The Journal of Thoracic and Cardiovascular Surgery

The state of the Journal: A critique by the Editor

Lawrence H. Cohn — 2012-02-01

As I write this editorial, we are coming to the end of 2011 and looking forward to a happy, healthy, and productive 2012. The past year has seen some new developments in the Journal of Thoracic and Cardiovascular Surgery, which we believe has not only enhanced the quality of the JTCVS but also the entire profession of cardiothoracic surgery. No better example is the Cardiothoracic Surgical Education and Training section introduced in May 2011 under the capable direction of Ara Vaporciyan. Education and training at the resident and postgraduate level are crucial to the future of our specialty especially with reduced work hours. The purpose of this section is to highlight articles central to the evolution of thoracic and cardiovascular surgery as it relates to education and training, including the expanding interest in prospective randomized studies. As my mentor Dr Shumay used to say, “Nothing ever stays the same” and I believe this section is an important adjunct to that theory.

Historical perspectives of The American Association for Thoracic Surgery: Alfred Blalock (1899–1964)

Claude A. Beaty, Timothy J. George, John V. Conte — 2012-02-01

Alfred Blalock, the 30th president of The American Association for Thoracic Surgery (AATS), was born on April 5, 1899, in the small town of Culloden, Georgia. Located in Monroe County in central Georgia, Culloden is approximately 0.8 square miles in size and, according to the United States Census of 1900, had a population of 334. Blalock was the eldest of 5 children born to George Z. Blalock and Martha (Davis) Blalock. The elder Blalock was a merchant and the owner of a cotton plantation. Often referenced as a firm disciplinarian, Blalock’s father placed a significant value on education. According to his sister, Alfred would “…rather [his] mother use the hairbrush on him than [his] father look at him hard.” When Alfred was a youth, the family moved to nearby Jonesboro owing to his father’s fading health. There, Alfred excelled in academics and athletics. At 14 years of age, he was granted admission to the senior class at the Georgia Military College of Milledgeville, a preparatory school for the University of Georgia. In 1915, he was admitted to the University of Georgia as a sophomore, bypassing the freshman year. Blalock continued to do well, although admittedly not excessively diligent in his studies. His grades were acceptable, but he had many outside interests. He played tennis, was a member of many organizations and societies, and was both the secretary and treasurer of his senior class. In his senior year he became enamored with the field of medicine, and with the help of an endorsement from his zoology professor, Dr John Campbell, Blalock applied and was accepted to the Johns Hopkins University School of Medicine after receiving his Bachelor of Arts degree in 1918.

Evaluation of simulation training in cardiothoracic surgery: The Senior Tour perspective

2011-11-11

Objective: The study objective was to introduce senior surgeons, referred to as members of the “Senior Tour,” to simulation-based learning and evaluate ongoing simulation efforts in cardiothoracic surgery.Methods: Thirteen senior cardiothoracic surgeons participated in a 2½-day Senior Tour Meeting. Of 12 simulators, each participant focused on 6 cardiac (small vessel anastomosis, aortic cannulation, cardiopulmonary bypass, aortic valve replacement, mitral valve repair, and aortic root replacement) or 6 thoracic surgical simulators (hilar dissection, esophageal anastomosis, rigid bronchoscopy, video-assisted thoracoscopic surgery lobectomy, tracheal resection, and sleeve resection). The participants provided critical feedback regarding the realism and utility of the simulators, which served as the basis for a composite assessment of the simulators.Results: All participants acknowledged that simulation may not provide a wholly immersive experience. For small vessel anastomosis, the portable chest model is less realistic compared with the porcine model, but is valuable in teaching anastomosis mechanics. The aortic cannulation model allows multiple cannulations and can serve as a thoracic aortic surgery model. The cardiopulmonary bypass simulator provides crisis management experience. The porcine aortic valve replacement, mitral valve annuloplasty, and aortic root models are realistic and permit standardized training. The hilar dissection model is subject to variability of porcine anatomy and fragility of the vascular structures. The realistic esophageal anastomosis simulator presents various approaches to esophageal anastomosis. The exercise associated with the rigid bronchoscopy model is brief, and adding additional procedures should be considered. The tracheal resection, sleeve resection, and video-assisted thoracoscopic surgery lobectomy models are highly realistic and simulate advanced maneuvers.Conclusions: By providing the necessary tools, such as task trainers and assessment instruments, the Senior Tour may be one means to enhance simulation-based learning in cardiothoracic surgery. The Senior Tour members can provide regular programmatic evaluation and critical analyses to ensure that proposed simulators are of educational value.

Trends in isolated coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons adult cardiac surgery database

2012-02-01

Objective: Coronary artery bypass grafting (CABG) is the operation most commonly performed by cardiac surgeons. There are few contemporary data examining evolving patient characteristics and surgical outcomes of isolated CABG. We used the Society of Thoracic Surgeons adult cardiac surgery database to characterize trends in patient characteristics and outcomes after CABG over the past decade.Methods: From 2000 to 2009, 1,497,254 patients underwent isolated primary CABG at Society of Thoracic Surgeons participating institutions. Demographics, operative characteristics, and postoperative outcomes were assessed, and risk-adjusted outcomes were calculated.Results: Compared with the year 2000, patients undergoing isolated primary CABG in 2009 were more likely to have diabetes mellitus (33% vs 40%) and hypertension (71% vs 85%). There were clinically insignificant differences in age, gender, and body surface area. Between 2000 and 2009, there has been a 6.3% and 19.5% increase in the preoperative use of aspirin and beta-blockers, respectively. Between 2004 and 2009, there was a 7.8% increase in the use of angiotension-converting enzyme inhibitors preoperatively. Furthermore, between 2005 and 2009 there was a 3.8% increase in the use of statins preoperatively. The median number of distal anastomoses performed was unchanged between 2000 and 2009 (3; interquartile range, 2–4). There was a significant increase in the use of the internal thoracic artery (88% in 2000 vs 95% in 2009). The predicted mortality rates of 2.3% were consistent between 2000 and 2009. The observed mortality rate over this period declined from 2.4% in 2000 to 1.9% in 2009 representing a relative risk reduction of 24.4%. The incidence of postoperative stroke decreased significantly from 1.6% to 1.2%, representing a risk reduction of 26.4%. There was also a 9.2% relative reduction in the risk of reoperation for bleeding and a 32.9% relative risk reduction in the incidence of sternal wound infection.Conclusions: Over the past decade, the risk profile of patients undergoing CABG has changed, with fewer smokers, more diabetic patients, and better medical therapy characterizing patients referred for surgical coronary revascularization. The left internal thoracic artery is nearly universally used and outcomes have improved substantially, with a significant decline in postoperative mortality and morbidity.

Discussion

2012-02-01

Dr T. Bruce Ferguson (Greenville, NC). This nice analysis of major patient risk factor observational processes and outcomes compared between 2000 and 2009 (>1.4 million patients) is an excellent update. They did a nice job of handling different versions of the STS database data in their trends over time analysis. The study clearly documented continued improvement in CABG outcomes, particularly in the CABG PCI era of the last decade.

Long-term implications of emergency versus elective proximal aortic surgery in patients with Marfan syndrome in the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Consortium Registry

2011-11-21

Objective: Patients with Marfan syndrome with aortic root aneurysms undergo elective aortic root replacement to avoid the life-threatening outcomes of aortic dissection and emergency repair. The long-term implications of failed aortic surveillance leading to acute dissection and emergency repair are poorly defined. We compared the long-term clinical courses of patients with Marfan syndrome who survive emergency versus elective proximal aortic surgery.Methods: The Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Registry is a National Institutes of Health–funded multicenter database and biorepository that enrolls patients with genetically triggered thoracic aortic aneurysms. Of the 635 patients with Marfan syndrome enrolled as of March 2011, 194 had undergone proximal aortic replacement. Patients were grouped according to emergency (n = 47) or elective (n = 147) status at the time of surgery.Results: Patients in the emergency group were more likely to have incomplete proximal aortic resection; 83% of emergency procedures included aortic root replacement, compared with 95% of elective procedures. At long-term follow-up (mean, >6 years), the emergency group had a higher incidence of chronic dissection of the distal aorta and significantly larger diameters in distal aortic segments than elective patients. Patients in the emergency group had undergone more operations (1.31 vs 1.11 procedures/patient; P = .01) and had lower activity scores on a health-related quality of life survey.Conclusions: For patients with Marfan syndrome, failed aortic surveillance and consequent emergency dissection repair have important long-term implications with regard to the status of the distal aorta, need for multiple procedures, and quality of life. These findings emphasize the importance of aortic surveillance and timely elective aortic root aneurysm repair for patients with Marfan syndrome.

Quality, not volume, determines outcome of coronary artery bypass surgery in a university-based community hospital network

2011-11-21

Objectives: The present study examined the relationship between hospital and surgeon coronary artery bypass grafting procedural volume, mortality, morbidity, and National Quality Forum care processes in a university-based community hospital quality improvement program.Methods: The study population consisted of 2218 consecutive patients undergoing isolated coronary artery bypass grafting from 2007 to 2009 in a university-based quality improvement program that emphasizes involvement of all surgeons in the academic quality endeavor. The endpoints included operative mortality, major morbidity, and National Quality Forum-endorsed process measures as defined by the Society of Thoracic Surgeons. The procedural volume was analyzed as a categorical and continuous variable using general estimating equations, which accounted for clustering effects and which were adjusted for Society of Thoracic Surgeons risk scores and the propensity for operation in a low- versus high-volume program.Results: The annual program volume ranged from 67 to 292 (median, 136; interquartile range, 88–224) and surgeon volume from 1 to 124 (median, 58; interquartile range, 30–89). The mortality rate among the hospitals was 0.47% to 2.23% (0.8% overall), and the observed/expected mortality ranged from 0 to 1.20 (0.41 overall). When comparing low-volume (<200 cases/year) and high-volume centers, no difference was found in the mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.46–2.54, P = .85), morbidity (OR, 1.34; 95% CI, 0.73–2.43), or any of the medication process measures. No difference was found in mortality (OR, 1.59; 95% CI, 0.81–3.13; P = .18), morbidity (OR, 1.20; 95% CI, 0.86–1.66; P = .28), or medication failure (OR, 0.57, 95% CI, 0.3–1.10; P = .10) between the high- and low-volume surgeons (<87). After adjustment for both the Society of Thoracic Surgeons risk score and the propensity score, no association was found for either hospital or surgeon volume with mortality or morbidity. However, a lack of compliance with National Quality Forum measures was highly predictive of morbidity (OR, 1.51; 95% CI, 1.18–1.93; P = .001), regardless of volume, even after adjustment for predicted risk.Conclusions: In the setting of a university-based community hospital quality improvement program, excellent surgical results can consistently be obtained even in relatively low-volume programs. The surgical outcomes were not associated with program or surgeon volume, but were directly correlated with the focus on quality as manifested by compliance with evidence-based quality standards. Meaningful university affiliation might represent a new quality paradigm for cardiac surgery in the community hospital setting.

Discussion

2011-11-21

Dr Thoralf Sundt (Boston, Mass). Thanks, Paul, beautifully presented, and I would like to say thanks for getting your slides and your manuscript to me much earlier than I ever do for my invited discussants.

Valve-sparing aortic root repair without down-sizing of the annulus

Paul P. Urbanski, Xiaochun Zhan, Husam Hijazi, Michael Zacher, Anno Diegeler — 2011-11-21

Objectives: The study was conducted to evaluate the intermediate results after patient-tailored aortic root repair with replacement of isolated sinuses adjusted to the existing aortic annulus diameter rather than annulus downsizing.Methods: Between 2000 and 2009, 236 patients with aortic root disease underwent patient-tailored restoration of the aortic root according to its anatomopathologic condition with repair of 1, 2, or all 3 sinuses in 73, 94, and 69 patients, respectively. Concomitant cusp repair was performed in 106 patients. Insufficiency grades of 0/1+, 2+, 3+, and 4+ were presented in 59, 74, 74, and 29 patients, respectively. All data were collected prospectively and intention-to-treat analysis was performed.Results: Valve repair was successful in all but 6 patients. At the most recent clinical and echocardiographic follow-up of the remaining patients, which averaged 43 ± 24 months (range, 0.3-115 months), 216 patients showed no or slight aortic regurgitation (grade 0/1+) and 10 patients showed grade 2+. Another 4 patients had grade 3+ regurgitation and underwent aortic valve replacement. The actuarial freedom from aortic regurgitation grade 3+ or more at 8 years was 95.2%. Multivariate logistic regression analysis identified cusp repair as the independent risk factor for an aortic regurgitation grade of 2+ or more with an odds ratio of 10.9 (95% confidence interval, 2.5-47.7; P = .002). The association between aortic annulus size and functional results after repair could not be demonstrated.Conclusions: Aortic root repair with replacement of isolated sinuses adjusted to the existing aortic annulus leads to excellent, durable results and can be recommended. Cusp disease is a leading aspect affecting functional results of repair. Therefore, establishment of reproducible cusp repair techniques is of utmost importance for further development of reconstructive aortic valve surgery.

Discussion

2011-11-21

Dr Tirone E. David (Toronto, Ontario, Canada). I have no conflicts to disclose. I commend you, Paul, for these excellent clinical outcomes in patients with a variety of proximal aortic aneurysms with and without aortic insufficiency. Contrary to what your second slide showed, isolated aneurysms of the aortic sinuses do not cause aortic insufficiency. Aortic insufficiency is obviously caused by cusp disease, annular dilatation, and/or sinotubular junction dilation. Isolated sinus of Valsalva aneurysm causes no aortic valve dysfunction.

Expanding the indications for septal myectomy in patients with hypertrophic cardiomyopathy: Results of operation in patients with latent obstruction

2011-12-12

Objective: Many patients with symptomatic hypertrophic cardiomyopathy have minimal left ventricular outflow tract gradients, and there is uncertainty whether their limitation is due to diastolic dysfunction or labile outflow tract obstruction. The purpose of this study was to characterize the clinical presentation and outcome of septal myectomy in patients with hypertrophic cardiomyopathy and latent obstruction.Methods: Among 749 patients who underwent septal myectomy, 249 had latent obstruction with minimal (0–30 mm Hg) resting gradients preoperatively. All were symptomatic and had more severe left ventricular outflow tract obstruction provoked by Valsalva maneuver or amyl nitrite inhalation during Doppler echocardiography or by stimulation with isoproterenol during catheterization. Clinical characteristics, survival, and functional outcome of these patients were compared with those of 500 patients with more severe resting left ventricular outflow tract obstruction who underwent myectomy during the same period.Results: Compared with those with severe obstruction, more patients with latent obstruction were male (63% vs 52%, P < .003), but ages were similar (53 ± 14 years vs 52 ± 15 years). Preoperative symptoms and functional limitation were similar in the 2 groups with 86% and 85%, respectively, having New York Heart Association class III or IV disability. Among patients with latent obstruction, mixed venous oxygen saturation was 61.6% ± 19.0% of predicted compared with 56.8% ± 17.3% for those with severe resting obstruction (P < .008). Septal thickness was less in patients with latent obstruction (20 ± 9 mm vs 22 ± 15 mm, P < .001). Early mortality was 1% in each group, and survival at 5 and 10 years was 93% and 87%, respectively, for patients with latent obstruction compared with 93% and 74%, respectively, for patients with severe resting obstruction preoperatively (P = .34). Self-reported late functional status was similar; 3 to 5 years postoperatively, 81% of patients with latent obstruction preoperatively were in New York Heart Association class I or II compared with 77% of patients with severe resting obstruction.Conclusions: Patients with obstructive hypertrophic cardiomyopathy who have low resting gradients and latent obstruction may have limiting symptoms comparable to those of patients with more severe resting gradients. Septal myectomy should be offered to these patients because survival and symptom relief are excellent, suggesting that dynamic obstruction is the major hemodynamic problem rather than diastolic dysfunction.

Discussion

2011-12-12

Dr Ralph Damiano (St. Louis, Mo). Dr Schaff, I congratulate you and your coauthors on an important contribution. This is a landmark report that will have a significant impact on the clinical management of patients with symptomatic HCM.

Beyond the short-term: Clinical outcome and valve performance 2 years after transcatheter aortic valve implantation in 227 patients

2011-12-05

Objective: Although the procedural feasibility of transcatheter aortic valve implantation has been shown by multiple groups, longer-term data are rare. We report on 2-year follow-up clinical and echocardiographic results after transcatheter aortic valve implantation in 227 patients.Methods: Patients’ mean age was 81 ± 7 years, 59% were female, mean European System for Cardiac Operative Risk Evaluation was 21% ± 14%, mean Society of Thoracic Surgeons score was 7% ± 5%, and access routes were transfemoral (n = 164), transapical (n = 54), axillary (n = 5), or transaortic (n = 4). A CoreValve (Medtronic Inc, Minneapolis, Minn) prosthesis was implanted in 174 patients, and a SAPIEN prosthesis (Edwards Lifesciences, Irvine, Calif) was implanted in 53 patients. Clinical and echocardiographic investigations were performed at 6 months, 1 year, and 2 years.Results: Survival was 88.5% at 30 days, 75.9% at 6 months, 74.5% at 1 year, and 64.4% at 2 years. Patients improved significantly in New York Heart Association class after 6 months (from 3.2 ± 0.5 to 1.7 ± 0.7, P < .001) and up to 2 years (1.9 ± 0.7). Cumulative incidences of myocardial infarction, stroke, and life-threatening or major bleeding were 2.7%, 6.2%, and 16.2% at 2 years, respectively. The postprocedural mean transprosthetic gradient was 12 ± 4 mm Hg for all valves and did not change up to 2 years, and the effective orifice area was 1.5 ± 0.4 cm² with no change over 2 years of follow-up. Moderate or severe prosthetic regurgitation was present in 8% of patients at 2 years. In 6% of patients, the paravalvular or valvular regurgitation grade increased significantly over time.Conclusions: With excellent functional recovery of the patients, good systolic valve function, and overall low morbidity at 2 years, transcatheter aortic valve implantation may be considered the treatment of choice for aortic valve stenosis in elderly patients with an increased risk for surgery with a heart–lung machine.

Discussion

2011-12-05

Dr Gregory Fontana (Los Angeles, Calif). Dr Bleiziffer, your program in Munich is unique in that this is one of the largest TAVI experiences in the world but includes both the balloon-expandable and self-expanding devices, and, arguably, the most surgeon-driven program that I am aware of. Drs. Bleiziffer and Lange work as surgeons with all access approaches along with their cardiologists as primary operators and should serve as a model for other surgical programs.

Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized controlled trial

2011-12-05

Objective: The purpose of this study was to test the hypothesis that a liberal blood glucose strategy (121–180 mg/dL) is not inferior to a strict blood glucose strategy (90–120 mg/dL) for outcomes in patients after first-time isolated coronary artery bypass grafting and is superior for glucose control and target blood glucose management.Methods: A total of 189 patients undergoing coronary artery bypass grafting were investigated in this prospective randomized study to compare 2 glucose control strategies on patient perioperative outcomes. Three methods of analyses (intention to treat, completer, and per protocol) were conducted. Observed power was robust (>80%) for significant results.Results: The groups were similar on preoperative hemoglobin A1c and number of diabetic patients. The liberal group was found to be noninferior to the strict group for perioperative complications and superior on glucose control and target range management. The liberal group had significantly fewer patients with hypoglycemic events (<60 mg/dL; P < .001), but severe hypoglycemic events (<40 mg/dL) were rare and no group differences were found (P = .23). These results were found with all 3 methods of analysis except for blood glucose variability, maximum blood glucose, and perioperative atrial fibrillation.Conclusions: This study demonstrated that maintenance of blood glucose in a liberal range after coronary artery bypass grafting led to similar outcomes compared with a strict target range and was superior in glucose control and target range management. On the basis of the results of this study, a target blood glucose range of 121 to 180 mg/dL is recommended for patients after coronary artery bypass grafting as advocated by the Society of Thoracic Surgeons.

Discussion

2011-12-05

Dr Harold Lazar (Boston, Mass). I enjoyed your presentation and appreciate you sending me the manuscript well ahead of time. My only conflict is that I have received grant support from the Eli Lilly Company to study the effects of glycemic control during cardiac surgery.

Transapical aortic valve implantation at 3 years

2011-07-04

Objective: Our objective was to analyze the results of transapical aortic valve implantation in high-risk patients with aortic stenosis at up to 3 years after the procedure.Methods: A total of 299 patients underwent transapical aortic valve implantation from February 2006 until January 2010 using the Edwards SAPIEN transcatheter xenograft. Mean patient age was 82 ± 6 years and 70% were female. Logistic EuroSCORE and Society of Thoracic Surgeons score predicted risks for mortality were 31% ± 16% and 12% ± 8%, respectively. All patients were treated in a hybrid operative theater by a team of anesthetists, cardiologists and cardiac surgeons.Results: Successful valve implantation was performed in all patients. Transapical aortic valve implantation was uneventful in 267 patients (89.3%), whereas 32 patients (10.7%) required additional interventions. Such interventions included cardiopulmonary bypass support in 18, implantation of a second SAPIEN valve in 15, coronary intervention in 9, conversion to conventional surgery in 6, and annulus perforation in 3 patients (not mutually exclusive). Intraprocedural stroke was not observed in any patient, although 2 (0.7%) patients had a delayed stroke during their hospital stay. Overall survival was 91% at 30 days, 73% at 1 year, 68% at 2 years, and 58% at 3 years.Conclusions: Transapical aortic valve implantation can be performed with good outcomes in high-risk patients with aortic stenosis. Perioperative complications occur in approximately 10% of patients, and a variety of interventions are required for these events. We believe a team approach is therefore essential for the success of transapical aortic valve implantation

Surgical management of aortic root abscess: A 13-year experience in 172 patients with 100% follow-up

2011-07-04

Objective: The study objective was to evaluate the outcomes of surgery for active infective endocarditis with aortic root abscess formation.Methods: Between July 1996 and June 2009, 1161 patients underwent operation for aortic valve endocarditis, of whom 172 had aortic root abscess. The infected valve was native in 96 patients and prosthetic in 76 patients. Patients’ mean age (± standard deviation) and logistic EuroSCORE-predicted risk of mortality were 62 ± 13 years and 23.1% ± 26%, respectively. Surgery was emergent in 96 patients (58%). The abscess involved the aortic annulus in 90 patients (52%), the intervalvular fibrous body in 81 patients (47%), and the mitral annulus in 21 patients (12%). Surgery consisted of radical resection of the abscess, reconstruction of the annulus with patches, and valve replacement. Estimated mean follow-up was 4.0 ± 0.3 years (range, 0–8.2 years).Results: Thirty-day mortality was 25% (n = 43) (prosthetic valve endocarditis vs native valve endocarditis, 35.5% vs 16.7%, P = .005). Independent predictors of mortality were sepsis (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.2–10.7), renal insufficiency (OR, 3.3; 95% CI, 1.1–9.5), concomitant coronary artery bypass grafting (OR, 2.8; 95% CI, 1.1–7.0), and prosthetic valve endocarditis (OR, 2.4; 95% CI, 1.1–5.6). Survival at 1 and 5 years was 55% ± 4% and 50% ± 4%, respectively, and predicted by concomitant mitral endocarditis (OR, 3.2; 95% CI, 1.3–8.2), sepsis (OR, 2.7; 95% CI, 1.6–4.5), renal insufficiency (OR, 1.9; 95% CI, 1.1–3.4), and age (OR, 1.05; 95% CI, 1.02–1.07). Endocarditis recurred in 15 patients (8.7%) at a mean of 1.8 ± 2.4 years postoperatively (39 days to 6 years).Conclusions: The surgical treatment of aortic root abscess remains a challenge with relatively high perioperative morbidity and mortality, although long-term survival is satisfactory.

Outcome after repair of atrioventricular septal defect with tetralogy of Fallot

2011-08-22

Background: Long-term outcomes of repair of tetralogy of Fallot associated with complete atrioventricular septal defect are seldom reported. We report our survival and reintervention outcomes over a 29-year time period.Methods: Between March 1979 and April 2008, 61 patients with the combined cardiac defect of atrioventricular septal defect and tetralogy of Fallot were surgically managed. Trisomy 21 was present in 49 (80%) patients. Primary repair was performed in 36 patients at a median age of 9 months (range, 1 month to 16 years), whereas 25 patients had initial palliation by systemic–pulmonary shunt at a median age of 21 months (range, 0 days to 36 years). Thirty-one (51%) patients had a transannular patch. Fifty-three patients required right ventriculotomy for relief of the right ventricular outflow tract obstruction. Four patients had a right ventricle–pulmonary artery conduit with a homograft. Relationships between patient characteristics and outcome variables were examined using Kaplan-Meier survival curves; comparisons were performed using the log–rank test.Results: Median follow-up was 4.7 years. A total of 12 patients died during the course of follow-up: 4 (7%)deaths within 30 days of surgery and 8 late deaths (range, 4 months to 9.9 years after repair). Since 2000, there have been no early deaths and 1 late death, 5 months after the operation. The estimated survival at 5 years after definitive repair was 82% (95% confidence interval, 69%, 90%). Time to death was not associated with any patient or surgical variables examined. Overall, 30% of the survivors required a reoperation. The type of reoperations was on the mitral valve (4 repairs, 4 replacements) and 7 pulmonary valve replacements. We did not find an effect of era on mortality (P = .23 for comparison of 1979-1989, 1990-1999, and 2000-2008). The percentage of patients with primary repair did not change during the different quartiles. The estimated freedom from reoperation at 5 years was 80% (65%, 90%). Time to reoperation was shorter for patients with a conduit (P = .01).Conclusions: Excellent long-term survival was achieved after repair of tetralogy of Fallot associated with complete atrioventricular septal defect. Palliation and primary repair resulted in comparable outcomes; as such, primary repair is favored. The choice of right ventricular outflow tract reconstruction affects the need for reoperation.

A decade of pediatric mechanical circulatory support before and after cardiac transplantation

2011-12-06

Objectives: We reviewed the use of pediatric mechanical circulatory support before and after transplantation to examinine current results and future strategies.Methods: All patients listed for transplantation from January 2000 to December 2010 who required either extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) support before (“intention to transplant”) or after transplantation were included. Indications for mechanical assistance, age, weight, duration of support, complications while on support, causes of death, and overall actuarial survival were recorded.Results: Thirty-seven patients were received VADs; 32 (86.5%) survived to transplantation. Postoperative hemorrhagic or thrombotic complications affected all of those under 15 kg. One patient in the survivor cohort demonstrated focal neurologic findings. Three (8.1%) had panel reactive antibody levels of 10% or more while on device support; all received transplants. ECMO as an intention to bridge to transplantation was used in 28 patients; 7 died, 7 were weaned, and 14 were bridged to transplantation. Nineteen patients required ECMO after transplantation; 3 additional patients had percutaneous VAD support for late rejection. There was a significant (P = .02) difference in survival after listing for transplantation among those supported with ECMO, with VAD, and those not supported with a device. No difference in posttransplant survival was demonstrated between those patients supported with either ECMO or VAD before transplant compared with all others not bridged to transplantation.Conclusions: Both VAD and ECMO support are highly effective means of bridging patients to transplantation and supporting patients after transplanatation. Ideally, the availability of smaller devices for children will have a favorable impact on the morbidity related to anticoagulation in the smallest patients.

Discussion

2011-12-06

Dr J. William Gaynor (Philadelphia, Pa). I congratulate Dr Chen and his co–investigators on a very interesting presentation and thank them for allowing me to review the manuscript.

Younger age and valve oversizing are predictors of structural valve deterioration after pulmonary valve replacement in patients with tetralogy of Fallot

2011-12-09

Objective: We sought to identify predictors of structural valve deterioration after pulmonary valve replacement in patients with tetralogy of Fallot.Methods: A retrospective review of 227 patients with tetralogy of Fallot who underwent stented bioprosthetic pulmonary valve replacement at Children’s Hospital Boston between 1994 and 2009 was performed. Patient and valve characteristics were assessed as potential predictors of structural valve deterioration by using univariate and multivariable analysis. Freedom from pulmonary valve reintervention and structural valve deterioration were determined by using Kaplan–Meier analysis.Results: Two hundred twenty-nine pulmonary valve replacement operations were performed, with no early mortalities. Freedom from reintervention and structural valve deterioration were 94% (95% confidence interval, 87%–100%) and 74% (95% confidence interval, 63%–85%) at 5 years, respectively, and median time to reintervention was 6.4 years (range, 2–10.1 years). Younger age and higher indexed valve internal diameter were predictors of reduced time to structural valve deterioration. Among patients aged less than 20 years at the time of pulmonary valve replacement, indexed valve internal diameter was a significant predictor of increased risk of structural valve deterioration. Valve manufacturer was not a significant predictor of structural valve deterioration.Conclusions: Younger age at the time of pulmonary valve replacement and valve oversizing in patients less than 20 years of age at the time of pulmonary valve replacement were significant predictors of structural valve deterioration and could potentially affect the timing of pulmonary valve replacement and the extent of valve oversizing in small children. No statistically significant difference in valve performance was seen between bioprosthetic valve types at short-term follow-up.

Discussion

2011-12-09

Dr Carl L. Backer (Chicago, Ill). I want to congratulate Dr Chen and his colleagues from Children's Hospital of Boston on their outstanding results with PVR in children and young adults with repaired TOF. A total of 229 operations with no mortality and no significant morbidity is truly a notable achievement.

The impact of additional epicardial imaging to transesophageal echocardiography on intraoperative detection of residual lesions in congenital heart surgery

2011-07-13

Objective: Transesophageal echocardiography is the primary intraoperative imaging modality used to evaluate cardiac surgery. Its predecessor, epicardial echocardiography, enables visualization of certain cardiovascular structures that are beyond the visual scope of transesophageal echocardiography. We review the current use of epicardial echocardiography to analyze its contemporary application and benefit.Methods: A retrospective review of the intraoperative echocardiograms of 1204 children undergoing bypass cardiovascular surgery between January 2007 and December 2009 was performed. The incidence of epicardial echocardiography use, intraoperative revisions, and early reinterventions were analyzed.Results: Epicardial echocardiography was performed in 7.9% of all intraoperative studies: epicardial echocardiography alone (n = 38) and transesophageal echocardiography + epicardial echocardiography (n = 57). Epicardial echocardiography alone was performed in patients with contraindications for transesophageal echocardiography. In the transesophageal echocardiography + epicardial echocardiography group, indications to obtain additional information by epicardial echocardiography were for the assessment of branch pulmonary arteries (40%), coronary arteries (28%), aortic arch/Blalock–Taussig shunt (14%), Glenn/Fontan circuit (9%), pulmonary veins/baffles (7%), and residual ventricular septal defects (1.7%). The overall intraoperative surgical revision incidence was 10.2%, consisting of 21% of the transesophageal echocardiography + epicardial echocardiography group, 5.3% of the epicardial echocardiography alone group (P = .01), and 9.8% of transesophageal echocardiography alone group (P = .02). Intraoperative revisions indicated after epicardial echocardiography were mostly related to extracardiac structures (77%), whereas they were mostly related to intracardiac structures in the transesophageal echocardiography alone group (80.7%) (P = .0002). Early reintervention was indicated mostly for pulmonary artery and Glenn obstructions, the majority (75%) with previously known stenosis or interventions on the pulmonary arteries.Conclusions: Epicardial echocardiography detects residual intraoperative lesions not visualized by transesophageal echocardiography, most frequently related to pulmonary arteries. Its use, in addition to standard transesophageal echocardiography, may decrease the need for early reintervention.

Congenital heart surgery in infants: Effects of acute kidney injury on outcomes

2011-07-28

Objectives: We sought to characterize factors and outcomes associated with postoperative acute kidney injury in infants undergoing cardiac surgery.Methods: We retrospectively studied 430 infants (<90 days) who underwent heart surgery for congenital defects. With a pediatric modified version of the Acute Kidney Injury Network classification, we performed statistical analyses to detect factors and outcomes associated with postoperative acute kidney injury.Results: Postoperative acute kidney injury occurred in 225 patients (52%): 135 patients (31%) reached maximum acute kidney injury stage I, 59 (14%) reached stage II, and 31 (7%) reached stage III. On multivariable analysis, single-ventricle status (odds ratio, 1.6; 95% confidence interval, 1.08–2.37; P = .02), cardiopulmonary bypass (odds ratio, 1.2; 95% confidence interval 1.01–1.47; P = .04), and higher reference serum creatinine (odds ratio, 5.1; 95% confidence interval, 1.94–13.2; P = .0009) were associated with postoperative acute kidney injury. Thirty-two (7%) patients died in the hospital. Multivariable logistic regression showed that more severe acute kidney injury was associated with in-hospital mortality (maximum acute kidney injury stage II odds ratio, 5.1; 95% confidence interval, 1.7–15.2; P = .004; maximum acute kidney injury stage III odds ratio, 9.46; 95% confidence interval, 2.91–30.7; P = .0002) and longer mechanical ventilation and inotropic support. All acute kidney injury stages were associated with longer intensive care durations. Stage III acute kidney injury was associated with systemic ventricular dysfunction at hospital discharge.Conclusions: Perioperative acute kidney injury is common in infant heart surgery and portends a poor clinical outcome.

Increasing duration of circulatory arrest, but not antegrade cerebral perfusion, prolongs postoperative recovery after neonatal cardiac surgery

2011-09-09

Objective: Deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) are 2 cardiopulmonary bypass techniques applied in aortic arch repair. In recent literature, cerebral effects of both techniques have received most attention, whereas the consequences for other organs have not been thoroughly investigated. Therefore, in this study, the impact of duration of DHCA and ACP on postoperative recovery was analyzed in a cohort of neonates undergoing aortic arch reconstruction.Methods: All consecutive neonates who underwent aortic arch reconstruction from 2004 to 2009 were included in this retrospective study. Length of stay on the intensive care unit (ICU-LOS), duration of mechanical ventilation, inotrope score, and areas under the curve (AUC) for lactate and creatinine were compared with respect to durations of DHCA and ACP, respectively. Correction for confounders was performed using multivariable linear regression.Results: Eighty-three neonates were included, with a 30-day mortality of 4.8%. Longer duration of DHCA was associated with longer ICU-LOS both in univariable and multivariable analyses. Similarly, duration of mechanical ventilation and lactate and creatinine AUCs increased with duration of DHCA. Inotrope score was only associated with DHCA duration in univariable analysis. Duration of ACP did not affect any of the outcome parameters.Conclusions: Increasing duration of DHCA, but not ACP, during neonatal aortic arch reconstruction prolongs short-term postoperative recovery. This suggests all efforts should be made to reduce the duration of DHCA to the shortest period possible, which may be achieved by exclusive use of ACP or a combination of the 2 perfusion techniques.

Robotic lobectomy for non–small cell lung cancer (NSCLC): Long-term oncologic results

2011-11-21

Objective(s): We evaluated a large series of patients undergoing robotic lobectomy for the treatment of early-stage non–small cell lung cancer (NSCLC) to assess long-term oncologic efficacy.Methods: A multi-institutional retrospective review of patients undergoing robotic lobectomy for NSCLC was performed. Robotic lobectomy was performed in a manner consistent with the Cancer and Leukemia Group B (CALGB) consensus video-assisted thoracic surgery (VATS) lobectomy technique using a robotic surgical system. Perioperative outcomes and long-term follow-up were recorded prospectively, and survival was calculated from the date of surgery to last follow-up.Results: From November 2002 through May 2010, a total of 325 consecutive patients underwent robotic lobectomy for early-stage NSCLC at 3 institutions. The median age of patients was 66 years (range, 30-87 years), and 37% (120) were female. The majority were in clinical stage I (IA, 247; IB, 63). Conversion rate to thoracotomy was 8% (27/325). Overall morbidity rate was 25.2% (82/325), and major complication rate was 3.7% (12/325). There was 1 in-hospital death (0.3%), and the median length of stay was 5 days (range, 2-28 days). Pathologic stage distribution was 54% (176) IA, 22% (72) IB, 13% (41) IIA, 5% (15) IIB, and 6% (21) IIIA. With a median follow-up of 27 months, overall 5-year survival was 80% (95% confidence intervals [CI] = 73-88), and by pathologic stage, 91% (CI = 83-99) for stage IA, 88% (CI = 77-98) for stage IB, and 49% (CI = 24-74) for all patients with stage II disease. Overall 3-year survival for patients with stage IIIA disease was 43% (CI = 16-69).Conclusions: Robotic lobectomy for early-stage NSCLC can be performed with low morbidity and mortality. Long-term stage-specific survival is acceptable and consistent with prior results for VATS and thoracotomy.

Discussion

2011-11-21

Dr Thomas A. D'Amico (Durham, NC). Robotics has been used in numerous surgical procedures, but, with few exceptions, this technologic advance has not translated into improved outcomes. Many robotic applications have been unveiled as the manifestation of a tool—sometimes a marketing tool—in search of an application. The principal advantages of robotic assistance in surgery are the greater degree of instrumental articulation and motion scaling. However, despite these recognized technical advantages, the demonstration of superior outcomes has been disappointing. As well, several disadvantages of the robotic system have been proven, including the lack of tactile feedback, personnel commitment, cost of the robot and its instruments, and the length of the procedures. In addition, the instrumentation that is currently available for use robotically is still limited.

Impact of tumor size on outcomes after anatomic lung resection for stage 1A non–small cell lung cancer based on the current staging system

2011-12-12

Objective: Anatomic segmentectomy may achieve results comparable to lobectomy for early-stage non–small cell lung cancer. The 7th edition of the AJCC Cancer Staging Handbook stratified the previous T1 tumor designation into T1a and T1b subsets, which still define stage 1A node-negative non–small cell lung cancer. We are left to hypothesize whether this classification may aid in directing the extent of surgical resection. We retrospectively reviewed our anatomic segmentectomy and lobectomy management of stage 1A non–small cell lung cancer to determine differences in survival and local recurrence rates based on the new stratification.Methods: We performed a retrospective review of 429 patients undergoing resection of pathologically confirmed stage 1A non–small cell lung cancer via lobectomy or anatomic segmentectomy. Primary outcome variables included mortality, recurrence, and survival. Recurrence-free and cancer-specific survivals were estimated using the Kaplan–Meier method.Results: Patients undergoing segmentectomy were older than patients undergoing lobectomy (mean age 69.2 vs 66.8 years, P < .006). The mean preoperative forced expiratory volume in 1 second was significantly lower in the segmentectomy group than in the lobectomy group (71.8% vs 81.1%, P = .02). Mortality was similar after segmentectomy (1.1%) and lobectomy (1.2%). There was no difference in mortality, recurrence rates (14.0% vs 14.7%, P = 1.00), or 5-year cancer-specific survival (T1a: 90% vs 91%, P = .984; T1b: 82% vs 78%, P = .892) when comparing segmentectomy and lobectomy for pathologic stage 1A non–small cell lung cancer, when stratified by T stage.Conclusions: Anatomic segmentectomy may achieve equivalent recurrence and survival compared with lobectomy for patients with stage 1A non–small cell lung cancer. Prospective studies will be necessary to delineate the potential merits of anatomic segmentectomy in this setting.

Discussion

2011-12-12

Dr Paul Schipper (Portland, Ore). I appreciate what you and your coauthors have done to evaluate the surgical treatment of these early-stage tumors. Your historical data applied to the new system get information out there quicker. However, you have to be cautious when you are making prospective or clinical decisions using retrospective pathologic data.

Repair of giant paraesophageal hernias routinely produces improvement in respiratory function

2011-11-21

Objective: Assessment of the clinical impact of giant paraesophageal hernias have historically focused on upper gastrointestinal symptoms. This study assesses the effect of paraesophageal hernia repair on respiratory function.Methods: All patients undergoing repair of giant paraesophageal hernia were prospectively entered into a database approved by the institutional review board. Patients had symptoms documented preoperatively, including dyspnea. Pulmonary function tests (PFTs) were done preoperatively and repeated a median of 106 days after repair (range, 16-660 days).Results: Preoperative and postoperative PFTs were obtained in 120 unselected patients treated for paraesophageal hernia between 2000 and 2010. Patients’ median age was 74 years (range, 45-91 years), 74 (62%) were female, and median body mass index was 28.0 (range, 16.8-46.6). Median length of stay was 4 days (range, 3-10 days), and perioperative mortality was zero. Hernias were classified as type II in 3 (3%) patients, III in 92 (77%), and IV in 25 (21%). Percent of intrathoracic stomach was assigned from preoperative contrast studies and grouped as less than 50% (n = 6; 5%), 50% to 74% (n = 35; 29%), 75% to 99% (n = 29; 24%), and 100% (n = 50; 42%). Preoperative symptoms included heartburn 71 (59%), early satiety 65 (54%), dyspnea 63 (52%), chest pain 48 (40%), dysphagia 56 (47%), regurgitation 47 (39%), and anemia 44 (37%). PFTs significantly improved after paraesophageal hernia repair (mean volume change, percent reference change): forced vital capacity +0.30 L,+10.3%pred; FEV1 +0.23 L,+10.4%pred (all P < .001); diffusion capacity of the lung for carbon monoxide +0.58 mL · mm Hg−1 · min−1 (P = .004), and +2.9%pred (P = .002). Greater improvements were documented in older patients with significant subjective respiratory symptoms and higher percent of intrathoracic stomach (P < .01).Conclusions: Paraesophageal hernia has a significant effect on respiratory function, which is largely underappreciated. This study demonstrates that these repairs can be done safely and supports routine consideration for elective repair; older patients with borderline respiratory function may achieve substantial improvements in their respiratory status and quality of life.

Discussion

2011-11-21

Dr Sean C. Grondin (Calgary, Alberta, Canada). I thank the Association for the opportunity to review this paper and I thank Drs Carrott and Low and their coauthors for providing me with the manuscript in a timely fashion for review.

Lung cancer cell invasion and expression of intercellular adhesion molecule-1 (ICAM-1) are attenuated by secretory phospholipase A2 inhibition

2012-02-01

Objective: Invasive lung tumors are associated with intercellular adhesion molecule-1 (ICAM-1) expression. Secretory phospholipase A2 (sPLA2) enzymes produce inflammatory mediators that stimulate ICAM-1 expression, and upregulation of PLA2 activity can enhance metastasis. We hypothesize a link between sPLA2 activity, ICAM-1 expression, and tumor cell invasion. We propose that inhibition of sPLA2 modulates ICAM-1 expression in cancer cells and attenuates their invasiveness.Methods: Human lung adenocarcinoma cells (A549) were treated with an ICAM-1 blocking antibody and assayed for invasion. Lung cancer cells (A549 and H358) were then treated with an sPLA2 inhibitor and evaluated by immunoblotting for ICAM-1 expression. Next cells (A549) treated with sPLA2 inhibitor were assayed for invasion. Finally, sPLA2 messenger RNA and protein expression were evaluated by quantitative reverse-transcriptase polymerase chain reaction and immunofluorescence microscopy, respectively. Statistical analysis was performed by the Student t test or analysis of variance, as appropriate.Results: Antibody blockade of ICAM-1 decreased lung cancer cell invasion. sPLA2 inhibition significantly reduced ICAM-1 expression and invasion. sPLA2 inhibition also significantly decreased sPLA2 mRNA expression and immunofluorescent staining of sPLA2.Conclusions: sPLA2 plays a significant role in mediating the inflammatory signals that induce ICAM-1 expression in lung cancer cells. Inhibition of the enzyme can significantly decrease ICAM-1 expression and subsequent cancer cell invasion. This lays the groundwork for further investigation into the cellular mechanisms of sPLA2 and its role in lung cancer.

Discussion

2012-02-01

Dr Michael Mulligan (Seattle, Wash). Congratulations on your paper and a very nice presentation. I always appreciate seeing a lot of effort put into work, and clearly you did that. I noticed the article that your group put out via e-publication last month evaluating ICAM regulation with sPLA2 in esophageal cancer cells, and this is a nice extension of that work. It is always difficult to know what the next great research question is and you seem to be onto something here.

Neoadjuvant chemoradiotherapy followed by surgery for esophageal adenocarcinoma: Significance of microscopically positive circumferential radial margins

2011-12-15

Objectives: The incidence and consequence of an isolated involved circumferential radial margin (CRM) after resection for esophageal adenocarcinoma in the setting of neoadjuvant chemoradiotherapy (CRT) has not been reported. We aimed to determine the frequency and significance of a close (<1 mm) or involved CRM in patients undergoing esophagectomy after CRT.Methods: We retrospectively analyzed the data from patients undergoing resection from 1997 to 2008 for esophageal adenocarcinoma after neoadjuvant CRT. A positive CRM was defined as microscopic tumor at or less than 1 mm of the radial margin. An R1 resection was tumor at the radial margin. Only patients with ypT3 or greater tumors were included. R2 resections were excluded. Statistical comparisons were performed using Cox regression and Kaplan-Meier analyses.Results: A total of 160 patients met the inclusion criteria, 42 (26%) had a positive CRM. The median survival did not significantly differ between the CRM-negative and -positive groups (28 vs 50 months, P = .84). A propensity score matching analysis also failed to find a significant difference in outcomes. When analyzed by tumor present at the margin (R1), R0 patients had a longer median survival compared with R1 patients (28 vs 8 months, P = .01). This difference, however, was not seen on propensity score matching.Conclusions: Resections of locally advanced esophageal adenocarcinoma with residual transmural viable tumor after CRT frequently showed involvement of the radial margin with tumor either close to or at the margin. Tumor close (<1 mm) to the radial margin did not result in a significant decrease in overall or disease-free survival or increase in local recurrence.

Discussion

2011-12-15

Dr Gail E. Darling (Toronto, Ontario, Canada). I want to thank Dr Harvin for an excellent presentation and for providing me with the manuscript well in advance of the meeting.

A novel detection method of non–small cell lung cancer using multiplexed bead-based serum biomarker profiling

2011-11-21

Objectives: Non–small cell lung cancer (NSCLC) is the leading cause of cancer-related mortality. Development of an early diagnosis method may improve survivals. We aimed to develop a new diagnostic model for NSCLC using serum biomarkers.Methods: We set up a patient group diagnosed with NSCLC (n = 122) and a healthy control group (n = 225). Thirty serum analytes were selected on the basis of previous studies and a literature search. An antibody-bead array of 30 markers was constructed using the Luminex bead array platform (Luminex Inc, Austin, Tex) and was analyzed. Each marker was ranked by importance using the random forest method and then selected. Using selected markers, multivariate classification algorithms were constructed and were validated by application to independent validation cohort of 21 NSCLC and 28 control subjects.Results: There was no difference in demographics between patients and the control population except for age (64.8 ± 10.0 for patients vs 53.0 ± 7.6 years for the control group). Among the 30 serum proteins, 23 showed a difference between the 2 groups (12 increased and 11 decreased in the patient group). We found the highest accuracy of multivariate classification algorithms when using the 5 highest-ranked biomarkers (A1AT, CYFRA 21-1, IGF-1, RANTES, AFP). When we applied the algorithms on a validation cohort, each method recognized the patients from the controls with high accuracy (89.8% with random forest, 91.8% with support vector machine, 88.2% with linear discriminant analysis, and 90.5% with logistic regression).Conclusions: We confirmed that a new diagnostic method using 5 serum biomarkers profiling constructed by multivariate classification algorithms could distinguish NSCLC from healthy controls with high accuracy.

Discussion

2011-11-21

Dr Daniel Kreisel (St Louis, Mo). Congratulations on a very nice presentation and a nice study. Thank you for allowing me to review your manuscript in a timely fashion. Your study addresses an important issue in thoracic oncology, the identification of biomarkers, which would ideally allow us to accurately identify patients with lung cancer in a cost-effective and practical manner. Your study extends numerous previous studies that have used profiling of serum markers in an attempt to detect patients who harbor malignancies, including ovarian cancers.

A comparison of surgical intervention and stereotactic body radiation therapy for stage I lung cancer in high-risk patients: A decision analysis

2011-12-12

Objective: We sought to compare the relative cost-effectiveness of surgical intervention and stereotactic body radiation therapy in high risk patients with clinical stage I lung cancer (non–small cell lung cancer).Methods: We compared patients chosen for surgical intervention or SBRT for clinical stage I non–small cell lung cancer. Propensity score matching was used to adjust estimated treatment hazard ratios for the confounding effects of age, comorbidity index, and clinical stage. We assumed that Medicare-allowable charges were $15,034 for surgical intervention and $13,964 for stereotactic body radiation therapy. The incremental cost-effectiveness ratio was estimated as the cost per life year gained over the patient’s remaining lifetime by using a decision model.Results: Fifty-seven patients in each arm were selected by means of propensity score matching. Median survival with surgical intervention was 4.1 years, and 4-year survival was 51.4%. With stereotactic body radiation therapy, median survival was 2.9 years, and 4-year survival was 30.1%. Cause-specific survival was identical between the 2 groups, and the difference in overall survival was not statistically significant. For decision modeling, stereotactic body radiation therapy was estimated to have a mean expected survival of 2.94 years at a cost of $14,153 and mean expected survival with surgical intervention was 3.39 years at a cost of $17,629, for an incremental cost-effectiveness ratio of $7753.Conclusions: In our analysis stereotactic body radiation therapy appears to be less costly than surgical intervention in high-risk patients with early stage non–small cell lung cancer. However, surgical intervention appears to meet the standards for cost-effectiveness because of a longer expected overall survival. Should this advantage not be confirmed in other studies, the cost-effectiveness decision would be likely to change. Prospective randomized studies are necessary to strengthen confidence in these results.

Discussion

2011-12-12

Dr Alessandro Brunelli (Ancona, Italy). Mr Chairmen, colleagues. I have no conflicts of interest to disclose. Dr Puri, I want to congratulate you and your colleagues from St Louis for this timely and interesting contribution. As usual, your group has performed this very accurate analysis in the context of a nonrandomized observational investigation. SBRT is emerging as an effective treatment for functionally inoperable NSCLC. However, you have demonstrated with a decision model that surgical intervention remains cost-effective, even for these high–risk patients. I have 3 comments and questions, and I will ask you one at a time.

Novel biodegradable polydioxanone stents in a rabbit airway model

2011-09-01

Objective: This study was undertaken to evaluate safety and biocompatibility of a novel biodegradable polydioxanone stent in a rabbit tracheal model. Metallic and silicone stents represent standard therapeutic approaches for hollow organ stenosis, although complications have been reported repeatedly. Biodegradable stents could reduce the risks associated with this procedure while still achieving the purpose of maintaining lumen patency.Methods: A commercially available polydioxanone suture strand with a long safety record was used to manufacture the self-expanding stents. The polydioxanone stents were then implanted bronchoscopically and under fluoroscopic guidance into the tracheas of white rabbits (N = 25). Periodic clinical examination was performed. Histopathologic examination concluded the study for the 5 experimental groups at 3, 4, 5, 10, and 15 weeks after implantation.Results: There were no unexpected deaths and no stent displacements during the study. The animals remained in good condition, without stent debris expectoration. Macroscopic examination revealed that the tracheal lumen stayed open. Histologic examination showed that tracheal damage score was highest 5 weeks after stenting, including in-stent necrosis of the epithelium. Stent degradation was complete with no remnants after 10 weeks, leaving the trachea completely healed at 15 weeks after implantation.Conclusions: This animal airway model has demonstrated acceptable safety and biocompatibility of this novel biodegradable polydioxanone stent. We suggest that polydioxanone stenting be used for further clinical studies for cases in which complete stent degradation after temporary airway treatment is desirable.

Decrease in inflammatory response does not prevent placental dysfunction after fetal cardiac bypass in goats

Cheng-Bin Zhou, Jian Zhuang, Ji-Mei Chen, Xiao-Hua Zhang, Raphael C. Lui — 2011-08-08

Objective: One of the most significant responses to fetal cardiac bypass is severe placental dysfunction characterized by increased vascular resistance. We tested the hypothesis that fetal cardiac bypass triggers the activation of nuclear factor kappa-B (NF-KB), a major regulator of inflammatory response, and that pharmacologic inhibition of NF-KB activation by pyrrolidine dithiocarbamate alleviates fetal cardiac bypass–induced placental dysfunction.Methods: Fifteen pregnant goats at 120 to 140 days’ gestation were equally divided into the control group with a sham procedure of fetal sternotomy and cannulation (CG), the fetal bypass group (FB), and the fetal bypass group with 300 mg pyrrolidine dithiocarbamate before sternotomy (FP). Fetal cardiac bypass was performed for 30 minutes. Umbilical arterial flow rate was measured by ultrasonic flowmeter and placental vascular resistance was calculated. Fetal plasma levels of nitric oxide (NO), endothlin-1 (ET-1), 6-keto-prostaglandin F1α (6-K), thromboxane B2 (TXB2), interleukin 6 (IL-6), and tumor necrosis factor-α (TNF-α) were assayed. IL-6 and TNF-α mRNA were analyzed by real-time polymerase chain reaction. NF-KB activation was evaluated by electrophoretic mobility shift assay.Results: Placental vascular resistance significantly increased in the FB and FP groups compared with the CG group. Increases in plasma levels of NO were observed in all 3 groups. Plasma levels of ET-1 rose significantly in the FB and FP groups without noticeable difference between them. Plasma levels of 6-K, TXB2, IL-6, and TNF-α increased significantly in the FB group compared with the CG and FP groups. The transcription levels of IL-6 and TNF-α mRNA in the placental tissues of the FB group were significantly higher than in the FP and CG groups. The amount of activated NF-KB in the placental tissues of the FB group was also significantly higher than that in the FP and CG groups.Conclusions: Fetal cardiac bypass–induced inflammatory response possibly mediated by NF-KB caused placental dysfunction. Pharmacologic inhibition of NF-KB activation and decrease in the inflammatory response did not alleviate the placental dysfunction.

Impaired cardiac autophagy in patients developing postoperative atrial fibrillation

2011-09-01

Objectives: Postoperative atrial fibrillation (POAF) is a common complication after on-pump heart surgery. Several histologic abnormalities, such as interstitial fibrosis and vacuolization, have been described in atrial samples from patients developing POAF. This ultrastructural remodeling has been associated with the establishment of a proarrhythmic substrate. We studied whether atrial autophagy is activated in patients who develop POAF.Methods: A total of 170 patients in sinus rhythm who had undergone elective coronary artery bypass grafting were included. Systemic inflammatory markers were measured at baseline and 72 hours after surgery. During the procedure, samples of the right atrial appendages were obtained for evaluation of remodeling by light and electron microscopy. Protein ubiquitination and autophagy-related LC3B processing were assessed by Western blot.Results: Of these patients, 22% developed POAF. The level of high-sensitivity C-reactive protein, fibrosis, inflammation, myxoid degeneration, and ubiquitin-aggregates in the atria did not differ between patients with and without POAF. Electron microphotographs of those with POAF showed a significant accumulation of autophagic vesicles and lipofuscin deposits. Total protein ubiquitination was similar in the patients with and without POAF, but LC3B processing was markedly reduced in those with POAF, suggesting a selective impairment in autophagic flow.Conclusions: This study provides novel evidence that ultrastructural atrial remodeling characterized by an impaired cardiac autophagy is present in patients developing POAF after coronary artery bypass surgery.

Effect of aneurysm on the mechanical dissection properties of the human ascending thoracic aorta

Salvatore Pasta, Julie A. Phillippi, Thomas G. Gleason, David A. Vorp — 2011-08-26

Objectives: The acute dissection of an ascending thoracic aortic aneurysm (ATAA) represents a devastating separation of elastic layers occurring when the hemodynamic loads on the diseased wall exceed the adhesive strength between layers. At present, the mechanics underlying aortic dissection are largely unclear, and the biomechanical delamination properties of the aneurysmal aorta are not defined. Individuals with bicuspid aortic valve (BAV) are particularly predisposed to ascending aortic aneurysm formation, with a marked risk of aortic dissection. The purpose of this study was to evaluate and compare the dissection properties of nonaneurysmal and aneurysmal human ascending thoracic aorta from patients with BAV morphology or normal tricuspid aortic valve (TAV) morphology using biomechanical delamination testing.Methods: The influence on the delamination strength (Sd) of the aorta associated with BAV was compared with that in patients with TAV. After complete delamination of ATAA tissue samples, tensile tests were performed on each delaminated half for comparison of their tensile strengths.Results: The results showed that the aneurysmal aortas with BAV and TAV have lower Sd than nonaneurysmal aortas and that ATAA with BAV has a lower Sd than that with TAV. We have found a significant difference in Sd between longitudinal and circumferential directions of the nondiseased aorta, suggesting anisotropic dissection properties.Conclusions: The tensile testing results suggest that the weaker intimal half of the aortic wall might fail before the outer adventitial half. Scanning electron microscope analyses suggest different failure modalities of dissection between the two morphologies, and the lower Sd in ATAAs appears to be associated with a disorganized microstructure. BAV ATAAs have a lower Sd than TAV ATAAs, suggesting a greater propensity for aortic dissection.

Factors associated with 5-year survival in older heart transplant recipients

Arman Kilic, Eric S. Weiss, David D. Yuh, Ashish S. Shah, John V. Conte — 2012-02-01

Objectives: The aim of the present study was to identify the predictors of 5-year survival in elderly patients undergoing orthotopic heart transplantation (OHT).Methods: A review of the United Network for Organ Sharing database was conducted of recipients 60 years old or older undergoing OHT from 1995 to 2004. The variables were compared between the 5-year survivors and the patients who died within 5 years of OHT. A multivariate logistic regression model was constructed using the covariates significantly associated with 5-year survival on univariate analysis.Results: A total of 5330 elderly patients underwent OHT during the study period. Of these patients, 3492 (65.5%) were 5-year survivors, 1580 (29.6%) had died within 5 years of OHT and were considered controls, and 258 (4.8%) were lost to follow-up. The predictors of improved 5-year survival included younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95–1.00; P = .03), lower creatinine (OR, 0.92; 95% CI, 0.87–0.98; P = .01), white race (OR, 1.23; 95% CI, 1.02–1.49; P = .03), shorter ischemic time (OR, 0.93; 95% CI, 0.87–0.99; P = .02), and younger donor age (OR, 0.99; 95% CI, 0.99–1.00; P = .03). The following significantly reduced the odds of surviving to 5 years: mechanical ventilation (OR, 0.48; 95% CI, 0.33–0.71; P < .001), hypertension (OR, 0.79; 95% CI, 0.69–0.91; P = .001), and diabetes (OR, 0.79; 95% CI, 0.67–0.92; P = .003). Ventricular assist device data were only available for 2538 patients (49.6%). When added to the multivariate model, the use of a ventricular assist device significantly reduced the odds of surviving 5 years after OHT (OR, 0.63; 95% CI, 0.50–0.81; P < .001).Conclusions: In the present study of more than 5000 elderly OHT patients, younger recipient age, white race, lower creatinine, younger donor age, and shorter ischemic time were associated with improved 5-year survival. In contrast, bridging with a ventricular assist device, mechanical ventilation, hypertension, and diabetes significantly decreased the odds of 5-year survival. These findings might be useful for prognostication in this higher risk patient population.

The universal bed model for patient care improves outcome and lowers cost in cardiac surgery

2011-12-08

Objective: With the escalating demands to increase the efficiency and decrease the cost, innovations in postoperative cardiac surgical patient care are needed. The universal bed model is an innovative care delivery system that allows patient care to be managed in one setting from postoperation to discharge. We hypothesized that the universal bed model in the context of cardiac surgery would improve outcomes and efficacy.Methods: A total of 610 consecutive patients were admitted to the universal bed unit and prospectively entered into the Society of Thoracic Surgeons National Cardiac Database. Intensive care unit level of care was determined by acuity and staffing needs. Telemetry was employed from admission to discharge, and multidisciplinary rounds were conducted twice daily. Postoperative outcomes were recorded during hospital stay, and comparisons were made with the Society of Thoracic Surgeons National Cardiac Database using identical variables over the same period of time.Results: Decreased ventilation time, intensive care unit and hospital stay, and reduction in the incidence of atrial fibrillation and infectious complications yielded a financial benefit in the universal bed group compared with the traditional model of admission. Stroke rate and in-hospital mortality were the same compared with regional and national centers. Compared with regional centers, there was an average cost savings between $6200 and $9500 per patient depending on the operation. Patient care satisfaction by independent survey was in the 99th percentile.Conclusions: The universal bed patient care model allows for expedient and efficacious care as measured by decreased length of intensive care unit and hospital stay, improved postoperative outcomes, patient satisfaction, and cost savings.

Discussion

2011-12-08

Dr James Brevig (Everett, Wash). I work in Everett, Washington, at a community hospital. I thank the membership for the opportunity to discuss this presentation. This is a difficult issue to study because it is hard to get a control group, which is evident to us from the presentation. Nevertheless, having worked in a similar model since 2004, which is when we opened our single-stay unit, a similar concept to the UB model, I am convinced this is a better model of care than the traditional model of care that involves a critical care unit and a variety of step-down, progressive care, or telemetry units. I am delighted to see this article and the concept getting some attention from our peers.

Preoperative left atrial dysfunction and risk of postoperative atrial fibrillation complicating thoracic surgery

2011-09-28

Objective: Postoperative atrial fibrillation complicating general thoracic surgery increases morbidity and stroke risk. We aimed to determine whether preoperative atrial dysfunction or other echocardiographic markers are associated with postoperative atrial fibrillation.Methods: In 191 patients who had undergone anatomic lung or esophageal resection, preoperative clinical and echocardiographic data were compared between patients with and without postoperative atrial fibrillation. Presence of postoperative atrial fibrillation lasting more than 5 minutes during hospitalization was detected using continuous telemetry or 12-lead electrocardiography. Maximal left atrial volume and indices of left atrial function were assessed.Results: Patients with postoperative atrial fibrillation (33/191, 17%) were older (71 ± 5 years vs 64 ± 12 years, P < .0001), were taking β-blockers more often, had greater left atrial volume, had decreased left atrial emptying fraction, and had lower E′ and A′ septal velocities compared with patients without postoperative atrial fibrillation. The incidence of postoperative atrial fibrillation in patients with left atrial volume 32 mL/m2 or greater was 37% (11/30) and greater than in those with left atrial volume less than 32 mL/m2 (14%, 22/160, P = .002). Length of hospital stay was significantly increased in patients with postoperative atrial fibrillation compared with patients without (P = .04). Older age was significantly associated with greater β-blocker use and left atrial volume and lower left atrial emptying fraction. On multivariate analysis, lower left atrial emptying fraction (odds ratio, 1.03 per unit decrement; 95% confidence interval, 1.002–1.065; P = .04) and preoperative use of β-blockers (odds ratio, 2.82; 95% confidence interval, 1.18–6.77; P = .02) were the only independent risk factors associated with postoperative atrial fibrillation.Conclusions: These data show that an echocardiogram before major thoracic surgery, increased use of preoperative β-blockers, and decreased left atrial emptying fraction were associated with postoperative atrial fibrillation. Echocardiographic predictors of left atrial mechanical dysfunction may prove clinically useful in risk stratifying patients in whom postoperative atrial fibrillation is more likely to develop and to benefit from prevention strategies aimed at mitigating atrial function before surgery.

Effect of low-dose human atrial natriuretic peptide on postoperative atrial fibrillation in patients undergoing pulmonary resection for lung cancer: A double-blind, placebo-controlled study

2011-10-12

Objectives: We previously reported that patients with preoperative B-type natriuretic peptide levels of 30 pg/mL or more have increased risk of postoperative atrial fibrillation after pulmonary resection. This study evaluated the effects of human atrial natriuretic peptide on postoperative atrial fibrillation in patients undergoing pulmonary resection for lung cancer.Methods: A prospective, randomized study was conducted with 40 patients who had preoperative elevated B-type natriuretic peptide (≥30 pg/mL) and underwent a scheduled pulmonary resection for lung cancer. Results were compared between patients who received low-dose human atrial natriuretic peptide and those who received a placebo. The primary end point was the incidence of postoperative atrial fibrillation during the first 4 days after surgery.Results: The incidence of postoperative atrial fibrillation was significantly lower in the human atrial natriuretic peptide group than in the placebo group (10% vs 60%; P < .001). Patients in the human atrial natriuretic peptide group also showed significantly lower white blood cell counts and C-reactive protein levels after surgery.Conclusions: Continuous infusion of low-dose human atrial natriuretic peptide during lung cancer surgery had a prophylactic effect against postoperative atrial fibrillation after pulmonary resection in patients with preoperative elevation of B-type natriuretic peptide levels. A larger sample size is needed to establish the safety and efficacy of this intervention.

Preoperative proteinuria predicts acute kidney injury in patients undergoing cardiac surgery

2011-11-04

Objective: The study objective was to examine the utility of using proteinuria in preoperative risk stratification for acute kidney injury. Acute kidney injury is a common and important complication for patients undergoing cardiac surgery. Proteinuria, which reflects structural damage to the glomeruli or renal tubules, may aid the prediction of acute kidney injury.Methods: The urine albumin to creatinine ratio and dipstick proteinuria concentration were prospectively measured in 1159 patients undergoing cardiac surgery. The cohort was organized into 4 clinical risk categories based on the preoperative urine albumin to creatinine ratio: 10 mg/g or less (≤1.1 mg/mmol), 11 to 29 mg/g (1.2–3.3 mg/mmol), 30 to 299 mg/g (3.4–33.8 mg/mmol), and 300 mg/g or greater (≥33.9 mg/mmol). The primary outcome was postoperative acute kidney injury, defined by the Acute Kidney Injury Network stage I criterion (serum creatinine increase ≥ 50% or ≥ 0.3 mg/dL; 26.5 μmol/L).Results: An increase in the incidence of acute kidney injury was noted across the urine albumin to creatinine ratio categories. Adding the urine albumin to creatinine ratio to the clinical model to predict acute kidney injury improved the area under the curve from 0.67 to 0.70 (P < .001), and the continuous net reclassification improvement was 29% (P < .001). The urine albumin to creatinine ratio was also independently associated with the risk of in-hospital dialysis and intensive care unit and hospital lengths of stay. Surgery status and preoperative glomerular filtration rate were effect modifiers; the association was stronger among those undergoing elective surgery and those with an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater.Conclusions: Preoperative proteinuria provides graded stratification risk for acute kidney injury and is an independent predictor of other outcomes in patients undergoing cardiac surgery.

Dual anterior and posterior mitral valve clefts evaluated by 3-dimensional echocardiography with robot-assisted surgical correction

Ailin Barseghian, Daniel M. Bethencourt, Gabriel Vorobiof — 2011-12-09

We report a case of dual mitral valve clefts in both the anterior and posterior leaflets of the mitral valve. Three-dimensional transesophageal echocardiography (TEE) facilitates visualization of the mitral leaflet pathology and assists with accurate surgical planning. This rare mitral valve anomaly is confirmed surgically and corrected with minimally invasive robotic technique.

Anomalous left coronary artery from the right pulmonary artery with aortic fusion

T. K. Susheel Kumar, Pranava Sinha, Mary T. Donofrio, Richard A. Jonas — 2011-08-22

Anomalous left coronary artery from the right pulmonary artery (RPA) with aortic fusion is a rare variant of anomalous left coronary artery from the pulmonary artery (ALCAPA). Three consecutive cases of this ALCAPA variant were managed, including a case with associated pink tetralogy. The challenges that can present in the diagnosis and treatment of this rare condition are described.

Placement of 2 implantable centrifugal pumps to serve as a total artificial heart after cardiectomy

Martin Strueber, Jan D. Schmitto, Ingo Kutschka, Axel Haverich — 2011-08-19

In recent years, the role of ventricular assist devices for management of chronic heart failure has continued to increase. This increase stems mainly from the success of improved technology, greater surgical experience, and increasing experience with management of ventricular assist device–related complications. Collectively, these advances have led to overall better outcomes.

Massive calcified left ventricular aneurysm and ventricular septum: Successful surgical repair and reconstruction

Xianqiang Wang, Hengchao Wu, Hansong Sun — 2011-09-12

Massive calcification of a ventricular aneurysm, particularly of the ventricular septum, is uncommon after myocardial infarction. Surgical repair and reconstruction of an extensive calcified left ventricular aneurysm and septum are unrecorded to our knowledge. This report describes the successful surgical repair of a massive calcified left ventricular aneurysm and ventricular septum 13 years after the initial myocardial infarction.

Implantation of a centrifugal pump as a left ventricular assist device through a novel, minimized approach: Upper hemisternotomy combined with anterolateral thoracotomy

Jan D. Schmitto, Ulrich Molitoris, Axel Haverich, Martin Strueber — 2011-09-08

The role and the use of ventricular assist devices (VADs) for the treatment of chronic heart failure are increasing tremendously worldwide. The VAD-related success is mainly based on 2 important factors: (1) novel technologies and (2) increased surgical experience leading to lower complication rates and better outcomes.

Ascending–descending aortic bypass with valve-sparing root replacement for coarctation with aortic root aneurysm

Nicholas D. Andersen, Judson B. Williams, J. Kevin Harrison, G. Chad Hughes — 2011-08-24

A 55-year-old man with critical aortic coarctation, aortic root aneurysm, and aortic insufficiency underwent median sternotomy for ascending–descending aortic bypass and aortic root replacement. The patient was found to have a salvageable trileaflet aortic valve, allowing for valve-sparing root replacement (VSRR). Aortic bypass with VSRR has not previously been reported and may be the ideal operation for repair of coarctation with concomitant aortic root aneurysm.

Left atrial myxoma in association with life-saving mitral stenosis

Philippe Demers, Nicolas Beaulieu — 2012-02-01

This case report highlights the occurrence of a free left atrial myxoma with concomitant mitral stenosis (). Myxomas, although rare, are the most common benign cardiac tumors. They are generally located in the left atria (75%), most often attached by a stalk to the endocardium and growing toward 1 or more of the heart’s cavities. Their average size is 5 cm in diameter. Although most are pedunculated, attached by a broad base, and relatively immobile, a small portion are attached by a long stalk or even unattached, leading to many possible complications, which are separated into (1) obstructive complications, (2) embolization, and (3) constitutional symptoms. The dislodgement of the mass near on orifice is a cause for obstruction. When this occurs near the mitral valve, it leads to a mitral stenosis. The mass can also embolize, most commonly manifesting as central nervous system disturbances.

Cardiac herniation during robot-assisted cardiac operation

Shojiro Yamaguchi, Norihiko Ishikawa, Go Watanabe — 2012-02-01

Cardiac herniation during a cardiac operation is extremely rare. We report a rare case of intraoperative cardiac herniation. Our patient had herniation develop in response to strong positive ventilation to the left lung.

Pentacuspid aortic valve causing severe aortic regurgitation

Hidehito Kuroki, Kazunobu Hirooka, Masahiro Ohnuki — 2011-11-21

Aortic valve dysfunction in relatively young adults may indicate congenital valve malformation. There have been occasional reports of anomalous monocuspid, bicuspid, and quadricuspid valves.

Early stenosis of Medtronic Mosaic bioprosthesis in the aortic position

Sheen Peeceeyen, Christopher Cao, Gary Fermanis, Con Manganas — 2011-11-21

The Medtronic Mosaic valve (Medtronic, Inc, Minneapolis, Minn) is a third-generation stented porcine bioprosthesis combining physiologic fixation and α-amino-oleic acid antimineralization treatment to improve hemodynamic performance and durability. Despite encouraging short-term and midterm clinical results, however, there has been a heightened interest in the safety and efficacy of this device after a recent case series study of early valve failure resulting from an unknown cause. We present here 2 case reports of early structural valve dysfunction after implantation of the Mosaic valve in the aortic position.

Saphenous vein graft bronchopulmonary fistula after coronary artery bypass grafting presenting as chronic cough and subsequent massive hemoptysis

Elizabeth Belcher, Edward Townsend, Fabio De Robertis — 2011-11-21

Aortocoronary conduit bronchopulmonary fistula is a rare, potentially lethal complication seen after coronary artery bypass grafting (CABG). The ideal diagnostic modality in such cases is not established. We present a case of early-onset aortocoronary conduit bronchopulmonary fistula diagnosed by coronary angiography and immediate noncontrast computed tomography (CT) in a patient with massive hemoptysis 8 weeks after CABG.

Left atrial appendage aneurysm causes severe mitral regurgitation and heart failure: Report of a successfully treated case

Mitsuhiro Kawata, Kazuhito Imanaka, Takahiro Matsuoka, Hideaki Yamabi — 2011-10-21

Left atrial appendage aneurysm (LAAA) is a rare cardiac anomaly. Its cause is believed to be a congenital dysplasia of the left atrial muscle. LAAA is different from acquired enlargement of the left atrium secondary to other cardiac diseases. In the second to third decades of life, some patients with LAAA experience palpitation, atrial tachyarrhythmia, progressive dyspnea, or atypical chest pain. LAAA usually appears as an isolated anomaly, and resultant mitral regurgitation (MR) has not been reported in the literature.

Aortic Symposium 2012

2012-02-01

April 26–27, 2012 Sheraton Hotel & Towers

AATS 92nd Annual Meeting

2012-02-01

(Immediately following the Aortic Symposium 2012 in New York, NY) April 28–May 2, 2012

AATS Online Award Applications

2012-02-01

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

Applications for Membership

2012-02-01

The WTSA Application for Membership is now online and must be submitted electronically. A candidate’s application must include the following uploads: A photo, a complete curriculum vitae with bibliography, and the three most significant articles that s/he personally wrote. The candidate’s electronic membership application must be completed and submitted online by March 1, 2012, and all support letters uploaded by that candidate’s sponsors by March 31, 2012, in order for the candidate to be considered for election to membership at the 2012 Annual Meeting. Visit the WTSA Web site at www.westernthoracic.org to read membership eligibility requirements and to initiate an online application.

WTSA 38th Annual Meeting

2012-02-01

Save the Date! June 27–30, 2012

Notices

2012-02-01

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

Requirements for Maintenance of Certification

2012-02-01

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

2012-02-01

JTCVS Disclosure Statement

2012-02-01

Information for Readers

2012-02-01

The Journal of Thoracic and Cardiovascular Surgery

The state of the Journal: A critique by the Editor

Historical perspectives of The American Association for Thoracic Surgery: Alfred Blalock (1899–1964)

Evaluation of simulation training in cardiothoracic surgery: The Senior Tour perspective

Trends in isolated coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons adult cardiac surgery database

Discussion

Long-term implications of emergency versus elective proximal aortic surgery in patients with Marfan syndrome in the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions Consortium Registry

Quality, not volume, determines outcome of coronary artery bypass surgery in a university-based community hospital network

Discussion

Valve-sparing aortic root repair without down-sizing of the annulus

Discussion

Expanding the indications for septal myectomy in patients with hypertrophic cardiomyopathy: Results of operation in patients with latent obstruction

Discussion

Beyond the short-term: Clinical outcome and valve performance 2 years after transcatheter aortic valve implantation in 227 patients

Discussion

Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized controlled trial

Discussion

Transapical aortic valve implantation at 3 years

Surgical management of aortic root abscess: A 13-year experience in 172 patients with 100% follow-up

Outcome after repair of atrioventricular septal defect with tetralogy of Fallot

A decade of pediatric mechanical circulatory support before and after cardiac transplantation

Discussion

Younger age and valve oversizing are predictors of structural valve deterioration after pulmonary valve replacement in patients with tetralogy of Fallot

Discussion

The impact of additional epicardial imaging to transesophageal echocardiography on intraoperative detection of residual lesions in congenital heart surgery

Congenital heart surgery in infants: Effects of acute kidney injury on outcomes

Increasing duration of circulatory arrest, but not antegrade cerebral perfusion, prolongs postoperative recovery after neonatal cardiac surgery

Robotic lobectomy for non–small cell lung cancer (NSCLC): Long-term oncologic results

Discussion

Impact of tumor size on outcomes after anatomic lung resection for stage 1A non–small cell lung cancer based on the current staging system

Discussion

Repair of giant paraesophageal hernias routinely produces improvement in respiratory function

Discussion

Lung cancer cell invasion and expression of intercellular adhesion molecule-1 (ICAM-1) are attenuated by secretory phospholipase A2 inhibition

Discussion

Neoadjuvant chemoradiotherapy followed by surgery for esophageal adenocarcinoma: Significance of microscopically positive circumferential radial margins

Discussion

A novel detection method of non–small cell lung cancer using multiplexed bead-based serum biomarker profiling

Discussion

A comparison of surgical intervention and stereotactic body radiation therapy for stage I lung cancer in high-risk patients: A decision analysis

Discussion

Novel biodegradable polydioxanone stents in a rabbit airway model

Decrease in inflammatory response does not prevent placental dysfunction after fetal cardiac bypass in goats

Impaired cardiac autophagy in patients developing postoperative atrial fibrillation

Effect of aneurysm on the mechanical dissection properties of the human ascending thoracic aorta

Factors associated with 5-year survival in older heart transplant recipients

The universal bed model for patient care improves outcome and lowers cost in cardiac surgery

Discussion

Preoperative left atrial dysfunction and risk of postoperative atrial fibrillation complicating thoracic surgery

Effect of low-dose human atrial natriuretic peptide on postoperative atrial fibrillation in patients undergoing pulmonary resection for lung cancer: A double-blind, placebo-controlled study

Preoperative proteinuria predicts acute kidney injury in patients undergoing cardiac surgery

Dual anterior and posterior mitral valve clefts evaluated by 3-dimensional echocardiography with robot-assisted surgical correction

Anomalous left coronary artery from the right pulmonary artery with aortic fusion

Placement of 2 implantable centrifugal pumps to serve as a total artificial heart after cardiectomy

Massive calcified left ventricular aneurysm and ventricular septum: Successful surgical repair and reconstruction

Implantation of a centrifugal pump as a left ventricular assist device through a novel, minimized approach: Upper hemisternotomy combined with anterolateral thoracotomy

Ascending–descending aortic bypass with valve-sparing root replacement for coarctation with aortic root aneurysm

Left atrial myxoma in association with life-saving mitral stenosis

Cardiac herniation during robot-assisted cardiac operation

Pentacuspid aortic valve causing severe aortic regurgitation

Early stenosis of Medtronic Mosaic bioprosthesis in the aortic position

Saphenous vein graft bronchopulmonary fistula after coronary artery bypass grafting presenting as chronic cough and subsequent massive hemoptysis

Left atrial appendage aneurysm causes severe mitral regurgitation and heart failure: Report of a successfully treated case

Aortic Symposium 2012

AATS 92nd Annual Meeting

AATS Online Award Applications

Applications for Membership

WTSA 38th Annual Meeting

Notices

Requirements for Maintenance of Certification

Condensed Contents

Table of Contents

JTCVS Disclosure Statement

Information for Readers