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Notes: Abstract In repair of coarctation in neonates or young infants, inadequate removal of ductal tissue, failure to address hypoplasia of the aortic arch, and suture line tension have been reported to be important factors of residual or early recurrent stenosis at the coarctation repair site. In a consecutive series of neonates and young infants with coarctation, who were all operated without delay with extended resection, the clinical outcome regarding the development of restenosis and hypertension was studied. In addition, the resected specimens were investigated regarding the completeness of resection of ductal tissue. Twenty-five consecutive neonates and young infants (median age 22 days, range 5 to 39 days) who underwent surgical correction of coarctation were reviewed; the resected specimens were examined histologically to document the extent of ductal tissue in the aortic wall. Fifteen patients had a preductal coarctation with associated cardiovascular anomalies including a hypoplastic aortic arch (n = 11). The remaining 10 patients had a paraductal coarctation without associated intracardiac anomalies. In all patients, the isthmus was bypassed and an end-to-side anastomosis was constructed between the descending aorta and the undersurface of the proximal aortic arch (n = 13) or the distal ascending aorta (n = 12). In 13 patients without marked hypoplasia of tbe aortic arch, the coarctation repair was performed through a left thoracotomy. In the remaining 12 patients, the coarctation was repaired through a median sternotomy with CPB and hypothermic circulatory arrest, on the basis of an associated hypoplastic aortic arch (n = 4), hypoplastic aortic arch with intracardiac anomalies (n = 7), or a “bovine” innominate artery (n = 1). There was no perioperative or late mortality. At a median follow-up of 15 months, 1 patient (4%) developed a recurrent stenosis at the coarctation repair site; in the remaining 24 patients, echocardiograpby showed a widely patent anastomosis with no evidence of a hemodynamically significant gradient. None of the patients had hypertension. Histologic examination of the resected specimens demonstrated the presence of ductal tissue in the descending aorta with maximal extension into its lateral wall (mean 5.2 mm). In all specimens of the paraductal subtype, there was also extension of ductal tissue into the lateral wall of tbe isthmus (mean 3.9 mm). We conclude that: (1) in the absence of marked hypoplasia of the proximal aortic arch, coarctation can be repaired with low mortality and morbidity via a left thoracotomy; (2) in the presence of marked hypoplasia of the proximal aortic arch and/or if associated intracardiac defects also need to be repaired, we advocate repair of the coarctation and associated defects through a median sternotomy with circulatory arrest; (3) in view of the absence of postoperative hypertension in this series, early repair of aortic coarctation is recommended; and (4) because ductal tissue may extend not only into the descending aorta but also into the isthmus, complete excision of the coarctation and bypass of the isthmus are valuable techniques to avoid secondary constriction of the aorta by ductal tissue.

Notes: Abstract  Patients with severe calcified ascending aorta (“porcelain aorta”) present a surgical challenge. Off-pump coronary artery bypass grafting (OPCAB), using new automated proximal anastomotic devices, provide a surgical alternative for patients who are not candidates for in situ arterial grafting. We present a 74-year-old male with double-vessel disease and a large calcified aneurysm of the left anterior wall. Left ventricular function was poor with an ejection fraction of 24%. The beating heart technique was used for the distal anastomosis and ventriculoplasty. The proximal anastomosis was constructed with an automated aortic connector system, thereby avoiding clamping of the severely diseased aorta. (J Card Surg 2004;19:62-64)

Notes: Abstract  Background: Approximately 1% of patients require temporary circulatory support due to refractory cardiogenic shock following cardiac surgery. Such patients are at very high risk for subsequent morbidity and mortality. We evaluated the results of temporary extracorporeal membrane oxygenation (ECMO) support in patients with postcardiotomy cardiogenic shock. Methods: From November 1997 to February 2000, 7900 patients underwent cardiac surgery in our institution. Ninety-five patients (1.2%) (CABG, n = 63; AVR, n = 16; CABG and AVR, n = 8; other procedures, n = 8) required temporary postoperative ECMO support. ECMO implantation was performed via the femoral vessels or via the right atrium and ascending aorta. Intraaortic balloon counterpulsation was employed in all patients. Results: Mean duration of ECMO support was 2.8 ± 2.1 days. Forty-five patients (47%) were successfully weaned from ECMO. Of these, 28 patients were discharged from hospital 35.8 ± 20.8 days post-ECMO support. Overall hospital mortality for all ECMO patients was considerable at 71%. Mortality rate in the combined CABG and AVR group was 100% (P 〈 0.05 versus the other surgical groups). ECMO support was complicated by renal failure in 64% of patients, bleeding requiring mediastinal reexploration in 62%, ischemia of the lower limbs in 16%, cerebral edema in 6%, and cerebral hemorrhage in 3%. Conclusions: ECMO is a suitable technique for short-term treatment of refractory postoperative low cardiac output. Mortality rates are comparable to other cardiac assist devices, with approximately 30% of patients able to be discharged from hospital. (J Card Surg 2003;18:512-518)

Notes: Abstract A repair technique is reported for Ebstein's anomaly associated with partial atrioventricular canal. When there is inadequate size of the anterior leaflet of the tricuspid valve, pericardial patch augmentation of the anterior leaflet may result in a well functioning monocusp tricuspid valve.

Notes: AbstractIn three patients, coronary artery fistulas originating from a conal branch of the midsegment of the left anterior descending coronary artery (n = 2) and right coronary artery (n = 1) with drainage into the right atrium (n = 2) and right ventricle (n = 1) were successfully closed without the use of cardiopulmonary bypass. The use of a coronary artery stabilizer greatly facilitated the operation by immobilization of the fistula, its supplying coronary artery, and the regional myocardium. In selected patients, this technique allows secure closure of the fistula and meticulous reconstruction of the coronary artery without the use of cardiopulmonary bypass.

Notes: Cervical aortic arch is a developmental entity consisting of persistence of the right or left third branchial arch and regression of the fourth branchial arches. In most cases, the aorta is redundant and crosses behind the esophagus to the opposite side. In the presence of an aberrant subclavian artery contralateral to the side of the aortic arch and a ligamentum arteriosum, a vascular ring is formed around the trachea and esophagus. Two young patients with right-sided cervical aortic arch, aberrant left subclavian artery, and ligamentum arteriosum presented with dys-phagia and exertional dyspnea. In one patient, through a left thoracotomy, the ligamentum arteriosum was divided, and the trachea and esophagus were dissected thoroughly above and below the level of the ring. In addition, the aberrant left subclavian artery was divided at its origin from a large diverticulum and implanted into the left common carotid artery; the aortic di-verticulum was resected. In the other patient, who had associated 22q11 chromosomal deletion, in addition to left-sided compression of the trachea and esophagus, there was additional marked compression of the right anterolateral trachea by the redundant ascending aorta. Through a median sternotomy, the ligamentum arteriosum was divided, and the trachea and esophagus were widely mobilized; an additional aortopexy of the ascending aorta to the right of the sternum resulted in the absence of tracheal compression. The cases of the two reported patients illustrate the clinical variability of vascular ring, including a right cervical aortic arch and the consequently versatile surgical approach that is needed to successfully address this combination of vascular anomalies.