A 14-year-old boy who underwent aortic valve-sparing operation for annuloaortic ectasia at the age of 9 was referred to our service with a diagnosis of acute type A aortic dissection. Emergency total arch replacement with the elephant trunk technique was done successfully and the postoperative course was uneventful. However, computed tomography (CT) 2 weeks after the operation showed a new dissection and enlargement in left subclavian artery and folded elephant trunk. Dilatation in coronary buttons were also seen since the time of surgery. No residual dissection was found in the aorta. Careful follow up is necessary for this case due to multiple aneurysmal changes and a new dissection lesion in a short period. Loeys-Dietz syndrome (LDS) is characterized by vascular findings (aortic aneurysm and dissection) and skeletal manifestations. Due to aortic dissection occurring in smaller diameter aortas in LDS patients than in Marfan syndrome, early and aggressive surgery is recommended for patients with LDS.

The incidence of wound infection and delayed wound healing was greater in neonates and infants less than 3 months old who had undergone open heart surgery through a median sternotomy than in older patients. To reduce these problems, we stopped using continuous absorbable braided suture for skin and subcutaneous tissue closure in August 2005, and used interrupted non-absorbable monofilament suture instead. Around the same time, we adopted hydrocolloid dressing as a substitute for gauze dressing. We evaluated the effectiveness of wound management by comparing 28 patients who had undergone surgery before August 2005 with 22 patients who underwent surgery after that date. The age at surgery was 45±30 and 21±23 days, respectively. The patients in the earlier period were significantly older than in the later period. There were no significant differences in body weight at surgery, operating time, or cardiopulmonary bypass time between the groups. The time for wound closure was 30±11 and 22±4 min, respectively, and the patients were hospitalized after surgery for 61±41 and 44±31 days. Both were significantly shorter in the later group of patients. There was a single case of mediastinitis, in the earlier period. Wound infection or delayed wound healing occurred in 8 patients in the earlier period and in 3 patients in the later period. The only 4 patients who required wound resuturing were all in the earlier period. The incidence of wound infection and delayed wound healing tended to be low in the later period. We believe that interrupted non-absorbable monofilament sutures improved the wound microcirculation and that the hydrocolloid dressing accelerated wound healing via its moisturizing and heat-retention action, pH buffering ability, and bacteriostatic activity, and that all these contributed to the better outcomes in the later period.

Multisite pacing has recently been available as a new treatment for patients with congestive heart failure. This study was intended to evaluate the effects of atrioventricular myocardial pacing on left or biventricular sites. Eleven patients (4 men, 7 women) who had undergone atrioventricular myocardial pacing between January 2000 and April 2002 were selected for this study. They ranged in age from 24 to 74 years (mean age 58.5 years). The diagnosis was dilated cardiomyopathy in 3 patients, ischemic cardiomyopathy in 4, complete atrioventricular heart block in 2, sick sinus syndrome in 1, and atrial fibrillation with bradycardia in 1. The method of pacemaker implantation was atrioventricular myocardial pacing on left or biventricular sites by means of mini-thoracotomy under general anesthesia. A DDD-R pacemaker was used. When biventricular pacing was employed, the ventricular pacing lead was cut, connected with a Y adapter, and implantation was made biventricularly. We analyzed pre- and postoperative hemodynamic states by means of a Swan-Ganz catheter, and clinical course (NYHA class). There was a significant difference between pre- and postoperative clinical course and hemodynamic state. The atrioventricular myocardial pacing on left or biventricular sites was a useful method of improving the clinical course and hemodynamic state. It is concluded that this method is available as a new therapeutic option in patients with congestive heart failure.

A 2-month-old male infant was transferred to our hospital for suspected cardiomyopathy because he had livedo reticularis and peripheral coldness. An electrocardiogram showed ischemic change and an echocardiogram showed a dilated, poorly functioning left ventricle. Therefore, we performed urgent cardiac catheterization. The coronary artery was not visualized by aortography, but the single coronary artery arising from the pulmonary artery was depicted by pulmonary angiography. Therefore, we performed emergent surgery. The whole coronary arteries traveled directly inferiorly from the left side of the pulmonary trunk. A patent ductus arteriosus (PDA) was closed at the operation. We established cardiopulmonary bypass using two arterial cannulae through both ascending aortas and pulmonary trunk to maintain coronary blood flow. Direct implantation is difficult because the coronary ostium is far from the ascending aorta. Therefore, we chose to perform the Takeuchi procedure using an intrapulmonary artery tunnel. The patient's postoperative course was good, and he was discharged on postoperative day 22. A case of an anomalous origin of a single coronary artery from the pulmonary artery without any other heart disease is extremely rare. Management of cardiopulmonary bypass and myocardial protection in this abnormality is discussed.