Coronary artery obstruction, pulmonary stenosis, aortic valve regurgitation, and enlargement of the neo-aortic root are major complications of arterial switch operation (ASO) for transposition of the great arteries (TGA). Supravalvular aortic stenosis following ASO is rarely reported, and technical factors should be considered as causes in such cases. We report a case of supravalvular aortic stenosis following ASO, in which we speculated that the cause of the stenosis was tissue overgrowth caused by the surgical suture. The patient was a 4-month-old girl with TGA (II) who had undergone ASO on the 12th day after birth. Neo-aortic anastomosis was performed with 7-0 polydioxanone absorbable suture (PDS^®, Ethicon, Somerville, NJ, USA). Transthoracic echocardiography performed 1 month after the surgery showed severe stenosis at the aortic anastomosis which worsened progressively. Therefore, the patient was reoperated 4 months after the previous surgery. The concentrically stenosed aortic wall at the anastomotic site was resected and aortic reanastomosis was performed using an interrupted suture pattern with 7-0 polypropylene (Prolene^®, Ethicon). The histological findings showed proliferation of collagenous fibers around the PDS^® suture. Because of the worsening stenosis over time and the histological findings, we speculated that the tissue overgrowth in reaction to the PDS^® suture was the main cause of the stenosis. Absorbable sutures are useful because they do not leave a foreign substance in the body ; however, the possibility of tissue overgrowth leading to anastomotic stenosis cannot be denied. When using absorbable suture, careful observation is mandatory until the material is completely absorbed.

We reviewed our experience of tricuspid valve surgery for tricuspid regurgitation in hypoplastic left heart syndrome (HLHS) in terms of surgical timing, surgical procedures and long-term results. From May 1991 to July 2010, 105 classic HLHS patients underwent cardiac surgery, 28 of whom underwent a total of 31 tricuspid valve surgical procedures. Tricuspid valve surgery was performed in cases of moderate or more tricuspid regurgitation (TR). Type of the first tricuspid valve surgery was as follows : Annuloplasty in 15 patients, annuloplasty+commissure closure in 7 patients, commissure closure in 2 patients, edge-to-edge repair in 2 patients, tricuspid valve replacement in 2 patients. Three patients underwent re-operation because of progression of TR. Two of them underwent tricuspid valve repair and one of them underwent tricuspid valve replacement. Follow-up was 60.1±53.0 months. Freedom from moderate or more TR after tricuspid valve surgery was 50.9% at 1 year, 42.0% at 3 years, 36.0% at 5 years. Among 17 patients who achieved total cavopulmonary connection procedure, 35.2% of patients had moderate or more TR, but central venous pressure (9.1±2.2 mmHg), cardiac index (3.5±6.8 l/min/m²), arterial oxygen saturation (94.2±1.7%) showed as good hemodynamics after a Fontan procedure as non-tricuspid valve surgery cases. Appropriately timed aggressive tricuspid valve surgery yielded as good long-term results as HLHS without tricuspid valve surgery.

Persistent massive air leak after pediatric cardiac surgery is a rare and possibly life-threatening complication which is difficult to treat. We report a 3-month-old boy with hypoplastic left heart syndrome that underwent Glenn take-down, suffered from pulmonary hemorrhage during surgery and needed mechanical ventilation with high airway pressure that caused bilateral pneumothorax. After pulmonary hemorrhage improved, pneumothorax with persistent air leaks did not resolve under prolonged chest tubes. This patient underwent an autologous “blood patch” pleurodesis on postoperative day 32. The procedure was repeated a second time 48 h after the application of the first blood patch. After these procedures, air leaks dramatically ceased. The patient was successfully weaned from the ventilator on postoperative day 70. Pleurodesis with an autologous blood patch is a safe and an effective technique for the treatment of persistent air leaks, even for a 3-month-old boy with hypoplastic left heart syndrome.

Bleeding control during aortic surgery is one of the most important issue. The well-known fibrinogen-based hemostat contains the blood product, which means the potential risk of the blood-related infection. Recently, the newly-designed hemostat “Hydrofit”, which is assembled with urethane-based polymer without blood product (Matsudyte : Sanyo-chemical industry, Kyoto, Japan). Hydrofit is applicated for the hemostasis of thoracic aortic surgery. In sealing of the Hydrofit gel to the anastomosis site of aorta, water-contact initiation boosts the chemical change to the forming elastomer and adheres around anastomosis site rapidly. We experienced the extirpation of the Hydrofit which was used over 4 years ago. The patient is 42 year-old female who was operated aortic valve replacement and graft replacement of ascending aorta using a Hydrofit as a hemostat at 4 year 8 months ago due to the aortitis syndrome. Re-sternotomy and re-AVR was performed because of the prosthetic valve dehiscence due to the active aortitis syndrome. Hydrofit left around suture line without infection, and functioned very well as the elastic sealant for the long-term period.