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This is an excellent opportunity for a General Surgeon with training in either Thoracic or Vascular Surgery to join a bread and butter group of 3. The new member is needed to bring that expertise to

Locum Tenens Thoracic Surgery Job in Facility in Arkansas seeks Thoracic Surgeon Arkansas with Weatherby Locums

Job 9509573-0009 Hospital based practice seeks locums CT Surgeon to provide vacation coverage. Physician will be responsible for rounding on in house patients, consults, backing up cath lab and emergency

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Thoracic/Vascular Surgery This opportunity includes a first-year competitive income guarantee , overhead assistance (including 1st years rent), relocation package (moving, house hunting), marketing

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Job 6511020 Experienced Non-Cardiac Thoracic Surgeon needed for ideal northern California location Board Certified / Board Eligible in Thoracic Surgery Shared call of 1:5 Named one of "America's Best

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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

Specialized California Medical Center (Heart411.com) Offers Top ... - MarketWatch

Specialized California Medical Center (Heart411.com) Offers Top ...MarketWatchDr. Mohammad A Gharavi has decades of experience in the cardiovascular and thoracic surgery fields. He served at the Los Angeles St. Vincent Medical Center, ...and more »

The Joint Council on Thoracic Surgery Education (J, Chicago, IL - ADVANCE

The Joint Council on Thoracic Surgery Education (J, Chicago, ILADVANCEWork with volunteer cardiothoracic surgeons on Workforces and associated Task Forces related to STS National Database and Patient Safety. ...and more »

Bone growth agents increase spine surgery costs - Reuters

TopNews United StatesBone growth agents increase spine surgery costsReuters... or the upper back or thoracic spine. They also found no increased complications in neck surgery in which the incision was done in the back of the neck. ...Spinal Surgery Protein Associated With Cervical Spine ComplicationseMaxHealthAgent used in spinal surgery linked to higher complications rate ...EurekAlert (press release)Spinal Fusion Agent Raises Costs, Complication RatesMedPage Todayall 125 news articles »

Seek Out Credentials Before Choosing a Physician - Is Your ... - PR Newswire (press release)

Seek Out Credentials Before Choosing a Physician - Is Your ...PR Newswire (press release)... of Psychiatry and Neurology, American Board of Radiology, American Board of Surgery, American Board of Thoracic Surgery, and American Board of Urology.and more »

REMINDER: Webcast Double Feature Showcases Treatment Options at ... - SYS-CON Media (press release)

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Efficacy of Intraoperative Neurologic Monitoring in Surgery ... - Journal of Bone and Joint Surgery (subscription)

Efficacy of Intraoperative Neurologic Monitoring in Surgery ...Journal of Bone and Joint Surgery (subscription)In Europe, Hell et al. reported the results in fifteen patients who had undergone VEPTR surgery for treatment of thoracic insufficiency syndrome (nine ...Efficacy of Intraoperative Neurologic Monitoring in Surgery ...Journal of Bone and Joint Surgery (subscription)all 2 news articles »

Rare heart surgery conducted at AIMS - Express Buzz

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What's New in Spine Surgery - Journal of Bone and Joint Surgery (subscription)

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MEDICINE, MUSIC, KEEP DOCTOR YOUNG AT HEART - Larchmont Chronicle

Larchmont ChronicleMEDICINE, MUSIC, KEEP DOCTOR YOUNG AT HEARTLarchmont ChronicleHe opened his practice at UCLA Harbor General Hospital in 1961 as a general and thoracic surgeon. He has been chairman of the general surgery department at ...and more »

Public Invited to Meet General Surgeon - Mason County News

Public Invited to Meet General SurgeonMason County NewsHe specializes in thoracic, anti-reflux, colon, stomach and intestinal surgery, hernia repair, diagnostic and therapeutic laparoscopy, splenectomy, ...and more »

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...

Airway Bypass Treatment of Severe Homogeneous Emphysema: Taking Advantage of Collateral Ventilation

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 239-245Cliff K., Choong , Paulo F.G., Cardoso , Gerhard W., Sybrecht , Joel D., Cooper

Treatment of Heterogeneous Emphysema Using the Spiration IBV Valves

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 247-253Steven C., Springmeyer , Chris T., Bolliger , Thomas K., Waddell , Xavier, Gonzalez , Douglas E., Wood

Endobronchial Treatment of Emphysema with One-Way Valves

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 255-260Federico, Venuta , Erino A., Rendina , Giorgio F., Coloni

Update on Donor Assessment, Resuscitation, and Acceptance Criteria, Including Novel Techniques—Non–Heart-Beating Donor Lung Retrieval and Ex Vivo Donor Lung Perfusion

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 261-274Jonathan C., Yeung , Marcelo, Cypel , Thomas K., Waddell , Dirk, van Raemdonck , Shaf, Keshavjee

Update on Lung Transplantation for Emphysema

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 275-283Chadrick E., Denlinger , Bryan F., Meyers

Index

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 2, May 2009, Pages 285-288[No author name available]

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages v-viii[No author name available]

Forthcoming Issues

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Page ix[No author name available]

Preface

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Page xiFederico, Venuta

Surgery of the Mediastinum: Historical Notes

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 1-5Philip A., Rascoe , John C., Kucharczuk , Joel D., CooperSurgical management of diseases of the mediastinum ushered in the era of chest surgery, as the risks of exploration of the pleural spaces were prohibitive until the advent of positive-pressure ventilation. Early procedures were undertaken for suppurative and tuberculous bacterial infections. These approaches were subsequently applied for extirpation of primary and secondary neoplasms of the mediastinum. Finally, less invasive techniques for the diagnosis of mediastinal processes and the staging of bronchogenic carcinoma were developed. This article discusses the historical perspectives of mediastinal surgery.

Utility of Positron Emission Tomography in the Mediastinum: Moving Beyond Lung and Esophageal Cancer Staging

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 7-15Varun, Puri , Bryan F., MeyersFunctional imaging using positron emission tomography (PET) has been a major advance in tumor imaging over the last decade. Its role is established in breast cancer, colorectal cancer, nonsmall cell lung cancer, and lymphoma. This article discusses the indications and applications of PET to evaluate mediastinal pathology.

Genetic Markers of Mediastinal Tumors

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 17-27Matthew D., Taylor , David R., JonesMost adult mediastinal tumors are thymic in nature, and only more recently has there been scientific inquiry into the molecular biology and genetic alterations associated with these tumors. There is an increasing appreciation of specific genetic polymorphisms in myasthenia gravis and associated thymoma. In addition, thymic tumor progression is regulated by perturbations in expression of specific tumor suppressor genes and signal transduction pathways important in oncogenesis. This article highlights the known genetic and signaling pathway alterations important in the tumor biology of mediastinal tumors, with emphasis on thymic tumors. It also discusses the association of genetic markers with thymoma, thymic...

Diagnostic Strategies for Mediastinal Tumors and Cysts

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 29-35Hiroshi, DateMany histologically different tumors and cysts that affect people of all ages arise from the multiple anatomic structures present in the mediastinum. The number of diagnostic possibilities can be narrowed by considering the patient's age, tumor location, the presence or absence of symptoms and signs, the association of a specific systemic disease, radiographic findings, and biochemical markers. Pathologic diagnosis is often required to confirm a presumed diagnosis and to select the optimal treatment modality. A variety of biopsy techniques for obtaining tissue from the mediastinum have been described, including ultrasound-guided endoscopic biopsy, percutaneous image-guided needle biopsy, parasternal anterior mediastinotomy, cervical...

Infections of the Mediastinum

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 37-45Kalliopi A., AthanassiadiInfections of the mediastinum (ie, mediastinitis) are serious, are associated with high morbidity and mortality, and may result from adjacent disease with direct extension, hematogenous spread, or direct introduction into the mediastinal space. The organs and tissues involved determine the manifestations and approach to treatment of these infections. The most common ones are those secondary to perforation of the esophagus or penetrating trauma, and those that extend from an adjacent infection. Today, the most common cause of mediastinitis is direct invasion of the mediastinum after surgical intervention. Cases of mediastinitis can be classified as either acute or chronic. Two broad...

Mediastinal Tumors and Cysts in the Pediatric Population

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 47-61Cameron D., WrightPediatric mediastinal tumors and cysts are rare disorders that share many similarities with adults, yet which have important differences unique to the child. Posterior mediastinal tumors are relatively more common in children than in adults and are also more likely to be malignant in children. CT imaging facilitates the diagnostic evaluation of mediastinal masses in children. Airway compression is always a concern with large mediastinal tumors in children given their relative softer and smaller airway.

Multimodality Treatment of Germ Cell Tumors of the Mediastinum

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 63-69Kenneth A., Kesler , Lawrence H., EinhornGerm cell tumors originating in the anterior mediastinal compartment represent a rare but biologically interesting group of neoplasms. Knowledge of the specific biologic behaviors and therapeutic strategies for the three histologic types is important. This article discusses the multimodality treatment strategy for primary mediastinal nonseminomatous germ cell tumors.

Multimodality Treatment of Thymic Tumors

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 71-81Federico, Venuta , Erino A., Rendina , Giorgio F., ColoniTumors of the thymus are rather infrequent compared with all the other thoracic neoplasms. They may display a variable clinical presentation and outcome. Although they may present as a capsulated lesion with an indolent course, in other cases they may be locally aggressive, invading the surrounding structures, or show the presence of distant metastases. At these advanced stages, cure and complete resection may be difficult, and only a multimodality approach integrating surgery with induction chemotherapy and adjuvant treatment can contribute to improve outcome.

Surgical Approaches to the Thymus in Patients with Myasthenia Gravis

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 83-89Mitchell J., Magee , Michael J., MackMyasthenia gravis is an autoimmune disorder of neuromuscular transmission affecting 2 out of every 100,000 people. Neurologists and surgeons still debate what role surgery should play in its management. Many patients who might benefit from thymectomy are denied the opportunity because of misconceptions, ignorance, or trepidation. By offering effective methods of less invasive thymectomy to these patients, a significant number of patients and treating neurologists previously unwilling to consider surgery may realize the benefits of this established, proven treatment alternative. The surgical approaches reviewed include: transcervical, videothoracoscopic, robotic-assisted, transsternal, and combined transcervical–transsternal maximal thymectomy.

Vascular Lesions of the Mediastinum

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 91-105Percy, Boateng , Waqas, Anjum , Andrew S., WechslerThis article highlights the vascular lesions that present as mediastinal masses. Some radiographic findings represent interesting clinical findings that do not require further intervention, such as a persistent left superior vena cava. Differentiating these findings from true pathologic entities then becomes paramount. In other cases, the clinical presentation will prompt immediate surgical or medical management to mitigate or prevent the mortality and morbidity associated with the condition, such as acute aortic dissection. Although specific details about the management of each clinical or pathologic entity are beyond the scope of this article, a brief mention is made of currently recommended therapy...

Combined Cervicothoracic Approaches for Complex Mediastinal Masses

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 107-112Clemens, Aigner , Mir Ali, Reza Hoda , Walter, KlepetkoThe cervicothoracic junction is an anatomical complex region that contains important neurovascular structures as well as the central routes of the airway and upper digestive tract. Masses arising in either compartment—the mediastinum or the cervical region—may extensively involve the other one, requiring a combined surgical approach to achieve complete resection. The choice of the most appropriate approach is therefore crucial and requires careful preoperative planning.

Intraoperative Strategy in Patients with Extended Involvement of Mediastinal Structures

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 113-120Domenico, Massullo , Pia, Di Benedetto , Giovanni, PintoThe mediastinum is a virtual space containing several vital organs and structures. Biopsy and resection of lesions located within this region often require several considerations that bear on intraoperative strategy. To optimize outcome, clinicians must be able to predict which patients are at highest risk of anesthetic complications. Superior vena cava involvement, extensive compression of the airway, and pericardial effusion have a clear impact on the decision-making of the anesthetist and surgeon, who should plan together when forming the surgical strategy.

The Role of Surgery in Recurrent Thymic Tumors

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 121-131Enrico, Ruffini , Pier Luigi, Filosso , Alberto, OliaroMediastinal neoplasms include various malignancies arising from structures anatomically located in this area and from adjacent organs. Treatment options in mediastinal tumors are chemotherapy, radiotherapy and surgery, or a combination of both. Although the role of surgery in the treatment of most mediastinal malignancies is well-established either alone or as part of a combined modality treatment, far less clear is the value of surgical resection for recurrent or chemorefractory mediastinal tumors. In particular, recurrent thymoma may take advantage from surgery that often allows complete resection and long-term survival.

Advances in Radiotherapy for Tumors Involving the Mediastinum

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 133-141Kevin S., Choe , Joseph K., SalamaVarious malignancies either arise from or spread into the mediastinum. Radiotherapy in the area of the mediastinum is challenging because of the proximity to other critical organs, such as the heart, lungs, esophagus, and spinal cord. With recent advances in imaging, treatment, and the understanding of tumor biology, these diseases now can be treated more effectively and safely. This article reviews such innovations in radiotherapy and discusses their applications in tumors that involve the mediastinum.

Index

Publication year: 2009Source: Thoracic Surgery Clinics, Volume 19, Issue 1, February 2009, Pages 143-147[No author name available]

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages v-vii[No author name available]

Forthcoming Issues

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Page viii[No author name available]

Preface

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Page ixMithran S., Sukumar

Defining N2 Disease in Non–Small Cell Lung Cancer

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 333-337Edmund S., Kassis , Ara A., VaporciyanSimply defined, N2 disease in non–small cell lung cancer (NSCLC) is the presence of ipsilateral mediastinal nodal metastases. This definition does little justice to what is in actuality a heterogeneous and challenging patient population. The presence of ipsilateral mediastinal nodal metastases (N2 disease) in NSCLC is a poor prognostic sign. This article demonstrates that the definition of N2 disease includes many subgroupings with widely disparate effects on prognosis.

Detection of Occult N2 Disease with Molecular Techniques

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 339-347Loretta, Erhunmwunsee , Thomas A., D'AmicoLymph node involvement is the most important factor affecting the prognosis and treatment of patients with potentially resectable NSCLC. Radiographic imaging is inadequate to ascertain lymph node involvement. Currently, lymph nodes are assessed pathologically using conventional histologic techniques; however, lymph node micrometastases may be missed, leading to inaccurate staging and suboptimal treatment. Assessment of occult involvement using antibody expression improves the sensitivity of lymph node analysis, and more advanced techniques, using molecular biologic methods, may further improve lymph node staging. Optimizing outcomes of patients with lung cancer depends on accurate lymph node staging, and the development of the strategies that...

Radiographic Staging of Mediastinal Lymph Nodes in Non–Small Cell Lung Cancer Patients

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 349-361Shawn S., Groth , Bryan A., Whitson , Michael A., MaddausIn order for non–small cell lung cancer patients to undergo the most appropriate treatment, accurate clinical staging (including an assessment for mediastinal lymph node metastasis) is essential. Imaging studies play a critical role in this process. To screen for mediastinal lymph node metastasis, the most sensitive and accurate imaging modality is a positron emission tomography/computed tomography scan. Despite improvements in the sensitivity and accuracy of imaging techniques, histologic assessment of the mediastinum is still required.

Minimally Invasive Staging of N2 Disease: Endobronchial Ultrasound/Transesophageal Endoscopic Ultrasound, Mediastinoscopy, and Thoracoscopy

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 363-379Paul, Schipper , Matt, SchoolfieldMultiple methods of minimally invasive evaluation of the N2 lymph nodes have been developed in hope of providing information similar to that obtained by a lymph node dissection, but with less morbidity. This article details four minimally invasive procedures: endobronchial ultrasound and needle biopsy, endoscopic transesophageal ultrasound and needle biopsy, cervical mediastinoscopy and biopsy, and thoracoscopy and biopsy. It discusses the lymph nodes that can be evaluated by these procedures, the limitations of the procedures, additional information the procedures can yield beyond lymph node staging, the procedures' reliability in determining whether cancer is present in the N2 lymph nodes, and,...

Intraoperative Staging and Surgical Management of Stage IIIA/N2 Non–Small Cell Lung Cancer

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 381-391Igor, Brichkov , Steven M., KellerThorough staging of the mediastinum is an integral component of the operative treatment of non–small-cell lung cancer. Systematic sampling and systematic lymph node dissection provide similar and accurate staging information; however, systematic lymph node dissection is more likely to identify multiple levels of N2 disease and may be associated with improved survival. Although every effort should be made to identify N2 disease before surgery, if intraoperative metastases to mediastinal lymph nodes are discovered, the planned operation should proceed. Cisplatin-based adjuvant chemotherapy has moderate but proven survival benefit after resection of N2 disease. The role of postoperative radiotherapy remains uncertain.

Definitive Chemoradiotherapy for Non–Small Cell Lung Cancer with N2 Disease

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 393-401Shilpen, Patel , Rachel E., Sanborn , Charles R., Thomas Jr.Non–small cell lung cancer remains the leading cause of cancer death in men and women, with a significant proportion of patients having locally advanced, unresectable disease at the time of diagnosis. Although significant advances in definitive therapy have been made with the concurrent administration of combination cytotoxic chemotherapy and thoracic irradiation, recurrence rates are still high, and long-term survival rates are suboptimal. The application of more modern radiation techniques and the addition of molecularly targeted systemic agents may add further benefit in survival.

Neoadjuvant Therapy for Resectable Non–Small Cell Lung Cancer with Mediastinal Lymph Node Involvement

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 403-415Brandon H., Tieu , Rachel E., Sanborn , Charles R., Thomas Jr.Survival outcomes of patients with stage IIIA non–small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2 disease) have been poor when treated with surgery alone. Numerous studies have investigated induction chemotherapy, radiation, and chemoradiation to attempt to improve outcome in this high-risk population. The appropriate application and sequence of these treatments is still the subject of ongoing study. Surgical resection appears to have the greatest benefit in patients who have decreased mediastinal involvement following induction therapy, although the type of surgical resection (pneumonectomy or lesser resection) impacts morbidity and mortality risks after induction therapy. Molecularly targeted agents are...

Restaging After Neo-Adjuvant Chemoradiotherapy for N2 Non–Small Cell Lung Cancer

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 417-421Robert J., Cerfolio , Ayesha S., BryantRecent studies have shown that patients who are down-staged via neoadjuvant therapy and undergo resection have a significant increased 5-year survival rate (as high as 40%–50%) when compared with patients who have residual N2 disease. The identification of patients who are N2 negative after the completion of their neoadjuvant therapy is a critical component of proper patient selection for thoracotomy. Some may even argue that it is a necessary step before resection. In this article we review the best ways to restage patients with N2 disease after they have completed their neoadjuvant therapy.

Adjuvant Therapy for Non–Small Cell Lung Cancer with Mediastinal Nodal Involvement

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 423-435Rachel E., Sanborn , Brian E., LallyThe presence of ipsilateral mediastinal lymph node involvement (N2 disease) is a marker of poor prognosis in patients with resected non–small-cell lung cancer. The addition of systemic chemotherapy to the adjuvant setting has been shown to improve survival by eliminating occult micrometastatic disease. The administration of adjuvant radiotherapy for resected N2 disease is more controversial, although the data regarding outcomes rest primarily on older modalities of delivering radiotherapy. Other modalities of possibly improving survival for resected non–small-cell lung cancer with N2 disease, such as combined modality chemoradiation, prophylactic cranial irradiation, or the addition of molecularly targeted agents, remain to be...

Management Algorithms for Stage IIIA Non–Small Cell Lung Cancer with N2 Node Involvement

Publication year: 2008Source: Thoracic Surgery Clinics, Volume 18, Issue 4, November 2008, Pages 437-441Frank, Detterbeck , Mithran S., SukumarStage IIIA non–small cell lung cancer (NSCLC) with N2 node involvement (IIIA[N2]) is a complex area characterized by much confusion and controversy, because data derived from a particular subgroup of IIIA(N2) often are inappropriately applied to another subgroup. The problem is not so much that stage IIIA(N2) encompasses a spectrum of disease, which is true in each stage of NSCLC. Rather, our ability to describe a patient cohort has been limited, and it is therefore often difficult to determine how and when to apply data from published studies. A simple, pragmatic approach is taken in this article to define algorithms...

[Editorial - Pulmonary] The use of sealants in modern thoracic surgery: a survey

[Work in progress report - Cardiac general] Transpulmonary versus continuous thermodilution cardiac output after valvular and coronary artery surgery

Residual left-sided valvular insufficiencies after valvular surgery may confound transpulmonary thermodilution cardiac output (COtp). We compared the technique with the continuous right-sided thermodilution technique (CCO) after valvular surgery (n=8) and coronary artery surgery (n=8). Patients with pulmonary and femoral artery catheters in the intensive care unit (ICU) were included. After valvular surgery, there was minimal aortic insufficiency in four patients and minimal to moderate mitral valve insufficiency in six. Five fluid loading steps (250 ml) were done in each patient. CCO and COtp were measured prior to and 15 min after each step. The cardiac output was lower after valvular than coronary artery surgery but responses to fluid loading steps were similar among surgery types and techniques. After valvular and coronary artery surgery, cardiac output was lower prior to responses than in non-responses to fluids, by either technique. After valvular surgery, COtp and CCO correlated (r=0.64, P<0.001, n=48) but fluid-induced changes did not. After coronary artery surgery, COtp and CCO correlated (r=0.81, P<0.001) and changes also did (r=0.55, P<0.001). At fluid-induced CCO increases <20%, the r for changes in cardiac output measured by both techniques was similar after valvular and coronary artery surgery. Thus, COtp and CCO were of similar value in predicting and monitoring fluid responses after both surgery types. This argues against left-sided valvular insufficiencies confounding COtp.

[Work in progress report - Cardiopulmonary bypass] Video-assisted right atrial surgery with a single two-stage femoral venous cannula

In the present paper, we report our experience with a single two-stage femoral venous cannula, ideated to drain simultaneously both the superior and the inferior vena cava during minimally invasive cardiac surgery. This cannula has been used in 79 patients (mean age 66.2±11.3 years; mean body surface area 1.9±0.2 m2) who underwent limited access mitral and tricuspid valve surgery at our institution. In our experience, this cannula permits to obtain a safe venous drainage (mean arterial flow 4.7±0.6 l/min, 104±13.3% of the theoretical flow) and it allows for a correct functioning of the pump even when the right atrium is opened. In redo cases (17 patients) the procedure was conducted without snaring the caval veins. In all cases, insertion and positioning of the venous cannula was easily obtained and no patients required a conversion to an alternative perfusion strategy. In conclusion, during minimally invasive procedures requiring opening the right atrium, venous return can be safely accomplished with this two-stage femoral venous cannula. The use of this cannula permits the avoidance of the risk associated with the insertion of a second venous cannula and, in so doing, significantly simplifies the procedure.

[Institutional report - Thoracic non-oncologic] Comparing bipolar electrothermal device and endostapler in endoscopic lung wedge resection

Video-assisted thoracoscopy (VATS) is gaining on thoracic surgery, having newly developed devices next to endostaplers for haemostatic and airtight sealing of lung parenchyma. Though the bipolar electrothermal Ligasure has good results for pulmonary wedge resection, its literature is small in numbers. Authors compared Ligasure and endostapler for pulmonary wedge resection of solitary pulmonary nodules (SPN). Authors performed a retrospective analysis of 44 consecutive patients. The indication of operation was non-verified SPN in all cases. They carried out pulmonary wedge resection for 22 patients with Ligasure–Atlas and 22 patients with ETS Flex endostapler via VATS. Authors examined the gender, average age (62 vs. 49 years), mean hospital stay (6.6 vs. 6.8 days), average operation time (55 vs. 50 min), number of complications (2 vs. 1), average drainage time (2.8 vs. 2.7 days), average fluid loss (190 vs. 160 ml), and instrumental costs ( 367 vs. 756) of both groups. They accomplished the histological analysis of the coagulated lung parenchyma as well. According to the results, the Ligasure–Atlas is eligible for pulmonary wedge resection. The method is safe, easy to use, having minimal rate of complications. It can moderate costs of operation, compared to endostaplers.

[Institutional report - Experimental] A randomised controlled trial comparing Mediwrap(R) heat retention and forced air warming for maintaining normothermia in thoracic surgery

Hypothermia is one of the common complications in the perioperative period. Currently, normothermia is maintained with forced air warming (FAW) or passive heat retention methods. We compared the efficacy of the Mediwrap® blanket with FAW in maintaining normothermia during intra-operative period in thoracic surgery in a prospective randomised controlled trial on 30 patients. Core temperature was measured at 30-min intervals in the perioperative period and the time taken to attain baseline in the postoperative periods in the two groups was compared. There was no difference in core temperatures between the groups during pre- and intra-operative period, with mean±S.D. final core temperatures of 36.2±0.6 °C with Mediwrap® and 36±0.9 °C with the FAW blanket. However, the postoperative core temperatures were significantly higher in the Mediwrap® group. The time required to reach baseline temperature was lower in the Mediwrap® group with a mean±S.D. of 66±66 min as compared to 161±108 min in the FAW group. The Mediwrap® blanket is as effective as the FAW blanket in maintaining core body temperature during thoracotomy when applied thirty minutes before the surgery.

[Institutional report - Experimental] Single high-dose intramyocardial administration of erythropoietin promotes early intracardiac proliferation, proves safety and restores cardiac performance after myocardial infarction in rats

Various studies demonstrate erythropoietin (EPO) as a cardioprotective growth hormone. Recent findings reveal EPO in addition might induce proliferation cascades inside myocardium. We aimed to evaluate whether a single high-dose intramyocardial EPO administration safely elevates early intracardiac cell proliferation after myocardial infarction (MI). Following permanent MI in rats EPO (3000 U/kg) in MI EPO-treatment group (n=99) or saline in MI control group (n=95) was injected along the infarction border. Intramyocardial EPO injection activated the genes of cyclin D1 and cell division cycle 2 kinase (cdc2) at 24 h after MI (n=6, P<0.05) evaluated by real time-PCR. The number of Ki-67+ intracardiac cells analyzed following immunohistochemistry was significantly enhanced by 45% in the peri-infarction zone at 48 h after EPO treatment (n=6, P<0.001). Capillary density was significantly enhanced by 17% as early as seven days (n=6, P<0.001). After six weeks, left ventricular performance assessed by conductance catheters was restored under baseline and dobutamine induced stress conditions (n=11–14, P<0.05). No thrombus formation was observed in the heart and in distant organs. No deleterious systemic adverse effects were apparent. Single high-dose intramyocardial EPO delivery proved safety and promoted early intracardiac cell proliferation, which might in part have contributed to an attenuated myocardial functional decline.

[Institutional report - Cardiac general] Effect of melatonin in the prevention of postoperative pericardial adhesion formation

To evaluate the efficacy of melatonin in preventing postoperative pericardial adhesions, 12 single breed dogs were randomized equally into experimental (melatonin) and control groups. After ketamine anesthesia, a vertical midsternal incision was done and the parietal pericardium of the inferior site of the heart was opened vertically. To promote adhesion formation, abrasions were created on both parietal and visceral pericardial surfaces in an area of 2 cm2 with two vertically reciprocal movements of dry gauze. In the melatonin group, 5% ethanol plus 10 mg/kg melatonin in 10 ml NaCl and, in control group, 10 ml NaCl dilution vehicle containing 5% ethanol was instilled intra-pericardium on to the abrasion sites. After a 6-week recovery period, the animals were evaluated for grading of adhesion formation by an examiner blinded to the groups. The extent of adhesions was graded from 0 (no adhesion) to 3 (total involvement of the traumatized area). The results showed that adhesion scores were significantly lower in melatonin group (1.00±0.63) compared with controls (2.66±0.51); P=0.001. We conclude that melatonin administration effectively reduced postoperative pericardial adhesions in dogs. The use of melatonin in the prevention of pericardial adhesion formation in human subjects warrants further investigations.

[Institutional report - Valves] Minimally invasive mitral valve surgery through right thoracotomy in patients with patent coronary artery bypass grafts

We report our institutional experience, with 25 consecutive patients with patent coronary artery bypass grafts (71.8±12.7 years), who underwent video-assisted minithoracotomic approach for mitral valve surgery. The surgical technique includes: right minithoracotomy, femoral cannulation and hypothermic ventricular fibrillation. Mean preoperative EuroSCORE was 10.2±2.4 and mean ejection fraction was 45±9%. Operative mortality was 4% (1/25). No patient required a conversion to sternotomy. Procedures performed were: mitral valve repair in 15 patients (60%), replacement in 10 (40%) and associated tricuspid repair in seven (28%). Mean blood transfusion was 1.2 package/patient. No cardiological, neurological, vascular and wound complications were observed. Postoperative major morbidity includes: severe pulmonary dysfunction in two patients (8%) and acute renal failure in one (4%). Mean ICU and hospital stay were 3.4±2.9 and 10.6±7.9 days. Echocardiographic follow-up (22.8±14.9 months) revealed trace or mild mitral valve regurgitation in all the mitral repair patients. When interrogated, all the surviving patients preferred the minithoracotomic approach rather than the sternotomy. In conclusion, minimally invasive right thoracotomy can be safely performed in patients with functioning coronary bypass grafts requiring mitral valve operation. Low blood transfusion, the avoidance of deep wound infection and the high patient satisfaction are the main advantages of this approach.

[Institutional report - Congenital] Brain natriuretic peptide is removed by continuous veno-venous hemofiltration in pediatric patients

We wanted to evaluate if brain natriuretic peptide (BNP) is cleared during continuous veno-venous hemofiltration (CVVH) sessions in children with congenital heart disease. A prospective observational single-center study was conducted in a post-cardiac surgery intensive care unit of the city children's hospital. Ten children requiring CVVH for acute kidney injury following cardiac surgery were enrolled. Seven of them were undergoing postoperative extracorporeal membrane oxygenation. BNP clearance was evaluated by the difference between pre-filter and post-filter BNP blood amount indexed to pre-filter BNP concentration. All CVVH treatments were performed with 0.6 m2 polyacrylonitrile filter, in predilution setting, at a dose of 80 ml/kg/h. Troponin I and myoglobin levels were also measured and CVVH clearances of these markers calculated for comparison with BNP. A significant decrease in post-filter compared with pre-filter levels of BNP was shown in all 10 cases (P<0.01). Median BNP clearance was 35.6 (29–39.3) ml/min. Troponin I and myoglobin levels did not show any significant drop between pre- and post-filter values (P>0.05) and their clearance was significantly lower than BNP (P: 0.0004). A daily analysis of BNP levels showed a significant decrease of its blood concentration. BNP levels were significantly reduced after three and four days from CVVH start (P<0.05). During 80 ml/kg/h CVVH, utilizing polyacrylonitrile membranes, BNP is efficiently cleared from blood in a small cohort of pediatric post-cardiosurgical patients. In this situation, BNP absolute blood levels may be unpredictable.

[eComment] eComment: Brain natriuretic peptide is removed by continuous veno-venous hemofiltration in pediatric patients

[Institutional report - Cardiopulmonary bypass] Comparison of minimally invasive closed circuit versus standard extracorporeal circulation for aortic valve replacement: a randomized study

To evaluate the clinical results of aortic valve replacement performed with a miniaturized closed circuit extracorporeal circulation (MECC) system and to compare it to standard cardiopulmonary bypass (CPB). One hundred and twenty consecutive patients undergoing isolated aortic valve replacement were randomly assigned to either a miniaturized closed circuit CPB with the maquet-cardiopulmonary MECC System© (study group, n=60) or to a standard CPB (control group, n=60). Demographic characteristic and operative data were similar in the two groups. No hospital death occurred in either group and no difference in intensive care unit (ICU) stay and in-hospital stay was observed. Patients in the study group showed lower chest tube drainage (212±62 ml vs. 420±219 ml, P<0.05) and lower need for blood products (6.1% vs. 40.4%, P<0.05) than patients in the control group. Platelet count at ICU arrival was significantly higher in the study group (139±40x10 9/l vs. 164±75x10 9/l, P=0.05). Peak postoperative troponin I release was significantly lower in the MECC group (3.81±2.7 ng/dl vs. 6.6±6.8 ng/dl, P<0.05). In this randomized study the MECC system has demonstrated best postoperative clinical results in terms of need for transfusion, platelets consumption and myocardial damage as compared to standard CPB.

[Institutional report - Thoracic oncologic] Chromosomal deletion in patients with malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is associated with frequent deletions of specific chromosomal regions within 1p, 3p, 6q, 9p, 13q, 15q, and 22q. In this retrospective review of our patients with MPM, the tumor tissue of 40 patients (31 male and 9 female) was evaluated for chromosomal deletions and was karyotyped. Chromosomal deletions in regions 1p, 3p, 6p, 9p, 6q, 9q, 22q were observed in 22 of 40 patients (55%). Of this group of 22 patients, 15 (68%) demonstrated deletions in chromosome 6; 12 (54%) exhibited deletions in chromosome 22q; and 13 (59%) had deletions in chromosome 9p. Asbestos exposure was found in only 13 of the 22 patients (59%) with chromosomal deletions. There was no correlation between asbestos exposure and chromosomal deletion (95% CI –0.38–0.23, P=0.63). Chromosomal deletion did not correlate with age (95% CI –0.45–0.14, P=0.29). The majority of patients with chromosomal deletions had epithelial histology (17 of 22 patients; 77%), which was not statistically significant (95% CI –0.14–0.46, P=0.27). Chromosomal deletion is common in tumor tissue of MPM and the inactivation of tumor suppressor genes (TSGs) residing in these chromosomes may contribute to mesothelial cell tumorigenesis.

[Institutional report - Thoracic non-oncologic] Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients

A retrospective study aimed to analyze our experience in 46 patients with blunt traumatic diaphragmatic rupture (BTDR) admitted to our tertiary hospital from 1995 to 2007. Charts, chest roentgenograms (CXR), and computed tomography (CT) scans were carefully reviewed. The mean age was 36.5±10.1 years, 36 (78.3%) were males. The etiology was a traffic accident in 36 (78.3%) patients. BTDR was left-sided in 34 (73.9%) and right-sided in 12 (26.1%) patients. CXR was diagnostic in 26 (56.5%) and CT in 12 (26.1%) patients. Associated injuries included lung 12 (26.1%), liver 10 (21.7%), spleen 24 (52.2%) and bowel 2 (4.2%) patients. BTDR was approached through thoracotomy 26 (56.5%), laparotomy 16 (34.8%), and combined approach 4 (8.7%) patients. The repair was primarily with interrupted non-absorbable sutures in 42 (91.3%) and by prosthetic mesh in four patients. Complications developed in 20 patients. Mortality was observed in 2 (4.3%) patients. We concluded that BTDR is a common lesion in young adult males on the left side caused by a traffic accident. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis. Associated injuries represent the main prognostic factor affecting morbidity and mortality. Thoracotomy and primary repair is adequate surgical treatment.

[eComment] eComment: A practical approach for imaging of diaphragmatic injury

[Institutional report - Congenital] Do we need fenestration when performing two-staged total cavopulmonary connection using an extracardiac conduit?

Between August 1999 and December 2007, 72 consecutive patients with single ventricle physiology underwent a modified Fontan procedure after a bidirectional Glenn shunt using an extracardiac polytetrafluoroethylene conduit without fenestration. Nitric oxide gas inhalation was commenced just after cardiopulmonary bypass together with intravenous phosphodiesterase III inhibitor administration. After oral intake was started, pulmonary vascular dilators such as beraprost, sildenafil, bosentan were given orally according to amount of chest drainage and patient's condition. After discharge, oxygen therapy at home was continued for three months. No hospital death occurred after surgery. All patients were followed by our institute and follow-up period was 44.2±26 (36–106.8) months. One late death occurred during this follow-up period after re-operation. Cardiac catheterization after the Fontan completion showed transpulmonary gradient of 5.9±2.4 mmHg, systemic output of 3.4±2.1 l/min m2. Arterial oxygen saturation (SaO2) at the latest outpatient visit was 94.4±3.8%. According to our clinical experience with two-staged total cavopulmonary connection using an extracardiac conduit without fenestration, fenestration in the Fontan circuit is not necessary when performing the Fontan completion. Two-staged extracardiac total cavopulmonary connection without fenestration can be satisfactorily completed with the aid of pulmonary vasodilation therapy.

[eComment] eComment: Re: Do we need fenestration when performing two-staged total cavopulmonary connection using an extracardiac conduit?

[Institutional report - Cardiac general] The effect of using microplegia on perioperative morbidity and mortality in elderly patients undergoing cardiac surgery

Old age is a significant risk factor for perioperative morbidity and mortality following cardiac surgery and optimal myocardial protection strategy should be sought in this group of patients. We, therefore, reviewed the data on 295 consecutive patients older than 75 years who underwent any cardiac surgical procedure. Microplegia was used in 144 patients compared to 151 patients who had the standard 4:1 blood cardioplegia. Logistic regression analysis was used for propensity matching to balance the differences between the two groups. The microplegia group included more females and sicker patients as indicated by higher Parsonnet scores. There were differences in the pump time, aortic cross-clamp time, procedure type and surgeons between the two groups. These differences were balanced using the propensity matching. In-hospital mortality, acute renal injury and confusion were higher in the microplegia group (17%, 34%, 35%, respectively) compared to the standard 4:1 cardioplegia group (9%, 23%, 24%, respectively) (P=0.04, 0.04, 0.04, respectively). These differences were not statistically significant after propensity matching. These results demonstrate that the use of microplegia is safe in patients older than 75 years who are undergoing cardiac surgery and results in similar in-hospital morbidity and mortality to the standard 4:1 blood cardioplegia.

[Institutional report - Aortic and aneurysmal] Mid-term results of thoracic endovascular aortic repair in surgical high-risk patients

Between May 2001 and June 2008, the outcome and morphological changes in thoracic aortic lesions of 20 surgical high-risk patients who underwent TEVAR were evaluated. Aortic lesions included 8 (40%) type B dissections, 5 (25%) atherosclerotic aneurysms, 4 (20%) penetrating ulcers and 3 (15%) traumatic aortic ruptures. All patients were classified as American Society of Anaesthesiologists class IV and obtained high scores in both the logistic European System for Cardiac Operative Risk Evaluation, median of 14.5% (range 8.1–65.7%), and the STS Parsonet 95 scoring system, median of 14 (range 10–52). Endovascular stent-graft deployment was technically successful in all cases. No surgical conversion occurred. Early mortality was observed in two patients. Clinical and imaging follow-up was available in all patients at a median time of 28 months (range 4–89 months). Overall actuarial survival was 90% at one and five years and 60% at seven years. Mean diameter of the descending aorta decreased from 51.1±13 mm to 45.3±8 mm (P=0.032). Mean reduction in dimension of aneurysms was 10.7±8 mm. Endovascular thoracic aorta repair will probably benefit more patients with multiple comorbidities that limit their life expectancy than patients with a lower profile.

[Institutional report - Esophagus] A surgeon's case volume of oesophagectomy for cancer does not influence patient outcome in a high volume hospital

The aim of this study is to assess if individual case volume of oesophageal resections influences the operative mortality rate in a high volume hospital. Between June 1994 and June 2006, 252 total thoracic oesophageal resections (75% male, mean age 63 years) were performed by five surgeons in tertiary referral centre. Operative approach was standardised in all cases and consisted of left thoracolaparotomy, resection of all intrathoracic and abdominal oesophagus and left cervical incision for anastomosis. Operative mortality, defined as in-hospital death irrespective of length of stay, was compared among consultants and also trainees. A total of 207 operations were performed by five consultants with nine deaths (4.3%) compared to two deaths after 45 operations by 17 trainees (4.4%) [Fisher's exact test, P=0.61 (CI=0.84–1.26)]. Individual case volume for consultants ranged from 5 to 10.5 cases/years [2-test, P=0.34 (CI=0.89–1.29)] with 0–5.4% mortality rate [2-test, P=0.24 (CI=0.96–1.19)]. Overall hospital volume ranged from 17 to 57 cases/years. This study confirms that surgeons with appropriate training in oesophageal resection may get good results despite lower individual case volumes when a standardised approach is taken in an institution with a high case volume.

[Institutional report - Thoracic oncologic] The maximum standardized uptake values on positron emission tomography to predict the Noguchi classification and invasiveness in clinical stage IA adenocarcinoma measuring 2 cm or less in size

This study investigated whether the standardized uptake value (SUV) of the tumor correlated with the Noguchi classification and tumor invasiveness in patients with clinical stage IA adenocarcinoma ≤2 cm in size. Fifty-four patients that underwent a curative surgical resection for clinical stage IA adenocarcinoma ≤2 cm from April 2005 to December 2008 had integrated positron emission tomography (PET) – computed tomography (CT) with 18F-fluorodeoxyglucose (FDG) as part of the preoperative workup. The relationships between the maximum SUV (SUVmax) and Noguchi classification, pathological results of intratumoral lymphatic or vascular invasion of tumor cells, and pleural invasion were examined. In comparison to tumors with an SUVmax>1.0, tumors with an SUVmax≤1.0 were more frequently classified as Noguchi type A or B (P<0.0001). Tumors with an SUVmax>1.0 had more intratumoral lymphatic or vascular invasion of tumor cells and pleural invasion (P=0.0005 and P=0.0002). These results suggest that an SUVmax is an important predictor for the Noguchi classification and tumor invasiveness in patients with clinical stage IA adenocarcinoma ≤2 cm in size.

[Institutional report - Thoracic non-oncologic] Long-term functional results after surgical treatment of parapneumonic thoracic empyema

Retrospective evaluation of long-term functional results of surgical treatment of chronic pleural empyema. Two different surgical procedures (debridement vs. decortication) and approaches (VATS vs. thoracotomy) were analyzed. Three end-points were considered: short-term surgical results, short- and long-term radiological results, clinico-functional long-term results. Fifty-one debridement (52% VATS, 48% thoracotomy) and 68 decortication were performed. Postoperative mortality and morbidity were 1.5% and 24%, respectively. Older age (>70 years old) had worse postoperative morbidity (P=0.048). Video-assisted thoracic surgery (VATS) debridement had lower postoperative hospital stay (P=0.006) and shorter duration of chest drainage (P=0.006). The infectious process was resolved in all patients. All patients presented a postoperative radiological improvement, 63 patients (60%) with a complete pulmonary re-expansion. Sixty patients (58%) referred a complete respiratory recovery. VATS debridement had a greater improvement in subjective dyspnea degree (P=0.041). The long-term spirometric evaluation was normal in 58 patients (56%). Age >70 years old resulted the only variable associated to poor long-term results (FEV1% <60% and/or MRC grade ≥2) at multivariate analysis. Surgical treatment of pleural empyema achieves excellent long-term respiratory outcomes. VATS is associated to less postoperative mortality and shorter postoperative hospital stay. In elderly patients, postoperative morbidity could be higher and long-term functional improvement less warranted.

[eComment] eComment: Is video-assisted thoracoscopic surgery really superior to open decortication for empyema thoracis?

[Institutional report - Thoracic oncologic] The maximum standardized 18F-fluorodeoxyglucose uptake on positron emission tomography predicts lymph node metastasis and invasiveness in clinical stage IA non-small cell lung cancer

In patients with clinical stage IA non-small cell lung cancer (NSCLC), we investigated whether the maximum standardized uptake value (SUVmax) of 18F-fluorodeoxyglucose (FDG) by the tumor correlated with lymph node metastasis, intratumoral lymphatic and vascular invasion of tumor cells, and pleural invasion. From April 2005 to November 2008, 58 patients underwent a lobectomy with systematic hilar and mediastinal lymph node dissection for clinical stage IA NSCLC. All patients had integrated FDG-positron emission tomography (PET)/computed tomography (CT) performed in our center as part of the preoperative workup within one month of resection. The relationships between the SUVmax and pathologic results of lymph node metastasis, intratumoral lymphatic and vascular invasion of tumor cells, and pleural invasion were examined. Compared with tumors with an SUVmax≤2.0, tumors with an SUVmax>2.0 had more frequent lymph node metastasis, intratumoral lymphatic and vascular invasion of tumor cells and pleural invasion (all P<0.05). Our results suggest that in patients with clinical stage IA NSCLC, SUVmax is an important predictor of tumor invasiveness.

[Institutional report - Congenital] Outcome after reoperation for atrioventricular septal defect repair

Results of surgical repair of atrioventricular septal defect (AVSD), both partial (PAVSD) and complete (CAVSD), have improved. However, reoperation is not uncommon. This report describes our experience in 59 patients who underwent reoperation after AVSD repair, between 1977 and 2008. Thirty-one patients had a PAVSD, 28 had a CAVSD. Mean interval between initial repair and reoperation was 10±11 years (PAVSD vs. CAVSD: 13±12 vs. 6±9 years, P=0.063). Reoperations were required for left atrioventricular valve regurgitation (LAVVR) in 53 patients (combined with right atrioventricular valve regurgitation in 10, atrial septal defect (ASD) in 11, ventricular septal defect (VSD) in 7, left ventricular outflow tract (LVOT) obstruction in 1, and aortic valve stenosis in 1), ASD in 3, and LVOT obstruction in 3. Valve repair was performed in 45 patients and replacement in 8. Repair techniques of the left-sided atrioventricular valve (LAVV) included cleft closure in 44 patients, commissuroplasty in 19, and annuloplasty in 1. Freedom from additional reoperation was 85%, and 80% at 5 and 15 years. Hospital mortality was 3%. Overall survival was 91%, and 86% after 5 and 15 years. The most common indication to undergo reoperation is LAVVR. Reoperation is safe and in the majority of cases, a durable repair of the LAVV can still be achieved.

[eComment] eComment: Discrete subaortic stenosis following repair of atrioventricular septal defects

[Institutional report - Coronary] Prevention of perioperative atrial fibrillation with betablockers in coronary surgery: betaxolol versus metoprolol

In this study, we tried to compare the efficacy and safety of betaxolol vs. metoprolol immediately postoperatively in coronary artery bypass grafting (CABG) patients and to determine whether prophylaxy for atrial fibrillation (AF) with betaxolol could reduce hospitalization and economic costs after cardiac surgery. Our trial was open-label, randomized, multicentric enrolling 1352 coronary surgery patients randomized to receive betaxolol or metoprolol. The primary endpoints were the composites of 30-day mortality, in-hospital AF (safety endpoints), duration of hospitalization and immobilization, quality of life, and the above endpoint plus in-hospital embolic event, bradycardia, gastrointestinal symptoms, sleep disturbances, cold extremities (efficacy plus safety endpoint). At the end of the study the incidence and probability of early postoperative AF with betaxolol was lower than with metoprolol in coronary surgery (P<0.0001). In the two study groups minor side effects were similar and no major complication was reported (P<0.001). Patient compliance was good and the general condition improved due to shortened hospitalization and immobilization with subsequent improvement in the psychological status, less arrhythmias and lack of significant side effects. In conclusion, because of its efficacy and safety, betaxolol was superior to metoprolol for the prevention of the early postoperative AF in coronary surgery.

[Institutional report - Valves] Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts

As the population ages, an increasing number of patients with patent coronary grafts will require subsequent aortic valve replacement. Major operative problems include those associated with re-entry and, in particular, damage of the patent grafts. Between January 2007 and October 2008, 10 patients who had previous coronary bypass surgery underwent aortic valve replacement through upper j-shaped mini re-sternotomy. In all patients the previous grafts were patent. The operation was performed with normothermic cardiopulmonary bypass without dissection and temporary closure of the arterial and venous coronary bypass grafts. The mean age was 73.2±13.6 years. The patients had a mean of 2.8±0.6 bypass grafts. There were no intraoperative complications due to redo ministernotomy and at no time conversion to full re-sternotomy was necessary. No damage to the previous grafts was reported and the incidence of perioperative myocardial infarction was 0%. One patient required a pacemaker implantation for atrio-ventricular block. The in-hospital mortality was 0%. Aortic valve replacement in previous coronary bypass grafting can be performed safely with a mini re-sternotomy. This approach avoids extensive dissection, decreasing the risk of injuries to heart chambers and previous patent coronary grafts with low morbidity and mortality.

[eComment] eComment: Mini resternotomy for aortic valve replacement in patients with patent bypass

[eComment] eComment: Aortic valve replacement in patients with patent coronary grafts: how to do it?

[Institutional report - Cardiac general] Aprotinin increases mortality as compared with tranexamic acid in cardiac surgery: a meta-analysis of randomized head-to-head trials

To determine whether aprotinin increases mortality as compared with tranexamic acid in cardiac surgery, we performed a meta-analysis of randomized head-to-head trials. All prospective randomized head-to-head trials of aprotinin vs. tranexamic acid enrolling patients undergoing cardiac surgery were identified using a web-based search engine (PubMed). For each study, data regarding mortality in both the aprotinin and tranexamic acid groups were used to generate risk ratios (RRs) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted averages of logarithmic RRs in random-effects models. Our search identified nine trials (eight trials included in the previous meta-analysis and the blood conservation using antifibrinolytics in a randomized trial [BART] study). Seven trials were composed of low-risk patients (n=1291) and two trials consisted of low-risk patients (n=1628). Pooled analysis of the nine trials demonstrated a statistically significant 45% increase in mortality with aprotinin relative to tranexamic acid therapy (RR, 1.45; 95% CI, 1.00 [1.0002]–2.11; P=0.05 [0.0499]). The present meta-analysis of updated all randomized head-to-head trials, the best evidence, demonstrated a statistically significant increase in mortality with aprotinin relative to tranexamic acid therapy in cardiac surgery.

[eComment] eComment: A comparison of the safety of aprotinin and tranexamic acid in cardiac surgery

[Institutional report - Thoracic oncologic] Prognostic significance of pleural lavage cytology after thoracotomy and before closure of the chest in lung cancer

Some reports have described pleural lavage cytology (PLC) to be a prognostic factor for non-small cell lung cancer (NSCLC) patients. However, there have only been a few reports describing the findings both immediately after thoracotomy (PLC after thoracotomy) and before the closure of the chest (PLC before closure). From April 2002 to April 2008, both PLC after thoracotomy and PLC before closure were performed in 296 consecutive patients who underwent resections for NSCLC. PLC after thoracotomy was positive in 14 patients. The survival rate in the PLC after thoracotomy positive cases was significantly poorer than in PLC after thoracotomy negative cases (P=0.047). In contrast, there were 26 PLC before closure positive cases. The survival rate in the PLC before closure positive cases was significantly poorer than in the PLC before closure negative cases (P<0.0001). Multivariate analyses revealed that PLC after thoracotomy is not an independent prognostic factor in our study. However, PLC before closure was an independent prognostic factor based on multivariate analyses. We conclude that PLC before closure was found to be a better prognostic factor than PLC after thoracotomy for NSCLC patients.

[ESCVS article - Vascular general] Nitric oxide: link between endothelial dysfunction and inflammation in patients with peripheral arterial disease of the lower limbs

Objectives: To analyse the role of nitric oxide (NO) in peripheral arterial disease (PAD) and its association with inflammation and brachial artery flow-mediated dilation (BAFMD) as an estimation of endothelial dysfunction. Material and methods: Cross-sectional study of 82 patients with ischaemia (50 with Fontaine stage II and 32 with Fontaine stage III–IV) in whom BAFMD, hsCRP and nitrite levels in plasma were determined by colorimetric assay using the Griess reaction. They were compared with a control group of healthy subjects (n=41) with ABI >0.9, under 30 years of age. Results: No significant differences were found between the different stages of ischaemia in relation to risk factors or concomitant treatments. The patients with PAD had significantly higher NO levels in plasma than the control group (23.92±23.27 µM vs. 12.77±11.12 µM, P=0.001). However, no statistically significant differences were observed in the NO levels between the two groups of patients with PAD (25.24±24.47 µM vs. 21.86±19.86 µM, P=0.38). Neither were differences found between the two in BAFMD (4.7±4.2 vs. 4.3±2.8, P=0.1). The hsCRP values were statistically higher in PAD stage III–IV (8.2±13.5 vs. 29.2±33.2, P=0.0001). Conclusions: The presence of elevated NO values in PAD, in conjunction with elevated CRP levels, reinforces the theory that atherosclerosis has an inflammatory nature. Its lack of correlation with the clinical severity, also occurring in BAFMD, lends weight to the hypothesis that endothelial dysfunction is an event which takes place in the first stages of the disease.

[ESCVS article - Aortic and aneurysmal] Reimplantation valve-sparing aortic root replacement with the Valsalva graft: what have we learnt after 100 cases?

Objectives: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and mid-term results. The success of this operation primarily depends on preserving the highly sophisticated dynamic function of the aortic valve by recreating an anatomical three-dimensional configuration similar to the normal aortic root, thus minimizing the mechanical stress and strain on the cusps. Over the years several techniques have been proposed to reproduce the sinuses of Valsalva. We reviewed our experience with aortic valve reimplantation by means of a modified Dacron graft that incorporates sinuses of Valsalva, in a series of 100 consecutive patients. Methods: During a 60-month period, 100 patients with aortic root aneurysm underwent aortic valve reimplantation using the Gelweave ValsalvaTM prosthesis. There were 74 males and the mean age was 60±12 years (range 28–83 years). Five patients had the Marfan's syndrome, 15 had a bicuspid aortic valve. Cusp repair was performed in five patients. The mean follow-up time was 28.6 months (range 1–60). Transesophageal echocardiogram was performed at the end of each procedure to assess the aortic valve in terms of competence, dynamic motion and level of coaptation within the graft. Results: There was one hospital death and two late deaths. Overall survival at 60 months was 91.7±5.1%. Five patients developed severe aortic incompetence (AI) during follow-up requiring aortic valve replacement (AVR). The 60 months freedom from re-operation due to AI was 90.9±4.4%. One patient had moderate AI at latest echocardiographic study. The 60 months freedom from AI>2+ was 91.6±7.9%. Cox regression identified cusp's repair as independent risk factor (P=0.001) for late reimplantation failure (AVR or AI>2+). There were no episodes of endocarditis and the majority of the patients (88%) were in New York Heart Association functional class I. Conclusions: The aortic valve reimplantation with the Gelweave ValsalvaTM prosthesis provided satisfactory mid-term results. An accurate assessment of the level of coaptation of the aortic cusps in respect to the lower rim of the Dacron graft by means of intraoperative transesophageal echocardiogram at the end of each procedure is mandatory in order to avoid early reimplantation failure. Cusp's repair may play an important role in the development of late AI. However, long-term results are needed in order to define the durability of this technique.

[Negative results - Pulmonary] Sudden hemothorax following lobectomy caused by staple

A 74-year-old female with lung cancer underwent a right lower lobectomy by video-assisted thoracic surgery (VATS), and suddenly developed hemothorax soon after discharge. The bleeding point was an intercostal artery which faced a stump of the right lower vein divided by a stapler. Operative finding suggested that it was caused by an incidental injury of the artery by a staple.

[Best evidence topic - Cardiac general] Does preoperative computed tomography reduce the risks associated with re-do cardiac surgery?

A best evidence topic was written according to the structured protocol. The question addressed was whether preoperative computed tomography (CT) scan reduces the risk associated with re-do cardiac surgery. A Medline search revealed 412 papers, of which seven were deemed relevant to the topic. We conclude that preoperative CT angiography using ECG-gated multi-detector scan enables excellent anatomical details of heart, aorta and previous grafts, and highlights high-risk cases due to adherent grafts or ventricle or aortic atherosclerosis. This allows for better risk stratification and change of surgical strategy to reduce the potential risk in patients coming for re-do cardiac surgery. According to published reports, high-risk CT-scan findings in these patients caused clinicians to cancel surgery in up to 13% of cases, while preventive surgical strategies including non-midline approach, peripheral vascular exposure or establishing cardiopulmonary bypass prior to re-sternotomy have been reported in over two-thirds of patients with significant reduction in the operative risk. The risk of damage to vital structures, including previous grafts, heart or larger vessels is generally reported fewer than 10%, with evidence of significantly lower incidence of intra-operative injuries in patients who had prior CT-scans compared to those who did not. Hence, adequate preoperative imaging using ECG-gated multi-slice CT is essential for optimum planning of re-do cardiac surgery.

[Case report - Cardiac general] Treatment of high-output coronary artery fistula by off-pump coronary artery bypass grafting and ligation of fistula

Coronary artery fistulas (CAF) are uncommon entities often associated with myocardial ischemia and high output failure. Surgical options include ligation of the fistula, with/without simultaneous coronary artery bypass grafting (CABG). We report a case of left main coronary artery (LMCA) fistula to the coronary sinus (CS), which was associated with high-output bi-ventricular failure, and moderate mitral (MR) and tricuspid regurgitation (TR), related to the volume overload and annular dilatation. This was tackled elegantly by off-pump CABG to protect the territories supplied by the LMCA, followed by ligation of the fistula. This resulted in resolution of the MR and TR. Intraoperative transesophageal echocardiogram (TEE) greatly facilitated the surgical treatment, by identifying the origin and the draining points for the fistula, and aided in the quantification of MR and TR, which had regressed sufficiently at the end of the procedure and did not require surgical correction. This article outlines the importance of multi-disciplinary treatment approach for this complex condition.

[Case report - Cardiac general] Unusual presentation of primary cardiac lymphoma

Cardiac lymphomas are rare neoplasms and account for a minor proportion of primary cardiac malignancies. Secondary involvement of the heart and pericardium by systemic lymphoma is well documented, but primary lymphomas of heart and pericardium are extremely rare, accounting for ~2% of all primary cardiac tumours. Most cases are diagnosed at autopsy, but nowadays, with modern imaging technologies, early diagnosis and treatment is possible. Here, we present two unique incidental presentations of primary cardiac lymphomas (PCL), one in an atrial myxoma and other involving a valvular homograft and discuss the potential pitfalls and prognosis of this rare entity.

[Case report - Pulmonary] Haemo-pneumothorax and haemoptysis in a patient with suspected Ehlers-Danlos syndrome

We present a case of recurrent haemo-pneumothorax in a young female patient with previously undiagnosed Ehlers–Danlos syndrome (EDS). The patient presented with a spontaneous haemo-pneumothorax not associated with menstruation. Following further subsequent episodes, left lower lobectomy was performed. In the past, the patient had suffered recurrent atraumatic bilateral patella dislocations which were never fully investigated. Histology of the lung tissue revealed features suggestive of EDS. Haemothorax is a rare complication of type IV EDS. There are very few reported cases of pulmonary presentation of EDS type IV.

[Case report - Thoracic non-oncologic] Delayed cardiac tamponade following posttraumatic diaphragmatic hernia without an intrapericardial component

We describe a case of posttraumatic diaphragmatic laceration with unusual late sequelae of presentation. Ventilatory and gastrointestinal compromises are known complications of such herniae; but delayed cardiac tamponade without an intrapericardial component of such a hernia has not been reported so far.

[eComment] eComment: Chilaiditis syndrome leading to tamponade

[Case report - Assisted circulation] Safety and efficacy of transbrachial intra-aortic balloon pumping with the use of 7-Fr catheters in patients undergoing coronary bypass surgery

We report the cases of five consecutive patients undergoing coronary artery bypass grafting (CABG) who required a transbrachial approach for 7-Fr catheter intra-aortic balloon pumping (IABP) insertion because of unsuitable femoral arteries. No adverse outcomes occurred in any patient during a mean 72 h of IABP support. Our experience with 7-Fr catheters appears to confirm previous reports of the safety and efficacy of transbrachial IABP assistance and suggests that such support can be provided safely for an extended duration with the use of these smaller catheters.

[Case report - Valves] On-pump beating heart mitral valve repair in patients with patent bypass grafts and severe ischemic cardiomyopathy

Re-operative mitral valve surgery in patients with poor ventricular function can be challenging especially in the presence of patent bypass grafts. We report the case of 11 patients with severe ischemic cardiomyopathy who underwent reoperative mitral valve repair through a limited right thoracotomy approach, on a non-fibrillating beating heart. All patients had their valves successfully repaired with no operative mortality and minimal morbidity. The technical aspects of the procedure are discussed, and the pertinent literature reviewed.

[Case report - Aortic and aneurysmal] Aortic dissection due to sildenafil abuse

This report deals with a 28-year-old male patient, admitted with a type A aortic dissection, potentially related to the use of sildenafil. In the literature, we found only two other potentially sildenafil-related cases of aortic dissections, one type A and one type B. In our patient, a bicuspid aortic valve and an ascending aortic aneurysm were other underlying anomalies that could have led to the aortic dissection.

[eComment] eComment: Acute aortic dissection in children and young adults - the role of sildenafil

[Case report - Thoracic non-oncologic] Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocyst

Acute mediastinitis is a life-threatening disease. Common etiologies include surgical infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. Mediastinitis caused by pancreatic disease is rare. The most common thoracic complication of pancreatic disease is reactive pleural effusion. We report a case of acute mediastinitis and bilateral empyema thoracis arising from a pancreatic pseudocyst. We utilized thoracoscopy to drain the mediastinum without drainage of the intra-abdominal cyst. The patient recovered well after operation.

[eComment] eComment: Optimal exposure for debridement of necrotizing mediastinitis and bilateral empyema thoracis

[ETHICS IN CARDIOTHORACIC SURGERY] Ethical Obligation of Surgeons to Noncompliant Patients: Can a Surgeon Refuse to Operate on an Intravenous Drug-Abusing Patient With Recurrent Aortic Valve Prosthesis Infection?

[CASE REPORTS] Reconstruction of Two Independent Neo-Atria After Resection of Recurrent Leiomyosarcoma

We describe a case of a patient with recurrent leiomyosarcoma involving both atria after a previous right pneumonectomy. The patient was treated with wide resection of the mass and separate reconstruction of the cardiac cavities with prosthetic material.

[CASE REPORTS] Aortic Valve Replacement in a Patient With Osler-Rendu-Weber Disease

Osler-Rendu-Weber (hereditary hemorrhagic telangiectasia) disease is an uncommon disease characterized by the presence of abnormal telangiectasias and arteriovenous malformations that cause recurrent episodes of bleeding. We present a patient with Osler-Rendu-Weber disease, with a history of multiple major bleeding events and severe aortic valve stenosis, who underwent aortic valve replacement. Unexpectedly, the postoperative course was uneventful, and there was no untoward bleeding in the early or in the late postoperative follow-up.

[CASE REPORTS] Ossifying Thymoma Clinically Presenting With Peripheral T-Cell Lymphocytosis

We believe there has been only one ossifying thymoma reported in the English literature. We herein reported another such case with additional peculiar presentation of peripheral T-cell lymphocytosis. A 62-year-old woman was incidentally found to have an anterior mediastinal tumor during a medical check-up, which was surgically resected 42 months later and histopathologically confirmed to be a type B1 thymoma with stromal ossification. Fifty months after tumor removal, this patient remains alive and well without relapsed disease.

[IMAGES IN CARDIOTHORACIC SURGERY] Aberrant Right Subclavian Artery Aneurysm in Coexistence With a Common Carotid Trunk

[ORIGINAL ARTICLES: ADULT CARDIAC] Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management

Background The benefit of cerebrospinal fluid (CSF) drainage during thoracic aortic repair has been established. Few studies, however, report management and safety of CSF drainage. Methods Between September 1992 and August 2007, 1,353 repairs of the thoracic aorta were performed, with 82% using CSF drainage. The CSF drainage was not used in cases of rupture, acute trauma, infection, or prior paraplegia. Thirty-one percent (76 of 246) of patients without CSF drainage were repaired prior to standardized use. All drains were inserted by cardiovascular anesthesia staff. Repairs were performed using distal aortic perfusion with heparinization. Early management involved free drainage to maintain CSF pressure less than10 mm Hg, but was later modified to limit CSF drainage unless neurologic deficit occurred. Results Cerebrospinal fluid drainage was technically achieved in 99.8% (1,105 of 1,107) of cases. The CSF catheter-related complications occurred in 1.5% (17 of 1,107) of patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without spinal headache, spinal headache, intracranial hemorrhage, catheter fracture, and meningitis occurred in 6 (0.54%), 1 (0.1%), 2 (0.2%), 5 (0.45%), 1 (0.1%), and 2 (0.2%) cases, respectively. Mortality from subdural hematoma was 40% (2 of 5), and from meningitis was 50% (1 of 2). Spinal headaches resolved with conservative management. All CSF leaks resolved, but 71% (5/7) required blood patches. Since implementation of a limited CSF drainage protocol, no subdural hematomas have been observed. Conclusions Cerebrospinal fluid drainage for thoracic aortic repairs can be performed safely with excellent technical success. Perioperative management of CSF drains requires diligent monitoring and judicious drainage. Standardizing CSF management may be beneficial.

[ORIGINAL ARTICLES: ADULT CARDIAC] Arch Aneurysm Repair With Long Elephant Trunk: A 10-Year Experience in 111 Patients

Background We studied the long-term outcome of arch aneurysm repair with a long elephant trunk (LET) anastomosed at the base of brachiocephalic artery. Methods Between 1998 and 2008, 111 patients underwent arch aneurysm repair with LET. A 4-branched graft was sutured to the sinotubular junction, the distal ascending aorta transected, and a LET inserted into the aortic arch while selective cerebral perfusion was maintained. The graft distal end was anastomosed to the LET, incorporating the distal ascending aorta, and arch vessels were anastomosed to graft branches. Results Concomitantly, 33 patients (30%) underwent other cardiac procedures, including 11 aortic root replacements. Two patients died (1.8%) within 30 days and 7 died (6.3%) after 30 days. Perioperative morbidity included 2 (1.8%) with stroke, 3 (2.7%) with paraplegia, and 1 (0.9%) with paraparesis. Postoperative computed tomography scans revealed complete aneurysmal thrombosis around the LET in 88 patients (79%), who were monitored without a second-stage procedure. Among 23 patients with incomplete thrombosis, 19 underwent a second-stage procedure to complete distal fixation of the LET. Overall survival was 88%, 83%, and 75%, at 1, 3, and 5 years after aneurysm repair with the LET. No aneurysm rupture or reexpansion occurred in patients with complete thrombosis. Four patients with incomplete thrombosis died of rupture before the second-stage procedure. Conclusions Our results demonstrated safety and good durability of the LET technique and suggest that this technique is a simple and safe procedure that is applicable to a variety of arch aneurysms.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Long-Term Patency of 1108 Radial Arterial-Coronary Angiograms Over 10 Years

Background To avoid late vein graft atheroma and failure, we have used arterial grafts extensively in coronary operations. The radial artery (RA) is the conduit of second choice. This study determined the long-term patency of the RA as a coronary graft. Methods Two independent observers evaluated 1108 consecutive postoperative RA conduit angiograms performed between January 1997 and June 2007 for cardiac symptoms. Mean time to postoperative angiography was 48.3 months (range, 1 to 132 months). An RA graft was considered failed (nonpatent) if there was stenosis exceeding 60%, string sign, or occlusion. Patency was determined over time, by coronary territory grafted and by the degree of native coronary artery stenosis (NCAS). Results At a mean of 48.3 months, 982 of the 1108 RA grafts (89%) were patent. RA patencies for the left anterior descending were 96% (24 of 25), diagonal/intermediate, 90% (121 of 135); circumflex marginal, 89% (499 of 561); right coronary, 83% (38 of 46); posterior descending, 89% (253 of 286); and left ventricular branch/posterolateral, 86% (47 of 55). Patency was 87.5% (56 of 64) for NCAS of less than 60% compared with 89% (926 of 1044; p = 0.89) for NCAS exceeding 60%. Of 318 RAs in place more than 5 years, 294 (92.5%) were patent, and for 107 RAs in place for more than 7 years, 99 were patent (92.5%). Patency was consistent through each year of the decade. Mechanisms of failure did not involve development of atherosclerosis. Patent RA grafts were smooth, with no angiographic evidence of atheroma. Conclusions Late patencies of RA grafts are excellent and justify continuing use of the RA in coronary operations.

[ORIGINAL ARTICLES: ADULT CARDIAC] Sequential Radial Artery Grafts for Multivessel Coronary Artery Bypass Graft Surgery: 10-Year Survival and Angiography Results

Background Increasing the number of arterial grafts for coronary artery bypass grafting (CABG) has been linked to improved late survival. Currently, it is not known if these long-term benefits are also true when sequential radial artery (RA) grafts are the primary means to maximizing arterial revascularization. Methods We compared late survival of 532 consecutive patients receiving sequential RA grafts (sequential RA group: 438 men; 462 with three-vessel disease) with that of a 4,131 contemporaneous internal thoracic artery (ITA) with saphenous vein (SV) multivessel CABG cohort (conventional group). Graft failure rates were determined from symptom-driven repeat angiography films in 122 sequential RA patients performed 2 to 4,317 days after surgery. Median survival sequential RA follow-up was 5.3 years (range, 0.5 to 12.3). Results The sequential RA patients received a total of 1,181 RA grafts (538 sequential [30 triple] and 75 single) along with 636 SV and 533 ITA. Overall RA graft failure (80 of 272; 29%) was intermediate to that for ITA (7 of 121; 5.8%; p < 0.001) and vein (54 of 133, 41.6%; p = 0.032) grafts. Sequential versus nonsequential RA failure did not differ (77 of 252 [31%] versus 3 of 20 [15%]; p = 0.202), while failure of the proximal (36 of 123; 29%) and distal (40 of 129; 31%) components of sequential RA grafts were essentially identical. A total of 69 deaths (6 operative; 1.1%) have occurred in the sequential RA cohort. Unadjusted 10-year sequential RA cohort survival was 76.2% overall, and 79.0% for the 454 primary isolated CABG subgroup. The risk-adjusted 10-year survival using a logit propensity score was substantially better for the sequential RA cohort versus the conventional CABG cohort (risk ratio [95% confidence interval] 0.61 [0.44 to 0.85]; p = 0.003). Conclusions Sequential RA grafting is a safe method for maximizing arterial revascularization and is associated with excellent 10-year survival that seems to be superior to conventional or ITA/SV CABG results. Also, the similar proximal and distal sequential RA patency mitigates concerns of a clinically significant effect of increased vasoreactivity of distal segments of RA conduits.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Additive Costs of Postoperative Complications for Isolated Coronary Artery Bypass Grafting Patients in Virginia

Background Complications after open-heart surgery result in an increased length of stay and greater financial burdens for all. The purpose of this study was to measure the additive costs of postoperative complications for selected subgroups of patients after coronary artery bypass grafts in the Commonwealth of Virginia. Methods A multiyear statewide data repository with clinical and billing data was used to measure outcomes for the period 2004 to 2007. The Society of Thoracic Surgeons records matched with Universal Billing (UB-04) charge data for all payers were used to estimate the additive costs of cardiac surgical outcomes using cost-to-charge ratios. Additive cost was defined as the difference between the baseline cost of an average case with no complications and one with a postoperative morbidity or mortality. Multivariate analysis was used to account for important covariates and apportion incremental costs. Results The baseline cost of isolated coronary artery bypass grafting (CABG) cases with no complications during the study period was $26,056. Isolated atrial fibrillation was the most frequently cited complication and had the lowest additive cost ($2,574). Additive costs for isolated CABG patients were greatest for those cases involving prolonged ventilation ($40,704), renal failure ($49,128), mediastinitis ($62,773), and operative mortality ($49,242). Conclusions Additive costs can serve as an indicator for pursuing quality improvement initiatives. Our results suggest additive costs vary according to type of postoperative complication and comorbidities. Regional collaborations of multidisciplinary groups in cardiac surgery are an effective means to implement quality guidelines and drive down additive costs.

[ORIGINAL ARTICLES: ADULT CARDIAC] In-Hospital Outcomes of Off-Pump Multivessel Total Arterial and Conventional Coronary Artery Bypass Grafting: Single Surgeon, Single Center Experience

Background Despite increasing recognition that off-pump coronary artery bypass surgery and total arterial revascularization individually are associated with improved outcomes, concerns persist regarding the safety of combining these two techniques. We compared in-hospital outcomes for off-pump multivessel total arterial and conventional coronary artery bypass grafting. Methods From September 1998 to September 2008, 580 consecutive patients receiving off-pump multivessel arterial grafts only were compared with a control group of patients (n = 806) undergoing off-pump coronary artery bypass grafting with internal thoracic artery and saphenous veins operated on by the same surgeon. Two different statistical approaches were used to compare groups in this retrospective analysis. First, propensity score analysis was used to match patients from each group. Second, a multivariate analysis was performed looking at a combined patient outcome of death, intraaortic balloon counterpulsation utilization, myocardial infarction, stroke, prolonged ventilation, and reoperation for any cause on all patients in both groups. Results After matching by propensity score, the major clinical outcomes in total arterial (n = 346) and control (n = 346) groups were found to be similar. The in-hospital mortality in the total arterial group was 1.2% as compared with 2.0% in matched patients (p = 0.8). However, patients in the total arterial group were found to have a significantly increased incidence of reexploration for bleeding (p < 0.0001) and blood product usage (p < 0.0001). There was a higher incidence of combined morbidity outcome (18.8% versus 12.1%; p = 0.001) for the control group compared with the total arterial group. Multivariate analysis failed to show that total arterial grafting was an independent predictor of the combined morbidity outcome. Conclusions Off-pump multivessel total arterial grafting can be performed safely with superior in-hospital outcomes compared with off-pump conventional coronary artery bypass grafting.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Remodeling of Reconstructed Left Anterior Descending Coronary Arteries With Internal Thoracic Artery Grafts

Background The internal thoracic artery (ITA) remodels its diameter in response to flow requirements. The objective of this study was to elucidate the remodeling capacity of the reconstructed coronary artery using the ITA. Methods We evaluated coronary angiograms in 63 patients who had left anterior descending artery (LAD) segmental reconstruction with or without endarterectomy after off-pump coronary artery bypass graft surgery. The diameters of the ITA and reconstructed coronary artery were measured early and at 1 year after surgery. Results The mean diameter of the reconstructed LAD was significantly larger than that of the ITA, but significantly decreased 1 year after surgery (2.69 ± 0.53 mm versus 1.87 ± 0.39 mm; p > 0.0001). The proximal ratio, the ratio of the ITA to proximal reconstructed coronary artery, and the distal ratio, the ratio of the distal LAD to distal reconstructed coronary artery, increased to a value of almost 1.0 (0.77 ± 0.11 versus 1.05 ± 0.18, p < 0.0001, and 0.77 ± 0.14 versus 0.92 ± 0.12, p < 0.0001, respectively). Based on the mean diameter of the reconstructed coronary artery, there were no relationships between the use of endarterectomy and the degree of native coronary stenosis. The proximal ratio in the group with severe stenosis was significantly greater than that in the group with mild stenosis (1.08 ± 0.18 versus 0.95 ± 0.16; p = 0.036), although the distal ratio was not different between the two groups. Conclusions Vascular remodeling of the coronary artery reconstructed with the ITA is observed within 1 year after surgery.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Clopidogrel and Aspirin Versus Clopidogrel Alone on Graft Patency After Coronary Artery Bypass Grafting

Background Clopidogrel and aspirin are the most popular antiplatelet agents for anticoagulation management after coronary artery bypass grafting (CABG) in clinical practice, but there is neither a standard antiplatelet therapy for patients undergoing CABG, nor an exact conclusion about its effects on graft patency until now. Methods One-hundred and ninety-seven selected patients undergoing CABG were assigned to two groups according to antiplatelet drug: the clopidogrel group of 102 patients who received clopidogrel (75 mg) daily; and the combination group of 95 patients who received clopidogrel (75 mg) plus aspirin (100 mg) daily. Multislice computed tomography angiography was performed to evaluate graft patency at 1 month and 12 months after CABG. Results There were no significant differences between the two groups in preoperational data. At 1 month and 12 months after CABG graft patency rates of clopidogrel group were, respectively, 99.0% and 96.9% for the left internal mammary artery (LIMA) and 98.1% and 93.5% for the saphenous vein grafts; those of the combination group were, respectively, 98.9% and 97.8% for LIMA, and 98.2% and 96.3% for saphenous vein grafts. There were no significant differences in graft patency between the two groups (p > 0.05). Conclusions Either clopidogrel plus aspirin or clopidogrel alone maintain high graft patency in the early postoperative phase after CABG. The observed trend toward higher patency rates in patients treated with clopidogrel plus aspirin compared to those in the clopidogrel group did not reach statistical significance.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Survival of Cardiorespiratory Arrest After Coronary Artery Bypass Grafting or Aortic Valve Surgery

Background Study objectives were to (1) report the clinical profile of and outcome for patients who experience a cardiorespiratory arrest after coronary artery bypass grafting or aortic valve replacement, and (2) identify factors associated with improved probability of survival. Methods We identified 108 consecutive patients who had cardiorespiratory arrest after coronary artery bypass grafting or aortic valve replacement between April 1999 and June 2008. We studied the characteristics of arrests and survivors, and performed a multivariate logistic analysis to determine features associated with survival to hospital discharge. Results Cardiac arrest (n = 86) was more common than respiratory arrest (n = 13; unknown cause, n = 9). Cardiorespiratory arrest occurred with decreasing frequency from the day of surgery. Ventricular fibrillation or tachycardia was the dominant mechanism of cardiac arrest (70% versus 17% for asystole versus 13% for pulseless electrical activity), and the principal causes were postoperative myocardial infarction (n = 46; 53%) and tamponade or bleeding (n = 21; 24%). Resternotomy was performed in 45 patients (52%), cardiopulmonary bypass reinstituted in 14 (16%), and additional grafts constructed in 5 (6%). The causes of respiratory arrest were mainly pulmonary (n = 8) and neurologic (n = 5). Survival to hospital discharge was better for respiratory arrest (69%) than for cardiac arrest (50%). Older age, ejection fraction less than 0.30, and postoperative myocardial infarction decreased the probability of survival. Conclusions Ventricular fibrillation or tachycardia was the most common mechanism, and myocardial infarction, the predominant precipitating cause of cardiac arrest after coronary artery bypass grafting or aortic valve replacement. Despite aggressive resuscitation, outcome is poor. Young patients with good left ventricular function had a better probability of survival if they did not suffer a postoperative myocardial infarction.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] The July Effect: Impact of the Beginning of the Academic Cycle on Cardiac Surgical Outcomes in a Cohort of 70,616 Patients

Background Because surgical residents' level of experience may be at its nadir early in the academic year, academic seasonality—or the "July effect"—could affect cardiac surgical outcomes. Methods Prospectively collected data from the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program were used to identify 70,616 consecutive cardiac surgical procedures performed between October 1997 and October 2007. Morbidity and mortality rates were compared between early (July 1 to August 31, n = 11,975) and late (September 1 to June 30, n = 58,641) periods in the academic year. A prediction model was constructed by using stepwise logistic regression modeling. Results The two patient groups had similar demographic and risk variables. Isolated coronary artery bypass grafting accounted for 76.7% of early-period procedures and 75.8% of later-period procedures (p = 0.03). Morbidity rates did not differ significantly between the early (14.0%) and later periods (14.2%; odds ratio [OR], 1.01; 95% confidence interval [CI], 0.96 to 1.07; p = 0.67) and operative mortality was similar, 3.7% vs 3.9% (OR, 0.99; 95% CI, 0.89 to 1.11; p = 0.90). The early portion of the year was associated with longer cardiac ischemia times (84 ± 40 vs 83 ± 42 minutes), cardiopulmonary bypass times (126 ±52 vs 124 ±56 minutes), and total surgical times (295 ± 90 vs 288 ± 90 minutes; p < 0.05 for all). Conclusions The early part of the academic year was associated with slightly longer operative times; however, risk-adjusted outcomes were similar in both periods. This finding should lessen concerns about the quality of cardiac surgical care at the beginning of the academic year.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Is Prosthetic Anuloplasty Necessary for Durable Mitral Valve Repair?

Background Because emerging percutaneous mitral valve repair may address only leaflets and not the anulus, we compared durability of mitral valve repair with and without prosthetic anuloplasty. Methods From 1985 to 2007, 3,057 patients underwent primary isolated posterior leaflet repair for degenerative mitral disease either with prosthetic anuloplasty (n = 2,754, 90%) or without (n = 303, 9.9%: no anuloplasty, 68; suture anuloplasty, 7; pericardial anuloplasty, 228). Most of the latter operations occurred in the early 1990s. Differences in patient characteristics were addressed by propensity-score adjustment and matching (214 pairs). In all, 3,870 echocardiograms for 1,236 patients were available for assessing mitral regurgitation after prosthetic anuloplasty and 257 in 99 patients without one. Mean follow-up for mitral valve reoperation was 4.2 ± 4.1 years, with 13,003 patient-years of data available for analysis. Results Early, and to a lesser degree late, postoperative mitral regurgitation was less after prosthetic anuloplasty than repair without one, and this difference persisted after risk adjustment and in propensity-matched patients (p = 0.0002). Freedom from mitral valve reoperation was 96% and 94% at 10 years after repair with versus without prosthetic anuloplasty in unmatched groups, and 97% and 96% in matched groups (p = 0.3), respectively. Unadjusted survival was greater with than without prosthetic anuloplasty (84% versus 81% at 10 years, p = 0.009), but similar after propensity adjustment and in matched pairs. Conclusions Mitral valve repair without a prosthetic anuloplasty was associated with accelerated return of mitral regurgitation, although risk-adjusted survival was similar. This finding has important implications for durability of percutaneous mitral repair techniques that do not address both leaflets and anulus.

[ORIGINAL ARTICLES: ADULT CARDIAC] Long-Term Results of the Leaflet Extension Technique in Aortic Regurgitation: Thirteen Years of Experience in a Single Center

Background We evaluated the effectiveness and durability of the leaflet extension technique for correction of aortic regurgitation (AR) and the long-term clinical results. Methods Between March 1995 and August 2004, 41 consecutive patients were included. The mean age was 32.2 ± 13.9 years. The causes of AR were rheumatic in 31 patients (75.5%), degenerative in 2 patients (4.9%), bicuspid aortic valve in 4 patients (9.8%), infective endocarditis in 1 patient (2.4%), and congenital in 3 patients (7.3%). Leaflet extensions were performed in three leaflets for 32 patients, two leaflets for 3 patients, and only one leaflet for 6 patients. The mean follow-up duration was 92.9 ± 48.4 months. Results There were no early deaths and 2 late deaths. One patient died of cancer and the other patient died of infective endocarditis. The cardiac-related mortality was 2.4% (1 of 41 patients). During a mean follow-up of 7 years, severe AR was detected in 1 patient and moderate AR in 6 patients (17.0%; 7 of 41 patients). The causes of recurrent AR were infective endocarditis in 3 patients, disease progression in 3 patients, and Behçet's diseases in 1 patient. We performed 6 reoperations (14.6%), 3 in patients owing to infective endocarditis, 2 in patients owing to disease progression, and 1 in a patient owing to the suture dehiscence associated with Behçet's disease. The cumulative survival was 92.6% at 13 years. Freedom from recurrent AR was 97.5% at 5 years, 81.7% at 10 years, and 68.1% at 13 years. Conclusions The long-term durability of the leaflet extension technique was acceptable. The reoperations increased with time, but pericardial leaflet dysfunction was not the cause.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Unexpected Complications of Transapical Aortic Valve Implantation

Background Recent series have reviewed the results of transapical aortic valve implantation (TAVI). However, specific problems of this new procedure are not well-described. Unexpected complications due to the procedure and their management are reported. Methods Eighteen patients underwent TAVI using the Edwards Sapien bioprosthesis (Edwards Lifesciences Inc, CA) between September 2007 and June 2008 due to contraindications of conventional surgery (n = 5) or high operative risk (n = 13). The system was introduced through 2 purse string sutures in the apex under echocardiographic and fluoroscopic control. Results The implantation success rate and initial procedural success were 100%. There was no intraoperative death and no stroke. During the procedure, two cases of ventricular fibrillation consequent to rapid pacing were treated by cardioversion. Acute mitral regurgitation due to traction of the subvalvular apparatus by the guidewire and acute aortic regurgitation from pressure on a bioprosthesis cusp by the guidewire were diagnosed by transesophageal echocardiography and reversed by the removal of the guidewire. Another case of aortic regurgitation was due to incomplete deployment of the bioprosthesis and was managed by a "valve after valve" procedure. Two patients died on postoperative day 2 from left ventricular failure. In one patient the postmortem study showed, despite correct implantation of the bioprosthesis, a hematoma of the septum with a small ventricular septal defect. The total in-hospital death was 27.7% (5 patients). There was no periprocedural bleeding but in one patient delayed rupture of the apex (36 hours after the procedure) necessitated emergency surgery. A false aneurysm of the apex appeared 3 months after surgery in another patient. Closure of the apex was performed through sternotomy and cardiopulmonary bypass with an uneventful follow-up. Conclusions The TAVI is associated with incidents and complications different to those encountered in conventional aortic valve surgery. Recognizing their existence contributes to elucidating their mechanisms and to propose solutions to avoid or treat them.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] The Effect on Long-Term Survival of Erythrocyte Transfusion Given for Cardiac Valve Operations

Background Studies in patients undergoing coronary artery bypass grafting (CABG) have shown an increased long-term mortality rates associated with perioperative blood transfusions. However, some studies in other patient populations have shown no effect on death or even a lowered mortality rate in patients receiving blood transfusions, which suggests that the effects of blood transfusion may be disease-dependent. Methods Data of all patients who underwent valve operations with or without associated CABG between October 2, 1991, and November 14, 2007, were obtained from the department's database and analyzed using logistic regression for 30-day and Cox models for long-term mortality to determine the effects of transfusion on death. To control for the potential interaction between transfusion and complications and sicker patients being more likely to receive blood, we separately analyzed the data for the different valve populations and used propensity analysis to control for sicker patients being more likely to receive blood. Results Of 1823 patients who underwent valve operations, the operation was isolated in 993 and combined with CABG in 830. By 30 days, 125 patients (6.9%) had died, and 717 (39%) were dead at follow-up. After controlling for type of operation and factors that influenced the transfusion decision, transfusion was associated with increased death only in patients who had combined valve and CABG, and not in isolated valve operations. Conclusions Transfusion had no effect on the mortality rate after isolated valve operations but was associated with increased mortality when valve operations were combined with CABG.

[ORIGINAL ARTICLES: ADULT CARDIAC] The Cox-Maze III Procedure Success Rate: Comparison by Electrocardiogram, 24-Hour Holter Monitoring and Long-Term Monitoring

Background The detection of atrial arrhythmia recurrence is more accurate when using long-term (5 days to 3 weeks) continuous monitoring devices. In this study, we focus on the comparison of the recurrence of atrial arrhythmias in patients after the Cox-Maze III procedure obtained by three modalities: electrocardiography (ECG), 24-hour Holter monitoring, and long-term monitoring (LTM). Methods Patients with follow-up longer than 6 months who reported sinus rhythm while not taking antiarrhythmic drugs were eligible. Atrial arrhythmias longer than 30 s were considered a recurrence. The ECG, 24-hour Holter monitoring, and LTM (5 days) reports were ascertained and compared at the same time. Results Patients (n = 291) underwent the full Cox-Maze III procedure, with 194 eligible for the study and 76 agreeing to participate. The average time to monitoring after surgery was 9.8 (± 7.7) months. The ECGs determined 96% of patients in sinus rhythm, Holter monitoring determined 91% in sinus rhythm, and LTM indicated 84% in sinus rhythm. Comparing ECG results and LTM results revealed that 9 patients (12%) had a significant rhythm change. Holter monitoring did not capture all the patients having events lasting longer than 1 hour. No additional information was captured by the use of LTM in patients with paroxysmal atrial fibrillation. Conclusions This study reconfirmed that ECG overestimated the success rate after the Cox-Maze III operation by 12% compared with LTM. These changes may carry clinical significance when determining the success of the Cox-Maze III procedure and determining the medical management, including antiarrhythmic and anticoagulation therapy, of the patients who were found to have significant events.

[ORIGINAL ARTICLES: ADULT CARDIAC] Current Use of Prophylactic Strategies for Postoperative Atrial Fibrillation: A Survey of Canadian Cardiac Surgeons

Background Evidence from multiple trials demonstrates the efficacy of prophylactic β-blocker, amiodarone, and corticosteroid administration in reducing the incidence of postoperative atrial fibrillation. Despite this information, these interventions remain infrequently or inappropriately utilized. This study was designed to assess the frequency with which these prophylactic strategies are currently being used and to identify concerns and barriers to more widespread application. Methods A link to an online survey was e-mailed to all practicing cardiac surgeons in Canada. Each surgeon was given a unique log-in identification number to complete the survey online through a secure web page. Results Surveys were sent to 166 surgeons; 119 completed surveys (72%) were returned. Only 58% of respondents routinely use β-blockade for prophylaxis. For nonusers, 44% are unconvinced of the evidence for this practice. The routine use of amiodarone among surgeons was 19%. Of the remainder, 43% cited a perceived increased risk of complications as the reason for not using this therapy. An additional 29% considered the therapy was excessively complicated or time consuming. Corticosteroids were routinely used by only one surgeon. Major barriers to use of steroids were unconvincing evidence (76%), a perceived increased risk of wound infection (38%), and hyperglycemia (30%). Conclusions Despite level 1 evidence, the use of β-blockers, amiodarone, and corticosteroids for prophylaxis of atrial fibrillation among Canadian surgeons remains less than expected. The results of this survey support the need for further clinical trials with robust and clinically relevant outcomes that may further influence surgeons to adopt this practice.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Nontraditional Surgical Approaches for Implantation of Pacemaker and Cardioverter Defibrillator Systems in Patients With Limited Venous Access

Background Indications for placement of implantable cardioverter-defibrillators (ICD) and pacemakers have expanded, and traditional transvenous implantation may not be feasible in patients with aberrant anatomy or venous obstruction. In these settings, successful lead placement has required innovative surgical approaches. A case series of successful placement of these systems in challenging patients is presented. Methods A 2-year retrospective study of patients undergoing placement of minimally invasive epicardial pacing leads or ICD coils was performed. Results Eleven patients underwent minimally invasive surgical placement of leads or coils. None were converted to open sternotomy. One required extension to minianterior thoracotomy. Causes of intravenous placement failure included aberrant anatomy with failure to access coronary sinus in 9 and venous occlusion in 2. Four patients had previous operations through a median sternotomy. Procedures included left video-assisted thoracoscopic (VATS) placement of a left ventricular epicardial lead in 8, left VATS conversion to minianterior thoracotomy left ventricular epicardial lead placement in 1, left VATS placement of ICD coil in 1, subxiphoid placement of a right ventricular epicardial lead in 1, subxiphoid ICD coil in 2, and subcutaneous ICD coil placement in 3. Mean hospitalization was 4.6 days. Postoperative hypotension and pulmonary edema occurred in 27% of patients. No patients died. Conclusions Conventional transvenous lead implantation may be difficult or impossible in some patients with aberrant or occluded venous access. Novel surgical approaches with the use of minimally invasive procedures can establish optimally functional pacing and ICD systems without sternotomy and low associated morbidity.

[ORIGINAL ARTICLES: ADULT CARDIAC] Cardiac Vagal Stimulation Eliminates Detrimental Tachycardia Effects of Dobutamine Used for Inotropic Support

Background Many patients require temporary inotropic support after cardiac surgery, and dobutamine is one of the commonly used drugs for this purpose. However, dobutamine infusion is frequently associated with unwanted sinus tachycardia. Selective sinus node electrical vagal stimulation through a discrete epicardial ganglionic plexus (fat pad) approach can achieve sinus rate slowing. Because sinus node fat pad vagal stimulation (SNFP-VS) can easily be applied during or after cardiac surgery, we hypothesized that combining selective SNFP-VS with dobutamine could produce desired hemodynamic improvement while avoiding sinus tachycardia in patients when inotropic drug support is needed. Methods This exploratory experimental study was performed in 7 open-chest dogs. Dobutamine (2.5 to 10 µg · kg–1 · min–1) was infused at a rate producing at least 30% increase in sinus rate and cardiac output. Then electrical SNFP-VS was applied in the epicardial ganglionic plexus located at the right pulmonary vein-atrial junction, to slow the sinus rate back to control level. Hemodynamic data during control, with steady-state dobutamine infusion, and with dobutamine plus SNFP-VS were collected and compared. Results Dobutamine significantly increased heart rate, systolic and diastolic blood pressures, peak left ventricular systolic pressure, positive and negative maximal derivatives of left ventricular pressure, and cardiac output. Combining SNFP-VS with dobutamine eliminated sinus rate increase while preserving all major hemodynamic benefits. Selective SNFP-VS itself had no direct effect on cardiac contractility during atrial pacing. Conclusions Combining SNFP-VS with dobutamine could achieve hemodynamic improvement while avoiding sinus tachycardia in this dog model, suggesting that similar strategy may also be applied in patients.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: ADULT CARDIAC] Novel Biomarkers Early Predict the Severity of Acute Kidney Injury After Cardiac Surgery in Adults

Background The purpose of this study was to investigate the ability of neutrophil gelatinase-associated lipocalin (NGAL), cystatin C, and their combination in predicting the duration and severity of acute kidney injury (AKI) after cardiac surgery in adults. Methods Using data from a prospective observational study of 100 adult cardiac surgical patients, we correlated early postoperative concentrations of plasma NGAL and serum cystatin C with the duration (time during which AKI persisted according to the Acute Kidney Injury Network criteria) and severity of AKI (change in serum creatinine) and with length of stay in intensive care. Results We found a mean AKI duration of 67.2 ± 41.0 hours which was associated with prolonged hospitalization (p < 0.001). NGAL, cystatin C, and their combination on arrival in intensive care correlated with subsequent AKI duration (all p < 0.01) and severity (all p < 0.001). The area under the receiver operating characteristic curve for AKI prediction was 0.77 (95% confidence interval: 0.63 to 0.91) for NGAL and 0.76 (95% confidence interval: 0.61 to 0.91) for cystatin C on arrival in intensive care. Both markers also correlated with length of stay in intensive care (p = 0.037; p = 0.001). Neutrophil gelatinase-associated lipocalin and cystatin C were independent predictors of AKI duration and severity and of length of stay in intensive care (all p < 0.05). The value of cystatin C on arrival in intensive care appeared to be due to a carry-over effect from preoperative values. Conclusions Immediately postoperatively, NGAL and cystatin C correlated with and were independent predictors of duration and severity of AKI and duration of intensive care stay after adult cardiac surgery. The combination of both renal biomarkers did not add predictive value.

[ORIGINAL ARTICLES: ADULT CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] Mid-Term Outcomes in Adults With Ebstein Anomaly and Cavopulmonary Shunts

Background In patients with Ebstein anomaly and poorly functioning right ventricles, a cavopulmonary shunt (CPS) can be created to reduce the preload on the right ventricle. The purpose of this study was to examine the early and mid-term outcomes in adults with Ebstein anomaly who have undergone tricuspid valve repair or replacement with or without a concomitant CPS. Methods We examined the outcomes of 40 consecutive patients seen at our center with Ebstein anomaly who had undergone tricuspid valve repair or replacement with (n = 23) or without (n = 17) concomitant CPS. Follow-up data were obtained by either chart review or contacting the referring cardiologist. Mid-term survival was examined using Kaplan-Meier curves. Results The mean age at surgery was similar in patients with and without CPS (42 ± 12 versus 39 ± 19 years; p = 0.63). There were 2 early postoperative deaths owing to refractory right-sided heart failure. Mid-term follow-up data were available in 95% of patients. The mean follow-up time was 6.7 ± 4.8 years. Patients who received a CPS more commonly had preoperative heart failure or cyanosis (p = 0.04) and had worse preoperative functional status (p = 0.09). In both groups, arrhythmias were the most common late complication. There were 5 late deaths, 3 of which occurred in patients with CPS. Five-year survival with or without CPS was comparable (83% ± 9% versus 86% ± 10%; p = 0.85). Conclusions Adolescent and adult patients with Ebstein anomaly undergoing tricuspid valve replacement or repair and concomitant CPS are at risk for early and mid-term complications. However, Ebstein surgery along with CPS appears to be a reasonable surgical strategy in patients not thought to be suitable for tricuspid valve surgery alone.

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] The Rastelli Procedure for Transposition of the Great Arteries: Resection of the Infundibular Septum Diminishes Recurrent Left Ventricular Outflow Tract Obstruction Risk

Background The Rastelli procedure is the standard surgical treatment of d-transposition of great arteries (d-TGA), ventricular septal defect (VSD), and pulmonary stenosis. Late morbidity is significant due to recurrent left ventricular outflow obstruction (LVOTO), early conduit obstruction, and arrhythmias, with troublesome late mortality. To avoid recurrent LVOTO, we routinely enlarge the VSD and resect the infundibular septum before LV baffling to the aorta. We examined the efficacy of this approach in mitigating recurrent LVOTO risk. Methods Late echocardiographic and time-related clinical results of patients undergoing the Rastelli procedure were examined. Demographics and operative variables affecting outcomes were analyzed. Results The Rastelli cohort comprised 36 patients with d-TGA, VSD, and pulmonary stenosis. Median age at operation was 2.4 years (range, 0.3 to 8.3 years). Pulmonary stenosis was present in 31 and atresia in 5. Twenty-two patients had undergone a previous aortopulmonary shunt, and 6 had an atrial septectomy. No operative or late deaths occurred. Time-related freedom from permanent pacemaker implantation, recurrent LVOTO on echocardiogram, and conduit replacement at 10 years was 82%, 100%, and 49%, respectively. Systolic function was normal in all but 3 patients and 92% were in New York Heart Association functional class I and II. None of the patients had late arrhythmias or required heart transplantation. Conclusions Early and midterm survival after the Rastelli procedure is satisfactory. Aggressive resection of the infundibular septum to enlarge the VSD has mitigated the risk of LVOTO recurrence. Late conduit obstruction remains an important source of morbidity and frequently requires reintervention.

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] Assessment of the Level of Sedation in Children After Cardiac Surgery

Background There is no reference method for the evaluation of the level of sedation in children after cardiac surgery. The utility of the bispectral index and middle latency auditory evoked potentials has not been evaluated. Methods The bispectral index, middle latency auditory evoked potentials, Ramsay scale, and COMFORT scale were used for assessment of the level of sedation in critically ill children after cardiac surgery and other surgical procedures. The measurements with these four methods were recorded simultaneously once a day for five days. The level of sedation was categorized in two levels, moderate or deep, according to the values obtained from each method. Correlations and agreements among the methods and the best bispectral index and middle latency auditory evoked potential values that discriminated between the two levels of sedation were calculated. Results Thirty-two children after cardiac surgery were included in the study, together with eighteen children after other surgical procedures who formed the control group. In each group, the correlation and agreement between the four methods varied between moderate and good. In the cardiac surgery patients, when the level of sedation was determined by the Ramsay scale, the best values of bispectral index and middle latency auditory evoked potentials that discriminated between the two levels of sedation were 63.5 and 37.5, respectively, and these values predicted the level of sedation correctly in 84.4% of the patients with each method. Conclusions Bispectral index and middle latency auditory evoked potentials could be useful to assess the level of sedation in children after cardiac surgery.

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] Interinstitutional Comparison of Risk-Adjusted Mortality and Length of Stay in Congenital Heart Surgery

Background Risk Adjustment for Congenital Heart Surgery (RACHS) and basic Aristotle scores (BCS) have been shown to correlate with mortality and length of stay (LOS) after congenital heart surgery. Interinstitutional comparisons using these scores, as well as comprehensive Aristotle score (CCS), have not been demonstrated. Methods We recorded age, weight, RACHS, BCS, CCS, mortality, and LOS for 1,103 patients undergoing cardiac surgery between September 1, 2004, and June 1, 2007, at two institutions. We used binary logistic and multiple linear regressions to evaluate determinants of mortality and LOS, respectively, the C statistic to compare the predictive power of the three scoring systems for mortality, the odds ratio to compare the two institutions, and regression coefficients to compare scoring systems and institutions for LOS. Results Raw mortality was 2.9% at both institutions. Final logistic regression models contained only CCS. Odds ratios for death at institutions 1 and 2 were 1.25 and 1.26, respectively (not significant). C statistics for RACHS, BCS, and CCS were 0.73, 0.63, and 0.81, respectively (p = 0.01 for CCS versus BCS; p = 0.02 for CCS versus RACHS). Final regression model for LOS retained age, RACHS, and CCS (R2 = 0.44). The RACHS regression coefficient was greater for institution 2. Conclusions The CCS tends to have more predictive power than RACHS and BCS for mortality. The LOS is moderately correlated with CCS, RACHS, and age together, but the model is a poor predictor of individual LOS. The LOS for RACHS category 6 cases differed between the institutions. This study suggests methods that can be used to compare institutions in a risk-adjusted manner.

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] Invited Commentary

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] One Thousand Repeat Sternotomies for Congenital Cardiac Surgery: Risk Factors for Reentry Injury

Background Reentry injury is a risk associated with repeat sternotomy for cardiac surgery. This risk has been well defined for adults, but there is less information available for patients with congenital heart disease. The goal of this review was to identify the incidence, risk factors, and outcomes for reentry injury in patients with congenital heart disease. Methods Eight hundred two patients with congenital heart disease had 1,000 consecutive repeat sternotomies between August 2000 and November 2007. Records were reviewed for demographics, history, operative techniques, and outcomes. Univariate risk factors for reentry injury and operative mortality were assessed. Results Median age and weight were 2.1 years (range, 0.1 to 34.6 years) and 11 kg (range, 2.5 to 123 kg). There were 639 second, 287 third, and 74 fourth or higher sternotomies. There were 13 reentry injuries (1.3%) involving right ventricle–pulmonary artery conduits (n = 4), aorta or aortic conduits (n = 3), right ventricular outflow tract patches or pseudoaneurysms (n = 3), and others (n = 3). Risk factors for injury were presence of a right ventricle–pulmonary artery conduit (6 of 115 with conduit [5.2%] versus 7 of 885 without [0.8%]; p < 0.001) and sternotomy number (relative risk, 2.28; p < 0.001). Reentry injury was associated with longer procedure times (median, 420 minutes with injury versus 248 without; p < 0.001). Operative mortality occurred in 18 patients and was associated with sternotomy number and procedure time (p < 0.001), but not reentry injury (p = 0.2). Conclusions Risk of reentry injury during repeat sternotomy for congenital heart disease is low. Increasing sternotomy number and the presence of a right ventricle–pulmonary artery conduit are risk factors for reentry injury. However, reentry injury is not associated with increased risk of operative mortality.

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] Selective Cerebral Perfusion: Real-Time Evidence of Brain Oxygen and Energy Metabolism Preservation

Background Deep hypothermic circulatory arrest (DHCA) is commonly used for complex cardiac operations in children, often with selective cerebral perfusion (SCP). Little data exist concerning the real-time effects of DHCA with or without SCP on cerebral metabolism. Our objective was to better define these effects, focusing on brain oxygenation and energy metabolism. Methods Piglets undergoing cardiopulmonary bypass were assigned to either 60 minutes of DHCA at 18°C (n = 9) or DHCA with SCP at 18°C (n = 8), using pH-stat management. SCP was administered at 10 mL/kg/min. A cerebral microdialysis catheter was implanted into the cortex for monitoring of cellular ischemia and energy stores. Cerebral oxygen tension and intracranial pressure also were monitored. After DHCA with or without SCP, animals were recovered for 4 hours off cardiopulmonary bypass. Results With SCP, brain oxygen tension was preserved in contrast to DHCA alone (p < 0.01). Deep hypothermic circulatory arrest was associated with marked elevations of lactate (p < 0.01), glycerol (p < 0.01), and the lactate to pyruvate ratio (p < 0.001), as well as profound depletion of the energy substrates glucose (p < 0.001) and pyruvate (p < 0.001). These changes persisted well into recovery. With SCP, no significant cerebral microdialysis changes were observed. A strong correlation was demonstrated between cerebral oxygen levels and cerebral microdialysis markers (p < 0.001). Conclusions Selective cerebral perfusion preserves cerebral oxygenation and attenuates derangements in cerebral metabolism associated with DHCA. Cerebral microdialysis provides real-time metabolic feedback that correlates with changes in brain tissue oxygenation. This model enables further study and refinement of strategies aiming to limit brain injury in children requiring complex cardiac operations.

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] An Artificial Right Ventricle for Failing Fontan: In Vitro and Computational Study

Background The aim of this study is to develop a destination low-pressure artificial right ventricle (ARV) to correct the impaired hemodynamics in the failing Fontan circulation. Methods An in vitro model circuit of the Fontan circulation was created to reproduce the hemodynamics of the failing Fontan and test ARV performance under various central venous pressures (CVP) and flows. A novel geometry of the extracardiac conduit was designed to adapt to the need of the pump. The ARV was a low-pressure axial flow pump designed to produce a low suction inflow pressure and moderate outflow increase. With the power off, the passive forward gradient across the propeller is 2 mm Hg at 4.5 L/min. The ARV would require 4 watts at a rotation of 5000 rpm. To examine the shear loading on the red blood cells, virtual particles were injected upstream of the ARV inducer and tracked by computerized modeling. Results The effect of the ARV on the failing Fontan was studied at various CVP pressures and flows, and under constant values of lung resistances and left atrial pressure set respectively to 2.5 Woods Units and 7 mm Hg. The CVP pressures decreased respectively from 25, 22.5, 20, 17.5, 15, and 10 mm Hg to a minimal value of 2 to 5 mm Hg with a pump speed varying from 1700 to 4500 rpm. The pulmonary artery pressures increased moderately between 12.5 and 25 mm Hg at 4500 rpm. Cardiac output at 4500 rpm was increased by an average gain of 2 L/min. The average blood damage index was 0.92%, far below the 5% value considered to cause hemolysis. The flow structure produced by the pump was suitable. Conclusions The performance of this novel low-pressure ARV was satisfactory, showing good decrease of CVP pressures, a moderate increase of pulmonary artery pressures, adequate increase of cardiac output, and minimal hemolysis. The use of a mock Fontan model circuit facilitates device prototyping and design to a far greater extent than can be achieved using animal studies, and is an essential first step for rapid design iteration of a novel ARV device. The next steps are the manufacturing of this device, including an electromagnetic engine, a regulatory system, and further testing the device in a survival animal experiment.

[ORIGINAL ARTICLES: PEDIATRIC CARDIAC] Invited Commentary

[HAWLEY H. SEILER RESIDENT AWARD PAPER] Analysis of Cervical Esophagogastric Anastomotic Leaks After Transhiatal Esophagectomy: Risk Factors, Presentation, and Detection

Background Transhiatal esophagectomy with cervical esophagogastric anastomosis is a common approach in patients requiring esophagectomy. Factors for developing cervical esophagogastric anastomosis leaks (CEGAL), their presentation, and the value of a routine postoperative screening barium swallow in detecting CEGALs and other complications were analyzed. Methods This single-institution retrospective study used medical records and an esophagectomy database to assess results in 1,133 patients who underwent transhiatal esophagectomy and a cervical esophagogastric anastomosis, 241 for benign disease and 892 for cancer, between January 1996 and December 2006. Results Esophagectomy patients who experienced CEGALs included 127 (14.2%) with cancer and 23 (9.5%) with benign disease. Logistic regression analysis identified increasing number of preoperative comorbidities (p < 0.001), active smoking history (p = 0.044), and postoperative arrhythmia (p = 0.002) as risk factors for CEGALs, and a side-to-side stapled cervical esophagogastric anastomosis compared with a manually sewn one as protective (p < 0.001). For cancer patients, higher pathologic stage disease (p = 0.050) was a risk factor for CEGALs. For patients with benign disease, a higher number of prior esophagogastric operations (p = 0.007) is a risk factor for CEGALs. Of the 90.7% of CEGALs that occurred on or before postoperative day 10, cervical wound drainage (63.3%) was the most common presenting symptom. Screening barium swallow identified postoperative complications and influenced outcome in 39 patients (3.8%). Conclusions Higher number of preoperative comorbidities, advanced pathologic stage, postoperative arrhythmia, an increased number of prior esophagogastric surgeries, and active smoking history are risk factors for developing CEGAL, and a side-to-side stapled cervical esophagogastric anastomosis is protective. Screening barium swallow identifies few postoperative complications, but provides quality control.

[ORIGINAL ARTICLES: GENERAL THORACIC] Predictors of Long-Term Survival After Resection of Esophageal Carcinoma With Nonregional Nodal Metastases

Background Patients with esophageal carcinoma and celiac, cervical, or other nonregional nodal metastases generally have a poor prognosis after surgical resection. Factors predicting long-term survival are unclear. The goal of this study was to analyze factors predicting long-term survival in this subset of patients. Methods We conducted a retrospective review of a prospective database over a 20-year period to identify patients with resected esophageal carcinoma with nonregional lymph node metastases. Medical records were reviewed and risk factors were analyzed. Results Sixty-seven patients underwent esophagectomy for M1a or M1b disease from 1987 to 2007. Esophagectomy was transthoracic in 62 patients and transhiatal in 5. The median number of lymph nodes harvested was 36. Sites of nodal metastases were the following: recurrent nodal chain in 42 patients, celiac in 20, both recurrent and celiac in 4, and paratracheal in 1. Median length of follow-up was 66 months. The 5-year overall survival for the entire cohort was 25%. The 5-year overall survival was significantly higher with earlier T-status, (pathologic tumor [pT]1/T2 vs pT3/T4; 62% vs 15%, p = 0.006). Thirteen patients who had nonregional nodal metastases without involvement of regional nodes (pN0) had a significant improvement in 5-year survival (67% vs 15%; p < 0.001). Patients with squamous cell carcinomas had higher 5-year survival compared with those with adenocarcinomas (42% vs 14%; p = 0.009). Patients treated with induction chemotherapy had prolonged 5-year survival (41%, p = 0.06) compared with those treated with adjuvant chemotherapy (11%) or no therapy (20%). Multivariate analysis demonstrated that chemotherapy treatment, squamous cell type, and early T stage (pT1/T2) are significant positive predictors of survival. Conclusions Surgical resection for patients with esophageal cancer associated with nonregional nodal metastases results in 25% survival at five years. Squamous histology, earlier T status, and perioperative chemotherapy are independent positive predictors of long-term survival.

[ORIGINAL ARTICLES: GENERAL THORACIC] Esophageal Stent Placement for the Treatment of Spontaneous Esophageal Perforations

Background Traditional therapy for spontaneous esophageal perforation has most often been urgent operative repair. This investigation summarizes the treatment of spontaneous perforations of the esophagus using an occlusive removable esophageal stent. Methods During a 48-month period, patients with a spontaneous esophageal perforation were offered endoluminal esophageal stent placement as the initial therapy instead of operation. Excluded were patients with an esophageal malignancy or a chronic esophageal fistula. Silicone-coated stents were placed endoscopically using general anesthesia and fluoroscopy. Adequate drainage of infected areas was achieved. Leak occlusion was confirmed by esophagram. Results Twenty-one esophageal stents were placed in 19 patients for spontaneous esophageal perforations. Associated endoscopic (n = 19) or surgical procedures (n = 9) were also simultaneously performed. Leak occlusion occurred in 17 patients (89%). Fifteen patients (79%) were able to initiate oral nutrition within 72 hours of stent placement. Two patients (10%) with a perforation extending across the gastroesophageal junction experienced a continued leak after stent placement and underwent operative repair. Stent migration in 4 patients (21%) required repositioning (n = 4) or replacement (n = 2). Stents were removed at a mean of 20 ± 15 days after placement. Hospital length of stay was 9 ± 12 days. Conclusions Endoluminal esophageal stent placement is an effective treatment of most spontaneous esophageal perforations. These stents result in rapid leak occlusion, provide the opportunity for early oral nutrition, may significantly reduce hospital length of stay, are removable, and avoid the potential morbidities of operative repair.

[ORIGINAL ARTICLES: GENERAL THORACIC] Invited Commentary

[ORIGINAL ARTICLES: GENERAL THORACIC] Intrathoracic Lymph Node Metastases From Extrathoracic Carcinoma: The Place for Surgery

Background Intrathoracic hilar or mediastinal lymph node metastases (HMLNMs) of extrathoracic carcinomas are infrequent. Their treatment strategy is not established and their prognosis poorly known. We reviewed the place of surgical intervention in their management. Methods Among 565 patients with mediastinal lymph node enlargement, 37 had a history of extrathoracic carcinoma. The enlargement consisted in HMLNMs in 26 (15 men, 11 women), with a mean age of 57.6 (range 19-78) years. Surgical procedures were reviewed. Results Diagnostic procedures, comprising mediastinoscopy in 9, anterior mediastinotomy in 2, and video-assisted thoracic surgery (VATS) in 4, were performed mainly because of unresectability due to diffuse and bilateral HMLNMs. Cancer location was breast in 6, kidney or prostate in 2 each, and bladder, rectum, testis, melanoma, and larynx in 1 each. Median survival was 21 months. Resection was performed in 11 patients, comprising posterolateral thoracotomy in 6, muscle sparing thoracotomy in 2, and VATS in 3. Seventeen involved LN stations were removed; of these, primary were kidney in 3, testis or thyroid in 2 each, and larynx, nasopharynx, and intestinum in 1 each. Five-year survival was 41.6% (median, 45 months). Conclusions HMLNMs of extrathoracic carcinoma may be isolated, probably in the context of a particular lymphatic mode of spread. Our experience demonstrates that operation is mainly diagnostic but resection may safely achieve local control of the disease and deserves being advocated in patients with isolated and resectable HMLNMs.

[ORIGINAL ARTICLES: GENERAL THORACIC] Invited Commentary

[ORIGINAL ARTICLES: GENERAL THORACIC] Surgical Resection of Pulmonary Malignant Tumors After Living Donor Liver Transplantation

Background The aim of this study is to report on patients who developed tumor recurrence of the lung or de novo pulmonary malignancies after living donor liver transplantation (LDLT) and to show the benefit of a surgical resection for these pulmonary malignant tumors. Methods A total 246 patients who underwent LDLT were investigated. Results Pulmonary malignant tumors after LDLT were observed in 12 (4.9%) of 246 patients studied. These patients included 9 tumor recurrences and 3 de novo malignancies. The frequency of pulmonary recurrence was 9.4% (9 of 96 patients) and that of pulmonary de novo malignancies including 2 primary lung cancer and 1 mucosa-associated lymphoid tissue (MALT) lymphoma, was 1.2% (3 of 246 patients). Four of 9 recurrent patients could undergo surgical resections and the survival range in patients who received surgery was 17 to 56 months with a mean of 36 months after LDLT; on the other hand, the survival range in patients that could not undergo a surgical resection was 4 to 26 months with a mean of 18 months. Among the de novo malignancies, only the MALT lymphoma patient could undergo a surgical resection. Repeated surgical resections of pulmonary malignant tumors could be performed in 3 patients and all these patients have been long-term survivors. Conclusions These results suggest a surgical resection of pulmonary malignancies including tumor recurrences or de novo malignancies after LDLT is a feasible procedure and may prolong survival in selected patients, even under immunosuppressive conditions.

[ORIGINAL ARTICLES: GENERAL THORACIC] Transdiaphragmatic Harvesting of the Omentum Through Thoracotomy for Bronchial Stump Reinforcement

Background We present our technique of omental flap transposition performed through a thoracotomy for bronchial stump protection, and employed over 11 years. Methods Between February 1997 and January 2008, the transdiaphragmatic harvesting of the omentum was performed, using an original technique through a thoracotomy approach, in 45 patients. Forty-three patients (29 male, 14 female), considered at high risk for bronchial dehiscence, simultaneously underwent pneumonectomy and 2 patients (1 male, 1 female) were treated for an early postpneumonectomy bronchopleural fistula by the standard thoracotomy route. The omental flap was mobilized through a radial incision in the diaphragm avoiding an additional laparotomy. The only contraindication for this technique was a previous abdominal intervention. Duration of follow-up ranged between 6 and 102 months (median, 46). Results There were no complications related to the omentoplasty. Major complications related to pneumonectomy occurred in 4 patients (9%). Perioperative mortality rate was 2.1% (1 of 45). The non-life threatening complication rate was 11.1% (5 of 45). Postoperative hospital stay ranged between 5 and 21 days (median, 8.3) in the 43 patients undergoing prophylactic omentoplasty and was 11 and 14 days, respectively, in the 2 patients receiving omentoplasty after bronchial dehiscence. No neoplastic recurrence on the bronchial stump or late fistula occurred during follow-up. Conclusions This technique of omental flap transposition for bronchial stump coverage through a thoracotomy is an effective method for the prevention and treatment of postpneumonectomy bronchopleural fistula. The amount of omentum obtained by this technique is appropriate for bronchial reinforcement but not for filling the pleural cavity. This procedure can be performed safely through thoracotomy access avoiding an additional laparotomy.

[ORIGINAL ARTICLES: GENERAL THORACIC] The Safe Transition from Open to Thoracoscopic Lobectomy: A 5-Year Experience

Background We hypothesized that established thoracic surgeons without formal minimally invasive training can learn thoracoscopic lobectomy without compromising patient safety or outcome. Methods Data were retrospectively collected on patients who underwent pulmonary lobectomy at a single health system between August 1, 2003, and April 1, 2008. Age, sex, pulmonary function tests, preoperative and postoperative stages, pathologic diagnosis, anatomic resection, extent of lymph node sampling, surgical technique and duration, complications, blood loss, transfusion requirement, chest tube duration, length of hospital stay, 30-day readmission, and mortality rate were examined. The percentage of patients who underwent thoracoscopic lobectomy and their outcomes were then compared among three chronologic cohorts. Results Three hundred sixty-four patients underwent pulmonary lobectomy (239 open; 99 thoracoscopic; 26 thoracoscopic converted to open). Baseline characteristics, staging, pathologic diagnosis, and anatomic resections were similar in the early, middle, and late cohorts. The percentage of thoracoscopic lobectomies increased from 16% to 49%, whereas open lobectomy decreased from 81% to 42% (p < 0.0001). The complication rate remained constant with the exception of air leaks lasting more than 7 days (9% versus 10% versus 2%; p = 0.02). Hospital length of stay (6 versus 5 versus 4 days; p < 0.0001) and chest tube duration (4 versus 3 versus 3 days; p < 0.0001) decreased and operative duration increased as more thoracoscopic lobectomies were performed. Blood loss, transfusion requirement, 30-day readmission, and 1-year survival were not significantly different among chronologic cohorts. Conclusions Established thoracic surgeons can safely incorporate thoracoscopic lobectomy with no increase in morbidity or mortality.

[ORIGINAL ARTICLES: GENERAL THORACIC] Diagnostic Surgical Lung Biopsies for Suspected Interstitial Lung Diseases: A Retrospective Study

Background Current guidelines for interstitial lung disease support a surgical biopsy for optimal diagnosis and treatment, yet only a minority of patients undergo such biopsy. Our objectives were to address the properties of a surgical lung biopsy for suspected interstitial lung disease, the diagnostic yield of the procedure, and whether it resulted in changes in diagnosis and treatment. Methods A retrospective nationwide study including 73 patients (mean age, 57.3 years; 58% males) who underwent a surgical lung biopsy for suspected interstitial disease in Iceland between 1986 and 2007 was conducted. Patient records and histologic specimens were reviewed. Before the surgical biopsy a transbronchial or computed tomography–guided biopsy had been performed in two thirds of the patients. Results The complication rate for surgical lung biopsy was 16%, and 30-day operative mortality was 2.7%, both significantly higher in patients with preoperative respiratory failure. After the procedure, a definite histopathologic diagnosis was obtained in 81% of the patients. Usual interstitial pneumonia was the most common diagnosis (31%). The clinical diagnosis was changed for 73% of the patients, and in 53% of the patients the biopsy resulted in changes in treatment. Conclusions Surgical lung biopsy is a powerful tool for diagnosis of suspected interstitial lung disease. It results in a specific diagnosis for the majority of patients and changes in treatment for more than half. Operative morbidity and mortality are low but still significant, so patients should be carefully selected for the procedure, especially those with respiratory failure.

[ORIGINAL ARTICLES: GENERAL THORACIC] Invited Commentary

[ORIGINAL ARTICLES: GENERAL THORACIC] Operative Strategies for Pulmonary Artery Occlusion Secondary to Mediastinal Fibrosis

Background Fibrosing mediastinitis is a rare disease characterized by an excessive fibrotic reaction in the mediastinum, which may entrap mediastinal structures including the pulmonary arteries. Our objectives were to assess the surgical strategies and outcomes of repair of pulmonary artery occlusion attributable to mediastinal fibrosis. Methods With approval from the Mayo Clinic Institutional Review Board, we identified all patients with fibrosing mediastinitis who underwent an operation for relief of pulmonary artery obstruction between 1980 and 2008. Perioperative data were collected using medical records and late follow-up surveys. Results Operative procedures to bypass or reconstruct an obstructed pulmonary artery were performed in 5 patients. Patients' median age was 40 years (range, 27 to 51 years), and all patients were symptomatic and had right ventricular hypertension. In 3 patients, a double-outlet right ventricle was constructed using a valved conduit (porcine valved conduit, n = 1; aortic homograft, n = 2) from the right ventricle to the right pulmonary artery. Two patients required complete reconstruction of the pulmonary artery confluence using a pulmonary homograft in 1 patient and a hybrid technique of autologous pericardial reconstruction and intraoperative stenting in another patient. All patients had a reduction in right ventricular pressures after operation. One patient died perioperatively owing to respiratory failure; the remaining 4 patients were alive at a median follow-up of 7.4 years (range, 0.5 to 14.7 years). One patient required late balloon dilatation of the conduit and distal pulmonary arteries 10 years after initial operation, but the remaining conduits were widely patent at late follow-up. Late functional improvement was limited owing to other complications from mediastinal fibrosis or other comorbidities. Conclusions Treatment of pulmonary artery occlusion attributable to mediastinal fibrosis can be challenging. Successful operative strategies include both creation of a double-outlet right ventricle and complete reconstruction of the pulmonary artery confluence. Hybrid techniques of both conduit placement and stenting should also be considered for patients with occluded pulmonary arteries.

[ORIGINAL ARTICLES: GENERAL THORACIC] Bilateral Thoracoscopic T2 to T3 Sympathectomy Versus Botulinum Injection in Palmar Hyperhidrosis

Background Bilateral T2 to T3 thoracoscopic sympathectomy and injection of botulinum toxin-A are presently the most effective modalities in the treatment of primary palmar hyperhidrosis. In this study we evaluated comparative merits of the two therapies. Methods Patients suffering primary palmar hyperhidrosis were treated by either bilateral T2 to T3 thoracoscopic sympathectomy (n = 68) or by injection of botulinum toxin-A (n = 86). The groups were homogeneous for relevant demographic, physiologic, and clinical data. Quantification of sweat production was performed by Minor's iodine starch and glove tests. Subjective changes were assessed by quality of life questionnaires (Hyperhidrosis, Dermatology Life Quality Index, Short Form-36, Nottingham's Health Profile) and patient's satisfaction self-assessment. A cost comparison between groups was also carried out. Results No operative mortality or major morbidity was recorded in either group. Minor's test showed a more significant reduction in the surgical group: +94% versus +63% at 6 months and +94% versus +30% at 12 months. Compensatory sweating was significantly greater and long-lasting in the surgical group. All subjective tests improved rapidly and significantly in both groups. After 6 months, results mildly worsened in the surgical group and more significantly in the botulinum group. Patient's satisfaction was initially greater in the botulinum group (p = 0.03), but after 6 months it significantly reversed (p = 0.04). Surgical treatment cost approximately as much as four botulinum treatments. Conclusions Thoracoscopic sympathectomy is superior to botulinum toxin-A injection. The greater initial costs and discomfort are offset by a greater reduction in compensatory sweating.

[ORIGINAL ARTICLES: GENERAL THORACIC] Thoracic Duct Ligation for Persistent Chylothorax After Pediatric Cardiothoracic Surgery

Background There is considerable literature on incidence and medical management of postsurgical chylothorax in children but little is known about outcomes of thoracic duct ligation (TDL) for patients refractory to medical therapy. Methods A retrospective review of patients undergoing TDL after cardiothoracic surgery (1992 through 2007) was done. Data on demographics including cardiac morphology, characteristics of chylous drainage, medical management, and post-TDL course were collected. When available, imaging studies of the upper body venous drainage vessels were examined. Results Twenty patients (median age, 0.65 years; range, 0.03 to 11 years; weight, 7.0 kg; range, 2.6 to 30 kg) had a diagnosis of chylothorax made 8.5 days (range, 2 to 118 days) after initial operation. Median duration of pre-TDL medical management was 17.5 days (range, 7 to 69 days). Median drainage for 5 days preceding TDL was 34.5 mL · kg–1 · d–1 (range, 15 to 135 mL · kg–1 · d–1) with maximal output of 65 mL · kg–1 · d–1 (range, 30 to 200 mL · kg–1 · d–1). After TDL, there was a decrease in median drainage to 13 mL · kg–1 · d–1 (range, 4 to 160 mL · kg–1 · d–1; p = 0.003). Chest tubes were removed 8.5 days (range, 4 to 34 days) after TDL. There were 4 deaths (none attributed to TDL), 2 treatment failures (post-TDL chest tube drainage > 2 mL · kg–1 · d–1 > 14 days), and 2 recurrences (after initial chylothorax resolution and hospital discharge). Three patients had documented upper body venous thrombosis. Univariate analysis demonstrated thrombosis of upper body venous vessels (p = 0.02) and prolonged post-TDL chest tube drainage (p = 0.01) were risk factors for death, treatment failure, or chylothorax recurrence. Conclusions Thoracic duct ligation leads to a major reduction in chest tube drainage and prompt tube removal in most pediatric patients and should be considered early in refractory postoperative chylothorax. Patients with upper body venous thrombosis associated with chylothorax are at a high risk for failure of TDL and mortality.

[NEW TECHNOLOGY] The EmBlocker: Efficiency of a New Ultrasonic Embolic Protection Device Adjunctive to Heart Valve Surgery

Purpose Perioperative cerebral microemboli in cardiac surgery are associated with postoperative neurologic complications. The EmBlocker (Neurosonix Ltd, Rehovot, Israel), a newly developed device should be positioned against the ascending aorta, and it produces an ultrasonic force expected to divert microemboli away from the cerebral vasculature and reduce cerebral emboli. Description Twenty-one consecutive patients, undergoing a valve procedure, were enrolled into this nonrandomized pilot study. The EmBlocker (Neurosonix Ltd) was positioned in 11 consecutive patients and activated for 1 minute (1.5 W/cm2) during seven selected aortic manipulations and for 10 minutes (0.5 W/cm2) intermittently after cross-clamp removal. Transcranial Doppler-based quantification of microembolic signals was performed in all patients. Evaluation The use of the EmBlocker showed a significant overall reduction of the cerebral microembolic signals of 53%. Conclusions The use of the EmBlocker during valve surgeries is associated with a reduction of perioperative cerebral microembolic signals. This new technology holds the potential to lower the risk of postoperative neurologic complications.

[NEW TECHNOLOGY] An Experimental Study of Type I Endoleak Repair With a Suturing Device

Purpose An experimental study was done to investigate repair of type I endoleaks in thoracic aortic aneurysms using the T-Fix suturing device (Smith & Nephew Co, Ltd, London, United Kingdom). Description A saccular descending aortic aneurysm was made in 5 pigs experimentally. A stent graft was deployed to produce a proximal type I endoleak. Under fluoroscopy, the aorta was punctured with the spinal needle with the T-Fix plastic bar, and the plastic bar was deployed with a push rod. A sufficient number of T-Fix sutures were used until angiography revealed that the type I endoleak had disappeared. Evaluation No hemodynamic events occurred during the procedure. An average of 2.5 ± 0.6 T-Fix sutures were required to eliminate the endoleak. The experimental T-Fix repair was performed without any complications. A new method of repairing type I endoleaks for thoracic aortic aneurysms was successfully performed using the T-Fix system. Conclusions Although the T-Fix repair currently has some anatomic and clinical limitations, improvement of the device should lead to the increased use of this repair.

[CASE REPORTS] Iliac Arterial Intussusception From an Aortic Endoclamp Catheter

Minimally invasive cardiac surgical procedures are gaining widespread acceptance with the advent and development of the femoral route for cardiopulmonary bypass. Aortic endoclamps are widely used and are one of the most important parts of these surgical techniques. This report presents iliac arterial intussusception from an aortic endoclamp catheter, which is a very rare complication with this type of device. Preventative strategies are presented.

[CASE REPORTS] Subclinical Thrombosis of the Ascending Aorta: A Possible Paraneoplastic Syndrome

Thrombosis of the ascending aorta is a rare, potentially lethal complication. We report the case of a 56-year-old woman with a massive but subclinic thrombosis of the ascending aorta after two cycles of chemotherapy due to an epidermoid lung carcinoma stage T3 N2 M0. An emergent aortic thrombectomy was performed under deep hypothermic circulatory arrest. This thrombotic event occurred in an arterial vessel with high laminar flow, which is extremely uncommon and did not present any clinical manifestation.

[CASE REPORTS] A Modified Technique for Preventing Spinal Cord Ischemia During Type II Thoracoabdominal Aneurysm Repair

A 51-year-old man required replacement of the thoracoabdominal aorta due to a type II thoracoabdominal aortic aneurysm. We tailored and plicated the aortic aneurysm to make a closed tube. All of the intercostal arteries and lumbar arteries were reimplanted using a closed tube constructed with an aneurysmoplasty to the main aortic graft, using this tube to protect the spinal cord. The closed tube maintained blood flow to the intercostal and lumbar arteries, and no neurologic deficits developed.

[CASE REPORTS] Aortic Valve Vegetation Without Endocarditis

We present a 30-year-old man with an acute middle cerebral artery territory infarction. A transesophageal echocardiogram showed a large, highly mobile mass attached to the patient's aortic valve. We discuss the differential diagnosis of a cardiac mass that includes infection, tumor, and thrombus. A complete workup showed no evidence of systemic infection but did reveal the presence of antiphospholipid antibodies. The patient also had a history of a right lower extremity deep venous thrombosis. Anticoagulation therapy was started, and follow-up showed complete resolution of the aortic valve lesion. This case highlights that when a valvular vegetation is encountered in a clinical setting that does not suggest infectious endocarditis, the diagnosis of antiphospholipid antibody syndrome should be considered. This case and our review of the literature suggest that vegetations in antiphospholipid antibody syndrome, no matter how large and ominous in appearance, can be treated successfully with anticoagulation and vigilant observation.

[CASE REPORTS] Mitral Valve Repair by Leaflet Sliding and Annular Downsizing in Active Infective Endocarditis

We repaired a large defect in the posterior mitral leaflet after an extensive removal of infected tissue, using an extended leaflet sliding and annular downsizing with a small prosthetic ring in 2 patients with active endocarditis.

[CASE REPORTS] Successful Treatment of Heart Failure due to Acute Transplant Rejection With the Impella LP 5.0

Cardiogenic shock resulting from transplant rejection is a serious complication with high mortality and morbidity. Often resistant to maximal medical therapy, this condition frequently requires mechanical circulatory support until recovery or retransplantation. We present a 52-year-old patient with multiorgan failure secondary to acute graft rejection after orthotopic heart transplantation. Maximal medical therapy was not successful, and the patient was bridged to recovery with an Impella LP 5.0 (Abiomed Inc, Danvers, MA) left ventricular assist device (LVAD). The relative merits of this therapeutic approach are outlined and discussed. The patient was discharged 3 weeks after LVAD removal and remains clinically stable.

[CASE REPORTS] Idiopathic Pulmonary Artery Aneurysm Treated With Surgical Correction and Concomitant Coronary Artery Bypass Grafting

Idiopathic pulmonary artery aneurysm is a rare clinical entity, and therefore the natural course and clinical management are not well established. We present the case of an elderly woman with a symptomatic idiopathic pulmonary artery aneurysm who underwent surgical repair along with simultaneous coronary artery bypass grafting. With long-term follow-up presented in this report, we describe the safety and durability of surgical repair.

[CASE REPORTS] Surgical Repair of Anomalous Origin of the Left Coronary Artery Arising From the Left Pulmonary Artery

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly. We report an extremely uncommon variety of ALCAPA, in which the left coronary artery arose from the left pulmonary artery in a patient who presented with severe heart failure in early infancy. After direct reimplantation of the left coronary artery into the ascending aorta, the patient's cardiac function recovered successfully.

[CASE REPORTS] Hybrid Treatment of Superior Vena Cava Syndrome in a Child

A 10-year-old boy with a history of renal failure and hemodialysis by indwelling superior vena cava (SVC) catheters was diagnosed with SVC obstruction and clinically severe SVC syndrome. During attempted recanalization of the SVC in the cardiac catheterization laboratory, he suffered a perforation of his SVC with pericardial tamponade. After treatment of the perforation and relief of tamponade, he underwent a hybrid procedure to recanalize his SVC. A needle and then guidewire were passed directly from the right atrium through the SVC obstruction and were used to successfully dilate and stent the obstruction.

[CASE REPORTS] Surgical Treatment of Cardiac Pheochromocytoma: A Case Report

Primary cardiac pheochromocytoma is an extremely rare neoplasm. We report a 15-year-old girl who was presented with paroxysmal hypertension. An iodine-131 metaiodobenzylguanidine scintigraphy scanning showed a pheochromocytoma in her right atrial and ventricular wall. The tumor was subsequently confirmed by magnetic resonance imaging and coronary angiogram. This patient underwent a successful surgical resection of the tumor, a reconstruction of the atrial ventricular wall and right coronary artery bypass grafting. Her blood pressure remained normal thereafter. A follow-up coronary angiogram revealed a patent saphenous vein graft 4 months after the operation.

[CASE REPORTS] Idiopathic Pulmonary Vein Thrombosis: A Rare Cause of Massive Hemoptysis

The case history of an adult female with massive hemoptysis due to idiopathic left inferior pulmonary vein thrombosis necessitating lower lobectomy is presented with a review of the current literature.

[CASE REPORTS] Inadvertent Total Spinal Anesthesia After Intercostal Nerve Block Placement During Lung Resection

Intercostal nerve block is a recognized way of providing analgesia at thoracotomy. There is a rare association between intercostal nerve block and the complication of total spinal anesthesia. This may arise inadvertently by injection into a dural cuff extending outside the intervertebral foramen. We report our experience with a patient who sustained this life-threatening complication. The patient required postoperative ventilation until the neurologic deficits resolved. The operator must be aware that intercostal nerve block runs the rare but potentially fatal risk of total spinal block.

[CASE REPORTS] Managing Pulmonary Artery Catheter-Induced Pulmonary Hemorrhage by Bronchial Occlusion

A 76-year-old woman underwent mitral valve repair and coronary artery bypass grafting. Intrabronchial bleeding occurred after inflation of the balloon tip of the pulmonary artery catheter in the wedge position. A Forgaty catheter was introduced into the trachea parallel to the endotracheal tube and advanced under bronchoscopic vision into the intermediate bronchus. Tamponade of the bleeding was achieved by by filling the Forgaty balloon tip with saline. Weaning from extracorporeal circulation was uneventful. On the first postoperative day, the Forgaty catheter was removed and bronchial lavage of the middle and lower lobe was performed without any additional bleeding complication.

[CASE REPORTS] Severe Hypoxemia Due to Intrapulmonary Shunting Requiring Surgery for Bronchioloalveolar Carcinoma

Bronchioloalveolar carcinoma is a rare, but well-known disease that symptomatically worsens with intrapulmonary shunting and consequent hypoxemia. Surgical resection of the involved area offers relief from disabling hypoxemia and may improve survival. We present 3 patients with intrapulmonary shunting.

[CASE REPORTS] Novel Method to Repair Tracheal Defect by Pectoralis Major Myocutaneous Flap

Inflammatory myofibroblastic tumor is extremely uncommon in the trachea. Surgery is recommended when airway obstruction becomes evident. The surgical technique and material used for repairing a massive tracheal defeat is a challenge for the thoracic surgeon. We present a case of repair and reconstruction of a massive defect of the thoracic trachea and right mainstem bronchus with a pectoralis major myocutaneous flap after resection of an inflammatory myofibroblastic tumor. The myocutaneous flap provides reliable material to repair and reconstruct a massive central airway defect. This novel surgical procedure may present new strategies for the treatment of extensive defects of the trachea.

[CASE REPORTS] Extralobar Sequestration in Anterior Mediastinum With Pericardial Agenesis

We report a very rare case of extralobar sequestration and pericardial agenesis in a 22-year-old man. A computed tomographic (CT) scan demonstrated an anterior mediastinal mass. No aberrant artery was preoperatively identified. The patient underwent surgery with an impression of thymoma. An extralobar sequestration receiving its blood supply from the left pulmonary artery, accompanied with pericardial agenesis, was noted at the time of operation. The anterior mediastinum is an unusual site for extralobar sequestions. It is recommended to include extralobar sequestration in the differential diagnosis of anterior mediastinal masses, even if the aberrant artery is not recognized on the computed tomographic scan.

[CASE REPORTS] Sclerosing Mediastinitis Mimicking Anterior Mediastinal Tumor

A 54-year-old asymptomatic man presented with an anterior mediastinal mass discovered on chest roentgenogram. Chest computed tomography revealed a noncalcified round mass in the mediastinum. A white solid mass, 5-cm in diameter, had arisen from the pericardial adipose tissue with multiple small nodular lesions mimicking mediastinal tumor with pleural dissemination. Postoperative pathologic examination confirmed a diagnosis of sclerosing mediastinitis. Details of the clinical and radiographic feature are presented.

[CASE REPORTS] Limb-Threatening Ischemia Secondary to a Congenital Acromioclavicular Remnant

Upper extremity vascular compromise from thoracic outlet syndrome is rare and is usually the result of a "cervical rib," anterior scalene muscle abnormality, or clavicular trauma. We report a case of acute axillary artery thrombosis secondary to a congenital acromioclavicular remnant in a 40-year-old woman.

[CASE REPORTS] A Case of Primary Synovial Sarcoma of the Thorax With a Variant SYT-SSX1 Fusion Transcript

With synovial sarcoma (SS) of the thorax, being exceptionally rare, its definite diagnosis is difficult, and the optimal therapy has not yet been established. An examination of our patient, a 64-year-old man with SS using a chest roentgenogram showed a large mass with homogeneous density in the lower two-thirds of the left hemithorax. A computed tomographic image of the chest revealed a large, heterogeneous, enhanced mass in the left hemithorax. Histologic examination of the resected tumor tissues suggested monophasic fibrous SS. A fragment of the SYT-SSX1 fusion transcript, which was smaller than the control, was amplified with reverse transcriptase polymerase chain reaction. Direct sequence analyses revealed the fusion between exon 9 of SYT and exon 5 of SSX1 instead of fusion between exon 10 of SYT and exon 6 of SSX1, which is found in most cases. Although the biological and clinical significance of this rare variant is not yet known, our data present another example of the usefulness of molecular analyses for making a definite diagnosis of SS in unusual sites.

[CASE REPORTS] Bronchial Angiolipoma

Angiolipoma occurs preferentially in the extremities and trunk. We present a patient with involvement of the bronchus and describe successful localized resection of the lesion.

[IMAGES IN CARDIOTHORACIC SURGERY] Left Circumflex to Bronchial Artery Fistula

[IMAGES IN CARDIOTHORACIC SURGERY] Harlequin Syndrome

[IMAGES IN CARDIOTHORACIC SURGERY] An Unusual Location of a Persistent Vein of Marshall

[IMAGES IN CARDIOTHORACIC SURGERY] Hemothorax Caused by a Solitary Costal Exostosis

[HOW TO DO IT] Combined Open Proximal and Stent-Graft Distal Repair for Distal Arch Aneurysms: An Alternative to Total Debranching

We present herein a novel, combined, simultaneous open proximal and stent-graft distal repair for complex distal aortic arch aneurysms involving the descending aorta. In the first surgical step, the transverse arch is opened during selective antegrade cerebral perfusion, and a Dacron graft (DuPont, Wilmington, DE) is positioned down the descending aorta in an elephant trunk-like fashion with its proximal free margin sutured circumferentially to the aorta just distal to the left subclavian or left common carotid artery. With the graft serving as the new proximal landing zone, subsequent endovascular repair is performed antegrade during rewarming through the ascending aorta.

[HOW TO DO IT] Preventing Blood Loss During Application of the HEARTSTRING Proximal Seal System

The HEARTSTRING Proximal Seal System (Guidant Corp, Santa Clara, CA) is used to avoid aortic clamping while the proximal anastomoses are sewn. To protect surgeons from spurting blood while the device is used, we use a see through plastic sheet to cover the area being operated on. This modified technique is applied whenever the system is used and allows the safe use of the device even in high-risk patients with hepatitis or human immunodeficiency virus.

[HOW TO DO IT] Ventricular Septal Defect Closure in Taussig-Bing Heart: The "Pulmonic Rule"

Accurate ventricular septal defect patch sizing and tailoring remain challenging in many surgical procedures. Surgical exposure frequently limits complete visualization of the ventricular septal defect. Moreover, examination of the heart cavity under cardioplegic arrest may lead to skewed appreciation of the ventricular septal defect caliber and shape. Here we describe a simple and safe surgical tip to predict the size and shape of the ventricular septal defect patch in Taussig-Bing malformation before starting extracorporeal circulation. The patch should be circular with a diameter equal to the under pressure, proximal, pulmonary artery diameter.

[HOW TO DO IT] A Cervical Approach to Investigating Pleural Disease

We describe a modern cervical approach to the pleural space using video-mediastinoscopy, which allows both mediastinoscopy and pleuroscopy to be performed simultaneously. Mediastinoscopy is carried out with lymph node sampling, and the pleura are exposed and the pleural cavity is entered under direct vision. A thoracoscope is admitted into the pleural space, where lavage, biopsy, and pleurodesis can be carried out. Fifteen patients underwent mediastino-pleuroscopy to investigate pleural effusion and stage malignancy. One patient underwent bilateral pleuroscopy through a single cervical approach. There were no mortalities and the mean postoperative stay was 2.4 days. Mediastino-pleuroscopy is safe, uses a small incision, is well tolerated, and allows access to both pleura and the mediastinum.

[REVIEWS] Thrombin in Myocardial Ischemia-Reperfusion During Cardiac Surgery

Thrombin is a multifunctional protease with procoagulant, pro-inflammatory, and pro-apoptotic effects. Thrombin has direct potentially adverse effects on the endothelium and on cardiomyocytes, which are independent of its procoagulant effects, and it has emerged as a possible mediator of ischemia-reperfusion injury. Several lines of experimental evidence specifically implicate thrombin to be involved in myocardial ischemia-reperfusion injury. Cardiopulmonary bypass increases thrombin generation progressively, but reperfusion after myocardial ischemia induces an additional distinct and rapid increase in thrombin generation. Clinical studies have shown that thrombin formation during cardiac surgery, especially during myocardial reperfusion, is involved with myocardial damage and impaired hemodynamic recovery. Therefore, strategies to improve thrombin control during cardiopulmonary bypass might be beneficial.

[REVIEWS] Postoperative Inflammatory Reaction and Atrial Fibrillation: Simple Correlation or Causation?

Atrial fibrillation after cardiac operations is a source of morbidity and resource consumption. This systematic review of literature analyzes the current evidence on its pathophysiologic link with the systemic inflammatory response elicited by surgery and cardiopulmonary bypass. Meta-analysis of randomized studies on the effect of off-pump surgery or statin pre-treatment on the incidence of atrial fibrillation was performed. The concept of inflammation as a pathophysiologic determinant of postoperative atrial fibrillation is supported by the literature. The modulation of post-cardiopulmonary bypass systemic inflammation will probably represent a major therapeutic goal in the prevention of postoperative atrial fibrillation. Statins seem to be the most promising pharmacological strategy.

[REPORT FROM THE STS BOARD OF DIRECTORS] Forty-Fifth Annual Meeting, The Society of Thoracic Surgeons

[OUR SURGICAL HERITAGE] Bhagavant Kalke and His Pioneering Work on the Bi-Leaflet Heart Valve Prosthesis

[CORRESPONDENCE] Mitral Repair Is Not Superior to Replacement in Elderly Patients

[CORRESPONDENCE] Reply

[CORRESPONDENCE] Long-Term Follow-Up of the Frozen Elephant Trunk Technique for Distal Aortic Arch Aneurysm

[CORRESPONDENCE] Postoperative Delirium in Cardiac Operations: Microembolic Load is an Important Factor

[CORRESPONDENCE] Reply

[CORRESPONDENCE] Is a 1-cm Margin From Major Vessels Adequate for Radiofrequency Ablation of Pulmonary Neoplasms?

[CORRESPONDENCE] Paracorporeal Artificial Lung Circuit as a Possibility for Bridge to Lung Transplantation

[CORRESPONDENCE] Reply

[CORRESPONDENCE] Vascular Tumors of the Sternum

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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

Airway Bypass Treatment of Severe Homogeneous Emphysema: Taking Advantage of Collateral Ventilation

Treatment of Heterogeneous Emphysema Using the Spiration IBV Valves

Endobronchial Treatment of Emphysema with One-Way Valves

Update on Donor Assessment, Resuscitation, and Acceptance Criteria, Including Novel Techniques—Non–Heart-Beating Donor Lung Retrieval and Ex Vivo Donor Lung Perfusion

Update on Lung Transplantation for Emphysema

Index

Contents

Forthcoming Issues

Preface

Surgery of the Mediastinum: Historical Notes

Utility of Positron Emission Tomography in the Mediastinum: Moving Beyond Lung and Esophageal Cancer Staging

Genetic Markers of Mediastinal Tumors

Diagnostic Strategies for Mediastinal Tumors and Cysts

Infections of the Mediastinum

Mediastinal Tumors and Cysts in the Pediatric Population

Multimodality Treatment of Germ Cell Tumors of the Mediastinum

Multimodality Treatment of Thymic Tumors

Surgical Approaches to the Thymus in Patients with Myasthenia Gravis

Vascular Lesions of the Mediastinum

Combined Cervicothoracic Approaches for Complex Mediastinal Masses

Intraoperative Strategy in Patients with Extended Involvement of Mediastinal Structures

The Role of Surgery in Recurrent Thymic Tumors

Advances in Radiotherapy for Tumors Involving the Mediastinum

Index

Contents

Forthcoming Issues

Preface

Defining N2 Disease in Non–Small Cell Lung Cancer

Detection of Occult N2 Disease with Molecular Techniques

Radiographic Staging of Mediastinal Lymph Nodes in Non–Small Cell Lung Cancer Patients

Minimally Invasive Staging of N2 Disease: Endobronchial Ultrasound/Transesophageal Endoscopic Ultrasound, Mediastinoscopy, and Thoracoscopy

Intraoperative Staging and Surgical Management of Stage IIIA/N2 Non–Small Cell Lung Cancer

Definitive Chemoradiotherapy for Non–Small Cell Lung Cancer with N2 Disease

Neoadjuvant Therapy for Resectable Non–Small Cell Lung Cancer with Mediastinal Lymph Node Involvement

Restaging After Neo-Adjuvant Chemoradiotherapy for N2 Non–Small Cell Lung Cancer

Adjuvant Therapy for Non–Small Cell Lung Cancer with Mediastinal Nodal Involvement

Management Algorithms for Stage IIIA Non–Small Cell Lung Cancer with N2 Node Involvement

[Editorial - Pulmonary] The use of sealants in modern thoracic surgery: a survey

[Work in progress report - Cardiac general] Transpulmonary versus continuous thermodilution cardiac output after valvular and coronary artery surgery

[Work in progress report - Cardiopulmonary bypass] Video-assisted right atrial surgery with a single two-stage femoral venous cannula

[Institutional report - Thoracic non-oncologic] Comparing bipolar electrothermal device and endostapler in endoscopic lung wedge resection

[Institutional report - Experimental] A randomised controlled trial comparing Mediwrap(R) heat retention and forced air warming for maintaining normothermia in thoracic surgery

[Institutional report - Experimental] Single high-dose intramyocardial administration of erythropoietin promotes early intracardiac proliferation, proves safety and restores cardiac performance after myocardial infarction in rats

[Institutional report - Cardiac general] Effect of melatonin in the prevention of postoperative pericardial adhesion formation

[Institutional report - Valves] Minimally invasive mitral valve surgery through right thoracotomy in patients with patent coronary artery bypass grafts

[Institutional report - Congenital] Brain natriuretic peptide is removed by continuous veno-venous hemofiltration in pediatric patients

[eComment] eComment: Brain natriuretic peptide is removed by continuous veno-venous hemofiltration in pediatric patients

[Institutional report - Cardiopulmonary bypass] Comparison of minimally invasive closed circuit versus standard extracorporeal circulation for aortic valve replacement: a randomized study

[Institutional report - Thoracic oncologic] Chromosomal deletion in patients with malignant pleural mesothelioma

What's New in Spine Surgery - Journal of Bone and Joint Surgery (subscription)