Interactive CardioVascular and Thoracic Surgery current issue

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

Maruyama, Y., Chambers, D. J. — 2008-09-18

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 mmol/l (LVDP recovery after 50 min at 37 °C global ischaemia (GI) for 16, 25, 35, 50 mmol/l magnesium vs. STH2 was 48±3, 50±2, 50±3, 30±3 and 51±2%, respectively). Contracture-related measurements (onset time, peak) for 25 mmol/l RS-C (32±1 min, 35±1 mmHg) compared favourable (P<0.05) to STH2 (26±1 min, 43±2 mmHg). LVDP recovery after a 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 vs. 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 mmol/l 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.

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

Bockeria, L. A., Movsesyan, R. R., Ryabtsev, D. V., Grigoryants, T. R. — 2008-09-18

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

Bottio, T., Tarzia, V., Rizzoli, G., Gerosa, G. — 2008-09-18

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.

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

Augoustides, J. G., Watcha, S. M., Pochettino, A., Jobes, D. R. — 2008-09-18

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.

[Work in progress report - 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. — 2008-09-18

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 minute (rpm) (group I) or 4350 rpm (group II) with different washing pump speeds – 500, 800 and 1000 ml/min. Hemoglobin, free hemoglobin, hematocrit, erythrocytes, leukocytes, platelets, and 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. Red blood cells concentration was higher 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. Platelet recovery in group I was higher than in group II at all washing pump speeds. Leukocytes 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.

[Work in progress report - Thoracic general] Dramatic hemostasis of the transected pulmonary artery model using SOFT COAG electrosurgical output

Sakuragi, T., Okazaki, Y., Mitsuoka, M., Itoh, T. — 2008-09-18

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.

[Work in progress report - 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. — 2008-09-18

In our study, we found cardiocytes expressed CXCR4, and the number of cardiocytes apoptosis with SDF-1 treatment decreased obviously through SDF-1 induced the 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.

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

2008-09-18

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 seven patients, two patients died due to infectional circumstances, and 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 randomised prospective studies are necessary.

[Institutional report - 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. — 2008-09-18

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 three 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.

[Institutional report - Aortic and aneurysmal] Translumbar treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysm

2008-09-18

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-enhanced ultrasound (CEUS) was used to document the outcome of the embolization. Translumbar embolization was successful in four 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.

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

Ando, M., Murai, T., Takahashi, Y. — 2008-09-18

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.

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

2008-09-18

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. One hundred and twenty 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.

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

Chen, I-M., Shih, C.-C. — 2008-09-18

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.

[Institutional report - Coronary] Non-harvestable radial artery. A bilateral problem?

Kohonen, M., Teerenhovi, O., Terho, T., Laurikka, J., Tarkka, M. — 2008-09-18

Since radial artery is preferably harvested from a non-dominant hand, our aim was to study whether there are contraindications for radial artery harvest in the dominant hand if the radial artery of the other hand is not suitable for harvesting. Thirty-three patients scheduled to coronary artery bypass grafting with contraindication for radial artery harvest in the non-dominant hand underwent Allen test, upper arm Doppler ultrasonography and digital pletysmography. In ultrasonography, both anatomical and circulatory measurements were performed. Both hands were then compared to each other. Furthermore, twelve control patients without contraindication for radial artery harvest in the non-dominant hand were examined. All 33 patients had contraindication for radial artery harvest in the non-dominant hand. Twenty-four (73%) had contraindication in the dominant hand as well. In terms of morphology, there was no statistically significant difference between the hands but circulatory parameters as a group suggested contraindication. Among controls, four patients (33%) had contraindication in the dominant hand. In the case of a non-harvestable radial artery in a hand there is clearly an increased risk for contraindication for radial artery harvest also in the other hand.

[eComment] eComment: Is the inner diameter of radial artery reliable for its suitability as a graft?

Apostolakis, E., Koniari, I., Dougeni, D. — 2008-09-18

[eComment] eComment: Radial artery doppler study in every case?

Kofidis, T., Woitek, F. — 2008-09-18

[Institutional report - Cardiac general] Management of open chest and delayed sternal closure with the vacuum assisted closure system: preliminary experience

2008-09-18

The management of open chest with the vacuum assisted closure (VAC) system was evaluated in terms of impact on cardiac hemodynamics, respiratory parameters, complications, incidence of wound infection, overall handling and outcome in 22 patients during 2005 and 2008 after cardiac surgery. The decision to leave the sternum open was made electively in all patients at the time of primary operation or reexploration. In four patients the VAC was implanted during the primary operation. In the remainder the VAC was implanted after a mean of five days after the primary operation. The overall mortality rate was 45% (10/22). None of the patients developed a sternal wound infection, nor were there any VAC related complications. Management of open chest with the VAC system can be considered as an alternative to sterile draping. The VAC has no negative impact on cardiac hemodynamics as well as respiratory mechanics. The feared complication of right ventricular rupture and massive bleeding can be effectively prevented. Through the stabilizing of the thoracic cage, the patient can be easily moved and mobilized for nursing reasons and pneumonia prevention. Furthermore, the VAC effectively prevents the contamination of the wound and the mediastinum with potential subsequent infection.

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

2008-09-18

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 than 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 than 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.

[eComment] eComment: Biventricular pacing in cardiac surgery - potential role for non-invasive cardiac output monitoring and nt-pro-BNP determination

Knobloch, K. — 2008-09-18

[Institutional report - Pulmonary] Pulmonary resection for metastasis from esophageal carcinoma

2008-09-18

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, five 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 three patients, lung metastases were found to be unilateral and solitary. The other two patients presented several metastases in the unilateral or bilateral lungs. All patients underwent wedge resection or segmentectomy. Currently, four patients are alive without evidence of disease and one patient has died of disease. All patients undertook or were 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.

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

2008-09-18

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.

[eComment] eComment: Prospective assessment of quality of life of octogenarians after cardiac surgery

Bockeria, L. A., Skopin, I.I., Kuts, E.V. — 2008-09-18

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

Chenuel, B., Poussel, M., Nguyen Thi, P.-L., Villemot, J.-P., Haouzi, P. — 2008-09-18

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.

[Institutional report - Pulmonary] Pulmonary resection for metastasis from renal cell carcinoma

2008-09-18

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, eight 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 three patients, lung metastases were found to be unilateral and solitary. Four patients presented two metastases in the unilateral lungs. One patient showed five metastases in the bilateral lungs. Six patients underwent wedge resection or segmentectomy, while two 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.

[eComment] eComment: Surgery for pulmonary metastases of renal cell carcinoma. Video-assisted thoracoscopic or open procedure?

Barbetakis, N., Samanidis, G., Paliouras, D., Tsilikas, C. — 2008-09-18

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

Manche, A., Casha, A., Rychter, J., Farrugia, E., Debono, M. — 2008-09-18

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. Thirty-four patients did not receive dialysis and six 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. Thirty-one 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).

[Institutional report - 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. — 2008-09-18

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.

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

Atoui, R., Essebag, V., Wu, V., Ge, Y., Auclair, M.-H., Hadjis, T., Shum-Tim, D. — 2008-09-18

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.

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

2008-09-18

Previous reports have described penetrating cardiac injuries as the anatomic injury with the greatest opportunity for emergency department thoracotomy (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 eight 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.

[eComment] eComment: Emergency department thoracotomy and middle income countries

Hudorovic, N. — 2008-09-18

[ESCVS article - Aortic and aneurysmal] 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. — 2008-09-18

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.

[ESCVS article - Carotid and imaging] Occult carotid artery disease in patients who have undergone coronary angioplasty

2008-09-18

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.

[Proposal for bail-out procedures - Thoracic general] Donor cryopreserved rib allografts for chest wall reconstruction

Aranda, J. L., Varela, G., Benito, P., Juan, A. — 2008-09-18

Reconstruction after large chest wall resections must ensure not only anatomical coverage but a normal respiratory function, specially 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.

[Proposal for bail-out procedures - Transplantation] Intraoperative removal of a knotted Swan-Ganz catheter during lung transplantation

2008-09-18

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 being 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.

[eComment] eComment: Double-knotted Swan-Ganz catheter - potential for non-invasive ultrasonic cardiac output monitoring?

Knobloch, K. — 2008-09-18

[Negative results - Esophagus] Esophageal laceration with intramural dissection mimics esophageal perforation

Wu, H.-C., Hsia, J.-Y., Hsu, C.-P. — 2008-09-18

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 three days prior to admission. Esophagoscopy revealed a deep longitudinal laceration with pus discharge in the esophagus. Computed tomography of the 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.

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

Barbetakis, N., Samanidis, G., Paliouras, D., Tsilikas, C. — 2008-09-18

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 a bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration.

[eComment] eComment: Autologous or bovine pericardial patch for the repair of membranous tracheal wall lacerations?

Foroulis, C. N. — 2008-09-18

[eResponse] eResponse: Should autologous irradiated pericardium be used for tracheal lacerations?

Barbetakis, N., Samanidis, G., Paliouras, D., Tsilikas, C. — 2008-09-18

[Negative results - Thoracic general] Transmediastinal migration of Kirschner wire

Marchi, E., Reis, M. P., Carvalho, M. V. — 2008-09-18

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.

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

2008-09-18

Objectives: Percutaneous coronary intervention of unprotected left main (ULM) stenosis is increasing despite surgical revascularisation 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% (three patients) undergoing elective PCI. Major adverse cardiac events during the nine 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.

[Best evidence topic - 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. — 2008-09-18

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 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, four 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 four case reports after cardiothoracic surgery and five 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 are 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 borne in mind when external massage is being performed on a patient after cardiac surgery.

[eComment] eComment: Avoiding the adverse consequences of external cardiac massage during in-hospital resuscitation after cardiac surgery

Rottenberg, E. M. — 2008-09-18

[eComment] eComment: Early emergency resternotomy is crucial in cardiac arrest after cardiac surgery

Al Khaddour, A. — 2008-09-18

[eComment] eComment: External cardiac massage may be harmful as well as unnecessary

Nashef, S. A.M. — 2008-09-18

[eComment] eComment: Also in cardiac arrest it is important to think first

Versteegh, M. I., Braun, J. — 2008-09-18

[eComment] eComment: The sooner the beginning of cardiopulmonary resuscitation, the better the outcome for the arrested cardiac operated patient

Apostolakis, E. — 2008-09-18

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

Day, T. G., Perring, R. R., Gofton, K. — 2008-09-18

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 four 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 vs. 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.

[Best evidence topic - 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. — 2008-09-18

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 <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.

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

Richardson, L., Hunter, S. — 2008-09-18

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 14 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 they 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.

[Best evidence topic - Aortic and aneurysmal] Does the administration of mannitol prevent renal failure in open abdominal aortic aneurysm surgery?

Hersey, P., Poullis, M. — 2008-09-18

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 eight represented the best evidence to answer the clinical question. In total, 319 patients were included in these eight studies. Five of the included studies date from 1961–1965, and the remaining three from 1986, 1996 and 2002. The age of study is reflected in the level of evidence presented. The three recent studies provide evidence at a level of 1b, the remaining five 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.

[Brief communication - Coronary] Awake subxyphoid minimally invasive direct coronary artery bypass grafting yielded minimum invasive cardiac surgery for high risk patients

Watanabe, G., Yamaguchi, S., Tomiya, S., Ohtake, H. — 2008-09-18

Off-pump coronary artery bypass graft (CABG) surgery has become a widely used modality and has received recognized as a minimally invasive surgery with few complications. However, for patients with severely impaired pulmonary function, further considerations have to be given to reduce the complications associated with general anesthesia. We have accumulated experience in awake off-pump surgery combined with high thoracic epidural anesthesia. In this report we describe the use of alternative subxiphoid approach in patients with severe pulmonary dysfunction. A catheter for high thoracic epidural anesthesia was inserted one day before surgery. After obtaining an adequate level of anesthesia, a small subxiphoid incision was made and the pericardium was opened to expose the left anterior descending branch. The conduit for bypass, gastroepiploic artery was accessed through a minilaparotomy, and separated under the same surgical field and anatomozed under beating heart. This procedure was performed in three patients. Patency was confirmed by postoperative angiography in all three cases. All patients were discharged after an uneventful postoperative course. Awake subxiphoid approach has the advantages that both thoracotomy and sternotomy can be avoided thus permitting surgery with extremely low invasiveness. This method is recommended for patients with severe pulmonary dysfunction.

[Brief communication - Thoracic general] Usefulness of sentinel lymph node biopsy for the detection of lymph node micrometastasis in early lung cancer

Sugi, K., Kobayashi, S., Yagi, R., Matsuoka, T. — 2008-09-18

The purposes of this study were to examine the usefulness of the biopsy of the sentinel lymph nodes (SNs) for the accurate and effective detection of lymph node micrometastasis in early lung cancer and to clarify the spread of lymph node micrometastasis. One hundred and thirty-three c-stage IA non-small cell lung cancer patients in whom SNs could be identified by radioisotope (RI) method were enrolled. All dissected lymph nodes were stained with cytokeratin AE1/AE3 for the examination of micrometastasis. A total of 1375 lymph nodes including 220 SNs were dissected from the 133 patients. From the 220 SNs, 35 (15.9%) were found to be positive for metastasis. Of the other 185 SNs negative for metastasis, 19 (8.6%) were positive for micrometastasis. When patients were limited to those with pN0, there were no lymph nodes positive for micrometastasis other than SNs. In pN1–2 patients, micrometastasis to non-SNs were observed in 2.3–13.2%. In patients with pN0, micrometastasis was limited to SNs, and the results of the examination of SNs for micrometastasis accurately represented those of the examination of all lymph nodes. With advancement of the stage, micrometastasis was not limited to SNs and showed an irregular distribution.

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

Pai, K. R., Conant, A. R., Browning, P. G., Dihmis, W. C. — 2008-09-18

Phenoxybenzamine, an irreversible -adrenoceptor antagonist, is used as a topical treatment against catecholamine-induced contraction in radial artery bypass grafts. Published data suggest 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.

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

Leacche, M., Balaguer, J. M., Umakanthan, R., Byrne, J. G. — 2008-09-18

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 do not 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.

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

Camboni, D., Philipp, A., Schebesch, K.-M., Schmid, C. — 2008-09-18

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 deviations 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.

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

Migneco, F., Huang, Y.-C., Coyan, G. N., Birla, R. K. — 2008-09-18

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 through the right carotid artery, repeated seven 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.

[eComment] eComment: Left ventricular catheterization for pressure-volume loop measurements in small laboratory animals

Ugurlucan, M., Furlani, D., Klopsch, C., Steinhoff, G. — 2008-09-18

[eResponse] eResponse: Left ventricular catheterization for pressure-volume loop measurements in small laboratory animals

Migneco, F., Huang, Y.-C., Coyan, G. N., Birla, R. K. — 2008-09-18

[Case report - Cardiac general] Hypereosinophilic syndrome and myocardial fibrosis

Carnero-Alcazar, M., Reguillo-Lacruz, F., O'Connor, F., Rodriguez-Hernandez, E. — 2008-09-18

A 62-year-old man was accepted to our institution because of hypereosinophilia, severe tricuspid regurgitation and isolated right restrictive myocardiopathy, with thrombi inside the right atrium and ventricle. Based on the diagnosis of hypereosinophilic syndrome plus eosinophilic myocarditis, the patient underwent a tricuspid valve repair and endomyocardiectomy. We briefly discuss hypereosinophilic syndrome myocardiopathy, and its management.