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We experienced 3 cases of port-access robot-assisted totally endoscopic technique for mitral valve repair and concomitant coronary artery bypass. The right internal mammary artery was harvested, mitral valve was fixed, and the right internal mammary artery to right coronary artery anastomosis was carried out on the arrested heart. The use of cardiac arrest and a V-shaped hook technique facilitated the coronary anastomosis and the da Vinci Firefly test (Intuitive Surgical Inc., Sunnyvale, CA) could confirm patency of the graft. [ABSTRACT FROM AUTHOR]

Background The present study aimed to determine whether aortic cross-clamp duration (ACCD) was directly related to postoperative morbidity and mortality rates and to identify the inflection point of ACCD for increased mortality and morbidity rates in patients who had undergone isolated aortic valve replacement (AVR) for aortic stenosis. Methods From the Japan Cardiovascular Surgery Database, we extracted data from 16,272 patients with AS who underwent isolated AVR between January 2008 and December 2012. We evaluated postoperative mortality and morbidity rates after stratifying patients into five groups based on ACCD (<60 minutes, ≥60 to <90 minutes, ≥90 to <120 minutes, ≥120 to <150 minutes, and ≥150 minutes). Results The overall hospital mortality rate was 2.8%. Multivariate logistic analysis revealed that the odds ratio for operative mortality increased as ACCD incrementally increased and was markedly higher for ACCD of 150 minutes or longer (odds ratio, 2.68; 95% confidence interval, 1.66 to 4.32; p < 0.001). There were significant increases in risks of reoperation for bleeding for ACCD of120 minutes or longer, stroke for ACCD of 60 minutes or longer, deep sternal infection for ACCD of 120 minutes or longer, ventilation for more than 24 hours for ACCD of 90 minutes or longer, and new requirement for dialysis for ACCD of 150 minutes or longer. Conclusions Prolonged ACCD offers an independent predictor of postoperative morbidity and mortality after isolated AVR for AS despite recent technologic advances and surgical refinements. [ABSTRACT FROM AUTHOR]

Purpose In surgical atrial septal defect (ASD) closure, there are no techniques or devices that can close the ASD accurately in a short time under a beating heart. We have developed a simple and automatic ASD closure technique using a circular stapler. This study assessed the feasibility and efficacy of a new circular stapler closure for ASD. Description Under a continuous beating heart, hand-sewn patch plasty ASD closure was performed in 6 pigs (group A) and circular stapler ASD closure was performed in 6 pigs (group B). The time to close the ASD and the effectiveness of the closure were compared. Evaluation Closure was significantly faster in group B (10.5 ± 1.0 seconds) than in group A (664 ± 10 seconds; p < 0.05). There was no leakage at the closure site, and sufficient tolerance was confirmed. Conclusions A circular stapler can be used to treat ASD faster than hand-sewn patch plasty, with sufficient pressure tolerance in a beating heart porcine model. [ABSTRACT FROM AUTHOR]

Background: The radial artery (RA) is a useful conduit for coronary artery bypass grafting (CABG) but is susceptible to vasospasm during harvesting. We evaluated the usefulness of fasudil, a Rho kinase inhibitor, in dilating the RA graft and increasing graft free flow (GFF) compared with the conventional graft-dilating agents papaverine and verapamil-nitroglycerin (VG). Methods: Between June 2012 and January 2013, 45 patients with ischemic heart disease who underwent isolated CABG using the RA were enrolled and randomly assigned to fasudil (n = 15), papaverine (n = 15), or VG (n = 15). Fasudil (2.67 mmol/L), papaverine (1.0 mmol/L) mixed with heparinized blood, or VG (30 μmol/L each of verapamil and nitroglycerin) was injected intraluminally into the RA graft after harvesting. Main outcome measures were RA GFF, hemodynamic changes, and histopathologic examination of the RA. Results: In the fasudil group, GFF increased significantly (p < 0.001) from 36.8 ± 20.4 at baseline to 148.0 ± 88.3 mL/min after injection. GFF increased significantly (p < 0.001) from 36.0 ± 19.0 to 72.3 ± 36.7 mL/min in the papaverine group and increased significantly (p < 0.001) from 39.5 ± 23.3 to 64.3 ± 29.9 mL/min in the VG group. The GFF was significantly higher (p = 0.001) in fasudil-treated RA than in papaverine- or VG-treated RA. Histopathologically, RA graft diameter was markedly increased after fasudil injection, and the structure of the multiple elastic lamellae was intact. Blood pressure did not change significantly after drug injection in all groups. Conclusions: Fasudil exhibited a very potent vasodilatory effect on the RA compared with conventional papaverine or VG, resulting in increased GFF. This agent is useful for dilating RA grafts in CABG. [Copyright &y& Elsevier]

Background: The internal thoracic artery (ITA) is a very useful conduit for coronary artery bypass artery (CABG), with excellent long-term patency. With the purpose to dilate the ITA graft and increase graft free flow (GFF) intraoperatively, we evaluated the usefulness of intraluminal injection of fasudil, a Rho-kinase inhibitor, in comparison to the conventional graft dilating agent, papaverine. Methods: Between June 2011 and January 2012, 30 patients with ischemic heart disease who underwent isolated CABG using ITA were enrolled. The patients were randomly assigned to 2 groups: the fasudil group (n = 15) in which fasudil solution 0.9 mg/dL was injected into the ITA, and the papaverine group (n = 15) in which papaverine solution (0.4 mg/mL) mixed with heparinized blood was used. Outcome measures were left ITA GFF, heart rate, and mean blood pressure during flow measurements, and histopathologic examination of the ITA. Results: In the fasudil group, GFF increased significantly (p < 0.01) from 19.7 ± 15.2 mL/minute at baseline to 66.9 ± 31.7 mL/minute after fasudil injection. In the papaverine group, GFF increased significantly (p < 0.01) from 22.9 ± 17.3 mL/minute at baseline to 44.8 ± 26.7 mL/minute after papaverine injection. Blood pressure and heart rate did not change significantly after drug injection in both groups. The GFF was significantly higher (p = 0.038) in fasudil-treated ITA than in papaverine-treated ITA. Histopathologically, the diameter of the ITA was markedly increased after fasudil injection. Elastica van Gieson staining showed that the multiple elastic lamellae structure was intact. Conclusions: Fasudil exhibited very potent vasodilatory effect on the ITA compared with conventional papaverine resulting in increased GFF. This agent is a useful graft dilating agent. [Copyright &y& Elsevier]

Background: This study investigated the usefulness of fluorine-18 fluorodeoxyglucose-positron emission tomography (FDG-PET) during the treatment of thymic epithelial tumors in combination with Ki-67 evaluation based on surgical cases in our department. Methods: Between November 2003 and May 2011, 39 patients with thymic epithelial tumor underwent preoperative FDG-PET. The maximum standardized uptake value (SUVmax) of each category within Masaoka stage, World Health Organization classification, tumor diameter, myasthenia gravis, and Ki-67 label index were compared. To examine risk factors for relapse, SUVmax, age, sex, and surgical radicality were investigated in addition to those items. Results: The mean SUVmax was 4.5 (range, 1.2 to 14.6) and was significantly higher for Masaoka stage IV than for I and II (all p < 0.008) and for World Health Organization classified thymic cancer compared with all other types (all p < 0.0001). Mean SUVmax revealed significantly higher values for large tumors than for small tumors (p = 0.02). Mean SUVmax was significantly higher for high Ki-67–positive samples (p = 0.0004), indicating a strong correlation between SUVmax and the Ki-67 label index (ρ = 0.77, p = 0.0001). SUVmax accurately reflected therapeutic efficacy in patients with induction therapy. Univariate analysis revealed Masaoka stages III and IV and pathologically incomplete resection as risk factors for relapse. On multivariate analysis, independent risk factors for relapse comprised only Masaoka stages III and IV. Conclusions: FDG-PET SUVmax does reflect proliferation and invasiveness of thymic epithelial tumors and can provide an index for diagnosis and treatment, although it is not a risk factor for relapse. FDG-PET is also useful for evaluating induction therapy efficacy and detecting relapse. [ABSTRACT FROM AUTHOR]

Purpose: An experimental study was done to investigate repair of type I endoleaks in thoracic aortic aneurysms using the T-Fix suturing device (Smith & Nephew Co, Ltd, London, United Kingdom). Description: A saccular descending aortic aneurysm was made in 5 pigs experimentally. A stent graft was deployed to produce a proximal type I endoleak. Under fluoroscopy, the aorta was punctured with the spinal needle with the T-Fix plastic bar, and the plastic bar was deployed with a push rod. A sufficient number of T-Fix sutures were used until angiography revealed that the type I endoleak had disappeared. Evaluation: No hemodynamic events occurred during the procedure. An average of 2.5 ± 0.6 T-Fix sutures were required to eliminate the endoleak. The experimental T-Fix repair was performed without any complications. A new method of repairing type I endoleaks for thoracic aortic aneurysms was successfully performed using the T-Fix system. Conclusions: Although the T-Fix repair currently has some anatomic and clinical limitations, improvement of the device should lead to the increased use of this repair. [Copyright &y& Elsevier]

Purpose: We report our initial experience with the PAS-Port proximal anastomosis system (Cardica Inc, Redwood City, CA) using full-skeletonized radial artery (RA) in patients requiring off-pump coronary artery bypass grafting. Description: The PAS-Port system (Cardica Inc) was used in 25 patients undergoing off-pump coronary artery bypass surgery. All patients received at least one RA graft using the PAS-Port system on the proximal anastomosis. The radial arteries were harvested in a fully skeletonized fashion before loading to the PAS-Port system. Evaluation: Our attempt to use the PAS-Port system for proximal anastomosis of the RA was successful in 25 anastomoses. Postoperative angiography showed 24 grafts to be widely patent. During the mean postoperative follow-up of 9.2 ± 3.1 months, there was no cardiac-related event in any patient. Mid-term patency collected from the first 8 patients was 87.5% (mean follow-up, 12.8 ± 2.8 months). Conclusions: The PAS-Port system does not require aortic clamping and enables the creation of uniform and widely patent anastomosis with use of RA grafts. [Copyright &y& Elsevier]

Background: We assessed the surgical results along with the clinical and biological features of nonsmall-cell lung cancer (NSCLC) patients with localized large tumors. Methods: The study population consisted of 86 NSCLC patients who underwent complete resection of tumors 5 cm or larger in diameter in stage IB (T2N0M0). We immunohistochemically assessed the expression of angiostatin and endostatin. Results: The median tumor size was 6.0 cm (range, 5 to 14 cm). The operative procedures used were lobectomy in 71 cases, bilobectomy in 8 cases, and pneumonectomy in 11 cases. Fifty patients (58.1%) relapsed during the mean follow-up period of 33.6 ± 4.5 months. The median disease-free interval was 9 months. Of 44 recurrent patients whose disease-free interval could be identified, 25 patients (56.8%) relapsed within 12 months after the operation. The overall 5- and 10-year survival rates were 42.0% and 24.2%, respectively. Multivariate analysis showed that the degree of pleural involvement and angiostatin expression within the tumor were independent prognostic indicators. The endostatin expression within tumors also had a weaker relationship with outcome. Conclusions: Long-term surgical results were poor and early relapse was common in this cohort. In addition to pleural involvement, the tumor-induced expression of angiostatin and endostatin merit further investigation to gain possible insights into selection of patients who will benefit from surgery as the first line treatment. [Copyright &y& Elsevier]

Background: We evaluated the pathologic and biological aspects of lung tumors 3.0 cm or less in diameter with the appearance of ground-glass opacity (GGO). Methods: Of 988 patients with non-small cell lung cancer who underwent operations at our institute between January 1994 and December 2004, 87 resected lung tumor specimens that showed GGO appearance on helical computed tomography were obtained from 81 patients. Forty-four lesions were pure GGO with no solid component in the tumor and 43 lesions were mixed GGO consisting of areas of attenuation with a solid component. Together with histological features, MIB1 and nm23 expression within tumors were examined immunohistochemically. Results: The mean tumor size in the pure GGO group was significantly smaller than that in the mixed GGO group. The composition of pathologic subtypes and biological characteristics were clearly different between the two groups. Although atypical adenomatous hyperplasia and localized bronchioloalveolar cell carcinoma of Noguchi’s A and B were the predominant pathologic subtypes and nm23 negativity was rare in the pure GGO group, a high score for expression of MIB1 was often found in pure GGO tumors even though the tumors were less than 10 mm in diameter. Conclusions: If the tumor is 2 cm or less in diameter, the ability of invasion and metastasis seems to be low in pure GGO tumors. However, the proliferation ability of these tumors suggests the necessity of a careful follow-up schedule if the tumor is greater than 5 mm in diameter. For mixed GGO tumors, surgical resection instead of observation is justified. [Copyright &y& Elsevier]

Background: There is still debate regarding the use of surgery in the management of non–small cell lung cancer patients with N2 disease. The primary aim of the present study was analysis of the results of initial operations in non–small cell lung cancer patients with single-level N2 disease. Methods: Ninety-four patients with the disease who underwent initial surgery consisting of complete resection of the primary site plus systematic lymphadenectomy were examined. We also immunohistochemically examined lymphatic vessel density and vascular endothelial growth factor-C expression. Results: The overall 5- and 10-year survival rates for the 94 patients were 27.1% and 12.1%, respectively, with a median survival of 22 months. When stratified by skipping status, the 5-year survival rates for the patients in skip-N2 and non–skip-N2 groups were 33.4% and 19.8%, respectively (p = 0.0189). Skip metastasis, T factor, subcarinal lymph node metastasis, and adjuvant chemotherapy were recognized as independent prognostic indicators. In both skip-N2 and non–skip-N2 groups, distant relapse was the dominant pattern of recurrence. Although the peritumoral lymphatic vessel density was associated with vascular endothelial growth factor-C expression in tumors, the lymphangiogenic profile appeared to be different between skip-N2 and non–skip-N2 tumors, suggesting different nodal metastatic process. Conclusions: Lung cancer patients with single-level N2 disease are an oncologically heterogeneous cohort. Although further studies involving randomized comparisons are required, the poor outcomes found here indicate that the initial operation has yet to be validated for patients with this disease. [Copyright &y& Elsevier]

Purpose: The present study was performed to develop a new perfusion system for off-pump coronary artery bypass grafting and to examine whether even a simple coronary perfusion system can maintain adequate blood flow delivery during anastomosis. Description: The experiment was performed in two stages. In procedure 1, 3 pigs with left anterior descending artery occlusion were used to evaluate optimal perfusion flow rate and coronary artery internal pressure, and to evaluate the safety area of perfusion. In procedure 2, 6 pigs were used to validate the new portable coronary perfusion system. Evaluation: The optimal blood flow in the portable coronary active perfusion system was less than approximately 40 mL/min. The small, easy to use pump system (ie, the portable coronary active perfusion system) may prevent hemodynamic deterioration and ventricular arrhythmia during coronary occlusion, resulting in better maintenance of left ventricular function. Conclusions: Even a simple pump system can achieve effective perfusion for safe anastomosis. Further studies are required to allow the clinical use of this system. [Copyright &y& Elsevier]

Background: The conditions at the injection site are important in cell transplantation for severe ischemic heart disease. The omentum is both a well-vascularized tissue and a source of angiogenic factors. We examined the effectiveness of autologous bone marrow-derived mononuclear cells (BM-MNCs) with or without omentopexy in a large animal model. Methods: Myocardial infarction was generated in the lateral wall by ligation of coronary artery branches in miniswine. Animals received BM-MNC injection with or without omentopexy. Controls received saline only. Three weeks after surgery, regional myocardial blood flow and contractility were measured, and density of arterioles was evaluated immunohistologically. Angiography and postmortem examinations were performed to determine collateral communication. Results: Regional myocardial contractility was significantly improved by BM-MNC transplantation both with and without omentopexy (0.29 ± 0.02 vs 0.11 ± 0.03, p < 0.01, 0.30 ± 0.02 vs 0.12 ± 0.01, p < 0.01, respectively). Relative regional myocardial blood flow in the combined omentopexy group was significantly higher than the controls both at rest (1.05 ± 0.11 vs 0.57 ± 0.07, p < 0.01) and under stress (1.09 ± 0.08 vs 0.40 ± 0.10, p < 0.01). The number of arterioles (< 50 μm) in both groups were higher than the controls (88.1 ± 5.00 vs 38.1 ± 8.99, p < 0.01 and 109.2 ± 9.91 vs 38.1 ± 8.99, p < 0.01, respectively). The number of large arterioles (> 50 μm) in the combined omentopexy group was significantly higher than in both BM-MNC alone (26.9 ± 2.4 vs 17.6 ± 1.8, p = 0.011) and controls (26.9 ± 2.4 vs 10.0 ± 1.3, p < 0.01). Collateral communication between the omentum and myocardium was demonstrated by angiography and postmortem injection. Conclusions: The BM-MNC transplantation may attenuate cardiac contractile dysfunction, and omentopexy may enhance angiogenesis induced by BM-MNC transplantation. [Copyright &y& Elsevier]

Purpose: This study was performed to investigate the safety and efficacy of a method using free pericardial fat pads as a sealant to prevent intraoperative and postoperative alveolar air leaks. Description: Animal experiments were performed. After pulmonary parenchymal defects were created in 4 dogs, the alveolar air leaks were sealed with free pericardial fat pads. Clinical application was applied in 23 patients who underwent pulmonary resection, air leaks with stream of bubbles, or worse, were sealed with free pericardial fat pads. Evaluation: All dogs survived for 1 month without complications. At sacrifice, all treated lungs had expanded adequately and the implanted fats remained on the lung surface. Histologic examination showed that the excised edge of the lung was closed with granulation. The clinical outcome showed the mean duration of air leaks, chest drain, and postoperative hospitalization were 2.3 ± 3.1 days, 4.3 ± 3.2 days, and 11.1 ± 3.7 days, respectively. Recurrent air leaks were not observed after removal of the chest tube. No adverse effects were observed after surgery. Conclusions: The use of free pericardial fat pads was able to successfully prevent alveolar air leaks. [Copyright &y& Elsevier]

Purpose: We developed a synchronized, arterial-flow, ensuring system to perform coronary anastomoses safely without any ischemia-related event. Description: Arterial blood is removed from the femoral artery. The resulting blood passes a switching valve and is pumped out to a syringe pump. This pump controller provides pulsatile arterial blood flow synchronized with the diastolic phase on an electrocardiogram. The arterial blood is perfused to the coronary artery through a fine flexible cannula during anastomosis. Evaluation: From February 1999, 524 consecutive patients were operated on using the synchronized arterial flow ensuring system. Mean duration for each anastomosis was 7.6 ± 3.3 minutes (range, 4 to 20 min). There were no intraoperative fatal arrhythmias, ventricular arrhythmias, or short-run or hemodynamic deterioration during anastomoses. No hospital death was observed, and postoperative myocardial infarction occurred in 2 patients (0.4%). Postoperative angiography showed a 98.1% patency rate. Conclusions: The early clinical and angiographical results for off-pump CABG with the synchronized arterial flow ensuring system were excellent without mortality. We believe that off-pump CABG can be more safely performed using the synchronized arterial flow ensuring system based on our favorable results. [Copyright &y& Elsevier]

Background: There is controversy about performing cervical lymph node dissections in all middle and lower thoracic esophageal squamous cell carcinoma patients. The purpose of this study was to evaluate whether intraoperative examination of thoracic paratracheal lymph node by real-time reverse transcription-polymerase chain reaction was worthwhile for selecting patients for cervical lymph node dissection. Methods: Under informed consent, 30 middle and lower thoracic esophageal squamous cell carcinoma patients were examined for thoracic paratracheal lymph node metastasis intraoperatively by hematoxylin-eosin staining and real-time reverse transcription-polymerase chain reaction for messenger RNA encoding squamous cell carcinoma antigen. When thoracic paratracheal lymph node metastasis was found, cervical lymph node dissection was performed. If the patients had no thoracic paratracheal lymph node metastasis, a randomized study for selection of cervical lymph node dissection was performed. Results: Eleven of 30 patients with middle or lower third thoracic esophageal squamous cell carcinoma had thoracic paratracheal lymph node metastasis. Five of these 11 patients had cervical lymph node metastasis. Nineteen patients who had no metastasis in the thoracic paratracheal lymph nodes were enrolled in a randomized study. Eight of the 19 patients received cervical lymph node dissection and they were found not to have cervical lymph node metastasis. The other 11 patients did not receive cervical lymph node dissection, and there was no cervical lymph node recurrence. Conclusions: The intraoperative diagnosis of metastasis in the thoracic paratracheal lymph node may be used as an indicator for cervical lymph node dissection in middle and lower thoracic esophageal cancer patients. [Copyright &y& Elsevier]

Background: We developed a new instant regional myocardial blood flow (RMBF) monitor utilizing the thermal diffusion method in which the RMBF value is presented as the value inversely proportional to the thermocouple voltage output (1/V). The purposes of this study were (1) to validate the accuracy of RMBF measurement by the instant RMBF monitor in comparison with the colored microsphere method for calibration; (2) to investigate influences of it on the RMBF; and (3) to assess changes in RMBF caused by the shunt tube insertion.Methods: Twenty pigs were used for this study: 4 for comparison between the instant RMBF meter and the colored microsphere method, 4 for validation of reproducibility, and 6 for measurement of RMBF during shunt tube.Results: The relation between RMBF values obtained by the colored microsphere method and 1/V values by instant RMBF monitor was colored microsphere = 140,992 (1/V) - 231 in epicardial layer (R2 = 0.819) and colored microsphere = 111,381 (1/V) - 165 in endocardial layer (R2 = 0.693). The correlation coefficient and R2 values between RMBF values measured by both methods were 0.985 and 0.839 in epicardial layer, and 0.963 and 0.679 in endocardial layer, respectively. The RMBF at each layer did not change after the attachment of the monitor. Fifteen minutes after shunt tube insertion, RMBF measured by the colored microsphere method decreased to 31.1% (p = 0.0001) and 33.7% (p = 0.0001) in epicardium and endocardium, respectively, and no difference was observed from the value measured by the instant RMBF monitor.Conclusions: This instant RMBF monitor can provide instantaneous and continuous information of RMBF without requiring tissue examination. [Copyright &y& Elsevier]

Background: Recently skeletonization has been recognized as an alternative to pedicle harvesting of the internal thoracic artery as a technique that increases the length and caliber size of the graft compared with pedicled internal thoracic artery grafts; however, this is not yet popular for harvesting the gastroepiploic artery (GEA). We report here our experience of skeletonized GEA grafting in off-pump coronary artery bypass grafting with early clinical and angiographic results. The purpose of this study was to evaluate skeletonization of GEA grafting in off-pump coronary artery bypass grafting with a large patient volume.Methods: One hundred sixty-eight patients including 131 men and 37 women (mean age, 65 years; range, 45 to 87 years) underwent the skeletonized GEA grafting in off-pump coronary artery bypass grafting. These patients represent 41% (168 of 407 patients) of those who underwent off-pump coronary artery bypass grafting operations during the same period. We used the GEA graft of choice in patients with right coronary artery lesion. Skeletonization was performed in a unique manner we developed.Results: There were no in-hospital deaths among the study patients. One patient had a perioperative myocardial infarction, which was considered a result of vasospasm of the GEA graft. None of the other patients had severe morbidity. The patency rate of the skeletonized GEA graft was 98.1% (151 of 154 distal anastomoses).Conclusions: This study suggests that skeletonization of the GEA graft can enlarge its caliber size and improve its flow capacity. In addition, the acceptable early clinical and angiographic outcome suggests that use of the skeletonized GEA graft in off-pump coronary artery bypass grafting surgery is safe and effective. [Copyright &y& Elsevier]

Primary pulmonary sarcoma is an extremely rare malignancy, pulmonary osteogenic sarcoma is even more rare and has a poor prognosis. We present a report of a 58-year-old woman with primary pulmonary osteosarcoma occupying the right main pulmonary artery and extending to the main pulmonary artery. Right pneumonectomy was performed with total right main pulmonary artery resection under cardiopulmonary bypass. Microscopic examination demonstrated that tumor cells contained mainly chondromatous components and were atypical cells that became osteoid. There is no sign of recurrence 24 months postoperatively. The present case is the only case yet reported with even an intermediate-term survival without recurrence. [Copyright &y& Elsevier]

Background. This study was conducted to assess the efficacy and applicability of on-pump beating heart valvular operations using retrograde coronary sinus perfusion.Methods. A prospective, randomized study was conducted. A total of 50 patients participated in this study after having been allocated to one of two groups. On-pump beating heart valvular operations using retrograde coronary sinus perfusion as myocardial protection were performed in 25 patients (beating heart procedure group: aortic = 8 patients, mitral = 15 patients, double = 2 patients). Twenty-five patients underwent conventional valvular operation using retrograde continuous warm blood cardioplegia (conventional procedure group: aortic = 9 patients; mitral = 13 patients; double = 3 patients). The remaining operative variables and early outcomes of these procedures were compared. In the beating heart procedure group, myocardial tissue oxygen was measured by near infrared spectroscopy, and partial oxygen pressure of coronary sinus perfusion was also measured.Results. The visual field of the on-pump beating heart was equal to that of conventional valvular operation, and technical accuracy was not compromised. In the beating heart procedure group, tissue oxygen saturation was maintained at 79% ± 2%, and partial oxygen pressure of coronary sinus perfusion blood and returned blood were maintained at 383 ± 29 mm Hg and 38 ± 2 mm Hg, respectively. Postoperative peak creatine kinase-MB (measured every 3 hours postoperatively) and peak troponin T concentrations were significantly lower than those of conventional procedures (17.5 ± 7.8 vs 32.1 ± 9.3 IU/L and 0.12 ± 0.04 vs 0.21 ± 0.06 ng/mL, respectively; p < 0.05). There was no operative mortality and no major complications.Conclusions. On-pump beating heart valvular operation is a good surgical option, and has advantages because conditions for the heart are more physiologic with beating tonus than with cardioplegia. [Copyright &y& Elsevier]

Robot-assisted annuloplasty using a mitral band has a major issue: suturing is time consuming because knot tying is performed mechanically under endoscopic view. We suture the mitral band to the native valve by running sutures using the V-Loc barbed suture nonabsorbable wound closure device (Covidien, Mansfield, MA) with 3-0 monofilament. This technique allows rapid suturing of the band to the valve. Although conventional interrupted sutures leave multiple knots protruding on the band, using the V-Loc eliminates the need to tie surgical knots and leaves a clean surface, which may potentially reduce the risk of thrombogenesis. This method is highly useful for robotic mitral annuloplasty. [ABSTRACT FROM AUTHOR]

The optimal technique for antegrade cardioplegia delivery during totally endoscopic robotic surgery is still evolving. Cardioplegia delivery with endovascular balloon clamping of the aorta is commonly used but this method has several disadvantages and may lead to serious complications. We describe a novel cardioplegia delivery procedure for totally endoscopic intracardiac surgeries such as atrial septal defect closure and mitral valve repair. The method uses a transthoracic aortic clamp and an antegrade cardioplegia cannula without the need for thoracotomy. The technique is safe and reliable, permits simple cardioplegic arrest, and prevents complications related to endovascular balloon clamping during robot-assisted intracardiac surgery. [ABSTRACT FROM AUTHOR]

The presence of isolated accessory mitral valve tissue (AMVT) is extremely rare in adults. We successfully performed robot-assisted resection of dual AMVT that was attached to the papillary muscle and anterior mitral leaflet. Echocardiography was invaluable for identifying the most suitable approach. The short-axis view on echocardiography revealed the precise location where the AMVT was attached. The robotic operation enabled fine visualization; we clearly observed the AMVT and removed its entire extra structure. The patient recovered well and was discharged 3 days after the operation. To the best of our knowledge, this is the first report of successful robotic AMVT resection. [ABSTRACT FROM AUTHOR]

Mycotic aneurysms of the coronary artery are extremely uncommon and can be very difficult to diagnose. We report a unique case of a mycotic aneurysm of the left anterior descending coronary artery with a history of two-vessel off-pump coronary artery bypass graft surgery 9 months previously. The aneurysmectomy was successful. [Copyright &y& Elsevier]

We have devised a T-graft technique for selected extensive aortic arch replacement under antegrade cerebral perfusion. Under hypothermic circulatory arrest using antegrade cerebral perfusion, one graft was island-anastomosed to the supraaortic arteries. The other graft was anastomosed to the descending aorta. Proximal and distal grafts were then end-to-side anastomosed in a T-shape. During rewarming, the ascending aorta and proximal graft were anastomosed. The surgical field was good in the 6 patients included in this report. No perioperative deaths or serious complications were encountered. This procedure was effective for patients with extensive aortic arch aneurysm and relatively intact orifices of the supraaortic arteries. [ABSTRACT FROM AUTHOR]

We herein present a case of a 20-year-old man who presented with complex rupture of bronchus after blunt chest trauma. The involvement of both the main bronchus and right upper bronchus separately is unusual. Emergency double-barrel bronchial reconstruction was performed with complete preservation of the right lung. Such a serious bronchial injury with a positive outcome has not been reported so far. The features of this uncommon entity are discussed. [Copyright &y& Elsevier]

The most severe complication of high-dose endobronchial brachytherapy is fatal hemoptysis. Intractable tracheobronchial ulceration due to high-dose endobronchial brachytherapy often develops into tracheobronchial necrosis and fatal hemoptysis. Our experience demonstrated that when bleeding from tracheobronchial ulcer, after high-dose endobronchial brachytherapy occurs, blocking the blood supply to the tracheobronchial ulcer alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis. This is the first report that describes an effective management for preventing fatal hemoptysis. [Copyright &y& Elsevier]

Coronary artery disease is rare in patients with Takayasu’s arteritis or Behcet’s disease. We report the case of a patient with concomitant Takayasu’s arteritis and Behcet’s disease who had angina pectoris develop due to severe narrowing of the left main coronary artery. The patient underwent revascularization with saphenous vein grafts with the assistance of the PAS–Port Proximal Anastomosis System (Cardica, Inc, Redwood City, CA). In conclusion, the PAS–Port Proximal Anastomosis System seems to be a safe and effective method of facilitating revascularization, particularly when severe calcification of the ascending aorta precludes cross-clamping during off-pump coronary artery bypass grafting. [Copyright &y& Elsevier]

: BackgroundWe report our initial experience with an automatic anastomotic device using skeletonized radial artery in patients requiring off-pump coronary artery bypass grafting (CABG).: MethodsSt. Jude Medical, Inc, Symmetry Bypass System (aortic connector system [ACS]) (St Jude Medical, St. Paul, MN) was used in ten patients. Ten consecutive patients who underwent off-pump CABG and who received at least one radial artery graft proximal anastomosis using the ACS were evaluated. The radial artery (RA) was harvested in a skeletonized fashion and applied to the ACS in the same manner as applying saphenous vein graft. The creation of the anastomosis lasted no longer than a few seconds.: ResultsOur attempt to use the ACS for proximal anastomosis of the RA was successful in all ten patients. Mean operating time was 3.2 ± 0.6 minutes and an average of 3.0 ± 0.9 bypass grafts (range, 2 to 5 grafts) were performed. There was no postoperative fatal complication. Postoperative angiographic control showed that all grafts were widely patent including grafts other than the RA. During the mean postoperative follow-up of 10.3 ± 2.9 months, there was no cardiac-related event in any patient.: ConclusionsThe St. Jude Medical Symmetry aortic connector system allows the construction of uniform and widely patent anastomoses in RA graft and does not require aortic side biting. Skeletonization of the RA is a safe and effective technique for applying ACS in off-pump CABG using multiple arterial grafts. [Copyright &y& Elsevier]

We report a patient with an absent right lobe of the lung, a very rare anomaly. A superior lobectomy was performed for adenocarcinoma, and the right upper bronchus and pulmonary artery of the upper lobe (truncus superior) were absent. The first artery originating from the right main pulmonary artery was located at the major fissure, and four relatively small arteries entered the superior lobe. Anatomically, in this patient, the superior lobe was determined to be the middle lobe. The natural upper lobe was missing. [Copyright &y& Elsevier]

We present the case of an 80-year-old man with chronic atrial fibrillation associated with mitral regurgitation. The atrial fibrillation was successfully treated with the maze procedure combined with mitral valve replacement. The electrophysiological data are also reported. Recordings of sinus rhythm and intraatrial activity demonstrated the coexistence of sinus rhythm and fibrillation of both atria. This finding indicates that the sinus node was protected from segmental atrial fibrillation by entrance block, and this, in turn, is evidence of the efficacy of the maze procedure. [Copyright &y& Elsevier]

Radiofrequency ablation procedures for atrial fibrillation are occasionally associated with pulmonary vein stenosis (PVS). A common treatment for PVS is catheter intervention; however, because of the high restenosis rate, it is not suitable for young patients. The case presented herein is of a young male patient with severe bilateral PVS who underwent successful surgical pulmonary vein repair by sutureless technique. The stenotic lesions of the pulmonary veins were dissected and were covered using autologous pericardium. An enhanced computed tomographic scan revealed that all the pulmonary veins were widely patent after 6 months from the operation. [ABSTRACT FROM AUTHOR]

We report a technique of injecting a high concentration of potassium chloride into the aorta root to resolve refractory ventricular tachycardia after aortic declamping, which occurs occasionally in open heart surgeries. Using this technique, normal sinus rhythm can be restored without the need for defibrillation and aortic clamping. [ABSTRACT FROM AUTHOR]

In patients with massive destruction caused by mitral endocarditis, surgical valve repair remains a challenging issue. Although several procedures have previously been introduced, no standard method for complicated lesions has been established. We describe a technique of mitral valve repair for extensive destructive endocarditis involving both leaflets and the mitral annulus that has provided satisfactory initial results in 2 patients. This procedure is believed to be technically simple and beneficial in terms of mitral repair for active endocarditis. [Copyright &y& Elsevier]

A 51-year-old man with severe mitral regurgitation was admitted. While undergoing preoperative examination for mitral disease, he was found to have absence of the right superior vena cava and a persistent left superior vena cava. Minimally invasive cardiac surgery (MICS) was performed through a right anterior thoracotomy. Cardiopulmonary bypass was established with venous drainage through the internal jugular and right femoral veins and arterial return through the right femoral artery. There were no difficulties during the operation. Isolated persistent left superior vena cava is very rare, but if it is diagnosed preoperatively and an appropriate operative plan is made, MICS can be performed safely., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The suitability of the radial artery after transradial catheterization as a bypass conduit has been of great concern to surgeons., Methods: A total of 67 patients underwent isolated coronary artery bypass grafting using the radial artery: 22 patients received preoperative transradial catheterization (group 1) and 45 patients did not receive transradial catheterization (group 2). Those patients were retrospectively reviewed., Results: Patient characteristics, operative procedures, and early clinical outcome were not different between groups. The stenosis-free graft patency rates in groups 1 and 2 were 88% (16 of 18 patients) and 90% (38 of 42 patients) in the left internal thoracic artery (p = 0.87); 77% (17 of 22 patients) and 98% (48 of 49 patients) in the radial artery (p = 0.017); and 87% (13 of 15 patients) and 84% (21 of 25 patients) in the saphenous vein (p = 0.42), respectively. Intimal hyperplasia of the radial artery was observed in 68% (11 of 16 patients) in group 1 and in 39% (14 of 34 patients) in group 2 (p = 0.046)., Conclusions: Transradial catheterization reduced early graft patency and caused intimal hyperplasia, although it did not affect early clinical outcomes. We suggest that the use of the radial artery as a bypass conduit after transradial catheterization should be undertaken cautiously.

Bronchogenic cysts in the interatrial septum are very rare. We experienced a case in which a 39-year-old man, incidentally diagnosed through echocardiography as having a cardiac tumor, was surgically treated. Pathologic investigation of the tumor, which was located in the interatrial septum and resected, revealed that the tumor was a bronchogenic benign cyst. Tumor enucleation was performed and the resultant atrial septal defect was closed by an autopericardial patch.