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Background Despite improvements in pump design and durability, left ventricular assist device patients still suffer from life-threatening complications such as pump thrombosis (PT) and infection, often necessitating device exchange. Surgical exchange from HeartMate II (HM2; Abbott, Pleasanton, CA) to another HM2 is safe and associated with low mortality, but recurrent device thrombosis rates are high. Switching from axial-flow to centrifugal-flow pump, such as the HeartWare ventricular assist device (HVAD; Medtronic, Framingham, MA) may offer certain advantages due to it being a smaller, newer generation device, although there are limited data to support this strategy. Herein, we aimed to assess the surgical approach and feasibility, safety, and outcomes of surgical exchange from HM2 to HVAD. Methods We evaluated HM2 patients who underwent device exchange to HVAD due to PT or infection at 4 large-volume left ventricular assist device implant centers. Results Twenty-four patients underwent HM2 to HVAD exchange due to PT (92%) and refractory infection (8%). Patients were male (75%), white (88%), with ischemic cardiomyopathy (54%), Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) scale level 1-3 (90%), and destination therapy (62%). The majority underwent redo-sternotomy (79%) and the remainder underwent minimally invasive thoracotomy with subcostal approach. The existing HM2 outflow graft was maintained in 79% of cases. Recurrent PT was noted in 9% of patients. Mortality was 8% at 30 days and 33% at 1 year. Conclusions The surgical exchange from a HM2 to HVAD is safe and feasible, despite the differences in device specifications and surgical adaptation required. Newer-generation pumps are increasingly considered for exchange in the setting of HM2 device complication, and increasing experience with modified surgical approaches may be valuable in the current era.

BACKGROUND: Organ-mounted robots adhere to the surface of a mobile organ as a platform for minimally invasive interventions, providing passive compensation of physiological motion. This approach is beneficial during surgery on the beating heart. Accurate localization in such applications requires accounting for the heartbeat and respiratory motion. Previous work has described methods for modeling quasi-periodic motion of a point and registering to a static preoperative map. The existing techniques, while accurate, require several respiratory cycles to converge. METHODS: This paper presents a general localization technique for this application, involving function approximation using radial basis function (RBF) interpolation. RESULTS: In an experiment in the porcine model in vivo, the technique yields mean localization accuracy of 1.25 mm with a 95% confidence interval of 0.22 mm. CONCLUSIONS: The RBF approximation provides accurate estimates of robot location instantaneously.

Background Stroke and transient ischemic attack after transcatheter aortic valve replacement results in significantly higher morbidity and mortality. Severe carotid artery disease may be a contributing factor to this increased risk. We report our technique and outcomes of combined carotid endarterectomy (CEA) with transcatheter aortic valve replacement (TAVR). Methods From March 2013 to November 2017 a total of 753 TAVRs were performed at our institution for symptomatic severe aortic stenosis. Of this group, 16 patients underwent concomitant TAVR and CEA. A retrospective review was performed to assess risk, outcomes, and short-term survival. Results Sixteen patients underwent concomitant CEA/TAVR procedures for severe carotid and severe aortic stenosis. The mean Society of Thoracic Surgeons (STS) Risk Score was 7.0 ± 4.7. All patients had severe carotid artery stenosis and aortic stenosis. Nine patients had a transfemoral TAVR approach and eight patients had a transapical TAVR approach. The mean length of stay was 6.4 ± 3.7 days. At 30 days there were no cerebrovascular events and no mortalities. Conclusions The use of concomitant CEA and TAVR in patients with severe aortic stenosis and severe carotid stenosis can be done safely without increased risk of complications. This approach may reduce the risk of stroke associated with TAVR in appropriately selected patients.

Case: An eighteen-year-old polytrauma patient sustained multiple nonorthopaedic and orthopaedic injuries, including a closed femoral shaft fracture. She was started on extracorporeal membrane oxygenation (ECMO) for respiratory failure. After added resuscitation and stabilization, she underwent intramedullary nailing of the femoral fracture while on ECMO on the third day after the injury. She remained stable throughout the case and recovered after a prolonged hospital course. At the most recent clinical follow-up, she was walking without assistance and had union of the fracture. Conclusions: ECMO successfully stabilized and mitigated any potential pulmonary complications during intramedullary nailing of a femoral shaft fracture in an unstable patient with polytrauma.

Background and Aim of Study Traditionally aortic arch anomalies have been viewed as a “normal” and clinically insignificant; therefore, they are often overlooked by radiologists and go unreported. Arch anomalies have been reported to occur in 7% to 15% of patients without thoracic aortic aneurysm or dissection. This study aims to define the incidence of aortic arch anomalies in patients with a thoracic aortic dissection (TAD). Methods We retrospectively reviewed all patients from 2006 to 2010 with a TAD admitted to a single institution. Thoracic computed tomography images of 176 patients with dissected thoracic aortas and 179 consecutive, unselected age-matched patients without dissection as controls were reviewed to determine the incidence of bovine arch and other arch anomalies. Statistical analysis of demographic data and clinical outcomes was performed to evaluate significant differences between the groups. Results Arch anomalies occurred in 34% of patients with TAD compared to controls (19%, p = 0.0017). The most common variant was a common origin of the innominate and left common carotid arteries (“bovine” arch) found in 31% of dissection patients compared to 15% in the control group (p = 0.0004). Overall arch anomalies occurred in 27% of all Type A dissections and 39% (p = 0.1409) of all Type B dissections. The association was statistically significant in patients ages 50 to 79 with TAD (36.4%, p = 0.0011) and in African Americans collectively (43.2%, p = 0.0033). Conclusions Aortic arch anomalies occur frequently in patients with TAD and therefore may represent a proclivity for this life threatening condition. doi: 10.1111/jocs.12072 (J Card Surg 2013;28:151–154)

Objectives: Acute refractory cardiogenic shock with early multisystem organ failure has a poor outcome without mechanical circulatory support. We review our experience with emergent peripheral cardiopulmonary support as a bridge to decision in these patients. Methods: A retrospective review from January 2009 through December 2010 was conducted of 26 consecutive adult patients at a single institution with acute refractory cardiogenic shock who underwent salvage peripheral cardiopulmonary support. Results: There were 18 men and 8 women with a mean age of 54 years (range 18 to 76). Indications for support: acute myocardial infarction (n = 16), decompensated chronic heart failure (n = 2), refractory arrhythmic arrest (n = 3), acute valvular pathology (n = 4), and unknown (n = 1). Patients with primary postcardiotomy shock were excluded. Median duration of support was 3 days (range 1 to 14). Decisions included: withdraw of support (n = 4), recovery (n = 5), and bridge to a procedure (n = 17). The procedures were percutaneous coronary intervention (n = 4), left ventricular assist device (n = 9), heart transplantation (n = 1), and miscellaneous cardiac surgery (n = 3). Overall survival to discharge was 65%. In the recovery and bridge to a procedure group, 78% were discharged from the hospital and survival at three months was 72%. Conclusions: Salvage peripheral cardiopulmonary support is a useful tool to rapidly stabilize acute refractory cardiogenic shock permitting an assessment of neurologic and end-organ viability. (J Card Surg 2012;27:521-527)

Background: Jehovah's Witnesses (JW) are a Christian faith, with an estimated 1.1 million members in the United States, well recognized for their refusal of blood and blood products. JW may not be considered for cardiac surgery due to perceived higher risks of morbidity and mortality. This study reviews our contemporary strategies and experience with JW undergoing routine and complex cardiac surgery. Methods: From November 2001 to April 2010, 40 JW were referred for cardiac surgery at a single quaternary referral institution. A retrospective analysis of demographic data, perioperative management, and clinical outcomes was examined. Published validated clinical risk calculator and model for prediction of transfusion were used to identify high-risk patients (risk of mortality >6% or probability of transfusion >0.80). Results: The mean age was 70 (± 9.5) years with 21 men and 19 women. Patients were classified as high risk (45%, n = 18) and low risk (55%, n = 22) with demographics and comorbidities listed in Table 2. Operative procedures included: isolated coronary artery bypass grafting (CABG) (n = 19), isolated valve replacement/repair (n = 7), valve/CABG (n = 7), reoperative valve replacement (n = 4), reoperative CABG (n = 2), valve/ascending aorta replacement (n = 1), and CABG/ascending aorta replacement (n = 1). All JW were evaluated by The Department of Bloodless Medicine to individually define acceptable blood management strategies. The mean preoperative hemoglobin was 14.1 g/dL (±1.6). Overall mortality was 5% (n = 2) all of which were in the high-risk group. Discussion: Using a multidisciplinary approach to blood management, JW can safely undergo routine and complex cardiac surgery with minimal morbidity and mortality. (J Card Surg 2011;26:135-143) Table 2. Patient Demographics Variables Total (n = 40) Low Risk (n = 22) High Risk (n = 18) p value AGH = Allegheny General Hospital; NS = not significant; TRUST score = transfusion risk understanding scoring tool. Age (years) 70 (+9.5) 66.7 (+10) 74.1 (+6.2) 0.01 Women 48% 27 % 72% 0.01 Body surface area (m2) 2.0 (+0.3) 2.3 (+0.2) 2.0 (+0.4) 0.01 Congestive heart failure 32% 27 % 38% NS Cerebral vascular accident 7.5% 9% 5% NS Chronic obstructive pulmonary disease 10% 0 % 22% 0.03 Diabetes mellitus 32% 32% 33% NS Hypertension 75% 77% 77% NS Peripheral vascular disease 15% 5% 27% NS Renal insufficiency (serum creatinine > 1.3) 25% 32% 17% NS History myocardial infarction 18% 18% 17% NS Urgent operation 18% 14% 22% NS Previous cardiac surgery 15% 5% 27% NS Preoperative hemoglobin 14.1 (+1.6) 14.1 (+1.5) 14.3 (+1.6) NS AGH clinical risk score 6.0 (+3.5) 3.9 (+1.9) 8.6 (+3.5) 0.001 TRUST score 2.7 (+1.2) 2.0 (+0.8) 3.6 (+1) 0.001

BACKGROUND Organ-mounted robots address the problem of beating-heart surgery by adhering to the heart, passively providing a platform that approaches zero relative motion. Because of the quasi-periodic deformation of the heart due to heartbeat and respiration, registration must address not only spatial registration but also temporal registration. METHODS Motion data were collected in the porcine model in vivo (N = 6). Fourier series models of heart motion were developed. By comparing registrations generated using an iterative closest-point approach at different phases of respiration, the phase corresponding to minimum registration distance is identified. RESULTS The spatiotemporal registration technique presented here reduces registration error by an average of 4.2 mm over the 6 trials, in comparison with a more simplistic static registration that merely averages out the physiological motion. CONCLUSIONS An empirical metric for spatiotemporal registration of organ-mounted robots is defined and demonstrated using data from animal models in vivo.

It is estimated that more than 8% of the population above the age of 85 suffer from significant aortic stenosis [1]. Transcatheter aortic valve replacement (TAVR) is increasing being utilized in the treatment of surgically high risk or inoperable patients with severe symptomatic aortic stenosis and has been shown to increase survival [2]. With the unavoidable operator learning curve, unexpected adverse events are likely to be encountered. These should be promptly recognized and the appropriate management strategy instituted. Feared complications include, annulus rupture, “frozen leaflet, coronary occlusion, embolization of the prosthetic device, Cerebrovascular accidents, as well as complications related to the vascular access site [3,4]. However, other uncommon events may occur that also have the potential to be catastrophic. We describe a case of acute native leaflet avulsion during a TAVR procedure. Fortunately, this was of no significant hemodynamic importance and the patient was successfully managed conservative.

Background The association between malnutrition and worse outcomes as pressure ulcers and mortality is well established in a variety of setting. Currently none investigation was conducted in patients with long-term consequences of the acquired brain injury in which recovery from brain injury could be influenced by secondary complications. The aim of this study was to investigate the association between various nutritional status parameters (in particular albumin) and pressure ulcers formation and short-term mortality in minimal conscious state patients. Methods In this prospective, observational study of 5-months duration, a 30 patients sample admitted to a Neurological Institute was considered. All patients underwent a complete medical examination. Anthropometric parameters like mid-arm circumference and mid-arm muscle circumference and nutritional parameters as serum albumin and blood hemoglobin concentration were assessed. Results At univariate and logistic regression analysis, mid-arm circumference (p = 0.04; beta = −0.89), mid-arm muscle circumference (p = 0.050; beta = −1.29), hemoglobin (p = 0.04, beta −1.1) and albumin (p = 0.04, beta −7.91) were inversely associated with pressure ulcers. The area under the ROC curve for albumin to predict sores was 0.76 (p = 0.02) and mortality was 0.83 (p = 0.03). Patient with lower albumin had significantly higher short-term mortality than those with higher serum albumin (p = 0.03; χ2 test = 6.47). Conclusion Albumin, haemoglobin and mid-arm circumference are inversely associated with pressure ulcers. Albumin is a prognostic index in MCS patients. Since albumin and haemoglobin could be affected by a variety of factors, this association suggests to optimize nutrition and investigate on other mechanism leading to mortality and pressure ulcers.

BackgroundCognitive dysfunction and cerebral vascular accidents remain some of the most devastating problems related to cardiac surgery. Despite the major advances in perioperative care and operative technique in coronary artery bypass, this cohort of patients appears to have poor cerebral physiologic reserve. The aim of this study was to describe regional cerebral perfusion of patients with coronary artery disease referred for coronary artery bypass grafting.MethodsEighty-two consecutive patients with coronary artery disease referred for coronary artery bypass grafting were enrolled after providing informed consent in an institutional review board–approved study. Patients with prior cerebral vascular accident, transient ischemic attacks, head trauma, or other neurologic afflictions were excluded from the study. We prospectively measured preoperative regional cerebral perfusion using single photon emission computed tomography (SPECT) imaging of 12 regions. Patients were determined to have an abnormal SPECT if regional cerebral perfusion was less than 2 standard deviations below the mean of age-matched controls.ResultsThe mean age was 67.5 (range, 34-89) years. The study group comprised 22% women and 78% men with known risk factors for atherosclerosis: current tobacco use (30%), hypertension (69%), and diabetes (27%). Seventy-five percent of the SPECT scans demonstrated abnormal regional cerebral perfusions, which were associated with older age (P < .008), current tobacco use (P < .005), and diabetes mellitus (P < .005). The incidence of postoperative cerebral vascular accident was 5% and only occurred in patients with abnormal regional cerebral perfusion.ConclusionSeventy-five percent of patients undergoing coronary bypass grafting have a significant impairment in regional cerebral perfusion compared with published age-matched controls, which may contribute to their proclivity for cerebral complications.

Background Post-cardiotomy cardiogenic shock is an infrequent devastating complication with few options for support. Materials and Methods We present a case highlighting use of the Impella 5.0 (ABIOMED; Danvers, MA) for postcardiotomy cardiogenic shock after coronary artery bypass and bioprosthetic aortic valve replacement. Results Support was maintained for 7 days before being successfully weaned with myocardial recovery and no damage to the bioprosthetic aortic valve. Conclusions This is the first published report of successful use of an Impella 5.0 (ABIOMED; Danvers, MA) for post-cardiotomy cardiogenic shock through a new implanted bioprosthetic aortic valve. doi: 10.1111/jocs.12118 (J Card Surg 2013;28:469–471)

Systemic mastocytosis is a hematologic disorder with important perioperative implications. A variety of stimuli and medications can cause severe anaphylaxis in these patients. We report successful preoperative, intraoperative, and postoperative management of a patient with systemic mastocytosis who underwent an aortic valve replacement and review the literature pertaining to cardiac surgery in these patients.

Acquired inhibitors to FVIII (anti-FVIII) are uncommon in children. An acquired anti-FVIII developed in a previously healthy 4-year-old boy treated with penicillin for streptococcal pharyngitis. Aspirin prophylaxis begun for suspected rheumatic fever led to compartment syndromes of all four extremities, which resolved with high-dose FVIII and surgical decompression. Anti-FVIII in this patient, and the five additional cases identified in a survey of 160 haemophilia treatment centres, occurred at a median age of 8 years, with median initial and peak titres of 4.6 and 6.9 Bethesda Units (BU), respectively. All six presented with bleeding, including haematomas (three intramuscular, one intracranial), and ecchymoses in three. The median baseline FVIII was 0.05 U mL(-1), and the median baseline activated partial thromboplastin time (APTT) was 79.8 s. The inhibitor resolved completely in five patients (83%) within a median 5 months, after treatment with FVIII concentrate, steroids, cytoxan, methotrexate, and no treatment. The inhibitor persisted in the patient with Goodpasture's disease, despite steroids, cytoxan, cyclosporin, and intravenous gamma globulin. Aspirin therapy, in two, worsened ongoing bleeding. The association of penicillin-like drugs in this and three other cases in the literature suggest that to avoid potential catastrophic bleeding, it is prudent to obtain an APTT prior to initiating aspirin for suspected rheumatic fever. In conclusion, acquired anti-FVIII inhibitors in children may cause severe bleeding, and remit in the majority after FVIII and/or immunosuppressive therapy.

STUDY DESIGN Case report. OBJECTIVE To present the first reported case of using extracorporeal membrane oxygenation (ECMO) support in an emergent decompression and evacuation of a thoracic epidural abscess. SUMMARY OF BACKGROUND DATA Thoracic epidural abscesses with neurological deficits require surgical evaluation and intervention in most cases. We report a case of a 35-year-old patient with an acute onset of paraplegia diagnosed with a thoracic epidural abscess. The patient was emergently taken to the operating room and was unable to tolerate prone positioning secondary to cardiopulmonary collapse. ECMO was initiated for cardiopulmonary support to complete the case. METHODS Retrospective chart review of patient case. RESULTS The patient was stabilized with ECMO support and tolerated a T4-T8 laminectomy and decompression. The source of the patients abscess was hematogenous and at 6 months of clinical follow-up, the patient has no motor or sensory function of his bilateral lower extremities. CONCLUSION The use of ECMO support in adult spinal surgery has not been previously reported in the literature. Therefore we describe the first reported use of ECMO to maintain cardiopulmonary support in a patient unable to tolerate prone positioning during spine surgery. ECMO support can be a viable option in adult patients who need emergent spinal surgery but are unable to tolerate prone positioning secondary to cardiopulmonary complications.

Background In the past decade, there has been an increase in the amount of patients with medical co-morbidities referred for coronary artery bypass surgery (CABG). Significant carotid artery disease in patients undergoing CABG procedures increases the risk of neurological complications. We review the results of routine carotid screening in patients undergoing CABG to determine the contemporary incidence and risk factors for carotid artery disease. Methods Between 2008 through 2010, 673 patients were referred for isolated coronary artery bypass surgery at a single institution. Patients were identified through a systematic review of The Department of Cardiothoracic Surgery Society of Thoracic Surgery Outcomes Database. A retrospective analysis of prospectively collected demographic, clinical data and outcomes were performed. All patients with screening preoperative carotid duplex were reviewed. We defined the degree of carotid disease as: none to mild stenosis ( Results 559 (83%) patients underwent screening preoperative carotid ultrasonography prior to CABG. The incidence of carotid artery disease (>50% stenosis) was 36% with 18% unilateral moderate disease, 10% bilateral moderate and 8% severe disease. Risk factors associated with carotid artery disease included: advanced age, renal failure, previous stroke, peripheral vascular disease, left main coronary artery disease, and previous myocardial infarction. Conclusions There is a significant incidence of carotid artery stenosis in patients referred for CABG. Routine screening will identify patients with carotid artery disease and may reduce the risk of postoperative stroke.

Background: Left heart mechanical circulatory support (MCS) through the left chest via the pulmonary vein and descending thoracic aorta is a good option for patients with an inaccessible anterior mediastinum and/or poor peripheral access. Materials and Methods: We report the case of a 19-year-old small female with a newly discovered bulky primary mediastinal diffuse large B-cell lymphoma (PMBL) who developed refractory inverted Takotsubo cardiomyopathy (TC) with cardiogenic shock. Results: Temporary MCS was implemented in order to stabilize the patient and proceed with a chemotherapy treatment. Given the patient's oncologic “frozen” mediastinum and the presence of poor peripheral arterial access, the left heart temporary MCS was successfully implanted through a left mini-thoracotomy via the left inferior pulmonary vein and descending thoracic aorta. Conclusions: This is the first report of temporary MCS to treat inverted TC and diffuse PMBL. (J Card Surg 2012;27:119–121)

Introduction In the past decade, there has been an increase in the amount of patients with medical co-morbidities referred for coronary artery bypass surgery (CABG). Cerebrovascular accident (CVA) after CABG is a devastating and multi-factorial problem. Carotid artery disease in patients undergoing cardiopulmonary bypass procedures may increase the risk of significant neurological complication. We review the results of carotid screening, management and outcome of carotid disease in patients referred for CABG. Methods Between 2008 through 2010, 673 patients were referred for isolated coronary artery bypass surgery at a single institution. Patients were identified through a systematic review of The Department of Cardiothoracic Surgery Society of Thoracic Surgery Outcomes Database. A retrospective analysis of prospectively collected demographic, clinical data and outcomes were preformed. All patients with screening preoperative carotid duplex were reviewed. We defined the degree of carotid disease as: none to mild stenosis ( Results 559 (83%) patients underwent screening preoperative carotid ultrasonography prior to surgery. Patient demographics and clinical variable are listed in Table 1 . Severity of carotid disease on preoperative imaging was none/mild (68%), unilateral moderate disease (17%), bilateral moderate (7%) and severe (8%). 12 (2.1 %) of patients underwent a preoperative carotid endarterectomy and subsequent CABG, with no peri-operative cardiac events or CVAs. Only 4 (0.7%) patients in the entire series had a peri-operative CVA. Conclusions Routine use of carotid ultrasound in patients referred for CABG with aggressive management may reduce the incidence of peri-operative CVA.

Background: Aberrant right subclavian artery (ARSA) is the most common congenital arch anomaly, which can be complicated by aneursymal dilation at its ostium. We describe a successful repair of an ARSA with a three-stage operative procedure using a left carotid to subclavian bypass, coiling of the ARSA, and thoracic endovascular aortic repair with long-term clinical and radiographic follow-up. (J Card Surg 2010;25:390-393)

Background The purpose of this study was to compare operative mortality and long-term outcome of patients undergoing tricuspid valve replacement versus tricuspid valve repair. Methods From February 1986 to July 2006, 315 patients underwent tricuspid valve surgery including 93 replacements (72 biologic, 21 mechanical) and 222 repairs. To control for selection bias and varying comorbidities, a matched cohort of patients undergoing repair versus replacement was selected using propensity score analysis (68 patients in each group). Results In the propensity-matched cohorts, operative mortality was similar for tricuspid valve replacement (13% ± 4%) and repair (18% ± 5%; p = 0.64). Intensive care unit length of stay was similar between cohorts (replacement, 4 days; repair, 3 days; p = 0.45), but the replacements had a significantly longer hospital lengths of stay (9 days versus 6 days; p = 0.01). In the replacement cohort, survival was 85% at 1 year, 79% at 5 years, and 49% at 10 years. In the repair cohort, survival rates were similar with 80% at 1 year, 72% at 5 years, and 66% at 10 years ( p = 0.66 versus replacement). Conclusions Surgical treatment of tricuspid valve disease, regardless of the operative approach, is associated with significant early and late mortality. However, there is no difference favoring tricuspid valve repair over replacement. Thus, we should not hesitate to consider tricuspid valve replacement for patients in whom we believe there is a reasonable chance for recurrence of regurgitation after repair.

Knee arthrodesis is a surgical procedure performed in order to salvage a limb in which the knee joint is compromised in a way to preclude any possibility to re-create a new articulation through a prosthetic replacement. This is especially true in severe periprosthetic septic cases.

Objective:After a bypass surgery blood pressure can go up for multiple reasons among which are: the pain of the cut, stress and tense of the patient unsure about the future and because some of the blood pressure medication, which the patient was receiving preoperatively may get withdrawn post operat

Hypothesis The reported morbidity and mortality associated with esophagectomy for high-grade dysplasia (HGD) and intramucosal cancer (IMC) have led asymptomatic patients to consider less invasive and possibly less effective treatments. This study provides a critical assessment of outcomes and health-related quality of life (HRQL) after esophagectomy for HGD and IMC. Design Cohort analytic study. Setting Section of thoracic surgery at a tertiary referral center. Patients All patients who presented between May 1991 and February 2003 with a biopsy-proven diagnosis of Barrett esophagus with HGD or IMC were assessed. Main Outcome Measures Prospective analysis of postoperative morbidity, mortality, HRQL, and gastrointestinal symptoms. Results Follow-up was complete in 36 patients. Mean follow-up was 4.9 years (range, 0.5-12.0 years). The incidence of postoperative invasive cancer was 39%, with stages ranging from I to IIB. There were 4 major complications (11%) and no operative mortality. Twenty-eight patients were alive, with a cancer-free survival of 85%. The HRQL outcomes (Medical Outcomes Study 36-Item Short-Form Health Survey) were comparable with those of age- and sex-matched controls. Significant differences in postesophagectomy gastrointestinal symptoms were seen with a decreased incidence of heartburn ( P ≤.001) and increased requirement for a slower speed of eating. Twenty-two (79%) of the 28 patients described their current eating pattern as “normal or insignificantly impacted.” Conclusions Esophagectomy for HGD and IMC can be accomplished with low morbidity and mortality. Furthermore, most patients are able to resume a normal eating pattern, and postoperative HRQL can be equivalent to that of the general population.

Hypothesis Normal biliary function can be achieved after reconstruction for major bile duct injuries using either hepaticoduodenostomy (HD) or Roux-en-Y hepaticojejunostomy (HJ). Design Retrospective analysis of consecutive patients requiring biliary enteric reconstructions from February 1, 1993, through January 1, 2002, for bile duct injuries. Setting Academic multispecialty referral clinic. Patients Twenty-seven consecutive patients were evaluated who underwent biliary enteric reconstruction for bile duct injury caused during cholecystectomy. Patients were reconstructed either by HD (18 patients) or HJ (9 patients). Interventions Patients' medical records were reviewed and long-term evaluations were obtained via telephone questionnaire by 2 separate observers (R.J.M. and F.T.L.). Biliary function was evaluated in all using symptoms and liver function test results. Cholangiography was obtained, if indicated clinically. These were reviewed for stricture or dilatation. Any biliary interventions were recorded. Main Outcome Measures Comparison of long-term biliary function after HD vs HJ reconstructions. Results All patients were contacted after a median postoperative time of 54 months. Excellent or good results were observed for biliary function in 25 (92%) of the 27 patients. These results were obtained regardless of the type of reconstruction—HD (18 patients) or HJ (9 patients). Conclusions We found biliary function to be normal at more than 4 years after biliary-enteric reconstruction for bile duct injury. When surgically feasible, we prefer HD to HJ.

The aim of this study was to assess the importance of paraneoplastic syndromes as an early sign of non-small cell lung cancer (NSCLC). A procedure for searching paraneoplastic syndromes, based on 40 years of reports in the literature, was established and the prevalence of paraneoplastic syndromes estimated in 68 patients with resectable NSCLC. Stages I and II were considered eligible for surgery straight away. Patients in Stage IIIA underwent surgery if partially or completely responsive to three courses of neo-adjuvant chemotherapy. Paraneoplastic syndromes were assessed and confirmed in nine patients (13%). Motor-sensory neuropathy, arthritis and arthralgias to the knees, periarthritis to the shoulder, hypertrophic osteopathy, clubbing, pruritus were observed. Only three patients with painful osteoar-thropathies were diagnosed with NSCLC by tracing their paraneoplastic syndrome, whereas most of them (36/68) were diagnosed incidentally through a chest radiograph taken for tumour-unrelated symptoms. A careful research of paraneoplastic syndromes in high risk patients may guide the doctor to a resectable NSCLC diagnosis. Recent onset arthritis and arthralgias, which cannot be explained otherwise, should be considered to be early clues of lung cancer.

The closed chest convergent procedure is a multidisciplinary approach to atrial fibrillation (AF) treatment. Epicardial posterior left atrial (PLA) ablation is performed by a cardiac surgeon using a transdiaphragmatic endoscope, immediately followed by percutaneous pulmonary vein (PV) isolation performed by a cardiac electrophysiologist. Interim outcomes for the treatment of non-paroxysmal AF (NPAF) were evaluated based on peri-procedural safety and complications, freedom from recurrent AF, and need for cardioversion or repeat catheter ablation at three, six and 12 months post-procedure. A total of 43 patients (86 % NPAF) underwent the convergent procedure. Patients were 84 % male, with mean age 58.6 ± 8.7 years. Mean AF duration was 45.4 ± 40.3 months. Pre-procedure left atrium (LA) volumetric data using cardiac magnetic resonance imaging (MRI) or computed tomography (CT) was available for 30 patients (70 %). Average LA volume was 155.5 ± 48.4 millilitres (ml); two-thirds of patients had a LA volume >130 ml. There was no operative or peri-operative mortality. Sinus rhythm (SR) was recorded at three months in 31 of 39 (79 %) patients, at six months in 24 of 27 (89 %) patients and at 12 months in nine patients. The convergent procedure is a safe and effective option for both PV isolation and PLA substrate ablation in NPAF patients. Long-term follow-up is required and randomised clinical trials warranted.

Purpose: DTRS was developed to predict risk of 90 day in hospital mortality in DT pts with pulsatile flow LVADs from 2002-2005. Discrimination of mortality using DTRS in BTT and DT pts with continuous flow LVADs is dubious, with reported c-statistics of 0.54-0.59. We sought to reinvestigate its applicability in continuous flow LVADs at our center. Methods and Materials: Charts for 88 pts with continuous flow LVADs implanted from 2007-2011 were reviewed. DTRS was calculated for 76 pts and divided into low, medium, high and very high risk categories. Outcomes were measured at discharge, 1, 3 and 12 months. Z score was used to assess difference between the DTRS predicted and actuarial survival rate. Results: Mean age was 59 yrs with 77% men, 58% ischemic myopathy, and mean LVEF of 16% in 23 DT, 58 BTT and 7 BTD LVADs. Overall 30-day survival was 92% with 14 deaths occurring prior to hospital discharge. One-year survival, censored for transplant(n 34) or explant(n 2) was 55%. A medium DTRS overestimated mortality at hospital discharge, whereas a very high score overestimated mortality at both discharge and 90 days. Univariate predictors of 90-day mortality included need for dialysis (p 0.002), no ACEI/ARBs on admission (p 0.04) and DTRS (p 0.04). By multivariate analysis, DTRS was an independent predictor of 90-day mortality(p 0.01), though interpretation is limited by low event rate (n 14).

To review the potential and proven benefits and complications of epidural anesthesia/analgesia.Advances in analgesia/anesthesia have improved patient satisfaction and perioperative outcomes. Epidural anesthesia/analgesia is one of these advances that is gaining rapid acceptance due to a perceived reduction in morbidity and overall patient satisfaction.A MEDLINE search was conducted for all pertinent articles on epidural anesthesia/analgesia.Retrospective, prospective, and meta-analysis studies have demonstrated an improvement in surgical outcome through beneficial effects on perioperative pulmonary function, blunting the surgical stress response and improved analgesia. In particular, significant reduction in perioperative cardiac morbidity ( approximately 30%), pulmonary infections ( approximately 40%), pulmonary embolism ( approximately 50%), ileus ( approximately 2 days), acute renal failure ( approximately 30%), and blood loss ( approximately 30%) were noted in our review of the literature. Potential complications related to epidural anesthesia/analgesia range from transient paresthesias (10%) to potentially devastating epidural hematomas (0.0006%).Epidural anesthesia/analgesia has been demonstrated to improve postoperative outcome and attenuate the physiologic response to surgery.

We present the case history of a 30-yr-old woman who suffered a cerebral haemorrhage toward the end of pregnancy (at 35 wk). The pregnancy was terminated by Caesarean section because aggravation of cerebral bleeding was feared. Extensive studies revealed that the patient was suffering from a multiple endocrine neoplasia syndrome (type 2A or Sipple's syndrome) with bilateral pheochromocytomas and a medullary thyroid carcinoma. She made an uneventful recovery. The relevant literature is discussed.

• A complete, temporary arrest of cardiac motion was induced and an almost bloodless operative field was obtained by the use of potassium citrate in 37 patients undergoing open-heart surgery. The largest group consisted of 18 children with congenital interventricular septal defect. The heart-lung machine, consisting of a pump and an oxygenator, was connected so as to remove blood from the venae cavae, oxygenate it, and return it to the aorta. The aorta was occuluded 2 or 3 cm. above the heart, and a mixture of 2 ml. of 25% potassium citrate solution with 18 ml. of blood was injected into the aorta proximal to the point of occlusion. The potassium citrate solution was injected until the heart stopped. If 20 ml. was not enough, more was injected. It was found that under these conditions the human heart could resume its normal action after periods of arrest as long as 40 minutes. The flaccidity of the heart facilitated extensive repairs, but distortions and tensions that were produced when large defects were closed sometimes resulted in tears elsewhere after the spontaneous beat was restored. The potassium citrate itself did not seem to introduce any new dangers. Of the 13 patients who died, three had transposition of the great vessels and one had a single ventricle. Twenty-four patients recovered. All of the nine patients who had the tetralogy of Fallot were in the group who recovered.