Objective: To verify the accuracy and precision of the logistic European system for cardiac operative risk evaluation (EuroSCORE) in high-risk cardiac surgery patients and to develop and externally validate a new system of recalibration. Methods: The development series included 4279 high-risk patients who had undergone cardiac operations at the IRCCS Policlinico S. Donato. Performance, accuracy, and precision of the logistic EuroSCORE were assessed in this series, using a deciles-based comparison between expected and observed mortality rates, a receiver operating characteristic analysis, and a Hosmer–Lemeshow test for calibration. Differences between predicted and observed mortality rates were mathematically evaluated to develop an adjusted logistic EuroSCORE. This adjusted risk score was subsequently validated with the same approach on an external series of 1459 high-risk patients who had undergone cardiac operations at the Siena hospital. Results: The adjusted logistic EuroSCORE was based on five different correction factors applied to the crude logistic EuroSCORE depending on its value. At the external validation, this model provided a good performance, with observed mortality rates not significantly different from the expected in 8 out of 10 deciles of risk distribution. The adjusted EuroSCORE had the same moderate balanced accuracy of the crude logistic EuroSCORE (area under the curve: 0.695), with a better precision (Hosmer–Lemeshow calibration test: ²: 3.6, p = 0.891). Conclusions: Recalibration of the logistic EuroSCORE in high-risk patients is needed due to its tendency to overestimate the mortality risk. The application of a variable correction factor results in a better performance, increased precision, with unaltered balanced accuracy.

Objective: We derived a new risk-scoring method by modifying some of the risk factors included in the EuroSCORE algorithm. Methods: This study includes 3613 patients who underwent cardiac surgery at the Vaasa Central Hospital, Finland. The EuroSCORE variables, along with modified age classes (<60 years, 60–69.9 years, 70–79.9 years and ≥80 years), eGFR-based chronic kidney disease classes (classes 1–2, class 3 and classes 4–5) and the number of cardiac procedures, were entered into the regression analysis. Results: An additive risk score was calculated according to the results of logistic regression by adding the risk of the following variables: patients’ age classes (0, 2, 4 and 6 points), female (2 points), pulmonary disease (3 points), extracardiac arteriopathy (2 points), neurological dysfunction (4 points), redo surgery (3 points), critical preoperative status (8 points), left ventricular ejection fraction (>50%: 0; 30–50%: 2 and <30%: 3 points), thoracic aortic surgery (8 points), postinfarct septal rupture (9 points), chronic kidney disease classes (0, 3 and 6 points), number of procedures (1: 0; 2: 2 and 3 or more: 7 points). The modified score had a better area under the receiver operating characteristic curve (additive: 0.867; logistic: 0.873) than the EuroSCORE (additive: 0.835; logistic: 0.840) in predicting 30-day postoperative mortality. The modified score, but not EuroSCORE, correctly estimated the 30-day postoperative mortality. Conclusion: EuroSCORE still performs well in identifying high-risk patients, but significantly overestimates the immediate postoperative mortality. This study shows that the score's accuracy and clinical relevance can be significantly improved by modifying a few of its variables. This institutionally derived risk-scoring method represents a modification and simplification of the EuroSCORE and, likely, it would provide a more realistic estimation of the mortality risk after adult cardiac surgery.

Objective: Transcatheter aortic valve implantation (TAVI) is an alternative treatment for aortic stenosis in selected cases, but requires appropriate vascular access. We report our initial clinical experience with a novel endovascular approach for TAVI. Methods: Between 1 April 2007 and 31 August 2008, 48 patients underwent TAVI at our institution. Of these, eight patients (17%) were deemed to be best served through direct surgical exposure of the left axillary artery rather than a trans-femoral or TA approach. Results: Procedural success was achieved in seven of eight cases. In one patient the axillary artery was too small to accept the 18 French sheath. In the remaining seven, the device was implanted without major complication and with only trivial paravalvular aortic regurgitation. The in-hospital mortality was 0%. The 30-day mortality was 12.5% (one patient). There was one localised dissection at the origin of the vertebral artery. There was one late pericardial effusion and a permanent pacemaker was implanted in five patients. Conclusions: TAVI can be performed through a left axillary artery approach. This is a technically simple procedure and, in this small initial clinical experience, was performed with encouraging results. It is a realistic option in patients in whom neither the trans-femoral or trans-apical approaches are optimal.

Background: Severe peripheral arterial disease may pose a limitation to the applicability of trans-arterial aortic valve implantation in patients who are otherwise candidates. For this reason, transapical aortic valve implantation has been proposed as a possible alternative. Objective: To evaluate the acute safety and performance of a specially designed delivery system, the CoreValve Tranzap^TM delivery catheter, for the transapical implantation of a self-expandable aortic valve prosthesis in a porcine animal model. Methods: Thirteen pigs were implanted with a self-expandable aortic valve bioprosthesis using a 21F catheter delivery system through a transapical approach. The delivery system was evaluated for: (1) the ability to access the implantation site; (2) the ability to precisely position the delivery catheter; (3) control of the delivery of the prosthesis; (4) safe retrieval of the delivery catheter; and (5) the ability to close the apical access site of the heart. Results: Successful implantation was achieved in 100% of the cases. The following points were achieved in all animals: (1) passage of the delivery catheter through an incision in the left ventricular apex; (2) positioning of the delivery catheter on the implantation site; (3) controlled deployment of the aortic valve prosthesis; (4) the safe retrieval of the delivery catheter system; and (5) the adequate closure of the apex of the heart. Conclusion: This study demonstrates the acute safety and feasibility of the CoreValve Tranzap^TM delivery system for the transapical implantation of the CoreValve self-expanding aortic valve bioprosthesis in a porcine animal model.

Objective: Advancing life expectancy with the increased prevalence of aortic valve degenerative disease brings the need for an aortic bioprosthesis with excellent haemodynamic performance and comparable durability. The Mitroflow bioprosthesis has been on the worldwide market, except in the United States, since 1982, while the current model (1991) has only recently gained regulatory approval in the latter country. This study was primarily performed to determine the durability of the current Mitroflow bioprosthesis. Methods: The contemporary Mitroflow bioprosthesis was implanted in 381 patients in three centres. The mean age was 76.4 years (range 53–91 years) and the mean follow-up period was 5.4 ± 3.4 years, a total of 2048.7 years of evaluation. Prosthesis–patient mismatch (PPM) was classified by reference effective orifice area index categories: normal ≥0.85 cm² m^–2 (53.9%), mild 0.84–0.76 cm² m^–2 (33.9%), moderate ≤0.75–0.66 cm² m^–2 (11.7%) and severe ≤0.65 cm² m^–2 (0.5%). Results: The survival, at 10 years, was 39.9 ± 7.9% for 50–69 years, 27.0 ± 3.7% for 70–79 years and 16.6 ± 4.4% for ≥80 years (p = 0.011). There was a trend (p = 0.063) influencing survival for moderate-to-severe PPM. Of the independent predictors influencing survival – moderate-to-severe projected effective orifice area index (pEOAI) (Hazard Ratio (HR) 1.6, p = 0.0142) and left ventricular dysfunction (ejection fraction <35%) (HR 1.9, p = 0.0193) were included. The 10-year freedom from structural valve deterioration (SVD) at explant assessing the same age groups as survival was not different (p = 0.081). The 10-year actual/actuarial freedom from SVD, at explant was for ≥60 years – 94.4 ± 1.4% (85.2 ± 3.9%), for ≥65 years – 94.2 ± 1.4% (85.0 ± 4.0%), for 61–70 years – 97.4 ± 2.6% (95.7 ± 4.3%) and for >70 years – 94.0 ± 1.5% (83.2 ± 4.6%). Conclusions: The Mitroflow external mounted, pericardial aortic bioprosthesis with documented excellent haemodynamics (especially for the small aortic root), demonstrates that prosthesis–patient mismatch in moderate and severe categories can essentially be eliminated, with durability performance comparable to other heterograft (porcine and pericardial) bioprostheses.

Objective: Tricuspid valve replacement (TVR) has a high postoperative mortality, despite recent advances in perioperative care. We report the results of our experience in TVR with an emphasis on early mortality and morbidity and long-term follow-up. Methods: Between October 1994 and August 2007, 80 consecutive TVRs were performed in 78 patients. The mean age was 48 ± 14 (range: 20–70) years. The underlying disease of the patients was classified as rheumatic (n = 54), congenital (n = 12), endocarditis (n = 10) or degenerative (n = 4). Previous cardiac surgery had been performed in 40 patients (50%). Isolated TVR was performed in 24 patients (30%). Results: Hospital mortality occurred in one patient (1.4%). Postoperative morbidities included intra-aortic balloon pump (n = 5), bleeding re-operation (n = 4), delayed sternal closure (n = 3), acute renal failure (n = 3), subdural haematoma (n = 3), extracorporeal membrane oxygenation (n = 1), mediastinitis (n = 1) and pacemaker insertion (n = 4). In 42 patients, ventilator support was needed for more than 72 h. Based on multivariate analysis, age (p < 0.001) and the cardiopulmonary time (p = 0.004) were the identified risk factors. Follow-up was completed in all patients with a mean duration of 56 ± 37 (range: 0–158) months. During the follow-up period, there were seven deaths (8.8%), including five cardiac deaths. The 5- and 8-year survival rates were 95 ± 3% and 79 ± 9% and event-free survival rates were 76 ± 6% and 61 ± 9%, respectively. Based on multivariate analysis, the only identified predictors of late deaths was a postoperative low cardiac output (p = 0.024). Conclusions: TVR can be performed and low operative mortality can be achieved thorough optimal perioperative management in the current era.

Objective: Experimental testing of annuloplasty ring (AR) effects requires a control group if the AR is implanted conventionally. Our goal was to develop a reversible AR insertion method that allows for beating heart assessment with and without an AR, providing the ability to evaluate the effects of an AR in the same animal (internal control). We tested the feasibility of this technique in an in vivo ovine model using four-dimensional (4-D) radiopaque marker tracking. Methods: Before the operation, a rigid AR (Edwards Geoform^®, Edwards Lifesciences, Irvine, CA, USA) was prepared by stitching the middle parts of eight double-armed sutures evenly spaced through the ring fabric using a Spring Eye needle. The resulting loops were ‘locked’ with polypropylene sutures. In addition, two drawstring sutures were attached to the AR. Using cardiopulmonary bypass and cardioplegic arrest, 12 adult sheep had 16 radiopaque markers sewn to the mitral annulus. The AR was implanted by stitching the eight sutures equidistantly in a perpendicular direction through the mitral annulus. The sheep were transferred to the catheterisation laboratory and 4-D marker coordinates were obtained using biplane videofluoroscopy (60 Hz) with the AR inserted (Geo-AR). The locking sutures were then released, the AR was pulled up to the atrial roof using the drawstring sutures and another dataset was acquired (control). Maximum and minimum mitral annular areas (MAA_max, MAA_min) during the cardiac cycle were derived from implanted markers. Data are provided from one representative animal. Results: AR insertion and release were uneventful in all animals. Whereas the mitral annulus was dynamic in the control state (MAA_max: 9.0 cm², MAA_min: 7.8 cm²), mitral annular dynamics were abolished in the Geo-AR case (MAA_max: 6.2 cm², MAA_min: 6.0 cm²). Conclusions: This novel releasable AR implantation method is feasible and permits in vivo assessment of AR effects in the same heart. The new technique should facilitate experimental AR testing and promote the development of ARs based on physical criteria.

Objective: Pulmonary vein isolation (PVI) using ablation energy appears an effective treatment for atrial fibrillation (AF) with a success rate of approximately 80%. However, post-procedural neurological complications still occur in 0.5–10% of all patients undergoing PVI, presumably due to embolism. Therefore, we investigated the occurrence of cerebral micro-embolic signals (MES) as a surrogate marker for the risk of neurological impairment of two different PVI methods: (1) percutaneous endocardial radio-frequency (RF) ablation and (2) thoracoscopic epicardial ablation using RF energy. Methods: Ten patients (eight persistent AF and two paroxysmal AF) underwent a minimally invasive thoracoscopic epicardial (EPI) RF ablation and 10 patients (one persistent AF and nine paroxysmal AF) underwent a percutaneous endocardial (ENDO) isolation. Transcranial Doppler (TCD) was used to detect an MES in the middle cerebral arteries. Results: An average of 5 (±6) MES were detected during epicardial PVI procedure versus 3908 (±2816) MES during percutaneous endocardial PVI procedure. During the ablation application period, respectively, 1 (±1) and 2566 (±2296) cerebral MES were detected. Conclusions: Cerebral micro-emboli during epicardial ablation are almost absent when compared to the thousands of emboli measured during percutaneous endocardial ablation.

Objectives: Considering the role of inflammatory reaction on the pathogenesis of atrial fibrillation (AF), the aim of this study is to investigate perioperative risk factors of AF, as well as to validate the predictive value of high-sensitive C-reactive protein (hsCRP), and transfusion requirement following off-pump coronary bypass surgery (OPCAB) in a prospective and observational trial. Methods: In this cohort, 315 consecutive patients with normal sinus rhythm (NSR) undergoing elective isolated OPCAB are prospectively studied. The patients were classified as either NSR or AF group according to their postoperative rhythm, which was continuously monitored for the first 6 postoperative days. Results: AF developed in 66 patients (19%). Univariate analysis demonstrated old age, pre-existing chronic renal failure, low left ventricle ejection fraction (LVEF <30%), highest hsCRP before the onset of AF, vasopressor and inotropic therapy, packed red blood cells (pRBCs) transfusion and amount of chest tube drainage as predictors of postoperative AF. In a stepwise multivariate analysis of these risk factors, low LVEF (odds ratio: 2.88; 95% confidence interval: 1.07–7.75; p = 0.037), highest hsCRP before the onset of AF (odds ratio: 1.06; 95% confidence interval: 1.01–1.11; p = 0.018), vasopressor therapy (odds ratio: 1.93; 95% confidence interval: 1.04–3.57; p = 0.038) and pRBC transfusion (odds ratio: 5.32; 95% confidence interval: 2.80–10.11; p < 0.001) remained as independent predictors of postoperative AF. Conclusions: Prophylactic strategies aimed at AF reduction may also be considered especially in patients with increased transfusion requirement, which showed highest predictive value for postoperative AF.

Background: Coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC) is the gold standard for surgical coronary re-vascularisation. Recently, minimised extracorporeal circulation system (MECC) has been postulated a safe and advantageous alternative for multi-vessel CABG. Method: Between January 2004 and December 2007, 244 high-risk patients (logistic EuroScore (ES) > 10%) underwent CABG in our institution. ECC was used in 139 (57%) and MECC in 105 (43%) patients. Demographic data including age (MECC: 73.4 ± 7.4 years; ECC: 73.3 ± 6.4 years), ES (MECC: 19.2 ± 9.8%; ECC: 21.4 ± 11.9%), left-ventricular ejection fraction (MECC: 45.6 ± 16.1%; ECC: 43.1 ± 15.3%), diabetes mellitus (MECC: 14.3%; ECC: 15.1%) and COPD (MECC: 6.7%; ECC: 7.9%) did not differ between the two groups. Preoperative end-stage renal failure was an exclusion criterion. The clinical course and serological/haematological parameters in the ECC and MECC patients were compared in a retrospective manner. Results: Although the numbers of distal anastomoses did not differ between the two groups (MECC: 3.0 ± 0.9; ECC: 2.9 ± 0.9), ECC time was significantly shorter in the MECC group (MECC: 96 ± 33 min; ECC: 120 ± 50 min, p < 0.01). Creatinine kinase (CK) levels were significantly lower 6 h after surgery in the MECC group (MECC: 681 ± 1505 U l^–1; ECC: 1086 ± 1338 U l^–1, p < 0.05) and the need of red blood cell transfusion was significantly less after MECC surgery (MECC: 3 [range: 1–6]; ECC: 5 [range: 2–9] p < 0.05). Moreover, 30-day mortality was significantly lower in the MECC group as compared to the ECC group (MECC: 12.4%; ECC: 26.6, p < 0.01). Discussion: MECC is a safe alternative for CABG surgery. A lower 30-day mortality, lower transfusion requirements and less renal and myocardial damage encourage the use of MECC systems, especially in high-risk patients.

Objective: Acute kidney injury (AKI) post-cardiac surgery is associated with mortality rates approaching 20%. The development of effective treatments is hindered by the poor homology between rodent models, the mainstay of research into AKI, and that which occurs in humans. This pilot study aims to characterise post-cardiopulmonary bypass (CPB) AKI in an animal model with potentially greater homology to cardiac surgery patients. Methods and results: Adult pigs, weighing 50–75 kg, underwent 2.5 h of CPB. Pigs undergoing saphenous vein grafting procedures served as controls. Pre-CPB measures of porcine renal function were within normal ranges for adult humans. The effect of CPB on renal function; a 25% reduction in ⁵¹Cr-EDTA clearance (p = 0.068), and a 33% reduction in creatinine clearance (p = 0.043), was similar to those reported in clinical studies. CPB resulted in tubular epithelial injury (median NAG/creatinine ratio 2.6 u mmol^–1 (interquartile range (IQR): 0.81–5.43) post-CPB vs 0.48 u mmol^–1 (IQR: 0.37–0.97) pre-CPB, p = 0.043) as well as glomerular and/or proximal tubular injury (median albumin/creatinine ratio 6.8 mg mmol^–1 (IQR: 5.45–13.06) post-CPB vs 1.10 mg mmol^–1 (IQR: 0.05–2.00) pre-CPB, p = 0.080). Tubular injury scores were significantly higher in kidneys post-CPB (median score 2.0 (IQR: 1.0–2.0) relative to vein graft controls (median score 1.0 (IQR 1.0–1.0), p = 0.019). AKI was associated with endothelial injury and activation, as demonstrated by reduced DBA (dolichos biflorus agglutinin) lectin and increased endothelin-1 and vascular cell adhesion molecule (VCAM) staining. Conclusions: The porcine model of post-CPB AKI shows significant homology to AKI in cardiac surgical patients. It links functional, urinary and histological measures of kidney injury and may offer novel insights into the mechanisms underlying post-CPB AKI.

Objective: The optimal timing for discontinuation of clopidogrel before surgery remains under debate. The purpose of this study is to determine the effect of preoperative clopidogrel administration on postoperative blood loss and the total requirements of homologous blood products after coronary artery bypass grafting (CABG). We also evaluated the perioperative complications. Methods: Consecutive patients (n = 130) undergoing elective CABG were recruited and randomised between 2006 and 2007. In 38 patients (group 1), treatment with clopidogrel was discontinued 5 days prior to surgery, in 40 patients (group 2) 3 days before surgery and in 40 other patients (group 3) clopidogrel was stopped on the day of surgery. Results: Significantly more postoperative blood loss was observed in group 3 compared to group 1 (929 ± 472 ml vs 664 ± 312 ml; p = 0.009). Other group comparisons were not significant. Blood loss after 12 h and at drain removal was also significantly higher in group 3. Patients in group 3 also had higher total requirements of homologous blood products (p = 0.046) and a significantly higher need for fresh frozen plasma (FFP) transfusion (p = 0.034). Univariable regression analyses revealed that continuing clopidogrel till the day of surgery (group 3) was predictive for postoperative blood loss (β = 0.289; p = 0.007) and the total requirements of homologous blood products after surgery (β = 0.280; p = 0.008). These effects remained the same in multivariable analyses. Conclusions: Continuation of clopidogrel until the day of surgery induces significantly more postoperative blood loss and increases significantly the total requirements of homologous blood products and FFP transfusion after surgery. The blood loss and the use of blood products in the group that stopped at 3 days preoperatively were similar to that of the group that stopped at 5 days preoperatively.

Objective: The effectiveness and safety of aprotinin use in cardiac surgery have been questioned. More data reflecting everyday clinical practice from large-scale, unselected populations are needed. We compared the effectiveness and safety of aprotinin in cardiac surgery with those of tranexamic acid in a follow-up study using the population-based Danish health-care databases. Methods: We identified a total of 3535 patients who underwent cardiac surgery at the Aarhus University Hospital, Skejby, between 1 January 2003 and 31 December 2006; of these, 635 patients were treated with aprotinin and 2900 with tranexamic acid. We used propensity score matching to match aprotinin-treated patients with tranexamic-acid-treated patients in a 1:1 ratio, followed by Poisson regression analysis to compute relative risks (RRs). Results: Patients treated with aprotinin had more severe preoperative risk profiles than the tranexamic-acid-treated patients. The rates of postoperative drainage and transfusion of red blood cells were similar in the two groups, whereas the aprotinin group received plasma (adjusted RR = 1.39; 95% confidence interval (CI): 1.15–1.68) and platelets (adjusted RR = 1.47; 95% CI: 1.19–1.81) more frequently than the tranexamic acid group. There were no statistically significant differences in risks of re-operation due to bleeding (adjusted RR = 1.22; 95% CI: 0.84–1.78), 30-day mortality (adjusted RR = 1.03; 95% CI: 0.69–1.54), acute myocardial infarction (adjusted RR = 1.06; 95% CI: 0.69–1.64), stroke (adjusted RR = 1.36; 95% CI: 0.75–2.44) or composite major event (adjusted RR = 1.14; 95% CI: 0.87–1.50) between the two groups. However, patients who received aprotinin had an increased risk of postoperative dialysis (adjusted RR = 1.76; 95% CI: 1.15–2.70). Conclusions: Aprotinin treatment was associated with an increased use of plasma and platelet transfusion and an increased risk for postoperative dialysis, but not with other adverse outcomes, including short-term mortality.

Background: Aprotinin is the only Food and Drug Administration-approved agent to reduce haemorrhage related to cardiac surgery and its safety and efficacy has been extensively studied. Our study sought to compare the efficacy, early and late mortality and major morbidity associated with aprotinin compared with e-aminocaproic acid (EACA) in cardiac surgery operations. Methods: Between January 2002 and December 2006, 2101 patients underwent coronary artery bypass grafting (CABG), valve surgery or CABG and valve surgery in our institution with the use of aprotinin (1898 patients) or EACA (203 patients). Logistic regression and propensity score analysis were used to adjust for imbalances in the patients’ preoperative characteristics. The propensity score-adjusted sample included 570 patients who received aprotinin and 114 who received EACA (1–5 matching). Results: Operative mortality was higher in the aprotinin group in univariate (aprotinin 4.3% vs EACA 1%, p = 0.023) but not propensity score-adjusted multivariate analysis (4% vs 0.9%, p = 0.16). In propensity score-adjusted analysis, aprotinin was also associated with a lower rate of blood transfusion (38.8% vs 50%, p = 0.04), a lower rate of haemorrhage-related re-exploration (3.7% vs 7.9%, p = 0.04) and a higher risk of in-hospital cardiac arrest (3.7% vs 0%, p = 0.03) and a marginally but not statistically significantly higher risk of acute renal failure (6.8% vs 2.6%, p = 0.09). In Cox proportional hazards regression analysis, the risk of late death was higher in the aprotinin compared to EACA group (hazard ratio = 4.33, 95% confidence interval (CI) = 1.60–11.67, p = 0.004). Conclusion: Aprotinin decreases the rate of postoperative blood transfusion and haemorrhage-related re-exploration, but increases the risk of in-hospital cardiac arrest and late mortality after cardiac surgery when compared to EACA. Cumulative evidence suggests that the risk associated with aprotinin may not be worth the haemostatic benefit.

Objective: Leucocyte filtration of salvaged blood has been suggested to prevent patients from receiving activated leucocytes during auto-transfusion in cardiac surgery. This study examines whether leucocyte filtration of salvaged blood affects the red blood cell (RBC) function and whether there is a difference between filtration of the concentrated and diluted blood on RBC function. Methods: Forty patients undergoing cardiac surgery with cardiopulmonary bypass were randomly divided into a group receiving leucocyte filtration of concentrated blood (High-Hct, n = 20) and another group receiving leucocyte filtration of the diluted blood (Low-Hct, n = 20). During operation, all the salvaged blood, as well as the residual blood, from the heart–lung machine was filtered. In the High-Hct group, blood was concentrated with a cell saver prior to filtration, whereas in the Low-Hct group, blood was filtered without concentration. RBC function was represented by RBC aggregation and deformability measured by a laser-assisted optical rotational cell analyser and by the RBC 2,3-diphosphoglycerate (2,3-DPG) and adenosine triphosphate (ATP) contents with conventional biochemical tests. Results: Leucocyte filtration of diluted blood with a low haematocrit (14 ± 4%) did not affect RBC function. However, when the concentrated blood with a high haematocrit (69 ± 12%) was filtered, there was a reduction of ATP content in RBCs after passing through the filter (from 1.45 ± 0.57 µmol g^–1 Hb to 0.92 ± 0.75 µmol g^–1 Hb, p < 0.05). For patients who received the concentrated blood, their in vivo RBC function did not differ from those who received diluted blood. Conclusions: Leucocyte filtration of the diluted salvaged blood during cardiac surgery does not affect RBC function, but it tends to deplete the ATP content of RBCs as the salvaged blood has been concentrated prior to filtration.

Objective: Diaphragmmatic eventration is a relatively uncommon entity with a simple surgical correction technique – plication of the diaphragm. This study aims to assess the clinical and ventilatory impact of this technique. Materials: From April 1988 to February 2007, we operated on 20 patients (12 men) with diaphragmmatic eventration using the postero-lateral approach and correction by radial plication. The mean age of the patients studied was 56.3 ± 15.6 years (range: 13–74 years). A traumatic cause was identified in 13 patients; one patient had a congenital cause and the remainder were of idiopathic origin. Chronic obstructive pulmonary disease and arterial hypertension were present in one-half of the study group, while diabetes mellitus was present in three patients. Dyspnoea was the most common complaint in 75% of the patients, and thoracic pain was present in 25%. The mean forced expiratory volume in 1 s (FEV₁) and vital capacity (VC) were 66.2 ± 15.3% and 70.4 ± 16% of the predicted values, respectively. Results: There was no operative mortality. Apart from a patient with moderate/severe pain and another who had pneumonia, there were no other important perioperative complications. Average drainage time was 3.3 ± 1.6 days (range: 2–7 days). Hospitalisation time was 6.2 ± 1.6 days (5–10 days). Follow-up was complete, for a mean of 59.6 ± 55.1 months (4–206 months). There were three late deaths (one sudden, one stroke and one trauma). Eight of the 17 survivors (47%) are asymptomatic. According to the MRC/ATS grading system, the dyspnoea score was 2.06 ± 0.97 preoperatively and 1.06 ± 1.14 postoperatively (p = 0.007). At follow-up, the FEV₁ was 76.1 ± 20.1% and the VC was 78.4 ± 17.3% (p > 0.1). Two patients had chronic pain. Conclusion: Plication of the diaphragm is a safe and efficient procedure. Most patients experienced significant clinical improvement with enhancement of the FEV₁ and VC. Chronic surgical pain still remains a potential problem with the classical approach.

Objective: Oesophagectomy, whether open or minimal access, is associated with a significant incidence of gastric-conduit-related complications. Previous animal and human studies suggest that ischaemic conditioning of the stomach prior to oesophagectomy improves perfusion of the gastric conduit. We have adopted laparoscopic ligation of the left gastric artery 2 weeks prior to minimally invasive oesophagectomy, having identified a relative high incidence of gastric-tube complications through a cumulative summation (CUSUM) analysis. Methods: This study included 77 consecutive patients who underwent a Total MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric tube formation, cervical anastomosis). The ligation group comprised 22 consecutive patients, excluding those with middle-third squamous tumours or early-stage adenocarcinoma, who underwent ligation 2 weeks prior to MIO at staging laparoscopy. The control group comprised 55 patients who did not undergo ischaemic conditioning in this way. We have defined conduit-related complications as: leak managed conservatively (L); tip necrosis requiring resection and re-anastomosis (TN) and conduit necrosis needing resection and oesophagostomy (CN). The values are reported as medians. The effect of ligation of the left gastric artery was followed with a CUSUM analysis. Results: Ligation was performed 15.5 days pre-operatively (median). There were no complications and the length of hospital stay was 1 day. Although gastric mobilisation at MIO was technically more difficult after ligation, there was no significant difference in operating time (ligation, 407 min; control, 425 min) or blood loss (ligation and control, 500 ml). There was less gastric-conduit morbidity in the ligation group (two of 22, 10%; one L, one CN) compared with the control group (11 of 55, 20%; four L, five TN, two CN), but these differences did not reach statistical significance (p = 0.211 and p = 0.176 Fisher's exact test). The CUSUM analysis showed that during ligation of the left gastric artery, conservatively treated gastric-conduit-related morbidity (leak, resection and re-anastomosis or conduit necrosis) remained within safe limits (10%). Conduit-related-morbidity increased after stopping ligation. Conclusion: In this non-randomised clinical setting, our results suggest that ischaemic conditioning of the stomach prior to MIO is safe. There is a trend to reduced morbidity related to gastric-conduit ischaemia, which was demonstrated by a CUSUM analysis. A randomised trial is needed before ligation of the left gastric artery can be routinely recommended.

Objective: Controversy still persists regarding the ideal length of myotomy to treat oesophageal achalasia. This investigation reports the effects of a short myotomy with an added partial fundoplication for reflux prevention. Methods: From 1997 to 2007, 22 patients (13 men, 9 women, median age: 41 years) with achalasia underwent a 6-cm short myotomy (four oesophagus and two stomach) with a Belsey partial fundoplication by left thoracotomy. Assessments include clinical and radiological evaluation, radionuclide transit studies, manometry, 24-h pH and endoscopy. Results: No morbidity and no mortality occurred. Median follow-up is 54 months (range: 4–139 months). Dysphagia present in all 22 patients left an episodic slow emptying sensation in three patients after operation (p < 0.001). Fresh food regurgitation decreased significantly after the myotomy (17 pre-, four post-regurgitation, p < 0.001). Heartburn present in four patients before the operation was recorded in nine patients postoperatively (p = 0.179). Radiologically, barium stasis decreased significantly from 85% to 30% (p = 0.007). No diverticular formation was seen in the myotomy zone. On the oesophageal scintigram, stasis at 2 min decreased from a median of 60% before the operation to 16% (p < 0.001). The lower oesophageal sphincter (LOS) gradient decreased from 30 to 9.7 mmHg (p < 0.001). LOS relaxation improved from 40% pre- to 93% postoperatively (p = 0.003). Endoscopies and biopsies documented increased mucosal damage after the operation (one preoperative, 13 postoperative; p < 0.001). Conclusions: When treating achalasia, the myotomy, despite being shortened in length, reduces the LOS gradient, relieves obstructive symptoms and improves oesophageal emptying. The LOS relaxation is improved. Complete coverage of the myotomysed zone by the fundus prevents diverticular formation. Oesophageal mucosal damage from reflux is significant despite the partial fundoplication.

Objective: Paravertebral block (PVB) is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. Rib spreading (RS) is an important noxious stimulus considered a major cause of post-thoracotomy pain. Our hypothesis was that a bolus of ropivacaine 0.2% through a paravertebral catheter (PVC) inserted before RS could decrease pain during the first 72 postoperative hours. Methods: The methodology employed was to perform a prospective randomised study of 60 consecutive patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). A catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group, patients were randomised to receive a bolus of 20 ml of ropivacaine 0.2% before rib spreading (pre-RS) or after (post-RS), just before closing the thoracotomy. They postoperatively received 15 ml of ropivacaine 0.2% every 6 h combined with methamizol (every 6 h). Subcutaneous meperidine was employed as a rescue drug. The level of pain was measured with the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as a rescue drug and secondary effects were also recorded. Results: We did not register secondary effects in relation to the PVC (paravertebral or cutaneous bleeding or haematoma, respiratory depression, cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting or pruritus). Seven patients (11.6%) needed meperidine as rescue drug (four pre-RS and three post-RS). The mean VAS values were the following: all cases (n = 60): 4.7 ± 2.0; AT (n = 32): 4.0 ± 2.1; PT (n = 28): 5.6 ± 1.8; pre-RS (n = 30): 4.8 ± 1.9; post-RS (n = 30): 4.6 ± 2.0; AT-pre-RS (n = 16): 4.1 ± 2.0; AT-post-RS (n = 16): 3.9 ± 2.1; PT-pre-RS (n = 14): 5.6 ± 1.6; PT-post-RS (n = 14): 5.4 ± 1.7. Conclusions: Post-thoracotomy analgesia combining PVC and a non-steroidal anti-inflammatory drug is a safe and effective practice. VAS values are acceptable (only 11.6% of patients required meperidine). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.0 vs 5.6; p < 0.01). PVB with ropivacaine before RS got similar VAS values than the block after RS (4.8 vs 4.6; p > 0.05). The moment of the insertion of the PVC does not seem to affect postoperative pain levels.

Objective: Pleurectomy ± bullectomy by video-assisted thoracoscopic surgery (VATS) is an established surgical procedure for pneumothorax. Early ambulation and discharge should be a reasonable goal. This study explores the feasibility of day-case surgery and identifies the obstacles requiring further work to facilitate day-case pneumothorax surgery. Methods: Between June 2007 and May 2008, 16 consecutive patients underwent video-assisted thoracoscopic surgery bullectomy ± pleurectomy (under the care of a single surgeon) with immediate connection to an ambulatory drainage system in the theatre following surgery. Analgesia comprised temporary paravertebral with early conversion to oral opiate ± paracetamol. There were 13 males (81%), average age 23 (range: 17–29) years, and three females (19%), average age 35 (range: 22–46) years. Twelve patients (75%) had left-sided disease, of which nine (56%) underwent elective surgery. All patients had previously suffered at least one primary spontaneous pneumothorax. Patients with probable secondary pneumothorax were excluded from the study. Length of stay (LOS) was compared with a control group of patients conventionally treated prior to the study. Results: In 13 patients (81%), early discharge was achieved 1 (range: 1–2 days) day post-op, whilst connected to an ambulatory drainage system. In three patients, early discharge was not achieved. One of these patients had the chest drain removed prematurely and remained an inpatient for 3 days with aspiration and observation for a small pneumothorax. The two remaining patients required extended inpatient admissions due to postoperative non-surgical complications. In the 13 patients discharged immediately, the time to drain removal (in clinic) was electively 7 days (range: 2–11 days). Two patients required re-admission: one for contralateral spontaneous pneumothorax and another for an ipsilateral basal pneumothorax treated with a drain. Conclusion: We have shown early discharge with ongoing ambulatory drainage following VATS pleurectomy ± bullectomy in patients with primary pneumothorax to be feasible with paravertebral in the theatre and rapid conversion to oral analgesia. Patients managed intercostal drains at home. Limiting factors such as postoperative nausea and pain control usually can be sufficiently managed in the outpatient. Shorter stays may have a beneficial financial result. Long-term follow-up and a quantification of the patients experience is warranted.

Objective: Lung resection for complex aspergilloma (CA) carries high morbidity and mortality and remains controversial in high-risk patients. Cavernostomy followed by muscle-flap plombage has been recommended for patients considered unfit for resection, but subsequent muscle-flap atrophy may be a main cause of failure. We reviewed the place of a limited thoracoplasty in association with that procedure. Methods: Five patients complaining of haemoptysis related to CA were denied lung resection because of bilateral lung destruction (n = 1), and required completion pneumonectomy (previous lobectomy for cancer followed by adjuvant radiation therapy, n = 4). We analysed the data concerning the alternative surgical procedures performed and their immediate and late results. Results: The surgery consisted in cavernostomy, removal of the fungus ball, cavity obliteration with the most directly available muscle flaps (rhomboid muscle n = 2, trapezius and rhomboid n = 2, serratus major and subscapular n = 1). A limited thoracoplasty ranging from 2 to 5 portions of rib (mean resected rib portions n = 3.4) was performed in addition to this procedure. The postoperative course was uneventful. All patients are still alive (mean follow-up 3 years; range: 1–6 years) and faring well without thoracoplasty-related aftereffect, complication related to muscle-flap disuse atrophy nor recurrence of the disease. Conclusion: Cavernostomy followed by muscle transposition has been reported to provide encouraging results. Combining a limited thoracoplasty during the same operation is a simple, safe and well-tolerated procedure regularly achieving good results, and thus deserving consideration.

Objective: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. Methods: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17–82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. Results: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p < 0.0001), postoperative air leak (p = 0.004), operative time (p < 0.0001), hospital stay (p = 0.020) and time to return to work (p < 0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. Conclusions: In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.

Objective: We hypothesised that the agonal phase prior to cardiac death may negatively influence the quality of the pulmonary graft recovered from non-heart-beating donors (NHBDs). Different modes of death were compared in an experimental model. Methods: Non-heparinised pigs were divided into three groups (n = 6 per group). Animals in group I [FIB] were sacrificed by ventricular fibrillation resulting in immediate circulatory arrest. In group II [EXS], animals were exsanguinated (45 ± 11 min). In group III [HYP], hypoxic cardiac arrest (13 ± 3 min) was induced by disconnecting the animal from the ventilator. Blood samples were taken pre-mortem in HYP and EXS for measurement of catecholamine levels. After 1 h of in situ warm ischaemia, unflushed lungs were explanted and stored for 3 h (4 °C). Left lung performance was then tested during 60 min in our ex vivo reperfusion model. Total protein concentration in bronchial lavage fluid was measured at the end of reperfusion. Results: Pre-mortem noradrenalin (mcg l^–1) concentration (baseline: 0.03 ± 0) increased to a higher level in HYP (50 ± 8) vs EXS (15 ± 3); p = 0.0074. PO₂ (mmHg) at 60 min of reperfusion was significantly worse in HYP compared to FIB (445 ± 64 vs 621 ± 25; p < 0.05), but not to EXS (563 ± 51). Pulmonary vascular resistance (dynes s cm^–5) was initially higher in EXS (p < 0.001) and HYP (NS) vs FIB (15824 ± 5052 and 8557 ± 4933 vs 1482 ± 61, respectively) but normalised thereafter. Wet-to-dry weight ratio was higher in HYP compared to FIB (5.2 ± 0.3 vs 4.7 ± 0.2, p = 0.041), but not to EXS (4.9 ± 0.2). Total protein (g l^–1) concentration was higher, although not significant in HYP and EXS vs FIB (18 ± 6 and 13 ± 4 vs 4.5 ± 1.3, respectively). Conclusion: Pre-mortem agonal phase in the NHBD induces a sympathetic storm leading to capillary leak with pulmonary oedema and reduced oxygenation upon reperfusion. Graft quality appears inferior in NHBD lungs when recovered in controlled (HYP) vs uncontrolled (EXS and FIB) setting.

Objective: Single-lung transplantation (SLTX) in patients with previous contralateral pneumonectomy (PN) is a rarely observed situation. Intrathoracic anatomical changes caused by mediastinal shift may complicate the surgical procedure. We collected observations from different transplantation centres to analyse the technical aspects and results. Patients and methods: Between July 1990 and September 2008, 14 patients (seven women and seven men) with previous PN underwent SLTX for end-stage pulmonary failure. Patients were categorised in three groups according to lung disease: cystic fibrosis bronchiectasis (group 1; n = 4), non-cystic fibrosis bronchiectasis (group 2; n = 6) and bronchioloalveolar carcinoma (group 3; n = 4). We reviewed patients’ characteristics according to mediastinal shift, thoracic approach, bypass cannula procedure, perioperative difficulties and immediate and long-term results. Results: Median age was 19.5, 33.5 and 52.5 years in groups 1, 2 and 3, respectively; there were nine left and five right cases of SLTX. Surgery was performed by sternotomy (n = 4), anterolateral thoracotomy (n = 4), clamshell (n = 4) or posterolateral thoracotomy (n = 2). Cannulas for bypass were inserted into femoral (n = 7) or central vessels (n = 5) or both (n = 2). Mediastinal shift did not complicate surgical procedure but rendered cannulation more difficult with ensuing cardiopulmonary bypass dysfunction (n = 3) and early bronchial complications (n = 2). In-hospital mortality rate was 29% (4 out of 14 patients), including two deaths due to perioperative difficulties linked to mediastinal shift. Median global survival was 108 months. Median survival was higher in group 2 (108 months vs 1 month in the other groups) and in case of PN during childhood (n = 6, median survival 108 months corresponding to one death). Conclusions: SLTX after PN is associated with high perioperative morbidity and mortality due to mediastinal shift. Best results are observed in patients undergoing PN for non-cystic fibrosis bronchiectasis and during childhood. Anatomical changes induced by PN must be anticipated to adapt the thoracic approach and cardiopulmonary bypass access.

Trans-apical aortic bioprosthesis implantation is currently evaluated as an alternative technique in high-risk patients. We report the case of a delayed upward displacement of a prosthesis after this procedure. It is hypothesised that the asymmetric calcification of the native valve and the presence of a mitral prosthesis caused the dislocation.

The trans-apical aortic valve implantation (TA-AVI) is an established technique for high-risk patients requiring aortic valve replacement. Traditionally, preoperative (computed tomography (CT) scan, coronary angiogram) and intra-operative imaging (fluoroscopy) for stent-valve positioning and implantation require contrast medium injections. To preserve the renal function in elderly patients suffering from chronic renal insufficiency, a fully echo-guided trans-catheter valve implantation seems to be a reasonable alternative. We report the first successful TA-AVI procedure performed solely under trans-oesophageal echocardiogram control, in the absence of contrast medium injections.

Objective: Coronary artery bypass grafting (CABG) has been shown to provide better results than percutaneous coronary intervention (PCI) in multivessel coronary disease. Drug-eluting stents (DES) have significantly improved results of PCI in terms of restenosis but the advantages of such a treatment compared to CABG remain uncertain. This meta-analysis summarizes available data from observational cohorts comparing DES-PCI versus CABG. Methods: We performed a systematic literature search for observational cohorts comparing CABG versus DES-PCI in patients with multivessel coronary disease. The mixed model method was used to obtain the pooled hazard ratio (HR) for outcomes of interest. Results: A total of nine observational nonrandomized studies were identified and analyzed including a total of 24,268 patients with multivessel coronary disease who underwent DES-PCI (n = 13,540) and CABG (n = 10,728). Mean follow-up time was 20 months. Pooled analysis showed that DES-PCI and CABG were comparable in terms of composite occurrence of death, acute myocardial infarction and cerebrovascular accidents (HR = 0.94; 95% CI = 0.72–1.22; p = 0.66). However, there was a significantly higher risk of repeat revascularization in the DES-PCI group (HR = 4.06; 95% CI = 2.64–6.24; p < 0.001). Overall major adverse cardiac and cerebrovascular events rate in the DES-PCI was higher compared to the CABG group (HR = 1.86; 95% CI = 1.36–2.54; p < 0.001). Conclusions: In the ‘real world’ clinical practice, overall major adverse cardiac and cerebrovascular events rate continues to be higher after DES-PCI due to an excess of redo revascularization compared with CABG.

Background: Summary Left main disease (LMD) and associated cardiac risk factors are often perceived as a limiting factor for the outcome of off-pump coronary artery bypass (OPCAB) grafting. In this study, we assess whether the outcome of OPCAB surgery is affected in such patients. Methods: We retrospectively compared perioperative parameters in 66 OPCAB patients (group A) with LMD and 216 OPCAB patients without (group B) LMD. The patients were operated in the time frame between 2002 and 2007. LMD was defined as a stenosis >50%. Results: Patients in group A had a higher EuroSCORE (logistic: 3.7 ± 0.1 vs 6.3 ± 0.3, p = 0.027), increased coronary artery disease (CAD) family history (p = 0.015) and cerebrovascular accidents (p = 0.027), increased history of congestive heart failure (p = 0.013), more urgent surgery (p = 0.008), previous percutaneous transluminal coronary angioplasties (PTCAs) (p = 0.05) and previous stent implantation (p = 0.023). An intra-aortic balloon pump (IABP) was inserted more frequently in the LMD group preoperatively (p = 0.004). There were two conversions to on-pump during OPCAB surgery. There were no differences in the postoperative outcomes in the LMD group A versus group B, such as cardiac-related events, neurological deficits, cardiac enzyme course, arrhythmias, blood loss, infections and renal failure. Conclusions: The presence of LMD and higher EuroSCORE does not yield adverse outcomes in OPCAB patients.

Objective: To identify independent factors associated with early (30-day) mortality and in surviving patients, identify factors for late (1-year) mortality following primary coronary artery bypass graft (CABG) surgery and to test the interaction with age. Methods: An analysis of a single centre's data contribution to the Society for Cardiothoracic Surgery in Great Britain and Ireland database was performed. Data on consecutive patients aged ≥75 years (n = 659) and aged 60–74 years (n = 3024) undergoing primary CABG surgery (1999–2005) were analysed. One-year mortality data were collected using the Office of National Statistics (ONS) tracking system. Factors associated with early and late mortality were identified using Cox regression; hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. Results: The proportion of patients aged ≥75 years increased by 10% over 5 years (2000–2005). One-year mortality in the elderly showed a significant linear decrease from 15% to 7% (p = 0.01) while mortality in the younger cohort remained static at 2–4%. Early mortality in the elderly group was 5% compared to 1.8% in the younger group (p < 0.001), while late mortality was 4.1% vs 1.8%, respectively (p < 0.001). Factors independently associated with early mortality were age ≥75 years, HR 2.0 (95% CI 1.28, 3.11); female gender; angina (CSS III–IV); and cardiopulmonary bypass duration >97 minutes. Arrhythmia and renal impairment were risk factors common in both early and late mortality models. Risk factors for late mortality also included ventricular ejection fraction < 30%, non-elective surgery and arteriopathy. Age was not an independent risk factor for late mortality. Conclusion: Mortality in elderly patients showed a substantial improvement, but remained over twice that of younger patients. The difference in factors associated with early and 1-year morality suggests the need for effective short- and long-term strategies, particularly in the management of chronic diseases such as heart and renal failure.

The progression of atherosclerosis following coronary artery bypass graft (CABG) surgery results in the need for re-vascularisation therapy in a significant proportion of patients. It is well recognised that this risk can be lowered by controlling the level of low-density lipid cholesterol (LDL-C) which can be achieved easily and safely with the use of statins. The choice of which is the best statin in post-CABG patients remains unclear. It has been shown that for milligram-equivalent doses, rosuvastatin provides the greatest LDL-C reduction and greatest number of patients achieving LDL-C targets in comparison with simvastatin and atorvastatin. Rosuvastatin's superiority over other statins in allowing patients to reach LDL-C targets has been maintained in ‘real-world’ observational studies. Rosuvastatin has also been shown to increase high-density lipid cholesterol (HDL-C) by greater proportions in comparison with other statins, providing increased anti-atherogenic effects. There are several statins currently available, some of which are now generic. However, the empirical use of generic statins does not necessarily translate into a cost-effective treatment option. This article reviews the rationale for lipid-lowering therapy in patients following CABG. We also look objectively at which is the best statin for use in the post-CABG patient, discussing effectiveness, cost and tolerability.

Objective: Cell therapy for patients with ischaemic cardiomyopathy (IC) is still an open issue. We aimed to assess the long-term safety and therapeutic potency of autologous bone marrow mononuclear cell (ABMMNC) implantation into ungraftable coronary artery (UCA) territories in patients with IC. Methods: Bone marrow was aspirated from the iliac crest, and transepicardial ABMMNC implantation (n = 25, 24 men, aged 57 ± 7 years) as an adjunct to coronary artery bypass grafting (CABG) was performed into an area of reversible ischaemia within the territory of UCA (1.29 ± 0.09 x 10⁹ ABMMNCs). Control group (n = 25, 23 men, aged 59 ± 7 years) underwent incomplete CABG due to poor target vessel graftability. The study protocol consisted of coronary angiography, stress echocardiography, nuclear imaging and Holter monitoring at baseline and follow-up. The mean follow-up time was 988 ± 423 days. Results: There was no difference between the groups regarding postoperative complications and outcome. Overall 5-year survival for the ABMMNC group was 79 ± 10%, and 71 ± 12% for the controls (p = 0.48). Left ventricular ejection fraction (LVEF) at baseline was 24.8 ± 3.7 versus 25.9 ± 3.1 in the ABMMNC group and the controls, respectively. After 6 months, mean global LVEF increased to 36.3 ± 7.4 (p < 0.001) versus 31.4 ± 4.1 (p = 0.001), respectively. A significant difference was noted in delta LVEF between the groups (p < 0.001, 95% confidence interval (CI): 3.4–8.9) at 6 months, and (p = 0.001, 95% CI: 2.0–7.4) at 1 year. Accordingly, perfusion scores in UCA segments detected by single-photon emission computed tomography (SPECT) improved with ABMMNC therapy to 18.0 ± 24.4 from 7.1 ± 25.7 (p = 0.001 vs control UCA segments). Conclusion: Cellular therapy for IC within UCA could augment myocardial perfusion and contractility but does not improve overall survival. No adverse events were detected after cell therapy at mid-term follow-up.

Background: In addition to its multipotent capability, the mesenchymal stem cell (MSC) can secrete and supply a large amount of vascular endothelial growth factor (VEGF). The stromal-derived factor-1 alpha (SDF-1) plays an important role in the homing of stem cells to the injured tissues of the heart. Therefore, the MSCs over-expressing SDF-1 could augment the angiogenesis pathway. Methods: In vitro, the differentiation of the MSCs into endothelial-like cells was induced by cultivation of cells in 10% foetal calf serum and 50 ng ml^–1 SDF-1 or in specific inhibitors for endothelial nitrous oxide synthase (eNOS). In vivo, the rat model of myocardial infarction was established by occlusion of the left anterior descending coronary artery. Seven days following surgery, 5.0 x 10⁹ pfu Ad-SDF-1 (adenoviral vector containing human SDF-1 gene under the control of the rous sarcoma virus (RSV) promoter), 5.0 x 10⁶ Ad-LacZ-MSC or 5.0 x 10⁶ Ad-SDF-MSC suspension in a 0.2-ml serum-free medium was injected into four sites in infarcted areas (0.05 ml per site). The rats receiving Ad-SDF-MSC also received the nitrous oxide (NO) synthesis inhibitor N^G-nitro-l-arginine methyl ester (l-NAME) in drinking water (1 mg kg^–1). The rats in the control group received the same volume of cell-free medium. Four weeks following transplantation, the heart function was assessed, and histological and molecular analyses were conducted. Results: The MSCs could differentiate into endothelial cells in the presence of SDF-1, and the effect could be inhibited by l-NAME in vitro and in vivo. Western Blotting revealed an increased expression of VEGF, Akt and eNOS. Four weeks following transplantation, a reduced infarct size and fibrosis, greater vascular density and thicker left ventricular wall were observed in the Ad-SDF-MSC group. The measurement of haemodynamic parameters showed an improvement in the left ventricular performance in the Ad-SDF-MSC group as compared with other groups. Conclusion: The MSCs over-expressing the SDF-1 can produce effective angiogenesis, resulting in the prevention of progressive heart dysfunction after a myocardial infarction.

Objective: Renal dysfunction is one of the most serious complications following cardiac surgery with cardiopulmonary bypass. The causes of renal dysfunction following cardiac surgery are poorly understood. We hypothesised that T-786C endothelial NO synthase (eNOS) polymorphism may lead to an increase in the occurrence of postoperative renal dysfunction following cardiac surgery with cardiopulmonary bypass. Methods: A total of 497 patients undergoing cardiac surgery with cardiopulmonary bypass were included in the study. The T-786C eNOS polymorphism was detected by a polymerase chain reaction. The patients were grouped on the basis of whether they were homozygous or heterozygous for the C allele (TC + CC; n = 289) or only homozygous for the T allele (TT; n = 208). Results: No significance was demonstrated in the preoperative risk factors, with the exclusion of smoking habits (p = 0.04) for the C-allele carrier. The administration of anti-lipid agents (p = 0.01) and anti-arrhythmics (p = 0.01) was significantly lower in the TC/CC group. The TC + CC genotype group had a significantly greater decrease in creatine clearance (p = 0.024), the lowest creatine clearance (p = 0.004) and more C-allele carriers received acute renal replacement therapy (p = 0.04). The usage of norepinephrine (p = 0.02) and dobutamine (p = 0.02) was significantly higher in C-allele carriers. In the TC + CC genotype group, cross-clamp time (p = 0.02) and administration of red cell transfusion (p = 0.04) achieved statistically significant difference. The overall in-hospital mortality rate was 8.2% for all patients and was not significant between genotypes. Conclusions: The present findings support the hypothesis that the T-786C eNOS polymorphism may play a role in the development of renal dysfunction and increase the occurrence of renal replacement therapy following cardiac surgery with cardiopulmonary bypass. This polymorphism may be useful in stratifying the risk for the development of postoperative renal dysfunction.

Objectives: Phosphodiesterase-5 inhibitors and elevated myocardial cyclic guanosine monophosphate levels can induce potent cardioprotection-like effects against ischaemia–reperfusion injury. We investigated the effects of vardenafil, a selective phosphodiesterase-5 inhibitor on myocardial and endothelial functions during reperfusion in a canine model of cardioplegic arrest and extracorporal circulation. Methods: Vehicle-treated (control, n = 8) and vardenafil-treated (30 µg kg^–1 intravenous (IV); n = 8) anaesthetised dogs underwent hypothermic cardiopulmonary bypass with 60 min of hypothermic cardiac arrest. Left and right ventricular end-systolic pressure volume relationship (E _es) was measured by a combined pressure–volume conductance catheter at baseline and after 60 min of reperfusion. Left anterior descending coronary blood flow and endothelium-dependent vasodilatation to acetylcholine were determined. Isolated coronary arterial rings were investigated for vasomotor function using an in vitro organ bath system. Results: Pharmacological preconditioning with vardenafil led to significantly higher plasma cyclic guanosine monophosphate levels and myocardial adenosine triphosphate content to a better recovery of left and right ventricular E _es ( left ventricular E _es given as percent of baseline: 74.2 ± 4.5% vs 50.4 ± 5.0%, p < 0.05) and to a higher coronary blood flow (58 ± 12 vs 24 ± 7 ml min^–1, p < 0.05). Endothelium-dependent vasodilatory responses to acetylcholine – measured both in vivo and in vitro – were improved in the vardenafil group. Conclusions: Application of vardenafil improves myocardial and endothelial functions after cardiopulmonary bypass with hypothermic cardiac arrest. The observed protective effects imply that phosphodiesterase-5 inhibition could be a novel therapeutic option in the protection against ischaemia–reperfusion injury in cardiac surgery.

Background: Recently, a compact cardiopulmonary support (CPS) system designed for quick set-up for example, during emergency cannulation, has been introduced. Traditional rectilinear percutaneous cannulas are standard for remote vascular access with the original design. The present study was designed to assess the potential of performance increase by the introduction of next-generation, self-expanding venous cannulas, which can take advantage of the luminal width of the venous vasculature despite a relatively small access orifice. Methods: Veno-arterial bypass was established in three bovine experiments (69 ± 10 kg). The Lifebridge^® (Lifebridge GmbH, Munich, Germany) system was connected to the right atrium in a trans-jugular fashion with various venous cannulas; and the oxygenated blood was returned through the carotid artery with a 17 F percutaneous cannula. Two different venous cannulas were studied, and the correlation between the centrifugal pump speed (1500–3900 RPM), flow and the required negative pressure on the venous side was established: (A) Biomedicus 19 F (Medtronic, Tolochenaz, Switzerland); (B) Smart canula 18 F/36 F (Smartcanula LLC, Lausanne, Switzerland). Results: At 1500 RPM, the blood flow was 0.44 ± 0.26 l min^–1 for the 19 F rectilinear cannula versus 0.73 ± 0.34 l min^–1 for the 18/36 F self-expanding cannula. At 2500 RPM the blood flow was 1.63 ± 0.62 l min^–1 for the 19 F rectilinear cannula versus 2.13 ± 0.34 l min^–1 for the 18/36 F self-expanding cannula. At 3500 RPM, the blood flow was 2.78 ± 0.47 l min^–1 for the 19 F rectilinear cannula versus 3.64 ± 0.39 l min^–1 for the 18/36 F self-expanding cannula (p < 0.01 for 18/36 F vs 19 F). At 1500 RPM, the venous line pressure was 18 ± 8 mmHg for the 19 F rectilinear cannula versus 19 ± 5 mmHg for the 18/36 F self-expanding cannula. At 2500 RPM the venous line pressure accounted for –22 ± 32 mmHg for the 19 F rectilinear cannula versus 2 ± 5 mmHg for the 18/36 F self-expanding cannula. At 3500 RPM, the venous line pressure was –112 ± 42 mmHg for the rectilinear cannula versus 28 ± 7 mmHg for the 18/36 F self-expanding cannula (p < 0.01 for 18 F/36 F vs 19 F). Conclusions: The negative pressure required to achieve adequate venous drainage with the self-expanding venous cannula accounts for approximately 31% of the pressure necessary with the 19 F rectilinear cannula. In addition, a pump flow of more than 4 l min^–1 can be achieved with the self-expanding design and a well-accepted negative inlet pressure for minimal blood trauma of less than 50 mmHg.

Background: Coarctation of the aorta accounts for almost 5% of all congenital cardiac malformations, and it is usually treated by open surgical procedures. Despite the excellent primary results, many patients may develop anastomotic pseudo-aneurysms, associated with considerable morbidity and mortality rates. We investigated the role of endovascular repair as an alternative to open re-do surgery on the descending aorta. Methods: We retrospectively collected data of 11 consecutive patients who presented with pseudo-aneurysms of the descending aorta following previous surgical repair of congenital aortic coarctation. Nine patients developed a pseudo-aneurysm after patch aortoplasty, while an interposition graft repair was performed in two cases. Seven patients underwent an endovascular repair (26.9 years after the previous open surgery). Four patients with a pseudo-aneurysm after coarctation repair associated with arch hypoplasia underwent conventional open re-operation. Results: No complications or death were observed in the conventional surgical group. Technical success was obtained in all patients who received a stent-graft procedure. More than one stent graft was necessary only in one case. A left carotid–left subclavian artery bypass was performed in three patients. Type II endoleak was detected by angiography in one patient who had previously undergone subclavian re-vascularisation. The median follow-up (FU) was 44.5 months and was 100% complete. Neither re-operations nor complications or deaths occurred during FU. Conclusions: Endovascular repair of pseudo-aneurysms following open surgery for aortic coarctation is feasible and safe. However, more patients and longer follow-up are necessary to assess the efficacy of this promising less-invasive alternative to open re-do surgery.

Objective: To compare the mid-term results of two techniques used for the reconstruction of the pulmonary outflow tract during common arterial trunk repair in infancy, with special attention paid to re-operation rate and pulmonary arterial growth. Methods: Between 2000 and 2006, 32 consecutive neonates or infants underwent common arterial trunk repair. In 15 patients, the pulmonary outflow tract was reconstructed using an extracardiac valved conduit (conduit group). In 17 patients, right ventricle to pulmonary artery connection was achieved without conduit, using the left atrial appendage and including a monocusp valve (non-conduit group). The decision regarding the type of ventricle to pulmonary artery connection was at the discretion of the attending surgeon. The two groups were similar in terms of age, weight, type of common arterial trunk, truncal valve dysfunction and coronary abnormalities. Follow-up was 93% complete and included echo-Doppler evaluation, catheterisation and CT scan imaging. Results: Hospital mortality (five patients – 16%) was increased by coronary abnormalities and preoperative ventilation but did not differ between the two groups (13.3% in the conduit group vs 18% in the non-conduit group). The mean follow-up was 40 ± 25 months. There were six late deaths (three in each group), yielding an actuarial survival of 76% at 5 years. One late death was procedure related (percutaneous dilatation for obstructive monocusp patch). Re-operation for right ventricular outflow tract obstruction was necessary in seven patients (five in the conduit group and two in the non-conduit group); the actuarial freedom from re-operation was higher in the non-conduit group (p = 0.026). At last follow-up, the right ventricle–pulmonary artery gradient and the right ventricle/left ventricle pressure ratio were higher in the conduit group (p = 0.006 and p = 0.007, respectively). At late computed tomography (CT)-scan evaluation, the growth of the proximal pulmonary arterial tree had improved in the non-conduit group, as shown by a higher Nakata ostial index and right ventricular outflow tract growth. Conclusions: Repair of common arterial trunk without conduit for right ventricular outflow tract reconstruction (1) does not increase mortality and morbidity, (2) decreases the need for re-intervention and (3) promotes a better growth of the proximal pulmonary arteries. These preliminary results need confirmation by further experience.

Objective: Although a staged Fontan strategy allows for an excellent outcome in high-risk patients, an impaired ventricular function remains a significant factor of early/late mortality and morbidity. This study evaluated the clinical outcome of the Fontan operation in patients with impaired ventricular function. Methods: A retrospective review was performed on 217 patients who had undergone the Fontan operation between 1991 and 2007. Results: Twenty-nine (13%) of the 217 patients had an impaired ventricular function (ejection fraction (EF) <50%). The median age at the time of the operation was 3 (range: 1–31 years) years. There were five adult patients. The ventricular morphology was right in 20 patients (including five hypoplastic left heart syndrome (HLHS)) and others (left and two-ventricle) in nine patients. Heterotaxy syndrome was present in eight patients. Previous surgical interventions included bidirectional Glenn anastomoses in 24, modified Blalock–Taussig shunts in two and pulmonary artery banding in two. The preoperative EF was 43 ± 6%. Significant (moderate or severe) atrioventricular valve regurgitation was noted in four patients. The percutaneous oxygen saturation (SpO₂) was 82 ± 5%. The pulmonary artery pressure and pulmonary artery index were 11 ± 3 mmHg and 296 ± 102 mm² m^–2, respectively. All 29 patients underwent the Fontan operation without any early mortality. There were two late mortalities and two re-operations. EF was maintained at 59 ± 15% at a median follow-up of 7.5 (range: 1–19) years. The percent normal systemic ventricular end-diastolic volume decreased from 174 ± 95% to 124 ± 39% (p < 0.05). The SpO₂ increased to 92 ± 2%. The mean cardiothoracic ratio in chest X-ray and B-type natriuretic peptide were 51% (range: 35–68%) and 22 pg ml^–1 (range: 9–382 pg ml^–1), respectively. Three patients developed congestive heart failure, seven had arrhythmia and two developed protein-losing enteropathy. The New York Heart Association (NYHA) class functional class is I in 21 patients, II in five and III in one. Conclusions: Acceptable clinical outcomes were observed at an intermediate follow-up of the Fontan operation in patients with an impaired ventricular function.

Objective: Hyperglycaemia has been associated with worse outcome following traumatic brain injury and cardiac surgery in adults. We have previously reported no relationship between early postoperative hyperglycaemia and worse neurodevelopmental outcome at 1 year following biventricular repair of congenital heart disease. It is not known if postoperative hyperglycaemia results in worse neurodevelopmental outcome after infant cardiac surgery for single-ventricle lesions. Methods: Secondary analysis of postoperative glucose levels in infants <6 months of age undergoing Stage I palliation for various forms of single ventricle with arch obstruction. The patients were enrolled in a prospective study of genetic polymorphisms and neurodevelopmental outcomes assessed at 1 year of age with the Bayley Scales of Infant Development-II yielding two indices: mental developmental index (MDI) and psychomotor developmental index (PDI). Results: Stage I palliation was performed on 162 infants with 13 hospital and 15 late deaths (17.3% 1-year mortality). Neurodevelopmental evaluation was performed in 89 of 134 (66.4%) survivors. Glucose levels at admission to the cardiac intensive care unit and during the first 48 postoperative hours were available for 85 of 89 (96%) patients. Mean admission glucose value was 274 ± 91 mg dl^–1; the maximum was 291 ± 90 mg dl^–1, with 69 of 85 (81%) patients having at least one glucose value >200 mg dl^–1. Only two patients had a value <50 mg dl^–1. Mean MDI and PDI scores were 88 ± 16 and 71 ± 18, respectively. There were no statistically significant correlations between initial, mean, minimum or maximum glucose measurements and MDI or PDI scores. Only delayed sternal closure resulted in a statistically significant relationship between initial, minimum and maximum glucose values within the context of a multivariate analysis of variance model. Conclusions: Hyperglycaemia following Stage I palliation in the neonatal period was not associated with lower MDI or PDI scores at 1 year of age.

Objective: The ability of the right ventricle to tolerate acute pulmonary regurgitation (PR) following tetralogy of Fallot (TOF) repair is variable and the mechanisms that underlie this are not completely understood. We hypothesise that dyssynchronous wall mechanics affects the RV tolerance to postoperative PR with adverse effect on early surgical outcome. Methods: Twenty-four TOFs (mean age 19.5 ± 15.5 months) undergoing elective repair were prospectively recruited. Ventricular wall mechanics was studied by tissue Doppler echocardiography following induction (preop) and postoperative day one (POD1) and compared with a control group (10 VSD/AVSD). Segmental dyssynchrony, defined as out-of-phase peak myocardial contraction, was determined at the base, mid, apical segments of the septum, RV and LV free walls and scored by the total number of affected segments. PR was graded from absent to severe and RV dimension was quantified by end-diastolic area index (RVEDAI). Cardiac index (CI) was measured by pulse contour cardiac output analysis. Outcome measures were CI, mixed venous oxygen saturation (SvO2), lactate, and duration of ventilation and critical care stay. Results: Preoperatively, biventricular free-wall motion was synchronous in both groups. Following surgery, TOF developed RV-septal dyssynchrony (>2 segments in 11 (46%) vs none in control, p = 0.01), while the LV free wall remained normal in both groups. RV-septal dyssynchrony correlated with the ventilation time (rho = 0.69, p = 0.003), critical care stay (rho = 0.58, p = 0.02) in the presence of PR (n = 16), but not with other outcome measures. The relationships between dyssynchrony and early outcome were not seen when PR was absent. In the presence of PR, median RVEDAI was greater with higher dyssynchrony score (>3 segments; p = 0.009). The degree of PR did not affect critical care/ventilation time or RVEDAI. The presence of transannular patch (p = 0.007) or at least moderate PR (p = 0.01) was associated with a more severe dyssynchrony. Conclusions: Dyssynchronous RV-septal wall mechanics occurs early after Fallot repair. The magnitude of dyssynchrony appears to interact synergistically with pulmonary regurgitation to influence RV dimension and early outcome.

Objective: Fibrin glue products and collagen surgical patches (TachoSil^®) coated with coagulation factors I and IIa are increasingly being used to prevent oozing from distal or proximal coronary anastomosis. Furthermore, an increasing number of patients are being operated upon anti-platelet therapy. These patients often exhibit diffuse bleeding. Especially in an off-pump scenario surgeons refrain from placing additional stitches in order to avoid an impairment of the graft. In these situations, a biological glue can help resolve this dilemma. It is, however, assumed that these products may exert negative effects on the anastomosis. For obvious reasons a systematic histological assessment in humans is impossible. Therefore, a chronic, large animal model was developed to study the fate of these products on a coronary anastomosis. Methods: In 15 pigs receiving off-pump coronary artery bypass graft of the left mammary artery to the left anterior descending coronary artery, three groups were defined. Group A served as control. In group B the anastomosis was covered with 1 ml fibrin glue; in group C TachoSil^® coverage was performed. Bypass flow (BF) was measured using a Doppler probe. After 3 months the pigs were sacrificed and the anastomoses were evaluated macroscopically and by means of light microscopy regarding patency and fibrosis. Results: In group A, all five animals survived, three of the five anastomoses were patent and the mean BF was 26 ml min^–1. In group B, three of the five animals survived, all anastomoses were patent. The BF was 21 ml min^–1. In group C, all five animals survived, four of the five anastomoses were patent and BF was 21 ml min^–1. Macroscopic and histological evaluation showed no differences between the groups. Remnants of Tachosil^® or fibrin glue were not observed. Conclusions: In the chronic course, no evidence of adverse effects of TachoSil^® or fibrin glue was noted. Both agents can therefore be used safely in clinical practice for haemostyptic or positioning purposes.

Objective: Prolonged bleeding during cardiovascular surgery presents a risk for the patient and increases the time and cost of surgery. TachoSil^® is a ready-to-use haemostatic agent that consists of an equine collagen patch coated with human fibrinogen and thrombin. This trial evaluated the efficacy and safety (≤30 days post-surgery) of TachoSil surgical patch compared with standard haemostatic fleece for the control of bleeding in patients undergoing cardiovascular surgery. Methods: Patients scheduled for elective surgery on the heart, ascending aorta or aortic arch requiring cardiopulmonary bypass were eligible for this open-label multicentre trial. After primary haemostatic measures, patients were randomised to TachoSil or conventional haemostatic fleece if an area of persisting haemorrhage was identified (target area). After the application of trial treatment, haemostasis was evaluated at 3 min (primary endpoint). If haemostasis was not achieved, trial treatment was re-applied and haemostasis assessed at 6 min (secondary endpoint). Results: A total of 120 patients were randomised and 119 received trial treatment (TachoSil, n = 59; standard treatment, n = 60). Twenty-six percent of patients were female and the mean age was 67 years (range: 23–86 years). Baseline characteristics were similar in both the groups. Bleeding occurred mainly from the aorta (56%), right ventricle (16%) or right atrium (13%), more often from a vessel (68%) than tissue (32%), and was assessed to be arterial in 74% of cases. TachoSil was significantly superior to standard haemostatic fleece in controlling bleeding after insufficient primary haemostasis, with 75% (95% confidence interval (CI): 0.64–0.86) of the TachoSil group achieving haemostasis at 3 min compared with only 33% (95% CI: 0.21–0.45) of the standard treatment group (p < 0.0001). This difference persisted at 6 min, with 95% of patients achieving haemostasis in the TachoSil group compared with 72% in the standard treatment group (p = 0.0006). Three (5%) TachoSil patients compared with 17 (28%) standard treatment patients failed to achieve haemostasis at 6 min and received rescue treatment. TachoSil was well tolerated with adverse events generally similar in the two treatment groups. Conclusions: TachoSil was significantly superior to standard haemostatic fleece material in obtaining effective and fast intra-operative haemostasis in cardiovascular surgical procedures. TachoSil was safe and well tolerated.

Objective: The early diagnosis of chronic organ rejection after lung transplantation (LTx) is currently hampered by the lack of reliable diagnostic markers. The present study aims to establish the procedure of gene expression profiling in bronchial epithelial cells for the identification of candidate genes that might prove useful in the early diagnosis. Methods: Twenty-three patients who underwent lung transplantations were investigated at a time point when no clinical signs of bronchiolitis obliterans syndrome (BOS) were apparent. Bronchial epithelial cells were obtained by bronchial brushing. Gene expression profiles were determined using a human whole-genome cDNA microarray (Stanford Faculty, Stanford, CA, USA). Results: Unsupervised hierarchical cluster analysis revealed that the samples from LTx patients can be clearly distinguished from the comparison group. We also found that the samples from LTx patients with the same underlying disease do not form major clusters of gene expression pattern. Using biostatistical analysis, ‘haemoglobin beta’, expressed by alveolar type II and Clara cells, and CD99, involved in inflammatory processes, were identified comparing lung transplantation and comparison group. Conclusions: Thus, global expression analyses of bronchial epithelial cells might be a new approach to identify diagnostic markers, especially if patients with LTx are monitored sequentially and if patients with and without BOS are compared.

Objectives: For successful reconstruction with tracheal allotransplants following long tracheal resections, problems related to the preservation and vascularisation of the tracheal graft have to be solved. In this study, instead of using a long-segment single-piece graft, we used a graft that has been split into two. The aim was to use this graft after cryopreservation in order to ease neo-vascularisation and to maintain tracheal integrity by transplanting it to two separate regions of the dog cervical trachea. Methods: This experimental study was conducted in animal laboratories of the medical school on 11 half-blood dogs. The trachea obtained from the first dog was 8 cm in length; it was split into two pieces of 4 cm each and stored in the preservation solution at –80 °C for 4 weeks. Following this, the dog was sacrificed. Two 2 cm portions of cervical trachea were excised from the second dog. These parts were then reconstructed with two tracheal grafts of the same length as the cryopreserved ones. Ten dogs that were grouped into five groups of two dogs each underwent the same procedure. The subjects had a bronchoscopic evaluation on the third postoperative week. Anastomosis regions of the test tracheas were resected to be examined histopathologically. Results: Seven subjects were found to have third-degree obstructions during bronchoscopy; two had close to fourth-degree obstructions. In the histopathological examination, contrary to the findings of the bronchoscopies, 75% of the anastomoses had intact epithelium. The cartilage was seen to have well-preserved structural characteristics in all the anastomoses. Twelve anastomoses had moderate, seven mild and one had severe inflammation. All anastomoses had either good or very good level of vascularisation. Conclusions: The integrity of the tracheal epithelium can be maintained with cryopreservation and split anastomosis technique. The cartilage preserves its structural characteristics despite losing its viability, thereby offering an advantage to maintain airway patency.

Background: Video-assisted modified segmentectomy is segmental resection using an end-stapler without regards to anatomical broncho-segmental planes. This procedure is effective for deep pulmonary lesions, and preserves pulmonary function better as compared to lobectomy. However, the biggest disadvantage of this approach is the inability to manually palpate the lung. It is difficult to determine the staple line for pulmonary division during surgery as the tumour is located near the border of the burdened segments. This study evaluated whether multi-detector row computed tomographic angiography could contribute to the preoperative arrangement of video-assisted modified segmentectomy. Patients and methods: Video-assisted modified segmentectomy was planned for nine patients with deep pulmonary tumours measuring 3 cm or smaller (Clinical T1N0M0 lung cancer, n = 4; metastatic lung tumour, n = 4 and undiagnosed lesions suspicious for lung cancer, n = 1). All patients underwent contrast-enhanced multi-detector row computed tomography preoperatively to determine the vessels that were to be detached and the line for dividing the pulmonary parenchyma. Results: All the lesions were resected with safe surgical margins under video view in keeping with the preoperative plan. Conclusion: Our experience suggests that multi-detector row computed tomographic angiography provides information for determining the division of the pulmonary vessels and lung parenchyma in video-assisted segmentectomy.

Objective: Mediastinal lymph node staging determines the treatment strategy for non-small-cell lung cancer. This study aims to evaluate prospectively the accuracy of preoperative integrated 18-fluoro-2-deoxy-d-glucose positron emission tomography–computerised tomography (¹⁸FDG PET-CT) for mediastinal lymph node staging. Methods: Preoperative integrated ¹⁸FDG PET-CT was used to analyse mediastinal lymph nodes in patients with non-small-cell lung cancer. Nodal stations were identified according to the American Thoracic Society mapping system. Lymph nodes with a standardised uptake value (SUVmax) >3 were considered to be positive. The mediastinal lymph nodes were harvested during lung resection and the results of integrated ¹⁸FDG PET-CT were compared to the mediastinal lymph node histology results. Results: A total of 51 patients were enrolled in this study. The mean interval between integrated ¹⁸FDG PET-CT and surgery was 31 ± 15.8 days (range: 2–78 days). The mean mediastinal lymph node harvested and station number per patient during surgery were 11.8 ± 5.6 (range: 2–27) and 3.8 ± 1 (range: 2–6), respectively. The incidence of N2 pathological disease was 19.6%. The integrated ¹⁸FDG PET-CT sensitivity and specificity were 40 ± 30% and 85 ± 11%, respectively. The positive and negative predictive values were 40 ± 30% and 85 ± 11%, respectively. False-positive results (six patients) were mainly due to inflammatory lymph nodes. False-negative results (six patients) were mainly due to infra-centimetrical, malignant lymph node invasion. Conclusion: The sensitivity of integrated ¹⁸FDG PET-CT for mediastinal lymph node staging in patients selected for surgery is low. When positive mediastinal lymph nodes are detected, invasive mediastinal staging must be performed. On the other hand, the specificity is high: patients with negative integrated ¹⁸FDG PET-CT can be operated upon without invasive mediastinal staging.

Objective: Video-assisted thoracoscopic surgical (VATS) lung biopsy is frequently used in the diagnosis of parenchymal lung disease. However, there is still debate over the need for routine use of an intercostal chest drain after this procedure. This study aimed to evaluate the necessity of positioning an intercostal chest drain as an integral part of VATS lung biopsy. Methods: Data from VATS lung biopsies performed over a 5-year period were retrospectively analysed. Patients in whom there was evidence of air leak intra-operatively following lung biopsy were excluded. Patients in whom no air leak was detected on testing were included in this study. A chest drain was inserted solely according to the surgeons’ practice. Results: This study included 175 patients. Of these, 82 patients had an intercostal chest drain positioned during the VATS procedure and 93 did not. There were no significant differences between the two groups in terms of mean (standard deviation (SD)), age (54.4 (14.9) vs 55.8 (13.5) years, p = 0.58), gender (63% vs 59% males, p = 0.56) or side of procedure (45% vs 56% right side, p = 0.22). One patient in the ‘no drain’ group developed a clinically significant pneumothorax 24 h after surgery and required a drain to be inserted. There was also no significant difference between the two groups in the incidence of radiologically detected pneumothorax immediately post-procedure (23% vs 20%, p = 0.66) or on postoperative day 1 (26% vs 20%, p = 0.63). There was no significant difference in the incidence of pneumothorax on follow-up (at 4–6 weeks) chest radiograph (10% vs 7%, p = 0.61). In all cases, the pneumothoraces were small and not clinically significant. However, there was a significant difference in the median (inter-quartile range (IQR)) length of stay between the two groups (3 (2,4) vs 2 (1,3) days, respectively, p < 0.001). Conclusions: The routine use of an intercostal chest drain after VATS lung biopsy unnecessarily increases the length of hospital stay without reduction in the incidence of pneumothorax.

Objective: Superior sulcus tumours (SSTs) or Pancoast tumours are preferably treated with chemoradiotherapy (CRT) followed by surgical resection. However, when followed by surgery, it is associated with an increased complication rate. This study aims to evaluate the efficacy and safety of a concurrent induction protocol of 66 Gy radiotherapy with cisplatinum and evaluate the rationale for subsequent surgery. Methods: Patients with SST treated in our institute from 1994 to 2006 were identified. The preferred induction treatment consisted of accelerated radiation (66 Gy in fractions of 2.75 Gy) with concurrent daily cisplatinum 6 mg m^–2. Surgical resection was planned 4–6 weeks thereafter. Performance status, co-morbidity, clinical and pathological tumour stage, (response to) treatment and survival were reviewed. Survival analysis was performed using the Kaplan–Meier method. Results: Over these 12 years, 85 patients with Pancoast tumours, 57 men and 28 women, were referred. Mean follow-up was 42 months (range: 2–120 months). Twenty-five patients had stage IIB (29%), seven had stage IIIA (8%), 32 had stage IIIB (38%) and 21 had stage IV (25%). Of the 64 patients presenting with stage II or III disease, 38 medically operable patients with potentially resectable tumours received induction therapy. After restaging, 22 patients underwent resection. All resections were complete and local recurrences were not observed. In 13 patients (62%) a pathologic complete response was found. In most cases, pathologic response was not evident from radiological imaging. The morbidity of surgery after induction treatment was acceptable. There was no fatal toxicity or treatment-related mortality. The 2- and 5-year overall survival of this selected group was 70% and 37%, respectively. Conclusion: This schedule of induction therapy with high-dose radiation and concurrent cisplatinum was safe and highly effective in fit patients. At this time, pathologic complete response cannot be reliably recognised preoperatively, and better tools for response assessment are critical for more tailored treatment of patients with SST.

Pancoast or superior pulmonary sulcus tumours are a rare subset of non-small-cell lung carcinomas (NSCLCs) which occur with an incidence of less than 5% of all lung cancers. Today, induction chemoradiation followed by surgical resection has become the established standard treatment approach for patients with sulcus superior tumours in the absence of other contraindications. This review focusses on the historical change of the treatment strategy, the evolution of surgical and multimodality management of this disease and the most recent published clinical outcome data of patients suffering from superior pulmonary sulcus carcinoma.

Objective: Chronic empyaema deteriorates lung function and causes thoracic asymmetry due to intercostal narrowing in the diseased hemithorax. This study aims to investigate the rates of improvement in the pulmonary function tests (PFTs) and the thoracic deformity in late postoperative period of lung decortication, performed for chronic empyaema. Methods: A total of 50 patients who underwent standard open decortication for empyaema were included. The PFTs and computed tomographic (CT) scans of the chest were analysed in all patients after 6–58 months postoperatively. The measurements of antero-posterior and transverse diameters of both hemithoraxes were performed on both preoperative and postoperative chest CTs. The thoracic asymmetry was calculated as the ratio of the measurements of the diseased side to the normal side. The pre- and postoperative parameters were compared statistically. Results: The mean preoperative forced expiratory volume in first second (FEV₁) and forced vital capacity (FVC) increased from 61.40% and 60.89% to 78.92% and 77.48%, respectively, in the late postoperative period (p < 0.001). The mean preoperative transverse diameter of affected hemithorax increased from 11.22 cm to 11.98 cm (p < 0.001) and, the transverse asymmetry improved from 11.52% to 5.94%, postoperatively (p < 0.001). The mean preoperative antero-posterior chest diameter improved from 15.58 cm to 16.67 cm (p < 0.001), and the antero-posterior asymmetry improved from 11.42% to 5.42% (p < 0.001) in the late postoperative period. Conclusions: The open decortication for chronic pleural empyaema significantly increases FEV₁ and FVC. Due to the re-expansion of the lung and enlargement of the intercostal spaces, the chest wall deformity also improves considerably after the operation.

Objective: To report on the experience with radical surgery, with emphasis on the long-term outcome, for malignant pleural mesothelioma (MPM) at a single institution. Methods: From our prospective database over a 17-year period, we reviewed 83 consecutive patients undergoing radical surgery for MPM in a multimodality programme. The long-term overall survival was analysed using the Kaplan–Meier method. Results: A total of 83 patients (65 males, median age: 60 years) underwent an extra-pleural pneumonectomy (EPP) with a curative intent. Epitheliod MPM was the most frequent (82%) cause. A right-sided disease was present in half of the cases (n = 42). The International Mesothelioma Interest Group (IMIG) stage of the disease was 2 in 36%, 3 in 45% and 4 in 9% of the cases. Preoperative chemotherapy consisting of a doublet cisplatin–pemetrexed (mean of three cycles) was offered to 10 patients (12%). Postoperative therapies, either chemotherapy or radiotherapy, were given in 25 patients (30%). The 30-day and 90-day mortality rates were 4.8% and 10.8%, respectively. Postoperative complications occurred in 39.8% and were major in 23 patients (27.7%). Re-operation was necessary in 12 cases (14.5%) for one of the following reasons: broncho-pleural fistula (n = 4), bleeding (n = 3), diaphragmatic patch rupture (n = 3), oesophago-pleural fistula (n = 1) and empyaema (n = 1). The mean hospital stay was 43 days. The median survival was 14.5 months, while the overall 1-, 2- and 5-year survival rates were 62.4%, 32.2% and 14.3%, respectively. Conclusions: These results concur with the published data of the most experienced centre with regards to the mortality and morbidity after EPP for MPM. In line with the biggest series reported in the past, the observed 5-year survival rate of almost 15% is disappointing.

We describe a new technique of aortic valve replacement (AVR) in patients with porcelain aorta. Three patients (mean age 75 years) were treated. The cardiopulmonary bypass (CPB) was established after side-graft right axillary artery and direct femoral artery cannulation. Venous drainage was obtained by atrio-caval cannulation. The procedures were performed in mild hypothermia (30 °C). Cerebral perfusion was carried out by clamping the innominate artery and all epiaortic vessels. The aorta was endoclamped by a Foley balloon inserted into the isthmus. The aorta was then opened longitudinally for 10 cm to expose and replace the aortic valve. Near-infra-red spectroscopy (NIRS) and bilateral radial artery pressure were used to monitor effective cerebral perfusion. Operative mortality was absent. The mean time of CPB was 73 min. NIRS-derived tissue oxygenation was maintained above 55%. Postoperative course was uneventful. This technique has several advantages: first, the cannulation of right axillary and the common femoral artery allows simultaneous cerebral and systemic perfusion. Second, any form of cross-clamp is avoided and the aorta is occluded away from the epiaortic vessels. Third, there is an increased freedom to choose the best place for aortotomy.

Aortic valve replacement (AVR) for aortic regurgitation due to Behcet's disease is often complicated with valve detachment. In our institute, between 1981 and 2006, five consecutive patients with aortic regurgitation secondary to Behcet's disease underwent valve detachment after initial surgery. A novel modification of AVR termed ‘subannular ring reinforcement technique’ was introduced to prevent valve detachment. We performed AVR with this new manoeuvre in three patients. No prosthetic valve detachment was noted after a mean period of 3 ± 1.8 years (range: 1.5–5.1 years). In this technique, we put a ring-shaped prosthetic graft in subannular position and sandwiched the aortic valve annulus between the prosthetic valve and graft with vertical mattress sutures. We consider that the subannular ring may be effective in distributing the stress to the annulus and the vertical mattress suture may help in fixing the prosthesis to annulus tissue rigidly.

There is an ever-growing trend towards less-invasive procedures in all fields of medicine. We designed an animal study to prove the concept that trans-apical aortic valve replacement from an incision within the umbilicus through a single channel for instruments is feasible, which would be a major leap towards no-scar cardiac surgery. In three adult pigs, after creating a single 3-cm incision at a place where the human umbilicus would be, we introduced a 30F sheath through a tunnel created by an endoscopic vein-harvesting device up to the cardiac apex, through it and up to the left ventricle simulating the approach for trans-apical aortic valve replacement. We used a standard Amplatz nitinol occluder to seal the defect in ventricle wall later. The animals were followed up for 1 h. Blood loss was minimal, and no tamponade occurred in any of the animals. In addition, we performed a test with water column static pressure to evaluate the impact of preclotting on the sealing properties of the occluders: 1 min flow-through was 2860 ± 176 ml for the standard occluders and 348 ± 56 ml for preclotted occluders (p < 0.001).

Extensive annular calcification of the mitral valve can make anatomic implantation of a prosthesis extremely difficult and challenging. We herein describe a surgical technique of mitral valve replacement in a 78-year-old man with multiple medical co-morbidities suffering from severe mitral regurgitation with extensive circumferential calcification of the mitral annulus. The pertinent literature is reviewed and the technical steps and clinical presentation are discussed.

We present a case of chest wall reconstruction after sternochondral resection for sternal metastasis of breast origin. We used three transverse titanium plates to stabilise the chest wall and provide support for a polytetrafluoroethylene dual mesh, which was used to cover the chest wall defect. The pectoralis muscles flaps were approximated in the midline to cover the dual mesh.

Objective: Analysis of single centre results and identification of prognostic factors of surgical combined modality treatment in pathological proven stage IIIA-N2 non-small cell lung cancer (NSCLC). Methods: Out of a total of 996 resections for NSCLC between 2000 and 2006, 92 patients with radiological response or stable disease after induction chemotherapy for pathologically proven ipsilateral positive lymph nodes (N2-disease) underwent surgical exploration with the aim of complete resection. Adenocarcinoma and squamous cell carcinomas were equally present (48% vs 43%). Median follow-up of surviving patients (n = 36) was 51 (10–94) months. Results: Complete resection (i.e., tumour with free margins and negative highest mediastinal lymph nodes, R0) was achieved in 68% (n = 63), resection was uncertain or incomplete in 24% (n = 22), while surgery was explorative in 8% (n = 7). Pneumonectomy was performed in 24%, (bi)lobectomy in 62%, and sleeve lobectomy in 13% of patients. In-hospital mortality was 2.3%. Overall need for ICU stay was 18% (30% after pneumonectomy). Median hospital stay was 10 days (6–157). Downstaging of mediastinal lymph nodes (ypN0-1) was found in 43% (n = 40). Overall survival at 5 years (5YS) was 33% (n = 92), and after complete resection 43% (n = 63). Detection of multilevel compared to single level positive nodes at initial mediastinoscopy was related to lower 5YS (17% vs 39%; p < 0.005), and this was identified as an independent prognostic factor in a multivariate analysis of the examined presurgical variables. We found a trend for a better 5YS in patients with mediastinal nodal downstaging compared to patients with persistent N2 disease (49% vs 27%; p = 0.095). In the subgroup with persistent N2 disease, single level disease has a significantly better survival (37% vs 7% 5YS, p < 0.005). Multivariate survival analysis of the examined surgical variables identified completeness of resection and classification of ypN category (ypN0-1 and ypN2-single level vs multilevel-ypN2 and ypN3) as independent prognostic factors. Conclusions: Surgery after induction chemotherapy for stage IIIA-N2 NSCLC can be performed with an acceptable mortality and morbidity. Baseline single level N2 disease is an independent prognostic factor for long-term survival. Patients with mediastinal downstaging, but also a subgroup of patients with single level persistent N2 disease, after induction therapy have a rewarding survival.

Objective: To evaluate the accuracy of integrated positron emission tomography with ¹⁸F-fluoro-2-deoxy-d-glucose (FDG) and computed tomography (PET/CT) in preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer (NSCLC) and to ascertain the role of invasive staging in verifying positron emission tomography (PET)/computed tomography (CT) results. Methods: Retrospective, single institution study of consecutive patients with suspected or pathologically proven, potentially resectable NSCLC undergoing integrated PET/CT scanning in the same PET centre. Lymph node staging was pathologically confirmed on tissue specimens obtained at mediastinoscopy and/or thoracotomy. Statistical evaluation of PET/CT results was performed on a per-patient and per-nodal-station bases. Results: A total of 1001 nodal stations (723 mediastinal, 148 hilar and 130 intrapulmonary) were evaluated in 159 patients. Nodes were positive for malignancy in 48 (30.2%) out of 159 patients (N1 = 17; N2 = 30; N3 = 1) and 71 (7.1%) out of 1001 nodal stations (N1 = 24; N2 = 46; N3 = 1). At univariate analysis, lymph node involvement was significantly associated (p < 0.05) with the following primary tumour characteristics: increasing diameter, maximum standardised uptake value >9, central location and presence of vascular invasion. PET/CT staged the disease correctly in 128 out of 159 patients (80.5%), overstaging occurred in nine patients (5.7%) and understaging in 22 patients (13.8%). The overall sensitivity, specificity, positive and negative predictive values, and accuracy of PET/CT for detecting metastatic lymph nodes were 54.2%, 91.9%, 74.3%, 82.3% and 80.5% on a per-patient basis, and 57.7%, 98.5%, 74.5%, 96.8% and 95.6% on per-nodal-station basis. With regard to N2/N3 disease, PET/CT accuracy was 84.9% and 95.3% on a per-patient basis and on per-nodal-station basis, respectively. Referring to nodal size, PET/CT sensitivity to detect malignant involvement was 32.4% (12/37) in nodes <10 mm, and 85.3% (29/34) in nodes ≥10 mm. Conclusion: Our data show that integrated PET/CT provides high specificity but low sensitivity and accuracy in intrathoracic nodal staging of NSCLC patients and underscore the continued need for surgical staging.

Objective: Emerging evidence suggests that specific sub-populations of cancer cells with stem cell characteristics within the bulk of tumours are implicated in the pathogenesis of heterogeneous malignant tumours. The cells that drive tumour growth have been denoted cancer-initiating cells or cancer stem cells (hereafter CSCs). CSCs have been isolated initially from leukaemias and subsequently from several solid tumours including brain, breast, prostate, colon and lung cancer. This study aimed at isolating and characterising the population of tumour-initiating cells in non-small-cell lung cancer (NSCLC). Methods: Specimens of NSCLC obtained from 89 patients undergoing tumour resection at the Cancer National Institute of Naples were analysed. Three methods to isolate the tumour-initiating cells were used: (1) flow cytometry analysis for identification of positive cells for surface markers such as CD24, CD29, CD31, CD34, CD44, CD133 and CD326; (2) Hoechst 33342 dye exclusion test for the identification of a side-population characteristic for the presence of stem cells; (3) non-adherent culture condition able to form spheres with stem cell-like characteristics. Definition of the tumourigenic potential of the cells through soft agar assay and injection into NOD/SCID mice were used to functionally define (in vitro and in vivo) putative CSCs isolated from NSCLC samples. Results: Upon flow cytometry analysis of NSCLC samples, CD133-positive cells were found in 72% of 89 fresh specimens analysed and, on average, represented 6% of the total cells. Moreover, the number of CD133-positive cells increased markedly when the cells, isolated from NSCLC specimens, were grown as spheres in non-adherent culture conditions. Cells from NSCLC, grown as spheres, when assayed in soft agar, give rise to a 3.8-fold larger number of colonies in culture and are more tumourigenic in non-obese diabetic (NOD)/severe combined immunodeficiency (SCID) mice compared with the corresponding adherent cells. Conclusions: We have isolated and characterised a population of CD133-positive cells from NSCLC that is able to give rise to spheres and can act as tumour-initiating cells.

Objective: Recent trials have evaluated adjuvant chemotherapy in patients with non-small-cell lung cancer (NSCLC). For stage IB to IIIA, a significant improvement of treatment results for platin-based chemotherapy was shown, but only one of the 20 patients treated has a benefit of disease-free and overall 5-year survival. In future the implementation of biomarkers, novel agents and individual selection may contribute to better treatment results in adjuvant therapy. Pre-clinical models are one way to study treatment innovations. Materials and methods: We have developed a lung cancer xenograft model. Fresh tumour material of patients with NSCLC was subcutaneously transplanted to immunodeficient mice shortly after surgical resection. In total, 102 samples have been transplanted from which 25 passagable models could be generated. Of the established xenograft lines, 48% were derived from squamous cell carcinomas and 24% from adenocarcinomas. All but one originated from long-term smokers. Results: It could be shown that the early murine passages (maximum 10) were similar to the original tumour with regard to histology and the expression of the surface proteins as E-cadherin, EpCAM or the cell proliferation marker Ki-67. The growth rate of the established xenografts was a unique feature of the different models and not related to patient characteristics or to the histology type. All xenograft models showed a wide variability in response to both classical chemotherapy and targeted anti-epidermal growth factor receptor agents. Response rates were in good accordance with the results of recent clinical studies. Discussion: In summary, we have developed a panel of patient-derived NSCLC xenografts. These xenograft models could be used for pre-clinical studies to evaluate chemotherapy, novel targeted therapies and expression of potential biomarkers.

Objective: To detect telomerase activity in pleural lavage fluid specimens in patients with non-small-cell lung cancer (NSCLC) and to evaluate its clinical value. Methods: From July 2005 to May 2007, 167 pleural lavage fluid specimens were obtained from 135 patients with NSCLC and 32 patients with benign lung tumour during operation. Telomeric repeated amplification protocol (TRAP)-enzyme-linked immunosorbent assay (ELISA) was performed to measure the telomerase activity in these specimens. Pleural lavage cytology (PLC) analysis of the pleural lavage fluid specimens was used for comparison. All the above specimens were examined within 3 h. Results: The positive rate of telomerase activity and PLC in pleural lavage fluid from patients with NSCLC was 25.2% (34/135) and 8.1% (11/135), respectively, with a significant difference (P < 0.05). Telomerase activity was detected in all 11 specimens with positive cytological examination. Telomerase activity was negative in all 32 patients with benign lung tumour. There was a significant relationship between telomerase activity and pleural extension, T level, N level as well as the clinical TNM (tumour, node, metastasis) stage of lung cancer. A significant association was found between positive telomerase activity and overall survival rate, even stage I survival rate. Multivariate Cox regression analysis demonstrated that telomerase activity, as well as PLC and the TNM stage were independent predictors of prognosis. Conclusion: Telomerase activity is a useful adjunct for cytological method in the diagnosis of pleural micro-metastasis and was related to prognosis in a patient with NSCLC.

Objective: To evaluate the diagnostic yield, the learning curve and the safety of endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) in mediastinal staging of patients with lung cancer. Methods: Mediastinal staging was performed with EBUS-TBNA according to the Danish national guidelines in patients fulfilling one or more of the following criteria: (1) central tumour; (2) enlarged (>10 mm) mediastinal lymph nodes on computed tomography; or (3) positron emission tomography (PET)-positive mediastinal lymph nodes. The study period began in January 2006 when EBUS-TBNA was introduced in the department and ended in December 2007. All records were reviewed retrospectively. None of the four examiners had any previous experience with EBUS-TBNA or ultrasound when the study began. All examinations were performed under general anaesthesia. Patients without useful cytological material from the EBUS-TBNA were subjected to a supplementary standard cervical mediastinoscopy if the mediastinal lymph nodes were found to be enlarged (>10 mm), PET positive or if the examiner was insecure of the result of the EBUS-TBNA. Patients with mediastinal lymph node involvement, detected by EBUS-TBNA or standard cervical mediastinoscopy, were referred to oncological treatment, while those without mediastinal lymph node involvement underwent – if they were otherwise eligible for surgery – resection and systematic lymph node sampling either by thoracotomy or by video-assisted thoracoscopy. Final mediastinal staging was defined as positive if mediastinal lymph node involvement was detected by EBUS-TBNA, standard cervical mediastinoscopy or surgery, or defined as negative otherwise. Results: A total of 157 patients were included in the study. N2/N3 disease was found in 67 patients (42.6%). EBUS-TBNA missed the mediastinal spread in 10 patients. Five of the ten patients had lymph node metastases in station 5, 6 or 8 – out of reach of EBUS-TBNA or standard cervical mediastinoscopy. EBUS-TBNA had a sensitivity of 0.85 (0.74–0.93) and a negative predictive value of 0.90 (0.82–0.95). No complications occurred from EBUS-TBNA. The number of supplementary standard cervical mediastinoscopies decreased significantly in the study period. Conclusion: The results of this study suggest that staging of the mediastinum with EBUS-TBNA is safe and easy to learn – even without previous experience with ultrasound. The diagnostic yield of EBUS-TBNA is in accordance with the yield of standard cervical mediastinoscopy reported in the literature. We do not find any indications in the present study of the recommended necessity for mediastinoscopy in all EBUS-TBNA-negative patients.

Objective: The use of VATS metastasectomy remains controversial because of doubt surrounding its ability to remove palpable but CT occult lesions. We aim to evaluate our policy of elective VATS and compare it with our results with open metastasectomy. Methods: Pulmonary metastasectomy was performed for metastatic colorectal adenocarcinoma in 52 patients: 27 open and 25 VATS over 8 years. The age and sex distribution was similar: median age was 66 for open and 69 years for VATS, p = 0.48, 70% male in open and 64% male in VATS, p = 0.31. Liver metastases were present in 37% in the open and 32% in the VATS group, p = 0.46. The choice of surgical approach was dependent on the distance of the lesion from the surface of the lung. We examined the survival using the Kaplan–Meier method and we tested for differences in the incidence of missed lesions, pulmonary disease progression and repeat metastasectomy. Results: There was no in-hospital mortality. There was no difference in the incidence of missed lesions (1 in VATS, none in open, p = 0.48), pulmonary disease progression (11 in open, 9 in VATS, p = 0.47) or recurrence in the same lobe (4 in open, 3 in VATS, p = 0.54). Median follow-up was 22 (1–70) months and there was no difference to the estimated actuarial survival. Mean survival for the open group was 47 months, SE 6 with 95% CI 36–59 months and mean survival for the VATS group 35.4 months, SE 3 with 95% CI 30–41.3 months. The estimated 1- and 2-year survival was 90% and 80% for open and 90% and 72% for VATS. Conclusions: The selective use of VATS therapeutic metastasectomy in conjunction with multi-detector CT is justified in metastatic colorectal adenocarcinoma. The insertion of the surgical digit is not mandatory. Trust the radiologist's eye.

Objective: The purpose of the study was to explore the usefulness of fluorine-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET-CT) in the preoperative assessment of isolated anterior mediastinal lesions, especially in the planning of operative strategy (biopsy or upfront resection). Methods: During the last 36 months, 19 consecutive patients (10 males, mean age 54 ± 16 years) underwent PET-CT in the preoperative work-up of isolated anterior mediastinal diseases. Maximal transverse diameter at CT and the postoperative histology and Masaoka staging for thymomas were collected and related to the maximum standardised uptake values (SUVs). Thymomas were divided into low-risk thymoma (LRT = A, AB and B1) and high-risk thymoma (HRT = B2, B3 and C). Results: There were 13 thymomas (six LRT and seven HRT), three lymphomas and three other primitive thymic tumours (one paraganglioma, two non-seminomatous germ cell tumours). In LRT, the mean SUV was 3.3 ± 0.5 resulting significantly lower than HRT, 13.5 ± 7 (p = 0.009). The SUV in LRT was also significantly lower with respect to lymphoma, 12.4 ± 4 (p = 0.001), and the other primitive anterior mediastinal tumours, 8 ± 0.8 (p = 0.001). Between thymomas we found a significant correlation between Masaoka stage and SUV, r = 0.718, p = 0.006. No correlation was found between transverse diameters and SUV, r = 0.141, p = 0.6. Conclusions: In our experience, low SUV (<5) is associated with LRT and minimal invasive thymoma (Masaoka stages I–II) and, therefore, susceptible to upfront surgery. For lesions with an infiltrative aspect on CT scan associated with a higher SUV (>5), an open biopsy is mandatory to exclude mediastinal lymphomas or, in case of HRT, to address a neoadjuvant treatment.

Background: Oesophageal squamous cell carcinoma (SCC) is a common type of cancer in China. The knowledge of its pattern of lymphatic metastasis would be of clinical value for surgical and radiation oncologists to treat this disease. Material and methods: A large series of 1850 thoracic oesophageal SCC was retrospectively analysed after extended oesophagectomy with three-field lymphadenectomy (3FL). Specimens were assessed for pattern of lymphatic spread. Result: Of the 1850 patients, 1081 (58.4%) developed mediastinal, cervical and/or abdominal node metastases. The lymphatic metastasis rates were 35.6%, 22.2%, 26.5%, 6.1% and 26.5%, respectively, for the cervical, upper, middle, lower mediastinal nodes and abdominal nodes. The adjacent mediastinal node metastasis alone occurred in 5.5% of patients, and the multiple level or skip node spread accounted for 20.9% and 73.6% of patients with node metastases. Upward lymphatic spread developed in 46.4% of patients, both up- and downward in 33.2%, and the downward, 20.5%. For the upper oesophageal SCC, the most common node metastasis was in the cervical (49.5%) and followed by the upper mediastinal (28.7%), middle mediastinal (11.4%), abdominal (8.0%) and lower mediastinal (1.4%) nodes. For the middle oesophageal SCC, the highest incidence of node spread was also in the cervical (35.0%) and similar rates in the middle mediastinal (29.8%), abdominal (27.2%) and upper mediastinal (22.4%) nodes, but the least in the lower mediastinal (6.0%) node. For the lower oesophageal SCC, more node metastasis occurred in the abdominal (51.7%), and followed by the middle mediastinal (25.6%), cervical (17.2%), lower mediastinal (13.9%) and upper mediastinal (10.0%). However, the lymphatic metastasis rates of the upper, middle and lower thoracic oesophageal SCC were similar. The unfavourable factors for lymphatic metastasis were long oesophageal lesion (p < 0.000), late T stage (p < 0.000) and poor differentiation of tumour cells (p < 0.000). Conclusion: The prevalence was: (1) lymphatic spread prone to the upward in the upper oesophageal SCC, downward in the lower one and both up- and downward in the middle one with in favour of the upward and (2) multiple level and skip node metastases were very often seen. The unfavourable factors for node spread were long oesophageal lesion, late T stage and poor differentiation of tumour cells.

Objective: Video-assisted thoracoscopic surgery (VATS) lobectomy has been employed for the treatment of lung cancer. Many investigators have reported that the outcomes of VATS lobectomy for lung cancer are comparable to those of thoracotomy; however, several controversial issues remain. One of the critical concerns is the safety. VATS lobectomy often requires an emergency conversion to thoracotomy, for example, in the event of massive bleeding. In this study, cases in which VATS lobectomy for lung cancer was converted to thoracotomy intra-operatively (converted VATS lobectomy) were identified. The safety of the converted VATS lobectomy was evaluated. Methods: Between 2003 and 2007, VATS lobectomy was converted to thoracotomy in 24 out of 492 cases. Information regarding the patients’ characteristics, reasons for the conversion and perioperative complications as well as the recurrence and survival data were carefully reviewed. The reasons for the conversion were classified into two groups: (1) problems related to the VATS procedure (VATS-related problems) and (2) problems not related to the VATS procedure (non-VATS-related problems). Results: Of the 24 converted cases, 19 (79%) had a history of smoking. Nine patients (38%) had a history of lung disease. Left upper lobectomy was the most frequently associated with conversion (11/24, 46%), followed by right lower lobectomy and right upper lobectomy. The most frequent reasons for the conversion were hilar lymphadenopathy and bleeding (seven patients each), followed by fused fissure. Eight of the conversions were considered to be attributable to VATS-related problems. Perioperative complications were observed in four patients, consisting of prolonged air leak in three patients and transient recurrent laryngeal nerve palsy in one patient. However, there were no life-threatening complications. The median follow-up period was 26 months. Recurrence occurred in two patients: pleural dissemination in one and bone metastasis in the other. Two deaths were observed during the follow-up period: one related to lung cancer and another related to other type of cancer. Conclusions: The safety of the conversion was acceptable. Our findings suggest that VATS lobectomy for lung cancer is feasible from the viewpoint of safety, even after taking into account the potential need for conversion to thoracotomy in some patients.

Introduction: Endoscopic thoracic sympathectomy (ETS) is performed for the treatment of primary hyperhidrosis (PH). The second and third sympathetic thoracic ganglions excised in ETS also innervate the heart and lung. Objective: In the present work we studied the cardiopulmonary effects of ETS in a group of patients with PH. Methods: We performed a prospective study in 38 patients with severe PH. Pulmonary function, echocardiographic assessment of left ventricular function and myocardial contractility and maximal, symptom-limited, incremental exercise tests were evaluated 2 weeks before, and 6 months after ETS. Data were analysed with the paired t-test. Differences were considered significant when p < 0.05. Results: In pulmonary function tests, we found a statistically significant decrease forced expiratory flow in small airways and an increase of residual volume, a significant decrease in heart rate and ejection fraction, a significant decrease of ‘rest’ and ‘peak’ heart rate, and a significant increase of oxygen pulse (O₂ pulse) and oxygen peak uptake ( peak) after ETS (p < 0.05). Conclusions: These cardiopulmonary effects observed 6 months after ETS in the treatment of patients with PH are all in normal ranges and are not relevant in cardiopulmonary function. We concluded that ETS in patients with PH is a safe procedure. Patients must be informed about these cardiopulmonary effects before the operation.

Objective: The lung allocation score (LAS) has changed the distribution of donor lungs for transplantation. This study was undertaken to evaluate the impact of the LAS on a unique patient population undergoing lung transplantation (LTX) at the single national Veterans Affairs (VA) LT center. Methods: One hundred and ten consecutive VA patients underwent LTX between 1994 and 2007. Patients transplanted using the LAS (LAS, n = 26) were compared to patients transplanted prior to introduction of the LAS (pre-LAS, n = 84). Results: Waiting time decreased from 353.8 ± 254.7 (pre-LAS) to 238.0 ± 306.6 (LAS) days (p < 0.01). Recipient diagnoses have changed with an increase in idiopathic pulmonary fibrosis [11% (9/84) pre-LAS vs 46% (12/26) LAS, p < 0.01] and a decrease in emphysema [57% (48/84) pre-LAS vs 35% (9/26) LAS, p < 0.01]. Mean LAS calculation was 33.1 ± 2.9 for pre-LAS versus 41.9 ± 9.8 for the LAS (p < 0.01). Postoperative complications did not differ between the groups. Length of hospital stay decreased from 44.3 ± 42.9 (pre-LAS) to 18.1 ± 12.3 (LAS) days (p < 0.01). Hospital mortality and 1-year survival did not differ between the pre-LAS and LAS groups (7% vs 8%; p = 0.72 and 92% [95% confidence interval (CI) 86–98] vs 92% [CI 82–100]; p = 0.23, respectively). Conclusions: The LAS appears to be achieving its objectives by reducing waitlist time and altering the distribution of lung disease being transplanted on the basis of medical necessity in the U.S. VA population. In addition, the LAS does not appear to have adversely affected short-term post-transplant outcomes in our recipient cohort.

The diagnosis of constrictive pericarditis (CP) continues to be a challenge in the modern era. Understanding the pathophysiology and integrating the results of invasive and non-invasive techniques are important in the differential diagnosis of CP and e.g. restrictive cardiomyopathy. New echocardiographic techniques such as tissue Doppler imaging (TDI) and 2D-speckle tracking, dual-source CT (computed tomographic imaging) and especially tagged cine-MRI (magnetic resonance imaging) with the analysis of phase contrast angiography sequences are promising novel approaches. Pericardiectomy in experienced centers with complete decortication (if technically feasible) is the treatment of choice for CP and it results in symptomatic relief in most patients. However, some patients may not benefit from pericardiectomy and this may be due to myocardial compliance abnormalities, myocardial atrophy after prolonged constriction, residual constriction or other myocardial processes. An important predictor of long-term outcome after pericardiectomy is the etiology of the pericardial disease. The overall mortality in the current literature is nearly 5–6%. Survival with post-surgical CP is worse than with idiopathic CP, but significantly better than with post-radiation CP.

Introduction: Compliance with the European Working Time Directive has made obvious the need for a surgical skills training system that will produce surgeons fast and reliably. We have previously proposed a model for objective assessment of surgical dexterity. In this paper we aim to place an updated version of that model into the context of a holistic approach on assessment of a trainee's progress towards becoming an independently operating surgeon. Methods: The PAR matrix breaks down an operation into clearly defined skills that need to be successively acquired. It consists of a 3 x 6 table depicting 18 skill-goals. The y-axis is divided into six levels and the x-axis into three columns. The initials of the three skills on each level form the acronym PAR. Each skill is further graded from 1 to 3 (unsatisfactory, competent, good). The levels are: Level 1 – posture, address, relaxation; Level 2 – pick-up, airtime, rotation; Level 3 – placing, angles, rhythm; Level 4 – precision, adaptability, reproducibility; Level 5 – pace, awareness, relations; Level 6 – planning, announce, review/reflexion. Results: The format of the PAR model is such that it allows trainer and trainee to objectively assess progress, identify deficiencies and strengths and formulate an appropriate plan of action. Conclusion: Ergonomics and crew resource management skills are essential for a safe operating environment. The PAR matrix may prove helpful in selection of trainees and revalidation of trainee surgeons as a competence and performance testing method, placed in the appropriate training curriculum.

Background: Although understanding the association between surgical volume and outcome has been the focus of much research, no study has yet reported the volume-outcome effect for thoracic aortic surgery. Methods: From the clinical database, we identified and analyzed 2875 procedures that took place across 36 centers between 2003 and 2005. The effect of hospital procedural volume was assessed for each outcome measure using a hierarchical mixed-effects logistic regression model. Clinical risk factors, procedural year, clinical processes, range of replacement, hospital volume and surgeon volume were set as fixed effects and sites were used as random intercepts. Results: The logistic regression model revealed that hospital thoracic aortic surgery volume was linked to statistically significant decreases in both 30-day mortality (p = 0.127: OR 0.988–0.999) and operative mortality (p = 0.022: 0.989–0.999). In addition, subgroup analysis showed that increased hospital volume was associated with reduced mortality rates in patients under 65 years of age (p = 0.038: 0.982–0.999) and in high-risk surgical candidates (p = 0.019: 0.989–0.999). Thoracic aortic surgery volume of surgeons, hospital adult cardiovascular surgery volume and surgeons adult cardiovascular surgery volume did not significantly impact these outcomes. Conclusions: In this study higher annual hospital thoracic aortic surgery volume of hospitals is associated with reduced mortality rates for thoracic aortic surgery. In Japan it is not the hospital general adult cardiovascular surgery volume, but the hospital specific thoracic aortic surgery volume that might be preferable for quality indicator of thoracic aortic surgery.

Background: Hypothermic circulatory arrest (HCA) is employed for aortic arch and other complex operations, often with selective cerebral perfusion (SCP). Our previous work has demonstrated real-time evidence of improved brain protection using SCP at 18 °C. The purpose of this study was to evaluate the utility of SCP at warmer temperatures (25 °C) and its impact on operating times. Methods: Piglets undergoing cardiopulmonary bypass (CPB) and 60 min of HCA were assigned to three groups: 18 °C without SCP, 18 °C with SCP and 25 °C with SCP (n = 8 animals per group). CPB flows were 100 ml kg^–1 min^–1 using pH-stat management. SCP flows were 10 ml kg^–1 min^–1 via the innominate artery. Cerebral oxygenation was monitored using NIRS (near-infrared spectroscopy). A microdialysis probe placed into the cerebral cortex had samples collected every 15 min. Animals were recovered for 4 h after separation from CPB. All data are presented as mean ± standard deviation (SD; p < 0.05, significant). Results: Cerebral oxygenation was preserved during deep and tepid HCA with SCP, in contrast to deep HCA without SCP (p < 0.05). Deep HCA at 18 °C without SCP resulted in significantly elevated brain lactate (p < 0.01) and glycerol (p < 0.01), while the energy substrates glucose (p < 0.001) and pyruvate (p < 0.001) were significantly depleted. These derangements were prevented with SCP at 18 °C and 25 °C. The lactate/pyruvate ratio (L/P) was profoundly elevated following HCA alone (p < 0.001) and remained persistently elevated throughout recovery (p < 0.05). Piglets given SCP during HCA at 18 °C and 25 °C maintained baseline L/P ratios. Mean operating times were significantly shorter in the 25 °C group compared to both 18 °C groups (p < 0.05) without evidence of significant acidemia. Conclusion: HCA results in cerebral hypoxia, energy depletion and ischaemic injury, which are attenuated with the use of SCP at both 18 °C and 25 °C. Procedures performed at 25 °C had significantly shorter operating times while preserving end organs.

Objective: We sought to compare the outcomes of minimally invasive mitral valve (MV) surgery for anterior (anterior mitral leaflet, AML), posterior (posterior mitral leaflet, PML) or bileaflet (BL) MV prolapse. Methods: Between August 1999 and December 2007, 1230 patients who presented with isolated AML (n = 156, 12.7%), isolated PML (n = 672, 54.6%) or BL (n = 402, 32.7%) MV prolapse underwent minimally invasive MV surgery. The preoperative mitral regurgitation (MR) grade was 3.3 ± 0.8, left ventricular ejection fraction (LVEF) was 62 ± 12% and mean age was 58.9 ± 13.0 years; 836 patients (68.0%) were male. Mean follow-up time was 2.7 ± 2.1 years, and the follow-up was 100% complete. Results: Overall, the MV repair rate was 94.0% (1156 patients). Seventy-four patients (6.0%) received MV replacement. MV repair for PML prolapse was accomplished in 651 patients (96.9%), for AML in 142 patients (91%) and for BL in 363 patients (90.3%). Repair techniques consisted predominantly of leaflet resection and/or implantation of neochordae, combined with ring annuloplasty. Concomitant procedures were tricuspid valve surgery (n = 56), atrial fibrillation ablation (n = 286) and closure of an atrial septal defect or patent foramen ovale (PFO) (n = 89). The overall duration of cardiopulmonary bypass was 127 ± 40 min and aortic cross-clamp time was 78 ± 33 min. The mean postoperative hospital stay was 11.6 ± 9.7 days for the overall group. Early echocardiographic follow-up revealed excellent valve function in the vast majority of patients, regardless of the repair technique, with a mean MR grade of 0.3 ± 0.5. For the overall group, 5-year survival rate was 87.3% (95% CI: 83.9–90.1) and 5-year freedom from cardiac reoperation rate was 95.6% (95% CI: 94.1–96.7). The log-rank test revealed no significant difference between the three groups regarding long-term survival or freedom from reoperation. Conclusions: Minimally invasive MV repair can be achieved with excellent results. Long-term outcomes and reoperation rates for AML prolapse are not significantly different from PML or BL prolapse.

Objective: To assess the long-term survival, the incidence of cardiac complications and the factors that predict outcome in asymptomatic patients with severe degenerative mitral regurgitation (MR) undergoing mitral valve repair. Methods: Up to 143 asymptomatic patients (mean age 63 ± 12 years) with severe degenerative MR who underwent mitral valve repair between 1990 and 2001 were subsequently followed up for a median of 8 years. The study population was subdivided into three subgroups: patients with left ventricular (LV) dysfunction and/or dilatation (n = 18), patients with atrial fibrillation and/or pulmonary hypertension (n = 44) and patients without MR-related complications (n = 81). Results: For the patients, 10-year overall and cardiovascular survival was 82 ± 4% and 90 ± 3%. At 10 years, patients without preoperative MR-related complications had significantly better overall survival than patients with preoperative LV dysfunction and/or dilatation (89 ± 4% vs 57 ± 13%, log rank p = 0.001). Patients without preoperative MR-related complications also tended to have a better 10-year overall and cardiovascular survival than patients with atrial fibrillation and/or pulmonary hypertension (overall survival of 79 ± 8%), although this did not reach statistical significance (log rank p = 0.17). Cox regression analysis identified the baseline left ventricular ejection fraction and age as the sole independent predictors of outcome. Conclusion: Our data indicate that in asymptomatic patients with severe degenerative MR, mitral valve repair is associated with an excellent long-term prognosis. Nonetheless, the presence of preoperative MR-related complications, in particular LV dysfunction and/or dilatation, greatly attenuates the benefits of surgery. This suggests that mitral valve repair should be performed early, before any MR-related complications ensue.

Objective: Anatomic alterations of the mitral valve such as increased mitral leaflet area, length and laxity, and anterior displacement of the papillary muscles in hypertrophic obstructive cardiomyopathy predispose patients to residual systolic anterior motion and persistence of outflow obstruction and mitral regurgitation after septal myectomy. We investigate the long-term results of combined anterior mitral leaflet retention plasty and septal myectomy in children with hypertrophic obstructive cardiomyopathy. Methods and results: Anterior mitral leaflet retention plasty and subaortic septal myectomy were performed in 12 children (mean age 10.8 ± 1.7 years) with hypertrophic obstructive cardiomyopathy. Mean preoperative left ventricular outflow tract pressure gradient was 49 ± 11 mmHg. After careful assessment of the mobility of the anterior leaflet and subvalvular apparatus, segments of the anterior leaflet nearest the trigones were sutured to the corresponding posterior annulus with polypropylene reinforced with untreated autologous pericardial pledgets. Intraoperative valve orifice measurement based on age-related valve diameter ensures that no mitral stenosis is produced. Mean intraoperative pre- and post-septal myectomy pressure gradient was 60 ± 25 mmHg and 5 ± 6 mmHg, respectively. Post-myectomy mitral insufficiency was reduced to a regurgitant fraction of 0–10%. Mean follow-up is 11.85 ± 1.22 years. Mean left ventricular outflow tract pressure gradient was 6.2 ± 3.95 mmHg. No mortality, no repeat myectomy or repeat mitral valve repair or replacement, no mitral stenosis and no systolic anterior motion occurred. Conclusions: Long-term follow-up shows sustained absence of systolic anterior motion, attenuation of mitral regurgitation, sustained improvement in functional status, and reduction of outflow tract obstruction.

Objective: The left atrial appendage is a significant source of cardioembolic thrombi. Open mitral valve surgery presents an opportune time to exclude this appendage from cardiovascular circulation. However, sparse randomized trial support exists for this concomitant procedure. We therefore designed a randomized controlled trial to assess the short- and long-term outcomes of concomitant left atrial appendage exclusion. This report details early outcomes of the pilot trial. Methods: Forty-three patients were randomized to either undergo concomitant suture exclusion of their left atrial appendage under direct vision or not during their open mitral valve surgery. Clinical and biochemical postoperative outcomes, including hemodynamic and hemostatic parameters, were analyzed. Results: There were no deaths in either group. The incidence of cerebrovascular events, myocardial infarction, respiratory failure, and acute renal injury were similar between groups; a composite outcome of 10 major postoperative complications occurred in 32% of the left atrial appendage exclusion group versus 38% of the control group (p = 0.75). Intensive care (median stay 2 days vs 1 day in the control group, p = 0.55) and hospital lengths of stay (median stay 9 days in both groups, p = 0.98) were also similar between groups. Specifically, no additional hemodynamic alterations (need for intra-aortic balloon pump in 1 vs 2 patients in the control group, p = 0.61) or hemostatic complications (no re-operations for bleeding in either group, need for blood product transfusion in 2 vs 1 patient in the control group, p = 1.0) were noted in the left atrial appendage exclusion group. Conclusions: This pilot trial demonstrates the safety of and feasibility of a larger trial powered to detect clinically relevant short- and long-term outcomes of concomitant left atrial appendage exclusion with open mitral valve surgery.

Background: Cox Maze surgery for atrial fibrillation (AF) has been found to have high efficacy in maintaining sinus rhythm and has been shown to improve quality of life early after surgery, but reports on long-term effects in this respect are lacking. This study was therefore undertaken to evaluate the effect of the Maze procedure on health-related quality of life in the long term. Methods: Patients with drug-refractory AF undergoing the ‘cut and sew’ Maze III procedure without any modification were assessed with the SF-36 Health Survey regarding quality of life at baseline and late after surgery. Totally 61 patients, mean age 55 years (range: 29–74 years), were evaluated. At the time of surgery, 34 patients (56%) had paroxysmal or persistent AF and the remainder had permanent AF. Results: At late follow-up, at a mean of 55 ± 12 months, 54 patients (89%) were free from AF recurrences and another five patients (8%) had experienced only one or a few AF episodes. All eight scales on the SF-36 Health Survey were significantly improved at long-term follow-up compared to baseline. The quality-of-life improvement was seen both in patients with paroxysmal/persistent AF and in those with permanent AF. At long-term follow-up, the quality-of-life scores were comparable with those of the general population. Conclusions: The Cox Maze III procedure has good long-term efficacy for rhythm control in patients with medically refractory AF, resulting in a quality-of-life improvement, which is maintained late after surgery.

Considerable research efforts have recently been made towards the application of autologous stem cell therapy for cardiovascular regeneration. Patients with coronary artery disease undergoing surgery represent a potential target. As yet, this approach has failed to obtain satisfactory evidence in clinical studies. However, several observational studies have described mobilising effect of cardiac surgery on endogenous stem cells, although the mechanisms of this phenomenon and its clinical relevance are not defined. This article reviews available clinical data on the effect of cardiac surgery on endogenous stem cells and outlines some of the controversies in this area.

Background: Cardiogenic dysfunction with acute renal failure (ARF) and diuretic drug resistance increases mortality after cardiac surgery with cardiopulmonary bypass (CPB) in adults. Until few years ago, intermittent renal replacement therapy (IRRT) was the only therapeutical strategy proposed to such patients. Few data are available in the literature regarding the use of continuous veno-venous haemofiltration (CVVH) in this clinical context. The aim of our observational study was to evaluate the impact of CVVH strategy on ARF in conjunction with cardiogenic shock after cardiac surgery and on its well-known associated poor outcome. Methods: During the period 2005–2006, we prospectively collected data from our database as we controlled the renal replacement therapy using CVVH (n = 73). We also retrospectively collected data from our computerised database on patients who were treated with IRRT (n = 68, period 2002–2003). Among CVVH-treated patients, a multivariate analysis of the data aimed to identify risk factors associated with 30-day mortality. Results: In patients who presented with ARF in conjunction with cardiogenic shock after cardiac surgery, 30-day mortality rate was 59% for the IRRT group and 42% for the CVVH group. Within the CVVH group, the logistic regression and multivariate analyses reported that some variables were associated with higher mortality risk: a score F concerning the urinary output criteria of the RIFLE (risk, injury, failure, loss, end-stage kidney disease) classification (for scores R or I: odds ratio (OR): 0.01, 95% confidence interval (95% CI): 0.02–0.59; p = 0.01), plasma bilirubin (OR: 1.44, 95% CI: 1.12–1.84; p = 0.04), total CVVH duration <50 h over 72 h (>50 h; OR: 0.009, 95% CI: 0.04–0.93; p = 0.01), the need of catecholamine support (OR: 12.88, 95% CI: 1.95–84.96; p = 0.01), tachycardia in the intensive care unit (ICU; OR: 1.64, 95% CI: 1.02–2.65; p = 0.04), surgery duration (<300 min; OR: 0.11, 95% CI: 0.02–0.71; p = 0.02) and combined cardiac surgery (OR: 7.00, 95% CI: 1.29–37.88; p = 0.02). Conclusion: In patients with ARF in conjunction with cardiogenic shock after cardiac surgery, renal replacement therapeutic strategy based on long-lasting CVVH could improve patients’ outcome. The identification of risk factors associated with a poor outcome would help to better manage such patients in the ICU. Low total duration of CVVH within the first 72 h was one criteria related to poor outcome. This suggests that CVVH must be initiated as soon as possible when ARF with diuretic resistance occurs in patients after cardiac surgery and continued as long as possible for the first 3 days.

Introduction: Implantation of a ventricular assist device (VAD) is a seminal therapeutic option for patients with terminal cardiac failure. However, haemolysis remains a clinically relevant adverse effect of several VAD types. Lysed erythrocytes release lactate dehydrogenase (LDH) and haemoglobin. Free haemoglobin in plasma is bound by haptoglobin with high affinity. The complex is internalised by monocytes/macrophages and degraded. Any more released free haemoglobin is captured by haemopexin. This complex also undergoes lysosomal degradation in various cells. Only now, the excessive free haemoglobin can be measured in plasma. Here, we investigated haemolysis in patients supported by different VAD types. Methods: Five patients with an intracorporeal centrifugal left ventricular VAD (LVAD), 10 patients with an axial LVAD and seven patients with a paracorporeal biventricular assist device (BVAD) were analysed preoperatively and 3 days (3.0 ± 0.4 days, early), 2 weeks (14 ± 1 days, intermediate) and 2 months (62 ± 5 days, later) after VAD implantation for haptoglobin, haemopexin, free haemoglobin in plasma, LDH, total haemoglobin, haematocrit and transfusion requirements. Results: Patients with a centrifugal LVAD displayed normal haptoglobin and haemopexin, low free haemoglobin and moderately increased LDH. In comparison, axial LVADs were accompanied by lower haptoglobin and haemopexin and higher free haemoglobin and LDH values. In contrast, BVADs led to an almost complete loss of haptoglobin and haemopexin and to high levels of free haemoglobin and LDH at each analysed time point. Conclusions: While severe haemolysis accompanies BVAD support, erythrocyte damage is less pronounced in the axial LVAD examined and only slight in the intracorporeal centrifugal LVAD. Haemopexin, a scavenger of free haemoglobin, can be used, in combination with haptoglobin and free haemoglobin, to assess erythrocyte damage.

There are certain aortic root pathologies where only one or two of the aortic sinuses are diseased. We aimed to evaluate our mid-term results after a partial remodeling of the aortic root. A total of 220 patients underwent a valve-sparing operation at our institution. In 29 patients (mean age: 62 ± 10 years), two (n = 22) or one (n = 7) native aortic sinuses were preserved. Operative indication was type A aortic dissection (n = 12) or aortic root aneurysm (n = 17). Preoperative aortic valve regurgitation was 1.8 ± 1.1 grades. Mean follow-up time was 46 ± 32 months. At the latest follow-up, 23 patients were alive and asymptomatic. One ascending aorta re-operation was observed due to late aortic graft infection. Echocardiographic measurements at latest follow-up were excellent: aortic regurgitation: 0.6 ± 0.5 grades; aortic valve area: 2.7 ± 0.7 cm²; aortic root dimensions: anulus 23 ± 3 mm, sinus 34 ± 5 mm, sinotubular junction 28 ± 5 mm and ascending aorta: 30 ± 2 mm. Longitudinal analysis revealed no development of clinically significant aortic regurgitation (<0.03 grades per year). However, in contrast to the group that underwent complete remodeling (n = 108), a significant dilatation at sinus and ST junction (STJ) level could be observed in the partial remodeling group over time (0.35 and 0.48 mm per year, respectively). This should be taken into consideration when applying this technique in patients operated on an elective basis.

Computed tomography scans were performed before and after aortic valve resection with consecutive implantation of a valved stent in human hearts with highly calcified aortic valves in situ (n = 2). This demonstrates that the valved stent shows better fitting in the annulus after removal of the native valve.

Patients who develop a severe stenosis in biological pulmonary conduits previously implanted for pulmonary outflow trunk reconstructions are treated either by surgical re-replacement, or by transcatheter stent-valve implantation through a femoral vein access. A catheter-based sub-xyphoidian access through the right ventricle for stent-valve positioning in a pulmonary conduit has rarely been proposed. We describe the case of a 20-year-old man who underwent a pulmonary trunk reconstruction for a congenital pulmonary valve dysplasia and a few years later developed a stenosis in the pulmonary conduit. He was successfully treated with a 23 mm Edwards Sapien^© stent-valve implantation in pulmonary position, through an unusual right ventricular, sub-xyphoidian access and without contrast medium injections and pleura opening.

Although use of carbon dioxide (CO₂) blower has been regarded safe during off-pump coronary bypass surgery (OPCAB), we experienced a case of right coronary artery ischaemia induced by retrograde CO₂ embolism originating from the opened obtuse marginalis artery during OPCAB. The spray pressure can exceed the diastolic pressure, especially during grafting at the lateral or posterior wall when haemodynamic compromise due to mechanical heart displacement is most severe. In this situation, CO₂ blowing at an incompletely slinged coronary arteriotomy site can result in retrograde migration of CO₂ into the ascending aorta causing coronary embolism of the right coronary artery. When signs of ischaemia on the right coronary artery are encountered during grafting of other coronary artery, although CO₂ blower has been used, gas embolism should also be considered as the cause and identified at the mid-oesophageal aortic valve long-axis view. When confirmed, the use of gas blower should immediately be discontinued and coronary perfusion pressure increased while allowing time for the CO₂ to be absorbed. In case of massive embolism, needle aspiration of the gas should also be considered.

Tracheo-oesophageal fistula (TEF) is an uncommon and potentially life-threatening complication of blunt chest trauma. We describe our surgical experience in a patient with huge TEF (5.6 cm in diameter) and evaluate the short-term results of surgical management by oesophageal exclusion (cervical gastro-oesophagostomy) and show that the use of oesophagus segment in situ as replacement of the posterior membranous wall of the trachea is feasible. Improving the nutrition status and controlling the lung infection were critical in the perioperation period.