Late disruption of a Freestyle stentless bioprosthesis used for repair of sinus of Valsalva aneurysm of noncoronary cusp

We present a case of disruption of the porcine aortic wall of the 27-mm Freestyle stentless bioprosthesis 5 years after the subcoronary implantation to exclude the sinus of Valsalva aneurysm of the noncoronary cusp. At the urgent reoperation, the inflow suture line was found to be intact, and therefore a new stented valve was sutured with the inflow Dacron cuff after removal of ruptured valve. The subcoronary implantation technique creates a cavity between the prosthetic and native aortic walls filled with hematoma. The outflow suture line dehiscence caused blood flow into the cavity, porcine aortic wall rupture, and leaflet destruction.     

Resolution of protein-losing enteropathy and normalization of mesenteric Doppler flow with sildenafil after Fontan

A 9.5-year-old girl after Fontan procedure for hypoplastic left heart syndrome had recurrent protein-losing enteropathy (PLE) develop 2 months after partial catheter closure of the Fontan fenestration. Despite satisfactory hemodynamic measurements under general anesthesia, we postulated that she suffered from increased pulmonary vascular reactivity and commenced her on Sildenafil treatment. After 6 weeks of oral Sildenafil treatment, her serum albumin and the fecal alpha-1-antitrypsin levels normalized, and her exercise tolerance had increased. There was also an improvement of the mesenteric arterial flow patterns on Doppler studies. Sildenafil should be considered in the treatment of PLE after the Fontan procedure.     

Rare presentation of subclavian artery isolation in a neonate with a family history of aortic arch anomalies

Isolation of the left subclavian artery is a rare aortic arch anomaly in which the artery originates from the pulmonary artery through a ductus arteriosus rather than the aorta. In neonates it is usually diagnosed incidentally with other aortic or cardiac anomalies and can be associated with chromosomal deletions. We describe an extremely rare presentation whereby subclavian artery isolation was presented with left arm ischemia in a 6-day-old child. There were also a concurrent right aortic arch, ventricular septal defect, persistent left superior vena cava, and both radial and ulnar artery hypoplasia. A family history of aortic arch anomalies with no known chromosomal aberration was also present, whereby all the male family members on the maternal side had undergone aorto-cardiac surgery as neonates. Diagnosis and surgical management are discussed.     

A new technique of subcutaneous colon interposition

A colon interposition graft may be placed in the subcutaneous position when other routes are not available. Creation of an adequate subcutaneous tunnel may be difficult, especially in patients with prior sternotomy. In this report we describe a method that utilizes tissue expanders to facilitate subcutaneous esophageal reconstruction.     

Primary synovial sarcoma of the posterior chest wall

Synovial sarcoma is a malignant soft-tissue tumor that most commonly occurs in the extremities of young adults. Only several cases of synovial sarcomas of the chest wall and pleura had been reported. We present a 24-year-old man who had right back pain, chest pain, dyspnea, and intermittent fever from a huge primary synovial sarcoma of the right posterior chest wall. Multimodality therapies, including surgical resection, and chemotherapy and radiation therapy were applied, but the tumor progressed rapidly and the patient died 6 months after diagnosis. Prompt diagnosis and aggressive surgical resection is mandatory for primary synovial sarcoma of the chest wall because of its aggressive behavior.     

Alternative approach to the surgical management of congenital tracheal stenosis

Congenital tracheal stenosis is a serious disease associated with high operative mortality and morbidity, especially in the newborn period. Its surgical management involves either sliding tracheoplasty, which is associated with extensive dissection and recurrent stenosis, or with pericardial patch tracheoplasty that fails to address recoiling of the stenotic complete ring and collapse of the patch into the tracheal lumen. We report a modification of the latter technique, in which a half ring external stenting device is used to keep the rings from recoiling.     

Transverse plate fixation of sternum: a new sternal-sparing technique

We report 2 cases of vacuum-assisted closure therapy and thoracic reconstruction using new sternum titatium plates in patients with deep sternal wound infection after median sternotomy. The specific advantage of this new approach is anatomical reduction of the sternum that prevents paradoxical movement and severe anterior chest instability, and improves postoperative outcome.     

Obstruction of left ventricular outflow tract after mechanical mitral valve replacement

We successfully operated on a patient with a rare complication of left ventricular outflow tract obstruction after mitral valve replacement. In a 57-year-old woman with previous mitral valve replacement, transthoracic echocardiography showed left ventricular outflow tract obstruction as a result of anterior displacement of the mitral prosthesis and local thickening of the interventricular septum. Cardiac surgery verified this rare lesion. During the operation, the anterior half of the prosthesis ring was cut away from hyperplastic tissue and sutured to the natural mitral annulus. Subaortic hyperplastic tissue was excised to enlarge the left ventricular outflow tract. The patient had an uneventful postoperative recovery, and left ventricular outflow tract obstruction disappeared on postoperative transthoracic echocardiography.     

Successful treatment of infected ascending aortic prosthesis by omental wrapping without graft removal

A deep wound infection after a midline sternotomy is a very serious complication. The severity of it can be increased by the presence of prosthetic material. We present a case of a 76-year-old man who had an infection of an ascending aortic graft develop after a Bentall procedure. Rather than following the "traditional" surgical therapy of graft explantation and debridement, we chose to preserve the graft and protect it by omental translocation. The relative merits of this therapeutic approach are outlined and discussed. The patient was discharged on the postoperative day 6 after an uneventful postoperative course.