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Background: Due to current medical improvements, more women with cardiac disease are being operated during pregnancy. Fetal loss has been found to be significant between 9-30% of them and the surgery is supposed to be done maximal in the first trimester., Objectives: The aim of this study was to report our experience with urgent cardiopulmonary bypass carried out in early pregnancy and to analyze factors that may influence fetal and maternal morbidity and mortality after surgery., Materials and Methods: We have retrospectively reviewed the case notes of the patients who underwent cardiac surgery during early pregnancy in our institution from January 1997 to October 2011., Results: During that period cardiac surgery was done in 305 patients in childbearing age (between 15-50 years) from which 4 were pregnant and in the first half of their pregnancy. All of them had previous surgery due to rhumatismal heart disease .The surgery was emergent in 3 cases and urgent in 1 case. They were operated under normothermic conditions, high flow and hemodynamic stability throughout the procedure. There was no fetal loss but one patient sustained a cardiac arrest secondary to asthma complicated by post-anoxic brain injury., Conclusions: Normothermia and hemodynamic stability are the most important factors which help to reduce fetal loss during open heart surgery in pregnancy. The fetus has an auto-regulation which comes into play when the mother is experiencing shock.

Objectives: Because of the limited availability of pulmonary homografts (PH), porcine stentless xenografts (SX) have been proposed as an alternative for pulmonary valve replacement in the Ross operation. However, it is unknown whether they have similar good long-term durability. Therefore, we compared mid- to long-term outcomes between those two right ventricular outflow tract (RVOT) substitutes., Methods: In 288 adults (>18 years) undergoing a Ross operation between 1991 and 2012, Freestyle(®) SX was used in 18 patients and a cryopreserved PH was used in 270 for RVOT reconstruction. Only patients with follow-up >2 years were included. According to the operative period, gender and age, 37 patients with PH could be matched with 17 SX patients. Clinical and echocardiographic follow-up were obtained. In a subset of patients (SX, n = 11 and PH, n = 25), a cardiac computed tomographic (CT) scan was performed to analyse graft calcification., Results: The mean follow-up period was 8.2 ± 4.0 (range 2-14.6 years). During this period, 3 patients died from cancer, 2 in the SX group and 1 in the PH group (P = 0.15). No patient needed RVOT reoperation. At follow-up, RVOT peak gradient was 21 ± 5.9 mmHg in the SX and 16.3 ± 8.7 in the PH groups (P = 0.07). Peak gradient >40 mmHg was observed in only 1 patient in the PH group. Mean RVOT regurgitation was 0.1 ± 0.4 in the SX group and 0.8 ± 0.6 in the PH group (P = 0.008). CT scan analyses showed progressive calcification mainly of the graft wall, while the valve remained relatively free of calcium. Patients with the SX presented significantly higher calcium scores than those with PH (P = 0.01)., Conclusions: In adult patients having the Ross operation, calcic degeneration is observed in both the PH and the SX used as pulmonary substitutes. Calcification progresses more rapidly in the SX compared with the PH. In both grafts, calcifications affect mainly the wall, while the valve remains relatively free of calcium. As a consequence, both grafts show good and similar haemodynamic outcomes at mid- to long-term follow-up. The Freestyle(®) SX can be considered as an acceptable alternative for RVOT reconstruction when PH is not available.

Background: To evaluate the effect of higher post-operative valve gradient on freedom from valve re-intervention and death in patients undergoing aortic valve repair (AVr)., Methods: Patients who underwent AVr between March 1996 and June 2010 were divided into 2 groups: I: peak gradient (PG) <20 mmHg (n=358) and II: PG ≥20 mmHg (n=113). Age (53.6±16.0 vs. 50.6±16.4 years; P=0.08), impaired LV (n=44, 12.2% vs. n=12, 10.6%: P=0.73) as well as the body surface area (1.97 vs. 1.95 m(2); P=0.4) were similar. Pre-operative AI >2+ was greater in Group II compared to Group I (n=78, 69.0% vs. n=192, 53.6%; P=0.004). Patients in Group II had higher proportion of bicuspid valves (BV) (n=58, 51.3% vs. n=106, 29.6%; P=0.0001) and restrictive valves (n=34, 30.0% vs. n=52, 14.5%; P=0.0001) while Marfan patients were seen only in Group I (n=19; P=0.010). Mean follow-up for Group I and Group II was 123.1±89.7 and 147.1±108.0 months, respectively., Results: In-hospital mortality was n=2 (0.5%) for Group I and none for Group II (P=1.0). Valve-sparing was higher in Group I (P=0.0001) but sub-commissural annuloplasty was similar (P=0.15). Shaving and/or decalcification was performed more in Group II (n=68, 60.1% vs. n=117, 32.6%; P=0.0001). Logistic regression analysis identified calcified, restrictive and bicuspid valves as independent predictors of PG ≥20 mmHg (P=0.04 for each). Predictors of re-operation were increased end-diastolic diameter (P=0.03) and younger age (P=0.007), but not PG ≥20 mmHg (P=0.98) (based on logistic regression). Overall 10-year cardiac survival and freedom from AV re-intervention was 82.3±4.6% vs. 89.5±4.2% (P=0.53) and 89.1±3.0% vs. 76.8±8.4% (P=0.02), in Group I and II, respectively (based on Kaplan-Meier analysis). Sub-group analysis showed that Group II patients requiring re-intervention (n=10) were younger (41.8±13.1 vs. 51.0±16.0 years; P=0.08) with similar proportion of bicuspid valves (n=6; 60%; P=0.74). The main reason for AV re-operation was aortic insufficiency (n=7) and AI + stenosis (n=3)., Conclusions: Higher gradient after AVr is associated with a reduced freedom from AV re-intervention, especially in younger patients.

Objective: Patients with supracoronary ascending aortic aneurysms can have aortic insufficiency (AI) due to dilatation of the sinotubular junction and/or associated cusp pathology. The incidence and types of cusp lesions as well as the effect of AI severity and cusp repair techniques on outcome in this patient population is not well defined., Methods: Since 1996, 55 patients (mean age: 65 ± 13 years, 17 bicuspid valves) presented with supracoronary ascending aortic aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated pathology included cusp prolapse in 18 (33%), cusp restriction in nine (16%) and both in three (5%). All patients underwent aortic replacement and remodeling of the sinotubular junction. Adjunctive techniques included subcommissural annuloplasty in 38(69%) and cusp repair in 28 (51%)., Results: AI severity was not significantly associated with the presence of cusp pathology (p=0.35). Cusp disease was present in 100% of bicuspid aortic valves compared with only 34% of trileaflet valves (p<0.001). There was no hospital mortality and overall survival was 94 ± 4% and 75 ± 10%, respectively, at 5 and 7 years. Freedom from re-operation was 100% at 7 years and freedom from recurrent AI (>2+) was 87 ± 7% at 5 years. Neither the presence of preoperative severe AI, nor the need for cusp repair was predictive of late outcome., Conclusions: Cusp pathology is frequently encountered in patients with ascending aortic dilatation and AI. Severe AI is not a contraindication to valve-preserving surgery, but careful identification and repair of cusp pathology, in addition to sinotubular junction reduction, is critical for durable, long-term outcome., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Exercise capacity is improved in patients supported with continuous flow rotary blood pumps (RP). The aim of this study was to investigate the mechanisms underlying this improvement. Ten patients implanted with a RP underwent cardiopulmonary exercise testing (CPET) at 6 months after surgery with hemodynamic and metabolic measurements (RP group). A group of 10 matched heart failure patients were extracted from our heart transplant database, and the results of their last CPET before transplantation were used for comparison (heart failure [HF] group). Peak VO(2) was significantly higher in RP than in HF patients (15.8 ± 6.2 vs. 10.9 ± 3 mL O(2)/kg.min) reaching 52 ± 16% of their predicted peak VO(2). The total output measured by a Swan-Ganz catheter increased from 5.6 ± 1.6 to 9.2 ± 1.8 L/min in the RP group and was significantly higher at rest and at peak exercise than in the HF group, whose output increased from 3.5 ± 0.4 to 5.6 ± 1.6 L/min. In the RP group, the estimated pump flow increased from 5.3 ± 0.4 to 6.2 ± 0.8, whereas the native cardiac output increased from 0.0 ± 0.5 to 3 ± 1.7 L/min. Cardiac output at peak exercise was inversely correlated with age (r = -0.86, P = 0.001) and mean pulmonary artery pressure (r = -0.75, P = 0.012). Maximal exercise capacity is improved in patients supported by RP as compared to matched HF patients and reaches about 50% of the expected values. Both a spontaneous increase of pump flow at constant pump speed and an increase of the native cardiac output contribute to total flow elevation. These findings may suggest that an automatic pump speed adaptation during exercise would further improve the exercise capacity. This hypothesis should be examined., (© 2011, Copyright the Authors. Artificial Organs © 2011, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background/aims: Undiagnosed occlusive disease of celiac trunk and/or superior mesenteric artery may lead to life-threatening complications after pancreatoduodenectomy., Methodology: Retrospective analysis of a consecutive series of 171 patients scheduled for pancreatico- duodenectomy or total pancreatectomy., Results: The prevalence of arterial occlusive disease was 5.9% (10 patients), including complete celiac artery occlusive disease in 2 patients (1.2%). Preoperative diagnosis was achieved in 90% of the patients by lateral-views of imaging studies. In arterial stenosis <50% (3 patients), abstention was always successful. In arterial stenosis >50%, successful treatment options included abstention (n=1), preoperative endovascular dilatation (n=1) or stenting (n=1), division of the median arcuate ligament with (n=1) or without (n=1) postoperative endovascular stenting, and aorto-hepatic bypass (2 patients). No early postoperative ischemic complications occurred. However, one patient died from late intestinal ischemia., Conclusions: Arterial occlusive disease is rare in patients undergoing pancreatico-duodenectomy but expose the patient to severe complications if undiagnosed. A tailored management according to the type of arterial stenosis, to patients' indication for surgery and to patients' arterial anatomy is indicated. Surgical and endovascular management may be successfully combined.

Objective: To date, quality of life (QoL) after extensive chest wall resection is not known. This study analyses QoL in long-term survivors after extensive resection., Methods: Retrospective analysis of 51 patients operated for non-small-cell lung cancer (NSCLC)/mediastinal tumour invading the chest wall, primary/secondary chest wall tumours. QoL and functional status of long-term survivors (>36 months) were studied using Borg scale, Mahler dyspnoea index, Functional Autonomy Measuring System (SMAF) and 36-item Short Form Health Survey (SF-36) questionnaire. Out of the 51 patients, pulmonary function tests were available before and after resection in 24 patients and were subjected to analysis., Results: Five-year survival was 50%, 26 patients survived>36 months. At follow-up, 22/28 deaths were cancer related. Compared to baseline, the reduction of flow expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were 18% and 15%, respectively (p<0.001). The QoL study included 23 long-term survivors. A moderate/severe dyspnoea was present in 5/23 patients (21%). The SF-36 questionnaire revealed that, compared to controls, patients with chest wall resection experienced impaired QoL in physical functioning, in role physical, in body pain, in social functioning and in mental health. Objective measurements of pulmonary function correlated poorly with QoL, whereas subjective assessment of dyspnoea was significantly associated with QoL., Conclusions: This study shows that long-term survivors after extensive chest wall resection experienced moderate impairments in several QoL subscales. As previously reported in patients after pulmonary resection, subjective assessment such as dyspnoea correlated well with patient-perceived QoL., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Failure of the pulmonary autograft following the Ross Procedure is mainly due to dilatation and/or cusp prolapse causing insufficiency. We analysed the result of pulmonary autograft valve sparing and repair, using techniques developed for native aortic root and valve., Methods: Of a total of 275 patients who underwent Ross operation between 1991 and 2009, 31 needed autograft re-operation. Of the 28 patients re-operated in our centre, 26 (93%) had autograft valve preservation and they represent the study cohort. At the initial Ross procedure, root remplacement technique was performed in 20 patients and autograft inclusion technique was performed in 6. Mean redo interval was 9.3 + or - 3.5 years and mean age at redo was 44 + or - 13 years. Indications for re-operations were neo-aorta dilatation (n=12; 46%), autograft insufficiency (n=4; 15%) and dilatation with autograft insufficiency (n=10; 40%). Neo-aorta dilatation was repaired using valve-sparing root replacement (n=12, 46%) or ascending aorta replacement (n=10; 40%). Cusp prolapse was repaired by commissural re-suspension (n=1), free margin plication (n=10) or re-suspension with polytetrafluoroethylene (PTFE; n=6). Cusp repair was performed in isolation (n=4) or in association with sparing (n=5) or ascending aorta replacement (n=4)., Results: There was no in-hospital mortality. Two patients having undergone isolated cusp repair needed valve replacement for recurrent insufficiency after 5 days and 8 years postoperatively. At follow-up (100% complete, median: 27 months) all patients were alive, in New York Heart Association (NYHA) class I (n=22; 84%) or II (n=4; 16%). No autograft regurgitation was present in nine patients (five sparing and four ascending aorta replacement); grade I insufficiency was present in 11 (six sparing and five ascending aorta replacement), grade 2 in two (one sparing and one isolated cusp repair) and grade 3 in two (one ascending aorta replacement and one isolated cusp repair). At 3 years, overall freedom from autograft insufficiency > or = grade 3 was 80%., Conclusion: Preservation of the pulmonary autograft valve can be safely performed in selected patients. At midterm, repair of neo-aorta dilatation using valve-sparing root replacement or ascending aorta replacement showed acceptable results. In contrast, results of cusp repair for isolated autograft insufficiency were unsatisfactory., (Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: : Bypass surgery and percutaneous coronary interventions improve the clinical status of patients with left anterior descending coronary artery disease. However, these techniques differ in invasiveness and in the need for subsequent reinterventions. The development of minimally invasive direct coronary artery bypass (MIDCAB) surgery and of drug-eluting stents (DES) offers perspectives to close this gap., Methods: : We compared the long-term clinical outcome of 308 patients after revascularization for isolated left anterior descending coronary artery disease. One hundred fifty-four patients were treated with MIDCAB and 154 with percutaneous coronary interventions and DES implantation., Results: : Both groups were similar in age (63 ± 13 and 62 ± 10 years), Euroscore (3.3 ± 2.8 and 3.4 ± 2.6), and mean duration of follow-up (30 ± 17 and 24 ± 10 months). Two-year survival was similar after MIDCAB and after DES (97.4% and 94.8%). During follow-up, four patients (2.6%) of the MIDCAB group and 21 patients (13.6%) of the DES group needed subsequent revascularization of the target vessel (P = 0.001). Revascularization of a nontarget vessel was needed in 11 patients (7%) of the MIDCAB group and in 17 patients (11%) of the DES group (NS). Neurologic complications included two transient ischemic accidents and two strokes in the MIDCAB group but three fatal cerebral hemorrhages and one stroke in the DES group. Major adverse coronary and cerebrovascular events rates were 14% in the MIDCAB and 31% in the DES group., Conclusions: : MIDCAB and DES implantation showed similar rates of mortality but a higher reintervention rate after DES. Anticoagulation implications remain critical for the future of DES.

Background: The presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been suggested as a risk factor for poorer outcomes after aortic valve (AV)-sparing surgery. We analyzed the influence of these factors on the mid-term outcomes of AV surgery., Methods and Results: Between 1996 and 2008, 164 consecutive patients underwent elective AV-sparing surgery. Severe preoperative AI (grade > or =3+) was present in 93 patients (57%), and 54 (33%) had a bicuspid valve. Root repair was performed with either the reimplantation (74%) or the remodeling (26%) technique, and cusp repair was performed in 90 patients (55%). Mean clinical follow-up was 57 months. Hospital mortality was 0.6%. Cusp repair was required in 52% of the patients with preoperative AI < or =2+ and in 57% of those with AI > or =3+ (P=0.6). Cusp repair was required more frequently in bicuspid versus tricuspid valves (91% versus 38%, P<0.001). Overall survival at 8 years was 88+/-8%. Freedom from AV reoperation at 8 years was similar with preoperative AI < or =2+ versus preoperative AI > or =3+ (89+/-11% versus 90+/-7%, P=0.7) and with versus without cusp repair (84+/-17% versus 92+/-8%, P=0.5). Freedom from recurrent AI (grade > or =3+) at 5 years was also similar between groups (90+/-10% versus 89+/-8%, P=0.9, and 90+/-8% versus 89+/-9%, P=0.8, respectively). By multivariate analyses, predictors of recurrent AI > or =2+ were preoperative left ventricle end-diastolic diameter and AI >1+ on discharge echocardiography., Conclusions: With a systematic approach to cusp assessment and repair, AV-sparing surgery for root pathology has an acceptable mid-term outcome, irrespective of preoperative AI or need for cusp repair.

Objective: Y-graft configuration with left and right ITA (RITA) allows complete arterial revascularisation. We previously compared two types of ITA revascularisation in a prospective randomised trial with a systematic 6-month angiographic follow-up study. The present study is a secondary analysis of these populations to evaluate the angiographic parameters influencing the function of the RITA used in a Y-graft configuration., Methods: The functionality of the RITA was based on the TIMI grade flow: in TIMI grade 0 (occluded graft) and in TIMI grade 1 or 2 (balanced flow), the RITA was considered not functional. RITA was considered functional when a complete opacification (TIMI 3) of all anastomoses of the targeted coronary vessels was observed., Results: A total of 25.3% of RITA were not functional. In univariate analysis, the number of anastomoses, the type and size of grafted coronary segments and the severity of the native coronary stenosis influenced ITA function. In multivariate analysis, the function of the RITA was positively influenced by the number of anastomoses (OR=0.5, 95% CI: 0.4-0.7), and a severely narrowed first circumflex (OR=39.1, CI: 8.1-189.2) and negatively by the presence of a grafted intermediate coronary artery (OR=0.01, CI: 0.003-0.06), and of a grafted RCA (OR=0.08, CI: 0.02-0.35). The size of targeted vessel, history of infarction and regional myocardial function did not influence ITA function., Conclusions: In this systematic angiographic study, the function of the RITA used as a Y-graft was significantly improved when used on several branches of the circumflex artery or on a severely narrowed first circumflex. Grafting of the intermediate branch or of a RCA has a negative prognostic influence on graft function.

Background and Aim of the Study: The impact of adding mitral ring annuloplasty (MRA) to coronary bypass grafting (CABG) in patients with ischemic mitral regurgitation (iMR) is unclear. The study aim was to compare the 30-day and four-year survival of patients with moderate to severe iMR undergoing CABG or CABG+MRA, and to investigate the role of contractile reserve (CR) in the prognostic response to MRA., Methods: A total of 76 coronary patients (61 men, 15 women; mean age 62 +/- 9 years) with poor left ventricular ejection fraction (LVEF) of 33 +/- 11% and grade > or =2 iMR underwent low-dose dobutamine echocardiography to identify their CR before CABG. The survival of 34 patients undergoing CABG+MRA was compared to that of 42 patients who underwent CABG alone. The groups were further substratified according to their preoperative CR., Results: During follow up, 24 patients died from cardiac causes, and two others required heart transplantation. At one year, the residual iMR and NYHA functional class were lower in patients undergoing MRA than in those that did not. The 30-day and four-year survivals were lower in patients undergoing MRA in the absence of CR than in the other patients (71 +/- 11% versus 95 +/- 3% at 30 days, p = 0.002; 35 +/- 11% versus 69 +/- 6% at four years, p = 0.008). Cox's proportional hazard analysis identified CR (HR = 0.14, 95% CI 0.05-0.38, p < 0.001), MRA (HR = 3.54, 95% CI 1.48-8.50, p = 0.004), additive EuroSCORE (HR = 1.29, 95% CI 1.08-1.55, p = 0.006) and LVEF (HR = 0.93, 95% CI 0.59-0.98, p = 0.001) as independent predictors of long-term outcome in this population., Conclusion: In patients with moderate to severe iMR, survival after CABG is mainly influenced by the presence of CR. By contrast, adding MRA to CABG does not affect long-term survival, except in patients without CR, in whom it increases early mortality.

Objective: Leaflet plication (PL), triangular resection (TR), resuspension with running suture of Gore-Tex (GTx) and extension with autologous pericardial patch (PP) are different techniques to repair aortic leaflet prolapse (LP) for aortic insufficiency (AI). In this study, we report and compare the early and mid-term results of these techniques for aortic valve repair., Methods: From 1996 to 2006, 298 patients underwent elective aortic valve (AV) repair. In 146 of them, prolapse of one (n=72) or more than one leaflet (n=74) was found. LP was defined either as a longer or lower leaflet free margin compared to the other leaflet(s) or a relatively low coaptation level of all leaflets. When leaflet tissues were of good quality (thin and pliable), prolapse was treated by GTx (n=39), PL (n=25) or GTx+PL (n=23). When leaflet tissues were of poor quality (thickened, calcified), prolapse was treated by TR or PP (n=13) or TR or PP+GTx (n=47)., Results: There was no hospital mortality. During the initial hospitalization two patients required reoperation for recurrent AI and one for aorto-right ventricular fistula; of them, two were re-repaired. Median follow-up was 35 months (range 9-136). Three patients needed late reoperation for recurrent AI. At 4 years, overall survival was 99+/-1% and freedom from reoperation and from recurrent AI (grade >2) was 94+/-5% and 91+/-7% respectively. Freedom from recurrent AI was similar in patients having one versus more than one LP repair (88+/-11% vs 92+/-8%, p=0.2) and among the different techniques used to repair leaflet of good quality (PL: 95+/-8% vs GTx: 83+/-18% vs PL+GTx: 100%; p=0.37). When leaflet resection was needed, the addition of GTx significantly reduced the recurrence of AI (TR or PP: 82+/-18% vs TR or PP+GTx: 97+/-4%; p=0.026)., Conclusions: Leaflet plication and Gore-Tex resuspension are both effective and durable techniques for aortic leaflet prolapse repair. The addition of Gore-Tex to triangular resection and pericardial patch repair techniques is efficient to reinforce the suture line and to improve the outcome of the repair. Multiple leaflet prolapse is not a prohibitive factor for successful repair even in the absence of a clear reference level such as a normal leaflet, as long as normal anatomical coaptation is achieved.

Background: The true relevance of allosensitization in patients benefiting from left ventricular assist device (LVAD) as bridge to transplant (BTT) is still debated. Available registry data referred to numerous devices precluding LVAD-specific analysis. Therefore, we studied all patients with Novacor LVAD prior to transplantation., Methods: From 1985 to 2006, 37 Novacor LVADs were implanted as BTT, with 30 patients surviving to transplantation (81%). Post-LVAD sensitization was determined for anti-HLA-class I and class II IgGs. Study endpoints were overall survival and/or graft loss, > or =3A cellular rejection and chronic allograft vasculopathy (CAV). The results from LVAD patients were compared to non-LVAD primary heart transplant recipients (n=318)., Results: After LVAD insertion, 5 out of 27 patients available for analysis developed anti-HLA antibodies (18.5%). The mean anti-HLA titer after Novacor LVAD implantation was 14% [SD 31]. Actuarial 5- and 10-year patient/graft survival for LVAD and non-LVAD transplant recipients were 73% and 55%, and 70% and 55%, respectively (p=NS). Overall prevalence of rejection > or =3A was 23.3 % (LVAD group) and 18.9% (non-LVAD group) (p=NS). At follow-up, the respective incidence of CAV was 8% (LVAD group) and 32.4% (non-LVAD group) (p<0.01). However, mean follow-up was significantly different for LVAD and non-LVAD patients, 46 vs 90 months (p<0.001)., Conclusion: In this study, allosensitization occurred infrequently after Novacor LVAD implantation. Secondly, analysis of outcome variables shows that Novacor-LVAD BTT patients can anticipate similar survival to non-LVAD patients, thus minimizing the impact of allosensitization after LVAD implantation.

Background: Non-small cell lung cancer (NSCLC) has a poor prognosis even for early stages of the disease (stage I and II). We studied the prognostic value of PET FDG in patients with completely resected stage I and II NSCLC., Methods: Retrospective study of 96 patients with NSCLC whose staging included 18F-FDG PET (fluoro deoxy glucose positron emission tomography). Histopathological stage was either stage I (75) or stage II (n=21). FDG uptake was measured as maximal standardized uptake value for body weight (SUVmax). Mean follow-up was 45+/-30 months (1-142 months). Overall and cancer-free survival rates were recorded., Results: SUVmax were higher for stage II than for stage I (10.5+/-4.5 vs 8.5+/-5, p=0.04). Mean tumor volumes were equivalent for both stages (33 cm3, p=0.18), excluding a partial volume effect. The median SUVmax in the whole study population was 7.8. The median survival was significantly longer in patients with a lower (SUVmax7.8 (p=0.001). For stage II tumors (n=21), no statistical difference was observed: 72 months vs 40 months for SUVmax7.8, respectively (p=0.11), although there was a clear trend towards reduced survival for highly metabolic tumors. Disease-free survival was also significantly better for lower metabolic tumors: 96.1 months vs 87.7 months (p=0.01)., Conclusion: High FDG uptake is associated with reduced overall survival and disease-free survival of patients with completely resected stage I-II NSCLC. Whether patients with highly metabolic tumors should undergo a closer postoperative surveillance or adjuvant chemotherapy has to be addressed in a properly designed prospective trial.

Objective: In recent studies focusing on the prognostic significance of histologic features of NSCLC tumors, vessel invasion was correlated to survival across all surgical stages. We similarly analyzed whether intra-tumoral permeation could affect survival in subgroups of stage I and II NSCLC., Methods: A retrospective single institution analysis of a prospectively computed database. Specimens were analyzed for intra-tumoral vascular, lymphatic and nervous permeation. Overall mortality was determined and for each stage, a Cox regression analysis of selected variables was performed. Detailed histologic information was available in all patients. Follow-up was 100% complete (median=69 months)., Results: From 1989 to 2004, out of 346 patients with stage I and II NSCLC, 253 patients with p stage I (75.7%) and 81 patients with p stage II (24.3%) underwent surgery with complete resection, for a completeness resection rate of 97% (334/346). We performed 70 pneumonectomies, 255 lobectomies and 9 lesser resections (respectively, 21%, 76.3% and 2.7%). In-hospital mortality was 2.1%. The incidence of intra-tumoral permeation was 14.4% (48/334). Permeation correlated both with T status (p=0.04), grade of differentiation (p=0.03) and stage (p=0.02). Median survival and overall 5-year survival for patients with and without permeation were 42.3 months (95% CI [20-64.6]) and 72.1 months (95% CI [56.9-87.2]), respectively; and 44% and 54%, respectively (p=NS). However, intra-tumoral permeation was not a significant predictor for overall death (HR=1.1 [95% CI=0.74-1.66)., Conclusion: In this large institutional study of early stage NSCLC, the presence of intra-tumoral permeation was correlated both to T, grade of differentiation, as well as to stage. However, in contrast to recent reports, we did not find that intra-tumoral permeation adversely affects long-term survival.

Objectives: To evaluate a simple treatment algorithm in sternal wound infection (SWI) allowing for primary closure and to describe the different surgical techniques and their associated morbidity and mortality., Methods: A retrospective analysis of all patients operated on between 1996 and 2004 in a single tertiary care institution. All epidemiological and surgical data were prospectively collected in our database. Univariate and multivariate analysis were used to determine preoperative and perioperative risks factors for 90-day and long-term mortality., Results: Out of 5905 procedures, 146 sternal wound infections were documented (2.4%). The respective incidence of SWI for CABG, isolated valve, or combined procedures were 2.8%, 1.1%, and 3.2%. Pathogens involved were S. epidermidis (44.5%), S. aureus (31.5%), and gram-negative rods (19.2%). Re-operation was required in 131/146 patients. Mean time to the first re-operation was 17.3+/-12 days. Modalities of treatment consisted of drainage alone (44 patients), rewiring (25 patients), debridement, rewiring and mediastinal lavage (52 patients), and partial/complete sternal resection (10 patients). Additional procedures were required in 49 patients (37.7%). The 90-day mortality for uninfected patients and patients with superficial SWI were 4.4% and 2.8% (p=0.78) whereas for patients with deep SWI, 90-day mortality was 14.5% (DSWI vs others, p<0.0001)., Conclusions: Deep sternal wound infection (DSWI) remains a dreadful complication in contemporary cardiac surgery while risk factors are currently well defined. Using a simple approach of primary closure together with liberal use of vascularized flaps has allowed us to achieve satisfactory short-term outcome in this subset of patients.

Objective: To evaluate timing for surgery and management of complex valve lesions in patients with active mitral valve (MV) endocarditis. Results are based on 13 years of experience with MV repair in active endocarditis., Method: Between 1993 and 2005, 81 patients were operated for active MV endocarditis, of which 63 (or 78%) had MV repair. For all patients, the median time between diagnosis and surgery was 10 days. Diverse surgical techniques were applied to restore MV competence. In 59% of the patients, pericardial patches, tricuspid autograft or partial MV homografts were used as leaflet substitutes. In addition, prosthetic rings were employed in 44% of the patients., Results: The overall operative mortality was 17.5%. However, considering only patients in preoperative NYHA class I or II, the operative mortality could be reduced to 4.8%. NYHA class > or =3, elevated age (above 70 years) and history of valvular were the three independent risks factors for early mortality in our multivariate analysis. The average follow-up time was 60+/-37 months. During this period, five late deaths occurred, two of which were cardiac-related. The overall 5- and 10-year survival rate was 73+/-12% and 69+/-13%, respectively. In hospital survivors, freedom from cardiac death after 5 and 10 years was 93+/-8%. Three early and five late MV reoperations occurred in seven patients, of them four could have MV re-repair. Only one endocarditis recurrence occurred after 4 months in a chronic haeamodialysed patient. Freedom from MV reoperation was 89+/-10% and 72+/-24% at 5 and 10 years, respectively. Ten-year freedom from MV replacement and from endocarditis recurrence were 95+/-5% and 98+/-1%, respectively. Annular abscesses and calcified or rheumatic MV disease were two independent risk factors associated with reoperation in our multivariate analysis. During the follow-up period, all patients were in NYHA class I or II; 89% of patients had mitral regurgitation grade < or =I, only 11% had grade II on transthoracic echocardiography., Conclusion: Using diverse and advanced techniques of MV repair, a reparability rate of 80% can be reached among patients with active endocarditis. We demonstrate that a high level of safety and excellent durability of MV repair can be obtained even for complex repairs.

Quadricuspid aortic valve in adulthood is a rare pathology which often leads to aortic valve regurgitation that requires surgical treatment. Herein are described two patients with severe regurgitation on a quadricuspid aortic valve and with dilated left ventricle, who where successfully repaired using a technique of tricuspidation of the valve at the level of the abnormal commissure. In each patient, the repair was stabilized and leaflet coaptation increased by subcommissural annuloplasty stitches at the level of the three commissures. After one year and six months' follow up, respectively, both patients presented with trivial aortic regurgitation and good mobility of the three leaflets.

Background: Although the internal thoracic artery was proven superior to saphenous vein graft in long-term patency, it is thought to be a more resistive conduit than the vein graft. Moreover, patency studies comparing both left and right internal thoracic arteries have provided results favoring the former. Fractional flow reserve is an established functional index of coronary blood flow., Methods: To compare the fractional flow reserve between both internal thoracic arteries and saphenous vein grafts, 43 bypass grafts were studied 6 months after revascularization. Intra-graft pressures were measured during cardiac catheterization using a pressure-wire advanced to the first distal anastomosis of 12 left internal thoracic arteries (ITAs), 10 right ITAs and of 21 vein grafts. Pressure gradients between the aorta and the graft were measured at baseline and during a maximal hyperemia., Results: At baseline, pressure gradient was recorded in the left ITA (2.9+/-2.2 mmHg), in the right ITA (1.2+/-1.2 mmHg) and in the vein graft (0.4+/-0.7 mmHg). During maximal hyperemia, pressure gradient increased to 9.6+/-3.2 mmHg in left ITA, to 4.5+/-2.0 mmHg in the right ITA (p<0.001 vs left ITA) and to 3.3+/-2.7 mmHg in vein (p<0.001 vs left ITA; NS vs right ITA). Fractional flow reserve was 0.90+/-0.04 in left ITA, 0.95+/-0.03 in right ITA (p<0.01 vs left ITA) and 0.96+/-0.03 in vein (p<0.001 vs left ITA)., Conclusion: Internal thoracic arteries and saphenous vein grafts allow myocardial revascularization with minimal resistance to maximal blood flow. The resistance appears significantly higher in left ITA compared to both the right ITA and venous grafts.

Objective: To compare survival results after resection in patients with thoracic parenchymal metastatic disease versus non-parenchymal metastatic disease and to identify prognostic factors for survival., Methods: From 1990 to 2002, we retrospectively studied 134 procedures performed on 93 patients (3-84 years old). There were 73 patients with parenchymal resection and 20 patients with non-parenchymal resection. Tumor histology was epithelial in 62 patients, sarcoma in 21 patients, and teratomas and melanoma in 6 and 4 patients, respectively. Sixty-five patients underwent a metastasectomy once, whereas 28 had their metastatic disease repeatedly resected., Results: Follow-up was 100% complete with a mean time of 43 months (range 1-169). In-hospital mortality was 2.2% (3/134 procedures) and major morbidity 5.5%. Median survival was 39 months (95% CI: 21-56 months). Overall, the actuarial survival at 1, 3, and 5 years were 84%, 55%, and 44%, respectively. For the entire group, by univariate analysis, among the 13 predictor variables selected, only the number of metastases (Hazard Ratio (HR)=3.4 [95% CI: 1.9-6.1]) and completeness of resection (HR=2.3 [95% CI: 1.3-4.2]) were found to be significant for death whereas repeated metastasectomy was found to be a significant predictor for survival (HR=0.25 [95% CI: 0.12-0.55]). In the group of parenchymal metastatic disease, a size greater than 3cm was a predictor for death (HR=2 [95% CI: 1.1-3.7]). In the subgroup of patients with colorectal metastasis, bilateral disease was also found to be a significant predictor for death (HR=3.6, [95% CI: 1.2-11.1])., Conclusion: This study supports our current aggressive approach to metastatic thoracic disease. Indeed, patient's survival is improved while a low mortality and morbidity is achieved. The most beneficial impact on long-term survival is correlated to the completeness of the surgery whereas the increasing number and size of the metastasis inversely correlate with survival.

We report on the case of a 48-year-old male patient suffering from a severe carcinoid heart disease with involvement of the four valves. The primary carcinoid tumor was diagnosed in the ileum. The patient developed a moderate stenosis and severe insufficiency of the tricuspid valve, a severe insufficiency of the pulmonary valve, and a moderate insufficiency of the mitral and aortic valves. Ultimately, a stentless pulmonary valve replacement was performed, as well as a tricuspid valve replacement with a pericardial prosthesis and aortic and mitral valve plasty. The patient recovered well and he was discharged from hospital on day 10.

Background and Aim of the Study: A variety of reliable techniques are now available for chordal disease management and repair of the anterior mitral valve leaflet prolapse. The study aim was to review the authors' experience with polytetrafluoroethylene (PTFE), using a standardized technique for length adjustment, and to analyze the long-term results in patients who underwent mitral valve repair., Methods: A total of 111 patients (mean age 56.2 +/- 16.1 years) underwent mitral valve repair with PTFE neochordae, in addition to a variety of other surgical procedures. Etiologies were degenerative in 82 patients (73.9%), Barlow disease in 13 (11.7%), rheumatic in 10 (9%), and infection in six (5.4%). Prolapse of the anterior leaflet was present in 78 patients (70.3%), of the posterior leaflet in 15 (13.5%), a bileaflet prolapse was present in 12 (10.8%), and a commissural prolapse in six (5.4%). In all cases the anterior annulus was used as the reference level in order to assess the appropriate length of the PTFE neochordae., Results: The mean number of PTFE neochordae used was 6 +/- 4 per patient. In-hospital mortality was 1.8% (n = 2); mean follow up was 36.8 +/- 25.6 months (range: 12-94 months). There were no late deaths. At five years postoperatively the patient overall survival was 98.2 +/- 1.8%, freedom from reoperation rate 100%, and freedom from grade 1+ mitral regurgitation rate 97.2 +/- 2.8%. There were no documented thromboembolism or hemorrhagic events., Conclusion: In degenerative and myxomatous mitral valve disease, leaflet prolapse can be successfully repaired by implantation of PTFE neochordae. Both immediate and long-term results proved the versatility, efficiency and durability of this technique.

Dextrocardia with complete situs inversus is a rare condition that occurs approximately in 2/10,000 live births. Coronary revascularization management in this setting differs in the technical considerations imposed by the malposition of the heart itself. We report here a case of complete arterial revascularization using both internal thoracic arteries and the left (homologous vessel to the right) gastroepiploic artery in an adult patient with triple-vessel disease and situs inversus totalis. Strategies for the choice of conduits and anastomoses as well as technical details are discussed.

This is a case report of a 78-year-old patient with a 7-cm aneurysm of the saphenous vein graft that was used 17 years before to perform a coronary artery bypass grafting on the circumflex artery. CT scan displayed a mass with an internal lumen compressing the left atrium as well as the left pulmonary artery.

Background: The therapeutic effects of nonspecific beta-blockers are limited by vasoconstriction, thus justifying the interest in molecules with ancillary vasodilating properties. Nebivolol is a selective beta1-adrenoreceptor antagonist that releases nitric oxide (NO) through incompletely characterized mechanisms. We identified endothelial beta3-adrenoreceptors in human coronary microarteries that mediate endothelium- and NO-dependent relaxation and hypothesized that nebivolol activates these beta3-adrenoreceptors., Methods and Results: Nebivolol dose-dependently relaxed rodent coronary resistance microarteries studied by videomicroscopy (10 micromol/L, -86+/-6% of prostaglandin F2alpha contraction); this was sensitive to NO synthase (NOS) inhibition, unaffected by the beta(1-2)-blocker nadolol, and prevented by the beta(1-2-3)-blocker bupranolol (P<0.05; n=3 to 8). Importantly, nebivolol failed to relax microarteries from beta3-adrenoreceptor-deficient mice. Nebivolol (10 micromol/L) also relaxed human coronary microvessels (-71+/-5% of KCl contraction); this was dependent on a functional endothelium and NO synthase but insensitive to beta(1-2)-blockade (all P<0.05). In a mouse aortic ring assay of neoangiogenesis, nebivolol induced neocapillary tube formation in rings from wild-type but not beta3-adrenoreceptor- or endothelial NOS-deficient mice. In cultured endothelial cells, 10 micromol/L nebivolol increased NO release by 200% as measured by electron paramagnetic spin trapping, which was also reversed by NOS inhibition. In parallel, endothelial NOS was dephosphorylated on threonine(495), and fura-2 calcium fluorescence increased by 91.8+/-23.7%; this effect was unaffected by beta(1-2)-blockade but abrogated by beta(1-2-3)-blockade (all P<0.05)., Conclusions: Nebivolol dilates human and rodent coronary resistance microarteries through an agonist effect on endothelial beta3-adrenoreceptors to release NO and promote neoangiogenesis. These properties may prove particularly beneficial for the treatment of ischemic and cardiac failure diseases through preservation of coronary reserve.

Purpose of Review: Patients with aortic root pathology may benefit from 'valve-conservation' surgery although application of this philosophy is limited by a lack of 'standardized' surgical techniques. A functional classification of aortic root and valvular abnormalities has been developed in 260 patients and correlated with the etiology of the pathologic process and the surgical procedure performed. Early outcome was assessed using hospital records and medium-term follow-up by cardiological review., Recent Findings: From January 1995 until March 2001, 260 patients were operated on for aortic root pathology using valve-conserving surgical techniques. Hospital mortality was 2%; intra-operative echocardiography showed residual aortic regurgitation (Grade 1-2) in 11%, none in the remaining patients. Follow-up at a mean of 20 months (87% of patients) showed trivial or Grade 1 aortic regurgitation in 80%., Summary: Application of a simple functional classification for aortic root pathology and aortic valve disease allows the logical application of 'valve-conserving' surgical procedures with excellent early and medium-term results.

Background: Neurologic complication is an adverse event associated with mechanical circulatory support. To decrease the incidence of embolic cerebrovascular accidents (CVA) during support with the Novacor left ventricular assist system (LVAS), an expanded polytetrafluoroethylene (ePTFE) inflow conduit has been developed and introduced clinically., Methods: Using clinical data from Europe and Canada, we conducted a retrospective analysis of the incidence of embolic CVA with the ePTFE inflow conduit (n=88) in comparison with the previously used polyester inflow conduits (n=310, including Vascutek n=155 and Cooley n=155). We calculated freedom from embolic CVA, risk reduction for embolic CVA, and linearized rates of embolic CVA., Results: A significant decrease in the incidence of embolic CVA was demonstrated with the ePTFE conduit (ePTFE 10% vs polyester 23%, p=0.002). Kaplan-Meier analysis of freedom from embolic CVA at 180 days after implantation was 86% for the ePTFE group vs 72% for the polyester group (log-rank test, 0.0185). We also found an associated risk reduction of 55% in CVA occurrence in the ePTFE group when compared with the Polyester group (hazard ratio, 0.445; 95% confidence limit, 0.222-0.890; p=0.0221). Linearized CVA rates also were decreased at all time intervals after implantation in the ePTFE group., Conclusions: Preliminary clinical results with the newly introduced ePTFE inflow conduit provide compelling evidence that the ePTFE conduit material significantly decreases thromboembolic complications during mechanical circulatory support with the Novacor LVAS.

Objectives: In regurgitant tricuspid aortic valves, cusp prolapse may be isolated or associated with dilatation of the proximal aorta. Newly appearing cusp prolapse can also appear after an aortic valve sparing operation (AVSO) and be responsible for residual aortic regurgitation. In this report, we describe our experience in repairing prolapsing aortic cusps in 44 patients with aortic regurgitation., Methods: Between 1996 and 2003, 260 patients had aortic valve repair or valve sparing procedures in our department. All patients had peri-operative TEE. Prolapse of one or more of the aortic cusps was identified by TEE and confirmed by careful surgical inspection before and after valve sparing surgery. Forty-four patients with cusp prolapse were identified. Fifteen had an isolated prolapse, with a normal root (group I), 18 had cusp prolapse associated with dilatation of the proximal aorta (group IIa), and 11 had a newly appearing prolapse after AVSO (group IIb). Correction of the prolapsing cusp was achieved by either free edge plication, triangular resection or resuspension with PTFE. This procedure was associated with an aortic annuloplasty in group I, and with AVSO in groups II and III., Results: Post-operative TEE showed AR trivial or grade I regurgitation. At a mean of 23 months follow-up, one patient with recurrent regurgitation required an aortic valve replacement with a homograft. All remaining patients were in NYHA class I or II. Echocardiography confirmed the durability of the valve repair., Conclusions: Among the common causes of aortic regurgitation, isolated cusp prolapse is frequent and is amenable to surgical repair with excellent mid-term results. In particular, in patents who are potential candidates for AVSO, identification and correction of an associated prolapse, either pre-existing or secondary to the AVSO procedure, may further extend the indications for this technique, increase its success rates and improve its long-term outcome.

Background: Coronary vessel tone is modulated in part by beta-adrenergic relaxation. However, the implication of specific beta-adrenoceptor subtypes and their downstream vasorelaxing mechanism(s) in human coronary resistance arteries is poorly defined. beta3-Adrenoceptors were recently shown to vasodilate animal vessels and are expressed in human hearts., Methods and Results: We examined the expression and functional role of beta3-adrenoceptors in human coronary microarteries and their coupling to vasodilating nitric oxide (NO) and/or hyperpolarization mechanisms. The expression of beta3-adrenoceptor mRNA and protein was demonstrated in extracts of human coronary microarteries. Immunohistochemical analysis revealed their exclusive localization in the endothelium, with no staining of vascular smooth muscle. In contractility experiments in which videomicroscopy was used, the nonspecific beta-agonist isoproterenol and the beta3-preferential agonist BRL37344 evoked an approximately 50% relaxation of endothelin-1-preconstricted human coronary microarteries. Relaxations were blocked by the beta1/beta2/beta3-adrenoceptor antagonist bupranolol but were insensitive to the beta1/beta2-adrenoceptor antagonist nadolol, confirming a beta3-adrenoceptor-mediated pathway. Relaxation in response to BRL37344 was absent in human coronary microarteries devoid of functional endothelium. When human coronary microarteries were precontracted with KCl (thereby preventing vessel hyperpolarization), the relaxation to BRL37344 was reduced to 15.5% and totally abrogated by the NO synthase inhibitor L-omega-nitroarginine, confirming the participation of a NO synthase-mediated relaxation. The NO synthase-independent relaxation was completely inhibited by the Ca2+-activated K+ channel inhibitors apamin and charybdotoxin, consistent with an additional endothelium-derived hyperpolarizing factor-like response. Accordingly, membrane potential recordings demonstrated vessel hyperpolarization in response to beta3-adrenoceptor stimulation., Conclusions: Beta3-adrenoceptors are expressed in the endothelium of human coronary resistance arteries and mediate adrenergic vasodilatation through both NO and vessel hyperpolarization.

Background and Aim of the Study: Right ventricular dilatation observed after tetralogy of Fallot repair regresses after pulmonary valve implantation, unless the dilation is too severe. The presence of an akinetic patch in the right ventricular outflow tract (RVOT), a known factor promoting right ventricular dilatation, may prevent right ventricular recovery after valve implantation. The exclusion of a large akinetic RVOT area during reoperation of patients presenting with severe post-repair right ventricular dilatation was investigated., Methods: Eight patients underwent a pulmonary infundibuloplasty between May 2000 and October 2002. Their mean preoperative cardothoracic index was 0.66 +/- 0.08, and preoperative NYHA class II (n = 4), III (n = 3) or IV (n = 1). Three patients were offered heart transplantation but refused. All had severe pulmonary regurgitation and underwent a RVOT valve implantation except one patient who had a previous homograft pulmonary valve insertion. Concomitant procedures were tricuspid ring implantation (n = 3), atrial septal defect closure (n = 2), mitral valve repair (n = 1) and modified right atrial Maze (n = 1)., Results: Median follow up time was 13 months (range: 6 -29 months). One patient suffered a fatal ventricular fibrillation at home. All patients but one were in NYHA class I. After a mean of 5 +/- 3 months, their mean workload capacity rose from 115 +/- 19 W to 155 +/- 62 W, and mean VO2max rose from 16.5 +/- 2 to 18.3 +/- 2 ml/min/kg., Conclusion: Pulmonary infundibuloplasty may be a useful adjunct in reoperation of tetralogy of Fallot patients presenting with severe right ventricular dilatation and large akinetic area of the RVOT.

Cardiac surgery in Belgium has reached since many years a high quality level and improves continuously. In mitral valve surgery, repair of the valve has been substituted to its replacement. Repair is now the standard operation for degenerative pathology. Long-term results are well established and indications standardised. In aortic valve surgery, prolapse of a leaflet, dilatation of the sinotubular junction, aneurysm of the sinus of Valsalva are now repaired with very good results. When the valve is unrepairable, a wide choice of available homograft, stentless valve or aortic root allows the most adequate operation. In coronary artery bypass graft (CABG), arterial grafts are increasingly used over the least years because of their higher long-term patency rates. Off-pump coronary bypass, that is CABG on the beating heart, is more and more frequently performed from 2.4% in 1998 to 17.9% of the cases in 2000. The development of mechanical circulatory support, also called "artificial heart" is encouraging but still far from perfect. During the 2 last years, 31 devices were implanted in Belgium. Twenty patients were either successfully transplanted or weaned from the pump and returned to their home. Cardiac surgery in Belgium is still developing and remains of high quality thanks to the continuous introduction of new therapeutic approaches and to the close collaboration between intensivists, anaesthesiologists, perfusionists and cardiologists. As a result, patients benefit today from the best therapeutic modalities.

A 60-year-old patient developed an acute type A aortic dissection in the postoperative course of a Novacor left ventricular assist device. We performed a resection of the ascending aorta with an aortic valve patch closure, end-to-end anastomosis of the outflow graft to the distal ascending aorta and two venous grafts to the coronary arteries, in order to avoid residual aortic insufficiency and bleeding related to exposure of the fragilized tissues to high pressures.

Because of their rich blood supply and of their original detersive and filling properties, the muscular pedicled flaps harvested from the trunk or the omental flap elevated from the abdomen may be very usefull to treat large defects or major septic problems in pleural, pericardic or mediastinal cavities. We here describe the main principles to be followed in such intrathoracic reconstructions performed in order to control severe mediastinites, aortic prosthetic infections, pleural empyemas and broncho-pleural, tracheo-esophageal or broncho-esophageal fistulas. In all these circumstances, the muscular or omental flaps which are transferred into the chest are selected according to the recipient field and to their respective access to the upper, middle and lower portions of the pleural space or mediastinum. Twelve different flaps so appear available to achieve the adequate reconstruction, filling or coverage of nine distinct topographic sites. Their rational use, based on various anatomical guidelines, allows to prevent or to cure efficiently 90% of the infectious or fistular complications frequently observed in the postoperative course of aggressive, functional or oncological, intrathoracic surgical procedures.

A 72-yr-old man was electively admitted for cardiac revascularisation 6 weeks after an inaugural inferior infarct. His physical examination and laboratory test were unremarkable. According to his coronarography the patient was programmed for an off pump coronary artery by-pass. During surgery the heart was found to be completely herniated in the left chest, passing on the posterior aspect of the phrenic nerve. Symptomatology and complications of congenital pericardial defects are reviewed.

Background: Non randomized studies suggest that mitral valve repair for rheumatic disease is technically more difficult than repair for degenerative disease, and that operative and late results are worse. New surgical techniques have been developed in our and other institutes during the last 5 years, and this moved us to review the experience with these two pathologies and to compare the operative and mid-term, Methods: From March 1996 to September 1997, 66 patients underwent primary mitral valve repair for treatment of degenerative or rheumatic disease. Fifty-two patients (79%) were in the former group (group A) and 14 in the latter (group B). Surgery was performed by 2 experienced cardiac surgeons. A new technique to calculate the exact artificial chordae length was introduced. In 2 cases, tricuspid autografts were transposed to mitral position and reinforced with artificial chordae. Patients were followed both clinically and echocardiographically. The follow-up data were collected in a 1-month period (May 2000). The average clinical follow-up was 3.1+/-0.9 years (range 1.7 to 4.2 years) while the average echocardiographic follow-up was 2.7+/-0.7 years (range 9 months to 4 years). All values were expressed by means of the average and standard deviation. chi(2) and Student's "t"-test were used to analyze the significance between variables. The Kaplan-Meyer method was used for actuarial statistics., Results: There were no operative deaths in either group. In group A, 1 patient underwent a second surgical repair 1 week later, successfully. In group B no patients underwent reoperation within 30 days or during the initial hospitalization. At follow-up of group A there were the following events: deaths from cancer (n=2), endocarditis (n=1), aortic dissection (n=1). At follow-up of group B there were mitral valve replacement (1 year after first operation, n=1), Ross procedure (n=1), ischemic heart failure (n=1). Among the remaining 62 patients followed, 32 were in NYHA class I, 15 in class II, 3 in class III, and none in class IV, in group A. In group B, 7 patients were in class I, 4 in class II, 1 in class III and none in class IV (p=ns). In group A mitral regurgitation was absent in 23 patients, mild in 21, moderate in 6, while in group B it was absent in 4, mild in 6, and moderate in 2 (p=ns). In both groups there were no cases of severe insufficiency. The mean gradient was 1.1+/-1.7 mmHg in group A (median=0), and 2.4+/-3.1 mmHg in group B (median=0), (p=ns). No case of systolic anterior movement was seen at mid-term. The event free-survival rate was 92.8% in group A and 92.3% in B., Conclusions: Perfecting and innovation of surgical techniques make possible nowadays to reach good and equivalent operative and mid-term results in both pathologies.

Quantification of mRNAs from extremely small human samples remains a challenge. Requiring minimal amounts of tissue and no post-reaction manipulation, real-time reverse transcriptase-polymerase chain reaction (RT-PCR) is an attractive method to quantitatively assess the expression of rare mRNAs. We evaluated the applicability of the technique on RNA extracted from human endomyocardial biopsies and isolated cardiomyocytes, and compared the technique to the RT-competitive PCR approach. Primers and probes were designed to amplify the three subtypes of human beta -adrenoceptors (beta1-, beta2- and beta3 AR), as well as reference genes such as glyceraldehyde-3-phosphate dehydrogenase (GAPDH), Hypoxanthine-guanine phosphoribosyltransferase (HPRT), and the oncogene ABL by real-time RT-PCR. Specific primers and a deleted competitor were synthetized to compare the quantitation of the beta 3 AR mRNA expression by RT-competitive PCR. We validated the technique on human cardiomyocytes either freshly isolated or selectively excised from fixed sections of human myocardium by Laser Capture Microdissection. The standard curves obtained for the cDNA's analysed showed mean slopes comprised between -3.3 and -3.7. Inter- and intra-assay variability of gene quantitation was reflected by mean values of the variance coefficients of Ct of 4.84+/-1.13% and 2.73+/-0.39% or 3.32+/-1.03% and 2.21+/-0.24% (corresponding to percent variances of copy numbers of 83.07+/-12.72% and 34.45+/-9.03% or 47.40+/-8.59% and 23.83+/-3.16%) for human beta3 AR and GAPDH genes, respectively. The expression of GAPDH, HPRT and ABL mRNA was characterized by a very low dispersion of individual values across cardiac pathologies, suggesting that these genes may be used as reference genes in quantitative PCR studies. Finally, we applied the technique to detect rare mRNAs, such as beta -AR mRNAs, from small human endomyocardial biopsies and even isolated cardiomyocytes. Real-time RT-PCR is appropriate to quantitate rare messenger RNAs, including in extremely small human tissue samples. This method appears very promising for futures studies of gene expression in several pathophysiological conditions, including heart failure., (Copyright 2000 Academic Press.)

Objective: To evaluate the influence of perfusion temperature on the systemic effects of cardiopulmonary bypass (CPB), including extravascular lung water index (EVLWI), and serum cytokines., Design: Prospective, randomized, controlled study., Setting: Cardiothoracic intensive care unit of a university hospital., Patients: Patients undergoing elective coronary artery bypass grafting., Interventions: Twenty-one patients undergoing elective coronary artery bypass grafting were randomly assigned to receive either normothermic bypass (36 degrees C, n = 8) with intermittent antegrade warm blood cardioplegia (IAWBC), or hypothermic (32 degrees C, n = 13) CPB with cold crystalloid cardioplegia., Measurements and Main Results: Mean arterial pressure, heart rate, cardiac output, systemic vascular resistance, mean pulmonary arterial pressure, and pulmonary vascular resistance were determined at baseline, i.e., after induction of anesthesia but before sternal opening (T-1), at arrival in the intensive care unit (T0), and 4 hrs (T4), 8 hrs (T8), and 24 hrs (T24) after surgery. EVLWI, intrathoracic blood volume index (ITBVI), and EVLW/ITBV ratio were obtained by using thermal dye dilution utilizing an arterial thermistor-tipped fiberoptic catheter and were recorded at T-1, T0, T4, T8, and T24. Serial blood samples for cytokine measurements were obtained at each hemodynamic measurement time point. Before, during, and after CPB, there were no differences in the conventional hemodynamic measurements between the groups. There were no changes in EVLWI up to T8 in either group. Furthermore, no change in the ratio EVLW/ITBW was observed between the groups at any time, further indicating the absence of a change in pulmonary permeability. Plasma levels of interleukin-6, tumor necrosis factor-alpha, and interleukin-10 increased during and after CPB, independently of the perfusion temperature., Conclusion: Normothermic CPB is not associated with additional inflammatory and related systemic adverse effects regarding cytokine production and EVLWI as compared with mild hypothermia. The potential temperature-dependent release of cytokines and subsequent inflammation has not been observed and normothermic CPB may be seen as a safe technique regarding this issue.

Objective: Recently we reviewed the 10-year clinical and angiographic outcomes of sequential internal thoracic artery grafting. Most of the patients also received complementary saphenous grafts, and their overall long-term patency rates were surprisingly high. Therefore, we decided to analyze these results in more detail., Methods: The first consecutive 500 patients having received at least one sequential internal thoracic artery graft between October 1985 and August 1991 were restudied retrospectively. The saphenous grafts were only used to achieve complete revascularization in addition to complex arterial grafting on less significant or remote coronary vessels. A total of 161 patients consented to a late angiographic restudy at a mean postoperative interval of 7.5 years (1-12.2 years)., Results: At 5 and 10 years postoperatively, freedom from angina was 96% and 82%, and freedom from any cardiac event was 92.8% and 69%, respectively. Only 15 (3.1%) patients needed additional revascularization (0.3% per patient-year): 4 coronary artery bypass grafting (0.8%) and 11 percutaneous transluminal coronary angioplasty (2.3%). The overall patency and intactness rates of saphenous anastomoses were 72.5% and 60.2%, respectively. There was a significant difference between the patency and intactness of sequential versus single anastomoses: 76% versus 60% and 64.5% versus 44.4%, respectively. There was no significant difference in either patency or intactness between right internal thoracic and sequential saphenous grafts anastomosed to the right coronary artery: 83.4% versus 75.2% and 77.8% versus 62.4%, respectively. The same was true for the anastomoses to the "remote area" (distal circumflex, distal right coronary artery)., Conclusions: Complementary sequential saphenous grafting still deserves consideration in some patients below 70 years of age, particularly for those with disease in the "remote area": the distal circumflex and right coronary branches.

Non-specific interstitial pneumonia is characterized pathologically by uniform interstitial inflammation and fibrosis. This disease is most commonly demonstrated on high resolution CT as subpleural ground-glass opacity mixed with irregular linear opacities. The authors report a case of non-specific interstitial pneumonia with high resolution findings consistent with a "crazy paving pattern". This appearance, represented by smoothly thickened interlobular septa with a background of geographic areas of ground-glass opacity, is unusual for non-specific interstitial pneumonia and was indistinguishable from other interstitial or alveolar lung diseases.

Background and Aim of the Study: Coverage of large commissural defects may present a surgical challenge in mitral valve repair, for which the transfer of posterior tricuspid valve leaflet tissue is an attractive approach., Methods: Five patients aged between 35 and 55 years underwent this procedure. After wide excision of the diseased mitral commissures, the posterior leaflet of the tricuspid valve was carefully checked, removed with its subvalvular apparatus, and transferred to the commissural area of the mitral valve. The stress on the papillary muscle suture was relieved by reinforcement of the free edge of the transferred leaflet by natural or artificial chordae. The tricuspid valve was repaired using either a sliding plasty or an annuloplasty., Results: One patient who had no reinforcement of the subvalvular apparatus had a papillary muscle rupture and required mitral valve replacement during the early postoperative period. The four remaining patients remained asymptomatic and had no or trivial mitral regurgitation after a median of 13 months (range: 3-18 months), with excellent result at transesophageal echocardiography., Conclusion: We conclude that transfer of the tricuspid valve leaflet allows coverage of large commissural defect, and deserves a place among the surgeon's arsenal of reconstructive techniques for mitral valve repair.

Background and Aim of the Study: Repair of the prolapsing anterior leaflet (AML) in degenerative mitral valve disease is more demanding than that of the posterior leaflet. We reviewed our experience in the past eight years, to examine the safety, efficacy and stability of various repair artifices., Methods: Between January 1989 and December 1997, 102 patients (mean age 64 years; range: 26-86 years) with mitral regurgitation (MR) due to prolapse of the anterior or both mitral leaflets underwent mitral valve repair. Sixty-six patients were in NYHA class > or =III, and 94 had MR grade >II. Acute endocarditis was present in 12 patients and Barlow disease in 16. Surgical techniques consisted of chordal shortening (n = 36), chordal transposition (n = 16), papillary muscle shortening or plication (n = 10), flip-over (n = 20) and artificial chordae implantation (n = 20)., Results: There was no early mortality; one patient required early mitral valve replacement (MVR) for late-appearing systolic anterior motion, and one patient benefited from a successful re-repair on day 8 for partial posterior leaflet desinsertion. Mean follow up was 30 months (range: 3-92 months); there were four late deaths (two valve-related cerebrovascular accidents); two patients required re-repair (one after three months for prosthetic ring thrombosis, and one after 10 months for rupture of shortened chordae (corrected by flip-over)). Five patients had MVR between four and 32 months later: one for mitral stenosis due to posterior leaflet calcification, and four for recurrent MR due to the rupture of shortened chordae (n = 3) or plicated papillary muscle (n = 1). One patient suffered bacterial endocarditis which was treated medically. Of the 92 remaining patients with valve repair, 81 are currently asymptomatic, five are in NYHA class II and four in class III. Transesophageal echocardiographic restudy (n = 76) at a mean of 30 months after surgery revealed no MR in 68 patients, and MR of grade

Background: To overcome problems of lack of conduit and to maximize the number of arterial anastomoses in coronary reoperations we reused previously placed arterial grafts., Methods: Sixteen patients were identified from February 1994 to July 1997. Mean age was 62.8 years (range, 44 to 75 years). Fifteen (94%) were in Canadian Cardiovascular Society angina class III or IV. The mean interval from primary to secondary operation was 8.5 years (range, 3 to 12 years). Eleven patients had a patent internal mammary artery graft used as the recipient for a proximal Y anastomosis. In 3 cases an arterial graft was reimplanted distally on the same coronary vessel and in 2 onto different coronary vessels. One patient had a combination of these techniques. Five patients required venous conduit., Results: There were no deaths. Mean length of intensive care stay was 69 hours (range, 24 to 144) and mean hospital stay was 14 days (range, 10 to 28 days). All patients were discharged home. Follow-up averages 13 months (range, 2 to 43 months). Twelve patients (75%) are now in Canadian Cardiovascular Society angina class I and 3 (19%) in class II., Conclusions: Reusing arterial conduits during coronary reoperations is possible with minimal in-hospital morbidity and satisfactory results in terms of freedom from angina. Using these techniques can help overcome the problems of inadequate conduit and maximize the number of arterial anastomoses that can be made per patient.

Aim: Median nerve somatosensory evoked potentials (SEP) monitoring performed in deep hypothermic circulatory arrest is useful in determining when brain cooling may sufficiently permit circulatory arrest, and to immediately indicate when brain injury occurs. The aim of this retrospective study, including 58 patients, is to determine SEP sensitivity, specificity and impact on the surgical strategy., Method: Sensitivity was determined on patients presenting new neurological complications. Specificity was measured on the patients without any new neurological defect. The impact of intraoperative SEP on the surgical strategy was determined when the occurrence of SEP alterations had provoked a modification of the surgical procedure., Results: Five patients died intraoperatively due to non-neurological complications. Fourteen patients presented new neurological complications. SEP sensitivity reaches 64.3% when all the complications are included, but increases to 100% in our series if late postoperative complications, paraplegia and tibial posterior nerve lesion are excluded because median nerve SEP are not able to detect such complications. SEP monitoring was uneventful in the 39 patients whose did not present neurological complication: thus SEP specificity is absolute in our series. SEP had an impact on the surgical procedure whenever neurological complications due to hemodynamic disturbances occurred., Conclusion: This retrospective study shows the interest of intraoperative SEP as an useful tool for promptly identifying and preventing the neurological complication of hypothermic circulatory arrest.

Background: Combined heart-kidney transplantation has become a new therapeutic solution for patients with coexisting, irreversible heart and kidney failure. Though this combined approach has several theoretical advantages over sequential transplantation, it has yet to be established that it does not jeopardize patient and graft outcomes. We here report our experience with six cases of combined heart-kidney transplantation from single donors and review the literature in order to clarify this issue., Methods: Four patients were kidney-transplant candidates with severe heart failure and two were heart-transplant candidates with independent chronic renal failure. Donors were selected on the basis of weight and size matching, ABO compatibility, and negative T-cell cross-match., Results: The heart was always grafted first. The surgical procedure was uneventful in all cases. Heart and kidney function recovered quickly in all patients. Two patients died, one at day 45 from heart subacute rejection and the other one at day 157 from cerebral haemorrhage. The four remaining patients are alive 23-84 months after transplantation (2-year survival rate: 67%) and have well-functioning kidneys (creatinine clearance 31-83 ml/min) and hearts (left ventricular ejection fraction 53-83%). Remarkably, four of six patients had no acute rejection episode of either organ. These patient and graft outcomes are in agreement with previous reports and compare favourably with the results of isolated heart and kidney transplantation., Conclusions: Combined heart-kidney transplantation from the same donor should be proposed to patients who would qualify for transplantation of each organ within a few years.