel Technique of Sternal Closure With Absorbable Mesh for Osteoporotic Patients.

After a median sternotomy, sternal instability can result in sternal infection. The usual sternal closure with stainless steel wires may result in sternal instability, especially in osteoporotic patients. An absorbable mesh (Super-FIXSORB-MX®40, Takiron Co Ltd, Osaka, Japan) for reinforcing the sternum has become commercially available. This paper reports a modified sternal closure procedure using this absorbable mesh in combination with heavy braided Polydiaxanon (PDS cord®, Ethicon, Inc., Somerville, NJ, USA) for osteoporotic patients.

A Safe Technique for Using an Enclose II Anastomosis Assist Device During Off-Pump Coronary Bypass.

Several proximal anastomosis devices have been developed to facilitate the creation of a clampless, hand-sewn coronary artery bypass-to-ascending aorta anastomosis. An Enclose II anastomosis assist device (Novare Surgical Systems, Cupertino, CA) is a device commonly used for this purpose. We demonstrate a new, easy, and safe technique for cutting the aortic wall and making a punch hole over the aorta.

Nine-year experience of recurrent anastomotic pseudoaneurysms after thoracoabdominal aneurysm graft replacement in a patient with Behçet disease.

A 47 year-old woman with Behçet disease presented with back pain. Computed tomography showed an extent IV thoracoabdominal aneurysm. Graft replacement with reconstruction of all visceral arteries was performed. At five years postoperatively, anastomotic pseudoaneurysm of the left renal artery occurred, and it was reconstructed with an 8-mm graft. Two years after the second reconstruction, anastomotic pseudoaneurysms of the abdominal aorta developed. Y-shaped graft replacement was performed. There has been no recurrence for one year since the last operation. In situ graft reconstruction for recurrent pseudoaneurysms in a Behçet disease patient more than five years after graft replacement with reconstruction of all visceral arteries is rare.

A novel chest packing technique for intractable bleeding after open heart surgical procedures.

Intractable bleeding after cardiac surgical procedures is a life-threatening complication. In most cases, the main bleeding site is present in the retrosternal space, not the pericardial space. Packing the chest may be a useful technique for achieving hemostasis. Herein, we describe a novel and effective procedure for the treatment of intractable bleeding in the retrosternal space using a sheet of oxidized regenerated cellulose and sponges after cardiac surgical procedures.

Right ventricular perforation caused by pulmonary artery catheter three days after insertion in a patient with acute pulmonary embolism.

A 68 year-old man presented with dyspnoea and chest pain. Computed tomography showed a massive bilateral pulmonary embolism. A 7.5 French pulmonary artery catheter (PAC) was inserted from the right internal jugular vein, and placed at the main pulmonary artery (PA) due to a thrombus in the distal PA. Continuous heparin sodium and urokinase infusions (240,000 units/day) were started. The PA pressure decreased gradually to within the normal range after two days. Three days after insertion, the PA waveform suddenly changed, he subsequently complained of chest pain, and the blood pressure rapidly decreased. Echocardiography demonstrated marked pericardial effusion. Computed tomography showed right ventricular perforation by the catheter, and contrast dye injection from the catheter tip demonstrated pericardial space enhancement. A median sternotomy was performed, and the perforation was detected in the anterior right ventricular wall. Direct buttress suture was placed, and the catheter was removed. He was subsequently discharged without any further complications. We encountered a rare case of postoperative RV perforation caused by a PAC. It is important to keep in mind that such a complication could arise not only during but also a few days after PAC insertion.

Pancreaticoduodenal artery aneurysm involving papilla of vater successfully treated with endovascular approach despite intraoperative rupture.

An 81-year-old woman presented with dizziness and nasal bleeding. Gastrointestinal fiberscopy (GIF) showed a pulsatile aneurysm in the duodenum, and that the orifice of the papilla of Vater was involved. Three-dimensional computed tomography imaging showed an unruptured aneurysm in the pancreatic duodenal arcade. The patient underwent an emergent endovascular embolization of the donor arteries using coils and gelatin sponge particles. She was discharged without any complications. This case was extremely rare because of the anatomic location of the unruptured pancreaticoduodenal artery aneurysm and the fact that it involved the papilla of Vater, was detected with GIF, and was successfully treated endovascularly.

Aortic bleeding one week after removal of an intraoperative epicardial temporary pacing wire.

A 56-year-old man had left nephrectomy and resection of a cavoatrial tumor thrombus under a cardiopulmonary bypass assist for left renal cell carcinoma. An intraoperative bipolar temporary epicardial atrial pacing wire was removed on postoperative day 8. The patient collapsed on postoperative day 15. Emergent transthoracic echocardiography and computed tomography scanning with contrast media detected cardiac tamponade. The three-dimensional volume-rendering images from the multislice computed tomography scan demonstrated bleeding from the aortic root. Upon emergency operation, active arterial bleeding from the aortic root distal to the sites of cannulation and cardioplegia was confirmed, and hemostasis with sutures was completed. It is well known that the intraoperative temporary epicardial pacing wire can cause bleeding or arrhythmia, especially when the wire is being removed. However, bleeding usually occurs from the inserted epicardial point of the pacing wire soon after removal of the wire. To our knowledge, this late bleeding complication of the pacing wire is a previously unreported serious iatrogenic complication after cardiac surgery.

Non-density dependent pollen dispersal of Shorea maxwelliana (Dipterocarpaceae) revealed by a Bayesian mating model based on paternity analysis in two synchronized flowering seasons.

Pollinator syndrome is one of the most important determinants regulating pollen dispersal in tropical tree species. It has been widely accepted that the reproduction of tropical forest species, especially dipterocarps that rely on insects with weak flight for their pollination, is positively density-dependent. However differences in pollinator syndrome should affect pollen dispersal patterns and, consequently, influence genetic diversity via the mating process. We examined the pollen dispersal pattern and mating system of Shorea maxwelliana, the flowers of which are larger than those of Shorea species belonging to section Mutica which are thought to be pollinated by thrips (weak flyers). A Bayesian mating model based on the paternity of seeds collected from mother trees during sporadic and mass flowering events revealed that the estimated pollen dispersal kernel and average pollen dispersal distance were similar for both flowering events. This evidence suggests that the putative pollinators - small beetles and weevils - effectively contribute to pollen dispersal and help to maintain a high outcrossing rate even during sporadic flowering events. However, the reduction in pollen donors during a sporadic event results in a reduction in effective pollen donors, which should lead to lower genetic diversity in the next generation derived from seeds produced during such an event. Although sporadic flowering has been considered less effective for outcrossing in Shorea species that depend on thrips for their pollination, effective pollen dispersal by the small beetles and weevils ensures outcrossing during periods of low flowering tree density, as occurs in a sporadic flowering event.

Cardiac xanthoma originating from primary cardiac lymphoma.

A 67-year-old man presented with dyspnea, general fatigue, and leg edema. Echocardiography demonstrated a large pericardial effusion with a 5 cm × 3 cm, dense hetero-echogenic tumor in the right atrium. At the time of the operation, the tumor was composed of soft but tough, yellowish, smaller smooth processes, and fragile, reddish, bigger nodules. Pathologic examination revealed that the yellow processes were xanthoma and that the reddish nodules were B-cell lymphoma. This case strongly supports the theory that normolipemic xanthomatosis is a secondary event in the lymphoid tissue neoplasm.

[Late mediastinal hematoma presenting cardiac tamponade after re-do off-pump coronary artery bypass grafting in octogenarian; report of a case].

An 86-year-old man was admitted to our hospital with angina due to the instent restenosis. He had a history of coronary artery bypass grafting( CABG). Re-do off-pump CABG was performed. Aspirin and warfarin were started on the next day. The drainage tubes were removed on the postoperative day (POD) 2 and clopidogrel was resumed. On POD 9, he complained of nausea and dyspnea even at rest. Chest computed tomography (CT) and transthoracic echocardiography showed anterior mediastinal hematoma. 550 ml bloody effusion was discharged by percutaneous drainage. Because the accumulation of the mediastinal fluid was mainly anterior to the pericardial space, it was thought to be due to oozing from the sternum and soft tissues. The cause was unclear, but both antiplatelet and anticoagulant agents could have caused the oozing. He was discharged without reaccumulation of the effusion. It is important to take account of such delayed complications when multiple antiplatelet and anticoagulant agents are used after cardiovascular surgery especially in the octogenarian.

Deformities of pulmonary and aortic annulus 42 years after repair of tetralogy of Fallot.

We report an extremely rare case of deformity of the pulmonary sinus of Valsalva with pulmonary valvular stenosis 42 years after a pulmonary annular-sparing operation for tetralogy of Fallot. Aortic regurgitation with deformity of the sinus is also noted. At the previous operation, the right ventricular outflow tract was augmented by a prosthetic subvalvular patch. Through the years, the pulmonary valve and sinus were distorted because the patch was pulled over toward the right ventricle.

A dental mirror provides excellent exposure of the right coronary artery during cardioplegia.

It sometimes is very difficult to achieve good exposure of the orifice of the right coronary artery through a typical aortotomy when inserting the cannula for the selective antegrade administration of cardioplegic solution to the right coronary artery. A simple technique of exposing the orifice of the right coronary artery using a dental mirror is described.

Slime method: modified hemostatic technique of fibrin glue in major cardiothoracic surgery.

Surgical bleeding from anastomoses due to systemic heparinization or prolonged extracorporeal circulation, which is more effectively controlled with topical hemostatic agents than with sutures, has been one of the major problems in cardiovascular surgery. We describe a novel hemostatic technique using fibrin glue. Briefly, the two components of fibrinogen and thrombin solutions are mixed and put over the bleeding point immediately after the glue has become a viscous gel. Within a minute of local compression, the glue sets well enough to stop the bleed.

Early experience with combined use of two plant-based hemostatic agents.

Bleeding from anastomoses, which is more effectively controlled with topical hemostatic agents than with sutures, has been one of the major problems in cardiovascular surgery. We describe a novel hemostatic technique using microporous polysaccharide hemosphere (Arista; Medafor Inc, Minneapolis, MN) in conjunction with a patch of oxidized regenerated cellulose (Nu-Knit; Ethicon, Johnson & Johnson, Somerville, NJ). Both of them are plant-based products and eliminate the risk of animal-borne or human-borne contaminants and have bactericidal advantages.

The sinker technique: a simple, effective technique for exposing coronary arteries in off-pump surgery.

Exposure and stabilization of coronary arteries in the circumflex and right territory is essential for off-pump coronary artery bypass grafting. A new, easy technique of exposing and stabilizing coronary arteries using a sinker (weight) hung on a silicone elastomer suture for hemostasis from the arteriotomy is described.