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The sublethal effects of infectious disease on reproductive behaviour and mating success are not well understood. Here, we investigated predictors of male mating success in one of Australia's most critically endangered vertebrates: the northern corroboree frog, Pseudophryne pengilleyi. Using a genomic approach to assign parentage, we explored whether infection with the amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd), a pathogen responsible for amphibian declines globally, influenced male calling behaviour and mating success. We also explored whether male mating success was predicted by phenotypic traits (age, body size, coloration, call characters) that potentially signal genetic quality, and the soil moisture (water potential) of male-constructed terrestrial nests, which may directly impact offspring survival. We found that Bd significantly influenced male advertisement; Bd-infected males produced calls with significantly higher pulse repetition rates than uninfected males. Older males had a higher probability of mating; however, variation in the number of eggs in a nest was most strongly explained by an interaction between male Bd infection status and call pulse repetition rate. We propose that these relationships may result from either pathogen-mediated changes to host behaviour or host-mediated changes to behaviour (e.g. terminal investment). Regardless of the mechanism, this is the first evidence that male mating success in an amphibian can be influenced by male Bd infection status, highlighting a novel mechanism through which this virulent pathogen can affect amphibian fitness. More broadly, these findings add to a growing body of evidence that pathogens can alter the reproductive biology of their hosts. From a conservation perspective, increased consideration of how sexual selection operates in altered environments has the potential to assist with the management of threatened amphibians worldwide.

In resource defence mating systems where males control nest sites, complex interrelationships between nest characteristics and nest advertisement are likely to influence female mate choice. Surprisingly, however, we know little about the influence of such relationships on female mating decisions. In terrestrial-breeding oviparous species, one character likely to have a major influence on female nest site selection is nest moisture. In addition to influencing the susceptibility of eggs to desiccation, nest moisture also stands to influence nest pH and offspring fitness, as well as the hydration state of resident males, and their potential to advertise. Together, such interrelationships could strongly influence female mating decisions. The aim of this study was to use a long-term field study combined with a multivariate approach to investigate the combined influence of nest moisture, nest pH and male acoustic advertisement on female nest site selection in a wild population of red-backed toadlets, Pseudophryne coriacea. We found that females deposited more eggs in wetter and less acidic nests, and that these variables were positively correlated. Moreover, nest moisture and pH in combination were positively related to the calling potential of resident males, and nests that were advertised more often received more eggs. These results suggest that nest site selection in red-backed toadlets is influenced by a complex interplay between covarying nest characteristics that together influence male sexual signalling and nest advertisement. More broadly our findings highlight the potential for nesting behaviour to be mechanistically intertwined with mate choice.

Escape-response behaviour is essential to ensure an individual’s survival during a predator attack, however, these behaviours are energetically costly and may cause oxidative stress. Oxidative stress can be reduced by supplementing an individual’s diet with exogenous antioxidants or through regular moderate exercise training, which stimulates the upregulation of the endogenous antioxidant system. Two studies have tested the simultaneous effects of dietary antioxidant supplementation and exercise training on animal escape-response behaviour. The present study investigated the effects of dietary carotenoids and exercise training on the escape-response behaviour of Southern Corroboree frogs. Frogs were fed either a carotenoid-supplemented or unsupplemented diet and were exposed to repeated escape-response trials (training) for five consecutive weeks. Carotenoid-supplemented individuals outperformed unsupplemented individuals in initial hopping speed, length of the first hop and hopping distance, however, the performance of frogs in each treatment group became statistically similar after training. Within treatment groups, exercise training significantly improved the hopping speed of unsupplemented frogs, with speeds almost doubling between training weeks one and five. By contrast, exercise training did not significantly improve the hopping speed of carotenoid-supplemented frogs. Our results provide some of the first evidence that exercise training improves escape performance, and that dietary antioxidants may inhibit training-induced benefits.

Proximate mechanisms underpinning between-individual variation in repeatedly expressed behaviours (animal personality) remain poorly understood. Recent theoretical models have focused on the concept of adaptive state-dependent behaviour, proposing that repeatable differences in behaviour emerge due to individual differences in repeatable state variables such as metabolic rate, age, sex or body size. Few studies have attempted to investigate the effect of state on personality empirically, and evidence for links between individual variation in state and personality remains equivocal. We used a captive colony of southern corroboree frogs, Pseudophryne corroboree , to (1) test for innate, temporally repeatable behavioural differences (animal personality) along the activity, exploration/avoidance and boldness/shyness behavioural axes, (2) test for behavioural syndromes (between-individual correlations between behavioural traits) and (3) determine whether behavioural traits are correlated with body size at the between-individual level. Individuals exhibited repeatable variation along all three behavioural axes, but between-individual correlations did not deviate from zero, providing no evidence for behavioural syndromes. Body size explained 40% of the between- individual variance in exploration behaviour, with larger frogs exhibiting greater mobility and travelling further in a novel environment. These associations indicate that there is potential for innate body size variation in P. corroboree to act as an important state variable underpinning repeatable between-individual behavioural differences. Future research may test this idea experimentally. Continued investigation of state-dependent individual behaviour in P. corroboree and other animals is likely to provide important insights into the proximate causes of animal personality.

This investigation outlines a straight-forward and low cost methodology for determining thermal properties of wall structures. The method eliminates the need to produce a step change boundary condition, and the error inherent in the departure from a step change that finite properties necessarily impose. The transient technique involves an experimental component whereby a high temperature thermal ramp boundary condition is applied to one wall face with the other exposed to the cooler ambient surroundings. Temperature and heat flux sensors are installed to monitor the transient heating behaviour at the wall faces. The measured transient wall temperature profiles are subsequently imposed as boundary equations to Fourier's equation in such a way that the analytic solution can provide a prediction of the transient surface heat flux. With this, the thermal diffusivity is estimated by using the effective thermal diffusivity of the wall material as a tuning parameter to regression fit the predicted and measured heat flux histories. Additionally, the steady solution facilitates the approximation of the effective thermal conductivity when used in conjunction with the steady surface temperature and heat flux measurements. To illustrate the technique, a test was performed on a 900 mm × 900 mm × 120 mm thick solid concrete wall section. The effective thermal diffusivity was determined to be 7.2 × 10 −7 m 2 /s with corresponding effective thermal conductivity of 1.64 W/m K and specific heat of 0.99 kJ/kg K. Each property value is within the range of published literature for concrete.

Captive breeding programmes offer a method for preventing the extinction of threatened species, but often have difficulty establishing self-sustaining populations and generating individuals for release. This difficulty can arise because the behaviour of captive-reared animals differs from wild animals. Whilst the effect of captivity on animal behaviour has been widely reported, few studies have explicitly compared differences between captive-reared and wild-caught animals. Even fewer have examined behavioural types (a composition of behavioural traits) displayed in novel environments, which is particularly relevant for determining reintroduction success. Further, the transgenerational effects on behavioural type, and potential differences between sexes in response to captivity, remain almost completely unknown. Using house mouse (Mus musculus) as a model for small mammals, we tested whether behavioural types displayed in a novel environment differed between captive-reared and wild-caught animals. In addition, it was tested whether behavioural types were subject to transgenerational effects in captivity, and whether there were sex-specific differences in behavioural types. We used an open field test to simulate a novel environment. Captive-reared mice were found to differ in their boldness and activity behavioural type compared to their wild-caught mice (p

In this study, a reflux thermosyphon using HFE-7000 as the working fluid is fitted with a concentric electrode in order to investigate the influence of electrostatic forces on the evaporator thermal performance. Importantly, the thermosyphon is constructed from an ITO coated sapphire tube resulting in a thermosyphon enclosure with high thermal conductivity that is electrically conductive and transparent. This allows visualisation of the boiling dynamics within the thermosyphon for both the scenarios where there is no electric field and when electric fields of increasing intensity and frequency are imposed. Results are obtained for two heat fluxes, 8 kW/m 2 and 15 kW/m 2 , for applied voltages ranging from 0 kV to 8 kV with AC frequencies between 20 Hz and 100 Hz. Fill ratios for the evaporator of 50% and 100% are considered. The main results show that the evaporator thermal resistance is fairly insensitive to applied electric field strength until it is strong enough to overcome local gravitational forces, and this occurs in the region of 3–4 kV. Subsequent to this the boiling dynamics and resulting heat transfer performance is notably augmented by the Electrohydrodynamic (EHD) forces. For low heat fluxes the evaporator heat transfer coefficient is enhanced up to ∼40% for the highest applied voltage. However, for the higher heat flux, the EHD forces result is a substantial deterioration of the heat transfer coefficient, being up to ∼70%. The mechanisms responsible for the heat transfer augmentation are discussed in context of the flow visualisation obtained using high speed videography. The opportunity for using an EHD thermosyphon as a thermal potentiometer is also discussed.

The residential sector represents 27% of primary energy consumption in Ireland. This paper examines the case study of the Irish government’s national grant scheme to encourage energy efficiency retrofit in private housing. That is the Home Energy Saving (HES) Scheme, later rebranded the Better Energy: Homes (BEH) Scheme. The methodology involved monitoring several homes immediately before and after retrofit alongside discussions with occupants. The examination focused on specific measures commonly introduced through the HES/BEH programme − cavity and external wall insulation. It has been found that a significant decrease in heat loss through the walls was measured in all cases. Regardless, the occupant played a considerable role in the change in energy use in the buildings, and the main motivation for retrofit was found to be comfort and not energy savings or environmental concerns. As a result, the actual energy savings are notably less than the potential savings had the pre and post comfort levels remained the same.

Background Current guidelines for the treatment of adult patients in cardiac arrest are supplied by the American Heart Association through basic life support and advanced cardiovascular life support (ACLS) provider courses. When treatments defined by the ACLS guidelines are unsuccessful in terminating a lethal dysrhythmia, the use of alternative strategies may prove useful. In this case, two defibrillators were used to deliver a greater than normal energy waveform over an extended time interval to return a patient to a normal sinus rhythm. Case Report A 56-year-old woman presented to the emergency department with complaints of chest pain, nausea, and vomiting. The patient's initial work-up, including an electrocardiogram and cardiac troponin, did not show evidence of acute ischemia, and she was admitted to the observation unit for further evaluation. While in the emergency department, the patient developed ventricular fibrillation, and ACLS was initiated. After four unsuccessful defibrillation attempts, a second defibrillator was placed on the patient, and the two were activated almost simultaneously. The patient had immediate return of spontaneous circulation, underwent cardiac catheterization, and was discharged home 1 week later. Why Should an Emergency Physician Be Aware of This? This case shows that dual sequential defibrillation may be a successful method for terminating refractory ventricular fibrillation. Further investigation on cardiac resuscitation should be conducted to standardize the dual sequential defibrillation delivery procedure. Until such guidelines are established, physicians should take this treatment into consideration when standard ACLS measures have failed to successfully terminate refractory ventricular fibrillation.

High-resolution X-ray microtomography was used to get deeper insight into the underlying mass transport mechanisms controlling drug release from coated pellets. Sugar starter cores were layered with propranolol HCl and subsequently coated with Kollicoat SR, plasticized with 10% TEC. Importantly, synchrotron X-ray computed microtomography (SR-μCT) allowed direct, non-invasive monitoring of crack formation in the film coatings upon exposure to the release medium. Propranolol HCl, as well as very small sugar particles from the pellets' core, were expulsed through these cracks into the surrounding bulk fluid. Interestingly, SR-μCT also revealed the existence of numerous tiny, air-filled pores (varying in size and shape) in the pellet cores before exposure to the release medium. Upon water penetration into the system, the contents of the pellet cores became semi-solid/liquid. Consequently, the air-pockets became mobile and fused together. They steadily increased in size (and decreased in number). Importantly, “big” air bubbles were often located in close vicinity of a crack within the film coating. Thus, they play a potentially crucial role for the control of drug release from coated pellets.

Nutritional conditions experienced by an individual are known to affect phenotype and performance. In particular, dietary carotenoids influence vertebrate immune function, vision and coloration and have recently been suggested to enhance exercise performance. Despite growing interest in investigating the effect of dietary carotenoids on exercise performance, studies to date have been limited to short-term supplementation during a single life stage. The present study elucidates, for the first time, the effect of long-term carotenoid supplementation during both developmental and adult life stages on the aquatic and terrestrial escape performance of adult southern corroboree frogs, Pseudophryne corroboree, testing the predictions of the ‘environmental matching’ and the ‘silver spoon’ hypotheses. Individuals (N = 24 per treatment) were exposed to one of four dietary treatments: (1) both developmental and adult life stages were fed a carotenoid-supplemented diet (C–C); (2) developmental life stage, but not adult life stage, was fed a carotenoid-supplemented diet (C–U); (3) adult life stage, but not developmental life stage, was fed a carotenoid-supplemented diet (U–C); (4) both developmental and adult life stages were fed an unsupplemented diet (U–U). There was no effect of dietary carotenoids on swimming speed, hopping speed or righting ability. However, our results do indicate an effect of carotenoid supplementation on both swimming distance and hopping distance. Frogs receiving a carotenoid-supplemented diet during both developmental and adult life stages consistently outperformed other dietary treatments in the distance travelled during aquatic and terrestrial escape trials. Our results do not show support for either the silver spoon or the environmental matching hypothesis, but indicate an overall benefit of exposure to a carotenoid-rich environment across both life stages.

The phenotype-linked fertility hypothesis proposes that secondary sexual characters (SSCs) advertise a male's fertility to prospective mates. However, findings from empirical studies attempting to test this hypothesis are often ambivalent or even contradictory, and few studies have simultaneously evaluated how both morphological and behavioural SSCs relate to ejaculate characteristics. Males of the small hairy maggot blowfly, Chrysomya varipes, possess conspicuous foreleg ornaments and display highly stereotyped courtship behaviour. These traits are favoured by females during pre-copulatory mate choice, but it remains unknown whether they correlate with post-copulatory traits expected to influence male fertility. The aim of this study was to investigate whether male courtship and ornamentation correlate with testis size and sperm length in C. varipes. We found that males investing more in courtship had bigger testes, and males with more extensive foreleg ornamentation released sperm with longer tails. Based on the assumption that larger testes enable males to produce more sperm, and that sperm with longer tails have greater propulsive force, our findings suggest that more vigorous and more ornamented males may be more fertile. These findings lend support to the phenotype-linked fertility hypothesis. However, a complete test of this hypothesis will require evaluating whether testis size and sperm length influence male fertilisation ability, as well as female fecundity and/or fertility.

This work presents an experimental investigation of a two-phase looped thermosyphon design for cooling Air Circuit Breakers (ACBs) in switchgear used in data center power distribution systems. The FC72 charged thermosyphon is comprised of a bespoke evaporator that is fixed tightly to the copper adaptor of the ACB. Dielectric tubing connects the evaporator to a remote naturally aspirated and thin form factor condenser. Since both the working fluid and the connection tubing are dielectric, the thermosyphon provides electrical isolation between the ACB and the remote heat sink. The condenser is a thin serpentine channel with surface extensions and is cooled by natural convection and radiation to the ambient environment. Benchtop thermal performance tests were performed for increasing load power for two scenarios: for the stand-alone looped thermosyphon and for the case where copper bus bars are also fixed to the ACB adapter. For 60 W thermal power dissipation, a nominal operational condition, the thermal resistance of the looped thermosyphon system was determined to be 0.55 K/W without bus bars attached. With bus bars attached, this decreases to 0.42 K/W which results in a breaker to ambient temperature rise of about 25 K, which is significantly lower than operational limits of 85 K temperature rise. In-situ tests were then performed on a live ACB system carrying a 2000 A load and showed that the looped thermosyphon system was capable of decreasing the ambient temperature rise by 26 K, which is significant. The low thermal resistance of this passive cooling technology opens the opportunity for increased electrical service per breaker and/or a significant reduction in the volume of copper bus bars used with associated cost reduction of ACB technologies.

In order to quantify precipitates such as Laves phase, M23C6 carbides and modified Z-phase in 9–12 wt% Cr power plant steels, a range of microscopy techniques, including scanning electron microscope (SEM) and focussed ion beam (FIB) imaging, are currently used. This paper's key finding reports on the novel application of a field emission SEM (FESEM) in-column upper secondary electron detector (USD) for imaging and quantification of precipitates in a thermally aged 11–12 wt% Cr steel sample. The USD produces images from first order secondary electrons generated directly from primary electron beam interaction. These images were found to not only show significant contrast between the matrix and the precipitates to enable quantification, but between particles which otherwise have identical greyscale intensities in FIB images. Previously assumed to be the same phase, some of these precipitates appeared significantly darker than others. The greyscale differential between these precipitate types was sufficient for separate quantification. Energy dispersive x-ray spectroscopy and selected area diffraction analysis identified the darker particles as modified Z-phase and the lighter grey particles as M23C6 carbides. When analysing all particles together, comparison of data from FESEM USD and FIB images confirmed that both techniques produce statistically comparable precipitate analysis results. However, as modified Z-phase and M23C6 carbide distributions can be analysed separately from a FESEM in-column USD image at low accelerating voltages, it was found that this technique provides for more reliable precipitate quantification than FIB imaging alone in these steels. With future work, this could enable faster characterisation and may lead to automated larger area mapping.

Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period.Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients.Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018).This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.

Intersexual selection drives the evolution of reproductive traits, including ornamentation and courtship behaviour. However, most studies attempting to explain the relationships between reproductive traits are oversimplified because traits are evaluated independently, and assessment of mate choice is restricted to one sex. Further research is required to understand the extent to which interactions between traits influence mating decisions in both sexes. The small hairy maggot blowfly, Chrysomya varipes, offers an ideal opportunity to examine how interactions between foreleg ornamentation (males have conspicuous white and black hairs, whereas females have only black hairs) and complex courtship behaviour influence mating success in males and females. This study involved mate choice trials between single females and males that varied in foreleg ornamentation. Courtship investment was quantified for males, and ornamentation and body size were quantified for both sexes. Mating success was predicted by time invested in courtship, but not by either male and female ornamentation or body size alone. However, there was a significant interaction between courtship investment, ornamentation and body size. At any given courtship investment, males with more ornamentation had an increased probability of mating success. Females with more ornamentation also had an increased probability of mating success, because males invested more courtship in more ornamented females. Furthermore, the lightest males had an increased probability of mating success compared to the heaviest males, as lighter males invested more in courtship. Female weight, however, did not significantly affect the probability of mating. The results suggest that male foreleg ornamentation in C. varipes acts as an amplifier of the visual courtship display, adding to a small but growing body of evidence that multiple male and female traits can interact to influence mating decisions.

Valve endocarditis is associated with high morbidity and mortality and requires a thorough evaluation including early surgical consultation to identify patients who may benefit from surgery. We review 5 recent articles that highlight the current debates related to best treatment strategies for valve endocarditis. Recent publications have focused on neurologic risk assessment, timing of surgery, and prognostic factors associated with native and prosthetic valve endocarditis. The initial patient assessment and management is best performed by a multidisciplinary team. Future investigations should focus on identifying surgical candidates early and the outcomes affected by replacement valve choice in both native and prosthetic valve endocarditis.

Granting clinical staff privileges to physicians is the primary mechanism institutions use to uphold quality care. The Joint Commission requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians themselves are charged with defining the

Robert A. Harrington, MD, FACC, Chair Eric R. Bates, MD, FACC[¶][1] Deepak L. Bhatt, MD, MPH, FACC Charles R. Bridges, MD, MPH, FACC[¶][1] Mark J. Eisenberg, MD, MPH, FACC[¶][1] Victor A. Ferrari, MD, FACC John D. Fisher, MD, FACC Timothy Gardner, MD, FACC Federico Gentile, MD, FACC

Although behaviours associated with territory maintenance are extensively studied, little is known about the establishment of territorial boundaries, a key process influencing individual fitness and population demography. In this regard, conspicuous features of the landscape and constructions such as scent marks (landmarks) can have an effect on whether and where boundaries are established. Landmarked boundaries have also been associated with altered social interactions, particularly contests that take place on boundaries. Some of these landmarks physically constrain a resident’s perception or movement and may thus make the use of space beyond the landmark too costly. Other landmarks are purely conspicuous and appear to have no constraining effect, yet still have strong influences on boundary location by affecting social interactions. Factors that may influence whether a landmark is adopted for a boundary include the properties of the resident, properties of the landmark and the rate of encounter between neighbours. The purpose of this review is to consolidate and explicitly describe hypotheses relating to landmarked boundaries and highlight areas most in need of research. Ultimately, understanding the decision to adopt landmarked boundaries and the implications of these decisions for territorial populations is critical for understanding the link between landscapes, individual decisions and population ecology.

2011;58;2584-2614; originally published online Nov 7, 2011; J. Am. Coll. Cardiol. Winniford Joseph F. Sabik, Ola Selnes, David M. Shahian, Jeffrey C. Trost, and Michael D. A. Lange, Martin J. London, Michael J. Mack, Manesh R. Patel, John D. Puskas, Adolph M. Hutter, Jr, Michael E. Jessen, Ellen C. Keeley, Stephen J. Lahey, Richard Bridges, John G. Byrne, Joaquin E. Cigarroa, Verdi J. DiSesa, Loren F. Hiratzka, L. David Hillis, Peter K. Smith, Jeffrey L. Anderson, John A. Bittl, Charles R. Surgeons Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Developed in Collaboration With the American Association for Thoracic Foundation/American Heart Association Task Force on Practice Guidelines Executive Summary: A Report of the American College of Cardiology 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: This information is current as of January 22, 2012 http://content.onlinejacc.org/cgi/content/full/58/24/2584 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Background This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes. Methods From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 ± 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete. Results Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years. Conclusions The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure.

Graft patency strongly influences early and late outcomes after coronary artery bypass grafting (CABG) surgery. The current standard of care in CABG surgery does not require intraoperative imaging. Because coronary angiography is rarely available in the operating room (OR), other techniques have been developed to assess graft integrity intraoperatively. The 2 most commonly used are the transit time flow measurement (TTFM) and the intraoperative fluorescence imaging (IFI). The TTFM is a quantitative volume flow technique, whereas the IFI is based on the fluorescent properties of indocyanine green. TTFM cannot define the degree of graft stenosis nor discriminate between the influence of the graft conduit and the coronary arteriolar bed on the mean graft flow. IFI provides a "semiquantitative" assessment of the graft patency with images that provide some details about the quality of coronary anastomoses. Both methods are valuable in identifying only at the extremes, that is, either patent or occluded grafts, and can confirm very good grafts; however, neither method is sensitive or specific enough in identifying more subtle abnormalities. These abnormal grafts most likely have poor long-term patency and are predestined to fail. The hybrid suite has the capability of serving both as a complete surgical OR and as a catheterization laboratory. It allows for routine completion angiogram following CABG surgery and identifies abnormal grafts, providing the opportunity to revise them with percutaneous coronary intervention or surgery before leaving the OR.

Objectives: This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (...

A hybrid strategy combines the treatments traditionally available only in the catheterization laboratory with those traditionally available only in the operating room to offer patients the best available therapies for any given set of cardiovascular lesions. Examples include hybrid coronary revascularization (coronary artery bypass grafting [CABG]/percutaneous coronary intervention [PCI]) wherein a left internal mammary artery graft is placed on the left anterior descending artery (left anterior descending coronary artery [LAD]) either by minimally invasive or open technique and combined with PCI of non-LAD vessels. Other examples include minimally invasive valve surgery combined with PCI to coronary lesions (valve/PCI), to convert a high-risk valve/CABG into a lower-risk isolated minimally invasive valve procedure. Several questions remain unresolved, such as the order in which surgery and PCI should be performed, the duration of the staging of the 2 procedures, antiplatelet strategies, the costs, and the logistics. Other areas in which hybrid approaches are being developed include hybrid endomyocardial/epicardial atrial fibrillation procedures and hybrid aortic arch debranching combined with endovascular grafting for thoracic aortic procedures. The key requirement in all of these approaches is the need for collaboration between cardiac surgeons, vascular surgeons, and interventional cardiologists to obtain optimal patient outcomes.

Among anuran amphibians evidence for chemical communication is scarce. We carried out three experiments to evaluate whether chemosignals influence the sexual behaviour of an Australian terrestrial toadlet, Pseudophryne bibronii. Substrate choice trials (experiment 1) revealed that females preferred to associate with substrate marked by either sex rather than an unmarked substrate and that males preferred substrate marked by females, but avoided substrate marked by other males. These results suggest that the odour of both sexes functions as a sexual attractant and that male odour may also function to repel potential male competitors. In experiment 2 we assessed whether females use male chemosignals during mate location by making gravid females navigate a two-choice Y-maze to reach calling males. Almost invariably, females followed a path outlined with male gland secretions. This result indicates that male chemosignals combined with acoustic signals improve the ability of females to find nest sites. In experiment 3 we tested whether conspecific odour influences the calling behaviour of nesting males. Female odour stimulated a twofold increase in advertisement calling and male odour stimulated a switch to territorial calling. These findings indicate that nesting males use conspecific odour as a cue for regulating investment in acoustic courtship and territory defence. Our results advance a small body of evidence to suggest that anurans use chemosignals to identify and locate potential mates and provide the first demonstration that odour can influence anuran calling behaviour.

Electroplating quality is established through a number of factors, where the visual appearance tends to be the immediate indicator of a surface quality defect. In high-volume connector manufacture, electroplating is a continuous production step, yet quality inspection is an offline, operator-dependent process. In this paper, the objective was to determine whether a color vision system could identify the variation in an electroplated deposit color and attribute this change to a particular defect. Design of experiments (DOE) was used to indicate the correct factor adjustments required to obtain the maximum color difference recorded between deposits. The vision system was then subjected to varying degrees of a burnt defective deposit. The outputs were analyzed using statistical tools to establish whether transitions from a good to a burnt deposit could be identified. The research has been implemented into an industrial application, and vital elements such as effective user feedback and defect traceability have been addressed. To establish an effective solution in practice required dedicated software to be designed and developed due to the challenges of both speed and volume of data. The benefits are seen through the combination of (1) the removal of a subjective visual inspection and (2) an increased detection process that is robust, repeatable, and reproducible.

We present a series of 405 consecutive patients agedor =80 years who underwent isolated or combined valve surgery over a 5-year period. Our results demonstrate that valve surgery in the elderly can be performed with acceptable early mortality, good late survival, and excellent late functional outcome.

We examined the impact of concomitant coronary artery bypass grafting (CABG) on hospital survival after aortic root replacement. We sought to determine whether CABG procedures that were not originally planned but rather added after the aortic root procedure was completed (CABG/bailout) skewed the results to shift patients with bad outcomes to the CABG group, making the non-CABG group appear undeservedly low risk.Between May 1992 and January 2001, 369 consecutive patients underwent aortic root replacement. Concomitant CABG was required in 95 patients (26%). Indications for CABG were significant coronary artery disease in 73 patients (20%), active endocarditis or acute aortic dissection involving the coronary orifices in 14 patients (4%), and difficulty weaning from bypass because of regional wall motion abnormality from presumed but unconfirmed coronary artery disease or technical error at coronary ostial reimplantation (CABG/bailout) in 8 patients (2%).Operative mortality for the entire cohort was 5.7% (21 patients). The operative mortality rate for the non-CABG group was 0.4% (1 of 274 patients), and for the CABG group, 21% (20 of 95 patients; p0.001). Independent predictors of operative mortality in the CABG group were New York Heart Association functional class III or IV (odds ratio, 3.9; 95% confidence interval, 1.07 to 14.5), active endocarditis (odds ratio, 9.2; 95% confidence interval, 2.06 to 41.5), acute aortic dissection (odds ratio, 7.6; 95% confidence interval, 1.81 to 32.0), and failure to use retrograde cardioplegia (odds ratio, 6.4; 95% confidence interval, 1.06 to 38.8). The use of CABG/bailout was not a predictor.Adding CABG at the end of an aortic root procedure is a rare event, and because it is rare, there is no significant shift of risk as a result of the CABG/bailout patients on the overall CABG group.

Objectives The goal of this study was to determine if a “hybrid” approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons9 (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients. Background With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery. Methods We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCIand compared it with the observed mortality. Results There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively. Conclusions Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

Background With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized. Methods Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations. Results All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years. Conclusions Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.

Minimally invasive approaches in cardiac surgery have emerged as an alternative to standard techniques particularly in patients undergoing valvular surgery. Their established benefits for the patients are likely to cause their widespread use in the future. The purpose of this is to provide an overview of modern minimally invasive approaches in valvular surgery with an emphasis on aspects of the surgery relevant for cardiovascular pathologists.

The use of cardiopulmonary bypass (CPB) for locally advanced thoracic malignancies is highly controversial. The purpose of this study was to document the techniques and results of CPB to facilitate the resection of complex thoracic malignancies and to identify common themes that provided for successful outcomes. This was a retrospective study that took place from January 1992 to September 2002. Fourteen consecutive patients (median age, 59 years; age range, 18 to 69 years; seven men and seven women) underwent CPB during the resection of locally advanced thoracic malignancies at two Boston hospitals. CPB was planned in 8 of 14 patients (57%) with centrally located tumors, while 6 of 14 patients (43%) required emergent institution of CPB due to injury of the superior vena cava (2 patients), inferior vena cava (2 patients), or pulmonary artery (2 patients). Complete microscopic resection was achieved in 12 of 14 patients (86%). The operative mortality rate was 1 of 14 patients (7%) due to pulmonary embolism (ie, the elective group). The median ICU and hospital lengths of stay were 5 and 9 days, respectively. The overall 1-year, 3-year, and 5-year survival rates were 57%, 36%, and 21%, respectively. The planned use of CPB to facilitate complete resection of thoracic malignancies should be considered only after careful patient selection. The availability of CPB also provides a safety net in the event of injury to vascular structures during tumor resection.

Objective We began minimally invasive mitral valve surgery in August, 1996, to reduce hospital costs, to improve patient recovery, cosmetic appearance, and to decrease trauma, yet maintain the same quality of surgery. To validate this approach we reviewed our entire experience through May 2002. Methods From August 1996 to May 2002, we performed 413 minimally invasive mitral valve operations including 51 mitral valve replacements and 362 mitral valve repairs. Excluding 4 robotically assisted repairs, we evaluated 358 patients, using the mitral valve repairs as the basis for this retrospective survey. These operations were performed through a 6- to 8-cm minimally invasive incision, beginning with parasternal and, most recently, lower ministernotomy (181 patients). The mitral valve reparative techniques include repair of 94 prolapsed anterior leaflets, posterior leaflet resection, leaflet advancement, commissuroplasty, Polytetrafluoroethylene (PTFE; Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) chordal placement, and ring annuloplasty. Cannulation sites varied but primarily utilized a miniaturized system of 24F catheters in both the inferior and superior venae cavae with assisted venous suction. The Cosgrove ring was used in 95% of the patients undergoing this procedure. Results The operative mortality was 0/358. Perioperative morbidity included a 26% incidence of new atrial fibrillation, 2% incidence of pacemaker implantation, 0.5% incidence of deep sternal wound infection, and 1.9% incidence of stroke after an operation. There were 10 arterial and 3 venous complications. The mean length of stay was 6 days and 208 patients stayed ≤5 days. Only 25% of the patients underwent homologous blood transfusion. The mean follow-up was 36 months with 1.4% lost to follow-up. There were 12 late deaths and a survival at 5 years of 95%. There were 21 valves requiring reoperation for structural valve failure of 5.8%. The probability of freedom from reoperation at 5 years was 92%. Conclusion This study documents the safety of minimally invasive mitral valve repair surgery in 358 patients. It also documents a low incidence of homologous blood use, requirement for post–hospital rehabilitation, and general morbidity.

An important aspect of screen design is aesthetic evaluation of screen layouts. While it is conceivable to define a set of variables that characterize the key attributes of many alphanumeric display formats, such a task seems difficult for graphic displays because of their much greater complexity. This paper proposes a theoretical approach to capture the essence of artists' insights with 14 aesthetic measures for graphic displays. Our empirical study has suggested that these measures are important to prospective viewers and may help gain attention and build confidence in using computer system.

Background . Aortic valve surgery after coronary artery bypass grafting (CABG) in the setting of patent pedicled internal mammary artery (IMA) grafts poses a high risk because of the underlying ischemic and valve disease. Unlike mitral valve surgery or CABG, in which aortic clamping (AoX) may be optional, aortic valve surgery uniformly requires AoX unless circulatory arrest is used. Management of the IMA graft in these circumstances has traditionally involved dissection and clamping to prevent regional myocardial warming and cardioplegia "washout" during AoX. An alternative strategy involves avoiding dissection of the IMA, leaving the IMA graft open and establishing moderate-to-deep hypothermia during AoX and cardioplegic arrest. To date, no study has been published documenting the safety and efficacy of the latter practice. Methods . A total of 94 patients who had patent IMA graft and underwent aortic valve surgery under AoX and cardioplegia between April 1992 and March 2001 were analyzed. The IMA was avoided and left open during AoX, and the patients were cooled systemically (median 20°C). Patients ranged in age from 55 to 90 years (median 73.5 years). Ejection fraction was 15% to 83% (median 50%). Of the patients, 18 (19%) underwent minimally invasive upper hemi-resternotomy. Analysis for predictors of outcome was performed. Results . The operative mortality, perioperative myocardial infarction (MI), and stroke rates were 6.4%, 7%, and 11%, respectively. No significant independent predictors of operative mortality or MI could be identified in the multivariate analysis, although a trend was shown for operative mortality with urgent procedures and patients requiring concomitant surgery of the ascending or arch aorta or aortic root. Advanced age and prolonged cardiopulmonary bypass predicted stroke in the multivariate analysis. There were five (5%) IMA injuries, all occurring during reentry or mediastinal dissection, but none in the subgroup of patients who underwent minimally invasive procedures. All patients survived. Conclusions . Patients undergoing aortic valve surgery after CABG in the presence of patent IMA represent a potentially high-risk group. Because AoX is almost uniformly required, a decision regarding the management of the IMA pedicle is needed. We have found that leaving the IMA undissected and unclamped is a reasonable strategy, provided that systemic cooling for myocardial protection is established to prevent regional warming and to compensate for cardioplegia washout effect during AoX.

With recent improvements in microvascular techniques, the use of combined distal bypass and free-flap transfer has been advocated for salvaging the critically ischaemic limb in extreme conditions. Distal bypass, however, carries an inherent risk of graft failure due to thrombosis, and this may threaten the viability of the free flap and, indeed, the lower limb. We present the case of a 66-year-old man with acute-on-chronic ischaemia of his left leg and rectus abdominis free flap. Despite a prolonged ischaemic time of 72 h, both were successfully salvaged using catheter-directed recombinant tissue plasminogen activator. This is previously unreported in the literature.

A screen often has to present information clearly and also act as the locus for interacting with the system. This is a complex area, involving some psychological understanding, as well as aspects of graphical design. Although knowledge of the users' tasks and abilities is the key to designing effective screen displays, an objective, automatable metric of screen design is an essential aid. In this paper, we describe a new model for quantitatively assessing screen formats. The results of applying the model to data entry screens support the use of the model. We also describe a critiquing mechanism embedded in a user interface design environment as a demonstration of our approach.

Background . Reoperative coronary artery bypass grafting (CABG) through a left thoracotomy is a challenging operation with no one dominant approach. We developed a tailored strategy for this difficult group of patients, integrating the currently available newer technologies for each patient indication. Methods . Between October 1991 and October 1999, 50 consecutive patients underwent reoperative CABG through a left thoracotomy. Age was 65 ± 9 years, 40 (80%) were men, and preoperative ejection fraction was 40 ± 13. In 36 patients (72%) the left internal mammary artery had been placed to the left anterior descending coronary artery during the primary CABG and in 25 of 36 patients (70%) this left internal mammary artery–left anterior descending coronary artery graft was patent. The mean duration from previous CABG was 8.0 ± 4.8 years. Three approaches were used: (1) conventional cardiopulmonary bypass using fibrillatory or circulatory arrest (n = 33, 66%); (2) Heartport endoaortic balloon occlusion (n = 4, 8%); and (3) off-pump beating heart techniques (n = 13, 26%). Results . The off-pump CABG technique was used in the majority of recent patients and 1 (7.7%) had to be converted to cardiopulmonary bypass due to hemodynamic instability. When cardiopulmonary bypass was used its duration was 122 ± 59 minutes and mean temperature on bypass was 24° ± 6°C. In the 4 patients in whom the Heartport system was used, the median endo-aortic occlusion duration was 49 minutes. Patients received an average of 1.4 grafts/patient. In 60 of 70 patients (89%) distal anastomoses were performed to an anterolateral coronary target. There were 3 of 50 (6%) operative deaths, 2 in the conventional group and 1 in the endo-aortic balloon occlusion group. The mean length of stay in the 47 survivors was 7.8 ± 3.9 days (median, 7 days). Conclusions . Reoperative CABG by left thoracotomy remains a challenging operation. Several techniques, including off-pump CABG, conventional cardiopulmonary bypass, circulatory arrest, and endoaortic balloon occlusion, should be in the surgeon's armamentarium to allow a tailored approach for each operation based on patient indications.

Background: Neutrophils are major participants in myocardial reperfusion injury, but the relationship between ischemic time and the extent of the neutrophil sequestration in heart transplantation has not yet been systematically studied. This study was designed to determine whether increased ischemic time would cause greater neutrophil sequestration during reperfusion of the globally ischemic heart. Methods Rabbit hearts were arrested with cardioplegia, explanted, and subjected to either 1 or 4 hours of global ischemia at 4°C before being heterotopically transplanted into a recipient rabbit's abdomen for reperfusion. Each heart was reperfused for either 4, 8, or 12 hours. Between 3 and 7 hearts were studied (average = 5.8) for each combination of ischemic and reperfusion time (total = 35). A myeloperoxidase (MPO) assay was used to qualify neutrophil content. Results MPO activity (U/g wet weight) was not significantly different at 4, 8, and 12 hours of reperfusion (0.33 ± 0.05, 0.20 ± 0.04, 0.26 ± 0.04: p = 0.13), but was significantly increased at 4 hours compared to 1 hour ischemia (0.34 ± 0.04 vs 0.19 ± 0.03: p = 0.006). Interaction between ischemic and reperfusion times was not significant ( p = 0.12). MPO activity was below the measurable threshold in 5 freshly excised control hearts. Conclusions These results suggest that acute reperfusion injury will be more severe in the hearts subjected to 4 hours ischemia and indicate the need to consider neutrophil-mediated reperfusion injury when addressing cardioprotective interventions for cardiac preservation and reperfusion after transplantation. Neutrophil-mediated reperfusion injury of the rabbit myocardium after heterotopical transplantation is more severe in hearts subjected to 4 hours of ischemia vs 1 hour of ischemia prior to transplantation.

Background . Transmyocardial laser revascularization (TMR) has been established with the carbon dioxide (CO 2 ) laser. The largely unstudied excimer laser creates channels through chemical bond dissociation instead of thermal ablation, thereby avoiding thermal injury. We sought to compare the effects of CO 2 and excimer TMR in a porcine model of chronic ischemia. Methods . Pigs underwent ameroid constrictor placement on the circumflex artery to create chronic ischemia. TMR was performed with CO 2 (n = 8) or excimer (n = 8) laser 6 weeks later; controls (n = 7) had ameroid placement only. Regional myocardial blood flow (RMBF), determined by radioactive microspheres, and regional myocardial function, determined by percent segmental shortening (%SS), were assessed 18 weeks after ameroid placement. Results . Values are mean ± SD. In the ischemic zone, RMBF (mL/min/g) was improved in the CO 2 (0.73 ± 0.19) and excimer (0.78 ± 0.22) groups when compared with controls (0.55% ± 0.12%, p 2 (15.2% ± 5.5%) and excimer (15.3% ± 5.1%) groups when compared with controls (8.0% ± 4.2%, p Conclusions . Excimer and CO 2 TMR significantly improve RMBF and regional function in this porcine model of chronic myocardial ischemia despite fundamentally different tissue interactions.

An important aspect of screen design is aesthetic evaluation of screen layouts. While it is conceivable to define a set of variables that characterise the key attributes of many alphanumeric display formats, such a task seems difficult for graphic displays because of their much greater complexity. This article proposes a theoretical approach to capture the essence of artists’ insights with fourteen aesthetic measures for graphic displays. Our empirical study has suggested that these measures are important to prospective viewers and may help gain attention and build confidence in using computer systems.

Background . We developed a prosthetic left ventricle (LV) to coronary sinus (CS) shunt (LVCSS) that is autoregulating and provides LV-powered retrograde perfusion of the coronary sinus. Methods . Each of 20 Yorkshire pigs underwent 1 hour of left anterior descending diagonal artery occlusion followed by 3 hours of reperfusion. The controls (n = 5) did not have shunt treatment. The LVCSS group (n = 9) underwent shunt treatment during the ischemic period. The LVCSS with partial coronary sinus occlusion (PCSO) group (LVCSS+PCSO, n=6) underwent shunt treatment and PCSO during the ischemic period. Vital staining and planimetry techniques were used to determine the area at risk for infarction and the area of necrosis. Results . The area at risk was not significantly different among groups. The area of necrosis was decreased by 53% in the LVCSS group and by 73% in the LVCSS+PCSO group when compared to controls ( p Conclusions . The LVCSS reduces infarct size in pigs after acute coronary artery occlusion. The addition of PCSO to LVCSS further improves myocardial salvage.

Objective: Extremely thin and overly obese patients may not tolerate cardiac surgery as well as other patients. A retrospective study was conducted to determine whether the extremes of body mass index (weight/height2 [kg/m2]) and/or cachexia increased the morbidity and mortality associated with cardiac operations. Methods: Body mass index was used to objectively measure “thinness” (body mass index < 20) and “heaviness” (body mass index > 30); preoperative serum albumin was used to quantify nutritional status and underlying disease. Data were gathered between 1993 and 1997 from 5168 consecutive patients undergoing coronary artery bypass or valve operations, or both. Results: No significant correlations were observed between body mass index and preoperative albumin levels. Low body mass index (

This report documents our early experience with minimally invasive direct-access surgical repair of atrial septal defect (ASD) in adults. We have developed minimally invasive techniques for direct-access ASD repair in adults while maintaining the efficacy of the open operative procedure. Between June 1996 and September 1998, 59 consecutive patients underwent repair of ASD, 34 (58%) of whom underwent minimally invasive direct-access surgical closure of ASD through a right parasternal, submammary, or upper hemisternotomy incision. Twenty-three (68%) were secundum type ASD, 5 (15%) were sinus venosus types, 2 (6%) were primum types, and 4 (122%) were patent foramen ovales. Twenty-six (77%) were women (mean age 39 +/- 15 years, range 18 to 79). The mean pulmonary-to-systemic shunt ratio (Qp/Qs) was 2.3 +/- 0.6 (n = 15). There were no operative or late deaths. Follow-up was 100% complete. Four patients (12%) developed major complications. All were alive and well at the time of follow-up and there was 1 late arrhythmia (atrial fibrillation). In all but 1 patient, New York Heart Association functional class was improved or unchanged (1.47 +/- 0.51 vs 1.06 +/- 0.25, p = 0.0001). These results indicate that minimally invasive direct-access repair of ASD in adults is safe and effective, and is broadly applicable to the entire spectrum of defects.