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Actinomyces endocarditis is very rare. At present the only Actinomyces species identified causing endocarditis are A. israelii, A. bovis, A. viscosus, A. pyogenes, A. meyeri and A. funkei. We here report the first case of endocarditis caused by Actinomyces neuii.

Objective: The introduction of drug-eluting stents significantly reduced restenosis and reinterventions in patients undergoing percutaneous coronary interventions. This study compares results of Cypher stenting with those of surgical arterial revascularization in patients with diabetes mellitus., Methods: From May 2002 through May 2005, 523 consecutive diabetic patients underwent myocardial revascularization: 244 underwent percutaneous coronary interventions incorporating drug-eluting stents, and 279 were treated surgically. All single-vessel patients in the surgical group were treated with the left internal thoracic artery, and most multivessel patients were treated with 2 internal thoracic arteries. After propensity score matching, 2 groups (93 patients each) were used to compare the 2 revascularization modalities., Results: The number of coronary vessels treated per patient was higher in the surgical group (2.72 vs 1.75, P < .001). Follow-up ranged between 6 and 42 months (mean, 19 months). Overall mortality (early and late) was 3.2% in the surgical group and 2.2% in the Cypher group (P = .65). Two-year angina-free survival and reintervention-free survival (Kaplan-Meier) of the surgical group were 88% and 95%, respectively, compared with 47.8% (P = .001) and 83.6% (P = .01), respectively, in the percutaneous coronary intervention group. Cox proportional hazards modeling revealed assignment to the Cypher group to be the only predictor of reintervention (odds ratio, 3.86; 95% confidence interval, 1.25-11.9). Assignment to the Cypher group (hazard ratio, 5.92; 95% confidence interval, 2.96-11.87) and insulin treatment (hazard ratio, 2.06; 95% confidence interval, 1.06-4.02) were independent predictors of angina recurrence., Conclusions: The midterm clinical outcome of diabetic patients who underwent surgical arterial revascularization is better than that of patients undergoing percutaneous coronary intervention treated with drug-eluting stents.

Purpose: Morbid obesity caries an increased risk of cardiovascular morbidity and might be associated with intraoperative hemodynamic instability. Based on clinical observation, we hypothesized that during laparoscopic surgery, morbidly obese patients behave hemodynamically similar to the nonobese patients and remain hemodynamically stable., Methods: In a prospective trial, thirty nonobese and tthirty morbidly obese (BMI > or = 35 kg/m(2)) patients scheduled for elective laparoscopic surgery were assigned to receive standard balanced anesthesia. We aimed at equianesthetic levels by keeping the BIS (bispectral index) value between 40-50 throughout surgery. End-tidal isoflurane was measured every 5 min. Noninvasive hemodynamic measurements included cardiac index (CI), mean arterial pressure (MAP) and heart rate (HR), recorded every 5 min and at specific predetermined times. Systemic vascular resistance (SVR) was calculated. Episodes of MAP < or = 60 and MAP > or = 130 mmHg or HR < or = 50 and HR > or = 110 bpm occurring throughout surgery and requiring pharmacological intervention were considered main end-points. Additionally, hemodynamic variables were compared at specific time points and overall throughout surgery. Secondary end-points were CI and SVRI., Results: Heart rate was higher in obese patients in head-up position (79 +/- 15 mmHg vs. 65 +/- 12 mmHg - P=0.011). SVR was higher in the nonobese group with head-up position (1978 +/- 665 dynes s cm(-5) vs. 1394 +/- 496 dynes s cm(-5) P=0.01). Mean overall intraoperative MAP, HR, CI and SVR were similar. There were no episodes of MAP < or = 60 and > or =130 mmHg or HR < or = 50 and > or =110 bpm in either of the groups., Conclusion: Our study confirmed our hypothesis that for the most periods of laparoscopic surgery, obese patients are hemodynamically as stable as their nonobese counterparts.

Study Objective: Transurethral resection of prostate (TURP) is more frequently associated with perioperative fluid and electrolyte disturbances than transurethral resection of bladder tumors (TURT) because of irrigating fluid absorption. Because fluid overload may cause hypertension, we compared the patients' intraoperative hemodynamic profiles (including the incidence of hypertension) during TURP vs TURT, both performed during spinal anesthesia, by using the bioimpedance method., Design: Prospective single-blind study., Setting: University hospital., Patients: 80 (40 in each group) men, ASA physical status I and II., Interventions: Patients underwent TURP or TURT surgery with spinal anesthesia., Measurements: Mean arterial pressure, heart rate, cardiac index, and systemic vascular resistance were compared between the 2 groups. A mean arterial pressure greater than 30% from the baseline value was considered as hypertension. Plasma sodium was measured preoperatively, intraoperatively, and postoperatively., Main Results: Transurethral resection of prostate patients received more irrigating fluid (7900 +/- 2310 vs 5650 +/- 21560, P < 0.05) and had a higher calculated volume of fluid absorbed: 638 +/- 60 vs 303 +/- 40 mL for the TURT patients (P < 0.05). Mean arterial pressures were higher with TURP, 30 minutes after the onset of surgery and at the end of the procedure (111 +/- 15 vs 100 +/- 10 and 109 +/- 14 vs 99 +/- 14 mmHg, respectively; P < 0.05). However, there was no hypertension in either group. There were no differences in hemodynamic measurements of hyponatremic vs normonatremic patients. Plasma sodium decreased postoperatively more in the TURP group (140.4 +/- 2.6 mEq/L baseline to 134.1 +/- 3.5 mEq/L, P < 0.05) and was lower postoperatively in the TURP group compared with TURT (134.1 +/- 3.5 vs 137.2 +/- 2.9 mEq/L, P = 0.04)., Conclusions: Although more irrigating fluid was absorbed in the TURP group, there were no episodes of hypertension in either group.

Study Objective: Main stem bronchial intubation is not always detected by routine means and may occur more frequently during laparoscopic procedures. Tracheal tube positional changes in non-obese patients undergoing laparoscopic cholecystectomy were detected by either the Rapiscope (Cook Critical Care, Bloomington, Ind) or chest auscultation., Design: Prospective, double-blind, crossover study., Setting: University hospital., Patients: Forty non-obese patients (BMI <28 kg.m(-2)), aged 18 to 80 years, American Society of Anesthesiologists risk class I-III, who underwent elective laparoscopic cholecystectomy were enrolled in this double-blind, prospective study., Interventions: After endotracheal intubation by one anesthesiologist, two other anesthesiologists assessed the tracheal tube's positioning by either the Rapiscope or chest auscultation; the results of one anesthesiologist's measurement were concealed from the other., Measurements: Assessments of the endotracheal tube tip's position were performed after intubation, head-down, and head-up positioning, after maximal abdominal insufflation and before extubation. At the same time points, Sp(O2), ET(CO2), and peak inspiratory pressures were also recorded., Main Results: Postintubation Rapiscope assessment revealed normal tracheal positioning of the tube's tip in all patients. Changes in tube's position were subsequently detected by the Rapiscope in 16 patients. In 8 cases, the tip moved endobronchially. Half of the endobronchial intubations occurred after maximal abdominal insufflation and the other half after changing the table position from neutral to 30 degrees head-down. Chest auscultation detected bronchial intubation in two cases only (P = .01). There were 4 additional events of downward movements and 4 events of cephalad migration of the tube's tip identified by the Rapiscope only. ET(CO2), Sp(O2), and peak inspiratory pressures did not change in patients who did experience bronchial intubation., Conclusion: The Rapiscope detected significantly more events of endobronchial intubation as compared with chest auscultation; it could be considered useful during procedures where tracheal tube movements are potential.

Background: Hyperphosphatemic acidosis and severe electrolyte disturbances caused by phosphate salts (PO) used for mechanical bowel preparation have been described in occasional case reports prior to bowel resection surgery. We hypothesized that PO used preoperatively for bowel preparation may cause more pronounced acid base and electrolyte changes than polyethylene glycol (PG)., Methods: Forty American Society of Anesthesiologists physical status II-III patients were randomly allocated to receive either PO or PG for bowel preparation before intra-abdominal surgery (bowel resection or other major elective intra-abdominal surgeries). Measurements of pH, base deficit, blood gases, lactate, hemoglobin, calcium, magnesium, potassium and phosphorus were undertaken before the laxative administration, intraoperatively, and postoperatively., Results: Preoperative demographic, hemodynamic and laboratory data were similar in the two groups. Intraoperative calcium (8.4 [0.6] vs 9 [0.5] mg x dL(-1)) and pH (7.35 [0.04] vs 7.41 [0.03]) were lower, while lactate (1.3 [0.4] vs 0.9 [0.3] mmol x L(-1)) was higher with PO. Postoperative calcium, magnesium and potassium were lower (8 [0.5] vs 8.9 [0.2] mg x dL(-1), 1.68 [0.3] vs 1.8 [0.4] and 3.5 [0.36] vs 3.7 [0.33] mEq x L(-1) respectively) while phosphorus (4.1 [0.3] vs 3.3 [0.2] mEq x L(-1)) was higher with PO. A higher percentage of abnormal values for calcium, potassium, phosphorus and base deficit (66% vs 33%, 25% vs 10%, 19% vs 2% and 28.3% vs 5% respectively) were observed with PO., Conclusions: Calcium and magnesium changes were more pronounced in patients who received PO for bowel preparation.

Background: Intradepartmental and interdepartmental benchmarking requires scoring systems with reliability (calibration) and stability over the complete spectrum of periprocedural risk. The aim of this single-center study was to assess the performance of the 2000 Bernstein-Parsonnet risk stratification model in cardiac surgery, by itself and against the EuroSCORE., Methods: A prospective observational design was used. The study group consisted of 1,639 consecutive patients of mean age 64.6 +/- 12.04 years who underwent elective or emergency cardiac surgery from January 2003 to June 2004. The probabilities of hospital death were estimated with the 2000 Bernstein-Parsonnet and EuroSCORE algorithms. The correlation of predicted and observed mortality was compared between the two models, and score validity was assessed by calculating the area under the receiver operating characteristic (ROC) curve., Results: The patients were stratified into five risk groups according to their scores in the two models. For the 2000 Bernstein-Parsonnet model, findings were as follows: score 0-10: predicted mortality 0%-2.2%, observed mortality 0.6%; score 10.5-20: predicted 2.3%-4.7%, observed 2.3%; score 20.5-30: predicted 4.8%-10%, observed 6.7%; score 30.5-40: predicted 10.1%-23%, observed 11.5%; and score greater than 40: predicted 23.1%-80%, observed 29.9%. For the EuroSCORE, findings were as follows: score 0%-2%: predicted mortality 1.1%, observed mortality 0.6%; score 3%-5%: predicted 2.1%, observed 3.0%; score 6%-8%: predicted 4.1%, observed 3.5%; score 9-11: predicted 7.6%, observed 6.6.%; and score greater than 12: predicted 13.8%, observed 14.0%. There was good agreement between the observed and expected number of deaths, with both models. The area under the ROC curve was higher for the Bernstein-Parsonnet model (0.83, odds ratio [OR] 2.01, 95% confidence interval [CI] 1.75-2.31, p < 0.0001) than for the EuroSCORE (0.73, OR 1.05, 95% CI 1.04-1.07, p < 0.001)., Conclusions: The 2000 Bernstein-Parsonnet model is a simple, objective system for the estimation of hospital mortality in patients undergoing cardiac surgery, with slightly higher calibration and discrimination than the EuroSCORE additive model.

Background: We hypothesized that the incidence of hypotension during total knee replacement (TKR) surgery is lower in patients given combined spinal-epidural (CSE) anesthesia vs those receiving epidural anesthesia alone., Methods: In a prospective study, 80 American Society of Anesthesiologists I-II patients (aged 40-80 yr), undergoing elective TKR surgery were randomly assigned to either CSE anesthesia (CSE, n = 40) or epidural anesthesia alone (Epidural, n = 40). Hemodynamic measurements included oscillometric mean arterial blood pressure (MAP), heart rate (HR), and cardiac index (CI) as determined by thoracic bioimpedance; systemic vascular resistance (SVR) was calculated. Our primary endpoint (outcome) was the number of hypotension episodes (defined as MAP < 70 mmHg)., Results: Using univariate analysis, we found no differences between the groups in regards to MAP, HR, CI, or SVR during the perioperative period. The incidence of hypotension was similar in both groups (two patients in each group), as was the incidence of bradycardia (12 patients in CSE, 7 in Epidural; P = 0.2). There were no differences between groups in other hemodynamic measurements including CI and calculated SVR. Analgesia supplementation with fentanyl was more frequently required in the Epidural group (20 vs 6 patients - P = 0.03)., Conclusion: Combined spinal-epidural anesthesia and epidural anesthesia alone during TKR surgery are associated with the same incidence of hypotension with statistically and clinically similar hemodynamic responses.

Objective: To investigate the effect of milrinone combined with nitric oxide (NO) on the pulmonary artery pressures (PAP) after cardiopulmonary bypass (CPB), for repair of congenital heart defects (CHD) in children., Design: Prospective, randomized, double-blind study., Setting: University affiliated community hospital., Participants: Ninety children with pulmonary hypertension and repair of CHD., Interventions: After weaning from CPB, patients (30 in each group) received 3 drug regimens: group 1, nitric oxide (NO); group 2, a continuous infusion of milrinone; and group 3, a combination of the 2. Drugs were started after CPB and given for 20 minutes., Measurements and Main Results: Pulmonary and systemic pressures, PaCO(2), SaO(2), and pH values were recorded before bypass, after weaning from CPB, 10 and 20 minutes after starting each regimen, and 10 minutes after the cessation of treatment. Mean systemic blood pressure was lower (p < 0.05) in the combined treatment group after discontinuation of the drugs. Although mean PAP values were lower in the combined group (p < 0.05), no difference was recorded with regard to pH, PaCO(2), and PaO(2). The ratio between pre- and post-treatment mean PAP was highest in group 3(1.26 +/- 0.5) and lowest in group 2 (0.99 +/- 0.3, p < 0.001). The mean PAP recorded after discontinuation of the drug was lower than the baseline value in groups 1 and 3 (p < 0.05)., Conclusions: The combination of milrinone and NO produced a more pronounced decrease in PAP than milrinone alone.

A young woman with bileaflet mitral valve prolapse and anomalous left coronary artery arising from the pulmonary artery, accompanied by significant mitral regurgitation (MR), underwent dobutamine stress echocardiography to assess the effect of anomalous left coronary artery arising from the pulmonary artery on MR severity. On the basis of the dobutamine stress echocardiography-induced ischemia, which exacerbated the degree of MR, a revascularization operation sparing the mitral valve was performed, resulting in significant improvement of the MR. We suggest that dobutamine stress echocardiography could be used to assess the relative contribution of each syndrome to the pathophysiology of MR, directing the surgical procedure.

Objective: Cardiac surgery patients might have a higher incidence of difficult laryngoscopy than the general population because of older age, dental problems, and obesity. The authors estimated the incidence and predictors of difficult laryngoscopy in coronary artery bypass surgery patients., Design: Prospective, controlled study., Setting: University setting., Participants: Patients undergoing coronary artery bypass or general surgery., Interventions: Two hundred consecutive patients undergoing coronary artery bypass graft and 444 general surgery patients, all aged >40 years, were compared for the incidence and predictors of difficult laryngoscopy, defined as a grade III or IV view., Measurements and Main Results: Predictors of difficult laryngoscopy were considered mouth opening <4 cm, limited cervical mobility, thyromental distance <6 cm, protruding or partially missing upper teeth, and Mallampati classes 3 and 4. More cases of difficult laryngoscopy were recorded in cardiac patients (10% v 5.2%, p <0.023). The cardiac patients were older, mostly men, and belonged to ASA III-IV risk classes. Mallampati classes 3 and 4 were more frequent in the control group. With univariate analysis, difficult laryngoscopy correlated with 7 variables: older age, ASA-IV risk class, protruding or partially missing upper teeth, limited mouth opening, limited neck movement, thyromental distance <6 cm, and diabetes mellitus. Multivariate analysis adjusted for propensity score identified older age (odds ratio = 1.05/yr, 95% confidence interval = 1.005-1.09, p < 0.03) and limited neck movement (odds ratio = 9.5, 95% confidence interval = 2.2-41, p < 0.003), but not cardiac surgery per se, as independent predictors of difficult laryngoscopy., Conclusions: Difficult laryngoscopy was more frequent in cardiac surgery patients (10% v 5.2%). Older age and limited neck movement, but not cardiac surgery per se, were independent predictors of difficult laryngoscopy.

Purpose: We investigated the association between morbid obesity and difficult laryngoscopy (DL)., Methods: In a prospective, controlled study we evaluated the impact of different variables on the prediction of DL in 200 morbidly obese (study group-SG), and 1272 non-obese (control group-CG) patients undergoing elective surgery. Variables assessed included age, sex, body mass index (BMI), protruding, loose, and missing upper teeth, thyro-mental distance, temporo-mandibular joint (TMJ) function, neck extension, and Mallampati class. A Cormack grade III or IV was considered DL., Results: The SG patients were younger (P < 0.000), there were more females in the SG (P < 0.000) and more in the SG had teeth problems (P = 0.026). More patients in the SG (10% vs 1%), had obstructive sleep apnea (P < 0.001) with 90% of them in the SG having a grade III laryngoscopy. High BMI did not affect the laryngoscopy difficulty (P = 0.56). Multivariable regression analysis revealed that morbid obesity, increased age, male sex, pathology of TMJ, and higher Mallampati class, were independent predictors of DL. When interaction between the predictors and the group was added to the multivariable model, the SG was no longer a predictor by itself, rather its association with abnormal upper teeth turned to be significant for prediction of DL., Conclusions: Increased age, male sex, TMJ pathology, Mallampati 3 and 4, a history of obstructive sleep apnea and abnormal upper teeth were associated with a higher incidence of DL. The magnitude of BMI had no influence on difficulty with laryngoscopy.

Objective: To compare the effect of high-frequency ventilation versus other ventilation methods applied during cardiopulmonary bypass on postbypass oxygenation., Design: Prospective, randomized study., Setting: University hospital., Participants: Seventy-five patients undergoing coronary artery bypass graft surgery., Interventions: Patients were allocated to 5 equal groups of different ventilation methods during bypass. Groups 1 and 2 received high-frequency, low-volume ventilation with 100% and 21% oxygen, respectively. Groups 3 and 4 received 5 cm H(2)O of continuous positive airway pressure (CPAP) with either 100% or 21% oxygen. Patients from group 5 were disconnected from the ventilator during the bypass period., Measurements and Main Results: Spirometry data, blood gas analysis, oxygen saturation as measured by pulse oximetry, and end-tidal carbon dioxide were recorded 5 minutes before chest opening, 5 minutes before bypass, 5 minutes after bypass, 5 minutes after chest closure and 6, 12, 18, and 24 hours after surgery. There were no differences in compliance and mean airway pressures. Alveolar-to-arterial oxygen gradients increased, and PaO(2) decreased significantly (p < 0.05) in all groups 5 minutes after bypass and this trend continued in the postoperative period. Patients from group 3 had higher PaO(2) and lower alveolar-to-arterial oxygen gradients, 5 minutes after weaning from bypass (p < 0.05). Extubation times were similar in all groups., Conclusions: The alveolar-arterial oxygen gradient was lower, and the PaO(2) was higher 5 minutes after bypass in patients receiving CPAP (100% O(2)) as compared with those ventilated with high-frequency ventilation., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Unlabelled: We evaluated the efficacy of intubation over a gum-elastic bougie by using either a blind technique or indirect laryngoscopy with a laryngeal mirror in patients with unexpected difficult direct laryngoscopy. In a prospective study, 60 consecutive patients with an unexpected Grade III or IV direct laryngoscopy were randomly allocated for intubation with a gum-elastic bougie either blindly (Group 1) or by indirect laryngoscopy with a laryngeal mirror (Group 2). We evaluated the failure rate of each method of intubation, complications related to either method, and the time required for intubation. Out of 725 patients evaluated over a 2-mo period, 60 patients (8.3%) had a Grade III laryngoscopy, and 30 of these were randomized into each group. There were 8 failed intubations in Group 1 compared with 1 failed intubation in Group 2 (P < 0.05). All eight failures in the blind intubation group ended with esophageal intubation. No additional complications were noted in either group. The time required for endotracheal intubation with each group was not significantly different (45 +/- 10 s versus 44 +/- 11 s). We conclude that intubation with a gum-elastic bougie had a lower failure rate using indirect laryngoscopy with a laryngeal mirror than a traditional blind technique., Implications: We evaluated the efficacy of intubation over a gum-elastic bougie by using either a blind technique or a laryngeal mirror. Intubation with a gum-elastic bougie had a lower failure rate using indirect laryngoscopy with a laryngeal mirror (P < 0.05) than a traditional blind technique.

Background: The objective of this study was to study the effect of low-dose tranexamic acid (TA) on postoperative bleeding and coagulation variables after coronary artery bypass grafting operation., Methods: Fifty patients undergoing primary coronary artery bypass grafting were randomly assigned to receive either placebo (0.9% NaCl; n = 25) or 10 mg/kg TA followed by infusion of 1 mg/kg per hour during the operation (n = 25). Data measured included blood loss, transfusion, reoperation, fibrinogen level, fibrinogen split products, platelet size, and platelet function. Measurements were made after induction of anesthesia, after heparin administration, during patient warming, after skin closure, and 24 hours after operation., Results: Patients in the TA study group weighed less. Other demographic characteristics were similar between groups. Postoperative bleeding was less in the TA group (194 +/- 135 mL versus 488 +/- 238 mL, p < 0.001), whereas blood requirement was higher in the control group (1.68 +/- 1 versus 0.52 +/- 0.9 U of packed cells per patient, p < 0.001). The percent of patients exposed to blood products was significantly less in the TA group (36% versus 100%, p < 0.001). Fibrinogen split products were lower in the TA group during bypass (p < 0.001). Fibrinogen levels fell in both groups during cardiopulmonary bypass. Platelet number and function were reduced equally in both groups by cardiopulmonary bypass. Other test results were not different between groups., Conclusions: The use of low-dose TA during coronary artery bypass grafting significantly reduced the coagulopathy-induced postoperative bleeding and allogeneic blood products requirement. The low levels of fibrinogen split products during bypass in the study group reflect the inhibiting effect of TA in fibrinolysis. Tranexamic acid had no effect on platelet function during cardiopulmonary bypass.

Objective: We sought to prospectively evaluate the long-term effect of left internal thoracic artery harvesting on sternal vascularity., Methods: Twelve consecutive patients undergoing primary coronary artery bypass grafting were studied. In all patients a pedicled left internal thoracic artery was harvested. Each patient underwent a preoperative technetium-99m methylene diphosphonate bone scan with single photon emission computed tomography. The ratio of the mean counts per pixel for each side of the sternum was obtained. All patients had early repeat bone scans 6 plus minus 2.4 days postoperatively and late repeat bone scans 18.6 plus minus 3.5 months after the operation. Ratios of unilateral sternal uptakes were compared between the different scans. One patient died during follow-up and was excluded from the study., Results: There was a significant decrease in flow to the left hemisternum in the early postoperative scan compared with that in the preoperative scan (P <.001). At late follow-up scans, flow to the left hemisternum had returned to normal (P =.119). Midterm clinical follow-up demonstrated 3 superficial wound infections. No musculoskeletal pain existed at the time of follow-up, but 3 patients had numbness or tingling at the skin area corresponding to the site from which the left internal thoracic artery was harvested., Conclusions: Acute postoperative sternal ischemia caused by harvesting of a pedicled left internal thoracic artery is temporary and resolves with time.

We describe the very rare event of delayed transient paraplegia after repair of type A dissection of the aorta and discuss therapeutic options. We also suggest insertion of a spinal catheter as soon as there are signs or symptoms of spinal cord injury to drain spinal fluid and maximize the effect of elevated spinal cord perfusion pressure.

This report describes an unusual course of rupture of the left ventricular free wall, complicating acute myocardial infarction. Spontaneous sealing of the rupture site enabled close echocardiographic follow-up, during which we monitored the development of intramyocardial dissecting hematoma and, finally, development of a full tear in the left ventricular free wall, leading to the formation of a pseudoaneurysm. The pathophysiology, management, and diagnostic criteria of these processes are being revised.

Objective: To evaluate the clinical significance of low arterial oxygen tension-inspired oxygen concentration (PaO2-FIO2) ratio, as a measure of hypoxemia, in the early period after cardiac surgery with cardiopulmonary bypass (CPB); and to evaluate the preoperative, intraoperative, and postoperative factors contributing to the development of hypoxemia within the first 24 hours after cardiac surgery with CPB., Design: Prospective observational study., Setting: University hospital., Participants: Patients who underwent elective or emergency cardiac surgery with CPB (n = 466)., Interventions: Preoperative clinical and laboratory data were recorded, as were intraoperative and postoperative data regarding the PaO2-FIO2 ratio, fluid and drug therapy, and chest radiograph. Data analysis evaluated hypoxemia as depicted by the PaO2-FIO2 ratios at 1, 6, and 12 hours after surgery. Thereafter, the effect of the PaO2-FIO2 ratios on time to extubation, lung injury, and length of hospital stay was evaluated. The risk factors were analyzed in 3 separate periods: preoperative, intraoperative, and postoperative. Univariate and multivariate analyses were performed on each period separately. All data were analyzed in 2 consecutive steps: univariate analysis and multivariate analysis., Measurements and Main Results: PaO2-FIO2 ratios after CPB were significantly lower compared with baseline values. Six patients (1.32%) met the clinical criteria compatible with acute lung injury. All 6 patients had prompt recovery. Significant risk factors for hypoxemia were age, obesity, reduced cardiac function, previous myocardial infarction, emergency surgery, baseline chest radiograph with alveolar edema, high creatinine level, prolonged CPB time, decreased baseline PaO2-FIO2, use of dopamine after discontinuation of CPB, coronary artery bypass grafting, use of left internal mammary artery, higher pump flow requirement during CPB, increased level of hemoglobin or total protein content, persistent hypothermia 2 and 6 hours after surgery, requirement for reexploration, event requiring reintubation, and chest radiograph with alveolar edema 1 hour after surgery. Six hours after surgery, a lower PaO2-FIO2 ratio correlated significantly with time to extubation and lung injury., Conclusions: This study shows that despite improvements in the technique of CPB, hypoxemia depicted by low PaO2-FIO2 ratios is common in patients after CPB. It is short lived, however, and has minimal effect on the postoperative clinical course of these patients.

Objective: We sought to determine whether aortic prosthesis size adversely influences survival after aortic valve replacement., Methods: A total of 892 adults receiving a mechanical (n = 346), pericardial (n = 463), or allograft (n = 83) valve for aortic stenosis were observed for up to 20 years (mean, 5.0 +/- 3.9 years) after primary isolated aortic valve replacement. We used multivariable propensity scores to adjust for valve selection factors, multivariable hazard function analyses to identify risk factors for all-cause mortality, and bootstrap resampling to quantify the reliability of the results., Results: Twenty-five percent of patients had indexed internal orifice areas of less than 1.5 cm(2)/m(2) and more than 2 SDs (Z-value) below predicted normal aortic valve size. Mechanical valve orifices were smaller (1.3 +/- 0. 29 cm(2)/m(2), Z = -2.2 +/- 1.16) than pericardial (1.9 +/- 0.36 cm(2)/m(2), Z = -0.40 +/- 1.01) or allograft valves (2.1 +/- 0.50, Z = 0.24 +/- 1.17). The overall survival was 98%, 96%, 86%, 69%, and 49% at 30 days and 1, 5, 10, and 15 years postoperatively. Univariably, survival was weakly and inversely related to manufacturer valve size (P =.16) and internal orifice diameter (P =. 2) but completely unrelated to indexed valve area (P =.6) or Z-value (P =.8). These, and univariable differences among valve types (P =. 004), were accounted for by different prevalences in patient risk factors and not by valve size or type per se. Bootstrap resampling indicated that these findings had a less than 15% chance of being incorrect., Conclusions: Survival after aortic valve replacement is strongly related to patient risk factors but appears not to be adversely affected by moderate patient-prosthesis mismatch (down to about 4 SDs below normal). Aortic root enlargement to accommodate a large prosthesis may be required in few situations.

Background: Proliferation of smooth muscle cells (SMCs) of the arterial wall in response to local injury is an important factor in vascular proliferative disorders. Among the growth factors that promote SMC proliferation is basic fibroblast growth factor (bFGF), which is characterized by a high affinity for heparin and is associated with heparan sulfate on cell surfaces and extracellular matrices. We investigated whether heparin can displace endogenous active bFGF from the lumenal surface of blood vessels, whether bFGF is preferentially bound to injured blood vessels, and whether a synthetic, polyanionic, heparin-mimicking compound (RG-13577) can prevent sequestration of bFGF by the vessel wall., Methods and Results: Injured and noninjured saphenous vein segments were perfused with or without heparin, in the absence or presence of 125I-bFGF and/or RG-13577 (a polymer of 4-hydroxyphenoxy acetic acid). Heparin displaced bFGF from the lumenal surface of the vein, and the released bFGF stimulated proliferation of SMCs. Likewise, systemic administration of heparin during open heart surgery resulted in a marked increase in plasma bFGF levels. Injured veins sequestered 125I-bFGF to a much higher extent than noninjured vein segments, both in the absence and presence of heparin. This sequestration was inhibited by compound RG-13577., Conclusions: Despite its beneficial effects, heparin may displace active bFGF, which subsequently may be preferentially deposited on injured vessel walls, thus contributing to the pathogenesis of restenosis. This effect may be prevented by a synthetic heparin-mimicking compound.

The optimal surgical treatment for concomitant carotid and coronary artery disease is controversial. Between 1991 and 1995 we performed 34 procedures for combined disease of the carotid and coronary arteries. The first 8 operations were carotid endarterectomies followed by coronary artery bypass grafting (staged procedure). The next 26 operations were performed during a single anesthesia (combined procedure). The patients were 28 men and 6 women, aged 58-81 years (mean 68). 80% were in functional class III or IV. In 40% ventricular function was moderately or severely reduced. There was an average of 3.6 grafts per patient, and in all except 3 patients the left internal thoracic artery was used as a conduit for coronary artery bypass grafting. 30% had symptomatic carotid stenosis; there was no perioperative mortality. In the staged procedure group, 2 patients had postoperative cardiac complications: in 1 acute coronary insufficiency and acute myocardial infarction in the other. 1 had postoperative, transient, amaurosis fugax. In the combined procedure group, 1 had a myocardial infarction and 1 a minor occipital stroke. During follow-up, 1 patient died 4 months after operation of myocardial infarction, and 1 had a minor stroke. The results suggest that the combined procedure is safe and carries low risk of both mortality and morbidity. Whenever cardiac disease is stable and there is no main coronary artery disease, a staged procedure should be considered. In any other situation we continue to perform the combined procedure.

Heparan sulfate proteoglycans (HSPGs) are ubiquitous macromolecules associated with the cell surface and extracellular matrix (ECM) of a wide range of cells of vertebrate and invertebrate tissues [1, 2]. The basic HSPG structure consists of a protein core to which several linear heparan sulfate (HS) chains are covalently attached. The polysaccharide chains are typically composed of repeating hexuronic and D-glucosamine disaccharide units that are substituted to a varying extent with N- and O-linked sulfate moieties and N-linked acetyl groups [1, 2]. Beside serving as a scaffold for the attachment of various ECM components (e.g., collagen, laminin, fibronectin), the binding of HS to certain proteins has been suggested to induce a conformational change which may lead to the exposure of novel reactive determinants or conversely stabilize an inert protein configuration [1-4]. Of particular significance is the interaction of HS with fibroblast growth factors (FGFs), mediating their sequestration, stabilization and high affinity receptor binding and signaling [3-7]. Cellular responses to FGFs may hence be modulated by metabolic inhibitors of HS synthesis and sulfation, HS-degrading enzymes, and synthetic mimetics of heparin/HS. In the present review we focus on the involvement of HS in basic FGF (bFGF) receptor binding and mitogenic activity and its modulation by species of heparin, HS, and synthetic polyanionic 'heparin-mimicking' compounds. The results are discussed in relation to the current thoughts on the dual involvement of low and high affinity receptor sites in the growth promoting and angiogenic activities of bFGF and other heparin-binding growth factors.

Lung transplantation is becoming an acceptable mode of therapy worldwide for the end-stage lung disease. We present our initial experience with the first 10 consecutive lung transplant patients at Hadassah University Hospital. There were 5 males and 5 females with an age range 27 to 59 years. Eight patients underwent single lung transplantation, one patient had double lung transplantation and one had heart-lung transplantation. Indications were: pulmonary fibrosis in 4, emphysema in 4, cystic fibrosis in 1, and cystic bronchiectasis in 1. Two patients had primary graft failure (1 death). Nine patients had a serious infection after transplantation (1 death). Four patients developed airway complications including dehiscence of bronchial anastomosis (1 death), bronchial stenosis requiring placement of a stent in 2 patients, and pneumothorax in 1 patient. One patient required tracheostomy. One patient died of massive brain infarction secondary to pulmonary venous thrombosis and embolization. Six patients are intermediate-term survivors, with a follow-up period of 4-24 months. Four of them had at least one episode of rejection each. In all survivors pulmonary functions and quality of life improved and they do not need supplemental oxygen. We conclude that lung transplantation is a viable option for end-stage lung disease. Better selection of patients and perhaps improved immunosuppression agents will further improve outcome in lung transplantation. Shortage of donor supply is currently the limiting factor in successful lung transplantation in Israel.

Lung transplantation is now considered acceptable therapy for end-stage lung disease. Until recently therapy for emphysema was disappointing, but lung transplantation has brought new hope for those terminally ill with the disease. We present our early experience with single-lung transplantation in 5 men and 1 woman with emphysema, 40-61 years old. All recovered following surgery, with remarkable improvement in lung function and functional capacity. They are now 6-20 months post-transplantation, do not need oxygen supplementation and are able to perform their normal daily activities. Shortage of donor organs is the limiting factor for single-lung transplantation in these patients.

Until fairly recently, cardiac surgery was controversial in octogenarians. With the improvement of life quality and health services, the number of octogenarians in the population is steadily increasing. Furthermore, the improvement of surgical techniques and perioperative care permit safer cardiac surgery in this age group. Surgery is beneficial especially for patients undergoing coronary revascularization (early mortality rate, 0% to 12%) or isolated valve surgery (early mortality rate, 1.8% to 20%). Great caution should be exercised when considering candidates for combined coronary and valvular or multiple valve surgery as mortality is much higher in this group. Overall, the operative course in the very elderly is more complicated and is associated with various postoperative complications in 57% to 97% of the patients, which is reflected in longer postoperative hospitalization-an average of 10-19 days. Nevertheless, the 5-year survival in these patients is 47% to 71%. With proper selection of patients, carefully planned surgery, and meticulous postoperative care octogenarians can enjoy prolonged life expectancy and improved quality of life following open heart surgery.

A coronary artery bypass operation was performed successfully on a 70-year-old patient who had undergone left pneumonectomy 40 years earlier. This case, together with a search of the literature and a mail survey among 118 cardiothoracic surgeons worldwide, yielded data on 27 such patients for review. Two patients died perioperatively. Three patients had pneumothorax, and 1 patient had recurrent pleural effusion. Difficulty in exposing the circumflex marginal branches was reported in 2 patients after left pneumonectomy. We conclude that with attention to the specific features of the preoperative, intraoperative, and postoperative management, open heart procedures can be performed on patients after pneumonectomy with acceptable operative mortality and morbidity.