The number of minimally invasive operations, such as video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy, has enormously increased in recent years. These operations require extreme knowledge of the anatomy of pulmonary vessels and bronchi in each patient, and surgeons must carefully dissect the branches of pulmonary vessels during operation. Thus, foreknowledge of the anatomy of each patient would greatly contribute to the safety and accuracy of the operation. The development of multi-detector computed tomography (MDCT) has promoted three dimensional (3D) images of lung structures. It is possible to see the vascular and bronchial structures from the view of the operator; therefore, it is employed for preoperative simulation as well as navigation during operation. Due to advances in software, even small vessels can be accurately imaged, which is useful in performing segmentectomy. Surgical simulation and navigation systems based on high quality 3D lung modeling, including vascular and bronchial structures, can be used routinely to enhance the safety operation, education of junior staff, as well as providing a greater sense of security to the operators.

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Purpose: To evaluate the efficacy of taurolidine instillation on postoperative air leak by clinical study and to investigate the mechanism of action by animal experiments.
Methods: Outcomes of taurolidine instillation in patients with postoperative air leak were retrospectively reviewed. 100 ml of 1% taurolidine solution was instilled through a chest tube in patients with postoperative air leak lasting 4days or more. Success was defined as cessation of air leak within 24 hours with full expansion of lung on chest radiograph and subsequent removal of chest tube within another 24 hours. The effect of taurolidine instillation was estimated by development of adhesion and thickening of the visceral pleura in rabbits. The study group was compared with a control group and a talc poudrage group.
Results: Out of 75 patients, the success rate was 66.7%. Out of 96 total attempts, taurolidine instillation was successful in 55%. In animal experiments, pleural adhesion was minimal in the taurolidine and control groups, whereas the talc group showed more adhesions. The taurolidine group showed a moderate visceral pleural thickening. The talc group showed severe visceral pleural thickening, whereas the control group showed mild thickening.
Conclusion: Taurolidine is an effective alternative agent for the management of air leak. A chemical sclerosing effect is suggested as the mechanism of air leak cessation

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Purpose: Renal dysfunction remains a serious complication of coronary artery bypass grafting (CABG) surgery and is associated with increased mortality and morbidity. To date, a number of different strategies, including new pharmacologic agents, off-pump and cardiopulmonary bypass techniques have been used to avoid it, but none of them proves the excellent result.
Methods: Between April 2009 to September 2011, 185 consecutive patients with multivessel coronary artery disease undergoing elective CABG were included the study. Iloprost was given with the onset of rewarming period at a dose of 1.25–2.5 ng/kg/min and it was ended together with the ending of CPB in 94 patients and remaining were in the control group. Creatinine clearance (CCr) and GFR were measured at the time of hospitalisation and on day first and fifth postoperatively. Serum potassium level was determined every 6 hours, during the first 24 hours postoperatively, and every 12 hours for the next 72 hours, and glomerular filtration rate was estimated.
Results: There was no statistically significant difference in preoperative comorbidity. There were no significant differences in postoperative morbidity or mortality between either of the two groups that completed the study. However, urine output during the operation was significantly higher in the study group. An increase in creatine levels was more common in the control group. Development of a new CCr less than 50 ml/min was also significantly higher in the control group, postoperatively.
Conclusion: Our study demonstrates that prophylactic intravenous iloprost administration after initiation of a rewarming period during CPB in patients undergoing CABG surgery is associated with improved renal function, compared with conventional treatment in well-hydrated patients. It also has a good safety profile and is generally well tolerated.

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Background: The treatment of secondary pneumothorax in elderly patients is difficult because of underlying diffuse lung injury and complex medical comorbidities. Such patients still have high morbidity rates, resulting in longer periods of hospitalization.
Methods: To examine the results of video-assisted thoracic surgery for elderly patients (aged 70 years or over) with secondary pneumothorax and investigate the risk factors for hospital stay longer than 7 days, we retrospectively analyzed the results obtained in such patients at our institution.
Results: From among 73 patients who entered this study, 7 patients (9.6%) had postoperative complications. Video-assisted thoracic surgery could treat pneumothorax in 71 patients, except for the 2 who died in hospital. The median postoperative drainage and hospital stay periods were 2 days (1–40 days) and 5 days (2–51 days). Patients with interstitial pneumonitis, pulmonary infection and low total protein or sodium levels were the risk factors for hospital stay longer than 7 days.
Conclusions: VATS is a safe and effective procedure for secondary pneumothorax in elderly patients. Patients with interstitial pneumonitis, pulmonary infection, and hyponutrition state were the risk factors for postoperative hospital stay prolongation.

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Purpose: The purpose of this study was to determine whether cyclophosphamide (CP) can decrease myocardial and systemic TNF-α expression and thus protects myocardial I/R injury.
Methods: Open chest rats were subjected to 30 min of ischemia followed by 3h, 12h or 24h of reperfusion. Rats were divided into sham group, I/R group and CP group, and each group included 3 timepoint subgroups (3h, 12h and 24h). Plasma TNF-αwas measured by cytometric bead array (CBA) and immunohistochemistry was used to detect TNF-α in myocardium.
Results: Compared with I/R group, rats treated with CP showed a significant difference with decreased plasma TNF-α (13.31 ± 2.62 vs 14.13 ± 5.95 pg/mL at 3 h reperfusion, 10.1 ± 2.73 vs 12.54 ± 5.00 pg/mL at 12 h reperfusion, 10.38 ± 5.59 vs 13.00 ± 3.59 pg/mL at 24 h reperfusion, p <0.05 respectively). Immunostaining was less intense with CP injection at each reperfusion time. The score of the intensity of myocardial TNF-αstaining was down regulated.
Conclusions: TNF-α is expressed in the myocardium and plasma after myocardial I/R injury. CP might be a feasible strategy for anti-TNF-α to protect myocardial I/R injury.

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Objective: To evaluate the effect of sarpogrelate for patients with atherosclerotic obliterans (ASO). Patients and Methods: Patients with ASO were randomly divided into sarpogrelate group (n = 92) and control group (n = 84). The patients in sarpogrelate group received sarpogrelate (100 mg, tid), whereas in control group aspirin (100 mg, qd) was administered orally. The patients were followed up monthly to observe any side effect of medication. Clinical manifestation, painless walking distance, Rutherford type and ankle brachial Index (ABI) were studied. Results: In comparison with control group, the severity of pain, Rutherford type 0 and 1 were improved with statistic significance. Incidence of patients with intermittent claudication decreased from 56.6% before treatment to 28.3% after treatment; the painless walking distance was prolonged (116.3 ± 72.3m vs. 243.5 ± 175.3m, P <0.001); ABI values were increased (0.74 ± 0.17 vs. 0.86 ± 0.18; p <0.001). No side effect of medication was observed. Conclusion: Sarpogrelate has a therapeutic effect on patients with atherosclerotic obliterans.

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Purpose: Vessel damage after clamping may affect the success of surgical operations. A new pressure controlled clamp (SMA clamp) was designed using super elastic property of shape memory alloy (SMA) to realize atraumatic vessel occlusion. The ability and biological effect of the SMA clamp to control pressure was investigated in vivo.
Methods: The loading-displacement curves of the SMA clamps (experimental group) and conventional clamp (control group) by occlusion of pig carotid arteries were evaluated using a clamping-pressure analyzing system. To investigate macroscopically and histologically the vessel damage of the SMA and conventional clamps, pig carotid arteries were stained with Evan’s blue and its histological sections were stained with Elastica Massion after clamping for fifteen minutes.
Results: Constant value was shown in the loading-displacement curve of SMA clamp. In the control group, damaged area stained with Evan’s blue in the vessel wall showed enlargement with the pressure increasing. Less areas in experimental groups are observed than that in the control group. Histological section in the experimental group showed no obvious except a slight compressive damage in the tunica intima. In the control group, vessel wall showed irreversible damages.
Conclusions: This experiment indicated that the SMA clamp, which has a unique mechanical property, can be used without vessels damage. This pressure controlled clamp can be a selection in clinical apparatus to improve surgical safety.

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Background: Thymic cysts are usually located in the neck or anterior mediastinal compartment. Thymic cysts arising in the middle mediastinum are extremely rare, with only 2 previously reported cases. We herein describe the third case of a thymic cyst in the middle mediastinum.
Case: A 41-year-old female was referred to our department because of an incidental mediastinal mass detected on chest X-ray. Computed tomography showed a well-defined 7 cm mass located in the retroinnominate vein area. Magnetic resonance imaging showed a cystic lesion without any soft tissue density in the circumference. The border of the tumor was clear, without any invasion and continuity with the surrounding tissue. We performed thoracoscopic surgery. After aspiration of the serous contents in an end-pouch, the tumor was removed from the thoracic cavity. A pathological examination showed a fibrotic cyst wall containing the thymic cyst, which diagnosed it as thymic cyst.
Conclusion: Thymic cysts in the middle mediastinum are extremely rare. A surgical resection provided the histological diagnosis of a thymic cyst in the present case.

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We report a 64-year-old man with incidentally found uncorrected total anomalous pulmonary venous connection (TAPVC). There have been only a few case reports of untreated TAPVC diagnosed after 60 years of age. Also, this is a first case report of TAPVC in which ECG-gated CT and phase-contrast cine magnetic resonance imaging (PC-MRI) was performed. He was referred to our hospital for the surgery of rectal cancer. He had been diagnosed to have an arterial septal defect (ASD) and persistent left superior vena cava (PLSVC), and Eisenmenger’s syndrome was thought to be the cause of cyanosis at first. The vertical vein in TAPVC was initially misdiagnosed as PLSVC on enhanced axial CT images reconstructed with 5-mm slice thickness with gapless. ECG-gated CT and PC-MRI were useful to confirm the diagnosis. The vertical vein in TAPVC is morphologically similar to PLSVC. This kind of abnormality would be somewhat difficult to diagnose on non-ECG-gated CT, and might be misdiagnosed as a large ASD and PLSVC.

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We report an 86-year-old woman with a large tracheal laceration caused by tracheal intubation at cardiopulmonary arrest who underwent a successful stent procedure. Tracheal laceration developed in the membranous portion longitudinally 6 cm in length to 2 cm above the carina. Following 9 days’ tracheal intubation, a Y-shaped silicon stent was inserted over the lacerated trachea. Four months after the stenting procedure, we removed the Y-shaped silicon stent from the healed membranous wall. The patient returned to daily life without requiring thoracotomy.

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Complications of pectus excavatum surgery include pneumothorax, pleuritis, hemothorax, pericardial effusion, displacement of bar, pericarditis and cardiac injury, etc. This is the case of a 15-year-old boy with cardiac tamponade caused by pericarditis who had taken the operation for a pectus excavatum repair one year previously. The cause was a sternal wire which was used for attachment of the bar to sternum that had fractured and migrated through the pericardium causing a pericardial injury and a pericarditis.

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Central venous thrombosis may often arise following central venous cannulation for temporary haemodialysis access. Venous thrombosis may be clinically asymptomatic due to the presence of collateral circulation. However, if an arteriovenous (AV) fistula is prepared below the obstructed venous segment, then symptoms may occur. Central venous hypertension interferes with dialysis, compromises limb function and threatens its safety. Percutaneous treatment is mostly used. However, in some cases endovascular treatment may not be as easy and long term patency uncertain.
We report our experience on 3 patients on chronic hemodialysis treatment presenting with a patent AV fistula and ipsilateral subclavian vein chronic fibrotic obstruction. They were treated by ipsilateral internal jugular to distal subclavian vein transposition. Two separate surgical incisions were performed to expose the subclavian vein distally to the occlusion and the jugular vein that was distally ligated and transposed. There was no mortality nor significant postoperative complications. Resolution of hypertensive symptoms was achieved within 3–4 weeks in all patients. The AV fistula was used for dialysis treatment starting from the first postoperative day. At follow-up (mean 13 months), there was no recurrence of upper limb venous hypertension.
In patients with subclavian occlusion and ipsilateral low flow, patent AV fistula, jugular to distal subclavian vein transposition may prove useful in cases when percutaneous angioplasty is technically not feasible or long term patency is not expected.

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Tracheo-innominate artery fistula (TIF) is a surgical emergency with high mortality rates. Reported incidence is 0.1%–1.0% after tracheostomy with peak incidence 3 days to 6 weeks post procedure. TIF is usually fatal once it bleeds. For the successful management of TIF, treatment should be initiated immediately with the special considerations kept in mind. We describe two cases of TIF, and its clinical characteristics are reviewed in accordance with relevant literature.

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Although small experiences have been described with the use of apico-aortic valved conduit in the treatment of hypertrophic cardiomyopathy (HCM), the long-term follow-up has never been previously reported.
In a young female patient with symptomatic HCM and a prognostically unfavorable phenotype, apico-aortic conduit was chosen instead of conventional myectomy because severe ventricular hypertrophy involved the whole ventricle, making outflow tract cavity virtually absent in systole. Close clinical and imaging follow-up was postoperatively performed. The patient remained asymptomatic, without cardioactive drug therapy for 30 years, also experiencing 2 successful pregnancies. A striking finding was the perfect patency of the conduit at the last follow-up control (31 years), with computed tomography and echocardiography showing no calcification of the porcine Hancock bioprosthesis inside the graft. Nevertheless, the disease slowly evolved towards the dilative phase and the patient experienced sudden death while scheduled for implantation of defibrillator in waiting list for heart transplant.
The present case could suggest that, in selected cases of HCM not treatable by myectomy, apico-aortic conduit may be an option. The relief of the obstruction can provide even long-term freedom from symptoms, however, late evolution to end-stage cannot be prevented.

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Many surgical approaches have been taken when closing ventricular septal defects after correcting transposition of the great arteries in order to avoid postoperative complete heart block. We describe a residual ventricular septal shunt that developed after repair using de Leval’s method in a patient with congestive heart failure. The defect was closed transaortically without a complete heart block.

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A 68-year-old man underwent double-valve replacement (DVR) for active infective endocarditis caused by Enterococcus faecalis. Postoperative coronary angiography (CAG) revealed a saccular aneurysm originating from the distal portion of LMCA with severe stenosis at the ostium of the left anterior descending (LAD) artery and left circumflex artery (LCx). Emergent surgical resection with concomitant coronary artery bypass grafting were performed.
Mycotic coronary artery aneurysms have a great tendency to rupture, and this may result in cardiac tamponade and sudden death. Early recognition and prompt surgical intervention is mandatory to minimize those fatal complications.

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We report an 87-year-old woman with right ventricular perforation due to a permanent pacemaker lead detected 4-days after implantation. The pacemaker lead was seen to perforate through the myocardium and pericardium and to reach the left pleural cavity. We removed the wire surgically by median sternotomy. The pericardial effusion was cloudy and yellowish, suggesting infection. However, no bacteria were detected by bacterial cultures of the pericardial effusion and pacing wire. The patient developed neither mediastinitis nor sepsis after the operation, and a new pacemaker was implanted safely one month later.

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A 59-year-old male who had undergone aortic and mitral valve replacement with Starr-Edwards ball valves 27 years ago was admitted to our hospital for hemolytic anemia and heart failure. Echocardiography revealed prosthetic valve failure with a high-pressure gradient and small effective orifice area. The Starr-Edwards ball valves were successfully replaced with bileaflet mechanical valves. The explanted valves revealed no structural abnormalities.

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Thymoma has malignant potential and is the most common anterior mediastinal tumor. Video-assisted thoracic surgery (VATS), which is less invasive surgical procedure, is a good option for resecting Masaoka stage I tumors. Whether VATS is appropriate, depends on the surgeon’s judgment and accurate imaging diagnosis. We introduce a technique involving a combination of video-assisted thoracoscopic thymectomy (VAT-T) and lateral thoracotomy for stage II and some stage III thymomas that have locally invaded the lung and/or pericardium.

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