Objective: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) calculator performance in 30-day outcome prediction after isolated aortic valve replacement (AVR) was evaluated to assess its absolute reliability and usefulness as selection criteria to percutaneous aortic valve implantation (PAVI). Methods: We carried out a retrospective statistical analysis on 379 patients (group 0) consecutively submitted to isolated AVR in the past 10 years of surgical activity. We discriminated two periods of 5 years each, so we considered two subgroups of patients: group 1 (200 patients operated during 1999–2003); group 2 (179 patients operated during 2004–2008). We used receiver operating characteristics (ROC) curves for discriminatory power analysis. Model calibration was evaluated with the Hosmer–Lemeshow goodness-of-fit test and Pseudo R ² analysis. Results: The overall expected mortality rate at the logistic calculator was 9.37% compared with an observed 10-year mortality of 5.2% (p = 0.006). Absolute risk prediction in group 1 fitted the observed outcome (p = 0.24) while expected mortality in group 2 was significantly higher than observed (p = 0.005). Applying threshold values used as PAVI selection criteria (logistic EuroSCORE >20 or >15), against 29% and 24.3% expected mortality rate, respectively, we registered a significant difference in the observed values (11.4%, p = 0.022; 8.6%, p = 0.005, respectively). The Hosmer–Lemeshow test demonstrated a lack of model fit in the overall group (p = 0.019). ROC analysis revealed a sufficient discriminatory power for either total population (logistic area under curve (AUROC) 0.706; 95% confidence interval (CI): 0.604–0.809; p = 0.002) and group 1 (logistic AUROC 0.752; 95% CI: 0.643–0.860; p = 0.002). Group 2 showed a lack of risk stratification (logistic AUROC 0.613; 95% CI: 0.401–0.824; p = 0.348). Conclusions: EuroSCORE appears to be an invalid model in absolute and relative risk prediction for isolated AVR. On this basis, its use in selecting candidates to PAVI should be carefully weighted. Correct stratification and sufficient calibration of absolute risk estimate of high-risk patients are, therefore, mandatory in the aim of assigning those patients who show risk factors really responsible for the worst surgical outcome to new techniques. The goal should be reached by exploring the weight of each independent predictor of death in each single institution involved in PAVI procedures, evaluating local surgical results in terms of absolute risk and analysing those variables significantly affecting relative risk.

Objective: Left-ventricular function has been shown to be an important prognostic factor in estimating operative risk in cardiac surgery. As such, left-ventricular ejection fraction (LVEF) is included in the EuroSCORE. However, left-ventricular function is more comprehensively assessed by measures of both systolic and diastolic dysfunction. We hypothesised that end-diastolic dysfunction is an additional independent indicator for predicting outcome following coronary artery bypass grafting (CABG). Methods: We retrospectively assessed all patients undergoing isolated off-pump CABG between October 2000 and September 2004 by two surgeons. Left-ventricular end-diastolic pressure (LVEDP), measured during cardiac catheterisation, was used as a measure of left-ventricular diastolic dysfunction. Logistic regression was used to assess the association between LVEDP (a continuous and dichotomous variable) and mortality, while adjusting for EuroSCORE. Results: A total of 925 patients with complete LVEDP data were identified and stratified as follows: group 1 (LVEF >30% and LVEDP <20 mmHg), group 2 (LVEF <30% and LVEDP <20 mmHg), group 3 (LVEF >30% and LVEDP >20 mmHg) and group 4 (LVEF <30% and LVEDP >20 mmHg). Mortality increased progressively from group 2 (1.9%, odds ratio (OR) 1.22, RR 1.21, p 0.58) to group 3 (5.6%, OR 3.81, RR 3.66, p 0.07) and was highest in group 4 (7.4%, OR 5.18, RR 4.87, p 0.08). Receiver operating characteristic (ROC) curve c-characteristic improved from 0.7 to 0.78 when EuroSCORE was combined with LVEDP, identifying LVEDP as an independent predictor of mortality after adjusting for EuroSCORE. Logistic equation: odds of death = exp(–6.3283 + [EuroSCORE x 0.1813] + [EDP x 0.0954]). Conclusions: LVEDP as a marker of diastolic dysfunction seems an important variable in predicting patient-specific risk and should be considered for incorporation in future risk models.

Objective: We analysed the long-term results of mitral valve (MV) repair in children. Methods: We reviewed clinical records of 139 children (<18 years) who underwent MV repair between 1988 and 2007. Patients with atrioventricular septal defect, single ventricle or atrioventricular discordance were excluded. Median age was 2.3 years (2 months to 17.6 years), and 47 children (34%) were infants. Mitral regurgitation (MR) was predominant in 125 patients (90%), and 91 (73%) of these showed MR grade ≥3. Mitral stenosis (MS) was predominant in 14 patients (10%), and median mean pressure gradient across the MV was 9.0 mmHg (0–20 mmHg). Associated cardiac lesions were present in 111 patients (80%) and were addressed concurrently in 105 patients. Various surgical techniques were used according to the functional and pathologic findings of MV. Results: There was no early death. Median follow-up was 8 years (2 months to 20 years, 78% complete). Twenty-six patients required 29 MV re-operations, and 11 of these required MV replacements. At 15 years, freedom from MV re-operation and MV replacement was 77% and 90%, respectively. Diagnosis of MS and MV status on discharge (MR grade ≥3 or MS gradient ≥10 mmHg) were significant risk factors for re-operation. There were three late deaths, and the overall survival was 97% at 15 years. Among 122 survivors with MR, 102 patients (84%) underwent echocardiography during follow-up. The degree of MR decreased significantly and only five patients showed MR grade 3. Among 14 survivors with MS, eight patients (57%) underwent echocardiography during follow-up. The degree of MS decreased significantly and median MS gradient was 2.8 mmHg (0–10 mmHg). All survivors remain in the NYHA class I or II. Conclusions: MV repair in children showed excellent survival, acceptable re-operation rate and satisfactory valve function at long-term follow-up. Residual MV dysfunction was a significant risk factor for re-operation, but re-repair was successful in more than half of the patients who underwent re-operation.

Objectives: Incompetence of the left atrioventricular valve remains the final Achilles’ heel of repair of atrioventricular septal defects (AVSDs), despite low operative mortality in the modern era. We have analysed the morphological basis for valvar incompetence in our own series of repairs, and in doing so, reviewed the morphology of the annulus in AVSDs, before and after surgical repair. Methods: We reviewed retrospectively re-repair operations of the left atrioventricular valve following previous repair of AVSDs at the Great Ormond Street Hospital from 1 January 1994 to 31 December 2007. From this case series, the reasons for valvar incompetence were identified and techniques used for re-repair recorded. We also incorporated the detailed morphology of the annulus of the left atrioventricular valve before and after repair from our cardiac morphology archive. Results: Thirty-three patients had undergone re-repair of the left atrioventricular valve between 1 January 1994 and 31 December 2007. Twenty patients underwent re-repair of the left atrioventricular valve within 1 year of initial repair, and 13 cases beyond 1 year after repair. Cases re-repaired within 1 year mainly did so as a result of leaflet tears or valvar dysplasia. Cases re-repaired after this time mainly had multiple areas of valvar leakage, including central incompetence. Two patients underwent a second re-repair, which were dealt with by a partial ring from a thin-wall Gore-Tex graft for reduction annuloplasty. Out of the 121 cardiac morphologic specimens, 53 had undergone previous complete repair. Following repair, the annulus of the new left atrioventricular valve was composed of artificial patch material on its septal portion. Conclusions: Left atrioventricular valve incompetence following previous repair usually involves repair of the zone of apposition between the left bridging leaflets. Many of these valves also require annuloplasty to attain competence. Given the shape, growth potential and morphologic composition of the annulus in these cases, we have performed some of these repairs with a partial flexible ring from a thin-walled 3.5-mm Gore-Tex graft as a reduction annuloplasty that can be shaped to fit the exact contours of this annulus.

Objective: To define the outcomes following Ross and Yasui procedures for complex biventricular repair of critical left ventricular outflow tract obstruction (LVOTO). Methods: Of 1217 neonates presenting with critical LVOTO enrolled in the Congenital Heart Surgeons Society studies (1994–2008), 52 underwent the Ross or Yasui procedure and their outcomes were investigated using univariate and multivariable parametric models. Results: ROSS (N = 39): The Ross procedure (median age 87 days) was rarely the primary intervention (5/39, 13%). A significant number of cases were performed to treat iatrogenic aortic regurgitation after other previous interventions (25/39, 64%). Co-existing functional morphological defects were also common: 72% had preoperative evidence of mitral dysfunction, moderate-to-severe left ventricular dysfunction or endocardial fibroelastosis. Emergency iatrogenic aortic regurgitation (P = 0.005) and co-existing abnormalities (mitral stenosis, P = 0.02; mitral regurgitation, P = 0.05; LV dysfunction, P = 0.03) were strong determinants of death. Severe postoperative ventricular dysfunction or need for extracorporeal membrane oxygenation (ECMO) conferred negligible survival. Younger age was associated with disproportionately worse late outcome (5-year survival 44 ± 10% for neonates vs 76 ± 8% for age >3 months, P = 0.0013). However, mitral and left ventricular dysfunction and emergency presentation were significantly more common in the younger age groups. Infants less than 3 months of age without co-existing abnormalities had acceptable late survival (75 ± 20%). YASUI (N = 13): Yasui repair (median age 22 days) was usually the primary intervention (nine of 13) but occasionally followed Norwood palliation (four of 13). None was an emergency. All had a ventricular septal defect. Survival was 69 ± 13% at 10 years, which is not significantly different from other biventricular repair strategies in neonates. Aortic atresia was associated with better survival than stenosis (90 ± 12% vs 30 ± 14% at 3 years, P = 0.039). None reverted to univentricular physiology later. Conclusions: Case selection is key for complex biventricular repair and the importance of appropriate case selection is exaggerated at young ages. All available options should be considered before pursuing the Ross operation in the presence of co-existing functional morphological abnormalities or emergent iatrogenic aortic regurgitation. However, both the Ross and Yasui operations in children (including neonates and young infants) with favourable functional morphology offer good survival, at least matching that of other biventricular repair strategies.

Objective: The objective of this study was to analyse the postoperative course and early outcome after the Norwood operation for patients with hypoplastic left heart syndrome. We particularly aimed to assess the impact of surgical and pharmacological modifications introduced. Methods: Of 157 patients who underwent the Norwood operation between January 1996 and December 2007, postoperative intensive care data on haemodynamics, pharmacological support and ventilation were analysed from 146 patients (six patients died intra-operatively and data were incomplete in five). The cohort was divided into three groups depending on the surgical method and type of afterload reduction. Patients of group 1 (n = 39, January 1996–December 1999) were operated with deep hypothermic circulatory arrest. In patients of group 2 (n = 59, January 2000–June 2003) and group 3 (n = 59, July 2003–December 2007) antegrade selective cerebral perfusion was used. Patients of groups 1 and 2 received sodium nitroprusside to reduce afterload; in group 3 phentolamine was used. Results: There were no differences between the groups in terms of preoperative status and anatomy, except a higher incidence of prenatal diagnosis between groups 3 and 1. The duration and dosage of sodium nitroprusside administration were similar in groups 1 and 2. The median duration of afterload reduction was significantly longer in group 3 compared with both the other groups (72 h (range: 24–201 h) vs 48 h (range: 8–145 h) and 48 h (range: 4–173 h), respectively). The median ventilation times was shorter in group 2 compared with group 1 (61 h (range: 16–1191 h) vs 119 h (range: 26–648 h)). During the first 36 postoperative hours, the mean arterial blood pressure and coronary perfusion pressure were significantly lower in group 3 than in group 1 (50.7 ± 4.8 and 28 ± 3.7 mmHg vs 53.6 ± 5.2 and 31.4 ± 4.3 mmHg), but, in patients of group 3, the time period to consistently reach a mean arteriovenous oxygen difference below 5 ml dl^–1 was markedly shorter than in the other groups (group 3: 12 h 4.90 ± 1.97 ml dl^–1; group 1: 24 h 4.53 ± 2.25 ml dl^–1 and group 2: 24 h 4.57 ± 2.04 ml dl^–1). Complication rates were similar between the groups. However, 30-day mortality decreased over the study period to an exponentially weighted moving average of 2.3%. Conclusion: Adamant afterload reduction improves systemic blood flow early after the Norwood operation and may have contributed to the reduction in early postoperative mortality achieved over 12 years.

Objective: This study evaluated the efficiency and feasibility of dilatable bands in selected patients. Methods: Two types of dilatable handmade bands were retrospectively evaluated and divided into two groups: main pulmonary artery bands and bilateral branch pulmonary artery bands (hybrid stage I palliation). Stepwise balloon angioplasty (BA) was performed, increasing the diameter either to completely dilate with total release of the band, or in others, to partially dilate the bands in order to improve flow and/or saturation. Patients and results: Balloon angioplasty was performed in 20 patients (median birth weight 2.9 kg, range: 1.3–4.5 kg). Main pulmonary artery: Partial dilation: Six patients: Large ventricular septal defects (VSDs) and complex lesions requiring additional surgery. Progressive dilation allowed postponement of surgery in four children and allowed percutaneous VSD closure in one. Complete dilation: Eight patients: Spontaneous restriction of VSDs occurred in six patients; the bands were subsequently percutaneously completely released after a median of 39 weeks (7–91 weeks). The median gradient decreased from 90 to 38 mmHg (p < 0.0001). Bilateral branch pulmonary artery: An average 8.5% increase in saturations was achieved in five patients, and in one patient, a hybrid procedure with borderline left ventricle, complete dilation allowed successful percutaneous biventricular repair. Conclusions: Dilation of both main and bilateral branch pulmonary artery bands is possible, effective and safe. Dilatable main pulmonary artery bands allow for progressive dilation with postponement of surgery or complete release of the bands. Bilateral dilatable branch pulmonary bands offer palliative benefit, especially in hybrid cases where pulmonary blood flow may be limited by the bands before the ideal conditions for a stage II procedure exist.

Objective: Stereolithographic biomodelling is a technique where photosensitive liquid resin is polymerised with a pinpoint laser beam controlled by three-dimensional (3D) datasets. This study was designed to assess whether a stereolithographic biomodelling technique is applicable for precise anatomical diagnosis and simulation surgery of complicated congenital heart disease. Methods: Twelve stereolithographic biomodels were manufactured with multislice computed tomography (MSCT)-based 3D datasets. They were made of photosensitive liquid epoxy or urethane. Results: All the solid epoxy and rubber-like urethane biomodels reproduced the complex anatomical structures of the arteries and veins in congenital heart diseases. Furthermore, the rubber-like urethane biomodels allowed the surgeon to cut and suture, thus facilitating the simulation of the surgical operation. Conclusions: Stereolithographic biomodelling is a promising technique for the preoperative practice and simulation of individual surgery. This technique would be useful in the planning of novel and innovative surgical procedures of congenital heart disease.

Objective: Hypersensitivity to aprotinin is low (1–3%) but more likely with re-exposure. The manufacturer issued a black box warning which lists aprotinin re-exposure within 1 year of prior exposure as a contraindication. We investigated the temporal relationship between re-exposure interval and hypersensitivity in children. Methods: With Human Research Review Board approval, charts of all patients exposed to aprotinin during cardiac surgery were reviewed. We extracted data for re-exposure interval and hypersensitivity to skin tests, intravenous test dosing or infusion of the loading dose. We defined systemic hypersensitivity as haemodynamic instability, respiratory symptoms or diffuse skin reaction temporally related to exposure. Results: From March 1994 to June 2007, there were a total of 2333 aprotinin exposures in 1824 patients. A total of 509 re-exposures occurred in 381 patients: 280 in 244 patients with early (within 1 year) re-exposure and 229 in 222 patients with late (after 1 year) re-exposure. Thirteen systemic hypersensitivity reactions occurred in the 509 re-exposures (2.6%): two during skin testing and 11 during the loading dose. Although the incidence of local hypersensitivity was increased with early re-exposure (6/280 or 2.1% vs 0/229, p = 0.019), the incidence of the systemic reaction was not different between early and late re-exposures (6/280 or 2.1% (CI 0.8–4.6%) vs 7/229 or 3.1% (CI 1.2–6.2%), p = 0.6). Six patients with a previous hypersensitivity reaction had an additional re-exposure to aprotinin; one of these patients had a systemic reaction during the third exposure. Conclusion: The incidence and type of hypersensitivity to aprotinin re-exposure in our cohort is consistent with previous reports. Repeat exposure within 1 year did not increase the risk of systemic hypersensitivity.

Objective: The aim of this study was to evaluate the efficacy and safety of non-thoracoscopic extrapleural approach of the Nuss procedure for the correction of pectus excavatum in children. Methods: From October 2007 and January 2009, 42 patients with pectus excavatum were treated in the Tangdu Hospital, Xi’an, China, with surgical correction through the Nuss procedure. Among them, 20 underwent a Nuss procedure with thoracoscopic guidance, and the other 22 patients were treated with non-thoracoscopic extrapleural approach, in which a bilateral extrapleural tunnel to the edge of sternum was created using a blunt dissection through bilateral thoracic skin incisions. Without introducing the thoracoscopy into the thoracic cavity, a steel bar was inserted in the entirely extrapleural tunnel and turned as in the standard Nuss procedure. Results: The operations were completed successfully in all patients treated. The operation time and postoperative hospitalisation time of the non-thoracoscopic extrapleural Nuss group were significantly less than those of the thoracoscopic group (P < 0.05). There was no pneumothorax or hydrothorax in our series and no tube thoracostomy was further needed. All patients were followed up for more than 2 months, and the surgical outcomes were excellent. Conclusions: The non-thoracoscopic extrapleural approach of the Nuss procedure is a safe and less traumatic procedure for the correction of pectus excavatum.

Objective: Pectus excavatum is relatively common congenital chest deformity that is often accompanied by physical and psychological impairment. The surgical methods for pectus excavatum repair are the subject of some controversy. We review our experience using a procedure in which the introduction of exogenous material is unnecessary. Methods: From July 1993 to March 2008, 113 patients underwent surgical repair of pectus excavatum. Sterno-costal elevation was adopted for 102 patients, including all of the paediatric patients and most of the adults. Sternal turnover was employed for 11 adult patients with severe asymmetric deformities. In sterno-costal elevation, a section of the third or fourth to the seventh costal cartilages as well as the lower tip of the sternum below the sixth cartilage junction are resected, and all of the cartilage stumps are re-sutured to the sternum. The secured ribs generate 0.5–10 kg of tension, pulling the sternum bilaterally, such that the resultant force causes the sternum to rise anteriorly. These forces are sufficient to correct the deformities and to prevent flail chest. In sternal turnover, the sternum is cut at the third intercostal space. The lower part of the sternum is turned over and fixed to the upper sternum with an overlap of 1 cm. Sections of the third to the seventh rib cartilages are resected and affixed in the same fashion as in sterno-costal elevation. Results: There were no operative deaths, and in all cases the deformities were corrected satisfactorily. Ninety-nine patients (88%) were graded as Excellent, and the remaining 14 (12%) were graded Good. None of the patients developed any life-threatening complications. No patient reported residual pain. No re-operations were required for any reasons. The patients resumed daily activities of all types, including contact sports, within 3 months after surgery. Conclusions: We believe that morbidity is one of the most important factors to be considered in operative invasions. Our technique represents a less-invasive and lower-risk procedure for the repair of pectus excavatum in any age group.

Objective: To determine the safety and effectiveness of current endovascular treatment in adult patients with thoracic aortic coarctation and its complications. Methods: A cohort of 22 patients was treated for late presenting primary or recurrent coarctation or aneurysmal formation at varying intervals following childhood intervention. Results: Ten patients with recently discovered de novo coarctations were treated with balloon-expandable stents, and an endoluminal graft (ELG) was used in one additional patient. In the other 11 patients with recurrent lesions, three underwent repeat balloon dilation and stenting; eight patients with recurrence with aneurysms received ELGs. The gradients across the coarctation decreased from 49 + 16 to 4 + 7 mmHg (p = 0.001), and the diameters increased from 10 + 4 to 19 + 4 mm (p = 0.001). In five of the eight patients (63%) with aneurysms, the ELG covered the subclavian artery, and a carotid subclavian bypass was necessary. Two patients required iliac artery access. No early major complications occurred. At mean follow-up of 31 + 15.6 months, one patient with type II leak resolved spontaneously and another developed neck dilation and type I leak, requiring a second ELG placement. All patients except one had improvements in symptoms and better hypertension control. Conclusions: We conclude that primary or secondary endovascular intervention in adults with de novo or recurrent coarctation and aneurysms is feasible with good intermediate results.

Objective: Extracorporeal membrane oxygenation (ECMO) offers temporary haemodynamic support for those with refractory cardiogenic shock after cardiac surgery. We review our 5-year experience regarding ECMO use on those who cannot be weaned from cardiopulmonary bypass after cardiac surgery. We analyse our cases, predict the prognostic factors of survival and compare the short-term and medium-term results. Methods: From January 2002 to December 2006, 1764 patients underwent cardiac surgery with cardiopulmonary bypass in our division. Among these, 51 patients (2.9%) required venoarterial-mode ECMO for haemodynamic support because of refractory postcardiotomy cardiogenic shock. The indication of ECMO was refractory cardiogenic shock despite adequate filling volumes, large-dose inotropes and intra-aortic balloon pump support. The following cardiac surgical procedures were performed: coronary artery bypass grafting (CABG), n = 27; valvular surgery, n = 11; CABG plus valvular surgery, n = 7; heart transplantation, n = 4 and other procedures, n = 2. Results: Average age was 63.0 ± 15.7 years. There were 36 male and 15 female patients. Average duration of ECMO was 7.5 ± 6.7 days. Twenty-seven (53%) patients could be successfully weaned from ECMO. The 30-day and 3-month mortalities were 49% (25/51) and 65% (33/51). The in-hospital mortality was 67% (34/51 patients). Seventeen (33%) patients could be successfully discharged. Fifteen (29%) patients were still alive at 1-year outpatient department (OPD) follow-up. Conclusions: ECMO provides a good temporary cardiopulmonary support in patients with postcardiotomy shock. The preoperative risk factors of failure to withdraw ECMO are poor left-ventricular ejection fraction, systolic blood pressure <90 mmHg and refractory severe metabolic acidosis. The peri-ECMO predictors of mortality include low serum albumin level, low platelet count, low oxygen pressure of the venous tube of the ECMO and poor cardiac systolic function.

Introduction: Acute kidney injury (AKI) is one of the major complications in adult postcardiotomy patients on extracorporeal membrane oxygenation (ECMO) support. The RIFLE (the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-Stage Kidney Disease) classification and the Acute Kidney Injury Network (AKIN) criteria were proposed to identify and classify AKI recently. This study aims to evaluate the occurrence of AKI during the initial 48 h of ECMO support by using both the RIFLE classification and the AKIN criteria, and to determine which scoring tool has better capability for predicting hospital mortality of adult postcardiotomy patients with ECMO support. Methods: From 2004 to 2008, 67 patients (≥18 years) who received extracorporeal membrane oxygenation support after undergoing cardiac surgery were enrolled and retrospectively evaluated. Results: The average age was 50.5 ± 13.6 years; 48 patients (72%) were male. According to the RIFLE classification and the AKIN criteria, the incidence of AKI during first 48 h after receiving ECMO support was 81% and 85%, respectively. The overall mortality was 51% and the hospital mortality was much higher among patients who received renal replacement therapy (RRT) than in patients not receiving RRT (73% vs 32%, p = 0.001). Either class-Failure for the RIFLE classification (odds ratio (OR) = 12.6, 95% confidence interval (CI) = 2.2–72.3, p = 0.005) or the Stage 3 for the AKIN (OR = 30.8, 95% CI = 3.3–287.2, p = 0.003) was found to be independently associated with the hospital mortality. The area under the receiver operator characteristic (ROC) curve for hospital mortality was 0.738 for the RIFLE classification (p = 0.001) and was 0.799 for the AKIN criteria (p < 0.001). No significant differences were found in both the incidence of AKI and the hospital mortality of AKI by using the RIFLE/AKIN criteria. Conclusions: Acute kidney injury is a major complication and associated with high mortality in adult patients who received ECMO support after undergoing cardiac surgery. Both the RIFLE classification and the AKIN criteria have good short-term prognostic capability in these populations and either class-Failure for the RIFLE classification or the Stage 3 for the AKIN were found to be independently associated with the hospital mortality. However, it does not seem that the AKIN criteria have greater sensitivity and specificity, compared with the RIFLE classification in this study population.

Objective: The main objective is to describe and analyse hospital costs of the extracorporeal membrane oxygenation (ECMO) procedure. Study sample and methodology: Between January and December 2007, 14 ECMO patients were consecutively included in the study. Costs at the patient level were registered prospectively, while overhead costs were registered retrospectively. Patient costs were obtained from patient records and time–motion studies and included personnel resources, diagnostic and laboratory tests, radiology and operating room procedures, medication and blood products. Overhead costs were allocated to clinical departments and further to the individual patients by predefined keys. To achieve estimates of total costs, patient-specific costs and patient-specified overhead costs were summarised. Results: The mean estimated cost for the ECMO procedure was 73,122 USD (SD 34,786) and median 62,545 USD (range: 34,121–154,817). The mean estimated total hospital costs, including pre- and post-ECMO procedures, was 213,246 USD (SD 12,265), median 191,436 USD (range: 59,871–405,497). On average, 82% of costs for the total hospital stay were related to personnel use, and blood products constituted 7%, lab and radiology 2.5%, disposable items 3% and medication 1.5%. The mean duration of an ECMO procedure was 9.5 days (range: 4–23 days) and the average total length of stay in hospital was 51.5 days (range: 6–123 days). The cost data were converted from Norwegian kroner (NOK) to US dollars (USD), with an exchange rate of 1 USD = 5.5 NOK. Conclusion: ECMO procedure is a resource-demanding procedure.

Objective: Early graft failure (EGF) is a major risk for death after heart transplantation. We studied the impact of an extra-corporeal membrane oxygenation (ECMO) temporary support on the operative mortality and the mean-term survival after EGF. Materials and methods: Between January 2000 and December 2006, 394 patients underwent orthotopic heart transplantation at our institution. EGF was observed in 90 (23%) patients. Fifty-four patients (14%) were treated with ECMO support, eight (2%) with other assisting devices, and 28 (7%) received maximal inotropic drug support only. Results: The overall mortality was 21% (83 patients). EGF was a major risk for death: 13% (35 patients) without EGF versus 58% (49 patients) with EGF, p < 0001. Among patients supported with ECMO, 36 (67%) were weaned from the assisting device and 27 (50%) were discharged from the hospital. Overall survival was 73% at 1 year and 66% at 5 years. Absence of EGF improved long-term survival: 78% at 1 year and 70% at 5 years without EGF versus 37% at 1 year and 35% at 5 years with EGF. Patients treated with ECMO have the same 1-year conditional survival as patients not having suffered EGF: 94% at 3 years. Conclusions: ECMO support is a reliable therapeutic option in severe EGF after cardiac transplantation; furthermore, patients treated with ECMO have the same 1-year conditional survival as patients not having suffered EGF.

Objective: We tested the hypothesis that a miniaturised axial flow pump with infection-resistant power delivery could improve longevity and quality of life (QOL) in advanced heart failure patients deemed unsuitable for transplantation. Methods: The study included all non-United States Jarvik 2000 patients (n = 46), where a skull-pedestal-based power line was employed with the intention of long-term support. Patient age ranged from 29 to 80 years. Of the 46 patients, 42 were male. All were New York Heart Association (NYHA) IV predominantly with idiopathic dilated (n = 22) or ischaemic (n = 18) cardiomyopathy. The experience (2000–2008) included the learning curve of 10 centres. Results: The internal components are imperceptible. The power/control system is user friendly, allowing excellent QOL. There has been no pump malfunction. The Kaplan–Meier survival analysis is shown. The longest event-free survival is 7.5 years. Support exceeded 3 years in five cases. The cumulative experience exceeds 50 years. Three patients were transplanted, and two pumps were replaced at 90 and 203 days. Nineteen cases are ongoing (mean: 663 days), while 22 died during support (mean survival: 402 days), of which five from non-device-related diseases. Temporary local infection occurred in three pedestals, and there has been no pump infection. Incidence of thrombo-embolic events showed wide variation between centres. Conclusions: From this learning-curve experience, both left ventricular assist device (LVAD) and power delivery are reliable and promising for destination therapy. Early mortality is similar to other studies and relates to the severity of illness. Pump infection has not occurred and prolonged event-free survival is clearly possible with expert medical management.

Objective: The HeartMate II (HM II) LVAD is a small, quiet, continuous-flow, left ventricular assist device (LVAD) for circulatory support in advanced heart-failure patients, with over 2000 implants worldwide. This article reports on the European experience with this device. Methods: The HM II was implanted in 571 patients at 64 European institutions. In 72% of cases (411 patients), implantation has taken place at least 6 months before the closing date of the study (1 August 2008). Patients (19% female, 70% ischaemic aetiology) were on maximum medical therapy, including inotropic support. Body surface area ranged from 1.30 to 2.50 m² and age from 14 to 75 years (mean: 51 ± 14 years; n = 115, 28% over age 60 years). The intention of support was to provide a bridge to transplantation (73%), destination therapy (21%) and a bridge to recovery (6%). Adverse events were documented in the first 53 patients – for obtaining the Conformité Européenne (CE) Mark (group A) – from a European multicentric study (Strüber et al. [Strüber M, Sander K, Lahpor J, Ahn H, Litzler P-Y, Drakos SG, Musumeci F, Schlensak C, Friedrich I, Gustafsson R, Oertel F, Leprince P. HeartMate II left ventricular assist device; early European experience. Eur J Cardiovasc Surg 2008;34(2):289–94.]: 101 patients) and from a single-centre study (UMCU, The Netherlands: 30 patients). Results: The mean support duration ranged from 0 to 1019 days with a mean of 236 ± 214 days (249 patients: >6 months, 119: 1 year, 12: >2 years; total support time: 293 years). The overall survival to transplantation, recovery or ongoing device support at the end of the study was 69% (284) with an early mortality of 17.5% and late mortality of 13.5%. Of the surviving patients, 23% have been transplanted, 4% had their device removed after recovery of the left ventricle and 42% are still ongoing. Adverse events included bleeding (ranging from 42% in group C to 59% in group A), percutaneous lead infections (A: 0.19, B: 0.61 and C: 0.18 events per patient year), pocket infections (A: 0.08, B: 0.07 and C: 0.09 events per patient year), ischaemic stroke (A: 0.06, B: 0.09 and C: 0.04 events per patient year), haemorrhagic stroke (B: 0.07, C: 0.04 events per patient year) and transient ischaemic attacks (TIAs; A: 0.08, B: 0.02 and C: 0.13 events per patient year). Conclusions: These results support the use of the HM II continuous-flow LVAD for long-term support as a bridge to transplantation and possibly for destination therapy. Future emphasis should focus on minimising adverse events such as infections, bleeding and neurological events.

Objective: Surgical ventricular restoration (SVR) can be effective to treat ischaemic cardiomyopathy or left ventricular (LV) aneurysm. However, the initial improvement in LV function does not always last long because of LV remodelling. Beta-blockers prevent LV remodelling of failing hearts; however, their effects following SVR have not been elucidated. Thus, we sought to investigate the effects of a potent β-blocker, carvedilol, on LV remodelling and function following SVR in rats with myocardial infarction. Methods: Rats, which developed LV aneurysm 4 weeks after coronary artery ligation, underwent SVR. They were orally administered a vehicle (vehicle group), and low or high dose of carvedilol (20 or 50 mg kg^–1 day^–1 for C20 or C50 group) for 4 weeks following SVR (n = 7 in each group). Results: Four weeks following SVR, late cardiac remodelling was alleviated only in the C50 group (LV end-diastolic area: 65 ± 4 mm² vs 74 ± 11 mm² and 76 ± 11 mm² for C50, C20 and vehicle groups; p = 0.039 and p = 0.013, respectively). There was no difference in LV systolic function (end-systolic elastance) among the three groups; however, LV diastolic functions (LV end-diastolic pressure and the time constant of isovolumic relaxation) were significantly better in the C20 and C50 groups. Histologically, the percentage of myocardial fibrosis in the C50 group (4.1 ± 0.2%) was lower than those in the C20 (6.7 ± 0.4%, p < 0.0001) and vehicle (7.5 ± 0.6%, p < 0.0001) groups. The mRNA expression of transforming growth factor-β1 and brain natriuretic peptide in the C50 group were lower than those in the C20 and the vehicle groups. Conclusions: High-dose carvedilol alleviated LV remodelling and diastolic dysfunction following SVR accompanying with reduction in myocardial fibrosis. Blockade of β-adrenergic receptor may be a promising adjuvant therapy in patients following SVR.

Background: Heart failure is a common and often fatal disease. Numerous animal models are used to study its aetiology, progression and treatment. This article aims to demonstrate two minimally invasive models of congestive heart failure in a rabbit model and a precise method to assess cardiac performance. Methods: Fifty New Zealand White rabbits underwent cervicotomy incision and were then divided into three groups. Aortic regurgitation (AR group) was induced in 17 animals by catheter lesion through the right carotid artery, proximal aortic constriction (AC group) was created in 17 animals by metallic clip placement in the ascending aorta through a neck incision, while 16 animals served as controls (CO group). Eight weeks later, myocardial function and contractility indices were assessed by sonomicrometry crystals. Hearts were then collected for morphometric measurements and left ventricular tissues were subjected to immunohistochemical analysis of fibrosis, necrosis and apoptosis. Statistical analysis was by analysis of variance (ANOVA) with a Dunnett's post hoc test or by Kruskal–Wallis test with Dunn's post hoc test as appropriate, with significance at p ≤ 0.05. Results: The model of aortic regurgitation indicated early stages of heart failure by volume overload with increased end-diastolic and end-systolic volumes, stroke volume, cardiac output and pressure–volume loop areas. The elastance was higher in the control group compared with that in the AC and AR groups (131.00 ± 51.27 vs 88.77 ± 40.11 vs 75.29 ± 50.70; p = 0.01). The preload recruitable stroke work was higher in the control group compared with that in the AC and AR groups (47.70 ± 14.19 vs 33.87 ± 7.46 vs 38.58 ± 9.45; p = 0.01). Aortic constriction produced left ventricular concentric hypertrophy. Fibrosis appeared in both heart failure models and was elevated by aortic constriction when compared with that in controls. Necrosis and apoptosis indices were very low in all the groups. Clinical signs of congestive heart failure were not present. Conclusions: The two heart failure models we describe were relatively simple to create and maintain, minimally invasive, accurate, inexpensive and, importantly, had a low mortality rate. These models rapidly induced deterioration of contractility indices and onset of fibrosis, the hallmarks of early myocardial dysfunction associated with heart failure. Sonomicrometry assessments were able to detect early contractility changes prior to clinical signs.

Background: Calcium sensitising inotropes are increasingly being used in cardiac surgical patients. Theoretically, increasing contractile protein sensitivity to Ca²⁺ prevents the Ca²⁺ elevation associated arrhythmogenicity and potentiates the inotropic effect of catecholamines. On the other hand, we hypothesised that Ca²⁺ sensitisation exacerbates post-ischaemic myocardial stunning by impairing diastolic relaxation, which might have deleterious effects in postoperative cardiac surgical patients. Methods: In an isolated rabbit heart model, 45 min normothermic ischaemia with potassium-induced cardioplegic arrest was followed by 120 min reperfusion. Isovolumetric left ventricular (LV) function and myocardial oxygen consumption (MvO₂) were measured, and cytosolic Ca²⁺ was monitored by rhod-2 surface spectrofluorometry. During reperfusion, ORG 30029 (250 µM) and levosimendan (0.5 µM) were used as Ca²⁺ sensitisers (ORG, n = 6, Levo, n = 6), Ca²⁺ de-sensitisation was induced with butanedione-monoxime (5 mM, BDM, n = 6), and dopamine (20 nM) served as a representative catecholamine (n = 6). To counteract the PDE III inhibiting properties of ORG and Levo, IGF-1 (0.1 µM) and parathyroid hormone (0.05 µM) were used. Results: As expected, ischaemia/reperfusion induced moderate cytosolic calcium overload. Dopamine increased LV contractility and MvO₂ by augmenting the amplitude of the Ca²⁺ transient, but relaxation was unchanged due to faster diastolic Ca²⁺ removal. Dopamine-induced Ca²⁺ handling was unchanged after uncoupling the Mg-ATPase with BDM, and MvO2 decreased in proportion with the reduced LV mechanical work load. ORG improved contractility without apparent effects on Ca²⁺ handling, and MvO₂ remained constant despite increased contractile work. Conversely, ORG induced a rightward shift of the diastolic pressure-volume relationship in post-ischaemic hearts (diastolic pressure at 0.8 ml balloon volume 14.3 ± 5 mmHg, p = 0.01 vs control), but not in non-ischaemic control hearts. With levosimendan, the Ca²⁺ sensitising effects were less pronounced (7.6 ± 3 mmHg, p = 0.4 vs control). By counteracting the PDE inhibiting effects of ORG and Levo using parathyroid hormone and IGF-1, the negative lusotropic effects of Ca²⁺ sensitisation were unmasked. Conclusions: Calcium sensitisation improves systolic function and energetic efficiency. However, Ca²⁺ sensitisers should be used with caution during post-ischaemic reperfusion, as they may exacerbate myocardial stunning and thus impair cardiac output.

Objective: Mural thickening, combined with longitudinal and circumferential shortening, and apical along with basal twisting are critical components of the left ventricular systolic deformation that contribute to ventricular ejection. It is axiomatic that the spatial alignment of the actively contracting aggregates of myocytes must play a major role in the resulting ventricular deformation. The need to conserve functional global myocytic architecture, therefore, is an important aspect of the surgical manoeuvres affecting ventricular mass and geometry. To investigate the influence of the global alignment of the myocytes on ventricular contraction, we used a mathematical model simulating the large deformations produced by systolic contraction of the left ventricle of a human heart. Methods: The alignment and meshing of the myocytes within their supporting fibrous matrix cause mechanical anisotropy, which was included in the mathematical model in the form of a unit vector field, constructed from the measured trajectories of aggregated myocytes in an autopsied human heart. The relationship between ventricular structure and ventricular dynamics was assessed by analysing the influence of systematic deviations of the orientation of the myocytes from their original alignment, in longitudinal as well as radial directions, on the distribution of stress and strain within the myocardium, as well as on the ejection fraction. In addition, simplified idealised geometries were used to investigate the influence of the overall geometrical modifications. Results: Left ventricular function proved to be robust with respect to small-to-moderate rotational variations in myocytic alignment, up to 14°, a finding which we attribute to an equalising effect of the non-uniform anisotropic pattern found in a real heart involving substantial local irregularities in the architecture of the aggregated myocytes. Severe deterioration of function occurred only when deviations in alignment exceeded 30°. Conclusions: Our findings substantiate the concept of the myocardial walls representing a continuous three-dimensional meshwork, with the absence of any intermediate structures such as discrete bands or tracts extending over the ventricles, which could be destroyed surgically, thereby adversely affecting systolic function. With appropriate indications, they also support the validity of the surgical procedures performed to reduce ventricular radius and therefore to reduce mural stress.

Background: The right ventricle (RV) may be selectively impaired following coronary artery bypass graft (CABG) surgery. We tested this hypothesis in two study parts: a prospective cohort undergoing CABG, and a retrospective cross-sectional cohort of heart-failure patients with and without a history of CABG. Methods: In the prospective study, 20 patients undergoing CABG had echocardiography prior to surgery and 3 months postoperatively. In the retrospective study, 101 patients with established heart failure underwent echocardiography, 40 of whom had undergone previous CABG and 61 of whom had not. Myocardial tissue Doppler velocities were used as a measure of left and right ventricular function. To adjust for varying degrees of overall cardiac impairment, we calculated the ratio between the velocities of the RV and left ventricle (LV). Results: In the prospective study, there was a significant fall in RV:LV ratio following CABG surgery. For S', the ratio fell from 2.27 to 1.13 (50%, p < 0.0001), for E' from 1.49 to 0.94 (37%, p < 0.0001) and for A' from 1.66 to 1.05 (37%, p < 0.0001). In the retrospective study, the RV:LV ratio was lower in the CABG group compared with the non-CABG group for S' (by 32%, p < 0.001), E' (by 39%, p < 0.001) and A' (by 37%, p < 0.001). In the retrospective study, even when the CABG patients were compared with the ischaemic aetiology heart-failure patients without CABG, a similar relative impairment was seen: 25% in S' (p < 0.001), 34% in E' (p < 0.001) and by 38% in A' (p < 0.002). Conclusions: Both prospectively and cross-sectionally, there is evidence of substantial, selective right ventricular impairment following CABG. These features cannot be explained simply by some general feature of ischaemia and, therefore, must be a consequence of surgery.

To assess the accuracy of increased troponin (Tn) concentrations for the prediction of mid-term (≥12 months) mortality after coronary artery bypass graft (CABG) and valve surgery, we performed a systematic review identifying all studies reporting on the association between postoperative troponin release and mortality after cardiac surgery. Studies were identified through 30 April 2008 by electronic searches of the MEDLINE, EMBASE and BIOSIS databases. Two reviewers independently selected studies, assessed methodological quality and extracted the data. We primarily considered mid-term (≥12 months) and secondarily short-term (≤30 days) all-cause mortality. A bivariate random-effects model was used to study determinants and to pool measures of prognostic accuracy of Tn. Seventeen studies fulfilled the inclusion criteria with a total of 237 mid-term deaths in 5189 patients and 296 short-term deaths in 9703 patients. The diagnostic odds ratio of increased Tn concentrations was 5.46 (95% confidence interval (CI) 2.0–14.6) for mid-term mortality and 6.57 (95% CI 4.3–10.1) for short-term mortality after adult cardiac surgery. Alternatively expressed, for troponin elevation, the sensitivity was 0.45 (0.26–0.67) and the specificity 0.87 (0.73–0.90) to predict mid-term mortality. The sensitivity was 0.59 (0.48–0.69) and the specificity 0.82 (0.72–0.89) for short-term mortality. Between-study variability was high. In conclusion, this meta-analysis provides evidence for an association between postoperative Tn release with mid- and short-term all-cause mortality after adult cardiac surgery. However, differences in populations, timing of Tn testing, Tn subunit and Tn assays make definitive conclusions about effect size and cut-off values difficult.

Accompanying the continuously deepening understanding of the mechanism of pulmonary hypertension that many genes are found to be aetiologically involved in its development, burgeoning literature manifest that gene therapies aimed at correcting these genetic defects have the ability to restore deficient pulmonary gene expression, over-express biologically active gene products, reverse established disease and regenerate pulmonary vasculature, and may constitute a promising therapeutic strategy for pulmonary hypertension. Therefore, to provide new information to basic scientists and clinical investigators, we present a review that attempts a clear description of the therapeutic potential of gene therapy in the treatment of pulmonary hypertension.

Objective: Aprotinin has been widely used to reduce bleeding and transfusion requirements in cardiac surgery and in lung transplantation. A recent study found a significant reduction in severe (grade III) primary graft dysfunction (PGD) in lung transplantation where aprotinin had been used. However, recently, concerns regarding the safety of aprotinin have been raised, and the future use of aprotinin is uncertain. In our institution, aprotinin has been widely used in cardiac surgery and transplantation. We decided to review our lung transplant caseload to investigate the impact of aprotinin on PGD and mortality and to guide our future clinical use of this antifibrinolytic. Methods: A retrospective review of prospectively collected data on 213 consecutive patients who underwent single- or double-lung transplantation was performed. Ninety-nine patients, who received aprotinin, were compared with 114 patients who did not. The main outcome variables analysed were development of primary graft dysfunction, renal impairment and mortality. Results: Aprotinin was associated with a significantly increased risk of PGD in the first 48 h postoperatively (p = 0.01). Conclusions: In conclusion, although the benefits of aprotinin on blood loss are well established, this study does not provide support for the use of aprotinin to reduce PGD in lung transplantation and indicates that aprotinin may in fact have a detrimental effect.

Objective: E-cadherin is a major cell-to-cell adhesion molecule, of which the ectodomain is cleaved from epithelial cells to yield a soluble form after the pathological alteration of the alveolar epithelium. We investigated the excretion level of soluble E-cadherin in a rat lung isotransplant model, and demonstrated the involvement of this molecule in the pathogenesis of reperfusion injury after lung transplantation. Methods: Inbred male Lewis rats were used as both donor and recipient animals, and they were subjected to left lung isotransplantation. After 6 h of ischaemia, the left lung was transplanted into a recipient rat and reperfused for 4 h. The animals were injected intravenously with ¹²⁵I-labelled albumin at 3 h after the onset of reperfusion as a marker of pulmonary albumin leakage. We assessed pulmonary alveolar septal damage quantitatively based on the ¹²⁵I-albumin concentration ratio of bronchoalveolar lavage fluid (BALF) to plasma. Soluble E-cadherin fragments were detected in BALF on Western blot analysis using affinity-purified antibodies specific to rat E-cadherin synthetic peptides. Results: The BALF supernatant-to-plasma ratio of the graft lung was significantly increased compared to that of the control group. Western blot analysis showed a marked release of soluble E-cadherin into BALF, and its increase in BALF was associated with alveolar septal damage. Conclusions: These results suggest that one potential mechanism of lung reperfusion injury involves the cleavage of E-cadherin.

Objective: This study aims to assess the suitability rates and the causes of lung-donor refusal, to determine which factors could be improved to expand the donor pool available for transplantation (LTx). Methods: Lung donors offered to our Lung Transplantation Unit from October 1993 to December 2007 were reviewed to assess the causes of unsuitability. The donor-lung evaluation was divided into three stages: stage 1 (PaO₂/FiO₂ ratio, chest X-ray, bronchoscopic findings), stage 2 (donor-lung inspection and palpation) and stage 3 (assessment of grafts after harvesting). Variables from donors and recipients were analysed and compared between 1993–2001 (group A) and 2002–2007 (group B). An additional subgroup of extended donors was analysed to assess the recipient outcomes. Results: A total of 476 lung donors were assessed (278 men and 198 women; mean age 29 ± 13 years). Causes of death were trauma in 255, intracranial bleeding in 202 and others in 19. As many as 273 donors were suitable for LTx (57%; 162 double LTx and 111 single LTx). Acceptability rates were 68%, 58% and 57% at stages 1, 2 and 3, respectively, and were significantly higher in group B than in group A (overall: 64% vs 54%; stage 2: 91% vs 79%), with no changes in stages 1 and 3. Abnormal bronchoscopy precluded LTx in 79 cases (16%). Group B donors were older (p = 0.000), ventilated longer (p = 0.07) and with shorter ischaemic times (p = 0.000) than group A. In the recipients, primary graft dysfunction (PGD) (17% vs 15%) and 30-day mortality (11% vs 6%) did not differ between both the groups. No differences were observed between extended and ideal donors in terms of recipient 30-day mortality (extended 6% vs ideal 9%; p = 0.315) and development of PGD (extended 21% vs ideal 15%; p = 0.342). Conclusions: Despite the high rate of organ donation in Spain, the acceptability rate remains low (57%), mainly due to failure to meet the criteria for acceptance at the early stages of donor-lung assessment. Improvements in multi-organ donor care must be made to expand the lung-donor pool. The use of extended donors does not seem to have a negative impact on recipient outcomes.

Purpose: The present study examined the clinicopathological impact of survivin expression in oesophageal squamous cell carcinoma (ESCC). In addition, the biological role of anti-apoptosis parameter in ESCC was examined immunohistochemically. Patients and method: Subjects comprised 71 patients followed up for 5 years after surgery for ESCC and analysed immunohistochemically to examine the clinicopathological impact of survivin expression. Separately, 37 fresh frozen samples of ESCC obtained recently were examined concerning splicing variant expression of survivin using reverse-transcription polymerase chain reaction (RT-PCR). Results: Immunohistochemical survivin expression was detected in the nuclei of 10 ESCC specimens (14.1%) and cytoplasm of 22 specimens (31.0%). Nuclear expression displayed no clinicopathological implications, but cytoplasmic expression correlated with histological differentiation (p = 0.002) and tumour invasion (p = 0.073) and showed prognostic impacts in univariate (p = 0.0184) and multivariate (p = 0.0299) analyses. Survivin, survivin-2B and survivin-deltaEx3 mRNA were amplified in 31 (83.8%), 23 (62.2%) and 26 (70.3%) specimens, respectively, by RT-PCR. Survivin-2B level related significantly with histological differentiation (p = 0.038), but no other significant implication was identified between any mRNA and clinicopathological factors. Conclusion: As a molecular biological anti-apoptotic factor, survivin expression was of use in assessing prognosis in ESCC. Inhibition of survivin may be useful as a molecular biological therapy in ESCC.

Objective: Complete resection is the therapy of choice in non-small-cell lung cancer (NSCLC). There is no agreement on the type of resection, especially when interlobar N1 disease is present. The present study explored the effect of the type of resection on survival in the presence of N1 disease. Method: Medical records of 195 patients with NSCLC who underwent resection between 1998 and 2006 and whose histopathological examination showed N1 disease were reviewed retrospectively. This study included 162 patients with T status of T1, T2 or T3, who had complete resection (excluding superior sulcus tumours). The patients were divided into three groups, namely hilar N1 (n = 15, 9.3%), interlobar N1 (N1-i) (n = 54, 33.3%) and lobar N1 (n = 93, 57.4%). Frequency comparisons were carried out by chi-square test. Survival rates were calculated by the Kaplan–Meier method and compared by log-rank test after patients who had operative mortality (n = 10, 6.2%) were excluded. Results: Seventy-seven patients (47.5%) had lobectomy, 14 (8.6%) had bilobectomy (BL) and 71 (43.8%) had pneumonectomy (PN). Twenty-one of these patients (13.0%) had sleeve lobectomy and 19 had (11.7%) additional interventions (such as resection of the diaphragm or thoracic wall). Among all N1 patients, 5-year survival rate was 56.9% in patients who had BL or PN and 46.8% in patients who had lobectomy, a difference not statistically significant (p = 0.09). Similarly, there was no significant difference between patients who had sleeve resection and PN (p = 0.58). The type of resection was not found related to survival in the presence of interlobar (p = 0.75). Similarly, type of resection was not significantly associated with survival in patients with hilar N1 (p = 0.86). Conclusion: Those who had PN or BL had a higher survival rate, which was statistically insignificant. Further studies are required to determine whether or not the type of resection should be changed as a result of N1 only.

Objective: We evaluated video-assisted thoracic surgery (VATS) and open (OPEN) lobectomy for lung cancer and impact upon 6-month postoperative (postop) functional health status and quality of life. Methods: In this retrospective analysis of prospective, observational data, anatomic lobectomy with staging thoracic lymphadenectomy was performed with curative intent for lung cancer. OPEN consisted of either thoracotomy (TH) or median sternotomy (MS). Technique was selected on the basis of anatomic imperative (OPEN: larger or central; VATS smaller or peripheral tumours) and/or surgical skills (VATS lobectomy initiated in 2001). All patients completed the Short Form 36 Health Survey (SF36) and Ferrans and Powers quality-of-life index (QLI) preoperatively (preop) and 6 months postop. Results: A total of 241 patients underwent lobectomy (OPEN, 192; VATS, 49). OPEN included MS 128 and TH 64. Comparison of MS and TH patient demographics, co-morbidities, pulmonary variables, intra-operative variables, stage and cell type, postop complications and 6-month clinical outcomes found no differences, allowing grouping together into OPEN. The VATS group had better pulmonary function testing (PFT), more adenocarcinoma and lower stage. The VATS and OPEN groups did not differ regarding operating time, postop complications and operative or 6-month mortality. The VATS group had less blood loss, transfusion, intra-operative fluid administration and shorter length of stay. Comparing within each group's preop to 6-month postop data, VATS patients were either the same or better in all SF36 categories (physical functioning, role functioning – physical, role functioning – emotional, social functioning, bodily pain, mental health, energy and general health). The OPEN group, however, was significantly worse in SF36 categories physical functioning, role functioning – physical and social functioning. The preop and 6 months postop VATS versus OPEN QLI scores were not different. At 6 months postop, hospital re-admission and use of pain medication was less in the VATS group. In addition, the VATS group had better preservation of preop performance status. Conclusions: VATS lobectomy for curative lung cancer resection appears to provide a superior functional health recovery compared with OPEN techniques.

Objective: The present intervention study was conducted to prospectively evaluate the long-term prognosis for video-assisted limited surgery, such as wedge resection and segmentectomy, for clinically early lung cancers depending on findings in high-resolution computed tomography (HRCT). Subjects and methods: Patients were enrolled in the study between 2001 and 2004, and followed up for five subsequent years. Of these patients, those with a clinical stage IA lung cancer mainly comprising a ground glass-opacity (GGO) less than 1.5 cm across underwent thoracoscopic wedge resection of the lung (Group A). Patients with a tumour less than 2.0 cm in diameter, not classified in Group A, underwent video-assisted segmentectomy and hilar lymph node dissection with lobe-specific mediastinal nodes sampling (Group B). For patients with a tumour less than 3.0 cm in diameter, not classified in to any of the foregoing two groups, underwent video-assisted lobectomy and hilar and mediastinal lymph node dissection (Group C). Results: During the case registration period, 159 patients were registered for enrolment in the study (21 for Group A, 43 for Group B and 95 for Group C). Of the patients in Groups A and B, 28% were shifted to a surgical procedure involving a larger volume resected; 6% of the entire study population were shifted to thoracotomy. All patients completed the 5-year follow-up. The recurrence-free survival rate was 100% for Group A, 90.5% for Group B and 94.5% for Group C, with no significant difference among the groups. The total recurrence rate was 11.9% with localised recurrences observed in 6.3% of the patients and remote recurrences in 5.7%. The localised recurrences observed included stump recurrence in one case of Group B, and malignant pleural effusions/pleural dissemination in two cases of Group B and one case of Group C. Intrathoracic lymph node recurrences were observed in one case of Group B and five cases of Group C. Conclusions: The present intervention study showed that thoracoscopic-limited surgery for clinically early lung cancers depending on findings in preoperative HRCT is feasible and appropriate from the viewpoint of oncology.

Objective: In the treatment of advanced stages of lung cancer, increasingly more multimodality approaches applying radiotherapy and/or chemotherapy in a neo-adjuvant setting are being introduced. The impact of induction therapy, especially radiotherapy, on bronchial tissue viability has not been investigated so far. Methods: In 2008, we determined the tissue viability of bronchial segments obtained during surgery in 45 consecutive patients, including patients after neo-adjuvant radiochemotherapy (RCTX). Bronchial tissue viability was analysed by histology, life–dead assay and cell proliferation in tissue-specific culture media. Biomedical findings were compared with the clinical course of the patients. Results: Tissue samples of 44 patients were included into this study. Fourteen patients (32%) had undergone neo-adjuvant RCTX. Histology and life–dead assay of the bronchial segments did not show significant differences. While patient age, sex, tumour entity and site of resection had no influence on cell proliferation in vitro, previous RCTX resulted in a 46% decrease of bronchial tissue viability (P = 0.01). However, this effect was not reflected by the clinical course of the operated patients. Conclusions: Neo-adjuvant RCTX reduces bronchial tissue viability substantially. However, this impairment does not necessarily translate into an increased rate of postoperative bronchial insufficiencies. Standard histological work-up is not sensitive enough to characterise changes in bronchial tissue viability following RCTX.

Background: Thoracotomy is a surgical procedure associated with severe pain. Operative morbidity rates reduce by effective postoperative pain control. The aim of this study is to compare the effectiveness of the thoracic epidural blockade (TEB) and the paravertebral blockade (PVB) methods in relieving the pain caused by a thoracotomy incision. Materials and methods: We studied 44 consecutive patients who underwent elective posterolateral thoracotomy. The patients were classed into two groups: TEB (n = 19) and PVB (n = 25). Patients in both the groups could self-control the infusion of bupivacaine infusion and diclofenac sodium. The groups were compared according to the parameters such as analgesic efficacy (VAS), respiratory function tests (forced expiratory volume in 1 s (FEV₁), peak expiratory flow rate (PEFR) and arterial blood gases), stress response (serum cortisol and glucose levels), adverse effects, necessity for additional analgesia, duration of catheter application procedure, mean hospital stay and postoperative follow-up. Results are analysed statistically by Mann–Whitney U, Wilcoxon, chi-square and Fisher's exact tests, and a p-value of <0.05 was accepted to be statistically significant. Results: There was no significant difference between the two groups with regard to age, gender, VAS, FEV₁, PEFR, serum cortisol and glucose levels, necessity for additional analgesia and hospital staying days. In contrast, adverse effects and duration of catheterisation were statistically significantly lower in group PVB (p = 0.001 and p < 0.001, respectively). Conclusion: PVB catheterisation can be easily performed and placed in a short span perioperatively. Therefore, it might be the preferred method over TEB which has a high incidence of adverse effects and complication rates.

Background: Surgery for pulmonary tuberculosis (TB) has become rather limited. However, it is still required for some sequelae and complications. This is a 15-year retrospective study of cases operated upon for pulmonary TB at a centre. Patients and methods: A total of 2878 cases underwent surgical procedures for various complications of pulmonary TB over a 15-year-long period. After excluding those managed by tube thoracostomy, rib resection and open-window thoracostomy, 1297 cases out of this series were taken up for major thoracic surgical procedures. A total of 98 were operated for persistent sputum-positive status, 740 for recurrent massive haemoptysis or chest infections, 2024 for empyema and 18 for diagnostic reasons. Procedures were 830 lung resections, 12 primary thoracoplasties, 295 space-reducing thoracoplasties, 158 decortications, 744 open-window thoracoplasties and 837 tube thoracotomies alone. Results: There were 18 early deaths and 37 late deaths. The cause of death was haemorrhage in seven cases and respiratory failure in nine cases and septicaemia in two cases. Late deaths were mostly because of progressive tubercular disease. There was significant morbidity in terms of broncho-pleural fistula (BPF) in 95 cases and persistent sinus in 37 cases. Milder complications such as pneumonia, fever and wound sepsis were noticed in some cases but definite records were not available. BPF was managed by tube drainage followed by either window thoracostomy or thoracoplasty. In multi-drug-resistant (MDR) cases, persistent documented sputum negativity was achieved in 64 out of 86 cases. Results were better in haemoptysis and chest infection group where the desired result was achieved in 699 cases. Conclusions: Surgery in pulmonary TB is still relevant in many cases and yields a very gratifying result. It is a challenging surgery and this series is a very large one.

Objective: The objective of our article is to analyse the results of complex space-filling procedures for chronic intrathoracic suppurations. Methods: We performed a retrospective analysis of 76 consecutive patients operated in our unit between 1 January 2003 and 31 December 2008, who presented pleural and/or pulmonary suppurations not amenable to decortication or resection; 36 patients (47%) had tuberculosis (TB) lesions (28 with positive cultures at the moment of surgery, seven with multi-drug-resistant (MDR) infections), 13 patients (17%) had postoperative empyema, 18 patients (24%) presented with frank intrapleural rupture of a pulmonary cavity and 26 patients (34%) presented with bronchial fistula. In these patients, we performed a combination of thoracoplasty (5.3 ± 1.3 resected ribs) and intrathoracic transposition of extrathoracic muscles – 148 flaps (60 serratus anterior, 55 latissimus dorsi, 27 pectoralis and 6 subscapularis) with an average of 1.9 flaps per patient; in all patients, we used a closed-circuit irrigation–aspiration system and primary closure of the wound. Results: The overall mortality was 5% (four patients) and four other patients (5%) presented recurrence of infection requiring a modified open-window thoracostomy; other local complications included minor skin necrosis solved through excision (three cases) and external thoracic fistula closed through local lavages (two cases). Postoperative hospitalisation ranged between 4 and 180 days, with an average of 40 ± 5 days; all patients were discharged with healed wounds. Statistical analysis performed with the Fischer's exact test suggested that the flap or combination of flaps used to obliterate the space did not influence the rate of recurrence or the incidence of other major postoperative complications (p > 0.05). Mild impairment of shoulder function was encountered in five patients. A comparative evaluation of the pre- and postoperative VC and forced expiratory volume of 1 s (FEV1) showed no statistically significant difference (Wilcoxon signed-rank test – p > 0.05). Conclusions: Patients with complex intrathoracic suppurations not amenable to decortication or lung resection require complex space-filling procedures to achieve complete obliteration of the infected space. The association between thoracoplasty and intrathoracic muscle transposition is a safe and simple solution allowing a quick recovery with good functional and aesthetic postoperative outcome.

Cardiac tamponade occurring during the late postoperative period after open-heart surgery is an extremely serious complication. One surgical therapy is a finger dissection through subxiphoid incision. The main limitation is an incomplete view into the pericardial sac. To make subxiphoid exploration more effective, we developed a novel technique of endoscope-assisted removal of delayed cardiac tamponade through subxiphoid pericardiotomy. Surgery was performed under optical guidance of an endoscopic retractor routinely used for harvesting saphenous veins for bypass grafting. After the subxiphoid pericardiotomy, we introduced the endoscopic retractor into the pericardial space, and the haematoma was completely evacuated using a suction apparatus and endoscopic forceps. Between January 2008 and March 2009, three patients underwent endoscope-assisted removal of late cardiac tamponade. The haematoma was completely removed without re-sternotomy. No bleeding or tamponade occurred following the procedure. An endoscopic approach for treating late cardiac tamponade provides the advantages of minimally invasive surgery through subxiphoid pericardiotomy combined with an optimal surgical perspective. This novel technique permits exploration of the pericardium and helps prevent new wounds.

We describe a simple technique of constructing proximal vein graft anastomoses, in an open fashion, under brief periods of very low pump flows. We have used this technique without complications in more than 100 patients with significantly diseased ascending aorta wall. In our opinion, this technique is a good alternative to other, more complex, approaches often described.

Transcatheter aortic valve implantation is a new and rapidly evolving treatment option for high-risk surgical patients with degenerative aortic valve stenosis. Long-term results with these new valve prostheses are lacking, and potential valve dysfunction and failure would require valve replacement. We report the first case of surgical valve replacement in a patient with a dysfunctional transcatheter-implanted aortic valve prosthesis 4 months after implantation.

Objective: While thymectomy is an accepted treatment for myasthenia gravis (MG), video-assisted thoracoscopic surgery (VATS) thymectomy has recently become a popular surgical treatment, especially for non-thymomatous MG (NTMG). This study aims to compare the results of VATS thymectomy and trans-sternal thymectomy, and identify prognostic factors in NTMG patients after thymectomy. Methods: A 10-year retrospective review (January 1995 to December 2004) of 60 consecutive thymectomies (22 trans-sternal thymectomies and 38 VATS thymectomies) of NTMG patients performed in a university teaching hospital was undertaken. Results: There were 43 female patients and 17 male patients with a median MG-onset age of 25 years (range: 5–78 years). Median follow-up time was 44 months. VATS thymectomy patients had a shorter hospital stay than the trans-sternal thymectomy patients (5.6 days vs 8.1 days, p = 0.008). There was no other statistically significant difference between the two operative methods in NTMG patients, including intensive care unit (ICU) stay, ventilator support time, operative time, postoperative status, complete stable remission (CSR) rate, morbidity and mortality. Three prognostic factors associated with better remission rate were hyperthyroidism (p = 0.003), age <40 years (p = 0.022) and the presence of thymic hyperplasia (p = 0.041). Other factors, including gender, disease duration, preoperative MG severity, acetylcholine receptor antibody, perioperative therapy and operative methods (32% vs 36%, p = 0.91, 95% confidence interval (CI) = 0.27–3.21) were not statistically relevant to better remission rate. Conclusions: VATS thymectomy is more advantageous for NTMG patients because of shorter hospital stay, less tissue injury, better cosmetic result and equivalent CSR rate. NTMG patients aged <40 years with hyperthyroidism and a histologic diagnosis of lymphofollicular hyperplasia have better chances of remission after thymectomy.

Thymoma and thymic carcinoma are an extremely heterogeneous group of neoplastic lesions with an exceedingly wide spectrum of morphologic appearances. They show different presentations with a variable and unpredictable evolution ranging from an indolent non-invasive attitude to a highly infiltrative and metastasising one. Prognosis can be predicted on the basis of a number of variables, mainly staging, the WHO histological pattern and diameter of the tumour. Complete surgical resection is certainly the gold standard to achieve cure. However, especially in patients with lesions at advanced stage, complete resection may be difficult and recurrence often occurs; at these stages, disease-free long-term survival may be difficult to be accomplished. Chemo- and radiotherapy protocols have been designed to complete surgical treatment and improve results in inoperable patients as well, based on the reported sensitivity of thymic tumours to these treatment modalities. The integration of clinical staging and histology, with the new histogenetic morphological classification, has contributed to design multimodality treatment protocols that help to improve prognosis. Induction therapy can now be applied before surgery in patients with tumours considered inoperable, improving resectability and outcome without adding morbidity and mortality to the surgical procedure. This newly developed approach helps to reduce the recurrence rate and to ameliorate disease-free survival. New therapies are now being evaluated as for many other tumours; however, they still need confirmation in prospective randomised studies. In the future, integrated treatment modality should be incorporated in a standardised approach that goes from a careful assessment of histology, staging and lymph node status, and a constructive and non-empirical co-operation between medical and radiation oncologists, pathologists and thoracic surgeons.

Objective: Mediastinal staging is of paramount importance prior to surgery for non-small-cell lung cancer (NSCLC) to identify patients with N2-disease. Mediastinoscopy remains the gold standard, and sampling from at least three lymph node stations is generally recommended. It is unknown whether biopsy volume has any influence on the result of conventional cervical mediastinoscopy. In this study, we investigated the influence of biopsy volume and the number of lymph node stations biopsied during mediastinoscopy on the probability of demonstrating N2-disease in patients with NSCLC. Methods: We identified 678 consecutive patients who underwent mediastinoscopy for staging of NSCLC during an 8-year period (1999–2007), but 111 patients were later excluded from analysis because of misclassification or of missing data. All patient charts and pathology reports of the remaining 567 patients were reviewed retrospectively. Demographics and the number of lymph node stations biopsied were recorded, and the volume of biopsies from each lymph node station was calculated. Results: Multivariate logistic regression analysis demonstrated that larger biopsy volume was significantly associated with increased probability of demonstrating N2-disease (p < 0.001). However, sampling from several lymph node stations was significantly associated with a decreased probability of demonstrating N2-disease (p = 0.015) and volume was significantly larger per station when fewer stations were sampled (p < 0.001). Conclusions: Biopsy volume from lymph nodes during mediastinoscopy was significantly associated with the probability of demonstrating N2-disease; however, contrary to common belief, sampling from several lymph node stations was not associated with an increased probability of detecting N2-disease. Although purely speculative, these findings may be explained by a perioperative clinical decision by the surgeon: large volumes are secured from macroscopically large and suspicious lymph nodes if detected. Consequently, further dissection and possible complications were avoided.

Objective: We evaluated the short- and long-term results of sleeve resections in a cohort of elderly patients with centrally located non-small-cell lung cancer. Methods: We retrospectively reviewed our prospective database of all patients aged ≥70 years who underwent sleeve resection for non-small-cell lung cancer. Clinical data, morbidity, mortality and survival were analysed. Results: Between January 1999 and December 2005, 31 consecutive patients (26 men) of a mean age of 72.8 ± 2.4 years (range: 70–78 years) underwent bronchial (n = 21) and bronchovascular (n = 10) sleeve resections. A negative bronchial and vascular margin was achieved in all. No bronchial or vascular complications resulted. Morbidity and mortality were 41.9% and 6.2%, respectively. Calibre mismatch (p = 0.89), laterality (p = 0.22) and previous induction chemotherapy (p = 0.28) were not significantly related to morbidity. The overall 5-year survival rate was 56%. The nodal status did not influence the long-term survival in this study (p = 0.41). The type of sleeve resection (bronchial or bronchovascular) had no impact on survival (p = 0.62). Excessive dynamic airway collapse was associated with higher morbidity (p = 0.016) and poorer survival (p = 0.037). Conclusion: In the hands of experienced thoracic surgeons, bronchial and bronchovascular sleeve resections can be performed safely, even in elderly patients. Excessive dynamic airway collapse may be an important negative prognostic determinant of morbidity and mortality.

Objective: Anatomical repositioning and expansion of the ipsilateral preserved lung after lung resection may influence postoperative pulmonary function. To study the postoperative changes in pulmonary function of the preserved lung after lobectomy compared with that after segmentectomy, the preoperative and postoperative forced expiratory volume in 1 s (FEV₁) of the ipsilateral non-operated lobe was measured using perfusion single-photon-emission computed tomography and computed tomography (SPECT/CT). Methods: Eighty-nine patients (n = 24; lobectomy, n = 65; segmentectomy) who were examined with pulmonary function test and perfusion SPECT/CT both before and after surgery were enrolled in this study. The FEV₁ values of the ipsilateral non-operated lobes before and after surgery were measured using perfusion SPECT/CT. Results: The FEV₁ of the ipsilateral non-operated lobe increased after segmentectomy of the right upper lobe (p = 0.07) and after both lobectomy and segmentectomy of the left upper lobe (p = 0.04 and 0.001, respectively), but decreased after lobectomy of the right upper lobe (p = 0.06). In the right upper lobe, the percentage change in FEV₁ of the ipsilateral non-operated lobe after lobectomy was significantly lower than that after segmentectomy (p < 0.001). The FEV₁ of the ipsilateral non-operated lobe had not significantly changed after surgery on the lower lobes. Conclusions: The FEV₁ of the ipsilateral non-operated lobes increased after surgery on left upper lobe, whereas it decreased after right upper lobectomy. The surgery on lower lobe did not affect the FEV₁ of the ipsilateral non-operated lobes. Our data may facilitate determining the indications for lung cancer surgery, especially in patients with tumours involving the upper lobes.

Objective: Postoperative bronchopleural fistula (BPF) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study is to assess the efficacy of the use of the silver–human albumin (SHA) complex injected in the bronchial submucosa for the treatment of BPF. Methods: From January 2005 to March 2008, we treated 11 patients with BPF (seven post-pneumonectomy and four post-lobectomy) by endoscopic injection of the SHA complex into the bronchial submucosa. In all patients a chest drain was positioned and employed for antibiotic pleural irrigation. Simultaneously, the endoscopic treatment including repeated injection of the SHA complex was started. In 10 patients the diameter of the fistulas was equal to or smaller than 5 mm (range: 3–5 mm) and in one it was larger than 5 mm (8 mm). Results: There was no morbidity or mortality related to the procedure. Permanent closure of the fistula was achieved in all 10 patients with a BPF of 3–5 mm. In four of these patients (post-lobectomy fistula), the good general condition allowed early discharge with the Heimlich valve before the completion of treatment. Two other patients with a fistula smaller than 5 mm presented persisting empyema and compromised general conditions after closure of the post-pneumonectomy BPF. These patients underwent fast-track treatment of the empyema achieving definitive cure. In the patient with a BPF larger than 5 mm, the conservative treatment was not sufficient and an omental flap transposition was necessary. Conclusions: The SHA complex submucosal injection is easy, safe and inexpensive. It can be considered a valid therapeutic option in selected patients presenting an early fistula with a size equal to or smaller than 5 mm. Early diagnosis, simultaneous insertion of a chest drain and achievement of a sterile pleural cavity are fundamental conditions for the final success of the procedure.

Objective: Alpha-B-crystallin, a small heat-shock protein, recently gained major interest because of its differential expression during tumourigenesis and metastasis in various epithelial tumours. The purpose of this study was to investigate the expression of alpha-B-crystallin and its biologic and prognostic significance in non-small-cell lung cancer (NSCLC). Methods: Immunohistochemical analysis was performed on a tissue microarray slide containing samples from 146 NSCLC patients who were operated on between 2004 and 2005. Results: Cytoplasmic and nuclear staining was detected. Squamous cell carcinomas and adenocarcinomas had a distinctive profile of expression. The cytoplasmic staining of the tumours, however, is related to the local invasion – T-factor (p = 0.044). Nuclear staining was more commonly detected in advanced stages, and was a biomarker of an aggressive tumour biology (p = 0.042). Kaplan–Meier analysis showed that patients with positive nuclear staining had shorter overall survival (log-rank p = 0.002). Using Cox's proportional hazards model, we performed multivariate analyses to assess the independent prognostic value of nuclear staining. The variables used included age, histology, gender and stage. Alpha-B-crystallin was an independent negative prognostic factor of survival in addition to clinical stage. Conclusions: Alpha-B-crystallin plays an essential role in NSCLC biology and its nuclear staining is an independent factor of poor survival. Its clinical application in molecular biologic substaging of NSCLC patients needs further validation.

Objective: In many centres of thoracic surgery, milking of chest tubes is performed to prevent them from blocking. The usefulness of chest tube clearance is discussed controversially. Therefore, we investigated the impact of postoperative chest tube milking on postoperative outcome in a prospective, randomised trial. Methods: Within a period of 11 months, 145 patients undergoing pulmonary resection through thoracotomy were included in the study. Two chest tubes each (silicone drainage, Redax, Mirandola, Italy) were placed in all patients (ventral tube 21Ch and dorsal tube 24Ch). Milking was applied to both chest tubes for 1 min every 2 h within the first 48 h postoperatively and continuous suction of –20 cm H₂O was maintained for 48 h. Duration of chest tube drainage, quantity and quality of effusion or air leakage, co-morbidity, length of hospital stay and 30-day postoperative morbidity and mortality were analysed. Furthermore, outcome was measured by assessment of chest radiographs at the time of discharge from hospital. Results: Randomisation resulted in milking of chest tubes of 73 patients and in observation of chest tubes without any manipulation in 72 patients. Twenty-one patients had to be excluded from further analysis due to violation from the study protocol (n = 9), necessity of replacement of a chest tubes (n = 9) and re-operation for bleeding (n = 3). The 30-day mortality rate was 1.4% in each group and the 30-day morbidity was 49.3% in the milking group and 52.8% in the observation group. Milking of chest tubes was not associated with a lower postoperative mortality or morbidity (p = 0.99 and p = 0.67, respectively; chi-square test). We observed a significant increase of postoperative pleural effusion drainage in the milking group 48 h after surgery (p = 0.004; unpaired t-test). No correlation was seen between milking of chest tubes and the duration of chest tube drainage, quality of effusion, air leakage or length of hospitalisation. Conclusions: We showed for the first time that postoperative chest tube milking is associated with a significant increase of pleural fluid drainage. Postoperative morbidity and mortality was not improved and therefore chest tube milking cannot be recommended as a routine postoperative procedure.

Background: The objective of this randomised trial was to assess the effectiveness of a new fast-track chest tube removal protocol taking advantage of digital monitoring of air leak compared to a traditional protocol using visual and subjective assessment of air leak (bubbles). Methods: One hundred and sixty-six patients submitted to pulmonary lobectomy for lung cancer were randomised in two groups with different chest tube removal protocols: (1) in the new protocol, chest tube was removed based on digitally recorded measurements of air leak flow; (2) in the traditional protocol, the chest tube removal was based on an instantaneous assessment of air leak during daily rounds. The two groups were compared in terms of chest tube duration, hospital stay and costs. Results: The two groups were well matched for several preoperative and operative variables. Compared to the traditional protocol, the new digital recording protocol showed mean reductions in chest tube duration (p = 0.0007), hospital stay (p = 0.007) of 0.9 day, and a mean cost saving of \#8364;476 per patient (p = 0.008). In the new chest tube removal protocol, 51% of patients had their chest tube removed by the second postoperative day versus only 12% of those in the traditional protocol. Conclusions: The application of a chest tube removal protocol using a digital drainage unit featuring a continuous recording of air leak was safe and cost effective. Although future studies are warranted to confirm these results in other settings, the use of this new protocol is now routinely applied in our practice.

Background: Graft right ventricular (RV) function is compromised directly posttransplant, especially in heart transplantation (HTx) recipients with pretransplant pulmonary hypertension (PH). Graft RV size and systolic function, and the effect of the recipient's pulmonary haemodynamics on the graft extracellular matrix are not well characterised in the patients long-term after HTx. Aim: Comparison of RV size and systolic function in HTx recipients’ long-term posttransplant stratified by the presence of pretransplant PH. Methods: HTx survivors ≥2 years posttransplant were divided into group I without pretransplant PH (pulmonary vascular resistance, PVR <2.5 Wood units, n = 37) and group II with PH (PVR ≥2.5 Wood units, n = 16). RV size and systolic function were measured using cardiac magnetic resonance imaging (CMR). The collagen content was assessed in septal endomyocardial biopsies obtained at HTx and at study inclusion. Results: Mean posttransplant follow-up was 5.2 ± 2.9 years (group I) and 4.9 ± 2.2 years (group II) (p = 0.70). PVR was 1.5 ± 0.6 vs 4.1 ± 1.7 Wood units pretransplant (p < 0.001), and 1.2 ± 0.5 vs 1.3 ± 0.5 Wood units at study inclusion (p = 0.43). Allograft RV size and systolic function were similar in both groups (p always ≥0.07). Collagen content at transplantation and at follow-up were not different (p always ≥0.60). Conclusion: Posttransplant normalisation of pretransplant PH is associated with normal graft RV function long-term after HTx.

Objective: There are no guidelines to select isolated heart transplantation or simultaneous heart and kidney transplantation in patients with renal dysfunction. We sought to assess the effect of simultaneous kidney transplantation on heart-transplantation outcome in patients with renal dysfunction. Methods: Retrospective case review. Results: Between 1993 and 2006, 45 patients with preoperative serum creatinine ≥2 mg dl^–1 underwent heart transplantation, including 32 isolated heart transplantation and 13 simultaneous heart and kidney transplantation. The survival of 83.3 ± 10.8% at 30 days, 58.3 ± 14.2% at 1 year and 50.0 ± 14.4% at 3 years in simultaneous heart and kidney transplantation did not differ from the survival of 81.8 ± 6.7% at 30 days, 66.7 ± 8.2% at 1 year and 45.1 ± 9.3% at 3 years in isolated heart transplantation. The dialysis-free and patient survival of 66.7 ± 13.6% at 30 days, 58.3 ± 14.2% at 1 year and 50.0 ± 14.4% at 3 years in simultaneous heart and kidney transplantation also did not differ from the rate of 81.8 ± 6.7% at 30 days, 66.7 ± 8.2% at 1 year and 31.4 ± 8.9% at 3 years in isolated heart transplantation. Conclusions: Simultaneous kidney transplantation is an effective therapy for patients depending on dialysis pretransplant, reducing postoperative risk of mortality in these very sick patients to the level of patients with less severe renal disease not requiring dialysis before transplant.

Objective: The purpose of this study is to investigate the potential availability of hearts from adult donation after cardiac death (DCD) donors within an acceptable hypoxic period. Methods: We retrospectively reviewed a donor database from the University of Wisconsin Organ Procurement Organization Donor Tracking System between 2004 and 2006. The DCD population (n = 78) was screened using our inclusion criteria for DCD cardiac donor suitability, including warm ischaemic time (WIT) limit of 30 min. In the same period, 70 hearts were donated from brain-dead donors. Results: Of 78 DCD donors, 12 (15%) met our proposed DCD cardiac donor criteria. The mean WIT of these 12 DCD donors was 21 min (range 14–29 min). When inclusion criteria are further narrowed to (1) age <30 years, (2) WIT <20 min and (3) male gender, only two out of 12 met the criteria. Conclusions: Based on our proposed DCD cardiac donor criteria, the potential application of DCD cardiac donors would represent an increase in cardiac donation of 17% (12/70) during the 3-year period. When the criteria were narrowed to the initial ‘ideal’ case, only two donors met such criteria, suggesting that such ‘ideal’ DCD donors are rare but they do exist.

Objective: The management of heart failure (HF), peri-transplant care and immunosuppression has changed in the last decade. Here we describe the changes that have occurred in the UK national programme of adult heart transplantation (HTx). Methods: Using the data accrued with the UK Cardiothoracic Transplant Audit we undertook a prospective cohort study of 2958 consecutive adult patients listed for HTx and 2005 adult orthotopic HTx performed in three time periods – Era-1 (July 1995–March 1999, 1321 listed, 907 transplanted), Era-2 (April 1999–March 2003, 842 listed, 600 transplanted) and Era-3 (April 2003–March 2007, 795 listed, 498 transplanted). Results: The median time on the waiting list reduced from 109 days in Era-1 to 40 days in Era-3. The proportion of HTx in non-ambulatory HF patients requiring inotropic or circulatory support increased from 12% in Era-1 to 35% in Era-3. The proportion undergoing HTx for non-ischaemic dilated cardiomyopathy increased from 40% in Era-1 to 58% in Era-3 while ischaemic cardiomyopathy decreased. Survival after HTx remained constant (81% (95% CI: 78–83%) at 1 year in Era-1 and 80% (95% CI: 77–84%) in Era-3). There was an increase in the use of mycophenolate and induction therapy and a reduction in rejection episodes over the eras. Conclusions: Although waiting list and HTx activity have declined, HTx continues to have an important role in the management of advanced HF, especially for patients on inotropic or circulatory support. Despite a deterioration of donor organ quality, survival after HTx has remained unchanged.

Objective: To report our experience with the laparoscopically harvested omental flap in the treatment of deep sternal wound infection, and to present a modification and introduce two supportive techniques in the perioperative management. Methods: Between June 2005 and September 2007, six patients with grade IV (El Oakley–Wright classification) deep sternal wound infection following a median sternotomy for coronary artery bypass grafting underwent a reconstruction with a laparoscopically harvested omental flap. The median age of the cohort of six, consisting of one female and five males, was 67 years (range: 61–77 years). In five patients, an unilateral internal thoracic artery had been used. Considerable preoperative risk factors were present: one patient suffered from severe chronic obstructive pulmonary disease (COPD) Forced expiratory volume in 1 s (FEV1)1L; two from moderate chronic obstructive airway disease, three from insulin-dependent diabetes mellitus and three were on glucocorticoid steroid therapy preoperatively. Abdominal surgery had previously been performed in four patients. In all cases, the mediastinal wound was prepared with vacuum-assisted (≤125 mmHg) therapy following debridement and pulsed irrigation. White, small-pore foam was placed over the right ventricle when the risk of adhesion to the sternal remnants or secondary haemorrhage was a concern. In all cases, the position of the spread-out omental flap was maintained intrathoracically with autologous fibrin glue and in one case the split-skin graft covering the flap was also dealt with in this way. In the five other cases, the omental flap was covered by mobilising and advancing the local soft tissue and skin towards the midline. Portable sonography proved useful in monitoring the doubtful intrathoracic flap. Results: The 30-day perioperative mortality rate was zero, with a 2-year overall survival of 100%. One patient received a temporary colostomy due to a partial transverse colon necrosis. Follow-up ranged from 20 to 53 months (median: 39 months) for the group as a whole. Death occurred in one case 2.8 years after reconstruction due to reasons other than cardiac or mediastinal conditions. Conclusion: The laparoscopically harvested omental flap can contribute to a successful outcome following deep sternal wound infection and deserves serious consideration in type IV mediastinitis in particular, regardless of the co-morbidity or previous abdominal surgery.

Objective: We sought to delineate the safety and efficacy of sequential and composite coronary artery bypass grafting (CABG) with exclusively arterial grafts to more than five coronary branches including small coronary vessels. Methods: We reviewed the clinical records of 633 consecutive patients with 2617 bypass grafts who underwent total arterial off-pump complete revascularisation for three-vessel coronary regions without aortic manipulation. Group I consisted of 263 patients with a single in situ internal thoracic artery (ITA), while group II consisted of 370 patients with bilateral in situ ITA. Subgroups I-A and I-B consisted of 242 patients with three or four distal anastomoses and 21 patients with more than five distal anastomoses, respectively. Subgroups II-A and II-B consisted of 199 patients with three or four anastomoses and 171 patients with more than five anastomoses, respectively. Results: The early mortality and morbidity rate and the angiographic graft patency in the groups I and II were similar, while the rate of antegrade flow in group II (92.4%, 1349/1460) was significantly higher than that in group I (89.4%, 638/714, p = 0.02). Intra-operative graft flow measured at the proximal portion of the in situ ITA in group II (79 ± 35 ml min^–1) was significantly larger that that in group I (53 ± 31 ml min^–1, p < 0.0001). The patency rate of bypass grafts to small coronary vessels (1.25 mm or less in diameter) was 97.4% (626/643). The early mortality rates in subgroups I-A and I-B were 1.2% (3/242) and 0% (0/21), respectively (p = 0.61). The graft flow and incidence of competitive flow was comparable in subgroups I-A and I-B. The early mortality rates in subgroups II-A and II-B were 0.5% (1/199) and 0.6% (1/177), respectively (p = 0.91). The graft flow to five or more coronary branches (81 ± 35 ml min^–1) was significantly greater than that to three branches (67 ± 30 ml min^–1, p = 0.01). Conclusions: For more than five target branches, sequential and composite arterial grafting with the ITA and a radial artery was safe and reliable, even when the target vessels were small. Bilateral in situ ITA would be feasible for the patients with multiple stenotic lesions, because of abundant bypass flow and less incidence of competitive flow. Durable completeness of revascularisation can be expected.

Objective: Atrial fibrillation (AF) remains the most commonly observed complication following myocardial revascularisation surgery. We aimed to evaluate the clinical utility of N-terminal fragment of the brain natriuretic peptide (NT-pro-BNP), troponin T, transcoronary lactate gradient (TCLG) and C-reactive protein (CRP) as predictors of AF in patients undergoing isolated coronary artery bypass surgery (CABG). Methods: This study included 215 consecutive patients in sinus rhythm (SR) undergoing elective CABG between May 2007 and May 2008. The patients were grouped according to their respective postoperative rhythm into SR and AF groups. The data are presented as mean values ± standard deviation, or medians with quartiles. Results: Fifty-five patients developed AF (26%). The preoperative NT-pro-BNP values were 273 ± 347 and 469 ± 629 pg ml^–1 in the SR and AF groups, respectively (p < 0.0001). The postoperative NT-pro-BNP values were 3110 ± 3600 pg ml^–1 in the SR and 4625 ± 5640 pg ml^–1 in the AF groups (p = 0.027). The transcoronary lactate gradient rose from the pre-cardiopulmonary bypass values to those observed 5 min after revascularisation in both groups (–0.05 ± 0.37 to 0.39 ± 0.46 mmol l^–1 (p < 0.0001) in the SR group and –0.01 ± 0.27 to 0.43 ± 0.46 mmol l^–1 (p < 0.0001) in the AF group). The CRP values increased from 6 ± 13 to 163 ± 88 mg l^–1 (p < 0.0001) in the SR group, and from 6 ± 16 to 163 ± 104 mg l^–1 (p < 0.0001) in the AF group. The dynamics of TCLG and CRP did not differ between the groups (p = 0.71, p = 0.44, respectively). The troponin T values on postoperative day 1 were significantly higher in the AF than the SR group (0.86 (0.49–2.1) ng ml^–1 vs 0.67 (0.37–1.16) ng ml^–1, p = 0.046). The duration of cardiopulmonary bypass (CPB) was 85 ± 24 min in the SR and 93 ± 30 min in the AF group (p = 0.05). Patients who developed AF were older (66 ± 7 years vs 60 ± 9 years, p < 0.0001) and had a higher EuroSCORE (3.9 ± 2.7 vs 2.9 ± 2.2, p = 0.009). Multivariate analysis identified age (p = 0.0043), preoperative NT-pro-BNP (p = 0.019) and duration of CPB (p = 0.035) as independent predictors of AF. Conclusions: Preoperative and postoperative NT-pro-BNP as well as TnT values were significantly higher in patients who subsequently developed AF. TCLG and CRP were not useful in identifying patients at higher risk for AF. Multivariate analysis identified age, preoperative NT-pro-BNP and duration of CPB as independent correlates of AF.

Objective: Various definitions of impairment of renal function after coronary artery bypass grafting (CABG) are used in the literature. Depending on the definition, several risk factors are identified. We analysed our data to determine the risk factors for postoperative deterioration of the creatinine clearance of 10% or more. Methods: All patients undergoing isolated coronary surgery in a single centre between January 1998 and December 2007 are included. Clinical data, including demographics and renal risk factors, were prospectively collected in our database. The most recent preoperative serum creatinine level and the maximum serum creatinine level within the first week postoperatively were used to calculate the creatinine clearance. A deterioration of 10% or more was considered to be an endpoint for this study. Results: In 10 098 out of a total of 10 626 patients, the preoperative as well as the postoperative creatinine clearance could be calculated. In 1053 patients, the deterioration of the creatinine clearance was 10% or more. We could identify the following risk factors: advanced age, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, emergency operation, previous cardiac surgery, low preoperative haemoglobin level, high preoperative C-reactive protein level, perioperative myocardial infarction, re-exploration and the number of blood transfusions. Conclusions: Risk factors for the deterioration of renal function after revascularisation have been confirmed in this study. In addition, we found peripheral vascular disease, previous cardiac surgery, low preoperative haemoglobin, increased preoperative C-reactive protein level, perioperative myocardial infarction and the number of blood transfusions to be risk factors that have not been described earlier.

Aim: To describe changes in chest pain and dyspnoea during a period of 15 years after coronary artery bypass grafting (CABG) and to define factors at the time of operation that were associated with the occurrence of these symptoms after 15 years. Design: Prospective observational study in western Sweden. Subjects: All patients who underwent first-time CABG, without simultaneous valve surgery, between 1 June 1988 and 1 June 1991. There were no exclusion criteria. Follow-up: All patients were followed up prospectively for 15 years. The evaluation of symptoms took place through postal questionnaires prior to and 5, 10 and 15 years after the operation. Results: Totally, 2000 patients were included in the survey and 904 (45%) of them survived to 15 years. Among these 904 survivors, the percentage of patients with chest pain increased from 44% to 50% between the 5- and 15-year follow-up (p = 0.004). The percentage of patients who reported symptoms of dyspnoea increased from 60% after 5 years to 74% after 15 years (p < 0.001). Factors at the time of surgery that independently tended to predict chest pain after 15 years were higher age (p = 0.04) and prolonged duration of symptoms prior to surgery (p = 0.04). Predictors of dyspnoea after 15 years were higher age (p < 0.0001), the use of inotropic drugs at the time of surgery (p = 0.001), a history of diabetes (p = 0.01) and obesity (p = 0.01). Conclusion: After CABG, relief from chest pain and dyspnoea is generally maintained over a long period of time. Eventually, however, functional-limiting symptoms tend to recur and about half the patients report symptoms of chest pain, while three-quarters report dyspnoea after 15 years. Even if no clear predictor of chest pain was found at the time of surgery, age, the use of inotropic drugs, diabetes and obesity predicted dyspnoea.

Background: Detection of myocardial ischaemia during and after cardiac surgery remains a challenge. Echocardiography is more sensitive in ischaemia detection than echocardiography (ECG) and haemodynamic monitoring, but demands repeated examinations for monitoring over time. We have developed and validated an ultrasonic system that permits continuous real-time assessment of myocardial ischaemia using miniature epicardial ultrasound transducers. Methods: In an open-chest porcine model (n = 8), prototype ultrasound transducers were fixed on the epicardium in the left anterior descending and circumflex coronary artery supply regions, providing continuous measurement of transmural myocardial velocities. Peak systolic velocity and post-systolic velocity were recorded simultaneously with ECG, left ventricular pressure and arterial pressure. Two-dimensional (2D) echocardiographic strain was used as a reference. Global changes were induced by infusing fluid, epinephrine, nitroprusside and esmolol. Regional changes were induced by occluding the left anterior descending coronary artery (LAD). Subsequent LAD stenosis was performed in a subgroup, with flow reduction to 50% of baseline level and further to occlusion. Results: Systolic velocity in the LAD region decreased during LAD occlusion (0.9 ± 0.1 to 0.1 ± 0.1 cm s^–1, P < 0.01), whereas post-systolic velocity increased (0.3 ± 0.1 to 2.3 ± 0.1 cm s^–1, P < 0.01). No changes occurred in the circumflex coronary artery (CX) region. Severe ischaemia was confirmed by reduction in 2D echocardiography strain calculations. Changes in myocardial velocities assessed by miniature transducer during ischaemia differed from changes during all global interventions. Significant reduction in systolic velocity occurred at 50% LAD flow (0.9 ± 0.1 to 0.5 ± 0.1 cm s^–1, P = 0.02) with further decrease on following occlusion (0.0 ± 0.0 cm s^–1, P < 0.01). Post-systolic velocity increased both from baseline to 50% LAD flow, and further to occlusion. Conclusion: The epicardial transducers provided continuous assessment of regional myocardial function and detected ischaemia with high sensitivity and specificity. Further development of this system may provide a useful tool for myocardial monitoring during and after cardiac surgery.

Objective: Aortic valve replacement for aortic regurgitation (AR) has been established as a standard treatment but implies prosthesis-related complications. Aortic valve repair is an alternative approach, but its mid- to long-term results still need to be defined. Methods: Over a 12-year period, 640 patients underwent aortic valve repair for regurgitation of a unicuspid (n = 21), bicuspid (n = 205), tricuspid (n = 411) or quadricuspid (n = 3) aortic valve. The mechanism of regurgitation involved prolapse (n = 469) or retraction (n = 20) of the cusps, and dilatation of the root (n = 323) or combined pathologies. Treatment consisted of cusp repair (n = 529), root repair (n = 323) or a combination of both (n = 208). The patients were followed clinically and echocardiographically; follow-up was complete in 98.5% (cumulative follow-up: 3035 patient years). Results: Hospital mortality was 3.4% in the total patient cohort and 0.8% for isolated aortic valve repair. The incidences of thrombo-embolism (0.2% per patient per year) and endocarditis (0.16%per patient per year) were low. Freedom from re-operation at 5 and 10 years was 88% and 81% in bicuspid and 97% and 93% in tricuspid aortic valves (p = 0.0013). At re-operation, 13 out of 36 valves could be re-repaired. Freedom from valve replacement was 95% and 90% in bicuspid and 97% and 94% in tricuspid aortic valves (p = 0.36). Freedom from all valve-related complications at 10 years was 88%. Conclusions: Reconstructive surgery of the aortic valve is feasible with low mortality in many individuals with aortic regurgitation. Freedom from valve-related complications after valve repair seems superior compared to available data on standard aortic valve replacement.

Objective: The present study evaluates the impact of prosthesis–patient mismatch (PPM) on left ventricular remodelling following aortic valve replacement (AVR) for severe aortic insufficiency. Methods: In this study, 230 patients undergoing aortic valve surgery were divided into two groups depending on whether or not they exhibited PPM. Postoperative left ventricular (LV) dimensions and function were compared to the preoperative status. Results: The incidence of PPM (EOAi ≤0.85 cm² m^–2) was 22.2%. There was no significant difference in the reduction of mean end-diastolic LV diameter (LVEDD; p = 0.31) or mean end-systolic LV diameter (LVESD; p = 0.79) between the non-PPM and the PPM groups. The LVEDD was reduced in the non-PPM group from 66 ± 9 to 55 ± 9 mm postoperatively (p < 0.001) while the LVEDD in the PPM group was reduced from 65 ± 9 to 56 ± 10 mm (p < 0.001). The LVESD was reduced in the non-PPM group from 49 ± 10 to 40 ± 10 mm postoperatively (p < 0.001) while the LVESD in the PPM group was reduced from 50 ± 11 to 39 ± 10 mm (p < 0.001). Patients with preoperative LV dysfunction (ejection fraction (EF) <50%) demonstrated a significant improvement in postoperative LVEF in both the non-PPM (36 ± 8% to 44 ± 12%, p < 0.001) and PPM groups (33 ± 7% to 46 ± 11%, p = 0.001) but no significant difference could be demonstrated in the rate of improvement between the two groups (p = 0.23). Furthermore, no significant difference was found in survival between patients with PPM and those without (p = 0.23). Conclusions: PPM did not influence left ventricular remodelling or survival following AVR for severe aortic insufficiency. The left ventricular remodelling process was initiated regardless of preoperative LVEF, and the impact of PPM seems to be of little importance.

Objective: Bioprosthesis structural valve deterioration (SVD) is an incompletely understood process involving the accumulation of calcium and lipids. Whether this process could be delayed with lipid-lowering therapy (LLT) is currently unknown. The purpose of this observational study was to evaluate if an association exists between early LLT and a slowing of bioprosthesis SVD, with a view to designing a prospective trial. Methods: We followed 1193 patients who underwent aortic valve replacement with contemporary bioprostheses between 1990 and 2006 (mean follow-up 4.5 ± 3.1 years, maximum 17.3 years). Of these patients, 150 received LLT (including statins) early after surgery. Prosthetic valve haemodynamics on echocardiography and freedom from re-operation for SVD were compared between patients who did and did not receive postoperative LLT. Results: After bioprosthetic implantation, the progression of peak and mean trans-prosthetic gradients during echocardiographic follow-up (mean 3.3 years) was equivalent between patients treated with and without LLT (peak increase: 0.9 ± 7.7 vs 1.1 ± 10.9 mmHg, LLT vs no LLT, P = 0.87; mean increase: 0.8 ± 4.1 vs 0.2 ± 5.9 mmHg, LLT vs no LLT, P = 0.38). The annualised linear rate of gradient progression following valve replacement was also similar between groups (peak increase per year: 2.0 ± 12.1 vs 1.0 ± 12.9 mmHg per year, LLT vs no LLT, P = 0.52; mean increase per year: 0.5 ± 2.2 vs 0.6 ± 6.0 mmHg per year, LLT vs no LLT, P = 0.94). The incidence of mild or greater aortic insufficiency on the most recent echocardiogram was comparable (16.3% vs 13.8%, LLT vs no LLT, P = 0.44), and there was no difference in the 10-year freedom from re-operation for SVD between the two groups [98.9% (95% confidence interval (CI): 91.9%, 99.8%) vs 95.4% (95% CI 90.5%, 97.9%), LLT vs no LLT, P = 0.72]. Conclusions: In this observational study, there was no association demonstrated between early postoperative LLT and a slowing of bioprosthesis SVD. With the excellent durability of bioprostheses in the current era, a prospective randomised trial of statin therapy to prevent bioprosthetic SVD does not appear to be justified, let alone feasible.

Background: The Mosaic bioprosthesis is a third-generation stented porcine bioprosthesis combining physiologic fixation and alpha-amino oleic acid (AOA) antimineralisation treatment to improve haemodynamic performance and durability. This single-centre study reports the clinical results, including haemodynamic performance, of the Mosaic bioprosthesis after implant in aortic or mitral position. Methods: Between February 1994 and October 1999, 255 patients with aortic valve replacement (AVR; mean age: 67 years, range: 23–82 years) and 47 patients with mitral valve replacement (MVR; mean age: 67 years, range: 41–84 years) were enrolled in this prospective non-randomised clinical trial. Follow-up visits were performed 30 days and 6 months after implant and annually thereafter. The cumulative follow-up was 1976.2 patient-years (pt-yrs) after AVR (median: 8.3 years, maximum: 14.0 years) and 336.9 pt-yrs after mitral valve replacement (MVR) (median: 8.2 years, maximum: 13.3 years). Results: After AVR, mean systolic gradient and effective orifice area at 4, 8 and 13 years follow-up were 13.3 ± 5.6, 15.5 ± 7.7 and 16.0 ± 7.2 mmHg and 1.8 ± 0.5, 1.8 ± 0.5 and 1.7 ± 0.4 cm². After MVR, respective data were 4.7 ± 2.1, 4.3 ± 1.2 and 5.0 mmHg (only one recording) and 2.2 ± 0.7, 2.3 ± 0.6 and 1.8 cm². Transvalvular regurgitation at 13-year follow-up was mild or less in both the AVR and MVR patients. Thirteen-year survival was 63.1 ± 4.5% in the AVR group and 51.2 ± 13.6% in the MVR group. Early mortality after AVR and MVR was 1.2% and 0.0%, respectively; late mortality was 3.2% pt-yr^–1 and 3.3% pt-yr^–1, including a valve-related/unexplained mortality of 1.1% pt-yr^–1 and 0.9% pt-yr^–1. Freedom from adverse events in the AVR and MVR group was permanent neurological event: 97.4 ± 1.2% and 96.0 ± 3.9%; valvular thrombosis: 97.8 ± 1.1% and 100%; structural valve deterioration: 84.8 ± 7.8% and 93.8 ± 6.1%; explant: 73.3 ± 7.3% and 89.3 ± 6.5%. Conclusions: The Mosaic bioprosthesis demonstrates excellent clinical performance and safety after 13 years of follow-up. Continued follow-up will determine whether this new design will provide increased durability.

Objective: Antiphospholipid syndrome (APS) is a rare coagulation disorder associated with recurrent arterial and venous thrombotic events. Heart valve abnormalities are commonly found in patients with APS. Methods: From March 1998 to March 2007, nine patients with APS underwent heart valve surgery using cardiopulmonary bypass. We retrospectively reviewed their clinical data, operative and postoperative courses and the long-term results. Results: The mean age was 43.6 ± 10.4 years, six were female and three male. Four patients underwent mitral valve replacement, three went through aortic valve replacement, one underwent combined mitral–aortic valve replacement and another aortic valve plasty. The syndrome was primary in seven patients and associated with systemic lupus erythematosus (SLE) in two. Follow-up was 8 days to 8 years (median 66 months). Two patients died in the early postoperative period: both due to an acute cerebrovascular accident. Four patients presented an uneventful late postoperative course. One patient experienced an ischaemic stroke 5 years after mitral valve replacement (MVR) and developed refractory congestive heart failure requiring heart transplantation three years postoperatively. Conclusions: Heart valve surgery in patients with antiphospholipid syndrome may carry considerable early and late mortality and morbidity. Thrombo-embolic complications are the most common complications. Mechanical prostheses have been used at our Institution in the previous years; however, today, after reviewing our historical results, we reconsider our general strategy and believe that tissue heart valve prostheses are the possible ideal substitutes, minimising the risks of morbidity and mortality due to the hypercoagulable state of APS.

Objective: Bias against operating on patients with prosthetic valve endocarditis (PVE) who have multiple prostheses may preclude the use of life-saving valve replacement. We investigated the accuracy of the preoperative diagnosis of PVE in patients with both mitral and aortic prosthesis and the safety of single-valve replacement when only one valve seemed infected. Methods: Patients with a diagnosis of active PVE who had mitral and aortic prosthesis in place were assessed. We looked at the methods for diagnosis, causative agents, indication for valve replacement, operative findings and outcome. Results: Twenty patients, who had both mitral and aortic prostheses and a diagnosis of PVE, were assessed. Streptococci and staphylococci caused 70% of cases. By means of echocardiography, the valves involved were: mitral (11 patients), aortic (six patients), and in three cases both prosthetic valves seemed infected. Surgery was undertaken in 17 patients (85%). The positive predictive value of transesophageal echocardiogram (TEE) for the preoperative diagnosis of the site of infection was 100%. In 13 patients, only the prosthetic valve that seemed infected was replaced. Four of these patients died within a week after the procedure. Nine patients survived the surgical procedure, completed a course of antimicrobial therapy and were followed up for 15.78 months (95% CI: 12.83–18.72). All were considered cured and relapses were not observed. Conclusions: TEE allowed a diagnosis of site involvement that did correlate with the anatomic diagnosis obtained during the operation. This fact contributed to the management of patients and was of great help in guiding the surgical intervention. Echo-oriented single-valve replacement may be a safe strategy for patients with PVE and double prostheses.

Objective: Microbiological examination of donated human cardiac tissue is a necessary procedure for Heart Valve Banks to determine the biological safety of preserved allografts. Test protocols must be validated to prevent false-negative outcomes that pose a risk of infection to recipients of the tissue. The Heart Valve Bank in Rotterdam evaluated a validated, alternative entry test for donated tissues to compare the performance of its standard microbiological examinations. Methods: Samples of explanted heart transport medium from 275 donors were examined for the presence of microorganisms using blood culture flasks (standard test) and fluid thioglycolate medium (alternative test). Results were compared with the outcome of microbiological assessment of subvalvular myocardial fragments and the cryoprotective medium that were collected before and after treatment of the grafts with antibiotics, respectively. Results: Microorganisms, mainly skin flora, were detected in transport medium of 177 hearts (64%). The alternative validated culture method detected a growth in 80 transport medium samples that was not identified by the standard method. Microorganisms were only identified in the cultivated cardiac tissue fragments from 56 donors (20%). After antibiotic treatment of the tissue, microorganisms could still be encountered in cryoprotective medium samples from 55 donors (20%). Most of the contaminants in these final samples were identified as Propionibacterium species and Corynebacterium species and had already been detected in the transport medium by the alternative validated culture method. Conclusions: The use of blood culture flasks for microbiological assessment of non-blood liquid media and the cultivation of myocardial tissue fragments may hamper detection of certain microorganisms and therefore provide less complete information about microbiological safety. Heart Valve Banks may want to review their microbiological examination and decontamination procedures regarding the ability to detect and eliminate anaerobic skin flora, respectively.

Chronic ischaemic mitral regurgitation (CIMR) remains one of the most complex and unresolved aspects in the management of ischaemic heart disease. This review provides an overview of the present knowledge about the different aspects of CIMR with an emphasis on mechanisms, current surgical treatment results and new mechanism-based surgical approaches. CIMR occurs in approximately 20–25% of patients followed up after myocardial infarction (MI) and in 50% of those with post-infarct congestive heart failure (CHF). The presence of CIMR adversely affects prognosis, increasing mortality and the risk of CHF in a graded fashion according to CIMR severity. The primary mechanism of CIMR is ischaemia-induced left ventricular (LV) remodelling with papillary muscle displacement and apical tenting of the mitral valve leaflets. CIMR is often clinically silent, and colour-Doppler echocardiography remains the most reliable diagnostic tool. The most commonly performed surgical procedure for CIMR (restrictive annuloplasty combined with coronary artery bypass grafting (CABG)) can provide good results in selected patients with minimal LV dilatation and minimal tenting. However, in general the persistence and recurrence rate (at least MR grade 3+) for restrictive annuloplasty remains high (up to 30% at 6 months postoperatively), and after a 10-year follow-up there does not appear to be a survival benefit of a combined procedure compared to CABG alone (10-year survival rate for both is approximately 50%). Patients at risk of annuloplasty failure based on preoperative echocardiographic and clinical parameters may benefit from mitral valve replacement with preservation of the subvalvular apparatus or from new alternative procedures targeting the subvalvular apparatus including the LV. These new procedures include second-order chordal cutting, papillary muscle repositioning by a variety of techniques and ventricular approaches using external ventricular restraint devices or the Coapsys device. In addition, percutaneous transvenous repair techniques are being developed. Although promising, at this point these new procedures still lack investigation in large patient cohorts with long-term follow-up. They will, however, be the subject of much anticipated and necessary ongoing and future research.

Objective: Various surgical valve repair and replacement techniques have been developed over the past decades for patients with Ebstein's anomaly. Determination of the appropriate moment for surgery, however, has not been elucidated clearly enough. Methods: From 1976 to 2007, 130 patients (mean age 23.8 ± 17.8 years, range: 1 month to 73.6 years) underwent surgery for Ebstein's anomaly at our centre. Four patients (3.0%), who underwent univentricular palliation, and four (3.0%), who only had an atrial septal defect closure, were excluded. In 110/122 (90.2%) patients, a primary tricuspid valve repair was feasible. Valve replacement was necessary in 12 (9.8%). Mean follow-up time was 10.5 ± 9.1 years (94.3% complete, 1284 patient years). Results: There were two (1.5%) hospital deaths. Overall survival was 87.2% ± 3.6%, 85.1% ± 4.1% and 81.2% ± 5.4% at 10, 20 and 25 years, respectively, without significant difference between the repair and replacement group (p = 0.31). The New York Heart Association functional class >II (p = 0.01) and cardiothoracic ratio >0.6 (p = 0.02) were significant risk factors for mortality. Overall freedom from re-operation was 79.9 ± 4.6%, 61.9 ± 6.8% and 58.0 ± 7.4% at 10, 20 and 25 years, respectively. Age ≤ 12 years (p = 0.005) and cardiothoracic ratio >0.6 (p = 0.009) were significant risk factors for the need of a re-operation. Conclusions: Repair, as opposed to replacement, is feasible in the vast majority of patients presenting with Ebstein's anomaly with a low early mortality rate. Outcome, in terms of survival and freedom from re-operation in the long term is determined by the clinical state at the time of surgery. Therefore, timely operation is warranted before significant cardiomegaly develops and functional status deteriorates.

Objective: Fast-track patient pathways for cardiac surgery are used in adult practice and by necessity is a mainstay in the developing world. We aimed to introduce a fast-track protocol for uncomplicated paediatric open-heart surgery cases and to subsequently review the results of this change in practice. Methods: A fast-track protocol co-ordinated by the Advanced Nurse Practitioners was introduced in January 2006 for children aged over 6 months undergoing uncomplicated open-heart procedures. We conducted a review of prospectively collected data on all included patients. The setting was a tertiary paediatric cardiac surgical centre in the UK. The outcome measures for audit were: patient fitness to leave the intensive care unit (ICU) on the day of surgery and hospital length of stay. Results: Included children had a mean age 6 (standard deviation (SD) 4.9) years and mean weight 22.7 (SD 17.6) kg. Of the 194 patients included, 153 (79%) were fit to leave the ICU on the day of surgery. Patients undergoing surgery for ventricular septal defect: odds ratio (OR) 2.8 (95% CI: 1.2–5.6) P = 0.01 and left ventricular outflow tract obstruction: OR 5.5 (95% CI: 1.4–21.2) P = 0.01, were more likely to be unfit than atrial septal defect and right ventricular outflow tract obstruction. Patients undergoing surgery in the afternoon were more likely to be unfit than those undergoing surgery in the morning: OR 2.3 (95% CI: 1.2–4.8) P = 0.03. No relationship was found between age or weight and fitness to fast track. Median length of hospital stay for the whole cohort was 3 (range: 2–11) days. After adjustment for case mix, there was significant evidence that length of hospital stay reduced as experience with the protocol increased over the series of patients RC –0.02 (95% CI: –0.01 to –0.03) P < 0.01. Conclusion: A fast-track programme can be implemented safely and effectively if the appropriate support including a step-down ward area is put in place. Greater experience with this type of protocol leads to reductions in the length of hospital stay for children aged over 6 months undergoing uncomplicated open-heart surgery. Fast-track cases should be performed in the morning.

Objective: The extracardiac conduit procedure is widely used for patients with heterotaxy syndrome with complex systemic and pulmonary venous anomalies; however, it lacks conduit-growth potential and requires long-term anticoagulation. We present the intracardiac Fontan procedure, which eliminates the above-mentioned disadvantages. Patients and methods: Twenty-four patients (mean age, 4.1 years; weight, 13.0 kg) with heterotaxy syndrome underwent intracardiac Fontan operations between March 1995 and March 2008. In each patient, the anomalous systemic venous return with the isolated hepatic vein was redirected to the pulmonary artery using an intra-atrial baffle without obstructing the pulmonary venous pathway; this was accomplished by anterior (n = 5), lateral (n = 15) or posterior tunnel methods (n = 4), depending on the anatomical relationship of the systemic and pulmonary venous pathways. Results: There was one (4%) in-hospital and two (8%) late deaths in total. Five (21%) patients underwent re-operation for either pulmonary venous obstruction or supraventricular tachycardia. The actuarial 12-year survival was 86% (the Kaplan–Meier survival plot). The freedom from re-operation at 10 years was 77%. Anticoagulation was not required except for two patients (8%) who had prosthetic valves and coagulation disorder. Obstruction of the systemic venous pathway was not observed in any patient; however, five (20%) patients had clinically significant postoperative arrhythmias. At the final follow-up, all survivors were categorised as the New York Heart Association class I. Conclusions: Aided by detailed preoperative anatomical and physiological diagnoses, intracardiac Fontan procedures were technically feasible in patients with complex systemic and pulmonary venous anomalies. The specific cardiac anatomy in these patients warranted this procedure; however, taking into consideration the improved outcomes of the modified Fontan procedure, this method should be performed with deliberation.

Objective: Early circuit separation enhances the long-term success of Fontan haemodynamics. To test this hypothesis, we analysed the postoperative cardiopulmonary capacity in children and adults. Patients: Spiroergometry was performed at least twice in 43 patients with a median age of 14 (range: 7–43) years, with a median time interval of 4.6 (1.1–10.4) years between early and late testing. Twenty-eight patients had been operated on in childhood and 15 as adults. The exercise capacity (W _max) and oxygen consumption capacity ( ) were compared between children and adults. Results: The in children early postoperatively was better than in adults (median 27.9 vs 22.9, p = 0.032). Both (median 30.1 ml min^–1 kg^–1 vs 16.9 ml min^–1 kg^–1, p < 0.001), and W _max (median 2.2 W kg^–1 vs 1.4 W kg^–1, p < 0.001) were significantly better in children late after surgery. In the patient group as a whole, there was a significant decrease of between early and later testing (median 26.5 l min^–1 kg^–1 vs 20.7 l min^–1 kg^–1, p < 0.001). Conclusions: Fontan palliation in early childhood results in better cardiopulmonary capacity during long-term follow-up. Regular surveillance of the physical capacity by spiroergometry is indispensable for the supervision of patients with Fontan haemodynamics.

Objective: The Aristotle basic complexity (ABC) score (1.5–15 points) is the sum of potentials for early mortality, morbidity and anticipated surgical technique difficulty. The Aristotle comprehensive complexity (ACC) score (1.5–25 points) is the sum of ABC score and patient-adjusted complexity score; it comprises six complexity levels. We used the ACC score to evaluate quality in surgical management of congenital heart disease. Methods: Procedures performed in year 2002 and 2007 were analysed. Proportion of procedures requiring at least 1 week of stay in the intensive care unit was chosen as the marker of morbidity. We adopted threshold duration of 120 min for cardio-pulmonary bypass (CPB) cases and the same duration for operations without CPB as surrogate of surgical technical difficulty. The ACC scores were correlated to mortality, morbidity and technical difficulty. Results: This study included 758 patients who underwent 787 primary procedures. The mean ABC and ACC scores amounted to 7.61 ± 2.46 and 9.51 ± 3.84. Early mortality was 3.05% (24/787), 95% confidence interval (CI): 1.97–4.51%. Zero at ACC levels 1 and 2, it increased from 1.2% (2/161) for level 3 up to 22.2% (2/9) for level 6. Morbidity index was evaluated at 25.9% (204/787), 95% CI: 22.9–29.1%. 1.9% at level 1, it escalated up to 77.8% at level 6. Index of technique difficulty was estimated at 35.2% (277/787), 95% CI: 31.8–38.6%, ranging from 4.8% for level 1 to 66.7% for level 6. A high correlation was found between the ACC scores and mortality, indices of morbidity and technique difficulty, Spearman's correlation coefficient r being 0.9856, 1 and 0.9429, respectively. Mortality (p = 0.037) and morbidity (p = 0.041) were lower in year 2007 than in 2002 with ABC (p = 0.18) and ACC (p = 0.37) surgical performance being not significantly different. Conclusions: The Aristotle score is still under development. Morbidity evaluation should be ideally based on observed postoperative complications; estimation of surgical technical difficulty chosen in this study may not be generalised. Nevertheless, the actual Aristotle comprehensive complexity score, as evaluated in its three components, accurately determined the outcome of surgical management of congenital heart disease. It appears to be an adequate tool to evaluate quality in paediatric cardiac surgery, over time.

Background: Blood-flow control during cardiopulmonary bypass (CPB) is by tradition based on the patient's body surface area. Emergence of new techniques enables dynamic blood-flow control based on online measurement of venous oxygen saturation and oxygen consumption. Present investigation aimed to compare static versus dynamic blood-flow control with respect to use of oxygen and effects upon organ function. Methods: In this study, 100 coronary-artery-bypass surgical patients were prospectively randomised to static or dynamic hypothermic blood-flow control during CPB. In the static group, pump flow was set to 2.4 (litres per minute) times the patient's body surface area (m²) throughout the procedure. Pump flow in the dynamic group was varied according to the reading of the venous oxygen saturation and maintained at >75%. CPB-specific information was collected online. Blood samples were collected for analysis of haemoglobin, lactate, amylase, creatinine and C-reactive protein: pre-CPB, at weaning from CPB and on day 1 postoperatively. Results: Randomisation formed two uniform groups. Choice of static or dynamic blood-flow control during CPB had no significant effects on organ function as judged by lactate, amylase or creatinine levels. On increasing oxygen demand, oxygen balance was maintained by increasing venous oxygen extraction rates in the static flow mode and by increasing the pump flow rate in the dynamic group. Conclusions: Independent of the blood-flow control mode, oxygen balance remained preserved. However, the dynamic mode provided higher oxygen delivery, which may increase margins of safety and protection of organ function.

Objective: Advocates of pulsatile flow postulate that the flow pattern during extracorporeal circulation (ECC) should be similar to the physiological one. However, the waveforms generated by clinically used pulsatile pumps are by far different from the physiological ones. Therefore, we constructed a new computer-controlled pulsator which can provide nearly physiological perfusion patterns during ECC. We compared its effect (group 1) with pulsatile (group 2) and non-pulsatile (group 3) perfusion generated by a conventional roller pump. Methods: Thirty pigs (10 per group) underwent 180 min ECC with an aortic cross-clamp time of 120 min. Pulse pressure, peak aortic flow, dp/dt _max, pulsatility index and energy-equivalent pressure were measured online. Renal and intestinal blood flow was calculated by fluorescent microspheres. The inflammatory response was assessed by the level of interleukin 6/1ra, the haemolysis by the free haemoglobin, and the escape rate of plasma protein by the disappearance rate of Evans Blue dye. Results: When compared to the preoperative curves, pulsatile waveforms during ECC were similar in group 1 and severely damped in group 2. Inflammatory response increased without significant differences between the groups. There were no differences between groups in renal and bowel blood flow. Free haemoglobin after ECC was higher in the pulsatile groups (group 1 = 43 ± 144 mg dl^–1, group 2 = 40 ± 164 mg dl^–1, group 3 = 11 ± 4 mg dl^–1; group 1 vs 2 (ns); group 1 or 2 vs 3 (p < 0.001)). The escape rate of Evans Blue increased after ECC in group 1 1.8-fold (p < 0.05), in group 2 1.45-fold (p < 0.05) and in group 3 1.27-fold (ns). Conclusion: Even when using pulsatile flow patterns which mimic closely the physiological waveforms, there is no advantage concerning organ perfusion or inflammatory response. Moreover, the extent of haemolysis and capillary leak is higher compared to non-pulsatile perfusion. Efforts to optimise pulsatility are not justified.

The widespread use of computed tomography (CT) scans for evaluating patients has resulted in the detection of many small solitary pulmonary nodules of uncertain significance. Workup of these nodules can be expensive and emotionally draining, especially in patients who have an established diagnosis of malignancy. Since the early 1990s, video-assisted thoracoscopic surgery (VATS) has become a procedure of choice in the workup and therapy of small lung lesions. Many different techniques have been described that would assist surgeons in localising small non-descript lesions in the lung during VATS. Most commonly, a single agent or mechanical device has been used for tumour localisation. We have modified the existing pre-VATS localisation techniques, evolving from one single agent with single spot injection to a dual-agent approach. In this approach, each agent is injected at two different locations. This technique provides us with a more precise ‘linear projection’ to the lesion of interest rather than the vague ‘field localisation’ provided by a single agent with a single spot injection. This modified dual agent's preoperative localisation is logical, practical and easy to be adopted into the clinical setting for surgeons who choose to use the VATS technique in addressing these lung nodules.

A few successful reports exist of late revascularisation of an ‘occluded’ left anterior descending coronary artery (LAD) with no angiographically visible collateral circulation. Epicardial high-frequency ultrasound and colour Doppler mapping can directly provide accurate anatomical landmarks and also detect very slow coronary flow velocities, with greater sensitivity than coronary angiograms. Late revascularisation of a chronically occluded LAD was performed successfully in two diabetic patients using high-frequency epicardial echo guidance. This had a positive effect on the left ventricular ejection fraction in the hibernating myocardial segments, and there were no subsequent cardiac events as well. These results indicate that the poor prognosis in diabetic patients with very severely reduced left ventricular function and reduced myocardial viability may be improved by late surgical revascularisation of chronic total occlusion (CTO) with no retrograde collateral channel.

Our experience with the Sapien trans-apical aortic valve (Edwards Lifesciences Inc., Irvine, CA, USA) has been straightforward without per-procedural mortality except in 1/16 consecutive cases who developed non-apical haemorrhage early after valve implantation. We describe the case of an 84-year-old female carrying a very high operative risk (logistic EuroScore of 44%), who underwent a trans-apical stent-valve implantation for severe and symptomatic aortic valve stenosis (23 mm). Due to massive blood loss, an emergency sternotomy and cannulation for cardiopulmonary bypass resuscitation were necessary to treat (without success) an unusual and unexpected subaortic left ventricular free-wall rupture that occurred few minutes after the stent-valve positioning and implantation. To the best of our knowledge, this is the first described case of a left ventricular free-wall rupture occurring after an otherwise non-complicated standard catheter-based aortic valve replacement.

Objective: To shorten cooling/rewarming associated with hypothermic neuroprotection strategies during complex aortic arch surgery, selective cerebral perfusion (SCP) at 28 °C has recently been advocated, although its safe limits – especially with regard to the ischaemic tolerance of the spinal cord – have not been systematically examined. Methods: Twenty juvenile Yorkshire pigs (30.3 ± 2.8 kg) were randomly allocated to undergo circulatory arrest and SCP at 28 °C for 90 min (group A; N = 12) or 120 min (group B; N = 8) at 50 mmHg using alpha-stat pH management. Spinal cord blood flow (SCBF) was assessed using fluorescent microspheres at baseline (prior to SCP); at 5 and 80 min during SCP, and at 1, 5 and 48 h after cardiopulmonary bypass (CPB). A modified Tarlov score was used to evaluate neurobehavioural recovery in all survivors blindly from videotapes for 5 days postoperatively. Histological ischaemic spinal cord injury was scored after sacrifice. Results: All pigs could be weaned from CPB and ventilation, but seven pigs (58%) in group A and five (63%) in group B developed multi-organ failure and died within 24 h. SCBF diminished immediately after initiation of SCP and was absent throughout SCP in all segments below T8/9, recovering to baseline 1 h after SCP at all cord levels. All survivors suffered moderate-to-severe histological lumbar spinal cord damage, more severe in group B (p ≤ 0.049). Three of five group A pigs recovered normal function, but two suffered paraparesis. Group B survivors had a worse neurologic outcome (p < 0.0001): all suffered paraplegia (one immediate, and two on day 2, after initial recovery). Conclusion: SCP provides insufficient SCBF below T8/9 to sustain cord viability. At 28 °C, the ischaemic tolerance of the cord may be exceeded enough by 90 min to impair function; by 120 min, SCP at 28 °C invariably results in paraplegia.

Background: Aortic aneurysm affecting the arch and proximal descending thoracic aorta may require a two-stage repair, which includes proximal elephant trunk graft placement and completion of descending thoracic aortic repair. The combination of open surgery and endovascular grafting may improve the morbidity and mortality of the patient population at risk. Methods: Between February 2001 and March 2007, 258 patients underwent thoracic aortic endovascular grafting at our institution, wherein 31 patients underwent a hybrid approach involving proximal arch repair and elephant trunk graft replacement, and endovascular completion procedures. All patients, who underwent combined endovascular and open procedures in the management of the aortic arch and proximal descending thoracic aortic aneurysms, were reviewed and analysed retrospectively. Results: The interval between the first and second stage ranged from 0 to 14 months with a mean interval of 3.1 months. Follow-up ranged from 0 to 70 months with a mean of 31 months. Technical success was achieved in all patients. The 1, 12, 36 and 60-month mortality rates were 6.4%, 16.5%, 26.7% and 26.7%, respectively. Caudal migration of the endograft occurred in three patients, who underwent conversion to open surgery. Two cases of paraparesis but no paraplegias or strokes were recorded. Conclusions: Staged procedures using endovascular grafting in the treatment of the arch and proximal descending thoracic aneurysm may have the potential to reduce morbidity and mortality rates. Although long-term results are still pending, this early experience demonstrates the safety and early-term effectiveness of this hybrid approach, which consists both of endovascular and open surgical procedures.

Background: Gelatin–resorcin–formalin (GRF) glue, a haemostatic agent often employed for aortic surgery, has beneficial effects on early results in surgery for acute aortic dissection but may have late adverse effects, probably due to excess use of the activators such as formaldehyde and glutaraldehyde. The purpose of this study was to determine the optimal proportions of GRF components that minimise toxicity to human aortic smooth muscle cells and elastin with acceptable adhesive strength. Methods: (1) The degree of polymerisation was examined at various proportions (activator/gelatin + resorcinol = 0%, 2%, 4%, 6%, 8% and 10%) to estimate adhesive strength. (2) (i) The toxicity of the activator was confirmed 24 h after its supplementation to human aortic smooth muscle cells in various proportions (activator/human aortic smooth muscle cell = 0%, 0.5%, 1%, 1.5%, 2% and 2.5%). (ii) The toxicity of GRF glue to human aortic smooth muscle cells was evaluated 1 h and 60 h after its supplementation (activator/gelatin + resorcinol = 0%, 2%, 4%, 6%, 8% and 10%). Another set of experiments in the same study was also performed. The only difference was that GRF glues were washed after polymerisation to exclude non-polymerised constituents. (3) Effects of 8%-GRF glue on toxicity to elastin derived from human aortic wall cells were investigated using an immunoblotting method. Results: (1) The polymerisation area increased dose dependently and that of the 10% activator/gelatin + resorcinol mixture was significantly wider than those of 6%, 4%, 2% and 0%, but had no significant difference from that of 8%. (2) (i) Human aortic smooth muscle cell death occurred in all dishes except activator-free dishes. (ii) Sixty hours after exposure to GRF glue, human aortic smooth muscle cell death occurred only in the 10% dish. In a washed GRF glue study, no human aortic smooth muscle cell death occurred in any dishes. (3) Toxicity to elastin was not significantly different between 8%-GRF glue and the control, whereas toxicity of elastase to elastin was significantly higher than for both the glue and the control. Conclusions: An 8%-GRF glue provides lower toxicity to human aortic smooth muscle cells and elastin with an acceptable degree of polymerisation, and thus seems to be an optimal proportion for GRF glue.

Objective: The aim of this study is to create a standard test to approve the efficacy of a surgical sealant. An industrial test, the bulge-and-blister test, which is very convenient for measuring adhesion energy, is applied to the surgical field to quantify adhesion of bioadhesives. Methods: Samples were composed of two circular layers of equine pericardium glued by the surgical sealant studied. The sample was fixed to a support with an industrial glue. The support and the bottom layer were perforated in the centre to allow injection of pressurised water. Water was progressively introduced through the hole in the support and the bottom layer to create a blister with constant radius, increasing height and internal pressure during this first step. At a critical pressure, delamination started, the radius and height of the blister increased and the pressure decreased. At this point, the adhesion energy could be determined. The experimental parameters were measured with a pressure sensor and an optical profilometry device for deflection. Results: Adhesion testing was carried out in eight paired equine pericardium samples bonded with a Dermabond^® cyanoacrylate glue. The average value of the practical adhesion energy is 2.3 J m^–2 with a standard deviation of 1.5 J m^–2. Conclusion: Application of the bulge-and-blister test to the surgical field was achieved and allowed a quantification of adhesion of a surgical glue. Such information is essential to compare the different surgical glues presently available. The study of the impact of bonding conditions such as pressure, hygrometry or setting conditions will provide a better understanding of the characteristics of adhesion in the surgical field.

Objective: To compare the haemodynamics and perioperative course of initial palliation with bilateral pulmonary artery banding (PAB) and the Norwood procedure. Methods: Between April 2004 and December 2007, 43 consecutive children with hypoplastic left heart syndrome (HLHS) or a variant underwent initial palliation (PAB, n = 18; Norwood, n = 25). Clinical perioperative data were analysed. In the PAB group, lipo-prostaglandin E1 administration was continued with hospitalisation until stage 2 palliation with a bi-directional Glenn shunt and the Norwood procedure. Results: There were no significant differences in the age and operative weight of patients who received stage 1 palliation (PAB, 12 ± 9 days, 2.7 ± 0.6 kg; Norwood, 12 ± 8 days, 2.8 ± 0.4 kg). The PAB group had more high-risk patients than the Norwood group (PAB, 83%; Norwood, 48%, p = 0.04). Increased early and inter-stage mortality were observed in patients who underwent the Norwood procedure (early mortality with PAB, 6% vs Norwood, 12%; inter-stage mortality, 6% vs 27%, respectively). Mortality between stages 1 and 2 was 11% for the PAB group and 36% for the Norwood group. The Kaplan–Meier survival estimate at 1 year did not differ between groups (77% for the PAB group, 64% for the Norwood group). Ductal stenosis was found in one patient in the PAB group during the follow-up period. Twenty-eight patients underwent stage 2 reconstruction, and the patients in the PAB group were younger at the time of surgery (PAB, 116 days; Norwood, 224 days). There were no significant differences between groups in pulmonary artery index regarding body surface area (BSA) (PAB, 179 mm² BSA^–1; Norwood, 194 mm² BSA^–1) and the incidence of ventricular dysfunction after stage 2 construction (PAB, 21%; Norwood, 21%). Conclusions: Bilateral PAB with continuous lipo-prostaglandin E1 administration may improve early and intermediate mortality in infants with HLHS. Intimate care with hospitalisation may contribute to the results.

Objective: Outcome of staged palliation for hypoplastic left heart syndrome has improved over the past decades. However, only little is known about the exercise capacity of children with palliated hypoplastic left heart syndrome where a systemic right ventricle supports the systemic circulation. The aim of the study was to assess exercise capacity in a contemporary cohort of children with hypoplastic left heart syndrome palliated in a single centre according to a uniform surgical strategy. Methods: Standardised cardiopulmonary exercise testing on a treadmill was performed in 46 consecutive hypoplastic left heart patients (median age: 6.0 (4.1–11.4) years). All but one patient reached the anaerobic threshold. Exercise data were compared to normal values obtained with a similar exercise protocol in a large cohort of paediatric volunteers. Results: Oxygen uptake at anaerobic threshold (26.9 ± 6.0 ml kg^–1 min^–1; 74.5 ± 18.2% of predicted) and maximal oxygen uptake (31.0 ± 6.8 ml kg^–1 min^–1; 60.8 ± 15.0% of predicted) were significantly reduced compared with controls (P < 0.0001 for both). The limitation in exercise capacity was due to an impaired rise in heart rate (158 ± 23 bpm; 79.7 ± 11.5% of predicted; P < 0.0001) and oxygen pulse (4.5 ± 1.6 ml per beat; 85.5 ± 22.0% of predicted; P < 0.0001). Furthermore, respiration during exercise was inefficient with an elevated respiratory rate and reduced maximal tidal volume and minute ventilation at maximal exercise. Conclusions: The exercise capacity of children with hypoplastic left heart syndrome is markedly reduced. Limitations in heart rate increase and stroke volume augmentation are the major contributors to this. An abnormal ventilatory response to exercise also adds to their limitation in exercise tolerance. However, the degree of physical disability does not justify discouraging these patients from school and leisure sports.

Objective: Because of their poor clinical status, infants may require surgery for congenital heart disease regardless of weight or prematurity. This retrospective review describes a single-centre experience with open-heart surgery in low-weight infants. Methods: From November 1997 to December 2006, 411 open-heart surgery procedures were performed in neonates. This included 46 consecutive infants weighing less than 2500 g, who underwent cardiopulmonary bypass for correction of congenital heart defects (n = 34) or Norwood stage I palliation of hypoplastic left heart syndrome (HLHS) (n = 12). In the low-weight group were 23 males and 23 females with a median age of 10 days and a median weight of 2.26 kg (range: 1.28–2.49 kg). Results: Early mortality was 8.2% in patients weighing more than 2.5 kg and 13% in the low-weight group. Within the low-weight group, weight at surgery, history of prematurity and prevalence of additional extracardiac malformations did not influence early mortality. At a median follow-up time of 32 months overall mortality was 21%. Thirty-four patients had a neurological follow-up examination 30 months postoperatively. Of the 34 survivors, 11 showed neurological deficits. Conclusions: In our patient population, early mortality was higher for infants weighing less than 2.5 kg. However, within the low-weight group, lower weight at surgery or history of prematurity was not associated with a higher mortality or bad neurological outcome.

Objective: Selective antegrade cerebral perfusion (SCP) has been widely used during complex congenital heart surgery and theoretically affords some degree of neuroprotection. There are limited data to support this claim, however. This study was designed to compare, at profound hypothermia, continuous cardiopulmonary bypass, SCP and circulatory arrest in a survival model of extracorporeal circulation in immature swine. Methods: Fifteen piglets (5.9 ± 1.1 kg) were placed on cardiopulmonary bypass (CPB), cooled to a rectal temperature of 15 °C and subjected to 90 min of hypothermic circulatory arrest (HCA), selective cerebral perfusion (30 ml kg^–1 min^–1) (SCP) or systemic full-flow perfusion (FF; 100 ml kg^–1 min^–1). Piglets were weaned from CPB and extubated. Daily neurologic assessments were performed for 5 days using neurologic deficit scoring (NDS) and overall performance categories (OPC). On postoperative day (POD) 5, all brains were perfusion-fixed and assigned a total histologic score (THS) of neuronal injury by a neuropathologist blinded to the study groups. Results: The median POD 1 NDS/OPC was 0 (range 0–115)/1(range 1–2) for FF, 130 (range 0–195)/2 (range 1–3) for HCA and 0 (range 0–30)/1 for SCP. Although there was a trend for the neurologic status in the HCA group to be worse on POD 1, this did not achieve significance, and both NDS and OPC scores for HCA animals normalised by POD 5. Median THS was 9 (range, 0–11) for FF, 12 (range, 4–14) for HCA and 9 (range, 0–11) for SCP with no statistically significant difference between the groups. Conclusions: In this survival model of hypothermic extracorporeal circulatory support in immature swine, histologic brain injury was similar in piglets subjected to FF, SCP or HCA. Although the HCA group tended to have worse early neurologic outcome, any difference clearly disappeared by POD 5. These data raise the possibility that profound hypothermia alone during extracorporeal support may produce this observed brain injury. Additional study is required to define the precise aetiology of the brain injury observed in this animal model.

Objective: To determine if preoperative statin treatment is associated with a reduction in systemic inflammatory response (SIR) and myocardial damage markers following cardiac surgery with cardiopulmonary bypass (CPB). Methods: We study a prospective cohort of 138 patients who underwent coronary and valvular surgery with CPB. We differentiate two study groups: patients with (group A, n = 72) or without (group B, n = 66) statins. Plasma levels of pro-inflammatory interleukins (tumour necrosis factor-alpha (TNF-), interleukin (IL)-6, IL-8 and IL-2R), creatine phosphokinase (CPK), CPK-MB and troponin I were measured before and 1, 6, 24 and >72 h after surgery. Results: The baseline, operative and postoperative morbidity and mortality characteristics were similar for both the groups. Group A had significantly lower postoperative levels of IL-6 than group B at 6 h (68.8 ± 5 pg ml^–1 vs 108.9 ± 108 pg ml^–1, p = 0.01), 24 h (71.7 ± 7 pg ml^–1 vs 110.4 ± 106 pg ml^–1, p = 0.01) and before hospital discharge (21.6 ± 12 pg ml^–1 vs 32.8 ± 27 pg ml^–1, p = 0.005), as well as significantly lower average IL-6 levels in the first 24 h following surgery (71.8 ± 5 pg ml^–1 vs 112.8 ± 82 pg ml^–1, p = 0.002). The postoperative CPK-MB at 24 h (19.7 ± 23 ng ml^–1 vs 33.1 ± 32 ng ml^–1, p = 0.02) and troponin I levels at the end of the intervention (2.2 ± 2.2 ng ml^–1 vs 3.3 ± 3.1 ng ml^–1, p = 0.03) and at 24 h (4.1 ± 3.5 ng ml^–1 vs 6.6 ± 8 ng ml^–1, p = 0.04) were also significantly lower in the group treated with statins prior to surgery. Conclusions: Preoperative treatment with statins is associated with a lower biochemical parameters of SIR and myocardial damage following cardiac surgery with CPB, regardless of it being coronary bypass grafting (CABG) or valvular surgery.

Background: We evaluated the efficacy of a well-prepared left internal thoracic artery (LITA) auto Y graft for simultaneous left anterior descending artery (LAD) and diagonal artery (DA) re-vascularisation in selected patients for the reduction of the number of required grafts and improved graft patency, while limiting technical problems. Methods: Twenty well-controlled diabetic patients, mean age 62.8 ± 8.3, 17 males and three females, underwent isolated elective off-pump coronary artery bypass grafting using the LITA auto Y graft from July 2003 to August 2004. Results: In-hospital data and angiographic results at 6 months after the surgery showed that there was no early mortality, early graft failure and major morbidity except for two cases of superficial wound infection. The 3-year follow-up results including angiographic findings (mean of 37 ± 3.3-month follow-up) demonstrated that all patients are alive and have excellent graft patency in both the LAD and DA. Only two cases required right coronary artery (RCA) stenting during the follow-up period. Compared with our previous routine LITA composite Y graft technique, it is assumed that LITA auto Y graft technique may reduce the number of mobilised conduits or avoided sequential anastomosis. Conclusions: This small study showed that our technique is technically feasible and may be safely performed to the selective patients. The LITA auto Y graft might be an additional surgical option, in terms of not only preserving the other grafts and maintaining patency in the LAD area bypass, but also preventing the need for sequential anastomoses.

Background: This study assesses the accuracy of the new dual-source computed tomography (DSCT) for detection of coronary artery disease (CAD) compared with invasive coronary angiography (ICA) with a specifically designed data presentation protocol for cardiac surgeons. Methods: Forty patients (30 males/10 females) underwent ICA and DSCT. Best-quality images were prepared by radiologists. Evaluation of 12 segments of significant coronary stenosis was done by two cardiac surgeons with a data presentation protocol including different coronary views in two-/three-dimensional (2D/3D) images. No beta-blockers were administered prior to DSCT. Results: ICA revealed CAD in 21 patients and valvular disease but no CAD in 19 patients. In DSCT, 20/21 patients were diagnosed with CAD (at least one significant stenosis per patient). In 11/21 patients, all 12 segments were assessed correctly; in 7/21 patients one segment and in 3/21 patients two segments were evaluated incorrectly. Of all 21 patients with CAD, 239/252 segments (95%) were correctly evaluated. In 18/19 patients without CAD, DSCT correctly ruled-out the ICA results in 226/228 segments (99%). In total, 465/480 segments were correctly assessed (97%). Of 480 segments, only six were considered not assessable. DSCT assessments of the segments showed a sensitivity of 91%, specificity of 99%, a positive predictive value of 92% and a negative predictive value of 99%. Conclusions: The accuracy of DSCT coronary angiography especially for exclusion of CAD is promising. The introduced data presentation protocol allows for the independent evaluation by cardiac surgeons after pre-arrangement from the radiologists.

Background: Although adenosine (ADO) has been shown to have beneficial effects against tissue injury after myocardial ischaemia, the controversy still remains regarding the optimal timing, dose, temperature, method of ADO administration and duration of exposure to the drug. This study investigates the cardioprotective effect of exogenous ADO pretreatment as an adjunct to 1 mmol l^–1 ADO cold (12 °C) blood cardioplegia during heart valve replacement surgery. Materials and methods: Thirty patients with rheumatic heart valve disease undergoing heart valve replacement operations were randomly assigned to two groups: group C (n = 15) and group A (n = 15). Patients in group C were the control group and received antegrade cold (12 °C) high-potassium ([K⁺] = 20 mol l^–1) institute blood cardioplegia. The patients in group A received 10-min 100 µg kg^–1 min^–1 ADO pretreatment before application of the aortic cross-clamp and antegrade 1 mmol l^–1 adenosine high-potassium ([K⁺] = 20 mol l^–1) cold (12 °C) blood cardioplegia. Clinical outcomes were observed before, during and after the operation. Plasma level markers of myocardial damage: cardiac Troponin I (cTnI), creatine kinase (CK-MB) and inflammatory factors (interleukin (IL)-6 and IL-8) were obtained from serial venous blood samples after induction, 5 min after cross-clamp of aorta, 10 min after clamp-off, 1 h after return to ICU and postoperatively 24 h and 48 h. Right atrial samples were harvested before cross-clamp and after clamp-off. Results: Heart valve replacement was successful in all patients. There were no differences regarding operative parameters in the two groups. Time to arrest (during cardiolegia perfusion electrocardiography (ECG) change to a line) was shorter in group A compared to group C (19.9 ± 4.6 s vs 29.3 ± 10.6 s; p = 0.03). Group A also had lower cTnI and IL-8 levels (p = 0.03) at 10 min after aortic declamping, and lower IL-6 (p = 0.04) at 24 h postoperatively as well. Ultrastructural changes were slighter in group A than group C after clamp-off. Compared to group C, post-reperfusion biopsies in group A displayed only slight overall ultrastructural changes, and scored significantly better on mitochondrial damage (group A 2.23 ± 0.65 vs group C 2.85 ± 0.66) (p = 0.04). Conclusion: Compared with simple cold blood cardioplegia in heart valve replacement patients, ADO pretreatment as an adjunct to 1 mmol l^–1 ADO cold blood cardioplegia may reduce cTnI, IL-6 and IL-8 release, resulting in reduced myocardial injury in ultrastructure after surgery.

Objective: Levosimendan is a calcium-sensitising inotropic agent and a vasodilator used in the treatment of heart failure. Post-cardiotomy cardiac failure is more common in patients with a low preoperative left ventricular ejection fraction (LVEF). We aim at investigating how prophylactic treatment with levosimendan before weaning from cardiopulmonary bypass (CPB) affects postoperative haemodynamics and outcome in patients with low preoperative LVEF. Methods: Patients with a preoperative LVEF ≤30% treated with levosimendan before weaning from CPB were included in the study. Each patient was matched to a control patient with respect to the following criteria: surgical procedure, EuroSCORE, age, gender and the use of intra-aortic balloon pump. We investigated postoperative haemodynamics in the intensive care unit (ICU) at time points: 1, arrival; 2, approximately 7 h after arrival; and 3, the first postoperative morning. In addition, mortality was evaluated. Results: Thirty patients treated with levosimendan and 30 matched controls were enrolled in the study. No statistically significant differences in cardiac index (CI) (l min^–1 m^–2), stroke volume index (SVI) (ml m^–2), mixed venous O₂-saturation (SvO₂) (%) or heart rate (HR) (beats per minute) between the two groups measured at the three time points 1–3 were registered. Mean arterial blood pressure (MAP) (mmHg) was lower in the levosimendan group both at time points 2 (68, range: 65–71 vs 75, range: 72–78; p = 0.009) and 3 (72, range: 69–74 vs 78, range: 74–82; p = 0.01), despite a higher dose of norepinephrine in the treatment group (p = 0.021). A significantly higher number of control patients were treated with classic adrenergic inotropes both in the operating room (p = 0.013) and in the ICU (p < 0.001). Thirty days mortality was the same in both groups (7%). Conclusions: Prophylactic infusion of levosimendan initiated before weaning from CPB did not lead to superior haemodynamic parameters (CI, SVI, SvO₂) compared to controls. Levosimendan reduced MAP and increased the need for norepinephrine postoperatively.

Objective: A new staging system for lung cancer has been proposed by The International Association for the Study of Lung Cancer Staging Committee. We assessed the feasibility of this system for surgical patients. Methods: We reviewed the surgical outcome of 1623 consecutive patients with non-small-cell lung cancer (NSCLC), who underwent pulmonary resection in our institution, with regard to the subpopulations categorised in the current and proposed (2009) systems for postoperative pathologic staging. Results: The proportion of patients staged as IIA, IIB, IIIA and IV increased, while those staged as IB and IIIB decreased. Diseases staged as IIIA or earlier were significantly increased in the new system (current system: N = 1281, 78.9% vs new system: N = 1457, 89.8%). The 5-year survival rates of patients with new stages IB and IIA were clearly dissociated with 72.5% and 51.3%, respectively (P < 0.0001). The 5-year survival rates of the newly classified T1 patients were 90.3% for T1aN0M0 and 81.5% for T1bN0M0 (P = 0.009). Re-classification of T2bN0M0 as stages IIA and T3 (same lobe nodules) N0M0 as stage IIB appropriately emphasised prognostic differences, while T4 (ipsilateral different lobe nodules) N2–3M0 (stage IIIB) and M1a (pleural effusion, stage IV) did not. Conclusions: This study demonstrated that the new system is superior to the current system in terms of the proportion and prognostic prediction of each stage, although it contains minor contradictions. Therefore, revision of the staging system will contribute to the decision for limited operation and adjuvant therapy of resected NSCLC.

Objective: The International Association for the Study of Lung Cancer (IASLC) recently recommended changes for T and N descriptors for the next TNM (Tumour, Node, Metastasis) edition. We re-classify our operated patients to evaluate the effectiveness of the IASLC suggestions. Methods: IASLC proposals include: (1) a subdivision of T1 into T1a (≤2 cm) and T1b (2–3 cm); (2) a subdivision of T2 into T2a (3–5 cm) and T2b (5–7 cm); (3) a re-assignment of T2 >7 cm to T3; (4) a re-assignment of intrapulmonary metastasis in the primary lobe (PM1) and in ipsilateral different lobes (PM2) from T4 to T3 and from M1 to T4, respectively; and (5) a classification of N descriptor by the number of involved lymph node zones into: N0; single-zone N1 (N1a); multiple-zone N1/single-zone N2 (N1b/N2a) and multiple-zone N2 (N2b). From 1994 to 2007, 1805 patients were operated on for non-small-cell lung carcinoma (NSCLC); survival analysis was performed using Cox proportional hazard model to assess the prognostic significance of the T and N descriptors. Results: Stratification by T descriptor was: T1a (362 patients), T1b (286), T2a (536), T2b (154), T2 >7 cm (58), T3 (243), PM1 (50) and PM2 (36). Stratification by N descriptor was: N0 (1150 patients), N1a (289), N1b/N2a (200) and N2b (67). A significant survival difference was found between T1a and T1b (hazard ratio (HR) 1.45, 95% confidence interval (CI): 1.10–1.90, p = 0.006) but not between T2a and T2b (HR: 1.11, 95% CI: 0.86–1.43, p = 0.38). Tumours >7 cm and PM1 had a survival similar to other T3 tumours (HR: 1.05, 95% CI: 0.97–1.14, p = 0.2 and HR: 0.99, 95% CI: 0.81–1.21, p = 0.94). An excellent patient stratification was provided with the proposed four-category nodal grouping, with significant survival differences between N0 and N1a (HR: 1.81, 95% CI: 1.50–2.21, p = 0.0000001), N1a and N1b/N2a (HR: 1.54, 95% CI: 1.21–2.00, p = 0.02) and between N1b/N2a and N2b (HR: 1.61, 95% CI: 1.14–2.27, p = 0.02). Conclusions: Our experience confirms the IASLC recommendations to subdivide patients by tumour size at 2, 3 and 7 cm, to re-assign PM1 tumours to T3 and to group patients according to the number of involved lymph nodal zones are valid and provide excellent survival stratification.

Objective: Pulmonary parenchyma-saving procedures, indicated for central tumours, seem to have better results than pneumonectomy, an alternative procedure. The purpose of this study is to report our experience at our institution with sleeve lobectomy with regard to surgical technique and outcome. Methods: We retrospectively reviewed the records of 45 patients who underwent sleeve lobectomy for non-small-cell lung cancer, with a curative intent, during the period of January 2004 and January 2008. Four of these patients underwent bronchovascular reconstructive procedures. A minor modification of the running suture technique used for bronchoplasties is described here. Results: The study identified 40 men and five women with a median age of 64 years (range: 24–80 years). All 45 patients underwent oncological resections with negative results for malignancy bronchial resection margins. Neither bronchial nor vascular complications occurred. Complications were observed in 15% of our patients and included prolonged air leak in three, atelectasis needing daily bronchoscopy in three and respiratory failure due to pneumonia in one patient, who eventually died, accounting for a mortality rate of 2%. The follow-up period ranged from 1 to 52 months, with a median of 26 months, and it was complete for 43 (96%) of the patients. The overall 4-year survival was 57%. Conclusions: Sleeve lobectomy for lung cancer, although technically demanding, is associated with low morbidity and mortality and satisfactory immediate and long-term results. With increasing experience, more lung-sparing procedures should be performed in selected patients.

Objective: Concurrent chemoradiotherapy is standard of care in stage III non-small-cell lung cancer, although surgery may be beneficial in selected patients in whom induction therapy has achieved ‘down-staging’ of mediastinal nodal disease. Previous studies incorporated treatment ‘splits’ for re-evaluation, and such gaps lead to poorer survival in patients undergoing chemoradiotherapy. We describe the outcome of a treatment strategy to limit the duration of treatment splits. Methods: A prospective database (2003–2007) of stage III non-small-cell lung cancer patients treated with concurrent chemoradiotherapy outwith clinical trials at our centre was reviewed. Preoperative chemoradiotherapy consisted of one induction course of cisplatin–gemcitabine, followed by two courses of cisplatin–etoposide with once-daily thoracic radiotherapy using four-dimensional involved-field treatment planning. After a dose of 46–50 Gy, potentially resectable patients without disease progression underwent immediate planned mediastinal re-staging and patients with persistent N2 disease or who were unfit for surgery continued to full-dose radiotherapy. Effort was made to shorten the treatment split by substituting mediastinoscopy for endoscopic procedures (transbronchial and -oesophageal). Results: A total of 34 patients had potentially resectable disease at the start of treatment. Toxicity of chemoradiotherapy was predominantly leucocytopaenia grade III/IV in 38% of courses and grade III oesophagitis in five patients (15%), but was manageable and reversible. After re-staging, 24 patients (71%) proceeded to surgery. A radical resection was achieved in 23 patients; nine had a complete pathological response. Re-staging was accurate with only one false-negative mediastinoscopy. One patient died 10 days after surgery. Median time from end of induction treatment to re-staging or surgery was 12 (range: 0–51 days) and 35 days (range: 18–63 days), respectively. Median survival for resected patients was not reached. Six patients had persisting N2 disease, of which two continued radiotherapy after a split of 3 and 4 days. Conclusions: Image-guided, involved-field preoperative chemoradiotherapy can be performed with acceptable toxicity, and the present strategy achieves the goal of limiting splits in treatment delivery that may adversely affect survival in patients who do not undergo down-staging with induction therapy.

Objective: During surgery for colon carcinoma, tumour cells may spread into the blood and may lead to the development of distant metastases. The most frequent sites of metastases are the liver and lungs. A new therapeutic approach is required to prevent tumour implantation of freely circulating tumour cells during and after surgery and to treat established metastases. The aim of this prospective study was to observe the influence of long-term intravenous taurolidine on the development of lung metastases after intravenous injection of colon adenocarcinoma cells. Methods: Tumour cells (DHD/K12/TRb colon adenocarcinoma cell line, 1 x 10⁶ cells) were injected into the right vena jugularis interna of BDIX rats. The animals (n = 13) were randomised into three groups: group 1: tumour cell implantation without taurolidine application (control group); group 2: tumour cell implantation and simultaneous start of the taurolidine injection through osmotic pump, removal of the osmotic pump on day 7; group 3: tumour cell implantation on day 0 and start of the taurolidine injection through osmotic pump on day 14. Results: In the taurolidine groups, the number and size of lung metastases were significantly lower compared to the control group (p = 0.018; p = 0.018 and p = 0.036; p = 0.018). Although the results of the intravenous long-term therapy with taurolidine in group 2 did not reach statistical significance in comparison with the results of group 3, a positive trend was revealed: The mean number of metastases in group 2 was 18.2 versus 28.2 in group 3. Conclusions: The application of taurolidine tends to prevent the development of lung metastases. Furthermore, taurolidine seems to reduce established lung metastases in this in vivo model. Taurolidine may offer additional therapeutic options in patients with colon adenocarcinoma.

Surgical treatment of lung cancer is associated with an elevated risk of thrombo-embolic complications. The question is whether the extent of pulmonary resection influences the concentration of serum coagulation system proteins. Objective: This study aims to compare the blood coagulation activation parameters among patients undergoing pneumonectomy and lobectomy due to primary lung cancer. Methods: A prospective study was carried out in 40 patients. Of whom, 30 underwent lobectomy and 10 treated with pneumonectomy. Serum concentrations of tissue factor (TF), tissue factor pathway inhibitor (TFPI), tissue factor pathway inhibitor-activated factor X complex (TFPI/Xa), thrombin–antithrombin complex (TAT), L-selectin, E-selectin and P-selectin were measured on the first and seventh postoperative days. Results: On the first postoperative day, the results of selected proteins concentrations were similar in both groups. However, on the seventh postoperative day, significantly higher concentrations of TF, TAT complex and E-selectin were found in patients who underwent pneumonectomy (median values: TF: 182.4 pg ml^–1 vs 116.6 pg ml^–1, P = 0.031; TAT: 6.2 mg ml^–1 vs 3.9 mg ml^–1, P = 0.048; E-selectin 40.24 ng ml^–1 vs 26.54 ng ml^–1, P = 0.049). Conclusions: Pneumonectomy was associated with significantly higher activation of coagulation system on the seventh postoperative day than lobectomy. TAT complex, TF and E-selectin are promising markers of extensive postoperative activation of coagulation and efficacy of antithrombotic prophylaxis.

Objective: The impact of type of resection for lung cancer, that is, pneumonectomy or lobectomy, on postoperative quality of life is not clearly defined. The aim of the study was to compare the changes in health-related quality of life in patients undergoing lobectomy or pneumonectomy for lung cancer. Methods: We performed a prospective, population-based, cohort study and used a validated quality-of-life instrument to gather information on health-related quality of life before and 6 months after surgery. The main outcome measures were fractional change in the Short Form-36 physical and mental component summary scores. Results: There was no statistically significant difference in any of the Medical Outcome Study 36-Item Short Form subscales or summary scores between the lobectomy (n = 101) and pneumonectomy (n = 16) group at baseline. There was a significant difference in the fractional change in the physical component summary score between the lobectomy and pneumonectomy group (–17% vs –32%, p = 0.04), but not in the mental component summary score (6.5% vs 12%, p = 0.72). Conclusions: Pneumonectomy had a larger negative impact on the physical aspect of health-related quality of life than lobectomy 6 months following surgery for lung cancer. The mental component of quality of life was not affected by the extent of surgical resection.

A 21-year-old male developed significant swelling of his tongue after a respiratory arrest. The patient had a history of Hurler's syndrome. Magnetic resonance imaging (MRI) angiogram delineated that the swelling was due to compression of his internal jugular veins at the level of the first rib, resulting in thoracic inlet obstruction. The standard surgical treatment of thoracic inlet obstruction was not suitable in this patient's case due to his short thick neck and his characteristic Hurler's syndrome body habitus. Therefore, a novel surgical strategy was used to decompress his head and neck vessels. The manubrium was widened using an iliac crest bone graft, stabilised using internal fixation plates and reconstructed with a pectoral muscle flap.