Posterolateral Chest Wall Research Articles

Giant cellulitis-like Sweet syndrome mimicking cellulitis: a case report

BackgroundSweet syndrome (acute febrile neutrophilic dermatosis) is an uncommon inflammatory disorder characterized by the abrupt appearance of painful, edematous, and erythematous papules, plaques, or nodules on the skin. There are various subtypes, such as classical, drug-induced, malignancy-associated, and the less common variant giant cellulitis-like Sweet syndrome. This case is unique due to its presentation of the giant cellulitis-like variant of Sweet syndrome in a patient from Ethiopia. The unusual distribution of the skin lesions and the initial lack of response to antibiotics make this case particularly noteworthy. It underscores the importance of considering Sweet syndrome in differential diagnoses when faced with atypical skin manifestations and ineffective antibiotic treatment. This contribution adds valuable insights to the scientific literature by highlighting the need for heightened awareness of this rare variant and improving diagnostic accuracy in similar clinical scenarios.Case presentationA 60-year-old Ethiopian male patient who presented to the accident and emergency department with a 5-day history of fever, chills, sweating, and rigor accompanied by a reddish skin color change around the anterolateral region of the right chest wall. On physical examination, there were erythematous, indurated tender plaques with ill-defined borders over the right antero- and posterolateral chest wall with extension to the lateral part of the right neck and medial aspect of the right arm. Subsequently, the patient was started on antibiotics, but there was a suboptimal response. Skin biopsy revealed features suggestive of giant cellulitis-like Sweet syndrome. He was then started on steroids, which significantly improved his symptoms.ConclusionA cautious stance is essential when identifying Sweet syndrome in individuals displaying erythematous plaque-like skin lesions in atypical areas of the body with uneven distribution. Such presentation may signal Sweet syndrome rather than a common infection. If conventional treatments, such as antibiotics, fail to resolve symptoms, consider Sweet syndrome as a potential diagnosis. This approach ensures timely and appropriate treatment, preventing treatment delay and misdiagnosis.

Regional anesthesia in coronary artery bypass grafting: a narrative review

Coronary artery bypass grafting (CABG) is one of the most frequently performed procedures in modern cardiac surgery because it is indicated in most patients with coronary artery disease. Currently, there are no standard methods for regional anesthesia in cardiac surgery. The purpose of this review was to describe the available techniques for regional anesthesia in post-CABG. Studies published in the databases PubMed, The Cochrane Library, Google Scholar, Russian science citation index were included. Techniques reported in the literature were local blockade of the postoperative wound with local anesthetics in the anteromedial chest wall (parasternal-intercostal plane blocks), anterolateral chest wall (interpectoral plane blocks, serratus anterior plane block), and posterolateral chest wall (erector spinae plane block, thoracic paravertebral block, retrolaminar block, rhomboid intercostal block). Numerous studies demonstrate that the use of regional anesthesia as a component of multimodal anesthesia after coronary artery bypass grafting significantly improves pain relief. Blockade of the peripheral nerves of the chest wall under ultrasound guidance can be considered not only as an alternative to epidural anesthesia when not indicated or not feasible. It also contributes to early tracheal extubation, reduced duration of mechanical ventilation, adequate pain control, and a decrease in the need for narcotic analgesics, reduced postoperative nausea and vomiting, and reduced length of stay in the intensive care unit. Further research is needed to determine the optimal technique for performing interfascial blockades of the chest wall post-CABG, which would require data on the effectiveness, safety, and dosing regimen for each specific blockade.

PO-04-084 LOW SHOCK IMPEDANCE OF SUBCUTANEOUS IMPLANTABLE CARDIAC DEFIBRILLATOR (S-ICD) IN THE SETTING OF ACUTE DECOMPENSATED HEART FAILURE

Shock impedance represents the resistance between the coil and generator of subcutaneous ICDs. It is an important metric to predict device defibrillation success. Several factors have been implicated in determining system impedance of S-ICDs such as generator-lead distance, body habitus as well as generator position (subcutaneous vs. intermuscular pocket). We present a case report highlighting the impact of volume status on shock impedance. N/A A 60-year-old female presents to the office. She has a past medical history of obesity, Heart Failure with Preserved Ejection Fraction (HFpEF), ventricular fibrillation followed by implantation of transvenous ICD. This was complicated by device infection requiring device extraction and implantation of S-ICD. She has been having progressive shortness of breath with minimal exertion weeks prior to presentation. She denied chest pain, palpitations or dizziness but endorsed generalized fatigue as well as significant weight gain. She usually weighs around 165-170 lbs, but was 220 lbs on presentation. Her physical exam was remarkable for elevated jugular venous pressure, anasarca with crackles in the lung bases as well as abdominal ascites and lower extremity edema. Interrogation of her device was performed which showed no significant arrythmias. However, device detected low system impedance of <30 ohms. Her previous interrogation about 3 months earlier showed impedance of 50 Ohms. She was admitted for inpatient intravenous diuresis. Chest radiograph demonstrated normal position of the generator in the posterolateral chest wall and normal lead position in the parasternal area. Serial device interrogations were performed during the hospitalization showing gradual improvement in system impedance up to 45 Ohms once euvolemia was achieved (Figure 1). Due to improvement in shock impedance with diuresis, defibrillation threshold testing (DFT) was deferred and patient was discharged home in stable condition. Her repeat interrogation at follow up showed an impedance of 60 ohms. In the setting of heart failure exacerbation, excess fluid accumulation in the chest and abdominal cavities may result in a decrease in S-ICD shock impedance. Interpretation of device impedance should factor in patient’s volume status. Further studies are needed to ascertain if low impedance caused by fluid overload can impact device defibrillation success rate.

Predictors and characteristics of Rib fracture following SBRT for lung tumors

BackgroundThe utilization of stereotactic body radiation therapy (SBRT) is increasing for primary and secondary lung neoplasms. Despite encouraging results, SBRT is associated with an increased risk of osteoradionecrosis-induced rib fracture. We aimed to (1) evaluate potential clinical, demographic, and procedure-related risk factors for rib fractures and (2) describe the radiographic features of post-SBRT rib fractures.MethodsWe retrospectively identified 106 patients who received SBRT between 2015 and 2018 for a primary or metastatic lung tumor with at least 12 months of follow up. Exclusion criteria were incomplete records, previous ipsilateral thoracic radiation, or relevant prior trauma. Computed tomography (CT) images were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was employed to determine clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location).ResultsA total of 106 patients with 111 treated tumors met the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total fractured ribs). The highest number of fractured ribs per patient was five. Multivariate regression identified posterolateral tumor location as the only independent risk factor for rib fracture. On CT, fractures showed discontinuity between healing edges in 77% of affected patients.ConclusionsNearly one third of patients receiving SBRT for lung tumors experienced rib fractures, 34% of whom experienced pain. Many patients developed multiple fractures. Post-SBRT fractures demonstrated a unique discontinuity between the healing edges of the rib, a distinct feature of post-SBRT rib fractures. The only independent predictor of rib fracture was tumor location along the posterolateral chest wall. Given its increasing frequency of use, describing the risk profile of SBRT is vital to ensure patient safety and adequately inform patient expectations.

Two Endovascular Stent Graft Repairs Needed for an Extrathoracic Aortic Graft: Distant Complications After an Original Open Repair for a Gunshot Wound to the Chest

Although the management of traumatic injuries to the thoracic aorta has shifted toward endovascular management, the historical standard of care is open reconstruction. Choosing to reoperate when faced with a complication from a prior open repair can be challenging; endovascular management can be a reasonable option in this situation. This report describes a 54-year-old man with a remote history of open surgery for a traumatic injury to the descending thoracic aorta who underwent endovascular aortic stent graft placement for coverage of extrathoracic graft extension with pseudoaneurysm formation and distal embolization. He returned a year later with a type IIIb endoleak with rupture into the posterolateral chest wall. A sec ond endovascular approach was used to successfully reline the graft and exclude the rupture.

Injuries of the posterior and lateral chest wall-importance of an additional clavicular fracture

Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show ahigh incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to aloss of function of the shoulder and apronounced deformation of the chest wall. This article shows the origin and clinical importance of FCI. What importance does aconcomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively? After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in acorpse study and then put into practice. This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and amarked deformation of the thoracic wall are present. Remaining misalignments are associated with asimultaneous loss of function of the chest wall and shoulder.

Unusual case of primary spontaneous hemopneumothorax in a young man with atypical tension pneumothorax: a case report

BackgroundSpontaneous life-threatening hemopneumothorax is an atypical but treatable entity of unexpected circulatory collapse in young patients, affecting 0.5–11.6% of patients with primary spontaneous pneumothorax. Spontaneous pneumothorax is a well-documented disorder with a classic clinical presentation of acute onset chest pain and shortness of breath. This disorder might be complicated by the development of hemopneumothorax or tension pneumothorax.Case presentationA 23-year-old Asian man was referred to the emergency room of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. A physical examination revealed a young man who was awake and alert but in mild to moderate painful distress. His vital parameters were relatively stable at first. The examining physician noted slight tenderness along the right posterolateral chest wall along the eighth and tenth ribs. Primary spontaneous pneumothorax was considered, and a standing chest X-ray confirmed the diagnosis. A right thoracostomy tube was immediately placed under sterile conditions, and he was referred to the respiratory service. While in the respiratory department, approximately 420 mL of blood was drained from the thoracostomy tube over 15 minutes. Our patient developed obvious hemodynamic instability with hypovolemic shock and was subsequently admitted to the cardiothoracic surgical ward after fluid resuscitation. During the ensuing 4 hours after admission, 750 mL of blood was drained through the thoracostomy tube. A bedside chest X-ray was requested after he was temporarily hemodynamically stabilized. Primary spontaneous hemopneumothorax associated with right tension pneumothorax was considered based on the radiological impression and clinical signs. An emergency limited posterolateral thoracotomy was performed. A standing chest X-ray performed on day 6 of admission after the removal of the thoracostomy tube showed a complete re-expansion of his right lung. He remained stable and was discharged within 1 week.ConclusionsThe successful treatment of a large spontaneous hemopneumothorax depends on early recognition, proactive intervention, and early consideration by a cardiothoracic surgeon. Once the diagnosis is confirmed, early thoracotomy should be considered. Such an aggressive surgery not only leads to shorter hospitalization but also confers better long-term outcomes.

Reduced invasive and muscle-sparing operative approaches to the posterolateral chest wall provide an excellent accessibility for the operative stabilization! : Minimized approaches to the posterolateral chest wall.

Stabilizing techniques for flail chest injuries are described through wide surgical approaches to the chest wall, especially in the most affected posterior and lateral regions. Severe morbidity due to these invasive approaches needs to be considered due to dissection of the scapular guiding muscles and the risk of injuries to neurovascular bundles. This study discusses possibilities for minimized approaches to the posterior and lateral regions. Ten fresh-frozen cadavers in lateral decubitus position were observed on both sides. Each surgical arm was kept mobile during the procedure. Approaches were performed following a standard protocol with muscle-sparing incisions starting with 5cm in length and extending to 10 and 15cm. The accessible surface comparing the extensions was measured. Visible ribs were counted. In a next step, MatrixRib® Plates were fixed to those ribs to prove the feasibility of rib stabilization through limited approaches. Combinations of the posterior and lateral minimized approaches allow surgical fixation of 6-9 and 7-11 ribs through 5 and 10cm incisions, respectively. In the case of an extreme expansion of a rib fracture series, an access extension can be made to 15cm to be able to adequately supply the entire hemithorax using two approaches. Extensive invasive surgical approaches to the thoracic wall can be replaced by reduced invasive and muscle-sparing access combinations. A free-moving positioning of the arm and an accurate preoperative plan for minimizing approaches are essential. Minimally invasive plate techniques are very helpful adjuncts.

Surgical Stabilization of Costoclavicular Injuries - A Combination of Flail Chest Injuries and a Clavicula Fracture.

Background: Flail chest injuries (FCI) are associated with a high morbidity and mortality rate. As a concomitant clavicle fracture in FCI even worsens the outcome, the question is how can those costoclavicular injuries (CCI) be managed surgically. Methods: 11 patients with CCI were surgically treated by a locked plate osteosynthesis of the Clavicle and the underlying ribs through limited surgical approaches under general anesthesia. Patients were followed up after 2, 6, 12, 26 and 52 weeks. Results: All patients showed severe chest wall deformity due to severely displaced fractures of the ribs and the clavicle. They were suffering from pain and restriction of respiratory movements. The chest wall could be restored to normal shape in all cases with uneventful bone healing and a high patient convenience. Fractures of the clavicle and the second rib were managed through an innovative clavipectoral approach, the others through standard approaches to the anterolateral and the posterolateral chest wall. Two patients complained about numbness around the lateral approach and lasting periscapular pain. Conclusions: Surgical stabilization might be the appropriate therapy in CCI with dislocated fractures since they would cause severe deformity and loss of function of the chest wall and the shoulder.

Angiomyolipoma of the thoracic wall: an extremely rare diagnostic challenge.

Extrarenal angiomyolipoma (AML) is an extremely uncommon lesion, accounting for less than 9% of all angiomyolipomas. We present a previously unreported case of a rarely located gigantic extrarenal angiomyolipoma at the posterolateral chest wall of a 35-year-old woman. Clinically, the lesion had all the characteristics of a benign tumor, being soft in palpation, painless, and growing in size in a slow rate. Histologically, the lesion consisted of convoluted thick-walled blood vessels without an elastic layer, interlacing fascicles of smooth muscle, and mature adipose tissue, features consistent with an angiomyolipoma. The mass was surgically removed, without any postoperative complications, and the patient has an uneventful postoperative course. Signs of local recurrence have not been observed. The purpose of this brief report is to point out the necessity of including angiomyolipoma in the differential diagnosis of adipose layer lesions.

Reconstruction of chest wall using a two-layer prolene mesh and bone cement sandwich.

Wide surgical resection is the most effective treatment for the vast majority of chest wall tumors. This study evaluated the clinical success of chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich. The records of all patients undergoing chest wall resection and reconstruction were reviewed. Surgical indications, the location and size of the chest wall defect, diaphragm resection, pulmonary performance, postoperative complications, and survival of each patient were recorded. From 1998 to 2008, 43 patients (27 male, 16 female; mean age of 48years) underwent surgery in our department to treat malignant chest wall tumors: chondrosarcoma (23), osteosarcoma (8), spindle cell sarcoma (6), Ewing's sarcoma (2), and others (4). Nine sternectomies and 34 antero-lateral and postero-lateral chest wall resections were performed. Postoperatively, nine patients experienced respiratory complications, and one patient died because of respiratory failure. The overall 4-year survival rate was 60%. Chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich is a safe and effective surgical procedure for major chest wall defects.

Osteoblastoma of the rib: A rare benign tumor with an unusual location

INTRODUCTIONOsteoblastoma is a rare benign bone tumor commonly located at spine and long bones. However, rib involvement has been reported less frequently. PRESENTATION OF CASEIn this report, we describe a young adult male presenting with left posterolateral chest wall pain. Chest computed tomography showed a calcified tumor in the left third posterior segment of the rib. Radical mass resection was performed and histopathology confirmed a benign osteoblastoma. At last follow-up, 10 months postoperatively, the patient has eventually relieved of the unbearable chest pain. Imaging evaluation revealed no evidence of recurrent tumor. DISCUSSIONOsteoblastoma is an uncommon primary bone tumor accounting for only 1% of all bone tumors. Ribs are involved in less than 5% of patients. The disease has usually good prognosis with a tendency for local destruction and recurrence. CONCLUSIONRadical surgery remains the treatment of choice to prevent recurrences and to provide a definite diagnosis differentiating it from osteoblastoma-like osteosarcoma.

Use of the titanium vertical ribs osteosynthesis system for reconstruction of large posterolateral chest wall defect in lung cancer

We report a case of reconstruction of a large full-thickness posterolateral defect of the chest wall after resection of a stage III non-small cell lung carcinoma (NSCLC) using the combination of a vertical expandable prosthetic titanium device and a polytetrafluoroethylene (PTFE) mesh. A 40-year-old female presented with a NSCLC classified as type IIIA and required both neoadjuvant radiotherapy and chemotherapy. An en bloc resection including the left upper lobe, posterolateral segments of five ribs (K3-K7) and vertebral bodies (T3-T6) was performed through a posterior J-shaped approach. A vertical rib osteosynthesis system was used to ensure thoracic wall stability and mechanical organ protection, prevent ventilatory impairment, avoid incarceration of the tip of the scapula, and maintain an acceptable cosmetic aspect. The device was locked onto the middle arch of the second and eighth ribs. We hung the PTFE mesh from the titanium bars with multiple non-absorbable sutures under maximal tension. Final pathological classification was T4N0M0 with an R0 final resection status. After an uneventful course, the patient was discharged on postoperative day 10. This first experience indicates that vertical rib osteosynthesis combined with a PTFE mesh can be used safely and easily in a one-stage procedure for major posterior chest wall defects.

Incarcerated spontaneous transdiaphragmatic intercostal hernia

IntroductionProlapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency. Presentation of caseA 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect. DiscussionThe clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient's history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient. ConclusionSpontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.

125 Vertical ribs osteosynthesis system (VEPTR) combined with ePTFE: a modern reconstruction of a large posterolateral chest wall defect after en-bloc resection for vertebral-T4 NSCLC

125 Vertical ribs osteosynthesis system (VEPTR) combined with ePTFE: a modern reconstruction of a large posterolateral chest wall defect after en-bloc resection for vertebral-T4 NSCLC

Cardiopulmonary Bypass to Facilitate Excision of a Giant Pleural Tumour

A 55-year-old female developed dyspnoea following an elective hysteroscopy. A chest radiograph demonstrated a tissue density opacity occupying the right hemithorax. A CT scan suggested this was a tumour arising from the postero-lateral chest wall. Surgical resection was attempted; however, mobilisation of the tumour caused significant airway compromise. Cardiopulmonary bypass was used to facilitate oxygenation while the tumour was dissected and removed. Although cardiopulmonary bypass has been used as an adjunct to aid resection of tumours invading major vascular or upper airway structures, in this case CPB was used to aid mobilisation of a giant pleural tumour.

The radiologic appearance of intercostal muscle flap

Background The intercostal muscle flap (ICMF) is commonly used in airway and esophageal surgery to reinforce an anastomosis or site of closure. These flaps undergo heterotopic ossification that may result in stenosis of adjacent airways or the esophagus. We evaluated the computer tomography (CT) scan, technetium-99m-methylene diphosphonate bone scan and positron emission tomography with 2-[ 18F]-fluoro-2-deoxy-D-glucose (FDG-PET) findings of ICMF and the frequency of airway or esophageal stenosis. Methods A retrospective review was made of the radiologic records of 23 patients (9 women, 14 men) who underwent ICMF. The CT scans were obtained a mean of 36 months (range, 1 week to 58 months) after surgery and the size, morphology, and density of the ICMFs were recorded. Correlative bone scan in 13 patients and FDG-PET scans in 11 patients were reviewed. Results A discontinuous, thin, linear calcified stripe or parallel stripes (mean thickness, 4 mm; mean density, 430 Houndsfield unit [HU]) were present in all patients on CT. The flap contained fat density (mean, −59 HU) in 18 patients and soft tissue density (mean, 41 HU) in 8 patients and measured about 1 cm in thickness. The appearance of ICMF is characteristic when the ossification extends from the posterolateral chest wall to an adjacent bronchial stump. There was no increased uptake on bone scan or FDG-PET scan. None of the patients had airway or esophageal stenosis. Conclusions The ICMF manifests on CT as a thin, linear calcified stripe or parallel stripes with central fat or soft tissue density. Airway stenosis due to ICMF is likely quite rare. We did not detect any airway stenosis.

Asbestos: when the dust settles an imaging review of asbestos-related disease.

Asbestos-related neoplastic and nonneoplastic diseases of the lungs and pleura range from pleural effusion and pleural plaques to lung cancer and malignant mesothelioma. Pleural effusions are typically hemorrhagic exudates of mixed cellularity but do not typically contain asbestos bodies. The classic distribution of pleural plaques seen on chest radiographs is the posterolateral chest wall between the seventh and tenth ribs, lateral chest wall between the sixth and ninth ribs, the dome of the diaphragm, and the mediastinal pleura. Computed tomographic (CT) findings support this distribution but also show anterior and paravertebral plaques not well shown at chest radiography. Imaging features of diffuse pleural thickening include a continuous sheet, often involving the costophrenic angles and apices, that rarely calcifies. The typical CT features of round atelectasis are of a round or oval mass that abuts the pleura, a "comet tail" of bronchovascular structures going into the mass, and thickening of the adjacent pleura. Features of asbestosis on chest radiographs include ground-glass opacification, small nodular opacities, "shaggy" cardiac silhouette, and ill-defined diaphragmatic contours. CT, however, is more sensitive in their detection. Chest radiography in patients with malignant mesothelioma may show an effusion, pleural thickening, and as the tumor progresses, a more lobulated outline. CT can help identify the disease in its early stages. Asbestos-related cancers can occur anywhere in the lungs. Recognition of the clinical, radiologic, and pathologic features of these diseases will be important for some years to come.

Elastofibroma dorsi: prevalence in an elderly patient population as revealed by CT.

We wanted to determine the prevalence and appearance of elastofibroma dorsi in an elderly patient population (n = 258) who underwent CT of the chest for reasons other than to evaluate posterolateral chest wall pain, stiffness, or a mass. Five elastofibromas were detected in four patients; none of these elastofibromas were noted at initial examination. Our study suggests that the prevalence of elastofibroma dorsi revealed by CT is 2%, which is lower than the 11-24% found in autopsy series but higher than expected for such a rare tumor. Elastofibroma dorsi typically has a layered appearance on CT; however, in our study, homogeneous soft-tissue attenuation was noted. The diagnosis is often missed prospectively. Familiarity with the location and imaging appearance of elastofibroma dorsi may enhance detection and characterization of posterolateral chest wall masses in elderly patients.

Reverse flap of distal latissimus dorsi for diaphragm reconstruction in the adult: Specification of the technical procedure and report on six cases

autograft rather than other valve prostheses in children, some specific reasons were present in this special situation. Resection of the aneurysmal aortic root was necessary and the relatively difficult access to the aortic root made the choice of a homograft less preferable in view of the inevitable reoperation. The operation turned out to be straightforward. The anterior placement of the pulmonary trunk made its harvesting easy. Coronary artery problems were not encountered. Transposition may, however, be combined with coronary artery patterns that make harvesting of the pulmonary trunk more difficult, especially a right coronary artery crossing the right ventricular outflow tract. No important mismatch between the diameters of the pulmonary trunk and aortic anulus existed, which further encouraged us to choose the pulmonary autograft for aortic root replacement. In conclusion, the Ross procedure is technically feasible after an arterial switch operation and may be a particularly attractive alternative for this special population. This may be even more true because it is the original aortic valve that is used to replace the insufficient neoaortic valve. R E F E R E N C E S 1. Gittenberger-de Groot AC, Sauer U, Oppenheimer-Dekker A, Quaegebeur JM. Coronary arterial anatomy in transposition of the great arteries: a morphological study. Pediatr Cardiol 1983;4(suppl 1):15-24. 2. Klautz RIM, Ottenkamp J, Quaegebeur JM, Buis-Liem TN, Rohmer J. Anatomic correction for transposition of the great arteries: first follow-up (38 patients). Pediatr Cardiol 1989;10: 1-9. 3. Yamaguchi M, Hosokawa Y, Imai Y, Kurosawa H, Yasui H, Yagihari T, et al. Early and midterm results of the arterial switch operation for transposition of the great arteries in Japan. J Thorac Cardiovasc Surg 1990;100:261-9. 4. Ungerleider RM, Gaynor JW, Israel P, Kanter RJ, Armstrong BE. Report of neoaortic valve replacement in a ten-year-old girl after an arterial switch procedure for transposition. J Thorac Cardiovasc Surg 1992;104:213-5. 5. Serraf A, Roux D, Lacour-Gayet F, Touchot A, Bruniaux J, Sousa-Uva M, et al. Reoperation after arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;110:892-9.