The Journal of Thoracic and Cardiovascular Surgery - Articles in Press

Predictors for hemodynamic improvement with temporary pacing after pediatric cardiac surgery - Corrected Proof

2010-07-26

Objectives: Temporary epicardial pacing wires are commonly placed during pediatric cardiac surgery. Data are sparse on postoperative pacing in this population. The objective of this study was to determine the frequency of use and identify predictors for the use of temporary epicardial pacing wires.Methods: Perioperative data were prospectively collected on all patients who underwent cardiac surgery at our institution (n = 162).Results: A total of 117 (72%) patients had temporary epicardial pacing wires placed. Postoperatively, 23 (20%) of 117 patients had hemodynamic improvement with the use of temporary epicardial pacing wires. Indications for pacing were slow junctional rhythm (11/23 [48%]), junctional ectopic tachycardia (7/23 [31%]), pace termination of supraventricular tachycardia (3/23 [13%]) and atrial flutter (1/23 [4%]), and complete heart block (1/23 [4%]). By using univariate analysis, single-ventricle anatomy, heterotaxy, the Fontan procedure, use of circulatory arrest, intraoperative arrhythmia, pacing in the operating room, and use of vasoactive medications were predictors for hemodynamic improvement with the use of temporary epicardial pacing wires (P < .05). On multivariate analysis, the Fontan procedure, circulatory arrest, and intraoperative arrhythmias were independent predictors (P < .01). When excluding all patients with any of these 3 risk factors, only 2% were paced. Patients with clinically significant pacing had longer chest tube drainage (P < .01) and intensive care unit length of stay (P < .01). There were no complications associated with temporary epicardial pacing wires.Conclusions: The Fontan procedure, use of circulatory arrest, and intraoperative arrhythmias were associated with hemodynamic improvement with postoperative pacing and might represent indications for empiric intraoperative placement of temporary epicardial pacing wires. Patients without these risk factors were less likely to require pacing. Temporary epicardial pacing wires were safe and useful in the management of arrhythmias after pediatric cardiac surgery.

Protecting the aged heart during cardiac surgery: The potential benefits of del Nido cardioplegia - Corrected Proof

Stacy B. O'Blenes, Camille Hancock Friesen, Ahmad Ali, Susan Howlett — 2010-07-26

Objective: Aged hearts are more vulnerable than mature hearts to reperfusion injury during cardiac surgery because of altered cardiomyocyte Ca2+ homeostasis. Inasmuch as immature cardiomyocytes have similar properties, a specialized cardioplegic solution (del Nido cardioplegia) designed to protect children's hearts may also be beneficial for elderly patients. Our objective was to evaluate the ability of del Nido cardioplegic solution, containing lidocaine and less Ca2+ than our standard cardioplegic solution, to protect aged cardiomyocytes during cardioplegic arrest and reperfusion.Methods: We used our novel isolated cell model of cardioplegic arrest and reperfusion to compare the effect of del Nido cardioplegic solution with that of our standard cardioplegic solution on intracellular Ca2+ concentration, contractions, and membrane potential in cardiomyocytes from senescent rat hearts.Results: The incidence of spontaneous contractions during cardioplegic arrest was lower with del Nido cardioplegia (3/11 vs 9/11 cells; P < .05) than with standard cardioplegia, and contractions could not be induced by field stimulation of cardiomyocytes arrested with del Nido cardioplegia (0/11 vs 9/11 cells; P < .05). Intracellular diastolic Ca2+ levels were lower during arrest with del Nido cardioplegia (57.10 ± 3.06 vs 76.19 ± 3.45 nmol/L; P < .05). During early reperfusion, a potentially injurious rapid recovery of intracellular Ca2+ associated with hypercontraction in cardiomyocytes arrested with standard cardioplegic solution was avoided in cells treated with del Nido cardioplegia (81.42 ± 2.99 vs 103.15 ± 4.25 nM; P < .05).Conclusions: Del Nido cardioplegic solution has the potential to provide superior myocardial protection in senescent hearts by preventing electromechanical activity during cardioplegic arrest and Ca2+-induced hypercontraction during early reperfusion.

Aortic valve repair by cusp extension for rheumatic aortic insufficiency in children: Long-term results and impact of extension material - Corrected Proof

2010-07-26

Objective: Aortic valve repair has encouraging midterm results in selected patients. However, neither the long-term results of cusp extension nor the durability of different pericardial fixation techniques has been reported. Our goal was to address these issues.Methods: Seventy-eight children with severe rheumatic aortic regurgitation (mean age 12 ± 3.5 years) underwent aortic valve repair using cusp extension over a 15-year period, with fresh autologous pericardium in 53 (67.9%), glutaraldehyde-fixed bovine pericardium in 9 (11.5%), and PhotoFix bovine pericardium (Sorin CarboMedics, Milano, Italy) in 16 (20.5%). Fifty-seven children (73.1%) underwent concomitant mitral valve repair, and 8 children (10.3%) underwent tricuspid valve repair.Results: There was 1 operative death from left ventricular failure. During a median follow-up of 10.7 years (range 1 month to 16.4 years), 1 late death occurred and 15 patients (19.7%) required reoperation at a mean of 43 ± 33.7 months (range 1 month to 9 years), 9 within the autologous pericardium group (18%), 3 within the bovine pericardium group (33%), and 3 within the PhotoFix pericardium group (19%). Freedom from reoperation was 96% ± 2.3% at 1 year, 87.5% ± 3.9% at 5 years, 80.7% ± 4.9% at 10 years, and 75.3% ± 6% at 15 years, and was significantly decreased in the bovine pericardium group (P = .039). On multivariable analysis, greater age (hazard ratio 1.25, P < .001) and acute rheumatic carditis (hazard ratio 8.15, P = .001) at operation were significant predictors of reoperation.Conclusions: Aortic cusp extension provides adequate valve repair in a large proportion of children with rheumatic aortic regurgitation. Fresh autologous and PhotoFix pericardium trended toward better durability than glutaraldehyde-fixed bovine pericardium.

Norwood procedure using modified Blalock–Taussig shunt: Beware of the circle of Willis - Corrected Proof

Selma O. Algra, Floris Groenendaal, Ton Schouten, Felix Haas — 2010-07-26

Neonates undergoing complex cardiac surgery are at high risk of developing cerebral damage. In the past decades, surgical and cardiopulmonary bypass strategies have been modified to improve neurodevelopmental outcome. One example is the introduction of antegrade cerebral perfusion (ACP) during aortic arch repair, instead of deep hypothermic circulatory arrest. Although it is not yet known whether this indeed is a superior strategy, ACP is now widely used in congenital heart surgery. This case report shows that when ACP is performed, cerebral near-infrared spectroscopy (NIRS) can provide important information about the circle of Willis, which may influence the surgical strategy.

Tissue-derived proinflammatory effect of adenosine A2B receptor in lung ischemia–reperfusion injury - Corrected Proof

2010-07-26

Objective: Ischemia–reperfusion injury after lung transplantation remains a major source of morbidity and mortality. Adenosine receptors have been implicated in both pro- and anti-inflammatory roles in ischemia–reperfusion injury. This study tests the hypothesis that the adenosine A2B receptor exacerbates the proinflammatory response to lung ischemia–reperfusion injury.Methods: An in vivo left lung hilar clamp model of ischemia–reperfusion was used in wild-type C57BL6 and adenosine A2B receptor knockout mice, and in chimeras created by bone marrow transplantation between wild-type and adenosine A2B receptor knockout mice. Mice underwent sham surgery or lung ischemia–reperfusion (1 hour ischemia and 2 hours reperfusion). At the end of reperfusion, lung function was assessed using an isolated buffer-perfused lung system. Lung inflammation was assessed by measuring proinflammatory cytokine levels in bronchoalveolar lavage fluid, and neutrophil infiltration was assessed via myeloperoxidase levels in lung tissue.Results: Compared with wild-type mice, lungs of adenosine A2B receptor knockout mice were significantly protected after ischemia–reperfusion, as evidenced by significantly reduced pulmonary artery pressure, increased lung compliance, decreased myeloperoxidase, and reduced proinflammatory cytokine levels (tumor necrosis factor-α; interleukin-6; keratinocyte chemoattractant; regulated on activation, normal T-cell expressed and secreted; and monocyte chemotactic protein-1). Adenosine A2B receptor knockout→adenosine A2B receptor knockout (donor→recipient) and wild-type→ adenosine A2B receptor knockout, but not adenosine A2B receptor knockout→wild-type, chimeras showed significantly improved lung function after ischemia–reperfusion.Conclusion: These results suggest that the adenosine A2B receptor plays an important role in mediating lung inflammation after ischemia–reperfusion by stimulating cytokine production and neutrophil chemotaxis. The proinflammatory effects of adenosine A2B receptor seem to be derived by adenosine A2B receptor activation primarily on resident pulmonary cells and not bone marrow-derived cells. Adenosine A2B receptor may provide a therapeutic target for prevention of ischemia–reperfusion-related graft dysfunction in lung transplant recipients.

Discussion - Corrected Proof

2010-07-26

Dr B. Stiles (New York, NY). Farshad, that was nicely presented. It is a good continuation of the work your group has done. I am a bit curious why you didn't use a sham experiment on the knockout mice. Or did you do that?

Discussion - Corrected Proof

2010-07-26

Dr Emile Bacha (New York, NY). Although retrospective, this is an important article for the following reasons: It comes from a center with a large experience with AV repair, thus having digested the learning curve. It reports on a homogeneous group of patients, all of whom had rheumatic fever. It focuses on patch material, something that hasn't been done really in the past series.

Dynamic effects of the Nuss procedure on the spine in asymmetric pectus excavatum - Corrected Proof

2010-07-22

Objective: This study aimed to elucidate dynamic effects of the Nuss procedure on the spine in the treatment of patients with pectus excavatum with asymmetric thoraces.Methods: Twenty-five patients with pectus excavatum who underwent the Nuss procedure were categorized into 4 groups by preoperative morphology of the spine and thoracic asymmetry. In group 1 (n = 8), the right side of the thorax was concave and the spine bowed to the right. In group 2 (n = 4), the right side of the thorax was concave and the spine bowed to the left. In group 3 (n = 5), the left side of the thorax was concave and the spine bowed to the right. In group 4 (n = 8), the left side of the thorax was concave and the spine bowed to the left. With computed tomographic data, finite-element models were produced to simulate each patient's thorax. Thereafter, dynamic response patterns of the spine to the Nuss procedure were examined. Validity of these biomechanical findings was verified by referring to clinical outcomes.Results: In group 1 and group 4 models, deformed spines were straightened; in group 2 and group 3 models, spinal bowing increased. These biomechanical findings were compatible with clinical evaluations.Conclusions: Performance of the Nuss procedure for asymmetric pectus excavatum exerts dynamic influence on the spine. Response patterns of the spine are predictable from morphologic relationships between the asymmetric patterns of the anterior thoracic wall and the spine.

Simple preoperative management for cold agglutinins before cardiac surgery - Corrected Proof

Shinji Kanemitsu, Koji Onoda, Kiyohito Yamamoto, Hideto Shimpo — 2010-07-22

Cold agglutinins (CAs) are of particular relevance in cardiac surgery because of the use of hypothermic cardiopulmonary bypass. CAs activate at varying levels of hypothermia and can cause catastrophic hemagglutination, microvascular thrombosis, or hemolysis. The detection of CAs before operation may change the management of cardiopulmonary bypass and myocardial protection. We describe here a case of aortic valve replacement in which CAs with high titer and high thermal amplitude were detected preoperatively.

Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta - Corrected Proof

2010-07-22

Objective: This study evaluated long-term results of thoracic endovascular aortic repair for atherosclerotic aneurysms involving descending aorta.Methods: One hundred thirteen patients underwent thoracic endovascular aortic repair for this indication from 1996 to 2009. Mean follow-up was 54 ± 38 months (5–144 months). In-hospital mortality, neurologic injury, need for rerouting, occurrence of endoleaks and their treatment, and survival were recorded.Results: In-hospital mortality was 5.3%. Transient neurologic injury rate was 2.6%. Previous rerouting was performed in 51%. Assisted early and late type I and III endoleak rates were 7.9% and 5.7%, respectively. Five percent of patients required late surgical conversion. Actuarial survivals were 86%, 60%, and 42% at 1, 5, and 10 years, respectively. Aorta-related actuarial survivals were 94%, 90%, and 83% at 1, 5, and 10 years, respectively. Cox regression analysis revealed higher number of prostheses as independent risk factor for early (hazard ratio, 5.38; 95% confidence interval, 1.68–42.37) and late (hazard ratio, 8.49; 95% confidence interval, 1.09–66.06) endoleak formation. Female sex (hazard ratio, 0.35; 95% confidence interval, 0.13–0.99), no arch involvement (hazard ratio, 0.21; 95% confidence interval, 0.05–0.08), and higher number of prostheses (hazard ratio, 7.95; 95% confidence interval, 1.36–46.58) affected survival.Conclusions: Aorta-related survival is excellent among patients undergoing thoracic endovascular aortic repair for atherosclerotic aneurysms involving the descending aorta. Life-long surveillance remains mandatory, with early and late failure uncommon but still needing consideration. Thoracic endovascular aortic repair in this group of patients remains attractive and has now proven durability.

Late complete atrioventricular block and tricuspid regurgitation after percutaneous closure of a perimembranous ventricular septal defect - Corrected Proof

Huiwen Chen, Jinfen Liu, Wei Gao, Haifa Hong — 2010-07-20

Percutaneous closure of a perimembranous ventricular septal defect (VSD) is nowadays a valuable alternative to surgical closure. Preliminary results regarding the safety of this device and the low incidence of aortic and tricuspid regurgitation are encouraging. However, owing to the close proximity of the perimembranous VSD to the conduction system, concern about atrioventricular block has been raised. The published reports on this complication describe the latest onset of complete atrioventricular block (CAVB), presenting at 37.8 months after implantation. We report here 1 case of delayed CAVB with severe tricuspid regurgitation occurring 5 years after implantation of an eccentric Amplatzer perimembranous VSD occluder (APmVSDO; AGA Medical, Golden Valley, Minn).

Rehabilitation of pulmonary artery in congenital unilateral absence of intrapericardial pulmonary artery - Corrected Proof

2010-07-20

Objective: We evaluated the efficacy of the early rehabilitation of remnant pulmonary artery in unilateral absent intrapericardial pulmonary artery and the factors affecting pulmonary artery growth.Methods: We retrospectively reviewed the medical records and imaging modalities of 15 patients with unilateral absent intrapericardial pulmonary artery (7 left and 8 right; median age at diagnosis, 5 months) from 1991 to 2008.Results: The remnant pulmonary artery was found in 12 patients (mean diameter, 2.6 ± 0.7 mm) at the hilum. Eleven patients underwent operation (main pulmonary artery flap angioplasty in 5 patients; tube graft interposition in 6 patients), and 4 patients were inoperable. Transcatheter balloon angioplasty or stent implantation was required for the remaining pulmonary artery stenosis in 6 patients (55%). The last ipsilateral lung perfusion proportion at lung perfusion scan was 39% (range, 15%–51%), and the Z value of the last ipsilateral pulmonary artery diameter was −0.5 (range, 4.2 to 2). The patients with a smaller initial remnant pulmonary artery required more interventions (P = .003). The final perfusion proportion of affected lung was higher in the patients treated early (≤6 months, n = 7) than in those treated late (>6 months, n = 4) (41.9% ± 8.5% vs 24.9% ± 10.7%, respectively, P = .024). The patients with graft interposition showed a lower perfusion proportion of affected lung than those with main pulmonary artery flap angioplasty (P = .017).Conclusion: In patients with unilateral absent intrapericardial pulmonary artery, early and aggressive management of combined surgical reconstruction and transcatheter intervention improved pulmonary artery growth and lung perfusion.

A rare case of vascular ring: Retroesophageal artery between the right brachiocephalic artery and the left descending aorta - Corrected Proof

Yoshio Ootaki, Mohamed Sulaiman, Ross M. Ungerleider — 2010-07-20

A vascular ring is a congenital aortic arch anomaly that presents with tracheal and esophageal compression by vascular structures. Vascular rings have been classified according to embryologic, pathologic, and radiographic criteria. We describe a very rare vascular ring due to an abnormal retroesophageal artery in an infant.

Disseminated primary coccidioidomycosis of the chest wall - Corrected Proof

Kimberly Evans, Royce F. Calhoun, Hugh Black, David T. Cooke — 2010-07-20

Pulmonary coccidioidomycosis, or valley fever, is a diagnosis with increasing incidence in the western United States. Although coccidioidomycosis is an infectious disease classically described to be endemic to the southwestern United States, the first cases were indentified in central California. One defined population that has been especially subject to this disease is residents of the greater Sacramento counties in California, with 0.1 to 5.0 cases per 100,000 population from 2001 to 2008. Coccidioidomycosis spreads through inhalation of aerosolized mold or arthroconidia. Although pulmonary (acute pneumonia, chronic progressive pneumonia, and pulmonary nodules) and certain extrapulmonary (nonmeningeal and meningitis) manifestations of coccidioidomycosis infection are well described, treatment of disseminated coccidioidomycosis presenting as chest wall disease is not.

Video-assisted thoracoscopic bullectomy and talc poudrage for spontaneous pneumothoraces: Effect on short-term lung function - Corrected Proof

Luc Dubois, Richard A. Malthaner — 2010-07-20

Objective: We measured lung function before and after video-assisted thoracoscopic apical bullectomy and talc poudrage in patients with spontaneous pneumothoraces.Methods: Seventy-two patients were prospectively followed up for 12 months. The indications for surgery were recurrent pneumothoraces (n = 58), bilateral pneumothoraces (n = 8), and persistent air leak (n = 6). There were 46 males and 26 females with mean age of 29 years (range 15–61 years). The results were analyzed using paired t tests.Results: There were no recurrences. There were 4 complications (5.6%): 1 wound infection, 1 case of pneumonia, and 2 persistent air leaks each lasting 1 week. There were no conversions to open surgery. Preoperative and 6-month pulmonary function test results were available on 41 patients, and 35 patients completed 12-month pulmonary function tests. Twelve-month values (mean percent ± SD) were as follows: Forced expiratory volume in 1 second fell from 95 ± 19 to 89 ± 16 (P = .02); forced expiratory volume in 1 second/forced vital capacity ratio was unchanged, 95 ± 12 versus 94 ± 13 (P = .9); total lung capacity fell from 106 ± 19 to 98 ± 12 (P = 0.002); vital capacity fell from 100 ± 22 to 96 ± 16 (P = .05); residual volume fell from 126 ± 32 to 107 ± 29 (P = .002); and diffusion capacity for carbon monoxide corrected for alveolar volume was unchanged, 88 ± 15 versus 91 ± 17 (P = .07). Flow rates and diffusion capacities were preserved, but lung volumes were slightly reduced at 1 year.Conclusions: Video-assisted thoracoscopic apical bullectomy and talc poudrage is an effective treatment for spontaneous pneumothoraces with a low complication rate and recurrence rate and only minor changes in pulmonary function at 1 year.

Tracheostomy after pediatric cardiac surgery: Frequency, indications, and outcomes - Corrected Proof

Timothy Cotts, Jennifer Hirsch, Marc Thorne, Robert Gajarski — 2010-07-20

Objectives: This study was designed to review baseline characteristics and outcomes of children requiring tracheostomy after cardiac surgery.Methods: A retrospective review of children under age 2 requiring tracheostomy after cardiac surgery between January 1999 and December 2005 was performed. Indications for tracheostomy, survival, and completion of staged palliation were documented.Results: After cardiac surgery, 59 (1.3%) of 4503 patients with a median age at surgery of 15 days and weight of 3.5 kg required tracheostomy. Median duration from surgery to tracheostomy was 36 days (range 10–145 days). Genetic syndromes or major noncardiac comorbidities were present in 40% of patients. Biventricular repair was performed in 34 patients and univentricular repair in 25. Tetralogy of Fallot variants (29%) and coarctation ± ventricular septal defect (21%) constituted the majority of biventricular lesions associated with tracheostomy, whereas unbalanced atrioventricular septal defect and hypoplastic left heart syndrome with highly restrictive atrial septal defect accounted for 52% of the single ventricle group. Indications for tracheostomy included the following: multifactorial (37%), tracheobronchomalacia, (24%), cardiac (12%), bilateral vocal cord paralysis (10%), bilateral diaphragm paralysis (2%), and other airway issues (15%). Hospital survival was 75% with intermediate-term (median, 25.5 months; range, 1–122 months) survival of 53%. Of 25 single ventricle patients, 6 (24%) had successful completion of the Fontan procedure. Of 12 patients with single ventricle who were ventilator-dependent after initial repair, 10 died, 1 remains at hemi-Fontan, and 1 has undergone completion of the Fontan procedure.Conclusions: Requirement for tracheostomy in pediatric patients after cardiac surgery was associated with significant mortality. Patients with single ventricle have the highest late death rate and those with chronic ventilator dependency were unlikely to undergo successful Fontan completion.

Decellularization reduces immunogenicity of sheep pulmonary artery vascular patches - Corrected Proof

2010-07-16

Objectives: Allograft vascular tissue is important in the repair of complex structural lesions of the heart and great vessels, but induces a deleterious immune response that might shorten the effective lifespan of the tissue and sensitize the recipient. We hypothesized that decellularizing allograft vascular tissue reduces the host allogeneic immune response.Methods: Allograft ovine pulmonary artery patches were decellularized, cryopreserved, and implanted into the descending thoracic aorta. The humoral immune response was measured by means of flow cytometry at regular intervals over 6 months. Graft histology, immunohistochemistry, and calcification were assessed after 4 weeks or 6 months.Results: Leukocyte infiltration was reduced in decellularized grafts. A trend toward decreased in-patch calcification was observed in the decellularized group (7.6 ± 4.3 vs 40.0 ± 15.9 mg of calcium/mg of protein, P = .107). Decellularization reduced IgG antibody binding to donor splenocytes (9.8% ± 3.3% vs 57.8% ± 13.7% [control value], P = .010), as assessed by means of flow cytometry. All cytokines examined were detected in nondecellularized tissues after 4 weeks but not at 6 months, indicating complete graft rejection at that time. In contrast, transforming growth factor β1 and interleukin 10 were the only prominent cytokines in all decellularized grafts at 4 weeks after transplantation.Conclusions: Decellularization of allograft vascular tissue minimized the recipient cellular immune response and eliminated the production of anti-donor antibodies in recipients.

Double-barrel Damus–Kaye–Stansel operation is better than end-to-side Damus–Kaye–Stansel operation for preserving the pulmonary valve function: The importance of preserving the shape of the pulmonary sinus - Corrected Proof

2010-07-16

Objective: The Damus–Kaye–Stansel operation sometimes results in deteriorating semilunar valve insufficiency. We verified the semilunar valve function after the Damus–Kaye–Stansel operation and compared the end-to-side Damus–Kaye–Stansel with the double-barrel Damus–Kaye–Stansel.Methods: Forty-seven patients who underwent the Damus–Kaye–Stansel operation between June 1993 and August 2008 were retrospectively reviewed. Any patient who underwent a Norwood-type operation was excluded. The median age at operation was 19 months (range, 0–276 months). Forty-five patients were Fontan candidates. Thirty-nine patients underwent pulmonary artery banding before the Damus–Kaye–Stansel operation. Twenty-two patients had undergone an arch repair previously. The semilunar valve function was evaluated by echocardiography.Results: Thirteen patients underwent the end-to-side Damus–Kaye–Stansel operation, and 34 patients underwent the double-barrel Damus–Kaye–Stansel operation. The mean follow-up period was 71 ± 50 months (range, 1–188 months). Although there were 4 deaths, no death was related to the Damus–Kaye–Stansel procedure. Two of the patients with early death could not undergo a postoperative evaluation of the semilunar valves. The semilunar valve regurgitation mildly deteriorated in 7 patients (pulmonary regurgitation in 5 patients and aortic regurgitation in 2 patients). Pulmonary regurgitation deteriorated from none to mild in 1 patient, none to trivial in 2 patients, and trivial to mild in 2 patients. Both deteriorations in aortic regurgitation ranged from none to trivial. Semilunar valve regurgitation did not affect patients' circulatory condition. The end-to-side Damus–Kaye–Stansel operation more frequently caused a deterioration in pulmonary regurgitation than the double-barrel Damus–Kaye–Stansel operation (4/11 vs 1/34, P = .001). No surgical intervention for a systemic ventricular outflow obstruction was observed in the follow-up period.Conclusions: The double-barrel Damus–Kaye–Stansel operation was found to be superior to the end-to-side Damus–Kaye–Stansel operation for the prevention of postoperative pulmonary regurgitation.

Outcomes of unexpected pathologic N1 and N2 disease after video-assisted thoracic surgery lobectomy for clinical stage I non–small cell lung cancer - Corrected Proof

Hong Kwan Kim, Yong Soo Choi, Jhingook Kim, Young Mog Shim, Kwhanmien Kim — 2010-07-15

Objective: The objective of this study was to assess early and late outcomes of pathologic N1 or N2 disease unexpectedly detected in patients undergoing video-assisted thoracic surgery lobectomy for clinical stage I non–small cell lung cancer.Methods: We retrospectively reviewed the clinical and pathologic features of patients with unexpected N1 or N2 disease after video-assisted thoracic surgery lobectomy for clinical stage I disease and their early and late outcomes, including survival and recurrence pattern.Results: Between 2004 and 2008, 547 patients with clinical stage I disease underwent video-assisted thoracic surgery lobectomy, and of these, 89 were found to have pathologic N1 (n = 49) or N2 (n = 40) disease. No in-hospital mortality was noted during the postoperative period. For patients receiving adjuvant treatment, the median time interval between discharge from surgical intervention and start of adjuvant treatment was 24 days. The median follow-up time was 21.3 months. The 3-year overall survival was 98% for patients with N1 disease and 89% for patients with N2 disease. During follow-up, 33 (37%) patients had a recurrence. The pattern of recurrence was locoregional in 7, distant in 21, and both in 5 patients. The 3-year disease-free survival was 59% for patients with N1 disease and 33% for patients with N2 disease.Conclusions: For patients with pathologic N1 or N2 disease after video-assisted thoracic surgery lobectomy, survival was comparable with that after lobectomy through a thoracotomy. Even if lymph node metastasis is unexpectedly detected during video-assisted thoracic surgery lobectomy for clinical stage I disease, there is no need to convert to conventional thoracotomy.

Straight bronchial stent placement across the right upper lobe bronchus: A simple alternative for the management of airway obstruction around the carina and right main bronchus - Corrected Proof

Yun-Hen Liu, Yi-Cheng Wu, Ming-Ju Hsieh, Po-Jen Ko — 2010-07-15

A variety of techniques have been described for stent placement in airway obstruction around the carina and the right main bronchus. These techniques use the silicone Y-stent, the double Y-stent, or an open “window” toward the right upper lobe (RUL). However, there is still no clear consensus on the optimal management of patients in this category. We describe 2 patients who were successfully treated with the simplified straight Dumon stent (Novatech, Grasse, France).

An option for intraoperative placement of an intra-aortic balloon pump in patients with occlusive peripheral vascular disease - Corrected Proof

Domenico Calcaterra, Karam Karam, Jurabek B. Babajanov, James E. Davis — 2010-07-15

Intra-aortic counterpulsation therapy is unanimously recognized as a fundamental tool to support patients with cardiac failure in the preoperative and postoperative periods. The intra-aortic balloon pump (IABP) is routinely inserted through the femoral artery, but in many circumstances this option is not available in patients with occlusive peripheral vascular disease. Access through the upper extremities represents a possible alternative but is often cumbersome and exposed to a high incidence of complications.

Concomitant mitral valve replacement and re-re-repair of severe pectus deformity correction in a patient with Marfan syndrome - Corrected Proof

Christoph Haller, Koppany Sarai, Matthias Siepe, Friedhelm Beyersdorf — 2010-07-15

We herein present the replacement of an insufficient mitral valve owing to annular dilatation, fibroelastic deficiency, and ruptured chordae tendineae and concomitant correction of a recurrent pectus excavatum in a 47-year-old man with Marfan syndrome.

A novel vascularized patch enhances cell survival and modifies ventricular remodeling in a rat myocardial infarction model - Corrected Proof

Qi Zhou, Jian-Ye Zhou, Zhe Zheng, Hao Zhang, Sheng-Shou Hu — 2010-07-12

Objective: Although stem cells hold a great therapeutic potential for injured tissues, limited survival of transplanted stem cells has hindered the clinical application of this technology. We hypothesized that an omentum-based stem cell–supporting patch could provide adequate nutrients and microenvironment to prolong cell survival. We examined this hypothesis in rats with experimental myocardial infarction.Methods: The omentum-based supporting patch was constructed by stitching polylactic acid-co-glycolic acid polymer seeded with mesenchymal stem cells from male Sprague–Dawley rats. Eight weeks after the experimental myocardial infarction, which was created by ligating the left coronary artery of female Sprague–Dawley rats, mesenchymal stem cells were transplanted with (n = 16) or without (n = 14) the supporting patch. After 4 weeks, transplanted mesenchymal stem cell survival, ventricular remodeling, and cardiac performance were examined.Results: Significantly more cells survived after 4 weeks in rats transplanted with mesenchymal stem cells on the supporting patch assessed by means of polymerase chain reaction detection of the Sry gene than seen in those without the supporting patch (2.61 ± 0.40 vs 1.19 ± 0.12, P < .05). Rats with myocardial infarction that received mesenchymal stem cells with the patch also had significantly improved ventricular remodeling and cardiac function than those without the patch. Wrapping infarcted myocardium with omentum alone did not change the myocardial function.Conclusions: The omentum-based cell-supporting patch provided a favorable microenvironment for transplanted mesenchymal stem cell survival, which resulted in favorable ventricular remodeling and restoration of cardiac function in rats with experimental myocardial infarction. Further validation of the technique in human subjects could make mesenchymal stem cell transplantation a viable therapeutic option for patients with cardiac disease.

Perioperative monitoring in high-risk infants after stage 1 palliation of univentricular congenital heart disease - Corrected Proof

2010-07-12

Objective: Survival of high-risk patients with univentricular heart disease after Norwood palliation is reduced. We hypothesized that early goal-directed monitoring with venous oximetry and near-infrared spectroscopy would offset their increased vulnerability and improve survival.Methods: A prospective database of patients undergoing stage 1 palliation was used to assess differences in outcomes across risk groups in the setting of a comprehensive, goal-directed monitoring program. High-risk criteria included gestational age 35 weeks or less, birth weight less than 2.5 kg, and additional cardiac or extracardiac anomalies. Outcomes included survival to defined end points and measures of postoperative support.Results: From September 2000 to September 2008, 162 patients underwent stage 1 palliation: 28% (45/162) high-risk and 72% (117/162) standard-risk patients. Lesions other than hypoplastic left heart syndrome were more common among high-risk patients (38%, 17/45, vs 15%, 18/117, P = .003). Operative survival was not statistically different(87%, 39/45, high risk vs 95%, 111/117, standard risk, P = .1). High-risk patients were more likely to receive inpatient treatment until stage 2 palliation (24%, 11/45, vs 10%, 12/117, P = .001) and had lower 1-year survival (78% vs 93%, P = .01) and survival to date (71% vs 92%, P = .001).Conclusions: Intensive monitoring partially offset biologic vulnerability of high-risk patients, helping attain comparable early outcomes. Vulnerability persisted throughout the interstage period, however, and increased mortality beyond cavopulmonary shunt was seen only among high-risk patients. Although enhanced monitoring reduced early mortality, high resource use and attrition after stage 2 palliation suggest an ongoing need to evaluate our current palliative strategy for this subset of patients.

Histomorphometric analysis of intrapulmonary vessels in patients undergoing bidirectional Glenn shunt and total cavopulmonary connection - Corrected Proof

2010-07-12

Objectives: The purposes of this study were to elucidate the histomorphometry of the intrapulmonary arteries in patients undergoing univentricular type of repairs and to identify the histomorphometric characteristics, if any, that may predispose patients to postoperative Fontan failure.Patients and methods: Operatively resected wedges of lung tissue from 44 patients undergoing univentricular type of repairs (aged 17 months to 34 years; mean, 83.52 ± 75.90 months) was subjected to histomorphometric analysis.Results: Despite pulmonary arterioplasty, a low Nakata index was associated with 9.61 (95% confidence interval: 1.01–91.5; P = .003) times increased risk of death after the operation. A statistically significant difference in the mean indexed diameter of the intra-acinar pulmonary arteries (P = .03) was observed between patients undergoing superior and total cavopulmonary connections. Overall, there were 8 (8.2%), 4 (9.1%), 13 (29.5%), and 29 (65.9%) instances of intrapulmonary arterial intimal lesions, thrombosis, smooth muscle extension, and interstitial fibrosis, respectively. Among patients undergoing total cavopulmonary connection, only low Nakata index was significantly associated with the presence of severe intimal lesions, abnormal smooth muscle extension, intra-acinar pulmonary arterial thrombus, and smaller intra-acinar pulmonary arteries.Conclusions: A low Nakata index is significantly associated with the presence of severe intimal lesions, thrombus, abnormal smooth muscle extension, a lower mean indexed area of the intrapulmonary arteries, and poor postoperative outcome. However, none of the histomorphometrically derived parameters could conclusively predict the outcome after univentricular repair.

Inducible left ventricular obstruction after apical-conduit aortic valve bypass surgery - Corrected Proof

Catherine Y. Campbell, Ashish S. Shah, Matthews Chacko — 2010-07-12

In recent years, apical-aortic bypass surgery has been used for patients with a heavily calcified or “porcelain” ascending aorta or hostile mediastinum because these patients would be at high risk for cerebrovascular events during crossclamping of the calcified ascending aorta. In this case, we describe a previously unreported complication of apical aortic bypass and illustrate the role of cardiac catheterization and ventriculography in the hemodynamic evaluation of this patient.

Impact of evolving strategy on clinical outcomes and central pulmonary artery growth in patients with bilateral superior vena cava undergoing a bilateral bidirectional cavopulmonary shunt - Corrected Proof

2010-07-12

Objective: We reported a high incidence of thrombosis, central pulmonary artery hypoplasia, and mortality for bilateral bidirectional cavopulmonary shunts. We hypothesized that technical modifications in the cavopulmonary anastomosis and anticoagulation would limit thrombus and central pulmonary artery hypoplasia, and thereby improve outcomes.Methods: Sixty-one patients (median age, 8.4 months; weight, 6.6 kg) underwent bilateral bidirectional cavopulmonary shunt from 1990 to 2007. The cohort was divided into 2 groups: 1) the conventional group (1990–1999, n = 37) and 2) the V-shaped group, with a hemi-Fontan or modification in which the cavae were anastomosed to the pulmonary artery adjacent to each other so they formed the appearance of a V (1999–2007, n = 24). Central and branch pulmonary artery growth, survival, and reinterventions were determined.Results: The pre-Fontan study showed equivalent superior venae cavae and Nakata indices. The central pulmonary artery index and central pulmonary artery/Nakata index ratio were significantly higher in the V-shaped group (P < .05). There were no differences in freedom from death or transplant (conventional 69% vs V-shaped 75% at 3 years, P = .5), and a nonsignificant trend toward improving freedom from reinterventions (63% vs 81% at 3 years, P = .15) and thrombosis (82% vs 95% at 1 year, P = .11) was observed in the V-shaped group. Multivariate analysis showed anastomotic strategy, low saturation, and thrombosis were predictors for death. Anastomotic strategy, lack of anticoagulation, thrombosis, and small superior venae cavae were predictors for reintervention (P < .05). Predictors for thrombus included small superior venae cavae, Nakata index, and low saturation (P < .03).Conclusions: Surgical modifications for bilateral bidirectional cavopulmonary shunts were associated with the larger central pulmonary artery size. Lack of anticoagulation and anastomotic strategy affected reintervention. Anastomotic strategy and postoperative thrombus affected mortality.

Effect of duration of red blood cell storage on early and late mortality after coronary artery bypass grafting - Corrected Proof

2010-07-12

Objectives: Recently, concern has been expressed about the transfusion of older red blood cells after cardiac surgery. We tested the hypothesis that longer storage of transfused red blood cells increases the risk of early and late mortality in patients who undergo coronary artery bypass grafting.Methods: We retrospectively analyzed data of patients who underwent isolated coronary artery bypass grafting between January 1998 and December 2007 in Catharina Hospital, Eindhoven, The Netherlands, and received up to 10 U of red blood cells intraoperatively or during the first 5 postoperative days. The patients were divided into 3 groups according to the storage time of the red blood cells, with a cutoff point of 14 days, as follows: “only younger blood” (n = 1422), “only older blood” (n = 1719), and at least 1 U of older RBCs (“any older blood”; n = 2175).Results: The mean follow-up time was 1693 ± 1058 days (range, 0–3708 days). The median follow-up time was 1629 days. Univariate and multivariate logistic regression analyses revealed that the number of transfused units but not the storage time of blood entered either as a continuous variable or as a dichotomous variable with a cutoff point of 14 days was a risk factor for early mortality. Neither the number of transfused units nor the storage time was an independent risk factor for late mortality. Log-rank testing revealed no statistical difference in survival among the groups.Conclusions: The storage time of transfused red blood cells is not a risk factor for early or late mortality in patients who undergo coronary artery bypass grafting.

Preoperative high-dose atorvastatin for prevention of atrial fibrillation after cardiac surgery: A randomized controlled trial - Corrected Proof

2010-07-12

Objective: The preventative effect of statins on postoperative atrial fibrillation has been hypothesized. However, all studies to date have examined patients who did not receive statins before their further allocation to treatment or no treatment. Because guidelines recommend the routine use of statins in patients with coronary artery disease, we set out to examine the effect of intensive statin pretreatment versus continuation of usual statin dose on atrial fibrillation after cardiac surgery.Methods: Patients receiving routine statin treatment and undergoing coronary artery bypass surgery or aortic valve replacement with no history of atrial fibrillation or antiarrhythmic medication were randomized to receive atorvastatin 80 mg or atorvastatin 10 mg for 7 days before surgery in a single-blind fashion. The primary end point was the development of postoperative atrial fibrillation during hospital stay.Results: A total of 104 consecutive patients were included. Postoperative atrial fibrillation occurred in 33 patients (32.4%). No significant differences were found in demographics, medical history, or intraoperative variables between treatment groups, with the exception of higher rate of β-blocker use in the atorvastatin 10 mg group (75% vs 53%, P = .002) and previous myocardial infarction (62% vs 42%, P = .049). The incidence of postoperative atrial fibrillation was lower in the atorvastatin 80 mg group when compared with the atorvastatin 10 mg group, but this difference did not reach statistical significance (29% vs 36%, P = .43).Conclusion: High-dose atorvastatin for 7 days before cardiac surgery conferred a nonsignificant reduction in postoperative atrial fibrillation when compared with a low-dose regimen. A larger study would be necessary to confirm the beneficial effect of high-dose statins in this setting.

Intermediate-term clinical outcomes of primary biventricular repair for left ventricular outflow tract obstruction and ventricular septal defect - Corrected Proof

2010-07-12

Objective: Primary biventricular repair for left ventricular outflow tract obstruction and ventricular septal defect remains challenging. The intermediate-term outcomes and risk factors for mortality remain undefined.Methods: All patients undergoing primary biventricular repair of left ventricular outflow tract obstruction and ventricular septal defect from 1995 to 2008 at the C. S. Mott Children's Hospital, University of Michigan Health Systems were analyzed.Results: Thirty-one patients (mean age, 18 days; 20 male) with a median follow-up of 6.7 years (range, 0.3–13.5 years) were identified. The ventricular septal defect was enlarged in 15 patients, and a limited atrial septal defect was constructed in 16 patients. There were 6 hospital and 2 late deaths. Ten-year patient survival was 72.3%. Lower body weight (P = .040), complete atrial septal defect closure (P = .026), and longer cardiopulmonary bypass time (P = .026) were risk factors of hospital mortality. An atrial septal defect was patent in 16 patients at discharge, 2 of whom required later surgical closure. Relief of recurrent left ventricular outflow tract obstruction was performed in 1 patient. No patient required pacemaker implantation. Five-year freedom from right ventricle-to-pulmonary artery conduit replacement was 39.3%. Smaller-sized conduit (P = .020) and use of aortic allograft (P = .048) were risk factors for early failure.Conclusion: Primary biventricular repair for patients with left ventricular outflow tract obstruction and ventricular septal defect provides good early and intermediate-term outcomes. Maintaining a small atrial septal defect may improve hospital mortality. Selective ventricular septal defect enlargement and careful construction of the intraventricular pathway result in a low incidence of recurrent left ventricular outflow tract obstruction, as well as avoidance of heart block. Maximizing valve diameter and avoiding aortic allografts may lengthen conduit longevity.

Pulmonary hepatic flow distribution in total cavopulmonary connections: Extracardiac versus intracardiac - Corrected Proof

2010-07-12

Objective: Pulmonary arteriovenous malformations can occur after the Fontan procedure and are believed to be associated with disproportionate pulmonary distribution of hepatic venous effluent. We studied the effect of total cavopulmonary connection geometry and the effect of increased cardiac output on distribution of inferior vena caval return to the lungs.Methods: Ten patients undergoing the Fontan procedure, 5 with extracardiac and 5 with intracardiac configurations of the total cavopulmonary connection, previously analyzed for power loss were processed for calculating the distribution of inferior vena caval return to the lungs (second-order accuracy). One idealized total cavopulmonary connection was similarly analyzed under parametric variation of inferior vena caval offset and cardiac output flow split.Results: Streaming of the inferior vena caval return in the idealized total cavopulmonary connection model was dependent on both inferior vena caval offset magnitude and cardiac output flow-split ratio. For patient-specific total cavopulmonary connections, preferential streaming of the inferior vena caval return was directly proportional to the cardiac output flow-split ratio in the intracardiac total cavopulmonary connections (P < .0001). Preferential streaming in extracardiac total cavopulmonary connections correlated to the inferior vena caval offset (P < .05) and did not correlate to cardiac output flow split. Enhanced mixing in intracardiac total cavopulmonary connections is speculated to explain the contrasting results. Exercising tends to reduce streaming toward the left pulmonary artery in intracardiac total cavopulmonary connections, whereas for extracardiac total cavopulmonary connections, exercising tends to equalize the streaming.Conclusions: Extracardiac and intracardiac total cavopulmonary connections have inherently different streaming characteristics because of contrasting mixing characteristics caused by their geometric differences. Pulmonary artery diameters and inferior vena caval offsets might together determine hepatic flow streaming.

Outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest - Corrected Proof

Alexander Kulik, Catherine F. Castner, Nicholas T. Kouchoukos — 2010-07-12

Objective: Recent advances in endovascular surgery have put into question the role of open operative treatment of thoracoabdominal aortic aneurysms. In this context we evaluated our experience with thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass and hypothermic circulatory arrest.Methods: From January 1986 to December 2008, 218 patients (mean age, 63 ± 14 years) underwent thoracoabdominal aortic aneurysm repair with cardiopulmonary bypass and hypothermic circulatory arrest. The degree of repair was as follows: Crawford extent I, 57 (26%) patients; Crawford extent II, 91 (41%) patients; and Crawford extent III, 70 (32%) patients. Degenerative aneurysms were present in 160 (73%) patients. Eighteen (8%) patients underwent emergency operations.Results: The mean durations of cardiopulmonary bypass and hypothermic circulatory arrest were 160 ± 44 and 31 ± 12 minutes, respectively. Stroke occurred in 8 (3.7%) patients, and spinal cord ischemic injury occurred in 10 (4.6%) patients (8 with paraplegia and 2 with paraparesis). Temporary dialysis for new-onset renal failure was required in 3.6% of hospital survivors. Thirty-day and 1-year mortality rates were 7.3% and 24.5%, respectively. After emergency operations, the 30-day mortality rate was 33.3% compared with 5.0% after elective operations (P = .001). Five- and 10-year survivals were 55% and 23%, respectively. Twenty-five patients required reoperation on the graft or contiguous aorta at a mean of 5 ± 3 years after the initial procedure. Five- and 10-year rates of freedom from reoperation were 87% and 60%, respectively.Conclusions: Cardiopulmonary bypass with hypothermic circulatory arrest can be safely used for thoracoabdominal aortic aneurysm repair, providing excellent protection against end-organ injury. Early mortality and morbidity rates do not exceed those reported for endovascular repair, with particularly favorable outcomes among patients undergoing elective operations.

Axillary arteriovenous fistula for the palliation of complex cyanotic congenital heart disease: Is it an effective tool? - Corrected Proof

2010-07-09

Objective: Patients with complex cyanotic congenital heart disease and a bidirectional cavopulmonary connection who are not candidates for or had failed Fontan operation may experience progressive cyanosis. An axillary arteriovenous anastomosis may be constructed to augment pulmonary blood flow. This report reviews our results with this approach in this complex group of patients.Methods: The records of patients with previous cavopulmonary connections who underwent a surgical anastomosis between the axillary artery and the vein for palliation of severe progressive cyanosis were reviewed.Results: Eleven patients were identified. The median age at the time of the axillary arteriovenous anastomosis was 19.2 years (7.97–41.75 years). Seven patients were not candidates for the Fontan operation, and 4 patients had failed Fontan surgery. Three of the anastomoses were constructed with a side-to-side technique, and 8 anastomoses were constructed with a short interposition graft. Median fistula size was 5 mm (3–6 mm). There was no operative mortality and 1 late death. Median survival was 2.85 years (0.01–7.22 years). All fistulae were patent at follow-up. Median preoperative arterial oxygen saturation was 84% (80%–86%) and 82% (76%–88%) at follow-up (P = .38). Median preoperative hemoglobin was 18.5 g/dL (11.7–22.6 g/dL) and 19.2 g/dL (14.6–22.6 g/dL) at follow-up (P = .97). Median preoperative systemic ventricular ejection fraction was 51% (27%–60%) and 46.5% (28%–60%) at follow-up (P = 1). Significant functional improvement was seen in only 1 patient.Conclusions: In patients with complex cyanotic congenital heart disease who are not candidates for or had failed Fontan operation, palliation with an axillary arteriovenous fistula did not improve cyanosis or polycythemia. Functional outcome and ventricular ejection fraction did not improve or deteriorate.

“Freezing” the left ventricular outflow tract for homograft reconstruction in aortic root endocarditis - Corrected Proof

Daniel Pereda, Soon J. Park — 2010-07-05

Root replacement with cryopreserved homografts is frequently used to treat active endocarditis. To alleviate concerns with tissue fragility, it would be desirable to stabilize the left ventricular outflow tract (LVOT) and aortic annulus. We report the case of a patient with active endocarditis who underwent placement of an aortic root homograft protected by a novel technique of “freezing” the LVOT with a circumferential continuous suture and a sizer.

Emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset in 30 cases - Corrected Proof

2010-07-05

Objective: To investigate the results of emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset.Methods: A retrospective analysis of the clinical data of 30 patients with complicated Stanford type B aortic dissections who underwent emergency endovascular repair between June 2007 and October 2008. Endovascular repairs were performed within 24 hours of symptom onset. Stent-grafts were deployed at the first entry tear through the femoral artery under fluoroscopic guidance. Follow-up computed tomography scans were performed at 1, 3, 6, 12, and 18 months after treatment.Results: The mean patient age was 64 years (range, 43–83 years). There were 3 cases associated with rupture, 6 cases associated with refractory hypertension, 15 cases associated with persistent pain, 2 cases associated with retrograde dissection, and 4 cases associated with malperfusion. The technical success rate was 100%, and the incidence of immediate postoperative endoleaks was 13.4%. One patient died of dissection rupture within 30 days. The mean follow-up period was 12 ± 8 months. A small, persistent endoleak (<10%) occurred in 1 patient, and 1 patient died of acute liver failure 2 months after the operation. No stent dislocation, false lumen expansion, or paraplegia occurred. The false lumen was completely thrombosed in 6 patients and partially thrombosed in 19 patients. The mortality rate was 6.67%.Conclusion: Our results suggest that emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset is associated with good outcomes and can decrease mortality.

Early reperfusion with warm, polarizing adenosine–lidocaine cardioplegia improves functional recovery after 6 hours of cold static storage - Corrected Proof

Donna M. Rudd, Geoffrey P. Dobson — 2010-07-05

Objective: Rewarming and reanimating the donor heart from cold static storage predisposes the organ to injury and graft dysfunction. Our main aim was to investigate the effects of 5 minutes of continuous rewarming with a normokalemic, oxygenated, polarizing adenosine–lidocaine arrest solution after 6 hours of cold static storage (4°C) in adenosine–lidocaine or Celsior (Genzyme Corp, Cambridge, Mass) solutions.Methods: Male Sprague–Dawley rats (350–450 g, n = 40) were randomly assigned to one of 5 groups: (1) adenosine–lidocaine cold arrest with modified Krebs–Henseleit rewarming, (2) adenosine–lidocaine cold arrest with adenosine–lidocaine rewarming, (3) Celsior cold arrest with Celsior rewarming, (4) Celsior cold arrest with Krebs–Henseleit, and (5) Celsior cold arrest with adenosine–lidocaine arrest rewarming. Hearts were perfused in working mode, arrested (37°C), removed and stored for 6 hours at 4°C, reattached in Langendorff mode, and rewarmed for 5 minutes (37°C). Hearts were switched to working mode, and function was compared with prestorage values. Myocardial oxygen consumption and effluent lactate and pH values were measured during rewarming and recovery.Results: Cold adenosine–lidocaine hearts rewarmed with Krebs–Henseleit recovered 40% aortic flow and 58% coronary flow at 60 minutes of reperfusion. Rewarming with adenosine–lidocaine arrest solution led to significantly higher aortic flow (63%) and coronary flow (77%) at 60 minutes. Cold Celsior hearts rewarmed with Celsior had 9 times higher effluent lactate values with acidosis (pH 6.5) during the last minute of rewarming compared with all groups, and this was associated with early myocardial, vascular, and electrical stunning. At 5 and 10 minutes of recovery, the aortic flow was 1.0 and 8 mL/min, respectively. If cold Celsior hearts were rewarmed with adenosine–lidocaine, they generated 18-fold higher aortic flow and 16-fold higher coronary flow at 5 minutes. At 60 minutes, cold Celsior with Celsior-rewarmed hearts recovered 35% aortic flow and 50% coronary flow compared with 44% aortic flow and 67% coronary flow (P < .05) for Celsior with adenosine–lidocaine–rewarmed hearts. Celsior with Krebs–Henseleit–rewarmed hearts recovered 39% aortic flow and 51% coronary flow and were not significantly different from Celsior-rewarmed hearts. The myocardial oxygen consumption in the last minute of rewarming was 1.6 times higher for cold adenosine–lidocaine hearts rewarmed with adenosine–lidocaine compared with cold Celsior and Celsior hearts (19 vs 12 μmol O2/min/g dry weight) along with low lactate values and no acidosis.Conclusions: Rewarming the rat heart after cold static storage in polarizing adenosine–lidocaine arrest solution resulted in significantly higher aortic flow, coronary flow, and cardiac output compared with that seen after Krebs–Henseleit or Celsior rewarming. Rewarming cold Celsior hearts with adenosine–lidocaine solution reduced stunning. Adenosine–lidocaine cardioplegia might offer a new reperfusion strategy after cold static storage.

Outcomes of a multicenter trial of the Levitronix CentriMag ventricular assist system for short-term circulatory support - Corrected Proof

2010-07-05

Objective: The Levitronix CentriMag (Levitronix LLC, Waltham, Mass) ventricular assist system is designed for temporary left, right, or biventricular support. Advantages include ease of use, excellent reliability, and low thrombosis risk,. which may allow wider application of short-term support and improved outcomes in patients with cardiogenic shock. This multi-institutional study evaluated safety, effectiveness, and outcomes of the CentriMag in patients with cardiogenic shock.Methods: Thirty-eight patients were supported at 7 centers. Patients included 12 after cardiotomy, 14 after myocardial infarction, and 12 with right ventricular failure after implantable left ventricular assist device placement. Devices were implanted in left (n = 8), right (n = 12), or biventricular (n = 18) configuration. Support was continued until recovery, transplantation, or implantation of long-term ventricular assist device.Results: Mean support duration for the entire cohort (n = 38) was 13 days (1–60 days), with 47% of patients (18/38) surviving 30 days after device removal. Mean CentriMag biventricular support (n = 18) duration was 15 days (1–60 days), with 44% (8/18) surviving at 30 days. Mean CentriMag right ventricular support with a commercially available left ventricular assist device (n = 12) duration was 14 days (1–29 days), with 58% (7/12) surviving at 30 days. Complications included bleeding (21%), infection (5%), respiratory failure (3%), hemolysis (5%), and neurologic dysfunction (11%). There were no CentriMag or pump failures.Conclusions: In this preliminary study, the CentriMag provided short-term support for patients with cardiogenic shock with a low incidence of device-related complications and no device failures.

Dual actions of cilnidipine in human internal thoracic artery: Inhibition of calcium channels and enhancement of endothelial nitric oxide synthase - Corrected Proof

2010-07-05

Objective: Cilnidipine is a novel, long-action L/N-type dihydropyridine calcium channel blocker that has recently been used for antihypertensive therapy. We investigated the vasorelaxation effect of cilnidipine with regard to its calcium channel blockage and nitric oxide-cyclic guanosine monophosphate-dependent mechanism in human internal thoracic artery.Methods: Fresh human internal thoracic arteries taken from discarded tissues of patients undergoing coronary artery bypass surgery were studied. Concentration-relaxation curves for cilnidipine in comparison with nifedipine were studied. The expression level of endothelial nitric oxide synthase mRNA was assayed by quantitative real-time polymerase chain reaction, and the phosphorylation of endothelial nitric oxide synthase at Ser1177 was determined by Western blotting analysis.Results: Cilnidipine and nifedipine caused nearly full relaxation in potassium-precontracted internal thoracic artery. Pretreatment with cilnidipine at the clinical plasma concentration significantly depressed the maximal contraction. Endothelium denudation (47.7% ± 7.0%, P < .05) and inhibition of endothelial nitric oxide synthase (48.6% ± 6.1%, P < .05) or guanylate cyclase (41.6% ± 3.8%, P < .01) significantly reduced the cilnidipine-induced endothelium-dependent relaxation (73.9% ± 6.4%). Cilnidipine increased the expression of endothelial nitric oxide synthase mRNA by 42.4% (P < .05) and enhanced phosphorylation level of endothelial nitric oxide synthase at Ser1177 by 37.0% (P < .05).Conclusions: The new generation of calcium channel antagonist cilnidipine relaxes human arteries through calcium channel antagonism and increases production of nitric oxide by enhancement of endothelial nitric oxide synthase. The dual mechanisms of cilnidipine in human arteries demonstrated in this study may prove particularly important in vasorelaxing therapy in cardiovascular diseases.

Membrane polarity: A target for myocardial protection and reduced inflammation in adult and pediatric cardiothoracic surgery - Corrected Proof

Geoffrey P. Dobson — 2010-07-05

The spectrum of opinion regarding the safety, simplicity, clinical application and reversibility of cardioplegia varies from total scepticism and discouragement of its use to advocacy of constant employment with remarkable success. Similar disagreement exists as to which of the cardioplegic agent is the best.—Kaplan and Fisher (1959) p. 833

Activated protein C attenuates cardiopulmonary bypass–induced acute lung injury through the regulation of neutrophil activation - Corrected Proof

Sachiko Yamazaki, Syunji Inamori, Takeshi Nakatani, Michiharu Suga — 2010-07-05

Objective: Cardiopulmonary bypass is known to induce systemic inflammatory responses that injure multiple organs, especially the lungs. Activated protein C has been demonstrated to play an important role in the regulation of inflammation in addition to coagulation. We investigated the anti-inflammatory effects of activated protein C in a rat model of cardiopulmonary bypass.Methods: Rats were randomized to receive an intravenous bolus of vehicle (control), 0.1 mg/kg diisopropyl fluorophosphate-activated protein C, or 0.1 mg/kg activated protein C 10 minutes before the initiation of cardiopulmonary bypass. Rats underwent cardiopulmonary bypass for 60 minutes followed by another 60-minute observation.Results: The activated protein C group showed significantly higher mean arterial oxygen pressure and lower mean lung wet-to-dry weight ratio after cardiopulmonary bypass than the control and diisopropyl fluorophosphate-activated protein C groups. Furthermore, lung pathology revealed minimal inflammatory change in the activated protein C group. A marked increase in CD11b expression and a decrease in CD62L expression after cardiopulmonary bypass were observed in the control and diisopropyl fluorophosphate-activated protein C groups. However, administration of activated protein C significantly attenuated these changes. Lung content of tumor necrosis factor-α and interleukin-1β in the activated protein C group tended to be lower than in the other groups. Lung content of macrophage inflammatory protein-2 in the activated protein C group was significantly lower than in the diisopropyl fluorophosphate-activated protein C group.Conclusion: Administration of activated protein C before cardiopulmonary bypass attenuates acute lung injury induced by cardiopulmonary bypass at least in part through the inhibition of neutrophil activation and possibly via the attenuation of proinflammatory cytokine production in this rat model of cardiopulmonary bypass.

Aortic valve replacement: Results and predictors of mortality from a contemporary series of 2256 patients - Corrected Proof

2010-07-05

Objective: The study's objectives were to evaluate results and identify predictors of hospital and mid-term mortality after primary isolated aortic valve replacement; compare early and mid-term survival of patients aged more than 80 years or less than 80 years; and assess the effectiveness of the logistic European System for Cardiac Operative Risk Evaluation in predicting the risk for hospital mortality in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% who are undergoing aortic valve replacement.Methods: Data from 2256 patients undergoing primary isolated aortic valve replacement between January 2003 and December 2007 were prospectively collected in a Regional Registry (Regione Emilia Romagna Interventi Cardiochirurgia) and analyzed to estimate hospital and mid-term results.Results: Overall hospital mortality was 2.2%. By multivariate analysis, New York Heart Association III and IV, Canadian Cardiovascular Society III and IV, pulmonary artery pressure greater than 60 mm Hg, dialysis, central neurologic dysfunction, and severe chronic obstructive pulmonary disease emerged as independent predictors of hospital mortality. At 3 years, the survival was 89.3%. The same predictors of hospital mortality plus ejection fraction of 30% to 50% and age more than 80 years emerged as independent risk factors for 3-year mortality. Compared with younger patients, octogenarians had a higher hospital mortality rate (3.72% vs 1.81%; P = .0143) and a reduced 3-year survival (82.3% vs 91.3%; P < .001). Three-year survival of octogenarians was comparable to the expected survival of an age- and gender-matched regional population (P = .157). The observed mortality rate in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% (mean: 22.4%) was 7% (P < .001).Conclusions: This study provides contemporary data on the characteristics and outcome of patients undergoing first-time isolated aortic valve replacement.

Translocation of a single coronary artery from the nonfacing sinus in the arterial switch operation: Long-term patency of the interposition graft - Corrected Proof

Igor E. Konstantinov, Tyson A. Fricke, Yves d'Udekem, Dorothy J. Radford — 2010-07-05

In the current era, a single coronary artery originating from one of the facing sinuses is no longer a risk factor for the arterial switch operation (ASO) in high-volume units. Although an anterior looping or a commissural malalignment increases the distance between the original coronary orifice and neoaorta, both anatomic variations can still be managed successfully by means of tube reconstruction of the single coronary artery with autologous pericardium or aorta. However, a single coronary artery originating from a nonfacing sinus presents a rare yet significant problem, often making ASO impossible. Herein we describe a successful translocation of the single coronary artery with an interposition graft, with a documented patency at 20 years of follow-up.

Radiolucent retractor for angiographic analysis during hybrid congenital cardiac procedures - Corrected Proof

Gareth J. Morgan, Karen Clarke, Christopher Caldarone, Lee N. Benson — 2010-07-05

Management of congenital heart disease by using a combination of surgical and interventional cardiology skills is a growing field, and as such, many technical innovations are being described.

The impact of sequential versus single anastomoses on flow characteristics and mid-term patency of saphenous vein grafts in coronary bypass grafting - Corrected Proof

2010-07-02

Objective: To assess the influence of bypass grafting technique on the flow characteristics and mid-term patency of saphenous vein coronary bypass grafts.Methods: In the present study, 309 patients who underwent either sequential (group A, N = 84 grafts) or individual (group B, N = 244 grafts) saphenous vein coronary bypass grafting between February 2002 and September 2007 were investigated. Individual bypassing only was performed in 212 patients, and sequential bypassing only was performed in 78 patients. The remaining 19 patients received both. A total of 436 distal anastomoses were performed with 328 saphenous vein grafts. The intraoperative flow characteristics and the graft patency were assessed with the transit time flow meter and serial multi-detector computed tomography coronary angiograms, respectively.Results: Group A showed a higher mean flow compared with group B at 49.4 ± 27.4 mL/min versus 37.1 ± 20.1 mL/min, respectively (P = .001). The mean flow increased linearly as the number of anastomoses increased per graft (P < .001). Graft patency at 3 years was 93.3% ± 3.4% in group A and 86.5% ± 3.1% in group B (P = .048). After adjustment for baseline characteristics, group A showed a tendency for superior mid-term patency than group B (hazard ratio 0.362; 95% confidence interval, 0.129–1.017; P = .0538).Conclusion: Sequential bypass grafts were associated with higher mean flows and superior mid-term patency compared with individual grafts. These findings suggest the more favorable results of sequential bypass grafting to be attributed to the enhanced flow hemodynamics.

Complete atrioventricular septal defect: Outcome of pulmonary artery banding improved by adjustable device - Corrected Proof

2010-07-02

Objective: We sought to evaluate pulmonary artery banding in infants with complete atrioventricular septal defects.Methods: From 2000 to 2009, 20 infants with complete atrioventricular septal defects underwent pulmonary artery banding because of unsuitable anatomy (unbalanced ventricles, associated lesions, or both) or clinical condition (infection, chronic lung disease, or noncardiac malformation). Patients were divided into 2 groups: the conventional PAB group (n = 13 [65%]; mean age, 74 ± 56 days [range, 6–187 days]; mean weight, 3.3 ± 1.1 kg [range, 2.1–5.8 kg]) and the FloWatch-PAB group (n = 7 [35%]; mean age, 111 ± 40 days [range, 81–187 days]; mean weight, 4.3 ± 1.2 kg [range, 3.2–6.1 kg]). There was no statistical difference in age or weight. Preoperative mechanical ventilation was required in 3 (23%) of 13 infants in the conventional PAB group and 5 (71%) of 7 infants in the FloWatch-PAB group (P < .05).Results: Ten (77%) of 13 infants in the conventional PAB group died versus 0 (0%) of 7 infants in the FloWatch-PAB group (P < .001). Sternal closure was delayed in 6 (46%) of 13 infants in the conventional PAB group and 0 (0%) of 7 infants in the FloWatch-PAB group (P < .05). The mean duration of mechanical ventilation, intensive care unit stay, and hospital stay was significantly longer (P < .05) in the conventional PAB group than in the FloWatch-PAB group (21 ± 17 days [range, 4–61 days] vs 3 ± 2 days [range, 1–8 days], 22 ± 18 days [range, 5–61 days] vs 7 ± 6 days [range, 2–21 days], and 54 ± 12 days [range, 40–71 days] vs 29 ± 25 days [range, 9–81 days], respectively). Left atrioventricular valve regurgitation increased (mild to moderate) in 2 infants in the conventional PAB group and decreased (severe to moderate) in 2 infants in the FloWatch-PAB group. Six of 10 survivors (1 in the conventional PAB group and 5 in the FloWatch-PAB group) underwent pulmonary artery debanding and repair after a median interval of 125 days (range, 34–871 days); 4 of 10 are awaiting repair.Conclusion: In selected patients with complete atrioventricular septal defects, pulmonary artery banding followed by late repair is a viable alternative strategy. In our study the FloWatch-PAB device resulted in improved survival and made later repair possible in a better clinical state.

Palliative role of percutaneous radiofrequency ablation for severe hemoptysis in an elderly patient with inoperable lung cancer - Corrected Proof

Alessandro Baisi, Federico Raveglia, Matilde De Simone, Ugo Cioffi — 2010-07-02

Surgical resection remains the standard therapeutic treatment for patients with resectable non–small cell lung cancer and for selected patients with limited pulmonary metastases from extrathoracic tumors, even if only a small number of patients are suitable for potentially curative resection. Percutaneous image-guided radiofrequency ablation (RFA) is a minimally invasive therapeutic option that has been successfully applied to local control of tumors in different organs including the lung. This technique has recently been recognized as the primary therapy in patients who are not candidates for limited surgery or radiotherapy and can be used to treat recurrent lesions. The procedure is well tolerated and the complication rate is acceptable even when considering the treatment of large masses. We report a case of an elderly patient with advanced lung cancer leading to severe and recurring hemoptysis that was successfully treated with RFA.

Valve-sparing procedure and Lecompte maneuver in patients with late aortic regurgitation and aortic aneurysm after the arterial switch operation - Corrected Proof

Yih-Sharng Chen, Ing-Sh Chiu, Shu-Chien Huang, Shyh-Jye Chen — 2010-07-02

Aortic regurgitation and root dilatation can develop during long-term follow up after the arterial switch operation (ASO). Despite the fact that few patients required surgical reintervention, significant regurgitation was still an important cause of late mortality. Aortic valve replacement with or without a graft was the most common procedure.

Complete mapping of the tricuspid valve apparatus using three-dimensional sonomicrometry - Corrected Proof

2010-06-30

Objective: Many surgeons consider the tricuspid valve to be a second-class structure. Our objective was to determine the normal anatomy and dynamic characteristics of the tricuspid valve apparatus in vivo and to discern whether this would aid the design of a tricuspid valve annuloplasty ring model.Methods: Sixteen sonomicrometry crystals were placed around the tricuspid annulus, at the bases and tips of the papillary muscles, the free edges of the leaflets, and the right ventricular apex during cardiopulmonary bypass in 5 anesthetized York Hampshire pigs. Animals were studied after weaning of cardiopulmonary bypass on 10 cardiac cycles of normal hemodynamics.Results: Sonomicrometry array localizations demonstrate the multiplanar shape of the tricuspid annulus. The tricuspid annulus reaches its maximum area (97.9 ± 25.4 mm2) at the end of diastole and its minimum area (77.3 ± 22.5 mm2) at the end of systole, and increases again in early diastole. Papillary muscles shorten by 0.8 to 1.5 mm (11.2%) in systole, and chordae tendineae straighten by 0.8 to 1.7 mm (11.4%) in systole.Conclusion: The shape of the tricuspid annulus is a multiplanar 3-dimensional one with its highest point at the anteroseptal commissure and its lowest point at the posteroseptal commissure, and the anteroposterior commissure is in a middle plane in between. The tricuspid annulus area reaches its maximum during diastole and its minimum during systole. The papillary muscles contract by the same amount of chordal straightening. The optimal tricuspid annuloplasty ring may be a multiplanar 3-dimensional one that mimics the normal tricuspid annulus.

Reconstruction of a resected subclavian vein by transposition of the ipsilateral internal jugular vein - Corrected Proof

Michel Gonzalez, Sébastien Déglise, Hans-Beat Ris, Jean-Marc Corpataux — 2010-06-30

A heterogeneous group of solid benign and malignant tumors may involve the thoracic inlet. Their surgical management requires complete en bloc resection, sometimes involving major adjacent structures. Generally, the vein is the first invaded element and debate still exists concerning the optimal management. Indeed, owing to the rich collateral circulation, most authors advocate simple ligation after removal of the invaded segment. Nevertheless, it is sometimes recommended to perform reconstruction owing to the risks of venous hypertension. Herein, we report an interesting reconstruction after subclavian vein resection. A young woman with a thoracic inlet sarcoma invading the left subclavian vein benefited from a superior thoracic wall en bloc resection, with removal of the vein. Venous continuity was restored by transposing the ipsilateral internal jugular vein to the axillary vein.

Branched vascular network architecture: A new approach to lung assist device technology - Corrected Proof

2010-06-30

Objective: A lung assist device would serve an important clinical need as a bridge to transplant or destination therapy for patients with end-stage lung disease. A new lung assist device has been developed that incorporates a branched network of vascular channels adjacent to a gas chamber, separated by a thin, gas-permeable membrane. This study investigated 2 potential gas exchange membranes within this new architecture.Methods: Oxygen and carbon dioxide exchange within the device was tested in vitro using 3 gas-permeable membranes. Two of the membranes, silicone only and silicone-coated microporous polymer, were plasma impermeable. The third, a microporous polymer, was used as a control. Gas exchange testing was done using anticoagulated porcine blood over a range of flow rates.Results: Oxygen and carbon dioxide transfer was demonstrated in the device and increased nearly linearly from 0.6 to 8.0 mL/min blood flow for all of the membranes. There was no significant difference in the gas transfer between the silicone and the silicone-coated microporous polymer membranes. The transfer of oxygen and carbon dioxide in the device was similar to existing hollow fiber oxygenators controlling for surface area.Conclusion: The silicone and silicone-coated microporous polymer membranes both show promise as gas-permeable membranes in a new lung assist device design. Further optimization of the device by improving the membranes and reducing the channel diameter in the vascular network will improve gas transfer. The current device may be scaled up to function as an adult lung assist device.