ICVTS - Interactive Feed

[Thoracic general] Transmediastinal migration of Kirschner wire

Marchi, E., Reis, M. P., Carvalho, M. V. — 2008-07-25

The authors describe a case of transmediastinal migration, and lodging into the right lung, of a Kirschner wire used to fix a fracture of the left clavicle. The medical literature reports cases of intrathoracic migration of Kirschner wire; however, a transmediastinal migration has not been previously described. A small right thoracotomy was performed and the wire was removed without complications. We discuss aspects of this uncommon finding and alert physicians for the potential risks of the migration of metallic pins used to fixate boney structures within the chest. Keywords: Bone wires; Chest pain; Foreign-body migration

[Cardiac general] Accuracy of core temperature measurement in deep hypothermic circulatory arrest

Camboni, D., Philipp, A., Schebesch, K. M., Schmid, C. — 2008-07-25

Deep hypothermia is an effective technique for neuroprotection in cardiac surgery. However, standard body temperature measurement may deviate from actual brain temperature. Therefore, we simultaneously measured brain and core temperatures during neurosurgical interventions in hypothermic circulatory arrest to determine its accuracy. Between 1994 and May 2007, 26 patients (12 female, mean age 46±14 years) with complex intracranial aneurysms underwent resection or clipping applying closed chest cardiopulmonary bypass and hypothermic circulatory arrest via inguinal cannulation. During surgery, temperature probes were positioned in the brain, tympanum, bladder, rectum and pulmonary artery. Mean cardiopulmonary bypass time was 147±39 min, mean circulatory arrest time was 28± 8 min. Brain temperatures were best reflected by bladder and tympanum probes (Pearson's correlation coefficients: bladder = 0.83; tympanum = 0.80; pulmonary artery = 0.63; rectum = 0.37; p<0.05). Mean deviation from brain temperature were +0.2±2.7 °C at the tympanum, -0.8±2.6 °C in the bladder, -0.7±2.6 °C in the pulmonary artery and -1.8±4.4 °C in the rectum. In conclusion temperature monitoring in the bladder and tympanum reliably reflects brain temperature. Temperature measurements in the pulmonary artery and rectum are less optimal. Keywords: Circulatory arrest; Temperature monitoring; Hypothermia; Cardiopulmonary bypass; Cerebral aneurysm

[Vascular thoracic] Extending hybrid approach to residual Stanford type A dissecting aortic aneurysm

Chen, I-M., Shih, C.-C. — 2008-07-25

Residual Stanford type A dissecting aortic aneurysm was frequently encountered several years after emergent repair. Surgical approach remained challenging and hazardous not only due to the extensive involvement of the dilated false lumen but also the high comorbility of redo sternotomy and extensive thoraco-abdominal procedure. We present a modified hybrid technique incorporating arch replacement with bifurcated graft to relocate supra-aortic branches followed by anastomosis with reverse sleeve graft of elephant trunk over distal arch. After stent graft insertion over proper landing zone, all the communicating holes could be sealed and the compressed true lumen of descending aorta would be fully dilated. This technique not only simplified some laborious situations but also simultaneously resolved the entire thoracic dissection segment with an acceptable and optimal midterm result. Keywords: Aortic dissection; Aortic operation; Endovascular procedures/stents

[Transplantation] Intraoperative removal of a knotted Swan-Ganz catheter during lung transplantation

Camargo, J. d. J. P., Camargo, S. M., Machuca, T. N., Wagner, P. — 2008-07-24

We describe the case of a 52-year-old man with end-stage emphysema who underwent a right-sided lung transplantation. During preoperative monitoring an apparently non-functioning Swan-Ganz catheter could not be removed through the insertion site - right internal jugular vein. Another Swan-Ganz catheter was successfully installed through the left internal jugular vein, pulmonary artery pressures could be recorded and the transplant was performed uneventfully. Then, the first catheter was inspected and superior vena cava palpation surprisingly revealed a knot at approximately 25 cm. The catheter was pushed to the azygous vein, proximal and distal controls were obtained and a venotomy was performed. The knotted side was sectioned and removed, while the remaining catheter was removed through the insertion site. Despite rare, knotted intravascular devices have been increasingly reported. Removal with interventional radiology techniques can be accomplished in most instances, nevertheless, complex knots or knots fixed into cardiac structures require open removal. Since in our case the knot was detected intraoperatively, it was readily removed through the azygous vein. To the best of our knowledge, this is the first report to describe such a route of removal. Keywords: Lung transplantation; Catheter; Complications

[Aortic and aneurysmal (ICVTS only)] Does the administration of mannitol prevent renal failure in open abdominal aortic aneurysm surgery?

Hersey, P., Poullis, M. — 2008-07-24

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was whether mannitol might prevent renal failure in patients undergoing open repair of an abdominal aortic aneurysm. Altogether more than 25 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. In total, 319 patients were included in these 8 studies. Five of the included studies date from 1961-1965, and the remaining 3 from 1986, 1996 and 2002. The age of study is reflected in the level of evidence presented. The 3 recent studies provide evidence at a level of 1b, the remaining 5 giving evidence only at level 3b or 4. Of note also is that the earlier studies used urine output as their main indicator of renal failure in reaching their conclusions. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that no clinical trials to date have demonstrated any clinical reduction in the incidence of renal failure in patients undergoing repair of an abdominal aortic aneurysm who have been given mannitol. Keywords: Abdominal aorta; Aneurysm; Mannitol; Renal; Failure

[Cardiac general] Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective

2008-07-23

Previous reports have described penetrating cardiac injuries as the anatomic injury with the greatest opportunity for EDT survival. We hypothesize that actual survival rates are lower than that initially reported. A retrospective review of our EDT experience was performed. Data collected included injury mechanism and location, presence of measurable ED vital signs, initial ED cardiac rhythm, GCS, method of transportation, and survival. Logistic regression analysis identified predictors of survival. Ninety-four of 237 patients presented penetrating cardiac injuries after EDT. Eighty-nine patients (95%) were males. Measurable ED vital signs were present in 15 patients (16%). Cardiac injuries were caused by GSW in 82 patients (87%) and SW in 12 patients (13%). Fifteen patients (16%) survived EDT and were taken to the operating room, while 8 patients (8%) survived their entire hospitalization. All survivors were neurologically intact. Survival rates were 5% for GSW and 33% for SW. Mechanism of injury (SW), prehospital transportation by police, higher GCS, sinus tachycardia, and measurable ED vital signs were associated with improved survival. In urban trauma centers where firearm injuries are much more common than stabbings, the presence of a penetrating cardiac injury may no longer be considered a predictor of survival after EDT. Keywords: Trauma penetrating; Emergency surgery; Thoracotomy

[Experimental] New and simplified method for multiple left ventricle catheterizations in small animals

Migneco, F., Huang, Y.-C., Coyan, G. N., Birla, R. K. — 2008-07-23

Ventricular catheterization in the rat is a widely deployed procedure. Current options allow a one-time catheterization procedure, introducing an error due to the inter-individual variability. Six Fischer rats underwent left ventricular catheterization though the right carotid artery, repeated 7 days later via the left carotid artery. We acquired volume and pressure data from each animal during both procedures. Volumes and pressures were plotted to construct pressure-volume loops at the two time-points. The neurological outcome and the gross anatomy of the heart were also evaluated. We did not observe any major behavioral or neurological alteration in any of the animals. We observed a Horner syndrome with palpebral ptosis and enophtalmus in one animal. At the macroscopic evaluation of the explanted hearts, we observed perforation of the left ventricle in one case. This is a safe, easy, and reproducible procedure; it can be performed twice in the same animal with no neurological consequences. It is particularly suitable for longitudinal studies, to minimize the statistical error due to inter-individual variability. Keywords: Rat catheterization; Animal models; In-vivo measurement; Left ventricle catheterization

[Aortic and aneurysmal (ICVTS only)] Giant left coronary ostial aneurysm after modified Bentall procedure in a Marfan patient

Okamoto, K., Casselman, F. P., De Geest, R., Vanermen, H. — 2008-07-23

We performed surgical repair of a giant left coronary ostial aneurysm after aortic root replacement using composite valve graft (modified Bentall procedure) in a patient with Marfan syndrome. Aneurysmal formation in the left main stem itself is very rare. In order to avoid mobilizing the coronary ostium from severe adhesions after previous surgery and to reduce the tension on the anastomosis, the left main trunk was reconstructed using an interposition Dacron graft. In aortic root surgeries in Marfan patients, the size of side hole on the composite graft should be kept relatively small to fit the diameter of native coronary arteries for prevention of coronary buttons from forming aneurysms at the level of coronary button anastomosis. In addition, close observation to the coronary button anastmosis is indispensable in postoperative check-up. Keywords: Aortic root; Aneurysm; Reoperation; Surgery complications

[Cardiac general] Is steroid therapy ever of benefit to patients in the intensive care unit going into septic shock?

Richardson, L., Hunter, S. — 2008-07-21

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, is steroid therapy ever of benefit to patients in the intensive care unit going into septic shock? Using the reported search 1505 papers were identified. Fourteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. Recent guidelines from the Surviving Sepsis Campaign recommend using stress doses of corticosteroids for septic shock regardless of adrenal function. All patients undergoing cardiothoracic surgery are at risk of developing septic shock. The fourteen papers demonstrated that 28-day mortality is unaffected by hydrocortisone, however, the time to shock reversal is significantly reduced. Steroids reduced inflammatory mediators (IL-6, IL-8 and CRP) and neutrophil activation whilst maintaining neutrophil phagocytic functions. Haemodynamically, they increased systemic vascular resistance (SVR) and mean arterial pressure (MAP) and reduced heart rate (HR) and glomerular permeability. We conclude that steroids have no effect on mortality but shorten time to shock reversal, therefore have a limited capacity in septic shock patients. Their immunological and haemodynamic effects cannot be discounted and could benefit patients in severe septic shock with adrenal insufficiency. Keywords: Steroid; Hydrocortisone; Septic shock; Intensive care unit; Mortality; Shock reversal

[Cardiopulmonary bypass] Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery?

Malvindi, P. G., Scrascia, G., Vitale, N. — 2008-07-21

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether unilateral antegrade cerebral perfusion is equivalent to bilateral cerebral plegia for cerebral protection during aortic arch surgery. Altogether 233 papers were found using the reported search, of which 17 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. These papers documented antegrade selective cerebral perfusion in a total of 3548 patients: bilateral cerebral perfusion in 2949 patients and unilateral perfusion in 599 patients. Both methods of cerebral perfusion resulted in neurological injury rates of less than 5%, but the period of antegrade cerebral perfusion allowed by bilateral perfusion was significantly higher. While unilateral perfusion allowed around 30-50 min, bilateral perfusion allowed 86 to over 164 min of ASCP with an acceptably low CVA rate. Therefore we conclude that while both methods are acceptable, once the ASCP time is expected to rise over 40-50 min, bilateral cerebral perfusion is the technique that is best documented to be safe. Keywords: Aortic arch surgery; Cerebral perfusion; Neurologic outcome

[Cardiac general] Is manipulation of mediastinal chest drains useful or harmful after cardiac surgery?

Day, T. G., Perring, R. R., Gofton, K. — 2008-07-18

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients who have undergone cardiothoracic surgery does manipulation of drainage tubes affect drainage volumes or post-surgical outcome? Altogether 681 papers were found using the reported search, of which 4 represented the best evidence to answer the clinical question. Duncan and Erickson in 1982 found that chest tube stripping can lead to very low negative intrathoracic pressures. The authors report that this has the potential to cause tissue injury. Issacson et al. in 1986 compared two different methods of drain manipulation. They found no significant differences in the milking and stripping methods, suggesting that they are of similar efficacy in enhancing drainage. Lim-Levy et al. in 1986 also compared milking versus stripping, with a control group that received no manipulation. They found no significant differences between the three groups in drainage volume. Furthermore, they recorded no incidences of tube occlusion in any of the three groups, implying that leaving the drains free of manipulation is acceptable in terms of clot clearance in the majority of patients. The milking and stripping methods were also compared by Pierce et al. in 1991. They also found no significant differences between the two manipulation methods. The studies by Issacson et al., Lim-Levy et al., and Pierce et al. were included in a Cochrane systematic review by Wallen et al. in 2002. No other relevant studies other than the three mentioned above were found after an extensive search of the literature. Overall, the authors concluded that there was insufficient evidence to recommend one type of drain manipulation technique over another, or to support or refute the need for drain manipulation at all. In our paper the authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that due to possible tissue damage and lack of demonstrable benefit, in most patients drainage tube manipulation should not be performed. No differences in either safety or efficacy have been demonstrated between the milking and stripping methods of manipulation. Keywords: Thoracic surgery; Cardiac surgical procedures; Chest drain; Drainage

[Coronary] Off-pump coronary artery bypass surgery in very high-risk patients: adjustment and preliminary results

2008-07-18

Left ventricle dysfunction and comorbidities are responsible for a large number of complications after CABG. OPCAB could be an interesting alternative for very high-risk patients. Patients were included if EuroSCORE >9, or with at least two of the following criteria, severe LV dysfunction, recent myocardial infarction (MI), terminal renal failure, lung dysfunction, PVD, BMI >30. Patients were operated using the Octopus® (Medtronic) system. 120 patients, mean age 68±10 years, 72% male, were operated. Mean EuroSCORE was 10.2±5.3, LV function 36.79±11.3%, recent MI 57%, renal failure 52%, COPD 44%, PVD 52%, obesity 34%. Mean graft per patient was 2.1±0.8. Three patients underwent secondary PTCA treatment for incomplete revascularization. Combined surgery was required for 20%. Early mortality was 3%. Intensive care unit stay was 2.7 days. Early complications were: low output syndrome 3%, MI 0.8%, stroke 0.8%, kidney support 7%. Graft patency was systematically analyzed with MCTA or angiocardiography. OPCAB strategy seems to be safe and secure in this population of very high-risk patients reducing multi-organ failure. However, long-term results are needed to confirm this strategy. Keywords: Coronary artery bypass graft; Off-pump; High-risk surgery

[Esophagus] Esophageal laceration with intramural dissection mimics esophageal perforation

Wu, H.-C., Hsia, J.-Y., Hsu, C.-P. — 2008-07-18

Esophageal laceration with intramural dissection is a rare type of injury but without perforation. It is difficult to differentiate from esophageal perforation at presentation time. We report the case of a 46-year-old man who was admitted to our hospital complaining of progressive chest pain, dysphagia, and odynophagia after swallowing a fish bone 3 days ago. Esophagoscopy revealed a deep longitudinal laceration with pus discharge in the esophagus. Computed tomography of chest revealed low posterior mediastinal abscess formation. Surgery was performed under the impression of esophageal perforation. The definite diagnosis was esophageal laceration with intramural dissection. Keywords: Esophageal laceration; Intramural dissection; Perforation

[Thoracic general] Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients?

Chamogeorgakis, T., Ieromonachos, C., Georgiannakis, E., Mallios, D. — 2008-07-18

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients?'. Altogether 225 papers were found using the reported search, of which nineteen represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. A meta-analysis published in 2005 showed a 0.7% (p=0.3659) survival difference at one year, 1.9% (p=0.5088) at 3 years and 3.6% (p=0.3603) at 5 years. The largest study prior to the meta-analysis was a randomized controlled study of 247 patients with T1N0 tumors that showed 8 locoregional recurrences in the lobectomy group compared to 21 in the sublobar group which was statistically significant. Since the meta-analysis we identified three studies, two of which showed no difference in survival and recurrence between wedge resection and lobectomy for T1N0 tumors and one that showed improved survival after lobectomy compared to wedge resection for T1N0 tumors. We conclude that wedge resection is not comparable to lobectomy for stage IA NSCLC. The increased long-term mortality associated with wedge resection is mainly due to non-cancer deaths, reflecting a higher risk patient group with many comorbid conditions. Segmental resection is comparable to lobectomy for small peripheral tumors. Sublobar resection is associated with shorter hospital stay. For bronchioalveolar carcinoma sublobar resection is recommended provided intra-operative pathologic consultation confirms pure bronchioalveolar histology without evidence of invasion, and surgical margins are free of disease. Keywords: Non-small cell lung cancer; Limited resection; Sublobar resection; Segmentectomy; Wedge resection; Lobectomy; Recurrence

[Cardiac general] Primary left atrial haemangioendothelioma

Messias, P., Bernardo, J. E., Antunes, M. J. — 2008-07-17

We describe the case of a 21-year-old female patient with epithelioid haemangioendothelioma of the roof of the left atrium. The patient underwent radical resection of the tumour with large disease-free margins, which required reconstruction of left and right atrial superior walls. The prognosis is unpredictable, but life expectancies ranging from 1 to 20 years have been described. There is no single treatment that can be prescribed but, because of their biologic behavior, epithelioid hemangioendotheliomas must be regarded as fully malignant neoplasms and ought to be resected radically to prevent metastatic disease, and to improve life expectancy and quality of life. Keywords: Cardiac tumour; Cancer; Hemangioendothelioma

[Cardiac general] The Haemonetics(R) Cell Saver 5 washing properties: effect of different washing pump and centrifuge speeds

Naumenko, K. S., Kim, S. F., Cherkanova, M. S., Naumenko, S. E. — 2008-07-17

This study evaluated the effect of different washing and centrifuge rates of the Cell Saver 5 on the quality of processed autologous blood. Autologous blood was washed with 1000 ml of sterile normal saline at centrifuge speed of 5650 revolutions per min (rpm) (group I) or 4350 rpm (group II) with different washing pump speeds - 500, 800 and 1000 ml/min. Hemoglobin, free hemoglobin, hematocrit, erythrocytes, leucocytes, platelets, protein were measured before and after processing. The highest values of hemoglobin, hematocrit and erythrocytes were achieved using 800 and 1000 ml/min pump speeds in group I and 500 ml/min speed in group II. There was more effective red blood cells concentration in group I. There were no significant changes of free hemoglobin removal within group I. In group II the lowest free hemoglobin was achieved when 1000 ml/min rate was used. Platelets and protein did not depend on wash pump speeds in both groups. Platelets recovery in group I was higher than in group II at all washing pump speeds. Leuucocytes were not adequately removed at all pump speeds. The Cell Saver 5 produces optimum results when the high wash pump speeds (800 and 1000 ml/min) and standard centrifuge speed are used. Keywords: Blood; Cardiopulmonary bypass; Cell saver

[Vascular thoracic] Rapid and safe establishment of cardiopulmonary bypass in repair of acute aortic dissection: improved results with double cannulation

Minatoya, K., Ogino, H., Matsuda, H., Sasaki, H. — 2008-07-17

There is no agreement at present as to which is the optimal site for artery cannulation for cardiopulmonary bypass in repair of acute aortic dissection (AAD). We have employed right axillary artery cannulation (RAAC) in combination with femoral artery cannulation to overcome the drawbacks of single cannulation. From January 2000 to August 2006, eighty-eight patients underwent emergency surgical repair of the aortic arch (mean age 65±13, 37 men) for AAD. All operations were performed under hypothermic circulatory arrest with antegrade selective cerebral perfusion. Preoperatively, 9 patients were in shock and 18 patients showed malperfusion. The average duration of circulatory arrest was 52±17 min and that of myocardial ischemia was 135±53 min. Total aortic arch replacement was done in 47 patients and hemiarch aortic replacement in 41. The hospital mortality rate was 2.3% (2 of 88); the fatal cases were among those who were in shock preoperatively. The perioperative stroke rate was 5.7% (5 of 88). The hospital mortality rate of the 25 patients with preoperative malperfusion was 4.0% (1 of 25); the fatal case had coronary malperfusion. Our approach for AAD was associated with a low mortality even in patients with malperfusion. Keywords: Acute aortic dissection; Cannulation; Axillary artery

[Transplantation] Early tracheal extubation in adults undergoing single-lung transplantation for chronic obstructive pulmonary disease: pilot evaluation of perioperative outcome

Augoustides, J., Watcha, S. M., Pochettino, A., Jobes, D. R. — 2008-07-15

The objective of this pilot study was to evaluate the safety and success of early tracheal extubation (ETE) as compared to delayed tracheal extubation (DTE) in single-lung transplantation (SLT) for chronic obstructive pulmonary disease (COPD). This retrospective observational study was undertaken at a university hospital. Fifty-seven adult patients who underwent SLT for COPD (1998-2003) were enrolled. The study cohort was divided into an ETE subgroup (tracheal extubation in the operating room) or a DTE subgroup (tracheal extubation in the intensive care unit). There were no significant differences in perioperative outcomes between subgroups (in-hospital mortality; length of stay; prolonged mechanical ventilation; primary graft dysfunction; pneumonia; atrial fibrillation; renal dysfunction; and, sepsis). The anesthetic technique associated with ETE in SLT for COPD was characterized by limited systemic anesthetics and perioperative thoracic epidural analgesia. Appropriate ETE in SLT for COPD is not only safe but also results in equivalent perioperative outcome when compared to the traditional technique of DTE. Future studies should be powered to examine whether ETE reduces native lung complications such as hyperinflation, pneumonia and pneumothorax. Keywords: Lung transplantation; Perioperative outcomes; Chronic obstructive pulmonary disease; Early tracheal extubation

[Valves] The changing spectrum of bioprostheses hydrodynamic performance: considerations on in-vitro tests

Bottio, T., Tarzia, V., Rizzoli, G., Gerosa, G. — 2008-07-15

The aims of the present study were to compare hydrodynamics of three pericardial and two porcine valves while performing at different stroke volume (SV) and increasing pulse rate (PR). Carpentier-Edwards Magna-21 (CEM), Sorin Soprano-20 (SS), Mitroflow-23 (MF), SJM-Biocor-Epic-Supra-21 (SJME), and Medtronic Mosaic Ultra-23 (MMU) were tested in the aortic chamber (23-mm in diameter) of the Sheffield-Pulse-Duplicator. The tests were carried out at increasing pulse-rate and at each pulse-rate the valve was tested at different SV. CEM and MF showed significantly lower gradients than porcine valves and SS. Transvalvular gradients were unrelated to PR showing a constant value with increasing PR. While SJME valve showed the lowest regurgitant volume, on the contrary CEM showed the highest. At increasing SV, effective-orifice-area (EOA) observed with CEM was significantly larger than with the other tested valves, even though at SV 60 ml MF was comparable and at SV 65 ml significantly better. SS, SJME and MMU showed comparable EOAs with bigger area at increasing PR. The latter relation was reversed for CEM and MF. Our results show that CEM and MF have shown significantly better in-vitro hydrodynamics in comparison with their porcine counterpart and SS. Nevertheless, at increasing pulse rate, porcine tissue valves and SS may guarantee higher EOA values. Keywords: Sheffield Pulse Duplicator; Supra-annular tissue valves; In-vitro tests; Patient prosthesis mismatch

[Carotid and imaging (ICVTS only)] Occult carotid artery disease in patients who have undergone coronary angioplasty

2008-07-15

Objectives: The aim was to evaluate the prevalence of asymptomatic mild (30-49%), moderate (50-69%) and severe (70-99%) ICA stenosis in patients who underwent previous coronary angioplasty (PTA). Methods: After obtaining ethics committee approval, 144 consecutive patients aged between 65 and 75 years were invited for carotid Duplex evaluation with a linear 6 MHz array transducer by trained vascular sonographers within a single unit. A peak systolic velocity )230 cm/s in the ICA was considered as significant (>70% stenosis). Results: Of the 144 patients approached, 117 (81%) attended (male:female ratio 3.2:1, age range 65–75 years, median age 71 years). Duplex ultrasound revealed one occlusion, 70% or more ICA stenosis in three patients (2.6%), 50-69% stenosis in 12 patients (10.3%) and 30–49% stenosis in 29 patients (24.8%). Conclusions: Carotid artery disease with a luminal stenosis of 30% or more is common in patients who underwent previous PTA. The yield of significant ICA stenosis (70% or more), which would benefit from carotid endarterectomy according to the Asymptomatic Carotid Surgery Trial is low. Recommendation for initial screening and subsequent follow-up Duplex examination for evaluation of disease progression of such cohorts remains debatable. Keywords: Carotid artery stenosis; Coronary angioplasty; Screening

[Arrhythmia] Surgical treatment of atrial fibrillation using cryothermy in patients undergoing mitral valve surgery

2008-07-15

Surgical treatment of atrial fibrillation (AF) using a variety of energy sources and a mixture of lesion sets has become an important adjunct in patients undergoing cardiac surgery. We retrospectively analyzed prospectively collected data of 141 patients with a history of AF (mean duration of AF 35±39 months; intermittent AF: n=72; 51%; permanent AF: 69 (49%)) who underwent a left-sided Cryomaze procedure in conjunction with mitral valve (MV) surgery between January 2003 and September 2006. Freedom from AF was 77% at discharge and 87% at a mean follow-up of 305±195 days with a decreasing rate of AF during the first 3-9 months from 13% to 9% and an increase beyond the first year (29% at 2 years). Predictors of failed Cryomaze in multivariate analysis were left atrial size >50 mm (OR=5.7), AF at surgery (OR=5.0) and cardiac reoperation (OR=3.4), whereas preoperative beta-blocker treatment was a predictor of success (OR=0.2). Our data suggest that a left-sided Cryomaze procedure effectively restores sinus rhythm in patients with AF undergoing MV surgery. The success rate should not be evaluated immediately postoperatively because there is a steady increase in the rate of patients with freedom from AF in the first year. It appears, however, that there is a higher rate of recurrence during later follow-up. Keywords: Atrial fibrillation; Maze procedure; Mitral valve surgery; Outcome

[Thoracic general] Donor cryopreserved rib allografts for chest wall reconstruction

Aranda, J. L., Varela, G., Benito, P., De Juan, A. — 2008-07-10

Reconstruction after large chest wall resections must ensure not only anatomical coverage but a normal respiratory function, esspecially in the case of associated ventilatory disturbance. Since prosthetic reconstruction can present some problems such as rejection, excessive rigidity or infection, bone grafts have been proposed as an alternative to synthetic materials, due to their effectiveness and capability of integration with host tissues. Although iliac bone allograft or autologous ribs harvested from the opposite operative side are described for reconstruction, we present here the first reported clinical case of donor cryopreserved rib allografts use after extensive chest wall resection in a patient with severe COPD, showing excellent short-term results in the absence of pulmonary function impairment. Keywords: Rib grafts; Tissue bank; Chest wall resection; Reconstruction

[Aortic and aneurysmal (ICVTS only)] Impact of pre-existing conditions, age and the length of cardiopulmonary bypass on postoperative outcome after repair of the ascending aorta and aortic arch for aortic aneurysms and dissections

Schwartz, J. P., Bakhos, M., Patel, A., Botkin, S., Neragi-Miandoab, S. — 2008-07-10

Background: Repair of the ascending aorta and aortic arch carries a high morbidity and mortality, which can be complicated by the often emergent nature of the intervention. Methods: We retrospectively evaluated the morbidity, mortality, and long-term survival in 101 patients who underwent repair of ascending aorta and aortic arch. Depending on the urgency of the operation, the patients were categorized as elective (EL, n=82) or emergent (EM, n=19). Log-rank-list and SPS were used to evaluate the data. Results: The average age was 58±16 years. The aortic diameter was 5.5±1 cm in the EL group and 6.1±1.4 cm for EM group. The aortic dissection in EL and EM groups was 15% and 79%, respectively. The mean circulatory arrest time (n=32 patients) was 38±18.5 min. The overall 30-day mortality was 4%: 0% for the EL group and 26% for the EM group. The overall 6-month mortality was 8%: 3.7% and 26% in EL and EM groups, respectively. Overall CVA was 3%: 0% in the EL group and 15.7% in the EM group. The mean CPB time was 176±81 min. The prolonged CPB time correlated with increased need for blood transfusion. The LOS was 12±8 days and correlated with increasing age (95% CI 0.06860–0.2307, P=0.0004), with NYHA stage of patients at the time of surgery (95% confidence intervals, 1.328–4.202, P=0.0003), with left ventricular ejection fraction (95% CI 0.2357 to -0.003029, P=0.0442) and with postoperative atrial fibrillation (95% CI 0.1192–0.4745, P=0.0018). The average ICU stay was 123±145 h. A prolonged CPB time resulted in extended ICU stay (95% CI 0.3655-1.486, P=0.0014). Further, the length of ICU stay correlated with NYHA status (95% CI 19.98–73.42, P=0.0008), age (95% confidence intervals 0.01668-3.761, P=0.0477), urgency of surgery (95% CI 65.00-124.0, P<0.0001), and length of CPB time (95% CI 0.3655-1.486, P=0.0014). Conclusion: Emergent operations are associated with high morbidity and mortality. Pre-existing heart failure, advanced age, and prolonged cardiopulmonary bypass are associated with prolonged monitoring in the ICU. Keywords: Aortic dissection; Ascending aorta; Aortic arch; Aortic aneurysm

[Experimental] Effect of systemically administered low potassium dextran solution on oxidative stress in a rat model of lung ischemia

Torres, R. L., Martins, L. K., Andrade, C. F., Cardoso, P. F. G. — 2008-07-10

Systemic administration of the low-potassium dextran solution on the peripheral oxidative stress was evaluated in an animal model of lung ischemia-reperfusion in rats. In one experiment, male Wistar rats were divided into two groups (n=5): one received intravenous saline, whereas in the other the animals were given intravenous low potassium dextran solution. In another experiment, male Wistar rats were divided into four groups (n=5): control, ischemia, saline and low potassium dextran. Except for the control animals, all groups were submitted to left hilar clamping for 30 min, followed by reperfusion for 30 min. Saline or low potassium dextran was administered intravenously immediately before clamp removal. In the first experiment there were no significant differences in lipid peroxidation. Total radical trapping potential measurements showed a significant increase in animals receiving low potassium dextran; in the second experiment, there was an increase in lipid peroxidation in both saline and ischemia groups compared to controls, and low potassium dextran. Low potassium dextran group showed an increase in total radical trapping potential measurements compared to all other groups. Ischemia-reperfusion injury mediated by reactive oxygen species was attenuated by the systemic use of low potassium dextran in this animal model of ischemia-reperfusion of the lung. Keywords: Ischemia-reperfusion; Free radicals; Low potassium dextran; Lung; Transplantation; Rats

[Coronary] Spontaneous left main coronary artery dissection

Cini, R., Iezzi, F., Sordini, P., Pasceri, V. — 2008-07-09

Spontaneous coronary artery dissection is a rare and generally fatal disease. A review of the literature demonstrates that the aetiopathogenesis of the disease is unknown and that the histology is rarely described. It usually occurs in young women during the post- partum period or while taking oral contraceptives. The treatment depends on the clinical presentation and the results of the angiography. We report here a case of spontaneous dissection of the left main stem coronary artery, with extension into the left coronary territory which which occurred in a 43-year-old woman. Keywords: Coronary dissection; Estro-progestinic therapy; Surgical revascularization

[Valves] Amplatzer occlusion of paravalvular leak of mitral mechanical prosthesis following a reoperation for trombosed mitral mechanical prosthesis

Nikolic, A., Schranz, D., Hristov, N., Mitrev, Z. — 2008-07-09

We describe a case of a 46-year-old woman with dehiscence and paravalvular leak of a second-time replaced mitral mechanical prosthesis, successfully treated with Amplatzer occlusion of the paravalvular leak, thus avoiding a second reoperation and improving the patient's symptoms. Keywords: Thrombosed mitral prosthetic valve; Prosthetic valve endocarditis; Reoperation; Paravalvular leak; Amplatzer occlusion

[Thoracic general] Incidence of atrial fibrillation after extrapleural pneumonectomy versus pleurectomy in patients with malignant pleural mesothelioma

Neragi-Miandoab, S., Winer, S., Sugarbaker, D. J. — 2008-07-09

Extrapleural pneumonectomy (EPP) and pleurectomy are the surgical procedures for the treatment of pleural mesothelioma. However, EPP increases the risk for postoperative atrial fibrillation (AF) in this patient population, which might be partly explained by increase in right heart stress after EPP. We conducted a retrospective chart review of 130 patients who were treated for malignant pleural mesothelioma with either pleurectomy or EPP between 2001 and 2003 in a single institution. Risk factors for AF were evaluated with logistic regression and the postoperative AF events were evaluated. The absence of a history of cardiac arrhythmia was an inclusion criterion. Seventy patients (excluding the 3 patients with a prior history of AF) underwent EPP and 57 patients underwent pleurectomy. The mean ages were 60±11 and 63±13, and the male to female ratios were 50/20 and 44/13, respectively. Postoperative AF was observed in 45 patients with 36 (51%) of these cases occurring after EPP and 9 (17%) after pleurectomy (p<0.0001). There were no significant differences between the two treatment groups for gender, age, side of affected lung, preoperative heart rate and history of beta-blocker use, coronary heart disease, and chronic obstructive pulmonary disease. There were significant differences between the two groups for cancer histology (p=0.03) with the EPP group having a larger proportion of epithelial-type histology. Through logistic regression, EPP (OR=7.1, 95% CI: 2.9, 17.8) and age over 65 (OR=2.9, 95% CI: 1.2, 6.8) were found to be risk factors for AF. Abnormal cardiac structure and function were identified as important possible confounder, which could not be adequately evaluated due to missing data. Most of these patients had at least one additional expected risk factor for AF. EPP versus pleurectomy and age over 65 are risk factors for postoperative AF. The increased odds of having AF after EPP could be due to right heart stress caused by pneumonectomy. Increased right heart stress might not be sufficient to cause AF alone, but may be an important risk factor that warrants further investigation. Keywords: Right heart stress; Extrapleural pneumonectomy; Pleurectomy; Atrial fibrillation

[Arrhythmia] Biventricular pacing for end-stage heart failure: early experience in surgical versus transvenous left ventricular lead placement

Atoui, R., Essebag, V., We, V., Ge, Y., Auclair, M.-H., Hadjis, T., Shum-Tim, D. — 2008-07-09

Transvenous coronary sinus lead placement is currently the standard approach for left ventricular pacing. The aim of this study is to assess whether a mini-thoracotomy approach would be feasible and safe when used for cases in which transvenous procedures were ineffective or judged unlikely to succeed. Biventricular pacing was performed in 138 consecutive patients with 47 patients undergoing a mini-thoracotomy procedure. NYHA status, quality of life, electrical and echocardiographic data were assessed in the two groups over a follow-up period of 17.6±4.2 weeks. There was no significant difference in the preoperative characteristics in both groups other than a greater prevalence of renal failure and previous cardiac surgery among the surgical patients. The mean procedure time was significantly longer in the transvenous group. No significant differences were noted in the immediate or long-term pacing parameters. Two mortalities were observed in the surgical group > 2 weeks following the procedure. During the follow-up period, we noted a comparable improvement in the echocardiographic parameters, QRS duration and NYHA status with both approaches. Our results suggest that even when performed on high-risk patients, epicardial lead placement through a mini-thoracotomy is beneficial and feasible as a 'rescue' procedure after a failed transvenous approach. Keywords: Mini-thoracotomy; Chronic resynchronization therapy; Epicardial leads; Biventricular pacing; Congestive heart failure

[Thoracic general] Mortality, complications and loss of pulmonary function after pneumonectomy versus sleeve lobectomy in patients younger and older than 70 years

2008-07-04

Retrospective single institution analysis of all patients undergoing sleeve lobectomy or pneumonectomy between 2000 and 2005. Seventy-eight patients underwent pneumonectomy (65 patients <70 years, 13 patients >70 years) and 69 sleeve lobectomy (50 patients <70 years, 19 patients >70 years). Pre-existing co-morbidity, surgical indication and induction therapy was similarly distributed between treatment by age-groups. In patients <70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 3% vs 0 and an overall complication rate of 26% vs 44%, respectively. In patients >70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 15% vs 0 and an overall complication rate of 23% vs 32%. In both age groups, pneumonectomy was associated with more airway complications (NS) and a significantly higher postoperative loss of FEV₁ than sleeve lobectomy (p<0.0001, p<0.03). Age per se did not influence the loss of FEV₁ and DLCO for a given type of resection. Sleeve lobectomy may have a therapeutic advantage over pneumonectomy in the postoperative course of elderly patients. Keywords: Age; Pneumonectomy; Sleeve lobectomy; Pulmonary function; Morbidity; Mortality

[Cardiac general] Early dialysis in acute kidney injury after cardiac surgery

Manche, A. R., Casha, A. R., Rychter, J., Farrugia, E., Debono, M. — 2008-07-04

Acute kidney injury following cardiac surgery (AKICS) remains a frequent cause of major morbidity and mortality. The aim of this study was to examine the influence of timing of dialysis. A retrospective analysis of 3528 patients undergoing cardiac surgery between April 1995 and July 2006 was performed. In group 1 (April 1995-January 2000) intermittent haemodialysis was resorted to when other supportive measures failed. In group 2 (January 2000-July 2006) intermittent haemodialysis was commenced immediately when oliguria did not respond to fluid replacement or single-dose diuretics. In group 1, 49/1511 (3.2%) patients developed AKICS. 34 patients did not receive dialysis and 6 patients died (18%). Of the remaining 15 patients who underwent dialysis 13 died (87%). The overall mortality for group 1 AKICS patients was 19/49 (39%). In group 2, 87/2017 (4.3%) patients developed AKICS. 31 patients did not require dialysis and none died. Of the 56 patients who were dialysed, 14 died (25%). During January 2005-July 2006, mortality following dialysis fell further to 17% (4/24). The overall mortality for group 2 patients developing AKICS was 14/87 (16%). Although the incidence of AKICS increased from 3.2% to 4.2%, earlier dialysis resulted in significantly improved survival (p = 0.00001). Keywords: Acute kidney injury; Cardiac surgery; Early dialysis; Outcome

[Cardiac general] Utilization and outcome of coronary revascularization and valve procedures in acute heart failure. An evaluation based on the classification from the European Society of Cardiology

Hermansen, S. E., Hansen, M., Roaldsen, M., Muller, S., How, O.-J., Myrmel, T. — 2008-07-04

Early invasive treatments in patients with acute heart failure (AHF) are critical components to improve outcome. We aimed to establish if such treatments were applied according to existing guidelines and also to assess the subsequent mortality in the complete AHF population. All patients with AHF admitted to the intensive care unit/coronary care unit during the years 2003-2004 (n=302) were retrospectively reviewed and classified according to the European Society of Cardiology. Invasive revascularization was applied more frequently in patients with cardiogenic shock following acute coronary syndromes (78%, n=40) than in less severe AHF (58%, n=62, p<0.05). Only 8% (n=4) of eligible patients with acute coronary syndromes and cardiogenic shock were treated non-invasively. Valvular dysfunction was a precipitating factor for AHF in 15% (n=38). Acute mitral regurgitation was treated surgically exclusively in patients with mechanical defects. In-hospital mortality rates for less severe AHF was 12%, cardiogenic shock 46% and postcardiotomy HF 32%. Invasively treated patients had lower in-hospital mortality in both cardiogenic shock (35% vs. 70%, p=0.006) and less severe AHF (6% vs.17%, p=0.042). The study revealed an appropriate use of invasive revascularization. The high mortality in patients with severe AHF indicates that more effective treatment options are needed in eligible patients. Keywords: Heart failure; Shock; Cardiogenic; Myocardial revascularization; Mortality; Acute coronary syndrome; Heart valve disease

[Coronary] Acute and long-term outcome of unprotected left main coronary angioplasty compared to the anticipated surgical risk

2008-07-04

Objectives: Percutaneous coronary intervention of unprotected left main (ULM) stenosis is increasing despite surgical revascularization being the recommended treatment by the current guidelines. We compared the 30-day and 9-month mortality after ULM stenting with the predicted surgical outcome as determined by the EuroSCORE. Methods and results: We included 81 consecutive patients who underwent ULM stenting. The patient cohort was divided into a normal risk group (EuroSCORE ≤5, predicted 30-day mortality <3%), and a high-risk group (EuroSCORE >5, predicted 30-day mortality 11%). Follow-up examinations were scheduled for one and nine months after the initial PCI. The average EuroSCOREs in the normal- and high-risk group were 3.0 (29 patients, 36%) and 10.0 (52 patients, 64%), respectively. Mortality rates at 30 days were 3% in the normal-risk group and 8% in the high-risk group. Subacute stent thrombosis occurred in 3.4% (3 patients) undergoing elective PCI. Major adverse cardiac events during the 9 months follow-up were registered in 24% of patients in the normal-risk group, and in 27% of the patients in the high-risk group. Conclusion: Short-term outcome of ULM stenting in our high-risk patients is comparable to surgical outcome predicted by the EuroSCORE. Long-term outcome was less favourable due to a high mortality rate. ULM stenting in patients with low surgical risk could be associated with higher mortality rates compared to CABG because of the unpredictable risk of a fatal stent thrombosis. Keywords: Left main coronary artery; Coronary artery bypass grafting; Angioplasty; Mortality; Risk stratification

[Cardiac general] Prosthetic valve sparing aortic root replacement: an improved technique

Leacche, M., Balaguer, J. M., Umakanthan, R., Byrne, J. G. — 2008-07-02

We describe a modified surgical technique to treat patients with a previous history of isolated aortic valve replacement who now require aortic root replacement for an aneurysmal or dissected aorta. This technique consists of replacing the aortic root with a Dacron conduit, leaving intact the previously implanted prosthesis, and re-implanting the coronary arteries in the Dacron graft. Our technique differs from other techniques in that we don't leave behind any aortic tissue remnant and also in that we use a felt strip to obliterate any gap between the old sewing ring and the newly implanted graft. In our opinion, this promotes better hemostasis. We demonstrate that this technique is safe, feasible, and results in acceptable outcomes. Keywords: Root replacement; Reoperation; Aortic valve prosthesis

[Experimental] The effect of sivelestat sodium on post-cardiopulmonary bypass acute lung injury in a neonatal piglet model

Ando, M., Murai, T., Takahashi, Y. — 2008-07-02

Cardiopulmonary bypass may cause acute lung injury and can seriously affect postoperative outcome, especially in younger patients. A synthesized neutrophil elastase inhibitor, sivelestat sodium, may be most effective when used during cardiopulmonary bypass. After anesthesia induction, sivelestat (2 mg/kg/h) was given to the SS group (n=7), and 0.9% saline solution to the placebo group (n=7). Piglets were placed on hypothermic cardiopulmonary bypass and subjected to myocardial ischemia (2 h) induced by cold crystalloid cardioplegia. At 24 h after surgery, PaO₂/FiO₂ ratio and alveolar-arterial oxygen difference were significantly better in the SS group (379.1±93.9 mmHg and 250.5±89.3 mmHg) than the placebo group (232.4±105.3 mmHg, and 378.3±90.8 mmHg, p<0.05). Interleukin-8 level in the epithelial lining fluid was above the lowest standard in 6 out of 7 (4.5, 12.9, 24.6, 27.7, 37.7, and 159.8; mean=44.5±57.6 g/l) in the placebo group, and in 2 out of 7 (36.1 and 67.8 g/l) in the SS group (p<0.05). The median histological score of acute lung injury in the harvested lung was 3 (2-5) in the placebo group and 1 (1-5) in the SS group (p<0.05). Intraoperative administration of sivelestat effectively reduced neutrophil induction and activation in the lung and improved oxygenation after cardiopulmonary bypass in a piglet model. Keywords: Sivelestat sodium; Neutrophil activation; Systemic inflammatory response; Cardiopulmonary bypass

[Aortic and aneurysmal (ICVTS only)] Translumbar treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysm

2008-07-02

The modality of treatment and the appropriate time point to treat type II endoleaks after endovascular repair of abdominal aortic aneurysms (EVAR) remain controversial issues. The purpose of the present study was to assess the efficacy of translumbar embolization of type II endoleaks after endovascular repair of aortic aneurysm repair. Eighty-four consecutive patients after EVAR were analyzed for the onset of type II endoleaks. Of these, five patients had experienced translumbar embolization after ineffective intraartrial approach to exclude the endoleak. A combination of several liquid embolic agents was used as sealant. Post-procedural contrast enhancedultrasound (CEUS) was used to document the outcome of the embolization. Translumbar embolization was successful in 4 patients. Complete sealing of the nidus was seen on CEUS 24 h after the procedure. In one patient with a duplication of the inferior vena cava, the procedure was aborted because an additional type Ib endoleak was found. The procedure was well tolerated by all patients. The translumbar approach to treat growing aneurysm sacs in patients with persistent type II endoleaks is safe and well tolerated. The immediate post-interventional outcome as documented on CEUS is promising. Long-term follow-ups are yet to be performed. Keywords: Endovascular; Aortic aneurysm; Endoleak; Embolization

[Cardiac general] A 5-year clinical experience with bipolar radiofrequency ablation for permanent atrial fibrillation concomitant to coronary artery bypass grafting and aortic valve surgery

Geidel, S., Lass, M., Ostermeyer, J. — 2008-07-02

This study analyses the 5-year results of permanent atrial fibrillation (pAF) bipolar radiofrequency (RF) ablation surgery concomitant to coronary artery bypass grafting (CABG) and/or aortic valve (AV) surgery. Eighty-five patients with pAF (0.5-30 years) underwent bipolar RF ablation procedure concomitant to CABG/AV surgery. All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class at 8±1 days and at 3±1 and 32±15 months after surgery. Survival at time of re-examination was 100, 98 and 96%, respectively (three non-cardiac deaths), SR could be documented in 61, 74 and 78% of patients. Long-term AF before surgery and larger size of the left atrium (LA) were predictive for postoperative AF return (p=0.005, p=0.03); 88% of patients with small preoperative LA-size (<50 mm) and 85% with pAF-duration time <5 years had stable SR at late follow-up. Cardiac rhythm at 3 months was predictive for long-term rhythm-prognosis (p<0.0001). NYHA-class improved significantly after surgery (p<0.0005), particularly when SR was achieved (p=0.046). Permanent AF bipolar RF ablation surgery revealed excellent results in AV/CABG patients. It could be demonstrated that established SR remained stable over time. Preoperative pAF-duration time and LA-size are useful variables to predict the success-rate of ablation. Keywords: Aortic valve surgery; Arrhythmia surgery; Atrial fibrillation; Bipolar radiofrequency ablation; Coronary artery bypass grafting; Radiofrequency ablation

[Pulmonary] Pulmonary resection for metastasis from renal cell carcinoma

2008-07-01

The treatment of metastatic renal cell carcinoma still represents a widely debated issue due to the introduction of several immunotherapies. To confirm again a role for resection of pulmonary metastases for such tumors, we reviewed our institutional experience. Between 1992 and 2007, 8 patients with pulmonary metastases from renal cell carcinoma underwent complete pulmonary resection. All patients had undergone curative resection of their primary renal cell carcinomas and also had obtained or had obtainable locoregional control of their primaries. Various perioperative variables were investigated retrospectively. Disease-free interval varied from 25 to 156 months, with a median of 73 months. In 3 patients, lung metastases were found to be unilateral and solitary. Four patients presented 2 metastases in the unilateral lungs. One patient showed 5 metastases in the bilateral lungs. Six patients underwent wedge resection or segmentectomy, while 2 patients underwent more than lobectomy. Five patients showed recurrence after pulmonary metastasectomy. Five-year and 10-year overall survival rate was 83.3% and 41.7%, respectively, while 3-year and 5-year disease-free survival rate was 35.0% and 17.5%, respectively. Our study suggested that pulmonary metastasectomy for renal cell carcinoma might be well justified. Keywords: Renal cell carcinoma; Pulmonary metastasis; Metastasectomy

[Cardiac general] Repair of an acute type A aortic dissection combined with an emergency cesarean section in a pregnant woman

Shihata, M., Pretorius, V., MacArthur, R. — 2008-06-26

This case report describes a 35-week pregnant woman presenting with an acute type A aortic dissection. She underwent a successful emergency surgical repair and a concomitant cesarean section with a favorable outcome for the mother and the child. Keywords: Aortic dissection; Pregnancy; Hypothermic circulatory arrest

[Thoracic general] Arterial oxygen partial pressure and cardiovascular surgery in elderly patients

Chenuel, B. J., Poussel, M., Nguyen Thi, P.-L., Villemot, J.-P., Haouzi, P. — 2008-06-26

Arterial blood gas assessment is still routinely performed in candidates for a cardiovascular surgery. Whether sampling arterial blood is useful in an elderly patient with a near normal lung function and who meets all other criteria for operability, is unknown. Therefore, it was our purpose to provide reference values for arterial blood gases in these patients and to examine how the level of arterial oxygen partial pressure (PaO₂) might influence postoperative outcome. We retrospectively studied arterial blood gases in 201 patients, aged 70-92 years with normal or near normal ventilatory function awaiting a planned cardiovascular surgery. PaO₂ averaged 81.6±7.6 mmHg and PaCO₂ averaged 37.7±3.2 mmHg. Both were independent of age. Factors associated with mortality according to bivariate analysis were: gender (female), type of surgery (valve replacement), and a low PaO₂ with strictly no ventilatory abnormality. In conclusion, PaO₂ values in elderly patients with cardiac disease and normal ventilatory function are greater than those obtained by extrapolation from healthy younger subjects. PaO₂ measurement should be recommended prior to cardiovascular surgery in elderly patients since a low PaO₂ with strictly normal ventilatory function is significantly associated with an increased risk for postoperative mortality. Keywords: Arterial blood gases; Cardiovascular surgery; Elderly; Mortality risk; Pulmonary function test

[Thoracic general] Tracheal laceration following double-lumen intubation during Ivor Lewis esophagogastrectomy

Barbetakis, N., Samanidis, G., Paliouras, D., Tsilikas, C. — 2008-06-24

A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration. Keywords: Membranous trachea; Rupture; Intubation; Esophagogastrectomy

[Experimental] Adenovirus-mediated stromal cell-derived-factor-1{alpha} gene transfer induces cardiac preservation after infarction via angiogenesis of CD133+ stem cells and anti-apoptosis

Tang, J., Wang, J., Yang, J., Kong, X. — 2008-06-24

In our study, we found cardiocytes expressed CXCR4, and the number of cardiocytes apoptosis with SDF-1 treatment decreased obviously through SDF-1 induced up-regulation of phosphorylated Akt. On day 7 after myocardial infarction, marked expression of SDF-1, and the number of CD133⁺ cells was the highest in the AdV-SDF-1 injection hearts. On day 28 post-treatment, blood vessel density in the AdV.SDF-1 group was higher in infracted zones. Infarct size and collagen accumulation in the infracted area decreased significantly, thickness of LV wall, vessels and cardiocytes density increased obviously in the AdV-SDF-1 group than in control or Adv-LacZ group, and hemodynamics showed the improvement of left ventricle heart function in the AdV.SDF-1 group. Therefore, SDF-1 could improve cardiac structure and function through the combined effects of angiogenesis and anti-apoptosis. Keywords: Myocardial infarction; SDF-1; Stem cell; Angiogenesis; Apoptosis

[Thoracic general] Dramatic hemostasis of the transected pulmonary artery model using SOFT COAG electrosurgical output

Sakuragi, T., Okazaki, Y., Mitsuoka, M., Itoh, T. — 2008-06-23

We report the use of low-voltage, automatically regulated, electrosurgical coagulation to seal the bleeding from pulmonary arteries inadvertently during surgical intervention. Conventional electrosurgical coagulation uses high voltage, which generates intensive heat in the tissue. The heat results in carbonized eschar formation that can be easily broken by mechanical stress and lead to postoperative bleeding. SOFT COAG output automatically regulates the output voltage to a maximum of 200 Volts, preventing the generation of sparking. Thus, there is no formation of carbonized eschar. The instrument generates Joule heat alone in the tissue and the temperature rises to below boiling point, which effectively coagulates protein. Initial experiments, using a beagle model, clearly demonstrated the effectiveness and reliability of sealing both macroscopically and histopathologically. SOFT CAOG can be easily adopted both in open thoracotomy as well as in thoracoscopic procedures. Keywords: Pulmonary artery; Bleeding; Hemostasis; SOFT COAG

[Cardiac general] Phenoxybenzamine treatment can lead to loss of endothelial cell viability

Pai, K. R., Conant, A., Browning, P. G., Dihmis, W. C. — 2008-06-23

Phenoxybenzamine, an irreversible -adrenoceptor antagonist, is used as a topical treatment against catecholamine-induced contraction in radial artery bypass grafts. Published data suggests that a wide range of phenoxybenzamine doses may be equally effective. This study aimed to investigate whether lower doses of phenoxybenzamine would benefit grafts by better preserving endothelium. To this end human vascular endothelial cells were isolated from sections of radial artery or saphenous vein, and treated with phenoxybenzamine for 30 min. Cells were then washed free of drug and viability assayed using a resazurin-based toxicology assay or returned to culture for assay at 24 h. Phenoxybenzamine treatment showed a dose-dependent, effect on cell viability over several clinically employed concentrations. Concentrations above 0.1 mM led to a loss of viability, which became more pronounced with time. The loss of viability was shown to be independent of the carrier used, as results were identical when phenoxybenzamine was dissolved in dimethylsulphoxide, which alone did not affect viability. Changes in pH alone were also not sufficient to affect viability. In conclusion, phenoxybenzamine treatment is likely to cause damage to graft endothelium if employed at concentrations above 0.1 mM (0.03 mg/ml). Phenoxybenzamine may be safely used at lower doses with no potential loss of endothelial cell viability. Keywords: Coronary artery bypass conduits; Arteries; Endothelium; Vasodilators; Viability

[Thoracic general] Surgical treatment of pulmonary aspergillosis/mycosis in immunocompromised patients

2008-06-23

Invasive pulmonary aspergillosis is a severe complication in immunosuppressed patients. Surgical resection can be curative in certain patients after antifungal treatment. Over a 7-year period, ten patients with suspected invasive pulmonary aspergillosis of two university hospitals were retrospectively reviewed. A literature review was undertaken. Patient's age was 48.1 years (mean); the cause of immunosuppression was a hematological disease with consecutive therapy in seven patients and chronically corticoid therapy in three patients. After an antifungal therapy, surgical resection was performed with lobectomy/segmentectomy in 60% and with wedge-resection in 40%. Postoperative course were uneventful in 7 patients, two patients died due to infectional circumstances, one patient was reoperated because of empyema. The underlying disease marked long-term follow up. Resection of focal pulmonary invasive aspergillosis can be curative. Clinical circumstances and dissemination must be taken into consideration to indicate surgery. To point out the best pathway randomized prospective studies are necessary. Keywords: Pulmonary aspergillosis; Thoracic surgery; Immunosuppression

[Pulmonary] Pulmonary resection for metastasis from esophageal carcinoma

2008-06-13

Pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs; however, few data have been available regarding lung metastasectomy for esophageal carcinoma. To confirm a role for resection of pulmonary metastases for such tumors, we reviewed our institutional experience. Between 2001 and 2007, 5 patients with pulmonary metastases from esophageal carcinoma underwent complete pulmonary resection. All patients had undergone curative resection of their primary esophageal carcinomas and also had obtained locoregional control of their primaries. Disease-free interval varied from 13 to 56 months, with a median of 21 months. In 3 patients, lung metastases were found to be unilateral and solitary. The other 2 patients presented several metastases in the unilateral or bilateral lungs. All patients underwent wedge resection or segmentectomy. Currently 4 patients are alive without evidence of disease and 1 patient died of disease. All patients undertook or going to undertake chemotherapy after the pulmonary metastasectomy. Three patients with solitary metastasis are all alive without disease 13, 48, and 90 months after the first pulmonary metastasectomy respectively. Pulmonary metastasectomy for esophageal carcinoma with postoperative chemotherapy was seemingly justified. Solitary pulmonary metastasis might be a good candidate for favorable prognostic factor. Keywords: Esophageal carcinoma; Pulmonary metastasis; Metastasectomy

[Cardiac general] Prospective assessment of quality of life of octogenarians after cardiac surgery: factors predicting long-term outcome

2008-06-13

Our objective was to assess the long-term prognosis and quality of life (QoL) of elderly patients after cardiac surgery. The Nottingham Health Profile (NHP) QoL data were recorded from 104 patients who were older than 70 years at the time of primary cardiac surgery in 1993. All living patients were controlled at 15±3.2 months and 8.2±0.27 years after discharge. The 1-year, 5-year and actual survival rates were 94%, 76% and 59%, respectively. Risk factors for death were urgency of the operation (relative risk ratio, 2.0; 95% confidence interval, 1.2-3.6), ejection fraction below 50% (2.1; 1.1-3.9), and preoperative renal failure (2.1; 1.0-4.0). Cardiac operated octogenarians took advantage from age and sex matched reference populations at 15 months in the NHP dimension of pain (p=0.001). The QoL decreased gradually during the follow-up similarly in both groups in dimensions describing energy (p=0.001), pain (p=0.003), and mobility (p=0.042). Diabetes, low energy score and high pain score at 15 months, treatment in intensive care unit > 3 days, and duration of symptoms > 120 days preoperatively were associated with impaired QoL. Survival and QoL were similar for cardiac operated octogenarians and age and sex matched controls at 15 months and 8.2 years after cardiac surgery. Keywords: Quality of life; Survival; Octogenarians; Cardiac surgery

[Valves] Built-in defect of a biological pericardial aortic prosthesis?

Buklas, D., Massetti, M., Neri, E., Chocron, S. — 2008-06-12

We report a case on an early complication of a biological pericardial tissue valve in the aortic position that required emergency replacement. One of the three leaflets of the valve was stuck open in a fixed-open position and would not unfold in diastole. This resulted in severe aortic insufficiency, diagnosed by standard postoperatory echocardiography and confirmed in the operating room. Keywords: Aortic valve; Pericardial tissue heart valve; Aortic insufficiency

[Cardiac general] Renal tumours with cavo-atrial extension: surgical management and outcome

2008-06-12

Surgery is the most effective treatment for the management of patients with renal cell carcinoma (RCC) and involvement of inferior vena cava (IVC). Data were accrued for 68 consecutive patients, who underwent surgical resection for RCC with IVC extension and required cardiothoracic surgical input from May 1993 to May 2005. The mean age of patients was 60.7 years (range 25-84, SD 11.6 years), 49 of these were males. The majority required application of vascular clamp at the junction of IVC with right atrium (RA), however 21 patients required cardiopulmonary bypass (CPB) (29-193 min, mean 131 min). Hypothermic circulatory arrest (HCA) (12-42 min, mean 26 min) was used in 17 patients. The 30-day mortality was 6% (4 patients) with no death in the elective CPB group. At a mean follow-up of 31 months, the overall two and five year survival rates were 50% and 37% respectively. Cox regression revealed presence of metastasis (Odds ratio (OR) 3.1, 95% CI 1.2-8.2) and age greater than 70 years (OR 2.9, 95% CI 1.3-6.3) adversely affected the long-term outcome. The management of RCC with IVC involvement is evolving for this complex group of patients. A multidisciplinary approach in selected patients is associated with good short and long-term results. Keywords: Renal cell carcinoma; Caval extension; Cardiopulmonary bypass; Hypothermia

[Thoracic general] Intra-scaffold continuous medium flow combines chondrocyte seeding and culture systems for tissue engineered trachea construction

Tan, Q., Hillinger, S., van Blitterswijk, C. A., Weder, W. — 2008-06-12

In this study we tested the possibility of seeding chondrocytes into poly (ethylene glycol)-terephthalate-poly (butylene terephthalate) PEOT/PBT scaffold through an intra-scaffold medium flow and the impact of this continuous medium flow on subsequent chondrocyte-scaffold culture. Eight cubic PEOT/PBT co-polymers (1 cm³) were assigned into two groups. In semi-dynamic seeding group a continuous medium flow was created inside the scaffolds by a pump system. Around six million chondrocytes were harvested each day, suspended in 1 ml medium and delivered onto the scaffold through the perfusion for sequential five days. Traditional chondrocytes directly seeding and static culture method was performed as control. Scanning electron microscope (SEM) and histology assessments were performed to evaluate the distribution of chondrocytes inside the scaffolds and MTT test was chosen to check cell vitality. SEM pictures and histology slices from the perfusion group showed a better three-dimensional cell growth and extensive cell distribution inside the scaffolds; while in the control group chondrocytes only dispersedly formed a monolayer on the surface of scaffolds. Accordingly MTT results from the perfusion group were much higher than those from control group (0.123 vs. 0.067, p<0.01). Continuous medium perfusion inside PEOT/PBT scaffold effectively combines chondrocyte seeding and culture systems for the reconstruction of tissue engineered trachea. Keywords: Tissue engineering, Trachea replacement; Bioreactor; Cell seeding; Cell culture

[Experimental] Myocardial protection: efficacy of a novel magnesium-based cardioplegia (RS-C) compared to St Thomas' Hospital cardioplegic solution

Maruyama, Y., Chambers, D. J. — 2008-06-11

Cardiac surgery patients now tend to be sicker with more severe disease; consequently, improved protection is important. We compared St Thomas' Hospital solution (STH2: hyperkalaemia and hypermagnesaemia) to a hypermagnesaemia-alone cardioplegia (RS-C) based on a novel non-phosphate buffered crystalloid solution (Aqix®RS-I). Isolated Langendorff-perfused rat hearts were used (function measured). Initial studies established optimal magnesium concentration as 25 mM (LVDP recovery after 50 min at 37 °C global ischaemia (GI) for 16, 25, 35, 50 mM magnesium versus STH2 was 48±3, 50±2, 50±3, 30±3 and 51±2% respectively). Contracture-related measurements (onset time, peak) for 25 mM RS-C (32±1 min, 35±1 mmHg) compared favourable (p<0.05) to STH2 (26±1 min, 43±2 mmHg). LVDP recovery after single 2 min cardioplegic infusion (with RS-C-25 or STH2) and 20, 30, 40 or 50 min GI was higher for RS-C-25 than STH2 after 20 min GI (81±1% vs 74±1%; [p<0.05]) but similar at other GI durations. Subsequent multi-infusion studies (60 min GI, 3x2 min infusions every 20 min) demonstrated significantly improved recovery with RS-C-25 versus STH2 (LVDP: 73±2%, 44±1% [p<0.001]; LVEDP: 9±2 mmHg, 45±2 mmHg [p<0.001]). We conclude that single RS-C infusion with optimal 25 mM magnesium improved protection after short (20 min) GI durations, or after multi-infusions during prolonged (60 min) GI durations. Magnesium-based cardioplegia may be a useful alternative to hyperkalaemic cardioplegia under certain specific conditions. Keywords: Myocardial protection; Cardioplegia; Magnesium

[Cardiac general] Surgical repair of triple coronary-pulmonary artery fistulae with associated atrial septal defect and aortic valve regurgitation

Dimitrakakis, G., Von Oppell, U., Luckraz, H., Groves, P. — 2008-06-10

Coronary arterio-venous fistulae are congenital or acquired cardiac anomalies whereby blood bypasses the myocardial capillary network. Involvement of all three coronary arteries is rare. There is a wide variation in the clinical presentation and the actual morphological malformations. The mainstay of treatment is either surgical or coil embolisation. Associated congenital malformations can be dealt with during the same surgical setting if required. We present a case of coronary arterio-venous fistula involving all three coronary arteries with associated atrial septal defect and acquired aortic regurgitation, all of which were dealt with surgically with good surgical outcome. Keywords: Coronary artery fistula

[Cardiac general] If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

Lockowandt, U., Levine, A., Strang, T., Dunning, J. — 2008-06-10

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage? Altogether 550 papers were found in Medline and 990 in Embase papers were found using the reported search, of which 22 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that current resuscitation guidelines state that there is no evidence to support or refute external cardiac massage prior to defibrillation in-hospital, although a benefit has been shown for patients out-of-hospital if the response time is over 4-5 min. In addition 4 large studies including the AHA National Registry of Cardiopulmonary Resuscitation who reported the findings of 6789 in-hospital arrests emphasise the importance of early defibrillation within 1-2 min. More concerning in patients post-cardiac surgery are 4 case reports after cardiothoracic surgery and 5 in the non-surgical literature where significant harm has been caused from external cardiac massage, although equally we found cohort studies of cardiac surgical patients who had external cardiac massage followed by re-sternotomy and found no trauma due to external cardiac massage. We recommend that guidelines for immediate external massage should be adhered to currently as the evidence that these guidelines may do harm is not yet strong enough to recommend a change in practice. However we acknowledge that there is no in-hospital data to support very short periods of external massage prior to defibrillation and there have been examples of damage to the myocardium due to external massage. This should be born in mind when external massage is being performed on a patient after cardiac surgery. Keywords: Cardiopulmonary resuscitation; Ventricular fibrillation; Electrical countershock; Cardiac surgical procedures

[Cardiac general] Impact of pacing modality and biventricular pacing on cardiac output and coronary conduit flow in the post cardiotomy patient

2008-06-09

We have previously demonstrated the role of univentricular pacing modalities in influencing coronary conduit flow in the immediate post-operative period in the cardiac surgery patient. We wanted to determine the mechanism of this improved coronary conduit and in addition to explore the possible benefits with biventricular pacing. Sixteen patients undergoing first time elective coronary artery bypass grafting who required pacing following surgery were recruited. Comparison of cardiac output and coronary conduit flow was performed between VVI and DDD pacing with a single right ventricular lead and biventricular pacing lead placement. Cardiac output was measured using arterial pulse waveform analysis while conduit flow was measured using ultrasonic transit time methodology. Cardiac output was greatest with DDD pacing using right ventricular lead placement only [DDD-univentricular 5.42 l (0.7), DDD-biventricular 5.33 l (0.8), VVI-univentricular 4.71 l (0.8), VVI-biventricular 4.68 l (0.6)]. DDD-univentricular pacing was significantly better then VVI-univentricular (P=0.023) and VVI-biventricular pacing (P=0.001) but there was no significant advantage to DDD-biventricular pacing (P=0.45). In relation to coronary conduit flow DDD pacing again had the highest flow [DDD-univentricular 55 ml/min (24), DDD-biventricular 52 ml/min (25), VVI-univentricular 47 ml/min (23), VVI-biventricular 50 ml/min (26)]. DDD-univentricular pacing was significantly better then VVI-univentricular (P=0.006) pacing but not significantly different to VVI-biventricular pacing (P=0.109) or DDD-biventricular pacing (P=0.171). Pacing with a DDD modality offers the optimal coronary conduit flow by maximising cardiac output. Biventricular lead placement offered no significant benefit to coronary conduit flow or cardiac output. Keywords: Pacing; Biventricular; Cardiac output; Coronary conduit flow; DDD; VVI