The latest research articles published by Journal of Cardiothoracic Surgery
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Two approaches for repeat cardiac surgery

Mon, 10/22/2012 – 00:00
Background: With recent advances in post-operative care and surgical methods, the number of cardiovascular re-operations is increasing. We analyzed our institutional experience to evaluate the safety and efficacy of the approach methods for cardiac re-operations. Methods: Between September 2007 and December 2010, we performed 208 cardiac re-operations, defined as surgery which was not performed within a month from the previous operation or during the same hospitalization for the same disease and reviewed retrospectively. According to the surgical approach, we divided patients into two groups: median sternotomy group (S-group, n = 146), and thoracotomy group (T-group, n = 62). Results: There were no differences in sex or mean interval from the first surgery to re-operation between the two groups. Mean cardiopulmonary bypass, adhesion dissection time, bleeding control time, and operation time were significantly shorter in the T-group. The need for transfusion (p = 0.001) during adhesion dissection and the chest tube drainage (p < 0.001) were significantly lower in the T-group. There were 10 operative deaths in the S-group (6.8%) and 5 in the T-group (8.1%) (p = 0.757). Pneumonia was the most common cause of death in both groups. Post-operative bleeding did not result in death and there were no cases of wound infection in the T-group. Conclusions: Two approaches for repeated cardiac surgery were safe and effective in terms of mortality, wound infection, bleeding, operation time, adhesion dissecting time, and bleeding control time. We were able to obtain a good visual field and perform safe surgery by applying the thoracotomy method in selective patients for cardiovascular re-operation.

Temporary epicardial left ventricular and biventricular pacing improves cardiac output after cardiopulmonary bypass

Mon, 10/22/2012 – 00:00
ObjectiveTo evaluate, with different pacing modes, acute changes in left ventricular systolic function, obtained by continuous cardiac output thermodilution in various subsets of patients undergoing cardiopulmonary bypass surgery. Increments of mean arterial pressure and cardiac output were considered the end point Methods: Fifty cases electively submitted to cardiac surgery were analyzed. Isolated valve surgery 62%, coronary revascularization 30% and 8% mixed disease. Left ventricular ejection fraction was preserved in 50%,36% had moderate depression,(EF 36%-50%) whereas 14% had severe depression (EF<35%).Left bundle branch block occurred in 18%. Preoperatively 84 % were in sinus rhythm and 16% in atrial fibrillation. The different subgroups were analyzed for comparisons. Right atrial-right ventricular and right atrial-left ventricular pacing were employed in sinus rhytm. Biventricular pacing was also used in atrial fibrillation. Results: Right atrium-right ventricular pacing, decreased significantly mean arterial pressure and cardiac output (2.3%) in the overall population and in the subgroups studied. Right atrium-left ventricle, increased mean arterial pressure and cardiac output in 79% of patients and yielded cardiac output increments of 7.5% (0.40 l/m) in the low ejection fraction subgroup and 7.3% (0.43 l/m) in the left bundle branch block subset. In atrial fibrillation patients, left ventricular and biventricular pacing produced a significant increase in cardiac output 8.5% (0.39 l/min) and 11.6% (0.53 l/min) respectively. The dP/dt max increased significantly with both modes (p=0.021,p=0.028). Conclusion: Right atrial-right ventricular pacing generated adverse hemodynamic effects. Right atrium-left ventricular pacing produced significant CO improvement particularly in cases with depressed ventricular function and left bundle branch block. The greatest increments were observed with left ventricular or biventricular pacing in atrial fibrillation with depressed ejection fraction.

What factors predict recurrence of a spontaneous pneumothorax?

Wed, 10/17/2012 – 00:00
Background: The purpose of this retrospective study was to identify the risk factors for postoperative recurrence for the patients with a spontaneous pneumothorax (SP). A total of 214 patients were studied over a period of five years. Of these patients, 189 (88.3%) and 25 (11.7%) underwent video assisted thoracoscopic surgery (VATS) and an open approach for treatment, respectively. There were 35 (16.4%) postoperative recurrences. Methods: The data on patient characteristics, surgical details, and perioperative outcomes were analyzed. We compared the clinicopathological characteristics between recurrent and non-recurrent cases, and used logistic regression models to predict the risk factors for postoperative recurrence. Results: The differences in the age, gender, lesion site, location, ipsilateral SP (ISP), and contralateral SP (CSP) did not reach statistical significance between the two groups. However, the incidence of recurrence was higher in the subjects without any smoking history, and who had comorbidities, and a history of surgery for ISP. Concerning intraoperative factors, there were no significant differences with regard to the approach, buttress stapling, covering, surgeon, or length of the operation. The postoperative recurrence rate was higher in the patients who had been hand-stitched compared to those who had undergone instrument-based repair for blebs. There were no significant differences in the perioperative outcomes. The logistic regression models indicated that non smokers, those with comorbidities, and those who had previously undergone surgery for ISP had a higher rate of postoperative recurrence. Conclusions: We conclude that a history of no smoking, the existence of comorbidities, previous surgery for ISP, and hand stitching increase the risk of postoperative recurrence. Therefore, surgeons must be aware of these risk factors, and more carefully monitor such patients for recurrence.

Interdisciplinary team approach for complicated type B aortic dissection with concomitant hematothorax by Endovascular grafting and left side mini thoracotomy: a case report

Fri, 10/12/2012 – 00:00
Due to high mortality rates in surgical treatment, total endovascular stent grafting has become a promising therapeutic option in patients with acute aortic dissection type B. In our case, a 76- year- old patient with acute ruptured aortic dissection type B and hematothorax achieved concomitant total endovascular stent grafting and left side mini thoracotomy. With moderate neurologic impairment he was discharged from hospital after 20 days.This case shows that early mortality of live threatening acute aortic dissection type B with hemorrhagic pleural effusion may be reduced by total endovascular stent grafting and concomitant mini thoracotomy.

Coronary Artery bypass grafting and/or valvular surgery in patients with previous pneumonectomy

Wed, 10/10/2012 – 00:00
There is a lack of data regarding heart surgery on patients who have been previously pneumectomized. These patients pose unique challenges and surgical management may necessitate deviations from standard methods in the perioperative course. To summarize the available knowledge and to assess the optimal methods, we reviewed all reported patients with prior pneumonectomy who were subjected to coronary artery bypass grafting and/or valve surgery.In a Medline search from 1966 to May 2011 carefully undertaken, we identified 22 articles, including 29 patients who underwent 30 operations: CABG 70%, valvular surgery 23%, and combination 7%. Severe morbidity was 37% and 30-day mortality 13%.Although postoperative morbidity and mortality remain higher in previously pneumectomized patients undergoing coronary artery bypass grafting and valvular surgery, the gathered experience up to date suggests that a carefully planned surgical strategy, along with the use of advanced modern techniques may reduce morbidity and improve final outcome.

Loffler endocarditis: a rare cause of acute cardiac failure

Wed, 10/10/2012 – 00:00
We describe a patient with acute cardiogenic shock due to cardiac involvement in idiopathic hypereosinophilic syndrome (Loffler endocarditis). At the echocardiography, there was a huge mass in the left ventricular cavity, resulting in inflow- and outflow tract obstruction. The posterior leaflet of the mitral valve apparatus was completely embedded in a big (organized) thrombus mass. The patient was treated with high dose corticosteroids, however without effect. Partial remission was achieved after treatment with hydroxycarbamide. He was also treated with anticoagulants and high dose beta-blockers. The patient’s condition improved remarkably after correction of the mitral valve insufficiency by a mitral valve bioprothesis.

Postoperative abdominal complications after cardiopulmonary bypass

Tue, 10/09/2012 – 00:00
Background: To summarize the diagnostic and therapeutic experiences on the patients who suffered abdominal complications after cardiovascular surgery with cardiopulmonary bypass(CPB). Methods: A total of 2349 consecutive patients submitted to cardiovascular surgery with CPB in our hospital from Jan 2004 to Dec 2010 were involved. The clinical data of any abdominal complication, including its incidence, characters, relative risks, diagnostic measures, medical or surgical management and mortality, was retrospectively analyzed. Results: Of all the patients, 33(1.4%) developed abdominal complications postoperatively, including 11(33.3%) cases of paralytic ileus, 9(27.3%) of gastrointestinal haemorrhage, 2(6.1%) of gastroduodenal ulcer perforation, 2(6.1%) of acute calculus cholecystitis, 3(9.1%) of acute acalculus cholecystitis, 4(12.1%) of hepatic dysfunction and 2(6.1%) of ischemia bowel diseases. Of the 33 patients, 26 (78.8%) accepted medical treatment and 7 (21.2%) underwent subsequent surgical intervention. There were 5(15.2%) deaths in this series, which was significantly higher than the overall mortality (2.7%). Positive history of peptic ulcer, advanced ages, bad heart function, preoperative IABP support, prolonged CPB time, low cardiac output and prolonged mechanical ventilation are the risk factors of abdominal complications. Conclusions: Abdominal complications after cardiovascular surgery with CPB have a low incidence but a higher mortality. Early detection and prompt appropriate intervention are essential for the outcome of the patients.

Completion pneumonectomy for lung cancer treatment: early and long term outcomes

Tue, 10/09/2012 – 00:00
Background: To analyze the experience of completion pneumonectomy for lung cancer at a single institution in China. Methods: From January 1988 to December 2007, 92 patients underwent completion pneumonectomy for the treatment of lung cancer. The indications were second primary lung cancer (n = 51), Local metastasis (n = 37) and Lung metastasis (n = 4). The median interval between the primary operation and CP was 24.4 months (1.5-145 m). Results: There was no intraoperative deaths. The CP procedure lasted 4.3 h (1.5-8 h). Blood loss in the CP performance was 1854.5 ml (200-9100 ml) 9 (9.78%) patients died in the postoperative period: pulmonary embolism (n = 2), disseminated intravascular coagulation (DIC) after the multisystem failure (n = 1), respiratory failure after contralateral pneumonia (n = 5), bronchopleural fistula (BPF) with acute respiratory distress syndrome (ARDS) (n = 1) 31(33.7%) patients had at least one major nonfatal complication. The 1, 3 and 5 year survival rates were 81%, 26% and 14% respectively. Conclusions: Completion pneumonectomy for lung cancer is a safe surgical procedure for the skilled surgeon though it has a relatively higher complications and the long-term survival is acceptable.

Use of a sealant to prevent prolonged air leaks after lung resection: a prospective randomized study

Mon, 10/08/2012 – 00:00
Background: Pulmonary air leaks are common complications of lung resection and result in prolonged hospital stays and increased costs. The purpose of this study was to investigate whether, compared with standard care, the use of a synthetic polyethylene glycol matrix (CoSeal(R)) could reduce air leaks detected by means of a digital chest drain system (DigiVentTM), in patients undergoing lung resection (sutures and/or staples alone). Methods: Patients who intraoperatively showed moderate or severe air leaks (evaluated by water submersion tests) were intraoperatively randomized to receive just sutures/staples (control group) or sutures/staples plus CoSeal(R) (sealant group). Differences among the groups in terms of air leaks, prolonged air leaks, time to chest tube removal, length of hospital stay and related costs were assessed. Results: In total, 216 lung resection patients completed the study. Nineteen patients (18.1%) in the control group and 12 (10.8%) patients in the sealant group experienced postoperative air leaks, while a prolonged air leak was recorded in 11.4% (n = 12) of patients in the control group and 2.7% (n = 3) of patients in the sealant group. The difference in the incidence of air leaks and prolonged air leaks between the two groups was statistically significant (p = 0.0002 and p = 0.0013). The mean length of hospital stay was significantly shorter in the sealant group (4 days) than the control group (8 days) (p = 0.0001). We also observed lower costs in the sealant group than the control group. Conclusion: The use of CoSeal(R) may decrease the occurrence and severity of postoperative air leaks after lung resection and is associated with shorter hospital stay.Trial registrationNot registered. The trial was approved by the Institutional Review Board of the IRCCS-CROB Basilicata Regional Cancer Institute, Rionero in Vulture, Italy.

Assessment of the effect on blood loss and transfusion requirements when adding a polyethylene glycol sealant to the anastomotic closure of aortic procedures: a case–control analysis of 102 patients undergoing Bentall procedures

Mon, 10/08/2012 – 00:00
Background: The use of CoSeal®, a polyethylene glycol sealant, in cardiac and vascular surgery for prevention of anastomotic bleeding has been subject to prior investigations. We analysed our perioperative data to determine the clinical benefit of using polyethylene glycol sealant to inhibit suture line bleeding in aortic surgery. Methods: From January 2004 to June 2006, 124 patients underwent aortic surgical procedures such as full root replacements, reconstruction and/or replacement of ascending aorta and aortic arch procedures. A Bentall procedure was employed in 102 of these patients. In 48 of these, a polyethylene glycol sealant was added to the anastomotic closure of the aortic procedure (sealant group) and the other 54 patients did not have this additive treatment to the suture line (control group). Results: There were no significant between-group differences in the demographic characteristics of the patients undergoing Bentall procedures. Mean EuroSCORES (European System for Cardiac Operative Risk Evaluation) were 13.7 ± 7.7 (sealant group) and 14.4 ± 6.2 (control group), p = NS. The polyethylene glycol sealant group had reduced intraoperative and postoperative transfusion requirements (red blood cells: 761 ± 863 versus 1248 ± 1206 ml, p = 0.02; fresh frozen plasma: 413 ± 532 versus 779 ± 834 ml, p = 0.009); and less postoperative drainage loss (985 ± 972 versus 1709 ± 1302 ml, p = 0.002). A trend towards a lower rate of rethoracotomy was observed in the sealant group (1/48 versus 6/54, p = 0.07) and there was significantly less time spent in the intensive care unit or hospital (both p = 0.03). Based on hypothesis-generating calculations, the resulting economic benefit conferred by shorter intensive care unit and hospital stays, reduced transfusion requirements and a potentially lower rethoracotomy rate is estimated at €1,943 per patient in this data analysis. Conclusions: The use of this polymeric surgical sealant demonstrated improved intraoperative and postoperative management of anastomotic bleeding in Bentall procedures, leading to reduced postoperative drainage loss, less transfusion requirements, and a trend towards a lower rate of rethoracotomy. Hypothesis-generating calculations indicate that the use of this sealant translates to cost savings. Further studies are warranted to investigate the clinical and economic benefits of CoSeal in a prospective manner.

Elevated levels of anti inflammatory IL-10 and pro inflammatory IL-17 in malignant pleural effusions

Thu, 10/04/2012 – 00:00
Background: Pleural effusions can be caused by highly different underlying diseases and are characterized by complex interactions of various local and circulating cells as well as numerous soluble parameters like interleukins (IL). Knowledge of this complex network can be helpful in order to make the differential diagnosis in known malignant pleural effusions and understand the underlying immunochemistry of each disease or condition. Methods: We investigated immunoreactive concentrations of Interleukin 10 (IL-10) and Interleukin 17 (IL-17) in malignant pleural effusions and peripheral blood from patients with bronchial carcinomas and other carcinomas, excluding other conditions such as congestive heart failure (CHF) and pneumonias in twenty four (24) patients (9 men/15 women), 37-74 years (mean:61) with already diagnosed malignant pleural effusions applying the ELISA method. Results: The SPSS 15 program for Windows was used. Quantitative analysis showed high concentrations of IL-10 and IL-17 in pleural fluid and blood. Even though IL-17 levels -both blood and pleural- were lower than IL-10’s, statistical correlation between blood and pleural concentations was proven, confirming once more the systematic action of these cytokines. At the same time high IL-17 levels in malignant effusions shows maybe a new perspective in understanding the pathophysiology of malignant pleural effusions. Conclusions: Our results confirm the pathogenetic role of these cytokines in malignant pleural effusions combining for the first time a pro- and an anti- inflammatory cytokine . The observation that IL-17 is elevated in malignant pleural effusions may give a new meaning in Virchow’s remarks 100 years ago. Larger number of patients is needed to confirm our hypothesis.

Metachronous pulmonary metastasis after radical esophagectomy for esophageal cancer: prognosis and outcome

Tue, 10/02/2012 – 00:00
We retrospectively reviewed the prognosis and clinical outcome of 25 patients who developed metachronous pulmonary metastasis after esophagectomy for esophageal cancer. The site of recurrence was pulmonary without extrapulmonary metastasis in 14 patients and extrapulmonary metastasis was observed in 11. Nineteen patients had multiple pulmonary metastasis and 6 had solitary pulmonary metastasis. Twenty-four of patients underwent systemic chemotherapy during initial treatment for metastatic lesions. Pulmonary metastasectomy was indicated in 5 patients with solitary metastasis. The actual 1-, 2- and 4-year survival rates were 60%, 36% and 27%, respectively. Gender, operative procedure, and postoperative morbidity were not significant prognostic factors. However, pathological staging of primary esophageal cancer was a significant prognostic factor. Survival was significantly worse in patients who did not undergo resection than in those who did. The number of pulmonary metastasis, complicated extrapulmonary metastasis and the time of recurrence were also significant prognostic factors. In conclusions, multiple pulmonary metastases or complicated extrapulmonary metastasis were unfavorable prognostic factors for patients with pulmonary metastasis arising from esophageal cancer. Although, surgical intervention is not recommended in such cases, metastasectomy is an acceptable choice of treatment for solitary pulmonary metastasis.

Delayed Sternal Closure After Pediatric Cardiac Operations; Single Center Experience: A Retrospective Study

Tue, 10/02/2012 – 00:00
Background: Delayed sternal closure (DSC) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in pediatric cardiac surgery. The results with the technique of DSC over a 4-year period are examined with regard to mortality and morbidity. Methods: We retrospectively reviewed records of 38 patients who had undergone DSC among 1100 congenital cardiac operations. Indication of DSC, time to sternal closure, pre and post closure cardiopulmonary and metabolic status, mortality, rate of wound and bloodstream infections were recorded. Results: The mean sternal closure time was 2.9 days. The mortality rate was 34.2% (n = 13). Twenty (52.6%) patients required prolonged antibiotic use due to postoperative infection. There was gram negative microorganism predominance. There were 4 (10.5%) patients with postoperative mediastinitis. Postoperative infection rate statistically increased with cardiopulmonary bypass time (CPBT), sternal closure time (SCT) and intensive care unit (ICU) stay time (p = 0.039;p = 0.01;p = 0.012). On the other hand, the mortality rate significantly increased with increased cross clamp time (CCT), SCT, and extracorporeal membrane oxygenation (ECMO) use (p = 0.017; p = 0.026; p = 0.03). Single ventricular physiology was found to be risk factor for mortality in delayed sternal closure (p < 0.007). Conclusions: Elective DSC does not reduce the morbidity. The prolonged sternal closure time is associated with increased rate of postoperative infection rate; therefore early closure is strongly advocated.

Comparative pulmonary functional recovery after Nuss and Ravitch procedures for pectus excavatum repair: a meta-analysis

Sat, 09/29/2012 – 00:00
Background: Pectus excavatum (PE) is a common chest wall malformation, with surgery being the only method known to correct the defect. Although the Nuss and Ravitch procedures are commonly used, there is no consensus as to whether surgical repair improves pulmonary function. We therefore investigated whether pulmonary function recovers after surgical repair, and if recovery is dependent on the type of procedure or time after surgery. Methods: Literature searches were performed using PubMed, EMBASE, Health Periodicals Database, and CNKI (Chinese National Knowledge Index) from January 1990 to December 2007. The following keywords were used: pectus excavatum, chest wall deformity, funnel chest, pulmonary function, respiratory, lung function, and pectus severity index. The primary outcome of interest was possible changes in pulmonary function following surgical repair. Results: Meta-analysis of 23 studies showed that, although there was evidence of statistically significant heterogeneity among studies (Chi-square, 17.11, p < 0.05), changes in pulmonary functional indices, including forced expiratory volume over 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC), were similar 1 year after the Ravitch and Nuss procedures. Several years after surgery and bar removal, however, the changes in pulmonary functional indices significantly favored the Nuss procedure. Conclusions: Pulmonary function tends to improve after the surgical correction of pectus excavatum. Although the Nuss procedure was not significantly better 1 year after surgery, long-term postoperative pulmonary function improvement was significantly better after bar removal.

Mitral valve repair and redo repair for mitral regurgitation in a heart transplant recipient

Sat, 09/29/2012 – 00:00
A 37-year-old man with end-stage idiopathic dilated cardiomyopathy underwent an orthotopic heart transplant followed by a reoperation with mitral annuloplasty for severe mitral regurgitation. Shortly thereafter, he developed severe tricuspid regurgitation and severe recurrent mitral regurgitation due to annuloplasty ring dehiscence. The dehisced annuloplasty ring was refixated, followed by tricuspid annuloplasty through a right anterolateral thoracotomy. After four years of follow-up, there are no signs of recurrent mitral or tricupid regurgitation and the patient remains in NYHA class II. Pushing the envelope on conventional surgical procedures in marginal donor hearts (both before and after transplantation) may not only improve the patient’s functional status and reduce the need for retransplantation, but it may ultimately alleviate the chronic shortage of donor hearts.

The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: a retrospective study

Sat, 09/29/2012 – 00:00
Background: Thoracoscopic surgery is a commonly used endoscopic surgical treatment approach in patients with primary spontaneous pneumothorax. The conventional thoracoscopic approach utilizes three or more small wounds for surgery. Currently, a single port approach is a potential alternative procedure in general thoracoscopic surgery. We investigated whether a single-port approach is suitable as a first-line endoscopic approach for all patients with primary spontaneous pneumothorax requiring surgery. Methods: From July 1st, 2008 to Dec 31, 2009, a total of 62 patients was included in this study. All the patients were admitted to our ward because they had surgical indications for surgery. Twenty-six patients underwent conventional three-port thoracoscopic surgery and thirty-six underwent single-port thoracoscopic surgery. All of the clinical data were analyzed retrospectively. Variables were compared and analyzed to determine the outcomes of the different surgical approaches. Results: The mean age of the 62 patients was 27.2 years. Forty-nine patients were men and thirteen patients were women. The mean time required for the operation was 61.6 minutes. There was one patient who had a recurrence in single-port group and 2 patients had a recurrence in three-port group during the period of follow-up. The average pain scores at 24 and 48 hrs after the operation were similar, but the pain scores at 72 hrs in the single-port group were better than the three-port group. There was no case that required conversion from a single-port to multiple wound approach in this study. There was no immediate postoperative recurrence. The follow-up duration was greater than 12 months. Conclusion: This study showed that single-port thoracoscopic surgery is a feasible and reasonable first-line endoscopic approach in the surgical treatment of primary spontaneous pneumothorax.

Intravenous flurbiprofen for post-thymectomy pain relief in patients with myasthenia gravis

Sat, 09/29/2012 – 00:00
Background: Post-thymectomy pain in myasthenia gravis (MG) patients can inhibit breathing and coughing. Inappropriate usage of analgesics may exacerbate respiratory inhibition and even cause myasthenic crisis. Flurbiprofen is a non-steroidal anti-inflammatory drug (NSAID) that is commonly used to control moderate postoperative pain and is not associated with respiratory inhibition. We hypothesized that flurbiprofen may provide post-thymectomy pain relief without increasing the risk of complications in MG patients. Methods: Two hundred MG patients underwent extended thymectomy from March 2006 to December 2010 and were randomly allocated to a flurbiprofen group (110 patients, 50 mg intravenous flurbiprofen axetil) or a control group (90 patients, 100 mg intramuscular tramadol) as postoperative analgesia. Visual analog scale (VAS) pain score, heart rate, blood pressure, respiratory rate, pulse oximetry (SpO2), and adverse effects were recorded before and up to 24 h after drug administration. Results: There were no significant differences in the preoperative clinical characteristics of the flurbiprofen and control (tramadol) groups. Both flurbiprofen and tramadol significantly alleviated post-thymectomy pain (p < 0.05 for both), but patients in flurbiprofen group had significantly lower VAS pain scores at 0.5 h, 2 h, 4 h, and 8 h after surgery (p < 0.05 for all times). There were no significant post-thymectomy changes of heart rate, respiratory rate, mean arterial blood pressure, or SpO2 in either group at all time points. Conclusions: Post-thymectomy intravenous administration of flurbiprofen axetil provides safe and effective analgesia for MG patients.

Correlation between single nucleotide polymorphisms in CYP4F2 and warfarin dosing in chinese valve replacement patients

Thu, 09/27/2012 – 00:00
Background: Individuals with implanted mechanical valve prostheses require lifelong anticoagulation therapy with warfarin. The narrow therapeutic index of warfarin makes it difficult to dose and maintain proper anticoagulation. A number of single nucleotide polymorphisms (SNPs) affecting vitamin K or warfarin metabolism have been shown to affect warfarin dosing. Our aim was to study the effect of the CYP4F2 rs2108622-1347 (C > T) variant on warfarin dosing in Chinese patients. Methods: We studied 352 patients after heart valve replacement surgery. Warfarin dosing for patients was adjusted to achieve 1.8 <= INR <= 2.5. We determined the presence of SNPs in CYP4F2 in these patients and investigated their association with warfarin dosing. Results: We found the frequency of the CYP4F2 rs2108622 C allele was 79.5% and T-allele frequency was 20.5%. The warfarin dose requirement for CC individuals was significantly lower than that for CT or TT individuals (P < 0.05). TT-homozygous individuals required a 0.56 mg/day higher dose of warfarin than their CC counterparts. Conclusions: This study demonstrates that CYP4F2 rs2108622 significantly affects the warfarin dose requirement to achieve adequate anticoagulant activity in Chinese individuals. Genotyping of this SNP may allow clinicians to determine the initiation dose for patients following valve-replacement surgery in China.

Complete resection of undifferentiated cardiac sarcoma and reconstruction of the atria and the superior vena cava: case report

Thu, 09/27/2012 – 00:00
Primary cardiac tumors are rare with an incidence ranging from 0.001% to 0.03% in autopsy series. The prognosis of cardiac sarcomas remains poor because it proliferates rapidly and distant metastases are often found at diagnosis. A 47-year-old male complained of persistent cough. The chest roentgenogram was normal. Subsequent computed tomography revealed a mass in the right atrium. Echocardiography and magnetic resonance imaging confirmed also a right atrial mass (34 x 35 mm) infiltrating the atrial septum. The tumor was completely resected en bloc, including the anterior and lateral right atrial walls, the left atrial dome, and a large segment of the superior vena cava, and reconstructed the atria and superior vena cava with bovine pericardium. The tumor was histologically and immunohistochemically diagnosed as undifferentiated pleomorphic sarcoma. This type of cardiac sarcoma is very rare and usually found in the left atrium. Twenty-seven months after surgery, the patient is doing well without metastasis or local tumor recurrence.

Outcomes in cardiac surgery in 500 consecutive Jehovah’s Witnesess patients: 21 year Experience

Thu, 09/27/2012 – 00:00
Background: Refusal of heterogenic blood products can be for religious reasons as in Jehovah’s Witnesses or otherwise or as requested by an increasing number of patients. Furthermore blood reserves are under continuous demand with increasing costs. Therefore, transfusion avoidance strategies are desirable. We describe a historic comparison and current results of blood saving protocols in Jehovah’s Witnesses patients. Methods: Data on 250 Jehovah Witness patients operated upon between 1991 and 2003 (group A) were reviewed and compared with a second population of 250 patients treated from 2003 to 2012 (group B). Results: In group A, mean age was 51 years of age compared to 68 years in group B. An iterative procedure was performed in 13% of patients in group B. Thirty days mortality was 3% in group A and 1% in group B despite greater operative risk factors, with more redo, and lower ejection fraction in group B. Several factors contributed to the low morbidity-mortality in group B, namely: preoperative erythropoietin to attain a minimal hemoglobin value of 14 g/dl, warm blood cardioplegia, the implementation of the Cornell University protocol and fast track extubation. Conclusions: Cardiac surgery without transfusion in high-risk patients such as Jehovah Witnesses can be carried out with results equivalent to those of low risk patients. Recent advances in surgical techniques and blood conservation protocols are main contributing factors.

A case report of paraesophageal bronchogenic cyst with esophageal communication

Wed, 09/26/2012 – 00:00
Paraesophageal bronchogenic cyst was one of common mediastinal congenital cystic lesions of foregut origin. Because of an intimate embryologic relationship with the esophagus, they were usually found intramural (intramural esophageal bronchogenic cysts) with the local esophageal mucosa being intact and the paraesophageal bronchogenic cysts were rarely communicated with esophageal lumen. We report a case of para-esophageal bronchogenic cyst communicating to the esophageal lumen thorough a pedicle of canal, which looked liked a diverticulum on X-ray. During the operation, a communication of paraesophageal bronchogenic cyst with esophageal was found and the pathology diagnosis were made then. The symptoms of chest pain and dysphagia were relieved immediately after operation. The follow-up was well 2 years after the surgery.

Ventricular assist device outflow graft in congenitally corrected transposition of great arteries – a surgical challenge

Wed, 09/26/2012 – 00:00
Congenitally corrected transposition of the great arteries is a complex congenital cardiac anomaly with a wide spectrum of morphologic features and clinical profiles. Most patients are diagnosed late in their life, undergoes surgical repairs, eventually leading to systemic ventricular failure needing heart transplant or mechanical circulatory assistance. As, aorta is located anterior to and left of the PA (Transposition of great arteries), the outflow graft of ventricular assist device traverse across pulmonary artery to reach aorta which poses challenge during further surgical explorations.

Antioxidant vitamins A, C, E and coenzyme Q10 vs Dexamethasone: comparisons of their effects in pulmonary contusion model

Wed, 09/26/2012 – 00:00
Background: The goal of our study is to evaluate the effects of antioxidant vitamins (vitamin A, C and E), Coenzyme Q10 (CoQ10) and dexamethasone (Dxm) in experimental rat models with pulmonary contusion (PC). Methods: Rats were randomly divided into six groups. Except for the control, all subgroups had a moderate pulmonary contusion. Animals in the group I and group II received intraperitoneal saline, group III received 10mg.kg-1 CoQ10 group IV received 100mg.kg-1 vitamin C, group V received 150mg.kg-1 vitamin E, and group VI received 10mg.kg-1 Dxm. Blood gas analysis, serum nitric oxide (NO) and malondialdehyde (MDA) levels as well as superoxide dismutase (SOD) activity assays, bronchoalveolar lavage (BAL) fluid and histopathological examination were performed. Results: Administration of CoQ10 resulted in a significant increase in PaO2 values compared with the group I (p = 0.004). Levels of plasma MDA in group II were significantly higher than those in the group I (p = 0.01). Early administration of vitamin C, CoQ10, and Dxm significantly decreased the levels of MDA (p = 0.01). Lung contusion due to blunt trauma significantly decreased SOD activities in rat lung tissue compared with group I (p = 0.01). SOD levels were significantly elevated in animals treated with CoQ10, Vitamin E, or Dxm compared with group II (p = 0.01). Conclusions: In our study, CoQ10, vitamin C, vitamin E and Dxm had a protective effect on the biochemical and histopathological outcome of PC after experimental blunt thorax trauma.

Re-do aortic operation in a young patient for aggressive Takayasu’s arteritis

Wed, 09/26/2012 – 00:00
Takayasu’s arteritis is an inflammatory arteriopathy which involves the aorta and its major branches, causing mainly stenosis of their lumen, though aneurysmal lesions can also occur. A young female with Takayasu’s disease presented to our hospital with acute lung oedema due to severe aortic insufficiency and ascending aorta dilatation. She had already undergone distal ascending aorta and hemiarch replacement due to Standford type A aortic dissection five years ago. The patient had also undergone reconstruction of abdominal arteries’ stenoses with extraanatomical bypass. We performed a Bentall procedure with a valved conduit and implantation of the coronary ostia as buttons on the conduit. A mechanical valved graft was used instead of a bioprosthesis, due to possible early degradation of a bioprosthesis. The postoperative course was uneventful and the one year follow-up was normal. Valve-sparing aortic root replacement should be avoided in Takayasu’s arteritis due to high rate of recurrent regurgitation.

Influence of ischemia before vein grafting on early hyperplasia of the graft and the dynamic changes of the intima after grafting

Mon, 09/24/2012 – 00:00
Background: To investigate both the influence of ischemia before grafting on early hyperplasia of the vein grafts, and the dynamic changes of the intima after grafting in a rabbit model of vein graft disease. Methods: We performed paired vein graft experiments under different ischemic conditions (15 vs. 60 min; 15 vs. 90 min) in the neck of the rabbits and compared the differences between the grafts. Clopidogrel, an anti-platelet agent, was administered before and after surgery. Twenty-eight days after the grafting procedure, the veins were evaluated microscopically. The dynamic changes of the intima after grafting were evaluated by scanning electron microscopy over time. Results: The vein grafts subjected to 60- or 90-min ischemia exhibited no differences compared to those subjected to 15-min ischemia in terms of the mean thickness of the intimal, medial, and adventitial layers of the graft. Similarly, there was no difference in the Ki-67 labeling index (proliferation marker) between the vein grafts. Vein grafts with 15-min ischemia lost endothelial cells (ECs) but healed by 3 days post graft, whereas vein grafts with 90-min ischemia suffered serious EC loss, which was restored with new ECs during days 2 to 14 post graft. Conclusions: Ninety-minute ischemia before vein grafting can cause serious EC loss, but does not increase early intimal hyperplasia when clopidogrel is administered. Protecting the vein from ischemia and reperfusion injury preserves ECs.

EuroScore 2 for identification of patients for transapical aortic valve replacement – a single center retrospective in 206 patients

Fri, 09/21/2012 – 00:00
Background: Operative risk scoring algorithms identify patients with severe AS for transcatheter valve implantation in whom the anticipated operative mortality for conventional surgery would be considered prohibitive. We compared the three risk scores EuroScore 1 (LES), society of thoracic surgeons’ (STS) score and ACEF (age-creatinine-ejection fraction score) to the readjusted EuroScore 2 recently presented. Methods: We reviewed all consecutive patients receiving either isolated conventional aortic valve replacement (cAVR) or transapical aortic valve implantation (TA-TAVI) in a two-year period (n = 206). 30-days mortality was considered as primary endpoint. Results: TA-TAVI was performed in 76 patients, isolated cAVR in 130 patients. Overall mortality was 4.4% (TA-TAVI: 7.9%; cAVR: 2.3%). EuroScore 2 showed a good estimation for the entire population as well as within the subgroups: 4,02 +/- 5,36% (TA-TAVI: 6.16 +/- 7.14%, cAVR: 2.77 +/- 3.42%). Predicted mortalities as assessed by LES were largely overestimated (TA-TAVI: 27.4 +/- 20.9% cAVR: 10.6 +/- 10.6%, sensitivity: 0.89, specificity: 0.71). STS predicted mortality was 6.3 +/- 4.4% for TA-TAVI patients as to 3.2 +/- 3.1% for cAVR patients (sens.: 0.22, spec.: 0.96) and ACEF predicted a mortality of 1.16 +/- 0.36% for cAVR and 1.58 +/- 0.59% for TA-TAVI patients (sens.: 0.78, spec.: 0.89). Conclusion: The newly refined EuroScore 2 showed a good correlation within the studied population. For the individual patient, new cut-offs will have to be defined to triage patients for TAVI procedure. A drawback for complex score systems such as EuroScore and STS is the lack of recalibration to smaller populations as encountered in even large single centers.

Application of Regent mechanical valve in patients with small aortic annulus: 3-year follow-up

Fri, 09/21/2012 – 00:00
Background: Aortic valve replacement (AVR) with a small aortic annulus is always challenging for the cardiac surgeon. In this study, we sought to evaluate the midterm performance of implantation with a 17-mm or 19-mm St. Jude Medical Regent (SJM Regent) mechanical valve in retrospective consecutive cohort of patients with small aortic annulus (diameter <= 19 mm). Methods: From January 2008 to April 2011, 40 patients (31 female, mean age = 47.2 +/- 5.8 years) with small aortic annulus (<=19 mm in diameter) underwent aortic valve replacement with a 17-mm or 19-mm St. Jude Medical Regent (SJM Regent) mechanical valve. Preoperative mean body surface area, New York Heart Association class, and mean aortic annulus were 1.61 +/- 0.26 m2, 3.2 +/- 0.4, and 18 +/- 1.4 mm respectively. Patients were divided into two groups, according to the implantation of 17 mm SJM Regent mechanical valve (group 1, n = 18) or 19 mm SJM Regent valve (group 2, n = 22). All patients underwent echocardiography examination preoperatively and at one year post-operation. Results: There were no early deaths in either group. Follow-up time averaged 36 +/- 17.6 months. The mean postoperative New York Heart Association class was 1.3 +/- 0.6 (p < 0.001). By echocardiography, in group 1, the left ventricular ejection fraction (LVEF), left ventricular fraction shortening (LVFS), and the indexed effective orifice area (EOAI) increased from 43.7% +/- 11.6%, 27.3% +/- 7.6%, and 0.70 +/- 0.06 cm2/m2 to 69.8 +/- 9.3%, 41.4 +/- 8.3%, and 0.92 +/- 0.10 cm2/m2 respectively (P < 0.05), while the left ventricular mass index (LVMI), and the aortic transvalvular pressure gradient decreased from 116.4 +/- 25.4 g/m2, 46.1 +/- 8.5 mmHg to 86.7 +/- 18.2 g/m2 , 13.7 +/- 5.2 mmHg respectively. In group 2, the LVEF, LVFS and EOAI increased from 45.9% +/- 9.7%, 30.7% +/- 8.0%, and 0.81 +/- 0.09 cm2/m2 to 77.4% +/- 9.7%, 44.5% +/- 9.6%, and 1.27 +/- 0.11 cm2/m2 respectively, while the LVMI, and the aortic transvalvular pressure gradient decreased from 118.3 +/- 27.6 g/m2, 44.0 +/- 6.7 mmHg to 80.1 +/- 19.7 g/m2, 10.8 +/- 4.1 mmHg as well. The prevalence of PPM was documented in 2 patients in Group 1. Conclusions: Patients with small aortic annulus and body surface area, experienced satisfactory clinical improvement after aortic valve replacement with modern SJM Regent bileaflet prostheses.

Atrial fibrillation following cardiac surgery: risk analysis and long- term survival

Wed, 09/19/2012 – 00:00
Background: We studied potential risk factors for postoperative atrial fibrillation (POAF) in a large cohort of patients who underwent open-heart surgery, evaluating short- and long-term outcome, and we developed a risk-assessment model of POAF. Methods: A retrospective study of 744 patients without prior history of AF who underwent CABG (n = 513), OPCAB (n = 207), and/or AVR (n = 156) at Landspitali Hospital in 2002–2006. Logistic regression analysis was used to study risk factors for POAF, comparing patients with and without POAF. Results: The rate of POAF was 44%, and was higher following AVR (74%) than after CABG (44%) or OPCAB (35%). In general, patients with POAF were significantly older, were more often female, were less likely to be smokers, had a lower EF, and had a higher EuroSCORE. The use of antiarrythmics was similar in the groups but patients who experienced POAF were less likely to be taking statins. POAF patients also had longer hospital stay, higher rates of complications, and operative mortality (5% vs. 0.7%). In multivariate analysis, AVR (OR 4.4), a preoperative history of cardiac failure (OR 1.8), higher EuroSCORE (OR 1.1), and advanced age (OR 1.1) were independent prognostic factors for POAF. Overall five-year survival was 83% and 93% for patients with and without POAF (p <0.001). Conclusion: POAF was detected in 44% of patients, which is high compared to other studies. In the future, our assessment score will hopefully be of use in identifying patients at high risk of POAF and lower complications related to POAF.

The impact of preoperative anxiety and education level on long-term mortality after cardiac surgery

Fri, 09/14/2012 – 00:00
Background: Psychosocial factors have shown independent predictive value in the development of cardiovascular diseases. Although there is strong evidence to support the role of psychosocial factors in cardiovascular mortality, there is a scarcity of knowledge about how these factors are related. Therefore, we investigated the relationship between depression, anxiety, education, social isolation and mortality 7.5 years after cardiac surgery. Methods: After informed consent, 180 patients undergoing cardiac surgery between July 2000 and May 2001 were prospectively enrolled and followed for ten years. During the follow-up period, the patients were contacted annually by mail. Anxiety (Spielberger State-Trait Anxiety Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI) and the number and reason for rehospitalizations were assessed each year. Those patients who did not respond were contacted by telephone, and national registries were searched for deaths. Results: During a median follow-up of 7.6 years (25th to 75th percentile, 7.4 to 8.1 years), the mortality rate was 23.6% (95% confidence interval [CI] 17.3-29.9; 42 deaths). In a Cox regression model, the risk factors associated with an increased risk of mortality were a higher EUROSCORE (points; Adjusted Hazard Ratio (AHR):1.30, 95%CI:1.07-1.58)), a higher preoperative STAI-T score (points; AHR:1.06, 95%CI 1.02-1.09), lower education level (school years; AHR:0.86, 95%CI:0.74-0.98), and the occurrence of major adverse cardiac and cerebral events during follow up (AHR:7.24, 95%CI:2.65-19.7). In the postdischarge model, the same risk factors remained. Conclusions: Our results suggest that the assessment of psychosocial factors, particularly anxiety and education may help identify patients at an increased risk for long-term mortality after cardiac surgery.

Prevention of sternal dehiscence with the Sternum External Fixation (Stern-E-Fix) corset — a randomized trial in 750 patients

Sun, 09/09/2012 – 00:00
Background: The main objective of this study will be to determine the effects of a new advanced sternum external fixation (Stern-E-Fix) corset on prevention of sternal instability and mediastinitis in high-risk patients. Methods: This prospective, randomized study (January 2009 — June 2011) comprised 750 male patients undergoing standard median sternotomy for cardiac procedures (78% CABG). Patients were divided in two randomized groups (A, n = 380: received a Stern-E-Fix corset postoperatively for 6 weeks and B, n = 370: control group received a standard elastic thorax bandage). In both groups, risk factors for sternal dehiscence and preoperative preparations were similar. Results: Wound infections occurred in n = 13 (3.42%) pts. in group A vs. n = 35 (9.46%) in group B. In group A, only 1 patient presented with sternal dehiscence vs. 22 pts. in group B. In all 22 patients, sternal rewiring followed by antibiotic therapy was needed. Mediastinitis related mortality was none in A versus two in B. Treatment failure in group B was more than five times higher than in A (p = 0.01); the mean length of stay in hospital was 12.53 +/- 7.4 days (A) versus 17.9 +/- 15.1 days (B)(p = 0.02). Re-operation for sternal infection was 4 times higher in group B. Mean ventilation time was relatively longer in B (2.5 vs. 1.28 days) (p = 0.01). The mean follow-up period was 8 weeks (range 6 — 12 weeks). Conclusions: We demonstrated that using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence and secondary sternal infection in high-risk poststernotomy patients.

Intrathoracic splenosis presenting as persistent chest pain

Fri, 09/07/2012 – 00:00
Thoracic splenosis is a rare entity resulting from splenic and diaphragmatic injury. Patients remain asymptomatic, and surgical intervention is not indicated in the majority of cases. We report a case of a 50-year-old male with a history of splenectomy due to a gunshot wound 30 years previously who presented with vague, progressively worsening chest pain. He was found to have a large intrathoracic splenosis. Unique features of our patient include the presence of symptoms, the significant interval growth of the splenic tissue, and the unprecedented size of the mass, which we believe to be the largest among those previously described.

Midterm results after arterial switch operation for transposition of the great arteries: a single centre experience

Fri, 09/07/2012 – 00:00
Background: The arterial switch operation (ASO) has become the surgical approach of choice for d-transposition of the great arteries (d-TGA). There is, however an increased incidence of midterm and longterm adverse sequelae in some survivors. In order to evaluate operative risk and midterm outcome in this population, we reviewed patients who underwent ASO for TGA at our centre. Methods: In this retrospective study 52 consecutive patients with TGA who underwent ASO between 04/1991 and 12/1999 were included. To analyze the predictors for mortality and adverse events (coronary stenoses, distortion of the pulmonary arteries, dilatation of the neoaortic root, and aortic regurgitation), a multivariate analysis was performed. The follow-up time was ranged from 1–10 years (mean 5 years, cumulative 260 patient-years). Results: All over mortality rate was 15.4 % and was only observed in the early postoperative period till 1994. The predictors for poor operative survival were low APGAR-score, older age at surgery, and necessity of associated surgical procedures. Late re-operations were necessary in 6 patients (13.6 %) and included a pulmonary artery patch enlargement due to supravalvular stenosis (n = 3), coronary revascularisation due to coronary stenosis in a coronary anatomy type E, aortic valve replacement due to neoaortic valve regurgitation (n = 2), and patch-plasty of a pulmonary vein due to obstruction (n = 1). The dilatation of neoaortic root was not observed in the follow up. Conclusions: ASO remains the procedure of choice for TGA with acceptable early and late outcome in terms of overall survival and freedom of reoperation. Although ASO is often complex and may be associated with morbidity, most patients survived without major complications even in a small centre.

Mitral valve restoration using the No-React(R) MitroFixTM: a novel concept

Tue, 09/04/2012 – 00:00
Background: Mitral Valve Repair (MVRP) has been shown to be significantly superior to Mitral Valve Replacement (MVR). Since the majority of repairs involve the Posterior Mitral Leaflet (PML) and not the Anterior Mitral Leaflet (AML), the monocuspidalisation of the Mitral Valve (MV) can be achieved with a bio-posterior leaflet that imitates a closed PML. This approach may have the benefit of restoring the competence of the MV without reducing its effective orifice area. Methods: We have used a new concept and device, the MitroFixTM, to correct MV regurgitation due to pathology of the PML. The device comes with functional sizers both of which have identical shape and size. This allows the surgeon to pre-test the success of the restoration. From December 2006 to October 2011, 51 MitroFixTM devices were implanted at three institutions. Results: The mean age of the patients (32 males and 19 females) was 67.7 years. 37 of them were in NYHA class III or IV and all patients suffered from severe mitral valve regurgitation (MR). 31 patients underwent combined surgery. Successful implantation of the MitroFixTM device was performed in 51/53 patients.Mean cross-clamp time was 63.6 min (range: 29-118 min). Six patients had additional reconstructive procedures of the AML (chordae transfer, neo-chordae, triangular resection). At discharge, 33 patients showed no MR in the TTE and 17 patients exhibited trivial (I) or moderate (II) MR. The mean gradient was 4.0 mmHg and mean EOA was 2.52cm^2 (range: 1.5-4.0cm2). All patients were classified as being in NYHA class I or II. Conclusion: The MitroFixTM Mitral Valve Restoration Device is a new concept that offers an effective treatment of MR. The restoration of the mitral valve with the MitroFixTM device offers the advantage of preserving the AML and providing good coaptation with a prosthetic PML. Importantly, this preliminary evaluation indicates a mean effective orifice area ( EOA ) of 2.5cm2 in MV receiving a MitroFixTM device, witch is higher than EOA resulting from MVR or MVRP. The present study has also shown that severe regurgitation due to ischemic/rheumatic MR, endocarditis and complex prolapse of the PML are clear candidates for correction with the MitroFixTM. Larger studies and a longer follow up period are needed to validate these promising results.

Daptomycin as supportive treatment option in patients developing mediastinitis after open cardiac surgery

Tue, 09/04/2012 – 00:00
Background: Mediastinitis is a severe complication after cardiac surgery. While improvement of prophylaxis and of medical and surgical therapy has reduced its incidence, the treatment of mediastinitis continues to be a challenging problem. Within this study, we report the successful use of daptomycin as supportive therapy in patients developing mediastinitis after open cardiac surgery. Methods: The records of 21 consecutive patients who developed mediastinitis after cardiac surgery were retrospectively reviewed. After diagnosis, all patients received surgical debridement and antibiotic therapy with daptomycin. All patients were followed up to death or discharge. Results: Clinical improvement after combined surgical and antibiotic therapy with daptomycin was found in 90.5% of the patients. The median time until clinical improvement occurred was 5 [4/6] days. Daptomycin was well-tolerated and no major adverse events during therapy were observed observed. Conclusions: This study provides new and helpful information regarding the beneficial use of daptomycin as supportive treatment option in patients developing mediastinitis after cardiac surgery.

Minimal access excision of Aortic Valve Fibroelastoma: A case report and review of the literature

Mon, 09/03/2012 – 00:00
Papillary fibroelastomas are rare primary tumours of cardiac origin accounting for approximately 10% of all primary cardiac neoplasms. Due to a high thromboembolic risk, surgical excision is the mainstay of treatment these patients and median sternotomy the most widely used approach. We describe the case of a 43 year-old lady presenting with acute myocardial infarction secondary to aortic valve papillary fibroelastoma subsequently excised using a minimal access technique. From our experience mini-sternotomy offers excellent exposure and allows for safe resection in such cases, improving cosmesis without compromising either intra or post-operative outcome.

Simultaneous nephrectomy and coronary artery bypass grafting through extended sternotomy

Thu, 08/30/2012 – 00:00
Background: The advances in surgical techniques, resuscitation and anesthesiology support over the last years have allowed simultaneous thoracic and abdominal operations to be made for cancer and concomitant severe heart vessel disease relieving the patient from several diseases simultaneously and achieving long lasting remission or cure.Clinical caseA simultaneous nephrectomy and coronary artery bypass grafting procedure through extended sternotomy is reported. A 63-year-old man with severe coronary artery disease was found to have renal carcinoma.DiagnosisPostoperative pathological investigation of the tumor revealed the presence of renal cell carcinoma pT3a N0 M0, G2. Coronarography revealed advanced three-vessel coronary artery disease.TreatmentWe successfully performed a simultaneous curative surgery for renal carcinoma and coronary artery bypass graft surgery under cardiopulmonary bypass using a novel technique of extended sternotomy. Simultaneous surgery thus appears to be a beneficial and safe approach for the treatment of coronary artery disease and resectable renal cancer in carefully selected patients.

Contemporary incidence and risk factors for carotid artery disease in patients referred for coronary artery bypass surgery

Tue, 08/28/2012 – 00:00
Background: In the past decade, there has been an increase in the amount of patients with medical co-morbidities referred for coronary artery bypass surgery (CABG). Significant carotid artery disease in patients undergoing CABG procedures increases the risk of neurological complications. We review the results of routine carotid screening in patients undergoing CABG to determine the contemporary incidence and risk factors for carotid artery disease. Methods: Between 2008 through 2010, 673 patients were referred for isolated coronary artery bypass surgery at a single institution. Patients were identified through a systematic review of The Department of Cardiothoracic Surgery Society of Thoracic Surgery Outcomes Database. A retrospective analysis of prospectively collected demographic, clinical data and outcomes were performed. All patients with screening preoperative carotid duplex were reviewed. We defined the degree of carotid disease as: none to mild stenosis (<50%), moderate stenosis (50-69%), severe stenosis (70-99%). Multivariate analysis was performed to identify risk factors. Results: 559 (83%) patients underwent screening preoperative carotid ultrasonography prior to CABG. The incidence of carotid artery disease (>50% stenosis) was 36% with 18% unilateral moderate disease, 10% bilateral moderate and 8% severe disease. Risk factors associated with carotid artery disease included: advanced age, renal failure, previous stroke, peripheral vascular disease, left main coronary artery disease, and previous myocardial infarction. Conclusions: There is a significant incidence of carotid artery stenosis in patients referred for CABG. Routine screening will identify patients with carotid artery disease and may reduce the risk of postoperative stroke.

Left pulmonary artery banding to repair ipsilateral diffuse pulmonary arteriovenous fistula

Mon, 08/27/2012 – 00:00
Congenital pulmonary arteriovenous fistula (PAVF) is a rare disease which causes hypoxemia by shunting deoxygenated blood from the pulmonary artery into pulmonary venous return. Lung transplantation is the most effective therapy to treat severe, diffuse PAVF. However, the availability of lungs for transplantation is limited in most parts in the world. For patients with diffuse PAVF affecting only one side of the lungs, ipsilateral pulmonary artery banding (PAB) is an effective treatment, but not yet standard of care. We report successful treatment of a patient with diffuse left-sided PAVF with PAB. We believe that PAB is an effective therapy for severe unilateral PAVF and may serve as a bridge to lung transplantation.

Hospital costs fell as numbers of LVADs were increasing: experiences from Oslo University Hospital

Mon, 08/27/2012 – 00:00
Background: The current study was undertaken to examine total hospital costs per patient of a consecutive implantation series of two 3rd generation Left Ventricle Assist Devices (LVAD). Further we analyzed if increased clinical experience would reduce total hospital costs and the gap between costs and the diagnosis related grouped (DRG)-reimbursement.MethodCost data of 20 LVAD implantations (VentrAssist TM) from 2005-2009 (period 1) were analyzed together with costs from nine patients using another LVAD (HeartWareTM) from 2009-June 2011 (period 2). For each patient, total costs were calculated for three phases – the pre-LVAD implantation phase, the LVAD implantation phase and the post LVAD implant phase. Patient specific costs were obtained prospectively from patient records and included personnel resources, medication, blood products, blood chemistry and microbiology, imaging and procedure costs including operating room costs. Overhead costs were registered retrospectively and allocated to the specific patient by predefined allocation keys. Finally, patient specific costs and overhead costs were aggregated into total hospital costs for each patient. All costs were calculated in 2011-prices. We used regression analyses to analyze cost variations over time and between the different devices. Results: The average total hospital cost per patient for the pre-LVAD, LVAD and post-LVAD for period 1 was $ 585, 513 (range 132, 640- 1 247, 299), and the corresponding DRG- reimbursement (2009) was $ 143, 192 . The mean LOS was 54 days (range 12- 127). For period 2 the total hospital cost per patient was $ 413, 185 (range 314, 540- 622, 664) and the corresponding DRG- reimbursement (2010) was $ 136, 963. The mean LOS was 49 days (range 31- 93).The estimates from the regression analysis showed that the total hospital costs, excluding device costs, per patient were falling as the number of treated patients increased. The estimate from the trend variable was -14, 096 US$ (CI -3, 842 to -24, 349, p < 0.01). Conclusion: There were significant reductions in total hospital costs per patient as the numbers of patients were increasing. This can possibly be explained by a learning effect including better logistics, selection and management of patients.

Isolated right coronary lesion and anterolateral papillary muscle rupture – case report and review of the literature

Thu, 08/16/2012 – 00:00
Ischemic rupture of the anterolateral papillary muscle is uncommon due to its dual blood supply. It usually follows an ischemic event involving branches of the left circumflex or left anterior descending arteries.We present a case of a patient admitted with an acute inferior wall myocardial infarction and an isolated distal right coronary artery occlusion. Acute mitral regurgitation with rupture of the anterolateral papillary muscle was diagnosed on the fifth post-infarction day. The patient underwent mitral valve replacement and coronary artery bypass grafting to the posterior descending artery. We conclude that anterolateral papillary muscle rupture may also result from an isolated right coronary lesion.

False positive endobronchial ultrasound-guided real-time transbronchial needle aspiration secondary to bronchial carcinoma in situ at the point of puncture: a case report

Tue, 08/14/2012 – 00:00
Since the development of endobronchial ultrasound-guided real-time needle aspiration (EBUS-rt-TBNA) no false positive (FP) cases have been described. We present the first FP case for EBUS-rt-TBNA secondary to a carcinoma in situ (CIS) in the bronchial point of puncture. A 66-years-old male was referred to our Institution because of a mass in left lower lobe. The bronchoscopy did not show any endobronchial lesion. The cytology of the washing confirmed an unspecified non-small cell lung cancer. An EBUS-rt-TBNA for staging was carried out. No mediastinal nodes over 5 mm length were found but one single left hilar node at station 11 L was sampled. The cytology of the TBNA showed lymphocytes and neoplastic squamous cells. The patient underwent thoracotomy. On the surgical specimen no metastasis on any of the nodes resected were detected but a CIS on the bronchial resection margin was described. A bronchial biopsy confirmed CIS on the bronchial stump. The reported case depicts an unusual situation, we consider EBUS-rt-TBNA an accurate technique if minimal requirements are met

The efficacies of modified mechanical post conditioning on myocardial protection for patients undergoing coronary artery bypass grafting

Thu, 08/09/2012 – 00:00
Background: Coronary artery bypass grafting (CABG) with cardioplegic cardiac arrest and cardiopulmonary bypass (CPB) is associated with myocardial injury. The aim of this study was to investigate whether a modified mechanical post-conditioning (MMPOC) technique has a myocardial protective effect by enhancing early metabolic recovery of the heart following revascularization. Methods: A prospective, randomized trial was conducted at a single-center university hospital performing adult cardiac surgery. Seventy-nine adult patients undergoing first-time elective isolated multivessel coronary artery bypass grafting were prospectively randomized to MMPOC or control group. Anesthetic, cardiopulmonary bypass, myocardial protection, and surgical techniques were standardized. The post reperfusion cardiac indices, inotrope use and biochemical-electrocardiographic evidence of myocardial injury were recorded. The incidence of postoperative complications was recorded prospectively. Results: Operative characteristics, including CPB and aortic cross-clamp time, were similar between the two groups (p>0.05). The MMPOC group had lower troponin I and other cardiac biomarkers level post CPB and postoperatively, with greater improvement in cardiac indices (p<0.001). MMPOC shortened post surgery hospitalization from 9.1 [PLUS-MINUS SIGN] 2.1 to 7.5 [PLUS-MINUS SIGN] 1.6 days (p<0.001). Conclusions: MMPOC technique promotes early metabolic recovery of the heart during elective CABG, leading to better myocardial protection and functional recovery.

Development of post-pericardiotomy syndrome is preceded by an increase in pro-inflammatory and a decrease in anti-inflammatory serological markers

Mon, 07/23/2012 – 00:00
The post-pericardiotomy syndrome (PPS) is a common complication after cardiac surgery, occuring in 10-40% of patients. PPS may prolong hospitalization, and even serious complications like tamponade and constrictive pericarditis may occur. Early diagnosis and treatment may reduce morbidity. In 50 patients transferred to our hospital after cardiac surgery we found an increase in pro-inflammatory and a decrease in anti-inflammatory cytokines at admission in the patients later developing PPS compared to the patients who did not develop PPS. If confirmed in larger studies, these findings may prove useful in early identification of and targeted treatment in patients developing PPS.

The hybrid approach for the surgical treatment of lone atrial fibrillation: One-year results employing a monopolar radiofrequency source

Thu, 07/19/2012 – 00:00
Background: The hybrid technique combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure. We present our early results with this technique employing a monopolar radiofrequency source through a right thoracoscopy in patients with lone atrial fibrillation (LAF). Methods: Between June 2009 and December 2010 nineteen consecutive patients (mean 60.8 ± 8.6 years, 84.2% male) underwent right unilateral minimally invasive hybrid procedure for LAF at our Institution. Ten patients (52.6.6%) had long-standing persistent AF while four (21.1%) had persistent and five (26.3%) paroxysmal AF. All patients were followed-up according the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) and Society of Thoracic Surgeon (STS) guidelines. Results: There were neither early nor late deaths. It was possible to complete all the procedures as planned without any conversion to cardiopulmonary bypass. No patient died during the follow up. At one year, 7/19 (36.8%) patients were in sinus rhythm with no episode of AF and off antiarrhythmic drugs (AAD). Time-related prevalence of postoperative AF peaked at 44.4% (41.3–47.4) at two weeks, was 30.4% (27.3–34.9) at three months, fell to 14.2% (11.6–18.1) by 6 months and was 13.3% (11.0–17.4) at 12 months Among patients with long-standing persistent (LSP) AF, 20% (2/10) were in Sinus rythm and off AAD. One-year success rates were 50% (2/4) in persistent and 60% (3/5) in paroxysmal AF. At 12 months estimated prevalence of antyarrhythmic drugs and Warfarin use were 26% (22.4–33.1) and 48% (37.2–53.2), respectively. Conclusions: One year results combining the percutaneous endocardial with the right thoracoscopic epicardial technique were, in our experience, not satisfactory, particularly in patients with LSP and persistent AF. Our findings need to be confirmed by larger studies.

Primary cardiac B-cell lymphoma with atrioventricular block and paroxysmal ventricular tachycardia

Wed, 07/18/2012 – 00:00
Primary cardiac lymphoma (PCL) is very rare, and is extremely challenging to diagnose due to nonspecific symptoms. When discovered, the right atrium and ventricle are most commonly affected, while diffuse cardiac involvement is uncommon. PCL is fatal unless promptly diagnosed and treated. Herein, we present the case of a 36-year-old immunocompetent male who presented with a 5-year history of non-specific chest symptoms and was diagnosed with primary diffuse cardiac large B-cell lymphoma involving the entire heart.

Elective minimally invasive coronary artery bypass: Shunt or tournique occlusion? Assessment of a protective role of perioperative left anterior descending shunting on myocardial damage. A prospective randomized study

Wed, 07/18/2012 – 00:00
Background: To determine impact of intraluminal-left anterior descending shunt to prevent myocardial damage in minimally invasive coronary artery bypass. Methods: 38 patients were randomly assigned to external tournique occlusion (n = 19) or intraluminal-left anterior descending shunt group (n = 19). Blood samples for cardiac troponin T were collected at 30 minutes prior to, 6 and 24 hours after surgery. Results: One patient in external tournique occlusion and two patients in intraluminal-left anterior descending shunt group were excluded from futher analysis due to preoperative cardiac troponin T level above the 99th-percentile. Postoperatively, each six patients in external tournique occlusion (33.3%) and intraluminal-left anterior descending shunt (35.3 %) group were above the 99th-percentile. Two patients from each group (external tournique occlusion group 11.1 % vs. intraluminal-left anterior descending shunt group 11.8 %) had peak values above 10-% coeficient of variation cutoff (p = 1). There were no significant differences in between both groups at all studied timepoints. Conclusion: There was no protective effect of intraluminal shunting on myocardial damage compared to tournique occlusion. It is upon the surgeon’s discretion which method may preferrably be used to achieve a bloodless field in grafting of the non-occluded left anterior descending in minimally invasive coronary artery bypass.

Ectopic thymoma presenting as a giant intrathoracic mass: A Case Report

Mon, 07/16/2012 – 00:00
Thymoma is an epithelial neoplasm of the thymus, which commonly lies in the anterior mediastinum and, therefore, an intrathoracic origin is considered to be rare. This report presents a case of giant thymoma arising in the thoracic cavity. A 61-year-old male presented with a chronic cough and breathlessness. Chest CT revealed a well enhanced giant mass approximately 18 cm in diameter in the right thoracic cavity. FDG-PET showed that the SUVmax of the tumor was 5.0 in the center and almost 2.5 in the surrounding area. A trans- bronchial needle biopsy was performed to find atypical cells. Surgery was scheduled based on the radiological and histological findings. A well-defined giant mass in the thoracic cavity, measuring 18 × 14.5 × 11 cm had undergone expansive growth without apparent invasion. The tumor was completely resected without combined resection of the other organs. The weight of the tumor was 1350 g. The tumor was histologically diagnosed to be type AB thymoma according to the World Health Organization classification and Masaoka stage IIB.