ICVTS - Interactive Feed

Rerouting revascularization of the living right gastroepiploic artery graft in a patient with de novo gastric cancer [Coronary]

Yamamoto, Y., Ushijima, T., Kikuchi, Y., Watanabe, G. — Tue, 17 Nov 2009 00:48:42 PST

We present a case in which a redo patient in whom advanced gastric cancer was detected after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA), and in which re-grafting to the distal RGEA using the right internal thoracic artery (RITA) was performed. To minimize the surgical invasion before gastrectomy, we performed a thoracoscopic RITA harvest and small subxyphoid incision. A month later, distal gastrectomy was carried out and no complications occurred during the operation. Keywords: Coronary artery bypass grafting; Reoperation; Endoscopy/Endoscopic procedures

Infection after endoscopic ultrasound-guided aspiration of mediastinal cysts [Thoracic non-oncologic]

Diehl, D. L., Cheruvattath, R., Facktor, M. A., Go, B. D. — Mon, 16 Nov 2009 05:52:09 PST

Foregut duplication cysts are rare congenital anomalies of enteric origin that arise during early embryonic development. They are usually incidentally found on routine imaging studies. The diagnosis can usually be made by computed tomography (CT) and endoscopic ultrasound (EUS) appearance. On CT, cyst attenuation values usually measure 0±20 Hounsfield units (HU). Higher HU is possible with hemorrhage, proteinaceous material or septations. At EUS, characteristic location and anechoic as well as hypoechoic but not necessarily anechoic appearance may be suggestive of a foregut duplication cyst. EUS-guided fine needle aspiration (FNA) has been thought to provide a safe, minimally invasive approach to establish the diagnosis. The purpose of this report is to highlight the potential for infectious risk of EUS-FNA for these cysts, and to suggest CT and EUS features that can suggest this diagnosis without FNA. Three patients who underwent EUS-FNA for diagnosis of incidental mediastinal lesions developed cyst infection despite accepted techniques including prophylactic antibiotics. Combined CT and EUS appearance may be sufficient in making this diagnosis without FNA. IV antibiotics may not be completely protective against infectious complications of FNA of mediastinal duplication cysts. Keywords: Cysts, mediastinal; Endoscopy; Endoscopic procedures; Mediastinal infection; Endoscopic ultrasound

Innominate artery cannulation for congenital heart disease [Congenital]

Bhat, A. N., Bradley, S. M. — Mon, 16 Nov 2009 05:04:07 PST

Arterial cannulation of the ascending aorta is the standard for congenital heart surgery. However, in some situations ascending aortic cannulation can be difficult, and cannulation of the innominate artery may be preferable. These situations may include: operations on the ascending aorta, a small ascending aorta which may be obstructed by the arterial perfusion cannula, redo operations where vascular structures including the ascending aorta are adherent to the back of the sternum, and neoaortic calcification in a patient who has undergone a previous Norwood operation. Innominate artery cannulation also permits the use of low flow cerebral perfusion, with avoidance of total circulatory arrest. In neonates and infants, the femoral and axillary arteries are generally too small to permit adequate flows on cardiopulmonary bypass . We describe four cases as examples of operations in which we have found innominate artery cannulation to be advantageous. Keywords: Cannulation; Cardiopulmonary bypass; Innominate artery

Short- and medium-term survival following coronary artery bypass surgery in British Indo-Asian and white Caucasian individuals: impact of diabetes mellitus [Coronary]

Hadjinikolaou, L., Klimatsidas, M., Iacona, G. M., Spyt, T., Samani, N. J. — Mon, 16 Nov 2009 01:30:26 PST

Previous studies have suggested that South Asian (SA) ethnicity is a predictor of poorer outcome after coronary artery bypass grafting (CABG). Our aim was to identify potential reasons for the higher postoperative mortality in SA patients and investigate all individuals undergoing isolated CABG in a tertiary cardiac centre in the period April 2002 to Sept 2007. In total, there were 2897 subjects (2623 white subjects; 274 SA subjects) who were included in an observational study showing the effect of ethinicity on the medium-term survival following CABG. Survival at 30 days and survival up to 5 years (median 2.7 years) were measured. SA subjects undergoing CABG were younger (62±9 vs 66±9 years, p<0.001), less obese [body mass index (BMI) 26±4 vs 28±4 kg/m², p<0.001] and had a higher prevalence of diabetes mellitus (58% vs 33%, p<0.001) compared with white subjects. 30-day mortality was higher in SA subjects (2.6% vs 1.0%, p=0.02). Non-diabetic SA had similar 30-day mortality, 5-year survival and life expectancy compared to non-diabetic white subjects. In contrast, diabetic SA had a higher 30-day mortality (3.8% vs 1.4%, p=0.01) and worse life expectancy compared to diabetic white subjects. The higher early postoperative mortality observed in SA patients is related to higher incidence of diabetes among them. SA diabetics have a significantly higher postoperative mortality and worse overall life expectancy. Ethnicity per se is not an independent predictor of short- or medium-term survival after CABG. Keywords: Ethnicity; Coronary artery bypass grafting; Postoperative mortality; Five-year survival

Failed closure of a ventricular septal defect with an Amplatzer occluder [Cardiac general]

Wippermann, J., Hoppe, U. C., Sreeram, N., Wahlers, T. — Fri, 13 Nov 2009 03:48:25 PST

A 74-year-old man was diagnosed to have a ventricular septal defect (VSD), which was detected shortly following transvenous pacemaker implantation. Transoesophageal echocardiography suggested the presence of 2 VSDs, one of which was closed with a device. At surgery, a single large VSD was seen, with the implanted device having embolised into the left ventricle. The defect was successfully closed using a pericardial patch, and the embolised device explanted. Keywords: Ventricular septum defect; Pacemaker; Transcatheter closu

Deferoxamine, the newly developed iron chelator LK-614 and N-{alpha}-acetyl-histidine in myocardial protection [Experimental]

Koch, A., Loganathan, S., Radovits, T., Sack, F.-U., Karck, M., Szabo, G. B. — Fri, 13 Nov 2009 03:11:17 PST

During cold storage of donor hearts, reactive oxygen species produced by intracellular redox-active chelatable iron potentially alter myocardial function. To reduce this cold-induced injury we investigated the efficacy of two new modifications of the well established histidine-tryptophan-ketogluterate (HTK) solution (Custodiol®) with the addition of N--acetyl-L-histidine and iron-chelators in a heterotopic rat heart transplantation model. The donor hearts were cardioplegically arrested with 20 ml cardioplegia and stored for 1 h. Then the hearts were anastomosed to the abdominal aorta and vena cava of the recipient (n=30). After 1 h reperfusion, myocardial function and energy charge potential were measured in three groups: HTK-1: addition of L-arginine and N--acetyl-L-histidine; HTK-2: addition of iron-chelators deferoxamine and LK-614; traditional HTK - control. After 1 h reperfusion, left ventricular systolic pressure (106±33 vs. 60±39, vs. 67±8 mmHg, p<0.05) and dP/dt minimal (-1388±627 vs -660±446, vs. 871±188 mmHg/s, p<0.05) were significantly higher in the HTK-1 group. Energy charge potentials were not significantly different. This study showed that the novel modified HTK-1 solution improves myocardial contractility and relaxation after heart transplantation. Nevertheless, addition of the iron-chelators deferoxamine and LK-614 diminished these beneficial effects. Keywords: Rat heart transplantation; Iron chelators; N--acetyl-L-histidine; Cold ischemic injury

Is pH-stat or alpha-stat the best technique to follow in patients undergoing deep hypothermic circulatory arrest? [Cardiopulmonary bypass]

Abdul Aziz, K. A., Meduoye, A. — Fri, 13 Nov 2009 02:18:34 PST

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pH-stat or alpha-stat is the best technique to follow in patients undergoing deep hypothermic circulatory arrest. Altogether 206 papers were found using the reported search, of which sixteen represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Excluding one paper which provided inconclusive results, six studies found better cerebrovascular metabolism with alpha-stat while three studies found better cerebrovascular metabolism with pH-stat. Four other studies showed no significant difference in the cerebrovascular metabolism between the two acid-base management strategies in patients undergoing deep hypothermic circulatory arrest. Nine studies compared the neuropsychological outcome in patients who underwent deep hypothermic circulatory arrest with three studies supporting each alternative conclusion of preference towards alpha-stat or pH-stat management. The remaining three studies showed no significant difference between the two groups of acid-base management. Comparing the sixteen studies based on the age of the patients studied, three out of the four papers which demonstrated that the pH-stat method is a better strategy to improve intraoperative and postoperative outcome were based on a sample of paediatric patients. Conversely, all seven papers that suggested alpha-stat method is associated with better intraoperative and postoperative outcome were based on studies done on adult patients. The remaining four papers suggested no significant difference between the pH-stat group and alpha-stat group. In conclusion, there is evidence to suggest that the best technique to follow in the management of acid-base in patients undergoing deep hypothermic circulatory arrest during cardiac surgery is dependent upon the age of the patient with better results using pH-stat in the paediatric patient and alpha-stat in the adult patient. Keywords: pH-stat; Alpha-stat; Hypothermic

Twenty-six-year durability of an Ionescu-Shiley standard profile pericardial aortic valve [Valves]

Honda, K., Okamura, Y., Nishimura, Y., Uchita, S. — Fri, 13 Nov 2009 01:16:58 PST

The Ionescu-Shiley pericardial valve (Shiley, Inc, Irvine, CA, USA) is a first generation bioprosthesis made from bovine pericardium. Despite its excellent hemodynamic performance, use of this prosthesis ceased because it had an unacceptably high rate of early structural deteriorations, especially in the era of the standard profile valve. We experienced a rare case of very long durability of an Ionescu-Shiley standard profile bioprosthesis (ISSP). Keywords: Ionescu-Shiley standard valve; Long durability

The semi-clamshell approach for the single-stage treatment of thoracic mycotic aneurysm [Aortic and aneurysmal (ICVTS only)]

Saito, Y., Fukuda, I., Daitoku, K., Taniguchi, S. — Fri, 13 Nov 2009 00:51:31 PST

Mycotic aneurysms located on aortic arch are rare and have extremely high mortality. The presented case is a 75-year-old man with a thoracic aortal mycotic aneurysm successfully treated with surgical intervention. To prevent recurrent infection and postoperative pulmonary complications, we performed single-stage surgery including extensive debridement, graft replacement using rifampicin soaked prosthetic graft and omental wrapping. Although mycotic aneurysm with inflammation tissue usually interferes with surgical manipulation because of severe adhesion to the lung, semi-clamshell approach helped us perform all these procedures. The patient rapidly recovered from the surgery, and has shown no recurrence after 35 months follow-up. Keywords: Clamshell approach; Mycotic aneurysm; Aortic aneurysm; Omental wrapping; Rifampicin

Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy? [Thoracic non-oncologic]

Freynet, A., Falcoz, P.-E. — Thu, 12 Nov 2009 05:27:50 PST

A best evidence topic was constructed according to a structured protocol. The question addressed was whether the use of transcutaneous electrical nerve stimulation (TENS) is effective in reducing post-thoracotomy pain. Of the 74 papers found with a report search, 9 prospective randomized controlled trials (RCT), among which three were double-blind, presented the best evidence to answer the clinical question. All investigated the effect of TENS as an adjunct therapy for relieving acute post-thoracotomy pain in patients undergoing thoracic surgery. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that a vast majority - seven of the nine retrieved studies - were in favor of TENS as an adjuvant to narcotic analgesics for improving outcome after thoracic surgery. Indeed, the interest and benefit has been shown not only in the treatment of acute post-thoracotomy pain (pain scores and narcotic requirements were consistently lower in the TENS group as opposed to the Placebo-TENS group), but also when used together with narcotic analgesics to reduce the duration of recovery room stay and to increase chest physical tolerance (better coughing attempts during chest physiotherapy) with positive effects on pulmonary ventilator function [forced expiratory volume in 1 s (FEV₁) and/or forced vital capacity (FVC)]. Specifically, the TENS treatment was shown to be ineffective when used alone in severe post-thoracotomy pain (i.e. posterolateral thoracotomy incision), but useful as an adjunct to other medications in moderate post-thoracotomy pain (i.e. muscle sparing thoracotomy incision) and very effective as the sole pain-control treatment in patients experiencing mild post-thoracotomy pain (i.e. video-assisted thoracoscopy incision). Hence, current evidence shows TENS associated with postoperative medications to be safe and effective in alleviating postoperative pain and in improving patient recovery, thus enhancing the choice of available medical care and bettering outcome after thoracic surgery. Keywords: Thoracic surgery; Thoracotomy; Transcutaneous electrical nerve stimulation; Postoperative pain

Diagnosis and surgical treatment of an aneurysm on a cervical aortic arch associated with an anomalous origin of the left main coronary artery [Aortic and aneurysmal (ICVTS only)]

Charrot, F., Tarmiz, A., Glock, Y., Leobon, B. — Thu, 12 Nov 2009 04:35:28 PST

Cervical aortic arch (CAA) is a rare congenital anomaly. An aneurysm developed on a CAA is even rarer and a life threatening condition. We report the diagnosis and surgical treatment of an aneurysm on a CAA associated with an anormalous origin of the left main coronary artery. The surgical procedure consisted in the resection of the aneurysm, a direct aorto aortic anastomosis and a coronary artery bypass to the left anterior descending (LAD) with a good result at 11 months. This first case reported of an anomaly of a coronary artery origin associated with an aneurysm on a CAA, underlines the interest of a preoperative complete anatomical and functional diagnosis, to define an optimal intraoperative strategy. Keywords: Congenital; Thoracic aorta; Aneurysm; Anomalous coronary artery

Isolated iliac artery aneurysms: six-year experience [Aortic and aneurysmal (ICVTS only)]

Thu, 12 Nov 2009 03:50:28 PST

Objective: To review the experience of our institution in repairing isolated iliac artery aneurysm (isolated IAA) in the last six years. Methods: The medical records of patients who underwent isolated IAA repair were reviewed, to obtain information on patients' demographics, vascular risk factors, type of treatment and outcome. Results: A total of 11 patients with 16 aneurysms, all men, with a mean age of 69.2±6.0 years were treated. The mean diameter was 3.7±1.0 cm (3.5±1.1 cm at elective repair; 5.7±2.9 cm on the emergency cases). The majority of aneurysms were at the common iliac artery and 27.3% of them were multiple. The diagnosis of multiple aneurysms was performed 10 years later, compared with the mean age of the diagnosis of single aneurysms, and this difference is statistically significant. Seven (63.6%) had elective operations, and one elective endovascular repair. Analysing the vascular risk factors, it was evident that hypertension was the most prevalent and the diagnosis of aneurysm was done 10 years sooner in the smoker patients. There was no postoperative death in this series. The mean follow-up period was of 21 months, and during it, one patient developed a non-infection anastomotic aneurysm of common femoral artery, one died with a myocardial infarction, one presented with limb graft thrombosis and another was lost. Conclusion: This series contributes a to better characterization of a rare pathology demonstrating that both surgical and endovascular treatment can be performed with very low morbidity and mortality. Keywords: Isolated iliac artery aneurysm; Open repair; Endovascular repair

Kawasaki disease presenting as cardiac tamponade with ruptured giant aneurysm of the right coronary artery [Cardiac general]

Kuppuswamy, M., Gukop, P., Sutherland, G., Venkatachalam, C. — Thu, 12 Nov 2009 01:59:07 PST

We report a case of a 22-year-old man with Kawasaki disease presenting with features of cardiac tamponade following rupture of giant aneurysm of his right coronary artery. He underwent an emergency operation. Aneurysmal sac was of size 4x4 cm. The entry point of the aneurysm was sutured. Right coronary artery was grafted with left radial artery. He had an uneventful recovery in the postoperative period. Keywords: Kawasaki disease; Giant aneurysm; Cardiac tamponade

Preliminary experience with no prolapse system. A new device for ensuring the proper length of artificial chordae in mitral valve repair [Valves]

Ruyra-Baliarda, X. — Thu, 12 Nov 2009 01:12:02 PST

Mitral valve repair is the procedure of choice to treat mitral valve regurgitation. However, the feasibility and durability of repair are influenced strongly by the valve pathology. The classic features of degenerative mitral valve disease include leaflet prolapse and annular dilatation. Risk of repair failure is increased by isolated anterior leaflet prolapse or bileaflet prolapse. A variety of techniques have been used to treat this pathology. The most popular include partial leaflet resection, chordal shortening, chordal transfer and chordal replacement. Use of artificial chordae with expanded polytetrafluoroethylene (PTFE) sutures is a well-known technique for mitral valve repair and long-term data validates this approach. The primary challenges with this technique are judging the proper length of the neochordae and tying the PTFE. Several different techniques have been proposed to solve these items but, none of the established are very satisfactory. I describe a preliminary experience with a new device to determine the correct length of the neo-chordae and tying the knots without sliding in ten patients with severe mitral insufficiency referred for mitral valve repair. Keywords: Mitral valve; Mitral valve repair; Sutures

When harvested for coronary artery bypass graft surgery, does a skeletonized or pedicled radial artery improve conduit patency? [Coronary]

Ali, E., Saso, S., Ahmed, K., Athanasiou, T. — Wed, 11 Nov 2009 01:16:34 PST

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonization of the radial artery (RA) improves conduit patency in coronary artery bypass grafting (CABG). Altogether 15 papers were found using the reported search, of which 4 papers represented the best evidence to answer the clinical question. 2 papers compared patency rates between skeletonized and pedicled radial arteries. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We acknowledge that evidence is limited in this area of cardiac surgery. When assessing the skeletonized RA, 3 studies provided patency data one year after CABG. No patency data was available 5 years after CABG. Only 2 papers were comparative studies (skeletonized conduits versus pedicled conduits). Despite the above, short- and medium-term patency rates of skeletonized conduits are excellent. In the 2 comparative studies, patency of skeletonized vessels was superior to the pedicled conduits. Patency was assessed with the use of angiography and rates exceeded 95% in all 4 studies. Overall patency rates were 100% within 18 days, 98.3% within 3 months, 97.6% at a mean of approximately 1 year, and 100% at 4 years in one study. From these studies we can conclude that the patency rates of pedicled conduits are excellent, however our study suggests that skeletonization may offer the radial conduit some patency benefit when compared to the pedicled technique. The remaining 2 non-comparative studies support the above conclusion. Keywords: Arterial conduits; Coronary artery bypass grafting; Radial artery; Patency; Skeletonized; Pedicled

Sutureless pericardial patch augmentation for impending left ventricular free wall rupture [Cardiac general]

Galvin, S., Chen, V., Bunton, R., Doyle, T. — Wed, 11 Nov 2009 03:20:57 PST

Left ventricular rupture may occur as a complication of acute myocardial infarction and is associated with significant morbidity and mortality. The risk associated with impending rupture of the left ventricular free wall has not been quantified but it is likely a predisposing factor to complete rupture. Few cases of impending rupture of the left ventricular free wall have been discussed in the literature; we present one such case and describe simple operative management with an autologous pericardial patch and subsequent outcome. Keywords: Ventricle; Left ventricle; Imaging (all modalities)

Throw-off instruments for advanced thoracoscopic procedures [Thoracic non-oncologic]

Gossot, D., Pryshchepau, M., Barenys, C. M., Magdeleinat, P. — Tue, 10 Nov 2009 03:49:00 PST

Performing complex thoracoscopic procedures can necessitate the use of multiple instruments and, consequently, the use of multiple ports. This results in parietal harm and in overcrowding of the operative field with instrument conflicts. We present the interest of lung retractors and vascular clamps that can be released inside the chest cavity without blocking a trocar access. Keywords: Video-assissted thoracic surgery; Lobectomy; Vascular clamp; Lung retractor

Does a skeletonized or pedicled right gastro-epiploic artery improve patency when used as a conduit in coronary artery bypass graft surgery? [Coronary]

Ali, E., Saso, S., Ashrafian, H., Athanasiou, T. — Tue, 10 Nov 2009 03:30:55 PST

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonization of the right gastro-epiploic artery (RGEA) improves graft patency in coronary artery bypass grafting (CABG). Altogether more than 25 papers were found using the reported search, of which 11 papers represented the best evidence to answer this clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. 4 out of the 11 papers were comparative studies (skeletonized conduits versus pedicled conduits) and 4 studies produced one-year follow-up data. No studies revealed long-term patency rates as there was no follow-up data beyond 5 years. It is important to note that the evidence in the literature is based in a Japanese population. The vast majority of the target vessel which had been grafted by the RGEA was the right coronary artery and more specifically the posterior descending artery (PDA). The association between off-pump technique, sequential grafting, skeletonization of the RGEA with the harmonic scalpel and angiographic patency has not been adequately assessed. The studies reveal excellent patency rates for both early and mid-term skeletonized RGEA conduits. Overall patency rates were 97.7% within 3 months, 92.4% at a mean of approximately 1 year, 91.5% at a mean of approximately 2 years, and 86.4% at 4 years. In the 4 comparative studies, skeletonization patency was at least comparable and in one study superior to pedicled conduits. One study revealed a higher 4-year cumulative patency rate for skeletonized conduits in comparison to a previous study by the same author where pedicled grafts were used. In conclusion, patency rates exceeded 95% in 10 studies for a follow-up of up to 3 months postoperatively. The evidence which supports the use of a 'skeletonized' RGEA is growing and this paper demonstrates clearly that in terms of patency, a skeletonized RGEA to the PDA should be considered as a conduit for CABG surgery especially when total arterial revascularization strategy with in situ conduits and no manipulation of the ascending aorta is the treatment of choice. Keywords: Arterial conduits; Coronary artery bypass grafting; Gastro-epiploic artery; Patency; Skeletonized; Pedicled

Ultrasound estimation of volume of postoperative pleural effusion in cardiac surgery patients [Cardiac general]

Usta, E., Mustafi, M., Ziemer, G. — Tue, 10 Nov 2009 03:10:02 PST

The aim of this study was to establish a practical simplified formula to facilitate the management of a frequent occurring postoperative complication, pleural effusion. Chest ultrasonography with better sensitivity and reliability in the diagnosis of pleural effusions than chest X-ray can be repeated serially at the bedside without any radiation risk. 150 patients after cardiac surgery with basal pleural opacity on chest X-ray have been included in our prospective observational study during a 2-year period. Effusion was confirmed on postoperative day (POD) 5.9±3.2 per chest ultrasound sonography. Inclusion criteria for subsequent thoracentesis based on clinical grounds alone and were not protocol-driven. Major inclusion criteria were: dyspnea and peripheral oxygen saturation (SpO₂) levels ≤92% and the maximal distance between mid-height of the diaphragm and visceral pleura (D≥30 mm). 135 patients (90%) were drained with a 14-G needle if according to the simplified formula: V (ml)=[16xD (mm)] the volume of the pleural effusion was around 500 ml. The success rate of obtaining fluid was 100% without any complications. There is a high accuracy between the estimated and drained pleural effusion. Simple quantification of pleural effusion enables time and cost-effective decision-making for thoracentesis in postoperative patients. Keywords: Cardiac surgery; Pleural effusion; Thoracentesis; Ultrasound

Aortocoronary bypass graft fistula after surgical treatment of circumflex coronary artery fistula: a unique variation of a rare condition successfully treated with percutaneous embolization [Cardiac general]

White, R. W., Sivananthan, M. U., Kay, P. H. — Tue, 10 Nov 2009 02:47:39 PST

Multiple coronary artery fistulae are rare, complications can be life-threatening, and with large or symptomatic fistulae, intervention is mandatory. Both surgical and percutaneous interventions are well-described. We believe this is the first report of the embolization of an acquired fistula following initial surgical treatment of multiple congenital fistulae. Keywords: Coronary sinus, Fistula; Embolism; Coronary artery bypass grafts (CABG)

Impact of preoperative anemia on cardiac surgery in octogenarians [Cardiopulmonary bypass]

Wed, 04 Nov 2009 02:59:39 PST

Objectives: Preoperative anemia has been related with adverse outcomes in elective valve replacement and CABG surgery. Impact of preoperative anemia on outcome in octogenarians submitted to cardiopulmonary bypass (CPB) has not yet been precisely described. Methods: We analyzed association between preoperative hemoglobin level, minimum intraoperative and immediate postoperative hematocrit (HCT), and other co-morbidities and occurrence of adverse outcomes in 227 octogenarians who underwent cardiac surgery. Results: Frequency of preoperative anemia was 41.9% (40.4% in male and 43.5% in female patients). Postoperative mortality was 13.2% (9% in non-anemic patients vs. 18.9% in anemic). 44.5% of patients suffered no postoperative adverse outcome (43.1% non-anemic vs. 46.3% anemic). In multivariate analysis (after adjusting independent preoperative risk factors for operative mortality and EuroSCORE) preoperative creatinin level [odds ratio (OR), 2.29; 95% confidence interval (CI), 1.06-4.98; P=0.035], immediate postoperative HCT <24% (OR, 2.78; 95% CI, 1.04-7.38; P=0.039), perioperative red blood cell (RBC) transfusion (OR, 1.58; 95% CI, 1.24-2.00; P=0.0001), peripheral vascular disease (OR, 4.92; 95% CI, 1.45-16.69; P=0.012) and urgent surgery (OR, 10.57; 95% CI, 2.54-43.91; P=0.0001) were identified as independent predictors for in-hospital mortality. Conclusions: Mortality and adverse postoperative outcome increase in anemic octogenarians undergoing cardiac surgery. Although mortality is directly related to immediate postoperative anemia, adverse outcomes mainly depend on associated co-morbidities. Keywords: Octogenarians; Anemia; Cardiac surgery

The treatment of infectious aneurysms in the thoracic aorta; our experience in treating five consecutive patients [Vascular thoracic]

Nakashima, M., Usui, A., Oshima, H., Ueda, Y. — Tue, 03 Nov 2009 07:34:51 PST

The surgical strategy for infected thoracic aortic aneurysms (ITAA) remains controversial. Effective antibiotic therapy is mandatory and surgical intervention is indicated only to prevent an aneurismal rupture. In-situ reconstruction through an aseptic route is ideal; however, urgent surgery is often required in the uncontrolled infectious phase. Five patients were recently treated surgically for ITAA. They were all males with a mean age of 61.2 (range: 58-66) years. Two patients were operated on urgently in the active infectious phase due to impending aneurysmal rupture. A total arch reconstruction with an extra-anatomical bypass between the ascending aorta and both femoral arteries in one and an extended aortic arch resection with an in-situ graft reconstruction were performed in the other. The other 3 patients underwent in-situ graft reconstructions in the controlled infectious phase. Four patients had multiple aneurysms, including 9 saccular or nodular aneurysms. Short-interval computed tomography (CT) re-examinations revealed a rapid enlargement of the aneurysms and confirmed the diagnosis. All patients successfully survived and are doing well without any evidence of a recurrent aortic infection. The surgical strategy for ITAA should be determined on a case-by-case basis under a careful follow-up with short-interval CT re-examinations. Keywords: Infected aneurysm; Thoracic aneurysm; Surgical reconstruction

Smoking behaviour and attitudes in patients undergoing cardiac surgery. The Radboud experience [Cardiac general]

Saksens, N. T.M., Noyez, L. — Mon, 02 Nov 2009 06:09:58 PST

Changes in smoking behaviour and attitudes of 2642 patients, undergoing cardiac surgery, between January 2000 and July 2008 were studied. All patients completed a preoperative questionnaire concerning smoking behaviour and attitude. Study endpoints are behaviour and attitude in relation to tobacco use in hospitals, cessation smoking before and after the operation. Over the years there have been no notable differences in smoking behaviour, however significantly less patients accept smoking in the hospital (0.9% versus 5.3%). Signifcantly more patients stopped within the 2 weeks before surgery (9.4% versus 5.3%). The percentage of patients who did not have the intention to stop smoking after the operation decreased not significantly. Significantly less older patients smoke (1.6% versus 13.4%) and are less tolerant towards smoking in the hospital (1.8% versus 4.1%). A signifcant higher percentage of older patients have stopped smoking over 5 years before the operation. Concerning the intention to stop smoking after the operation, there is no signifcant difference. These results show that over the years, patients undergoing cardiac surgery seem to be more aware about the relation between health and smoking. This is not related to the type of operation, however apparently with age. Keywords: Cardiac surgery; Smoking; Behaviour; Attitude

Variability of ascending aorta diameter measurements as assessed with electrocardiography-gated multidetector computerized tomography and computer assisted diagnosis software [Vascular thoracic]

Mon, 02 Nov 2009 02:28:52 PST

Recently morphometric measurements of the ascending aorta have been done with ECG-gated multidetector computerized tomography (MDCT) to help the development of future novel transcatheter therapies (TCT); nevertheless, the variability of such measurements remains unknown. Thirty patients referred for ECG-gated CT thoracic angiography were evaluated. Continuous reformations of the ascending aorta, perpendicular to the centerline, were obtained automatically with a commercially available computer aided diagnosis (CAD). Then measurements of the maximal diameter were done with the CAD and manually by two observers (separately). Measurements were repeated one month later. The Bland-Altman method, Spearman coefficients, and a Wilcoxon signed-rank test were used to evaluate the variability, the correlation, and the differences between observers. The interobserver variability for maximal diameter between the two observers was up to 1.2 mm with limits of agreement [-1.5, +0.9] mm; whereas the intraobserver limits were [-1.2, +1.0] mm for the first observer and [-0.8, +0.8] mm for the second observer. The intraobserver CAD variability was 0.8 mm. The correlation was good between observers and the CAD (0.980-0.986); however, significant differences do exist (p<0.001). The maximum variability observed was 1.2 mm and should be considered in reports of measurements of the ascending aorta. The CAD is as reproducible as an experienced reader. Keywords: ECG-gated computed tomography; Ascending aorta diameter; Interobserver variability; Intraobserver variability; Computer aided diagnosis; Centerline based segmentation software

A new absorbable collagen membrane to reduce adhesions in cardiac surgery [Experimental]

Mon, 02 Nov 2009 02:02:55 PST

Reduction of sternal adhesions is still an issue in cardiac surgery. To evaluate a new fibrillar porcine collagen absorbable membrane (Cova^TM CARD), sixteen sheep underwent a sternotomy followed by scratching of surface of the heart. They were then divided into three groups: pericardium left opened (n=4), placement of Seprafilm®, the reference absorbable substitute, (hyaluronic acid and carboxymethylcellulose, n=6) or of Cova^TM CARD membrane (n=6). Four months thereafter, the animals underwent repeat sternotomy and were macroscopically assessed for the degree of resorption of the material and the intensity of adhesions. Explanted hearts were blindly evaluated for the magnitude of the inflammatory response and fibrosis. The Cova^TM CARD membrane was almost totally absorbed by 4 months and replaced by a loosely adherent tissue. There was no inflammatory reaction and both the extent and density of fibrosis were minimal. The composite score (median [min;max]) integrating tightness of adhesions and histological findings of inflammation and fibrosis was two-fold lower in the Cova^TM CARD than in the Seprafilm® group (2.0 [0;3.5] vs. 5.5 [3;7], p = 0.01 by Wilcoxon test). The Cova^TM CARD membrane might represent an attractive pericardial substitute for preventing postoperative adhesions in cardiac surgery. Keywords: Biocompatible materials; Reoperation; Surgical adhesions; Collagen membrane

Measured posterior annuloplasty for repair of non-ischemic mitral regurgitation. A single unit follow-up [Cardiac general]

Jyrala, A. J., Gatto, N. M., Kay, G. L. — Fri, 30 Oct 2009 02:15:02 PDT

The aim of this report is to evaluate short- and long-term outcomes of annuloplasty method of our choice: measured posterior annuloplasty (MPA). MPA is a piece of a Duran ring cut to the length of free-edge of anterior mitral leaflet (AML) and anchored with multiple pledgeted U-sutures from trigone to trigone into the posterior annulus. Material and methods: From 1988 to 2000, 103 consecutive patients with non-ischemic mitral regurgitation were scheduled preoperatively to be repaired by MPA. Results: Preoperative mitral valve regurgitation (MR) grade was 3.8±0.5 and decreased to 0.1±0.3 (p<0.0001) after repair. One patient was converted to insertion of mechanical prosthesis after grade 3 MR persisted after septal myectomy and MPA. Three patients needed instant revision of the repair one due to SAM and 2 due to stenosis. No patient had a stenosis or unacceptable (>1) MR after the procedure. There was 1 operative death (1.0%) and 3 hospital/30 day deaths (2.9%). 16 patients (16.3%) expired during the follow-up to 91 months (mean 57.4±19.5, median 60 months) none due to failure of MPA. There were no reoperations due to failure of MPA. Three pts had a reoperation, one for dehiscence of reconstruction after P2 resection and two patients due to progression of anterior leaflet degeneration and calcification with 4+ MR. New York Heart Association (NYHA) functional classification decreased from 2.3±0.8 to 1.4±0.6 (p<0.0001) and only one patient had an increase from II to III. 88 patients (96.7%) were in NYHA class I-II. 10 pts had an increase of MR from 0 to trace or 1 and one from 0 to 2. 2 patients were diagnosed with mild stenosis without need of reoperation. Conclusions: MPA is a durable and stable alternative for repair of non-ischemic mitral regurgitation of different etiologies. The technique gives an objective measure of the length of the band and no patient is left with a significant MR or MS. First-time success rate is very high and instant repairs few and minor. Freedom of MPA related reoperations is 100%. Keywords: Mitral regurgitation; Annuloplasty; Measured posterior annuloplasty

An unexpected cause of poor venous drainage during robotic mitral valve repair [Cardiopulmonary bypass]

Sareyyupoglu, B., Suri, R. M., Rehfeldt, K. H., Burkhart, H. M. — Fri, 30 Oct 2009 01:05:11 PDT

We present a case with an unusual cause of poor venous drainage during cardiopulmonary bypass for robotic-assisted mitral valve repair. Keywords: Cardiopulmonary bypass; Circulation; Mitral valve; Veins

Micropapillary pattern in lung adenocarcinoma: aspect on 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging [Thoracic oncologic]

Prior, J. O., Stupp, R., Christodoulou, M., Letovanec, I. — Thu, 29 Oct 2009 10:42:51 PDT

We diagnosed a non-small cell lung carcinoma in a 49-year-old female patient with the histopathological diagnosis of stage IIIB mixed bronchioloalveolar and papillary adenocarcinoma with extensive micropapillary feature, which was not visualized on the preoperative multimodality imaging with positron emission tomography (PET) and computed tomography (CT). The micropapillary component characterized by a unique growth pattern with particular morphological features can be observed in all subtypes of lung adenocarcinoma. Micropapillary component is increasingly recognized as a distinct entity associated with higher aggressiveness. Even the most modern multimodality PET/CT imaging technology may fail to adequately visualize this important component with highly relevant prognostic implications. Thus, the pathologist needs to consciously look for a micropapillary component in the surgical specimen or in preoperative biopsies or cytology. This may have potential future treatment implications, as adjuvant or neoadjuvant chemotherapy may be of relevance, even in the early stages of the disease. Keywords: Non-small cell lung cancer; ¹⁸F-FDG; Positron emission tomography; Micropapillary component; PET/CT

Treatment of an acquired esophageal-bibronchial benign fistula using an original combination of techniques [Pulmonary]

Boaron, M., Kawamukai, K., Forti Parri, S. N., Trisolini, R. — Thu, 29 Oct 2009 09:01:00 PDT

We report on the successful surgical treatment of an esophageal-bibronchial fistula originating from a iatrogenic mediastinal abscess. Endoscopic treatment had been excluded due to the extensive damage to the right main stem bronchus wall. The surgical treatment was carried out as follows: 1) Endoscopic stenting of the left main broncus with a self-expanding metallic stent followed by selective left main bronchus intubation; 2) Laparotomic harvesting of the omentum pedicled on both gastro-epiploic vessels; 3) Right thoracotomy, complete dissection of both main bronchi and esophageal wall at the site of the leakage; 4) Harvesting of a pericardial vascularized graft; 5) Deployment of a self-expanding metallic stent from the surgical field into the right main stem bronchus; 6) Reconstruction of the right bronchus wall with the pericardial patch; 7) Positioning a T-tube in the esophageal leak; and 8) Intrathoracic transposition of the omental graft for buttressing all sutures and potential leakage points. The postoperative course was uneventful from a surgical point of view and the patient recovered completely. Keywords: Esophageal fistula; Bronchial fistula; Bronchial stent; Pericardial patch

Minimally invasive video-assisted approach for left atrial myxoma resection [Cardiac general]

Vistarini, N., Alloni, A., Aiello, M., Vigano, M. — Tue, 27 Oct 2009 02:00:11 PDT

Minimally invasive surgery has become the standard approach for several cardiac diseases. We report in the present study our ten-year experience with endoscopic cardiac surgery for left atrial myxoma resection. Between January 1998 and January 2008, 14 patients (median age: 61 years) underwent surgery for left atrial myxoma resection at our institution. The HeartPort® access system and the video-assistance were systematically employed to provide excellent vision and facilitate surgery. The aortic clamping was obtained with an 'EndoClamp' in 11 cases (using a central or peripheral endoaortic balloon, depending on the site of the arterial cannulation) or transthoracically with the Portaclamp® system in 2 cases and the Chitwood clamp in 1 case. The average time needed for cross-clamping was 49±29 min, with a mean cardiopulmonary bypass (CPB) time of 89±57 min. There were no early or late hospital deaths. Mean intensive care unit and hospital stay were 3 and 8 days, respectively. The mean follow-up time was 67 months and there was no evidence of residual or recurrent tumor. There were 2 late deaths due to acute ischemic stroke. Minimally invasive video-assisted surgery for left atrial myxoma resection is a safe, reproducible and cosmetic operation and can be considered an effective oncologic approach as an alternative to standard sternotomy. Keywords: Minimally invasive surgery; Cardiac tumors

Comprehensive approach for clamping severely calcified ascending aorta using computed tomography [Cardiac general]

Nishi, H., Mitsuno, M., Ryomoto, M., Miyamoto, Y. — Tue, 27 Oct 2009 01:23:34 PDT

A severely calcified ascending aorta is generally considered unclampable. Many surgeons have developed procedures to avoid manipulation such as cross-clamping on such calcified aorta. However, these alternatives are sometimes complicated and require a more invasive procedure than the conventional method. We assessed our comprehensive strategy for clamping of a severely calcified aorta using preoperative computed tomography (CT). We found that the extent of calcification just below the innominate artery was significantly less than that at the usual ascending aorta clamp site. After confirming that the extent of calcification just below the innominate artery was less than 75% of the entire circumference by preoperative CT, ascending aorta was clamped with a soft cross-clamp placed on the ascending aorta with particular care to orientate the clamp parallel to the calcification. All operations were completed under usual cardiopulmonary bypass with mild hypothermia. All patients survived surgery and no patients had postoperative neurological complication. Our results provide important information for the management of these high-risk patients, with a comprehensive approach used to choose the appropriate option for an optimal outcome. Keywords: Aorta; Calcification; Computed tomography

Remodelling acquired chest wall deformity after removal of a large axillary lipoma [Thoracic non-oncologic]

Pop, D., Venissac, N., Mouroux, J. — Mon, 26 Oct 2009 03:23:18 PDT

Acquired chest wall deformities are rarely encountered. Most of them result from pathologic process within the thorax, chest wall disease, iatrogenic deformities or post-traumatic. We present a case of a huge axillary mass deforming the chest wall. Surgery treated a well-encapsulated lipoma. Six months postoperatively, the chest wall restored in normal shape with active respiratory physiotherapy. This is the first reported case of spontaneous 'remodelling' of the chest wall without surgery. Keywords: Acquired chest wall deformity; Benign chest wall tumour; Lipoma

Comparison of detection of F-18 fluorodeoxyglucose positron emission tomography and 99mTc-hexamethylpropylene amine oxime labelled leukocyte scintigraphy for an aortic graft infection [Vascular general (ICVTS only)]

Gardet, E., Addas, R., Monteil, J., Le Guyader, A. — Mon, 26 Oct 2009 03:02:47 PDT

To compare F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG-PET) and ^99mTC-hexamethylpropylene amine oxime (^99mTC-HMPAO) labelled leukocyte scintigraphy for the diagnosis of vascular graft infection. A thoraco-abdominal CT-angiography and a ^99mTC-HMPAO labelled leukocyte scintigraphy did not show any graft infection in this case report whereas a F-18 FDG-PET showed a metabolic uptake around and all along the vascular graft. Further comparison between these two explorations is needed since the two techniques have not been compared in vascular graft infection. Keywords: Vascular graft infection; CT-scan; ^99mTC-HMPAO labelled leukocyte scintigraphy; F-18 FDG-PET

Plasmacytoid lymphoma within a left atrial myxoma: a rare coincidental dual pathology [Cardiac general]

White, R. W., Hirst, N. A., Edward, S., Nair, U. R. — Mon, 26 Oct 2009 02:25:03 PDT

Primary malignant cardiac neoplasms are extremely rare. The occurrence of a malignant lymphoid tumour within a left atrial myxoma is highly atypical, with only one such case previously reported. Here we describe a patient who presented with symptoms and signs of a left atrial myxoma. Subsequent specimen histology demonstrated the presence of lymphoma within the myxoma. We discuss the importance of histological diagnosis in order to best direct treatment and prognosis of such cases. Keywords: Lymphoma; Myxoma; Cardiac surgery

Does a skeletonized or pedicled left internal thoracic artery give the best graft patency? [Coronary]

Ali, E., Saso, S., Ashrafian, H., Athanasiou, T. — Fri, 23 Oct 2009 06:30:44 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether skeletonization of the internal thoracic artery (ITA) improves graft patency in coronary artery bypass grafting (CABG). Altogether more than 60 papers were found using the reported search, of which 17 papers represented the best evidence to answer the clinical question. Grafts used were either as single ITAs (left or right, LITA or RITA) or bilateral ITAs (BITAs). The author, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We acknowledge that evidence is limited in this area of cardiac surgery. The skeletonized ITA has not been used long enough to establish whether a decline in patency will occur after several years. The follow-up data was not long-term with only 2 studies providing patency rates beyond 5 years. Also, only 4 out of 17 papers were comparative studies (skeletonized conduits versus pedicled conduits). However the available evidence demonstrates that short- and medium-term patency rates of both skeletonized and pedicled conduits are excellent. In the 4 comparative studies, skeletonization patency was at least comparable to pedicled conduits and in 2 studies even higher. Patency was assessed with the use of angiography, performed on average within 4 years of CABG surgery. Patency rates exceeded 95% in the 10 non-comparative studies where angiographic follow-up was within 3 years of surgery. This is an important finding because it justifies further use of skeletonized technique for CABG surgery. It adds also to a growing field of evidence that skeletonized ITA grafts are preferable to pedicled grafts because they may cause less degree of devascularization of the sternum and consequently reduction of sternal wound infection. The evidence presented here demonstrates that in terms of patency, skeletonized and pedicled left internal thoracic arteries provide excellent patency rates. Keywords: Arterial conduits; CABG; Internal thoracic artery; Patency; Skeletonized; Pedicled

In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? [Thoracic non-oncologic]

Scarci, M., Joshi, A., Attia, R. — Fri, 23 Oct 2009 03:03:51 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing thoracic surgery is paravertebral block (PVB) as effective as epidural analgesia for pain management? Altogether more than 184 papers were found using the reported search, seven of which represented the best evidence to answer the clinical question. All studies agreed that PVB is at least as effective as epidural analgesia for pain control post-thoracotomy. In one paper, the visual analogue pain score (VAS) at rest and on cough was significantly lower in the paravertebral group (P 0.02 and 0.0001, respectively). Pulmonary function, as assessed by peak expiratory flow rate (PEFR), was significantly better preserved in the paravertebral group. The lowest PEFR as a fraction of preoperative control was 0.73 in the paravertebral group in contrast with 0.54 in the epidural group (P<0.004). Oximetric recordings were better in the paravertebral group (96%) compared to the epidural group (95%) (P=0.0001). Another article reported that statistically significant differences (forced vital capacity 46.8% for PVB and 39.3% for epidural group P<0.05; forced expiratory volume in 1 s (FEV₁) 48.4% in PVB group and 35.9% in epidural group, P<0.05) were reached in day 2 and continued until day 3. Plasma concentrations of cortisol, as marker of postoperative stress, increased markedly in both groups, but the increment was statistically different in favour of the paravertebral group (P=0.003). Epidural block was associated with frequent side-effects (urinary retention (42%), nausea (22%), itching (22%) and hypotension (3%) and rarely respiratory depression (0.07%). Additionally, it prolonged operative time and was associated with technical failure or displacement (8%). Epidurals were also related to a higher complication rate (atelectasis/pneumonia) compared to the PVB (2 vs. 0). PVB was found to be of equal efficacy to epidural anaesthesia, but with a favourable side effect profile, and lower complication rate. The reduced rate of complication was most marked for pulmonary complications and is accompanied by quicker return to normal pulmonary function. We conclude intercostal analgesia, in the form of PVB, can be at least as effective as epidural analgesia. Keywords: Intercostal analgesia; Epidural analgesia

A single centre experience of simultaneous open abdominal aortic aneurysm and cardiac surgery [Aortic and aneurysmal (ICVTS only)]

Kordowicz, A., Ghosh, J., Baguneid, M. S. — Fri, 23 Oct 2009 05:56:11 PDT

Objective: Controversy exists over the optimal management of patients with both symptomatic cardiac disease and significant abdominal aortic aneurysm (AAA), but who are unsuitable for endovascular treatment for either pathology. We present our single centre series of synchronous cardiac and aortic aneurysm surgery in patients anatomically unsuitable for endovascular AAA repair. Methods: All patients undergoing synchronous cardiac and open AAA surgery between June 2002 and December 2008 were analysed using a prospectively maintained database supplemented with case note review. Results: Thirteen patients with a median age of 78 years underwent combined surgery. Two AAA were juxtarenal and the remainder infrarenal with a median diameter of 7 cm (4.8-11), of which three were symptomatic. In all cases endovascular repair was not possible due to either hostile iliac or neck anatomy. Eleven patients underwent coronary artery bypass (CABG), one CABG plus aortic valve replacement and one patient aortic valve replacement only. All patients were operated on cardiopulmonary bypass (CPB) and received autologous cell salvaged blood. Median CPB and operative time was 182 (141-260) and 420 (360-490) min respectively. There were two deaths: the first after 90 days from multi-organ failure and stroke, the second following three days from multi-organ failure. Complications comprised: 4 transient renal impairment; 1 transient jaundice; 4 pneumonia; 1 unstable sternum; and 4 arrhythmias with one patient requiring a permanent pacemaker. Two patients suffered transient diarrhoea but no other features of intestinal ischaemia. The remaining 11 patients are alive with a median New York Heart Association (NYHA) score improvement from III to II at six months. Conclusion: Simultaneous open repair of AAA and cardiac surgery is a feasible option for this high-risk and anatomically challenging patient group. This experience highlights the need for close cooperation between vascular and cardiac teams. Keywords: Cardiac; CABG; Aorta; Aneurysm; Combined

Impact of clonidine administration on delirium and related respiratory weaning after surgical correction of acute type-A aortic dissection: results of a pilot study [Cardiac general]

Fri, 23 Oct 2009 04:47:17 PDT

Delirium and transient neurologic dysfunctions (TND) often complicate the postoperative course after surgery for acute type-A aortic dissection (AAD). We evaluated the role of clonidine on neurological outcome and respiratory function in thirty consecutive patients undergoing surgery for AAD. Patients were prospectively randomized to receive either clonidine (0.5 µg/kg bolus, followed by continuous infusion at 1-2 µg/kg/h) or placebo (NaCl 0.9%) in on starting and throughout the weaning period from the mechanical ventilation. Incidence of delirium and TND, Delirium Detection Score (DDS), weaning parameters [respiratory rate to tidal volume ratio - f/VT ; pressure-frequency product (PFP); partial pressure of arterial oxygen to fractional inspired oxygen concentration (PaO₂/FiO₂); partial pressure of carbon dioxide (PaCO₂)], weaning duration and intensive care unit (ICU) length of stay were recorded. The two groups were similar for preoperative and operative variables and also for the incidence of postoperative complications. DDS was lower in the clonidine group (p<0.001). Patients weaned with clonidine showed lower f/VT and PFP, higher PaO₂/FiO₂ and PaCO₂, lower DDS, weaning period and the related ICU length of stay (p<0.001). This was further confirmed in patients developing delirium/TND. Intravenous clonidine after surgery for AAD reduces the severity of delirium, improves the respiratory function, shortens the weaning duration and the ICU length of stay. Keywords: Acute aortic dissection; Neurological complications; Postoperative care

Effect of clopidogrel on perioperative blood loss and transfusion in coronary artery bypass graft surgery patients [Coronary]

Badreldin, A. M.A., Kroener, A., Kamiya, H., Lichtenberg, A., Hekmat, K. — Thu, 22 Oct 2009 05:24:18 PDT

The effect of antiplatelet therapy (APT) on postoperative bleeding, transfusion needs and re-exploration remains unclear. This study examines the influence of APT, as well as antiplatelet mono- and combined therapy, on haemorrhage and transfusion requirements in patients undergoing coronary artery bypass on cardiopulmonary bypass (CPB). 650 patients were reviewed retrospectively, 325 patients received APT within 7 days and 325 control patients. APT group had two subgroups: clopidogrel (CLO) group: n=48 patients received CLO as mono-therapy; combined group: n=277 patients received both CLO and aspirin (ASS). The mediastinal drainage at 12 h was control group: 505 ml±445 ml and APT: 802 ml±720 ml, p<0.001. APT group (versus control group) received significantly more units of blood (3.9±4.2 versus 1.9±2.6; p<0.001), platelet units (1.0±1.4 versus 0.1±0.3; p<0.001), and fresh frozen plasma (FFP) units (2.9±3.9 versus 0.9±2.2; p<0.001), respectively. Combined and mono-therapy groups had no significant differences in bleeding and blood transfusion. Considerations should be given to delaying elective coronary surgery for patients received APT for 7 days. Keywords: Clopidogrel; CABG; Antiplatelet therapy; Postoperative bleeding

Right or left anterolateral minithoracotomy for repair of congenital ventricular septal defects in adult patients [Congenital]

Jung, S.-H., Je, H. G., Choo, S. J., Yun, T.-J., Chung, C. H., Lee, J. W. — Thu, 22 Oct 2009 04:17:52 PDT

For most patients who present with ventricular septal defects (VSDs) in adulthood, the major concern is not the mortality or morbidity associated with repair surgery, but rather cosmetic problem arising from surgical scarring as a result of median sternotomy. From March 2005 to August 2008, 9 patients (M:F=1:8) underwent repair of congenital VSD using right (n=7) or left (n=2) anterolateral minithoracotomy. We compared the perioperative data of these patients with that of the patients (n=8) who underwent VSD repair using median sternotomy during the same period. VSDs were of the perimembranous (n=6), subarterial (n=1), muscular inlet (n=1), and muscular outlet (n=1) type in minithoracotomy group. There was no in-hospital mortality in both groups. Mean cardiopulmonary bypass (CPB) time in minithoracotomy group was longer than that of sternotomy group (98.0±23.7 min vs 68.5±13.3 min, p=0.011), but aorta cross-clamping (ACC) time was not different (45.9±20.0 min in minithoracotomy group vs 40.5±12.1 min in sternotomy group) (p=0.481). There were no postoperative complications related to surgery or peripheral cannulation. The mean hospital stay was 3.6 days in minithoracotmy group and 6.1 days in sternotomy group, respectively (p=0.004). Minimally invasive cardiac surgery using minithoracotomy with peripheral cannulation can be safely applied to adult VSD patients irrespective of VSD type. Keywords: Minimally invasive surgery; CHD septal defects; Adult

Complete video-assisted thoracoscopic surgery lobectomy and its learning curve. A single center study introducing the technique in The Netherlands [Thoracic oncologic]

Thu, 22 Oct 2009 03:15:21 PDT

Data regarding the benefits for the complete video-assisted thoracic surgery (c-VATS) lobectomy over the open lobectomy are numerous. This article describes the experience of introducing this technique in a training hospital, the first reported cohort in The Netherlands. From March 2006 to November 2008, all patients operated on for proven or suspected lung cancer were analyzed. Prospective data from these patients were evaluated. A subgroup analysis for the c-VATS lobectomy is presented. A total of 184 operations were performed on 172 patients. In 122 (66.3%) of the operations the resection ended in a lobectomy of which 70 were done by complete thoracoscopic procedure. For the c-VATS lobectomy the mean operating time was 179 min, with a mean blood loss of 444 ml. The median hospital stay was 4 days. Complications were present in 10% of c-VATS lobectomies. No mortality was seen in the c-VATS group. After thorough evaluation and training, c-VATS lobectomy is a safe procedure that can be performed in a relatively low volume hospital. It has exceptional short-term benefits. For training purposes all operations must start thoracoscopically. All patients must be operated according the intention to treat method. Keywords: Thoracoscopy/VATS; Lobectomy; Lung cancer surgery; Education

Large mediastinal thoracic duct cyst [Thoracic non-oncologic]

De Santis, M., Martins, V., Fonseca, A. L., Santos, O. — Thu, 22 Oct 2009 02:45:49 PDT

Thoracic duct cysts of the mediastinum are extremely rare. The etiology is related to a congenital or degenerative weakness in the wall of the thoracic duct. Symptoms may arise from compression of adjacent structures. Surgical resection is recommended and allows a definitive histological diagnosis. Postoperative chylothorax is the most frequent complication. We describe a 30-year-old female who presented to us with a history of dry cough and hiccups within the last 4 months. Keywords: Cyst; Thoracic duct; Mediastinum; Chylothorax

Pyoderma gangrenosum associated with chronic idiopathic myelofibrosis after coronary artery bypass graft surgery [Coronary]

Sebastian, V. A., Carroll, B. T., Jessen, M. E. — Wed, 21 Oct 2009 00:42:16 PDT

Pyoderma gangrenosum (PG) is an ulceronecrotizing dermatosis that can occur after minor trauma or surgery and is rare after cardiac surgery. We report a case of PG after coronary artery bypass grafting (CABG) in a patient with chronic idiopathic myelofibrosis (CIMF). Diagnosis was made with punch skin biopsy and he was treated with systemic steroids. His lesions showed remarkable improvement with this therapy. Cardiothoracic surgeons need to consider this diagnosis in all rapidly expanding postoperative lesions, especially those that do not improve with debridement or antibiotics or conservative wound care. Keywords: Pyoderma gangrenosum; Coronary artery bypass graft surgery; Necrotizing lesion

Endobronchial schwannoma presenting with bronchial obstruction [Thoracic oncologic]

Stouffer, C., Allan, R. W., Shillingford, M. S., Klodell, C. T. — Wed, 21 Oct 2009 00:20:19 PDT

Schwannomas are relatively uncommon, benign nerve sheath tumors. Thoracic schwannomas most often appear in the posterior mediastinum. Pulmonary schwannomas are exceedingly rare and can present a diagnostic challenge. We present a case of an endobronchial schwannoma presenting with bronchial obstruction and review the literature of this unusual entity. Keywords: Bronchial neoplasm; Thoracic oncology

Staging algorithm for diffuse malignant pleural mesothelioma [Pulmonary]

Zielinski, M., Hauer, J., Hauer, L., Pankowski, J., Nabialek, T., Szlubowski, A. — Tue, 20 Oct 2009 07:20:18 PDT

An algorithm of preoperative mediastinal nodal staging with endobronchial/endoesophageal ultrasonography (EBUS/EUS) and transcervical extended mediastinal lymphadenectomy (TEMLA) combined with laparoscopy/peritoneal lavage and cytology was analyzed to establish the realistic criteria for radical multimodality treatment of malignant pleural mesothelioma (MPM). The algorithm included computed tomography (CT), thoracoscopy with multiple pleural biopsies and talc pleurodesis, EBUS/EUS and one-stage TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid. 42 patients were diagnosed from 1 January 2004 to 31 December 2008. There were 16 women and 26 men in ages ranging from 43 to 77 (mean 57.8); 31 epithelioid, 2 sarcomatoid and 9 biphasic type MPM. 21/42 patients were considered possible candidates for multimodality treatment. 3 patients who received neoadjuvant chemotherapy were excluded from this study. EBUS/EUS was performed to stage the mediastinal nodes. In 3/18 patients metastatic nodes were discovered. In the rest of the 15 patients simultaneous TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid were performed. In 3 patients TEMLA was positive, in 6 patients laparoscopy was positive and in 2 patients both TEMLA and laparoscopy were positive. Finally, 4/42 (9.5%) patients underwent thoracotomy with 1 exploration (chest wall infiltration) and 3 pleuropneumonectomies with the subsequent chemo- and radiotherapy. The proposed algorithm of preoperative staging spared the majority of MPM patients from futile surgery. Keywords: Malignant mesothelioma; Pleura; Staging

Coronary revascularization in a child with homozygous familial hypercholesterolemia [Cardiopulmonary bypass]

Nemati, M. H. — Tue, 20 Oct 2009 00:36:55 PDT

Familial hypercholesterolemia (FH) is a genetic disease caused by a mutation in low-density lipoprotein (LDL) receptor gene. It causes various presentations including tendon xanthoma and cardiac manifestations. Herein we present a young patient with homozygous FH (HFH) who presented with dyspnea and chest pain caused by coronary arteries stenosis and treated with coronary artery bypass graft (CABG) surgery at the age of 13 years. To the best of our knowledge, he is one of the the youngest patients in the English language literature for whom coronary revascularization has been done in childhood. Keywords: Familial hypercholesterolemia; Children; CABG

Spontaneous rupture of an intercostal artery in a patient with neurofibromatosis type 1 [Aortic and aneurysmal (ICVTS only)]

Aizawa, K., Iwashita, C., Saito, T., Misawa, Y. — Thu, 15 Oct 2009 04:47:11 PDT

A 48-year-old man with neurofibromatosis type 1 (NF1) presented with a right pleural effusion. A 3D computer tomography (CT)angiogram showed an aneurysm of the right 11th intercostal artery. He had no history of chest trauma so we diagnosed a spontaneous rupture of the aneurysm causing a massive effusion. We opened his pleural cavity and found lacerated pleura and active bleeding in the posterior 11th intercostal space. After controlling the active bleeding, we treated a persistent oozing from the region of the 10th–12th vertebrae with pressure hemostasis by absorbable oxidized cellulose packing. The next day, the patient gradually developed a paraplegia affecting both lower limbs. Magnetic resonance imaging (MRI) showed spinal cord compression at the level of the 9th and 10th vertebrae. We evacuated the cellulose and coagulum. The patient’s paraplegia improved and within six months he was walking without a crutch. Keywords: Neurofibromatosis type 1; Spontaneous rupture of the peripheral artery; Hemothorax; Absorbable oxidized cellulose; Paraplegia

Clinicopathologic features in resected subcentimeter lung cancer - status of lymph node metastases [Thoracic oncologic]

Zhou, Q., Suzuki, K., Anami, Y.-i., Oh, S., Takamochi, K. — Thu, 15 Oct 2009 03:35:32 PDT

Widely used low dose helical thoracic computed tomography (CT) scan in screening results is detecting more and more small-sized lung cancers. Whether systematic lymph node (LN) dissection should be done or not on subcentimeter lung cancers still remains controversial. From June 2000 to December 2008, the records of all patients who underwent resection of primary non-small cell lung cancer (NSCLC) 1 cm or less in diameter were reviewed. LN metastases and lymphatic vessel invasion (LVI) were studied between different subgroups to determine the predictors of metastases. Of all 41 patients, there were 35 (85%) cases of adnocarcinoma, 3 (7%) cases of squamous cell carcinoma, 3 (7%) cases of other types. There were 6 (15%) cases with nodal metastase. Lymphatic invasion was found in 11 (27%) patients. Tumor differentiation, visceral pleural involvement, preoperative serum carcinoembryonic antigen (CEA), ground-glass opacity content on CT and blood vessel invasion (BVI) were significant predictors for both LN metastases and LVI. Systematic LN dissection is recommended for subcentimeter patients with good risk, however, if the patient is female, or with normal CEA, or with ground-glass opacity, or with Noguchi A or B type, surgeons might omit the procedure. Keywords: Lung cancer; Subcentimeter; Lymph node metastases; Ground-glass opacity

Right ventricular failure after left ventricular assist device implantation with concomitant pulmonary embolectomy needing right ventricular assist device support in patient with terminal heart failure and asymptomatic pulmonary thrombus [Assisted circulation]

Stepanenko, A., Potapov, E. V., Krabatsch, T., Hetzer, R. — Thu, 15 Oct 2009 02:00:37 PDT

We present a case in which a left ventricular assist device (LVAD) was implanted in a patient with terminal heart failure and preoperatively diagnosed asymptomatic thrombus in the right pulmonary artery. LVAD implantation was performed with concomitant thromboembolectomy in deep hypothermic circulatory arrest (DHCA) and intra-operatively right ventricular assist device (RVAD) implantation for the treatment of acute right ventricular failure became necessary. The patient was weaned from the RVAD after 8 days of support. Keywords: Terminal heart failure; Left ventricular assist device; Asymptomatic pulmonary thrombus; Right ventricular assist device

Aorto-gastroduodenal bypass grafting for an inferior pancreaticoduodenal aneurysm and celiac trunk thrombosis [Aortic and aneurysmal (ICVTS only)]

Ritter, J. C., Johnston, M., Caruana, M. F., Laws, P. E. — Thu, 15 Oct 2009 01:27:07 PDT

We present a case of a male patient diagnosed with a large inferior pancreaticoduodenal artery (IPDA) aneurysm, associated with a fresh thrombotic occlusion of the celiac trunk. Given the risk of splanchnic ischaemia, radiologic embolisation of the aneurysm combined with celiac axis stenting was deemed unsafe. Management was therefore modified to elective revascularisation of the celiac axis prior to surgical resection of the aneurysm. A retropancreatic aorto-gastroduodenal artery bypass graft was performed prior to exposing and resecting the pancreaticoduodenal artery aneurysm. This ensured near uninterrupted retrograde supply to the celiac axis during the procedure. This is an effective, efficient and expeditious patient pathway for these rare and complex aneurysms complicated by celiac trunk involvement. Keywords: Aneurysm; Celiac artery; Splanchnic circulation

Mediastinal epithelioid hemangioendothelioma: a rare mediastinal tumour [Thoracic oncologic]

Mansour, Z., Neuville, A., Massard, G. — Thu, 15 Oct 2009 01:13:09 PDT

We report the case of a 35-year-old patient with an incidental finding of an asymptomatic large (9.5 cm in diameter) anterior mediastinal tumour. Radiological findings favoured the diagnosis of a benign mediastinal teratoma. During surgical resection, we found a tumour adhering to the surrounding tissues, and encompassing the innominate vein which was totally occluded. Total tumoral exeresis was performed as well as the double cross-section of the innominate vein. Postoperatively, there was no left upper limb swelling, probably because of a chronic occlusion of the innominate vein. The hospital stay was uneventful. Immunohistochemistry diagnosed a mediastinal 'epithelioid hemangioendothelioma', which is a tumour of vascular origin. We believe that the tumour took origin from the innominate vein and invaded the anterior mediastinum. After a simple radiological follow-up, the patient is in complete remission 30 months after the operation. We present the case of this patient with the iconography, along with a review of the available literature concerning mediastinal epithelioid hemangioendotheliomas. Keywords: Tumour; Thoracic surgery; Mediastinum

Brown-Sequard syndrome after thoracic endovascular aortic repair [Aortic and aneurysmal (ICVTS only)]

Ozaki, N., Wakita, N., Inoue, K., Yamada, A. — Thu, 15 Oct 2009 00:20:13 PDT

A 76-year-old female had suffered from distal arch aortic aneurysm and chronic DeBakey IIIB type dissecting aneurysm. The patient underwent thoracic endovascular aortic repair (TEVAR). After TEVAR the patient had a motor and proprioceptive loss on the left side and a pain and body temperature loss on the right side below the level of T7. At diagnosis of Brown-Sequard syndrome, corticosteroid and free radical scavenger were administered soon afterwards. Her neurological deficits gradually improved and the patient was discharged with walking with a stick 3 months after TEVAR. Keywords: Brown-Sequard syndrome; TEVAR

Ruptured pseudoaneurysm of the pulmonary artery - rare manifestation of a primary pulmonary artery sarcoma [Cardiac general]

Koch, A., Mechtersheimer, G., Tochtermann, U., Karck, M. — Wed, 14 Oct 2009 06:26:39 PDT

A 64-year-old male developed chest pain while gardening. Aortic dissection and coronary artery disease were excluded but chest computed tomography (CT) scan showed an aneurysmic enlargement of the pulmonary artery and a fluttering structure within. He underwent immediate sternotomy for replacement of the pulmonary artery. Histology showed an intimal sarcoma of both branches of the pulmonary artery. The pulmonary artery was replaced by a T-shaped Gore-Tex-prothesis. Keywords: Pulmonary artery sarcoma; Aneurysm; Pulmonary artery

Mechanical prosthetic mitral valve thrombosis in a first trimester pregnant woman [Cardiopulmonary bypass]

Mon, 12 Oct 2009 05:22:05 PDT

Pregnant women with a mechanical heart prosthesis are at a higher risk of thromboembolic complications. The optimal anticoagulation strategy in this setting remains unclear. When prosthesis thrombosis happens and cardiac surgery must be performed, the risk of fetal mortality is high. Special attention must be paid to improve the placental perfusion during cardiopulmonary bypass (CPB) in order to improve fetal outcomes. A 31-year-old woman, 9 weeks pregnant, was admitted to our institution due to a mitral mechanical prosthesis thrombosis. She had been receiving low molecular weight heparin (LMWH) since pregnancy was detected. She underwent a mitral valve replacement with CPB at 34 °C and a short cardiac arrest time. Both mother and fetus survived. We briefly review the different anticoagulation options during pregnancy and perfusion strategies on CPB to improve fetal outcomes. Keywords: Pregnancy; Mechanical heart valve

Barotraumatic oesophageal perforation with bilateral tension pneumothorax [Esophagus]

Chien, L.-C., Chang, H.-T., Chou, Y.-P. — Mon, 12 Oct 2009 08:46:19 PDT

Barotraumatic oesophageal perforation with bilateral tension pneumothorax is extremely rare and this is a first case reported in the literature. The possibility of the oesophageal perforation due to high-pressure gas flow should be kept in mind and the standard of diagnosis is oesophagography. Keywords: Barotrauma; Oesophageal perforation; Tension pneumothorax; Oesophagography

Perfusion temperature, thyroid hormones and inflammation during pediatric cardiac surgery [Congenital]

Mon, 12 Oct 2009 06:28:42 PDT

Objectives: During cardiopulmonary bypass (CPB) surgery there are several alterations in concentrations of thyroid hormones. Although hypothermia and inflammation have been implicated in the disturbed thyroid axis during CPB, these issues are far from clear. Methods and results: We measured serum/plasma concentrations of thyroid hormones and inflammatory mediators in children with body weight <10 kg, undergoing open heart surgery, randomized to mild (n=15, 32 °C) or moderate (n=15, 25 °C) hypothermia. During CPB there was a marked decrease in triiodothyronine (T3), free thyroxin (FT4) and thyroid-stimulating hormone (TSH), followed by a slight increase after 24 h, but without normalization 48 h after CPB. There was no difference in the thyroid response between the two hypothermia groups. During CPB the maximal changes in plasma levels of interleukin (IL)-6 and the chemokines, regulated on activation normal T cell expressed and secreted (RANTES) and monocyte chemoattractant protein (MCP)-1 were inversely correlated with the maximal changes in serum levels of T3. Conclusion: Our findings in this randomized trial do not support a role for hypothermia as a major cause of altered thyroxin responses in children undergoing CPB. Our finding may also suggest that in addition to IL-6, other inflammatory cytokines such as chemokines should be further investigated for their possible influence on the thyroid axis during CPB. Keywords: CPB; Thyroid hormones; Pediatric; Congenital heart disease; Hypothermia; Inflammatory mediators

Surgical closure of big pulmonary artery-left atrial fistula [Congenital]

Margaryan, R., Arcieri, L., Cantinotti, M., Murzi, B. — Mon, 12 Oct 2009 05:02:28 PDT

Big pulmonary artery-left atrial fistula malformation (PALAF) was diagnosed in a 5-year-old boy. Although transcatheter therapy would be preferred as a treatment of PALAF, the lesion, which was 20 mm in diameter and almost totally shunting the right main pulmonary artery, it was decided to treat by surgical approach. Keywords: Congenital heart disease; Pulmonary artery malformations; Pulmonary artery fistula

Three strikes - don't die of a broken heart [Aortic and aneurysmal (ICVTS only)]

Field, M. L., Sastry, P., Richens, D. — Thu, 08 Oct 2009 06:38:23 PDT

There are multiple layers of complexity in prevention of vehicle related blunt traumatic aortic rupture (BTAR), many of which are enshrined within government policy and car design. We present a 'layers of protection analysis' (LOPA) based loosely on original work by Professor John Doyle, which describes these attempts to 'design out' the risk of BTAR following a vehicle collision. We have modified this approach to include a physiological dimension suggesting that this may be a factor in susceptibility to aortic injury following trauma. Understanding processes involved in BTAR following vehicle collisions is key to designing preventative processes. Keywords: Trauma; Aorta; Layers of protection

Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up [Coronary]

Thu, 08 Oct 2009 05:45:52 PDT

Transfusion of red blood cells (RBC) and other blood products in patients undergoing coronary artery bypass grafting (CABG) is associated with increased mortality and morbidity. We retrospectively analyzed data of patients who underwent an isolated coronary bypass graft operation between January 1998 and December 2007. Mean follow-up was 1696±1026 days, with exclusion of 122 patients lost to follow-up and 80 patients who received more than 10 units of RBC. Of the remaining patients, 8001 (76.7%) received no RBC, 1621 (15.2%) received 1-2 units of RBC, 593 (5.7%) received 3-5 units and 220 (2.1%) received 6-10 units. The number of transfused RBC was a predictor for early but not for late mortality. When compared to expected survival, survival of patients not receiving any blood product was better, while survival of patients receiving more than 3 units of red blood cells was worse. Transfusion of RBC is an independent, dose-dependent risk factor for early mortality after revascularization. Compared to expected survival, receiving no RBC improves patient long-term survival, whereas receiving three or more units of RBC significantly decreases patient survival. Keywords: Revascularization; Blood cells; Survival; Epidemiology; Coronary disease

Surgical management of right coronary artery-coronary sinus fistula causing severe mitral and tricuspid regurgitation [Cardiac general]

El-Watidy, A. M., Ismail, H. H., Calafiore, A. M. — Thu, 08 Oct 2009 00:04:57 PDT

Coronary arteriovenous (AV) fistula is rare congenital anomaly, mostly diagnosed incidentally during routine coronary angiography. We report a symptomatic patient with right coronary artery to coronary sinus (RCA-CS) fistula, complicated by aneurysmal dilatation and thrombosis of the CS, causing severe mitral regurgitation (MR) and tricuspid regurgitation (TR). Keywords: Coronary sinus thrombosis; Coronary arteriovenous fistula; Giant coronary sinus

Warm, beating heart aortic valve replacement in a sickle cell patient [Valves]

Usman, S., Saiful, F. B., DiNatale, J., McGinn, J. T. — Tue, 06 Oct 2009 00:14:42 PDT

Patients with sickle cell abnormalities undergoing surgery are generally considered to be at greater risk for perioperative complications. We present a 25-year-old woman with sickle cell disease (SCD) and severe aortic insufficiency. A minimally invasive, warm, beating heart approach was adopted to try and minimize the risk of sickling due to cardiopulmonary bypass (CPB), low-flow states, cold cardioplegia and aortic cross-clamping. Compared to classical methods, we believe our technique further reduces the risk of systemic and organ hypothermia and thus, sickling. Keywords: Extracorporeal circulation; Minimally invasive surgery; Sickle cell; Valve disease

Excellent functional result in children after correction of anomalous origin of left coronary artery from the pulmonary artery - a population-based complete follow-up study [Congenital]

Ojala, T., Salminen, J., Happonen, J.-M., Pihkala, J., Jokinen, E., Sairanen, H. — Tue, 06 Oct 2009 00:53:04 PDT

Surgical strategy to construct a two-coronary system for a patient with anomalous origin of coronary artery from pulmonary artery (ALCAPA) has evolved with time. Limited long-term follow-up data are available on these children. We report population based follow-up in children operated on for ALCAPA. In total, 29 patients underwent aortic reimplantation of ALCAPA between 1979 and 2006. Twenty (69%) children were repaired with direct aortic implantation, five (17%) with a modified tubular extension technique, and four (14%) patients with an intrapulmonary baffling technique. Early postoperative mortality (<30 days) was 17%. No late mortality (>30 days) was detected. The median length of follow-up was 11 years (range 10 months-27 years). Global left ventricular function by echocardiography (M-mode) was within normal limits (>30%) in all patients one year after operation. Functionally, 80% of patients were classified in class NYHA I, 20% in NYHA II, and 0% in NYHA classes III/IV at the time of the last examination. Excellent results with good long-term outcome can be achieved in infants with ALCAPA using reimplantation techniques. Normalization of cardiac function is expected within the first year in all operative survivors with a patent coronary system. Keywords: ALCAPA; Child; Coronary; Follow-up; Population-based

Stented within a stentless aortic valve. A simple surgical solution for the replacement of a stentless aortic bioprosthesis [Valves]

Panagiotou, M. S., Kogerakis, N. E., Crockett, J. R., Economidou, S. V. — Mon, 05 Oct 2009 09:21:00 PDT

Stentless aortic bioprostheses are designed to offer better hemodynamics, less mechanical stress to the leaflets and as a result less degeneration. Although encouraging results are reported, little evidence has been published regarding reoperations of stentless valves. We are reporting a case of a structural valve dysfunction of an O'Brien-Angell stentless prosthesis, which could not be extracted during reoperation without damaging the aortic root. We are presenting a simple, quick and effective surgical solution, the surgical 'valve within a valve' technique for the avoidance of a redo complex root procedure. Keywords: Aortic valve surgery; Valve disease; Stentless valve

Isolated rib metastases from renal cell carcinoma [Thoracic oncologic]

Mon, 05 Oct 2009 08:49:14 PDT

Osseous metastases of renal cell carcinoma (RCC) are the second more frequent location after lung metastases. They rarely present as isolated location. When isolated, resection may offer five-year survival rates of 30-60%. The purpose of the current study is to focus on a particular subset, the isolated rib metastases (IRM). The files of six patients who underwent radical resection for IRM were reviewed. All had previous radical nephrectomy for clear-cell renal cancer. The mean age of these six men was 55.3 years. Preoperative evaluation included in all patients a conventional chest radiograph and thoracic computed tomography (CT) scanning. Chest wall resections were wide and curative. The mean disease-free interval (DFI) after renal cancer treatment was 25 months. There was no postoperative death. Two patients had synchronous disease. One of them developed two recurrences operated on by large resections. They survived for 77 and 81 months. The overall five and ten-year survival rates were respectively 83 and 66.7%. IRM of RCC are rare and remain not well-known. Surgical wide resection is a safe and effective treatment. Keywords: Chest wall; Thoracic duct; Cancer; Kidney; Osseous metastasis; Renal cancer; Metastasectomy

Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety [Cardiac general]

Papaspyros, S. C., Javangula, K. C., Adluri, R. K. P., O'Regan, D. J. — Fri, 02 Oct 2009 02:01:50 PDT

Error in health services delivery has long been recognised as significant cause of inpatient morbidity and mortality. Root-cause analyses have cited communication failure as one of the contributing factors in adverse events. The formalised fighter pilot mission brief and debrief formed the basis of the National Aeronautics and Space Administration (NASA) crew resource management (CRM) concept produced in 1979. This is a qualitative analysis of our experience with the briefing-debriefing process applied to cardiac theatres. We instituted a policy of formal operating room (OR) briefing and debriefing in all cardiac theatre sessions. The first 118 cases were reviewed. A trouble-free operation was noted in only 28 (23.7%) cases. We experienced multiple problems in 38 (32.2%) cases. A gap was identified in the second order problem solving in relation to instrument repair and maintenance. Theatre team members were interviewed and their comments were subjected to qualitative analysis. The collaborative feeling is that communication has improved. The health industry may benefit from embracing the briefing-debriefing technique as an adjunct to continuous improvement through reflective learning, deliberate practice and immediate feedback. This may be the initial step toward a substantive and sustainable organizational transformation. Keywords: Briefing-debriefing; Crew resource management; Communication; Patient safety; Team attitude

Tracheobronchomalacia treated by inserting a long T-tube into the left main bronchus [Thoracic non-oncologic]

Goto, T., Oyamada, Y., Wakaki, M., Kato, R. — Fri, 02 Oct 2009 01:06:40 PDT

An 88-year-old woman with advanced Parkinson's disease (stage V on the Yahr scale) had difficulty in expectoration and underwent tracheostomy in 1999. In July 2004, granulation tissue was formed in the tracheal lumen at the tip of the tracheostomy tube, and a standard type silicone T-tube was inserted. Thereafter, she was cared for at home, where she was doing well until early March 2009, when a decrease in SaO₂ and difficulty in sputum aspiration were noted. Bronchoscopy showed crescent type tracheobronchomalacia involving the trachea down to the orifice of the left main bronchus. Considering its localization, an intact right main bronchus, a history of tracheostomy tube placement resulting in granulation tissue formation in the lower trachea, and the future need for frequent sputum aspiration, we inserted a long T-tube into the left main bronchus, which is easily replaceable and facilitates sputum aspiration. Right-lung ventilation was maintained through a side aperture made in the long T-tube. After its insertion, her respiratory status stabilized, secretion drainage improved, and she was discharged for treatment at home. Herein, we describe a tracheobronchomalacia patient in whom airway patency was achieved by inserting a long T-tube with a side aperture into the left main bronchus. Keywords: Tracheobronchomalacia; Airway stenosis; T-tube; Bronchoscopy

Clinical usefulness of {alpha}-crystallin antibodies in non-small cell lung cancer patients [Thoracic oncologic]

Cherneva, R., Petrov, D., Georgiev, O., Trifonova, N. — Thu, 01 Oct 2009 10:19:33 PDT

The non-invasive approach of finding biomarkers in peripheral blood of cancer patients makes it useful for clinical application and cancer screening. The aim of the study was to explore the clinical utility of -crystallin antibodies as markers for diagnosis of non-small cell lung cancer (NSCLC) and screening among high-risk groups. -Crystallin antibodies were detected with enzyme-linked immunosorbent assay (ELISA) in 51 NSCLC patients, 38 high-risk chronic obstructive pulmonary disease (COPD) patients and 52 age and sex matched healthy volunteers. -Crystallin IgG antibodies differed significantly between the groups of cancer patients and the healthy volunteers (p<0.001). A cut-off value of 0.317 discerned NSCLC patients with sensitivity 62% and specificity 72% among the control group. The assay was effective in distinguishing the patients with and without lymphogenic metastatic spread of the disease (p=0.045) - sensitivity 60% and specificity 70%. The clinical significance of this marker has a modest implication in lung cancer diagnosis and screening in high-risk groups. Its importance as a prognostic marker or a marker of disease recurrence and lymph node micrometastasis should be further explored. Keywords: -Crystallin antibodies; Non-small cell lung cancer; Biomarker; Lymph node metastasis

Repair of spontaneous right ventricular rupture following sternal dehiscence. A novel technique [Cardiac general]

Efthymiou, C. A., Kay, P. H., Nair, U. R. — Thu, 01 Oct 2009 08:29:29 PDT

Spontaneous rupture of the right ventricle during the early postoperative period is a serious and potentially lethal complication. The inherent friability of the ventricular tissue makes repair difficult since myocardium is frequently weakened by infarction, mediastinitis or trauma caused by an unstable sternum or broken sternal wires. We present a novel yet simple technique for repairing the ruptured anterior wall of the right ventricle in a patient three weeks following coronary artery bypass surgery. Keywords: Ventricle rupture; Trauma; Repair

Heart transplantation using bivalirudin as anticoagulant [Transplantation]

Simsir, S. A., Schwarz, E. R., Czer, L. S.C., Hamburg, S. I. — Thu, 01 Oct 2009 08:09:53 PDT

We present the case of a man with heparin-induced thrombocytopenia (HIT) and acute idiopathic decompensated cardiomyopathy who underwent successful heart transplantation with the use of bivalirudin as anticoagulant. Keywords: Transplantation; Heart; Adult

Cardiac stunning in the clinic: the full picture [Cardiac general]

Tue, 22 Sep 2009 00:17:41 PDT

Cardiac stunning refers to different dysfunctional levels occurring after an episode of acute ischaemia, despite blood flow is near normal or normal. The phenomenon was initially identified in animal models, where it has been very well characterized. After being established in the experimental setting, it remained unclear, whether a similar syndrome occurs in humans. In addition, it remained controversial, whether stunning was of any clinical relevance as it is spontaneously reversible. Hence, many studies continue to focus on the properties and mechanisms of stunning, although therapies seem more relevant for attenuating and treating myocardial ischemia/reperfusion (I/R) injury, i.e. to bridge until recovery. This article reviews the different facets of cardiac stunning, i.e. myocardial, vascular/microvascular/endothelial, metabolic, neural/neuronal, and electrical stunning. This review also displays where these facets exist and which clinical relevance they might have. Particular attention is directed to the different therapeutic interventions that the various facets of this I/R-induced cardiac injury might require. A final outlook displays possible alternatives to further reduce the detrimental consequences of brief episodes of ischaemia and reperfusion. Keywords: Myocardial; Electrical; Metabolic; Neural; Vascular; Endothelial stunning

Up to twenty-five-year survival after aortic valve replacement with size 19 mm valves [Valves]

Mon, 21 Sep 2009 00:44:34 PDT

Long-term survival was investigated in 202 patients that underwent isolated aortic valve replacement (AVR) with 19 mm valves. There were 171 women with a mean age of 69±9 and 31 men with a mean age of 64±13 years. Patients had a mean body surface area of 1.61±0.13 m². Patient-prosthesis mismatch was moderate in 196 and severe in 6 patients. The mean follow-up for all patients was 78 months. There were 79 late deaths. The actuarial survival rates for all patients were 95±1% at 1 year, 75±2% at 5 years, 56±2% at 10 years, 41±2% at 15 years, 34±3% at 20 years and 34±2% at 25 years. Patients over 70 years old had a lower survival rate (p=0.0001). There were significant differences between ejection fraction (EF) >55% and EF <55% (p=0.0305). AVR with 19 mm valves appeared to provide satisfactory mid-term survival. Age and low EF were risk factors for shorter survival. Keywords: Mid-term survival; Patient-prosthesis mismatch; Small aortic prosthesis

Left paraxiphoidian approach for drainage of pericardial effusions [Thoracic oncologic]

Motas, C., Motas, N., Rus, O., Horvat, T. — Tue, 15 Sep 2009 00:01:27 PDT

Pericardial effusion is one of the frequent complications of malignancies, up to 15-20% of the autopsy specimens showing pericardial or cardiac metastasis. Often the pericardial fluid accumulates in large quantities leading to cardiac tamponade, which can be fatal in the absence of appropriate treatment. The authors present another type of pericardial drainage: the approach is paraxiphoidian, not subxiphoidian or with xiphoid resection. Without xiphoid proces resection, the surgery is better tolerated by patients (frequently the drainage is made under local anaesthesia). In the case of xiphoid preservation, the surgical intervention is easier (no need for hard retraction of this bone). In all the five cases with this access, the postoperative results were very good, with complete evacuation of pericardial effusion. In all the cases, the pericardial biopsy performed under visual control was sufficient for a histological diagnosis and the immunohistochemical tests, if required. Keywords: Subxiphoid pericardial window; Cardiac tamponade; Neoplasic pericardial effusion

A comparative analysis of saphenous vein conduit harvesting techniques for coronary artery bypass grafting - standard bridging versus the open technique [Cardiopulmonary bypass]

Thu, 20 Aug 2009 00:17:23 PDT

Coronary artery bypass graft (CABG) surgery involves harvesting the great saphenous vein (GSV) using the traditional open technique (TOT). This can be associated with significant leg morbidity and patient dissatisfaction. Alternatively, the standard bridging technique (SBT) is a minimally invasive procedure of vein retrieval that uses smaller frequent incisions along the length of the leg and may reduce postoperative complications. This study was designed to compare the success of SBT in reducing leg morbidity and increasing patient satisfaction. One hundred patients were recruited into the study and computer randomised into two groups of 50 undergoing SBT or TOT. Leg morbidity and patient satisfaction were analysed by assessment of pain scores, wound development and scar formation. Closure and harvesting time were also compared between the two groups. SBT was associated with better wound development (P<0.001) and a significantly higher patient satisfaction (P<0.001). Leg pain was significantly reduced amongst SBT group at rest and with movement (P<0.001). There was also a reduction in saphenous neuropathy with the use of SBT (P<0.001). No difference in closure or harvesting time was demonstrated (P=0.26 and P=0.23, respectively). This study demonstrates that harvesting the GSV by the minimally invasive SBT reduces postoperative leg morbidity and increases patient satisfaction without the need of costly equipment. SBT represents a safe, effective and financially viable technique for vein harvesting. Keywords: Saphenous vein harvesting; Standard bridging technique; Traditional open technique; Prospective comparative study; Coronary artery bypass graft

WITHDRAWN - Radial artery grafts' string-sign - role of graft spasm and competitive flow [Coronary]

Chong, C. F., Moat, N. E., Collins, P. — Fri, 05 Jan 2007 12:40:59 PST

WITHDRAWN - OWING TO AN AUTHORSHIP DISPUTE AND SUBSEQUENT REFUSAL TO SIGN OVER COPYRIGHT, THIS PAPER WAS DEFINITIVELY WITHDRAWN ON 3 JANUARY 2007.