Interactive CardioVascular and Thoracic Surgery recent issues

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

Three strikes - don't die of a broken heart [New ideas - Aortic and aneurysmal]

Field, M. L., Sastry, P., Richens, D. — Thu, 17 Dec 2009 08:35:37 PST

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

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

Motas, C., Motas, N., Rus, O., Horvat, T. — Thu, 17 Dec 2009 08:35:37 PST

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

eComment: Pericardiocentesis followed by intrapericardial cisplatin administration in patients with neoplastic pericarditis [eComment]

Barbetakis, N., Asteriou, C., Papadopoulou, F., Bischiniotis, T. — Thu, 17 Dec 2009 08:35:37 PST

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

Panagiotou, M., Kogerakis, N., Crockett, J. R., Economidou, S. — Thu, 17 Dec 2009 08:35:37 PST

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

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

Vistarini, N., Alloni, A., Aiello, M., Vigano, M. — Thu, 17 Dec 2009 08:35:37 PST

Minimally invasive surgery has become the standard approach for several cardiac diseases. We report in the present study our ten-year experience with endoscopic cardiac surgery for left atrial myxoma resection. Between January 1998 and January 2008, 14 patients (median age: 61 years) underwent surgery for left atrial myxoma resection at our institution. The Heartport^® access system and the video-assistance were systematically employed to provide excellent vision and facilitate surgery. The aortic clamping was obtained with an ‘EndoClamp’ in 11 cases (using a central or peripheral endoaortic balloon, depending on the site of the arterial cannulation) or transthoracically with the Portaclamp^® system in two cases and the Chitwood clamp in one case. The average time needed for cross-clamping was 49±29 min, with a mean cardiopulmonary bypass (CPB) time of 88±57 min. There were no early or late hospital deaths. Mean intensive care unit and hospital stay were three and eight days, respectively. The mean follow-up time was 64 months and there was no evidence of residual or recurrent tumor. There were two late deaths due to acute ischemic stroke. Minimally invasive video-assisted surgery for left atrial myxoma resection is a safe, reproducible and cosmetic operation and can be considered an effective oncologic approach as an alternative to standard sternotomy.

Repair of spontaneous right ventricular rupture following sternal dehiscence. A novel technique [Work in progress report - Cardiac general]

Efthymiou, C. A., Kay, P. H., Nair, U. R. — Thu, 17 Dec 2009 08:35:37 PST

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

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

Cherneva, R., Petrov, D., Georgiev, O., Trifonova, N. — Thu, 17 Dec 2009 08:35:37 PST

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

Comprehensive approach for clamping severely calcified ascending aorta using computed tomography [Work in progress report - Cardiac general]

Nishi, H., Mitsuno, M., Ryomoto, M., Miyamoto, Y. — Thu, 17 Dec 2009 08:35:38 PST

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

eComment: Cross-clamping the heavily calcified ascending aorta after a preoperative computed tomography evaluation [eComment]

Karimov, J. H., Latsuzbaia, K., Glauber, M. — Thu, 17 Dec 2009 08:35:38 PST

eComment: Clamping a calcified aorta: note of caution [eComment]

Zingone, B. — Thu, 17 Dec 2009 08:35:38 PST

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

Jung, S.-H., Gon Je, H., Choo, S. J., Yun, T.-J., Chung, C. H., Lee, J. W. — Thu, 17 Dec 2009 08:35:38 PST

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

eComment: A limited antero-lateral minithoracotomy for congenital ventricular septal defects repair in adult patients [eComment]

Karimov, J. H., Glauber, M. — Thu, 17 Dec 2009 08:35:38 PST

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

Bockeria, L. A., Kim, A. I., Ryabtsev, D. V., Grigoryants, T. R. — Thu, 17 Dec 2009 08:35:38 PST

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

Thu, 17 Dec 2009 08:35:38 PST

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

eComment: Leg wound morbidities after saphenous vein harvesting techniques. Which is better? [eComment]

Gunay, R., Sensoz, Y., Kayacioglu, I. — Thu, 17 Dec 2009 08:35:38 PST

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

Thu, 17 Dec 2009 08:35:38 PST

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

eComment: Influence of 19 mm size aortic valve substitutes on long-term survival [eComment]

Bockeria, L. A., Skopin, I. I., Tsiskaridze, I. M. — Thu, 17 Dec 2009 08:35:38 PST

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

Thu, 17 Dec 2009 08:35:38 PST

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

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

Papaspyros, S. C., Javangula, K. C., Prasad Adluri, R. K., O'Regan, D. J. — Thu, 17 Dec 2009 08:35:38 PST

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

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

Badreldin, A., Kroener, A., Kamiya, H., Lichtenberg, A., Hekmat, K. — Thu, 17 Dec 2009 08:35:38 PST

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

eComment: Controversies on the antiplatelet therapy before coronary artery bypass grafting surgery [eComment]

Gunay, R., Sensoz, Y., Kayacioglu, I., Demirtas, M. M. — Thu, 17 Dec 2009 08:35:39 PST

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

Zhou, Q., Suzuki, K., Anami, Y.-i., Oh, S., Takamochi, K. — Thu, 17 Dec 2009 08:35:39 PST

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

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

Thu, 17 Dec 2009 08:35:39 PST

Delirium and transient neurologic dysfunctions (TND) often complicate the postoperative course after surgery for acute type-A aortic dissection (AAD). We evaluated the role of clonidine on neurological outcome and respiratory function in 30 consecutive patients undergoing surgery for AAD. Patients were prospectively randomized to receive either clonidine (0.5 µg/kg bolus, followed by continuous infusion at 1–2 µg/kg/h) or placebo (NaCl 0.9%) in on starting and throughout the weaning period from the mechanical ventilation. Incidence of delirium and TND, Delirium Detection Score (DDS), weaning parameters [respiratory rate to tidal volume ratio – f/VT; pressure–frequency product (PFP); partial pressure of arterial oxygen to fractional inspired oxygen concentration (PaO₂/FiO₂); partial pressure of carbon dioxide (PaCO₂)], weaning duration and intensive care unit (ICU) length of stay were recorded. The two groups were similar for preoperative and operative variables and also for the incidence of postoperative complications. DDS was lower in the clonidine group (P<0.001). Patients weaned with clonidine showed lower f/VT and PFP, higher PaO₂/FiO₂ and PaCO₂, lower DDS, weaning period and the related ICU length of stay (P<0.001). This was further confirmed in patients developing delirium/TND. Intravenous clonidine after surgery for AAD reduces the severity of delirium, improves the respiratory function, shortens the weaning duration and the ICU length of stay.

A single centre experience of simultaneous open abdominal aortic aneurysm and cardiac surgery [ESCVS article - Aortic and aneurysmal]

Kordowicz, A., Ghosh, J., Baguneid, M. — Thu, 17 Dec 2009 08:35:39 PST

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

Warm, beating heart aortic valve replacement in a sickle cell patient [Proposal for bail-out procedures - Valves]

Usman, S., Saiful, F. B., DiNatale, J., McGinn, J. T. — Thu, 17 Dec 2009 08:35:39 PST

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

eComment: Cardiopulmonary bypass without exchange transfusion in sickle cell disease - An update [eComment]

Edwin, F., Aniteye, E., Tamatey, M., Frimpong-Boateng, K. — Thu, 17 Dec 2009 08:35:39 PST

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

Ojala, T., Salminen, J., Happonen, J.-M., Pihkala, J., Jokinen, E., Sairanen, H. — Thu, 17 Dec 2009 08:35:39 PST

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

eComment: Incomplete left ventricular reverse remodeling after revascularization of anomalous left coronary artery from the pulmonary artery [eComment]

Edwin, F. — Thu, 17 Dec 2009 08:35:39 PST

Perfusion temperature, thyroid hormones and inflammation during pediatric cardiac surgery [Follow-up papers - Congenital]

Thu, 17 Dec 2009 08:35:39 PST

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

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

Jyrala, A., Gatto, N. M., Kay, G. L. — Thu, 17 Dec 2009 08:35:39 PST

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

Cardiac stunning in the clinic: the full picture [State-of-the-art - Cardiac general]

Thu, 17 Dec 2009 08:35:39 PST

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

eComment: Re: Cardiac stunning in the clinic: the full picture [eComment]

Bockeria, L., Bockeria, O. L., Goustova, I. A. — Thu, 17 Dec 2009 08:35:39 PST

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

Scarci, M., Joshi, A., Attia, R. — Thu, 17 Dec 2009 08:35:39 PST

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

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

Ali, E., Saso, S., Ashrafian, H., Athanasiou, T. — Thu, 17 Dec 2009 08:35:40 PST

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

eComment: Sternal microcirculation following pedicled or skeletonized internal thoracic artery harvesting [eComment]

Knobloch, K., Vogt, P. M., Lichtenberg, A. — Thu, 17 Dec 2009 08:35:40 PST

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

Pop, D., Venissac, N., Mouroux, J. — Thu, 17 Dec 2009 08:35:40 PST

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

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

Goto, T., Oyamada, Y., Wakaki, M., Kato, R. — Thu, 17 Dec 2009 08:35:40 PST

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

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

El Watidy, A. M., Ismail, H. H., Calafiore, A. M. — Thu, 17 Dec 2009 08:35:40 PST

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

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

Margaryan, R., Arcieri, L., Cantinotti, M., Murzi, B. — Thu, 17 Dec 2009 08:35:40 PST

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

eComment: Congenital direct communication between the right pulmonary artery and the left atrium: anatomic variations and surgical experience [eComment]

Bockeria, L., Podzolkov, V., Makhachev, O., Kim, A. — Thu, 17 Dec 2009 08:35:40 PST

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

Thu, 17 Dec 2009 08:35:40 PST

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

eComment: Cardiac operation during pregnancy: what is the appropriate management? [eComment]

Gunay, R. — Thu, 17 Dec 2009 08:35:40 PST

eComment: Are low molecular weight heparin effective in mechanical valve prosthesis anticoagulation during pregnancy? [eComment]

Carrascal, Y. — Thu, 17 Dec 2009 08:35:40 PST

eComment: Re: Mechanical prosthetic mitral valve thrombosis in a first trimester pregnant woman [eComment]

Bockeria, L. A., Bockeria, O. L., Soboleva, N. N., Mordvinova, A. S. — Thu, 17 Dec 2009 08:35:40 PST

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

Koch, A., Mechtersheimer, G., Tochtermann, U., Karck, M. — Thu, 17 Dec 2009 08:35:40 PST

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

Mediastinal epithelioid haemangioendothelioma: a rare mediastinal tumour [Case report - Thoracic oncologic]

Mansour, Z., Neuville, A., Massard, G. — Thu, 17 Dec 2009 08:35:40 PST

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

Aorto-gastroduodenal bypass grafting for an inferior pancreaticoduodenal aneurysm and celiac trunk thrombosis [Case report - Aortic and aneurysmal]

Ritter, J. C., Johnston, M., Caruana, M. F., Laws, P. E. — Thu, 17 Dec 2009 08:35:40 PST

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

Spontaneous rupture of an intercostal artery in a patient with neurofibromatosis type 1 [Case report - Aortic and aneurysmal]

Aizawa, K., Iwashita, C., Saito, T., Misawa, Y. — Thu, 17 Dec 2009 08:35:40 PST

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

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

Nemati, M. H. — Thu, 17 Dec 2009 08:35:40 PST

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

Endobronchial schwannoma presenting with bronchial obstruction [Case report - Thoracic oncologic]

Stouffer, C. W., Allan, R. W., Shillingford, M. S., Klodell, C. T. — Thu, 17 Dec 2009 08:35:41 PST

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

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

Sebastian, V. A., Carroll, B. T., Jessen, M. E. — Thu, 17 Dec 2009 08:35:41 PST

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

Large mediastinal thoracic duct cyst [Case report - Thoracic non-oncologic]

De Santis, M., Martins, V., Fonseca, A. L., Santos, O. — Thu, 17 Dec 2009 08:35:41 PST

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

eComment: Supradiaphragmatic ligation of the thoracic duct for prevention of postoperative chylothorax [eComment]

Barbetakis, N., Asteriou, C., Vlaikos, D., Psatha, A. — Thu, 17 Dec 2009 08:35:41 PST

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

White, R. W., Hirst, N. A., Edward, S., Nair, U. R. — Thu, 17 Dec 2009 08:35:41 PST

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

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

Gardet, E., Addas, R., Monteil, J., Guyader, A. L. — Thu, 17 Dec 2009 08:35:41 PST

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

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

Prior, J. O., Stupp, R., Christodoulou, M., Letovanec, I. — Thu, 17 Dec 2009 08:35:41 PST

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

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

Sareyyupoglu, B., Suri, R. M., Rehfeldt, K. H., Burkhart, H. M. — Thu, 17 Dec 2009 08:35:41 PST

We present a case with an unusual cause of poor venous drainage during cardiopulmonary bypass for robotic-assisted mitral valve repair.

Brown-Sequard syndrome after thoracic endovascular aortic repair [Case report - Aortic and aneurysmal]

Ozaki, N., Wakita, N., Inoue, K., Yamada, A. — Thu, 17 Dec 2009 08:35:41 PST

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

Heart transplantation using bivalirudin as anticoagulant [Case report - Transplantation]

Simsir, S. A., Schwarz, E. R., Czer, L. S.C., Hamburg, S. I. — Thu, 17 Dec 2009 08:35:41 PST

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

Barotraumatic oesophageal perforation with bilateral tension pneumothorax [Case report - Esophagus]

Chien, L.-C., Chang, H.-T., Chou, Y.-P. — Thu, 17 Dec 2009 08:35:41 PST

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

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

Stepanenko, A., Potapov, E. V., Krabatsch, T., Hetzer, R. — Thu, 17 Dec 2009 08:35:41 PST

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

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

Boaron, M., Kawamukai, K., Forti Parri, S. N., Trisolini, R. — Thu, 17 Dec 2009 08:35:41 PST

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

Lung function evaluation before surgery in lung cancer patients: how are recent advances put into practice? A survey among members of the European Society of Thoracic Surgeons (ESTS) and of the Thoracic Oncology Section of the European Respiratory Society (ERS) [Editorial - Thoracic oncologic]

Tue, 17 Nov 2009 10:56:35 PST

Controlled antegrade single lung reperfusion during double lung transplant [New ideas - Pulmonary]

Khalpey, Z., Gilfeather, M. S., Camp, P. C., Jaklitsch, M. T. — Tue, 17 Nov 2009 10:56:35 PST

Prompt controlled reperfusion of a pulmonary allograft in a sequential double lung transplant may correct cellular ischemia prior to exposure to full hydrostatic pressures and minimize organ dysfunction. We reviewed the process of a sequential double lung transplant and describe the technique of controlled antegrade graft reperfusion of the initial implant as performed at our institution.

Influence of major pulmonary resection on postoperative daily ambulatory activity of the patients [Work in progress report - Thoracic non-oncologic]

Novoa, N., Varela, G., Jimenez, M. F., Aranda, J. L. — Tue, 17 Nov 2009 10:56:35 PST

To describe and compare the daily ambulatory activity of the patients before and one month after major lung resection. Daily activity was measured using a pedometer (OMROM Walking Style PRO^®) given preoperatively in a prospective way to a series of 21 consecutive cases scheduled for lobectomy or pneumonectomy. Analyzed variables were age, pulmonary function, mean number of total and aerobic steps per day, walked distance and mean daily time of aerobic activity. Activity variables were analyzed individually and as a new differential variable DELTA. Wilcoxon and Mann–Whitney nonparametric tests were used for comparison between groups. General series data: 19 male. Age: 63±10.9 years. FEV₁%: 88.4±22.7. DLCO: 86.2±21.6. Eleven cases had COPD criteria. Type of surgery: 3 pneumonectomy/18 lobectomy. Activity data: all patients showed a global decrease of their activity one month after surgery but, patients in the pneumonectomy group are unable to keep aerobic activity meanwhile patients that undergone lobectomy showed only a 25% reduction in the measured variables. Major pulmonary resection decreases the time and the quality of the daily ambulatory activity of the patients during the first postoperative month. Despite limitations, the chosen pedometer OMRON Walking Style Pro^® is an efficient tool to evaluate the perioperative daily ambulatory activity of patients.

Graft fixation with a side graft holder for sequential and composite graft anastomosis in coronary artery bypass surgery [Work in progress report - Coronary]

Shimamura, Y., Hayashi, I. — Tue, 17 Nov 2009 10:56:35 PST

The purpose of this study was to assess the feasibility and effectiveness of graft fixation with a novel side graft holder for sequential or composite graft anastomosis in coronary artery bypass grafting (CABG). Records of 34 patients who underwent CABG using sequential or composite graft anastomosis technique were reviewed. The device was used on 47 anastomoses (sequential=43; composite graft=4). Excellent fixation and visualization of the graft was obtained in all patients without graft injury. Postoperative angiographic patency rate of distal anastomoses was 95.2% (arterial, 91.2%; venous, 96.7%). All sequential and composite graft anastomoses were patent and without stenosis. One operative death occurred due to low cardiac output after emergent CABG for acute myocardial infarction. No elective patient died during hospitalization. Postoperative complications occurred in two patients (ventricular fibrillation, 1; postoperative catheter intervention, 1). No perioperative myocardial infarctions or re-operations occurred. Our clinical experience shows that graft fixation with the device is safe, reliable, and effective for sequential and composite graft anastomosis during CABG.

Effect of 5-azacytidine induction duration on differentiation of human first-trimester fetal mesenchymal stem cells towards cardiomyocyte-like cells [Work in progress report - Experimental]

Zhang, Y., Chu, Y., Shen, W., Dou, Z. — Tue, 17 Nov 2009 10:56:35 PST

The aim of this study is to investigate effects of 5-azacytidine (5-aza) induction duration on differentiation of bone marrow mesenchymal stem cells (MSCs) from human first-trimester abortus (hfMSCs) towards cardiomyocyte-like cells. hfMSCs were stimulated with 10 µmol/l 5-aza for 24 h (group A), 48 h (group B) and 21 days (group C), respectively. During the induction, 30–40% of the cells gradually enlarged, elongated, connected with adjoining cells and formed myotube-like structures, branches and string-bead-like nuclei. Some of the cells congregated into cell clusters or strips. After the induction, numerous myofilaments in the cytoplasm and conjunction of intercalated disc-like structure between adjoining cells were observed. The induced cells expressed messenger ribonucleic acids (mRNAs) and proteins of myocardium-specific -actin, sarcomeric β-myocin heavy chain and troponin-T. The positive cell percentages for the three antigens in group C were each significantly higher than those antigens in group A and B (P<0.01) and the cell population doubling time (PDT) of group C was longer than those of group A and B (P<0.01). These indicate that 21-d induction with 10 µmol/l 5-aza slows down proliferation speed of hfMSCs but increases differentiation rate of hfMSCs into cardiomyocyte-like cells if compared with 24–48 h induction.

Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results [Work in progress report - Aortic and aneurysmal]

Da Rocha, M., Zarka, Z. A., Riambau, V. A. — Tue, 17 Nov 2009 10:56:35 PST

Endovascular correction of aorta thoracic pathology in renal transplant patients is a challenge. The aim of this study is to review early and intermediate-term results of endovascular repair of thoracic aorta pathology in patients with functioning previous renal transplant. The records of 81 patients submitted to a thoracic endograft between 2003 and 2008 were reviewed. Five patients with six previous renal transplants were submitted to six thoracic endografting. Two were women. The mean age was 55.4 years (range, 43–75 years). There were two patients with type B aortic dissection, one penetrating ulcer, one aneurysm of the aortic arch and one descending thoracic aorta aneurysm. Three patients underwent hybrid procedures: two total supra-aortic transpositions and one partial transposition of visceral trunks. Three patients presented postoperative complications. There were two cases of pneumonia, one acute limb ischemia and a stroke, with an early death. The mean follow-up was 16.2 months (range, 1–40 months). In this period all patients sustained renal function without any related complication. Despite the fact that it is a small series, in our clinical experience, endovascular thoracic aortic surgery can be performed as an alternative to open correction, in high-risk patients with a previous working renal transplant.

Myocyte injury along myofibers in left ventricular remodeling after myocardial infarction [Institutional report - Cardiac general]

Tue, 17 Nov 2009 10:56:35 PST

Left ventricular (LV) remodeling following myocardial infarction (MI) is considered to contribute to cardiac dysfunction. Though myofiber organization is a key component of cardiac structure, functional and anatomical features of injured myofiber during LV remodeling have not been fully defined. We investigated myocyte injury after acute MI in a mouse model. Mice were subjected to surgical coronary occlusion/reperfusion by left anterior descending coronary artery (LAD) ligation and examined at 1 week and 4 weeks post-MI. Magnetic resonance imaging (MRI) analysis demonstrated a significant decrease in systolic regional wall thickening (WT) in the border and remote zones at 4 weeks post-MI compared to that at 1 week post-MI (–86% in border zone, P<0.05, and –77% in remote zone, P<0.05). Histological assays demonstrated that a broad fibrotic scar extended from the initial infarct zone to the remote zone along mid-circumferential myofibers. Of particular note was the fact that no fibrosis was found in longitudinal myofibers in the epi- and endo-myocardium. This pattern of the scar formation coincided with the helical ventricular myocardial band (HVMB) model, introduced by Torrent-Guasp. MRI analysis demonstrated that the extension of the fibrotic scar along the band might account for the progression in cardiac dysfunction during LV remodeling.

Monitoring of atrial fibrillation burden after surgical ablation: relevancy of end-point criteria after radiofrequency ablation treatment of patients with lone atrial fibrillation [Institutional report - Arrhythmia]

Beukema, R., Beukema, W. P., Sie, H. T., Misier, A. R., Delnoy, P. P., Elvan, A. — Tue, 17 Nov 2009 10:56:35 PST

Studies have shown that continuous rhythm monitoring enables the detection of significantly more atrial fibrillation (AF) episodes than routine follow-up of patients, i.e. based on perception of symptoms or on 24–48 h Holter monitoring. The positive outcome of radiofrequency ablation (RFA) may be easily overestimated, especially in patients with paroxysmal AF. Thirty-three consecutive patients, aged 59.4±8.9 years (range 38–75 years) participated in this study. All patients had documented AF episodes with an AF duration of 9.4±7.1 years (range 1.5–25 years). A new monitoring device, the AF-Alarm was used to more accurately assess the outcome after surgical isolation of pulmonary veins. The AF-Alarm was applied for a duration of 128±42.5 h (range 49–191 h) during a period of 8–15 days. The success rate was 87% based on serial electrocardiograms (ECGs) and 24–48 h Holter monitoring during regular outpatient visits. Combination of ECG, Holter and AF-Alarm data yielded a significantly lower success rate, i.e. at the latest follow-up 69% of the patients were free from AF after surgical ablation (P<0.05). Furthermore, the AF-Alarm device demonstrated a dissociation between symptoms and atrial arrhythmic events and confirmed the occurrence of asymptomatic AF episodes. The most important limitation of the AF-Alarm device was noise detection with oversensing and inappropriate detection of non-existing AF episodes in 9% of patients. Long-term follow-up of the patients seems to be essential as success rates of the initial ablation procedure might vary over time. External recorders like the AF-Alarm may be used as an additional tool to document symptomatic and asymptomatic episodes of atrial arrhythmias in the outpatient setting.

eComment: Monitoring of atrial fibrillation burden after surgical ablation [eComment]

Bockeria, L., Revishvili, A. Sh., Dzhordzhikiya, T. R. — Tue, 17 Nov 2009 10:56:35 PST

Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters [Institutional report - Thoracic oncologic]

Efthymiou, C. A., Masudi, T., Charles Thorpe, J. A., Papagiannopoulos, K. — Tue, 17 Nov 2009 10:56:35 PST

Malignant pleural effusions in the presence of trapped lung remain notoriously difficult to treat. Various methods exist ranging from minimally invasive procedures including repeated needle thoracocentesis to the need for a formal surgical procedure such as placement of a pleuroperitoneal shunt and even thoracotomy and decortication. Controversy exists as to what is the optimum treatment for this condition. Any planned treatment should balance the therapeutic benefit provided against convalesce for a disease with a limited life expectancy. Patients should not spend a significant proportion of their remaining life span recovering from palliative procedures. In a series of patients with malignant pleural effusion the medial survival time was 20 weeks, with 30 days and 1 year mortality rates of 12.8% and 83.6%, respectively. We describe our five-year experience with the use of indwelling PleurX catheters in patients with malignant pleural effusions in the presence of confirmed trapped lung on radiological or VATS investigation. Patient health related quality of life was investigated by telephone questionnaire. The parameters analysed were symptomatic relief, mobility and ease of management following insertion. One hundred and sixteen patients underwent PleurX catheter insertion by a single operator, 48 questionnaires were completed. Of the 48 cases analysed, improvement in all three quality of life indices was recorded following catheter insertion. Ease of mobility was recorded as moderately satisfied and very satisfied in 50% and 15% of patients, respectively. Symptomatic improvement was found to have been increased with 42% and 6% of patients responding to moderately satisfied and very satisfied, respectively. Ease of management was recorded as ‘slightly satisfied’ and moderately satisfied in 50% and 33% of patients, respectively, demonstrating a high satisfaction index in patients with chronic progressively debilitating malignancies. Complications were either transient or readily correctable. Pain was the predominant complication occurring in 35% of patients lasting <3 days. No patient required catheter removal for resolution of discomfort. Our findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung. The catheters are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliative patients with compromised life expectancy.

The hemiclamshell approach in thoracic surgery: indications and associated morbidity in 50 patients [Institutional report - Thoracic oncologic]

Tue, 17 Nov 2009 10:56:35 PST

This retrospective study was carried out to evaluate the indications for and outcomes of the hemiclamshell (HCS) approach (longitudinal partial sternotomy with antero-lateral thoracotomy) in patients undergoing mass resection in thoracic surgery. All patients (50) who underwent a HCS procedure in our department, between July 1996 and July 2005, were studied retrospectively, analyzing the indications, morbidity and outcome (pain, neurological or shoulder defects, mortality) at one month and one year. The main indications were apical tumours (38%), tumours of the cervicothoracic junction (46%) and chest wall (10%), and ‘bulky’ tumours (6%). One-month mortality was 6%. Two patients suffered from a chylothorax and one from phrenic paralysis. The postoperative analgesic requirements were similar to those after other thoracic surgery approaches. Twelve percent of patients suffered pain at one month and 6% at one year. Shoulder dysfunction was observed in 10% of patients at one month and 6% at one year. In conclusion, the HCS surgical approach was associated with an uncomplicated postoperative course. This anterior approach is suitable for apical tumours, tumours of the cervicothoracic junction and ‘bulky’ lung tumours, providing good access for control of the large vessels and radical mediastinal clearance.

Effectiveness of sympathetic block by clipping in the treatment of hyperhidrosis and facial blushing [Institutional report - Thoracic non-oncologic]

Fibla, J. J., Molins, L., Manuel Mier, J., Vidal, G. — Tue, 17 Nov 2009 10:56:35 PST

Main cause of dissatisfaction after videothoracoscopic (VATS) sympathectomy in the treatment of hyperhidrosis (HH) and facial blushing (FB) is compensatory sweating (CS). Sympathetic nerve (SN) clipping permits to revert the block effect by removing the clips in case of an intolerable CS. We present our experience with this technique. Sixty-one patients diagnosed for HH and/or FB were operated on VATS SN clipping. Clipping levels varied in function for the sort of disease: FB: T2, palmar HH: T3, axillary HH: T4, palmar-axillary HH: T3-4. Results were evaluated 1 week, 3 months and 12 months after surgery. Fifty-eight of the 61 patients showed improvement of their symptoms (95%). There were minor complications in three patients (5.5%). CS was seen in 38/61 (62.2%), being labelled as mild in 33/61 (54%) and severe in 5/61 patients (8.2%), no patient qualified it as intolerable and it was not necessary to remove the clips for CS in any case. SN clipping by VATS is a safe and effective procedure for the management of FB and palmar/axillary HH. Levels of CS are similar or lesser than with the standard sympathicotomy and, if necessary, this technique allows to revert the sympathetic block removing the clips.

Air-leak management after upper lobectomy in patients with fused fissure and chronic obstructive pulmonary disease: a pilot trial comparing sealant and standard treatment [Institutional report - Thoracic non-oncologic]

Tue, 17 Nov 2009 10:56:36 PST

A pilot trial to compare the efficacy of two different procedures to prevent postoperative air-leak in chronic obstructive pulmonary disease (COPD) patients submitted to upper lobectomy for non-small cell lung cancer. Sixty patients with COPD and lung cancer at the upper pulmonary lobes eligible for lobectomy were enrolled and randomly assigned either to standard treatment (ST) with stapling device or to electrocautery dissection and application of a collagen patch coated with human fibrinogen and thrombin (TachoSil^®) (experimental treatment [ET]) for the intra-operative completion of their fused fissures. Thirty patients were enrolled in each group during a three-year period. Preoperative characteristics were similar between the two groups. Statistically significant reduction of air-leak was registered in the ET group when overall incidence of postoperative air-leak (55% vs. 96%; P=0.03), postoperative air-leak (mean 1.63±1.96 vs. 4.33±4.12 days; P=0.0018), chest-drain (mean 3.53±1.59 vs. 5.90±3.72 days; P=0.0021) and hospital stay duration (mean 5.87±1.07 vs. 7.50±3.20 days; P=0.01) were considered. The use of TachoSil^® to prevent postoperative air-leak after interlobar fissure completion in patients with COPD submitted to upper lobectomy seems to be safe and more effective than the ST based on stapling device application.

An observational study of CoSeal(R) for the prevention of adhesions in pediatric cardiac surgery [Institutional report - Congenital]

Tue, 17 Nov 2009 10:56:36 PST

We sought to evaluate the utility and safety of CoSeal^® Surgical Sealant (Baxter) for the prevention of cardiac adhesions in children. Seven cardiac surgery centers in Europe recruited consecutive pediatric patients requiring primary sternotomy for staged repair of congenital heart defects. Exclusion criteria included immune system disorder, unplanned reoperation, or reoperation within three months of primary repair. CoSeal was sprayed onto the surface of the heart at the end of surgery. Evaluation of adhesions took place at first reoperation. Data on safety, duration of surgery, and ease of CoSeal use were also collected. Seventy-nine pediatric patients were recruited between February 2005 and September 2007. Of these, 76 underwent major surgery to repair a wide range of congenital heart defects. Thirty-six patients underwent reoperation >3 months after primary repair, and were included in the efficacy analysis. Mean adhesions score was 8.3 (standard deviation [S.D.] 2.4; range 7–16). Six adverse events (5 serious) were possibly/definitely attributed to CoSeal. CoSeal's ease of use at primary operation was graded by surgeons as 12.1 mm (S.D. 9.8) on a visual analog scale of 0 (‘very easy’) to 100 mm (‘very difficult’). Results of this prospective uncontrolled trial justify further investigation in a randomized, controlled trial.

Urgent segmental resection as the primary strategy in management of benign tracheal stenosis. A single center experience in 164 consecutive cases [Institutional report - Thoracic non-oncologic]

Tue, 17 Nov 2009 10:56:36 PST

The report is a retrospective review of 238 benign tracheal stenoses of various etiologies treated between 1995 and 2008. To show that urgent segmental resection has complication rates similar to elective resection and, therefore, preoperative dilation is not necessary, we analysed records of patients who underwent either standard segmental resections with anterolateral mediastinal tracheal mobilization, single-suture anastomosis and neck flexion; or insertion of T-tube with oval-shaped horizontal arm. Primary segmental resection was performed in 164 patients (68.9%), including 14 cases with concomitant tracheo-esophageal fistula (TEF). T-tube as an initial treatment suited 74 (31.1%) patients. We encountered two partial and one complete anastomotic disruptions following subglottic resections treated by T-tube insertion and costal cartilage tracheoplasty or permanent tracheostomy. Restenosis rate in segmental resection was 3.1%. No difference in complication rate between urgent and elective segmental resections was experienced. We treated a small number of patients by endotracheal stent insertion but the results were discouraging. Urgent segmental resection without prior rigid bronchoscopy dilation is our strategy of choice whenever possible. As an alternative to dilation we prefer temporary insertion of modified T-tube. Stand-alone endoluminal dilation and stenting has yet to prove its safety and long-term efficacy.

Long-term follow-up after minimal invasive direct coronary artery bypass grafting procedure: a multi-factorial retrospective analysis at 1000 patient-years [Institutional report - Cardiac general]

Tue, 17 Nov 2009 10:56:36 PST

We provide a multi-factorial long-term follow-up following minimal invasive direct coronary artery bypass grafting (MIDCABG) to evaluate the long-term efficacy. From 1996 onwards, 390 patients underwent MIDCABG (follow-up: 30.0±11.2 months). We analyzed peri-operative and postoperative complications (<30 days) and we obtained early and late angiography. Cumulative follow-up was 1000 patient-years. Early postoperative mortality was 0.8% and myocardial infarction occurred in 1.3% of all patients. Early postoperative angiography (<30 days) was obtained in 238 patients (66.3%) and revealed patency in 97.5% (232/238) including 211 (88.6%) who had no stenosis, 13 with a <50% stenosis (5.5%) and 8 with a >50% stenosis (3.4%), but a patent graft. Only six patients had a total occlusion (2.5%). In the long-term follow-up (completed 74.6%; 291/390 patients), the overall mortality was 5.8%, whereas only 1.7% died due to cardiac reasons. Myocardial infarction occurred in 3.0%, redo CABG was necessary in 1.3%. Seventy-eight patients had late postoperative angiography (>30 days) of those 93.6% (n=73) had a patent graft: 58 had no stenosis (74.4%), 4 had a <50% stenosis (5.1%) and 11 had a >50% stenosis (14.1%), but a patent graft. Only in five patients (6.4%) the anastomosis was occluded. MIDCABG is a safe procedure with long-term anastomotic patency rates comparable with those of open-chest LIMA–left-anterior descending artery (LAD) bypass.

Early outcomes of video-assisted thoracoscopic resection of thymus in 181 patients with myasthenia gravis: who are the candidates for the next morning discharge? [Institutional report - Thoracic non-oncologic]

Tue, 17 Nov 2009 10:56:36 PST

The aims of this study are to present the results of videothoracoscopic thymectomy in patients with myasthenia gravis (MG) and to predict the factors affecting the next morning discharge (NMD). This is a retrospective analysis of the prospectively recorded data of 181 consecutive myasthenic patients who underwent videothoracoscopic thymectomy from June 2002 to September 2009. Sixty-one patients (33.7%) were discharged on the next morning. Univariate and multivariate analyses were evaluated to determine the predictors for NMD. Mean calculated variables were: age (29.8 years), duration of symptoms (22.5 months), duration of surgery (51.3 min), postoperative stay (2.1) days, and visual analogue scale (2.1). No mortality occurred. Four patients were required to stay in intensive care unit (ICU) with a mean of 18.6 h. With logistic regression analysis, duration of operation (DoO) was calculated to be the only predictive factor for NMD (P=0.006). Video-assisted thoracoscopic thymectomy (VAT thymectomy) is a safe surgery procedure with a smooth postoperative period for MG. Although a detailed analysis was performed, only DoO was found to be a predictive factor for NMD in MG patients.

Can chronic neuropathic pain following thoracic surgery be predicted during the postoperative period? [Institutional report - Thoracic oncologic]

Searle, R. D., Simpson, M. P., Simpson, K. H., Milton, R., Bennett, M. I. — Tue, 17 Nov 2009 10:56:36 PST

Chronic pain following thoracic surgery is common and associated with neuropathic symptoms, however, the proportion of patients with neuropathic pain in the immediate postoperative period is unknown. We aimed to determine the proportion of patients who have neuropathic symptoms and signs immediately after, and at three months following thoracic surgery. The study was designed as a prospective observational cohort study. We identified patients with pain of predominantly neuropathic origin using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) score in the immediate postoperative period and the self-report LANSS (S-LANSS) version three months after surgery. One hundred patients undergoing video assisted thoracic surgery (VATS) or thoracotomy completed LANSS scores preoperatively and in the immediate postoperative period. Eighty-seven percent completed three months S-LANSS follow-up scores. Eight percent of patients had positive LANSS scores in the immediate postoperative period; 22% of patients had positive S-LANSS scores three months following surgery. There was a significant association between positive scores in the acute and chronic periods (relative risk (RR) 3.5, [95% confidence interval (CI) 1.7–7.2]). Identifying pain of predominantly neuropathic origin in the postoperative period with a simple pain score can help identify those at risk of developing chronic pain with these features following thoracic surgery.

In patients with first-episode primary spontaneous pneumothorax is video-assisted thoracoscopic surgery superior to tube thoracostomy alone in terms of time to resolution of pneumothorax and incidence of recurrence? [Best evidence topic - Thoracic non-oncologic]

Chambers, A., Scarci, M. — Tue, 17 Nov 2009 10:56:36 PST

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether video-assisted thoracoscopic surgery (VATS) was justifiable for first-episode primary spontaneous pneumothorax (PSP). Altogether 183 papers were found using the reported search, of which nine 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 VATS has superior outcomes in terms of recurrence rates of pneumothorax (from 0 to 13% according to several studies for VATS vs. 22.8 to 42% for tube thoracostomy alone), duration of chest tube drainage (CTD) (4.56 vs.7.6 days) and mean hospital stay (from 2.4 to 7.8 days vs. 6 to 12 days for CTD) with first-episode PSP compared with conservative treatment. Additionally, even if VATS is associated with an average increased cost of $408, this is mitigated by the reduced length of stay and decreased pneumothorax recurrence, both resulting in a reduction of cost of 42% compared to conservative approach. These findings were not replicated in an article considering primary VATS (PV) vs. secondary VATS (SV) as the best treatment modality for PSP in children. Although the total treatment length of stay was significantly shorter for PV vs. SV (7.1±0.96 vs. 10.5±1.2, P=0.04), morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs. 0/20, P<0.05). In this article the observed recurrence rate was 54%. Performing PV on all patients with PSP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach, therefore, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with spontaneous pneumothorax (SP). Instead, secondary treatment is recommended. Lastly, two articles also examined the rate of recurrence of VATS compared to open thoracotomy (OT). The range was from 0 to 7.7% for OT vs. 10.3 to 13% for VATS, a non-statistical difference.

Which patient undergoing mitral valve surgery should also have the tricuspid repair? [Best evidence topic - Valves]

Bianchi, G., Solinas, M., Bevilacqua, S., Glauber, M. — Tue, 17 Nov 2009 10:56:36 PST

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Which patient undergoing mitral valve surgery should also have the tricuspid repair?’ Altogether 390 papers were found using the reported search, of which 17 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. While a general agreement exists for tricuspid valve (TV) repair in cases of severe regurgitation and concomitant multivalvular disease requiring surgical intervention, current guidelines provide more vague indications for patients with less severe tricuspid regurgitation (TR). Since this condition has a lower event-free survival rate and the prognosis after symptoms development is dismal, a lower threshold and a more aggressive strategy for intervention is needed. In rheumatic valve disease, mitral valve involvement and disease spreading to TV may be responsible for further regurgitation. Although patients with pulmonary hypertension (PH) may benefit from mitral valve replacement (MVR) or balloon valvotomy, many studies found that preoperative PH does not predict late TR. However, patients with high pulmonary pressure have a lower occurrence of late TR. Tricuspid annular dilation is probably the most important factor for late TR. Once established, it might be irreversible even after resolution of PH as well as absence of ‘reverse remodelling’. It has been proposed to treat TR independently from the grade of regurgitation when the annular dimension is over 21 mm/m² or ≥3.5 cm at echo measurement or when the intra-operative tricuspid annulus (TA) diameter is >70 mm. TV repair should be accomplished in patients with preoperative atrial fibrillation (AF), since it may cause late significant TR development and affect the patient's long-term survival. The presence of a trans-tricuspid pacemaker lead is another known factor for late TR development secondary to adhesions and fibrous retraction. TV repair is probably better than replacement in non-severe organic TV disease. Annuloplasty ring repair has better outcome compared with non-ring based repair techniques; the beneficial effect is also independent of the type of mitral valve surgery performed.

eComment: Which functional tricuspid regurgitation should be surgically corrected? [eComment]

Bockeria, L. A., Skopin, I. I., Tsiskaridze, I. M. — Tue, 17 Nov 2009 10:56:36 PST

A technique of an upper V-type ministernotomy in the second intercostal space [Brief communication - Cardiac general]

Karimov, J. H., Santarelli, F., Murzi, M., Glauber, M. — Tue, 17 Nov 2009 10:56:36 PST

Since cardiac surgeons found themselves able to offer a less invasive access to heart and great vessels, one of the first techniques to satisfy the tendency of minimizing the surgical trauma during general cardiac surgical procedure was a ministernotomy. In the current paper, we present the technique of V-type ministernotomy in the 2nd intercostal space, which has been employed in our department from June 2007 in 85 consecutive patients (mean age: 58±18 years); those operations consisted of the aortic valve replacement (AVR), surgery of the ascending aorta and epiaortic arterial segment.

Heparin induced thrombocytopenia in a patient with factor V Leiden following cardiac surgery [Case report - Vascular general]

Chaubey, S., Davidson, S. J., DeSouza, A. C. — Tue, 17 Nov 2009 10:56:36 PST

We report a patient who died as a result of heparin induced thrombocytopenia (HIT) and arterial thromboses following cardiac surgery. The onset was three days after exposure to low molecular weight heparin on the eighth postoperative day. The patient was heterozygous for the factor V Leiden mutation. We have reviewed 15 patients previously diagnosed as HIT on clinical and laboratory criteria and found an incidence of 6.7% (1/15) activated protein C resistance. This second patient had a pulmonary embolus and HIT after only three days exposure to low molecular weight heparin. We postulate that factor V Leiden hastens the onset and magnifies the severity of HIT.

eComment: Heparin-induced thrombocytopenia [eComment]

Bockeria, L., Samsonova, N., Klimovich, L. — Tue, 17 Nov 2009 10:56:36 PST

Primary synovial sarcoma of the lung as an incidental finding [Case report - Thoracic oncologic]

Watzka, S. B., Setinek, U., Prosch, H., Muller, M. R. — Tue, 17 Nov 2009 10:56:36 PST

Synovial sarcoma of the lung (SSL) is a very rare but aggressive primary lung tumor. Due to its unusual histological features, it can easily be misdiagnosed, if only small biopsies of the tumor are investigated. Here, we review two recent cases of SSL diagnosed and treated in our institution. The first case is a 37-year-old male with a round nodule in the right lower lobe; he underwent a lobectomy. Histologically, the nodule resembled a biphasic tumor. Cytogenetic analysis revealed a translocation t (X; 18), and the diagnosis of primary SSL could be established. The patient is alive and disease-free since 45 months following surgery. The second case is a 41-year-old male with a cystic lesion in the right lower lobe, removed by video-assisted thoracic surgery (VATS) segmentectomy. In the tumor tissue, spindle cell-rich and cystic structures could be found, together with epithelial elements. Because the tumor contained also a translocation t (X; 18), it could be diagnosed as monophasic SSL. The patient is alive and disease-free since 11 months. Since rare diseases of the lung may present as subtle and focal changes, complete removal of suspect pulmonary lesions is always advisable.

Hamartoma of mature cardiac myocytes of the pulmonary infundibulum [Case report - Cardiac general]

Galeone, A., Validire, P., Gayet, J.-B., Laborde, F. — Tue, 17 Nov 2009 10:56:36 PST

We describe the incidental finding and treatment of a very rare and voluminous cardiac tumour located near to the pulmonary infundibulum. The mass was surgically resected and final diagnosis was hamartoma of mature cardiac myocytes. Postoperative course was uneventful and the patient is asymptomatic after six months of follow-up.

Concurrent benign schwannoma of oesophagus and posterior mediastinum [Case report - Thoracic oncologic]

Dutta, R., Kumar, A., Jindal, T., Tanveer, N. — Tue, 17 Nov 2009 10:56:36 PST

A 52-year-old female with recent onset dysphagia and haematemesis was found to have an intramural tumour of the oesophagus. A separate tumour in the posterior mediastinum was also detected. Both the tumours were immunohistochemically and histomorphologically compatible with benign schwannoma. Oesophageal schwannoma is extremely rare and its association with a concurrent schwannoma in posterior mediastinum is not reported earlier in the literature.

Surgical treatment of a rare case of tracheal inflammatory pseudotumor in pediatric age [Case report - Thoracic oncologic]

De Palma, A., Loizzi, D., Sollitto, F., Loizzi, M. — Tue, 17 Nov 2009 10:56:36 PST

Tracheal inflammatory pseudotumor (IPT) is a rare solid lesion with an unpredictable biological course. Treatment can vary and surgical resection may sometimes be necessary, even in pediatric age. We report the case of a 12-year-old male patient who presented to our institution with sudden dyspnoea after some months of wheezing and cough, wrongly considered and treated as asthma. Neck-chest CT-scan and fiberbronchoscopy showed an intraluminal tracheal mass, originating from the left antero-lateral wall at the level of the 5th cartilagineous tracheal ring, involving three rings, that was removed by rigid bronchoscopy. Histopathology revealed a tracheal IPT. Due to rapid tendency to recurrence of the lesion, two more endoscopic recanalizations were performed, but a new recurrence appeared, with CT evidence of transmural involvement of the tracheal wall. Resection of the three involved tracheal rings and termino-terminal tracheal anastomosis were successfully performed through cervicotomy and sternal split. CT-scan and fiberbronchoscopy at 17 months from surgery show a stable tracheal lumen without signs of recurrence. A tracheal IPT should be suspected in any pediatric patients with tracheal mass and asthmatic symptoms. After radical removal prognosis is generally excellent and recurrences after tracheal resection are rare.

Crutch-induced bilateral brachial artery aneurysms [Case report - Vascular general]

Konishi, T., Ohki, S.-i., Saito, T., Misawa, Y. — Tue, 17 Nov 2009 10:56:36 PST

A 57-year-old man, who was a chronic axillary crutch user as a result of childhood poliomyelitis, was referred to our hospital because of a sudden onset of right forearm ischemia. The right forearm had no pulse, and three-dimensional computed tomography (3DCT) showed an aneurysm of the right brachial artery associated with arterial occlusion. The thrombosed aneurysm of the brachial artery was resected and the brachial artery was successfully revascularized by interposing a saphenous vein graft. Postoperative 3DCT revealed an asymptomatic left brachial artery aneurysm. His postoperative course was uneventful under warfarin anticoagulation therapy.

Spontaneous circumferential esophageal dissection in a young man with eosinophilic esophagitis [Case report - Esophagus]

Quiroga, J., Prim, J. M. G., Moldes, M., Ledo, R. — Tue, 17 Nov 2009 10:56:36 PST

Spontaneous esophageal dissection is a rare condition that may happen in patients with eosinophilic esophagitis. Conservative management is an important therapeutic option to be considered. We describe an unusual case of a young man with eosinophilic esophagitis who presented complaining of acute retrosternal pain, fever and vomiting. After a thorough evaluation including CT-scan and esophagogram, circumferential esophageal dissection and mediastinal abscess without visible perforation was observed. Abscess resolution and oral nutrition reintroduction was achieved with non-surgical management. Corticoid therapy was initiated for esophagitis treatment.

Peripheral venous embolized intracardiac foreign body [Case report - Cardiac general]

Marcello, P., Garcia-Bordes, L., Mendez Lopez, J. M. — Tue, 17 Nov 2009 10:56:36 PST

Embolized intracardiac foreign bodies have been previously described in the literature. Those related to iatrogenic procedures, such as catheters and pacemaker electrodes, are the most common. However, traumatic embolization of a metal foreign body is scantily described. We report a case of a peripheral venous embolized intracardiac metal foreign body after traumatic elbow injury. A review of the literature is therefore performed. Intracardiac foreign body removal must be considered when its diameter exceeds 5 mm, its shape is irregular or when symptomatic.

Splenic injury following diaphragmatic plication: an avoidable life-threatening complication [Case report - Thoracic non-oncologic]

Pathak, S., Page, R. D. — Tue, 17 Nov 2009 10:56:36 PST

We report an unusual complication of left-sided diaphragmatic plication, namely bleeding from the spleen due to tearing of adhesions between the spleen and the abdominal aspect of the diaphragm. We believe that making a small incision in the diaphragm prior to the plication to identify and divide the adhesions could have prevented the complication, and that this manoeuvre should be a standard part of the operation.

Syncope triggered by a giant unruptured sinus of Valsalva aneurysm [Case report - Cardiac general]

Matteucci, M. L.S., Rescigno, G., Capestro, F., Torracca, L. — Tue, 17 Nov 2009 10:56:36 PST

Sinus of Valsalva aneurysms are rare anomalies, most often caused by congenital absence of muscular and elastic tissue in the aortic wall of the sinus. The indication for surgical repair is controversial at the time of diagnosis. As well, the repair technique depends on how many sinuses are dilated, whether the aneurysm is ruptured and whether the aneurysm is symptomatic. We report a case of a single unruptured sinus of Valsalva aneurysm of a 54-year-old woman.

Splenic tear causing a hemoperitoneum after cardiac surgery [Case report - Cardiac general]

Ceresa, F., Francio, G., Aldo Intili, P., Patane, F. — Tue, 17 Nov 2009 10:56:36 PST

Hemoperitoneum after cardiac surgery is a very rare but life-threatening complication. We have only found a few cases described in the literature, in which the intra-abdominal hemorrhages were caused by liver bleeding, due to direct hepatic trauma or spontaneous hepatic rupture. We describe the first case of hemoperitoneum caused by a spontaneous rupture of the spleen.

Feasibility of ablation as an alternative to surgical metastasectomy in patients with unresectable sarcoma pulmonary metastases [Case report - Thoracic oncologic]

Ding, J. H., Chua, T. C., Glenn, D., Morris, D. L. — Tue, 17 Nov 2009 10:56:36 PST

Percutaneous radiofrequency ablation (RFA) is an alternate treatment modality for pulmonary metastasis in non-surgical candidates. Four patients not suitable for surgery underwent percutaneous RFA for pulmonary metastases from leiomyosarcoma. Success of RFA was assessed with computed tomography (CT). The median length from the radiographic diagnosis of metastatic pulmonary disease (CT-scan) from the primary tumor diagnosis was 67.0 months with a range of 15.0–81.0 months. The median disease free interval following RFA was 19.0 months with a range of 4.0–35.0 months. Three of four patients underwent the procedure uneventfully. RFA is a safe and minimally invasive intervention in non-surgical candidates with sarcoma pulmonary metastases.