Partial cardiopulmonary bypass through left thoracotomy for coarctation repair in children.

BACKGROUND: A left thoracotomy approach is anatomically appropriate for childhood aortic coarctation; however, the pediatric femoral arteriovenous diameters are too small for cardiopulmonary bypass cannulation. We aimed to determine the safety of a partial cardiopulmonary bypass through the main pulmonary artery and the descending aorta in pediatric aortic coarctation repair. METHODS: We retrospectively reviewed 10 patients who underwent coarctation repair under partial main pulmonary artery-to-descending aorta cardiopulmonary bypass with a left thoracotomy as the CPB group. During the same period, 16 cases of simple coarctation of the aorta repair, with end-to-end anastomosis through a left thoracotomy without partial CPB assistance, were included as the non-CPB group to evaluate the impact of partial CPB. RESULTS: The median age and weight at surgery of the CPB group were 3.1 years (range, 9 days to 17.9 years) and 14.0 (range, 2.8-40.7) kg, respectively. Indications for the partial cardiopulmonary bypass with overlap were as follows: age > 1 year (n = 7), mild aortic coarctation (n = 3), and predicted ischemic time > 30 min (n = 5). Coarctation repair using autologous tissue was performed in seven cases and graft replacement in three. The mean partial cardiopulmonary bypass time, descending aortic clamp time, and cardiopulmonary bypass flow rate were 73 ± 37 min, 57 ± 27 min, and 1.6 ± 0.2 L/min/m2, respectively. Urine output during descending aortic clamping was observed in most cases in the CPB group (mean: 9.1 ± 7.9 mL/kg/h), and the total intraoperative urine output was 3.2 ± 2.7 mL/kg/h and 1.2 ± 1.5 mL/kg/h in the CPB and non-CPB group, respectively (p = 0.020). The median ventilation time was 1 day (range, 0-15), and the intensive care unit stay duration was 4 days (range, 1-16) with no surgical deaths. No major complications, including paraplegia or recurrent coarctation, occurred postoperatively during a median observation period of 8.1 (range, 3.4-17.5) years in the CPB group. In contrast, reoperation with recurrent coarctation was observed in 2 cases in the non-CPB group (p = 0.37). CONCLUSIONS: Partial cardiopulmonary bypass through the main pulmonary artery and descending aorta via a left thoracotomy is a safe and useful option for aortic coarctation repair in children.

Surgical repair of the adult form of scimitar syndrome.

Scimitar syndrome has various clinical presentations and anatomic features, and some cases are diagnosed in adulthood. Reconstruction using autologous tissue to reroute the right pulmonary venous blood flow to the left atrium is ideal. However, if the scimitar vein drains to the caudal segment of the inferior vena cava, reconstruction using prosthetic material may be necessary due to the distance between the left atrium and the scimitar vein. We describe the case of a 16-year-old boy with scimitar syndrome. We anastomosed the scimitar vein to the right atrium using an artificial graft and created an atrial septal defect for rerouting the right pulmonary venous blood to the left atrium. It has been 9 years since this procedure, and the patient has not experienced graft stenosis or thromboembolic events.

Postoperative Maximal Aortic Diameter is a Significant Predictor of Dilation of the Residual Dissected Aorta after Aortic Replacement for Acute Debakey Type I Aortic Dissection.

BACKGROUND: This study investigated the impact of aortic diameter on late aortic dilation of the residual dissected aorta after tear-oriented aortic replacement for acute DeBakey type I aortic dissection. METHODS: Of 133 patients who underwent aortic replacement for acute DeBakey type I/II aortic dissection between 2008 and 2019, 45 patients with a residual dissected aorta after surgery for acute DeBakey type I aortic dissection and who underwent computed tomography at predischarge and after 1 year were retrospectively assessed. The aortic diameter and false lumen area were measured at 3 levels: the maximal aortic site, seventh thoracic vertebra, and celiac axis. Multivariable Cox regression analysis was employed to identify the predictors of late aortic dilation, defined as an aortic growth rate of ≥5 mm/year or a maximal aortic diameter of ≥55 mm. RESULTS: During a median follow-up of 75 [range: 13-152] months, 6 patients (5 men; mean age: 57 ± 14 years) experienced aortic dilation. All 6 patients had the maximal aortic diameter between the distal aortic arch and seventh thoracic vertebra level at the last computed tomography. Multivariable Cox regression analysis showed that the predischarge maximal aortic diameter was an independent determinant of late aortic dilation (hazard ratio: 2.28/mm, 95% confidence interval: 1.10-5.86). CONCLUSIONS: Predischarge maximal aortic diameter is a significant predictor of late aortic dilation in patients with a residual dissected aorta after tear-oriented surgical repair of acute DeBakey type I aortic dissection.

Coronary artery patch augmentation for congenital left coronary ostial stenosis in Williams syndrome.

Left coronary ostial stenosis, which is associated with sudden death, occasionally occurs in individuals with Williams syndrome. However, surgical methods that provide reliable long-term revascularization remain unknown among infants and young children with coronary ostial stenosis. We describe the case of an 18-month-old boy with Williams syndrome who presented with cardiogenic shock due to left coronary ostial stenosis. We performed patch augmentation of the left coronary ostium using glutaraldehyde-treated autologous pericardium. At the last follow-up, the patient was well without any adverse events or myocardial ischemia.

Unilateral Embolization of the Internal Iliac Artery for Endovascular Aortic Repair Does Not Induce Gluteal Muscle Atrophy.

BACKGROUND: To investigate the effect of unilateral internal iliac artery (IIA) embolization for endovascular aortic repair (EVAR) on gluteal muscle size. METHODS: We assessed the gluteal muscle size in 111 consecutive patients who underwent elective EVAR with unilateral IIA embolization (n = 31) or without IIA embolization (n = 80) for abdominal aortic and/or iliac artery aneurysm. The cross-sectional area (CSA) of the gluteus maximus (Gmax) and gluteus medius/minimus (Gmed/min) was measured on computed tomography preoperatively, 6 months postoperatively, and final follow-up. Mean changes in the Gmax and Gmed/min CSA were evaluated using a mixed model analysis of variance. RESULTS: In the patients with embolization, both the Gmax and Gmed/min CSA significantly decreased over time on the embolization and nonembolization sides (P < 0.001); however, embolization did not affect the changes in the Gmax CSA (P = 0.64) and Gmed/min CSA (P = 0.99). In the patients with embolization and those without embolization, both the Gmax and Gmed/min CSA significantly decreased over time (P < 0.001); however, embolization did not affect the changes in the Gmax CSA (P = 0.76) and Gmed/min CSA (P = 0.11). CONCLUSIONS: Unilateral IIA embolization was not associated with gluteal muscle atrophy after EVAR. Pre-emptive unilateral IIA embolization for EVAR seems to be an acceptable procedure in terms of maintenance of gluteal muscle size.

A case of cardiac strangulation following epicardial pacemaker implantation.

An 8-year-old boy had undergone permanent epicardial pacemaker implantation with a Y-shaped bipolar ventricular lead on day 6 after birth for treatment of congenital complete atrioventricular block. He was found to have pulmonary stenosis and mitral stenosis by follow-up echocardiography. Further studies including computed tomography and cardiac catheterization revealed that the pacemaker lead had completely encircled the cardiac silhouette and was in a state of "cardiac strangulation". We removed the previous pacing leads and generator and implanted a new epicardial dual-chamber pacing system in the right atrium and right ventricle. Additionally, an expanded polytetrafluoroethylene sheet was placed between the new leads and the heart to prevent recurrence of cardiac strangulation.

Atypical Hemolytic Uremic Syndrome following Acute Type A Aortic Dissection.

Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA)-related disease that manifests as a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI) and is caused by uncontrolled activation of the complement system. We report the case of a 61-year-old woman with acute type A aortic dissection that subsequently developed into aHUS. The hematologic disorders underlying aHUS improved after treatment with the complement inhibitor eculizumab. It is important to consider aHUS when a patient clinically develops a triad of microangiopathic hemolytic anemia, thrombocytopenia, and an increasing creatinine level following cardiovascular surgery.

Use of computed tomography-guided biopsy to detect Peptostreptococcus micros-induced mycotic abdominal aortic aneurysm after endovascular repair.

Mycotic aortic aneurysm (MAA) is rare but lethal. Detection of the causative bacteria is important for successful treatment. In some cases, however, no micro-organisms are detected by repeated blood cultures. Open surgery is the standard procedure for MAA, but endovascular intervention is also performed. An aneurysm specimen cannot be taken for culture when using an endovascular approach, decreasing the opportunity to detect the causative organism. We performed successful endovascular repair in a rare case of a Peptostreptococcus micros-induced MAA as detected by postoperative computed tomography-guided biopsy. This case may help to establish appropriate medical treatment for MAAs.

[How to Place Percutaneous Cardiopulmonary Support(PCPS)].

Cannulation for percutaneous cardiopulmonary support (PCPS) is usually performed percutaneously. However, cut down exposure of the vessels is needed if percutaneous cannulation is difficult. Once the vessels are exposed, cannulas can be placed either by a direct cut down cannulation or by a Seldinger technique. Vascular access is usually achieved through femoral vessels, but other large vessels can be used in specific patient conditions. For instance, neck vessels are commonly used for veno-venous extracorporeal membrane oxygenation (ECMO). In patients who cannot come off cardiopulmonary bypass, direct cannulation of the aorta and right atrium( central ECMO) is a simple way. Complications related to cannulation are bleeding, vascular injury, arterial embolism, and distal malperfusion. Thoracic surgeons must have up-to-date information and become proficient in these procedures.

Endovascular Repair for Ruptured Axillary Artery Aneurysm Proximal to Hemodialysis Access.

Axillary artery aneurysms are uncommon and potentially high-risk lesions threatening the upper extremities. In hemodialysis patients, arteriovenous fistulae creation rarely triggers aneurysmal degeneration and arterial aneurysms in inflow arteries. These aneurysms are usually treated by surgical repair. However, this may lead to complications because of the anatomical complexity surrounding aneurysms of axillary arteries. We report a patient undergoing hemodialysis who had a ruptured ipsilateral axillary artery aneurysm proximal to vascular access. We successfully treated it by endovascular repair with the GORE Excluder AAA contralateral leg endoprosthesis, approaching from the left brachial artery proximal to the shunt. No complications occurred during 15 months after the endovascular repair.

Size and Stiffness of the Pulmonary Autograft after the Ross Procedure in Children.

Progressive dilatation of the pulmonary autograft is one of the greatest concerns after the Ross procedure. Increased stress in the arterial wall may cause changes in the elastic properties of the pulmonary autograft, and thus lead to pathological dilatation. The present study aimed to investigate the changes in the autograft diameter and stiffness during follow-up after the Ross procedure. A total of ten patients underwent the Ross procedure at our institution between 2003 and 2011. Echocardiography was used to measure the diameters of the pulmonary autograft at the level of the annulus, sinus of Valsalva, and sinotubular junction. The stiffness index was calculated from the angiographic data, and compared with that of 16 age-matched control children. The diameters of the pulmonary autograft increased throughout the follow-up period, particularly at the level of the sinus of Valsalva and at the sinotubular junction. The aortic root was stiffer in Ross patients compared with control children (7.9 ± 1.8 vs. 3.9 ± 0.7 immediately postoperatively, p < 0.01; 10.1 ± 2.8 vs. 4.2 ± 1.4 at 5 years postoperatively, p < 0.01). Although no significant relationship was found between the stiffness index and the autograft diameter, the stiffness index tended to increase over time. Dilatation of the pulmonary autograft was accompanied by progressive change in aortic stiffness. Longer follow-up is warranted to clarify the impact of this change in aortic stiffness on autograft failure.

Sutureless pericardial marsupialization for the repair of congenital right pulmonary veins atresia.

We present a very rare case of isolated right pulmonary veins atresia in a 4-year-old girl. As the presence of a pulsatile blind pulmonary venous confluence adjacent to the left atrium was demonstrated by preoperative right pulmonary arterial wedge angiography, we applied sutureless pericardial marsupialization for the repair of right pulmonary veins atresia. She is currently 8 years old without pulmonary veins stenosis.

A Technique to Make Multiple Proximal Anastomoses with One HEARTSTRING Suture Device.

The HEARTSTRING device allows a secure proximal anastomosis, but one device is typically used for each anastomosis. We report a technique to make multiple proximal anastomoses with one HEARTSTRING suture device. doi: 10.1111/jocs.12706 (J Card Surg 2016;31:206-207).

Exophytic Atheroma Mimicking Papillary Fibroelastoma Adjacent to the Aortic Valve.

Follow-up echocardiography in a 69-year-old man with alcoholic cardiomyopathy showed a mass above the aortic valve near the left coronary ostium. Transesophageal echocardiography and computed tomography suggested a papillary fibroelastoma with a high risk of embolism. At operation we found an exophytic atheroma adjacent to the left coronary artery orifice. The atheroma was removed, and the patient made an uneventful recovery. We describe this very rare case of an exophytic atheroma mimicking a papillary fibroelastoma situated at the left coronary orifice.

Cuff leakage, not paravalvular leakage, in the Carpentier Edwards PERIMOUNT Magna Ease aortic bioprosthesis.

Though the Carpentier Edwards PERIMOUNT Magna Ease valve is a bioprosthesis with documented excellent haemodynamics and easy implantability, this valve has a gap between the cobalt-chromium-nickel alloy stent and silicone sewing ring. This gap, which is widest just below each of the three commissural struts, lacks silicone and leaves the two-layer polytetrafluoroethylene fabric unsupported and unprotected. If the needle of a valve suture is placed in this structurally weak area of the sewing ring, the resultant fabric tear may result in a true cuff leakage, not the usual paravalvular leakage. We describe this pitfall in the context of a recent operation to alert surgeons everywhere that suture placement too close to the stent (missing the silicone sewing ring) can result in postoperative cuff leakage. We need to be very careful to include the silicone ring in each stitch to prevent injury to the valve cuff of this prosthesis and to avoid cuff leakage.

Devised reinforcement of distal stump in total arch replacement using BioGlue.

Although thoracic endovascular aortic repair and the open stent-grafting technique have become popular, surgical replacement of the aorta remains the procedure of choice for arch aneurysms. Distal anastomosis in total arch replacement is fraught with danger in the patient with a fragile aortic wall, and can lead to uncontrollable bleeding from the fragile distal stump with existing reinforcement techniques. We describe an easy and secure distal anastomosis reinforcement technique, the "BioGlue rolled sandwich technique", for total arch replacement, which avoids the difficulties of application of BioGlue near the vagus and phrenic nerves.

Devised loop-in-loop technique in mitral valve repair.

The loop technique is useful for multiple chordal reconstructions in mitral valve repair. Although it is easy to anchor the loop to the tip of the prolapsed leaflet, take-down of the anchored loop is not easy. The devised loop-in-loop technique makes intraoperative adjustment of the neochordae quick and easy. This article describes a straightforward and reproducible method for secure anchoring and, if necessary, take-down of neochordae using the loop-in-loop technique for mitral valve repair.

An easy and useful exposure technique using a malleable u-shaped retractor for proximal anastomosis in abdominal aortic replacement.

During surgery for an abdominal aortic aneurysm, various problems can occur at the proximal anastomosis. Adequate exposure must be secured, and the proximal anastomosis must be sutured firmly. We have used a malleable U-shaped retractor to easily secure exposure of the proximal anastomosis. Despite recent advances in endovascular treatment, abdominal aortic aneurysm repair often requires open surgery. We describe our malleable U-shaped retractor technique, which is very easy and facilitates the creation of a secure proximal anastomosis.

Left atrium ball thrombus in a patient with hemorrhagic cerebral infarction.

The patient was a 72-year-old man with left hemiparesis. Multiple hemorrhagic cerebral infarctions were recognized on a computed tomographic (CT) scan. A transesophageal echocardiogram showed a huge left atrial mass, which was floating and nearly obstructed the mitral orifice in the diastolic phase. Emergency left atrial mass removal was performed. To reduce the risk of critical brain hemorrhage, the dose of heparin was reduced (100 U/kg) and 1 mg/kg/h of nafamostat mesilate was administered into the venous circuit during extracorporeal circulation. A postoperative brain CT scan showed no evidence of deterioration of cerebral hemorrhage. Pathologic examination showed a ball thrombus.

Partial translocation mitral valve replacement with autologous pericardial patch reinforcement of ventricularized left atrial wall for severe annular calcification extending to the left ventricle.

We describe a technique of partial translocation with an autologous pericardial patch reinforcement of the left atrial wall in patients with extensive mitral annular calcification (MAC) who require mitral valve replacement.