Thoracic RSS : Gourt

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

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

Cerfolio Named Endowed Chair for Lung Cancer Research at UAB - UAB News

Cerfolio Named Endowed Chair for Lung Cancer Research at UABUAB NewsCerfolio joined the faculty of the UAB Department of Surgery in 1996, becoming professor and section chief of thoracic surgery in the Division of ...and more »

Looking after their own: Surgeons may provide better care than intensivists in ICU - TheHeart.Org

Looking after their own: Surgeons may provide better care than intensivists in ICUTheHeart.OrgFort Lauderdale, FL - Thoracic surgeons can provide better care to critical cardiac patients in the ICU than intensivists not board-certified in thoracic ...and more »

Library of hearts teaches what books can't - Chicago Tribune

Chicago TribuneLibrary of hearts teaches what books can'tChicago TribuneEven Backer, a pediatric open- heart surgeon who is head of the division of cardiovascular-thoracic surgery at Children's, does not have a key. ...

Mesothelioma Prognostic Factors Studied in Long-Term Survivors - Asbestos.com

Mesothelioma Prognostic Factors Studied in Long-Term SurvivorsAsbestos.comThe purpose of the prognostic study, published in The Annals of Thoracic Surgery, was to assess prognostic features in long-term pleural mesothelioma ...

Former Roman provides medical help in Haiti, says rebuilding effort will take ... - Rome News Tribune

Former Roman provides medical help in Haiti, says rebuilding effort will take ...Rome News Tribune... Augusta and the University of Kentucky Medical Center specializing in surgery. He practiced in general and thoracic surgery in Boone, NC, until he retired.and more »

New Ways to Calculate the Risks of Surgery - Wall Street Journal

New Ways to Calculate the Risks of SurgeryWall Street JournalFor example, the Society of Thoracic Surgeons offers heart surgeons a calculator to predict the risk of death and complications from heart-bypass and other ...and more »

Dr. Craig R. Smith Named Chair of Surgery and Surgeon-in-Chief at Columbia ... - Newswise (press release)

Dr. Craig R. Smith Named Chair of Surgery and Surgeon-in-Chief at Columbia ...Newswise (press release)Currently vice president of the American Association for Thoracic Surgery, he has been named president of that organization, a post he will assume in May ...

Ten-year experience with off-pump coronary artery bypass grafting: Lessons ... - The Journal of Thoracic and Cardiovascular Surgery

Ten-year experience with off-pump coronary artery bypass grafting: Lessons ...The Journal of Thoracic and Cardiovascular SurgeryRead at the Eighty-ninth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 9–13, 2009. Received for publication April 30, ...The Graft Imaging to Improve Patency (GRIIP) clinical trial resultsThe Journal of Thoracic and Cardiovascular Surgeryall 3 news articles »

Decision support in surgical management of ischemic cardiomyopathy - The Journal of Thoracic and Cardiovascular Surgery

Decision support in surgical management of ischemic cardiomyopathyThe Journal of Thoracic and Cardiovascular SurgeryAddress for reprints: Nicholas G. Smedira, MD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave/Mail Stop J4-1, ...Second Arterial Conduit Improves Survival After Coronary Artery Bypass ...DG Newsall 2 news articles »

Host Marfan Syndrome Surgery Series at MVCC - Southwest News-Herald

Host Marfan Syndrome Surgery Series at MVCCSouthwest News-HeraldMalaisrie is board certified by both the American Board of Surgery and the American Board of Thoracic Surgery. He performs the full spectrum of cardiac ...

Throw-off instruments for advanced thoracoscopic procedures [New ideas - Thoracic non-oncologic]

Performing complex thoracoscopic procedures can necessitate the use of multiple instruments and, consequently, the use of multiple ports. This results in parietal harm and in overcrowding of the operative field with instrument conflicts. We present the interest of using lung retractors and vascular clamps that can be released inside the chest cavity without blocking a trocar access.

Expandable device type III for easy and reliable approximation of dissection layers in sutureless aortic anastomosis. Ex vivo experimental study [Work in progress report - Experimental]

In past years, we developed expandable devices (type I and II) for sutureless aortic anastomosis. We have now further modified the device (type III) incorporating a second expandable ring, external to the main one, which can be operated contrariwise in such a way that the aortic wall (i.e. the dissection layers) is compressed between the two expandable rings, providing full control on both the layers compression pressure and the anastomosis final diameter. The device was evaluated in ex vivo experimental models of swine aortic arch fresh samples; air-tight sealing at increasing endovascular pressures was also evaluated and compared with sealing achieved by standard suturing. Ex vivo data suggest that the present version of the device can be used easily and quickly also in elliptical, asymmetric ‘oblique’ anastomosis as when concavity arch is involved. Perfect air-tight sealing of the anastomosis was verified at endovascular pressures up to 150 mmHg, while standard suture cannot withstand even minimal endovascular air pressure. Compared to the previous versions, the present device is less bulky and softer, can be used also for concavity arch resection and provides full and standardizable control on dissection layers stable and sealed approximation.

Preliminary experience with the no prolapse system. A new device for ensuring the proper length of artificial chordae in mitral valve repair [Work in progress report - Valves]

Mitral valve repair is the procedure of choice to treat mitral valve regurgitation. However, the feasibility and durability of repair are influenced strongly by the valve pathology. The classic features of degenerative mitral valve disease include leaflet prolapse and annular dilatation. Risk of repair failure is increased by isolated anterior leaflet prolapse or bileaflet prolapse. A variety of techniques have been used to treat this pathology. The most popular include partial leaflet resection, chordal shortening, chordal transfer and chordal replacement. Use of artificial chordae with expanded polytetrafluoroethylene (e-PTFE) sutures is a well-known technique for mitral valve repair and long-term data validate this approach. The primary challenges with this technique are judging the proper length of the neochordae and tying the PTFE. Several different techniques have been proposed to solve these items but none of the established are very satisfactory. I describe a preliminary experience with a new device to determine the correct length of the neo-chordae and tying the knots without sliding in ten patients with severe mitral insufficiency referred for mitral valve repair.

Influence of clamp duration and pressure on endothelial damage in aortic cross-clamping [Work in progress report - Cardiopulmonary bypass]

Aortic cross-clamping during cardiac operations may injure the vessel wall and cause tissue lesions. This experimental study analyses the influence of the intravascular and external pressure and the duration of aortic cross-clamping on endothelial tissue damage. Fresh porcine aortas (n=20) were tested with intravascular pressures from 30 to 80 mmHg. The external clamp pressure, necessary to occlude the aorta, was applied by using the second cog of a commercial aortic clamp and cross-clamping was performed for 1 and 30 min. The observed pressure curves were compared to the histological findings. For occlusion of the aorta, an external pressure of at least 10-fold higher than the intravascular pressure (max. 812 mmHg) had to be applied. After 30 min of clamping, a complete endothelial destruction was observed, irrespective of intra-aortic pressure. The aortic media remained intact. After 1 min clamping, fractions of intact endothelial cells were left, ranging from 40 to 70% at different intra-aortic pressures. These results indicate that endothelial tissue lesions due to aortic cross-clamping are not avoidable, even in moderate clamp application. The duration of aortic cross-clamping but not intravascular pressure is the pivotal factor. The integrity of the aortic media can be preserved if low-force cross-clamping is achieved.

eComment: Influence of cross-clamp duration and pressure on aortic damage [eComment]

Isolated rib metastases from renal cell carcinoma [Institutional report - Thoracic oncologic]

Osseous metastases of renal cell carcinoma (RCC) are the second most frequent location after lung metastases. They rarely present as isolated location. When isolated, resection may offer five-year survival rates of 30–60%. The purpose of the current study is to focus on a particular subset, the isolated rib metastases (IRM). The files of six patients who underwent radical resection for IRM were reviewed. All had previous radical nephrectomy for clear-cell renal cancer. The mean age of these six men was 55.3 years. Preoperative evaluation included in all patients a conventional chest radiograph and thoracic computed tomography (CT) scanning. Chest wall resections were wide and curative. The mean disease-free interval (DFI) after renal cancer treatment was 25 months. There was no postoperative death. Two patients had synchronous disease. One of them developed two recurrences operated on by large resections. They survived for 77 and 81 months. The overall five and ten-year survival rates were respectively, 83 and 66.7%. IRM of RCC are rare and remain not well-known. Surgical wide resection is a safe and effective treatment.

Complete video-assisted thoracoscopic surgery lobectomy and its learning curve. A single center study introducing the technique in The Netherlands [Institutional report - Thoracic oncologic]

Data regarding the benefits for the complete video-assisted thoracic surgery (c-VATS) lobectomy over the open lobectomy are numerous. This article describes the experience of introducing this technique in a training hospital, the first reported cohort in The Netherlands. From March 2006 to November 2008, all patients operated on for proven or suspected lung cancer were analyzed. Prospective data from these patients were evaluated. A subgroup analysis for the c-VATS lobectomy is presented. A total of 184 operations were performed on 172 patients. In 122 (66.3%) of the operations the resection ended in a lobectomy of which 70 were done by complete thoracoscopic procedure. For the c-VATS lobectomy the mean operating time was 179 min, with a mean blood loss of 444 ml. The median hospital stay was four days. Complications were present in 10% of c-VATS lobectomies. No mortality was seen in the c-VATS group. After thorough evaluation and training, c-VATS lobectomy is a safe procedure that can be performed in a relatively low volume hospital. It has exceptional short-term benefits. For training purposes all operations must start thoracoscopically. All patients must be operated according the intention to treat method.

Deferoxamine, the newly developed iron chelator LK-614 and N-{alpha}-acetyl-histidine in myocardial protection [Institutional report - Experimental]

During cold storage of donor hearts, reactive oxygen species produced by intracellular redox-active chelatable iron potentially alter myocardial function. To reduce this cold-induced injury we investigated the efficacy of two new modifications of the well established histidine-tryptophan-ketogluterate (HTK) solution (Custodiol®) with the addition of N--acetyl-l-histidine and iron-chelators in a heterotopic rat heart transplantation model. The donor hearts were cardioplegically arrested with 20 ml cardioplegia and stored for 1 h. Then the hearts were anastomosed to the abdominal aorta and vena cava of the recipient (n=30). After 1 h reperfusion, myocardial function and energy charge potential were measured in three groups: HTK-1: addition of l-arginine and N--acetyl-l-histidine; HTK-2: addition of iron-chelators deferoxamine and LK-614; traditional HTK – control. After 1 h reperfusion, left ventricular systolic pressure (106±33 vs. 60±39, vs. 67±8 mmHg, P<0.05) and dP/dt minimal (–1388±627 vs. –660±446, vs. 871±188 mmHg/s, P<0.05) were significantly higher in the HTK-1 group. Energy charge potentials were not significantly different. This study showed that the novel modified HTK-1 solution improves myocardial contractility and relaxation after heart transplantation. Nevertheless, addition of the iron-chelators deferoxamine and LK-614 diminished these beneficial effects.

Staging algorithm for diffuse malignant pleural mesothelioma [Institutional report - Pulmonary]

An algorithm of preoperative mediastinal nodal staging with endobronchial/endoesophageal ultrasonography (EBUS/EUS) and transcervical extended mediastinal lymphadenectomy (TEMLA) combined with laparoscopy/peritoneal lavage and cytology was analyzed to establish the realistic criteria for radical multimodality treatment of malignant pleural mesothelioma (MPM). The algorithm included computed tomography (CT), thoracoscopy with multiple pleural biopsies and talc pleurodesis, EBUS/EUS and one-stage TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid. Forty-two patients were diagnosed from 1 January 2004 to 31 December 2008. There were 16 women and 26 men in ages ranging from 43 to 77 years (mean 57.8); 31 epithelioid, 2 sarcomatoid and 9 biphasic type MPM. 21/42 patients were considered possible candidates for multimodality treatment. Three patients who received neoadjuvant chemotherapy were excluded from this study. EBUS/EUS was performed to stage the mediastinal nodes. In 3/18 patients metastatic nodes were discovered. In the rest of the 15 patients simultaneous TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid were performed. In three patients TEMLA was positive, in six patients laparoscopy was positive and in two patients both TEMLA and laparoscopy were positive. Finally, 4/42 (9.5%) patients underwent thoracotomy with one exploration (chest wall infiltration) and three pleuropneumonectomies with the subsequent chemo- and radiotherapy. The proposed algorithm of preoperative staging spared the majority of MPM patients from futile surgery.

Early outcomes using alemtuzumab induction in lung transplantation [Institutional report - Transplantation]

Immunosuppressive regimens for lung transplantation frequently fail to prevent rejection and are toxic. Alemtuzumab was used as induction to investigate whether oral immunosuppression could be reduced. From November 2006 to March 2008, 20 consecutive lung transplant patients received alemtuzumab induction, with reduced maintenance immunosuppression; tacrolimus (target level 10 ng/ml), mycophenolate mofetil (MMF) 250 mg bid and prednisone 7.5 mg. Twenty control cases transplanted before 2006 were treated with standard immunosuppression; tacrolimus (target level 10 ng/ml), MMF 750 mg bid and prednisone 15 mg qd. End-points included patient and graft survival, acute rejection (AR) and infection rate. There were no significant differences in six-month and 12-month survival (alemtuzumab 90% vs. controls 95%, P=0.52 and 76% vs. 95%, respectively, P=0.19). AR events were similar (alemtuzumab 2/16 vs. controls 5/20, P=0.43) – as were – bacteria positive bronchoalveolar lavage (BAL) cultures (alemtuzumab 4.9±7.3 per patient per year vs. controls 2.7±3.3, P=0.26) and viral or fungal infections (alemtuzumab 0.4±1.4 per patient per year vs. controls 0.1±0.3, P=0.87; alemtuzumab 3.9±6.6 vs. controls 2.3±1.9, P=0.57, respectively). Alemtuzumab induction and reduced immunosuppression appears to offer comparable early survival, rejection and infection rates to high-dose standard immunosuppression.

Smoking behaviour and attitudes in patients undergoing cardiac surgery. The Radboud experience [Institutional report - Cardiac general]

Changes in smoking behaviour and attitudes of 2642 patients, undergoing cardiac surgery, between January 2000 and July 2008 were studied. All patients completed a preoperative questionnaire concerning smoking behaviour and attitude. Study endpoints are behaviour and attitude in relation to tobacco use in hospitals, cessation smoking before and after the operation. Over the years there have been no notable differences in smoking behaviour, however, significantly less patients accept smoking in the hospital (0.9% vs. 5.3%). Significantly more patients stopped within the two weeks before surgery (9.4% vs. 5.3%). The percentage of patients who did not have the intention to stop smoking after the operation did not decrease significantly. Significantly less older patients smoke (1.6% vs. 13.4%) and are less tolerant towards smoking in the hospital (1.8% vs. 4.1%). A significant higher percentage of older patients have stopped smoking over five years before the operation. Concerning the intention to stop smoking after the operation, there is no significant difference. These results show that over the years, patients undergoing cardiac surgery seem to be more aware about the relation between health and smoking. This is not related to the type of operation, however, apparently with age.

The role of integrated positron emission tomography and computed tomography in the assessment of nodal spread in cases with non-small cell lung cancer [Institutional report - Thoracic oncologic]

Integrated positron emission tomography and computed tomography (PET/CT) scanning has become the standard for oncologic imaging. We sought to determine the role of PET/CT in mediastinal non-small cell lung cancer staging. One hundred and twenty-seven consecutive patients were enrolled in the study where PET/CT was performed due to pathologically defined non-small cell carcinoma from a single center. They all underwent complete resection with a thoracotomy and systemic lymph node dissection (SLND) between October 2005 and January 2007. Postoperative pathology results of lymph node stations regarding the nodal spread and stage were compared with clinical stage obtained by PET/CT. The sensitivity, specificity, accuracy, negative predictive value (NPV) and positive predictive value (PPV) of PET/CT in N2 cases were determined to be 72.0%, 94.4%, 92.7%, 97.7% and 49.2%, respectively. Maximum standard uptake (SUVmax) cut-off value for mediastinal N2 involvement in PET/CT was obtained by applying ‘receiver operating characteristic’ (ROC) analysis that was set to 5.2. Correct stage with PET/CT was established in 76.3% of cases. Staging of non-small cell lung cancer (NSCLC), according to the PET/CT for which we determined 97.79% NPV, we consider that thoracotomy without preoperative mediastinal invasive staging in cases of negative mediastinal involvement in PET/CT can be certainly performed.

Ultrasound estimation of volume of postoperative pleural effusion in cardiac surgery patients [Institutional report - Cardiac general]

The aim of this study was to establish a practical simplified formula to facilitate the management of a frequently occurring postoperative complication, pleural effusion. Chest ultrasonography with better sensitivity and reliability in the diagnosis of pleural effusions than chest X-ray can be repeated serially at the bedside without any radiation risk. One hundred and fifty patients after cardiac surgery with basal pleural opacity on chest X-ray have been included in our prospective observational study during a two-year period. Effusion was confirmed on postoperative day (POD) 5.9±3.2 per chest ultrasound sonography. Inclusion criteria for subsequent thoracentesis based on clinical grounds alone and were not protocol-driven. Major inclusion criteria were: dyspnea and peripheral oxygen saturation (SpO2) levels ≤92% and the maximal distance between mid-height of the diaphragm and visceral pleura (D≥30 mm). One hundred and thirty-five patients (90%) were drained with a 14-G needle if according to the simplified formula: V (ml)=[16xD (mm)] the volume of the pleural effusion was around 500 ml. The success rate of obtaining fluid was 100% without any complications. There is a high accuracy between the estimated and drained pleural effusion. Simple quantification of pleural effusion enables time and cost-effective decision-making for thoracentesis in postoperative patients.

Left ventricular circumferential plication: novel off-pump ventricular restoration in swine model [Institutional report - Experimental]

We hypothesized that left ventricular (LV) and subvalvular geometries could be restored in a less invasive manner by circumferential plication without a ventriculotomy or a cardiopulmonary bypass (CPB). Continuous sutures were placed circumferentially on the epicardial surface of the LV wall without using a CPB in six healthy pigs. Coronary artery occlusion was precluded by placing the sutures underneath the peripheral coronary artery. After the circumferential sutures were plicated to 75% of the original length, hemodynamics were recorded and LV geometries and function were measured. All animals survived after plication without arrhythmia or hemodynamic deterioration. Angiogram findings demonstrated that plication reduced the LV end-diastolic volume (LVEDV) (72±10 vs. 58±12 ml, P<0.05), and sphericity (0.62±0.04 vs. 0.58±0.03, P<0.05). Also, three-dimensional echocardiography (3D-echo) showed that plication reduced the papillary muscle distance (27±3 vs. 18±2 mm, P<0.05). We demonstrated the effectiveness of off-pump circumferential plication, which reduced LV volume and altered subvalvular geometry without causing hemodynamic deterioration in an acute animal model. This pilot study suggests that our novel technique is feasible and should next be tested in a chronic model with a dilated failing heart, before clinical application is warranted.

A new absorbable collagen membrane to reduce adhesions in cardiac surgery [Institutional report - Experimental]

Reduction of sternal adhesions is still an issue in cardiac surgery. To evaluate a new fibrillar porcine collagen absorbable membrane (CovaTM CARD), 16 sheep underwent a sternotomy followed by scratching of surface of the heart. They were then divided into three groups: pericardium left opened (n=4), placement of Seprafilm®, the reference absorbable substitute (hyaluronic acid and carboxymethylcellulose, n=6) or of CovaTM CARD membrane (n=6). Four months thereafter, the animals underwent repeat sternotomy and were macroscopically assessed for the degree of resorption of the material and the intensity of adhesions. Explanted hearts were blindly evaluated for the magnitude of the inflammatory response and fibrosis. The CovaTM CARD membrane was almost totally absorbed by four months and replaced by a loosely adherent tissue. There was no inflammatory reaction and both the extent and density of fibrosis were minimal. The composite score (median [min;max]) integrating tightness of adhesions and histological findings of inflammation and fibrosis was two-fold lower in the CovaTM CARD than in the Seprafilm® group (2.0 [0;3.5] vs. 5.5 [3;7], P=0.01 by Wilcoxon test). The CovaTM CARD membrane might represent an attractive pericardial substitute for preventing postoperative adhesions in cardiac surgery.

Variability of ascending aorta diameter measurements as assessed with electrocardiography-gated multidetector computerized tomography and computer assisted diagnosis software [Institutional report - Vascular thoracic]

Recently, morphometric measurements of the ascending aorta have been done with ECG-gated multidector computerized tomography (MDCT) to help the development of future novel transcatheter therapies (TCT); nevertheless, the variability of such measurements remains unknown. Thirty patients referred for ECG-gated CT thoracic angiography were evaluated. Continuous reformations of the ascending aorta, perpendicular to the centerline, were obtained automatically with a commercially available computer aided diagnosis (CAD). Then measurements of the maximal diameter were done with the CAD and manually by two observers (separately). Measurements were repeated one month later. The Bland–Altman method, Spearman coefficients, and a Wilcoxon signed-rank test were used to evaluate the variability, the correlation, and the differences between observers. The interobserver variability for maximal diameter between the two observers was up to 1.2 mm with limits of agreement [–1.5, +0.9] mm; whereas the intraobserver limits were [–1.2, +1.0] mm for the first observer and [–0.8, +0.8] mm for the second observer. The intraobserver CAD variability was 0.8 mm. The correlation was good between observers and the CAD (0.980–0.986); however, significant differences do exist (P<0.001). The maximum variability observed was 1.2 mm and should be considered in reports of measurements of the ascending aorta. The CAD is as reproducible as an experienced reader.

Parabolic resection for mitral valve repair [Institutional report - Valves]

Parabolic resection, named for the shape of the cut edges of the excised tissue, expands on a common ‘trick’ used by experienced mitral surgeons to preserve tissue and increase the probability of successful repair. Our objective was to describe and clinically analyze this simple modification of conventional resection. Thirty-six patients with mitral regurgitation underwent valve repair using parabolic resection in combination with other techniques. Institution specific mitral data, Society of Thoracic Surgeons data and preoperative, post-cardiopulmonary bypass (PCPB) and postoperative echocardiography data were collected and analyzed. Preoperative echocardiography demonstrated mitral regurgitation ranging from moderate to severe. PCPB transesophageal echocardiography demonstrated no regurgitation or mild regurgitation in all patients. Thirty-day surgical mortality was 2.8%. Serial echocardiograms demonstrated excellent repair stability. One patient (2.9%) with rheumatic disease progressed to moderate regurgitation 33 months following surgery. Echocardiography on all others demonstrated no or mild regurgitation at a mean follow-up of 22.8±12.8 months. No patient required mitral reintervention. Longitudinal analysis demonstrated 80% freedom from cardiac death, reintervention and greater than moderate regurgitation at four years following repair. Parabolic resection is a simple technique that can be very useful during complex mitral reconstruction. Early and intermediate echocardiographic studies demonstrate excellent results.

eComment: Physiological chordal stress sharing [eComment]

Tyrosine kinase expression in pulmonary metastases and paired primary tumors [Institutional report - Thoracic oncologic]

Tyrosine kinase inhibitors against the receptors of vascular endothelial growth factor (VEGFR), epidermal growth factor (EGFR) and the platelet derived growth factor (PDGFR) are increasingly used in the treatment of progressive cancers. However, the expression of these receptors especially in lung metastases has not been examined. Tissue specimen from 35 lung metastases of 33 patients with renal cell carcinoma (n=8), sarcoma (n=10), colorectal carcinoma (n=6), otolaryngologic carcinoma (OLC, n=4), testicular and endometrial cancer (n=1 each), malignant melanoma (n=1), adrenal cancer (n=2), malignant fibrous histiocytoma and malignant peripheral nerve sheath tumor (n=1 each) have been immunohistochemically tested for the expression of PDGFR /β, VEGFR and EGFR. None of the patients had been pretreated with angiogenic inhibitors prior to metastasectomy. PDGFR was expressed in all metastases; 31% stained negative for PDGFRβ, 86% negative for VEGFR and 45% negative for EGFR. Primary tumors revealed positive staining for PDGFR in 88%, for PDGFRβ in 59%, for VEGFR in 0% and for EGFR in 18%. Our investigation of a pilot character represents a ‘biomarker-based’ analysis of pulmonary metastases of different primary tumors; we conclude that an immediate ‘tumor profiling’ at initial diagnosis should be considered in order to guide tumor therapy individually.

Quality of life in patients related to gender differences before and after coronary artery bypass surgery [ESCVS article - Coronary]

Objective: The different aspects of quality of life (QOL) in patients of different sex structure have been examined as well as the presumption that sex structure could be a predictor of QOL changes after coronary artery bypass grafting (CABG). Methods: The study included 243 consecutive patients who underwent an elective CABG. The QOL analysis was performed by using structured interviews with the Nottingham Health Profile (NHP) questionnaire part 1. Results: Compared to men, women had worse preoperative QOL (in all sections except the section of sleep) and worse postoperative QOL (in all sections). Six months after CABG the QOL statistically improved in men and in women. Multivariate analysis showed that being female was an independent predictor of QOL worsening in section of pain [P=0.001, odds ratio (OR)=3.93, 95% confidence interval (CI) 1.74–8.88]. Conclusions: Compared to men, women have worse preoperative and postoperative QOL. Female sex was an independent predictor of QOL worsening six months after CABG.

The EuroSCORE - still helpful in patients undergoing isolated aortic valve replacement? [ESCVS article - Cardiac general]

Background: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most prominent scores used for the evaluation of predicted mortality in cardiac surgery. The aim of our study was to analyze the logistic and additive EuroSCORE in view of its accuracy for patients undergoing isolated aortic valve replacement (AVR). Methods: A total of 652 patients underwent isolated AVR from January 1999 to June 2007. Emergency and redo operations were included. Acute endocarditis was excluded. Out of logistic regression analyses, receiver operating characteristic (ROC) curve statistics were calculated both for the logistic and additive EuroSCORE. Results: By using the identical variables used in the EuroSCORE, the area under curve was 70.7% for the logistic and 72.4% for the additive EuroSCORE, respectively. If age, which is by nature positively correlated with increasing cardiac and non-cardiac comorbidity, is calculated as a single parameter, the area under curve remains at 69.9% being very close to the result of the EuroSCORE. Conclusions: For the subgroup of patients undergoing isolated AVR, the use of the EuroSCORE provides a comparable precision concerning the estimation of early mortality compared with the simple factor ‘age’. The extended use of the EuroSCORE in view of percutaneous AVR, the insufficient accuracy of the score bears the risk of incorrect decision-making.

eComment: Re: The EuroSCORE - still helpful in patients undergoing isolated aortic valve replacement? [eComment]

Isolated iliac artery aneurysms: six-year experience [ESCVS article - Aortic and aneurysmal]

Objective: To review the experience of our institution in repairing isolated iliac artery aneurysm (isolated IAA) in the last six years. Methods: The medical records of patients who underwent isolated IAA repair were reviewed, to obtain information on patients' demographics, vascular risk factors, type of treatment and outcome. Results: A total of 11 patients with 16 aneurysms, all men, with a mean age of 69.2±6.0 years were treated. The mean diameter was 3.7±1.0 cm (3.5±1.1 cm at elective repair; 5.7±2.9 cm on the emergency cases). The majority of aneurysms were at the common iliac artery and 27.3% of them were multiple. The diagnosis of multiple aneurysms was performed 10 years later, compared with the mean age of the diagnosis of single aneurysms, and this difference is statistically significant. Seven (63.6%) had elective operations, and one elective endovascular repair. Analysing the vascular risk factors, it was evident that hypertension was the most prevalent and the diagnosis of aneurysm was done 10 years sooner in the smoker patients. There was no postoperative death in this series. The mean follow-up period was of 21 months, and during it, one patient developed a non-infection anastomotic aneurysm of common femoral artery, one died with a myocardial infarction, one presented with limb graft thrombosis and another was lost. Conclusion: This series contributes to a better characterization of a rare pathology demonstrating that both surgical and endovascular treatment can be performed with very low morbidity and mortality.

Impact of preoperative anemia on cardiac surgery in octogenarians [ESCVS article - Cardiopulmonary bypass]

Objectives: Preoperative anemia has been related with adverse outcomes in elective valve replacement and CABG surgery. Impact of preoperative anemia on outcome in octogenarians submitted to cardiopulmonary bypass (CPB) has not yet been precisely described. Methods: We analyzed association between preoperative hemoglobin level, minimum intraoperative and immediate postoperative hematocrit (HCT), and other co-morbidities and occurrence of adverse outcomes in 227 octogenarians who underwent cardiac surgery. Results: Frequency of preoperative anemia was 41.9% (40.4% in male and 43.5% in female patients). Postoperative mortality was 13.2% (9% in non-anemic patients vs. 18.9% in anemic). 44.5% of patients suffered at least one postoperative adverse outcome (43.1% non-anemic vs. 46.3% anemic). In multivariate analysis (after adjusting independent preoperative risk factors for operative mortality and EuroSCORE) preoperative creatinin level [odds ratio (OR), 2.29; 95% confidence interval (CI), 1.06–4.98; P=0.035], immediate postoperative HCT <24% (OR, 2.78; 95% CI, 1.04–7.38; P=0.039), perioperative red blood cell (RBC) transfusion (OR, 1.58; 95% CI, 1.24–2.00; P=0.0001), peripheral vascular disease (OR, 4.92; 95% CI, 1.45–16.69; P=0.012) and urgent surgery (OR, 10.57; 95% CI, 2.54–43.91; P=0.0001) were identified as independent predictors for in-hospital mortality. Conclusions: Mortality and adverse postoperative outcome increase in anemic octogenarians undergoing cardiac surgery. Although mortality is directly related to immediate postoperative anemia, adverse outcomes mainly depend on associated co-morbidities.

Aortocoronary bypass graft fistula after surgical treatment of circumflex coronary artery fistula: a unique variation of a rare condition successfully treated with percutaneous embolization [Proposal for bail-out procedures - Cardiac general]

Multiple coronary artery fistulae are rare, complications can be life-threatening, and with large or symptomatic fistulae, intervention is mandatory. Both surgical and percutaneous interventions are well-described. We believe this is the first report of the embolization of an acquired fistula following initial surgical treatment of multiple congenital fistulae.

Experimental use of an elastomeric surgical sealant for arterial hemostasis and its long-term tissue response [Follow-up papers - Experimental]

Objective: Reliable suture line hemostasis should improve the outcome of aortic surgery. We examined the hemostatic effect and the tissue response of a novel elastomeric surgical sealant. Methods: Using porcine internal carotid arteries, we performed 16 end-to-end anastomoses with four stitches of simple interrupted sutures under full heparinization. The anastomoses were divided into two groups (eight anastomoses per group). Either novel sealant or fibrin glue was applied. The amount of bleeding was measured during the 30 s period after removing the vascular clamp. In a separate experiment, we applied the novel sealant around the abdominal aorta of rabbits (n=6) to assess the effect of the elastomeric property of the sealant on arterial wall histology. For comparison, we applied cyanoacrylate, which has no elastomeric property (n=6). A histological study was performed three months after the operation. Results: The novel sealant prevented arterial bleeding. The amount of bleeding from the anastomoses applied with novel sealant and fibrin glue was 0.12±0.03 g vs. 91.8±16.5 g, respectively (P<0.001). Thinning of the rabbit aortic wall was observed in the cyanoacrylate-treated abdominal aorta, whereas no thinning was observed in the novel sealant group. Histological examination revealed neither cell death nor necrosis in the novel sealant group. Conclusions: The novel sealant effectively prevented arterial bleeding from the anastomosis under full heparinization. In addition, the elastomeric property of the sealant prevented thinning of the aortic wall. The novel sealant may be a promising hemostatic agent for arterial anastomosis.

Volume load paradox while preparing for the Fontan: not too much for the ventricle, not too little for the lungs [State-of-the-art - Congenital]

Ventricular dysfunction is frequently encountered in Fontan patients. Cardiologists and cardiac surgeons have, therefore, mainly focused on preservation of cardiac function, limiting the early volume overload as much as possible both in magnitude and duration. This resulted in improved cardiac function but, in some patients, also in poor pulmonary artery (PA) growth which in turn resulted in a poor final Fontan circuit. The volume requirements for optimal growth and development of the ventricle and the lungs are different and divergent. Avoiding overload of the ventricle is important, but excessive protection from volume overload may not be necessary and may result in PA hypoplasia, which in turn will severely affect the Fontan circuit.

A meta-analysis of minimally invasive versus traditional open vein harvest technique for coronary artery bypass graft surgery [State-of-the-art - Coronary]

The long saphenous vein remains the most commonly used conduit in coronary artery bypass surgery. Vein harvest is a critical component of this operation with significant morbidity associated with large leg wounds from open techniques. Here, we analyse the available literature comparing minimally invasive techniques vs. the traditional open method for vein harvest. A systematic literature search of Medline, Embase and Cochrane databases was performed using the following terms; ‘saphenous vein’, ‘coronary artery bypass’, ‘tissue and organ harvesting’ and ‘endoscopic’. Relevant papers were then analysed using Statsdirect software. There was significantly reduced leg wound infection, leg wound haematoma and postoperative pain in the minimally invasive group. There was no statistical difference between the groups for vein harvest time, length of hospital stay and incidence of vein injury. There was a significantly reduced long-term graft patency in veins harvested by a minimally invasive technique. The results of this meta-analysis demonstrate the operative advantages of minimally invasive techniques for the purposes of vein harvest in coronary artery bypass surgery. However, further studies are required to look at long-term graft patency following minimally invasive vein harvest as this remains a major concern.

Is pH-stat or alpha-stat the best technique to follow in patients undergoing deep hypothermic circulatory arrest? [Best evidence topic - Cardiopulmonary bypass]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pH-stat or alpha-stat is the best technique to follow in patients undergoing deep hypothermic circulatory arrest. Altogether 206 papers were found using the reported search, of which 16 represent 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. Excluding one paper which provided inconclusive results, six studies found better cerebrovascular metabolism with alpha-stat while three studies found better cerebrovascular metabolism with pH-stat. Four other studies showed no significant difference in the cerebrovascular metabolism between the two acid-base management strategies in patients undergoing deep hypothermic circulatory arrest. Nine studies compared the neuropsychological outcome in patients who underwent deep hypothermic circulatory arrest with three studies supporting each alternative conclusion of preference towards alpha-stat or pH-stat management. The remaining three studies showed no significant difference between the two groups of acid-base management. Comparing the 16 studies based on the age of the patients studied, three out of the four papers which demonstrated that the pH-stat method is a better strategy to improve intraoperative and postoperative outcome were based on a sample of paediatric patients. Conversely, all seven papers that suggested alpha-stat method is associated with better intraoperative and postoperative outcome were based on studies done on adult patients. The remaining four papers suggested no significant difference between the pH-stat group and alpha-stat group. In conclusion, there is evidence to suggest that the best technique to follow in the management of acid-base in patients undergoing deep hypothermic circulatory arrest during cardiac surgery is dependent upon the age of the patient with better results using pH-stat in the paediatric patient and alpha-stat in the adult patient.

Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy? [Best evidence topic - Thoracic non-oncologic]

A best evidence topic was constructed according to a structured protocol. The question addressed was whether the use of transcutaneous electrical nerve stimulation (TENS) is effective in reducing post-thoracotomy pain. Of the 74 papers found with a report search, nine prospective randomized controlled trials (RCT), among which three were double-blind, presented the best evidence to answer the clinical question. All investigated the effect of TENS as an adjunct therapy for relieving acute post-thoracotomy pain in patients undergoing thoracic surgery. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that a vast majority – seven of the nine retrieved studies – were in favor of TENS as an adjuvant to narcotic analgesics for improving outcome after thoracic surgery. Indeed, the interest and benefit has been shown not only in the treatment of acute post-thoracotomy pain (pain scores and narcotic requirements were consistently lower in the TENS group as opposed to the Placebo-TENS group), but also when used together with narcotic analgesics to reduce the duration of recovery room stay and to increase chest physical tolerance (better coughing attempts during chest physiotherapy) with positive effects on pulmonary ventilator function [forced expiratory volume in 1 s (FEV1) and/or forced vital capacity (FVC)]. Specifically, the TENS treatment was shown to be ineffective when used alone in severe post-thoracotomy pain (i.e. posterolateral thoracotomy incision), but useful as an adjunct to other medications in moderate post-thoracotomy pain (i.e. muscle sparing thoracotomy incision) and very effective as the sole pain-control treatment in patients experiencing mild post-thoracotomy pain (i.e. video-assisted thoracoscopy incision). Hence, current evidence shows TENS associated with postoperative medications to be safe and effective in alleviating postoperative pain and in improving patient recovery, thus enhancing the choice of available medical care and bettering outcome after thoracic surgery.

When harvested for coronary artery bypass graft surgery, does a skeletonized or pedicled radial artery improve conduit patency? [Best evidence topic - Coronary]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonization of the radial artery (RA) improves conduit patency in coronary artery bypass grafting (CABG). Altogether 15 papers were found using the reported search, of which four papers represented the best evidence to answer the clinical question. Two papers compared patency rates between skeletonized and pedicled radial arteries. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We acknowledge that evidence is limited in this area of cardiac surgery. When assessing the skeletonized RA, three studies provided patency data one year after CABG. No patency data were available five years after CABG. Only two papers were comparative studies (skeletonized conduits vs. pedicled conduits). Despite the above, short- and medium-term patency rates of skeletonized conduits are excellent. In the two comparative studies, patency of skeletonized vessels was superior to the pedicled conduits. Patency was assessed with the use of angiography and rates exceeded 95% in all four studies. Overall patency rates were 100% within 18 days, 98.3% within three months, 97.6% at a mean of ~1 year, and 100% at 4 years in one study. From these studies, we can conclude that the patency rates of pedicled conduits are excellent, however, our study suggests that skeletonization may offer the radial conduit some patency benefit when compared to the pedicled technique. The remaining two non-comparative studies support the above conclusion.

Does a skeletonized or pedicled right gastro-epiploic artery improve patency when used as a conduit in coronary artery bypass graft surgery? [Best evidence topic - Coronary]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonization of the right gastro-epiploic artery (RGEA) improves graft patency in coronary artery bypass grafting (CABG). Altogether >25 papers were found using the reported search, of which 11 papers represented the best evidence to answer this clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. Four out of the 11 papers were comparative studies (skeletonized conduits vs. pedicled conduits) and four studies produced one-year follow-up data. No studies revealed long-term patency rates as there was no follow-up data beyond five years. It is important to note that the evidence in the literature is based in a Japanese population. The vast majority of the target vessel which had been grafted by the RGEA was the right coronary artery and more specifically the posterior descending artery (PDA). The association between off-pump technique, sequential grafting, skeletonization of the RGEA with the harmonic scalpel and angiographic patency has not been adequately assessed. The studies reveal excellent patency rates for both early and mid-term skeletonized RGEA conduits. Overall patency rates were 97.7% within three months, 92.4% at a mean of ~1 year, 91.5% at a mean of ~2 years, and 86.4% at 4 years. In the four comparative studies, skeletonization patency was at least comparable and in one study superior to pedicled conduits. One study revealed a higher four-year cumulative patency rate for skeletonized conduits in comparison to a previous study by the same author where pedicled grafts were used. In conclusion, patency rates exceeded 95% in 10 studies for a follow-up of up to three months postoperatively. The evidence which supports the use of a ‘skeletonized’ RGEA is growing and this paper demonstrates clearly that in terms of patency, a skeletonized RGEA to the PDA should be considered as a conduit for CABG surgery especially when total arterial revascularization strategy with in situ conduits and no manipulation of the ascending aorta is the treatment of choice.

Should patients with asymptomatic severe mitral regurgitation with good left ventricular function undergo surgical repair? [Best evidence topic - Cardiac general]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, ‘Does severe asymptomatic mitral regurgitation (MR) require surgery or is watch and wait the optimal strategy?’. Over 103 papers were found using the reported search, and 10 represented the best evidence to answer this clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No studies in the modern era have shown significant survival benefit for patients undergoing surgery for asymptomatic severe MR if they have good left ventricular (LV) function. The progression rate to surgery on developing symptoms is 10% per year in these patients. Ling et al. reported a 63% incidence of congestive heart failure and 30% incidence of chronic atrial fibrillation (AF) at 10 years for conservative treatment, during which period 90% either underwent surgery or died. In addition, one study of 478 patients with good LV operated on in the 1980s showed a 76% 10-year survival in patients who were NYHA I/II but only a 48% 10-year survival in patients with NYHA III/IV although this group was older and had more AF. Early surgery has very good peri- and postoperative survival rates, and the American Heart Association currently recommend that these patients may be operated on if the chance of repair is >90%. Patients may, therefore, be reassured that either strategy is acceptable.

eComment: Optimal management of severe asymptomatic mitral regurgitation [eComment]

Should patients undergoing cardiac surgery with atrial fibrillation have left atrial appendage exclusion? [Best evidence topic - Cardiac general]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Should patients undergoing cardiac surgery with atrial fibrillation (AF) have left atrial appendage (LAA) exclusion?’ Altogether 310 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that despite finding five clinical trials including one randomised controlled trial, that studied around 1400 patients who underwent LAA occlusion, the results of these studies do not clearly show a benefit for appendage occlusion. Indeed of the five studies, only one showed a statistical benefit for LAA occlusion, with three giving neutral results and in fact one demonstrating a significantly increased risk. One reason for this may be the inability to achieve acceptably high rates of successful occlusion on echocardiography when attempting to perform this procedure. The highest success rate was only 93% but most studies reported only a 55–66% successful occlusion rate when attempting closure in a variety of methods including stapling, ligation and amputation. Currently, the evidence is insufficient to support LAA occlusion and may indeed cause harm especially if incomplete exclusion occurs.

eComment: The eternal dilemma of the left atrial appendage in the atrial fibrillation surgery [eComment]

Minimally invasive non-endoscopic vein harvest using a laryngoscope. A preliminary experience [Brief communication - Cardiac general]

Minimally invasive vein harvesting (MIVH) has been developed in order to reduce the wound healing complications and the related cost. Therefore, the operative cost of endoscopic harvesting remains higher in comparison with the open harvesting. We describe a laryngoscope-assisted technique of saphenous vein harvesting, performing a few small skin incisions and with minimum additional cost. We have used our technique in 20 patients up to now without infection or other wound-related complications and with good cosmetic results.

Twenty-six-year durability of an Ionescu-Shiley standard profile pericardial aortic valve [Case report - Valves]

The Ionescu–Shiley pericardial valve (Shiley, Inc, Irvine, CA, USA) is a first generation bioprosthesis made from bovine pericardium. Despite its excellent hemodynamic performance, use of this prosthesis ceased because it had an unacceptably high rate of early structural deteriorations, especially in the era of the standard profile valve. We experienced a rare case of very long durability of an Ionescu–Shiley standard profile (ISSP) bioprosthesis.

Kawasaki disease presenting as cardiac tamponade with ruptured giant aneurysm of the right coronary artery [Case report - Cardiac general]

We report a case of a 22-year-old man with Kawasaki disease presenting with features of cardiac tamponade following rupture of giant aneurysm of his right coronary artery. He underwent an emergency operation. Aneurysmal sac was of size 4x4 cm. The entry point of the aneurysm was sutured. Right coronary artery was grafted with left radial artery. He had an uneventful recovery in the postoperative period.

eComment: Coronary artery aneurysms in Kawasaki disease [eComment]

Failed closure of a ventricular septal defect with an Amplatzer occluder [Case report - Cardiac general]

A 74-year-old man was diagnosed to have a ventricular septal defect (VSD), which was detected shortly following transvenous pacemaker implantation. Transoesophageal echocardiography suggested the presence of two VSDs, one of which was closed with a device. At surgery, a single large VSD was seen, with the implanted device having embolised into the left ventricle. The defect was successfully closed using a pericardial patch, and the embolised device explanted.

The semi-clamshell approach for the single-stage treatment of thoracic mycotic aneurysm [Case report - Aortic and aneurysmal]

Mycotic aneurysms located on aortic arch are rare and have extremely high mortality. The presented case is a 75-year-old man with a thoracic aortal mycotic aneurysm successfully treated with surgical intervention. To prevent recurrent infection and postoperative pulmonary complications, we performed single-stage surgery including extensive debridement, graft replacement using rifampicin soaked prosthetic graft and omental wrapping. Although mycotic aneurysm with inflammation tissue usually interferes with surgical manipulation because of severe adhesion to the lung, semi-clamshell approach helped us perform all these procedures. The patient rapidly recovered from the surgery, and has shown no recurrence after 35 months follow-up.

Successful use of continuous flow ventricular assist device in a patient with mechanical mitral and aortic valve prosthesis without replacement or exclusion of valves [Case report - Assisted circulation]

In patients with left-sided mechanical aortic prostheses, it is recommended that the mechanical valve be replaced with a bioprosthesis, or excluded, at implantation of left ventricular assist device (LVAD). As changes in flow across the valve leads to potential thromboembolic complications, mechanical valves within the native heart are a relative contraindication to LVAD therapy. We here describe a patient who had long-standing valvular cardiomyopathy with mitral Starr-Edwards mechanical valve (Edwards Lifesciences, CA, USA) and aortic bileaflet tilting disc (St Jude Medical, St Paul, MN, USA) where LVAD was placed without explantation of the mechanical heart valves. The patient was bridged successfully to transplantation without thromboembolic events.

Repair of coronary artery perforation following angioplasty using TachoSil(R) patches [Case report - Coronary]

Coronary perforation is a rare complication of percutaneous interventional procedures, occurring in 0.2–3% of procedures, which may require emergency coronary bypass surgery. We describe here an alternative method to deal with such complication, which proved effective in a patient with active bleeding from the left anterior descending (LAD) coronary artery. By temporary pressing on beating heart patches of TachoSil®, a sponge impregnated with human fibrinogen and thrombin, on the bleeding site, complete and stable hemostasis was achieved.

Innominate artery cannulation for congenital heart disease [Case report - Congenital]

Arterial cannulation of the ascending aorta is the standard for congenital heart surgery. However, in some situations ascending aortic cannulation can be difficult, and cannulation of the innominate artery may be preferable. These situations may include: operations on the ascending aorta, a small ascending aorta which may be obstructed by the arterial perfusion cannula, redo operations where vascular structures including the ascending aorta are adherent to the back of the sternum, and neoaortic calcification in a patient who has undergone a previous Norwood operation. Innominate artery cannulation also permits the use of low flow cerebral perfusion, with avoidance of total circulatory arrest. In neonates and infants, the femoral and axillary arteries are generally too small to permit adequate flows on cardiopulmonary bypass. We describe four cases as examples of operations in which we have found innominate artery cannulation to be advantageous.

eComment: Re: Innominate artery cannulation for congenital heart disease [eComment]

The treatment of infectious aneurysms in the thoracic aorta; our experience in treating five consecutive patients [Case report - Vascular thoracic]

The surgical strategy for infected thoracic aortic aneurysms (ITAA) remains controversial. Effective antibiotic therapy is mandatory and surgical intervention is indicated only to prevent an aneurysmal rupture. In-situ reconstruction through an aseptic route is ideal; however, urgent surgery is often required in the uncontrolled infectious phase. Five patients were recently treated surgically for ITAA. They were all males with a mean age of 61.2 (range: 58–66) years. Two patients were operated on urgently in the active infectious phase due to impending aneurysmal rupture. A total arch reconstruction with an extra-anatomical bypass between the ascending aorta and both femoral arteries in one and an extended aortic arch resection with an in-situ graft reconstruction were performed in the other. The other three patients underwent in-situ graft reconstructions in the controlled infectious phase. Four patients had multiple aneurysms, including nine saccular or nodular aneurysms. Short-interval computed tomography (CT) re-examinations revealed a rapid enlargement of the aneurysms and confirmed the diagnosis. All patients successfully survived and are doing well without any evidence of a recurrent aortic infection. The surgical strategy for ITAA should be determined on a case-by-case basis under a careful follow-up with short-interval CT re-examinations.

eComment: Endovascular treatment of mycotic aneurysm as a definitive therapy or bridge to surgery in critically ill patients [eComment]

Infection after endoscopic ultrasound-guided aspiration of mediastinal cysts [Case report - Thoracic non-oncologic]

Foregut duplication cysts are rare congenital anomalies of enteric origin that arise during early embryonic development. They are usually incidentally found on routine imaging studies. The diagnosis can usually be made by computed tomography (CT) and endoscopic ultrasound (EUS) appearance. On CT, cyst attenuation values usually measure 0±20 Hounsfield units (HU). Higher HU is possible with hemorrhage, proteinaceous material or septations. At EUS, characteristic location and anechoic as well as hypoechoic but not necessarily anechoic appearance may be suggestive of a foregut duplication cyst. EUS-guided fine needle aspiration (FNA) has been thought to provide a safe, minimally invasive approach to establish the diagnosis. The purpose of this report is to highlight the potential for infectious risk of EUS-FNA for these cysts, and to suggest CT and EUS features that can suggest this diagnosis without FNA. Three patients who underwent EUS-FNA for diagnosis of incidental mediastinal lesions developed cyst infection despite accepted techniques including prophylactic antibiotics. Combined CT and EUS appearance may be sufficient in making this diagnosis without FNA. IV antibiotics may not be completely protective against infectious complications of FNA of mediastinal duplication cysts.

Sutureless pericardial patch augmentation for impending left ventricular free wall rupture [Case report - Cardiac general]

Left ventricular rupture may occur as a complication of acute myocardial infarction and is associated with significant morbidity and mortality. The risk associated with impending rupture of the left ventricular free wall has not been quantified but it is likely a predisposing factor to complete rupture. Few cases of impending rupture of the left ventricular free wall have been discussed in the literature; we present one such case and describe simple operative management with an autologous pericardial patch and subsequent outcome.

Video-assisted cardioscopy for removal of primary left ventricular fibroma [Case report - Cardiac general]

We present a case of a cardiac fibroma affecting the base of the anterior papillary muscle resected under cardiopulmonary bypass with cardioscopy and video-assisted thoracic surgery (VATS) instruments through the mitral valve. The surgical approach and instrumentation of previous case reports are reviewed.

Diagnosis and surgical treatment of an aneurysm on a cervical aortic arch associated with an anomalous origin of the left main coronary artery [Case report - Aortic and aneurysmal]

Cervical aortic arch (CAA) is a rare congenital anomaly. An aneurysm developed on a CAA is even rarer and a life threatening condition. We report the diagnosis and surgical treatment of an aneurysm on a CAA associated with an anomalous origin of the left main coronary artery. The surgical procedure consisted in the resection of the aneurysm, a direct aorto aortic anastomosis and a coronary artery bypass to the left anterior descending (LAD) artery with a good result at 11 months. This first case reported of an anomaly of a coronary artery origin associated with an aneurysm on a CAA, underlines the interest of a preoperative complete anatomical and functional diagnosis, to define an optimal intraoperative strategy.

Rerouting revascularization of the living right gastroepiploic artery graft in a patient with de novo gastric cancer [Case report - Coronary]

We present a case in which a redo patient in whom advanced gastric cancer was detected after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA), and in which re-grafting to the distal RGEA using the right internal thoracic artery (RITA) was performed. To minimize the surgical invasion before gastrectomy, we performed a thoracoscopic RITA harvest and small subxyphoid incision. A month later, distal gastrectomy was carried out and no complications occurred during the operation.

Atypical presentation of an apical pseudoaneurysm in a patient on prolonged left ventricular mechanical support [Case report - Assisted circulation]

Prolonged support with left ventricular assist system (LVAS) increases the risk of device-related infection. We experienced a rare complication of LVAS: an infectious aneurysm at the apical cannula, which appeared with atypical presentation. A 27-year-old male, who developed acute aggravation of dilated cardiomyopathy, was placed on extra-corporeal type LVAS. Six months later, the patient suffered from methicillin-resistant Staphylococcus aureus (MRSA) sepsis that lasted for as long as three months despite intensive antibiotic therapy. At 17 months after the implantation, he presented with obstructive ileus. Monthly assessment with transthoracic echocardiography (TTE) did not document any abnormalities around the ventricle. A contrast computed tomographic (CT) scan revealed a huge apical aneurysm protruding into the preperitoneal space. The aneurysm oppressed the transverse colon, resulting in obstructive ileus. Aneurysmectomy was carried out and MRSA was identified from the resected tissue. We reached the precise diagnosis with a CT-scan, although routine assessment with TTE failed to reveal abnormalities. Knowledge of this complication is essential in LVAS management. This is certainly rare, but possibly occurs in all the patients on prolonged LVAS support. Early and accurate diagnosis together with aggressive intervention would bring favorable outcome in such serious cases.

Corrigendum to 'eComment: A comparison of the safety of aprotinin and tranexamic acid in cardiac surgery' [Interact CardioVasc Thorac Surg 9 (2009) 101] [Corrigendum]

Pulmonary Sequestration Supplied by Giant Aneurysmal Aortic Branch [CASE REPORTS]

We report a case of an intralobar sequestration supplied by a 13-cm aneurysmal vessel originating from the abdominal aorta. The malformation was discovered during a roentgenogram investigation of an abdominal infrarenal aneurysm. During the endovascular repair of the abdominal aneurysm, the giant feeding vessel of the pulmonary sequestration was embolized. Two days later the patient underwent an uneventful resection of the malformation en bloc with the right lower lobe through a standard right thoracotomy.

Accessory Lobe of Right Liver Mimicking a Pulmonary Tumor in an Adult Male [CASE REPORTS]

We describe a rare case of ectopic liver tissue in the right thoracic cavity. A 39-year-old man with a suspected lung tumor underwent thoracotomy. The intraoperative finding revealed an accessory liver lobe connected to the right lobe of the liver by a small pedicle that pierced the diaphragm. A pathologic evaluation confirmed the specimen to be hepatic tissues. In retrospect, the correct diagnosis of accessory liver could have been achieved using appropriate radiologic investigations if this possibility had been considered.

Internal Mammary Artery to Pulmonary Artery Fistula After Coronary Bypass Surgery [IMAGES IN CARDIOTHORACIC SURGERY]

A Simple Method of Making Artificial Chordal Loops for Mitral Valve Repair [HOW TO DO IT]

Artificial chordal replacement with expanded polytetrafluoroethylene is an established technique for mitral valve repair. This report describes a simple technique of using Hegar dilators for making premeasured artificial chordal loops, whether as a single set of loops or as two connected sets of loops arising from the same stem. This technique uses a simple and widely available tool, the Hegar dilator, for preparation of chordal loops and further establishes the repair of opposing two segments of mitral valve by securing only one stem of the neochordae to the papillary muscle.

Pulmonary Endarterectomy Improves Dyspnea by the Relief of Dead Space Ventilation [ORIGINAL ARTICLES: GENERAL THORACIC]

Background In chronic thromboembolic pulmonary hypertension (CTEPH), dyspnea is considered to be related to increased dead space ventilation caused by vascular obstruction. Pulmonary endarterectomy releases the thromboembolic obstruction, thereby improving regional pulmonary blood flow. We hypothesized that pulmonary endarterectomy reduces dead space ventilation and that this reduction contributes to attenuation of dyspnea symptoms. Methods In this follow-up study we assessed dead space ventilation, hemodynamic severity of disease, and symptomatic dyspnea in 54 consecutive CTEPH patients, before and 1 year after pulmonary endarterectomy. Dead space ventilation was calculated using the Bohr-Enghoff equation. Dyspnea was assessed by Borg scores and the New York Heart Association functional classification. Results Preoperatively, dead space ventilation was increased (0.40 ± 0.07) and correlated with severity of disease (mean pulmonary artery pressure: r = 0.49, p < 0.001; total pulmonary resistance: r = 0.53, p < 0.001), and resting (r = 0.35, p < 0.05) and post-exercise Borg dyspnea scores (r = 0.44, p < 0.01). Postoperatively, dead space ventilation (0.33 ± 0.08, p < 0.001) and dyspnea symptoms decreased significantly. Changes in symptomatic dyspnea were independently associated with changes in pulmonary hemodynamics and absolute dead space. Conclusions Dead space ventilation in CTEPH is increased and correlates significantly with hemodynamic severity of disease and dyspnea symptoms. Pulmonary endarterectomy decreases dead space ventilation. The induced change in dead space upon surgical removal of chronic thromboembolism contributes to the postoperative recovery of symptomatic dyspnea.

Long-Term Survival After Video-Assisted Thoracic Surgery Lobectomy for Primary Lung Cancer [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Despite its feasibility and safety, use of video-assisted thoracic surgery (VATS) lobectomy for malignancies has spread slowly during the past decade because no definitive conclusions have been reached regarding the oncologic validity of this approach for malignancies. Thus, the purpose of this study was to analyze the indications and long-term results of VATS major pulmonary resections for primary lung cancers. Methods Of 502 patients who had surgical resections for primary lung cancers at the National Hospital Organization Himeji Medical Center from May 2000 to December 2003, the cases of the 325 patients who were originally scheduled for VATS major pulmonary resections (pneumonectomy, bilobectomy, lobectomy, and segmentectomy) were retrospectively reviewed. At this hospital, after an initial learning-curve period, indications for VATS were extended to all cases for which this approach was thought possible. For better analysis of long-term survival rates, patients whose follow-up periods were more than 5 years after surgery were analyzed. Results Of the 325 scheduled VATS resections, 21 procedures (6.4%) were eventually converted to open thoracotomies. In-hospital death occurred in 1 patient (0.3%). The average follow-up period for all censored cases was 66 months. Overall and disease-free 5-year survival rates were 85% and 83% for stage Ia (192 cases), 69% and 64% for stage Ib (50 cases), 48% and 37% for stage II (27 cases), and 29% and 19% for stage III (50 cases), respectively (p < 0.0001). Patients who were operated on using the VATS approach increased year by year, especially after 2002, when indications for using this method were extended (ratio of VATS to total cases, approximately 50% in the first 2 years and more than 80% in the latter 2 years). Long-term survival rates during the entire study period were comparable, especially in early stage lung cancer cases. Conclusions Use of VATS major pulmonary resection for primary lung cancer is feasible, with long-term patient survival comparable to that of conventional thoracotomy. Thus, it is possible that this approach might become the standard in experienced surgical centers, especially for early stage lung cancer cases. Further investigation at multiple centers is required.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Robotic Brachytherapy and Sublobar Resection for T1 Non-Small Cell Lung Cancer in High-Risk Patients [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Sublobar lung resection and brachytherapy seed placement is gaining acceptance for T1 non-small cell lung cancer (NSCLC) in select patients with comorbidities precluding lobectomy. Our institution first reported utilization of the da Vinci system for robotic brachytherapy developed experimentally in swine and applied to high-risk patients 5 years ago. We now report seed dosimetrics and midterm follow-up. Methods Eleven high-risk patients with stage IA NSCLC who were not candidates for conventional lobectomy underwent limited resection of 12 primary tumors. To reduce locoregional recurrence, 125I brachytherapy seeds were robotically sutured intracorporeally over resection margins to deliver 14,400 cGy 1 cm from the implant plane. Patients were followed with dosimetric computed tomography scans at 30 ± 16 days. Survival and sites of recurrence were documented. Results Resected tumor size averaged 1.48 ± 0.38 cm (range, 1.1 to 2.1 cm). Perioperative mortality was 0% and recurrence was 9% (1 of 11 [margin recurrence at 6 months with resultant mortality at 1 year]). Follow-up duration was 31.82 ± 17.35 months. Dosimetrics confirmed 14,400 cGy delivery using 24.21 ± 4.6 125I seeds (range, 17 to 30 seeds) over a planning target volume of 10.29 ± 2.39 cc3. Overall, 84.1% of the planning target volume was covered by 100% of the prescription dose (V100), and 88.2% was covered by 87% of the prescription dose (V87), comparable to open dosimetric data at our institution. Follow-up imaging confirmed seed stability in all patients. Conclusions Robotic 125I brachytherapy seed placement is a feasible adjuvant procedure to reduce the incidence of recurrence after sublobar resection in medically compromised patients. Tailored robotic seed placement delivers an exact dosing regimen in a minimally invasive fashion with equivalent precision to open surgery.

Fiducial Marker Placement Using Endobronchial Ultrasound and Navigational Bronchoscopy for Stereotactic Radiosurgery: An Alternative Strategy [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Stereotactic radiosurgery is being increasingly used to treat patients with early-stage non-small cell lung cancers (NSCLC) who are not candidates for surgical resection. Stereotactic radiosurgery usually needs fiducial markers (FMs) for the tracking process. FMs have generally been placed using percutaneous computed axial tomography scan guidance. We report the results of FM placement using endobronchial ultrasound (EBUS) in 43 patients. Methods A multidisciplinary tumor board evaluates NSCLC patients before they are offered stereotactic radiosurgery. In patients selected for stereotactic radiosurgery, FMs were inserted into peripheral, central, and mediastinal tumors using EBUS and, in selected patients, navigational bronchoscopy. Patients underwent repeat computed axial tomography chest scans 2 weeks later to ensure stability of the FMs before beginning stereotactic radiosurgery. Results Included were 43 consecutive patients (21 men, 22 women; mean age, 74.4 years). Forty-two (98%) had NSC carcinomas (5 recurrences); 1 had a carcinoid tumor. Twenty-two tumors were located in the left lung, 19 in the right lung, 1 at the carina, and 1 pretracheal. Two to 5 FMs were placed in and around all tumor masses using EBUS and, for peripheral lesions, EBUS combined with navigational bronchoscopy. Thirty patients had no displacement of FMs. In the 13 who had displaced 1 or more FMs, the ability to use the remaining FMs for stereotactic radiosurgery was unimpaired. Conclusions EBUS and navigational bronchoscopy are safe and effective methods to position FMs for preparing patients with both central and peripheral lung cancers for stereotactic radiosurgery.

Pulmonary Resection for Metastases of Colorectal Adenocarcinoma [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Surgery is a safe and effective treatment for patients with lung metastases from colorectal carcinoma. Combining chemotherapy and surgery seems to prolong survival time after metastasectomy. Our purpose was to review the effectiveness of surgery with time and evolving managements. Methods The records of 127 patients were retrospectively analyzed. The characteristics of primary cancer, lung metastases, resections, and associated therapy were studied according to their incidence on survival. Results There were 74 male and 53 female patients (mean age, 65 years); 223 operations were performed and 314 metastases were resected. Completeness of surgery (n = 117) was the main factor for prolonged survival (5- and 10-year survival, 41% and 27%, versus 0%). There was no factor of significantly better prognosis, but a tendency to higher survival rates was observed in cases of single metastasis, in patients undergoing several lung operations, and in patients in whom liver metastases were previously removed. Three of 7 patients with mediastinal lymph node involvement survived more than 5 years; 58 patients were operated on before January 2000, and 59 between January 2000 and December 2007. Five-year survival rates were 35.1% versus 63.5%, respectively (p = 0.0096), probably related to better selection with modern workup, more frequent use of chemotherapy, and repeated pulmonary resections. Conclusions Different treatment protocols were reported in the literature and in our series with time, resulting in better survival rates and a more aggressive surgical tendency. The beneficial role of such combined therapy justifies further research, including prospective trials.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Effect of Preincisional Epidural Fentanyl and Bupivacaine on Postthoracotomy Pain and Pulmonary Function [ORIGINAL ARTICLES: GENERAL THORACIC]

Background This study attempts to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain, its effects on pulmonary function and stress response. Methods Forty patients undergoing posterolateral thoracotomy received TEA either before (preoperative-TEA group) or after (postoperative-TEA group) surgery. Postoperative analgesia was maintained with epidural infusion of bupivacaine and fentanyl. Pain scores, pulmonary functions, arterial blood gases, plasma glucose, cortisol levels and epidural fentanyl consumption were compared for 48 hours after surgery. Results The preoperative-TEA group demonstrated significantly reduced pain scores at 2, 4, 8, 12, 24, and 48 hours at rest (p = 0.001, p = 0.002, p = 0.004, p = < 0.001, p = 0.006, and p = 0.001, respectively) and at 4, 8, 12, 24, 48 hours on coughing (p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.004, respectively), and a significant reduction in epidural fentanyl consumption (208.6 ± 49.3 mL, versus 260 ± 28.8 mL, p = 0.001). The preoperative-TEA group showed significant improvement in pulmonary functions as compared with the postoperative-TEA group (p < 0.05), except forced expiratory volume in one second at 24 hours (p = 0.061) and peak expiratory flow rate at 48 hours (p = 0.188). The postoperative-TEA treated patients were more likely to have a higher arterial carbon dioxide pressure at 4, 8, 12, and 24 hours (p = 0.017, p = 0.001, p = 0.003, p = 0.001), respectively. However, we could not demonstrate a statistical difference in oxygenation, cortisol, or glucose level. Conclusions Though preemptive TEA appeared to reduce the severity of acute pain, preserve pulmonary function, and reduce analgesic requirements, these statistically significant differences were not enough to conclude a clinical significant difference between groups.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Awake Upper Airway Surgery [ORIGINAL ARTICLES: GENERAL THORACIC]

Background The need to compromise between surgical and anesthetic access in airway surgery is an important clinical problem. We wanted to determine the feasibility of performing upper airway surgery under awake anesthesia and spontaneous respiration. Methods This was a prospective, clinical feasibility study. Patients with upper tracheal stenosis were managed through cervical epidural anesthesia and conscious sedation, and atomized local anesthetic. No intraoperative intubation or jet ventilation was required. Outcome measures were ease of surgery, observer-rated functional result, early (less than 30 days) complications, and patient-reported satisfaction. Results Twenty consecutive patients with idiopathic (n = 4) or postintubation (n = 16) complete (n = 3) or severe (>80%, n = 17) subglottic (n = 12) or upper trachea (n = 8) stenosis were enrolled. Operations included 12 subglottic and 8 segmental resections with primary anastomosis. Permissive hypercapnia was well tolerated. Median length of resection was 4.5 cm (range, 2 to 6 cm), and 12 releases (8 thyrohyoid, 4 suprahyoid) were required. One patient required a nasotracheal tube for 36 hours. All but 1 were able to cough and talk immediately, and to swallow fluids and solids, and were fully mobilized at 6 hours. There were no early complications. Median hospitalization was 3.1 days (range, 2 to 15). Patients had excellent (n = 16) or good (n = 4) functional (n = 20) outcomes, with no early relapse of stenosis. Median self-reported satisfaction at median 12 months was 9.5 ± 1.0 (scale, 0 to 10). All patients indicated that they would be happy to repeat the procedure. Conclusions Awake and tubeless upper airway surgery is feasible and safe, and has a high level of patient satisfaction. If supported by randomized controlled trial, this method will change the way airway stenosis surgery is approached by both surgeons and anesthesiologist.

Factors Associated With Postoperative Symptoms After Laparoscopic Heller Myotomy [ORIGINAL ARTICLES: GENERAL THORACIC]

Background Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia. Methods From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit. Results In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and a fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an odds ratio of 1.80. Conclusions Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.

Invited Commentary [ORIGINAL ARTICLES: GENERAL THORACIC]

Clopidogrel Increases Blood Transfusion and Hemorrhagic Complications in Patients Undergoing Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Utilization of the irreversible antiplatelet agent clopidogrel is increasing in the treatment acute coronary syndrome patients. Consequently, more patients are presenting for urgent cardiac surgery with an irreversible defect in platelet function. The objective of this study was to determine whether recent clopidogrel administration predicts transfusion and hemorrhagic complication in cardiac surgery patients. Methods This retrospective study included all patients undergoing isolated coronary artery bypass graft surgery (CABG), isolated valve, or CABG plus valve at a single center between 2004 and 2008. The outcomes of interest were transfusion and hemorrhagic complication. Clopidogrel stop interval was defined as the time between last dose and presentation to the operating room, and was examined in daily increments from 0 to 5 days, more than 5 days, and not receiving clopidogrel preoperatively. By logistic regression, the association of clopidogrel stop interval with transfusion and with hemorrhagic complication was examined after adjusting for other risk factors. Results Of 3,779 patients included in this study, 26.4% (999) received clopidogrel preoperatively. The overall rates of transfusion and hemorrhagic complication were 34.1% and 4.1%, respectively. Clopidogrel use within 24 hours was an independent predictor of transfusion (odds ratio 2.4; 95% confidence interval: 1.8 to 3.3) and of hemorrhagic complication (odds ratio 2.1; 95% confidence interval: 1.3 to 3.6). Conclusions Patients receiving clopidogrel within 24 hours of surgery are at increased risk for transfusion and hemorrhagic complication. Timing of surgery for patients receiving clopidogrel should take into account the interval from the last dose.

Impact of Endoscopic Versus Open Saphenous Vein Harvest Techniques on Outcomes After Coronary Artery Bypass Grafting [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Endoscopic saphenous vein harvest (EVH) decreases leg wound infections and improves cosmesis after coronary artery bypass grafting (CABG). Recent data, however, suggest that EVH may be associated with reduced graft patency rates. The objective of this study is to assess the effect of EVH on short-term and midterm outcomes after CABG. Methods Data were prospectively collected on all first-time isolated CABG and combined valve/CABG with saphenous vein graft between 1998 and 2007 at a single center. Patients having traditional "open" vein harvest (OVH) were compared with patients having EVH. Multivariate models were used to examine the risk-adjusted impact of EVH on postoperative leg infection, composite in-hospital adverse events, and individual and composite midterm adverse events. Results The study included 5,825 patients, of whom 2,004 (34.4%) had EVH. Patients having EVH were more likely to have ejection fraction less than 50% (32.0% versus 29.3%, p = 0.04), recent myocardial infarction (24.2% versus 18.3%, p < 0.0001), and left main disease (26.0% versus 22.1%, p = 0.0009). Median follow-up was 2.6 years. After risk adjustment, EVH was associated with reduced rates of leg infection (odds ratio 0.48, p = 0.003) but had no association with either in-hospital (odds ratio 0.93, p = 0.56) or midterm adverse outcomes (hazard ratio 0.93, p = 0.22). Endoscopic saphenous vein harvest was associated with reduced readmission to hospital for unstable angina (odds ratio 0.74, p = 0.01). Conclusions Endoscopic saphenous vein harvest is associated with a lower rate of leg infection and is not an independent predictor of in-hospital or midterm adverse outcomes. Endoscopic saphenous vein harvest is a safe alternative to OVH for patients undergoing CABG with saphenous vein.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Preserved Blood Flow in the Composite Right Gastroepiploic Artery Graft During Norepinephrine Infusion [ORIGINAL ARTICLES: ADULT CARDIAC]

Background We examined the effect of norepinephrine infusion on blood flow in Y-composite right gastroepiploic artery grafts after off-pump coronary artery bypass grafting. Methods Enrolled were 28 patients who were scheduled for revascularization with a Y-composite graft (end-to-side anastomosis of the right gastroepiploic artery to the in situ left internal thoracic artery graft). After all planned anastomoses were completed in each patient, blood flow in the right gastroepiploic artery composite graft and the internal thoracic artery graft (proximal and distal to the right gastroepiploic artery graft) was measured before and after continuous norepinephrine infusion. Results Blood flow in right gastroepiploic artery (26.4 ± 15.8 vs 33.8 ± 18.0 mL/min, p = 0.0004), proximal left internal thoracic artery (47.5 ± 21.2 vs 61.6 ± 23.4 mL/min, p < 0.0001), and distal left internal thoracic artery (20.1 ± 12.1 vs 26.8 ± 14.6 mL/min, p < 0.0001) grafts increased after norepinephrine infusion. In addition, the proportion of blood flow in right gastroepiploic artery grafts based on the blood flow in proximal left internal thoracic artery grafts was preserved (57.2% ± 24.7% vs 55.1% ± 25.6%, p = 0.607). Conclusions Blood flow in right gastroepiploic artery composite grafts after off-pump coronary artery bypass grafting was preserved during norepinephrine infusion.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Peripheral Vascular Disease as a Predictor of Survival After Coronary Artery Bypass Grafting: Comparison With a Matched General Population [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The European system for cardiac operative risk evaluation, the most popular European scoring system in cardiac surgery, uses the extracardiac arteriopathy as a risk factor for early mortality. We studied the effect of peripheral vascular disease (PVD) on early and late mortality in a large group of patients undergoing isolated coronary artery bypass surgery (CABG) surgery. Methods During a ten-year period (January 1998 through December 2007) 10,626 patients underwent isolated CABG in our hospital. The primary endpoints of this study were early and late all-cause mortality. For each year of the study period, general population cohorts were matched with the patient groups for age and gender (expected survival). Results Out of 10,504 patients included in the analysis, 1,222 (11.63%) patients had PVD. The PVD was identified as an independent risk factor for late mortality (death at any time after hospital discharge) (hazard ratio of 1.67 [1.43 to 1.95], p < 0.0001), but not for early mortality (death within 30 days or before discharge) (hazard ratio of 1.06 [0.70 to 1.60], p = 0.776). Patients without PVD had a better survival than patients with PVD (log-rank p < 0.0001) and even a better survival compared to the normal Dutch population survival (p value < 0.002). The PVD patients had a worse than expected survival (log-rank p < 0.0001). Conclusions Peripheral vascular disease is an independent risk factor only for late mortality but not for early mortality. Compared with age-matched and sex-matched cohorts from the general Dutch population, the ten-year survival of patients with peripheral vascular disease was worse; whereas the survival of patients with no peripheral vascular disease was better.

Coagulation-Fibrinolysis Changes During Off-Pump Bypass: Effect of Two Heparin Doses [ORIGINAL ARTICLES: ADULT CARDIAC]

Background To date, no study has tested the effect of different heparin dosages on the hemostatic changes during off-pump coronary artery bypass graft (OPCABG) surgery, and a wide variety of empirical anticoagulation protocols are being applied. We tested the effect of two different heparin dosages on the activation of the hemostatic system in patients undergoing OPCABG procedures. Methods Forty-two patients eligible for OPCABG procedures were assigned in a randomized fashion to low-dose heparin (150 IU/kg) or high-dose heparin (300 IU/kg). Prothrombin fragment 1+2, plasmin/alpha 2 -plasmin inhibitor complex, D-dimer, soluble tissue factor, tissue factor pathway inhibitor, total thrombin activatable fibrinolysis inhibitor (TAFI), and activated TAFIa were assayed by specific enzyme-linked immunosorbent assays at six different timepoints, before, during, and after surgery. Platelet function was evaluated by means of an in vitro bleeding time test, platelet function analyzer-100. Results The OPCABG surgery was accompanied by significant changes of all plasma biomarkers, indicative of systemic activation of coagulation and fibrinolysis. A significant increase in circulating TAFIa was detected perioperatively and postoperatively, and multiple regression analysis indicated that prothrombin F1+2 but not plasmin/alpha 2 -antiplasmin complex was independently associated with TAFIa level. Platelet function analyzer-100 values did not change significantly after OPCABG. All hemostatic changes were similar in the two heparin groups, even perioperatively, when the difference in anticoagulation was maximal. Conclusions Both early and late hemostatic changes, including TAFI activation, are similarly affected in the low-dose and high-dose heparin groups, suggesting that the increase in heparin dosage is not accompanied by a better control of clotting activation during OPCABG surgery.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Current Role and Outcomes of Ascending Aortic Replacement for Severe Nonaneurysmal Aortic Atherosclerosis [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Severe atherosclerosis of the ascending aorta is a challenging issue potentially affecting indications for surgery, operative choices, and patients' outcome. No standard treatment has emerged to date, and uncertainties persist about criteria for selecting patients and procedures. Methods Replacement of the atherosclerotic ascending aorta was performed in 64 patients at time of either aortic (n = 49), mitral (n = 21), or tricuspid (n = 7) valve surgery. Coronary artery bypass grafting was performed in 53 patients, and the majority of patients underwent combined procedures (n = 49). Mean age was 72.0 ± 7.6 years. The expected operative mortality, by logistic European System for Cardiac Operative Risk Evaluation, was 29.0% accounting for ascending aortic replacement and 13.1% disregarding it. Circulatory arrest under deep hypothermia, eventually combined with either retrograde or antegrade brain perfusion, was required in 61 cases. Results Early death, stroke, and myocardial infarction rates were 10.9%, 6.3%, and 7.8%, respectively. Factors univariately associated with early deaths were preoperative renal failure requiring dialysis (p = 0.001) and longer cardiopulmonary bypass (p = 0.001) and cardioplegia (p = 0.008) times. Cumulative survival at 1, 3, and 5 years was 86% ± 4%, 74% ± 6%, and 68% ± 8%, respectively. Conclusions Replacement of the atherosclerotic ascending aorta can be carried out at acceptable mortality rates despite the high rates of preoperative comorbidity and the significant incidence of postoperative complications.

Atherosclerotic Arch Aneurysm Operations With Perfusion Toward the Aortic Valve [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The study objective was to investigate the efficacy of perfusion toward the aortic valve in patients who had undergone total arch replacement for atherosclerotic arch aneurysms. Methods Transesophageal echocardiography was used to measure the peak velocities of each perfusion method in the aortic arch. The latest 15 patients with perfusion toward the aortic valve in the arch procedure were compared with 15 patients with perfusion toward the aortic arch in other cardiac operations as controls. Between April 2005 and February 2009, 65 consecutive patients underwent total arch replacement for atherosclerotic aneurysms. Among them, 48 patients underwent operations with perfusion toward the aortic valve and were reviewed. Results The peak forward aortic flow velocities with perfusion toward the aortic valve were 48 ± 26 cm/s before cardiopulmonary bypass and 29 ± 13 cm/s on cardiopulmonary bypass. The velocities with perfusion toward the aortic arch were 67 ± 28 cm/s before cardiopulmonary bypass and 226 ± 114 cm/s on cardiopulmonary bypass (p < 0.001). Of the 48 patients with perfusion toward the aortic valve, postoperative temporary and permanent neurologic dysfunctions occurred in 4 (8.2%) and in 1 (2.0%), respectively. One (2.0%) hospital death occurred. Conclusions Perfusion toward the aortic valve resulted in a significant decrease in peak forward aortic flow velocity in the aortic arch during cardiopulmonary bypass, which might reduce the risk of erosion or disruption of existing atheroma and ensuing embolic complications in patients with atherosclerotic aneurysm.

Glutamate Excitotoxicity Mediates Neuronal Apoptosis After Hypothermic Circulatory Arrest [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Prolonged hypothermic circulatory arrest results in neuronal cell death and neurologic injury. We have previously shown that hypothermic circulatory arrest causes both neuronal apoptosis and necrosis in a canine model. Inhibition of neuronal nitric oxide synthase reduced neuronal apoptosis, while glutamate receptor antagonism reduced necrosis in our model. This study was undertaken to determine whether glutamate receptor antagonism reduces nitric oxide formation and neuronal apoptosis after hypothermic circulatory arrest. Methods Sixteen hound dogs underwent 2 hours of circulatory arrest at 18°C and were sacrificed after 8 hours. Group 1 (n = 8) was treated with MK-801, 0.75 mg/kg intravenously prior to arrest followed by 75 µg/kg/hour infusion. Group 2 dogs (n = 8) received vehicle only. Intracerebral levels of excitatory amino acids and citrulline, an equal coproduct of nitric oxide, were measured. Apoptosis, identified by hematoxylin and eosin staining and confirmed by electron microscopy, was blindly scored from 0 (normal) to 100 (severe injury), while nick-end labeling demonstrated DNA fragmentation. Results Dogs in groups 1 and 2 had similar intracerebral levels of glutamate. However, MK-801 significantly reduced intracerebral glycine and citrulline levels compared with hypothermic circulatory arrest controls. The MK-801 significantly inhibited apoptosis (7.92 ± 7.85 vs 62.08 ± 6.28, group 1 vs group 2, p < 0.001). Conclusions Our results showed that glutamate receptor antagonism significantly reduced nitric oxide formation and neuronal apoptosis. We provide evidence that glutamate excitotoxicity mediates neuronal apoptosis in addition to necrosis after hypothermic circulatory arrest. Clinical glutamate receptor antagonists may have therapeutic benefits in ameliorating both types of neurologic injury after hypothermic circulatory arrest.

Utility of Remote Wireless Pressure Sensing for Endovascular Leak Detection After Endovascular Thoracic Aneurysm Repair [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The goal of thoracic endovascular aneurysm repair (TEVAR) is to exclude and depressurize the aneurysm sac. Type I and III endovascular leaks (EL) transmit systemic pressure and represent treatment failures. The significance of type II EL is more controversial. Remote pressure sensing is a novel nonradiographic technology for EL detection and monitoring. However, little experience exists with regard to use in the thoracic aorta. We present our experience with the EndoSure wireless pressure measurement system (CardioMEMS, Atlanta, GA) for monitoring aneurysm sac pulse pressure (ASP) after TEVAR. Methods Beginning May 2006, the EndoSure system was routinely implanted in TEVAR patients with suitable anatomy (36 aneurysm patients; 7 chronic dissection patients). The ASP measurements were taken predischarge and at scheduled follow-up visits. Computed tomography angiograms were performed at scheduled follow-up appointments. Data were prospectively maintained in an institutional aortic database. Results Through June 2008, 43 patients (34% of TEVARs performed during this interval) underwent implantation. In 10 patients (23%), the device was suboptimally positioned between the endovascular graft and the aortic wall, rather than in an area of thrombus-free lumen, with subsequent transmission of systemic pressure despite no radiographic evidence of EL. In patients with well-positioned sensors, predischarge ASP averaged 43% ± 22% of systemic. In 2 patients, systemic ASP measurements before discharge prompted imaging, confirming type I EL; both patients were treated successfully with cuff extension. One patient exhibited reduced ASP before discharge but exhibited increased ASP (70% systemic) at 1 month; computed tomography scan confirmed a type I EL. Additional TEVAR sealed the EL and reduced ASP to 39% systemic. For all patients at midterm follow-up, ASP decreased further, averaging 19% ± 12% systemic (p = 0.019); this correlates with computed tomography imaging demonstrating a 5 mm or greater reduction in aortic diameter in 76% of patients (25 of 33) with follow-up of 6 months or longer. No patients manifested a recurrent type I or type III EL at latest follow-up. The device has also been used to follow 8 patients with type II EL with low ASP. Conclusions Implantation of a wireless ASP sensor provides useful information regarding type I and type III EL after TEVAR and permits serial observation of type II EL. This information may guide clinical therapy and improve outcomes. Longer term follow-up will define sensor reliability in postoperative surveillance.

Severe Aortic Stenosis in a Veteran Population: Treatment Considerations and Survival [ORIGINAL ARTICLES: ADULT CARDIAC]

Background We examined factors affecting the choice of surgical versus medical treatment of severe aortic stenosis and evaluated associated patient survival. Methods We retrospectively reviewed data from all patients diagnosed with severe aortic stenosis at a Veterans Affairs medical facility between January 1997 and April 2008. Results Of 345 patients with severe aortic stenosis, 260 (75%) underwent surgical evaluation, and 205 (59%) underwent aortic valve replacement (AVR). The patient's decision to decline surgical referral or AVR (n = 47) and severe comorbidities (n = 34) were the top two reasons for medical treatment rather than AVR. The AVR group was younger (69.5 ± 9.6 years versus 75.7 ± 8.6 years; p < 0.001) and had a higher prevalence of symptoms (96% versus 71%; p < 0.001) than the medical group. The medical group had a lower cardiac ejection fraction (0.42 ± 0.15 versus 0.50 ± 0.12; p < 0.001) and was less likely to be independent in activities of daily living (64% versus 74%). The AVR group had higher survival rates than the medical patients at 1 year (92% versus 65%), 3 years (85% versus 29%), and 5 years (73% versus 16%; log-rank test p < 0.0001). Valve replacement was independently associated with decreased mortality (hazard ratio, 0.17; 95% confidence interval, 0.10 to 0.27; p < 0.0001). Conclusions The management of severe aortic stenosis in veterans is sometimes limited to medical evaluation and treatment. Surgeons should be involved in the complex process of risk assessment, to select patients with severe aortic stenosis who would benefit from the survival advantage associated with AVR.

Concomitant Septal Myectomy at the Time of Aortic Valve Replacement for Severe Aortic Stenosis [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Left ventricular outflow tract obstruction may be unmasked after a successful aortic valve replacement (AVR) for severe aortic stenosis in the setting of asymmetrical basal septal hypertrophy (ABSH). The quantitative assessment of the obstructive potential of ABSH adjacent to a severely stenotic valve can be challenging. We reviewed our experience with patients who underwent concomitant septal myectomy at the time of AVR for severe aortic stenosis. Methods During the 10-year period ending January 2009, 3,523 patients underwent AVR for the primary indication of severe aortic stenosis. Forty-seven of these patients underwent concomitant septal myectomy. Preoperative and postoperative echocardiograms, operative data, hospital course, morbidity, and mortality were assessed. Results The mean age of the group was 73 ± 11 years. The mean aortic valve area was 0.74 cm2 preoperatively. On preoperative transthoracic echocardiography, only 28% of the patients were considered to be at risk for possible left ventricular outflow tract obstruction. The mean left ventricular mass index decreased from 113.7 ± 24.3 g preoperatively to 90.0 ± 17.2 g at 1 year after the surgery (p < 0.001). The operative mortality was 2%. Complete heart block was observed in 2 patients (4.2%), and no iatrogenic ventricular septal defect was noted. Conclusions A quantitative assessment of the obstructive ABSH in the setting of severe aortic stenosis may be difficult preoperatively. Surgeons should inspect left ventricular outflow tract for possible obstructive ABSH at the time of AVR. Concomitant myectomy is a safe and effective procedure without additional complications and should be considered for patients with a preoperative or intraoperative diagnosis of ABSH even though dynamic obstruction was not demonstrated.

Minimally Invasive Transapical Aortic Valve Implantation and the Risk of Acute Kidney Injury [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The new technique of minimally invasive transapical aortic valve implantation (TAP-AVI) deals with high-risk patients and despite the absence of cardiopulmonary bypass it might lead to renal impairment. The aim of this study was to estimate the risk of the development of acute kidney injury (AKI) after TAP-AVI and to identify possible risk factors with regard to the morbidity and mortality of the patients. Methods Data of 30 consecutive patients undergoing TAP-AVI were recorded and followed up for 8 weeks. Postoperative AKI has been defined according to RIFLE criteria. Two patients on chronic hemodialysis have been followed up. Results Of 28 patients, AKI occurred in 16 patients (57%). Statistical analysis revealed no influence on the risk of developing AKI caused by the dose of applicated contrast medium (p = 0.09), the patient's age (p = 0.5), or the existence of diabetes (p = 0. 16). Analysis concerning the relationship between a preexisting coronary heart disease and AKI showed a tendency to be associated with a higher risk of the development of AKI (70% preexisting congenital heart disease in the AKI group versus 50%; p = 0.28). Only a preoperative serum creatinine greater than 1.1 mg/dL was a strong predictor for developing AKI (p < 0.01). Length of stay in the intensive care unit and the complete length of hospital stay revealed no difference with regard to postoperative development of AKI though statistical analysis showed a trend to a higher mortality in the AKI group (27% vs 6%); univariate analysis did not reach statistical significance (p = 0.13). Conclusions The TAP-AVI seems to be a feasible procedure for high-risk patients with a clear risk of developing AKI. Patients at risk should be identified and, if indicated, already preoperatively treated in collaboration with the attending nephrologists.

Early Results of Valve-Sparing Aortic Root Replacement in High-Risk Clinical Scenarios [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The feasibility of valve-sparing aortic root procedures (David) in certain high-risk situations has been questioned. We sought to determine the safety of the David procedure in the following high-risk subgroups: acute type A dissection, severe aortic insufficiency (AI), and reoperations. Methods From 2005 through 2007, 110 root replacements were performed for the above criteria: 73 root replacements with a composite valve-conduit (Bentall) and 37 David procedures. The reimplantation technique was used in all 37 David patients, with 7 requiring aortic cusp repair. Results There were no significant differences in preoperative or intraoperative variables between the groups, with the exception of cross-clamp time, which was longer for David patients. There was a slight, but nonsignificant increase in mortality among Bentall patients (8.2% [6 of 73]) compared with David patients (5.4% [2 of 37], p = 0.59]. There were no differences with respect to postoperative stroke, renal failure, or respiratory failure. Predischarge echocardiogram in the surviving 35 David patients demonstrated no AI in 25 patients and trace/mild AI in 10. Freedom from AVR at a mean follow-up of 8.8 months (range, 1 to 40) was 94.3% (33 of 35). One patient required AVR because of endocarditis at 9 months, and 1 had severe AI 13 months postoperatively. Conclusions Valve-sparing aortic root replacement can be performed safely in the setting of acute dissection, severe AI, and reoperations with acceptable early results. Long-term follow-up is needed to determine the durability of repair in these high-risk groups.

Third-Time Aortic Valve Replacement: Patient Characteristics and Operative Outcome [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Reoperative cardiac surgery is being performed with increasing frequency. Third-time aortic valve surgery remains a rare procedure. We retrospectively analyzed the outcome of third-time aortic valve replacement (AVR) at our institution. Methods Between 1990 and 2005, 49 patients underwent third-time AVR. Data analyzed included preoperative patient characteristics, type of preexisting aortic valve prosthesis, prosthetic valve pathology necessitating third-time AVR, postoperative morbidity and mortality, and echocardiographic data. Results The mean age was 47.4 ± 17 years. The mean interval between the first and second operation was 8.7 ± 5.7 years, and between the second and third operation it was 10.2 ± 5.6 years. Prosthetic valves at the time of second AVR included 32 homografts (65.4%), 11 mechanical prostheses (22.4%), and 6 xenografts (12.2%). At third-time AVR, 29 patients (59.2%) received a homograft or autograft, 12 (24.5%) received a mechanical valve, and 8 (16.3%) received a xenograft. In-hospital mortality was 4.1%. The mean follow-up was 80 ± 69 months. Freedom from reoperation was 84% ± 6% at 5 years and 65% ± 11% at 10 years. Long-term survival was 79% ± 6% at 5 years and 73% ± 7% at 10 years. Multivariate analysis showed that age, female sex, and postoperative high left ventricular mass were factors associated with decreased long-term survival. Mean left ventricular mass decreased from 320 ± 133 g to 263 ± 102 g at 1 year postoperatively (p = 0.01). Conclusions Third-time AVR can be performed with low operative mortality, low cumulative operative mortality, and satisfactory long-term survival and freedom from reoperation. The procedure results in significant regression of left ventricular mass.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Ten-Year Results of Folding Plasty in Mitral Valve Repair [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Folding plasty (FP) for posterior mitral leaflet repair (PLR) is a technique that reduces the height of the repaired leaflet, closes the gap created by leaflet resection by rotation of residual leaflet, and reduces the need for localized annular plication. This report reviews late outcomes with FP repair. Methods From January 1994 to August 2006, 1,402 mitral valve repairs were performed for degenerative disease: 1,012 had PLR and 531 had FP technique. Results Overall hospital mortality was 2.4% (33 of 1,402 patients) and 1.3% (14 of 1,103 patients) for isolated mitral repair. For those patients with PLR, mortality for all procedures was 1.5% (15 of 1,012 patients) and 1.2% (11 of 891 patients) for isolated PLR repairs. Mortality was 0.9% (5 of 531 patients) for FP. In the last 5 years FP was used in 64.4% of PLR, compared with 35.6% of PLR in the prior era (p < 0.001). The 10-year actuarial freedom from mitral reoperation was 89%; 10-year freedom from reoperation or recurrent severe mitral insufficiency was 86% with FP and 87% without (p = 0.76). The 5-year freedom from reoperation or recurrent severe insufficiency was 89% when an annuloplasty device was used and 62% when not used (p < 0.001). Conclusions Repair of posterior leaflet prolapse with FP is straightforward and durable. In our experience, FP is currently used for two thirds of PLR. These data also confirm that valve repair for degenerative disease should include an annuloplasty device for optimal late results.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Survival and Quality of Life in Cardiac Surgery Patients With Prolonged Intensive Care [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The clinical outcome in discharged cardiac surgery patients after prolonged postoperative intensive care needs further investigation. The aim was to study survival, functional status, and quality of life in cardiac surgery patients with more than 10 days postoperative intensive care unit stay. Methods We performed a population-based study including 4,086 cardiac surgery patients and identified 141 patients who had a postoperative intensive care unit stay of more than 10 days. Data regarding patients and outcome were collected, and all discharged patients alive in May 2008, or a family member, were contacted to assemble information regarding functional status and quality of life using the Karnofsky performance scale and the Short Form-36 questionnaire. Results Early mortality was 33%. Risk factors for early mortality were advanced age and postoperative dialysis. Survival at 1, 3, and 5 years was 62%, 56%, and 52%, respectively. Ninety-five patients were discharged from the hospital, and during a mean follow-up of 1.9 years, 62% were readmitted at least once. In discharged patients, 65% had a Karnofsky score of 80 or more. We found significantly lower physical (39.7 versus 43.6; p = 0.03), and mental (44.1 versus 50.8; p = 0.001) scores in the study group compared with a reference group. Conclusions Early mortality was high, especially in patients who required dialysis. However, long-term survival and functional status were encouraging. Quality of life was worse compared with the general population in both physical and mental aspects, but the difference was moderate. Extensive efforts in this patient group seem reasonable despite high resource utilization.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

The Effect of Various Fenoldopam Doses on Renal Perfusion in Patients Undergoing Cardiac Surgery [ORIGINAL ARTICLES: ADULT CARDIAC]

Background The hypothesis that fenoldopam mesylate, by increasing renal flow, could reduce renal damage in patients undergoing cardiac surgery with cardiopulmonary bypass has gained great interest. The aim of the current study was to quantify the relationship of the increase of the renal blood flow as a function of the fenoldopam dose in these patients and to evaluate renal flow distribution within the renal parenchyma using Doppler. Methods Twenty-five patients admitted to cardiac surgery have been enrolled. We used the Doppler technique to measure renal blood flow at the level of the renal, segmental, interlobar, and interlobular arteries. We calculated both the resistive and pulsatility indexes in all the renal segments. Moreover, we calculated echographically all the variables of preload, afterload, and cardiac index. Measurements were performed at baseline and after the infusion of fenoldopam mesylate at the doses of 0.05, 0.1, 0.2, and 0.3 µg · kg–1 · min–1. Results Fenoldopam infusion at doses more than 0.1 µg · kg–1 · min–1 significantly increases blood flow in all renal compartments, thus improving the resistive and pulsatility indexes starting at a dose of 0.1 µg · kg–1 · min–1. The highest renal flow increase is observed with 0.3 µg · kg–1 · min–1. Fenoldopam seems to increase the renal flow directed to the most external kidney areas. Systemic hemodynamically significant changes are observed only in patients receiving doses more than 0.1 µg · kg–1 · min–1. Conclusions In hemodynamically stable patients undergoing cardiac surgery with preserved renal function, fenoldopam shows a pharmacodynamic dose-dependent profile: it significantly increases renal flow and reduces the resistances of the renal circulation starting at a dose of 0.1 µg · kg–1 · min–1.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Renal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported. Methods Between May 1997 and January 2009, 102 patients (mean age, 63 years) underwent resection of renal tumor extending into the IVC by techniques developed to avoid sternotomy and CBP. The tumor thrombus in 12 patients (13%) extended into the supradiaphragmatic IVC and RA. Results Complete resection was successful through the transabdominal approach without CBP in all patients. Mean operative time was 8 hours 15 minutes. Estimated blood loss was 2960 mL, and a mean of 9 U of blood was transfused. Two patients died postoperatively, 1 on day 4 of arrhythmia and 1 on day 22 of multisystem organ failure. All discharged patients were alive at the last follow-up. Three patients had tumor recurrence and have been referred for adjuvant therapy. Conclusions In select cases, renal cell carcinoma extending into the IVC to the intrapericardial level and RA can be resected without sternotomy, CBP, or DHCA.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Impact of Normothermic Perfusion and Protein Supplementation on Human Endothelial Cell Function During Organ Preservation [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Hypothermia-induced changes in endothelial cell (EC) morphology and function after organ storage may influence the initial outcome and development of transplant-associated coronary artery disease. Methods Human saphenous vein ECs were incubated with saline (NaCl), University of Wisconsin (UW), and histidine-tryptophan-ketoglutarate (HTK) solution, with and without protein additives, at 4°C and 37°C. After 6 hours, ECs were recultivated for 24 and 48 hours with culture medium (reperfusion). Mitochondrial activity, adenosine triphosphate concentration, cell count, and inflammatory responses were analyzed. Results Cold preservation did not affect the mitochondrial activity of ECs and allowed a complete regeneration of the metabolic turnover after reperfusion. However, under normothermic conditions the metabolism of the cells was influenced by time and type of preservation solution. While both the mitochondrial activity and cell count did not change after treatment with NaCl and culture medium, the metabolic turnover of cells treated with HTK and UW solution significantly increased (twofold) and decreased (twofold, p < 0.05), respectively, after reperfusion. The endothelial reactivity remained unchanged after treatment with NaCl and HTK. The addition of serum proteins significantly improved mitochondrial activity of cells treated with warm NaCl and HTK (p < 0.05). The UW-treated cells burned out through a significant up-regulation of the ATP concentration resulting in a complete metabolic regression after reperfusion and induction of apoptosis. Conclusions Normothermic preservation in UW prevented regeneration of ECs, while treatment with HKT solution did not irreversibly affect mitochondrial activity of ECs and allowed complete regeneration of metabolism and function. Serum proteins improved the preservation effect of HTK and NaCl.

Invited Commentary [ORIGINAL ARTICLES: ADULT CARDIAC]

Impact of Abdominal Complications on Outcome After Mechanical Circulatory Support [ORIGINAL ARTICLES: ADULT CARDIAC]

Background Mechanical circulatory support (MCS) is life sustaining for patients with end-stage heart failure. Most devices require abdominal wall transgression, creating a potential for abdominal complications. The incidence and impact of these relatively underreported complications are unknown. Methods A retrospective review was performed on 179 patients who received MCS therapy from 1999 to 2008. Abdominal complications were grouped as abdominal wall, gastrointestinal tract, and solid organ. Results Ninety-eight patients (55%) experienced 157 abdominal complications. These involved the abdominal wall in 69 (44%), the gastrointestinal tract in 52 (33%), and the solid organs in 36 (23%). Surgical intervention was required in 36% of patients with abdominal wall complications, 19% of patients with gastrointestinal tract complications, and 14% of patients with solid organ complications. Multivariate analysis identified diabetes mellitus (p < 0.001), emergent device placement (p = 0.019), and preimplant mechanical ventilation (p = 0.045) as independent risk factors for developing an abdominal complication. Kaplan-Meier survival while receiving MCS was significantly reduced for patients with abdominal complications versus those without (p = 0.0142). Multivariate analysis identified only solid organ abdominal complications (p = 0.001) as an independent risk factor for death while receiving device support. Conclusions Abdominal complications are common in patients supported with MCS devices and significantly reduce survival. Surgical intervention is more frequently required for complications related to the abdominal wall compared with other complications. Patients with significant comorbidities (diabetes mellitus, respiratory failure) requiring urgent or emergent device placement are at higher risk for the development of abdominal complications with an attendant reduction in device-related survival.

Partial and Transitional Atrioventricular Septal Defect Outcomes [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Surgical and perioperative improvements permit earlier repair of partial and transitional atrioventricular septal defects (AVSD). We sought to describe contemporary outcomes in a multicenter cohort. Methods We studied 87 patients undergoing primary biventricular repair of partial or transitional AVSD between June 2004 and February 2006 across seven North American centers. One-month and 6-month postoperative data included weight-for-age z-scores, left atrioventricular valve regurgitation (LAVVR) grade, residual shunts, and left ventricular ejection fraction. Paired methods were used to assess 6-month change. Results Median age at surgery was 1.8 years; median weight z-score was –0.88. Median days for ventilation were 1, intensive care 2, and hospitalization 5, all independent of age, with 1 in-hospital death. At 1 month, 27% (16 of 73) had ejection fraction less than 55%; 20% (17 of 87) had significant LAVVR; 2 had residual shunts; 1 each had subaortic stenosis and LAVV stenosis. At 6 months (n = 60), there were no interim deaths, reinterventions, or new development of subaortic or LAVV stenosis. Weight z-score improved by a median 0.4 units (p < 0.001), especially for underweight children less than 18 months old. Left atrioventricular valve regurgitation occurred in 31% (change from baseline, p = 0.13), occurring more frequently in patients repaired at 4 to 7 years (p = 0.01). Three patients had ejection fraction less than 55%, and 1 had a residual atrial shunt. Conclusions Surgical repair for partial/transitional AVSD is associated with low morbidity and mortality, short hospital stays, and catch-up growth, particularly in underweight children repaired between 3 and 18 months of age. Left atrioventricular valve regurgitation remains the most common residual defect, occurring more frequently in children repaired after 4 years of age.

Biventricular Repair of Atrioventricular Septal Defect With Common Atrioventricular Valve and Double-Outlet Right Ventricle [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background The combination of an atrioventricular septal defect with a common atrioventricular junction guarded by a common valve, and double-outlet right ventricle, is a rare lesion that presents a challenge for surgical repair. This report describes our surgical approach and results in 16 patients undergoing biventricular repair for such a combination of lesions. Methods A retrospective analysis was performed for all patients undergoing biventricular repair of atrioventricular septal defect with common atrioventricular valve and double-outlet right ventricle between 1991 and 2008. Patients with tetralogy of Fallot and common atrioventricular valve were excluded from analysis. Early and actuarial outcomes were evaluated using the 2 test for categorical variables and Wilcoxon rank sum for ordinal variables. Results The median age at operation was 16 months. Heterotaxy syndrome was present in 12 of the 16 patients (9 right isomerism and 3 left isomerism), and 6 had concurrent totally anomalous pulmonary venous connections. Primary repair was achieved in 6 patients, and 10 underwent one or more prior operations (most frequently a shunt, banding of the pulmonary trunk, or repair of the anomalous pulmonary venous connections). Enlargement of the ventricular septal defect by resection of the muscular outlet septum was required in 11 patients, in whom the ventricular septal defect emptied entirely or primarily to the inlet of the right ventricle. A conduit was placed from the right ventricle to the pulmonary arteries in 13. There was 1 death before discharge from hospital, 1 late death, and 2 episodes of heart block. Among survivors, follow-up was complete with a median follow-up of 66 months. No patient had late obstruction of the left ventricular outflow tract. The presence of heterotaxy with totally anomalous pulmonary venous connections was associated with combined mortality and significant morbidity (p = 0.008). Conclusions Although technically challenging, the surgical repair can be accomplished with acceptable early results. Heterotaxy syndrome, with concurrent anomalous connections of the pulmonary veins, represented the strongest identified risk factor for death or significant complication.

Current Expectations for Surgical Repair of Isolated Ventricular Septal Defects [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Ventricular septal defect (VSD) is the most commonly recognized congenital heart defect. With the development of device closure for intracardiac defects, we sought to evaluate current expectations for surgical closure of isolated VSD. Methods Between January 1, 2000, and December 31, 2006, 215 patients underwent isolated VSD repair at a median age of 10 months (range, 20 days to 18 years) and a median weight of 7 kg (range, 2 to 66 kg). The following VSD types were found: 172 perimembranous (80%), 28 supracristal (13%), 6 inlet (3%), and 9 muscular (4%). One hundred eight patients (50%) had evidence of congestive heart failure or failure to thrive preoperatively. Thirty-one patients (14%) had aortic valve cusp prolapse, and 63 (29%) had genetic abnormalities. Results Incidence of significant postoperative complications was extremely low. No patient underwent reoperation for a residual VSD. None had complete heart block. One operative mortality (0.5%) and 2 late deaths (0.9%) occurred. Median postoperative hospital length of stay was 5 days (range, 2 to 187 days). In the immediate postoperative period, 6 patients (2.8%) required reoperation. No patients were discharged on antiarrhythmic agents, had complete heart block, or required permanent pacing. At mean follow-up of 2.1 ± 2.0 years, 99.5% (211 of 212) of patients were asymptomatic from a cardiac standpoint. None exhibited greater than mild new-onset tricuspid valve regurgitation. No aortic valve injuries occurred. Conclusions Surgical closure of isolated VSD is a safe, effective therapy. Risk of death, complete heart block, and reoperation is minimal. As new technologies for VSD closure evolve, results such as these should be considered when evaluating patients, choosing therapeutic options, and counseling families.

Ventricular Septal Defects Closure Using a Minimal Right Vertical Infraaxillary Thoracotomy: Seven-Year Experience in 274 Patients [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background From December 2001 to February 2008, right vertical infraaxillary thoracotomy (RVIAT) was used to perform ventricular septal defect (VSD) closure in selected patients. This retrospective study reviews our results and experiences. Methods The study included 274 patients (143 females, 131 males) undergoing VSD closure through a RVIAT approach. Patients were a mean age of 10.5 ± 8.9 years (range, 0.5 to 43 years). Body weight was 37.8 ± 12.5 kg (range, 8 to 72 kg). The VSD was subpulmonary in 14 patients and perimembranous in 260. Results No perioperative or late deaths occurred during the follow-up. Cardiac defects were corrected in all patients through RVIAT. The mean incision length was 7.2 ± 2.9 cm (range, 4.1 to 8.9 cm). Cardiopulmonary bypass time was 61.6 ± 27.8 minutes (range, 29 to 187 minutes), and aortic clamp time was 33.4 ± 20.8 minutes (range, 5 to 139 minutes). The mean postoperative hospital stay was 4.9 ± 2.6 days (range, 2 to 14 days). Postoperative echocardiograms revealed 3 patients with residual shunt with later catheter intervention. The cosmetic advantage of the RVIAT is the short incision under the armpit that is often invisible. All patients were satisfied with the cosmetic results during the follow-up. Conclusions The RVIAT can be performed with favorable cosmetic and clinical results for VSD closure. It provides a good alternative to standard median sternotomy for VSD patients.

Lateral Tunnel Fontan in the Current Era: Is It Still a Good Option? [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Construction of a total cavopulmonary anastomosis using an intra-atrial lateral tunnel Fontan (LTF) is known to yield good early and midterm results. Given the current controversy regarding indications for a total extracardiac conduit Fontan, we reviewed the long-term outcomes after a LTF operation and compared them with recently published series using one or both techniques. Methods Between 1992 and 2008, 220 of 280 patients (median age, 2.5 years; range, 1 to 45) with a wide range of underlying diagnoses underwent a fenestrated or nonfenestrated LTF operation at our institution. Current follow-up information was available for 215 patients (98%; mean follow-up, 6.7 ± 3.9 years). Risk factor analysis included patient-related and procedure-related variables, with death, failure (takedown or transplantation), and bradyarrhythmia or tachyarrhythmia as outcome variables. Results There was 1 early death, 10 late deaths, 3 takedown operations, and 1 heart transplantation. Kaplan-Meier estimated survival was 96% at 5 years and 95% at 10 and 15 years, and freedom from failure was 94% at 5 years and 93% at 10 years. Freedom from new supraventricular tachyarrhythmia was 98% at 5 years and 95% at 10 years; freedom from new bradyarrhythmia was 97% at 5 years and 96% at 10 years. Six patients have protein-losing enteropathy, and 2 of 6 have had Fontan takedown. Multivariable risk factors for development of supraventricular tachyarrhythmia included atrioventricular valve abnormalities (p = 0.02), and preoperative bradyarrhythmia (p = 0.01). Risk factors for bradyarrhythmia included the need for early postoperative pacing (p = 0.001). None of the patient-related variables significantly influenced survival. Conclusions The LTF operation results in excellent midterm outcome even when used in patients with complex anatomy. The incidence of postoperative atrial tachyarrhythmia is low and depends largely on the underlying cardiac morphology and incidence of preoperative arrhythmia. The good midterm outcome after a LTF operation should serve as a basis for comparison with other surgical alternatives to complete the Fontan circulation.

Outcomes Using Predominantly Single-Stage Approach to Interrupted Aortic Arch and Associated Defects [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Neonatal repair of interrupted aortic arch (IAA) involves an early choice between a single-stage or two-stage strategy. Risk factors for each are not yet fully investigated, especially as they relate to major associated cardiac malformations. We aimed to assess the outcome of neonates undergoing biventricular repair of IAA and associated congenital heart defects. Methods Preoperative assessment, operative management, and outcome were retrospectively reviewed for 18 consecutive patients undergoing biventricular IAA repair at Starship Children's Hospital from 2000 to 2005. Results Seventeen patients underwent a single-stage procedure and one patient weighing 970 g underwent a two-stage procedure. All but one had a ventricular septal defect. Major associated cardiac defects were present in 7 and included aortopulmonary window (1), truncus arteriosus (3), transposition of the great arteries (1), and aortic valve atresia (2). Those with major associated cardiac defects had longer procedural times but similar early mortality and intensive care unit and hospital stay. One patient required a pacemaker for complete heart block. Mean follow-up was 4.5 years with one late death and all survivors reporting normal functional status. Developmental delay was present in 5 (27%), 4 of whom had 22q deletion. Late reoperation was required in 4, including two Konno procedures and two pulmonary conduit changes. Conclusions A good functional outcome and low reoperation rate can be achieved with a single-stage repair regardless of the presence of major additional cardiac abnormalities. Neonates with risk factors such as low birth weight and prematurity require an individualized approach.

Invited Commentary [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Thrombotic Risk of Recombinant Factor Seven in Pediatric Cardiac Surgery: A Single Institution Experience [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Recombinant activated factor seven (rFVIIa) is increasingly being used as a hemostatic adjunct in pediatric cardiac surgery. We evaluated the thrombotic safety profile of rFVIIa in pediatric congenital heart disease (CHD) surgery. Methods This was a retrospective matched case-control study over six years at a single institution. Patients who received rFVIIa after CHD surgery were matched to controls based on age, diagnosis, and procedure. We compared thrombosis, hemorrhage, transfusions, length of stay, and repeat procedures between groups. Results Twenty-five patients received rFVIIa (mean dose: 70 mcg/kg); 50 controls were matched. There was no significant difference in the rate of thrombosis between patients who received rFVIIa and controls (8% vs 4%). After rFVIIa, there was a significant reduction in transfusion volume (median 77.1 mL/kg vs 14.6 mL/kg; p < 0.001) as well as a significant decrease in hemorrhagic chest tube output (8.3 ± 1.6 mL/kg/hour vs 1.4 ± 0.3 mL/kg/hour; mean ± standard error of the mean; p < 0.001). No difference was seen in intensive care unit or hospital length of stay or mortality between patients receiving rFVIIa and controls. Conclusions The rFVIIa therapy did not increase thrombotic complications when used as rescue therapy after CHD surgery but did appear to decrease bleeding complications in this small cohort.

Invited Commentary [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Intraoperative Hyperglycemia and Postoperative Bacteremia in the Pediatric Cardiac Surgery Patient [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Intraoperative hyperglycemia has been found to be associated with a higher incidence of postoperative infections in the adult cardiac surgery population. The goal of this study was to determine the association of intraoperative hyperglycemia and postoperative bacteremia in the pediatric population. Methods A retrospective chart review of all cardiac surgical cases for patients 18 years of age or younger requiring cardiopulmonary bypass support between June 2002 and July 2007 yielded 1,132 total cases representing 992 unique patients. Patient demographic and clinical data of interest were collected. Descriptive statistics and regression analyses were performed to investigate the hypothesized relationship between glucose levels and infection rates. Results From the 992 patient records examined, 15 patients exhibited a bacteremia within 14 days of surgery (1.5%). The association between the highest glucose during cardiopulmonary bypass and bacteremia reached statistical significance when the glucose level reached 175 mg/dL (2 = 4.59, 1 degree of freedom; p = 0.032). A patient was more than three times as likely to have a postoperative bacteremia when the glucose level reached this amount or exceeded it (odds ratio, 3.3, 95% confidence interval, 1.04 to 10.39). Ten of the 15 (66.7%) postoperative infections occurred in patients with peak bypass glucose levels of at least 175 mg/dL. Conclusions Intraoperative hyperglycemia was found to be associated with a higher risk of postoperative bacteremia in the pediatric cardiac surgery population.

Human Cord Blood Stem Cells Enhance Neonatal Right Ventricular Function in an Ovine Model of Right Ventricular Training [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

Background Nonischemic right ventricular dysfunction and cardiac failure is a source of considerable morbidity in children with congenital heart disease. Cell transplantation has not previously been studied in the pediatric setting in which enhancing ventricular function in response to supraphysiologic workloads might be beneficial. Methods Engraftment and differentiation of human cord blood stem cells were studied in an immunosuppressed neonatal ovine model of right ventricular training. Week-old sheep underwent pulmonary artery banding and epicardial injection of cord blood stem cells (n = 8) or pulmonary artery banding and placebo injection (n = 8). Control groups received cord blood stem cells (n = 6) or placebo (n = 6) injection without pulmonary artery banding. Right ventricular function was measured at baseline and 1 month later using conductance catheter. Results Cord blood stem cells were detected in the myocardium, spleen, kidney, and bone marrow up to 6 weeks after transplantation and expressed the hematopoietic markers CD45 and CD23. We identified neither differentiation nor fusion of transplanted human cells. In the groups undergoing pulmonary artery banding, cord blood stem cell transplantation was accompanied by functional benefits compared with placebo injection: end-systolic elastance increased by a mean of 1.4 ± 0.2 mm Hg/mL compared with 0.9 ± 0.1 mm Hg/mL, and the slope of preload recruitable stroke work increased by 21.1 ± 2.9 mm Hg compared with 15.8 ± 2.5 mm Hg. Cord blood stem cell transplantation had no significant effect on right ventricular function in the absence of pulmonary artery banding. Conclusions Our data demonstrate that in the presence of increased workload, cord blood stem cells engraft and augment right ventricular function. Transplanted cells adopt hematopoietic fates in the myocardium, bone marrow, and spleen.

Invited Commentary [ORIGINAL ARTICLES: PEDIATRIC CARDIAC]

An Inexpensive, Reproducible Tissue Simulator for Teaching Thoracoscopic Lobectomy [NEW TECHNOLOGY]

Purpose Simulation is rapidly becoming an integral part of surgical education at all levels including the education of practicing surgeons in new techniques such as thoracoscopic lobectomy. Current thoracoscopic lobectomy simulator models have significant limitations including expense and requirement for specialized facilities. This study describes a novel low-cost, easily reproducible, bench top simulator. Description Tissue blocks consisting of a porcine heart and bilateral lungs with intact pericardium were secured from a commercially available source. The pulmonary artery and veins were statically distended with ketchup to more realistically mimic the technique of dissection and allow for simultaneous identification of technical errors. Evaluation This simulator has been used at seven different industry and society sponsored thoracoscopic lobectomy training programs by more than 100 participants. Qualitative data on the performance of the model was collected from faculty and course participants. Conclusions A low-cost porcine heart-lung block statically perfused with ketchup provides an inexpensive, easily reproducible model for teaching thoracoscopic lobectomy, which reasonably and accurately simulates a clinical experience.

Removal of Long-Term Tracheal Stents With Excellent Tracheal Healing [CASE REPORTS]

Covered metallic endobronchial stents are increasingly used in the management of diverse large airway pathology and once deployed they are considered permanent. Long-term complications of stent fracture and airway granulation tissue formation may necessitate stent removal. We describe successful endoscopic removal of the Ultraflex expandable tracheal metallic stents (Microvasive; Boston Scientific, Natick, MA) in 5 patients at 105, 84, 50, 38, and 21 months after deployment, with excellent tracheal healing and clearance of granulation tissue noted at 6 weeks after removal in each patient.

Restrictive Chest Wall Deformity as a Complication of Surgical Repair for Pectus Excavatum [CASE REPORTS]

The Ravitch operation is frequently performed to correct pectus excavatum. However, extensive destruction of the perichondrium and rib growth centers may lead to failure of subsequent chest wall development. A 29-year-old man who underwent a Ravitch operation 26 years previously developed a restrictive chest wall deformity, which resulted in severe pulmonary hypertension and restrictive lung disease.

Acellular Dermal Matrix Closure of Catastrophic Bronchopleural Fistula [CASE REPORTS]

Early, complete disruption of bronchial closure is a rare complication after pulmonary resection that will result in almost certain death if immediate intervention is not taken. We present a case of a catastrophic bronchopleural fistula that was successfully closed using an Alloderm patch (LifeCell Corp, Branchburg, NJ) in the acute setting.

Thoracic Empyema After Pneumonectomy: Intrathoracic Application of Vacuum-Assisted Closure Therapy [CASE REPORTS]

We report the use of vacuum-assisted closure (V.A.C. Therapy, KCI Medical, Wiesbaden, Germany) to treat an intrathoracic empyema that occurred after resection of the right lung. Successful closure of the thoracic cavity was achieved with an omental plombage.

Barrett's Adenocarcinoma 52 Years After Subtotal Esophagectomy for Pediatric Peptic Stricture [CASE REPORTS]

Barrett's esophagus results from the long-term effects of both acid and bile reflux. After subtotal esophagectomy and reconstruction with a gastric tube, many patients experience profound reflux. Development of Barrett's epithelium in the esophageal remnant has been reported. Here we report the case of a man who was diagnosed with adenocarcinoma in his esophageal remnant on a background of Barrett's change 52 years after undergoing one of the first esophageal resections for benign disease as a child.

Inflammatory Myofibroblastic Tumor of the Esophagus [CASE REPORTS]

Inflammatory myofibroblastic tumors are regarded as intermediate-grade tumors with a potential for recurrence. Although these lesions have been found in nearly every anatomic location, there are few documented cases of esophageal localization. The rare case reported here concerns a 55-year-old woman with an extremely large inflammatory myofibroblastic tumor of the esophagus; the tumor was 20 cm in length and 6 cm in diameter. Wide surgical excision was performed. Histopathologic and immunohistochemical analyses confirmed the diagnosis of an inflammatory myofibroblastic tumor. There was no recurrence or tumor metastasis 6 months after the operation.

Giant Multi-Polypoid Liposarcoma of the Esophagus: An Atypical Presentation [CASE REPORTS]

Liposarcomas of the esophagus are rare with only 19 cases reported in the English literature. We present a giant, well-differentiated liposarcoma of the esophagus with multiple pedunculated polypoid-like growths, which made it radiographically and pathologically noncharacteristic. We discuss the diagnostic dilemmas, clinical and pathologic findings, and surgical treatment.

Invasive Thymoma With Endobronchial Metastasis [CASE REPORTS]

Endobronchial thymoma is an exceedingly rare presentation. We report a 70-year-old woman undergoing bronchoscopy for dyspnea and a computed tomographic scan believed to be most consistent with a right lower lobe neoplasm. Thoracoscopy was ultimately required for diagnosis.

Percutaneous Extracorporeal Membrane Oxygenation for Cardiogenic Shock Due to Acute Fulminant Myocarditis [CASE REPORTS]

Percutaneous extracorporeal membrane oxygenation is an invasive technique that provides emergent circulatory support for patients with cardiogenic shock. We report a favorable outcome of an acute fulminant myocarditis in a 25-year-old myasthenia patient with cardiogenic shock supported by percutaneous extracorporeal membrane oxygenation.

Transapical Deployment of Endovascular Thoracic Aortic Stent Graft for an Ascending Aortic Pseudoaneurysm [CASE REPORTS]

We report a case of a patient with a history of previous coronary artery bypass grafting undergoing endovascular aortic repair of a large pseudoaneurysm in the ascending aorta. Due to the limitations of the current technology, the endograft was deployed through a left ventricular transapical approach by using a left mini-thoracotomy.

Closure of the Left Main Trunk of the Coronary Artery and Total Arch Replacement in Acute Type A Dissection During Coronary Angiography [CASE REPORTS]

A 64-year-old woman was complicated with acute type A dissection arising from the left main trunk during percutaneous coronary angiography. As the extent of dissection was localized in the ascending aorta, a bare-metal stent was inserted into the left main trunk to cover the entry of dissection. Two days after an angiography, the patient's hemodynamic status suddenly deteriorated. A computed tomographic scan showed expansion of a thrombosed false lumen severely compressing the true lumen. Emergency total arch replacement was performed, combined with ligation of the left main trunk and coronary artery bypass grafting. The patient recovered well without residual dissection in the sinus of Valsalva.

Apico-Brachiocephalic Artery Bypass for Aortic Stenosis With Porcelain Aorta [CASE REPORTS]

Apicoaortic bypass for left ventricular outflow tract obstruction has been performed with acceptable mid-term mortality. However, sometimes it is difficult to anastomose the distal end of the conduit to the calcified descending aorta in patients with a porcelain aorta. We report an aortic non-touch modification of the apicoaortic bypass in an 80-year-old woman with valvular aortic stenosis and a porcelain aorta extending from the ascending to abdominal aorta. We performed apico-brachiocephalic artery bypass under circulatory arrest with deep hypothermia. This procedure may become a useful surgical option for patients with a severe porcelain aorta.

Coronary Artery Bypass in the Context of Polyarteritis Nodosa [CASE REPORTS]

A 46-year-old man with polyarteritis nodosa and multiple myocardial infarctions treated with multiple percutaneous coronary interventions presented again with atypical angina. Coronary angiography revealed triple-vessel coronary artery disease. This patient underwent four-vessel coronary artery bypass graft and recovered uneventfully. A review of the literature and discussion of the surgical management of this patient is presented.

Implications for Cardiac Surgery in Patients With Factor XII Deficiency [CASE REPORTS]

Factor XII deficiency is associated with a prolonged activated partial thromboplastin time and activated clotting time used for monitoring during cardiopulmonary bypass. It does not predispose to an increased risk of bleeding. We present the strategy used for a case of coronary artery bypass grafting in a patient with factor XII deficiency, followed by a brief discussion of the important clinical considerations when patients with factor XII deficiency undergo cardiac surgery. Monitoring of heparin and the avoidance of anti-fibrinolytic agents are the main intraoperative issues. Postoperative care must include careful thromboembolic prophylaxis and vigilance against infection.

Malignant B-Cell Lymphoma Arising in a Large, Left Atrial Myxoma [CASE REPORTS]

A case of large cardiac myxoma associated with primary B cell lymphoma is described in a patient presenting with acute obstructive left heart failure. Emergent surgical removal was performed along with mitral valve repair.

Congenital Mitral Disease: Anomalous Mitral Arcade in a Young Man [CASE REPORTS]

We present the case of a 33-year-old man referred to our institution with a diagnosis of severe mitral valvular stenosis and insufficiency. We realized the valvular disease was due to an "anomalous mitral arcade," a rare congenital malformation of the mitral tensor apparatus characterized by enlarged papillary muscles connected to mitral leaflets by a typical fibrous tissue bridge. This arrangement creates a fibrous continuity between valvular and subvalvular apparatus. The reported echocardiographic images shows in detail the anatomic and functional features of this rare condition.

Radical Resection of the Superior Vena Cava Using the Contegra Bovine Jugular Vein Conduit [CASE REPORTS]

Radical resection of the superior vena cava poses a challenge for the cardiothoracic surgeon. The Contegra graft (Medtronic Inc, Minneapolis, MN), a biologic conduit comprising the valved segment of the bovine jugular vein, is established as a right ventricular to pulmonary artery conduit for right ventricular outflow tract repair in the pediatric population. We describe the use of the Contegra graft to facilitate radical resection and reconstruction of the superior vena cava in 2 patients, with demonstrable patency of grafts at 12 months and 7 months postoperatively.

Aortic Translocation for the Management of Double-Outlet Right Ventricle and Pulmonary Stenosis With Dextrocardia: Technique to Avoid Coronary Insufficiency [CASE REPORTS]

The management of D-loop transposition of the great arteries with left ventricular outflow tract obstruction and related forms of double-outlet right ventricle is challenging. Association with right ventricular and tricuspid valve hypoplasia and dextrocardia represents a major obstacle to achieve a biventricular repair. The most commonly used technique to deal with this condition, which is the Rastelli operation, further reduces the potentially compromised right ventricular volume due to the left ventricle-to-aorta baffle. Because the Rastelli operation risks later development of left ventricular outflow tract obstruction, aortic translocation can be considered for these patients. We report a case of double-outlet right ventricle with left ventricular outflow tract obstruction in the setting of dextrocardia, left juxtaposition of the atrial appendages, and a small tricuspid valve, which was successfully managed with a biventricular repair by means of an aortic translocation technique.

Successful Staged Fontan Completion for Truncus Arteriosus With Hypoplastic Left Ventricle [CASE REPORTS]

We report a case of truncus arteriosus type II with a large outlet ventricular septal defect and a hypoplastic left ventricle. The first-stage palliation was the removal of both branch pulmonary arteries from the ascending aorta, patch augmentation of the pulmonary artery confluence, and modified Blalock-Taussig shunt at age 1 month. The second stage palliation was a bidirectional Glenn at 6 months. The final stage was an extracardiac Fontan at age 3 years. Eight years later, the patient is doing well, with an unobstructed Fontan pathway and mild-to-moderate truncal valve insufficiency.

Left Arm Underdevelopment Secondary to an Isolated Left Subclavian Artery in Tetralogy of Fallot [CASE REPORTS]

The anomalous origin of the left subclavian artery is known to be associated with right aortic arch and tetralogy of Fallot. In our case, the left subclavian artery arose from the left pulmonary artery. Therefore, the left arm was perfused by poorly oxygenated blood from pulmonary arteries and some retrograde vertebral artery flow. Thus, the left arm was cyanotic and less developed than the right one. The patient underwent surgical repair with complete correction of tetralogy of Fallot and reimplantation of the left subclavian artery to the left carotid artery.

Iatrogenic Pneumomediastinum and Facial Emphysema After Surgical Tooth Extraction [IMAGES IN CARDIOTHORACIC SURGERY]

Unusual Migration of a Foreign Body From Sternal Notch to the Left Pleural Lateral Sulcus [IMAGES IN CARDIOTHORACIC SURGERY]

Necessitating, Recurrent Pseudoaneurysm of the Left Ventricle [IMAGES IN CARDIOTHORACIC SURGERY]

Plicated Patch Repair for Acquired Gerbode Defect Involving the Tricuspid Valve [HOW TO DO IT]

Gerbode's defect, a left ventricular-to-right atrial communication, with involvement of the tricuspid valve acquired after bacterial endocarditis can be challenging to repair. We report a modified technique for a shunt closure and reconstruction of the tricuspid valve using a plicated bovine pericardial patch. Combining such a repair with a left ventricular patch resulted in a complete defect closure and competent tricuspid valve without regurgitation.

En Bloc Neochordae and Cusp Formation From Autologous Pericardium for Repair of Congenital Tricuspid Regurgitation [HOW TO DO IT]

A simple technique for reconstruction of the tricuspid valve in patients with congenital isolated tricuspid reurgitation is described. A single piece of autologous pericardium is used for en bloc reconstruction of the tricuspid valve and its chordae.

A Multidisciplinary Approach to the Minimally Invasive Pulmonary Vein Isolation for Treatment of Atrial Fibrillation [HOW TO DO IT]

Bilateral pulmonary vein isolation along with amputation of the left atrial appendage has become a well-recognized technique for the management of atrial fibrillation. We describe our multidisciplinary approach to minimally invasive bilateral pulmonary vein isolation, left atrial appendage resection, and ablation of autonomic ganglia.

Simple and Inexpensive Technique for Internal Mammary Artery Harvest [HOW TO DO IT]

A simple, inexpensive, and easy-to-use method for exposure of the left internal mammary artery is described. Two blades of the conventional four-blade sternal spreader hooking the Adson forceps, which passes through the loops of sternal wires, provides excellent exposure of the IMA. The same retractor is used for the rest of the procedure.

Lung Transplantation, Gastroesophageal Reflux, and Fundoplication [REVIEWS]

Lung transplantation is an accepted treatment strategy for end-stage lung disease; however, bronchiolitis obliterans syndrome is a major cause of morbidity and mortality. This review explores the role of gastroesophageal reflux disease in bronchiolitis obliterans syndrome and the evidence suggesting the benefits of anti-reflux surgery in improving lung function and survival. There is a high prevalence of gastroesophageal reflux in patients post lung transplantation. This may be due to a high preoperative incidence, vagal damage and immunosuppression. Reflux in these patients is associated with a worse outcome, which may be due to micro-aspiration. Anti-reflux surgery is safe in selected lung transplant recipients; however there has been one report of a postoperative mortality. Evidence is conflicting but may suggest a benefit for patients undergoing anti-reflux surgery in terms of lung function and survival; there are no controlled studies. The precise indications, timing, and choice of fundoplication are yet to be defined, and further studies are required.

Effect of Skeletonization of the Internal Thoracic Artery for Coronary Revascularization on the Incidence of Sternal Wound Infection [REVIEWS]

Use of the internal thoracic artery in coronary revascularization confers excellent benefit. We assessed the impact of skeletonization on the incidence of postoperative sternal wound infection in patients undergoing coronary artery bypass grafting. We also investigated whether there is an advantage in using this technique when harvesting both internal thoracic arteries in high-risk groups, such as diabetic patients. Skeletonization was associated with beneficial reduction in the odds ratio of sternal wound infection (odds ratio, 0.41; 95% confidence interval, 0.26 to 0.64). This effect was more evident when analyzing diabetic patients undergoing bilateral internal thoracic artery grafting (odds ratio, 0.19; 95% confidence interval, 0.10 to 0.34).

Management of Patients With Persistent Air Leak After Elective Pulmonary Resection [CORRESPONDENCE]