Major iatrogenic tracheal injury during pneumonectomy: conservative treatment

Anomalous origin of the left main coronary from the pulmonary trunk in an elderly patient is extremely rare. We report a 73-year-old woman who presented with new onset of angina and atrial fibrillation. Evaluation revealed anomalous origin of the left main coronary artery from the main pulmonary artery and tight proximal left anterior descending coronary artery stenosis. The patient underwent primary closure of the anomalous left main coronary artery orifice within the pulmonary artery, aorta-to-left anterior descending coronary artery saphenous vein bypass grafting and Maze procedure. Six months postoperatively the patient was asymptomatic and a Thallium stress test was negative for ischemia.     

Anomalous left coronary artery from pulmonary artery with mitral stenosis

The usual presentation of anomalous left coronary artery from pulmonary artery is severe left-sided heart failure and mitral valve insufficiency presenting during the first months of life. The manifestations of left heart failure may be masked if pulmonary artery pressure remains high. We believe this is a rarest of rare case of anomalous left coronary artery from pulmonary artery with severe mitral stenosis and pulmonary hypertension in which pulmonary hypertension, along with good collateral circulation helped to preserve left ventricular function.     

Aortopulmonary window and anomalous coronary artery: an exceptional association

Aortopulmonary window is rarely associated with other cardiac anomalies, such as anomalous origin of one coronary artery. This exceptional association has been reported in 15 patients, with different surgical solutions. We describe 2 patients with aortopulmonary window with anomalous origin of the right coronary artery, one of which presented with tetralogy of Fallot-pulmonary atresia. A neonatal modified Blalock-Taussig shunt and ligature of the distal pulmonary artery at the level of pulmonary bifurcation was performed in the first patient, and the second patient underwent aortopulmonary window division with anomalous coronary artery reimplantation. Both patients had an uneventful postoperative course.     

Multiple schwannomas of the bilateral mediastinal vagus nerves

Multiple schwannomas arising from the mediastinal vagus nerve are very rare, but herein we report a case with such lesions involving the bilateral intrathoracic vagus nerves. A 43-year-old man presented with multiple mediastinal tumors during a check-up. A chest computed tomographic scan revealed multiple lesions that appeared strung together like beads along the right vagus nerve. Three small tumors were also evident on the left side of the esophagus. We performed a complete resection of the bilateral mediastinal tumors through right thoracoscopic surgery. The pathologic diagnosis for each of these tumors was a schwannoma without malignant components.     

Functional total anomalous pulmonary venous drainage by left atrium-to-superior vena cava shunt

Total anomalous pulmonary venous connection is occasionally associated with a functional single ventricle and is thought to be a risk for the staged Fontan approach. We report a patient with a very rare presentation of mitral atresia and intact atrial septum with physiologically total anomalous pulmonary venous drainage by a connecting vein between the left atrium and the superior vena cava. A surgical atrioseptectomy as a functional repair of total anomalous pulmonary venous connection and pulmonary artery banding was successfully performed as the first palliation for Fontan completion.     

Myocardial ischemia caused by an abnormal origin and course of the left coronary artery in an adult

An anomalous course of the left anterior descending artery is a rare but potentially fatal condition. We herein describe the treatment and management of a patient who was diagnosed with this ailment.     

Modified T-shaped left atrium incision in the bi-atrial approach for infracardiac type TAPVR repair

The bi-atrial approach "in-situ" technique of vertical confluence to the left atrial repair avoids the risks of anastomosis site kinking and twisting for infracardiac-type total anomalous pulmonary venous connection reconstruction, but how to obtain the adequate left atrial orifice size is an important issue. Herein, we describe our vertical confluence vein flap with the modified T-shaped left atrium incision technique in managing those patients with infracardiac type total anomalous primary venous reconstruction.     

A rare case of partial anomalous pulmonary venous return to azygos vein without direct connection to great cardiac vessels

A 17-year-old girl visited our hospital for an operation to correct a partial anomalous pulmonary venous return. All the right-side pulmonary veins returned to the azygos vein, which had no connection to the cardiac chamber through the great venous system, such as the superior or inferior vena cava. The azygos vein lacked a normal azygos arch and was connected by multiple connections only to the paravertebral plexus. For the surgical correction, a pericardiostomy was created in the right posterior pericardial wall and azygos vein which was divided at the diaphragm level and was anastomosed to the left atriotomy area through the pericardiostomy site.     

Partial anomalous pulmonary venous connection to the superior vena cava

We describe the surgical technique of reimplantation of the right superior pulmonary vein into the left atrium in 2 patients with partial anomalous pulmonary venous connection to the superior vena cava without atrial septal defect. A right axillary minithoracotomy is done through the fourth intercostal space. The pulmonary vein is detached from its origin in the superior vena cava. This is sutured with 6-0 reabsorbable polydioxanone suture (Ethicon, Somerville, NJ). A lateral clamp is applied to the left atrium, and the pulmonary vein is reimplanted. The patient is extubated in the operating room. Neither cardiopulmonary bypass nor blood transfusion was required. It is simple, safe, and reproducible.     

Congenital aortopulmonary artery fistulas combined with bilateral coronary artery fistulas

We describe an extremely rare case of "congenital aorto-pulmonary artery fistulas" combined with bilateral coronary artery fistulas associated with clinically significant left-to-right shunt. A multi-detector row computed tomographic scan revealed that tortuous anomalous vessels arising from the aortic arch, left anterior descending coronary artery, diagonal branch, and right coronary artery were connected to the main pulmonary trunk. After surgical intervention, the systemic-to-pulmonary flow ratio nearly normalized from 2.02 to 1.05. We describe the case and speculate as to the embryological pathogenesis of these unique fistulas.     

Right aortic arch with left lung cancer: focusing on left recurrent laryngeal nerve

We report a case of a 64-year-old Japanese man with an anomalous right aortic arch who had left lung cancer. We performed lobectomy and mediastinal lymphadenectomy, paying attention to the pathway of left recurrent laryngeal nerve. The left recurrent laryngeal nerve hooked around from the left dorsal to the right ventral part of the left ductus arteriosus, which connected the left pulmonary artery with the aortic diverticulum.     

Right superior vena cava draining in the left atrium: anatomical, embryological, and surgical considerations

A newborn, with SDS (S = situs viscero-atrialis solitus, D = D-loop of the ventricles, S = solitus, normally related great arteries) anomalous drainage of the right superior vena cava in the left atrium, intact atrial septum, and anomalous drainage of the right superior pulmonary veins in the right superior vena cava, underwent surgical repair at our institution. This rare cyanotic, congenital, cardiac malformation is herein described with particular regard to its anatomical, embryological, and surgical implications.     

High anomalous origin of both coronary arteries in a patient with aortic valve disease

High anomalous origin of both coronary arteries is extremely rare. We report the case of a patient with a right coronary artery that originated from the left surface of the ascending aorta approximately 25 mm above the sinotubular junction and a left coronary artery that originated from the sinotubular junction close to the non-left commissure. The patient also had persistent left superior vena cava. We diagnosed the anomaly preoperatively using 64-slice multidetector computed tomographic angiography. The detailed imaging information helped us to avoid coronary artery injury and perform the operation safely with adequate myocardial protection.     

Left ventricular rupture during off-pump coronary artery bypass grafting

Left ventricular rupture is a highly lethal, but rare, complication of myocardial infarction. We report the first case of a postinfarction, intraoperative left ventricular apical rupture during an off-pump coronary artery bypass grafting due to the application of apical suction used to expose target vessels.     

Staged hybrid left pulmonary artery rehabilitation in post-fontan left pulmonary artery hypoplasia

Left pulmonary artery hypoplasia in the setting of Fontan circulation predisposes to pulmonary artery discontinuity. We describe a novel approach to correct post-Fontan left pulmonary artery discontinuity by a strategy to produce isolated left pulmonary artery growth, followed by a catheter-based reincorporation of the left pulmonary artery into the Fontan circuit.     

Mixed-type total anomalous pulmonary venous connection in an adult

Cardiac plus infracardiac mixed-type total anomalous pulmonary venous connection is an extremely rare congenital heart disease. We describe a case in which the pulmonary veins made a confluence and connected to a vertical vein running into the inferior vena cava by the way of the hepatic vein. Surgical correction was successfully obtained by deroofing the coronary sinus and using the pericardial patch to reconstruct the interatrial septum. The patient showed no signs of any complication at her 5-month follow-up.     

Pyloroplasty divides vagus nerve fibers to the greater curvature of the stomach. An axonal tracing study.

Recent studies have demonstrated the location in the dorsal motor nucleus of the vagus nerve (dmnX) of nerve cells that project preganglionic efferent vagus nerve fibers to the greater curvature of the stomach. Although it is clear that these fibers are contained within the vagus nerve trunks, the intra-abdominal pathways of these fibers are unknown. When a neurotracer was applied to the right gastroepiploic pedicle, nerve cells in the bilateral dmnX were labeled. If a preliminary anterior or posterior pyloroplasty was performed before the application of the neurotracer, cellular labeling was seen on the right or left side of the dmnX, respectively. Furthermore, division of the anterior Latarjet nerve eliminated labeling in cells of the left dmnX. This study demonstrates that the preganglionic vagus nerve fibers within the right gastroepiploic pedicle traverse an intramural course across the pylorus and are contained in the Latarjet nerve.     

Posterior reduction aortoplasty for left pulmonary artery compression after Norwood procedure

All patients following the Norwood I procedure have a very large ascending aorta. This can lead to extrinsic compression of the surrounding vessels. We report a case of left pulmonary artery compression secondary to an aneurysmal neo-aorta and describe a technique of posterior reduction aortoplasty to decompress the left pulmonary artery.     

Preserving the pulmonary vagus nerve branches during thoracoscopic esophagectomy

Background

Pulmonary vagus branches are transected as part of a transthoracic esophagectomy and lymphadenectomy for cancer. This may contribute to the development of postoperative pulmonary complications. Studies in which sparing of the pulmonary vagus nerve branches during thoracoscopic esophagectomy is investigated are lacking. Therefore, this study aimed to determine the feasibility and pitfalls of sparing pulmonary vagus nerve branches during thoracoscopic esophagectomy.

Methods

In 10 human cadavers, a thoracoscopic esophagectomy was performed while sparing the pulmonary vagus nerve branches. The number of intact nerve branches, their distribution over the lung lobes and the number and location of the remaining lymph nodes in the relevant esophageal lymph node stations (7, 10R and 10L) were recorded during microscopic dissection.

Results

A median of 9 (range 5–16) right pulmonary vagus nerve branches were spared, of which 4 (0–12) coursed to the right middle/inferior lung lobe. On the left side, 10 (3–12) vagus nerve branches were spared, of which 4 (2–10) coursed to the inferior lobe. In 8 cases, lymph nodes were left behind, at stations 10R and 10L while sparing the vagus nerve branches. Lymph nodes at station 7 were always removed.

Conclusions

Sparing of pulmonary vagus nerve branches during thoracoscopic esophagectomy is feasible. Extra care should be given to the dissection of peribronchial lymph nodes, station 10R and 10L.

     

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.