Between September 1992 and August 2007, 1,353 repairs of the thoracic aorta were performed, with 82% using CSF drainage. The CSF drainage was not used in cases of rupture, acute trauma, infection, or prior paraplegia. Thirty-one percent (76 of 246) of patients without CSF drainage were repaired prior to standardized use. All drains were inserted by cardiovascular anesthesia staff. Repairs were performed using distal aortic perfusion with heparinization. Early management involved free drainage to maintain CSF pressure less than10 mm Hg, but was later modified to limit CSF drainage unless neurologic deficit occurred.

Cerebrospinal fluid drainage was technically achieved in 99.8% (1,105 of 1,107) of cases. The CSF catheter-related complications occurred in 1.5% (17 of 1,107) of patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without spinal headache, spinal headache, intracranial hemorrhage, catheter fracture, and meningitis occurred in 6 (0.54%), 1 (0.1%), 2 (0.2%), 5 (0.45%), 1 (0.1%), and 2 (0.2%) cases, respectively. Mortality from subdural hematoma was 40% (2 of 5), and from meningitis was 50% (1 of 2). Spinal headaches resolved with conservative management. All CSF leaks resolved, but 71% (5/7) required blood patches. Since implementation of a limited CSF drainage protocol, no subdural hematomas have been observed.

Cerebrospinal fluid drainage for thoracic aortic repairs can be performed safely with excellent technical success. Perioperative management of CSF drains requires diligent monitoring and judicious drainage. Standardizing CSF management may be beneficial.

Between 1998 and 2008, 111 patients underwent arch aneurysm repair with LET. A 4-branched graft was sutured to the sinotubular junction, the distal ascending aorta transected, and a LET inserted into the aortic arch while selective cerebral perfusion was maintained. The graft distal end was anastomosed to the LET, incorporating the distal ascending aorta, and arch vessels were anastomosed to graft branches.

Concomitantly, 33 patients (30%) underwent other cardiac procedures, including 11 aortic root replacements. Two patients died (1.8%) within 30 days and 7 died (6.3%) after 30 days. Perioperative morbidity included 2 (1.8%) with stroke, 3 (2.7%) with paraplegia, and 1 (0.9%) with paraparesis. Postoperative computed tomography scans revealed complete aneurysmal thrombosis around the LET in 88 patients (79%), who were monitored without a second-stage procedure. Among 23 patients with incomplete thrombosis, 19 underwent a second-stage procedure to complete distal fixation of the LET. Overall survival was 88%, 83%, and 75%, at 1, 3, and 5 years after aneurysm repair with the LET. No aneurysm rupture or reexpansion occurred in patients with complete thrombosis. Four patients with incomplete thrombosis died of rupture before the second-stage procedure.

Our results demonstrated safety and good durability of the LET technique and suggest that this technique is a simple and safe procedure that is applicable to a variety of arch aneurysms.

Two independent observers evaluated 1108 consecutive postoperative RA conduit angiograms performed between January 1997 and June 2007 for cardiac symptoms. Mean time to postoperative angiography was 48.3 months (range, 1 to 132 months). An RA graft was considered failed (nonpatent) if there was stenosis exceeding 60%, string sign, or occlusion. Patency was determined over time, by coronary territory grafted and by the degree of native coronary artery stenosis (NCAS).

At a mean of 48.3 months, 982 of the 1108 RA grafts (89%) were patent. RA patencies for the left anterior descending were 96% (24 of 25), diagonal/intermediate, 90% (121 of 135); circumflex marginal, 89% (499 of 561); right coronary, 83% (38 of 46); posterior descending, 89% (253 of 286); and left ventricular branch/posterolateral, 86% (47 of 55). Patency was 87.5% (56 of 64) for NCAS of less than 60% compared with 89% (926 of 1044; p = 0.89) for NCAS exceeding 60%. Of 318 RAs in place more than 5 years, 294 (92.5%) were patent, and for 107 RAs in place for more than 7 years, 99 were patent (92.5%). Patency was consistent through each year of the decade. Mechanisms of failure did not involve development of atherosclerosis. Patent RA grafts were smooth, with no angiographic evidence of atheroma.

Late patencies of RA grafts are excellent and justify continuing use of the RA in coronary operations.

We compared late survival of 532 consecutive patients receiving sequential RA grafts (sequential RA group: 438 men; 462 with three-vessel disease) with that of a 4,131 contemporaneous internal thoracic artery (ITA) with saphenous vein (SV) multivessel CABG cohort (conventional group). Graft failure rates were determined from symptom-driven repeat angiography films in 122 sequential RA patients performed 2 to 4,317 days after surgery. Median survival sequential RA follow-up was 5.3 years (range, 0.5 to 12.3).

The sequential RA patients received a total of 1,181 RA grafts (538 sequential [30 triple] and 75 single) along with 636 SV and 533 ITA. Overall RA graft failure (80 of 272; 29%) was intermediate to that for ITA (7 of 121; 5.8%; p < 0.001) and vein (54 of 133, 41.6%; p = 0.032) grafts. Sequential versus nonsequential RA failure did not differ (77 of 252 [31%] versus 3 of 20 [15%]; p = 0.202), while failure of the proximal (36 of 123; 29%) and distal (40 of 129; 31%) components of sequential RA grafts were essentially identical. A total of 69 deaths (6 operative; 1.1%) have occurred in the sequential RA cohort. Unadjusted 10-year sequential RA cohort survival was 76.2% overall, and 79.0% for the 454 primary isolated CABG subgroup. The risk-adjusted 10-year survival using a logit propensity score was substantially better for the sequential RA cohort versus the conventional CABG cohort (risk ratio [95% confidence interval] 0.61 [0.44 to 0.85]; p = 0.003).

Sequential RA grafting is a safe method for maximizing arterial revascularization and is associated with excellent 10-year survival that seems to be superior to conventional or ITA/SV CABG results. Also, the similar proximal and distal sequential RA patency mitigates concerns of a clinically significant effect of increased vasoreactivity of distal segments of RA conduits.

A multiyear statewide data repository with clinical and billing data was used to measure outcomes for the period 2004 to 2007. The Society of Thoracic Surgeons records matched with Universal Billing (UB-04) charge data for all payers were used to estimate the additive costs of cardiac surgical outcomes using cost-to-charge ratios. Additive cost was defined as the difference between the baseline cost of an average case with no complications and one with a postoperative morbidity or mortality. Multivariate analysis was used to account for important covariates and apportion incremental costs.

The baseline cost of isolated coronary artery bypass grafting (CABG) cases with no complications during the study period was $26,056. Isolated atrial fibrillation was the most frequently cited complication and had the lowest additive cost ($2,574). Additive costs for isolated CABG patients were greatest for those cases involving prolonged ventilation ($40,704), renal failure ($49,128), mediastinitis ($62,773), and operative mortality ($49,242).

Additive costs can serve as an indicator for pursuing quality improvement initiatives. Our results suggest additive costs vary according to type of postoperative complication and comorbidities. Regional collaborations of multidisciplinary groups in cardiac surgery are an effective means to implement quality guidelines and drive down additive costs.

From September 1998 to September 2008, 580 consecutive patients receiving off-pump multivessel arterial grafts only were compared with a control group of patients (n = 806) undergoing off-pump coronary artery bypass grafting with internal thoracic artery and saphenous veins operated on by the same surgeon. Two different statistical approaches were used to compare groups in this retrospective analysis. First, propensity score analysis was used to match patients from each group. Second, a multivariate analysis was performed looking at a combined patient outcome of death, intraaortic balloon counterpulsation utilization, myocardial infarction, stroke, prolonged ventilation, and reoperation for any cause on all patients in both groups.

After matching by propensity score, the major clinical outcomes in total arterial (n = 346) and control (n = 346) groups were found to be similar. The in-hospital mortality in the total arterial group was 1.2% as compared with 2.0% in matched patients (p = 0.8). However, patients in the total arterial group were found to have a significantly increased incidence of reexploration for bleeding (p < 0.0001) and blood product usage (p < 0.0001). There was a higher incidence of combined morbidity outcome (18.8% versus 12.1%; p = 0.001) for the control group compared with the total arterial group. Multivariate analysis failed to show that total arterial grafting was an independent predictor of the combined morbidity outcome.

Off-pump multivessel total arterial grafting can be performed safely with superior in-hospital outcomes compared with off-pump conventional coronary artery bypass grafting.

We evaluated coronary angiograms in 63 patients who had left anterior descending artery (LAD) segmental reconstruction with or without endarterectomy after off-pump coronary artery bypass graft surgery. The diameters of the ITA and reconstructed coronary artery were measured early and at 1 year after surgery.

The mean diameter of the reconstructed LAD was significantly larger than that of the ITA, but significantly decreased 1 year after surgery (2.69 ± 0.53 mm versus 1.87 ± 0.39 mm; p > 0.0001). The proximal ratio, the ratio of the ITA to proximal reconstructed coronary artery, and the distal ratio, the ratio of the distal LAD to distal reconstructed coronary artery, increased to a value of almost 1.0 (0.77 ± 0.11 versus 1.05 ± 0.18, p < 0.0001, and 0.77 ± 0.14 versus 0.92 ± 0.12, p < 0.0001, respectively). Based on the mean diameter of the reconstructed coronary artery, there were no relationships between the use of endarterectomy and the degree of native coronary stenosis. The proximal ratio in the group with severe stenosis was significantly greater than that in the group with mild stenosis (1.08 ± 0.18 versus 0.95 ± 0.16; p = 0.036), although the distal ratio was not different between the two groups.

Vascular remodeling of the coronary artery reconstructed with the ITA is observed within 1 year after surgery.

One-hundred and ninety-seven selected patients undergoing CABG were assigned to two groups according to antiplatelet drug: the clopidogrel group of 102 patients who received clopidogrel (75 mg) daily; and the combination group of 95 patients who received clopidogrel (75 mg) plus aspirin (100 mg) daily. Multislice computed tomography angiography was performed to evaluate graft patency at 1 month and 12 months after CABG.

There were no significant differences between the two groups in preoperational data. At 1 month and 12 months after CABG graft patency rates of clopidogrel group were, respectively, 99.0% and 96.9% for the left internal mammary artery (LIMA) and 98.1% and 93.5% for the saphenous vein grafts; those of the combination group were, respectively, 98.9% and 97.8% for LIMA, and 98.2% and 96.3% for saphenous vein grafts. There were no significant differences in graft patency between the two groups (p > 0.05).

Either clopidogrel plus aspirin or clopidogrel alone maintain high graft patency in the early postoperative phase after CABG. The observed trend toward higher patency rates in patients treated with clopidogrel plus aspirin compared to those in the clopidogrel group did not reach statistical significance.

We identified 108 consecutive patients who had cardiorespiratory arrest after coronary artery bypass grafting or aortic valve replacement between April 1999 and June 2008. We studied the characteristics of arrests and survivors, and performed a multivariate logistic analysis to determine features associated with survival to hospital discharge.

Cardiac arrest (n = 86) was more common than respiratory arrest (n = 13; unknown cause, n = 9). Cardiorespiratory arrest occurred with decreasing frequency from the day of surgery. Ventricular fibrillation or tachycardia was the dominant mechanism of cardiac arrest (70% versus 17% for asystole versus 13% for pulseless electrical activity), and the principal causes were postoperative myocardial infarction (n = 46; 53%) and tamponade or bleeding (n = 21; 24%). Resternotomy was performed in 45 patients (52%), cardiopulmonary bypass reinstituted in 14 (16%), and additional grafts constructed in 5 (6%). The causes of respiratory arrest were mainly pulmonary (n = 8) and neurologic (n = 5). Survival to hospital discharge was better for respiratory arrest (69%) than for cardiac arrest (50%). Older age, ejection fraction less than 0.30, and postoperative myocardial infarction decreased the probability of survival.

Ventricular fibrillation or tachycardia was the most common mechanism, and myocardial infarction, the predominant precipitating cause of cardiac arrest after coronary artery bypass grafting or aortic valve replacement. Despite aggressive resuscitation, outcome is poor. Young patients with good left ventricular function had a better probability of survival if they did not suffer a postoperative myocardial infarction.

Prospectively collected data from the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program were used to identify 70,616 consecutive cardiac surgical procedures performed between October 1997 and October 2007. Morbidity and mortality rates were compared between early (July 1 to August 31, n = 11,975) and late (September 1 to June 30, n = 58,641) periods in the academic year. A prediction model was constructed by using stepwise logistic regression modeling.

The two patient groups had similar demographic and risk variables. Isolated coronary artery bypass grafting accounted for 76.7% of early-period procedures and 75.8% of later-period procedures (p = 0.03). Morbidity rates did not differ significantly between the early (14.0%) and later periods (14.2%; odds ratio [OR], 1.01; 95% confidence interval [CI], 0.96 to 1.07; p = 0.67) and operative mortality was similar, 3.7% vs 3.9% (OR, 0.99; 95% CI, 0.89 to 1.11; p = 0.90). The early portion of the year was associated with longer cardiac ischemia times (84 ± 40 vs 83 ± 42 minutes), cardiopulmonary bypass times (126 ±52 vs 124 ±56 minutes), and total surgical times (295 ± 90 vs 288 ± 90 minutes; p < 0.05 for all).

The early part of the academic year was associated with slightly longer operative times; however, risk-adjusted outcomes were similar in both periods. This finding should lessen concerns about the quality of cardiac surgical care at the beginning of the academic year.

From 1985 to 2007, 3,057 patients underwent primary isolated posterior leaflet repair for degenerative mitral disease either with prosthetic anuloplasty (n = 2,754, 90%) or without (n = 303, 9.9%: no anuloplasty, 68; suture anuloplasty, 7; pericardial anuloplasty, 228). Most of the latter operations occurred in the early 1990s. Differences in patient characteristics were addressed by propensity-score adjustment and matching (214 pairs). In all, 3,870 echocardiograms for 1,236 patients were available for assessing mitral regurgitation after prosthetic anuloplasty and 257 in 99 patients without one. Mean follow-up for mitral valve reoperation was 4.2 ± 4.1 years, with 13,003 patient-years of data available for analysis.

Early, and to a lesser degree late, postoperative mitral regurgitation was less after prosthetic anuloplasty than repair without one, and this difference persisted after risk adjustment and in propensity-matched patients (p = 0.0002). Freedom from mitral valve reoperation was 96% and 94% at 10 years after repair with versus without prosthetic anuloplasty in unmatched groups, and 97% and 96% in matched groups (p = 0.3), respectively. Unadjusted survival was greater with than without prosthetic anuloplasty (84% versus 81% at 10 years, p = 0.009), but similar after propensity adjustment and in matched pairs.

Mitral valve repair without a prosthetic anuloplasty was associated with accelerated return of mitral regurgitation, although risk-adjusted survival was similar. This finding has important implications for durability of percutaneous mitral repair techniques that do not address both leaflets and anulus.

Between March 1995 and August 2004, 41 consecutive patients were included. The mean age was 32.2 ± 13.9 years. The causes of AR were rheumatic in 31 patients (75.5%), degenerative in 2 patients (4.9%), bicuspid aortic valve in 4 patients (9.8%), infective endocarditis in 1 patient (2.4%), and congenital in 3 patients (7.3%). Leaflet extensions were performed in three leaflets for 32 patients, two leaflets for 3 patients, and only one leaflet for 6 patients. The mean follow-up duration was 92.9 ± 48.4 months.

There were no early deaths and 2 late deaths. One patient died of cancer and the other patient died of infective endocarditis. The cardiac-related mortality was 2.4% (1 of 41 patients). During a mean follow-up of 7 years, severe AR was detected in 1 patient and moderate AR in 6 patients (17.0%; 7 of 41 patients). The causes of recurrent AR were infective endocarditis in 3 patients, disease progression in 3 patients, and Behçet's diseases in 1 patient. We performed 6 reoperations (14.6%), 3 in patients owing to infective endocarditis, 2 in patients owing to disease progression, and 1 in a patient owing to the suture dehiscence associated with Behçet's disease. The cumulative survival was 92.6% at 13 years. Freedom from recurrent AR was 97.5% at 5 years, 81.7% at 10 years, and 68.1% at 13 years.

The long-term durability of the leaflet extension technique was acceptable. The reoperations increased with time, but pericardial leaflet dysfunction was not the cause.

Eighteen patients underwent TAVI using the Edwards Sapien bioprosthesis (Edwards Lifesciences Inc, CA) between September 2007 and June 2008 due to contraindications of conventional surgery (n = 5) or high operative risk (n = 13). The system was introduced through 2 purse string sutures in the apex under echocardiographic and fluoroscopic control.

The implantation success rate and initial procedural success were 100%. There was no intraoperative death and no stroke. During the procedure, two cases of ventricular fibrillation consequent to rapid pacing were treated by cardioversion. Acute mitral regurgitation due to traction of the subvalvular apparatus by the guidewire and acute aortic regurgitation from pressure on a bioprosthesis cusp by the guidewire were diagnosed by transesophageal echocardiography and reversed by the removal of the guidewire. Another case of aortic regurgitation was due to incomplete deployment of the bioprosthesis and was managed by a "valve after valve" procedure. Two patients died on postoperative day 2 from left ventricular failure. In one patient the postmortem study showed, despite correct implantation of the bioprosthesis, a hematoma of the septum with a small ventricular septal defect. The total in-hospital death was 27.7% (5 patients). There was no periprocedural bleeding but in one patient delayed rupture of the apex (36 hours after the procedure) necessitated emergency surgery. A false aneurysm of the apex appeared 3 months after surgery in another patient. Closure of the apex was performed through sternotomy and cardiopulmonary bypass with an uneventful follow-up.

The TAVI is associated with incidents and complications different to those encountered in conventional aortic valve surgery. Recognizing their existence contributes to elucidating their mechanisms and to propose solutions to avoid or treat them.

Data of all patients who underwent valve operations with or without associated CABG between October 2, 1991, and November 14, 2007, were obtained from the department's database and analyzed using logistic regression for 30-day and Cox models for long-term mortality to determine the effects of transfusion on death. To control for the potential interaction between transfusion and complications and sicker patients being more likely to receive blood, we separately analyzed the data for the different valve populations and used propensity analysis to control for sicker patients being more likely to receive blood.

Of 1823 patients who underwent valve operations, the operation was isolated in 993 and combined with CABG in 830. By 30 days, 125 patients (6.9%) had died, and 717 (39%) were dead at follow-up. After controlling for type of operation and factors that influenced the transfusion decision, transfusion was associated with increased death only in patients who had combined valve and CABG, and not in isolated valve operations.

Transfusion had no effect on the mortality rate after isolated valve operations but was associated with increased mortality when valve operations were combined with CABG.

Patients with follow-up longer than 6 months who reported sinus rhythm while not taking antiarrhythmic drugs were eligible. Atrial arrhythmias longer than 30 s were considered a recurrence. The ECG, 24-hour Holter monitoring, and LTM (5 days) reports were ascertained and compared at the same time.

Patients (n = 291) underwent the full Cox-Maze III procedure, with 194 eligible for the study and 76 agreeing to participate. The average time to monitoring after surgery was 9.8 (± 7.7) months. The ECGs determined 96% of patients in sinus rhythm, Holter monitoring determined 91% in sinus rhythm, and LTM indicated 84% in sinus rhythm. Comparing ECG results and LTM results revealed that 9 patients (12%) had a significant rhythm change. Holter monitoring did not capture all the patients having events lasting longer than 1 hour. No additional information was captured by the use of LTM in patients with paroxysmal atrial fibrillation.

This study reconfirmed that ECG overestimated the success rate after the Cox-Maze III operation by 12% compared with LTM. These changes may carry clinical significance when determining the success of the Cox-Maze III procedure and determining the medical management, including antiarrhythmic and anticoagulation therapy, of the patients who were found to have significant events.

A link to an online survey was e-mailed to all practicing cardiac surgeons in Canada. Each surgeon was given a unique log-in identification number to complete the survey online through a secure web page.

Surveys were sent to 166 surgeons; 119 completed surveys (72%) were returned. Only 58% of respondents routinely use β-blockade for prophylaxis. For nonusers, 44% are unconvinced of the evidence for this practice. The routine use of amiodarone among surgeons was 19%. Of the remainder, 43% cited a perceived increased risk of complications as the reason for not using this therapy. An additional 29% considered the therapy was excessively complicated or time consuming. Corticosteroids were routinely used by only one surgeon. Major barriers to use of steroids were unconvincing evidence (76%), a perceived increased risk of wound infection (38%), and hyperglycemia (30%).

Despite level 1 evidence, the use of β-blockers, amiodarone, and corticosteroids for prophylaxis of atrial fibrillation among Canadian surgeons remains less than expected. The results of this survey support the need for further clinical trials with robust and clinically relevant outcomes that may further influence surgeons to adopt this practice.

A 2-year retrospective study of patients undergoing placement of minimally invasive epicardial pacing leads or ICD coils was performed.

Eleven patients underwent minimally invasive surgical placement of leads or coils. None were converted to open sternotomy. One required extension to minianterior thoracotomy. Causes of intravenous placement failure included aberrant anatomy with failure to access coronary sinus in 9 and venous occlusion in 2. Four patients had previous operations through a median sternotomy. Procedures included left video-assisted thoracoscopic (VATS) placement of a left ventricular epicardial lead in 8, left VATS conversion to minianterior thoracotomy left ventricular epicardial lead placement in 1, left VATS placement of ICD coil in 1, subxiphoid placement of a right ventricular epicardial lead in 1, subxiphoid ICD coil in 2, and subcutaneous ICD coil placement in 3. Mean hospitalization was 4.6 days. Postoperative hypotension and pulmonary edema occurred in 27% of patients. No patients died.

Conventional transvenous lead implantation may be difficult or impossible in some patients with aberrant or occluded venous access. Novel surgical approaches with the use of minimally invasive procedures can establish optimally functional pacing and ICD systems without sternotomy and low associated morbidity.

This exploratory experimental study was performed in 7 open-chest dogs. Dobutamine (2.5 to 10 µg · kg^–1 · min^–1) was infused at a rate producing at least 30% increase in sinus rate and cardiac output. Then electrical SNFP-VS was applied in the epicardial ganglionic plexus located at the right pulmonary vein-atrial junction, to slow the sinus rate back to control level. Hemodynamic data during control, with steady-state dobutamine infusion, and with dobutamine plus SNFP-VS were collected and compared.

Dobutamine significantly increased heart rate, systolic and diastolic blood pressures, peak left ventricular systolic pressure, positive and negative maximal derivatives of left ventricular pressure, and cardiac output. Combining SNFP-VS with dobutamine eliminated sinus rate increase while preserving all major hemodynamic benefits. Selective SNFP-VS itself had no direct effect on cardiac contractility during atrial pacing.

Combining SNFP-VS with dobutamine could achieve hemodynamic improvement while avoiding sinus tachycardia in this dog model, suggesting that similar strategy may also be applied in patients.

Using data from a prospective observational study of 100 adult cardiac surgical patients, we correlated early postoperative concentrations of plasma NGAL and serum cystatin C with the duration (time during which AKI persisted according to the Acute Kidney Injury Network criteria) and severity of AKI (change in serum creatinine) and with length of stay in intensive care.

We found a mean AKI duration of 67.2 ± 41.0 hours which was associated with prolonged hospitalization (p < 0.001). NGAL, cystatin C, and their combination on arrival in intensive care correlated with subsequent AKI duration (all p < 0.01) and severity (all p < 0.001). The area under the receiver operating characteristic curve for AKI prediction was 0.77 (95% confidence interval: 0.63 to 0.91) for NGAL and 0.76 (95% confidence interval: 0.61 to 0.91) for cystatin C on arrival in intensive care. Both markers also correlated with length of stay in intensive care (p = 0.037; p = 0.001). Neutrophil gelatinase-associated lipocalin and cystatin C were independent predictors of AKI duration and severity and of length of stay in intensive care (all p < 0.05). The value of cystatin C on arrival in intensive care appeared to be due to a carry-over effect from preoperative values.

Immediately postoperatively, NGAL and cystatin C correlated with and were independent predictors of duration and severity of AKI and duration of intensive care stay after adult cardiac surgery. The combination of both renal biomarkers did not add predictive value.

We examined the outcomes of 40 consecutive patients seen at our center with Ebstein anomaly who had undergone tricuspid valve repair or replacement with (n = 23) or without (n = 17) concomitant CPS. Follow-up data were obtained by either chart review or contacting the referring cardiologist. Mid-term survival was examined using Kaplan-Meier curves.

The mean age at surgery was similar in patients with and without CPS (42 ± 12 versus 39 ± 19 years; p = 0.63). There were 2 early postoperative deaths owing to refractory right-sided heart failure. Mid-term follow-up data were available in 95% of patients. The mean follow-up time was 6.7 ± 4.8 years. Patients who received a CPS more commonly had preoperative heart failure or cyanosis (p = 0.04) and had worse preoperative functional status (p = 0.09). In both groups, arrhythmias were the most common late complication. There were 5 late deaths, 3 of which occurred in patients with CPS. Five-year survival with or without CPS was comparable (83% ± 9% versus 86% ± 10%; p = 0.85).

Adolescent and adult patients with Ebstein anomaly undergoing tricuspid valve replacement or repair and concomitant CPS are at risk for early and mid-term complications. However, Ebstein surgery along with CPS appears to be a reasonable surgical strategy in patients not thought to be suitable for tricuspid valve surgery alone.

Late echocardiographic and time-related clinical results of patients undergoing the Rastelli procedure were examined. Demographics and operative variables affecting outcomes were analyzed.

The Rastelli cohort comprised 36 patients with d-TGA, VSD, and pulmonary stenosis. Median age at operation was 2.4 years (range, 0.3 to 8.3 years). Pulmonary stenosis was present in 31 and atresia in 5. Twenty-two patients had undergone a previous aortopulmonary shunt, and 6 had an atrial septectomy. No operative or late deaths occurred. Time-related freedom from permanent pacemaker implantation, recurrent LVOTO on echocardiogram, and conduit replacement at 10 years was 82%, 100%, and 49%, respectively. Systolic function was normal in all but 3 patients and 92% were in New York Heart Association functional class I and II. None of the patients had late arrhythmias or required heart transplantation.

Early and midterm survival after the Rastelli procedure is satisfactory. Aggressive resection of the infundibular septum to enlarge the VSD has mitigated the risk of LVOTO recurrence. Late conduit obstruction remains an important source of morbidity and frequently requires reintervention.

The bispectral index, middle latency auditory evoked potentials, Ramsay scale, and COMFORT scale were used for assessment of the level of sedation in critically ill children after cardiac surgery and other surgical procedures. The measurements with these four methods were recorded simultaneously once a day for five days. The level of sedation was categorized in two levels, moderate or deep, according to the values obtained from each method. Correlations and agreements among the methods and the best bispectral index and middle latency auditory evoked potential values that discriminated between the two levels of sedation were calculated.

Thirty-two children after cardiac surgery were included in the study, together with eighteen children after other surgical procedures who formed the control group. In each group, the correlation and agreement between the four methods varied between moderate and good. In the cardiac surgery patients, when the level of sedation was determined by the Ramsay scale, the best values of bispectral index and middle latency auditory evoked potentials that discriminated between the two levels of sedation were 63.5 and 37.5, respectively, and these values predicted the level of sedation correctly in 84.4% of the patients with each method.

Bispectral index and middle latency auditory evoked potentials could be useful to assess the level of sedation in children after cardiac surgery.

We recorded age, weight, RACHS, BCS, CCS, mortality, and LOS for 1,103 patients undergoing cardiac surgery between September 1, 2004, and June 1, 2007, at two institutions. We used binary logistic and multiple linear regressions to evaluate determinants of mortality and LOS, respectively, the C statistic to compare the predictive power of the three scoring systems for mortality, the odds ratio to compare the two institutions, and regression coefficients to compare scoring systems and institutions for LOS.

Raw mortality was 2.9% at both institutions. Final logistic regression models contained only CCS. Odds ratios for death at institutions 1 and 2 were 1.25 and 1.26, respectively (not significant). C statistics for RACHS, BCS, and CCS were 0.73, 0.63, and 0.81, respectively (p = 0.01 for CCS versus BCS; p = 0.02 for CCS versus RACHS). Final regression model for LOS retained age, RACHS, and CCS (R² = 0.44). The RACHS regression coefficient was greater for institution 2.

The CCS tends to have more predictive power than RACHS and BCS for mortality. The LOS is moderately correlated with CCS, RACHS, and age together, but the model is a poor predictor of individual LOS. The LOS for RACHS category 6 cases differed between the institutions. This study suggests methods that can be used to compare institutions in a risk-adjusted manner.

Eight hundred two patients with congenital heart disease had 1,000 consecutive repeat sternotomies between August 2000 and November 2007. Records were reviewed for demographics, history, operative techniques, and outcomes. Univariate risk factors for reentry injury and operative mortality were assessed.

Median age and weight were 2.1 years (range, 0.1 to 34.6 years) and 11 kg (range, 2.5 to 123 kg). There were 639 second, 287 third, and 74 fourth or higher sternotomies. There were 13 reentry injuries (1.3%) involving right ventricle–pulmonary artery conduits (n = 4), aorta or aortic conduits (n = 3), right ventricular outflow tract patches or pseudoaneurysms (n = 3), and others (n = 3). Risk factors for injury were presence of a right ventricle–pulmonary artery conduit (6 of 115 with conduit [5.2%] versus 7 of 885 without [0.8%]; p < 0.001) and sternotomy number (relative risk, 2.28; p < 0.001). Reentry injury was associated with longer procedure times (median, 420 minutes with injury versus 248 without; p < 0.001). Operative mortality occurred in 18 patients and was associated with sternotomy number and procedure time (p < 0.001), but not reentry injury (p = 0.2).

Risk of reentry injury during repeat sternotomy for congenital heart disease is low. Increasing sternotomy number and the presence of a right ventricle–pulmonary artery conduit are risk factors for reentry injury. However, reentry injury is not associated with increased risk of operative mortality.

Piglets undergoing cardiopulmonary bypass were assigned to either 60 minutes of DHCA at 18°C (n = 9) or DHCA with SCP at 18°C (n = 8), using pH-stat management. SCP was administered at 10 mL/kg/min. A cerebral microdialysis catheter was implanted into the cortex for monitoring of cellular ischemia and energy stores. Cerebral oxygen tension and intracranial pressure also were monitored. After DHCA with or without SCP, animals were recovered for 4 hours off cardiopulmonary bypass.

With SCP, brain oxygen tension was preserved in contrast to DHCA alone (p < 0.01). Deep hypothermic circulatory arrest was associated with marked elevations of lactate (p < 0.01), glycerol (p < 0.01), and the lactate to pyruvate ratio (p < 0.001), as well as profound depletion of the energy substrates glucose (p < 0.001) and pyruvate (p < 0.001). These changes persisted well into recovery. With SCP, no significant cerebral microdialysis changes were observed. A strong correlation was demonstrated between cerebral oxygen levels and cerebral microdialysis markers (p < 0.001).

Selective cerebral perfusion preserves cerebral oxygenation and attenuates derangements in cerebral metabolism associated with DHCA. Cerebral microdialysis provides real-time metabolic feedback that correlates with changes in brain tissue oxygenation. This model enables further study and refinement of strategies aiming to limit brain injury in children requiring complex cardiac operations.

An in vitro model circuit of the Fontan circulation was created to reproduce the hemodynamics of the failing Fontan and test ARV performance under various central venous pressures (CVP) and flows. A novel geometry of the extracardiac conduit was designed to adapt to the need of the pump. The ARV was a low-pressure axial flow pump designed to produce a low suction inflow pressure and moderate outflow increase. With the power off, the passive forward gradient across the propeller is 2 mm Hg at 4.5 L/min. The ARV would require 4 watts at a rotation of 5000 rpm. To examine the shear loading on the red blood cells, virtual particles were injected upstream of the ARV inducer and tracked by computerized modeling.

The effect of the ARV on the failing Fontan was studied at various CVP pressures and flows, and under constant values of lung resistances and left atrial pressure set respectively to 2.5 Woods Units and 7 mm Hg. The CVP pressures decreased respectively from 25, 22.5, 20, 17.5, 15, and 10 mm Hg to a minimal value of 2 to 5 mm Hg with a pump speed varying from 1700 to 4500 rpm. The pulmonary artery pressures increased moderately between 12.5 and 25 mm Hg at 4500 rpm. Cardiac output at 4500 rpm was increased by an average gain of 2 L/min. The average blood damage index was 0.92%, far below the 5% value considered to cause hemolysis. The flow structure produced by the pump was suitable.

The performance of this novel low-pressure ARV was satisfactory, showing good decrease of CVP pressures, a moderate increase of pulmonary artery pressures, adequate increase of cardiac output, and minimal hemolysis. The use of a mock Fontan model circuit facilitates device prototyping and design to a far greater extent than can be achieved using animal studies, and is an essential first step for rapid design iteration of a novel ARV device. The next steps are the manufacturing of this device, including an electromagnetic engine, a regulatory system, and further testing the device in a survival animal experiment.

This single-institution retrospective study used medical records and an esophagectomy database to assess results in 1,133 patients who underwent transhiatal esophagectomy and a cervical esophagogastric anastomosis, 241 for benign disease and 892 for cancer, between January 1996 and December 2006.

Esophagectomy patients who experienced CEGALs included 127 (14.2%) with cancer and 23 (9.5%) with benign disease. Logistic regression analysis identified increasing number of preoperative comorbidities (p < 0.001), active smoking history (p = 0.044), and postoperative arrhythmia (p = 0.002) as risk factors for CEGALs, and a side-to-side stapled cervical esophagogastric anastomosis compared with a manually sewn one as protective (p < 0.001). For cancer patients, higher pathologic stage disease (p = 0.050) was a risk factor for CEGALs. For patients with benign disease, a higher number of prior esophagogastric operations (p = 0.007) is a risk factor for CEGALs. Of the 90.7% of CEGALs that occurred on or before postoperative day 10, cervical wound drainage (63.3%) was the most common presenting symptom. Screening barium swallow identified postoperative complications and influenced outcome in 39 patients (3.8%).

Higher number of preoperative comorbidities, advanced pathologic stage, postoperative arrhythmia, an increased number of prior esophagogastric surgeries, and active smoking history are risk factors for developing CEGAL, and a side-to-side stapled cervical esophagogastric anastomosis is protective. Screening barium swallow identifies few postoperative complications, but provides quality control.

We conducted a retrospective review of a prospective database over a 20-year period to identify patients with resected esophageal carcinoma with nonregional lymph node metastases. Medical records were reviewed and risk factors were analyzed.

Sixty-seven patients underwent esophagectomy for M1a or M1b disease from 1987 to 2007. Esophagectomy was transthoracic in 62 patients and transhiatal in 5. The median number of lymph nodes harvested was 36. Sites of nodal metastases were the following: recurrent nodal chain in 42 patients, celiac in 20, both recurrent and celiac in 4, and paratracheal in 1. Median length of follow-up was 66 months. The 5-year overall survival for the entire cohort was 25%. The 5-year overall survival was significantly higher with earlier T-status, (pathologic tumor [pT]1/T2 vs pT3/T4; 62% vs 15%, p = 0.006). Thirteen patients who had nonregional nodal metastases without involvement of regional nodes (pN0) had a significant improvement in 5-year survival (67% vs 15%; p < 0.001). Patients with squamous cell carcinomas had higher 5-year survival compared with those with adenocarcinomas (42% vs 14%; p = 0.009). Patients treated with induction chemotherapy had prolonged 5-year survival (41%, p = 0.06) compared with those treated with adjuvant chemotherapy (11%) or no therapy (20%). Multivariate analysis demonstrated that chemotherapy treatment, squamous cell type, and early T stage (pT1/T2) are significant positive predictors of survival.

Surgical resection for patients with esophageal cancer associated with nonregional nodal metastases results in 25% survival at five years. Squamous histology, earlier T status, and perioperative chemotherapy are independent positive predictors of long-term survival.

During a 48-month period, patients with a spontaneous esophageal perforation were offered endoluminal esophageal stent placement as the initial therapy instead of operation. Excluded were patients with an esophageal malignancy or a chronic esophageal fistula. Silicone-coated stents were placed endoscopically using general anesthesia and fluoroscopy. Adequate drainage of infected areas was achieved. Leak occlusion was confirmed by esophagram.

Twenty-one esophageal stents were placed in 19 patients for spontaneous esophageal perforations. Associated endoscopic (n = 19) or surgical procedures (n = 9) were also simultaneously performed. Leak occlusion occurred in 17 patients (89%). Fifteen patients (79%) were able to initiate oral nutrition within 72 hours of stent placement. Two patients (10%) with a perforation extending across the gastroesophageal junction experienced a continued leak after stent placement and underwent operative repair. Stent migration in 4 patients (21%) required repositioning (n = 4) or replacement (n = 2). Stents were removed at a mean of 20 ± 15 days after placement. Hospital length of stay was 9 ± 12 days.

Endoluminal esophageal stent placement is an effective treatment of most spontaneous esophageal perforations. These stents result in rapid leak occlusion, provide the opportunity for early oral nutrition, may significantly reduce hospital length of stay, are removable, and avoid the potential morbidities of operative repair.

Among 565 patients with mediastinal lymph node enlargement, 37 had a history of extrathoracic carcinoma. The enlargement consisted in HMLNMs in 26 (15 men, 11 women), with a mean age of 57.6 (range 19-78) years. Surgical procedures were reviewed.

Diagnostic procedures, comprising mediastinoscopy in 9, anterior mediastinotomy in 2, and video-assisted thoracic surgery (VATS) in 4, were performed mainly because of unresectability due to diffuse and bilateral HMLNMs. Cancer location was breast in 6, kidney or prostate in 2 each, and bladder, rectum, testis, melanoma, and larynx in 1 each. Median survival was 21 months. Resection was performed in 11 patients, comprising posterolateral thoracotomy in 6, muscle sparing thoracotomy in 2, and VATS in 3. Seventeen involved LN stations were removed; of these, primary were kidney in 3, testis or thyroid in 2 each, and larynx, nasopharynx, and intestinum in 1 each. Five-year survival was 41.6% (median, 45 months).

HMLNMs of extrathoracic carcinoma may be isolated, probably in the context of a particular lymphatic mode of spread. Our experience demonstrates that operation is mainly diagnostic but resection may safely achieve local control of the disease and deserves being advocated in patients with isolated and resectable HMLNMs.

A total 246 patients who underwent LDLT were investigated.

Pulmonary malignant tumors after LDLT were observed in 12 (4.9%) of 246 patients studied. These patients included 9 tumor recurrences and 3 de novo malignancies. The frequency of pulmonary recurrence was 9.4% (9 of 96 patients) and that of pulmonary de novo malignancies including 2 primary lung cancer and 1 mucosa-associated lymphoid tissue (MALT) lymphoma, was 1.2% (3 of 246 patients). Four of 9 recurrent patients could undergo surgical resections and the survival range in patients who received surgery was 17 to 56 months with a mean of 36 months after LDLT; on the other hand, the survival range in patients that could not undergo a surgical resection was 4 to 26 months with a mean of 18 months. Among the de novo malignancies, only the MALT lymphoma patient could undergo a surgical resection. Repeated surgical resections of pulmonary malignant tumors could be performed in 3 patients and all these patients have been long-term survivors.

These results suggest a surgical resection of pulmonary malignancies including tumor recurrences or de novo malignancies after LDLT is a feasible procedure and may prolong survival in selected patients, even under immunosuppressive conditions.

Between February 1997 and January 2008, the transdiaphragmatic harvesting of the omentum was performed, using an original technique through a thoracotomy approach, in 45 patients. Forty-three patients (29 male, 14 female), considered at high risk for bronchial dehiscence, simultaneously underwent pneumonectomy and 2 patients (1 male, 1 female) were treated for an early postpneumonectomy bronchopleural fistula by the standard thoracotomy route. The omental flap was mobilized through a radial incision in the diaphragm avoiding an additional laparotomy. The only contraindication for this technique was a previous abdominal intervention. Duration of follow-up ranged between 6 and 102 months (median, 46).

There were no complications related to the omentoplasty. Major complications related to pneumonectomy occurred in 4 patients (9%). Perioperative mortality rate was 2.1% (1 of 45). The non-life threatening complication rate was 11.1% (5 of 45). Postoperative hospital stay ranged between 5 and 21 days (median, 8.3) in the 43 patients undergoing prophylactic omentoplasty and was 11 and 14 days, respectively, in the 2 patients receiving omentoplasty after bronchial dehiscence. No neoplastic recurrence on the bronchial stump or late fistula occurred during follow-up.

This technique of omental flap transposition for bronchial stump coverage through a thoracotomy is an effective method for the prevention and treatment of postpneumonectomy bronchopleural fistula. The amount of omentum obtained by this technique is appropriate for bronchial reinforcement but not for filling the pleural cavity. This procedure can be performed safely through thoracotomy access avoiding an additional laparotomy.

Data were retrospectively collected on patients who underwent pulmonary lobectomy at a single health system between August 1, 2003, and April 1, 2008. Age, sex, pulmonary function tests, preoperative and postoperative stages, pathologic diagnosis, anatomic resection, extent of lymph node sampling, surgical technique and duration, complications, blood loss, transfusion requirement, chest tube duration, length of hospital stay, 30-day readmission, and mortality rate were examined. The percentage of patients who underwent thoracoscopic lobectomy and their outcomes were then compared among three chronologic cohorts.

Three hundred sixty-four patients underwent pulmonary lobectomy (239 open; 99 thoracoscopic; 26 thoracoscopic converted to open). Baseline characteristics, staging, pathologic diagnosis, and anatomic resections were similar in the early, middle, and late cohorts. The percentage of thoracoscopic lobectomies increased from 16% to 49%, whereas open lobectomy decreased from 81% to 42% (p < 0.0001). The complication rate remained constant with the exception of air leaks lasting more than 7 days (9% versus 10% versus 2%; p = 0.02). Hospital length of stay (6 versus 5 versus 4 days; p < 0.0001) and chest tube duration (4 versus 3 versus 3 days; p < 0.0001) decreased and operative duration increased as more thoracoscopic lobectomies were performed. Blood loss, transfusion requirement, 30-day readmission, and 1-year survival were not significantly different among chronologic cohorts.

Established thoracic surgeons can safely incorporate thoracoscopic lobectomy with no increase in morbidity or mortality.

A retrospective nationwide study including 73 patients (mean age, 57.3 years; 58% males) who underwent a surgical lung biopsy for suspected interstitial disease in Iceland between 1986 and 2007 was conducted. Patient records and histologic specimens were reviewed. Before the surgical biopsy a transbronchial or computed tomography–guided biopsy had been performed in two thirds of the patients.

The complication rate for surgical lung biopsy was 16%, and 30-day operative mortality was 2.7%, both significantly higher in patients with preoperative respiratory failure. After the procedure, a definite histopathologic diagnosis was obtained in 81% of the patients. Usual interstitial pneumonia was the most common diagnosis (31%). The clinical diagnosis was changed for 73% of the patients, and in 53% of the patients the biopsy resulted in changes in treatment.

Surgical lung biopsy is a powerful tool for diagnosis of suspected interstitial lung disease. It results in a specific diagnosis for the majority of patients and changes in treatment for more than half. Operative morbidity and mortality are low but still significant, so patients should be carefully selected for the procedure, especially those with respiratory failure.

With approval from the Mayo Clinic Institutional Review Board, we identified all patients with fibrosing mediastinitis who underwent an operation for relief of pulmonary artery obstruction between 1980 and 2008. Perioperative data were collected using medical records and late follow-up surveys.

Operative procedures to bypass or reconstruct an obstructed pulmonary artery were performed in 5 patients. Patients' median age was 40 years (range, 27 to 51 years), and all patients were symptomatic and had right ventricular hypertension. In 3 patients, a double-outlet right ventricle was constructed using a valved conduit (porcine valved conduit, n = 1; aortic homograft, n = 2) from the right ventricle to the right pulmonary artery. Two patients required complete reconstruction of the pulmonary artery confluence using a pulmonary homograft in 1 patient and a hybrid technique of autologous pericardial reconstruction and intraoperative stenting in another patient. All patients had a reduction in right ventricular pressures after operation. One patient died perioperatively owing to respiratory failure; the remaining 4 patients were alive at a median follow-up of 7.4 years (range, 0.5 to 14.7 years). One patient required late balloon dilatation of the conduit and distal pulmonary arteries 10 years after initial operation, but the remaining conduits were widely patent at late follow-up. Late functional improvement was limited owing to other complications from mediastinal fibrosis or other comorbidities.

Treatment of pulmonary artery occlusion attributable to mediastinal fibrosis can be challenging. Successful operative strategies include both creation of a double-outlet right ventricle and complete reconstruction of the pulmonary artery confluence. Hybrid techniques of both conduit placement and stenting should also be considered for patients with occluded pulmonary arteries.

Patients suffering primary palmar hyperhidrosis were treated by either bilateral T2 to T3 thoracoscopic sympathectomy (n = 68) or by injection of botulinum toxin-A (n = 86). The groups were homogeneous for relevant demographic, physiologic, and clinical data. Quantification of sweat production was performed by Minor's iodine starch and glove tests. Subjective changes were assessed by quality of life questionnaires (Hyperhidrosis, Dermatology Life Quality Index, Short Form-36, Nottingham's Health Profile) and patient's satisfaction self-assessment. A cost comparison between groups was also carried out.

No operative mortality or major morbidity was recorded in either group. Minor's test showed a more significant reduction in the surgical group: +94% versus +63% at 6 months and +94% versus +30% at 12 months. Compensatory sweating was significantly greater and long-lasting in the surgical group. All subjective tests improved rapidly and significantly in both groups. After 6 months, results mildly worsened in the surgical group and more significantly in the botulinum group. Patient's satisfaction was initially greater in the botulinum group (p = 0.03), but after 6 months it significantly reversed (p = 0.04). Surgical treatment cost approximately as much as four botulinum treatments.

Thoracoscopic sympathectomy is superior to botulinum toxin-A injection. The greater initial costs and discomfort are offset by a greater reduction in compensatory sweating.

A retrospective review of patients undergoing TDL after cardiothoracic surgery (1992 through 2007) was done. Data on demographics including cardiac morphology, characteristics of chylous drainage, medical management, and post-TDL course were collected. When available, imaging studies of the upper body venous drainage vessels were examined.

Twenty patients (median age, 0.65 years; range, 0.03 to 11 years; weight, 7.0 kg; range, 2.6 to 30 kg) had a diagnosis of chylothorax made 8.5 days (range, 2 to 118 days) after initial operation. Median duration of pre-TDL medical management was 17.5 days (range, 7 to 69 days). Median drainage for 5 days preceding TDL was 34.5 mL · kg^–1 · d^–1 (range, 15 to 135 mL · kg^–1 · d^–1) with maximal output of 65 mL · kg^–1 · d^–1 (range, 30 to 200 mL · kg^–1 · d^–1). After TDL, there was a decrease in median drainage to 13 mL · kg^–1 · d^–1 (range, 4 to 160 mL · kg^–1 · d^–1; p = 0.003). Chest tubes were removed 8.5 days (range, 4 to 34 days) after TDL. There were 4 deaths (none attributed to TDL), 2 treatment failures (post-TDL chest tube drainage > 2 mL · kg^–1 · d^–1 > 14 days), and 2 recurrences (after initial chylothorax resolution and hospital discharge). Three patients had documented upper body venous thrombosis. Univariate analysis demonstrated thrombosis of upper body venous vessels (p = 0.02) and prolonged post-TDL chest tube drainage (p = 0.01) were risk factors for death, treatment failure, or chylothorax recurrence.

Thoracic duct ligation leads to a major reduction in chest tube drainage and prompt tube removal in most pediatric patients and should be considered early in refractory postoperative chylothorax. Patients with upper body venous thrombosis associated with chylothorax are at a high risk for failure of TDL and mortality.

Twenty-one consecutive patients, undergoing a valve procedure, were enrolled into this nonrandomized pilot study. The EmBlocker (Neurosonix Ltd) was positioned in 11 consecutive patients and activated for 1 minute (1.5 W/cm²) during seven selected aortic manipulations and for 10 minutes (0.5 W/cm²) intermittently after cross-clamp removal. Transcranial Doppler-based quantification of microembolic signals was performed in all patients.

The use of the EmBlocker showed a significant overall reduction of the cerebral microembolic signals of 53%.

The use of the EmBlocker during valve surgeries is associated with a reduction of perioperative cerebral microembolic signals. This new technology holds the potential to lower the risk of postoperative neurologic complications.

A saccular descending aortic aneurysm was made in 5 pigs experimentally. A stent graft was deployed to produce a proximal type I endoleak. Under fluoroscopy, the aorta was punctured with the spinal needle with the T-Fix plastic bar, and the plastic bar was deployed with a push rod. A sufficient number of T-Fix sutures were used until angiography revealed that the type I endoleak had disappeared.

No hemodynamic events occurred during the procedure. An average of 2.5 ± 0.6 T-Fix sutures were required to eliminate the endoleak. The experimental T-Fix repair was performed without any complications. A new method of repairing type I endoleaks for thoracic aortic aneurysms was successfully performed using the T-Fix system.

Although the T-Fix repair currently has some anatomic and clinical limitations, improvement of the device should lead to the increased use of this repair.

The study compared outcomes of 78 elderly patients (aged > 75 years) with stage I NSCLC undergoing segmentectomy and 106 undergoing lobectomy for stage I NSCLC from 2002 to 2007. Primary outcome variables included perioperative morbidity and mortality, hospital course, recurrence patterns, and survival.

Age, gender, tumor histology, and surgical approach were similar between groups. Comorbidities were similar except for a higher incidence of chronic obstructive pulmonary disease and diabetes in segmentectomy patients. The tumors in the lobectomy group were significantly larger (3.5 vs 2.5 cm, p = 0.0001). Operative mortality was 1.3% for segmentectomy and 4.7% for lobectomy. Segmentectomy patients had fewer major complications (11.5% vs 25.5%, p = 0.02). There were no differences in median hospitalization (7 vs 6 days). The estimated overall survival at 2, 3, and 5 years was 76%, 69%, and 46% for segmentectomy patients and 68%, 59%, and 47% for lobectomy patients (p = 0.28). The 5-year disease-free survival was equivalent (segmentectomy, 49.8%; lobectomy, 45.5%; p = 0.80).

Anatomic segmentectomy can be performed safely in elderly patients with early-stage NSCLC. This approach is associated with reduced perioperative complications and comparable oncologic efficacy compared with lobectomy in older patients with a limited life expectancy.

A total of 30 consecutive lung cancer patients who underwent thoracotomy were included. The CTCs in peripheral blood and in PV blood from the primary tumor site were quantitatively examined with the CellSearch system, and the numbers of CTCs per 7.5 mL peripheral and PV blood in each patient were represented as periCTC count and pvCTC count, respectively.

Circulating tumor cell was detected in peripheral blood in 5 patients (16.7%; the periCTC count was 1 in 2 patients; and 2, 3, and 16 in 1 patient each), and the incidence of positive periCTC was higher in squamous carcinoma patients than in adenocarcinoma patients (p = 0.028). Circulating tumor cell was detected in PV blood in most patients (29 of 30, 96.7%), and the mean and median pvCTC counts were 1,195 and 81, respectively (range, 0 to 10,034). There was no significant correlation between pvCTC count and any other patient characteristic, including periCTC count.

In resectable lung cancer, CTC was positive in peripheral blood of some patients and in PV blood of most patients. A long-term follow-up study to clarify the clinical significance of pvCTC status is warranted.

Included were all patients with potentially resectable, previously untreated stage III non–small cell lung cancer operated on between February 1999 and May 2006 in the General Thoracic Surgery Unit of the Schillerhöhe Clinic following the same neoadjuvant protocol. Treatment-related morbidity, recurrence, survival after R0 resection, and risk factors for survival (pN0 after trimodal therapy, downstaging of International Union Against Cancer stage, T downstaging, N downstaging, regression rate, and histologic type of tumor) were analyzed.

From 107 patients with stage III non–small cell lung cancer, 55 patients with mediastinoscopy-positive N2 or N3 were eligible for this study. Forty patients (72%) had the effect of International Union Against Cancer downstaging. Treatment-related comorbidity was 54% with hospital and 120-day mortality of 3.6% and 5.4%, respectively. Overall mean survival (Kaplan-Meier) was 43 months (95% confidence interval, 35 to 52) with an estimated 5-year survival rate of 49%. In multivariate testing, International Union Against Cancer downstaging after trimodal therapy achieved a level of significance (p = 0.031), and patients with UICC-downstaging after trimodal therapy had a mean survival of 53 months (95% confidence interval, 44 to 63) with an estimated 5-year survival rate of 60%.

Neoadjuvant trimodal treatment for histologically proven N2 or N3 stage III non–small cell lung cancer is promising and can, like no other approach at present time, considerably improve 5-year survival rates up to 63% in selected patients.

A retrospective chart review of prospectively maintained thoracic surgery databases identified 378 patients who underwent pulmonary resection for colorectal cancer metastases with curative intent from 1998 to 2007.

The primary site of disease was rectum (52%), left colon (26%), right colon (16%), and unknown (6%). Before thoracic recurrence, 166 patients (44%) had previously undergone resection of extrathoracic metastases. Median disease-free interval (DFI) was 24 months from the time of the primary operation. The number of metastatic deposits resected was one in 60%, two in 20%, three in 10%, and four or more in 10%. Chemotherapy was administered to 87 patients (23%) before resection and to 169 patients (45%) after resection. Three-year recurrence-free survival was 28%, and 3-year overall survival was 78%. Multivariable analysis revealed age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three as independent predictors of recurrence. Of 44 patients with three or more lesions and less than 1 year DFI, none was cured by operation. By contrast, recurrence-free survival was 49% at 3 years for those with one lesion and DFI greater than 1 year.

Age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three predict recurrence. Medical management alone should be considered standard for patients who have both three or more pulmonary metastases and less than 1 year DFI.

This study was a retrospective cohort study of a prospective database. Patients who underwent elective pulmonary resection and were discharged home with a chest tube were eligible.

Between July 2000 and July 2007, 6,038 patients underwent elective pulmonary resection by one general thoracic surgeon. One hundred and ninety-nine patients (3.8%) with a persistent air leak had their chest tubes placed to a suctionless portable drainage device and were discharged home. One hundred ninety-four patients (97%) returned to our clinic (median, postdischarge day 16). One hundred thirty-seven patients had no air leak, and 57 patients still had an air leak. All 137 patients (including 26 with a nonexpanding pneumothorax) had their chest tubes removed. In addition, all 57 patients (including 19 who had pneumothorax as well) had their chest tubes removed without sequela (9 after provocative clamping). At 3 months' follow-up, all patients were asymptomatic without evidence of pleural space problems, except 3 (all in the persistent air leak group) in whom an empyema developed.

Patients with air leaks can be safely discharged home with their chest tubes. These tubes can be safely removed even if the patients have a pneumothorax, if the following criteria are met: the patients have been asymptomatic, have no subcutaneous emphysema after 14 days on a portable device at home, and the pleural space deficit has not increased in size.

Three hundred sixty-six patients with mid-thoracic esophageal squamous cell carcinoma who underwent modified Ivor-Lewis esophagectomy between June 1999 and June 2004 were retrospectively reviewed. All patients were followed up within 3 years after surgery to detect lymph node recurrence. The Kaplan-Meier method was used to calculate the recurrence rate, and Cox regression analysis was performed to identify risk factors of lymph node recurrence.

The overall 3-year and 5-year survival rates in all patients were 57.9% and 43.7%, respectively. Lymph node recurrence occurred in 105 patients (28.7%) within 3 years after surgery. The lymph node recurrence rate of patients with postoperative adjuvant radiotherapy was significantly lower than that of those with adjuvant chemotherapy (p = 0.03) and those without adjuvant therapy (p < 0.01). Cox regression analysis showed that T stage, N status, and postoperative adjuvant radiotherapy were independent relevant factors for lymph node recurrence.

Postoperative adjuvant radiotherapy after modified Ivor-Lewis esophagectomy might prevent lymph node recurrence of mid-thoracic esophageal carcinoma.

The medical records of all patients undergoing esophagectomy at a single institution by 3 surgeons between January 2002 and July 2008 were reviewed. Patients who underwent a 2-layer, hand-sewn, esophageal anastomosis using a mucosal tube were included. The unique aspect of the anastomosis was the creation of an esophageal mucosal tube that facilitates a tension-free, precise mucosal approximation.

Of the 61 patients who underwent esophageal reconstructions (60 gastric, 1 colonic), 49 (80%) had a diagnosis of esophageal neoplasm. Of those with cancer, 20 (41%) had neoadjuvant therapy before the resection. Two patients presented with perforation. The anastomoses were intrathoracic in 57 of 61 (93%) and cervical in 4 cervical. There were no operative deaths. All patients underwent contrast study at an average of 5 days postoperatively. The anastomotic leak rate was 2% (1 of 61). Postoperative dilations (mean, 1.3 dilations) were done in 12 of 61 patients (20%), using a low symptom threshold for endoscopy and dilation.

The use of the esophageal mucosal tube and 2-layer anastomosis is a robust technique that results in a low leak rate. Strictures are minimal and easily dilated if they occur. Use of a gastrotomy larger than 2.5 cm may decrease stricture rates.

Patient data were collected in a prospective fashion at a single institution. Forty-eight patients underwent intrapyloric botulinum toxin injection during esophagectomy during a 26-month period (October 2005 to January 2008). Three patients were excluded from analysis because of complications, which interfered with postoperative evaluation of emptying. Forty-five patients were evaluated clinically for signs of delayed gastric emptying. Objective assessment included a dysphagia score in 15, barium swallow in 43, and nuclear gastric emptying scans in 15 patients. The data were also reviewed for evidence of aspiration events leading to pulmonary complications.

Forty-three of 45 patients (96%) had no clinical evidence of delayed gastric emptying in the immediate postoperative period. Four barium studies were interpreted as delayed gastric emptying; however, only 2 patients were symptomatic. These 2 patients underwent balloon pyloric dilation, which resulted in resolution of symptoms in 1. Three additional patients exhibited "late" delayed gastric emptying after initially doing well (mean of 3 months postoperatively) and required endoscopic intervention. No complications were identified in the study related to botulinum toxin injection.

Intrapyloric injection with botulinum toxin is a simple, safe, and effective means of avoiding delayed gastric emptying after esophagectomy. When necessary, reintervention may be performed endoscopically.

Between March 1999 and January 2008, a total of 1,708 patients underwent minimally invasive MV repair. Six hundred and seventy patients (39.2%) had isolated PML prolapse and were treated with either the loop technique (n = 317) or the leaflet resection (n = 353) technique, according to surgeon preference. Mean follow-up time was 2.8 ± 2.2 years, and follow-up was 99% complete.

Early postoperative echocardiography showed a significantly larger mitral orifice area (3.3 ± 0.3 cm² versus 3.0 ± 0.8 cm², p < 0.001) and lower mean pressure gradient (2.7 ± 1.7 mm Hg versus 3.1 ± 1.7 mm Hg, p = 0.03) after implantation of loops. Other perioperative outcomes were similar for the two groups of patients. Freedom from reoperation at 5 years was significantly higher after the loop technique (98.7%, 95% confidence interval [CI]: 96.7% to 99.5%) when compared with leaflet resection (93.9%, 95% CI: 90.7% to 96.1%, log-rank p = 0.005). Cox regression analysis revealed that implantation of a flexible, incomplete band was an independent predictor of reoperation (hazard ratio 6.2, 95% CI: 1.3 to 110.7), whereas use of leaflet resection had a nonsignificant trend toward an increased reoperation rate (hazard ratio 2.6, 95% CI: 0.9 to 9.1). Reoperation for excessive systolic anterior motion did not occur in any loop patient.

Both the loop technique and conventional leaflet resection yield excellent results for repair of isolated PML prolapse. The technical ease of performing the loop technique through a minimally invasive approach, however, makes this method a particularly valuable alternative for MV repair surgery.

There were 169 patients. A flexible ring was implanted in 117 and a rigid ring in 52. Age and clinical profile, degree of left ventricular dysfunction, and degree of MR (mean 3.2) were similar between groups.

Operative mortality was 9% in each group. Follow-up (58 ± 30 months for flexible group and 14 ± 7 months for rigid group) was available for 91%. For the flexible and rigid ring groups, respectively, mean New York Heart Association functional class was 1.9 and 1.6, with 33% and 14% in classes III to IV (p = 0.03); mean MR grade was 1.25 and 0.7 (p = 0.006). There was no difference in left ventricle function or dimensions. At follow-up, 29 patients (34%) in the flexible group had residual MR of moderate degree or greater compared with 6 (15%) in the rigid group (p = 0.03). Mean tricuspid incompetence gradient was 39 and 34 mm Hg (p = nonsignificant); however, the degree of reduction was greater in the rigid group (p = 0.001). Late mortality was observed in 32 patients, all in the flexible group.

Clinical and hemodynamic results are better with rigid mitral annuloplasty rings compared with flexible rings. That result may be due to ring design, which dictates not only the annular diameter but also annular configuration. Longer follow-up is needed to determine differences in survival.

We reviewed 89 consecutive operations in 87 patients for native mitral valve IE at a single institution from 2002 to 2007. Operations occurred promptly after completion of preoperative studies. Independent risk factors for death were investigated using multivariable logistic regression.

Mitral valve repair was accomplished in 56 of 89 patients (63%). Perioperative mortality was 4.4% (n = 4). Survival rates at 1 and 5 years were 89.9% (80 of 89) and 82.0% (73 of 90). There was a survival benefit for repair vs replacement at 1 (p = 0.03) and 5 years (p = 0.0017). Repair vs replacement (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.06 to 0.72), diabetes (OR, 4.43; 95% CI, 1.18 to 16.66), and renal failure (OR, 3.65; 95% CI, 1.3 to 12.91) were independent risk factors for late mortality. Among 59 patients with active IE, preoperative head computed tomography (CT) showed 29 (49%) had abnormalities, including 12 (41%) with intracerebral hemorrhage. The median interval was 4 days from admission to operation. The rate of permanent postoperative stroke was 1.1% (1 of 89).

These results support early surgical therapy for mitral valve IE. Head CT abnormalities do not warrant delay of operation. Mitral valve repair was associated with a long-term survival advantage compared with valve replacement.

From July 1996 to June 2007, 78 patients underwent mitral valve repair for rheumatic valve disease. Over the same time interval, 54 patients underwent mitral valve replacement. Mean age was 56.4 ± 16 years. Clinical follow-up (mean 60 ± 36 months) was complete in 100% of patients, and echocardiographic follow-up (mean 52 ± 37 months) was 96% complete.

There was no hospital mortality or early reoperations. Overall survival was 94% ± 6% at 8 years, and 95% of patients were in New York Heart Association functional class II or less. Three patients (4%) required reoperation for mitral restenosis and 2 underwent re-repair. At 8 years of follow-up, freedom from cardiac death and mitral valve reoperation were 98% ± 2% and 94% ± 5%, respectively. Freedom from valve-related events at 5 and 10 years was 90% ± 8% and 86% ± 11%, and freedom from significant mitral regurgitation was 98% ± 2% at 5 years and 83% ± 9% at 8 years.

A more aggressive approach to resection of diseased valvular tissue with subsequent reconstruction is feasible, with good midterm results, and may extend the scope of valve repair in rheumatic disease patients.

Patients with severe aortic valve stenosis who underwent aortic valve replacement with or without concomitant coronary artery bypass graft surgery from January 1, 2003, to December 31, 2005, were included in the study. Statistical models were developed to identify significant risk factors for mortality, to compare survival for patients with and without selected risk factors, and to compare survival to an age- and sex-matched group from US life tables.

There was total of 6,369 patients in the study. The in-hospital and 30-day mortality rates were 3.97% for aortic valve replacement and 5.69% for aortic valve replacement with concomitant coronary artery bypass graft surgery. Significant risk factors for 30-month mortality included concomitant coronary artery bypass graft surgery, advancing age, lower body surface area, emergency status, low ejection fraction, congestive heart failure, previous heart surgery, and several comorbidities. The 64.3% of patients with isolated aortic valve replacement who had neither congestive heart failure, ejection fraction less than 0.40, acute myocardial infarction less than 24 hours, nor hemodynamic instability had a risk-adjusted survival of 89.9% compared with the 90.0% survival rate of the age- and sex-matched general population (p = 0.28).

For the large number of patients without high-risk conditions, the 30-month survival is essentially as high as that of an age- and sex-matched group of the US population.

A total of 186 patients (62 ± 11 years, 38 female) received full root replacement at our institution with the Toronto Root bioprosthesis from June 2001 until November 2007. The predominant aortic valve lesion was stenosis in 34, incompetence in 80, and mixed lesions in 72 patients. Additional procedures included replacement of the ascending aorta in 139, replacement of the ascending aorta plus aortic arch in 38, coronary artery bypass graft surgery in 31, mitral valve repair in 26, atrial fibrillation ablation in 14, and atrial septal defect closure in 8 patients. Previous cardiac surgery had been performed in 10 patients. Mean follow-up was 50 ± 26 months (770 patient-years).

The mean implanted valve size was 26.8 ± 1.8 mm (14 x 23 mm, 36 x 25 mm, 87 x 27 mm, and 48 x 29 mm). Aortic cross-clamp time was 99.8 ± 29 minutes, and cardiopulmonary bypass time was 140.9 ± 52 minutes. All patients showed a clinical improvement of at least one New York Heart Association class during follow-up. Most recent echocardiographic examination revealed a maximum transvalvular blood flow velocity of 2.1 ± 0.5 m/s and a mean pressure gradient of 9.6 ± 8.5 mm Hg. Left ventricular ejection fraction was 61% ± 11%. Early mortality was 5.9% ± 1.7%, and 5-year survival was 83.3% ± 3.0%. Patients who underwent isolated aortic root surgery had a 5-year survival of 90.3% ± 4.2%.

The Toronto Root bioprosthesis is safe and provides good clinical and hemodynamic function after full root replacement with or without additional aortic surgery. Owing to the specific anticalcification treatment, long-term durability may be promising.

Fifty patients were consecutively treated with TAVI because of high surgical risk or contraindications to operation. Mean age was 83 ± 6 years, and most were in New York Heart Association classes III and IV. The predicted surgical mortality was 28% ± 14% using the European System for Cardiac Operative Risk Evaluation and 16% ± 7% using the Society of Thoracic Surgeons Predicted Risk of Mortality. The Edwards-SAPIEN (Edwards Lifesciences Inc, Irvine, CA) valve was implanted using a transfemoral approach in 35 patients and the transapical approach in 15. The transapical patients had more comorbidity (diabetes, previous myocardial infarction, previous coronary artery bypass grafting, peripheral artery disease, renal failure, porcelain aorta, and previous stroke).

Successful implantation was 85.7% and 100% in the transfemoral and transapical group, respectively. Gradients were satisfactory. In-hospital mortality was 8% in the transfemoral and 27% in the transapical group. Stroke was only observed in the transfemoral group. Overall 1-year survival was 74% ± 11% in the transfemoral group and 60% ± 13% in the transapical.

The results attributed to each approach (transfemoral or transapical) are strongly influenced by the selection strategy. Patients in the transapical group had more comorbidity and consequently a more critical early postoperative period. The respective places of transfemoral and transapical approaches need to be clarified for each approach by a randomized study.

A catheter was inserted into the distal end of a ligated thoracic segmental artery (SA) (T6 to L1) in 13 patients, 7 of whom underwent descending thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest. Spinal cord perfusion pressure was recorded from this catheter before, during, and after serial SA sacrifice, in pairs, from T3 through L4, at 32°C. Somatosensory and motor evoked potentials were also monitored during SA sacrifice and until 1 hour after cardiopulmonary bypass. Target mean arterial pressure was 90 mm Hg during SA sacrifice and after nonpulsatile cardiopulmonary bypass, and 60 mm Hg during cardiopulmonary bypass.

A mean of 9.8 ± 2.6 SAs were sacrificed without somatosensory and motor evoked potential loss. Spinal cord perfusion pressure fell from 62 ± 12 mm Hg (76% ± 11% of mean arterial pressure) before SA sacrifice to 53 ± 13 mm Hg (58% ± 15% of mean arterial pressure) after SA clamping. The most significant drop occurred with initiation of nonpulsatile cardiopulmonary bypass, reaching 29 ± 11 mm Hg (46% ± 18% of mean arterial pressure) before deep hypothermic circulatory arrest. Spinal cord perfusion pressure recovered during rewarming to 40 ± 14 mm Hg (51% ± 20% of mean arterial pressure), and further within the first hour of reestablished pulsatile flow. Somatosensory and motor evoked potentials returned in all patients intraoperatively. Recovery of SCPP began intraoperatively, and in 5 patients with prolonged monitoring, continued during the first 24 hours postoperatively. All but 1 patient, who had remarkably low postoperative SCPPs and experienced paraparesis, regained normal spinal cord function.

This study supports experimental data showing that SCPP drops markedly but then recovers gradually during the first several hours after extensive SA sacrifice. Direct monitoring may help prevent a fall of SCPP below levels critical for spinal cord recovery after surgery and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms.

Nineteen patients with aortic regurgitation attributable to Behçet's disease were surgically treated between March 1986 and June 2008. There were 15 men and 4 women with ages ranging from 24 to 55 years (mean, 39 ± 7 years). Mean follow-up duration from index operations was 77.4 ± 68.1 months (range, 9 to 271 months).

Overall mortality was 47.3% (9 of 19 patients), but no early deaths occurred at index operations. All deaths occurred after second operations, and the causes of death were low cardiac output (n = 6) and sudden aggravation of aortic regurgitation (n = 3). Erythrocyte sedimentation rates and C-reactive protein concentrations were negatively correlated with event-free period. Event-free survival at 13 years was 39.2% ± 14.1% in patients who underwent aortic root replacement, but this was 4% ± 3.9% in patients who underwent valve replacement (p = 0.001). Event-free survival at 13 years in patients who were administered immunosuppressive therapies was 33.7% ± 11.0% and 0% in patients not administered immunosuppressive therapy (p = 0.001).

The mortality in this condition was very high and was found to depend on levels of postoperative inflammatory markers. Aortic root replacement and postoperative immunosuppressive therapy may be helpful.

We operated on 254 patients from June 1993 to November 2008 for aortic root replacement with Bentall de Bono procedure. Two hundred five patients were male (80.7%) and 49 patients (19.3%) were female. The mean age was 48.3 ± 14.7 years (range, 14 to 78 years). We performed 72 concomitant procedures in 69 patients, and the most commonly performed procedure was coronary artery bypass grafting in 37 patients (14.6%). The most common indication for aortic root replacement was aneurysm in 235 patients (92.5%). Thirty-four patients (13.4%) had Marfan syndrome. Hypothermic circulatory arrest was used in 52 patients (20.5%). After removing the clamp, we had to reclamp the aorta in 26 patients (10.2%) undergoing operation.

Postoperatively 30 patients (11.8%) had in-hospital mortality. The late mortality was 2.8% (7 patients). The most common reason for hospital mortality was low cardiac output (18 in 30 patients; 51.4%). Neurologic complications were seen in 16 patients (6.3%). The mean duration of hospital stay was 16.6 ± 11.3 days (range, 5 to 77 days). Postoperative follow-up was 6.3 ± 4.5 years (range, 0 to 15.5 years) on average. Late mortality was significantly affected by Marfan syndrome (p = 0.025) and reclamping the aorta (p = 0.036). Actuarial survival for the overall 254 patients is 88.4% ± 2.1%, 87.4% ± 2.2%, and 84.5% ± 2.56% at 1, 3, and 10 years, respectively.

The late-term results of aortic root replacement with the modified Bentall de Bono procedure are satisfactory. Survival is decreased in patients with Marfan syndrome and in the patients who had reclamping intraoperatively.

Between 1997 and 2008, 55 consecutive patients (33 men, 71 ± 11 years) underwent ascending aortic replacement using Medtronic Freestyle with Dacron graft extension (DuPont). Indications included aneurysm (n = 31, 56%), dissection (n = 16, 29%), and endocarditis (n = 8, 15%). Associated procedures were performed in 25 patients (46%). Preoperative logistic EuroSCORE averaged 34% ± 28%. Mean cardiopulmonary bypass and aortic cross-clamp times were 244 ± 134 minutes and 162 ± 69 minutes, respectively.

Clinical follow-up was 100% complete and averaged 2 ± 3 years. Early mortality was 0% (n = 0) in patients with a preoperative EuroSCORE of less than 20 (n = 26, mean expected mortality, 13% ± 5%) and 31% (n = 9) in those with preoperative logistic EuroSCORE of at least 20 (n = 29, mean expected mortality, 52% ± 28%). One- and 3-year survival rates were 83% ± 5% and 78% ± 7%, respectively. No major thromboembolic or spontaneous bleeding events were recorded. One patient (2%) required late reoperation for prosthetic valve endocarditis. Echocardiographic follow-up showed no valve dysfunction and low mean transvalvular gradients (7 ± 5 mm Hg). A 64-channel computed tomographic scan was performed in 33 patients at 32.4 ± 34 months and revealed two small pseudoaneurysms in a single patient.

Composite Freestyle with Dacron graft extension appears to be a safe option for bioprosthetic replacement of the aortic root and tubular ascending aorta. However, long-term results using this composite graft will have to be determined.

The operation started with downsizing annuloplasty followed by sinotubular junction plication until full valve competence was observed and tested with the saline squirt test. Subsequent measurements (basal ring and sinotubular junction size, the depth of each sinus of Valsalva) formed the basis of graft sizing and tailoring. Reconstruction was completed with a new proximal suture line technique combining David subannular pledgeted fixation with Yacoub remodeling.

Ten patients were operated on during a 3-year period. Intraoperative (nonpressurized) competence by open testing translated into good postoperative valve function seen on transesophageal echocardiography. In situ measurements were done in the last 7 patients, and in 5 of them the restored root geometry was of a reverse cone (sinotubular junction 2 to 4 mm larger than basal ring size).

Rebuilding the aortic root based on in situ measurements with a fully competent aortic valve is a conceptually new surgical approach. Our observations suggest that postoperative valve competence, particularly with elongated valve leaflets, may not depend on the normal truncated cone geometry.

Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient.

Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98 considering 1.7 stent-grafts per patient and including 5900.00 (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12 was calculated. Days of care accounted for 31.230.00 and total costs of 50.764.12 were calculated. The difference between total costs of the two procedures was 12.543.14.

Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.

Between 1992 and 2007, 136 consecutive patients underwent tricuspid valve repair or valve replacement with a biologic valve at Kuopio University Hospital. Comprehensive clinical data were recorded prospectively. Data for the Nottingham Health Profile quality of life analysis were collected cross-sectionally.

The mean follow-up time was 7.9 ± 4.1 years (range, 0.8 to 15.7 years). A pacemaker was implanted in 28 patients (21%); 54% were implanted before hospital discharge. The 10-year survival of patients with a pacemaker was higher (94%) than of patients without a pacemaker (59%; p = 0.050). The need of a pacemaker was related to a significantly higher rate of transient ischemic attacks (30% vs 6%, p = 0.004), strokes (9% vs 4%; p = 0.008), and impaired physical capacity in terms of higher New York Heart Association functional class (p = 0.03) and the quality of life scores describing energy (31 vs 17; p = 0.01) and mobility (32 vs 17; p = 0.005).

The need for pacemaker implantation after tricuspid valve operations was high. Unexpectedly, the life expectancy of the patients who needed a pacemaker postoperatively was higher compared with those who did not. This beneficial effect on mortality was offset by impaired morbidity: patients with a pacemaker experienced a significantly higher rate of thromboembolic complications and impaired quality of life.

In 2003, we began a program providing an introduction to cardiothoracic laboratory research and surgery for medical students. Students are competitively selected for our three-part 8-week summer program. First, students are paired with a cardiothoracic surgery attending for shadowing in clinic and the operating room. Second, students actively participate in large-animal operations in the laboratory. Finally, students complete a clinical research project under the direction of a laboratory resident and faculty mentor. These projects are the students' own. They are responsible for presenting their findings to the division of cardiac surgery at the end of the program.

Since 2003, 18 students have completed the program. Each one has completed a project, collectively resulting in 39 peer-reviewed manuscripts. One student has published 28 peer-reviewed manuscripts. Of 10 students eligible for residency, 8 have applied in general surgery or surgical subspecialty (3 general, 2 plastic, 2 cardiothoracic, and 1 neurosurgery).

Implementing a program to introduce medical students to clinical and laboratory surgery has been successful, as measured by academic productivity. Eighty percent of eligible students entered a surgical field. Programs like these serve to stimulate interest in our specialty.

In the 2004 Nationwide Inpatient Sample database, we identified 63,047 discharge records of patients who underwent CABG (n = 48,658) or OPCAB (n = 14,389). We analyzed seven preoperative variables, including the Deyo comorbidity index and five outcome measures. Multivariable logistic regression was used to identify independent predictors of outcomes.

CABG and OPCAB patients had similar demographics and comorbidities. They also had similar rates of in-hospital mortality (3.0% vs 3.2%; p = 0.14) and postoperative stroke (1.8% vs 1.7%; p = 0.53). However, OPCAB patients had longer hospital stays (10.2 ± 9.4 vs 9.9 ± 8.5 days; p < 0.0001) and higher hospital costs ($38,793 ± $30,830 vs $37,806 ± $28,705; p = 0.0005) than CABG patients. Multivariable regression analysis showed that OPCAB independently predicted 0.6 more days of hospital stay (95% confidence interval [CI], 0.4 to 0.8 day; R ² = 0.09; p < 0.0001) and $1,497 more in hospital costs (95% CI, $779 to $2,216; R ² = 0.09; p < 0.01) per patient.

OPCAB does not produce lower postoperative mortality or stroke rates than CABG. Furthermore, OPCAB is associated with longer hospital stays and higher hospital costs.

Washington State's prospective clinical registry was used to analyze volumes, risk profiles, and outcomes of all patients undergoing isolated CABG and percutaneous coronary intervention.

A total of 154,602 revascularization procedures were performed between 1999 and 2007. Total revascularizations procedures (percutaneous coronary intervention plus CABG) increased by 32% (from 14,084 in 1999 to 18,620 in 2007). Compared with 1999, by 2007 CABG volume decreased by 37%, while percutaneous coronary intervention volume increased by 71%. The ratio of percutaneous coronary intervention to CABG increased by 2.7-fold from 1.7:1 to 4.6:1 (p < 0.0001). Three time intervals were compared (1999–2000, 2001–2003, 2004–2007). For patients undergoing CABG, the prevalence of diabetes (28% to 36%), hypertension (66% to 76%), and three-vessel or left main disease (57% to 68%) increased significantly (p < 0.0001 for all). Female sex (28% to 24%), congestive failure (24% to 13%), and smoking (64% to 59%) decreased significantly (p < 0.0001 for all), whereas patients' age, low ejection fraction, and use of intraaortic balloon pump were unchanged. Although mortality (2.4% to 2.2%; p = 0.79), return to the operating room (3.4% to 3.6%; p = 0.41), and need for postoperative hemodialysis (1.2% to 1.0%; p = 0.44) were unchanged, the incidences of stroke (1.9% to 1.3%; p = 0.01), myocardial infarction (1.7% to 0.8%; p < 0.0001), transfusion (40% to 34%; p < 0.0001), and extubation within 6 hours (43% to 60%; p < 0.0001) improved significantly in the past 9 years.

Despite significant reduction in both the volume and ratio of patients referred for surgical revascularization, risk profiles of patients undergoing isolated CABG in Washington State changed only modestly. Coronary artery bypass grafting mortality was not adversely affected, and morbidity was reduced.

We analyzed 2,516 consecutive patients who underwent first elective isolated CABG. The primary endpoint was strokes within 30 days. The temporal onset of the deficits was classified by consensus as either an "early stroke," which is present just after emergence from anesthesia, or a "delayed stroke," which is present after first awaking from surgery without a neurologic deficit.

More than half of strokes (29 of 46; 63%) were delayed strokes. Patients undergoing off-pump CABG had significantly lower risk of early stroke (0.1% versus 1.1%, p = 0.0009), whereas the incidence of delayed strokes was not different significantly (0.9% versus 1.4%, p = 0.3484) between patients undergoing on-pump and off-pump CABG. In multivariate analyses, undergoing off-pump CABG was an independent protective factor for all strokes (relative risk 0.29, 95% confidence interval: 0.14 to 0.56, p = 0.0005) and early strokes (relative risk 0.05, 95% confidence interval: 0.003 to 0.24, p < 0.0001), but it was not an independent protective factor for delayed strokes (relative risk 0.54, 95% confidence interval: 0.24 to 1.17, p = 0.1210).

Undergoing off-pump CABG reduces the incidence of perioperative stroke mainly by minimizing early strokes; however, the risk of delayed strokes is not different between patients undergoing on-pump and off-pump CABG.

Among patients who underwent CABG between July 2005 and June 2007 at Seoul National University Bundang Hospital, 224 with normal thyroid function and 36 with SCH were enrolled. Preoperative risks and postoperative outcomes were evaluated prospectively without thyroid hormone replacement.

There were no significant differences in primary outcomes (major adverse cardiovascular events) and secondary outcomes such as wound problems, mediastinitis, leg infection, respiratory complications, delirium, or reoperation during the same hospitalization. However, patients with SCH had a higher incidence of postoperative atrial fibrillation than those with normal thyroid function after adjustment for age, gender, body mass index, and other independent variables such as emergency operation, the use of cardiopulmonary bypass, combined valvular operation, preoperative creatinine levels, left ventricular systolic dysfunction, and nonuse of β-blockers (45.5% vs 29%; odds ratio, 2.552; 95% confidence interval, 1.117 to 5.830; p = 0.026).

SCH appears to influence the postoperative outcome for patients by increasing the development of postoperative atrial fibrillation. However, it is still unproven whether preoperative thyroxine replacement therapy for patients with SCH might prevent postoperative atrial fibrillation after CABG.

Of 8,946 patients undergoing isolated coronary artery bypass grafting at the Bristol Heart Institute from April 1996 to September 2006, 6,321 (70.6%) received preoperative statins. Of these, 2,152 patients (statin group) were matched to a control group (no statin) by propensity score analysis.

Preoperative characteristics, number of distal anastomoses, and the use of off -pump procedures were similar in both groups. Hospital mortality was 1.3% (56 patients) with no difference between the two groups. Postoperative atrial fibrillation was significantly higher in the statin compared with the no statin group (411, 19.5%, versus 336; 15.8% respectively; p = 0.002). In a multivariate regression analysis, age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.05), pulmonary disease (OR, 1.42; 95% CI, 1.12–1.82), history of paroxysmal atrial fibrillation (OR, 3; 95% CI, 2.13 to 4.19), preoperative angiotensin-converting enzyme inhibitor therapy (OR, 1.26; 95% CI, 1.07 to 1.49), ejection fraction less than 0.30 (OR, 1.71; 95% CI, 1.22 to 2.38), emergency operations (OR, 4.5; 95% CI, 2 to 10.12), and preoperative statin treatment (OR, 1.31; 95% CI, 1.11 to 1.55) were all independent predictors of postoperative atrial fibrillation.

Preoperative statin is associated with a significantly higher incidence of postoperative atrial fibrillation compared with no statin treatment in patients undergoing isolated coronary artery bypass grafting.

We retrospectively reviewed all patients who underwent first-time coronary artery surgery in our institution during the 11-month period. Among 814 patients, 239 patients (29.4%) had diabetes and 575 patients (70.6%) were nondiabetic. Blood glucose levels were registered every 2 hours in all patients during the first 24 postoperative hours. Outcomes were difficult glycemic control (postoperative blood glucose levels >11.0 mmol/L despite aggressive insulin treatment), hospital mortality, and morbidity (defined as any postoperative complication such as stroke, renal failure, wound infection, perioperative myocardial infarction, ventilation > 24 hours, sepsis, and multiorgan failure).

Glycemic control was significantly worse in patients who underwent coronary artery bypass grafting, in comparison with off-pump coronary artery bypass grafting surgery, particularly in nondiabetic patients. Patients with difficult glycemic control had more serious postoperative complications resulting in higher mortality (2.5% versus 0.4%; p = 0.02). In the multivariate analysis, difficult glycemic control was significantly associated with a female sex (odds ratio [OR], 2.36), presence of diabetes (OR, 2.22), and the usage of cardiopulmonary bypass (OR, 1.81). Mortality was significantly associated with the left ventricular ejection fraction less than 0.35 (OR, 7.38), difficult glycemic control (OR, 7.06), and previous stroke (OR, 5.66). Difficult glycemic control was also significantly associated with postoperative morbidity (OR, 1.87).

Cardiopulmonary bypass increases postoperative glycemia and insulin consumption in both diabetic and nondiabetic patients. The use of cardiopulmonary bypass during coronary artery surgery in diabetic women is associated with a more difficult glycemic control in the early postoperative period. Difficult glycemic control is significantly associated with early mortality and morbidity in patients undergoing coronary artery surgery.

A hydrodynamic analysis of the Dispersion arterial cannula (Edwards Lifescience LLC, Irvine, CA) was performed using particle image velocimetry in glass perfusion models of healthy and aneurysmal aortic arches. Flow velocity, streamline, distribution of magnitude of the strain rate tensor (function of shear stress), and degree of flow turbulence were comparatively analyzed for cannula tip directed toward the aortic arch (standard direction) and toward the aortic root (root direction).

Standard direction cannulation in the model of the healthy aorta showed the flow velocity in the transverse aortic arch was rapid, the streamlines were nonlinear, and the magnitude of the strain rate tensor was high along aortic curvatures. Conversely, directing the cannula tip toward the aortic root generated slower and less turbulent flow in the transverse aortic arch despite high velocity and turbulence and nonlinear streamlines in the ascending aorta. In the aneurysmal aortic arch model, the flow velocity was more rapid in the area where aortic arch vessels originated, and a reversely directed vortex was observed between the aneurysm and the origination of the arch vessels. In the root direction model, the flow velocity distribution was slower than that in the standard direction.

Directing the cannula tip of the Dispersion cannula toward the aortic root generated slower and less turbulent flow in the transverse arch of the glass models of both healthy and aneurysmal aortic arches.

Between 1972 and 2007, 50 patients (26 male) underwent reoperation at our institution after initial repair of CAVSD (median interval, 15 months; range, 3 days to 29 years). Median age at first reoperation was 4.5 years (range, 53 days to 38 years). Indications for first reoperation included left atrioventricular valve (LAVV) regurgitation in 41 patients, subaortic stenosis in 5, and LAVV stenosis, residual atrial septal defect (ASD), pulmonary artery (PA) stenosis, and aortic coarctation in 1 each.

The first reoperation included LAVV repair in 21 patients and replacement in 21, modified Konno procedure in 3, septal myectomy in 2, and PA reconstruction, coarctation repair, and ASD re-repair in 1 each. After LAVV repair (n = 21) 5 patients required a second reoperation, and after LAVV replacement (n = 21) 6 patients required a second reoperation. Overall freedom from further reoperation after the first reoperation was 63%, 48%, and 42% at 5, 10, and 15 years, respectively. There were 2 early deaths (4%) after first reoperation, and none after subsequent reoperations. During late follow-up (median 10.7 years, maximum 30 years), actuarial overall survival was 91%, 91%, and 86% at 5, 10, and 15 years, respectively.

The most common indication for reoperation after CAVSD repair is LAVV regurgitation. LAVV re-repair offers good durability, and LAVV replacement does not preclude additional reoperations. Long-term survival is very good despite need for multiple reoperations in some.

Secondary pulmonary valve repairs in 7 patients (5 children and 2 adults) in our institution were reviewed. All patients presented with a severe pulmonary valve regurgitation associated with RV dilatation and dysfunction after primary RVOT reconstruction.

The surgical techniques varied in our series, but secondary repair of the incompetent pulmonary valve was possible in all patients. Follow-up was complete, with a mean follow-up of 4.1 ± 2.7 years. There were no operative or late deaths in our group. All valves were repaired successfully, with a mean regurgitation grade of 1.28 ± 0.5 postoperatively. The mean transvalvular gradient was 20 ± 4.1 mm Hg for children and 22.5 ± 3.5 mm Hg for adults, and no significant increase of pulmonary valve regurgitation occurred during follow-up. The mean RV dilatation index (RVDI) decreased significantly from 0.85 ± 0.25 to 0.6 ± 0.2 for children and from 1.4 ± 0.01 to 0.9 ± 0.05 for adults.

Our results showed functional recovery of the right ventricle after reoperation, with RVDI recovering to almost normal values in children. No significant regurgitation of the secondarily reconstructed pulmonary valve was observed during the 4-year follow-up period. Secondary repair for pulmonary valve incompetence after RVOT procedures might be a valuable alternative to conduit replacement.

In all, 58 patients underwent Norwood (Blalock-Taussig shunt; n = 39) or hybrid (n = 19) single ventricle palliation (2004 to 2007). Hemodynamics, PA morphology, hemodynamics, resource utilization, and survival were reviewed.

At pre–stage 2 evaluation, there were nonsignificant trends toward lower ventricular end-diastolic pressure, higher mixed venous saturation, and larger Nakata and lower lobe indices in the hybrids. Mean PA pressures were not different between groups. Four Norwood patients (10%) underwent transplantation before stage 2 palliation. Forty-two patients underwent stage 2 palliation (bidirectional cavopulmonary shunt or stage 2 hybrid (aortic arch reconstruction and bidirectional cavopulmonary shunt). Requirement for PA plasty, postoperative CVP, stage 2 survival, and 1-year survival were similar between groups. Combined (stage 1 plus stage 2) intubation time, intensive care unit time, and hospital length of stay was shorter for hybrids in comparison with Norwood survivors (p < 0.05). Comparison of resource utilization at the time of arch reconstruction (Norwood procedure or stage 2 hybrid), demonstrated a time-related trend toward improvement (weak negative correlation: intubation, rho = –0.386, p = 0.172; intensive care unit stay, rho = –0.487, p = 0.077; hospital stay, rho = –0.429, p = 0.126) in the hybrid group, but not in the Norwood group.

Hybrid palliation does not have a significant adverse impact on PA development, with comparable PA growth and hemodynamics. The demonstration of equivalent survival, diminished hospital utilization, and trends indicating ongoing refinement of the hybrid strategy warrants a prospective randomized trial.

Data for 55 consecutive children undergoing BTT between 2001 and 2008 were abstracted from an institutional database. The analysis excluded 13 patients because EXCOR was not used for acute postcardiotomy BTT. Patients were divided into ECMO (n = 21) and EXCOR groups (n = 21). Specific end points included survival to transplant, overall survival, and bridge to recovery. Incidences of adverse events and the duration of support were determined.

Groups were similar in weight, age, and etiologies of heart failure. Likewise, the incidences of stroke and multisystem organ failure were similar. Survival to transplant, recovery, or continued support was 57% in ECMO and 86% in EXCOR (p = 0.040). EXCOR patients had overall significantly better survival (p = 0.049). Two ECMO patients and 1 EXOR patient were bridged to recovery. The mean duration of support was 15 ± 12 days in the ECMO group and 42 ± 43 days in the EXCOR group (p < 0.001).

In children requiring BTT, EXCOR provided substantially longer support times than ECMO, without significant increase in the rates of stroke or multisystem organ failure. Survival to transplant and long-term survival was higher with EXCOR.

For the study group institutional and UNOS databases (July 2000 to December 2008) were reviewed to examine outcomes of pediatric heart transplantation using donor hearts that had been previously refused one or more times because of organ quality. Variation between outcomes of this cohort and recipients who received primarily offered heart grafts in a single institution was analyzed.

In 29 recipients, transplantation or retransplantation was with heart grafts previously declined on the basis of quality. Recovery distances (p < 0.002) and graft cold ischemic times (p < 0.001) were significantly longer for declined hearts. Operative survival was 93% ± 5.0% (27 of 29). Seven-year actuarial survival was 74% ± 10.5%. At the present time, 24 of the 29 recipients (83%) are alive. These results do not vary statistically from those experienced by 84 recipients of 86 primarily offered donor organs during the same time.

Despite longer distance recovery (ie, longer graft cold ischemic times), outcomes of pediatric heart transplantation using donor heart grafts refused on the basis of organ quality are highly competitive. Pediatric donor hearts should seldom be declined on the basis of organ quality (UNOS code 830).

The PAS-Port system (Cardica Inc) was used in 25 patients undergoing off-pump coronary artery bypass surgery. All patients received at least one RA graft using the PAS-Port system on the proximal anastomosis. The radial arteries were harvested in a fully skeletonized fashion before loading to the PAS-Port system.

Our attempt to use the PAS-Port system for proximal anastomosis of the RA was successful in 25 anastomoses. Postoperative angiography showed 24 grafts to be widely patent. During the mean postoperative follow-up of 9.2 ± 3.1 months, there was no cardiac-related event in any patient. Mid-term patency collected from the first 8 patients was 87.5% (mean follow-up, 12.8 ± 2.8 months).

The PAS-Port system does not require aortic clamping and enables the creation of uniform and widely patent anastomosis with use of RA grafts.

The procedure was performed using cardiopulmonary bypass with cardioplegic arrest. After resection of the stenotic aortic valve and debridement of the annulus, the valve was inserted and released. Mean age was 78 ± 3; mean logistic Euroscore was 13.7. Concomitant procedures were mitral valve and tricuspid valve repair (n = 1), coronary artery bypass graft (n = 9), and subvalvular myectomy (n = 3).

Implantation of the valve required 9 ± 5 minutes. Cardiopulmonary bypass and aortic cross-clamp time were 87 ± 16 and 55 ± 11 minutes for stand-alone procedures. Combined procedures required 126 ± 42 and 84 ± 28 minutes, respectively. Two patients were abandoned intraoperatively and converted to standard procedures due to misalignment of the valve. In the other 30 patients, no paravalvular leakage was detected. The transvalvular gradient at discharge was 9 ± 6 mm Hg (mean) and 18 ± 9 mm Hg (peak). Six months after surgery, gradients were 10 ± 4 mm Hg (mean) and 18 ± 6 mm Hg (peak).

Sutureless valve implantation is feasible and safe with the 3f Enable (ATS Medical) bioprosthesis. Reduction of cardiopulmonary bypass and aortic cross-clamp time seems to be possible with increasing experience. Hemodynamic data are promising with low gradients at discharge and after 6 months.

A retrospective clinical review of Marfan patients undergoing ARR at our institution was performed. Follow-up data were obtained from hospital and office records and from telephone contact with patients or their physicians.

Between September 1976 and September 2006, 372 Marfan syndrome patients underwent ARR: 269 had a Bentall composite graft, 85 had valve-sparing ARR, 16 had ARR with homografts, and 2 had ARR with porcine xenografts. In the first 24 years of the study, 85% received a Bentall graft; during the last 8 years, 61% had a valve-sparing procedure. There was no operative or hospital mortality among the 327 patients who underwent elective repair; there were 2 deaths among the 45 patients (4.4%) who underwent emergent or urgent operative repair. There were 74 late deaths (70 Bentalls, 2 homograft, and 2 valve-sparing ARRs). The most frequent causes of late death were dissection or rupture of the residual aorta (10 of 74) and arrhythmia (9 of 74). Of the 85 patients who had a valve-sparing procedure, 40 had a David II remodeling operation; there was 1 late death in this group, and 5 patients required late aortic valve replacement for aortic insufficiency. A David I reimplantation procedure using the De Paulis Valsalva graft has been used exclusively since May 2002. All 44 patients in this last group have 0 to 1+ aortic insufficiency.

Prophylactic surgical replacement of the ascending aorta in patients with Marfan syndrome has low operative risk and can prevent aortic catastrophe in most patients. Valve-sparing procedures, particularly using the reimplantation technique with the Valsalva graft, show promise but have not yet proven as durable as the Bentall.

An initial survey instrument was content-validated, and the final instrument was distributed electronically between March 24 and May 2, 2008 through 251 general surgery program directors to all Accreditation Council for Graduate Medical Education-accredited general surgery residents (7,508).

The response rate was 29% (2153 residents; 89% programs). Respondent's demographics matched existing data; 6% were committed to CTS, and 26% reported prior or current interest in CTS. Interest waned after postgraduate year 3. Interest correlated with CTS rotation duration. Of the respondents committed to CTS, 76% had mentors (71% were cardiothoracic surgeons). CTS had the most shortcomings among 9 subspecialties. Job security and availability accounted for 46% of reported shortcomings (3 to 14 times higher than other subspecialties). Work schedule accounted for 25%. Length of training was not a very important factor, although it was identified as an option to increase interest in CTS. Residents who were undecided or uninterested in CTS were twice as likely to cite the ability to balance work and personal life as important than residents who chose CTS.

The dominant concern documented in the survey is job security and availability. The importance of mentorship and exposure to CTS faculty in promoting interest was also evident. Decision makers should consider these findings when planning changes in education and the specialty.

From 1997 to 2004, 106 patients exclusively with classic complicated or symptomatic type B aortic dissection were treated with thoracic endovascular aortic repair, using the same device. We present in-hospital outcomes and late follow-up for 73 patients.

Technical success was achieved for 99% of patients, and the clinical success rate was 83% (exclusion of the false lumen, no early death or surgical conversion). In-hospital death occurred in 5 patients, 2 of them after surgical conversion. Three patients required urgent surgical conversion. Neurologic complications occurred in 5 patients (1 case of paraplegia). The average time of follow-up was 35.9 ± 28.5 months. During follow-up, 37% of patients initially successfully treated reached a failure criterion (new endovascular or surgical intervention in the same aortic segment or death due to aortic or unknown cause). Kaplan-Meier curve showed late survival rates higher than 80% in 2 years.

Patients with both acute and chronic type B aortic dissection had excellent initial results with thoracic endovascular aortic repair. Although event-free survival rates decreased gradually with time owing to the frequent need for new interventions, survival curves were comparable to those for less complex patients undergoing clinical or surgical treatment. Randomized studies are required to establish the actual benefit of this new approach.

Of 170 patients undergoing thoracic endovascular repair (1993 to 2008), 20 presenting with ITAP were identified. Indications for intervention included aortobronchial (n = 10), aortoesophageal (n = 2), or aortocutaneous fistulae (n = 1), or mycotic aneurysms (n = 7). Underlying disease included fusiform aneurysm (n = 1), saccular aneurysm or pseudoaneurysm (n = 18), or dissection (n = 1). Four patients had ITAP from infected grafts. Follow-up was 100% complete (mean, 28.6 months).

Median age was 73 years. A history of immunosuppression was present in 4; concurrent malignancy was present in 5. Arch repair was needed in 8; total descending, in 6. Three patients underwent hybrid thoracic endovascular repair or debranching procedures. Causes of in-hospital mortality (n = 3; 15.0%) included refractory hypoxemia (n = 1) and sepsis from tracheoesophageal fistula (n = 1) or pneumonia (n = 1). Dialysis was needed in 2; none sustained postoperative stroke or paraplegia. Mean Kaplan-Meier survival was 39.0 months. Late mortality was seen in 13 patients, with 3 attributed to recurrent ITAP. There was a trend for recurrence of ITAP when thoracic endovascular repair was originally performed in an infected graft (p = 0.08). At last imaging follow-up, 14 patients had a healed aorta.

Treatment with thoracic endovascular repair for ITAP can be accomplished with acceptable results. Late mortality is frequently related to underlying comorbidities, rather than complications from the aortic disease itself, suggesting that thoracic endovascular repair is an appropriate palliative therapeutic option in this high-risk cohort.

Forty-six patients were divided into the following three groups based on pathology: group A, 21 patients with thoracic aortic aneurysm; group B, 15 patients with chronic aortic dissection; and group C, 10 patients without any aortic diseases. Using an echo-tracking system on the carotid artery, we measured stiffness parameter β, arterial compliance, and the augmentation index.

There was no significant difference in stiffness parameter β and arterial compliance among the three groups. The augmentation index was significantly higher in groups A and B than group C (22 ± 10%, 22 ± 13% vs 8 ± 17%; p = 0.012). Female (p = 0.028) and heart rate (p = 0.005) were significantly associated with the augmentation index and the significance of aortic diseases was marginal (p = 0.056).

The carotid augmentation index is elevated in patients with aortic aneurysm and dissection.

We studied 71 patients (41 male) with a mean age of 83 ± 2.8 years, who underwent cardiac reoperation between 1994 and 2006. These patients were compared with 71 octogenarians who underwent primary cardiac operation. Patients were matched for age, sex, year of operation, and surgical procedure. Demographic profiles, operative data, long-term survival, and quality of life by the Short-Form 36-Item Health Survey questionnaire were analyzed.

Average time between previous operation and reoperation was 10.8 ± 5.6 years (range: 1.7 to 30.6). The 30-day mortality rate was 14.7% in the reoperation group and 8.5% (p = 0.43) in the control group. Actuarial survival at 1, 3, and 6 years was 71% ± 5.5%, 60.5% ± 6.1%, and 30% ± 8.1% for patients who underwent cardiac reoperation; and 77.2% ± 5%, 58.3% ± 6.3%, and 36.3% ± 7.8% for matched octogenarians who underwent primary cardiac surgery (p = 0.68). No significant differences were found between groups regarding the physical health summarized score (40.7 ± 9.4 versus 39.1 ± 10; p = 0.55) and the mental health summarized score (51.9 ± 10.9 versus 48 ± 12.9; p = 0.24) of the Short-Form 36-Item Health Survey questionnaire.

Octogenarians exhibit a similar long-term survival and quality of life after primary and redo cardiac surgery. Therefore, cardiac reoperation should not be a contraindication per se in octogenarians.

Isolated CABG procedures (June 1, 2001 to May 31, 2008) within the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database were included. Redo status as a predictor for early outcomes was assessed with logistic regression analysis. Midterm survival was determined from the National Death Index. Effect of redo status on midterm survival was assessed using a Cox proportional hazards model.

Inclusion criteria were met by 13,436 patients, and 458 (3.4%) underwent redo CABG. Operative mortality was 4.8% for redo CABG and 1.8% for first-time CABG (p < 0.001). After adjustment, redo status remained a predictor for operative mortality (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3 to 3.6), myocardial infarction (OR, 2.8; 95% CI, 1.6 to 6.0), and prolonged ventilation (OR, 1.5; 95% CI, 1.1 to 2.0). Unadjusted survival was lower for the redo CABG group vs the first-time CABG group at up to 6 years (p = 0.01, log-rank test. After adjusting for differences in patient variables, redo status was not a predictor of midterm survival (OR, 1.03; 95% CI, 0.78 to 1.35; p = 0.85).

Early postoperative outcomes of redo CABG are encouraging. Midterm survival is excellent; however, redo remains a significant risk factor for operative mortality in contemporary practice.

From 1971 to 2000, 4,640 patients with prior coronary artery bypass grafting that included left internal thoracic artery to LAD grafting were found on angiography during active follow-up to have a patent left internal thoracic artery to LAD graft, but at least 50% stenosis of non-LAD territories or grafts to them. Two survival analyses were performed: (1) intent-to-treat, which included patients undergoing reoperative coronary artery bypass grafting (n = 731) or percutaneous intervention (n = 994) within 6 weeks of angiography or medical management (n = 2,782), and (2) competing risk/crossover, in which patients were classified as medically managed until crossover to coronary artery bypass grafting or percutaneous intervention.

In the intent-to-treat analysis, propensity-adjusted early (<1 year) survival was similar for all patients, but late survival was slightly better after percutaneous intervention than with medical management (p ≤ 0.05). In the competing risk/crossover analysis, adjusted survival was best for medically treated patients early; however, late survival was similar among all three groups.

Patients with patent left internal thoracic artery to LAD grafts who develop non-LAD territory jeopardy derive no survival benefit from reintervention, consistent with previous observations that for coronary reintervention to improve survival, the LAD territory must be jeopardized. Reintervention in patients with a patent left internal thoracic artery to LAD graft may be warranted to relieve symptoms, without expecting a survival benefit.

Data from 302 consecutive patients (mean age, 62 ± 8.7 years) with LVEF of 0.35 or less who had undergone CABG were analyzed. Epinephrine and enoximone with or without norepinephrine were used to increase cardiac index. Intra-aortic balloon pump or left ventricular assist devices, or both, were used in case of postoperative low output syndrome.

Complete revascularization was achieved in 298 of 302 patients (98.7%); internal thoracic artery was used in 294 (97.4%). Operative mortality was 5.3%; independent predictors of operative mortality were emergency CABG (p = 0.005), history of ventricular arrhythmias (p = 0.007), and previous anterior myocardial infarction (p = 0.05). At follow-up, all-cause mortality was 30.8%, and 10-year survival was 63% ± 4%; independent predictors of late all-cause mortality were history of ventricular arrhythmias (p < 0.0001), chronic renal dysfunction (p = 0.0004), and diabetes mellitus (p = 0.04). Cardiac death was 20.4%, and 10-year freedom from cardiac death was 73% ± 3.3%; independent predictors of cardiac death were history of ventricular arrhythmias (p = 0.004), chronic renal dysfunction (p = 0.03), and more than one previous anterior myocardial infarction (p = 0.004). At 80 ± 44 months of follow-up, echocardiography showed significant LVEF improvement (0.43 ± 0.09 versus 0.28 ± 0.06, p < 0.0001). Ten-year freedom from myocardial infarction was 87% ± 3%.

Excellent long-term results after CABG can be expected for patients with LVEF of 0.35 or less. Complete revascularization and internal thoracic artery grafting are associated with high freedom from myocardial infarction. Careful treatment of arrhythmias, diabetes, and renal dysfunction is necessary to improve long-term survival.

In 581 patients 1,390 grafts were nested into left internal mammary artery to left anterior descending artery, single vein grafts, or double and triple sequential vein grafts, and analyzed.

Within the single vein graft group there were no differences between flow of grafts to different target vessels except for diagonals (diagonal versus obtuse marginal, p < 0.001; versus posterior descending artery, p = 0.035; versus right coronary artery, p = 0.003). Flows measured in single vein grafts were significantly lower than in double (p < 0.001) and triple sequential vein grafts (p < 0.001). Flows were lower in double versus triple sequential vein grafts (p = 0.017) and higher in men versus women (p < 0.001). Mean pulsatility index of vein grafts were lower in the left versus the right coronary system, 2.0 ± 0.01 and 2.4 ± 0.06, respectively (p < 0.001). Between sex and groups of vein grafts within each coronary system, mean pulsatility index had similar values.

Blood flow increases from single to double and up to triple sequential grafts. Single grafts directed to diagonals have the lowest flow. Graft blood flows are higher in male versus female patients. Single, double, and triple saphenous vein grafts have similar pulsatility indexes. Pulsatility index of grafts to the right coronary system is significantly higher than that of grafts to the left coronary system.

Patients (n = 232) were enrolled who underwent OPCAB with SV grafts from 2004 to 2007 and had follow-up angiography. For proximal anastomoses, a clampless device was used in 73 (group A; HEARTSTRING [Guidant Corporation, Santa Clara, CA] in 54, Enclose II [Novare Surgical Systems, Inc, Cupertino, CA] in 19), and partial clamping was used in 159 (group B). The proximal anastomosis procedure was modified according to the results of epiaortic ultrasonography. Coronary angiography was performed early (11.8 ± 10.4 days) and one-year postoperatively (n = 180, 371.5 ± 102.6 days).

There were no significant differences in patient characteristics between the two groups except for a higher reoperation rate in group A. The overall SV patency rate at the early and one-year postoperative angiography was 95.7% and 83.0%, respectively. The patency rates were similar between the two groups (early: 97.3% vs 98.1%, p = 0.729; 1 year: 87.0% vs 81.3%, p = 0.316). There was also no significant difference in the target vessel revascularization rate during follow-up (6.8% vs 10.1%, p = 0.623).

Intermediate-term angiographic follow-up demonstrate an acceptable SV patency rate after OPCAB. The SV patency rate with a clampless device for proximal anastomosis is comparable with that with partial clamping during the first postoperative year.

A total of 32 consecutive patients (mean age, 62.5 ± 10.5 years) underwent postinfarction VSD repair using a standardized technique in our department. A retrospective analysis of clinical and operative data, predictors of early mortality, and long-term survival was performed. The localization of VSD was posterior in 50% and anterior in 50% of the patients.

The hospital mortality was 31.2% (10 patients). The most common cause of hospital death was persistent low cardiac output. The mortality of the posterior VSD group was significantly lower than that of the anterior VSD group (18.7% and 43.7%, respectively, p = 0.01). Intra-aortic balloon pump support and absence of cardiac shock were significantly associated with a lower risk of hospital mortality (p = 0.0001 and p = 0.0009, respectively). The actuarial survival rates of in-hospital survivors at 5 and 10 years were 79% ± 2% and 51% ± 3%, respectively.

The repair of postinfarction VSD by the infarct exclusion is feasible and safe. This technique seems to offer sufficient favorable early and long-term results compared with other techniques. Early indication, preoperative intra-aortic balloon pump support may improve the surgical results. Preoperative cardiogenic shock carries a poor prognosis for this patient group.

From 1998 through July 2007, 651 port access MV procedures were performed. In 107 patients (16.4%), previous cardiac surgery had been performed through midline sternotomy. Mean age was 67.5 ± 11.2 years, and 60.7% (n = 65) were male. Previous surgery included CABG (n = 45, 42.1%), aortic valve replacement (n = 9, 8.4%), aortic valve replacement/MV repair (n = 2, 1.9%), MV repair (n = 21, 19.6%), MV replacement (n = 5, 4.7%), CABG/MV replacement (n = 1, 0.9%), CABG/MV repair (n = 8, 7.5%), CABG/aortic valve replacement (n = 2, 1.9%), and others (n = 14, 13.1%). New York Heart Association functional classes were I (n = 2, 1.9%), II (n = 28, 26.2%), III (n = 50, 46.7%), and IV (n = 27, 25.2%). The endoaortic balloon was used in 75 patients (70.1%) and the Chitwood clamp in 11 patients (10.2%). In the remaining patients (n = 21, 19.6%), fibrillatory arrest was employed.

Mitral valve repair and MV replacement were performed in 60 patients (56.1%) and 47 patients (43.9%), respectively. The 30-day mortality was 4.7% (n = 5). The mean cardiopulmonary bypass and aortic cross-clamp times were 140.8 ± 43.7 minutes and 77.0 ± 49.7 minutes, respectively. Complications included 6 reoperations for bleeding (5.6%), 1 stroke (0.9%), and 2 wound infections (1.9%). Conversion to sternotomy was required in 1 patient (0.9%) because of an acute type A dissection secondary to aortic occlusion with Chitwood clamp. The mean hospital stay was 9.6 days. During follow-up, reoperation for failure of MV repair was performed in 4 patients (3.7%).

Reoperative port access MV surgery can be performed with minimal morbidity and mortality. This approach may be the preferred technique for patients who require MV procedures after previous cardiac surgery performed through median sternotomy.

The study population included isolated mitral valve operations performed between January 2000 and December 2007 at 910 hospitals participating in the STS ACSD. Patients with endocarditis, prior cardiac operation, shock, emergency operation, and concomitant coronary artery bypass graft or aortic valve surgery were excluded.

During the 8-year study period, 58,370 patients underwent isolated primary MV operations. For patients with isolated mitral regurgitation (n = 47,126), the rate of MV repair (versus replacement) increased from 51% to 69% (p < 0.0001). Among patients having replacement (n = 24,404), there has been a pronounced decline in the use of mechanical valves: 68% to 37% (p < 0.0001). The operative mortality for MV replacement was consistently higher than that for repair (3.8% versus 1.4%), a finding that persisted after risk-adjustment (adjusted odds ratio 0.52, 95% confidence interval: 0.45 to 0.59; p < 0.0001). Among patients having elective isolated MV repair (n = 28,140), the operative mortality was 1.2%. For asymptomatic (class I) patients, operative mortality was 0.6%.

This study documents several important trends in MV surgery, including the progressive adoption of mitral valve repair and increasing use of bioprosthetic replacement valves. Operative risks of MV repair are significantly lower than those for MV replacement. Operative mortality for isolated elective mitral valve repair is 1% in contemporary clinical practice.

All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES_log) risk stratification. Surgical risk was defined as low risk (ES_log ≤ 10% [n = 107]), moderate risk (10% < ES_log < 20% [n = 103]), and high risk (ES_log ≥ 20% [n = 72]). Patient age was 82 ± 2 years (low risk), 82.7 ± 2.7 years (moderate risk), and 83.6 ± 3.1 years (high risk), respectively (p < 0.05). Mean ES_log predicted risk of mortality was 7.3% ± 1.4% (low risk), 13.7% ± 2.5% (moderate risk), and 33.0% ± 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete.

In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum.

Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

A retrospective cohort study was performed of 112 consecutive laser-assisted lead extractions at a single university medical center during a 6-year period. Patient and lead characteristics were analyzed as well as indications, outcomes, and major complications.

Successful lead extraction was accomplished in 103 (92%) of the 112 patients. Elective sternotomy after failure of laser-assisted lead removal was successfully performed in 4 patients. Emergent surgical intervention was required in 4 patients for caval perforation (n = 2), subclavian vein injury (n = 1), or right atrial injury (n = 1). Three of the 4 patients requiring emergent intervention died, for an overall series mortality of 2.6%. In July of 2006, a policy of cardiothoracic surgeon presence during the laser-assisted extraction was instituted. Since that time, there has been one emergent sternotomy and one elective sternotomy for lead removal with no procedure-related deaths.

Despite recent advances in laser technology for the removal of pacemaker and defibrillator leads, the potential for major cardiovascular injury and death remains. Involvement of the cardiothoracic surgeon in both the preoperative decision-making process as well as the laser-assisted lead extraction is critical to prevent or emergently treat any major complications.

Between July 2002 and November 2005, 119 consecutive patients underwent surgical AF correction with the CryoMaze procedure. Mitral valve disease was the primary indication for operation in 66%. AF was continuous in 65%. Rhythm assessment was with 2-week continuous electrocardiographic (ECG) monitoring in 75% of patients and by noncontinuous ECG in the remainder. Median follow-up was 3.2 years and was 98% complete.

There was one hospital (0.8%) death. Survival at 3 years was 84%. One perioperative stroke resolved completely. No late strokes occurred. In 4 of 119 patients (4 (3.4%), pacemakers were inserted during the index hospitalization. Median length of stay was 7 days. Overall freedom from AF more than 3 years after operation was 60%. Among patients with preoperative intermittent AF, 85% (28 of 33) were in normal sinus rhythm, and 47% (27 of 58) with continuous AF were in normal sinus rhythm (p < 0.001).

CryoMaze AF correction is safe and is associated with a very low risk of stroke. Rates of normal sinus rhythm at more than 3 years postoperatively were high for patients with intermittent AF and acceptable for those with continuous AF. This experience supports wider application of the CryoMaze to all patients with AF who need cardiac operations.

From 1994 to 2008, 168 patients (mean age, 61 ± 14 years; male = 72, female = 96) underwent tricuspid repair (n = 156) or replacement (n = 12). Concomitant operations were performed in 87% (146 of 168). Patients with history of cirrhosis or MELD score 15 or greater (MELD = 3.8*LN [total bilirubin] + 11.2*log normal [international normalized ratio] + 9.6*log normal [creatinine] + 6.4) were compared with patients without liver disease or MELD score less than 15. Preoperative risk, intraoperative findings, and complications including operative mortality were evaluated. Statistical analyses were performed using ², Fisher's exact test, and area under the curve (AUC) analyses.

Patients with a history of liver disease or MELD score of 15 or greater had significantly higher mortality (18.9% [7 of 37] versus 6.1% [8 of 131], p = 0.024). To further characterize the effect of MELD, patients were stratified by MELD alone. No major differences in demographics or operation were identified between groups. Mortality increased as MELD score increased, especially when MELD score of 15 or greater (p = 0.0015). A MELD score less than 10, 10 to 14.9, 15 to 19.9, and more than 20 was associated with operative mortality of 1.9%, 6.8%, 27.3%, and 30.8%, respectively. By multivariate analysis, MELD score of 15 or greater remained strongly associated with mortality (p = 0.0021). The MELD score predicted mortality (AUC = 0.78) as well as the European System for Cardiac Operative Risk Evaluation logistic risk calculator (AUC = 0.78, p = 0.96).

The MELD score predicts mortality in patients undergoing tricuspid valve surgery and offers a simple and effective method of risk stratification in these patients.

In this prospective follow-up study, a questionnaire was used 1 to 1.5 years after cardiac surgery in our earlier cohort of 112 patients who underwent elective cardiac surgery, of which 24 patients (21%) developed postoperative delirium as diagnosed by a single psychiatrist.

Postoperative delirium after cardiac surgery may be associated with increased mortality (12.5% in patients with delirium versus 4.5% in patients without delirium; p = 0.16), more readmissions to the hospital (47.6% vs 32.6%; p = 0.19), dysfunction in memory (31.6% vs 22.6%; p = 0.39), and concentration problems (36.8% vs 20.2%; p = 0.13); and is associated with sleep disturbance (47.4% vs 23.8%; p = 0.03).

Postoperative delirium after cardiac surgery may be associated with increased mortality and readmissions to the hospital, as well as poorer cognitive and functional outcomes. Therefore, prevention and (or) early recognition of delirium must be improved. In addition, patients and caregivers (family and general practitioner) must be better informed about the long-term consequences of delirium and what they can do about it.

One hundred fourteen patients who underwent a superior vena cava to pulmonary artery anastomosis as an adjunct to biventricular repair were identified for the years 1965 to 2003. Median follow-up was 92.3 months (range, 1 month to 38 years).

The long-term outcome for operative survivors was 83.4%, 80.1%, and 69.3% at 5, 10, and 20 years, respectively. The survival in the most recent 10 years is 91.8% ( p = 0.063). Of the late deaths, 69.6% (16 of 23) were known cardiac deaths or sudden. Patients with chronic right ventricular dysfunction demonstrated the best 10-year survival (91.6%). Of the late survivors, 98.8% of patients are in New York Heart Association class I or II. Arterial O₂ saturation increased significantly from before to late after repair. (83.5% to 94.5%, p < 0.001; n = 82). Freedom from new atrial arrhythmia was 92.2% at 20 years. The superior vena cava to pulmonary artery anastomosis was taken down in 3. There was no patient with clinically evident protein-losing enteropathy.

The most common cause of late mortality is cardiac. Atrial and ventricular arrhythmias occur, but no protein-losing enteropathy was identified. The serious complication risk related to pulsatility in the superior vena cava was 2.6%.

Two hundred thirty-six consecutive Fontan procedures were retrospectively reviewed. Group 1 (n = 21, with concomitant AVV repair [n = 19] or replacement [n = 2]) was compared with group 2 (n = 215, no AVV surgery) with regard to preoperative characteristics and perioperative outcomes. Atrioventricular valve regurgitation was graded as 1 (none or trivial) to 4 (severe).

Group 1 patients were older (4.3 ± 3.7 versus 3.0 ± 2.6 years; p = 0.04) and had longer cardiopulmonary bypass (118 ± 38 versus 85 ± 28 minutes; p < 0.001) and aortic cross-clamp times (33 ± 32 versus 14 ± 21 minutes; p < 0.001). There were no differences between groups regarding diagnosis, weight, hospital or intensive care unit length of stay, ventilator time, or 12-hour chest tube output. Postoperative complications were similar between groups, including bleeding (0 of 21 versus 8 of 215; p = 0.8), neurologic injury (1 of 21 versus 9 of 215; p = 0.7), arrhythmias (1 of 21 versus 24 of 215; p = 0.6), and operative mortality (0 of 21 versus 1 of 215; p = 0.1). Group 1 AVV regurgitation significantly decreased after surgery (3.0 ± 0.9 preoperatively versus 1.7 ± 0.9 postoperatively; p < 0.001).

Atrioventricular valve surgery has been shown to improve late outcomes for single-ventricle patients. This study demonstrates that AVV surgery performed with the Fontan procedure increased operative times, but did not significantly increase perioperative morbidity or mortality. This information supports appropriate utilization of AVV surgery for single-ventricle patients.

We reviewed the first 48 hours of postoperative hemodynamic data on 50 patients with hypoplastic left heart syndrome at our institution who underwent the Norwood procedure. Cerebral oxygen saturation data within 48 hours of surgery were analyzed for association with subsequent adverse outcome, which was defined as intensive care unit length of stay greater than 30 days, need for extracorporeal membrane oxygenation, or hospital death after 48 hours.

There were 18 adverse events among the 50 subjects. The mean cSaO₂ for the entire cohort at 1 hour, 4 hours, and 48 hours after surgery was 51% ± 7.5%, 50% ± 9.4%, and 59% ± 8.1%, respectively. Mean cSaO₂ for the first 48 postoperative hours of less than 56% was a risk factor for subsequent adverse outcome (odds ratio 11.9, 95% confidence interval: 2.5 to 55.8). Mean cerebral NIRs of less than 56% over the first 48 hours after surgery yielded a sensitivity of 75.0% and a specificity of 79.4% to predict those at risk for subsequent adverse events.

Low regional cerebral oxygen saturation by NIRS in the first 48 hours after the Norwood procedure has a strong association with subsequent adverse outcome. Monitoring of cerebral saturation can serve as a valuable monitoring tool and can identify patients at risk for poor outcome.

We reviewed six specimens with common arterial trunk and atrioventricular septal defect, focusing on how to establish a nonobstructed connection between the left ventricle and the truncal valve.

In all cases, the common trunk arose exclusively from the right ventricle, and the only exit from the left ventricle was the ventricular component of the septal deficiency. In particular, the preferential route was limited to a space below the superior bridging leaflet that did not have any tendinous cords inserting onto the ventricular crest, in contrast to the inferior bridging leaflets that were always tethered to the crest with many short cords. Accordingly, the size of potential left ventricular outflow depended on the shape of the anterosuperior margin of the ventricular crest below the superior bridging leaflet. The potential outflow was narrower than the truncal valvar area in all hearts but one having extensive anterosuperior excavation of the ventricular crest, suggesting the necessity of septal enlargement had anatomical repair been attempted during life.

Owing to the unique ventriculoarterial connection, the surgeon, considering anatomical repair, needs to pay attention to the anterosuperior margin of the ventricular scoop, which determines the adequacy of left ventr