We present a surgical technique for closure of a patent ductus arteriosus (PDA) in pre-term neonates. Left anterior mini-thoracotomy is a surgical procedure that consists of an anterior mini-thoracotomy (∼1.5 cm) below the clavicle, clipping the PDA, and closing the thorax without a tube thoracotomy.

Using this method between 2009 and 2012, we performed PDA closure in 32 pre-term neonates. Logistic regression analysis of potential risk factors for mortality was determined.

The mean weight of the patients at the operation was 822.81 ± 24.59. The mean age at the operation was 28.97 ± 2.20 days. No surgery-related mortalities occurred. Four short-term mortalities occurred after the operation (12.5%) before the patients could be discharged. Three were due to sepsis, and one was due to necrotizing enterocolitis. According to the linear regression analysis, no other variables were found to be statistically significant for predicting mortality. A negative linear correlation was found between the weight of the patients at the operation and extubation time (p = 0.39; r = −0.39).

The surgical outcome of anterior mini-thoracotomy for PDA closure in neonates is compatible with good results. This technique may be advantageous for extremely low birth weight infants and results in less traction on the lungs.

Heyde syndrome (the combination of iron deficiency anemia and aortic stenosis) has been a controversial entity. The proposed mechanisms between aortic valve disease and iron deficiency anemia are examined in this article along with impact valve replacement on iron deficiency anemia.

This report describes an effective cerebral perfusion method using an additional 4th side limb graft sewn to a trifurcated graft in patients undergoing redo aortic root reconstruction combined with total aortic arch replacement. This method is useful in cases where the origin of the innominate artery is unsuitable for clamping or when axillary perfusion is not employed, and assures continuous brain protection and minimizes circulatory arrest time.

To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size.

Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) < 0.85 cm²/m². Patients having IEOA < 0.75 cm²/m² and IEOA < 0.60 cm²/m² were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete.

PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm²/m², and 23 had an IEOA ≤ 0.60 cm²/m². The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF < 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups.

PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.

Post-cardiotomy cardiogenic shock is an infrequent devastating complication with few options for support.

We present a case highlighting use of the Impella 5.0 (ABIOMED; Danvers, MA) for postcardiotomy cardiogenic shock after coronary artery bypass and bioprosthetic aortic valve replacement.

Support was maintained for 7 days before being successfully weaned with myocardial recovery and no damage to the bioprosthetic aortic valve.

This is the first published report of successful use of an Impella 5.0 (ABIOMED; Danvers, MA) for post-cardiotomy cardiogenic shock through a new implanted bioprosthetic aortic valve.

This is a case of an 18-year-old male who presented with hip pain, shortness of breath, and respiratory failure and was found to have a large saddle pulmonary embolus involving the pulmonary artery bifurcation, which extended into the main right and left pulmonary arteries, as well as the lobar branches bilaterally. The patient was taken to the operating room for an emergent pulmonary embolectomy where a significant amount of tumor was removed through an incision in the main pulmonary artery with pathology consistent with metastatic chondrosarcoma.

This paper reports the outcomes of patients initially deemed inoperable for standard aortic valve replacement who received transcatheter aortic valve insertion. Each patient experienced a transcatheter valve insertion complication and was then subsequently reconsidered for urgent standard valve replacement. We review the outcomes of these inoperable patients and discuss recommendations for managing this complication.

Management of late sternal dehiscence is challenging and time consuming. Although numerous techniques exist including rewiring and titanium plates screwing to stabilize the sternum, we describe an alternative technique by using four titanium clips and one connecting bar.

The surgical approach to a large pseudoaneurysm of the brachiocephalic trunk may be hazardous because of its high risk of rupture. An adequate vascular control is vital before attempting to manage the pseudoaneurysm. We describe a surgical technique using deep hypothermic circulatory arrest to repair a giant pseudoaneurysm of the brachiocephalic trunk with impending rupture and severe respiratory distress and superior vena cava compression secondary to multisystem trauma.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly of the aortic valve. We describe transplanting a donor heart with a QAV with successful mid-term outcome.

Since 2008 we have performed 10 hybrid procedures for perventricular muscular ventricular septal defects (mVSD) closure. The mean age was 8.5 months (range 2.7 to 17.8), the mean diameter of mVSD was 6.3 mm (range 4 to 10 mm). The postoperative course was uncomplicated and complete closure of the mVSD was accomplished in all patients. There was neither in-hospital nor late mortality, and the longest follow-up now exceeds three years (range 2 months to 3.1 years). doi: 10.1111/jocs.12106 (J Card Surg 2013;XX:1–3)

Conversion to a full sternotomy may complicate up to 1.8% of the sternal-sparing coronary artery surgery. Left internal mammary artery injury and anastomotic problems are the common causes. The purpose of this article is to retrospectively review the outcomes of six patients that required conversion to sternotomy during minimally invasive direct coronary artery bypass and also to point out technical aspects in order to avoid such a complication. doi: 10.1111/jocs.12110 (J Card Surg 2013;XX:1–2)

Interrupted aortic arch is a rare congenital malformation. We describe the case of an interrupted aortic arch with a bicuspid aortic valve and severe aortic stenosis. The patient underwent a single-stage aortic valve replacement (AVR) and ventral aorta repair through a median sternotomy–laparotomy. doi: 10.1111/jocs.12116 (J Card Surg 2013;XX:1–3)

We report a 76-year-old female with Takayasu arteritis who was found to have multiple coronary arteriovenous fistulas (CAVFs), a pulmonary-to-systemic ratio of 2:1, and aortic valve insufficiency. Aortic valve replacement and ligation of multiple CAVFs with cardiopulmonary bypass were performed under cardioplegic arrest, thus minimizing coronary steal.

We report the case of a 66-year-old male with increasing angina occurring after two previous coronary artery surgery procedures. The second operation had been complicated by severe mediastinitis necessitating surgical drainage, and sternal stabilization. Angiography revealed an occlusion of the LAD bypass with a patent LAD associated with a stenotic circumflex coronary artery. The ascending aorta was severely calcified. An off-pump axillo-LAD coronary artery bypass was safely performed in conjunction with stenting of the circumflex artery. This approach dramatically simplified the procedure and reduced the operative risk. At the 52-month follow-up, the patient is free of any angina symptoms.

We describe the surgical management of three distinct coronary artery aneurysms in conjunction with coronary artery bypass grafting.

Cardiac angiofibromas are rare tumors. We report a patient with an angiofibroma of the mitral valve and discuss the management of these tumors.

Young patients requiring myocardial revascularization are considered at low operative risk, but data on their outcome are scarce. This study was undertaken to evaluate the prevalence and 30-day mortality of patients aged <50 years after isolated coronary artery bypass surgery (CABG).

This is a multicenter study including 2207 patients aged <50 years undergoing isolated CABG at 68 Italian hospitals.

The proportion of patients aged <50 years in this series was 5.3% and varied significantly from 0% to 9.9% in different institutions (p < 0.0001). The 30-day mortality rate was 0.9%. One-to-one propensity score matching of patients aged <50 years versus older patients resulted in 2013 pairs whose 30-day mortality was 0.9% and 2.2%, respectively (p = 0.001). Logistic regression showed that left ventricular ejection fraction <30% (OR 5.5, 95% CI 1.6–18.6), peripheral vascular disease (OR 3.6, 95% CI 1.1–12.0), pulmonary hypertension (OR 18.1, 95% CI 1.8–187.0), critical preoperative state (OR 4.7, 95% CI 1.5–14.3), and emergency operation (OR 3.8, 95% CI 1.1–12.9) were independent predictors of 30-day mortality. Meta-analysis of five studies reporting on patients aged <50 years who underwent isolated CABG showed that operative mortality in these patients was 0.9% (95% CI, 0.8–1.1%, I² 0%, 135/14,316 patients).

The proportion of patients aged <50 years undergoing CABG is low and varies significantly among institutions. The results of this study and a meta-analysis of the literature data showed that CABG can be carried out in young patients with an extremely low risk of operative mortality. doi: 10.1111/jocs.12091 (J Card Surg 2013;28:207–211)

The purpose of this study was to evaluate the clinical outcomes and risk of tricuspid valve replacements and to compare bioprosthetic versus mechanical valves.

Between 1991 and 2009, 104 consecutive patients (71 women; mean age, 57 ± 10.8 years) with tricuspid valvular disease underwent mechanical TVR (mechanical group; n = 59) or bioprosthetic TVR (bioprosthesis group; n = 45). Follow-up was complete in 97.1% (n = 101) with a median duration of 49.9 months (range 0–230 months).

Hospital mortality after mechanical TVR and bioprosthetic TVR was not different on adjusted analysis by propensity score. Ten-year actuarial survival after mechanical and bioprosthetic TVR was 83.9 ± 7.6% and 61.4 ± 9.1%, respectively (p = 0.004). However, there was also no significant difference in terms of adjusted analysis by propensity score (p = 0.084). No statistically significant difference was detected between mechanical and bioprosthetic valves in regard to event-free survival.

Mechanical TVR is not inferior to bioprosthetic TVR in terms of occurrence of valve-related events, especially anticoagulation-related complications. doi: 10.1111/jocs.12093 (J Card Surg 2013;28:212–217)

We aimed to evaluate the graft patency rate following coronary artery bypass grafting (CABG) to the left anterior descending artery (LAD) with proximal myocardial bridging (MB). While MB is generally a benign coronary abnormality, ischemia, stunning, and sudden death have been reported. In symptomatic patients with proximal LAD systolic compression of >50%, positive for ischemic noninvasive testing and noneffective optimal medical therapy, coronary intervention could be indicated. Few studies of CABG in myocardial bridging have been reported. The influence of high flow in coronaries with MB on graft patency is cause for concern.

We retrospectively studied 39 patients operated on for isolated MB of proximal LAD with >50% systolic compression. All patients were severely symptomatic despite optimal medical therapy and positive noninvasive tests for myocardial ischemia. CABG was performed through the midsternotomy with cardiopulmonary bypass and cardioplegia. Patients were divided into two groups: in 20 patients, LAD was bypassed with left internal mammary artery (LIMA) (Group 1) and in 19 patients with saphenous vein graft (SVG) (Group 2). All patients underwent follow-up coronary angiography.

Demographics and degree of systolic compression of the LAD were similar in both groups. There was no mortality or major morbidity. Freedom from angina was 68% in Group 1 and 94% in Group 2 at 18 months postoperatively (p = 0.58). Twelve LIMA grafts and three SVGs were found occluded (p = 0.002).

LIMA patency in myocardial bridging of the LAD can be low. SVGs should be considered in cases of CABG for myocardial bridging. doi: 10.1111/jocs.12101 (J Card Surg 2013;28:218–221)

Coronary artery fistula (CAF) is rare in patients undergoing coronary angiography. Coronary artery ectasia (CAE) is found in 1.2% to 4.9% of patients at autopsy or during angiographic studies. CAF combined with CAE is a extremely rare clinical condition. This study aimed to summarize a treatment strategy for this complex disorder.

Ten consecutive patients who underwent surgical repair of CAF combined with CAE between 2000 and 2012 are reported. The main outcome measure was death. Secondary outcome measures included surgical technique, the extracorporeal circulation time, intubation duration, the intensive care unit stay period and discharge period.

The mean extracorporeal circulation period was 103.8 W 25.7 minutes. The mean intubation duration was 10.5 W 3.2 hours. The mean intensive care unit stay period was 2.0 W 0.8 days and the mean discharge period was 11.4 W 2.6 days two patients were lost to follow-up. The other eight patients were asymptomatic and there were no deaths during the follow-up period.

Surgical repair for CAF combined with CAE is effective with satisfactory results in adults.Objectives: Coronary artery fistula (CAF) is rare in patients undergoing coronary angiography. Coronary artery ectasia (CAE) is found in 1.2% to 4.9% of patients at autopsy or during angiographic studies. CAF combined with CAE is a extremely rare clinical condition. This study aimed to summarize a treatment strategy for this complex disorder. Methods: Ten consecutive patients who underwent surgical repair of CAF combined with CAE between 2000 and 2012 are reported. The main outcome measure was death. Secondary outcome measures included surgical technique, the extracorporeal circulation time, intubation duration, the intensive care unit stay period and discharge period. Results: The mean extracorporeal circulation period was 103.8 W 25.7 minutes. The mean intubation duration was 10.5 W 3.2 hours. The mean intensive care unit stay period was 2.0 W 0.8 days and the mean discharge period was 11.4 W 2.6 days two patients were lost to follow-up. The other eight patients were asymptomatic and there were no deaths during the follow-up period. Conclusions: Surgical repair for CAF combined with CAE is effective with satisfactory results in adults. doi: 10.1111/jocs.12109 (J Card Surg 2013;28:222–227)

Atheromatous plaques of the ascending aorta are one of the most important risk factors for postoperative mortality and morbidity in coronary artery bypass grafting (CABG). We have retrospectively analyzed the results of proximal anastomoses constructed on the innominate artery in patients with calcific atheromatous plaques (CAP) in their ascending aorta detected intraoperatively.

This study is a retrospective review of 16 consecutive patients who underwent CABG operations and had CAP on their ascending aorta between November 2006 and June 2009. The atheromatous lesions were detected intraoperatively and the operation plan was changed to off-pump surgery. All the proximal anastomoses were made on the innominate artery, left internal thoracic artery (LITA) or the other saphenous vein grafts (SVG). Thirteen patients were male and three were female with a mean age of 63.7 ± 5.3 (ranged, 53–71) years.

A total of 56 distal anastomoses (3.5 per patient) and 25 proximal anastomoses on the innominate artery were performed. Of the 16 patients, seven (43.7%) had received a sequential SVG; two (12.5%) patients, sequential LITA graft; and one (6.25%) patient sequential SVG and LITA graft. One of the proximal anastomoses was performed on the SVG in four patients (25%) and on the LITA graft in one patient (6.2%). One patient (6.2%) died due to cerebrovascular morbidity. No other complications were observed.

The innominate artery is an alternative site for proximal anastomoses in patients with calcific atheromatous aorta. doi: 10.1111/jocs.12112 (J Card Surg 2013;28:228–232)

Q fever is a zoonotic disease caused by Coxiella burnetii, an uncommon intracellular bacterium found in livestock and domesticated dogs and cats. A minority of patients who acquire acute Q fever will subsequently develop chronic Q fever endocarditis, which often manifests in valvular insufficiency.

We review recent literature and report the clinical presentation, treatment, and serology of three surgical patients with Q fever.

Three patients with Q fever were successfully treated at our institution, including the first known case of a C. burnetii infection manifesting in a pediatric patient with isolated aortic coarctation. doi: 10.1111/jocs.12098 (J Card Surg 2013;28:233–237)

Fibrin sealants are used for hemostasis and tissue adherence.

This systematic review summarizes published clinical data for fibrin sealant use in cardiovascular surgery.

A literature search for the following terms was conducted using PubMed and EMBASE: (TISSEEL or Tissucol or Beriplast P or Evicel or Quixil or Crosseal or Reliseal or Fibringluraas or Bolheal or Tachosil or Vivostat or Vitagel or Artiss or “fibrin glue” or “fibrin sealant” or “fibrin tissue adhesive”) and (cardiac or cardiovascular or vascular or heart or coronary or surgery). Case reports and series were excluded; although reports of controlled trials were preferred, uncontrolled trial data were also considered.

Clinical trials and chart review analyses of fibrin sealants were identified and summarized. Although clinical trial data were available for other agents, the majority of published studies examined TISSEEL. Overall, TISSEEL and other fibrin sealants showed improvements over standard of care or control groups for a variety of predefined endpoints. Safety findings are also summarized.

Data from these studies showed that fibrin sealants were well tolerated and provided effective hemostasis in a range of cardiac and aortic surgeries. doi: 10.1111/jocs.12099 (J Card Surg 2013;28:238–247)

To evaluate the effects of thoracic epidural anesthesia (TEA) as an adjunct to general anesthesia (GA) on postoperative pain after coronary artery bypass grafting (CABG).

Between April 2009 and March 2010, 40 patients with ischemic heart disease scheduled for elective CABG were prospectively randomized to receive either GA (n = 20) or GA + TEA (n = 20). Through epidural catheters, patients received an infusion of (10–20 mg/h) 0.25%-bupivacaine intraoperatively and during the first 24 hours after surgery. Study endpoints included assessment of postoperative pain at rest and with coughing, rescue analgesic need, and postoperative course.

The differences in pain scores were decreased at rest during 6 (0.1 ± 0.3 vs. 2.4 ± 1.8; p < 0.05) and 12 hours (0.1 ± 0.3 vs. 3.9 ± 2.3; p < 0.05) and with coughing at 6 (0.1 ± 0.3 vs. 5.6 ± 2.2; p < 0.05), 12 (0.1 ± 0.3 vs. 5.9 ± 2.3; p < 0.05), and 24 hours (0.05 ± 0.2 vs. 4.6 ± 2.9; p < 0.05) in the GA + TEA group. At one-month follow-up, pain scores were decreased in GA + TEA group (0.3 ± 0.7 vs. 1.6 ± 1.3; p = 003). There was no significant difference at three and six months. Mechanical ventilation time (4.7 ± 1.2 vs. 2.9 ± 1.1 hours; p < 0.05), intensive care unit stay (28.4 ± 9.0 vs. 22.4 ± 3.4 hours; p < 0.05), and hospital stay (7.2 ± 1.1 vs. 6.1 ± 0.3 days; p = 0.001) were reduced in the GA + TEA group.

TEA significantly reduced the intensity of postoperative pain and analgesic consumption in the early postoperative period following CABG. The delivery of effective analgesia along with conventional medications may prevent chronic pain after surgery. doi: 10.1111/jocs.12086 (J Card Surg 2013;28:248–253)

To compare the international normalised ratio (INR) value of patients evaluated using the CoaguChek XS versus conventional laboratory methods, in the period after open-heart surgery for mechanical valve replacement until a therapeutic range is achieved using vitamin K antagonists (VKA) together with low molecular weight heparin (LMWH).

One hundred and five patients undergoing open-heart surgery for mechanical valve replacement were enrolled. Blood samples were collected from patients before surgery, and on the second and fifth postoperative days, simultaneously for both the point of care device and conventional laboratory techniques. Patients were administered VKA together with LMWH at therapeutic doses (enoxaparin 100 IU/kg twice daily) subcutaneously, until an effective range was achieved on approximately the fifth day after surgery.

The mean INR values using the CoaguChek XS preoperatively and on the second and fifth days postoperatively were 1.20 (SD ± 0.09), 1.82 (SD ± 0.45), and 2.55 (SD ± 0.55), respectively. Corresponding results obtained using conventional laboratory techniques were 1.18 (SD ± 0.1), 1.81 (SD ± 0.43), and 2.51 (SD ± 0.58). The correlation coefficient was r = 0.77 preoperatively, r = 0.981 on postoperative day 2, and r = 0.983 on postoperative day 5.

Results using the CoaguChek XS Handheld Coagulation Analyzer correlated strongly with conventional laboratory methods, in the bridging period between open-heart surgery for mechanical valve replacement and the achievement of a therapeutic range on warfarin and LMWH. doi: 10.1111/jocs.12100 (J Card Surg 2013;28:254–257)

Evaluation of graft patency is an important component of coronary bypass surgery. In the present study, intraoperative cineangiography was performed in a cardiovascular hybrid operating room to evaluate anastomosis quality and patency of coronary venous grafts.

This prospective study evaluated coronary bypass grafts in 34 patients between January 2012 and June 2012. Radiopaque material was administered into the grafts through a vessel cannula before the proximal anastomosis. Then, cineangiographic images were obtained using a mobile C-arm cineangiography system. The myocardial perfusion scintigraphy (MPS) of the patients was compared between preoperative and first month postoperative periods to assess graft function.

The localization of the grafts in the target vessel, structural status of the grafts, anastomosis line, and availability of the target vessel were easily evaluated. Angiographic defects were detected in two grafts (3%, n = 60) in two patients (6%, n = 34). Staining was observed in the distal myocardial segments of the saphenous vein grafts following the administration of radiopaque material. The procedure took eight minutes, on average (range, 5–14 minutes), and a mean of 15 mL (range, 10–35 mL) of opaque material was used. None of the patients developed intraoperative myocardial infarction, postoperative complications, or contrast material-induced renal failure. No mortality was observed. The distal myocardial segments of saphenous vein grafts were detected to be perfused 92% normally, 5% reversibly defective, and 3% irreversibly defective with postoperative MPS controls.

Cineangiographic graft evaluation in a hybrid operating room is a practical, safe, noninvasive, easily available, and easily applicable method. doi: 10.1111/jocs.12084 (J Card Surg 2013;28:258–261)

Idiopathic cardiac rupture in the absence of coronary artery disease is rare. We describe a case of idiopathic left ventricular free wall rupture with successful surgical repair. doi: 10.1111/jocs.12089 (J Card Surg 2013;28:262–264)

Early valve thrombosis is uncommon after pericardial aortic valve replacement. In this report, we describe such a complication after transcatheter aortic valve insertion. doi: 10.1111/jocs.12096 (J Card Surg 2013;28:264–266)

Epithelioid haemangioendothelioma (EH) is a rare malignant tumor of vascular origin that usually arises in bone, liver, soft tissue, or lung. EH originating in the pleura has been less frequently described.

We describe an uncommon case of pleural EH compressing the myocardium in a 39-year-old woman. The patient was diagnosed with pleural EH confirmed by surgery and immunohistochemistry. She sustained stable disease 14 months after the diagnosis and her symptoms improved after systemic chemotherapy with carboplatine and etoposide. Complete surgical excision of pleural EH followed chemotherapy may prolong survival. doi: 10.1111/jocs.12094 (J Card Surg 2013;28:266–268)

A 35-year-old female presented with nonsustained ventricular tachycardia (NSVT) and a large intrapericardial mass. The mass was attached to the left ventricular wall with a broad stalk. On histopathology, the tumor was diagnosed as a lipoma. Postoperatively, the NSVT disappeared. doi: 10.1111/jocs.12095 (J Card Surg 2013;28:268–270)

The purpose of this study is to evaluate the long-term outcomes of the button Bentall procedure for the correction of aortic root disease.

A total of 195 patients who underwent the button Bentall procedure between 1997 and 2010 were studied. The main pathology was annuloaortic ectasia. A mechanical valve was used in 163 patients (83.6%). The median duration of follow-up was 64 months (14133.0 patient-years).

There were five operative deaths (2.6%). Late overall mortality was 7.9%. The actuarial overall survival rate was 95.8 ± 1.5% at 5 years, 89.6 ± 3.4% at 10 years, and 75.9 ± 7.3% at 15 years. Multivariate logistic regression analysis identified preoperative poor mobility, cardiopulmonary bypass time, deep hypothermic circulatory arrest (DHCA) use, embolism, and bleeding event as significant independent risk factors for the late overall mortality. At 5, 10, and 15 years, actuarial composite valve graft-related event-free survival was 85.8 ± 2.8%, 75.5 ± 4.4%, and 69.3 ± 7.3%, respectively. Hypertension and concomitant coronary artery bypass graft (CABG) were independent predictors of composite valve graft-related events. Age, concomitant CABG, and DHCA use were associated with bleeding.

Valve-related morbidities, such as embolism and bleeding, determine the long-term overall mortality in aortic root replacement with button Bentall operation, similar to that in routine valve surgery. doi: 10.1111/jocs.12085 (J Card Surg 2013;28:280–284)

Concerns of increased surgical risks with ascending aortic replacement have led surgeons to manage post-stenotic aortic dilatation more conservatively during aortic valve replacement (AVR). The present study aimed to assess the prognostic implications and surgical risks of replacing the dilated aorta during AVR.

Between January 1999 and March 2010, 134 patients who received surgery for aortic stenosis and post-stenotic dilatation (aorta size ≥40 mm) were included in the present study. AVR was performed in 92 patients (AVR group) while aortic valve and ascending aorta replacement (AVR + aorta group) were performed in 42 patients. Overall survival was compared between the two groups using Cox proportional hazard model after adjustment with inverse-probability-of-treatment weighting.

The mean follow-up duration was 3.5 ± 3 years. There were no significant differences in the operative mortality and morbidity between the two groups. The late cardiac deaths were also not significantly different between the two groups (p = 1.00). In the AVR group, the ascending aortic expansion rate which was 0.18 mm/year over a mean follow-up duration of 2.3 ± 2.2 years by echocardiography showed a positive correlation with time (r = 0.3, p = 0.08). A relatively greater aortic expansion rate was identified as a risk factor for late mortality (p = 0.015, HR 1.08 (CI: 1.02 to 1.15).

Concomitant replacement of the dilated ascending aorta during AVR did not increase the immediate postoperative morbidity or mortality risks and tended to exert a long-term beneficial effect on the risk of late mortality. doi: 10.1111/jocs.12111 (J Card Surg 2013;28:285–290)

Near-infrared spectroscopy (NIRS) is a noninvasive continuous monitoring method for measuring the oxyhemoglobin saturation of the brain tissue. NIRS monitoring can suggest neuronal hypoxia in the frontal-brain before irreversible impairment of cellular metabolism. We report two cases of Type B aortic dissection surgery in which spinal regional perfusion monitoring was performed by placing two NIRS sensors on the back-skin through T6–T8 and T9–T11 vertebraes. doi: 10.1111/jocs.12082 (J Card Surg 2013;28:291–294)

Aortic prosthetic graft infection is a rare, potentially fatal complication. Surgical explantation of the infected native and prosthetic material with sufficient debridement has sometimes been limited by the lack of a suitable conduit to bridge the residual long segment defect. We describe the implantation of a bovine pericardial fashioned neo-aorta to manage this problem. doi: 10.1111/jocs.12077 (J Card Surg 2013;28:295–297)

A repeat Bentall procedure or a Bentall procedure in an immobile aortic root such as a prior homograft that has calcified can be problematic. Separating the valve from the conduit and with a modified elephant trunk concept we have simplified the proximal graft anastomosis using a running suture technique. This is followed by coronary ostia implantation and then by lowering the aortic valve onto the aortic annulus using a running suture technique. doi: 10.1111/jocs.12078 (J Card Surg 2013;28:298–300)

We performed closure of apical muscular ventricular septal defects (VSDs) using the sandwich technique and assessed its role in the treatment of the defects.

Twenty-one patients (nine males and 12 females) underwent VSD closure at a mean age of 15.4 months (range, 1 month to 6 years) and a mean weight of 8.3 kg (range, 4 to 20 kg). Associated cardiac malformations were present in all of the patients. VSDs were exposed through the tricuspid valve and also from the left ventricular (LV) side through a coexisting large perimembranous VSD or through the mitral valve through an interatrial septostomy. All the apical muscular VSDs were closed using the sandwich technique.

There were no hospital deaths, and the postoperative course was uneventful in all patients. There was no residual shunt in 13 patients, and a minimal residual shunt (diameter ≤2 mm) was observed in four patients. Mild residual shunt (diameter ≤4 mm) was observed in two patients. At the latest follow-up, all the residual shunts had disappeared except in one patient. The wall motion of the interventricular septum and cardiac function were normal in all the patients one month after surgery. All patients were free of cardiac medications.

We conclude that the sandwich technique is safe and reliable. Even in cases when a residual shunt is present, the shunt tends to decrease with time. Further experience and longer follow-up of these patients are necessary to conclude whether this technique is applicable to neonates and young infants. doi: 10.1111/jocs.12104 (J Card Surg 2013;28:301–305)

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly present in approximately one in 300,000 live births. Here, we present a unique ALCAPA variant identified in a neonate. The left anterior descending artery originated posterolaterally on the main pulmonary artery, and the circumflex originated separately from the distal right pulmonary artery. doi: 10.1111/jocs.12079 (J Card Surg 2013;28:306–308)

Occult coronary artery obstruction can be a late source of morbidity and mortality following the arterial switch operation for transposition of the great arteries. We describe a case of undiagnosed left coronary ostial obstruction in a teenager which may have contributed to perioperative ventricular dysfunction and subsequent mortality following a reoperation many years after arterial switch. doi: 10.1111/jocs.12083 (J Card Surg 2013;28:308–311)

Acute ascending aortic dissection (AAAD) is a rare complication after orthotopic heart transplantation. We report a patient with AAAD after heart transplantation in whom repair was complicated by infection of the ascending aortic prosthetic graft. This was successfully managed by re-do replacement with two cryopreserved aortic homografts. Despite extensive calcification in the wall, the homografts show no aneurysm or dilation after 10 years. doi: 10.1111/jocs.12097 (J Card Surg 2013;28:312–314)

Trials to maintain sinus rhythm in patients with atrial fibrillation (AF) and refractory symptoms have been complicated by lack of success or intolerance of medications. Experience with minimally invasive AF surgery is relatively new, and early results have been promising. However, the study populations and techniques were heterogeneous, and the follow-up periods were short in many series.

We present a single center experience through a retrospective review of medical records of patients who had minimally invasive AF surgery.

The surgical techniques addressed several possible mechanisms of AF and causes of recurrence, including pulmonary vein isolation, underlying substrates modification, ligament of Marshall interruption, ganglion plexus ablation, and left atrial appendage exclusion. Thirty-three cases were identified. The mean duration of follow-up was 23.2 months, and 58.6% were maintained in a sinus rhythm and were off antiarrhythmic drugs at the end of the follow-up period. Cases with persistent AF had a lower success rate.

Results with minimally invasive surgery are suboptimal at two years of follow-up, particularly for patients with persistent AF. doi: 10.1111/jocs.12092 (J Card Surg 2013;28:315–320)

Complete device and lead removal is recommended for management of infected implantable cardiac device. Management of large lead vegetation (2 cm) is still in debate.

We report a series of patients involving percutaneous extraction of large vegetations (>2 cm) from ICD/pacing leads using the AngioVac Cannula in patients with infective endocarditis. This approach was used to debulk the ICD/pacing lead vegetations in order to minimize the risk of septic pulmonary embolism during lead explantation.

AngioVac Cannula can be used safely and effectively as an adjunctive method for patients with large lead vegetation. doi: 10.1111/jocs.12087 (J Card Surg 2013;28:321–324)

Cardiac ventricle perforation by a pacemaker (PM) lead is an uncommon complication of PM implantation. We report a patient with a delayed right ventricular perforation from a permanent PM lead which presented as a left hemothorax. doi: 10.1111/jocs.12080 (J Card Surg 2013;28:325–327)