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The article focuses on a consensus on standardizing clinical end points in aortic arch surgery by the International Aortic Arch Surgery Study Group (IAASSG). Topics discussed include standardizing definitions, the impact of surgical techniques on patient outcomes, and management-oriented classification system for complications. It mentions classifications of clinical end points for several systems including the respiratory system, the cardiovascular system, and the neurological system.

OBJECTIVE A number of factors limit the effectiveness of current aortic arch studies in assessing optimal neuroprotection strategies, including insufficient patient numbers, heterogenous definitions of clinical variables, multiple technical strategies, inadequate reporting of surgical outcomes and a lack of collaborative effort. We have formed an international coalition of centres to provide more robust investigations into this topic. METHODS High-volume aortic arch centres were identified from the literature and contacted for recruitment. A Research Steering Committee of expert arch surgeons was convened to oversee the direction of the research. RESULTS The International Aortic Arch Surgery Study Group has been formed by 41 arch surgeons from 10 countries to better evaluate patient outcomes after aortic arch surgery. Several projects, including the establishment of a multi-institutional retrospective database, randomized controlled trials and a prospectively collected database, are currently underway. CONCLUSIONS Such a collaborative effort will herald a turning point in the surgical management of aortic arch pathologies and will provide better powered analyses to assess the impact of varying surgical techniques on mortality and morbidity, identify predictors for neurological and operative risk, formulate and validate risk predictor models and review long-term survival outcomes and quality-of-life after arch surgery. [ABSTRACT FROM PUBLISHER]

Abstract: Objective: The optimal myocardial preservation strategy at re-operation for aortic valve replacement (AVR) after prior coronary artery bypass grafting (CABG) in the presence of a patent internal thoracic artery (ITA) remains undefined. Methods: Patients undergoing AVR after prior CABG at our institution between 1 January 1996 and 31 December 2007 were identified; operative notes and outcomes were reviewed. Results: Of 628 patients with prior CABG undergoing AVR with or without concomitant procedures, 427 patients had a patent ITA. In 390, management of the ITA was detailed in the operative note, including 251 in whom it was clamped and 139 in whom it was left uncontrolled. Groups were demographically similar, although re-operative CABG was more frequent in the clamped group (42% vs 23%, p <0.001). The operative mortality rate among those undergoing only AVR±CABG was 7.7% (19/246), while that for all cases was 10.8% (42/390), and was lower when the ITA was left uncontrolled both for AVR±CABG (4.1% vs 10.1%, p =0.08) and overall (7.2% vs 12.7%, p =0.09). By multivariate analysis, leaving the ITA uncontrolled appeared protective (odds ratio (OR) 0.46, p =0.08). There was no clear trend supporting an optimal perfusion temperature when the ITA was left uncontrolled. Conclusions: Efforts to control the patent ITA at re-operation for AVR after prior CABG increase risk of injury and may actually increase operative mortality rate compared with leaving this critical graft open and perfusing the heart. [Copyright &y& Elsevier]

It is not well known if the size of the ascending thoracic aorta at presentation predicts features of presentation, management, and outcomes in patients with acute type B aortic dissection. The International Registry of Acute Aortic Dissection (IRAD) database was queried for all patients with acute type B dissection who had documentation of ascending thoracic aortic size at time of presentation. Patients were categorized according to ascending thoracic aortic diameters ≤4.0, 4.1 to 4.5, and ≥4.6 cm. Four hundred eighteen patients met inclusion criteria; 291 patients (69.6%) were men with a mean age of 63.2 ± 13.5 years. Ascending thoracic aortic diameter ≤4.0 cm was noted in 250 patients (59.8%), 4.1 to 4.5 cm in 105 patients (25.1%), and ≥4.6 cm in 63 patients (15.1%). Patients with an ascending thoracic aortic diameter ≥4.6 cm were more likely to be men (p = 0.01) and have Marfan syndrome (p <0.001) and known bicuspid aortic valve disease (p = 0.003). In patients with an ascending thoracic aorta ≥4.1 cm, there was an increased incidence of surgical intervention (p = 0.013). In those with an ascending thoracic aorta ≥4.6 cm, the root, ascending aorta, arch, and aortic valve were more often involved in surgical repair. Patients with an ascending thoracic aorta ≤4.0 were more likely to have endovascular therapy than those with larger ascending thoracic aortas (p = 0.009). There was no difference in overall mortality or cause of death. In conclusion, ascending thoracic aortic enlargement in patients with acute type B aortic dissection is common. Although its presence does not appear to predict an increased risk of mortality, it is associated with more frequent open surgical intervention that often involves replacement of the proximal aorta. Those with smaller proximal aortas are more likely to receive endovascular therapy. [ABSTRACT FROM AUTHOR]

Pregnancy and congenitally bicuspid aortic valve (BAV) are thought to be risk factors for aortic dissection; however, the population-based risk for patients with the 2 risk factors remains unknown. We investigated the relation between pregnancy and ascending aortic events in women with congenital BAV living in Olmsted County, Minnesota. Our institutional echocardiographic database was searched for women residing in Olmsted County with congenital BAV diagnosed from 1980 to 1999. We reviewed medical records for end points of aortic events (dilatation, dissection, or surgery) and aortic valve replacement (AVR). Obstetric history and further outcome follow-up were collected by postal survey. We identified 88 women with BAV. Median age at diagnosis was 35 years. Obstetric history totaled 216 pregnancies and 186 deliveries. There were no aortic dissections. During follow-up (median 12.3 years), 24 patients underwent AVR (n = 14), ascending aortic surgery (n = 3), or AVR and ascending aortic surgery (n = 7). Pregnancy was not associated with dilatation of the aorta, aorta surgery, or AVR. At echocardiographic diagnosis of BAV, 5 patients (6%) had aortas >40 mm in greatest diameter and 1 patient has >50 mm. Of 60 patients with serial echocardiograms for comparison (median interval 10.7 years), 21 patients (35%) had aortas measuring >40 mm in greatest dimension and 2 patients had >50 mm. In conclusion, aortic dissection in women with BAV and pregnancy is rare in the community. There is a significant rate of progressive enlargement of the aorta, warranting longitudinal follow-up. [ABSTRACT FROM AUTHOR]

Bicuspid aortic valve (BAV) is associated with ascending aortopathy predisposing to aneurysmal dilatation and dissection, even after successful aortic valve replacement (AVR). There is, however, scant evidence on which to make recommendations for prophylactic replacement of the ascending aorta at the time of AVR. The medical records of patients who underwent AVR for BAV without aortic replacement or repair from 1960 to 1995 were reviewed. Follow-up was by review of the medical record and postal questionnaire. Among 1,286 patients, the mean age at operation was 58 ± 14 years. During the follow-up interval (median 12 years, range 0 to 38), there were 13 documented aortic dissections (1%), 11 ascending aortic replacements (0.9%), and 127 documented cases of progressive aortic enlargement (9.9%). Fifteen-year freedom from aortic dissection, enlargement, or replacement was 89% (95% confidence interval [CI] 87% to 91%) and was lower in patients with documented aortic enlargement at the time of AVR (85%, 95% CI 81% to 89%) compared to those whose aortic dimensions were normal (93%, 95% CI 90% to 96%) (p = 0.001). Multivariate predictors of aortic complications included interval (subsequent) AVR (hazard ratio [HR] 3.5, 95% CI 2.3 to 5.4, p <0.001), concomitant coronary artery bypass grafting (HR 2.6, 95% CI 1.7 to 4.0, p <0.001), enlarged aorta (HR 1.8, 95% CI 1.3 to 2.6, p = 0.001), and history of tobacco abuse (HR 1.8, 95% CI 1.2 to 2.6, p = 0.003). Aortic dilatation did not predict mortality. In conclusion, despite a true risk for aortic events after AVR for BAV, the occurrence of aortic dissection was low. Any incremental surgical risk imposed by prophylactic replacement of the ascending aorta must be equally low. [ABSTRACT FROM AUTHOR]

Abstract: Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper. [Copyright &y& Elsevier]

Objective: To examine operative outcomes after acute pulmonary embolectomy (APE), a recently adopted, more aggressive surgical approach.Patients and Methods: We retrospectively identified patients who underwent surgical APE from April 1, 2001, through March 31, 2009, and reviewed their clinical records for perioperative outcome. Operations were performed with normothermic cardiopulmonary bypass and a beating heart, absent a patent foramen ovale. For completeness, embolectomy was performed via separate incisions in the left and right pulmonary arteries (PAs) in 15 patients.Results: Of the 18 patients identified, the mean age was 60 years, and 13 patients (72%) were men. Thirteen patients (72%) had been hospitalized recently or had systemic disease. The preoperative diagnosis was established by echocardiography or computed tomography (or both). The median (range) follow-up time for all surviving patients was 16 months (2-74 months). Indications for APE included cardiogenic shock (n=12; 67%) and severe right ventricular dysfunction as shown by echocardiography (n=5; 28%). Seven patients (39%) had an embolus in transit. Seven patients (39%) experienced cardiopulmonary arrest before APE. Four early deaths (22%) occurred; all 4 of these patients had preoperative cardiopulmonary arrest, and 2 had APE via the main PA only, without branch PA incisions. Two late deaths (11%) occurred. Right ventricular function improved in all survivors.Conclusion: The results of emergent APE are encouraging, particularly among patients without cardiopulmonary arrest. It should not be reserved for patients in extremis; rather, it should be considered for patients with right ventricular dysfunction that is an early sign of impending hemodynamic collapse. [ABSTRACT FROM AUTHOR]

Intraoperative (IO) transesophageal echocardiography (TEE) is widely used for assessing the results of valvular heart disease (VHD) surgery. Epiaortic ultrasonography (EAU) has been recommended for prevention of perioperative strokes. To what extent does high-quality evidence justify the widespread use of these imaging modalities? In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU. We found no randomized trials or studies with control groups assessing the impact of IOTEE in VHD surgery. Pooled analysis of 8 observational studies including 15,540 patients showed an average incidence of 11% for prebypass surgical changes and 4% for second pump runs, suggesting that patients undergoing VHD surgery may benefit significantly from IOTEE, particularly from postcardiopulmonary bypass IOTEE in aortic repair and mitral repair and replacement, but less so in isolated aortic replacement. Further available indirect evidence was satisfactory in the test accuracy and surgical quality control aspects, with low complication rates for IOTEE. The data supporting EAU included 12,687 patients in 2 prospective randomized studies and 4 nonrandomized, controlled studies, producing inconsistent outcome-related results. Despite low-quality scientific evidence supporting IOTEE in VHD surgery, we conclude that indirect evidence supporting its use is satisfactory and suggests that IOTEE may offer considerable benefit in valvular repairs and mitral replacements. The value of IOTEE in isolated aortic valve replacement remains less clear. Evidence supporting EAU is scientifically more robust but conflicting. These findings have important clinical policy and research implications. [ABSTRACT FROM AUTHOR]

Background: Preprocedural briefings have been adopted in many high consequence environments, but have not been widely accepted in medicine. We sought to develop, implement, and evaluate a preoperative briefing for cardiovascular surgery. Study Design: The briefing was developed by using a combined questionnaire and semistructured focus group approach involving five subspecialties of surgical staff (n=55). The results were used to design and implement a preoperative briefing protocol. The briefing was evaluated by monitoring surgical flow disruptions, circulating nurse trips to the core, time spent in the core, and cost-waste reports before and after implementation of the briefing across 16 cardiac surgery cases. Results: Focus group data indicated consensus among surgical staff concerning briefing benefits, duration, location, content, and potential barriers. Disagreement arose concerning timing of the brief and the roles of key participants. After implementation of the briefing, there was a reduction in total surgical flow disruptions per case (5.4 preimplementation versus 2.8 postimplementation, p=0.004) and reductions in per case average of procedural knowledge disruptions (4.1 versus 2.17, p=0.004) and miscommunication events (2.5 versus 1.17, p=0.03). There was no significant reduction in disruptions because of equipment preparation or disruptions from patient-related issues. On average, briefed teams experienced fewer trips to the core (10 versus 4.7, p=0.004) and spent less time in the core (397.4 seconds versus 172.3 seconds, p=0.006), and there was a trend toward decreased waste (30% versus 17%, p=0.15). Conclusions: These findings demonstrate the feasibility of creating a specialty-specific preoperative briefing to decrease surgical flow disruptions and improve patient safety in the operating room. [Copyright &y& Elsevier]

Acute and chronic aortic diseases have been diagnosed and studied by physicians for centuries. Both the diagnosis and treatment of aortic diseases have been steadily improving over time, largely because of increased physician awareness and improvements in diagnostic modalities. This comprehensive review discusses the pathophysiology and risk factors, classification schemes, epidemiology, clinical presentations, diagnostic modalities, management options, and outcomes of various aortic conditions, including acute aortic dissection (and its variants intramural hematoma and penetrating aortic ulcers) and thoracic aortic aneurysms. Literature searches of the PubMed database were conducted using the following keywords: aortic dissection, intramural hematoma, aortic ulcer, and thoracic aortic aneurysm. Retrospective and prospective studies performed within the past 20 years were included in the review; however, most data are from the past 15 years. [ABSTRACT FROM AUTHOR]

Objectives. We reviewed the spectrum of disease and early outcomes of patients undergoing ascending aortic surgery for Giant cell aortitis (GCA). Design. Of 1 259 patients undergoing repair of ascending aortic aneurysms between January 1993 and July 2006, 100 had histologic evidence of GCA or lymphoplasmacytic aortitis. Results. Operative Mortality was 4% (4/100). One patient underwent aortoplasty and aortic valve replacement (AVR). Among 99 patients undergoing graft replacement of the ascending aorta, distal disease required hemiarch replacement in 33 and total arch replacement in 14. Proximal aneurismal disease of the root was managed by mechanical or biological root replacement (n=18), Yacoub remodeling (n=2) or David reimplantation (n=9). Another 12 patients had separate AVR and ascending graft, while 26 had AR corrected by restoration of proper sinotubular junction diameter. In total, of 63 patients with AR, 38 had a valve-preserving procedure (61%). Conclusions. Ascending aortic aneurismal disease due to GCA is frequently associated with proximal and/or distal disease. Valve sparing procedures are technically feasible for many, although late durability is uncertain. [ABSTRACT FROM AUTHOR]

Abstract: Background: Previous research has found teamwork failures to be strongly associated with the occurrence of surgical error. There have been few efforts to prospectively collect data regarding teamwork failures and technical errors in order to create interventions that would maximize teamwork effectiveness thereby minimizing technical error. Methods: Thirty-one cardiac surgical cases were prospectively observed by a trained human factors observer. Events were characterized according to human factors theory and included teamwork failures and technical errors. Surgical team structure was also evaluated in an effort to identify if it had an impact on surgical team performance. Results: A strong correlation (r =0.67, p <0.001) was recognized between the occurrence of technical error (n =155) and teamwork failures (n =178). Teamwork failures consisted of surgeon–technical team failures (n =90, 51%), procedural information failures (n =36, 20%), surgeon–anesthesiologist failures (n =27, 15%), surgeon–perfusionist failures (n =18, 10%), and failures due to handoffs (n =7, 4%). Teams made up of members that were familiar with the operating surgeon had significantly fewer total event failures (8.6±1.6 vs 22±3.1, p <0.0001) and teamwork failures (5.6±1.8 vs 15.4±1.9, p <0.0001) in comparison to those teams where the majority of members were unfamiliar with the operating surgeon. Conclusions: These results indicate that the process of cardiac surgery would benefit from interventions to improve teamwork and communication. Such interventions could include preoperative briefings, revised approach to structuring of operative teams to favor members that have gained familiarity with the operating surgeon, standardized communication practices, and postoperative debriefings. [Copyright &y& Elsevier]

Background: Historically, patients with AL amyloidosis and overt congestive heart failure have had an ominous prognosis with median survival of approximately 6 months. Methods: Between 1994 and 2005, 11 patients underwent sequential orthotopic heart transplantation (HT) followed by autologous peripheral blood stem cell transplantation (SCT) for treatment of AL amyloidosis. Patients were accepted for this approach if they had heart-dominant AL with minimal/no other organ impairment and no evidence of multiple myeloma. Conditioning chemotherapy consisted of melphalan 200 mg/m2 (6 patients) or melphalan 140 mg/m2 (5 patients). Results: Two patients died of complications from the SCT (18% transplant-related mortality). Nine patients survived both the HT and the SCT. Three patients subsequently died from progressive amyloidosis at 66, 56.7 and 55 months after SCT. The 1- and 5-year survival for HT was 82% and 65%. The median survival was 76 months from HT and 57 months from SCT. Conclusions: These data suggest that aggressive treatment of the underlying plasma cell clone after HT may improve long-term outcomes in patients with cardiac amyloid. HT followed by SCT is feasible and offers the possibility of remission for carefully selected patients with cardiac amyloidosis. [Copyright &y& Elsevier]

Brain (B-type) natriuretic peptide (BNP) and tissue Doppler imaging may distinguish restrictive cardiomyopathy (RCMP) from idiopathic constrictive pericardial disease (CP). However, their comparative efficacy is unknown for patients with CP from secondary causes (e.g., surgery or radiotherapy). We compared the efficacy of tissue Doppler imaging and BNP for differentiation of RCMP (n = 15) and CP (n = 16) were compared. BNP was higher in patients with RCMP than CP (p = 0.008), but the groups overlapped, particularly for BNP <400 pg/ml. BNP was lower with idiopathic CP than secondary CP (139 ± 50 vs 293 ± 69 pg/ml; p <0.001) or RCMP (139 ± 50 vs 595 ± 499 pg/ml; p <0.001), but not significantly different between those with secondary CP and RCMP (293 ± 69 vs 595 ± 499 pg/ml; p = 0.1). Patients with CP and RCMP had less overlap in early diastolic and isovolumic contraction tissue Doppler imaging velocities compared with BNP, with clear separation of groups evident with mean early diastolic annular velocities (averaged from 4 walls). Early diastolic tissue Doppler imaging velocity was superior to BNP for differentiation of CP and RCMP (area under the curve 0.97 vs 0.76, respectively; p = 0.01). In conclusion, mean early diastolic mitral annular velocity correctly distinguished CP from RCMP even when there was a large overlap of BNP between the 2 groups. [Copyright &y& Elsevier]

Objectives: We sought to define thromboembolic risk after surgery for mitral regurgitation (MR), particularly ischemic stroke (IS) compared with the general population. Background: Guidelines recommend surgery in asymptomatic patients with MR, but IS risks are unknown. Methods: In 1,344 patients (age 65 ± 12 years) consecutively operated for MR (procedures: 897 mitral valve repair [MRep] and 447 valve replacement: 231 mechanical mitral valve replacement [MVRm], 216 biological mitral valve replacement [MVRb]), thromboembolic complications, particularly IS (diagnosed by neurologists), during follow-up were assessed early (<30 days), midterm (30 to 180 days), and long-term (≥180 days). Results: Ischemic stroke occurred in 130 patients: 1.9 ± 0.4% and 2.7 ± 0.5% at 30 days and 180 days, respectively, and 8.1 ± 0.8% at 5 years. We found that IS rates were lowest after MRep versus MVRb and MVRm (6.1 ± 0.9% vs. 8 ± 2.1%, and 16.1 ± 2.7% at 5 years, respectively, p < 0.001). Comparison with population-expected IS showed high risk at <30 days (risk ratio 41, 95% confidence interval 26 to 60, p < 0.001 but p > 0.10 between procedures) and moderate risk at >30 days (risk ratio 1.7 overall; 1.3 for MRep; 0.98 for MVRb; 4.8 for MVRm). Beyond 180 days, IS risk declined further and was similar to the population for MRep (relative risk 1.2) and for MVRb (relative risk 0.9). Bleeding risk >30 days was lowest in MRep versus MVRb and MVRm (10-year risk 7 ± 1%, 14 ± 4%, and 16 ± 3%, respectively). Conclusions: Thromboembolic complications after MR surgery are a reason for both concern and encouragement. The risk of IS is notable early, irrespective of procedure, but in the long term it is not greater than in the population after MRep and MVRb. Preference for MRep should be emphasized, and trials aiming at preventing IS should be conducted to reduce thromboembolic and hemorrhagic risk after surgery for MR. [Copyright &y& Elsevier]

Objective: We sought to determine if the gene responsible for bicuspid aortic valve (BAV) in an extended family corresponds to previously reported loci for inherited forms of the disorder. Background: Loci at 15q25.1-26 and 9q34 have been reported to be associated with cardiovascular abnormalities involving BAV. Methods: Linkage analysis was performed on DNA collected from a large multigenerational family in which BAV disease segregates in an autosomal dominant manner, using microsatellite markers from the regions previously reported to segregate with the phenotype. Results: Lod scores were determined for genetic markers near the NOTCH1 gene and for a locus on chromosome 15q25.1-26 previously reported as being linked to BAV. The lod scores were negative or less than 1.0 for all markers tested. Conclusions: There is no evidence of linkage of BAV in our pedigree to either the NOTCH1 gene or to the chromosome 15 locus. The disorder in this family appears to be caused by a gene at a novel locus. [Copyright &y& Elsevier]

Background: The pacing model of heart failure produces heterogeneous changes in wall stress and myocyte diameter. The purpose of this study was to measure regional changes in cardiotrophin-1 (CT-1), a cytokine thought to play a role in LV remodeling, and regional changes in LV strain as measured with magnetic resonance imaging. Materials and methods: Dilated cardiomyopathy was induced in nine mongrel dogs over 4 wk by rapid pacing using a right ventricular epicardial lead. Baseline CT-1 was measured from an apical myocardial biopsy, and regional CT-1 was measured from anterior, lateral, inferior, and septal walls after the induction of heart failure and in six control dogs. Tissue tagged images were divided into similar regions and minimal principal strain (MPS), ejection fraction, and ventricular volumes were compared after induction of heart failure. Results: After induction of heart failure, LV ejection fraction and end-diastolic volume differed significantly from baseline (P < 0.01 and P = 0.02, respectively). Additionally, regional CT-1 and MPS were significantly different (P < 0.01 for both). Cardiotrophin-1 increased significantly in the inferior and septal walls (both P < 0.01) but not in the anterior or lateral walls (both P = NS). Minimum principal strain decreased significantly in the inferior and septal walls (both P < 0.01) but not in the anterior or lateral walls (both P = NS). Conclusion: The pacing model of heart failure produces heterogeneous changes in regional CT-1 and wall motion as measured by MPS. The greatest regional changes are closest to the pacemaker site: the inferior and septal walls. These differences in regional CT-1 may account for previously noted myocyte hypertrophy and preserved ventricular function in these regions. [Copyright &y& Elsevier]

Abstract: Objective: Ascending aortic aneurysms (AscAAs) are a highly lethal condition whose pathobiology remains to be poorly understood. Although most AscAAs occur in the presence of a trileaflet aortic valve (TAV), a bicuspid aortic valve (BAV) is a common congenital anomaly associated with an increased risk for an AscAA and dissection independent of functional valve pathology but secondary to inherent structural abnormality of the aorta. The objective of this investigation was to compare the patterns of gene expression in aortas between TAV and BAV patients with the aim of identifying markers for AscAAs. Methods: We used microarray analysis to first compare messenger RNA expressions between aneurysmal aortas from TAV patients (n=11) and those from BAV patients (n=11), identified genes overexpressed in TAV aneurysms, and compared expressions of the selected genes among TAV aneurysms, BAV aneurysms, and normal aortas (n=3). Finally, expressions of the selected genes were assessed by immunostaining of aortas from the TAV, BAV, and normal specimens. Results: Two overexpressed genes in the TAV group, osteopontin (OPN) and tenascin C (TNC), were consistently more highly expressed in TAV aneurysms than in BAV aneurysms and normal aortas as determined by real-time reverse transcriptase quantitative polymerase chain reaction and immunohistochemistry. Differential staining revealed that OPN protein was concentrated in the medial smooth muscle and that TNC protein was concentrated around the vasa vasorum. Conclusions: We identified two novel potential markers, OPN and TNC, that are strongly associated with TAV aneurysms. The roles of OPN and TNC in influencing extracellular matrix remodeling in AscAAs warrant further investigation. [Copyright &y& Elsevier]

Objectives: We report a series of patients with severe tricuspid valve regurgitation due to a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) lead. Background: Severe tricuspid regurgitation caused by a PPM or ICD lead is an under-recognized but treatable etiology of severe right heart failure. Methods: We reviewed the records of 41 patients who underwent tricuspid valve operation for severe tricuspid regurgitation caused by previously placed PPM or ICD leads. Results: During surgery, severe tricuspid regurgitation was found to be caused by the PPM or ICD leads in all 41 patients. There was a perforation of the tricuspid valve leaflet by the PPM or ICD lead in 7 patients, lead entanglement in the tricuspid valve occurred in 4 patients, lead impingement of the tricuspid valve leaflets occurred in 16 patients, and lead adherence to the tricuspid valve occurred in 14 patients. The septal leaflet was most often perforated (6 of 7). In the preoperative evaluation, valve malfunction due to the PPM or ICD lead was diagnosed preoperatively in only 5 of 41 (12%) patients by transthoracic echocardiography. All patients underwent successful tricuspid valve operation (22 tricuspid valve replacement), with one perioperative death occurring. During follow-up (range, 1 to 99 months), there was one patient who died from left-sided heart failure and three patients died of other causes. The remaining patients showed improvement in signs and symptoms of heart failure. Conclusions: Damage to the tricuspid valve by PPM or ICD leads may result in severe symptomatic tricuspid regurgitation and may not be overtly visualized by echocardiography. This etiology should be considered when evaluating patients with severe right heart failure after PPM or ICD implantation. [Copyright &y& Elsevier]

: BackgroundCoronary artery disease characteristically impacts left ventricular (LV) function on a regional basis, although ultimately global function may be affected as well. Echocardiography is commonly clinically used for the assessment of regional function; however, it is only semiquantitative and in its current iteration is only two-dimensional in nature. Magnetic resonance imaging (MRI) with tissue tagging offers the possibility for noninvasive, three-dimensional (3D) assessment of transmural and segmental left ventricular strain and, thereby, function. Accordingly, we have explored methodologies to accurately and quantitatively characterize regional systolic function in three dimensions in patients with ischemic heart disease using MRI.: Materials and methodsMRI radiofrequency tissue tagging was performed at rest and during dobutamine administration (10 mg/kg/min) on 10 normal volunteers (age: 26 ± 6) and 8 patients with severe ischemic cardiomyopathy (age: 60 ± 5, EF 26 ± 11%). Three-dimensional global and regional systolic strain calculations were made based on 3D myocardial point displacements and compared with conventional measures.: ResultsGlobal left ventricular strains were significantly decreased in ischemic patients at rest (0.14 ± 0.04 versus 0.25 ± 0.02, P < 0.001) and with dobutamine (0.14 ± 0.03 versus 0.29 ± 0.03, P < 0.001). In the regional analysis (216 LV wall segments) this methodology accurately differentiated normal from abnormally contracting regions.: ConclusionsNoninvasive dobutamine MRI tissue tagging with calculation of 3D regional strains has significant promise as a clinical tool which is capable of the identification, quantification, and display of regionally varying ventricular function. [Copyright &y& Elsevier]

A response from the author of the article "Surgical Ineligibility and Mortality Among Patients With Unprotected Left Main or Multivessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention," that was published in the 2014 issue is presented.

Abstract: Background: The classification of aortic dissection into acute (<14 days from symptom onset) versus chronic (≥14 days) is based on survival estimates of patients treated decades before modern diagnostic and treatment modalities were available. A new classification of aortic dissection in the current era may provide clinicians with a more precise method of characterizing the interaction of time, dissection location, and treatment type with survival. Methods: We developed separate Kaplan-Meier survival curves for Type A and Type B aortic dissection using data from the International Registry of Aortic Dissection (IRAD). Daily survival was stratified based on type of therapy provided: medical therapy alone (medical), nonsurgical intervention plus medical therapy (endovascular), and open surgery plus medical therapy (surgical). The log-rank statistic was used to compare the survival curves of each management type within Type A and Type B aortic dissection. Results: There were 1815 patients included, 67.3% male with mean age 62.0 ± 14.2 years. When survival curves were constructed, 4 distinct time periods were noted: hyperacute (symptom onset to 24 hours), acute (2-7 days), subacute (8-30 days), and chronic (>30 days). Overall survival was progressively lower through the 4 time periods. Conclusions: This IRAD classification system can provide clinicians with a more robust method of characterizing survival after aortic dissection over time than previous methods. This system will be useful for treating patients, counseling patients and families, and studying new diagnostic and treatment methods. [Copyright &y& Elsevier]