Direct Suture Closure Research Articles

P406 LAUBRY–PEZZI SYNDROME: EVERYTHING IS NOT AS IT SEEMS

Abstract Introduction Laubry–Pezzi syndrome is a congenital heart disease characterized by the prolapse of an aortic valve cusp into a subjacent ventricular septal defect (VSD), mostly supracristal, leading to severe aortic regurgitation (AR). It has been reported nearly always in childhood, the Venturi effect is the predominant factor and onset symptoms may be variable. Case Report A 61–years–old male was admitted to our intensive case unit for chest pain radiated to interscapular region and exertional dyspnea. Hemodynamic parameters were normal. At ECG sinus rytm with heart rate 92 bpm and non–specific repolarization abnomalities were reported. Hs troponin I was 276 ng/L, myoglobin 30.2 ng/mL and BNP 325 pg/mL. Transthoracic echocardiography showed a dilated left ventricle (LV EDV 107 mL/m2) with normal ejection fraction (55%), severe AR without aortic root dilation and a suspicious shunt left to right at level of interventricular septum. Therefore, transesophageal echocardiography was performed and confirmed severe AR by probable bicuspid valve and right cusp prolapse, in absence of calcifications and/or vegetations by endocarditis, restrictive perimembranous VSD (maximum diameter 0.6 cm) and ostium secundum ASD with shunt L–R. Right chambers were not dilated and non invasive systolic pulmonary artery pressure was 43 mmHg. Coronary angiography was performed and showed a significant stenosis of distal left anterior descending (LAD) artery and of proximal circumflex artery. Right heart catetherization excluded significant high values of pulmonary pressures (mPAP=18 mmHg), of pulmonary capillary wedge pressure (9 mmHg), with a mild increase of pulmonary vascular resistances (1.16 HRU; nv < 96). Coronary artery bypass grafting (left internal mammary artery on LAD and Y–graft radial artery on obtuse marginal artery), aortic valve replacement with bioprothesis (Inspiris Resilia 23 mm), ASD closure by direct suture and VSD closure with pericardial patch were performed. No post–surgical complications were reported. Interestingly, during the replacement of aortic valve, it resulted tricuspid, confirming the suspicion of Laubry Pezzi syndrome. Conclusions our case was object of great debate because restrictive VSD and severe AR were not previously known, were diagnosed in middle age and until then paucisymptomatic. Laubry–Pezzi syndrome is a very rare disease that may explain controversial cases of severe AR.

Dural Tear During Thoracic Laminectomy Using Craniotome With Footplate Attachment.

Laminectomy can be accomplished using the craniotome with a footplate attachment, and the technique has been advanced as a superior alternative to using a high-speed drill-driven burr and Kerrison rongeurs. Laminectomy can be accomplished more rapidly and with less bone destruction, an advantage when planning laminoplasty. There is, however, scant literature describing complications of dural laceration using this technique. A 48-year-old male underwent T7-10 laminectomy for resection of an intramedullary spinal cord tumor. During the upward cut of the hemi-lamina at T7-9, a dural laceration occurred that proved not amenable to direct suture closure. The dural was closed with a dural patch placed along the inner surface of the dura and a fat graft on the outer surface with adjunctive use of a lumbar drain. While the footplate laminectomy technique has merits touted in prior publications, including the ability to open the spinal canal quickly at numerous levels and an enhanced ability to achieve an osteoplastic laminoplasty, surgeons should be cognizant of the risk of associated dural laceration. We believe that it is important to emphasize that the initial placement of the lip of the footplate must be well-seated under the inferior aspect of the lowest lamina and over the ligamentum flavum and that the footplate should not be directed beyond the border of the laminae and facet, as this can result in dura and root injury.

Pericardial cyst: revisited

Pericardial cysts are rare mediastinal abnormalities, which are usually congenital but may also be acquired after cardiothoracic surgery. Pericardial cysts are most commonly located at the cardiophrenic angle or, rarely, in the posterior or anterior superior mediastinum. The majority of pericardial cysts are asymptomatic and are found incidentally on imaging studies. Our case was an 18-year-old female with a diagnosis of ostium secundum atrial septal defect (ASD). She was planned for surgical closure of ASD. On the opening of the pericardium, a pericardial cyst of around 3.0×2.0-cm size, filled with clear fluid, was found in the aorta–pulmonary artery groove. Marsupialization of the cyst was done followed by routine direct suture closure of ASD. Postoperative recovery was uneventful, and the patient was discharged on the third postoperative day. Histopathology of tissue confirmed our diagnosis. Our aim to present this case report is to show an incidental finding of the pericardial cyst at a rare location and to discuss its perioperative implications.

Segmental excision of congenital melanocytic nevus by multiple incisions

Direct appositional suture closure after total resection of a large congenital pigmented nevus can result in a dog-ear deformity. Alternatively, serial, staged, sequential excisions can be used, but the process is both time consuming and tedious. Avoiding a long scar and obviating the need for repeated operations remain important goals.

Association of PAX3 and TMTC2 gene polymorphism with the face morphology change after excision of skin tumors

Background/Aim. The group of genes, known as PAX (paired box), has a great role in organogenesis, as well as in maintaining the normal function of certain cells after the birth. In addition to these genes, the impact on the organogenesis, at the cellular level, has a transmembrane tetratricopeptid group of genes (TMTC). The term polymorphism in the human genome implies variations in the hereditary basis that occur in human populations, the presence of two or more different alleles of one genome in the population. The aim of the work was to determine whether there is an association of PAX3 and TMTC2 genes polymorphism with changes of the face morphology after skin tumor excision and direct suture closure. Methods. The study included 130 patients of both sexes, older than 50 years, with the medical indication for the elliptical surgical excision of the skin tumor. DNA was isolated from 5 mL of peripheral blood. Gene polymorphisms were analyzed with pre-designed single nucleotide polymorphisms (SNP) assays, by allelic discrimination method on REAL-TIME apparatus. The patients were subjected to a laser scanning preoperatively, and 7 and 90 days postoperatively, in order to obtain x, y and z coordinates of 5 cephalometric points on the face, which determined the shape of the medial cheek region. The shape of the medial cheek region, as well as the coordinates of 5 cepahlometric points, were compared among genotypes of both genes preoperatively, as well as 7 days and 90 days postoperatively. Results. A statistically significant difference in the shape of the medial cheek region between wildtype and mutant of PAX3 gene was found preoperatively, while the statistically significant difference in the shape of the medial cheek region was not found between wild-type and heterozygote, nor between wild-type and heterozygote and mutant of PAX3 gene, nor among genotypes of TMTC2 gene. Seven days and 90 days postoperatively, there were no statistically significant differences in the shape of the examined region among genotypes of both genes. Conclusion. Polymorphisms of PAX3 and TMTC2 genes are not associated with the change in the face morphology after the skin tumor excision and direct suture closure of the defect.

Application of self-made chronic wound closure device in the repair of scarred lower extremity wounds

To investigate the effectiveness of self-made limb chronic wound closure device in the treatment of scarred lower limbs and complex skin and soft tissue defects. Between January 2014 and January 2017, 29 patients with complex fractures of the lower extremities and skin and soft tissue defects were treated. There were 19 males and 10 females with an average age of 31.1 years (range, 21-66 years). The causes of injury included 14 cases of traffic accidents, 5 cases of falling from height, 4 cases of heavy object crushing injury, 4 cases of mechanical crushing injury, and 2 cases of exposed steel plate after fracture. There were 26 cases of calf fracture and skin defect, 3 cases of metatarsal bone fracture and skin defect of the foot. The skin defect ranged from 5 cm×3 cm to 18 cm×8 cm. The time from injury to admission was 5-31 days, with an average of 14.3 days. All patients underwent a thorough debridement, open wound drainage, self-made chronic wound closure device combined with Ilizarov stretching technique for a slow skin and soft tissue traction. After the wound was cleaned up and the granulation tissue was freshened, the skins on both sides were closed, and then proceed to the second stage operation of skin grafting or direct suture closure based on the size of the wound. All patients were followed up 8-20 months, with an average of 13 months. Twenty-nine patients were treated with self-made chronic wound closure device combined with Ilizarov technique for 1-2 times with an average of 1.3 times, then the wound infection was controlled and the granulation tissue grew well. In the course of treatment, the pain was not obvious and the patients had good compliance. All patients' wounds healed clinically without skin traction complications and formed linear or flaky scars. The self-made chronic wound closure device is effective in repairing complex scarred wounds of lower extremities, and it is easy to operate.

Is Surgery after Chemoradiotherapy Feasible in Lung Cancer Patients with Superior Vena Cava Invasion?

Purpose: The purpose of this study is to explore the possibility of surgery after chemoradiotherapy (CRT) for locally advanced-non-small-cell lung cancer (LA-NSCLC) with superior vena cava (SVC) resection in terms of prognosis and early and late postoperative course.Methods: The medical records of NSCLC patients who underwent surgery after CRT at our institution between January 2001 and March 2016 were reviewed. We evaluated the feasibility of surgery with SVC resection after CRT.Results: A total of 8 LA-NSCLC patients were enrolled in this study. The SVC management included a graft replacement in two patients, pericardial patch repair in two, and direct suture closure in four. A complete resection was achieved in seven of the eight patients (87.5%). Postoperative early and late complication rate (Clavien-Dindo classification ≥ grade III) was 25%. All the complications were manageable, and no treatment-related deaths occurred in this series. Although seven out of eight patients showed good patency of reconstructed SVC, one patient exhibited the SVC occlusion during long-term follow-up period. Regarding the prognosis, the 5-year overall survival (OS) rate was 60.0%, and the 2-year recurrence-free survival (RFS) rate was 75.0%.Conclusion: Our results suggest that surgery with SVC resection after CRT is a feasible procedure in terms of clinical outcomes and postoperative course.

The Mid-term Results of Thoracoscopic Closure of Atrial Septal Defects.

Background and ObjectivesRecently, minimally invasive surgical (MIS) techniques including robot-assisted operations have been widely applied in cardiac surgery. The thoracoscopic technique is a favorable MIS option for patients with atrial septal defects (ASDs). Accordingly, we report the mid-term results of thoracoscopic ASD closure without robotic assistance.Subjects and MethodsWe included 66 patients who underwent thoracoscopic ASD closure between June 2006 and July 2014. Mean age was 27±9 years. The mean size of the ASD was 25.9±6.3 mm. Eleven patients (16.7%) had greater than mild tricuspid regurgitation (TR). The TR pressure gradient was 32.4±8.6 mmHg.ResultsFifty-two (78.8%) patients underwent closure with a pericardial patch and 14 (21.2%) underwent direct suture closure. Concomitant procedures included tricuspid valve repair in 8 patients (12.1%), mitral valve repair in 4 patients (6.1%), and right isthmus block in 1 patient (1.5%). The mean length of the right thoracotomy incision was 4.5±0.9 cm. The mean cardiopulmonary bypass time was 159±43 minutes, and the mean aortic cross clamp time was 79±29 minutes. The mean hospital stay lasted 6.1±2.6 days. There were no early deaths. There were 2 reoperations. One was due to ASD patch detachment and the other was due to residual mitral regurgitation after concomitant mitral valve repair. However, there have been no reoperations since July 2010. There were 2 pneumothoraxes requiring chest tube re-insertion. There was one wound dehiscence in an endoscopic port. The mean follow-up duration was 33±31 months. There were no deaths, residual shunts, or reoperations during follow-up.ConclusionThoracoscopic ASD closure without robotic assistance is feasible, suggesting that this method is a reliable MIS option for patients with ASDs.

Intra-Atrial Excision of the Left Atrial Appendage: A Simple and Easy Technique

In patients with atrial fibrillation, closure of the left atrial appendage (LAA) is recommended to prevent thromboembolic events, however, conventional exclusion or excision techniques have potential drawbacks such as persistent blood flow into the appendage and a residual stump. We propose a simple and easy technique for LAA closure consisting of intra-atrial excision of the LAA, which is invaginated into the left atrium (LA), and direct suture closure of the orifice from inside the LA. In this technique, complete elimination of the LAA was achieved without leaving a residual stump because the LAA was excised at the orifice and was closed at the base of the LAA.

Surgery for sinus of Valsalva aneurysm: 33-year of a single center experience

Background Sinus of Valsalva aneurysm (SVA) is a rare anomaly and few large or long-term series are well established. This study was designed to review 33-year surgical experience of SVA in one center. Methods From August 1980 to December 2013, patients with SVA underwent surgical repair were retrospectively studied. Results A total of 160 patients were identified with mean age of (30±12) years and 112 (70%) of them were males. The right coronary sinus origin of SVA was found in 108 patients (67.5%), the non-coronary sinus in 51 patients (31.9%), and the left coronary sinus in one patient (0.6%). The rupture of SVA into the right ventricle was identified in 89 (55.6%) cases, the right atrium in 61 (38.1%), the left ventricle in 2 (1.3%) and no rupture in 8 (5.0%). Ventricular septal defect (VSD) and aortic regurgitation (AR) were found in 59 (37%) and 45 (28%) patients respectively. An approach via the involved chamber was used in 86 patients (54%), aortotomy in 8 (5%), and a combined approach in 66 (41%). Either direct suture (56, 35%) or patch (104, 65%) closure were used to repair the SVA. The VSD was closed with a patch (44/59, 75%) or direct suture (15/59, 25%). aortic valve replacement (AVR) was performed in 23/45 (51%) and aortic valvuloplasty (AVP) in 9/45 (20%) patients combined with AR. There were 3 hospital deaths (1.9%) and 2 late deaths and 84% of the patients were followed up for (17.6±4.2) years. New York Heart Association functional class improved significantly after surgery (P < 0.01). Actuarial survival was 94% at 10 years, and 88% at 20 years. Conclusions Surgical treatment of SVA is safe and effective, ruptured SVA or unruptured SVA with VSD and/or AR should be repaired surgically as early as possible. However, late progressive AR is still a risk during long-term follow-up, and early aggressive measures are recommended. These include more use of a combined approach to achieve optimal evaluation of lesions, more patch repairs to reduce the chance of recurrence, and more AVR in patients with moderate to severe AR.

気管支―死腔瘻を伴う肺アスペルギローマに対する手術工夫：菌球除去後の気管支瘻孔閉鎖

気管支―死腔瘻を伴う肺アスペルギローマに対する手術工夫：菌球除去後の気管支瘻孔閉鎖

Isthmus-dependent right atrial flutter as the leading cause of atrial tachycardias after surgical atrial septal defect repair

The purpose of this study was to evaluate clinical and electrophysiologic characteristics of AT in patients after surgical ASD repair as well as outcome after ablation. Atrial tachycardias (AT) are a common complication after surgical closure of an atrial septal defect (ASD). From a prospective ablation database we analyzed data of patients with a history of ASD repair who presented to our institution for AT ablation. We investigated ECG characteristics and the electrophysiologic mechanism of AT in this collective and analyzed follow-up data. Data of 54 patients (47.3 ± 14.5 years, 35 females) were included. In 30 patients (55.6%) ASD had been closed by direct suture, 24 patients (44.4%) had a patch for ASD repair without significant difference in terms of gender and age at the time of the procedure (p=0.234, p=0.231). In 42 patients (77.8%), electrophysiological studies were performed in AT. All patients had right atrial macro-reentrant AT. The leading mechanism was isthmus-dependent right atrial flutter in 29 patients (69.0%) with clockwise atrial activation in 41%. The mechanism of AT (typical atrial flutter (n=29), atriotomy-dependent flutter (n=7), and double loop flutter (n=5)) did not differ with regard to type of surgery. Only 70.6% of patients with proven isthmus dependent counter-clockwise atrial flutter presented with an ECG morphology typical for this mechanism. However, all clockwise typical atrial flutter patients showed the characteristic positive P-waves in the inferior leads. Of note, 83.3% of clockwise typical flutter ECGs had long isoelectric lines (mean 74.5 ms). Follow-up was complete in 45 of 54 patients. During a mean follow-up of 7.7 ± 3.7 years, 27 patients (60%) remained free of any arrhythmia, two patients had AT recurrence with different mechanisms compared to the first procedure and underwent successful ablation. Five patients (11%) developed atrial fibrillation. Isthmus dependent right atrial flutter is the leading AT mechanism in patients with a history of ASD repair. The mechanism of atrial flutter did not differ in relation to the mode of ASD closure (direct suture versus patch closure). ECG characteristics of the tachycardia may be misleading as they are more often atypical in patients after ASD repair.

Preliminary results of direct closure of an atrioventricular septal defect: revisiting the original technique

Background: This study aims to assess the preliminary results of direct closure of atrioventricular septal defect (AVSD). Methods: Thirteen patients (complete type n=7, partial type n=6) who underwent AVSDs correction with direct closure technique in our department between September 2009 and June 2011 were included. Two patients with concomitant pulmonary stenosis were managed in a single session. For direct suture closure of ventricular septal defect (VSD), multiple interrupted Teflon pledgets sutures were placed on the right side of the interventricular septal crest and then they were passed through the bridging leaflets of the common valve. For direct closure of primum atrial septal defect (ASD) in patients with complete type VSD closure sutures were used by passing through the remnant of interatrial septum and tied off. Results: The median age of the patients was 13 months. The median age (7.5 months) and weight (4.3 kg) of the patients with complete type was lower. The mean VSD size was 30.4±10 mm/m2. The mean cardiopulmonary bypass and ischemic cross clamp times were 51.3±11.2 min and 34.7±10.9 min, respectively. There was no in-hospital mortality. All patients were discharged with sinus rhythm and less than (2+) atrioventricular valve regurgitation. All the patients were followed. The mean follow-up was 12.1±4.1 months. Repeated echocardiograms did not revealed any progressive atrioventricular valve dysfunction or left ventricular outflow tract gradient. Conclusion: Direct closure technique for repair of atrioventricular septal defect is rapid and simple surgery for the management of this complex pathology. This easily reproducible technique could also encourage and facilliate earlier repair of this pathology, preventing potential technical challenges.

Excision or exclusion of left atrial appendage?

Stroke is one of the leading causes of mortality and morbidity today. In the majority of the cases, stroke results from cardiac emboli predominantly in patients with atrial fibrillation. Theoretically, the most likely site for generation of thrombus formations as a prerequisite for emboli and stroke is the left atrial appendage (LAA). Here, the three characteristics of Virchow's triad are realized, especially flow abnormalities, besides those of the vessel wall and constituents in blood [1]. Therefore, it makes theoretical sense to exclude the LAA in order to prevent stroke as recommended in the ACC/AHA Guidelines [2] during mitral valve surgery and MAZE procedures, although some authors argue that LAA exclusion is not the whole story [3] of stroke prevention and that strokes occur also after LAA occlusion, related to unsuccessful exclusion [4] or other sources. In this issue, Hernandez-Estefania report on a special technique for LAA occlusion including invagination and double-suture technique [5]. A purse-string suture is used to delineate the rim of the orifice which is facilitated by the invagination of the LAA. Although this might help to better define the borders of the os of the LAA, a clearly defined ridge is not present at the anterior and inferior borders of the LAA os [6]. Furthermore, the rim of the os is smooth [6]. Thus, there may be few firm tissues to anchor securely the sutures for occlusion. In addition, the oval area of the os is tugged together by the sutures, potentially creating tension forces in the tissue tending to reset the oval shape of the os. These are the factors that might cause some kind of re-opening of the LAA orifice years after the operation [4]. Whether this occurs with the proposed LAA occlusion technique remains to be seen. Therefore, long-term follow-up is needed to decide whether this is an effective technique for LAA occlusion. A more definite approach would be the complete excision of the LAA. Since our negative results years after direct suture closure of the LAA [7], we switched our technique to complete excision of LAA. The LAA atriotomy is closed between two 4–5 mm wide strips of Teflon felt to reinforce the fragile tissue, using a mattress suture followed by a continuous over and over suture to definitely close the resection line. The excision technique was reported to yield the most successful results compared with exclusion by suture or stapling [4]. In that report, 27% of patients in the excision group showed a residual stump of >1 cm, but the author did not find thrombus material in the residual stump at follow-up investigation, indicating that this residual stump at the base may not generate thrombus formation. Taken together, it would be appropriate for the proposed occlusion technique to stand the test of time for final judgment of its effectiveness. The most successful technique still remains the excision of the LAA.

Hydatid cyst open in biliary tract: Therapeutic approaches. Report of 22 cases

Discuss the different therapeutic options based on results of a series of patients undergoing operation for hydatid cyst ruptured into the biliary tract. This was a retrospective study of 22 patients operated on between 2001 and 2007 for hydatid cyst ruptured into the biliary tract. The mean age of patients was 37 years old. There were 14 men and eight women. Cholangitis was present in 59% of patients and isolated pain in the right upper quadrant was found in 20% of patients. Procedures performed included internal fistula drainage through the sphincter of Oddi (37.3%), cystobiliary disconnection by percutaneous transhepatic cystocholedochostomy (27.3%), bipolar drainage (27.3%), direct suture closure of the fistula (9.1%). The postoperative course was uneventful in 15 patients. Specific morbidity concerned four patients. An external biliary fistula and suppuration of the residual cavity was observed in two patients each. One patient died. Median survival was 24 months. No recurrence or late complications were seen in this series. The management of hydatid cyst ruptured into the biliary tract is not consensual. Radical treatment is best because it provides definitive treatment of both the fistula and the cyst at the same time. However, conservative treatment is the preferred treatment in endemic countries. The choice of the technique depends of the experience of the surgeon, as well as local and topographic conditions. The best treatment remains preventive by eradication of echinococcosis.

Risk Factors for Preoperative and Postoperative Progression of Aortic Regurgitation in Congenital Ruptured Sinus of Valsalva Aneurysm

We reviewed our experience with congenital ruptured sinus of Valsalva aneurysms (RSVA) to determine risk factors influencing occurrence and postoperative worsening of aortic regurgitation (AR). Over an 11-year period, 210 patients (33 ± 9.7 years old) underwent surgical repair of RSVA. Aneurysm originated from the right noncoronary sinus and other sinuses in 171, 35 and 4 patients, respectively; and ruptured into right ventricle outlet tract in 115 patients, right ventricle in 16, right atrium in 75, and other chambers in 4. Aortic regurgitation (111) and ventricular septal defect (108) were common coexisting anomalies. Patch closure of RSVA was performed in 61 patients, direct sutures in 18 patients, patch closure plus direct sutures in 88 patients, and repair simultaneous with aortic valve replacement in 43 patients. All but one patient survived the operation. In early postoperative periods, AR improved in 26 patients and worsened in 23. In 114 late follow-up patients with echocardiographic assessment, 18 showed deteriorated AR. By logistic regression analysis, RSVA ruptured into the right ventricle outlet tract and secondary changes of the aortic valve were risk factors for preoperative AR, and RSVA repaired with direct sutures had a significantly higher incidence of early worsening of AR. By Cox regression analysis, AR at discharge was an independent risk factor for late follow-up AR worsening. The RSVA can be repaired with a low mortality and excellent long-term result. An early, aggressive treatment should be recommended to prevent postoperative AR, and a direct-suture closure of RSVA should be avoided to prevent early worsening of AR.

Midterm Results of Repair of Perimembranous or Conal Ventricular Septal Defects Using the Transaortic Direct Suture Technique

A midterm retrospective analysis of the transaortic primary suture repair of perimembranous or conal ventricular septal defects with aortic valve prolapse was conducted. From January 1998 to January 2006, 56 patients underwent transaortic repair of perimembranous or conal ventricular septal defects using the direct suture technique. The mean age at operation was 7.7+/-5.0 years (37 males). Twenty-eight patients had none or trivial aortic regurgitation (AR), 19 had mild AR, and 9 had moderate or severe AR. The mean defect size was 7.0+/-2.6 mm at operation. There was no early mortality. In the immediate postoperative period, AR remained unchanged in 32 patients, improved in 17, and worsened in 9, including 2 patients who required early reoperation. Median follow-up was 3 years (range, 2 months to 8 years). There was 1 late death. Aortic regurgitation had deteriorated in 21 patients, 3 of whom required late reoperation, and improved in 5 compared with the preoperative state. Freedom from deterioration in AR was 97% at 2 years and 71% at 4 years. Deterioration in aortic valve function was independent of demographic and morphologic features. This surgical technique does not prevent progressive aortic valve dysfunction, which may be related to structural deficiency of the valve leaflet or distortion of the annulus by direct suture closure of the ventricular septal defect. Early closure may prevent structural leaflet damage, whereas adaptation of the transaortic technique to include a shallow ventricular septal defect patch may be beneficial in older patients.

Giant aneurysm of the right coronary artery and fistula to the coronary sinus

We describe the case of a 67-year-old man with a rare combination of a giant coronary artery aneurysm with a fistula draining into the coronary sinus. The patient presented with a sensation of retrosternal pressure. He was examined by coronary angiography, which revealed a large aneurysm of the right coronary artery (RCA) with a fistula. This fistula originated from the distal RCA shortly beyond the crux and drained into the coronary sinus. The aneurysm was in the proximal portion of the RCA, measuring 4 cm in diameter and 7 cm in length. Surgical repair by closure of the fistula under direct vision, suture closure and plication of the aneurysm, and coronary artery bypass was performed. Postoperative echocardiography and computed tomography confirmed closure of the fistula. The patient remains symptom-free at 4 months after surgery.

Surgical Treatment of Aortico-Left Ventricular Tunnel: A 12-Year Experience

Objectives: This study reviews 9 patients with aortico-left ventricular tunnel (ALVT) and aims to establish the optimal surgical strategies for this exceptional and rare pathology. Methods: 54,882 patients underwent open-heart surgery at the Fuwai Hospital between July 1996 and May 2008. Nine of these patients were diagnosed with ALVT. One patient died of acute heart failure before operation. The remaining 8 patients underwent operation. The mean age of these 8 patients was 22.5 years. Clinical, echocardiographic and surgical details were reviewed. Results: At operation the diagnosis was confirmed, and then repaired by direct suture closure (n = 1), single patch closure of the aortic end of the ALVT (n = 4), or aortic valve replacement (n = 3). In 5 patients, the aortic opening of the tunnel was above the right coronary sinus of Valsalva while in the other 3 it was above the left coronary sinus. All patients recovered safely. There was 1 late death (from perivalvular leak). The remaining patients remain asymptomatic at a mean follow up of 30.1 months. Conclusions: ALVT is a rare cardiac entity that should be treated soon after the diagnosis is made. The specific surgical operation should be individualized based on unique cardiac anomaly of each patient.

Simultaneous Bilateral Spontaneous Pneumothorax With Pleural Window Communicating With Bilateral Pleural Spaces

A pleural window communicating between bilateral pleural cavities is a serious condition in patients with pneumothorax, allowing air to leak from the affected lung into the contralateral pleural cavity and resulting in bilateral spontaneous pneumothorax. We treated a patient with a history of right-sided bullectomy for simultaneous bilateral spontaneous pneumothorax that subsequently recurred. A pleural window (1 cm long) was detected in the mid-mediastinum, and direct suture closure with localized pleural abrasion using argon beam coagulation on the circumference of the lesion was performed at video-assisted thoracoscopic surgery.