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Background: Interventions in patients with a left ventricular assist device (LVAD) in the intensive care unit (ICU) are typically performed based on the results of conventional monitoring, such as vital signs and Swan-Ganz catheter (SGC) and LVAD parameters. These variables might not always accurately reflect a patient's cardiac function, volume status, and interventricular septal configuration, however. To assess the accuracy of standard monitoring, we performed routine continuous hemodynamic transesophageal echocardiography (hTEE) to evaluate cardiac function, volume status, and septal position., Methods: Between 2011 and 2015, 93 HeartMate II LVADs were implanted. The study group comprised 30 patients with an SGC in place who were monitored routinely by hTEE in the ICU every 1 to 3 hours until extubation. A total of 147 hTEE studies were analyzed retrospectively to observe differences between conventional monitoring and hTEE., Results: Among the 30 patients studied, 26 (87%) had at least 1 disagreement between conventional monitoring and hTEE findings. In 22 patients (73%), at least 1 of the hTEE studies was abnormal whereas conventional parameters were normal. Abnormal hTEE findings included a shift in the interventricular septum in 19 patients (63%), abnormal ventricular volume status in 22 patients (73%), and right ventricular failure in 9 patients (30%). Based on conventional monitoring, none of the patients required an LVAD speed change, whereas hTEE showed that 14 patients (47%) needed an LVAD speed adjustment., Conclusions: Conventional monitoring in the ICU might not provide an accurate representation of cardiac function, ventricular volume status, or septal position in patients with LVAD. Continuous monitoring with hTEE in patients with an LVAD may help guide optimal intervention in the ICU setting during the early postoperative period., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Systemic inflammatory response syndrome (SIRS) is frequently observed after extracorporeal membrane oxygenation (ECMO) decannulation; however, these issues have not been investigated well in the past., Methods: Retrospective chart review was performed to identify post-ECMO SIRS phenomenon, defined by exhibiting 2/3 of the following criteria: fever, leukocytosis, and escalation of vasopressors. The patients were divided into 2 groups: patients with documented infections (Group I) and patients with true SIRS (Group TS) without any evidence of infection. Survival and pre-, intra- and post-ECMO risk factors were analyzed., Results: Among 62 ECMO survivors, 37 (60%) patients developed the post-ECMO SIRS phenomenon, including Group I (n = 22) and Group TS (n = 15). The 30-day survival rate of Group I and TS was 77% and 100%, respectively (p = 0.047), although risk factors were identical., Conclusions: SIRS phenomenon after ECMO decannulation commonly occurs. Differentiating between the similar clinical presentations of SIRS and infection is important and will impact clinical outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Despite advances in medical care, survival to discharge and full neurologic recovery after cardiac arrest remains less than 20% after cardiopulmonary resuscitation. An alternate approach to traditional cardiopulmonary resuscitation is extracorporeal cardiopulmonary resuscitation, which places patients on extracorporeal membrane oxygenation during cardiopulmonary resuscitation and provides immediate cardiopulmonary support when traditional resuscitation has been unsuccessful. We report the results from extracorporeal cardiopulmonary resuscitation at the Thomas Jefferson University., Methods: Between 2010 and June 2014, 107 adult extracorporeal membrane oxygenation procedures were performed at the Thomas Jefferson University. Patient demographics, survival to discharge, and neurologic recovery of patients who underwent extracorporeal cardiopulmonary resuscitation were retrospectively analyzed with institutional review board approval., Results: A total of 23 patients (15 male and 8 female; mean age, 46 ± 12 years) underwent extracorporeal cardiopulmonary resuscitation. All patients who met criteria were placed on 24-hour hypothermia protocol (target temperature 33°C) with initiation of extracorporeal membrane oxygenation. The mean duration of extracorporeal membrane oxygenation support was 6.2 ± 5.5 days. Nine patients died while on extracorporeal membrane oxygenation from the following causes: anoxic brain injury (4), stroke (4), and bowel necrosis (1). Two patients with anoxic brain injury on extracorporeal cardiopulmonary resuscitation donated multiple organs for transplant. The survival to discharge was 30% (7/23 patients) with approximately 100% full neurologic recovery., Conclusions: The extracorporeal cardiopulmonary resuscitation procedure provided reasonable patient recovery. Extracorporeal cardiopulmonary resuscitation also allowed for neurologic recovery and made multiorgan procurement possible. On the basis of the survival, extracorporeal cardiopulmonary resuscitation should be considered when determining the optimal treatment path for patients who need cardiopulmonary resuscitation. The proper use of extracorporeal cardiopulmonary resuscitation improved the hospital outcomes for patients with in-hospital cardiac arrest., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The precise comparison of the voice characteristics of Parkinson disease (PD) patients with age-matched normal subjects is still one of the important research projects. The present study aimed at comparing the voice characteristics in sustained phonations of PD patients with an age-matched control group., Methods: The subjects were 30 Japanese PD patients (15 males and 15 females). The control group consisted of 30 age-matched normal Japanese subjects (15 males and 15 females). Each subject was required to phonate into a mouthpiece attached to Vocal Function Analyzer (PS-77E; Nagashima Medical Instrumental Corporation, Tokyo, Japan) with the airway interruption system, and expiratory lung pressure, mean flow rate, fundamental frequency and intensity of voice, and pitch range were measured. Maximum phonation time was also assessed., Results: The highest pitch level was significantly lower in the PD group than that of the control group in both sexes, whereas the lowest pitch level was significantly higher in the PD group only in males. In both sexes, the pitch range was significantly narrower in the PD group than in the control group. There was no significant difference in intensity, mean flow rate, expiratory pressure, or maximum phonation time between the two groups, for both males and females., Conclusion: Only remarkable difference in the voice characteristics between PD patients and age-matched normal elderlies was limited to the narrowing of the pitch range in PD patients. The restriction in pitch regulation in PD patients was considered to be because of difficulty in reciprocal control of the laryngeal muscles secondary to latent rigidity., (Copyright © 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been used for profound cardiogenic shock to bridge to decision, ventricular assist device(s) (VADs), or transplant. To assess ventricular function and volume status along with hemodynamics during ECMO weaning, we developed a standardized weaning protocol, guided by a miniaturized transesophageal echocardiography probe designed for continuous hemodynamic monitoring (hemodynamic transesophageal echocardiography [hTEE]). We reviewed our experience with this weaning protocol with hTEE guidance to assess if we could predict patient outcomes., Methods: During the academic year of 2011, hTEE-guided ECMO weaning was performed in 21 patients on VA ECMO. Left and right ventricular function and volume status were assessed by continuous hTEE, while attempting to wean ECMO after a standardized protocol. The clinical outcomes, management, and positive predictive value of the device were investigated and analyzed for this cohort of patients., Results: Of the 21 patients, 6 (29%) had left and right ventricular recovery and underwent optimal medical therapy or revascularization for underlying coronary artery disease; 7 (33%) had nonrecoverable left and right ventricular function; and 8 (38%) had right ventricular recovery without improvement of the left ventricular function. These 8 patients underwent left VAD placement; none subsequently developed profound right ventricular failure. The positive predictive value for ventricular recovery by hTEE was 100% using our standardized ECMO weaning protocol (95% confidence interval, 73%-100%)., Conclusions: The hTEE-guided ECMO weaning protocol accurately predicted the ability to wean ECMO to decision. This protocol can be applied by cardiac intensivists as a part of standard bedside intensive care unit assessment., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Proper valve selection is critical to ensure appropriate valve replacement for patients, because implantation of a small valve might place the patient at risk for persistent gradients. Labeled valve size is not the same as millimeter measure of prosthetic valve diameters or the annulus into which it will fit. Studies that use the labeled valve size in lieu of actual measured diameter in millimeters to compare different valves might be misleading. Using human cadaver hearts, we sized the aortic annulus with 8 commonly used prosthetic aortic valve sizers and compared the valves using geometric orifice area. This novel method for comparing prosthetic valves allowed us to evaluate multiple valves for implantation into the same annulus., Methods: Aortic annular area was determined in 66 cadavers. Valve sizers for 8 prosthetic valves were used to determine the appropriate valve for aortic valve replacement. Regression analyses were performed to compare the relationship between geometric orifice area and aortic annular area., Results: Tissue valves had a larger orifice area for any annular size but were not different at small sizes. Supra-annular valves were larger than intra-annular valves for the small annulus, but this relationship was not uniform with increasing annular size., Conclusions: Labeled valve size relates unpredictably to annular size and orifice area. No advantage in geometric orifice area could be demonstrated between these tissue valves at small annular sizes. Valves with the steepest slope on regression analysis might provide a larger benefit with upsizing with respect to geometric orifice area.

Objective: We have used artificial chordal replacement with expanded polytetrafluoroethylene sutures for mitral valve repair in children and reported favorable early clinical results. In this article we evaluate the midterm results of mitral valve repair with expanded polytetrafluoroethylene sutures in 39 children., Methods: From April 1995 through September 2003, mitral valve repair with chordal replacement using expanded polytetrafluoroethylene sutures was performed in 39 patients. In all patients the preoperative grade of mitral regurgitation was moderate or more because of prolapse of the anterior mitral leaflet. The mean age and body weight at the time of the operation were 4.7 +/- 5.3 years (range, 1 month to 17.8 years) and 14.4 +/- 12.2 kg (range, 3.9-54.4 kg), respectively. The number of expanded polytetrafluoroethylene sutures ranged from 1 to 3 (mean, 1.4). The mean follow-up period and body weight at the latest follow-up were 5.0 +/- 2.3 years (range, 1.1-8.5 years) and 25.7 +/- 16.4 kg (range, 6.9-73 kg), respectively., Results: There were no operative or late deaths. Only one patient required mitral valve replacement, which occurred 17 days after repair. Two patients underwent redo mitral valve repair 2 and 5 years after initial repair, respectively. The actuarial freedom from reoperation at 5 and 8 years was 94.8% and 89.5%, respectively. At the latest follow-up, trivial or less mitral regurgitation was observed in 33 (84.6%) patients., Conclusions: Mitral valve repair with expanded polytetrafluoroethylene sutures in children demonstrated favorable midterm outcome. The procedure is safe and effective, with potential for patients' growth.

Background: In acute type A dissection, replacing the ascending aorta with the transverse aortic arch recently has been recommended for event-free long-term survival. Since 1994, we have performed our new transverse aortic arch replacement, in which the distal end of the graft is anastomosed between the left common carotid artery and the left subclavian artery to reduce the risk by obtaining a good surgical view, resulting in good hemostasis. The "elephant trunk technique" was used in anticipation of a staged descending aortic operation for residual dissecting aorta. We analyzed the surgical survival of patients with Stanford type A aortic dissection undergoing our operative procedure using hypothermic selective antegrade cerebral perfusion., Methods: We performed our new technique in 27 patients (aged 61 +/- 11 years, 15 male and 12 female patients, 22 patients with acute type A dissection, and 5 patients with chronic dissection)., Results: One in-hospital death (3.7% in total: 4.5% in acute dissection, 0% in chronic dissection) occurred in patients undergoing our new technique. Actuarial survival (including early death) was 91% at 5 years after the operation. One late death occurred as the result of a malignant tumor. Four patients underwent a staged reoperation for aneurysmal dilatation of the residual descending aorta or renal and splenic embolism as the result of thrombus from the false lumen 2 to 11 months (mean interval 6 months) after the initial operation. They have been doing well since the reoperation., Conclusions: Our "distal anastomosis to the proximal level of the distal aortic arch" technique made aortic arch replacement easier and improved the survival of the arch replacement for aortic dissection, especially for acute type A dissection, by securing hemostasis in the suture line. Combining the elephant trunk technique with our new procedure is useful to perform a staged aortic replacement for dilatation and complication of the false lumen in the descending aorta.

Background: Off-pump coronary artery bypass grafting (CABG) has been performed since 1996 in our institute, and its application has recently been expanded to patients with three-vessel disease. A study was performed to clarify the benefit of off-pump CABG for patients with three-vessel disease., Methods: Between June 1, 1991 and September 30, 2001, a total of 1089 patients with three-vessel disease (832 men and 257 women; mean age, 64.0 +/- 9.1 years) underwent on-pump CABG. After 1997, a total of 310 patients with three-vessel disease (223 men and 87 women; mean age, 68.8 +/- 8.6 years) underwent off-pump CABG. Data of the historical cohort of on-pump CABG and the concurrent cohort of off-pump CABG were analyzed retrospectively., Results: The 2 groups were age and gender matched. Significant comorbidities were more often observed in the off-pump group than in the on-pump group. The mean number of bypass grafts in the off-pump versus on-pump CABG was 3.3 vs 3.7, P <.0001. The mean intubation period, intensive care unit stay, and postoperative hospital stay were 7.9 vs 11.7 hours, 2.2 vs 3.0 days, and 14.5 vs 17.5 days, respectively (P <.0001). In-hospital mortality rate (0.6% vs 1.2%, respectively) and morbidity rates (10.3% vs 12.9%, respectively) were not significantly different. After surgery, calculated event-free rates at 2 years were 93.3% vs 91.9%, respectively; P = not significant., Conclusions: In patients with multivessel disease, off-pump CABG provided early recovery, and its complication rates and early follow-up results were equivalent to on-pump CABG.

A voice therapy program using pushing exercises to correct glottal incompetence is described. The program utilizes various types of instrumentation to determine whether or not a given patient is likely to benefit from the treatment. The program also provides feedback of target voices. Three cases with incomplete glottal closure and subsequent vocal dysphonia characterized by an asthenic breathy quality are used to illustrate the program. Details of the program, termination criteria, and problems and precautions learned from treating 29 patients over a 3-year period are presented.

Right ventricular function was assessed by regional wall motion analysis and by global function in 62 patients after repair for tetralogy of Fallot. Its relation to surgical procedures, with special attention to right ventriculotomy, was investigated. Patients were classified as follows: group Ia (n = 17), transpulmonary-transatrial repair without right ventriculotomy; group Ib (n = 22), transpulmonary-transatrial repair with minimal right ventriculotomy and small transannular patch; and group II (n = 23), transventricular repair with or without transannular patch. For regional wall motion analysis, fractional area change was used for three anterior parts obtained from hemiaxis area analysis of the lateral right ventriculogram. Ejection fractions were used for global right ventricular function. Functional assessment was done both at rest and during isoproterenol infusion, which is a stress test to evaluate cardiac functional reserve. At rest, group Ia showed better right ventricular anterior wall motion as well as global ejection fraction than did group II. Group Ib showed a global ejection fraction comparable to group Ia, with better regional wall motion in the middle anterior part of the right ventricle despite the depressed upper and lower anterior parts of the right ventricle. Group II showed depressed wall motion of the middle anterior part and the resultant impaired global ejection fraction. During isoproterenol infusion, group Ia showed significant increase in fractional area change of all anterior parts and in global ejection fraction. Group Ib showed significant increases in fractional area change at the middle and lower parts and in global ejection fraction comparable with group Ia. Otherwise, group II showed no significant change in fractional area change, or in global ejection fraction, at the upper and middle parts. These results indicated that transpulmonary-transatrial repair for tetralogy of Fallot provided better postoperative global right ventricular function and its reserve, with less impaired regional wall motion, than did the transventricular repair.

A new model of complete right heart bypass was devised in dogs. All systemic venous blood was directly led to the bilateral pulmonary arteries by end-to-side superior vena cava-right pulmonary anastomosis, diverting the inferior vena caval blood to the superior vena cava with a graft, ligating the inferior vena cava at its end and the pulmonary artery at its trunk, and shunting the coronary venous return from the right-ventricle to the left atrium. Nine consecutive dogs tolerated the procedures, and acute hemodynamic characteristics and responses to vasoactive drugs were observed for 5 hours throughout the following full studies. Cardiac output ranged from 66 to 102 ml/min/kg at a central venous pressure of 15 to 26 mm Hg. Norepinephrine, isoproterenol, and phentolamine were administered with the central venous pressure maintained constant at 18 mm Hg. Isoproterenol and phentolamine increased cardiac output while reducing pulmonary and/or systemic vascular resistance, with a possible concomitant inotropic effect in the former. Norepinephrine was detrimental, causing an increase in both pulmonary and systemic vascular resistance.

From January 1972 to December 1984, 347 consecutive patients underwent open mitral commissurotomy for mitral stenosis. Commissurotomy was performed in 86% of 404 patients undergoing mitral valve operations for stenosis during the same period. These 347 patients had three different types of mitral stenosis: type I, mobile cusps without subvalvular changes (43 patients); type II, thickened cusps with subvalvular changes (210 patients); type III, rigid cusps with severe subvalvular changes (94 patients). Concomitant mild mitral regurgitation was seen in 87 patients (25.1%) and mild to moderate valve calcification in 61 patients (17.6%). There were eight early deaths (2.3%) and 12 late deaths (3.5%), yielding an actuarial survival rate of 94.6% (excluding early deaths) 14 years after operation. There were 17 reoperations (5.0%) The actuarial rates of freedom from reoperation were as follows: 83.8% at 14 years for the entire series; 73.5% for type I stenosis; 88.9% for type II; 84.0% for type III; 91.7% for mitral stenosis with calcification; 82.6% for stenosis without calcification; 90.6% for pure mitral stenosis; and 52.5% for stenosis combined with regurgitation (p less than 0.05). Postoperative effective mitral valve areas calculated according to the hydraulic formula were 2.52 cm2 (mean) at rest and 3.06 cm2 during exercise in six patients with type I stenosis, 2.21 and 2.48 cm2, respectively, in 10 with type II, and 1.85 and 1.87 cm2, respectively, in 14 with type III. Our data clearly demonstrated that open mitral commissurotomy provided excellent long-term results with acceptable valve function and a low incidence of reoperation in patients with pure mitral stenosis not combined with regurgitation, even when associated with severe subvalvular changes with or without mild to moderate valve calcification.

Eighty-eight patients with tetralogy of Fallot and two patients with ventricular septal defect and pulmonary atresia underwent repair without right ventriculotomy (n = 43) or with a minimal right ventriculotomy (n = 47) of 10 to 15 mm. The ventricular septal defect was closed through the tricuspid valve in 75 patients. The pulmonary valve was either preserved or reconstructed to maintain its competence. The age at operation was 1 or 2 years in 51 patients. There was one operative death and there were no late deaths. The results of postoperative cardiac catheterization in the present series of patients (n = 34) were compared with those of control patients (n = 21) who had repairs with a conventional right ventriculotomy in the preceding period. There was no significant difference in right ventricular/left ventricular systolic pressure ratio or in cardiac index either at rest or during isoproterenol infusion between the two groups. The incidence of significant pulmonary regurgitation (Grade greater than or equal to 2/4) was less (p less than 0.05) in the present patients (47%, n = 34) than in the control patients (81%, n = 21). The right ventricular end-diastolic volume index (ml/m2) was smaller in the present patients than in the control patients both at rest (91 +/- 37 versus 142 +/- 28, p less than 0.01) and during isoproterenol infusion (81 +/- 21 versus 109 +/- 30, p less than 0.01). The right ventricular ejection fraction was higher in the present patients than in the control patients during isoproterenol infusion (57% +/- 4% versus 49% +/- 6%, p less than 0.01). The incidence of ventricular arrhythmias (Lown's grade greater than or equal to 2) was less in the present patients (6/35) than in the control patients (36/65) (p less than 0.005). This method of repair for tetralogy of Fallot carries no more risk than the conventional method, and the results are better with respect to postoperative right ventricular function and ventricular arrhythmia.

In five patients (aged 5 to 11 years) with atrioventricular discordance, pulmonary stenosis or atresia, and origin of the aorta from the right ventricle, transaortic closure of the ventricular septal defect was performed. Double-outlet right ventricle was confirmed in four patients. All patients underwent placement of an extracardiac valved conduit from the anatomic left ventricle to the pulmonary artery. Neither operative death nor postoperative complete heart block resulted. Postoperative follow-up periods were from 3 months to 4 years (average 35 months), and one patient who had no evidence of complete heart block died suddenly 2 years postoperatively. Aortic regurgitation developed in two patients from possible trauma during the operation: Regurgitation was mild (causing symptoms) in one patient who had had poor surgical exposure with a subpulmonic ventricular septal defect and a well-developed subaortic conus; it was trivial (asymptomatic) in the other patient. Transaortic ventricular septal defect closure, suturing a patch on the anatomic left ventricular side in patients with atrioventricular discordance and double-outlet right ventricle or similar anomalies, might help to avoid postoperative complete heart block if the aorta is large and the subaortic conus is not well developed.

Acute liver dysfunction was analyzed in 15 patients who received a modified Fontan operation for single ventricle in nine (atrial isomerism, seven) and tricuspid or mitral atresia in six. Nine patients had elevation of serum glutamic-pyruvic transaminase levels above 1000 U/L during the first week. As an analysis of postoperative liver function during the first week, the highest values of serum glutamic-pyruvic transaminase and total bilirubin and the lowest prothrombin time were scored from 0 to 4 within each parameter, and totaled to give a liver dysfunction score. The liver dysfunction score was 0 to 2 (no or trivial injury) in five patients, 3 to 5 (mild) in two, and 6 to 11 (moderate or severe) in eight (53.3%). The group operated on for single ventricle had a higher incidence (67%) of a liver dysfunction score of 6 or higher than the other group (33%). A multivariate analysis for the prediction of the liver dysfunction score mainly from early postoperative hemodynamics showed the highest correlation with cardiac index, followed by urine output, systolic arterial pressure, and central venous pressure. One patient required plasmapheresis. Four died early (less than 1 month); three of these had a liver dysfunction score of 6 or higher. Those with scores of 6 or above had higher serum glutamic-pyruvic transaminase levels at 1 month after operation than those with scores less than 5. In three patients (single ventricle), hepatic venous oxygen saturation was monitored and showed a marked decrease to below 20% with subsequent acute liver dysfunction. These results indicate that acute liver dysfunction appears to occur in patients with complex lesions after a modified Fontan operation from possible hepatic hypoperfusion and that low cardiac output may be more crucial than high central venous pressure alone.

Between 1968 and 1985, 133 consecutive patients underwent bicuspidalization annuloplasty for moderate to severe functional tricuspid regurgitation associated with mitral or combined mitral and aortic valve disease. Over this period, the incidence of tricuspid valve replacement was only 2.3% (3/136 patients). There were 18 early deaths (13.5%) in the entire series--three (5.0%) of 60 patients in the last 5 years of the study--and 10 late deaths (8.7%). Actuarial survival rate for the entire series, excluding early deaths, was 91.0% +/- 3.0% at 10 and 17 years. There were seven reoperations (6.1%) on the tricuspid valve, needed because of residual or recurrent mitral valve lesions after the initial operation. Actuarial rates of freedom from reoperation on the tricuspid valve were 93.6% +/- 3.0% (10 years) and 69.7% +/- 16% (17 years) for the entire series: 78% +/- 10% (15 years) for the open mitral commissurotomy plus tricuspid annuloplasty group (44 patients); 90% +/- 9.0% (15 years) for the mitral plus tricuspid annuloplasty group (10); 75.2% +/- 22% (17 years) for the mitral replacement plus tricuspid annuloplasty group (58); and 92.6% +/- 7.0% (16 years) for the combined aortic and mitral valve surgery plus tricuspid annuloplasty group (21). Ninety-eight percent of the survivors were in New York Heart Association class I or II postoperatively. Of 21 randomly selected patients investigated by pulsed Doppler echocardiography, 14 (67%) had no regurgitation or grade 1/4 tricuspid regurgitation and the remaining seven (33%) had grade 2/4 regurgitation postoperatively. Our experiences suggest that bicuspidalization annuloplasty can be a reliable method in the vast majority of patients with functional tricuspid regurgitation.

Four patients with presently uncorrectable cyanotic cardiac anomalies underwent a new operation, "total cavopulmonary shunt operation" or "total right heart bypass operation." These anomalies included single ventricle, single atrium, common atrioventricular valve with or without regurgitation, pulmonary stenosis, and most important, absent inferior vena cava with azygos or hemiazygos continuation. All patients had had previous systemic-pulmonary shunts. The new operation consisted of end-to-side anastomosis between the superior vena cava with azygos or hemiazygos continuation and the confluent pulmonary artery, division or ligation of the pulmonary artery trunk, and replacement of the common atrioventricular valve when regurgitation was present. Thus total venous return, except for hepatocardiac venous and coronary sinus flow, drains directly into the pulmonary artery, bypassing the right atrium and ventricle. Three patients survived the operation, and two of the three patients are now alive 4 years, 8 months and 2 years, 6 months after the operation. The two long-term survivors are in significantly improved condition, both clinically and hemodynamically. We believe that this new operation is promising in the treatment of the otherwise uncorrectable complex cardiac anomalies associated with azygos or hemiazygos continuation of the inferior vena cava. A longer follow-up is certainly mandatory before final conclusions can be reached.

Extended operation for lung cancer and mediastinal carcinoma involving the aortic arch or superior vena cava was performed in six patients. In three patients with lung cancer invading the right side of the mediastinum, sleeve pneumonectomy (two patients) or sleeve lobectomy was followed by resection and reconstruction of the superior vena cava with ringed polytetrafluoroethylene grafts. One patient with squamous cell carcinoma and T4 N1 M0 disease was alive and free of disease more than 34 months after the operation. The other patients with adenocarcinoma (T4 N1 M0) and adenosquamous cell carcinoma (T4 N2 M0) died 18 and 5 months after the operation of systemic metastases. In two patients with invasion of lung cancer into the left side of the mediastinum, resection and reconstruction of the aortic arch and left common carotid artery were performed by a femoro-femoral bypass. These patients had adenocarcinoma (T4 N2 M0) and large cell carcinoma (T4 N1 M0) and died of systemic metastases and bleeding during reoperation 12 and 4 months after the initial operation. In one patient with mediastinal squamous cell carcinoma, resection and reconstruction of the aortic arch and left subclavian artery were performed by application of a temporary bypass graft between the ascending and descending aorta. This patient was alive and free of disease more than 17 months after the operation.

The relationship between the perfusion flow rate and cerebral oxygen consumption during deep hypothermic cardiopulmonary bypass at 20 degrees C was investigated in dogs. In 10 dogs the perfusion flow rate was decreased in steps from 100 to 60, 30, and 15 ml/kg/min every 30 minutes. Although cerebral blood flow decreased as perfusion flow rate decreased, the ratio of cerebral blood flow to the perfusion flow rate increased significantly (p less than 0.05) at a perfusion flow rate of 15 ml/kg/min compared to that at a perfusion flow rate of 100 or 60 ml/kg/min. The arterial-sagittal sinus blood oxygen content difference increased as perfusion flow rate decreased. Consequently, cerebral oxygen consumption did not vary significantly at perfusion flow rates of 100 (0.48 +/- 0.10), 60 (0.43 +/- 0.14), and 30 ml/kg/min (0.44 +/- 0.12 ml/100 gm/min), and it decreased significantly to 0.31 +/- 0.22 ml/100 gm/min at a perfusion flow rate of 15 ml/kg/min. In five dogs the perfusion flow rate was decreased in one step from 100 to 15 ml/kg/min, and after 60 minutes' perfusion at a perfusion flow rate of 15 ml/kg/min, the perfusion flow rate was returned to 100 ml/kg/min. Cerebral oxygen consumption decreased significantly during 60 minutes' perfusion at a perfusion flow rate of 15 ml/kg/min and did not return to its initial value after the perfusion flow rate was returned to 100 ml/kg/min. These data indicate that the optimal perfusion flow rate for the brain during deep hypothermic cardiopulmonary bypass at 20 degrees C appears to be 30 ml/kg/min, with a possible oxygen debt in the brain resulting in anaerobic metabolism if the perfusion flow rate is kept at 15 ml/kg/min or less.