The Journal of Thoracic and Cardiovascular Surgery

Replacement of the descending thoracic aorta: Contemporary outcomes using hypothermic circulatory arrest

Alexander Kulik, Catherine F. Castner, Nicholas T. Kouchoukos — 2009-12-07

Objective: Recent advances in endovascular repair have put into question the role of open surgery on the descending thoracic aorta. We evaluated our experience with replacement of the descending thoracic aorta using hypothermic circulatory arrest.Methods: From May 1989 to August 2008, 151 patients (mean age 62 ± 15 years) had descending thoracic aorta replacement using cardiopulmonary bypass and hypothermic circulatory arrest. Concurrent distal aortic arch repair was performed in 71 patients (47%). Seventeen patients (11%) had emergency operation.Results: The mean durations of bypass and circulatory arrest were 107 ± 34 and 32 ± 9 minutes, respectively. Stroke occurred in 5 patients (3.3%), spinal cord ischemic injury in 2 patients (1.3%; 1 paraplegia, 1 paraparesis), and renal failure requiring dialysis in 2 patients (1.3%). Thirty-day and 6-month mortality rates were 4.0% and 9.9%, respectively. Following emergency operation, the 30-day mortality rate was 17.6% compared with 2.2% after elective surgery (P = .02). Five- and 10-year survival rates were 71% and 45%, respectively. Five patients required reoperation on the graft or contiguous aorta at a mean of 5 ± 4 years after the initial repair. Five- and 10-year rates of freedom from reoperation were 96% and 92%, respectively.Conclusions: Cardiopulmonary bypass with hypothermic circulatory arrest can be safely used for replacement of the descending thoracic aorta. Although more invasive than endovascular stent grafting, this open surgical technique provides definitive repair, maintenance of left subclavian artery patency, protection against spinal cord injury, and early mortality and morbidity rates that do not exceed those reported for endovascular repair.

Ten-year experience with off-pump coronary artery bypass grafting: Lessons learned from early postoperative angiography

2010-02-01

Objective: We performed early postoperative angiography to assess anastomosis accuracy and patency after off-pump coronary artery bypass grafting.Methods: One thousand three hundred forty-five patients who underwent off-pump coronary artery bypass grafting between January 1998 and December 2007 were studied. Grafts for distal anastomoses were left internal thoracic artery (n=1281), right internal thoracic artery (n=679), right gastroepiploic artery (n=836), radial artery (n=14), and saphenous vein (n=188). Groups underwent off-pump coronary artery bypass grafting without (group I, n=234) or with (group II, n=1111) intraoperative graft flowmetry. Early postoperative (≤7 days) angiography was performed in 1278 cases (95.0%) at 1.6±1.2 postoperative days.Results: Operative mortality was 1.6%. Average number of distal anastomoses was 3.0±1.0. Postoperative angiography showed early patencies of 98.9% for arterial grafts and 88.2% for venous grafts (P < .001). In group II, intraoperative flowmetry-guided revision was performed in 2.2% of distal anastomoses. Patency of arterial grafts was significantly higher in group II than group I (97.2% vs 99.1%, P < .001); however, patency of venous grafts was not significantly different (86.0% vs 92.2%, P=.099). Early reoperation for graft revision according to angiographic findings was performed in 35 patients.Conclusions: Early patency of venous grafts was significantly lower than that of arterial grafts. Intraoperative flowmetry and revision of abnormal grafts improved early graft patency, and reoperation according to early angiographic findings may further improve graft patency.

Discussion

2010-02-01

Dr Joseph F. Sabik (Cleveland, OH). Dr Kim and colleagues report on their 10-year experience with early ITA and saphenous vein graft patency after OPCAB. Their observations provide insight into the early results of OPCAB and the roles that intraoperative and postoperative graft assessment may have in improving the results of surgical revascularization.

Outcomes of reoperative aortic valve replacement after previous sternotomy

2009-12-14

Objective: Increasingly, patients with previous sternotomy require aortic valve replacement. We compared outcomes of reoperative aortic valve replacement after previous sternotomy and primary aortic valve replacement by surgical era. Effect of initial cardiac operation on reoperative aortic valve replacement was also investigated.Methods: Between January 1996 and December 2007, a total of 1603 patients undergoing elective aortic valve replacement were entered prospectively into our clinical database. Patients were divided into eras A (1996–1999), B (2000–2003), and C (2004–2007). A total of 191 patients (12%) had previous sternotomy for coronary artery bypass grafting (n = 88), coronary artery bypass grafting with aortic valve replacement (n = 16), aortic valve replacement with or without other aortic procedure (n = 70), and other cardiac procedures (n = 17). Mean ages were 66.5 ± 13.1 years in reoperative group and 65.5 ± 14.9 years in primary group.Results: Mortality in reoperative group decreased significantly with time (A 15.4% vs B 15.1% vs C 2.0%, P = .004) and was equivalent to primary group in era C (3.5% vs 2.0%, P = .65). Major complications also significantly decreased with time in reoperative group (A 25.6% vs B 17.0% vs C 6.1%, P = .006). Importantly, patients had more comorbidities with time and increased preoperative risk in era C. There were no differences in outcome by initial cardiac operation in reoperative group.Conclusions: Reoperative aortic valve replacement now carries similar morbidity and mortality to primary replacement. Risk of reoperation is not affected by primary operation.

Discussion

2009-12-14

Dr Leonard N. Girardi (New York, NY). I congratulate Dr LaPar for an excellent presentation and the University of Virginia group for outstanding results in a patient population that we are all seeing more of, those with previous cardiac surgery now requiring AVR. The 2% mortality in their last 100 cases is truly remarkable, actually lower than their mortality among patients undergoing primary AVR. To help us to learn more from their experience and perhaps incorporate some of their experiences and recommendations into our own practice, I have a few questions.

Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score

2009-12-21

Objective: This study examines the association of hospital coronary artery bypass procedural volume with mortality, morbidity, evidence-based care processes, and Society of Thoracic Surgeons composite score.Methods: The study population consisted of 144,526 patients from 733 hospitals that submitted data to the Society of Thoracic Surgeons Adult Cardiac Database in 2007. End points included use of National Quality Forum–endorsed process measures (internal thoracic artery graft; preoperative β-blockade; and discharge β-blockade, antiplatelet agents, and lipid drugs), operative mortality (in-hospital or 30-day), major morbidity (stroke, renal failure, reoperation, sternal infection, and prolonged ventilation), and Society of Thoracic Surgeons composite score. Procedural volume was analyzed as a continuous variable and by volume strata (<100, 100–149, 150–199, 200–299, 300–449, and ≥450). Analyses were performed with logistic and multivariate hierarchical regression modeling.Results: Unadjusted mortality decreased across volume categories from 2.6% (<100 cases) to 1.7% (>450 cases, P < .0001), and these differences persisted after risk factor adjustment (odds ratio for lowest- vs highest-volume group, 1.49). Care processes and morbidity end points were not associated with hospital procedural volume except for a trend (P = .0237) toward greater internal thoracic artery use in high-volume hospitals. The average composite score for the lowest volume (<100 cases) group was significantly lower than that of the 2 highest-volume groups, but only 1% of composite score variation was explained by volume.Conclusion: A volume–performance association exists for coronary artery bypass grafting but is weaker than that of other major complex procedures. There is considerable outcomes variability not explained by hospital volume, and low volume does not preclude excellent performance. Except for internal thoracic artery use, care processes and morbidity rates were not associated with volume.

Discussion

2009-12-21

Dr T. Bruce Ferguson (Greenville, NC). Thank you, Dr Patterson. I have no disclosures. This study extends the CABG volume–outcome relationship beyond mortality alone to an evaluation of morbidity and processes of care. Among the most sophisticated of STS database analyses thus far, I congratulate Dr Shahian and his coworkers on this work. This analysis highlights what we all know: it is very difficult to provide continuous, highest-quality delivery of standardized care practices unless you “keep your edge.” Although the magic number for annual CABG volume is unknown, re-examination in light of overall decreasing CABG volumes nationwide is merited. However, the lack of variability across the country is all the more remarkable when compared with the 10-fold differences in procedure volume for CABG. This is a direct testament to the deliberate focus on measuring and disseminating best practices by our specialty and in moving beyond risk-adjusted outcomes to processes of care. I have 2 questions for Dr Shahian.

Decision support in surgical management of ischemic cardiomyopathy

2010-02-01

Objectives: The surgical approach to ischemic cardiomyopathy maximizing survival remains a dilemma, with decisions complicated by secondary mitral regurgitation, ventricular remodeling, and heart failure. As a component of decision support, we sought to develop prediction models for comparing survival after coronary artery bypass grafting alone, coronary artery bypass grafting plus mitral valve anuloplasty, coronary artery bypass grafting plus surgical ventricular restoration, and listing for cardiac transplantation.Methods: From 1997 to 2007, 1468 patients with ischemic cardiomyopathy (ejection fraction <30%) underwent coronary artery bypass grafting alone (n = 386), coronary artery bypass grafting plus mitral valve anuloplasty (n = 212), coronary artery bypass grafting plus surgical ventricular restoration (n = 360), or listing for cardiac transplantation (n = 510). Mean follow-up was 3.8 ± 2.8 years, with 5577 patient-years of data available for analysis. Risk factors were identified for early and late mortality by using 80% training and 20% validation sets. Outcomes were calculated for each applicable strategy to identify which maximized predicted 5-year survival. Models were programmed as a strategic decision-support tool.Results: One-, 5-, and 9-year survival were as follows, respectively: coronary artery bypass grafting, 92%, 72%, and 53%; coronary artery bypass grafting plus mitral valve anuloplasty, 88%, 57%, and 34%; coronary artery bypass grafting plus surgical ventricular restoration, 94%, 76%, and 55%; and listing for cardiac transplantation, 79%, 66%, and 54%. Risk factors included older age, higher New York Heart Association class, lower ejection fraction, longer interval from myocardial infarction to operation, and numerous comorbidities. Predicted and observed survivals in validation groups were similar (P > .1). Patient-specific simultaneous solutions of applicable models revealed therapy potentially providing maximum survival benefit. Coronary artery bypass grafting alone and listing for cardiac transplantation often maximized 5-year survival; only 15% of patients undergoing coronary artery bypass grafting plus mitral valve anuloplasty were predicted to fare best with this therapy.Conclusion: Validated prediction models can aid surgeons in recommending personalized treatment plans that maximize short- and long-term survival for ischemic cardiomyopathy.

Discussion

2010-02-01

Dr Curtis G. Tribble (Gainesville, Fla). I have been handing out Dr Bruce Lytle's single–authored essay on this subject that was published in the Annals of Thoracic Surgery about 5 years ago to most of my junior house officers and students ever since he wrote it. It is a great article for anybody who would like to read about his thoughts at that time. His last sentences in that article state that (1) coronary artery bypass surgery is best for most of these patients with ischemic cardiomyopathy, (2) we do not know very much about any of the other options, and (3) the other options should be studied. Today's article presented by Mr Yoon is obviously an attempt to address that charge.

The Graft Imaging to Improve Patency (GRIIP) clinical trial results

2009-12-14

Objective: This trial aimed to determine whether intraoperative graft assessment with criteria for graft revision would decrease the proportion of patients with 1 or more graft occlusions or stenoses or major adverse cardiac events 1 year after coronary artery bypass grafting.Methods: A single-center, randomized, single-blinded, controlled clinical trial was designed. Patients were randomized to either of 2 groups: intraoperative graft patency assessment using indocyanine-green fluorescent angiography and transit-time flowmetry, with graft revision according to a priori criteria (imaging group), or standard intraoperative management (control group). Patients underwent follow-up angiography at 1 year.Results: Between September 2005 and August 2008, 156 patients undergoing isolated coronary bypass grafting were enrolled (imaging, n = 78; control, n = 78). Demographic and angiographic characteristics were similar between groups. Operative, crossclamp, and cardiopulmonary bypass times were all nonsignificantly longer in the imaging arm. The number of grafts per patients was similar (imaging, 3.0 ± 0.7; control, 3.0 ± 0.7). The frequency of major adverse cardiac events (death, myocardial infarction, repeat revascularization) was not different between groups at 1 year postoperatively (imaging, 7.7%; control, 7.7%). One-year angiography was performed in 107 patients (imaging, 55 patients/160 grafts; control, 52 patients/152 grafts). The proportion of patients with 1 graft occlusion or more was comparable in the imaging (30.9%) and control (28.9%) groups (relative risk [95% confidence interval], 1.1 [0.6–1.9]; P = .82), as were other graft patency end points. The incidence of saphenous vein graft occlusion was high in both groups.Conclusions: Routine intraoperative graft assessment is safe but does not lead to a marked reduction in graft occlusion 1-year after bypass grafting. The incidence of saphenous vein graft failure remains high despite contemporary practice and routine intraoperative graft surveillance.

Discussion

2009-12-14

Dr Munir Boodhwani (Brussels, Belgium). Can you comment on your power and sample size calculations? It is a smallish study with negative results. What were your assumptions? Dr Singh. In our original protocol and proposal for funding, we hypothesized and calculated that roughly 200 patients would be required per arm. This would achieve a power of 80%, given an assumed event rate in the control group of 9% of grafts occluded, with a relative risk reduction of 60%. Although we did not actually recruit our intended sample, the event rate, occlusions in the control group, was significantly higher at 30%. As well, the relative risk reduction confidence interval included that which we had hypothesized. On the basis of these parameters, it is reasonable to assume a reasonable power and to make a meaningful conclusion from this study.

Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock

2010-02-01

Objective: Adult postcardiotomy cardiogenic shock potentially requiring mechanical circulatory support occurs in 0.5% to 1.5% of cases. Risk factors influencing early or long-term outcome after extracorporeal membrane oxygenation implantation are not well described.Methods: Between May 1996 and May 2008, 517 adult patients received extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock. Procedures were isolated coronary artery bypass grafting (37.4%), isolated valve surgery (14.3%), coronary artery bypass grafting plus valve surgery (16.8%), thoracic organ transplantion (6.5%), and other combinations (25.0%). Fifty-four preoperative and 42 procedural risk factors concerning in-hospital mortality were evaluated by logistic regression analyses.Results: Mean age was 63.5 years, 71.5% were male, ejection fraction was 45.9% ± 17.6%, logistic EuroSCORE was 21.6% ± 20.7%. Extracorporeal membrane oxygenation was established through thoracic (60.8%) or extrathoracic (39.2%) cannulation. Extracorporeal membrane oxygenation support was 3.28 ± 2.85 days. Intra-aortic balloon pumps were implanted in 74.1%. Weaning from extracorporeal membrane oxygenation was successful for 63.3%, and 24.8% were discharged. Cerebrovascular events occurred in 17.4%, gastrointestinal complications in 18.8%, and renal replacement therapy in 65.0%. Risk factors for hospital mortality were age older than 70 years (odds ratio, 1.6), diabetes (odds ratio, 2.5), preoperative renal insufficiency (odds ratio, 2.1), obesity (odds ratio, 1.8), logistic EuroSCORE greater than 20% (odds ratio, 1.8), operative lactate greater than 4 mmol/L (odds ratio, 2.2). Isolated coronary artery bypass grafting (odds ratio, 0.44) was protective. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years.Conclusions: Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors. Because of high morbidity and mortality, extracorporeal membrane oxygenation must be decided by individual risk profile.

Discussion

2010-02-01

Dr R. Duane Davis (Durham, NC). Dr Rastan and colleagues have reported on a large cohort of patients with PCS supported by ECMO. Not surprisingly, for this difficult group of patients, this experience featured substantial mortality and morbidity, particularly bleeding and thromboembolic complications. The hospital survival of approximately 25% is similar to numerous previous reports as well as to registry data, which are approximately in the 30% to 35% range. So their results are well within the range of what we would expect. My questions are going to be related first to technical issues, second to patient selection issues, and third to overall strategic issues.

Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol-driven communication during cardiopulmonary bypass

2010-02-01

Objective: There is general enthusiasm for applying strategies from aviation directly to medical care; the application of the “sterile cockpit” rule to surgery has accordingly been suggested. An implicit prerequisite to the evidence-based transfer of such a concept to the clinical domain, however, is definition of periods of high mental workload analogous to takeoff and landing. We measured cognitive demands among operating room staff, mapped critical events, and evaluated protocol-driven communication.Methods: With the National Aeronautics and Space Administration Task Load Index and semistructured focus groups, we identified common critical stages of cardiac surgical cases. Intraoperative communication was assessed before (n = 18) and after (n = 16) introduction of a structured communication protocol.Results: Cognitive workload measures demonstrated high temporal diversity among caregivers in various roles. Eight critical events during cardiopulmonary bypass were then defined. A structured, unambiguous verbal communication protocol for these events was then implemented. Observations of 18 cases before implementation including 29.6 hours of cardiopulmonary bypass with 632 total communication exchanges (average 35.1 exchanges/case) were compared with observations of 16 cases after implementation including 23.9 hours of cardiopulmonary bypass with 748 exchanges (average 46.8 exchanges/case, P = .06). Frequency of communication breakdowns per case decreased significantly after implementation (11.5 vs 7.3 breakdowns/case, P = .008).Conclusions: Because of wide variations is cognitive workload among caregivers, effective communication can be structured around critical events rather than defined intervals analogous to the sterile cockpit, with reduction in communication breakdowns.

Discussion

2010-02-01

Dr James I. Fann (Palo Alto, Calif). Dr Sundt, thank you for a comprehensive and compelling presentation on this patient safety issue. The concept of sterile cockpit is well established in the field of aviation, with Federal Aviation Administration regulations specifically mandating that pilots refrain from nonessential activities during critical phases of flight. In the context of surgery, on first pass, one might consider the sterile cockpit model to be applicable because of the common perception that the surgeon has a role analogous to that of the pilot. But is this aviation model of the sterile cockpit directly applicable to the cardiac surgical environment? That question, along with a potential solution in a communication protocol, is thoughtfully analyzed in this study.

Concomitant surgery for renal neoplasm with pulmonary tumor embolism

2009-06-11

Objective: Gross tumor pulmonary embolism from renal carcinoma is rarely diagnosed preoperatively. Individual cases of intraoperative embolization of tumor during radical resection of the kidney have been reported. We report on 9 patients who underwent pulmonary arterial tumor removal concomitant with nephrectomy.Methods: Between 2000 and 2008, 9 patients underwent simultaneous nephrectomy and removal of gross embolic tumor from the pulmonary arteries. In 7 of these patients the diagnosis was made preoperatively by either computed tomography or magnetic resonance imaging. Cardiopulmonary bypass was used in all cases. Bilateral removal of pulmonary artery tumor was required in 7 patients and unilateral in 2.Results: All patients survived to hospital discharge after a median stay of 8.8 days (mean, 6–17 days). Two patients are currently alive 4 and 56 months after the operation. Six patients died of distant metastasis or local recurrence of disease after 6, 9, 12, 17, 25, and 29 months. Actuarial survival at 6 months, 1, 2, and 3 years was 100%, 75%, 50%, and 25%, respectively.Conclusions: Pulmonary artery embolic tumor removal concomitant with nephrectomy for renal carcinoma can be performed safely. Survival of patients with combined surgery is comparable with that of patients with the same stage of renal neoplasm without pulmonary tumor embolism. The pulmonary tumor embolism in patients with renal carcinoma should be considered as extension of vena caval tumor but not as a distant metastasis. Pulmonary tumor removal provides symptomatic relief and may provide a survival benefit in these patients.

Video-assisted minimally invasive surgery for lone atrial fibrillation: A clinical report of 81 cases

2009-07-27

Objective: We sought to evaluate the feasibility and efficacy of a new type of video-assisted minimally invasive surgery for patients with atrial fibrillation.Methods: Between December 2006 and February 2008, 81 patients with lone atrial fibrillation (49 with paroxysmal, 17 with persistent, and 15 with long-standing persistent atrial fibrillation) underwent this therapy with a bipolar radiofrequency ablation system. The main surgical procedures included bilateral pulmonary vein antrum isolation, obliteration of the left atrial appendage, division of the ligament of Marshall, and intraoperative electrophysiologic testing.Results: The mean operation duration was 2.5 hours. One (1.2%) case was confirmed of left atrial appendage thrombus during the procedure. One (1.2%) patient was converted to sternotomy during the operation. Reintubation occurred in 1 (1.2%) patient, and acute heart failure occurred in 1 (1.2%) patient. One (1.2%) patient died of cerebral infarction 1 month after the operation. Follow-up was done between 3 and 19 months (mean, 12.7 ± 3.9 months) after the operation. At discharge, 72.5% (58/81) of all patients were in sinus rhythm (paroxysmal atrial fibrillation, 83.7%; persistent atrial fibrillation, 64.7%; and long-standing persistent atrial fibrillation, 40.0%). At 3 months, overall 78.5% (62/79) were in sinus rhythm (paroxysmal atrial fibrillation, 85.7%; persistent atrial fibrillation, 82.4%; and long-standing persistent atrial fibrillation, 46.2%). At 6 months, overall 78.5% (62/79) were in sinus rhythm (paroxysmal atrial fibrillation, 85.7%; persistent atrial fibrillation, 70.6%; and long-standing persistent atrial fibrillation, 61.5%). At 12 months, overall 79.6% (39/49) were in sinus rhythm (paroxysmal atrial fibrillation, 80.0%; persistent atrial fibrillation, 75.0%; and long-standing persistent atrial fibrillation, 66.7%). At 18 months, 88.9% (8/9) of the paroxysmal group were in sinus rhythm.Conclusions: This minimally invasive technique proves to be safe and less traumatic and presents optimistic early outcomes for patients with paroxysmal and persistent atrial fibrillation. It might find wider application if more ablation lesions could be enrolled for long-standing persistent atrial fibrillation.

Midterm outcomes of myocardial revascularization in children

2009-12-14

Objective: Pediatric coronary artery bypass grafting is uncommon. Small target vessels and appropriate conduit choice are the main technical challenges.Methods: Fourteen patients undergoing coronary artery bypass grafting from January 1986 to December 2008 were retrospectively reviewed.Results: Median age was 10 years (range, 3–15 years); median weight was 36 kg (range, 12–71 kg). Indications included symptoms or evidence of inducible ischemia and angiographically documented coronary stenosis. Diagnoses included Kawasaki disease (5/14), anomalous left coronary artery originating from the pulmonary artery (2/14), previous stent implant (1/14), and metabolic disease (3/14). The remaining 3 patients had coronary stenosis after other cardiac operations. Preoperatively 5 patients (45%) had no symptoms and 9 (64%) had positive stress test. Single-vessel disease was demonstrated in 2 (14%), double-vessel disease in 7 (50%), triple-vessel disease in 1 (7%), and left main coronary artery involvement in 4 (29%). With standard cardiopulmonary bypass, 18 (81%) in situ internal thoracic arteries and 4 (19%) long saphenous veins were grafted. There was 1 early reoperation for graft failure. All patients survived to hospital discharge. Follow-up angiography was performed in 5 patients (36%; median, 2 years; range, 1 day–10 years), and 1 (7%) required late balloon dilatation. Median follow-up was 3.3 years (1 month–10 years), and 12 patients had no symptoms. There was 1 late death of noncardiac cause.Conclusions: Pediatric coronary artery bypass grafting can be performed for a wide range of indications. Midterm results are excellent. Preoperative stress testing can detect silent myocardial ischemia.

Performance of the CryoValve∗ SG human decellularized pulmonary valve in 342 patients relative to the conventional CryoValve at a mean follow-up of four years

2010-02-01

Objective: This study compared clinical outcomes of patients receiving CryoValve SG decellularized pulmonary valves with those of patients receiving conventionally processed CryoValve pulmonary valves.Methods: All consecutive patients undergoing Ross procedures and right ventricular outflow tract reconstructions with SG valves at 7 institutions (February 2000–November 2005) were assessed retrospectively (193 Ross procedures, 149 right ventricular outflow tract reconstructions). Patient, procedural, and outcome data were compared with those from 1246 conventional implants (665 Ross procedures, 581 right ventricular outflow tract reconstructions). Hemodynamic function was assessed at latest follow-up.Results: Follow-up was complete for 99% in SG group and 94% in conventional group, with mean follow-ups of 4.0 years (range, 0–6.7 years) for SG and 3.7 years (range, 0–6.7 years) for conventional. Five-year cumulative survivals and freedoms from adverse events were comparable between SG and conventional valves. Among patients undergoing Ross procedures, peak gradient at last follow-up was lower with SG valves (P < .01); no difference was observed in the right ventricular outflow tract reconstruction population. Pulmonary insufficiency was significantly reduced with SG valves in patients undergoing both Ross procedures (P < .01) and right ventricular outflow tract reconstructions (P < .01). Valve type was not a significant predictor of valve-related failure in propensity-adjusted analysis of either procedure.Conclusions: CryoValve SG decellularized pulmonary valves have acceptable clinical outcomes and favorably compare with conventionally processed valves. Improved hemodynamic function observed with SG valves could signify improved long-term outcomes and may be due to the decreased antigenicity of these valves.

Outcome of coronary artery bypass grafting performed in young children

2009-09-23

Objectives: The long-term patency rate of coronary artery bypass grafting for which arterial grafts are used is known to be high in the pediatric population. However, this issue remains uncertain in children under 3 years of age. Here, we report the outcome in this specific population.Methods: From July 1988 to July 2007, 18 children less than 3 years of age (age at operation, 0.1–35 months; median, 4 months) underwent 20 coronary artery bypass graft operations using an arterial graft. Indications for bypass grafting were coronary artery complications related to the arterial switch operation for transposition of the great arteries in 12 patients (coronary obstruction in 8 patients, peroperative coronary anomalies precluding coronary transfer in 4 patients), congenital anomalies of the coronary arteries in 4 patients, and Kawasaki disease in 2 patients.Results: After a mean follow-up of 55 months (range, 1–176 months; median, 41 months), patency of 19 bypass grafts was assessed. One was occluded and 2 have necessitated a percutaneous procedure. Two patients died suddenly (1 with an occluded graft and 1 with a patent graft and hypertrophic myocardiopathy) 3.5 and 4.6 months, respectively, after bypass grafting.Conclusions: Coronary artery bypass grafting should be considered as a possible alternative for coronary revascularization in young children. Although our series shows quite a good patency rate, this procedure remains a technical challenge and requires careful follow-up.

Management and long-term outcome of neonatal Ebstein anomaly

2009-09-23

Objective: The objective of this study was to review the long-term results of symptomatic patients with Ebstein anomaly in the neonatal period.Methods: The medical records of 40 neonates with a diagnosis of Ebstein anomaly who were admitted to our institution between January 1988 and June 2008 were retrospectively reviewed. Primary outcomes studied included patient survival and need for reintervention.Results: No early intervention was required in 16 of the 40 patients with a hospital survival of 94% (15/16) and no late mortality. The remaining 24 patients underwent surgical intervention in the neonatal period. A shunt alone was performed in 9 patients with an actuarial survival of 88.9% at 1 year and 76.2% at 5 and 10 years. For the patients undergoing intervention on the tricuspid valve, survival estimates for the 11 patients with a right ventricular exclusion procedure were 63.6% at 1, 5, and 10 years and 47.7% at 15 years compared with 25.0% at 1, 5, and 10 years for the 4 patients with tricuspid valve repair. All long-term survivors were in New York Heart Association class I or II, and only 1 patient required antiarrhythmic medication.Conclusion: Symptomatic neonates with Ebstein anomaly requiring no intervention or shunting alone have good long-term survival. For patients needing intervention on the tricuspid valve, overall survival is lower. For these patients, right ventricular exclusion may be superior to tricuspid valve repair.

Outcome of the Norwood operation in patients with hypoplastic left heart syndrome: A 12-year single-center survey

2009-11-02

Objective: Recent advances in perioperative care have led to a decrease in mortality of children with hypoplastic left heart syndrome undergoing the Norwood operation. This study aimed to evaluate the outcome of the Norwood operation in a single center over 12 years and to identify clinical and anatomic risk factors for adverse early and longer term outcome.Methods: Full data on all 157 patients treated between 1996 and 2007 were analyzed.Results: Thirty-day mortality of the Norwood operation decreased from 21% in the first 3 years to 2.5% in the last 3 years. The estimated exponentially weighted moving average of early mortality after 157 Norwood operations was 2.3%. Risk factors were an aberrant right subclavian artery, the use and duration of circulatory arrest, and the duration of total support time. The anatomic subgroup mitral stenosis/aortic atresia and female gender tended to show an increased early mortality. In the group of patients who required postoperative cardiopulmonary resuscitation, the ascending aorta was significantly smaller than in the remainder (3.03 ± 1.05 vs 3.63 ± 1.41 mm). Interstage mortality was 15% until the initiation of a home surveillance program in 2005, which has zeroed it so far. It was significantly higher in the mitral stenosis/aortic atresia subgroup and tended to be higher in patients who required cardiopulmonary resuscitation after the Norwood operation. The best actuarial survival was observed in the mitral atresia/aortic atresia subgroup.Conclusion: The Norwood operation can now be performed with low mortality. Patients with mitral stenosis/aortic atresia still constitute the most challenging subgroup.

Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database

2010-02-01

Background: Several single-institution series have demonstrated that compared with open thoracotomy, video-assisted thoracoscopic lobectomy may be associated with fewer postoperative complications. In the absence of randomized trials, we queried the Society of Thoracic Surgeons database to compare postoperative mortality and morbidity following open and video-assisted thoracoscopic lobectomy. A propensity-matched analysis using a large national database may enable a more comprehensive comparison of postoperative outcomes.Methods: All patients having lobectomy as the primary procedure via thoracoscopy or thoracotomy were identified in the Society of Thoracic Surgeons database from 2002 to 2007. After exclusions, 6323 patients were identified: 5042 having thoracotomy, 1281 having thoracoscopy. A propensity analysis was performed, incorporating preoperative variables, and the incidence of postoperative complications was compared.Results: Matching based on propensity scores produced 1281 patients in each group for analysis of postoperative outcomes. After video-assisted thoracoscopic lobectomy, 945 patients (73.8%) had no complications, compared with 847 patients (65.3%) who had lobectomy via thoracotomy (P < .0001). Compared with open lobectomy, video-assisted thoracoscopic lobectomy was associated with a lower incidence of arrhythmias [n = 93 (7.3%) vs 147 (11.5%); P = .0004], reintubation [n = 18 (1.4%) vs 40 (3.1%); P = .0046], and blood transfusion [n = 31 (2.4%) vs n = 60 (4.7%); P = .0028], as well as a shorter length of stay (4.0 vs 6.0 days; P < .0001) and chest tube duration (3.0 vs 4.0 days; P < .0001). There was no difference in operative mortality between the 2 groups.Conclusions: Video-assisted thoracoscopic lobectomy is associated with a lower incidence of complications compared with lobectomy via thoracotomy. For appropriate candidates, video-assisted thoracoscopic lobectomy may be the preferred strategy for appropriately selected patients with lung cancer.

Discussion

2010-02-01

Dr Neil Christie (Pittsburgh, Pa). I have no conflicts to disclose. Earlier studies in thoracoscopic lobectomy focused on feasibility and technique. That having been established, there is now an interest to determine if it is superior to the open thoracotomy technique and, as such, should become the standard of care. This paper has demonstrated a significant decrease in perioperative complications and a shortened length of stay with the thoracoscopic approach to lobectomy.

Minimally invasive repair of pectus excavatum: A novel morphology-tailored, patient-specific approach

2010-02-01

Objective: Minimally invasive repair of pectus excavatum, introduced by Nuss in 1998, has undergone a serious learning curve because of a lack of understanding on morphologies and repair techniques. To summarize the current status of minimally invasive repair of pectus excavatum, we reviewed and appraised our 10-year experience with a novel approach, a morphology-tailored technique, including diverse bar shaping, bar fixation, and techniques for adults.Methods: We analyzed the data of 1170 consecutive patients with pectus excavatum who underwent minimally invasive repair between August 1999 and September 2008. All pectus repairs were performed by the primary author (H.J.P.) with our modified technique.Results: The mean age was 10.3 years (range, 16 months to 51 years). There were 331 adult patients (>15 years) (28.3%). A total of 576 patients (49.2%) had bar removal after a mean of 2.5 years (range, 10 days to 7 years). The asymmetry index change (1.10–1.02, P < .001) demonstrated post-repair symmetry. Complication rates decreased through the 3 time periods (1999–2002 [n = 335]; 2003–2005 [n = 441]; 2006–2008 [n = 394]) as follows: pneumothorax rate (7.5% vs 4.3% vs 0.8%; P < .001) and bar displacement rate (3.8% vs 2.3% vs 0.5%; P = .002). Reoperation rate also decreased (4.8% vs 2.5% vs 0.8%; P = .002). Satisfaction outcomes were excellent in 92.7%, good in 5.9%, and fair in 1.4% of patients. After bar removal, 3 patients (0.6%) had minor recurrences.Conclusion: Minimally invasive repair of pectus excavatum based on a novel morphology-tailored, patient-specific approach is effective for quality repair of the full spectrum of pectus excavatum, including asymmetry and adult patients. Continuous technical refinements have significantly decreased the complication rates and postoperative morbidity.

Discussion

2010-02-01

Dr Daniel L. Miller (Atlanta, Ga). Dr Park, I applaud you on an outstanding series of minimally invasive pectus repair from your institution. You have taken the standard Nuss procedure to a new level of expertise. I congratulate you on that. The most common complication after a Nuss procedure in an adult is pain. Approximately 50% of patients will experience pain, and some of it can be debilitating. My question for you is, what do you do for the severe discomfort and pain that occur after this procedure? If it does become debilitating, how do you manage the pain with early bar removal, and if you do, have you had an increase in recurrence?

Predictors of survival in patients with persistent nodal metastases after preoperative chemotherapy for esophageal cancer

2009-12-14

Objective: In patients with esophageal cancer, a complete pathologic response after preoperative therapy is universally regarded as a favorable prognostic factor. However, less is known about factors predictive of outcome in patients with persistent nodal disease. The purpose of this study is to determine which variables affect survival in this patient population.Methods: We reviewed a prospectively maintained esophageal cancer database. Patients with positive lymph nodes after preoperative therapy and surgery were selected. Predictors of survival were examined univariately using the log–rank test. Factors identified at P < .20 by univariate analysis were selected for inclusion in a multivariate model.Results: Ninety-six patients with 1 or more positive nodes received preoperative therapy. Pathologic T classification was 0 to 2 in 25 (26%) patients and 3 to 4 in 71 (74%) patients. In 29 (30%) patients, nonregional nodal disease was present (M1). Final pathologic stages were IIB in 18 (19%), III in 49 (51%), and IV in 29 (30%). Postoperatively, 44 (46%) patients received additional chemotherapy. On univariate analysis, pathologic stage, pathologic T classification, and number of positive nodes significantly affected overall survival. On multivariate analysis, clinical stage (hazard ratio [HR], 2.25; P = .05), pathologic T classification (HR, 3.06; P = .006), and number of positive nodes (HR 1.03 per node, P = .09) were significant predictors of overall survival.Conclusion: Long-term survival can be achieved in patients with esophageal cancer who have persistent nodal disease after neoadjuvant therapy and surgical resection. Clinical stage, pathologic T classification, and number of positive nodes best predict survival. Nonregional nodal disease does not adversely affect outcome. Postoperative chemotherapy conferred no additional survival benefit in this patient population.

Discussion

2009-12-14

Dr Antoon E. M. R. Lerut (Leuven, Belgium). I have no financial disclosures. This was an excellent presentation on a topic that indeed has not been investigated thoroughly until this presentation. The conclusions are first that indeed you can obtain long-term survival and disease-free survival in 1 of 4 patients. Second, patients with more than 7 positive lymph nodes have a poor prognosis and dismal survival, and finally, adjuvant chemotherapy, at least one cycle, does not seem to be of any benefit.

Outcomes after a decade of laparoscopic giant paraesophageal hernia repair

2009-12-11

Objective: Laparoscopic repair of giant paraesophageal hernia is a complex operation requiring significant laparoscopic expertise. Our objective was to compare our current approach and outcomes for laparoscopic repair of giant paraesophageal hernia with our previous experience.Methods: A retrospective review of patients undergoing nonemergency laparoscopic repair of giant paraesophageal hernia, stratified by early versus current era (January 1997–June 2003 and July 2003–June 2008), was performed. We evaluated clinical outcomes, barium esophagogram, and quality of life.Results: Laparoscopic repair of giant paraesophageal hernia was performed in 662 patients (median age 70 years, range 19–92 years) with a median percentage of herniated stomach of 70% (range 30%–100%). With time, use of Collis gastroplasty decreased (86% to 53%), as did crural mesh reinforcement (17% to 12%). Current era patients were 50% more likely to have a Charlson comorbidity index score greater than 3. Thirty-day mortality was 1.7% (11/662). Mortality and complication rates were stable with time, despite increasing comorbid disease in current era. Postoperative gastroesophageal reflux disease health-related quality of life scores were available for 489 patients (30-month median follow-up), with good to excellent results in 90% (438/489). Radiographic recurrence (15.7%) was not associated with symptom recurrence. Reoperation occurred in 3.2% (21/662).Conclusions: With time, we have obtained significant minimally invasive experience and refined our approach to laparoscopic repair of giant paraesophageal hernia. Perioperative morbidity and mortality remain low, despite increased comorbid disease in the current era. Laparoscopic repair provided excellent patient satisfaction and symptom improvement, even with small radiographic recurrences. Reoperation rates were comparable to the best open series.

Discussion

2009-12-11

Dr Toni Lerut (Leuven, Belgium). It is a privilege for me to discuss this excellent and important presentation reporting an in-depth study on the results of what is now by far the largest series on repairs of GPEH. The conclusion is that laparoscopic repair provides excellent patient satisfaction and symptom resolution, with reoperation rates comparable to those of the best open series. Despite your obvious enthusiasm, Dr Luketich, I do have some concerns and questions.

Long-term cardiopulmonary function after thoracic sympathectomy: Comparison between the conventional and simplified techniques

2009-06-29

Objective: We sought to compare the long-term effects of conventional and simplified thoracic sympathectomy on cardiopulmonary function.Methods: We performed a prospective and randomized study of 32 patients with diagnoses of primary hyperhidrosis who were candidates for either conventional or simplified thoracic sympathectomy. Patients were randomized according to the type of procedure: conventional thoracic sympathectomy (18 patients) and simplified thoracic sympathectomy (14 patients). Before surgical intervention, forced spirometry, body plethysmography, measurement of the diffusing capacity of the lung for carbon monoxide (Dlco), and exercise tests were carried out in all patients. These evaluations were performed again 1 year after the procedure to assess the long-term effects of sympathectomy.Results: Lung function tests revealed a significant decrease in forced expiratory volume in 1 second (FEV1) and forced expiratory flow between 25% and 75% of vital capacity (FEF25%–75%) in both groups (FEV1 of −6.3% and FEF25%–75% of −9.1% in the conventional thoracic sympathectomy group and FEV1 of −3.5% and FEF25%–75% of −12.3% in the simplified thoracic sympathectomy group). Dlco and heart rate at rest and maximal values after exercise were also significantly reduced in both groups (Dlco of −4.2%, Dlco corrected by alveolar volume of −6.1%, resting heart rate of −11.8 beats/min, and maximal heart rate of −9.5 beats/min in the conventional thoracic sympathectomy group and Dlco of −3.9%, Dlco corrected by alveolar volume of −5.2%, resting heart rate of −10.7 beats/min, and maximal heart rate of −17.6 beats/min in the simplified thoracic sympathectomy group). Airway resistance increased significantly in the group of patients undergoing conventional thoracic sympathectomy (+13%). Despite all these changes, the patients remained asymptomatic. No significant differences were found between the conventional and simplified thoracic sympathectomy groups.Conclusions: Simplified and conventional thoracic sympathectomy resulted in a long-term reduction in FEV1, FEF25%–75%, Dlco, and resting and maximal heart rate, as well as a mild but significant increase in airway resistance in the conventional thoracic sympathectomy group, without any clinical consequence to the patient. These changes were unrelated to the level of transection of the thoracic sympathetic chain.

Management of severe pediatric subglottic stenosis with glottic involvement

Mercy George, Yves Jaquet, Christos Ikonomidis, Philippe Monnier — 2009-07-02

Objective: We sought to describe our experience in the management of complex glotto-subglottic stenosis in the pediatric age group.Methods: Between 1978 and 2008, 33 children with glotto-subglottic stenosis underwent partial cricotracheal resection, and they form the focus of this study. They were compared with 67 children with isolated subglottic stenosis (no glottic involvement). The outcomes measured were need for revision open surgical intervention, delayed decannulation (>6 months), and operation-specific and overall decannulation rates. Fisher's exact test was used for comparison of outcomes.Results: Results of preoperative evaluation showed Myer–Cotton grade III or IV stenosis in 32 (97%) patients and grade II stenosis in 1 patient. All patients with glotto-subglottic stenosis were treated with partial cricotracheal resection and simultaneous repair of the glottic pathology. Bilateral fixed vocal cords were seen in 19 (58%) of 33 patients, bilateral restricted abduction was seen in 7 (21%) of 33 patients, and unilateral fixed vocal cord was seen in 7 (21%) of 33 patients. Ten patients underwent single-stage partial cricotracheal resection with excision of interarytenoid scar tissue. The endotracheal tube was kept for a mean period of 7 days as a stent. Twenty-three patients underwent extended partial cricotracheal resection with LT-Mold (Bredam S.A., St. Sulpice, Switzerland) or T-tube stenting. The overall decannulation rate included 26 (79%) patients, and the operation-specific decannulation rate included 20 (61%) patients.Conclusions: Glotto-subglottic stenosis is a complex laryngeal injury associated with delayed decannulation and decreased overall and operation-specific decannulation rates when compared with those after subglottic stenosis without glottic involvement after partial cricotracheal resection.

The papillary muscle sling for ischemic mitral regurgitation

Ulrik Hvass, Thomas Joudinaud — 2010-02-01

Objective: Our objective was to evaluate long-term stability of mitral repair and reverse remodeling in patients with severe ischemic left ventricular dysfunction and functional mitral regurgitation.Methods: Since June 2000, a total of 37 patients with ischemic functional mitral regurgitation have benefited from a double-level mitral repair that comprises an intraventricular peripapillary muscle sling completed by a classic intra-atrial mitral annuloplasty ring (mean age, 56 years; left ventricular end-diastolic diameter, 70 ± 0 mm; left ventricular end-systolic diameter, 55 ± 5.6 mm; ejection fraction, 15% to 45%; pulmonary hypertension > 60 in all patients; all were in New York Heart Association class III-IV). All patients had both papillary muscles encircled with a 4-mm polytetrafluoroethylene tube, correcting their lateral and downward displacement. Annuloplasty rings were moderately undersized or normal. Efficiency was evaluated on mitral stability, ventricular parameters, and functional status. According to the Leyden algorithm based on preoperative end-diastolic and end-systolic left ventricular diameters, only a minority of our patients were expected to experience reverse remodeling.Results: Regurgitation is none to trivial in 31 and mild to moderate in 4. Follow-up (3–84 months; mean, 55 ± 22 months) shows stability of all initially successful double-level mitral repairs. Follow-up beyond 1 year shows improvements in ventricular diameters (56 ± 5 mm), ejection fraction (49 ± 6), volume (130 ± 10 mL), and sphericity index (0.55). Two patients died during follow-up and 1 underwent transplantation.Conclusion: Reapproximating the papillary muscles has an immediate effect on mitral leaflet mobility by suppressing the tethering resulting from displacement of the papillary muscles. It has an effect in preventing recurrent mitral regurgitation by avoiding further papillary muscle displacement. In this cohort of severely disabled patients, reverse remodeling can be expected with the double-level repair.

Discussion

2010-02-01

Dr Robert A. Dion (Genk, Belgium). Dr Hvass, as you mentioned, our group in Leiden has demonstrated that a preoperative cutoff value of the LV end-diastolic diameter of 65 mm is an independent predictor of survival and of LV reverse remodeling. Below this value, a stringent undersizing annuloplasty by two sizes using a complete semirigid ring (Physio ring), as you also now use, yields a coaptation length of at least 8 mm. In our hands, this is invariably efficient in correcting MR without producing mitral stenosis and also addresses LV remodeling, even after a follow-up of 5 years. We also concluded that something else should be added to the annuloplasty at the ventricular level in the presence of a more dilated left ventricle, in case the LV end-diastolic diameter is more than 65 mm.

Midterm results of transapical aortic valve replacement via real-time magnetic resonance imaging guidance

2009-12-07

Objective: Percutaneous valve replacements are presently being evaluated in clinical trials. As delivery of the valve is catheter based, the safety and efficacy of these procedures may be influenced by the imaging used. To assist the surgeon and improve the success of the operation, we have performed transapical aortic valve replacements using real-time magnetic resonance imaging guidance.Methods: Twenty-eight swine underwent aortic valve replacement by real-time magnetic resonance imaging on the beating heart. Stentless bioprostheses mounted on balloon-expandable stents were used. Magnetic resonance imaging (1.5 T) was used to identify the critical anatomic landmarks. In addition to anatomic confirmation of adequate placement of the prosthesis, functional assessment of the valve and left ventricle and perfusion were also obtained with magnetic resonance imaging. A series of short-term feasibility experiments were conducted (n = 18) in which the animals were humanely killed after valve placement and assessment by magnetic resonance imaging. Ten additional animals were allowed to survive and had follow-up magnetic resonance imaging scans and confirmatory echocardiography at 1, 3, and 6 months postoperatively.Results: Real-time magnetic resonance imaging provided superior visualization of the landmarks needed. The time to implantation after apical access was 74 ± 18 seconds. Perfusion scanning demonstrated adequate coronary flow and functional imaging documented preservation of ventricular contractility in all animals after successful deployment. Phase contrast imaging revealed minimal intravalvular or paravalvular leaks. Longer term results demonstrated stability of the implants with preservation of myocardial perfusion and function over time.Conclusions: Real-time magnetic resonance imaging provides excellent visualization for intraoperative guidance of aortic valve replacement on the beating heart. Additionally, it allows assessment of tissue perfusion and organ function that is not obtainable by conventional imaging alone.

Late-term results of tissue-engineered vascular grafts in humans

2010-02-01

Objective: The development of a tissue-engineered vascular graft with the ability to grow and remodel holds promise for advancing cardiac surgery. In 2001, we began a human trial evaluating these grafts in patients with single ventricle physiology. We report the late clinical and radiologic surveillance of a patient cohort that underwent implantation of tissue-engineered vascular grafts as extracardiac cavopulmonary conduits.Methods: Autologous bone marrow was obtained and the mononuclear cell component was collected. Mononuclear cells were seeded onto a biodegradable scaffold composed of polyglycolic acid and ε-caprolactone/l-lactide and implanted as extracardiac cavopulmonary conduits in patients with single ventricle physiology. Patients were followed up by postoperative clinic visits and by telephone. Additionally, ultrasonography, angiography, computed tomography, and magnetic resonance imaging were used for postoperative graft surveillance.Results: Twenty-five grafts were implanted (median patient age, 5.5 years). There was no graft-related mortality (mean follow-up, 5.8 years). There was no evidence of aneurysm formation, graft rupture, graft infection, or ectopic calcification. One patient had a partial mural thrombosis that was successfully treated with warfarin. Four patients had graft stenosis and underwent successful percutaneous angioplasty.Conclusion: Tissue-engineered vascular grafts can be used as conduits in patients with single ventricle physiology. Graft stenosis is the primary mode of graft failure. Further follow-up and investigation for the mechanism of stenosis are warranted.

Discussion

2010-02-01

Dr John Edmund Mayer, Jr (Boston, Mass). You have some patients who have not survived long term in your tissue-engineered extracardiac Fontan group. Do you have any histologic studies on those explanted grafts from autopsy?

Both epithelial cells and mesenchymal stem cell–derived chondrocytes contribute to the survival of tissue-engineered airway transplants in pigs

2009-12-08

Objective: We sought to determine the relative contributions of epithelial cells and mesenchymal stem cell–derived chondrocytes to the survival of tissue-engineered airway transplants in pigs.Methods: Nonimmunogenic tracheal matrices were obtained by using a detergent-enzymatic method. Major histocompatibility complex–unmatched animals (weighing 65 ± 4 kg) were divided into 4 groups (each n = 5), and 6 cm of their tracheas were orthotopically replaced with decellularized matrix only (group I), decellularized matrix with autologous mesenchymal stem cell–derived chondrocytes externally (group II), decellularized matrix with autologous epithelial cells internally (group III), or decellularized matrix with both cell types (group IV). Autologous cells were recovered, cultured, and expanded. Mesenchymal stem cells were differentiated into chondrocytes by using growth factors. Both cell types were seeded simultaneously with a dual-chamber bioreactor. Animals were not immunosuppressed during the entire study. Biopsy specimens and blood samples were taken from recipients continuously, and animals were observed for a maximum of 60 days.Results: Matrices were completely covered with both cell types within 72 hours. Survival of the pigs was significantly affected by group (P < .05; group I, 11 ± 2 days; group II, 29 ± 4 days; group III, 34 ± 4 days; and group IV, 60 ± 1 days). Cause of death was a combination of airway obstruction and infection (group I), mainly infection (group II), or primarily stenosis (group III). However, pigs in group IV were alive, with no signs of airway collapse or ischemia and healthy epithelium. There were no clinical, immunologic, or histologic signs of rejection despite the lack of immunosuppression.Conclusions: We confirm the clinical potential of autologous cell– and tissue-engineered tracheal grafts, and suggest that the seeding of both epithelial and mesenchymal stem cell–derived chondrocytes is necessary for optimal graft survival.

Discussion

2009-12-08

Dr Yolonda Colson (Boston, Mass). I have no conflicts. You are to be congratulated on doing an amazing job in getting this to actually work, and I think that you have defined a very nice clinical problem that currently does not have a great solution. Having said that, I think there are a lot of obvious questions in terms of longer-term follow-up and analysis. I have several questions.

Vagal denervation and reinnervation after ablation of ganglionated plexi

2009-09-10

Objective: Surgical ablation of ganglionated plexi has been proposed to increase efficacy of surgery for atrial fibrillation. This experimental canine study examined electrophysiologic attenuation and recovery of atrial vagal effects after ganglionated plexi ablation alone or with standard surgical lesion sets for atrial fibrillation.Methods: Dogs were divided into 3 groups: group 1 (n = 6) had focal ablation of the 4 major epicardial ganglionated plexi fat pads, group 2 (n = 6) had pulmonary vein isolation with ablation, and group 3 (n = 6) had posterior left atrial isolation with ablation. All fat pads were ablated. Sinus and atrioventricular interval changes during bilateral vagosympathetic trunk stimulation were examined before and both immediately and 4 weeks after ablation. Vagally induced effective refractory period changes and mean QRST area changes (index of local innervation) were examined in 5 atrial regions.Results: Sinus and atrioventricular interval changes and heart rate variability decreased immediately after ablation, but only sinus interval changes were restored significantly after 4 weeks in all groups. Ablation-modified vagal effects on effective refractory period or QRST area changed heterogeneously in groups 1 and 2. In group 3, regional vagal effects were attenuated extensively postablation in both atria. Posterior left atrial isolation with ablation incrementally denervated the atria. In the long term, vagal stimulation increased QRST area changes relative to control values in all groups. Heart rate variability was also assessed.Conclusions: Ganglionated plexi ablation significantly reduced atrial vagal innervation. Restoration of vagal effects at 4 weeks suggests early atrial reinnervation.

Efficacy of a cooled bipolar epicardial radiofrequency ablation probe for creating transmural myocardial lesions

2009-09-14

Objective: Creation of transmural myocardial lesions with epicardial surgical devices to treat atrial fibrillation is difficult. A new cooled bipolar radiofrequency ablation probe was used to create transmural myocardial lesions under controlled conditions.Methods: The Coolrail (AtriCure, Inc, West Chester, Ohio) is a handheld probe with 2 parallel 30-mm long radiofrequency conductors. Conductors are cooled by water irrigation. Lesions were delivered to epicardial surface of isolated bovine myocardium sliced 3- to 8-mm thick, with blood flow beneath tissue at 0 or 0.4 m/s. Contact pressure between probe and tissue was either 450 g or 900 g. Tissue temperatures were measured. Tissue was sectioned every 5 mm along lesion long axis to determine lesion dimensions.Results: For 80 experiments with 450-g contact pressure, epicardial lesion length was 31.3 mm (interquartile range, 30.1–32.8 mm); endocardial lesion length was 14.1 mm (interquartile range, 0.0–22.6 mm). Average lesion depth was 4.2 ± 0.74 mm. Temperature at probe interface was 81°C ± 21°C; that at blood pool interface was 53°C ± 12°C. Lesions were always transmural when tissue thickness was 4.0 mm or less. Endocardial blood flow did not influence lesion depth. With 900-g contact pressure, increased depth was always transmural at 4.8-mm tissue thickness or less.Conclusions: This irrigated bipolar radiofrequency probe consistently produced transmural lesions in tissue 4 mm or thinner under controlled conditions in vitro. Lesion depth was increased by greater pressure on probe and not affected by blood flow. Endocardial lesions were smaller than epicardial dimensions.

Impaired angiogenic potency of bone marrow cells from patients with advanced age, anemia, and renal failure

2009-09-14

Objective: The implantation of autologous bone marrow–derived cells has been used for the treatment of ischemic diseases, but obvious interindividual differences were observed in the improvement of regional perfusion and cardiac function after treatment. We examined the angiogenic potency of bone marrow cells from patients with different clinical backgrounds.Methods: Bone marrow cells were collected from 25 patients scheduled to undergo sternotomy for various surgical procedures. We examined the quality of bone marrow cells and investigated their angiogenic potency by using an ischemic limb model in mice with severe combined immunodeficiency.Results: When compared with their control cohort, bone marrow cells from patients with advanced age, renal failure, or anemia had significantly less c-kit– and CD34-positive stem cells (P < .05) and showed significantly lower vascular endothelial growth factor production and colony-forming units in culture (P < .05). Furthermore, the implantation of bone marrow cells from patients with advanced age, renal failure, or anemia into the ischemic limbs of mice also resulted in significantly worse blood flow recovery and clinical score when compared with the implantation of bone marrow cells from their control cohorts (P < .05). However, the bone marrow cells from patients with diabetes and hypertension did not show significant impairment of angiogenic potency when compared with their control cohorts.Conclusions: The quality and angiogenic potency of bone marrow cells differs among patients. Advanced age, renal failure, and anemia should be the risk factors related to poor angiogenic potency of bone marrow cells for the treatment of ischemic diseases.

Thoratec implantable ventricular assist device: The Papworth experience

2009-10-15

Objective: The Thoratec (Thoratec Corp, Pleasanton, Calif) implantable ventricular assist device (IVAD) can be used for univentricular or biventricular support. The objective of this study is to review the 5-year experience of bridging patients to heart transplantation with this device in a single center. Surgical aspects, including hybrid pump pocket, double tunneling of driveline, and optimal cannulae placement, are discussed.Methods: This is a retrospective review of 24 patients treated between January 2002 and December 2007. Nineteen patients (79.1%) received a single implantable ventricular assist device as left ventricular assist devices, and 5 patients (21.9%) received 2 implantable ventricular assist devices as biventricular assist devices. The devices were implanted in pre-peritoneal/posterior rectus hybrid pump pockets. The driveline was passed through a 2-stage double-tunnel to exit onto the lateral chest wall. Patients were anticoagulated with Warfarin aiming for an international normalized ratio of 2.0 to 3.0.Results: Twenty male and 4 female patients with a mean age of 39.8 years (17–57 years) and a body surface area of 1.87 m2 (1.63–2.2 m2) were supported for a total of 2308 patient-days. Mean duration of support was 96 days (10–301 days). The cause of heart failure was dilated cardiomyopathy in 18 patients and ischemic cardiomyopathy in 6 patients. Preoperatively, 23 patients were receiving inotropes, 12 patients required intra-aortic balloon pump support, 5 patients were intubated and mechanically ventilated, and 3 patients required continuous venovenous hemofiltration for renal support. Eleven patients (45.8%) were discharged with ventricular assist device support (1015 home patient-days). Complications observed were a) neurologic: stroke in 3 patients, transient ischemic attacks in 4 patients; and b) infection: driveline infection in 3 patients and pump pocket infection in 1 patient. There was no mechanical device failure. Support to transplantation was achieved in 17 patients (70.8%): 3 of 5 biventricular assist devices (60%) and 14 of 19 left ventricular assist devices (73.7%).Conclusion: The Thoratec IVAD is a versatile and reliable ventricular assist device. It can provide univentricular or biventricular support for bridging patients to heart transplantation with acceptable complication rates. The portable Thoratec TLC-II console facilitated discharge while patients waited for a suitable donor heart.

Adenosine A2A receptor activation on CD4+ T lymphocytes and neutrophils attenuates lung ischemia–reperfusion injury

2009-11-12

Objective: Adenosine A2A receptor activation potently attenuates lung ischemia–reperfusion injury. This study tests the hypothesis that adenosine A2A receptor activation attenuates ischemia–reperfusion injury by inhibiting CD4+ T cell activation and subsequent neutrophil infiltration.Methods: An in vivo model of lung ischemia–reperfusion injury was used. C57BL/6 mice were assigned to either sham group (left thoracotomy) or 7 study groups that underwent ischemia–reperfusion (1 hour of left hilar occlusion plus 2 hours of reperfusion). ATL313, a selective adenosine A2A receptor agonist, was administered 5 minutes before reperfusion with or without antibody depletion of neutrophils or CD4+ T cells. After reperfusion, the following was measured: pulmonary function using an isolated, buffer-perfused lung system, T cell infiltration by immunohistochemistry, myeloperoxidase and proinflammatory cytokine/chemokine levels in bronchoalveolar lavage fluid, lung wet/dry weight, and microvascular permeability.Results: ATL313 significantly improved pulmonary function and reduced edema and microvascular permeability after ischemia–reperfusion compared with control. Immunohistochemistry and myeloperoxidase content demonstrated significantly reduced infiltration of neutrophils and CD4+ T cells after ischemia–reperfusion in ATL313-treated mice. Although CD4+ T cell–depleted and neutrophil-depleted mice displayed significantly reduced lung injury, no additional protection occurred when ATL313 was administered to these mice. Expression of tumor necrosis factor-α, interleukin 17, KC, monocyte chemotactic protein-1, macrophage inflammatory protein-1, and RANTES were significantly reduced in neutrophil- and CD4+ T cell–depleted mice and reduced further by ATL313 only in neutrophil-depleted mice.Conclusions: These results demonstrate that CD4+ T cells play a key role in mediating lung inflammation after ischemia–reperfusion. ATL313 likely exerts its protective effect largely through activation of adenosine A2A receptors on CD4+ T cells and neutrophils.

Common genetic variants on chromosome 9p21 predict perioperative myocardial injury after coronary artery bypass graft surgery

2009-10-12

Objective: Approximately 10% of patients undergoing cardiac surgery have perioperative myocardial injury. A recent genome-wide association study identified an association between myocardial infarction in nonsurgical populations and common genetic variants on chromosome 9p21. We hypothesized that these variants are also associated with perioperative myocardial injury after isolated primary coronary artery bypass graft surgery.Methods: In a prospective observational study of 846 Caucasian patients undergoing primary coronary bypass surgery at 2 US centers, we genotyped 61 linkage-disequilibrium tagging single nucleotide polymorphisms, encompassing 436 kbp of the 9p21 region. A multivariable logistic model was used to adjust for previously identified clinical covariates of perioperative myocardial injury. Perioperative myocardial injury was defined as a postoperative day 1 cardiac troponin I in the top 10th percentile (>9.13 μg/L) of the cohort. Multiple testing of single nucleotide polymorphisms was corrected for with family-wise errors.Results: Prior myocardial infarction and longer cardiopulmonary bypass time were significant independent predictors of perioperative myocardial injury. Levels of postoperative cardiac troponin I were incrementally increased for each additional copy of the risk alleles of 3 single nucleotide polymorphisms: rs10116277, rs6475606, and rs2383207. Adjusted additive odds ratios ranged between 1.64 and 1.79 (asymptotic P value between 3.7 × 10−3 and 6 × 10−4) and remained significantly associated with perioperative myocardial injury even after accounting for clinical covariates including severity of coronary disease, and multiple comparisons.Conclusions: We have now demonstrated that common genetic variants in the same 9p21 locus, previously known to be associated with myocardial infarction in nonsurgical populations, are also associated with perioperative myocardial injury after coronary artery bypass grafting. Further investigation is warranted to elucidate functional mechanisms.

Ibuprofen for neuroprotection after cerebral ischemia

Yusuke Iwata, Olivier Nicole, David Zurakowski, Toru Okamura, Richard A. Jonas — 2009-10-26

Objective: Ibuprofen has been shown to reduce cerebral ischemic injury, such as may occur after deep hypothermic circulatory arrest. We investigated whether ibuprofen has direct protective effects against excitotoxic neuronal injury, as may be seen after cerebral ischemia, by using a cell culture model.Methods: Mixed cortical cultures containing neuronal and glial cells were prepared from fetal mice at 13 to 15 days gestation, plated on a layer of confluent astrocytes from 1- to 3-day-old postnatal pups. Near-pure neuronal cultures containing less than 5% astrocytes were obtained from mice of the same gestational stage. Slowly triggered excitotoxic injury was induced at 37°C by 24-hour exposure to 12.5 μmol/L N-methyl-D-aspartate or 50 μmol/L kainate. Neuronal death was quantified by release of lactate dehydrogenase from damaged cells. Data were analyzed using 1-way analysis of variance with Tukey post hoc multiple comparisons.Results: In mixed cultures, ibuprofen concentrations of 25 μg/mL, 50 μg/mL, and 100 μg/mL all significantly reduced N-methyl-D-aspartate–induced neuronal cell death from 74.5% to 56.1%, 38.7%, and 12.3%, respectively, revealing a strong dose response (P < .001). In near-pure cultures, ibuprofen at a concentration of 25 μg/mL failed to protect neurons, indicating that the neuroprotective effects of ibuprofen require interaction with glial cells. Furthermore, ibuprofen at 100 μg/mL was not protective against neuronal cell death induced by kainate exitotoxicity in near-pure culture but was effective in mixed cultures.Conclusion: Ibuprofen provides neuroprotection through glial cells against excitotoxic neuronal injury caused by glutamatergic excitotoxicity after cerebral ischemia as demonstrated by reduced neuronal cell death in mixed cell cultures. Further studies are needed to evaluate the potential of ibuprofen to reduce neurologic injury in patients experiencing an hypoxic/ischemic insult.

Silicone Y stent placement at secondary left carina for malignant central airway obstruction

Septimiu D. Murgu, Henri G. Colt — 2009-02-23

The Y silicone stents are shaped with long tracheal and left main bronchial limbs and a shorter right main bronchial limb. These stents can be used for patients with fixed or dynamic central airway obstruction from benign or malignant disease. More often, these stents are used for patients with extensive tumor involvement in the lower trachea and mainstem bronchi. To our knowledge, their use specifically for unilateral central airway obstruction has not been previously published. In this report, we describe the indication, method, and outcome of Y stent insertion at the level of the secondary left carina separating the left upper and lower lobe bronchi, to restore airway patency of the left lobar bronchi in a patient with primary squamous cell lung cancer.

Synthetic biodegradable hydrogel (PleuraSeal) sealant for sealing of lung tissue after thoracoscopic resection

Amulya K. Saxena — 2009-03-27

Postoperative air leaks are a major cause of morbidity after lung resections. A variety of biologic and synthetic materials have been used to seal resected lung tissue to address this problem; however, none of the products have been proved effective. Between the 2 groups, synthetic materials have found a preference because they overcome the issues that are associated with the manufacture, storage, and application of biologic substitutes. The use of a novel synthetic biodegradable hydrogel that can be applied as a spray to seal lung tissue after thoracoscopic resection is presented.

The application of nitinol thermoreactive Flexigrips for late post–cardiac surgery sternal instability

Hunaid A. Vohra, Robert N. Whistance, Marcob Bolgeri, Geoffrey M.K. Tsang — 2009-05-11

Median sternotomy is the most frequently used incision in cardiac surgery. Sternal instability is a chronic complication following malunion or nonunion. This is traditionally managed by reopening the sternum completely, removing fractured or loose metalwork, and rewiring. Reoperation may be hazardous due to adhesions, adjacent right ventricle, and patent grafts. We report for the first time the application of nitinol thermoreactive Flexigrips (Preasidia SRL, Bologna, Italy) in the management of sternal instability without the need to enter the mediastinum.

A novel solution for repeated migration of an implantable cardiac defibrillator

Amir M. Sheikh, Imran Raza, Simon Charles Edwin Sporton, Kulvinder S. Lall — 2009-03-09

Migration and extrusion of pacemakers and implantable cardiac defibrillators (ICDs) has been reduced over the years as devices have become smaller and lighter. However, this phenomenon still occurs. We present a case in which this problem occurred repeatedly, leading to a novel easily fashioned solution for this previously more common problem.

Heart transplantation in situs inversus totalis

Tobias Deuse, Bruce A. Reitz — 2009-02-09

Heart transplantation for situs inversus totalis is surgically challenging because it requires reconstruction of the mirror-image systemic venous pathways. The patient presented is a 6-year-old boy in heart failure, weighing 17 kg, with situs inversus, dextrocardia, unbalanced atrioventricular canal, double-outlet right ventricle, mitral and pulmonary atresia, and bilateral superior vena cavae (SVCs). He had previous Blalock–Taussig and bidirectional Glenn shunts placed (, A). Heart transplantation was performed as described in , using a normal donor heart. The postoperative chest radiograph demonstrated dextrocardia of the transplanted heart (, B).

Techniques of inserting peritoneal dialysis catheters in neonates and infants undergoing open heart surgery

2009-11-02

Renal impairment in children undergoing open surgery is preferably managed by peritoneal dialysis. It is common practice to insert a peritoneal dialysis catheter (PDC) in neonates and infants at the end of open heart surgery. One of the authors (G.N.) has been placing PDCs intraoperatively in neonates and infants since 1988 if a high possibility of hemodynamic instability or renal compromise is anticipated postoperatively. We describe the intraoperative techniques used by the authors.

Minimally invasive ablation of a migrating focus of inappropriate sinus tachycardia

2009-03-20

A 31-year-old echocardiography technician experienced tachycardia after pregnancy 3 years before presentation. The patient reported symptoms of dizziness, shortness of breath, and fatigue. An echocardiogram revealed an ejection fraction of 65% and mild mitral valve prolapse. Twenty-four-hour Holter monitoring showed a resting heart rate between 70 and 175 beats/min with rare premature ventricular complexes and rare atrial premature complexes with no evidence of sinoatrial or atrioventricular nodal block. Metoprolol, atenolol, sotalol, digoxin, and amiodarone therapy had failed. Prior catheter-based ablation attempts had mapped the focus of tachycardia laterally at the superior vena cava and right atrial junction. The catheter ablation attempts were able to modify the heart rate; however, they were aborted because of proximity of the right phrenic nerve.

Left atrioesophageal fistula following catheter ablation for atrial fibrillation: Off-bypass, primary repair using an extrapericardial approach

Sandeep Khandhar, Stephanie Nitzschke, Niv Ad — 2009-03-18

Catheter ablation for the treatment of atrial fibrillation is becoming the treatment of choice for drug-refractory symptomatic atrial fibrillation. This technique has increased in popularity, and the number of cases performed each year has risen dramatically. Although widely utilized, the technique of catheter ablation varies widely among electrophysiology labs. Overall, this procedure is considered safe, with the incidence of significant complications at 6%. This report deals with the clinical details and the surgical approaches to left atrioesophageal fistula, a complication with an estimated, but likely underrepresented, incidence of 0.05%. It is of major concern, as the diagnosis can be subtle and often unrecognized, and it can result in a very high mortality rate as documented by the majority of case reports.

Thymic carcinoma associated with Sjögren's syndrome and syndrome of inappropriate antidiuretic hormone

Chin-Chih Chang, Yih-Leong Chang, Yung-Chie Lee — 2008-09-01

Thymomas are thymic epithelial tumors. The term thymoma has been customarily restricted to those neoplasms arising from or exhibiting differentiation toward thymic epithelial cells. Thymomas with capsular or extracapsular invasion were thought to be malignant thymomas. Thymic carcinoma was defined as a malignant epithelial tumor with overt cytologic atypia and without organotypic features. Thymic carcinoma is rare and accounts for 0.06% of all thymic tumors. Thymoma is frequently associated with parathymic autoimmune diseases. In contrast, the association of thymic carcinoma and autoimmune disease is rare. We present an interesting case of thymic carcinoma associated with 2 rare parathymic syndromes.

Accessory left atrial chordae: An unusual cause of mitral valve insufficiency

Hisham M.F. Sherif, Michael K. Banbury — 2008-10-13

Accessory chordae tendinae are exceedingly rare. We report an unusual case of severe mitral valve insufficiency caused by abnormal chordae tendinae tethering the middle scallop of the anterior mitral valve leaflet.

Acute torsion of the left lower lobe caused by chronic traumatic hernia of the diaphragm

2008-09-16

Lung lobar torsion is very rare and mostly occurs after lobectomy. We present a rare case of acute torsion of the left lower lobe caused by chronic traumatic hernia of the diaphragm that was successfully treated with resection of the left lower lobe and repair of a traumatic diaphragmatic rupture.

Heparin-induced thrombosis without thrombocytopenia

Frederick A. Tibayan, Lawrence L. Leung, Thomas A. Burdon, James I. Fann — 2008-09-22

Heparin-induced thrombocytopenia (HIT) is a prothrombotic complication of heparin therapy mediated by antibodies that recognize platelet factor 4/heparin complexes and cause platelet activation and thrombin generation. Early recognition of HIT and treatment with non-heparin anticoagulants are essential in reducing thrombotic events, but diagnosis of HIT in patients postcardiac surgery may be confounded by thrombocytopenia because of bleeding, infection, drugs, or intraaortic balloon pump counterpulsation. Furthermore, postoperative thrombocytosis after cardiac surgery may mask platelet consumption because of HIT.

A rare coronary artery anomaly: Origin of the right coronary artery from an aortico-left ventricular tunnel

2008-09-22

Aortico-left ventricular tunnel (ALVT) is a rare congenital anomaly that may be associated with the right coronary artery (RCA) arising directly from the tunnel. In 1977, an ALVT with a 32-mm–wide saccular aneurysm was diagnosed in a 7-year-old boy. Corrective surgery was performed. Intraoperatively, the aortic valve (AoV) was tricuspid and normally developed. In the left coronary sinus, 2 coronary orifices were identified, lying side by side. The origin of the RCA could not be detected.

Covert presentation of strangulated hiatus hernias after cardiac surgery: A note of caution

Ben Davies, J. Stephen Billing, Patrick Yiu — 2008-09-09

Intra-abdominal catastrophes are an uncommon and unpredictable source of morbidity after cardiac surgery. We report the cases of two patients in whom strangulated hiatus hernias developed in the postoperative period and highlight their covert presentations.

Extracorporeal membrane oxygenation via sternotomy for circulatory shock

2008-09-09

Extracorporeal membrane oxygenation (ECMO) has been used to treat sepsis in children at the Royal Children's Hospital since 1988, with overall survival of 47%. Before 2000, our pediatric population requiring mechanical support for sepsis was supported with ECMO with cannulae implanted peripherally in the right common carotid artery and the right internal jugular vein. Since 2000, to improve delivered flows, we started to cannulate directly the aorta and right atrium through a sternotomy.

Coexistence of catamenial pneumothorax and catamenial hemoptysis in a patient with pulmonary hemangiomatosis-like foci: A case report

2008-10-13

Catamenial pneumothorax and catamenial hemoptysis are syndromes specific to women of reproductive age. Thoracic endometriosis syndrome most commonly presents as catamenial pneumothorax and very rarely as catamenial hemoptysis. Thoracic endometriosis syndrome is not the only cause of catamenial pneumothorax and hemoptysis. Some cases of catamenial pneumothorax and more than half of patients with hemoptysis lack evidence of ectopic endometrial tissue. Coexistence of catamenial pneumothorax and hemoptysis is extremely rare, and only one patient has been reported in the English literature. We report a case of catamenial pneumothorax and hemoptysis presenting with pulmonary capillary hemangiomatosis-like foci instead of ectopic endometrial implants.

Gunshot wound of the main pulmonary artery: A case report

Hasan Hakan Atalay, Orhan Saim Demirtürk, Dalokay Kılıç, Rıza Türköz — 2009-02-05

Clinical pulmonary embolism resulting from a bullet entering the main pulmonary artery is rare. We describe a gunshot wound to the chest in an 18-year-old man that caused pulmonary embolism but no infarction.

Mitral-aortic intervalvular fibrosa pseudoaneurysm resulting in the displacement of the left main coronary artery after aortic valve replacement

Hwan Wook Kim, Cheol Hyun Chung — 2009-05-18

Mitral-aortic intervalvular fibrosa (MAIVF) pseudoaneurysms are usually secondary to infection and common in patients with aortic valve replacement for infective endocarditis. Because MAIVF pseudoaneurysms may lead to potentially perilous outcomes, such as rupture to the adjacent cardiac chamber or pericardium, alteration of the 3-dimensional structure of the mitral valve, or disturbance of coronary artery blood flow, the early detection of these pseudoaneurysms using periodic echocardiography or radiologic imaging is important. We describe a case of a MAIVF pseudoaneurysm 6 months after aortic valve replacement that resulted in displacement and compression of the left main coronary artery, causing symptoms of angina.

Independent lung ventilation in the postoperative management of large bronchopleural fistula

Igor E. Konstantinov, Pankaj Saxena — 2009-01-19

Independent lung ventilation (ILV) is rarely used to separately ventilate each lung in patients with respiratory failure caused by unilateral lung disease or injury. Herein we describe a successful application of ILV in the postoperative management of a critically ill patient with empyema, large bronchopleural fistula (BPF), bilateral pneumonia, and sepsis.

Solitary fibrous mediastinal tumor with coronary vascular supply: An unusual case

N. Qedra, M. Kadry, E. Ivanitskaia-Kühn, S. Buz, R. Meyer, H. Laube, R. Hetzer — 2009-01-19

Solitary fibrous tumor (SFT) of the mediastinum occurs most commonly in the visceral and parietal pleura; it is extremely rare for it to affect cardiac structures. We report, for the first time, a case of mediastinal SFT with an unusual vascular supply from the coronary arteries and an unusual location. The tumor was diagnosed 34 months after aortic valve replacement and revascularization of the left anterior descending coronary artery with the left internal thoracic artery (ITA). It was completely resected, and 16 months later, there have been no local or distant recurrences.

A word of caution: Cerebral air emboli caused by tubing elastic recoil while performing low-flow antegrade cerebral perfusion in a low-birth-weight neonate

2009-01-19

With continuous improvement of cardiac surgical techniques, we are currently able to perform complex congenital heart surgery, even in small neonates. Some of the complex operations of the aortic arch involve hypothermia and either deep hypothermic circulatory arrest or antegrade cerebral perfusion (ACP). Traditionally, deep hypothermic circulatory arrest has been used when neonatal arch surgery was performed. Recently, the use of ACP has been advocated as a means of brain protection. Two basic techniques for ACP have been used: either suturing a polytetrafluoroethylene shunt (Gore-Tex shunt; W. L. Gore & Associates, Inc, Flagstaff, Ariz) to the innominate artery or direct cannulation of either the ascending aorta or the innominate artery. We herein report a case in which ACP was used in a 2-kg neonate. Once ACP was initiated, air bubbles were seen in the arterial cannula, rising toward the pump. The air bubbles were caused by a tubing recoil phenomenon apparent only when low pump flows were used.

Edema does matter

Jennifer S. Lawton — 2010-02-01

To the Editor: My colleagues and I read with great interest the recent article by Butler and colleagues titled, “Dysfunction Induced by Ischemia Versus Edema: Does Edema Matter?” The authors demonstrated significant myocyte swelling after exposure to ischemia and hypotonic solutions (0.75 T) and reduced myocyte contractility after exposure to the ischemic solution but not the hypotonic solution. In an isolated rat heart model, they demonstrated a significant reduction in systolic function during exposure to hypotonic solution. The authors conclude that their data argue against edema as a major contributor to reduced cardiac performance.

Reply to the Editor

Tanya L. Butler, Jonathan R. Egan, David Scott Winlaw — 2010-02-01

We thank Dr Lawton for her interest in our article and the Editor for the opportunity to respond. Our principal focus is postoperative low cardiac output syndrome (LCOS) in pediatric patients. By studying myocardial water content and function, we were expecting to scientifically validate the clinical dogma linking edema with dysfunction. However, use of three related models—isolated myocytes, Langendorff hearts, and whole animals on cardiopulmonary bypass— failed to implicate edema as a significant causal influence in LCOS.

What is the real risk of stent-graft infection in the treatment of aortobronchial fistulas?

Antonio Bozzani, Vittorio Arici, Attilio Odero — 2010-02-01

To the Editor: A recent article by Hacker and colleagues describes a single case report of aortobronchial fistula (ABF) in a patient who was successfully treated (27 years ago) for isthmic posttraumatic pseudoaneurysm by placement of thoracic endoprosthesis. The authors conclude by saying that “endovascular intervention and stent grafting are feasible and should be the first option in the treatment of ABFs.”

Reply to the Editor

Hendrik Jan Ankersmit — 2010-02-01

Bozzani and colleagues state that surgical correction of an aortobronchial fistula, particularly open correction of a thoracic aneurysm, carries a fairly high postoperative incidence of stent-graft infection. To the contrary, minimal infection rates were observed after endovascular stent placement. The authors question whether antibiotic therapy should be administrated after this minimally invasive operational procedure. There is scarce literature on immunologic consequences after stent implantation in humans. According to immunologic data obtained from patients undergoing heart operations with cardiopulmonary support and abdominal surgery, any operation performed in humans induces a state of immune suppression in vivo. Therefore, patients undergoing heart surgery (cardiopulmonary support) should receive aggressive 5-day antibiotic treatment in accordance with the insight of an induced “systemic immune suppression” after heart surgery. In regard to the ongoing discussion of antibiotic treatment after endovascular stent implantation, the following approach seems to be feasible. Studies have to be initiated to investigate the immunologic consequence of open and endovascular stent implantation in humans (eg, abdominal aorta aneurysm repair, open, closed), and “yes,” antibiotic treatment should be applied for 4 to 5 days after endovascular stent placement to potentially “prohibit” pain from infection (local, systemic) in patients.

A complementary technique to carbon dioxide de-airing in open cardiac operations?

Peter Svenarud, Mikael Persson, Jan van der Linden — 2010-02-01

To the Editor: In a recent study Al-Rashidi and associates concluded that “bilateral … pulmonary collapse and successive filling of the lungs with … concomitant increase in mechanical ventilation during de-airing of the left side of the heart significantly reduces the number of systemic MES [microembolic signals]… and … air emboli.”

Reply to the Editor

Bansi Koul, Faleh Al-Rashidi, S. Blomquist, P. Höglund, C. Meurling, A. Roijer — 2010-02-01

We thank Peter Svenarud and his colleagues for their valuable comments and questions about our article in the Journal. We will try to answer their queries in the order of their appearance in their letter to the Editor.

Highlights from Transcatheter Cardiovascular Therapeutics 2009: San Francisco, California, September 21 to 25, 2009

Jeffrey M. Sparling, Frederic S. Resnic — 2010-02-01

Transcatheter Cardiovascular Therapeutics, the annual interventional cardiology scientific symposium, was held September 21 to 25, 2009, in San Francisco, California. This internationally attended meeting was the venue for the release of new clinical trial data and an ongoing comprehensive review of many subjects of interest to the cardiothoracic surgical community.

Meetings and Courses

2010-02-01

The Tenth Annual International Symposium on Congenital Heart Disease will be held February 6-9, 2010, at the Renaissance Vinoy Resort, St. Petersburg, Florida, USA. The Tenth Annual International Symposium on Congenital Heart Disease will focus on the latest in rare and challenging lesions. In addition to lecture presentations, the program will include lectures, hands-on demonstrations, panel discussions, question and answer sessions, and pathologic heart specimen exhibits. We are honored to present a distinguished faculty of domestic and international experts in Cardiology, Cardiac Intensive Care, Cardiac Anesthesia, and Cardiac Surgery for this exciting program. For more information, contact: Suzanne Anderson (telephone: 727-767-8584; E-mail: andersons@allkids.org).

AATS 90th Annual Meeting

2010-02-01

May 1–5, 2010 Metro Toronto Convention Centre

Aortic Symposium 2010

2010-02-01

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

AATS Meetings and Sponsored Events

2010-02-01

February 6–9, 2010 The 10th Annual International Symposium on Congenital Heart Disease

2010 Summer Intern Scholarship Applications Now Available

2010-02-01

The American Association for Thoracic Surgery (AATS) Summer Intern Scholarship program introduces the field of cardiothoracic surgery to first- and second-year medical students from North American medical institutions. By providing an opportunity to spend 8 weeks during the summer working in an AATS member's cardiothoracic surgery department, the summer intern scholarship provides medical students with insight into the scientific investigation and study of cardiothoracic surgery.

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

2010-02-01

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

2010-02-01

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

2010-02-01

June 23–26, 2010 Ojai Valley Inn

Notices

2010-02-01

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

Requirements for Maintenance of Certification

2010-02-01

Diplomates of the American Board of Thoracic Surgery (ABTS) who plan to participate in the Maintenance of Certification (MOC) process must hold an unrestricted medical license in the locale of their practice and privileges in a hospital accredited by the JCAHO (or other organization recognized by the ABTS). In addition, a valid ABTS certificate is an absolute requirement for entrance into the Maintenance of Certification process. If your certificate has expired, the only pathway for renewal of a certificate is to take and pass the Part I (written) and the Part II (oral) certifying examinations.

JCTSE Board of Directors 2010 Announcement

2010-02-01

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).

Condensed Contents

2010-02-01

JTCVS Disclosure Statement

2010-02-01

Information for Readers

2010-02-01

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.