The Journal of Thoracic and Cardiovascular Surgery

The critical role of imaging navigation and guidance in transcatheter aortic valve implantation

Pencilla Lang, Terry M. Peters, Bob Kiaii, Michael W.A. Chu — 2012-03-09

Transcatheter aortic valve implantation (TAVI), an innovative stent-based technique for delivery of a bioprosthetic valve, has seen remarkable growth since 2002 and has resulted in a paradigm shift in treatment options for elderly patients with aortic stenosis. Although there have been major advancements in transcatheter valve design and endovascular access routes, TAVI still relies largely on single-plane fluoroscopy for intraoperative navigation and guidance, with only gross structures visible. Patient outcomes have improved with experience; however, early complications still occur and are commonly associated with limited intraoperative imaging and suboptimal valve positioning. We discuss these concepts and describe how a greater emphasis on imaging research could significantly reduce the current perioperative morbidity and mortality of TAVI and lead to a better controlled, more accurate, and safer procedure.

Historical perspectives of The American Association for Thoracic Surgery: Lyman A. Brewer III (1907–1988)

James I. Fann — 2011-08-08

Lyman A. Brewer III, the 54th president of The American Association for Thoracic Surgery (AATS), was born in Toledo, Ohio, on July 28, 1907 (). Brewer’s father, an engineer and innovative businessman, was the first to import seamless steel tubes into this country. Notably, Brewer’s grandfather, Lyman A. Brewer, was a Civil War surgeon, and his uncle Lyman A. Brewer II was Professor of Surgery at the Toledo Medical College. Recognizing his family’s surgical legacy, Brewer chose medicine as his calling, although his engineering inventiveness was to be later evident. He attended Scott High School and matriculated in 1924 at Amherst College, an environment that nurtured his lifelong interest in history, literature, and the humanities. After graduation from college in 1928, Brewer attended University of Michigan Medical School, obtaining his doctorate in medicine in 1932. He, along with his friend Paul C. Samson, the 48th AATS president, continued postgraduate study for 6 months in the department of pathology. Known as the “Toledo Terrors,” they were to cross paths many times as the 2 became future leaders of thoracic surgery. Brewer then trained for 6 months in surgery in Toledo, followed by 18 months in internal medicine at Boston City Hospital and 12 months each of treating thoracic disease and of surgery at Bellevue Hospital in New York.

Training residents in off-pump coronary artery bypass surgery: A 14-year experience

Michele Murzi, Massimo Caputo, Giuseppe Aresu, Simon Duggan, Gianni D. Angelini — 2011-11-04

Objective: Off-pump coronary artery bypass grafting (OPCAB) is an established procedure in many cardiothoracic centers. For it to be widely applicable, however, teaching methods must be developed for surgical trainees. Early clinical outcomes and long-term survival of patients who underwent OPCAB at our institution by trainees supervised and unsupervised were compared with those of patients whose procedures were performed by senior surgeons. To evaluate evolution of training, outcomes were analyzed according to 3 different periods (1996–1999, 2000–2004, 2005–2009) and trainee seniority level.Methods: This was a retrospective, observational cohort study of prospectively collected data from 5566 consecutive patients who underwent isolated OPCAB performed by trainees (1589, 28.6%; 1111 supervised, 478 unsupervised) and by senior surgeons (3977, 71.4%).Results: Patients of senior surgeons were more likely to have left ventricular dysfunction (P = .001), peripheral vascular disease (P = .05), more extensive coronary artery disease (P = .001), and higher EuroSCOREs than patients of trainees. In addition, trainees were less likely to have performed urgent operations (P = .02) or reoperations (P = .03) but more likely to have operated on patients with previous percutaneous coronary intervention (P = .006). Early clinical outcomes and long-term survival were similar between groups and not related to trainee seniority, level of supervision by senior surgeon, or period during which training took place.Conclusions: OPCAB is a safe and reproducible surgical technique that can be taught successfully to cardiothoracic trainees. Clinical outcomes are unrelated to level of supervision or seniority of trainees.

Multisociety (AATS, ACCF, SCAI, and STS) expert consensus statement: Operator and institutional requirements for transcatheter valve repair and replacement, part 1: Transcatheter aortic valve replacement

2012-06-01

The granting of staff privileges to physicians is an important mechanism to ensure quality care. The Joint Commission on Accreditation of Healthcare Organizations requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians are charged with defining the criteria that constitute professional competence and with evaluating their peers accordingly. With the evolution of transcatheter aortic valve replacement (TAVR), an important opportunity arises for both cardiologists and surgeons to come together to identify the criteria for performing these procedures. The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology Foundation (ACCF), and the Society of Thoracic Surgeons (STS) have, therefore, joined together to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns TAVR. As TAVR is in its infancy, there are few data on which to base this consensus statement. Therefore, many of these recommendations are based on expert consensus. As the procedures evolve, technology changes, experience grows, and more data is accumulated, there will certainly be a need to update this consensus statement. However, with the Food and Drug Administration (FDA) having just approved the first generation of TAVR devices, the writing committee and participating societies believe that the recommendations listed in this report serve as an appropriate starting point. In some ways, these recommendations apply to institutions more than to individuals. As there is a strong consensus that these new valve therapies are best performed using a team approach, these credentialing criteria may be best applied at the institutional level. Partnering societies used the ACCF’s policy on relationships with industry and other entities (RWI) to author this document (http://www.cardiosource.org/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/Relationships-With-Industry-Policy.aspx). To avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the writing committee, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current health care–related relationships, including those existing 12 months before initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI, and be led by an interventional cardiology co-chair and a surgical co-chair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in , respectively. In addition, to ensure complete transparency, authors’ comprehensive disclosure information (including RWI not pertinent to this document) is available as an online supplement to this document. The work of the writing committee was supported exclusively by the partnering societies without commercial support. Writing committee members volunteered their time to this effort. Conference calls of the writing committee were confidential and attended only by committee members. SCAI, AATS, ACCF, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.

Regional alterations in cerebral growth exist preoperatively in infants with congenital heart disease

2011-12-06

Objectives: Magnetic resonance imaging has been used to define the neurologic abnormalities in infants with congenital heart disease (CHD), including preoperative injury and delayed brain maturation. The present study used qualitative scoring, cerebral biometry, and diffusion imaging to characterize the preoperative brain abnormalities in infants with CHD, including the identification of regions of greater vulnerability.Methods: A total of 67 infants with CHD had preoperative magnetic resonance imaging scans available for analysis of brain injury using qualitative scoring and brain development using qualitative scoring, metrics, and diffusion imaging.Results: Qualitative abnormalities were common, with 42% of infants having preoperative focal white matter lesions. Infants with CHD had smaller brain measures in the frontal lobe, parietal lobe, cerebellum, and brainstem (P < .001), with the frontal lobe and brainstem displaying the greatest alterations (P < .001). A smaller brain size in the frontal and parietal lobes correlated with delayed white matter microstructure reflected by diffusion imaging.Conclusions: Infants with CHD commonly display brain injury and delayed brain development. Regional alterations in brain size are present, with the frontal lobe and brainstem demonstrating the greatest alterations. This might reflect a combination of developmental vulnerability and regional differences in cerebral circulation.

Coronary artery perfusion and myocardial performance after patent ductus arteriosus ligation

Arvind Sehgal, Patrick J. McNamara — 2011-12-08

Objectives: To study coronary artery (CA) perfusion and myocardial performance after patent ductus arteriosus (PDA) ligation. The postoperative course in premature infants undergoing surgical ligation of PDA is often complicated by cardiorespiratory instability secondary to impaired left ventricular performance.Methods: Serial echocardiography was performed before and after (1, 8, and 24 hours) PDA ligation to assess systolic (left ventricular output [LVO]) and diastolic (isovolumic relaxation time, E and A wave peak velocity) myocardial performance, and CA diastolic flow (CA velocity time integral and flow). The ratio of CA flow to LVO was calculated as a surrogate of coronary flow.Results: A total of 20 infants (gestational age at birth, 26.3 ± 0.7 weeks) requiring PDA ligation at a median of 28.5 days (range, 9–40) after birth and weight of 780 g (range, 570–2840) were studied. A postoperative increase in the CA flow/LVO ratio was demonstrated. An early decrease in E and A wave peak velocity (P < .05) and increase in isovolumic relaxation time (P < .05) were demonstrated at 1 hour, before any clinical deterioration. A low baseline CA velocity time integral was associated with a low E/A ratio (r = 0.63, P = .01) at 1 hour and lower systolic blood pressure at 8 hours (r = 0.5, P = .05). The postoperative need for inotropes (n = 8) was associated with a low baseline CA velocity time integral at 1 hour (r = 0.52, P < .05), low LVO at 1 and 8 hours (P < .05), and increased oxygen requirement at 24 hours (P < .05).Conclusions: PDA ligation is followed by altered CA perfusion. Perioperative evaluation of the CA perfusion can help identify neonates at risk of impaired myocardial performance, systolic hypotension, and the need for inotropes.

Power loss and right ventricular efficiency in patients after tetralogy of Fallot repair with pulmonary insufficiency: Clinical implications

2011-12-12

Objectives: To quantify right ventricular output power and efficiency and correlate these to ventricular function in patients with repaired tetralogy of Fallot. This might aid in determining the optimal timing for pulmonary valve replacement.Methods: We reviewed the cardiac catheterization and magnetic resonance imaging data of 13 patients with tetralogy of Fallot (age, 22 ± 17 years). Using pressure and flow measurements in the main pulmonary artery, cardiac output and regurgitation fraction, right ventricular (RV) power output, loss, and efficiency were calculated. The RV function was evaluated using cardiac magnetic resonance imaging.Results: The RV systolic power was 1.08 ± 0.62 W, with 20.3% ± 8.6% power loss owing to 41% ± 14% pulmonary regurgitation (efficiency, 79.7% ± 8.6%; 0.84 ± 0.73 W), resulting in a net cardiac output of 4.24 ± 1.82 L/min. Power loss correlated significantly with the indexed RV end-diastolic and end-systolic volume (R = 0.78, P = .002 and R = 0.69, P = .009, respectively). The normalized RV power output had a significant negative correlation with RV end-diastolic and end-systolic volumes (both R = −0.87, P = .002 and R = −0.68, P = .023, respectively). A rapid decrease occurred in the RV power capacity with an increasing RV volume, with the curve flattening out at an indexed RV end-diastolic and end-systolic volume threshold of 139 mL/m2 and 75 mL/m2, respectively.Conclusions: Significant power loss is present in patients with repaired tetralogy of Fallot and pulmonary regurgitation. A rapid decrease in efficiency occurs with increasing RV volume, suggesting that pulmonary valve replacement should be done before the critical value of 139 mL/m2 and 75 mL/m2 for the RV end-diastolic and end-systolic volume, respectively, to preserve RV function.

Anomalous coronary arteries: Depiction at dual-source computed tomographic coronary angiography

Hai Xu, Yinsu Zhu, Xiaomei Zhu, Lijun Tang, Yi Xu — 2011-12-12

Objective: To retrospectively determine the imaging features of coronary artery anomalies depicted at dual-source computed tomographic coronary angiography (DSCT-CA).Methods: We reviewed the case histories of 12,145 patients with suspected coronary arterial disease who underwent DSCT-CA at our institution. Multiplanar reformation, maximum-intensity projection, and volume-rendered imaging were performed on an offline workstation. Each study was assessed retrospectively for the origin and course of the anomalous coronary artery by a minimum of 2 cardiovascular radiologists; decisions were made in consensus.Results: There were 124 (1.02%) patients with coronary anomalies. Fifty-one patients demonstrated an anomalous origin of the right coronary artery from the left sinus of Valsalva or the left main artery. An anomalous origin of a left circumflex artery from the right sinus of Valsalva or the right coronary artery was depicted in 17 patients. An anomalous origin of a left main artery from the right sinus of Valsalva was depicted in 1 patient. A single coronary artery was shown in 4 patients, and congenital transposition of the great arteries was associated with this anomaly in 1 patient. In the remaining 50 patients, coronary artery fistulas were identified. Eight patients were referred after an equivocal conventional coronary angiogram.Conclusions: DSCT-CA is a reliable noninvasive tool that allows accurate delineation of coronary arterial anomalies in an appropriate clinical setting and provides detailed 3-dimensional anatomic information that may be difficult to obtain with invasive coronary angiography.

Pulmonary root translocation in malposition of great arteries repair allows right ventricular outflow tract growth

2011-12-12

Objective: Optimal surgical treatment of patients with transposition of the great arteries (TGA), ventricular septal defect (VSD), and pulmonary stenosis (PS) remains a matter of debate. This study evaluated the clinical outcome and right ventricle outflow tract performance in the long-term follow-up of patients subjected to pulmonary root translocation (PRT) as part of their surgical repair.Methods: From April 1994 to December 2010, we operated on 44 consecutive patients (median age, 11 months). All had malposition of the great arteries as follows: TGA with VSD and PS (n = 33); double-outlet right ventricle with subpulmonary VSD (n = 7); double-outlet right ventricle with atrioventricular septal defect (n = 1); and congenitally corrected TGA with VSD and PS (n = 3). The surgical technique consisted of PRT from the left ventricle to the right ventricle after construction of an intraventricular tunnel that diverted blood flow from the left ventricle to the aorta.Results: The mean follow-up time was 72 ± 52.1 months. There were 3 (6.8%) early deaths and 1 (2.3%) late death. Kaplan-Meier survival was 92.8% and reintervention-free survival was 82.9% at 12 years. Repeat echocardiographic data showed nonlinear growth of the pulmonary root and good performance of the valve at 10 years. Only 4 patients required reinterventions owing to right ventricular outflow tract problems.Conclusions: PRT is a good surgical alternative for treatment of patients with TGA complexes, VSD, and PS, with acceptable operative risk, high long-term survivals, and few reinterventions. Most patients had adequate pulmonary root growth and performance.

Impact of pressure load caused by right ventricular outflow tract obstruction on right ventricular volume overload in patients with repaired tetralogy of Fallot

2012-01-13

Objectives: In correction of tetralogy of Fallot (TOF), surgical strategies to minimize right ventricular outflow tract (RVOT) enlargement have recently been preferred. However, we may be confronted with residual pulmonary stenosis (PS) combined with pulmonary regurgitation (PR), and how the pressure load affects these patients is not evident.Methods: We compared 51 patients with PR and significant PS (PR with PS group) with 87 patients with PR without significant PS (PR group) using echocardiography and cardiac magnetic imaging. We evaluated the differences in parameters derived by magnetic resonance imaging between the 2 groups and the influence of the pressure load on right ventricular (RV) volume and function.Results: Although the PR fraction was similar between the 2 groups, the PR with PS group showed significantly smaller RV end-diastolic volume (136.7 ± 26.5 mL/m2 vs 151.2 ± 34.7 mL/m2; P = .01), RV end-systolic volume (68.1 ± 23.7 mL/m2 vs 80.2 ± 27.5 mL/m2; P = .01), and slightly better RV ejection fraction (51.1% ± 9.8% vs 47.6% ± 8.9%; P = .03) than the PR group. For influence of the pressure load, PR fraction (r = −0.18, P = .03), RV end-diastolic volume (r = −0.25, P = .003), and RV end-systolic volume (r = −0.24, P = .005) were decreased as peak pressure gradient of PS was higher. Linear regression analysis revealed that both PR fraction and peak pressure gradient of PS were independent predictors for RV volume.Conclusions: Our study demonstrated that the RV pressure load prevented RV dilatation from chronic PR without systolic dysfunction. It is suggested that a proper relief of RVOT obstruction with acceptable residual stenosis is more advantageous than aggressive RVOT enlargement in the long-term outcome of repaired TOF.

Tetralogy of Fallot repair: Ready for a new paradigm

Tal Geva — 2012-02-20

Since Alfred Blalock and Helen Taussig described the first surgical treatment option for patients with tetralogy of Fallot (TOF) in 1945, the management of this once nearly uniformly lethal disease has evolved considerably. As a consequence of seminal advances in management made during the ensuing 6 decades, early surgical mortality has decreased from 50% in the late 1950s to less than 2% in the modern surgical era. This remarkable success story, however, is tempered by the realization that both past and current surgical management strategies still result in nearly universal residual hemodynamic and electrophysiologic abnormalities. Consequently, patients with repaired TOF face an increased mortality risk, which manifests beginning in the third decade of life and accelerates thereafter.

Five-year survival does not equal cure in non–small cell lung cancer: A Surveillance, Epidemiology, and End Results–based analysis of variables affecting 10- to 18-year survival

2012-02-23

Objective: Five-year survival after the diagnosis of non–small cell lung cancer is the most common benchmark used to evaluate long-term survival. Data on survival beyond 5 years are sparse. We sought to elucidate variables affecting 10- to 18-year survival.Methods: A total of 31,206 patients alive at least 5 years after diagnosis of non–small cell lung cancer who were registered in the Surveillance, Epidemiology, and End Results database from 1988 to 2001 were examined. Primary end points were disease-specific survival and overall survival. Survival analysis was performed with Kaplan–Meier estimates, multivariable Cox proportional hazards regression, and competing risk models.Results: Overall survival at 10, 15, and 18 years was 55.4%, 33.1%, and 24.3%, respectively. Disease-specific survival at 10, 15, and 18 years was 76.6%, 65.4%, and 59.4%, respectively. In multivariable regression analysis, squamous cell cancers had a disease-specific survival advantage (hazard ratio, 0.88; P < .0001) but an overall survival disadvantage (hazard ratio, 1.082; P = .0002) compared with adenocarcinoma. Pneumonectomy (hazard ratio, 0.44) and lobectomy (hazard ratio, 0.474) had improved disease-specific survival compared with no surgery (P < .0001). Left-sided tumors (hazard ratio, 0.723; P = .036) and node-negative cancers (hazard ratio, 0.562; P < .001) also had a better disease-specific survival and, to a lesser extent, overall survival advantage.Conclusions: Five-year survivors of non–small cell lung cancer have a persistent risk of death from lung cancer up to 18 years from diagnosis. More than one half of all deaths in 5-year survivors are related to lung cancer. In multivariable regression analysis, age, node-negative disease, and lobar or greater resection were strong predictors of long-term survival (ie, 10–18 years).

Surgical treatment of lung cancer: Predicting postoperative morbidity in the elderly population

2012-02-17

Objectives: Surgical resection is standard treatment for early-stage non–small cell lung cancer; however, perception of postoperative risk may influence the decision to proceed for elderly patients. With population data, we analyzed postoperative complications and morbidity predictors for older patients undergoing lobectomy for stage I non–small cell lung cancer.Methods: The Surveillance Epidemiology and End-Results–Medicare linked database (2000–2005) identified patients (ages 66–80 years) undergoing lobectomy for stage I non–small cell lung cancer. We comprehensively evaluated in-hospital postoperative complications (pulmonary, cardiac, infectious, noncardiopulmonary) with International Classification of Diseases, Ninth Revision, diagnosis codes. Logistic regression models were constructed to identify patient, tumor, and treatment characteristics associated with complications.Results: In all, 4171 patients were included, 2329 of whom had 4097 in-hospital postoperative complications (55.8%). Pulmonary complications were most common (n = 1598; 38.3%) followed by cardiac (n = 1020; 24.5%). Complications were significantly associated with age at least 75 years, male sex, higher comorbidity index, larger tumors, and treatment at nonteaching hospitals (P < .05). Patients with complications had a longer median stay (8 days) than patients without (6 days; P < .001). The 30-day mortality was 4.2%.Conclusions: Population-based analysis demonstrated that perioperative complications after lobectomy for stage I non–small cell lung cancer in older patients exceeded 50% and were associated with specific patient, tumor, and treatment characteristics. Better understanding of the impact of these risk factors may facilitate surgical decision making and encourage implementation of more effective perioperative care guidelines for older surgical patients.

Prospective study of endobronchial ultrasound–guided transbronchial needle aspiration of lymph nodes versus transbronchial lung biopsy of lung tissue for diagnosis of sarcoidosis

2012-02-17

Objective: Endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) has been reported to be an accurate and safe method to confirm a pathologic diagnosis of sarcoidosis. However, only a few retrospective or small prospective studies have been published on EBUS-TBNA versus transbronchial lung biopsy (TBLB), which has been the standard method for making a pathologic diagnosis of sarcoidosis so far. The aim of this study was to compare the diagnostic yield of EBUS-TBNA and TBLB through a flexible bronchoscope in patients with stage I and II sarcoidosis.Methods: A total of 62 patients with suspected stage I and II sarcoidosis were included in this prospective study. EBUS-TBNA was performed (2 lymph nodes, 2 needle passes for each lymph node), followed by TBLB (5 biopsy specimens from multiple lung segments) in the same setting. The final diagnosis of sarcoidosis was based on clinicoradiologic compatibility and pathologic findings.Results: Of the 62 patients enrolled, 54 were given a final diagnosis of sarcoidosis. The diagnostic yield of EBUS-TBNA and TBLB for sarcoidois by showing noncaseating epithelioid cell granuloma was 94% (stage I, 97%; stage II, 88%) and 37% (stage I, 31%; stage II, 50%), respectively. The difference was statistically significant (P < .001). One case of pneumothorax and 3 cases of moderate bleeding (7%) resulted from TBLB, and 1 case of severe cough (2%) from EBUS-TBNA.Conclusions: The diagnostic yield of EBUS-TBNA for stage I and II sarcoidosis is higher than for TBLB.

A simple and effective technique for identification of intersegmental planes by infrared thoracoscopy after transbronchial injection of indocyanine green

Yasuo Sekine, Eitetsu Ko, Hideto Oishi, Mitsuharu Miwa — 2012-02-24

Objective: Pulmonary segmentectomy has been recognized as an operative option for complete resection of early-stage lung cancer in patients with poor pulmonary function. However, identification of anatomic pulmonary segments is sometimes difficult in patients with emphysema. We developed an intraoperative method for identifying intersegmental planes of the lung with high-sensitivity infrared fluorescence imaging after transbronchial injection of indocyanine green.Methods: The study included 10 patients with early-stage lung cancer who underwent thoracoscopic segmentectomy. Under general anesthesia, indocyanine green was injected into the bronchus of target pulmonary segments. The target segments of the lung were identified using the indocyanine green fluorescence endoscope (Hamamatsu Photonics, Hamamatsu, Japan). The intersegmental lines and planes were identified and allowed removal of the segments. To evaluate operative outcomes, we compared the indocyanine green injection group with a retrospective control group with 10 matched-pair patients who underwent traditional thoracoscopic segmentectomy.Results: Accurate, real-time intraoperative detection of indocyanine green with an infrared thoracoscope was confirmed. Sparing of intersegments was safely performed using both staples and electric cautery. Furthermore, infrared thoracoscopy allowed visualization of any residual portion of resected segments after segmentectomy. There was no difference between the experimental indocyanine green and control groups in terms of operative time, duration of postoperative chest drainage, or postoperative complications. Length of stay was shorter in the indocyanine green group than in the control group (P = .055).Conclusions: Transbronchial indocyanine green injection into the relevant bronchus with the use of an infrared thoracoscope allows identification of intersegmental lines and planes during thoracoscopic segmentectomy.

Extensive endarterectomy and reconstruction of the left anterior descending artery: Early and late outcomes

2012-04-16

Objectives: Coronary endarterectomy has been shown to be an effective adjunctive technique of revascularization for diffuse coronary artery disease. A long arteriotomy and reconstruction of the left anterior descending artery (LAD) are occasionally required for complete extraction of the atherosclerotic plaque. The aim of this study was to examine early and late results of this technique and compare 2 different reconstruction methods.Methods: We retrospectively reviewed 224 consecutive patients who underwent extensive LAD endarterectomy and reconstruction between January 1992 and March 2010. For reconstruction, 101 patients underwent saphenous vein patch and LAD grafting (group A) and 123 patients had left internal thoracic artery onlay patch grafting (group B). We compared early and late outcomes and assessed the association of the reconstruction method and long-term survival.Results: The mean age was 66 and 67 years in groups A and B, respectively. Operative mortality was 3.0% and 4.1%, and the incidence of perioperative myocardial infarction in the LAD territory was 4.0% and 4.1% in groups A and B, respectively. There was no significant difference in early operative outcomes (P > .05). Actuarial 5-year survival was 78.6% and 87.1% and 10-year survival was 45.4% and 49.4% in groups A and B, respectively. Cox hazard proportional analysis showed that the reconstruction method did not have a significant impact on long-term survival.Conclusions: Extensive LAD endarterectomy and reconstruction is a safe and feasible technique of revascularization for diffuse coronary artery disease. The reconstruction method should be based on the availability of conduits and length of the arteriotomy.

Midterm survival in patients treated for atrial fibrillation: A propensity-matched comparison to patients without a history of atrial fibrillation

2012-04-02

Objective: Patients undergoing cardiac surgery with a history of untreated atrial fibrillation have reduced survival compared with similar patients without atrial fibrillation. We sought to compare the midterm survival of patients who received concomitant surgical ablation treatment for atrial fibrillation (atrial fibrillation ablated) with that of matched patients without a history of atrial fibrillation (no atrial fibrillation).Methods: We evaluated 3262 consecutive patients (813 [25%] with atrial fibrillation and 2449 [75%] without preoperative atrial fibrillation) undergoing cardiac surgery at a single institution from April 2004 to April 2009. Of patients with atrial fibrillation, 565 (70%) were treated with a concomitant surgical ablation procedure. Propensity scores were calculated on the basis of 37 known preoperative risk factors and yielded 744 patients. Midterm survival was compared between patients with atrial fibrillation ablation (n = 372) and patients without atrial fibrillation (n = 372). Survival was also compared between patients with successful vs unsuccessful ablation, and a matched analysis was performed at 1 year between the 2 groups.Results: Mean follow-up was 2.7 ± 1.6 years. Patients without atrial fibrillation and patients with treated atrial fibrillation had similar early 30-day mortality (1.2% vs 0.3%, P = .37) and overall mortality rates (11.6% vs 9.4%, P = .344), respectively. Survival analysis showed no differences at 1, 3, and 5 years between the 2 groups (log-rank P = .22). At last follow-up, 78% of treated patients were free of atrial fibrillation. At 1 year, 68% of patients were free of atrial fibrillation and antiarrhythmic medication. Freedom from atrial fibrillation and antiarrhythmic medication at 1 year predicted improved midterm survival (P = .03) compared with patients in atrial fibrillation or taking antiarrhythmic medication. Propensity-matched analysis after 1 year demonstrated improved survival for patients who were successfully treated (P = .016).Conclusions: Patients undergoing surgical treatment of atrial fibrillation had survival similar to that of patients without a history of atrial fibrillation. Those with successful sinus restoration had improved survival compared with those who were treated but remained in atrial fibrillation.

Discussion

2012-04-02

Dr John Doty (Murray, Utah). This study emphasizes the importance of concomitant treatment of AF, particularly your last graphs. Your follow-up is relatively short, but we may see that those patients have improved survival by treatment of AF. There is ongoing debate about the wide range of operations that are used for the treatment of AF. Would you describe the particular procedures your group uses for treatment of AF and how you decide which patient gets what procedure in this complex group?

Papillary muscle relocation in conjunction with valve annuloplasty improve repair results in severe ischemic mitral regurgitation

2011-11-04

Objective: The incidence of recurrent mitral regurgitation (MR) after restrictive annuloplasty (RA) was 5% to 20% in several reports. There are many opinions in favor of adding subvalvular procedures to RA to reduce the tenting forces and improve the repair results.Methods: From March 2003 to May 2010, 55 patients with severe ischemic MR who had undergone papillary muscle (PPM) relocation in conjunction with mitral annuloplasty in our institutions were enrolled. The patients were matched 1:1 with those who underwent isolated RA using the propensity score. The mean left ventricular ejection fraction was 42% ± 6%. The mean tenting area and coaptation depth was 3.2 ± 0.6 cm2 and 1.3 ± 0.2 cm, respectively. The study endpoints were early mortality and clinical and echocardiographic outcomes, freedom from cardiac-related deaths, and cardiac-related events.Results: In-hospital death occurred in 5 patients (4.5%), without a statistically significant difference between the 2 groups (P = .72). The 5-year freedom from cardiac-related deaths and cardiac-related events in the PPM relocation group versus the RA group was 90.9% ± 1.8% versus 89% ± 1.6% (P = .82) and 83% ± 2.1% versus 65.4% ± 1.2% (P < .001), respectively. Recurrent MR equal to or greater than moderate occurred in 2 (3.7%) and 6 (11.5%) patients in the PPM relocation group and RA group (P = .01), respectively. Moreover, we found statistically significant differences for the postoperative mean tenting area and coaptation depth in both groups (P < .001).Conclusions: PPM relocation in conjunction to mitral annuloplasty is an easy and safe method and can be performed without an increase in-hospital mortality. This technique reduced the tenting area and coaptation depth compared with isolated RA, leading to improvement in the incidence of recurrent MR. The PPM group of patients experienced fewer cardiac-related events.

Transapical aortic valve implantation in patients with severely depressed left ventricular function

2011-08-16

Objectives: Transapical aortic valve implantation significantly reduces operative risk in elderly patients with aortic valve stenosis and comorbidities. However, it is unknown whether this procedure is feasible in patients with advanced heart failure.Methods: Between April 2008 and July 2010, 258 patients underwent transapical aortic valve implantation. Twenty-one patients had advanced heart failure with decompensation and a left ventricular ejection fraction of 10% to 25%. The mean age of these patients was 74 ± 11 years (range, 36-88 years). The mean left ventricular ejection fraction was 20% ± 5% (range, 10%-25%). Mean logistic EuroSCORE was 66% ± 21% (range, 27%-97%) and mean Society of Thoracic Surgeons score 33% ± 25% (range, 4%-90%). Nine patients were operated on using femorofemoral cardiopulmonary bypass and 12 without.Results: Technical success of the procedure was 100% with no conversion to conventional surgery. The mean time of cardiopulmonary bypass was 27 ± 25 minutes (range, 6-81 minutes). Postoperatively, the left ventricular ejection fraction increased to 38% ± 12% (range, 20%-60%). There were no postoperative neurologic complications. A new pacemaker implantation was needed in 2 (10%) patients. The 30-day mortality was 4.8%. Survival at 1, 3, 12, and 24 months was 95%, 81%, 76%, and 62%, respectively.Conclusions: Transapical aortic valve implantation can be performed safely in patients with decompensated heart failure or even in the presence of cardiogenic shock.

Effect of benchmarking projects on outcomes of coronary artery bypass graft surgery: Challenges and prospects regarding the quality improvement initiative

2012-06-01

Objective: The Japan Cardiovascular Surgery Database (JCVSD) was established in 2000 and initiated a benchmarking project to improve the quality of cardiovascular surgery. Although the importance of quality improvement initiatives has been emphasized, few studies have reported the effects on outcomes.Methods: To examine the time-trend effects in initial JCVSD participants (n = 44), we identified 8224 isolated coronary artery bypass graft (CABG) procedures performed between 2004 and 2007. The impact of surgery year was examined using a multiple logistic regression model that set previously identified clinical risk factors and surgery year as fixed effects. To examine the difference in outcomes between initial participants (n = 44) and halfway participants (n = 55), we identified 3882 isolated CABG procedures performed in 2007. The differences between the 2 hospital groups were examined using a multiple logistic regression model that set clinical risk factors, hospital procedure volume, and hospital groups as fixed effects.Results: For operative mortality, the odds ratio of surgery year was 0.88 (P = .083). Observed/expected (OE) ratios for operative mortality were 0.71 in 2004, 0.73 in 2005, 0.63 in 2006, and 0.54 in 2007. As for composite mortality and major morbidities (reoperation, stroke, dialysis, infection, and prolonged ventilation), odds ratio of surgery year was 0.97 (P = .361). OE ratios for composite mortality and morbidities were 1.01 in 2004, 1.04 in 2005, 1.04 in 2006, and 0.94 in 2007. Compared with halfway participants, initial participants had a significantly lower rate of operative mortality (odds ratio = 0.527; P = .008) and composite mortality and major morbidities (odds ratio 0.820; P = .047).Conclusions: This study demonstrated that a quality improvement initiative for cardiovascular surgery has positive impacts on risk-adjusted outcomes. Although the primary target of benchmarking was 30-day mortality in Japan, major morbidities were less affected by those activities.

Surgical treatment of tricuspid valve insufficiency promotes early reverse remodeling in patients with axial-flow left ventricular assist devices

2011-08-12

Objective: The HeartMate II (Thoratec Corp, Pleasanton, Calif) continuous-flow left ventricular assist device has emerged as the standard of care for patients with advanced heart failure. The objective of this study was to assess the safety and early effectiveness of concomitant tricuspid valve procedures in patients undergoing implantation of a HeartMate II device.Methods: From February 2007 to April 2010, 83 patients underwent HeartMate II left ventricular assist device implantation. Of these, 37 patients had concomitant tricuspid valve procedures (32 repairs, 5 replacements) for severe tricuspid regurgitation. The effects of a tricuspid valve procedure on tricuspid regurgitation and right ventricular remodeling were assessed comparing echocardiographic findings at baseline and 30 days after left ventricular assist device implantation. Overall survival was also compared.Results: Patients undergoing a concomitant tricuspid valve procedure had more tricuspid regurgitation (vena contracta, 5.6 ± 2.1 mm vs 2.9 ± 2.0 mm; P < .001), worse right ventricular dysfunction (right ventricular end-diastolic area, 33.6 ± 6.2 mm vs 31.6 ± 8.5 mm; P = .05), higher mean right atrial pressure (17.4 ± 7.1 mm Hg vs 14.9 ± 5.1 mm Hg; P = .03), and a higher Kormos score (2.6 ± 2.1 vs 1.2 ± 1.4; P = .0008) preoperatively. One month after surgery, tricuspid regurgitation was worse in patients who underwent left ventricular assist device implantation alone (+18.6%), whereas it improved significantly in patients undergoing a concomitant tricuspid valve procedure (−50.2%) (P = .005). A corresponding significant reduction in right ventricular end-diastolic area (33.6% ± 6.2% vs 30.1% ± 9.7%; P = .03) and a trend toward better right ventricular function (55.5% ± 79.7% vs 35.7% ± 60.5%; P = .28) were noted in patients undergoing a concomitant tricuspid valve procedure. Survival was comparable between the 2 groups.Conclusions: In patients with severe tricuspid regurgitation undergoing left ventricular assist device implantation, a concomitant tricuspid valve procedure effectively reduces tricuspid regurgitation and promotes reverse remodeling of the right ventricle.

Outcomes of total arch replacement with stepwise distal anastomosis technique and modified perfusion strategy

2011-08-08

Objective: Total arch replacement has been reported to present high morbidity and mortality. We have introduced a stepwise distal anastomosis technique and modified perfusion strategy, including selective antegrade cerebral perfusion, moderate hypothermia, and separate lower-body perfusion, to minimize organ ischemia and secondary morbidities. We report the operative outcomes of total arch replacement with our modified perfusion strategy.Methods: Between August 2006 and December 2008, 119 patients underwent total arch replacement with the current perfusion strategy. Of these patients, 56 (47%) underwent emergency operation for acute type A aortic dissection (n = 48) or ruptured thoracic aneurysm (n = 8). The mean age of patients was 68 years, and the mean follow-up period was 25 months. We analyzed operative mortality, morbidity, and 4-year survival of this patient group.Results: The mean operation, cardiopulmonary bypass, and circulatory arrest times were 313, 183, and 47 minutes, respectively. Operative mortality was 3.4%. Operative mortality of elective cases was 1.6%. The incidences of permanent neurologic deficit, paraparesis, and renal insufficiency were 5.0%, 1.7%, and 7.6%, respectively. Actuarial 4-year survival was 86.5%.Conclusions: Total arch replacement with our modified perfusion strategy has demonstrated low operative mortality and morbidity.

On-pump and off-pump coronary artery bypass grafting in patients with left main stem disease: A propensity score analysis

2011-08-16

Objective: This study compared safety and efficacy between off-pump coronary artery bypass grafting (OPCAB), a relatively new technique, and conventional on-pump coronary artery bypass grafting (CCAB) in patients with left main stem disease.Methods: In a retrospective, observational, cohort study of prospectively collected data on 2375 consecutive patients with left main stem disease undergoing isolated CABG (1297 OPCAB, 1078 CCAB) between April 1996 and December 2009 at the Bristol Heart Institute, 548 patients undergoing OPCAB were matched with 548 patients undergoing CCAB by propensity score.Results: After propensity matching, groups were comparable in preoperative characteristics. Relative to CCAB, OPCAB was associated with lower in-hospital mortality (0.5% vs 2.9%; P = .001), incidence of stroke (0% vs 0.9%; P = .02), postoperative renal dysfunction (4.9% vs 10.8%; P = .001), pulmonary complications (10.2% vs 16.6%; P = .002), and infectious complications (3.5% vs 6.2%; P = .03). The OPCAB group received fewer grafts than did the CCAB group (2.7 ± 0.7 vs 3 ± 0.7; P = .001) and had a lower rate of complete revascularization (88.3% vs 92%; P = .04). In multivariable analysis, cardiopulmonary bypass was confirmed to be an independent predictor of in-hospital mortality (odds ratio, 5.74; P = .001). Survivals at 1, 5, and 10 years were similar between groups (OPCAB, 96.8%, 87.3%, and 71.7%; CCAB, 96.8%, 88.6%, and 69.8%).Conclusions: OPCAB in patients with left main stem disease is a safe procedure with reduced early morbidity and mortality and similar long-term survival to conventional on-pump revascularization.

Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair

2011-08-22

Objective: Technical controversies exist in valve-preserving aortic root replacement. We sought to determine predictors of long-term stability of the aortic valve.Methods: A total of 430 patients (aged 57 ± 15 years, 323 male) underwent valve-preserving aortic root surgery (remodeling in 401, reimplantation in 29) between 1995 and 2009 and were followed echocardiographically. Factors influencing late recurrence of aortic valve regurgitation grade II or greater (n = 45) or need for reoperation on the aortic valve (n = 25) were analyzed.Results: Early mortality was 2.8% (1.9% for elective cases), and actuarial survival at 10 years was 83.5% ± 2.4%. Ten-year freedom from aortic valve regurgitation grade II or greater was 85.0% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm and postoperative effective height of the aortic cusp less than 9 mm were identified as significant predictors for late aortic valve regurgitation grade II or greater in multivariate analysis (both P < .001). Ten-year freedom from reoperation on the aortic valve was 89.3% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm (P < .001), use of pericardial patch (P = .022), and effective height of the aortic cusp less than 9 mm (P = .049) were identified as significant predictors for reoperation in multivariate analysis. Operative technique (remodeling, reimplantation), Marfan syndrome, bicuspid valve anatomy, concomitant central cusp plication, size of prosthesis used, and acute dissection were not associated with an increased risk of late aortic valve regurgitation grade II or greater or reoperation. In patients with preoperative aortoventricular junction diameter greater than 28 mm (n = 94), the addition of central cusp plication significantly improved freedom from aortic valve regurgitation grade II or greater (P = .006) regardless of root procedures (remodeling, P = .011; reimplantation, P = .053).Conclusions: Long-term stability of valve-preserving aortic root replacement was influenced not by the technique of root repair but by the preoperative aortic root geometry and postoperative cusp configuration.

Optimal surgical management of severe ischemic mitral regurgitation: To repair or to replace?

2011-11-07

Background: Ischemic mitral regurgitation, a complication of myocardial infarction and coronary artery disease more generally, is associated with a high mortality rate and is estimated to affect 2.8 million Americans. With 1-year mortality rates as high as 40%, recent practice guidelines of professional societies recommend repair or replacement, but there remains a lack of conclusive evidence supporting either intervention. The choice between therapeutic options is characterized by the trade-off between reduced operative morbidity and mortality with repair versus a better long-term correction of mitral insufficiency with replacement. The long-term benefits of repair versus replacement remain unknown, which has led to significant variation in surgical practice.Methods and Results: This article describes the design of a prospective randomized clinical trial to evaluate the safety and effectiveness of mitral valve repair and replacement in patients with severe ischemic mitral regurgitation. This trial is being conducted as part of the Cardiothoracic Surgical Trials Network. This article addresses challenges in selecting a feasible primary end point, characterizing the target population (including the degree of mitral regurgitation) and analytical challenges in this high mortality disease.Conclusions: The article concludes by discussing the importance of information on functional status, survival, neurocognition, quality of life, and cardiac physiology in therapeutic decision making.

Cardiac catheterization within 1 to 3 days of proximal aortic surgery is not associated with increased postoperative acute kidney injury

2012-02-20

Objective: Cardiac catheterization shortly before coronary artery bypass grafting or valve surgery has been associated with increased postoperative acute kidney injury. The relationship between catheterization timing and acute kidney injury after proximal aortic surgery remains unknown.Methods: Between August 2005 and February 2011, a total of 285 consecutive patients underwent cardiac catheterization before elective proximal aortic surgery with cardiopulmonary bypass at a single institution. The association between timing of catheterization and postoperative acute kidney injury (defined as postoperative increase in serum creatinine ≥50% of baseline) was assessed using logistic regression analysis.Results: Of 285 patients, 152 (53%) underwent catheterization on preoperative days 1 to 3 and 133 (47%) underwent catheterization on preoperative day 4 or before. Acute kidney injury occurred in 88 (31%) patients, 3 (1.1%) requiring dialysis. Acute kidney injury occurred in 37 (24%) patients catheterized on preoperative days 1 to 3, and 51 (38%) patients catheterized on preoperative day 4 or before. Catheterization on preoperative days 1 to 3 was not associated with an increased risk of acute kidney injury relative to catheterization on preoperative day 4 or before (unadjusted odds ratio, 0.52; 95% confidence interval, 0.31-0.86; P = .01; adjusted odds ratio, 0.35; 95% confidence interval, 0.17-0.73; P = .005).Conclusions: Cardiac catheterization within 1 to 3 days of elective proximal aortic surgery appears safe and should be considered acceptable practice for patients at low risk of acute kidney injury.

Diagnosis of infection in patients undergoing extracorporeal membrane oxygenation: A case-control study

2012-02-10

Objective: Diagnosis of infection in patients receiving extracorporeal membrane oxygenation is challenging in clinical practice but represents a crucial aspect of the upgrading of therapeutic options. The aim of this study was to analyze the role of C-reactive protein and procalcitonin in the diagnosis of infection in patients requiring extracorporeal membrane oxygenation and to assess the difference between venovenous and venoarterial extracorporeal membrane oxygenation settings.Methods: A case-control study was performed on 27 patients. Serum values of procalcitonin and C-reactive protein were analyzed according to the presence of infection.Results: Forty-eight percent of patients had infection. Gram-negative bacteria were the predominant pathogens, and Candida albicans was the most frequent isolated microorganism. Procalcitonin had an area under the curve of 0.681 (P = .0062) for the diagnosis of infection in the venoarterial extracorporeal membrane oxygenation group but failed to discriminate infection in the venovenous extracorporeal membrane oxygenation group (P = .14). The area under the curve of C-reactive protein was 0.707 (P < .001) in all patients receiving extracorporeal membrane oxygenation. In patients receiving venoarterial extracorporeal membrane oxygenation, procalcitonin had good accuracy with 1.89 ng/mL as the cutoff (sensitivity = 87.8%, specificity = 50%) and C-reactive protein with 97.70 mg/L as the cutoff (sensitivity = 85.3%, specificity = 41.6%). The procalcitonin and C-reactive protein combined assay had a sensitivity of 87.2% and specificity of 25.9%. Four variables were identified as statistically significant predictors of infection: procalcitonin and C-reactive protein combined assay (odds ratio, 1.184; P < .001), age (odds ratio, 0.980; P < .001), presence of infection before extracorporeal membrane oxygenation implantation (odds ratio, 1.782; P < .001), and duration of extracorporeal membrane oxygenation support (odds ratio, 1.056; P < .001).Conclusions: Traditional and emerging inflammatory biomarkers, especially if compounded in the procalcitonin and C-reactive protein combined assay, can aid in the diagnosis of infection in patients undergoing venoarterial extracorporeal membrane oxygenation.

Impairment of pericardial leaflet structure from balloon-expanded valved stents

2012-01-13

Objective: Malpositioning is one of the major problems in transcatheter aortic valve implantation. To evaluate the influence of mechanical balloon inflation on aortic valve stent positioning, the expansion process and the impact on the valve leaflet’s structure were investigated.Methods: Custom-made stents were laser cut from a 22-mm diameter stainless steel tube and mounted with a glutaraldehyde-treated bovine pericardial valve. The valved stents were crimped onto a standard balloon catheter and expanded by inflation of the balloon with 2 bar for 3 seconds. Expansion was studied using a high-speed camera, and the histology of the pericardial tissue was analyzed.Results: The valved stents were fully expanded within 3 seconds. Balloon inflation was observed to be asymmetric starting proximally. At the beginning of expansion, the valved stents were pulled proximally. During further inflation, the stents slipped distally on the balloon and experienced a total displacement of 13.5 mm. Macroscopic examination showed severe imprinting of the stent struts into the pericardial tissue. Histology revealed disrupted tissue layers and collagen fibers.Conclusions: Analysis of valved stent expansion showed a displacement of the stent on the catheter during balloon inflation. Therefore, precise placement of the valved stent cannot be accomplished. Histologic analysis of the expanded pericardial tissue revealed disruption of collagen fibers. Disruption of pericardial tissue structures due to balloon expansion may result in early functional valve failure.

Integrated morphologic and functional assessment of the aortic root after different tissue valve root replacement procedures

2012-02-23

Objectives: This study was undertaken to explore aspects of the hemodynamic function of different biologic tissue aortic valve root replacements. We set out to image and display the spatiotemporal distributions of axially directed blood velocity through the aortic root.Methods: The flow velocities through a plane transecting the aortic root were measured by 2-dimensional cine phase-contrast magnetic resonance velocity mapping in 44 subjects: 29 patients who had undergone aortic root replacement approximately 10 years previously (13 autografts, 10 stentless xenografts, and 6 homografts) and 15 healthy control subjects. With cine as well as velocity images, aortic sinus dimensions, effective orifice area, and several velocity parameters were measured. Color-coded plots of velocity relative to the sinus cross sections and velocity-time plots were used to compare spatiotemporal distributions of velocity.Results: Peak flow velocity was similar between the autografts (102 ± 28.0 cm/s) and control valves (119 ± 20.0 cm/s) but was higher in xenografts (167 ± 36.0 cm/s) and homografts (206 ± 91.0 cm/s). These measurements showed an inverse relationship with the effective orifice area (7.27 ± 0.20, 4.24 ± 0.81, 3.37 ± 0.32, and 3.28 ± 0.87 cm2, respectively). Autograft peak flow velocity showed no significant difference from control valve peak flow velocity, despite larger root dimensions (P < .001). The graphic displays provided further spatiotemporal information.Conclusions: Peak velocities and spatiotemporal flow patterns depend on the type of valve substitute. In the parameters measured, autograft replacements differed least from normal aortic valves.

Implantation of fetal rat lung fragments into bleomycin-induced pulmonary fibrosis

2012-02-10

Objective: Pulmonary fibrosis is a life-threatening disease that results in progressive respiratory failure. We have suggested the possibility of fetal lung tissue as an option for further investigation into lung regeneration. The objective was to prove whether fetal lung fragments can survive and differentiate in fibrotic lung.Methods: Lewis rats were administered bleomycin and used as recipients after 3 or 4 weeks. Day 17 fetal lung tissue from green fluorescent protein Lewis rats was used as donor material. Donor lungs were removed, cut into small pieces, and implanted into the recipients’ left lung. The recipients received cyclosporin to prevent immune response to green fluorescent protein and were killed after 1, 2, 4, 8, and 12 weeks and histologically evaluated. Furthermore, the expression of thyroid transcription factor-1 and Clara cell secretory protein in the implanted fetal lung tissue was immunohistologically evaluated.Results: Fibrotic changes were recognized for a long period of time in the recipient lungs. The implanted fetal lung fragments could be clearly distinguished from recipient lungs because of the luminescence of grafts. Fetal lung fragments could survive in the recipient lungs with fibrotic changes. The air spaces of implanted fetal lungs were narrow at 1 and 2 weeks but expanded with the passage of time. The connection between the recipient lung and the implanted fetal lung was recognized, particularly in the peripheral grafts. The expression patterns of thyroid transcription factor-1 and Clara cell secretory protein in implanted lungs resembled those in the process of normal lung morphogenesis.Conclusions: Fetal rat lung fragments could survive and differentiate in bleomycin-induced completely fibrotic lung.

Effect of granulocyte-colony stimulating factor on expression of selected proteins involved in regulation of apoptosis in the brain of newborn piglets after cardiopulmonary bypass and deep hypothermic circulatory arrest

2012-02-10

Objective: The study objective was to investigate the effect of granulocyte-colony stimulating factor on the expression of proteins that regulate apoptosis in newborn piglet brain after cardiopulmonary bypass and deep hypothermic circulatory arrest.Methods: The newborn piglets were assigned to 3 groups: (1) deep hypothermic circulatory arrest (30 minutes of deep hypothermic circulatory arrest, 1 hour of low-flow cardiopulmonary bypass); (2) deep hypothermic circulatory arrest with prior injection of granulocyte-colony stimulating factor (17 μg/kg 2 hours before cardiopulmonary bypass); and (3) sham-operated. After 2 hours of post-bypass recovery, the frontal cortex, striatum, and hippocampus were dissected. The expression of proteins was measured by gel electrophoresis or protein arrays. Data are presented in arbitrary units. Statistical analysis was performed using 1-way analysis of variance.Results: In the frontal cortex, only Fas ligand expression was significantly lower in the granulocyte-colony stimulating factor group when compared with the deep hypothermic circulatory arrest group. In the hippocampus, granulocyte-colony stimulating factor increased Bcl-2 (54.3 ± 6.4 vs 32.3 ± 2.2, P = .001) and serine/threonine-specific protein kinase (141.4 ± 19 vs 95.9 ± 21.1, P = .047) when compared with deep hypothermic circulatory arrest group. Caspase-3, Bax, Fas, Fas ligand, death receptor 6, and Janus protein tyrosine kinase 2 levels were unchanged. The Bcl-2/Bax ratio was 0.33 for deep hypothermic circulatory arrest group and 0.93 for the granulocyte-colony stimulating factor group (P = .02). In the striatum, when compared with the deep hypothermic circulatory arrest group, the granulocyte-colony stimulating factor group had higher levels of Bcl-2 (50.3 ± 7.4 vs 31.8 ± 3.8, P = .01), serine/threonine-specific protein kinase (132.7 ± 12.3 vs 14 ± 1.34, P = 2.3 × 106), and Janus protein tyrosine kinase 2 (126 ± 17.4 vs 77.9 ± 13.6, P = .011), and lower levels of caspase-3 (12.8 ± 5.0 vs 32.2 ± 11.5, P = .033), Fas (390 ± 31 vs 581 ± 74, P = .038), Fas ligand (20.5 ± 11.5 vs 57.8 ± 15.6, P = .04), and death receptor 6 (57.4 ± 4.4 vs 108.8 ± 13.4, P = .007). The Bcl-2/Bax ratio was 0.25 for deep hypothermic circulatory arrest and 0.44 for the granulocyte-colony stimulating factor groups (P = .046).Conclusions: In the piglet model of hypoxic brain injury, granulocyte-colony stimulating factor decreases proapoptotic signaling, particularly in the striatum.

Catalytic peroxynitrite decomposition improves reperfusion injury after heart transplantation

2012-03-09

Objective: Peroxynitrite, a reactive nitrogen species, has been implicated in the development of ischemia–reperfusion injury. The present study investigated the effects of the potent peroxynitrite decomposition catalyst FP15 on myocardial and endothelial function after hypothermic ischemia–reperfusion in a heterotopic rat heart transplantation model.Methods: After a 1-hour ischemic preservation and implantation of donor hearts, reperfusion was started after application of vehicle (5% glucose solution) or FP15 (0.3 mg/kg). The assessment of left ventricular pressure–volume relations, total coronary blood flow, endothelial function, immunohistochemical markers of nitro-oxidative stress, and myocardial high-energy phosphates was performed at 1 and 24 hours of reperfusion.Results: After 1 hour of reperfusion, myocardial contractility (maximal slope of systolic pressure increment at 140 μL left ventricular volume: 5435 ± 508 mm Hg/s vs 2346 ± 263 mm Hg/s), coronary blood flow (3.98 ± 0.33 mL/min/g vs 2.74 ± 0.29 mL/min/g), and endothelial function were significantly improved, nitro-oxidative stress was reduced, and myocardial high-energy phosphate content was preserved in the FP15-treated animals compared with controls.Conclusions: Pharmacologic peroxynitrite decomposition reduces reperfusion injury after heart transplantation as the result of reduction of nitro-oxidative stress and prevention of energy depletion and exerts a beneficial effect against reperfusion-induced graft cardiac and coronary endothelial dysfunction.

Modified aortoplasty for discrete congenital supravalvular aortic stenosis

Matthew L. Stone, Ahmet Kilic, Irving L. Kron, James J. Gangemi — 2012-01-13

Congenital supravalvular aortic stenosis (SVAS) is a rare obstructive lesion of the left ventricular outflow tract, and novel surgical treatments have fostered improved outcomes and survival for children with this condition. We present here a successful 3-sinus patch reconstruction for SVAS with extended patch augmentation to the right coronary sinus of Valsalva, maintaining aortic root geometry and providing a simplified approach for ascending aortic augmentation at the right coronary sinus.

Double closure repair of mitral paravalvular leak by way of right thoracotomy

Shinsuke Kotani, Koji Hattori, Yasuyuki Kato, Toshihiko Shibata — 2011-12-12

Paravalvular leak (PVL) occurs in up to 12.5% of mitral valve replacements (MVRs) and sometimes recurs. Although various techniques to repair such leaks have been described, surgical intervention for patients undergoing multiple repeat surgery poses a formidable challenge. For the purposes of good exposure and durable repair of mitral PVL, we describe a double closure technique with pledgeted sutures and a pericardial patch using right thoracotomy. This technique might provide greater durability of the repair site and good exposure of the mitral valve.

Transaortic balloon-expandable aortic valve implantation

2011-12-19

In patients with severe symptomatic aortic valve stenosis who are inoperable or at high risk for surgical aortic valve replacement, transcatheter aortic valve implantation (TAVI) represents an alternative therapeutic strategy. Currently, there are 2 commercially available devices: the self-expandable CoreValve revalving system (Medtronic Inc, Minneapolis, Minn) and the balloon-expandable Sapien XT valve (Edwards Lifesciences, Irvine, Calif). For the latter, a transapical approach is the first choice in case of unavailable femoral access. However, in patients with severe left ventricular (LV) dysfunction, a surgical approach of the apex can potentially further worsen heart contractility, and the presence of an LV aneurysm with mural thrombi contraindicates the procedure. Bleiziffer and colleagues reported that 1 year after transapical TAVI, a new apical hypo- or akinesia was present in up to 37% of patients, and that because of the apical scar, a significant reduction of the LV ejection fraction was found in 13% of patients. In these patients with “no access,” a subclavian/axillary approach has been described, but it is not feasible in case a 29-mm device is necessary or both subclavian arteries are heavily calcified or extremely tortuous. A transaortic implantation has been described using the CoreValve revalving system. We describe the technique for 29-mm Sapien XT implantation via a transaortic access.

A simplified technique for total anomalous pulmonary venous connection repair associated with functional single ventricle

Naritaka Kimura, Ayumu Masuoka, Toshiyuki Katogi, Takaaki Suzuki — 2012-01-13

Surgical repair of total anomalous pulmonary venous connection (TAPVC) with single ventricle remains challenging because of the risk of late pulmonary venous obstruction. Since 2007, we have used the vertical vein to establish the continuity between the common atrium and the pulmonary vein without cutting into the pulmonary venous confluence. This report describes the outcome associated with this simplified technique for TAPVC repair.

Prosthetic aortic valve–pexy: Stitch closure of the aortic valve in a patient with a ventricular assist device

Salil V. Deo, Soon J. Park, Lawrence J. Sinak, Alfredo L. Clavell — 2012-01-24

Intermittent opening of the mechanical aortic valve after placement of a ventricular assist device (VAD) can lead to an increased risk of thromboembolism. It has been recommended to close the aorta with a patch or replace it with a bioprosthesis. Both these methods, however, increase the ischemic time. A single-stitch method to close the mechanical aortic valve has been described; however, placement of the suture as illustrated in the article is technically very difficult. We therefore describe our modification as used in a patient with a mechanical aortic valve undergoing VAD placement and include intraoperative photographs and an illustration.

AATS Online Award Applications

2012-06-01

Now Available at www.aats.org, Deadline July 1, 2012 Second John W. Kirklin Research Scholarship 2013–2015 provides an opportunity for research, training, and experience for North American surgeons committed to pursuing an academic career in cardiothoracic surgery.

2012 Heart Valve Summit: Medical, Surgical, and Interventional Decision Making

2012-06-01

October 11–13, 2012 JW Marriott Chicago

2012 Heart Failure Summit

2012-06-01

21st Century Treatment of Heart Failure: Synchronizing Surgical and Medical Therapies for Better Outcomes October 18–19, 2012

AATS Focus on Thoracic Surgery: Lung Cancer

2012-06-01

November 16–17, 2012 Boston Marriott Copley Place

WTSA 38th Annual Meeting

2012-06-01

June 27–30, 2012 The Grand Wailea Hotel

Notices

2012-06-01

The part I (written) examination was held on December 3. It is planned that this examination will be given at multiple sites throughout the United States using an electronic format. The closing date for registration is August 1 each year. Those wishing to be considered for examination must apply online at www.abts.org.

Requirements for Maintenance of Certification

2012-06-01

Diplomates of the American Board of Thoracic Surgery (ABTS) who plan to participate in the Maintenance of Certification (MOC) process must hold an unrestricted medical license in the locale of their practice and privileges in a hospital accredited by the JCAHO (or other organization recognized by the ABTS). In addition, a valid ABTS certificate is an absolute requirement for entrance into the Maintenance of Certification process. If your certificate has expired, the only pathway for renewal of a certificate is to take and pass the Part I (written) and the Part II (oral) certifying examinations. The names of individuals who have not maintained their certificate will no longer be published in the American Board of Medical Specialties Directories. Diplomates’ names will be published upon successful completion of the Maintenance of Certification process.

JTCVS Disclosure Statement

2012-06-01

Condensed Contents

2012-06-01

Information for Readers

2012-06-01

The Journal of Thoracic and Cardiovascular Surgery

The critical role of imaging navigation and guidance in transcatheter aortic valve implantation

Historical perspectives of The American Association for Thoracic Surgery: Lyman A. Brewer III (1907–1988)

Training residents in off-pump coronary artery bypass surgery: A 14-year experience

Multisociety (AATS, ACCF, SCAI, and STS) expert consensus statement: Operator and institutional requirements for transcatheter valve repair and replacement, part 1: Transcatheter aortic valve replacement

Regional alterations in cerebral growth exist preoperatively in infants with congenital heart disease

Coronary artery perfusion and myocardial performance after patent ductus arteriosus ligation

Power loss and right ventricular efficiency in patients after tetralogy of Fallot repair with pulmonary insufficiency: Clinical implications

Anomalous coronary arteries: Depiction at dual-source computed tomographic coronary angiography

Pulmonary root translocation in malposition of great arteries repair allows right ventricular outflow tract growth

Impact of pressure load caused by right ventricular outflow tract obstruction on right ventricular volume overload in patients with repaired tetralogy of Fallot

Tetralogy of Fallot repair: Ready for a new paradigm

Five-year survival does not equal cure in non–small cell lung cancer: A Surveillance, Epidemiology, and End Results–based analysis of variables affecting 10- to 18-year survival

Surgical treatment of lung cancer: Predicting postoperative morbidity in the elderly population

Prospective study of endobronchial ultrasound–guided transbronchial needle aspiration of lymph nodes versus transbronchial lung biopsy of lung tissue for diagnosis of sarcoidosis

A simple and effective technique for identification of intersegmental planes by infrared thoracoscopy after transbronchial injection of indocyanine green

Extensive endarterectomy and reconstruction of the left anterior descending artery: Early and late outcomes

Midterm survival in patients treated for atrial fibrillation: A propensity-matched comparison to patients without a history of atrial fibrillation

Discussion

Papillary muscle relocation in conjunction with valve annuloplasty improve repair results in severe ischemic mitral regurgitation

Transapical aortic valve implantation in patients with severely depressed left ventricular function

Effect of benchmarking projects on outcomes of coronary artery bypass graft surgery: Challenges and prospects regarding the quality improvement initiative

Surgical treatment of tricuspid valve insufficiency promotes early reverse remodeling in patients with axial-flow left ventricular assist devices

Outcomes of total arch replacement with stepwise distal anastomosis technique and modified perfusion strategy

On-pump and off-pump coronary artery bypass grafting in patients with left main stem disease: A propensity score analysis

Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair

Optimal surgical management of severe ischemic mitral regurgitation: To repair or to replace?

Cardiac catheterization within 1 to 3 days of proximal aortic surgery is not associated with increased postoperative acute kidney injury

Diagnosis of infection in patients undergoing extracorporeal membrane oxygenation: A case-control study

Impairment of pericardial leaflet structure from balloon-expanded valved stents

Integrated morphologic and functional assessment of the aortic root after different tissue valve root replacement procedures

Implantation of fetal rat lung fragments into bleomycin-induced pulmonary fibrosis

Effect of granulocyte-colony stimulating factor on expression of selected proteins involved in regulation of apoptosis in the brain of newborn piglets after cardiopulmonary bypass and deep hypothermic circulatory arrest

Catalytic peroxynitrite decomposition improves reperfusion injury after heart transplantation

Modified aortoplasty for discrete congenital supravalvular aortic stenosis

Double closure repair of mitral paravalvular leak by way of right thoracotomy

Transaortic balloon-expandable aortic valve implantation

A simplified technique for total anomalous pulmonary venous connection repair associated with functional single ventricle

Prosthetic aortic valve–pexy: Stitch closure of the aortic valve in a patient with a ventricular assist device

AATS Online Award Applications

2012 Heart Valve Summit: Medical, Surgical, and Interventional Decision Making

2012 Heart Failure Summit

AATS Focus on Thoracic Surgery: Lung Cancer

WTSA 38th Annual Meeting

Notices

Requirements for Maintenance of Certification

JTCVS Disclosure Statement

Condensed Contents

Table of Contents

Information for Readers