Successful minimally invasive triple coronary bypass through bilateral parasternal incisions.

A 58-year-old man with left main and right coronary artery disease requiring preoperative intraaortic balloon pumping underwent successful minimally invasive triple coronary bypass through bilateral parasternal incisions. Despite taking immunosuppressive drugs because of a previous liver transplantation, the patient had all-arterial grafts without sternotomy. He was discharged on the fourth postoperative day, returned to work in 4 weeks, and has a negative thallium stress test.

Brain protection during circulatory arrest.

Previous nuclear magnetic resonance studies in this laboratory have shown a beneficial biochemical effect of antegrade cerebroplegia (CP-A) during hypothermic circulatory arrest. This study compared CP-A with other methods of cerebral protection during hypothermic circulatory arrest to assess the clinical utility of this technique. Twenty-three sheep were divided into four groups: systemic hypothermia alone (SYST) and systemic hypothermia combined with external cranial cooling (EXTNL), retrograde cerebroplegia (CP-R), or CP-A. Cardiopulmonary bypass was started, and the sheep were cooled to 15 degrees C and subjected to 2 hours of circulatory arrest. Cardiopulmonary bypass was restarted, and the animals were rewarmed and weaned from cardiopulmonary bypass. Serial neurological examinations were performed and hourly scores assigned until the animals were extubated. Postanesthetic neurological scores improved in all groups throughout the 6-hour recovery period except the CP-R group. The improvement over time for these scores was similar for the EXTNL and CP-A groups and significantly better than for the SYST or CP-R groups (p = 0.004). The CP-A group had 5 of 7 animals with deficit-free survival despite the similarity in recovery of baseline brainstem function. We conclude that both antegrade infusion of cerebroplegia and external cranial cooling confer distinct cerebroprotective effects after a protracted period of hypothermic circulatory arrest when compared with the other methods studied.

Pulmonary adenocarcinoma simulating malignant mesothelioma.

Adenocarcinoma of the lung with pleural involvement frequently resembles pleural epithelioid mesothelioma clinically as well as macro- and microscopically. Special stains, immunohistochemical studies, and electron microscopic studies are needed to differentiate these 2 tumors. We report a case of pleural involvement by adenocarcinoma, mimicking in the hematoxylin-eosin stain an epithelioid mesothelioma, correctly identified only after immunohistochemical and electron microscopic examinations.

A new technique for the repair of pediatric hydroceles.

The major difficulties encountered in the surgical correction of pediatric communicating hydroceles are separating the hernial sac from the spermatic vessels and vas, and identifying the anatomical location of the internal inguinal ring. The passage of a pediatric Foley catheter through the hernial sac via a high scrotal incision greatly expedites this surgery. Herein, we describe a new surgical technique and discuss its merits.

The use of the myouterine flap in closure of defects of the bladder.

A new surgical technique to close bladder defects using well vascularized myouterine flap is described. The flap serves as a temporary scaffold while the bladder is being bridged by natural bladder regeneration. The advantage of this flap is that it is not a free flap, being well vascularized through its pedicle, enhancing optimal bladder regeneration. This technique may be a useful surgical alternative for repair of large bladder defects.

Unusual presentation of metastatic carcinoma of prostate.

An unusual case of metastatic carcinoma of prostate, which presented as a huge abdominal mass and responded extremely well to endocrine therapy, is presented. The literature is reviewed.

Transvenous pacemaker insertion ipsilateral to chronic subclavian vein obstruction: an operative technique for children and adults.

Subclavian vein occlusion limits insertion of pacing electrodes in children and adults. The concern is greatest in children with a long-term need for pacing systems necessitating use of the contralateral vein and potential bilateral loss of access in the future. We describe an operative technique to provide ipsilateral access in chronic subclavian vein occlusion in five consecutive pediatric (n = 4, mean age 6.5 years) and adult (n = 1, age 70 with bilateral subclavian vein occlusion) patients in whom this condition was noted at the time of pacemaker or ICD implant. Occlusion was documented by venography. Pediatric cardiac diagnoses included complete heart block in all patients, tetralogy of Fallot in three, and L-transposition of the great vessels in one. Percutaneous brachiocephalic (innominate) or deep subclavian venous access was achieved by a supraclavicular approach using an 18-gauge Deseret angiocath, a Terumo Glidewire, and dilation to permit one or two 9-11 Fr sheaths. Electrode(s) were positioned in the heart and tunneled (pre- or retroclavicularly) to a pre- or retropectoral pocket. Pacemaker and ICD implants were successful in all without any complication of pneumothorax, arterial or nerve injury, or need for transfusion. Inadvertent arterial access did not occur as compared with prior infraclavicular attempts. One preclavicularly tunneled electrode dislodged with extreme exertion and was revised. Ipsilateral transvenous access for pacemaker or ICD is possible via a deep supraclavicular percutaneous approach when the subclavian venous obstruction is discovered at the time of implant. In children, it avoids the use of the contralateral vein that may be needed for future pacing systems in adulthood. This venous approach provides access large enough to allow even dual chamber pacing in children and can be accomplished safely.