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A nationwide contingent-valuation survey of consumer preferences for consumer fuel blends E-10 (a blend of 10% ethanol and 90% gasoline for use in standard vehicles) and E-85 (a blend of 85% ethanol and 15% gasoline for use in flex-fuel vehicles) was conducted to estimate willingness to pay (WTP) and identify key characteristics driving demand. Results indicate that overall perceptions of ethanol are positive, but ethanol is not the globally-preferred transportation-energy alternative, even among consumers with a positive WTP. Results indicate also that demand for E-85 is more price inelastic than E-10, with this result driven by consumers with no preference for E-10 but strong preferences for E-85. Finally, results also indicate that those consumers who are unsure about the micro-level benefits of E-85 are nonetheless more inclined to pay a premium.

Udgivelsesdato: 2008-Oct Energy loss is a well-established engineering concept that when applied to evaluating the performance of native heart valves and valvular prostheses has the potential for providing valuable information about the impact of valve function on myocardial performance. The concept has been understood for many years, but its routine application has been hindered not only by a lack of understanding of its meaning but also because of the lack of investigational tools to easily obtain the data necessary for its estimation. Today the gathering of that information is becoming easier, and thus the time has come to revisit the efficacy of energy loss for evaluating heart valve performance. This review defines what energy loss is, how it is measured, and how it might be applied to clinical situations of heart valve disease to better understand the impact of valvular disease on ventricular function.

uidelines for Reporting Mortality and Morbidity fter Cardiac Valve Interventions ary W. Akins, MD, D. Craig Miller, MD, Marko I. Turina, MD, icholas T. Kouchoukos, MD, Eugene H. Blackstone, MD, ary L. Grunkemeier, PhD, Johanna J. M. Takkenberg, MD, PhD, irone E. David, MD, Eric G. Butchart, MD, David H. Adams, MD, avid M. Shahian, MD, Siegfried Hagl, MD, John E. Mayer, MD, and ruce W. Lytle, MD The American Association for Thoracic Surgery, Beverly, Massachusetts; The Society of Thoracic Surgeons, Chicago, Illinois; and The European Association for Cardio-Thoracic Surgery, Windsor, Berks, United Kingdom

Background The need for bileaflet repair in bileaflet mitral valve prolapse (MVP) remains controversial. Will anterior leaflet prolapse resolve with posterior leaflet repair or should both leaflets be addressed? Single-leaflet MVP produces oppositely directed mitral regurgitant jets. Some patients show two crossed jets oppositely directed from the coaptation zone. We hypothesized that these indicate bileaflet lesions requiring complex repair. Methods Echocardiograms and surgical reports of 52 consecutive patients with MVP undergoing surgery were reviewed. Results First, all 14 patients with two oppositely directed jets had prolapse of more than one leaflet. Each jet was related to discrete leaflet distortions causing malcoaptation. Six underwent valve replacement. Seven had both leaflets repaired. One had posterior leaflet repair and annuloplasty, with persistent mitral regurgitation requiring valve replacement. Second, 36 of 38 patients with single jets had single-leaflet MVP. One underwent replacement; all others did well with single-leaflet repair. Two patients with bileaflet MVP but only one jet did well with single-leaflet repair or annuloplasty. Conclusion This crossed swords sign is an important clue to bileaflet mechanism of mitral regurgitation in MVP, associated with complex repair procedures. Thus, it provides a clue in the dilemma of bileaflet versus single-leaflet repair.

Patients who survive out-of-hospital cardiac arrest are at high risk for recurrent arrest. Coronary artery bypass grafting (CABG) confers a survival advantage, but it is unclear whether antiarrhythmic drugs or an implanted defibrillator confer added benefit. This study was designed to determine predictors for further treatment, survival, and therapeutic internal cardiac defibrillator (ICD) discharge in this patient population.One hundred and eight patients undergoing CABG after out-of-hospital cardiac arrest were identified over a 12-year period. Case records were retrospectively reviewed. Follow-up was obtained and predictors of outcome events were analyzed.Fifty-four (50%) patients underwent CABG only. Fifty-four received additional treatment that included ICD placement in 23 (21%), antiarrhythmic medications in 19 (18%), or both in 12 (11%). Predictors of ICD placement included left ventricular ejection fraction (LVEF) less than 40% and perioperative intraaortic balloon counterpulsation. ICD or medical management increased survival in patients with LVEF40%. Predictors of increased mortality included age65 years, Cleveland Severity Score8, and female gender. Predictors of therapeutic ICD discharge included age65 years, reoperative CABG, LVEF40%, and positive postoperative electrophysiological (EP) study. No patient with a negative postoperative EP study received an ICD, and none suffered sudden cardiac death during follow-up.Patients with coronary artery disease anatomically suitable for CABG who survive an acute out-of-hospital cardiac arrest should undergo EP testing after CABG. Approximately half of these patients are adequately treated by CABG alone. The remainder may benefit from ICD placement or medical antiarrhythmic management.

Concomitant coronary artery disease with aortic valve disease is an established risk factor for diminished late survival. This study evaluated the results of bioprosthetic (BAVR) or mechanical aortic valve replacement (MAVR) performed with coronary artery bypass grafting (CABG).From January 1984 through July 1997, combined AVR + CABG was performed in 750 consecutive patients; 469 received BAVR and 281 received MAVR. BAVR recipients were significantly older (mean age, 75 vs 65 years), and had more nonelective operations, congestive heart failure, peripheral vascular disease, preoperative intraaortic balloons, lower cardiac indices, more severe aortic stenosis, less aortic regurgitation, and more extensive coronary artery disease.Early complications included operative mortality, 32 patients (4.3% total: 3.8% BAVR and 5.0% MAVR); perioperative infarction, 10 (1.3%); and perioperative stroke, 22 (2.9%). Significant multivariable predictors of early mortality were age, perioperative infarction or stroke, nonelective operation, operative year, ventricular hypertrophy, and need for intraaortic balloon. Ten-year actuarial survival was 41.7% for all patients. Predicted survival for age- and gender-matched cohorts from the general population versus observed survival were BAVR, 45% versus 36%; MAVR, 71% versus 48% (survival differences BAVR 9% vs MAVR 23%, p0.007). Significant multivariable predictors of late mortality included age, congestive failure, perioperative stroke, extent of coronary disease, peripheral vascular disease, and diabetes. Valve type was not significant. Ten-year actuarial freedom from valve-related complications were (BAVR vs MAVR) structural deterioration, 95% versus 100%, p = NS; thromboembolism, 86% versus 84%, p = NS; anticoagulant bleeding, 93% versus 88%, p0.005; reoperation, 98% versus 98%, p = NS.AVR + CABG has diminished late survival despite the type of prosthesis inserted. Although valve type did not predict late mortality, mechanical AVR was associated with worse survival compared with predicted and more valve-related complications due to anticoagulation requirements.

The more extensive conflict of interest information will permit reviewers and editors to ensure the accuracy, balance,and lack of bias of papers accepted for publication.Therefore, a brief conflict statement will be published on the cover page and a more extensive description will be published at the end of the paper to allow concerned readers to make their own judgments about the quality of the information reported.

Because the elderly are increasingly referred for operation, we reviewed results with cardiac surgical patients 80 years old or older.Records of 600 consecutive patients 80 years old or older having cardiac operations between 1985 and 1995 were reviewed. Follow-up was 99% complete.Two hundred ninety-two patients had coronary grafting (CABG), 105 aortic valve replacement (AVR), 111 AVR + CABG, 42 mitral valve repair/ replacement (MVR) +/- CABG, and 50 other operations. Rates of hospital death, stroke, and prolonged stay (14 days) were as follows: CABG: 17 (5.8%), 23 (7.9%) and 91 (31.2%); AVR: 8 (7.6%), 1 (1.0%), and 31 (29.5%); AVR + CABG: 7 (6.3%), 12 (10.8%), and 57 (51.4%); MVR +/- CABG: 4 (9.5%), 3 (7.1%), and 16 (38.1%); other: 9 (18.0%), 3 (6.0%), and 23 (46.0%). Multivariate predictors (p0.05) of hospital death were chronic lung disease, postoperative stroke, preoperative intraaortic balloon, and congestive heart failure; predictors of stroke were CABG and carotid disease; and predictors of prolonged stay were postoperative stroke and New York Heart Association class. Actuarial 5-year survival was as follows: CABG, 66%; AVR, 67%; AVR + CABG, 59%; MVR +/- CABG, 57%; other, 48%; and total, 63%. Multivariate predictors of late death were renal insufficiency, postoperative stroke, chronic lung disease, and congestive heart failure. Eighty-seven percent of patients believed having a heart operation after age 80 years was a good choice.Cardiac operations are successful in most octogenarians with increased hospital mortality, postoperative stroke, and longer hospital stay. Long-term survival is largely determined by concurrent medical diseases.

Objectives: A total of 4756 cases of intraaortic balloon pump support have been recorded at the Massachusetts General Hospital since the first clinical insertion for cardiogenic shock in 1968. This report describes the patterns of intraaortic balloon use and associated outcomes over this time period. Methods: A retrospective record review was conducted. Results: Balloon use has increased to more than 300 cases a year at present. The practice of balloon placement for control of ischemia (2453 cases, 11.9% mortality) has become more frequent, whereas support for hemodynamic decompensation (congestive heart failure, hypotension, cardiogenic shock) has been relatively constant (1760 cases, 38.2% mortality). Mean patient age has increased from 54 to 66 years, and mortality has fallen from 41% to 20%. Sixty-five percent (3097/4756) of the total patient population receiving balloon support underwent cardiac surgery. Placement before the operation (2038 patients) was associated with a lower mortality (13.6%) than intraoperative (771 patients, 35.7% mortality) or postoperative use (276 patients, 35.9% mortality). Independent predictors of death with balloon pump support were insertion in the operating room or intensive care unit, transthoracic insertion, age, procedure other than angioplasty or coronary artery bypass, and insertion for cardiogenic shock. Independent predictors of death with intraoperative balloon insertion were age, mitral valve replacement, prolonged cardiopulmonary bypass, urgent or emergency operation, preoperative renal dysfunction, complex ventricular ectopy, right ventricular failure, and emergency reinstitution of cardiopulmonary bypass. Conclusions: Balloons are being used more frequently for control of ischemia in more patients who are elderly with lower mortality. An institutional bias toward preoperative use of the balloon pump appears to be associated with improved outcomes. (J Thorac Cardiovasc Surg 1997;113:758-69)

Mechanical cardiac valvular prostheses continue to be more popular than bioprostheses for heart valve replacement operations. Five different brands of mechanical heart valves are now approved for implantation in the United States: Starr-Edwards models 1260 and 6120, Medtronic-Hall, St. Jude Medical, Omniscience, and CarboMedics. Each model of mechanical valve has certain positive and negative attributes, but none is functionally mechanically perfect. A review of the published long term results with these valves favors the Medtronic-Hall and St. Jude Medical valves. A new method of assessing the thrombogenic potential and requirement for anticoagulation of the different mechanical valves, namely the composite thromboembolism and bleeding index, is proposed. Evaluation of the new index demonstrates a modest advantage for the Medtronic-Hall valve, particularly in the aortic position.

Between January 1985 and June 1992, 263 consecutive patients had mitral valve reconstruction (133 patients) or replacement (130 patients) for degenerative or ischemic mitral regurgitation. The two groups were similar in sex, age, prior infarctions or cardiac operations, hypertension, angina, and functional class. Both groups were similar in mean ejection fraction, pulmonary artery pressure, cardiac index, and incidence of coronary artery disease. More reconstruction than replacement patients had ischemic etiology (22 [16%] versus 12 [9%]; p = not significant), and fewer reconstruction patients had ruptured anterior leaflet chordae (9 [7%] versus 39 [30%]; p0.01). More reconstruction than replacement patients had concomitant cardiac procedures (67 [50%] versus 59 [45%]; p = not significant). Hospital death occurred in 4 reconstruction patients (3%) and 15 (12%) replacement patients (p0.01). Median postoperative stay was shorter in reconstruction patients (10 versus 12 days; p = 0.02). Late valve-related death occurred in 3 reconstruction patients (2%) and 8 (6%) replacement patients (p = 0.08). Six-year actuarial freedom from thromboembolism was 92% for the reconstruction group and 85% for the replacement group (p = 0.12). Freedom from all valve-related morbidity and mortality was 85% for the reconstruction patients and 73% for the replacement patients (p = 0.03). Significant multivariate predictors of hospital death were age, mitral valve replacement, functional class, congestive heart failure, no posterior chordal rupture, and nonelective operation. Mitral valve reconstruction, when technically feasible, is the procedure of choice for degenerative or ischemic mitral regurgitation because of significantly lower hospital mortality and late valve-related events.

To assess the changing trends in patient profiles, operative indications and techniques, and their impact on the results of reoperative myocardial revascularization, we reviewed the records of 750 consecutive patients who had an isolated first reoperation for coronary artery disease at the Massachusetts General Hospital from 1977 to 1992. The patients were chronologically grouped into three equal cohorts of 250 patients. Our assessment over time revealed a significantly (p0.03) increased incidence of the following: older age, peripheral vascular disease, grafts at the first revascularization, longer operative interval, interval infarctions and angioplasties, and congestive heart failure and unstable angina requiring greater use of preoperative intraaortic balloon pumping. At catheterization significantly more left main coronary disease, lower ejection fractions, and more patent but diseased grafts were found. The reoperations were significantly done more urgently, with more grafts placed and a greater use of mammary artery grafting. Despite these increased risks over time, median postoperative hospital stay was significantly shortened (p0.001), though hospital mortality (5.3%) and perioperative myocardial infarction (6.3%) did not change significantly. Significant multivariate predictors of hospital death were nonelective operation, perioperative myocardial infarction, prior myocardial infarction, and mammary artery grafting at the initial operation.

Study objective: To evaluate the safety and effectiveness of temporary IV antihypertensive therapy in patients with acute traumatic thoracic aortic disruption. Design: Retrospective chart review of all patients treated for proven traumatic aortic disruption during the ten-year period of 1980 through 1989. Setting: Emergency department of a large, urban, Level I trauma center. Interventions: Preoperative IV β-blockade and nitroprusside after initial resuscitation in hemodynamically stable patients. Results: Thirty-seven patients with angiographically proven aortic disruption were separated retrospectively into one of three groups. Group 1 (15 patients without preoperative antihypertensive therapy) had two deaths. Group 2 (15 patients treated for two to seven hours [mean, 3.8 hours] before surgery with antihypertensives) had one death. Group 3 (seven patients treated with antihypertensives for 24 hours to four months before surgery to allow recovery from associated severe injuries) had one death. There were no complications resulting from antihypertensive therapy. Conclusion: Temporary antihypertensive therapy appears to be safe and effective in patients with aortic disruption.

We managed 51 patients with thoracic aortic injuries caused by blunt trauma between 1977 and 1990. Fortynine injuries were located in the upper descending aorta and one each in the ascending aorta and anatic arch. Three patients arrived moribund and underwent thoracotomy for resuscitation, and all died. The diagnosis was confirmed by aortography in 48. One patient died of aortic rupture, 1 died of hypoxemia, and 1 refused operation and died. Forty-four patients had aortic repair, 42 with graft insertion. Gott shunts were placed in 23 with 3 cases of paraplegia (13%). Simple cross-clamping was used in 19 with 1 case of paraplegia (5.2%). We found statistically significant differences between the cross-clamp times of patients without paraplegia compared with those in whom paraplegia developed in both the shunt and no-shunt groups. Logistic regression analysis showed that the only factor significantly associated with paraplegia was cross-clamp time. There were two postoperative deaths (4.4%). Seven patients had medical therapy initially and aortic repair was delayed to allow other injuries to stabilize. Before aortic repair, 18 patients had intraarterial pressure monitoring and 34 received β-blockers or antihypertensive drugs. We conclude that aortic repair with graft insertion is usually successful in nonmoribund patients, simple crossclamping is associated with a relatively low risk of paraplegia, the incidence of paraplegia is directly associated with the duration of cross-clamp time, and selected patients can be managed medically while awaiting aortic repair.

Mechanical cardiac valvular prostheses currently enjoy a 60% to 40% market-share advantage over tissue prostheses in the United States and worldwide. Only the Starr-Edwards caged Silastic (Dow Corning) ball, Medtronic-Hall, St. Jude Medical, and Omniscience valves remain available in the United States. Although each valve has certain advantages and disadvantages, no design has achieved functional mechanical perfection. Late follow-up of valve-related complications from the literature favors the St. Jude Medical and Medtronic-Hall valves.

To determine the safety of intraaortic balloon pump catheter insertion for critical coronary ischemia through suprainguinal prosthetic bypass grafts, we examined our experience of 19 intraaortic balloon pumps placed through grafts in 17 patients by means of surgical exposure (8) or the percutaneous (11) approach. Fourteen intraaortic balloon pumps were placed through matured grafts at a time remote (2 to 13 years; mean, 7 years) from their vascular bypass surgery. Five were inserted through nonmatured grafts during the same hospitalization as their vascular reconstructive surgery (1 to 12 days; mean, 4 days). One patient, a day after an aortoiliac bypass, died during an urgent, surgical intraaortic balloon pump insertion for cardiogenic shock. All other patients had prompt reversal of their cardiac ischemia. Decreased limb perfusion developed during use of the intraaortic balloon pump in three patients, all of whom had their intraaortic balloon pump placed percutaneously through mature grafts. Two of these required surgical thrombectomy. Ten intraaortic balloon pump insertions in eight patients survived the hospitalization and were followed for a mean of 24 months (range, 2 weeks to 64 months). No localized groin or graft infections were identified. No bleeding complications or pseudoaneurysms occurred. Thus in patients with unstable, severe, cardiac disease, intraaortic balloon pumps can be safely placed through indwelling suprainguinal bypass grafts. (J VASC SURG 1991;13:830-7.)

A total of 101 patients (mean age 64.9 years) underwent surgical correction of postinfarction ventricular septal defect at this institution over a 15-year period (1973 to 1988). The overall early mortality rate was 20.8%, although the most recent experience with 36 patients (January 1987 to October 1988) has seen this decline to 11.1%. Factors found to influence early death significantly, when analyzed univariately, were as follows: (1) site of infarction (anterior 12.1%, inferior 32.6%, p = 0.02); (2) time interval between infarction and operation ( 1 week 10.5%, p = 0.008); (3) cardiogenic shock (present 38.1%, absent 8.5%, p = 0.001). Nonsignificant variables included preoperative renal function, age, and concomitant coronary artery bypass, although older age (>65 years) became significant when examined in a multivariate fashion. Of the 80 hospital survivors, eight were subsequently found to have a recurrent or residual defect necessitating reoperation, with survival in seven. Late follow-up is 99% complete and reveals an actuarial survival rate for 100 patients of 71.1% at 5 years (95% confidence interval 60.6 to 80.0), and 40.0% at 10 years (95% confidence interval 21.7 to 58.4). A significant recent change in policy of not using coronary angiography in patients with a ventricular septal defect caused by anterior wall infarction has not resulted in any increase in either the early mortality or in the late prevalence of angina. The functional status of 38 surviving patients has been analyzed by a graded treadmill exercise protocol, whereas left ventricular functional assessment was by nuclear scan with additional information on mitral valve function by echocardiogram. Color Doppler flow mapping has been used to determine the presence of a residual defect. Most late survivors have limited exercise tolerance related to both cardiac and noncardiac factors. Left ventricular function is moderately impaired (mean ejection fraction = 0.39). However, many patients are elderly and have adapted to their residual symptoms without significant changes in life-style.

DOI:€10.1016/j.athoracsur.2008.10.094 Ann Thorac Surg 2009;87:359-360 Marko I. Turina Cary W. Akins, Eugene H. Blackstone, D. Craig Miller, Nicholas T. Kouchoukos andInterventions Need for a Reappraisal? (Response) Guidelines for Reporting Mortality and Morbidity After Cardiac Valvehttp://ats.ctsnetjournals.org/cgi/content/full/87/2/359 located on the World Wide Web at: The online version of this article, along with updated information and services, is