The Journal of Thoracic and Cardiovascular Surgery

Non Solus—A leadership challenge

G. Alexander Patterson — 2010-09-01

It has been a true privilege to serve as the 90th President of the American Association for Thoracic Surgery (AATS). I view the AATS as an extraordinarily productive organization. I take pride in the fact that I have always belonged to productive outfits, starting with my own family.

“Back to the future”: Recruiting the best and brightest into cardiothoracic surgery

2010-09-01

Thoracic Surgery has witnessed a notable decrease in applicants over the past decade. In this context Kron and colleagues reported that the “United States will face a severe shortage of cardiothoracic surgeons within 10 years if entry into the profession keeps declining.” Although recent innovations, such as drug-eluting stents and percutaneous valves, are extraordinary, they do not make the unique skills and training of the cardiac and thoracic surgeon obsolete. Although we are rumored to be facing extinction and applicant interest is low, the potential to enhance thoracic surgery residency interest remains paramount to our discipline's future. We must respond to the current crisis by being even more focused and committed to recruit the best and the brightest into the field of cardiothoracic surgery.

Epithelial to mesenchymal transition: The doorway to metastasis in human lung cancers

Chadrick E. Denlinger, John S. Ikonomidis, Carolyn E. Reed, Francis G. Spinale — 2010-09-01

Lung cancer remains a disease characterized by early metastasis and poor 5-year survival. Lung cancers are almost exclusively derived from epithelial tissues, and most tumor cells retain epithelial characteristics even as the tumor progresses. Small numbers of cells, however, are thought to undergo a process of epithelial to mesenchymal transition in which the malignant cells acquire a fibroblastlike morphology, lose intracellular adhesions, and become mobile. This process represents a crucial event in cancer invasion and metastasis. These mesenchymal cells may subsequently revert to an epithelial phenotype, allowing clinically relevant growth of metastases. Ongoing studies are required to determine ways in which the process of epithelial to mesenchymal transition can be exploited in patients with lung cancer for screening, diagnostic studies, and therapeutic options.

Atrioventricular valve repair in patients with functional single ventricle

2010-06-28

Objective: We aimed to evaluate surgical repair of atrioventricular valve regurgitation in patients with functional single ventricle.Methods: The medical records of 65 consecutive patients with functional single ventricle who underwent atrioventricular valve repair between January 1999 and October 2008 were reviewed retrospectively. Their characteristics were as follows: median age, 9.5 months; median weight, 6.0 kg; atrial isomerism, 31 patients; and hypoplastic left heart syndrome, 12 patients. Regurgitation was repaired at the palliative, Glenn, and Fontan stage in 21, 29, and 15 patients, respectively.Results: The overall survival was 79% and 70% at 1 and 5 years, respectively. The risk factors for mortality were age less than 3 months (P < .001), body weight less than 4 kg (P < .001), hypoplastic left heart syndrome (P = .001), concomitant Norwood (P < .001), and the palliative stage (P = .004) on the univariate analysis, and body weight less than 4 kg (P = .010, hazard ratio, 9.8; 95% confidence interval, 1.7–55.6) on the multivariate analysis. Twenty patients underwent reoperation (repairs in 15; replacements in 5), and freedom from reoperation at 1 and 5 years was 69% and 57%, respectively. Concomitant systemic-to-pulmonary shunt (P = .040) was a risk factor for reoperation on the univariate analysis. Of the 48 survivors, 38 underwent Fontan completion, 7 underwent the Glenn procedure, and 3 are awaiting the Glenn procedure.Conclusions: The midterm results of atrioventricular valve repair in patients with functional single ventricle were favorable; however, young and small patients, especially those with hypoplastic left heart syndrome, still had poor outcomes.

Impact of evolving strategy on clinical outcomes and central pulmonary artery growth in patients with bilateral superior vena cava undergoing a bilateral bidirectional cavopulmonary shunt

2010-07-12

Objective: We reported a high incidence of thrombosis, central pulmonary artery hypoplasia, and mortality for bilateral bidirectional cavopulmonary shunts. We hypothesized that technical modifications in the cavopulmonary anastomosis and anticoagulation would limit thrombus and central pulmonary artery hypoplasia, and thereby improve outcomes.Methods: Sixty-one patients (median age, 8.4 months; weight, 6.6 kg) underwent bilateral bidirectional cavopulmonary shunt from 1990 to 2007. The cohort was divided into 2 groups: 1) the conventional group (1990–1999, n = 37) and 2) the V-shaped group, with a hemi-Fontan or modification in which the cavae were anastomosed to the pulmonary artery adjacent to each other so they formed the appearance of a V (1999–2007, n = 24). Central and branch pulmonary artery growth, survival, and reinterventions were determined.Results: The pre-Fontan study showed equivalent superior venae cavae and Nakata indices. The central pulmonary artery index and central pulmonary artery/Nakata index ratio were significantly higher in the V-shaped group (P < .05). There were no differences in freedom from death or transplant (conventional 69% vs V-shaped 75% at 3 years, P = .5), and a nonsignificant trend toward improving freedom from reinterventions (63% vs 81% at 3 years, P = .15) and thrombosis (82% vs 95% at 1 year, P = .11) was observed in the V-shaped group. Multivariate analysis showed anastomotic strategy, low saturation, and thrombosis were predictors for death. Anastomotic strategy, lack of anticoagulation, thrombosis, and small superior venae cavae were predictors for reintervention (P < .05). Predictors for thrombus included small superior venae cavae, Nakata index, and low saturation (P < .03).Conclusions: Surgical modifications for bilateral bidirectional cavopulmonary shunts were associated with the larger central pulmonary artery size. Lack of anticoagulation and anastomotic strategy affected reintervention. Anastomotic strategy and postoperative thrombus affected mortality.

Cavopulmonary assist for the univentricular Fontan circulation: von Kármán viscous impeller pump

2010-06-21

Objective: In a univentricular Fontan circulation, modest augmentation of existing cavopulmonary pressure head (2–5 mm Hg) would reduce systemic venous pressure, increase ventricular filling, and thus substantially improve circulatory status. An ideal means of providing mechanical cavopulmonary support does not exist. We hypothesized that a viscous impeller pump, based on the von Kármán viscous pump principle, is optimal for this role.Methods: A 3-dimensional computational model of the total cavopulmonary connection was created. The impeller was represented as a smooth 2-sided conical actuator disk with rotation in the vena caval axis. Flow was modeled under 3 conditions: (1) passive flow with no disc; (2) passive flow with a nonrotating disk, and (3) induced flow with disc rotation (0–5K rpm). Flow patterns and hydraulic performance were examined for each case. Hydraulic performance for a vaned impeller was assessed by measuring pressure increase and induced flow over 0 to 7K rpm in a laboratory mock loop.Results: A nonrotating actuator disc stabilized cavopulmonary flow, reducing power loss by 88%. Disk rotation (from baseline dynamic flow of 4.4 L/min) resulted in a pressure increase of 0.03 mm Hg. A further increase in pressure of 5 to 20 mm Hg and 0 to 5 L/min flow was obtained with a vaned impeller at 0 to 7K rpm in a laboratory mock loop.Conclusions: A single viscous impeller pump stabilizes and augments cavopulmonary flow in 4 directions, in the desired pressure range, without venous pathway obstruction. A viscous impeller pump applies to the existing staged protocol as a temporary bridge-to-recovery or -transplant in established univentricular Fontan circulations and may enable compressed palliation of single ventricle without the need for intermediary surgical staging or use of a systemic-to-pulmonary arterial shunt.

Discussion

2010-06-21

Dr Glen Van Arsdell (Toronto, Ontario, Canada). With this presentation, Dr Rodefeld and his colleagues have introduced an important conceptual leap around the ideas for mechanical assist in single-ventricle palliation. This is the first time one can actually envision one of the holy grails for single-ventricle surgery, ie, 1-stage neonatal Fontan with outcomes that match neonatal biventricular repair. Except for incremental improvements in single-ventricle surgery, it appears to me that we have reached a ceiling. Now we can see beyond that ceiling, at least conceptually. I have 3 questions for you. One, in your model, it appears that the study is based on a rigid wall concept. In humans, there is some rigidity and some flexibility in a standard Fontan setup. Can you talk with us about how you envision dealing with this conceptually? I know you mentioned the cage, but one of the issues with the microaxial devices is wall trauma and cavitation.

A contemporary comparison of the effect of shunt type in hypoplastic left heart syndrome on the hemodynamics and outcome at Fontan completion

2010-09-01

Objective: We previously reported no difference in morbidity or mortality in a cohort of infants undergoing stage 1 and 2 reconstructions for hypoplastic left heart syndrome with either a modified Blalock–Taussig shunt or a right ventricular to pulmonary artery conduit. This article compares the hemodynamics and perioperative course at the time of the Fontan completion and reports longer-term survival for this cohort.Methods: We retrospectively reviewed the hospital records of all patients who underwent stage 1 reconstruction between January 2002 and May 2005 and subsequent surgical procedures, as well as cross-sectional analysis of hospital survivors.Results: A total of 176 patients with hypoplastic left heart syndrome or a variant underwent stage 1 reconstruction with either modified Blalock–Taussig shunt (n = 114) or right ventricular to pulmonary artery conduit (n = 62). Shunt selection was at the discretion of the surgeon. The median duration of follow-up was 58 months (range 1–87 months). By Kaplan–Meier analysis, shunt type did not influence survival or freedom from transplant at 5 years (right ventricular to pulmonary artery conduit 61%; 95% confidence limit, 47–72 vs modified Blalock–Taussig shunt 70%; 95% confidence limit, 60–77; P = .55). A total of 107 patients underwent Fontan (69 modified Blalock–Taussig shunts and 38 right ventricular to pulmonary artery conduits) with 98% (105/107) early survival. Patients with a right ventricular to pulmonary artery conduit shunt pre-Fontan had higher pulmonary artery (13 ± 8 mm Hg vs 11 ± 3 mm Hg, P = .026) and common atrial (8 ± 2.3 mm Hg vs 6.8 ± 2.7 mm Hg, P = .039) pressures. By echocardiography evaluation, there was more qualitative moderate to severe ventricular dysfunction (right ventricular to pulmonary artery conduit 31% [12/36] vs modified Blalock–Taussig shunt 17% [11/67], P = .05) and moderate to severe atrioventricular valve regurgitation (right ventricular to pulmonary artery conduit 40% [14/35] vs modified Blalock–Taussig shunt 16% [11/67], P = .01) in the right ventricular to pulmonary artery conduit group. Use of diuretic therapy, angiotensin-converting enzyme inhibition, reflux medications, and tube feedings were not different between groups. Overall, 5 patients underwent heart transplantation (right ventricular to pulmonary artery conduit 4 vs modified Blalock–Taussig shunt 1, P = .1) before Fontan. There was no difference in age or weight at Fontan, bypass time, intensive care unit or hospital length of stay, postoperative pleural effusions, or need for reoperation between groups.Conclusions: Interim analyses continue to suggest there is no survival advantage of one shunt type compared with the other. Longer-term follow-up of a randomized patient population remains of utmost importance.

Discussion

2010-09-01

Dr Christian Pizarro (Wilmington, Del). I congratulate Dr Ballweg and colleagues on a timely study comparing the outcomes of patients who underwent Fontan completion after receiving alternative sources of pulmonary blood flow at the time of their Norwood procedure. While the pediatric cardiac surgical community awaits the results of the Single Ventricle Reconstruction trial, these data provide important information about the impact of each shunt on the candidacy of these patients to undergo a Fontan procedure and their operative results and midterm outcome.

Reintervention for arch obstruction after stage 1 reconstruction does not adversely affect survival or outcome at Fontan completion

2010-09-01

Objective: To determine the effect of reintervention for coarctation after stage 1 reconstruction for hypoplastic left heart syndrome and variants on survival, suitability for Fontan, and morbidity at Fontan.Methods: A retrospective review of echocardiograms, catheterizations, hospital records of patients who underwent stage 1 reconstruction from January 2002 to May 2005, with a cross-sectional analysis of hospital survivors, was performed. Kaplan–Meier curves were derived for patients alive more than 30 days after stage 1 reconstruction.Results: A total of 176 patients underwent stage 1 reconstruction. Forty-three patients (23%) underwent balloon angioplasty (n = 43) or surgical intervention (n = 4) for re-coarctation. Median time to intervention was 123 (1–316) days. Seven of 43 patients (16%) underwent more than 1 balloon angioplasty. Thirty-nine patients underwent intervention before stage 2 reconstruction, and 4 patients had intervention between stage 2 reconstruction and Fontan. Kaplan–Meier curves showed no difference in freedom from death or transplant between patients who did and did not undergo intervention for re-coarctation. Fontan completion was performed in 107 patients. By echocardiogram, the prevalence of moderate to severe ventricular dysfunction between groups was similar at Fontan; however, significant atrioventricular valve regurgitation was more common in patients who required intervention (28/33 vs 40/65, P = .02). Overall Fontan mortality was 2% and not different between groups. Length of stay was not different between patients with and without re-coarctation.Conclusions: Reintervention for coarctation after stage 1 reconstruction is common. Hemodynamic differences between groups did not affect Fontan completion, mortality, or hospital length of stay. Follow-up is necessary to determine the impact of re-coarctation on longer-term mortality and morbidity.

Clinically silent preoperative brain injuries do not worsen with surgery in neonates with congenital heart disease

2010-04-30

Objective: Preoperative brain injury, particularly stroke and white matter injury, is common in neonates with congenital heart disease. The objective of this study was to determine the risk of hemorrhage or extension of preoperative brain injury with cardiac surgery.Methods: This dual-center prospective cohort study recruited 92 term neonates, 62 with transposition of the great arteries and 30 with single ventricle physiology, from 2 tertiary referral centers. Neonates underwent brain magnetic resonance imaging scans before and after cardiac surgery.Results: Brain injury was identified in 40 (43%) neonates on the preoperative magnetic resonance imaging scan (median 5 days after birth): stroke in 23, white matter injury in 21, and intraventricular hemorrhage in 7. None of the brain lesions presented clinically with overt signs or seizures. Preoperative brain injury was associated with balloon atrial septostomy (P = .003) and lowest arterial oxygen saturation (P = .007); in a multivariable model, only the effect of balloon atrial septostomy remained significant when adjusting for lowest arterial oxygen saturation. On postoperative magnetic resonance imaging in 78 neonates (median 21 days after birth), none of the preoperative lesions showed evidence of extension or hemorrhagic transformation (0/40 [95% confidence interval: 0%–7%]). The presence of preoperative brain injury was not a significant risk factor for acquiring new injury on postoperative magnetic resonance imaging (P = .8).Conclusions: Clinically silent brain injuries identified preoperatively in neonates with congenital heart disease, including stroke, have a low risk of progression with surgery and cardiopulmonary bypass and should therefore not delay clinically indicated cardiac surgery. In this multicenter cohort, balloon atrial septostomy remains an important risk factor for preoperative brain injury, particularly stroke.

Single double-lumen venous–venous pump-driven extracorporeal lung membrane support

2010-09-01

Objective: We sought to investigate the safety and feasibility of obtaining total respiratory support during 72 hours using a pump-driven (Levitronix CentriMag; Levitronix LLC, Waltham, Mass) venous–venous extracorporeal lung membrane (Novalung; Novalung GmbH, Hechingen, Germany) attached through a single double-lumen cannula (Novalung) into the femoral or jugular vein in pigs.Methods: Twelve pigs were initially mechanically ventilated for 2 hours (respiratory rate, 20–25 breaths/min; tidal volume, 10–12 mL/kg; fraction of inspired oxygen, 1.0; positive end-expiratory pressure, 5 cm H2O). Thereafter, the extracorporeal lung membrane was attached to the right femoral (n = 6, 26F) or jugular (n = 6, 22F) vein by using a single double-lumen cannula placed transcutaneously. Ventilatory settings were then reduced to near-apneic ventilation (respiratory rate, 4 breaths/min; tidal volume, 1–2 mL/kg; fraction of inspired oxygen, 0.21; positive end-expiratory pressure, 10 cm H2O), and pump flow was increased hourly until maximal efficacy. Blood gases and hemodynamics were measured hourly, and lung and plasma cytokine levels were measured every 4 hours.Results: The device's mean blood flow was 2.16 ± 0.43 L/min, permitting an oxygen transfer and carbon dioxide removal of 203.6 ± 54.6 and 590.3 ± 23.3 mL/min, respectively. Despite static ventilation, all pigs showed optimal respiratory support, with a Pao2, Paco2, and mixed venous oxygen saturation of 226.2 ± 56.4, 59.7 ± 8.8, and 85.6 ± 5.3 mm Hg, respectively. There were no significant inflammatory, cellular, or coagulatory responses; lung cytokine levels remained in the normal range. Route (femoral vs jugular) or size (22F vs 26F) of the cannula did not change hemodynamic or respiratory parameters significantly.Conclusions: This circuit provides total respiratory support over 72 hours without inducing significant hemodynamic, coagulatory, cellular, or inflammatory responses.

Discussion

2010-09-01

Dr Joseph B. Zwischenberger (Lexington, Ky). Paulo Macchiarini's laboratory is to be congratulated as one of a handful in the world that can do these long-term studies. What they have done is put together a system with the Novalung double-lumen catheter, a CentriMag pump, and a Novalung gas exchange device in which they used catheters in both the internal jugular vein and the femoral vein to accomplish total gas exchange with only 2 to 3 L of flow, and these studies lasted for 72 hours.

National Emphysema Treatment Trial redux: Accentuating the positive

2010-09-01

Objective: Under the Freedom of Information Act, we obtained the follow-up data of the National Emphysema Treatment Trial (NETT) to determine the long-term outcome for “a heterogeneous distribution of emphysema with upper lobe predominance,” postulated by the NETT hypothesis to be optimal candidates for lung volume reduction surgery.Methods: Using the NETT database, we identified patients with heterogeneous distribution of emphysema with upper lobe predominance and analyzed for the first time follow-up data for those receiving lung volume reduction surgery and those receiving medical management. Furthermore, we compared the results of the NETT reduction surgery group with a previously reported consecutive case series of 250 patients undergoing bilateral lung volume reduction surgery using similar selection criteria.Results: Of the 1218 patients enrolled, 511 (42%) conformed to the NETT hypothesis selection criteria and received the randomly assigned surgical or medical treatment (surgical = 261; medical = 250). Lung volume reduction surgery resulted in a 5-year survival benefit (70% vs 60%; P = .02). Results at 3 years compared with baseline data favored surgical reduction in terms of residual volume reduction (25% vs 2%; P < .001), University of California San Diego dyspnea score (16 vs 0 points; P < .001), and improved St George Respiratory Questionnaire quality of life score (12 points vs 0 points; P < .001). For the 513 patients with a homogeneous pattern of emphysema randomized to surgical or medical treatment, lung volume reduction surgery produced no survival advantage and very limited functional benefit.Conclusions: Patients most likely to benefit from lung volume reduction surgery have heterogeneously distributed emphysema involving the upper lung zones predominantly. Such patients in the NETT trial had results nearly identical to those previously reported in a nonrandomized series of similar patients undergoing lung volume reduction surgery.

Discussion

2010-09-01

Dr Rodney J. Landreneau (Pittsburgh, Pa). This is a very nice rehashing of what we have known for many years about LVRS. I can remember when Jim Luketich joined me at the University of Pittsburgh back in 1995 from Memorial. He believed it was like a laminar air flow coming into the intensive care unit because of all the negative suction coming from the chest tubes in place for our LVRS patients. That was back in 1995 or so, right, Jim? By 1998, however, we had come to recognize that we were operating on a lot of people erroneously, and then the NETT trial began.

Increased age is an independent risk factor for radiographic aspiration and laryngeal penetration after thoracotomy for pulmonary resection

2010-05-31

Objectives: Aspiration is an increasingly recognized complication after thoracotomy for pulmonary resection, but mechanisms of postoperative aspiration are poorly characterized. This study sought to evaluate risk factors to better define postthoracotomy aspiration.Methods: Three hundred twenty-one consecutive patients underwent clinical bedside swallowing evaluations after thoracotomy for pulmonary resection on postoperative day 1. Results of videofluoroscopic swallowing studies were independently reviewed by 2 speech pathologists and were assigned aspiration–penetration scores of either 1 (normal) or greater than 1 (abnormal) based on the worst swallow. Operative, demographic, and outcomes data were abstracted for each patient, and multivariate regression analysis was performed.Results: Seventy-three (22.7%) patients failed bedside evaluation and proceeded to undergo videofluoroscopic swallowing studies. Forty-four (60.3%) patients had an abnormal videofluoroscopic swallowing study result with a mean aspiration–penetration score of 3.9 ± 0.3. Multivariate analysis showed that older age (68.8 vs 56.2 years, P = .002), prior premature spillage (P = .0006), and vallecular residuals after the swallow (P < .0002) were all associated with aspiration. Interestingly, certain variables were not independently associated with aspiration, including presence of gastroesophageal reflux disease, operative approach or degree of resection, mediastinal lymphadenectomy, preoperative thoracic radiation, same hospitalization reoperation, and pathology.Conclusions: Postoperative risk of aspiration after thoracotomy for pulmonary resection is characterized by repeatable episodes of oropharyngeal discoordination on videofluoroscopic swallowing studies. We recommend routine videofluoroscopic swallowing studies for all patients older than 67 years before the initiation of oral intake to diminish the incidence of postoperative aspiration.

Intraoperative recurrent laryngeal nerve monitoring during surgery for left lung cancer

Jinbo Zhao, Hui Xu, Wenhai Li, Lianhong Chen, Daixing Zhong, Yongan Zhou — 2010-05-17

Objective: This study evaluated the safety and efficacy of intraoperative recurrent laryngeal nerve monitoring during surgery for left lung cancer.Methods: From April 2008 to April 2009, a total of 25 patients at high risk for left recurrent laryngeal nerve injury agreed to and underwent intraoperative recurrent laryngeal nerve monitoring during surgery for left lung cancer in our hospital. Results and clinical records were reviewed.Results: All the patients' left recurrent laryngeal nerves were identified during operation by intraoperative recurrent laryngeal nerve monitoring. Twenty-four patients retained normal left recurrent laryngeal nerves after the operation. One patient, in whom part of the left recurrent laryngeal nerve was found to be invaded, underwent single-stage nerve anastomosis under recurrent laryngeal nerve monitoring after the invaded nerve was resected. There were no significant intraoperative or postoperative complications among the other patients.Conclusions: Intraoperative recurrent laryngeal nerve monitoring during thoracotomy is a safe and effective way of identifying the nerve. It may help surgeons to avoid injuring the recurrent laryngeal nerve during some thoracic procedures.

Size matters: A comparison of T1 and T2 peripheral non–small-cell lung cancers treated with stereotactic body radiation therapy (SBRT)

2010-05-17

Objective: The purpose of this study was to compare the outcomes and local control rates of patients with peripheral T1 and T2 non–small-cell lung cancer treated with stereotactic body radiation therapy.Methods: The records of 40 consecutive patients treated with 3- or 5-fraction lung stereotactic body radiation therapy for peripheral, clinical stage I non–small-cell lung cancer were reviewed. Stereotactic body radiation therapy was delivered at a median dose of 60 Gy. Doses to organs at risk were limited based on the Radiation Therapy Oncology Group 0236 treatment protocol. Patients were staged clinically. Median follow was 12.5 months.Results: Twenty-seven (67%) patients and 13 (33%) patients had T1 and T2 tumors, respectively. Thirty-seven (94%) patients were medically inoperable. Nine (23%) patients had chest wall pain after stereotactic body radiation therapy. Symptomatic pneumonitis developed in 4 (10%) patients. Increasing tumor size correlated with worse local control and overall survival. The median recurrence-free survival for T1 and T2 tumors was 30.6 months (95% confidence interval [CI], 26.9–34.2) and 20.5 months (95% CI, 14.3–26.5), respectively (P = .038). Local control at 2 years was 90% and 70% in T1 and T2 tumors, respectively (P = .03). The median survival for T1 and T2 tumors was 20 months (95% CI, 20.1–31.6) and 16.7 months (95% CI, 10.8–21.2), respectively (P = .073).Conclusions: Stereotactic body radiation therapy for T2 non–small-cell lung cancer has a higher local recurrence rate and trended toward a worse survival than did T1 lesions. Tumor size is an important predictor of response to stereotactic body radiation therapy and should be considered in treatment planning.

Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction

2010-09-01

Objective: Open total arch procedures have been associated with significant morbidity and mortality in patients with multiple comorbidities. Aortic arch debranching with endovascular graft placement, the hybrid arch procedure, has emerged as a surgical option in this patient population. This study evaluates the outcomes of a contemporary comparative series from one institution of open total arch and hybrid arch procedures for extensive aortic arch pathology.Methods: From July 2000 to March 2009, 1196 open arch procedures were performed, including 45 elective and 7 emergency open total arch procedures. From 2005 to 2009, 64 hybrid arch procedures were performed: 37 emergency type A dissections and 27 elective open arch debranchings. Hemiarch procedures were excluded.Results: The hybrid arch cohort was significantly older (P = .008) and had greater predominance of atherosclerotic pathophysiology (P < .001). The incidence of permanent cerebral neurologic deficit was similar at 4% (1/27) for the hybrid arch cohort and 9% (4/45) for the open aortic arch cohort. In-hospital mortality was similar at 11% (3/27) for the hybrid arch cohort and 16% (7/45) for the open aortic arch cohort. However, in the open arch group, there was a significant difference in mortality between patients aged less than 75 years at 9% (3/34) and patients aged more than 75 years at 36% (4/11) (P = .05).Conclusions: Hybrid arch procedures provide a safe alternative to open repair. This study suggests the hybrid arch approach has a lower mortality for high-risk patients aged more than 75 years. This extends the indication for the hybrid arch approach in patients with complex aortic arch pathology previously considered prohibitively high risk for conventional open total arch repair.

Discussion

2010-09-01

Dr Yutaka Okita (Kobe, Japan). I have no disclosures. Drs Milewski and Bavaria's group are to be congratulated on reporting a systematic approach to aortic arch pathologies. They compared 27 patients who underwent elective open hybrid arch procedures and 45 patients who underwent elective open total arch replacement at the University of Pennsylvania. Although patients' backgrounds were not similar and the number of patients was small, they concluded the hybrid arch procedures provided better outcome in elderly patients.

Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma

2010-06-25

Objective: Traumatic blunt aortic injury has traditionally been viewed as a surgical emergency, whereas nonoperative therapy has been reserved for nonsurgical candidates. This study reviews our experience with deliberate, nonoperative management for blunt thoracic aortic injury.Methods: A retrospective chart review with selective longitudinal follow-up was conducted for patients with blunt aortic injury. Surveillance imaging with computed tomography angiography was performed. Nonoperative patients were then reviewed and analyzed for survival, evolution of aortic injury, and treatment failures.Results: During the study period, 53 patients with an average age of 45 years (range, 18–80 years) were identified, with 28% presenting to the Stanford University School of Medicine emergency department and 72% transferred from outside hospitals. Of the 53 patients, 29 underwent planned, nonoperative management. Of the 29 nonoperative patients, in-hospital survival was 93% with no aortic deaths in the remaining patients. Survival was 97% at a median of 1.8 years (range, 0.9–7.2 years). One patient failed nonoperative management and underwent open repair. Serial imaging was performed in all patients (average = 107 days; median, 31 days), with 21 patients having stable aortic injuries without progression and 5 patients having resolved aortic injuries.Conclusions: This experience suggests that deliberate, nonoperative management of carefully selected patients with traumatic blunt aortic injury may be a reasonable alternative in the polytrauma patient; however, serial imaging and long-term follow-up are necessary.

Discussion

2010-06-25

Dr Timothy Van Natta (Torrance, Calif). I can tell you as a traumatologist this is very important work. It is true that the cohort size is small, 27 patients, and the follow-up time with a median 31 days is relatively short, but to paraphrase Dr Miller from yesterday, follow-up is short but still very valuable.

Clinical depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder as risk factors for in-hospital mortality after coronary artery bypass grafting surgery

2010-01-14

Objective: The goal of this study was to examine the effect of clinical depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder on in-hospital mortality after a coronary artery bypass grafting surgery. It is hypothesized that depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder will independently contribute to an increased risk for in-hospital mortality rates after coronary artery bypass grafting surgery.Methods: We performed a retrospective analysis of the 2006 Nationwide Inpatient Sample database. The Nationwide Inpatient Sample database provides information on approximately 8 million US inpatient stays from about 1000 hospitals. We performed χ2 and unpaired t tests to evaluate potential confounding group demographic and medical variables. Hierarchic logistic regression was used with forced order entry of depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder.Results: Deceased patients were more likely to have had depression (alive, 24.8%; deceased, 60.3%; P < .001), posttraumatic stress disorder (alive, 13.4%; deceased, 56.1%; P < .001), and cormorbid depression and posttraumatic stress disorder (alive, 7.8%; deceased, 48.5%; P < .001). After adjusting for potential confounding factors, patients with depression (odds ratio, 1.24; 95% confidence interval, 1.02–1.50), posttraumatic stress disorder (odds ratio, 2.09; 95% confidence interval, 1.65–2.64), and comorbid depression and posttraumatic stress disorder (odds ratio, 4.66; 95% confidence interval, 3.46–6.26) had an increased likelihood of in-hospital mortality compared with that seen in patients who were alive.Conclusions: Two findings were noteworthy. First, depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder are prevalent in patients undergoing coronary artery bypass grafting procedures. Second, depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder increase the risk of death by magnitudes comparable with well-established physical health risk factors after coronary artery bypass grafting surgery. The implications for clinical practice and future directions are discussed.

Intermittent regurgitation caused by incomplete leaflet closure of the Medtronic ADVANTAGE bileaflet heart valve: Analysis of the underlying mechanism

2010-02-01

Objective: Clinical echocardiographic assessments of the Medtronic ADVANTAGE (Medtronic Inc, Minneapolis, Minn) prosthesis in the aortic position revealed a phenomenon identified as “intermittent regurgitation.” An in vitro investigation was initiated to identify the underlying mechanism.Methods: In a pulse duplicator environment, 6 ADVANTAGE size 23 aortic valves were analyzed. Leaflet motion and flow through the valves were documented using echocardiography with color Doppler flow, digital high speed imaging, and flow meter assessment.Results: Intermittent regurgitation could be reproduced in all 6 of the tested valves within limited ranges of flow, pressure, and valve orientation. By virtue of high-speed imaging, the mechanism underlying intermittent regurgitation was identified. During intermittent regurgitation, the leading edge of the second-to-close leaflet makes contact with the chamfer on the leading edge of the first-to-close leaflet. The fluid closing forces working on the first-to-close leaflet prevent it from shifting back so that the leading edge of the second-to-close leaflet remains positioned against the chamfer of the first-to-close leaflet. In this position, the major radius of the second-to-close leaflet does not reach the housing's major radius. Therefore, a crescent-shaped gap remains between the leaflet tip of the second-to-close leaflet and the housing major radius during all or part of diastole. The regurgitant fraction can increase from a normal range of 6% to 25% during an intermittent regurgitation beat.Conclusions: In vitro intermittent regurgitation can be induced in the size 23 aortic ADVANTAGE valve under a limited range of conditions. To avoid possible misinterpretations, the phenomenon must be known in detail by all physicians dealing with patients with an ADVANTAGE valve.

Functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitation: Importance of subvalvular tethering in the mechanism and dynamic deterioration during exertion

2010-02-01

Objective: Diastolic subvalvular mitral leaflet tethering by left ventricular remodeling that restricts leaflet opening in the presence of annular size reduction by surgery for ischemic mitral regurgitation potentially causes functional mitral stenosis in the absence of organic leaflet lesions. Exercise, known to worsen systolic tethering and ischemic mitral regurgitation, might also dynamically exacerbate such mitral stenosis by increasing tethering. This study evaluates the mechanism and response of such mitral stenosis to exercise.Methods: We measured the diastolic mitral valve area, annular area, and peak and mean transmitral pressure gradient by echocardiography in 20 healthy individuals and 31 patients who underwent surgical annuloplasty for ischemic mitral regurgitation.Results: Although the mitral valve area and annular area did not significantly differ in healthy individuals (4.7 ± 0.6 cm2 vs 5.2 ± 0.6 cm2, not significant), mitral valve area was significantly smaller than the annular area in patients after annuloplasty (1.6 ± 0.2 cm2 vs 3.3 ± 0.5 cm2, P < .01). The mitral valve area was less than 1.5 cm2 only after the surgery (P < .01) and was significantly correlated with restricted leaflet opening (r2 = 0.74, P < .001), left ventricular dilatation (r2 = 0.17, P < .05), and New York Heart Association functional class (P < .05). Exercise stress echocardiography of 12 patients demonstrated dynamic worsening in functional mitral stenosis (mitral valve area: 2.0 ± 0.5 cm2 to 1.4 ± 0.2 cm2, P < .01; mean pressure gradient: 1.5 ± 0.9 mm Hg to 6.0 ± 2.2 mm Hg, P < .01).Conclusions: Persistent subvalvular leaflet tethering in the presence of annular size reduction by surgery in ischemic mitral regurgitation frequently causes functional mitral stenosis at the leaflet tip level, which is related to heart failure symptoms and can be dynamic with significant exercise-induced worsening.

Cardiac dysfunction induced by experimental myocardial infarction impairs the host defense response to bacterial infection in mice because of reduced phagocytosis of Kupffer cells

2010-02-08

Objective: This study was undertaken to investigate the effects of cardiac dysfunction induced by experimental myocardial infarction on the host defense response to bacterial infection and the role of Kupffer cells in mediating this response.Methods: Myocardial infarction was induced in C57BL/6 mice by ligation of the left anterior descending coronary artery. Mice were challenged with Escherichia coli intravenously 1, 5, and 14 days after myocardial infarction or sham operation. Thereafter, the cytokine production and the function of their Kupffer cells were assessed.Results: Mice with myocardial infarction showed remarkable cardiac dysfunction and had a significantly lower survival than sham mice after bacterial challenge at 5 days after surgery; bacterial challenge at 1 or 14 days after surgery resulted in no difference in survival between myocardial infarction and sham mice. The phagocytic activity of Kupffer cells, assessed by fluorescein isothiocyanate microspheres, remarkably decreased in mice with myocardial infarction 5 days after surgery. Serum peaks of tumor necrosis factor and interferon-γ after bacterial challenge were also suppressed in mice with myocardial infarction at 5 days. Production of these cytokines and immunoglobulin-M from liver mononuclear cells was also impaired in mice with myocardial infarction. Enhancement of the phagocytic activity of Kupffer cells by C-reactive protein significantly improved survival after infection in mice with myocardial infarction, although neither interleukin-18 nor immunoglobulin-M treatment improved survival.Conclusions: Cardiac dysfunction induced by myocardial infarction renders mice susceptible to bacterial infection and increases mortality because of a reduced ability of Kupffer cells to clear infectious bacteria. C-reactive protein-enhanced phagocytic activity of Kupffer cells may improve the poor prognosis after bacterial infection in mice with myocardial infarction.

Thoracoscopic pulmonary vein isolation in patients with atrial fibrillation and failed percutaneous ablation

2010-02-01

Objective: Pulmonary vein isolation is indicated in patients with symptomatic isolated atrial fibrillation not controlled with antiarrhythmic therapy. We describe our surgical experience with thoracoscopic pulmonary vein isolation in patients in whom percutaneous ablation has failed.Methods: Thirty-four adult patients with unsuccessful catheter ablations (range 1–4, mean 2 ± 1) underwent thoracoscopic bipolar-radiofrequency pulmonary vein isolation. Seventeen patients had paroxysmal atrial fibrillation, 12 with persistent and 5 with long-standing persistent fibrillation, for a mean of 6 years (range 3–10 years), 13 years (5–25 years), and 9 years (3–15 years), respectively.Results: There was no mortality during the procedure or follow-up (mean 16 ± 11 months). Two patients needed conversion to thoracotomy owing to hemorrhage, and ablation could not be completed. Antiarrhythmic therapy was withdrawn 3 months postoperatively. Postoperative sinus rhythm was maintained in 82% of those with paroxysmal atrial fibrillation (13/15 at 6 months, 9/11 at 12 months), 60% had persistent atrial fibrillation (8/12 at 6 months and 6/10 at 12 months), and 20% had long-standing persistent atrial fibrillation (1/5 at 6 and 12 months). Preoperative left atrial diameter significantly differed between patients with paroxysmal fibrillation (mean 42 ± 6 mm) and those with persistent and long-standing persistent fibrillation (means 50 ± 4 and 47 ± 2 mm). Left atrial size greater than 45 mm and atrial fibrillation type were preoperative factors that significantly influenced outcome in the univariate logistic regression analysis.Conclusions: Thoracoscopic pulmonary vein isolation in patients with previously unsuccessful catheter ablations demonstrates satisfactory sinus rhythm maintenance rates in paroxysmal and persistent atrial fibrillation, but not in long-standing persistent atrial fibrillation. As with other minimally invasive surgical techniques, there is an important learning curve.

Comparison of fractional flow reserve of composite Y-grafts with saphenous vein or right internal thoracic arteries

2010-02-18

Background: Composite Y-grafts, using the left internal thoracic artery as the inflow, allow a more efficient use of conduits without the need to touch a diseased ascending aorta. Among other conduits, the saphenous vein graft may be an alternative to the radial artery in elderly patients.Patients and Methods: We evaluated the hemodynamic characteristics of 17 composite Y-grafts made with the left internal thoracic artery anastomosed to the left anterior descending coronary artery in all cases and with either the free right internal thoracic artery (RITA group, n = 10) or a saphenous vein graft (SVG group, n = 7) implanted proximally to the left internal thoracic artery and distally to the circumflex territory 6 months after the operation.Results: At baseline, the pressure gradient measured with a 0.014-inch pressure wire was minimal between the aorta and the internal thoracic artery stem (2 ± 1 mm Hg), the internal thoracic artery and left anterior descending (4 ± 2 mm Hg), the internal thoracic artery and left circumflex (3 ± 1 mm Hg), and the saphenous vein graft and left circumflex (2 ± 2 mm Hg). During hyperemia induced by adenosine, the pressure gradient increased significantly to 6 ± 2 mm Hg in the internal thoracic artery stem, 9 ± 4 mm Hg in the internal thoracic artery and left anterior descending artery, 9 ± 3 mm Hg in the internal thoracic artery and left circumflex, and 7 ± 4 mm Hg in the saphenous vein graft and left circumflex. Fractional flow reserve was 0.94 ± 0.02 in internal thoracic artery stem, 0.90 ± 0.04 mm Hg in the internal thoracic artery and left anterior descending, 0.91 ± 0.03 mm Hg in the internal thoracic artery and left circumflex, and 0.92 ± 0.06 mm Hg in the saphenous vein graft and left circumflex. No difference between the two types of composite Y-grafts was observed for pressure gradients or fractional flow reserve measured in internal thoracic artery stem or in distal branches.Conclusions: Composite Y-grafts with saphenous vein or right internal thoracic arteries allow similar and adequate reperfusion of the left system with minimal resistance to maximal flow and an even distribution of flow in both distal branches.

Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams

2010-06-07

Objectives: Resuscitation of pediatric cardiac patients involves unique and complex physiology, requiring multidisciplinary collaboration and teamwork. To optimize team performance, we created a multidisciplinary Crisis Resource Management training course that addressed both teamwork and technical skill needs for the pediatric cardiac intensive care unit. We sought to determine whether participation improved caregiver comfort and confidence levels regarding future resuscitation events.Methods: We developed a simulation-based, in situ Crisis Resource Management curriculum using pediatric cardiac intensive care unit scenarios and unit-specific resuscitation equipment, including an extracorporeal membrane oxygenation circuit. Participants replicated the composition of a clinical team. Extensive video-based debriefing followed each scenario, focusing on teamwork principles and technical resuscitation skills. Pre- and postparticipation questionnaires were used to determine the effects on participants' comfort and confidence regarding participation in future resuscitations.Results: A total of 182 providers (127 nurses, 50 physicians, 2 respiratory therapists, 3 nurse practitioners) participated in the course. All participants scored the usefulness of the program and scenarios as 4 of 5 or higher (5 = most useful). There was significant improvement in participants' perceived ability to function as a code team member and confidence in a code (P < .001). Participants reported they were significantly more likely to raise concerns about inappropriate management to the code leader (P < .001).Conclusions: We developed a Crisis Resource Management training program in a pediatric cardiac intensive care unit to teach technical resuscitation skills and improve team function. Participants found the experience useful and reported improved ability to function in a code. Further work is needed to determine whether participation in the Crisis Resource Management program objectively improves team function during real resuscitations.

Cellular phenotype transformation occurs during thoracic aortic aneurysm development

2010-03-10

Objective: Thoracic aortic aneurysms result from dysregulated remodeling of the vascular extracellular matrix, which may occur as a result of altered resident cellular function. The present study tested the hypothesis that aortic fibroblasts undergo a stable change in cellular phenotype during thoracic aortic aneurysm formation.Methods: Primary murine aortic fibroblasts were isolated from normal and thoracic aortic aneurysm-induced aortas (4 weeks post induction with 0.5mol/L CaCl2 15minutes) by the outgrowth method. Normal and thoracic aortic aneurysm cultures were examined using a focused polymerase chain reaction array to determine fibroblast-specific changes in gene expression in the absence and presence of biological stimulation (endothelin-1, phorbol-12-myristate-13-acetate, angiotensin-II). The relative expression of 38 genes, normalized to 4 housekeeping genes, was determined, and genes displaying a minimum 2-fold increase/decrease or genes with significantly different normalized cycle threshold values were considered to have altered expression.Results: At steady state, thoracic aortic aneurysm fibroblasts revealed elevated expression of several matrix metalloproteinases (Mmp2, Mmp11, Mmp14), collagen genes/elastin (Col1a1, Col1a2, Col3a1, Eln), and other matrix proteins, as well as decreased expression of Mmp3, Timp3, and Ltbp1. Moreover, gene expression profiles in thoracic aortic aneurysm fibroblasts were different than normal fibroblasts after equivalent biological stimuli.Conclusion: This study demonstrated for the first time that isolated primary aortic fibroblasts from thoracic aortic aneurysm-induced mice possess a unique and stable gene expression profile, and when challenged with biological stimuli, induce a transcriptional response that is different from normal aortic fibroblasts. Together, these data suggest that aortic fibroblasts undergo a stable phenotypic change during thoracic aortic aneurysm development, which may drive the enhancement of extracellular matrix proteolysis in thoracic aortic aneurysm progression.

Exacerbation of systemic inflammation and increased cerebral infarct volume with cardiopulmonary bypass after focal cerebral ischemia in the rat

2010-03-17

Objective: Stroke remains a significant contributor to morbidity and mortality after cardiac surgery. Cardiopulmonary bypass is known to induce a significant inflammatory response, which could adversely influence outcomes. We hypothesized that cardiopulmonary bypass, through an enhanced systemic inflammatory response, might affect outcomes after focal cerebral ischemia.Methods: Wistar rats (275–300 g) were anesthetized, surgically prepared for cardiopulmonary bypass and right middle cerebral artery occlusion, and randomly allocated to 2 groups: focal cerebral ischemia alone (n = 9) and focal cerebral ischemia combined with normothermic cardiopulmonary bypass (n = 8). Serum cytokines (tumor necrosis factor α and interleukins 1β, 6, and 10) were measured at baseline, at end of bypass, and at 2, 6, and 24 hours after bypass. On postoperative day 3, animals underwent neurologic testing, after which the brains were prepared for assessment of cerebral infarct volume. Data were compared between groups by Mann–Whitney U test.Results: Compared with the ischemia-alone group, the ischemia plus bypass group had significantly higher levels of circulating tumor necrosis factor α and interleukins 1β and 10 at the end of bypass and 2 hours after bypass. In addition, the ischemia plus bypass animals had larger total cerebral infarct volumes (286 ± 125 mm3) than did those with ischemia alone (144 ± 85 mm3, P = .0124).Conclusions: Cardiopulmonary bypass increased cerebral infarct size after focal cerebral ischemia in rats. This worsening of outcome may in part be related to an augmented inflammatory response that accompanies cardiopulmonary bypass.

Tissue-engineered pro-angiogenic fibroblast scaffold improves myocardial perfusion and function and limits ventricular remodeling after infarction

2010-04-05

Objective: Microvascular malperfusion after myocardial infarction leads to infarct expansion, adverse remodeling, and functional impairment. Native reparative mechanisms exist but are inadequate to vascularize ischemic myocardium. We hypothesized that a 3-dimensional human fibroblast culture (3DFC) functions as a sustained source of angiogenic cytokines, thereby augmenting native angiogenesis and limiting adverse effects of myocardial ischemia.Methods: Lewis rats underwent ligation of the left anterior descending coronary artery to induce heart failure; experimental animals received a 3DFC scaffold to the ischemic region. Border-zone tissue was analyzed for the presence of human fibroblast surface protein, vascular endothelial growth factor, and hepatocyte growth factor. Cardiac function was assessed with echocardiography and pressure–volume conductance. Hearts underwent immunohistochemical analysis of angiogenesis by co-localization of platelet endothelial cell adhesion molecule and alpha smooth muscle actin and by digital analysis of ventricular geometry. Microvascular angiography was performed with fluorescein-labeled lectin to assess perfusion.Results: Immunoblotting confirmed the presence of human fibroblast surface protein in rats receiving 3DFC, indicating survival of transplanted cells. Increased expression of vascular endothelial growth factor and hepatocyte growth factor in experimental rats confirmed elution by the 3DFC. Microvasculature expressing platelet endothelial cell adhesion molecule/alpha smooth muscle actin was increased in infarct and border-zone regions of rats receiving 3DFC. Microvascular perfusion was also improved in infarct and border-zone regions in these rats. Rats receiving 3DFC had increased wall thickness, smaller infarct area, and smaller infarct fraction. Echocardiography and pressure–volume measurements showed that cardiac function was preserved in these rats.Conclusions: Application of a bioengineered 3DFC augments native angiogenesis through delivery of angiogenic cytokines to ischemic myocardium. This yields improved microvascular perfusion, limits infarct progression and adverse remodeling, and improves ventricular function.

Endothelin A receptor blockade improves regression of flow-induced pulmonary vasculopathy in piglets

2010-09-01

Objectives: In patients with chronic thromboembolic pulmonary hypertension, high flow in unobstructed lung regions may induce small-vessel damage responsible for persistent pulmonary hypertension after pulmonary thromboendarterectomy. In piglets, closure of an experimental aortopulmonary shunt reverses the flow-induced vascular lesions and diminishes the elevated levels of messenger RNA (mRNA) expression for endothelin-1 and endothelin receptor A (ETA). We wanted to study the effect of the ETA antagonist TBC 3711 on reversal of flow-induced pulmonary vascular lesions.Methods: Twenty piglets were studied. In 15 piglets, pulmonary vasculopathy was induced by creating an aortopulmonary shunt. After 5 weeks of shunting, some animals were studied (n = 5); others underwent shunt closure for 1 week with (n = 5) or without (n = 5) TBC3711 treatment. Anti-ETA treatment started 1 week before and ended 1 week after the shunt closure. The controls were sham-operated animals (n = 5).Results: High blood flow led to medial hypertrophy of the distal pulmonary arteries (54.9% ± 1.3% vs 35.3% ± 0.9%; P < .0001) by stimulating smooth muscle cell proliferation (proliferating cell nuclear antigen) and increased the expression of endothelin-1, ETA or endothelin receptor type A or endothelin receptor A, angiopoietin 1, and Tie2 (real-time polymerase chain reaction). One week after shunt closure, gene expression levels were normal and smooth muscle cells showed increased apoptosis (terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling) without proliferation. However, pulmonary artery wall thickness returned to control values only in the group given TBC3711 (33.2% ± 8% with and 50.3% ± 1.3% without; P < .05).Conclusions: Anti-ETA therapy accelerated the reversal of flow-induced pulmonary arterial disease after flow correction. In patients with chronic thromboembolic pulmonary hypertension and severe distal pulmonary vasculopathy, anti-ETA agents may prove useful for preventing persistent pulmonary hypertension after pulmonary thromboendarterectomy.

A novel mutation in GATA4 gene associated with dominant inherited familial atrial septal defect

2010-03-29

Objective: Atrial septal defect (ASD) is a common congenital heart disease (CHD). Although most cases are sporadic, familial cases have been reported. The transcription factors NKX2.5 and GATA4 play important roles in the pathogenesis of ASD. Mutations in either gene have been identified in familial cases of ASD. Here, we examine a Chinese family with isolated ASD to find out whether there is any mutation in NKX2.5 or GATA4 accounting for the etiology.Methods: We identified kindred spanning 3 generations in which 8 of 31 (38%) individuals had ASD. One hundred seventy unrelated individuals were included as controls. Peripheral blood samples were collected and genomic DNA was extracted from the leukocytes. NKX2.5 and GATA4 were amplified by polymerase chain reaction (PCR) with specific primers. The sequences of PCR products were compared between affected members and unaffected members, as well as controls.Results: Direct sequencing of NKX2.5 from the genomic DNA of family members failed to identify mutations, whereas sequencing of GATA4 identified an A-to-G transition at nucleotide 928 in exon 5 that predicted a methionine to valine substitution at codon 310 (M310V) in the NLS region. All affected members and a patriarch of the family who was recognized as a carrier exhibited this mutation, whereas the other unaffected family members or control individuals did not. This mutation has not been reported previously in either familial or sporadic cases of CHD.Conclusions: We identified a novel M310V mutation in GATA4 gene that is located in the NLS region and leads to hereditary ASD in a Chinese family. In this family, we identified a carrier with incomplete penetrance and 8 patients with variable expressivity. However, the mechanism by which this mutation contributes to the development of a congenital heart defect remains to be ascertained.

Serum cystatin C is an easy to obtain biomarker for the onset of renal impairment in heart transplant recipients

2010-05-06

Objective: With the increasing longevity of heart transplant recipients, the long-term effects of cyclosporine on renal function have become more evident. Highly sensitive, early, and effective monitoring of posttransplant renal function is still being researched. This study aimed to evaluate the prognostic value of cystatin C for patients after heart transplantation.Methods: Seventy-three long-term recipients of a heart transplant more than 5 years before the study start were included in the analysis with a follow-up of 4 years. Serum creatinine, renal glomerular filtration rate calculated by the Modification of Diet in Renal Disease formula, and serum cystatin C levels were collected, and risk factors for renal dysfunction were assessed. Statistical analysis was performed for all patients.Results: Univariate analysis showed a prognostic impact of antihypertensive medication and onset of diabetes (P < .001) on renal failure after transplantation. Multivariate analysis yielded cystatin C measured at the study start as a superior prognostic parameter for all time points (area under the receiver operating characteristic 12 months: 0.963; 24 months: 0.910; 48 months: 0.949) compared with the conventionally used creatinine levels.Conclusions: Our results showed an enormous potential of serum cystatin C as an early prognostic and easy to obtain biomarker for renal dysfunction after heart transplantation.

Impact of antibodies against human leukocyte antigens on long-term outcome in pediatric heart transplant patients: An analysis of the United Network for Organ Sharing database

2010-05-31

Objectives: Controversy exists regarding the importance of circulating antibodies as determined by panel-reactive antibody screening as a risk factor for graft failure in pediatric patients undergoing heart transplantation. This study sought to determine the association of elevated anti-human leukocyte antibodies with long-term survival in pediatric heart transplant patients.Methods: The United Network for Organ Sharing registry was queried for pediatric patients (aged < 18 years at listing) with panel-reactive antibody levels obtained before heart transplantation from 1987 through 2004. Survival analysis methods were used to assess the association of elevated panel-reactive antibodies with long-term graft and patient survival.Results: Panel-reactive antibodies were obtained before transplantation from 3534 patients, median age 4 years (interquartile range 0–12 years). Most, 2711 (77%), had no detectible panel-reactive antibodies, 436 (12%) had panel-reactive antibodies of 1% to 10%, and 387 (11%) had panel-reactive antibodies greater than 10%. Patients with panel-reactive antibodies greater than 10% were more likely to be older (P = .04), have congenital heart disease (P < .001), and have a longer wait list time (P = .006). Patients with panel-reactive antibodies greater than 10% had significantly worse graft survival and patient survival than did patients with undetectable panel-reactive antibodies and panel-reactive antibodies of 1% to 10% (P < .05 for all). Controlling for confounding variables, elevated panel-reactive antibodies as a continuous variable and panel-reactive antibodies greater than 10% as a categorical variable were independently associated with decreased graft survival (P = .04 and P = .02, respectively).Conclusions: Elevated panel-reactive antibodies are independently associated with worse long-term graft survival in pediatric patients undergoing heart transplantation. Further study is needed to determine the optimal management of this high-risk population.

Standard versus bicaval techniques for orthotopic heart transplantation: An analysis of the United Network for Organ Sharing database

2010-06-28

Objective: Most studies of anastomotic technique have been underpowered to detect subtle differences in survival. We analyzed the United Network for Organ Sharing database for trends in use and outcomes after either bicaval or traditional (biatrial) anastomoses for heart implantation.Methods: Review of United Network for Organ Sharing data identified 20,999 recipients of heart transplants from 1997 to 2007. Patients were stratified based on the technique of atrial anastomosis: standard biatrial (atrial group, n = 11,919, 59.3%), bicaval (caval group, n = 7661, 38.1%), or total orthotopic (total group, n = 519, 2.6%).Results: The use of the bicaval anastomosis is increasing, but many transplantations continue to use a biatrial anastomosis (1997, 0.2% vs 97.6%; 2007, 62.0% vs 34.7%; P < .0001). Atrial group patients required permanent pacemaker implantation more often (odds ratio, 2.6; 95% confidence interval, 2.2–3.1). Caval group patients had a significant advantage in 30-day mortality (odds ratio, 0.83; 95% confidence interval, 0.75–0.93), and Cox regression analysis confirmed the decreased long-term survival in the atrial group (hazard ratio, 1.11; 95% confidence interval, 1.04–1.19).Conclusions: Heart transplantations performed with bicaval anastomoses require postoperative permanent pacemaker implantation at lower frequency and have a small but significant survival advantage compared with biatrial anastomoses. We recommend that except where technical considerations require a biatrial technique, bicaval anastomoses should be performed for heart transplantation.

Sewing needles embedded in the cardiac interventricular septum and chest wall

2010-09-01

A 61-year-old woman with a history of anxiety and depression, status post left mastectomy, and with resultant diminished sensation in her left chest wall presented with a 2-month history of left-sided chest pain and shortness of breath. Chest roentgenograms revealed the presence of thoracic foreign bodies consistent with sewing needles (). Computed tomographic scanning with 3-dimensional reconstruction demonstrated the location of one the needles to be in the cardiac interventricular septum and right ventricular apex; the remaining 2 additional needles were embedded in her left chest wall (, A). The patient attributed the presence of these needles to accidental penetration while sleeping with her sewing materials nearby. Transthoracic echocardiographic analysis showed the needle as a linear echodensity in the right ventricular cavity extending to the midinterventricular septum (, B). Cardiac catheterization revealed no flow-limiting coronary disease (, C). The patient was taken to the operating room. At the time of the operation, careful inspection demonstrated the needle's presence approximately 0.5 cm from the left anterior descending artery associated with a surrounding hematoma (). By carefully pressing down in the region of interest, we could grasp the needle and remove it en bloc (). The chest wall needles were extracted through an incision in the fourth intercostal space.

Secure closure of the tracheal incision after natural orifice transluminal endoscopic surgery with a silicone tracheal stent

Yun-Hen Liu, Yi-Chen Wu, Tzu-Ping Chen, Po-Jen Ko — 2010-02-01

Video clip is available online.

Bridge to lung transplantation using short-term ambulatory extracorporeal membrane oxygenation

2010-04-12

Severe respiratory failure refractory to mechanical ventilation can occur in patients awaiting lung transplantation (LTx). Use of extracorporeal membrane oxygen (ECMO) to bridge these patients to LTx is associated with considerable morbidity and mortality. Most techniques rely on femoral cannulation, thereby immobilizing patients. This in turn can lead to rapid deconditioning and predisposes patients to nosocomial pneumonia, deep venous thrombosis, and muscle wasting. This case highlights the use of upper-extremity ECMO, which was established without intubation in a critically ill transplant candidate, allowed ambulation, and ultimately served as a successful bridge to LTx.

Direct aortic access through right minithoracotomy for implantation of self-expanding aortic bioprosthetic valves

2010-04-15

The development of transcatheter aortic valve implantation (TAVI) for the treatment of severe aortic stenosis (AS) offers a viable option for patients at high risk or with contraindications for standard cardiac surgery. We report our experience of a novel surgical approach using direct aortic access through a right minithoracotomy for implanting a self-expanding aortic valve bioprosthesis (CoreValve, Medtronic-CV Luxembourg S.a.r.l.).

Carinal stabilization technique in severe tracheobronchial malacia after slide tracheoplasty

Igor E. Konstantinov — 2010-04-12

Pulmonary artery (PA) sling complex is a spectrum of anomalies that commonly include left PA sling, left ligamentum arteriosum, hypoplastic right lung, and severe long-segment tracheal stenosis. During the last decade, slide tracheoplasty has become the method of choice in repairing severe long-segment tracheal stenosis. However, fewer than 250 children have undergone slide tracheoplasty worldwide. The operative mortality ranges from 5% to 33%. PA sling complex and other concomitant cardiovascular anomalies add to the complexity and risk of slide tracheoplasty. Furthermore, severe tracheobronchial malacia often persists after tracheoplasty, resulting in unstable airways. Collapse at the carina results in an inability to deflate both lungs and is life-threatening. This report describes a simple technique of carinal stabilization that provided effective relief of carinal collapse in severe tracheobronchial malacia after extensive slide tracheoplasty.

Aortic valve replacement and coronary artery bypass via left anterior thoracotomy after previous left pneumonectomy

Sotiris C. Stamou, Michael C. Murphy, Nicholas T. Kouchoukos — 2010-03-26

Left anterior thoracotomy is an infrequent approach to perform open cardiac operations. It has been used for coronary artery bypass grafting (CABG) and rarely for valvular procedures. We describe a left anterior thoracotomy approach for combined aortic valve replacement (AVR) and myocardial revascularization in a patient with a marked shift of mediastinal structures after previous left pneumonectomy.

Explantation of a 44-year-old Starr–Edwards mitral valve for delayed hemolysis

Joss Fernandez, Robert Saeid Farivar — 2010-02-01

A 68-year-old woman was admitted 44 years after undergoing mitral valve replacement with a Starr–Edwards (SE) prosthesis (Edwards Lifesciences, Irvine, Calif) for rheumatic mitral valve stenosis. Since implantation of the prosthesis in 1965 via thoracotomy, the patient had done well and maintained her anticoagulation with warfarin sodium (Coumadin). She now had fatigue and anemia. Of note, 2 years earlier the patient had had third-degree heart block necessitating the implantation of a dual-chamber pacemaker. A full workup including upper and lower endoscopy did not reveal a source of bleeding. Hematologic testing showed decreased haptoglobin, a high lactic dehydrogenase value, and increased reticulocyte count, consistent with a hemolytic anemia. Bone marrow biopsy was performed, which showed erythroid hyperplasia, normocellular bone marrow, normal megakaryocytes, and absent iron, indicative of iron deficiency anemia. Despite iron replacement therapy she continued to become increasingly transfusion dependent. She received 9 units of blood in 1 month alone. Echocardiogram revealed normal prosthetic mitral valve function with a mitral valve mean gradient of 6 mm Hg, a severely calcified aortic valve with an aortic valve mean gradient of 58 mm Hg, and an aortic valve area of less than 1.0 cm2.

Two cases of aneurysm of the anterior mitral valve leaflet associated with transcatheter aortic valve endocarditis: A mere coincidence?

2010-02-18

The incidence of transcatheter aortic valve endocarditis (TAVE) is currently unknown. To the best of our knowledge, 2 clinical case reports of TAVE have been published (1 Edwards SAPIEN [Edwards Lifesciences, Irvine, Calif] and 1 Medtronic CoreValve ReValving System [Medtronic CV, Luxembourg Sarl]). Interestingly, both cases were associated with aneurysm and perforation of the anterior mitral valve leaflet—a link that has not been previously reported. We briefly review the clinical presentations of these cases and discuss the possible implications of endocarditis in the context of transcatheter aortic valve implantation.

Video-assisted anterior approach to Pancoast tumors

Philip A. Linden — 2010-04-19

Significant advances in the treatment of Pancoast tumors have been made over the past 50 years. Some advances have been in neoadjuvant treatments, whereas others have been in surgical technique. The classic approach to Pancoast tumors involves a posterolateral thoracotomy extending posteriorly to the base of the neck. With tumors invading the anterior aspects of the first rib or subclavian artery or vein, an anterior approach is helpful. Dartevelle and colleagues pioneered the anterior cervicothoracic approach with an L-shaped incision paralleling the anterior border of the sternocleidomastoid muscle down the midline to the level of the second or third ribs, extending laterally to the deltopectoral groove. The medial clavicle is resected. Excellent exposure of the subclavian vessels, anterior aspects of ribs, and brachial plexus is possible through this incision. Lobectomy is performed after detachment of the chest wall. Grunenwald and Spaggiari described a clavicle-sparing modification of the anterior approach involving detachment and elevation of the clavicle with an attached portion of sternum to gain access to the first rib and thoracic inlet. With either approach, a simultaneous posterolateral thoracotomy has been advocated for completing the upper lobectomy and nodal dissection.

Architecture of a pulmonary thrombus removed during embolectomy in a patient with acute pulmonary embolism

Anetta Undas, Ewa Stępień, Paweł Rudziński, Jerzy Sadowski — 2009-08-19

To our knowledge, thrombus structure in patients with pulmonary embolism (PE) has not been analyzed with scanning electron microscopy (SEM). We hypothesized that particular features of a pulmonary embolus explain in part a failure of thromboprophylaxis. Microscopic examination of a fresh thromboembolus from a pulmonary artery obtained at autopsy indicated that its structure is composed of layers of platelets and fibrin alternating with layers of erythrocytes. Fibrin clot architecture largely determines the fibrinolysis rate because a compact clot structure impairs the transport of endogenous proteins involved in fibrinolysis through fibrin networks. Here we describe the structure of the embolic material obtained from a patient with PE.

Pulmonary thromboendarterectomy in Klippel–Trénaunay syndrome

Jonathan N. Johnson, David J. Driscoll, Christopher G.A. McGregor — 2010-05-03

Chronic thromboembolic pulmonary hypertension (CTEPH) occurs in 4% of patients with pulmonary embolism (PE). Untreated, the likelihood of survival is poor. Klippel–Trénaunay syndrome (KTS) is a rare complex vascular malformation that typically includes the triad of capillary vascular malformation (port-wine stain), venous malformation(s), and soft tissue or bony hypertrophy. Patients with KTS are at increased risk for peripheral venous thrombosis and pulmonary emboli. When medical management of PE and CTEPH fails, pulmonary thromboendarterectomy (PTE) is an important, potentially lifesaving therapy.

Successful surgery for atrioesophageal fistula caused by transcatheter ablation of atrial fibrillation

Alexandre Cazavet, Fabrice Muscari, Marie Agnès Marachet, Bertrand Léobon — 2010-04-12

Catheter ablation (CA) is an effective and safe technique to treat atrial fibrillation; however, it can cause rare but lethal complications. Atrioesophageal fistula (AEF) caused by diffusion of the ablative energy through the left atrial wall to the esophagus (because of the absence of pericardium) is lethal if not treated surgically.

Lower graft patency after off-pump than on-pump coronary artery bypass grafting: An updated meta-analysis of randomized trials

Hisato Takagi, Masafumi Matsui, Takuya Umemoto — 2010-01-14

Our previous meta-analysis of randomized trials demonstrated a significant increase in overall graft occlusion, especially in saphenous vein graft occlusion, in off-pump coronary artery bypass grafting (CABG) compared with on-pump CABG. Since we conducted the meta-analysis, graft patency in several randomized trials has been reported. The likelihood of graft occlusion was no different between off-pump and on-pump CABG groups in a study by Angelini and associates, whereas Shroyer and collaborators revealed that the overall rate of graft patency was lower in the off-pump group than in the on-pump group. We performed an updated meta-analysis of graft patency after off-pump versus on-pump CABG from randomized trials.

Recurrent ventricular tachycardia in the postoperative period: The danger of malfunctioning epicardial pacing wires

Simon Modi, Diane Barker, Nathaniel Hawkins, Mark Hall — 2010-05-14

Ventricular arrhythmias in the postoperative period can be caused by a number of factors including ischaemia, left ventricular impairment or stunning, metabolic or mineral derangement, operative scar, and medication induced QT abnormalities. Of similar gravity, failure of postoperative epicardial pacing wires will generally leave patients either asystolic or markedly bradycardic, requiring either temporary transvenous pacing or permanent pacing. We report an unusual cause of recurrent ventricular arrhythmias secondary to epicardial pacing system malfunction.

Gastroaortic fistula: A rare and lethal complication of esophageal stenting after esophagectomy

Daniel Whitelocke, Michael Maddaus, Rafael Andrade, Jonathan D'Cunha — 2010-05-10

The use of esophageal stenting for postesophagectomy leak is increasing, with acceptable clinical results. Gastroaortic fistula is a potential highly lethal complication of stenting. To increase awareness of this potential complication, we present a case of postesophagectomy gastroaortic fistula after esophageal stenting.

Giant mycotic pseudoaneurysm of the left main coronary artery after pneumococcal pneumonia

Dimitri Kalavrouziotis, François Dagenais — 2010-03-17

Coronary artery aneurysms are mainly atherosclerotic in origin. Conversely, mycotic coronary artery aneurysms are extremely uncommon. We describe a unique case of mycotic pseudoaneurysm of the left main coronary artery after pneumococcal pneumonia.

Pleural pressure immediately after pulmonary lobectomy: Single versus double chest tubes for suction

Alessandro Brunelli, Stephen D. Cassivi, Juan Fibla, Luca Di Nunzio — 2010-05-14

Recent studies have shown that a single chest tube after pulmonary lobectomy is at least as effective as 2 chest tubes in evacuating air and fluid from the pleural space. In addition, a single tube may produce less pain and may be a more suitable option for patients being treated with fast-tracking approaches. Most surgeons still favor the use of −20 cm H2O suction in the first postoperative hours, with the theoretic aim of promoting lung expansion. This level of suction has persisted in most practices since being adapted from early thoracic drainage devices designed by Emerson in the 1940s. The benefits of chest tube suction, however, remain a topic of debate. This study investigated whether the use of 1 or 2 chest tubes after pulmonary lobectomy might influence the level of intrapleural pressure as measured in the first postoperative hours.

Deployed Edwards Sapien prosthesis is always deformed

2010-04-19

Data regarding stent geometry of the deployed Sapien prosthesis (Edwards Lifesciences, Irvine, Calif) are lacking. We report here the fluoroscopic morphologic analysis of the stent shape after implantation of this prosthesis through a retrograde transfemoral approach in high-risk surgical patients with severe symptomatic aortic stenosis.

Novel use of plasmapheresis in a patient with heparin-induced thrombocytopenia requiring urgent insertion of a left ventricular assist device under cardiopulmonary bypass

Rochus K. Voeller, Spencer J. Melby, Brett E. Grizzell, Nader Moazami — 2010-09-01

The management of heparin-induced thrombocytopenia (HIT) remains a major clinical challenge in adults requiring cardiac surgery, especially when present preoperatively. Patients with end-stage heart failure are particularly vulnerable to the development of HIT owing to their frequent and long-term exposure to heparin. We report a case in which plasmapheresis was successfully used to eliminate the circulating antiheparin platelet factor 4 (PF4) antibodies (Ab) to implant a left ventricular assist device (LVAD) under cardiopulmonary bypass (CPB) with full heparinization, as routinely performed.

Hemophagocytic syndrome: A rare but specific complication of lung transplantation

Takahiro Oto, Gregory I. Snell, Keiji Goto, Shinichiro Miyoshi — 2010-06-16

Hemophagocytic syndrome (HPS) is a rare but occasionally life-threatening complication after solid organ transplantation. This syndrome is characterized by phagocytizing histiocytes that infiltrate tissues and phagocytize blood elements and their precursors. The cause of this syndrome is unknown. The development of HPS has been associated with an uncontrolled excessive inflammatory response, and the timely initiation of potentially life-saving therapy with immunoglobulins and steroids is mandatory. Nonetheless, the reported prognosis of this syndrome remains poor. There is no published information regarding HPS in lung transplantation.

Late complete atrioventricular block and tricuspid regurgitation after percutaneous closure of a perimembranous ventricular septal defect

Huiwen Chen, Jinfen Liu, Wei Gao, Haifa Hong — 2010-07-20

Percutaneous closure of a perimembranous ventricular septal defect (VSD) is nowadays a valuable alternative to surgical closure. Preliminary results regarding the safety of this device and the low incidence of aortic and tricuspid regurgitation are encouraging. However, owing to the close proximity of the perimembranous VSD to the conduction system, concern about atrioventricular block has been raised. The published reports on this complication describe the latest onset of complete atrioventricular block (CAVB), presenting at 37.8 months after implantation. We report here 1 case of delayed CAVB with severe tricuspid regurgitation occurring 5 years after implantation of an eccentric Amplatzer perimembranous VSD occluder (APmVSDO; AGA Medical, Golden Valley, Minn).

Inducible left ventricular obstruction after apical-conduit aortic valve bypass surgery

Catherine Y. Campbell, Ashish S. Shah, Matthews Chacko — 2010-07-12

Video clip is available online.

Multiple calcified right ventricular masses presenting with pulmonary embolism and severe pulmonary hypertension

Ji-Yong Jang, Byung-Chul Chang, Chi Young Shim — 2010-06-16

Intracardiac calcified masses may represent neoplastic or nonneoplastic processes. Most cardiac neoplastic disorders are benign, such as myxomas. Nonneoplastic disorders include mural thrombi and infectious processes, such as endocarditis. We report a case of multiple calcified right ventricular masses in a young man, probably resulting from an episode of blunt chest trauma, and subsequent chronic thrombus that appeared as pulmonary embolism and severe pulmonary hypertension.

Experimental design for optimal flow rate of antegrade cerebral perfusion

Bingyang Ji, Jinping Liu, Long Cun — 2010-09-01

To the Editor: We read with great interest the recent article by Sasaki and colleagues. The purpose of this neonatal animal investigation was to determine the optimal flow rate of antegrade cerebral perfusion (ACP) during deep hypothermic circulatory arrest (DHCA). Sasaki and colleagues should be congratulated, and we believe that their study is a good attempt to use varied flow rates to filtrate the optimal flow rate of ACP during DHCA in this neonatal model.

Pseudoaneurysm of the mitral–aortic intervalvular fibrosa

Serkan Cay — 2010-09-01

To the Editor: I read with great interest the case presentation titled “Mitral–Aortic Intervalvular Fibrosa Pseudoaneurysm Resulting in the Displacement of the Left Main Coronary Artery after Aortic Valve Replacement” by Kim and Chung in this Journal. They presented the case history of a male patient with angina and previous infectious disease in whom infective endocarditis of the aortic valve developed. Then he underwent aortic valve replacement surgery with a mechanical valve. Late after surgery, angina pectoris occurred and a large pseudoaneurysm in the mitral–aortic intervalvular fibrosa (MAIVF) was identified. Compression of the left coronary system by this expanding cavity was also demonstrated with 3-dimensional magnetic resonance imaging. An open cardiac operation with a Dacron patch was performed without any complication.

The trap for researchers: Misrepresentation of data from articles

Dusko Nezic, Aleksandar Knezevic, Petar Vukovic — 2010-09-01

To the Editor: We read with great interest the reply by Benedetto and colleagues to our letter, in which we challenged the inclusion of Gaudino and associates' data in a meta-analysis (controlled, randomized trials comparing the angiographic patency of radial artery [RA] versus saphenous vein grafts [SVGs]) by Benedetto and coauthors that was recently published in the Journal. In their reply, we were criticized for misrepresentation of the data from Gaudino and colleagues' article included in their meta-analysis. The article by Gaudino and colleagues reported 2 controlled, randomized trials including patients with previous percutaneous stent implantation (in any coronary vessel) with preoperative angiographic confirmation of a failed (trial I) or patent (trial II) intracoronary stent. As the authors stated, for the purpose of their meta-analysis they included only Gaudino and colleagues' data on conduits randomly assigned to targeted obtuse marginal (OM) branches of the circumflex artery. Therefore, they stated that the Gaudino I study included RA versus SVG conduits randomly grafted to previously stented OM branches, and that the Gaudino II study included RA versus SVG conduits grafted to unstented OM branches.

Treatment of subglottic stricture

Nicholas J. Demos — 2010-09-01

To the Editor: It was a pleasure reading the article by Mercy George and colleagues in the Journal. I would like to note that the technique for treating benign subglottic stricture on pages 414 and 415 of their article was described in previously published studies.

Reply to the Editor

Mercy George, Philippe Monnier — 2010-09-01

We thank Dr Demos for his comment on our article on the management of pediatric subglottic stenosis with glottis involvement. The management of glotto-subglottic stenosis is challenging, and its surgical management, therefore, has evolved over the years with descriptions of the surgical technique and its modifications, along with the use of stents. The technique we have used in this large pediatric series is different from that described earlier by Demos and colleagues in 1969. Notably, this series is the first pediatric series of its kind. The technique combines a subglottic resection and thyrotracheal anastomosis with a posterior cricoid split and costal cartilage graft for glotto-subglottic stenoses. This operation was named “extended partial cricotracheal resection.” The LT-Mold prosthesis is also different in that it calibrates the supraglottic and glottic spaces in the abducted position of the vocal cords, while restoring a triangular shape to the glottis with a sharp anterior laryngeal commissure. All currently available stents are round or cigar shaped and do not restore a triangular glottis, especially in the case of vocal cord synechia or grade IV transglottic stenosis. The use of the LT-Mold prosthesis has significantly diminished the incidence of postoperative granulations that require repeat endoscopic/open procedures. This study was therefore a synthesis of our experience of complex pediatric glotto-subglottic stenosis that documents the evolution of the technique with an emphasis on the silicone LT-Mold.

The future of cardiac surgery

Octavio E. Pajaro — 2010-09-01

To the Editor: What is the future of cardiac surgery? This question undoubtedly brings to mind images of fancy new technology, robots, stents, lasers, and other minimally invasive or futuristic techniques. However, the real question that our specialty needs to address is this: How should cardiac surgery deal with the fact that technology changes rapidly, that the potential therapeutic options for patients increase faster than prospective trials can evaluate them, and that each year patients who undergo cardiac surgery continue to be sicker, older, and at higher risk for complications?

Is early antithrombotic therapy necessary in bioprosthetic valves?

Carlos-A. Mestres, José I. Aramendi — 2010-09-01

To the Editor: We read with great interest the contribution by ElBardissi and associates addressing a controversial issue: the need for early antithrombotic therapy in patients with tissue valves. The authors sought to determine whether this therapy was necessary in patients in sinus rhythm with a tissue valve in the aortic position. Their sample of 861 patients is large enough to conclude that early anticoagulation after isolated aortic valve replacement with a tissue valve does not reduce the risk of thromboembolism.

Reply to the Editor

Andrew W. ElBardissi, Lawrence H. Cohn — 2010-09-01

We appreciate the comments from Drs Mestres and Aramendi regarding our retrospective institutional analysis, which identified no difference in the overall incidence of thromboembolic events in patients who electively received anticoagulants after bioprosthetic aortic valve implantation. Although we identified subsets of patients that may benefit from some form of antithrombotic therapy in the immediate postoperative phase (either antiplatelet therapy or a vitamin K antagonist with a goal international normalized ratio of 2 to 3), our findings differ markedly from the American Heart Association/American College of Cardiology (AHA/ACC) and other international cardiac organizations, which recommend anticoagulation with a vitamin K antagonist for the first 90 postoperative days.

Reporting of mortality associated with pediatric and congenital cardiac surgery

Richard A. Jonas, Jeffrey P. Jacobs, Marshall L. Jacobs, Constantine Mavroudis — 2010-09-01

To the Editor: We congratulate Furck and colleagues for their excellent analysis of outcomes after the Norwood operation in patients with hypoplastic left heart syndrome, as described in their recent publication. However, we are concerned that the authors have reported the rate of mortality using a nonstandard strategy for this type of reporting. Furck and colleagues reported a 30-day mortality of 2.5% for the last 3 years. They stated that “Death after this period and until the subsequent palliative surgery, regardless of whether in or out of the hospital, was defined as interstage mortality.” They reported interstage mortality of 15%. This manner of reporting of outcomes is not consistent with standardized reporting strategies. It can be potentially misleading and can create unrealistic expectations among referring physicians, caregivers, and families.

Reply to the Editor

A.K. Furck, A. Uebing, J.H. Hansen, J. Scheewe, H.H. Kramer — 2010-09-01

We thank Jonas and his colleagues for their interest in our study and for drawing our attention to the definition of operative mortality. During the review process of the manuscript, we offered to recalculate our data on mortality of the Norwood operation according to the definition of The Society of Thoracic Surgeons Congenital Database Taskforce and the Joint EACTS–STS Congenital Database Committee, but as we gave data on both 30-day mortality and interstage mortality, we were allowed to leave the data as presented.

Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: Results from the Radial Artery Patency and Clinical Outcomes trial

Mats Dreifaldt, Domingos S. Souza, Michael Richard Dashwood — 2010-09-01

To the Editor: A recent article by Hayward and colleagues presents important data regarding the long-term patency and clinical outcome of the radial artery (RA), right internal thoracic artery (ITA), and saphenous vein (SV) when used as conduits in patients undergoing coronary artery bypass grafting. The main purpose of the authors' trial was to identify the place of the RA in the hierarchy of options available to supplement the ITA to the left anterior descending coronary artery. Patients were monitored at defined time points (mean, 5.5 years), with the results leading the authors to suggest that the RA or free ITA are equally satisfactory in younger patients and that RA and SV grafts produce similar angiographic outcomes in older patients.

Reply to the Editor

Philip A.R. Hayward, Brian F. Buxton — 2010-09-01

We thank Dreifaldt and colleagues for their interest and their comments. We are aware of their previous published experience with atraumatic harvesting of the saphenous vein and its potential effect on graft patency.

Delayed paraplegia in transition countries: Are we missing something?

Nikola Ilić, Lazar B. Davidovic, Igor Končar, Marko Dragaš, Miroslav Markovic — 2010-09-01

To the Editor: The phenomenon of delayed neurologic deficit after thoracoabdominal aortic aneurysm repair was first documented fairly recently, and it has been considered a problem of modern thoracoabdominal surgery. The incidence is somewhere between 2% and 30%, depending on the report. Estrera and colleagues made an interesting observation that although the uses of adjuncts have decreased the overall paraplegia rate, there was a paradoxically higher incidence of delayed paraplegia in patients in whom they used adjuncts compared with those who had clamp-and-sew repairs.

Reply to the Editor

Anthony L. Estrera, Charles C. Miller, Hazim J. Safi — 2010-09-01

We appreciate the interest of Ilić and colleagues in our previous work on delayed neurological injury after thoracoabdominal aneurysm (TAAA) repair. They acknowledge that paraplegia remains significant, complicating TAAA repair in as many as 30% of their cases, with 6% occurring in a delayed fashion. They suggest that without neurological monitoring, such as somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs), distal aortic perfusion (DAP) remains their primary adjunct in preventing paraplegia. As such, they suggest that by calculating the spinal collateral network pressure for each patient, the necessary DAP pressure can be determined. By maintaining this calculated distal pressure goal, optimal “spinal perfusion dynamics” can provide protection against paraplegia.

In situ right internal thoracic artery is usually long enough for grafting the circumflex artery through the transverse sinus

Marco Agrifoglio, Samer Kassem, Francesco Alamanni — 2010-09-01

To the Editor: We read with great interest the article by Hayward and colleagues about comparable patencies of the radial artery and free right internal thoracic artery (RITA) or saphenous vein at a mean of 5 to 6 years' follow-up after coronary artery bypass grafting (CABG) surgery. We congratulate the authors for their excellent results. Nonetheless, their article raises some concerns, and the conclusions should be debated.

Stroke prevention by means of left atrial appendage strangulation?

Claudia Stöllberger, Birke Schneider, Josef Finsterer — 2010-09-01

To the Editor: With great interest we read the article by McCarthy and colleagues about occlusion of canine atrial appendages with an expandable silicone band. Performing a thoracoscopy, they occluded the right atrial appendage (RAA) and left atrial appendage (LAA) with silicone bands in 15 healthy dogs. The dogs were killed 1, 2, and 12 weeks after the procedure and investigated pathoanatomically. The appendages were 100% occluded, and there was no migration of any bands. There was no bleeding, rupture, or systemic emboli. After occlusion, the appendages became necrotic and were replaced by scar tissue. It is concluded that band occlusion of the LAA could improve outcomes in patients with high risk of atrial thrombus formation. We have the following questions and concerns.

Meetings and Courses

2010-09-01

The 5th International Meeting of the Onassis Cardiac Surgery Center: Current Trends in Cardiac Surgery and Cardiology will be held September 16-18, 2010 (NOTE DATE CHANGE) at the Eugenides Foundation Congress Center, Athens, Greece. For information, contact: Liana Iliopoulou, Triaena Tours & Congress, 206 Sygrou Avenue, 176 72 Athens (Kallithea) (telephone: +30 210 7499353; Fax: +30 210 7705752; E-mail: lianae@triaenatours.gr). Additional information: http://www.ocsc2010.gr/

The 91st AATS Annual Meeting

2010-09-01

May 7–11, 2011 Pennsylvania Convention Center

AATS Applications for Membership Now Available Online

2010-09-01

Applications for membership in the Association are now available online at www.aats.org. Interested applicants are encouraged to review the membership requirements and guidelines on the AATS Web site.

AATS Meetings and Sponsored Events www.aats.org

2010-09-01

September 21–25, 2010 TCT for Surgeons∗

2010 Heart Valve Summit: Medical, Surgical, and Interventional Decision Making

2010-09-01

October 7–9, 2010 Chicago Marriott Downtown Magnificent Mile

Applications for Membership

2010-09-01

Applications for membership in the Association must be received by the Membership Committee Chair no later than March 1, 2011, to be considered at the 2011 Annual Meeting. Applicants must be sponsored by three members of the Association who are not members of the Membership Committee. Application forms will be issued only to sponsoring members.

WTSA 37th Annual Meeting

2010-09-01

Save the Date! June 22–25, 2011

Notices

2010-09-01

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

2010-09-01

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.

Condensed Contents

2010-09-01

JTCVS Disclosure Statement

2010-09-01

Information for Readers

2010-09-01