ICVTS - Interactive Feed

Acute and chronic response of the right ventricle to surgically induced pressure and volume overload - an analysis of pressure-volume relations [Experimental]

Wed, 20 Jan 2010 07:43:40 PST

We aimed to determine the response of the right ventricle (RV) to surgically induced pressure and volume overload in both acute and chronic settings. Four-month-old sheep were operated via left anterior thoracotomy. Pressure overload of the RV was established by banding of the pulmonary trunk. Volume overload was induced by the implantation of a transannular patch to the right ventricular outflow tract. Right ventricular function was obtained with conductance catheters before and after surgery as well as three months postoperatively. Acute pressure overload resulted in an increase of end-systolic volume (ESV) (P=0.002) and end-diastolic volume (EDV) (P=0.004), increments in contractile indexes [maximal slope of systolic pressure increment (dP/dt_max), P=0.002; slope of end-systolic pressure volume relation (Ees), P=0.002; preload recruitable stroke work (PRSW), P=0.002] and an acceleration of early diastole [relaxation time (), P=0.012; maximal slope of diastolic pressure decrement (dP/dt_min), P=0.002]. Acute volume overload revealed better contractility and more prominent increases in preload (ESV, EDV; both P=0.008). Three months postoperatively, pressure overloaded hearts demonstrated superior systolic (Ees, P=0.022; PRSW, P=0.013) and diastolic reserves (dP/dt_min, P=0.013; slope of end-diastolic pressure volume relation (Eed), P=0.005; P₂₀, P=0.003) than volume overloaded hearts. Acute pressure overload leads to enhanced contractility of the RV as a result of the Anrep effect and the Frank-Starling mechanism whereas volume overload institutes only the latter. The chronically pressure overloaded RV exposes more contractile and elastic reserves than the chronically volume overloaded RV under stress conditions. Keywords: Heart defects; Congenital; Right ventricle; Pressure-volume loops; Volume overload; Pressure overload

Repair of intra-thoracic autonomic nerves using chitosan tubes [Experimental]

Matsumoto, I., Kaneko, M., Oda, M., Watanabe, G. — Wed, 20 Jan 2010 06:45:36 PST

We investigated the safety and usefulness of chitosan nano/microfiber mesh tubes (C-tubes) in regenerating damaged thoracic autonomic nerves. Animal experiments were performed in six dogs. The right thoracic sympathetic nerve (Experiment 1, n=3) and phrenic nerve (Experiment 2, n=3) were resected and sutured with C-tubes. After surgery, in Experiment 1, Horner's syndrome was observed. In Experiment 2, mobility of diaphragm was assessed by chest X-ray imaging. Nerve regeneration was assessed pathologically in both experiments. All six dogs survived without complication throughout the observational period. In Experiment 1, sympathetic nerve began to regenerate inside the C-tube at three months. At 7 and 12 months after surgery, the sympathetic nerves were connected. Though all three dogs had right Horner's syndrome after surgery, it improved at 12 months. In Experiment 2, at 12 months, the phrenic nerves were connected in two of the three dogs. In X-ray imaging, though all three dogs had eventration of the diaphragm, the right diaphragm moved in response to breathing in the dogs in which phrenic nerve regenerated. C-tubes can be safely used to facilitate the regeneration of damaged sympathetic and phrenic nerves and the restoration of their lost functions. Keywords: Bioengineering; Neurology/neurologic injury; Sympathectomy; Phrenic nerve; Autonomic nervous system

Dual left anterior descending artery distribution [Coronary]

Belostotsky, V., Veljanovska, L., Hristov, N., Mitrev, Z. — Fri, 15 Jan 2010 00:58:32 PST

Dual left anterior descending (LAD) coronary artery with distribution of the vessels from the left main coronary artery and the right aortic sinus of Valsalva is a rare coronary anomaly. Here, we report such a rare anomaly in a young female with anterior wall myocardial infarction and stenting of the 'short' LAD coronary artery, which was subsequently confirmed in the operating room and by multi-slice cardiac computerized tomography after surgery. Keywords: Dual left anterior descending artery distribution; Heart vascular anomaly

Major venous anomalies and abdominal aortic surgery [Aortic and aneurysmal (ICVTS only)]

Jimenez Gil, R., Morant Gimeno, F. — Fri, 15 Jan 2010 00:46:38 PST

Patients with an infrarenal venous anomaly are relatively rare, but are most likely to suffer bleeding from an injury during abdominal aortic surgery. During the last five years, we have performed nine abdominal aortic surgeries with major venous anomalies. There was no severe haemorrhage and actually, after 3-53 months (median 28 months) all the patients have done well. Preoperative assessment and intraoperative awareness are important to prevent unexpected injuries and subsequent excessive bleeding. If the venous anomalies are recognized and treated correctly, serious injuries can be prevented and the outcome should not be affected. In elderly patients, with severe comorbidities or inflammatory aneurysms, an endoprosthesis is preferred. Keywords: Abdominal aortic aneurysm; Inferior vena cava abnormalities; Leriche syndrome; Renal veins abnormalities

Cold-plasma coagulation in the treatment of malignant pleural mesothelioma: results of a combined approach [Thoracic oncologic]

Hoffmann, M., Bruch, H.-P., Kujath, P., Limmer, S. — Thu, 14 Jan 2010 01:39:00 PST

Malignant pleural mesothelioma is on a continuous rise throughout the Western countries. It is associated with asbestos fibre exposition in the past. Surgical approaches include extrapleural pneumonectomy and pleurectomy/decortication (P/D). We investigated the feasability of the implementation of cold-plasma coagulation (CPC) on the pleura, pericardium and diaphragm into an established therapeutic algorithm consisting of P/D and hyperthermic intrathoracal chemoperfusion (HITHOC) therapy. The underlying rationale was the prevention of cardiotoxic effects during HITHOC as well as accidental translocation of malignant cells to the abdomen. CPC was done as part of a multimodal therapy in stage III mesothelioma patients. Histologic examinations of pleural excisates after CPC were done. The patients were followed up in three-month intervals. Neither parenchymal fistulas, nor cardiotoxic effects were observed. The histologic examination of the pleural excisates showed complete predictable necrosis. Moreover, until now (median time after operation 1 year) no relapse of the disease was observed. CPC proved to be a safe technique when used on the pleura, pericardium and diaphragm. We consider our trial as a pilot-study. To evaluate potential survival benefits using this technique larger trials are mandatory. Keywords: Malignant pleural mesothelioma; Cold-plasma coagulation; Hyperthermic intrathoracic chemoperfusion

Valve repair in congenital aortic valve abnormalities [Congenital]

Pozzi, M., Quarti, A., Colaneri, M., Oggianu, A., Baldinelli, A., Colonna, P. L. — Thu, 14 Jan 2010 01:21:40 PST

Many surgical techniques have been described either to repair and to replace the aortic valve. Among the paediatric population the potential for growth has to be preserved and valve reconstruction is therefore of great importance. In the last two years 25 consecutive patients, mean age 8.6 years, with aortic valve disease, underwent aortic valve repair for aortic regurgitation (AR) (10 patients), aortic valve stenosis (5 patients) or mixed lesion (10 patients). None of the patients died neither during hospitalization nor at follow-up (median 9.25 months). In the aortic stenosis (AS) group, one patient required reoperation (re-repair). None of the patients in the AR group developed more than mild AS and mild AR during follow-up. Nine out of 10 patients of the mixed lesion group had no or trivial AR at the follow-up. Left ventricular dimension decreased in all patients after repair. With a better understanding of the causes of AS or AR and the adoption of different techniques, often used in multiple association, we believe that aortic valve repair can be achieved in most patients with a normal left ventricular outflow tract. Keywords: Aortic valve; Valve repair; Congenital

Surgical ventricular reconstruction with different myocardial protection strategies. A propensity matched analysis [Cardiac general]

D'Onofrio, A., Cugola, D., Bolgan, I., Menicanti, L., Fabbri, A., Di Donato, M. — Wed, 13 Jan 2010 05:38:53 PST

The aim of this study is to compare outcomes of patients undergoing surgical ventricular reconstruction (SVR) with normothermic cardiopulmonary bypass (CPB) and beating heart or hypothermic CPB and cardioplegic arrest. Between 2001 and 2008, 588 patients underwent SVR. A propensity score matching was performed and 91 matched pairs were created: group 1 (G1) operated with normothermic CPB and beating-heart technique, and group 2 (G2) operated with hypothermic CPB and cardioplegic arrest. Mean age was 62±9 years in G1 and 63±10 years in G2 (NS). Average follow-up was 42.7±26 months (range 1-72). Major cardiac and cerebro-vascular events (MACCE) were assessed. Thirty-day mortality was 4% in G1 and 5% in G2 (NS). Kaplan-Meier survival at six years was 79±4% and 72±9% (NS) and freedom from MACCE was 82±4% and 83±7% in G1 and G2, respectively (NS). Left ventricular volume reduction, ejection fraction and New York Heart Association (NYHA) class improvement were significant in the overall population; no significant differences were found between groups. The following independent risk factors for cardiac death were identified: mitral valve regurgitation, surgery <3 months from myocardial infarction, NYHA class III-IV. This study showed that outcomes following SVR are not affected by myocardial protection strategies neither in cardiac function and clinical status nor in survival. Keywords: Left ventricle; Myocardial remodeling/reshaping/ventriculectomy; Myocardial protection/cardioplegia

Spontaneous dissection of the splanchnic arteries [Renal and visceral (ICVTS only)]

Ozaki, N., Wakita, N., Yamada, A., Tanaka, Y. — Wed, 13 Jan 2010 05:52:21 PST

Three patients had severe abdominal pain of sudden onset. Computed tomography showed localized dissection in the superior mesenteric artery in two patients and in the celiac artery in one. With conservative therapy abdominal symptoms were self-remitted. All patients were successfully treated with medication and have been doing well during follow-up. Keywords: Dissection; Splanchnic arteries

An isolated aneurysm of the thigh anterolateral branch of the greater saphenous vein in a young patient presenting as an inguinal hernia [Venous (ICVTS only)]

Marcucci, G., Accrocca, F., Antignani, P. L., Siani, A. — Tue, 12 Jan 2010 06:14:42 PST

We report the first case of isolated aneurysm of the anterolateral branch of the greater saphenous vein in a 24-year-old man. The aneurysm was initially confused with an inguinal hernia. The patient referred with a respiratory distress due to a pulmonary embolism. The Doppler ultrasounds permitted to clarify the diagnosis. The aneurysm was removed en block under local anaesthesia. Surgeons should be aware to consider a venous aneurysm in the differential diagnosis of an inguinal mass. Indeed, due to its potential risk or embolism, the surgical treatment is mandatory. Keywords: Saphenous vein; Venous aneurysm; Pulmonary embolism

Low postoperative dose of aprotinin reduces bleeding and is safe in patients receiving clopidogrel before coronary artery bypass surgery. A prospective randomized study [Coronary]

Ovrum, E., Tangen, G., Tollfosrud, S., Ringdal, M.-A. L., Oystese, R., Istad, R. — Tue, 12 Jan 2010 05:44:01 PST

Clopidogrel (Plavix) given before the operation increases bleeding complications following coronary artery bypass grafting (CABG). High perioperative doses of aprotinin (Trasylol) are known to reduce bleeding and transfusions after cardiac surgery, but may increase the risk of thrombosis, renal impairment, and mortality. The aim of the study was to evaluate the clinical effects of aprotinin given in high doses intra- and postoperatively vs. a low postoperative dose in patients on clopidogrel. Patients admitted for first-time CABG and receiving clopidogrel with or without aspirin, were prospectively randomized either to receive a total of 75,000 kallikrein inhibitor unit (KIU)/kg aprotinin given intra- and postoperatively or 25,000 KIU/kg aprotinin after the operation. Three hundred and ninety-nine patients aged 67 years (32-87 years) were included. Postoperative bleeding was slightly different, but moderate in both groups. The transfusion rate was similar, as were the incidences of postoperative neurological disturbances and myocardial infarction. Renal impairment and need for inotropic drugs were more frequent in the high dose group. Thirty-day mortality was similar (high dose 2%, low dose 0.5%, P=0.22). A low postoperative dose of aprotinin in patients receiving clopidogrel is safe and has comparable effects regarding postoperative bleeding complications as a high dose. Keywords: Coronary surgery; Clopidogrel; Aprotinin; Bleeding; Transfusion

Primary extraskeletal Ewing's sarcoma of the lung [Thoracic oncologic]

Hancorn, K., Sharma, A., Shackcloth, M. — Tue, 12 Jan 2010 06:00:14 PST

Ewing's sarcoma is a neuroectodermal tumour characteristically presenting during the second decade of life and arising from bone. Extraskeletal Ewing's sarcoma is exceptionally rare. We present a case of a 44-year-old man who underwent pneumonectomy for a primary extraskeletal Ewing's sarcoma of the lung. This demonstrates a very rare pulmonary Ewing's sarcoma and highlights the importance of preoperative evaluation in aggressive tumours. Keywords: Lung; Tumour; Pulmonary; Extraskeletal Ewing's sarcoma

Risk of subsequent aortic dilatation is low in patients with bicuspid aortic valve and normal aortic root diameter at the time of aortic valve replacement [Cardiac general]

Dayan, V., Cura, L., Munoz, L., Areco, D., Ferreiro, A., Pizzano, N. — Tue, 12 Jan 2010 05:15:19 PST

Bicuspid aortic valves (BAVs) are associated with ascending aortic aneurysms. We studied BAV patients before and after aortic valve replacement (AVR) to determine the risk and predictors of aortic root dilatation after surgery. BAV patients (n=60) with an aortic root ≤45 mm who underwent AVR were followed by echocardiography (6.2±2 years) and aortic root measured. No statistical difference was found between the preoperative and postoperative diameter of the aortic root as well as association with the variables studied. The use of statins or b-blockers did not affect the follow-up on the aortic root diameter. Preoperative aortic root diameter between patients who died due to cardiovascular cause in the long-term did not vary when compared with those who survived. Even though the numbers of patients studied is low to make any kind of conclusions, our study permits us to suggest that AVR prevents aortic root dilation in BAV patients whose aortic root diameter at time of surgery was ≤45 mm. Keywords: Aorta; Aneurysm; Valves

Reimplantation of anomalous right coronary artery from left main coronary artery: a surgical option [Congenital]

Karimi, M., Murdison, K., Blackwood, W., Davis, W. — Fri, 08 Jan 2010 03:10:39 PST

Anomalous right coronary artery (ARCA) from left sinus of Valsalva could present in several forms either being intramural or extramural, and most occurring with separate ostium from left coronary system. ARCA originating from the left main coronary artery (LMCA) is very rare and treatments proposed for this type of anomaly are pulmonary artery translocation or coronary artery bypass grafting (CABG) of the right coronary system. There has not been any report in the literature of successful reimplantation of ARCA from LMCA, to the best of our knowledge, as another surgical option for this anomaly. We are reporting a case of successful surgical reimplantation of an ARCA from LMCA. Keywords: Acyanotic congenital heart disease; Anomalous right coronary artery; Left main coronary artery; Reimplantation

Prostatic abscess associated with Bacteroides fragilis mediastinitis after heart surgery [Cardiac general]

Radermecker, D., Michaux, I., Louagie, Y., Dive, A. — Fri, 08 Jan 2010 02:09:31 PST

Anaerobic mediastinitis after cardiac surgery is a rare and poorly understood condition. We observed a patient with diabetes and myelodysplastic syndrome who developed Bacteroides fragilis mediastinitis in conjunction with a prostatic abscess, several days after coronary artery bypass surgery; this hitherto unpublished observation suggests that suppurative infection of the genito-urinary tract may constitute a portal of entry for postoperative anaerobic mediastinitis in predisposed patients. Keywords: Coronary artery bypass grafts; Mediastinal infection; Complication; Infection; Comorbidity

Closed cardiopulmonary bypass circuits suppress thrombin generation during coronary artery bypass grafting [Cardiopulmonary bypass]

Fri, 08 Jan 2010 03:02:11 PST

Thrombin generation is considered unavoidable during cardiac surgery using cardiopulmonary bypass (CPB). We compared the effects of open and closed circuits on coagulation and fibrinolysis under identical conditions of priming volume, heparin-coating, and anticoagulation and transfusion protocols. Thirty coronary surgery patients were randomized to surgery using open circuits with open reservoirs and cardiotomy suction (open group, n=15) or closed circuits without either (closed group, n=15). In the closed group, a cell-saving device was used instead of cardiotomy suction. Blood samples were collected at eight time points from before the operation to the first postoperative morning. Thrombin-antithrombin III (TAT), fibrinogen degradation products, and D-dimer were not elevated during CPB in the closed group, but were significantly increased in the open group (P<0.0001 for all markers). The peak TAT value at the termination of CPB in the open group was significantly correlated with CPB time (r²=0.879, P=0.037) and the simultaneous peak D-dimer value (r²=0.640, P=0.040). In conclusion, the use of closed circuits maximally suppressed thrombin generation and coagulofibrinolytic activation during coronary artery bypass grafting. The respective contribution of open reservoirs and cardiotomy suction to the perioperative thrombin generation remains to be elucidated. Keywords: Cardiopulmonary bypass; Coronary artery bypass grafting; Thrombin

Argatroban as a substitute of heparin during cardiopulmonary bypass: a safe alternative? [Cardiopulmonary bypass]

Fri, 08 Jan 2010 02:47:28 PST

Objective: The patient with a diagnosis of heparin-induced thrombocytopenia and thrombosis who requires urgent cardiac surgery represents a formidable challenge. Among the alternatives to heparin, argatroban has gained widespread use in non-cardiac surgery patients. The object of this communication is to report our recent experience with this agent during cardiopulmonary bypass (CPB) and to review the cases previously published in order to better define indications, dosage, monitoring and limitations in cardiac surgery patients. Methods: A case of mitral valve replacement where argatroban was used for anticoagulation during CPB is described. The literature on the subject is reviewed and the relationship between argatroban dosage and activated clotting time (ACT) is studied by regression analysis. Results: Clotting of the oxygenator requiring prompt replacement occurred after release of cross-clamp. Upon termination of the drug, ACT remained elevated beyond the expected half-life. A significative (P<0.05) relationship was disclosed between increasing dosage and ACT, while the same relationship was absent on decreasing dosage. Conclusions: Because of unresolved issues like the possibility of clotting in the extracorporeal circuit and prolonged anticoagulation after discontinuing the drug, at present, the use of argatroban as a substitute of heparin during CPB should be restricted to those cases where the other thrombin inhibitors are contraindicated. Keywords: Cardiopulmonary bypass; Blood coagulationyanticoagulation; Physiologyypathophysiology

Impact of Clopidogrel use on mortality and major bleeding in patients undergoing coronary artery bypass surgery [Coronary]

Fri, 08 Jan 2010 02:34:46 PST

Patients who received Clopidogrel prior to coronary bypass surgery are at increased risk for bleeding that must be balanced with risk of ongoing ischemia if coronary artery bypass grafting is delayed. This study aimed to evaluate the impact of Clopidogrel on mortality and major bleeding in patients undergoing urgent coronary bypass surgery. We reviewed 451 consecutive patients who underwent urgent isolated coronary bypass surgery; 262 had not received Clopidogrel, whereas 189 received Clopidogrel ≤5 days preoperative. The primary endpoint was in-hospital death, massive transfusion or massive blood loss. Patient characteristics were almost similar between groups. There was no difference in in-hospital death or massive bleeding indices between groups (Clopidogrel: 7% vs. no Clopidogrel: 6%, P=0.9). No difference was observed even after adjusting for the date of stopping Clopidogrel preoperatively. Multivariate regression analysis showed that Clopidogrel or the duration it was stopped preoperatively, did not predict adverse outcomes. Significant independent predictors included preoperative renal dysfunction, hemoglobin level and peripheral vascular disease. Clopidogrel, or the time it was stopped prior to surgery, was not a risk factor for in-hospital death, massive bleeding, or other poor early outcomes in patients undergoing urgent coronary artery bypass surgery. Keywords: Clopidogrel; Bleeding; Coronary artery bypass surgery; Mortality

Biatrial reduction plasty with reef imbricate technique as an adjunct to maze procedure for permanent atrial fibrillation associated with giant left atria [Arrhythmia]

Wang, W., Guo, L. R., Martland, A. M., Feng, X.-D., Ma, J., Feng, X. Q. — Wed, 06 Jan 2010 08:47:31 PST

Success of the modified maze procedure after valvular operation with giant atria and permanent atrial fibrillation (AF) remains suboptimal. We report an aggressive approach for these patients utilizing biatrial reduction plasty with a reef imbricate suture technique concomitantly with valvular and maze procedure for AF. From January 1999 to December 2006, 122 consecutive Chinese patients with permanent AF and biatrial enlargement who required mitral valve±tricuspid valve (TV) surgery underwent aggressive left atrial reduction combined with radiofrequency bipolar full maze procedure. Left atrial dimensions were measured by TTE or TEE. There were 71 women (58.1%) and 51 men (41.9%) and their mean age was 45±9.5 years. Mean duration of AF was 48.4±21.4 months. All patients underwent left atrial reduction plasty with reef imbricate suture technique and full maze procedure. Their preoperative left atria measured 64±12 mm in the enlarged left atria (ELA) group and 86±17 mm in the giant left atria (GLA). Mitral valve replacement (MVR) combined with TV repair was performed in 102 patients (83%) while 21 patients underwent MVRs combined with aortic valve replacements (17%). Sixty-six (54%) patients required additional procedures and 61 (50%) of the patients also underwent left atrial appendage clot evacuation. Postoperative left atrial size was reduced to 49±8 mm (ELA) and 51±11 mm (GLA), respectively (P<0.05). Ninety-three of 122 (76%) patients were restored in normal sinus rhythm after one year clinical follow-up. Aggressive biatrial reduction plasty combined with full Maze procedure is an effective treatment for patients with permanent AF undergoing concomitant valvular surgery. Further studies utilizing the reef imbricate suture technique for atrial reduction need to subsequently be evaluated. Keywords: Atrial fibrillation; Maze; Biatrial reduction plasty; Giant left atria

Multimodality treatment of malignant pleural mesothelioma with or without immunotherapy: does it change anything? [Thoracic oncologic]

Wed, 06 Jan 2010 07:43:37 PST

The purpose of this study was to investigate immunological effector cells and angiogenesis in MPM patients, who underwent multimodality treatments. Clinical and pathological characteristics of 57 patients, with International Mesothelioma Interest Group stage II-III MPM, who underwent two different multimodality treatments (with and without immunotherapy) between 1999 and 2008 were analyzed. CD8+, CD4+ and Foxp3+ tumor-infiltrating lymphocytes, tryptase and chymase mast cells (MCs), CD34, number of microvessels and vascular endothelial growth factor were determined by immunohistochemistry. The histology was 51 epitheliomorf and 6 biphasic. The stage was III in 41 cases and II in 16 cases. With an average follow-up of 69 months (range 9-115) 14 patients are still alive and the overall median actuarial survival is 21.4 months. Tryptase MCs, CD8+ and Foxp3+ lymphocytes had significantly increased in the interleukin 2 (IL-2) treated group. Moreover, the number of microvessels was significantly lower in IL-2 treated patients. This study indicates that immunotherapy leads to an increase in cytotoxic CD8+ lymphocytes and tryptase MCs and to a decrease of the tumoral neoangiogenesis. Changes in MPM microenvironment induced by immunotherapy may play a major role in the local control of this disease and need further investigations. Keywords: Mesothelioma; Multimodality treatments; Pleurectomy; Chemotherapy; Immunotherapy

Occlusion of the right coronary artery ostium by an aortic cusp attachment [Congenital]

Shikata, F., Nagashima, M., Higaki, T., Kawachi, K. — Wed, 06 Jan 2010 05:55:51 PST

Occlusion of the right coronary artery (RCA) ostium by an aortic cusp is a rare anomaly and can be a cause of sudden death. We report the case of a child with progressive stenosis of the right coronary ostium caused by a hypoplastic right coronary cusp that adhered to the aortic wall resulting in severe myocardial ischemia. The patient underwent a Ross-Konno operation with mitral valvuloplasty for congenital aortic valvular stenosis and mitral regurgitation caused by ischemia-induced posteromedial papillary muscle dysfunction. The myocardial ischemia was relieved by resection of the deformed pouch-like cusp to disclose the RCA ostium. Postoperative myocardial scintigraphy demonstrated no myocardial ischemia and multidetector computed tomography showed no coronary ostial stenosis. Keywords: Coronary ostial stenosis; Aortic stenosis; Myocardial ischemia

In hypoplastic left heart patients is Sano shunt compared with modified Blalock-Taussig shunt associated with deleterious effects on ventricular performance? [Congenital]

Raja, S. G., Atamanyuk, I., Kostolny, M., Tsang, V. — Wed, 06 Jan 2010 05:39:13 PST

A best evidence topic in congenital cardiac surgery was written according to a structured protocol. The question addressed was: in hypoplastic left heart patients is Sano shunt compared with modified Blalock-Taussig (mBT) shunt associated with deleterious effects on ventricular performance? Sano shunt modification of Norwood procedure involves construction of a right ventricle to pulmonary artery (RV-PA) conduit as an alternative source of pulmonary blood flow. Compared with the mBT shunt, the RV-PA conduit provides a more stable haemodynamic state in the immediate postoperative period and is reported to be associated with lower interstage mortality. However, concerns regarding the impact of ventriculotomy on short- and long-term performance of single ventricle have been expressed. Altogether 101 papers were found using the reported search terms, from which seven represented 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. None of the echocardiographic or clinical outcome studies showed poor ventricular performance after ventriculotomy of the systemic RV for construction of Sano shunt. A small autopsy study of 11 patients showed greater remodelling of the ventricular myocardial extracellular matrix in patients with RV-PA conduit with potential implications for poor ventricular performance. We conclude that the current available evidence, although weak, does not show any adverse effects of ventriculotomy on ventricular performance in patients with Sano shunt in the short- and medium-term. However, all the existing studies are limited by small numbers, non-randomised design and retrospective nature with failure of correlation of echocardiographic indices to clinical outcomes. It is expected that the Pediatric Heart Network randomised controlled trial will address this important issue. Keywords: Hypoplastic left heart syndrome; Norwood procedure; Modified Blalock–Taussig shunt; Sano shunt; Ventricular function

Surgical management of primary empyema of the pleural cavity: outcome of 81 patients [Thoracic non-oncologic]

Shahin, Y., Duffy, J., Beggs, D., Black, E., Majewski, A. — Wed, 06 Jan 2010 08:14:35 PST

Postpneumonic empyema is the most common form of empyema thoracis and is still recognised as a major cause of morbidity and prolonged hospital stay. We reviewed 106 patients retrospectively who underwent surgical management of pleural empyema over a period of three years from August 2005. We identified 81 patients (76%) (58 males, mean age 52 years) with primary empyema and 25 patients (24%) with secondary empyema. The first group of patients with primary empyema was analysed. Twenty-nine patients (36%) had stage II empyema and 52 patients (64%) had stage III. The majority of stage II empyema patients underwent thoracoscopic debridement (28 patients) and one patient had open thoracotomy and debridement. Stage III patients underwent thoracoscopic decortication (32 patients) of those six patients (19%) were converted to open decortication, open decortication (19 patients) and fenestration (one patient). Mortality rate was 0% for all procedures. Median length of hospital stay was six days for thoracoscopic debridement, five days for thoracoscopic decortication and eight days for open decortication. Patients treated with video-assisted thoracoscopic surgery (VATS) debridement or decortication spent less time in hospital and the conversion rate to open procedure for stage III empyema was only 19%, which encourages us to consider VATS debridement/decortication as a first choice treatment. Keywords: Empyema thoracis; Primary empyema; Postpneumonic empyema; Video-assisted thoracoscopic surgery; VATS debridement; VATS decortication

Management of a pulsatile mass coming through the sternum. Pseudoaneurysm of ascending aorta 35 years after repair of tetralogy of Fallot [Congenital]

Attia, R. Q., Venugopal, P., Whitaker, D., Young, C. — Tue, 05 Jan 2010 02:39:43 PST

We describe a case of an ascending aortic pseudoaneurysm during long-term follow-up after repair of tetralogy of Fallot (TOF). The patient had a complex cardiac surgical history with multiple operations for the correction of TOF. The aneurysm was located at the presumed site of previous aortic cannulation. It was initially treated percutaneously with an Amplatzer^TM septal occluder device, with limited early success. After 12 months it was found to have migrated into the sac and open surgical repair was undertaken successfully. Keywords: Tetralogy of Fallot; Pseudoaneurysm; Amplatzer^TM septal occluder device

Is the use of Steri-StripTM S for wound closure after coronary artery bypass grafting better than intracuticular suture? [Cardiopulmonary bypass]

Tue, 05 Jan 2010 01:53:11 PST

Several methods have been used in wound closure after coronary artery bypass grafting (CABG). In this study, the safety and efficacy of one of these methods, Steri-Strip^TM S is compared with the traditional intracuticular suture method. Eighty-one patients undergoing CABG were prospectively randomized into two groups according to the method of skin closure: Steri-Strip^TM S group and traditional suture group. Comparison between the two methods was done with regards to the length of the wound and the time needed to close it. The median closure time with Steri-Strip^TM S was 5.45±3.35 min vs. 7.53±3.41 min in the suture group. A pain score of G6 at the first postoperative day was found in 30% of the patients in the suture group vs. 14% of the patients in the Steri-Strip^TM S group (P=0.07). Cosmetic evaluation showed a non-significant difference in the linear visual analogue score in favor of Steri-Strip^TM S group compared to the intracuticular suture group (73.1 vs. 70.1) (P=0.07). Steri-Strip^TM S is a fast, safe alternative for wound closure of the sternotomy incision and graft harvesting site. A larger study is needed to establish the potential beneficial effect of Steri-Strip^TM S on wound infection prevention. Keywords: Surgical tape; Sutures; Surgical wound; Coronary artery bypass grafting

Despite modern off-pump coronary artery bypass grafting women fare worse than men [Coronary]

Tue, 05 Jan 2010 01:31:28 PST

Female gender is an established risk factor for worse outcomes after cardiac surgery. Avoiding cardiopulmonary bypass (CPB) for coronary bypass grafting has an unknown effect on gender differences. Herein, we evaluate if gender has an impact on outcomes after modern off-pump coronary artery bypass grafting (OPCAB). From 2002 to 2007, we analyzed 983 patients (male: n=807/female: n=176) who underwent OPCAB with symptomatic multi-vessel disease at our institution. The link between gender and outcome was assessed by multivariate analysis and logistic regression. A composite endpoint was constructed from: 30-day-mortality, renal failure, prolonged intensive care unit (ICU) stay, neurological complications, use of intra-aortic balloon pump (IABP) and conversion to CPB. Mortality was 3.2% in women vs. 1.8% in men (P=0.15) and the EuroSCORE was significantly correlated to gender (6.8 vs. 5.2; P<0.001), even after correction (P=0.036). Significant more occurrence of the composite endpoint was noted in women (39.8% vs. 29.0%; P=0.007) whereas for men the risk was much lower [odds ratio (OR) 0.65; 95% CI: 0.46-0.92; P=0.015]. For both genders the logistic regression revealed a risk increase of 15% per one-point-increase of EuroSCORE (corrected) (OR 1.15; 95% CI: 1.10-1.19; P<0.0001). Women had more frequently a prolonged stay at ICU (P=0.006) and had a higher stroke rate (2.3% vs. 1.2%; P=0.29). Complete revascularization was achieved similarly (95% vs. 94%; P=0.93). OPCAB offers low mortality and excellent clinical outcome. Women are more likely to experience postoperative complications. Even if partially neutralized by avoiding CPB, gender differences remain present with modern OPCAB strategies. Keywords: Coronary heart disease; Gender differences; Off-pump surgery

Effect of hydrogen sulfide on myocardial protection in the setting of cardioplegia and cardiopulmonary bypass [Cardiopulmonary bypass]

Tue, 05 Jan 2010 02:20:29 PST

We investigated the impact of hydrogen sulfide (H₂S) on myocardium in the setting of cold crystalloid cardioplegia and cardiopulmonary bypass (CP/CPB). Eighteen male Yorkshire pigs underwent 1 h CP/CPB followed by 2 h of reperfusion. Pigs received either: placebo (control, n=9), or H₂S (as NaHS) as a bolusyinfusion (bolusyinfusion, n=6), or as an infusion (infusion, n=6). The expression pattern of various myocardial effector pathways was investigated. Coronary microvascular relaxation to endothelium-dependent and -independent agonists was assessed. No differences in cardiac function were observed among groups. Endothelium-dependent microvascular relaxation to adenosine diphosphate was improved in the H₂S bolusyinfusion group only (P<0.05). The expression of hemeoxygenase-1, phospho-heat shock proteins27 and phospho-p44/42 MAPK extracellular signal-regulated kinase were higher in H₂S-treated groups (P<0.05). Phospho-endothelial nitric oxide synthase (P=0.08), phospho-B-cell lymphoma 2 (P=0.09), and phospho-Bad (P=0.06) all displayed a trend to be higher with H₂S treatment. The expressions of apoptosis inducing factor and Bcl 2/adenovirus E1B 19 kDa-interacting protein were lower in H₂S treated groups (P<0.05). The microtubule-associated protein 1 light chain 3 ratio was lower in the infusion group vs. control animals (P<0.05). There was a trend for lower phospho-mammalian target of rapamycin expression in the infusion group (P=0.07), whereas phosphorylation of p70S6K1 was higher with H₂S-treatment (P=0.09). This study demonstrates that H₂S-treatment may offer biochemical myocardial protection via attenuation of caspase-independent apoptosis and autophagy in the setting of CP/CPB. Keywords: Cardiopulmonary bypass; Myocardial protectionyCardioplegia; Cardiac function; Apoptosis

Reopening acutely occluded cavopulmonary connections in infants and children [Congenital]

Tue, 29 Dec 2009 03:09:15 PST

Little is known about the outcome of acute thrombotic occlusion of segments of the cavopulmonary connections (CPC) in infants and children with univentricular hearts. Early recognition and aggressive therapy may result in successful salvage of some of these patients. Five consecutive patients (age range 4-8 months) presenting with acute occlusion of a CPC segment underwent emergency cardiac catheterization. After angiographic confirmation, the occluded segment was crossed using an endhole catheter and guidewire combination. Serial balloon dilation and stent implantation (ten stents in total) were undertaken to recanalize the occlusion. The stents used were mounted on balloons ranging in diameter from 6 mm to 8 mm, depending on the size of the native vessel. The sites of occlusion were the left pulmonary artery (n=4), and the left-sided superior caval vein (n=3). All occlusions could be successfully recanalized. In three patients, early reocclusion necessitated either surgery or repeat catheterization and angioplasty. There were two early deaths, due to recurrent thrombotic obstruction confirmed either at autopsy or angiography. The remaining patients are alive and well; the majority of survivors have undergone completion of the Fontan operation. A high index of clinical suspicion combined with aggressive therapy can result in successful recanalization in some infants with acutely occluded CPC segments, with acceptable long-term outcome. Keywords: Univentricular heart; Cavopulmonary shunt; Thrombosis; Recanalization; Stents

Inflammatory myofibroblastic tumour at the pacemaker site [Thoracic oncologic]

Rathinam, S., Kuntz, H., Panting, J., Kalkat, M. — Tue, 29 Dec 2009 02:53:49 PST

Inflammatory myofibroblastic tumour (IMT) or inflammatory pseudotumour is a histologically distinctive lesion occurring primarily in the viscera and soft tissue of children and young adults. We report an unusual case of IMT which had undergone malignant transformation in the chest wall at the pacemaker site. A 64-year-old male presented with a history of high fever, loss of appetite and weight loss of three months duration. He had a dual chamber pacemaker reinserted in the left infraclavicular region in the previous year. This was followed by a gradually enlarging hard swelling at the insertion site. The CT-scan showed a soft tissue mass encasing the pacing box, without intrathoracic extension. The trucut biopsy was suspicious of soft tissue sarcoma. A well encapsulated hard mass, with pacemaker embedded within it was resected en-bloc ensuring wide resection margins. Histology revealed fascicles of spindle cell proliferation with prominent inflammatory component, occasional spindle cells with prominent nucleoli and scattered atypical mitotic figures, with areas of focal necrosis. The lesional cells were negative for CD21, smooth muscle actin, ckit, cytokeratins and anaplastic lymphoma kinase 1. A diagnosis of IMT with malignant transformation i.e. inflammatory fibrosarcoma was made. He had adjuvant radiotherapy and uneventful recovery. Keywords: Pacemaker; Inflammatory myofibroblastic tumour

Intraoperative fluorescence imaging during surgery for coronary artery fistula [Congenital]

Hosono, M., Sasaki, Y., Sakaguchi, M., Suehiro, S. — Tue, 29 Dec 2009 02:37:10 PST

A 45-year-old man had a history of myocardial infarction at one month prior to admission. Coronary angiography revealed a dilated fistula originating from the left anterior descending coronary artery to the pulmonary artery. Two orifices of the draining artery were closed through pulmonary arteriotomy. Ligation of the fistulous vessels was performed at three places to ensure complete closure of the fistula. Before and after the cardiopulmonary bypass, fluorescent dye angiography was performed with indocyanine green. Fluorescence imaging revealed complete closure of the fistula and no residual shunt flow. Postoperative coronary angiography revealed neither a residual fistula nor injury to the coronary artery. Keywords: Coronary artery imaging; Fistula; Congenital heart disease; Ischemic heart disease; Pulmonary artery

Giant thymoma in the anterior-inferior mediastinum [Thoracic non-oncologic]

Limmer, S., Merz, H., Kujath, P. — Tue, 29 Dec 2009 02:22:44 PST

Thymomas are usually found in the superior mediastinum and sternotomy is the standard approach for resection. We report a case of a male patient with a giant left-sided thymoma, nearly fulfilling the whole hemithorax. Due to the sheer size of the tumor and its location in the anterior-inferior mediastinum, we performed a lateral approach for thymectomy. On resection the specimen measured 18x16x12 cm. Histology revealed a mixed stage I thymoma. The patient is doing well 36 months after resection and has no signs of recurrence. In literature, a significant increase in the risk of recurrence for thymomas >8 cm is reported. Keywords: Thymoma; Mediastinal mass; Anterior-inferior mediastinum

The rupture of descending thoracic aorta due to the necrosis of aortic intimal sarcoma [Vascular thoracic]

Tanaka, M., Tabata, M., Shimokawa, T., Takanashi, S. — Tue, 29 Dec 2009 01:20:57 PST

Aortic intimal sarcoma is rare and the prognosis is very poor. We experienced a case of ruptured aortic intimal sarcoma in the descending aorta. A 69-year-old man underwent an emergency operation for the rupture of descending aorta. The postoperative course was uneventful. The histological examination of aortic wall showed aortic intimal sarcoma. The patient developed a local recurrence and abdominal dissemination of the tumor three months after surgery. We report the case and discuss about the diagnosis and treatment of thoracic aortic intimal sarcoma. Keywords: Aortic diseases; Vascular neoplasms; Aortic rupture

New approach to reduce allograft tissue immunogenicity. Experimental data [Experimental]

Tue, 29 Dec 2009 01:59:06 PST

Objectives: Rejection is thought to contribute to the degeneration of valved allografts. Most proposed methods of decellularisation allow usage of treated valves in pulmonic position. We developed a new protocol of devitalization, which provides cell death and suppression of calcification using digitonin and ethylenediaminetetraacetic acid. The aim of the study was to evaluate new allografts in a chronic canine model. Methods: Two groups of adult mongrel dogs (5 in each) were used for allograft implantation. The cryopreserved viable (group 1) and devitalized (group 2) heart valve aorta allografts were tested. Allografts were implanted as valved patches into the thoracic aorta and explanted after four months. Histologic examination and fluorescence microscopy were used to test tissue matrix and cells in allografts. Mineralized calcium in the samples was detected using absorption spectroscopy. Results: The fluorescence microscopy proved that a significant number of cells were viable in the allografts after their cryopreservation (group 1) and all the cells were dead after anticalcinosis devitalisation (group 2). No damage of tissue matrix was observed in group 2 after devitalisation. After explantation, the cusps in both groups were either stuck to aorta wall of the allografts, or there were thrombus clots between the cusps and the wall. Internal surface was covered with neointima. Media of aortic wall was acellular. Repopulation of the viable and devitalized tissues with recipient cells during a 4-month follow-up period was not observed. In non-treated allografts, aortic walls had areas of dissection and infiltration of lymphoid cells. Devitalized patches were homogenous without dissection areas. There was no immune-cell infiltration in devitalized matrix as opposed to cryopreserved vital tissue. Conclusions: The new devitalizing technology seems effective in decreasing immune response to homologous tissue. It does not affect elasto-mechanic properties and collagenous structure of allografts. The presented data stimulate interest to the anticalcinosis devitalisation technology as an affective tool for improving biocompatibility of allografts. Keywords: Heart valve allograft; Decellularization; Devitalisation; Calcification; Immunogenicity; Canine model

Unusual primary pleural leiomyoma [Thoracic oncologic]

Rodriguez, P. M., Freixinet, J. L., Plaza, M. L., Camacho, R. — Tue, 29 Dec 2009 01:41:08 PST

Primary pleural leiomyoma is extremely rare and has only been described a few times. We present a case of a young woman with right pleuritic pain. A computed tomography confirmed the existence of a solid right pleural tumor which had compressed and displaced the lung, mediastinum and heart. Percutaneous biopsy showed a 'proliferation of smooth muscle cells without evidence of malignancy'. Surgical excision was done and the tumor was not associated to vascular, broncho-pulmonary or mediastinal structures. The definitive diagnosis was primary pleural leiomyoma. Primary pleural leiomyoma should be included in a differential diagnosis of pleural tumors and suspected in asymptomatic patients with radiologically-apparent benign tumors and the presence of smooth muscle fibers in the biopsy. Complete resection and follow-up is advised because it can grow very large and has malignant potential. Keywords: Pleural tumor; Leiomyoma

Clinical performance and biocompatibility of hyaluronan-based heparin-bonded extracoporeal circuits in different risk cohorts [Cardiopulmonary bypass]

Gunaydin, S., McCusker, K., Sari, T., Onur, M. A., Zorlutuna, Y. — Mon, 21 Dec 2009 04:29:13 PST

This prospective randomized study compares novel hyaluronan-based heparin-bonded circuits versus uncoated controls across EuroSCORE patient risk strata including biomaterial evaluation. Over a two-year period, 90 patients undergoing coronary artery bypass grafting were prospectively randomized to one of the two perfusion protocols: Group 1 was treated with hyaluronan-based heparin-bonded preconnected circuits (Vision HFO-GBS^TM, Gish, CA, USA) and Group 2 with identical uncoated controls. Each group was composed of three subgroups (n=15) with respect to preoperative evaluation of low (EuroSCORE 0-2), medium (3-5) and high (6+) risk patients. Blood samples were collected after induction (T1) and heparinization (T2), 15 min after cardiopulmonary bypass start (T3), before cessation of CPB (T4), 15 min after reversal (T5), and the first postoperative day (T6). In high-risk patients, platelet counts demonstrated significant preservation at T4, T5 and leukocyte counts were lower at T5 in hyaluronan group (p≤0.05 vs. control). C3a (ng·ml^-1) levels were significantly lower at T3 (0.2±0.04 vs. 0.31±0.05), T4 (0.25±0.04 vs. 0.51±0.05), T5(0.38±0.04 vs. 0.56±0.05) and interleukin-6 (pg·ml^-1) at T4 (91±18 vs. 124±20), T5 (110±20 vs. 220±25) in coated group vs. control (p≤0.05). Protein desorption (microalbumin) on fibers (mg·mm^-3) ) was less in hyaluronan vs. control groups (p≤0.05). Hyaluronan coating reduced platelet adhesion and cell adsorption, and modulated inflammatory response in high-risk patients. Keywords: Cardiopulmonary bypass; Hyaluronic acid; Coronary artery bypass grafting

Necrotizing fasciitis following drainage of Streptococcus milleri empyema [Thoracic non-oncologic]

Tcherveniakov, P., Svennevik, E., Tzafetta, K., Milton, R. — Mon, 21 Dec 2009 05:15:46 PST

Streptococcus milleri (SM) is a heterogeneous group of Streptococci, which is a recognized cause of purulent infections of the mediastinal and pleural spaces. These infections are notoriously resistant and require aggressive surgical management. We present our experience with a 60-year-old patient, who developed necrotizing fasciitis of the chest wall after initial bedside drainage of a SM empyema. He required extensive debridement with significant soft tissue loss and subsequent latissimus dorsi flap reconstruction to cover the defect. Keywords: Empyema; Necrotizing fasciitis; Streptococcus milleri

Scoop and run strategy for a resuscitative sternotomy following unstable penetrating chest injury [Cardiac general]

Sanchez, G. P., Peng, E. W.K., Marks, R., Sarkar, P. K. — Mon, 21 Dec 2009 03:44:35 PST

The optimal management strategy of an unstable penetrating thoracic trauma remains a debate. It is unclear whether a 'stay and treat' or 'scoop and run' to the nearest operating theatre with cardiothoracic expertise is the best strategy. We described a successful outcome of a young patient with injuries to left internal mammary artery, upper lobe and main pulmonary artery following a stab injury to his left chest. He was transferred to the nearest cardiac centre for emergency sternotomy. Thoracotomy is the classical surgical approach in emergency setting but sternotomy allows adequate exposure to repair any cardiac injury, institution of cardiopulmonary bypass, and careful inspection of the mediastinal structures to prevent any late complications including pulmonary artery pseudoaneurysm. An immediate transfer, where possible, to the nearest trauma centre with cardiothoracic expertise for 'resuscitative' sternotomy is advocated in penetrating thoracic injury for optimal outcome. An emergency room thoracotomy should be reserved to those in the extremis. Keywords: Chest; Trauma, Penetrating; Emergency

Surgical resection of solitary cardiophrenic lymph node metastasis by video-assisted thoracic surgery after complete resection of hepatocellular carcinoma [Thoracic oncologic]

Shoji, F., Shirabe, K., Yano, T., Maehara, Y. — Fri, 18 Dec 2009 00:03:23 PST

This report presents the case of a patient that developed a postoperative metastastatic tumor in the cardiophrenic lymph node as a rare pattern of distant lymph node metastases of hepatocellular carcinoma (HCC) after a complete resection. This is the case of surgically and pathologically proved cardiophrenic lymph node metastasis of HCC using video-assisted thoracic surgery. General thoracic surgeons should therefore be aware of the possibility of this rare form of extrahepatic recurrence when a growing nodule is found in the pericardial fat pad during the follow-up of a malignancy in the liver. Keywords: Cardiophrenic lymph node metastasis; Hepatocellular carcinoma; Rare form of extrahepatic recurrences; Video-assisted thoracic surgery

Cervico-mediastinal goiter: is telescopic exploration of the mediastinum (video mediastinoscopy) useful? [Thoracic non-oncologic]

Migliore, M., Costanzo, M., Cannizzaro, M. A. — Fri, 18 Dec 2009 00:26:30 PST

Surgeons are aware that most mediastinal goiters can be excised through a Kocher transverse collar incision, but in rare circumstances a partial-complete median sternotomy or a thoracotomy are mandatory. During an operation to remove a large cervico-mediastinal goiter (CMG) a profound, not massive, bleeding in the anterior mediastinum developed. Bleeding was unsuccessfully treated with packing. Instead, to perform an urgent sternotomy we used telescoping imaging to identify the source of hemorrhage, and a metallic clip was used to stop the bleeding. Since then we have prospectively used the telescope in case of large CMG causing compression of an adjacent structure. This report is a preliminary communication demonstrating the technique. Telescopic exploration of the mediastinum was performed in 7 patients. The goiters were located in the middle mediastinum in 5 patients and in the anterior and middle mediastinum in 1, respectively. The use of a telescope can help the surgeon during the removal of a large mediastinal goiter. It facilitates a) the visualization of the intrathoracic tributaries reducing the risk of haemorrhage, b) the research of ectopic thyroid gland, and finally c) minimizes the risks of complications of a median sternotomy. Keywords: Video-assisted thoracic surgery; Cervico-mediastinal goiter; Mediastinum

Necrotizing fasciitis of the chest wall [Thoracic non-oncologic]

Birnbaum, D. J., D'Journo, X. B., Casanova, D., Thomas, P. A. — Thu, 17 Dec 2009 01:05:15 PST

Necrotizing fasciitis (NF) is an uncommon infection caused by microorganism called 'flesh eating bacteria'. It remains a life-threatening condition associated with high mortality rate. Its location to the chest wall is exceptional. Herein, we report the case of a 39-year-old female, without comorbidity, presenting a NF of the chest wall complicating an empyema. We describe the surgical management with a three-step procedure: antibiotherapy-debridement, vacuum-assisted closure and delayed surgical reconstruction. Keywords: Necrotizing fasciitis; Chest wall; Group A beta-haemolytic streptococcus; Vacuum-assisted closure

Continuous coronary perfusion in redo aortic valve replacement following prior coronary surgery; an old trick for new dogs? [Cardiopulmonary bypass]

Ganesh, J. S., Bonser, R. S. — Thu, 17 Dec 2009 03:51:13 PST

The optimal myocardial protection method for aortic valve replacement in the setting of prior coronary artery bypass surgery remains a subject of debate. Protection is particularly challenging when a patent pedicled internal thoracic artery graft supplies a proximally obstructed left anterior descending artery. Herein, we describe a modification of an old technique; continuous coronary perfusion, which can be used in selected, anatomically suitable cases. Keywords: Myocardial protection; Coronary perfusion; Redo valve surgery

Removal of an external stent of the bronchus [Congenital]

Nakamura, Y., Aoki, M., Nagase, Y., Fujiwara, T. — Thu, 17 Dec 2009 03:24:26 PST

We report a case of a patient who underwent removal of an external stent of the bronchus. She had undergone external stenting for tracheobronchomalacia. After removal of the external stent, the bronchus was just as widely patent as preoperative state. Keywords: External stent; Tracheobronchomalacia

Esophageal cyst producing CA-19-9 and CA125 [Thoracic non-oncologic]

Goto, T., Maeshima, A., Oyamada, Y., Kato, R. — Tue, 15 Dec 2009 05:43:06 PST

The patient was a 59-year-old woman in whom computed tomography revealed a posterior mediastinal cyst and ovarian cystoma at a medical check-up in March 2007. Blood tests showed high CA19-9 and CA125 levels. She underwent left adnexectomy for ovarian cystoma in July 2008 and histopathological examination led to a diagnosis of dermoid cyst. The postoperative levels of CA19-9 and CA125 remained high. She developed dysphagia in February 2009, and the posterior mediastinal cyst showed a tendency to enlarge. Therefore, she underwent tumorectomy through a small thoracotomy. The cyst contained greenish fluid with CA19-9 and CA125 contents of 65,000 and 78,000 U/ml, respectively. Histologically, the cyst had a thickened wall, which contained two muscle layers, and was lined by squamous and pseudostratified ciliated epithelium. No cartilage or bronchial glands were identified. These findings led to a diagnosis of esophageal cyst. On immunohistochemical staining, the cyst-lining epithelial cells were positive for CA19-9 and CA125. The serum CA19-9 and CA125 levels returned to normal 2 months after surgery. We report a resected case of esophageal cyst producing CA-19-9 and CA125. Keywords: Esophageal cyst; CA19-9; CA125

Cardiac troponin I levels after cardiac surgery as predictor for in-hospital mortality [Cardiac general]

van Geene, Y., van Swieten, H. A., Noyez, L. — Tue, 15 Dec 2009 07:58:41 PST

Purpose: Troponin is a specific marker of myocardial damage. Increased troponins, however, are observed after almost all cardiac surgery. The clinical significance of this elevation is controversial. The aim of this study was to evaluate if troponin I (cTnI) measured 1 h after cardiac surgery provides additional information to identify patients at risk for hospital mortality. Methods: Nine hundred and thirty-eight patients undergoing cardiac surgery between October 2006 and June 2008 served as development set. This group including 688 isolated CABGs and 250 valvular (+CABG) operations, and cTnI levels were measured 1 h (CTnI) after surgery. Hospital mortality, defined as death occurring at the Radboud University Nijmegen Medical Centre (UMCN) at any time after surgery, is the studied outcome. To assess the value of cTnI as a predictor for hospital mortality, receiver-operator characteristic (ROC) curves were used. The Youden-index was used for identifying the best cut-off point. Five hundred and seventy-nine patients undergoing cardiac surgery between July 2008 and February 2009 served as validation set. Results: The median cTnI level was 1.3 µg/l, 75% inter-quartile range (IQR) 0.68-2.59 µg/l. Ten patients (1.1%) died, cTnI release of the dead, median: 6.8 µg/l was significantly higher than the measured values in the group of survivors, median: 1.3 µg/l (p<0.001). Regression analysis showed a significant correlation between cTnI and hospital mortality (p<0.001). The ROC indicates a cTnI level of 4.25 µg/l with a ROC of 0.80 as optimal cut-off point for predicting hospital mortality, with a sensitivity of 70% and a specificity of 89%. Addition of type of surgery, isolated CABG versus valve surgery, acute versus elective surgery and EuroSCORE class did not improved the ROCs. In the validation set, the median cTnI level was 1.17 µg/l. Fifty-six patients had a cTnI level >4.25 µg/l. Of the 579 patients, eleven patients (1.8%) died, 6 of them had a cTnI level >4.25 µg/l. Conclusion: Postoperative cTnI level, measured within the first hour after cardiac surgery, can identify a subgroup of patients with increased risk for hospital mortality. These patients may benefit from better monitoring, eventually with specific diagnostic and therapeutic interventions. Keywords: Cardiac surgery; Mortality; Troponin; Risk stratification

Impact of meteorological conditions on the occurrence of acute type A aortic dissections [Vascular thoracic]

Benouaich, V., Soler, P., Gouraud, P. A., Lopez, S., Rousseau, H., Marcheix, B. — Tue, 15 Dec 2009 04:27:57 PST

The impact of meteorological conditions on the occurrence of various cardiovascular events has been reported. The aim of this work was to study the correlations between weather conditions and the occurrence of type A acute aortic dissections (AADs). Between 1997 and 2007, all the medical records of patients who underwent surgery for type A AADs in Toulouse University Hospital (France) were reviewed. The clinical data were confronted with the meteorological data provided by the French national meteorological office (MeteoFrance) over the same period. Two hundred and six patients with spontaneous type A AADs underwent surgery during this period. The incidence of aortic dissection was higher in winter time than in summer (p=0.018). The days with aortic dissections were colder than those without aortic dissections (p=0.017). Statistical analysis highlighted a decrease of atmospheric temperature during the three days preceding the upset of the symptoms (p=0.0009). This work demonstrates a correlation between spontaneous type A acute aortic dissections and low atmospheric temperature. Keywords: Meteorology; Acute aortic dissection; Chronobiology; Temperature

Manufacturing and placing a bespoke support for the Marfan aortic root: description of the method and technical results and status at one year for the first ten patients [Vascular thoracic]

Fri, 11 Dec 2009 03:34:50 PST

Fatal aortic dissection commonly occurs in Marfan syndrome. Prevention currently relies on elective replacement of the aortic root. We are evaluating placement of a manufactured, bespoke external support derived from a computer aided design in a prospective study. In the first ten patients, measurements were made consistently of the ascending aorta at the level of closure of the aortic valve cusps from magnetic resonance imaging (MRI) studies taken preoperatively and at fixed intervals thereafter. Before and after images were presented for measurement amongst duplicate images of 37 unoperated Marfan patients to permit assessment of intra-observer measurement reproducibility. All images were presented in random sequence to a radiologist unaware of the research question. The largest difference between the preoperative measurement and that made at least one year after surgery was determined. All patients had surgery as planned without complications and were alive at one year. In eight of the ten patients, the largest observed change was a marked reduction in aortic root diameter. The primary objective of this surgery was achieved in each case, reinforcing the ascending aorta whilst leaving the native aortic valve intact and conserving the blood/endothelium interface. Keywords: Marfan; Aorta; Aortic root; Computer aided design

Thrombus in the distal aortic arch after apicoaortic conduit for severe aortic stenosis [Valves]

Kotani, S., Hattori, K., Kato, Y., Shibata, T. — Thu, 10 Dec 2009 00:59:06 PST

We report an uncommon case of thrombogenesis in the distal aortic arch after apicoaortic conduit (AAC) for severe aortic stenosis (AS). A 71-year-old woman underwent AAC with a bioprosthetic valve for severe AS because of heavy calcification of the ascending aorta. Although anticoagulant therapy with warfarin was performed, a postoperative computed tomographic (CT) scan revealed a thrombus in the distal aortic arch. Cine magnetic resonance imaging (MRI) revealed stagnation of the blood flow at that site. Administration of warfarin was continued. A follow-up CT-scan showed a marked reduction of the thrombus at 6 months after the surgery. A follow-up MRI revealed that the antegrade flow through the native aortic valve was decreased at one year after the surgery. We suggest that thrombogenesis may occur after AAC because of stagnation of the blood flow and that the distribution of the blood flow may change during the follow-up period. Therefore, we recommend that postoperative anticoagulant therapy should be initiated immediately, even when a bioprosthetic valve is used. Keywords: Aortic stenosis; Apicoaortic conduit; Thrombus; Anticoagulant

Operative stabilization of skeletal chest injuries secondary to cardiopulmonary resuscitation in a cardiac surgical patient [Thoracic non-oncologic]

Ananiadou, O., Karaiskos, T., Givissis, P., Drossos, G. — Thu, 10 Dec 2009 05:38:36 PST

Chest injury, including sternal and rib fractures, is the most common complication of cardiopulmonary resuscitation (CPR) that usually heals spontaneously. However, a small subset of patients has fractures that need mechanical treatment. We present a case of flail chest with sternum and left anterior rib fractures secondary to CPR in a cardiac surgical patient, which was mechanically ventilated due to respiratory complications. Open reduction and operative fixation with titanium osteosynthesis plates and locking screws in sternum and ribs was performed by a thoracic surgeon assisted by an orthopaedic surgeon. Anterior plating achieved chest stability and facilitated weaning from mechanical ventilation. The patient had an uneventful postoperative course, painfree, and experienced no sternal instability or infection throughout a 6-month follow-up period. Sternal instability after cardiac surgery occurs infrequently but can be challenging to manage. Titanium plate fixation is an effective method to stabilize complicated flail chest, with clinical utility in a cardiothoracic practice. Keywords: Cardiopulmonary resuscitation; Flail chest; Sternal osteosynthesis

Infected aneurysm of the aortic arch with purulent pericarditis caused by Streptococcus pneumonia [Vascular thoracic]

Nagano, N., Yamamoto, T., Amano, A., Kikuchi, K. — Wed, 09 Dec 2009 02:23:20 PST

A 76-year-old woman had a chest pain and high fever, who was admitted to the intensive care unit diagnosed as acute pericarditis. Enhanced CT-scan showed a 47-mm aneurysm in the aortic arch which seemed to be impending rupture and the part of the aorta looked like a pseudoaneurysm. Emergent total aortic arch replacement with a rifanpicin-bonded Dacron graft was performed. Pericardial effusion was purulent and the aorta was infected with pus discharge in the aortic wall. There were some ulcerations on the surface of the luminal wall of the aorta. One of them was penetrating into the pericardial space causing a pseudoaneurysm. Both pericardial effusion and excised aortic wall were sent to culture study and resulted in positive for Streptococcus pneumonia. The infection of the aorta, with erosion into the pericardial space, seemed to be the cause of purulent pericarditis. Antibiotic therapy was commenced immediately after surgery and continued for four weeks. Though she had neurological deficit after surgery, her infection was well controlled and there was no recurrence of infection eleven months after surgery. Keywords: Infected aortic aneurysm; Aortic arch; Streptococcus pneumonia; Purulent pericarditis

Traumatic fracture of nitinol thermoreactive sternal clips [Cardiac general]

Broadhurst, J. F., Moorjani, N., Ohri, S. — Wed, 09 Dec 2009 03:17:37 PST

Median sternotomy can be associated with significant morbidity, including non-union, dehiscence and mediastinitis. The use of flexible thermoreactive sternal clips has been introduced recently as an alternative method of sternal closure and is advocated in patients at increased risk of sternal breakdown. It is associated with a decreased incidence of sternal complications as well as allowing faster sternal closure and easy removal on resternotomy. This report describes the case of a fractured thermoreactive clip following trauma, resulting in sternal dehiscence necessitating sternal rewiring. Keywords: Thermoreactive sternal clips; Sternal closure

Granulation tissue formation at the bronchial stump is reduced after stapler closure in comparison to suture closure in dogs [Experimental]

Izumi, Y., Kawamura, M., Gika, M., Nomori, H. — Wed, 09 Dec 2009 02:59:28 PST

The aim of this study was to compare the morphology of the bronchial stump after lobectomy between mechanical stapler closure and manual suture closure. The effect of fibrin glue application on each method of closure was also observed. Right upper lobectomy was performed in beagles (n=31) using staplers (ST group) or sutures (SU group). In a separate experiment, fibrin glue was sprayed on to the stump after each respective method of closure. After 1 week, the stump region was examined macroscopically, and also by histology. Chi-square test, and Mann-Whitney test were used for comparative analysis. The incidence of adhesion formation between the surrounding tissues was significantly reduced in the ST group in comparison to the SU group (22 vs. 80%, p=0.04). The thickness of granulation tissue over the stump was significantly reduced in the ST group in comparison to the SU group (0.8±0.2 vs. 2.5±0.3 mm, p<0.0001). Vessel density in the granulation tissue was also significantly reduced in the ST group in comparison to the SU group (6±2 vs. 16±2, p=0.003). Fibrin glue application after stapler closure significantly increased the incidence of adhesion formation, granulation tissue thickness, and vessel density in the granulation tissue over the stump. Keywords: Granulation tissue; Bronchial stump; Lung lobectomy

Gastrointestinal complications after cardiac surgery - improved risk stratification using a new scoring model [Cardiac general]

Tue, 08 Dec 2009 04:51:55 PST

Gastrointestinal (GI) complications are serious consequences of cardiac surgery. The aim of this study was to develop, evaluate and validate a new risk score model for GI complications after cardiac surgery. The risk score model, named gastrointestinal complication score (GICS), was developed using prospectively collected data from 5593 patients who underwent 5636 cardiac surgical procedures between 1996 and 2001. The model was validated on 1031 cardiac surgery patients between 2005 and 2006. The scoring system's ability to predict GI complications was estimated by receiver operating characteristic (ROC)-curves and Hosmer-Lemeshow test. Fifty GI complications were identified in 47 patients (0.8%) in the developmental data set and eight (0.8%) in the validation data set. The ROC area in the developmental data set was 0.81 with a good calibration estimated by Hosmer-Lemeshow test (p=0.89). In the validation data set, the area under the curve was 0.83. The estimated probability for the patient to develop a GI complication after cardiac surgery at a GICS ≥15 is >20% and at a GICS ≤5 is <0.4%. Risk stratification according to GICS, specifically developed to predict GI complications after cardiac surgery, showed a good predictive ability. Keywords: Gastrointestinal; Risk factors; Complication; Cardiac surgery

Systematic evaluation of quality of care provided to patients undergoing pulmonary surgery helps to identify areas for improvement [Pulmonary]

Tue, 08 Dec 2009 03:31:34 PST

Systematic assessment of care pathways may identify areas of potential improvement beyond that generated by traditional outcome measures alone. This approach was used to audit a single-surgeon's practice of pulmonary resection [182 patients over 21 months, median age of 69 (range 18-86) years] by choosing 10 gold standards in 3 areas of care. Preoperative: 1) Percentage cancer patients undergoing PET scan prior to surgery, 2) Percentage of patients with predicted postoperative FEV₁ (ppoFEV₁) <40% who had gas transfer (DLCO) measured. Perioperative: 3) Percentage of operations postponed, 4-5) Percentage of cancer patients undergoing anatomical resections and systematic lymph node excision, 6) Rate of exploratory thoracotomies. Postoperative: 7-8) Risk-adjusted mortality according to thoracoscore and ESOS.01, 9) Percentage patients admitted to intensive care unit (ICU), and 10) Percentage patients discharged directly home from our unit. Postoperative mortality (2.2%), ICU admission (4%), exploratory thoracotomy (2.7%), and home discharge (98%) fared within standards. Only 57% of patients with a ppoFEV₁ <40% had DLCO tested, and 8 cases (4.4%) were postponed on the day of surgery. Analysis of the processes of care identified areas for improvement (preoperative preparation of patients, theatre cancellations and intraoperative lymph node management) even in a practice with satisfactory risk-adjusted results. Keywords: Audit; Operative mortality; Process of care; Risk-stratification

Five years follow-up after Y-graft arterial revascularization: on pump versus off pump; prospective clinical trial [Coronary]

Tue, 08 Dec 2009 00:29:40 PST

Objectives: We report our comparative experience of on-pump and off-pump full arterial coronary artery bypass grafting (CABG) using both internal mammary arteries (IMAs) anastomosed as a Y-graft. Methods: A single-center clinical study was conducted prospectively between January 2003 and May 2008. It compared the short- and mid-term clinical outcomes of on- and off-pump arterial revascularization where the left internal mammary artery (LIMA) was anastomosed to the left anterior descending (LAD) artery while the free right internal mammary artery (RIMA) graft taking off from the LIMA was used to bypass different coronary targets. Results: 192 patients were divided into 77 on-pump and 115 off-pump procedures based on the intention to treat. The mean age in both groups was 60.2±11.7 and 68.1±10.6 years, respectively (p<0.05). Mean predictive logistic EuroSCORE was 3.5±6.7% for the on-pump group and 7.3±8.6% for the off-pump group (p<0.0001). Mean number of distal anastomoses were 2.7±0.6 (group ON) and 2.5±0.6 (group OFF) (p=NS). Postoperative mortality was 2 patients (2.6%) in the on-pump group and 4 patients (3.4%) in the off-pump group (p=0.63). No major adverse cardiac event, no stroke and no late death were reported during the follow-up that averaged 36.5±18.6 months. Angina recurrence was 3 patients (2.6%) in off-pump and 2 patients (3.5%) in on-pump group (p=NS). Conclusions: The use of a free RIMA as Y-graft from the LIMA performed off pump eradicates aortic manipulations and provides complete revascularization to high-risk patients with mortality similar to the one of a lower risk population operated on pump. The morbidity and cost was lower in the off-pump group. This advocates for the widespread usage of the technique in high-risk patients. Keywords: Coronary; Off pump; On pump

The Fontan circulation: who controls cardiac output? [Congenital]

Mon, 07 Dec 2009 08:53:52 PST

In a Fontan circuit the mechanisms involved in control of cardiac output at rest and during exercise differ significantly from normal. The classical model presumes an unlimited preload which is not available in the Fontan circuit. This review critically analyzes the role of contractility, heart rate, and afterload and highlights the importance of pulmonary vascular resistance (PVR) in determining adequate preload and therefore cardiac output in these patients. A conceptual model of the determinants of cardiac output in Fontan patients is presented. Keywords: Univentricular heart; Fontan circulation; Cavopulmonary connection; Cardiac output

Right ventricular rupture due to recurrent mediastinal infection with a closed chest [Cardiac general]

Niclauss, L., Delay, D., Stumpe, F. — Thu, 03 Dec 2009 02:25:20 PST

Right ventricular (RV) rupture in cases of mediastinitis following cardiac surgery is a rare and dangerous complication. Bleeding from the right ventricle occurs mainly after sternal reopening, due to either iatrogenic manipulation (wire removal, lesions due to wiring maneuvers) or mechanical shearing forces, producing direct injury. We present a case of RV wall perforation due to infection in a recurrent postoperative mediastinitis with a closed chest. The current literature on treatment of postoperative mediastinitis is also reviewed. Keywords: Complication of CABG; Mediastinal infection; Rupture of right ventricle; Classification of sterno-mediastinitis

Determinants of body weight gain and association with neurodevelopmental outcome in infants operated for congenital heart disease [Congenital]

Thu, 03 Dec 2009 04:58:43 PST

The aim of this prospective study was to examine the determinants of growth failure and the association with neurodevelopmental outcome in infants undergoing open-heart surgery. In 107 infants undergoing open-heart surgery for congenital heart disease (CHD), we evaluated weight at birth, at surgery, and at one year of age (expressed as z-scores). Neurodevelopmental status was assessed before surgery and at one year of age. Median age at surgery was 3.9 months (range: 0.1-10.2). Mean [±standard deviation (S.D.)] weight z-score at birth was -0.27 (±1.45), before surgery -1.34 (±1.45) (p<0.001 vs. birth weight), and at one year -0.86 (±1.35), (p<0.001 vs. weight at surgery). Poor preoperative weight (<10th percentile) was associated with genetic disorders [odds ratio (OR) 5.9, p<0.001], preoperative neurological abnormalities (OR 3.41, p<0.05), and older age at surgery (OR 1.01, p<0.05). Weight <10th percentile at one year was associated with the same factors as poor preoperative weight, however, also with risk adjustment for congenital heart surgery-1 (RACHS) score >3 (OR 3.22, p<0.05). Neurodevelopmental outcome at one year was not determined by growth failure. In conclusion, impaired body weight gain before surgery is followed by a catch-up growth after surgery. However, there is no relationship to neurodevelopmental outcome. Genetic comorbidity is the most significant factor for poor weight gain. Keywords: Neurodevelopmental outcome; Cardiac surgery; Genetic disorders

Life-threatening tracheal perforation secondary to descending necrotizing mediastinitis [Thoracic non-oncologic]

Murakawa, T., Yoshida, Y., Fukami, T., Nakajima, J. — Wed, 02 Dec 2009 04:22:25 PST

Survival from destruction of the mediastinal structures secondary to descending necrotizing mediastinitis (DNM) is very rare. We present a successfully treated case of tracheal perforation secondary to DNM. A 34-year-old man with a history of type 1 diabetes mellitus, diagnosed as pharyngeal abscess and subsequent DNM affecting the anterior mediastinum and paratracheal space, was referred to our institute. The patient underwent cervico-mediastinal drainage for DNM. Nine days after the drainage operation, the membranous portion of the trachea perforated, resulting in life-threatening ventilation failure. The patient underwent closure of the fistula with the pedicled intercostal muscle flap under posterolateral thoracotomy with veno-venous extracorporeal membranous oxygenation support. Before complete recovery, open window thoracostomy was required to control residual air leak. Keywords: Mediastinal infection; Tracheal surgery; Emergency surgery; Extracorporeal membrane oxygenation

Optimal sampling methods for margin cytology examination following lung excision [Thoracic oncologic]

Utsumi, T., Sawabata, N., Inoue, M., Okumura, M. — Wed, 02 Dec 2009 02:19:30 PST

Local recurrence of the tumor after lung excision often occurs in cases with positive cytology results at the surgical stump. Some reports have described the efficacy of margin cytology examinations with various sampling procedure, though an optimum method has not been established. In the period between 2005 and 2008, 58 patients underwent a lung excision followed by a margin cytology examination at our hospital, of whom 49 were finally diagnosed with malignancy. Cytology samples were obtained by scratching the staple lines of both resected and residual lungs, and collecting lavage from washed stapler cartridges used in the procedure, with the results compared. Of the 49 cases with malignancy, 44 underwent both sampling techniques, of which 4 had positive results, 3 detected in lavage samples and 1 by the scratching method. Since neither technique detected all positive cases, it is recommended that samples be obtained using both techniques to avoid missing malignancy. Keywords: Lung cancer surgery; Lung tumor; Thoracoscopy; Video-assisted thoracic surgery

Calcifying fibrous pseudotumours: an unusual case with multiple pleural and mediastinal lesions [Thoracic non-oncologic]

Sleigh, K., Lai, W., Keen, C. E., Berrisford, R. G. — Wed, 02 Dec 2009 00:50:27 PST

Calcifying fibrous pseudotumour (CFPT) is a rare soft tissue lesion that has been reported in the pleura and mediastinum. The literature contains reports of multiple pleural lesions. We describe a case of a 22-year-old woman with multiple bilateral pleural and mediastinal CFPTs. The diagnosis was established following the resection of multiple lesions. However, many lesions remain. We discuss the clinical behaviour of CFPTs and the dilemma of leaving remaining lesions in situ. Keywords: Pleura; Neoplasia; Pseudotumour; Mediastinum

Cavo-atrial thrombectomy combined with left hemi-hepatectomy for vascular invasion from hepatocellular carcinoma on diseased liver under hypothermic cardio-circulatory arrest [Cardiopulmonary bypass]

Leo, F., Rapisarda, F., Stefano, P. L., Batignani, G. — Tue, 01 Dec 2009 08:12:43 PST

Vascular invasion of supra-hepatic veins (SHV) is a major complication of primary liver tumours. The tumorous thrombus, when extended to the vena cava and right atrium, may produce occlusion of the tricuspid valve or pulmonary embolism with sudden cardiac death. The presence of macroscopic vascular infiltration represents an advanced stage of the tumour contraindicating liver transplantation, thus liver resection with thrombectomy is the only therapeutic option in this setting despite the concerns of postoperative liver failure and the dismal results at distance. A 45-year-old male with chronic active hepatitis/cirrhosis was referred to our department for a tumour in the left hemi-liver with infiltration of the left-middle hepatic veins and a tumour thrombus extension to the right atrium. We reported a successful cavo-atrial thrombectomy, along with left hemi-hepatectomy, under hypothermic cardio-circulatory arrest (HCA). To our knowledge this technique has been used only once for primary liver cancer on chronic liver disease, this being the second case reported in literature. We conclude that this technique should be considered for atrial thrombi removal in patients affected by liver tumours in the presence of a healthy liver or of a well compensated liver cirrhosis in order to prolong the patient's life span. Keywords: Liver tumours; Liver resection; Atrial thrombus; Extracorporeal circulation; Hypothermic cardio-circulatory arrest

Mid-term evaluation of Sorin Soprano bioprostheses in patients with a small aortic annulus <=20 mm [Valves]

Tue, 01 Dec 2009 03:29:43 PST

We set to examine the mid-term outcome after aortic valve replacement (AVR) with Soprano pericardial stented bioprosthesis measuring ≤20 mm. Sixty-eight patients underwent AVR between June 2003 and January 2006 (50 women; median age 77 years; range 60-89 years). Preoperatively 60 patients (88.2%) were in NYHA class III/IV. The mean EuroSCORE was 6.7±2.3. Supra-annular aortoplasty was performed in 21 patients (30.9%), out of which 11 patients received an 18 mm prosthesis (55%). The median follow-up was 45.5 months (0.1-62 months). The 30-day mortality was 4.4% (n=3) with no early valve-related deaths. No patient suffered a cerebrovascular accident and no patient required replacement of prosthesis for coronary malperfusion. Postoperatively, the mean gradient across the 18 mm bioprosthesis (n=20) was 25±8.9 mmHg and across the 20 mm bioprosthesis (n=48) was 25.5±7.3 mmHg (p=NS). During follow-up, there was no valve-related death, re-operation for structural valve degeneration, endocarditis or valve thrombosis. There were 5 late deaths and actuarial survival at 3 and 5 years was 92.7±3.1% and 81.0±6.9%, respectively. At last follow-up, 86.7% (n=52) of survivors were in NYHA class I/II. AVR with Soprano bioprosthesis measuring ≤20 mm is associated with excellent mid-term outcome. Continued follow-up is required to determine the long-term efficacy of the prosthesis. Keywords: Aortic valve; Soprano; Aortoplasty

Impact of high titre of antiphospholipid antibodies on postoperative outcome following pulmonary endarterectomy [Cardiac general]

Tue, 24 Nov 2009 01:15:58 PST

Objective: Antiphospholipid (a-PL) antibodies, especially IgG isotype, have been associated with a variety of neurological manifestations related to thrombotic mechanism and reactivity against nervous tissues. Furthermore, high titre of a-PL antibodies has been also correlated to chronic thromboembolic pulmonary hypertension (CTEPH) and, therefore, is frequently reported in patients undergoing pulmonary endarterectomy (PEA). The impact of a-PL antibodies in postoperative outcome following PEA, however, has not been clearly evaluated yet. In this paper we investigated the impact of a high a-PL IgG titre (HAPT) on postoperative outcome following PEA. Methods: From April 1994 to October 2008, out of 204 patients undergoing PEA at our centre, 184 were prospectively screened for a-PL antibodies. According to the preoperative IgG titre, patients were divided into 2 groups: Group A (high a-PL antibodies titre - HAPT) with a-PL IgG titre >10 U/ml and Group B (low a-PL antibodies titre - LAPT) with a-PL IgG titre <10 U/ml. Early outcomes were compared between the two groups. Results: Twenty-eight patients (15%) were included in Group A, whereas 156 (85%) patients were included in Group B. HAPT influenced preoperative parameters as patients of Group A were younger compared to those of Group B (42±16 and 52±16 for group A and B, respectively, p=0.001) and presented more frequently a previous history of deep venous thrombosis (96% and 62% for group A and B, respectively, p=0.001).The two groups were homogeneous for all other operative parameters. As far as postoperative outcome, in terms of mortality and major complications, there were no differences between the two groups. Incidence of transient neurological complications, however, was significantly different (32% and 10% for Group A and B, respectively, p=0.023). Conclusions: The presence of high titre of IgG isotype a-PL antibodies significantly influences preoperative characteristics of patients undergoing PEA. Furthermore, despite that no significant differences were shown in major end points, the presence of high titre of a-PL did interfere with postoperative course as caused by an increased rate of minor and transient neurological impairment (TNI). An accurate monitoring especially during hypothermic circulatory arrest (CA) period seems, therefore, mandatory in this subgroup of patients undergoing PEA. Keywords: Pulmonary endarterectomy; Cerebral protection; Antiphospholipid syndrome

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

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.