The Journal of Thoracic and Cardiovascular Surgery - Articles in Press

Effects of selective cyclooxygenase-2 and nonselective cyclooxygenase inhibition on ischemic myocardium - Corrected Proof

2010-09-01

Objective: We explored effects of nonselective cyclooxygenase and selective cyclooxygenase 2 inhibition on collateral development in a model of chronic myocardial ischemia. We hypothesized that cyclooxygenase 2 inhibitors would negatively effect angiogenic and inflammatory pathways.Methods: Yorkshire swine were made chronically ischemic by placing an ameroid constrictor on the left circumflex coronary artery. Swine were divided into 3 groups and given no drug (control, n = 7), a nonselective cyclooxygenase inhibitor (naproxen 400 mg daily, n = 7), or a selective cyclooxygenase 2 inhibitor (celecoxib 200 mg daily, n = 7). After 7 weeks, coronary angiography was performed. Myocardial function and microvascular reactivity were assessed. Serum and myocardial tissue were analyzed for prostaglandin levels and markers of inflammation and angiogenesis.Results: The celecoxib group demonstrated significantly increased mean arterial pressure and decreased left ventricular function. Myocardial perfusion in the celecoxib group was similar to control value but less than in the naproxen group. Coronary microvascular contraction in the collateral-dependent territory was increased in the naproxen group but minimally affected in the celecoxib group. Oxidative stress and apoptosis were increased in the celecoxib group. Expression of angiogenic markers vascular endothelial growth factor and phospho–endothelial nitric oxide synthase (ser1177) and tissue levels of prostacyclin were decreased in both celecoxib and naproxen groups. The naproxen group had diminished endostatin expression.Conclusions: Selective and nonselective cyclooxygenase inhibition are more complex in effect than previously published, but they did not decrease collateral-dependent blood flow to the myocardium in our model of chronic myocardial ischemia.

Diazoxide maintenance of myocyte volume and contractility during stress: Evidence for a non-sarcolemmal KATP channel location - Corrected Proof

2010-09-01

Objective: Animal and human myocytes demonstrate significant swelling and reduced contractility during exposure to stress (metabolic inhibition, hyposmotic stress, or hyperkalemic cardioplegia), and these detrimental consequences may be inhibited by the addition of diazoxide (adenosine triphosphate-sensitive potassium channel opener) via an unknown mechanism. Both SUR1 and SUR2A subunits have been localized to the heart, and mouse sarcolemmal adenosine triphosphate-sensitive potassium channels are composed of SUR2A/Kir6.2 subunits in the ventricle and SUR1/Kir6.2 subunits in the atria. This study was performed to localize the mechanism of diazoxide by direct probing of sarcolemmal adenosine triphosphate-sensitive potassium channel current and by genetic deletion of channel subunits.Methods: Sarcolemmal adenosine triphosphate-sensitive potassium channel current was recorded in isolated wild-type ventricular mouse myocytes during exposure to Tyrode's solution, Tyrode's + 100 μmol/L diazoxide, hyperkalemic cardioplegia, cardioplegia + diazoxide, cardioplegia + 100 μmol/L pinacidil, or metabolic inhibition using whole-cell voltage clamp (N = 7–12 cells per group). Ventricular myocyte volume was measured from SUR1(-/-) and wild-type mice during exposure to control solution, hyperkalemic cardioplegia, or cardioplegia + 100 μmol/L diazoxide (N = 7–10 cells per group).Results: Diazoxide did not increase sarcolemmal adenosine triphosphate-sensitive potassium current in wild-type myocytes, although they demonstrated significant swelling during exposure to cardioplegia that was prevented by diazoxide. SUR1(-/-) myocytes also demonstrated significant swelling during exposure to cardioplegia, but this was not altered by diazoxide.Conclusions: Diazoxide does not open the ventricular sarcolemmal adenosine triphosphate-sensitive potassium channel but provides volume homeostasis via an SUR1-dependent pathway in mouse ventricular myocytes, supporting a mechanism of action distinct from sarcolemmal adenosine triphosphate-sensitive potassium channel activation.

Discussion - Corrected Proof

2010-09-01

Dr Y. Joseph Woo (Philadelphia, Pa). That is a very impressive amount of work. The microvascular perfusion in the NSAID group was higher than the other groups, correct? Dr Robich. Yes, the perfusion in the myocardium, the blood flow, was increased.

Discussion - Corrected Proof

2010-09-01

Dr Friedhelm Beyersdorf (Freiburg, Germany). Swelling of cardiomyocytes is an important aspect of ischemia–reperfusion injury of the heart that leads to impaired myocardial function. You simulate ischemia in your experiments by MI using a specific solution. I have 2 questions for you:

General thoracic surgery is safe in patients taking clopidogrel (Plavix) - Corrected Proof

Robert James Cerfolio, Douglas J. Minnich, Ayesha S. Bryant — 2010-09-01

Background: The objective of this study was to assess the safety of general thoracic surgery in patients taking antiplatelet (clopidogrel) therapy.Methods: A prospective study was conducted of consecutive patients who underwent general thoracic surgery and who were taking clopidogrel perioperatively. They were matched using a propensity score from our prospective database of 11,768 patients. Intraoperative and postoperative outcomes were compared.Results: Between January 2009 and April 2010 there were 33 patients on clopidogrel at the time of surgery and 132 controls. The most common procedures were thoracotomy with lobectomy in 11 patients (robotic in 1), video-assisted wedge resection in 6, mediastinoscopy in 4, and Ivor Lewis esophagogastrectomy in 2. Epidurals were not used. There was no intraoperative morbidity or bleeding in primary thoracotomy; however, 2 of the 4 patients who underwent redo thoracotomy had bleeding that required transfusions. None of the 8 patients receiving clopidogrel who had a coronary artery stent and underwent lobectomy had a perioperative myocardial infarction whereas 5 of the 14 control patients undergoing lobectomy who had a coronary artery stent did (P = .05). Otherwise, morbidity, mortality, and length of stay were no different.Conclusions: Patients who are receiving clopidogrel and who have a coronary artery stent placed can safely undergo general thoracic surgery. The widely held belief that surgery cannot be performed without bleeding is untrue. This new finding not only eliminates much of the preoperative dilemma posed by these patients but also may reduce their risk of a postoperative myocardial infarction. However, patients who require a redo thoracotomy may be at increased risk of bleeding.

Discussion - Corrected Proof

2010-09-01

Dr David Park Mason (Cleveland, Ohio). I have no disclosures. Dr Cerfolio, I enjoyed the talk and I enjoyed your paper very much. I do not think that it can be overstated that clopidogrel is a potent inhibitor of coagulation, but also that you had excellent results, I think, because you did excellent surgery and cautious surgery, and not everyone is you. We have to think a little bit about the generalizability of the results. Careful and cautious surgery is obviously what you did, and the results are outstanding.

Optimized temporary biventricular pacing acutely improves intraoperative cardiac output after weaning from cardiopulmonary bypass: A substudy of a randomized clinical trial - Corrected Proof

2010-08-30

Objective: Permanent biventricular pacing benefits patients with heart failure and interventricular conduction delay, but the importance of pacing with and without optimization in patients at risk of low cardiac output after cardiac surgery is unknown. We hypothesized that pacing parameters independently affect cardiac output. Accordingly, we analyzed aortic flow measured with an electromagnetic flowmeter in patients at risk of low cardiac output during an ongoing randomized clinical trial of biventricular pacing (n = 11) versus standard of care (n = 9).Methods: A substudy was conducted in all 20 patients in both groups with stable pacing after coronary artery bypass grafting, valve surgery, or both. Ejection fraction averaged 33% ± 15%, and QRS duration was 116 ± 19 ms. Effects were measured within 1 hour of the conclusion of cardiopulmonary bypass. Atrioventricular delay (7 settings) and interventricular delay (9 settings) were optimized in random sequence.Results: Optimization of atrioventricular delay (171 ± 8 ms) at an interventricular delay of 0 ms increased flow by 14% versus the worst setting (111 ± 11 ms, P < .001) and 7% versus nominal atrioventricular delay (120 ms, P < .001). Interventricular delay optimization increased flow 10% versus the worst setting (P < .001) and 5% versus nominal interventricular delay (0 ms, P < .001). Optimized pacing increased cardiac output 13% versus atrial pacing at matched heart rate (5.5 ± 0.5 vs 4.9 ± 0.6 L/min, P = .003) and 10% versus sinus rhythm (5.0 ± 0.6 L/min, P = .019).Conclusions: Temporary biventricular pacing increases intraoperative cardiac output in patients with left ventricular dysfunction undergoing cardiac surgery. Atrioventricular and interventricular delay optimization maximizes this benefit.

Chronic thromboembolic pulmonary hypertension in pediatric patients - Corrected Proof

2010-08-30

Objective: Chronic thromboembolic pulmonary hypertension is a rare form of pulmonary hypertension that can lead to progressive right heart failure and death. Pulmonary thromboendarterectomy surgery is the treatment of choice resulting in significant improvements in functional status, cardiopulmonary hemodynamics, and survival. This study reports the largest case series of pediatric patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy surgery at one institution.Patient and Methods: The University of California, San Diego, chronic thromboembolic pulmonary hypertension database identified patients 18 years or younger at the time of pulmonary thromboendarterectomy surgery (n = 17). Medical charts were reviewed for hemodynamics, thromboembolic risk factors, and postoperative outcomes.Results: Pulmonary thromboendarterectomy surgery in pediatric patients resulted in improved functional status and significantly improved cardiopulmonary hemodynamics: mean arterial pressure decreased from 45.5 mm Hg ± 20.7 to 27.3 ± 13.0 mm Hg (P = .00073), pulmonary vascular resistance decreased from 929 ± dynes · s · cm−5 to 299 ± 307 dynes · s · cm−5 (P = .0012), and cardiac output improved from 3.8 ± 1.1 L/min to 5.6 ± 1.6 L/min (P = .0061). There were no deaths during surgery or 30 days after surgery, and long-term survival (5+ years) was achieved in 87.5%. As compared to adults with chronic thromboembolic pulmonary hypertension, there was a higher rate of rethrombosis in pediatric patients (38% vs 1%–4%).Conclusions: This study demonstrates that pulmonary thromboendarterectomy surgery in pediatric patients with chronic thromboembolic pulmonary hypertension is well tolerated with improved postoperative hemodynamics, functional status, minimal postoperative complications, and low perioperative mortality, similar to that reported for adults with chronic thromboembolic pulmonary hypertension, with the notable exception being a higher rate of rethrombosis in pediatric patients.

One single dose of histidine–tryptophan–ketoglutarate solution gives equally good myocardial protection in elective mitral valve surgery as repetitive cold blood cardioplegia: A prospective randomized study - Corrected Proof

2010-08-30

Objectives: Histidine-tryptophan-ketoglutarate (HTK–Custodiol) cardioplegic solution is administered as one single dose for more than 2 hours of ischemia. No prospective randomized clinical study has compared the effects of HTK and cold blood cardioplegia on myocardial damage in elective mitral valve surgery. Thus, the main aim of the present study was to examine whether one single dose of cold antegrade HTK gives as good myocardial protection as repetitive antegrade cold blood cardioplegia in mitral valve surgery.Methods: Eighty consecutive patients undergoing elective isolated mitral valve surgery for mitral regurgitation, with or without ablation for atrial fibrillation, were included in the study and randomized to HTK or blood cardioplegia. Markers of myocardial injury (troponin-T and creatine kinase MB) were analyzed at baseline and 7 hours, 1 day, 2 days, and 3 days after surgery.Results: No significant difference in creatine kinase MB and troponin-T between HTK and blood cardioplegia groups was found at any time point. There was a significant correlation between ischemic time and markers of myocardial injury in the HTK group only and significantly more spontaneous ventricular fibrillation after release of crossclamping in the HTK group.Conclusions: One single dose of antegrade cold HTK cardioplegic solution in elective mitral valve surgery protects the myocardium equally good as repetitive antegrade cold blood cardioplegia.

A combined procedure of thoracoabdominal aortic aneurysm repair and coronary artery bypass grafting: Report of two cases - Corrected Proof

Saina Attaran, Mark Field, Manoj Kuduvalli, Aung Oo — 2010-08-30

The prevalence of coronary artery disease in patients with aneurysm of the aorta is 40% to 60%. Coronary artery disease is a significant predictor of early mortality after aneurysm repair. Therefore, coronary artery revascularization before the repair of aneurysms is recommended but carries a 10% risk of perioperative aneurysm rupture. Moreover, a 2-staged approach will leave the patient with 2 scars, twice the hospitalizations, and an increase in interval delays.

Cardiotomy suction, but not open venous reservoirs, activates coagulofibrinolysis in coronary artery surgery - Corrected Proof

2010-08-30

Objectives: Closed and miniaturized cardiopulmonary bypass circuits, which eliminate cardiotomy suction and open venous reservoirs with a reduced priming volume, have been reported to be advantageous. We comparatively examined the respective contribution of cardiotomy suction and open venous reservoirs to perioperative activation in coagulofibrinolysis and inflammation systems, with identical conditions of priming volume and anticoagulation.Methods: A total of 75 consecutive coronary artery bypass grafting procedures were performed using 1 of the following 3 cardiopulmonary bypass circuits under identical conditions of priming volumes, heparin coating, and protocols of anticoagulation and transfusion, as follows: a circuit with an open venous reservoir and cardiotomy suction (open group, n = 25), a circuit with an open venous reservoir without cardiotomy suction (nonsuction group, n = 25), or a circuit without either (closed group, n = 25). Blood samples were collected at 8 points up to the first postoperative morning.Results: The thrombin-antithrombin III complex, fibrinogen degeneration products, D-dimer, plasmin-α2 plasmin inhibitor complex, and plasminogen activator inhibitor-1 levels were significantly greater in the open group than those in the other 2 groups (P < .0001, for all markers). The C3a and interleukin-6 levels were similar among all the groups. The incidences of perioperative transfusion and postoperative bleeding were increased and the early graft patency rate of saphenous veins was lower in the open group than those in the other 2 groups.Conclusions: Cardiotomy suction, but not open venous reservoirs, causes perioperative coagulofibrinolysis activation, although neither affects the inflammation system. The use of cardiotomy suction needs to be examined further in association with postoperative PAI-1 elevation and early vein graft occlusion.

The “thymopericardial fat flap”: A versatile flap in thoracic and cardiovascular surgery - Corrected Proof

Alain Wurtz, Francis Juthier, Massimo Conti, André Vincentelli — 2010-08-23

Major tracheal reconstructive surgery requires a flap to reinforce the suture line and prevent erosion of contiguous large vessels. Omentoplasty, myoplasty, or flaps with a blood supply arising from the branches of the internal thoracic (IT) artery such as the “pericardial fat graft” or the “thymus flap” can be used. We describe the “thymopericardial fat flap” (TPF), which includes the IT pedicle, overlying mediastinal pleura, homolateral thymic lobe, and continuous pericardial fat tissue.

Sutureless replacement of aortic valves with St Jude Medical mechanical valve prostheses and Nitinol attachment rings: Feasibility in long-term (90-day) pig experiments - Corrected Proof

2010-08-23

Objective: Nitinol attachment rings (devices) used to attach mechanical aortic valve prostheses suturelessly were studied in long-term (90 days) pig experiments.Methods: The aortic valve was removed and replaced by a device around a St Jude Medical mechanical valve prosthesis in 10 surviving pigs. Supravalvular angiography was done at the end of the operation. No coumarin derivates were given.Results: No or minimal aortic regurgitation was confirmed in all surviving pigs at the end of the operation. Total follow-up was 846 days. In 4 pigs, follow-up was shorter than 90 days (28–75 days); the other 6 pigs did reach 90 days' survival or more. Repeat angiography in 4 pigs at the end of follow-up confirmed the unchanged position of the device at the aortic annulus, without aortic regurgitation. At autopsy, in all pigs the devices proved to be well grown in at the annulus, covered with endothelium, and sometimes tissue overgrowth related to not using coumarin derivates. There was no case of para-device leakage, migration, or embolization. No damage to surrounding anatomic structures or prosthetic valves was found.Conclusions: Nitinol attachment rings can be used to replace the aortic valve suturelessly with St Jude Medical mechanical aortic valve prostheses, without para-device leakage, migration, or damage to the surrounding tissues, in long-term pig experiments during a follow-up of 90 days or more. Refraining from anticoagulation in pigs with mechanical valve prostheses can lead to tissue overgrowth of the valve prosthesis. Further studies are needed to determine long-term feasibility of this method in human beings.

Aortic dissection caused by aortitis associated with hepatitis C virus–related cryoglobulinemia - Corrected Proof

Naoto Fukunaga, Hiroshi Fujiwara, Michihiro Nasu, Yukikatsu Okada — 2010-08-23

Cryoglobulinemia can generally cause systemic vasculitis to small and medium-sized vessels, not to great vessels, resulting in neuropathy, renal impairment, and coagulopathy. To our knowledge, this is the first description of acute aortic dissection caused by aortitis associated with hepatitis C virus–related cryoglobulinemia.

Intravenous omega-3, a technique to prevent an excessive innate immune response to cardiac surgery in a rodent gut ischemia model - Corrected Proof

John Byrne, Jonathan McGuinness, Gang Chen, Arnold D.K. Hill, Mark J. Redmond — 2010-08-16

Objectives: Neutrophil infiltration of tissues as part of the inflammatory response to cardiac surgery is one of the major mediators of postoperative multiple-organ dysfunction. Omega-3 fatty acids markedly attenuate endothelial cell inflammatory responses, including upregulation of neutrophil adhesion molecules. The efficacy of a clinically safe form of omega-3 to produce this effect in vivo was examined.Methods: Rat gut intravital microscopic analysis was used to visualize neutrophil transmigration from the microcirculation into the tissues of the gut. Inflammatory activation was in the form of 30 minutes of ischemia and 90 minutes of reperfusion. Sham, control (0.9% saline infusion over 4 hours), and omega-3 (Omegaven [Fresenius Kabi, Bad Homburg, Germany] infusion over 4 hours) pretreatments were compared.Results: Ischemia–reperfusion resulted in a 4-fold increase in neutrophil adherence to the endothelium (baseline: 4.3 ± 0.2 vs control group: 19.2 ± 3.5 adherent neutrophils per 100 μm, P < .01), which intravenous omega-3 suppressed (7.8 ± 1.7 adherent neutrophils per 100 μm, P < .01). Omega-3 pretreatment also reduced neutrophil transmigration into the tissues after reperfusion (sham group: 6.3 ± 0.8 vs control group: 13.2 ± 1.4 vs omega-3 group: 9.4 ± 0.9 neutrophils per field, P = .037). Gut tissue levels of the neutrophil-released enzyme myeloperoxidase were similarly markedly reduced with omega-3 pretreatment (sham group: 10.5 ± 1.6 vs control group: 19.0 ± 3.3 vs omega-3 group: 10.1 ± 1.2 U/g, P = .03).Conclusions: Four hours' pretreatment with a relatively safe form of intravenous omega-3 suppressed neutrophil adherence and tissue infiltration, resulting in lower levels of the tissue-damaging enzyme myeloperoxidase. This suggests a possible strategy for diminishing postoperative multiple-organ dysfunction.

Pulsed ultrasounds accelerate healing of rib fractures in an experimental animal model: An effective new thoracic therapy? - Corrected Proof

2010-08-16

Objectives: Rib fractures are a frequent traumatic injury associated with a relatively high morbidity. Currently, the treatment of rib fractures is symptomatic. Since it has been reported that pulsed ultrasounds accelerates repair of limb fractures, we hypothesized that the application of pulsed ultrasounds will modify the course of healing in an animal model of rib fracture.Methods: We studied 136 male Sprague–Dawley rats. Animals were randomly assigned to different groups of doses (none, 50, 100, and 250 mW/cm2 of intensity for 3 minutes per day) and durations (2, 10, 20, and 28 days) of treatment with pulsed ultrasounds. In every subgroup, we analyzed radiologic and histologic changes in the bone callus. In addition, we examined changes in gene expression of relevant genes involved in wound repair in both control and treated animals.Results: Histologic and radiologic consolidation was significantly increased by pulsed ultrasound treatment when applied for more than 10 days. The application of 50 mW/cm2 was the most effective dose. Only the 100 and 250 mW/cm2 doses were able to significantly increase messenger RNA expression of insulin-like growth factor 1, suppressor of cytokine signaling-2 and -3, and vascular endothelial growth factor and decrease monocyte chemoattractant protein-1 and collagen type II-alpha 1.Conclusions: Our findings indicate that pulsed ultrasound accelerates the consolidation of rib fractures. This study is the first to show that pulsed ultrasound promotes the healing of rib fractures. From a translational point of view, this easy, cheap technique could serve as an effective new therapeutic modality in patients with rib fractures.

Tumor angiogenesis in predicting the survival of patients with stage I lung cancer - Corrected Proof

2010-08-16

Objective: The effects of angiogenesis on survival were assessed by measuring the tumor microvessel density and vascular endothelial growth factor expression in patients with resected stage I non–small cell lung carcinoma.Methods: The study population included 141 patients who underwent complete resection for stage pT1 and T2 N0 M0 tumors between 1999 and 2007. Lobectomy and pneumonectomy were performed in 131 and 10 patients, respectively. Tumor specimens were analyzed immunohistochemically for staining with anti-CD105 antibody to determine tumor microvessel density and anti–vascular endothelial growth factor antibody to determine the vascular endothelial growth factor expression level. Univariate and multivariate analyses were performed for factors influencing patients' survival.Results: The overall 5-year survival was calculated as 68%, with rates of 76.9% for patients with T1 disease and 66.2% for patients with T2 disease (P = .4). The vascular endothelial growth factor expression rate was 94.3% for patients with stage I non–small cell lung carcinoma. Vascular endothelial growth factor expression did not influence survival (P = .9). The median microvessel density of the tumors measured based on the level of CD105 expression was 19.8. The effect of microvessel density on survival was significant (P = .02). The 5-year survivals of patients with tumors with 20 or more microvessels and less than 20 microvessels were 76.8% and 56.1%, respectively; this difference was highly significant (P = .004). The microvessel density was determined as an independent factor influencing survival on multivariate analysis (P = .03).Conclusion: The level of vascular endothelial growth factor expression in tumors was not a successful predictor of survival in patients with resected stage I non–small cell lung carcinoma. A high microvessel density based on CD105 is a strong predictor of prognosis in these patients.

Heparinized cardiopulmonary bypass circuits and low systemic anticoagulation: An analysis of nearly 6000 patients undergoing coronary artery bypass grafting - Corrected Proof

2010-08-16

Objective: Heparin coating of cardiopulmonary bypass circuits reduces the inflammatory response and increases the thromboresistance during extracorporeal circulation. These properties enables a lower systemic heparin dose, which has been shown to reduce the need for blood transfusions. Experience with this technique accumulated over 11 years has been analyzed.Methods: All patients underwent on-pump coronary artery bypass grafting with heparin-coated circuits. Apart from some patients receiving a high intraoperative dose of aprotinin, the systemic heparin dose was reduced, with a lower level of an activated clotting time of 250 seconds during extracorporeal circulation. The overall strategy aimed at a fast-track regimen, with early extubation, minimal use of blood transfusions, and rapid postoperative recovery.Results: Altogether, 5954 patients were included; 1131 (19.0%) were female (median age, 70 years), and 4823 were male (median age, 65 years). The median additive EuroSCORE was 3 (range, 0–14; mean 3.5 ± 2.5). No significant signs of clotting were seen in any part of the extracorporeal circuit. Bank blood products were given to 427 (7.2%) patients. Median extubation time was 1.7 hours. The stroke rate was 1.0%, transient neurologic deficits occurred in 0.7%, and perioperative myocardial infarction occurred in 1.2%. On the fifth day, 88.1% of the patients were physically rehabilitated and ready for discharge. Thirty-day mortality was 0.9% (54 patients).Conclusions: The experience with this patient cohort including mostly low- to medium-risk patients with a relatively short cardiopulmonary bypass time indicates that coronary artery bypass grafting performed with heparin-coated circuits and reduced level of systemic heparinization is safe and results in a very satisfactory clinical course. No signs of clotting or other technical incidents were recorded.

Outcomes of 1½- or 2-ventricle conversion for patients initially treated with single-ventricle palliation - Corrected Proof

2010-08-16

Objective: As outcomes for the Fontan procedure have improved, it has become more difficult to select between a single-ventricle repair or biventricular repair for patients with complex anatomy and 2 ventricles. However, late complications after the Fontan procedure remain a concern. Our strategy, which has favored an aggressive preferential approach for biventricular repair in these patients, has also been applied to patients initially treated on a single-ventricle track elsewhere.Methods: Nine patients (4 male patients) who had previously undergone the Fontan procedure (n = 3) or bidirectional cavopulmonary shunting (n = 6) with intent for a later Fontan procedure were referred to our center for complex 1½- or 2-ventricle repair over the last 10 years. Indications for conversion in these patients were protein-losing enteropathy (n = 2), pulmonary arteriovenous malformation (n = 1), and preference for biventricular anatomy (n = 6). The conversion mainly consisted of takedown of the Fontan procedure or bidirectional cavopulmonary shunt connection, reconstruction of 1 or both of venae cavae, creation of an intraventricular pathway for left ventricular output, and placement of a right ventricle–pulmonary artery conduit (Rastelli-type operation).Results: Five patients underwent 1½-ventricle repair, and 4 had complete biventricular repair. Median cardiopulmonary bypass and aortic crossclamp times were 202 minutes (range, 169–352 minutes) and 129 minutes (range, 100–168 minutes), respectively. There were 2 early deaths and 1 late death. At a median follow-up of 27 months (range, 3.3–99.8 months), all survivors are in New York Heart Association class I.Conclusions: Patients initially treated with intent to perform single-ventricle palliation can be converted to 1½- or 2-ventricle physiology with acceptable outcomes.

Echocardiographically based treatment of chronic ischemic mitral regurgitation - Corrected Proof

2010-08-16

Objectives: We evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation.Methods: From March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm2, and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42.Results: Thirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm2 to 2.3 ± 0.4 mm2 (P < .001). Nine patients showed residual effective regurgitant orifice 10 to 19 mm2. Reverse remodeling was present in 69 patients (59.0%), no remodeling in 40 (34.1%), and continuous remodeling in 8 (6.9%). Ejection fraction changed from 37% ± 10% to 43% ± 10% (P <.001), improving in 47, remaining unchanged in 63, and worsening in 7.Conclusions: Echocardiographically based strategy contributed to reduced postoperative mitral regurgitation persistence (effective regurgitant orifice ≥10 mm2 in 7.7% of cases, with no patients showing effective regurgitant orifice ≥20 mm2). All patients remained in New York Heart Association functional class I or II, but more than mitral annuloplasty was performed in close to 40%.

Mitroflow pericardial aortic bioprosthesis in patients younger than 60 years - Corrected Proof

Charles A. Yankah — 2010-08-16

To date, the longest durability of pericardial aortic valves was found in 49- and 70-year-old patients in series reported by my colleagues and me, with explantation and death as end points: 22 and 22.75 years, respectively.

Role of biofilm in Staphylococcus aureus and Staphylococcus epidermidis ventricular assist device driveline infections - Corrected Proof

Faustino A. Toba, Hirokazu Akashi, Carlos Arrecubieta, Franklin D. Lowy — 2010-08-16

Objective: Infections, especially those involving drivelines, are among the most serious complications that follow ventricular assist device implantation. Staphylococci are the most common causes of these infections. Once driveline infections are established, they can remain localized or progress as an ascending infection to cause metastatic seeding of other tissue sites. Although elaboration of biofilm appears to be critical in prosthetic device infections, its role as a facilitator of staphylococcal infection and migration along the driveline and other prosthetic devices is unclear.Methods: A murine model of driveline infection was used to investigate staphylococcal migration along the driveline. A biofilm-producing strain of Staphylococcus epidermidis and a Staphylococcus aureus strain and its intercellular adhesion gene cluster (ica)–negative (biofilm-deficient) isogenic mutant were used in these studies. Bacterial density on the driveline and the underlying tissue was measured over time. Scanning electron microscopy was used to examine the morphology of S epidermidis biofilm formation as the infection progressed.Results: The biofilm-deficient S aureus mutant was less effective at infecting and migrating along the driveline than the wild-type strain over time. However, the ica mutation had no effect on the ability of the strain to infect underlying tissue. S aureus exhibited more rapid migration than S epidermidis. Scanning electron microscopy revealed the deposition of host matrix on the Dacron material after implantation. This was followed by elaboration of a bacterial biofilm that correlated with more rapid migration along the driveline.Conclusions: Biofilm formation is a critical virulence determinant that facilitates the progression of drivelines infections.

Infections occurring during extracorporeal membrane oxygenation use in adult patients - Corrected Proof

2010-08-16

Objective: The application of extracorporeal membrane oxygenation in adults has been increasing, but infections occurring during extracorporeal membrane oxygenation use are rarely described.Methods: We retrospectively analyzed the prospectively collected data on nosocomial infection surveillance of 334 patients aged 16 years or more undergoing their first extracorporeal membrane oxygenation for more than 48 hours at a university hospital from 1996 to 2007 for respiratory (20.4%) and cardiac (79.6%) support.Results: During a total of 2559 extracorporeal membrane oxygenation days, 55 episodes of infections occurred in 45 patients (13.5%), including 38 bloodstream (14.85 per 1000 extracorporeal membrane oxygenation days), 6 surgical site, 4 respiratory tract, 3 urinary tract, and 4 other infections. Stenotrophomonas maltophilia (16.7%) and Candida species (14.6%) were the predominant blood isolates. In stepwise logistic regression analysis, longer duration of extracorporeal membrane oxygenation use (odds ratio 1.003; 95% confidence interval, 1.001–1.005; P = .004), mechanical complications (odds ratio, 4.849; 95% confidence interval, 1.569–14.991; P = .006), autoimmune disease (odds ratio, 6.997; 95% confidence interval, 1.541–31.766; P = .012), and venovenous mode (odds ratio, 4.473; 95% confidence interval, 1.001–19.977; P = .050) were independently associated with a higher risk for infections during extracorporeal membrane oxygenation use. Overall in-hospital mortality was 68.3%, and its independent risk factors included older age (odds ratio, 1.037; 95% confidence interval, 1.021–1.054; P < .001), neurologic complications (odds ratio, 51.153; 95% confidence interval, 6.773–386.329; P < .001), and vascular complications (odds ratio, 1.922; 95% confidence interval, 1.112–3.320; P < .001), but not infections during extracorporeal membrane oxygenation use.Conclusions: Bloodstream infection was the most common infection during extracorporeal membrane oxygenation use. Duration of extracorporeal membrane oxygenation, mechanical complications, autoimmune disease, and venovenous mode seemed to be independently associated with infections.

Covered stents for the treatment of life-threatening cervical esophageal anastomotic leaks - Corrected Proof

Amitabh Chak, Rohit Singh, Philip A. Linden — 2010-08-16

Esophagectomy with a cervical anastomosis is associated with a leak rate of approximately 10% to 20%. These leaks are usually managed by drainage and are allowed to heal over several days to weeks. Rarely, a cervical anastomotic leak may drain into the chest and cause a life-threatening infection. In such instances, repair of the leak is often not possible, and takedown of the gastric conduit is necessary. After several weeks to months of recovery, reoperation is required to restore gastrointestinal continuity. Restoration of gastrointestinal continuity generally requires a major reoperation rerouting the gastric conduit through the left side of the chest or use of a colon interposition. We describe the use of a temporary fully covered silastic expandable metallic esophageal stent to treat cervical leaks that otherwise would have required takedown of the conduit.

Thyroid storm after coronary artery bypass grafting - Corrected Proof

Lawrence T. Bish, Joseph E. Bavaria, John Augoustides — 2010-08-09

We describe a 45-year-old woman with thyroid storm developing after urgent coronary artery bypass grafting (CABG). The hallmark clinical features included fever, tachycardia, depressed mental status, and jaundice. Thyroid testing confirmed severe hyperthyroidism caused by Graves disease. The patient was rendered euthyroid after initiation of therapy with methimazole (INN, thiamazole), potassium iodide, and hydrocortisone.

The use of ventricular assist devices in pediatric patients with univentricular hearts - Corrected Proof

Christina J. VanderPluym, Ivan M. Rebeyka, David B. Ross, Holger Buchholz — 2010-08-09

Improved survival outcomes for pediatric patients with ventricular assist devices (VADs) has expanded their application to complex univentricular cardiac lesions, including patients with systemic-to-pulmonary shunts, bidirectional cavopulmonary anastomoses (BCPAs), and total cavopulmonary Fontan circulations. Although it is generally recognized that complex cardiac anatomy is likely a significant risk factor affecting VAD survival, there remains a paucity of data examining the pediatric VAD experience with univentricular hearts.

Risk model of in-hospital mortality after pulmonary resection for cancer: A national database of the French Society of Thoracic and Cardiovascular Surgery (Epithor) - Corrected Proof

2010-08-09

Objectives: The estimation of risk-adjusted in-hospital mortality is essential to allow each thoracic surgery team to be compared with national benchmarks. The objective of this study is to develop and validate a risk model of mortality after pulmonary resection.Methods: A total of 18,049 lung resections for non–small cell lung cancer were entered into the French national database Epithor. The primary outcome was in-hospital mortality. Two independent analyses were performed with comorbidity variables. The first analysis included variables as independent predictive binary comorbidities (model 1). The second analysis included the number of comorbidities per patient (model 2).Results: In model 1 predictors for mortality were age, sex, American Society of Anesthesiologists score, performance status, forced expiratory volume (as a percentage), body mass index (in kilograms per meter squared), side, type of lung resection,extended resection, stage, chronic bronchitis, cardiac arrhythmia, coronary artery disease, congestive heart failure, alcoholism, history of malignant disease, and prior thoracic surgery. In model 2 predictors were age, sex, American Society of Anesthesiologists score, performance status, forced expiratory volume, body mass index, side, type of lung resection, extended resection, stage, and number of comorbidities per patient. Models 1 and 2 were well calibrated, with a slope correction factor of 0.96 and of 0.972, respectively. The area under the receiver operating characteristic curve was 0.784 (95% confidence interval, 0.76–0.8) in model 1 and 0.78 (95% confidence interval, 0.76–0.797) in model 2.Conclusions: Our preference is for the well-calibrated model 2 because it is easier to use in practice to estimate the adjusted postoperative mortality of lung resections for cancer.

A simplified technique of full-thickness transabdominal laparoscopic repair of Morgagni hernia - Corrected Proof

Rajeev Pathak Misra, Jess Schwartz — 2010-08-09

Morgagni hernia (MH) represents less than 5% of all congenital diaphragmatic hernias. In adults, MH is usually symptomatic, with common symptoms, including pain in the chest or abdomen, obstruction, dysphagia, and rarely gastroesophageal reflux disease or bleeding. Predisposing conditions, such as chronic cough, constipation, trauma, pregnancy, and obesity, can contribute to the likelihood of symptomatic presentation. Repairs traditionally have been via laparotomy or thoracotomy; however, new technology has resulted in novel techniques for repair being reported, including thoracoscopic, laparoscopic, and even robotic repairs. Various strategies to deal with the hernia sac and close the defect have been described, and no consensus exists on whether to resect the sac or use prosthetic mesh. We report our experience of laparoscopic MH repair using a simple technique of transabdominal wall suturing without the use of prosthetic mesh in 2 adult patients.

Predictive value of preoperative tissue Doppler echocardiographic analysis for postoperative atrial fibrillation after pulmonary resection for lung cancer - Corrected Proof

2010-08-09

Objective: The objective of the present study was to evaluate the utility of tissue Doppler imaging for predicting the development of postoperative atrial fibrillation.Methods: In this prospective observational study, we evaluated 126 patients with lung cancer who underwent a lobectomy during the 18-month period from August 2007 to January 2009. Preoperative evaluations for all patients included tissue Doppler imaging in addition to conventional echocardiographic analysis. The study end point was the development of postoperative atrial fibrillation.Results: Postoperative atrial fibrillation was identified in 29 (23%) patients, in whom significantly higher early transmitral velocity/tissue Doppler mitral annular early diastolic velocity values were noted compared with those seen in patients without atrial fibrillation (9.76 ± 2.3 vs 7.14 ± 1.7, P < .0001). The area under the receiver operating characteristic curve for early transmitral velocity/tissue Doppler mitral annular early diastolic velocity to predict postoperative atrial fibrillation after pulmonary resection for lung cancer was 0.83 (95% confidence interval, 0.74–0.92; P < .001). An early transmitral velocity/tissue Doppler mitral annular early diastolic velocity value of greater than 8 had a sensitivity of 90% and a specificity of 73% for predicting postoperative atrial fibrillation.Conclusions: Postoperative atrial fibrillation after pulmonary resection might be associated with left ventricular diastolic dysfunction before surgical intervention revealed by using tissue Doppler imaging. Additional studies to establish the significance of tissue Doppler imaging as a tool to predict postoperative atrial fibrillation could contribute to improvements in lung cancer treatments.

Salvage surgery for advanced non–small cell lung cancer after response to gefitinib - Corrected Proof

2010-08-05

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (EGFR-TKI) gefitinib has dramatic efficacy in more than 70% of advanced non–small cell lung cancers with EGFR gene mutations. Some patients with inoperable systemic non–small cell lung cancers demonstrate a downstaging of their cancer to operable disease status after gefitinib treatment. Despite high response rates for EGFR mutant tumors, the median time to progression is about 1 year. The EGFR T790M mutation and MET amplification are thought to be the underlying mechanisms of the acquired resistance to EGFR-TKIs. When complete resection of residual disease is possible, the patients can then be considered disease free. We have aggressively performed salvage lung resections for patients with gefitinib responses and demonstrated downstaging to N0M0. The purpose of this study was to assess the perioperative safety and survival benefit of these salvage lung resections.

Pulmonary valve replacement in repaired tetralogy of Fallot by left thoracotomy avoid ascending aorta injury - Corrected Proof

Roland Henaine, Naoki Yoshimura, Sylvie Di Filippo, Jean Ninet — 2010-08-05

We report the follow-up of a patient born with tetralogy of Fallot (TOF), which was corrected in childhood, who required when he was 28-years-old a pulmonary valve replacement (PVR) through a left anterolateral thoracotomy. This case demonstrates the advantages of this approach of simplicity and low risks of aortic lesions in particular.

Sutureless aortic valve replacement with the Trilogy Aortic Valve System: Multicenter experience - Corrected Proof

2010-08-05

Objective: To evaluate the modular sutureless Arbor Trilogy Aortic Valve System (Arbor Surgical Technologies, Irvine, Calif), designed for minimally invasive aortic valve replacement.Methods: In a prospective multicenter study, 32 patients with severe aortic valve stenosis underwent aortic valve replacement with the Trilogy valve between 2006 and 2008. Concomitant coronary artery bypass grafting was performed in 6 patients. Transthoracic echocardiography was performed at baseline, at discharge, at 4 to 6 months, at 11 to 14 months, and annually thereafter.Results: Valve implantation was successful in 30 patients. The procedure was converted to conventional aortic valve replacement in 2 patients. Mean bypass time was 111 ± 42 minutes, and crossclamp time was 70 ± 23 minutes. Valve implantation took 21 ± 7 minutes. The transvalvular gradients at discharge were 10 ± 3 mm Hg (mean) and 20 ± 7 mm Hg (peak), and the effective orifice area was 1.9 ± 0.4 cm2. At 2-year follow-up, gradients were 7 ± 3 mm Hg (mean) and 14 ± 4 mm Hg (peak), and the effective orifice area was 1.9 ± 0.3 cm2. There was no intraoperative mortality: Two patients died of causes unrelated to the valve during follow-up. One redo aortic valve replacement was performed at 22 months for prosthetic valve endocarditis.Conclusions: Sutureless aortic valve replacement is feasible and safe with the Trilogy System. After an initial learning curve, the modular valve design allows a more rapid and simple implantation compared with conventional stented tissue valves. The simplicity may also facilitate a greater adoption of minimally invasive aortic valve replacement by a broader spectrum of surgeons.

Surgical pitfalls of excising an intramyocardial lipoma - Corrected Proof

Abdallah K. Alameddine, Victor K. Alimov, George S. Turner, David W. Deaton — 2010-08-05

This report highlights an extremely rare right atrial intramyocardial lipoma (RAIL) with surgically significant morphologic features in a transgender male patient. The tumor mass was generally encapsulated; however, the absence of a clear delineation between the tumor and the adjacent coronary artery led to an intraoperative reversible myocardial ischemia during surgical dissection. Furthermore, the tumor had a bosselated “diverticulum-like” inner cavity lined by myocardium, identifying it as a truly intramyocardial lipoma.

Aortic dissection and rupture in adolescents after tetralogy of Fallot repair - Corrected Proof

Igor E. Konstantinov, Tyson A. Fricke, Yves d'Udekem, Terry Robertson — 2010-08-05

Aortic dissection in children and adolescents is rare, yet it is associated with high mortality. A recent article describing 13 patients with aortic dissections operated between 1970 and 2000 reported an operative mortality of 38%. Progressive aortic root dilatation is a recognized feature of tetralogy of Fallot (TOF) and generally managed conservatively. However, 2 recent reports of aortic dissection in patients with aortic aneurysm after TOF repair together with the case presented reemphasize the fact that aortic root dilatation must be monitored closely in patients with TOF.

Selective antegrade cerebral perfusion during aortic arch surgery confers survival and neuroprotective advantages - Corrected Proof

2010-08-05

Objective: To assess the impact of using antegrade cerebral perfusion during aortic arch surgery on postoperative survival and neurologic outcomes.Methods: All operations were performed at the same hospital between January 2001 and January 2009. Patients undergoing aortic arch surgery using antegrade cerebral perfusion during deep hypothermia were compared with patients undergoing aortic arch surgery without antegrade cerebral perfusion during the same study period. Multivariable logistic regression and Cox proportional hazards model were used to identify predictors of postoperative cerebrovascular accidents and midterm survival, respectively. There were 46 patients in the antegrade cerebral perfusion group and 78 patients in the non-antegrade cerebral perfusion group.Results: There were no statistically significant differences in age, proportion of emergency operations, or proportion of type A aortic dissection between the 2 groups. There was a statistically significant and clinically important difference in the rates of postoperative cerebrovascular complications (2% antegrade cerebral perfusion vs 13% non-antegrade cerebral perfusion, P = .03), postoperative duration of mechanical ventilation (1.15 ± 0.19 days antegrade cerebral perfusion vs 2.13 ± 0.38 days non-antegrade cerebral perfusion, P = .02), and 3-year survival (93% antegrade cerebral perfusion vs 78% non-antegrade cerebral perfusion, P = .03). Antegrade cerebral perfusion was shown to be a significant predictor of reduced postoperative stroke rates and better survival at 3 years.Conclusion: Antegrade cerebral perfusion was associated with improved survival and neurologic outcomes in patients undergoing aortic arch surgery, especially for cases requiring prolonged aortic arch repair periods.

Fetal surgical management of congenital heart block in a hydropic fetus: Lessons learned from a clinical experience - Corrected Proof

2010-08-05

Congenital complete heart block (CHB) in the absence of cardiac malformations occurs in approximately 1 in 10,000 live births. It is the most serious fetal complication of maternal autoimmune disease, leading to antibody-mediated injury of the fetal atrioventricular node and resulting in fetal bradycardia and low output. Hydrops develops in up to 42% of these fetuses at 27.6 ± 5.1 weeks gestation and is associated with high mortality (>90%). Although resolution of hydrops can occur with sympathomimetic treatment, or even spontaneously, a permanent pacemaker is required in approximately 66% of cases, with placement immediately after birth. Although fetal pacing has been attempted, there are no reports of survival beyond the intraoperative period.

Composite reconstruction with cryopreserved fascia lata, single mandibular titanium plate, and polyglactin mesh after redo surgery and radiation therapy for recurrent chest wall liposarcoma - Corrected Proof

Gaetano Rocco, Flavio Fazioli, Rocco Cerra, Rosario Salvi — 2010-08-05

Repeated chest wall resections after irradiation often mandate individualized reconstructive strategies. We report a case of a simplified reconstruction with a combination of materials recently used by thoracic surgeons because of their favorable biologic characteristics and user friendliness during implantation.

Discussion - Corrected Proof

2010-08-05

Dr Nawwar Al-Attar (Paris, France). In the conclusion of your talk you described a faster implantation time, but when you showed us the crossclamping times, they had an average of 71 minutes. Does this compare favorably with what you do with conventional AVR or do you really see a gain in time?

Predictors for hemodynamic improvement with temporary pacing after pediatric cardiac surgery - Corrected Proof

2010-07-26

Objectives: Temporary epicardial pacing wires are commonly placed during pediatric cardiac surgery. Data are sparse on postoperative pacing in this population. The objective of this study was to determine the frequency of use and identify predictors for the use of temporary epicardial pacing wires.Methods: Perioperative data were prospectively collected on all patients who underwent cardiac surgery at our institution (n = 162).Results: A total of 117 (72%) patients had temporary epicardial pacing wires placed. Postoperatively, 23 (20%) of 117 patients had hemodynamic improvement with the use of temporary epicardial pacing wires. Indications for pacing were slow junctional rhythm (11/23 [48%]), junctional ectopic tachycardia (7/23 [31%]), pace termination of supraventricular tachycardia (3/23 [13%]) and atrial flutter (1/23 [4%]), and complete heart block (1/23 [4%]). By using univariate analysis, single-ventricle anatomy, heterotaxy, the Fontan procedure, use of circulatory arrest, intraoperative arrhythmia, pacing in the operating room, and use of vasoactive medications were predictors for hemodynamic improvement with the use of temporary epicardial pacing wires (P < .05). On multivariate analysis, the Fontan procedure, circulatory arrest, and intraoperative arrhythmias were independent predictors (P < .01). When excluding all patients with any of these 3 risk factors, only 2% were paced. Patients with clinically significant pacing had longer chest tube drainage (P < .01) and intensive care unit length of stay (P < .01). There were no complications associated with temporary epicardial pacing wires.Conclusions: The Fontan procedure, use of circulatory arrest, and intraoperative arrhythmias were associated with hemodynamic improvement with postoperative pacing and might represent indications for empiric intraoperative placement of temporary epicardial pacing wires. Patients without these risk factors were less likely to require pacing. Temporary epicardial pacing wires were safe and useful in the management of arrhythmias after pediatric cardiac surgery.

Protecting the aged heart during cardiac surgery: The potential benefits of del Nido cardioplegia - Corrected Proof

Stacy B. O'Blenes, Camille Hancock Friesen, Ahmad Ali, Susan Howlett — 2010-07-26

Objective: Aged hearts are more vulnerable than mature hearts to reperfusion injury during cardiac surgery because of altered cardiomyocyte Ca2+ homeostasis. Inasmuch as immature cardiomyocytes have similar properties, a specialized cardioplegic solution (del Nido cardioplegia) designed to protect children's hearts may also be beneficial for elderly patients. Our objective was to evaluate the ability of del Nido cardioplegic solution, containing lidocaine and less Ca2+ than our standard cardioplegic solution, to protect aged cardiomyocytes during cardioplegic arrest and reperfusion.Methods: We used our novel isolated cell model of cardioplegic arrest and reperfusion to compare the effect of del Nido cardioplegic solution with that of our standard cardioplegic solution on intracellular Ca2+ concentration, contractions, and membrane potential in cardiomyocytes from senescent rat hearts.Results: The incidence of spontaneous contractions during cardioplegic arrest was lower with del Nido cardioplegia (3/11 vs 9/11 cells; P < .05) than with standard cardioplegia, and contractions could not be induced by field stimulation of cardiomyocytes arrested with del Nido cardioplegia (0/11 vs 9/11 cells; P < .05). Intracellular diastolic Ca2+ levels were lower during arrest with del Nido cardioplegia (57.10 ± 3.06 vs 76.19 ± 3.45 nmol/L; P < .05). During early reperfusion, a potentially injurious rapid recovery of intracellular Ca2+ associated with hypercontraction in cardiomyocytes arrested with standard cardioplegic solution was avoided in cells treated with del Nido cardioplegia (81.42 ± 2.99 vs 103.15 ± 4.25 nM; P < .05).Conclusions: Del Nido cardioplegic solution has the potential to provide superior myocardial protection in senescent hearts by preventing electromechanical activity during cardioplegic arrest and Ca2+-induced hypercontraction during early reperfusion.

Aortic valve repair by cusp extension for rheumatic aortic insufficiency in children: Long-term results and impact of extension material - Corrected Proof

2010-07-26

Objective: Aortic valve repair has encouraging midterm results in selected patients. However, neither the long-term results of cusp extension nor the durability of different pericardial fixation techniques has been reported. Our goal was to address these issues.Methods: Seventy-eight children with severe rheumatic aortic regurgitation (mean age 12 ± 3.5 years) underwent aortic valve repair using cusp extension over a 15-year period, with fresh autologous pericardium in 53 (67.9%), glutaraldehyde-fixed bovine pericardium in 9 (11.5%), and PhotoFix bovine pericardium (Sorin CarboMedics, Milano, Italy) in 16 (20.5%). Fifty-seven children (73.1%) underwent concomitant mitral valve repair, and 8 children (10.3%) underwent tricuspid valve repair.Results: There was 1 operative death from left ventricular failure. During a median follow-up of 10.7 years (range 1 month to 16.4 years), 1 late death occurred and 15 patients (19.7%) required reoperation at a mean of 43 ± 33.7 months (range 1 month to 9 years), 9 within the autologous pericardium group (18%), 3 within the bovine pericardium group (33%), and 3 within the PhotoFix pericardium group (19%). Freedom from reoperation was 96% ± 2.3% at 1 year, 87.5% ± 3.9% at 5 years, 80.7% ± 4.9% at 10 years, and 75.3% ± 6% at 15 years, and was significantly decreased in the bovine pericardium group (P = .039). On multivariable analysis, greater age (hazard ratio 1.25, P < .001) and acute rheumatic carditis (hazard ratio 8.15, P = .001) at operation were significant predictors of reoperation.Conclusions: Aortic cusp extension provides adequate valve repair in a large proportion of children with rheumatic aortic regurgitation. Fresh autologous and PhotoFix pericardium trended toward better durability than glutaraldehyde-fixed bovine pericardium.

Norwood procedure using modified Blalock–Taussig shunt: Beware of the circle of Willis - Corrected Proof

Selma O. Algra, Floris Groenendaal, Ton Schouten, Felix Haas — 2010-07-26

Neonates undergoing complex cardiac surgery are at high risk of developing cerebral damage. In the past decades, surgical and cardiopulmonary bypass strategies have been modified to improve neurodevelopmental outcome. One example is the introduction of antegrade cerebral perfusion (ACP) during aortic arch repair, instead of deep hypothermic circulatory arrest. Although it is not yet known whether this indeed is a superior strategy, ACP is now widely used in congenital heart surgery. This case report shows that when ACP is performed, cerebral near-infrared spectroscopy (NIRS) can provide important information about the circle of Willis, which may influence the surgical strategy.

Tissue-derived proinflammatory effect of adenosine A2B receptor in lung ischemia–reperfusion injury - Corrected Proof

2010-07-26

Objective: Ischemia–reperfusion injury after lung transplantation remains a major source of morbidity and mortality. Adenosine receptors have been implicated in both pro- and anti-inflammatory roles in ischemia–reperfusion injury. This study tests the hypothesis that the adenosine A2B receptor exacerbates the proinflammatory response to lung ischemia–reperfusion injury.Methods: An in vivo left lung hilar clamp model of ischemia–reperfusion was used in wild-type C57BL6 and adenosine A2B receptor knockout mice, and in chimeras created by bone marrow transplantation between wild-type and adenosine A2B receptor knockout mice. Mice underwent sham surgery or lung ischemia–reperfusion (1 hour ischemia and 2 hours reperfusion). At the end of reperfusion, lung function was assessed using an isolated buffer-perfused lung system. Lung inflammation was assessed by measuring proinflammatory cytokine levels in bronchoalveolar lavage fluid, and neutrophil infiltration was assessed via myeloperoxidase levels in lung tissue.Results: Compared with wild-type mice, lungs of adenosine A2B receptor knockout mice were significantly protected after ischemia–reperfusion, as evidenced by significantly reduced pulmonary artery pressure, increased lung compliance, decreased myeloperoxidase, and reduced proinflammatory cytokine levels (tumor necrosis factor-α; interleukin-6; keratinocyte chemoattractant; regulated on activation, normal T-cell expressed and secreted; and monocyte chemotactic protein-1). Adenosine A2B receptor knockout→adenosine A2B receptor knockout (donor→recipient) and wild-type→ adenosine A2B receptor knockout, but not adenosine A2B receptor knockout→wild-type, chimeras showed significantly improved lung function after ischemia–reperfusion.Conclusion: These results suggest that the adenosine A2B receptor plays an important role in mediating lung inflammation after ischemia–reperfusion by stimulating cytokine production and neutrophil chemotaxis. The proinflammatory effects of adenosine A2B receptor seem to be derived by adenosine A2B receptor activation primarily on resident pulmonary cells and not bone marrow-derived cells. Adenosine A2B receptor may provide a therapeutic target for prevention of ischemia–reperfusion-related graft dysfunction in lung transplant recipients.

Discussion - Corrected Proof

2010-07-26

Dr B. Stiles (New York, NY). Farshad, that was nicely presented. It is a good continuation of the work your group has done. I am a bit curious why you didn't use a sham experiment on the knockout mice. Or did you do that?

Discussion - Corrected Proof

2010-07-26

Dr Emile Bacha (New York, NY). Although retrospective, this is an important article for the following reasons: It comes from a center with a large experience with AV repair, thus having digested the learning curve. It reports on a homogeneous group of patients, all of whom had rheumatic fever. It focuses on patch material, something that hasn't been done really in the past series.

Dynamic effects of the Nuss procedure on the spine in asymmetric pectus excavatum - Corrected Proof

2010-07-22

Objective: This study aimed to elucidate dynamic effects of the Nuss procedure on the spine in the treatment of patients with pectus excavatum with asymmetric thoraces.Methods: Twenty-five patients with pectus excavatum who underwent the Nuss procedure were categorized into 4 groups by preoperative morphology of the spine and thoracic asymmetry. In group 1 (n = 8), the right side of the thorax was concave and the spine bowed to the right. In group 2 (n = 4), the right side of the thorax was concave and the spine bowed to the left. In group 3 (n = 5), the left side of the thorax was concave and the spine bowed to the right. In group 4 (n = 8), the left side of the thorax was concave and the spine bowed to the left. With computed tomographic data, finite-element models were produced to simulate each patient's thorax. Thereafter, dynamic response patterns of the spine to the Nuss procedure were examined. Validity of these biomechanical findings was verified by referring to clinical outcomes.Results: In group 1 and group 4 models, deformed spines were straightened; in group 2 and group 3 models, spinal bowing increased. These biomechanical findings were compatible with clinical evaluations.Conclusions: Performance of the Nuss procedure for asymmetric pectus excavatum exerts dynamic influence on the spine. Response patterns of the spine are predictable from morphologic relationships between the asymmetric patterns of the anterior thoracic wall and the spine.

Simple preoperative management for cold agglutinins before cardiac surgery - Corrected Proof

Shinji Kanemitsu, Koji Onoda, Kiyohito Yamamoto, Hideto Shimpo — 2010-07-22

Cold agglutinins (CAs) are of particular relevance in cardiac surgery because of the use of hypothermic cardiopulmonary bypass. CAs activate at varying levels of hypothermia and can cause catastrophic hemagglutination, microvascular thrombosis, or hemolysis. The detection of CAs before operation may change the management of cardiopulmonary bypass and myocardial protection. We describe here a case of aortic valve replacement in which CAs with high titer and high thermal amplitude were detected preoperatively.

Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta - Corrected Proof

2010-07-22

Objective: This study evaluated long-term results of thoracic endovascular aortic repair for atherosclerotic aneurysms involving descending aorta.Methods: One hundred thirteen patients underwent thoracic endovascular aortic repair for this indication from 1996 to 2009. Mean follow-up was 54 ± 38 months (5–144 months). In-hospital mortality, neurologic injury, need for rerouting, occurrence of endoleaks and their treatment, and survival were recorded.Results: In-hospital mortality was 5.3%. Transient neurologic injury rate was 2.6%. Previous rerouting was performed in 51%. Assisted early and late type I and III endoleak rates were 7.9% and 5.7%, respectively. Five percent of patients required late surgical conversion. Actuarial survivals were 86%, 60%, and 42% at 1, 5, and 10 years, respectively. Aorta-related actuarial survivals were 94%, 90%, and 83% at 1, 5, and 10 years, respectively. Cox regression analysis revealed higher number of prostheses as independent risk factor for early (hazard ratio, 5.38; 95% confidence interval, 1.68–42.37) and late (hazard ratio, 8.49; 95% confidence interval, 1.09–66.06) endoleak formation. Female sex (hazard ratio, 0.35; 95% confidence interval, 0.13–0.99), no arch involvement (hazard ratio, 0.21; 95% confidence interval, 0.05–0.08), and higher number of prostheses (hazard ratio, 7.95; 95% confidence interval, 1.36–46.58) affected survival.Conclusions: Aorta-related survival is excellent among patients undergoing thoracic endovascular aortic repair for atherosclerotic aneurysms involving the descending aorta. Life-long surveillance remains mandatory, with early and late failure uncommon but still needing consideration. Thoracic endovascular aortic repair in this group of patients remains attractive and has now proven durability.

Rehabilitation of pulmonary artery in congenital unilateral absence of intrapericardial pulmonary artery - Corrected Proof

2010-07-20

Objective: We evaluated the efficacy of the early rehabilitation of remnant pulmonary artery in unilateral absent intrapericardial pulmonary artery and the factors affecting pulmonary artery growth.Methods: We retrospectively reviewed the medical records and imaging modalities of 15 patients with unilateral absent intrapericardial pulmonary artery (7 left and 8 right; median age at diagnosis, 5 months) from 1991 to 2008.Results: The remnant pulmonary artery was found in 12 patients (mean diameter, 2.6 ± 0.7 mm) at the hilum. Eleven patients underwent operation (main pulmonary artery flap angioplasty in 5 patients; tube graft interposition in 6 patients), and 4 patients were inoperable. Transcatheter balloon angioplasty or stent implantation was required for the remaining pulmonary artery stenosis in 6 patients (55%). The last ipsilateral lung perfusion proportion at lung perfusion scan was 39% (range, 15%–51%), and the Z value of the last ipsilateral pulmonary artery diameter was −0.5 (range, 4.2 to 2). The patients with a smaller initial remnant pulmonary artery required more interventions (P = .003). The final perfusion proportion of affected lung was higher in the patients treated early (≤6 months, n = 7) than in those treated late (>6 months, n = 4) (41.9% ± 8.5% vs 24.9% ± 10.7%, respectively, P = .024). The patients with graft interposition showed a lower perfusion proportion of affected lung than those with main pulmonary artery flap angioplasty (P = .017).Conclusion: In patients with unilateral absent intrapericardial pulmonary artery, early and aggressive management of combined surgical reconstruction and transcatheter intervention improved pulmonary artery growth and lung perfusion.

A rare case of vascular ring: Retroesophageal artery between the right brachiocephalic artery and the left descending aorta - Corrected Proof

Yoshio Ootaki, Mohamed Sulaiman, Ross M. Ungerleider — 2010-07-20

A vascular ring is a congenital aortic arch anomaly that presents with tracheal and esophageal compression by vascular structures. Vascular rings have been classified according to embryologic, pathologic, and radiographic criteria. We describe a very rare vascular ring due to an abnormal retroesophageal artery in an infant.