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After a median sternotomy, sternal instability can result in sternal infection. The usual sternal closure with stainless steel wires may result in sternal instability, especially in osteoporotic patients. An absorbable mesh (Super-FIXSORB-MX®40, Takiron Co Ltd, Osaka, Japan) for reinforcing the sternum has become commercially available. This paper reports a modified sternal closure procedure using this absorbable mesh in combination with heavy braided Polydiaxanon (PDS cord®, Ethicon, Inc., Somerville, NJ, USA) for osteoporotic patients.

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Several proximal anastomosis devices have been developed to facilitate the creation of a clampless, hand-sewn coronary artery bypass-to-ascending aorta anastomosis. An Enclose II anastomosis assist device (Novare Surgical Systems, Cupertino, CA) is a device commonly used for this purpose. We demonstrate a new, easy, and safe technique for cutting the aortic wall and making a punch hole over the aorta.

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BACKGROUND: Adjunctive thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) was reported to promote better coronary and myocardial reperfusion. However, long-term mortality benefit of TA remains controversial. The objective of this study is to investigate the clinical impact of TA on long-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI. METHODS AND RESULTS: The CREDO-Kyoto AMI Registry is a large-scale cohort study of acute myocardial infarction patients undergoing coronary revascularization in 2005-2007 at 26 hospitals in Japan. Among 5429 patients enrolled in the registry, the current study population consisted of 3536 patients who arrived at the hospital within 12 hours after the symptom onset and underwent primary PCI. Clinical outcomes were compared between the 2 patient groups with or without TA. During primary PCI procedures, 2239 out of 3536 (63%) patients underwent TA (TA group). The cumulative 5-year incidence of all-cause death was significantly lower in the TA group than in the non-TA group (18.5% versus 23.9%, log-rank P<0.001). After adjusting for confounders, however, the risk for all-cause death in the TA group was not significantly lower than that in the non-TA group (hazard ratio: 0.90, 95% CI: 0.76 to 1.06, P=0.21). The adjusted risks for cardiac death, myocardial infarction, stroke, and target-lesion revascularization were also not significantly different between the 2 groups. CONCLUSIONS: Adjunctive TA during primary PCI was not associated with better 5-year mortality in STEMI patients.

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A 47 year-old woman with Behçet disease presented with back pain. Computed tomography showed an extent IV thoracoabdominal aneurysm. Graft replacement with reconstruction of all visceral arteries was performed. At five years postoperatively, anastomotic pseudoaneurysm of the left renal artery occurred, and it was reconstructed with an 8-mm graft. Two years after the second reconstruction, anastomotic pseudoaneurysms of the abdominal aorta developed. Y-shaped graft replacement was performed. There has been no recurrence for one year since the last operation. In situ graft reconstruction for recurrent pseudoaneurysms in a Behçet disease patient more than five years after graft replacement with reconstruction of all visceral arteries is rare.

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Intractable bleeding after cardiac surgical procedures is a life-threatening complication. In most cases, the main bleeding site is present in the retrosternal space, not the pericardial space. Packing the chest may be a useful technique for achieving hemostasis. Herein, we describe a novel and effective procedure for the treatment of intractable bleeding in the retrosternal space using a sheet of oxidized regenerated cellulose and sponges after cardiac surgical procedures.

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An 81-year-old woman presented with dizziness and nasal bleeding. Gastrointestinal fiberscopy (GIF) showed a pulsatile aneurysm in the duodenum, and that the orifice of the papilla of Vater was involved. Three-dimensional computed tomography imaging showed an unruptured aneurysm in the pancreatic duodenal arcade. The patient underwent an emergent endovascular embolization of the donor arteries using coils and gelatin sponge particles. She was discharged without any complications. This case was extremely rare because of the anatomic location of the unruptured pancreaticoduodenal artery aneurysm and the fact that it involved the papilla of Vater, was detected with GIF, and was successfully treated endovascularly.

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A 68 year-old man presented with dyspnoea and chest pain. Computed tomography showed a massive bilateral pulmonary embolism. A 7.5 French pulmonary artery catheter (PAC) was inserted from the right internal jugular vein, and placed at the main pulmonary artery (PA) due to a thrombus in the distal PA. Continuous heparin sodium and urokinase infusions (240,000 units/day) were started. The PA pressure decreased gradually to within the normal range after two days. Three days after insertion, the PA waveform suddenly changed, he subsequently complained of chest pain, and the blood pressure rapidly decreased. Echocardiography demonstrated marked pericardial effusion. Computed tomography showed right ventricular perforation by the catheter, and contrast dye injection from the catheter tip demonstrated pericardial space enhancement. A median sternotomy was performed, and the perforation was detected in the anterior right ventricular wall. Direct buttress suture was placed, and the catheter was removed. He was subsequently discharged without any further complications. We encountered a rare case of postoperative RV perforation caused by a PAC. It is important to keep in mind that such a complication could arise not only during but also a few days after PAC insertion.

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A 56-year-old man had left nephrectomy and resection of a cavoatrial tumor thrombus under a cardiopulmonary bypass assist for left renal cell carcinoma. An intraoperative bipolar temporary epicardial atrial pacing wire was removed on postoperative day 8. The patient collapsed on postoperative day 15. Emergent transthoracic echocardiography and computed tomography scanning with contrast media detected cardiac tamponade. The three-dimensional volume-rendering images from the multislice computed tomography scan demonstrated bleeding from the aortic root. Upon emergency operation, active arterial bleeding from the aortic root distal to the sites of cannulation and cardioplegia was confirmed, and hemostasis with sutures was completed. It is well known that the intraoperative temporary epicardial pacing wire can cause bleeding or arrhythmia, especially when the wire is being removed. However, bleeding usually occurs from the inserted epicardial point of the pacing wire soon after removal of the wire. To our knowledge, this late bleeding complication of the pacing wire is a previously unreported serious iatrogenic complication after cardiac surgery.

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A 67-year-old man presented with dyspnea, general fatigue, and leg edema. Echocardiography demonstrated a large pericardial effusion with a 5 cm × 3 cm, dense hetero-echogenic tumor in the right atrium. At the time of the operation, the tumor was composed of soft but tough, yellowish, smaller smooth processes, and fragile, reddish, bigger nodules. Pathologic examination revealed that the yellow processes were xanthoma and that the reddish nodules were B-cell lymphoma. This case strongly supports the theory that normolipemic xanthomatosis is a secondary event in the lymphoid tissue neoplasm.

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An 86-year-old man was admitted to our hospital with angina due to the instent restenosis. He had a history of coronary artery bypass grafting( CABG). Re-do off-pump CABG was performed. Aspirin and warfarin were started on the next day. The drainage tubes were removed on the postoperative day (POD) 2 and clopidogrel was resumed. On POD 9, he complained of nausea and dyspnea even at rest. Chest computed tomography (CT) and transthoracic echocardiography showed anterior mediastinal hematoma. 550 ml bloody effusion was discharged by percutaneous drainage. Because the accumulation of the mediastinal fluid was mainly anterior to the pericardial space, it was thought to be due to oozing from the sternum and soft tissues. The cause was unclear, but both antiplatelet and anticoagulant agents could have caused the oozing. He was discharged without reaccumulation of the effusion. It is important to take account of such delayed complications when multiple antiplatelet and anticoagulant agents are used after cardiovascular surgery especially in the octogenarian.

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We report an extremely rare case of deformity of the pulmonary sinus of Valsalva with pulmonary valvular stenosis 42 years after a pulmonary annular-sparing operation for tetralogy of Fallot. Aortic regurgitation with deformity of the sinus is also noted. At the previous operation, the right ventricular outflow tract was augmented by a prosthetic subvalvular patch. Through the years, the pulmonary valve and sinus were distorted because the patch was pulled over toward the right ventricle.

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It sometimes is very difficult to achieve good exposure of the orifice of the right coronary artery through a typical aortotomy when inserting the cannula for the selective antegrade administration of cardioplegic solution to the right coronary artery. A simple technique of exposing the orifice of the right coronary artery using a dental mirror is described.

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Surgical bleeding from anastomoses due to systemic heparinization or prolonged extracorporeal circulation, which is more effectively controlled with topical hemostatic agents than with sutures, has been one of the major problems in cardiovascular surgery. We describe a novel hemostatic technique using fibrin glue. Briefly, the two components of fibrinogen and thrombin solutions are mixed and put over the bleeding point immediately after the glue has become a viscous gel. Within a minute of local compression, the glue sets well enough to stop the bleed.

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Bleeding from anastomoses, which is more effectively controlled with topical hemostatic agents than with sutures, has been one of the major problems in cardiovascular surgery. We describe a novel hemostatic technique using microporous polysaccharide hemosphere (Arista; Medafor Inc, Minneapolis, MN) in conjunction with a patch of oxidized regenerated cellulose (Nu-Knit; Ethicon, Johnson & Johnson, Somerville, NJ). Both of them are plant-based products and eliminate the risk of animal-borne or human-borne contaminants and have bactericidal advantages.

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Exposure and stabilization of coronary arteries in the circumflex and right territory is essential for off-pump coronary artery bypass grafting. A new, easy technique of exposing and stabilizing coronary arteries using a sinker (weight) hung on a silicone elastomer suture for hemostasis from the arteriotomy is described.

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