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The article announces that Michael J. Reardon and Stephen Little have been appointed as associate editors of the journal.

Background: In patients with heart failure secondary to left ventricular (LV) systolic dysfunction, a short deceleration time (DT) successfully predicts clinical outcome. The impact of myocardial viability and revascularization on the mitral inflow velocities, however, is unknown., Methods and Results: Forty patients with ischemic cardiomyopathy underwent (201)Tl scintigraphy (SPECT) and 2D, Doppler, and dobutamine echocardiography (DE, to 40 microg. kg(-1). min(-1)) 2 days before CABG. Echocardiography was repeated 3 months after revascularization to determine recovery of function. Significant correlations were present between DT and LV contractile reserve by DE (r=0.72), scar perfusion defect by SPECT (r=-0.69), and the change in ejection fraction (DeltaEF) after surgery (r=0.77) (all P:<0.01). DT >150 ms effectively identified (sensitivity 79%, specificity 81%) patients with DeltaEF >/=5%. The population was divided into 2 groups according to DT: group 1 (DT >150 ms, n=21) and group 2 (DT

Use of the autologous pulmonary valve for replacement of a diseased aortic valve (Ross procedure) was introduced in the late 1960s but has gained widespread use only in the last 10 to 15 years. Part of the reason for the delay in acceptance of this surgical procedure has been its perceived complexity. We describe herein the technical aspects of the Ross procedure as it is performed at our surgical service.

We describe our technique for harvesting the radial artery for coronary revascularization. Anatomy and preoperative preparation are also presented, as well as the history of the radial artery as a bypass conduit, the advantages, and some contraindications. We have found that, with proper harvesting, the radial artery is an effective means of coronary artery revascularization.

Objectives: We sought to evaluate the relation of segmental tissue Doppler (TD) velocities to both the regional amount of interstitial fibrosis and the myocyte beta-adrenergic receptor density in humans., Background: The systolic myocardial velocity (Sm) and early diastolic myocardial velocity (Em) acquired by TD are promising new indexes of left ventricular function. However, their structural and functional correlates in humans are still unknown., Methods: Ten patients with coronary artery disease underwent echocardiographic examination including TD imaging, along with transmural endomyocardial biopsy at the time of coronary bypass surgery (two biopsies per patient for a total of 20 specimens). The specimens were analyzed for percent interstitial fibrosis and beta-adrenergic receptor density., Results: Normal segments (n = 8) had a higher beta-adrenoceptor density (2,280 +/- 738 vs. 1,373 +/- 460, p = 0.03) and a lower amount of interstitial fibrosis (13 +/- 3.3% vs. 28 +/- 11.5%, p = 0.002) than dysfunctional segments (n = 12). Myocardial systolic velocity and Em were also significantly higher (9.5 +/- 2.7 vs. 5.9 +/- 1.8 cm/s, p = 0.025 and 11.3 +/- 2.8 vs. 6.4 +/- 2.1 cm/s, p = 0.002, respectively) in normal segments. A significant relationship was present between Em and the beta-adrenergic receptor density (r = 0.78, p < 0.001) and percent interstitial fibrosis (r = -0.7, p = 0.0026), which together accounted for 81% of the variance observed in Em. Likewise, a significant relationship was present between Sm and the beta-adrenergic receptor density (r = 0.68, p < 0.001) and the percent interstitial fibrosis (r = -0.66, p = 0.004) and together accounted for 62% of the variance observed in Sm., Conclusions: Systolic myocardial velocity and Em are strongly dependent on both the number of myocytes and the myocardial beta-adrenergic receptor density.

Mediastinal thymic cysts are usually asymptomatic and found incidentally on a routine chest roentgenogram. Rarely, they may cause symptoms of vascular obstruction. A 55-year-old woman presented with intermittent swelling in her left neck. The swelling was positional and was worse while supine and disappeared while upright. Evaluation revealed a thymic cyst causing extrinsic compression of the left brachiocephalic vein. The cyst was resected with complete resolution of the left neck swelling.

Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal fistula, secondary to thoracic aortic aneurysm, but techniques used have varied. We report a successful repair of primary aortoesophageal fistula, secondary to descending thoracic aortic aneurysm, and review the evolution of management since the three previously reported successful repairs at our institution.

For many years, pleural effusions have been recognized as a complication of cirrhosis, occurring in approximately 5.5% of patients. Recent studies have confirmed that small defects in the diaphragm allow for passage of ascitic fluid into the pleural space. Successful management of these patients is challenging, as many of the treatment options can be associated with increased morbidity. The initial treatment should focus on eliminating and preventing the recurrence of ascites with diuretics and water and salt restriction. For those patients who do not respond medically, more invasive techniques have been used including serial thoracentesis, chest tube placement, chemical pleurodesis, and peritoneovenous shunts. We present a patient with recurrent pleural effusions secondary to hepatic cirrhosis who was unsuccessfully treated medically, and subsequently treated with thoracentesis, chest tube drainage and pleurodesis, with ultimate resolution after transjugular intrahepatic portosystemic shunt placement.

Esophagectomy after pneumonectomy has been reported rarely, and the surgical approach presents a challenge. We report a case of a transthoracic esophagectomy in a 54-year-old man who had undergone right pneumonectomy for non-small cell lung cancer 16 years previously.

There are few reports of a surgical approach to T4 lung carcinoma that has invaded the heart. Although most cases will be considered inoperable, cases in which there is potential for complete resection and no distant or nodal metastatic disease (T4 N0 M0, Stage IIIB) may be considered for surgical therapy. We report a case of squamous cell carcinoma of the lung with cardiac involvement, in which we performed a completion pneumonectomy using total cardiopulmonary bypass. We describe indications and techniques for use of cardiopulmonary bypass in such cases.

The long QT syndrome (LQTS) is a rare inherited cardiac disorder that may induce fatal cardiac arrhythmias. Patients diagnosed with this disorder generally have several treatment options, including beta-blockade, cardiac pacing, an implantable automatic defibrillator, or a high thoracic left sympathectomy. We report the case of a 6-year-old girl with the LQTS treated by left thoracoscopic sympathectomy and stellate ganglionectomy. The procedure was performed after an initial thorascopic attempt at another institution failed due to inadequate resection of the sympathetic chain. Operative time was 85 min and blood loss was minimal. There were no intraoperative or postoperative complications. The girl's QT interval decreased and she was discharged on the 4th postoperative day. After 9 months of follow-up, she remains asymptomatic. We conclude that the LQTS patients who fail medical treatment can be treated successfully with left thoracoscopic cervicothoracic sympathectomy. We recommend that the extent of sympathectomy for treating the LQTS be T1-T4 and either the entire stellate ganglion or at least the inferior one-third.

Uteroglobin/CCSP is expressed specifically in the Clara cells. This allows the gene to be used as a marker to identify the elements regulating the physiologic and cell-specific expression of this gene. The regulation of UG/CCSP by IFN-gamma was shown to be at the level of the proximal promoter by the upregulation of HNF3 beta. This has allowed the determination of the factors responsible for the expression of UG/CCSP.

The coexistence of pheochromocytoma and other tumor types in a single adrenal gland has been rarely documented. This type of pheochromocytoma is designated "composite" or "mixed," depending on whether the pheochromocytoma and the nonpheochromocytoma components show the same embryologic origin. The nonpheochromocytoma components reported in the composite pheochromocytoma include ganglioneuroma, ganglioneuroblastoma, neuroblastoma, and malignant schwannoma. The components found in the mixed pheochromocytoma include adrenal cortical neoplasms and spindle cell sarcoma. We report a unique case of composite pheochromocytoma in which the nonpheochromocytoma element is a neuroendocrine carcinoma. The histologic and the immunohistochemical profiles of the 2 distinct components of this tumor were typical for those of pheochromocytoma and neuroendocrine carcinoma. This dual differentiation was also supported by ultrastructural findings. This case not only broadens the morphologic spectrum of composite pheochromocytoma but also provides some additional insight into the histogenesis of this rare but fascinating type of tumor.

Background: The results of pulmonary transplantation are compromised by acute and chronic rejection. We hypothesized that a liposomal form of aerosolized cyclosporine A (CsA) would be selectively deposited and concentrated in the lungs. The theoretical advantage of this therapy is selective pulmonary immunosuppression with prolonged utilization., Methods: Eighteen dogs were endotracheally intubated; aerosolized liposomal CsA was administered for 15 min. CsA levels were measured in whole blood, lung, trachea, heart, kidney, liver, and spleen at various times after treatment., Results: The lung rapidly absorbs aerosolized liposomal CsA; other organs have much lower concentrations. The retention of pulmonary CsA delivered by liposome aerosol is approximately 120 min in this model., Conclusions: Aerosolized liposomal CsA is selectively deposited and concentrated in the lungs; other organs absorb less CsA.

Objective: Despite many technological advances in cardiovascular surgery, some patients still experience postcardiotomy left ventricular (LV) failure that is refractory to both inotropic support and intra-aortic balloon pump (IABP) placement. The primary author (MJR) recently changed from inflow cannulation at the right superior pulmonary vein/left atrial junction to inflow cannulation at the dome of the left atrium. The purpose of this study was to compare data collected during placement of a left ventricular assist device (LVAD) at the junction of the right superior pulmonary vein with positioning the device in the dome of the left atrium. Experimental design, setting, and participants: the medical records of all patients undergoing cardiac surgery by one author (MJR) between 1994 and 1997 were retrospectively reviewed, and 4 patients requiring LVAD placement for short term postcardiotomy support were identified. Each patient's chart was reviewed for duration of LVAD support, average LVAD blood flows, pulmonary capillary wedge pressures (PCWP), preoperative characteristics, postoperative complications, and final outcome for the patients., Results: Accessing the left atrium through the dome resulted in excellent blood flow through the LVAD and allowed for good LV decompression. Hemostasis remained the most common complication regardless of the technique employed; however, the enhanced visibility provided by accessing the left atrium via the dome made repairs less technically difficult. Three patients (75%) were able to be weaned from the LVAD and were discharged from the hospital to home. Two of these patients were cannulated via the left atrial dome making removal of the LVAD easier, thus exposing the patients to less additional operative time. One patient could not be weaned from LVAD support secondary to development of right ventricular failure requiring RVAD insertion and subsequent development of multiple organ failure syndrome., Conclusions: Patients requiring LV assistance following cardiopulmonary bypass surgery traditionally have high levels of morbidity and mortality. In spite of the complications associated with the placement of an assist device, we remain encouraged by the excellent LV decompression and systemic flows we achieved following implantation of the LVAD through the dome of the left atrium. The superior ease of implantation and decannulation provided better operative care and postoperative management for our patients.

Background: Although dobutamine echocardiography (DE) is widely used to assess myocardial viability in humans, little is known about the relation between contractile reserve and myocardial structure., Methods and Results: We evaluated 20 patients with coronary disease (64+/-13 years old, ejection fraction 28+/-7.5%) with DE (up to 40 micrograms . kg(-1). min(-1)), rest-redistribution (201)Tl single photon emission CT, and quantitative angiography before bypass surgery. During surgery, patients underwent transmural myocardial biopsies (n=37) guided by transesophageal echocardiography to determine the extent of interstitial fibrosis and intracellular and interstitial proteins by histopathology and immunohistochemistry. Among the 37 segments biopsied, 16 recovered function as assessed 2 to 3 months later. Segments with postoperative functional recovery had more wall thickening at low-dose DE (28% versus 3%, P<0.001), higher thallium uptake (69% versus 48%, P=0.03), and less interstitial fibrosis (2% versus 28%, P<0.001). Quantitative angiographic parameters did not predict recovery of function. Segments with DE viability (contractile reserve and/or ischemia) had less fibrosis (2.7% versus 28%, P<0.001), less vimentin and fibronectin (both P<0.01), more glycogen (P=0.016), and higher thallium uptake (64% versus 35.5%, P<0.05) than those without viability. Viable segments by both DE and thallium had less fibrosis (1%) than those viable by 1 of the 2 techniques (9%) or not viable by both (28%, P=0.005). Thickening at low-dose DE correlated well with the extent of interstitial fibrosis (r=-0.83, P<0.01)., Conclusions: Contractile reserve during DE correlates inversely with the extent of interstitial fibrosis and the amount of fibronectin and vimentin and directly with rest-redistribution thallium uptake.

Because of their anatomic location, cardiac sarcomas often interfere with cardiac function. Excision is considered to palliate the cardiac defect, but complete excision is often difficult owing to access, particularly in left atrial tumors. Incomplete resection results in tumor recurrence. To achieve complete resection of a large left atrial sarcoma, we used the technique of cardiac explantation, extracorporeal resection of the tumor with cardiac reconstruction, and cardiac autotransplantation.

Multifunction display and control systems (MFDCSs) in modern cockpits use computer-generated graphics and symbology that have integrated and largely replaced the myriad discrete electromechanical flight instruments found in older aircraft. While much is known about the physical and visual properties of MFDCSs, less is known about which human factors are the most important for optimum design and use. Reports in the literature indicate that poor MFDCS design can adversely influence flight performance. However, current MFDCS content design methods do not quantify the relative importance of different cognitive and psychomotor factors. This article discusses the need for practical human factors-oriented MFDCS design tools to optimize the distribution of systems information and functionality. Such advances may lead to better designed MFDCSs that reduce aircrew workload and stress and improve flight performance during both routine and emergency procedures.

Although neurogenic tumors are the most frequent posterior mediastinal tumors, few reports exist on thoracoscopic resection, and methods are not yet standardized. Two cases of thoracoscopic resection of benign posterior mediastinal schwannomas are presented. We believe that in carefully selected patients, thoracoscopic resection can be performed easily and with minimal morbidity.

Traumatic diaphragmatic hernia is not an uncommon problem and has been noted after either penetrating or blunt trauma. A high index of suspicion must be maintained in order to identify patients with this injury, as delay in identification may result in significant morbidity and death. It is essential that a thorough evaluation be performed, and if a diaphragmatic hernia is found, surgical repair is necessary. We present a case of thoracoscopic repair of an incarcerated recurrent diaphragmatic hernia appearing several years after successful open (via laparotomy) repair of an acute blunt traumatic hernia. A brief review of the surgical literature is also presented. With the broadening use of minimally invasive surgical techniques, we feel that their application to the repair of chronic diaphragmatic hernia is safe and effective, reduces morbidity, and results in a faster recovery.

We report the case of a 31-year-old woman who presented with epigastric pain and weight loss. Esophagogastroduodenoscopy revealed a submucosal mass in the distal antrum and pylorus. Endoscopic biopsy of the mass was nondiagnostic. A CT scan confirmed a 3.0-cm mass in the posterior wall of the distal antrum. She underwent laparoscopic resection of the distal antrum and pylorus with end-to-end gastroduodenostomy. Pathologic examination showed an adenomyoma of the antrum and pylorus. Her postoperative course was uncomplicated, and she continues to do well 38 months postoperatively. Gastric adenomyoma is a rare, benign intramural tumor of the antrum and pylorus. Fewer than 40 cases have been described in the literature. The lesions are generally within 4 cm of the pylorus. Histologically, they are characterized by ductal structures lined by cuboidal to columnar epithelium surrounded by smooth muscle bundles and, occasionally, Brunner's-type glands and heterotopic pancreas. Treatment is by resection, and recurrence has not been reported. Laparoscopic resection of portions of the stomach has been reported. Side-to-side gastrojejunostomies (Billroth II) performed laparoscopically have been reported. This is the first report in the English-language literature of a completely laparoscopically performed sutured gastroduodenostomy. Technical details of the procedure and adenomyomas are discussed.

Stentless xenograft aortic valves were designed to provide superior hemodynamic characteristics and durability, in comparison with stented tissue valves. The senior author (MJR) has implanted 46 St. Jude Toronto stentless porcine valves--with excellent hemodynamic results and no aortic insufficiency--since this valve was released by the Food and Drug Administration in November 1997. Because the implantation technique is significantly different from that of implanting a stented valve, and because proper implantation is critical for proper valve function and avoidance of aortic insufficiency, we discuss our technique in some detail.

Cadaveric dissections were carried out to examine the relationship of the cardiac valve structures to the surface anatomy of the chest as it relates to our approaches to minimally invasive valvular operations. The techniques of upper hemisternotomy and lower hemisternotomy as used at our institution are described.

Mitral valve replacement with a mitral valve allograft is receiving a resurgence of interest. We discuss the technical aspects of this procedure as it applies to cases of acute bacterial endocarditis infecting the mitral valve.

Homograft use for aortic valve replacement (AVR) in aortic valve acute bacterial endocarditis (ABE) has gained in popularity, due mainly to the relative resistance of homografts to infection. Recent success with mitral valve homograft use led us to apply homograft mitral valve replacement (MVR) in a patient with severe ABE that was not amenable to valve repair. Following surgery, the patient improved rapidly with normalization of infection parameters and chest radiography, and was discharged home on postoperative day 11. Follow up echocardiography showed good function of the homograft mitral valve with no regurgitation. After four months, the patient had normal valve function, with no evidence of infection. In conclusion, MVR with a mitral valve homograft in the setting of ABE was satisfactory, though patient follow up was relatively short (four months).

In conclusion, surgical myocardial revascularization has utilized diverse methods to increase blood flow to the starving myocardium. These methods initially used the microcirculation as the portal to reach myocytes until angiography showed that the obstructions were macrovascular. This resulted in a 30-year era of direct attack on the coronary blockages by coronary bypass. Surgical conduits unfortunately have longevity considerably less than that of native arteries and are limited in number. Alternative conduits, both biologic and prosthetic, have not yet proved to have the same clinical results as the ITA. More patients are living long enough to have the extensiveness of their disease exhaust conventional therapies. Newer therapy, restricted thus far to untreatables, revisits the microcirculation by making laser channels. These many innovative procedures have benefited hundreds of thousands of patients. They emerged from the probity and innovation of many individual surgeons.

Background: In previous studies of the neurologic outcome of patients undergoing thoracoabdominal aortic aneurysm repair with the simple cross-clamp technique, cross-clamp time of greater than 30 minutes was identified as an important risk factor. We retrospectively examined the effect of clamp time of 30 minutes or greater on outcome for patients undergoing repair with the addition of surgical adjuncts., Methods: Between February 1991 and June 1996 we operated on 370 patients for thoracoabdominal or descending thoracic aortic aneurysm. Two hundred seventy-one of these patients with cross-clamp times of 30 minutes or greater were included in this study. One hundred twelve patients underwent simple cross-clamp repair, whereas 159 were operated on with the surgical adjuncts of distal aortic perfusion and cerebrospinal fluid drainage., Results: By multivariate analysis, acute dissection, surgical adjuncts, and aneurysm extent proved most significant in overall patient outcome. The overall rate of early neurologic deficits was 23 of 271 (8.5%). For highest risk patients with type II thoracoabdominal aortic aneurysms, the rate of neurologic deficits was 11 of 29 (38%) for cross-clamp versus 6 of 82 (7.3%) for adjunct operation patients (odds ratio = 0.13; p < 0.001)., Conclusions: The adjuncts of cerebrospinal fluid drainage and distal aortic perfusion decreased the risk of extended cross-clamp time during thoracoabdominal aortic aneurysm repair, particularly for highest risk type II.

Purpose: Although some authors advocate hypothermic circulatory arrest for spinal cord protection in descending thoracic and thoracoabdominal repair, this method has been associated with high morbidity and mortality rates in other studies. The safety and effectiveness of this surgical adjunct were evaluated., Methods: Between February 1991 and April 1997, 409 patients underwent thoracic or thoracoabdominal aortic repair. Because of an inability to gain proximal aortic control because of anatomic or technical difficulty, hypothermic circulatory arrest was used in 21 patients (4.9%). Thirteen patients were men, 8 were women, and the median age was 57 (range, 21 to 81 years). Four patients (19%) had Marfan's syndrome, and 1 had aortitis. Seven patients (33%) had aortic dissection (4 chronic type A, 2 chronic type B, 1 acute B), and 1 had aortic laceration. All but 6 patients had hypertension. Fifteen patients (73%) were operated on for repair of the distal arch and descending thoracic aorta, 4 (19%) for repair of the distal arch and thoracoabdominal aorta, and 2 for repair of either the thoracoabdominal or descending thoracic aorta alone. Surgery for 9 patients (43%) also included bypass grafts to the subclavian or innominate arteries. Six operations (29%) were urgent., Results: The overall 30-day mortality rate was 29% (6 of 21 patients). Among urgent patients, the mortality rate was 50% (3 of 6 patients) versus 20% (3 of 15) for elective patients. Of the remaining 15 patients, renal failure occurred in 1 (7%) and heart failure in 2 (13%). Ten patients (67%) had pulmonary complications. Encephalopathy occurred in 5 patients (33%) and stroke in 2 (13%), and spinal cord neurologic deficit developed in 2 (13%). The median recovery was 28 days (range, 10 to 157 days)., Conclusion: Hypothermic circulatory arrest did not reduce the incidence of deaths and morbidity to a rate comparable with our conventional methods. We recommend the judicious application of this method in rare instances when proximal control is not feasible or catastrophic intraoperative bleeding leave the surgeon with no other option.

Background: We reviewed our experience in the repair of acute and chronic aortic dissection with regard to early neurologic deficit and death., Methods: Between February 1991 and June 1996, we performed 206 operations on 195 patients for aortic dissection. Ascending or arch repair, or a combination (type A dissection) was performed on 92 of 206 patients (45%); 44 of 92 (48%) were acute dissection and 48 of 92 (52%) were chronic. Descending or thoracoabdominal repair (type B dissection) was performed on 114 of 206 patients (55%); 22 of 114 (19%) were acute and 92 of 114 (81%) were chronic., Results: Among type A cases, strokes occurred in 6 of 92 patients (7%) overall; 4 of 44 (9%) were acute cases and 2 of 48 (4%) were chronic (p < 0.34). Early deaths for type A were 11 of 92 (12%) overall; 9 of 44 (20%) acute and 2 of 48 (4%) chronic (p < 0.02). In type B cases, neurologic complications were 15 of 114 (13%) overall; 7 of 22 (32%) were acute cases and 8 of 92 (9%) were chronic (p < 0.004). Early deaths for type B were 12 of 114 (11%) overall; 3 of 22 (14%) acute and 9 of 92 (10%) chronic (p < 0.6). Preoperative hypotension was significant in acute type A patients, with strokes in 2 of 7 (29%) hypotensives compared with 2 of 37 (5%) normotensives (p < 0.05) and early death in 4 of 7 (57%) hypotensives versus 5 of 37 (14%) normotensives (p < 0.009)., Conclusions: Morbidity and mortality for repair of chronic dissection types A and B were acceptable. Preoperative hypotension in acute type A dissection was a major predisposing factor toward stroke (29% versus 5%, p < 0.05). Acute type B dissection had acceptable mortality (14%) but a high rate of neurologic complications (32%).

Mitral valve injury from blunt trauma to the chest is an uncommon entity. We report a case of mitral valve injury after a fall, and its repair. The English literature is reviewed from the earliest report in 1873 to the present. The diagnosis, types of injury and surgical correction are discussed.

The effects on flight performance of the four combinations of an unencumbered mission oriented protective posture (MOPP) aviator battle dress uniform (ABDU) and encumbered MOPP4 over ABDU flight ensemble in cool (70 degrees F or 21.1 degrees C, 50% relative humidity [RH]) and hot (100 degrees F or 37.8 degrees C, 50% RH) UH-60 simulator cockpit conditions were evaluated with a repeated measures, 2 x 2 factorial study using nine crews. The encumbered MOPP4 uniform had the most frequent adverse effect on flight performance followed by heat stress, with less frequent effects from the combination or interaction of these two factors. This study confirmed that heat stress and wearing an encumbered U.S. Army MOPP4 flight uniform significantly reduced endurance and flight performance in a UH-60 simulator.