Protection and expanded use of the left internal mammary artery graft by pericardial flap technique

A pericardial flap can protect and enhance the use of the left internal mammary artery. The left free edge of the pericardium is sutured to the anterior chest wall, which protects the left internal mammary artery graft from lung encroachment and provides a more direct course. In our large experience, including several reoperations, no internal mammary artery was injured.     

Should the supplemental vein graft be anastomosed upstream or downstream of the internal thoracic artery (ITA) for ITA hypoperfusion?

BACKGROUND: This study was designed to compare internal thoracic artery (ITA) flow in different settings of supplemental vein grafting for ITA hypoperfusion. METHODS: Fourteen dogs each received two coronary bypass grafts to the circumflex artery (CFX), using left ITA and vein grafts, and then the proximal CFX was ligated. The animals were divided into two groups. G-I dogs receiving the vein graft proximally to the ITA graft and G-II receiving the vein distally. ITA flow was evaluated regarding 1) effects of competition from the vein graft, and 2) pharmacological or physiological effects on the ITA's contribution to distal perfusion. Flow is expressed as a mean (ml/min). RESULTS: ITA flow was 44.2+/-5.9 in G-I, and 45.7+/-6.5 in G-II (p=ns), when the vein graft was occluded. With a vein graft open, ITA flow decreased to 7.5+/-1.6 in G-I, and 6.8+/-1.8 in G-II (p=ns), and ITA's contribution to total perfusion requirements was 18% in G-I and 16% in G-II. Adenosine (0.2 mg/min/kg) increased the ITA flow in both groups, 18.4+/-3.2, and 16.3+/-3.8, respectively (p=ns), and ITA's contribution to distal perfusion was increased to 32% in G-I and 27% in G-II. In contrast, phenylephrine (0.003 mg/min/kg) decreased ITA flow and ITA's contribution to distal flow in both groups (6.1+/-1.1, 11% vs 6.2+/-1.4, 11%, p=ns), but increased vein flow significantly. Cardiac pacing (150 bpm) increased the ITA flow and ITA's contribution to distal perfusion equally in both groups (8.4+/-1.5, 16% vs 7.6+/-2.6, 15%, p=ns). CONCLUSIONS: Supplemental vein grafting, whether it is placed distally or proximally, limits ITA flow and ITA's contribution to distal perfusion both in the resting heart and during the increased myocardial oxygen demand.     

Partial left pericardial defect with herniation of the left atrial appendage

A case is reported of herniation of the left atrial appendage through a partial pericardial defect, probably congenital. The diagnosis was suggested by the history of chest pain and bulging of the middle segment of the left heart border on the plain chest film, without other signs. Angiography revealed a dilated left atrial appendage. An artificial left pneumothorax confirmed the presence of a pleuropericardial defect. The surgical procedure included excision of the appendage and closure of the defect.     

Tension-free open mesh repair of ventral hernias--Stoppa's technique

Tension-free prosthetic mesh repair of giant, complex, or recurrent ventral hernias in the form of a modified Stoppa technique has been used in 60 cases. Complication rate has been comparable with other such studies. In obese patients with a pendulous anterior abdominal wall, limited panniculectomy was carried out while repairing the hernia through a low transverse abdominal incision. None of the patients required a progressive preoperative pneumoperitoneum. The incidence of wound infection was 5%. One patient had a wound hematoma that required evacuation; minor wound complications occurred in 11% cases. The hospital stay ranged from 1 to 6 weeks (mean, 10.3 days). One case required readmission for resuturing of the wound. None of the cases required removal of the mesh. There was no recurrence at follow-up (mean, 26 months) in 80% of the cases. This technique is an excellent but somewhat tedious procedure.     

Optimal length of pericardial strip for posterior mitral overreductive annuloplasty

Our recent experience with an autologous pericardium strip to obtain an overreducing posterior mitral annuloplasty is reported. From March 2001 to May 2002, 31 patients underwent this procedure to correct functional (n = 19) or postischemic (n = 12) mitral regurgitation. The length of the pericardium strip was always 4 cm; mean final mitral area was 2.9 cm², with a mean gradient of 2.9 mm Hg. Eight patients underwent a stress test. Mitral area increased from 3.1 to 3.6 cm², and the mean gradient increased from 3.1 to 5.2 mm Hg. Residual mitral regurgitation was 0.5 and, when present, remained unchanged at the end of the stress. Overreducing posterior mitral annuloplasty by using a 4-cm pericardial strip gives reproducible results and is effective in correcting functional or postischemic mitral regurgitation. Residual mitral regurgitation, when present, remains stable after stress.     

Eyelash reconstruction with strip composite eyebrow graft

Eyelash hairs have certain unique properties such as parallel direction, limited length, and tapering, which makes eyelash reconstruction considerably difficult. Several methods for eyelash reconstruction have been reported. Among them, strip composite eyebrow graft is the most suitable because the properties of eyebrow hairs are very similar to those of the original eyelash hairs. A rich blood supply in the eyelid ensures a good survival of the graft. Careful selection of the donor strip harvesting site is critical for preserving a good direction of hairs. The thickness of the graft strip should be determined considering the optimal thickness of hairs being obtained. When suturing the graft strip to the recipient bed, the burying method is suitable for preventing the protrusion of the graft. A well-performed surgical procedure results in a postoperative outcome that closely resembles the natural eyelashes.     

Closed mitral commissurotomy following pericardial strip posterior mitral annuloplasty.

We report a case of rheumatic multivalvular heart disease for whom closed mitral commissurotomy (CMC) was done four years after pericardial strip posterior mitral annuloplasty and aortic valve replacement (AVR). An 18-year-old male who presented initially with rheumatic mitral regurgitation and aortic regurgitation was treated with AVR and pericardial strip posterior mitral annuloplasty in 1997. One year postoperatively he presented with moderate to severe mitral regurgitation. On further follow-up, the patient developed mitral stenosis and as a redo procedure, CMC has been successfully done for the same.     

Comparison of the in vitro isolated strip methodology with the superfused strip technique

There are several methodologies available for determining the contractile effects of specific agents on isolated smooth muscle. The standard isolated bath technique utilizes strips mounted in a physiological buffer. The agent under study is added to the buffer and the response is recorded on a polygraph. The superfused strip technique utilizes strips in which buffer is pumped over the strip at relatively low flow rates. The agent under investigation is either infused into the stream of buffer bathing the tissue strip or administered directly onto the tissue. We have compared the response of these two methodologies using isolated strips of rabbit urinary bladder body. Isolated strips of rabbit urinary bladder were mounted in standard isolated baths containing 30 ml Tyrode's solution. The response of these strips to the autonomic agonists bethanechol, ATP, and isoproterenol were determined via cumulative addition at 5-minute intervals. Similar strips were mounted as above, after equilibration, the Tyrode's was drained, and fresh oxygenated Tyrode's was pumped over the strip at a rate of 4 ml per minute. Flow was stopped and drugs were administered directly onto the tissue in 100-μl aliquots. After either maximal response or 2 minutes, flow was resumed. Drugs were added at 10-minute intervals. The results can be summarized as follows: 1) The superfused bladder strips responded to 100-fold lower amounts of autonomic agonist than the strips in the isolated bath. 2) The maximum response to ATP (an agent that produces rapid desensitization) was threefold greater in the superfused model than in the bladder bath, and the rate of response of the tissues in the superfused system was significantly greater than in the isolated baths. In summary, the superfused isolated bladder preparation is an excellent methodology to use in specific investigations.     

Application of pericardial graft in the surgical management of Peyronie's disease

PURPOSE: We investigated the use of Tutoplast cadaveric pericardium as an alternative material for grafting the tunica albuginea defect after Peyronie's plaque excision. MATERIALS AND METHODS: A total of 11 patients with significant penile curvature interfering with sexual intercourse were evaluated after at least 12 months of conservative therapy. Preoperative evaluation in all cases included penile duplex Doppler ultrasound studies. Chemically processed and gamma irradiated pericardium was used to graft the cavernosal defect after surgical excision of the penile plaque. In 3 patients a penile prosthesis was simultaneously placed secondary to documented erectile dysfunction at duplex Doppler ultrasound evaluation. RESULTS: Penile curvature resolved in all patients, allowing for normal sexual function after a mean followup of 14 months (range 9 to 19). No postoperative evidence of tissue rejection or infection was noted. In 1 patient urethro-corporal communication developed and a single penile cylinder was explanted. Another patient had a mild dorsal bulge at the site of graft placement when the prosthesis was fully inflated. CONCLUSIONS: Polymeric silicone material used to provide satisfactory results in the surgical treatment of Peyronie's disease but it is no longer available for biomedical use. We demonstrate the effective use of cadaveric pericardium as a graft material for cavernosal defects after Peyronie's plaque excision. Overall patient satisfaction, absence of a second surgical incision, relative low risk and ease of surgical placement make this material ideal for the surgical treatment of this disease process.     

A simple technique for tension-free pericardial closure

Closure of the pericardium after cardiac operations is desirable but is not always possible to achieve. We describe here a simple technique for tension-free, anterior closure of the pericardium.     

Equine pericardial roll graft replacement of infected pseudoaneurysm of the ascending aorta

ABSTRACT: The standard procedure for treating infected aortic aneurysms is to resect the infected aorta, debridement of the surrounding tissue, in situ graft replacement, and omentopexy. However, the question of which graft material is optimal is still a matter of controversy. We recently treated a patient with an infected ascending aortic aneurysm. Because of previous abdominal surgery, the omentum was unavailable. The ascending aorta was replaced in situ with equine pericardial roll grafts. The patient is alive and well 29 months after the operation.     

Localized tamponade on the left ventricle by a tuberculous pericardial abscess

The infrequent entity of a tubercular abscess causing localized tamponade on the left ventricle is reported. The imaging findings of tuberculous pericarditis including pericardial abscess are discussed.