The Journal of Thoracic and Cardiovascular Surgery

Variability in data: The Society of Thoracic Surgeons National Adult Cardiac Surgery Database

Morgan L. Brown, Judy R. Lenoch, Hartzell V. Schaff — 2010-05-24

Objective: Since 1989, data have been reported to the Society of Thoracic Surgeons National Adult Cardiac Surgery Database for quality improvement. This information is also data mined for national quality indicators, policy initiatives, and research. Such use has important limitations, because data elements cannot be verified for accuracy. We determined variability of disease etiology and operative data database elements when abstracted by untrained physician abstractors.Methods: We selected 30 patients who underwent cardiovascular surgery from January to December 2005 (10 each of coronary artery bypass grafting, mitral valve repairs, and aortic valve and associated aortic procedures). Four abstractors (2 cardiothoracic residents and 2 fellows) abstracted 28 variables. Results were compared with abstraction performed by a professional abstractor.Results: Median percentage agreement among all cases was 89% (range, 42%–100%). Agreements were 94% (28%–100%) for mitral valve, 84% (48%–100%) for aortic valve, and 93% (35%–100%) for coronary artery bypass grafting. Among the aortic valve group, etiology of aortic valve disease had poor agreement (68%) because of cases in which multiple definitions could apply. Degree of valvular regurgitation also had poor agreement (median, 67%; range, 28%–95%). Number of internal thoracic artery grafts and absence of significant valvular disease were reported consistently. Agreements between types of aortic valve procedure and between methods of mitral valve repair (65% and 83%, respectively) were less than expected.Conclusions: We found variable agreement among untrained data abstractors. This has important implications regarding interpretation of database studies with de-identified data. Without good quality control and consistent standardized definitions, aggregate data in clinical databases may be suspect.

Data variability and validity: The elephant in the room

Gary L. Grunkemeier, Anthony P. Furnary — 2010-08-01

The Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database (NCD), begun in 1989, has found almost universal acceptance, with more than 1000 cardiac surgery programs currently participating. Cardiac surgery has been a leader in this effort, with worldwide acknowledgment, and is no doubt the envy of other surgical specialties. Only now, 20 years later, for example, is orthopedic surgery attempting to create a national registry, motivated by a 4-year, $12 million grant from the Agency for Healthcare Research and Quality. Not only is cardiac surgery ahead of the pack, it is far ahead.

Repair of regurgitant bicuspid aortic valves: A systematic approach

2010-05-20

Objective: Patients with bicuspid aortic valves can present with aortic insufficiency caused by cusp disease or the aortic root pathology. We present our 13-year experience with a functional and systematic approach to bicuspid aortic valve repair.Methods: Between 1995 and 2008, 122 consecutive patients (mean age, 44 ± 11 years) with bicuspid aortic valves underwent non-emergency valve repair for isolated aortic insufficiency (43%), aortic root dilatation (14%), or both (43%). Preoperative echocardiography identified aortic dilatation (n = 75), cusp prolapse (n = 96), and cusp restriction (n = 45) as mechanisms of aortic insufficiency. Raphé repair (n = 98) was performed by shaving (21%) or resection with primary closure (60%) or pericardial patch (18%). Functional aortic annuloplasty was performed using subcommissural annuloplasty (n = 51), ascending aortic replacement (n = 17), or aortic root replacement (n = 54) using a reimplantation (76%) or remodeling technique (24%).Results: There was no operative mortality. Five patients underwent early aortic valve reoperation (3 re-repairs). At discharge, 93% of patients had aortic insufficiency grade 0/1 and 7% of patients had grade 2. Seven additional patients underwent aortic valve reoperation during follow-up (2 re-repairs). Overall survival was 97% ± 3% at 8 years. At 5 and 8 years follow-up, freedom from aortic valve reoperation was 94% ± 2% and 83% ± 5%, respectively, and freedom from aortic valve replacement was 96% ± 2% and 90% ± 5%, respectively. Freedom from recurrent aortic insufficiency (>2+) was 94% ± 3% at 5 years. Freedom from thromboembolism and bleeding was 96% ± 2% at 8 years.Conclusion: A systematic approach to bicuspid aortic valve repair yields good early and midterm results. Repair of bicuspid valves for aortic insufficiency is a feasible and attractive alternative to mechanical valve replacement in young patients.

Discussion

2010-05-20

Dr Hartzell Schaff (Rochester, Minn). Congratulations to Drs Boodhwani and El Khoury and their associates for a beautiful presentation, which is useful to us because it shows the spectrum of operations in patients with BAV disease and is notable for the very low mortality.

Effects of surgical ventricular reconstruction on diastolic function at midterm follow-up

2009-12-28

Objective: Limited data are available on the effects of surgical ventricular reconstruction on diastolic function. The aim of the present study was to evaluate changes in diastolic function induced by surgical ventricular reconstruction at 2 time intervals after surgery (discharge and follow-up) and to assess the impact of diastolic changes on clinical outcome.Methods: A total of 129 patients (65 ± 9 years, 14 women) underwent echocardiographic Doppler evaluation before surgical ventricular reconstruction, at discharge, and at follow-up (median 7 months). Patients with mitral regurgitation were excluded. Diastolic pattern was graded as follows: 0 (normal), 1 (abnormal relaxation), 2 (pseudo normalization), 3 (restrictive, reversible), and 4 (restrictive, irreversible).Results: At follow-up, 28 (21.7%) of 129 patients showed a restrictive diastolic pattern (grade 3–4; group 1) and 101 did not (diastolic pattern grade 0–2; group 2). Preoperative and postoperative factors strongly associated with late diastolic restriction included sphericity index (higher in group 1), ventricular shape (nonaneurysmal shape more frequent in group 1), internal dimensions (greater in group 1), diastolic pattern (higher in group 1), ejection fraction (lower in group 1); left atrial dimensions (greater in group 1); mitral regurgitation rate (higher in group 1). At multivariate analysis the most powerful predictors of restriction were preoperative pseudonormalization of diastolic pattern (diastolic pattern 2) and septolateral dimensions (short axis). Overall, ejection fraction improved from 33% ± 9% to 40% ± 9% to 40% ± 9%; P = .001; end-diastolic and end-systolic volumes decreased (112 ± 41 to 73 ± 21 to 88 ± 28mL/m2, respectively; P = .001; and 77 ± 38 to 44 ± 17 to 52 ± 24mL/m2, respectively; P = .001); New York Heart Association class improved (2.4 ± 0.8 to 1.6 ± 0.6; P = .001).Conclusions: Mild preoperative diastolic dysfunction (pseudonormalized pattern) and increased septolateral dimensions are independent predictors of diastolic restriction after surgical ventricular reconstruction.

In vivo functional flowmetric behavior of the radial artery graft: Is the composite Y-graft configuration advantageous over conventional aorta–coronary bypass?

2009-12-28

Introduction: Intraoperative flowmetric results of different configurations (Y-graft or aorta–coronary) of radial artery grafts have been poorly investigated.Methods: We report the results of an observational study designed to analyze transit-time flow measurements at baseline and during 1:1 intra-aortic balloon pumping in 114 consecutive patients receiving the radial artery as a aorta–coronary bypass (group A, 72 patients) or as a Y-graft with the left internal thoracic artery (group B, 42 patients). Graft flow reserve, recruited by 1:1 intra-aortic balloon pumping) greater than 1 indicated recruitment of surplus graft flow. Results were stratified by grafted territory and surgical technique.Results: Hospital outcome was comparable. Baseline transit-time flow results were similar between the 2 groups in terms of maximum diastolic flow, minimum systolic flow, mean flow, and pulsatility index. Graft flow reserve was not recruited by intra-aortic balloon pumping in 3 (2.7%) malfunctioning single aorta–oronary radial artery bypass grafts (P = .005 versus successful radial artery bypass grafts). Graft flow reserve was recruited (>1) by intra-aortic balloon pumping in the remaining 111 patent radial artery bypass grafts. Y-grafts showed higher maximum diastolic flow P < .0001), mean flow (P < .0001), graft flow reserve (P < .0001), percentage improvement of maximum diastolic flow (P < .0001), and of mean flow (P < .0001) compared with aorta–coronary radial artery bypass grafts. These results were confirmed for the right coronary (P ≤ .004) and the circumflex territory (P ≤ .001), for off-pump (P ≤ .008) or cardiopulmonary bypass (P < .0001) and for patients undergoing isolated bypass grafting (P < .0001).Conclusions: Intraoperative flows of radial artery bypass grafts showed comparable baseline results in single aorta–coronary conduits and Y-grafts. Graft flow reserve recruited by intra-aortic balloon pumping was higher in Y-conduits, regardless of the grafted territory and the perfusion strategy chosen. Failed radial artery bypass grafts did not improve transit-time flow results during 1:1 intra-aortic balloong pumping nor showed any recruitment of graft flow reserve.

Angiotensin II receptor type 1 is upregulated in atrial tissue of patients with rheumatic valvular disease with atrial fibrillation

Hongliang Cong, Ximing Li, Lijun Ma, Hua Jiang, Yongmin Mao, Meilin Xu — 2010-01-18

Objective: The purpose of this study was to examine the changes in expression of angiotensin II receptor type 1/2 in left or right atrial tissue from patients with rheumatic valvular disease with or without atrial fibrillation.Methods: Atrial tissue samples were obtained from 39 patients with rheumatic mitral valve disease during cardiac surgery. Among these patients, there were 25 with atrial fibrillation and 14 with sinus rhythm. The level of angiotensin II receptor type 1 or type 2 mRNA transcription was measured by means of a semiquantitative reverse transcription–polymerase chain reaction technique. Expression of angiotensin II receptor type 1 or type 2 protein was detected by means of immunohistochemistry assay and Western blot analysis.Results: The inner diameter of the left atrium was clearly enlarged in the atrial fibrillation group in comparison with that seen in the sinus rhythm group. The expression levels of both angiotensin II receptor type 1 mRNA and protein in the left atrial tissue were significantly increased in the patients with atrial fibrillation compared with those seen in patients with sinus rhythm (P < .05). Interestingly, the comparison of angiotensin II receptor type 2 expression levels in the left atrial tissue between these 2 groups is not statistically significant. In addition, the results of angiotensin II receptor type 1 or 2 expression in the right atrial tissue did not show any obvious change in the patients with atrial fibrillation versus those with sinus rhythm.Conclusions: Expression of angiotensin II receptor type 1 but not type 2 is highly upregulated only in the left atrial tissue of patients with rheumatic valvular disease with atrial fibrillation. This suggests that there is a possible pathophysiologic role of the renin–angiotensin system in patients with atrial fibrillation and that a series of effects mediated by the activation of angiotensin II receptor type 1 in the left atrial tissue might be one of the molecular mechanisms involved in the process of atrial remodeling in atrial fibrillation.

Effectiveness of combination of losartan potassium and doxycycline versus single-drug treatments in the secondary prevention of thoracic aortic aneurysm in Marfan syndrome

2010-03-02

Objective: Losartan potassium (INN losartan), an antihypertensive drug, has been shown to prevent thoracic aortic aneurysm in Marfan syndrome through the inhibition of transforming growth factor β. Recently we reported that doxycycline, a nonspecific inhibitor of matrix metalloproteinases 2 and 9, normalized aortic vasomotor function and suppressed aneurysm growth. We hypothesized that a combination of losartan potassium and doxycycline would offer better secondary prevention treatment than would single-drug therapy to manage thoracic aortic aneurysm.Methods: A well-characterized mouse model of Marfan syndrome (Fbn1C1039G/+) was used. At 4 months of age, when aneurysm had established, mice (n = 15/group) were given doxycycline alone (0.24 g/L), losartan potassium alone (0.6 g/L), or combined (0.12-g/L doxycycline and 0.3-g/L losartan potassium) in drinking water. Littermate Fbn1+/+ mice served as control. Thoracic aortas at 6 and 9 months were studied.Results: At 9 months, aortic diameter in untreated group was increased by 40% relative to control. Losartan potassium or doxycycline reduced aortic diameter by 10% to 16% versus untreated aortas. Losartan potassium and doxycycline combined completely prevented thoracic aortic aneurysm and improved elastic fiber organization, also downregulating matrix metalloproteinases 2 and 9 and transforming growth factor β and normalizing aortic contractile and relaxation functions to control values.Conclusions: Neither losartan potassium nor doxycycline alone completely restored vascular integrity and cell function when given during delayed treatment, indicating the importance of timed pharmacologic intervention. Combined, however, they synergistically offered better aneurysm-suppressing effects than did single-drug medication in the secondary prevention of thoracic aortic aneurysm.

Clinical experience with the second-generation 3f Enable sutureless aortic valve prosthesis

2010-08-01

Objective: The 3f Enable aortic bioprosthesis (ATS Medical, Inc, Minneapolis, Minn) represents a new generation of equine pericardial self-expanding valve designed for sutureless implantation. This study evaluated technical aspects of implantation and safety and effectiveness of the valve in the short term.Methods: In an outcome analysis of a consecutive series of 28 patients who underwent aortic valve replacement for aortic stenosis with the 3f Enable during an 18-month period, mean age was 75.7 ± 6.6 years, 18 patients were female (64.2%), and mean EuroSCORE was 7.1% ± 1.7%.Results: Most implanted valves were 23 mm in diameter (19–27 mm). Mean aortic crossclamp time was 39 ± 15 minutes (29–103 minutes), mean cardiopulmonary bypass time was 58 ± 20 minutes (41–127 minutes), mean hospital stay was 11 days (7–22 days), and 30-day mortality was 3.5%. Mean and peak intraoperative transvalvular pressure gradients were 6.1 ± 2.6 and 18 ± 5 mm Hg, respectively. Trivial and mild paravalvular leaks were observed in 1 patient each. One patient underwent reoperative aortic valve replacement 4 months after initial surgery for severe valve-unrelated paravalvular leakage. Five patients (18.5%) required permanent pacemakers. No patients were unavailable for follow-up. One-year survival was 86.2%.Conclusions: The 3-f Enable aortic bioprosthesis can be implanted safely with favorable early hemodynamics. The self-expanding stent allows sutureless implantation with a large valve area. The procedure was fast, although not as fast as expected. This experience has led to continued design and procedural enhancements to facilitate and accelerate future implantation.

Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation

2009-12-28

Objective: In patients with hypertrophic cardiomyopathy with bifid hypermobile papillary muscles and a dynamic left ventricular outflow tract gradient, we performed surgical papillary muscle reorientation, fixing the mobile papillary muscle to the posterior left ventricle to reduce mobility. We report the outcomes of patients with hypertrophic cardiomyopathy undergoing surgical papillary muscle reorientation versus those of patients undergoing standard surgical procedures.Methods: We studied 204 consecutive patients with hypertrophic cardiomyopathy undergoing surgical intervention (after consensus decision) for symptomatic left ventricular outflow tract gradient. Preoperative and postoperative maximal (resting/provocable) left ventricular outflow tract gradients were recorded by using echocardiographic analysis.Results: The population was divided into 3 groups: (1) isolated myectomy (n = 143; age, 54 ± 14 years; 48% men), (2) myectomy plus mitral valve repair/replacement (n = 39; age, 54 ± 13 years; 54% men), and (3) papillary muscle reorientation with or without myectomy (n = 22; age, 50 ± 14 years; 59% men). The mean preoperative (103 ± 32, 103 ± 32, and 114 ± 36 mm Hg; P = .3) and predischarge (15 ± 18, 14 ± 14, and 16 ± 21 mm Hg; P = .9) maximal left ventricular outflow tract gradients were similar. There were no deaths either in the hospital or at 30 days. At a median follow-up of 166 days (interquartile range, 74–343 days), 21 of 22 patients in group 3 were asymptomatic. One patient in group 3 had a symptomatic left ventricular outflow tract gradient (87 mm Hg) requiring mitral valve replacement.Conclusions: In patients with hypertrophic cardiomyopathy with bifid hypermobile papillary muscles (even with a basal septal thickness <1.5 cm), papillary muscle reorientation reduces the symptomatic left ventricular outflow tract gradient. Long-term outcomes need to be ascertained.

Long-term follow-up after primary complete repair of common arterial trunk with homograft: A 40-year experience

2010-04-29

Background: We sought to determine the long-term performance of homograft and truncal valve after complete repair of common arterial trunk.Methods: From January 1964 to June 2008, 32 patients (median age, 14 days; range, 5 days to 2.5 years) underwent primary homograft repair of common arterial trunk. Twenty-four (75%) were neonates. The homograft used in the right ventricular outflow tract was aortic in 24 patients and pulmonary in 8 patients (mean diameter, 15.8 ± 3.5 mm; median diameter, 16 mm [range, 8–24 mm]). The median follow-up was 24.5 years (range, 5.6 months to 43.5 years).Results: There were 3 hospital deaths and 1 late death. The actuarial survival at 30 years was 83.1% ± 6.6%. Of the 28 survivors, 25 reoperations were performed in 19 (76%) patients. The mean and median times to homograft reoperation were 11.5 ± 7.4 and 12.1 years (range, 1.0–26.1 years), respectively. Overall freedom from homograft reoperation after 10, 20, and 30 years was 68.4% ± 8.7%, 37.4% ± 9.5%, and 26.7% ± 9.3%, respectively. Twelve patients retained the original homografts at a median follow-up of 16.4 years (range, 0–30.2 years). Six underwent a truncal valve replacement with a mechanical prosthesis at a median of 10.5 years (range, 3.4–22 years) after truncus repair. Freedom from truncal valve replacement at 10 and 30 years was 93.1% ± 4.7% and 81.8% ± 8.9%, respectively. In the 22 surviving patients who did not undergo truncal valve replacement, the peak truncal valve gradient was 8.9 ± 8.3 mm Hg at a median follow-up of 24.5 years (range, 5.6 months to 32.9 years). At the last follow-up, 27 (96.4%) patients had good left ventricular function, and 24 patients (85.7%) were New York Heart Association class I.Conclusions: Oversizing the homograft at the time of the initial repair can lead to a homograft lasting more than 12 years. During long-term follow-up, 20% of patients require truncal valve replacement.

Extracorporeal membrane oxygenation in postcardiotomy patients: Factors influencing outcome

2010-08-01

Objective: Our objective was to assess the morbidity and mortality in children requiring extracorporeal membrane oxygenator support after cardiac surgery and to determine factors influencing outcome.Methods: Between January 2003 and June 2008, 58 patients required extracorporeal membrane oxygenator support after cardiac surgery. A retrospective study was performed and factors influencing outcome were determined by logistic regression modeling with the probability of outcome based on a combination of multivariate predictors.Results: Median age and weight were 12 days and 3.3 kg, respectively. Thirty-one patients had single ventricle repair and 27 had biventricular repair. Median duration of support with the oxygenator was 6 days. Thirty-nine (67%) patients were successfully weaned off the support, but only 24 (41%) survived to hospital discharge. Chief complications were renal failure (31%), neurologic complications (29%), and sepsis (16%). Multivariable logistic regression analysis identified 10 days or more of extracorporeal membrane oxygenation (odds ratio = 6.1), urine output less than 2 mL · kg−1 · h−1 in first 24 hours (odds ratio = 15), renal failure (odds ratio = 9.4), and pH less than 7.35 after 24 hours of extracorporeal membrane oxygenation (odds ratio = 82) as significant independent factors associated with failure to wean off extracorporeal membrane oxygenation. Factors associated with failure of hospital discharge despite successful decannulation were as follows: extracorporeal membrane oxygenator support time of 10 days or more, red blood cell transfusion of greater than 1000 mL/kg during the entire period of oxygenator support, and sepsis. Patients with single ventricle repair were at higher risk of hospital mortality.Conclusion: Longer duration of extracorporeal membrane oxygenator support, low pH and urine output in the first 24 hours, and renal failure are significant factors associated with mortality during extracorporeal membrane oxygenator support. Exposure to high amounts of blood transfusion during extracorporeal oxygenation, extended extracorporeal membrane oxygenator support, and sepsis increase risk of death after successful decannulation.

Transcriptomic analysis of patients with tetralogy of Fallot reveals the effect of chronic hypoxia on myocardial gene expression

2010-04-23

Objectives: In cyanotic patients undergoing repair of heart defects, chronic hypoxia is thought to lead to greater susceptibility to ischemia and reoxygenation injury. We sought to find an explanation to such a hypothesis by investigating the cardiac gene expression in patients with tetralogy of Fallot undergoing cardiac surgery.Methods: The myocardial gene profile was investigated in right ventricular biopsy specimens obtained from 20 patients with a diagnosis of cyanotic (n = 11) or acyanotic (n = 9) tetralogy of Fallot undergoing surgical repair. Oligonucleotide microarray analyses were performed on the samples, and the array results were validated with Western blotting and enzyme-linked immunosorbent assay.Results: Data revealed 795 differentially expressed genes in cyanotic versus acyanotic hearts, with 198 upregulated and 597 downregulated. Growth/morphogenesis, remodeling, and apoptosis emerged as dominant functional themes for the upregulated genes and included the apoptotic gene TRAIL (tumor necrosis factor–related apoptosis-inducing ligand), the remodeling factor OPN (osteopontin), and the mitochondrial function gene COX11 (cytochrome-c oxidase 11). In contrast, transcription, mitogen-activated protein kinase signaling, and contractile machinery were the dominant functional classes for the downregulated genes, which included the calcium-handling gene NCX1 (sodium-calcium exchanger). Protein levels of COX11, NCX1, OPN, and LYZ (lysozyme) in the myocardium followed the same pattern obtained by means of transcriptomics. The TRAIL level did not change in myocardium but increased in circulating blood of cyanotic patients, suggesting the myocardium as a possible source. Additionally, our data showed increased protein expression of apoptosis markers in cyanotic myocardium.Conclusions: Chronic hypoxia in cyanotic children with tetralogy of Fallot induced the expression of genes associated with apoptosis and remodeling and reduced the expression of genes associated with myocardium contractility and function.

Bosentan induces clinical and hemodynamic improvement in candidates for right-sided heart bypass surgery

2010-05-03

Objective: To investigate the efficacy of bosentan in patients with single-ventricle physiology who were unable to undergo right-sided heart bypass surgery because of high pulmonary vascular resistance and pulmonary artery pressure.Methods: Eight patients with single-ventricle physiology (2 male and 6 female; aged 7 months to 5 years, median 1 year) were enrolled. Prior surgical interventions included pulmonary artery banding in 4 patients, Blalock–Taussig shunt operation in 2 patients, and bidirectional Glenn operation in 5 patients. Right-sided heart bypass surgery was contraindicated for all patients because of high pulmonary vascular resistance and pulmonary artery pressure.Results: Bosentan therapy successfully reduced pulmonary artery pressure and pulmonary vascular resistance in all patients. Mean pulmonary artery pressure at baseline and after bosentan therapy was 21.1 ± 7.2 mm Hg and 11.9 ± 4.1 mm Hg, respectively (P < .01). Mean pulmonary vascular resistance index at baseline and after bosentan therapy was 5.7 ± 3.3 U/m2 and 1.3 ± 0.4 U/m2, respectively (P < .01). Mean pulmonary vascular resistance/systemic vascular resistance at baseline and after bosentan therapy was 0.25 ± 0.11 and 0.07 ± 0.03, respectively (P < .01). All patients had improved clinical symptoms and underwent successful Fontan operations.Conclusion: Bosentan induces mid-term clinical and hemodynamic improvement in patients with single-ventricle physiology and elevated pulmonary vascular resistance and pulmonary artery pressure. Bosentan therapy may increase the surgical options and improve outcomes in candidates for right-sided heart bypass surgery.

Prevalence of in vitro chemotherapeutic drug resistance in primary malignant pleural mesothelioma: Result in a cohort of 203 resection specimens

2010-05-31

Objective: Optimizing the multimodality treatment of malignant pleural mesothelioma depends on many factors including an adequate chemotherapeutic response. Currently, chemotherapy regimens for patients with mesothelioma are empirically selected. In vitro chemotherapy resistance in human mesothelioma has not been reported. Our goal was to determine the prevalence of drug resistance in a large sample of malignant pleural mesothelioma using a commercially available assay.Methods: Tumors specimens (n = 203) were cultured for analysis of chemoresistance using the extreme drug resistance assay. Evaluable results were obtained in 168 (168/203 = 83%) specimens. Each specimen was tested with 3 drugs: cisplatin, gemcitabine, and vinorelbine. Drug resistance was characterized as low, intermediate, or extreme. Median age was 64 years (30–85 years). Forty-four (26%) patients received neoadjuvant chemotherapy before sampling and testing. The distribution of histopathologic cell types was epithelial (103; 61%), mixed (57; 34%), and sarcomatoid (8; 5%).Results: A significant proportion of tumors had extreme/intermediate drug resistance to cisplatin (27%), gemcitabine (31%), or vinorelbine (59%). Nineteen tumors (11%) had extreme/intermediate resistance to all 3 drugs. Resistance (extreme/intermediate) to cisplatin was more prevalent in epithelial tumors than in nonepithelial (33% vs 18%; P = .0394). No significant differences in chemoresistance were found in tumors of patients who had received neoadjuvant chemotherapy compared with those who had not.Conclusions: The feasibility of performing off-site in vitro drug resistance assays on resected malignant mesothelioma specimens is reported. A significant proportion of mesothelioma tumors exhibited extreme/intermediate resistance to cisplatin, gemcitabine, or vinorelbine.

Which patients should be operated on after induction chemotherapy for N2 non–small cell lung cancer? Analysis of a 7-year experience in 175 patients

2010-04-12

Objective: The role of surgery in patients with N2 non–small cell lung cancer is debated. The aim of this study was to evaluate the results of surgical resection after induction chemotherapy.Methods: We retrospectively reviewed the cases of patients with N2 non–small cell lung cancer who underwent neoadjuvant chemotherapy followed by resection between 2001 and 2007. They all had tumors deemed resectable.Results: One hundred seventy-five patients entered the study. Most of them received 2 or 3 cycles of chemotherapy (81%), in all cases platinum-based regimens. Chemotherapy response rate was 62%. Operations included 96 lobectomies/bilobectomies and 79 pneumonectomies. Complete resection rate was 94%, and perioperative mortality was 4.5%. A pathologic mediastinal downstaging was found in 39% of patients. Overall median survival time and 5-year survival were 34.7 months and 30%, respectively. Survival was affected by clinical response (median survival time 51 months and 5-year survival 42% for responders versus 19 months and 10% for nonresponders) and by nodal downstaging (51 months and 45% versus 25% and 22%). In the group of responders, nondownstaged patients showed satisfying survival (median survival time 30 months, 5-year survival 30%). In the group of nonresponders, survival was unsatisfactory when a lobectomy was performed (median survival time 20 months, 5-year survival 13%) and poor in case of pneumonectomy (15 months and 6%). Multivariate analysis found 4 factors significantly affecting survival: clinical response, nodal downstaging, number of chemotherapy cycles, and histopathologic response.Conclusions: Surgery after chemotherapy could be effective for selected patients with N2 non–small cell lung cancer. Survival for responders is satisfactory, even in case of persistent N2 disease. Prognosis for nonresponders is disappointing.

Effect of statins on atrial fibrillation after cardiac surgery: A duration- and dose-response meta-analysis

Wendy T. Chen, Guru M. Krishnan, Nitesh Sood, Jeffrey Kluger, Craig I. Coleman — 2010-04-12

Objective: This meta-analysis of randomized, controlled trials evaluated effects of statins on postoperative atrial fibrillation risk after cardiac surgery.Methods: Randomized, controlled trials evaluating statins in cardiac surgery were selected from MEDLINE (1996–August 2009), Cochrane CENTRAL Register, and manual review of references without any language restrictions. End points examined included postoperative atrial fibrillation, intensive care unit stay, and total hospital stay. Meta-regression analyses were conducted to determine whether statins' effects were duration or dose dependent. A random-effects model was used in all instances.Results: Eight trials (n = 774) were identified and subjected to meta-analysis. Statins reduced postoperative atrial fibrillation risk (relative risk 0.57, 95% confidence interval 0.45–0.72, P < .0001, risk difference −0.14, 95% confidence interval −0.20 to −0.08, P < .0001, number needed to treat 8) and total hospital stay (weighted mean difference −0.66 days, 95% confidence interval −1.01 to −0.30 days, P = .0004) relative to placebo. Intensive care unit stay was also reduced (weighted mean difference −0.17 days, 95% confidence interval −0.37 to 0.03 days, P = .09) but did not meet prespecified criteria for statistical significance. Metaregression analysis revealed association between duration of preoperative statin prophylaxis and postoperative atrial fibrillation risk reduction (3% reduction per day, P = .008). No association was found between statin dose used and risk reduction (P = .47).Conclusions: Evidence suggests that statins are associated with reduced risk of postoperative atrial fibrillation and shorter hospital stay after cardiac surgery and that earlier therapy results in more profound benefit.

Pharyngostomy tubes for gastric conduit decompression

2010-04-15

Objective: This article illustrates our operative technique for pharyngostomy tube placement and describes our clinical experience with pharyngostomy use for gastric conduit decompression after esophagectomy.Methods: We retrospectively reviewed patients undergoing pharyngostomy tube placement for gastric conduit decompression after esophagectomy from January 2008 to August 2009. Patients were included if they had a pharyngostomy tube placed at esophagectomy (prophylactic placement) or as a means of decompression after postesophagectomy anastomotic leak (therapeutic placement). We collected operative and clinical data and performed a descriptive statistical analysis.Results: We placed 25 pharyngostomy tubes for gastric conduit decompression after esophagectomy. Eleven were placed prophylactically (44%); the remaining 14 were placed therapeutically (56%) after anastomotic leak. Prophylactic pharyngostomy tubes remained in place a median of 8 days (range 4–17 days), whereas therapeutic pharyngostomy tubes were left in place a median of 15 days (range 7–125 days). There were 4 infectious complications (16%) unrelated to length of pharyngostomy use: 2 cases of cellulitis (resolved with antibiotics, tube remaining in place) and 2 superficial abscesses after tube removal requiring bedside débridement. Seventy-two percent of patients underwent swallow evaluation; 22% of these patients had radiographic evidence of aspiration.Conclusions: Pharyngostomy tube placement for gastric conduit decompression after esophagectomy is simple, and tubes can stay in place for prolonged periods. Our experience suggests that pharyngostomy tubes are a safe alternative to nasogastric drainage.

Stereotactic body radiation therapy versus surgical resection for stage I non–small cell lung cancer

2010-04-19

Objectives: Stereotactic body radiation therapy has been proposed as an alternative local treatment option for high-risk patients with early-stage lung cancer. A direct comparison of outcomes between stereotactic body radiation therapy and surgical resection has not been reported. This study compares short-term outcomes between stereotactic body radiation therapy and surgical treatment of non–small cell lung cancer.Methods: We compared all patients treated with surgery (January 2000–December 2006) or stereotactic body radiation therapy (February 2004–May 2007) with clinical stage IA/B non–small cell lung cancer staged by computed tomography and positron emission tomography. Comorbidity scores were recorded prospectively using the Adult Co-Morbidity Evaluation scoring system. Charts were reviewed to determine local tumor recurrence, disease-specific survival, and overall survival. A propensity score matching analysis was used to adjust estimated treatment hazard ratios for confounding effects of patient age, comorbidity index, and clinical stage.Results: A total of 462 patients underwent surgery and 76 received stereotactic body radiation therapy. Overall, surgical patients were younger (P < .001), had lower comorbidity scores (P < .001), and better pulmonary function (forced expiratory volume in 1 second and carbon monoxide diffusion in the lung) (P < .001). Among the surgical and stereotactic body radiation therapy groups, 62.6% (291/462) and 78.9% (60/76) were in clinical stage IA, respectively. Final pathology upstaged 35% (161/462) of the surgery patients. In an unmatched comparison, overall 5-year survival was 55% with surgery, and the 3-year survival was 32% with radiation therapy. Among patients with clinical stage IA disease, 3-year local tumor control was 89% with radiation therapy and 96% with surgery (P = .04). There was no difference in local tumor control in stage IB disease (P = .89). No disease-specific survival differences were found in patients with 1A (P = .33) or IB disease (P = .69). Propensity analysis matched 57 high-risk surgical patients to 57 patients undergoing stereotactic body radiation therapy. In the matched comparison of this subgroup, there was no difference in freedom from local recurrence (88% vs 90%), disease-free survival (77% vs 86%), and overall survival (54% vs 38%) at 3 years.Conclusions: In an unmatched comparison of clinical stage IA disease, surgical patients were healthier and had better local tumor control compared with those receiving stereotactic body radiation therapy. Propensity analysis in clinical stage IA/B non–small cell lung cancer revealed similar rates of local recurrence and disease-specific survival in patients treated with surgery compared with stereotactic body radiation therapy.

Surgical technique and results of tracheal and carinal replacement with aortic allografts for salivary gland–type carcinoma

2010-04-12

Objective: We describe the surgical technique and peroperative management of tracheal and carinal replacement with aortic allografts for large salivary gland–type carcinoma and report the results with a mean 34 months' follow-up.Methods: We performed tracheal and carinal replacements with aortic allografts in 6 patients with extensive mucoepidermoid (n = 1) or adenoid cystic (n = 5) carcinomas. Tracheal tumor resection was followed by carinal restitution (n = 3) and interposition of the graft, splinted by a silicone stent. The allograft consisted of an aortic segment, either fresh (in the first 2 patients) or cryopreserved (in the last 4). All grafts were wrapped with bulky and well-vascularized flaps (pectoral muscle flap all patients, with an additional “thymopericardial fat flap” in the last 2) to promote revascularization and to prevent erosion of adjacent large vessels or fistulas. No immunosuppressive therapy was administered.Results: Complete resection (R0) was achieved in 5 (83%) of 6 patients. Three of the first 4 patients experienced major morbidity, mainly fistulas between the esophagus and graft. The last 2 patients had an uneventful outcome. All grafts transformed into well-vascularized conduits focally lined with respiratory epithelium. So far, the last 4 patients are disease-free and 3 of them have returned to full-time employment. Stent removal has not been attempted in any patient.Conclusion: Tracheal replacement with aortic allografts enables resection of extensive tumors with a curative intent. Efficient protective wrap around the graft is mandatory. Further follow-up is required to determine whether cartilage rings are generated within the graft, as in animal models.

A balanced perspective for management of tracheal salivary gland-type carcinomas

Chadrick E. Denlinger — 2010-08-01

I read with great interest the article by Wurtz and colleagues describing their experience with aortic allografts for tracheal reconstruction after resection of salivary gland–type tumors. A series of 6 patients underwent tracheal resection for adenoid cystic carcinoma (ACC) (n = 5) or a mucoepidermoid tumor (n = 1). Three patients required tracheal resections measuring 5.5, 9, and 10.5 cm. Resections in the remaining 3 patients extended from the first, second, or sixth tracheal ring to at least the level of the carina. Negative resection margins were achieved by frozen section analysis in each case. An average of 5.3 frozen sections was required, and it is unclear how much additional tracheal length was resected to achieve negative margins compared with the initial resection. In each case, the trachea was reconstructed with an aortic allograft supported with a silicone stent.

A reliable rabbit model for hyperkinetic pulmonary hypertension

2010-06-07

Objective: To study the mechanisms of vascular remodeling and increased vascular reactivity, a reliable, economic, easy, and stable animal model of hyperkinetic pulmonary hypertension is needed. The purpose of this study was to construct an animal model of hyperkinetic pulmonary arterial hypertension by chronic systemic–pulmonary shunt in young rabbits.Methods: Thoracotomy was performed through a midsternal incision in 1-month-old rabbits, and anastomosis between the left carotid artery and pulmonary artery trunk created a chronic left-to-right shunt. After 3 months, the shunted artery was checked by echocardiography. Systolic, diastolic, and mean pulmonary arterial pressures were measured by microcatheterization. The pathologic changes of small pulmonary arteries were observed after staining with hematoxylin and eosin. Thickness and area indices were calculated.Results: High-flow pulmonary hypertension was successfully established in 24 rabbits 3 months after operation. Relative to a sham operation group, the systolic, diastolic, and mean pulmonary arterial pressures were obviously increased in the experimental group (P < .05). Histologic examination showed that the thickness of arterial wall increased, the lumen became narrowed, and thickness and area indices increased in small pulmonary arteries (P < .05).Conclusions: We constructed a model mimicking the aberrant hemodynamic state in children with congenital heart disease with increased pulmonary blood flow to produce early characteristic morphology of hyperkinetic pulmonary hypertension. This method may provide an economic, easy, and stable animal model to study the mechanisms of pulmonary vascular remodeling in hyperkinetic pulmonary hypertension.

Excessively high systemic blood pressure in the early phase of reperfusion exacerbates early-onset paraplegia in rabbit aortic surgery

2010-05-31

Objective: We have demonstrated that therapeutic augmentation of systemic blood pressure during spinal cord ischemia plays an important role in minimizing spinal cord injury in both experimental and clinical aortic surgery. However, there remain concerns that excessively high blood pressure during spinal cord reperfusion may aggravate the reperfusion injury. The purpose of this study is to investigate the effect of high blood pressure during spinal cord reperfusion on postoperative neurologic outcomes after aortic surgery in rabbits.Methods: Experiments were performed using a rabbit spinal cord ischemia-reperfusion model in 2 randomly divided groups: (1) In the HR group, the mean blood pressure was maintained at a high level (121 ± 1.3 mm Hg) during reperfusion with intravenously administered phenylephrine; and (2) in the CR group, the mean blood pressure was not medically controlled (75 ± 9.1 mm Hg) during reperfusion. Neurologic and histologic assessments and evaluation of early reperfusion injury were performed.Results: In the HR group, slow and incomplete recovery of transcranial motor-evoked potentials (P = .02) and low neurologic scores (P < .005) were observed during spinal cord reperfusion compared with the CR group. At 48 hours of reperfusion, there were significantly fewer viable neuron cells, more apoptosis, and more perivascular edema with gray matter vacuolation in the HR group (P < .001 for each). At 3 hours, myeloperoxidase activity (P = .0021), vascular permeability (P = .0012), and superoxide generation (P < .0001) were significantly increased in the HR group.Conclusion: Excessively high blood pressure in the early phase of spinal cord reperfusion increased reperfusion injury in the spinal cord, leading to exacerbation of early-onset paraplegia. Avoidance of spinal cord reperfusion with high blood pressure may be one management strategy in thoracoabdominal aortic surgery.

Pioglitazone preserves vein graft integrity in a rat aortic interposition model

Zhi Chen, Tomomi Hasegawa, Akiko Tanaka, Yutaka Okita, Kenji Okada — 2010-03-02

Objective: Improvement of vein graft patency may be highly beneficial in coronary artery bypass grafting, but graft degeneration is considered to be one of the main pathophysiologic causes for vein graft failure. Because peroxisome proliferator-activated receptor-γ activator pioglitazone was recently reported to possess pleiotropic protective effects on various organs and tissues, we conducted experiments to test the hypothesis that pioglitazone could prevent graft degeneration, leading to the preservation of vein graft integrity.Methods: In a rat aortic interposition model with autologous femoral vein, pioglitazone (3 mg/kg/d) or vehicle (normal saline) was given to rats by gastric gavage once per day beginning 3 days before surgery and ending 8 weeks after surgery. Vein graft degeneration and remodeling were assessed at 24 hours, 7 days, 8 weeks, and 6 months after surgery.Results: At 24 hours, pioglitazone significantly reduced endothelial desquamation, reactive oxygen species generation, myeloperoxidase activity, and lipid peroxidation in vein grafts. At 7 days, mRNA expression and gelatinolytic activity of matrix metalloproteinase-2 and 9 in vein grafts were significantly suppressed by pioglitazone treatment. Immunofluorescent staining showed that pioglitazone enhanced peroxisome proliferator-activated receptor-γ expression in vein grafts at 8 weeks, especially in their intimal side. At 6 months, pioglitazone treatment prevented graft dilation (52.3% ± 3.1% vs 90.7% ± 9.9%, P = .0041) and neointimal hyperplasia (14.6% ± 1.3% vs 29.9% ± 2.9%, P = .0008), and increased graft flow velocity ratio (0.86 ± 0.03 vs 0.59 ± 0.04, P < .0001), compared with vehicle treatment.Conclusion: Pioglitazone prevents graft degeneration under arterial pressure stress and preserves the vein graft integrity in a rat aortic interposition model.

Cryoprobe biopsy increases the diagnostic yield in endobronchial tumor lesions

2010-03-12

Objective: Forceps biopsy is the standard method to obtain specimens in endoscopically visible lesions. It is common to combine forceps biopsy with cytology methods to increase the diagnostic yield. Although the flexible cryoprobe has been established for bronchoscopic interventions in malignant stenosis, the obtained biopsies, called “cryobiopsies,” have not been investigated in a large cohort of patients. The aim of this feasibility study was to prospectively evaluate the diagnostic yield and safety of cryobiopsy and forceps biopsy.Methods: During a 6-year period, 296 patients with visible endoluminal tumor lesions were included in the study at the bronchoscopy unit of a university hospital. In the first consecutively conducted 55 cases, both techniques, forceps biopsy and cryobiopsy, were applied simultaneously. Pathologic and quantitative image analyses were performed to evaluate the size and quality of the obtained specimens. We evaluated the safety and diagnostic yield to describe the feasibility of cryobiopsy.Results: Comparative analysis of the first conducted and randomly assigned 55 cases revealed a significantly higher diagnostic yield for cryobiopsy compared with forceps biopsy (89.1% vs 65.5%, P < .05). In this cohort, quantitative image analysis showed significantly larger biopsies regarding size and artifact-free tissue sections for cryobiopsy compared with forceps biopsy (P < .0001). The overall diagnostic yield of cryobiopsy was 89.5%. Mild bleeding occurred in 11 cases (3.7%), moderate bleeding occurred in 3 cases (1.0%), and severe bleeding occurred in 1 case (0.3%).Conclusion: Cryobiopsy is safe and increases the diagnostic yield in endobronchial tumor lesions. The method also is feasible under routine conditions.

Transapical mitral valved stent implantation: A survival series in swine

2010-03-12

Objective: To assess short-term survival after transcatheter mitral valve replacement using a unique mitral valved stent design and anchoring system.Methods: The new nitinol self-expandable valved stent houses a trileaflet glutaraldehyde-preserved bioprosthesis and contains atrial and ventricular fixation systems. Eight pigs underwent transesophageal echocardiogram-guided transapical mitral valved stent implantation through a lower mini-sternotomy. Intracardiac pressure gradients were estimated by transesophageal echocardiogram.Results: The mean mitral annulus size was 24.6 ± 1.4 mm, and the valved stent size was 26.0 ± 2.6 mm. The average mean transvalvular gradient across the valved stent immediately after deployment, at 6 hours, and after 1 week remained low. The gradient across the neighboring left ventricular outflow tract was not affected. Average animal survival was 7.3 days (8 hours to 29 days). Animals that died before 1 week (n = 4) were found at necropsy to have valved stent malpositioning. Animals that survived 1 week or more had accurate deployment and only trace post-deployment paravalvular leak. The causes of death in this latter group were endocarditis (n = 1), failure of atrial fixation (n = 2), and failure of ventricular fixation (n = 1). There was no valved stent embolization in any of the animals.Conclusion: Adequate function and effective anchoring of the new mitral valved stent allowed for short-term animal survival after transapical mitral valved stent implantation.

Extracorporeal membrane oxygenation in pediatric lung transplantation

2010-06-10

Objective: Effectiveness of preoperative and postoperative extracorporeal membrane oxygenation support in pediatric lung transplantation was studied.Methods: Institutional database of pediatric lung transplants from 1990 to 2008 was reviewed.Results: Three hundred forty-four patients underwent lung transplants in the study period. Thirty-three of 344 patients (9.6%) required perioperative extracorporeal membrane oxygenation support. Fifteen patients (median, age 1.3 years; range, 0.2–18 years) required 16 pretransplant extracorporeal membrane oxygenation runs. Indications were respiratory failure (8/16, 50%), severe pulmonary hypertension (5/16, 31%), and cardiopulmonary collapse (3/16, 19%). Four of these patients (27%) also required postoperative support. Six (40%) were weaned before lung transplant. Six (40%) survived to hospital discharge. Survival to discharge was higher among patients weaned before lung transplant (4/6, 66% vs 2/9, 22%). Twenty-two patients (median age, 9.4 years; range, 0.2–21 years) underwent 24 extracorporeal membrane oxygenation runs after lung transplant. Indications for postoperative support were primary graft dysfunction (18/24, 75%), pneumonia (4/24, 16%), and others (2/24, 9%). Median time between lung transplant and institution of extracorporeal membrane oxygenation was 32 hours (range, 0–1084 hours); median duration of support was 141 hours (range, 48–505 hours). Five of these patients (23%) survived to hospital discharge. Among nonsurvivors, causes of death were intractable respiratory failure (12/17, 70%) and infectious complications (4/17, 24%).Conclusions: Need for perioperative extracorporeal membrane oxygenation support is associated with significant morbidity and mortality among pediatric patients receiving lung transplants. A subset of patients who can be weaned from support preoperatively have greater likelihood of survival.

Discussion

2010-06-10

Dr Victor Morell (Pittsburgh, Pa). Dr Puri and associates presented their extensive experience with preoperative and postoperative ECMO support in their pediatric lung transplant population. I would have to admit that at Children's Hospital of Pittsburgh, we consider preoperative ECMO a contraindication for lung transplant; however, there is certainly adult literature that would support transplants for patients with ECMO support, and the results have been reasonable.

Cardiac surgery late after heart transplantation: A safe and effective treatment option

2010-04-12

Objective: Owing to the improved long-term outcome after cardiac transplantation, cardiac allograft vasculopathy or valvular disease is developing late after heart transplantation in a growing number of patients. In this study, we evaluated our results of nonretransplant cardiac surgery in these patients and compared them with those after retransplantation.Methods: Since 1983, a total of 867 heart transplantations have been performed at our institution. Among them, 44 patients underwent nonretransplant cardiac surgery, 4 of them repeatedly. The procedures included 19 coronary artery revascularizations, 20 tricuspid valve procedures, 4 other valvular procedures, 4 aortic operations, and 1 right atrial thrombectomy. Long-term results of these patients were compared with those of 20 patients after late cardiac retransplantation.Results: Indications for nonretransplant surgery included cardiac allograft vasculopathy, tricuspid regurgitation, aortic and mitral valve insufficiency, as well as acute aortic dissection type A. Mean interval between heart transplantation and reoperation was 8.4 years. Mean follow-up was 5.8 years. Early mortality was 4.5% (2/44). The early deaths were caused by intracerebral bleeding and acute rejection. Actuarial survivals at 1, 5, and 7 years were 84%, 64%, and 58%, respectively. In comparison, early mortality in the retransplant group was 20% (4/20) and survivals at the same time points were 70%, 70%, and 47%, respectively.Conclusions: According to these results, we consider nonretransplant surgical options for cardiac allograft vasculopathy and valvular disease a safe and effective therapeutic approach with low early mortality and acceptable long-term results.

Activation of A1, A2A, or A3 adenosine receptors attenuates lung ischemia-reperfusion injury

2010-04-16

Objective: Adenosine and the activation of specific adenosine receptors are implicated in the attenuation of inflammation and organ ischemia-reperfusion injury. We hypothesized that activation of A1, A2A, or A3 adenosine receptors would provide protection against lung ischemia-reperfusion injury.Methods: With the use of an isolated, ventilated, blood-perfused rabbit lung model, lungs underwent 18 hours of cold ischemia followed by 2 hours of reperfusion. Lungs were administered vehicle, adenosine, or selective A1, A2A, or A3 receptor agonists (CCPA, ATL-313, or IB-MECA, respectively) alone or with their respective antagonists (DPCPX, ZM241385, or MRS1191) during reperfusion.Results: Compared with the vehicle-treated control group, treatment with A1, A2A, or A3 agonists significantly improved function (increased lung compliance and oxygenation and decreased pulmonary artery pressure), decreased neutrophil infiltration by myeloperoxidase activity, decreased edema, and reduced tumor necrosis factor-α production. Adenosine treatment was also protective, but not to the level of the agonists. When each agonist was paired with its respective antagonist, all protective effects were blocked. The A2A agonist reduced pulmonary artery pressure and myeloperoxidase activity and increased oxygenation to a greater degree than the A1 or A3 agonists.Conclusion: Selective activation of A1, A2A, or A3 adenosine receptors provides significant protection against lung ischemia-reperfusion injury. The decreased elaboration of the potent proinflammatory cytokine tumor necrosis factor-α and decreased neutrophil sequestration likely contribute to the overall improvement in pulmonary function. These results provide evidence for the therapeutic potential of specific adenosine receptor agonists in lung transplant recipients.

Effects on pre- and posttransplant pulmonary hemodynamics in patients with continuous-flow left ventricular assist devices

2010-05-03

Objective: Pulsatile left ventricular assist devices have been shown to effectively reduce pulmonary hypertension in patients with end-stage heart failure. However, it remains to be seen whether newer continuous-flow left ventricular assist devices have a similar effect on pulmonary hypertension. The objective of this study was to determine whether the HeartMate II (Thoratec Corp, Pleasanton, Calif), a continuous-flow left ventricular assist device, is effective in improving pulmonary hemodynamics in the period after left ventricular assist device support and posttransplant.Methods: Fifty patients with end-stage heart failure underwent HeartMate II left ventricular assist device placement as a bridge to transplant. We evaluated their pulmonary hemodynamics with right-sided heart catheterization at baseline, after left ventricular assist device placement, and after heart transplant.Results: The mean age of patients was 53.7 ± 13.5 years. Ischemic etiology was present in 60% of the patients. After left ventricular assist device placement (mean duration, 135 ± 60 days), mean systolic and diastolic pulmonary artery pressures decreased significantly from a baseline of 55.2 ± 13.4 mm Hg and 27.3 ± 6.8 mm Hg, respectively, to 35.9 ± 10.8 mm Hg and 15.8 ± 6.5 mm Hg, respectively (P < .001). Similarly, mean pulmonary vascular resistance decreased significantly from a baseline of 3.6 ± 1.9 Woods units to 2.1 ± 0.8 Woods units (P < .001). Posttransplant pulmonary hemodynamics also remained within normal limits, even in patients with previously severe pulmonary hypertension.Conclusion: Continuous-flow left ventricular assist devices effectively improve pulmonary hemodynamics associated with end-stage heart failure. Moreover, pulmonary hemodynamics remain within normal limits in the posttransplant period, even in patients with severe pulmonary hypertension. Therefore, adequate left ventricular decompression achieved with newer left ventricular assist devices can reverse significant pulmonary hypertension in patients with end-stage heart failure, making them eligible for cardiac transplantation.

Acute kidney injury and regional abdominal perfusion during neonatal aortic arch reconstruction

2010-05-06

Objective: Our objective was to determine whether regional visceral perfusion during neonatal aortic arch reconstruction attenuates postoperative acute kidney injury.Methods: A technique to provide simultaneous perfusion to the brain and viscera during aortic arch reconstruction in neonates was developed and applied (multisite perfusion). The effect of the technique on postoperative renal function was assessed by comparing the incidence of acute kidney injury in neonates undergoing multisite perfusion to a control group of neonates who underwent aortic arch reconstruction with regional cerebral perfusion alone.Results: Thirteen neonates underwent multisite perfusion during procedures involving reconstruction of the aortic arch. Twenty-four neonates who underwent similar procedures with regional cerebral perfusion alone were selected as controls. The incidence of acute kidney injury in those undergoing multisite perfusion was 8% (n = 1), compared with 50% (n = 12) in the control group (P = .01). The median percentage change in estimated creatinine clearance was 0 (−33 to +60) in the multisite perfusion group, compared with −29 (−50 to +14) in the control group (P < .01). Patients in the multisite perfusion group were less frequently exposed to preoperative nephrotoxins and intraoperative aprotinin and had a higher prevalence of preoperative comorbidity, a shorter duration of regional cerebral perfusion, and a longer length of stay in the intensive care unit.Conclusions: Acute kidney injury is common after reconstruction of the aortic arch in neonates. By providing direct visceral perfusion during surgery, this simple multisite perfusion technique may ameliorate acute kidney injury in these neonates. Further investigation of this technique is warranted.

CLOVES syndrome with thoracic and central phlebectasia: Increased risk of pulmonary embolism

2010-05-31

Objective: CLOVES syndrome (congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal/scoliosis and spinal abnormalities) is a rare, complex overgrowth syndrome with serious morbidity. In this communication we studied the presence of central and thoracic phlebectasia in patients with CLOVES syndrome and its clinical implications.Methods: We conducted a comprehensive search of our databases at Children's Hospital Boston over the last 10 years (1999–2008) for patients with CLOVES syndrome and central and thoracic phlebectasia. Medical records, clinical photographs, and imaging studies of varying modalities were reviewed.Results: Review of the clinical data and imaging studies of 12 patients with CLOVES syndrome documented the presence of central and thoracic phlebectasia in 11 patients. Two patients had serious perioperative pulmonary embolism, and 1 died.Conclusions: Central and thoracic phlebectasia in patients with CLOVES syndrome is common and increases the risk of pulmonary embolism. Aggressive prophylactic measures should be considered before major interventions.

Acute kidney injury after coronary artery bypass grafting: Does rhabdomyolysis play a role?

2010-04-23

Objective: In clinical situations in which rhabdomyolysis is common, renal dysfunction association with myoglobinemia is well described. After coronary artery bypass grafting, a rapid increase in serum myoglobin concentration is generally seen, but whether it might independently increase the risk of acute kidney injury remains to be determined.Methods: The study population consisted of 731 consecutive patients undergoing coronary artery bypass grafting. Creatine kinase, myoglobin, and creatinine concentrations were assessed in each patient preoperatively and postoperatively. Acute kidney injury was defined as an absolute increase in serum creatinine concentration of 0.3 mg/dL or greater.Results: Overall, 295 (40.3%) of 731 patients had acute kidney injury. Patients' risk profiles were significantly worse in those with acute kidney injury, and 31 (4.2%) of 731 patients required dialysis. Acute kidney injury was associated with a higher increase in serum myoglobin concentration after 1 hour from aortic declamping (534 μg/mL [interquantile range, 354–733 μg/mL] vs 377 μg/mL [interquantile range, 278–528 μg/mL], P < .0001), which persisted at 24 and at 48 hours. After adjusting for confounding factors, myoglobin concentration was found to independently predict postoperative acute kidney injury (odds ratio, 1.0011 [1 μg/mL increase]; 95% confidence interval, 1.0003–1.0019; P = .005), and this result persisted when patients with perioperative myocardial infarction were excluded from the analysis (odds ratio, 1.0007; 95% confidence interval, 1.0002–1.0009; P = .01). Myoglobin concentration had a better accuracy to discriminate patients having acute kidney injury than creatine kinase concentration at any time.Conclusions: An increase in laboratory findings of muscle injury postoperatively, especially serum myoglobin concentration, predicts the incidence of acute kidney injury and renal replacement therapy requirement, as reported in other surgical settings. Perioperative myocardial injury cannot totally explain the occurrence of increased myoglobinemia. These results suggest an important role of skeletal muscle breakdown and necrosis in determining an increased myoglobinemia concentration after coronary artery bypass grafting.

Cefazolin bolus and continuous administration for elective cardiac surgery: Improved pharmacokinetic and pharmacodynamic parameters

2010-06-07

Objective: Cefazolin (1–2 g bolus at induction possibly repeated after cardiopulmonary bypass) remains the standard for antibiotic prophylaxis in cardiac surgery. Data indicate, however, that it is underdosed with this dosing schedule. A prospective, randomized study comparing intermittent versus loading dose plus continuous infusion for the same total dose of cefazolin was performed to assess which modality is pharmacokinetically and pharmacodynamically advantageous.Methods: Patients received 2 g cefazolin as a starting dose and then were divided into an intermittent group (receiving another 1 g at 3, 9, and 15 hours after the first dose) and a continuous group (continuous infusion started after the first dose, providing 1 g every 6 hours for 18 hours). Cefazolin levels were measured in blood and atria.Results: Mean total and calculated free trough concentrations in blood varied greatly among patients in the intermittent group and were lower than those in the continuous group (P 90%) was achieved, whereas the goal was met for only 3 of 10 (30%) in the intermittent group (P < .05). The mean atrial tissue concentration was also higher with continuous infusion (P < .05).Conclusions: Administration of cefazolin as bolus plus continuous infusion has pharmacokinetic and pharmacodynamic advantages relative to intermittent administration. It provides more stable serum levels, lower interpatient variability, and higher myocardial tissue penetration.

Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function

Teodorico Iarussi, Alessandro Pardolesi, Pierpaolo Camplese, Rocco Sacco — 2009-09-10

Although multiple techniques have been used to correct chest wall defect, the impact of these on chest wall function (chest wall mechanism/pulmonary function) is poorly studied. In our experience, composite chest wall reconstruction using titanium plates and mesh correct both the cosmetic and physiologic abnormalities.

Transcatheter valve replacement: Resection and valved stent implantation in a beating heart

René Hubert Bombien, Lucian Lozonschi, Jochen Cremer, Georg Lutter — 2010-03-26

During the past 10 years, different models for the transcatheter removal of heart valves have been evaluated. The experiments were performed in different in vitro or in vivo models. This report describes a model for complete heart valve replacement with resection before valved stent implantation in a beating heart.

One-stage repair for interrupted aortic arch and associated cardiac anomalies in an adult

Zhang Jinzhou, Wang Wen, Zhu Hailong, Wang Hongbing — 2010-03-26

For infants with interrupted aortic arch (IAA) and associated cardiac malformation, 1-stage repair is preferred, and excellent results have been reported. However, similar experiences in adult patients are limited because of the rarity of the condition. We report a woman with IAA and associated cardiac malformations who was treated surgically by 1-stage repair.

A new concept for correction of systolic anterior motion and mitral valve regurgitation in patients with hypertrophic obstructive cardiomyopathy

Joerg Seeburger, Jurgen Passage, Michael A. Borger, Friedrich Wilhelm Mohr — 2010-03-26

In patients with hypertrophic obstructive cardiomyopathy (HOCM), systolic anterior motion (SAM) of the anterior mitral leaflet (AML) can occur as a result of acceleration of flow in the left ventricular outflow tract. In addition, relative shortening of the chordae tendineae may reduce AML mobility and contribute to the generation of mitral regurgitation (MR). We present a new concept for correction of SAM and MR in patients with HOCM and restricted AML movement.

Surgical repair of aortopulmonary window associated with interrupted aortic arch: Long-term outcomes

Igor E. Konstantinov, Norihiko Oka, Yves d'Udekem, Christian P. Brizard — 2010-04-05

Association of aortopulmonary window (APW) with interrupted aortic arch (IAA) is very rare. Only 3.5% to 4.2% of patients with IAA have APW. Thus the cumulative experience with this combination of lesions is limited to isolated case reports. The largest multi-institutional study of 20 patients operated on from 1987 to 1997 demonstrated survival of 91%, 86%, and 84% at 1, 5, and 10 years, respectively. Furthermore, competing risk analysis estimated that at 5 years after repair, 51% had arch reintervention, 6% had pulmonary artery reintervention, and only 43% were alive without reintervention. Herein we report the long-term outcomes of 5 patients from a single institution and describe our aortic mobilization and advancement technique, which resulted in a low reintervention rate in this rare subgroup of patients.

Surgical excision of right ventricular carcinoid tumor in a symptomatic patient without carcinoid valve disease

Basar Sareyyupoglu, Heidi M. Connolly, Hartzell V. Schaff — 2010-04-05

This report describes the unusual presentation of a 55-year-old man with normal cardiac valves who had metastatic carcinoid tumor in the heart. The patient underwent coronary artery bypass grafting at another hospital in 1982. In 2004 he had partial colectomy for tumor removal, and pathologic examination disclosed carcinoid cell type. Hepatic metastases were treated with arterial embolization. At the time of evaluation at the Mayo Clinic, he did not report diarrhea but had noticed increasing frequency of facial flushing; he had started taking somatostatin 4 months earlier. A computed tomography scan in March of 2008 demonstrated a tumor in the mediastinum, and this was a new finding compared with a similar study in September 2005. The 4- to 5-cm mass compressed the right ventricle (, A, B). In addition to worsening flushing, he had symptoms of presyncope, shortness of breath, and limited exercise capacity. His echocardiogram showed no evidence of valvular disease, and his left ventricular function was normal.

Use of a hybrid operating room to diagnose and treat delayed coronary spasm after mitral valve repair

Jared L. Antevil, Alexandros N. Karavas, John H. Selby, John G. Byrne — 2009-09-27

We describe a case of delayed circulatory collapse after mitral valve repair caused by diffuse coronary artery vasospasm. The cause and management of this condition are discussed.

Anomalous left coronary artery origin from the opposite sinus of Valsalva: Evidence of intermittent ischemia

Julie Brothers, Chris Carter, Michael McBride, Thomas Spray, Stephen Paridon — 2009-08-31

Although a rare anomaly, anomalous aortic origin of a coronary artery that courses between the great vessels (AAOCA) is the second leading cardiovascular cause of death in young athletes. Common presenting symptoms include chest pain, dizziness, and syncope during or just after exertion; however, patients may also have no symptoms, which makes the diagnosis challenging. After diagnosis, most patients undergo provocative ischemia testing with an exercise stress test. We present the case of a 13-year-old boy with anomalous left coronary artery arising from the opposite sinus of Valsalva (ALCA), with evidence of ischemia on stress electrocardiography (ECG) on one occasion and a normal stress ECG several days later.

Primary thoracic cavity gastrointestinal stromal tumor

2010-04-12

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that mostly arise in the gastrointestinal tract. Other locations such as the omentum, the mesentery, and the retroperitoneum have also been reported. Here we report a rare case of primary thoracic cavity GIST. Although this rare tumor may be difficult to distinguish clinically from more common mass lesions of the thoracic cavity, a correct diagnosis is necessary because treatment is specific for GIST.

Feasibility of transapical aortic valve implantation guided by intracardiac ultrasound without angiography

Enrico Ferrari, Carlo Marcucci, Stefano Di Bernardo, Ludwig Karl von Segesser — 2010-03-18

Transcatheter aortic valve implantation (TAVI) is indicated for high-risk patients requiring aortic valve replacement. Valve positioning and postoperative control traditionally are based on intraoperative transesophageal echocardiogram (TEE) and aortography. We report, for the first time in humans, a transapical TAVI performed using an intracardiac echocardiogram (ICE) without angiography.

Advantages of the segmental nondivided intercostal muscle flap

Federico Venuta, Marco Anile, Erino A. Rendina — 2010-08-01

To the Editor: The intercostal muscle has been increasingly used to protect and revascularize bronchial stumps and anastomoses after pneumonectomy, sleeve pneumonectomy, lung transplantation, and bronchial sleeve resection. The muscle can be mobilized with a generous flap of parietal pleura to increase coverage. This flap allows protection of the stump or anastomosis, early revascularization of the bronchus, and prevention of bronchopleural fistula in case of dehiscence. The flap can be easily prepared during thoracotomy, before spreading the ribs, and left posteriorly in the costovertebral groove protected with a wet gauze during the lung procedure. If not used, the flap can be placed again between the ribs while closing the thoracotomy. However, sometimes the need for this flap cannot be anticipated preoperatively (thus, if required, it has not been prepared). Alternatively, a flap prepared while opening the chest, as decided at preoperative workup, would not be required because of intraoperative strategy changes (eg, a simple lobectomy instead of a sleeve resection or pneumonectomy, or an exploratory thoracotomy because of unexpected metastatic disease or locally advanced disease). In these situations, the surgeon would add operative time in preparing the unnecessary flap or have a useless intercostal muscle deeply crushed by the retractor at the thoracotomy site. The latter situation requires mobilization of other flaps.

To pump, or not to pump, that is the question

Hisato Takagi, Takuya Umemoto — 2010-08-01

To the Editor: We read with great interest the article by Kuss and associates, who aimed to systematically review all propensity score analyses comparing off- and on-pump coronary artery bypass grafting (CABG). Their meta-analysis of 28 studies (100,066 patients) found off-pump CABG superior to on-pump CABG in short-term mortality, the most valid criterion (odds ratio 0.69; 95% confidence interval [CI], 0.60–0.75; P < .0001). Meanwhile, Møller and collaborators' meta-analysis of 57 randomized trials (5202 patients) showed no significant difference in mortality (relative risk [RR] 0.98; 95% CI, 0.66–1.44). In the future, the largest ongoing randomized trial (CORONARY trial, 4700 patients planned, ClinicalTrials.gov Identifier: NCT00463294) will contribute to the definite answer, as stated by Kuss and colleagues. Shroyer and coworkers recently reported the results of another large randomized trial (ROOBY trial, 2203 patients enrolled, not included in Møller and associates' meta-analysis). There was no significant difference between off-pump and on-pump CABG in the rate of death from any cause before discharge or within 30 days after the procedure (1.6% vs 1.2%; RR 1.38; 95% CI, 0.68–2.80; P = .47). Furthermore, even though this result of the ROOBY trial is added to Møller and collaborators' meta-analysis, there is no significant difference in short-term mortality (RR 1.06; 95% CI, 0.67–1.67; P = .80; calculated by us). The evidence from randomized trials obviously demonstrated equivalent short-term mortality between off-pump and on-pump CABG, which is contradictory compared with Kuss and colleagues' results from nonrandomized studies.

Reply to the Editor

Oliver Kuss, Jochen Börgermann — 2010-08-01

We thank Takagi and Umemoto for their interest in our recent systematic review of propensity score (PS) analyses in off-pump versus on-pump coronary artery bypass grafting. As Takagi and Umemoto correctly point out, our estimate for the effect of off-pump coronary artery bypass grafting on short-term mortality (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.60–0.75) differs from the corresponding estimate from randomized controlled trials (RCTs). In their large meta-analysis, Møller and colleagues found a relative risk of 0.98 (95% CI, 0.66–1.44). Takagi and Umemoto calculated a relative risk of 1.06 (95% CI, 0.67–1.67) by adding the results of the ROOBY trial to Møller and colleagues' results.

Theoretical cost benefits of cryobiopsy

Andrew R.L. Medford — 2010-08-01

To the Editor: I commend the study by Schumann and colleagues that demonstrated the clear superiority of cryobiopsy over standard forceps biopsy for endoluminal tumor, showing a 36% relative increase and 24% absolute increase in yield as the result of larger and less fragmented samples. Unfortunately, the acquisition of new equipment and technology is hampered by resource rationing in health care systems. Because tariff-base health care systems require demonstration of cost benefit, this article provides useful evidence with which to develop cryobiopsy in bronchoscopy units. At Glenfield Hospital, Leicester, which includes an annual number of 531 fiberoptic bronchoscopies annually, we have audited our own diagnostic yield with forceps biopsy for endoluminal tumor and found this to be only 77% overall for 132 cases over 1 year with evidence of tumor (with some variation between trainees and consultants).

Reply to the Editor

Christian Schumann, Jürgen Hetzel, Philipp M. Lepper, Martin Hetzel — 2010-08-01

We thank Dr Medford for the valuable additional analysis concerning the cost benefits of cryobiopsy based on our recently published article in the Journal. We assume that routine use of a flexible cryoprobe to obtain tissue samples is cost-effective. However, it has to be considered that cryobiopsies generally require protected airways (ie, intubation). In addition, deep sedation using midazolam or disoprivan, if not general anesthesia, is required. In most countries, this makes additional personnel or an additional physician (eventually an anesthetist) necessary, which in turn leads to an increase in costs. Further, different health care systems may have different tariffs for bronchoscopic procedures, and this might cause a variation in final cost-effectiveness between different countries. Studies investigating the cost-effectiveness are under way. Most likely, cryobiopsy is a method that will result in cost savings over time. In this sense, we absolutely agree with Dr Medford.

Benefit of using total arch replacement combined with stented elephant trunk implantation during arch reconstruction

Bingyang Ji, Cun Long, Junming Zhu, Yongmin Liu, Lizhong Sun — 2010-08-01

To the Editor: We read with great interest the recent article by Xydas and colleagues. In this study, they introduced a novel technique using left carotid–subclavian bypass (CSB) before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction. Compared with the conventional method, the major advantage of this technique is using prepared CSB to anastomose the left carotid artery to the graft before cardiopulmonary bypass (CPB). Only 2 anastomoses (anastomoses of the distal graft to the aorta and the graft to the innominate artery) must be done during hypothermic circulatory arrest (HCA), decreasing selective antegrade cerebral perfusion (SACP), CPB and aortic crossclamp times, and limiting HCA.

Reply to the Editor

Steve Xydas, Allan Stewart — 2010-08-01

We read with appreciation the letter by Ji and associates from the Beijing Anzhen Hospital concerning our article, “Use of Carotid–Subclavian Bypass and Thoracic Endovascular Aortic Repair to Minimize Cerebral Ischemia.” We described the use of left carotid–subclavian bypass (CSB) combined with staged thoracic stent grafting to achieve total aortic arch replacement (TAAR) with decreased selective antegrade cerebral perfusion (SACP), cardiopulmonary bypass (CPB), and aortic crossclamp times.

Meetings and Courses

2010-08-01

The 5th International Meeting of the Onassis Cardiac Surgery Center: Current Trends in Cardiac Surgery and Cardiology will be held September 16-18, 2010 (NOTE DATE CHANGE) at the Eugenides Foundation Congress Center, Athens, Greece. For information, contact: Liana Iliopoulou, Triaena Tours & Congress, 206 Sygrou Avenue, 176 72 Athens (Kallithea) (telephone: +30 210 7499353; Fax: +30 210 7705752; E-mail: lianae@triaenatours.gr). Additional information: http://www.ocsc2010.gr/

The 91st AATS Annual Meeting

2010-08-01

May 7–11, 2011 Pennsylvania Convention Center

AATS Applications for Membership Now Available Online

2010-08-01

Applications for membership in the Association are now available online at www.aats.org. Interested applicants are encouraged to review the membership requirements and guidelines on the AATS Web site.

AATS Meetings and Sponsored Events www.aats.org

2010-08-01

September 21–25, 2010 TCT for Surgeons∗

2010 Heart Valve Summit: Medical, Surgical, and Interventional Decision Making

2010-08-01

October 7–9, 2010 Chicago Marriott Downtown Magnificent Mile

Applications for Membership

2010-08-01

Applications for membership in the Association must be received by the Membership Committee Chair no later than March 1, 2011, to be considered at the 2011 Annual Meeting. Applicants must be sponsored by three members of the Association who are not members of the Membership Committee. Application forms will be issued only to sponsoring members.

WTSA 37th Annual Meeting

2010-08-01

Save the Date! June 22–25, 2011

Notices

2010-08-01

The part I (written) examination was held on December 3. It is planned that this examination will be given at multiple sites throughout the United States using an electronic format. The closing date for registration is August 1 each year. Those wishing to be considered for examination must apply online at www.abts.org.

Requirements for Maintenance of Certification

2010-08-01

Diplomates of the American Board of Thoracic Surgery (ABTS) who plan to participate in the Maintenance of Certification (MOC) process must hold an unrestricted medical license in the locale of their practice and privileges in a hospital accredited by the JCAHO (or other organization recognized by the ABTS). In addition, a valid ABTS certificate is an absolute requirement for entrance into the Maintenance of Certification process. If your certificate has expired, the only pathway for renewal of a certificate is to take and pass the Part I (written) and the Part II (oral) certifying examinations. The names of individuals who have not maintained their certificate will no longer be published in the American Board of Medical Specialties Directories. Diplomates' names will be published upon successful completion of the Maintenance of Certification process.

Condensed Contents

2010-08-01

JTCVS Disclosure Statement

2010-08-01

Information for Readers

2010-08-01

The Journal of Thoracic and Cardiovascular Surgery

Variability in data: The Society of Thoracic Surgeons National Adult Cardiac Surgery Database

Data variability and validity: The elephant in the room

Repair of regurgitant bicuspid aortic valves: A systematic approach

Discussion

Effects of surgical ventricular reconstruction on diastolic function at midterm follow-up

In vivo functional flowmetric behavior of the radial artery graft: Is the composite Y-graft configuration advantageous over conventional aorta–coronary bypass?

Angiotensin II receptor type 1 is upregulated in atrial tissue of patients with rheumatic valvular disease with atrial fibrillation

Effectiveness of combination of losartan potassium and doxycycline versus single-drug treatments in the secondary prevention of thoracic aortic aneurysm in Marfan syndrome

Clinical experience with the second-generation 3f Enable sutureless aortic valve prosthesis

Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation

Long-term follow-up after primary complete repair of common arterial trunk with homograft: A 40-year experience

Extracorporeal membrane oxygenation in postcardiotomy patients: Factors influencing outcome

Transcriptomic analysis of patients with tetralogy of Fallot reveals the effect of chronic hypoxia on myocardial gene expression

Bosentan induces clinical and hemodynamic improvement in candidates for right-sided heart bypass surgery

Prevalence of in vitro chemotherapeutic drug resistance in primary malignant pleural mesothelioma: Result in a cohort of 203 resection specimens

Which patients should be operated on after induction chemotherapy for N2 non–small cell lung cancer? Analysis of a 7-year experience in 175 patients

Effect of statins on atrial fibrillation after cardiac surgery: A duration- and dose-response meta-analysis

Pharyngostomy tubes for gastric conduit decompression

Stereotactic body radiation therapy versus surgical resection for stage I non–small cell lung cancer

Surgical technique and results of tracheal and carinal replacement with aortic allografts for salivary gland–type carcinoma

A balanced perspective for management of tracheal salivary gland-type carcinomas

A reliable rabbit model for hyperkinetic pulmonary hypertension

Excessively high systemic blood pressure in the early phase of reperfusion exacerbates early-onset paraplegia in rabbit aortic surgery

Pioglitazone preserves vein graft integrity in a rat aortic interposition model

Cryoprobe biopsy increases the diagnostic yield in endobronchial tumor lesions

Transapical mitral valved stent implantation: A survival series in swine

Extracorporeal membrane oxygenation in pediatric lung transplantation

Discussion

Cardiac surgery late after heart transplantation: A safe and effective treatment option

Activation of A1, A2A, or A3 adenosine receptors attenuates lung ischemia-reperfusion injury

Effects on pre- and posttransplant pulmonary hemodynamics in patients with continuous-flow left ventricular assist devices

Acute kidney injury and regional abdominal perfusion during neonatal aortic arch reconstruction

CLOVES syndrome with thoracic and central phlebectasia: Increased risk of pulmonary embolism

Acute kidney injury after coronary artery bypass grafting: Does rhabdomyolysis play a role?

Cefazolin bolus and continuous administration for elective cardiac surgery: Improved pharmacokinetic and pharmacodynamic parameters

Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function

Transcatheter valve replacement: Resection and valved stent implantation in a beating heart

One-stage repair for interrupted aortic arch and associated cardiac anomalies in an adult

A new concept for correction of systolic anterior motion and mitral valve regurgitation in patients with hypertrophic obstructive cardiomyopathy

Surgical repair of aortopulmonary window associated with interrupted aortic arch: Long-term outcomes

Surgical excision of right ventricular carcinoid tumor in a symptomatic patient without carcinoid valve disease

Use of a hybrid operating room to diagnose and treat delayed coronary spasm after mitral valve repair

Anomalous left coronary artery origin from the opposite sinus of Valsalva: Evidence of intermittent ischemia

Primary thoracic cavity gastrointestinal stromal tumor

Feasibility of transapical aortic valve implantation guided by intracardiac ultrasound without angiography

Advantages of the segmental nondivided intercostal muscle flap

To pump, or not to pump, that is the question

Reply to the Editor

Theoretical cost benefits of cryobiopsy

Reply to the Editor

Benefit of using total arch replacement combined with stented elephant trunk implantation during arch reconstruction

Reply to the Editor

Meetings and Courses

The 91st AATS Annual Meeting

AATS Applications for Membership Now Available Online

AATS Meetings and Sponsored Events www.aats.org

2010 Heart Valve Summit: Medical, Surgical, and Interventional Decision Making

Applications for Membership

WTSA 37th Annual Meeting

Notices

Requirements for Maintenance of Certification

Condensed Contents

Table of Contents

JTCVS Disclosure Statement

Information for Readers