Commentary: "Details make perfection, and perfection is not a detail" (Leonardo da Vinci).

In 1995, I (G.E.K.) had the chance to visit during some months Professor Carpentier in Paris and Professor David in Toronto. Both events marked undoubtfully my further professional career; nonetheless, the months spent in Toronto decided my main field of development in cardiac surgery. While reading the last report by David and colleagues1 on the reimplantation of the aortic valve (AV), published in the current issue of the Journal, I reflected on the evolution of valve-sparing procedures during these last 25 years, in particular on what is widely known as the David procedure. [...

Commentary: A symmetrical bicuspid aortic valve is not just 180°.

Type 0 bicuspid aortic valves (BAVs) according to Sievers classification1 present 2 symmetrical cusps of same size with a perfectly fused cusp, no raphe, and symmetrical anterior and posterior annulus. These valves have shown improved results after repair compared with type 1,2 where there is an incomplete fusion of the conjoined cusps with a raphe and a certain degree of asymmetry between the fused and nonfused cusps. In recent years, we have observed an increased interest in achieving the symmetry during type 1 BAV repair to approach the type 0 configuration and improved result

Commentary: The depth of the virtual basal ring.

The anatomic demarcation between the left ventricular outflow tract (LVOT) and the aortic root, and thus the beginning of the arterial system, is the ventriculoaortic junction (VAJ). However, in an anatomic study in human hearts, we have demonstrated that the VAJ is rather curvilinear. [...

Ischemic gastric ulcer after coronary bypass using the right gastroepiploic artery

The gastroepiploic artery has been widely used for complete arterial myocardial revascularization of young patients. Gastric complications related to the harvesting of this artery are exceptional. We describe here a case of ischemic gastric ulcer due to the use of a gastroepiploic artery in a patient with severe celiac trunk disease. The patient was cured by angioplasty completed by a stenting procedure

Differences in vasoreactivity between gastroepiploic artery grafts late after bypass surgery and grafted coronary arteries

BACKGROUND: The gastroepiploic artery is increasingly used as an alternative arterial coronary bypass conduit. In vitro studies have reported differences in vasoreactivity among various types of coronary graft conduits, susceptible to influencing the adaptation of myocardial blood flow and long-term patency rate. METHODS AND RESULTS: To evaluate in vivo the vasoreactivity of gastroepiploic artery grafts implanted long-term, nine angiographically smooth grafts implanted to the distal right or to the left circumflex coronary artery were studied with quantitative angiography 6 to 36 months after surgery. Angiograms were obtained on 35mm cinefilms in basal conditions, after injection of methylergometrine (0.4 mg IV), and after intragraft injection of 1 mg isosorbide dinitrate. In basal conditions, there was no difference in luminal diameter between gastroepiploic and coronary arteries (1.64 +/- 0.32 versus 1.51 +/- 0.31 mm; P = NS). After methylergometrine, a constriction was observed in all gastroepiploic artery grafts (-14 +/- 6% of basal diameter) and in all but one grafted coronary artery (-6 +/- 5%). After isosorbide dinitrate, a dilation was consistently observed in all gastroepiploic artery grafts (+26 +/- 9%) and grafted coronary arteries (+14 +/- 7% of basal). Changes in lumen diameter in response to these constrictor and dilator stimuli, either expressed in absolute values or in percentage of control were significantly greater (P < .001) in gastroepiploic artery grafts than in grafted coronary arteries. CONCLUSIONS: Gastroepiploic artery grafts implanted long-term are more reactive than grafted coronary arteries to ergometrine and nitrates. This response differs from that previously reported of internal mammary artery grafts to the same pharmacological vasoactive stimuli. This suggests that the concept of a more efficient endothelium-dependent control of vasomotor tone contributing to better long-term functional results of internal mammary artery grafts cannot be directly extrapolated to gastroepiploic artery grafts

Minimally invasive robotic excision of a cardiac septal neuroendocrine metastasis.

We present a rare case of a myocardial neuroendocrine metastasis in a 45-year-old male patient. The tumor was localized on the left side of the interventricular septum. Complete surgical excision of the tumor was successfully performed robotically  through a left atriotomy, using a transmitral approach. The patient's postoperative course was uneventful. A robotic mini-invasive approach is a safe and feasible alternative to conventional surgery and should be considered when the anatomy is suitable for a minimally invasive procedure. FULL TEXT and VIDEOS Free online (https://mmcts.org/tutorial/1497

Surgical angioplasty of the left main coronary artery

OBJECTIVE: The conventional surgical treatment of isolated critical stenosis of the left main coronary artery (LMCA) leads to the definitive occlusion of LMCA, restores only a retrograde perfusion to a rather extensive myocardial area and consumes bypass material. Direct surgical angioplasty avoids these inconveniences. METHODS: Between June 1985 and August 1996, 49 surgical angioplasties have been performed in 47 patients. LMCA was approached posteriorly in the first 11 procedures, and an anterior approach was preferred in the last 38 because of better exposure. The onlay patch consisted of saphenous vein in 37 cases; pericardium was used in 12 cases, and only for ostial stenosis. RESULTS: No technical failure occurred in the last 28 cases. 44 procedures, (90%), succeeded, but 1 patient (2.3%) died later of a massive air embolism, and 2 patients needed conventional CABG after 3 and 5 months, respectively. The 35 survivors still benefiting from a successful LMCA angioplasty on the long term are free of ischemia after a mean follow-up of 75 months (2-136). Angiographic restudy was obtained in 30 patients (70%) at an average of 38 months and revealed an excellent result in 26 (87%). In 10 patients, a late angiographic restudy at an average of 71 months (32-119) still revealed a perfect result. CONCLUSION: Provided that well-defined contra-indications (involvement of the distal bifurcation, heavy calcification) are respected, LMCA surgical angioplasty deserves a place in the array of surgical strategies

Huge left ventricular aneurysm in a minimally symptomatic 11-year-old boy

An 11-year-old boy presented with mild shortness of breath and tachycardia and was diagnosed with a huge left ventricular aneurysm ruptured in a secondary pseudoaneurysm. This report highlights the complementary use of echocardiography and cardiac magnetic resonance imaging in the preoperative assessment of this anomaly

Aortic allograft and pulmonary autograft for aortic valve replacement: mid-term results

Between April 1990 and August 1996, 138 patients (median age 42 years, range 10 days to 66 years) underwent aortic valve or root replacement with allografts (n = 70) or autografts (n = 68). Aortic stenosis was the main indication (80 patients, 58%) followed by aortic incompetence (31 patients, 22%). Twenty-five patients had endocarditis (18%) and two patients had truncus repair (2%). Some 140 allograft valves were inserted (70 pulmonary, 70 aortic). Most of the valves were conditioned and cryopreserved by the European Homograft Bank, Brussels, Belgium. Subcoronary implantation was performed in 46 patients, intraluminal cylinder in 29 and root replacement in 63. Peroperative transoesophageal echocardiography was routinely used. Three patients required valves replacement by mechanical valves at the time of surgery due to technical failure. Seven patients (5%) died early, while 131 were followed up from 1 to 76 months (mean 32 months). There were two late deaths. All survivors are in NYHA class I and currently free of any medication. There have been no thromboembolic events. Three patients developed endocarditis (2%). Transthoracic echocardiography was performed routinely in all patients; an initial study showed grade 1 aortic incompetence in nine patients and grade 2 in two. Late studies up to 6 years after surgery showed progression of aortic incompetence in 18 of 43 survivors with subcoronary implantation and in four of 75 survivors who underwent other techniques (P < 0.002). In congenital patients with preoperative aortic incompetence, the left ventricular function has been prospectively analysed by echocardiography. Risk factors have been identified as dilated ventricles with spherical shapes, thin wall and reduced velocities by measuring ejection fraction and velocity of shortening of myocardial fibres. Allograft and autograft replacement of the aortic valve can be performed with excellent results. Considering the risk of degeneration of allografts, and the growth potential of the pulmonary autograft, this should be regarded as the optimal method of treatment for diseased aortic valves in neonates, children and young adults