Paraesophageal hiatal hernia (PHH), accounting for only 5% of all hiatal hernias, may result in potentially life threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the gastric mucosa. It is traditionally believed that PHH is an indication for surgery. The repair of paraesophageal hernia is technically challenging and controversial. The purpose of this article is to overview the current status of indication of surgery; operative techniques including hernia sac resection, esophageal lengthening procedure, crural repair, and additional antireflux procedure. Results: All symptomatic patients should be surgically treated, when operation is possible. It seems reasonable that asymptomatic or minimally symptomatic patients do not necessarily require surgery and that a more selective approach should be used. The penetration rate is not high, laparoscopic approach is currently the standard care. The hernia sac should be excised and resected circumferentially. Collis-Nissen procedure continues to be the method of choice also in the laparoscopic era, when lengthening procedure of the shortened esophagus is in consideration. Although symptomatic recurrence after suture closure of the crura is uncommon, primary repair is associated with a high rate of anatomic recurrence. Prosthetic mesh repair is reportedly associated with a recurrence rate as low as 5%, at the price of rare but serious complications such as erosion and fibrosis. Although scientific proof is lacking, fundoplication is the most common procedure to be added after crural repair.

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The sentinel node (SN) concept has revolutionized the surgical staging of both melanoma and breast cancer over the past two decades. However, the validity of the SN hypothesis has been controversial for esophageal cancer, because SN mapping for esophageal cancer is technically complicated, and the number of early-stage esophageal cancer is very limited. Nevertheless previous studies nicely demonstrated that SN mapping may be feasible in patients with early-stage esophageal cancer. Transthoracic extended esophagectomy with three-field radical lymph node dissection has been recognized as a curative procedure for thoracic esophageal cancer in Japan. However, uniform application of this highly invasive procedure might increase the morbidity and markedly reduce the quality of life (QOL) after surgery. Although further accumulation of evidence based on multicenter clinical trials using a standard protocol is needed, SN mapping and SN navigation surgery would provide significant information to perform individualized selective lymphadenectomy which might reduce the morbidity and retain the patients’ QOL. In addition, technical innovation including the development of new tracers is expected to confirm the accuracy and reliability of SN mapping in esophageal cancer.

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Purpose: Several small studies have reported that acute exacerbation (AE) of idiopathic interstitial pneumonia (IIP) can occur after lung resection for patients with non-small cell lung cancer, though the incidence rate is unclear.
Methods: We examined our institutional data and performed a search of the MEDLINE database for publications regarding AE of IIP following surgery for lung cancer. Studies reporting the incidence rates of IIP and AE were included.
Results: Eleven studies including our institutional data were determined to be eligible. Seven studies designated the incidence of IIP. Of 4749 patients (from 7 studies) who underwent lung resection for NSCLC, 277 had IIP, for an incidence rate of 5.8% (range 1.1%–11.7%). Eleven studies designated the incidence of AE from IIP patient, 67 (15.8%) of 424 IIP patients (from 11 studies) developed AE after surgery, of whom 38 (56.7%) died during the postoperative course.
Conclusion: Coexistent IIP in patients with lung cancer increases the risk of lung cancer surgery. Furthermore, AE of IIP may be a major cause of operation-related death.

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Background: Residual shunting and mortality are problems associated with current surgical repair techniques for post-infarction ventricular septal defects.
Methods: We describe the mid-term results of the “sandwich technique” to repair a post-infarction ventricular septal defect (VSD), performed via a right ventricle incision. Application of direct ultrasonography to the right ventricular wall enables a surgeon to visualize the region, perform an appropriate incision into the right ventricle, and perform a trabecula resection. One patch is placed on the left ventricular (LV) side and the other on the right ventricular (RV) side of the VSD. The VSD is sealed with gelatin-resorcin-formalin (GRF) glue between the two patches.
Results: We had seven consecutive patients. The sandwich technique resulted in geometric preservation of the LV shape. There were no significant leaks, no mortality within a thirty-day postoperative period, and no bleeding problems. Hospital mortality was 14.3% (1/7 cases). Late survival longer than a year was obtained in five cases (71%). The longest patient survival time was nine years. No tissue degeneration was noted.
Conclusion: This technique may be useful for repairing a post-infarction VSD.

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Purpose: To compare the outcomes of isolated off-pump coronary artery bypass grafting (OPCAB) to those of mitral annuloplasty (MAP) with revascularization in patients with moderate ischemic mitral regurgitation (MR).
Methods: Between April 2001 and December 2009, 140 patients with moderate ischemic MR who underwent isolated OPCAB (OPCAB group, n = 77) or MAP with revascularization (MAP group, n = 63) were analyzed.
Results: Freedom from cardiac-related death at eight years was similar between groups (78.4 ± 5.5%, the OPCAB group versus 81.5 ± 5.9%, the MAP group, p = 0.297). In patients with left ventricular ejection fraction (LVEF) >40%, the MAP group were similar to the OPCAB group in freedom from recurrent MR at eight years (85.7± 10.0% versus 84.9 ± 8.3%, p = 0.738), but a significant difference was found in patients with LVEF ≤40% (93.5± 4.5%, the MAP group versus 36.9 ± 18.4%, the OPCAB group, p = 0.013). On multivariate analysis, emergency operation and low LVEF were predictive of recurrent MR.
Conclusion: Concomitant MAP was more effective against recurrent MR than was OPCAB alone, in patients with LVEF ≤40%. We suggest that MAP should be considered in moderate ischemic MR with low LVEF.

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Aim: Late occlusion of bypass grafts is one of the main issues associated with long-term survival after coronary artery bypass grafting (CABG) surgery. Left coronary system is generally revascularized using arterial conduits, whereas saphenous venous grafts are used for right coronary system. We investigated the prognostic factors that are related to the patency and risk of occlusion of saphenous venous grafts used for revascularization of diseased right coronary arteries.
Patients and Method: 92 patients who underwent CABG operation including a right coronary artery (RCA) bypass using saphenous venous graft (SVG) between January 2003 and July 2010 were evaluated retrospectively. Mean time of follow up was 66.9 ± 27.2 months (range 104–13 months). Grafts patencies were investigated using coronary angiography, and associated risk factors for mortality and morbidity were determined during the mid-term and long-term follow up. During the data collection phase, a significant association was noticed between patency of right coronary bypass grafts and site of distal anastomoses on RCA. Thus, patients were divided into two groups, according to the site of anastomosis. Right coronary anastomoses were performed either proximal (Group A, n = 44) or distal (Group B, n = 46) to the crux of the RCA (PDA).
Results: Patency rates were similar in-group A (50% occluded and 50% patent) whereas patency rates were significantly higher in-group B (occluded 16.7%, patent 83.3%, p = 0.001). Mean age was significantly higher in-group A compared to Group B (p <0.05); however, there was no statistically significant difference between the two groups with regard to risk factors associated with cardiovascular disease (p >0.05). Also, mean diameter of the target vessel was significantly higher in-group A (p <0.01).
Conclusion: Based on the results of our study we suggest that even though an appropriate segment for anastomosis is available proximal to the crux of the RCA, right posterior descending artery (PDA) should be preferred for revascularization when RCA is the target vessel in CABG.

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Background: The results of emergency coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) are less than satisfactory, and readmission for cardiac events is common.
Methods and Results: 105 patients underwent emergency CABG for AMI. We examined the long-term results of emergency CABG for AMI from the viewpoints of preoperative, intraoperative, and postoperative factors. The operative mortality rate was 11.4%. Risk factors for early death were age ≥80 years, shock, veno-arterial bypass, creatine kinase isoenzyme Mb ≥100 U/L, non-use of a left internal thoracic artery graft and an extracorporeal circulation time ≥120 min. Risk factors for late cardiac events were ejection fraction <40%, non-use of human atrial natriuretic peptide (hANP) therapy, angiotensin II receptor blockers (ARB) and aldosterone blockers, and a 3-month postoperative brain natriuretic peptide level ≥200 pg/ml.
Conclusions: Early results of this study are similar to those seen in previous reports, whereas late phase results yield some new and interesting findings. We suggest that intraoperative hANP, and postoperative aldosterone blocker and ARB, following CABG for AMI, will, through control of the renin-angiotensin-aldsterone system, inhibit left ventricular remodelling, reduce the extent of infarction, and improve cardiac function, yielding a favourable long-term prognosis.

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Pulmonary angiosarcomas are usually secondary tumors, and only a few primary cases have been reported. Effective strategies for treating this tumor have not been established, and the prognosis of affected individuals is generally very poor. We report a case of primary angiosarcoma presenting as a hemorrhagic solitary nodule at the bifurcation of the left main bronchus, followed for two years before surgery. Bronchial arteriography revealed a tumor stain sign, and racemose hemangioma of the bronchial artery was excluded. The hemoptysis was not controlled by repeated bronchial artery embolization, and the patient underwent left pneumonectomy with routine mediastinal lymph node dissection. Histopathologically, the excised tissue revealed a highly-cellular growth of atypical spindle cells with a storiform pattern. These atypical cells showed relatively low mitotic activity; the MIB-1 index was 10%. The tumor was diagnosed as a primary angiosarcoma of the lung by the following immunohistological findings: positivity for factor VIII-related antigen and CD31. One year after resection, the patient remains well without signs of recurrence.

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A 68-year-old man presented at the outpatient clinic with epigastric discomfort. He had suffered a myocardial infarction 10 years previously. Chest radiography and computed tomography showed a giant calcified aneurysm in the left ventricle. Electrocardiography indicated atrial fibrillation. Echocardiography showed moderate mitral regurgitation and enlarged left atrium. End-diastolic volume and ejection fraction were 164 ml and 31%, respectively. Coronary angiography revealed total occlusion of the left anterior descending artery and diffuse stenosis of the right coronary artery. Aneurysmectomy, mitral annuloplasty, maze procedure, and coronary artery bypass were performed. The patient was discharged 16 days postoperatively in a satisfactory condition without complications.

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Surgical management of tuberculosis is uncommon in children. We report a case of a 14-month-old boy with miliary tuberculosis and recurrent pneumothorax due to cavities in the left lung. This boy had no previous medical history and was referred to our hospital for a severe pneumonia. Initial chest radiograph showed bilateral miliary pattern. Direct microscopy of gastric lavage showed the presence of tubercle bacilli, providing definitive diagnosis. In spite of effective medication, his status rapidly worsened. A cardiac resuscitation was followed by intubation, and he required high-pressure ventilation for four weeks. He developed left pneumothorax, for which several drainages were performed. Computed tomography revealed a huge cavern system involving the entire lingula and surrounded by the left pneumothorax. Eventually, a massive enlargement of the initial cavity necessitated a thoracotomy and wedge resection.

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Coronary artery spasm after coronary artery bypass grafting is a rare cause of acute myocardial infarction. A 68-year-old man who successfully tolerated off-pump coronary artery bypass grafting had a life-threatening spasm at 16 hours postoperatively. Emergent coronary angiography was performed and demonstrated whole vessel spasm of the bilateral coronary arteries and completely patent grafts. Several transcatheter intracoronary injections of vasodilators failed to relieve the spasm completely. After observation in ICU for 4 days with intra-aortic balloon pumping and a high dose of catecholamine, cardiac function was re-established and the patient recovered.

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Pericardial cysts are rare benign mediastinal lesions and most commonly located at the cardiophrenic angle. We present a case of an atypically located pericardial cyst in a patient who underwent myocardial revascularization. A 61-year-old man with acute myocardial infarction was scheduled for coronary artery bypass grafting (CABG). Preoperative chest computed tomography revealed a homogenous cystic lesion in the superior mediastinum. The mass was located between the ascending aorta, the superior vena cava, and the left innominate vein. It was growing to the anterior of the aorta and to the right anterior paratracheal area. The density of the mass was close to that of water; thus, the contrast medium failed to enhance its visualization. A concomitant resection of the mass and the CABG was scheduled. After a medial sternotomy and bypass graft harvest, a median pericardectomy was performed. The surgeon found the cystic mass along the roof of the pericardium and located between the ascending aorta and superior vena cava. There was no adhesion between the mass and cardiovascular components. The mass was resected en bloc; therefore, off-pump CABG was completed. Histopathological examination of the resected specimen confirmed diagnosis of a pericardial cyst.

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We report a case of HeartMate II^® left ventricular assist device (LVAD) implantation as a destination therapy in a patient with a patent ventriculoperitoneal (VP) shunt after being suffered from subarachnoid hemorrhage. Because the patient’s VP shunt was running through her right anterior chest and abdominal wall, a driveline exit site was selected in her left upper quadrant to avoid unnecessary perioperative complication in relation to the patent VP shunt tube. Tailored driveline placement was a key element of this LVAD implantation in this already sick patient with multiple comorbidities.

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Introduction: Multiple cardiac ruptures after radiofrequency catheter ablation that requires surgical repair are uncommon.
Methods and Results: We describe a 64-year old male patient with paroxysmal atrial fibrillation who had a cardiac tamponade following radiofrequency ablation. Surgical exploration demonstrated two ruptures in the left atrium, one in the right atrium, and one hematoma in the right atrium. MEDLINE, the Cochrane Library, and related databases were searched up to June 2011 without language restrictions, and related literature was reviewed and discussed. The patient has survived from prompt cardiac repair of cardiac ruptures and recovered from surgery without complications.
Conclusions: Urgent exploratory surgery with cardiopulmonary bypass is the key to salvage the patient.

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Autosomal dominant polycystic kidney disease (ADPKD) is primarily associated with renal failure, but it also causes systemic diseases, including cysts of other systemic organs and cerebral or visceral aneurysm. To make matters worse, life-threatening aortic diseases are associated with ADPKD in some cases. However, only a few reports of ADPKD-associated with thoracic aortic dissection have been published. Herein, we present a case of dissecting aneurysm in a patient with hypertension and ADPKD. He had been followed up for type B aortic dissection for six years. Preoperative creatinine level ranged from 2.1 to 2.4 mg/dl. We performed replacement of the thoracic aorta with prosthetic graft successfully, and postoperatively, dialysis was not required.
It is very important for us to recognize the relationship between ADPKD and thoracic aortic dissection, which can cause high mortality and morbidity rates.

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We report a case of an apico-aortic bioprothesis-valved conduit for a 70-year-old-woman with symptomatic, severe aortic stenosis and severe calcification of the ascending aorta. She had a history of mastectomy and radiation therapy for breast cancer and was suffering from radiodermatitis and chronic thoracic wall infection. Transthoracic echocardiography showed severe aortic valve stenosis with heavy calcification and high aortic valve pressure gradients. In patients with a chronically infected thoracic wall, median sternotomy is considered to be a high risk procedure, resulting in postoperative mediastiniti; therefore, we applied a technique in which we used an apico-aortic conduit via posterolateral thoracotomy. We underwent apico-aortic bypass with a hand-made composite graft: 19-mm bioprosthetic valve and a 22-mm woven polyester vascular graft. The surgical intervention successfully decreased pressure gradient across the aortic valve, also separating an incision from chronic infection allowed us to avoid postoperative mediastinitis. The patient had remained in good condition for 15 months without developing any complications.

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We report a previously healthy 21-year-old man who developed disseminated varicella zoster infection complicated with encephalitis, acute renal insufficiency, liver dysfunction, and an apparent pustular skin superinfection with Staphylococcus aureus. He later developed an extensively destructive endocarditis affecting a congenital bicuspid aortic valve, accompanied with leaflet perforation, complete atrio-ventricular (AV) block, and invasion of vegetation to both left and right atrium; the endocarditis was attributed to the same skin pathogen, S. aureus. He underwent radical debridement of the aortic valve, membranous ventricular septum, and mitral anterior fibrous trigone, followed by reconstruction of intracardiac defects with 2 autologous pericardial patches and aortic valve replacement. After a permanent pacemaker implantation and 4 weeks of antibiotic treatment, he was discharged after an uneventful postoperative course.

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A 74-year-old man underwent aortic valve replacement due to aortic regurgitation after two months of medication for congestive heart failure. At surgery, the cause of the aortic regurgitation appeared to be dehiscence of an aortic valve commissure. Dehiscence was closed with mattress sutures from outside of the sinus. Dehiscence of an aortic valve commissure is rare and difficult to be diagnosed preoperatively, and we carefully repaired it, and the patient had a good recovery.

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Vascular malformations located in the posterior mediastinum are extremely rare. Most of them are found coincidentally during routine examinations. Only a small percentage of these posterior mediastinal arteriovenous malformation cases may cause symptoms such as dyspnea due to compression of surrounding tissues. Radiologic imaging can be insufficient in some cases for differential diagnosis. Because of their vascular nature, diagnostic needle biopsy may have a high risk of bleeding. Open surgical resection is a safe treatment choice under many circumstances, and it helps the diagnosis as well. In this paper, a case of a 31-year-old male is presented with an incidentally diagnosed arteriovenous malformation, originating from the descending aorta and located in the posterior mediastinum.

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Atrial myxoma is the most common benign tumor of the heart. Patients who have atrial myxoma usually present with cardiac obstruction, arrhythmia, or peripheral embolization. We encountered an unusual case of acute upper extremity ischemia due to a massive atrial myxoma in a young man. A 38-year-old man was admitted to our hospital with an acute onset of severe, right upper extremity pain and paralysis while working. Neurologic examination yielded normal results, but the patient showed no palpable right radial or ulnar artery. Routine sonographic evaluation revealed acute aortic embolism in his right brachial artery. Because of his young age and otherwise healthy condition, we decided to perform transthoracic echocardiography, which showed a huge left atrial tumor, which we suspected to be myxoma. We then performed urgent concurrent open heart surgery and embolectomy to avoid further embolism. The microscopic findings of the resected tumor and embolism specimens were myxoma. He was discharged without complications.

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Purpose: We have introduced a new surgical approach for extended thoracic aortic repair, anterolateral thoracotomy with partial sternotomy (ALPS).
Description: The surgical approach to the chest was made via left anterolateral thoracotomy and lower median sternotomy through the third or fourth intercostal space. All cannulations (arterial, venous, venting, and cardioplegia) could be easily performed using a retractor in this approach.
Evaluation: From November 2005 to December 2010, we performed surgical treatment in 12 patients by employing the ALPS approach for a complex, extended thoracic aortic diseases with different pathologies, i.e., arteriosclerotic aneurysms in 5, acute type B dissection in 5, and chronic type B dissection in 2 patients. One patient died in the hospital, and 1 had temporary spinal cord injury.
Conclusion: The ALPS approach might become an alternative for a complex, extended thoracic aortic replacement.

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