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Objectives: Both partial and complete annuloplasty rings are used for mitral valve repair for patients with functional mitral regurgitation (FMR). We sought to determine if recurrence of mitral regurgitation (MR) is affected by the type of ring used., Methods: Five hundred forty-eight patients diagnosed with FMR underwent mitral valve repair with ring annuloplasty between 1998 and 2008 in our institution. Medical records were reviewed retrospectively for clinical and echocardiographic data to determine the presence of recurrent MR (defined as moderate or severe)., Results: Among 479 patients for whom postoperative echocardiographic data were available, recurrent MR occurred less frequently in the complete versus partial ring group (20 of 209 [10%] vs 56 of 270 [21%] patients; P = .001), despite lower preoperative ejection fractions in the complete ring group (median, 35%; interquartile range, 25%-45% vs median, 40%; interquartile range, 30%-55%; P < .001). Kaplan-Meier analysis demonstrated greater freedom from recurrent MR in the complete ring group (108 vs 103 months; P = .001). Risk-matched propensity analysis of 102 patients per group (area under the curve, 0.824; 95% confidence interval, 0.788-0.861; P < .001) also demonstrated that complete ring recipients had greater freedom from recurrent MR than partial ring recipients by univariate analysis (7 [7%] vs 17 [17%] patients; P = .049), and a trend toward greater freedom by Kaplan-Meier analysis (110 vs 104 months; P = .068)., Conclusions: The use of complete mitral annuloplasty rings provides improved freedom from recurrent MR in patients with FMR., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Minimal-access approaches through upper hemisternotomy is an established technique for aortic valve replacement (AVR) and aortic surgery in our institution. We assessed the outcome of undergoing AVR with concomitant aortic surgery through upper hemisternotomy., Methods: We retrospectively reviewed 109 patients from January 2002 to May 2011 who had AVR with concomitant aortic surgery through upper hemisternotomy. Aortic valve replacement with supracoronary ascending aortic replacement was performed in 65 patients; AVR with ascending and proximal arch replacement, in 8 patients; AVR with aortoplasty, in 11 patients; Bentall procedure, in 8 patients; and AVR with root enlargement, in 13 patients. In-hospital outcomes and 1- and 5-year survival were examined., Results: The mean age was 58.5 years (range, 23-89 years); 41.3% of patients had bicuspid aortic valve (n = 45). Of the patients, 82.6% had true aneurysm (n = 90), 2.8% had calcified aorta (n = 3), 8.3% had small annulus (n = 9), and 3.7% had calcified annulus (n = 4). There were 6 (5.5%) reoperations and 15 (13.8%) urgent cases. Mean perfusion time was 152 ± 61 minutes, and cross-clamp time was 108 ± 47 minutes. Nine cases were performed with deep hypothermic circulatory arrest (8.3%). Operative mortality was 2.8% (n = 3). There were 4 (3.7%) cases with reoperation for bleeding, 2 (1.8%) myocardial infarctions, and 2 (1.8%) new-onset renal failure. Mean length of stay was 7.1 ± 5.6 days. Kaplan-Meier analysis showed that 1-year postoperative survival was 96.2% and 5-year survival was 92.4%., Conclusions: An upper hemisternotomy approach is safe and feasible for AVR and concomitant aortic surgery with good early and midterm outcomes. This approach is also associated with low morbidity rate and short length of stay.

Objective: Risk-stratifying algorithms are currently used to determine which patients may be at prohibitive risk for surgical aortic valve replacement, and thus candidates for transcatheter aortic valve implantation. Minimally invasive surgical approaches have been successful in reducing morbidity and improving survival after aortic valve replacement, especially in octogenarians. We documented outcomes after minimally invasive aortic valve replacement in high-risk octogenarians who may be considered candidates for percutaneous/transapical aortic valve replacement., Methods: From 1996 to 2009, minimally invasive aortic valve replacement was performed in 249 consecutive octogenarians. We used the modified European System for Cardiac Operative Risk Evaluation and Society of Thoracic Surgeons score to risk-stratify patients and characterize all early and late results., Results: The mean age at operation was 84±3 (range 80-95) years, and 111 patients (45%) were male. Twenty-one percent (n=52) had previous cardiac surgery. Operative mortality was 3% (n=8/249). The median modified European System for Cardiac Operative Risk Evaluation (11%; interquartile range, 6-14) and Society of Thoracic Surgeons score (10.5%; interquartile range, 7-17) were not predictive of 30-day mortality in this cohort of patients (European System for Cardiac Operative Risk Evaluation c-index=0.527, P=.74, Society of Thoracic Surgeons score c-index=0.67, P=.18). Despite their poor predictive power, the Society of Thoracic Surgeons score and European System for Cardiac Operative Risk Evaluation were correlated with each other (r=0.40, P<.0001). Postoperative complications included stroke in 10 patients (4%), pneumonia in 3 patients (1%), renal failure requiring dialysis in 2 patients (1%), cardiac arrest in 2 patients (1%), pulmonary embolism in 1 patient (1%), and sepsis in 1 patient (1%). Follow-up was available for 238 patients (96%) and extended up to 12 years. Overall, long-term survival after minimally invasive aortic valve replacement at 1, 5, and 10 years was 93%, 77%, and 56%, respectively. There was no significant difference in long-term survival compared with that of a US age- and gender-matched population (standardized mortality ratio, 1.01; 95% confidence interval, 0.76-1.37; P=.88). A multivariate Cox-proportional hazards model indicated that increasing age (hazard ratio, 1.10; P=.008) and severe chronic obstructive pulmonary disease (hazard ratio, 2.52; P<.007) were significant predictors of survival. By using these factors, a clinical prediction model (P=.02) was developed and demonstrated that low-risk patients (first quartile prediction score) had 1-, 5-, and 8-year survival of 94%, 84%, and 67%, whereas high-risk patients (third quartile prediction score) had 1-, 5-, and 8-year survival of 89%, 74%, and 49%, respectively., Conclusions: Patients thought to be high-risk candidates for surgical aortic valve replacement have excellent outcomes after minimally invasive surgery with long-term survival that is no different than that of an age- and gender-matched US population. These data provide a benchmark against which outcomes of transcatheter aortic valve implantation could be compared., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Ventricular assist device (VAD) support inpatients with a prosthetic heart valve had previously been considered a relative contraindication due to an increased risk of thromboembolic complications. We report our clinical experience of VAD implantation in patients with prosthetic heart valves, including both mechanical and bioprosthetic valves. The clinical records of 133 consecutive patients who underwent VAD implantation at a single institution from January 2002 through June 2009 were retrospectively reviewed. Six of these patients had a prosthetic valve in place at the time of device implantation. Patient demographics,operative characteristics, and postoperative complications were reviewed.Of the six patients,four were male.The mean age was 57.8 years (range 35–66 years). The various prosthetic cardiac valves included a mechanical aortic valve (n = 2), a bioprosthetic aortic valve (n = 3), and a mechanical mitral valve (n = 1).The indications for VAD support included bridge to transplantation (n = 2), bridge to recovery (n = 1), and postcardiotomy ventricular failure(n = 3). Three patients underwent left ventricular assist device placement and three received a right ventricular assist device. Postoperatively, standard anticoagulation management began with a heparin infusion (if possible)followed by oral anticoagulation.The 30-day mortality was50% (3/6). The mean duration of support among survivors was 194.3 days (range 7–369 days) compared with 16.0 days(range 4–29 days) for nonsurvivors. Of the three survivors,two were successfully bridged to heart transplantation and one recovered native ventricular function.Among the three nonsurvivors,acute renal failure developed in each case, and two developed heparin-induced thrombocytopenia. This study suggests that VAD placement in patients with a prosthethic heart valve, either mechanical or bioprosthetic,appears to be a reasonable option.

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., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery., Methods: From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed., Results: Median patient age was 68 years (range: 24-95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (> or =80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time., Conclusions: Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly.

The safety and benefit of minimally invasive aortic valve replacement in patients with left ventricular dysfunction has not been well investigated. We conducted a retrospective review of 140 patients with ejection fraction

Background and Aim of the Study: Between January 1998 and March 2004, a total of 1,596 mitral valve repairs was performed at the authors' institution. Among these operations, 23 constituted re-repair of previously repaired mitral valves. The cases were analyzed retrospectively to ascertain the etiology of the failed repair, the technical considerations of re-repair, and outcome., Methods and Results: Previous repairs were performed for myxomatous valve disease in 14 of 23 patients. In seven patients recurrence occurred within three months of the original procedure (two as a result of infective endocarditis and five after technical failure). Incorrect annuloplasty ring size or failure to use a ring, resulting in progressive annular dilatation with or without new valvular dysfunction, were the main causes of delayed recurrence of mitral regurgitation (i.e. more than one year after the original repair procedure). Most patients (n = 12) required a new annuloplasty ring and additional repair procedures. Two patients died within the immediate post-operative period, and five died subsequently from non-cardiac causes during a mean follow up period of 24 months. Among the remaining 16 patients, 13 were free from mitral regurgitation at follow up and two required subsequent mitral valve replacement., Conclusion: Re-repair of the mitral valve is a technically feasible operation that can be safely performed with good functional results. It is, however, associated with some increase in postoperative morbidity and mortality due to the reoperative setting.

We present a series of 405 consecutive patients aged > or =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.

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 < or =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.

Objective: We developed techniques for 'inverted T' partial upper re-sternotomy for aortic valve replacement (AVR) or re-replacement (AVreR) after previous cardiac surgery. We previously reported on decreased blood loss, transfusion requirements and total operative duration when compared to conventional full re-sternotomy. This report updates our series, one of the few to document a substantial benefit from a 'minimally-invasive' approach, refines a number of technical aspects of this new approach and reports follow-up., Methods: Between November 1996 and December 1999, we performed 34 AVRs or AVreRs after previous cardiac surgery by use of an 'inverted T' partial upper re-sternotomy. There were 25 (74%) men. Median ejection fraction was 54%, range 15-80%. Median age was 72, range 38-93. All were New York Heart Association functional class (NYHA) functional class II or III. Twenty-one (62%) had previous coronary artery bypass grafts (CABG) while 14 (41%) had previous valve surgery. Follow-up was 100% complete for a total of 593 patient months (median 19 months)., Results: Twenty-three (66%) underwent AVR of the native aortic valve while 11 (33%) underwent AVreR of a prosthetic aortic valve. There were no intraoperative or valve-related complications, and no conversion to full re-sternotomy was necessary. There were two (5.9%) operative deaths from an arrhythmia on postoperative day 4 and a large stroke during surgery, respectively. Twenty-four (75%) patients were free of major complications. There was no need for reoperation for bleeding and patients required a median of two units of packed red blood cells. Complications included new atrial fibrillation (n=3, 9%), pacemaker implantation (n=3, 9%) and deep sternal wound infection (n=2, 6%). Median lengths of stay in the intensive care unit (ICU) and in the hospital were 1 and 7 days, respectively. There was one (3%) late deep sternal wound infection and 2/32 (6%) late deaths due to congestive heart failure at 22 months and myocardial infarction at 23 months, respectively., Conclusions: Partial upper re-sternotomy presents a safe and effective alternative approach to AVR and AVreR after previous cardiac surgery, and is associated with low morbidity and mortality.

We review our experience with minimally invasive direct access (MIDA) heart valve surgery in 518 patients. Two hundred fifty-two patients underwent MIDA aortic valve replacement (AVR) or repair and 266 underwent MIDA mitral valve repair or replacement. Among the 250 AVRs, 157 (63%) were men, aged 63.2 +/- 14.6 years, NYHA functional Class 2.4 +/- 0.8. The surgical approach was right parasternal in 36 (14%) or upper hemisternotomy in 216 (86%). There were four (2%) operative deaths. Perioperative complications included 14 (5.6%) reexplorations for bleeding, 7 (3%) chest wound infections, 5 (2%) strokes, and 1 (0.4%) external iliac vein injury. Follow-up was complete in 193 (77%) patients, with a mean follow-up of 12 +/- 8 months. Late complications included 2 (0.8%) nonfatal myocardial infarctions, 4 (2%) reoperations for, respectively, 2 pericardial complications, 1 paravalvar leak, and 1 infected valve. There were five (2%) late deaths from congestive heart failure, pneumonia, hemorrhage, aneurysm, and cancer. Mean follow-up NYHA Class was 1.4 +/- 0.6. For the 266 mitral patients, 145 (54.5%) were men, age 58.7 +/- 13.6 years, functional Class 2.3 +/- 0.5. The surgical approach was right parasternal in 195 (73%), lower hemisternotomy in 53 (20%), right submammary thoracotomy in 9 (3.4%), or full sternotomy through a small skin incision in 9 (3.4%). There were 2 (0.8%) operative deaths. Perioperative complications included 4 (1.5%) reoperations for bleeding, 4 (1.5%) strokes, and 5 (2%) wound infections, and 3 (1%) ascending aortic complications. Follow-up was complete in 202 (76%) patients with a mean follow-up of 9.5 +/- 6.4 months. Late complications included one (0.4%) nonfatal myocardial infarction and three (1%) reoperations all converting repairs to replacements. There were three (1%) late deaths from suicide, pneumonia, and sudden death, respectively. Mean follow-up NYHA functional Class was 1.3 +/- 0.5. We conclude that MIDA heart valve surgery is safe and effective for the majority of patients requiring isolated elective aortic or mitral valve surgery.

Objective: We developed techniques for partial upper hemisternotomy for reoperative aortic valve replacement and compared the results with those of reoperative aortic valve replacement by way of conventional full resternotomy., Methods: We retrospectively analyzed data from 19 patients who underwent conventional full sternotomy and 20 patients who underwent partial hemisternotomy for isolated elective reoperative aortic valve replacements performed between November 1996 and September 1998. Univariable and multivariable analyses were used to document the differences between the groups., Results: The 2 groups were similar with respect to age, sex, New York Heart Association functional class, valve pathologic characteristics, and numbers and types of previous operations. There were neither any operative deaths nor any postoperative valve-related morbidities in either group. There was 1 injury to a cardiac structure, which occurred in the conventional full sternotomy group. Univariable analysis documented that patients in the conventional full sternotomy group were significantly more likely to have at least 1000 mL blood loss during the first 24 hours after the operation (odds ratio 8.1, P =.02), were more likely to require transfusion of more than 5 units of packed red blood cell (odds ratio 3.6, P =.08), and were more likely to have a total operative duration longer than 5 hours (odds ratio 3.6, P =.08). In the multivariable analysis conventional full resternotomy remained a risk factor for greater blood loss (odds ratio 5.7, P =.06), greater transfusion requirement (odds ratio 2.4, P =.25), and longer total operative duration (odds ratio 7.7, P =.03)., Conclusions: Partial upper hemisternotomy for reoperative aortic valve replacement avoids unnecessary lower mediastinal dissection, thereby reducing blood loss, transfusion needs, and total operative duration. These beneficial effects, which are accomplished without compromising the efficacy of the valve operation, make the partial upper hemisternotomy an excellent alternative to conventional full resternotomy for reoperative aortic valve replacement.

Purpose: We retrospectively analyzed our early results with minimally invasive aortic root replacement., Methods: Between August 1996 and April 1999, our center performed 137 aortic root replacements. Thirty-seven (27%) were accomplished through a 5 to 8 cm minimally invasive upper hemi-sternotomy incision. All minimally invasive operations were elective. The mean age for this cohort was 46 +/- 12 yrs. Thirty one (84%) of the patients were male and 3 (8%) were reoperations. The average preoperative NYHA classification was 2.4 +/- 0.6 and ejection fraction (EF) was 58% +/- 12%. Valve pathology was congenitally bicuspid in 19 (51%), endocarditis (SBE ) in 5 (14%), calcific degeneration in 4 (11%), annuloaortic ectasia in 3 (8%), rheumatic in 2 (5%) and other etiologies in 4 (11%). Nine patients (24%) had associated ascending aortic or arch aneurysms., Results: The surgical techniques performed through mini-hemisternotomy consisted of 1) full root replacement in 31 (84%), 2) subcoronary replacement in 4 (11%), and 3) hemiroot in 2 (5%). Valve implants consisted of a homograft in 30 (81%), "Freestyle" bioprosthesis in 4 (11%) and a St Jude valved conduit in 3 (8%). Mean cardiopulmonary bypass duration was 193 +/- 47 min. and aortic cross-clamp duration was 157 +/- 40 min. Myocardial protection included systemic hypothermia in all (24 +/- 4 degrees C), antegrade cardioplegia (CP) in 35 (95%) with supplemental retrograde CP in 23 (62%). Three patients (8%) experienced postoperative low cardiac output syndrome (LCO). There was one operative death (3%). There was one (3%) reoperation for bleeding and 13 patients (35%) required blood transfusions. New onset atrial fibrillation occurred in 7 patients (19%) and there were 3 (8%) minor complications. Hospital length of stay (LOS) was 6.7 +/- 4.3 days and LOS was less than 7 days in 29 patients (78%)., Conclusions: Minimally invasive aortic root replacement is feasible for a broad range of aortic valve pathology, can incorporate full root, hemiroot and subcoronary techniques, can be used for homografts and "Freestyle" valves as well as valved conduits, and can be accomplished with acceptable morbidity and mortality. However, the operation takes longer through the smaller incision and therefore requires more careful attention to myocardial protection.

Objective: This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement., Summary Background Data: With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches., Methods: Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared., Results: Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group., Conclusions: Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.

Aortic valve replacement has proven reliable, relieves life-threatening symptoms, and improves long-term survival of patients with aortic stenosis and aortic regurgitation. Minimally invasive aortic valve replacement uses small incisions; reduces exposure of the patient to surgical trauma, blood utilization, and operative dissection; although still using cardiopulmonary bypass and achieving the same general quality as with the open operation. Early and medium term results for minimally invasive aortic valve replacement approaches show a reduction in pain, improved patient satisfaction, and improved mobility and return to full-time activity. Concomitantly, there should be decreased cost and a decreased reliance on post-hospital rehabilitation.