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We report on structural valve deterioration in patients with the Medtronic Freestyle aortic bioprosthesis (Medtronic, Inc, Minneapolis, MN), including spontaneous perforation of the Valsalva sinus. These occurred in four prosthesis in 3 patients using the modified subcoronary method or full root technique. One patient died of ruptured pseudoaneurysm and the others survived reoperation well. Careful follow-up is required after Freestyle bioprosthesis implantation.

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Left ventricular (LV) free wall rupture particularly in blow-out type is still one of the fatal complications after myocardial infarction. Seven patients had LV rupture following acute myocardial infarction. LV rupture was divided into two categories: blow-out type (true rupture) in 5 cases, or oozing type (incipient rupture) in 2 cases. All patients were in deep shock condition and underwent surgery on emergency basis. Patch and glue (fibrin glue) technique was applied for oozing type patients, while direct closure using buttress sutures with additional sutured patch and glue (including GRF glue) technique for blow-out type patients. Surgery was performed on heart beating without cardioplegic arrest. Complete homeostasis and circulatory recovery were obtained in all cases. One blow-out type patient (14.3%), who had preoperative cardiopulmonary arrest (CPA), died of multiple organ failure. Four patients (57.1%) who had preoperative CPA or were in prolonged deep shock resulted in vegetative condition regardless of rupture type. Two patients (28.5%) of blow-out type were successfully rescued without any severe brain complications. No recurrence of free wall rupture was demonstrated during follow-up in all cases. Fifty-seven percent of patients had postoperative vegetative condition because of inadequacy of cardiopulmonary resuscitation including delayed circulatory support. Our surgical procedure provided sufficient circulatory recovery and survival without recurrence, even in patients with blow-out type rupture, as long as prompt resuscitation was performed.

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Pulmonary artery sling associated with tetralogy of Fallot was successfully repaired in 2 patients. In 1 patient, extensive reconstruction was needed for severe hypoplasia in the left pulmonary artery, followed by definitive repair. In the other patient, surgical repair was achieved in a single-stage fashion.

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OBJECTIVE: Right axillary artery (AxA) perfusion, which can prevent cerebral embolism caused by retrograde perfusion via the femoral artery (FA), was used for selective cerebral perfusion (SCP) as well as cardiopulmonary bypass (CPB) in aortic arch repair. We review the outcome of aortic arch surgery using SCP with right AxA perfusion to clarify its efficacy. METHOD: Between 1998 and 2002, 120 patients underwent aortic arch repair using SCP with right AxA perfusion. The mean age was 69+/-10 years. Aneurysms were atherosclerotic in 79, dissecting in 32, and others in nine patients. Twenty of them (16.7%) required emergency surgery. CPB was initiated with right AxA and FA perfusion, and following SCP was established using right AxA and left common carotid artery perfusion. RESULTS: With right AxA perfusion, hospital mortality was 5.8%. Multivariate analysis showed only ruptured aneurysm was an independent determinant for hospital mortality. Permanent neurological dysfunction developed in one patient (0.8%), while seven (5.8%) suffered from temporary one. In univariate analysis, SCP time, stenosis of the carotid arteries, past history of cerebrovascular events, and atherosclerotic aneurysm were not related to temporary neurological deficits CONCLUSION: Right AxA perfusion in conjunction with SCP is a safe and useful alternative for brain protection in total arch replacement.

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BACKGROUND: The surgical management of type A dissection with the intimal tear in the descending aorta--retrograde dissection--has some challenging aspects because the standard approach through a median sternotomy for ascending aortic dissection is difficult in these cases in which the intimal tear is located in the descending aorta. METHODS: From January 1995 to December 2001, 12 (8.6%) consecutive patients aged 40 to 71 years underwent total arch replacement with an elephant trunk procedure through a median sternotomy for retrograde dissection of the ascending aorta (acute: 10, chronic: 2) among 139 patients with type A dissection. The intimal tear was located in the descending aorta in all patients. Dissection extended proximally to the aortic root in 7 patients and to the ascending aorta in 5, and extended distally to the abdominal aorta in 4 and to the common iliac artery in 8. RESULTS: Hospital mortality occurred in 1 patient (8%) owing to multiple organ failure after malperfusion of the renal arteries. Postoperatively the false lumen in the descending aorta was closed in all patients who survived but the false lumen in the abdominal aorta was patent in 9. The thoracic and abdominal aorta had slight dilatation in 2 patients. CONCLUSIONS: These data suggest that total arch replacement with an elephant trunk procedure through a median sternomy should be recommended in patients with type A dissection and the intimal tear in the descending aorta. This procedure induces thrombosis of the remaining false lumen in the distal aorta postoperatively.

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