A retrospective study of 680 consecutive patients undergoing coronary bypass graft surgery and/or aortic valve replacement was done. Excluded were 57 patients (8.4%) with history of AF, permanent pacemakers, and those receiving antiarrhythmic medication. Preoperative statin treatment and occurrence of postoperative AF were examined using propensity score matching to adjust for differences in patient characteristics between the statin and no-statin groups.

The cohort comprised 623 patients. The statin group had a 27.1% incidence of postoperative AF vs 38.3% in the no-statin group (adjusted odds ratio [OR], 2.00; 95% confidence interval, 1.24 to 3.24; p = 0.004). Simvastatin (40 mg) and atorvastatin (40 mg) demonstrated the greatest effect on postoperative AF at 15.6% and 21.2%, respectively, vs no statins (respective adjusted ORs, 3.89 [p < 0.0001] and 2.76 [p = 0.012]). Intermediate-dose (20 mg) statins were also effective against AF, at 24.4% for simvastatin (adjusted OR, 2.32; p = 0.004) and 26.4% for atorvastatin (adjusted OR, 1.99, p = 0.047). Low-dose statins, simvastatin or atorvastatin (10 mg), did not influence postoperative AF.

Statin treatment may reduce the incidence of AF after cardiac surgery. Higher-dose statins have the greatest preventative effect, whereas low-dose statins do not influence postoperative AF.

This retrospective study included 447 consecutive patients undergoing valve operations between July 2004 and February 2006; 203 patients (45.6%) received statins preoperatively and postoperatively vs 244 who did not. Preoperative risk factors and outcome data for both cohorts were compared. Primary outcomes included 30-day mortality, renal failure, and postoperative stroke.

The statin group had more comorbidities. Although they had increased risk factors, including previous stroke (30 of 203 vs 16 of 244, p = 0.004), diabetes (66 of 203 vs 32 of 244, p < 0.0001), cerebrovascular disease (45 of 203 vs 24 of 244, p = 0.003), and dyslipidemia (191 of 203 vs 63 of 244, p < 0.0001), they had better outcomes. The unadjusted odds ratio (OR) for the composite end point of death/stroke/renal failure was 1.90 (95% confidence interval [CI], 0.95 to 3.76; p = 0.068) favoring the statin group. By univariate analysis, the adjusted OR for the composite end point demonstrated a benefit with statin therapy: diabetes, 2.29 (95% CI, 1.16 to 4.71; p = 0.024); stroke, 2.15 (95% CI, 1.06 to 4.35; p = 0.034); and renal dysfunction, 2.05 (95% CI, 1.02 to 4.13; p = 0.045).

Statin therapy in this population undergoing cardiac valve procedures was associated with decreased postoperative morbidity and death. The mechanism may be independent of statins' lipid-lowering effects. A prospective, randomized-control trial of statin therapy in this population is warranted.

From 1986 to 2003, 851 patients with HCM underwent operation, and 115 had a concomitant MV procedure. Detailed analysis of their 784 transthoracic and transesophageal echocardiograms, performed intraoperatively and postoperatively, was conducted. Outcomes were assessed by cross-sectional follow-up.

Sixty-seven patients (58%) underwent MV repair, and 48 (42%) had MV replacement. The mean left ventricular outflow tract peak gradient was 70 ± 50 mm Hg. Systolic anterior motion was present in 95%. Valve abnormalities were degenerative in 36 (31%), myxomatous in 23 (20%), papillary muscle in 23 (20%), restrictive chordal in 22 (19%), restrictive leaflet in 80 (70%), and long leaflet in 64 (56%). Patients undergoing MV repair had higher prevalence of long leaflets and degenerative MV pathology. The anterior mitral leaflet was 3.0 ± 0.49 cm in the repair group vs 2.5 ± 0.40 cm in the replacement group (p = 0.0001). MV replacement patients were older, more symptomatic, and had more renal dysfunction and lower hematocrits. By 3 years, 91% of patients with a repair were free of reoperation.

Intrinsic MV pathology is frequently observed in HCM patients with symptomatic obstruction who undergo myectomy. Echocardiography can identify MV features predictive of successful valve repair. Repair, although durable, is feasible in only about half of patients.

A retrospective study was performed on 257 consecutive patients undergoing mitral valve repair exclusively for IMR from 1996 to 2005. Potential preoperative and perioperative risk factors for death and postoperative echocardiographic data were recorded.

Preoperative echocardiography demonstrated 3+ to 4+ MR in 98.4% (252 of 257). Concomitant coronary artery bypass grafting was performed in 80.9% (208 of 257). Operative mortality was 10.1% (26 of 257). Overall survival by Kaplan-Meier analysis was 68.3% at 3 years and 52.0% at 5 years. Factors associated with late mortality by multivariate analysis include advanced age (relative risk [RR], 1.037; 95% confidence interval [CI], 1.016 to 1.059; p ≤ 0.001), preoperative dialysis (RR, 3.504; 95% CI, 1.590 to 7.720; p = 0.008), and diabetes (RR, 2.047; 95% CI, 1.319 to 3.177; p = 0.001). Echocardiographic data at 20 ± 25 months were available in 57% (147 of 257). Their survival by Kaplan-Meier analysis was 76.4% at 3 years and 65.1% at 5 years with 0 to 2+ MR postoperatively (n = 106) vs 61.3% and 35.8% with 3+ to 4+ MR (n = 41; p = 0.003). Cause of death was available in 72.3% (60 of 83) of late deaths, with 42.2% (35 of 83) attributed to cardiac causes and 30.1% (25 of 83) noncardiac.

Mortality for IMR remains high despite surgical management and may be related to risk factors for progression of coronary artery disease. Despite repair, MR progresses in many patients and is associated with poor survival, although more detailed prospective data are needed to characterize this relationship.

One hundred and ninety-five consecutive patients (103 male and 92 female), age 69 ± 8 years, underwent surgery between January 2006 and July 2007. Mean preoperative New York Heart Association function class was 2.2 ± 0.7. Thirty-five patients (18%) had an ejection fraction 0.35 or less. Cardiopulmonary bypass was instituted through femoral (176 of 195, 90%), axillary (18 of 195, 9%), or direct aortic (1 of 195, 0.5%) cannulation. Under cold fibrillatory arrest (mean temperature 28.2°C) without aortic cross-clamp, mitral valve repair (72 of 195, 37%), mitral valve replacement (117 of 195, 60%), or other (6 of 195, 3%) procedures were performed. Concomitant procedures included maze (45 of 195, 23%), patent foramen ovale closure (42 of 195, 22%) and tricuspid valve repair (16 of 195, 8%), or replacement (4 of 195, 2%).

Thirty-day mortality was 3% (6 of 195). Duration of fibrillatory arrest, cardiopulmonary bypass, and "skin to skin" surgery were 88 ± 32, 118 ± 52, and 280 ± 78 minutes, respectively. Ten patients (5%) underwent reexploration for bleeding and 44% did not receive any blood transfusions. Six patients (3%) sustained a postoperative stroke, eight (4%) developed low cardiac output syndrome, and two (1%) developed renal failure requiring hemodialysis. Mean length of hospital stay was 7 ± 4.8 days.

This simplified technique of minimally invasive open heart surgery is safe and easily reproducible. Fibrillatory arrest without aortic cross-clamping, with coronary perfusion against an intact aortic valve, does not increase the risk of stroke or low cardiac output. It may be particularly useful in higher risk patients in whom sternotomy with aortic clamping is less desirable.

From March 2000 to September 2006, 100 patients underwent MV repair (n = 42), MV annuloplasty (n = 28), MV replacement (n = 18), atrial septal defect closure (n = 10), tricuspid valve repair (n = 1), and left atrial myxoma excision (n = 1). A modified maze procedure (n = 4) or left minimally invasive direct coronary bypass grafting (MIDCABG) (n = 2) was combined in six cases. The mean age was 57 ± 11 years (range, 22 to 89); 27 patients were in New York Heart Association (NYHA) class III or IV; 24 cases were first or second time reoperations; 20 patients had a left ventricular ejection fraction of less than 0.3. All the operations were carried out on the fibrillating heart without cross-clamping the aorta through a right minithoracotomy using peripheral cannulation.

Mean fibrillation time was 73 ± 31 minutes (range, 10 to 198 minutes). There was no conversion to sternotomy. Postoperative inotropic support was needed in 20 cases. One patient who underwent a third time reoperation died within 30 days of mesenteric ischemia (hospital mortality = 1%). Complications were the following: four reoperations for bleeding (4%); two strokes (2%). Postoperative median hospital length of stay was five days (range, 2 to 58 days). None of the patients has required MV reoperation after hospital discharge. Follow-up was complete. All survivors were in NYHA class I or II.

Ventricular fibrillation simplifies less invasive intracardiac procedures and carries lower complication rates and perioperative mortality compared with conventional surgery.

We performed a retrospective review of 7201 consecutive cardiac surgical patients during a 10-year period and identified 202 strokes. Postoperative stroke after CPB was classified as early (≤ 24 hours) or late (> 24 hours). Data were collected on patient characteristics, intraoperative variables and outcomes, postoperative course, stroke severity, and discharge status, including death from stroke. Logistic regression analysis was used to assess the relationship between the timing of stroke and discharge status after adjusting for clinically relevant factors.

The stroke incidence was 2.8%. Postoperative strokes occurred within 24 hours in 22.8% (46 of 202) and after 24 hours in 77.2% (156 of 202). Factors found in logistic regression analysis to be independently associated with stroke-related death included stroke within 24 hours postoperatively (odds ratio [OR], 9.16; p < 0.0001), preoperative chronic renal insufficiency (OR, 4.46; p = 0.01), and National Institute of Health Stroke Scale (NIHSS) score (OR, 1.16 per NIHSS point increase; p < 0.0001). Among survivors, early stroke was associated with greater rehabilitation needs (p < 0.001).

Early stroke after CPB is independently associated with higher stroke-related death and is associated with increased need for skilled rehabilitation at discharge. Neuroprotective strategies aimed at reducing early postoperative stroke may positively impact death and neurologic disability after CPB.

Between June 2000 and June 2006, 95 surgically treated patients with definite infective endocarditis by the modified Duke criteria were included.

Fifty-eight patients were operated on within the first 7 days after diagnosis of infective endocarditis and 37 at more than 7 days after diagnosis up to immediately after completion of antibiotic treatment. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 15%. Early operation showed a trend towards increased mortality vs late operation. In univariable analysis, factors associated with 6-month mortality included staphylococci and septic shock. Multivariable analysis revealed that septic shock predicted 6-month mortality. Despite early operation in patients experiencing septic shock, 57% died. No patients without heart failure died after undergoing (early or late) procedures for severe regurgitation.

The prognosis in surgically treated patients was determined by the occurrence of septic shock. The outcome in patients who underwent late operations was favorable compared with the early group. This difference was probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefit in length of hospitalization and prevention of development of new heart failure.

Neuropsychological data were gathered from 46 healthy controls, 42 cardiac patients referred for percutaneous coronary intervention (PCI), and 43 cardiac patients referred for coronary artery bypass grafting (CABG). Fourteen cognitive function tests were utilized at baseline and at three time points after surgery (3 weeks, 4 months, 1 year). Measures showing acceptable test-retest reliability based on intraclass correlations were compared using regression-based reliable change indices.

No clear pattern of group differences or change at follow-up emerged. A greater percentage of CABG patients than controls worsened in seven tests (three at 1 year), but a greater percentage of PCI patients than controls also worsened in seven tests (three at 1 year). Generalized estimating equations showed only two tests (Wechsler Adult Intelligence Scale, Third Edition, Digit Symbol, and Hopkins Verbal Learning Test, Revised, Total Recall) to be significantly different between groups from baseline to 1 year. Interestingly, compared with healthy controls, more PCI patients than CABG patients worsened in the former of those two tests, whereas more PCI and CABG patients improved on the latter.

Using healthy controls and a relevant nonsurgical comparison group to contend with important methodological considerations, current CABG procedure does not appear to create cognitive decline.

A total of 99 patients undergoing elective off-pump coronary bypass surgery were randomized to receive their proximal anastomoses with either the hand-sewn conventional technique or with the PAS-Port system. Patient follow-up consisted of multislice computed tomographic scans performed at discharge and one year postoperatively.

Three patients had to be converted to on-pump due to technical reasons. Fifty-one patients were randomly assigned to the PAS-Port group and 48 patients to the control group. In five patients in the control group severe atherosclerosis of the aorta required cross-over to the use of the PAS-Port device, and in one patient in the PAS-Port group conversion to a hand-sewn anastomosis. Sequential anastomoses were performed in 88% of the control group and 73% of PAS-Port group grafts. Time needed for completion of the proximal anastomosis including graft loading was 187 ± 19 seconds for the PAS-Port group and 406 ± 34 seconds for the control group (p < 0.001). One patient died unrelated to cardiac events due to septic multiorgan failure and one stroke was observed in the control group. There was a trend toward a lower rate of postoperative delirium in the PAS-Port group (11.7% vs 25%, p = 0.088). Patency at discharge (100% PAS-Port group vs 97.8% control group) and after one year (97.8% PAS-Port group vs 93.7% control group) were comparable. One patient of the PAS-Port group died during long-term follow-up as a result of a severe stroke due to cerebrovascular disease.

This prospective randomized study demonstrated excellent short and midterm patency in both the hand-sewn and PAS-Port grafts. The PAS-Port system allowed for the rapid, safe, and effective creation of a proximal anastomosis without the need to clamp the aorta. Based on this study we consider this product a valid alternative for proximal anastomosis, especially in patients with severe aortic disease, to avoid side clamping of the aorta.

Between June 2006 and October 2007, 7 patients with long-segment left anterior descending artery in-stent stenosis were operated on in our institution. Two of the operations were off pump with minimally invasive techniques, whereas the latter 5 patients were operated on through cardiopulmonary bypass.

All patients were male, except for the last patient; their ages were between 43 and 71 years (59.67 ± 12.36). They all had received an intracoronary stent for the left anterior descending artery (3 to 11 months before surgery). The first 2 operations were minimally invasive off-pump procedures; however, the latter 5 were with cardiopulmonary bypass. Mean follow-up was 6.33 ± 4.13 months, and a postoperative coronary angiogram was performed on all the patients.

Although long-segment in-stent stenosis complicates subsequent coronary artery bypass grafting operations, stent removal with coronary endarterectomy seems to be the technique of choice because it is effective and safe.

Based on patient files and register data we performed a review of 64 consecutive patients with ventricular septal rupture complicating acute myocardial infarction, admitted to our tertiary center.

The mean age of the patients was 70 ± 7. The median time was five days from onset of symptoms to the diagnosis of the ventricular septal rupture. The overall 30-day, one-, and five- year mortalities were 62%, 72%, and 95%, respectively. Medical treated patients (n = 19) had a 30-day mortality of 100%. Among surgically treated patients (n = 45) the survival at one month, one and five years was 71%, 48%, and 32%, respectively. History of hypertension, complicating congestive heart failure, and age were associated with poor outcome.

Despite improvements in medical and interventional techniques the early as well as the long-term prognosis remains poor in this contemporary series.

Since 1993, 93 patients aged 75 years and older have undergone open (n = 41) or endovascular (n = 52) descending aortic repair. Intervention indications included aneurysms, dissection, or traumatic injury. Mean maximum aortic diameter was 6.1 cm. Contained rupture was more frequent in TEVAR (p = 0.005); 52 needed arch repair, and 46 needed total descending repair.

The mean age was 78.9 years (TEVAR, 80.6 vs DTAR, 76.9; p < 0.0001). The TEVAR patients had more significant comorbidities; 42 (80.8%) were prospectively identified as nonoperative candidates. Thirty-day mortality was higher in DTAR at 7 (17.1%) vs TEVAR at 3 (5.7%, p = 0.1). The composite end point of 30-day death, stroke, permanent paralysis, or dialysis requirement was similar (TEVAR, 9; DTAR, 10; p = 0.45). Median postoperative length of stay was shorter in TEVAR (6 days) vs DTAR (13 days; p = 0.003). Endoleaks were observed in 12. Actuarial survival at 48 months was similar (mean survival: TEVAR, 30.2 months vs DTAR, 33.7 months; p = 0.49).

Despite more complex preoperative comorbidities, the TEVAR group had shorter hospitalization, a trend towards a reduction in early mortality, and similar late outcomes. This comparative analysis suggests that thoracic endovascular repair may be a more suitable therapeutic option in this complex elderly group.

A post hoc analysis of a prospectively collected consecutive series of 136 patients presenting with surgical diseases of the descending aorta between January 2001 and December 2005 was conducted. Fourteen patients were excluded because of involvement of the ascending aorta. Assessed treatment cohorts were TEVAR (n = 52) and OAR (n = 70). Mean follow-up was 34 ± 18 months. End points were perioperative and late mortality rates and long-term quality of life as assessed by the Short Form Health Survey (SF-36) and Hospital Anxiety and Depression Score questionnaires.

Mean age was significantly higher in TEVAR patients (69 ± 10 years versus 62 ± 15 years; p = 0.002). Perioperative mortality rates were 9% (OAR) and 8% (TEVAR), respectively (p = 0.254). Accordingly, cumulative long-term mortality rates were similar in both cohorts. Overall quality-of-life scores were 93 (63–110, OAR) and 83 (60–112, TEVAR), respectively. Normal quality-of-life scores range from 85 to 115. Anxiety and depression scores were not increased after open surgery.

Thoracic endovascular aortic repair and OAR both provide excellent long-term results in treatment of thoracic aortic disease. Long-term quality of life, however, is reduced after thoracic aortic repair. Interestingly, TEVAR patients did not score higher in overall quality of life despite all advantages of minimized access trauma. Similarly, anxiety and depression scores are not reduced by TEVAR, possibly reflecting a certain caution against the new technology.

Perioperative data of 567 consecutive patients who underwent surgery of the aortic arch using deep hypothermic circulatory arrest have been analyzed. Patients were divided into three groups, according to the management of cerebral protection. Three hundred eighty-seven patients (68.3%) had deep hypothermic circulatory arrest with pharmacologic protection with pentothal only, 91 (16.0%) had selective antegrade cerebral perfusion and pentothal, and 89 (15.7%) had continuous cerebral perfusion through the right subclavian artery and pentothal. All in-hospital data were assessed, and quality of life was analyzed prospectively 2.4 ± 1.2 years after surgery with the Short Form-36 Health Survey Questionnaire.

Major perioperative cerebrovascular injuries were observed in 1.1% of the patients with continuous cerebral perfusion through the right subclavian artery, compared with 9.8% with selective antegrade cerebral perfusion (p < 0.001) and 6.5% in the group with no antegrade cerebral perfusion (p = 0.007). Average quality of life after an arrest time between 30 and 50 minutes with continuous cerebral perfusion through the right subclavian artery was significantly better than selective antegrade cerebral perfusion (90.2 ± 12.1 versus 74.4 ± 40.7; p = 0.015).

Continuous cerebral perfusion through the right subclavian artery improves considerably perioperative brain protection during deep hypothermic circulatory arrest. Irreversible perioperative neurologic complications can be significantly reduced and duration of deep hypothermic circulatory arrest can be extended up to 50 minutes without impairment in quality of life.

Between May 2002 and February 2007, 107 patients with initial femoral artery cannulation for the repair of type A aortic dissection were enrolled in this study. The mean age was 63.7 ± 11.8 years; 51 patients were female. Preoperative findings indicated malperfusion in 16 patients. Intraoperative malperfusion syndrome was diagnosed by both radial arterial pressure measurements and transesophageal echocardiography. Clinical outcomes, including specific operative procedures and complications related to the cannulation, were assessed.

The ascending aorta was replaced in 59 patients, hemiarch in 16, and total aortic arch in 32. Intraoperative malperfusion syndrome was noted in 3 patients (lowering of radial pressure in 2, obstruction of the true lumen in 1) at the initiation of cardiopulmonary bypass. After immediately switching to transventricular cannulation, the surgical replacement was successfully performed. The remaining 104 patients underwent surgery during femoral artery bypass without perfusion abnormalities. There was 1 in-hospital death (0.9%), but no deaths among the malperfusion patients. Cerebrovascular deficit occurred in 7 patients (6.5%). One vascular and 3 wound complications occurred related to the femoral cannulation.

During the repair of acute ascending aortic dissection, malperfusion syndrome related to femoral artery cannulation has an acceptable incidence, and can be managed under appropriate intraoperative monitoring, particularly at the initiation of cardiopulmonary bypass.

From July 2005 to present, 26 patients presenting with blunt aortic injury were treated with thoracic aortic endografting; these patients were retrospectively compared with the prior 26 patients presenting with similar aortic injury who were treated by open surgical repair. A Severity Characterization of Trauma score calculated for each patient predicts mortality based on severity of injury and degree of physiologic derangement on presentation.

Patients treated with endografting had a significantly shorter length of stay, less intraoperative blood loss, decreased 24-hour blood transfusion, and lower incidence of postoperative tracheostomy compared with patients undergoing open repair. Survival in both groups was similar despite a trend toward higher injury severity among patients treated with endografting.

This early experience suggests that aortic endografting may provide a safe and efficient treatment of aortic tears that cardiac surgeons can be successful in employing.

Square specimens, oriented in the longitudinal and circumferential directions, were excised from the left coronary, right coronary, and noncoronary porcine sinuses. Tissue thickness was measured, and specimens were subjected to equibiaxial mechanical testing. Stress-strain data corresponding to a 35% stretch were fitted to a Fung strain energy function. Tissue stiffness and anisotropy were compared at 0.3 strain.

The circumferential direction was more compliant than the longitudinal one for left coronary (183.03 ± 40.78 kPa versus 231.17 ± 45.38 kPa, respectively; p = 0.04) and right coronary sinuses (321.74 ± 129.68 kPa versus 443.49 ± 143.59 kPa, respectively; p = 0.02) at 30% strain. No such differences were noted for noncoronary sinuses (331.74 ± 129.68 kPa versus 415.98 ± 191.38 kPa; p = 0.19). Left coronary sinus was also significantly more compliant than right and noncoronary sinuses. There were no differences between right coronary and noncoronary sinus tissues.

We demonstrate that the material properties of the porcine aortic sinuses are not symmetric. The left coronary sinus is significantly more compliant than the remaining sinuses. Realistic modeling of the aortic root must take into account the asymmetric differences in tissue material properties of the aortic sinuses.

A multiinstitutional risk factor analysis of the CardioWest total artificial heart, as a bridge to transplantation in 81 patients, was conducted. Univariate analyses were performed on 43 preimplantation prognostic factors. From this group, eight factors were chosen for multivariate analysis. Our results were compared with all recent risk factor analyses for other devices.

Independent predictors for death at three intervals by multivariate analysis were as follows: "implant to transplant": history of smoking (odds ratio, 34); "implant to 30 days after transplant": history of smoking (odds ratio, 10.00), prothrombin time greater than 16 seconds (odds ratio, 4.76); and "implant to 1 year after transplant": prothrombin time greater than 16 seconds (odds ratio, 3.85). The major difference between this experience and multiple reported experiences with left ventricular assist devices is that for left ventricular assist devices, but not for the temporary CardioWest total artificial heart, right heart failure, high central venous pressure, and being on a ventilator (with or without sepsis) were independent predictors of mortality.

Risk factors for bridge to transplantation with the CardioWest total artificial heart are different from those reported for left ventricular assist devices. Recognition of these risk factor differences may facilitate appropriate device selection.

To determine whether left ventricular assist device exchange can be accomplished with low morbidity and mortality, we retrospectively reviewed the records of 14 patients who experienced pump malfunction and subsequently required replacement of their HeartMate XVE left ventricular assist devices with HeartMate II axial-flow pumps. We collected data regarding duration of support and reasons for pump failure, perioperative characteristics, and operative approach.

On average, patients were supported 473 ± 233 days with HeartMate XVE pumps. Seven early patients required both subcostal and sternotomy incisions; 7 later patients had subcostal incisions only. Thirteen patients underwent successful exchange to the HeartMate II; 1 patient died in the operating room. Another patient died in the perioperative period (30-day mortality, 14% [2 of 14]). There were significant differences between the two groups. The patients who required only subcostal incisions had shorter operative times (187 versus 220 minutes; p = 0.04) and required fewer transfused blood products (packed red blood cells, 8.6 versus 28.7 units; p = 0.03; and fresh-frozen plasma, 12.4 versus 30.9 units; p = 0.04). Additionally, the patients with subcostal incisions had shorter postoperative intensive care unit stays (5.3 ± 1.1 versus 8.4 ± 3.1 days for redo sternotomy patients; p = 0.03). Of the survivors, average hospital stay was 22 ± 14 days. Average long-term follow-up was 11.2 ± 7.8 months; 71% (10 of 14) of patients are currently alive.

Exchange of a HeartMate XVE to a HeartMate II can be accomplished with relatively low morbidity and mortality through a subcostal approach.

This is a retrospective review of all Abiomed (BVS5000, AB5000) and Thoratec (PVAD and IVAD) ventricular assist devices from May 2003 through May 2006 at a single institution. Postoperatively, patients received either heparin or argatroban as their anticoagulant. Patients in whom heparin-induced thrombocytopenia was suspected or confirmed were converted from heparin to argatroban.

There were 33 Abiomed and Thoratec ventricular assist devices implanted. Thirteen patients received heparin as their primary postoperative anticoagulant; 8 of the 13 were converted to argatroban as a secondary anticoagulant (hep-arg), and 5 patients remained with heparin as their only anticoagulant. Twenty patients received argatroban as their primary and only postoperative anticoagulant. Thrombocytopenia occurred in 26 patients (79%) overall, 16 (80%) with argatroban only, 6 (75%) with hep-arg, and 4 (80%) with heparin only. Thromboembolic events occurred in 5 patients (15%) overall, 3 (15%) with argatroban only, 1 (13%) with hep-arg, and 1 (20%) with heparin only. Postoperative bleeding requiring reexploration occurred in 5 patients overall (15%), 1 with argatroban only (5%), 3 (38%) with hep-arg, and 1 (20%) with heparin only. Enzyme-linked immunosorbent assay heparin-induced thrombocytopenia tests were positive in 7 patients overall (21%), 5 (25%) with argatroban only, 2 (25%) with hep-arg, and 0 (0%) with heparin only.

Argatroban is a comparable primary or secondary anticoagulant to heparin postoperatively in patients receiving ventricular assist devices.

In vitro functional and phenotypic markers of T cell activation and 6 month clinical outcome were compared between patients with ≥6-month LVAD therapy and heart failure control patients.

Recipients of LVADs had more infections (45.5% versus 0%; p < 0.05) and mortality (54% versus 16%; p < 0.05) than control patients. T-cell proliferative responses were lower among LVAD recipients than control patients when challenged with phytohemagglutinin (3.4 ± 4.7 versus 28.5 ± 19.6; p < 0.01), anti-CD3 (4.3 ± 4.5 versus 16.4 ± 17; p < 0.01), and staphylococcal enterotoxin B (7.2 ± 6.3 versus 26.1 ± 15.6; p = 0.002). Proliferative hyporesponsiveness among LVAD recipients was not caused by apoptosis (2.6% ± 2.7% versus 2.7% ± 2.1%; p = 0.94) or insufficient CD4+ cells (42.1% ± 11.3% versus 40.2% ± 7.5%; p = 0.71) relative to control patients. Instead, CD3+ cells from LVAD patients expressed less interleukin 2 (2.5% ± 1.5% versus 5.2% ± 3.1%; p = 0.03) and tumor necrosis factor- (6.0% ± 3.5% versus 25.8% ± 8.7%; p < 0.001) and more interleukin 10 (5.8% ± 6.1% versus 2.6% ± 2.1%; p < 0.05). In addition, suppressive T-regulatory cells were more prevalent in LVAD patients than control patients (12.9% ± 3.2% versus 1.2% ± 1.1%; p < 0.001).

Cellular immunity is compromised among long-term LVAD recipients because of a downregulatory cytokine imbalance and emergence of suppressive T-regulatory cells.

A total of 761 consecutive adult patients who underwent off-pump coronary artery bypass grafting were retrospectively reviewed. The majority (87%) received aspirin preoperatively. Heparin was intravenously administered for a kaolin-based activated clotting time of greater than 300 seconds. Aprotinin was administered as a 1 million or 2 million kallikrein inhibiting unit bolus to 391 patients after median sternotomy. The control group (n = 370) underwent surgery during the same period without receiving aprotinin. Blood loss was measured intraoperatively (cell-saving device) and postoperatively by quantifying mediastinal chest tube drainage.

Aprotinin was associated with a significant reduction in postoperative blood loss (p < 0.001) and less excessive postoperative hemorrhage (p < 0.001) compared with the control group. Transfusion rates and amount of blood products administered were also reduced by aprotinin (p < 0.01 for both). Significantly more patients in the aprotinin group were free of any blood product transfusion (54.7%) compared with the control group (41.4%; p < 0.01). The safety profile was comparable between aprotinin and control patients.

Aprotinin proved efficacious and safe in the reduction of postoperative bleeding and transfusion requirements in patients undergoing off-pump coronary artery bypass grafting.

A retrospective review evaluating 846 complex cardiovascular surgery patients of whom 36 received rFVIIa between January 1, 2001, and December 31, 2006, was performed. Efficacy and safety data were collected for the entire cohort in addition to delayed sternal closure requirements, reoperation, and operative mortality in the patient cohort temporally separated into two groups (pre-rFVIIa era, 2001 to 2003, 1 patient received rFVIIa; rFVIIa era, 2004 to 2006, 35 patients received rFVIIa).

A total of 36 patients received 41 rFVIIa doses with an in-hospital survival of 91.7%. Hemorrhage was controlled in 83.3% of patients, with 1 dose sufficient in 75.0%. There was a significant decrease (p < 0.005) in all blood product requirements post-rFVIIa compared with pre-rFVIIa administration. In the intensive care unit (n = 6), rFVIIa significantly reduced chest tube output (p = 0.028) and prevented reexploration for bleeding in 5 patients. The requirement for delayed sternal closure was significantly higher in the pre-rFVIIa era versus the rFVIIa era (p = 0.011). The incidence of thrombosis in all patients receiving rFVIIa was 11.1%. In the rFVIIa era, a higher incidence of postoperative renal failure (p = 0.005) and pneumonia (p < 0.002) was detected in patients receiving rFVIIa.

Recombinant activated factor VII appears to be effective in patients with refractory coagulopathy undergoing high-risk cardiovascular surgery.

Isolated hearts from wild-type mice, two strains of TLR4 mutants, TNF- knockouts, and IL-1β knockouts underwent global ischemia/reperfusion. Cardiac contractile function was analyzed, and myocardial nuclear factor-B activity and TNF- and IL-1β levels were measured.

In wild-type hearts, global ischemia/reperfusion induced nuclear factor-B activation and the production of TNF- and IL-1β peptides. In TLR4-mutant hearts, these changes were significantly reduced and postischemic functional recovery was improved. Application of TNF- and IL-1β to TLR4-mutant hearts abrogated this improvement in postischemic functional recovery. Postischemic functional recovery also improved in TNF- knockout and IL-1β knockout hearts, as well as in wild-type hearts treated with TNF-binding protein or IL-1 receptor antagonist.

This study demonstrates that TLR4 signaling contributes to cardiac dysfunction after global ischemia/reperfusion. TLR4 signaling mediates the production of TNF- and IL-1β peptides, and these two cytokines link TLR4 signaling to postischemic cardiac dysfunction.

Between 1979 and 2007, 20 consecutive patients underwent correction of atrioventricular septal defect and tetralogy of Fallot. Five patients had undergone prior palliative shunts. In all patients, a transatrial-transpulmonary approach was used and repair was accomplished without a conduit. The two-patch technique was used to correct the atrioventricular septal defect. Clinical data were obtained by retrospective review of inpatient and outpatient clinical charts.

There was no in-hospital mortality and one late, noncardiac death. Six patients required eight reoperations, six for left atrioventricular valve insufficiency (repair: n = 4; replacement: n = 2), one for residual ventricular septal defect, and one for pulmonary artery branch obstruction. Follow-up was complete for all patients (median, 17 years; range, 1.5 to 28 years). All 19 survivors were in good clinical condition at last control, without medication, and in New York Heart Association class I (n = 18) or II (n = 1). Transesophageal echocardiography revealed good right ventricular function, low right ventricular outflow tract gradients (mean, 9 ± 7.4 mm Hg), and trace pulmonary valve insufficiency (n = 11).

Atrioventricular septal defect and tetralogy of Fallot can be repaired with low mortality by the transatrial-transpulmonary approach without the use of a conduit.

As of October 1, 2007, 239 patients with HLHS and related malformations underwent surgical treatment at the Congenital Heart Institute of Florida. This manuscript focuses on the 199 initially treated with Norwood stage 1.

One hundred and ninety-nine patients were initially treated with Norwood stage 1. Univariate analysis demonstrated the following significant predictors of mortality: rig