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All Thoracic Surgery jobs for Mon Feb 6 2012

Thoracic Surgery jobs in "Chief Of Thoracic Oncology - Brand New Academic Cancer Center" - OK

Chief of Thoracic Oncology Clinical prestige, ahead-of-the-curve technology and an unrivaled team environment await you at The University of Oklahoma Medical Center. This summer, The Peggy

Thoracic Surgery jobs in "Thoracic Surgery employment opportunity located in New York" - NY

Job 9571978-0003 New Thoracic Surgeon need located in New York. The facility is seeking a Thoracic Surgeon to assist with one weekend of call coverage per month--ongoing. The ideal candidate will be board

Thoracic Surgery jobs in "Illinois medical center seeks Thoracic Surgeon" - IL

Job 9553272-0083 This Illinois-based medical group is currently seeking a Thoracic Surgeon to assist with 15 days of locum tenens coverage per month. Locums will cover clinic, evening call, and trauma

Thoracic Surgery jobs in "Thoracic Surgeon needed in South Carolina" - SC

Job 9622041-0111 South Carolina-based medical center is currently in need of a Thoracic Surgeon to assist with locum tenens coverage needs. The facility is seeking a provider that can offer weekend availability.

Thoracic Surgery jobs in "Thoracic Surgeon needed in Arkansas" - AR

Job 9509573-0033 Patient population is 100% adult. The facility is willing to license qualified candidates. Assistance with hospital privileges will be provided. Interested candidates should contact a

Thoracic Surgery jobs in "Thoracic Surgeon needed in Ohio" - OH

Job 9560909-0040 New locum tenens Thoracic Surgery need located in Ohio. The facility is seeking a Thoracic Surgeon to assist with locum tenens coverage needs. The ideal candidate will be boarded and

Thoracic Surgery jobs in "Great Location" - NC

Wonderful Locums Physician Assistant with Cardiac Surgery Experience need in NC, ASAP-Ongoing. This is a great opportunity! Onyx MD is physician owned and operated...we understand physicians. While

Thoracic Surgery jobs in "Great Location" - NC

Wonderful Locums Physician Assistant with Cardiac Surgery Experience need in NC, ASAP-Ongoing. This is a great opportunity! Onyx MD is physician owned and operated...we understand physicians. While

Thoracic Surgery jobs in "Crystal River" - FL

65% Vascular and 35% Thoracic. No Cardio. Join existing practice of 15 years "Seven Rivers Vascular". Call 1:3 . Relocation Allowance, Commitment Bonus, Marketing

Thoracic Surgery jobs in "Oklahoma City" - OK

Chief of Thoracic Oncology Clinical prestige, ahead-of-the-curve technology and an unrivaled team environment await you at The University of Oklahoma Medical Center. This summer, The Peggy and Charles

Thoracic Surgery jobs in "Portsmouth" - NH

Thoracic Surgery-New Hampshire-Physician Needed-Seeking a Thoracic Surgeon in Southern NH -- Seeking a Thoracic Surgeon in Southern NH . The hospital provides comprehensive

Thoracic Surgery jobs in "Stamford" - CT

Seeking a Thoracic Surgeon for 300+ bed, non- profit Hospital in Fairfield County Connecticut. Prefers General Thoracic, though will consider Cardiothoracic as well. Affiliated with

Thoracic Surgery jobs in "Stamford" - CT

Thoracic Surgery-Connecticut---less than one hour to NYC, Hospital is a 300 plus-bed, not-for-profit provider of comprehensive healthcare services in lower Fairfield County . Affiliated with New York

Thoracic Surgery jobs in "Gadsden" - AL

Seeking a cardiothoracic or cardiovascular surgeon to join an established practice. Practice will have emphasis on vascular procedures along with thoracic need. Flexible call rotation with

Thoracic Surgery jobs in "Lebanon" - NH

Surgery-New Hampshire-Physician Needed-Academic General Thoracic Surgeon needed in central NH Seeking a BC/BE General Thoracic Surgeon in central New Hampshire. The candidate's clinical

Thoracic Surgery jobs in "Augusta" - ME

Surgery-Maine-Physician Needed-Thoracic Surgeon Needed in Central Maine Seeking a BC/be Thoracic Surgeon in Central Maine. Join one other Board Certified Thoracic Surgeon to

Covidien Says Tissue Device Linked to Three Deaths in Chest-Cavity Surgery - Bloomberg

Covidien Says Tissue Device Linked to Three Deaths in Chest-Cavity SurgeryBloombergCovidien Plc (COV) said a tissue reinforcement product used in medical staplers has been connected with three patient deaths after use in thoracic surgery. The Duet TRS single-use cartridges, which contain a material that is applied along with staples, ...Covidien Contraindicates the Use of Duet TRS(TM) for Thoracic Surgery ...MarketWatch (press release)Deaths prompt Covidien to hold surgical stapler inventoryBoston Business JournalFatalities Prompt Recall of Staple CartridgeMedscapeall 26 news articles »

New Clinical Data for Symphony Presented in Late Breaking Clinical Trials ... - MarketWatch (press release)

New Clinical Data for Symphony Presented in Late Breaking Clinical Trials ...MarketWatch (press release)... was presented by Renzo Cecere, MD, FRCSC, FACS, Associate Professor of Surgery at McGill University, during the late-breaking clinical trials session at the Society of Thoracic Surgeons (STS) 2012 Annual Meeting in Fort Lauderdale, Florida.and more »

'Heartmate II' to make footfall in Kolkata - Deccan Chronicle

Deccan Chronicle'Heartmate II' to make footfall in KolkataDeccan ChronicleThe expensive device, sought all over the world for its efficient functioning, will be demonstrated at the 58th annual meeting of the Indian Association of Cardiovascular and Thoracic Surgeons beginning here from February eight.and more »

Preoperative left atrial dysfunction and risk of postoperative atrial ... - The Journal of Thoracic and Cardiovascular Surgery

Preoperative left atrial dysfunction and risk of postoperative atrial ...The Journal of Thoracic and Cardiovascular SurgeryObjective: Postoperative atrial fibrillation complicating general thoracic surgery increases morbidity and stroke risk. We aimed to determine whether preoperative atrial dysfunction or other echocardiographic markers are associated with postoperative ...

Former thoracic surgeon brings wealth of experience to position - Virgin Islands Daily News

Virgin Islands Daily NewsFormer thoracic surgeon brings wealth of experience to positionVirgin Islands Daily NewsShe was chief resident for general surgery her final year there before moving on to George Washington University Medical Center in Washington, DC, where she completed her two-year thoracic surgery residency. Her professional experience includes 18 ...and more »

Video Assisted Thoracic Surgery (VATS) for Stage 1 Lung Cancer - About - News & Issues

Video Assisted Thoracic Surgery (VATS) for Stage 1 Lung CancerAbout - News & IssuesBy Lynne Eldridge MD, About.com Guide January 22, 2012 Surgery for early stage lung cancer offers the chance for a cure, yet removing a lobe of a lung is a very major surgery. Because of this, newer techniques have been developed with the hope of ...

Rare heart surgery saves life of infant - Indian Express

Rare heart surgery saves life of infantIndian ExpressA baby boy, born to Monica and Amit Singh, suffering from a complication that resulted in the underdevelopment of his heart, has been operated upon and given a pacemaker by Dr Harinder Singh Bedi, head of Cardiovascular and Thoracic Surgery at ...

Brumbies edgy about Coleman's injury - Sydney Morning Herald

Sydney Morning HeraldBrumbies edgy about Coleman's injurySydney Morning HeraldA thoracic specialist will determine how severe the damage is and whether he requires surgery. It's a huge blow to the young Brumbies just 18 days out from the start of the season. The coach, Jake White, was grooming Coleman as a possible option at ...Stern test for Brumby's sternumThe Canberra Timesall 5 news articles »

Two Prominent Thoracic Surgeons Join White Plains Hospital - openPR (press release)

Two Prominent Thoracic Surgeons Join White Plains HospitalopenPR (press release)(openPR) - White Plains Hospital has welcomed two new Thoracic Surgeons to its group of integrated physician practices as of January 1st. Todd S. Weiser, MD and Cynthia S. Chin, MD have joined White Plains Hospital Physician Associates, a division of ...

Business digest: Naples hospital one of best in nation - The News-Press

Business digest: Naples hospital one of best in nationThe News-PressThe hospital was recognized recently as being among the top 10 percent of cardiac surgery destinations by the Society for Thoracic Surgery. The Beasley Broadcast Group Inc., a Naples-based radio broadcaster, Friday reported net income of about $3.4 ...

Calibrated cusp sizers to facilitate aortic valve repair: development and clinical application

Based on the natural mathematical relationships between the components of the human tri-leaflet aortic valve, new calibrated cusp sizers were developed in order to facilitate aortic valve assessment in the operating room and enhance the chance for a perfect restoration of aortic valve competence. These sizers were used clinically to guide the implementation of established aortic valve repair techniques in 10 consecutive patients with severe aortic valve regurgitation. Valve repair was successful in all cases, and at a median follow-up was 5.5 months, aortic valve function remained stable, with aortic regurgitation ≤1+ in every patient and no significant gradient across the aortic valves. This preliminary clinical experience indicates that the calibrated cusp sizers can provide reliable insight into the mechanism of aortic valve insufficiency, and can guide aortic valve repair techniques successfully. We hope that the simplicity and reproducibility of this method would assist in its dissemination and further increase the percentage of aortic valves that are repaired when compared with current practice.

A simple method for occlusion of both venae cavae in total cardiopulmonary bypass for robotic surgery

We describe a novel surgical technique for occlusion of the superior and inferior venae cavae which allows opening of the right atrium safely during robotic cardiac surgery.

Biology of colorectal pulmonary metastasis: implications for surgical resection

In colorectal cancer, little high grade evidence for cure, life extension, disease modification or palliation achieved by pulmonary metastasectomy exists. This has prompted the pulmonary metastasectomy in colorectal cancer (PulMiCC) trial. Reappraisal of the biological facts on colorectal metastasis may, however, shed light on an alternative avenue of clinical management. Early onset of metastasis, short doubling time and a short disease-free interval are all associated with poor clinical outcomes. Selecting who will be cured (i.e. no occult metastasis) remains the holy grail for pulmonary metastasectomy surgery. Serial CT scans can be utilized to calculate the tumour doubling time by volumetric analysis. Knowing the doubling time and size of the largest metastasis, which by definition is the first cell that has successfully spread from the primary site, the time of initial metastasis can be predicted. More importantly, using the doubling time, calculating the time interval from the primary surgery to the point at which all pulmonary metastases are visible should be possible. Perhaps watchful waiting, with interval CT scanning, followed by pulmonary metastasectomy should be utilized, rather than clinical opinion or randomization in a trial based upon first presentation.

Folding mitral valvuloplasty without posterior leaflet resection for calcified mitral annulus

Mitral valve annular calcification has long been a challenge in repairing posterior mitral valve prolapse. Folding valvuloplasty of the posterior leaflet without resection provides a means of circumventing common procedural complications. This report demonstrates the success of folding valvuloplasty without resection in the treatment of mitral valve prolapse and severe annular calcification.

Post-operative acute exacerbation of pulmonary fibrosis in lung cancer patients undergoing lung resection

Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) in lung cancer patients is a critical factor in post-operative mortality. The cause of AE development is unknown and AE may occur in patients without the diagnosis of IPF. We have conducted a retrospective study of consecutive patients who underwent lung cancer surgery since January 2004. Sixty-two patients with fibrous findings in preoperative high-resolution computed tomography were enrolled in the present study and clinicopathological factors were analysed. AE was observed in 6 of 62 patients. The frequency of AE according to the type of fibrous changes classification was 1/7 in the usual interstitial pneumonia (UIP) pattern, 1/16 in the cellular non-specific interstitial pneumonia (NSIP) pattern, 4/25 in the fibrotic NSIP pattern and 0/14 in the unclassified or focal fibrous changes pattern. Preoperative Krebs von den Lungen-6 (KL-6) was higher in patients with AE than in those without AE. In patients who underwent partial resection, AE did not develop even with high KL-6 levels. In conclusion, in patients with both the UIP and the NSIP patterns, AE development is possible. In patients with a high risk of AE, such as those with high KL-6 values, limited surgery may be an option to prevent AE development.

The effect of season of operation on the survival of patients with resected non-small cell lung cancer

Stage has been defined as the major prognostic factor in resected non-small cell lung cancer (NSCLC). However, there is some evidence that indicates season of operation could play a role in the survival of patients. Between January 1995 and June 2008, 698 (621 men and 77 women) patients who had undergone pulmonary resection for NSCLC were evaluated. Patients were analysed according to surgical–pathological stages and month of the year in which they were operated. Vitamin D receptor (VDR) polymorphism was also analysed in 62 patients. The median survival time in all patients was 60 ± 6 months (95% confidence interval (CI): 44–81 months). The survival of patients who underwent resection in winter was statistically significantly shorter than those operated in summer (P = 0.03). When patients were analysed according to T, N and season, resection time of the year was calculated to be an independent determinant of survival (P = 0.04). A VDR genotype was also associated with better prognosis (P = 0.04). Season of the operation, VDR polymorphism and N status seemed to have independent effects on survival of operated NSCLC patients.

Pulmonary metastasectomy: a multivariate analysis of 440 patients undergoing complete resection

Surgical resection is currently a standard approach for isolated lung metastases from different primary tumours. The aim of the present analysis is to evaluate the outcome of patients submitted to complete resection of pulmonary metastases and to determine prognostic factors for long-term survival. A group of 440 consecutive patients previously diagnosed with primary malignant solid tumours and submitted to complete surgical resection of lung nodules with suspected or diagnosed metastatic lesion were retrospectively reviewed. The average follow-up time was 43.2 months (range: 0–192) and the 60-month O.S. was 43.7%. Univariate analysis: patients with adenocarcinoma presented the highest 5-year survival rates (53.4%, P = 0.0001); DFI >36 months (P < 0.0001), number of nodules on CT scan (P = 0.0052), number of malignant nodules resected (P = 0.0252) and the size of the largest resected nodule (P < 0.0001) were also significant. Multivariate analysis: number of malignant nodules resected (P = 0.01), size of the largest nodule resected (P = 0.001), DFI >36 months (P < 0.001) and histology of the primary tumour (P = 0.017) had significant impact on survival. The benefit of such an aggressive surgical approach is only limited to selected subgroups of patients. The decision to consider a patient for resection of metastastic disease should include factors beyond the feasibility of complete removal.

Risk is not our business: safety of thoracic surgery in patients using antiplatelet therapy

American Heart Association recommendations have changed preoperative management of patients with antiplatelet therapy (APT). We assessed safety and outcomes of surgery in patients who were receiving APT. A prospective study of patients operated on while receiving APT was matched with those with no APT (ratio 1:4), using the propensity score method. Logistic regression analysis was used to identify covariates among imbalanced baseline patient variables. Both 2 test and Fisher's test were used to calculate the probability value for the comparison of dichotomous variables. Between January 2008 and December 2010, 38 patients who received APT at the time of surgery were matched with 141 patients who had not received APT. APT indications were a history of myocardial infarction, coronary artery by-pass graft and/or valve replacement (19), coronary artery stent (11) and severe peripheral vascular disease (8). None of the patients required re-operation for bleeding. Two patients received blood transfusions. The amount of chest tube drainage was not statistically significantly different. There were no statistically significant differences between the outcomes for the operative time, length of hospital stay, estimated blood loss or morbidity. The results show that thoracic surgical procedures can safely be performed in patients receiving APT at the time of surgery, with no increased risk of bleeding or morbidity and no differences in the operative time and the length of hospital stay.

Surgical treatment of stage IV non-small cell lung cancer

Most stage IV non-small-cell lung cancer (NSCLC) patients are not amenable to curative treatment. The purpose of this study was to analyse our initial experience with an aggressive surgical strategy for stage IV NSCLC, and to define which patients can benefit from this treatment. Forty-six stage IV NSCLC patients who underwent surgical resection of both primary lung cancer and metastatic sites from April 1989 to December 2010 were included in this study. The record of each patient was reviewed for age, gender, pN status, sites of metastasis, histology, surgical procedure and duration of survival. There were 13 females and 33 males. Their median age was 62.0 years (range, 44–82 years). The overall 5-year survival rate was 23.3% (median, 20.0 months), and the disease-free survival rate was 15.8% at 5 years (median, 16.1 months). Patients with the pN2 status had a significantly worse survival than patients with a pN0 or pN1 status (8.6 versus 33.1%, P = 0.0497). According to a multivariate Cox proportional hazards analysis, no independent predictor of survival was identified. The results of our study suggest that surgical treatment can extend the survival in stage IV NSCLC patients if the patients can tolerate surgery.

Can early aortic root surgery prevent further aortic dissection in Marfan syndrome?

We reviewed 50 patients with Marfan syndrome who underwent surgery for aortic root pathologies comprising a root aneurysm without (n = 25; group A) and with (n = 25; group B) dissection. Aortic root repair included Bentall (n = 37) and valve-sparing (n = 13) procedures. Hospital mortality was 4.0%. Twenty-two patients required 36 repeat surgeries on the distal aorta. The main indication for re-intervention was the dilation of the false lumen. In group A, the distal aorta was stable for up to 7 years, but new dissection developed in 5 (33.3%) of the 15 patients who were followed up for >7 years after the root repair. Actuarial survival including operative mortality was 88.1 and 65.0% at 10 and 20 years, respectively; groups A and B did not significantly differ. Rates of freedom from all-cause death, new dissection or repeated aortic surgery were 60.1, 44.5 and 26.0% at 5, 10 and 15 years, respectively. Group A was significantly better than group B. Prophylactic aortic root repair apparently reduces the likelihood of overall adverse events, but it cannot guarantee the prevention of further aortic dissection. A multidisciplinary approach is needed for patients with Marfan syndrome.

Impact of incomplete surgical revascularization on survival

Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization, where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible safe revascularization.

Does the use of extended criteria donors influence early and long-term results of lung transplantation?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether the presence of extended criteria donors influences the early and long-term results in patients referred for lung transplantation. Of the 30 papers found using a report search, 14 presented the best evidence to answer the clinical question. The authors, journal, date, country of publication, study type, group studied, relevant outcomes and results of these papers are given. In total, we recorded 10 retrospective studies that considered all the donor criteria for comparing marginal donors (MDs) and standard donors. On the one hand, six of them showed no difference between the two groups in terms of early and long-term results. On the other hand, four studies demonstrated a negative impact of MDs on various early outcomes (mortality, primary graft dysfunction, duration of mechanical ventilation, length of stay in intensive care unit), whereas no significant negative influence on survival has ever been described when screening MD results. More precisely, when analysing the role of individual factors of marginality, as done in two of the 14 studies, a significant negative impact was observed for a low level of PaO2 at the time of harvesting, positive bronchoscopy and smoking history. More specifically, the first two criteria have been validated by several authors, both in multicentre and cohort studies. Finally, the importance of avoiding the donation of the lung from an MD to a high-risk recipient emerged, whereas the association with single or bilateral transplants remains more controversial. Hence, current evidence suggests that there are no contraindications—given the absence of negative impact on survival—for the use of MDs for the transplant of a proposed standard receiver. However, given the low level of evidence of published studies, caution is necessary in order to avoid organ shortage, despite these encouraging results.

Impact of off-pump to on-pump conversion rate on post-operative results in patients undergoing off-pump coronary artery bypass

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In patients undergoing off-pump coronary artery bypass (OPCAB) surgery, does the off-pump to on-pump conversion rate have an impact on post-operative results? Altogether more than 420 papers were found using the reported search, of which 14 randomized controlled trials (RCTs) represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated and ordered according to the sample size. In the 14 RCTs reviewed, the off-pump to on-pump conversion rate incidence ranged from 0 to 13.3%. The most frequent causes of conversion were haemodynamic instability and intramyocardial-coronary target. A low conversion rate (<2%) was reported by five studies. Three of them did not show any difference in terms of mortality between the OPCAB and on-pump groups, one showed better survival of the OPCAB group at 5 years, and one reported better early survival of the OPCAB group. Three of these trials describe a high OPCAB experience and reported that patients undergoing OPCAB had a shorter post-operative stay and lower morbidity compared with patients undergoing on-pump coronary artery bypass grafting. Five RCTs showed a high conversion rate (>9%), and among them, one reported lower morbidity of the OPCAB patients, three were not able to show any benefit in terms of morbidity of the OPCAB, and one reported worse survival and patency graft rate of the OPCAB group. Four RCTs reported conversion rates ranging from 3.7 to 7.0%, describing a wide spectrum of results. We conclude that RCTs with a high off-pump to on-pump conversion rate were often associated with a lower experience in OPCAB of the surgeons participating in the trials. These studies were also mostly unable to show any benefit in terms of mortality or morbidity of OPCAB over the on-pump strategy. On the contrary, a low conversion rate is mostly reported by RCTs with a high structured experience in OPCAB. These trials were mostly able to show a benefit, in terms of morbidity and survival, of the OPCAB over the on-pump strategy.

Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was ‘is the addition of ketamine to morphine patient-controlled analgesia (PCA) following thoracic surgery superior to morphine alone’. Altogether 201 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This consisted of one systematic review of PCA morphine with ketamine (PCA-MK) trials, one meta-analysis of PCA-MK trials, four randomized controlled trials of PCA-MK, one meta-analysis of trials using a variety of peri-operative ketamine regimes and two cohort studies of PCA-MK. Main outcomes measured included pain score rated on visual analogue scale, morphine consumption and incidence of psychotomimetic side effects/hallucination. Two papers reported the measurements of respiratory function. This evidence shows that adding ketamine to morphine PCA is safe, with a reported incidence of hallucination requiring intervention of 2.9%, and a meta-analysis finding an incidence of all central nervous system side effects of 18% compared with 15% with morphine alone, P = 0.31, RR 1.27 with 95% CI (0.8–2.01). All randomized controlled trials of its use following thoracic surgery found no hallucination or psychological side effect. All five studies in thoracic surgery (n = 243) found reduced morphine requirements with PCA-MK. Pain scores were significantly lower in PCA-MK patients in thoracic surgery papers, with one paper additionally reporting increased patient satisfaction. However, no significant improvement was found in a meta-analysis of five papers studying PCA-MK in a variety of surgical settings. Both papers reporting respiratory outcomes found improved oxygen saturations and PaCO2 levels in PCA-MK patients following thoracic surgery. We conclude that adding low-dose ketamine to morphine PCA is safe and post-thoracotomy may provide better pain control than PCA with morphine alone (PCA-MO), with reduced morphine consumption and possible improvement in respiratory function. These studies thus support the routine use of PCA-MK instead of PCA-MO to improve post-thoracotomy pain control.

Washout after lobectomy: is water more effective than normal saline in preventing local recurrence?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: ‘is water washout more effective than normal saline washout after lobectomy in preventing local recurrence?’ Altogether more than 48 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Tumour cell ‘spillage’ after cancer resection is linked to a worse prognosis, so washout to minimize contamination is an established surgical technique. While the mechanical effects of lavage are well validated, the differential cytocidal effects of water versus saline as irrigation fluids are not. There are currently no studies addressing this issue in the thoracic surgery setting, after lung cancer lobectomy. However, the majority of relevant papers describe the use of basic in vitro methods and animal models to produce data that can conceivably be extrapolated to the clinical question in hand. The number of studies is small, and some have technical limitations. While two of the better-designed experiments suggest that water exerts a superior cytocidal effect on tumour cells, data from other studies are somewhat unimpressive, with two studies reporting that water washout controls tumour growth to a lesser extent than saline. This, together with the complete paucity of clinical trials on the subject, leads us to conclude that water is unlikely to represent a superior irrigation fluid in lung cancer patients after lobectomy.

What are the differences in outcomes between right-sided active infective endocarditis with and without left-sided infection?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with isolated right-sided infective endocarditis (RSE) is the outcome of surgical management the same as in patients with or without left-sided involvement? Altogether, 419 papers were found using the reported search, six of which represented the best evidence to answer the clinical question. Two studies point towards better outcomes with isolated RSE. In one paper, mortality was significantly lower in isolated RSE patients (P = 0.0093) for the duration of the follow-up time (median 488 patient-years). Two studies reported early mortality (<30 days) for RSE patients at 3.6 and 3.8%, respectively. Combined right- and left-sided endocarditis (RLSE) patients were found to have a poorer pre-operative clinical presentation than isolated RSE patients with a greater requirement for inotropic support (P < 0.006) and the likelihood of an emergency operation (P < 0.001). They had a poorer intra-operative course with a higher incidence of cardiac abscess formation (P < 0.001). One study suggested that there is no significant difference in in-hospital and long-term mortality between intravenous drug abuse (IVDA) patients and non-IVDA patients. Left-heart involvement in the IVDA group was 61.5%. This was in-line with the published literature, demonstrating a rise in RLSE in IVDA compared with non-IVDA patients. Three articles looking at isolated left-sided endocarditis (LSE) gave mortality rates in the surgical group to be 27.1, 27.8 and 38%, respectively. In one study, the LSE mortality was not different for native vs. prosthetic valve infection (OR 0.65, 95% CI 0.23–1.87). After propensity matching and adjusting for hazards, the complication rate in the LSE group was higher and this translated to a higher mortality rate. We conclude from the literature that outcomes are more favourable with lower early and late mortality for isolated RSE patients over pure LSE or combined RLSE.

What is the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device?

A best evidence topic was written according to a structured protocol. The question addressed was what the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device (LVAD) is. A total of 373 papers were found, of which 11 represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Eight retrospective and two prospective studies, including one randomized controlled trial (RCT), were identified. Although highly variable, the prophylactic antibiotic protocols employed in these studies generally favour the use of vancomycin, a cephalosporin, beta-lactam and quinolone, with the option of additional fluconazole and mupirocin. However, the lack of standardized definitions for infection, and variations in the choice, timing and duration of prophylactic antibiotics complicates the interpretation of reported infection rates. Driveline and pocket infections comprised the majority of infectious complications, and were principally attributed to Gram-positive organisms, such as Staphylococcus, as well as Pseudomonas species. We conclude that a beta-lactam be used for primary prophylaxis, with vancomycin where the risk of MRSA is high. Topical mupirocin and an anti-fungal are also recommended. Prophylaxis should commence prior to device insertion, and be continued into the peri- and post-operative period. Large-scale RCTs are necessary to assess the impact of different antibiotic regimens on infection within LVAD recipients.

Extracorporeal membrane oxygenation support for abdominal aortic aneurysms surgery in high-risk patients

Surgical treatment of an abdominal aortic aneurysm in patients with a heart disease is risky. Aortic cross-clamping is featured by important consequences on cardiac, renal and gastrointestinal functions. Endovascular aortic repair is considered to be the gold standard in patients with severe comorbidities. However, in the case of unsuccessful endovascular treatment, surgery can be reconsidered with the use of extracorporeal membrane oxygenation, which seems to be a new tool for the management of cardiac and gastrointestinal events ensuring better post-operative outcomes.

Endovascular aortic repair of patent ductus arteriosus in an adult patient

We describe the case of a large patent ductus arteriosus in a 52-year old man, which was deemed unsuitable for coil occlusion or Amplatzer duct occluder. His ductus was successfully closed using Talent prostheses (Medtronic AVE, Santa Rosa, CA, USA). The postoperative course was uneventful.

Ruptured aneurysm of replaced left hepatic artery as a cause of haemorrhagic shock: a challenge of diagnosis and treatment

An isolated, spontaneous, ruptured aneurysm of the replaced left hepatic artery (LHA) arising from the left gastric artery, in a 72-year-old female, leading to haemorrhagic shock treated by surgical ligation is reported. To our best knowledge, this is the second case report of a ruptured hepatic artery aneurysm in this location. A thorough knowledge of hepatic arterial anatomy and variations, and prompt diagnosis and urgent surgical intervention are necessary in such a potentially lethal condition.

Syphilitic aneurysm of the ascending aorta

Syphilitic aortic aneurysm is a rare occurrence in the antibiotic era, making the diagnose assumption even more infrequent. Nonetheless, this pathology can appear and should be suspected in patients with aortic aneurysm. We report a case of a 57-year old patient who presents with neurosyphilis and, in the following study, a large ascending aorta aneurysm is identified. The authors discuss the diagnostic challenge, the epidemiologic concerns, surgical indication and treatment and subsequent follow-up.

Early bioprosthetic valve failure caused by preserved native mitral valve leaflets

The importance of preservation of subvalvular apparatus and valve-ventricular continuity during mitral valve replacement (MVR) has been suggested for many years. The chordal-sparing MVR has been shown to be superior to the standard MVR with chordal resection in terms of improved left ventricular function and has been considered to be a safe procedure. However, we encounter a rare case requiring early reoperation for bioprosthetic valve failure caused by preserved leaflets after chordal-sparing MVR.

Intrathoracic gossypiboma causing intractable cough

A 45-year old woman presented with a 5-month history of coughing, eight months after surgery for post-tubercular fibrosis with bronchiectasis. Upon computerized tomography (CT) scanning, a sponge-like structure was seen in the pneumonectomy cavity near the stump of the right main bronchus. Bronchoscopic examination revealed a whitish mass blocking the right main bronchial stump which, upon attempted retrieval, yielded long threads of cotton fibres from a retained surgical gauze. The gossypiboma was removed surgically and the patient became symptom-free. Although rare after thoracic surgery, gossypibomas need to be considered in symptoms following surgery.

Acute lower limb ischaemia due to delayed upstream migration of an iliac stent

We report a case of acute limb ischaemia due to unusual upstream stent migration into the aorta 2 years after successful kissing stenting. Angiography showed a misplacement of both common iliac stent into the aorta, upstream migration with a fracture on the left external iliac stent into the iliac common artery, occlusion of the left iliac and femoral artery, dilatation of aortic bifurcation and stent separation on the right side. The patient underwent a successful axillo-bifemoral bypass graft. Vessel wall remodelling due to overestimation of stent size, aortic turbulence and rebound effect may explain this complication.

Fluorine-18-fluorodeoxyglucose uptake in a benign oesophageal leiomyoma: a potential pitfall in diagnosis

Positron-emission tomography scans (PET) with fluorine-18-fluorodeoxyglucose (18F- FDG) are usually negative in leiomyomas. Two patients underwent a PET that showed an increased 18F- FDG uptake of the distal oesophagus suggestive for malignancy. Both patients were operated on and histologic examination revealed a benign leiomyoma in both cases. We conclude that oesophageal leiomyomas are a potential cause of a false-positive PET. A high level of caution is needed in these diagnostically challenging cases to prevent unnecessary surgical procedures.

An Unusual First Presentation of Ebstein's Anomaly in a 72-Year-Old Patient [CASE REPORTS]

We report the unusual case of a 72-year-old woman with a primary presentation of right heart failure in the setting of recently diagnosed Ebstein's anomaly with concomitant atrial fibrillation (AF). The patient had New York Heart Association (NYHA) class III dyspnea for 12 months, with refractory right heart failure prior to undergoing surgical management in the form of a tricuspid annuloplasty ring and plication of the atrialized ventricle. The patient had an uneventful postoperative recovery and enjoyed an improvement in her exercise tolerance (NYHA class I) with minimal echocardiographic evidence of tricuspid regurgitation (TR) at the latest follow-up.

Aneurysmal Aorto-Right Ventricular Tunnel [CASE REPORTS]

A successful closure of an aneurysmal aorto-right ventricular tunnel (ARVT) in a 16-year-old male patient is reported here. An attempt at device closure had failed in this patient. Diagnosis was confirmed by Doppler echocardiography, 3-dimensional computed tomography, and cardiac catheterization. Surgical closure with a Dacron patch (W.L. Gore & Associates, Flagstaff, AZ) at the aortic end and direct closure at the ventricular end was done successfully with the patient under mild hypothermia. The postoperative echocardiogram showed a competent aortic valve with a closed ARVT.

Iatrogenic Atrial Septal Defect and Aortoatrial Fistula in a Patient With Endovascular Prosthesis in the Inferior Vena Cava [CASE REPORTS]

Percutaneous procedures and endovascular prostheses are becoming increasingly frequent, replacing classic interventions, and new complications are now appearing. We report the case of a liver transplant patient with a stenosis in the anastomosis of the suprahepatic veins to inferior vena cava, treated by self-expanding prosthesis, who developed an aorto–right atrial fistula and an atrial septal defect. Open heart surgery was performed to correct the defects. Transthoracic echocardiogram 1 year later revealed no evidence of residual shunt.

Primitive Neuroectodermal Tumor of the Heart [CASE REPORTS]

We present a case of primitive neuroectodermal tumor of the left atrium with involvement of the coronary sinus. The initial presentation was of cardiac tamponade resulting from the size of the tumor. There was no evidence of tumor elsewhere, and after complete resection and without adjuvant chemotherapy the patient is well at 2-year follow-up. There has been no evidence of tumor recurrence. This is a rare reported case of resection of a cardiac primitive neuroectodermal tumor without adjuvant chemotherapy. Other cases in the literature have been treated by orthoptic transplantation and resection with chemotherapy.

Three-Dimensional Printing of Models for Preoperative Planning and Simulation of Transcatheter Valve Replacement [CASE REPORTS]

In this study, we show the use of three-dimensional printing models for preoperative planning of transcatheter valve replacement in a patient with an extreme porcelain aorta. A 70-year-old man with severe aortic stenosis and a porcelain aorta was referred to our center for transcatheter aortic valve replacement. Unfortunately, the patient died after the procedure because of a potential ischemic event. Therefore, we decided to fabricate three-dimensional models to evaluate the potential effects of these constructs for previous surgical planning and simulation of the transcatheter valve replacement.

Intrathymic Primary Intrathoracic Goiter in a Patient With Breast Malignancy [CASE REPORTS]

We report a rare case of an intrathymic primary intrathoracic goiter. The patient with newly diagnosed breast carcinoma was also known to have a distinct large anterior mediastinal mass. This was removed via a median sternotomy, after a thorascopic biopsy had been performed in the past but a diagnosis had not been reached. A discussion relating to the extremely rare occurrence of intrathymic ectopic thyroid tissue and the surgical treatment of primary intrathoracic goiters is included.

Segmentectomy Simulation Using a Virtual Three-Dimensional Safety Margin [CASE REPORTS]

Three-dimensional computed tomography angiography (3D-CTA) is valuable for preoperative simulations for lung cancer. However, when using 3D-CTA alone, it is difficult to identify tumor safety margins, especially for a segmentectomy. We report 2 cases of primary lung cancer for which we performed segmentectomy based on preoperative simulations by 3D-CTA with virtual 3D safety margins. We found this technique easy to use for simulations and useful for safely performing segmentectomy for small tumors in lung cancer.

Voluminous Atrial Septal Aneurysm May Mask a Large Double Atrial Septal Defect [IMAGES IN CARDIOTHORACIC SURGERY]

Role of Prolene Mesh in Late Postpneumonectomy Empyema: Esophageal Pleural Fistula [IMAGES IN CARDIOTHORACIC SURGERY]

Femoral Cannulation With Long Arterial Cannula in Aortic Dissection [HOW TO DO IT]

The optimal cannulation site in repair of DeBakey type I aortic dissection is controversial, and malperfusion during cardiopulmonary bypass is facilitated by retrograde flow. We propose the use of a long arterial cannula through the femoral artery to achieve a proximal antegrade perfusion. The tip of the cannula is placed in the true lumen of the distal aortic arch through the common femoral artery (Seldinger technique and transesophageal echography guidance). In 9 patients, there was one case of operative mortality (cardiac death), and no cases of perioperative stroke, bowel ischemia, severe renal failure, or local complications. Proximal perfusion can achieved rapidly and through an easily accessible site.

The American Board of Thoracic Surgery: Update [EDITORIALS]

Improved Survival but Marginal Allograft Function in Patients Treated With Extracorporeal Membrane Oxygenation After Lung Transplantation [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Previous reports demonstrate that 1-year survival is severely compromised in patients with severe primary graft dysfunction (PGD) after lung transplantation. We examined if advances in extracorporeal membrane oxygenation (ECMO) support, including polymethylpentene oxygenators and reliance on venovenous (VV) ECMO have improved outcomes in patients with severe PGD after lung transplantation. Methods The analysis included data prospectively collected on all single-lung or double-lung transplants between November 2001 and December 2009. Heart-lung transplants were excluded. Comparisons were made between recipients who did and did not require ECMO for PGD after transplant. Results Since November 2001, when VV ECMO became the routine treatment for severe PGD after transplant at our center, 28 of 498 patients (6%) have required VV ECMO support. Successful weaning occurred in 27 of 28 (96%). Support was withdrawn for 1 patient with irreversible neurologic injury. Survival was substantially better than in previous reports: 30 days, 82%; 1 year, 64%; and 5 years, 49%. Freedom from bronchiolitis obliterans syndrome was 88% in the ECMO survivors at 3 years, but maximum allograft function was considerably worse than in transplant recipients not requiring ECMO (peak forced expiratory volume in 1 second: 58% in ECMO vs 83% in non-ECMO, p = 0.001). Conclusions Advances in ECMO technology, particularly VV ECMO, have greatly improved the ability to support patients with severe PGD after lung transplantation. VV ECMO is an important tool in the armamentarium of any lung transplant program to optimize patient outcomes; however, strategies to improve lung allograft function in patients experiencing severe PGD are still needed.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Impact of Hospital Volume of Thoracoscopic Lobectomy on Primary Lung Cancer Outcomes [ORIGINAL ARTICLES: GENERAL THORACIC]

Background This study evaluated hospital operative volume of video-assisted thoracoscopic surgery (VATS) lobectomy in primary lung cancer as a predictor of short-term outcomes after pulmonary lobectomy on a national scale. Some previous analyses comparing VATS vs open lobectomy outcomes have been limited by inaccuracies in patient cohort identification. Methods The 2008 Healthcare Utilization Project-Nationwide Inpatient Sample database was culled using the International Classification of Diseases (9th Clinical Modification) procedure codes specifically distinguishing VATS vs open lobectomies (32.41 and 32.49, respectively) available only after October 2007. High hospital VATS volume was defined as 95th percentile or higher (> 20 VATS/year). Univariable and multivariable analyses were used to identify independent predictors of the following outcome measures: 30-day in-hospital morbidity and mortality, hospital length of stay (LOS), and hospital costs. Results We identified 6,292 primary lung cancer patients undergoing pulmonary lobectomy, including 1,523 undergoing VATS (24%). Compared with open, VATS patients had fewer complications (38% vs 44%, p < 0.001) and median LOS (5 vs 7 days; p < 0.001). In multivariable analysis, VATS was an independent predictor of fewer total complications (odds ratio, 0.83; p = 0.004) and shorter LOS (2.3 ± 0.3-day difference, p < 0.001). Patients undergoing VATS at high-volume VATS hospitals had shorter median LOS (4 vs 6 days, p = 0.001) compared with low-volume VATS hospitals. Multivariable analysis showed high hospital VATS volume independently predicted shorter LOS (0.9 ± 0.4-day difference, p = 0.001). Conclusions In a national database, VATS lobectomy was associated with fewer complications and shorter LOS than open lobectomy in primary lung cancer patients. Among patients undergoing VATS, high hospital volume was also associated with shorter LOS.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Oncologic Efficacy of Anatomic Segmentectomy in Stage IA Lung Cancer Patients With T1a Tumors [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Segmentectomy provides an anatomic, parenchymal-sparing strategy for patients with limited lung function. Recently, interest has been renewed in segmentectomy for the treatment of early stage lung cancer. Methods We reviewed the medical records of all patients undergoing segmentectomy from January 1999 through December 2004. Survival curves were estimated using the Kaplan-Meier method. Results There were 113 consecutive patients (58 men, 55 women); median age was 72.5 years (range, 30 to 94 years). Median forced expiratory volume in 1 second was 1.53 L (range, 0.5 L to 3.27 L). Median diffusion capacity of lung for carbon monoxide was 69% predicted (range, 23% to 129%). Significant comorbidities were present in 62 patients (55%). There was no perioperative mortality. Major morbidity occurred in 28 patients (25%). Mean tumor size was 2.1 cm. Resection margins were negative in all cases. Ninety-two patients (81%) were stage I. Overall 5-year survival was 79% for stage IA patients. Current smoking, diffusion capacity of lung for carbon monoxide less than 69%, tumor size greater than 2 cm, N2 disease, and advanced histology grade were associated with decreased survival by univariate analysis. In a multivariate model, only tumor size greater than 2 cm remained significant. Tumor recurrence was observed in 39 patients (35%): local in 17 patients (15%) and distant only in 22 (20%). For stage IA patients with T1a lesions, local recurrence was 5% and distant recurrence was 13%. Five-year recurrence-free survival of these patients was 69%. Conclusions Pulmonary segmentectomy can be performed safely in selected patients with preoperative reduced lung function and comorbidities. For stage IA disease, survival approximates that seen after lobectomy, with similar local recurrence rates for patients with T1a tumors.

Local Extension at the Hilum Region Is Associated With Worse Long-Term Survival in Stage I Non-Small Cell Lung Cancers [ORIGINAL ARTICLES: GENERAL THORACIC]

Background The prognostic significance of hilar structures invasion, which remains undefined for non-small cell lung cancer (NSCLC), may have potential application for cancer staging. Tumor extension along the bronchus and pulmonary vessels was examined for survival significance. Methods In all, 213 pathologically proved central-type stage I NSCLC cases were enrolled. Four study groups were assigned based on the extent of resections: standard lobectomy (group L, n = 32), bronchoplastic procedures (group B, n = 94), standard lobectomy combined with pulmonary angioplasty (group A, n = 48), and bronchial sleeve resection combined with pulmonary artery angioplasty (group BA, n = 39). Univariate and multivariate analysis were performed by the Kaplan-Meier method and the Cox regression model. Results There were 2 postoperative deaths (pulmonary embolism and serious pulmonary infection). Complications were noted in 39 patients (18.3%). Among these patients, the overall 5-year survival rate was 60.2% ± 0.05%, with a median survival time of 75.0 ± 7.5 months. The 5-year survival rates of subgroups were 79.5%, 59.7%, 59.0%, and 47.9%, respectively for groups L, B, A, and BA. Univariate analysis indicated tumor size, bronchial invasion, arterial involvement, and type of operation as closely associated with long-term survival. Multivariate analysis indicated that type of operation and tumor size were the most prominent prognostic factors of 5-year survival. Conclusions Proximal tumor extension into bronchus, invasions into extrapericardial pulmonary vessels, and tumor size were the most important risk factors for 5-year survival with central-type stage I NSCLC. Tumor extension in the hilum was highly related to prognosis and might provide pertinent information to accurately define a tumor ("T") subclass.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Maximal Standardized Uptake Value on FDG-PET Is Correlated With Cyclooxygenase-2 Expression in Patients With Lung Adenocarcinoma [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Cyclooxygenase-2 (COX-2) is constitutively overexpressed in a variety of epithelial malignancies and is usually associated with a poor prognosis. Fluorodeoxyglucose positron emission tomography (FDG-PET) has become an important tool for the diagnosis and staging of non–small-cell lung cancer. The maximal standardized uptake values (SUVmax) of primary tumors on FDG-PET have been shown to be correlated with some clinicopathologic factors. In this study, we investigated the prediction of intratumoral COX-2 expression by FDG-PET in cases of lung adenocarcinoma. Methods We conducted a retrospective review of the data of 60 patients with lung adenocarcinoma measuring less than 3 cm in diameter. Immunohistochemical staining for COX-2 and other biological factors that might influence cancer progression was performed, and the correlations of the selective tumor marker expression with the SUVmax were evaluated. Results A significant correlation was observed between the SUVmax and the expressions of COX-2, Ki-67, and vascular endothelial growth factor (VEGF). Multiple stepwise regression analysis revealed significant relationships between the SUVmax and the expression of COX-2 (p < 0.001) and Ki-67 (p = 0.016). Of the 2, COX-2 expression was the stronger determinant of the SUVmax, which increased in proportion to the score for COX-2 expression. The recurrence-free survival of patients with elevated COX-2 expression was significantly worse than that of patients not showing COX-2 expression. Conclusions The expression of COX-2 in primary tumors is as strongly correlated with a worse clinical outcome as is increased FDG uptake in cases of lung adenocarcinoma. These findings indicate that the SUVmax of primary tumors might reflect the biological malignant potential in lung adenocarcinomas.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Human Immunodeficiency Virus Infection as a Prognostic Factor in Surgical Patients With Non-Small Cell Lung Cancer [ORIGINAL ARTICLES: GENERAL THORACIC]

Background The purpose of this study was to assess the effect of human immunodeficiency virus (HIV) infection on postoperative survival among non-small cell lung cancer (NSCLC) patients. Methods A retrospective cohort study compared 22 HIV-infected lung cancer patients to 2,430 lung cancer patients with HIV-unspecified status who underwent resection at Johns Hopkins Hospital from 1985 to 2009. Subcohort comparative analyses were performed using individual matching methods. Results Thirty-day mortality rates did not differ between HIV-infected and HIV-unspecified patients. Survival rates for HIV-infected lung cancer patients were significantly shorter than for HIV-unspecified patients (median, 26 versus 48 months; p = 0.001). After adjustment, the relative hazard of mortality among HIV-infected NSCLC patients was more than threefold that of HIV-unspecified patients (adjusted hazard ratio, 3.08; 95% confidence interval: 1.85 to 5.13). When additional surgical characteristics were modeled in a matched subcohort, the association remained statistically significant (adjusted hazard ratio, 2.31; 95% confidence interval: 1.11 to 4.81). Moreover, HIV-infected lung cancer patients with CD4 counts less than 200 cells/mm3 had shortened median survival compared with patients whose CD4 counts were 200 cells/mm3 or greater (8 versus 40 months; p = 0.031). Postoperative pulmonary and infectious complications were also elevated in the HIV-infected group (p = 0.001 and p < 0.001, respectively). After surgery, median time to cancer progression was shorter among HIV-infected patients (20.4 months) versus HIV-unspecified patients (p = 0.061). Conclusions The HIV-infected NSCLC patients have more postoperative complications, rapid progression to disease recurrence, and poorer postoperative survival. Optimizing immune status before surgery and careful patient selection based on diffusion capacity of lung for carbon monoxide may improve patient outcomes.

Molecular Detection of Microorganisms in Distal Airways of Patients Undergoing Lung Cancer Surgery [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications. Methods Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results. Results In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n = 13, and herpesvirus simplex, n = 1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p = 0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications. Conclusions When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Subcarinal Node Metastasis in Thoracic Esophageal Squamous Cell Carcinoma [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Subcarinal node metastasis is common in patients with esophageal cancer. Some scholars have suggested that subcarinal nodes might not need to be sampled or dissected in patients with superficial squamous cell carcinoma of the thoracic esophagus. This research investigated the frequency of subcarinal node metastasis in patients with esophageal squamous cell carcinoma, identified the factors correlated to subcarinal node metastasis, and evaluated the clinical relevance of subcarinal node metastasis in thoracic esophageal squamous cell carcinoma. Methods We retrospectively analyzed the clinical data of 1,812 consecutive patients with thoracic esophageal squamous cell carcinoma who underwent esophagectomy in the Cancer Center of Sun Yat-sen University. The surgical procedures included the left transthoracic procedure, Ivor-Lewis approach, and the cervical-thoracoabdominal procedure. Results The frequency of subcarinal node metastasis was 10.0%. The univariate and multivariate analysis showed that longer tumor length, higher pathologic T stage, lower histologic grade, and positive lymph node metastases of other groups were associated with a higher frequency of subcarinal node metastasis (all p < 0.05). Patients with solitary subcarinal node metastasis had a significantly lower 5-year cumulative survival rate than those with solitary paraesophageal node metastasis (25.3% vs 39.6%, p < 0.05). Conclusions Longer tumor length, higher pathologic T stage, lower histologic grade, and positive lymph node metastases of other groups are associated with a higher frequency of subcarinal node metastasis. Subcarinal node metastasis indicates worse prognosis of patients with thoracic esophageal squamous cell carcinoma compared with paraesophageal node metastasis.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Neoadjuvant Chemoradiation Therapy Is Beneficial for Clinical Stage T2 N0 Esophageal Cancer Patients Due to Inaccurate Preoperative Staging [ORIGINAL ARTICLES: GENERAL THORACIC]

Background It remains unclear if patients with clinical stage T2 N0 (cT2 N0) esophageal cancer should be offered induction therapy vs surgical intervention alone. Methods This was a retrospective cohort study of cT2 N0 patients undergoing induction therapy, followed by surgical resection, or resection alone, at the Johns Hopkins Hospital from 1989 to 2009. Kaplan-Meier analysis was used to compare all-cause mortality in cT2 N0 patients who had resection alone vs those who had induction chemoradiation therapy, followed by resection. Results A study cohort of 69 patients was identified and divided into two groups: 55 patients (79.7%) received induction therapy and 14 (20.3%) did not. No statistically significant difference in 5-year survival rate was observed for the two groups: 49.5% for the resection-only group and 53.8% for the induction group. More than 50% of cT2 N0 patients were understaged. Conclusions For cT2 N0 esophageal cancer patients, the benefit of neoadjuvant therapy is still unclear. Induction therapy for cT2 N0 did not translate into a statistically significant improvement in survival. However, due to the significant understaging of T2 N0 patients, we recommend neoadjuvant therapy to all cT2N0 patients before operation.

In Situ Replacement for Mycotic Aneurysms on the Thoracic and Abdominal Aorta Using Rifampicin-Bonded Grafting and Omental Pedicle Grafting [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The objective of this report is to discuss the efficacy of in situ replacement for treating mycotic aneurysm, particularly using rifampicin-bonded grafts and omental pedicle grafts, on the basis of our 7 years of experience. Methods Between December 2003 and December 2010, we performed surgical treatments in 23 patients (for the thoracic aorta in 6 patients, for the thoracoabdominal aorta in 8 patients, and for the abdominal aorta in 9 patients; 7 emergency, 10 urgent, and 6 elective operations) with mycotic aneurysm by using rifampicin-bonded grafting and omental pedicle grafting. Results One patient died in hospital because of local recurrent infection. One patient required an additional operation on another aortic site, and 3 patients had spinal cord injuries (2 transient and 1 permanent). Overall survival at 5 years was 95%, and the rate of freedom from aortic events at 5 years was 86%. Conclusions In situ replacement using rifampicin-bonded grafting and omental pedicle grafting is effective for treating mycotic aneurysms of the thoracic and abdominal aorta.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Modified Bentall Procedure Using Two Short Grafts for Coronary Reimplantation: Long-Term Results [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The modified Bentall procedure remains a gold standard of aortic root surgery. We present in this study the early and late outcomes of a particular modification using 2 separated grafts for the coronary reimplantation. Methods From 1995 to 2009, 153 patients aged 57 ± 12 (mean ± standard deviation [SD]) underwent elective (n = 113) or urgent (n = 40) aortic root replacement with a composite mechanical valve conduit reconstruction using 2 short, separated 8-mm Dacron grafts for the coronary reimplantation and were retrospectively reviewed. Results Aortic disease etiologies were annuloaortic ectasia (n = 108), type A aortic dissection (n = 38), aortic false aneurysm, or Valsalva aneurysm evolution after previous cardiac surgery (n = 7). The overall early mortality was 8.5% (20% for urgent procedure and 4.4% for elective procedure). For the whole group, actuarial survival at 5 and 10 years was 86.3% ± 2.78 and 73.7% ± 4.23, respectively. Among the 23 late deaths, 9 were valve-related deaths (stroke, n = 3; endocarditis, n = 1; unknown, n = 5). During the follow-up, linearized rates of major bleeding, thromboembolism, and endocarditic evolution were, respectively, 1.3 %/patient-years, 0.42 %/patient-years, and 0.22 %/patient-years. One patient presented a nonseptic false aneurysm of the right coronary anastomosis and no structural valve dysfunction has been diagnosed. In total, only 2 patients required an aortic root reoperation. Conclusions The modified Bentall procedure using 2 separated grafts for the coronary reimplantation is a feasible, safe, easy, and reproducible operative technique for aortic root surgery.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Reoperation After Surgical Correction of Acute Type A Aortic Dissection: Risk Factor Analysis [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Aortic dissection is an evolving process that may require one or several reoperations after its initial repair. We conducted a study to evaluate risk factors and define the incidence and locations of reoperations after surgical correction of acute type A aortic dissection (AAD). Methods Between 1998 and 2008, 250 consecutive patients (mean age 62.5 ± 12.4 years) underwent surgery for AAD at our institution. Replacement of the ascending aorta was done in 173 cases, composite graft replacement in 61 cases, separate aortic valve and ascending aorta replacement in 2 cases, and arch replacement required by distal repair in 14 cases. Mean follow-up time was 4.7 ± 5.6 years. Results Freedom from reoperation was 99%, 82%, and 79% at 1, 5, and 10 years, respectively. Twenty-five patients required 25 reoperations at a mean interval of 4.7 years after initial surgery for the correction of AAD. Reoperations included 21 procedures on the proximal aorta (ascending aorta, aortic root, or valve) and 4 procedures on the distal aorta (arch or descending aorta). Cox regression analysis identified the use of gelatin-resorcinol-formaldehyde (GRF) glue (p = 0.0270), and nonreplacement of the aortic root at the time of initial AAD repair (p = 0.0004), as a significant risk factor for proximal reoperation, and a patent false lumen (p = 0.0107) as a significant risk factor for distal reoperation. Conclusions A patent false lumen, the use of GRF glue, and aortic root preservation at initial operation influence the risk for surgical correction in patients undergoing surgery for AAD. These patients need long-term follow-up.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Aortic Dilatation With Bicuspid Aortic Valves: Cusp Fusion Correlates to Matrix Metalloproteinases and Inhibitors [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Congenital bicuspid aortic valves (BAVs) result from fusion of 2 valve cusps, resulting in left-noncoronary (L-N), right-left (R-L), and right-noncoronary (R-N) morphologic presentations. BAVs predispose to ascending thoracic aortic aneurysms (ATAAs). This study hypothesized that ATAAs with each BAV morphologic group possess unique signatures of matrix metalloproteinases (MMPs) and endogenous tissue inhibitors of metalloproteinases (TIMPs). Methods Ascending thoracic aortic aneurysm tissue from 46 patients with BAVs was examined for MMP/TIMP abundance, and global MMP activity was compared with normal aortic specimens (n = 15). Proteolytic balance was calculated as the ratio of MMP abundance to a composite TIMP score. Results were stratified by valve morphologic group (L-N [n = 6], R-L [n = 31], and R-N [n = 9]). Results The BAV specimens (p < 0.05 versus normal aorta, 100%) displayed elevated global MMP activity (273% ± 63%), MMP-9 (263% ± 47%), and decreased MMP-7 (56% ± 10%), MMP-8 (58% ± 11%), TIMP-1 (63% ± 7%), and TIMP-4 (38% ± 3%). The R-L group showed increased global MMP activity (286% ± 89%) and MMP-9 (267% ± 55%) with reduced MMP-7 (45% ± 7%), MMP-8 (68% ± 15%), TIMP-1 (58% ± 7%), and TIMP-4 (35% ± 3%). The L-N group showed elevated global MMP activity (284% ± 71%) and decreased MMP-8 (37% ± 17%) and TIMP-4 (48% ± 14) activity. In the R-N group, MMP-7 (46% ± 13%) and MMP-8 (36% ± 17%) and TIMP-1 (59% ± 10%) and TIMP-4 (42% ± 5%) were decreased. The R-L group demonstrated an increased proteolytic balance for MMP-1, MMP-9, and MMP-12 relative to L-N and R-N. Conclusions Each BAV morphologic group possesses a unique signature of MMPs and TIMPs. MMP/TIMP score ratios suggest that the R-L group may be more aggressive, justifying earlier surgical intervention.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Patients' Radiation Doses During Thoracic Stent-Graft Implantation: The Problem of Long-Lasting Procedures [ORIGINAL ARTICLES: ADULT CARDIAC]

Background This article investigates patient radiation doses during implantation of thoracic stent-graft. Aortic stengraft implantation can be disturbed by many factors, which, in turn, lead to prolongation of the procedure time and, as a consequence, increase the radiation dose. Methods Measurements of radiation length (fluoroscopy and exposure), air kerma (AK) in grays, and dose–area product in grays · square centimeters were conducted simultaneously in 100 patients. The patients were analyzed retrospectively, regarding their body mass index (BMI), type of aneurysms, number of stent-graft parts, angulation of aorta, and coverage of the left subclavian artery. Results Mean total dose–area product value for this kind of treatment was 361 Gy · cm2. This was caused by the fact that total mean AK was high for the cohort analyzed and reached 797 mGy. For 23 patients total AK was between 1 and 2 Gy, and for 3 it exceeded 2 Gy. In the remaining group, the maximal radiation dose was very high and exceeded 3 Gy. The total AK of patients with BMI within the range of 25 to 29.9 kg/m2 and with BMI greater than 30 kg/m2 significantly increased in comparison with the group of patients with BMI between 18 and 24.9 kg/m2 (p = 0.00005 and 0.000001, respectively). During the study, a good correlation between AK and fluoroscopy time (r = 0.6) and for AK (or dose–area product) and exposure time (r = 0.66 or 0.81, respectively) was observed. Conclusions The main factors contributing to a high radiation dose being acquired by patients during thoracic stent-graft were BMI greater than 25 kg/m2, number of parts of the stent-graft, and angulation of the neck of aneurysm exceeding 60 degrees.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Midterm Cost and Effectiveness of Thoracic Endovascular Aortic Repair Versus Open Repair [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Thoracic endovascular aneurysm repair (TEVAR) has been rapidly introduced as a primary treatment modality for thoracic aortic diseases with limited data available on midterm to late-term outcomes. Methods A retrospective single institution study comparing hospital and midterm outcomes and costs for TEVAR versus open elective repair of descending thoracic aneurysms was conducted. Fifty-seven patients were included between 2005 and 2007 (TEVAR = 28; open = 29) and were followed until May 2010. Results Patients in the TEVAR group were older (73.2 versus 62.3 years; p < 0.001). Hospital mortality was higher in the open repair group (10.3% versus 3.6%; p = 0.611). There was no statistical difference in stroke, paraparesis or paralysis, sepsis, or renal failure; however, a composite major adverse event variable showed a higher complication with open repair versus TEVAR (37.9% versus 14.3%; p = 0.043). Mean follow-up was 42.6 months for open repair versus 26.9 for TEVAR (p = 0.002). Kaplan-Meier survival analysis showed the initial survival benefit for TEVAR was lost in less than 6 months; however, the difference did not reach statistical significance during follow-up (log-rank test p = 0.232). Mean surveillance imaging costs for a TEVAR patient were $1,800.38 higher than for an open patient at 2 years. Compliance of TEVAR patients with follow-up imaging was 78%, 64%, 50%, and 42% at 1, 6, 12, and 24 months, respectively, and was even lower in those not registered in device trials. Conclusions Patients in the TEVAR group had favorable early outcomes; however, midterm survival was reduced secondary to comorbidities. This study raises concern for the ongoing costs of surveillance imaging in TEVAR as well as patient compliance with follow-up.

Graft Selection for Aortic Root Replacement in Complex Active Endocarditis: Does It Matter? [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Endocarditis affecting the aortic valve, with abscess formation and root destruction, remains a challenge to treat. Aortic root homografts have been advocated because of a perceived lower risk of infective complications than with other root replacement grafts. However, the theoretical advantage of homografts has not been re-evaluated in the modern era. This report is based on an examination of our results for all aortic root replacements in complex, active endocarditis affecting the aortic valve. Methods From 2000 to 2010, 134 patients (70.9% male; mean age 58.3 ± 14.8 years) at our institution underwent aortic root replacement for active endocarditis. Ninety of the patients (67.2%) had a previously implanted prosthetic aortic valve. Our findings for these patients included one or more of the following: abscess (n = 110, 82.1%), valve vegetation (n = 98, 73.1%), and pseudoaneurysm or rupture or both (n = 62, 46.3%). We retrospectively reviewed data for the patients from hospital records and the social security data base. Results A mechanical composite graft (MC) was used in 43 of the patients (32.1%), a non-homograft biologic valve conduit (BC) in 55 patients (41.0%), and a homograft (HG) valve in 36 patients (26.9%). There was no significant difference among the groups in the incidence of major complications or in-hospital mortality. During a mean follow-up of 32.1 ± 29.4 months, the rates of readmission, reinfection, and reoperation were similar for the three groups. The mean 5-year survival in the study was 58 ± 9% for the MC group, 62 ± 7% for the BC group, and 58 ± 9% for the HG group, respectively (p = 0.48). Conclusions Aortic root replacement in the presence of complex active infection is associated with significant morbidity and mortality. We report that the rates of major complications and late mortality were similar among MC, BC, and HG groups in our study.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Outcomes After Surgical Treatment of Native and Prosthetic Valve Infective Endocarditis [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The risk of death and complications of infective endocarditis (IE) treated medically has to be balanced against those from surgery in constructing a therapeutic approach. Recent literature has drawn conflicting conclusions on the benefit of surgery for IE. We reviewed patients treated surgically for IE at the Cleveland Clinic from 2003 to 2007 to examine their outcomes. Methods A retrospective review of consecutive patients who underwent surgery for native and prosthetic valve endocarditis between January 1, 2003, and December 31, 2007, was conducted. Surgical outcomes were reviewed to include survival and postoperative complications. Survival was evaluated at end of hospital stay, 30 days, 1 year, and at last follow-up. Results Four hundred twenty-eight patients underwent surgery for IE during the study period: 248 (58%) had native valve endocarditis and 180 (42%) had prosthetic valve endocarditis. Overall 90% of patients survived to hospital discharge. When compared with patients with native valve infection, patients with prosthetic infection had significantly higher 30-day mortality (13% versus 5.6%; p < 0.01), but long-term survival was not significantly different (35% versus 29%; p = 0.19). Patients with IE caused by Staphylococcus aureus had significantly higher hospital mortality (15% versus 8.4%; p < 0.05), 6-month mortality (23% versus 15%; p = 0.05), and 1-year mortality (28% versus 18%; p = 0.02) compared with non–S aureus IE. Conclusions Surgical treatment of IE was associated with 90% hospital survival. Outcomes within the 30 days were better for native valve than for prosthetic valve endocarditis. Long-term outcomes were similar. Finally, S aureus was associated with significantly higher mortality compared with other pathogens.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Long-Term Results of 203 Young and Middle-Aged Patients With More Than 10 Years of Follow-Up After the Original Subcoronary Ross Operation [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The choice of prosthesis for aortic valve replacement in young and middle-aged patients remains challenging owing to the accelerated degeneration of bioprostheses in these age groups and the risks of thromboembolism and bleeding with mechanical valves. Theoretically, the living pulmonary autograft (Ross operation) would be advantageous. Long-term results of the various Ross techniques are needed for defining the value of this surgical concept. Methods Of a total of 576 subcoronary Ross patients operated on between June 1994 and June 2011, we report on 203 consecutive subcoronary patients (mean age, 47.2 ± 13.6 years, 155 male, 2,491 patient-years) with a follow-up of at least 10 years (mean, 12.3 ± 2.9 years). Results Early and late mortality were 0.98% (n = 2) and 11.4% (n = 23). Valve-related mortality was 2.5% (n = 5). Survival did not differ from that of the general German population. Freedom from autograft or allograft reoperation was 92.2% at 10 years and 87.1% at 15 years. Five major bleeding (0.20%/patient-year) and 11 thromboembolic events (0.44%/patient-year) occurred in 5 and 10 patients, respectively. Neither a systematic increase in aortic regurgitation nor an increase in root dimensions with time could be observed. In the vast majority of patients, valvular hemodynamics at latest echocardiographic follow-up were excellent. Conclusions Long-term results of the original subcoronary Ross operation reveal normal survival, excellent hemodynamics, low risk of thromboembolism or bleeding, and small risk for reoperation. These results favor the pulmonary autograft concept in young and middle-aged patients in experienced centers and may serve to better define its role in surgical treatment of aortic valve disease in these patients.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Early and Late Outcome After Aortic Root Replacement With a Mechanical Valve Prosthesis in a Series of 528 Patients [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Aortic root replacement with a mechanical valve prosthesis is a widely accepted surgical technique. This study aims to evaluate short-term and long-term outcomes of this approach and to identify predictors of 30-day mortality. Methods We retrospectively analyzed a consecutive series of 528 patients (mean age, 54 ± 13 years) who underwent aortic root replacement for aneurysm (83%), acute type A dissection (15%), or endocarditis (2%) in the period between 1974 and 2008. The mean time of follow-up was 9.0 ± 7.0 years (range, 0 to 36 years). Concomitant aortic surgery was performed in 71%, coronary revascularization in 18%, and mitral valve surgery in 3%. Selective antegrade cerebral perfusion was applied in 25% and deep hypothermic circulatory arrest in 28% of patients. Results Overall 30-day mortality was 3.2% to 2.5% for elective surgery and 6.5% for urgent surgery. Morbidity included resternotomy for bleeding or tamponade (19%), pacemaker implantation (3.6%), myocardial infarction (4.0%), and neurologic damage (4.2%). Multivariate analysis revealed myocardial infarction (p < 0.001) and the lack of glue use (p = 0.018) as independent predictors of 30-day mortality. Subanalysis of the selective antegrade cerebral perfusion patients and the deep hypothermic circulatory arrest patients revealed infarction (p = 0.005) and coronary artery disease (p = 0.45) for selective antegrade cerebral perfusion and wrapping (p = 0.035) for deep hypothermic circulatory arrest as independent risk factors. The survival rate was 87%, 73%, and 29% after 5, 10, and 25 years, respectively. Conclusions Aortic root replacement with a mechanical valve prosthesis can be performed safely with low mortality and acceptable morbidity. Perioperative myocardial infarction is the strongest independent risk factor of 30-day mortality.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Aortic Valve Replacement With the Medtronic Mosaic Bioprosthesis: A 13-Year Follow-Up [ORIGINAL ARTICLES: ADULT CARDIAC]

Background This study evaluated the long-term clinical performance of the Mosaic bioprosthesis (Medtronic Inc, Minneapolis, MN) after aortic valve replacement. Methods From 1995 to 2008, 178 patients (48 women; mean age, 74 ± 6 years) had aortic valve replacement. Mean functional class was 2.3 ± 0.5, and 157 patients (88%) were in sinus rhythm. Prosthetic sizes were 23 mm in 98 patients and 25 mm in 66. Follow-up was completed in December 2009 with a cumulative duration of 1,015 patient/years (mean, 5.7 ± 3.5 years, maximum, 13.7 years). Results Early mortality was 4%, none being valve-related; of 38 late deaths 7 were valve-related. Actuarial survival at 13 years was 48% ± 8%. Mean functional class of current survivors was 1.2 ± 0.6. Six embolic episodes occurred and four cases of endocarditis, with respective actuarial freedom of 92% ± 5% for embolism and 97% ± 2% for endocarditis at 13 years. Four patients required reoperations for endocarditis and 2 for structural deterioration. Actuarial freedom from structural deterioration and from reoperation for all causes was 89% ± 7% and 86% ± 7% at 13 years, with an actuarial freedom from prosthesis-related deaths of 86% ± 5%. Results of echocardiographic evaluation at 1 year were mean peak gradient, 20 ± 6 mm Hg and mean effective orifice area index, 1.07 ± 0.21 cm2/m2 for size 23 mm and 22 ± 6 mm Hg and 1.11 ± 0.26 cm2/m2for size 25 mm; at 10 years, mean peak gradient and mean effective orifice area index were 28 ± 13 mm Hg and 1.01 ± 0.19 cm2/m2 for size 23 mm and 26 ± 8 mm Hg and 1.08 ± 0.18 cm2/m2for size 25 mm. Conclusions The Mosaic bioprosthesis showed good overall performance, with low incidence of structural valve deterioration and hemodynamic stability in the long-term. Expected increased durability of this device should be verified at longer follow-up intervals.

Pulsatile Distention of the Nondiseased and Stenotic Aortic Valve Annulus: Analysis With Electrocardiogram-Gated Computed Tomography [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Knowledge of the dynamic changes of the aortic valve (AV) annulus may aid in the sizing and design of transcatheter valve prostheses. We assessed AV annulus distention in patients without AV disease and with severe AV stenosis (AS) using computed tomography (CT). Methods Electrocardiogram-gated multislice CT scans of 15 patients without AV disease (age 53 ± 12 years) and 20 patients with severe AS (age 81 ± 6 years) were analyzed. Images in plane with the AV annulus were reconstructed for every 10% to 12.5% of the cardiac cycle. With the use of dedicated software the annulus was segmented. In all phases of the cardiac cycle the area was measured, as were the maximum radius (Rmax) and minimum radius (Rmin) of an ellipse fitted around the segmented lumen. The asymmetry ratio was defined as Rmax/Rmin. Direct comparison of both groups was not possible because age and scan protocols were confounding factors. Results The mean change of the area, Rmax, and Rmin was 122 ± 33 mm2, 1.8 ± 0.7 mm, and 2.4 ± 0.5 mm in the patients with nondiseased annulus and 98 ± 52 mm2, 1.4 ± 0.7 mm, and 1.9 ± 0.8 mm in those with AS. The mean asymmetry ratio was 1.3 ± 0.1, indicating an elliptic annulus. Both the asymmetry ratio and the area changed significantly over the cardiac cycle (p < 0.001). Conclusions With the use of CT and postprocessing software, significant area and radius changes during the cardiac cycle were demonstrated in both the nondiseased annulus and the stenotic annulus. This finding may help selection of the optimal size in patients undergoing AV implantation and also aid in prosthesis design.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Long-Term Survival of Patients With Ischemic Cardiomyopathy Treated by Coronary Artery Bypass Grafting Versus Medical Therapy [ORIGINAL ARTICLES: ADULT CARDIAC]

Background We prospectively applied the Surgical Treatment of Ischemic Cardiomyopathy trial entry criteria to an observational database to determine whether coronary artery bypass grafting (CABG) decreases mortality compared with medical therapy (MED) for patients with coronary artery disease and depressed left ventricular ejection fraction. Methods This was a retrospective, observational, cohort study of prospectively collected data from the Duke Databank for Cardiovascular Disease. Long-term mortality was the main outcome measure. Between January 1, 1995, and July 31, 2009, 86,874 patients underwent cardiac catheterization for suspected ischemic heart disease and were evaluated for inclusion in the analysis. Results A total of 2,624 patients were found to have left ventricular ejection fraction less than 0.35, coronary artery disease amenable to CABG, and no left main stenosis of greater than 50%. After exclusions including ongoing Canadian Cardiovascular Society class III angina and acute myocardial infarction, 763 patients were included for propensity score analysis, including 624 who received MED and 139 who underwent CABG. Adjusted mortality curves were constructed for those patients in the three quintiles most likely to receive CABG. The curves diverged early, with risk-adjusted mortality rates at 5 years of 46% for MED versus 29% for CABG, and the survival benefit of CABG over MED continued through 10 years of follow-up (hazard ratio, 0.63; 95% confidence interval, 0.45 to 0.88). Conclusions Among a propensity-matched, risk-adjusted, observational cohort of patients with coronary artery disease, left ventricular ejection fraction less than 0.35, and no left main disease of greater than 50%, CABG is associated with a survival advantage over MED through 10 years of follow-up.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Off-pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Elderly Patients [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The purpose of the present study was to compare outcome in propensity score-matched patients, aged 70 years or greater, undergoing isolated off-pump coronary bypass surgery using a bilateral (BITA) or single (SITA) skeletonized internal thoracic artery. Methods Of 912 consecutive patients undergoing isolated coronary bypass grafting (906 using the off-pump technique without emergent conversion to cardiopulmonary bypass), the 491 aged 70 years or greater undergoing off-pump skeletonized single (n = 247) or bilateral (n = 244) skeletonized internal thoracic artery grafting were retrospectively analyzed after excluding the 6 who were transferred to our hospital after receiving percutaneous cardiopulmonary bypass, the 72 who had only 1 target in the left coronary area, and the 343 aged less than 70 years. A total of 217 pairs were matched using propensity scores calculated from 9 preoperative factors (0.69). Results The rate of postoperative complications was similar between the groups. The 5-year estimated survival free from overall death and cardiac event, respectively, in the BITA group versus the SITA group were 86.4% ± 3.2% versus 73.5% ± 3.9% (p = 0.01) and 93.2% ± 2.7% versus 87.5% ± 3.0% (p = 0.01). In multivariate Cox models, bilateral internal thoracic artery grafting was significantly associated with a lower risk of overall death (hazard ratio 0.56; 95% confidence interval 0.31 to 0.99; p = 0.04) and cardiac event (hazard ratio 0.36; 95% confidence interval 0.15 to 0.88; p = 0.03). Conclusions In elderly patients, off-pump in situ left-sided bilateral skeletonized internal thoracic artery grafting is associated with lower risk of overall death and cardiac event than single internal thoracic artery grafting and carries no increased operative risk.

Metabolic Syndrome Affects Midterm Outcome After Coronary Artery Bypass Grafting [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Metabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting. Methods A total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up. Results A total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p = 0.04), cardiac arrhythmias (35.3% versus 25.2%; p < 0.0001), renal failure (12% versus 8.7%; p = 0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p < 0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensity-adjusted Cox proportional-hazards regression were age (p = 0.0008), preoperative left ventricular ejection fraction (p = 0.001), preoperative renal failure (p = 0.001), and MetS (p = 0.006). Higher C-reactive protein levels were found preoperatively (8.6 ± 2.3 versus 5.14 ± 3.1 mg/L; p < 0.0001) and both early (71.2 ± 9 versus 49.6 ± 8.7 mg/L; p < 0.0001) and late (7.4 ± 2.7 versus 4.8 ± 2.5mg/L; p < 0.0001) after surgery. Conclusions The main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy.

Refractory Spasm of Coronary Arteries and Grafted Conduits After Isolated Coronary Artery Bypass Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Refractory vascular spasm (RVS) concomitantly involving the entire coronary artery system and grafted conduits after coronary artery bypass grafting (CABG) surgery is a rare, but dreadful event. No consensus exists in terms of appropriate management. Methods Between 1986 and 2009, 5,762 patients underwent isolated CABG at our institution, and 7 patients experienced RVS involving the coronary arteries and implanted conduits. Mean age was 65.6 years and 3 were female. All patients received from 3 to 5 distal anastomoses, including use of the left internal mammary artery. During the same time period, 18 patients experienced perioperative vasospasm of a single coronary artery or of a grafted conduit. Results All diffuse RVS events occurred between 3 and 8 hours after surgery. All patients had diffuse ischemic-like electrocardiographic changes, and 5 patients rapidly developed cardiogenic shock in the intensive care unit. Angiography was quickly performed in all patients and showed diffuse RVS involving either the native coronary arteries or the anastomosed arterial and venous conduits. The first 5 patients of this series died in the catheterization lab due to rapidly evolving refractory cardiogenic shock and unresponsive cardiac arrest, despite intraaortic counterpulsation and aggressive pharmacologic interventions (selective vasodilators and systemic inotropes). In the last 2 patients, extracorporeal membrane oxygenation was quickly instituted (1 in the catheterization lab, 1 in the operating room) and RVS could be successfully managed with complete resolution of ongoing vasospasm. In the single vascular spasm, there was only 1 death for refractory cardiac arrest, whereas all the other patients were successfully treated with direct infusion of vasodilators. Conclusions Diffuse RVS after CABG is a rare but lethal condition. Our experience, although limited, indicates that in such cases an aggressive treatment, that is, prompt extracorporeal membrane oxygenation institution and controlled cardiocirculatory assistance, represents the preferred solution to face such a dramatic event and may save patient lives.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

High-Pressure Distention of the Saphenous Vein During Preparation Results in Increased Markers of Inflammation: A Potential Mechanism for Graft Failure [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Coronary artery disease is the single leading cause of death in the United States. Commonly it is treated with coronary bypass grafting using the saphenous vein (SV) or internal mammary artery (IMA) as a conduit. Unfortunately, the SV has much lower patency rates compared with the IMA. Several hypotheses exist as to why occlusion occurs more commonly in SV grafts than in IMA grafts. However detailed studies in this area have been limited. This study investigates the effects of pressure distention on inflammation in SV conduit used in coronary artery bypass grafting (CABG). Methods Saphenous vein distention pressure was measured intraoperatively during 48 CABG procedures. A segment of SV was excised from the conduit before distention. Because the vein was used for coronary artery grafting, sequential pieces were archived for evaluation. Real-time polymerase chain reaction (RT-PCR) and immunohistochemical analyses were performed to investigate a change in the expression of biomarkers. Results Upregulation of various biomarkers occurred. These biomarkers included scavenger receptors A and B (SR-A, SR-B), toll-like receptors 2 and 4 (TLR2, TLR4), platelet endothelial cell adhesion molecule (PECAM), vascular cell adhesion molecule (VCAM), and intercellular cell adhesion molecule (ICAM) in segments of SV that were subjected to distention. Immunohistochemical results mirrored RT-PCR findings. A significant correlation was observed between biomarkers and pressure values. Conclusions These studies demonstrate that markers of inflammation are upregulated in response to SV distention. The data suggest that the pressure used in graft preparation procedures should be regulated to avoid inflammation and its potential to induce graft failure.

Impact of Preoperative Angiotensin-Converting Enzyme Inhibitor Use on Clinical Outcomes After Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Controversy exists about whether preoperative angiotensin-converting enzyme inhibitor (ACEi) therapy is associated with adverse outcomes after coronary artery bypass grafting (CABG). Methods We analyzed the outcomes of consecutive patients who underwent isolated CABG between 1998 and 2007 at a single institution. We used multivariable models to examine the association between preoperative ACEi therapy and in-hospital and long-term outcomes. Results Of the 5946 patients undergoing isolated CABG during the study period, 3,262 (54.9%) were treated with an ACEi preoperatively and 2,684 (45.1%) were not. Median follow-up was 3.8 years. Patients treated with an ACEi preoperatively were more likely to have diabetes, hypertension, an ejection fraction of less than 40%, and recent myocardial infarction (all p < 0.0001). They were less likely to have pre-existing renal failure (p = 0.004) or require an urgent or emergent CABG (p = 0.03). Postoperative use of an inotrope (26% vs 20%, p < 0.0001) or intra-aortic balloon pump (1.8% vs 1.1%, p = 0.03) was more frequent in patients treated preoperatively with an ACEi; however, preoperative ACEi use was not an independent predictor of in-hospital mortality (odds ratio [OR], 1.1; p = 0.76), prolonged length of stay in the intensive care unit (OR, 0.9; p = 0.09), or new-onset renal failure (OR, 0.7; p = 0.09). Furthermore, preoperative use of an ACEi had no independent association with long-term survival (p = 0.54) or freedom from acute coronary syndrome (p = 0.07). However, it was associated with an increased risk of readmission for heart failure over time (hazard ratio, 1.2; p = 0.007). Conclusions We found no association between preoperative ACEi therapy and adverse in-hospital outcomes or long-term survival after CABG. Preoperative ACEi therapy appears to be safe in patients undergoing CABG.

Clinical Outcomes in Patients With Prolonged Intensive Care Unit Length of Stay After Cardiac Surgical Procedures [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Advances in critical care medicine have allowed for improved care of patients requiring prolonged intensive care unit length of stay (prICULOS) after cardiac operations, yet little is known regarding their eventual outcomes. The purpose of this study was to examine short- and long-term outcomes in patients undergoing cardiac operations with prICULOS. Methods All cases of coronary artery bypass grafting (CABG), aortic valve, mitral valve, and combined CABG/valve surgical procedures performed at a single institution from July 2002 to July 2007 were identified. All-cause mortality in patients discharged alive from the hospital was determined until December 2007 through linkage with the Social Security Death Index. Patients who experienced intraoperative death or those with missing or invalid social security numbers were excluded. The definition of prICULOS was total ICULOS greater than 7 days. Results A total of 3,478 patients met inclusion criteria. One hundred thirty-seven of three thousand four hundred seventy-eight patients (3.9%) experienced prICULOS. These patients were more likely to be older than 70 years (55.5% versus 30.5%; p < 0.0001) and to have had recent myocardial infarction (28.5% versus 20.1%; p = 0.02), previous cardiac operation (18.3% versus 6.9%; p < 0.0001), and emergent status (9.5% versus 1.6%; p < 0.0001). They experienced greater in-hospital mortality (37.2% versus 1.7%; p < 0.0001) and those who were discharged alive had worse long-term survival (log-rank, p < 0.0001). After risk adjustment, prICULOS emerged as a significant predictor of in-hospital death (odds ratio [OR] 20.9; 95% confidence interval [CI], 12.9–33.7) and decreased long-term survival (hazard ratio [HR] 2.9; 95% CI, 2.0–4.3). Conclusions Patients with prICULOS after cardiac operations have worse overall outcomes. These data may be used to inform these patients and their families of realistic expectations regarding their clinical course.

Determinants of Acute Kidney Injury Duration After Cardiac Surgery: An Externally Validated Tool [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Acute kidney injury (AKI) duration after cardiac surgery is associated with poor survival in a dose-dependent manner. However, it is not known what perioperative risk factors contribute to prolonged AKI and delayed recovery. We sought to identify perioperative risk factors that predict duration of AKI, a complication that effects short and long-term survival. Methods We studied 4,987 consecutive cardiac surgery patients from 2002 through 2007. Acute kidney injury was defined as a 0.3 or greater (mg/dL) or 50% or greater increase in serum creatinine from baseline. Duration of AKI was defined by the number of days AKI was present. Stepwise multivariable negative binomial regression analysis was conducted using perioperative risk factors for AKI duration. The c-index was estimated by Kendall's tau. Results Acute kidney injury developed in 39% of patients with a median duration of AKI at 3 days and ranged from 1 to 108 days. Patients without AKI had a duration of 0 days. Independent predictors of AKI duration included baseline patient and disease characteristics, and operative and postoperative factors. Prediction for mean duration of AKI was developed using coefficients from the regression model and externally validated the model on 1,219 cardiac surgery patients in a separate cardiac surgery cohort (Translational Research Investigating Biomarker Endpoints-AKI). The c-index was 0.65 (p < 0.001) for the derivation cohort and 0.62 (p < 0.001) for the validation cohort. Conclusions We identified and externally validated perioperative predictors of AKI duration. These risk factors will be useful to evaluate a patient's risk for the tempo of recovery from AKI after cardiac surgery and subsequent short and long-term survival. The levels of awareness created by working with these risk factors have implications regarding positive changes in processes of care that have the potential to decrease the incidence and mitigate AKI.

Combination of Two Urinary Biomarkers Predicts Acute Kidney Injury After Adult Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Urinary L-type fatty acid-binding protein (L-FABP) has not been evaluated for adult post-cardiac surgery acute kidney injury (AKI) to date. This study was undertaken to evaluate a biomarker panel consisting of urinary L-FABP and N-acetyl-β-D-glucosaminidase (NAG), a more established urinary marker of kidney injury, for AKI diagnosis in adult post-cardiac surgery patients. Methods This study prospectively evaluated 77 adult patients who underwent cardiac surgery at 2 general hospitals. Urinary L-FABP and NAG were measured before surgery, at intensive care unit arrival after surgery (0 hours), 4, and 12 hours after arrival. The AKI was diagnosed by the Acute Kidney Injury Network criteria. Results Of 77 patients, 28 patients (36.4%) developed AKI after surgery. Urinary L-FABP and NAG were significantly increased. However, receiver operating characteristic (ROC) analysis revealed that the biomarkers' performance was statistically significant but limited for clinical translation (area under the curve of ROC [AUC-ROC] for L-FABP at 4 hours 0.72 and NAG 0.75). Urinary L-FABP showed high sensitivity and NAG detected AKI with high specificity. Therefore, we combined these 2 biomarkers, which revealed that this combination panel can detect AKI with higher accuracy than either biomarker measurement alone (AUC-ROC 0.81). Moreover, this biomarker panel improved AKI risk prediction significantly compared with predictions made using the clinical model alone. Conclusions When urinary L-FABP and NAG are combined, they can detect AKI adequately, even in a heterogeneous population of adult post-cardiac surgery AKI. Combining 2 markers with different sensitivity and specificity presents a reasonable strategy to improve the diagnostic performance of biomarkers.

Risk Factors for Perioperative Acute Kidney Injury After Adult Cardiac Surgery: Role of Perioperative Management [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The development of acute kidney injury (AKI) after adult cardiac surgery is associated with increased morbidity and mortality. Our aim was to assess the risk factors for postoperative AKI and whether the addition of perioperative management variables can improve AKI prediction. Methods We studied 3,219 patients operated from January 2006 to December 2009. The AKI was defined as proposed by the Acute Kidney Injury Network. Patient preoperative characteristics, as well as intraoperative, cardiopulmonary bypass (CPB), and postoperative management variables, were evaluated for association with AKI with logistic regression analysis. The model including all variables was assessed first, then separate models including only preoperative variables followed by the sequential addition of intraoperative, CPB, and postoperative management variables were tested; receiver operating characteristic analysis was used to evaluate and compare models' discriminatory power. Results The AKI occurred in 288 of 3,219 patients (8.9%). Logistic regression analysis identified 15 predictors of AKI; 4 were preoperative (age, diabetes, smoking, and serum creatinine), 4 intraoperative (inotropes, erythrocytes transfusion, cross-clamp time, and need of a new pump run), 2 CPB-related (urine output and furosemide administration during CPB), and 5 postoperative (erythrocytes transfusion, administration of vasoconstrictors, inotropes, diuretics, and antiarrhythmics). Model-discrimination performance improved from an area under the curve of 0.830 (95% confidence interval 0.807 to 0.854) for the model including only preoperative variables to an area under the curve of 0.904 (95% confidence interval 0.886 to 0.921) for the model including all variables (p < 0.001). Conclusions Several factors influence AKI development after cardiac surgery and perioperative patient management significantly affects AKI occurrence. Predictive models can be sensibly improved by the addition of these variables.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Impact of a Six-Year Integrated Thoracic Surgery Training Program at the Medical College of Wisconsin [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Thoracic residency program enrollment continues to decline. While job market and decreasing reimbursements are often cited as the main reasons, length of and format of training may also be significant. Methods The Medical College of Wisconsin established an Accreditation Council for Graduate Medical Education-approved 6-year integrated thoracic training program. The number and characteristics of applicants to the 6-year program were then compared with previous applicants applying to the traditional 2-year program. Results Applicants to the 6-year integrated program scored higher on the United States Medical Licensing Examination part 1 and part 2 than previous applicants to the traditional2-year program. The 6-year applicants also were more published and a greater percentage of them held other advanced degrees. Conclusions Institution of a 6-year integrated thoracic surgery training program at the Medical College of Wisconsin led to a significant increase in number of applications. Additionally, the 6-year applicants appeared to be more academically accomplished than previous applicants to the traditional 2-year program. While early in the experience, it appears that interest in thoracic surgery is high among medical students and institution of a 6-year program has the potential to once again attract the "best and the brightest" to this specialty.

Reoperation After the Ross Procedure: Incidence, Management, and Survival [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background The risk of reoperation on the autograft and homograft is the major long-term drawback of the Ross procedure. The incidence and clinical implications of reoperations after the Ross procedure are reported. Methods Between March 1992 and February 2010, 336 consecutive patients had a Ross procedure (mean follow-up, 6.2 ± 4.9 years). Autograft implant technique was freestanding root replacement in 269 patients, subcoronary implantation in 52 patients and a modified root replacement with the autograft included in a Valsalva tube graft in 15. Results Subsequently, 38 patients (11.3%) underwent reoperations, for autograft dilatation in 23 and a significant autograft insufficiency in 9, at 9.6 ± 3.7 years and 2.6 ± 3.9 years, respectively. Aortic and pulmonary infective endocarditis occurred in 3 patients. Three patients underwent a non valve-related cardiac reoperation. Three patients received a transcatheter pulmonary valve implantation after 12.2 ± 1.7 years. At 15 years, freedoms for autograft and homograft explantation (with 95% confidence interval) were 83.3% (77.4%- to 9.2%) and 92.8% (87.6% to 97.9%), respectively. Native aortic valve regurgitation, indexed aortic annulus diameter exceeding 1.35 cm/m2 and autograft diameter were risk factors for dilated autograft reoperation (hazard ratio, 3.23 [95% confidence interval, 1.19 to 8.81], p = 0.02; 3.83 [0.9 to 16.33], p = 0.07 and 1.2 per mm [1.01 to 1.41], p = 0.03), respectively. Conclusions Autograft dilatation was the leading cause of reoperation in patients who underwent root replacement. Long-term follow-up is mandatory to determine whether modifications of the operative technique could limit autograft dilatation.

Surgical Results for Functional Univentricular Heart With Total Anomalous Pulmonary Venous Connection Over a 25-Year Experience [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Surgical results for functional univentricular heart with total anomalous pulmonary venous connection (TAPVC) have been unsatisfactory to date. Methods During a 25-year period until December 2009, 207 TAPVC patients underwent surgical repair at our institute, including 56 with a univentricular heart. The 10-year survival rate was 51.1% with univentricular heart and 84.7% with biventricular heart (p < 0.0001; log-rank, 27.6). Surgical outcomes and risk factors for early and late death after TAPVC repair in univentricular hearts were retrospectively analyzed. Results Patients were aged 3.8 ± 4.3 years and weighed 12.3 ± 10.7 kg at operation. Preoperative diagnoses included heterotaxy syndrome in 55, asplenia in 48, preoperative pulmonary venous obstruction in 35, and pulmonary atresia in 20. TAPVC was classified as I in 22, II in 26, III in 5, and IV in 3. Concomitant procedures included Fontan procedure in 29, bidirectional Glenn procedure in 5, systemic–pulmonary shunt in 11, and pulmonary artery banding in 5. There were 17 hospital deaths and 11 late deaths. Fontan completion was undertaken in 31 (55.3%). Postoperative pulmonary venous obstruction was found in 15. Multivariate analysis identified TAPVC III and IV and pulmonary atresia as risk factors for hospital death. Univariate analysis identified postoperative pulmonary venous obstruction and concomitant systemic–pulmonary shunt as risk factors for hospital and late death. Conclusions TAPVC III, IV, and pulmonary atresia are risk factors for early postoperative death. Intensive intervention, including perioperative management and operation, is required in these complex patients.

Risk Factor Analysis for Second-Stage Palliation of Single Ventricle Anatomy [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Single ventricle hearts can be surgically palliated by a series of operations culminating in the Fontan procedure, which establishes a total cavopulmonary connection. The second-stage procedure creates a physiologic connection between the superior vena cava and the pulmonary artery. Methods From 1998 to 2010, 557 patients with single ventricle heart disease underwent second-stage surgical palliation. This cohort was retrospectively analyzed to assess patient outcome by a number of anatomic, physiologic, and procedural factors. The analysis excluded patients undergoing hybrid first-stage procedures. Results The median age at operation was 165 days (range, 59 days to 49 years). The most common anatomic subtypes were hypoplastic left heart syndrome (52%), tricuspid atresia (12%), unbalanced atrioventricular septal defect (10%), double inlet left ventricle (9%), or other (17%). Left ventricular hypoplasia was present in 70%. A hemi-Fontan procedure was done in 89%, and 11% received a bidirectional Glenn. Concomitant atrioventricular valve repair was necessary in 9%. Early mortality was 4.7%, and 5.9% died after discharge but before Fontan. No early or late deaths occurred in patients with tricuspid atresia and double inlet left ventricle. Multivariate analysis demonstrated ventricular dysfunction, atrioventricular valve regurgitation, and unbalanced atrioventricular septal defect were significant adverse risk factors for survival to Fontan. Conclusions Second-stage palliation can be performed at low risk for patients with left ventricular dominance, but significant risk remains for patients with left ventricular hypoplasia and unbalanced atrioventricular septal defect. Atrioventricular valve insufficiency is a persistent problem that has not been neutralized by repair strategies.

Radionuclide and Angiographic Assessment of Pulmonary Perfusion After Fontan Procedure: Comparative Interim Outcomes [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Right-side heart function is essentially externalized during extracardiac total cavopulmonary connection. The Fontan procedure has a certain impact on pulmonary hemoperfusion and may explain various postsurgical complications. In this study, alterations of pulmonary perfusion in patients undergoing the Fontan procedure were analyzed at the 5-year postoperative mark by radionuclide imaging and angiocardiography, and results of both methods were compared. Methods For 43 post-Fontan patients, perfusion ratios of each lung segment were calculated based on radionuclide imaging data. The pulmonary vascular resistance and pulmonary artery index of each patient were also calculated from right angiocardiographic measurements. Results The radionuclide count and advantage perfusion ratio of right lung at follow-up did not differ significantly from early postoperative values (t = 0.38, p > 0.05; t = 1.12, p > 0.05), and superior/inferior vena cava perfusion ratios were stable (t = 0.88, p > 0.05; t = 0.74, p > 0.05). The superior/inferior segment perfusion ratio of the whole lung declined significantly (t = 2.54, p < 0.05), while that of the dorsal lung segment rose significantly (t = 2.16, p < 0.05). Compared with early postoperative status, the pulmonary arterial index of patients at follow-up were significantly increased (t = 2.41, p < 0.05), while small pulmonary vascular resistances declined significantly (t = 2.08, p < 0.05; t = 2.69, p < 0.05), and arterial oxygen saturation levels were unaltered (t = 1.12, p > 0.05). The early angiographic and radionuclide perfusion studies of 5 patients did not match. Conclusions After the Fontan procedure, hypostatic redistribution of pulmonary blood flow is characteristic. The weak pulse of blood, in the absence of ventricular ejection, can promote pulmonary vascular changes, but at later (intermediate) follow-up, the decline in vascular resistance that results carries no benefit in terms of blood perfusion or oxygenation. Microcirculatory arteriovenous shunting is the likely cause. In this study of functional pulmonary hemoperfusion, radionuclide imaging was deemed superior to angiocardiography.

Evolution of Mitral Valve Replacement in Children: A 40-Year Experience [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors. Methods From 1970 to 2010, 97 patients have undergone a total of 136 MVRs. Median age was 8 years (2 weeks to 18 years), 41 patients (42%) were less than 5 years, and 16 were infants (17%). Etiology was congenital in 65 patients (67%), rheumatic in 27 (28%), and endocarditis in 5 (5%). Regurgitation was the predominant lesion in 67 patients (69%), stenosis in 23 (24%), and mixed in 7 (7%) patients. Mechanical valves (ball, n = 11; or bileaflet disc, n = 66) and xenografts (porcine, n = 14; bovine, n = 2) were used in 93 initial MVR patients. Since 2002, 5 children have undergone Ross MVR with a pulmonary autograft in 3 and an aortic homograft in 2. Results Hospital mortality was 6% (6 of 97). There were 23 late deaths and 5 patients have required cardiac transplantation. Thirty-five year actuarial survival was 71%. Age less than 2 years, MVR prior to 1980, atrioventricular septal defect, univentricular heart, and additional left side obstructions were significant predictors of death. Mean follow-up was 12.8 ± 10.1 years (range, 2 months to 38 years). Seventeen patients with mechanical valves experienced systemic emboli in 9 (10%), valve thrombosis in 5 (6%), and bleeding requiring transfusion in 3 (3%) patients. Thirty-two patients required reoperations (35%) from 3 months to 14 years (mean, 6.5 ± 4.4 years) after initial MVR. Actuarial freedom from reoperation at 35 years was 63%. Variables associated with mitral re-replacement were younger age, small weight, valve diameter less than 23 mm, MVR prior to 1980, and type of implanted valves (xenograft, single-leaflet disk, ball-caged, or human valves). Conclusions Pediatric MVR can be performed with low initial mortality but should be reserved for medical and reconstruction failure because reoperation, valve-related complications, and late mortality are high. Bileaflet prostheses larger than 23 mm have the lowest reoperation risk. Ross MVR may offer select patients a durable tissue valve without lifelong anticoagulation and its associated complications.

Permanent Epicardial Pacing in Pediatric Patients: 12-Year Experience at a Single Center [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Permanent cardiac pacing is not often done in children, and when done is usually accomplished through epicardial pacing. We reviewed a 12-year experience with the implantation of epicardial pacemakers by our clinical group. Methods Fifty-three patients who underwent their first implantation of an epicardial pacemaker before the age of 18 years and between 1997 and 2009 were included in our study. The mean age of the patients at the time of first pacemaker implantation was 5.7 ± 4.8 years. Indications for pacemaker implantation included postoperative or congenital atrioventricular block and sinus node dysfunction. The patients underwent 105 operations for the replacement of pacemaker pulse generators and 75 operations for the replacement of pacemaker leads. The most commonly used generator mode was the rate-responsive accelerometer-based (DDDR) mode, which was used in 40.9% of the patients. We used more non-steroid-eluting leads (70.1%) than steroid-eluting leads (29.1%). Results The overall duration of follow-up in the study was 8.0 ± 4.5 years (range, 2.1 months to approximately 17.0 years). Freedom from the need for generator replacement was 98.0%, 60.7%, and 11.1% at 1, 5, and 8 years, respectively. A tendency toward early generator exhaustion was observed among younger patients (p = 0.058). The generator mode used for pacing did not significantly affect generator longevity. Freedom from the need for lead replacement was 98.3%, 83.8%, and 63.6% at 1, 5, and 10 years, respectively. The mean longevity of the leads used in the study was 10.8 ± 0.8 years. Neither patient age at the time of lead implantation nor type of lead significantly affected lead longevity. Conclusions Lead longevity was sufficiently long and did not vary significantly according to type of lead. Generator longevity was not affected by lead type, generator mode, or patient age at the time of pacemaker implantation.

Invited Commentary [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Fibrin Sealant Provides Superior Hemostasis for Sternotomy Compared With Bone Wax [NEW TECHNOLOGY]

Purpose The purpose of this study was to evaluate the hemostatic efficacy and feasibility of direct injection of fibrin sealant into the sternal marrow cavity in senior patients undergoing on-pump coronary artery bypass grafting (CABG). Description A total of 82 senior patients undergoing on-pump CABG were randomized to the bone wax group (n = 40) or the fibrin sealant group (n = 42) for the period July 2010 to January 2011. Evaluation The fibrin sealant–treated group had less chest drainage in the first 24 hours (186.67 ± 49.53 versus 333.75 ± 60.49 mL), less total chest drainage (326.19 ± 67.24 versus 516 ± 88.46 mL), less packed red blood cell (PRBC) administration (3.6 ± 1.25 versus 7.4 ± 2.13 U), less fresh frozen plasma (FFP) administration (5.52 ± 1.64 versus 8.95 ± 1.77 U), shorter intubation time (40.36 ± 8.62 versus 46.25 ± 10.46 hours), and shorter hospital stay (10.45 ± 1.17 versus 11.03 ± 1.37 days) compared with the bone wax group. No significant difference in the incidence of postoperative complications was found. Conclusions Direct injection of fibrin sealant into the sternal marrow cavity significantly reduces the amount of postoperative blood loss and offers an attractive new treatment alternative for senior patients undergoing on-pump CABG.

Angioplasty With Autologous Pericardium for Bilateral Coronary Ostial Stenosis in Takayasu Disease [CASE REPORTS]

Coronary ostial stenosis is usually treated by conventional coronary artery bypass graft surgery. Although patch angioplasty is a widely accepted alternative surgical treatment, it has been reported sporadically. We encountered bilateral ostial stenosis with Takayasu disease. This report describes successful patch angioplasty using glutaraldehyde-treated autologous pericardium of bilateral coronary ostial stenosis owing to Takayasu disease.

Transcatheter Aortic Valve-in-Valve-in-Valve Implantation for a Failed Xenograft [CASE REPORTS]

A 78-year-old gentleman with a diagnosis of symptomatic severe xenograft aortic stenosis with multiple comorbidities was referred for transcatheter aortic valve implantation, that is, a "valve-in-valve" procedure. Transcatheter aortic valve implantation was performed by transapical approach using a balloon-expandable bioprosthesis. During valve deployment, the prosthesis moved toward the left ventricle and a second balloon-expandable valve was implanted within the first one—a "valve-in-valve-in-valve" to avoid further ventricular embolization of the first bioprosthesis. Echocardiography at hospital discharge showed a residual mean transvalvular gradient of 17 mm Hg and trivial paravalvular aortic regurgitation. At 1 year follow-up, the patient was in New York Heart Association functional class II.

A Bad Experience With Endovascular Treatment of an Aortobronchial Fistula [CASE REPORTS]

A 35-year-old woman presented with an aortobronchial fistula after polyester graft replacement of coarctation of the descending thoracic aortic. Treatment of the fistula included antibiotic therapy and stent graft placement. Life-threatening sepsis developed in the postoperative period. Subsequent treatment required excision of the infected graft complex with extra-anatomic reconstruction of the thoracic aorta. The patient had a very stormy postoperative course and required heroic measures, including mechanical circulatory support, to achieve survival. The present case demonstrates failure of endovascular therapy of an aortobronchial fistula. The case should serve as a cautious reminder that the underlying cause for infection remains even after apparent successful endovascular therapy.

Type B Aortic Dissection After the Use of Tadalafil [CASE REPORTS]

A 63-year-old male patient with a type B aortic dissection after the use of tadalafil, a phosphodiesterase type 5 inhibitor, is presented. The possible role of a novel predisposing factor—sexual activity combined with tadalafil—is reviewed. This report and three other cases add a new dimension to the known predisposing factors such as chronic systemic hypertension, hereditary connective tissue diseases– and congenital aortic valve diseases. However, the precise role of phosphodiesterase type 5 inhibitors in the pathophysiology of aortic dissection remains unknown.

Fatal Hemorrhagic Infarction of Posterior Fossa Meningioma During Cardiopulmonary Bypass [CASE REPORTS]

Few publications address cardiac surgery in the presence of meningioma. Individual complications include transient visual loss from a suprasellar meningioma, hemiparesis after mitral valve replacement with recovery after resection, and non-fatal hemorrhage into a posterior fossa meningioma. The largest report of 16 patients with known meningiomas over 11 years suggested a benign course, with no new neurologic symptoms and no required resection of a meningioma over an average follow-up of 31 months. In 2 cases we report a presumed posterior fossa meningioma led to fatal outcome after cardiac surgery performed on bypass. Possible causes and future considerations are discussed.

Occlusion of Modified Blalock-Taussig Shunt After Clopidogrel Cessation [CASE REPORTS]

It has been suggested previously that rebound hypercoagulability may be responsible for morbidity and mortality following clopidogrel cessation in adults with acute coronary syndrome. We report a case of acute occlusion of a modified Blalock-Taussig shunt in an infant after clopidogrel discontinuation.

Modified Starnes Procedure in a Neonate With Severe Tricuspid Regurgitation [CASE REPORTS]

We report a modification of the Starnes technique for palliating severe tricuspid regurgitation associated with a dysplastic right ventricle in a neonate, using a fenestrated pericardial patch allowing for unidirectional flow. The patient eventually underwent a successful Glenn shunt construction with a persistent reduction in right ventricle size at 1 year follow-up.

Transventricular Pulmonary Valve Implantation in Corrected Truncus Arteriosus [CASE REPORTS]

Conventional surgery for revision of right ventricular outflow tract conduits is complex and demanding. Percutaneous implantation of pulmonary valves may not be feasible in all cases. We describe a safe, alternative hybrid transapical approach from the right ventricle that avoids the extensive dissection and potential complications of revision surgery.

Retrocardiac Herniation of Atelectatic Lung Into the Opposite Chest [CASE REPORTS]

A 64-year-old man with a history of esophageal adenocarcinoma status postneoadjuvant therapy underwent esophagogastrectomy. Postoperatively he was found with increasing dyspnea and oxygen requirements. Computed tomography of the chest showed retrocardiac herniation of atelectatic lung into the contralateral hemithorax.

Traumatic Bronchial Rupture and Platypnea-Orthodeoxia [CASE REPORTS]

A patient with blunt trauma and traumatic bronchial rupture and lung collapse had prominent symptoms of platypnea-orthodeoxia syndrome. These symptoms were relieved by bronchial repair. The syndrome is rarely seen and is usually associated with a patent foramen ovale or atrial septal defect. The syndrome has not been described previously in association with traumatic bronchial rupture.

A Rare Case of Bilateral Massive Hemothorax From Spontaneous Rupture of a Primary Mediastinal Mixed Germ Cell Tumor [CASE REPORTS]

Spontaneous rupture of a mediastinal germ cell tumor, while rare, is always accompanied by bleeding. In this report, we describe a case of a primary mediastinal mixed germ cell tumor that presented with bilateral massive hemothorax and hemorrhagic shock. An urgent thoracotomy, which was performed to control bleeding, confirmed bilateral hemothorax secondary to a ruptured mediastinal tumor. Pathologic diagnosis revealed the mediastinal tumor to be mixed choriocarcinoma and immature teratoma, with lung metastatic choriocarcinoma. The patient recovered well from the operation and received salvage chemotherapy. Two years after diagnosis, the patient remains in remission with no evidence of disease.

Bronchiolitis Obliterans Organizing Pneumonia Due to Titanium Nanoparticles in Paint [CASE REPORTS]

We present a case of a 58-year-old man who experienced Bronchiolitis obliterans organizing pneumonia after a 3-month exposure to polyester powder paint. Mineralogical analysis by transmission electron microscopy of a pulmonary sample and the polyester powder paint he was exposed to showed the presence of titanium dioxide nanoparticles in both. We suggest that exposure to titanium dioxide nanoparticles should be added to the etiology of Bronchiolitis obliterans organizing pneumonia.

Leiomyoma of the Trachea [CASE REPORTS]

Primary tracheal tumors are rare. Approximately 1% of them are leiomyoma. Given the rarity of these lesions, optimal management has not been defined. Bronchoscopic, local surgical excision and partial tracheal resection have all been described. One report of recurrence after resection has been published. The incidence of recurrence following local excision is unknown. We report a case of an incidental tracheal leiomyoma diagnosed and treated with a combined approach.

Life-Threatening Isometric-Exertion Related Cardiac Perforation 5 Years After Amplatzer Atrial Septal Defect Closure: Should Isometric Activity Be Limited in Septal Occluder Holders? [IMAGES IN CARDIOTHORACIC SURGERY]

Multiple Papillary Fibroelastomas on Aortic Valves [IMAGES IN CARDIOTHORACIC SURGERY]

Complete Aortic Arch Remodeling After Stent Graft of Acute Type B Dissection and Kommerell's Diverticulum [IMAGES IN CARDIOTHORACIC SURGERY]

HeartWare Left Ventricular Assist Device Implantation Through Bilateral Anterior Thoracotomy [HOW TO DO IT]

The HeartWare left ventricular assist device (LVAD) is a new addition to the family of second-generation continuous-flow LVADs. The miniaturized dimensions of the HeartWare LVAD provide the opportunity for its safe implantation through nonsternotomy incisions. We present our technique for HeartWare LVAD implantation through bilateral anterior thoracotomy incisions. This technique has proved to be safe and reproducible, with good clinical outcome.

Late Repair of the Native Pulmonary Valve in Patients With Pulmonary Insufficiency After Surgery for Tetralogy of Fallot [HOW TO DO IT]

Pulmonary regurgitation developing late after tetralogy of Fallot repair is now recognized as a serious threat to the long-term welfare of these patients. This article summarizes our experience with 5 patients who underwent reoperations for treatment of severe pulmonary regurgitation after transannular patch repair of tetralogy of Fallot. In each case, the intraoperative findings revealed anatomy favorable for valve repair and enabled preservation of the native pulmonary valves.

A Technique of Aortic Annulus Enlargement With a Freestyle Stentless Bioprosthesis [HOW TO DO IT]

We describe our surgical technique to manage a small aortic annulus during aortic valve replacement. Starting with the posterior annular enlargement incision described by Manouguian, a stentless porcine aortic root, with excision of the left and right porcine coronary segments and conservation of the mural wall (Freestyle MS design, Medtronic, Minneapolis, MN ), was used. The Freestyle bioprosthesis enlarges the aortic annulus using a direct suture of the valve on the enlarged annulus, and the aorta is closed by a direct suture of the mural wall of the bioprosthesis. Therefore, the aortic annulus enlargement is made only using the aortic bioprosthesis, without other material.

A Novel Cardiac Positioning Device for Left Main Coronary Artery Stenosis [HOW TO DO IT]

Significant hemodynamic alterations often occur during off-pump coronary artery bypass operations. Historically, left main coronary artery stenosis has been excluded from off-pump coronary artery bypass operations because of this concern. Many articles in recent times support off-pump operations in left main coronary artery (LMCA) stenosis. We describe here a safe and effective method to reduce the incidence of hemodynamic changes during beating heart surgery in patients with LMCA stenosis.

Mitral Valve Repair With Artificial Chordae: A Review of Its History, Technical Details, Long-Term Results, and Pathology [REVIEW]

Mitral valve repair is considered the procedure of choice for correcting mitral regurgitation in myxomatous disease, providing long-term results that are superior to those with valve replacement. The use of artificial chordae to replace elongated or ruptured chordae responsible for mitral valve prolapse and severe mitral regurgitation has been the subject of extensive experimental work to define feasibility, reproducibility, and effectiveness of this procedure. Artificial chordae made of autologous or xenograft pericardium have been replaced by chordae made of expanded polytetrafluoroethylene (PTFE), a material with the unique property of becoming covered by host fibrosa and endothelium. The use of artificial chordae made of PTFE has been validated clinically over the past 2 decades and has been an increasing component of the surgical armamentarium for mitral valve repair. This article reviews the history, details of the relevant surgical techniques, long-term results, and fate of artificial chordae in mitral reconstructive surgery.

A Better Option for Patients With TGA/VSD and Severe Pulmonary Hypertension Undergoing Palliative Arterial Switch Operation [CORRESPONDENCE]

Reply [CORRESPONDENCE]

Isoosmotic Hyponatremia After HTK-Induced Cardioplegia [CORRESPONDENCE]

Reply [CORRESPONDENCE]

How Much Is Safe: The Flow of Antegrade Cerebral Perfusion During Deep Hyperthermia Circulatory Arrest [CORRESPONDENCE]