Thoracic RSS : Gourt

Gulf Coast of Florida Needs a General Surgeon :: Florida :: CompHealth Inc

Job 6511050 Fantastic Growth Area, affordable homes; within an hour of Tampa Known as the Nature Coast part of Florida Call is 1:5 Prefers surgeons with Minimally Invasive Skills Can do Vascular and

Call for Information :: Illinois :: 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

Aastrom Biosciences Reports First Quarter Fiscal Year 2010 Financial Results - CNNMoney.com (press release)

Aastrom Biosciences Reports First Quarter Fiscal Year 2010 Financial ResultsCNNMoney.com (press release)He is also a Professor of Cardiovascular & Thoracic Surgery at the University of Texas, Southwestern Medical School and has been a Visiting Professor at a ...and more »

Clear Catheter Systems Receives Major International Innovation Award for Its ... - Reuters

Clear Catheter Systems Receives Major International Innovation Award for Its ...ReutersThe award was established by the European Association of Cardio-Thoracic Surgery to recognize the most important technological breakthrough related to ...and more »

Moderate exercise may lower prostate cancer risk - WBNG-TV

Moderate exercise may lower prostate cancer riskWBNG-TVProviding the advanced surgical techniques and oncologic therapies, thoracic surgery at Guthrie is dedicated to the prevention, early diagnosis and ...

Mesothelioma Trimodality Therapy Benefits Patients - Asbestos.com

Mesothelioma Trimodality Therapy Benefits PatientsAsbestos.comIn a study recently published in The Annals of Thoracic Surgery, mesothelioma researchers found a trimodality therapeutic approach of chemotherapy, ...

"On-pump" heart bypass surgery beats out beating-heart technique - Scientific American

Scientific American"On-pump" heart bypass surgery beats out beating-heart techniqueScientific AmericanA six-year study published in August in The Annals of Thoracic Surgery followed 395 people, some of whom had coronary disease and other who didn't, ...Traditional CABG Edges Off-Pump ApproachMedPage Todayall 246 news articles »

NuVasive Appoints New Chief Financial Officer and Announces Additional ... - CNNMoney.com (press release)

NuVasive Appoints New Chief Financial Officer and Announces Additional ...CNNMoney.com (press release)With nearly 50 products today spanning lumbar, thoracic and cervical applications, the Company will continue to expand and evolve its offering predicated on ...and more »

Heart surgeon is suspended again - BBC News

expressandstar.comHeart surgeon is suspended againBBC NewsWhen not abroad, he continued to work at Royal Wolverhampton Hospitals in thoracic surgery as a consultant. The recent GMC assessment also found his ...Midlands surgeon banned from carrying out heart operationsThe Birmingham Postall 7 news articles »

Reversing the brain drain: Jewish doctor returns to Montreal from Harvard - Jewish Tribune

Reversing the brain drain: Jewish doctor returns to Montreal from HarvardJewish TribuneHe is an expert in airway surgery, minimally invasive thoracic surgery, bronchial and esophageal interventions, as well as the removal of benign and ...

Archive for November, 2009 - Asbestos.com

Archive for November, 2009Asbestos.comAccording to Harvey Pass, MD, Professor of Cardiothoracic Surgery and Director of the Division of Thoracic Surgery and Thoracic Oncology at New York ...and more »

Health Beat Live - November - San Angelo Standard Times

Health Beat Live - NovemberSan Angelo Standard TimesHe completed a fellowship in thoracic and cardiovascular surgery at the University of Florida and a fellowship in minimally invasive, robotic and adult ...

Chemotherapy in the Older Patient with Operable Non–Small Cell Lung Cancer: Neoadjuvant and Adjuvant Regimens

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 377-389Ilene, Browner , Michael, Purtell

Thoracic Irradiation in the Elderly

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 391-400Kristin J., Redmond , Danny Y., Song

Quality of Life and Ethical Concerns in the Elderly Thoracic Surgery Patient

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 401-407Holly M., Holmes

Thoracic Surgery in the Elderly: Areas of Future Research and Studies

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 409-413Joseph, LoCicero III , Jason Philip, Shaw

Index

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 415-418[No author name available]

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages v-vii[No author name available]

Forthcoming Issues

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Page viii[No author name available]

Foreword

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages ix-xMark K., Ferguson

Normal Changes of Aging and Their Impact on Care of the Older Surgical Patient

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 289-299Deirdre M., Carolan DoerflingerPatients 65 years of age or older constitute a large part of the perioperative population. Because the older patient's physiology is unique, it is essential that health care providers recognize the normal physiology of aging and be able to differentiate normal changes of aging from those of pathology. The normal changes of aging result in the older patient presenting differently with specific care needs. Care to this older population must be individualized by providers who are familiar with geriatrics in order to enhance outcomes.

Preoperative Evaluation and Risk Assessment for Elderly Thoracic Surgery Patients

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 301-312Michael, Jaklitsch , Sarah, Billmeier

Benign Thoracic Disease in the Elderly

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 313-319Rita A., Mukhtar , Pierre R., Theodore

Benign Esophageal Disease in the Elderly

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 321-332M. Blair, Marshall

Resection for Esophageal Cancer in the Elderly

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 333-343Andrew C., Chang , Julia S., Lee

The Emerging Role of Minimally Invasive Surgical Techniques for the Treatment of Lung Malignancy in the Elderly

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 345-351Paul M., Heerdt , Bernard J., ParkAs a consequence of the general aging of the population, improved diagnostic techniques, and preoperative interventions to enhance the efficacy of surgical therapy, increasing numbers of elderly patients are presenting for pulmonary resection. Clear association between advanced age and the perioperative morbidity and mortality associated with lung cancer surgery has generated considerable interest in applying minimally invasive operative techniques in the geriatric population under the belief that this approach will improve outcome. This review examines the available data regarding video-assisted thoracoscopic lobectomy and concludes that this technique for the surgical treatment of early-stage lung cancer may parallel conventional thoracotomy in...

Postoperative Pain Management in the Elderly Undergoing Thoracic Surgery

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 353-361Marie N., Hanna , Jamie D., Murphy , Kanupriya, Kumar , Christopher L., Wu

Evaluation and Management of the Elderly Patient at Risk for Postoperative Delirium

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 3, August 2009, Pages 363-376Anita S., Bagri , Alex, Rico , Jorge G., RuizGeriatric patients are at a high risk for the development of postoperative delirium. By recognizing predisposing and precipitating risk factors, preventive measures can be undertaken to reduce this risk. Accurate and timely diagnosis is essential, and we offer therapeutic strategies to help reduce the high morbidity and mortality of this important condition.

FORTHCOMING ISSUES

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Page v[No author name available]

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages vii-xi[No author name available]

Mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages xiii-xivDavid J., Sugarbaker , Michael Y., Chang

Malignant pleural mesothelioma: overview of the North American and European experience

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 435-445Jasleen, Kukreja , Michael T., Jaklitsch , Daniel C., Wiener , David J., Sugarbaker , Sjaak, Burgers , ...

Pathology of mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 447-460Joseph M., Corson

Genetics of malignant pleural mesothelioma: molecular markers and biologic targets

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 461-468Raphael, Bueno , Gavin J., Gordon

Epidemiology, biologic behavior, and natural history of mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 469-477Lambros, Zellos , David C., Christiani

Role of asbestos in etiology of malignant pleural mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 479-487John J., Godleski

Evidence of an important role for SV40 in mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 489-495Harvey I., Pass , Maurizio, Bocchetta , Michele, Carbone

Causality of mesothelioma: SV40 question

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 497-504Keerti V., Shah

Preoperative assessment and therapeutic options for patients with malignant pleural mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 505-516Subroto, Paul , Siyamek, Neragi-Miandoab , Michael T., Jaklitsch

Pleurectomy and decortication for malignant mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 517-521Scott W., Cowan , Taine T., Pechet

Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma: techniques and complications

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 523-530Michael Y., Chang , David J., Sugarbaker

Multimodality therapy in mesothelioma: role of chemotherapy

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 531-542Nicholas J., Vogelzang

External beam radiation therapy for the treatment of pleural mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 543-548Elizabeth H., Baldini

Innovative therapies: intraoperative intracavitary chemotherapy

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 549-556Michael Y., Chang , David J., Sugarbaker

Innovative therapies: photodynamic therapy

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 557-566Evelio, Rodriguez , Paul, Baas , Joseph S., Friedberg

Patterns of failure following surgical resection for malignant pleural mesothelioma

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 567-573Pasi A., Jänne , Elizabeth H., Baldini

Anesthetic strategies for patients undergoing extrapleural pneumonectomy

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 575-583Philip M., Hartigan , Ju-Mei, Ng

Pain management strategies for patients undergoing extrapleural pneumonectomy

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 585-592Ju-Mei, Ng , Philip M., Hartigan

Cumulative Index 2004

Publication year: 2004Source: Thoracic Surgery Clinics, Volume 14, Issue 4, November 2004, Pages 593-607[No author name available]

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages vii-x[No author name available]

Forthcoming Issues

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Page xi[No author name available]

PrefaceProgress in the Surgical and Endoscopic Treatment of Emphysema: Where Are We Now?

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages xiii-xviCliff K., Choong

The Epidemiology, Etiology, Clinical Features, and Natural History of Emphysema

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 149-158Samuel V., Kemp , Michael I., Polkey , Pallav L., Shah

Update on Radiology of Emphysema and Therapeutic Implications

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 159-167Jonathan G., Goldin , Fereidoun, Abtin

The National Emphysema Treatment Trial: Summary and Update

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 169-185Melanie A., Edwards , Stephen, Hazelrigg , Keith S., NaunheimEmphysema is a chronic and debilitating disease in which affected patients must deal with diminished quality of life and poor functional status. Because contemporary medical therapy has had little impact on mortality rates, the National Emphysema Treatment Trial was designed to provide prospective randomized evidence for the efficacy of lung volume reduction surgery. This multicenter trial showed a mortality benefit and improved function in defined subgroups of patients based on the distribution of emphysema and baseline exercise tolerance. Patients with upper-lobe predominant disease and low exercise capacity achieved the most consistent gains in survival, exercise capacity, and quality of live...

Staged Lung Volume Reduction Surgery—Rationale and Experience

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 187-192David, Waller , Inger, Oey

Lung Volume Reduction Surgery in Nonheterogeneous Emphysema

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 193-199Walter, Weder , Michaela, Tutic , Konrad E., Bloch

Lung Volume Reduction Surgery for Patients with Alpha-1 Antitrypsin Deficiency Emphysema

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 201-208James M., Donahue , Stephen D., CassiviAlpha-1 antitrypsin deficiency (A1AD) is a rare genetic disorder characterized by early-onset emphysema and, rarely, liver disease and vasculitis. In the lungs, unopposed and enhanced elastase activity results in accelerated parenchymal destruction leading to emphysematous changes predominantly in the lower lung fields. Medical treatment includes standard therapies for emphysema and so-called “augmentation therapy” using purified pooled plasma alpha-1 antitrypsin. Surgical options include lung transplantation and lung volume reduction surgery. The option of lung volume reduction surgery potentially provides palliation of dyspnea and a bridge to lung transplantation.

Concomitant Lung Cancer Resection and Lung Volume Reduction Surgery

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 209-216Cliff K., Choong , Balakrishnan, Mahesh , G. Alexander, Patterson , Joel D., Cooper

Combined Cardiac and Lung Volume Reduction Surgery

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 217-221Cliff K., Choong , Ralph A., Schmid , Daniel L., Miller , Julian A., Smith

Intraoperative and Postoperative Management of Air Leaks in Patients with Emphysema

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 223-231Joseph B., Shrager , Malcolm M., DeCamp , Sudish C., Murthy

Decision Making in the Management of Secondary Spontaneous Pneumothorax in Patients with Severe Emphysema

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 233-238K. Robert, Shen , Robert J., CerfolioIn patients who have advanced emphysema, development of a spontaneous pneumothorax can be a life-threatening event, warranting more aggressive management. Patients who have the most advanced stages of emphysema are at the highest risk to develop spontaneous pneumothoraces, have recurrences, and are the most difficult patients to treat. Early surgical intervention should be recommended for patients who have persistent or large air leaks or those who lack parietal-to-visceral pleural apposition after a trial of nonoperative management. Video-assisted thoracoscopy with resection of the offending bulla and pleurodesis or pleurectomy also should be considered to prevent recurrences in all patients with chronic...

Primary sternal plating to prevent sternal wound complications after cardiac surgery: early experience and patterns of failure [Work in progress report - Cardiac general]

Sternal closure with rigid titanium plates (primary sternal plating) may reduce sternal wound complications in high-risk patients. We began performing primary sternal plating for the following indications: obesity, manual laborer, osteoporotic sternum, or intraoperative transverse sternal fracture. Patients receiving plate closure were compared to a risk-matched control group receiving wire closure. Outcomes of interest were postoperative length of stay and sternal wound complications [sterile dehiscence or deep sternal wound infection (DSWI)]. Wound complications were classified by time of occurrence as early (≤30 days postoperation) or late (>30 days postoperation). Of 445 total cardiac cases during the 5-year study period, 129 (29%) met inclusion criteria. The plate group (n=30) and wire group (n=99) were generally well-matched in terms of risk factors. Postoperative length of stay was significantly shorter in the plate group (median 7 vs. 8 days, P=0.023). No early sternal wound complications occurred in the plate group, compared to 12 (12%) in the wire group (P=0.067). The incidence of late sternal wound complications was 10% in both groups (P=1.0). Primary sternal plating appears to provide benefits over wire closure during the early postoperative period, but may not prevent late wound complications in patients with osteoporosis or extreme obesity.

Efficacy of SOFT COAG for intraoperative bleeding in thoracic surgery [Work in progress report - Thoracic non-oncologic]

We present and examine two cases of the dramatic hemostasis with SOFT COAG in general thoracic surgery. SOFT COAG is a coagulation mode unique to VIO electrosurgical units (ERBE Elektromedizin GmbH, Germany). This system regulates the temperature rise below boiling point without generating sparks, which is high enough to denature protein. In addition to clinical applications, this coagulation system makes use of a reusable device, Slim line hand switch®, which has economically and ecologically major advantages for ecosurgery.

The heart of patients with aortic aneurysms: evidence from cardiac computed tomography [Institutional report - Cardiac general]

To determine in patients with abdominal aortic aneurysm (AAA) the coronary calcium burden and prevalence of coronary artery disease (CAD) in relation to cardiovascular risk factors, and to assess the left ventricular (LV) function using cardiac computed tomography (CT). Sixty consecutive patients (six females; 72.2±9.0 years) with AAA underwent dual-source CT calcium scoring and coronary angiography prior to AAA repair. In the 60 patients, the Framingham risk score (FRS) ranged from 5–43%. Twenty patients (33%) were at low, 16 (27%) at intermediate, and 24 (40%) at high risk for cardiovascular disease. The median Agatston score (AS) was 393 (0–3538). No significant correlation was found between AS and FRS (P=0.76). 846/851 coronary segments (99%) in 57/60 patients (95%) were depicted with a diagnostic image quality. Significant stenoses were found in 132/846 segments (16%) in 33/60 patients (55%). Five patients (8%) with significant coronary artery stenosis showed reduced LV function [ejection fraction (EF)<50%]. The extent of CAD was significantly correlated with AS (r=0.43, P<0.01), whereas no correlation was found for FRS (P=0.55). Cardiac CT is feasible in patients with AAA and allows for the assessment of coronary calcium, coronary stenoses, and LV function. The calcium burden and coronary stenoses assessment with cardiac CT provides incremental information beyond traditional cardiovascular risk factors alone.

eComment: Re: The heart of patients with aortic aneurysms: evidence from cardiac computed tomography [eComment]

Reconstruction of atrioventricular valves with photo-oxidized bovine pericardium [Institutional report - Valves]

Repair of complex valve pathological processes often requires the use of leaflet tissue or pericardium. The use of bovine photo-oxidized pericardium may be an alternative, a tissue less prone to calcification. The aim of this study is to evaluate the use of photo-oxidized bovine pericardial tissue in the reconstruction of atrioventricular valves in humans. Between July 2001 and September 2006, 21 patients with complex valve pathology underwent a reconstruction with photo-oxidized pericardium. The pericardial patch was used for the reconstruction of a tricuspid valve leaflet in two patients, the reconstruction of a mitral valve leaflet in six patients, the reconstruction of the tricuspid annulus in one patient and the reconstruction of the mitral annulus in 12 patients. The follow-up ranged from 13.9 to 43.2 months. There were five perioperative deaths. Four patients developed failure of the reconstruction, in one patient there was thinning and perforation of the pericardial patch without signs of infection or abrasion. The other patients were free from thromboembolism, endocarditis, hemorrhagic complications or echocardiographic signs of failure of the reconstruction. Photo-oxidized bovine pericardium is a versatile material for complex reconstruction of the atrioventricular valvular structures. Its durability should, however, be investigated in comparison with alternative tissues in a randomized trial.

Temporary cardiac support with a mini-circuit system consisting of a centrifugal pump and a membrane ventilator [Institutional report - Assisted circulation]

Commonly used extracorporeal membrane oxygenation (ECMO) systems for cardiac support are limited by bleeding complications, especially after surgery in the adult patient. Recently, we have switched from the use of a conventional ECMO system to a miniature-circuit including a centrifugal pump and the Novalung® membrane ventilator (iLA). This system allows us to administer less heparin compared to the conventional system. Between January and August 2007, 1469 patients underwent cardiac surgery at our center, of which 18 patients (1.2%) required temporary postoperative ECMO system support. Surgical procedures in these patients included coronary artery bypass grafting (CABG) surgery (n=5), valvular replacement (n=2), aortic surgery (n=2), cardiac transplantation (n=5), and other procedures (n=3). The mean age of the 18 patients was 50±15 years (n=13 male) with a mean duration of ECMO system support of 4.3 days (range: <1 to 14 days). Twelve patients (67%) were successfully weaned from ECMO system. The 30-day survival was 44% with a hospital mortality of 61%. Re-thoracotomy for bleeding was necessary in six patients (33%) under ECMO system support. In summary, the miniature ECMO system circuit seems to be suitable for middle-term cardiac support and is associated with a low rate of bleeding complications.

Extended videoscopic robotic thymectomy with the da Vinci telemanipulator for the treatment of myasthenia gravis: the Vienna experience [Institutional report - Thoracic non-oncologic]

Surgical treatment of myasthenia gravis should include the complete resection of the thymus with the whole fatty tissue adherent to the pericardium for immunologic as well as oncologic reasons. The aim of the current study was to investigate the efficacy and safety of robotic approach. A total of 18 patients with myasthenia gravis (mean age 44 years) have been operated robotically via a left-sided approach. Preoperative MGFA (Myasthenia Gravis Foundation of America) classification was: Class I n=4, Class IIa n=4, Class IIb n=5, and Class IIIa n=3, IIIb n=2. Total endoscopic resection was feasible in 17/18 patients. One patient had to be converted due to bleeding. In the remaining patients, operative time was 175 min, intensive care unit (ICU) one day, hospital stay four days. In all patients it was possible to perform an extended thymic resection. MGFA post-intervention status after a mean of 18 months follow-up showed complete stable remission n=5, pharmacologic remission n=4, minimal manifestations n=5, unchanged n=1. Complete endoscopic thymus surgery with the da Vinci surgical system enables a complete and extended resection of all thymic tissue in the mediastinum. Due to the minimal trauma, patients can return to full activity within a short time.

The impact of previous or concomitant myocardium revascularization on the outcomes of patients undergoing major non-cardiac surgery [Institutional report - Cardiac general]

The aim of this study was to analyze the results of major non-cardiac surgery in patients with severe coronary arterial disease who underwent concomitant vs. previous myocardial revascularization (MR) in terms of operative complications and hospital stay. Between June 1999 and October 2008, 37 patients with coronary arterial disease underwent neoplastic resection at our hospital. Fourteen patients with a curable left-main or multiple-vessel disease received surgical MR concomitantly, while 23 patients previously underwent surgical or transluminal MR. Univariate analysis determined the impact of the timing of MR on operative complications and hospital stay. The overall mortality and morbidity rates were 3% and 65%, respectively. Compared with simultaneous MR, neoplastic surgery with previous MR had shorter postoperative hospital stay. Occurrence of postoperative complications was influenced by surgical duration (P=0.014). Postoperative length of hospital stay was affected by the timing of revascularization (P=0.008) and surgical duration (P=0.007). Previous MR can shorten postoperative hospital length of stay for current major non-cardiac surgeries in patients with severe coronary artery disease (CAD). For patients with concomitant severe CAD and clinically rapidly progressive malignant neoplasm, simultaneous neoplastic resection and MR is associated with acceptable operative mortality.

The effect of diabetic medications on creatine kinase-myocardial band levels in patients undergoing coronary artery bypass surgery [Institutional report - Cardiac general]

Ischemic preconditioning has been shown to attenuate the rise in creatine kinase-myocardial band levels that occur with coronary artery bypass surgery (CABG). Recently, concerns have been raised that some sulfonylureas particularly glibenclamide may block ischemic preconditioning. The purpose of this study was to determine the effect of various diabetic medicines on creatine kinase-myocardial band levels after CABG. In this retrospective study of 799 patients undergoing CABG, patients continued their routine diabetic medicines up to the day of surgery. Intra-operatively and postoperatively, tight glycemic control was maintained with an insulin infusion. Anesthesia was maintained with isoflurane supplemented by fentanyl. Creatine kinase-myocardial band levels were determined the day after surgery at 05:00 h and the mean levels compared between diabetics and non-diabetics and further compared by type of diabetic medicine. After univariable comparisons, linear regression was used to determine the statistically significant predictors of creatine kinase-myocardial band levels. After correction for other factors, none of the diabetic medicines was a statistically significant predictor of creatine kinase-myocardial band levels. We found that the use of glibenclamide or other diabetic medications had no effect on creatine kinase-myocardial band levels the morning after patients underwent CABG.

Neutrophil gelatinase-associated lipocalin levels after use of mini-cardiopulmonary bypass system [Institutional report - Cardiopulmonary bypass]

Neutrophil gelatinase-associated lipocalin (NGAL) has been implicated as an early predictive urinary biomarker of ischemic acute kidney injury (AKI). The aim of this study was to compare the effects of miniaturized cardiopulmonary bypass system (MCPB) vs. standard cardiopulmonary bypass system (SCPB) system on kidney tissue in patients undergoing myocardial revascularization using urinary NGAL levels as an early marker for renal injury. Sixty consecutive patients who underwent myocardial revascularization were studied prospectively. An SCPB was used in 30 patients (group A) and MCPB was used in 30 patients (group B). The SCPB group but not the MCPB group showed a significant NGAL concentration increase from preoperative during the 1st postoperative day (169.0±163.6 ng/ml in the SCPB group vs. 94.1±99.4 ng/ml in the MCPB group, P<0.05, respectively). Two patients in the SCPB group developed AKI and underwent renal replacement therapy; no patient in MCPB developed AKI. The MCPB system is safe in routine clinical use. Kidney function is better protected during MCPB as demonstrated by NGAL levels. NGAL represents an early biomarker of renal failure in patients undergoing cardiac surgery and the valuation of its concentration can aid in medical decision-making.

Elective infrarenal abdominal aortic aneurysm repair - transperitoneal, retroperitoneal, endovascular? [Institutional report - Aortic and aneurysmal]

We retrospectively analyzed the peri-operative outcome of 210 consecutive patients undergoing elective infrarenal abdominal aortic aneurysm (AAA) repair according to the surgical approach: transperitoneal (TP; 63 patients), retroperitoneal (RP; 81 patients) and endovascular (EV; 66 patients) repair. Concerning gender, AAA diameter and classification of the American Society of Anesthesiologists (ASA score) all groups were comparable; the median age in the EV group was significantly higher (78 years vs. 68 years and 67 years, respectively, P=0.001). Mortality rates were 0% for TP, 1.2% for RP and 3% for EV repair (n.s.). Morbidity rates did not significantly differ between the groups. In specialized centres mortality rates of elective infrarenal aneurysm repair are low – regardless of the surgical approach. In such centres the best treatment options for each patient as to the surgical approach as well as peri-operative management can be provided individually.

Ventricular assist device as a bridge to heart transplantation in children [Institutional report - Assisted circulation]

The ventricular assist device (VAD) is a life-saving option for patients in heart failure refractory for conventional therapy. The aim of study was to assess the influence of VAD on heart transplantation (HT) outcome in children <16 years. Between October 1988 and August 2008, 73 children underwent HT: Group 1 (n=9) who received VAD as bridge to HT (left ventricular – 4, biventricular – 5), and Group 2 (n=64), without previous VAD. Diagnoses included cardiomyopathy (n=50 (68.5%)) and congenital heart defects (n=23 (31.5%)). Retrospective analysis of perioperative and long-term follow-up data was performed. The mean follow-up was 7.22±4.7 years. The diagnosis of cardiomyopathy appeared more often in Group 1 (P=0.074), but the difference was not significant. The two groups did not differ with respect to age (P=0.123) and weight (P=0.183). Mortality in long follow-up was: 11.1% (n=1) in Group 1 and 14.1% (n=9) in Group 2 (P=0.782). Analysis of preoperative end-organs function did not reveal significant differences between groups. There was also no significant differences with respect to waiting time for transplant (P=0.948), postoperative ventilatory support time (P=0.677), duration of hospital stay (P=0.711) and incidence of acute rejection episodes (P=0.156). VAD used as a bridge for HT in children does not negatively influence the outcome.

Postoperative administration of landiolol hydrochloride for patients with supraventricular arrhythmia: the efficacy of sustained intravenous infusion at a low dose [Institutional report - Arrhythmia]

The purpose of this study was to investigate the efficacy of landiolol hydrochloride, a short-acting β1 blocker, by initiating its administration at a low dose (5 µg·kg–1·min–1) in patients with postoperative supraventricular arrhythmia. The efficacy of landiolol was evaluated in 38 patients who, after developing postoperative atrial flutter or fibrillation, with sinus tachycardia and two patients who had a history of paroxysmal atrial fibrillation with frequent atrial extrasystole. The heart rate and blood pressure before and 2 h after the administration of landiolol were compared. A return to the sinus rhythm from supraventricular arrhythmia was noted in 89%. The heart rate was reduced from 137±26 bpm (before landiolol administration) to 93±18 bpm (2 h after the start of the medication, P<0.01). As an agent to correct an arrhythmic condition, landiolol successfully raised the systolic blood pressure from 108±24 mmHg (before medication) to 120±19 mmHg (2 h after the medication was started, P<0.05). Continuous intravenous infusion of landiolol at a low dose was found to be effective for postoperative supraventricular arrhythmia.

Anomalous left coronary artery from the pulmonary artery: intermediate results of coronary elongation [Institutional report - Congenital]

A two coronary system is preferred for correcting anomalous left coronary artery from the pulmonary artery (ALCAPA); however, translocation is not always possible. In countries where neonatal arterial switch operations have not been perfected coronary transfer can be difficult. The purpose of this report is to describe the intermediate results using the coronary elongation and translocation technique in developing countries. Records of patients undergoing operation by the International Children's Heart Foundation team were reviewed (April 1993–October 2008) for those undergoing ALCAPA repair. All patients received a 2-D echocardiographic–color Doppler examination prior to discharge and at follow-up. A total of 13 patients were identified, age ranged from 9 days to 41 years. All but one patient were operated upon at one of our affiliate hospitals in Croatia, Belarus, China and Colombia. All patients presented with moderate to severe mitral regurgitation and cardiac failure. Follow-up ranged from six months to 9.5 years postoperatively. Color Doppler showed a patent left coronary artery; echocardiography estimated a normal left ventricular ejection fraction and improved mitral regurgitation in all patients. The technique provides an alternative approach to translocation for ALCAPA in countries where routine neonatal coronary transfer techniques may not be perfected. Intermediate results are comparable to translocation.

eComment: Management of mitral regurgitation associated with anomalous left coronary artery from the pulmonary artery [eComment]

Ministernotomy for repair of congenital cardiac disease [Institutional report - Congenital]

We report our experience with repair of a variety of congenital heart defects utilizing a ministernotomy incision. A ministernotomy was used in 79 patients with a variety of congenital heart diseases from November 2004 to August 2007. Patients included 36 males and 43 females with ages ranging from 1 month to 122 months (median age, 22 months). The weight ranged from 3.5 kg to 40 kg (median weight, 10.9 kg). There were no deaths, and one conversion to full median sternotomy (1/79, 1.3%). The median cardiopulmonary bypass time was 59 min, and median aortic cross-clamp time was 38 min. One patient underwent atrial septal defect (ASD) repair with fibrillatory arrest time of 35 min. The operating time ranged from 103 min to 312 min (median operating time, 168 min). The intensive care unit (ICU) stay ranged from 1 to 21 days (median ICU stay, 1 day) and the hospital stay ranged from 2 to 56 days (median hospital stay, 4 days). There were no reinterventions for residual cardiac defects. We demonstrate the safety and efficacy of ministernotomy for the correction of a range of congenital heart defects with improved cosmetic results.

eComment: Re: Ministernotomy for repair of congenital cardiac disease [eComment]

eComment: Minimally invasive access for congenital heart disease repair [eComment]

Is there any difference in carotid stenosis between male and female patients undergoing coronary artery bypass grafting? [Institutional report - Carotid and imaging]

Cardiovascular diseases are among the leading causes of death in women. Significant gender differences have been reported among patients with symptomatic carotid artery disease. The aim of this study is to examine if the female sex is a predisposing factor for carotid stenosis in coronary artery bypass grafting (CABG) patients. We studied 965 CABG patients, 796 males and 169 females. We combined the gender with risk factors predicting carotid disease as a history of cerebrovascular accident (CVA), peripheral vascular disease (PVD), left main (LM) disease and advanced age. We compared the incidence of carotid disease for each gender against known risk factors, which are history of CVA, PVD, LM and advanced age. In our study, there was not a statistically significant difference for the presence of carotid disease between males and females undergoing CABG. However, patients with a history of CVA, with PVD and older age were at greater risk for carotid stenosis. We conclude that the female sex is not a predictive factor for carotid stenosis in CABG patients.

Age >=75 years is associated with greater resource utilization following coronary artery bypass grafting [Institutional report - Cardiopulmonary bypass]

We examined whether complication rates and resource utilization among elderly patients undergoing coronary artery bypass grafting (CABG) differed from their younger counterparts. A retrospective review of prospectively collected data was conducted of 2936 patients undergoing first-time isolated CABG. Demographic and baseline clinical characteristics were collected, and patients grouped according to age into those <75 years (n=2424, younger) and ≥75 years (n=512, older). Major postoperative complications were recorded and data collected on indicators of resource utilization, which included intensive care unit (ICU) length of stay (LOS), postoperative LOS and total hospital LOS. In comparison with younger patients, older patients were more likely to be female (26.6% vs. 18.1%, P<0.0001) and require an urgent procedure (46.4% vs. 33.3%, P<0.0001). Postoperative complications were significantly higher in elderly patients (43.7% vs. 23.0%; odds ratio (OR)=2.5, 95% confidence interval (CI) [2.0–3.1]; P<0.0001). Older patients incurred longer intensive care stays (2 days interquartile range (IQR) [1–3] vs. 1 day IQR [1–2]; P<0.0001) and a longer postoperative stay (8 days IQR [6–11] vs. 6 days IQR [5–8]; P<0.0001). Multivariate logistic regression analysis showed age ≥75 years was an independent predictor of postoperative LOS (OR=1.23, 95% CI [0.49–1.96]; P=0.001). Older patients aged ≥75 years undergoing CABG had significantly higher rates of postoperative complications and greater resource utilization than their younger counterparts.

Minimal extracorporeal circulation and off-pump compared to conventional cardiopulmonary bypass in coronary surgery [ESCVS article - Cardiopulmonary bypass]

Objectives: Although minimal extracorporeal circulation (MECC) and off-pump surgery are equal or better alternatives to conventional cardiopulmonary bypass (CCPB) regarding perioperative morbidity, use of blood and blood products and completeness of revascularization, CCPB is still being used in the majority of coronary artery bypass grafting (CABG) operations. Methods and Results: We investigated 1472 CABG operations in our center. A total of 1143 CABG operations were performed using CCPB, 220 using MECC and 109 were performed as off-pump coronary artery bypass (OPCAB). All patients were recorded prospectively. Perioperative follow-up was focused on the occurrence of arrhythmia, neurocognitive disorders and the need of blood and blood products. Operative mortality rates were comparable in all three groups. The mean number of distal anastomoses was 3.2±0.6 in the MECC group, 3.4±0.7 in the CCPB group and 1.9±0.8 in the OPCAB group (P=0.01). Arrhythmia occurred in 25% of the MECC group and in 35.6% of the CCPB group (P=0.05). Arrhythmia occurred in 21.7% of the OPCAB group. Seven patients (3%) of the MECC group suffered neurocognitive disorders perioperatively compared to 74 (7%) patients of the CCPB group (P=0.05) and three patients of the OPCAB group (3%). The median number of blood transfusions per patient was 0.8 in the MECC group, 1.8 in the CCPB group and 0.8 in the OPCAB group (P<0.0001). Conclusions: Perioperative morbidity of MECC and OPCAB is comparable to or even less in comparison to CCPB. MECC allows CABG surgery in cardiac arrest so that completeness of revascularization is being warranted and longer patency rates can be guaranteed. Furthermore, the use of blood and blood products is significantly less in MECC surgery so that MECC should be considered first choice in CABG surgery over CCPB and OPCAB.

When operable patients become inoperable: conversion of a surgical aortic valve replacement into transcatheter aortic valve implantation [Proposal for bail-out procedures - Valves]

Transcatheter aortic valve implantation (TAVI) is a relatively new treatment option for inoperable patients with severe aortic stenosis (AS). This case describes how a planned conventional surgical aortic valve replacement (AVR) on a 73-year-old woman was successfully converted to a TAVI procedure. On extracorporal circulation it was reconized that the aortic annulus, the coronary ostiae and the proximal part of the ascending aorta were severely calcified making valve implantation impossible. Surgical closure without valve substitution was estimated to be associated with a high risk of mortality due to the imparied left ventricular function. Consequently, TAVI was performed with a CoreValve ReValving® System prosthesis. The delivery of the valve prosthesis was made through the ascending part of aorta, proximal of the cannulation of aorta. Positioning of the valve prosthesis was made under visual guidance, and the prosthesis was sutured to the ascending aorta. With some manipulation of the prosthesis it was possible to suture the aorta circumferentially around the fully expanded upper part of the prosthesis. Post-procedurally the patient recovered successfully, with improved function capacity, aortic valve area and left ventricle function.

eComment. Sutureless aortic valve implantation in cases of calcified aortic annuli [eComment]

Aortic posterior wall perforation with automatic aortic cutter during routine off-pump coronary bypass grafting [Negative results - Coronary]

Aortic complications are very rare during off-pump coronary artery bypass grafting (OPCAB). When they occur, the mortality is high. We report a case of perforation of the posterior aortic wall after punching out the hole in the ascending aorta with an automatic aortic cutter to avoid clamping for the proximal anastomosis during a routine OPCAB procedure. The consequence was a massive hemorrhage, emergency conversion to cardiopulmonary bypass and replacement of the aortic valve and of the ascending aorta.

Early calcification of the aortic Mitroflow pericardial bioprosthesis in the elderly [Negative results - Valves]

Background: We report our experience in the elderly with aortic valve replacement using the Mitroflow A12 pericardial bioprosthesis. Methods: From January 1993 to January 2006, 491 patients over the age of 70 years received an aortic Mitroflow A12 bioprosthesis implantation. Concomitant procedures included coronary artery bypass grafting in 20% of patients. All patients had routine postoperative Echo-Doppler studies at discharge, one month and a mean of 11.1 months after surgery and annually thereafter. Results: Twenty (4%) patients underwent a second aortic valve replacement due to bioprosthetic valve dysfunction (Group 2). Calcified stenosis was the most common finding at reoperation (98%). Median time to valve reoperation was 76 months. Of patients requiring reoperation, median age at first and second implantation was 73 (70–78) and 79 (76–83) years, respectively. For all patients, freedom from structural valve dysfunction (SVD) was 95±3% at 5 years and 55.8±2% at 10 years. Bioprosthetic valve deterioration was identified in 27 patients (Group 1). Median age of these patients at first operation and at diagnosis of deterioration by echo was 75 (70–84) and 77 (70–82) years, respectively. The median interval between operation and detection of bioprosthesis valve deterioration was 46 months. Among the total patient population, freedom from bioprosthetic deterioration was 85.7±2% at 5 years and 33.5±4% at 10 years. Conclusion: The Mitroflow A12 pericardial bioprosthesis provides less than optimal performance in elderly patients.

eComment: Factors related to bioprosthetic valve calcification in the elderly [eComment]

Pectoral hematoma mimicking a hemothorax in an octogenarian following aortic valve replacement - a near miss [Negative results - Cardiac general]

Open-heart surgery is associated with higher risk of complications in the octogenarians, specifically because of frailty of tissues and delayed healing secondary to various factors. Here, we present a near miss, where an 86-year-old lady underwent tissue aortic valve surgery complicated with formation of a large retro-pectoral hematoma, which on the initial chest X-ray mimicked a left hemothorax. This was successfully explored surgically and drained promptly within 8 h of the primary surgery. This is illustrated with chest radiographs. The case highlights one of the rare complications that we encountered in cardiac surgery of the elderly.

Ministernotomy approach for surgery of the aortic root and ascending aorta [State-of-the-art - Cardiac general]

Different minimally invasive approaches have been proposed for cardiac surgery. Between those, the ministernotomy finds wide consensus for the treatment of the aortic disease, being both the upper reversed T and the upper J the mostly used type of incisions. The authors review the literature on the use of ministernotomy in the treatment of the ascending aorta and arch pathology. The scientific literature was reviewed by searching Medline, the Cochrane Library and the CINAHL database. A total of 1411 papers were found in Medline, 186 in the Cochrane database and 514 in CINAHL database; 50 papers were used to write the article; of which seven represent the most significant papers on the subject. The authors, journal, date and country of publication, patients group studied, relevant outcomes, and the results of these papers are tabulated. The ministernotomy is gaining consensus among surgeons. The indication to surgery, initially restricted only to selected elective patients, is now extended to more complex surgeries, including both the aortic root and aortic arch, redo-operations and, in minor cases, to emergency patients. Furthermore, the use of ministernotomy in redo aortic surgery with patent left internal mammary artery (LIMA) to left anterior descending (LAD) artery is a promising alternative. However, the use of this technique is still limited to few institutions and there are still a limited number of studies comparing this approach to full sternotomy in a prospective, randomized fashion. Even with those limitations, from the review of the literature, it seems that ministernotomy approach for aortic root and ascending aorta surgery is a feasible alternative, showing some advantages compared to full sternotomy. Those advantages include: reduced postoperative bleeding and pain, lower risk of mediastinitis, better aesthetic results, and faster respiratory function recovery. This is true not only for first time surgery, but also, and especially, for redo cases, where the limited exposure will reduce risks correlated to the surgical dissection of redo surgery. The ministernotomy approach for aortic root and ascending aorta surgery could in the future be more extensively used, offering greater benefits to cardiac surgical patients.

Primary graft dysfunction; possible evaluation by high resolution computed tomography, and suggestions for a scoring system [State-of-the-art - Transplantation]

We have reviewed and discussed current knowledge on existing scoring systems regarding high resolution computed tomography (HRCT) images for the assessment of primary graft dysfunction (PGD) after lung transplantation. Adult respiratory distress syndrome (ARDS) has been more widely studied and appears to have many morphological features similar to what is found in PGD, and might, therefore, be usefully extrapolated to PGD. Principles of HRCT, scoring systems based on HRCT and various terms describing PGD were reviewed and summarized. The sensitivity, inter-intra observer variability, and reproducibility of these systems were discussed. Lastly, the future perspectives for 64-multi-slice computed tomography (MSCT) in relation to PGD were discussed. Few studies on scoring systems of lung tissue by HRCT in ARDS patients and idiopathic pulmonary fibrosis (IPF) patients were found. Most studies were performed on patients with cystic fibrosis (CF). Sensitivity of HRCT for the detection of parenchymal changes is superior to other imaging methods. High levels of reproducibility are achievable amongst observers who score HRCT lung images. Development of standardized criteria that specify the inclusion/exclusion criteria of patients, pilot testing, and training investigators through review of disagreements, were possibilities suggested for decreasing inter/intra observer variability. Factors affecting the image attenuation (Hounsfield numbers) and thus, the reproducibility of CT densitometric measurements were of minimal influence. Studies have reported on how lung tissue images, derived by HRCT, can be scored and graded. There does not seem to be a golden standard for evaluating these images, which makes comparison between methods challenging. These scoring systems assess the presence, severity, and extent of parenchymal change in the lung. HRCT is considered relevant and superior in evaluating disease severity, disease progression, and in evaluating the effects of therapy regimes in the lung. It is, however, not clear to what extent these scoring methods may be implemented for grading PGD. Further efforts could be made to standardize scoring methods for lung tissue with regards to PGD.

In patients with acute aortic intramural haematoma is open surgical repair superior to conservative management? [Best evidence topic - Aortic and aneurysmal]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with acute aortic intramural haematoma (IMH) is open surgical repair superior to conservative management. IMH is defined as a clinical condition related to but pathologically distinct from aortic dissection. In this potentially lethal entity, there is haemorrhage into the aortic media in the absence of an intimal tear. Altogether more than 204 papers were found using the reported search terms, from which six systematic reviews represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. IMH represents 17% of all dissections, whereas in postmortem studies this condition is found in 4–13%. The 30-day mortality of IMH is 24% (36% with type A and 12% with type B IMH; P<0.05). With surgical repair, 30-day mortality of type A IMH was 14% for patients treated surgically and 36% for patients treated medically with a P-value of 0.02. Survival at 1, 2, 3, 5 and 10 years was respectively: 81±21%, 87±8%, 83±6%, 65±22% and 44±14%. In contrast, with 8% mortality associated with medical treatment, prognosis of type B IMH is more favourable without surgical intervention, the latter associated with a 30-day mortality of 33% (P<0.05). Symptomatic patients and those with rapid progression or overt dissection during follow-up need emergent surgery. Ascending aortic diameter of >50 mm or subadventitial haematoma thickness of >12 mm should be considered as the candidates for early surgery. Although IMH seems to have an improved prognosis over aortic dissection, survivors of IMH are at significant risk for progressive aortic abnormalities, including aortic rupture, aneurysm, and ulceration. We conclude that surgical treatment of aortic IMH involving the ascending aorta with open distal replacement of ascending aorta results in lower mortality and longer survival compared to conservative management. IMH affecting the descending aorta can be managed with medical or endovascular interventional approach. In this latter group, serial imaging of the aorta is recommended, as aneurysm formation is not uncommon.

Does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation? [Best evidence topic - Coronary]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation? Altogether, 58 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We identified 13 studies, of which eight were randomised prospective trials. None of these studies found increased mortality, seven analyzed serum cardiac enzymes and showed that intermittent ischemic arrest provides equal or better protection compared to cardioplegic techniques. Two studies found an increased usage of inotropes and intra aortic balloon pump (IABP) in the intermittent ischemic arrest group. We conclude that intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate postoperative outcome comparable to cardioplegic arrest in first-time coronary artery bypass graft (CABG). The ischaemic duration associated with intermittent cross-clamp fibrillation is invariably shorter than that associated with cardioplegic arrest, and this may be one explanation for the comparable outcomes. There may also be an element of preconditioning protection during the intermittent cross-clamp fibrillation method, as has been shown experimentally. During elective CABG in patients with no clinical evidence of aortic or cerebro-vascular disease, the incidence of peri-operative microemboli (ME) and postoperative neuropsychological disturbances are shown to be comparable with both techniques of myocardial preservation.

eComment: Myocardial protection in high risk coronary surgery [eComment]

In patients undergoing surgical repair of post-infarction ventricular septal defect, does concomitant revascularization improve prognosis? [Best evidence topic - Cardiac general]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘In patients undergoing surgical repair of post-infarction ventricular septal defect (VSD), does concomitant revascularization improve prognosis?’. The scientific literature was reviewed by searching Medline, using Ovid interface, from 1950 to April 2009. Four hundred and five papers were found, of which 18 were deemed relevant to the topics. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. Seven out of 18 papers showed statistical evidence of benefit of concomitant coronary artery bypass grafting (CABG) in patients undergoing surgical repair of VSD. They showed a benefit especially with complete revascularization. Another five papers recommended CABG with VSD even in the absence of statistical evidence. The reported papers showed a mortality benefit from 26.3% without revascularization down to 21.2% with revascularization and an actuarial survival at five years from 29 up to 72%. However, six out of 18 papers did not find any difference. The largest study in this area was by Jeppsson et al. where 119 patients underwent VSD repair with revascularization and 70 underwent VSD repair only, the mortality was 38% vs. 46% (P=0.29). Barker et al. compared a group of 23 patients undergoing repair of VSD only and 42 patients undergoing concomitant CABG. The in-hospital mortality was 39.2% vs. 26.2%, and the four-year survival rate was 33.2% and 88.2%, respectively. Lundblad et al. found that in 66 patients undergoing concomitant CABG out of 102 undergoing repair of VSD, complete revascularization and revascularization of the culprit artery, both resulted in improved 30-day survival and long-term survival. Muehrcke et al. reported on 75 patients undergoing surgical repair of post-infarction VSD. Out of those, 33 (44%) had a concomitant CABG. The authors found that concomitant CABG increases long-term survival when compared with patients with unbypassed coronary artery disease (CAD) (P=0.0015). We conclude that patients undergoing concomitant CABG to all the stenotic coronary arteries, supplying the non-infarcted area, fare better both in improved 30-day survival and long-term survival. The improvement of the collateral flow to the myocardium contributes to its better recovery.

Complicated ruptured sinus of Valsalva: cardiac computed tomographic angiography (64 slice) predicts surgical appearance and obviates need for invasive cardiac catheterization [Case report - Aortic and aneurysmal]

We present a case report of a ruptured sinus of Valsalva aneurysm (SVA) that presented as aortic insufficiency following bacterial endocarditits in a cardiac transplant patient. Cardiac computed tomographic angiography (CCTA) including volume rendered images predicted the appearance of the fistula entrance and defined spatial relationships facilitating the surgical approach. CCTA ability to define the coronary anatomy obviated the need for invasive coronary angiography. The use of this imaging modality especially with three-dimensional spatial visualization, and multiphase cine angiography can add significant value to the care of a patient with ruptured sinus of Valsalva.

A novel internal thoracic artery harvesting technique via subxiphoid approach - for the least invasive coronary artery bypass grafting [Case report - Coronary]

We have performed 12 cases of robotically assisted coronary artery bypass grafting (CABG) to accomplish less invasive revascularization. In this report, we describe a new method of robotically assisted internal thoracic artery (ITA) harvesting via subxiphoid approach, using the da Vinci surgical system. A 22-year-old man with three-vessel coronary artery disease due to Kawasaki disease was referred to our institution for coronary artery revascularization. A small subxiphoid incision was made, and the xiphoid process at the lower end of the sternum was excised. A U-shaped hook was inserted into the retrosternal space, and the lower sternum was lifted. A 30° angle-up camera was inserted under the U-shaped hook, bilateral ITAs were harvested in a totally skeletonized fashion endoscopically. The required time for right ITA harvesting was 50 min, and that for the left was 20 min. After bilateral ITAs were harvested, composite grafts were made, and then the distal anastomoses were made. The patient was discharged six days after the operation. We performed a new robotically assisted bilateral ITA harvesting technique via sub-xiphoid safely and with excellent results. This method might be an evolutionary step of minimally invasive direct coronary artery bypass (MIDCAB) using the da Vinci surgical system.

A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system [Case report - Cardiac general]

Pseudoaneurysms of the ascending aorta developing after previous aortic or aortic valve surgery pose a high risk of exsanguination upon sternal reentry. In the past, femorofemoral bypass and hypothermic circulatory arrest before sternotomy was the preferred approach. Today, however, availability of the PORT-ACCESS EndoCPB system (Edwards Lifesciences, Irvine, CA, USA) allows for endovascular clamping and cardioplegia before sternotomy, avoiding circulatory arrest.

Successful salvage right upper lobectomy and flap repair of trachea-esophageal fistula due to severe necrotizing pneumonia [Case report - Thoracic oncologic]

A 55-year-old previously well man developed a severe pneumonia. Endoscopy found tracheal and esophageal fistulae communicating with the right lung and pleural space. Bilateral main bronchi intubation was required. Emergency surgery was performed with a latissimus dorsi and serratus anterior muscle flap to close the tracheal and esophageal fistulae. The right upper lobe was found to be destroyed and resected. It was possible to salvage the patient who was discharged home despite challenging anesthetic and surgical circumstances.

Aortogenic cerebrovascular accident [Case report - Vascular thoracic]

A 59-year-old man was transferred to our hospital because of mural thrombus in the ascending aorta. He had suffered some neurological dysfunctions such as transient dysorientation. Electrocardiogram showed normal sinus rhythm without premature beats. Trans-thoracic echocardiogram and three-dimensional CT showed a mobile mural mass sticking to the ascending aortic wall. No coagulopathy was detected in the patient. The mural masses were thought to be a possible cause of the repeated cerebro-vascular symptoms. Under cardiopulmonary bypass and cardiac arrest, the masses were removed including the mass sticking to the aortic wall. Postoperative pathological findings showed the masses were organizing thrombi that had originated from the atherosclerotic aortic wall. Postoperative course was uneventful, and the patient was doing well one year after the operation without neurological dysfunction.

Use of Amplatzer device for endobronchial closure of bronchopleural fistulas [Case report - Thoracic oncologic]

Postpneumonectomy bronchopleural fistulas (BPFs) remain difficult management problems associated with considerable morbidity and mortality. Traditional therapies have included primary repair or delayed closure with the creation of an Eloesser cavity and tissue flap reinforcement. New bronchoscopic modalities have included the use of bioglues, stents, and coils. We describe another additional, less invasive bronchoscopic modality – the use of an atrial septal closure device.

Thymic neuroblastoma with the syndrome of inappropriate secretion of antidiuretic hormone [Case report - Thoracic oncologic]

We describe a rare case of thymic neuroblastoma with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). A 60-year-old male patient was admitted to our hospital for further examination and treatment of anterior mediastinal tumor found at a regular health check-up. On examination there was hyponatremia, decrease in plasma osmolarity and elevation of plasma antidiuretic hormone (ADH) level. Thus, he underwent total thymectomy under the diagnosis of thymoma with SIADH. The tumor was located in the right lobe of the thymus and the final diagnosis was thymic neuroblastoma. To our knowledge, this is the first reported case of thymic neuroblastoma in which production of ADH by tumor cells is demonstrated immunohistochemically. This case highlights the need to consider functional activity of thymic neuroblastoma and complete resection of the tumor is warranted for treatment.

Aorta non-touch coronary artery bypass grafting after total arch replacement for acute type A aortic dissection [Case report - Vascular thoracic]

We report successful surgical treatment of coronary artery disease (CAD) in a 53-year-old man. The man was admitted to our hospital due to severe anterior chest pain. He had a surgical history of total arch replacement for acute type A dissection 10 years previously. Angiography showed triple-vessel disease and partial dissection of the descending aorta. To avoid excessive excision and to perform surgery safely, we chose aorta non-touch techniques for coronary artery bypass grafting (CABG). The postoperative course was uneventful and the patient was discharged 30 days after surgery.

Heartmate XVE(R) destination therapy for end-stage heart failure in a patient with human immunodeficiency virus [Case report - Assisted circulation]

Cardiac dysfunction is a known predictor of survival in patients with acquired immunodeficiency syndrome. In this report, we describe a human immunodeficiency virus (HIV)-infected patient with worsening heart failure who was managed successfully for 16 months with placement of a left ventricular assist device.

Emergent surgery for ruptured aortic arch aneurysm in an octogenarian patient: quo vadis? [Case report - Cardiac general]

Aortic arch aneurysms induce great morbidity and mortality especially when clinical signs of rupture are present. Surgical indications for repair in the high-risk octogenarian population are controversial. We present the case of an 87-year-old man with a ruptured aortic arch aneurysm with a good surgical outcome. We discuss the clinical impact of the surgical treatment in this group of patients.

Catastrophic presentation of atrial myxoma with total occlusion of abdominal aorta [Case report - Cardiac general]

Cardiac myxoma is a rare disease with protean manifestations. Embolic phenomena are well-known entities. However, total occlusion of the descending aorta by saddle embolism along with multi-organ embolism is very unusual. We report a patient with cardiac myxoma presenting with multi-organ embolism including saddle embolism of the aorta in a previously healthy female.

Non-surgical closure of post-pneumonectomy empyema with bronchopleural fistula after open window thoracotomy using basic fibroblast growth factor [Case report - Thoracic non-oncologic]

Empyema with bronchopleural fistula (BPF) is one of the severest complications following pneumonectomy. Many papers have reported that it is difficult to cure, with a high rate of associated mortality. Closure of the fistula and an appropriate choice of obliteration materials are crucial for successful treatment. However, obliteration is sometimes impractical because of a lack of suitable materials, excessive surgical risk, or lack of patient willingness to undergo the procedure. We report a case of post-pneumonectomy empyema with BPF that was treated by non-surgical closure after open-window thoracotomy (OWT) with the use of basic fibroblast growth factor (bFGF), which was sprayed into the unepithelialized empyema cavity transiting from epidermis and surrounding the fistula. After spraying, the orifice of the OWT was covered by a film dressing. This procedure yielded successful results after two months.

Left ventricular assist device placement in a patient with end-stage heart failure and human immunodeficiency virus [Case report - Assisted circulation]

Left ventricular assist device (LVAD) insertion has been used more frequently within the recent years either as a bridge to transplant or as destination therapy in patients with advanced heart failure who fail medical therapy. We present a report of a 60-year-old male patient with end-stage heart failure and cardiomyopathy with a history of human immunodeficiency virus (HIV) infection who underwent LVAD placement as destination therapy. To our knowledge, LVAD placement in this fashion has not been reported previously. Following LVAD implantation, the patient recovered during the course of five weeks and was discharged home from the hospital in good condition. The patient was alive and free of any activity limitations sixteen months postoperatively. We conclude that LVAD placement for end-stage heart failure may be a feasible option as destination therapy in patients with HIV.

Multiple papillary fibroelastoma in left ventricle associated with obstructive hypertrophic cardiomyopathy [Case report - Cardiac general]

A 68-year-old man was referred to our hospital with a left ventricular (LV) mass and obstructive hypertrophic cardiomyopathy (HOCM). Although he was treated for the LV thrombosis and received anticoagulation therapy, the mass did not decrease in size for three years. His past history was colon cancer which was resected in its early phase. Laboratory studies revealed the absence of any inflammatory and tumor marker symptoms. Transthoracic and transesophageal echocardiography revealed a mass of 24x11 mm in diameter attached to the septal wall of LV and another two or three masses detected in LV wall. He received surgical treatment with complete mass excision with LV dissection and hypertrophied ventricular muscle was resected. Surgical resection of these LV masses and septal myectomy was performed. The histological examination showed that the lesions had a papillary configuration with an avascular connective tissue core lined by a single layer of endothelial cells, which was sufficient for a diagnosis of cardiac papillary fibroelastoma (CPF). The patient recovered without any complications.

eComment: Cardiac papillary fibroelastoma: a current assessment [eComment]

Left Ventricular Assist Devices: Psychosocial Challenges in the Elderly [CASE REPORTS]

As the baby boom generation ages, the number of people with heart failure is expected to rise exponentially. A rapid increase in the demand for heart transplants will result in an increased use of left ventricular assist devices. This case illustrates the challenges facing transplant teams in evaluating elderly heart failure patients as candidates for assist devices. The critical elements of a psychosocial assessment are described.

Percutaneous Implantation of CoreValve Aortic Prostheses in Patients With a Mechanical Mitral Valve [CASE REPORTS]

Concerns exist in the field of transcatheter aortic valve implantation regarding the treatment of patients with mechanical mitral valve for possible interference between the percutaneous aortic valve and the mechanical mitral prosthesis. We report our experience with percutaneous aortic valve implantation in 4 patients with severe aortic stenosis, previously operated on for mitral valve replacement with a mechanical prosthesis. All patients underwent uneventful percutaneous retrograde CoreValve implantation (CoreValve Inc, Irvine, CA). No deformation of the nitinol tubing of the prostheses (ie, neither distortion nor malfunction of the mechanical valve in the mitral position) occurred in any of the patients. All patients are alive and asymptomatic at a mean follow-up of 171 days.

Cardiac Tamponade: Chylopericardium Presenting 2 Weeks After Mechanical Aortic Valve Replacement Through a Median Sternotomy [CASE REPORTS]

Chylopericardium is a rare disorder that can be secondary to thoracic duct injury. Consequences include nutritional, metabolic, and immunologic abnormalities, as well as cardiac complications, such as pericarditis and cardiac tamponade. We present a case of chylopericardium presenting as cardiac tamponade after a median sternotomy for mechanical aortic valve replacement.

Extracorporeal Membrane Oxygenation Bridging to Living-Donor Lobar Lung Transplantation [CASE REPORTS]

A 21-year-old man with pulmonary fibrosis and a 27-year-old woman with idiopathic pulmonary hypertension, who were in pulmonary hypertensive crisis, were successfully treated by using venoarterial extracorporeal membrane oxygenation, followed by living-donor lobar lung transplantation. In both of the patients, bridging time of extracorporeal membrane oxygenation to lung transplantation was 2 days, and both could be weaned from cardiopulmonary support immediately after transplantation in the operating room. No major complications were seen, including primary graft dysfunction. The cardiopulmonary functions of these patients markedly improved after living-donor lobar lung transplantation.

Uncommon Etiology of an Anterior Chest Wall Mass [CASE REPORTS]

A rare but important constellation of musculoskeletal and cutaneous symptoms, including synovitis, acne, pustulosis, hyperostosis, and osteitis, has recently been designated the SAPHO syndrome. The exact etiology is unknown, although various infectious agents have been proposed. The most common site of osteoarticular involvement is the sternoclavicular joint, and therefore, recognition of this syndrome and appropriate workup and management is crucial in the differential diagnosis of an anterior chest wall mass.

Surgeon Specialty Is Associated With Better Outcomes: The Facts Speak for Themselves [EDITORIALS]

Microcirculatory Alterations in Cardiac Surgery: Effects of Cardiopulmonary Bypass and Anesthesia [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Heterogeneity in microvascular perfusion is associated with impaired tissue oxygenation. We hypothesized that cardiac surgery with or without cardiopulmonary bypass (CPB) could induce microvascular alterations. Methods We used an orthogonal polarization spectral imaging technique to evaluate the sublingual microcirculation in patients undergoing cardiac surgery with (n = 9) or without (n = 6) CPB. We also included, as a control group, 7 patients undergoing thyroidectomy with the same anesthetic procedure. Hemodynamic and microcirculatory variables were obtained the day before surgery, after induction of anesthesia, during CPB, on admission to the intensive care unit or the recovery room, and 6 and 24 hours after the end of the surgical procedure. Data are presented as median (25th to 75th percentile). Results No differences in hemodynamic variables were observed between the two cardiac surgery groups. The proportion of perfused vessels was similar in all three groups at baseline (89% [87% to 90%]), and decreased similarly after induction of anesthesia to 71% (69% to 74%). It decreased further during CPB to 53% (50% to 56%). On admission to the intensive care unit or recovery room, alterations were more severe in CPB than in off-pump patients (60% [59% to 62%] versus 64% [61% to 65%]; p = 0.03), whereas they had already normalized in thyroidectomy patients (89% [86% to 90%]; p = 0.0005 versus cardiac surgery). In both cardiac surgery groups these microcirculatory alterations decreased with time, but persisted at 24 hours. The severity of microvascular alterations correlated with peak lactate levels after cardiac surgery (y = 11.5 – 0.15x; r 2 = 0.65; p < 0.05). Conclusions Microcirculatory alterations are observed in cardiac surgery patients whether or not CPB is used. Anesthesia contributes to these alterations, but its effects are transient.

Choice of Conduit for the Right Coronary System: 8-Year Analysis of Radial Artery Patency and Clinical Outcomes Trial [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Previous reports have supported the use of bilateral internal thoracic arteries to revascularize the left coronary circulation. If this becomes standardized practice, the optimal conduit for the right coronary system remains to be established. Our objective is to compare the performance of the radial artery versus the saphenous vein when used to graft the right coronary artery or its branches during an 8-year period after primary coronary artery bypass graft surgery. Methods The Radial Artery Patency and Clinical Outcomes study is a randomized controlled trial comparing radial artery, saphenous vein, and free right internal thoracic artery. Of the 621 patients enrolled in the study, 465 patients received a graft to the right coronary artery or its branches. The retrospectively compiled database was used to establish patency rates and clinical events among these patients. Results Absolute graft patency rates were as follows: radial artery, 86.9% of 68 (95% confidence interval, 76.6% to 93.1%); and saphenous vein, 81.2% of 197 (95% confidence interval, 75.1% to 86.1%). Noninferiority tests show that absolute radial patency to saphenous patency is at least 0.9526 (p = 0.025). Kaplan-Meier estimates of angiographic outcomes show no significant difference (log rank p = 0.22). Cardiac events in the right coronary territory occurred in the radial artery group (1.79%) versus the saphenous vein group (4.93%; p = 0.26). Overall mortality was 8.03% in the radial artery group versus 12.5% in the saphenous vein group (p = 0.23). Conclusions The radial artery patency is at least comparable to that of the saphenous vein when grafted to the right coronary artery or its branches. The paucity of clinical events in both grafts is notable. Selection of best conduit may therefore be made according to other factors.

Transfusion and Pulmonary Morbidity After Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background True lung injury is among the leading causes of transfusion-related mortality. Pulmonary morbidity after cardiac surgery has been related to damaging effects of cardiopulmonary bypass and transfusion, but is confounded by cardiac-related events that may not reflect true lung injury. Thus, cardiac surgery poses unique challenges to criteria-specific diagnosis of transfusion-related acute lung injury (TRALI). Our objective was to determine the prevalence of pulmonary morbidity related to transfusion and whether TRALI consensus-criteria are applicable to cardiac surgery. Methods A total of 16,847 patients underwent on-pump, coronary artery bypass grafting (CABG), valve, or CABG-valve surgery from September 1998 to February 1, 2006. We performed four propensity-score-matching analyses with logistic regression on probability of receiving a transfusion: total hospital red blood cell (RBC) and fresh frozen plasma (FFP) transfusion and intraoperative RBC and FFP transfusion. Outcomes included traditional cardiac-surgery-defined pulmonary morbidity and ratio of arterial partial pressure of oxygen to fractional inspired oxygen concentration (Pao 2/Fio 2), a criterion for TRALI. Results Patients receiving RBC transfusion had more risk-adjusted pulmonary complications: respiratory distress 4.8% vs 1.5%, p < 0.001; respiratory failure 2.2% vs 0.39%, p < 0.0001; longer intubation times, 9.9 hours vs 7.5 hours, p < 0.0001; acute respiratory distress syndrome, 0.64% vs 0.21%, p = 0.015; and reintubation, 5.6% vs 1.3%, p < 0.0001. The FFP was similarly related to more pulmonary complications after surgery. By TRALI criteria, the majority manifested "lung injury" (Pao 2/Fio 2 ratio < 300) but unrelated to transfusion (65% vs 64%). Conclusions Transfusion is associated with many measures of postoperative pulmonary morbidity. Yet the Pao 2/Fio 2 ratio as important criterion of TRALI is unrelated to transfusion. Thus, due to the nature of cardiac surgery, application of consensus guided diagnosis of TRALI is problematic.

Improved Myocardial Perfusion and Thickening After Off-Pump Revascularization: 5-Year Follow-Up [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Late improvements in myocardial perfusion and thickening after off-pump revascularization were evaluated during a 5-year follow-up by myocardial single photon emission computed tomography. Methods Between 2001 and 2003, 68 patients who underwent off-pump coronary artery bypass grafting using bilateral internal thoracic artery Y-composite (group Y, n = 41) or in situ (group I, n = 27) grafts for revascularization of the left coronary artery territory were enrolled. Myocardial single photon emission computed tomography was performed preoperatively and at 3 months, 1 year, and 5 years postoperatively. A 20-segment model was adopted. As an indicator of ischemic myocardium, the reversibility score was defined as a measure of rest minus stress perfusion values. A total of 374 segments that showed a reversibility score of ≥7 preoperatively were included. Z values for thickening were calculated as observed values minus reference values divided by the reference standard deviation. Mixed-model analysis was used to compare the two groups with respect to the time sequences of myocardial reversibility scores and Z values. Results Postoperative reversibility scores improved significantly at 3 months (p < 0.001) and further at 5 years (p = 0.030). Postoperative Z values improved significantly at 3 months (p < 0.001), between 1 year and 5 years (p = 0.006), and further at 5 years (p = 0.004). In the mixed models, there were no significant differences in reversibility scores and Z values between groups Y and I at any point. Conclusions Reversibility scores and thickening gradually improved during 5 years after off-pump revascularization using bilateral internal thoracic arteries. No significant differences were observed between Y-composite and bilateral in situ grafts in terms of reversibility score and thickening improvement at 5 years postoperatively.

Plasma Amyloid {beta}42 and Amyloid {beta}40 Levels Are Associated With Early Cognitive Dysfunction After Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Decreased cognitive function associated with coronary artery bypass graft surgery is common. These deficits may be similar to the cognitive dysfunction seen in the spectrum of mild cognitive impairment to Alzheimer's disease, which are believed to result from the accumulation of amyloid beta (Aβ) peptide in the brain. We measured cognition both before and after coronary artery bypass graft surgery and assayed Aβ levels to investigate whether the cognitive dysfunction of cardiac surgery was associated with Aβ levels. Methods The plasma of 332 patients, who had undergone neuropsychological testing before and 3 and 12 months after coronary artery bypass graft surgery, was analyzed for Aβ42 and Aβ40. Patients were classified as having preexisting cognitive impairment if cognitive function was decreased in two or more tests compared with a healthy control group, and postoperative cognitive dysfunction was defined as a decline in two or more tests compared with the group mean baseline score. Results Preexisting cognitive impairment was present in 117 patients (35.2%), and postoperative cognitive dysfunction was present in 40 (12%) at 3 months and 41 (13%) at 12 months after surgery. Both plasma Aβ42 and Aβ40 levels assessed before the surgery were significantly lower in patients who later had postoperative cognitive dysfunction at 3 months. Conclusions Decreased preoperative plasma levels of Aβ42 and Aβ40 in patients who exhibit postoperative cognitive dysfunction at 3 months suggest that postoperative cognitive dysfunction at this time may share a common mechanism with mild cognitive impairment and Alzheimer's disease. This process may be exacerbated by anesthesia.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

A Three-Group Model to Predict Mortality in Emergent Coronary Artery Bypass Graft Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Emergent coronary artery bypass graft surgery (CABG) for acute myocardial infarction is associated with an increased operative risk. For estimation of mortality risk, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) is appropriate up to a medium risk score (<6 points). To predict mortality risk more accurately in cases of higher EuroSCORE, additional cardiac data can be helpful. Methods Over a 3-year period, patient data including acute myocardial infarction and emergent CABG were retrospectively reviewed. Univariate and multivariate analysis for in-hospital mortality was performed. The EuroSCORE analysis and follow-up was investigated. Results Overall in-hospital mortality was 18.3%. Preoperative cardiac related predictors for in-hospital mortality were cardiogenic shock (p < 0.001), very poor left ventricular function (p = 0.001), and ST-segment elevation (p = 0.012). In multivariate regression analysis, age, cardiogenic shock, and pulmonary hypertension were independent preoperative risk factors. According to the EuroSCORE, we could define three statistically different groups: intermediate-risk, high-risk, and very high risk, with an observed mortality of 3.3%, 20.0%, and 63.2%, respectively. The EuroSCORE correlates with but overestimates the mortality risk. In subgroup analysis, the creatine kinase-myocardial band/hour ratio for the intermediate-risk group and ST-segment elevation for the high-risk group were additional cardiac risk factors. Conclusions Patients with an acute myocardial infarction and emergency aortocoronary CABG have an elevated operative risk. Logistic EuroSCORE overestimates the mortality rate. Three different risk groups can be defined, in which creatine kinase-MB/h-ratio and ST-segment elevation can more accurately predict operative risk.

Efficacy of Aggressive Lipid Controlling Therapy for Preventing Saphenous Vein Graft Disease [ORIGINAL ARTICLES: ADULT CARDIAC]

Background We assessed the efficacy of aggressive lipid controlling therapy (ALCT), which maintains low-density lipoprotein cholesterol (LDL-C) below to 80 mg/dL and LDL/high-density lipoprotein cholesterol (HDL-C) ratio less than 1.5 for preventing postcoronary bypass (CABG) saphenous vein graft (SVG) diseases by using intracoronary angioscopy. Methods Twenty-one patients after CABG were divided into two groups: group I consisted of 10 patients whose serum LDL-C level and LDL/HDL could be controlled less than 80 mg/dL and 1.5, respectively, by rosuvastatin for about one year; group II consisted of 11 patients whose LDL-C level and LDL/HDL have been higher than 100 mg/dL and 2.5, respectively, regardless of having medication of pravastatin. Twenty-seven SVGs were assessed by intravascular ultrasound (IVUS) and angioscopy on postoperative 12 to 16 months. Results The serum LDL-C level (I: 64.1 vs II: 130.2 mg/dL) and LDL/HDL (I: 1.36 vs II: 2.64), and high sensitive C-reactive protein (I: 0.045 ± 0.100 vs II: 0.116 ± 0.020 mg/dL) were significantly lower in group I. In group II, IVUS detected eccentric plaques in 11 (78.6%) of 14 SVGs. Furthermore the angioscope showed yellow plaque in all 14 SVGs (100%) and 11 (78.6%) of them had thrombi. On the other hand, in group I, all 13 SVGs had no eccentric, yellow plaques or thrombi and the intima was entirely clear white. Conclusions Prophylactic treatment for yellow plaque and thrombus formation are extremely important in the development of early and late SVG disease. Aggressive lipid controlling therapy is quite attractive to avoid post CABG SVG disease and may be effective to maintain the long-term graft patency.

Randomized Prospective Study Comparing Conventional Subcuticular Skin Closure With Dermabond Skin Glue After Saphenous Vein Harvesting [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Dermabond (Ethicon UK, Edinburgh, United Kingdom) is a topical skin adhesive used for surgical wound closure, with purported advantages over conventional sutures on cosmetic outcomes, cost benefits, and operative times. This study compared results of skin closure using Dermabond and subcuticular sutures after coronary artery bypass grafting (CABG). Methods The study prospectively enrolled and randomized 106 patients who underwent CABG. The groups received closure with Dermabond skin glue or subcuticular sutures (n = 53 each) after saphenous vein harvesting using the bridging technique. Wound closure time for the two methods was recorded. Cosmetic appearance was assessed using the Hollander, the Vancouver, and the visual analog scale. Patient satisfaction was recorded before discharge and at week 6. Results There were no significant differences in the total operative time between the two groups (p = 0.43). Closure time was significantly shorter in the Dermabond group (p = 0.017). Patients in the Dermabond group also reported superior cosmetic outcome at weeks 1 (p < 0.001) and 6 (p = 0.001) and improved patient satisfaction (p < 0.001). Conclusions Dermabond has demonstrated superiority over traditional subcuticular skin sutures in terms of closure time, cosmetic appearance, and patient satisfaction. This technique provides a novel method of wound closure after CABG.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Diabetes Mellitus and Long-Term Outcome in Heart Failure Patients After Surgical Ventricular Restoration [ORIGINAL ARTICLES: ADULT CARDIAC]

Background This study aimed to identify the impact of diabetes mellitus and related comorbidities on long-term survival of heart failure patients who had undergone surgical ventricular restoration. Surgical ventricular restoration is an optional therapeutic strategy for patients with ischemic dilated cardiomyopathy. Reported prognostic predictors for late morbidity and mortality are predominantly related to cardiac conditions, whereas the prognostic impact of comorbidities still needs to be defined. Methods A total of 329 patients (234 nondiabetic and 95 diabetic) who survived the surgical ventricular restoration operation were admitted to this study. Cardiac mortality follow-up data were collected. Actuarial survival curves were calculated for the two groups; differences between groups and the impact of other comorbidities were established using a log-rank test and a Cox regression analysis. Results The mean follow-up time was 44 months. Diabetic patients had a significantly worse survival rate: at 5 years, their survival rate was 81%, versus 89% for nondiabetic patients (p = 0.019). Other comorbidities significantly associated with the survival rate were chronic renal failure, New York Heart Association class, and liver dysfunction. Diabetic patients without comorbidities had a survival rate similar to that of nondiabetic patients. Diabetic patients with at least one comorbidity had a significantly worse outcome. Diabetic patients with chronic renal failure had a 5-year survival rate of 40%, versus 85% for nondiabetic patients (p = 0.002). Conclusions Noncomplicated diabetes has no negative impact on long-term survival after surgical ventricular restoration. Conversely, complicated diabetes, namely the presence of chronic renal failure, carries a long-term cardiac mortality risk that is four times higher than the risk for nondiabetic patients.

Impact of Left Ventricular Assist Device Bridging on Posttransplant Outcomes [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Bridge to heart transplantation with a left ventricular assist device (LVAD) can be a promising therapy for patients who are not effectively stabilized with conservative measures. However, referral for LVAD therapy may be limited secondary to reports of poor outcomes when mechanical circulatory support is required before transplantation. Methods A retrospective review was undertaken to evaluate outcomes in United Network of Organ Sharing (UNOS) status 1 heart transplant recipients who were bridged to transplant with an implantable LVAD or with intravenous inotropes only from 1994 to 2007. Preoperative characteristics, posttransplant survival, and postoperative complications were compared between 86 patients with an implantable LVAD and 173 patients bridged with intravenous inotropes only. Results The patients had similar baseline characteristics and pretransplant hemodynamics. Hemodynamics in the LVAD group, as measured by cardiac index, pulmonary vascular resistance, central venous pressure, and pulmonary capillary wedge pressure, significantly improved during mechanical support. Short-term and long-term posttransplant survival and the incidence of posttransplant infectious complications and rejection episodes during the first year was similar. The incidence of posttransplant renal dysfunction was higher in patients bridged with inotropes. Conclusions Patients bridged to transplant with a LVAD represent a subset of UNOS status 1 patients who deteriorated on intravenous inotropic therapy. Bridging to heart transplantation with an implantable LVAD provides comparable outcomes to similar status 1 patients who were stabilized on inotropic infusions only. In contrast with International Society of Heart and Lung Transplantation data, no increase in posttransplant morbidity or mortality occurred in LVAD-bridged patients.

Role of a Percutaneous Ventricular Assist Device in Decision Making for a Cardiac Transplant Program [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The role of a percutaneous ventricular assist device (VAD) for left heart support in the management of patients in cardiogenic shock is not well defined. Methods All patients who received LV support using the percutaneous TandemHeart (percTH) ventricular support device (Cardiac Assist, Pittsburgh, PA) were retrospectively reviewed. Indications for insertion included bridge to decision (BTD) or "salvage" and bridge to transplant (BTT). Results Between April 2005 and December 2008, 22 percTH devices were successfully implanted in patients (13 men) with isolated left heart failure. Mean duration of support was 6.8 ± 9.4 days (median, 4; maximum, 45 days). Of patients requiring percTH support for at least 3 days, mean pump flows were 3.77 ± 1.10, 4.22 ± 0.69, and 4.04 ± 0.41 L/min on at days 1, 2, and 3. Mean serum aspartate aminotransferase levels were 455 ± 994 mg/dL before percTH, 551 ± 1046 mg/dL at day 1, and 231 ± 225 mg/dL at day 3 after percTH. No mechanical device failure, device-related infections, or cerebrovascular accidents occurred. Ten of 11 BTT patients were successfully bridged. Support was withdrawn in 7 of 11 BTD patients. The percTHs were successfully explanted in 4 BTD patients: 1 as recovery, 1 direct to transplant, and 2 to VAD. Conclusions The percTH was reliable, with no mechanical device failures and minimal associated adverse events. We support the use of the percTH in the BTD mode, allowing time for a more complete evaluation of neurologic and end-organ status without the added expense and morbidity of a long-term VAD.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Transcatheter Aortic Valve Implantation in Patients With Very High Risk for Conventional Aortic Valve Replacement [ORIGINAL ARTICLES: ADULT CARDIAC]

Background We sought to determine whether transcatheter aortic valve implantation is a reasonable treatment option in patients with a very or extremely high risk for conventional aortic valve replacement, presenting with a logistic EuroSCORE greater than 30% or a Society of Thoracic Surgeons score greater than 15%. Methods Between May 2005 and November 2008, 39 of 85 transcatheter aortic valve implantation patients with a very high risk for aortic valve replacement underwent either transfemoral (n = 15) or transapical (n = 24) transcatheter aortic valve implantation with a mean estimated logistic EuroSCORE of 44.2% ± 12.6% (mean ± standard deviation) and a Society of Thoracic Surgeons score of 17.9% ± 6.1%. Transcatheter aortic valve implantation was performed in a hybrid operative theater using the Cribier-Edwards or Edwards SAPIEN prosthesis. Results Valve implantation was successful in 97% of the patients. Operative mortality was 2.6%, and mortality at 30 days was 17.9%. After valve implantation, hemodynamic improvement was assessed by decreased mean pressure gradient (p < 0.001) and increased aortic valve area (p < 0.001), accompanied by improved New York Heart Association functional status (p < 0.01). Actuarial survival was 74.4% at 3 months, 74.4% at 6 months, and 64.1% at 12 months of follow-up. Echocardiography revealed aortic regurgitation in 58% of the patients during hospital stay, 43% at 6 months of follow-up, and 40% at 12 months of follow-up, but no structural valve deterioration could be observed during the complete follow-up period. Conclusions Transcatheter aortic valve implantation in patients with severe aortic stenosis and a very high risk for aortic valve replacement is feasible and may be a reasonable treatment option in these patients.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Mechanical Strain and the Aortic Valve: Influence on Fibroblasts, Extracellular Matrix, and Potential Stenosis [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Mechanical strain may affect aortic valve cusp, leading to an altered extracellular matrix ultrastructure and eventually aortic stenosis. The aim of this study was to evaluate the affect of these potential relationships on human tissue. Methods Extracellular matrix protein disposition was analyzed on human aortic valve cusp retrieved from 31 patients during routine aortic valve replacement surgery. Samples were immediately fixed in 2-hydroxyethyl methacrylate. Immunohistology and Western blot analysis were used to quantify decorin, tenascin-C, biglycan, alkaline-phosphatase, osteocalcin, and osteopontin content. Fibroblast function was analyzed on interstitial cells derived from aortic valve cups from patients undergoing aortic valve replacement. Cells were grown to confluency in modified Eagle's medium supplemented with 10% fetal calf serum under sterile conditions. Thereafter, mechanical strain was applied for 72 hours and 60 cycles per minute. Elongation of as much as 10% in comparison with no elongation (control group) was applied. All results were correlated to hemodynamic variables. Results Decorin and biglycan were mostly located at the inflow aspects of the cusp, tenascin-C in the central layer, and osteopontin, osteocalcin, and alkaline phosphatase were concentrated near the cell populations surrounding calcified areas. The intensity of this protein expression was significantly related to the pressure gradient. Expression levels were twice to five times higher than normal in patients with a preoperative pressure gradient of more than 100 mm Hg. On fibroblasts subjected to mechanical strain, a similar significant increase in the expression for decorin, biglycan, alkaline-phosphatase, tenascin-C, osteocalcin, and osteopontin was found by immunohistology. Western blot analysis confirmed significantly enhanced expressions of two and eight times the normal levels. Conclusions A specific pattern of extracellular matrix protein expression was found in relation to mechanical strain on human aortic valve cusp tissue and in mechanically stimulated human valvular fibroblasts. This new insight into the process of aortic valve degeneration may be important for further therapeutic approaches to ameliorate the progression or even the initiation of potential aortic valve stenosis.

A Comparison of Mechanical Properties of Materials Used in Aortic Arch Reconstruction [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Differences in the mechanical properties of aortic tissues and replacement materials can have unwanted hemodynamic effects leading to graft failure. The aim of this experimental study was to compare the mechanical properties of different graft-patch materials used in aortic arch reconstruction with those of healthy and dilated human ascending aortas (AAs). Methods Four square samples were taken from 30 healthy (n = 120) and 14 dilated (n = 56) AA rings and from 34 human pericardial sections (fresh [n = 68] and Carpentiers solution fixed [n = 68]). In addition, square samples from commercial bovine pericardium (n = 14) were also compared with woven Dacron grafts (n = 24) and tested biaxially. Stress-strain curves (0% to 30%) were generated using a biaxial tensile tester to quantify the anisotropic properties and stiffness of the materials at 37°C. Results We found significant differences in stiffness and anisotropy among all material types. Fresh and fixed human pericardia, bovine pericardium, and Dacron were 9.5, 7.1, 16.4, and 18.4 times stiffer than dilated AAs, which was 1.3 times stiffer than healthy AAs under physiologic stretch. Only dilated and healthy AAs showed an increase in anisotropic properties with increasing strain. Conclusions The significant differences in the mechanical properties among all materials we found are intended to increase the awareness of these differences in materials used in aortic reconstruction surgery. This finding suggests that improvements are needed in prosthetic material design to better mimic native tissue.

Early Clinical Experience and Echocardiographic Results With a New Semirigid Mitral Annuloplasty Ring: The Sorin Memo 3D [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The Sorin Memo 3D (Sorin Biomedica Cardio S.r.L., Saluggia, Italy) is a new, complete semirigid annuloplasty ring. Clinical use, outcomes, and echocardiographic results are reported as an evaluation of its safety and efficacy in the treatment of mitral valve regurgitation (MVR). Methods This device was assessed in 63 patients (63.5% men; mean age, 70.2 ± 10.3 years) who underwent MVR operations between January 2007 and June 2008. Functional classification was normal leaflet motion (type I; 1.6%), leaflet prolapse (type II; 66.7%), and restricted leaflet motion (type III; 31.7%). Valve disease was degenerative (68.25%), ischemic (25.4%), and nonischemic dilated cardiomyopathy (6.35%). Results Early mortality (≤30 days) was 3.3% (2 patients). Late mortality (11.2 ± 5.1 months) was 4.9% (3 patients). No deaths were device-related. Thromboembolic stroke occurred in 3.3% and endocarditis in 1.6%. Freedom from reoperation was 98.4%. At 6 months, MVR was grade 0/1 in 93.7% and grade 2+ in 6.4%. Left end-diastolic ventricular diameters decreased significantly from 59.3 ± 6.9 mm preoperatively to 50.6 ± 12.2 mm at 6 months, pulmonary arterial pressure decreased from 44.8 ± 7.1 mm Hg to 38.4 ± 5.5 mm Hg, and left ventricular ejection fraction increased significantly from 0.469 ± 0.129 to 0.582 ± 0.106. New York Heart Association functional class was I in 81% and II in 13.8%. Conclusions Early results indicate the Sorin Memo 3D ring safely and effectively minimizes secondary MVR resulting from all causes and preserves mitral annular flexibility and function at follow-up.

Saddle Shape of the Mitral Annulus Reduces Systolic Strains on the P2 Segment of the Posterior Mitral Leaflet [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The three-dimensional saddle shape of the mitral annulus is well characterized in animals and humans, but the impact of annular nonplanarity on valve function or mechanics is poorly understood. In this study, we investigated the impact of the saddle shaped mitral annulus on the mechanics of the P2 segment of the posterior mitral leaflet. Methods Eight porcine mitral valves (n = 8) were studied in an in-vitro left heart simulator with an adjustable annulus that could be changed from flat to different degrees of saddle. Miniature markers were placed on the atrial face of the posterior leaflet, and leaflet strains at 0%, 10%, and 20% saddle were measured using dual-camera stereophotogrammetry. Averaged areal strain and the principal strain components are reported. Results Peak areal strain magnitude decreased significantly from flat to 20% saddle annulus, with a 78% reduction in the measured strain over the entire P2 region. In the radial direction (annulus free edge), a 44.4% reduction in strain was measured, whereas in the circumferential direction (commissure-commissure), a 34% reduction was measured from flat to 20% saddle. Conclusions Nonplanar shape of the mitral annulus significantly reduced the mechanical strains on the posterior leaflet during systolic valve closure. Reduction in strain in both the radial and circumferential directions may reduce loading on the suture lines and potentially improve repair durability, and also inhibit progression of valve degeneration in patients with myxomatous valve disease.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Temperature Dependence of Cerebral Blood Flow for Isolated Regions of the Brain During Selective Cerebral Perfusion in Pigs [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Hypothermic circulatory arrest (HCA) and antegrade selective cerebral perfusion (ASCP) are utilized for cerebral protection during aortic surgery. However, no consensus exists regarding optimal ASCP-temperature showing a tendency toward higher values during the last years. This study investigates regional changes of cerebral blood flow (CBF) during ASCP at two temperatures. Methods In this blinded study, 20 pigs (35 to 37 kg) were randomized to two groups. Animals were cooled to 10 minutes of HCA followed by 60 minutes of ASCP. Afterward the animals were perfused at 25°C and 30°C according to the study group. Fluorescent microspheres were injected at seven time points during the experiment to calculate total and regional CBF. Hemodynamics, cerebrovascular resistance (CVR) and cerebral metabolic rate of oxygen (CMRO2) were assessed. Tissue samples from the cortex, cerebellum, hippocampus, and pons were taken for microsphere count. Results The CBF and CMRO2 decreased significantly (p < 0.002) during cooling in both groups; it was significantly higher throughout ASCP in the 30°C versus the 25°C group (p = 0.0001). These findings were similar among all brain regions, certainly at different levels. The CBF increased significantly (p = 0.002) during the early period of ASCP for analyzed regions and decreased significantly (p = 0.034) below baseline after 60 minutes of ASCP, reaching critical levels in the hippocampus and neocortex. The hippocampus turned out to have the lowest CBF, while the pons showed the highest CBF. Thirty minutes and more ASCP provides less CBF compared with baseline values at both temperatures. Conclusions Antegrade selective cerebral perfusion improves CBF in all regions of the brain for a limited time. Our study characterizes the brain specific hierarchy of blood flow during ASCP. These dynamics are highly relevant for clinical strategies of perfusion.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Simplified Management of Hemodialysis-Dependent Patients Undergoing Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The mortality and morbidity rates are high after cardiac surgery in hemodialysis (HD)-dependent patients. To improve their outcomes, optimal perioperative managements should be discussed. Methods A retrospective analysis of 245 HD patients who underwent cardiac surgery between 1994 and 2007 was conducted. The basic management strategies were (1) low-potassium HD for 2 days before surgery, (2) only hemofiltration during cardiopulmonary bypass, and (3) start of regular intermittent HD on the first postoperative day. Continuous venovenous hemodiafiltration was applied only for patients with hemodynamic instability. Results The causes of renal failure included diabetic (n = 89, 36%), glomerulonephritis (n = 49, 20%), and unknown (n = 75, 31%). The history of HD was 9.7 ± 7.6 years. The operative procedures included coronary (n = 135), valve (n = 103), and others. The amount of intraoperative ultrafiltration was 6,123 ± 324 mL during cardiopulmonary bypass for 197 ± 67 minutes. Two hundred eight patients (85%) were managed with only intermittent HD, whereas 36 patients (15%) needed continuous venovenous hemodiafiltration. The use of continuous venovenous hemodiafiltration significantly declined during the year (26% before 2003 and 3% after 2003; p < 0.001). The amount of fluid removal on the first postoperative day was 1,297 ± 81 mL. The hospital mortality was 9.7% with the causes including infection (n = 11), cardiac events (n = 6), gastrointestinal events (n = 5), and stroke (n = 2). A multivariate logistic regression analysis revealed that selection of intermittent HD or continuous venovenous hemodiafiltration was not related to the hospital mortality. Conclusions Simplified management only with intermittent HD can be safely performed in most HD-dependent patients undergoing cardiac surgery.

Prospective, Randomized Clinical Trial of the FloSeal Matrix Sealant in Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Topical hemostatic agents composed of a gelatin-based matrix and thrombin have been reported to be effective, in addition to traditional means, in terminating bleeding during cardiac operations. We compared a hemostatic matrix sealant agent (FloSeal; Baxter Inc, Deerfield, IL) with alternative topical hemostatic agents in a mixed cohort of elective cardiac and thoracic aortic operations. Methods Following sample size calculation, in a prospective randomized study design, 209 patients were treated with FloSeal matrix sealant (FloSeal group) and 206 patients received alternative agents as topical hemostatic materials (comparison group). FloSeal is composed of a self-expandable gelatin matrix component and purified bovine thrombin. Comparisons included hemostatic patches or sponges composed of either oxidized regenerated cellulose or purified porcine skin gelatin. Study endpoints were the following: rate of successful intraoperative hemostasis (identified by cessation of bleeding) and time required for hemostasis; overall postoperative bleeding; rate of transfusion of blood products; rate of surgical revision for bleeding; postoperative morbidity; and intensive care unit stay. Results Statistically higher rates of successful hemostasis and shorter time-to-hemostasis were observed in the FloSeal group (p < 0.001 both). Time-to-event analysis confirmed this finding (p = 0.0025). Postoperative bleeding and rate of transfusion of blood products were statistically decreased in the FloSeal group (p < 0.001 both). Rates of revision for bleeding and of minor complications were not statistically different among groups in the overall cohort, but were significantly lesser in the FloSeal group if only patients with overt intraoperative bleeding are considered (p = 0.04 both). The advantages observed in the FloSeal group were not offset in patients undergoing systemic hypothermia. Conclusions The topical hemostatic agent used in the FloSeal group is effective in terminating intraoperative bleeding as an adjunct to traditional surgical methods for stopping bleeding. Its judicious use is associated with lesser need for transfusion of blood products and rate of revision for bleeding. Its cost-utility profile should be addressed in dedicated trials.

Current Surgical Management of Ascending Aortic Aneurysm in Children and Young Adults [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background The low incidence of aortic aneurysm among children and young adults limits information about etiology, surgical indications, procedures of choice, and operative results. Methods From 2003 to 2008, 35 patients aged 7 to 35 years (mean 21) underwent replacement of the ascending aorta for 19 ascending aortic aneurysms and 16 aortic root aneurysms. Underlying diseases included 10 congenital aortic stenoses, 10 bicuspid aortic valves, 8 congenital heart diseases, 6 Marfan syndromes, and 1 aortitis. Results Indications for surgery were maximal diameter of 200% of normal for isolated aneurysms, and 160% of normal in case of associated aortic valve dysfunction or symptoms. Operative procedures included 27 ascending aortic replacements with or without aortic valve replacement (including 22 conduits) and 8 valve-sparing operations, performed in 6 patients with Marfan syndrome and 2 with congenital heart diseases. There was 1 in-hospital death. Thirty-four patients survived the operation and are in New York Heart Association functional class II or less at a maximum of 5 years of follow-up. All patients are free from reoperation, but 1 patient had a thromboembolic event. Aortic valve function is good in all 8 patients after the valve-sparing operation. Conclusions Ascending aortic aneurysm in children and young adults was surgically treated with excellent midterm outcome. A diameter of 200% of normal was the indication for surgery; however, in case of associated lesions, smaller diameters should be considered for surgery. Conduit implantation is the gold standard. Valve-sparing operation can be performed in selected patients with encouraging results.

A Comparative Study of Mechanical and Homograft Prostheses in the Pulmonary Position [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Homografts (HGs) are considered the gold standard for pulmonary valve replacement. However, to avoid further operations, the use of mechanical valves (MVs) might be considered, especially in patients who had had multiple prior operations or require an additional MV in another position. Methods Data of 19 patients with MVs were compared with 19 patients with HGs, matched for age, sex, and follow-up time. Development of gradient and regurgitation were analyzed using hierarchical multilevel modeling. Mean follow-up time was 5.8 ± 2.6 years. Results The initial pressure gradient was significantly lower in HGs compared with MVs (11.7 mm Hg vs 19.2 mm Hg, p = 0.006), but the annual increase was significantly higher in HGs compared with MVs (4.0 mm Hg/year vs 1.1 mm Hg/year, p = 0.008). The initial regurgitation grade was significantly higher in HGs compared with MVs (0.81 vs 0.37, p < 0.001), and the annual increase was also significantly higher in HGs compared with MVs (0.09 grade/year vs –0.01 grade/year, p < 0.001). Reintervention was required in 3 HGs (stenosis), and in 2 MVs (thrombosis after irregular anticoagulation, dysfunction due to ingrowth of tissue). Freedom from reintervention was not significantly different between both groups (p = 0.32). Conclusions The hemodynamic performances of MVs are superior to HGs because gradient and regurgitation develop significantly slower. However, this does not lead to lower reintervention rates. Because reoperations of MVs can be prevented by appropriate surgical technique and strict anticoagulation, MVs should be considered for the pulmonary position, especially in patients who require anticoagulation treatment for additional MVs or rhythm disturbances.

Invited commentary [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Ring-Enforced Right Ventricle-to-Pulmonary Artery Conduit in Norwood Stage I Reduces Proximal Conduit Stenosis [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background An increasing number of surgeons prefer to place a conduit from the right ventricle to the pulmonary artery at the time of the Norwood stage I procedure. Proximal conduit stenoses have led us to modify this technique by using ring-enforced polytetrafluoroethylene conduits. Methods Angiograms of 24 patients with conventional conduits (CC) and 28 patients with ring-enforced conduits (RC) before partial bidirectional cavopulmonary anastomosis were analyzed. The degree of conduit stenosis on three different levels—proximal anastomosis, substernal part of the conduit, and distal anastomosis—was compared between the two groups. Results In the RC group, the extent of conduit stenosis at the level of proximal anastomosis and within the substernal proximal third of the conduit was minimized (23% ± 22% vs 45% ± 22%, p = 0.001, and 7% ± 6% vs 49% ± 26%, p < 0.001, respectively). At the level of the anastomosis with the pulmonary arteries, results were similar in the RC group (24% ± 14%) vs CC group (31% ± 15%, p = 0.103). Significantly fewer patients in the RS group required urgent intervention (dilatation ± stenting) or early stage II operation (1 vs 6 patients, p = 0.034). Conclusions The use of a ring-enforced polytetrafluoroethylene conduit between the right ventricle and the pulmonary artery in Norwood stage I palliation effectively prevents substernal compression and reduces interstage morbidity.

Pericardiectomy for Pericarditis in the Pediatric Population [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Pericarditis requiring pericardiectomy is uncommon in the pediatric population. The aim of this study is to characterize our experience with this subset of patients. Methods Between February 1978 and May 2008 pericardiectomy was performed on 27 pediatric patients (25 male). The indication for surgery was inflammatory pericarditis in 16 and constrictive pericarditis in 11. Mean age was 16.7 years (range, 3 to 21 years). Chest pain was the most common presenting complaint. Median duration of symptoms prior to operation was 1 year. Most patients had aggressive pharmacologic treatment prior to operation. Before pericardiectomy, 10 patients were hospitalized for treatment of symptoms, 15 underwent pericardiocentesis, and 3 had a prior partial pericardiectomy. Results Twenty-one patients underwent complete pericardiectomy, 3 a biventricular pericardiectomy, and 3 a completion pericardiectomy. Pathologic histology of all specimens was positive for pericarditis. Pericardial cultures were obtained in 13 cases with bacteria retrieved from only 2 specimens. Median length of stay was 7 days, and the majority had an uneventful postoperative course. The one early mortality was due to acute hepatic failure in a patient with radiation-induced heart disease, 155 days after operation. After median follow-up of 1 year, complete resolution of symptoms was achieved in 89% of patients. Conclusions In properly selected pediatric patients, complete pericardiectomy can be performed with good outcomes. Although the etiology of pericardial irritation is frequently elusive, resolution of symptoms can be expected in most patients. Confronted with medically refractory pericarditis, earlier consideration for pericardiectomy may be warranted.

Transcatheter Closure of Postoperative Residual Perimembranous Ventricular Septal Defects [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background The presence of postoperative residual perimembranous ventricular septal defect (PmVSD) is relatively uncommon. However, reoperation might be associated with an increased surgical risk. Transcatheter device closure is an alternative strategy for management of postoperative residual defects. Methods Between July 2002 and November 2008, transcatheter closure of postoperative residual PmVSDs was attempted in 26 patients (11 male, 15 female). Symmetric and asymmetric PmVSD occluders were used. Results The diameter of residual defects was from 3 mm to 10 mm (mean 6.3 ± 2.3 mm) on transthoracic echocardiography. In 24 of 26 patients, the residual defects were successfully closed. No direct residual defect was found on left ventriculography after the procedure. Total occlusion rate was 62% (15 of 24) at completion of the procedure, rising to 71% (19 of 24) at one week and 96% (23 of 24) during the follow-up. Twenty patients had only one device implanted, whereas 4 patients had two devices implanted. The waist size of occluders used ranged from 5 mm to 12 mm (mean 8.6 ± 2.5 mm). One patient presented with complete atrioventricular block 3 days after the procedure and recovered 2 weeks later. Hemolysis occurred in 3 patients after the procedure within 12 hours. These patients recovered 4 weeks, 4 days, and 8 days later, respectively. During follow-up, the devices were in a stable position with optimal shapes. No late complications were observed. Conclusions Transcatheter closure of postoperative residual PmVSDs is possible without the need for reoperation. The early and midterm prognosis of patients with transcatheter closure is good.

Surgical Lung Resection for Severe Hemoptysis [ORIGINAL ARTICLES: GENERAL THORACIC]

Background The role of surgical lung resection in the management of severe hemoptysis has evolved after advances in interventional radiology. We sought to describe the indications for surgical lung resection in such patients and to identify predictive factors of postoperative complications. Methods This study is a retrospective analysis (May 1995 to July 2006) of consecutive patients referred to the intensive care unit of a tertiary hospital for severe hemoptysis who underwent surgical lung resection. Results Among 813 patients referred for severe hemoptysis, 111 underwent surgical lung resection. Interventional radiology had been first attempted in 87 patients (78%); 68 underwent surgery because of a failed procedure (n = 28) or bleeding persistence or recurrence within 72 hours despite a completed procedure (n = 40); 19 patients underwent surgery after bleeding control. The remaining 24 patients (22%) were directly referred to the surgeon (5 for emergency surgery). Overall, surgery was performed in emergency (n = 48), scheduled after bleeding control (n = 48), or planned after discharge (n = 15). The main indications for surgery were mycetoma, cancer, bronchiectasis, and active tuberculosis. Surgery for mycetoma (odds ratio, 9.4; 95% confidence interval, 2.8 to 32), emergency surgery (odds ratio, 5.3; 95% confidence interval, 1.8 to 16), and pneumonectomy (odds ratio, 4.7; 95% confidence interval, 1.2 to 18) independently predicted complications. Fifteen patients died in the intensive care unit, of whom 14 underwent emergency surgery. Chronic alcoholism (odds ratio, 4.6; 95% confidence interval, 1.1 to 19), the need for mechanical ventilation or vasoactive drugs on admission (odds ratio, 8.2; 95% confidence interval, 1.9 to 35), and blood transfusion before surgery (odds ratio, 8; 95% confidence interval, 1.5 to 42) predicted mortality. Conclusions Attempting at controlling bleeding with first-line nonsurgical approaches appears necessary to optimize the operative conditions and improve outcome of patients with severe hemoptysis.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

The Influence of Surgeon Specialty on Outcomes in General Thoracic Surgery: A National Sample 1996 to 2005 [ORIGINAL ARTICLES: GENERAL THORACIC]

Background While general thoracic surgical procedures are performed by several different surgical subspecialties, debate remains as to whether surgeon specialty impacts outcomes. Methods The Nationwide Inpatient Sample (NIS) was queried for procedure codes for pneumonectomy, lobectomy, limited lung resection, and decortication. We constructed multivariate logistic regression models to calculate odds of hospital mortality or length-of-stay (LOS) greater than 14 days (a marker of morbidity), adjusted for age, sex, patient comorbidities, hospital setting, and surgeon specialty. A surgeon was considered general thoracic if they performed greater than 75% general thoracic operations and less than 10% cardiac operations, Cardiac if greater than 10% cardiac operations, and general surgeon if less than 75% general thoracic and less than 10% cardiac operations. A second set of models additionally adjusted for procedure-specific hospital and surgeon volume. Results From 1996 to 2005, the NIS estimates 41,808 pneumonectomies, 321,767 lobectomies, 75,200 limited lung resections, and 149,318 decortications were performed in the United States. For all procedures studied, general thoracic surgeons had significantly decreased odds-of-death and LOS greater than 14 days compared with general surgeons. Cardiac surgeons had significantly decreased LOS greater than 14 days for all operations and decreased odds-of-death for decortications, lobectomy, and limited lung resection compared with general surgeons. When further adjusted for surgeon volume, most differences in odds-of-death were no longer present; however, significantly decreased LOS greater than 14 days largely persisted for both general thoracic and cardiac surgeons. Conclusions The majority of general thoracic surgical operations in the United States are performed by surgeons not specializing in thoracic surgery. Both general thoracic surgeons and cardiac surgeons achieve better outcomes than general surgeons. Differences in mortality may be more dependent on surgeon volume than subspecialty. Differences in morbidity are significantly impacted by surgeon specialty and volume.

Long-Term Results of Sleeve Lobectomy in the Management of Non-Small Cell Lung Carcinoma and Low-Grade Neoplasms [ORIGINAL ARTICLES: GENERAL THORACIC]

Background The objective of this study was to evaluate the operative mortality, morbidity, and long-term survival of sleeve lobectomy for non–small cell lung cancer and low-grade neoplasms. We evaluated the effects of neoadjuvant therapy on the bronchial anastomotic complication rate and determined whether sleeve lobectomy performed in patients with N1 disease resulted in decreased overall survival. Methods This study is a retrospective review of 196 patients who underwent sleeve lobectomy. One hundred twenty-five patients had non–small cell lung cancer. There were 117 men (59.7%) and 79 women (40.3%) with a mean age of 54 years. Sixteen patients (13%) received neoadjuvant therapy. Fifty-six patients with N1 disease underwent sleeve lobectomy. Results There were 4 (2.0%) postoperative deaths. The postoperative morbidity rate was 36.7%. Four patients (2.0%) experienced bronchopleural fistulas. Multivariate analysis demonstrated that age older than 70 years (p = 0.02) and the diagnosis of non–small cell lung cancer (p = 0.0002) were risk factors for postoperative complications. Multivariate analysis also demonstrated that neoadjuvant therapy predicted anastomotic complications (p = 0.01). For non–small cell lung cancer patients, the 5-year survival rate was 44%. The 5-year survival rates for patients with pathologic N0 disease and N1 disease were 52.6% versus 39.3%, respectively (p = 0.205). Conclusions Sleeve lobectomy can be performed with minimal bronchial anastomotic complications and low postoperative mortality. In our study, neoadjuvant therapy for non–small cell lung cancer adversely influenced the rate of anastomotic complications. Performing sleeve lobectomy for patients with N1 disease was not associated with decreased overall survival rates.

The Prognostic Impact of Main Bronchial Lymph Node Involvement in Non-Small Cell Lung Carcinoma: Suggestions for a Modification of the Staging System [ORIGINAL ARTICLES: GENERAL THORACIC]

Background The therapeutic strategies for non-small cell lung carcinoma (NSCLC) with N1 and N2 disease differ remarkably. Debate exists about the definition of the borderline between N1 and N2 stations. This study evaluated the prognostic effect of N1 disease, especially focused on the significance of the main bronchial node (No. 10) vs N2 disease. Methods The records of 1601 patients who underwent complete pulmonary resection for NSCLC were reviewed to examine the clinical features of lymph nodal involvement. Results There were 1086 patients (67.8%) with pN0 disease, 202 (12.6%) with pN1, and 274 (17.1%) with pN2 disease; overall 5-year survival rates were 74.7%, 56.1% and 28.9%, respectively (p < 0.001). Overall 5-year survival rates were 60.2% in hilar N1 and 49.6% in intralobar N1. Overall 5-year survival rates were 58.6% in N1 without node 10 and 35.1% in N1 with node 10. A significant difference was observed between N0 and N1 without node 10 (p < 0.001), and N1 without node 10 and N1 with node 10 (p = 0.033); however, the difference between N1 with node 10 and N2 was not significant. The status of node 10 involvement was an independent prognostic factor of pN1 patients, as well as age and gender. Conclusions Patients with node 10-positive N1 disease have an unfavorable prognosis, and the disease behaves like N2 disease. The definition of clear borderline between N1 and N2 is mandatory to achieve a uniform classification map. This study offers further information for clinical and therapeutic purposes.

Risk Factor Comparison and Clinical Analysis of Early and Late Bronchopleural Fistula After Non-Small Cell Lung Cancer Surgery [ORIGINAL ARTICLES: GENERAL THORACIC]

Background We retrospectively analyzed risk factors for late bronchopleural fistula after non-small cell lung cancer (NSCLC) surgery and compared with those for early bronchopleural fistula. Methods In all, 6,239 patients with NSCLC who underwent surgery were studied, and clinical risk factors were examined by univariate and multivariate analysis. This study included 23 patients (0.38%) with late bronchopleural fistula and 43 patients (0.65%) with early bronchopleural fistula among all 6,239 patients. Follow-up data were recorded until December 2005 or until death. Statistical significance was calculated using the log rank test. Results By univariate analysis, patients with radiotherapy after operation, pneumonia after operation, pneumonectomy, and advanced age were related to higher risk of bronchopleural fistula. In the multiple logistic regression models, both pneumonia and operative procedure were among the independent risk factors of early and late bronchopleural fistula. Early bronchopleural fistula was observed primarily in the aged. Late bronchopleural fistula was associated with postoperative radiotherapy. The average intervals of bronchopleural fistula between pneumonectomy and lobectomy were significantly different. Compared with the mortality rate of late bronchopleural fistula (0%), the mortality rate of early bronchopleural fistula (11.6%) was significantly higher. Conclusions There are both similarities and differences between the risk factors for early and late bronchopleural fistula. We should analyze the different reasons for the occurrence of bronchopleural fistula, and adopt different preventive measures. Different follow-up should be provided for the different operations.

Stereotactic Radiosurgery for the Treatment of Lung Neoplasm: Experience in 100 Consecutive Patients [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Surgical resection is the standard of care for patients with resectable non-small cell lung cancer or selected patients with pulmonary metastases. Stereotactic radiosurgery may offer an alternative option for high-risk patients who are not surgical candidates. We report our initial experience with stereotactic radiosurgery in the treatment of lung neoplasm in 100 consecutive patients. Methods Patients who were medically inoperable were offered stereotactic radiosurgery. Thoracic surgeons evaluated all patients, placed fiducials, and performed treatment planning in collaboration with radiation oncologists. Initially, a median dose of 20 Gy prescribed to the 80% isodose line was administered in a single fraction, and this was subsequently increased to a total of 60 Gy in three fractions. The primary end point evaluated was overall survival. Results We treated 100 patients (median age, 70 years; 51 men, 49 women) with stereotactic radiosurgery: 46 (46%) with primary lung neoplasm, 35 (35%) with recurrent cancer, and 19 (19%) with pulmonary metastases. The median follow-up was 20 months. The median overall survival was 24 months. Local recurrence occurred in 25 patients. The probability of 2-year overall survival was 50% for the entire group, 44% for primary lung cancer, 41% for recurrent cancer, and 84% for metastatic cancer. Conclusions Our initial experience indicates that stereotactic radiosurgery has reasonable results in these high-risk patients. Resection continues to remain the standard treatment; however, stereotactic radiosurgery may offer an alternative in high-risk patients. Further prospective studies with different dose schema are needed to evaluate the efficacy of stereotactic radiosurgery.

Image-Guided Radiofrequency Ablation of Lung Neoplasm in 100 Consecutive Patients by a Thoracic Surgical Service [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Surgical resection is the standard of care for patients with resectable non–small cell lung cancer or selected patients with pulmonary metastases. However, for high-risk patients radiofrequency ablation (RFA) may offer an alternative option. The objective of this study was to evaluate computed tomography–guided RFA for high-risk patients and report our initial experience in 100 consecutive patients by a thoracic surgical service. Methods Medically inoperable patients were offered RFA. Thoracic surgeons evaluated and performed RFA under computed tomography guidance. Patients were followed in the thoracic surgery clinic. The primary end point evaluated was overall survival. Results One hundred patients underwent image-guided RFA for lung neoplasm (40 men, 60 women; median age, 73.5 years; range, 26 to 95 years). Forty-six patients (46%) with primary lung neoplasm, 25 patients (25%) with recurrent cancer, and 29 patients (29%) with pulmonary metastases underwent RFA. The mean follow-up for alive patients was 17 months. The median overall survival for the entire group of patients was 23 months. The probabilities of 2-year overall survival for the entire group, primary lung cancer patients, recurrent cancer patients, and metastatic cancer patients were 49% (95% confidence interval, 37 to 60), 50% (95% confidence interval, 33 to 65), 55% (95% confidence interval, 25 to 77), and 41% (95% confidence interval, 19 to 62), respectively. Conclusions Our experience indicates that image-guided RFA done by the thoracic surgeons is feasible and safe in high-risk patients with lung neoplasm with reasonable results in patients who are not fit for surgery. Thoracic surgeons can perform RFA safely, and should continue to investigate this new image-guided modality that may offer an alternative option in medically inoperable patients.

Lung Transplantation and Donation After Cardiac Death: A Single Center Experience [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Lung donation after cardiac death (DCD) can enlarge the donor pool. Single-center reports have shown comparable outcomes after lung transplantation using conventional donors versus DCD in small numbers of patients. Methods We performed a retrospective review of DCD experience at a single lung transplant program using a prospective database. Results Between January 2003 and April 2008, 293 lung transplantations were performed, including 11 bilateral transplantations (3.7%) using DCD lungs. Similar criteria were used to assess donor quality. The hospital mortality for DCD recipients was 2 of 11 (18%) and overall mortality was 4 of 11 (36%) by 18 months of follow-up. Seven DCD patients (64%) are alive with a median follow-up of 32 months. The DCD group was comparable to the control group in age and ischemic times. The 4 deaths, when compared with 7 DCD survivors, had longer ischemic time (293 minutes versus 232 minutes) and a higher incidence of nonlocal donors (3 of 4 versus 1 of 7). Conclusions At our center, early outcomes after DCD lung transplantations are somewhat inferior to those of series from other centers but approach national averages for conventional lung transplantation. Thus, DCD lung transplantation has the potential to increase the donor pool but must be offered cautiously.

Survival After Single Versus Bilateral Lung Transplantation for High-Risk Patients With Pulmonary Fibrosis [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Whether single lung transplantation (SLT) or bilateral lung transplantation (BLT) is optimal for patients with severe idiopathic pulmonary fibrosis (IPF) is unknown. We examine a large multi-institutional cohort of high-risk IPF patients to address this question. Methods We retrospectively reviewed United Network for Organ Sharing data to identify 1,256 lung transplant (LTx) recipients with IPF between 2005 and 2007. Risk of 30-day, 90-day, and 1-year mortality for SLT versus BLT was examined across levels of the lung allocation score (LAS [both continuous with incorporation of interaction terms and categorized by LAS quartiles]). Multivariable analysis was conducted through Cox proportional hazards regression. Results Lung allocation score quartiles were as follows: quartile 1, 29.8 to 37.8, n = 315; quartile 2, 37.9 to 42.4, n = 313; quartile 3, 42.5 to 51.9, n = 314; and quartile 4, 52.0 to 94.1, n = 314. Overall, 21.1% more patients received BLT in the highest LAS quartile (59.5%) than in the lowest LAS quartile (38.4%, p < 0.05). In patients at highest risk, BLT was associated with a 14.4% decrease in mortality at 1 year after LTx. This survival benefit was confirmed on univariate analysis (hazard ratio 1.90 [95% confidence interval: 1.16 to 3.13], p = 0.01) and multivariable analysis (hazard ratio 2.09 [95% confidence interval: 1.07 to 4.10], p = 0.03) as well as in sensitivity analyses incorporating pulmonary hypertension and maximizing follow-up. There were no differences in the risk of death with SLT at 30 or 90 days after LTx in any quartile on unadjusted or multivariable adjusted analysis. Conclusions We provide an initial examination of survival by procedure type and LAS score for LTx recipients with IPF. Bilateral LTx appears to offer advantages over SLT for high-risk patients.

Surgery for Recurrent Pectus Deformities [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Pectus repair in adults can be challenging. Standard repair has been the modified Ravitch procedure. More recently the minimally invasive Nuss procedure, used exclusively in children, has been introduced for correction of pectus deformities in adults. There is a paucity of data on which procedure is most appropriate for adults and even less information on the most appropriate operation for pectus recurrence in adults. The purpose of this study is to determine if any specific patient characteristic exists that places patients at an increased risk for recurrence and describe our management of recurrent pectus defects in adults. Methods We retrospectively reviewed the records of all patients (>16 years of age) who underwent primary or recurrent repair of pectus deformities from April 1999 through December 2006. Results Forty-eight patients, 37 (77%) men and 11 women, underwent pectus repair with a median age of 28 years (range, 16 to 54 years). Indication for initial repair was pectus excavatum in 39 (81%) and pectus carinatum in 9. The primary procedure was a modified Ravitch repair in 40 patients and a Nuss procedure in 8. Thirteen patients (27%) underwent reoperation for recurrence; 8 (62%) patients had undergone a previous Nuss procedure and 5 had a modified Ravitch repair. All reoperative patients had a primary pectus index (PI) greater than 4.0, while 8 (62%) also had an asymmetrical defect. All failed Nuss procedure patients underwent a modified Ravitch repair for correction, while the recurrent open repair patients required complex reconstructions. Results were good or excellent in greater than 90% of patients undergoing a reoperative procedure. Conclusions Adults with severe pectus deformities (PI > 4.0) and asymmetric defects are at a greater risk of recurrence after a Nuss procedure. These patients may better be served with a modified Ravitch repair initially. Reoperation for failed pectus repair in adults can be performed safely with outstanding results.

Solitary Fibrous Tumors of the Pleura: An Analysis of 110 Patients Treated in a Single Institution [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Solitary (localized) fibrous tumors of the pleura (SFTP) are rare slow-growing neoplasms that generally have a favorable prognosis. The aim of this paper is to evaluate the predictors of outcome in a series of 110 patients with SFTP. Methods The records of 110 patients (63 men; mean age 56.4 years; range, 17 to 79) surgically treated for SFTP from July 1990 to February 2008, were evaluated for demographics, operative procedure, histopathology, morbidity, mortality, postoperative chemotherapy or radiotherapy, and long-term follow-up. Results Operative mortality was 0.9% (1 of 110) and the overall morbidity was 10.9% (12 of 110). The main surgical approach was video-assisted thoracoscopic surgery (69 procedures with a conversion rate of 14.5%); 40 patients underwent thoracotomy and 1 had sternotomy. The visceral pleura was the site of origin in 95 tumors, the parietal pleura in 13, the mediastinal pleura in 2 cases. Sixty-three tumors were pedunculated, 35 were sessile, and 12 were inverted fibroma. Tumors were pathologically benign in 95 cases (86.4%), and malignant in 15 (13.6%). Symptomatic patients presented with malignant tumors more often than asymptomatic (19.1% versus 9.5%). Overall 10-year survival rate was 97.5%. The overall disease-free survival rate was 90.8% (95.7% in benign cases and 67.1% in malignant cases; p < 0.05). Eight patients presented with recurrence of disease, 4 cases of which were malignant and 4 were benign. Conclusions Solitary fibrous tumor of the pleura is a rare disease that includes both benign and malignant variants.The outcome is mostly benign, with an overall 10-year survival rate of 97.5%. Pathologically benign lesions show a better disease-free survival rate than malignant lesions (95.7% versus 67.1%; p < 0.05). Surgery is the gold standard of treatment as neither radiotherapy nor chemotherapy proved to be effective.

Modified Maximal Thymectomy for Myasthenia Gravis: Effect of Maximal Resection on Late Neurologic Outcome and Predictors of Disease Remission [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Although thymectomy is a standard practice of care in patients with myasthenia gravis, the best approach to thymic resection remains controversial. This study was conducted to assess the effect of maximal resection on neurologic outcome and identify predictors of disease remission. Methods Data of 78 myasthenic patients who underwent modified maximal thymectomy during a 17-year period were retrospectively analyzed. The primary study end point was the achievement of complete remission. Separate analysis was performed for thymoma and nonthymoma patients regarding the factors predicting the neurologic outcome. Results No patients died perioperatively. Surgical morbidity was 7.7%. The rate of postoperative myasthenic crisis was 3.8%. Thymoma and nonthymoma patients experienced comparable complete stable remission prediction (74.5% vs 85.7% at 15 years; p = 0.632). The absence of steroids in the preoperative medical treatment was statistically related to the prediction for complete stable remission in both thymoma (95% confidence interval [CI], 2.687 to 339.182, p = 0.006) and nonthymoma patients (95% CI, 1.607 to 19.183; p = 0.007) in multivariate analysis. In thymomatous myasthenia gravis, there was a statistically significant association between disease remission and the World Health Organization (WHO) histologic classification (95% CI, 0.262 to 0.827; p = 0.009). Conclusions Maximal resections are recommended in myasthenic patients. Disease severity represents the prime determinant of the neurologic outcome after thymectomy. The neurologic outcome in patients after thymectomy may be statistically associated with the WHO classification subtypes but not necessarily with the aggressiveness of these tumors.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Colon Interposition After Esophagectomy With Extended Lymphadenectomy for Esophageal Cancer [ORIGINAL ARTICLES: GENERAL THORACIC]

Background The purpose of this retrospective study was to investigate the feasibility of colon interposition procedures after esophagectomy with extended lymphadenectomy. Methods Between 1990 and 2008, 95 consecutive patients underwent colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer in our Institution. We reviewed clinical data and long-term survival, and also investigated the association between anastomotic leakage and clinicopathologic findings. Results We applied three-field lymphadenectomy to 71 patients and two-field to 24 patients, by a right thoracotomy. Ninety-two patients underwent reconstruction by a retrosternal route, and a posterior mediastinal route was applied to only three patients. We performed hand-sewn anastomosis in the neck in all cases. Three patients required microvascular surgery. Sixty-one patients (64%) experienced postoperative morbidity, most commonly pulmonary complications. Anastomotic leakage occurred in 12 patients (13%). No colon conduit necrosis was detected. Overall mortality, including hospital mortality, was 5.3%. Dysphagia (39%) and diarrhea (38%) were common and stricture was low (6%) after discharge. The overall 5-year survival rate was 43%. During the latter period (1998 to 2008), when ileocolon grafts evolved as the primary choice for interposition, the rate of leakage decreased from 17% (1990 to 1997) to 5.4%. No mortality was recorded during the latter period. Conclusions Results from this study demonstrate that colon interposition after esophagectomy with extended lymphadenectomy is feasible and can have a favorable outcome.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

A New Epicardial Lesion Set for Minimal Access Left Atrial Maze: The Dallas Lesion Set [NEW TECHNOLOGY]

Purpose Improvements in enabling technology have facilitated minimal access techniques to the surgical ablation of atrial fibrillation. A variety of lesion sets (usually targeting only the left atrium) have been used in attempts to ablate atrial fibrillation. We describe a new epicardial approach to apply a set of left atrial lesions, which are electrophysiologically equivalent to all the left atrial lesions of the Cox maze III while using minimal access techniques. Description Using minimal access techniques, we have isolated the pulmonary veins and made connecting lesions on the dome of the left atrium to create a set of lesions electrophysiologically equivalent to all the left atrial lesions of the Cox maze III. Intraoperative electrophysiological evaluation is used to insure complete isolation across each lesion line. Evaluation Using these minimal access procedures, we have obtained a complete block across all lesion lines in all patients. Conclusions These techniques have made it possible to perform the full Cox maze III left atrial lesion set with minimal access techniques.

Calcium Phosphate Cements Improve Bone Density When Used in Osteoporotic Sternums [NEW TECHNOLOGY]

Purpose Calcium phosphate cements control bleeding and are safe to use in osteoporotic sternums during open heart surgery. We looked at the clinical and radiographic effects of this agent on bone healing. Description Since March 2006, 18 patients had calcium phosphate cement inserted in their sternal tables at heart surgery. They were followed-up by office visits and chest computed tomographic (CT) scans. All preoperative and postoperative CT chest scans were evaluated for cement absorption, bone replacement, and bone density. Evaluation Five preoperative and 41 postoperative CT chest scans were available for evaluation. Median interval from surgery to CT scan was 531 days (range, 3 to 966 days). At follow-up there were neither clinical dehiscences nor nonunions of the sternums. Calcium phosphate cement appears to reabsorb quickly, but not completely. Five patients with pre-surgical CT chest scans demonstrated an average, improved bone density of 281.66 Hounsfield units at follow-up (p = 0.006). Conclusions In each patient, cement was replaced by new bone, and there is evidence that more bone is present as a result of cement use.

Successful Transapical Aortic Valve Replacement in a Patient With a Previous Mechanical Mitral Valve Replacement [CASE REPORTS]

In this case we illustrate our experience with transapical minimal invasive aortic valve replacement in a patient who previously underwent mitral valve replacement. The implantation did not interfere with the existing prosthesis and could even be used as a further landmark, helping height positioning of the aortic valve.

Post-Traumatic Rupture of the Anterolateral Papillary Muscle [CASE REPORTS]

Rupture of cardiac valves as a consequence of nonpenetrating cardiac trauma is an uncommon phenomenon. We report the case of a 24-year-old patient with a "two-stage" traumatic rupture of the anterolateral papillary muscle of the mitral valve, after a blunt chest trauma, who successfully underwent emergency mitral valve replacement.

Prophylactic Use of Factor IX Concentrate in a Jehovah's Witness Patient [CASE REPORTS]

In Jehovah's Witness patients, the use of red blood cells, platelets, and fresh frozen plasma is not optional. Various blood conservation techniques are available, but complex cardiac surgery remains a major challenge. The feasibility of fractions of "primary components" has not been fully considered in published case reports. For Jehovah's Witness patients who preoperatively give consent, factor IX concentrates may be acceptable for hemostatic therapy. We hereby describe a combination of "secondary components" to prevent excessive bleeding in a Jehovah's Witness patient undergoing complex replacement of the aortic arch.

Surgical Treatment of a Thoracoabdominal Aneurysm in Cogan's Syndrome [CASE REPORTS]

Cogan's syndrome is a rare systemic disease which occurs predominantly in children and young adults. It was originally described as the combination of interstitial keratitis and audiovestibular disturbance. The nonspecific symptoms of the patients can be associated with numerous of systemic manifestations and, most characteristic, cardiovascular involvement. It affects large vessels (Takayasu-like) and medium size (polyarteritis nodosa-like) vessels. Here a case of extensive thoracoabdominal aortic replacement in a 28-year-old woman with Cogan's syndrome due to the symptomatic aortic aneurysm is described.

Acute Thrombosis of Abdominal Aortic Aneurysm During Cardiac Surgery [CASE REPORTS]

Aortic thrombosis has been described in the medical literature as a rare and catastrophic complication of abdominal aortic aneurysms. However, it has only been reported once in cardiac surgical settings. We report a unique case of thrombosis of an abdominal aortic aneurysms during the course of cardiac surgery, in a fully anticoagulated patient on cardiopulmonary bypass. Prompt diagnosis and immediate surgical management were critical for a successful outcome.

Syphilitic Aortitis: An Uncommon Cause of Acquired Aortopulmonary Fistula [CASE REPORTS]

Cardiovascular syphilis has become a medical curiosity with the advent of widespread use of penicillin for the treatment of early syphilis. We report a case of a 37-year-old man who presented with sudden onset breathlessness that worsened insidiously for 1 year. Diagnosis of syphilitic aortopulmonary fistula was confirmed by aortography, contrast computed tomography, and histopathology. The patient underwent successful surgical correction. A high level of suspicion and awareness is needed for the diagnosis of this now rare disease. This entity is only amenable to surgical correction, even as existing surgical techniques need constant improvisation and individualization to each patient.

Fibrosing Mediastinitis and Occlusion of Pulmonary Veins After Radiofrequency Ablation [CASE REPORTS]

Pulmonary vein stenosis is a known complication of radiofrequency ablation; its incidence ranges from 8% to 50%. However, complete occlusion of unilateral pulmonary veins is uncommon. We report a case with radiofrequency ablation that was complicated by complete occlusion of pulmonary veins along with fibrosing mediastinitis, which we believe has not been previously reported.

Parallel Application of Extracorporeal Membrane Oxygenation and the CardioWest Total Artificial Heart as a Bridge to Transplant [CASE REPORTS]

Circulatory assist devices are an increasingly common method of treating patients with refractory cardiogenic shock. We describe a patient who was a heart transplant candidate with biventricular failure who underwent CardioWest total artificial heart-temporary (SynCardia Inc, Tucson, AZ) implantation with extracorporeal membrane oxygenation to manage the patient's subsequent respiratory failure. After respiratory and hemodynamic stabilization, the CardioWest total artificial heart-temporary served as a successful 62-day bridge-to-heart transplantation.

Left Ventricular Aneurysm in a Child With Severe Combined Immunodeficiency Syndrome [CASE REPORTS]

We describe the case of a 23-month-old girl with combined immunodeficiency syndrome and a left ventricular aneurysm. Due to the size of the aneurysm and development of an intramural thrombus, repair was performed after confirmation of bone marrow transplant engraftment. Endoventricular circular patch plasty (Dor procedure) was performed, with excellent outcome and normalization of ventricular geometry and function.

A Symptomatic Neonate With Tetralogy of Fallot, an Absent Pulmonary Valve, and a Single Coronary Artery With a Major Fistula [CASE REPORTS]

We present a case with a rare combination of tetralogy of Fallot with an absent pulmonary valve, and a single coronary artery with a major fistula to the main pulmonary artery. Myocardial ischemia developed in response to increasing shunt flow through the coronary fistula, resulting in heart failure. We ligated the coronary fistula and plicated the anterior wall of the dilated pulmonary arteries during the neonatal period. Complete repair through a transatrial-transpulmonary approach was performed at the age of 17 months. The postoperative course was excellent and the patient maintained a stable hemodynamic and respiratory state with no evidence of myocardial ischemia.

Duplicate Mitral Valve in an Infant With Shone's Anomaly [CASE REPORTS]

Duplication of mitral valve is a very rare anomaly. It is characterized by two independent mitral valve apparatuses (leaflets and annulus) and subvalvular apparatuses (chordae and papillary muscles) that function well by themselves. In this report, we present duplicate mitral valve with parachute chordal attachment and mitral stenosis in an infant. The patient was successfully treated with the reconstruction of the larger valve without any intervention to the smaller one.

Isolated Subclavian Artery: Anatomical and Surgical Considerations [CASE REPORTS]

Isolated subclavial artery is a rare congenital anomaly. Herein we discuss a patient with isolated left subclavian artery and bilateral patent arterial ducts who underwent sucessful repair. We also describe the detailed anatomy of both recurrent nerves in this condition and embryology of the anomaly.

Percutaneous Atrioseptostomy for Right Heart Failure After Left Pneumonectomy [CASE REPORTS]

We present a case of right heart failure after left pneumonectomy as a result of an isolated, contralateral partial anomalous pulmonary venous return. We successfully treated this with percutaneous atrioseptostomy. For unstable patients with postoperative acute heart failure from an undetected partial anomalous pulmonary venous return, this minimally invasive procedure represents a useful primary option while allowing secondary conventional surgery if required.

Successful Treatment of Infected Residual Pleural Space After Pulmonary Resection With Autologous Platelet-Leukocyte Gel [CASE REPORTS]

Complications of the residual pleural space after pulmonary resection have been reported to be between 5% and 40% depending on the type of resection, and they increase morbidity, mortality, hospital stays, and costs. The therapeutic use of autologous prepared platelet leukocyte-enriched gel is a relatively new technology for the stimulation and acceleration of soft tissue and bone healing. This gel can be applied to a diversity of tissue. We describe the case of a successful application through a chest tube of platelet leukocyte gel to treat an infected residual pleural space that developed after pulmonary lobectomy for lung cancer.

Successful Endobronchial Seal of Surgical Bronchopleural Fistulas Using BioGlue [CASE REPORTS]

Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.

Cystic Seminoma With Elevated Value of Carbohydrate Antigen 19-9 in Tumor Fluid Mimicking Cystic Teratoma [CASE REPORTS]

The incidence of cystic lesions of anterior mediastinum is low, which is responsible for approximately 10% of anterior mediastinal tumors. We presented a special case of primary anterior mediastinal tumor with both prominent cystic change and extreme high carbohydrate antigen 19-9 level of cystic fluid here. From the finding of this case report, we suggested that the diagnosis of cystic anterior mediastinal tumors should include both cystic seminoma and mature cystic teratoma.

Lipoblastoma: A Rare Mediastinal Tumor [CASE REPORTS]

Lipoblastoma is a rare benign mesenchymal tumor of embryonal fat that occurs almost exclusively in infants and children less than age 3. It is a benign tumor with a high recurrence rate. We present a case of mediastinal lipoblastoma in a 21-month-old girl who presented with respiratory infection and progressive dyspnea. Complete surgical excision of the mass was achieved through a lateral thoracotomy. Her postoperative course was uneventful and the histopathologic examination proved that the mass was a lipoblastoma. We emphasize that this rare mediastinal tumor should be included in the differential diagnosis of infants having a mediastinal mass.

Two Cases of an Enormous Single-Lung Metastasis From Synovial Sarcoma [CASE REPORTS]

Synovial sarcoma constitutes 8% to 10% of all sarcomas, and most commonly it affects adults in the third to fifth decades of life. This malignancy usually involves the extremities, and although local control by curative resection and adjuvant irradiation has improved, metastases develop in 40% of patients, with lung involvement in the metastatic process in 90% of cases. A single metastasis to the lungs from synovial sarcoma is rare, and a case of a large, single metastasis is even rarer. Herein, we present two cases of patients with an enormous metastatic synovial sarcoma that were successfully removed surgically.

Repair of a Postesophagectomy Bronchogastric Tube Fistula With Polyglactin Mesh Supported With a Muscle Flap [CASE REPORTS]

A bronchogastric fistula is a very rare complication of transthoracic esophagectomy. We report a case of bronchogastric fistula after transthoracic esophagectomy caused by dehiscence of the staple line in the gastric tube, with subsequent erosion into the right main bronchus. The patient was managed successfully in two surgical stages. First, the bronchial defect was repaired using a polyglactin mesh covered by a serratus anterior muscle flap. Two months later, the esophagogastric continuity was restored with colon interposition.

A Rare Complication of Esophageal Stent: Spinal Epidural Abscess [CASE REPORTS]

The esophageal stent is used extensively for a malignant stricture, and many complications have been reported. We present a case of esophageal cancer with surgical esophageal stenting. Spinal epidural abscess occurred postoperatively, and we believe that the pathogenesis may be related to the esophageal stent.

Subaortic Stenosis in an Adult Caused by Two Discrete Membranes: A Three-Dimensional Transesophageal Echocardiographic Visualization [IMAGES IN CARDIOTHORACIC SURGERY]

Minocycline-Induced Pigmentation of the Aortic Valve and Sinuses of Valsalva [IMAGES IN CARDIOTHORACIC SURGERY]

A Modified Composite Valve Dacron Graft for Prevention of Postoperative Bleeding From the Proximal Anastomosis After Bentall Procedure [HOW TO DO IT]

Bleeding is one of the most devastating complications of the Bentall procedure. We describe a simple, modified composite valve Dacron (DuPont, Wilmington, DE) graft to prevent bleeding from the proximal anastomosis between the graft and aortic annulus. The composite graft was modified by adding a short skirt of Dacron tube to a standard composite graft root. After the proximal end of the modified composite graft was implanted in the aortic annulus, the short skirt of Dacron tube was sewed to the remaining native aortic wall to wrap the proximal graft and aortic annular anastomosis. Our initial application of the modified composite graft demonstrated that this modified composite graft is an easy and effective way to prevent bleeding from the proximal anastomosis after the Bentall procedure.

Double-Valve Endocarditis Homograft and Patch Repair [HOW TO DO IT]

We present our technique for reconstruction of aortic valve, mitral valve, and aortomitral curtain in double-valve endocarditis with involvement of intervalvular fibrous body.

Hybrid Approach to Repair of Pulmonary Venous Baffle Obstruction After Atrial Switch Operation [HOW TO DO IT]

Pulmonary venous pathway obstruction is a late complication of the atrial switch operation for transposition of the great arteries. Gaining peripheral access to the pulmonary venous baffle obstruction to treat the obstruction with stent deployment is difficult if not impossible. We present three patients in which we used hybrid procedures in the operating room to relieve the pulmonary venous pathway obstructions.

Bronchial Flap Closure of the Right Lower Lobe Bronchus [HOW TO DO IT]

We describe a novel method for closure of the bronchus intermedius, after right lower lobectomy, using a flap derived from the lower lobe apical segmental bronchus. We have successfully used this technique in an endobronchial carcinoid tumor occurring in a young man. It allowed middle lobe preservation despite a very proximal tumor position within the basal trunk bronchus. Adequate tumor margins were confirmed by on-table frozen section examination. This technique may have particular use in carcinoids or benign tumors.

Cell-Based Therapy for Ischemic Heart Disease: A Clinical Update [REVIEW]

Progenitor cell therapy is a promising treatment for ischemic heart disease. Early clinical trials of autologous bone marrow-derived progenitor cell therapy for acute and chronic myocardial ischemia showed modest functional improvements after cell delivery; however, the duration of these benefits remains unclear. Ongoing investigations continue to enhance our understanding of the mechanisms by which progenitor and stem cells function and how their survival and cardioprotective abilities can be improved. This review discusses: (1) relevant progenitor and stem cells in myocardial regenerative therapy, (2) routes of cell delivery to ischemic myocardium, (3) clinical trials investigating bone marrow-derived progenitor cell therapy for myocardial ischemia, and (4) future directions of the field.

When Is the Request of a Surrogate Too Unreasonable to Follow? [CORRESPONDENCE]

Reply [CORRESPONDENCE]

Is There Any Prospective, Randomized Study to Confirm Significantly Better Angiographic Radial Artery Conduit Patency Compared With Saphenous Vein Graft Patency? [CORRESPONDENCE]

Reply [CORRESPONDENCE]

A Patent Left Internal Thoracic Artery Should Not Be Dissected or Clamped During Reoperative Cardiac Surgery [CORRESPONDENCE]

Mechanism of Delayed Aortic Injury in Left-Sided Rib Fractures [CORRESPONDENCE]

Reply [CORRESPONDENCE]

Direct True Lumen Cannulation in Surgery for Acute Type A Aortic Dissection Is a Valuable but Risky Alternative [CORRESPONDENCE]

Reply [CORRESPONDENCE]

On the Association Between Body Mass Index and Barrett's Esophagus [CORRESPONDENCE]

Thoracic RSS : Gourt

Gulf Coast of Florida Needs a General Surgeon :: Florida :: CompHealth Inc

Call for Information :: Illinois :: Inhouse Physician Recruiters Network

Aastrom Biosciences Reports First Quarter Fiscal Year 2010 Financial Results - CNNMoney.com (press release)

Clear Catheter Systems Receives Major International Innovation Award for Its ... - Reuters

Moderate exercise may lower prostate cancer risk - WBNG-TV

Mesothelioma Trimodality Therapy Benefits Patients - Asbestos.com

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Heart surgeon is suspended again - BBC News

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Health Beat Live - November - San Angelo Standard Times

Chemotherapy in the Older Patient with Operable Non–Small Cell Lung Cancer: Neoadjuvant and Adjuvant Regimens

Thoracic Irradiation in the Elderly

Quality of Life and Ethical Concerns in the Elderly Thoracic Surgery Patient

Thoracic Surgery in the Elderly: Areas of Future Research and Studies

Index

Contents

Forthcoming Issues

Foreword

Normal Changes of Aging and Their Impact on Care of the Older Surgical Patient

Preoperative Evaluation and Risk Assessment for Elderly Thoracic Surgery Patients

Benign Thoracic Disease in the Elderly

Benign Esophageal Disease in the Elderly

Resection for Esophageal Cancer in the Elderly

The Emerging Role of Minimally Invasive Surgical Techniques for the Treatment of Lung Malignancy in the Elderly

Postoperative Pain Management in the Elderly Undergoing Thoracic Surgery

Evaluation and Management of the Elderly Patient at Risk for Postoperative Delirium

FORTHCOMING ISSUES

CONTENTS

Mesothelioma

Malignant pleural mesothelioma: overview of the North American and European experience

Pathology of mesothelioma

Genetics of malignant pleural mesothelioma: molecular markers and biologic targets

Epidemiology, biologic behavior, and natural history of mesothelioma

Role of asbestos in etiology of malignant pleural mesothelioma

Evidence of an important role for SV40 in mesothelioma

Causality of mesothelioma: SV40 question

Preoperative assessment and therapeutic options for patients with malignant pleural mesothelioma

Pleurectomy and decortication for malignant mesothelioma

Extrapleural pneumonectomy for diffuse malignant pleural mesothelioma: techniques and complications

Multimodality therapy in mesothelioma: role of chemotherapy

External beam radiation therapy for the treatment of pleural mesothelioma

Innovative therapies: intraoperative intracavitary chemotherapy

Innovative therapies: photodynamic therapy

Patterns of failure following surgical resection for malignant pleural mesothelioma

Anesthetic strategies for patients undergoing extrapleural pneumonectomy

Pain management strategies for patients undergoing extrapleural pneumonectomy

Cumulative Index 2004

Contents

Forthcoming Issues

PrefaceProgress in the Surgical and Endoscopic Treatment of Emphysema: Where Are We Now?

The Epidemiology, Etiology, Clinical Features, and Natural History of Emphysema

Update on Radiology of Emphysema and Therapeutic Implications

The National Emphysema Treatment Trial: Summary and Update

Staged Lung Volume Reduction Surgery—Rationale and Experience

Lung Volume Reduction Surgery in Nonheterogeneous Emphysema

Lung Volume Reduction Surgery for Patients with Alpha-1 Antitrypsin Deficiency Emphysema

Concomitant Lung Cancer Resection and Lung Volume Reduction Surgery

Combined Cardiac and Lung Volume Reduction Surgery

Intraoperative and Postoperative Management of Air Leaks in Patients with Emphysema

Decision Making in the Management of Secondary Spontaneous Pneumothorax in Patients with Severe Emphysema

Primary sternal plating to prevent sternal wound complications after cardiac surgery: early experience and patterns of failure [Work in progress report - Cardiac general]

Efficacy of SOFT COAG for intraoperative bleeding in thoracic surgery [Work in progress report - Thoracic non-oncologic]

The heart of patients with aortic aneurysms: evidence from cardiac computed tomography [Institutional report - Cardiac general]

eComment: Re: The heart of patients with aortic aneurysms: evidence from cardiac computed tomography [eComment]

Reconstruction of atrioventricular valves with photo-oxidized bovine pericardium [Institutional report - Valves]

Temporary cardiac support with a mini-circuit system consisting of a centrifugal pump and a membrane ventilator [Institutional report - Assisted circulation]

Extended videoscopic robotic thymectomy with the da Vinci telemanipulator for the treatment of myasthenia gravis: the Vienna experience [Institutional report - Thoracic non-oncologic]

The impact of previous or concomitant myocardium revascularization on the outcomes of patients undergoing major non-cardiac surgery [Institutional report - Cardiac general]

The effect of diabetic medications on creatine kinase-myocardial band levels in patients undergoing coronary artery bypass surgery [Institutional report - Cardiac general]

Neutrophil gelatinase-associated lipocalin levels after use of mini-cardiopulmonary bypass system [Institutional report - Cardiopulmonary bypass]

Elective infrarenal abdominal aortic aneurysm repair - transperitoneal, retroperitoneal, endovascular? [Institutional report - Aortic and aneurysmal]

Ventricular assist device as a bridge to heart transplantation in children [Institutional report - Assisted circulation]

Postoperative administration of landiolol hydrochloride for patients with supraventricular arrhythmia: the efficacy of sustained intravenous infusion at a low dose [Institutional report - Arrhythmia]

Anomalous left coronary artery from the pulmonary artery: intermediate results of coronary elongation [Institutional report - Congenital]

eComment: Management of mitral regurgitation associated with anomalous left coronary artery from the pulmonary artery [eComment]

Ministernotomy for repair of congenital cardiac disease [Institutional report - Congenital]

eComment: Re: Ministernotomy for repair of congenital cardiac disease [eComment]