Interactive CardioVascular and Thoracic Surgery recent issues

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.

Primary sternal plating to prevent sternal wound complications after cardiac surgery: early experience and patterns of failure [Work in progress report - Cardiac general]

Snyder, C. W., Graham, L. A., Byers, R. E., Holman, W. L. — Wed, 14 Oct 2009 09:58:27 PDT

Sternal closure with rigid titanium plates (primary sternal plating) may reduce sternal wound complications in high-risk patients. We began performing primary sternal plating for the following indications: obesity, manual laborer, osteoporotic sternum, or intraoperative transverse sternal fracture. Patients receiving plate closure were compared to a risk-matched control group receiving wire closure. Outcomes of interest were postoperative length of stay and sternal wound complications [sterile dehiscence or deep sternal wound infection (DSWI)]. Wound complications were classified by time of occurrence as early (≤30 days postoperation) or late (>30 days postoperation). Of 445 total cardiac cases during the 5-year study period, 129 (29%) met inclusion criteria. The plate group (n=30) and wire group (n=99) were generally well-matched in terms of risk factors. Postoperative length of stay was significantly shorter in the plate group (median 7 vs. 8 days, P=0.023). No early sternal wound complications occurred in the plate group, compared to 12 (12%) in the wire group (P=0.067). The incidence of late sternal wound complications was 10% in both groups (P=1.0). Primary sternal plating appears to provide benefits over wire closure during the early postoperative period, but may not prevent late wound complications in patients with osteoporosis or extreme obesity.

Efficacy of SOFT COAG for intraoperative bleeding in thoracic surgery [Work in progress report - Thoracic non-oncologic]

Sakuragi, T., Ohma, H., Ohteki, H. — Wed, 14 Oct 2009 09:58:27 PDT

We present and examine two cases of the dramatic hemostasis with SOFT COAG in general thoracic surgery. SOFT COAG is a coagulation mode unique to VIO electrosurgical units (ERBE Elektromedizin GmbH, Germany). This system regulates the temperature rise below boiling point without generating sparks, which is high enough to denature protein. In addition to clinical applications, this coagulation system makes use of a reusable device, Slim line hand switch^®, which has economically and ecologically major advantages for ecosurgery.

The heart of patients with aortic aneurysms: evidence from cardiac computed tomography [Institutional report - Cardiac general]

Wed, 14 Oct 2009 09:58:27 PDT

To determine in patients with abdominal aortic aneurysm (AAA) the coronary calcium burden and prevalence of coronary artery disease (CAD) in relation to cardiovascular risk factors, and to assess the left ventricular (LV) function using cardiac computed tomography (CT). Sixty consecutive patients (six females; 72.2±9.0 years) with AAA underwent dual-source CT calcium scoring and coronary angiography prior to AAA repair. In the 60 patients, the Framingham risk score (FRS) ranged from 5–43%. Twenty patients (33%) were at low, 16 (27%) at intermediate, and 24 (40%) at high risk for cardiovascular disease. The median Agatston score (AS) was 393 (0–3538). No significant correlation was found between AS and FRS (P=0.76). 846/851 coronary segments (99%) in 57/60 patients (95%) were depicted with a diagnostic image quality. Significant stenoses were found in 132/846 segments (16%) in 33/60 patients (55%). Five patients (8%) with significant coronary artery stenosis showed reduced LV function [ejection fraction (EF)<50%]. The extent of CAD was significantly correlated with AS (r=0.43, P<0.01), whereas no correlation was found for FRS (P=0.55). Cardiac CT is feasible in patients with AAA and allows for the assessment of coronary calcium, coronary stenoses, and LV function. The calcium burden and coronary stenoses assessment with cardiac CT provides incremental information beyond traditional cardiovascular risk factors alone.

eComment: Re: The heart of patients with aortic aneurysms: evidence from cardiac computed tomography [eComment]

Bockeria, L. A., Makarenko, V. N. — Wed, 14 Oct 2009 09:58:27 PDT

Reconstruction of atrioventricular valves with photo-oxidized bovine pericardium [Institutional report - Valves]

Verbrugghe, P., Meuris, B., Flameng, W., Herijgers, P. — Wed, 14 Oct 2009 09:58:27 PDT

Repair of complex valve pathological processes often requires the use of leaflet tissue or pericardium. The use of bovine photo-oxidized pericardium may be an alternative, a tissue less prone to calcification. The aim of this study is to evaluate the use of photo-oxidized bovine pericardial tissue in the reconstruction of atrioventricular valves in humans. Between July 2001 and September 2006, 21 patients with complex valve pathology underwent a reconstruction with photo-oxidized pericardium. The pericardial patch was used for the reconstruction of a tricuspid valve leaflet in two patients, the reconstruction of a mitral valve leaflet in six patients, the reconstruction of the tricuspid annulus in one patient and the reconstruction of the mitral annulus in 12 patients. The follow-up ranged from 13.9 to 43.2 months. There were five perioperative deaths. Four patients developed failure of the reconstruction, in one patient there was thinning and perforation of the pericardial patch without signs of infection or abrasion. The other patients were free from thromboembolism, endocarditis, hemorrhagic complications or echocardiographic signs of failure of the reconstruction. Photo-oxidized bovine pericardium is a versatile material for complex reconstruction of the atrioventricular valvular structures. Its durability should, however, be investigated in comparison with alternative tissues in a randomized trial.

Temporary cardiac support with a mini-circuit system consisting of a centrifugal pump and a membrane ventilator [Institutional report - Assisted circulation]

Wed, 14 Oct 2009 09:58:27 PDT

Commonly used extracorporeal membrane oxygenation (ECMO) systems for cardiac support are limited by bleeding complications, especially after surgery in the adult patient. Recently, we have switched from the use of a conventional ECMO system to a miniature-circuit including a centrifugal pump and the Novalung^® membrane ventilator (iLA). This system allows us to administer less heparin compared to the conventional system. Between January and August 2007, 1469 patients underwent cardiac surgery at our center, of which 18 patients (1.2%) required temporary postoperative ECMO system support. Surgical procedures in these patients included coronary artery bypass grafting (CABG) surgery (n=5), valvular replacement (n=2), aortic surgery (n=2), cardiac transplantation (n=5), and other procedures (n=3). The mean age of the 18 patients was 50±15 years (n=13 male) with a mean duration of ECMO system support of 4.3 days (range: <1 to 14 days). Twelve patients (67%) were successfully weaned from ECMO system. The 30-day survival was 44% with a hospital mortality of 61%. Re-thoracotomy for bleeding was necessary in six patients (33%) under ECMO system support. In summary, the miniature ECMO system circuit seems to be suitable for middle-term cardiac support and is associated with a low rate of bleeding complications.

Extended videoscopic robotic thymectomy with the da Vinci telemanipulator for the treatment of myasthenia gravis: the Vienna experience [Institutional report - Thoracic non-oncologic]

Wed, 14 Oct 2009 09:58:27 PDT

Surgical treatment of myasthenia gravis should include the complete resection of the thymus with the whole fatty tissue adherent to the pericardium for immunologic as well as oncologic reasons. The aim of the current study was to investigate the efficacy and safety of robotic approach. A total of 18 patients with myasthenia gravis (mean age 44 years) have been operated robotically via a left-sided approach. Preoperative MGFA (Myasthenia Gravis Foundation of America) classification was: Class I n=4, Class IIa n=4, Class IIb n=5, and Class IIIa n=3, IIIb n=2. Total endoscopic resection was feasible in 17/18 patients. One patient had to be converted due to bleeding. In the remaining patients, operative time was 175 min, intensive care unit (ICU) one day, hospital stay four days. In all patients it was possible to perform an extended thymic resection. MGFA post-intervention status after a mean of 18 months follow-up showed complete stable remission n=5, pharmacologic remission n=4, minimal manifestations n=5, unchanged n=1. Complete endoscopic thymus surgery with the da Vinci surgical system enables a complete and extended resection of all thymic tissue in the mediastinum. Due to the minimal trauma, patients can return to full activity within a short time.

The impact of previous or concomitant myocardium revascularization on the outcomes of patients undergoing major non-cardiac surgery [Institutional report - Cardiac general]

Zhang, H., Wang, D.-x., Xiao, F., Li, J., He, Z.-s., Wan, Y.-l. — Wed, 14 Oct 2009 09:58:27 PDT

The aim of this study was to analyze the results of major non-cardiac surgery in patients with severe coronary arterial disease who underwent concomitant vs. previous myocardial revascularization (MR) in terms of operative complications and hospital stay. Between June 1999 and October 2008, 37 patients with coronary arterial disease underwent neoplastic resection at our hospital. Fourteen patients with a curable left-main or multiple-vessel disease received surgical MR concomitantly, while 23 patients previously underwent surgical or transluminal MR. Univariate analysis determined the impact of the timing of MR on operative complications and hospital stay. The overall mortality and morbidity rates were 3% and 65%, respectively. Compared with simultaneous MR, neoplastic surgery with previous MR had shorter postoperative hospital stay. Occurrence of postoperative complications was influenced by surgical duration (P=0.014). Postoperative length of hospital stay was affected by the timing of revascularization (P=0.008) and surgical duration (P=0.007). Previous MR can shorten postoperative hospital length of stay for current major non-cardiac surgeries in patients with severe coronary artery disease (CAD). For patients with concomitant severe CAD and clinically rapidly progressive malignant neoplasm, simultaneous neoplastic resection and MR is associated with acceptable operative mortality.

The effect of diabetic medications on creatine kinase-myocardial band levels in patients undergoing coronary artery bypass surgery [Institutional report - Cardiac general]

Wed, 14 Oct 2009 09:58:28 PDT

Ischemic preconditioning has been shown to attenuate the rise in creatine kinase-myocardial band levels that occur with coronary artery bypass surgery (CABG). Recently, concerns have been raised that some sulfonylureas particularly glibenclamide may block ischemic preconditioning. The purpose of this study was to determine the effect of various diabetic medicines on creatine kinase-myocardial band levels after CABG. In this retrospective study of 799 patients undergoing CABG, patients continued their routine diabetic medicines up to the day of surgery. Intra-operatively and postoperatively, tight glycemic control was maintained with an insulin infusion. Anesthesia was maintained with isoflurane supplemented by fentanyl. Creatine kinase-myocardial band levels were determined the day after surgery at 05:00 h and the mean levels compared between diabetics and non-diabetics and further compared by type of diabetic medicine. After univariable comparisons, linear regression was used to determine the statistically significant predictors of creatine kinase-myocardial band levels. After correction for other factors, none of the diabetic medicines was a statistically significant predictor of creatine kinase-myocardial band levels. We found that the use of glibenclamide or other diabetic medications had no effect on creatine kinase-myocardial band levels the morning after patients underwent CABG.

Neutrophil gelatinase-associated lipocalin levels after use of mini-cardiopulmonary bypass system [Institutional report - Cardiopulmonary bypass]

Wed, 14 Oct 2009 09:58:28 PDT

Neutrophil gelatinase-associated lipocalin (NGAL) has been implicated as an early predictive urinary biomarker of ischemic acute kidney injury (AKI). The aim of this study was to compare the effects of miniaturized cardiopulmonary bypass system (MCPB) vs. standard cardiopulmonary bypass system (SCPB) system on kidney tissue in patients undergoing myocardial revascularization using urinary NGAL levels as an early marker for renal injury. Sixty consecutive patients who underwent myocardial revascularization were studied prospectively. An SCPB was used in 30 patients (group A) and MCPB was used in 30 patients (group B). The SCPB group but not the MCPB group showed a significant NGAL concentration increase from preoperative during the 1st postoperative day (169.0±163.6 ng/ml in the SCPB group vs. 94.1±99.4 ng/ml in the MCPB group, P<0.05, respectively). Two patients in the SCPB group developed AKI and underwent renal replacement therapy; no patient in MCPB developed AKI. The MCPB system is safe in routine clinical use. Kidney function is better protected during MCPB as demonstrated by NGAL levels. NGAL represents an early biomarker of renal failure in patients undergoing cardiac surgery and the valuation of its concentration can aid in medical decision-making.

Elective infrarenal abdominal aortic aneurysm repair - transperitoneal, retroperitoneal, endovascular? [Institutional report - Aortic and aneurysmal]

Muehling, B. M., Orend, K. H., Sunder-Plassmann, L. — Wed, 14 Oct 2009 09:58:28 PDT

We retrospectively analyzed the peri-operative outcome of 210 consecutive patients undergoing elective infrarenal abdominal aortic aneurysm (AAA) repair according to the surgical approach: transperitoneal (TP; 63 patients), retroperitoneal (RP; 81 patients) and endovascular (EV; 66 patients) repair. Concerning gender, AAA diameter and classification of the American Society of Anesthesiologists (ASA score) all groups were comparable; the median age in the EV group was significantly higher (78 years vs. 68 years and 67 years, respectively, P=0.001). Mortality rates were 0% for TP, 1.2% for RP and 3% for EV repair (n.s.). Morbidity rates did not significantly differ between the groups. In specialized centres mortality rates of elective infrarenal aneurysm repair are low – regardless of the surgical approach. In such centres the best treatment options for each patient as to the surgical approach as well as peri-operative management can be provided individually.

Ventricular assist device as a bridge to heart transplantation in children [Institutional report - Assisted circulation]

Wed, 14 Oct 2009 09:58:28 PDT

The ventricular assist device (VAD) is a life-saving option for patients in heart failure refractory for conventional therapy. The aim of study was to assess the influence of VAD on heart transplantation (HT) outcome in children <16 years. Between October 1988 and August 2008, 73 children underwent HT: Group 1 (n=9) who received VAD as bridge to HT (left ventricular – 4, biventricular – 5), and Group 2 (n=64), without previous VAD. Diagnoses included cardiomyopathy (n=50 (68.5%)) and congenital heart defects (n=23 (31.5%)). Retrospective analysis of perioperative and long-term follow-up data was performed. The mean follow-up was 7.22±4.7 years. The diagnosis of cardiomyopathy appeared more often in Group 1 (P=0.074), but the difference was not significant. The two groups did not differ with respect to age (P=0.123) and weight (P=0.183). Mortality in long follow-up was: 11.1% (n=1) in Group 1 and 14.1% (n=9) in Group 2 (P=0.782). Analysis of preoperative end-organs function did not reveal significant differences between groups. There was also no significant differences with respect to waiting time for transplant (P=0.948), postoperative ventilatory support time (P=0.677), duration of hospital stay (P=0.711) and incidence of acute rejection episodes (P=0.156). VAD used as a bridge for HT in children does not negatively influence the outcome.

Postoperative administration of landiolol hydrochloride for patients with supraventricular arrhythmia: the efficacy of sustained intravenous infusion at a low dose [Institutional report - Arrhythmia]

Wed, 14 Oct 2009 09:58:28 PDT

The purpose of this study was to investigate the efficacy of landiolol hydrochloride, a short-acting β₁ blocker, by initiating its administration at a low dose (5 µg·kg^–1·min^–1) in patients with postoperative supraventricular arrhythmia. The efficacy of landiolol was evaluated in 38 patients who, after developing postoperative atrial flutter or fibrillation, with sinus tachycardia and two patients who had a history of paroxysmal atrial fibrillation with frequent atrial extrasystole. The heart rate and blood pressure before and 2 h after the administration of landiolol were compared. A return to the sinus rhythm from supraventricular arrhythmia was noted in 89%. The heart rate was reduced from 137±26 bpm (before landiolol administration) to 93±18 bpm (2 h after the start of the medication, P<0.01). As an agent to correct an arrhythmic condition, landiolol successfully raised the systolic blood pressure from 108±24 mmHg (before medication) to 120±19 mmHg (2 h after the medication was started, P<0.05). Continuous intravenous infusion of landiolol at a low dose was found to be effective for postoperative supraventricular arrhythmia.

Anomalous left coronary artery from the pulmonary artery: intermediate results of coronary elongation [Institutional report - Congenital]

Wed, 14 Oct 2009 09:58:28 PDT

A two coronary system is preferred for correcting anomalous left coronary artery from the pulmonary artery (ALCAPA); however, translocation is not always possible. In countries where neonatal arterial switch operations have not been perfected coronary transfer can be difficult. The purpose of this report is to describe the intermediate results using the coronary elongation and translocation technique in developing countries. Records of patients undergoing operation by the International Children's Heart Foundation team were reviewed (April 1993–October 2008) for those undergoing ALCAPA repair. All patients received a 2-D echocardiographic–color Doppler examination prior to discharge and at follow-up. A total of 13 patients were identified, age ranged from 9 days to 41 years. All but one patient were operated upon at one of our affiliate hospitals in Croatia, Belarus, China and Colombia. All patients presented with moderate to severe mitral regurgitation and cardiac failure. Follow-up ranged from six months to 9.5 years postoperatively. Color Doppler showed a patent left coronary artery; echocardiography estimated a normal left ventricular ejection fraction and improved mitral regurgitation in all patients. The technique provides an alternative approach to translocation for ALCAPA in countries where routine neonatal coronary transfer techniques may not be perfected. Intermediate results are comparable to translocation.

eComment: Management of mitral regurgitation associated with anomalous left coronary artery from the pulmonary artery [eComment]

Edwin, F. — Wed, 14 Oct 2009 09:58:28 PDT

Ministernotomy for repair of congenital cardiac disease [Institutional report - Congenital]

Sebastian, V. A., Guleserian, K. J., Leonard, S. R., Forbess, J. M. — Wed, 14 Oct 2009 09:58:28 PDT

We report our experience with repair of a variety of congenital heart defects utilizing a ministernotomy incision. A ministernotomy was used in 79 patients with a variety of congenital heart diseases from November 2004 to August 2007. Patients included 36 males and 43 females with ages ranging from 1 month to 122 months (median age, 22 months). The weight ranged from 3.5 kg to 40 kg (median weight, 10.9 kg). There were no deaths, and one conversion to full median sternotomy (1/79, 1.3%). The median cardiopulmonary bypass time was 59 min, and median aortic cross-clamp time was 38 min. One patient underwent atrial septal defect (ASD) repair with fibrillatory arrest time of 35 min. The operating time ranged from 103 min to 312 min (median operating time, 168 min). The intensive care unit (ICU) stay ranged from 1 to 21 days (median ICU stay, 1 day) and the hospital stay ranged from 2 to 56 days (median hospital stay, 4 days). There were no reinterventions for residual cardiac defects. We demonstrate the safety and efficacy of ministernotomy for the correction of a range of congenital heart defects with improved cosmetic results.

eComment: Re: Ministernotomy for repair of congenital cardiac disease [eComment]

Bockeria, L. A., Kim, A. I., Grigoryants, T. R. — Wed, 14 Oct 2009 09:58:28 PDT

eComment: Minimally invasive access for congenital heart disease repair [eComment]

Karimov, J. H., Glauber, M. — Wed, 14 Oct 2009 09:58:28 PDT

Is there any difference in carotid stenosis between male and female patients undergoing coronary artery bypass grafting? [Institutional report - Carotid and imaging]

Wed, 14 Oct 2009 09:58:28 PDT

Cardiovascular diseases are among the leading causes of death in women. Significant gender differences have been reported among patients with symptomatic carotid artery disease. The aim of this study is to examine if the female sex is a predisposing factor for carotid stenosis in coronary artery bypass grafting (CABG) patients. We studied 965 CABG patients, 796 males and 169 females. We combined the gender with risk factors predicting carotid disease as a history of cerebrovascular accident (CVA), peripheral vascular disease (PVD), left main (LM) disease and advanced age. We compared the incidence of carotid disease for each gender against known risk factors, which are history of CVA, PVD, LM and advanced age. In our study, there was not a statistically significant difference for the presence of carotid disease between males and females undergoing CABG. However, patients with a history of CVA, with PVD and older age were at greater risk for carotid stenosis. We conclude that the female sex is not a predictive factor for carotid stenosis in CABG patients.

Age >=75 years is associated with greater resource utilization following coronary artery bypass grafting [Institutional report - Cardiopulmonary bypass]

Toor, I., Bakhai, A., Keogh, B., Curtis, M., Yap, J. — Wed, 14 Oct 2009 09:58:28 PDT

We examined whether complication rates and resource utilization among elderly patients undergoing coronary artery bypass grafting (CABG) differed from their younger counterparts. A retrospective review of prospectively collected data was conducted of 2936 patients undergoing first-time isolated CABG. Demographic and baseline clinical characteristics were collected, and patients grouped according to age into those <75 years (n=2424, younger) and ≥75 years (n=512, older). Major postoperative complications were recorded and data collected on indicators of resource utilization, which included intensive care unit (ICU) length of stay (LOS), postoperative LOS and total hospital LOS. In comparison with younger patients, older patients were more likely to be female (26.6% vs. 18.1%, P<0.0001) and require an urgent procedure (46.4% vs. 33.3%, P<0.0001). Postoperative complications were significantly higher in elderly patients (43.7% vs. 23.0%; odds ratio (OR)=2.5, 95% confidence interval (CI) [2.0–3.1]; P<0.0001). Older patients incurred longer intensive care stays (2 days interquartile range (IQR) [1–3] vs. 1 day IQR [1–2]; P<0.0001) and a longer postoperative stay (8 days IQR [6–11] vs. 6 days IQR [5–8]; P<0.0001). Multivariate logistic regression analysis showed age ≥75 years was an independent predictor of postoperative LOS (OR=1.23, 95% CI [0.49–1.96]; P=0.001). Older patients aged ≥75 years undergoing CABG had significantly higher rates of postoperative complications and greater resource utilization than their younger counterparts.

Minimal extracorporeal circulation and off-pump compared to conventional cardiopulmonary bypass in coronary surgery [ESCVS article - Cardiopulmonary bypass]

Wed, 14 Oct 2009 09:58:28 PDT

Objectives: Although minimal extracorporeal circulation (MECC) and off-pump surgery are equal or better alternatives to conventional cardiopulmonary bypass (CCPB) regarding perioperative morbidity, use of blood and blood products and completeness of revascularization, CCPB is still being used in the majority of coronary artery bypass grafting (CABG) operations. Methods and Results: We investigated 1472 CABG operations in our center. A total of 1143 CABG operations were performed using CCPB, 220 using MECC and 109 were performed as off-pump coronary artery bypass (OPCAB). All patients were recorded prospectively. Perioperative follow-up was focused on the occurrence of arrhythmia, neurocognitive disorders and the need of blood and blood products. Operative mortality rates were comparable in all three groups. The mean number of distal anastomoses was 3.2±0.6 in the MECC group, 3.4±0.7 in the CCPB group and 1.9±0.8 in the OPCAB group (P=0.01). Arrhythmia occurred in 25% of the MECC group and in 35.6% of the CCPB group (P=0.05). Arrhythmia occurred in 21.7% of the OPCAB group. Seven patients (3%) of the MECC group suffered neurocognitive disorders perioperatively compared to 74 (7%) patients of the CCPB group (P=0.05) and three patients of the OPCAB group (3%). The median number of blood transfusions per patient was 0.8 in the MECC group, 1.8 in the CCPB group and 0.8 in the OPCAB group (P<0.0001). Conclusions: Perioperative morbidity of MECC and OPCAB is comparable to or even less in comparison to CCPB. MECC allows CABG surgery in cardiac arrest so that completeness of revascularization is being warranted and longer patency rates can be guaranteed. Furthermore, the use of blood and blood products is significantly less in MECC surgery so that MECC should be considered first choice in CABG surgery over CCPB and OPCAB.

When operable patients become inoperable: conversion of a surgical aortic valve replacement into transcatheter aortic valve implantation [Proposal for bail-out procedures - Valves]

Olsen, L. K., Arendrup, H., Engstrom, T., Sondergaard, L. — Wed, 14 Oct 2009 09:58:28 PDT

Transcatheter aortic valve implantation (TAVI) is a relatively new treatment option for inoperable patients with severe aortic stenosis (AS). This case describes how a planned conventional surgical aortic valve replacement (AVR) on a 73-year-old woman was successfully converted to a TAVI procedure. On extracorporal circulation it was reconized that the aortic annulus, the coronary ostiae and the proximal part of the ascending aorta were severely calcified making valve implantation impossible. Surgical closure without valve substitution was estimated to be associated with a high risk of mortality due to the imparied left ventricular function. Consequently, TAVI was performed with a CoreValve ReValving^® System prosthesis. The delivery of the valve prosthesis was made through the ascending part of aorta, proximal of the cannulation of aorta. Positioning of the valve prosthesis was made under visual guidance, and the prosthesis was sutured to the ascending aorta. With some manipulation of the prosthesis it was possible to suture the aorta circumferentially around the fully expanded upper part of the prosthesis. Post-procedurally the patient recovered successfully, with improved function capacity, aortic valve area and left ventricle function.

eComment. Sutureless aortic valve implantation in cases of calcified aortic annuli [eComment]

Khaladj, N., Hagl, C., Haverich, A., Shrestha, M. — Wed, 14 Oct 2009 09:58:28 PDT

Aortic posterior wall perforation with automatic aortic cutter during routine off-pump coronary bypass grafting [Negative results - Coronary]

Syburra, T., Reuthebuch, O., Graves, K., Genoni, M. — Wed, 14 Oct 2009 09:58:28 PDT

Aortic complications are very rare during off-pump coronary artery bypass grafting (OPCAB). When they occur, the mortality is high. We report a case of perforation of the posterior aortic wall after punching out the hole in the ascending aorta with an automatic aortic cutter to avoid clamping for the proximal anastomosis during a routine OPCAB procedure. The consequence was a massive hemorrhage, emergency conversion to cardiopulmonary bypass and replacement of the aortic valve and of the ascending aorta.

Early calcification of the aortic Mitroflow pericardial bioprosthesis in the elderly [Negative results - Valves]

Wed, 14 Oct 2009 09:58:28 PDT

Background: We report our experience in the elderly with aortic valve replacement using the Mitroflow A12 pericardial bioprosthesis. Methods: From January 1993 to January 2006, 491 patients over the age of 70 years received an aortic Mitroflow A12 bioprosthesis implantation. Concomitant procedures included coronary artery bypass grafting in 20% of patients. All patients had routine postoperative Echo-Doppler studies at discharge, one month and a mean of 11.1 months after surgery and annually thereafter. Results: Twenty (4%) patients underwent a second aortic valve replacement due to bioprosthetic valve dysfunction (Group 2). Calcified stenosis was the most common finding at reoperation (98%). Median time to valve reoperation was 76 months. Of patients requiring reoperation, median age at first and second implantation was 73 (70–78) and 79 (76–83) years, respectively. For all patients, freedom from structural valve dysfunction (SVD) was 95±3% at 5 years and 55.8±2% at 10 years. Bioprosthetic valve deterioration was identified in 27 patients (Group 1). Median age of these patients at first operation and at diagnosis of deterioration by echo was 75 (70–84) and 77 (70–82) years, respectively. The median interval between operation and detection of bioprosthesis valve deterioration was 46 months. Among the total patient population, freedom from bioprosthetic deterioration was 85.7±2% at 5 years and 33.5±4% at 10 years. Conclusion: The Mitroflow A12 pericardial bioprosthesis provides less than optimal performance in elderly patients.

eComment: Factors related to bioprosthetic valve calcification in the elderly [eComment]

Gunay, R., Bicer, M., Sensoz, Y., Demirtas, M. M. — Wed, 14 Oct 2009 09:58:28 PDT

Pectoral hematoma mimicking a hemothorax in an octogenarian following aortic valve replacement - a near miss [Negative results - Cardiac general]

Nanjaiah, P., Agrawal, D., Prasad, S. U. — Wed, 14 Oct 2009 09:58:28 PDT

Open-heart surgery is associated with higher risk of complications in the octogenarians, specifically because of frailty of tissues and delayed healing secondary to various factors. Here, we present a near miss, where an 86-year-old lady underwent tissue aortic valve surgery complicated with formation of a large retro-pectoral hematoma, which on the initial chest X-ray mimicked a left hemothorax. This was successfully explored surgically and drained promptly within 8 h of the primary surgery. This is illustrated with chest radiographs. The case highlights one of the rare complications that we encountered in cardiac surgery of the elderly.

Ministernotomy approach for surgery of the aortic root and ascending aorta [State-of-the-art - Cardiac general]

Perrotta, S., Lentini, S. — Wed, 14 Oct 2009 09:58:29 PDT

Different minimally invasive approaches have been proposed for cardiac surgery. Between those, the ministernotomy finds wide consensus for the treatment of the aortic disease, being both the upper reversed T and the upper J the mostly used type of incisions. The authors review the literature on the use of ministernotomy in the treatment of the ascending aorta and arch pathology. The scientific literature was reviewed by searching Medline, the Cochrane Library and the CINAHL database. A total of 1411 papers were found in Medline, 186 in the Cochrane database and 514 in CINAHL database; 50 papers were used to write the article; of which seven represent the most significant papers on the subject. The authors, journal, date and country of publication, patients group studied, relevant outcomes, and the results of these papers are tabulated. The ministernotomy is gaining consensus among surgeons. The indication to surgery, initially restricted only to selected elective patients, is now extended to more complex surgeries, including both the aortic root and aortic arch, redo-operations and, in minor cases, to emergency patients. Furthermore, the use of ministernotomy in redo aortic surgery with patent left internal mammary artery (LIMA) to left anterior descending (LAD) artery is a promising alternative. However, the use of this technique is still limited to few institutions and there are still a limited number of studies comparing this approach to full sternotomy in a prospective, randomized fashion. Even with those limitations, from the review of the literature, it seems that ministernotomy approach for aortic root and ascending aorta surgery is a feasible alternative, showing some advantages compared to full sternotomy. Those advantages include: reduced postoperative bleeding and pain, lower risk of mediastinitis, better aesthetic results, and faster respiratory function recovery. This is true not only for first time surgery, but also, and especially, for redo cases, where the limited exposure will reduce risks correlated to the surgical dissection of redo surgery. The ministernotomy approach for aortic root and ascending aorta surgery could in the future be more extensively used, offering greater benefits to cardiac surgical patients.

Primary graft dysfunction; possible evaluation by high resolution computed tomography, and suggestions for a scoring system [State-of-the-art - Transplantation]

Wed, 14 Oct 2009 09:58:29 PDT

We have reviewed and discussed current knowledge on existing scoring systems regarding high resolution computed tomography (HRCT) images for the assessment of primary graft dysfunction (PGD) after lung transplantation. Adult respiratory distress syndrome (ARDS) has been more widely studied and appears to have many morphological features similar to what is found in PGD, and might, therefore, be usefully extrapolated to PGD. Principles of HRCT, scoring systems based on HRCT and various terms describing PGD were reviewed and summarized. The sensitivity, inter-intra observer variability, and reproducibility of these systems were discussed. Lastly, the future perspectives for 64-multi-slice computed tomography (MSCT) in relation to PGD were discussed. Few studies on scoring systems of lung tissue by HRCT in ARDS patients and idiopathic pulmonary fibrosis (IPF) patients were found. Most studies were performed on patients with cystic fibrosis (CF). Sensitivity of HRCT for the detection of parenchymal changes is superior to other imaging methods. High levels of reproducibility are achievable amongst observers who score HRCT lung images. Development of standardized criteria that specify the inclusion/exclusion criteria of patients, pilot testing, and training investigators through review of disagreements, were possibilities suggested for decreasing inter/intra observer variability. Factors affecting the image attenuation (Hounsfield numbers) and thus, the reproducibility of CT densitometric measurements were of minimal influence. Studies have reported on how lung tissue images, derived by HRCT, can be scored and graded. There does not seem to be a golden standard for evaluating these images, which makes comparison between methods challenging. These scoring systems assess the presence, severity, and extent of parenchymal change in the lung. HRCT is considered relevant and superior in evaluating disease severity, disease progression, and in evaluating the effects of therapy regimes in the lung. It is, however, not clear to what extent these scoring methods may be implemented for grading PGD. Further efforts could be made to standardize scoring methods for lung tissue with regards to PGD.

In patients with acute aortic intramural haematoma is open surgical repair superior to conservative management? [Best evidence topic - Aortic and aneurysmal]

Attia, R., Young, C., Fallouh, H. B., Scarci, M. — Wed, 14 Oct 2009 09:58:29 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with acute aortic intramural haematoma (IMH) is open surgical repair superior to conservative management. IMH is defined as a clinical condition related to but pathologically distinct from aortic dissection. In this potentially lethal entity, there is haemorrhage into the aortic media in the absence of an intimal tear. Altogether more than 204 papers were found using the reported search terms, from which six systematic reviews 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. IMH represents 17% of all dissections, whereas in postmortem studies this condition is found in 4–13%. The 30-day mortality of IMH is 24% (36% with type A and 12% with type B IMH; P<0.05). With surgical repair, 30-day mortality of type A IMH was 14% for patients treated surgically and 36% for patients treated medically with a P-value of 0.02. Survival at 1, 2, 3, 5 and 10 years was respectively: 81±21%, 87±8%, 83±6%, 65±22% and 44±14%. In contrast, with 8% mortality associated with medical treatment, prognosis of type B IMH is more favourable without surgical intervention, the latter associated with a 30-day mortality of 33% (P<0.05). Symptomatic patients and those with rapid progression or overt dissection during follow-up need emergent surgery. Ascending aortic diameter of >50 mm or subadventitial haematoma thickness of >12 mm should be considered as the candidates for early surgery. Although IMH seems to have an improved prognosis over aortic dissection, survivors of IMH are at significant risk for progressive aortic abnormalities, including aortic rupture, aneurysm, and ulceration. We conclude that surgical treatment of aortic IMH involving the ascending aorta with open distal replacement of ascending aorta results in lower mortality and longer survival compared to conservative management. IMH affecting the descending aorta can be managed with medical or endovascular interventional approach. In this latter group, serial imaging of the aorta is recommended, as aneurysm formation is not uncommon.

Does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation? [Best evidence topic - Coronary]

Scarci, M., Fallouh, H. B., Young, C. P., Chambers, D. J. — Wed, 14 Oct 2009 09:58:29 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation? Altogether, 58 papers were found using the reported search, of which 13 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 identified 13 studies, of which eight were randomised prospective trials. None of these studies found increased mortality, seven analyzed serum cardiac enzymes and showed that intermittent ischemic arrest provides equal or better protection compared to cardioplegic techniques. Two studies found an increased usage of inotropes and intra aortic balloon pump (IABP) in the intermittent ischemic arrest group. We conclude that intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate postoperative outcome comparable to cardioplegic arrest in first-time coronary artery bypass graft (CABG). The ischaemic duration associated with intermittent cross-clamp fibrillation is invariably shorter than that associated with cardioplegic arrest, and this may be one explanation for the comparable outcomes. There may also be an element of preconditioning protection during the intermittent cross-clamp fibrillation method, as has been shown experimentally. During elective CABG in patients with no clinical evidence of aortic or cerebro-vascular disease, the incidence of peri-operative microemboli (ME) and postoperative neuropsychological disturbances are shown to be comparable with both techniques of myocardial preservation.

eComment: Myocardial protection in high risk coronary surgery [eComment]

Ibrahim, M. F., Refaat, A. A. — Wed, 14 Oct 2009 09:58:29 PDT

In patients undergoing surgical repair of post-infarction ventricular septal defect, does concomitant revascularization improve prognosis? [Best evidence topic - Cardiac general]

Perrotta, S., Lentini, S. — Wed, 14 Oct 2009 09:58:29 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘In patients undergoing surgical repair of post-infarction ventricular septal defect (VSD), does concomitant revascularization improve prognosis?’. The scientific literature was reviewed by searching Medline, using Ovid interface, from 1950 to April 2009. Four hundred and five papers were found, of which 18 were deemed relevant to the topics. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. Seven out of 18 papers showed statistical evidence of benefit of concomitant coronary artery bypass grafting (CABG) in patients undergoing surgical repair of VSD. They showed a benefit especially with complete revascularization. Another five papers recommended CABG with VSD even in the absence of statistical evidence. The reported papers showed a mortality benefit from 26.3% without revascularization down to 21.2% with revascularization and an actuarial survival at five years from 29 up to 72%. However, six out of 18 papers did not find any difference. The largest study in this area was by Jeppsson et al. where 119 patients underwent VSD repair with revascularization and 70 underwent VSD repair only, the mortality was 38% vs. 46% (P=0.29). Barker et al. compared a group of 23 patients undergoing repair of VSD only and 42 patients undergoing concomitant CABG. The in-hospital mortality was 39.2% vs. 26.2%, and the four-year survival rate was 33.2% and 88.2%, respectively. Lundblad et al. found that in 66 patients undergoing concomitant CABG out of 102 undergoing repair of VSD, complete revascularization and revascularization of the culprit artery, both resulted in improved 30-day survival and long-term survival. Muehrcke et al. reported on 75 patients undergoing surgical repair of post-infarction VSD. Out of those, 33 (44%) had a concomitant CABG. The authors found that concomitant CABG increases long-term survival when compared with patients with unbypassed coronary artery disease (CAD) (P=0.0015). We conclude that patients undergoing concomitant CABG to all the stenotic coronary arteries, supplying the non-infarcted area, fare better both in improved 30-day survival and long-term survival. The improvement of the collateral flow to the myocardium contributes to its better recovery.

Complicated ruptured sinus of Valsalva: cardiac computed tomographic angiography (64 slice) predicts surgical appearance and obviates need for invasive cardiac catheterization [Case report - Aortic and aneurysmal]

Ro, T. K., Cotter, B. R., Simsir, S. A., Karlsberg, R. P. — Wed, 14 Oct 2009 09:58:29 PDT

We present a case report of a ruptured sinus of Valsalva aneurysm (SVA) that presented as aortic insufficiency following bacterial endocarditits in a cardiac transplant patient. Cardiac computed tomographic angiography (CCTA) including volume rendered images predicted the appearance of the fistula entrance and defined spatial relationships facilitating the surgical approach. CCTA ability to define the coronary anatomy obviated the need for invasive coronary angiography. The use of this imaging modality especially with three-dimensional spatial visualization, and multiphase cine angiography can add significant value to the care of a patient with ruptured sinus of Valsalva.

A novel internal thoracic artery harvesting technique via subxiphoid approach - for the least invasive coronary artery bypass grafting [Case report - Coronary]

Takata, M., Watanabe, G., Ushijima, T., Ishikawa, N. — Wed, 14 Oct 2009 09:58:29 PDT

We have performed 12 cases of robotically assisted coronary artery bypass grafting (CABG) to accomplish less invasive revascularization. In this report, we describe a new method of robotically assisted internal thoracic artery (ITA) harvesting via subxiphoid approach, using the da Vinci surgical system. A 22-year-old man with three-vessel coronary artery disease due to Kawasaki disease was referred to our institution for coronary artery revascularization. A small subxiphoid incision was made, and the xiphoid process at the lower end of the sternum was excised. A U-shaped hook was inserted into the retrosternal space, and the lower sternum was lifted. A 30° angle-up camera was inserted under the U-shaped hook, bilateral ITAs were harvested in a totally skeletonized fashion endoscopically. The required time for right ITA harvesting was 50 min, and that for the left was 20 min. After bilateral ITAs were harvested, composite grafts were made, and then the distal anastomoses were made. The patient was discharged six days after the operation. We performed a new robotically assisted bilateral ITA harvesting technique via sub-xiphoid safely and with excellent results. This method might be an evolutionary step of minimally invasive direct coronary artery bypass (MIDCAB) using the da Vinci surgical system.

A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system [Case report - Cardiac general]

Reyes, K. G., Pettersson, G. B., Mihaljevic, T., Roselli, E. E. — Wed, 14 Oct 2009 09:58:29 PDT

Pseudoaneurysms of the ascending aorta developing after previous aortic or aortic valve surgery pose a high risk of exsanguination upon sternal reentry. In the past, femorofemoral bypass and hypothermic circulatory arrest before sternotomy was the preferred approach. Today, however, availability of the PORT-ACCESS EndoCPB system (Edwards Lifesciences, Irvine, CA, USA) allows for endovascular clamping and cardioplegia before sternotomy, avoiding circulatory arrest.

Successful salvage right upper lobectomy and flap repair of trachea-esophageal fistula due to severe necrotizing pneumonia [Case report - Thoracic oncologic]

Evans, B., MacKenzie, I., Malata, C., Coonar, A. — Wed, 14 Oct 2009 09:58:29 PDT

A 55-year-old previously well man developed a severe pneumonia. Endoscopy found tracheal and esophageal fistulae communicating with the right lung and pleural space. Bilateral main bronchi intubation was required. Emergency surgery was performed with a latissimus dorsi and serratus anterior muscle flap to close the tracheal and esophageal fistulae. The right upper lobe was found to be destroyed and resected. It was possible to salvage the patient who was discharged home despite challenging anesthetic and surgical circumstances.

Aortogenic cerebrovascular accident [Case report - Vascular thoracic]

Ohki, S.-i., Kubota, I., Aizawa, K., Misawa, Y. — Wed, 14 Oct 2009 09:58:29 PDT

A 59-year-old man was transferred to our hospital because of mural thrombus in the ascending aorta. He had suffered some neurological dysfunctions such as transient dysorientation. Electrocardiogram showed normal sinus rhythm without premature beats. Trans-thoracic echocardiogram and three-dimensional CT showed a mobile mural mass sticking to the ascending aortic wall. No coagulopathy was detected in the patient. The mural masses were thought to be a possible cause of the repeated cerebro-vascular symptoms. Under cardiopulmonary bypass and cardiac arrest, the masses were removed including the mass sticking to the aortic wall. Postoperative pathological findings showed the masses were organizing thrombi that had originated from the atherosclerotic aortic wall. Postoperative course was uneventful, and the patient was doing well one year after the operation without neurological dysfunction.

Use of Amplatzer device for endobronchial closure of bronchopleural fistulas [Case report - Thoracic oncologic]

Gulkarov, I., Paul, S., Altorki, N. K., Lee, P. C. — Wed, 14 Oct 2009 09:58:29 PDT

Postpneumonectomy bronchopleural fistulas (BPFs) remain difficult management problems associated with considerable morbidity and mortality. Traditional therapies have included primary repair or delayed closure with the creation of an Eloesser cavity and tissue flap reinforcement. New bronchoscopic modalities have included the use of bioglues, stents, and coils. We describe another additional, less invasive bronchoscopic modality – the use of an atrial septal closure device.

Thymic neuroblastoma with the syndrome of inappropriate secretion of antidiuretic hormone [Case report - Thoracic oncologic]

Ogawa, F., Amano, H., Iyoda, A., Satoh, Y. — Wed, 14 Oct 2009 09:58:29 PDT

We describe a rare case of thymic neuroblastoma with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). A 60-year-old male patient was admitted to our hospital for further examination and treatment of anterior mediastinal tumor found at a regular health check-up. On examination there was hyponatremia, decrease in plasma osmolarity and elevation of plasma antidiuretic hormone (ADH) level. Thus, he underwent total thymectomy under the diagnosis of thymoma with SIADH. The tumor was located in the right lobe of the thymus and the final diagnosis was thymic neuroblastoma. To our knowledge, this is the first reported case of thymic neuroblastoma in which production of ADH by tumor cells is demonstrated immunohistochemically. This case highlights the need to consider functional activity of thymic neuroblastoma and complete resection of the tumor is warranted for treatment.

Aorta non-touch coronary artery bypass grafting after total arch replacement for acute type A aortic dissection [Case report - Vascular thoracic]

Takahashi, Y., Tsutsumi, Y., Monta, O., Ohashi, H. — Wed, 14 Oct 2009 09:58:29 PDT

We report successful surgical treatment of coronary artery disease (CAD) in a 53-year-old man. The man was admitted to our hospital due to severe anterior chest pain. He had a surgical history of total arch replacement for acute type A dissection 10 years previously. Angiography showed triple-vessel disease and partial dissection of the descending aorta. To avoid excessive excision and to perform surgery safely, we chose aorta non-touch techniques for coronary artery bypass grafting (CABG). The postoperative course was uneventful and the patient was discharged 30 days after surgery.

Heartmate XVE(R) destination therapy for end-stage heart failure in a patient with human immunodeficiency virus [Case report - Assisted circulation]

Mehmood, S., Blais, D., Martin, S., Sai-Sudhakar, C. — Wed, 14 Oct 2009 09:58:29 PDT

Cardiac dysfunction is a known predictor of survival in patients with acquired immunodeficiency syndrome. In this report, we describe a human immunodeficiency virus (HIV)-infected patient with worsening heart failure who was managed successfully for 16 months with placement of a left ventricular assist device.

Emergent surgery for ruptured aortic arch aneurysm in an octogenarian patient: quo vadis? [Case report - Cardiac general]

Gualis, J., Castano, M., Gomez-Plana, J., Mencia, P. — Wed, 14 Oct 2009 09:58:29 PDT

Aortic arch aneurysms induce great morbidity and mortality especially when clinical signs of rupture are present. Surgical indications for repair in the high-risk octogenarian population are controversial. We present the case of an 87-year-old man with a ruptured aortic arch aneurysm with a good surgical outcome. We discuss the clinical impact of the surgical treatment in this group of patients.

Catastrophic presentation of atrial myxoma with total occlusion of abdominal aorta [Case report - Cardiac general]

Yadav, S., Alvarez, J. M. — Wed, 14 Oct 2009 09:58:29 PDT

Cardiac myxoma is a rare disease with protean manifestations. Embolic phenomena are well-known entities. However, total occlusion of the descending aorta by saddle embolism along with multi-organ embolism is very unusual. We report a patient with cardiac myxoma presenting with multi-organ embolism including saddle embolism of the aorta in a previously healthy female.

Non-surgical closure of post-pneumonectomy empyema with bronchopleural fistula after open window thoracotomy using basic fibroblast growth factor [Case report - Thoracic non-oncologic]

Okuda, M., Yokomise, H., Tarumi, S., Huang, C.-L. — Wed, 14 Oct 2009 09:58:29 PDT

Empyema with bronchopleural fistula (BPF) is one of the severest complications following pneumonectomy. Many papers have reported that it is difficult to cure, with a high rate of associated mortality. Closure of the fistula and an appropriate choice of obliteration materials are crucial for successful treatment. However, obliteration is sometimes impractical because of a lack of suitable materials, excessive surgical risk, or lack of patient willingness to undergo the procedure. We report a case of post-pneumonectomy empyema with BPF that was treated by non-surgical closure after open-window thoracotomy (OWT) with the use of basic fibroblast growth factor (bFGF), which was sprayed into the unepithelialized empyema cavity transiting from epidermis and surrounding the fistula. After spraying, the orifice of the OWT was covered by a film dressing. This procedure yielded successful results after two months.

Left ventricular assist device placement in a patient with end-stage heart failure and human immunodeficiency virus [Case report - Assisted circulation]

Fieno, D. S., Czer, L. S., Schwarz, E. R., Simsir, S. — Wed, 14 Oct 2009 09:58:29 PDT

Left ventricular assist device (LVAD) insertion has been used more frequently within the recent years either as a bridge to transplant or as destination therapy in patients with advanced heart failure who fail medical therapy. We present a report of a 60-year-old male patient with end-stage heart failure and cardiomyopathy with a history of human immunodeficiency virus (HIV) infection who underwent LVAD placement as destination therapy. To our knowledge, LVAD placement in this fashion has not been reported previously. Following LVAD implantation, the patient recovered during the course of five weeks and was discharged home from the hospital in good condition. The patient was alive and free of any activity limitations sixteen months postoperatively. We conclude that LVAD placement for end-stage heart failure may be a feasible option as destination therapy in patients with HIV.

Multiple papillary fibroelastoma in left ventricle associated with obstructive hypertrophic cardiomyopathy [Case report - Cardiac general]

Kobayashi, Y., Saito, S., Yamazaki, K., Kurosawa, H. — Wed, 14 Oct 2009 09:58:30 PDT

A 68-year-old man was referred to our hospital with a left ventricular (LV) mass and obstructive hypertrophic cardiomyopathy (HOCM). Although he was treated for the LV thrombosis and received anticoagulation therapy, the mass did not decrease in size for three years. His past history was colon cancer which was resected in its early phase. Laboratory studies revealed the absence of any inflammatory and tumor marker symptoms. Transthoracic and transesophageal echocardiography revealed a mass of 24x11 mm in diameter attached to the septal wall of LV and another two or three masses detected in LV wall. He received surgical treatment with complete mass excision with LV dissection and hypertrophied ventricular muscle was resected. Surgical resection of these LV masses and septal myectomy was performed. The histological examination showed that the lesions had a papillary configuration with an avascular connective tissue core lined by a single layer of endothelial cells, which was sufficient for a diagnosis of cardiac papillary fibroelastoma (CPF). The patient recovered without any complications.

eComment: Cardiac papillary fibroelastoma: a current assessment [eComment]

Koniari, I., Apostolakis, E., Baikoussis, N. G. — Wed, 14 Oct 2009 09:58:30 PDT

Reinforced closure of the sternum with absorbable pins for high-risk patients [Work in progress report - Cardiac general]

Hamaji, M., Sakaguchi, Y., Matsuda, M., Kono, S. — Tue, 22 Sep 2009 08:21:52 PDT

We report our result of the reinforced sternal closure in 51 consecutive patients. We applied a new type of absorbable radiopaque pins (Super FIXSORB^®) composed of poly-lactide acid and hydroxyapatite, in addition to conventional stainless steel wires. The risk scores of our patients were calculated from the simplified risk scoring system for major infection based on the Society of Thoracic Surgeons National Cardiac Database. The expected probability of infection is significantly higher than the actual infection rate in our patients. Our procedure may contribute to minimizing the fatal sternal complication particularly in high-risk patients.

Total aortic arch stenting - hemodynamical impact of carotid artery perfusion [Work in progress report - Experimental]

Niclauss, L., von Segesser, L. K. — Tue, 22 Sep 2009 08:21:52 PDT

The aim of this experimental study is to evaluate the feasibility and the outcome of total endovascular stent implantation in the aortic arch. Indications for this operation-technique would be acute or chronic dissection of the aortic arch (non-A–non-B dissection) or type B dissection with retrograde extension. Four pigs were canulated via the distal abdominal aorta and a retrograde placement of a Djumbodis^® arch stent (4–9 cm) was controlled by using intravascular ultrasound and intracardiac ultrasound by the inferior cava vein and under radioscopic control. Cerebral perfusion, by using a flow meter placed on one prepared carotid artery, were controlled before, immediate post-procedural (<1 min), and in the early follow-up after aortic arch stent implantation. During the implantation process, especially during balloon inflation and deflation, mean carotid perfusion decreases slightly. A reactive increase of carotid perfusion after stent placements indicates transitory cerebral hypo-perfusion. Non-covered aortic arch stent implantation is technically feasible and could be a potential treatment option in otherwise inoperable arch dissections. The time required for balloon inflation and deflation causes an important risk of cerebral ischemia. The latter can be reduced by transaxillary perfusion.

Growth potential of U-clipTM interrupted versus polypropylene running suture anastomosis in congenital cardiac surgery: intermediate term results [Institutional report - Congenital]

Tue, 22 Sep 2009 08:21:52 PDT

Although U-clip anastomoses were studied for hemodynamics and patency, their potential for unimpeded growth after congenital cardiovascular surgery has not been investigated yet. In 53 children aged 2.1±3.3 years operated on between March 1998 and August 2005 growth of U-clip (U) vs. polypropylene running sutured (P) anastomoses in coarctation repair (Coarc; n=26), bi-directional Glenn (BDG; n=13) and arterial switch operation (ASO; n=14) was retrospectively analysed. Coarc showed 2.39±4.33 vs. 3.09±2.24 mm of growth during the observation period (21±16 vs. 30±27 months); no growth (0 vs.16%), restenosis (14 vs. 37%) and reinterventions (14 vs. 11%) were similar (all in U vs. P, P=ns). BDG showed 3.68±3.43 vs. 2.50±2.55 mm (P=ns) of growth during 15±5 vs. 29±18 months (P=0.046); no growth (17 vs. 0%), stenosis (0 vs. 14%) and reinterventions (0%) were similar in U vs. P, respectively (P=ns). Main pulmonary artery (MPA) anastomosis in ASO showed 0.28±1.73 vs. 1.30±3.16 mm of growth during 8±14 vs. 28±28 months; no growth (60 vs. 14%), stenosis (50 vs. 63%) and reinterventions (0%) were similar (all in U vs. P, P=ns). Anastomotic growth, stenosis and reintervention rates show no difference between interrupted U-clip and polypropylene running sutured technique in Coarc repair, BDG and MPA anastomosis in ASO.

Low incidence of bronchopleural fistula after pneumonectomy for lung cancer [Institutional report - Thoracic oncologic]

Tue, 22 Sep 2009 08:21:52 PDT

Bronchopleural fistula (BPF) after pneumonectomy for NSCLC remains a highly morbid complication. We examined possible factors including the surgical techniques associated with BPF development. From 221 pneumonectomies for NSCLC, bronchial stump closure was mechanically performed in 192 patients and manually in the remaining 29. In all right-sided pneumonectomies mechanical closure was performed with associated stump coverage. In 114/130 left-sided procedures where mechanical closure was selected, bronchial stump remained uncovered. In the remaining 16 left-sided cases where manual stump closure was selectively performed, the stump was covered utilizing various tissues. Risk factors were classified into preoperative, intra-operative and postoperative. Five patients (2.3%) developed BPF. Univariate analysis revealed peri-operative transfusion, respiratory infection at the time of presentation, neoadjuvant therapy, right-sided pneumonectomy, manual type of bronchial closure, days of postoperative hospitalization and mechanical ventilation as significant risk factors for BPF development. Multivariate analysis followed revealing preoperative respiratory infection and right pneumonectomy as the only independent risk factors. In our series, a selected stump coverage policy showed a low incidence of BPF development. Mechanical stapling was superior to manual closure, although not as an independent factor. Early recognition of possible risk factors associated with fistula development is of paramount importance.

eComment: Defective bronchial tissue homeostasis following neoadjuvant therapy for lung cancer [eComment]

Walles, T., Hampel, M., Dally, I., Friedel, G. — Tue, 22 Sep 2009 08:21:53 PDT

Long-term follow-up of elderly patients subjected to aortic valve replacement with mechanical prostheses [Institutional report - Valves]

Coutinho, G. F., Pancas, R., Antunes, P. E., Antunes, M. J. — Tue, 22 Sep 2009 08:21:53 PDT

We propose to analyse the long-term follow-up in patients older than 65 years of age who received a mechanical valve in the aortic position, using death and prosthetic-related complications as endpoints. From April 1988 to December 1995, 144 consecutive patients 65–75 years of age (mean 67.7±2.5) were enrolled. Total duration of follow-up was 1663 patient-years (median 13.0 years) and was complete for 99% of the patients. Thirty-day mortality was 1.4% (n=2). At the end of the study, 77 patients (53.8%) were alive, with ages ranging from 77 to 91 years (mean 82.1±3.2 years). The overall 5-, 10- and 15-year actuarial survival was 87.4%±3.0, 67.7%±4.3 and 58.5%±4.5, respectively. Freedom from stroke was 93.3±3.1%, 84.6±3.3% and 71.7±4.5%, respectively, after identical periods. Freedom from major bleeding was 97.2±1.1%, 90.4±3.5% and 86.4±4.0%, respectively. Freedom from endocarditis was 95.7±2.3%, 95.0±2.1% and 94.4±2.5%, respectively, and freedom from reoperation was 98.0±1.2%, 97.6±1.3%, 96.9±2.4% and 96.4±2.6%, respectively. Freedom from major valve-related events was 87.7±2.6%, 73.9±3.4% and 61.5±4.6%, respectively. Nearly two-thirds of the patients were alive and free from major adverse valve-related events. Hence, we consider implantation of a mechanical prosthesis in elderly patients safe and appropriate, but the choice must be tailored for each specific patient.

eComment: Re: Long-term follow-up of elderly patients subjected to aortic valve replacement with mechanical prostheses [eComment]

Bockeria, L. A., Skopin, I. I., Muratov, R. M., Olofinskaya, I. E. — Tue, 22 Sep 2009 08:21:53 PDT

eComment: Mechanical valve replacement in the elderly: does anticoagulation have benefit? [eComment]

Gunay, R. — Tue, 22 Sep 2009 08:21:53 PDT

Aortic valve replacement with minimal extracorporeal circulation versus standard cardiopulmonary bypass [Institutional report - Cardiopulmonary bypass]

Colli, A., Fernandez, C., Delgado, L., Romero, B., Camara, M. L., Ruyra, X. — Tue, 22 Sep 2009 08:21:53 PDT

The purpose of this study was to evaluate the safety and the clinical outcomes of aortic valve replacement (AVR) performed with minimally invasive extracorporeal circulation (miniECC) technique vs. standard cardiopulmonary bypass (CPB). From February 2006 to December 2007 a total of 181 isolated AVR were performed, of these 53 patients were operated using minimal extracorporeal circulation system and 128 patients were operated using the standard CPB. Demographic characteristics and operative data were similar in both groups except for EuroSCORE (P<0.0001). Operative mortality (<30 days) was 3.8% for miniECC group and 4.7% for CPB group (P=ns). Patients in both groups showed similar postoperative chest tube drainage (432±325 ml vs. 460±331 ml, P=ns). The percentage of transfused patients was similar in both groups (37.7% vs. 43.8%, P=0.45). The number of transfused blood bank products was higher in patients with a body surface area >1.7 m² and who underwent traditional CPB in respect to miniECC system. Postoperatively renal injury, atrial fibrillation episodes, neurologic event rate, ICU and hospital stay length were similar in both groups. The miniECC is suitable for AVR providing good clinical results but the present results should not identify the miniECC system to be superior to the conventional CPB.

A retrospective analysis of terlipressin in bolus for the management of refractory vasoplegic hypotension after cardiac surgery [Institutional report - Cardiac general]

Tue, 22 Sep 2009 08:21:53 PDT

Cardiac surgery performed with cardiopulmonary bypass (CPB) may be complicated by hypotension due to low systemic vascular resistance (SVR). Often in those cases, hypotension is resistant to pressor catecholamines. We report six cases of norepinephrine-resistant postcardiotomy hypotension, treated by terlipressin (TP), a potent vasopressor agent. Between May 2007 and May 2008, we treated six patients with TP administration (1 mg bolus) for post CPB refractory vasodilatory hypotension. Analyzed parameters were: mean arterial pressure (m-AP), SVR, cardiac output index (CI), mean pulmonary pressure (m-PP), and lactate, at baseline (before TP bolus) and 3 h after injection. Before TP bolus, the average m-AP was 53.32±8.86 mmHg, the CI was 3.45±0.24 l/min/m², the SVR was 650±62.03 dyne*s/cm⁵ and the arterial lactate level was 4.6±0.95 mmol/l. Three hours after the TP bolus, the m-AP increased to 81.83±9.71 mmHg (P=0.002), the CI decreased to 2.88±0.14 l/min/m² (P=0.002), the SVR increased to 1154±116 dyne*s/cm⁵ (P=0.002), and arterial lactates decreased to 3.13±0.78 mmol/l (P=0.015), without significant modification of m-PP and CVP. We treated postoperative refractory low SVR hypotension by TP administration in bolus. Exogenous administration of TP normalized SVR and increased the systemic arterial pressure with a minimum effect on pulmonary pressure. Subsequently, the effect on systemic blood pressure enhanced urine output. No major collateral effects were observed. The administration of TP in bolus may result as a useful alternative for treating refractory low SVR hypotension post CPB.

Age- and gender-specific values of estimated glomerular filtration rate among 6232 patients undergoing cardiac surgery [Institutional report - Cardiac general]

Diez, C., Mohr, P., Koch, D., Silber, R.-E., Schmid, C., Hofmann, H.-S. — Tue, 22 Sep 2009 08:21:53 PDT

Impaired preoperative renal function as estimated by glomerular filtration rate (GFR) is an independent risk factor for mortality after cardiac surgery. Little is known about the actual prevalence of renal dysfunction among patients undergoing cardiac surgery in Germany. We performed a retrospective analysis of 6232 patients from 20 to 80 years. GFR was estimated with the modification of diet in renal disease (MDRD) formula. There was an age-dependent decrease in estimated glomerular filtration rates (eGFR) among both men and women. There is a stepwise age-dependent increase of chronic kidney disease (CKD) stages 3–5 (<60 ml/min/1.73 m²). The lower the eGFR the higher the risk for mortality [odds ratio 2.93 95%-confidence interval (CI) 1.92–4.53] for eGFR<30 ml/min/1.73 m²; odds ratio 1.93 (95%-CI 1.56–2.39) for eGFR 30–60 ml/min/1.73 m² compared to patients with an eGFR>60 ml/min/1.73 m². The actual mortality rates varied between 6.3% (307/4869) for patients with an eGFR>60 ml/min/1.73 m², 11.3% (137/1051) for patients with an eGFR of 30–60 ml/min/1.73 m² and 16.6% (27/163) for patients with an eGFR<30 ml/min/1.73 m². Estimated GFR declines are age- and gender-dependent. Preoperative renal dysfunction is an important predictor of in-hospital mortality after cardiac surgery.

Cardioprotective effects of normothermic reperfusion with oxygenated potassium cardioplegia: a possible mechanism [Institutional report - Cardiopulmonary bypass]

Yamamoto, H., Magishi, K., Goh, K., Sasajima, T., Yamamoto, F. — Tue, 22 Sep 2009 08:21:53 PDT

Na⁺/K⁺ pump activation induced by normothermic reperfusion with high potassium cardioplegia may exert a protective effect on reperfusion-induced myocardial damage. We investigated (1) temperature dependency and extracellular potassium dependency of the Na⁺/K⁺ pump current (Ip), (2) effects of high potassium or ouabain during reperfusion on the post-ischemic left ventricular (LV) function. Ip-voltage relation was constructed at 5.0 and 20 mM of KCl (37 °C) using a whole-cell clamp technique in guinea pig myocytes. Ip at –40 mV was measured at 37, 27 and 18 °C (KCl: 5.0 mM). Isolated rat hearts were Langendorff-perfused and subjected to 20 min of global ischemia (37 °C) followed by 35 min of reperfusion (37 °C). The post-ischemic recovery of LV developed pressure (%LVDP) was assessed in the four reperfusate groups (4.8 mM KCl, 10 mM KCl, 20 mM KCl, or 4.8 mM KCl plus 50 µM ouabain during the first 10 min of reperfusion). The 4.8 mM KCl and 10.0 mM KCl groups were compared under metabolic inhibition (glucose-free, NaCN, or hypoxia) during reperfusion. The Ip-voltage relation shifted upward when extracellular KCl was increased from 5.0 to 20 mM. Ip was significantly greater at 37 °C than at 18 °C (114.3±17.2 vs. 22.7±1.2 pA, respectively). %LVDP was significantly greater at the 10.0 mM KCl group than at the 4.8 mM KCl group (54.9±5.5% vs. 34.2±5.9%, respectively). Metabolic inhibition abolished the difference between the two groups. Ouabain significantly decreased %LVDP (15.9±1.6%). Potassium-induced cardiac arrest during normothermic reperfusion may exert a cardioprotective effect by inducing Na⁺/K⁺ pump activation, which may be supported by aerobic metabolism during reoxygenation rather than by energy saving during cardiac arrest.

Enhanced coronary vascular turgor effect on post-ischemic diastolic function in hypertrophied hearts [Institutional report - Cardiopulmonary bypass]

Yamamoto, H., Yamamoto, F., Ichikawa, H. — Tue, 22 Sep 2009 08:21:53 PDT

We investigated the effect of coronary perfusion pressure on post-ischemic left ventricular (LV) diastolic function in the hypertrophied heart. LV pressure overload was induced in four-week-old rats by abdominal aortic constriction (AC), with controls (C) undergoing sham operations. At six weeks of age, isolated Langendorff-perfused hearts (perfusion pressures: 75 and 110 mmHg in C and AC hearts, respectively) were subjected to hypothermic global ischemia (15 °C, 210 min) followed by 65 min of reperfusion (group I: C hearts subjected to aerobic perfusion alone, group II: C hearts subjected to ischemia/reperfusion, group III: AC hearts subjected to aerobic perfusion alone, group IV: AC hearts subjected to ischemia/reperfusion; n=6/group). LV end-diastolic pressure (LVEDP) at a constant balloon volume was assessed under perfusion pressures of 110, 75, and 0 mmHg during aerobic perfusion alone (groups I and III) or post-ischemic perfusion (groups II and IV). The LVEDP differences between perfusion pressures of 75 and 110 mmHg were 6.2±3.2, 3.2±2.7, 3.2±1.5, and 12.8±4.2* mmHg in groups I, II, III, and IV, respectively (*P<0.05 vs. group III). Pressure overload-induced hypertrophied hearts exhibit post-ischemic diastolic dysfunction, which may be caused partly by the enhanced coronary vascular turgor effect on myocardial stiffness.

Restoration of atrial contractility after surgical cryoablation: clinical, electrical and mechanical results [Institutional report - Arrhythmia]

Tue, 22 Sep 2009 08:21:53 PDT

To assess the electrical sinus rhythm (SR) recovery and the mechanical effectiveness of the atrial contraction by echocardiography is essential in patients undergoing atrial fibrillation (AF) surgery. Between September 2006 and May 2008, patients with chronic AF (n=33; permanent=23 or paroxysmal=10) underwent mitral surgery and surgical cryoablation for AF. Exclusion criteria were: AF that has persisted for 10 years and left atrium (LA) >65 mm. Echocardiography study was performed at six months after surgery. Mean age was 62 years (22 female, 11 male). Mean AF duration was three years (range 0.5–7.4). Mean atria size was 52.4±5.6 mm. Mitral valve surgery involved 32 prosthetic replacements and one mitral valve repair. There was no surgical mortality. Success rate for SR at three and six months was 90% and 82%, respectively. The only predictor of conversion to SR at six months was being at SR when discharge from the hospital. In patients in SR, echocardiographic study provided mechanical effectiveness of the atria in 100% of right atrium and 70% of the LA. Cryoablation for AF is an effective technique to recover electrocardiographic SR while being able to recover atrial contraction effectiveness.

EuroSCORE predicts postoperative mortality, certain morbidities, and recovery time [Institutional report - Cardiac general]

Tue, 22 Sep 2009 08:21:53 PDT

EuroSCORE (European System for Cardiac Operative Risk Evaluation) used for calculating the risk of the postoperative mortality rate for patients undergoing open-heart surgery may be able to predict postoperative complications as well. Consecutive cases of isolated on-pump coronary artery bypass grafting (CABG) (n=1552) performed between 1991 and 2006 at our hospital group were placed into a systematic database. Patients were stratified using additive EuroSCORE. Incidence of postoperative mortality, morbidity (bleeding, heart failure, mediastinitis, pneumonia, myocardial infarction, renal failure, and stroke), and recovery time (intubation time, ICU stay, and postoperative length of stay) was assessed in each EuroSCORE group. EuroSCORE was well correlated with mortality, total incidence of major complications, heart failure, renal failure, stroke, pneumonia and mediastinitis, and three parameters of recovery time. Postoperative myocardial infarction and incidence of bleeding were not correlated with EuroSCORE. EuroSCORE can predict not only mortality but also postoperative complications and recovery time.

eComment: Does EuroSCORE predict postoperative complications? [eComment]

Bockeria, L. A., Skopin, I. I., Dmitrieva, Y. S. — Tue, 22 Sep 2009 08:21:53 PDT

Video-assisted thoracic surgery major pulmonary resection requiring control of the main pulmonary artery [Institutional report - Thoracic oncologic]

Nakanishi, R., Oka, S., Odate, S. — Tue, 22 Sep 2009 08:21:53 PDT

The purpose of this study is to examine the feasibility and safety of thoracoscopic major pulmonary resection requiring the cross-clamping of the main pulmonary artery (PA), in comparison to an open thoracotomy performed in patients with lung cancer. A retrospective database of 27 consecutive lung cancer patients, who underwent either video-assisted thoracic surgery (VATS) (n=13) or open thoracotomy (n=14) for a major pulmonary resection using these procedures, was analyzed regarding the demographic, perioperative, histopathologic, and outcome variables. The thoracoscopic procedures were successfully performed in 12 of 13 patients (92.3%). Two groups showed no differences in the demographic, perioperative, histopathologic and staging variables. Both groups presented with no mortality. The VATS group showed better results regarding the length of epidural anesthesia (P=0.0066), additional analgesic requirements (P=0.0009), and morbidity (P=0.0213) than the open thoracotomy group. Despite the short follow-up time, the two groups were comparable regarding both the recurrence and survival rates. The results indicate that VATS is feasible and safe for selected lung cancer patients requiring the cross-clamping of the main PA, with acceptable perioperative results in comparison to an open thoracotomy.

Death in low-risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FIASCO) study [Institutional report - Cardiac general]

Freed, D. H., Drain, A. J., Kitcat, J., Jones, M. T., Nashef, S. A.M. — Tue, 22 Sep 2009 08:21:53 PDT

Death in low-risk patients is not studied as frequently as it is in other cardiac patients. We, therefore, sought to determine why some low-risk patients die after cardiac surgery. All low-risk patients (EuroSCORE≤2) who died after cardiac surgery in one institution between 1996 and 2005 were included and meticulously studied by internal and independent external review of preoperative, operative and postoperative information from the case-notes and post-mortem findings. Deaths were classified into non-cardiac and cardiac and further subclassified into unavoidable deaths or due to failure in achieving a satisfactory cardiac outcome (FIASCO). Between 1996 and 2005, there were 16 deaths in 4294 low-risk patients (mortality 0.37%). Internal and external review agreed that nine deaths were non-preventable (CVA, bronchopneumonia, etc.) and that avoidable FIASCO accounted for seven deaths. Of the deaths considered to be preventable, all had probable errors of technique and three also had additional system errors. No cardiac operation is without risk. Mortality, though fortunately rare, can still occur, even in low-risk patients. Despite an extremely low mortality in the low-risk group FIASCO still accounts for nearly one-half of deaths. This suggests that mortality may be reduced even further as part of a quality improvement programme.

Mid-term results of surgery for chronic thromboembolic pulmonary hypertension [Institutional report - Vascular thoracic]

Tue, 22 Sep 2009 08:21:53 PDT

Pulmonary thromboendarterectomy is an effective surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH). In this study, we review our short- and mid-term results in the recent series of patients undergoing pulmonary thromboendarterectomy. Twenty-three patients (54±12 years) were re-evaluated 7–59 months (mean, 34 months) after surgery. Nine patients were in New York Heart Association functional class II, 11 patients in class III and three patients in class IV. All patients used supplemental oxygen therapy. After surgery, pulmonary hemodynamics were significantly improved: pulmonary vascular resistance (PVR) decreased from 925±342 to 337±260 dynes·s·cm^–5 (P<0.01); mean pulmonary artery pressure (MPAP) decreased from 47±12 to 25±10 mmHg (P<0.01). Three patients developed severe residual pulmonary hypertension and one of them died soon after surgery. During the follow-up period there were no deaths, but one recurrence of pulmonary embolism. Nineteen patients (86%) were in New York Heart Association functional class I or II and thirteen patients (59%) were weaned from oxygen therapy. In conclusion, pulmonary thromboendarterectomy provided remarkable early and late results with acceptable hospital mortality rate, normalization of pulmonary hemodynamics, and improvement in clinical functional status with relief of hypoxemia.

Is the aortic valve pathology type different for early and late mortality in concomitant aortic valve replacement and coronary artery bypass surgery? [Institutional report - Valves]

Tue, 22 Sep 2009 08:21:53 PDT

We assessed the effects of aortic valve pathology type on the long-term outcomes of patients who underwent concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) surgery. We retrospectively reviewed 150 patients who underwent AVR-CABG at our institution between January 1997 and December 2006. We divided patients into aortic stenosis (AS), aortic regurgitation (AR), and mixed-type groups consisting of 98 (65.3%), 20 (13.3%) and 32 (21.3%) patients, respectively. The AS group had more female patients, a higher mean angina class, older mean patient age, increased history of previous myocardial infarction (MI), and smaller valve size compared to other groups. No significant differences were observed among groups in the operative mortality for five or ten-year survival rates. Significant early mortality risk factors included cross-clamp and cardiopulmonary bypass (CBP) time, number of blood transfusion units, chronic obstructive pulmonary disease (COPD), intra-aortic balloon pump (IABP), inotropic drugs, and pacemaker use. Significant late mortality risk factors included intensive care unit (ICU) stay, IABP, stroke, and dialysis. The aortic valve pathology type in patients undergoing concomitant AVR-CABG does not adversely affect survival.

eComment: Re: Is the aortic valve pathology type different for early and late mortality in concomitant aortic valve replacement and coronary artery bypass surgery? [eComment]

Bockeria, L. A., Scopin, I. I., Kambarov, S. Yu., Dmitrieva, Y. S. — Tue, 22 Sep 2009 08:21:53 PDT

Mechanoenergetic function and troponin T release following cardioplegic arrest induced by St Thomas' and histidine-tryptophan-ketoglutarate cardioplegia - an experimental comparative study in pigs [Institutional report - Cardiac general]

Aarsaether, E., Stenberg, T. A., Jakobsen, O., Busund, R. — Tue, 22 Sep 2009 08:21:53 PDT

The study compares the single dose histidine-tryptophan-ketoglutarate (HTK) cardioplegia to the repeatedly delivered St Thomas' Hospital Solution (STHS) with respect to preservation of left ventricular mechanoenergetics and leakage of troponin T in a porcine experimental model. Fourteen pigs were randomized to a single infusion of 30 ml/kg HTK cardioplegia (n=7) or 500 ml STHS (n=7) followed by 200 ml after 20 and 40 min. After 1 h of aortic cross-clamping on cardiopulmonary bypass (CPB), the pigs were weaned and the hearts reperfused for 4 h. Stroke work (SW) was determined by a conductance catheter in the left ventricle. Myocardial oxygen consumption (MvO₂) was measured as a function of coronary blood flow and arterial-to-coronary sinus oxygen saturation difference. Troponin T was sampled from the coronary sinus. The slope of the SW-MvO₂ relationship increased by 1.09 (±0.53) in the HTK group compared with 0.33 (±0.70) in the STHS group following ischemia and 4 h of reperfusion (P=0.04). Troponin T was significantly higher in the HTK group compared with the STHS group (P=0.04). Repeatedly delivered STHS gives better preservation of postischemic mechanoenergetic function and lower troponin T release compared with single dose HTK cardioplegia, indicating improved cardioprotection with STHS.

Pulmonary resection for metastases from colorectal carcinoma [Institutional report - Thoracic oncologic]

Tue, 22 Sep 2009 08:21:53 PDT

A pulmonary resection of metastatic colorectal carcinoma is an accepted method of treatment. The purpose of this study was to confirm the role of resections for pulmonary metastases from colorectal carcinoma, and to determine the clinical course, outcome, and prognostic factors after surgery. A retrospective analysis was conducted of the records of all patients with pulmonary metastases from colorectal carcinoma who underwent a surgical resection between 1995 and 2008, at a single surgical center. The overall 5-year survival rate was 74%. Multivariate Cox analysis demonstrated that the number of pulmonary metastases (HR: 9.40, 95% confidence interval (CI): 1.08–82.2, P=0.0428) and prethoracotomy carcinoembryonic antigen (CEA) level (HR: 9.79, 95% CI: 1.11–86.8, P=0.0404) were statistically significant predictors of survival after the first pulmonary metastasectomy. In addition, a second resection for recurrent metastases was performed in eight patients, and a third resection was done in one patient. There were no major postoperative complications among the patients who underwent second or third resections. Pulmonary resections are considered to be a safe and effective treatment in selective patients.

eComment: The role of lymph node dissection in pulmonary resection for metastases from colorectal cancer [eComment]

Barbetakis, N., Asteriou, C., Boukovinas, I., Tsilikas, C. — Tue, 22 Sep 2009 08:21:53 PDT

Comparison of methods for placing and managing a silastic drain after pulmonary resection [Institutional report - Thoracic non-oncologic]

Tue, 22 Sep 2009 08:21:53 PDT

We have been using a silastic drain [Blake^® drain (BD)] after pulmonary resection by different placement methods and reviewed the daily amount of drainage in each patient. A 19-Fr BD was placed for each of 110 patients. First, a drain was inserted from the anterior chest wall and the tip reached the dorsal part of the diaphragm [anterior-to-posterior (AP)]. For the others [posterior-to-anterior (PA); n=37], we inserted a drain from the lower intercostal space, turned it around the apex and placed its tip in the lower front. Patients in the AP group included those placed under a water seal (AP-WS; n=43) or suction (AP-SC; n=30). The reference group consisted of 68 patients with a 32-Fr plastic drain during the same period [conventional drains (CD)]. The amount of drainage on the day of surgery in the PA group was significantly higher than that in the AP-WS group (P<0.0001) and similar to that in the CD group (P=0.54). The mean amount of drainage on postoperative day 1 and total amounts accumulating during drain placement showed no significant differences between the four groups. A BD placed using a PA approach with suction might be efficient for drainage.

Repeat resection of pulmonary metastasis is beneficial for patients with osteosarcoma of the extremities [Institutional report - Thoracic oncologic]

Tue, 22 Sep 2009 08:21:53 PDT

Pulmonary metastasectomy in osteosarcoma can lead to long-term survival, but the role for repeat pulmonary metastasectomy is undefined. To confirm the value of repeat pulmonary resection of recurrent pulmonary metastases, we herein reviewed our institutional experience. Between 1989 and 2007, 25 patients with pulmonary metastases from osteosarcomas of the extremities underwent pulmonary resection, and 14 patients underwent repeat pulmonary metastasectomy. Ten of 14 patients underwent complete resection. Various perioperative variables were investigated retrospectively in these patients to confirm a role for repeat metastasectomy and analyze prognostic factors for overall survival (OS) after repeat pulmonary metastasectomy. OS rate after repeat pulmonary metastasectomy was 43% at two years and 19% at five years. On multivariate analysis, patients with complete resection presented significantly favorable OS (P=0.02). Interestingly enough, survival curve of patients with complete resection after the first pulmonary metastasectomy was almost the same as that of patients with complete resection after the second pulmonary metastasectomy. In conclusion, patients with complete resection for recurrent pulmonary metastasis show a significantly better prognosis after repeat pulmonary metastasectomy. Our data imply that repeat pulmonary metastasectomy might be beneficial because it can salvage a subset of patients with osteosarcoma who retain favorable prognostic determinants.

Predicting prolonged intensive care unit length of stay in patients undergoing coronary artery bypass surgery - development of an entirely preoperative scorecard [Institutional report - Cardiac general]

Herman, C., Karolak, W., Yip, A. M., Buth, K. J., Hassan, A., Legare, J.-F. — Tue, 22 Sep 2009 08:21:53 PDT

We sought to develop a predictive model based exclusively on preoperative factors to identify patients at risk for PrlICULOS following coronary artery bypass grafting (CABG). Retrospective analysis was performed on patients undergoing isolated CABG at a single center between June 1998 and December 2002. PrlICULOS was defined as initial admission to ICU exceeding 72 h. A parsimonious risk-predictive model was constructed on the basis of preoperative factors, with subsequent internal validation. Of 3483 patients undergoing isolated CABG between June 1998 and December 2002, 411 (11.8%) experienced PrlICULOS. Overall in-hospital mortality was higher among these patients (14.4% vs. 1.2%, P≤0.0001). The following variables were found to be independent predictors of PrlICULOS: increased age, recent myocardial infarction, preoperative renal failure, cerebral and/or peripheral vascular disease, chronic obstructive pulmonary disease, ejection fraction <40%, previous CABG, triple-vessel and/or left main disease, NYHA class IV symptoms and urgent or emergent status. Subsequent validation of this model demonstrated a c-statistic of 78%. An internally-validated, risk predictive model of PrlICULOS in patients undergoing CABG was constructed. Based on preoperative clinical factors, a scorecard was developed allowing identification of these patients prior to surgery and allowing for strategies aimed at optimizing hospital resources.

Sentinel node mapping and micrometastasis in patients with clinical stage IA non-small cell lung cancer [Institutional report - Pulmonary]

Ono, T., Minamiya, Y., Ito, M., Saito, H., Motoyama, S., Nanjo, H., Ogawa, J. — Tue, 22 Sep 2009 08:21:54 PDT

Many evidences suggest that prognosis of non-small cell lung cancer (NSCLC) with lymph node micrometastases (LNMM) is poor compared with those without LNMM. Therefore, it is better to evaluate LNMM through immunohistochemistry (IHC) of serial sectioning of all dissected lymph nodes. However, this labor-intensive approach is impossible in a practical setting. Therefore, we examined whether we are able to efficiently diagnose LNMM using the sentinel node (SN) mapping. Fifty-one patients with clinical T1N0M0 NSCLC were enrolled in this study. SNs were then detected intraoperatively. After SN mapping, lobectomy and hilar and mediastinal lymph node dissection were performed. Metastases of all dissected lymph nodes were examined by hematoxylin and eosin (H&E) staining and immunohistochemical cytokeratin staining. SN detection rate was 80.4% (41/51). Average number of SNs was 1.8±1.1 in a patient. Lymph node metastases were diagnosed in two patients using H&E staining. LNMM were found only in SNs of two patients. On the other hand, micrometastasis was not found in non-SN. According to these results, two patients with clinical T1N0M0 NSCLC migrated to T1N1M0. Evaluation of micrometastases of all dissected lymph nodes may be substituted by evaluating micrometastases of SNs. We believe that further studies are warranted to determine the most useful clinical applications.

Brain natriuretic peptide a predictive marker in cardiac surgery [ESCVS article - Cardiac general]

Tue, 22 Sep 2009 08:21:54 PDT

Background: BNP which stands for B-type natriuretic peptide is a cardiac neurohormone and is secreted in response to myocardial stress and causes natriuresis and vasodilatation. Studies have reported close correlation between a high concentration of BNP in blood and worse short-term and long-term prognosis following myocardial infarction and heart failure. In this study, we have tested its usefulness and predictive value in the outcome post cardiac surgery. Methods: Between March 2006 and June 2007, 141 patients, undergoing cardiac surgery, were enrolled in this study. Their BNP concentration was measured prior to the operation and their comorbidities were examined against their BNP levels. Postoperatively their outcome was closely monitored. Main clinical endpoints were atrial fibrillation (AF), inotrope use, renal impairment, early deaths and hospital stay. Results: Some preoperative comorbidities, such as renal impairment, peripheral vascular disease (PVD) and low ejection fraction (EF) were associated with higher BNP level. Statistically, EuroSCORE and Parsonnet score showed significant correlation with preoperative BNP concentration (P<0.0001). Postoperatively, high-BNP concentration predicted inotropic use, higher than baseline creatinine level, longer ventilation time, longer hospital stay and early mortality (P<0.05) but our study did not reveal any predictive value for BNP in identifying those developing AF or infection postoperatively. Conclusions: BNP is a valuable biochemical marker, which is easy to measure and can be beneficial in predicting the operative outcome.

eComment: Re: Brain natriuretic peptide a predictive marker in cardiac surgery [eComment]

Bockeria, L. A., Bockeria, O. L., Kolesnikova, U. A. — Tue, 22 Sep 2009 08:21:54 PDT

Experience and intermediate-term results using the Contegra(R) heterograft for right ventricular outflow reconstruction in adults [ESCVS article - Valves]

Niclauss, L., Delay, D., Hurni, M., von Segesser, L. K. — Tue, 22 Sep 2009 08:21:54 PDT

Objective: The Contegra^® bioprosthesis (valved heterologous bovine jugular vein) is used for reconstruction of the right ventricular outflow tract (RVOT) in congenital heart malformations and pulmonary valve replacement in different settings. Compared to pulmonary homografts, the Contegra^® conduit is readily available ‘on the shelf’. So far, its use was mainly described in children. The aim of this study is to evaluate the feasibility and the outcome of Contegra^® graft implantation in the adult. Methods: Between November 1999 and December 2007, a total of 32 Contegra^® grafts were implanted in 31 patients (24 men and 7 women), with a mean age of 35.7±10.5 years (range 18–54 years). All operations have been completed through median sternotomy with cardiopulmonary bypass. Indications included: Ross procedure for aortic valve disease (n=22); re-operation of corrected Fallot-tetralogy (n=5); isolated pulmonary valve disease (n=2); re-operation of double outlet right ventricle (DORV) (n=1); pulmonary stenosis in congenital dilated cardiomyopathy (DCM) (n=1). Conduit sizes included 22 mm (n=31), 20 mm (n=1). Results: There was no hospital mortality and no valved conduit related early morbidity. In the median follow-up of 38 months (range 1–99 months) of 28 patients there was one late death, not conduit related (total mortality 3.6%). Re-operation for symptomatic graft stenosis was realised in two patients, 7 and 16 months after primo-implantation, corresponding to graft related late morbidity of 7.1%. Conclusions: In this small review of 32 operations using the Contegra^® graft for RVOT reconstruction in adult cardiac surgery for different indications, we observed good postoperative mid-term results concerning conduit function. Mean transpulmonary pressure gradients remain low (13.3±6.6 mmHg postoperative, 14.5±7.9 mmHg at follow-up). The use of the Contegra^® graft seems to be a good alternative to the homograft with low operative mortality and morbidity. Long-term outcome data are not available and further investigations must be performed to evaluate results.

Cutting precision in a novel aortic valve resection tool. Research in progress [ESCVS article - Experimental]

Tue, 22 Sep 2009 08:21:54 PDT

Background: We recently demonstrated the first in-vitro cutting results of a minimal-invasive aortic valve resection tool. The current study was designed to assess the cutting accuracy of this new device improved by the implementation of a linear motor-based propulsion unit. Methods: Native aortic valves of isolated swine hearts (valve diameter 17.8±0.9 mm, mean±S.D.) were artificially stenosed and calcified (n=7). Subsequently, valves were resected by the use of a new aortic valve resection tool. The cutting process was performed by fitting the instrument with foldable Nitinol cutting blades (diameter 15 mm) and two software-operated linear motors combined with separated manual rotation. Aortic valve area was measured pre- and postprocedure by software-guided binary area calculation. Aortic valve residue has been determined and the grade of accuracy has been assessed via calculating the average midpoint of the neoannulus. Furthermore, radial deviation of concentricity was calculated and cutting time was measured. Results: Aortic valve resection was successful in all cases and nearly all leaflets (2.5±0.4) with a weight of 0.22±0.12 g were cut. Aortic valve area increased significantly (0.3±0.1 cm² vs. 1.1±0.2 cm², P<0.001) with a mean cutting time of 49.7±15.0 s. Mean lateral leaflet rim within the annulus was 3.2±3.2 mm. Cutting precision revealed a median deviation of the cutting ring from the desired position of 1.3±0.6 mm (y-axis) and 1.4±0.5 mm (x-axis). Median center deviation of the cutting ring was 2.6±0.8 mm. Conclusions: The present study clearly confirmed ability of an accelerated cutting of stenotic aortic valve by the aortic valve resection tool. Nearly all leaflets were cut and a small rim was left within the annulus, hence providing an ideal ‘landing zone' for the new prosthesis. Nevertheless, the aortic valve resection tool should be enhanced by adding a centering mechanism, thus achieving a more precise cutting process in order to avoid secondary damage.

Failure to exclude a saccular arch aneurysm during hybrid repair: arch replacement without cerebral circulatory arrest [Proposal for bail-out procedures - Aortic and aneurysmal]

Dronavalli, V. B., Loubani, M., Riley, P., Bonser, R. S. — Tue, 22 Sep 2009 08:21:54 PDT

Thoracic endovascular aortic reconstruction (TEVAR) is increasingly used in the management of descending aortic pathology including aneurysms, dissections and transaction. When treating aortic arch pathology, hybrid procedures have been devised, in which major supra-aortic arteries are translocated using a variety of techniques. Such hybrid procedures offer an attractive alternative to open arch procedures in frail elderly patients in whom the risks of open repair are considerable. We describe a surgical bail-out procedure which was used during a hybrid aortic arch replacement when endovascular aneurysm exclusion could not be achieved.

Apico-aortic valved conduit as an alternative for aortic valve re-replacement in severe prosthesis-patient mismatch [Proposal for bail-out procedures - Valves]

Chahine, J. H., El-Rassi, I., Jebara, V. — Tue, 22 Sep 2009 08:21:54 PDT

Off-pump implantation of an apico-aortic bioprothesis-valved conduit in a 75-year-old female symptomatic patient with severe prosthesis–patient mismatch secondary to a previous aortic valve replacement, calcified ascending aorta, tight adhesion with the sternum, was successfully conducted to relieve the left ventricle from severe aortic stenosis.

Aortoesophageal fistula: an uncommon complication after stent-graft repair of an aortic thoracic aneurysm [Negative results - Aortic and aneurysmal]

Isasti, G., Gomez-Doblas, J. J., Olalla, E. — Tue, 22 Sep 2009 08:21:54 PDT

Objectives: To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. Methods: We analyze a case of AEF as a late complication of stent-graft repair of a thoracic aortic aneurysm in a 74-year-old male. We also include a discussion on alternatives of treatment based on a review of the literature currently available in MEDLINE. Results: This patient was admitted to our hospital because of constitutional symptoms. The diagnosis was established by computed tomography and upper gastrointestinal endoscopy. The patient died 50 days after admission. Conclusions: AEF is a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Conservative treatment is often associated with fatal results.

Acute mechanical prosthetic valve thrombosis after initiating oral anticoagulation therapy. Is bridging anticoagulation with heparin required? [Negative results - Valves]

Tue, 22 Sep 2009 08:21:54 PDT

Prosthetic valve thrombosis (PVT) represents a serious and potentially lethal complication. It can be attributed more frequently to inadequate anticoagulant therapy. We present a case of acute aortic mechanical valve thrombosis six months after implantation. The patient discontinued oral anticoagulation after being discharged following the primary operation. Two days after reinitiating warfarin as an outpatient, he developed acute valve thrombosis presenting with symptoms and signs of cardiac failure. He was managed with intravenous thrombolysis with a recombinant plasminogen activator which resulted in immediate resolution of thrombus and clinical improvement. A paradox procoagulant effect of warfarin is evident on the first one or two days after initiation of therapy. A ‘bridging’ protocol with unfractionated or low molecular weight heparin (LMWH) should be considered, according to recently published guidelines, until warfarin reaches therapeutic levels and exerts an antithrombotic effect.

The cardiovascular hybrid room a key component for hybrid interventions and image guided surgery in the emerging specialty of cardiovascular hybrid surgery [State-of-the-art - Cardiac general]

Kpodonu, J., Raney, A. — Tue, 22 Sep 2009 08:21:54 PDT

The last few years has seen a paradigm shift in the treatment of cardiovascular related diseases from once traditional open surgical modalities to the entire cardiovascular tree being amenable to percutaneous interventions. The tremendous advances in transcatheter endovascular procedures currently being applied to the heart and the peripheral vasculature have resulted in a treatment paradigm shift in the care of the cardiovascular patient. These changing winds in the treatment of cardiovascular disease require that a new type of cardiovascular specialist, code-named the cardiovascular hybrid surgeon, be trained to perform and provide seamless care in providing both endovascular as well as open surgical procedures to this increasingly complex group of patients.

Is reduction aortoplasty (with or without external wrap) an acceptable alternative to replacement of the dilated ascending aorta? [Best evidence topic - Aortic and aneurysmal]

Gill, M., Dunning, J. — Tue, 22 Sep 2009 08:21:54 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether reduction aortoplasty is an acceptable alternative to ascending aorta replacement. From 925 potential papers, 13 papers 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 aortoplasty seems to be a safe procedure which gives good postoperative outcomes in selected patients. Our literature review documents 716 patients from 13 papers, with only 25 patients that on follow-up suffered redilatation (3%). Thus, reduction aortoplasty is a viable alternative to conventional aortic root replacement or interposition tube grafting in some patients. In particular, an aortoplasty in elderly patients with post-stenotic dilatation, or in patients with significant co-morbidities is attractive. It should be acknowledged that only one study directly compares the technique with conventional replacement and that replacement remains the ‘gold standard’ technique. It should also be acknowledged that the external wrap is not without risk and wrap dislocation, erosion or fistula formation are recognised complications.

eComment: Re: Is reduction aortoplasty (with or without external wrap) an acceptable alternative to replacement of the dilated ascending aorta? [eComment]

Bockeria, L. A., Skopin, I. I., Mironenko, V. A., Aleksanyan, G. G. — Tue, 22 Sep 2009 08:21:54 PDT

Should you stand on the left or the right of a patient with dextrocardia who needs coronary surgery? [Best evidence topic - Congenital]

Saad, R. A., Badr, A., Goodwin, A. T., Dunning, J. — Tue, 22 Sep 2009 08:21:54 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which side of the operating table you should stand on when carrying out surgical revascularization on a patient with dextrocardia. Altogether 40 papers were found using the reported search, of which 19 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. The side on which the operating surgeon stood was mentioned in 20 out of the 24 cases. Surgery was carried out from the conventional right side of the patient in 5 cases, while in 10 cases, it was carried out from the left side. The surgeon needed to switch sides to facilitate surgery in three cases. In addition, the right internal mammary artery (RIMA) was anastomosed to the left anterior descending artery (LAD) in 16 cases. Of these, surgery was carried out from the left side in 11 cases. The left internal mammary artery (LIMA) to LAD anastomosis was carried out in two cases, one of which was a free LIMA graft. In six cases, only vein grafts were used. Fourteen cases were carried out using cardiopulmonary bypass while 10 cases were carried out as off-pump cases with one conversion. The majority of patients were operated on from the left of the table. More cases were performed with the RIMA as the conduit of choice to the LAD.

Apico-aortic conduit for aortic stenosis with a porcelain aorta; technical modification for apical outflow [Case report - Cardiac general]

Hirota, M., Oi, M., Omoto, T., Tedoriya, T. — Tue, 22 Sep 2009 08:21:54 PDT

A successful apico-aortic bypass for a patient with a porcelain aorta suffering from aortic stenosis is reported. A sewing cuff with an outflow graft to the apex and a hand-made composite graft were used instead of a rigid apical connector.

Septic shock secondary to infection of a left ventricular thrombus [Case report - Cardiac general]

Tue, 22 Sep 2009 08:21:54 PDT

We report the case of a 45-year-old woman who developed severe shock with multiorgan failure requiring admission to intensive care. Endomyocardial biopsy was performed and she was diagnosed with sepsis secondary to left ventricular thrombus abscess. Surgery was contraindicated and the patient received exclusively medical treatment; the clinical course was satisfactory and the patient is alive one year later. An apical thrombus may rarely be complicated by infection. Although management normally requires surgical excision, medical management may be effective in situations in which surgery is contraindicated.

Surgical repair of multiple unruptured aneurysms of sinus of Valsalva [Case report - Congenital]

Reddy, S. M., Bisoi, A. K., Sharma, P., Das, S. — Tue, 22 Sep 2009 08:21:54 PDT

Unruptured aneurysm of sinus of Valsalva (ASV) is a rare congenital anomaly. We describe a case of multiple unruptured ASV involving right and left aortic sinuses causing congestive cardiac failure in a 16-year-old boy who underwent successful surgical repair.

Successful administration of alteplase in a venous thromboembolism crossing through a patent foramen ovale [Case report - Cardiac general]

Ruiz-Bailen, M., Ramos-Cuadra, J. A., Machado-Casas, J., Rucabado-Aguilar, L. — Tue, 22 Sep 2009 08:21:54 PDT

We describe a case report observed via an echocardiography of a venous thromboembolism (VTE) that crosses through the patent foramen ovale to the left atrium and is successfully treated with alteplase. This is a case report of a tertiary care hospital without cardiac surgery facilities. An 81-year-old female seeking medical attention for dyspnoea, arriving at hospital with hypoxaemia, hypotension and prerenal failure. A computed tomographic (CT) pulmonary angiography was carried out, revealing a VTE. A transesophageal echocardiography (TEE) was carried out, exposing emboli in the right cavities, said thrombus crossing through the patent foramen ovale to the left atrium. A systemic thrombolysis is carried out using alteplase which improves the patient's condition and results in the disappearance of thrombotic images in the various cardiac cavities. The evolution is positive and there is no evidence of embolic or haemorrhagic complications. When a paradoxical embolism is present, in the context of a serious VTE, carrying out thrombolysis could be a therapeutic option.

eComment: Systemic thrombolysis with alteplase in impending paradoxical embolism [eComment]

Misfeld, M., Hanke, T. — Tue, 22 Sep 2009 08:21:54 PDT

Early acute aortic dissection of the donor aorta after orthotopic heart transplantation [Case report - Transplantation]

Martin Lopez, C. E., Lopez, M. J., de Diego, J., Cortina, J. M. — Tue, 22 Sep 2009 08:21:54 PDT

Acute type A aortic dissection is an uncommon complication after orthotopic heart transplantation and usually affects the native aorta. Seven cases reported in the literature describe an aortic dissection confined to the donor aorta and only in two of them were they detected during the early postoperative period. We describe the case of a 58-year-old man, the recipient of a cardiac allograft for ischemic cardiomyopathy 20 days earlier, who presented an acute type A aortic dissection limited to the donor aorta. Transesophageal echocardiography revealed severe aortic regurgitation and an intimal tear 2 cm above commissures. The patient was successfully treated with a composite valve graft. This case is the first successful repair in a cardiac allograft with acute aortic dissection of the donor aorta during the early postoperative period using a Bentall procedure.

Resection of intrapericardial hibernoma associated with constrictive pericarditis [Case report - Thoracic oncologic]

Ucak, A., Inan, K., Onan, B., Turan Yilmaz, A. — Tue, 22 Sep 2009 08:21:54 PDT

Hibernoma is a benign soft-tissue tumor, which arises from the remnants of fetal brown adipose tissue. Out of less than 300 cases of hibernoma described to date, pericardial sac is an unusual localization to develop. When the tumor increases in size, this benign pathology can lead to compression of cardiac chambers and cause life-threatening complications in an asymptomatic patient. Here, the authors present the case of a 20-year-old male who underwent an operation for the treatment of constrictive pericarditis, in which an intrapericardial sessile lesion over diaphragmatic surface of pericardial sac was incidentally discovered. The tumor was excised and diagnosed as hibernoma. No recurrence was evident two years after the procedure.

Asymptomatic false aneurysm of the right coronary sinus treated by a reimplantation valve sparing technique [Case report - Aortic and aneurysmal]

Sassard, T., Boussel, L., Jegaden, O., Farhat, F. — Tue, 22 Sep 2009 08:21:54 PDT

We describe the case of a 65-year-old man who presented with a false aneurysm of the right aortic coronary sinus, discovered after a routine medical examination. A complete resection of the aortic root and a reimplantation technique were performed. Herein, we describe the technical approach and immediate follow-up.

Post-sternotomy intercostal artery pseudoaneurysm. Sonographic diagnosis and thrombosis by ultrasound-guided percutaneous thrombin injection [Case report - Vascular thoracic]

Fernandez Alonso, S., Azcona, C. M., Heredero, A. F., de Cubas, L. R. — Tue, 22 Sep 2009 08:21:55 PDT

Intercostal artery pseudoaneurysms are extremely rare. We present a case of an intercostal artery pseudoaneurysm after median sternotomy that was treated by ultrasound-guided percutaneous thrombin injection. They are a potential source of complications, especially haemothorax, and treatment is mandatory. Different methods may be used for the confirmatory diagnosis of false aneurysms. Doppler ultrasound (DUS) and CT are the two most commonly used methods, but pseudoaneurysms have also been diagnosed by means of arteriography (AR), which enables endovascular treatment of the pseudoaneurysm in a single procedure. We used Doppler sonography alone, because this technique yielded a definitive diagnosis without the need for other complementary imaging modalities to treat the lesion. There are various possible treatments for lesions of this kind. Endovascular embolization is the commonly used treatment for intercostal pseudoaneurysm but also stent grafting has been described. Surgical aneurysmectomy with proximal ligation of the intercostal artery is an option described for the treatment of the pseudoaneurysm. To date only seven cases have been published in the literature. Our case is the only published instance of treatment of an intercostal artery pseudoaneurysm by direct percutaneous thrombin injection under sonographic guidance.

eComment: It could be an iatrogenic arteriovenous fistula [eComment]

Silva, J. — Tue, 22 Sep 2009 08:21:55 PDT

Spontaneous left main coronary artery dissection, possibly due to cystic medial necrosis found in the internal mammary arteries [Case report - Coronary]

Hirose, H., Matsunaga, I., Anjun, W., Strong, M. D. — Tue, 22 Sep 2009 08:21:55 PDT

A 55-year-old male without previous medical history developed chest pain. Coronary catheterization showed left main coronary dissection. Coronary artery bypass grafting was performed using bilateral internal mammary arteries, which were very fragile. The specimens of the internal mammary arteries sent for pathology showed cystic medial necrosis.

eComment: Routine preoperative evaluation of the internal mammary artery as conduit for coronary patients. Is it worth? [eComment]

Barbetakis, N., Lafaras, C., Efstathiou, A., Fessatidis, I. — Tue, 22 Sep 2009 08:21:55 PDT

Solitary pulmonary metastasis of mucoepidermoid carcinoma of the palate 43 years after the initial treatment [Case report - Thoracic oncologic]

Okami, J., Tomita, Y., Higashiyama, M., Kodama, K. — Tue, 22 Sep 2009 08:21:55 PDT

This report describes the case of a 71-year-old female presenting with a metastatic mucoepidermoid carcinoma (MEC) in the lung 43 years after the initial treatment for the primary tumor. This case represents a very long period between initial diagnosis and distant metastasis with a pathological examination of both the primary and metastatic tumors. Metastatic tumor should be considered for the differential diagnosis of a pulmonary nodule in a patient who has a history of this type of oral tumor.

Aneurysmal ascending to descending aorta bypass graft compressing the pulmonary artery [Case report - Aortic and aneurysmal]

Kalahasti, V., Roselli, E. E., Flamm, S. D., Krasuski, R. A. — Tue, 22 Sep 2009 08:21:55 PDT

We describe the first case of aneurysmal degeneration of ascending to descending aortic bypass graft with compression of main pulmonary artery in a young patient who had prior history of interrupted aortic arch. We also outline the value of multimodality imaging in the surgical management of this condition.

Trichoptysis: a hairy presentation of a rare tumour [Case report - Thoracic oncologic]

Makarawo, T. P., Finnikin, S., Woolley, S., Bishay, E. — Tue, 22 Sep 2009 08:21:55 PDT

We describe the case of a 17-year-old hairdresser who presented with haemoptysis and trichoptysis due to benign intrapulmonary teratoma and her surgical management. The clinical and radiological features of this rare tumour are reviewed and the symptom of trichoptysis discussed.

Surgical extraction of occluded stents: when stenting becomes a problem [Case report - Coronary]

Atoui, R., Mohammadi, S., Shum-Tim, D. — Tue, 22 Sep 2009 08:21:55 PDT

In this current ‘stent era’, cardiac surgeons are faced with a rapidly increasing number of patients in whom previous percutaneous coronary interventions (PCIs) have been performed before they are finally referred for coronary artery bypass surgery. We herein describe a technique of surgical revascularization in two patients with diffusely diseased left anterior descending arteries (LAD), covered with multiple overlapping stents extending to their distal portion. The pertinent literature is reviewed and the technical steps and clinical presentation are discussed.

eComment: How to reconstruct endarterectomized left anterior descending coronary artery [eComment]

Nezic, D., Knezevic, A., Cirkovic, M., Micovic, S. — Tue, 22 Sep 2009 08:21:55 PDT

Primary endobronchial non-Hodgkin lymphoma in an 80-year-old patient with prostate cancer [Case report - Thoracic oncologic]

Hardavella, G., Thalassinos, N., Anastasiou, N. — Tue, 22 Sep 2009 08:21:55 PDT

The identification of a primary endobronchial non-Hodgkin lymphoma (NHL) is rare. We hereby present the case of a primary solitary endobronchial NHL lesion in an 80-year-old patient with prostate cancer who did not present any systemic involvement at the time of diagnosis.

Recurrent dedifferentiated liposarcoma of mediastinum involving lung and pleura [Case report - Thoracic oncologic]

Coulibaly, B., Bouvier, C., Jose Payan, M., Thomas, P. — Tue, 22 Sep 2009 08:21:55 PDT

We report a case of primary recurrent mediastinal dedifferentiated liposarcoma with unusual long-term survival. A woman who complained of dyspnea showed on imaging features a bulky posterior mediastinal mass which was completely excised and initially misdiagnosed as an angiomyolipoma. She recurred 15 months later and histological examination showed a dedifferentiated liposarcoma. Resection was incomplete and the patient received adjuvant therapy. Eight years later a second recurrence occurred in the right pleura and lung. The patient died three months later.

Intra-diaphragmatic pacemaker implantation in very low weight premature neonate [Case report - Congenital]

Roubertie, F., Le Bret, E., Thambo, J. B., Roques, X. — Tue, 22 Sep 2009 08:21:55 PDT

Implantation of a pacemaker (PM) in very low weight premature neonates can be a challenging procedure because of the actual dimension of generators. Ideal placement of the PM is still controversial. We describe a technique of intra-diaphragmatic PM implantation in a 1.3 kg neonate.

eComment: Re: Intra-diaphragmatic pacemaker implantation in very low weight premature neonate [eComment]

Bockeria, L. A., Revishvili, A. Sh., Grygoryev, O. Y. — Tue, 22 Sep 2009 08:21:55 PDT

The acute chest syndrome of sickle cell disease following aortic valve replacement [Case report - Cardiac general]

Murtuza, B., Gupta, P., Lall, K. S. — Tue, 22 Sep 2009 08:21:55 PDT

The acute chest syndrome (ACS) of sickle cell disease (SCD) is a leading cause of death in SCD, with a high incidence following surgery, though only one case has been reported following cardiac surgery. We present a case of ACS in an adult undergoing aortic valve replacement (AVR) despite instituting established peri-operative optimization measures to prevent sickling. Early diagnosis of this condition in our patient as a distinct clinical entity facilitated appropriate, specific therapy and a good subsequent postoperative recovery. Greater recognition of this syndrome in the growing number of adult sickle cell patients presenting for cardiac surgery may help improve their outcome.

Right atrium traumatic rupture presenting as chronic tamponade [Case report - Cardiac general]

Permanyer, E., Ginel, A., Munoz-Guijosa, C., Padro, J. M. — Tue, 22 Sep 2009 08:21:55 PDT

Non-penetrating cardiac traumatisms can cause cardiac rupture, myocardial contusion or, rarely, commotio cordis. In cases of rupture of a cardiac cavity, acute and severe cardiac tamponade almost invariably occurs. This paper presents an exceptionally unusual case of non-penetrating cardiac trauma resulting in right atrium rupture contained by the pericardial cavity. A situation of exceptional hemodynamic balance was established with subacute, progressive cardiac tamponade that evolved during three months, presenting gradual right-heart failure instead of the expected acute and severe cardiac tamponade. The rupture of the atrium was successfully repaired.

Good syndrome accompanied by pure red cell aplasia [Case report - Thoracic oncologic]

Taniguchi, T., Usami, N., Kawaguchi, K., Yokoi, K. — Tue, 22 Sep 2009 08:21:55 PDT

Thymomas are often associated with various autoimmune disorders. We herein report a middle-aged female patient with thymoma and hypogammaglobulinemia (Good syndrome) who developed symptomatic normocytic anemia. Her computed tomography (CT) scans showed a cervico-mediastinal mass. The findings of a bone marrow biopsy suggested pure red cell aplasia (PRCA), and the serum levels of all immunoglobulins were extremely low. After the resection of the tumor, which was diagnosed to be Masaoka stage II and type AB thymoma, the normocytic anemia dramatically improved, but the hypogammaglobulinemia did not recover.

A sternotomy too far [Case report - Thoracic non-oncologic]

Ashour, K., Jamieson, K., Lakhoo, K. — Tue, 22 Sep 2009 08:21:55 PDT

Median sternotomy has been used for a long time as a standard approach for many cardiothoracic procedures in children. Many complications have been reported to result from this approach with different incidences. Iatrogenic diaphragmatic hernia has not been reported as a definite complication of such approach. This paper presents a case report for a 14-month-old boy with iatrogenic diaphragmatic hernia following median sternotomy.

Paraneoplastic extra limbic encephalitis associated with thymoma [Case report - Thoracic oncologic]

Rizzardi, G., Campione, A., Scanagatta, P., Terzi, A. — Tue, 22 Sep 2009 08:21:55 PDT

We report the case of a 55-year-old woman with thymoma diagnosed after finding of extra limbic encephalitis. She presented neurologic symptoms as seizure and aphasia; magnetic resonance imaging (MRI) of the brain showed multiple lesions located in insular, parietal and temporal lobes (in cortical and sub-cortical area). Brain biopsies confirmed the diagnosis of encephalitis and CT-scan of the thorax showed an anterior mediastinal mass suspected for thymoma. The patient was submitted to thymectomy through a median sternotomy and we assisted to secondary reduction of cerebral lesions and total remission of symptoms.

Multiple sternotomies for repeated aortic root replacement - optimising the surgical approach [Case report - Cardiac general]

Lim, J., Pillai, R. — Tue, 22 Sep 2009 08:21:55 PDT

A 44-year-old patient with fungal endocarditis required a total of five sternotomies over ten years. We present the course of his treatment, details of the surgical techniques employed as well as other interesting points encountered in the management of this patient.

Non-operative management of tube thoracostomy induced pulmonary artery injury [Case report - Pulmonary]

Sundaramurthy, S. R., Moshinsky, R. A., Smith, J. A. — Tue, 22 Sep 2009 08:21:55 PDT

Tube thoracostomy insertion is a common procedure in the management of air and fluid collections in the pleural space. Pulmonary artery injury is a rare but serious complication following intercostal catheterisation. This complication is usually managed surgically. We report a case of successful non-operative management of a pulmonary artery injury after tube thoracostomy.

eComment: Management options of tube thoracostomy-induced pulmonary artery injury [eComment]

Edwin, F. — Tue, 22 Sep 2009 08:21:55 PDT