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Direct cannulation of both venae cavae (bicaval venous cannulation) is the gold standard for right atrial isolation in intracavitary surgery, but there has been no consensus about an alternative site. Therefore, we studied an alternative method for bicaval venous drainage in which the left brachiocephalic vein (LBCV) is cannulated instead of the superior vena cava. From 2012 through 2014, we performed routine LBCV cannulation in 150 consecutive patients as part of bicaval venous drainage before right atrial isolation. We prospectively collected demographic information, operative data, total pump and LBCV cannula flows with their respective calculated and indexed rates, central venous pressures, and perioperative complications. All patients survived surgery. There were no adverse technical outcomes or functional deficits associated with the technique. The mean indexed LBCV cannula flow was 1,520 ± 216 mL/min/m2, representing an LBCV cannula-to-calculated pump-flow ratio of 64%. The mean central venous pressure during right atrial isolation was 3.7 ± 1.9 mmHg. Cannulation of the LBCV is intrinsically a safe and reproducible procedure with proven hemodynamic adequacy. Its versatility can be an asset to surgical techniques and perfusion methods. Furthermore, the hemodynamic results in our series promise alternative intrathoracic and extracardiac cannulation sites for mini-extracorporeal circulation, on-pump beating-heart procedures, and short-term circulatory assist device implementation.

One of the most challenging conditions to manage after previous cardiac surgery is chronic dissection of the ascending aorta. We operated on a 54-year-old man who had aortic dissection in addition to large aortic dimensions very close to the sternum, severe aortic regurgitation, and a false lumen in the descending aorta. We used a combination of perfusion and myocardial protection techniques, arising from port-access technology, that enabled antegrade flow into the aorta, endoclamping of the ascending aorta, the administration of cardioplegic solution before opening the sternum, and left ventricular venting to prevent ventricular distention. Our technique resulted in minimal blood loss, shorter circulatory-arrest and operative times, the ability to operate on a decompressed heart and descending aorta, good myocardial protection, and easier and safer access to the heart. Three years postoperatively, our patient was doing well. Other patients might benefit from this approach; however, the surgeon must ensure that an aortic segment is suitable for endoclamping.

Extracorporeal membrane oxygenation (ECMO) is generally used as a last resort to provide cardiopulmonary support in patients whose advanced cardiac or respiratory failure does not respond to less invasive treatments. Lower-limb ischemia secondary to the large diameter of the arterial cannula is one of ECMO's major limitations: in patients who have small-caliber arteries, the cannulas can reduce native blood flow. The creation of a T-graft—a well-described technique to avoid limb ischemia—enables flow into the ECMO cannula without jeopardizing blood flow to the limb. However, leaving the graft exposed through an open groin wound can result in dislodgment, and it increases the risk of infection. We describe our modification of a conventional T-graft in an 18-year-old woman who had systolic heart failure, acute respiratory distress syndrome, and small-caliber femoral vessels. We tunneled a polytetrafluoroethylene graft inside a Dacron graft, then ran the combined graft through a subcutaneous tunnel similar to that created for a peripheral bypass. Thus, the graft was protected from environmental exposure and the risk of infection. Our technique seems safer and more secure than the original T-graft technique, and we recommend its consideration during ECMO cannulation.

The Warden procedure for the correction of a right-sided partial anomalous pulmonary venous connection to the high superior vena cava is well established. It has the advantages of avoiding sinoatrial node dysfunction and pulmonary and systemic venous obstruction. In the case related here, a 3-year-old girl presented with a superior vena cava type of sinus venosus atrial septal defect and an anomalously draining right upper pulmonary vein, with bilateral superior venae cavae. Our approach to the Warden procedure was through a right posterolateral thoracotomy, which provided additional advantages.

We report our method of surgically repairing an unruptured giant aneurysm of the right coronary sinus of Valsalva, a lesion that caused moderate aortic regurgitation but no symptoms in a 61-year-old woman. We excised the aneurysm, reconstructed the right sinus of Valsalva with use of a patch, performed mechanical aortic valve replacement directly through the excised aneurysm's cavity, and constructed a single bypass graft to the right coronary artery. The patient was discharged from the hospital after 5 days. Twelve months postoperatively, her clinical and echocardiographic results were normal, and she was doing well. To our knowledge, our surgical approach to this repair has not been described previously.

In graft-replacement surgery of the ascending aorta and aortic arch, 2 separate grafts are frequently needed in order to construct a more physiologically configured aorta. We describe a new cutting method for accurate performance of graft-to-graft anastomosis. © 2015 by the Texas Heart ® Institute, Houston.

Herein, we describe a plate-fixation technique as an alternative method to close a fragile or fractured sternum. A 69-year-old obese woman with diabetes mellitus and chronic obstructive pulmonary disease underwent coronary artery bypass grafting. One week postoperatively, sternal instability was detected, and traditional rewiring was performed. A week later, because of multiple sternal fractures, we performed sternal resection, with use of longitudinally affixed titanium plates and figure-8 steel wires for the anterior chest wall. The procedure was uneventful, and, on short-term follow-up, the anterior chest wall was stable. This longitudinal plate-fixation technique can be tailored to each patient. We think that the technique is safe, effective, economical, and easy to implement, and it is readily reproducible. To evaluate any associated risks, long-term follow-up in additional patients is warranted.

Pulmonary endarterectomy is the treatment of choice in suitable patients who have chronic thromboembolic pulmonary hypertension. The most common surgical technique involves the use of deep hypothermic circulatory arrest. Herein, we describe a modified aortic clamping technique with selective antegrade cerebral perfusion, performed with moderate hypothermia but without circulatory arrest. This technique avoids the adverse effects of deep hypothermic circulatory arrest and also establishes a bloodless surgical field. We achieved good surgical results and acceptable long-term outcomes in 3 patients with use of this technique, which we recommend as a feasible alternative to the standard operative practice.

Patients with thoracic aortic aneurysms sometimes also have peripheral vascular disease. In such cases, staged operations are usually performed in order to avoid additional morbidity. We have achieved good long-term outcomes in 2 patients with use of a single-stage surgical technique. Our novel procedure uses a pre-sewn side branch with a Dacron graft as the inflow source for the aortofemoral bypass during thoracic aortic aneurysm repair. As of 25 and 52 months' follow-up, these grafts were patent in our 2 patients. We believe that this procedure is a safe and easy single-stage operation that achieves favorable patency. To our knowledge, this is the first report to document the use of a pre-sewn perfusion branch of a Dacron graft as an inflow source for aortofemoral bypass.

Congenital clefts of the mitral valve without an associated atrioventricular canal defect are rare, and they may cause mitral insufficiency that requires surgical correction. Repair is typically by direct suture; however, if the cleft is especially wide, the use of this technique may distort the valve leaflet and cause poor coaptation with valvular insufficiency.Herein, we present the case of a 39-year-old woman who had severe mitral valve insufficiency secondary to a wide isolated cleft of the anterior mitral leaflet. The valve was reconstructed with an autologous pericardial patch supported by polytetrafluoroethylene neochordae and an implanted annuloplasty ring. Echocardiographic examination 1 year postoperatively showed excellent competence of the mitral valve and good coaptation of the leaflets. To our knowledge, this is the 1st report that describes the use of artificial neochordae to support an autologous pericardial patch in the repair of a cleft in the anterior mitral valve leaflet.

Patent foramen ovale is increasingly diagnosed in patients who are undergoing clinical study for cryptogenic stroke or migraine. In addition, patent foramen ovale is often suspected as a cause of paradoxical embolism in patients who present with arterial thromboembolism. The femoral venous approach to closure has been the mainstay. When the femoral approach is not feasible, septal occluder devices have been deployed via a transjugular approach.

We analyzed the postoperative short- and mid-term outcomes of a series of patients with annuloaortic ectasia who underwent a modified Bentall operation in our clinic from September 2000 through March 2006. The study included 44 patients. Their average age was 53.4 +/- 14.1 years. The underlying disease was degenerative aortic aneurysm in 42 patients (95.5%) and acute aortic dissection in 2 patients (4.5%). Six patients (13.6%) had Marfan phenotype. Aortic insufficiency was moderate in 30 patients (68.2%) and severe in 14 patients (31.8%). In our modification of the Bentall technique, we completed the resection of the aortic root while leaving 5 to 10 mm of native aortic wall tissue to support the anastomosis. A long piece of Teflon felt (width, 0.5-1 cm) was laid on the annulus, and nonpledgeted 2-0 polyester sutures were passed in turn through the Teflon felt, the preserved aortic tissue, and the aortic annulus. A thin piece of Teflon felt was also used in the coronary artery reimplantation sites. Fibrin glue was routinely applied to all anastomoses. There were no intraoperative deaths. One patient died in the hospital after surgery for acute type I aortic dissection. Another patient died 1 year after the operation from prosthetic-valve endocarditis. No patient required surgical correction of excessive postoperative bleeding. Kaplan-Meier curves showed overall survival of 0.94 (95% confidence intervals, 0.9-0.99). We consider our approach an easy, effective way to minimize bleeding from the anastomoses and at the aortic root--a common challenge in aortic surgery.

There are many new alternative methods of minimally invasive myocardial revascularization that can be applied in selected patients who have multivessel coronary artery disease. However, these techniques often require new and expensive equipment. Most multivessel myocardial revascularization is performed via median sternotomy and involves the use of a conventional endotracheal tube. Both lungs are ventilated, and frequently the left pleural cavity is opened. In contrast, single-lung deflation naturally moves the mediastinum within the thorax toward the collapsed lung, without the need to open the pleural cavities. Herein, we describe a simple alternative procedure that facilitates off-pump multivessel coronary artery bypass grafting via complete median sternotomy: single-lung ventilation with contralateral lung deflation. This technique better exposes the more distal right and circumflex coronary artery branches with or without the opening of the pleural cavities.

We propose a new cannulation and perfusion technique for aortic arch surgery, in order to achieve continuous antegrade total-body perfusion under moderate hypothermia. The heart and the aortic arch are exposed through a median sternotomy. Cardiopulmonary bypass is established from the right atrium to the right axillary artery. At 26 degrees C of body temperature, the supra-aortic vessels are clamped, the ascending aorta and the aortic arch are incised, and a cuffed endotracheal cannula, connected to an arterial line geared by a separate roller pump, is inserted into the descending thoracic aorta. Perfusion is started in the distal body, while the brain is perfused through the right axillary artery. Once the aortic arch has been replaced with a Dacron graft and the supra-aortic vessels have been reimplanted on the graft, the arterial line in the descending thoracic aorta is clamped and removed. The supra-aortic vessel clamps are removed, the proximal part of the Dacron graft is clamped, and systemic cardiopulmonary bypass is resumed via the right axillary artery.From January 2002 through December 2005, this technique was used in 12 consecutive patients on an emergency basis, due to acute aortic dissection that required total arch replacement. Within the first 30 postoperative days, 1 patient (8.3%) died, and no patient had permanent neurologic deficits. This simple technique ensures a full-flow antegrade total-body perfusion during all phases of the surgical procedure, thereby eliminating ischemia-reperfusion syndrome and yielding excellent clinical results.

Postoperative tricuspid valve regurgitation is moderate to severe in 15% to 20% of heart transplant recipients despite use of the bicaval surgical technique. We hypothesized that the regurgitation might be partly due to increased tension on the donor right atrium. To study the right atrial distortion, we modified the standard bicaval anastomosis. Our technique involves augmenting the donor right atrial anterior wall with a flap of the recipient's right atrium, which is left attached in continuity with the anterior aspect of the inferior vena cava along 65% of its circumference. We measured tricuspid regurgitation, right atrial area, and right atrioventricular diameter in 7 consecutive patients who underwent orthotopic heart transplantation with the modified anastomosis. Tricuspid regurgitation was graded as follows: 1 = trace,10%; 2 = mild, 10%-24%; 3 = moderate, 25%-50%; and 4 = severe,50%. All patients were weaned from inotropic support within 1 week after transplantation with excellent ventricular function, no heart block, and 100% survival at 30 days. The median follow-up time was 173 days (44-358 days). Other median measurements included tricuspid valve regurgitation jet area, 0.30 cm(2) (0-1.90 cm(2)); right atrial area, 15.90 cm(2) (14.47-18.00 cm(2)); atrioventricular diameter, 2.70 cm (2.63-3.09 cm); and tricuspid regurgitation, 1.67% (0-12.42%). Mild regurgitation occurred in 1 recipient; in all others, it was trace. The modified inferior vena caval anastomosis is simple and safe. It eliminates moderate and severe tricuspid valve regurgitation without routine annuloplasty after orthotopic heart transplantation via the bicaval technique.

To the Editor: I read with interest the paper by Manoly and colleagues1 about their coronary extension technique, whereby they used a strip of pulmonary artery anteriorly and an aortic flap posteriorly in a 19-year-old woman who had Bland-White-Garland syndrome. Although our paper was not cited, my colleague and I had described this technique in 1992. We used it in a 21-month-old girl whose anomalous left coronary artery (LCA) arose from the anterior sinus of the pulmonary trunk.2 Because the patient's aortic defect was rather small, we did not patch it. I want to report on the long-term outcome in our patient. An aortogram showed an unobstructed LCA when she was 5 years old. Catheterization data at that time showed no significant pressure gradient in the right ventricular outflow tract (right ventricular pressure, 40/6 mmHg; pulmonary artery pressure, 36/13 mmHg). The patient is now 28 years old and is doing well, without symptoms or reoperation. This method, which we now call the double-flap method, produced good early and long-term results and is a useful adjunctive procedure for 2-coronary-system reconstruction when the LCA ostium is distant from the aorta.

The Seldinger technique is a method of femoral cannulation that has been used to establish cardiopulmonary bypass. Reports of cannulation of the ascending aorta for antegrade perfusion using the Seldinger method are anecdotal. To the best of our knowledge, the approach described herein for direct cannulation of the ascending aorta with use of the Seldinger technique for antegrade perfusion has not been previously described in the English-language medical literature. This method is helpful when the surgeon is treating a patient who has a calcified ascending aorta, complicated aortic dissection, calcified femoral vessels, or a diseased thoracoabdominal aorta. In such cases, retrograde perfusion has been associated with severe complications as a result of atheromatous embolization from the descending thoracic aorta. Herein, we describe our approach to cannulation for cardiopulmonary bypass, which entails insertion of an aortic cannula into the ascending aorta by means of the Seldinger technique. A soft-tip guidewire is inserted through an arterial entry catheter that has been used to puncture a hole in the wall of the vessel. Then the aortic cannula is introduced into the vessel, sliding along the guidewire. Guided by transesophageal echocardiography, the tip of the cannula is positioned carefully and is then advanced into the descending aorta. This positioning of the cannula decreases the chance of arterial embolization, thereby improving cerebral protection. If cannulation of the ascending aorta is not feasible, the transverse aortic arch or proximal descending aorta can be used.

We have modified the technique of perigraft-to-right atrial shunt to control hemorrhage after aortic root replacement. We have performed this operation in 2 patients, including one who had acute aortic dissection and another who underwent aortic root replacement and single-vessel coronary artery bypass. Neither patient required re-exploration for bleeding, and both shunts closed spontaneously during the follow-up period without any related complications. With this modification, even in the presence of concomitant coronary artery bypass grafting, hemostasis was achieved with preservation of the proximal vein graft. (Tex Heart Inst J 2003;30:205–7)

Aneurysms of the sinuses of Valsalva, when detected before rupture, are repaired electively. When they are small, they are most frequently repaired by direct closure; when they are large, they are repaired with a prosthetic patch. When they are associated with prolapse of the corresponding aortic cusp and aortic insufficiency, valve replacement is usually performed concomitantly. We present the case of a patient in whom both abnormalities were corrected by implantation of a Freestyle® bioprosthesis, the wall of which completely excluded the aneurysm of the sinus of Valsalva. The patient remains asymptomatic 18 months after surgery. (Tex Heart Inst J 2003;30:202–4)

Brachiocephalic atherosclerosis and aortoiliac occlusive disease are often encountered concomitantly. The authors report a technique of combined brachiocephalic and femoral revascularization in which a single transthoracic approach is used.

Use of the autologous pulmonary valve for replacement of a diseased aortic valve (Ross procedure) was introduced in the late 1960s but has gained widespread use only in the last 10 to 15 years. Part of the reason for the delay in acceptance of this surgical procedure has been its perceived complexity. We describe herein the technical aspects of the Ross procedure as it is performed at our surgical service.

To date, venous reconstruction has not been as successful as arterial reconstruction. Prosthetic materials used as venous substitutes produce much lower patency rates with a higher incidence of early thrombosis than those used as arterial substitutes. We describe the case of a 38-year-old obese woman in whom we encountered an unexpected tear of the common iliac vein intraoperatively, during an anterior approach to the lumbar spine. Because of limited options, we replaced the vein with an interposition tubulargraft that was custom-made from bovine pericardium. Two years later, the patient remained asymptomatic with a patent graft. To our knowledge, there has been no other reported case in the world medical literature of replacement of medium-sized veins by this technique.

We describe a technique for transapical cannulation in cases of acute aortic dissection. This method entails aortic cannulation via the apex of the left ventricle and the aortic valve. When this technique is used, retrograde perfusion prevents such fatal complications as malperfusion or cerebral embolism that can occur with femoral cannulation. Having found no disadvantage in this method, we recommend transapical cannulation as the best cannulation technique for acute aortic dissection.