Free internal mammary artery graft reimplantation on the same vessel in repeat coronary revascularization.

We describe the case of a 62-year-old man who needed a 3-vessel coronary artery bypass reoperation and mitral valve replacement. The patient's existing free left internal mammary artery graft was not functioning because of a critical stenosis in the native vessel just after the distal anastomosis. The free graft itself was in perfect condition, and we decided to reuse it. Because the course of the graft was so tortuous, we concluded that skeletonization would yield the extra length needed for reimplantation. After reimplanting the graft, we performed venous grafting and mitral valve replacement. The patient was well and had no signs of ischemia at 29 months postoperatively. There have been few reports on recycling internal mammary artery grafts in repeat coronary artery bypass grafting. To our knowledge, ours is the first report of the reimplantation of a free internal mammary artery graft on the same vessel. We describe the procedure and our decision-making process.

Valve-in-valve-in-valve transcatheter aortic valve implantation to treat a degenerated surgical bioprosthesis in a subaortic position.

Transcatheter aortic valve implantation for aortic stenosis has evolved as an alternative treatment for patients who are at high or excessive surgical risk. We report the case of an 84-year-old man with a degenerated surgically implanted valve in a subaortic position (9 mm below the native annulus) who underwent "valve-in-valve" transcatheter aortic valve implantation with use of a Medtronic CoreValve system. We planned to deploy the CoreValve at a conventional depth in the left ventricular outflow tract; we realized that this might result in paravalvular regurgitation, but it would also afford a "deep" landing site for a second valve, if necessary. Ultimately, we implanted a second CoreValve deep in the left ventricular outflow tract to seal a paravalvular leak. The frame of the first valve--positioned at the conventional depth--enabled secure anchoring of the second valve in a deeper position, which in turn effected successful treatment of the failing subaortic surgical prosthesis without paravalvular regurgitation.

Pulmonary valve leaflet extension with bovine pericardium: for treatment of pulmonary insufficiency.

Using a homograft in a pulmonic area is sometimes inadvisable due to the lack of optimal graft materials. We report a case of pulmonary valve insufficiency that we treated by leaflet extension using the commercially available E-Leafcon template and bovine pericardium. We suggest that this method can be an acceptable alternative for treating pulmonary valve insufficiency because the pulmonary valve area is similar to that of the aortic valve (for which application the template was designed). Further, the durability of bovine pericardium is comparable to that of a homograft or a xenograft.

Myocardial protection during reoperative cardiac surgery: early experience with a new technique.

We recently introduced a new adjunct to myocardial preservation in patients with a patent left internal mammary artery graft who were undergoing reoperative cardiac surgery. The purpose of this study was to review our early experience with this technique.The technique consists of preoperative insertion of a suitably sized angioplasty balloon catheter into the proximal part of the graft under fluoroscopic guidance. Intraoperative inflation of the balloon results in occlusion of the graft during aortic cross-clamping. We have used this technique in 9 patients. The case records of these patients were retrospectively reviewed. There were 5 men and 4 women with a mean age of 71 +/- 11 years and a mean Euro-SCORE of 10 +/- 3. The median time interval from previous cardiac operation to reoperation was 6 years (interquartile range, 2-11 yr). After the balloon catheter was inserted successfully into the left internal mammary artery graft, the balloon was inflated intraoperatively for successful occlusion of the graft in all patients. There was no in-hospital death, and no significant complications were observed.The early results of this technique seem favorable. A prospective randomized study is needed in order to evaluate the potential advantages of this method over other techniques of myocardial protection during cardiac reoperations.

Operative technique of liver retransplantation:a report of 22 cases / 中国普通外科杂志

Objective To explore the operative technique of liver retransplantation.Methods The clinical data of 24 patients who underwent liver retransplantation in the recent 4 years in our center were reviewed.In all of the patients a modified piggy-back liver transplantation was adopted.Extracorporeal venous bypass was used in 6 cases,and no bypass was used in 18 cases.We anastomosed the suprahepatic inferior vena cava to the annexed vena cava in a modified piggy-back figuration.The portal vein was reconstructed by end-to-end anastomosis.In 17 cases the hepaticy artery was anastomosed end-to-end,and in the other 7 cases was(anastomosed) to abdominal aorta by interposition graft.In 6 cases the biliary tract was reconstructed by(end-to-end) anastomosis,and in the others by choledochojejunostomy.All of the patients were routinely followed up after operation.Results Postoperative mortality of liver retransplantation was 41.6%(10/24).The cause of death was sepsis in 7 patients,intraoperative bleeding in 2,and cerebral hemorrhage in 1.The other patients(14/24,58.4%) successfully recovered after liver retransplantation.The complication rate in this group was 21.4%%(3/14),including biliary tract complications in 2 patients,and wound dehiscence in 1.Conclusions There was no significant difference in operative time and blood loss between liver(retransplantation) and primary transplantation.The key for success is to adopt individuation in selection of(methods) for liver retransplantation.The difficulty of liver retransplantation is exposure and mobilization of(inferior) vena cava. The probability of interposition graft from hepatic artery to abdominal aorta and(choledochojejunostomy) is higer than that of primary liver transplantation.