The Journal of Thoracic and Cardiovascular Surgery

A cancer staging primer: Esophagus and esophagogastric junction

Thomas W. Rice, Eugene H. Blackstone, Valerie W. Rusch — 2010-03-01

Staging cancer of the esophagus and esophagogastric junction has been extensively changed and improved in the 7th edition of the American Joint Committee on Cancer (AJCC), Cancer Staging Manual. Changes address problems of empiric stage grouping and lack of harmonization with stomach cancer. This was accomplished by assembling worldwide data and using modern machine learning techniques for data-driven staging. Improvements include new definitions of Tis, T4, regional lymph node, N classification, and M classification, and addition of the nonanatomic cancer characteristics: histopathologic cell type, histologic grade, and cancer location. Stage groupings were constructed by adherence to principles of staging, including monotonic decreasing survival with increasing stage group, distinct survival between groups, and homogeneous survival within groups.

Optimal flow rate for antegrade cerebral perfusion

2010-03-01

Objective: Antegrade cerebral perfusion is widely used in neonatal heart surgery, yet commonly used flow rates have never been standardized. The objective of this study was to determine the antegrade cerebral perfusion flow rate that most closely matches standard cardiopulmonary bypass conditions.Methods: Nine neonatal piglets underwent deep hypothermic cardiopulmonary bypass at a total body flow of 100 mL/kg/min (baseline). Antegrade cerebral perfusion was conducted via innominate artery cannulation at perfusion rates of 10, 30, and 50 mL/kg/min in random order. Cerebral blood flow was measured using fluorescent microspheres. Regional oxygen saturation and cerebral oxygen extraction were monitored.Results: Cerebral blood flow was as follows: baseline, 60 ± 17 mL/100 g/min; antegrade cerebral perfusion at 50 mL/kg/min, 56 ± 17 mL/100 g/min; antegrade cerebral perfusion at 30 mL/kg/min, 36 ± 9 mL/100 g/min; and antegrade cerebral perfusion at 10 mL/kg/min, 13 ± 6 mL/100 g/min. At an antegrade cerebral perfusion rate of 50 mL/kg/min, cerebral blood flow matched baseline (P = .87), as did regional oxygen saturation (P = .13). Antegrade cerebral perfusion at 30 mL/kg/min provided approximately 60% of baseline cerebral blood flow (P < .002); however, regional oxygen saturation was equal to baseline (P = .93). Antegrade cerebral perfusion at 10 mL/kg/min provided 20% of baseline cerebral blood flow (P < .001) and a lower regional oxygen saturation than baseline (P = .011). Cerebral oxygen extraction at antegrade cerebral perfusion rates of 30 and 50 mL/kg/min was equal to baseline (P = .53, .48) but greater than baseline (P < .0001) at an antegrade cerebral perfusion rate of 10 mL/kg/min. The distributions of cerebral blood flow and regional oxygen saturation were equal in each brain hemisphere at all antegrade cerebral perfusion rates.Conclusion: Cerebral blood flow increased with antegrade cerebral perfusion rate. At an antegrade cerebral perfusion rate of 50 mL/kg/min, cerebral blood flow was equal to baseline, but regional oxygen saturation and cerebral oxygen extraction trends suggested more oxygenation than baseline. An antegrade cerebral perfusion rate of 30 mL/kg/min provided only 60% of baseline cerebral blood flow, but cerebral oxygen extraction and regional oxygen saturation were equal to baseline. An antegrade cerebral perfusion rate that closely matches standard cardiopulmonary bypass conditions is between 30 and 50 mL/kg/min.

Discussion

2010-03-01

Dr Randall Griepp (New York, NY). I have no financial disclosures. Dr Sasaki, I congratulate you and your colleagues on addressing the issue of optimizing perfusion during pediatric cardiac surgery. I have a number of comments, criticisms, and questions, but I do have a soft spot for my colleagues from my former alma mater, so I will be as tactful as possible.

The Ross–Yacoub procedure for aneurysmal autograft roots: A strategy to preserve autologous pulmonary valves

2009-10-21

Objectives: Autograft dilatation is leading to an increase in root reoperations late after the Ross procedure. A 14-year clinical experience was reviewed to define the feasibility and outcome of the autograft valve–sparing root reoperation.Methods: One hundred twenty-six patients surviving an average of 7.4 ± 9.9 years after the Ross procedure underwent cross-sectional clinical and echocardiographic examination. Study end points were freedom from autograft dilatation (diameter >4 cm or 2.1 cm/m2), root reoperation, root replacement, and functional outcome after the valve-sparing reoperation.Results: Thirty-one (25%) patients had dilatation, with 45% ± 9% freedom at 14 years. In 14 (11%) patients an autograft aneurysm (>5.0 cm) was found: 12 had reoperations at 8.9 ± 2.6 years after the Ross procedure. Risk factors for root reoperation at multivariate analysis were root technique (P = .01), root dilatation (P = .001), and follow-up duration (P = .06). Two patients had root replacement, and 10 (83%) had remodeling with valve preservation (8 Yacoub procedures and 2 sinotubular junction/ascending aorta procedures); all survived reoperation. Absence of severe autograft insufficiency (P = .04) and convergent-type aneurysm (P = .05) were associated with successful valve preservation. Fourteen-year freedom from root reoperation was 80% ± 7%, and freedom from full root replacement was 97% ± 4%. At 3.2 ± 1.5 years (range, 0.2–4.8 years) after root reoperation, all patients are in New York Heart Association class I and are medication free: 9 of 10 patients have mild autograft valve insufficiency or less, and 1 required valve replacement 51 months after remodeling. One patient carried out 2 uncomplicated pregnancies 3 and 4 years after the Ross–Yacoub procedure.Conclusions: Root reoperation with pulmonary valve preservation is feasible in the majority of patients with autograft aneurysms, allowing for maintenance of normal quality of life. Referral of patients with a dilated root before the appearance of severe valve insufficiency increases the likelihood of pulmonary valve sparing. Functional behavior of remodeled autograft roots is rewarding; however, continued observation is warranted.

Brain immaturity is associated with brain injury before and after neonatal cardiac surgery with high-flow bypass and cerebral oxygenation monitoring

2009-11-12

Background: New intraparenchymal brain injury on magnetic resonance imaging is observed in 36% to 73% of neonates after cardiac surgery with cardiopulmonary bypass. Brain immaturity in this population is common. We performed brain magnetic resonance imaging before and after neonatal cardiac surgery, using a high-flow cardiopulmonary bypass protocol, hypothesizing that brain injury on magnetic resonance imaging would be associated with brain immaturity.Methods: Cardiopulmonary bypass protocol included 150 mL · kg−1 · min−1 flows, pH stat management, hematocrit > 30%, and high-flow antegrade cerebral perfusion. Regional brain oxygen saturation was monitored, with a treatment protocol for regional brain oxygen saturation < 50%. Brain magnetic resonance imaging, consisting of T1-, T2-, and diffusion-weighted imaging, and magnetic resonance spectroscopy were performed preoperatively, 7 days postoperatively, and at age 3 to 6 months.Results: Twenty-four of 67 patients (36%) had new postoperative white matter injury, infarction, or hemorrhage, and 16% had new white matter injury. Associations with preoperative brain injury included low brain maturity score (P = .002). Postoperative white matter injury was associated with single-ventricle diagnosis (P = .02), preoperative white matter injury (P < .001), and low brain maturity score (P = .05). Low brain maturity score was also associated with more severe postoperative brain injury (P = .01). Forty-five patients had a third scan, with a 27% incidence of new minor lesions, but 58% of previous lesions had partially or completely resolved.Conclusions: We observed a significant incidence of both pre- and postoperative magnetic resonance imaging abnormality and an association with brain immaturity. Many lesions resolved in the first 6 months after surgery. Timing of delivery and surgery with bypass could affect the risk of brain injury.

Larger aortic reconstruction corresponds to diminished left pulmonary artery size in patients with single-ventricle physiology

2009-11-02

Background: Pulmonary artery size is a crucial determinant of hemodynamic energy loss in total cavopulmonary connections. We investigated the effect of aortic arch reconstruction on left pulmonary artery size based on their anatomic proximity.Methods: Thirty-two patients undergoing the Fontan operation, 16 with hypoplastic left heart syndrome and 16 with non–hypoplastic left heart syndrome, were selected from the multicenter Fontan magnetic resonance imaging database at the Georgia Institute of Technology. The 16 datasets were consecutive with full anatomic reconstructions of the total cavopulmonary connection and aortic arch with no artifacts. The size of the aorta along the transverse arch and left pulmonary artery size in the region below the aortic arch was quantified by using a previously validated skeletonization technique.Results: The transverse aortic and left pulmonary artery measurements (median, maximum, and minimum, respectively) for non–hypoplastic left heart syndrome were 2.2, 3.1, and 1.5 cm/m and 1.2, 1.6, and 0.2 cm/m, respectively, compared with 2.5, 4.1, and 2.0 cm/m and 0.9, 1.5, and 0.4 cm/m for patients with hypoplastic left heart syndrome. Thus the transverse aortic diameter of patients with hypoplastic left heart syndrome was, on average, 24% greater than that for patients with non–hypoplastic left heart syndrome (P < .05), whereas the left pulmonary artery diameter of patients with hypoplastic left heart syndrome was smaller than that of patients with non–hypoplastic left heart syndrome (P < .05). Regression analysis showed a significant negative correlation (P < .05) between aortic and left pulmonary artery diameters in both the hypoplastic left heart syndrome and non–hypoplastic left heart syndrome groups. However, when the study population was regrouped into reconstructed aorta and nonreconstructed aorta groups, the negative correlation was only significant for patients with reconstructed aortas, regardless of ventricular pathology (P < .02).Conclusions: Stage 1 aortic reconstruction procedures that result in a large aorta limit left pulmonary artery size in patients undergoing the Fontan operation.

Outcomes of the bidirectional Glenn procedure in patients less than 3 months of age

Orlando Petrucci, Philip R. Khoury, Peter B. Manning, Pirooz Eghtesady — 2009-11-12

Objective: The bidirectional Glenn procedure is a well-established procedure performed as part of the single-ventricle palliation pathway. Numerous studies have highlighted the potential benefits of an “early” BDG procedure. The ideal age to perform the BDG procedure, however, remains uncertain. We report our experience with the BDG procedure in patients younger than 3 months.Methods: One hundred sixty-nine consecutive patients from 1998 to 2007 undergoing the BDG procedure were divided into 2 groups: younger than 3 months (n = 20) and older than 3 months. The groups were compared for 26 variables. All data were analyzed with Kaplan–Meier survival analysis and the Cox proportional hazard regression test to assess the probability of survival after the BDG procedure in both groups. A stepwise regression analysis was performed for identification of independent factors for postoperative oxygen saturation at hospital discharge.Results: The groups were comparable, with an equal distribution of patients with right-sided or left-sided single-ventricle anatomy. Although intensive care unit length of stay, ventilation time, and hospital length of stay were longer in the younger group, room air oxygen saturations at discharge, both early and late mortality, and time to the Fontan procedure were similar between groups. The independent variables found for death after the BDG procedure were preoperative mean pulmonary artery pressure, atrioventricular valve regurgitation, and postoperative oxygen saturations at hospital discharge. Survival in patients with hypoplastic left heart syndrome was comparable between groups after 5 years of follow-up.Conclusion: The BDG procedure is feasible and safe in patients as young as 2 months of age, with early and late mortality equivalent to that seen in older patients.

Lesion-specific outcomes in neonates undergoing congenital heart surgery are related predominantly to patient and management factors rather than institution or surgeon experience: A Congenital Heart Surgeons Society Study

2009-11-12

Objective: To identify the role of institution and surgeon factors, including case volume and experience, on survival of neonates with complex congenital heart disease.Methods: A total of 2421 neonates from 4 groups—transposition of the great arteries (n = 829), pulmonary atresia with intact ventricular septum (n = 408), Norwood (n = 710), and interrupted aortic arch (n = 474)—were prospectively enrolled from Congenital Heart Surgeons Society institutions. Multivariable analysis of risk-adjusted survival was performed for each group, entering each institution or surgeon into the multivariable analysis separately. Institutional performance was defined as [predicted survival – actual survival]. Neutralization of risk factors within each institution was evaluated using complex interaction terms. Institution and surgeon experience, defined by 5 domains (total case volume, total time each operation was performed, cases per year, rank-order of cases, case velocity), were also investigated.Results: Institutional performance varied among all groups. Improved outcomes in Norwood and pulmonary atresia with intact ventricular septum were unrelated to any “experience” domains, whereas improved outcomes in transposition of the great arteries were significantly related to increased experience in most domains. No institution enrolling in all 4 studies ranked number 1 in performance for all groups. Neutralization of low birth weight as a risk factor contributed to decreased mortality after Norwood in one institution.Conclusion: Survival of neonates with complex congenital heart disease is influenced more by patient and management factors than by institution or surgeon experience. Institutional excellence in managing some diagnostic groups does not indicate similar performance for all diagnostic groups. Weighted risk-adjusted comparisons could provide a mechanism to improve results in institutions with less than optimal outcomes.

Evaluation of mediastinal lymph nodes with endobronchial ultrasound: The thoracic surgeon's perspective

2010-03-01

Objective: The objectives of our study are to (1) describe our experience with endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes and (2) illustrate how thoracic surgeons facile with ultrasound-guided fine-needle aspiration have the potential to streamline patient care.Methods: We performed a retrospective review of all patients within our prospectively maintained database who underwent endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes by thoracic surgeons at the University of Minnesota from September 1, 2006, to April 15, 2009. We included patients in our analysis if (1) their malignancy diagnosis was based on immediate endobronchial ultrasound-guided fine-needle aspiration cytology or (2) they underwent a confirmatory procedure (ie, mediastinoscopy or thoracoscopy) that sampled the same mediastinal lymph node stations biopsied by endobronchial ultrasound-guided fine-needle aspiration to verify normal, benign, or nondiagnostic endobronchial ultrasound-guided fine-needle aspiration findings. We also collected data on additional diagnostic or therapeutic procedures performed in the same anesthesia setting as endobronchial ultrasound-guided fine-needle aspiration.Results: Over the study period, 192 patients underwent endobronchial ultrasound-guided fine-needle aspiration; 98 patients met our inclusion criteria. We achieved a sensitivity of 87.9%, specificity of 97.4%, and diagnostic accuracy of 91.7%. For patients undergoing lung cancer staging, we sampled a mean of 3.0 ± 0.9 mediastinal lymph node stations. Half of our patients underwent an additional diagnostic or therapeutic procedure at the time of endobronchial ultrasound-guided fine-needle aspiration.Conclusion: Thoracic surgeons who perform endobronchial ultrasound-guided fine-needle aspiration can achieve excellent sensitivity, specificity, and diagnostic accuracy while adhering to sound oncologic principles. Endobronchial ultrasound-guided fine-needle aspiration adds to the thoracic surgeon's unique capacity to expedite a diagnostic workup and treatment, thereby streamlining patient care.

Discussion

2010-03-01

Dr Hiran Fernando (Boston, Mass). Dr Andrade, a common clinical challenge for thoracic surgeons is accurately diagnosing a patient with a specific benign pathology, such as sarcoidosis, and often these patients will have a number of diagnostic procedures before referral to a thoracic surgeon, including transbronchial needle aspiration or fine-needle aspiration. You describe success rates for benign and malignant diagnoses, and you separate these in Table 3 in your article. You mention that you have a lower sensitivity for a benign diagnosis of 72.7% versus 87.9% for malignancy. Do you mean that this 72.7% was simply to make a benign rather than a cancer diagnosis or does this sensitivity refer to actually making a specific benign diagnosis, such as sarcoid or histoplasmosis? If you suspect that a patient up front has a benign diagnosis in a lymph node station that would be accessible by mediastinoscopy where you would get the whole lymph node, would you recommend mediastinoscopy for that patient or an initial EBUS on the basis of your results, and what would be your reasoning for your approach?

Nonoperative thoracic duct embolization for traumatic thoracic duct leak: Experience in 109 patients

2009-12-30

Objective: To demonstrate the efficacy of a minimally invasive, nonoperative, catheter-based approach to the treatment of traumatic chyle leak.Methods: A retrospective review of 109 patients was conducted to assess the efficacy of thoracic duct embolization or interruption for the treatment of high-output chyle leak caused by injury to the thoracic duct.Results: A total of 106 patients presented with chylothorax, 1 patient presented with chylopericardium, and 2 patients presented with cervical lymphocele. Twenty patients (18%) had previous failed thoracic duct ligation. In 108 of 109 patients, a lymphangiogram was successful. Catheterization of the thoracic duct was achieved in 73 patients (67%). In 71 of these 73 patients, embolization of the thoracic duct was performed. Endovascular coils or liquid embolic agent was used to occlude the thoracic duct. In 18 of 33 cases of unsuccessful catheterization, thoracic duct needle interruption was attempted below the diaphragm. Resolution of the chyle leak was observed in 64 of 71 patients (90%) post-embolization. Needle interruption of the thoracic duct was successful in 13 of 18 patients (72%). In 17 of the 20 patients who had previous attempts at thoracic duct ligation, embolization or interruption was attempted and successful in 15 (88%). The overall success rate for the entire series was 71% (77/109). There were 3 (3%) minor complications.Conclusion: Catheter embolization or needle interruption of the thoracic duct is safe, feasible, and successful in eliminating a high-output chyle leak in the majority (71%) of patients. This minimally invasive, although technically challenging, procedure should be the initial approach for the treatment of a traumatic chylothorax.

Discussion

2009-12-30

Dr N. Altorki (New York, NY). I have no disclosures. Dr Itkin, I want to congratulate your group, but especially Dr Cope, for developing this in 1998, perfecting it, and really advocating it. For decades the treatment of choice for high-volume chylous fistula has been surgical ligation of the thoracic duct, and over the years several important lessons have been learned. Foremost among these lessons is the need for prompt return to the operating room, usually within 7 or no more than 10 days from the index procedure, to avoid the deleterious effects of nutritional and immunologic depletion.

Modulation of growth in human esophageal adenocarcinoma cells by group IIa secretory phospholipase A2

2010-03-01

Objective: Esophageal adenocarcinoma is thought to arise from lesions produced by chronic esophageal inflammation. Secretory phospholipase A2 is an important mediator of mucosal response to gastroesophageal reflux, but its role in the function of mature cancer cells is unclear. We sought to determine the influence of group IIa secretory phospholipase A2 on proliferation of human esophageal adenocarcinoma cells.Methods: FLO-1 and OE33 cells derived from human esophageal adenocarcinoma were cultured with standard techniques. Cells were treated with 1-, 5-, 10-, and 20-μmol/L doses of 5-(4-benzyloxyphenyl)-4S-(7-phenylheptanoylamino)pentanoic acid, a specific inhibitor of group IIa secretory phospholipase A2, for 72 hours. Gene for group IIa secretory phospholipase A2 (PLA2G2A) was overexpressed and silenced with lentiviral infection techniques. Cell proliferation and viability were measured with standard 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide and bromodeoxyuridine incorporation assays. All assays were performed in triplicate. PLA2G2A expression was measured with quantitative reverse transcriptase polymerase chain reaction; protein levels were detected with immunofluorescence microscopy. Statistical analysis was by analysis of variance with Fisher post hoc analysis.Results: Secretory phospholipase A2 protein was found in both malignant esophageal adenocarcinoma cell lines. Treatment with specific group IIa secretory phospholipase A2 inhibitor resulted in dose-dependent reductions in growth and cell number in both cell lines. Overexpression of PLA2G2A resulted in enhanced cancer cell growth, whereas gene knockdown attenuated growth.Conclusions: Group IIa secretory phospholipase A2 appears significant in growth and proliferation of human esophageal adenocarcinoma cells. Secretory phospholipase A2 inhibition should be studied further regarding potential chemopreventive and therapeutic properties in esophageal adenocarcinoma.

Discussion

2010-03-01

Dr Ross M. Bremner (Phoenix, Ariz). I thank Dr Mauchley and colleagues for providing me with a manuscript well in advance of the meeting, but even more for providing me with a new and improved manuscript just this morning. This manuscript contains all their latest data, and it is a tribute to the Society that the opportunity of presenting this work today has stimulated Dr Mauchley and colleagues to produce another set of fairly intricate experiments to greatly add to this article. In fact, the manuscript is quite impressive.

Sutureless pneumostasis using bioabsorbable mesh and glue during major lung resection for cancer: Who are the best candidates?

Kazuhiro Ueda, Toshiki Tanaka, Tao-Sheng Li, Nobuyuki Tanaka, Kimikazu Hamano — 2009-08-05

Objective: Preventing air leaks after major lung resection for cancer is mandatory for successful fast-track surgical intervention. We reported our preliminary results with performance of pneumostasis by combining polyglycolic acid mesh and fibrin glue; however, the advantages of this combination over the conventional method have not been clarified.Methods: We controlled air leaks detected during an intraoperative water-seal test by using sutures and fibrin glue before April 2006 and by combining polyglycolic acid mesh and fibrin glue without sutures thereafter. We removed the chest tube the day after the air leaks stopped. For bias reduction in comparison with the 2 historical cohorts, we used the nearest available matching method with the estimated propensity score.Results: The durations of chest tube drainage and postoperative hospital stay were significantly shorter in the mesh-and-glue group (n = 61) than in the glue-alone group (n = 61). The incidence of postoperative pulmonary complications was lower in the mesh-and-glue group than in the glue-alone group (0% vs 7%, P = .042). According to a stratification analysis, the benefit of combining mesh and glue to reduce the duration of chest tube drainage was limited in patients undergoing upper lobe resection and in patients with severe emphysema undergoing other types of resection.Conclusion: Combining bioabsorbable mesh and glue for pneumostasis can reduce the duration of chest tube drainage, postoperative hospital stay, and pulmonary complications after major lung resection for cancer. Patients undergoing upper lobe resection and those with severe emphysema might be the best candidates for this technique.

Bilobectomy for non–small cell lung cancer: A search for clinical factors that may affect perioperative morbidity and long-term survival

2009-08-26

Objective: The resection of two lobes for non–small cell lung cancer has the potential for significant morbidity and mortality as well as a negative impact on survival. The purpose of this study is to analyze our bilobectomy experience.Methods: Age, gender, diagnosis, bilobectomy type, bilobectomy indication, operative technique, pathologic condition, major complications, stage, and survival were reviewed from 1984 through 2007. Major complications were compared by Fisher's exact testing. Kaplan–Meier survival curves were compared by log–rank and likelihood ratio analysis.Results: Bilobectomies were performed on 92 patients with non–small cell lung cancer. A total of 35 upper–middle and 57 middle–lower bilobectomies were performed. Indications for bilobectomy were bronchial involvement (n = 49), extension across the fissure (n = 36), or other reasons (n = 7). The 5-year survival for all patients was 42%. Significant differences in survival were observed among the different stages (stage I, 65%; stage II, 42%; stage III, 13%; P < .0001). Squamous cell carcinomas had a higher 5-year survival than adenocarcinomas (54% vs 32%), a difference that approached significance by log–rank test (P < .079) and reached significance by likelihood ratios (P < .048). When bilobectomy was performed for extension across the fissure, survival approached significance for squamous cell carcinomas (71%) over adenocarcinomas (42%) by log–rank test (P < .089) and was significant by likelihood ratio (P < .048) when comparing survival between adenocarcinoma and squamous cell carcinoma. Multivariate analysis demonstrated that increasing age (P = .0102) and upper&middle bilobectomy (P = .0285) adversely affected 5-year survival, whereas early-stage disease (P = .0245) beneficially affected 5-year survival.Conclusion: Bilobectomy can be performed with acceptable morbidity and mortality. Survival relates to disease stage. Optimal survival benefit occurs when the indication for bilobectomy is squamous cell carcinoma extending across the fissure.

Determination of the minimum number of lymph nodes to examine to maximize survival in patients with esophageal carcinoma: Data from the Surveillance Epidemiology and End Results database

2009-08-26

Objective: We used a population-based cancer registry to examine the association between lymph node counts and mortality to determine the minimum number of lymph nodes that should be examined as part of esophageal resection.Methods: Using the Surveillance Epidemiology and End Results database, we identified patients who had an esophagectomy for invasive esophageal carcinoma from 1988 through 2005 and who had a known number of lymph nodes examined pathologically. After stratifying patients (0, 1–11, 12–29, and 30 or more lymph nodes examined) based on a recursive partitioning analysis, we assessed the association between lymph nodes counts and mortality using the Kaplan-Meier method. To adjust for potential confounding covariates, we used a Cox proportional hazards regression model.Results: Of the patients in the Surveillance Epidemiology and End Results database with esophageal cancer, 4882 met our inclusion criteria. We noted a significant difference between the lymph node groups with regards to unadjusted all-cause (P < .0001) and cancer-specific mortality (P = .004). After adjusting for cancer registry, patient factors, tumor characteristics, and timing of radiation therapy, we noted a significant difference between the lymph node groups with regards to all-cause and cancer-specific mortality. Compared with patients who had no lymph node evaluation, only patients who had more than 12 lymph nodes examined had a significant improvement in mortality; patients who had 30 or more lymph nodes examined had significantly lower mortality rates than the other groups.Conclusion: To maximize all-cause and cancer-specific survival, esophageal cancer patients should have at least 30 lymph nodes examined pathologically as part of esophageal resection.

Preoperative very short-term, high-dose erythropoietin administration diminishes blood transfusion rate in off-pump coronary artery bypass: A randomized blind controlled study

2009-12-30

Objective: Human recombinant erythropoietin has been used to obtain a rapid increase in red blood cells before surgery. Previously, the shortest preparatory interval has been 4 days, but at the European Hospital only 2.4 days on average separate hospitalization and surgery. We therefore proposed a randomized blind trial to test the efficacy of high-dose erythropoietin for very short-term administration.Methods: All patients presenting with a diagnosis of isolated coronary vessel disease were randomized to either erythropoietin therapy or a control group. Patients with a creatinine level greater than 2 mg/dL or hemoglobin level greater than 14.5 g/dL were excluded. Hemoglobin values were collected preoperatively and on postoperative days 1 and 4. Blood loss and blood transfusion rate were recorded at the time of discharge.Results: We enrolled 320 consecutive patients in the study. No significant difference was found in preoperative parameters, postoperative blood loss, or mean preoperative hemoglobin levels. On postoperative day 4, mean hemoglobin was 15.5% higher in the erythropoietin group (10.70 ± 0.72 g/dL vs 9.26 ± 0.71 g/dL; P < .05). This group required 0.33 units of blood per patient, whereas the controls required 0.76 units per patient (risk ratio 0.43, P = .008).Conclusion: A significant reduction in transfusion rate and a significant increase in hemoglobin values were observed in the erythropoietin group. No adverse events related to erythropoietin administration were recorded. A very short preoperative erythropoietin administration seems to be a safe and easy method to reduce the need for blood transfusions.

Discussion

2009-12-30

Dr Colleen Koch (Cleveland, Ohio). You present intriguing data demonstrating reduced red cell transfusion in patients receiving very short-term use of erythropoietin. I have 3 questions for you, and they pertain to the timing of administration, adverse events, and cost.

Is robotic mitral valve repair a reproducible approach?

2009-12-28

Objective: We sought to review the surgical outcomes of our initial 120 robotic mitral valve repairs from June 2005 through April 2009.Methods: The initial 74 repairs were performed with the first-generation da Vinci robot (Intuitive Surgical, Inc, Sunny Vale, Calif), and the last 46 were performed with the da Vinci Si HD model. All patients received an annuloplasty band and 1 or more of the following: leaflet resection; annuloplasty; basal chord transposition, polytetrafluoroethylene neochordal replacement, or both; and edge-to-edge repair.Results: The overall mean age was 58.4 ± 10.5 years, and 64% were male. There was 1 (0.8%) hospital mortality. Five patients required mitral valve replacement for a failed repair. Another patient had mitral valve rerepair on postoperative day 2. Except for 2 early reoperations for postoperative bleeding, all of the complications and failed repairs requiring operative revision occurred with the original robot. Postdischarge transthoracic echocardiographic follow-up was available on 107 (93%) of 115 patients, with a median follow-up of 321 days. None to mild mitral regurgitation was seen in 102 (89%) patients, moderate mitral regurgitation was seen in 9 (8.4%) patients, and severe mitral regurgitation was seen in 3 (2.8%), with 1 patient undergoing mitral valve replacement and 2 patients being medically managed.Conclusions: The majority of complications and all the repeat operations for failed mitral valve repair occurred with the older-model da Vinci robot. The newer da Vinci Si HD system, with the addition of an adjustable left atrial roof retractor, improves mitral valve exposure, enhancing the surgeon's ability to repair and test the valve. We have progressed to successful repair of all types of degenerative mitral valve pathology and have found the approach reproducible.

Apical myectomy: A new surgical technique for management of severely symptomatic patients with apical hypertrophic cardiomyopathy

2010-03-01

Objective: Apical hypertrophic cardiomyopathy is a morphologic variant in which the hypertrophy is primarily localized to the apex of the left ventricle. A subset of patients have progressive, drug-refractory diastolic heart failure with severely limiting symptoms caused by low cardiac output. Heart transplantation has been the only therapeutic option available for such patients. This study analyzes clinical and hemodynamic outcomes of a novel surgical technique to improve diastolic filling by means of left ventricular cavity enlargement.Methods: Forty-four symptomatic patients underwent apical myectomy to augment left ventricular end-diastolic volume. Myectomy was performed through an apical incision, and hypertrophic muscle was excised at the apex and midventricle. Information from a prospective database was supplemented by surveys, patient contact, and medical records.Results: The mean age of the patients was 50 ± 17 years, and 66% were women. All patients were severely limited with dyspnea, 61% had angina, and 59% had syncope/presyncope. Ninety-one percent of patients were in New York Heart Association class III or IV. A mean of 16 ± 7 g of muscle was removed. Preoperative and postoperative hemodynamic catheterization (n = 14) showed a decrease in left ventricular end-diastolic pressure from 28 ± 9 to 24 ± 7 mm Hg (P = .002) and an increase in end-diastolic volume index from 55 ± 17 to 68 ± 18 mL/m2 (P = .003). Invasive measurements of stroke volume increased from 56 ± 17 to 63 ± 19 mL (P = .007). Of the 42 patients who survived to hospital discharge, 41 had improvement in symptoms. Mean peak maximum oxygen consumption with exercise (n = 5) increased from 13.5 ± 4.4 to 15.8 ± 4.6 mL/kg per minute. Survival at 1, 3, and 5 years was 95%, 81%, and 81%, respectively. At follow-up of 2.6 ± 3.1 years, 23 (74%) patients were in New York Heart Association class I or II. One patient underwent heart transplantation 5 years after apical myectomy.Conclusions: Apical myectomy improves functional status by decreasing left ventricular end-diastolic pressure, improving operative compliance, and increasing stroke volume. This procedure might be of value in other patients with hypertrophic cardiomyopathy who have severe hypertrophy and small left ventricular end-diastolic volume.

Discussion

2010-03-01

Dr Nicholas G. Smedira (Cleveland, Ohio). I have no disclosures. Dr Schaff, as usual, your presentation was clear and very informative, and I want to congratulate you on outstanding results. My first question relates to whether we are underestimating the prevalence of this disorder? We were taught 10 years ago that the incidence of obstruction in patients with hypertrophic obstructive cardiomyopathy was around 25%. We now know that with provocative maneuvers, it is as high as 75%. Are there more patients out there with this disorder than we are appreciating?

Is conventional aortic arch surgery justifiable in octogenarians?

2010-03-01

Objective: Although the surgical result of conventional aortic arch replacement has been improved with sophisticated techniques, it is still a deeply invasive procedure. On the other hand, advanced age has been reported as a factor of increased morbidity and mortality in patients undergoing cardiovascular surgery. The number of octogenarians, however, is steadily increasing. The aim of this study is to analyze the outcome of aortic arch surgery in octogenarians.Methods: From January 1995 to September 2007, 113 octogenarians and 1 nonagenarian underwent aortic arch replacement (mean age, 83.0 ± 2.5; 60 men) in our institute. All patients underwent surgery under hypothermic circulatory arrest. The lowest body temperature during circulatory arrest was below 22°C until 2001 and 28°C after 2002. Antegrade selective cerebral perfusion or retrograde cerebral perfusion was used as an additional brain protection technique. Emergency operations were performed in 37 (32.5%) patients; of them, 28 (75.7%) were for acute aortic dissection. Seventy-four (64.9%) patients underwent total arch aortic replacement and the other 40 (35.1%), hemiarch aortic replacement. Concomitant operations consisted of aortic root replacement in 1 patient, aortic valve replacement in 4, and coronary artery bypass grafting in 25.Results: The average duration of circulatory arrest, myocardial ischemic time, and pump time was 57 ± 21, 123 ± 45, and 224 ± 80 minutes, respectively. The total hospital mortality was 7.9% (9/114), 5.2% (4/77) for elective operations and 13.5% (5/37) for emergency operations (P = .12). The hospital mortality was 19.2% (5/26) until 2001 and decreased to 4.5% (4/88) after 2002 (P = .015). Eleven (9.6%) of the 114 patients had a perioperative stroke, and 8 (7.0%) had transient neurologic dysfunction. Other complications were respiratory failure in 17 (14.9%) patients, bleeding in 6 (5.3%), gastrointestinal tract problems in 3 (2.6%), and mediastinitis in 1 (8.8%) patient. Chronic obstructive pulmonary disease was a multivariate predictor (P < .05) of hospital death and emergency operation was a predictor of perioperative stroke. The postoperative 1-year survival was 84.8%, the 3-year survival was 68.5%, and the 5-year survival was 58.1%.Conclusions: The outcome of conventional aortic arch surgery in octogenarians is improving. The operations were performed with an acceptable operative risk even under emergency situations, including acute aortic dissection. The conventional surgical option for aortic arch diseases should not be abandoned only because of the high chronologic age of the patient.

Selective endothelin-1 receptor type A inhibition in subjects undergoing cardiac surgery with preexisting left ventricular dysfunction: Influence on early postoperative hemodynamics

2010-01-14

Objective: A robust release of endothelin-1 with subsequent endothelin-A subtype receptor activation occurs in patients after cardiac surgery requiring cardiopulmonary bypass. Increased endothelin-A subtype receptor activation has been identified in patients with poor left ventricular function (reduced ejection fraction). Accordingly, this study tested the hypothesis that a selective endothelin-A subtype receptor antagonist administered perioperatively would favorably affect post-cardiopulmonary bypass hemodynamic profiles in patients with a preexisting poor left ventricular ejection fraction.Methods: Patients (n = 29; 66 ± 2 years) with a reduced left ventricular ejection fraction (37% ± 2%) were prospectively randomized in a blinded fashion, at the time of elective coronary revascularization or valve replacement requiring cardiopulmonary bypass, to infusion of the highly selective and potent endothelin-A subtype receptor antagonist sitaxsentan at 1 or 2 mg/kg (intravenous bolus; n = 9, 10 respectively) or vehicle (saline; n = 10). Infusion of the endothelin-A subtype receptor antagonist/vehicle was performed immediately before separation from cardiopulmonary bypass and again at 12 hours after cardiopulmonary bypass. Endothelin and hemodynamic measurements were performed at baseline, at separation from cardiopulmonary bypass (time 0), and at 0.5, 6, 12, and 24 hours after cardiopulmonary bypass.Results: Baseline plasma endothelin (4.0 ± 0.3 fmol/mL) was identical across all 3 groups, but when compared with preoperative values, baseline values obtained from age-matched subjects with a normal left ventricular ejection fraction (n = 37; left ventricular ejection fraction > 50%) were significantly increased (2.9 ± 0.2 fmol/mL, P < .05). Baseline systemic (1358 ± 83 dynes/sec/cm−5) and pulmonary (180 ± 23 dynes/sec/cm−5) vascular resistance were equivalent in all 3 groups. As a function of time 0, systemic vascular resistance changed in an equivalent fashion in the post-cardiopulmonary bypass period, but a significant endothelin-A subtype receptor antagonist effect was observed for pulmonary vascular resistance (analysis of variance; P < .05). For example, at 24 hours post-cardiopulmonary bypass, pulmonary vascular resistance increased by 40 dynes/sec/cm−5 in the vehicle group but directionally decreased by more than 40 dynes/sec/cm−5 in the 2 mg/kg endothelin-A subtype receptor antagonist group (P < .05). Total adverse events were equivalently distributed across the endothelin-A subtype receptor antagonist/placebo groups.Conclusion: These unique findings demonstrated that infusion of an endothelin-A subtype receptor antagonist in high-risk patients undergoing cardiac surgery was not associated with significant hemodynamic compromise. Moreover, the endothelin-A subtype receptor antagonist favorably affected pulmonary vascular resistance in the early postoperative period. Thus, the endothelin-A subtype receptor serves as a potential pharmacologic target for improving outcomes after cardiac surgery in patients with compromised left ventricular function.

A novel approach to prevent spinal cord ischemia: Inoue stent graft with a side branch of small caliber for the reconstruction of the artery of Adamkiewicz

2009-12-09

Objectives: Paraplegia remains a serious complication after endovascular repair of thoracic aortic aneurysms, and it has been reported that paraplegia might be due to ischemia of the artery of Adamkiewicz. This study investigates the feasibility of an Inoue stent graft with a side branch of a small caliber for the reconstruction of the intercostal artery branching the artery of Adamkiewicz.Methods: Branched Inoue stent grafts were implanted into the thoracic aorta and 11th intercostal artery of 5 mongrel dogs. The side branch measured 3 × 5 mm and contained a bare-metal coronary stent for fixing to the intercostal arterial wall. Aortography and selective angiography of the 11th intercostal artery were performed before and immediately after implantation and after 1, 4, 8, and 12 weeks. The luminal diameter of the intercostal artery before implantation was 2.4 ± 0.3 mm.Results: All stent grafts were successfully deployed. The main body of the graft did not develop endoleak or migrate, and the side branch remained patent for 12 weeks. Angiography performed 1 week postoperatively revealed smooth flow with slight stenosis (4.2% ± 1.7%) along the side branches and the intercostal arteries in all dogs. Four weeks postoperatively, however, mild concentric stenosis (38% ± 16%) along the side branch was observed in 4 of the 5 dogs. The percent stenosis at 8 and 12 weeks was 38% ± 15% and 33% ± 11%, respectively; these values were not significantly different from the value at 4 postoperative weeks.Conclusions: A novel Inoue stent graft with a side branch of small caliber was successfully deployed into the canine thoracic aorta and intercostal artery; the side branch remained patent for 12 weeks. This novel technique may enable endovascular reconstruction of the Adamkiewicz artery.

Aortic valve reconstruction in myxomatous degeneration of aortic valves: Are fenestrations a risk factor for repair failure?

2009-08-19

Objective: Aortic valve repair is a more recent approach for the treatment of aortic regurgitation. Limited data exist for reconstruction in specific pathologies with isolated cusp pathology. We analyzed the results of aortic valve repair in patients with aortic regurgitation caused by myxomatous cusp prolapse in the presence of tricuspid valve anatomy and normal root size.Methods: Over a 12-year period, 111 patients underwent aortic valve reconstruction for regurgitant tricuspid aortic valves without concomitant root dilatation. Cusp prolapse was caused by myxomatous degeneration in 72 subjects (group I) and associated with fenestrations in 39 subjects (group II). Prolapse was corrected by means of plication of the free margin in the presence of normal cusp tissue only (n = 62) or combined with triangular resection of cusp tissue (n = 10). It was treated with additional closure of the fenestration with autologous pericardium in 39 instances (group II). Follow-up was complete in 98.5% (cumulative 385 years).Results: Hospital mortality was 1.8%, and during follow-up, there was 1 thromboembolic event and no endocarditis. Freedom from reoperation at 5 and 8 years was 96%.Conclusions: Isolated cusp prolapse is a relevant cause of aortic regurgitation in tricuspid aortic valves without concomitant root dilatation. In myxomatous stretching of cusp tissue, plication of the free margin suffices to restore cusp geometry and aortic valve function. In the presence of fenestrations, reconstruction of normal cusp configuration can be achieved by means of closure of the fenestration with a pericardial patch. The midterm stability of both approaches is good.

Homograft aortic root replacement in native or prosthetic active infective endocarditis: Twenty-year single-center experience

2009-09-22

Objective: We compared early and long-term results of cryopreserved homograft aortic root replacement in native valve endocarditis or prosthetic valve endocarditis associated with periannular abscess.Methods: Between May 1986 and December 2007, 1163 patients with endocarditis were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) had homograft aortic root replacement due to 99 cases of native valve endocarditis (45%) and 122 of prosthetic valve endocarditis (55%). Perinannular abscess developed in 189 patients (86%), and aortoventricular dehiscence in 120 (63.5%) of them. Perioperative characteristics, probability of survival, freedom from recurrence, and reoperation were analyzed. Follow-up (mean 5.2 ± 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1127 patient-years.Results: Overall native valve endocarditis survival at 30 days and 1, 5, and 10 years was 83.8% ± 3.7%, 76.6% ± 4.3%, 66.5% ± 4.9%, and 47.3% ± 5.6%, respectively, significantly better than for patients with prosthetic valve endocarditis, who had a greater tendency toward abscess formation (P = .029). Thirty-one patients (14.0%) required reoperation either for structural valve deterioration (n = 19, 8.6%), with a greater tendency in patients aged <40 years, or for recurrent endocarditis of the homograft (n = 12, 5.4%). One-year reoperation mortality rate was 16.1% (n = 5).Conclusions: Homograft aortic root replacement in active infective endocarditis with periannular abscess formation shows satisfactory early and long-term results with significantly better survival in native valve endocarditis than prosthetic valve endocarditis. It is associated with a low recurrence rate, although the risk of structural valve deterioration increases over time, especially in young patients, and reoperation remains a challenge. In our institution, the homograft remains the preferred valve substitute in active infective endocarditis with periannular abscess formation.

Skeletonized internal thoracic artery harvesting reduces chest wall dysesthesia after coronary bypass surgery

2009-09-23

Objective: A pain syndrome related to intercostal nerve injury during internal thoracic artery harvesting causes significant morbidity after coronary bypass surgery. We hypothesized that its incidence and severity might be reduced by using skeletonized internal thoracic artery harvesting rather than pedicled harvesting.Methods: In a prospective double-blind clinical trial, 41 patients undergoing coronary bypass were randomized to receive either unilateral pedicled or skeletonized internal thoracic artery harvesting. Patients were assessed 7 (early) and 21 (late) weeks postoperatively with reproducible sensory stimuli used to detect chest wall sensory deficits (dysesthesia) and with a pain questionnaire used to assess neuropathic pain.Results: At 7 weeks postoperatively, the area of harvest dysesthesia (percentage of the chest) in the skeletonized group (n = 21) was less (median, 0%; interquartile range, 0–0) than in the pedicled group (n = 20) (2.8% [0–13], P = .005). The incidence of harvest dysesthesia at 7 weeks was 14% in the skeletonized group versus 50% in the pedicled group (P = .02). These differences were not sustained at 21 weeks, as the median area of harvest dysesthesia in both groups was 0% (P = .89) and the incidence was 24% and 25% in the skeletonized and pedicled groups, respectively (P = 1.0). The incidence of neuropathic pain in the skeletonized group compared with the pedicled group was 5% versus 10% (P = .6) at 7 weeks and 0% versus 0% (P = 1.0) at 21 weeks.Conclusions: Compared with pedicled harvesting, skeletonized harvesting of the internal thoracic artery provides a short-term reduction in the extent and incidence of chest wall dysesthesia after coronary bypass, consistent with reduced intercostal nerve injury and therefore the reduced potential for neuropathic chest pain.

Reduction in incidence of deep sternal wound infections: Random or real?

2009-12-17

Objective: Comorbidities predisposing cardiac surgical patients toward deep sternal wound infection, such as diabetes and obesity, are rising in the United States. Longitudinal analysis of risk factors, morbidity, and mortality was performed to assessed effects of these health trends on deep sternal wound infection rates.Methods: In this retrospective analysis of all median sternotomies performed at a single institution from 1991 through 2006, demographic and surgical characteristics were identified from a prospective database. The cohort was separated into periods from 1992 through 2001 and 2002 through 2006 to identify longitudinal trends in risk factors for deep sternal wound infection. Univariate and matched multivariable analyses were performed.Results: Overall, study population had increased comorbidities associated with deep sternal wound infection such as obesity, diabetes, and advanced age. Deep sternal wound infections were treated in 285 of 21,000 sternotomies performed during study period (1.35%). Deep sternal wound infection rates decreased from 1.57% to 0.88% in last 5 years. Rate of deep sternal wound infection was reduced among patients with diabetes from 3.2% to 1.0%. Multivariable analysis showed diabetes and smoking to be eliminated as risk factors in last 5 years. Prolonged bypass time was the only variable independently associated with deep sternal wound infection for the entire period. Thirty-day and 1-year mortalities for deep sternal wound infection did not change significantly.Conclusions: Analysis of a large series of cardiac surgical patients demonstrates significant reduction in deep sternal wound infection incidence in 15 years. Introduction of perioperative intravenous insulin may explain some observed risk reduction. Efforts should focus on prevention, because mortality remains elevated.

The use of spirometry testing prior to cardiac surgery may impact the Society of Thoracic Surgeons risk prediction score: A prospective study in a cohort of patients at high risk for chronic lung disease

2009-12-11

Objectives: Chronic lung disease is a significant comorbidity in patients undergoing cardiac surgery. Chronic lung disease is currently being classified and reported to the Society of Thoracic Surgeons database by using either clinical interview or spirometric testing. We sought to compare the chronic lung disease classification captured by the 2 methods.Methods: We performed a prospectively designed study in which patients presenting for cardiac surgery, excluding emergent patients, were screened for a history of asthma, a history of 10 or more pack-years of smoking, a persistent cough, and the use of oxygen. Each selected patient underwent spirometry. The presence and severity of chronic lung disease was coded per Society of Thoracic Surgeons guidelines by using the 2 methods of clinical report and spirometric results. The chronic lung disease classifications were compared, and differences were determined by using concordance and discordance rates. The results were then used to construct Society of Thoracic Surgeons–predicted risk models.Results: The discordant rate was 39.1%, with underestimation of the severity of chronic lung disease in 94% of misclassified patients. This affected the Society of Thoracic Surgeons–predicted risk models for prolonged ventilation, morbidity/mortality, and mortality by increasing the predicted risk when spirometry was used for morbidity/mortality by an average of 1.5 ± 1.2 percentage points (P < .001) and prolonged ventilation time by an average of 1.3 ± 1.4 percentage points (P < .001).Conclusion: The use of patient history for symptoms, medication, and/or oxygen use as the only method to determine chronic lung disease for this subgroup of patients led to underreporting of chronic lung disease and underestimation of the risk for adverse outcomes. Therefore data submission to the Society of Thoracic Surgeons database should be designed to capture and correct for potential bias in the definition of chronic lung disease because the rate of spirometry in different centers in defining chronic lung disease is not regulated.

Urinary proteomics before and after extracorporeal circulation in patients with and without acute kidney injury

2010-03-01

Objective: Acute kidney injury is a well-known complication with high morbidity and mortality after cardiopulmonary bypass. Cardiopulmonary bypass–associated acute kidney injury is still poorly understood.Methods: Thirty-six patients undergoing elective cardiopulmonary bypass were enrolled. Spot urine samples before and after cardiopulmonary bypass were collected. Acute kidney injury was defined according to the RIFLE classification. To identify differentially regulated proteins after cardiopulmonary bypass, we first analyzed the urinary proteome before and after cardiopulmonary bypass. To identify differentially regulated proteins in acute kidney injury, we next compared the urinary proteome obtained on the first postoperative day between patients with and without acute kidney injury. Difference fluorescence gel electrophoresis was used to compare protein profiles and mass spectrometry to identify individual proteins.Results: After cardiopulmonary bypass, inflammation-associated (zinc-alpha-2-glycoprotein, leucine-rich alpha-2-glycoprotein, mannan-binding lectin serine protease 2, basement membrane-specific heparan sulfate proteoglycan, and immunoglobulin kappa) or tubular dysfunction-associated (retinol-binding protein, adrenomedullin-binding protein, and uromodulin) proteins were differentially regulated. Acute kidney injury developed in 6 of 36 patients. A modified urinary albumin was increased, and zinc-alpha-2-glycoprotein and a fragment of adrenomedullin-binding protein were decreased in patients with acute kidney injury. Decreased excretion of zinc-alpha-2-glycoprotein in patients with acute kidney injury was confirmed by Western blot and enzyme-linked immunosorbent assay in an independent cohort of 22 patients with and 46 patients without acute kidney injury.Conclusion: Cardiopulmonary bypass leads to increased urinary excretion of inflammatory proteins and markers of tubular injury. Zinc-alpha-2-glycoprotein is a potentially useful predictive marker for acute kidney injury after cardiopulmonary bypass surgery.

A multicenter randomized controlled trial to assess the feasibility of testing modified ultrafiltration as a blood conservation technology in cardiac surgery

2010-03-01

Objectives: Modified ultrafiltration is a technique after cardiopulmonary bypass whereby blood withdrawn from the aortic cannula is passed across a semipermeable membrane to hemoconcentrate. Unblinded trials have suggested that modified ultrafiltration is efficacious for blood conservation. The objective of this trial was to assess the feasibility of a model testing modified ultrafiltration in which all members of the surgical team were blinded to the intervention.Methods: Patients (<65kg) undergoing procedures involving cardiopulmonary bypass were randomized to undergo either modified ultrafiltration (n=29) or sham (circulation without an interposed filter, n=36) for 15minutes. The circuit was shielded from all members of the team except the perfusionist. A questionnaire was administered to determine the blinding success.Results: Modified ultrafiltration resulted in a removal of 1000±251mL of fluid and a reduction in the pump balance (1025±807 vs 1804±838; P < .001) with an increase in hemoglobin immediately after intervention (increase of 7.7±8.8g/L in modified ultrafiltration vs 3.8±5.1g/L in sham; P=.04). Introduction or increase in dose of vasopressors was more frequent in the modified ultrafiltration group (52% vs 28%; P=.048). Differences in red cell transfusion rates between groups did not reach statistical significance (P=.59). Blinding was successful for the anesthetist (blinding index 0.13 [95% confidence interval, 0.11–0.38] and the intensivist (blinding index, 0.09 [95% confidence interval, 0.14–0.31]) but not for the surgeon (blinding index, 0.24 [95% confidence interval, 0.05–0.42]). The compliance rate for the transfusion protocol was greater than 90%.Conclusions: Modified ultrafiltration was effective for hemoconcentration after cardiopulmonary bypass in patients of low body weight, but it is associated with an increased need for vasopressor support. The anesthetist and intensivist were successfully blinded to the intervention.

The successful application of simulation-based training in thoracic surgery residency

2009-12-28

Objective: We developed and tested a clinical simulation program in the principles and conduct of cardiopulmonary bypass with the aim of improving confidence and proficiency in this critical aspect of cardiac surgical care.Methods: Fifteen residents from 6 resident-training programs who reported no prior cardiopulmonary bypass observation or simulation-based perfusion experience participated in a cardiopulmonary bypass course involving both didactic lectures and hands-on simulation. A computer-controlled hydraulic model of the human circulation was used in a specifically designed multidisciplinary simulation center environment to give the participants hands-on training with both basic operations and specific perfusion crisis scenarios. Pretraining and posttraining assessments concerning confidence, knowledge, and applications with regard to cardiopulmonary bypass were administered and compared.Results: Likert scale scores on confidence-related items increased significantly (P < .001), from 59% ± 16% to 92% ± 8%. Pretraining versus posttraining scores (72% ± 14%) on similar cognitive items were not significantly different (P=.3636). Scores on similar open-ended application items before and after training improved from 62% ± 25% to 85±10% (P < .0001). All subjects agreed that simulation-based cardiopulmonary bypass training was superior to classroom- and clinic-based education and that the scenarios enhanced their learning experience.Conclusions: Simulation-based cardiopulmonary bypass training appears to be an effective technique to build the confidence of thoracic surgery residents regarding knowledge and applications. Scenario-based practice in a specifically designed simulated environment is a valuable adjunct to traditional educational methods and has the potential to improve the training of thoracic residents.

Radiofrequency ablation for Barrett's esophagus and low-grade dysplasia in combination with an antireflux procedure: A new paradigm

2010-01-14

Objective: Radiofrequency ablation for Barrett's esophagus in combination with an antireflux procedure has not been widely documented. We report our initial experience with radiofrequency ablation in association with antireflux procedure for Barrett's metaplasia and low-grade dysplasia.Methods: A total of 14 patients (10 male and 4 female patients) presented with Barrett's metaplasia (n=11) or low-grade dysplasia (n=3). Median age was 60 years (38–80 years). The severity of Barrett's esophagus was classified by length (in centimeters), appearance (circumferential/noncircumferential), and histology (1, normal; 2, Barrett's metaplasia; and 3, low-grade dysplasia). Radiofrequency ablation was performed with the HALO 360° or 90° systems (BARRX Medical, Sunnyvale, Calif).Results: Median follow-up was 17 months. The mean number of ablative procedures undertaken was 2.6 (range, 1–6). There was no mortality, but there were 2 perioperative complications after the antireflux procedure (pneumonia, 1; atrial fibrillation, 1). One patient had mild dysphagia requiring a single dilation 2 months after ablation. The mean length of Barrett's esophagus decreased from 6.2 to 1.2cm after treatment (P=.001). Barrett's grade decreased significantly (P=.003). Before therapy, circumferential Barrett's esophagus was present in 13 patients. At last endoscopy, only 1 patient had circumferential Barrett's esophagus present. The number of radiofrequency ablation treatments was significantly (P < .05) associated with success. All patients receiving 3 or more treatments had complete resolution of Barrett's metaplasia.Conclusions: Radiofrequency ablation performed either before or after an antireflux procedure is safe. This approach is effective for reducing or eliminating metaplasia and dysplasia. Long-term studies will be necessary to determine whether this approach can provide durable control of both reflux and Barrett's esophagus.

Use of carotid–subclavian arterial bypass and thoracic endovascular aortic repair to minimize cerebral ischemia in total aortic arch reconstruction

2010-01-18

Objective: Total aortic arch replacement typically requires hypothermic circulatory arrest, carrying risks of cerebral ischemia. We recently introduced left carotid–subclavian bypass before total aortic arch replacement with thoracic stent grafting to achieve hybrid arch reconstruction with short periods of selective antegrade cerebral perfusion.Methods: From 2004 to 2009, 332 patients underwent ascending aorta or arch replacements. Of these, 37 underwent total aortic arch replacement. In 2008, we began performing left carotid–subclavian bypass before subtotal arch replacement, with side-graft anastomoses to innominate and left carotid arteries. Patients then underwent aortic graft stent deployment to complete arch reconstruction. Twenty-eight patients underwent conventional arch replacement (group I); 9 underwent hybrid arch replacement (group II).Results: Selective antegrade cerebral perfusion time in group I was 33.3 ± 13.7 minutes versus 18.9 ± 9.2 minutes in group II (P = .007). Among group I patients, 82% required hypothermic circulatory arrest (vs 0% in group II, P < .001). Mean cardiopulmonary bypass and aortic crossclamp times were longer in group I than group II (P < .05). Incidence of neurologic complications was 14% in group I (4/28) versus 0% (0/9) in group II, although this finding did not reach statistical significance (P = .55).Conclusions: Left carotid–subclavian bypass before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction was associated with decreased selective antegrade cerebral perfusion, cardiopulmonary bypass, and aortic crossclamp times and eliminated hypothermic circulatory arrest. This technique may minimize neurologic complications associated with arch replacement and provide a viable hybrid approach to patients with arch aneurysms and dissections.

Discussion

2010-01-18

Dr John A. Kern (Charlottesville, Va). Dr Xydas, I congratulate you on a nice presentation and study. Looking back at your last 330-odd aortic patients, as you point out, 37 underwent TAAR procedures with good results. With the advent of endovascular technology, your group, like many groups, is getting creative in ways to minimize circulatory arrest times, minimize cerebral malperfusion times, and improve outcomes, and certainly with this study and this small group of patients you have done that. You have certainly demonstrated decreased CPB, crossclamp, and circulatory arrest times. I really have just a few questions, some of which are technical. Tell me about the CSB. Did you always do that concomitantly with the arch procedure, or did you do that a day or so before? In addition to that, because it appears that it is routine, because you are using the CSB to maintain carotid perfusion, did you necessarily image the head to define the cerebrovascular anatomy?

In vivo monitoring of function of autologous engineered pulmonary valve

2010-03-01

Objectives: Clinical translation of tissue-engineered heart valves requires valve competency and lack of stenosis in the short and long term. Early studies of engineered valves showed promise, although lacked complete definition of valve function. Building on prior experiments, we sought to define the in vivo changes in structure and function of autologous engineered pulmonary valved conduits.Methods: Mesenchymal stem cells were isolated from neonatal sheep bone marrow and seeded onto a bioresorbable scaffold. After 4 weeks of culture, valved conduits were implanted. Valve function, cusp, and conduit dimensions were evaluated at implantation (echocardiography), at the experimental midpoint (magnetic resonance imaging), and at explant, at 1 day, and 1, 6, 12, or 20 weeks postoperatively (direct measurement, echocardiography). Histologic evaluation was performed.Results: Nineteen animals underwent autologous tissue-engineered valved conduit replacement. At implantation, valved conduit function was excellent; maximum transvalvular pressure gradient by Doppler echocardiography was 17 mm Hg; most valved conduits showed trivial pulmonary regurgitation. At 6 postoperative weeks, valve cusps appeared less mobile; pulmonary regurgitation was mild to moderate. At 12 weeks or more, valved conduit cusps were increasingly attenuated and regurgitant. Valved conduit diameter remained unchanged over 20 weeks. Dimensional measurements by magnetic resonance imaging correlated with direct measurement at explant.Conclusions: We demonstrate autologous engineered tissue valved conduits that function well at implantation, with subsequent monitoring of dimensions and function in real time by magnetic resonance imaging. In vivo valves undergo structural and functional remodeling without stenosis, but with worsening pulmonary regurgitation after 6 weeks. Insights into mechanisms of in vivo remodeling are valuable for future iterations of engineered heart valves.

Discussion

2010-03-01

Dr Sunjay Kaushal (Chicago, Ill). I really enjoyed that talk. I know these are very difficult experiments to perform. Could you provide more details on the histology? For instance, was there actual elastin formation at 20 weeks or how was the collagen organized?

The novel synthetic serine protease inhibitor CU-2010 dose-dependently reduces postoperative blood loss and improves postischemic recovery after cardiac surgery in a canine model

2010-03-01

Background: Serine protease inhibitors such as aprotinin reduce perioperative blood loss and may improve postpump cardiac performance owing to their anti-inflammatory properties. After the “aprotinin era,” we investigated the efficacy of the novel synthetic serine protease inhibitors CU-2010 with improved coagulatory and anti-inflammatory profile on blood loss and reperfusion injury in a canine model.Methods: Thirty-six dogs were divided into 6 groups: control, aprotinin (n = 8; Hammersmith scheme), and CU-2010 (0.5, 0.83, 1.25, and 1.66 mg/kg). All animals underwent 90 minutes of cardiopulmonary bypass with 60 minutes of hypothermic cardioplegic arrest. End points were blood loss during the first 2 hours after application of protamine, as well as recovery of myocardial contractility (slope of the end-systolic pressure–volume relationship, coronary blood flow, and vascular reactivity.Results: CU-2010 dose-dependently reduced blood loss to a degree comparable with that of aprotinin at lower doses and even further improved at higher doses (control/aprotinin/CU-2010 in increasing doses: 142 ± 13, 66 ± 17, 95 ± 16, 57 ± 17, 46 ± 3, and 13 ± 4 mL; P < .05). Whereas aprotinin did not influence myocardial function, CU-2010 improved the recovery of end-systolic pressure–volume relationship (control 60 ± 6 mg kg vs aprotinin 73 ± 7 mg/kg vs CU-2010 1.66 mg/kg; 102% ± 8%; P < .05). Coronary blood flow (52 ± 4 vs 88 ± 7 vs 96 ± 7; P < .05) and response to acetylcholine (44% ± 6% vs 77% ± 7% vs 81% ± 6%; P < .05) were improved by both aprotinin and CU-2010.Conclusions: The novel serine protease inhibitor CU-2010 significantly reduced blood loss after cardiac surgery comparable with aprotinin. Furthermore, an additionally improved anti-inflammatory profile led to a significantly improved postischemic recovery of myocardial and endothelial function.

Discussion

2010-03-01

Dr John A. Elefteriades (New Haven, Conn). I congratulate the authors on an excellent experimental investigation. This is an important topic because patients with complex cardiac surgical disease currently have excess bleeding since the withdrawal of aprotinin. The members of our group are strong proponents of aprotinin. In 2006 in this Journal we published a study of patients with aneurysms operated on with and without aprotinin. Everything was better with aprotinin, not only blood product transfusion but also respiratory function and other parameters.

A multicenter prospective randomized trial of a second-generation anastomotic device in coronary artery bypass surgery

Lars Wiklund, Marek Setina, Katherine Tsang, Robert Cusimano, Terrence Yau — 2010-03-01

Objective: Our objective was to perform a prospective randomized trial to evaluate the clinical and angiographic outcomes of a second-generation anastomotic device used for saphenous vein grafts.Methods: Patients undergoing nonemergency isolated coronary artery bypass grafting at 3 centers from August 2003 to December 2004 with at least 2 saphenous vein grafts were included. The proximal anastomoses were randomized, within each patient, to be constructed by the connector or by suture. One-year graft patency was evaluated by coronary angiography, magnetic resonance imaging, or computed tomography and analyzed on an intent-to-treat basis.Results: A total of 151 patients (65 ± 9 years, 87% male) who met inclusion/exclusion criteria were enrolled in the study and were analyzed. A total of 489 grafts were constructed (3.2 ± 0.5 grafts per patient), including 327 vein grafts randomized to the connector (n = 162) or suture (n = 165). In 162 connector grafts, 151 devices were successfully implanted. Technical issues required explantation of 11 devices intraoperatively. Patency was evaluated in 120 (81%) patients with 260 study grafts. Seventy-four patients with 161 grafts were evaluated by coronary angiography, 31 patients with 69 grafts by magnetic resonance imaging, and 15 patients with 30 grafts by computed tomography. The 1-year patency rate for study grafts constructed with the anastomotic connector was 92.2% (118/128) and for hand-sutured grafts, 91.7% (121/132).Conclusions: This prospective multicenter randomized controlled trial demonstrated good in-hospital and late clinical outcomes and excellent 1-year patency for vein grafts anastomosed both by the St Jude Medical second-generation aortic connector system and by hand. The patency of the connector grafts did not differ from that of the hand-sutured grafts.

Discussion

2010-03-01

Dr John W. Hammon, Jr (Winston-Salem, NC). This study was a continued analysis of data that were presented at this meeting last year. That study also showed that brain injury was magnified by rewarming whereas the brain was not overtly protected by maintaining the patient at a hypothermic temperature, thus incriminating rewarming in the injury profile of two different organ systems. For the benefit of any perfusionists present and those of us who have been studying this, I would like to ask you a couple of questions.

Percutaneous pulmonary polyurethane valved stent implantation

2009-10-12

Objectives: Transfemoral application of pulmonary heart valves has been studied for the past 10 years. Nevertheless, size restriction of percutaneous heart valved stents is still imminent.Methods: In this study we implanted percutaneously a novel, low-profile polyurethane valved stent. Percutaneous implantation in pulmonary position was evaluated in 7 sheep. The new valved stent fits into a 14F delivery device. The self-expanding nitinol stent was produced by using a dip-coating technique, and a modified commercially available endovascular stent graft system served as a delivery device. The valved stents were deployed directly over the native pulmonary valve under fluoroscopic control. Transthoracic echocardiography was performed after 4 weeks. At the time of explantation, the animals were reanalyzed and killed. Angiography was performed at implantation and at the end of the study. Explanted constructs were analyzed macroscopically and microscopically.Results: Angiography and echocardiography in all animals demonstrated orthotopic position of the stents at the time of implantation and after 4 weeks. During the deployment procedure, rhythm disturbances occurred in all animals. The peak-to-peak transvalvular gradient was 2.3 ± 1.2 mm Hg initially and 4.1 ± 2.4 mm Hg at follow-up. One-month follow-up confirmed competent neovalves without any paravalvular leakage. Gross morphology demonstrated good opening and closure characteristics. No calcification was seen macroscopically, and surrounding tissue was free of calcification.Conclusion: In the present study we demonstrated successful merging of 2 novel technologies for percutaneous treatment of pulmonary valve diseases using polyurethane stent valve constructs.

A 20-year experience with urgent percutaneous cardiopulmonary bypass for salvage of potential survivors of refractory cardiovascular collapse

2010-03-01

Objective: In-hospital cardiac arrest or refractory shock carries a high mortality despite the use of advanced resuscitative measures. We have implemented an in-hospital, nurse-based, continuously available, percutaneous, venoarterial cardiopulmonary bypass system, also known as extracorporeal life support (ECLS), as an adjunct to resuscitation when initial measures are ineffective.Methods: In 1986, a system for the rapid initiation of ECLS, was created in which trained critical care nurses primed an ECLS circuit and in-house physicians percutaneously placed required cannulas. From a prospective registry, we assessed long-term survival (LTS) (≥30 days, cardiopulmonary support weaned), short-term survival (<30 days, CPS weaned), or death on CPS.Results: One hundred fifty patients (age, 57 ± 17 years) were urgently started on CPS for cardiac arrest (n = 127; witnessed, n = 124; unwitnessed, n = 3) and refractory shock (n = 23). Sixty-nine patients were weaned from CPS, and 81 could not be weaned. Overall, 39 (26.0%) patients achieved LTS with a subsequent Kaplan–Meier median survival of 9.5 years. Duration of CPS was 32 ± 38 hours for LTS and 21 ± 38 hours for non-LTS. LTS occurred in 29 (23.4%) of 124 patients started on CPS for witnessed cardiac arrest and 11 (47.8%) of 23 for refractory shock (P < .05). Among patients with CPS initiated in the cardiac catheterization laboratory, LTS was seen in 24 (50.0%) of 48 versus 15 (14.7%) of 102 in patients with CPS initiated in other locations (P < .001). Cardiopulmonary resuscitation times greater than or equal to 30 minutes were associated with lower LTS (P < .05). The most common cause of death during CPS was refractory cardiac dysfunction (39.5%), and the most common cause associated with short-term survival was neurologic/pulmonary dysfunction (53.6%). Seven patients were bridged to a left ventricular assist device, and 1 subsequently underwent heart transplantation. Multivariate analysis revealed only cardiac catheterization laboratory site of initiation as a significant independent predictor of LTS (P < .01). When dividing the 20-year experience in tertiles, recent recipients have had more common prearrest insertion. Rates of long-term survival have not changed.Conclusion: Of patients started on CPS, 46% were weaned, and 26.0% were long-time survivors. Rapid initiation of CPS permits LTS for some inpatients with cardiovascular collapse when initial advanced resuscitation fails. Strategies to improve end-organ function associated with use of CPS should lead to greater LTS. This practical application of inexpensive available technology should be more widely used.

Prevention of lung ischemia–reperfusion injury by short hairpin RNA–mediated caspase-3 gene silencing

2009-12-07

Background: Lung ischemia–reperfusion injury remains a significant problem after lung transplantation. Caspase-mediated apoptotic pathways play an important role in lung ischemia–reperfusion injury, and caspase-3 is presumed to be the “effector” protease in the apoptotic cascade. Silencing gene expression of caspase-3 by short hairpin RNA (shRNA) can downregulate the caspase cascade. Therefore, we evaluated the therapeutic efficacy of caspase-3 shRNA in a rat model of lung ischemia–reperfusion injury.Methods: Lung ischemia–reperfusion injury was induced in rats by clamping the hilum of the left lung for 1 hour. In vivo delivery of caspase-3 shRNA was performed by intratracheal administration 48 hours before ischemia. As controls, animals received either scrambled shRNA or RNase-free 5% dextrose in water solution. Real-time polymerase chain reaction, Western blotting, and immunohistochemistry were used to assess the gene silencing efficacy. The therapeutic effects of shRNA were evaluated by lung function analysis and the ratio of wet/dry weight.Results: In this study, we have shown that ischemia–reperfusion injury is associated with an increased level of lung caspase-3 messenger RNA. Animals treated with caspase-3 shRNA showed a significant downregulation in lung expression of caspase-3 at transcripts and protein levels. Lung function was protected by caspase-3 shRNA therapy, inasmuch as levels of partial pressure of oxygen and carbon dioxide were significantly increased and reduced, respectively.Conclusions: In summary, we have demonstrated the therapeutic potential of shRNA to knock down the expression of caspase-3 and prevent lung apoptotic injury. Our findings may have some potential therapeutic relevance for treating lung ischemia–reperfusion injury after transplantation.

Should lung transplantation be performed for patients on mechanical respiratory support? The US experience

2009-11-20

Objective: The study objectives were to (1) compare survival after lung transplantation in patients requiring pretransplant mechanical ventilation or extracorporeal membrane oxygenation with that of patients not requiring mechanical support and (2) identify risk factors for mortality.Methods: Data were obtained from the United Network for Organ Sharing for lung transplantation from October 1987 to January 2008. A total of 15,934 primary transplants were performed: 586 in patients on mechanical ventilation and 51 in patients on extracorporeal membrane oxygenation. Differences between nonsupport patients and those on mechanical ventilation or extracorporeal membrane oxygenation support were expressed as 2 propensity scores for use in comparing risk-adjusted survival.Results: Unadjusted survival at 1, 6, 12, and 24 months was 83%, 67%, 62%, and 57% for mechanical ventilation, respectively; 72%, 53%, 50%, and 45% for extracorporeal membrane oxygenation, respectively; and 93%, 85%, 79%, and 70% for unsupported patients, respectively (P < .0001). Recipients on mechanical ventilation were younger, had lower forced vital capacity, and had diagnoses other than emphysema. Recipients on extracorporeal membrane oxygenation were also younger, had higher body mass index, and had diagnoses other than cystic fibrosis/bronchiectasis. Once these variables, transplant year, and propensity for mechanical support were accounted for, survival remained worse after lung transplantation for patients on mechanical ventilation and extracorporeal membrane oxygenation.Conclusion: Although survival after lung transplantation is markedly worse when preoperative mechanical support is necessary, it is not dismal. Thus, additional risk factors for mortality should be considered when selecting patients for lung transplantation to maximize survival. Reduced survival for this high-risk population raises the important issue of balancing maximal individual patient survival against benefit to the maximum number of patients.

Video-assisted intercostal nerve cryoablation in managing intractable chest wall pain

Ian Hunt, Donna Eaton, Omar Maiwand, Vladimir Anikin — 2010-03-01

A 52-year-old women was referred to our unit with severe pain in the right side of the chest, having been kicked in the right flank by a horse 10 years earlier. At the time she sustained fractures to the right 10th, 11th, and 12th ribs and briefly required hospitalization. The pain was sharp and stabbing in nature. Standard oral analgesia including nonsteroidal anti-inflammatory drugs was ineffective. She obtained little relief from opiates and was reluctant to take them long term. Some transient analgesia was obtained through epidurals and intercostal nerve blocks. She had been managed with gabapentin 800 mg twice daily and amitriptyline 25 mg daily long term.

The Sorin Freedom SOLO stentless aortic valve: Technique of implantation and operative results in 109 patients

2009-10-09

Aortic valve replacement with a biological prosthesis is nowadays increasingly performed inasmuch as tissue valves have improved regarding hemodynamic performance and durability, although they leave younger patients (<60–65 years) at risk for reintervention. The first generation of stentless valves usually required two suture lines at the annulus level and above. The second generation includes adaptation of the outside profile of the framework to simplify technique of implantation. Whether this change in design will crucially improve the long-term performance is currently unknown.

Intraoperative recognition of an intracavitary left anterior descending coronary artery

2009-04-09

An intracavitary left anterior descending (LAD) coronary artery, the extreme form of an intramyocardial coronary artery, is difficult to recognize, even on retrospective review of the coronary angiogram. The right ventricle usually is entered during explorative dissection. An intracavitary LAD typically enters the right ventricle early in its descending course (possibly with an acute angle) and emerges to the surface subtly in a long curve. With an acute change of depth course, one may suspect an intracavitary or intramyocardial location. Preoperatively, an intramyocardial coronary artery is suggested by a straight course and a systolic “milking effect” of myocardial fibers on the artery.

Management of aortobronchial fistula developing 27 years after open aortic surgery by means of endovascular stent grafting

2009-04-27

Fistulous connections between the thoracic aorta and the bronchial systems are rare but potentially fatal complications. However, reports are limited and guidelines for diagnosis and treatment are not available. Most often, patients have a history of reconstructive vascular surgery followed by anastomotic aneurysm or dissection. Aortobronchial fistulas (ABFs) regularly present with mild to massive hemoptysis and chest pain. Given the high mortality of untreated patients, immediate patient management with either open surgery or endovascular repair is essential. We present the case of an ABF occurring 27 years after open surgical repair because of a false aortic aneurysm.

Bronchoscopic spray cryotherapy: Assessment of safety and depth of airway injury

William S. Krimsky, Jennifer N. Broussard, Saiyad A. Sarkar, Daniel P. Harley — 2009-08-07

Traditional approaches to managing occluded airways include surgery, mechanical debulking, brachytherapy, stents, photodynamic therapy, and thermal modalities, such as electrocautery, laser, argon plasma coagulation, and cryotherapy. Although cryotherapy with cryoprobes has been used safely for over a decade in airways management, it is often tedious and time-consuming because of surface area limitations of the probes, which must be inserted into or come in contact with the surface of the targeted lesion. Newer cryotherapy devices obviate the need for contact with the target tissue. Reports of promising results from use of low-pressure spray cryotherapy for ablation of esophageal lesions have led to the experience reported here, in which spray cryotherapy with low-pressure liquid nitrogen was used for the first time to treat human airways.

Ventricular assist device implantation in neonates: Adjustment of the BerlinHeart EXCOR arterial cannula with bovine pericardium

Tonny D.T. Tjan, Andreas Hoffmeier, Hans Heinrich Scheld, Stefan Klotz — 2009-07-06

In cases of terminal heart failure in neonates, implantation of an extracorporeal membrane oxygenation (ECMO) device is often considered as a first choice. Long-term support with ECMO, however, has several limitations.

Facilitated aortic root substitution after aortic valve replacement: Technique and results of the prosthesis-sparing operation

2009-06-01

Cardiac reinterventions are increasingly frequent; among these, reoperations on the aortic root are particularly demanding. Patients may have aortic valve replacement (AVR) complication (ie, ascending aortic pseudoaneurysm) or evolution toward frank aortic disease (aortic root ± ascending aortic aneurysm). Our current inability to reliably predict the course of borderline ascending aortic dilatation at the time of AVR in patients without Marfan disease may account for a significant number of cases presenting electively for this redo surgery.

Treatment of irradiated poststernotomy sternal nonunion with autologous stem cell–impregnated bone matrix and sternal plating

Tomasz A. Timek, Stuart B. Goodman, Richard I. Whyte — 2009-12-28

Sternal wound complications are an infrequent but significant cause of postoperative morbidity for cardiothoracic surgical patients. Sternal nonunion occurs in fewer than 1% of patients after median sternotomy, but it represents a challenging clinical problem because it is often associated with chronic pain of debilitating magnitude. Affected patients are often treated with débridement and sternal rewiring, which requires reexploration of the mediastinum. We describe the case of a patient successfully treated with an autologous stem cell–seeded bone matrix and sternal plating for chronic manubrial nonunion in a postsurgical, irradiated sternum.

Treatment of heparin-induced thrombocytopenia after cardiac surgery: Preliminary experience with fondaparinux

2009-02-06

Heparin-induced thrombocytopenia (HIT) is an immune-mediated prothrombotic disorder that is often encountered after cardiac surgery. The appropriate alternative anticoagulant to be used in this setting is not univocal, especially for the coexistence of renal failure and high bleeding risk.

Giant tracheocele

Abdul Razak, Prashant H. Patil, Jaspal Singh Sahota, S. Subramanian — 2009-01-19

Tracheocele, a protrusion of the mucous membrane through a defect in the tracheal wall, may be congenital or acquired. Tracheoceles are rare, and most cause only a few symptoms, which are usually well tolerated. We report the case of a 52-year-old man with a giant tracheocele that was incorrectly diagnosed preoperatively as a laryngocele.

Late embolization to the aortic arch of an Amplatzer Device used to occlude a baffle leak

Prem Venugopal, Hazem Fallouh, David Anderson — 2009-01-27

We report a case of late migration to the aortic arch of a percutaneous Amplatzer Septal Occluder Device (AGA Medical Corp, Plymouth, Minn) used to occlude a baffle leak after a Mustard procedure. After an unsuccessful attempt at percutaneous removal of the embolized device from the aortic arch, the device was removed surgically with uncomplicated recovery.

Successful implantation of a Berlin Heart ventricular assist device in ventricular heart failure 23 years after Senning operation

2009-04-03

Right (systemic) ventricular (RV) failure in patients with transposition of the great arteries (TGA) after the Senning operation is a well-known late complication. Although double switch operations have been advocated by some groups, orthotopic heart transplantation (HTx) remains the only definitive option to treat these patients. However, there is a high mortality rate for patients on transplant waiting lists, and the use of ventricular assist devices (VADs) is often required as a bridge to HTx.

Ventricular septal defect repair in an infant with severe pulmonary hypertension and preoperatively diagnosed left ventricular noncompaction

2009-03-27

Intracardiac repair for congenital heart disease complicated by left ventricular noncompaction (LVNC) has been rarely described. This is the first report of ventricular septal defect (VSD) repair in an infant with severe pulmonary hypertension (PH) and preoperatively diagnosed LVNC.

A rare case of Klebsiella pneumoniae myocardial abscess

2009-02-23

Myocardial abscess of the left ventricular free wall in the absence of infective endocarditis (IE) is very unusual. Most cases are discovered during autopsies and are due to Gram-positive cocci. We present a rare case of Klebsiella pneumoniae causing myocardial abscess of the left ventricular free wall. The patient had no evidence of valvular endocarditis or bacteremia, and the abscess was discovered during coronary artery bypass grafting surgery (CABG).

Sex reversal and hypoplastic left heart syndrome

Michael J. Walsh, Elizabeth T. Walsh, Yaw Appiagyei-Dankah, Andrew M. Atz — 2009-01-27

The prognosis of congenital heart disease, especially in its most complex forms, is complicated when associated with extracardiac anomalies. Meacham syndrome, or PAGOD syndrome (pulmonary tract and pulmonary artery hypoplasia, agonadism, omphalocele, diaphragmatic defect, and dextrocardia) is a constellation of genital, cardiac, and pulmonary malformations that carries a poor prognosis. We report the case of a patient with sex reversal and hypoplastic left heart syndrome without congenital diaphragmatic hernia who has survived to Fontan completion and is doing well.

Benign gastrobronchial fistula with adenocarcinoma of the right mainstem bronchus

2009-02-23

Fistulization of the gastric conduit into the tracheobronchial tree is a potential complication after esophageal reconstruction. In this situation, the effects of the refluxate on the mucosa of the tracheobronchial tree is unknown. This article presents the 11-year evolution of a patient who tolerated a fistulous communication between the gastric interposition and the right mainstem bronchus, resulting in an adenocarcinoma of the bronchus.

Primary pulmonary meningioma: Ten-year follow-up findings for a multiple case, implying a benign biological nature

Yukitoshi Satoh, Yuichi Ishikawa — 2008-12-22

In 1998 we reported the first case of multiple pulmonary meningioma, an extremely uncommon lung neoplasm. To date, there have been only 30 cases of primary pulmonary meningioma (PPM) reported in the English literature. Although the lesions are widely known to be usually benign, slow growing, and to have an excellent prognosis, the etiology is still uncertain. Hence, several mechanisms have been proposed. We here report the clinical course of the initial case 10 years after surgery with examination by different imaging modalities and additional biopsy findings for a metachronous pulmonary lesion.

Angiosarcoma in the aortic arch presented as repeat strokes

2009-02-23

A 51-year-old man visited a local medical clinic 4 weeks before admission because of a 6-month history of weight loss and anorexia. His medical history was unremarkable except for a blood pressure discrepancy in both arms on physical examination. Furthermore, a palpable abdominal mass was found and proved later to be a probable malignant adrenal tumor by means of abdominal computed tomographic analysis.

Late development of a large intrahepatic fistula after “closure” of an atrial septal defect

2009-02-23

Partial hepatic vein (HV) exclusion as an alternative for baffle fenestration was used as a modification in patients undergoing the Fontan repair to achieve reduced systemic venous pressure and reduced serous effusions. Large intrahepatic venovenous communications, which can create massive arterial desaturation through an increasing right-to-left shunt caused by venous pressure differences between the caval system and the left atrium (LA), are known to develop after that type of operation. An intrahepatic venovenous fistula was diagnosed 25 years after surgical closure of an atrial septal defect (ASD). The fistula developed after inadvertent malposition of the patch, which directed inferior vena caval (IVC) flow to the LA and also divided hepatic venous return. The pressure difference between the IVC and LA to the right atrium (RA) obviously opened up hepatic vessels and thus created a large shunt from the IVC to the RA. There are close relations to similar findings after the Fontan operation with partial exclusion of HVs.

Optimism derived from 7.5 years of continuous-flow circulatory support

2009-03-18

Severely symptomatic heart failure is increasingly common as the population ages. Both prognosis and quality of life are poor. These patients have limited options. Few are eligible for cardiac transplantation because of age or the common transplant comorbidities of pulmonary hypertension and renal impairment. In New York Heart Association (NYHA) class IV patients, ventricular resynchronization therapy provides only marginal benefit that is insufficient to improve quality of life. Lifetime circulatory support has a firm evidence base in the REMATCH trial. Because of the complication rates in first-generation left ventricular assist devices (LVADs), the compelling argument for an off-the-shelf solution for advanced heart failure has been slow to progress.

Successful lung transplantation in an octogenarian

2009-03-12

Advanced recipient age continues to be used as an exclusion criterion for lung transplantation. However, given the changing age demographics in most developed countries, redefinition of the appropriate recipient age limit for lung transplantation is needed because it has become an established therapeutic option with acceptable mortality for end-stage lung diseases. Given those conditions, we recently have expanded our criteria for both recipients and donors in lung transplantation. We present the case of an 81-year-old man with idiopathic pulmonary fibrosis (IPF) who is the oldest known successful lung transplant recipient reported.

Intra-atrial embolus trapped in patent foramen ovale before systemic embolization

2009-03-27

We present a case of an embolus traversing the patent foramen ovale (PFO) diagnosed on echocardiography with extensive bilateral pulmonary embolism demonstrated on subsequent computed tomography scan.

Lung transplantation for pulmonary alveolar microlithiasis

2009-02-23

Since the first description of pulmonary alveolar microlithiasis (PAM) by Puhr in 1933, nearly 500 related cases have been reported worldwide. No effective treatment for PAM currently exists, with the exception of lung transplantation. Herein, we present the case of a 63-year-old woman with PAM who, to the best of our knowledge, is the oldest successful lung transplant recipient with end-stage PAM reported. In addition, the present work reviews the outcomes of other cases of PAM after lung transplantation.

Prolonged use of right ventricular assist device for refractory graft failure following orthotopic heart transplantation

2009-03-09

The use of mechanical circulatory support for posttransplant right ventricular (RV) failure is well described. Nakatani and colleagues first reported on the feasibility of the right heart assist for acute RV failure after heart transplantation. However, longest possible duration of the RV support is unknown for recovery following heart transplantation.

Huge aneurysms of the aortic sinuses of Valsalva with leaflet perforation in an infant: A case report

Atsushi Kawaguchi, Kenji Waki, Yoshio Arakaki, Kiyoshi Baba — 2009-07-23

Congenital aneurysm of the sinus of Valsalva (ASV) is a rare cardiovascular anomaly in infants. ASV usually affects only one aortic sinus and is silent until rupture occurs. Only a few cases of multiple ASV have been reported and cardiac failure resulting from aortic regurgitation in an infant with ruptured ASV is very uncommon. Here, we report the case of a 5-month-old male infant with ruptured multiple ASV and severe aortic regurgitation.

Bleeding complications after off-pump coronary artery bypass surgery: Interpreting the contribution of hetastarch

Rachel Eshima McKay — 2010-03-01

To the Editor: I read with interest the article by Hecht-Dolnik and colleagues examining the association between intraoperative administration of hetastarch and bleeding complications after off-pump coronary artery bypass graft surgery. The authors conclude that administration of 1 L of hetastarch in addition to albumin and crystalloid versus albumin and crystalloid alone resulted in increased risk of postoperative transfusion requirement and chest tube drainage. Given the existing body of evidence showing an association between greater quantitative blood loss with the use of high molecular weight (HMW) hetastarch compared with both lower molecular weight hetastarch and albumin, in both cardiac and noncardiac surgery, it is not clear what further information this study provides. Also, features of the study design and ambiguity within the manuscript itself both create difficulty for a reader hoping to interpret the validity or clinical significance of these findings.

Reply to the Editor

Howard Barkan — 2010-03-01

We thank Dr McKay for her comments regarding our article. We examined the relative safety in off-pump coronary artery bypass grafting (CABG) of two volume replacement fluids in widespread use at the time we conducted our study. Dr McKay argues that the questions we investigated are moot, that the fluids whose safety we investigated are not in widespread contemporary use, and that there were methodologic flaws in our study conduct. We will now address each of Dr McKay's arguments, showing that the choice between the volume replacement fluids we studied remains clinically relevant, that her methodologic concerns are overstated, and that our findings raise a series of further questions.

Regional wall motion abnormalities and scarring in severe functional ischemic mitral regurgitation: A pilot cardiovascular magnetic resonance imaging study

Giuseppe D'Ancona, Michele Pilato — 2010-03-01

To the Editor: We read with interest Flynn and colleagues' article concerning preoperative evaluation with cardiac magnetic resonance imaging (MRI) in patients undergoing coronary artery bypass grafting and mitral valve annuloplasty for ischemic mitral valve regurgitation (IMVR).

Reply to the Editor

Tomislav Mihaljevic, Marc A. Gillinov — 2010-03-01

We thank Drs D'Ancona and Pilato for their thoughtful comments. Patients with ischemic cardiomyopathy represent a diverse population who differ in the extent of myocardial ischemia, severity of the left ventricular dysfunction, and severity of functional ischemic mitral regurgitation. A thorough understanding of the extent of ischemic changes is essential for the appropriate planning of surgical therapy. Magnetic resonance imaging has emerged as a powerful diagnostic tool for the comprehensive evaluation of patients with ischemic cardiomyopathy. In our practice, magnetic resonance imaging is routinely used in patients with ischemic cardiomyopathy for the assessment of the severity and distribution of myocardial scarring, as well as the estimation of residual myocardial viability. Severity of ischemic changes determines the choice of surgical therapy. Presence of transmural scarring in the region of the papillary muscles in patients with severe ischemic cardiomyopathy and severe functional mitral regurgitation is a poor prognostic sign indicating advanced disease. Myocardial revascularization and mitral valve repair with an undersized annuloplasty ring in these patients are often associated with the poor outcomes and high incidence of recurrent mitral regurgitation; therefore, alternative therapies, including heart transplantation, should be considered. In contrast, in patients with less severe forms of ischemic cardiomyopathy and moderate functional ischemic regurgitation, substantial improvement in functional status and survival can be accomplished with isolated coronary artery bypass grafting.

Safety of axillary artery cannulation

Aslihan Kucuker, Erol Sener — 2010-03-01

To the Editor: We read the report of Takayama and colleagues about the successful management of aortic root replacement with axillary artery cannulation and open distal anastomosis technique. For ascending and aortic arch repair, we use a similar cannulation site, the right brachial artery. We previously published our results of 104 arch repair cases that we performed with low-flow antegrade cerebral perfusion through the right brachial artery and with an open distal anastomosis technique during moderate hypothermia. We congratulate the authors for their excellent results, but we would like to remind them that neither axillary nor brachial artery cannulation is totally safe and reliable.

Reply to the Editor

Hiroo Takayama, Craig R. Smith, Michael E. Bowdish, Allan S. Stewart — 2010-03-01

We have read the article by Dr Küçüker and his colleagues with great interest. They should be congratulated on their excellent clinical outcome of arch repair using right brachial artery cannulation. Their technique achieves the same goal as the axillary artery cannulation technique. Although the brachial artery might be easier to access, its size might occasionally prevent it from being used. Monitoring of the antegrade selective perfusion pressure, which we believe to be a critical component of assessment of the cerebral perfusion, might be easier with axillary cannulation with an arterial pressure line placed in the right radial artery. Also, axillary artery cannulation itself is not very complicated and is usually done within 30 minutes. Therefore, we still prefer using the axillary artery as a cannulation site.

They also serve who only stand and wait

Vipin Zamvar — 2010-03-01

To the Editor: I read with great interest, and a degree of nostalgia, Dr Kumar's editorial on the second assistant.

Intra-atrial rerouting by the posterior left atrial wall flap for total anomalous pulmonary venous return drainage into the coronary sinus in neonates

Mitsugi Nagashima, Fumiaki Shikata, Kanji Kawachi — 2010-03-01

To the Editor: We read with great interest the new procedure for total anomalous pulmonary venous return (TAPVR) drainage into the coronary sinus (CS), which Yamagishi and colleagues successfully performed for an infant weighing 5.5kg. Briefly, the roof of the CS was incised toward the left atrium (LA) to create a flap from the posterior wall of the LA (=the anterior wall of the common chamber and the CS). The flap thus created was then moved anteriorly to cover the entire atrial communication and the CS orifice. However, we were unable to find any follow-up reports on this procedure. We recently successfully performed this procedure for 2 neonatal cases and recognized several important features associated with this surgery.

Reply to the Editor

Masaaki Yamagishi — 2010-03-01

I thank Dr Nagashima and colleagues for their insightful comments on our new surgical technique for cardiac-type total anomalous pulmonary venous drainage (TAPVD). Pulmonary venous obstruction (PVO) is an inevitable, serious complication after the repair of cardiac-type TAPVR by conventional surgical techniques. Turbulent blood flow at the warped pulmonary venous pathway through the coronary sinus or a narrow communication between the pulmonary venous channel and the left atrium may cause intimal proliferation followed by PVO. Although the coronary sinus is usually dilated in cardiac-type TAPVD, it is by no means wide enough to serve as the permanent pulmonary venous pathway. In contrast, the posterior wall transference technique can create laminar pulmonary venous blood flow through a wide and straight communication into the left atrium.

The fundamental importance of baseline comparisons in a clinical trial

David McIlroy, Ervant Nishanian — 2010-03-01

To the Editor: We read with interest the study by Hecht-Dolnik and associates in the September 2009 issue of the Journal, “Hetastarch Increases the Risk of Bleeding Complications in Patients After Off-Pump Coronary Bypass Surgery: A Randomized Clinical Trial.” In this article, they conclude that the intraoperative administration of 1 L of hetastarch was associated with an increase in postoperative chest tube drainage and transfusion of blood products, which resulted in early termination of the study.

Reply to the Editor

Marketa Hecht-Dolnik, Howard Barkan, Ananse Taharka, John Loftus — 2010-03-01

We extend our thanks to Drs McIlroy and Nishanian for their careful reading of our article. Their concerns would be well placed if the average baseline international normalized ratio (INR) in the hetastarch group were 1.47. Their comment led us to review the project source data. That review revealed several transcription errors in which the decimal place in the INR was misplaced. The average baseline INR after correction of those transcription errors is 1.06 (standard deviation = 0.11). This correction thus reverses the direction of the difference between the hetastarch and albumin groups in the average INR from that presented in the initial article. The statistical significance of the difference in average INR between the albumin and hetastarch groups becomes even weaker, remaining not statistically significant (Student t = 0.77; P = .44, not significant).

Technical options for the treatment of anomalous origins of right or left coronary arteries associated with aortopulmonary windows

Hakan Aydin, Ali Kutsal — 2010-03-01

To the Editor: Aortopulmonary window (APW) and anomalous right coronary artery (RCA) originating from the pulmonary trunk is a rare congenital anomaly. In the September 2009 issue of this Journal, Léobon and associates reported their clinical trial of 2 patients and options for the surgical treatment of the pathologic condition. Our group has also reported a successful surgical treatment for an infant with the same combination but with a novel technique.

Reply to the Editor

Bertrand Léobon — 2010-03-01

In their letter, Aydin and Kutsal report a new case of a right coronary artery originating from the pulmonary trunk associated with an aortopulmonary window in a 4-month old boy. They have corrected this anomaly with a modified technique of right coronary artery transfer, using the right coronary button to close the aortic wall defect. The pulmonary artery defect was closed with an autologous pericardial patch.

Statins prevent atrial fibrillation after cardiac surgery?

Hisato Takagi, Masafumi Matsui, Takuya Umemoto — 2010-03-01

To the Editor: In a systematic review by Liakopoulos and associates, statin use was associated with a 22% reduction in the unadjusted odds for any type of atrial fibrillation (random effects pooled odds ratio [OR], 0.78; 95% confidence interval, 0.67–0.90; P=.0010). Assessment of publication bias using visual examination of the funnel plot, however, revealed asymmetry around the mean OR with smaller studies tending toward larger positive effects. Significant publication bias was indeed confirmed (P=.0003) using Egger's weighted regression analysis. To assess the effect of possible publication bias, we calculated the pooled OR adjusted for publication bias using the “trim and fill” algorithm. The “trim and fill” is probably the most popular method for examining the possible effect of publication bias on the pooled estimate and can be defined as an iterative nonparametric adjustment method based on a rank-based data augmentation technique to account for asymmetry on the funnel plot. The estimated OR for 18 studies, including 5 “missing” studies (random effects pooled OR, 0.87; 95% confidence interval, 0.74–1.02), is substantially different from the original estimate without adjustment for missing studies (). Therefore, preoperative statin therapy may not be associated with a reduction in the incidence of atrial fibrillation after cardiac surgery.

Reply to the Editor

Oliver J. Liakopoulos, Elmar W. Kuhn, Thorsten Wahlers — 2010-03-01

With great interest we read the comment by Takagi and colleagues with regard to the analysis of publication bias in our previous report. Our systematic review carefully assessed the presence of publication bias by Egger's weighted regression statistic and visual assessment of the funnel plot, tools that are generally recommended for assessment of publication bias. As correctly stated by the authors, both tests revealed evidence of substantial publication bias for any of the analyzed outcomes (any atrial fibrillation: P = .0003; new-onset atrial fibrillation: P = .0001), with visual examination of the asymmetric funnel blot underscoring a small study effect. Consequently, the results of our systematic review showing a 22% reduction in the unadjusted odds for any type of atrial fibrillation in patients with preoperative statin intake are extensively discussed in light of existing publication bias, as presented in the Discussion, Results, and Limitations sections of our article.

Treatment of recurrent aortic prosthetic detachment with modified Bentall procedure

Frank A. Baciewicz — 2010-03-01

To the Editor: I enjoyed the recent article “The Treatment of Recurrent Aortic Prosthetic Detachment with Modified Bentall Procedure: Results of Two Cases.” The authors described 2 cases of surgical management using a translocated Bentall procedure with a mechanical prosthesis. I have used a similar technique with a porcine or bovine prosthesis in patients with severe endocarditis in whom a valve homograft was not available. A second useful application is in the case of an aortic root that requires replacement and a bioprosthesis is the prosthesis of choice. The technique has the advantage of being more hemostatic because a rigid mechanical or bioprosthetic ring is not positioned on the native aortic annulus at the root. In the event of bleeding at the root, it is much easier to place a suture into the cuff of the conduit rather than the rigid aortic valve prosthesis resting on the annulus.

Reply to the Editor

Chong Zhang, Zhengliang Tu, Youcai Zhu — 2010-03-01

We appreciate the comments by Dr Frank A. Baciewicz on our article, “The Treatment of Recurrent Aortic Prosthetic Detachment with Modified Bentall Procedure: Results of Two Cases.” His respectable clinical experiences briefly describe a similar technique with a bioprosthesis in patients with endocarditis or requirement of aortic root replacement and its advantages.

Silver nitrate: To discover already discovered…

Bartosz Kubisa, Tomasz Grodzki, Janusz Wójcik — 2010-03-01

To the Editor: We read the article by Stratakos and colleagues with great interest inasmuch as the treatment of bronchial fistulas is of utmost importance to both the pulmonary and thoracic surgery divisions. The exact method of silver nitrate (SN) application through the videobronchoscope shown by the authors is very valuable on one hand. However, on the other hand, it is rather evident for us, and we have treated many patients without publishing our experience owing to its obviousness. We appreciate this work as a well-planned scientific trial to prove the application of SN to heal bronchial fistulas, but its use has been known for longer than the 25 years postulated by the authors. Melfi, Schverlich, and Tambornini in 1954 used SN for endobronchial treatment of tuberculosis cavities. The same method of treating the opened bronchi was described by Guzeev in 1965. Worth mentioning is the toxicity induced by SN, sometimes even demanding lobectomy.

Reply to the Editor

G. Stratakos, Ch. Zisis, St. Gasparini — 2010-03-01

We appreciate the interest expressed by Kubisa, Grodzki, and Wójcik in our recently published study concerning silver nitrate technique for the management of small bronchopleural fistulas. We are glad to learn that other colleagues as well have experience with this method.

Pneumonectomy after induction radiochemotherapy: Is it time for a meta-analysis?

Giacomo Cusumano, Alfredo Cesario, Stefano Margaritora — 2010-03-01

To the Editor: The discussion regarding the safety and feasibility of pneumonectomy for non–small cell lung cancer after induction chemoradiotherapy (IT) is a long-standing, widely debated issue, in particular, in the past 2 decades.

Reply to the Editor

Mark J. Krasna — 2010-03-01

I thank Cusumano, Cesario, and Margaritora, of the Division of Thoracic Surgery, Catholic University, Rome, Italy, for their letter. I absolutely agree with them that there are cases in which pneumonectomy should be performed after induction chemoradiation therapy. It was the intent of my “counterpoint” article to identify through a review of recent articles whether there was enough evidence to state that the use of pneumonectomy in this setting was standard or not. Thus far, the number of articles supporting this approach remain outweighed by those against its use. Recently, however, several articles have appeared in the thoracic journals that do provide new data supporting the use of pneumonectomy in this setting. Given these recent articles, as well as the practice of several centers in the United States and in Europe, I would agree that a meta-analysis should be undertaken. This may be difficult inasmuch as many of the articles use different end points and definitions. Rather, a combined report from several sites sharing specific variables would be a helpful first step. I for one would look forward to joining with this effort.

Notice of Correction

2010-03-01

Re: Hecht-Dolnik M, Barkan H, Taharka A, Loftus J. Hetastarch increases the risk of bleeding complications in patients after off-pump coronary bypass surgery: a randomized clinical trial. J Thorac Cardiovasc Surg. 2009;138:703-11.

Meetings and Courses

2010-03-01

The 30th Annual Cardiothoracic Surgery Symposium will be held March 4-7, 2010, at The Newport Beach Marriott Hotel and Marina, San Diego, California, USA. Abstract submission deadline: February 1, 2010. For information, contact: Susan Westwood, San Diego Cardiothoracic Surgery Symposium, 793-A E Foothill Boulevard, #119, San Luis Obispo, CA 93405 (telephone: 1-805-541-3118; Fax: 1-716-809-4082; E-mail: susan@amainc.com). Additional information: http://www.amainc.com/cref_cardiothoracic.html

The American Association for Thoracic Surgery Volunteer Leadership and Senior Staff Disclosure Statement

2010-03-01

To best serve the interests of the specialty and its practitioners, the American Association for Thoracic Surgery requires the volunteer leadership, including its editors, associate editors, and section editors, to publicly disclose the existence and nature of any financial or other relationships that might influence, or appear to influence, their actions. In keeping with this policy, the following disclosures have been made by the editors and editorial board members responsible for making decisions about manuscripts submitted to and published in the official publications of the Association:

AATS 90th Annual Meeting

2010-03-01

May 1–5, 2010 Metro Toronto Convention Centre

Aortic Symposium 2010

2010-03-01

April 29–30, 2010 Sheraton New York Hotel and Towers

AATS Meetings and Sponsored Events

2010-03-01

March 21–26, 2010 15th Annual Update on Cardiopulmonary Bypass

AATS Online Award Applications Now Available at www.aats.org

2010-03-01

Deadline: July 1, 2010 Michael E. DeBakey Research Scholarship 2011–2013 provides an opportunity for research, training and experience for North American surgeons committed to pursuing an academic career in cardiothoracic surgery.

Applications for Membership

2010-03-01

Applications for membership in the Association must be received by the Membership Committee Chair no later than March 1, 2010 to be considered at the 2010 Annual Meeting. Applicants must be sponsored by three members of the Association who are not members of the Membership Committee. Application forms will be issued only to sponsoring members.

WTSA 36th Annual Meeting

2010-03-01

June 23–26, 2010 Ojai Valley Inn

Notices

2010-03-01

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

Requirements for Maintenance of Certification

2010-03-01

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.

JCTSE Board of Directors 2010 Announcement

2010-03-01

Four new directors were recently appointed to the Joint Council on Thoracic Surgery Education, Inc. (JCTSE) following its annual board meeting on Saturday, October 10, 2009. JCTSE is governed by an eight-member Board of Directors that is composed of two members each from its four founding organizations: the American Association for Thoracic Surgery (AATS), the American Board of Thoracic Surgery (ABTS), The Society of Thoracic Surgeons (STS), and the Thoracic Surgery Foundation for Research and Education (TSFRE).

JTCVS Disclosure Statement

2010-03-01

Condensed Contents

2010-03-01

Information for Readers

2010-03-01

Communications regarding original articles and editorial management should be addressed to Lawrence H. Cohn, MD, Editor, The Journal of Thoracic and Cardiovascular Surgery, American Association for Thoracic Surgery, 900 Cummings Center, Suite 221-U, Beverly, MA 01915; telephone: 978-299-4505; fax: 978-524-8890. Information for authors appears in each issue. Authors should consult these instructions before submitting manuscripts to this Journal.