The Journal of Thoracic and Cardiovascular Surgery - Articles in Press

Carbon dioxide insufflation in open-chamber cardiac surgery: A double-blind, randomized clinical trial of neurocognitive effects - Corrected Proof

2012-05-14

Objective: The aims of this study were first to analyze neurocognitive outcomes of patients after open-chamber cardiac surgery to determine whether carbon dioxide pericardial insufflation reduces incidence of neurocognitive decline (primary end point) as measured 6 weeks postoperatively and second to assess the utility of carbon dioxide insufflation in cardiac chamber deairing as assessed by transesophageal echocardiography.Methods: A multicenter, prospective, double-blind, randomized, controlled trial compared neurocognitive outcomes in patients undergoing open-chamber (left-sided) cardiac surgery who were assigned carbon dioxide insufflation or placebo (control group) in addition to standardized mechanical deairing maneuvers.Results: One hundred twenty-five patients underwent surgery and were randomly allocated. Neurocognitive testing showed no clinically significant differences in z scores between preoperative and postoperative testing. Linear regression was used to identify factors associated with neurocognitive decline. Factors most strongly associated with neurocognitive decline were hypercholesterolemia, aortic atheroma grade, and coronary artery disease. There was significantly more intracardiac gas noted on intraoperative transesophageal echocardiography in all cardiac chambers (left atrium, left ventricle, and aorta) at all measured times (after crossclamp removal, during weaning from cardiopulmonary bypass, and at declaration of adequate deairing by the anesthetist) in the control group than in the carbon dioxide group (P < .04). Deairing time was also significantly longer in the control group (12 minutes [interquartile range, 9–18] versus 9 minutes [interquartile range, 7–14 minutes]; P = .002).Conclusions: Carbon dioxide pericardial insufflation in open-chamber cardiac surgery does not affect postoperative neurocognitive decline. The most important factor is atheromatous vascular disease.

Predictors of in-hospital complications after pericardiectomy: A nationwide outcomes study - Corrected Proof

Raja R. Gopaldas, Tam K. Dao, Normand R. Caron, John G. Markley — 2012-05-11

Objective: Advances in medical care had caused a paradigm shift in the indications for pericardiectomy. We evaluated the current predictors of in-hospital complications for pericardiectomy.Methods: Patients who underwent pericardiectomy between 1998 and 2008 were identified from the US Nationwide Inpatient Sample. Risk-adjusted logistic regression model was used to analyze the predictors of surgical outcomes.Results: A total of 13,593 patients underwent pericardiectomy during this period. Pericardiectomy was performed for constrictive pericarditis (28%; n = 3851), pericardial calcification (15%; n = 2061), secondary malignancies (3%; n = 456), adhesive pericarditis (2%; n = 318), and other causes (40%; n = 5461). Unadjusted mortality and complication rates were approximately 8% and 48%, respectively. Fourteen percent of patients required blood transfusion. Only 62% were routinely discharged home. After risk adjustment, age, female gender, comorbidity index, and the primary diagnosis independently predicted in-hospital mortality and overall complication rates (P < .05). Calcific pericarditis was the only etiology associated with lower risk-adjusted mortality (odds ratio [OR], 0.48), operative complications (OR, 0.32), overall complications (OR, 0.32), incidence of transfusion (OR, 0.38), and highest routine discharge rates (OR, 1.84); P < .001 for all. Constrictive pericarditis had the highest requirement for cardiopulmonary bypass (OR, 6.41; P < .01) and incidence of bleeding complications (OR, 2.61; P < .01).Conclusions: Morbidity remains high for pericardiectomy. In addition to age, gender, and comorbidities, attention should be given to etiology during surgical planning or referral. This significantly influences the requirement for cardiopulmonary bypass, chances of bleeding complications, and transfusion requirements.

The pumpless extracorporeal lung membrane provides complete respiratory support during complex airway reconstructions without inducing cellular trauma or a coagulatory and inflammatory response - Corrected Proof

2012-05-11

Objective: Our objective was to investigate the capacity of a pumpless extracorporeal lung membrane (iLA) (Novalung; Novalung GmbH, Hechingen, Germany) to provide adequate respiratory support and the impact on morbidity/mortality during complex airway reconstruction.Methods: Only patients unable to be ventilated via conventional intubation were eligible for the study. A larynx mask or orotracheal tubes were placed above the airway defect and the iLA was attached via femoral vessels (arteriovenous), providing extracorporeal gas exchange, apneic hyperoxygenation, and total tubeless airway reconstruction. Haptoglobulin, plasmin–antiplasmin complex, P-selectin activation, and interleukin 6 were measured before, during, and after iLA use and 72 hours postoperatively.Results: Fifteen consecutive patients (age, 42 ± 17 years) underwent elective (n = 7) or emergency (n = 8) reconstruction of the airway owing to a variety of disorders or defects. The iLA was left in place for 185 ± 61 minutes, diverted 1.70 ± 0.48 L/min of the cardiac output, and provided an arteriovenous carbon dioxide removal and oxygen transfer of 173 ± 94 and 144 ± 83 mL/min, respectively. The arterial oxygen tension/inspired oxygen fraction (314 ± 31 mm Hg), and arterial carbon dioxide tension (40 ± 6 mm Hg) remained stable throughout the entire operations. The following procedures were performed: redo slide tracheoplasties (n = 3), redo tracheoesophageal fistula repair (n = 1), sleeve lobectomies (n = 2), main carina reconstructions (n = 7), and anastomotic stenting and myocutaneous coverages (n = 2). Three patients required prolonged (9 ± 2 days) postoperative iLA support. Two (13%) patients died during the hospital stay. The use of iLA was associated with significant (P < .05) but clinically nonrelevant and yet nonpathologic increases of haptoglobulin (hemolysis), plasmin–antiplasmin complex (coagulation activation), and P-selectin activation (platelet activation). Data normalized within 48 hours postoperatively.Conclusions: Data suggest that iLA provides complete intraoperative respiratory support in patients who cannot receive conventional intubation/ventilation without relevant effects on cellular trauma, coagulatory response, and inflammatory response.

Effect of hydroxyethyl starch on bleeding after cardiopulmonary bypass: A meta-analysis of randomized trials - Corrected Proof

Roberta J. Navickis, Gary R. Haynes, Mahlon M. Wilkes — 2012-05-11

Objective: The effects of hydroxyethyl starch on bleeding after cardiopulmonary bypass were determined.Methods: A meta-analysis was performed of postoperative blood loss in randomized clinical trials of hydroxyethyl starch versus albumin for fluid management in adult cardiopulmonary bypass surgery. Impacts of hydroxyethyl starch molecular weight and molar substitution were assessed. Randomized trials directly comparing different hydroxyethyl starch solutions were also included.Results: Eighteen trials with 970 total patients were included. Compared with albumin, hydroxyethyl starch increased postoperative blood loss by 33.3% of a pooled SD (95% confidence interval, 18.2%–48.3%; P < .001). Risk of reoperation for bleeding was more than doubled by hydroxyethyl starch (relative risk, 2.24; 95% confidence interval, 1.14–4.40; P = .020). Hydroxyethyl starch increased transfusion of red blood cells by 28.4% of a pooled SD (95% confidence interval, 12.2%–44.6%; P < .001), of fresh-frozen plasma by 30.6% (95% confidence interval, 8.0%–53.1%; P = .008), and of platelets by 29.8% (95% confidence interval, 3.4%–56.2%; P = .027). None of these effects differed significantly between hydroxyethyl starch 450/0.7 and 200/0.5. Insufficient data were available for hydroxyethyl starch 130/0.4 versus albumin; however, no significant differences were detected in head-to-head comparisons of hydroxyethyl starch 130/0.4 with 200/0.5. Albumin improved hemodynamics. There were no differences in fluid balance, ventilator time, intensive care unit stay, or mortality.Conclusions: Hydroxyethyl starch increased blood loss, reoperation for bleeding, and blood product transfusion after cardiopulmonary bypass. There was no evidence that these risks could be mitigated by lower molecular weight and substitution.

Unplanned reinterventions are associated with postoperative mortality in neonates with critical congenital heart disease - Corrected Proof

2012-05-11

Objective: Neonates with critical congenital heart disease remain at risk of adverse outcomes after cardiac surgery. Residual or undiagnosed anatomic lesions might be contributory. The present study aimed to describe the incidence and type of cardiac lesions that lead to early, unplanned cardiac reintervention, identify the risk factors for unplanned reintervention, and explore the associations between unplanned reinterventions and hospital mortality.Methods: The present single-center retrospective cohort study included 943 consecutive neonates with critical congenital heart disease who underwent cardiac surgery from 2002 to 2008. An unplanned cardiac reintervention was defined as a cardiac reoperation or interventional cardiac catheterization performed during the same hospitalization as the initial operation. Multivariate logistic regression analyses were used to identify the risk factors for unplanned cardiac reintervention and hospital mortality.Results: Of the 943 neonates, 104 (11%) underwent an unplanned cardiac reintervention. The independent predictors of unplanned reintervention included prenatal diagnosis, lower birth weight, need for mechanical ventilation before the initial cardiac operation, lower attending surgeon experience, and greater Risk Adjustment in Congenital Heart Surgery, version 1, category. Those who underwent reintervention had increased hospital mortality (n = 33/104, 32%) relative to those who did not (n = 31/839, 4%; adjusted odds ratio, 8.6; 95% confidence interval, 4.7 to 15.6; P < .001). The mortality rates among patients undergoing surgical reintervention (23/66, 35%) or transcatheter reintervention (4/16, 25%), or both (6/22, 27%) were similar (P = .66).Conclusions: The need for unplanned cardiac reintervention in neonates with critical congenital heart disease is strongly associated with increased mortality. Early unplanned reinterventions might be an important covariate in outcomes studies and useful as a quality improvement measure.

Intra/extracardiac fenestrated modification leads to lower incidence of arrhythmias after the Fontan operation - Corrected Proof

2012-05-11

Objective: The study objective was to compare the incidence of short- and intermediate-term arrhythmias among 3 different surgical modifications of the Fontan procedure.Methods: We performed a retrospective review of all patients who underwent the Fontan operation at a single institution between January 2004 and May 2010 for preoperative, perioperative, and follow-up variables. Three surgical modifications were studied: intra/extracardiac conduit with limited atriotomy, standard extracardiac conduit, and lateral tunnel. Rhythm was classified as normal or abnormal. A rhythm dysfunction grading was devised and used to identify worsening of rhythm for patients with abnormal rhythm preoperatively. Multivariable logistic regression was used to determine predictors of abnormal rhythm. To eliminate confounding effects of transient immediate postoperative arrhythmias, data were analyzed for abnormal rhythm within the first 2 weeks and for more than 2 weeks after surgery.Results: Of the 134 patients (n = 50 with intra/extracardiac conduit with limited atriotomy, n = 19 with standard extracardiac conduit, n = 65 with lateral tunnel) (median follow-up, 36 months; interquartile range, 22–50 months; 2 operative deaths and 6 late deaths), rhythm data for more than 2 weeks postoperatively were available in 88 (40 with lateral tunnel, 14 with standard extracardiac conduit, 34 with intra/extracardiac conduit with limited atriotomy). These patients constituted the study groups. Patients in the lateral tunnel group were relatively younger at the time of the Fontan operation (P < .001) and had a longer follow-up (P < .001). Multivariable logistic regression confirmed that greater than moderate atrioventricular valve regurgitation was the only independent predictor of abnormal rhythm during the first 2 postoperative weeks. Older age at Fontan (odds ratio, 1.20; 95% confidence interval, 1.05–1.38; P = .012) and higher preoperative mean pulmonary artery pressure (odds ratio, 1.2; 95% confidence interval, 1.03–1.44; P = .026) were predictors of abnormal rhythm more than 2 weeks postoperatively. Intra/extracardiac conduit with limited atriotomy Fontan modification was associated with a significantly lower incidence of abnormal rhythm after 2 weeks postoperatively compared with lateral tunnel modification (odds ratio, 0.28; 95% confidence interval, 0.10–0.84; P = .015).Conclusions: Intra/extracardiac conduit with limited atriotomy Fontan modification has a significantly lower risk of abnormal rhythm postoperatively in the short and intermediate term when compared with the lateral tunnel.

Use of modified ultrafiltration in adults undergoing coronary artery bypass grafting is associated with inflammatory modulation and less postoperative blood loss: A randomized and controlled study - Corrected Proof

2012-05-11

Objectives: Modified ultrafiltration (MUF) has been shown to decrease the postcardiac surgery inflammatory response and to improve respiratory function and cardiac performance in pediatric patients; however, this approach has not been well established in adults. The present study hypothesized that MUF could decrease the postsurgical inflammatory response, leading to improved respiratory and cardiac function in adults undergoing coronary artery bypass grafting.Methods: Sixty patients undergoing coronary artery bypass grafting were randomized to the MUF or control group (n = 30 each). MUF was performed for 15 minutes at the end of bypass. The following data were recorded at the beginning of anesthesia, end of bypass, end of experimental treatment, and 24 and 48 hours after surgery: alveolar-arterial oxygen gradient, red blood cell units transfused, chest tube drainage, hemodynamic parameters, and cytokine levels (interleukin-6, P-selectin, intercellular adhesion molecule, and soluble tumor necrosis factor receptor).Results: The MUF group displayed less chest tube drainage than the control group after 48 hours (598 ± 123 mL vs 848.0 ± 455 mL; P = .04) and less red blood cell transfusions (0.6 ± 0.6 units/patient vs 1.6 ± 1.1 units/patient; P = .03). Hematocrit level was higher in the MUF group than in the control group at the end of bypass (37.8% ± 1.1% vs 34.1% ± 1.1%; P < .05), but the levels were comparable at 48 hours. Similar values for interleukin-6 and P-selectin were observed at all stages. Plasma levels of intercellular adhesion molecule were higher in the MUF group than in the control group, particularly in the first sampling after experimental treatment (P = .01). Plasma levels of soluble tumor necrosis factor receptor were higher in the MUF group than in the control group at 48 hours. Hemodynamic and oxygen transport parameters were similar in both groups throughout the observation period. There were no differences in other clinical outcomes.Conclusions: Use of MUF was associated with increased inflammatory response, reduced blood loss, and less blood transfusions in adults undergoing coronary artery bypass grafting.

Effect of atherothrombotic aorta on outcomes of total aortic arch replacement - Corrected Proof

2012-05-10

Objective: The effect of an atherothrombotic aorta on the short- and long-term outcomes of total aortic arch replacement, including postoperative neurologic deficits, remains unknown. We evaluated this relationship and also elucidated the synergistic effect of multiple other risk factors, in addition to an atherothrombotic aorta, on the neurologic outcome.Methods: A group of 179 consecutive patients undergoing total aortic arch replacement were studied. An atherothrombotic aorta was present in 34 patients (19%), more than moderate leukoaraiosis in 71 (39.7%), and significant extracranial carotid artery stenosis in 27 (15.1%). In-hospital deaths occurred in 2 patients, 1 (2.9%) of 34 patients with and 1 (0.7%) of 145 patients without an atherothrombotic aorta (P = .26). Permanent neurologic deficits occurred in 4 (2.2%) and transient neurologic deficits in 17 (9.5%) patients. Multivariate analysis demonstrated that the risk factors for transient neurologic deficits were an atherothrombotic aorta (odds ratio, 4.4), extracranial carotid artery stenosis (odds ratio, 5.5), moderate/severe leukoaraiosis (odds ratio, 3.6), and cardiopulmonary bypass time (odds ratio, 1.02). To calculate the probability of transient neurologic deficits, the following equation was derived: probability of transient neurologic deficits = {1 + exp [7.276 − 1.489 (atherothrombotic aorta) − 1.285 (leukoaraiosis) − 1.701 (extracranial carotid artery stenosis) − 0.017 (cardiopulmonary bypass time)]}−1. An exponential increase occurred in the probability of transient neurologic deficits with presence of an atherothrombotic aorta and other risk factors in relation to the cardiopulmonary bypass time. Survival at 3 years after surgery was significantly reduced in patients with vs without an atherothrombotic aorta (75.0% ± 8.8% vs 89.2% ± 3.1%, P = .01).Conclusions: Patients with an atherothrombotic aorta and associated preoperative comorbidities might be predisposed to adverse short- and long-term outcomes, including transient neurologic deficits.

Elevated messenger RNA expression and plasma protein levels of osteopontin and matrix metalloproteinase types 2 and 9 in patients with ascending aortic aneurysms - Corrected Proof

2012-05-09

Objective: Ascending aortic aneurysms result from a degenerative process in the aortic wall, characterized by the loss of smooth muscle cells and elastic fibers. We hypothesized that there would be changes in plasma protein and aortic tissue messenger RNA levels of osteopontin, matrix metalloproteinase type 2, matrix metalloproteinase type 9, and tissue inhibitor of matrix metalloproteinases type 1 in ascending aortic aneurysm samples.Methods: Plasma, aortic tissue, and aortic mRNA samples were collected from patients with an ascending aortic aneurysm or an abdominal aortic aneurysm and from control individuals. Plasma protein levels of osteopontin, matrix metalloproteinase (MMP) types 2 and 9, and tissue inhibitor of matrix metalloproteinases type 1 were determined by quantitative sandwich enzyme-linked immunosorbent assay. Aortic mRNA levels of these same proteins were analyzed with the quantitative real-time polymerase chain reaction (RT-PCR) method and protein levels from the aortic tissues were assayed by immunostaining. Quantitative RT-PCR results were estimated by the normalized expression method (ΔΔCt).Results: Plasma protein levels were significantly elevated for osteopontin, MMP-2, and MMP-9 in the samples of ascending and abdominal aortic aneurysm group compared with controls. Plasma protein levels of MMP-9 were higher in the nonoperated compared with the operated ascending aortic aneurysm group. Aortic osteopontin, MMP-2, and MMP-9 mRNA levels were increased for ascending aortic aneurysm samples.Conclusions: This study reveals an important role of osteopontin, MMP-2 and MMP-9 in the development of ascending and abdominal aortic aneurysm.

Mechanism of myocardial ischemia with an anomalous left coronary artery from the right sinus of Valsalva - Corrected Proof

2012-05-07

Objective: An ectopic coronary artery that courses between the aortic root and the pulmonary trunk may lead to sudden cardiac death, especially in athletes. It has been speculated that during exercise, compression of the coronary artery between the great vessels may impair coronary blood flow and produce myocardial ischemia and fatal arrhythmia. However, this hypothesis cannot be tested in humans, and little experimental data exist to explain this phenomenon. To this end, in a calf with an anomalous left coronary artery that coursed from the right sinus of Valsalva between the great vessels, we assessed for myocardial ischemia during pharmacologically induced tachycardia and hypertension.Methods: We identified a juvenile male calf (103 kg) with an anomalous left coronary artery from the right sinus of Valsalva that coursed between the great vessels. Via thoracotomy, the animal was instrumented for hemodynamic measurements. Intravenous dobutamine increased heart rate and myocardial metabolic demands. Intravenous phenylephrine produced arterial hypertension and increased myocardial metabolic demands. Fluorescent-labeled microspheres were used to map regional myocardial blood flow, and hemodynamics were recorded during each condition. Masson’s trichrome staining for fibrosis, wheat-germ agglutinin staining for myocyte size, terminal deoxynucleotidyl transferase dUTP nick end-label staining for apoptosis, and isolectin-B4 staining for capillary density were performed.Results: For the first time, empiric data documented that an ectopic coronary artery produced myocardial ischemia during elevated myocardial metabolic demands. Left coronary artery resistance increased in a cardiac cycle–dependent pattern that was consistent with systolic compression between the great vessels. Increased cardiac fibrosis, myocyte hypertrophy, cardiac apoptosis, and capillary density indicated that regional ischemic, inflammatory-mediated myocardial remodeling was present.Conclusions: These findings confirm the proposed mechanism of sudden death and support early surgical repair of coronary arteries that course between the aortic root and the pulmonary trunk.

Tracheobronchial reconstructions with bronchoplastic closure: An alternative method in treatment of bronchogenic carcinoma involving the carina or tracheobronchial angle - Corrected Proof

2012-05-07

Objective: Our objective was to summarize our experience with tracheobronchial reconstructions using bronchoplastic closure for airway defects after noncircumferential resections of bronchogenic carcinoma involving the carina or tracheobronchial angle.Methods: From January 1990 to December 2005, all patients who underwent tracheobronchial reconstructions with bronchoplastic closure for bronchogenic carcinoma involving the carina or tracheobronchial angle were included. The clinical data for patients were collected retrospectively, including demographic characteristics, occurrences of postoperative complications, and survival.Results: A total of 40 patients were eligible, including 23 who had right pneumonectomies, 6 who had right upper lobectomies, and 11 who had left pneumonectomies, associated with lower lateral wall of the trachea resections or with partial carinal resections for centrally localized tumors. The airway defects ranged from 0.5 × 2 cm to 2 × 4 cm and involved up to 50% of the airway circumference. Microscopic residual disease was found postoperatively at the bronchial margin in 20% (8/40). Of 40 patients, 2 (5.0%) had pulmonary atelectasis develop, 2 (5.0%) arrhythmia, 2 (5.0%) bronchopleural fistula, and 1 (2.5%) airway stenosis after operation. Thirty-day mortality was 2.5% (1/40). Median survival for 40 patients was 18.5 months with a cumulative survival of 72.2%, 26.6%, and 21.3% at 1, 3, and 5 years, respectively.Conclusions: Tracheobronchial reconstruction using bronchoplastic closure might be a reasonable option for closing massive central airway defects for advanced bronchogenic carcinoma involving the tracheobronchial angle or carina, avoiding tracheal sleeve pneumonectomy with limited excision of the lateral wall of the trachea or carina.

Simulating hemodynamics of the Fontan Y-graft based on patient-specific in vivo connections - Corrected Proof

2012-05-07

Background: Using a bifurcated Y-graft as the Fontan baffle is hypothesized to streamline and improve flow dynamics through the total cavopulmonary connection (TCPC). This study conducted numerical simulations to evaluate this hypothesis using postoperative data from 5 patients.Methods: Patients were imaged with cardiac magnetic resonance or computed tomography after receiving a bifurcated aorto–iliac Y-graft as their Fontan conduit. Numerical simulations were performed using in vivo flow rates, as well as 2 levels of simulated exercise. Two TCPC models were virtually created for each patient to serve as the basis for hemodynamic comparison. Comparative metrics included connection flow resistance and inferior vena caval flow distribution.Results: Results demonstrate good hemodynamic outcomes for the Y-graft options. The consistency of inferior vena caval flow distribution was improved over TCPC controls, whereas the connection resistances were generally no different from the TCPC values, except for 1 case in which there was a marked improvement under both resting and exercise conditions. Examination of the connection hemodynamics as they relate to surgical Y-graft implementation identified critical strategies and modifications that are needed to potentially realize the theoretical efficiency of such bifurcated connection designs.Conclusions: Five consecutive patients received a Y-graft connection to complete their Fontan procedure with positive hemodynamic results. Refining the surgical technique for implementation should result in further energetic improvements that may help improve long-term outcomes.

Results of interventional bronchoscopy in the management of postoperative tracheobronchial stenosis - Corrected Proof

2012-05-07

Objectives: To investigate the role of bronchoscopic intervention in the management of postoperative tracheobronchial stenosis, a retrospective study was performed at a tertiary referral hospital.Methods: Thirty patients who underwent 106 bronchoscopic interventions between January 2000 and July 2010, including ballooning, bouginage, Nd:YAG laser resection, and stent insertion, were included and followed up for a median of 34 months.Results: Silicone stents were required in 19 of 30 patients (63%) to maintain airway patency. Bronchoscopic intervention provided improvement of dyspnea in 97% of the patients. After airway stabilization, the stents were removed successfully in 7 of 19 patients (37%) a median of 7 months after insertion. In 3 patients (10%), the intervention failed to widen the airway. There were no procedure-related deaths or cases of pneumonia, although additional interventions were needed in 9 patients (30%) within 30 days. Stent-related late complications (70%), such as restenosis (43%), overgrowth of granulation tissue (33%), stent migration (32%), mucostasis (30%), and malacia after stent removal (16%), were controllable at follow-up bronchoscopy.Conclusions: Bronchoscopic intervention could be a useful treatment modality for patients with postoperative tracheobronchial stenosis when surgery is not feasible.

Effect of changes in postoperative spirometry on survival after lung transplantation - Corrected Proof

2012-05-04

Objective: The decline in normalized forced 1-second expiratory volume after lung transplantation is inevitable; however, the effect of this change on survival is unknown. Additionally, the benefit of double versus single lung transplant is debated, particularly because pulmonary function is only slightly better after double lung transplant. Our goal was to determine the effect of the temporal pattern of post-transplant forced 1-second expiratory volume (percentage of predicted) on the risk of death after transplant and the differences in the sensitivity of single and double lung transplant to this relationship.Methods: From February 1990 to January 2008, 622 adults underwent lung transplantation, of whom 315 (51%) received 2 lungs. Of the 509 patients (82%) with available data, 9471 longitudinal evaluations of forced 1-second expiratory volume (percentage of predicted) were analyzed. The temporal pattern was characterized for each patient, and the resulting curve was evaluated as a time-varying covariable function in the survival analysis. Differences in sensitivity of single and double lung transplant were assessed by interaction.Results: Forced 1-second expiratory volume (percentage of predicted) increased from 50% immediately postoperatively to 55% at 1 year after single lung transplant and then gradually declined to 47% by 3 years. Although the pattern was similar after double lung transplant, the corresponding forced 1-second expiratory volume (percentage of predicted) at these points was greater—60%, 75%, and 65%. Lower post-transplant forced 1-second expiratory volume (percentage of predicted) was associated with a substantially increased risk of death after single lung transplant (P < .0001); however, this increase was far less after double lung transplant (P < .0001).Conclusions: The results of our study have demonstrated the effect of changing lung function after lung transplantation on survival. Survival after single lung transplant proved more sensitive to declining pulmonary function, demonstrating an advantage of the increased pulmonary reserve provided by double lung transplant.

Effects of preoperative aspirin in coronary artery bypass grafting: A double-blind, placebo-controlled, randomized trial - Corrected Proof

2012-05-03

Objective: This trial was undertaken to determine the safety and efficacy of preoperative aspirin administration in a contemporary cardiac surgical practice setting.Methods: This randomized, double-blind, parallel-group, single-center trial involved patients with stable coronary artery disease who were assigned to receive either 300 mg of aspirin or placebo the night before coronary bypass surgery. Using a random digit table, patients were allocated to receive the tablet from 1 of the 40 coded bottles containing either aspirin or placebo. Patients, surgeons, anesthetists, and investigators were all masked to treatment allocation. The primary safety end points were as follows: more than 750 mL of bleeding during the first postoperative 12 hours and more than 1000 mL of total discharge from the chest drains. The secondary efficacy end point was a composite of cardiovascular death, myocardial infarction, or repeat revascularization.Results: A total of 390 patients were allocated to aspirin (387 analyzed) and 399 to placebo (396 analyzed). The follow-up median was 53 months. Fifty-four placebo recipients and 86 aspirin recipients bled more than 750 mL in the first 12 hours (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.25-2.63), while total chest drain discharge was above 1000 mL in 96 placebo and 131 aspirin recipients (OR, 1.60; 95% CI, 1.17-2.18). Preoperative aspirin decreased the long-term hazard of nonfatal coronary event (infarction or repeat revascularization)—hazard ratio (HR), 0.58 (95% CI, 0.33-0.99)—and tended to decrease the hazard of a major cardiac event (cardiovascular death, infarction, or repeat revascularization—HR, 0.65 [95% CI, 0.41-1.03]).Conclusions: Performing coronary grafts on aspirin is associated with increased postoperative bleeding but may decrease the long-term hazard of coronary events.

Rethinking the terminology of mechanical circulatory support - Corrected Proof

Nader Moazami, David Feldman — 2012-05-03

Mechanical circulatory support (MCS) has continued to grow to become one of the most important advanced therapy options for patients with end-stage heart failure. Continued improvements in survival outcomes, coupled with declining adverse events, hold the promise of advancing this therapy further into the mainstream of our daily practice. Guidelines are expected to be published by all major organizations, including the International Society for Heart and Lung Transplantation, American Heart Association and American College of Cardiology Task Force, and the Heart Failure Society of America. It is certainly foreseeable that the guidelines would recommend that any patient with end-stage heart failure that is refractory to continued medical treatment be evaluated by an expert team of cardiologist and surgeons for MCS. These changes will probably increase the number of referrals for this therapy. Continued advances in the field related to development of totally implantable pumps and improved battery life will make this therapy even more socially acceptable to patients. In the near future, MCS could potentially replace heart transplantation as the therapy of choice or the new criterion standard treatment for end-stage heart failure.

Endothelin and vasopressin influence splanchnic blood flow distribution during and after cardiopulmonary bypass - Corrected Proof

2012-05-02

Objective: Gastrointestinal blood flow can be compromised during and after cardiopulmonary bypass. Endothelin has been shown to be involved in the intestinal microcirculatory disturbance of sepsis. The aim of the present study was to analyze the involvement of the endothelin system on intestinal blood flow regulation during cardiopulmonary bypass and the effect of vasopressin given during cardiopulmonary bypass.Methods: A total of 24 pigs were studied in 4 groups (n = 6): group I, sham; group II, ischemia/reperfusion with 1 hour of superior mesenteric artery occlusion; group III, cardiopulmonary bypass for 1 hour; and group IV, 1 hour of cardiopulmonary bypass plus vasopressin administration, maintaining the baseline arterial pressure. All the pigs were reperfused for 90 minutes. During the experiment, the hemodynamics and jejunal microcirculation were measured continuously. The jejunal mucosal expression of endothelin-1 and its receptor subtypes A and B were determined using polymerase chain reaction.Results: During cardiopulmonary bypass, superior mesenteric artery flow was preserved but marked jejunal microvascular impairment occurred compared with baseline (mucosal capillary density, 192.2 ± 5.4 vs 150.8 ± 5.1 cm/cm2; P = .005; tissue blood flow, 501.7 ± 39.3 vs 332.3 ± 27.9 AU; P = .025). The expression of endothelin-1 after cardiopulmonary bypass (3.2 ± 0.4 vs 12.2 ± 0.8 RQ, P = .006) and endothelin subtype A (0.7 ± 0.2 vs 2.4 ± 0.6 RQ; P = .01) was significantly increased compared to the sham group. Vasopressin administration during cardiopulmonary bypass led to normal capillary density (189.9 ± 3.9 vs 178.0 ± 6.3; P = .1) and tissue blood flow (501.7 ± 39.3 vs 494.7 ± 44.4 AU; P = .4) compared with baseline. The expression of endothelin-1 (3.2 ± 0.4 vs 1.8 ± 0.3 RQ; P = .3) and endothelin subtype A (0.7 ± 0.2 vs 0.9 ± 0.2 RQ; P = .5) was not different from the sham group.Conclusions: Cardiopulmonary bypass leads to microvascular impairment of jejunal microcirculation, which is associated with the upregulation of endothelin-1 and endothelin subtype A. The administration of vasopressin minimizes these cardiopulmonary bypass-associated alterations.

A left atrial myxomalike rhabdomyosarcoma - Corrected Proof

Domenico Corradi, Giovanni Andrea Contini, Tiziano Gherli, Francesco Nicolini — 2012-05-02

Cardiac tumors are exceedingly rare, with their frequency being estimated between 0.0017% and 0.33%. Despite its limited myocardial mass, the left atrium is very frequently involved in both benign and malignant primary cardiac tumors, with polypoid myxoma being the most frequent type. We report here the exceptional case of a fully polypoid left atrial rhabdomyosarcoma without myocardial infiltration, mimicking a cardiac myxoma.

Extra-anatomic pulmonary artery bypass for main pulmonary artery stenosis caused by neoplasm - Corrected Proof

Ryo Aeba, Hiroaki Nomori, Ryohei Yozu — 2012-05-02

Currently, tumor-related pulmonary artery obstruction is most often treated with the percutaneous stenting technique; however, this technique is not indicated for patients with tumors situated in close proximity to the pulmonary valve. We present here such a case, that of a patient who had adenoid cystic carcinoma of trachea that recurred at pulmonary artery near the pulmonary valve and who underwent surgical management with an extra-anatomic pulmonary artery bypass.

Cardiopulmonary bypass strategy with low-dose heparin and nafamostat mesilate in cardiac surgery: A safe option for patients with acute stroke - Corrected Proof

Naoto Morimoto, Soichiro Henmi, Masato Yoshida, Nobuhiko Mukohara — 2012-04-27

Patients undergoing open cardiac surgical procedures with a history of acute stroke pose a difficult management problem. There is always the risk that cardiopulmonary bypass (CPB) and heparinization may induce intracranial hemorrhage. A multicenter study suggests that open cardiac surgical procedures can be performed safely 4 weeks after stroke; however, some patients with acute cardiogenic stroke occasionally require emergency surgery because of uncontrollable heart failure or ongoing thromboembolism.

Comparison of 30-day outcomes of coronary artery bypass grafting surgery verus hybrid coronary revascularization stratified by SYNTAX and euroSCORE - Corrected Proof

2012-04-27

Objective: The optimal treatment of multivessel coronary artery disease is not well established. Hybrid coronary revascularization by combining the left internal mammary artery–left anterior descending artery graft and drug-eluting stents in non–left anterior descending artery territories might offer superior results compared with sole coronary artery bypass grafting or sole percutaneous coronary intervention.Methods: We retrospectively analyzed the 30-day outcomes of 381 consecutive patients undergoing coronary artery bypass grafting (n = 301) vs hybrid coronary revascularization (n = 80). In a 2 × 2 matrix, the 2 groups were stratified by the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (≤32 vs ≥33) and the European System for Cardiac Operative Risk Evaluation (euroSCORE) (<5 vs ≥5). The composite endpoint (death from any cause, stroke, myocardial infarction, low cardiac output syndrome) and secondary endpoints (worsening postprocedural renal function and bleeding) were determined.Results: After stratification using the SYNTAX and the euroSCORE, the preoperative characteristics were similar within the 4 groups, except for the ≥33 SYNTAX/>5 euroSCORE. The hybrid coronary revascularization patients were older (77 vs 65 years, P = .001). The postoperative outcomes using combined SYNTAX and the euroSCORE stratification showed a similar rate of the composite endpoint for all groups except for patients with ≥33 SYNTAX/>5 euroSCORE (0% for the coronary artery bypass grafting group vs 33% for the hybrid coronary revascularization group, P = .001). An analysis of the secondary endpoint showed similar results across all groups, except for in the ≥33 SYNTAX/>5 euroSCORE group, in which bleeding (re-exploration for bleeding and transfusion >3 packed red blood cell units per patient) was 44% in the hybrid coronary revascularization group vs 11% in the coronary artery bypass grafting group (P = .05).Conclusions: Hybrid coronary revascularization is a safe alternative to coronary artery bypass grafting in many patients with multivessel coronary artery disease. However, in high-risk patients with complex coronary artery disease (≥33 SYNTAX/>5 euroSCORE), coronary artery bypass grafting is superior to hybrid coronary revascularization.

Intra-aortic balloon pump inserted through the subclavian artery: A minimally invasive approach to mechanical support in the ambulatory end-stage heart failure patient - Corrected Proof

2012-04-23

Objective: Intra-aortic balloon pumps are traditionally inserted through the femoral artery, limiting the patient's mobility. We used alternate approaches of intra-aortic balloon pump insertion to provide temporary and minimally invasive support for patients with decompensating, end-stage heart failure. The present study describes the outcomes with closed-chest, transthoracic intra-aortic balloon pumps by way of the subclavian artery.Methods: During a 3-year period, 20 patients underwent subclavian artery–intra-aortic balloon pump in the setting of end-stage heart failure. The balloon was inserted through a polytetrafluoroethylene graft sutured to the right subclavian artery in 19 patients (95%) and to the left subclavian artery in 1 patient (5%). The goal of support was to bridge to transplantation in 17 patients (85%) and bridge to recovery in 3 patients (15%). The primary outcome measure was death during subclavian artery–intra-aortic balloon pump support. The secondary outcomes included survival to the intended endpoint of bridge to transplantation/bridge to recovery, complications during subclavian artery–intra-aortic balloon pump support (eg, stroke, limb ischemia, brachial plexus injury, dissection, bleeding requiring reoperation, and device-related infection), emergent surgery for worsening heart failure, and ambulation during intra-aortic balloon pump support.Results: The duration of balloon support ranged from 3 to 48 days (mean, 17.3 ± 13.1 days). No patients died during subclavian artery–intra-aortic balloon pump support. Of the 20 patients, 14 (70%) were successfully bridged to transplant or left ventricular-assist device. Two patients (10%) required emergent left ventricular-assist device for worsening heart failure.Conclusions: An intra-aortic balloon pump inserted through the subclavian artery is a simple, minimally invasive approach to mechanical support and is associated with limited morbidity and facilitates ambulation in patients with end-stage heart failure.

Cryoablation during left ventricular assist device implantation reduces postoperative ventricular tachyarrhythmias - Corrected Proof

2012-04-23

Background: The number of patients undergoing implantation of a HeartMate II left ventricular assist device (LVAD; Thoratec Corporation, Pleasanton, Calif) is rising. Ventricular tachyarrhythmia (VA) after placement of the device is common, especially among patients with preoperative VA. We sought to determine whether intraoperative cryoablation in select patients reduces the incidence of postoperative VA.Methods: From January 2009 through September 2010, 50 consecutive patients undergoing implantation of the HeartMate II LVAD were examined. Fourteen of these patients had recurrent preoperative VA. Of those patients with recurrent VA, half underwent intraoperative cryoablation (Cryo: n = 7) and half did not (NoCryo: n = 7). Intraoperatively, patients underwent localized epicardial and endocardial cryoablation via LVAD ventriculotomy. Cryothermal lesions were created to connect scar to fixed anatomic borders in the region of clinical VA. Demographics, risk factors, intraoperative features, and outcomes were analyzed to investigate the feasibility of cryoablation.Results: Thirty-day mortality remained low (n = 1, 2%) among all LVAD recipients. There were no differences in risk factors between groups except that preoperative inotropes were less prevalent in Cryo patients (P = .09). Compared with NoCryo, the Cryo group had significantly decreased postoperative resource use and complications (P < .05). Recurrent postoperative VA did not develop in any of the Cryo patients (P = .02).Conclusions: Postoperative VA can be minimized by preoperative risk assessment and intraoperative treatment. Localized cryoablation in select patients offers promising early feasibility when performed during HeartMate II LVAD implantation. Further prospective analysis is required to investigate this novel approach.

How should I wean my next intra-aortic balloon pump? Differences between progressive volume weaning and rate weaning - Corrected Proof

2012-04-23

Objective: Although the intra-aortic balloon pump is the most used ventricular assist device, no study has ever evaluated the best weaning method. We compared 2 different intra-aortic balloon pump weaning methods.Methods: Thirty consecutive patients needing an intra-aortic balloon pump because of perioperative low-output cardiac syndrome were randomized to be weaned by ratio (4 consecutive hours of a 1:2 assisting ratio followed by 1 hour of a 1:3 ratio; group R) or by progressive volume deflation (10% of total volume every hour for 5 consecutive hours; 15 patients, group V). A duration of 5 hours was set a priori as the weaning duration. The weaning protocol was started when the cardiac index was greater than 2.5 L/min/m2, the central venous pressure was 12 mm Hg or less, the blood lactate was less than 2.5 mmol/L, the mean arterial pressure was greater than 65 mm Hg, and the preserved urine output (≥1 mL/kg/hr) lasted for at least 5 consecutive hours before weaning. The cardiac index, indexed systemic vascular resistance, cardiac cycle efficiency, and central venous pressure were registered at 9 points (T0, start; T1 to T5, the first 5 weaning hours; T6, 2 hours after withdrawal; T7, 12 hours after withdrawal; and T8, at intensive care unit discharge) using the pressure recording analytical method. The interval from intra-aortic balloon pump withdrawal to intensive care unit discharge, weaning failure, perioperative troponin I, and lactate (same points) were compared.Results: All patients, except for 1 belonging to group R (P = 1.0), were successfully weaned. Group V had better preserved cardiac index, indexed systemic vascular resistance, cardiac cycle efficiency, and central venous pressure (group*time P = .0001). Group R had worse cardiac index from T5 to T8 (P ≤ .0001), indexed systemic vascular resistance from T2 to T8 (P ≤ .004), cardiac cycle efficiency from T3 to T8 (P ≤ .001), central venous pressure from T4 to T8 (P ≤ .0001), and a longer interval from intra-aortic balloon pump withdrawal to intensive care unit discharge (P = .0001). The lactate level was lower in group V from T5 to T8 (P ≤ .027; group*time P = .001).Conclusions: Intra-aortic balloon pump weaning by volume deflation allowed better hemodynamic and metabolic parameters.

Percutaneous device closure of a pseudoaneurysm arising from the junction of the innominate artery and the aorta - Corrected Proof

Dawn C. Scantlebury, Oluseun O. Alli, Lyle D. Joyce, Charanjit S. Rihal — 2012-04-23

A percutaneous approach to management of thoracic aortic disease has emerged as an alternative to open surgical repair for carefully selected patients. Approaches that have been used include stent-grafting and coil embolization. We report a case of closure of a pseudoaneurysm of the junction of the innominate artery and the aorta with an Amplatzer Vascular Plug II (St Jude Medical, St Paul, Minn).

Computational fluid dynamic simulations for determination of ventricular workload in aortic arch obstructions - Corrected Proof

2012-04-20

Objective: The cardiac workload associated with various types of aortic obstruction was determined using computational fluid dynamic simulations.Methods: Computed tomography image data were collected from 4 patients with 4 distinct types of aortic arch obstructions and 4 controls. The categorization of arch hypoplasia corresponded to the “A, B, C” nomenclature of arch interruption; a type “D” was added to represent diffuse arch hypoplasia. Measurements of the vessel diameter were compared against the normal measurements to determine the degree of narrowing. Three-dimensional models were created for each patient, and additional models were created for type A and B hypoplasia to represent 25%, 50%, and 75% diameter narrowing. The boundary conditions for the computational simulations were chosen to achieve realistic flow and pressures in the control cases. The simulations were then repeated after changing the boundary conditions to represent a range of cardiac and vascular adaptations. The resulting cardiac workload was compared with the control cases.Results: Of the 4 patients investigated, 1 had aortic coarctation and 3 had aortic hypoplasia. The cardiac workload of the patients with 25% narrowing type A and B hypoplasia was not appreciably different from that of the control. When comparing the different arch obstructions, 75% type A, 50% type B, and 50% type D hypoplasia required a greater workload increase than 75% coarctation.Conclusions: The present study has determined the hemodynamic significance of aortic arch obstruction using computational simulations to calculate the cardiac workload. These results suggest that all types of hypoplasia pose more of a workload challenge than coarctation with an equivalent degree of narrowing.

Right anterior minithoracotomy versus conventional aortic valve replacement: A propensity score matched study - Corrected Proof

2012-04-20

Objective: Minimally invasive aortic valve surgery by way of a right anterior minithoracotomy has shown excellent results in terms of mortality, morbidities, and patient satisfaction. The aim of the present study was to compare minimally invasive aortic valve surgery by way of a right anterior minithoracotomy with conventional full sternotomy on early outcomes and midterm survival.Methods: A retrospective, observational, cohort study was undertaken of prospectively collected data from 637 consecutive patients undergoing isolated aortic valve surgery from January 2005 to July 2010. Of the 637 patients, 192 (30%) underwent minimally invasive aortic valve surgery by way of a right anterior minithoracotomy. Of these, 138 patients (right anterior minithoracotomy group) were matched to a control group (full sternotomy group) using propensity score analysis.Results: The baseline characteristics were similar in both groups. The overall in-hospital mortality was 0.7% (2/276), with no difference between the 2 groups. Minimally invasive aortic valve surgery by way of a right anterior minithoracotomy was associated with a lower incidence of postoperative atrial fibrillation (25 [18.1%] vs 41 [29.7%]; P = .003) and blood transfusions (26 [18.8%] vs 47 [34.1%]; P = .0006). In addition, patients in the right anterior minithoracotomy group had a shorter mechanical ventilation time (median, 6 vs 8 hours; P = .004) and postoperative length of stay (median, 5 vs 6 days; P = .02). The occurrence of stroke, renal failure, reexploration for bleeding, and wound infection was similar in both groups. At a median follow-up of 30 months (range, 17–54 months), survival was 96% ± 2% vs 88% ± 4% (P = .3).Conclusions: Right anterior minithoracotomy in patients undergoing isolated aortic valve surgery is associated with a lower incidence of postoperative atrial fibrillation and blood transfusion and shorter ventilation time and hospital length of stay. Prospective randomized trials are needed to confirm our data.

Growth-associated hyperphosphatemia in young recipients accelerates aortic allograft calcification in a rat model - Corrected Proof

2012-04-19

Objectives: Cardiovascular allografts in the young have limited durability because of early graft calcification. The objective of this study was to examine the hypothesis that growth-associated hyperphosphatemia in youth accelerates aortic allograft calcification by osteogenic transformation of graft medial smooth muscle cells (SMCs).Methods: The descending aortas of donor rats were subcutaneously transplanted into recipients. Syngeneic (Lewis-to-Lewis) transplantations between 3-week-old “young” (Y) rats and between 10-week-old “adult” (A) rats were combined with standard (ST, 0.9% phosphate) and low-phosphate (LP, 0.2%) diets, resulting in Y-ST, Y-LP, and A-ST groups. Allotransplantations (Brown-Norway–to–Lewis) involving these ages and diets were also made. The grafts and sera were retrieved from recipients after 14 days. Cultured rat aortic SMCs were used to analyze the effects of tumor necrosis factor-alpha (TNF-α) and phosphate on SMC calcification.Results: In vivo, serum phosphate levels were higher in Y-ST (11.5 mg/dL) than those in Y-LP (8.9 mg/dL) and A-ST (8.5 mg/dL). Graft medial calcification appeared severe only in Y-ST. Allotransplants did not affect these outcomes. Graft medial cells showed phenotypic changes (contractile to synthetic) and osteogenic transformation (α-smooth muscle actin to Runx2 and osteocalcin), together with up-regulated proinflammatory TNF-α and sodium–phosphate cotransporter, Pit-1, despite ages and diets. In vitro, TNF-α induced phenotypic changes and osteogenic transformation of SMCs with Pit-1 up-regulation, but SMC calcification occurred only with high phosphate (4.5 mmol/L).Conclusions: Growth-associated hyperphosphatemia with inflammatory responses may be essential for accelerating allograft calcification in youth and could be a therapeutic target.

Endoscopic management of gastroesophageal reflux disease: A review - Corrected Proof

Chaitan K. Narsule, Jon O. Wee, Hiran C. Fernando — 2012-04-19

Gastroesophageal reflux disease is the most common esophageal disorder encountered in the United States. Gastroesophageal reflux disease symptoms are associated with a negative quality of life and increased healthcare costs and therefore require an effective management strategy. Although proton pump inhibitors remain the primary treatment of gastroesophageal reflux disease, they do not cure the disorder and can leave patients with persistent symptoms despite treatment. Moreover, patients are still at risk of developing such complications as peptic strictures, Barrett's metaplasia, and esophageal cancer. Although laparoscopic Nissen fundoplication has been the conventional alternative treatment for those patients who develop complications of gastroesophageal reflux disease, have intractable symptoms, or wish to discontinue taking proton pump inhibitors, investigators have persisted in developing a number of endoscopic approaches to the treatment of gastroesophageal reflux disease. The present report reviews the history of endoscopic treatments devised for the management of gastroesophageal reflux disease and explores the published data and outcomes associated with the latest approach—endoscopic fundoplication using the EsophyX2 device.

Complete revascularization is compromised in off-pump coronary artery bypass grafting - Corrected Proof

2012-04-19

Objective: Patients who undergo off-pump coronary artery bypass grafting (OPCAB) commonly receive fewer bypass grafts and are more often incompletely revascularized compared with those receiving conventional coronary artery bypass (CCAB) recipients. Because this can compromise survival, we sought to determine whether patients undergoing OPCAB are incompletely revascularized and whether this affects long-term survival and freedom from cardiac events.Methods: OPCAB cases (n = 411) performed from January 1, 1997 to June 30, 2003 were considered for inclusion and matching with 874 randomly selected, contemporary CCAB cases. After propensity matching, 308 OPCAB cases and 308 CCAB cases were included in the final analysis. We compared the number of bypass grafts and the completeness of revascularization by coronary territory. Survival and readmission for cardiac causes were monitored for up to 10 years postoperatively, with a median follow-up period of 5.9 years.Results: On average, the patients undergoing OPCAB received significantly fewer distal anastomoses than did those undergoing CCAB (mean ± standard deviation, 2.6 ± 0.9 vs 3.0 ± 1.0, P < .0001). The circumflex territory was the most likely territory to be ungrafted during OPCAB in patients with angiographically significant obstruction (P = .0006). The frequency of complete revascularization was significantly different between the 2 groups (OPCAB, 79.2% vs CCAB, 88.3%; P = .0.002). The OPCAB group had a significantly greater rate of total arterial grafting (OPCAB, 66.6% vs CCAB, 49.7%; P = .0001). No difference was seen in 8-year survival or freedom from cardiac cause hospital readmission between the 2 groups.Conclusions: Despite receiving fewer distal anastomoses and the decreased frequency of complete revascularization, OPCAB and CCAB techniques produced comparable results.

Lung cancer screening trials—Denmark, United States, and beyond - Corrected Proof

Jesper H. Pedersen, Rene H. Petersen, Henrik J. Hansen — 2012-04-19

Lung cancer is the leading cause of cancer death worldwide, with fewer than 15% of patients surviving 5 years after diagnosis, despite advances in treatment during the past 20 years. Lung cancer screening (secondary prevention), in addition to smoking cessation programs (primary prevention), might be the most exciting improvement in methods to reduce lung cancer mortality. The great interest in lung cancer screening was started by the introduction of low-dose multidetector computed tomography (CT) in the 1990s. The nonrandomized International Early Lung Cancer Action Project study (n = 32,000) was followed by several randomized clinical trials of high-risk current and former smokers. These included the National Lung Screening Trial (NLST) in the United States (n = 53,500), the Dutch-Belgian screening trial (n = 15,822), the Danish Lung Cancer Screening Trial (DLCST, n = 4104 ), and several other collaborating trials in Europe. Recently, the National Cancer Institute published the report that the NLST gave evidence for a mortality reduction of 20.3% with low-dose CT screening compared with chest radiographic screening and a 7% overall mortality reduction after 3 annual screening rounds and 8 years of follow-up. The NLST was a very well-performed randomized trial and has convincingly shown for the first time that CT screening, in high-risk subjects, can lead to a substantial reduction in lung cancer mortality and that the screening overall was not detrimental, because a reduction of 7% in general mortality was also observed. These are extremely important findings. The European trials have been smaller, but all have had a control group without any screening performed (usual care) and, therefore, potentially, the difference between the mortality in the CT and control arms could be more pronounced. In addition, the trials were started 2 to 3 years after the NLST and, therefore, have not yet performed a pooling of data and presented a combined mortality analysis. The Dutch-Belgian screening trial and the DLCST are expected to perform a final mortality analysis in 2015 but contemplated a preliminary pooling of data in 2011.

Educational program in crisis management for cardiac surgery teams including high realism simulation - Corrected Proof

2012-04-16

Introduction: Cardiac surgery demands effective teamwork for safe, high-quality care. The objective of this pilot study was to develop a comprehensive program to sharpen performance of experienced cardiac surgical teams in acute crisis management.Methods: We developed and implemented an educational program for cardiac surgery based on high realism acute crisis simulation scenarios and interactive whole-unit workshop. The impact of these interventions was assessed with postintervention questionnaires, preintervention and 6-month postintervention surveys, and structured interviews.Results: The realism of the acute crisis simulation scenarios gradually improved; most participants rated both the simulation and whole-unit workshop as very good or excellent. Repeat simulation training was recommended every 6 to 12 months by 82% of the participants. Participants of the interactive workshop identified 2 areas of highest priority: encouraging speaking up about critical information and interprofessional information sharing. They also stressed the importance of briefings, early communication of surgical plan, knowing members of the team, and continued simulation for practice. The pre/post survey response rates were 70% (55/79) and 66% (52/79), respectively. The concept of working as a team improved between surveys (P = .028), with a trend for improvement in gaining common understanding of the plan before a procedure (P = .075) and appropriate resolution of disagreements (P = .092). Interviewees reported that the training had a positive effect on their personal behaviors and patient care, including speaking up more readily and communicating more clearly.Conclusions: Comprehensive team training using simulation and a whole-unit interactive workshop can be successfully deployed for experienced cardiac surgery teams with demonstrable benefits in participant's perception of team performance.

Low-flow antegrade cerebral perfusion attenuates early renal and intestinal injury during neonatal aortic arch reconstruction - Corrected Proof

2012-04-16

Objective: Deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) are 2 cardiopulmonary bypass strategies mainly used in aortic arch reconstructions. It has been suggested that during ACP, abdominal organs are better protected than during DHCA owing to partial perfusion via collaterals. We tested this hypothesis using intraoperative near-infrared spectroscopy (NIRS), lactate measurements, and biomarkers for early abdominal injury in neonates undergoing complex aortic arch repair.Methods: Neonates scheduled for aortic arch reconstruction via median sternotomy between 2009 and 2011 were randomized to either DHCA or ACP. During surgery, regional oxygen saturations of the abdomen were monitored using NIRS. Immediately aafter DHCA or ACP, lactate concentrations from the inferior vena cava were compared with those from the arterial cannula. Postoperatively, biomarkers for early abdominal organ injury were measured in urine.Results: Twenty-five neonates were analyzed (DHCA, n = 12; ACP, n = 13). Procedures were performed at 18°C, and ACP flow was set at 35 to 50 mL · kg−1 · min−1. Median abdominal NIRS value during DHCA was 31% (IQR, 28%-41%) whereas during ACP it was 56% (IQR, 34%-64%; P < .01 between groups). Immediately after DHCA, median lactate from the inferior vena cava was 4.2 mmol/L (IQR, 3.3-5.3 mmol/L) compared with 3.1 mmol/L (IQR, 2.9-4.4 mmol/L) after ACP (P = .03). Postoperatively, biomarkers for renal and intestinal damage (gluthatione s-transferase and intestinal fatty acid binding protein, respectively) were higher in the DHCA group than for the ACP group (P = .03, P = .04, respectively).Conclusions: These results substantiate earlier suggestions that ACP provides more abdominal organ protection than DHCA in neonates undergoing aortic arch reconstruction.

Gaming in risk-adjusted mortality rates: Effect of misclassification of risk factors in the benchmarking of cardiac surgery risk-adjusted mortality rates - Corrected Proof

2012-04-16

Objective: Upcoding or undercoding of risk factors could affect the benchmarking of risk-adjusted mortality rates. The aim was to investigate the effect of misclassification of risk factors on the benchmarking of mortality rates after cardiac surgery.Methods: A prospective cohort was used comprising all adult cardiac surgery patients in all 16 cardiothoracic centers in The Netherlands from January 1, 2007, to December 31, 2009. A random effects model, including the logistic European system for cardiac operative risk evaluation (EuroSCORE) was used to benchmark the in-hospital mortality rates. We simulated upcoding and undercoding of 5 selected variables in the patients from 1 center. These patients were selected randomly (nondifferential misclassification) or by the EuroSCORE (differential misclassification).Results: In the random patients, substantial misclassification was required to affect benchmarking: a 1.8-fold increase in prevalence of the 4 risk factors changed an underperforming center into an average performing one. Upcoding of 1 variable required even more. When patients with the greatest EuroSCORE were upcoded (ie, differential misclassification), a 1.1-fold increase was sufficient: moderate left ventricular function from 14.2% to 15.7%, poor left ventricular function from 8.4% to 9.3%, recent myocardial infarction from 7.9% to 8.6%, and extracardiac arteriopathy from 9.0% to 9.8%.Conclusions: Benchmarking using risk-adjusted mortality rates can be manipulated by misclassification of the EuroSCORE risk factors. Misclassification of random patients or of single variables will have little effect. However, limited upcoding of multiple risk factors in high-risk patients can greatly influence benchmarking. To minimize “gaming,” the prevalence of all risk factors should be carefully monitored.

Development of a cardiac surgery simulation curriculum: From needs assessment results to practical implementation - Corrected Proof

Craig J. Baker, Raina Sinha, Maura E. Sullivan — 2012-04-16

Objective: A paradigm shift in surgical training has led to national efforts to incorporate simulation-based learning into cardiothoracic residency programs. Our goal was to determine the feasibility of developing a cardiac surgery simulation curriculum using the formal steps of curriculum development.Methods: Cardiothoracic surgery residents (n = 6) and faculty (n = 9) evaluated 54 common cardiac surgical procedures to determine their need for simulation. The highest scoring procedures were grouped into similarly themed monthly modules, each with specific learning objectives. Educational tools consisting of inanimate, animate, and cadaveric facilities and a newly created virtual operating room were used for curriculum implementation. Resident satisfaction was evaluated by way of a 5-point Likert scale. Perceived competency (scale of 1–10) and pre–/post–self-confidence (scale of 1–5) scores were collected and analyzed using cumulative mean values and a paired t-test.Results: Of the 23 highest scoring procedures (mean score, ≥4.0) on the needs assessment, 21 were used for curriculum development. These procedures were categorized into 12 monthly modules. The simulation curriculum was implemented using the optimal simulation tool available. Resident satisfaction (n = 57) showed an overwhelmingly positive response (mean score, ≥4.7). The perceived competency scores highlighted the procedures residents were uncomfortable performing independently. The pre–/post–self-confidence scores increased throughout the modules, and the differences were statistically significant (P < .001).Conclusions: It is feasible to develop and implement a cardiac surgery simulation curriculum using a structured approach. High-fidelity, low-technology tools such as a fresh tissue cadaver laboratory and a virtual operating room could be important adjuncts.

Prediction of the critical thermal zone during pulmonary cryoablation on computed tomography from correlated experimental and clinical findings - Corrected Proof

2012-04-16

Objective: During cryoablation, cells are destroyed at temperatures less than −20°C. The determining factors for local cancer control in pulmonary cryoablation were assessed using computed tomography (CT), isothermal curves, and histologic findings in pigs. Experimental findings were compared with clinical CT findings and were extrapolated to local cancer control outcomes.Methods: Cryoablation was performed with thermal monitoring, and the ablated areas were divided into 3 zones: less than −20°C, −20°C to 0°C, and greater than 0°C and were compared with histologic findings. CT findings with multiplanar reconstruction in 36 nodules were compared with the porcine histologic findings. The relationship between CT findings and 3-year local cancer control was evaluated in 98 nodules.Results: The 3 concentric thermal zones correlated with histologic findings as follows: less than −20°C zone, complete tissue destruction (zone D); −20°C to 0°C zone (which surrounded zone D), hemorrhage with air trapping and maintenance of alveolar structures (zone H); and greater than 0°C zone (outermost), edema with sustained alveolar structures (zone E). The CT findings in 36 nodules showed a central solid zone, a surrounding air-containing zone, and an outside solid zone, corresponding to zones D, H, and E, respectively. Local cancer control at 3 years in 80 nodules contained within the central solid zone was significantly greater compared with the 18 nodules that were not (82% vs 33%, P = .0002).Conclusions: Pulmonary cryoablation should be performed such that tumors are contained within the central solid zone on CT, which represents the less than −20°C zone.

Management of postdissection thoracoabdominal aneurysm after previous frozen elephant trunk procedure with the E-vita Open Plus stent-graft - Corrected Proof

Vito Giovanni Ruggieri, Amedeo Anselmi, Issam Abouliatim, Jean-Philippe Verhoye — 2012-04-16

The use of a hybrid stent-graft enables the extension of the aortic repair into the dissected descending aorta in patients undergoing aortic surgery through a median sternotomy. The frozen elephant trunk technique has been reported to decrease the rate of aortic reoperation, both open and endovascular, after repair of type A acute aortic dissection. Here we discuss a case of thoracoabdominal aneurysm treated with conventional surgery after a previous frozen elephant trunk procedure with the E-vita Open Plus hybrid endoprosthesis (JOTEC GmbH, Hechingen, Germany).

Aortopulmonary collateral flow volume affects early postoperative outcome after Fontan completion: A multimodality study - Corrected Proof

2012-04-16

Objective: Aortopulmonary collaterals are a frequent phenomenon in patients after bidirectional cavopulmonary connection. The aortopulmonary collateral flow volume can be quantified using cardiac magnetic resonance imaging. However, the significance of aortopulmonary collateral flow for the postoperative outcome after total cavopulmonary connection is unclear and was sought to be determined.Methods: The data from 33 patients were prospectively studied with cardiac magnetic resonance, echocardiography, and cardiac catheterization before the total cavopulmonary connection operation. The early postoperative outcomes after total cavopulmonary connection completion were recorded.Results: Aortopulmonary collateral flow was 1.59 L/min/m2 ± 0.65 L/min/m2 (range, 0.54 L/min/m2–3.34 L/min/m2), constituting 43% ± 13% (range, 12–87%) of pulmonary blood flow and 35% ± 12% (range, 11–62%) of the cardiac index, resulting in a pulmonary blood flow/systemic blood flow ratio of 1.06 ± 0.17 (range, 0.79–1.55). The aortopulmonary collateral flow correlated with pulmonary blood flow/systemic blood flow ratio (r = 0.69, P < .0001), oxygen saturation (r = 0.42, P = .018), and cardiac index (r = 0.53, P = .002). Of the 36 patients, 24 underwent fenestrated total cavopulmonary connection during the study period. The aortopulmonary collateral flow, relative to the cardiac index, correlated with the duration of hospital stay (r = 0.48, P = .02) and pleural drainage (r = 0.45, P = .03). Patients whose pleural drainage lasted 1 week or less had less aortopulmonary collateral flow before the Fontan operation than those with a longer period until chest tube removal (1.23 L/min/m2 ± 0.38 L/min/m2 vs 1.73 L/min/m2 ± 0.76 L/min/m2; P = .03). Compared with a contemporary group of total cavopulmonary connection patients with fenestration in their extracardiac conduit who were studied prospectively, with a similar protocol, the bidirectional cavopulmonary connection had a greater amount of aortopulmonary collateral flow (1.59 L/min/m2 ± 0.65 L/min/m2 vs 1.30 L/min/m2 ± 0.57 L/min/m2, P = .04).Conclusions: Patients after bidirectional cavopulmonary connection routinely acquire a large amount of aortopulmonary collateral flow. The hemodynamic consequences of aortopulmonary collateral flow translate into adverse outcomes early after total cavopulmonary connection completion.

Combined surgical and ablative cure for localized sternal compression–induced cardiomyopathy and ventricular tachyarrhythmia - Corrected Proof

Christopher V. DeSimone, Sandeep Sagar, Chris Moir, Samuel J. Asirvatham — 2012-04-16

Ventricular tachyarrhythmia (VT) in structurally normal hearts often arises in the right ventricular outflow tract and is characterized by left bundle-branch block (LBBB) inferior axis morphology. VT of other LBBB morphology has been associated with arrhythmogenic right ventricular cardiomyopathy and moderator band–related VT.

Segmentectomy for selected cT1N0M0 non–small cell lung cancer: A prospective study at a single institute - Corrected Proof

2012-04-16

Background: To examine whether segmentectomy is radical for cT1N0M0 non–small cell lung cancer (NSCLC), a prospective single-arm study was performed at a single institution.Methods: The criteria for segmentectomy were as follows: (1) peripheral-type cT1N0M0 NSCLC; (2) intraoperative frozen sections of sentinel nodes identified with isotope showing no metastasis; (3) surgical margins greater than 2 cm; (4) patient choice for segmentectomy; and (5) exclusion of right middle lobe tumors. From 2005 to 2009, of 245 patients with cT1N0M0 NSCLC, 195 (80%) were enrolled in the present study. Of these 195 patients, 179 ultimately underwent segmentectomy with systematic lymph node dissection. Of these 179 patients, 134 (75%) had tumors 2 cm or smaller, and 45 (25%) had tumors 2.1 cm to 3 cm. The median follow-up period was 43 months.Results: All 181 tumors from 179 patients were stage pN0. Of the 179 patients, 6 developed distant site recurrence and 3 local recurrence (ie, 1 developed pulmonary metastases within the same lobe 21 months after segmentectomy and 2 developed local recurrence at the surgical margin 60 and 62 months after segmentectomy, respectively). The 5-year overall survival was 94% for patients with tumors 2 cm or smaller and 81% for those with 2.1-cm to 3-cm tumors. Postoperative pulmonary function was preserved at 90% ± 12% of preoperative levels.Conclusions: Segmentectomy with systematic lymph node dissection with a sufficient surgical margin could be a radical treatment for selected cT1N0M0/pN0 NSCLC while preserving pulmonary function. The surgical margin should be monitored for the development of local recurrence for a long period after segmentectomy.

Extracorporeal membrane oxygenation after stage 1 palliation for hypoplastic left heart syndrome - Corrected Proof

2012-04-16

Objective: To report the outcomes from a large multicenter cohort of neonates requiring extracorporeal membrane oxygenation (ECMO) after stage 1 palliation for hypoplastic left heart syndrome.Methods: Using data from the Extracorporeal Life Support Organization (2000–2009), we computed the survival to hospital discharge for neonates (age ≤30 days) supported with ECMO after stage 1 palliation for hypoplastic left heart syndrome. The factors associated with mortality were evaluated using multivariate logistic regression analysis.Results: Among 738 neonates, the survival rate was 31%. The median age at cannulation was 7 days (interquartile range, 4–11). Black race (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.2–3.6), mechanical ventilation before ECMO (>15–131 hours: OR, 1.6; 95% CI, 1.1–2.4; >131 hours: OR, 1.9; 95% CI, 1.3–2.9), use of positive end expiratory pressure (>6–8 cm H2O: OR, 1.7; 95% CI, 1.1–2.7; >8 cm H2O: OR, 1.9; 95% CI, 1.2–3.1), and longer ECMO duration (per day, OR, 1.2; 95% CI, 1.1–1.3) increased mortality. ECMO support for failure to wean from cardiopulmonary bypass (OR, 1.6; 95% CI, 1.02–2.4) also decreased survival. ECMO complications, including renal failure (OR, 1.9; 95% CI, 1.2–3.1), inotrope requirement (OR, 1.5; 95% CI, 1.1–2.1), myocardial stun (OR, 3.2; 95% CI, 1.3–7.7), metabolic acidosis (OR, 2.9; 95% CI, 1.3–6.7), and neurologic injury (OR, 1.7; 95% CI, 1.1–2.6), during support also increased mortality.Conclusions: Mortality for neonates with hypoplastic left heart syndrome supported with ECMO after stage 1 palliation is high. Longer ventilation before cannulation, longer support duration, and ECMO complications increased mortality.

Left main coronary artery atresia with tetralogy of Fallot: A novel association - Corrected Proof

Nikhil Prakash Patil, Smita Mishra, Saket Agarwal, Deepak Kumar Satsangi — 2012-04-16

Left main coronary artery (LMCA) atresia is a rare coronary anomaly in which there is no left coronary ostium, the proximal left main trunk ends blindly, and blood flows from the right coronary artery (RCA) to the left through collaterals and retrogradely in at least 1 of the left-sided arteries. A novel case of LMCA atresia associated with tetralogy of Fallot (TOF) is reported here. The patient underwent successful surgical angioplasty for LMCA reconstruction with concomitant TOF palliation in the setting of biventricular dysfunction.

Is VAMLA/TEMLA the new standard of preresection staging of non–small cell lung cancer? - Corrected Proof

Sai Yendamuri, Todd L. Demmy — 2012-04-16

Accurate mediastinal staging is the hallmark of a good thoracic oncology program. Mediastinal lymph node staging is important for prognostication and to guide the administration of neoadjuvant and adjuvant therapy. In addition, accurate mediastinal staging is necessary for a fair comparison of different clinical studies. The most important surgical advance in mediastinal lymph node staging in the past few years is transcervical staging, by either sternal elevation or video-assisted mediastinoscopy. The present report summarizes the existing published data evaluating such an approach.

Adjuvant chemotherapy for surgically resected non–small cell lung cancer - Corrected Proof

Stephanie Heon, Bruce E. Johnson — 2012-04-16

Despite surgical resection, patients with early-stage (I to IIIA) non–small cell lung cancer (NSCLC) are at considerable risk of recurrence and death from their lung cancer. In recent years, multiple, large, randomized trials assessing the efficacy of adjuvant chemotherapy for resected NSCLC have been reported. Three of 6 trials with 300 or more patients with early-stage NSCLC have demonstrated that adjuvant cisplatin-based chemotherapy can significantly improve 5-year survival in carefully selected patients with resected NSCLC. These benefits have been confirmed in a meta-analysis of modern cisplatin-based adjuvant trials. The most consistent benefit has been reported in patients with resected stage II and IIIA NSCLC. The benefit of adjuvant chemotherapy in patients with resected stage IB NSCLC is less concrete. Herein, we review the results of the major adjuvant chemotherapy trials and their implications for the treatment of patients with completely resected NSCLC. A future challenge will be to identify the subsets of patients who will derive the greatest benefit from adjuvant chemotherapy. Current trials are also underway to define the role of novel targeted therapies, such as inhibitors of the epidermal growth factor receptor and monoclonal antibodies, in adjuvant treatment strategies.

Computed tomography lymphography by transbronchial injection of iopamidol to identify sentinel nodes in preoperative patients with non–small cell lung cancer: A pilot study - Corrected Proof

2012-04-16

Objective: The objective of the present study was to assess the safety and feasibility of computed tomography lymphography by transbronchial injection of a water-soluble extracellular computed tomography contrast agent.Methods: From April 2010 to May 2011, patients with clinical stage I non–small cell lung cancer who were candidates for lobectomy were enrolled in the present study. An ultrathin bronchoscope was inserted to the target bronchus under the guidance of virtual bronchoscopic navigation images. Computed tomography images of the chest were obtained 0.5 and 5 minutes after 2 or 3 mL of iopamidol was injected through a microcatheter. Sentinel nodes were identified when the maximum computed tomography attenuation value of the lymph nodes on the postcontrast computed tomography images increased by 30 Hounsfield units or more compared with the precontrast images. Patients underwent lobectomy with standard lymph node dissection.Results: The ultrathin bronchoscope could access the targeted bronchus, and iopamidol was delivered into the peritumoral area in all 13 patients without any complications. Sentinel nodes were identified in 12 (92.3%) of the 13 patients. The average number of sentinel nodes was 1.5 (range, 1–2). Pathologic examination revealed metastatic lymph nodes in 2 patients. Metastatic nodes were included with the sentinel nodes.Conclusions: Computed tomography lymphography by transbronchial injection of iopamidol was a safe and feasible method to identify the sentinel nodes in patients with clinical stage I non–small cell lung cancer.

Healing process after total cricoidectomy and laryngotracheal reconstruction: Endoscopic and histologic evaluation in a canine model - Corrected Proof

Kazumichi Yamamoto, Michitaka Honda, Tetsurou Yamamoto, Tatsuo Nakamura — 2012-04-16

Objective: The surgical procedure for subglottic stenosis is technically challenging when the vocal cords are involved and concomitant management for glottic involvement is required. After total cricoidectomy and laryngotracheal anastomosis, T-tube placement for 3 to 6 months is recommended. Bone grafts might shorten this period. We report the histologic and endoscopic changes after total cricoidectomy with or without bone grafts in a canine model to suggest an appropriate period for T-tube placement and the necessity for bone grafts.Methods: Ten dogs underwent total cricoidectomy and laryngotracheal anastomosis with or without bone grafts harvested from the ribs. Endoscopic examination was performed monthly, and 1 dog from both groups was humanely killed at 1, 2, 3, 6, and 12 months. The T-tube was removed before death in the dogs killed at 1, 2, and 3 months and at 3 and 6 months in those killed at 6 and 12 months, respectively.Results: Endoscopically, the glottic opening was in good condition in all dogs, except for 1 that had glottic stenosis. Histologically, active lymphocyte infiltration was observed in dense collagen fibers at the anastomosis at 1 month. At 2 and 3 months, fibroblasts were evident, suggesting active collagen fiber production. At 6 and 12 months, the collagen fibers had become looser. The bone grafts were intact and did not influence the surrounding tissue.Conclusions: In the canine model, 6 months of T-tube placement is probably sufficient; however, 3 months of placement might not be. Additionally, no difference was found between the dogs with and without a bone graft.

Surgical approaches to apical thoracic malignancies - Corrected Proof

Marc de Perrot, Raja Rampersaud — 2012-04-16

Objective: Several surgical approaches have been described to access apical thoracic malignancies extending into the thoracic inlet. However, most publications have focused on a specific approach and considered the thoracic inlet as 1 entity. In the present analysis, we divided the thoracic inlet into 5 different zones requiring specific surgical considerations to identify the best approach for each zone.Methods: A review of 22 consecutive patients undergoing surgery for apical thoracic malignancies extending into the thoracic inlet from January 2005 to November 2011 was performed.Results: Different surgical approaches were used for each zone. The first (anterolateral) zone required a subclavicular approach to open the costoclavicular space and expose the subclavian vein with or without elevating or removing the clavicle (n = 4). The second (anterocentral) zone required a transverse supraclavicular approach with or without extension to a partial (trapdoor) or full sternotomy (n = 10). The third (posterosuperior) zone located between the top of the subclavian artery and the T1 vertebra along the posterior superior border of the first rib was the most difficult area to access (n = 5). The transclavicular approach was ideally suited to expose this zone in our experience. The fourth (posteroinferior) zone and fifth (inferolateral) zone located posteriorly and laterally along the inferior border of the first rib were accessed using a posterolateral and posterotransaxillary approach, respectively (n = 3).Conclusions: The thoracic inlet could be divided into 5 zones requiring specific surgical considerations and different approaches. Division of the thoracic inlet into these zones could provide more clarity and guidance for thoracic surgeons to select the correct surgical approach.

Quality of life 4 years after complex heart surgery in infancy - Corrected Proof

2012-04-16

Objective: To determine the health-related quality of life at 4 years of age in children who had undergone cardiac surgery for congenital heart disease in early infancy.Methods: A prospective cohort study of infants undergoing cardiac surgery at 6 weeks of age or younger from July 2000 to June 2005 at the Stollery Children's Hospital. The quality of life was assessed using the Pediatric Quality of Life Inventory, version 4.0, generic core scales, and compared with normative values for the same age. The association between the perioperative variables and health-related quality of life was explored.Results: A total of 242 infants underwent complex heart surgery during the study period. Of the 166 eligible survivors, 130 were included. No significant differences were present between the children with single ventricle versus biventricular repairs, except for lower physical health summary scores in the single ventricle patients (P = .007). Compared with the normative data, the children with biventricular repair had lower total Pediatric Quality of Life Inventory, version 4.0, scores (P = .001) and psychosocial health summary scores (P < .001). The children with single ventricle repair also had lower physical health summary scores (P = .003). Older age at surgery and markers of postoperative low cardiac output syndrome were associated with worse health-related quality of life, and greater socioeconomic status was associated with better quality of life.Conclusions: At 4 years of age, health-related quality of life was significantly lower in children who had undergone surgery for congenital heart disease in early infancy. An association was found between age at surgery and postoperative low cardiac output and socioeconomic status and quality of life.

Penetrating injury to the right side of the heart without hemodynamic compromise - Corrected Proof

Zeljko Duric, Igor Gosev, Drazen Belina — 2012-04-16

We report the case of a 45-year-old man who attempted suicide with a kitchen knife. The knife (blade length, 20 cm; blade width, 4 cm) penetrated the anterior thoracic wall through the sternum and stayed fixed within the right ventricular cavity.

Transcatheter aortic valve implantation combined with conventional heart surgery: Hybrid approach for complex cardiac pathologic features - Corrected Proof

Miralem Pasic, Semih Buz, Axel Unbehaun, Roland Hetzer — 2012-04-16

A new hybrid approach, the combination of transcatheter aortic valve implantation (TAVI) and conventional cardiac surgery, might be a possible solution for patients considered not suitable for complex conventional surgery. We have summarized our preliminary experience.