Interactive CardioVascular and Thoracic Surgery current issue

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

Gossot, D., Pryshchepau, M., Martinez Barenys, C., Magdeleinat, P. — Wed, 20 Jan 2010 15:13:40 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 using lung retractors and vascular clamps that can be released inside the chest cavity without blocking a trocar access.

Expandable device type III for easy and reliable approximation of dissection layers in sutureless aortic anastomosis. Ex vivo experimental study [Work in progress report - Experimental]

Nazari, S. — Wed, 20 Jan 2010 15:13:40 PST

In past years, we developed expandable devices (type I and II) for sutureless aortic anastomosis. We have now further modified the device (type III) incorporating a second expandable ring, external to the main one, which can be operated contrariwise in such a way that the aortic wall (i.e. the dissection layers) is compressed between the two expandable rings, providing full control on both the layers compression pressure and the anastomosis final diameter. The device was evaluated in ex vivo experimental models of swine aortic arch fresh samples; air-tight sealing at increasing endovascular pressures was also evaluated and compared with sealing achieved by standard suturing. Ex vivo data suggest that the present version of the device can be used easily and quickly also in elliptical, asymmetric ‘oblique’ anastomosis as when concavity arch is involved. Perfect air-tight sealing of the anastomosis was verified at endovascular pressures up to 150 mmHg, while standard suture cannot withstand even minimal endovascular air pressure. Compared to the previous versions, the present device is less bulky and softer, can be used also for concavity arch resection and provides full and standardizable control on dissection layers stable and sealed approximation.

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

Ruyra-Baliarda, X. — Wed, 20 Jan 2010 15:13:40 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 (e-PTFE) sutures is a well-known technique for mitral valve repair and long-term data validate 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.

Influence of clamp duration and pressure on endothelial damage in aortic cross-clamping [Work in progress report - Cardiopulmonary bypass]

Babin-Ebell, J., Gimpel-Henning, K., Sievers, H.-H., Scharfschwerdt, M. — Wed, 20 Jan 2010 15:13:40 PST

Aortic cross-clamping during cardiac operations may injure the vessel wall and cause tissue lesions. This experimental study analyses the influence of the intravascular and external pressure and the duration of aortic cross-clamping on endothelial tissue damage. Fresh porcine aortas (n=20) were tested with intravascular pressures from 30 to 80 mmHg. The external clamp pressure, necessary to occlude the aorta, was applied by using the second cog of a commercial aortic clamp and cross-clamping was performed for 1 and 30 min. The observed pressure curves were compared to the histological findings. For occlusion of the aorta, an external pressure of at least 10-fold higher than the intravascular pressure (max. 812 mmHg) had to be applied. After 30 min of clamping, a complete endothelial destruction was observed, irrespective of intra-aortic pressure. The aortic media remained intact. After 1 min clamping, fractions of intact endothelial cells were left, ranging from 40 to 70% at different intra-aortic pressures. These results indicate that endothelial tissue lesions due to aortic cross-clamping are not avoidable, even in moderate clamp application. The duration of aortic cross-clamping but not intravascular pressure is the pivotal factor. The integrity of the aortic media can be preserved if low-force cross-clamping is achieved.

eComment: Influence of cross-clamp duration and pressure on aortic damage [eComment]

Karimov, J. H., Glauber, M. — Wed, 20 Jan 2010 15:13:40 PST

Isolated rib metastases from renal cell carcinoma [Institutional report - Thoracic oncologic]

Wed, 20 Jan 2010 15:13:40 PST

Osseous metastases of renal cell carcinoma (RCC) are the second most 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.

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

Wed, 20 Jan 2010 15:13:40 PST

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 four 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.

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

Koch, A., Loganathan, S., Radovits, T., Sack, F.-U., Karck, M., Szabo, G. B. — Wed, 20 Jan 2010 15:13:40 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.

Staging algorithm for diffuse malignant pleural mesothelioma [Institutional report - Pulmonary]

Zielinski, M., Hauer, J., Hauer, L., Pankowski, J., Nabialek, T., Szlubowski, A. — Wed, 20 Jan 2010 15:13:41 PST

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. Forty-two 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 years (mean 57.8); 31 epithelioid, 2 sarcomatoid and 9 biphasic type MPM. 21/42 patients were considered possible candidates for multimodality treatment. Three 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 three patients TEMLA was positive, in six patients laparoscopy was positive and in two patients both TEMLA and laparoscopy were positive. Finally, 4/42 (9.5%) patients underwent thoracotomy with one exploration (chest wall infiltration) and three pleuropneumonectomies with the subsequent chemo- and radiotherapy. The proposed algorithm of preoperative staging spared the majority of MPM patients from futile surgery.

Early outcomes using alemtuzumab induction in lung transplantation [Institutional report - Transplantation]

Wed, 20 Jan 2010 15:13:41 PST

Immunosuppressive regimens for lung transplantation frequently fail to prevent rejection and are toxic. Alemtuzumab was used as induction to investigate whether oral immunosuppression could be reduced. From November 2006 to March 2008, 20 consecutive lung transplant patients received alemtuzumab induction, with reduced maintenance immunosuppression; tacrolimus (target level 10 ng/ml), mycophenolate mofetil (MMF) 250 mg bid and prednisone 7.5 mg. Twenty control cases transplanted before 2006 were treated with standard immunosuppression; tacrolimus (target level 10 ng/ml), MMF 750 mg bid and prednisone 15 mg qd. End-points included patient and graft survival, acute rejection (AR) and infection rate. There were no significant differences in six-month and 12-month survival (alemtuzumab 90% vs. controls 95%, P=0.52 and 76% vs. 95%, respectively, P=0.19). AR events were similar (alemtuzumab 2/16 vs. controls 5/20, P=0.43) – as were – bacteria positive bronchoalveolar lavage (BAL) cultures (alemtuzumab 4.9±7.3 per patient per year vs. controls 2.7±3.3, P=0.26) and viral or fungal infections (alemtuzumab 0.4±1.4 per patient per year vs. controls 0.1±0.3, P=0.87; alemtuzumab 3.9±6.6 vs. controls 2.3±1.9, P=0.57, respectively). Alemtuzumab induction and reduced immunosuppression appears to offer comparable early survival, rejection and infection rates to high-dose standard immunosuppression.

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

Saksens, N. T.M., Noyez, L. — Wed, 20 Jan 2010 15:13:41 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% vs. 5.3%). Significantly more patients stopped within the two weeks before surgery (9.4% vs. 5.3%). The percentage of patients who did not have the intention to stop smoking after the operation did not decrease significantly. Significantly less older patients smoke (1.6% vs. 13.4%) and are less tolerant towards smoking in the hospital (1.8% vs. 4.1%). A significant higher percentage of older patients have stopped smoking over five years before the operation. Concerning the intention to stop smoking after the operation, there is no significant 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.

The role of integrated positron emission tomography and computed tomography in the assessment of nodal spread in cases with non-small cell lung cancer [Institutional report - Thoracic oncologic]

Tasci, E., Tezel, C., Orki, A., Akin, O., Falay, O., Kutlu, C. A. — Wed, 20 Jan 2010 15:13:41 PST

Integrated positron emission tomography and computed tomography (PET/CT) scanning has become the standard for oncologic imaging. We sought to determine the role of PET/CT in mediastinal non-small cell lung cancer staging. One hundred and twenty-seven consecutive patients were enrolled in the study where PET/CT was performed due to pathologically defined non-small cell carcinoma from a single center. They all underwent complete resection with a thoracotomy and systemic lymph node dissection (SLND) between October 2005 and January 2007. Postoperative pathology results of lymph node stations regarding the nodal spread and stage were compared with clinical stage obtained by PET/CT. The sensitivity, specificity, accuracy, negative predictive value (NPV) and positive predictive value (PPV) of PET/CT in N2 cases were determined to be 72.0%, 94.4%, 92.7%, 97.7% and 49.2%, respectively. Maximum standard uptake (SUV_max) cut-off value for mediastinal N2 involvement in PET/CT was obtained by applying ‘receiver operating characteristic’ (ROC) analysis that was set to 5.2. Correct stage with PET/CT was established in 76.3% of cases. Staging of non-small cell lung cancer (NSCLC), according to the PET/CT for which we determined 97.79% NPV, we consider that thoracotomy without preoperative mediastinal invasive staging in cases of negative mediastinal involvement in PET/CT can be certainly performed.

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

Usta, E., Mustafi, M., Ziemer, G. — Wed, 20 Jan 2010 15:13:41 PST

The aim of this study was to establish a practical simplified formula to facilitate the management of a frequently 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. One hundred and fifty patients after cardiac surgery with basal pleural opacity on chest X-ray have been included in our prospective observational study during a two-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). One hundred and thirty-five 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.

Left ventricular circumferential plication: novel off-pump ventricular restoration in swine model [Institutional report - Experimental]

Toda, K., Taniguchi, K., Sawa, Y. — Wed, 20 Jan 2010 15:13:41 PST

We hypothesized that left ventricular (LV) and subvalvular geometries could be restored in a less invasive manner by circumferential plication without a ventriculotomy or a cardiopulmonary bypass (CPB). Continuous sutures were placed circumferentially on the epicardial surface of the LV wall without using a CPB in six healthy pigs. Coronary artery occlusion was precluded by placing the sutures underneath the peripheral coronary artery. After the circumferential sutures were plicated to 75% of the original length, hemodynamics were recorded and LV geometries and function were measured. All animals survived after plication without arrhythmia or hemodynamic deterioration. Angiogram findings demonstrated that plication reduced the LV end-diastolic volume (LVEDV) (72±10 vs. 58±12 ml, P<0.05), and sphericity (0.62±0.04 vs. 0.58±0.03, P<0.05). Also, three-dimensional echocardiography (3D-echo) showed that plication reduced the papillary muscle distance (27±3 vs. 18±2 mm, P<0.05). We demonstrated the effectiveness of off-pump circumferential plication, which reduced LV volume and altered subvalvular geometry without causing hemodynamic deterioration in an acute animal model. This pilot study suggests that our novel technique is feasible and should next be tested in a chronic model with a dilated failing heart, before clinical application is warranted.

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

Wed, 20 Jan 2010 15:13:41 PST

Reduction of sternal adhesions is still an issue in cardiac surgery. To evaluate a new fibrillar porcine collagen absorbable membrane (Cova^TM CARD), 16 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 four 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.

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

Wed, 20 Jan 2010 15:13:41 PST

Recently, morphometric measurements of the ascending aorta have been done with ECG-gated multidector 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.

Parabolic resection for mitral valve repair [Institutional report - Valves]

Drake, D. H., Drake, C. G., Recchia, D. — Wed, 20 Jan 2010 15:13:41 PST

Parabolic resection, named for the shape of the cut edges of the excised tissue, expands on a common ‘trick’ used by experienced mitral surgeons to preserve tissue and increase the probability of successful repair. Our objective was to describe and clinically analyze this simple modification of conventional resection. Thirty-six patients with mitral regurgitation underwent valve repair using parabolic resection in combination with other techniques. Institution specific mitral data, Society of Thoracic Surgeons data and preoperative, post-cardiopulmonary bypass (PCPB) and postoperative echocardiography data were collected and analyzed. Preoperative echocardiography demonstrated mitral regurgitation ranging from moderate to severe. PCPB transesophageal echocardiography demonstrated no regurgitation or mild regurgitation in all patients. Thirty-day surgical mortality was 2.8%. Serial echocardiograms demonstrated excellent repair stability. One patient (2.9%) with rheumatic disease progressed to moderate regurgitation 33 months following surgery. Echocardiography on all others demonstrated no or mild regurgitation at a mean follow-up of 22.8±12.8 months. No patient required mitral reintervention. Longitudinal analysis demonstrated 80% freedom from cardiac death, reintervention and greater than moderate regurgitation at four years following repair. Parabolic resection is a simple technique that can be very useful during complex mitral reconstruction. Early and intermediate echocardiographic studies demonstrate excellent results.

eComment: Physiological chordal stress sharing [eComment]

Nazari, S. — Wed, 20 Jan 2010 15:13:41 PST

Tyrosine kinase expression in pulmonary metastases and paired primary tumors [Institutional report - Thoracic oncologic]

Muehling, B. M., Toelkes, S., Schelzig, H., Barth, T. F.E., Sunder-Plassmann, L. — Wed, 20 Jan 2010 15:13:41 PST

Tyrosine kinase inhibitors against the receptors of vascular endothelial growth factor (VEGFR), epidermal growth factor (EGFR) and the platelet derived growth factor (PDGFR) are increasingly used in the treatment of progressive cancers. However, the expression of these receptors especially in lung metastases has not been examined. Tissue specimen from 35 lung metastases of 33 patients with renal cell carcinoma (n=8), sarcoma (n=10), colorectal carcinoma (n=6), otolaryngologic carcinoma (OLC, n=4), testicular and endometrial cancer (n=1 each), malignant melanoma (n=1), adrenal cancer (n=2), malignant fibrous histiocytoma and malignant peripheral nerve sheath tumor (n=1 each) have been immunohistochemically tested for the expression of PDGFR /β, VEGFR and EGFR. None of the patients had been pretreated with angiogenic inhibitors prior to metastasectomy. PDGFR was expressed in all metastases; 31% stained negative for PDGFRβ, 86% negative for VEGFR and 45% negative for EGFR. Primary tumors revealed positive staining for PDGFR in 88%, for PDGFRβ in 59%, for VEGFR in 0% and for EGFR in 18%. Our investigation of a pilot character represents a ‘biomarker-based’ analysis of pulmonary metastases of different primary tumors; we conclude that an immediate ‘tumor profiling’ at initial diagnosis should be considered in order to guide tumor therapy individually.

Quality of life in patients related to gender differences before and after coronary artery bypass surgery [ESCVS article - Coronary]

Wed, 20 Jan 2010 15:13:41 PST

Objective: The different aspects of quality of life (QOL) in patients of different sex structure have been examined as well as the presumption that sex structure could be a predictor of QOL changes after coronary artery bypass grafting (CABG). Methods: The study included 243 consecutive patients who underwent an elective CABG. The QOL analysis was performed by using structured interviews with the Nottingham Health Profile (NHP) questionnaire part 1. Results: Compared to men, women had worse preoperative QOL (in all sections except the section of sleep) and worse postoperative QOL (in all sections). Six months after CABG the QOL statistically improved in men and in women. Multivariate analysis showed that being female was an independent predictor of QOL worsening in section of pain [P=0.001, odds ratio (OR)=3.93, 95% confidence interval (CI) 1.74–8.88]. Conclusions: Compared to men, women have worse preoperative and postoperative QOL. Female sex was an independent predictor of QOL worsening six months after CABG.

The EuroSCORE - still helpful in patients undergoing isolated aortic valve replacement? [ESCVS article - Cardiac general]

Wed, 20 Jan 2010 15:13:41 PST

Background: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most prominent scores used for the evaluation of predicted mortality in cardiac surgery. The aim of our study was to analyze the logistic and additive EuroSCORE in view of its accuracy for patients undergoing isolated aortic valve replacement (AVR). Methods: A total of 652 patients underwent isolated AVR from January 1999 to June 2007. Emergency and redo operations were included. Acute endocarditis was excluded. Out of logistic regression analyses, receiver operating characteristic (ROC) curve statistics were calculated both for the logistic and additive EuroSCORE. Results: By using the identical variables used in the EuroSCORE, the area under curve was 70.7% for the logistic and 72.4% for the additive EuroSCORE, respectively. If age, which is by nature positively correlated with increasing cardiac and non-cardiac comorbidity, is calculated as a single parameter, the area under curve remains at 69.9% being very close to the result of the EuroSCORE. Conclusions: For the subgroup of patients undergoing isolated AVR, the use of the EuroSCORE provides a comparable precision concerning the estimation of early mortality compared with the simple factor ‘age’. The extended use of the EuroSCORE in view of percutaneous AVR, the insufficient accuracy of the score bears the risk of incorrect decision-making.

eComment: Re: The EuroSCORE - still helpful in patients undergoing isolated aortic valve replacement? [eComment]

Bockeria, L. A., Scopin, I. I., Dmitrieva, Y. S. — Wed, 20 Jan 2010 15:13:42 PST

Isolated iliac artery aneurysms: six-year experience [ESCVS article - Aortic and aneurysmal]

Wed, 20 Jan 2010 15:13:42 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 to a better characterization of a rare pathology demonstrating that both surgical and endovascular treatment can be performed with very low morbidity and mortality.

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

Wed, 20 Jan 2010 15:13:42 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 at least one 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.

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

White, R. W., Sivananthan, M. U., Kay, P. H. — Wed, 20 Jan 2010 15:13:42 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.

Experimental use of an elastomeric surgical sealant for arterial hemostasis and its long-term tissue response [Follow-up papers - Experimental]

Oda, S., Morita, S., Tanoue, Y., Eto, M., Matsuda, T., Tominaga, R. — Wed, 20 Jan 2010 15:13:42 PST

Objective: Reliable suture line hemostasis should improve the outcome of aortic surgery. We examined the hemostatic effect and the tissue response of a novel elastomeric surgical sealant. Methods: Using porcine internal carotid arteries, we performed 16 end-to-end anastomoses with four stitches of simple interrupted sutures under full heparinization. The anastomoses were divided into two groups (eight anastomoses per group). Either novel sealant or fibrin glue was applied. The amount of bleeding was measured during the 30 s period after removing the vascular clamp. In a separate experiment, we applied the novel sealant around the abdominal aorta of rabbits (n=6) to assess the effect of the elastomeric property of the sealant on arterial wall histology. For comparison, we applied cyanoacrylate, which has no elastomeric property (n=6). A histological study was performed three months after the operation. Results: The novel sealant prevented arterial bleeding. The amount of bleeding from the anastomoses applied with novel sealant and fibrin glue was 0.12±0.03 g vs. 91.8±16.5 g, respectively (P<0.001). Thinning of the rabbit aortic wall was observed in the cyanoacrylate-treated abdominal aorta, whereas no thinning was observed in the novel sealant group. Histological examination revealed neither cell death nor necrosis in the novel sealant group. Conclusions: The novel sealant effectively prevented arterial bleeding from the anastomosis under full heparinization. In addition, the elastomeric property of the sealant prevented thinning of the aortic wall. The novel sealant may be a promising hemostatic agent for arterial anastomosis.

Volume load paradox while preparing for the Fontan: not too much for the ventricle, not too little for the lungs [State-of-the-art - Congenital]

Wed, 20 Jan 2010 15:13:42 PST

Ventricular dysfunction is frequently encountered in Fontan patients. Cardiologists and cardiac surgeons have, therefore, mainly focused on preservation of cardiac function, limiting the early volume overload as much as possible both in magnitude and duration. This resulted in improved cardiac function but, in some patients, also in poor pulmonary artery (PA) growth which in turn resulted in a poor final Fontan circuit. The volume requirements for optimal growth and development of the ventricle and the lungs are different and divergent. Avoiding overload of the ventricle is important, but excessive protection from volume overload may not be necessary and may result in PA hypoplasia, which in turn will severely affect the Fontan circuit.

A meta-analysis of minimally invasive versus traditional open vein harvest technique for coronary artery bypass graft surgery [State-of-the-art - Coronary]

Markar, S. R., Kutty, R., Edmonds, L., Sadat, U., Nair, S. — Wed, 20 Jan 2010 15:13:42 PST

The long saphenous vein remains the most commonly used conduit in coronary artery bypass surgery. Vein harvest is a critical component of this operation with significant morbidity associated with large leg wounds from open techniques. Here, we analyse the available literature comparing minimally invasive techniques vs. the traditional open method for vein harvest. A systematic literature search of Medline, Embase and Cochrane databases was performed using the following terms; ‘saphenous vein’, ‘coronary artery bypass’, ‘tissue and organ harvesting’ and ‘endoscopic’. Relevant papers were then analysed using Statsdirect software. There was significantly reduced leg wound infection, leg wound haematoma and postoperative pain in the minimally invasive group. There was no statistical difference between the groups for vein harvest time, length of hospital stay and incidence of vein injury. There was a significantly reduced long-term graft patency in veins harvested by a minimally invasive technique. The results of this meta-analysis demonstrate the operative advantages of minimally invasive techniques for the purposes of vein harvest in coronary artery bypass surgery. However, further studies are required to look at long-term graft patency following minimally invasive vein harvest as this remains a major concern.

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

Abdul Aziz, K. A., Meduoye, A. — Wed, 20 Jan 2010 15:13:42 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 16 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 16 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.

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

Freynet, A., Falcoz, P.-E. — Wed, 20 Jan 2010 15:13:42 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, nine 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.

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

Ali, E., Saso, S., Ahmed, K., Athanasiou, T. — Wed, 20 Jan 2010 15:13:42 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 four papers represented the best evidence to answer the clinical question. Two 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, three studies provided patency data one year after CABG. No patency data were available five years after CABG. Only two papers were comparative studies (skeletonized conduits vs. pedicled conduits). Despite the above, short- and medium-term patency rates of skeletonized conduits are excellent. In the two 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 four studies. Overall patency rates were 100% within 18 days, 98.3% within three months, 97.6% at a mean of ~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 two non-comparative studies support the above conclusion.

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

Ali, E., Saso, S., Ashrafian, H., Athanasiou, T. — Wed, 20 Jan 2010 15:13:42 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 >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. Four out of the 11 papers were comparative studies (skeletonized conduits vs. pedicled conduits) and four studies produced one-year follow-up data. No studies revealed long-term patency rates as there was no follow-up data beyond five 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 three months, 92.4% at a mean of ~1 year, 91.5% at a mean of ~2 years, and 86.4% at 4 years. In the four comparative studies, skeletonization patency was at least comparable and in one study superior to pedicled conduits. One study revealed a higher four-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 three 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.

Should patients with asymptomatic severe mitral regurgitation with good left ventricular function undergo surgical repair? [Best evidence topic - Cardiac general]

Ogutu, P., Ahmed, I., Dunning, J. — Wed, 20 Jan 2010 15:13:42 PST

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, ‘Does severe asymptomatic mitral regurgitation (MR) require surgery or is watch and wait the optimal strategy?’. Over 103 papers were found using the reported search, and 10 represented the best evidence to answer this clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No studies in the modern era have shown significant survival benefit for patients undergoing surgery for asymptomatic severe MR if they have good left ventricular (LV) function. The progression rate to surgery on developing symptoms is 10% per year in these patients. Ling et al. reported a 63% incidence of congestive heart failure and 30% incidence of chronic atrial fibrillation (AF) at 10 years for conservative treatment, during which period 90% either underwent surgery or died. In addition, one study of 478 patients with good LV operated on in the 1980s showed a 76% 10-year survival in patients who were NYHA I/II but only a 48% 10-year survival in patients with NYHA III/IV although this group was older and had more AF. Early surgery has very good peri- and postoperative survival rates, and the American Heart Association currently recommend that these patients may be operated on if the chance of repair is >90%. Patients may, therefore, be reassured that either strategy is acceptable.

eComment: Optimal management of severe asymptomatic mitral regurgitation [eComment]

Skopin, I. I., Tsiskaridze, I. M. — Wed, 20 Jan 2010 15:13:42 PST

Should patients undergoing cardiac surgery with atrial fibrillation have left atrial appendage exclusion? [Best evidence topic - Cardiac general]

Dawson, A. G., Asopa, S., Dunning, J. — Wed, 20 Jan 2010 15:13:42 PST

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Should patients undergoing cardiac surgery with atrial fibrillation (AF) have left atrial appendage (LAA) exclusion?’ Altogether 310 papers were found using the reported search, of which 12 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. We conclude that despite finding five clinical trials including one randomised controlled trial, that studied around 1400 patients who underwent LAA occlusion, the results of these studies do not clearly show a benefit for appendage occlusion. Indeed of the five studies, only one showed a statistical benefit for LAA occlusion, with three giving neutral results and in fact one demonstrating a significantly increased risk. One reason for this may be the inability to achieve acceptably high rates of successful occlusion on echocardiography when attempting to perform this procedure. The highest success rate was only 93% but most studies reported only a 55–66% successful occlusion rate when attempting closure in a variety of methods including stapling, ligation and amputation. Currently, the evidence is insufficient to support LAA occlusion and may indeed cause harm especially if incomplete exclusion occurs.

eComment: The eternal dilemma of the left atrial appendage in the atrial fibrillation surgery [eComment]

Garcia-Villarreal, O. A., Gonzalez-Oviedo, R. — Wed, 20 Jan 2010 15:13:42 PST

Minimally invasive non-endoscopic vein harvest using a laryngoscope. A preliminary experience [Brief communication - Cardiac general]

Ceresa, F., Patane, F. — Wed, 20 Jan 2010 15:13:42 PST

Minimally invasive vein harvesting (MIVH) has been developed in order to reduce the wound healing complications and the related cost. Therefore, the operative cost of endoscopic harvesting remains higher in comparison with the open harvesting. We describe a laryngoscope-assisted technique of saphenous vein harvesting, performing a few small skin incisions and with minimum additional cost. We have used our technique in 20 patients up to now without infection or other wound-related complications and with good cosmetic results.

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

Honda, K., Okamura, Y., Nishimura, Y., Uchita, S. — Wed, 20 Jan 2010 15:13:42 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 (ISSP) bioprosthesis.

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

Kuppuswamy, M., Gukop, P., Sutherland, G., Venkatachalam, C. — Wed, 20 Jan 2010 15:13:42 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.

eComment: Coronary artery aneurysms in Kawasaki disease [eComment]

Koniari, I., Apostolakis, E., Baikoussis, N. G., Tsigkas, G. — Wed, 20 Jan 2010 15:13:42 PST

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

Wippermann, J., Hoppe, U. C., Sreeram, N., Wahlers, T. — Wed, 20 Jan 2010 15:13:42 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 two 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.

The semi-clamshell approach for the single-stage treatment of thoracic mycotic aneurysm [Case report - Aortic and aneurysmal]

Saito, Y., Fukuda, I., Daitoku, K., Taniguchi, S. — Wed, 20 Jan 2010 15:13:42 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.

Successful use of continuous flow ventricular assist device in a patient with mechanical mitral and aortic valve prosthesis without replacement or exclusion of valves [Case report - Assisted circulation]

Krishan, K., Pinney, S., Anyanwu, A. C. — Wed, 20 Jan 2010 15:13:42 PST

In patients with left-sided mechanical aortic prostheses, it is recommended that the mechanical valve be replaced with a bioprosthesis, or excluded, at implantation of left ventricular assist device (LVAD). As changes in flow across the valve leads to potential thromboembolic complications, mechanical valves within the native heart are a relative contraindication to LVAD therapy. We here describe a patient who had long-standing valvular cardiomyopathy with mitral Starr-Edwards mechanical valve (Edwards Lifesciences, CA, USA) and aortic bileaflet tilting disc (St Jude Medical, St Paul, MN, USA) where LVAD was placed without explantation of the mechanical heart valves. The patient was bridged successfully to transplantation without thromboembolic events.

Repair of coronary artery perforation following angioplasty using TachoSil(R) patches [Case report - Coronary]

Celiento, M., Scioti, G., Pratali, S., Bortolotti, U. — Wed, 20 Jan 2010 15:13:43 PST

Coronary perforation is a rare complication of percutaneous interventional procedures, occurring in 0.2–3% of procedures, which may require emergency coronary bypass surgery. We describe here an alternative method to deal with such complication, which proved effective in a patient with active bleeding from the left anterior descending (LAD) coronary artery. By temporary pressing on beating heart patches of TachoSil^®, a sponge impregnated with human fibrinogen and thrombin, on the bleeding site, complete and stable hemostasis was achieved.

Innominate artery cannulation for congenital heart disease [Case report - Congenital]

Bhat, A. N., Bradley, S. M. — Wed, 20 Jan 2010 15:13:43 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.

eComment: Re: Innominate artery cannulation for congenital heart disease [eComment]

Talwar, S., Choudhary, S. K., Airan, B. — Wed, 20 Jan 2010 15:13:43 PST

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

Nakashima, M., Usui, A., Oshima, H., Ueda, Y. — Wed, 20 Jan 2010 15:13:43 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 aneurysmal 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 three patients underwent in-situ graft reconstructions in the controlled infectious phase. Four patients had multiple aneurysms, including nine 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.

eComment: Endovascular treatment of mycotic aneurysm as a definitive therapy or bridge to surgery in critically ill patients [eComment]

Marzban, M. — Wed, 20 Jan 2010 15:13:43 PST

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

Diehl, D. L., Cheruvattath, R., Facktor, M. A., Go, B. D. — Wed, 20 Jan 2010 15:13:43 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.

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

Galvin, S., Chen, V., Bunton, R., Doyle, T. — Wed, 20 Jan 2010 15:13:43 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.

Video-assisted cardioscopy for removal of primary left ventricular fibroma [Case report - Cardiac general]

Araji, O. A., Gutierrez-Martin, M. A., Miranda, N., Barquero, J. M. — Wed, 20 Jan 2010 15:13:43 PST

We present a case of a cardiac fibroma affecting the base of the anterior papillary muscle resected under cardiopulmonary bypass with cardioscopy and video-assisted thoracic surgery (VATS) instruments through the mitral valve. The surgical approach and instrumentation of previous case reports are reviewed.

Diagnosis and surgical treatment of an aneurysm on a cervical aortic arch associated with an anomalous origin of the left main coronary artery [Case report - Aortic and aneurysmal]

Charrot, F., Tarmiz, A., Glock, Y., Leobon, B. — Wed, 20 Jan 2010 15:13:43 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 anomalous 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) artery 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.

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

Yamamoto, Y., Ushijima, T., Kikuchi, Y., Watanabe, G. — Wed, 20 Jan 2010 15:13:43 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.

Atypical presentation of an apical pseudoaneurysm in a patient on prolonged left ventricular mechanical support [Case report - Assisted circulation]

Maeda, T., Tanoue, Y., Nakashima, A., Tominaga, R. — Wed, 20 Jan 2010 15:13:43 PST

Prolonged support with left ventricular assist system (LVAS) increases the risk of device-related infection. We experienced a rare complication of LVAS: an infectious aneurysm at the apical cannula, which appeared with atypical presentation. A 27-year-old male, who developed acute aggravation of dilated cardiomyopathy, was placed on extra-corporeal type LVAS. Six months later, the patient suffered from methicillin-resistant Staphylococcus aureus (MRSA) sepsis that lasted for as long as three months despite intensive antibiotic therapy. At 17 months after the implantation, he presented with obstructive ileus. Monthly assessment with transthoracic echocardiography (TTE) did not document any abnormalities around the ventricle. A contrast computed tomographic (CT) scan revealed a huge apical aneurysm protruding into the preperitoneal space. The aneurysm oppressed the transverse colon, resulting in obstructive ileus. Aneurysmectomy was carried out and MRSA was identified from the resected tissue. We reached the precise diagnosis with a CT-scan, although routine assessment with TTE failed to reveal abnormalities. Knowledge of this complication is essential in LVAS management. This is certainly rare, but possibly occurs in all the patients on prolonged LVAS support. Early and accurate diagnosis together with aggressive intervention would bring favorable outcome in such serious cases.

Corrigendum to 'eComment: A comparison of the safety of aprotinin and tranexamic acid in cardiac surgery' [Interact CardioVasc Thorac Surg 9 (2009) 101] [Corrigendum]

Koniari, I., Apostolakis, E., Mandellou, M. — Wed, 20 Jan 2010 15:13:43 PST