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Patients who are on a waiting list for cardiac transplantation often have a clinical profile that satisfies current recommendations for the implantation of an implantable cardioverter-defibrillator for the primary prevention of sudden death. The prospect that transplantation may take place within the short-to-medium term puts the effectiveness of this therapy in doubt. We investigated the incidence of therapy delivered by implantable cardioverter-defibrillators implanted for primary prevention in patients awaiting cardiac transplantation. Recent changes in the incidence of sudden death at our center were also investigated. Data on 308 patients listed for heart transplantation between 1998 and 2008 were reviewed. An implantable cardioverter-defibrillator was indicated for primary prevention at initial evaluation in 17 patients. Of these, 53% received appropriate implantable cardioverter-defibrillator therapy while carrying an implantable cardioverter-defibrillator for a mean period of 7.8 months (±4.8). Only one patient received inappropriate therapy and none had any complications associated with device use. The frequency of sudden death has decreased over the course of recent years., (Copyright © 2010 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Heavy metals have increased in natural woodlands and shrublands over the last several decades as a consequence of anthropogenic activities. However, our knowledge of the effects of these elements on woody species is scarce. In this study, we examined the responses of six Mediterranean woody species to increasing levels of zinc in hydroponic culture and discussed the possible implications for the restoration of contaminated sites. The species used, Pinus pinea L., Pinus pinaster Ait., Pinus halepensis Mill., Tetraclinis articulata (Vahl) Mast., Rhamnus alaternus L. and Quercus suber L. represent a climatic gradient from dry sub-humid to semi-arid conditions. Zinc concentrations in shoots ranged from 53 microg g(-1) in Q. suber to 382 microg g(-1) in T. articulata and were well below the levels found in roots. Zinc inhibited root elongation and root biomass and changed the root length distribution per diameter class, but the magnitude of the effects was species-specific. Only P. halepensis and Q. suber showed toxicity symptoms in aboveground parts. Species more characteristic from xeric environments (T. articulata, R. alaternus and P. halepensis) were more sensitive to zinc than species from mesic environments (Q. suber, P. pinaster and P. pinea). According to the Zn responses and bioaccumulation, Q. suber P. pinea and P. halepensis are the best candidates for field trials to test the value of woody species to restore contaminated sites. None of the species tested seemed suitable for phytoremediation., (Copyright 2010 Elsevier B.V. All rights reserved.)

A case is reported of infective endocarditis with extension into the annulus, presence of paravalvular abscesses, and fibrous body destruction. Treatment of this high-risk condition and eradication of infection represents a major surgical challenge. This 31-year-old patient was diagnosed with acute native aortic valve endocarditis caused by Staphylococcus aureus. He presented multiple paravalvular abscesses, left ventricular outflow destruction and fibrous body infection. Reconstruction of the intervalvular fibrous body was carried out with a single folded pericardial patch to simplify closure of the left atrium roof. In addition, the aortic root was reconstructed by the insertion of a composite graft attached to a semi-circumferential left ventricular outflow patch. The postoperative course was favorable, and transthoracic echocardiography after six months showed normal prosthesis function. In this type of situation, the extensive debridement of all infected tissues is mandatory, while surgery to eradicate the infection and restore functionality of the structures presents a formidable challenge.

Background: We reviewed our experience with aortic valve-sparing operations in Marfan syndrome during last 5 years., Methods: Between March 2004 and June 2009, 94 patients with aortic root aneurysms underwent valve-sparing operations. Of these, 37 (68% male) were diagnosed with Marfan syndrome, according to the Ghent diagnostic criteria. Mean age was 30 +/- 10 years (range, 11 to 59 years). Moderate/severe aortic regurgitation was present in 13%, and the mean diameter of the Valsalva sinuses was 50 +/- 4 mm (range, 42 to 62 mm). The David V modification was performed in the last 28 patients. Additional procedures were mitral valve repair in 6, tricuspid valve repair in 3, closure of septal atrial defect in 2, and closure of a patent foramen ovale in 13. Mean follow-up was 27 +/- 16 months (range, 1 to 61 months)., Results: There were no in-hospital deaths and no major adverse outcomes. One patient required implantation of a mechanical prosthesis during the same procedure because of moderate aortic regurgitation. One late death occurred. No patients required reoperation. In the last follow-up, 23 patients did not have aortic regurgitation, 12 had grade I, and 1 had grade II. No thromboembolic complications have been documented, and 97% of the patients are free from anticoagulation., Conclusions: Short-term and midterm results with the reimplantation technique for aortic root aneurysms in Marfan patients are excellent. If long-term results are similar, this technique could be the treatment of choice for these patients., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Here, we review our experience in acute type A aortic dissection analyzing the role of antegrade brain protection. A total of 105 patients underwent surgery for acute type A aortic dissection between March 1990 and October 2008. An open technique with deep hypothermia was used in 81 patients. Deep hypothermia alone was induced in 32 patients; in combination with retrograde cerebral perfusion in 26 patients and in combination with antegrade cerebral perfusion (ACP) in the final 23 patients. The overall hospital mortality rate was 15%. Hospital mortality risk factors were age >or=70 years and preoperative shock (P<0.05). Hospital mortality was reduced to 9% in the last 23 consecutive patients in whom ACP was accomplished (P=0.05). Survival rate after 1, 5, 10 and 15 years of follow-up was 97.6+/-1.7%, 84.3+/-4.4%, 60.7+/-7.5% and 57.1+/-7.8%, respectively. The only late death risk predictor was the non-use of ACP (P<0.05). Surgery for acute aortic dissection provides excellent results. ACP via the axillary artery improves the prognosis for these patients and should be the brain protection method of choice.

The accretion of matter onto a massive black hole is believed to feed the relativistic plasma jets found in many active galactic nuclei (AGN). Although some AGN accelerate particles to energies exceeding 10(12) electron volts and are bright sources of very-high-energy (VHE) gamma-ray emission, it is not yet known where the VHE emission originates. Here we report on radio and VHE observations of the radio galaxy Messier 87, revealing a period of extremely strong VHE gamma-ray flares accompanied by a strong increase of the radio flux from its nucleus. These results imply that charged particles are accelerated to very high energies in the immediate vicinity of the black hole.

One fundamental question about pulsars concerns the mechanism of their pulsed electromagnetic emission. Measuring the high-end region of a pulsar's spectrum would shed light on this question. By developing a new electronic trigger, we lowered the threshold of the Major Atmospheric gamma-ray Imaging Cherenkov (MAGIC) telescope to 25 giga-electron volts. In this configuration, we detected pulsed gamma-rays from the Crab pulsar that were greater than 25 giga-electron volts, revealing a relatively high cutoff energy in the phase-averaged spectrum. This indicates that the emission occurs far out in the magnetosphere, hence excluding the polar-cap scenario as a possible explanation of our measurement. The high cutoff energy also challenges the slot-gap scenario.

Primary sarcoma of the pulmonary artery (PSPA) is extremely rare. Many cases are misdiagnosed as pulmonary arterial hypertension (PAH) because of chronic thromboembolic disease (CTD). Four cases of PSPA with the initial misdiagnosis are reported. The presence of a unique mass in the main pulmonary artery or proximal branches, rapidly progressive dyspnea, and constitutional symptoms should raise the suspicion of PSPA. The pathological diagnosis is usually confirmed during surgery, which is done along with adjuvant chemotherapy, the treatment of choice.

The atmospheric Cherenkov gamma-ray telescope MAGIC, designed for a low-energy threshold, has detected very-high-energy gamma rays from a giant flare of the distant Quasi-Stellar Radio Source (in short: radio quasar) 3C 279, at a distance of more than 5 billion light-years (a redshift of 0.536). No quasar has been observed previously in very-high-energy gamma radiation, and this is also the most distant object detected emitting gamma rays above 50 gigaelectron volts. Because high-energy gamma rays may be stopped by interacting with the diffuse background light in the universe, the observations by MAGIC imply a low amount for such light, consistent with that known from galaxy counts.

The aim of this study was to describe a new technique to prevent the development of incisional hernias in trocar sites. Between March and June 2006, a pilot study was conducted to determine the feasibility of the safe port plug technique using the Bioabsorbable Hernia Plug to prevent incisional hernia in trocar sites. The device was implanted in the umbilical trocar site (10-11 mm) of 17 patients undergoing laparoscopic surgery during the study period. The mean follow-up of patients was 14.6 months. Implantation of the Bioabsorbable Hernia Plug device by the safe port plug technique was possible in all cases. No patient presented complications in the follow-up. Our preliminary experience suggests that this technique is simple and feasible, and we hypothesized that this technique could be superior to conventional fascial closure: a hypothesis that must be proven in a randomized prospective trial that is currently in progress.

The degradation of two groups of organic pollutants in three different Mediterranean forest soils amended with sewage sludge was studied for nine months. The sewage sludge produced by a domestic water treatment plant was applied to soils developed from limestone, marl and sandstone, showing contrasting alkalinity and texture. The compounds analysed were: linear alkylbenzene sulphonates (LAS) with a 10-13 carbon alkylic chain, and nonylphenolic compounds, including nonylphenol (NP) and nonylphenol ethoxylates with one and two ethoxy groups (NP1EO+NP2EO). These compounds were studied because they frequently exceed the limits proposed for sludge application to land in Europe. After nine months, LAS decomposition was 86-96%, and NP+NP1EO+NP2EO decomposition was 61-84%, which can be considered high. Temporal trends in LAS and NP+NP1EO+NP2EO decomposition were similar, and the concentrations of both types of compounds were highly correlated. The decomposition rates were higher in the period of 6-9 months (summer period) than in the period 0-6 months (winter+spring period) for total LAS and NP+NP1EO+NP2EO. Differences in decay rates with regard to soil type were not significant. The average values of decay rates found are similar to those observed in agricultural soils.

Ultrafiltration (UF) is used to ameliorate the deleterious effects of cardiopulmonary bypass (CPB) in cardiac surgery patients. There are two different methods; conventional ultrafiltration (CUF), performed during CPB, and modified ultrafiltration (MUF), performed after CPB is finished. It has not been established which is better, and controversy remains regarding the optimal UF strategy. The objective of this study was to evaluate if MUF alone, or combined with CUF, could achieve greater fluid removal and contribute to better postoperative clinical outcomes. Also, the potential technique complications were studied. This was a prospective study which enrolled 125 consecutive adult patients receiving elective cardiac surgery with CPB. We analysed three treatment groups: MUF, CUF and both. Ultrafiltration was performed using a non-pulsatile CPB with a non-occlusive roller pump, Sarns 9000, and a polysulfone ultrafilter, Minntech. We studied pre- and intraoperative data and immediate postoperative clinical outcomes: total amount of drainage, transfusion needs, respiratory outcome, cardiac, renal and neurologic complications. Statistical analysis was performed using SPSS 11.0. All three groups were homogeneous and did not have differences in terms of demographic factors, previous history, risk scores, intervention and operative data. Volume of filtrate removal in the group which applied both techniques was larger than in the CUF or MUF groups alone (2569+/-823 vs 1679+/-651 vs 1398+/-353 ml, respectively, p=0.0001); however, despite this difference, there was no difference in the immediate postoperative fluid balances between the groups (596+/-1244 vs 880+/-1054 vs 986+/-1190 ml, p=0.30). Respiratory parameters and postoperative morbidity data analysed (total amount of drainage, transfusion needs, haemoglobin, acute lung injury, time with inotropes, ventricular failure, cardiogenic shock, neurologic complications and renal failure) were similar in all three groups, without statistical differences. Extubation time (10+/-7 vs 8.9+/-3 vs 9.4+/-7.9 hours, p=0.72) and ICU stay (56.6+/-72 vs 66.5+/-109 vs 44.2+/-25 hours, p=0.43) also were similar between the groups. We did not find any technique complication associated with any patient. In the present study, with adult patients receiving elective cardiac surgery, the combined ultrafiltration group had a larger fluid removal. However, neither type of ultrafiltration nor amount of filtered volume was accompanied by different postoperative ICU clinical outcomes. Ultrafiltration was considered a safe and reliable technique, with no related complications.

The restoration of heavy metal contaminated areas requires information on the response of native plant species to these contaminants. The sensitivity of most Mediterranean woody species to heavy metals has not been established, and little is known about phytotoxic thresholds and environmental risks. We have evaluated the response of four plant species commonly used in ecological restoration, Pinus halepensis, Pistacia lentiscus, Juniperus oxycedrus, and Rhamnus alaternus, grown in nutrient solutions containing a range of copper, nickel and zinc concentrations. Seedlings of these species were exposed to 0.048, 1 and 4 microM of Cu; 0, 25 and 50 microM of Ni; and 0.073, 25 and 100 microM of Zn in a hydroponic silica sand culture for 12 weeks. For all four species, the heavy metal concentration increased in plants as the solution concentration increased and was always higher in roots than in shoots. Pinus halepensis and P. lentiscus showed a higher capacity to accumulate metals in roots than J. oxycedrus and R. alaternus, while the allocation to shoots was considerably higher in the latter two. Intermediate heavy-metal doses enhanced biomass accumulation, whereas the highest doses resulted in reductions in biomass. Decreases in shoot biomass occurred at internal concentrations ranging from 25 to 128 microg g-1 of Zn, and 1.7 to 4.1 microg g( -1) of Cu. Nickel phytoxicity could not be established within the range of doses used. Rhamnus alaternus and J. oxycedrus showed higher sensitivity to Cu and Zn than P. halepensis and, especially, P. lentiscus. Contrasted responses to heavy metals must be taken into account when using Mediterranean woody species for the restoration of heavy metal contaminated sites.

We investigated the response of Pinus halepensis seedlings to the application of biosolids enriched with Cu, Ni and Zn on three Mediterranean forest soils under semiarid conditions. One-year-old seedlings were planted in lysimeters on soils developed from marl, limestone and sandstone which were left unamended, amended with biosolids, or amended with biosolids enriched in Cu, Ni and Zn. Enriched biosolids increased plant heavy metal concentration, but always below phytotoxic levels. Seedlings receiving unenriched biosolids showed a weak reduction in Cu and Zn concentration in needles, negatively affecting physiological status during drought. This effect was alleviated by the application of enriched sludge. Sewage sludge with relatively high levels of Cu, Zn and Ni had minor effects on plant performance on our experimental conditions. Results suggest that micronutrient limitations in these soils may be alleviated by the application of biosolids with a higher Cu, Zn and Ni content than those established by current regulations.

Introduction: The use of Celsior solution for organ preservation has not been thoroughly studied in pancreas transplantation. The aim of this study was to compare University of Wisconsin and Celsior solutions for preservation of pancreas grafts., Patients and Methods: From March 1995 to December 2005, 72 patients with type 1 diabetes underwent pancreas transplantation. There were 42 men and 30 women, with a mean age at transplantation of 38.1 +/- 7.5 years (range: 27 to 55 years), and a mean duration of diabetes of 22.5 +/- 6.6 years. Recipients were classified into two groups according to the preservation solution: (A) Celsior (n = 28, 38.9%) and (B) Wisconsin (n = 44, 61.1%)., Results: The donor and recipient characteristics were similar in both groups. There were five cases of venous thrombosis in the Wisconsin group and two in the Celsior group (P = NS). The venous drainage technique in the former group was portocaval in 19 patients and portoiliac in 25; in the Celsior group, portocaval in 23 patients and portoiliac in five (P = .001). Enteric drainage was used in 19 patients from the Celsior group and 17 patients from the Wisconsin group (P = .01). Actuarial 2-year graft survival was 74.6% in the Wisconsin group and 77.4% in the Celsior group (P = NS)., Conclusions: No differences were observed in venous thrombosis between the two groups. The lower rate of venous thrombosis with the portocaval technique was related to the type of venous drainage rather than the type of preservation solution. Celsior solution may be considered as good as Wisconsin solution for pancreas transplantation.

Biological soil crusts are very sensitive to human-induced disturbances and are in a degraded state in many areas throughout their range. Given their importance in the functioning of arid and semiarid ecosystems, restoring these crusts may contribute to the recovery of ecosystem functionality in degraded areas. We conducted a factorial microcosm experiment to evaluate the effects of inoculation type (discrete fragments vs slurry), fertilization (control vs addition of composted sewage sludge), and watering frequency (two vs five times per week) on the cyanobacterial composition, nitrogen fixation, chlorophyll content, and net CO2 exchange rate of biological soil crusts inoculated on a semiarid degraded soil from SE Spain. Six months after the inoculation, the highest rates of nitrogen fixation and chlorophyll a content were found when the biological crusts were inoculated as slurry, composted sewage sludge was added, and the microcosms were watered five times per week. Net CO2 exchange rate increased when biological crusts were inoculated as slurry and the microcosms were watered five times per week. Denaturing gradient gel electrophoresis fingerprints and phylogenetic analyses indicated that most of the cyanobacterial species already present in the inoculated crust had the capability to spread and colonize the surface of the surrounding soil. These analyses showed that cyanobacterial communities were less diverse when the microcosms were watered five times per week, and that watering frequency (followed in importance by the addition of composted sewage sludge and inoculation type) was the treatment that most strongly influenced their composition. Our results suggest that the inoculation of biological soil crusts in the form of slurry combined with the addition of composted sewage sludge could be a suitable technique to accelerate the recovery of the composition and functioning of biological soil crusts in drylands.

Microquasars are binary star systems with relativistic radio-emitting jets. They are potential sources of cosmic rays and can be used to elucidate the physics of relativistic jets. We report the detection of variable gamma-ray emission above 100 gigaelectron volts from the microquasar LS I 61 + 303. Six orbital cycles were recorded. Several detections occur at a similar orbital phase, which suggests that the emission is periodic. The strongest gamma-ray emission is not observed when the two stars are closest to one another, implying a strong orbital modulation of the emission or absorption processes.

Unlabelled: Pulmonary hypertension (PHT) associated with chronic heart failure (CHF) is a risk factor of right ventricular failure after heart transplantation (HT). Our aim was to study pulmonary vascular changes in patients with CHF and to assess any correlation with haemodynamic data., Methods: We studied 17 HT recipients with preoperative CHF who died shortly after HT. Preoperative haemodynamic information was obtained immediately before HT. Vascular lesions in muscular arteries were assessed by linear morphometry. Haemodynamic data were correlated with the morphologic changes., Results: Mean transpulmonary gradient (TPG) was 8.9+/-4.5 mm Hg and pulmonary vascular resistance (PVR) was 2.25+/-1.34 Wu. According to the threshold for at-risk PHT (TPG>12 mm Hg or PVR>2.5 Wu), six patients had at-risk PHT. Medial thickness was 23.82+/-7.23% in patients with at-risk PHT and 17.16+/-3.24% in patients without at-risk PHT (p=0.018)., Conclusions: Medial hypertrophy of muscular pulmonary arteries is more common and severe than expected in patients with CHF, even in patients without at-risk PHT. This structural change could explain why PHT, even in range of values not excluding HT, is a risk factor for right ventricular failure after HT and influences post-HT haemodynamic behaviour.

Theoretical models predict that the relative importance of facilitation and competition may vary inversely across gradients of abiotic stress. However, these predictions have not been thoroughly tested in the field, especially in semi-arid environments. In this study, we evaluated how the net effect of the tussock grass Stipa tenacissima on the shrub Pistacia lentiscus varied across a gradient of abiotic stress in semi-arid Mediterranean steppes. We fitted the relationship between accumulated rainfall and the relative neighbour index (our measures of abiotic stress and of the net effect of S. tenacissima on P. lentiscus, respectively), which varied across this gradient, to a quadratic model. Competitive interactions dominated at both extremes of the gradient. Our results do not support established theory. Instead, they suggest that a shift from facilitation to competition under high abiotic stress conditions is likely to occur when the levels of the most limiting resource are so low that the benefits provided by the facilitator cannot overcome its own resource uptake.

Development of an intracardiac fistula is a rare complication after mitral valve replacement. In the literature we have found six cases of left ventricular-coronary sinus fistula and another one of left ventricular-coronary sinus and right atrial fistula. We report the history and course of a patient in whom a left ventricular-coronary sinus and right ventricular fistula developed late after mitral valve replacement. The current study examines this type of intracardiac shunt, and presents our report on a left ventricular-coronary sinus and right ventricular fistula complication.

Introduction and Objectives: Surgery for infective endocarditis with paravalvular abscesses and fibrous body destruction has the highest mortality and morbidity rates in this disease with high surgical risk. We report a new approach of radical resection of the abscess and affected tissues and reconstruction of the heart with pericardium as an alternative to conventional surgery., Methods: In the last two years six patients with infective endocarditis, paravalvular abscesses and fibrous body destruction underwent surgery (five prostheses with infective endocarditis). The main indication for surgery was persistent sepsis despite adequate antibiotic treatment in five patients and congestive heart failure in one. After wide resection of the abscesses and fibrous body the heart was reconstructed with glutaraldehyde-fixed bovine pericardium., Results: There was no hospital mortality. The median bypass and clamp times were 198 and 174 minutes, respectively. One patient presented complete AV block and a permanent transvenous pacemaker was implanted. Doppler echocardiographic studies performed in all the patients prior to discharge indicated that no patient had patch dehiscence or paravalvular leaks. Patients were followed a mean of 15 months with no deaths or other complications being reported., Conclusions: Resection of the abscesses and fibrous body, and reconstruction of the heart with glutaraldehyde-fixed bovine pericardial patch is a radical, feasible technique with all infected tissues being resected to thereby prevent reinfection or paravalvular leaks.

Objective: Variables associated with successful completion of residential substance abuse treatment were identified., Methods: The records of 340 veterans admitted to a 120-day substance abuse treatment program were retrospectively analyzed. The likelihood of successful treatment completion was calculated as a function of race, age, gender, psychiatric diagnosis, past suicide attempts, homelessness, legal history, childhood physical or sexual abuse, parental history of addiction, multiple substance dependence, medical problems, and the race of the therapist. Univariate analysis and logistic regression analysis were used to identify variables that were significant predictors of treatment completion., Results: Overall, 66 percent of veterans completed the program. Eighty-two percent of the veterans admitted to the program were black, and 16 percent were white. The completion rate of black veterans (71 percent) was significantly higher than that of white veterans (49 percent). Veterans completing treatment were significantly more likely to be older, by an average of two years, than those who did not complete treatment. The association between younger age and failure to complete the program was largely accounted for by younger black veterans. Veterans with back pain were significantly less likely to complete treatment than those without back pain. Completion rates did not vary by the other variables examined. In the regression analysis that included age, race, and back pain, each variable, when adjusted by the other variables, was a significant predictor of completion., Conclusions: White patients were less likely to complete residential substance abuse treatment in a program in which the majority of both therapists and patients were black. Younger black veterans and those with back pain were also less likely to complete treatment.

Objective: To compare the national samples of patients who underwent isolated coronary artery bypass grafting (CABG) during the European System for Cardiac Operative Risk Evaluation (EuroSCORE) trial in order to evaluate national differences in epidemiology, patient risk profile and surgical methods., Methods: From September to November 1995, 11731 patients had CABG in the six largest contributing nations to the EuroSCORE project: Germany, UK, Spain, Finland, France and Italy. The Chi-square and Kruskal-Wallis tests were applied to obtain an international comparison of patient general status, including pre-operative risk factors, cardiac status, critical pre-operative states, rare conditions, urgency of surgery, angina status, coronary lesions, procedures and EuroSCORE risk assessment., Results: Large national samples (from 984 patients in Finland to 3138 in Germany) identified significant differences in epidemiology, risk profile and surgical practice. Regarding epidemiology, CABG accounted for 62.8% of adult cardiac surgery, with a range of 46.2 in Spain to 77.7% in Finland (P<0.001). The mean age was 62.9 years (61.4 in Britain to 64.4 in France, P<0.001). The mean body mass index was 26.8 (26 in France to 27.5 in Finland, P<0.001). With regard to risk profile, diabetes was present in 20.3% of patients (11.8% in Britain to 27.7% in Spain, P<0.001). Chronic renal failure was present in 8.3% (6.8% in Germany to 10.6% in Spain, P<0.001). Chronic airway disease affected 3.8% (1.9% in Italy to 5. 1% in Germany, P<0.001). The mean ejection fraction was 0.56 (0.48 in Britain to 0.58 in Finland, P<0.001). The mean predicted mortality (according to EuroSCORE) was 3.3% (2.8% in Finland to 3.6% in France, P<0.001). The prevalence of chronic congestive heart failure, unstable angina and recent myocardial infarction also showed statistically significant differences. No differences were found for some critical preoperative states (such as immediate preoperative cardiac massage and pre-operative intubation), or for surgery for catheter laboratory complication. Regarding surgical practice, major differences were noted in preoperative intra-aortic balloon use (mean 1%, Finland 0%, Spain 2.3%, P<0.001), the number of mammary artery conduits used (mean 0.9, Spain 0.7, France 1.1, P=0.0001) and the number of distal anastomoses (mean 3, France 2.7, Finland 3.8, P=0.001)., Conclusion: There are important epidemiological differences in the national cohorts of CABG patients in the EuroSCORE database. Any international comparison of European surgical results must therefore take into account the risk profile of patients by using a compatible risk stratification system.

Objective: To assess risk factors for mortality in cardiac surgical adult patients as part of a study to develop a European System for Cardiac Operative Risk Evaluation (EuroSCORE)., Methods: From September to November 1995, information on risk factors and mortality was collected for 19030 consecutive adult patients undergoing cardiac surgery under cardiopulmonary bypass in 128 surgical centres in eight European states. Data were collected for 68 preoperative and 29 operative risk factors proven or believed to influence hospital mortality. The relationship between risk factors and outcome was assessed by univariate and logistic regression analysis., Results: Mean age (+/- standard deviation) was 62.5+/-10.7 (range 17-94 years) and 28% were female. Mean body mass index was 26.3+/-3.9. The incidence of common risk factors was as follows: hypertension 43.6%, diabetes 16.7%, extracardiac arteriopathy 2.9%, chronic renal failure 3.5%, chronic pulmonary disease 3.9%, previous cardiac surgery 7.3% and impaired left ventricular function 31.4%. Isolated coronary surgery accounted for 63.6% of all procedures, and 29.8% of patients had valve operations. Overall hospital mortality was 4.8%. Coronary surgery mortality was 3.4% In the absence of any identifiable risk factors, mortality was 0.4% for coronary surgery, 1% for mitral valve surgery, 1.1% for aortic valve surgery and 0% for atrial septal defect repair. The following risk factors were associated with increased mortality: age (P = 0.001), female gender (P = 0.001), serum creatinine (P = 0.001), extracardiac arteriopathy (P = 0.001), chronic airway disease (P = 0.006), severe neurological dysfunction (P = 0.001), previous cardiac surgery (P = 0.001), recent myocardial infarction (P = 0.001), left ventricular ejection fraction (P = 0.001), chronic congestive cardiac failure (P = 0.001), pulmonary hypertension (P = 0.001), active endocarditis (P = 0.001), unstable angina (P = 0.001), procedure urgency (P = 0.001), critical preoperative condition (P = 0.001) ventricular septal rupture (P = 0.002), noncoronary surgery (P = 0.001), thoracic aortic surgery (P = 0.001)., Conclusion: A number of risk factors contribute to cardiac surgical mortality in Europe. This information can be used to develop a risk stratification system for the prediction of hospital mortality and the assessment of quality of care.

Objective: Minimally invasive cardiac surgery is becoming more popular as an alternative technique in some cardiac operations. We report our experience with an inverted 'L' ministernotomy in 25 patients and describe the technical details of this new approach., Methods: From June 1996 to February 1997 we performed 25 ministernotomy approaches for cardiac surgery, 17 aortic and 7 mitral valve replacements and 1 atrial septal defect closure. A comparison group included all patients (n = 126) operated on for mitral or aortic valve replacement through a median sternotomy since June 1996., Results: Ventilatory support, Intensive Care Unit stay and hospital stay were 8.3 h (SD = 4 h), 25 h (SD = 8 h) and 5.5 days (SD = 3 days) in the L ministernotomy group and 11.5 h (SD = 5), 53 h (SD = 11) and 9.1 days (SD = 4 days) in the median sternotomy group (P < 0 05). Mortality and morbidity are similar to conventional sternotomy (hospital mortality 4% vs. 5.5%; P not significant)., Conclusions: We conclude that inverted L ministernotomy for cardiac surgery is a safe approach and can offer some advantages over the conventional approach.

Objective: The authors examined the refusal of antipsychotic medications and associated outcomes prospectively in a group of 348 psychiatric patients admitted to three acute inpatient units in a state-operated mental health facility in Virginia where psychiatrists have the discretionary power to administer treatment over patients' objections., Methods: Newly admitted patients were administered both a questionnaire to ascertain their attitudes toward admission and the Brief Psychiatric Rating Scale (BPRS). Patients who refused antipsychotic medication were identified, and data were collected on the length of refusal and whether the refusal episode was terminated voluntarily or involuntarily. A group of patients compliant with antipsychotic medication was selected for comparison on outcome measures, including the rate of seclusion and restraint and length of hospitalization., Results: Patients who refused treatment were found to have significantly higher BPRS scores than were patients who complied with antipsychotic treatment and more negative attitudes toward hospitalization and past, present, and future treatment. Refusal episodes were brief, on average 2.8 days, and all patients, who refused treatment were treated. When compared with the compliant patients, patients who refused treatment were more likely to be assaultive, were more likely to require seclusion and restraint, and had longer hospitalizations., Conclusions: Psychiatrists exercised their discretion to promptly treat all patients who refused treatment. Nonetheless, these patients suffered more morbidity than compliant patients. This study suggests that the negative sequelae of in-hospital treatment refusal cannot be eliminated by rapid treatment. The policy implications are discussed.

Minimally invasive cardiac surgery is arising as an alternative technique in some cardiac operations. We present the first aortic valve replacement via ministernotomy. We describe in detail the technique of ministernotomy and the limitations that this new approach would have. We conclude with the advantages of minimally invasive cardiac surgery over conventional approach and review other techniques described in the literature.

Chronic pulmonary hypertension is an extremely difficult disease to diagnose and is usually identified by the exclusion of other more recognized causes of enlargement in mean pulmonary arterial resistance. Up to now, treatments proposed for this disease, have not been very successful. Medical procedures are not a long term proper solution which leads the process to an irreversible point whose only solution should be a pulmonary transplantation. In recent years, study groups have established a surgical method, alternative to transplantation, which has been able to increase, with a decrease in mortality rates, a longer and a better quality of life for the patients affected by this disease: we are talking about pulmonary thromboendarterectomy.

In 22 anesthetized mongrel dogs, spectral methods were used to analyze the surface electrocardiogram (ECG) for the time course of the dominant frequency in ventricular fibrillation and its modifications under the influence of amiodarone, diltiazem, and flecainide. The ECG was recorded over 5 minutes after triggering ventricular fibrillation. Following A/D conversion and by applying the Fourier fast transform, the frequency spectrum of the signals was obtained. In group 1 (5 dogs), the ECGs were obtained without prior drug administration; group 2 (5 dogs) first received amiodarone, 5 mg/kg; group 3 (7 dogs) received diltiazem, 0.2 mg/kg; and group 4 (5 dogs) received flecainide, 2 mg/kg. All drugs were administered intravenously. An initial increase in the dominant frequency of ventricular fibrillation was found in the control group and also in the groups that received amiodarone, diltiazem, or flecainide. Diltiazem significantly increased the dominant frequency and diminished the arrhythmia-slowing process. Amiodarone and flecainide tended to diminish the dominant frequency.

The Spanish Society of Cardiovascular Surgery Registry of 1994 includes data from 44 hospitals. Within this year a total of 25,385 patients were operated on, with an average of 577 operations/ center. Fourteen thousand one hundred and fifteen of these were cardiac operations under extracorporeal circulation, with an average of 320 cases/hospital. The number of coronary surgeries was greater to that of valvular procedures (6,660 vs 5,386). The average of coronary graft/patient was 2.67. The 67.6% of these were arterial grafts. The hospital mortality was 7.8%, 5.9%, 6.6%, 7.0% and 4.1% for 1, 2, 3, 4 and 5 or more grafts, respectively. The number of valvular prothesis implanted was 6,243 and 80.7% of these were mechanical. There were 2,274 (58.2%) patients operated on aortic valvular surgery and 1,582 by mitral surgery, with a mortality of 5.9 and 8.6%, respectively. The number of patients operated on for congenital cardiac defects was 1,993 (1,367 open heart surgeries and 626 closed). There were 5,023 operations by peripheral vascular surgery. The number of aneurysms operated on during this year was 506.

Introduction and Objectives: Since physiological pacing systems have become available, a debate has raged about the merits of atrial versus ventricular pacing in the sick sinus syndrome. The goal of this retrospective report was to study the long term incidence and the independent predictors for atrial fibrillation and stroke in 153 paced patients with sick sinus syndrome, adjusting for differences in baseline clinical variables with multivariate analysis., Method and Results: From 1980 to 1994, we implanted 32 dualchamber, 33 atrial, and 88 ventricular pacemakers to treat patients with sick sinus syndrome. After a maximum follow-up of 177 months (median 30 months for paroxismal atrial fibrillation, 45 months for chronic atrial fibrillation and 43,5 months for stroke) the actuarial incidence of paroximal atrial fibrillation was 7.8% at 1 year, 29% at 5 years and 42% at 10 years. The actuarial incidence of chronic atrial fibrillation was 1.3% at 1 year, 9.8% at 5 years and 22% at 10 years. Independent predictors for paroxismal AF from Cox's model was history of atrial tachyarrhythmias (p < 0.0001), chronic obstructive pulmonary disease (p = 0,006) and age (> 70 years-old) (p = 0.035). Only a history of atrial tachyarrhythmias before pacemaker implant was an independent predictor for chronic atrial fibrillation (p < 0.0001). The odd ratio for paroxismal atrial fibrillation in patients with previous atrial tachyarrhythmias and chronic atrial fibrillation were 6 (2.8-12) and 4 (1.6-9.7) (95% confiance limits). Actuarial incidence of stroke was 3% at 1 year, 10% at 5 years and 14% at 10 years. Independent predictors for stroke were history of peripheral vascular disease (p = 0.033) and hypertensive cardiomyopathy (p = 0.015). Development of paroxysmal and chronic atrial fibrillation during the follow-up were higher in patients with stroke (p < 0.001 and p < 0.05)., Conclusions: Development of atrial fibrillation and stroke in paced patients with sick sinus syndrome are strongly determined by clinical variables. Preimplant paroxysmal atrial tachyarrhythmias is the most important predictor for atrial fibrillation in the follow-up.

Background: Sternal wound infection (SWI) is the most important complication in cardiac surgery. The aim of this study was to describe the frequency and clinical and microbiological features of this complication., Methods: All the cases of SWI which were observed in the authors' hospital in the first 1,000 cardiac surgery operations performed with extracorporeal circulation were retrospectively reviewed. The cases were identified through the Infectious Diseases and Cardiac Surgery Department files and were classified according to the depth of the infection. During the study period neither the prophylaxis against infection nor the surgical techniques were modified., Results: Forty-three patients (4.3%) presented SWI. Fourteen were superficial infections and 29 were deep infections of which 9 were classified as osteomyelitis and 20 as mediastinitis. A progressive decrease was observed in the proportion of SWI over time parallel to an increase in the number of operations performed. Staphylococcus aureus was the agent most frequently isolated (60.4%). Gram-positive aerobic cocci were found in 66.7% of the total number of isolations, being most frequent in the deep infections (83.3% of the isolations). The gram-negative aerobic bacilli were isolated more frequently in the superficial infections than in the deep infections (57.8% v.s. 16.7% of the isolations, respectively p < 0.01). In patients with SWI the predictive value of the positive blood cultures for the diagnosis of mediastinitis was 83.3%, with a sensitivity of 50% and specificity of 91.3%. Three patients with deep infection developed chronic complications and another three died (mortality by mediastinitis 15.0%). The mean postoperative stay was 52 days for the patients with deep infection and 39 days for those with superficial infection (p = NS)., Conclusions: The percentage of surgical wound infection during the study period showed a trend to a decrease parallel with an increase in the number of operations. The gram-positive bacteria were responsible for most of the SWI. Although the depth of SWI is difficult to clinically predict, the presence of bacteremia suggests the existence of mediastinitis. Despite their lesser clinical importance, the superficial infections carry a long postoperative stay.

Introduction and Objective: The hypothesis that ventricular pacing is the most important factor in the survival of patients with Sick Sinus Syndrome remains controversial. The aim of this report was to determine independent clinical variables to predict survival in paced SSS patients., Methods: Retrospective, nonrandomized study of 153 patients with a mean age of 69 +/- 11 years, who received an initial pacemaker for Sick Sinus Syndrome between 1980 and 1994: 65 physiologic pacing (32 dual chamber, 33 atrial) and 88 ventricular pacing mode. After a maximum follow up of 177 months (median 57 months) the end point was total mortality., Results: Total mortality was 21%. Using univariate analysis, single chamber ventricular pacing, age > or = 70 years and NYHA > or = 2, was associated with a higher risk for total mortality (4 times increased risk for ventricular pacing compared to other pacing modalities). Independent predictors using multivariate analysis were: 1) NYHA > or = 2 (p < 0.05). 2) Coronary artery disease (p < 0.01). 3) Chronic obstructive pulmonary disease (p < 0.05) and 4) Gender (p < 0.05)., Conclusions: Mortality in patients with the Sick Sinus Syndrome is strongly predicted by preimplant baseline clinical variables. Our data indicate that the role of ventricular pacing mode remains inconclusive. A large, randomized study is necessary to confirm these results.

Introduction: In order to test the efficiency of statistical predictive models, we compare the results of a standard method (Parsonnet) with the model created through the data of our population., Material and Methods: We used the chi 2 univariate model, lineal and logistic regression with the data of the whole population receiving cardiac surgical procedure from January 1, 1990 to December 31, 1993 (total 1626 patients). The population was divided into a control group (1100 cases, 68%) and a study group (526 cases, 32%). The coefficients of the control group were used to estimate the results in the study group., Results: Univariate model p value. Significant (p < 0.001) for emergency, age, pulmonary hypertension, left ventricular failure, preoperative use of intra-aortic balloon pump; p < 0.05 mitral valve disease, aortic aneurysm and reoperation. No significance (p < 0.01) was found for gender, aortic or tricuspid disease, percutaneous transluminal coronary angioplasty, unstable or postinfarction angina, transplant, left main or vessel disease number, and mitral, tricuspid or aortic procedure. MULTIVARIATE MODEL: Emergency, pulmonary hypertension, age, left ventricular dysfunction and aortic aneurysm. We estimated a 5.2%, 5.2% and 11.4% mortality with linear, logistic and Parsonnet method respectively with a real group mortality of 6.5%. The average error of the observed and predicted mortality after risk stratification was 5.7%, 6% and 12%., Conclusion: A model for risk prediction based on the data of the own institution is more accurate for that population than a model created for comparison between institutions, because the former takes account of the center and population peculiarities.

From the International Registry on Cardiac Transplantation we can not infer a higher mortality in urgent or emergent Cardiac Transplantation. The data in the Spanish Registry and in the literature show that the risk is higher in these patients compared to non urgent transplantation, implying ethical considerations which are discussed in the article. A different approach to urgent transplantation could be based on previous circulatory support, or heart assist systems as a bridge to transplantation.

Subthreshold stimuli trains may inhibit the response to a subsequent suprathreshold stimulus; the inhibitory effect decreases or even disappears when the subthreshold stimuli are delivered apart from the suprathreshold stimulus. The purpose of this study is to analyse, in atrial epicardium, the influence of different electrode configurations upon the inhibitory effect of subthreshold stimuli trains delivered at a short distance from the explored zone. In 18 anaesthetized dogs, the basal atrial effective refractory period was determined using an epicardial unipolar cathodal electrode. A second determination was performed when a subthreshold stimuli train (1 ms cathodal pulses, 800 Hz, and intensity 10% less than the diastolic threshold of the train) was delivered prior to the extrastimulus through: (a) 8 electrodes equidistant (4.5 mm) from the central test electrode (Group 1, n = 5); (b) a 1 mm wide ring electrode, 2.5 mm from the central test electrode (Group 2, n = 7); and (c) a 3.5 mm wide ring electrode, 2.5 mm from the central test electrode (Group 3, n = 6). A third determination was performed in all experiments delivering both the subthreshold stimuli train and the extrastimulus through the same central test electrode. Atrial effective refractory period did not vary significantly with respect to the basal values in Group 1 (141 +/- 22 vs 142 +/- 25 ms; ns) though it increased in Group 2 (168 +/- 27 vs 142 +/- 18 ms; P < 0.01) and in Group 3 (160 +/- 20 vs 133 +/- 25 ms; P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The impulses coming from the sinus node synchronically penetrate the AV node via the crista terminalis and inter-atrial septum. Studies in superfused rabbit AV preparations suggest that the crista terminalis is a more effective input than the inter-atrial septum, and that the summation of both inputs facilitates AV nodal conduction. The aim of this study was to verify the hypothesis in a more physiological model, such as the whole rabbit heart perfused by a Langendorff system. Fifteen rabbit hearts were studied in a Langendorff perfusion system with six bipolar extracellular electrodes: two for stimulating (crista terminalis and inter-atrial septum) and four for recording (crista terminalis, inter-atrial septum, His bundle electrogram and right ventricle). Seven hearts (Group I) were consecutively paced at the crista terminalis, inter-atrial septum and both sites simultaneously, to determine the AV nodal Wenckebach cycle length and effective refractory period under basal conditions and after acetylcholine (0.75 x 10(-6) M). In eight hearts under 0.75 x 10(-6) M acetylcholine (Group II), the crista terminalis and inter-atrial septum were simultaneously (delay = 0 ms) or sequentially (delay = 2, 4, 6, 8, 10, 12, 14, and 16 ms) stimulated to calculate the AV nodal effective refractory period and the AH interval at an atrial coupling interval 5 ms longer than the AV nodal effective refractory period, for each delay tested.(ABSTRACT TRUNCATED AT 250 WORDS)

A polytetrafluoroethylene tubular prosthesis was used to protect an internal mammary artery graft in a patient with high risk of reoperation. This technique was used to avoid the risk of damage of the graft and to reduce the difficulties of the injection of cardioplegia during the reoperation procedure. The usefulness of this technique is discussed in the article.

An asymptomatic 31-year-old woman was studied because she presented a systolic ejection cardiac murmur. The echocardiogram showed a mobile, sac-like mass attached to the ventricular surface of the anterior mitral leaflet and its chordae tendineae and papillary muscle. This structure moved to the left ventricular outflow tract during every systole occupying the subaortic area. Conventional and color-coded Doppler examination revealed left ventricular outflow obstruction caused by the accessory mitral valve tissue that produced a high-velocity turbulent flow pattern in the subaortic area where the sac-like structure approximated to the outflow tract walls.

A series of 2,474 hospital survivors of primary mitral, aortic, and double mitral-aortic valve replacement were observed for a cumulative period of 11.945 years (mean, 4.2 years; range, 0.6-14 years). The linearized incidences of reoperations for thrombotic obstructions were 0.33 +/- 0.08% for mitral valve replacement, 0.36 +/- 0.1% for aortic valve replacement, and 0.42 +/- 0.1% for double valve replacement (p = not significant). Forty-one patients (16 mitral, 12 aortic, and 13 double valve replacements) underwent a total of 44 reoperations with a mean interval of 36 +/- 29 months (range, 0.25-85 months) between operations. Diagnosis was established invasively only in 13 patients (30%). Hospital mortality at reoperation was 18% (8 patients); 28 patients (63%) required emergency surgery. The choice surgical procedures were thrombectomy for clotted aortic prostheses (18 of 24) and valve replacement for obstructed mitral valves (22 of 25; p less than .001). Rethrombosis occurred in 3 patients (1 aortic and 2 double valve replacements). At hospital admission 17 patients (38%) had prothrombin times outside therapeutic ranges (between 20 to 30% of the normal value). The incidence of reoperations for thrombosis in low-profile mechanical prostheses was unaffected by valvar position and number of prostheses implanted. Rethrombosis occurred only in previously cleaned valves, although its occurrence was not significant. The present results indicate that, as experience is gained in the diagnosis and surgical management of this complication, hospital mortality can be reduced significantly (from 37% to 4%).