The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provides this professional view on resuscitation in cardiac arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation including the extrapolation of existing guidelines from the International Liaison Committee on Resuscitation where possible, our own structured literature reviews on issues particular to cardiac surgery, an international survey on resuscitation hosted by CTSNet and manikin simulations of potential protocols. This protocol differs from existing generic guidelines in a number of areas, the most import of which are the following: successful treatment of cardiac arrest after cardiac surgery is a multi-practitioner activity with six key roles that should be allocated and rehearsed on a regular basis; in ventricular fibrillation, three sequential attempts at defibrillation (where immediately available) should precede external cardiac massage; in asystole or extreme bradycardia, pacing (where immediately available) should precede external cardiac massage; where the above measures fail, and in pulseless electrical activity, early resternotomy is advocated; adrenaline should not be routinely given; protocols for excluding reversible airway and breathing complications and for safe emergency resternotomy are given. This guideline is subject to continuous informal review, and when new evidence becomes available.

Objective: A survey was conducted on CTSNet, the cardiothoracic network website in order to ascertain an international viewpoint on a range of issues in resuscitation after cardiac surgery. Methods: From 40 questions, 19 were selected by the EACTS clinical guidelines committee. Respondents were anonymous but their location was determined by their Internet protocol (IP) address. The responses were checked for duplication and completion errors and then the results were presented either as percentages or median and range. Results: From 387 responses, 349 were suitable for inclusion from 53 countries. The median size of unit of respondents performed 560 cases per year. The incidence of cardiac arrest reported was 1.8%, emergency resternotomy after arrest 0.5% and emergency reinstitution of bypass 0.2%. Only 32% of respondents follow current guidelines on resuscitation in their unit and an additional 25% of respondents have never read these guidelines. Respondents indicated that they would perform three attempts at defibrillation for ventricular fibrillation without intervening external cardiac massage and for all arrests perform emergency resternotomy within 5 min if within 24 h of the operation. Fifty percent of respondents would give adrenaline immediately, 58% of respondents would be happy for a non-surgeon to perform an emergency resternotomy and 76% would allow a surgeon's assistant and 30% an anaesthesiologist to do this. Only 7% regularly practise for arrests, but 80% thought that specific training in this is important. Conclusion: This survey supports the EACTS guideline for resuscitation in cardiac arrest after cardiac surgery published in this issue of the journal.

Objective: Risk stratification allows preoperative assessment of cardiac surgical risk faced by individual patients and permits retrospective analysis of postoperative complications in the intensive care unit (ICU). The aim of this single-center study was to investigate the prediction of extended ICU stay after cardiac surgery using both the additive and logistic model of the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Methods: A retrospective observational study was conducted. We collected clinical data of 1562 consecutive patients undergoing cardiac surgery over a 2-year period at the Antwerp University Hospital, Belgium. EuroSCORE values of all patients were obtained. The outcome measure was the duration of ICU stay in days. The predictive performance of EuroSCORE was analyzed by the discriminatory power of a receiver operating characteristic (ROC) curve. Each EuroSCORE value was used as a theoretical cut-off point to predict duration of ICU stay. Three subsequent ICU stays were defined as prolonged: more than 2, 5 and 7 days. ROC curves were constructed for both the additive and logistic model. Results: Patients had a median ICU stay of 2 days and a mean ICU stay of 5.5 days. Median additive EuroSCORE was 5 (range, 0–22) and logistic EuroSCORE was 3.94% (range, 0.00–87.00). In the additive EuroSCORE model, a predictive value of 0.76 for an ICU stay of >7 days, 0.72 for >5 days and 0.67 for >2 days was found. The logistic EuroSCORE model yielded an area under the ROC curve of 0.77, 0.75 and 0.68 for each ICU length of stay, respectively. Conclusions: In our patient database, prolonged length of stay in the ICU correlated positively with EuroSCORE. The logistic model was more discriminatory than the additive in tracing extended ICU stay. The overall predictive performance of EuroSCORE is acceptable and most likely based on the presence of variables that are risk factors for both mortality and extended ICU stay. Hence, EuroSCORE is a useful predicting tool and provides both surgeons and intensivists with a good estimate of patient risk in terms of ICU stay.

Objective: For most newborns, congenital heart defects (CHD) appear to be isolated anomalies and the brain is presumed to have normal developmental potential. Most studies of neurodevelopmental outcomes have focused on operative management strategies. Methods: Infants with complex CHD and no identified syndromes other than 22q11 microdeletions enrolled in a study of apolipoprotein E (APOE) polymorphisms and developmental outcome were evaluated at one year of age; including genetic evaluation and the Bayley Scales of Infant Development-II [mental (MDI) and psychomotor developmental indices (PDI)]. Results: Five hundred and fifty infants enrolled and 359 (20 with 22q11) of 501 survivors (72%) returned. Mean MDI was 90 ± 15 and PDI was 78 ± 18. Genetic syndromes not identified at birth were confirmed in 28 (8.1%) and suspected in 51 (15.0%). By multivariable analysis, suspected/confirmed genetic syndromes and APOE 2 allele predicted lower MDI and PDI, all p < 0.04. Lower birth weight (p < 0.001) and preoperative intubation (p = 0.012) predicted lower MDI. Higher hematocrit during the initial operation was associated with higher MDI (p = 0.007). Longer postoperative length of stay was predictive of lower PDI (p = 0.002). Additional operations with cardiopulmonary bypass were associated with lower MDI and PDI (both p < 0.002), but use of deep hypothermic circulatory arrest was not. Conclusions: Patient factors (birth weight and preoperative status) are significant determinants of neurodevelopmental outcomes as opposed to operative management strategies. In this cohort, genetic syndromes unsuspected at birth were surprisingly common and correlate with poor neurodevelopmental outcomes. Without multiple congenital anomalies, syndromes may be missed in infancy. Genetic evaluation should be considered in all infants with CHD.

Objective: The purpose of this study is to evaluate the surgical repair of functional single ventricle and extracardiac total anomalous pulmonary venous connection (TAPVC). Methods: Between January 1998 and December 2007, 26 consecutive patients underwent surgical repair of extracardiac TAPVC. Their characteristics were as follows: median age, 34 (range 0–744) days; median weight 3.2 (range 2.0–9.6) kg; supracardiac TAPVC, 11 patients; infracardiac, 5; mixed, 10; right atrial isomerism, 24; pulmonary atresia, 16; and obstructed TAPVC, 17. Concomitant procedures included systemic-to-pulmonary shunt in 9 patients, pulmonary artery banding in 5, ventricle-to-pulmonary artery shunt in 1, Norwood procedure in 1, bidirectional Glenn in 9, and Fontan procedure in 1. Results: The overall survival after the repair of TAPVC was 58% (95% confidence interval [CI], 39–77%) and 54% (95% CI, 34–73%) at 1 and 5 years, respectively. Of the 14 survivors (supracardiac, 9; infracardiac, 4; and mixed, 1), 12 underwent Fontan completion; 1, bidirectional Glenn; and 1 is awaiting bidirectional Glenn. Anastomotic stenosis did not occur, but recurrent pulmonary venous ostial stenosis (PVS) was observed in nine patients. Freedom from recurrent PVS was 56% (95% CI, 34–78%) at both 1 and 5 years. Reoperation for recurrent PVS was performed in six patients; of these patients, two underwent Fontan completion, but three with bilateral and multiple PVS declined. By Cox multivariate regression analysis, mixed TAPVC (p = 0.001, hazard ratio, 13.4; 95% CI, 2.8–64.4) was a risk factor for mortality, and atrioventricular valve regurgitation, which required surgical intervention at the palliative stage (p = 0.024, hazard ratio, 23.4; 95% CI, 1.5–363.4) was a risk factor for recurrent PVS. Conclusions: The mid-term results of the surgical repair of functional single ventricle with supracardiac or infracardiac TAPVC are acceptable. The surgical treatment of patients with mixed TAPVC and with severe atrioventricular valve regurgitation is not promising, but can be improved.

Objective: To investigate whether the duration of pleural drainage after Fontan completion operations can be influenced by postoperative lisinopril administration or can be related to water balance hormone levels. Methods: In a prospective trial 21 patients scheduled for total cavopulmonary connection were randomized into two groups, with group I receiving lisinopril postoperatively, and group II receiving no angiotensin converting enzyme inhibitor. Plasma levels of antidiuretic hormone, renin and aldosteron were analyzed preoperatively and at four-time points postoperatively. Groups were comparable for age, preoperative saturation and pulmonary pressure, cardiopulmonary bypass time, cross-clamp time and preoperative hormone levels. Results: Mean duration of pleural drainage was comparable for both groups (group I: 9.6 ± 8 days vs group II: 10 ± 7 days; p = 0.78). The hormone profiles in each group changed significantly at 1 and 24 h postoperatively compared to preoperative values (p < 0.05), with no significant differences between the treatment groups. The duration of pleural drainage correlated significantly with hormone levels at 24 h postoperatively, and with longer bypass times. At multivariate analysis only aldosteron and antidiuretic hormone level at 24 h came out as factors reaching significance for prolonged pleural drainage. Conclusions: The Fontan completion induces significant changes in the levels of antidiuretic hormone, aldosteron and renin. Prolonged drainage correlates significantly with elevated levels of aldosteron, renin and antidiuretic hormone postoperatively, and with longer bypass time, but is not influenced by lisinopril. The eventual adjunct therapy with aldosteron antagonists warrants further study.

Objective: Extracardiac conduit Fontan procedure (ECFP) using Gore-Tex graft has been performed with increasing frequency for the patients with functional single ventricle. However, lack of growth potential and longevity of the conduit are consistent concerns and main points of criticism of the ECFP. In this study, we investigated the mid-term status of the Gore-Tex graft used in the ECFP by comparing the internal diameter of the graft with the inferior vena cava (IVC) diameter at 1 month and 5.2 years after the ECFP. Methods: Of 79 patients who underwent ECFP using Gore-Tex graft between November 1997 and December 2007, 33 patients who had completed cardiac catheterization at 1 month (21–73 days) and 5.2 years (3.3–9.6 years) after the ECFP were included in this study. We measured the internal diameter of the Gore-Tex graft and IVC at both catheterizations retrospectively. Results: The size of the Gore-Tex graft used in the ECFP was 16 mm in 17 patients, 18 mm in 9 patients, and 20 mm in 7 patients. Laminar flow through the conduits was maintained without any stenosis or kinking of the graft in these 33 patients. No intervention or reoperation related to the extracardiac conduit has been required. There were no significant differences in mean cross-sectional area (CSA) of the conduits at 1 month versus 5.2 years after the ECFP for each conduit size, and no significant changes in the conduit-to-IVC CSA ratio (0.98 ± 0.40 vs 0.82 ± 0.21 for 16 mm, 1.09 ± 0.30 vs 0.92 ± 0.33 for 18 mm, and 1.16 ± 0.55 vs 0.94 ± 0.44 for 20 mm conduit). Conclusions: The conduit CSA and conduit-to-IVC CSA ratio remained unchanged in small caliber grafts down to 16 mm at 5.2 years after the ECFP. However, further investigation is necessary to evaluate the fate of the Gore-Tex graft and late hemodynamics in the patients with small conduits after they achieve full somatic growth.

Objective: To evaluate the occurrence of pulmonary arteriovenous malformations after a Fontan operation in the left isomerism and absent inferior vena cava. Methods: We retrospectively reviewed 19 patients with the left isomerism and absent inferior vena cava who underwent Fontan operations at our institution. We divided the patients into two groups: bilateral superior vena cava (group A, n = 9), and single superior vena cava (group B, n = 10). Median age at Fontan operation was 6.2 years (1.0–24.1). Diagnosis of pulmonary arteriovenous malformations was made by pulmonary angiography and bubble contrast echocardiography. Results: Median follow-up was 5.3 years (0.2–17.3) with one hospital death. Seven patients suffered from pulmonary arteriovenous malformations. In six out of the seven patients, the occurrence of pulmonary arteriovenous malformations was related to biased pulmonary perfusion of the hepatic venous flow. In group A, the distance between the dominant superior vena cava (which the venous flow from the lower half of the body drains into) and the hepatic venous channel over the distance between the smaller superior vena cava and the hepatic venous channel was larger in patients with pulmonary arteriovenous malformations than in patients without pulmonary arteriovenous malformations (3.83 ± 1.28 vs 1.53 ± 1.45, p = 0.071). In group B, pulmonary arteriovenous malformations developed in two patients whose venous channels did not overlap. Pulmonary arteriovenous malformations developed in only one patient after we changed the hepatic venous channel design to approximate the hepatic venous channel to the dominant superior vena cava as closely as possible. Conclusions: We might prevent pulmonary arteriovenous malformations in patients with the left isomerism and absent inferior vena cava by designing the venous channels to achieve better mixing of the superior vena cava and the hepatic venous flow.

Hypoplastic left heart syndrome is a relatively common cardiac malformation, accounting for 4–9% of children born with congenital heart disease. Since 1981 the mainstay of treatment has been the Norwood series of operations which have been variously modified, most recently using an RV–PA conduit (Sano shunt). With these surgical modifications and with increased experience in perioperative care survival for the surgical approach to completion of stage 2 palliation has improved to 70–80%. However, in 1997 when surgical results were poorer, interventional cardiologists explored the possibility of hybrid palliation of these children using a combined transluminal and closed surgical technique as it was perceived this would be less traumatic. Poor initial results caused many to discontinue this approach but some persevered, and with increasing experience survival to completion of stage 2 following hybrid palliation is now 50–80%. Although these results may superficially appear to be poorer than for surgery, it must be observed that increasingly the hybrid approach has been used by many groups as palliation for the highest risk cases (particularly small size and adverse cardiac factors). This review therefore considers what is the optimal management of children with hypoplastic left heart syndrome currently, and, specifically, what is the role for the hybrid approach in palliation of patients with hypoplastic left heart syndrome?

Objective: The ideal valve substitute in children does not exist. Biologic and bioprosthetic valves do not require anticoagulation, however their use is complicated by accelerated degeneration and requirement for reoperation. We examine results following mitral (MVR) or aortic (AVR) replacement with biologic and bioprosthetic valves at our institution. Methods: Medical records of children who underwent AVR or MVR from 1986 to 2006 were reviewed. Median follow-up duration was 10.5 years. Competing-risks methodology determined time-related prevalence and associated factors for three mutually exclusive end states: death, valve reoperation, and survival without subsequent reoperation. Results: One hundred and ten children (age 15.6 ± 2.6 years, 80% females) underwent 123 valve replacements with biologic and bioprosthetic substitutes including 87 MVR and 36 AVR (13 had both). Underlying pathology was mainly rheumatic fever (91%). Thirty-nine patients (35%) had undergone a previous cardiac surgery. Most common mitral substitute was Hancock (73%) and homograft (8%); most common aortic substitute was homograft (41%) and Carpentier–Edwards (39%). Competing-risks analysis showed that 15 years after valve replacement, 16% of patients had died without subsequent reoperation, 66% underwent valve reoperations, and only 18% remained alive without further reoperation. Factors associated with increased reoperation risk included younger age at surgery (p = 0.005), AVR (p = 0.005), male gender (p = 0.02) and homograft use (p = 0.007) especially in the mitral position (p = 0.002). Fifteen-year freedom from endocarditis was 97% while freedom from bleeding and thrombo-embolic complications was 100%. Majority of patients (95%) were in NYHA functional classes I/II at last follow-up. Conclusion: While valve reoperation is inevitable following AVR and MVR with biologic and bioprosthetic substitutes; favorable results such as low valve-related morbidity rate, good long-term survival and functional status encourage their consideration as valid replacement alternatives in selected children especially females. Valve durability is higher in the mitral position and longevity of bioprosthetic valves is greater than that of homografts especially in the mitral position.

Objective: Coarctation of the aorta has often been described as a simple form of congenital heart disease. However, rates of re-coarctation reported in the literature vary from 7% to 60%. Re-coarctation of the aorta may lead to worsening systemic hypertension, coronary artery disease and/or congestive cardiac failure. We aimed to describe the rates of re-coarctation in subjects who had undergone early coarctation repair (<2 years of age) and referred for clinically indicated or routine magnetic resonance (MR) surveillance. Methods: We retrospectively identified 50 consecutive subjects (20.2 ± 6.9 years post-repair) imaged between 2004 and 2008. Patient characteristics, rates of re-coarctation and LV/aortic dimensions were examined. Results: Forty percent of subjects had bicuspid aortic valves (BAV). There were 40 cases of end-to-end repair and 10 cases of subclavian flap repair. Re-intervention with balloon angioplasty or repeat surgery had been performed in 32% of subjects. The MRI referrals were clinically indicated in 34% and routine in 66% of patients. Re-coarctation was considered moderate or severe in 34%, mild in 34% and no re-coarctation was identified in 32% of patients. There was no significant difference in the number of cases of re-coarctation identified in the clinically indicated versus routine referrals for MR imaging (p = 0.20). There were no cases of aortic dissection or aneurysm formation identified amongst the subjects. The mean indexed left ventricular mass and ejection fraction was 72 ± 16 g/m² and 66 ± 6%, respectively. Amongst those subjects with BAV there were larger aortic sinus (30 ± 1 mm vs 27 ± 1 mm, p = 0.03) and ascending aortic (27 ± 1 mm vs 23 ± 1 mm, p = 0.01) dimensions when compared to subjects with morphologically tricuspid aortic valves. Conclusions: We demonstrate that many years after early repair of coarctation of the aorta, MR surveillance detects significant rates of re-coarctation. These findings were independent of whether or not there was a clinical indication for imaging. Those patients with BAV disease had larger ascending aortic dimensions and may require more frequent non-invasive surveillance.

Objective: With a growing number of children with congenital heart disease (CHD) reaching adulthood, an extensive experience with cardiac surgery in adults with CHD is accumulating. To increase insight in this patient category we report our 17-year single centre experience including predictors for adverse outcome and EuroSCORE performance. Methods: Patients and operative characteristics of all consecutive adult CHD patients operated upon between January 1990 and January 2007 were collected. Categorisation was done according to the EACTS/STS congenital database. Early and late morbidity and mortality were assessed with follow-up extending up to 17 years. EuroSCORE performance was assessed. Results: Nine hundred and sixty-three procedures were performed in 830 patients (mean age 39.3 years, 50.3% male). A total of 49% were re-do procedures, frequent procedures were for left heart lesions (37%), right heart lesions (31%) and septal defects (8%). The 51% primary procedures largely consisted of less complex procedures but also included 1.4% of tetralogy of Fallot repairs, 4.1% of aortic coarctation repairs and 2.7% of Ebstein's disease repairs. Thirty-day mortality was 1.5% (n = 14); predicted mortality by logistic EuroSCORE was 4.6%. c-index was 0.61 (95% CI 0.46–0.75). Major complications such as tamponade requiring intervention occurred in 3.2%, postoperative bleeding requiring re-exploration in 7.1% and renal insufficiency requiring dialysis in 4 (0.4%). Pulmonary hypertension was a strong predictor for short-term mortality; impaired ventricular function and cyanosis for long-term mortality. Overall 17-year survival was 71% (95% CI 61%–82%). Eighty percent of patients were in NYHA class I at last follow-up, 17% in II, 3% in III, 0% in IV. Conclusions: Surgery in adult CHD patients can be performed with low operative mortality and good clinical outcome. EuroSCORE is not a good model for risk assessment in this group of patients.

Background: Due to better early and long-term outcome, the increasing population of grown-ups with congenital heart disease (GUCH) brings up unexpected quality of life (QoL) issues. The cardiac lesion by itself is not always the major problem for these patients, since issues pertaining to QoL and psychosocial aspects often predominate. This study analyses the QoL of GUCH patients after cardiac surgery and the possible impact of medical and psychosocial complications. Patients and methods: A questionnaire package containing the SF-36 health survey (health related QoL), the HADS test (anxiety/depression aspects) and an additional disease specific questionnaire was sent to 345 patients (mean 26 ± 11 years) operated for isolated transposition of the great arteries (TGA), tetralogy of Fallot (TOF), and ventricular septal defect (VSD). The scores were compared with age- and gender-matched standard population data and in relation to the underlying congenital heart disease (CHD). Results: In all SF-36 and HADS health dimensions the GUCH patients showed excellent scores (116 ± 20), which are comparable to the standard population (100 ± 15), regardless of the initial CHD (p = 0.12). Eighty-two percent of the patients were found to be in NYHA class I and 83% patients declared that they do not consider their QoL to be limited by their malformation. Complications like reoperations (p = 0.21) and arrhythmias (p = 0.10) do not show significant impact on the QoL. The additional questionnaire revealed that 76% of adult patients have a fulltime job, 18% receive a full or partial disability pension, 21% reported problems with insurances, most of them regarding health insurances (67%), and 4.4% of adult patients declared to have renounced the idea of having children due to their cardiac malformation. Conclusion: QoL in GUCH patients following surgical repair of isolated TOF, TGA and VSD is excellent and comparable to standard population, this without significant difference between the diagnosis groups. However, these patients are exposed to a high rate of complications and special psychosocial problems, which are not assessed by standardized questionnaires, such as the SF-36 and HADS. These findings highlight the great importance for a multidisciplinary and specialized follow-up for an adequate management of these complex patients.

Objective: Transluminal resection of the aortic valve was already successfully carried out by our group. The aim of this study was the analysis of the gross anatomy and the histology of the surrounding tissue after resection. Methods: Aortic valve resection was performed in postmortem human hearts (endoluminal (EL) n = 9, transapical (TA) n = 4). After deployment of the aortic valve isolation chamber, the leaflets were resected with a Thullium:YAG laser scalpel (cw, 20 W). After resection, the hearts were analyzed to check for lesions caused by resectioning the associated tools. Therefore, gross anatomy and histological analysis were performed (H&E staining). Results: Lesions of the aortic annulus were seen in 3/9 (EL) (depth: 583 ± 186 µm) and 2/4 (TA) (120 µm and one complete perforation), lesions of the aorta (ascending-arch-descending) in 4-9-0/9 (EL) and 0-0-0/4 (TA), lesions of the mitral valve in 0/9 (EL) and 0/4 (TA), lesions of the papillary muscle in 0/9 (EL) and 2/4 (TA) (depth: 400 µm and 450 µm), lesions of the endomyocardium in 0/9 (EL) and 4/4 (TA) (depth: 258 ± 102 µm). The coronary ostia remained unaffected. Conclusions: This study shows fewer severe lesions in the aorta after transapical antegrade access compared to the transluminal retrograde approach. Especially noteworthy is that the aortic arch remains unaffected by the transapical procedure. These data demonstrate the transapical approach as less hazardous.

Objective: Neochordae implantation is a standard method for treatment of mitral valve prolapse. We describe a transcatheter technology enabling transapical endovascular chordal implantation. Methods: Six adult pigs were anesthetized. Two 10F sheaths were introduced in the femoral vessels for monitoring and intracardiac echo. After midline sternotomy, the pericardium was opened, the apex was punctured inside two 2–0 polypropylene purse strings. A 0.035 in J tipped guidewire was introduced in the left ventricle and an ultra stiff 14F sheath (guide catheter) inserted through the apex. A suction-and-suture device was introduced in the left ventricle. The mitral valve was crossed under echo guidance. Using suction, either the anterior (two cases) or posterior (four cases) leaflet was captured and a loop of 4–0 polypropylene was thrown at the edge of the leaflet. The loop, with a pledget, was exteriorized through the introducer. The introducer was removed and the purse-string tied. Under echo guidance, the neochordae suture was pulled and tied over a pledget to evoke leaflet tethering. The animals were sacrificed and gross anatomy reviewed. Results: Leaflet capture was feasible in the intended location in all cases. Following suture tethering, variable degrees of MR were obtained. At gross anatomy, the neochordae were positioned at 1–4 mm from the leaflet free edge, and were firmly attached to the leaflets. Conclusions: Transcatheter endovascular neochordae implantation is feasible. A prolapse model is needed to further demonstrate feasibility under pathologic conditions. The apical approach allows easy and direct route to transcatheter beating heart minimally invasive mitral repair.

Objective: Percutaneous valve replacement was recently introduced, and reports of early clinical experience have already been published. To date, this technique is limited to the replacement of pulmonary and aortic valves in a strictly selected group of patients. The aim of this study was to analyse a self-expanding valved stent for minimally invasive replacement of the mitral valve in animals. Methods: A newly designed nitinol stent was specially designed for this experimental acute study. It comprised of a left ventricular tubular stent with star shaped left atrial anchoring springs and carried a trileaflet bovine pericardial valve. A polytetrafluoroethylene membrane was sutured to envelop the atrial springs and the outside of the ventricular stent. The ventricular anchoring system was the same as in our previously reported results with a similar mitral valved stent. Seven pigs underwent minimally invasive off-pump mitral valved stent implantation. This was performed through a lower mini-sternotomy and a standard transapical approach under transoesophageal echocardiographic (TEE) guidance was used. Results: The valved stent is fully retrievable and precise deployment and accurate adjustment of its intra-annular position is achievable to eliminate paravalvular leakage. The deployment time ranged from 127 to 255 s and the blood loss from 70 to 220 cc. One animal died of intractable ventricular fibrillation. Mitral regurgitation in all surviving animals was minimal (trace in 5/6 and mild in 1/6 during echo examination; on the contrast ventriculogram no mitral insufficiency was observed except in one documented as mild paravalvular regurgitation). These animals remained haemodynamically stable (6/6) and without TEE or ventriculographic changes for 1 h. Conclusion: Implantation of a tricuspid bovine pericardial valved stent in the mitral position is feasible in pigs through a transcatheter approach. This was possible through a smaller delivery system than previously reported. Additional studies are required to demonstrate long-term feasibility, durability, and heart function.

Objective: Y-graft configuration with left and right ITA (RITA) allows complete arterial revascularisation. We previously compared two types of ITA revascularisation in a prospective randomised trial with a systematic 6-month angiographic follow-up study. The present study is a secondary analysis of these populations to evaluate the angiographic parameters influencing the function of the RITA used in a Y-graft configuration Methods: The functionality of the RITA was based on the TIMI grade flow: in TIMI grade 0 (occluded graft) and in TIMI grade 1 or 2 (balanced flow), the RITA was considered not functional. RITA was considered functional when a complete opacification (TIMI 3) of all anastomoses of the targeted coronary vessels was observed. Results: A total of 25.3% of RITA were not functional. In univariate analysis, the number of anastomoses, the type and size of grafted coronary segments and the severity of the native coronary stenosis influenced ITA function. In multivariate analysis, the function of the RITA was positively influenced by the number of anastomoses (OR = 0.5, 95% CI: 0.4–0.7), and a severely narrowed first circumflex (OR = 39.1, CI: 8.1–189.2) and negatively by the presence of a grafted intermediate coronary artery (OR = 0.01, CI: 0.003–0.06), and of a grafted RCA (OR = 0.08, CI: 0.02–0.35). The size of targeted vessel, history of infarction and regional myocardial function did not influence ITA function. Conclusions: In this systematic angiographic study, the function of the RITA used as a Y-graft was significantly improved when used on several branches of the circumflex artery or on a severely narrowed first circumflex. Grafting of the intermediate branch or of a RCA has a negative prognostic influence on graft function.

Objective: To assess whether coronary graft flow patterns are affected differently by native coronary competitive flow or by stenosis of the coronary anastomosis. Methods: Nine pigs (65–70 kg) underwent off-pump grafting of the left internal mammary artery to the left anterior descending artery (LAD). Transit-time flow patterns in the mammary grafts were recorded under four different conditions: (1) baseline flow (proximal LAD occluded), (2) full competitive flow, (3) partial competitive flow and (4) after creation of a stenosis in the anastomosis. Competitive flow was achieved by an adjustable occluder on the left anterior descending artery. The mean luminal stenosis of the anastomosis was 75 ± 11%, calculated by epicardial ultrasound. Mean flow, systolic and diastolic antegrade and retrograde flow during different flow conditions were calculated as ratios of baseline flow and compared. Different derived flow indexes were calculated and compared in the same manner. Friedman's test and post hoc analyses by Wilcoxon signed-ranks were performed without correction for multiple comparisons. Results: Mean graft flow was more reduced by competitive flow than by a stenotic anastomosis of 75 ± 11%. Competitive flow significantly decreased diastolic antegrade flow and both diastolic and systolic maximum peak flows, but increased retrograde flow, compared with baseline and stenosis. Furthermore, competitive flow and stenosis could be distinguished by analysis of several derived indexes. Pulsatility index (maximum – minimum flow/mean flow) and insufficiency percent (retrograde flow as fraction of total flow) was increased significantly more by competitive flow than by stenosis. Diastolic filling percent was significantly reduced at competitive flow compared with stenosis and baseline. Conclusions: The mammary graft flow was significantly reduced by native coronary competitive flow, but marginally decreased by a stenotic anastomosis of 75% mean luminal stenosis. Reduction of graft flow due to competition was particularly evident in diastole. A detailed flow pattern analysis may differentiate between competitive flow and stenosis of the anastomosis.

Objective: Radial arteries are increasingly used as grafts in coronary artery bypass surgery. The surgical preparation and intraoperative management of this conduit artery may affect its early and long-term patencies. We investigated the effects of the colloidal Biseko^® and 5% albumin solutions as well as the crystalloid physiological saline (0.9% NaCl) and Bretschneider solutions on the contractile and relaxing capacities of isolated human radial artery grafts. Method: Radial artery segments were harvested using the technique with an ultrasonic scalpel, and 2.5–3 mm rings were obtained from the proximal part of the artery. Arterial rings were stored in Biseko^® or 5% albumin solutions and in 0.9% NaCl or Bretschneider solutions for 45 min. Isometric tensions of radial arteries obtained from 26 patients were measured in isolated organ baths. Contractions were induced by 0.31 µmol L^–1 5-hydroxytryptamine and 10 µmol L^–1 noradrenaline. Endothelium-dependent relaxations were induced by 10 µmol L^–1 acetylcholine and 1 µmol L^–1 bradykinin as well as the endothelium-independent relaxations by 10 µmol L^–1 glyceryl trinitrate and 100 µmol/l papaverine. Results: Contractions of radial arteries induced by 5-hydroxytryptamine were significantly lower following storage in Biseko^® solution (12.6 ± 4.4 mN) than in 5% albumin (37.9 ± 13.0 mN, p = 0.03) or in 0.9% NaCl solution (35.9 ± 11.9 mN, p = 0.04). Noradrenaline-induced contractions of the arteries were also diminished in Biseko^® solution compared to those stored in 5% albumin (32.9 ± 6.2 mN vs 49.2 ± 6.4 mN, p = 0.01). No significant differences in relaxations were obtained between the two crystalloid and the two colloidal solutions using endothelium-dependent and independent vasorelaxants. Conclusion: Our results suggest that storage of radial artery in Biseko^® colloidal solution before coronary artery bypass grafting decreases the sensitivity of the graft to vasoconstriction, thereby decreasing the risk of intra/perioperative graft failure.

Objective: Cardiopulmonary bypass (CPB) is associated with thyroid hormone changes consistent with euthyroid sick syndrome. Similar changes have been observed after general surgical operations. Thyroid hormone changes and their association with global oxygen consumption were studied in low-risk patients undergoing coronary artery bypass grafting (CABG) with and without CPB. Methods: Fifty-two patients undergoing primary CABG by the same surgeon were randomised into either on-pump (ONCAB, n = 26) or off-pump (OPCAB, n = 26) groups. Thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) levels were measured at sequential time-points using chemiluminescence assays. Global oxygen consumption was measured at sequential time-points using a continuous cardiac output Swan-Ganz catheter. Results: In both groups TSH and fT4 remained within normal range throughout the study. There was a similar and progressive decline in fT3 levels with no significant difference between the groups over time (p = 0.42). Mean fT3 levels at 24 h were below the normal range and significantly lower than baseline values (ONCAB, 3.3 ± 0.69 pmol/L vs 5.1 ± 0.41 pmol/L, p < 0.001; OPCAB, 3.3 ± 0.51 pmol/L vs 5.0 ± 0.46 pmol/L, p < 0.001). There was a significant inverse relationship between fT3 levels and global oxygen consumption. Conclusions: Off-pump surgery is associated with thyroid hormone changes similar to conventional surgical revascularisation. The data suggest that further studies into T3 administration during OPCAB may be warranted.

Objective: To better define early and long-term outcomes of patients undergoing thoracic metastasectomy for thyroid cancer. Methods: We identified, reviewed, and analyzed the medical records of all patients who underwent thoracic metastasectomy for thyroid cancer in our institution from 1971 to 2006. Results: There were 48 patients (25 men, 23 women). A complete resection (R0) of all known disease was performed in 33 (69%) patients, while 15 (31%) underwent incomplete resection (R1 or R2). By histology, the majority were papillary 31 (65%), follicular 8 (17%), medullary 5 (10%), and Hürthle cell 4 (8%). Ninety percent were confined to a single side of the chest, with 10% presenting with bilateral metastases. Thoracotomy was performed in 28 (58%), sternotomy in 12 (25%), and thoracoscopy was used in 8 (17%). Operative mortality was zero and postoperative complications occurred in 8 patients (17%). There are currently 18 surviving patients from the cohort (37%) with a median follow-up of 10 years (range, 1 month to 17 years). The overall 5-year survival after thoracic metastasectomy was 60%. Based on histology, 5-year survival for papillary cancer was 64% compared to 37% for follicular and Hürthle cell neoplasms (p = 0.03). All five medullary thyroid cancer patients were alive at 5 years. Five-year survival was also improved for patients less than 45 years old at the time of diagnosis of their initial thyroid malignancy (94% vs 49%; p = 0.03). Disease-free interval of >3 years between initial thyroid malignancy diagnosis and thoracic metastasectomy demonstrated improved 5-year survival (67% vs 52%; p = 0.01). Conclusion: Pulmonary resection for thyroid metastasis is safe with low morbidity and mortality. Retrospective analysis demonstrates improved long-term survival in patients with papillary histology, longer disease-free interval (>3 years) and younger age at diagnosis of initial thyroid malignancy. Excellent long-term survival was also achievable in selected patients with medullary thyroid metastasis.

Objective: Prognosis of primary thymic carcinomas is poor due to advanced stage progression at diagnosis and highly malignant behavior. We retrospectively evaluated patients with thymic carcinoma to determine the prognostic factors. Methods: Sixty patients diagnosed and treated for thymic carcinoma from 1986 to 2005 were reviewed retrospectively. Influences of demographic characteristics, Masaoka stage, histologic grade, completeness of resection and adjuvant treatment on survival were evaluated. We defined complete resection as macroscopically and microscopically total resection of a tumor (R0 resection) and incomplete resection was subdivided into microscopic incomplete resection (R1 resection) or macroscopically incomplete resection (R2 resection). Results: There were 42 male and 18 female patients and mean age was 53.9 (±14.4) years old. The 5-year overall survival rate was 38.8% and median survival time was 35.6 months. The most common histologic type was squamous cell carcinoma (n = 29). In our study, 5 patients (8.3%) were in Masaoka stage I, 5 (8.3%) were in stage II, 19 (31.7%) were in stage III, 15 (25.0%) were stage in IVa, and 16 (26.7%) were in stage IVb. Among 40 patients who underwent surgical resection, complete resection was achieved in 14 patients. The 5-year survival rate after complete resection was 85.1% and was considered significantly better than those after incomplete resection (29.0%, p = 0.001) and non-surgical treatment (16.7%, p < 0.001). But, no survival difference could be found between the incomplete resection group and non-surgical treatment group (p = 0.15). The 5-year survival rates of early Masaoka stage patients were significantly higher than advanced Masaoka stage (90.0% vs 28.3%, p = 0.001). The recurrence rates within 3 years after R1 resection (75.0%) were significantly higher than that after R0 resection (14.9%, p = 0.008). Conclusions: In thymic carcinoma, complete resection of early Masaoka stage lesions is the most important factor for disease control and long-term survival of patients.

Background: Thoracoscopic thymectomy has shown promise in the integrated management of myasthenia gravis (MG) although there is still scant data on long-term results. The aim of this study was to analyze long-term (>5 years) results of thoracoscopic extended thymectomy in nonthymomatous MG. Methods: We retrospectively reviewed 32 patients operated on between 1995 and 2003. MG foundation of America clinical classification (MGFA), symptoms’ duration, preoperative crisis, anticholinesterase-drugs dosage, steroid use, and acetylcholine receptor antibodies were evaluated in all patients with annual follow-up. Anti-MuSK antibody titer was also assessed at the last follow-up. Results: There were 21 females and 11 males with a median age of 36 years. Ten patients were seronegative for acetylcholine receptor antibodies. Patients in MGFA class I, II, III and IV were 7 (22%), 15 (44%), 9 (28%), 2 (6%) patients, respectively. Median symptoms duration was 11 months. There was no mortality or major morbidity. Median hospital stay was 4.0 days. Ectopic thymic tissue was found in 18 (56%) patients. Median follow-up was 119 months (range 60–156 months). There was no residual thoracic pain. Estimated 10-year remission rate was 50%. At 72 months, 27 (84.3%) patients were improved or in complete remission. At the univariate analysis, shorter duration of symptoms (<12 months) and absence of oropharyngeal involvement were both predictors of response to thymectomy (p < 0.02) whereas positivity for anti-MuSK antibody was a predictor of non-response (p = 0.0007). Conclusions: Thoracoscopic extended thymectomy yields satisfactory long-term results in patients with nonthymomatous myasthenia gravis although anti-MuSK positivity correlated with poor response to operation.

Chronic pain complaints after thoracic surgery represent a significant clinical problem in 25–60% of patients. Results from thoracic and other surgical procedures suggest multiple pathogenic mechanisms that include pre-, intra-, and postoperative factors. This review attempts to analyse the methodology and systematics of the studies on the post-thoracotomy pain syndrome (PTPS) after lung cancer surgery in adults, in order to clarify the relative role of possible pathogenic factors and to define future strategies for prevention. Literature published from 2000 to 2008 together with studies included in previous systematic reviews was searched recursively using PubMed and OVID by combining three categories of search terms. The available data have major inconsistencies in collection of pre-, intra- and postoperative data that may influence PTPS, thereby hindering precise conclusions as well as preventive and treatment strategies. However, intercostal nerve injury seems to be the most important pathogenic factor. Since there is a general agreement on the clinical relevance of PTPS, a proposal for design of future trials is presented.

The European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) established a joint task force with the purpose to develop clinical evidence-based guidelines on evaluation of fitness for radical therapy in patients with lung cancer. The following topics were discussed, and are summarized in the final report along with graded recommendations: Cardiologic evaluation before lung resection; lung function tests and exercise tests (limitations of ppoFEV1; DLCO: systematic or selective?; split function studies; exercise tests: systematic; low-tech exercise tests; cardiopulmonary (high tech) exercise tests); future trends in preoperative work-up; physiotherapy/rehabilitation and smoking cessation; scoring systems; advanced care management (ICU/HDU); quality of life in patients submitted to radical treatment; combined cancer surgery and lung volume reduction surgery; compromised parenchymal sparing resections and minimally invasive techniques: the balance between oncological radicality and functional reserve; neoadjuvant chemotherapy and complications; definitive chemo and radiotherapy: functional selection criteria and definition of risk; should surgical criteria be re-calibrated for radiotherapy?; the patient at prohibitive surgical risk: alternatives to surgery; who should treat thoracic patients and where these patients should be treated?

To increase the angiogenic response and clinical efficacy of TMR, the potential synergy and safety of combining TMR with concentrated autologous bone marrow derived stem cells was evaluated. Fourteen patients with diffuse coronary artery disease and medically refractory class III/IV angina who were not candidates for conventional therapies were treated using TMR in combination with intramyocardial injection of concentrated stem cells. At the time of surgery, autologous bone marrow (120 cc) was aspirated from the iliac crest and processed over 15 min into 20 cc of concentrated mononuclear cells using a centrifugal system (HARVEST, Boston, MA). A single device performed holmium: YAG:TMR (CardioGenesis, Irvine, CA) with injection of 1 cc of concentrated stem cells through three multi-holed needles into the border zone around each laser channel. There were no perioperative adverse events including no arrhythmias. Mean number of injected cells per milliliter were: total mononuclear cells (81.3 x 10⁶), CD34⁺ cells (0.6 x 10⁶), and CD133⁺ cells (0.37 x 10⁶). At 7 months mean follow-up average angina class was significantly improved (3.5 ± 0.5 vs 1.4 ± 0.5; p = 0.004). There was no death during the follow-up. Efficient delivery of stem cells combined with TMR in a single device seems to be safe and effective for treating unmanageable angina.

We present our initial experience in 10 patients operated on using a modified Ross operation. In our modification of the Ross operation the pulmonary autograft root was inserted in the Gelweave Valsalva graft to prevent dilatation of the neoaortic root. This type of graft was selected to match the discrepancy between diameters of the annulus and the sinotubular junction of the autograft and to preserve the characteristic configuration of the native root. In our group of 10 patients operated consecutively by this technique there was no change in the geometry of the neoaortic root in the follow-up 3–19 months (mean 14.6 months).

Although a septal-superior approach provides excellent exposure of the mitral valve, it requires novel strategies for concomitant ablation in patients with atrial fibrillation. Utilizing a combination of bipolar radiofrequency and cryothermy, we developed a novel technique for creating a biatrial lesion set via a septal-superior approach during mitral valve surgery. We treated 10 patients with functional mitral regurgitation and permanent atrial fibrillation with rhythm disturbance for a mean 87 months. A modified maze was successfully accomplished via a septal-superior approach in all. The mean follow-up period was 18 months, during which permanent pacemaker implantation was necessary for one due to sinus bradycardia. Sustained sinus rhythm, including atrial or atrial-based paced rhythm, was present in all immediately after surgery, in 70% at discharge, in 80% at 1 year after surgery, and in 90% at the latest follow-up examination. Our novel technique using a modified maze procedure in combination with mitral valve surgery via a septal-superior approach was safe and useful for eliminating atrial fibrillation, with a relatively low frequency of sinus node dysfunction.

A technique for extracardiac conduit fenestration specifically devised to achieve long-term patency is presented. From 2001 to 2007, 65 patients underwent a fenestrated extracardiac Fontan procedure using this technique where the atrial orifice of the divided inferior vena cava was sutured in an end to side fashion to the leftward aspect of the conduit. The circumferential suture line was centred by the fenestration but remained away from the edge of the latter. All patients receive oral anticoagulation. Clinical and echocardiographic follow-up were obtained. Concurrent follow-up was 100%. There was one early death (mortality 1.5%). Two patients had Fontan failure requiring takedown and another two were transplanted. The fenestration was found to be patent in the rest of patients of the series (n = 60) at a median follow-up of 11 months (range 1–91). The mean velocity across the fenestration was 1.6 ± 0.55 m/s. No patient required reintervention related to the fenestration. All patients remained in sinus rhythm. This technique is easily reproducible, consistently provides long-term patency and low incidence of complications. The use of inferior vena cava orifice of the right atrium explains the absence of supra ventricular arrhythmias.

We present a case of left anterior descending (LAD) coronary artery aneurysm at the site of previous stent placement 3 years previously. The patient presented with recent worsening of angina. Angiography and 64 slice CT angiography confirmed the presence of 6 mm aneurysm of LAD at the site of previous stent involving the origin of diagonal, with thrombus proximal and distal to the stent. This patient was successfully managed by taking the posterior wall of the anterior descending artery while suturing the heel of the left internal mammary artery (LIMA)-LAD anastomosis. The idea was to create severe stenosis upstream to prevent distal embolisation from the site of aneurysm. The diagonal was grafted with a saphenous venous graft. Follow-up angiogram at 3 months demonstrated successful exclusion of the aneurysm and unobstructed flow through the grafts.

Total arterial revascularization in patients with three-vessel disease cannot usually be achieved by bilateral internal thoracic artery grafts alone due to limited length. In this report we describe a technique by which the right internal thoracic artery can be elongated with radial artery for sequential grafting in redo total arterial revascularization procedure.

Diffuse coronary vasospasm is an unpredictable and serious complication following coronary artery bypass surgery. The treatment of this emergency is dependent on patient suitability for angiography and direct injection of vasodilators into the affected vessels. In patients unable to proceed to angiography the diagnosis can only be suspected but treatment is nevertheless still towards reinstitution of coronary blood flow. We present one such case in which re-grafting and extracorporeal membranous oxygenation proved successful in restoring cardiac function in a patient with diffuse coronary artery spasm.

Interventional treatment of hypertrophic obstructive cardiomyopathy has considerably developed and primary surgical approach is nowadays considered for a minority of patients with insufficient relief of obstruction following catheter intervention. We present the history of a patient who underwent alcohol ablation and developed a life-threatening ventricular septal defect consecutively to a large myocardial infarction because of alcohol injection into the LAD.

We report an extremely rare case of pulmonary artery dissection caused by an abrupt rupture of an aortic arch aneurysm into the pulmonary artery. An asymptomatic 80-year-old man was admitted to our hospital for elective surgical repair of aortic arch aneurysm. After admission, sudden onset of hoarseness and dyspnea developed. Echocardiography demonstrated an intimal flap in the pulmonary artery and abnormal shunt flow from aortic arch aneurysm into the pulmonary artery. At surgery, the pulmonary artery dissection involved the main pulmonary artery and both major branches. Total arch replacement and pulmonary artery reconstruction were successfully performed.

Iatrogenic injury is an underreported but potentially devastating complication of orthopedic wire migration. We report a 48-year-old man with a tracheoinnominate artery fistula caused by migration of a Kirschner wire that was inserted for fixation of a left clavicle fracture nine years before. Following surgical removal of the wire and repair of both trachea and innominate artery, the patient recovered eventually. Although migration of orthopedic wire to the trachea has been reported twice in previous literature, such a complication involving both the trachea and arch vessel was not previously described. Physicians who care for patients with orthopedic wires in place should be aware of migration with tracheoinnominate artery fistula and other iatrogenic injuries as potentially lethal complications.

Primary ectopic meningiomas are extremely rare tumors of controversial origin and they are usually limited to the head and neck region. Its occurrence at the mediastinum is even rarer. There has not been any official report regarding primary mediastinal malignant meningioma until today. Because of its rarity and potential value, we report here a case of primary mediastinal malignant meningioma, which turns out to be the first reported case of this type of meningioma. The clinical features, treatment plans, pathological findings, as well as prognosis of a case of primary mediastinal malignant meningioma were carefully analyzed and the literature on ectopic meningioma was reviewed. The diagnosis of ectopic meningioma can only be established based on microscopic and immunohistochemical findings. Surgery is the treatment of choice for ectopic meningioma and postoperative radiotherapy should be managed for patients with suspected invasive meningioma.

Congenital tracheal stenosis is a rare airway disorder characterized by a fixed tracheal narrowing. Surgical intervention is usually considered as the treatment of choice for long-segment type. However, due to wide spectrum of this disease, treatment modalities need to be individualized. The long-segment type has the most unfavorable outcome because it is often associated with multiple anomalies and, thus, the most difficult to manage. Here we present a case of long-segment congenital tracheal stenosis (LSCTS) that was managed by several sessions of flexible bronchoscopic balloon tracheoplasty as the primary treatment. In this particular situation, we had to deal with the parents’ request of a ‘non-surgical’ approach for an infant who had respiratory distress that also required a way to increase his tracheal diameter simultaneously. Having done this particular experience, we would like to show that this non-surgical approach can be viable for long-segment tracheal stenosis in selected cases.

Congenital bronchial atresia is a congenital obliteration of a segmental or lobar bronchus resulting in an inflation of the correspondent parenchyma. It may lead to infectious complications and in the long-term to alteration of the adjacent lung parenchyma. As it usually occurs in young and healthy patients with normal lungs, this disorder is particularly suitable for a full endoscopic pulmonary resection. We report our recent experience of two lobectomies and one segmentectomy in three patients.

Endovascular treatment of the thoracic aorta (TEVAR) is rapidly expanding, with new devices and techniques, combined with classical surgical approaches in hybrid procedures. The present guidelines provide a standard format for reporting results of treatment in the thoracic aorta, and to facilitate analysis of clinical results in various therapeutic approaches. These guidelines specify the essential information and definitions, which should be provided in each article about TEVAR:

It is hoped that strict adherence to these criteria will make the future publications about TEVAR more comparable, and will enable the readership to draw their own, scientifically validated conclusions about the reports.

Genes affect virtually all human characteristics and diseases. These influences can be ascertained in individual patients through a review of the family history, physical examination and the use of medical diagnostics. Aneurysms and dissections are a leading cause of morbidity and mortality, in addition to medical expense, and, on the whole, their specific molecular mechanisms are beginning to be identified. Over the past decade, genetic tests have become available for numerous heritable disorders especially inherited with mendelian models. An important fact is that the results of genetic tests may also be useful beyond the individual affected by the genetic disorder. Depending upon the disorder, knowledge of carrier status may be important. Because of these facts, some essential information regarding basic genetics of aneurysm and dissection has been presented in this study.

Objective: Elective ascending aortic replacement is recommended to prevent acute type A aortic dissection when any segment of the proximal aorta is greater than 5.5 cm. However, little data exist that meticulously describe the size of the ascending aorta at multiple levels in patients who suffer acute type A dissections. We sought to definitively characterize the size distribution of the proximal aorta in this patient population. Methods: Preoperative transesophageal echocardiography was used to measure the diameter of the proximal aorta at the aortic annulus, in the sinus segment, at the sinotubular junction and in the ascending aorta in 177 non-Marfan patients with tricuspid aortic valves who presented to one institution over a 10-year period with an acute type A dissection. Predicted aortic diameters for each patient based on the individual's age, gender and body size were also calculated at all four aortic positions using previously published regression equations derived from a large cohort of normal patients. Results: Sixty patients were female (33.9%; aged 67 ± 12 years) and 117 were male (66.1%; aged 60 ± 17 years). Sixty-two percent of all patients had maximum aortic diameters less than 5.5 cm at time of dissection and 42% of patients had maximum aortic diameters less than 5.0 cm. Over 20% of all patients had maximal aortic dimensions of less than 4.5 cm. In women, 12% of the dissected aortas had a maximal dimension less than 4.0 cm. Conclusions: The majority of patients with acute type A aortic dissection present with aortic diameters <5.5 cm and thus do not fall within current guidelines for elective ascending aortic replacement. Methods other than size measurement of the ascending aorta are needed to identify patients at risk for dissection. Aggressive medical management of patients with ascending aortic diameters over 4 cm is warranted. Preventative replacement of the ascending aorta at 4.5 cm should be considered especially at high volume aortic surgery centers and patients having cardiac surgery for other indications.

Objective: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is the first treatment of choice with good short-term results. Only limited data are available concerning the long-term outcome after PEA. The purpose of this study is to evaluate the long-term survival and functional outcome after PEA with nearly 10 years experience. Method: In the period of December 1998 and December 2007 120 patients with CTEPH were referred to the St Antonius Hospital (Nieuwegein, The Netherlands) of whom 72 underwent PEA. The clinical data are collected retrospectively. Results: In-hospital mortality was (5/72) 6.9%. Since 2004 one patient died in the hospital (1/38, 2.9%). Two patients died during long-term follow-up with a median observation of 3 years. The overall 1-, 3- and 5-year survival rates were 93.1%, 91.2% and 88.7% respectively. Prior to surgery patients were in New York Heart Association functional class III (58) and IV (14) with a mean pulmonary vascular resistance of 572 ± 313 dynes s cm^–5. The following data were compared before and after operation: mean pulmonary artery pressure (mPAP) decreased from 42 ± 11 to 22 ± 7 mmHg (p = 0.0001), NT-pro BNP improved from 1527 ± 1652 to 160 ± 3 pg/ml (p = 0.0001), 6 min walk distance (6MWD) from 359 ± 124 to 518 ± 11 m (p = 0.0001), and almost all patients returned to functional class I or II (p = 0.0001). Conclusion: Pulmonary endarterectomy for patients with CTEPH has shown a dramatic improvement of clinical status with excellent long-term survival.

Objective: Symptomatic severe aortic stenosis is an indication for aortic valve replacement. Some patients are denied intervention. This study provides insight into the proportion of conservatively treated patients and into the reasons why conservative treatment is chosen. Methods: Of a patient cohort presenting with severe aortic stenosis between 2004 and 2007, medical records were retrospectively analyzed. Only symptomatic patients (n = 179) were included. We studied their characteristics, treatment decisions, and survival. Results: Mean age was 71 years, 50% were male. During follow-up (mean 17 months, 99% complete) 76 (42%) patients were scheduled for surgical treatment (63 conventional valve replacement, 10 transcatheter, 1 heart transplantation, 2 waiting list) versus 101 (56%) who received medical treatment. Reasons for medical treatment were: perceived high operative risk (34%), symptoms regarded mild (19%), stenosis perceived non-severe (14%), and patient preference (9%). In 5% the decision was pending at the time of the analysis and in 20% the reason was other/unclear. Mean age of the surgical group was 68 years versus 73 years for medically treated patients (p = 0.004). Predicted mortality (EuroSCORE) was 7.8% versus 11.3% (p = 0.006). During follow-up 12 patients died in the surgical group (no 30-day operative mortality), versus 28 in the medical group. Two-year survival was 90% versus 69%. Conclusions: A large proportion (56%) of symptomatic patients does not undergo aortic valve replacement. Often operative risk is estimated (too) high or hemodynamic severity and symptomatic status are misclassified. Interdisciplinary team discussions between cardiologists and surgeons should be encouraged to optimize patient selection for surgery.

Echocardiographic assessment prior to valve surgery is crucial for clinical decision making, timing of surgery, planning the adequate surgical therapy and predicting the patient's outcome. Description of transvalvular velocities is not enough for sending a patient to the operating room. There are specific functional and morphological characteristics of each valve dysfunction that have to be addressed by the echocardiographer prior to surgery. Evaluation of the aortic valve, annulus, root, ascending aorta, left ventricular outflow tract and left ventricular function are important. In knowing these characteristics the surgeon may choose the appropriate valve and operation techniques and assess the need for additional surgical procedures. A detailed evaluation of valve morphology and function in context with cardiac hemodynamics should be achieved during echocardiography. This step-by-step evaluation allows the correct diagnosis and classification of patient's outcome. In conclusion, an echohemodynamic approach enables the cardiac surgeon to plan and perform the adequate surgical procedure.

Objective: Based upon recent developments in transcatheter technology, this study was designed to evaluate the feasibility and haemodynamic performance of transcatheter valve-in-a-ring (VinR) implantation for potentially failed mitral repair using a minimally invasive, transatrial, off-pump approach. Methods: Adult sheep (54.3 ± 3.0 kg) underwent mitral valve repair with a 26 mm complete annuloplasty ring (Physio^TM) using standard conventional techniques. To simulate the redo operation, a transcatheter 23 mm pericardial prosthesis (Edwards Sapien^TM) mounted on a balloon-inflatable steel stent was deployed within the annuloplasty ring. VinR implantation was performed off-pump under rapid pacing in four and on-pump in three animals using an antegrade transatrial approach under fluoroscopic guidance. Results: Transcatheter VinR implantation was successful in all seven sheep. Mean transvalvular gradient was 4.9 ± 0.3 mmHg. VinR function was excellent with no leak in one, good with mild leak in five (trans-stent: four, paravalvular: one) and sufficient with moderate central leak in one animal, respectively. Valve deployment required 10.0 ± 0.7 min and all transcatheter prostheses were confirmed in good position on postmortem analysis, without any signs of valve dislocation or embolisation. In an in-vitro model, the minimum force required to dislodge the valve was 32.9 ± 5.2 N, which was well above the normal estimated forces generated by the left ventricle. One animal was kept alive to assess mid-term outcome and is still well 12 months after the VinR implantation. Conclusions: Transatrial, transcatheter mitral VinR implantation is feasible using a minimally invasive off-pump approach. VinR implantation is a promising concept for re-operative surgery for selected patients after failed mitral valve repair.

Objective: Balloon-expandable stent valves require flow reduction during implantation (rapid pacing). The present study was designed to compare a self-expanding stent valve with annular fixation versus a balloon-expandable stent valve. Methods: Implantation of a new self-expanding stent valve with annular fixation (Symetis^®, Lausanne, Switzerland) was assessed versus balloon-expandable stent valve, in a modified Dynatek Dalta^® pulse duplicator (sealed port access to the ventricle for transapical route simulation), interfaced with a computer for digital readout, carrying a 25 mm porcine aortic valve. The cardiovascular simulator was programmed to mimic an elderly woman with aortic stenosis: 120/85 mmHg aortic pressure, 60 strokes/min (66.5 ml), 35% systole (2.8 l/min). Results: A total of 450 cardiac cycles was analysed. Stepwise expansion of the self-expanding stent valve with annular fixation (balloon-expandable stent valve) resulted in systolic ventricular increase from 120 to 121 mmHg (126 to 830 ± 76 mmHg)*, and left ventricular outflow obstruction with mean transvalvular gradient of 11 ± 1.5 mmHg (366 ± 202 mmHg)*, systolic aortic pressure dropped distal to the valve from 121 to 64.5 ± 2 mmHg (123 to 55 ± 30 mmHg) N.S., and output collapsed to 1.9 ± 0.06 l/min (0.71 ± 0.37 l/min* (before complete obstruction)). No valve migration occurred in either group. (* = p < 0.05). Conclusions: Implantation of this new self-expanding stent valve with annular fixation has little impact on haemodynamics and has the potential for working heart implantation in vivo. Flow reduction (rapid pacing) is not necessary.

Coronary heart disease (CHD) is the leading cause of death worldwide. Coronary artery bypass graft (CABG) surgery remains the procedure of choice for coronary artery revascularisation in a large number of patients with severe CHD. However, the profile of patients undergoing CABG surgery is changing with increasingly higher-risk patients being operated upon, resulting in significant morbidity and mortality in this patient group. Myocardial injury sustained during cardiac surgery, most of which can be attributed to acute myocardial ischaemia–reperfusion injury, is associated with worse short-term and long-term clinical outcomes. Clearly, new treatment strategies are required to protect the heart during cardiac surgery in terms of reducing myocardial injury and preserving left ventricular systolic function, such that clinical outcomes can be improved. ‘Conditioning’ the heart to harness its endogenous cardioprotective capabilities using either brief ischaemia or pharmacological agents, provides a potentially novel approach to myocardial protection during cardiac surgery, and is the subject of this review article.

Background: Hypothermic cardiopulmonary bypass is associated with low perfusion state causing a mismatch between demand and supply to various organs such as gut, kidneys and brain. The consequences are thought to be responsible for postoperative complications like systemic inflammatory response, renal failure, neurological injury, etc. Pharmacological agents like dopamine, dopexamine and dobutamine have been used in an attempt to reduce hypoperfusion and hence complications. Fenoldopam, a dopamine analog (DA-1 receptor agonist), has recently been shown to be specific reno-splanchnic vasodilator in animal studies. We studied the haemodynamic effects of fenoldopam and its effect on hepatic blood flow (HBF) during and after cardiopulmonary bypass and compared these with dopexamine. Methods: Ethics committee approval was obtained. Forty-two consecutive patients with good/moderate left ventricular function undergoing either elective/urgent coronary artery bypass grafting were included in the study. Patients were randomised to receive either fenoldopam (0.2 µg/kg min) (F; n = 14) or dopexamine (2.0 µg/kg min) (Dx; n = 14) normal saline (NS; n = 14) continuously after induction of anaesthesia for 24 h following completion of surgery. HBF was measured using the Indocyanine green dye disappearance rate method, before, during and after cardiopulmonary bypass. Data were collected pre-, intra- and postoperatively. Serum liver enzymes were measured during the perioperative period. Repeated measures ANOVA test was used to compare timed samples in both groups. Results: The study groups were comparable in pre- and intraoperative variables. In the fenoldopam and dopexamine groups there was a significant increase in heart rate 15 min following the commencement of the infusion (NS:F:DX::–2.0 ± 7.8 beats/min:13.6 ± 8.1 beats/min (p = 0.007):18.36 ± 20.2 beats/min (p = 0.004)). However the change in mean arterial blood pressure was similar (NS:F:DX::–12.7 ± 14.9:–4.0 ± 23.1 (p = 0.699):–2.6 ± 22.3) (p = 0.235). Cardiac index increased and systemic vascular resistance decreased (requiring noradrenaline infusion) in the fenoldopam group, however this did not reach statistical significance. Hepatic blood flow reduced during CPB and returned to near preoperative levels in all three groups with no statistical difference between groups. Conclusions: Fenoldopam infusion induced transient tachycardia, with no augmentation of hepatic blood flow whereas dopexamine induced tachycardia and did not augment hepatic blood flow. Fenoldopam and dopexamine may have hepato-protective effect.

Objective: Based on the adverse relationship between left ventricular (LV) remodeling and clinical outcome in ischemic cardiomyopathy, surgical ventricular restoration (SVR) is proposed as a valuable adjunct procedure. This study reports on the short-term clinical and hemodynamical performance of SVR. Methods: Using end-systolic LV volume as indication for SVR, 78 patients with ischemic cardiomyopathy are divided in two groups: group 1 comprised 55 patients treated by coronary revascularization and mitral annuloplasty, group 2 comprised 23 patients undergoing additional SVR. Hemodynamic investigation included echocardiographic assessment of systolic and diastolic function. Clinical follow-up focused on survival and functional status with exercise performance. Results: Both surgical approaches resulted in improvement of NYHA class (2.9–1.6 in group 1; 3.3–1.5 in group 2, p < 0.001), achieving similar exercise performance (peak VO₂ 13.7 vs 15.4 ml/kg min in groups 1 and 2, p = 0.25) and plasma BNP values (group 1: 1350 pg/ml and group 2: 767 pg/ml, p = 0.23). SVR provided additional benefit as patients basically had a worse NYHA class (2.9 in group 1 vs 3.3 in group 2, p = 0.03). Within mean follow-up of 20 months, survival rate was 84% in group 1 and 74% in group 2 (p = 0.11), including operative mortality of 7% and 13% (p = 0.42). Through effective volume reduction (LVEDVI 41%; LVESVI 49%) systolic function improved immediately after SVR (LVEF 27–39% in group 2, p < 0.05). Worsening of diastolic function was specifically observed after SVR within the first year (E/A-ratio 1.38–1.74 cm/s, p = 0.02). Recurrent mitral regurgitation (p = 0.004) and secondary remodeling (p = 0.01) were major determinants of decreasing LV compliance. Clinical outcome in terms of cardiac events and survival was compromised by restrictive diastolic function (p = 0.02) and increased LV volumes (p = 0.04). Conclusion: SVR in addition to coronary revascularization and restrictive mitral annuloplasty results in significant clinical improvement in selected patients with advanced ischemic heart disease and severely dilated ventricles. SVR entails immediate improvement of systolic function, which remains sustained during short-term follow-up. Serial assessment of diastolic function is mandatory as LV compliance seems more sensitive to early changes induced by recurrence of mitral regurgitation and secondary ventricular dilation. Moreover, worsening of diastolic dysfunction should be timely recognized because of its adverse clinical impact.

Objective: Application of extra-corporeal life support (ECLS) following pediatric cardiac surgery varies between different institutions based on manpower availability and philosophy towards ECLS utilization. We examined a large single institution experience with postoperative ECLS in children aiming to identify outcome predictors. Methods: Hospital records of all children who required postoperative ECLS at our institution were reviewed. Patients’ demographics, cardiac anatomy, surgical and ECLS support details were entered into a multivariable regression analysis to determine factors associated with survival. Results: Between 1990 and 2007, 180 consecutive children, median age 109 days (range: 1 day–16.9 years), required postoperative ECLS. Sixty-nine children (38%) had undergone palliative treatment for single ventricle pathology. ECLS support was required for failure to separate from cardiopulmonary bypass (n = 83) or for postoperative low cardiac output state (n = 97). Forty-eight patients (27%) received rescue extra-corporeal membrane oxygenation (ECMO) support during active chest compression for refractory cardiac arrest. Under ECLS support, 37 patients required surgical revision and 20 received orthotopic heart transplantation. One hundred and nine patients (61%) survived >24 h following ECLS discontinuation and 68 (38%) were discharged alive. Hospital survivors required shorter ECLS support duration compared to non-survivors (median 3 vs 5 days, respectively, p = 0.05) however survival occurred after up to 16 days of ECLS support. ECLS indication (OR: 0.85 for failure to separate from bypass vs postoperative low cardiac output 95% CI (0.47–1.56), p = 0.62) and rescue ECMO (OR: 0.63 for rescue ECMO vs not 95%CI (0.32–1.24), p = 0.18) were not associated with risk of mortality. In a multivariable logistic regression model, neurological complications (p = 0.0007), prolonged ECLS duration (p = 0.003), repeat ECLS requirement (p = 0.02), renal dysfunction (p = 0.04) and not performing heart transplantation (p = 0.04) were significant factors for hospital death. Conclusion: ECLS plays a valuable role in children with low cardiac output state following cardiac surgery. More than one third of those patients, including young neonates, older children, patients with single ventricle, or those requiring rescue ECMO can be salvaged. Although prognosis worsens with prolonged ECLS duration, survival can be noted up to 16 days of support. Heart transplantation is often an important ECLS exit strategy and should be considered early in selected children. Patients’ survival could improve if renal and neurological complications are avoided.

Objective: Intra-aortic balloon pump (IABP)-induced pulsatile perfusion has demonstrated that it can preserve organ function during cardiopulmonary bypass (CPB). We evaluated the role of IABP pulsatile perfusion on endothelial response. Methods: Forty consecutive isolated CABG undergoing preoperative IABP were randomized to receive IABP pulsatile CPB during aortic cross-clamping (group A, 20 patients) or standard linear CPB (group B, 20 patients) during cross-clamp time. Hemodynamic results were analyzed by Swan-Ganz catheter [mean arterial pressure (MAP), cardiac index (CI), indexed systemic vascular resistances (ISVR), indexed pulmonary vascular resistances (IPVR), wedge pressure (PCWP)]. Inflammatory/endothelial response was analyzed by pro-inflammatory (IL-2, IL-6, IL-8), anti-inflammatory cytokines (IL-10), and endothelial markers [vascular endothelial growth factor (VEGF) and monocyte chemotactic protein-1 (MCP-1)]. All measurements were recorded preoperatively (T0), before aortic declamping (T1), at the end of surgery (T2), 12 h (T3) and 24 h (T4) postoperatively. ANOVA for repeated measures was used to evaluate the differences of means. Results: Hemodynamic response was comparable except for higher MAP (p = 0.01 at T1) and lower ISVR (p = 0.001 at T1, p = 0.003 at T2) in group A. No differences were found in perioperative leakage of IL-2, IL-6, and IL-8 between the two groups (within-group p = 0.0001 either in group A and group B; between-groups p = NS at 2-ANOVA). Group A showed significantly lower VEGF (between-groups p = 0.001 at 2-ANOVA, p = 0.001 at T1, T2) and MCP-1 (between-groups p = 0.001 at 2-ANOVA, p = 0.001 at T1, T2) with higher IL-10 secretion (between-groups p = 0.001 at 2-ANOVA, p = 0.01 at T1, T2, T3). Conclusions: IABP-induced pulsatile perfusion allows lower endothelial activation during CPB and higher anti-inflammatory cytokines secretion.

Objective: The DuraHeart (Terumo Heart, Inc., Ann Arbor, Michigan, USA) is the world's first approved magnetically levitated centrifugal left ventricular assist system designed for long-term circulatory support. We report the clinical outcomes of 68 patients implanted with the DuraHeart as a bridge to cardiac transplantation in Europe. Methods: Sixty-eight patients with advanced heart failure (six females), who were eligible for cardiac transplantation were implanted with the DuraHeart between January 2004 and July 2008. Median age was 58 (range: 29–74) years with 31% over 65 years. Thirty-three of these patients received the device as a part of the European multi-center clinical trial. Survival analyses were conducted for 68 patients and other safety and performance data were analyzed based on 33 trial patients. Results: Mean support duration was 242 ± 243 days (range: 19–1148, median: 161) with a cumulative duration of 45 years. Thirty-five patients (51%) remain ongoing, 18 transplanted, 1 explanted, and 14 died during support with a median time to death of 62 days. The Kaplan–Meier survival rate during support was 81% at 6 months and 77% at 1 year. Of the 13 patients (21%) supported for >1 year, 4 supported for >2 years, 1 supported >3 years, 2 transplanted, 2 died, and 9 ongoing with a mean duration of 744 ± 216 days (range: 537–1148, median: 651). Major adverse events included driveline/pocket infection, stroke, bleeding, and right heart failure. There was no incidence of pump mechanical failure, pump thrombosis, or hemolysis. Conclusions: The DuraHeart was able to provide safe and reliable long-term circulatory support with an improved survival and an acceptable adverse event rate in advanced heart failure patients who were eligible for transplantation.

Objective: Pulmonary hypertension (PH), defined as a pulmonary vascular resistance (PVR) >2.5 Wood units (WU) and (or) a transpulmonary gradient (TPG) >12 mmHg, is an established risk factor for mortality in heart transplantation. Elevated PVR in heart transplant candidates can be reduced using a left ventricular assist device (LVAD), and LVAD is proposed to be the treatment of choice for candidates with PH. We analyzed the effect on PVR of pretransplant LVAD therapy in patients with PH and compared posttransplant outcome with matched controls. Long-term survival was compared between heart transplant recipients with mild, moderate or severe PH and patients with no PH. Methods: Heart transplant recipients 1988–2007 (n = 405) were reviewed and divided into two groups with respect to pretransplant PVR: <2.5 WU (n = 148) and >2.5 WU (n = 158). From the group with PH, patients subjected to pretransplant LVAD therapy (n = 11) were analyzed with respect to PVR at implant and at transplant and, with respect to outcome, compared to matched historical controls (n = 22). Patients with PH without LVAD treatment (n = 147) were stratified into three subgroups: mild, moderate and severe PH and survival according to Kaplan–Meier was analyzed and compared to patients with no PH. Results: LVAD therapy reduced PVR from 4.3 ± 1.6 to 2.0 ± 0.6 WU, p < 0.05. Three cases of perioperative heart failure required mechanical support whereas one control patient developed perioperative right heart failure requiring mechanical support. The incidence of other perioperative complications was comparable between groups. There was no difference in survival between LVAD patients and controls, 30-day survival was 82% and 91%, respectively and 4-year survival was 64% and 82%, respectively. Conclusions: Pretransplant LVAD therapy reduces an elevated PVR in heart transplant recipients, but there was no statistically significant difference in posttransplant survival in patients with PH with, or without LVAD therapy. The study revealed no differences in survival in patients regardless of the severity of the PH.

Heart transplantation is the treatment of choice for many patients with end-stage heart failure. Its success, however, is limited by organ shortage, side effects of immunosuppressive drugs, and chronic rejection. Gene therapy is conceptually appealing for applications in transplantation, as the donor organ is genetically manipulated ex vivo before transplantation. Localised expression of immunomodulatory genes aims to create a state of immune privilege within the graft, which could eliminate the need for systemic immunosuppression. In this review, recent advances in the development of gene therapy in heart transplantation are discussed. Studies in animal models have demonstrated that genetic modification of the donor heart with immunomodulatory genes attenuates ischaemia–reperfusion injury and rejection. Alternatively, bone marrow-derived cells genetically engineered with donor-type major histocompatibility complex (MHC) class I or II promote donor-specific hyporesponsiveness. Genetic engineering of naïve T cells or dendritic cells may induce regulatory T cells and regulatory dendritic cells. Despite encouraging results in animal models, however, clinical gene therapy trials in heart transplantation have not yet been started. The best vector and gene to be delivered remain to be identified. Pre-clinical studies in non-human primates are needed. Nonetheless, the potential of gene therapy as an adjunct therapy in transplantation is essentially intact.

The coming of age of lung transplantation is accompanied by an immunosuppressive armamentarium that has been brought forward from other transplant indications. Widely employed on the basis of few small randomized studies, and mostly single-center experience or empirical expert knowledge, anti-rejection therapeutic strategies in pulmonary transplantation have hardly been rigorously evaluated in large-scale prospective international trials. This review compiles the available findings on the use of current immunosuppressants in clinical lung transplantation, accentuating high level-of-evidence study results. Reporting on recent meeting and registry data, and assembling ongoing relevant trials from international databases, this article serves as an update on the state of the art of immunosuppression in lung transplantation.

We aim to perform a systematic review and meta-analysis of the cases of postintubation tracheal rupture (PiTR) published in the literature, with the aim of determining the risk factors that contribute to tracheal rupture during endotracheal intubation. A further objective has been to determine the ideal treatment for this condition (surgical repair or conservative management). A MEDLINE review of cases of tracheal rupture after intubation published in the English language and a review of the references in the articles found. The articles included were those that reported at least the demographic data (age and sex), the treatment performed, and the outcome. Those papers that did not detail the above variables were excluded. The search found 50 studies that satisfied the inclusion criteria. These studies included 182 cases of postintubation tracheal rupture. The overall mortality was 22% (40 patients). A statistical analysis was performed determining the relative risk (RR), 95% confidence intervals (95% CI) and/or statistical significance. The analysis was performed on the overall group and after dividing into 2 subgroups: patients in whom the lesion was detected intraoperatively, and other patients. Patient age (p = 0.015) and emergency intubation (RR = 3.11; 95% CI, 1.81–5.33; p = 0.001) were variables associated with an increased mortality. In those patients in whom the PiTR was detected outside the operating theatre (delayed diagnosis), emergency intubation (RR = 3.05; 95% CI, 1.69–5.51; p < 0.0001), the absence of subcutaneous emphysema (RR = 2.17; 95% CI, 1.25–4; p = 0.001), and surgical treatment (RR = 2.09; 95% CI, 1.08–4.07; p = 0.02) were associated with an increased mortality. In addition, age (p = 0.1) and male gender (RR = 1.89; 95% CI, 0.98–3.63; p = 0.13) showed a clear trend towards an increased mortality. PiTR is an uncommon condition but carries a high morbidity and mortality. Emergency intubation is the principal risk factor, increasing the risk of death threefold compared to elective intubation. Conservative treatment is associated with a better outcome. However, the group of patients who would benefit from surgical treatment has not been fully defined. Further studies are required to evaluate the best treatment options.

Objective: The clinical outcome of 180 non-thymomatous myasthenia gravis (MG) consecutive cases surgically treated is reported herein. The original surgical access, consisting of a video-assisted infra-mammary cosmetic incision and median sternotomy, has originally been designed and described by our group. Methods: The in-hospital patients’ charts and the outpatients’ clinic follow-up information of the 180 cases have been extensively reviewed. In addition to the strictly surgical benchmark referral, data on the rate of cure of the MG (complete stable remission – CSR; pharmacological remission – PR) as indicated by the Myasthenia Gravis Foundation of America (MGFA) have been analysed as recorded at the 12 months after surgery checkpoint. Cosmetic outcome was evaluated as well. Results: Female to male ratio was 156 (86.7%):24 (13.3%). Mean age: 29.1 ± 10.9 years. Preoperative MGFA score: stage I: 4 patients (2.2%); IIa: 57 (31.7%); IIb: 32 (17.8%); IIIa: 41 (23.3%); IIIb: 42 (23.3%); IVa: 2 (1.1%); V: 2 (1.1%). Median operative time was 110 min (70–130 min) and median postoperative hospital stay was 4 days (3–10 days). Postoperative mortality was nil and morbidity occurred in seven patients (3.8%). Final pathology was consistent with: 146 hyperplastic thymus (81.1%); 28 involuted thymus (15.6%) and 6 normal thymus (3.3%). Ectopic thymic tissue was found in 68% of the patients. Mean follow-up was 62.9 ± 34.6 months. A CSR was obtained in 55%; PR in 18.3%; improvement in 39.9%, unchanged in 3.5%, worse in 1.1% and died in 0.5%. Kaplan–Meier estimates of CSR were 34.1% and 75.8% at 5 and 10 years, respectively. The preoperative therapy was the only parameter significantly associated with Kaplan–Meier CSR rates (univariate analysis – p < 0.001). Remarkably, 171 (95%) patients judged their cosmetic results to be excellent or very good. Conclusions: Thymectomy in MG patients via video-assisted infra-mammary cosmetic incision and median sternotomy has shown to be a useful surgical approach as demonstrated by the good functional and very good aesthetic results, associated with a very low morbidity and no mortality. Patients with preoperative mono-therapy have higher CSR rates. CSRs are durable, as the CSR rate improves with extended follow-up.

Objective: To prospectively evaluate quality of life (QoL) evolution after lung cancer surgery in a cohort of septuagenarians with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and LC13. Methods: Between January 2003 and December 2006, QoL was prospectively recorded in 60 consecutive septuagenarians undergoing lung cancer surgery. Forty-nine lobectomies and 11 pneumonectomies were performed. Questionnaires were administered before surgery and 1, 3, 6 and 12 months postoperatively (MPO) with response rates of 100%, 83%, 87%, 90% and 77%, respectively. Results: After lobectomy, QoL scores returned to baseline 3–6 months after surgery, with the exception of a persistent decrease in physical functioning and an increase in dyspnea within the 12 months follow-up. In the 12 months follow-up period after pneumonectomy, there was no return to baseline in physical, role and social functioning. After pneumonectomy, most quality of life scores returned to baseline at 1-month follow-up, with the exception of dyspnea and general pain, which returned to baseline at 3 and 6 months, respectively. Comparing both resections, significant differences in evolution of physical functioning (6MPO p = 0.045), role functioning (3MPO p = 0.035), social functioning (6MPO p = 0.006, 12MPO p = 0.001) and general pain (6MPO p = 0.037) were reported in favor of lobectomy. Conclusions: The present study documented QoL evolution profiles of septuagenarians after pulmonary surgery. The results indicate that both resections have a major impact on elderly patients, especially physical functioning and dyspnea status. If both resections are compared, lobectomy patients have a more favorable evolution in QoL subscales compared to pneumonectomy.

A newborn presented with severe aortic valve stenosis and a borderline hypoplastic left ventricle due to disproportionate left ventricular hypertrophy (maternal diabetes). The aortic valve was balloon dilated and the infant tolerated a biventricular circulation. However, severe retrograde pulmonary hypertension and mitral regurgitation developed, indicating that biventricular circulation was not possible at that stage. A hybrid approach with ductal stenting, atrial septostomy and bilateral dilatable pulmonary artery band placement was followed on day 25. This allowed the left ventricle several months to adapt to lower pressure and normoglycemic conditions. At re-evaluation after 8 months biventricular repair appeared possible: the ductus was closed with Amplatzer occluders and the pulmonary artery bands were opened up with bilateral balloon angioplasty of the dilatable bands. At the age of 3 years, the infant is doing well with a biventricular circulation and normal pulmonary artery pressure. The hybrid approach allowed adequate time (months) for careful consideration and acted as a bridge to biventricular repair in this infant.

An 18-year-old patient, who had polysplenia and single ventricle, presented with altered mental status 9 years after a Fontan-type operation and pacemaker implantation. He underwent replacement of common atrioventricular valve and aortic valve plasty 1 year previously and has been placed on multiple medications including beta-blocker for his poor ventricular function. Blood chemistry revealed hyperammonemia of 2420 µg/l as a cause of this altered mental status disturbance. Superior mesenteric arteriography revealed large portal-systemic shunts in venous phase as a cause of hyperammonemia. To control blood ammonia level, we placed him on low protein diet, oral polymixin B, and lactulose instead of closing shunt with device. This case illustrates that portal-systemic shunt may result in hyperammonemia leading to altered mental status long after a Fontan-type operation.

We report the successful management of a circumflex coronary artery aneurysm with fistula to the coronary sinus. Our strategy aimed at closing the fistula and grafting the obtuse marginal artery. The calcified aneurysm was left intact, and showed secondary thrombus formation on the postoperative angiogram.

A 58-year-old female was referred to our hospital with an abnormal shadow on her chest X-ray. Further examination revealed the left anterior descending coronary artery to pulmonary artery fistula with aneurysms. The patient was successfully repaired with operation and had no residual fistulas and aneurysms.

Instead of pulsatile ventricular assist devices an increasing number of nonpulsatile ventricular assist devices are introduced to clinical practice. The different flow characteristics of this new technique lead to alteration in shear stress on blood components, which may affect the coagulation system. Repeated von Willebrand factor analyses were performed in a patient who first was implanted with a pulsatile ventricular assist device (Thoratec HeartMate XVE), which had to be replaced after 405 days with an axial flow device (HeartMate II). During support with the pulsatile ventricular assist device there was no sign of any coagulation disorder. However, on the axial flow device acquired von Willebrand syndrome Type 2 developed. Inhibition of platelet function was also observed, which may be in part due to the von Willebrand syndrome. The HeartMate II axial flow device may induce von Willebrand syndrome, which was not observed in HeartMate XVE pulsatile ventricular assist device. Patients put on continuous flow devices should be screened for acquired von Willebrand syndrome.

In this case report we illustrate our experience with a perforation of the pulmonary trunk during a transapical aortic valve implantation in a single case. The patient suffered from an aortic valve stenosis and was accepted for a minimally invasive procedure because of multiple comorbidities. After unproblematic transapical placement of the aortic valve, a venous bleeding from the anterolateral wound was observed. Median sternotomy showed a bleeding out of the pulmonary trunk that could be stopped with purse-string sutures. The further course of the patient was uneventful.

We describe a case of successful vegetectomy of the aortic valves for early infective endocarditis. An aortic vegetectomy was performed as an alternative to valve replacement for a 54-year-old man with three vegetations and mild regurgitation in aortic valve due to infective endocarditis. Postoperative clinical course was without signs of recurrent infection after follow-up of 19 months, and transesophageal echocardiography demonstrated aortic valve competence. We would suggest that vegetectomy with valve sparing may be a viable option in the context of early infective endocarditis involved aortic valve in selected patients.

Comprehensive aortic root and valve repair (CARVAR) surgery using specially designed aortic rings was introduced as a new surgical technique for aortic valve disease. We present five consecutive cases of iatrogenic coronary ostial stenosis after CARVAR surgery in patients with aortic stenosis. The preoperative coronary angiography confirmed that all the patients had normal coronary arteries. They underwent aortic valvuloplasty by aortic leaflet extension and insertion of specially designed inner and outer rings at the level of the sinotubular junction. Within 6 months after surgery, all the patients complained of resting chest pain and dyspnea with changes of electrocardiography. Repeated coronary angiography demonstrated right coronary artery (RCA) ostial stenosis in one patient and left main (LM) ostial stenosis in the other four patients. Intravascular ultrasonography demonstrated severe ostial stenosis and extensive echogenic tissue in the extravascular area. Four patients with LM ostial disease successfully underwent coronary bypass graft surgery, and percutaneous coronary intervention with stenting was performed in one case of RCA ostial stenosis. Because the mechanism of this complication is not fully confirmed, more clinical study is required to confirm the safety issues of CARVAR surgery.

This case report focuses on a completely asymptomatic proximal aortic dissection in a middle-aged male smoker with bullous lung disease. The possibility of a relationship between A1-antitrypsin (A1AT) deficiency and aortic dissection is discussed in light of the recent data.

Bronchial stump insufficiency after pneumonectomy is a severe problem and there is still debate about the appropriate method (transthoracic or transsternal) for reclosure. Access through a sterile operative field for a successful redo-procedure seems to be important so an alternative to the open methods could be the video-mediastinoscopy as it allows approaching the bronchial stump via the mediastinum. Previously in 1996 Azorin performed the first mediastinoscopic reclosure by stapling an early insufficiency after left pneumonectomy. We report the first case to our knowledge of resection and reclosure in bronchial stump insufficiency via mediastinoscopy. An HIV-positive man presented with late bronchial stump insufficiency after left pneumonectomy for lung cancer. The cause was a long bronchial stump and there was no sign of tumour recurrence. Decision was made for a video-mediastinoscopy and resection and reclosure successfully performed by using an endostapler device. Postoperative bronchoscopy at six months revealed a well-healed stump and two years postoperatively the patient is doing well. The mediastinoscopic approach is a novel option in highly selected patients. It warrants minimal surgical trauma; however, one has to be prepared to convert to an open technique immediately.

Tachy-brady syndrome or sick-sinus syndrome as it is also known is a cardiac rhythm disturbance resulting in alternating episodes of bradycardia and tachycardia. Diagnosis can be difficult because of its nonspecific symptoms and elusive findings on electrocardiogram or 24 h tape. Thymic cysts are relatively uncommon tumours that are predominantly asymptomatic and located in the anterior mediastinum. We present the first known report of tachy-brady syndrome associated with a large thymic cyst. Treatment consisted of dual-chamber pacemaker implantation prior to video-assisted removal of the thymic cyst.

Background: The surgeon's individual performance is a key component of total quality management (TQM) in cardiac surgery. Early mortality as well as postoperative complications can be stratified in order to develop a surgeon performance index (SPI). Material and methods: In three consecutive annual periods (3703 patients) data of board-certified cardiac surgeons were compared. Risk-adjustment of early mortality and postoperative complications was performed by logistical EuroSCORE (logES). Early mortality (EM), early rethoracotomy for bleeding (ReTh), sternal rewiring for instability (ReWr), and mediastinitis (Med) were assessed. ReTh, ReWr, and Med were weighted according to empiric data: (ReTh x 2; ReWr x 1; Med x 3). Surgeon performance index was computed as follows: SPI = (EM/logES + [((ReTh/logES) x 2) + ((ReWr/logES) x 1) + ((Med/logES) x 3)]/6)/2. Ideal SPI was considered ≤1. SPI of the respective previous period was handed out to each surgeon and discussed by means of a structured dialogue. Results: Patients from each period were allocated to 11 cardiac surgeons. Overall logES of the three periods were 6.6%, 9.1%, and 11.2% respectively; EM 5.7%, 6.6%, 5.6%; ReTh 5.8%, 7.3%, 10.9%; ReWr 2.4%, 1.9%, 1.4%; and Med 0.9%, 1.8%, 1.8%. SPI showed a mean of 0.71, 0.56, and 0.49. Conclusion: Comorbidity increased between periods 1 and 3 significantly whereas early mortality remained rather stable. SPI indicated improvement of the performance of the individual surgeon and a decrease of range and mean of the overall performance. SPI is therefore an effective tool to assess individual surgical quality and serves as an instrument for human resource management and development. Sustainable positive effects on overall performance can be expected.

Objective: Analysis of major perioperative morbidity has become an important factor in assessment of quality of patient care. We have conducted a prospective study of a large population of patients undergoing coronary artery bypass surgery (CABG), to identify preoperative risk factors and to develop and validate risk-prediction models for peri- and postoperative morbidity. Methods: Data on 4567 patients who underwent isolated CABG surgery over a 10-year period were extracted from our clinical database. Five postoperative major morbidity complications (cerebrovascular accident, mediastinitis, acute renal failure, cardiovascular failure and respiratory failure) were analysed. A composite morbidity outcome (presence of two or more major morbidities) was also analysed. For each one of these endpoints a risk model was developed and validated by logistic regression and bootstrap analysis. Discrimination and calibration were assessed using the under the receiver operating characteristic (ROC) curve area and the Hosmer–Lemeshow (H–L) test, respectively. Results: Hospital mortality and major composite morbidity were 1.0% and 9.0%, respectively. Specific major morbidity rates were: cerebrovascular accident (2.5%), mediastinitis (1.2%), acute renal failure (5.6%), cardiovascular failure (5.6%) and respiratory failure (0.9%). The risk models developed have acceptable discriminatory power (under the ROC curve area for cerebrovascular accident [0.715], mediastinitis [0.696], acute renal failure [0.778], cardiovascular failure [0.710], respiratory failure [0.787] and composite morbidity [0.701]). The results of the H–L test showed that these models predict accurately, both on average and across the ranges of patient deciles of risk. Conclusions: We developed a set of risk-prediction models that can be used as an instrument to provide information to clinicians and patients about the risk of postoperative major morbidity in our patient population undergoing isolated CABG.

Background: Performance measurement is an essential element of quality improvement initiatives. The objective of this study was to develop a composite performance score (CPS) incorporating processes and outcomes measures available in the European Society of Thoracic Surgeons (ESTS) Database and apply it to stratify performance of participating units. Methods: A total of 1656 major lung resections for malignant primary neoplastic disease were collected in the ESTS database from 2001 through 2003 and were analyzed. For the purpose of this study only data collected from units contributing more than 50 consecutive cases were included. Three quality domains were selected: preoperative care, operative care, and postoperative outcome. According to best available evidence the following measures were selected for each domain: preoperative care (% of predicted postoperative carbon monoxide lung diffusion capacity (ppoDLCO) measurement in patients with predicted postoperative forced expiratory volume in one second (ppoFEV1) <40%), operative care (% of systematic lymph node dissection), and outcomes (risk-adjusted cardiopulmonary morbidity and mortality rates). Morbidity and mortality risk models were developed by hierarchical logistic regression and validated by bootstrap analyses. Individual processes and outcomes scores were rescaled according to their standard deviations and summed to generate the CPS, which was used to rate units. Results: CPS ranged from –4.4 to 3.7. Individual scores were poorly correlated with each other. Two units were negative outliers and two positive outliers (outside 95% confidence limits). Compared to the rating obtained by using the risk-adjusted mortality rates, all units changed their positions when ranked by CPS. Conclusions: The composite performance score methodology may support future peer-based organizational quality benchmarking initiatives and may be used for regulatory and credentialing purposes.

Objective: Segmentectomy for non-small cell lung cancer (NSCLC) is believed to increase the rates of recurrence and postoperative air leak. We sought to present our clinical data and outcome of VATS (video-assisted thoracoscopic surgery) segmentectomies with systematic node dissection for selected NSCLC patients. Methods: Inclusion criteria were clinical T1N0M0 peripheral NSCLC measuring ≤2 cm (n = 38) and NSCLC with interlobar invasion, which cause positive surgical margin with malignancy after lobectomy of a primary lesion and only partial resection of invasion site (n = 3). Outcome variables include hospital course, complications, mortality, recurrence patterns and survival. The intersegmental border was identified using the intersegmental veins as landmark and the demarcation between the resected (inflated) and preserved (collapsed) lungs. The intersegmental plane was divided by an endoscopic stapler and electrocautery. Results: The mean operative time and intraoperative bleeding were 220 min (range 100–306) and 183 ml (30–730), respectively. The number of stapler cartridges used for intersegmental division was 2 (1–5). Postoperative air leak (>7 days), which required no surgical intervention, occurred in two patients. The chest tube drainage duration was 3 days. There were no in-hospital deaths. The numbers of resected subsegments and reserved subsegments in comparison with lobectomy were 5 (2–13) and 5 (3–13), respectively. The FEV1.0 after VS was higher than the predictive FEV1.0 after lobectomy, if the latter was performed as standard procedure. We experienced four cases of distant metastasis after segmentectomy, but there was no case of local recurrence. The 5-year survival and recurrence-free survival rates in pathological stage IA NSCLC were 89.9% and 93.3%, respectively. Conclusions: VATS segmentectomy with systematic node dissection is a reasonable treatment option for selected peripheral NSCLC.

Objective: Although widely utilised in the staging of lung cancer various studies have questioned whether the accuracy of this staging modality is sufficient to replace conventional invasive staging techniques. We have therefore reviewed our experience in order to assess the accuracy of PET CT as an intrathoracic staging tool for non-small cell lung cancer (NSCLC). Methods: Two hundred patients referred for surgery between June 2006 and January 2008 underwent PET CT followed by staging mediastinoscopy and, if appropriate, resection. Results of scans and histopathology were correlated and analysed. Results: Overall, PET CT correctly staged 99 out of 200 patients (49.5%), under-staged 59 (29.5%), and over-staged 42 (21%). Superior mediastinal nodes were incorrectly staged by PET CT in 35 (19%) of 186 patients undergoing mediastinoscopy: in 15 (8%) mediastinoscopy revealed metastatic disease not detected on PET CT and 20 (11%) had negative histology despite a positive scan. Five (2.5%) resections were benign despite avid FDG uptake, and 6 (3%) were malignant despite a negative scan. PET CT had false positive result of 6.5%, 5.5%, 4.5% and 3.5%, respectively for hilar, station 2, 7 and 5 node groups. The false negative result was 12.5%, 10.5% and 8%, respectively for hilar, intrapulmonary and station 4 nodes. Twelve (6%) of patients were under-staged regarding chest wall and mediastinal invasion, and 10 (5%) patients had metastatic nodules in the lung (T4) not detected by PET CT. Stage I or II disease was identified by PET CT in 141 patients of whom 26 (18.4%) had IIIa or higher stage disease. The false positive and negative predictive values for PET CT with respect to N2 or greater status were 17.2% (11.8–24.2) and 48.6% (32.2–65.3), respectively. Conclusions: Our experience would suggest that PET CT alone is not sufficiently accurate to replace mediastinoscopy and other conventional biopsy techniques in the evaluation of NSCLC cases. It may better be viewed as a valuable additional tool with which to inform decision making and to screen for disseminated disease.

Background: Video-assisted thoracoscopic surgery (VATS) is an increasingly used technique to treat patients with pulmonary metastases, but it does not usually afford lung palpation. Methods: A retrospective study on patients with lesions defined as ‘VATA-able’ who underwent open metastasectomy via thoracotomy. All patients underwent 64-slice helical CT scan with intravenous contrast using 5 mm cuts and integrated FDG-PET/CT. Unsuspected malignant pulmonary nodules that were palpitated and removed, and were not imaged pre operatively were defined as ‘malignant nodules’ and would have been missed by VATS metastasectomy. Results: From January 2004 to December 2005, 57 patients had ‘VAT-able’ metastatic pulmonary lesions that were resected via thoracotomy by one thoracic surgeon. Twenty-one (37%) patients had non-imaged pulmonary nodules that were discovered only by bi-manual palpation and would have been missed by VATS metastasectomy, but these nodules were only malignant in 10 (18%) patients. The median size of the non-imaged pulmonary nodule was 0.7 cm (range, 0.4–0.8 cm). Colorectal carcinoma was the most common tumor requiring metastasectomy. Non-imaged malignant pulmonary nodules were most frequently found in patients with leiyomyosarcoma and osteosarcoma (three of eight patients in both). Conclusion: Metastasectomy via open thoracotomy, which affords bi-manual lung palpation of the entire ipsilateral lung, may discover non-imaged malignant pulmonary metastases in 18% of patients who have had a previously treated solid organ cancer and have at least one imaged metastatic lesion in the lung. The clinical impact of these findings is unknown. A prospective study to further examine this issue is underway.

Background: Pulmonary metastasectomy is an accepted procedure in selected patients, very often requiring multiple non-anatomical resections. Although it is intuitive that functional loss is proportional to the number and extent of pulmonary resections, this link has never been proved and is the hypothesis behind this study. Methods: We retrospectively reviewed pulmonary function changes after lung metastasectomy. Baseline and postoperative spirometric values were evaluated and their changes were correlated to (a) number of resections, (b) extent of resections and (c) intervals between surgery. Results: Sixty-six patients were enrolled (31 men, mean age 56 years, range: 23–75); mean interval between surgery: 54.5 days; mean extent of resection: 11.45 cm; mean number of resections: 3. Preoperative mean spirometric values were: FEV1 2.73 l (97.75%); FVC 3.11 l (95.50%); DLCO/AV 1.21 l (99.80%). Mean changes in FEV1, FCV and DLCO/AV were –13.4%, –12.4% and +1.2% respectively. Patients receiving three or more non-anatomical resections had functional loss similar to those undergoing lobectomy. The extent of total resection (>11 cm, p < 0.05) and the interval between surgery (>90 days, p < 0.0001) influenced FEV1 and FVC modifications. At three months none of these functional modifications remained. Sex, age, side of the operation and histology of primary tumor did not affect spirometric changes. Conclusions: Spirometric changes after pulmonary metastasectomy are affected by total volume lung parenchyma resected within the first 90 days. Functional loss after three or more non-anatomical resections is comparable to that recorded after lobectomy.

Objective: Sleeve resections were introduced to preserve lung function in patients with limited pulmonary reserve. Ischaemia and infection of the distal part of the anastomosis is the leading cause of bronchial anastomotic leakage. We have learned from our experience in lung transplantation that inhalation with Tobramycin^® helps prevent anastomotic insufficiency. We would like to present our experience in patients with tracheobronchial sleeve and prophylactic Tobramycin^® inhalation. Patients and methods: Retrospective analysis of 114 patient records, between 01.01.2005 and 31.12.2006, where a bronchial anastomosis (patients with tracheal resection were excluded) was performed. All patients received Tobramycin^® inhalation (2 x 80 mg) for 7 days. Data analysed were; length of chest tube drainage in days, complications, morbidity and hospital mortality. Results: In 694 patients, an anatomic resection was performed. Of these, 114 (16%) were sleeve resections and 63 (9%) pneumonectomies. In 21 women and 93 men, between 25 and 84 years old, sleeve lobectomy was performed 104 times and carinal resection 10 times. A preoperative neoadjuvant therapy had been given in 26%. Radical (R0) resection was possible in 94%. The duration of the operation was between 83 and 225 min (median: 127 min). Chest tubes were removed on average after 6 days. Patients were discharged after 11 days. The rate of bronchial anastomotic leakage was 4.4%. There were two patients with postoperative respiratory insufficiency and mechanical ventilation, two patients with technical failure required early correction of the suture and one patient with a necrosis of the anastomosis. Thirty-day hospital mortality was 2.6% (3/114). Conclusions: Increasing experience with sleeve resection has reduced the rate of pneumonectomy below 10%, although a number of the patients had received neoadjuvant therapy and the carinal resection rate of necrosis and infection of the anastomosis was low. We therefore recommend use of local antibiotic inhalation after sleeve resection.

Objective: Optimising the preservation modality and thus maintaining the post-transplanted organ function remains a point of interest in research in order to prevent deleterious ischaemia/reperfusion injury. Microcirculation allows the assessment of initial graft function before obvious functional parameters. It was the aim of our study to compare the effects of epoprostenol and sildenafil on the pulmonary microcirculation and haemodynamics, when used in the preservation solution in lung transplantation. Methods: Twenty-one pigs underwent single LuTx after 24 h graft-ischaemia, preserved with buffered low potassium-dextran solution (I, control); with addition of 0.66 µg/kg/bw epoprostenol (II) or with 0.15 mg/kg/bw sildenafil (III). The pulmonary microcirculation, alveolar capillary diameter (ACD), red blood cell (RBC) velocity and functional capillary density (FCD), were assessed by intravital microscopy (OPS-imaging) hourly until 6 h after reperfusion. Haemodynamics and blood gas exchange were monitored at all timepoints. Results: ACD was increased in group III directly after reperfusion (132 ± 4.4% vs 121 ± 3.1%, in % of baseline, III vs I; mean ± SEM; p < 0.05) and decreased during the experiment. RBC velocity did not reach statistical significance (256 ± 93 vs 263 ± 85 and 283 ± 66 µm/s, III vs II and I; mean ± SD). FCD in group III was higher than in I and II beginning 3 h after reperfusion (10.1 ± 1.4 vs 6.1 ± 1.9 µm/µm², III vs I; mean ± SEM; p < 0.05). Conclusions: Our study demonstrated a significantly improved microcirculation after application of PDF V during organ procurement, probably because of better distribution of the preservation solution. Further studies are necessary, to prove the long-term effects of this observation.

Objective: Lung transplantation is a recognised surgical option for patients with end stage respiratory disease. We present data relating to the initiation of the Irish lung transplant programme in 2005. Methods: Seventeen patients: 7 male and 10 female have undergone lung transplantation. The indications for lung transplantation included COPD (n = 8), idiopathic pulmonary fibrosis (n = 5), bronchiolitis obliterans (n = 2), lymphangioleiomyomatosis (n = 1), and cystic fibrosis (n = 1). Eleven single lungs transplants were completed, while six patients underwent double sequential lung transplantation. The immunosuppression regimen included basiliximab as induction therapy, with steroids, mycophenolate mofetil nd cyclosporine or tacrolimus. Results: The operative mortality was zero. One patient died at 10 months post double lung transplantation secondary to bronchiolitis obliterans. Primary graft dysfunction was observed in two patients who required ventilatory support for 3 and 5 days respectively. Acute cellular rejection was observed in four patients (grade A2 n = 3, grade A3 n = 2). The cumulative 1-year survival was 94.1%, which compares favourably to an international standard of 78%. Conclusions: The initiation of a lung transplant programme in Ireland has been successfully undertaken and initially provided results comparable to established lung transplant programs.

Background: Thymoma occurs in about 10–20% of myasthenic patients and in turn, 20–25% of patients with a thymoma have myasthenia gravis. Both diseases are treated by surgery. The aims of this study were to analyze the clinical features of these patients and the oncological and neurological outcomes after thymectomy. Methods: Clinical and pathological data, complete remission rate as well as overall survival rates were retrospectively analyzed in a cohort of myasthenic patients who underwent extended thymectomy for thymoma between 1993 and 2006. Results: One hundred and twenty-three patients (60 m and 63 f) with a mean age of 56 years (range 22–83) underwent extended thymectomy. The WHO histological classification was: A in 22 cases, AB in 18, B1 in 33, B2 in 22, and B3 in 28. The Masaoka clinical staging was: I in 10 cases, IIA in 33, IIB in 50, III in 14, IVA in 15, IVB in 1. We experienced 2 postoperative deaths. With a overall mean follow-up of 76 months 42 patients had a complete remission, 39 a remission with medications, 35 an improvement of the symptoms, 3 remained nearly in the same status and 4 worsened. At the last follow-up, 112 patients were alive; 11 with disease. Four deaths were related to the tumor. Actuarial 5- and 10-year survival was 93.4% and 79.6%, respectively. Conclusions: Neurological outcome of the extended thymectomy in myasthenic thymoma patients was satisfactory. Higher complete remission rate is expected in early stage thymoma. Regarding the overall survival it was dependent on the Masaoka stage, the WHO classification and the achievement of complete remission of myasthenic symptoms.

Objective: A prospective, randomized study to evaluate the effectiveness and safety of a polymeric sealant (Coseal^®, Baxter Healthcare, Deerfield, IL) to reduce air leaks and to improve postoperative outcome in patients undergoing lung resection. Methods: Between November 2005 and February 2008, 203 (128 M, 75 F) patients showing moderate/severe intraoperative air leaks after pulmonary lobectomy/bilobectomy/sleeve lobectomy (110) or minor resection (segmentectomy/wedge) (93) have been prospectively enrolled and randomly assigned to receive one of the two following management strategies: suture/stapling (101 patients – standard care group (SCG)) or suture/stapling plus Coseal sealant (102 patients – Coseal group (CG)). To assess the effectiveness of the sealant the following data were registered and compared in the two groups: number of patients with air leak cessation intraoperatively, number of patients without air leaks at 24 h and 48 h, duration of air leaks, length of hospital stay. Results: No adverse event related to the sealant application occurred. Intraoperative air leak cessation rate was higher in the CG with a statistically significant difference (85.3% vs 59.4%; p < 0.001). Air leaks rate at 24 h and 48 h was significantly lower in the Coseal group (19.6% vs 40.6%; p = 0.001 at 24 h and 23.5% vs 41.6%; p = 0.006 at 48 h). Duration of air leaks was significantly shorter in the Coseal group (p = 0.01). The hospital stay was shorter in the Coseal group (mean: 5.7 ± 2.3 days vs 6.2 ± 2.5 days) but this difference did not reach statistical significance owing to the many known clinical interfering factors. Conclusions: The application of Coseal sealant proved safe and effective in reducing air leaks occurring after lung resection and in shortening the duration of postoperative air leak with a trend towards a shorter postoperative hospital stay.

Objective: Prolonged air leak occurs frequently after lung volume reduction surgery (LVRS) and can negatively affect both morbidity and hospital stay. We hypothesised that awake nonresectional LVRS could reduce the duration of air leak in emphysema patients. Methods: This analysis included 66 patients undergoing awake, unilateral plication of the most emphysematous lung regions under sole epidural anaesthesia. Primary outcome measure was the rate of prolonged (>7 days) air leak; secondary outcome measures included the mean duration of air leak, hospital stay and early discharges (≤4 days). All results were retrospectively compared with those of a similar control group undergoing resectional LVRS under general anaesthesia. Results: Intergroup comparisons showed that demographics and baseline data were well matched. Prolonged air leak occurred in 12 patients (18%) in the awake group versus 27 patients (40%) in the control group (p = 0.007) with a mean duration of 5.2 ± 6.5 days versus 7.9 ± 7.6 days (p < 0.0002). Mean hospital stay was significantly shorter in the awake group (6.3 ± 2.8 days vs 9.2 ± 5.6 days, p < 0.0001). At univariate analysis, resectional LVRS (p = 0.007), higher severity of emphysema (p < 0.0001) and lower diffusion capacity for carbon monoxide (p = 0.0001) correlated with occurrence of prolonged air leak; however, logistic regression indicated high severity of emphysema as the most important factor predicting prolonged air leak (odds ratio = 4.85, p < 0.0001). At 6 months, dyspnoea index, FEV1 and 6 min walking test improved significantly in both study groups. Conclusions: In this study, awake nonresectional LVRS was associated with a lower rate of prolonged air leak and a shorter hospital stay than the standard resectional technique.

Background: Thoracic paravertebral block (TPVB) is a regional block technique increasingly used for the early management of post-thoracotomy pain. We compare three different postoperative analgesic approaches based on TPVB: anesthetist, anesthetist plus surgeon, and surgeon. Materials and methods: We randomized 54 patients undergoing elective thoracotomy to three different postoperative analgesia groups: paravertebral percutaneous catheter (PVA group), paravertebral percutaneous catheter plus incisional (subcutaneous) catheter (PVA + Inc), and paravertebral catheter under direct vision (PVS group). During early postoperative 48 h, we measured pain intensity, intravenous morphine afforded by the patient-controlled analgesia pump, and the spirometric test. Results: There were no statistically significant differences among the collected preoperative data. No significant differences were observed on postoperative spirometric values. Analgesic quality was better in PVA + Inc group at 12 and 24 postoperative hours. In this group, intravenous morphine use to improve analgesia was significantly lower from 8 h until 48 h postoperative. Conclusions: Association of thoracic paravertebral block to continuous infusion of a local anesthetic in the surgical incision area affords a better pain relief than paravertebral block alone (introduced by the surgeon or the anesthetist).

Objective: Postoperative deep sternal wound infection is a severe complication of cardiac surgery, with a high mortality rate and a high morbidity rate. The objective of this prospective study is to report our experience with the vacuum assisted closure (VAC) system for the management of deep wound infection. We also devised an innovative closure technique post VAC therapy using thermo reactive clips. The advantage of this technique is that the posterior face of the sternum does not have to be separated from the mediastinal structures thus minimising the risk of damage. Methods: From October 2006 to October 2008, we prospectively evaluated 21 patients affected by mediastinitis after sternotomy. Nineteen patients had sternotomy for coronary artery bypass grafting (CABG), one patient for aortic valve replacement (AVR) and another one for ascending aortic replacement (AAR). All patients were treated with the VAC system at the time of infection diagnosis. When the wound tissue appeared viable and the microbiological cultures were negative, the chest was closed using the most suitable procedure for the patient in question; nine patients were closed using pectoralis flaps, nine patients using Nitinol clips, one patient with a combined technique (use of Nitinol clips and muscle flap), one patient with a direct wound closure and another patient, who needed AAR with a homograft performed in another institution, was closed using sternal wires. Results: We had no mortality; wound healing was successfully achieved in all patients. In more than 50% of the patients, the VAC therapy allowed direct sternal resynthesis. The average duration of the vacuum therapy was 26 days (range 14–37 days). Conclusions: VAC is a safe and effective option in the treatment of post-sternotomy mediastinitis, with excellent survival and immediate improvement of local wound conditions; furthermore, the use of Nitinol clips after VAC therapy demonstrated to be a safe and non-invasive option for sternal resynthesis. After VAC therapy, a reduction in number of muscular flaps used and an increase of direct sternal resynthesis were observed.

Objective: Cardioprotective properties of recombinant human Erythropoietin (rhEpo) have been shown in in vivo regional or ex vivo global models of ischemia–reperfusion (I/R) injury. The aim of this study was to characterize the cardioprotective potential of rhEPO in an in vivo experimental model of global I/R approximating the clinical cardiac surgical setting and to gain insights into the myocardial binding sites of rhEpo and the mechanism involved in its cardioprotective effect. Methods: Hearts of donor Lewis rats were arrested with cold crystalloid cardioplegia and after 45 min of cold global ischemia grafted heterotopically into the abdomen of recipient Lewis rats. Recipients were randomly assigned to control non-treated or Epo-treated group receiving 5000 U/kg of rhEpo intravenously 20 min prior to reperfusion. At 5 time points 5–1440 min after reperfusion, the recipients (n = 6–8 at each point) were sacrificed, blood and native and grafted hearts harvested for subsequent analysis. Results: Treatment with rhEpo resulted in a significant reduction in myocardial I/R injury (plasma troponin T) in correlation with preservation of the myocardial redox state (reduced glutathione). The extent of apoptosis (activity of caspase 3 and caspase 9, TUNEL test) in our model was very modest and not significantly affected by rhEpo. Immunostaining of the heart tissue with anti-Epo antibodies showed an exclusive binding of rhEpo to the coronary endothelium with no binding of rhEpo to cardiomyocytes. Administration of rhEpo resulted in a significant increase in nitric oxide (NO) production assessed by plasma nitrite levels. Immunostaining of heart tissue with anti-phospho-eNOS antibodies showed that after binding to the coronary endothelium, rhEpo increased the phosphorylation and thus activation of endothelial nitric oxide synthase (eNOS) in coronary vessels. There was no activation of eNOS in cardiomyocytes. Conclusions: Intravenous administration of rhEpo protects the heart against cold global I/R. Apoptosis does not seem to play a major role in the process of tissue injury in this model. After binding to the coronary endothelium, rhEpo enhances NO production by phosphorylation and thus activation of eNOS in coronary vessels. Our results suggest that cardioprotective properties of rhEpo are at least partially mediated by NO released by the coronary endothelium.

Objective: Advanced ischemic heart failure can be treated with surgical ventricular restoration (SVR). While numerous risk factors for mortality and recurrent heart failure have been identified, no plain predictor for identifying SVR patients with left ventricular damage beyond recovery is yet available. We tested echocardiographic wall motion score index (WMSI) as a predictor for mortality or poor functional result. Methods: One hundred and one patients electively operated between April 2002 and April 2007 were included for analysis. All patients had advanced ischemic heart failure (NYHA-class ≥ III and LVEF ≤ 35%). Mean logistic EuroSCORE was 10 ± 8. All patients were evaluated at 1-year follow-up. Risk factors for poor outcome, defined as mortality or poor functional result (NYHA class ≥ III) at 1-year follow-up were identified by univariable logistic regression analysis. Preoperatively, a 16-segment echocardiographic WMSI was calculated and receiver operating characteristic curve analysis was used to identify cut-off values for WMSI in predicting poor outcome. Results: Early mortality was 9.9%, late mortality 6.6%. NYHA class improved from 3.2 ± 0.4 to 1.5 ± 0.7. At 1-year follow-up, 10 patients (12%) were in NYHA class III and the remaining patients were in NYHA class I or II (75 patients, 88%). WMSI was found to be the only statistically significant predictor for poor outcome (odds ratio 139, 95% confidence interval (CI) 17–1116, p < 0.0001). The optimal cut-off value for WMSI in predicting mortality or poor functional result was 2.19 with a sensitivity and specificity of 82% (95% CI 81.5–82.5% and 81.4–82.6%). The area under the curve was 0.94 (95% CI 0.90–0.99). Positive and negative predictive values were 67% and 92% respectively (95% CI 66.4–67.6% and 91.4–92.6%). Conclusions: Sufficient residual remote myocardium is necessary to recover from a SVR procedure and to translate the surgically induced morphological changes into a functional improvement. Preoperative WMSI is a surrogate measure of residual remote myocardial function and is a promising tool for better patient selection to improve results after SVR procedures for advanced ischemic heart failure.

Various forms of renal replacement therapies (RRT) are available to treat acute kidney injury (AKI) after cardiac surgery. The objective of this review is to assess the incidence of postoperative AKI that necessitates the application of haemofiltration in adult patients undergoing cardiac operations with cardiopulmonary bypass (CPB), to determine the factors that influence the outcome in these patients. In addition, the review aims to assess the outcomes of postoperative early haemofiltration as compared to late intensive haemofiltration. Different forms of RRT such as intermittent haemodialysis, continuous haemofiltration, or hybrid forms which combine advantages of both are now available for application in cardiac surgery patients, and will be discussed in this article. The underlying disease, its severity and stage, the aetiology of AKI, clinical and haemodynamic status of the patient, the resources available, and different costs of therapy may all influence the choice of the RRT strategy. AKI, with its risk of uraemic complications, represents an independent risk factor for adverse outcomes in critically ill patients after cardiac surgery. Whether early initiation of RRT is associated with improved survival is unknown, and also clear guidelines on RRT durations are still lacking. In particular, it remains unclear whether haemodynamically unstable patients who develop septic shock pre- and postoperatively can benefit from early RRT initiation. In addition, it is not known whether in AKI patients undergoing cardiac surgery RRT modalities can eliminate significant amounts of clinically relevant inflammatory mediators. This review gives an update of information available in the literature on possible mechanisms underlying AKI and the recent developments in continuous renal replacement treatment modalities.

Objective: We evaluated the mid-term results of the right axillary incision used for the repair of various congenital heart defects. Methods: All the patients who were operated with this incision between March 2001 and December 2007 were reviewed. There were 123 patients (median age 4.7 {0.4–19.4} years and median weight 16.6 {3.8–62} kg) undergoing atrial septal defect (ASD) closure (62), repair of partial anomalous pulmonary venous connection (PAPVC) (22), correction of partial atrioventricular septal defect (AVSD) (19), and restrictive perimembranous ventricular septal defect (VSD) (20). Additional procedures involved tricuspid valve plasty (10), mitral annuloplasty (3), reduction plasty of the aortic sinus (2), resuspension of the aortic valve cusp (2), sub aortic membrane resection (1), or reimplantation of Scimitar vein (1). The surgical technique involved peripheral (groin) and central (SVC ± aorta) cannulation for institution of cardiopulmonary bypass. Fibrillatory arrest was used for repair of ASDs and cardioplegic arrest for repairs involving the atrioventricular valves as well as VSDs. The median CPB and aortic clamp times were 72 (35–232) and 0 (0–126) min, respectively. Results: There was no need for conversion to another approach in any patient. Early morbidity included transient paresis of left upper arm (1), stenting of SVC after repair of a sinus venosus defect (1) and revision for bleeding (1). Follow-up echo showed no residual defect in 116 patients and minor residual defects in 7 patients: tiny ASD (2), tiny VSD (1) and mitral regurgitation (4). One patient developed stenosis in the right external iliac artery used for cannulation, necessitating surgical intervention. All the patients are in excellent condition after a median follow-up of 4.1 (0.4–7.1) years. The incision healed well and the thorax and the breast showed no deformity on follow-up. Conclusions: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because of its deceitful location, and the camouflaging effect of being hidden by the resting arm, it has superior cosmetic appeal compared to conventional incisions. The incision does not interfere with subsequent development of the thorax or the breast (in case of females).

Objective: Patients with heterotaxy syndrome have a myriad of visceral and cardiac malformations historically resulting in significant morbidity and mortality. We sought to assess whether current era management strategies have improved outcomes in patients with visceral heterotaxy. Methods: A retrospective review (1994–2008) of our database identified 45 consecutive heterotaxy patients who underwent surgical palliation. There were 29 patients with right atrial isomerism (RAI) and 16 patients with left atrial isomerism (LAI). Functional single ventricle was present in 32 patients. Pulmonary outflow obstruction was present in 29 of the patients. Twenty patients had total anomalous pulmonary venous return (TAPVR), of which 9 were obstructed. An initial neonatal surgical approach was performed in 27 patients. Thirty patients had systemic to pulmonary artery shunt. Mean follow-up was 43.6 ± 47 months in RAI and 41.0 ± 40.8 months in LAI patients (p = 0.4). Results: There were three hospital deaths, all after the first operation, and four interstage deaths (six RAI; one LAI). There were no deaths after cavopulmonary shunt, Kawashima or Fontan operation. A multivariate Cox regression identified greater than moderate atrioventricular valve regurgitation (Hazard Ratio (HR) 17.5, p = 0.017) and obstructed TAPVR (HR 17.5, p = 0.007) as factors associated with increased RAI mortality. Due to the absence of late mortality in both groups, patient survival at 3 years were 79% in RAI and 94% in LAI patients and remained stable after that (p = 0.22). All survivors but one are in NYHA class I or II, without significant cardiovascular related symptoms. LAI patients have a higher incidence of sinus node dysfunction than RAI patients (47% vs 12.5%, p = 0.009). Conclusions: Surgical outcomes in heterotaxy patients are improving in the current era. The risk for operative mortality and attrition is highest between the first and second stage palliation procedures. Significant atrioventricular valve regurgitation and obstructed TAPVR remain risk factors for RAI mortality. Survivors are doing well with no activity restrictions, although LAI patients maintain a higher proclivity of sinus node dysfunction.

Background: Congenitally corrected TGA (CC-TGA) is characterized by discordant atrioventricular and ventriculo arterial connections. In absence of right ventricular outflow tract obstruction (RVOTO), repair by atrial and arterial switches remains a challenging procedure for which long term follow-up is uncertain. Methods: From 1995 to 2007, 20 patients (median age: 26 months) with CC-TGA had double switch procedure. Segmental anatomy was {SLL} in all patients, dextrocardia in two patients, mesocardia in two patients. Ventricular septal defect was present in 17 patients, aortic coarctation in 2 patients and interrupted aortic arch (IAoA) in 1 patient. Five patients had tricuspid valve regurgitation. Six patients had AV blocks, 4 patients had pacemaker implantation prior to repair. Pulmonary artery banding was performed in 17 patients, for congestive heart failure (14 patients) or left ventricular retraining (3 patients). Three patients, including one patient with IAoA had primary repair. After LV retraining, repair was performed when indexed LV mass to LV volume ratio was above 1.5. A median follow-up of 60 months was achieved in all. Results: There were no deaths. Postoperative pacemaker implantation was required in four patients. Reoperation for Senning obstruction was necessary in one patient, and pacemaker battery replacement in another patient. One patient had mild neoaortic insufficiency, two had mild tricuspid regurgitation and two had mild mitral regurgitation. All were in NYHA I–II. Actuarial survival at 10 years was 100% and freedom from reoperation at 5 and 10 years were 93% and 77.4%, respectively. Conclusion: Double switch for CC-TGA without RVOTO can be performed with no mortality and low morbidity. Since these results seem to last for several years, it should be considered as the optimal procedure.

Objective: Chronic volume overload in repair of tetralogy of Fallot (TOF) with transannular patch leads to significant late morbidity and mortality. Preserving pulmonary valve integrity offers a better long-term prognosis, despite a risk of residual stenosis. In our study we analyzed the evolution of pressure gradients in patients operated with conservative approaches, with particular regard to those babies with an immediate postoperative Prv/Plv ratio ≥0.70. Methods: Between January 2000 and June 2008, 24 patients with TOF underwent reparative surgery with a valve sparing procedure (median age 8.1 months, range 1.1–86.6). The intraoperative post-repair echocardiography showed a Prv/Plv ratio ≥0.70 in eight patients (33%, group A) and <0.70 in 16 patients (67%, group B). We realized a retrospective study of pre-, intra-, and postoperative data and of clinical and echocardiographic follow-up data. Results: There was no early or late mortality, nor functional or rhythmic disturbances. One patient required re-operation for residual stenosis at annular level at one year. After a median follow-up of 32.8 months (range 0.6–73.1), the Prv/Plv ratio decreased by 16% (p = 0.001) in all patients. In group A the reduction was 28% (p = 0.018) and in group B it was 12% (p = 0.14). Conclusions: After a valve sparing procedure there is a reduction of Prv/Plv ratio at medium-term follow-up; in our study this reduction was statistically significant in all patients and in the subgroup with higher postoperative ratios. A valve sparing strategy reduces pulmonary regurgitation, preserves RV function and decreases the incidence of late arrhythmias, which are the determinants of long-term outcome.

A wealth of experience has been gained in the management of atrioventricular septal defect (AVSD) since the first complete correction of this malformation in 1955. The success of surgical therapy followed an enhanced understanding of morphology and physiology as well as major improvements in imaging of this congenital heart defect. Therapeutic success in the management of patients with AVSD has been extended to include those with associated lesions such as tetralogy of Fallot, double outlet right ventricle and relative degrees of ventricular hypoplasia. Although operative mortality is low and long-term survival is relatively good, important detrimental residual or AVSD-related complications such as left atrioventricular valve regurgitation, left ventricular outflow tract obstruction still carry significant late morbidity in a proportion of patients. This article reviews our current understanding of the morphology of this defect, aspects of diagnosis and surgical treatment options.

Axillary artery has been proposed as a safe and effective alternative for arterial cannulation in surgical procedures involving ascending aorta and/or aortic arch, and is nowadays the site of choice in many centres. Advantages of axillary artery cannulation include antegrade flow and the possibility of selective mono-hemispherical brain perfusion during circulatory arrest. Experiences with the axillary vein cannulation, however, are scarce. Here we report our preliminary experience with axillo-axillary cardiopulmonary bypass, through both axillary artery and vein cannulation (using echo-guided Seldinger technique) at deltoido-pectoralis groove. We have used such an approach in 5 cases of redo surgery on ascending aorta and we have not had any inconvenience during cardiopulmonary bypass. Full flow was maintained in all patients (in 2 with vacuum assisted drainage) including 2 cases with deep hypothermic circulatory arrest. In conclusion such an approach seems to be feasible and effective and can be safely performed providing that accurate TE echo monitoring is provided.

We report an interesting case of a patient with Williams syndrome who presented with moderate supravalvar aortic stenosis and bilateral pulmonary artery stenosis at one week of age. The supravalvar aortic stenosis became severe by the age of one month with severe depression of left ventricular function. The patient had a difficult postoperative course, developed an acquired aortic arch hypoplasia and required multiple interventions during the first two months of life with an excellent outcome. The management of this difficult patient is discussed with focus on the importance of close follow-up, early diagnosis and early surgical intervention in improving the outcome in this difficult group of patients.

We report a rare case of recurrent thymoma with pleural dissemination invading the intervertebral foramen. A woman with Masaoka's stage IVa thymoma with myasthenia gravis (MG) underwent macroscopically complete resection. After 45 months, she developed back pain. Computed tomography (CT) of the chest demonstrated a mass in the right thoracic cavity invading the intervertebral foramen between thoracic vertebrae 10 and 11. She underwent complete resection of the tumor and postoperative radiotherapy. The resected specimen was histologically diagnosed as a pleural dissemination from thymoma. There has been no local recurrence.