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Objective Median sternotomy is a standard approach in cardiovascular surgery, and wire fixation is commonly used for sternal closure. However, postoperative intermittent stress on the sternum can lead to sternal breakdown, potentially resulting in deep sternal wound infection (DSWI). Sternal closure with rigid plate fixation was recently reported to be effective for preventing DSWI and promoting sternal healing. We investigated the effectiveness of a rigid plate fixation system in patients at a high risk of developing DSWI.Methods This retrospective observational study evaluated the incidence of DSWI and the progression of postoperative sternal fusion observed on computed tomography. Forty-eight patients at a high risk of DSWI who underwent sternal closure with a rigid plate fixation system between 2020 and 2023 were assessed.Results Among the 48 patients, 1 (2.1%) developed DSWI requiring surgical treatment. Sternal fusion improved over time, with significant progression observed during the follow-up period compared with the early postoperative period. Additionally, patients who did not show sternal fusion in the early postoperative period showed progressive fusion during follow-up.Conclusions The rigid plate fixation system prevents sternal displacement and may be beneficial in preventing DSWI by maintaining and promoting sternal fusion in high-risk patients.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2007.11.058 Byline: Kazumasa Orihashi, Taijiro Sueda, Kenji Okada, Katsuhiko Imai Author Affiliation: Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan Article History: Received 13 November 2007; Accepted 26 November 2007

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2005.08.011 Byline: Kenji Okada, Taijiro Sueda, Kazumasa Orihashi, Katsuhiko Imai, Katsutoshi Sato Author Affiliation: Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan

Byline: Kazumasa Orihashi, Yuichiro Matsuura, Taijiro Sueda, Masanobu Watari, Kenji Okada Author Affiliation: Hiroshima Japan From the First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan Article History: Received 26 August 1999; Accepted 7 October 1999 Article Note: (footnote) [star] Address for reprints: Kazumasa Orihashi, MD, First Department of Surgery, Hiroshima University School of Medicine, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551 Japan (E-mail: ka-ori@mcai.med.hiroshima-u.ac.jp) ., [star][star] J Thorac Cardiovasc Surg 2000;119:384-6, a 0022-5223/2000 $12.00 + 0 12/54/103601

Byline: Kazuhiro Kochi, Taijiro Sueda, Kazumasa Orihashi, Yuichiro Matsuura Author Affiliation: First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan Article History: Received 26 April 1999; Accepted 3 June 1999 Article Note: (footnote) [star] Address for reprints: Kazuhiro Kochi, MD, First Department of Surgery, Hiroshima University School of Medicine, 1-1-1 Kasumi, Minami-ku, Hiroshima,734-8551, Japan., [star][star] J Thorac Cardiovasc Surg 1999;118:756-8, a 0022-5223/99 $8.00 + 0 12/54/100615

Background: In clinical practice, various devices are implanted into the body for medical reasons. As X-ray fluoroscopy is necessary to visualize medical devices implanted into the body, the development of a less-invasive visualization method is highly desired. This study aimed to investigate the clinical applicability of our novel solid material that emits near-infrared fluorescence. Methods: We developed a solid resin material that emits near-infrared fluorescence. This material incorporates a near-infrared fluorescent pigment, with quantum yield ≥ 20 times than that of indocyanine green. It can be sterilized for medical treatment. This resin material is designed to be molded into a catheter and inserted into the body with an endoscope clip. In this preclinical experiment using a swine model, the resin material was embedded into the body of the swine and visualized with a near-infrared fluorescence camera system. Results: Endoscopic clips were placed in the mucosa of the stomach, esophagus, and large intestine, and the indwelling ureteral catheters were successfully visualized by near-infrared fluorescence laparoscopy. Conclusions: We confirmed the tissue permeability of the fluorescence emitted by our novel near-infrared fluorescent material and the possibility of its clinical application. This material may allow visualization of devices embedded in the body.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2008.02.008 Byline: Kazumasa Orihashi, Taijiro Sueda, Kenji Okada, Shinya Takahashi Author Affiliation: Hiroshima University Hospital, Hiroshima, Japan Article History: Received 3 January 2008; Accepted 7 February 2008

The present study was designed to evaluate the efficacy of photothermal ablation therapy for lung cancer by low-power near-infrared laser and topical injection of indocyanine green (ICG). In vitro study 1: an 808 nm laser with 250 mW was irradiated for 10 minutes using different dilutions of ICG and the temporal thermal effect was monitored. ICG (1 mL of 0.5 g/L) was heated to a temperature of >30°C from the base temperature by laser irradiation. In vitro study 2: the cytotoxic effect of hyperthermia on human lung cancer cells was examined in different temperature and time settings. Cell viability was quantified by both an MTS assay and reculturing. Fatal conditions evaluated by reculturing were as follows: thermal treatment at 55°C for 5 minutes, 53°C for 10 minutes, and 51°C for 15 minutes. The MTS assay study suggested that thermal treatment at 59°C for 5 minutes and 57°C for 20 minutes showed a severe cytotoxic effect. In vivo study: nude mouse subcutaneous NCI-H460 human lung cancer xenograft models were used for the study. Saline or 0.5 g/L of ICG was injected topically into the tumor (n=3/group). Tumors were irradiated with a laser at 500 mW for 10 minutes. Although the tumor diameter reached 1 cm within 24 days after treatment in all 3 mice using saline/laser, tumor sizes were gradually reduced in all 3 mice using the ICG/laser. In 2 of the 3 mice using ICG/laser, tumors had disappeared macroscopically. The efficacy of the photothermal ablation therapy by low-power near-infrared laser and a topical injection of ICG was clarified using a mouse subcutaneous a lung cancer xenograft model.

We have developed a novel method of measuring spinal cord-evoked potentials with stimulation and recording at the intercostal nerves (transintercostal-evoked spinal cord potential: Tic-ESCP). The purpose of this study was to examine the feasibility and accuracy of Tic-ESCP during thoracic aortic surgery.

In this article, we report the case of a 68-year-old woman who presented with shortness of breath. Respiratory function tests showed a slightly obstructive physiology. Computed tomography (CT) results revealed an aberrant left subclavian artery and a Kommerell diverticulum arising from a right-sided aortic arch that was compressing the trachea and the surrounding tissues. A median sternotomy was performed with the patient under circulatory arrest with moderate hypothermia, and a transaortic stent graft was inserted to exclude the Kommerell diverticulum. The aberrant left subclavian artery was ligated and an axillo-axillar bypass was constructed. Postoperative CT showed complete exclusion of the Kommerell diverticulum without an endoleak. The patient's breathing difficulty was resolved, and she was discharged uneventfully. This procedure should be considered as an alternative strategy for exclusion of Kommerell diverticulum.

Intraoperative transesophageal echocardiography (TEE) assessment of coronary artery graft anastomosed to posterior descending artery (PDA) was evaluated. Twenty-one patients with a saphenous vein (SV) graft (n=17) or right gastroepiploic artery (RGEA) graft (n=4) anastomosed to the PDA were examined. In the transgastric mid short-axis view, the graft was depicted as an echo-free zone between the right ventricle and diaphragm. The depth, diameter, angle for Doppler measurement, and angle-corrected blood flow velocity were determined. The graft was visualized in 20 cases (95.2%). The diameter of the SV graft was 3.0-6.5 mm (mean 4.0 mm), while that of RGEA graft was 2.2-2.9 mm (mean 2.5 mm), at the depth of 1.2-4.4 cm (mean 2.4 mm) with incident angle of 14-57 degrees (mean 38.6 degrees ). Blood flow was detected in 17 cases but was difficult to detect in three cases (velocity <10 cm/s). Postoperative coronary angiography showed patent graft in 16 of former cases (one case of operative death excluded) but occluded graft in all of latter cases. Intraoperative TEE assessment was feasible nearly consistently. Diastolic blood flow velocity <10 cm/s suggests an early occlusion of the graft.

Peripheral arterial disease (PAD) is 1 of the major manifestations of atherosclerosis. PAD is associated with endothelial dysfunction. Sarpogrelate hydrochloride, a selective 5-HT2Aantagonist, has been widely used as an anti-platelet agent for the treatment of PAD. There is no information on whether endothelial function is improved after initiation of sarpogrelate treatment in patients with PAD. The purpose of this study was to evaluate the effects of sarpogrelate on endothelial function in patients with PAD. We divided PAD patients into 2 groups: those treated with sarpogrelate at a dose of 100 mg 3 times per day orally for 12 weeks (sarpogrelate group, n = 10), and those who remained on conventional therapy (control group, n = 11). Forearm blood flow (FBF) and leg blood flow (LBF) responses to reactive hyperemia (RH) and sublingual administration of nitroglycerin (NTG) were measured using strain-gauge plethysmography. After 12 weeks of sarpogrelate administration, FBF and LBF responses during RH showed significant increases from 13.2 ± 1.7 to 18.1 ± 2.2 mL/min per 100 mL tissue (P< 0.01) and from 8.2 ± 0.9 to 14.2 ± 2.1 mL/min per 100 mL tissue (P< 0.05), respectively. Sarpogrelate-induced augmentation of FBF and LBF responses to RH was maintained at 24 weeks. No change was observed in the control group at each follow-up time point. The changes in FBF and LBF after sublingual NTG were similar during follow-up periods in the 2 groups. These findings suggest that long-term oral administration of sarpogrelate improves vascular function in patients with PAD.

Real-time 3D echo may open the way to off-pump closure of an atrial septal defect with a robotic surgery technique without remnant of closure device. We report the preliminary results of 3D echo-guided closure of defect in an experimental model. A sheet with an oval defect immersed in water was visualized with 3D echo as well as surgical instruments. The defect was closed under echo guidance. Visualization of objects and instruments, and feasibility and problems of this technique were examined. The defect was visualized like an endoscopic view. Changing the view point without moving the transducer was a unique advantage. Visualization of instruments was acceptable with the lowest gain level. Acoustic shadow was helpful for comprehending the spatial relationship among the objects. Position of needle entry could be confirmed by the movement of the sheet. As the defect was sutured, fold convergence appeared on the sheet. Difficulties were encountered in passing the needle between instruments because of echo dropout. The string was poorly visualized. 3D echo-guided suturing was feasible with adequate image quality. However, an improvement of the surface of instruments and a wider scanning area is necessary for achieving surgical procedures with more safety and reliability.

Objective:Although the Allen test is crude and subjective, an objective color Doppler method has yet to be established in the assessment of hand circulation before radial artery harvesting. Doppler studies so far have neglected the Doppler principle that the insonation angles should be less than 30° and have not been compared with any standard except the crude Allen test. We therefore introduced the snuffbox technique, measuring the radial artery at the anatomic snuffbox, which is the most distal area after harvesting. Color Doppler methods were compared with the stump pressure as a criterion standard. Methods:Maximal flow velocity and Doppler angles of the snuffbox, palmar artery, and ulnar artery were measured in 20 hands before and after radial artery harvesting. Stump pressure was measured during surgery. Results:Maximal flow velocity in the snuffbox decreased with radial artery compression and after radial artery harvesting. All the flow patterns in the snuffbox technique showed simultaneous reversal. Maximal flow velocity in the ulnar artery increased with radial artery compression and after radial artery harvesting. Maximal flow velocity in the palmar artery did not change significantly with radial artery compression or after radial artery harvesting. Doppler angles were 20.9° ± 6.0° in the radial artery of the snuffbox, 82.5° ± 6.1° at the palmar artery, and 81.0° ± 7.6° at the ulnar artery. The changes in the snuffbox technique were highly correlated with the stump pressure ratio (P<.001). Conclusions:Among various color Doppler methods, the snuffbox technique was precise and reliable.

Abstract: We hypothesized that the central retinal artery color Doppler (CRAD) technique can be used as an alternative monitoring method to the conventional transcranial Doppler (TCD) technique which does not consistently provide good signals during cardiopulmonary bypass. This is the first study to compare CRAD with TCD during cardiac surgery. Twenty patients without stroke were examined at the seven preset stages of the two procedures. The maximum flow velocity (V max) of the right central retinal artery was measured with a 7.5-MHz Doppler system. The V max of the right middle cerebral artery was measured with a TCD system. To estimate the relationship between V max and maximum blood pressure (BPmax), CRAD-V max (6.6 � 2.2 cm/s), TCD-V max (44.0 � 14.8 cm/s), and BPmax (114 � 28.5 mmHg) obtained at the initial stage were normalized. The V max values of CRAD were successfully obtained, at each of the seven study stages, in all 20 patients. The V max values of TCD were obtained at 125 points, and 15 missing values were seen during the stages of cardiopulmonary bypass. CRAD-V max was correlated to TCD-V max (r = 0.775, P < 0.0001). The normalized values of both TCD- and CRAD-V max were correlated to the normalized BPmax (r = 0.766, P < 0.0001) (r = 0.787, P < 0.0001). The accuracy of CRAD was confirmed by the significant correlation with TCD.

Summary: We investigated the relationship between left atrial spontaneous echo contrast (SEC) and cerebrovascular features in nonvalvular atrial fibrillation (NVAF). Few reports have been published to compare cardiac and cerebrovascular imaging in patients with NVAF. Forty-four patients with NVAF were studied using transesophageal echocardiography and noninvasive imaging including magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and transcranial color Doppler imaging (TCD) in the middle cerebral artery (MCA) territory. The symptomatic severity was divided into asymptomatic, transient ischemic attack (TIA), and stroke. The severity of the MRI findings was divided into normal, small, and large infarcts. The severity of the MRA findings was divided into normal, attenuation, and occlusion. MCA was bilaterally scanned and a side-to-side asymmetry ratio of pulsatility index (PI) was measured. The severity of SEC was divided into normal, SEC, and thrombi. Five patients with other thromboembolic risk or poor results of TCD were excluded. SEC and thrombi were detected in 12 (30%) and in 3 patients (5%), respectively. TIA and stroke were detected in 8 (21%) and in 17 patients (44%), respectively. Small and large infarcts were detected in 9 (23%) and in 18 patients (46%), respectively, on MRI. Attenuation and occlusion were detected in 14 (36%) and in 8 patients (21%), respectively, on MRA. PI ratio was 1.21 ± 0.25. SEC severity was highly associated with PI ratio and MRA severity in monovariate analysis (P < 0.005),P < 0.01, respectively). SEC severity was highly associated with PI ratio and MRA severity in stepwise multiple regression analysis (P = 0.0001,r = 0.630,n = 39). In patients with NVAF, left atrial SEC was highly related to attenuation or occlusion on MRA and imbalance of cerebral blood flow on TCD in the MCA territory.

Summary Transvenous mitral commissurotomy (TMC) was conducted with transesophageal echocardiography (TEE) in two patients with mitral stenosis. It was possible to see clearly not only the intracardiac structures to be examined by TMC, such as the right and left atria, interatrial septum, and mitral valve, but also the instruments used in TMC, such as the catheter, guidewire, and balloon. It was possible to determine the positional relation between the intracardiac structures and instruments. We could observe all procedures other than Brockenbrough's procedure by both TEE and fluoroscopy at the same time. Although safety and reliability cannot be confirmed from just the two present cases, TEE appears to be applicable to TMC.

Using transesophageal echocardiography during open heart operations, we found another form of retained intracardiac air, “pooled air,” in addition to the form of “bubbles” that had been reported by other authors. The pooled air was detected in all of 13 patients (100%); it was located at the right upper pulmonary vein in 13 (100%), left ventricular apex in 9 (69.2%), left atrium in 8 (61.5%), right coronary sinus of Valsalva in 8 (61.5%), left atrial appendage in 4 (30.8%), and left upper pulmonary vein in 3 (23.1%). The pooled air was found also in the pulmonary artery in 6 of 3 patients (75.0%) in whom the pulmonary artery was clearly visualized. In 1 patient, 5 mL of air was aspirated from the left ventricular apex, followed by a reduced size of the air on the transesophageal echocardiographic image. Because intracardiac air rapidly changes its locations and appearances, continuous monitoring is important, especially at weaning from bypass. The long-axis view of the heart is useful not only for detecting and locating the air, but also for guiding and evaluating the procedures to remove air.

Abstract: We have developed a direct mechanical left ventricular assist device (DMLVAD) for severe left ventricular failure. The DMLVAD was attached to the left ventricle and compressed the heart by a pneumatic driving unit. In a mock circulation model with an extracted non‐beating heart, a cardiac output (CO) of 1.93 L/min was obtained at a driving pressure of 200 mm Hg. In a canine left ventricular failure model induced by injection of sodium hydroxide into the myocardium, the systolic arterial pressure, systolic left ventricular pressure, maximum LV dP/dt, peak flow, and CO increased by 21, 24, 58, 144, and 37%, respectively. The mean left atrial pressure also decreased by 15% when the DMLVAD was driven. These effects were most prominent when the mean left atrial pressure was over 15 mm Hg, and the driving pressure was over 100 mm Hg. Compression at late systole was more effective in obtaining greater CO. We suggest that the DMLVAD could be an optional circulatory assist device for patients with left ventricular failure awaiting heart transplantation.

Abstract: A new intravascular pumping oxygenator (IVPO) was developed for intravascular gas exchange and circulatory assistance in critically ill patients with respiratory and circulatory failure. The IVPO utilizes new silicone hollow fibers (diameter. 1 mm: membrane width, 50 μm) and consists of two driving tubes for the oxygenation and pumping of circulating blood. The performance characteristics of the IVPO were studied using an experimental ex vivo model. With a mean hemoglobin concentration of 10.5 ± 2.3 g/dl, total oxygen transfer was 5.6 ± 1.5 ml/min at a blood flow of 200 ml/min and 6.3 ± 2.2 ml/min at a blood flow of 250 ml/min. Total CO2transfer was 3.8 ± 1.4 ml/min at a blood flow of 200 ml/min and 4.2 ± 1.6 ml/min at a blood flow of 250 ml/min during IVPO pumping. This preliminary experiment demonstrated that the IVPO has the capacity to function both as a circulatory assist pump and as an intravascular hollow fiber oxygenator.

Summary The usefulness of transesophageal echocardiography (TEE) for guiding the placement of a pulmonary artery (PA) catheter was evaluated in 31 patients (TEE group); 31 patients who were treated before TEE guidance was used (control group). In the control group, use of the PA catheter was abandoned in two patients; because of an unstable condition and marked arrhythmias, respectively. The key findings for TEE guidance were: (1) pulsatile to-and-fro movement of the balloon, i.e., “shuttle movement” and (2) loss of shuttle movement at wedging of the balloon, i.e., “anchoring sign.” When the PA catheter did not enter the right vertricle (RV), the balloon was found to be in the inferior vena cava or the right atrium (RA) without shuttle movement. Coiling of the catheter was suggested in the latter situation. Coiling also occurred in the RV, often associated with frequent arrhythmias. These findings indicate that the catheter should be withdrawn once. TEE allowed for readjustment of the catheter tip position by enabling the balloon to be wedged twice. An excessively deep placement of the catheter tip was seen in 5 of the controls, but in none of the TEE group. Biplane TEE was found to be advantageous for guiding PA catheter placement and for visualizing the RV inflow and outflow tract in a single view, with the shuttle movement of the balloon in its long axis. TEE acts as an “eye” in the operating room, as does fluoroscopy, enabling smooth placement of the PA catheter.

Background. A computerized 48-channel mapping system was used to investigate the characteristics of an atrial epicardial electrogram during chronic atrial fibrillation (AF) in patients with solitary mitral valve disease. We have devised a simple left atrial procedure to eliminate the chronic AF during a mitral valve operation.Methods. Using this mapping system, we performed intraoperative atrial mapping in 11 patients with chronic AF associated with mitral valve disease. The AF duration ranged from 0.4 to 15 years (mean, 8.0 ± 4.5 years). A simple surgical ablation of the AF on the left atrium only was performed during the mitral valve operation.Results. The mean AF cycle length of the atria ranged from 129 to 169 milliseconds in the right atrium and from 114 to 139 milliseconds in the left atrium. The mean AF cycle length of the left atrium was shorter than that of the right atrium. Regular and repetitive activation was found in the left atria of 7 of 11 patients. The AF disappeared in all patients immediately after the operation, and 10 of these patients continued to have a sinus rhythm postoperatively (AF-free rate, 91%).Conclusions. Computerized intraoperative mapping revealed a shorter mean AF cycle length in the left atrium. A simple left atrial procedure was effective in eliminating chronic AF associated with solitary mitral valve disease.

Abstract: To evaluate left ventricular diastolic filling (DF) using transesophageal Doppler echocardiography in 40 patients with or without diabetes mellitus and/or hypertension, we measured DF after induction of anesthesia, before and after cardiopulmonary bypass (CPB), and at the end of coronary artery bypass surgery (CABS). In 13 patients with complete measurements, there was no significant change in DF but diastolic filling time became shorter and peak velocity during atrial contraction increased significantly following CPB. In the other patients, the assessment of DF could be performed accurately in CABS patients without diabetes and/or hypertension, but not in CABS patients with these disorders because of a high incidence of fusion of the E-A waves, which is an indicator of impaired DF. When heart rate (HR) was more than 75 beatsmin−1 (RR interval of less than 800 ms), the incidence of fusion points was significantly higher in patients with diabetes and/or hypertension than without (13 of 29s 1 of 9,P<0.05). It is suggested that a slower HR (less than 75 beatmin−1) is desirable in CABS patients with these disorders to avoid impairment of DF due to either prolonged systolic time or isovolumic relaxation time.

Background. We have devised a simple surgical procedure to be performed on the posterior wall of the left atrium for the treatment of chronic atrial fibrillation (AF) associated with mitral valve disease. The effectiveness of this procedure for serial mitral valve operations was then evaluated. We postulated that chronic AF associated with mitral valve disease could be attributable to a distended left atrium. The refractory period of the distended left atrium was significantly shorter in the left posterior atrial wall, especially at the base of the left atrial appendage and at the orifice of the left posterior pulmonary vein. We hypothesized that the left posterior atrial wall with its shorter fibrillatory cycle length would act as a driver for maintaining the AF, and therefore, surgical ablation of this critical area in the left atrium could terminate the chronic AF.

Objective To determine the appropriate amount of indocyanine green for bronchial insufflation.Methods We enrolled 20 consecutive patients scheduled for anatomical segmentectomy in the Kochi Medical School Hospital. After inducing general anesthesia, 6 to 60 mL of 200-fold-diluted indocyanine green (0.0125 mg/mL) was insufflated into the subsegmental bronchi in the targeted pulmonary segmental bronchus. The volume of the targeted pulmonary segments was calculated using preoperative computed tomography. Fluorescence spread in the segmental alveoli was visualized using a dedicated near-infrared thoracoscope.Results The targeted segment was uniformly visualized by indocyanine green fluorescence in 16/20 (80.0%) cases after insufflating indocyanine green. A receiver operating characteristic curve indicated that the area under the curve was 0.984; the optimal cut-off volume of diluted indocyanine green for insufflation was 8.91% of the calculated targeted pulmonary segment volume.Conclusions The setting for indocyanine green insufflation was optimized for near-infrared fluorescence image-guided anatomical segmentectomy. By injecting the correct amount of indocyanine green, fluorescence-guided anatomical segmentation may be performed more appropriately.

A simple technique termed “clamp test and spinal cord-plegia” for descending thoracic aortic aneurysm surgery is described. The clamp test is a passive method of creating ischemic conditions, whereas spinal cord-plegia is an active method of decreasing metabolism. This technique is a practical test that double-checks for critical feeding arteries and seems to have an excellent spinal cord-preserving effect.

When a patient with Ehlers-Danlos syndrome (EDS) presents with a vascular emergency, performing life-saving surgery can be difficult because of the profound fragility of the arterial tissue. We report the case of a 27-year-old woman with EDS in whom a spontaneous arterial rupture was successfully treated with transcatheter embolization. The patient was brought to our hospital in shock, with left lower abdominal pain. She had been diagnosed with EDS type IV following a colonic rupture 8 years earlier. An emergency angiogram revealed rupture of the left external iliac artery. The active bleeding was managed by transarterial embolization of the ruptured artery using stainless steel coils, which took 30?min to achieve. The patient has not suffered any further vascular complications during the year since this procedure. Transcatheter coil embolization may be a reliable option for treating sudden arterial rupture in patients with this syndrome.

Extra-anatomic bypass is preferred for revascularization after removal of infected vascular grafts. The obturator canal technique has been used to bypass an infected field in the groin, although this method has not always been definitive because of several drawbacks. We present a unique method of extra-anatomic revascularization for use in such a situation. An autogenous graft is placed just below the sartorius muscle in the thigh and penetrates the iliacus muscle near the lateral end of the inguinal ligament. Limb loss and recurrent infection are prevented postoperatively. This retro-sartorius bypass technique may be a useful alternative to obturator bypass grafting in selected patients. (J Vasc Surg 2003;37:892-4.)

We report the case of a patient with a rare papillary fibroelastoma on the pulmonary valve visualized before surgical intervention. The tumor was an encapsulated, rounded mass. The gelatinous membrane on the surface tore easily, and multiple fronds appeared. This case emphasizes that when there is an encapsulated mass attached to a valve, the initial excision of valve tissue should be as minimal as possible. To avoid unnecessary injury to the valve, it is simple and practical to confirm that the tumor has the appearance of a sea anemone, thus identifying it as a papillary fibroblastoma, a benign tumor.

We describe herein the successful treatment of a patient with chronic atrial fibrillation (AF) associated with mitral valve stenosis and regurgitation, achieved by performing a modified maze procedure on the left atrium alone. The patient was a 51-year-old man who had suffered from intractable AF for 17 years, causing multiple cerebral emboli and palpitations. He had undergone open mitral commissurotomy and balloon commissurotomy 15 and 7 years ago, respectively. On admission, an echocardiogram revealed mitral valve restenosis and thrombosis in the left atrial appendage. Prosthetic valvular replacement was performed following isolation of all pulmonary veins with cryoablation to the posterior wall of the left atrium and excision of the left atrial appendage. Postoperatively, the AF disappeared and echocardiogram demonstrated a left atrial kick in the mitral valvular inflow without any evidence of thrombosis in the left atrium. Thus, we believe that our modified “left side only” maze procedure is a simple and efficient method for the treatment of chronic AF with mitral valve disease.

Abstract: An 80-year-old man suffering from angina on exertion due to stenosis of the left main coronary artery, heart failure due to mitral valve regurgitation, and an abdominal aortic aneurysm (AAA) was successfully operated on with simultaneous surgical procedures. A coronary cineangiography revealed 90% stenosis of the left main coronary artery in segment 5, and 99% and 90% stenosis in segments 2 and 4AV, respectively, of the right coronary artery. Left ventriculography and aortography showed moderate mitral valve regurgitation and the presence of a fusiform-shaped AAA with a maximum diameter of 6 cm. It was thought that insertion of an intraaortic balloon pump (IABP) would prove difficult due to AAA; therefore, simultaneous surgery combining triple coronary artery bypass grafting (CABG), mitral valve plasty, and prosthetic replacement of the AAA was undertaken. The patient's postoperative course was uneventful, and subsequent angiography showed good patency of all coronary bypass grafts and the abdominal prosthesis, along with the disappearance of mitral regurgitation. This patient's clinical course suggests that an extended surgical procedure is effective for the treatment of complicated cardiovascular disease, even in very elderly patients.

We report on an everted leaflet of a Carpentier-Edwards Perimount (CEP) valve in an aortic position. A 71-year-old female patient with aortic regurgitation underwent valve replacement with a 21-mm CEP valve. After aortic declamping, transesophageal echocardiography (TEE) revealed significant transvalvular regurgitation due to an immobilized non-coronary leaflet. Upon re-aortotomy, we found an everted leaflet without any structural damage to the valve. It was readily corrected and eversion did not recur spontaneously. The valve was not replaced because it had no intrinsic problems, eversion was unlikely to be induced by cardiac output, and there was no evidence that re-implantation would avoid further problems. Her postoperative course was uneventful without recurrence of aortic regurgitation during three months of follow-up after surgery. On TEE measurements, allocation of stent posts was slightly uneven. Since leaflet eversion was re-created by distortion of the stent in an ex-vivo model, a mild imbalance of sutures might increase the risk of this event. TEE was beneficial for detection, decision-making, and avoidance of an early reoperation. This case indicates that reimplantation or replacement of the valve is not always necessary for an everted valve leaflet. Although the patient has had an uneventful course thus far, careful follow-up is mandatory.

A right atrial separation procedure was performed for the ablation of atrial fibrillation during the concomitant repair of an atrial septal defect. This procedure consisted of a Y-shaped incision in the right atrium, followed by cryoablation of the tricuspid annulus and the atrial septum without any procedures performed on the left atrium. This is a simple and effective method for the elimination of chronic atrial fibrillation associated with atrial septal defects in adults.