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Background Prognostic value of concomitant aprtic regurgitation (AR) in patients operated for severe aortic stenosis (AS) is not clarified. The aim of this study was to prospectively examine the impact of presence and severity of concomitant AR in patients operated for severe AS on long-term functional capacity, left ventricular (LV) function and mortality. Methods Study group consisted of 110 consecutive patients operated due to severe AS. The patients were divided into AS group (56 patients with AS without AR or with mild AR) and AS+AR group (54 patients with AS and moderate, severe or very severe AR). Follow-up included clinical examination, six minutes walk test (6MWT) and echocardiography 12 and 104 months after AVR. Results Patients in AS group had lower LV volume indices throughout the study than patients in AS+AR group. Patients in AS group did not have postoperative decrease in LV volume indices, whereas patients in AS+AR group experienced decrease in LV volume indices at 12 and 104 months. Unlike LV volume indices, LV mass index was significantly lower in both groups after 12 and 104 months as compared to preoperative values. Mean LVEF remained unchanged in both groups throughout the study. NYHA class was improved in both groups at 12 months, but at 104 months remained improved only in patients with AS. On the other hand, distance covered during 6MWT was longer at 104 months as compared to 12 months only in AS+AR group (p = 0,013), but patients in AS group walked longer at 12 months than patients in AS+AR group (p = 0,002). There were 30 deaths during study period, of which 13 (10 due to cardiovascular causes) in AS group and 17 (12 due to cardiovascular causes) in AS+AR group. Kaplan-Meier analysis showed that the survival probability was similar between the groups. Multivariate analysis identified diabetes mellitus (beta 1.78, p = 0.038) and LVEF < 45% (beta 1.92, p = 0.049) as the only independent predictor of long-term mortality. Conclusion Our data indicate that the preoperative presence and severity of concomitant AR has no influence on long-term postoperative outcome, LV function and functional capacity in patients undergoing AVR for severe AS.

From ‘‘Dedinje’’ Cardiovascular Institute, Belgrade, Serbia. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publicationMarch 9, 2011; revisions receivedMay 8, 2011; accepted for publication May 17, 2011; available ahead of print June 27, 2011. Address for reprints: Dusko Nezic, MD, PhD, FETCS, Chief, Department of Cardiac Surgery I, ‘‘Dedinje’’ Cardiovascular Institute, M. Tepica 1, 11000 Belgrade, Serbia (E-mail: nezic@eunet.rs; nezic@ikvbd.com). J Thorac Cardiovasc Surg 2011;142:1579-80 0022-5223/$36.00 Copyright 2011 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2011.05.012

The administration of glucose-insulin-potassium (GIK) solution has beeen shown to exert cardioprotective and immunomodulatory properties in coronary disease. 49 patients (pts.) for coronary surgery were randomly assigned to receive high-dose GIK treatment (30% glucose, insulin 2 IU.kg(-1).l(-1) and K(+) 80 mmo/l solution; 1 ml/kg/h); low-dose GIK treatment (10% glucose, insulin 32 IU l(-1) and K(+) 80 mmol/l solution; 1 ml/kg/h) or control treatment (Ringer solution 1 ml/kg/h). Haemodynamic measurements were done for four time points: T1 - after induction of anaesthesia; T2 - after the operation; T3 - 6 h after the operation and T4 - 24 h after the operation. Significant recovery of cardiac function was evident in high-dose GIK (H-GIK) and low-dose GIK (L-GIK) groups after 24 h (cardiac index improved considerably (p = 0.0002)), with a statistically significant difference between the groups (p = 0.005). LVSWI covariated with PCWP, improved over time in group H-GIK (p = 0.0008) and between the groups (p = 0.046). Oxygen supply-consumption ratio evidently improved in the GIK groups, while inotropic drug support was used in 5.5% pts. in group H-GIK vs. 13% in group L-GIK and 31% pts. in control (C) group. Glucose-insulin treatment has a potential cardioprotective effect in coronary surgery. The effect is independent of the glucose-insulin concentration and amount.

Heparin-induced thrombocytopenia (HIT) might be lifethreatening in patients undergoing open heart surgery, due to thromboembolic events, thrombocytopenia and bleeding. If cardiac surgery with cardiopulmonary bypass (CPB) is necessary, anticoagulation therapy will be based on usage of danaparoid or direct thrombin inhibitors. Female patient was switched from per oral anticoagulant therapy to low molecular heparin therapy preparing for reredo mitral valve replacement due to endocarditis and artificial valve thrombosis. In next 10 days, thrombocytopenia was obvious (Tr 302 000 mm3 to 11 000 mm3) , and diagnoses of HIT were done. Anticoagulant therapy was continued with danaparoid, 750 IU/12 h sc. During the surgery, reredo mitral valve replacement and aortocoronary bypass on anterior descending coronary artery, blood salvage technique with rhirudin( intravenous bolus 0,4 mg/kg, in CPB prajming solution 0,4mg/kg and continuous infusion during CPB 0,15 mg/kg/h ) during cardiopulmonary bypass was used. Active coagulation time and +++ were monitored, without any sign of micro thrombosis in circuit. Postoperatively, per oral anticoagulation therapy was initiated with prolonged postoperative treatment due to basic disease, endocarditis. Patient was discharged from hospital on 21-st postoperative day without any complication.

To the Editor: We read with great interest the article by Singh and associates1 that was recently published in Circulation . We respect all subsequent analysis arising from an excellent, prospective, randomized basic study presented by Desai and colleagues2 a few years ago that compared the angiographic patency of radial artery (RA) grafts with that of saphenous vein (SV) grafts 1 year after surgery. Although that study demonstrated significantly better angiographic patency of RA conduits compared with SV grafts …

Introduction. Acute aortic dissection is an urgent surgical disease. Often, due to hemodynamic instability, that is an indication for emergent surgical intervention. Majority of surgeons uses Femoral or Axillary artery as arterial inflow site forextracorporal circulation. Both approaches have disadvantages that potentially may cause devastating complications. Some of them have been described in literature such as inadequate flow on heart- lung machine, retrograde dissection and malperfusion syndrome. Aim of study. Aim of study is to show, that by using transventricular cannulation we are eliminating all technical problems and lowering peroperative morbidity and mortality. Method: Between 1996 - 2006 at Institute for Cardiovascular Disease "Dedinje" 107 patients were operated for acute ascending aortic dissection Femoral artery was used for arterial cannulation in 91 patients. Last 16 patients were operated by using transventricular approach to establish extracorporeal circulation. We used retrograde cerebral perfusion in 21 cases at the beginning of our experience. Results. In group of patients where transapical cannulation was used, no neurological incidents were noticed. We didn't have any other problems related to extracorporeal circulation or placement of arterial cannula. Is this series we had only one death case. Patient passed away on eight postoperative day due to multiorgan insufficiency. Conclusion. Transapical cannulation is very simple and safe method for quick establishment of extracorporeal circulation. It always gives patient sufficient antegrade, physiological flow on heart-lung machine. This is the way to minimize possibility of malperfusion syndrome and to significantly diminish risk of neurological complication. By using this method all negative effects of other cannulation sites will be avoided.

Objective: Mitral incompetence is a chronic sequela of myocardial infarction. It is caused by apical displacement and tethering of the mitral valve leaflets after myocardial infarction, resulting in incomplete coaptation. The consensus is for mitral valve surgery in the presence of significant ischemic mitral regurgitation (IMR). Previously, the only option was mitral valve replacement (MVR) with a mechanical or tissue valve. The suboptimal results obtained prompted the development of several methods of mitral valve repair. Today, the most commonly used repair is undersized annuloplasty.Methods: We conducted a retrospective nonrandomized study of all patients who underwent operation for coronary artery disease and IMR between 2000 and 2006. The surgeon chose the surgical method used for the mitral valve procedure. The most commonly used procedures were restrictive mitral valve annuloplasty (MVP) and MVR with a mechanical prosthesis. We collected all pertinent preoperative, intraoperative, and early-postoperative data. We followed up with phone interviews of the patients and their relatives and with complete clinical and echocardiography examinations.Results: We carried out operations on 138 patients during the study period (MVR, 52 patients; MVP, 86 patients). The 2 groups had comparable demographic data and risk factors. The 2 groups were significantly different with respect to mean (±SD) New York Heart Association (NYHA) class (MVP, 2.72 ± 0.62; MVR, 2.48 ± 0.70; P < .01) and ejection fraction (MVP, 29.01% ± 11.00%; MVR, 35.87% ± 11.00%; P ? .01). The 30-day mortality rates for the MVR and MVP groups were significantly different (9.61% and 5.81%, respectively; P < .01). Our follow-up included 83% of the patients and continued for up to 84 months. The 2 groups showed no significant difference in mortality by the end of follow-up; however, the MVR patients had a better ejection fraction (37.79% versus 29.86%) and NYHA functional class (1.88 ± 0.498 versus 2.36 ± 0.564; P < .01).Conclusion: Correcting chronic IMR with either repair or replacement produces a good mid-term survival rate (approximately 75%) for survivors in NYHA classes I and II. In our study, mortality rates for the MVP and MVR groups were similar, even though the repair group had a lower mean ejection fraction and a higher NYHA class before and after the operation. We therefore conclude that repair is superior to replacement in treating ischemic mitral insufficiency. A prospective randomized study is needed to better compare these 2 approaches.

Risk adjusted perioperative mortality rate following cardiac surgery has been widely used as an indicator of quality of care as well as for comparison of outcomes among institutions and surgeons.

Introduction Nowadays, coronary-coronary bypass grafting (CCBG) has been applied in patients with heavily calcified ascending aorta or due to lack of graft material. Case report We describe a case in which the patient's large left anterior descending (LAD) coronary artery, running well over the cardiac apex, presented with proximal and distal stenosis. Although the pedicled left internal thoracic artery (ITA) graft is sometimes too short for sequential bypass in cases of distal stenosis of the LAD coronary artery, we used a free, short segment of the pedicled left ITA for coronary-coronary bypass grafting. The in situ remnant of the left pedicled ITA was used to bypass the proximal LAD stenosis. The patient's postoperative course was uneventful. Predischarge angiogram (on the 9th postoperative day) showed an in situ left ITA graft as well as a free coronary-coronary ITA graft. The patient had a regular follow-up after 3 months, and was classified as New York Heart Association (NYHA) class I. Discussion Primarily used in aorto-coronary bypass surgery (termino-terminal interposition of the saphenous vein between two parts of a resected coronary artery), CCBG was revised latter on, and from hemodynamic point of view the physiologic restoration of coronary blood flow has been confirmed. CCBG might be an attractive approach for bypassing distal lesions of large coronary arteries (combined with arterial or venous grafting of targeted arteries, if proximal stenoses are also present). The proximal remnant of ITA can be used as an in situ or free graft.

Two cases with catastrophic hemorrhage in redo cardiac surgery are described. In the first one tearing of right ventricle with uncontrolled bleeding occurred during sternal reentry. In the second one, tearing of the right atria occurred while the patient was on cardiopulmonary bypass. In both cases we were able to control bleeding using Foley catheter, which enabled us to proceed to deep hypothermic circulatory arrest to repair heart chambers (due to dense adhesions it was impossible to m?nage it in any other way). We have found this combined technique to be extremely useful tool to control catastrophic hemorrhage during redo cardiac surgery.

the effectiveness of adjuvant therapy for these aggressive tumors. The role of adjuvant radiation therapy is not well defined but is generally advocated because it might decrease the incidence of recurrent tumor. Primary PA sarcoma has a predilection to result in metastatic disease because of its tendency to embolize into the pulmonary arterial tree. Chemotherapy might be effective against microscopic metastatic disease and might decrease the burden of recurrent pulmonary and other systemic disease; however, there has been limited experience with this in the past. In summary, we present 2 cases of primary PA sarcoma that mimicked pulmonary thromboembolic disease. In both patients the diagnosis of PA sarcoma was made only after pathology was reviewed postoperatively. Despite diagnostic, operative, and oncologic advances over the last few decades, PA sarcoma still remains a diagnostic dilemma associated with a dismal prognosis.

A free short segment of left internal thoracic artery (ITA) has been used to bypass a single distal lesion on a large left anterior descending artery (LAD) running well over the cardiac apex. In our opinion this technique occasionally might be an attractive approach for bypassing very distal lesions of large coronary arteries (combined with regular arterial or venous grafting if there has also been proximal stenosis in the targeted artery). The proximal remnant of the left ITA can be easily used as an in situ graft.

We read the article “Screening for significant atherosclerotic renal artery stenosis with a regression model in patients undergoing transradial coronary angiography/intervention” by Pu et al. (2012), published in Journal of Zhejiang University-SCIENCE B (Biomedicine & Biotechnology), with great interest. Of particular interest to us was the part considering the logistic regression model in this specific cohort of patients for future screening for significant atherosclerotic renal artery stenosis (ARAS). Although arteriography represents the gold standard for evaluation of ARAS, this exam is invasive and requires nephrotoxic iodinated contrast media which makes it less suitable as a first option for diagnosis or screening. Several non-invasive assessment tools, such as Doppler ultrasound and non-enhanced magnetic resonance angiography, have high sensitivity and specificity rates, but also have certain shortcomings. It seems that the invasive approach presented is too aggressive, considering the results of the regression analysis in this paper (Pu et al., 2012); clearly, patients with these variables can be suspected of having significant ARAS. Also, the study design indicates that the primary indication for angiography was coronary artery disease, and that renal angiography was also performed after the completion of coronarography. The results from Table 1 of Pu et al. (2012) seem puzzling as more than half of the patients (n=805, 54.2%) had normal coronary angiograms. Although several authors (Alpert, 1994; da Costa et al., 2001; Bugiardini and Bairey Merz, 2005) have described a small series of myocardial infarctions occurring in patients with normal coronary arteries, the incidence of such events is considered to be low, varying from 1% to 12%. Based on this finding, our question is: what was the indication for coronarography in these patients, or how did the authors define the term “normal” in relation to coronary arteries?

We read with great interest the article by Koshiyama et al. [1] regarding reinforcement of the proximal anastomosis during composite graft replacement of the aortic root, using one of the modifications of the Bentall and DeBono technique [2]. Modified Bentall procedures have many beneficial effects such as prevention of excessive bleeding and development of false aneurysm, avoidance of the kinking of coronary arteries, as well as reduced tension on ‘button’ coronary anastomoses. However, a major weakness in the composite graft replacement of the ascending aorta is haemostasis at the proximal suture line. A refined, flanged Bentall technique using Vasalva tube graft reported by Koshiyama et al. [1] is similar to the flanged technique reported by Yakut [3], previously. The Valsalva sinus portion of the graft is resected, leaving 10 mm in length as the flange and is everted outwards using Koshiyama’s technique [1], whether a segment (several millimetres in a length) of the proximal end of vascular graft is everted outwards to form the flange of the graft using Yakut’s technique [3]. The polypropylene running suture (3–0 or 4–0) is used to anastomose the cuff of the prosthetic valve to the bottom border of the chosen conduit. Subsequently, the flange is returned to its original position. In both techniques, the homemade composite conduit is seated on the aortic annulus, using continuous 3–0 polypropylene suture [3], or everting pledgeted 2–0 polyester sutures [1], which are passed through the flange below the sewing cuff of the prosthetic valve. Koshiyama et al. [1] stated that using 3–0 polyprolene suture to sew the flange and the margin of the residual proximal aortic wall enabled them to wrap tightly all of the proximal anastomosis line. However, as it can be easily seen on figure 1D of their manuscript [1], only the pledgets of the tied everting pledgeted 2–0 polyester sutures are covered, while the knots of these sutures are still ‘naked’, outside, on the flange, between the flange and prosthetic tube, thus leaving pinholes of the everting mattress sutures as the potential sites of bleeding. On the contrary, Chen et al. [4] modified the composite graft by adding a short skirt (which was made of a part of the distal end of the prosthetic tube) to a standard composite graft root. After the proximal end of the modified composite conduit was secured in the aortic annulus, the short skirt was sewn to the remaining native proximal aortic wall to really wrap all of the proximal anastomosis line. However, we have to point out that Copeland et al. [5] reported an elegant, easily reproducible, and efficient technique to reduce bleeding from the proximal anastomosis after the Bentall procedure. After the composite conduit is seated into the aortic annulus and the sutures are tied, an additional 3–0 polypropylene suture is used to sew the cut edge of the proximal aortic wall and the prosthetic sewing cuff or the prosthetic tube, thus reinforcing and really completely covering all of the proximal anastomosis line.

We read with great interest the article by Akar et al. [1] regarding validation of the EuroSCORE risk models in the Turkish adult cardiac surgical population. This manuscript is in agreement with previous reports [2–4] that additive and logistic EuroSCORE models overpredict mortality in cardiac surgery nowadays. However, in our opinion there are a few issues that should be clarified. The first one is a definition of mortality. The original EuroSCORE model [5] defined operative mortality as death within 30 days from operation or even later than 30 days if still in hospital (not 30-day mortality as the authors stated in Discussion section of their manuscript [1]). On the other side, their calculation and statistical observations were based only on in-hospital mortality. It is possible that, with the inclusion of all patients who should be included as perioperative deaths (30-day mortality plus in-hospital mortality), the findings of the study [1] would no longer be statistically significant. When we validate a risk stratification model on a population out of its original database, we have to check its discriminatory power and calibration. Model discrimination was analysed by determining the area under the receiver operating characteristic (ROC) curve [1– 5]. However, several statistical procedures have been used to determine calibration. The Hosmer–Lemeshow (H-L) test has been used in >90% of all manuscripts to test the EuroSCORE calibration in different patient population (the H–L test confirms good calibration if the P-value is >0.05), including the EuroSCORE working group [5]. In a few manuscripts calibration plots, unpaired t-test [1], chisquare test [4] or observed to expected (O/E) ratios were used to prove that calibration of the EuroSCORE models was inadequate. Thus, we are curious as to what would be the results of the EuroSCORE calibration checking in these articles if the H–L test was used. On the contrary, Yap et al. [2] wrote an excellent manuscript with intention of validating the EuroSCORE model in Australia. Mortality definition was correct (in-hospital mortality plus 30-day mortality), areas under the ROC curves (0.82) confirmed an excellent discrimination for both additive and logistic EuroSCORE models, but calibration using the H–L test was poor (P 0.05) of the logistic EuroSCORE model. Finally, our question is—should we use the H–L test any more, or we are looking for a statistical procedure that will confirm poor calibration of the EuroSCORE models?

Emphysematous lung occupying the whole dome of the left pleural cavity and expanding well over the midline may occasionally present a significant problem for positioning of the left internal thoracic artery, although the graft has been mobilized up to its origin. To avoid an undue tension on it, we combined a well known technique of the pericardial incision with the pericardial strip technique, enabling the lung to expand freely.

Five years ago, the left internal thoracic artery free segment was used as a coronary-coronary bypass over a single, distal lesion of the large left anterior descending coronary artery in a patient with triple vessel disease. The patient has recently been readmitted, complaining of chest discomfort. Although he was scheduled for percutaneous coronary intervention due to disease progression on the circumflex coronary artery, the perfect angiographic patency of the arterial coronary-coronary conduit has been confirmed.

Objective: To evaluate serious cardiac events after combined (either single or two stage) coronary artery surgery (CAS) and carotid endarterectomy (CEA) for concomitant coronary and carotid artery disease. Methods: We have analyzed our 15 year experience (January 1981‐September 1996) with 201 consecutive patients operated on using both approaches. Group A consisted of 48 patients with the single-stage procedure, while in group B (153 patients), two stage procedure was carried out, either as carotid endarterectomy (CEA), followed by coronary artery bypass surgery (CAS) (group B1 103 patients), or as CAS followed by CEA (group B2 50 patients). Five patients from B1 group died after the CEA procedure, but were included, despite the fact they never reached the second stage. Left main coronary artery disease was found in 41 patients (20.4%), poor left ventricular function in 49 (24.4%) previous MI in 133 (66.2%), while 136 (67.7%) were in NYHA functional class III or IV. Bilateral carotid involvement was present in 61 patients (30.3%). Unstable angina was more prevalent in groups A and B2 (PB 0.0001), NYHA class III:IV in group A (versus B1, P0.001 and versus B2, P 0.02), low ejection fraction in groups A and B2 (PB0.0001), bilateral carotid stenosis in group B1 (versus A, P0.003 and versus B2, PB 0.0001), and ulcerated plaque in group B1 (PB0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management. Results: Early mortality for the entire group was 5.5% (11:201) 6.2% in group A, 7.8% in group B1 and 0% in group B2, respectively; (P\0.05). Serious morbidity occurred in 7.5% of patients (8.3% in group A, 7.8% in group B1 and 6% in group B2, respectively; P\0.05). Univariate analysis revealed only bilateral carotid stenosis to influence early outcome (P0.04). Conclusion: Patients with concomitant coronary and carotid artery disease have relatively good immediate operative results, providing all existing lesions are corrected. Despite it did not reach the statistical significance, cardiac events were less frequent in groups A and B2 indicating possible protective effect of prior CAS in patients with concomitant disease. © 1997 Elsevier Science B.V.

J Thorac Cardiovasc Surg 2004;127:599-600 Miomir Dj. Jovic and Miroslav M. Jakovljevic Dusko G. Nezic, Milan M. Vukovic, Milan V. Cirkovic, Aleksandar M. Knezevic,An unusual complication after chordal sparing mitral valve replacement http://jtcs.ctsnetjournals.org/cgi/content/full/127/2/599 located on the World Wide Web at: The online version of this article, along with updated information and services, is