Cardiothoracic RSS : Gourt

Permanent Cardiothoracic Surgery Job in Olympia Washington with Providence Health & Services

Olympia, Washington Providence St. Peter Hospital and an excellent local private Cardiothoracic Surgery practice are partnering in search of a Physician Assistant or ARNP to serve the community. Will

Permanent Cardiothoracic Surgery Job in Joplin Missouri with Heart & Vascular, PC

CV Surgeon needed to join busy cardiovascular/thoracic surgical practice. Very unique peripheral vascular case load with heavy emphasis on endovascular interventions. Regional tertiary referral

Locum Tenens Cardiothoracic Surgery Job in Florham Park Michigan with Medical Search International

CARDIOTHORACIC SURGEON - LOCUMS - MICHIGAN - Start May 15 & 16, 2009. THEREAFTER 5 to 7 day openings per month for the next several months. -- OUTSTANDING COVERAGE FEE $$$$$$$$ -- GREAT LOCATION

Locum Tenens Cardiothoracic Surgery Job in Michigan Michigan with Medical Search International

I have a hospital in Northern Michigan that needs a cardio thoracic surgeon for the dates of May 15 & 16. They are also going to be needing 5-7 day stints each month for the next several months. There

Locum Tenens Cardiothoracic Surgery Job in Call Coverage Opportunity in for Cardiothoracic and Vascular in Arkansas! Arkansas with LocumTenens.com

Details: Call only July 20th - 28th 8am - 8am Must be able to perform Cardio Thoracic And Cardio Vascular procedures. Located in northern Arkansas centered in a friendly active community! LocumTenens.com

Permanent Cardiothoracic Surgery Job in Northern California - 1 Hour to the Bay Area California with Cardiothoracic Surgery - Group Practice-California

Group Practice Northern California One hour to the East Bay In order to qualify for this opportunity, the Heart Surgeon must be Trained and experienced in Robotics (da vinci Robot onsite) Strong

Permanent Cardiothoracic Surgery Job in CTS111658 California with Northern CA/Robotic and Valve Experience Required

Group Practice Northern California One hour to the East Bay In order to qualify for this opportunity, the Heart Surgeon must be Trained and experienced in Robotics (da vinci Robot onsite) Strong

Permanent Cardiothoracic Surgery Job in Knoxville Tennessee with Job Job Recruiting

Cardiothoracic Surgery Busy, well-established group of cardiothoracic surgeons looking to add a cardiothoracic surgeon. Income guarantee Practice at a "Top 100 Heart Hospital", Medical Center

Permanent Cardiothoracic Surgery Job in Knoxville Tennessee with Job Job Recruiting

Busy, well-established group of cardiothoracic surgeons looking to add a cardiothoracic surgeon. Income guarantee Practice at a "Top 100 Heart Hospital", Medical Center

Permanent Cardiothoracic Surgery Job in Cardiothoracic Surgeon with Endovascular Skills Needed in Scenic Coastal Oregon - Close to PAC-10 Un Oregon with

Job 6512123 Opportunity for a Board Certified or Board Eligible Cardiothoracic Surgeon, with Endovascular training and skills. Prefer recently trained surgeons and prefer a 2009 or 2010 grad. No J1s

Permanent Cardiothoracic Surgery Job in Hospital Employed Cardiothoracic Surgery Position In College Town Mississippi with

Job 6512031 As an employee, avoid the headaches of running a practice Competitive compensation package with terrific benefits Commencement Bonus Benefits package includes retirement savings plan and

Permanent Cardiothoracic Surgery Job in CVT Practice Opportunity in a Great Location Alabama with CompHealth Inc

Job 6511766 Board Certified or Board Eligible Thoracic surgeon, CVT Fellowship trained Must do off pump procedures Partnership track with CVT surgery group Excellent location for family living - great

Permanent Cardiothoracic Surgery Job in CardioThoracic Surgery with Big Volume of Open Hearts Tennessee with CompHealth Inc

Job 6510246 SSG of CVT Surgeons Hospital based group Call of 1:3 Must have MIS Cardiac Surgery Skills Work out of one large hospital with 500+ beds Cardiac, thoracic and vascular available No State

Permanent Cardiothoracic Surgery Job in Call for information Illinois with Inhouse Physician Recruiters Network

The In-House Physician Recruiter Network, composed of over 500 hospital recruiters, represents over 10,000 hospitals and clinics. Our Network's special feature is to showcase outstanding physicians (who

Permanent Cardiothoracic Surgery Job in Statewide Virginia with The Doctor Job

Looking for a job in a big city? Even if you've heard that a market is "saturated", we can help! Many job openings for physicians may be hidden and unavailable unless you know where to look. An excellent

Permanent Cardiothoracic Surgery Job in Statewide Texas with The Doctor Job

Permanent Cardiothoracic Surgery Job in Statewide Pennsylvania with The Doctor Job

Permanent Cardiothoracic Surgery Job in Statewide New York with The Doctor Job

Permanent Cardiothoracic Surgery Job in Statewide Indiana with The Doctor Job

Permanent Cardiothoracic Surgery Job in Statewide Illinois with The Doctor Job

Penn Cardiac Care Ranked 12th in Nation

Penn Cardiac Care at the Hospital of the University of Pennsylvania has been ranked 12th in the nation, and best in the Philadelphia region, for heart care and heart surgery by U.S.News and World Report's 2008 Best Hospitals ranking. Since 1990, U.S.News has published this annual special issue, which provides a ranking of hospital quality of care on a nationwide basis and is meant to help consumers make informed decisions when looking for hospital care.

Join the 2008 Start Heart Walk

The 10th Annual Heart Walk will take place on Saturday, November 15, 2008 at Citizen’s Bank Park - Home to our own Philadelphia Phillies! We encourage you to join Penn’s Heart Walk team today! Your participation will help support Penn Cardiac Care and the American Heart Association’s efforts to develop programs and research dedicated to finding better treatments and cures for heart disease and stroke. These issues truly affect our business and touch our families, friends, associates, and the communities we serve.

Penn Cardiovascular Institute

Over the past decade, cardiovascular research and clinical care at the University of Pennsylvania has grown tremendously with many nationally and internationally recognized research and clinical programs. The Penn Cardiovascular Institute (CVI) was established in 2005 to build bridges between scientists and clinicians. This collaborative spirit has facilitated the development of novel treatments and therapies, which patients at Penn have been among the first in the world to benefit from. Our researchers and clinicians continue to discover new breakthroughs that lead to life-saving procedures, devices and medications that will positively impact the care of individuals with cardiovascular disease.

Women's Heart Health Program at Mercer Bucks

To help improve the cardiovascular health of women, Penn Cardiac Care at Mercer Bucks introduces the Women’s Heart Health Program. The Women’s Heart Health Program’s mission is to help improve the cardiac health of women by offering free screenings, comprehensive risk factor assessments and the knowledge to create healthy lives and lifestyles.

HUP Heart Transplant Recipients Compete in 2008 U.S. Transplant Games

In July, the 2008 U.S. Transplant Games where held in Pittsburgh, PA, where more than 1,200 men, women and children have traveled from across the country to prove that transplantation works. Participants all received life-saving transplants and celebrated their success by competing in these games.

New Physicians at Penn Cardiac Care

Read about new physicians and new practices here at University of Pennsylvania Health System.

Penn Cardiac Care Locations

Penn Cardiac Care's cardiologists and cardiothoracic surgeons see patients for evaluation and treatment at practices located in hospitals of the University of Pennsylvania Health System, and at other convenient locations throughout the region. To make an appointment with a Penn Cardiac Care physician or for more information, please call 800-789-PENN or visit www.pennhealth.com/cardiac.

[Presidential Obituary] David C. Sabiston, Jr, MD

[Editorials] Tribute to a pioneer: Viking Olov Bjork, 1918-2009

[Editorials] The second assistant in cardiac surgery: The challenges and answers

[Editorials] Invited Commentary

[Editorials] Not if, but when

[Thoracic Surgical Education] Weathering the storm: How can thoracic surgery training programs meet the new challenges in the era of less-invasive technologies?

Objective The introduction of new technologies has shifted some resident index procedures to nonsurgical specialists. We examined the operative case volume of thoracic surgery residents during the last 6 years to objectively identify changes and trends. Methods Program and resident data from 2002 to 2007 were entered into a database and analyzed. Program match information was obtained from the National Resident Matching Program. Resident operative experience and board examination results were obtained from the American Board of Thoracic Surgery. Results A total of 795 residents qualified for the written American Board of Thoracic Surgery examination; 627 residents graduated from 2-year programs, and 168 residents graduated from 3-year programs. The total number of resident cases was higher in 3-year programs compared with 2-year programs in all 10 index categories studied (P < .01). The total volume of cases has not significantly increased in 2-year programs. The volume of coronary artery bypass graft surgeries decreased in every resident program model studied. The volume of general thoracic cases increased in all program models. Two-year, 2-resident programs had the lowest volume in 5 of the 10 categories, reaching significance in 3 categories. The written board pass rate was lower among 2-year programs than among 3-year programs (86% vs 95%, respectively, P = .003). Conclusion Training programs have so far weathered the storm by maintaining index volume with a new case mix, but significant trends in revascularization procedures are concerning. This study indicates a significant advantage in case volume and board pass rates among 3-year programs. Thoracic residency programs should be reorganized so that the number of residents does not exceed the capacity of the program to provide a meaningful experience.

[Thoracic Surgical Education] Discussion

[Congenital Heart Disease] Cardiovascular surgery in children with Marfan syndrome or Loeys-Dietz syndrome

Objective This study was undertaken to assess the frequency and outcome of cardiovascular surgery in children with Marfan or Loeys-Dietz syndrome. Methods A retrospective review from 2 regional Marfan subspecialty clinics was performed. Between 1997 and 2007, 204 children with Marfan syndrome and 17 children with Loeys-Dietz syndrome were followed serially. Of these patients, 35 were identified who had undergone cardiovascular surgery at 18 years of age or less. Demographic, echocardiographic, and surgical data were collected. Results Surgery was performed at a median of 3 years (0–15 years) after diagnosis and a mean age of 11.5 ± 6.2 years. Aortic root replacement was the initial surgery in 30 patients, and mitral valve surgery was the initial surgery in 8 patients, with 3 patients undergoing both. Aortic root replacement was performed using a composite root replacement in 9 patients and valve-sparing techniques in 21 patients (remodeling in 8 patients and reimplantation in 13 patients). Eight patients underwent reoperation at a mean of 4.7 ± 3.0 years after aortic surgery: 3 for aortic insufficiency, 2 for dissection, 2 for valve thrombosis, and 1 for a distal aneurysm. Adverse outcomes included reoperation in 8 patients, aneurysm in 1 patient, and death due to dissection or stroke in 3 patients. Variables associated with an adverse outcome included preoperative aortic insufficiency, valve replacement, and absence of angiotensin-converting enzyme inhibitor therapy. Conclusion Patients with Marfan or Loeys-Dietz syndrome requiring surgery during childhood have a favorable long-term outcome. Those undergoing valve-sparing root replacement or mitral valve repair have a low risk for reoperation. Postoperative angiotensin-converting enzyme inhibitor therapy confers clinical benefit.

[Congenital Heart Disease] Discussion

[Congenital Heart Disease] Analysis of the US Food and Drug Administration Manufacturer and User Facility Device Experience database for adverse events involving Amplatzer septal occluder devices and comparison with the Society of Thoracic Surgery congenital cardiac surgery database

Objective Amplatzer (AGA Medical Corporation, Plymouth, Minn) septal and vascular occluder devices have significantly altered the care of patients with congenital heart disease. The relative frequency and consequence of complications resulting from the attempted placement of such devices, however, have not been well assessed. The purpose of this study is to use large databases to assess the frequency and severity of such complications and compare them with those of surgical atrial septal defect closure. Methods The US Food and Drug Administration Manufacturer and User Facility Device Experience database was quarried for all adverse events for Amplatzer septal occluder devices, which were categorized and analyzed with particular emphasis on management and outcome. The Society of Thoracic Surgery database was likewise quarried for the same data regarding atrial septal defect closures over a contemporaneous time period. By using a literature-derived denominator for total Amplatzer implant numbers, the results of the 2 therapies were compared. Results Since July 1, 2002, 223 adverse events in patients undergoing Amplatzer atrial septal defect closure were submitted to the Food and Drug Administration, resulting in 17 deaths (7.6%) and 152 surgical rescue operations (68.2%). Society of Thoracic Surgery data demonstrated 1537 primary operations with 2 deaths (0.13%) and 6 reoperations (0.39%). By extrapolating on published estimates of Amplatzer implantation to provide an implant denominator (n = 18,333), there was no difference between overall mortality for surgical (0.13%) and device closure (0.093%, P = .649). Rescue operation for device adverse events (0.83%) was 2.1 times more likely than reoperation for surgical closure (0.39%, P = .063). Mortality per adverse event was higher for device closure (7.6%) than for surgical closure (1.2%, P = .004), and the need for surgery per adverse event was higher for device closure (68.2%) than for surgical closure (3.6%, P < .001). The mortality for surgical management of a device adverse event (2.6%) was 20-fold higher than for primary elective atrial septal defect closure (0.13%, P < .0001). Conclusion Overall crude mortality for device and surgical closure atrial septal defect closure is equivalent, and the need for subsequent operation (surgical rescue) is more common in patients undergoing device closure than reoperation is in patients undergoing surgical closure. Complications from device closure tend to be serious and most often require urgent or emergency operative management, whereas the mortality for surgical management of a device complication appears higher than that of elective atrial septal defect closure. Further information is required in the form of postmarketing surveillance, such as a mandatory user registry with periodic end-user notification.

[Congenital Heart Disease] Discussion

[Congenital Heart Disease] Differential branch pulmonary artery growth after the Norwood procedure with right ventricle-pulmonary artery conduit versus modified Blalock-Taussig shunt in hypoplastic left heart syndrome

Objectives The Norwood procedure with right ventricle–pulmonary artery conduit is thought to improve postoperative hemodynamics in hypoplastic left heart syndrome, but its effects on pulmonary artery growth are unknown. This study evaluated pulmonary artery growth after the Norwood procedure in patients with a right ventricle–pulmonary artery conduit as compared with patients with a modified Blalock–Taussig shunt. Methods A total of 159 patients at our institution underwent the Norwood procedure between January 2000 and September 2005. Patients were divided into group A or B if they had a modified Blalock–Taussig shunt (n = 103) or a right ventricle–pulmonary artery conduit (n = 56). Angiograms from the pre-Glenn catheterizations were used to measure pulmonary artery size and assess shunt stenosis (n = 64). Results Fifty-five (53.4%) patients in group A versus 40 (71.4%) in group B underwent Glenn surgery. Group B patients often required an additional shunt (modified Blalock–Taussig) before the Glenn procedure because of hypoxemia (8/40 vs 1/55; P = .004). Branch pulmonary artery growth was better in group B patients who did not require an additional shunt (Nakata index 212 vs 169 mm2/m2; P = .004) and more balanced than in group A (right pulmonary artery/left pulmonary artery ratio = 1.02 vs 1.39; P = .001) as a result of greater left pulmonary artery size (29 vs 19 mm2; P = .001). However, group B experienced more shunt stenosis (8/32 vs 2/32; P = .001), underwent the Glenn operation earlier (192 vs 246 days; P = .03), and had central pulmonary artery hypoplasia develop more often than group A patients (25/32 vs 14/32; P = .01). Conclusion The Norwood procedure with a right ventricle–pulmonary artery conduit promotes better distal left pulmonary artery growth resulting in more balanced branch pulmonary artery size, but central pulmonary artery hypoplasia occurs more often. Early right ventricle–pulmonary artery conduit stenosis also increases the need for additional shunting or early Glenn surgery.

[Congenital Heart Disease] Inferior sinus venosus defect: Echocardiographic diagnosis and surgical approach

Objective We sought to define the inferior sinus venosus defect anatomically and document successful surgical approaches. Methods We identified all patients previously given a diagnosis of an inferior sinus venosus defect at the Hospital for Sick Children, Toronto, Canada, between 1982 and 2005 by interrogating the cardiology and cardiac surgery databases. We included those having interatrial communications in which 1 or more of the right pulmonary veins drained to the inferior caval vein but retained connection with the left atrium, the rims of the oval fossa, and the walls of the coronary sinus, both being intact. Results We identified 11 children who had an interatrial communication meeting the criteria for and undergoing surgical repair of an inferior sinus venosus defect. Median age was 1.2 years; 6 (55%) subjects were male, and none were cyanotic. Transthoracic echocardiographic analysis was performed preoperatively in all children, revealing right ventricular dilation in all. Surgical repair was accomplished with a pericardial patch. A complex baffle was needed in 3 children to maintain unobstructed inferior caval and pulmonary venous return. The echocardiographic diagnosis was complete in only 5 patients, but all diagnoses were correct since the year 2000. In all children the observations at surgical intervention showed that the defect was a venoatrial communication involving drainage of the right pulmonary veins to the inferior caval vein while retaining connection to the left atrium. Conclusions Transthoracic echocardiographic analysis should remain the modality of choice for diagnosis of the inferior sinus venosus defect. We report excellent surgical results with a patch or baffle, correctly redirecting the anomalous venoatrial connections.

[Congenital Heart Disease] Myocyte apoptosis occurs early during the development of pressure-overload hypertrophy in infant myocardium

Objective Abnormal hemodynamic loading often accompanies congenital heart disease both before and after surgical repair. Adaptive and maladaptive myocardial responses to increased load are numerous. This study examined the hypothesis that myocyte loss occurs during compensatory hypertrophic growth in the developing infant myocardium subjected to progressive pressure overload. Methods Pressure-overload left ventricular hypertrophy was induced in 7- to 10-day-old rabbits by banding the thoracic aorta. Left ventricular function and mechanics were quantified by serial echocardiography and noninvasive left ventricular wall stress analysis. Left ventricular tissue sections were examined for fibrosis by using Masson's trichrome stain and for myocyte apoptosis by using a myocyte-specific DNA fragmentation assay and caspase-3 activation (specific fluorescent substrate). Results Significant myocyte apoptosis (198 ± 37/106 myocytes, P < .01 vs control) and caspase-3 activation were present in early hypertrophy when left ventricular contractility was preserved and compensatory hypertrophy had normalized wall stress. By 6 weeks, multiple indices of left ventricular contractility were reduced, and left ventricular wall stress was increased. Myocyte apoptosis was accelerated (361 ± 56/106 myocytes), caspase-3 activity further increased, and the estimated total number of left ventricular myocytes was significantly reduced by 18% ± 4%. Conclusion In experimental infant left ventricular hypertrophy, myocyte apoptosis is initiated in the face of normalized wall stress and preserved contractility. The ongoing rate of apoptosis causes a measurable decrease in myocyte number that is coincident with the onset of ventricular dysfunction. It thus appears that pressure overload, even at its earliest stages, is not well tolerated by the developing ventricle.

[Congenital Heart Disease] Use of a novel valve stent for transcatheter pulmonary valve replacement: An animal study

Objective The goal of this study was to evaluate valvular functionality after transcatheter pulmonary valve replacement in sheep using a novel pulmonary valve stent. Methods Fresh porcine pericardium cross-linked with 0.6% glutaraldehyde was treated with L-glutamine to eliminate glutaraldehyde toxicity and sutured onto a valve ring before mounting on a nitinol stent to construct the pulmonary valve stent. Percutaneous femoral vein transcatheter pulmonary valve replacement was performed with the newly constructed valve stent. Pulmonary valve stents were implanted in 10 healthy sheep (6 males and 4 females) weighing an average of 25.7 ± 4.1 kg. Color Doppler echocardiography, 64-row computed tomography, and direct catheter examination were used to assess valvular function. Results Implantation was successful in 8 sheep. Shortly after surgery, all artificial valve stents exhibited normal open and close functionality and no stenosis or insufficiency. Heart rate was slightly elevated at this time, while all other hemodynamic parameters were normal. Six-month follow-up revealed no evidence of valve stent dislocation and normal valvular and cardiac functionality. There was no evidence of stent fracture. Repeated valve stent implantation was well tolerated as indicated by good valvular functionality 2 months postdelivery. Conclusion The novel pulmonary valve stent described herein can be delivered via percutaneous femoral vein transcatheter implantation and is highly efficacious at 6 months postdelivery. Furthermore, repeated valve stent replacement was successful.

[General Thoracic Surgery] Thoracoscopic sympathetic clipping for hyperhidrosis: Long-term results and reversibility

Objective The study objectives were to assess 1) postoperative satisfaction and the occurrence of compensatory sweating after endoscopic thoracic sympathetic clipping in a consecutive series of patients and 2) the reversibility of adverse effects by removing the surgical clips. Methods Between June 1998 and March 2006, 727 patients undergoing bilateral endoscopic thoracic sympathetic clipping for hyperhidrosis or facial blushing were prospectively followed for postoperative satisfaction and subjective compensatory sweating. The effect of removing the surgical clips was assessed in 34 patients who underwent a subsequent reversal procedure after endoscopic thoracic sympathetic clipping. Satisfaction and compensatory sweating were assessed using a visual analogue scale ranging from 0 to 10, with 10 indicating the highest degree. Results Follow-up was complete in 666 patients (92%). The median age was 26.9 years, and 383 (53%) were men. The level of sympathetic clipping was T2 in 399 patients (55%), T2+3 in 55 patients (8%), and T3+4 in 273 patients (38%). Median follow-up was 10.4 months (range 0–83 months). Excellent satisfaction (8–10 on visual analogue scale) was seen at last follow-up in 288 (74%) of the T2 group, 33 (62%) of the T2+3 group, and 184 (85%) of the T3+4 group. Postoperative satisfaction was significantly higher in the T3+4 group when compared with the T2 or T2+3 groups (P < .01). Severe compensatory sweating (8–10 on the visual analogue scale) was reported in 42 (13%) of the T2 group, 11 (28%) of the T2+3 group, and 17 (8%) of the T3+4 group. Postoperative compensatory sweating was significantly lower in the T3+4 group when compared with the T2 or T2+3 groups (P < .05). Thirty-four patients have subsequently undergone removal of the surgical clips after endoscopic thoracic sympathetic clipping. Follow-up was complete in 31 patients. The reasons for removal included severe compensatory sweating in 32 patients, anhydrosis of the upper limb in 4 patients, lack of improvement or recurrence of hyperhidrosis in 5 patients, and other adverse symptoms in 5 patients. The reversal procedure was done after a median time of 11.0 months (range 1–57 months) after endoscopic thoracic sympathetic clipping. The initial level of clipping was T2 in 21 patients, T2+3 in 7 patients, and T3+4 in 6 patients. There was a trend toward fewer subsequent reversal procedures in the T3+4 group when compared with the T2 or T2+3 groups (P = .06). Fifteen patients (48%) reported a substantial decrease in their compensatory sweating (5–10 on the visual analogue scale) after reversal. Thirteen patients (42%) reported that their initial hyperhidrosis or facial blushing has remained well controlled (8–10 on the visual analogue scale) after reversal. There was no significant relationship between the original level of clipping and the interval between endoscopic thoracic sympathetic clipping and the subsequent reversal and reversibility of symptoms. Conclusion When compared with endoscopic thoracic sympathetic clipping at the T2 or T2+3 levels, endoscopic thoracic sympathetic clipping at the T3+4 level was associated with a higher satisfaction rate, a lower rate of severe compensatory sweating, and a trend toward fewer subsequent reversal procedures. Subjective reversibility of adverse effects after endoscopic thoracic sympathetic clipping was seen in approximately half of the patients who underwent endoscopic removal of surgical clips. Although yet to be supported by electrophysiologic studies, reversal of sympathetic clipping seems to provide acceptable results and should be considered in selected patients.

[General Thoracic Surgery] Discussion

[General Thoracic Surgery] Superior sulcus tumors with vertebral body involvement: A multimodality approach

Objective Superior sulcus tumors with involvement of the spine have historically been considered unresectable. We have previously documented a 2-year survival of 54% in patients treated with a multimodality approach. This work builds on our previous experience and examines the long-term outcomes. Methods A retrospective review was performed on patients with superior sulcus non–small cell lung cancer tumors with involvement of the vertebral column (n = 39) treated at The University of Texas MD Anderson Cancer Center from 1990 to 2006. Their clinical and pathologic data were analyzed for short- and long-term outcomes. Results Group 1 included 8 (21%) patients with neuroforamen or transverse process involvement, group 2 had 16 (41%) patients with partial vertebrectomy, and group 3 had 15 (38%) patients with total vertebrectomy. There were 2 (5%) postoperative deaths, and 11 (28%) patients had major complications. Margins were positive in 17 (44%) patients. Recurrence occurred in 23 (59%) patients and was local in 11 (28%) patients, distant in 11 (28%) patients, and both in 1 (3%) patient. Median time to local recurrence was 7 months in patients with positive margins and has not been reached for patients with negative margins (P = .007). Median, 2-year, and 5-year overall survival was 18 months, 47%, and 27%, respectively. On multivariate analysis, the only independent predictor of shorter survival was nodal metastases (P = .001; hazard ratio, 6.5; 95% confidence interval, 2.2–19.2). Conclusion An aggressive multimodality approach involving surgical resection can be performed with acceptable morbidity in highly selected patients with superior sulcus tumors and vertebral invasion at a specialized center. Encouraging long-term survival can be achieved in patients with negative margins and no lymph node involvement.

[General Thoracic Surgery] Discussion

[General Thoracic Surgery] Thoracoscopic segmentectomy compares favorably with thoracoscopic lobectomy for patients with small stage I lung cancer

Objective As thoracoscopic lobectomy becomes widely applied for treatment of non–small cell lung cancer, thoracoscopic segmentectomy remains controversial for patients with small stage I lung cancers. Questions remain regarding safety, morbidity, mortality, and recurrence rate. This study compared outcomes between thoracoscopic segmentectomy and lobectomy. Methods Retrospective review was undertaken of patients who underwent thoracoscopic segmentectomy or lobectomy for clinical stage I non–small cell lung cancer between January 2002 and February 2008. Indications for segmentectomy were tumor smaller than 3 cm, limited pulmonary reserve, comorbidities, and peripheral tumor location. Results Thirty-one patients underwent segmentectomy and 113 underwent lobectomy. Patients after segmentectomy had worse mean forced expiratory volume in 1 second than after lobectomy (83% vs 92%, P = .04). There were no differences in mean number of nodes (10) and nodal stations (5) resected. Segmentectomy and lobectomy groups had similar median chest tube durations (2 vs 3 days, P = .18), stays (both 4 days), total complications, recurrence rates, and survivals at mean follow-ups of 22 and 21 months, respectively. Lobectomy group had 1 30-day death; segmentectomy group had none. There were 5 (17.2%) recurrences after segmentectomy and 23 (20.4%) after lobectomy (P = .71), with locoregional recurrence rates of 3.5% and 3.6%, respectively. Conclusion Thoracoscopic segmentectomy is a safe option for experienced thoracoscopic surgeons treating patients with small stage I lung cancers. No significant difference in oncologic outcome was seen between thoracoscopic segmentectomy and thoracoscopic lobectomy. Lymph node dissection could be performed as effectively during segmentectomy as lobectomy.

[General Thoracic Surgery] A prospective study of the association between drainage volume within 24 hours after thoracoscopic lobectomy and postoperative morbidity

Objectives We prospectively analyzed the association between drainage volume and development of complications to clarify the safety of early removal of chest tube after thoracoscopic lobectomy. Methods Between November 2001 and October 2007, 136 patients with suspected or histologically documented lung cancer were enrolled. Patients with no air leak and increased drainage underwent removal of the chest tube on the day after thoracoscopic lobectomy independent of the drainage volume. Patients were classified into three groups as tertiles according to the drainage volume. Demographic and perioperative variables were compared among the three groups. Age–sex adjusted odds ratios of the clinical variables associated with development of complications were estimated. In addition, the odds ratios of the drainage volume for development of complications were estimated after adjusting for potentially important factors. Results One hundred patients underwent early removal of the chest tube. Almost all demographic and perioperative variables showed no differences among the three groups (0–289 mL, n = 33; 290–399 mL, n = 33; and ≥400 mL, n = 34). Tumors in a lower lobe, preoperative stage II or higher, 5 or more anatomic segments resected, and advanced disease were all factors that were associated with higher odds ratios for complications. The drainage volume was not associated with an increased morbidity, even after adjusting for these factors. Conclusions Early removal of chest tube on the day after thoracoscopic lobectomy, independently of the drainage volume, appears to be safe in well-selected patients.

[General Thoracic Surgery] Lobectomy with pulmonary artery resection: Morbidity, mortality, and long-term survival

Objective We report our experience with 93 consecutive pulmonary artery reconstructions during pulmonary lobectomy with regard to morbidity, mortality, and long-term survival. Methods Clinical records of all patients who underwent lobectomy with partial or circumferential pulmonary artery resection in a single institution during an 8-year period were reviewed retrospectively. Results Lobectomy with partial (n = 90) or circumferential (n = 3) pulmonary artery resection was carried out in 93 patients. Indications for surgical intervention were non–small cell lung cancer in 87 patients and other malignancy in the remaining 6 patients. Bronchial sleeve resection was associated in 23 patients. Neoadjuvant chemotherapy had been administered in 34 cases because of cN2 disease. Operative mortality was 5.4%. Postoperative complications occurred in 27 (29.0%) patients. All the patients underwent contrast-enhanced computed tomographic scanning 6 to 8 weeks postoperatively, which always showed patency of the pulmonary arteries. In the whole population median and 5-year survivals were 40 months and 39.4%, respectively. Disease-free survival was 41.4% at 5 years. Among patients with non–small cell lung cancer, at univariate analysis, tumor size of less than 3 cm; presence of vascular peritumoral emboli, intratumoral emboli, or both; and dyspnea influenced 5-year survival. Multivariate analysis showed that the size of the primary tumor and the presence of vascular emboli were independent factors of worse outcome. Conclusions Lobectomy with arterial sleeve resection has acceptable mortality and no specific complications. Late results in terms of survival are satisfactory.

[General Thoracic Surgery] The normal configuration and interindividual differences in intramural lymphatic vessels of the esophagus

Objective Recently, interindividual differences in lymphatic vessel density among patients with cancer have become a focus of interest for surgeons as a significant prognostic factor. Little morphometric information is available about esophageal lymphatics in the absence of esophageal pathologic changes. We used D2-40 immunohistochemical examination to clarify the normal configuration of the esophageal intramural lymphatics and to evaluate morphometrically preexisting mucosal vessels. Methods D2-40 immunohistochemical staining for human lymphatic epithelium was performed at three sites in the cervical and thoracic esophagus in 16 donated cadavers without macroscopic malignancy or chronic inflammation. We determined the total numbers of lymphatic vessels and their complete circumferential lengths. Results Our immunohistochemical evaluation consistently demonstrated mucosal longitudinal and intermuscular circumferential vessels. In contrast to a previous diagram, the submucosal lymphatics were limited to a few circumferential and marginal vessels. On the basis of these findings, we suggest a new scheme for the intramural lymphatic vessels. In this morphometric study, interindividual differences in number and circumferential length of mucosal lymphatic vessels ranged from 100% to 200% (2–3 times), and site-dependent differences were not evident. After correction for esophageal thickness, interindividual differences in lymphatic vessel density were still 2-fold. Conclusion We hypothesized that the greater length and number of lymphatic vessels in the lamina propria mucosae are likely to provide greater opportunity for lymphatic vessel invasion of cancer. Thus propensity toward cancer invasion would seem to depend not only on cancer pathology but also on individual anatomic features.

[General Thoracic Surgery] Safety and efficacy of video-assisted versus conventional lung resection for lung cancer

Objective We sought to evaluate the use of video-assisted thoracoscopy among patients with lung cancer and its safety and effectiveness relative to conventional resection. Methods A cohort study (1994–2002) was conducted by using the Surveillance, Epidemiology, and End-Results Medicare database. Video-assisted thoracoscopy and conventional resection were hypothesized to be equivalent in terms of risks of death. Equivalency was defined by a confidence interval of 0.72 to 1.28 for the odds of 30-day death and 0.89 to 1.11 for the hazard of death, corresponding to a difference of no more than 1% for 30-day mortality and 5% for 5-year survival, respectively. Results Among 12,958 patients who underwent segmentectomy or lobectomy (mean age, 74 ± 5 years), 6% underwent video-assisted thoracoscopy. The use of video-assisted thoracoscopy increased from 1% to 9% between 1994 and 2002. Compared with those who underwent conventional resection, patients who underwent video-assisted thoracoscopy more frequently had smaller tumors (P < .001) and stage I disease (P = .03), underwent lymphadenectomy (P < .001), and were cared for by higher-volume surgeons (P < .001) and at higher-volume hospitals (P < .001). After adjusting for differences in patient, cancer, management, and provider characteristics, the odds of early death were not significantly different between patients undergoing video-assisted thoracoscopy and those undergoing conventional resection, although equivalency was not demonstrated (adjusted odds ratio, 0.93; 95% confidence interval, 0.57–1.50). The hazard of death was equivalent for video-assisted thoracoscopy and conventional resection (adjusted hazard ratio, 0.99; 95% confidence interval, 0.90–1.08). Conclusions Video-assisted thoracoscopy was uncommonly used to manage lung cancer, although its use has increased over time. Video-assisted thoracoscopy and conventional resection were equivalent in terms of long-term survival.

[Acquired Cardiovascular Disease] Surgery for aortic and mitral valve disease in the United States: A trend of change in surgical practice between 1998 and 2005

Objective The surgical treatment of valvular heart disease has changed significantly in the past decade with more mitral valves being repaired and tissue valves implanted in the aortic position. The National Inpatient Sample was used to document national trends of primary isolated aortic and mitral valve surgical procedures. Methods Subjects were adult patients who had an isolated aortic or mitral valve repair or replacement in the United States. Estimated institution cost and total billed charges data were provided by the Centers for Medicare and Medicaid Services. Results From 1998 to 2005, an estimated 330,000 aortic or mitral valve procedures were performed in the United States (repair, n = 46,342; replacement, n = 287,989). Since 1998, annual valve repair or replacement procedures increased 186.6% and 12.6%, respectively. Aortic valve repair or replacement procedures increased 102.5% and 28.0%, respectively, with an increased percentage for repairs from 2.0% in 1998 to 3.1% in 2005. Mitral valve repair procedures increased from18.9% in 1998 to 45.8% in 2005, with mitral replacements decreasing 17.2% over the same period. Since 1998, the total hospital billed charges for aortic valve repair procedures increased 80.6% and aortic valve replacement procedures 90.4%; mitral valve repair procedures increased from 37.8%, replacement 42.0%. Annual increases in estimated institution cost increased for both aortic and mitral procedures on average 8% to 9%. Conclusion During the last decade the practice of valve surgery has changed significantly. The surgical treatment for mitral disease has transitioned to primarily one of repair, not replacement, with the use of bioprostheses more than doubled. For the aortic position, the primary procedure remained valve replacement with bioprosthesis being the valve of choice. Regardless of valve disease, institutional costs and charges for the surgical treatment have greatly outpaced physician reimbursement.

[Acquired Cardiovascular Disease] Characterization and outcome of patients with severe symptomatic aortic stenosis referred for percutaneous aortic valve replacement

Objective Many high-risk patients with severe symptomatic aortic stenosis are not referred for surgical aortic valve replacement. Although this patient population remains ill-defined, many of these patients are now being referred for percutaneous aortic valve replacement. We sought to define the characteristics and outcomes of patients referred for percutaneous aortic valve replacement. Methods Between February 2006 and March 2007, 92 patients were screened for percutaneous aortic valve replacement. Clinical and echocardiographic characteristics of patients undergoing surgical aortic valve replacement, percutaneous aortic valve replacement, balloon aortic valvuloplasty, or no intervention were compared. The primary end point was all-cause mortality. Results Nineteen patients underwent successful surgical aortic valve replacement, 18 patients underwent percutaneous aortic valve replacement, and 36 patients had no intervention. Thirty patients underwent balloon aortic valvuloplasty, and of these, 8 patients were bridged to percutaneous aortic valve replacement and 3 were bridged to surgical aortic valve replacement. Of the remaining 19 patients undergoing balloon aortic valvuloplasty, bridging to percutaneous aortic valve replacement could not be accomplished because of death (n = 9 [47%)], exclusion from the percutaneous aortic valve replacement protocol (n = 6 [32%]), and some patients improved after balloon aortic valvuloplasty and declined percutaneous aortic valve replacement (n = 4 [21%]). The most common reasons for no intervention included death while awaiting definitive treatment (n = 10 [28%]), patient uninterested in percutaneous aortic valve replacement (n = 10 [28%]), and questionable severity of symptoms or aortic stenosis (n = 9 [25%]). Patients not undergoing aortic valve replacement had higher mortality compared with those undergoing aortic valve replacement (44% vs 14%) over a mean duration of 220 days. Conclusion Symptomatic patients with severe aortic stenosis have high mortality if timely aortic valve replacement is not feasible. Twenty percent of the patients referred for percutaneous aortic valve replacement underwent surgical aortic valve replacement with good outcome. Patients undergoing balloon aortic valvuloplasty alone or no intervention had unfavorable outcomes.

[Acquired Cardiovascular Disease] Impact of preconditioning protocol on anesthetic-induced cardioprotection in patients having coronary artery bypass surgery

Objective Anesthetic preconditioning may contribute to the cardioprotective effects of sevoflurane in patients having coronary artery bypass surgery. We investigated whether 2 different sevoflurane administration protocols can induce preconditioning in patients having coronary artery bypass. Methods Thirty patients were randomly allocated to 1 of 3 groups. All patients received a total intravenous anesthesia with sufentanil (0.3 µg–1 · kg· h–1) and propofol as target controlled infusion (2.5 µg/mL). The control group had no further intervention; 10 minutes prior to establishing the extracorporeal circulation, patients of the sevoflurane-I group received 1 minimum alveolar concentration of sevoflurane for 5 minutes. Patients of the sevoflurane-II group received (2 times) 5 minutes of sevoflurane, interspersed by 5-minute washout 10 minutes prior to extracorporeal circulation. Troponin I was measured as marker of cardiac cellular damage. Results Peak levels of troponin I release were observed at 4 hours after cardiopulmonary bypass and were not affected by 1 cycle of sevoflurane administration (controls: 14 ± 3 ng/mL vs sevoflurane-I group, 14 ± 3 ng/mL). Two periods of sevoflurane preconditioning significantly reduced cellular damage compared with controls (peak troponin I level sevoflurane-II group, 7 ± 2 ng/mL). Conclusion These data show that sevoflurane-induced preconditioning is reproducible in patients having coronary artery bypass but depends on the preconditioning protocol used.

[Acquired Cardiovascular Disease] Mild chronic kidney dysfunction and treatment strategies for stable coronary artery disease

Objective Our objective was to evaluate the association of chronic kidney dysfunction in patients with multivessel chronic coronary artery disease, preserved left ventricular function, and the possible interaction between received treatment and cardiovascular events. Methods The glomerular filtration rate was determined at baseline on 611 patients who were randomized into three treatment groups: medical treatment, percutaneous coronary intervention, and coronary artery bypass surgery. Incidence of myocardial infarction, angina requiring a new revascularization procedure, and death were analyzed during 5 years in each group. Results Of 611 patients, 112 (18%) were classified as having normal renal function, 349 (57%) were classified as having mild dysfunction, and 150 (25%) were classified as having moderate dysfunction. There were significant differences among the cumulative overall mortality curves among the three renal function groups. Death was observed more frequently in the moderate dysfunction group than the other two groups (P < .001). Interestingly, in patients with mild chronic kidney dysfunction, we observed that coronary artery bypass treatment presented a statistically higher percentage of event-free survival and lower percentage of mortality than did percutaneous coronary intervention or medical treatment Conclusions Our results confirm that coronary artery disease accompanied by chronic kidney dysfunction has a worse prognosis, regardless of the therapeutic strategy for coronary artery disease, when renal function is at least mildly impaired. Additionally, our data suggest that the different treatment strategies available for stable coronary artery disease may have differential beneficial effects according to the range of glomerular filtration rate strata.

[Acquired Cardiovascular Disease] Open distal anastomosis in aortic root replacement using axillary cannulation and moderate hypothermia

Objective Recent advance in surgical technique facilitates more aggressive approaches for thoracic aortic diseases. We sought to address the outcomes of our strategy of open distal anastomosis with aortic root replacement using axillary cannulation and moderate hypothermia. Methods A retrospective review of 228 patients who underwent aortic root replacement between July 2004 and December 2007 was performed. Results Axillary artery cannulation was successful in 98% of the attempted cases and resulted in no adverse events in 97%. The axillary artery was the site of arterial cannulation in 89% of the cases, among which 136 patients (60% of the cases) underwent an open distal anastomosis, consisting of the cohort of interest. Median age of the patients was 60 years (ranging from 16 to 89 years) with 79% being male. The principal diagnosis for the operation included aneurysmal disease without aortic dissection (78%), type A aortic dissection with or without aneurysm (12%), and endocarditis (5.9%). Performed operations were modified Bentall operation (53% of the cohort), valve-sparing aortic root replacement (26%), and replacement with a homograft (20%). Hemiarch replacement was added in 43%. Mean ± standard deviation of the lowest temperature was 27°C ±2.6°C. There were 5 deaths (mortality 3.7%). A total of 16 patients (12%) had major complications. Conclusions Open distal anastomosis at the time of aortic root replacement can safely be performed with axillary artery cannulation and moderate hypothermia. Axillary cannulation provides a reliable route of antegrade cerebral perfusion and enables the complex procedure to be performed without deep hypothermic circulatory arrest.

[Acquired Cardiovascular Disease] Outcomes after surgical resection of cardiac sarcoma in the multimodality treatment era

Objective Primary cardiac sarcomas are rare tumors carrying poor prognosis. Resection remains the primary therapy. Especially in recent years, chemotherapy and radiation have been used adjunctively. Methods All patients (n = 27) surgically treated for primary cardiac sarcoma at two tertiary referral centers from January 1990 to January 2006 were retrospectively reviewed. Results There were 13 women and 14 men, with 26 resections and 1 palliative debulking performed. Cardiac explantation was necessary in 8 cases because of tumor location. Concomitant valve surgery (repair or replacement) or coronary artery bypass grafting was performed in 9 and 3 patients, respectively. Synchronous or staged resections of associated pulmonary metastases were performed in 6 and 2 patients, respectively. Operative mortality was 7.4% (2/27). Preoperative or postoperative chemotherapy was administered to 16 and 19 patients, respectively. At follow-up (median 22 months, range, 2–119 months), 12 patients were alive, with 7 tumor free. Among patients who underwent resection with curative intent and survived surgery (n = 24), median survival was 23.5 months (range 4–119 months). Patients who underwent surgical resection, radiofrequency ablation, or radiation treatment for tumor recurrence (local or metastatic, n = 7) had median survival of 47 months (range 16–119 months), whereas patients with no further intervention for recurrent disease (n = 7) had median survival of 25 months (range 8–34 months). Conclusions Multimodal therapy can achieve reasonable survival for patients with resected cardiac sarcomas. Patients with local tumor recurrence or metastatic disease may still benefit from aggressive treatment.

[Acquired Cardiovascular Disease] The effect of biventricular pacing after coronary artery bypass grafting: A prospective randomized trial of different pacing modes in patients with reduced left ventricular function

Objectives Biventricular pacing acutely improves left ventricular function in patients with heart failure and left ventricular dyssynchrony. Pressure-volume loop analysis has shown acute perioperative hemodynamic benefits of biventricular pacing immediately after weaning from cardiopulmonary bypass in patients undergoing coronary artery bypass grafting, but whether these effects can be maintained for the early postoperative period is unclear. We hypothesized that biventricular pacing is superior to atrioventricular universal pacing at right ventricular outflowtract and atrial inhibited pacing in patients undergoing coronary artery bypass grafting. Methods Ninety-four patients (mean age, 67 ± 9 years; mean ejection fraction, 35% ± 4%) were prospectively randomized to undergo biventricular, atrioventricular universal, or atrial inhibited pacing at 90 beats/min for 96 postoperative hours. Clinical end points and postoperative hemodynamics, aminoterminal pro–brain natriuretic peptide, inotropic support, atrial fibrillation, ventricular arrhythmias, and renal function were evaluated. Results Diastolic pulmonary arterial pressure, mean arterial pressure, mixed venous saturation, cardiac index, and cardiac power index did not differ significantly among groups for all time points. Neither raw aminoterminal pro–brain natriuretic peptide nor differential from preoperative values differed significantly among groups at any time point. Median intensive care unit stay (19.5 hours) did not differ significantly by pacing mode. Incidences of postoperative atrial fibrillation were 40% for atrial inhibited, 29% for atrioventricular universal, and 37% for biventricular (differences not significant). Renal function was unaffected by pacing mode. Conclusion Despite short-term hemodynamic benefits for patients with reduced left ventricular function, biventricular pacing did not lead to improved postoperative hemodynamics or clinical outcome.

[Acquired Cardiovascular Disease] Influence of body mass index on the efficacy of revascularization in patients with coronary artery disease

Objective We examined the effect of body mass index on the association between revascularization strategy and survival in patients with coronary artery disease. Methods Using the Duke Database for Cardiovascular Disease, we selected 22,877 patients who underwent cardiac catheterization from January 1986 to August 2004 and were found to have significant coronary artery disease. Patients were categorized into three coronary disease management groups: no revascularization, percutaneous coronary intervention, and coronary artery bypass surgery. Propensity scoring was used to control for coronary artery revascularization strategy. The relationship between body mass index, coronary disease treatment, and survival was assessed via Cox multivariable models adjusting for baseline demographic, clinical, and angiographic characteristics. Results The median body mass index was 27.2 kg/m2 (24.4–30.4) in the overall cohort, 27.1 kg/m2 (24.1–30.3) in the no revacularization group, 27.4 kg/m2 (24.8–30.9) in the percutaneous intervention group, and 26.9 kg/m2 (24.4–30.1) in the coronary bypass group. Body mass index was a significant, but weak, predictor of revascularization, with higher indexes predicting lower rates of coronary bypass. Thirty-day survival did not differ across body mass indexes among treatment groups, but survival curves appeared to separate over longer-term follow-up. An inverted U-shaped survival function was noted across all time points after 30 days, with the lowest risk of death at a body mass index of approximately 26 kg/m2 (independent of revascularization strategy). Coronary bypass was associated with the highest survival at all later time points, whereas no revascularization was associated with the lowest. Conclusions Extremes of body mass index are associated with lower long-term survival in patients with significant coronary disease. Revascularization, particularly with coronary bypass, is consistently associated with the best survival across the spectrum of body mass indexes.

[Acquired Cardiovascular Disease] Surgical treatment of multivalvular endocarditis: Twenty-one-year single center experience

Objective Little information is available about surgical outcomes in patients with multivalvular endocarditis. The aim of this article is to review the 21-year experience with surgical treatment of patients with multivalvular endocarditis at our institution and, in particular, to determine the incidence, pathologic status, diagnosis, surgical strategies, and outcomes of patients with this disease. Methods From January 1986 to December 2006, a total of 48 patients (40 men, 8 women), with a mean age of 42 ± 12 years, underwent surgery for multivalvular endocarditis. Endocarditis was active in 32 patients and healed in 16. Preoperative transthoracic echocardiographic evaluation was performed in all 48 patients with addition of transesophageal echocardiography in 22 (45.8%). Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (40/48 patients). Triple or quadruple valve involvement was found in 1 and 2 patients, respectively. Preoperative, perioperative, and postoperative data were retrospectively analyzed and risk factors for early and late survival were determined. Results In only 24 (50.0%) patients was multivalvular endocarditis diagnosed by preoperative transthoracic echocardiography; 17 (77.3%) patients had multivalvular endocarditis confirmed by preoperative transesophageal echocardiography. The 30-day hospital mortality was 12.5% (n = 6). Preoperative renal failure, New York Heart Association class IV, and emergency surgery were identified as independent risk factors for hospital mortality. Overall long-term survival was 74% ± 6% at 5 years and 62% ± 3% at 10 years. Multivariate analysis revealed that renal failure and recurrent endocarditis were associated with increased late mortality. Ten-year freedom from recurrent endocarditis was 74% ± 5% and 10-year freedom from reoperation was 73% ± 6%. Conclusions In our institution, multivalvular endocarditis was diagnosed by transthoracic echocardiography in only half of the patients. Intraoperative transesophageal echocardiography provided a more effective means to identify this disease. Radical resection of all infected tissues for patients with multivalvular endocarditis and additional intraoperative interventions, depending on the intraoperative pathologic condition, produced satisfactory in-hospital and long-term results, similar to those in patients with a single infected heart valve.

[Acquired Cardiovascular Disease] Minimally invasive video-assisted mitral valve surgery: A 12-year, 2-center experience in 1178 patients

Objective To review a 2-institution experience with minimally invasive mitral valve surgery over a 12-year period. Methods We prospectively collected data on all patients having minimally invasive mitral valve surgery through a right minithoracotomy between May 1996 and May 2008. Results A total of 1178 patients included 941 (79.9%) patients having mitral valve repair and 237 (20.1%) having mitral valve replacement. The mean age was 61.1 ± 13.9 years, mean ejection fraction was 52.8% ± 12.1%, and 221 patients (18.8%) were having reoperations. Operative mortalities for mitral valve repair and mitral valve replacement were 2.1% and 4.6%, and for isolated primary MVP and MVR were 0.2% and 3.6%, respectively. Repair techniques included annuloplasty (98.2%), leaflet resection (40.7%), sliding plasty (21.0%), chordal transfer (9.0%), and neochordae placement (7.4%), with no or trivial residual MR in over 97% of patients. In patients having mitral valve replacement, a bioprosthesis was placed in 101 patients (42.6%) and a mechanical valve in 136 (57.4%). Concomitant procedures included atrial fibrillation ablation (22.5%), tricuspid valve surgery (5.4%), and atrial septal defect closure (9.4%). Nineteen patients (1.6%) experienced intraoperative conversion to sternotomy. Twenty-two patients (1.9%) had a reoperation at a mean of 732 ± 1014 days. Independent predictors of in-hospital mortality included New York Heart Association class III/IV (odds ratio 3.62), diabetes (odds ratio 2.81), bypass time > 180 minutes (odds ratio 2.63), preoperative atrial fibrillation (odds ratio 2.53), and age > 70 years (odds ratio 2.29). Prior cardiac surgery was not a significant predictor of mortality. Conclusions Video-assisted mitral valve surgery is safe with high rates of repair, low morbidity, and excellent outcomes. Reoperation after previous median sternotomy is not an independent predictor of mortality with this approach. Operative risk is increased if surgery is delayed until the onset of atrial fibrillation.

[Cardiothoracic Transplantation] Surgical revascularization for cardiac allograft vasculopathy: Is it still an option?

Objectives Cardiac allograft vasculopathy remains a major cause of mortality after cardiac transplantation. Percutaneous revascularization has become the mainstay of therapy given the poor historical outcomes with surgery. Outcomes following surgical revascularization are evaluated to determine whether surgery remains a viable therapeutic option. Methods A retrospective analysis was performed of 13 heart transplant recipients who had cardiac allograft vasculopathy requiring coronary artery bypass grafting with or without adjunctive percutaneous coronary intervention for revascularization from 1999 to 2008. Results Thirteen patients had 14 coronary artery bypass grafting procedures at 141 ± 66 months after transplantation. The average number of grafts was 2.3. Eight were performed without cardiopulmonary bypass, of which 5 were approached via left thoracotomy and the remainder via repeat sternotomy. One patient had renal failure and a cerebrovascular accident. Percutaneous coronary intervention before or after coronary artery bypass grafting was required in 3 patients. There were no perioperative mortalities. At mean follow-up of 39 ± 36 months, 3 patients have died, 2 from progressive cardiac allograft vasculopathy and 1 from lung cancer. Kaplan-Meier survival for this group of patients was 92%, 83%, and 83% at 1, 5, and 7 years, respectively. Conclusions Surgical revascularization for cardiac allograft vasculopathy remains a viable treatment option for appropriate patients and may be performed safely with good medium-term outcomes. However, patients remain at risk for disease progression and may require percutaneous or surgical reintervention.

[Cardiothoracic Transplantation] Prolonged venoarterial extracorporeal membrane oxygenation after transplantation restores functional integrity of severely injured lung allografts and prevents the development of pulmonary graft failure in a pig model

Objective Prolonged venoarterial extracorporeal membrane oxygenation support during transplantation provides reduction of pulmonary artery flow and allows for protective ventilation. This approach might have the potential to restore function of lungs that would be unsuitable for transplantation. Methods Left lung transplantation was performed on 16 pigs. Lungs from brain-dead animals were stored for 22 hours at 4°C. Recipients in group A (n = 8) underwent transplantation without cardiopulmonary support followed by ventilation with 10 mL/kg body weight tidal volume. Animals in group B (n = 8) underwent transplantation during venoarterial extracorporeal membrane oxygenation, which was continued for 22 hours, and received low-tidal-volume (5 mL/kg body weight) ventilation. One hour after transplantation, the right lung was excluded. Graft function was compared immediately after exclusion of the contralateral lung (time point 1), 1 hour later (time point 2), and 1 hour after discontinuation of extracorporeal membrane oxygenation (time point 3). Results Four animals in group A did not reach time point 2; all died of pulmonary edema. All animals in group B survived, and at time point 3, the mean Pao 2 value was 323 ± 129 mm Hg. At time point 2, oxygenation and lung compliance were higher in group B than in group A, whereas pulmonary artery pressure was lower. The same was true when comparing results of group B at time point 3 with results of group A at time point 2. Conclusions Transplantation during extracorporeal membrane oxygenation with continued use for 24 hours restores function of damaged donor lungs. This could expand the donor pool through wider use of marginal donors.

[Evolving Technology] Keratinocyte growth factor accelerates compensatory growth in the remaining lung after trilobectomy in rats

Objective In rats pulmonary resection is followed by lung compensatory growth. However, the molecular mechanism underlying lung compensatory growth remains unclear. Keratinocyte growth factor is expressed in lung tissue and is considered a possible mitogen for lung epithelial cells. The objectives of this study were to define the role of keratinocyte growth factor and its receptor in rat lung compensatory growth after trilobectomy and the effect of exogenous keratinocyte growth factor gene transfection. Methods Adult Lewis rats were used. Right trilobectomy was performed in the operation group and sham thoracotomy in the sham group. In the operation group, keratinocyte growth factor–FLAG or FLAG expression vector was transfected directly into the lung by means of electroporation. Expression of keratinocyte growth factor and its receptor and alveolar cell proliferation index based on proliferating cell nuclear antigen levels were measured in the right lung at day 14 after the operation. Results Proliferating cell nuclear antigen, keratinocyte growth factor, and keratinocyte growth factor receptor expression in lung epithelial cells was significantly increased at day 4 after trilobectomy. Transfection of keratinocyte growth factor–FLAG expression vector resulted in further significant enhancement of proliferating cell nuclear antigen at day 4 after trilobectomy; however, the transfection of FLAG expression vector did not alter the enhancement of proliferating cell nuclear antigen. Exogenous expression of keratinocyte growth factor in the remaining lung by means of electroporation significantly augmented epithelial proliferation and decreased the average airspace distance (mean linear intercept). Conclusion Our results implicate keratinocyte growth factor in the induction of alveolar epithelial cell proliferation for compensatory lung growth and indicate that overexpression of keratinocyte growth factor in the remaining lung by means of electroporation significantly augmented lung epithelial proliferation.

[Evolving Technology] Selective phosphodiesterase-5 inhibition reduces neointimal hyperplasia in rat carotid arteries after surgical endarterectomy

Objective Long-term results of surgical vessel reconstruction are compromised by restenosis caused by neointimal hyperplasia. Recent studies suggest that reduced cyclic guanosine monophosphate signaling is associated with neointima formation. In a rat model of endarterectomy, we investigated the effect of pharmacologic inhibition of cyclic guanosine monophosphate degradation on neointima formation by using the selective phosphodiesterase-5 inhibitor vardenafil. Methods Carotid endarterectomy was performed in male Sprague–Dawley rats by means of incision of the right common carotid artery with removal of intima. Four groups were studied: unoperated control rats (n = 4), sham-operated rats (n = 9), control rats with endarterectomy (n = 9), or endarterectomized rats treated with vardenafil (10 mg/kg/day) postoperatively (n = 9). After 3 weeks, vessel compartment areas were measured by means of conventional microscopy with hematoxylin and eosin staining. Immunohistochemical analysis was performed to confirm neointima formation and the local cyclic guanosine monophosphate content. Plasma levels of cyclic guanosine monophosphate were determined by means of enzyme immunoassay. Student's t test was used for statistical evaluation. Results Immunohistochemical analysis demonstrated intensive staining for transforming growth factor β1 and -smooth muscle actin in the control neointima. Vardenafil significantly reduced the stenosis grade (24.64% ± 7.46% vs 54.12% ± 10.30% in the control group, P < .05) and expression of transforming growth factor β1, as well as -smooth muscle actin, in the neointima. The immunohistochemical score for cyclic guanosine monophosphate was higher in the treated neointima (4.80 ± 0.76 vs 2.84 ± 0.40 in the control group, P < .05), and increased plasma cyclic guanosine monophosphate levels were found by means of enzyme immunoassay as well (84.65 ± 12.77 pmol/mL vs 43.50 ± 3.30 pmol/mL in the control group, P < .05). Conclusions Treatment with vardenafil can be considered a new possibility to prevent neointimal hyperplasia after endarterectomy.

[Evolving Technology] Plasma transforming growth factor {beta}1 as a biochemical marker to predict the persistence of atrial fibrillation after the surgical maze procedure

Objectives The Cox maze procedure was developed as a surgical treatment for atrial fibrillation. However, atrial fibrillation recurs in some patients, and atrial remodeling in the form of fibrosis can lead to perpetuation of atrial fibrillation. To identify the predictor of the persistence of atrial fibrillation after the maze procedure using cryoablation, we evaluated the preoperative plasma transforming growth factor β1. We also examined the correlations between plasma transforming growth factor β1 levels and the degree of atrial fibrosis. Methods Preoperative plasma transforming growth factor β1 levels were measured in 86 consecutive patients (age, 54 ± 12 years) who underwent both the open heart operation for valvular heart disease and the surgical maze procedure with cryoablation for persistent atrial fibrillation. We measured the degree of fibrosis from the tissue of the left atrium. Results At 1 year's follow-up, 10 of 86 patients had persistent atrial fibrillation. Patients with persistent atrial fibrillation had higher preoperative plasma transforming growth factor β1 levels than the patients with sinus rhythm (0.44 ± 0.29 vs 0.32 ± 0.15 ng/mL, P = .03). Patients with persistent atrial fibrillation had higher mRNA expressions of collagen III and lower mRNA expressions of atrial natriuretic peptide than those with sinus rhythm, and the plasma transforming growth factor β1 levels correlated with the degree of fibrosis in the left atrium (r = 0.497, P = .022). Multiple logistic regression analysis revealed that plasma transforming growth factor β1 levels were independently associated with the postoperative persistence of atrial fibrillation at 1 year's follow-up. Conclusions Preoperative plasma transforming growth factor β1 levels could be used to predict the persistence of atrial fibrillation at 1 year's follow-up after the surgical maze procedure by using cryoablation. Preoperative plasma transforming growth factor β1 levels were correlated with the degree of fibrosis in the left atria of patients with mitral valvular heart disease.

[Cardiopulmonary Support] Optimal dose of aprotinin for neuroprotection and renal function in a piglet survival model

Objective The efficacy of aprotinin in reducing blood loss after cardiopulmonary bypass is well established, although its neuroprotective potential is less well known. Furthermore, there is controversy regarding optimal dosing and possible renal complications. Methods Fifty-four piglets were randomized to one of 3 cardiopulmonary bypass groups designed to carry the risk of postoperative cerebral and renal dysfunction: circulatory arrest at 25°C and ultra–low flow bypass (10 mL · kg–1 · min–1) at either 25°C or 34°C. Animals were randomized to the following groups: control (no aprotinin), low dose (30,000 KIU/kg into prime only), standard full dose (30,000 KIU/kg bolus administered intravenously into prime plus 10,000 KIU/kg infusion), and double full dose. The tissue oxygenation index was monitored by means of near-infrared spectroscopy. Neurologic functional and histologic scores and creatinine and blood urea nitrogen values were outcomes of interest. Results Aprotinin significantly improved neurologic scores on postoperative day 1 after ultra–low-flow bypass at 25°C or 34°C (P < .01) but not after hypothermic circulatory arrest (P = .57). Linear regression indicated a strong dose-response relationship, with higher aprotinin doses having the best neurologic scores. During low-flow bypass, a higher tissue oxygenation index was correlated with a higher aprotinin dose (P < .05). Aprotinin dose had no significant effect on creatinine or blood urea nitrogen values on day 1. Low body weight was the only predictor of high blood urea nitrogen values (r = –0.39, P < .01). Conclusion Aprotinin significantly improves neurologic recovery without compromising renal function in the young piglet.

[Cardiopulmonary Support] Discussion

[Cardiopulmonary Support] Pulmonary injury after cardiopulmonary bypass: Beneficial effects of low-frequency mechanical ventilation

Objective Pulmonary dysfunction is a frequent postoperative complication after cardiac surgery with cardiopulmonary bypass, and atelectasis is thought to be one of the main causes. The aim of this study was to evaluate whether low-frequency ventilation and continuous positive airway pressure during cardiopulmonary bypass reduce postcardiopulmonary bypass lung injury. Methods Eighteen Yorkshire pigs were subjected to 120 minutes of cardiopulmonary bypass (1 hour of cardioplegic arrest) followed by 90 minutes of recovery before being sacrificed. Six animals served as control with the endotracheal tube open to atmosphere during cardiopulmonary bypass. The remaining animals were divided into 2 groups of 6: One group received continuous positive airway pressure of 5 cm H2O, and one group received low-frequency ventilation (5/minutes) during cardiopulmonary bypass. Lung tissue biopsy and bronchoalveolar lavage samples were obtained before and 90 minutes after discontinuation of cardiopulmonary bypass for measurement of adenine nucleotide (adenosine-5'-triphosphate, adenosine diphosphate, adenosine monophosphate), lactate dehydrogenase, DNA levels, and histology. Hemodynamic data and arterial blood gases were also collected through the study. Results The hemodynamic parameters were similar in the 3 groups. After cardiopulmonary bypass, the low-frequency ventilation group showed significantly better oxygen tension and alveolar arterial oxygen gradient, higher adenine nucleotide, lower lactate dehydrogenase levels, and reduced histologic damage in lung biopsy, as well as lower DNA levels in bronchoalveolar lavage compared with the control group. The continuous positive airway pressure group showed only significantly reduced lactate dehydrogenase levels compared with control. Conclusion Low-frequency ventilation during cardiopulmonary bypass in a pig experimental model reduces tissue metabolic and histologic damage in the lungs and is associated with improved postoperative gas exchange.

[Cardiopulmonary Support] Regression of flow-induced pulmonary arterial vasculopathy after flow correction in piglets

Objectives Chronic thromboembolic pulmonary hypertension is due to partial obstruction of the pulmonary arterial bed and may resolve after pulmonary thromboendarterectomy. Persistent pulmonary hypertension, the main complication after pulmonary thromboendarterectomy, may reflect vessel alterations induced by high flow in unobstructed lung territories. The aim of this study was to determine whether correcting high flow led to reversal of the vasculopathy in piglets. Methods The effects of high pulmonary blood flow were investigated 5 weeks after creation of an aortopulmonary shunt (n = 10), and reversibility of vessel disease was evaluated at 1 week (n = 10) and 5 weeks after shunt closure (n = 10), compared to sham-operated animals (n = 10). Hemodynamic variables, pulmonary artery reactivity, and morphometry were recorded. We also investigated the endothelin, angiopoietin, and nitric oxide synthase pathways. Results High flow increased medial thickness in distal pulmonary arteries (55.6% ± 1.2% vs 35.9% ± 0.8%; P < .0001) owing to an increase of smooth muscle cell proliferation (proliferating cell nuclear antigen labeling). The endothelium-dependent relaxation was altered (P < .05). This phenomenon was associated to an overexpression of endothelin-1, endothelin-A, angiopoietin 1, angiopoietin 2, and Tie-2 (P < .05). After 1 week of shunt closure, all overexpressed genes returned to control values, the proliferation of smooth muscle cells stopped, and smooth muscle cell apoptosis increased (terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling), preceding the normalization of the wall thickness hypertrophy and the pulmonary artery vasoreactivity observed at 5 weeks after shunt closure. Conclusion These results demonstrate that endothelin-1 and angiopoietin pathways are involved in vasculopathy development and may be important therapeutic targets for preventing persistent pulmonary hypertension after pulmonary thromboendarterectomy.

[Brief Communications] Mitral valve injury late after transcatheter aortic valve implantation

[Brief Communications] A new subspecialty in cardiac surgery: Scrap metal merchant

[Brief Communications] Concomitant bilateral lung volume reduction surgery and aortic valve replacement: Multidisciplinary strategies in achieving a successful outcome

[Brief Communications] Successful combined bilateral lung volume reduction and coronary artery bypass grafting surgery: Implications and advantages

[Brief Communications] Off-pump revascularization with the use of both internal thoracic arteries in a 3-year-old child with Kawasaki syndrome

[Brief Communications] Early stenosis of Medtronic Mosaic porcine valves in the aortic position

[Brief Communications] Tricuspid valve regurgitation after heart transplantation

[Brief Communications] Membranous tracheoplasty using an azygous vein pedicle graft with roundabout-field intubation: A novel surgical technique

[Brief Communications] A modified technique of selective lung ventilation through a tracheostomy to facilitate conservative management of iatrogenic tracheal rupture

[Brief Communications] Quadruple valve replacement for acute endocarditis

[Brief Communications] A new miniaturized cardiopulmonary bypass system reduces transfusion requirements during neonatal cardiac surgery: Initial experience in 13 consecutive patients

[Brief Communications] A novel technique for treatment of mitral valve prolapse/flail

[Brief Communications] An improved hemostatic aortic anastomotic technique for nondissected aortic aneurysms

[Letters to the Editor] Reference values: No need for confusion

[Letters to the Editor] Experimental ventricular pressure overload in young animals induces cardiomyocyte hypertrophy in addition to hyperplasia of contractile and noncontractile elements of the myocardium

[Letters to the Editor] Clamping the mitral and tricuspid annuli with bipolar devices

[Letters to the Editor] Reply to the Editor

[Letters to the Editor] Changes in noninfarcted myocardium explain benefits of on-pump beating-heart coronary artery bypass grafting for acute myocardial infarction

[Letters to the Editor] Reply to the Editor

[Letters to the Editor] Intraoperative coronary angiography: With or without ischemia?

[Letters to the Editor] Reply to the Editor

[Letters to the Editor] Predictor factors of transbronchial needle aspiration diagnostic yield in sarcoidosis