Harold G. Roberts

An Effective Modification to Simplify the Right Atrial Lesion Set of the Cox-Cryomaze

Reluctance to perform biatrial Cox-cryomaze is primarily to avoid the vexation of creating a right-atrial-lesion (RAL) set of Cox-Maze-III. An alternative pattern of RAL set includes (i) a horizontal atriotomy, continued medially as a linear cryolesion across the posterior tricuspid annulus, (ii) a cavocaval lesion, and (iii) a lateral cryolesion from the midportion of the atriotomy to the tip of the right atrial appendage (RAA). This latter lesion is a substitute for a cryolesion that, in past, was directed medially by a stab wound in the tip of the RAA to the anterior tricuspid annulus. Use of the simplified RAL set, therefore, allows for more deftly achieving a complete biatrial Cox-cryomaze.

Repairing the Posterior Postinfarction Ventricular Septal Defect: A Left Ventricular Approach With a Sealant Reinforced Multipatch Technique

An uncommon complication of acute myocardial infarction (AMI), postinfarction ventricular septal defect (PI-VSD), often yields devastating outcomes. Because of the strikingly poor quality of the residual tissue, the repair of PI-VSD poses a surgical challenge and is associated with high operative mortality as well as residual or recurrent shunting. Among the various techniques that have been developed, we prefer a left ventricular approach to repairing PI-VSD by using a multipatch technique reinforced with a sealant as an adjunct to surgical repair. In this method, 3 patches are used: two overlay the left side of the VSD with a sealant (composed of albumin cross-linked to glutaraldehyde) sandwiched between them, whereas a third patch is used to cover the ventriculotomy defect. The rationale is that the use of such a sealant decreases the complications of PI-VSD repair by providing a sturdier surface for suture placement, thereby decreasing suture dehiscence and consequent recurrence of septal rupture. This multipatch technique offers hope in improving the results of the surgical management of PI-VSD.