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Background: Secondary mitral regurgitation (SMR) is generally reduced after isolated aortic valve replacement (AVR), but there is important interindividual variability in the magnitude of this reduction. Prosthesis-patient mismatch (PPM) may hinder normalization of left ventricular geometry and pressure overload following AVR, therefore we aimed to investigate the relationship between PPM and regression of SMR following AVR for aortic valve stenosis., Methods and Results: A total of 419 patients with AS who underwent isolated AVR at 2 institutions and presenting moderate SMR (mitral regurgitant volume 30 to 45 mL/beat) not considered for surgical correction were included in this study. Clinical and echocardiographic follow-up were completed at a median follow-up time of 37 months. PPM was defined as an indexed effective orifice area ≤0.85 cm(2)/m(2) and was found in 170/419 patients (40.6%). There were no significant differences in baseline and operative characteristics between patients with or without PPM. Patients with PPM had less regression of SMR following AVR compared with those with no PPM (change in mitral regurgitant volume: -11±4 versus -17±5 mL, respectively; P<0.0001). Variables significantly associated with postoperative change in mitral regurgitant volume on univariable analysis were entered in a multivariable linear regression model, which showed indexed effective orifice area (P<0.0001) and left atrial diameter (P=0.006) to be independently associated with mitral regurgitant volume improvement. Patients with PPM also had less postoperative improvement in 6-minute walking test distance (80±78 versus 42±41 m, P<0.0001)., Conclusions: PPM is associated with lesser regression of SMR following AVR. This unfavorable effect was associated with worse functional capacity. These findings emphasize the importance of operative strategies aiming to prevent PPM in patients with aortic valve stenosis and concomitant SMR.

We study behavioral action sequences of players in a massive multiplayer online game. In their virtual life players use eight basic actions which allow them to interact with each other. These actions are communication, trade, establishing or breaking friendships and enmities, attack, and punishment. We measure the probabilities for these actions conditional on previous taken and received actions and find a dramatic increase of negative behavior immediately after receiving negative actions. Similarly, positive behavior is intensified by receiving positive actions. We observe a tendency towards antipersistence in communication sequences. Classifying actions as positive (good) and negative (bad) allows us to define binary 'world lines' of lives of individuals. Positive and negative actions are persistent and occur in clusters, indicated by large scaling exponents α ~ 0.87 of the mean square displacement of the world lines. For all eight action types we find strong signs for high levels of repetitiveness, especially for negative actions. We partition behavioral sequences into segments of length n (behavioral 'words' and 'motifs') and study their statistical properties. We find two approximate power laws in the word ranking distribution, one with an exponent of κ ~ -1 for the ranks up to 100, and another with a lower exponent for higher ranks. The Shannon n-tuple redundancy yields large values and increases in terms of word length, further underscoring the non-trivial statistical properties of behavioral sequences. On the collective, societal level the timeseries of particular actions per day can be understood by a simple mean-reverting log-normal model.

Despite the recent availability of large data sets on human movements, a full understanding of the rules governing motion within social systems is still missing, due to incomplete information on the socio-economic factors and to often limited spatio-temporal resolutions. Here we study an entire society of individuals, the players of an online-game, with complete information on their movements in a network-shaped universe and on their social and economic interactions. Such a "socio-economic laboratory" allows to unveil the intricate interplay of spatial constraints, social and economic factors, and patterns of mobility. We find that the motion of individuals is not only constrained by physical distances, but also strongly shaped by the presence of socio-economic areas. These regions can be recovered perfectly by community detection methods solely based on the measured human dynamics. Moreover, we uncover that long-term memory in the time-order of visited locations is the essential ingredient for modeling the trajectories.

We herein describe a simple and safe technique to avoid compartment syndrome/arm ischemia during direct right axillary artery cannulation, especially in patients who require long-term extracorporeal membrane oxygenation support., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Whether statins can improve postoperative outcome in patients without coronary artery disease undergoing heart valve operations was assessed., Methods: Data for 3,217 patients undergoing isolated valve procedures at 2 institutions between May 2003 and May 2009 were reviewed. Clinical follow-up was completed. Two propensity-matched cohorts of 1,104 patients each were identified. Multivariable regression and Kaplan-Meyer survival analysis were performed to investigate risk factors correlated with death, stroke, myocardial infarction, and cardiac arrhythmias., Results: The overall 30-day mortality rate was 2.7%, and 2,096 of 2,149 hospital survivors were alive at a median follow-up of 27 months. Preoperative statin treatment was independently associated with a significant reduction in the risk of hospital death (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.32 to 0.89; p=0.001), postoperative cardiac arrhythmias (OR, 0.76; 95% CI, 0.62 to 0.93; p<0.006), and stroke (OR, 0.54; 95% CI, 0.32 to 0.92; p=0.02) but was not independently associated with a reduced risk of postoperative myocardial infarction. At follow-up, Kaplan-Meyer survival analysis showed statistically significant lower rates of mortality (χ2, 4.41; hazard ratio [HR], 1.59; 95% CI, 1.13 to 2.27; p=0.03), stroke (χ2, 11.42; HR, 2.15; 95% CI, 1.37 to 3.27; p=0.0007), cardiac arrhythmias (χ2, 19.9; HR, 2.13; 95% CI, 1.81 to 2.72; p<0.0001), and major adverse cardiac and cerebrovascular events (χ2, 3.74; HR, 1.37; 95% CI, 0.99 to 1.74; p=0.05) in patients receiving statin treatment. No statistically significant difference was found between groups in myocardial infarction incidence at follow-up., Conclusions: Statin therapy is associated with a lower rate of adverse cardiovascular events after isolated heart valve operations., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Despite the robust evidence of the potential benefits of n-3 polyunsaturated fatty acid (PUFA) supplementation in patients with established coronary artery disease, the impact of this therapy on patients after coronary artery bypass grafting remains completely unknown., Methods: Among 2,100 patients undergoing isolated coronary artery bypass grafting in one tertiary care institution, 930 (44%) were put under n-3 PUFA therapy chronically at discharge. The impact of n-3 PUFAs was assessed by means of propensity-score adjusted analysis. The primary end point was all-cause mortality. Secondary end points were repeat revascularization and the composite of death, Q-wave myocardial infarction, and cerebrovascular events., Results: In a crude analysis, patients discharged on n-3 PUFAs had a lower risk for late mortality (unadjusted hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.36 to 0.73; p = 0.0002), which was conformed at multivariable adjusted Cox regression analysis (HR, 0.55; 95% CI, 0.26 to 0.90; p = 0.02). Adjusted risk of repeat revascularization was significantly lower in patients receiving n-3 PUFAs than in those who did not (HR, 0.52; 95% CI, 0.28 to 0.97; p = 0.04). The adjusted risk for the composite of death, Q-wave myocardial infarction, or cerebrovascular events was lower in patients who received n-3 PUFAs compared with patients who did not (HR, 0.56; 95% CI, 0.36 to 0.81; p = 0.001). Subgroup analyses showed that mortality benefit associated with n-3 PUFAs was particularly relevant in patients with poor left ventricular function (HR, 0.36; 95% CI, 0.17 to 0.76; p = 0.007), but it was only marginal in patients with good ventricular function (HR, 0.89; 95% CI, 0.65 to 1.01; p = 0.05)., Conclusions: This study showed that n-3 PUFAs after coronary artery bypass grafting were associated with a lower risk for repeat revascularization and overall mortality in patients with poor ventricular function., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Maximization of the entropy rate is an important issue to design diffusion processes aiming at a well-mixed state. We demonstrate that it is possible to construct maximal-entropy random walks with only local information on the graph structure. In particular, we show that an almost maximal-entropy random walk is obtained when the step probabilities are proportional to a power of the degree of the target node, with an exponent α that depends on the degree-degree correlations and is equal to 1 in uncorrelated graphs.

Background: Patients with prosthesis-patient mismatch (PPM) continue to show some degrees of left ventricular hypertrophy after aortic valve replacement for aortic stenosis. The renin-angiotensin system plays a major role in promoting and sustaining hypertrophy. In a controlled, randomized study, we tested the hypothesis that the combination of angiotensin-converting enzyme inhibitors (ACEi) plus angiotensin II receptor blocker (ARB) can be more effective in decreasing hypertrophy than a largely employed association such as ACEi plus ß-blockers in PPM patients., Methods: We enrolled a total of 72 patients with aortic valve replacement and evidence of PPM (effective orifice area <0.85 cm(2)/m(2)) at postoperative echocardiography. At discharge, they were randomly assigned to ramipril plus candesartan (n = 36) or ramipril plus metoprolol (n = 36)., Results: At baseline, age, 24-hour blood pressure, left ventricular measurements, and transprosthetic gradients were similar between the two groups. After 12 months, the extent of 24-hour systolic and diastolic blood pressure decrease was similar between the two groups (-13.3% and 16.3% versus -12.3% and 15.8%, respectively; p = 0.7 and 0.8, respectively). Left ventricular mass index significantly decreased in both groups (ACEi plus ARB 165 ± 19 g/m(2) to 117 ± 17 g/m(2); p < 0.0001; ACEi plus β-blockers 161 ± 15 g/m(2) to 128 ± 20 g/m(2); p < 0.0001). However, patients receiving ACEi plus ARB had a higher decrease of left ventricular mass (-46 ± 15 g/m(2) versus -35 ± 12 g/m(2); p = 0.001) and a lower rate of residual left ventricular hypertrophy (22% versus 47%; p = 0.04)., Conclusions: This study shows that in patients with PPM, the association ACEi and ARB has a greater antiremodeling effect compared with ACEi and β-blockers, and is independent of blood pressure., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Understanding the neural mechanisms responsible for human social interactions is difficult, since the brain activities of two or more individuals have to be examined simultaneously and correlated with the observed social patterns. We introduce the concept of hyper-brain network, a connectivity pattern representing at once the information flow among the cortical regions of a single brain as well as the relations among the areas of two distinct brains. Graph analysis of hyper-brain networks constructed from the EEG scanning of 26 couples of individuals playing the Iterated Prisoner's Dilemma reveals the possibility to predict non-cooperative interactions during the decision-making phase. The hyper-brain networks of two-defector couples have significantly less inter-brain links and overall higher modularity--i.e., the tendency to form two separate subgraphs--than couples playing cooperative or tit-for-tat strategies. The decision to defect can be "read" in advance by evaluating the changes of connectivity pattern in the hyper-brain network.

Context: Intense acute pain afflicts millions of patients each year. Despite the recently increased focus on the importance of pain control, management of acute pain has remained suboptimal., Objective: The objective of this study was to identify through a review of recent literature the barriers to effective treatment of acute pain and the potential consequences of inadequate pain management., Design: A comprehensive literature review was conducted to identify articles relevant to the management of acute pain. Information regarding the underlying causes of inadequate pain management, as well as the sequelae associated with undermanaged pain was extracted and summarized., Results: Studies indicate that treatment of acute pain remains suboptimal due to attitudes and educational barriers on the part of both physicians and patients, as well as the intrinsic limitations of available therapies. Inadequate management of acute pain negatively impacts numerous aspects of patient health, and may increase the risk of developing chronic pain. Although opioids are the preferred treatment for most moderate to severe acute pain, their side effects can impede their use, and thus, their clinical effectiveness. Analgesic regimens with an improved efficacy/tolerability balance have the potential to improve acute pain management, and thus reduce the incidence of chronic pain. Studies examining the use of multiple analgesics with different mechanisms of action suggest that multimodal therapies may offer an improved efficacy/tolerability balance over single agent regimens., Conclusions: There exists a significant need for effective, well-tolerated analgesic therapies to limit the negative consequences of undermanaged acute pain. The use of multimodal therapy has demonstrated increasing promise and is supported by current practice guidelines., (Wiley Periodicals, Inc.)

We introduce a method to convert an ensemble of sequences of symbols into a weighted directed network whose nodes are motifs, while the directed links and their weights are defined from statistically significant co-occurences of two motifs in the same sequence. The analysis of communities of networks of motifs is shown to be able to correlate sequences with functions in the human proteome database, to detect hot topics from online social dialogs, to characterize trajectories of dynamical systems, and it might find other useful applications to process large amounts of data in various fields.

Objective: In clinical situations in which rhabdomyolysis is common, renal dysfunction association with myoglobinemia is well described. After coronary artery bypass grafting, a rapid increase in serum myoglobin concentration is generally seen, but whether it might independently increase the risk of acute kidney injury remains to be determined., Methods: The study population consisted of 731 consecutive patients undergoing coronary artery bypass grafting. Creatine kinase, myoglobin, and creatinine concentrations were assessed in each patient preoperatively and postoperatively. Acute kidney injury was defined as an absolute increase in serum creatinine concentration of 0.3 mg/dL or greater., Results: Overall, 295 (40.3%) of 731 patients had acute kidney injury. Patients' risk profiles were significantly worse in those with acute kidney injury, and 31 (4.2%) of 731 patients required dialysis. Acute kidney injury was associated with a higher increase in serum myoglobin concentration after 1 hour from aortic declamping (534 microg/mL [interquantile range, 354-733 microg/mL] vs 377 microg/mL [interquantile range, 278-528 microg/mL], P < .0001), which persisted at 24 and at 48 hours. After adjusting for confounding factors, myoglobin concentration was found to independently predict postoperative acute kidney injury (odds ratio, 1.0011 [1 microg/mL increase]; 95% confidence interval, 1.0003-1.0019; P = .005), and this result persisted when patients with perioperative myocardial infarction were excluded from the analysis (odds ratio, 1.0007; 95% confidence interval, 1.0002-1.0009; P = .01). Myoglobin concentration had a better accuracy to discriminate patients having acute kidney injury than creatine kinase concentration at any time., Conclusions: An increase in laboratory findings of muscle injury postoperatively, especially serum myoglobin concentration, predicts the incidence of acute kidney injury and renal replacement therapy requirement, as reported in other surgical settings. Perioperative myocardial injury cannot totally explain the occurrence of increased myoglobinemia. These results suggest an important role of skeletal muscle breakdown and necrosis in determining an increased myoglobinemia concentration after coronary artery bypass grafting., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Left ventricular hypertrophy regression is assumed to be one of the most important goals after aortic valve replacement for aortic stenosis. A moderate decrease in the glomerular filtration rate is associated with a significantly increased risk of left ventricular hypertrophy in hypertensive patients. The effect of moderate kidney disease on left ventricular hypertrophic remodeling in other conditions of chronic left ventricular pressure overload, such as aortic stenosis, remains unknown. Therefore we tested the hypothesis that moderate chronic kidney disease affects left ventricular mass regression in patients undergoing isolated aortic valve replacement for aortic stenosis., Methods: In 157 patients with aortic stenosis, left ventricular mass regression was assessed at 18 months after aortic valve replacement. Among them, 73 (46%) had a moderate chronic kidney disease (glomerular filtration rate between 60 and 30 mL/min per 1.73 m(2)). Patients with severely impaired kidney function (glomerular filtration rate of <30 mL/min per 1.73 m(2)) were excluded., Results: After surgical intervention, left ventricular mass was significantly lower from baseline value in both groups, but patients with moderate chronic kidney disease continued to show an increased left ventricular mass (61 +/- 18 vs 50 +/- 16 g/m(2.7), P = .0001). The baseline glomerular filtration rate was significantly related to left ventricular mass at 18 months after surgical intervention (beta = -0.17, r(2) = 0.45, P = .01) and left ventricular mass absolute (beta = 0.18, r(2) = 0.19, P = .03) and relative (beta = 0.20, r(2) = 0.21, P = .02) regression. These associations persisted after adjusting for confounding factors, including hypertension and patient-prosthesis mismatch. After a mean time of 34 +/- 12 months from surgical intervention, congestive heart failure symptoms developed mainly in subjects with moderate chronic kidney disease (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-3.9; P = .035)., Conclusions: Patients with aortic stenosis with concomitant moderate chronic kidney disease present a less evident left ventricular mass regression after aortic valve replacement. Moreover, this condition is related to an increased occurrence of congestive heart failure after surgical intervention., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Preoperative renal function is an important risk factor in cardiac surgery for long-term and short-term outcomes. Renal function is best assessed by measuring or calculating the glomerular filtration rate (GFR). Several algorithms using the endogenous marker serum creatinine have been developed to estimate renal function. These include the Cockcroft and Gault and the modification of diet in renal disease (MDRD) formulae. The aim of this study was to compare the predictive power of the two formulae towards short-term outcomes after cardiac surgery, such as the length of intensive care unit (ICU) stay, the length of mechanical ventilation time, and the length of in-hospital stay., Methods: One hundred and fifty patients undergoing cardiac surgery and not affected by renal failure were followed up until hospital discharge. We collected data before, during and after surgery. Before surgery data consisted of date of birth, sex, height, weight, plasma creatinine level; during surgery data consisted of type of intervention (including number of bypasses, if any), cardiopulmonary bypass time and aortic cross-clamp time; after surgery data consisted of length of ICU stay, mechanical ventilation time, length of in-hospital stay after intensive-care discharge (ward stay), incidence of acute renal failure (expressed as the need for dialysis) and mortality. The dataset was analyzed using Cox regression., Results: The average mechanical ventilation time, ICU stay and ward stay were 11 h, 49 h and 10 days, respectively. After having adjusted for chronic obstructive pulmonary disease, diabetes and postsurgical dialysis, the GFR calculated with the Cockcroft and Gault formula appeared to be a predictor of ICU stay and mechanical ventilation time with very strong evidence (P = 0.002 and <0.001, respectively) and a predictor of ward stay with some evidence (P = 0.062). After an identical case-mix adjustment, the GFR calculated with the MDRD formula appeared to be a predictor of ICU stay with strong evidence (P = 0.007), a predictor of mechanical ventilation time with some evidence (P = 0.075) and it has shown no evidence of predicting ward stay (P = 0.197)., Conclusion: There is an indication that the Cockcroft and Gault formula could be more powerful than the MDRD formula for the preoperative prediction of early postoperative clinical outcomes in cardiac surgery, in patients not affected by renal failure. Further research is needed to confirm this result.

Background and Aim of the Study: It has been shown previously that elevated plasma levels of B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-pro-BNP) are related to the degree and progression of native aortic valve disease. In addition, NT-pro-BNP levels have been shown to decrease after successful aortic valve replacement (AVR). The presence of a valve prosthesis-patient mismatch (PPM) may affect the beneficial effects of AVR, however. The study aim was to investigate the relationship between PPM and NT-pro-BNP plasma levels late after AVR., Methods: A series of consecutive patients (42 males, 31 females; mean age 66 +/- 13 years) who had undergone isolated AVR between May 2004 and July 2007 was enrolled into the study. Patients with preoperative moderate to severe mitral regurgitation, coronary artery disease, left ventricular (LV) dysfunction (ejection fraction <45%) and serum creatinine >150 mmol/l were excluded. PPM was defined severe as an indexed effective orifice area (EOAi) < or = 0.65 cm2/m2, or moderate when the EOAi was 0.66-0.85 cm2/m2. Plasma NT-pro-BNP levels and echocardiographic assessments were performed in all patients during routine follow up after surgery., Results: The patients received either a biological (n = 42) or mechanical (n = 31) prosthesis. Among the patients, 21 had no PPM, 27 moderate PPM, and 25 severe PPM. At a median follow up of 18 months, the mean NT-pro-BNP plasma level was 532 pg/ml (95% CI: 393.1-671.6), and the mean LV mass index (LVMI) 120 +/- 4 g/m2, the LVEF 60 +/- 1%, the peak aortic prosthesis gradient 28 +/- 2 mmHg, and the EOAi 0.74 +/- 0.02 cm2/m2. Multivariate statistical analysis showed that NT-pro-BNP level correlated with age (beta = 0.57, p<0.0001), LVMI (beta = 0.32, p = 0.02), NYHA class (beta = 0.50, p = 0.003) and EOAi (beta = -0.38, p = 0.02)., Conclusion: The study results showed that NT-pro-BNP levels were independently related to PPM late after isolated AVR in patients with preserved LV function. However, further investigations are required to confirm these findings and to identify their clinical implications.

Objective: Coronary artery bypass grafting (CABG) has been shown to provide better results than percutaneous coronary intervention (PCI) in multivessel coronary disease. Drug-eluting stents (DES) have significantly improved results of PCI in terms of restenosis but the advantages of such a treatment compared to CABG remain uncertain. This meta-analysis summarizes available data from observational cohorts comparing DES-PCI versus CABG., Methods: We performed a systematic literature search for observational cohorts comparing CABG versus DES-PCI in patients with multivessel coronary disease. The mixed model method was used to obtain the pooled hazard ratio (HR) for outcomes of interest., Results: A total of nine observational nonrandomized studies were identified and analyzed including a total of 24,268 patients with multivessel coronary disease who underwent DES-PCI (n=13,540) and CABG (n=10,728). Mean follow-up time was 20 months. Pooled analysis showed that DES-PCI and CABG were comparable in terms of composite occurrence of death, acute myocardial infarction and cerebrovascular accidents (HR=0.94; 95% CI=0.72-1.22; p=0.66). However, there was a significantly higher risk of repeat revascularization in the DES-PCI group (HR=4.06; 95% CI=2.64-6.24; p<0.001). Overall major adverse cardiac and cerebrovascular events rate in the DES-PCI was higher compared to the CABG group (HR=1.86; 95% CI=1.36-2.54; p<0.001)., Conclusions: In the 'real world' clinical practice, overall major adverse cardiac and cerebrovascular events rate continues to be higher after DES-PCI due to an excess of redo revascularization compared with CABG.

Postoperative continuous venovenous hemofiltration decreases acute renal failure in patients with moderate renal dysfunction undergoing coronary artery bypass grafting, but it prolongs intensive care unit stay. We developed a simple method to connect a hemofiltration machine to the cardiopulmonary bypass system. To evaluate the benefit of intraoperative hemofiltration, 124 consecutive patients (mean age, 67 +/- 6 years) with moderate renal dysfunction were studied. Surgery was preformed between January 2005 and May 2007. On-pump coronary artery bypass with hemofiltration was carried out in 40 patients (group A), 44 had on-pump coronary artery bypass without hemofiltration (group B), and 40 had off-pump coronary artery bypass (group C). Postoperative acute renal failure was defined as either renal failure requiring dialysis or >or=50% decline from the baseline glomerular filtration rate but not requiring dialysis. The 3 groups had similar demographic data and preoperative renal function. After adjusting for covariates and propensity scores, multivariate analysis showed that intraoperative hemofiltration and off-pump surgery protected postoperative renal function. Independent risk factors for postoperative renal dysfunction were age >70 years, left ventricular ejection fraction <35%, and the preoperative glomerular filtration rate.

Background: Acute kidney injury (AKI) is one of the most important complications after on-pump coronary artery bypass graft surgery (CABG). Miniaturized cardiopulmonary bypass (mini-CPB) systems have been developed to allow the ease of on-pump surgery but tempering the disadvantages. Whether mini-CPB reduces the incidence of AKI remains to be determined., Methods: Using a propensity score matched analysis, we investigated the occurrence of AKI among patients undergoing CABG on mini-CPB (n = 104) versus conventional CPB (n = 601). Acute kidney injury was defined according to the recent Acute Kidney Injury Network classification., Results: Overall, acute kidney injury developed in 274 of 705 patients (38.8%). A total of 27 of 705 patients (3.8%) required renal replacement therapy. The median postoperative length of intensive care unit stay in survivors with AKI was 5.4 (3.9 to 6.8) days compared with 2.0 (1.0 to 3.0) days for patients without AKI (p = 0.0002). The overall incidence of AKI for patients undergoing mini-CPB was 30 of 104 (28.8%) compared with 244 of 601 (40.5%) for patients undergoing conventional CPB (p = 0.03). In the propensity score matched-pair statistical analysis, mini-CPB was independently associated with a decreased incidence of AKI (adjusted odds ratio [OR] 0.61; 95% confidence interval [CI]: 0.38 to 0.97). Other variables independently associated with AKI were preoperative glomerular filtration rate (OR 0.988 for 1 mL.min(-1).1.73 m(-2) increase; 95% CI: 0.98 to 0.99), postoperative red blood cell transfusion (OR 1.58; 95% CI: 1.12 to 2.23); CPB time (OR 1.005 for 1-minute increase; 95% CI: 1.0 to 1.009), and postoperative low output syndrome (OR 1.72; 95% CI: 1.23 to 2.41)., Conclusions: The present study showed that mini-CPB is associated with a lower incidence of AKI when compared with conventional CPB among patients undergoing CABG.

Aim: Optimal strategy (staged or combined) for the treatment of patients with concurrent severe carotid and cardiac disease is still controversial. Moreover, carotid artery stenting (CAS), has become a valid alternative to carotid endarterectomy (CEA) and has been proposed for the treatment of cardiac patients. The authors report the preliminary results of a new therapeutic strategy consisting in combined CAS and cardiac surgery., Methods: An initial series of 22 patients underwent combined CAS and cardiac surgery in the same operating room and under general anesthesia. All filter-protected CAS procedures were performed under only heparin and aspirin. A cervical approach (3-cm cervicotomy) was used in patients with documented vessel tortuosity or severe aorto-iliac occlusive arteriopathy. In all the other cases a femoral access was used. A double antiplatelet regimen was initiated in the early postoperative period, once major bleedings were excluded., Results: Among the 22 patients who underwent this combined procedure, no deaths, no myocardial infarctions and one controlateral stroke (overall complication rate: 4.5%) were observed. This stroke was observed after transcervical CAS, coronary artery bypass and mitral valve replacement. No major postoperative bleedings nor stent thrombosis were observed., Conclusions: Combined carotid stenting and cardiac surgery, performed in the same operating room under only heparin and aspirin, seems a safe and effective strategy for the treatment of patients with concomitant carotid and cardiac disease.

Objectives: Optimal treatment of significant (>or=2+ grade) ischemic mitral regurgitation remains controversial, and the impact of mitral valve surgery (MVS) at the time of coronary artery bypass grafting (CABG) on early and late results has to be still clarified., Methods: A systematic literature search for studies comparing CABG combined to MVS (repair or replacement) compared with CABG alone in patients with ischemic mitral regurgitation and meta-analysis for late mortality, postoperative New York Heart Association functional class and late residual mitral regurgitation grade was performed. Risk ratios and the standardized mean difference (SMD) under the fixed or random effects model were reported., Results: A total of nine observational nonrandomized studies were identified including 2479 patients with ischemic mitral regurgitation who underwent CABG alone (n = 1515) and CABG combined to MVS (n = 964).Meta-analysis of the pooled study population showed that MVS did not have advantages on late mortality [risk ratio 1.02; 95% confidence interval (CI) 0.90 to 1.14; P = 0.73] compared with CABG alone.Combined MVS was significantly associated with a lower residual mitral regurgitation grade compared with CABG alone (SMD = -0.9; 95% CI -1.250 to -0.559; P < 0.0001). However, postoperative New York Heart Association class was not significantly improved in the combined MVS group (SMD = -0.26; 95% CI -0.766 to -0.24; P = 0.30)., Conclusion: Most surgeons commonly use additional mitral valve procedure to treat moderate or severe ischemic mitral regurgitation, because it seems logical to assume that the volume overload associated with mitral regurgitation will be detrimental particularly to the patient with compromised left ventricular function. However, until definitive evidence about the superiority of this approach will be available, a tailored surgical strategy should be considered especially in mild ischemic mitral regurgitation.

Entrapment and fracture of coronary angioplasty hardware are rare complications of percutaneous coronary interventions for which cardiac surgery is sometimes required. We report a case of guidewire entrapment during stenting of the left anterior descending coronary artery (LAD) that required surgical removal. Although a piece of guidewire remained entrapped inside the stent, in the proximal tract of the LAD, a single bypass using the left mammary artery was performed. No perioperative complications were observed. There were no signs of perioperative or postoperative myocardial infarction, as indicated by clinical biomarkers or by electrocardiographic changes. The patient had an uneventful recovery and was discharged from the hospital on the sixth postoperative day.

Objectives: Coronary artery bypass graft surgery may result in perioperative myocardial injury during cardioplegic arrest. Angiotensin-converting enzyme (ACE) inhibitors protect the myocardium from ischemia in several clinical conditions, but no previous study has attempted to evaluate the impact of preoperative ACE inhibitor therapy on myocardial protection in patients undergoing coronary artery bypass graft surgery., Methods: A propensity score-based analysis of 481 patients undergoing isolated on-pump coronary artery bypass graft surgery was carried out, among which 245 patients received preoperative ACE inhibitors and 236 patients did not. Perioperative myocardial injury was assessed by ischemia marker cardiac troponin I (cTnI)., Results: Preoperative cTnI concentration was similar for patients receiving ACE inhibitors and those who did not [0.1 ng/ml (0.06-0.19) versus 0.1 ng/ml (0.06-0.19); P = 0.3]. Postoperative cTnI peak concentration was lower in patients receiving preoperative ACE inhibitors [1.6 ng/ml (1.05-3.4) versus 2.4 ng/ml (1.13-6.10); P = 0.0006]. After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to decrease postoperative cTnI peak concentration (beta = -0.12; P = 0.004). Other independent predictors of postoperative cTnI peak concentration were female gender, emergency surgery, number of distal anastomoses and aortic cross clamp time. Overall, operative mortality rate was 16/481 (3.3%). Patients receiving preoperative ACE inhibitors had a lower rate of postoperative myocardial infarction (2.0 versus 4.2%; P = 0.25) and low cardiac output syndrome (3.6 versus 6.3%; P = 0.24)., Conclusion: ACE inhibitors prior to surgery confer added myocardial protection during surgical revascularization. Prospective, randomized clinical trials will be necessary to better define the role of ACE inhibitors in improving outcomes when they are prescribed prior to coronary artery bypass graft surgery.

Background: Angiotensin-converting enzyme (ACE) inhibitors confer renal protection in different clinical settings. No final conclusions are available on the renal benefits of ACE inhibitors after coronary artery bypass grafting (CABG). Because ACE inhibitors decrease glomerular perfusion pressure, they may exacerbate kidney injury during cardiopulmonary bypass (CPB)-related hypoperfusion. We evaluated the effect of preoperative ACE inhibitors on acute kidney injury (AKI) after CABG., Methods: A propensity score-based analysis of 536 patients undergoing CABG on CPB was performed, among which 281 received ACE inhibitors preoperatively. Patients with preoperative end-stage renal failure requiring dialysis were excluded. Postoperative AKI was defined as 50% or more decrease in the glomerular filtration rate from preoperative or postoperative mechanical renal support., Results: After CABG, AKI developed in 49 patients (9.1%), and 23 (4.2%) required dialysis. The incidence of AKI was 6.4% in patients who received preoperative ACE inhibitors and 12.2% in patients who did not (p = 0.02). The incidence of AKI requiring dialysis was 2.4% in the treatment group and 6.3% in controls (p = 0.03). After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to reduce the incidence of postoperative AKI (odds ratio, 0.48; 95% confidence interval, 0.23 to 0.77; p = 0.04). Other independent predictors were age, preoperative glomerular filtration rate, left ventricular ejection fraction of less than 0.35, preoperative use of intraaortic balloon pump, emergency operation, and CPB time., Conclusions: Preoperative ACE inhibitors are associated with a reduced rate of AKI after on-pump CABG surgery.

Background: A 70-year-old man with diabetes mellitus, fever of unknown origin and oliguria was admitted to hospital. Blood cultures were positive for a Staphylococcus aureus infection and antibiotic therapy was started. A year previously the patient had received a DDD pacemaker to treat sick sinus syndrome with intermittent atrioventricular block. Transthoracic echocardiography showed severe tricuspid regurgitation and a mass attached to the ventricular pacemaker lead; transesophageal echocardiography showed the same finding but additionally showed a vegetation on the tricuspid septal leaflet and a mass attached to the atrial pacemaker lead. Coronary angiography revealed a lesion that occluded 70% of the proximal left anterior descending artery and occlusion of the proximal right coronary artery., Investigations: Electrocardiography, transthoracic echocardiography, transesophageal echocardiography, multidetector thoracic CT, coronary angiography, blood cultures and laboratory testing., Diagnosis: Pacemaker lead infection and tricuspid valve endocarditis., Management: The patient was surgically treated under cardiopulmonary bypass during which the pacemaker system was removed and an accurate debridement of the tricuspid tissue was performed.

Perioperative myocardial infarction is the most common cause of morbidity and mortality in cardiac surgery. It occurs in 8% to 35% of patients. The primary aim of this prospective study was to determine the level of cardiac troponin I that indicates perioperative myocardial infarction in patients undergoing coronary artery bypass. A secondary goal was to establish the best independent predictor of hospital death. There were 180 consecutive patients undergoing isolated coronary artery bypass surgery enrolled in this study. Values of cardiac troponin I > 12.9 ng.mL(-1) at 8 hours postoperatively predicted perioperative myocardial infarction with a sensitivity of 100% and a specificity of 93.2%. Compared to patients who survived, those who suffered hospital death were significantly older (74 +/- 7 vs 63 +/- 10 years), had significantly higher levels of cardiac troponin I at 24 hours (9 +/- 17 vs 27.3 +/- 16 ng.mL(-1)) and 48 hours (6.9 +/- 19 vs 30.3 +/- 24 ng.mL(-1)) postoperatively, and a significantly higher EuroSCORE (9 +/- 2 vs 4 +/- 3). At 8 hours postoperatively, cardiac troponin I led to an earlier diagnosis of perioperative myocardial infarction, while EuroSCORE was the strongest independent predictor of hospital death.

In the present study, we estimated the cortical networks were from high-resolution EEG recordings in a group of spinal cord injured patients and in a group of healthy subjects, during the preparation of a limb movement. Then, we use the Markov Clustering method to analyse the division of the network into community structures. The results indicate large differences between the injured patients and the healthy subjects. In particular, the networks of spinal cord injured patient exhibited a higher density of clusters. In the Alpha (7-12 Hz) frequency band, the two observed largest communities were mainly composed by the cingulate motor areas with the supplementary motor areas, and by the pre-motor areas with the right primary motor area of the foot. This functional separation could reflect the partial alteration in the primary motor areas because of the effects of the spinal cord injury.

Perioperative myocardial infarction remains a frequent complication after coronary artery bypass grafting, and is associated with a poor prognosis. This retrospective study compared cardiac troponin I concentrations after on-pump bypass grafting in 2 groups of patients: 100 operated on using a single-clamp technique to perform anastomoses, and 80 operated on using a double-clamp technique. Postoperative cardiac troponin I levels were not significantly different between groups. It was concluded that the double-clamp technique did not reduce the incidence of myocardial infarction after elective on-pump coronary artery bypass grafting, and use of a single clamp is safe with no adverse effect on postoperative outcome.

Persistence of patent foramen ovale is frequent in adults and usually asymptomatic. We report the case of a patient in whom a patent foramen ovale was diagnosed after weaning from cardiopulmonary bypass and was not recognised preoperatively. Intraoperative transoesophageal echocardiography is pivotal for surgical decision-making and should be performed in all patients undergoing cardiac surgery.

Background: Preoperative renal dysfunction is an important risk factor in cardiac surgery. Thus, the association between creatinine clearance (ClCr) and mechanical ventilation time and ICU length of stay, independent of other established preoperative risk indicators, was analyzed., Methods: In our study, 156 consecutive patients underwent open-heart surgery at the Department of Cardiac Surgery, University Hospital St. Andrea, Rome, and were prospectively studied for the relation between the ClCr, using the formula develop by Cockroft and Gault, and ICU length of stay and mechanical ventilation time. The 156 patients were divided into two groups in relation of ClCr: group A (n=78) ClCr<70 ml/min; group B (n=78) ClCr>70 ml/min., Results: In multivariate analysis, ICU length of stay was influenced by ClCr<70 ml/min, hypertension and COPD. ICU stay was median 48 h (range 24-72) in group A versus 24h (range 20.7-44) in group B (p=0.0001). In multivariate analysis, only ClCr<70 ml/min and EuroScore were associated with increasing VAM. VAM was median 8h (range 5.7-13.2) in group A versus 6h (range 4-10) in group B (p=0.001)., Conclusions: Our study demonstrates that after short-term outcome follow-up, preoperative mild renal dysfunction is an independent predictor of ICU length of stay and mechanical ventilation time.

We report the case of a 71-year-old man with creatinine clearance of 41 mL/min and acute anterior ST-segment elevation who underwent urgent coronary artery bypass grafting. A continuous intraoperative veno-arterial hemofiltration with high volumes of exchange (35 mL/kg/h) was used in a series for a miniaturized extracorporeal bypass system to minimize the inflammatory response and to protect the kidneys of this patient who had preoperative renal dysfunction. The patient had an uneventful postoperative recovery.

We herein present the case of a 75-year-old woman undergoing double valve replacement who experienced a massive bronchial hemorrhage due to a Swan-Ganz catheter pulmonary artery perforation after weaning from cardiopulmonary bypass. Early institution of extracorporeal membrane oxygenation allowed treatment of severe hypoxemia, refractory to mechanical ventilation, and the discontinuation of hemoptysis. Once clinical stability was achieved, the patient underwent pulmonary artery angiography with successful pseudoaneurysm embolization. It is hoped that this information can provide further insight into the management of such a complication.

Background: Atrial systolic dysfunction in patients with coronary artery disease might influence the development of atrial fibrillation after coronary artery bypass grafting (CABG). Tissue Doppler imaging of the mitral annulus during atrial systole has proved to quantify, accurately, left atrial contractile function. Therefore, the aim of the present study was to investigate the correlation between preoperative left atrial dysfunction assessed by tissue Doppler and postoperative atrial fibrillation after CABG., Methods: We studied a total of 96 patients (mean age 67 +/- 6 years; range, 55 to 81) undergoing CABG who were preoperatively in sinus rhythm. All patients underwent a preoperative transthoracic echocardiography with tissue Doppler evaluation. Until the day of discharge, all patients were monitored with continuous electrocardiographic telemetry., Results: There were no hospital deaths. Postoperative atrial fibrillation was recorded in 24 of 96 patients (25%). Patients with postoperative atrial fibrillation were significantly older (70 +/- 6 vs 65 +/- 8 years; p = 0.006), had a preoperative larger left atrium diameter (38 +/- 5 vs 36 +/- 4 mm; p = 0.045), a larger left atrium area (13.2 +/- 3.4 vs 11.5 +/- 2.3 cm2; p = 0.007), and a lower peak atrial systolic mitral annular tissue Doppler velocity (10 +/- 3 vs 13 +/- 5 cm/second; p = 0.01). Stepwise logistic regression analysis showed that age 70 years or greater (p = 0.02; odds ratio [OR] 2.0), preoperative medication with beta-blockers (p = 0.04; OR 0.7), left atrium area 13 cm2 or greater (p = 0.02; OR 2.5), and peak atrial systolic mitral annular tissue Doppler velocity 9 cm/second or less (p = 0.03; OR 1.8) were independently related with the incidence of postoperative atrial fibrillation., Conclusions: Tissue Doppler is useful for assessing preoperative atrial dysfunction and predicting atrial fibrillation after CABG. Further studies are needed to confirm this finding.

Complete rupture of the anterolateral papillary muscle after successful coronary artery bypass procedure is an extremely rare event. We have been able to detect the initial phase of this uncommon complication just after weaning from cardiopulmonary bypass using intraoperative transesophageal echocardiographic examination.

Coronary perforation is a recognized hazard following cardiac catheterization and may lead to a catastrophic outcome. Prompt decision-making following diagnosis is of key importance. Whether to perform prolonged attempts at percutaneous repair or to promptly refer the patient for emergency surgery soon after diagnosis still remains a matter of debate. We report the case of a 78-year-old woman suffering from coronary artery perforation during left anterior descending coronary artery percutaneous transluminal coronary angioplasty-stenting, who underwent unsuccessful multiple prolonged attempts at percutaneous repair followed by subsequent successful emergency surgery.

Serum levels of cardiac enzymes and troponins after external cardioversion (ECV) for atrial defibrillation and atrial flutter, and after endocardiac cardioverter defibrillation by implantable cardioverter defibrillator (ICD), have been well investigated. The aim of this study was to assess the effects of topic defibrillation (TD), after cardiac surgery, on cardiac enzymes in patients with uncomplicated clinical course. Biochemical markers were analyzed prospectively for 20 patients after TD (group A) and for 20 patients that were not defibrillated (Control group). We obtained serum concentrations of cardiac Troponin I (cTnI), total creatine-kinase (CK), CK MB isoenzyme (CK-MB), Myoglobin (Myo) in both groups. The difference in cTnI plasma level and curve of raise was not statistically significant between the two groups, but there was a difference in the CK-MB and Myoglobin curve of raise between the two groups. Topic defibrillation does not influence the increase of cTnI, so a high cTnI should be correlated to myocardial damage and not to TD. In patients that received TD, it would be preferable to use cTnI as a marker of myocardial disease than CK-MB which is influenced by the TD.

Objective: After aortic valve replacement, the effects of a small functional prosthesis on the extent and pattern of regression of left ventricular hypertrophy and on clinical outcomes may be less significant in older patients with low cardiac output requirements. The objective of this study was therefore to determine whether patient-prosthesis mismatch affects left ventricular mass regression in the elderly., Methods: The population studied was made up of 88 patients over 65 years of age with pure aortic stenosis who underwent mechanical aortic valve replacement. The effective orifice area index was calculated for each patient on the basis of the projected prosthesis in vivo effective orifice area. It was considered a continuous variable and influence of its entire range of values on the extent of left ventricular mass regression was analyzed in a multivariate prediction model., Results: Even though, in the group with prosthesis-patient mismatch there was a trend for lower postoperative left ventricular mass index (115+/-24 g/m(2) vs 102+/-27 g/m(2), p=0.24) and postoperative peak trans-prosthetic gradients (32+/-9.8 mmHg vs 28.9+/-7.79 mmHg, p=0.35) these differences were not statistically significant. The prevalence of residual left ventricular hypertrophy at follow-up was 50% in the group with patient-prosthesis mismatch and 50% in the group without patient-prosthesis mismatch (p=0.83). In multivariate analysis the only factors associated with indexed left ventricular mass were the follow-up time (p=0.015, r(2)=0.22) and preoperative indexed left ventricular mass (p=0.0012, r(2)=0.11)., Conclusions: The major finding of our study is that patient-prosthesis mismatch does not affect left ventricular mass regression in patients older than 65 with pure aortic stenosis who underwent mechanical aortic valve replacement. In older patients with low cardiac output requirements, even a small change in the valve effective orifice area after aortic valve replacement with modern efficient mechanical prosthesis, will result in a marked reduction of pressure gradient and this will be associated with a significant regression of left ventricular mass.

Background: Diabetes mellitus increases the risk of infections in patients undergoing cardiac surgery. We hypothesized that intensive perioperative hyperglycemia control by intravenous insulin infusion reduces postoperative infections in all patients undergoing open heart surgical procedures., Methods: Sixty diabetics patients who underwent CABG operation (Group 1) were compared with fifty-five patients who underwent other cardiac surgery (Group 2) between January 2004 and March 2005. A continuous infusion of insulin was used in all these patients., Results: There were no 30-day mortalities in either group. There was no difference in the incidence of infections between the two groups: in Group 1, 3 (5%) patients were diagnosed to have postoperative infection (superficial sternal wound infections in 1 (1.66%) and lung infection in 2 (3.33%) patients); postoperative infection occurred in only 2 patients (3.63%) in Group 2, 1 superficial sternal wound infections (1.81%) and 1 lung infection (1.81%)., Conclusions: Our analysis indicates that continuous intravenous insulin infusion improves outcome and reduces postoperative infections in patients undergoing CABG as well as those undergoing other cardiac surgery procedures.

Myocardial bridging may be associated with an unfavorable prognosis in patients with hypertrophic cardiomyopathy. We describe a case of a young symptomatic patient with myocardial bridging associated with hypertrophic cardiomyopathy successfully treated by surgical unroofing. Such a procedure should be strongly recommended in patients with hypertrophic cardiomyopathy.

Purpose of Review: The purpose of this review is to highlight the important recent advances in this fast developing field of pain mechanisms. It is now recognized that acute tissue and neural injuries can result in nociceptor sensitization (primary hyperalgesia) and spinal cord hyperexcitability or central sensitization that results in secondary hyperalgesia and allodynia., Recent Findings: New findings regarding peripheral and central sensitization are presented in this review. Newer ideas on pain modulation, pain states and pain syndromes, mechanisms of chronic pain, newer opioid and non opioid medications including newer N-methyl-D-asparate antagonists, cyclooxygenase-2 inhibitors and membrane stabilizing analgesics as well as pain control at the genetic level are discussed., Summary: The research of the last decade has focused on the biochemical and structural plasticity of the nervous system following tissue and nerve injury. The mechanisms involved in the transition from acute to chronic pain are complex with the involvement of interacting receptor systems and intracellular ion flux, second messenger systems, new synaptic connections and apoptosis.

Background: Several retrospective studies comparing off-pump and on-pump coronary surgery and the largest randomized studies published to date showed a lower number of grafts performed in patients submitted to off-pump coronary artery bypass surgery (OPCAB). These findings bring about the question of the general applicability of the results. We eliminated the selection bias correlated with the number of grafts per patient by comparing the short-term outcomes of patients undergoing OPCAB and standard coronary artery bypass grafting (CABG) matched for number of grafts., Methods: Eighty-seven consecutive patients undergoing OPCAB (group A) were selected from the database of our Institution during a 2-year period. Matching was performed by iterative selection prioritizing, in the following sequence: number of grafts, EuroSCORE, and age. A total of 87 patients operated upon with the on-pump technique represented the control group (group B)., Results: There were no significant differences in preoperative characteristics between the two groups. The number of grafts per patient was 2.2 +/- 0.5 in group A and 2.2 +/- 0.5 in group B. Early mortality did not differ between the two groups and it was 2.2% (2 patients) in group A and 3.4% (3 patients) in group B (p = NS). The incidence of myocardial infarction did not differ between the two groups. No patient in either group had stroke or coma. Five (5.7%) patients in group A and 7 (8.0%) patients in group B had atrial fibrillation (p = NS)., Conclusions: We were unable to demonstrate any significant differences in short-term mortality or morbidity outcome between OPCAB and standard CABG patients Our findings suggest that excellent results can be obtained with both surgical approaches.

Background: The aim of this study was to evaluate the early survival in patients submitted to left ventricular (LV) repair and concomitant myocardial revascularization., Methods: We retrospectively reviewed the records of 51 patients who were submitted to LV repair and concomitant myocardial revascularization between January 1998 and June 2003. Of 51 patients (44 males with a mean age of 60+/-9.2 years, and 7 females with a mean age of 61+/-6.5 years), 29 (56.9 %) were submitted to the McCarthy technique, 16 (31.3 %) to the technique that was described by Jatene and modified by Dor, and 6 (11.8%) to the Cooley technique (linear repair). The mean preoperative LV ejection fraction was 36.5+/-7.7 %, the mean preoperative LV end-diastolic diameter was 61.8+/-3.9 mm, the mean preoperative LV end-systolic diameter was 49.9+/-5.1 mm, the mean preoperative interventricular septal thickness was 9.7+/-1.7 mm, and finally, the mean posterior wall thickness was 8.9+/-1 mm. The mean follow-up was 30.7+/-23.4 months (range 11-82 months)., Results: One patient died during surgery (1.9%) and one early postoperatively (1.9%). The causes of death were respectively irreversible ventricular fibrillation and low cardiac output syndrome. The overall survival at follow-up was 98% (49 patients). One patient died during follow-up of myocardial infarction. At follow-up, all patients presented with improved clinical symptoms, and had a better mean NYHA functional class with respect to the preoperative value (3.3+/-0.3 vs 2.0+/-0.5, p < 0.05). Besides, the mean CCS angina class decreased in all patients (3.4+/-0.2 vs 1.9+/-0.3, p < 0.05). The average LV ejection fraction increased from 36.3+/-7.7 to 44.3+/-4.9% (p < 0.001), the average LV end-diastolic diameter decreased from 61.7+/-3.9 to 55.5+/-5.6 mm (p < 0.001), and the average LV end-systolic diameter decreased from 49.9+/-5.1 to 40.4+/-5.1 mm (p < 0.001). No statistically significant difference was found between the preoperative and postoperative data regarding the interventricular septal thickness (9.7+/-1.7 vs 10.3+/-1.6 mm, p = NS), and the posterior wall thickness (9.7+/-1 vs 8.8+/-1.3 mm, p = NS)., Conclusions: LV aneurysm repair and concomitant myocardial revascularization may be performed with an acceptable surgical risk and a good early survival.

Inadequate pain control in the postoperative period not only contributes to patient discomfort, but also causes physiological changes that may result in increased risk of myocardial ischaemia, deep vein thrombosis and pulmonary embolism. These events complicate postoperative recovery and may lead to longer hospital stays as well as increased healthcare costs. Patient-controlled analgesia (PCA) has emerged as an effective way for patients to manage their pain, allowing self-administration of small doses of analgesics to maintain a certain level of pain control. PCA is most commonly delivered via an intravenous (IV) or epidural route, and while patient satisfaction is higher with PCA than with conventional methods of analgesic administration, the invasiveness, costs and risk of errors associated with currently available modalities may limit their utility. These systems also require significant healthcare resources, as nurses must manually program the pumps to deliver the correct amount of medication. Several new PCA modalities are being developed to address these limitations. These systems deliver drug through a variety of routes, including nasal transmucosal and transdermal. Most notably, a self-contained, credit card-sized, transdermal PCA system is currently in the final stages of development. The fentanyl HCl patient-controlled transdermal system (PCTS; IONSYS, Ortho-McNeil Pharmaceutical, Inc., Raritan, NJ) uses an imperceptible, low-intensity direct current to transfer fentanyl on demand across the skin into the systemic circulation. This compact system is patient-activated, can be applied to the patient's upper arm or chest, and is designed to manage moderate-to-severe pain requiring opioid analgesia. The system delivers a preprogrammed amount of fentanyl HCI over 10 minutes, for a total of 80 doses, or for 24 hours, whichever occurs first. The on-demand dosing and pharmacokinetics of this system differentiate it from the passive transdermal formulation of fentanyl designed for the management of chronic pain. Clinical studies have shown that the fentanyl HCl PCTS is effective in the management of acute postoperative pain. These studies have also demonstrated that the system is safe and well tolerated by patients.

In the past decade the rate of reoperative coronary bypass grafting has averaged 8%. In these patients adequate myocardial protection is often difficult because delivery of cardioplegia is frequently suboptimal when the internal mammary artery graft is patent. We describe a simple technique for performing cardiac reoperation in patients with a patent left internal mammary artery graft through a balloon catheter used for angioplasty and positioned in the left internal mammary artery graft. Our study included 3 patients and there were no operative deaths and complications.

Background: External manipulation of the diseased aorta during cardiac surgery is the most important mechanism leading to the detachment of atherosclerotic debris due, especially, to the use of aortic clamping. The aim of the present study was to determine the best occluding clamp technique to minimize the risk of postoperative cerebrovascular accidents in patients who undergo isolated coronary artery bypass grafting (CABG): single-clamp technique (SCT) or double-clamp technique (DCT)?, Methods: Two hundred and eighty-one consecutive patients undergoing isolated CABG in our center between January 2001 and December 2003 were enrolled. SCT was used in 145 cases and DCT was used in 136 cases. Postoperative adverse events were retrospectively compared between these two groups., Results: The aortic cross-clamp times were longer for patients in the SCT group, whereas the mean cardiopulmonary bypass time was shorter in the DCT group. There were no differences between the two groups in terms of postoperative stroke (0.6% SCT vs 0.7% DCT, p = NS) and hospital mortality (1.3% SCT vs 1.4% DCT, p = NS)., Conclusions: The results of this study suggest that, among patients who undergo CABG, there are no differences in neurologic outcome between those in whom DCT was used and those in whom SCT was employed.

Purpose: This study was undertaken because, although there is evidence that cyclooxygenase type 2 (COX)-2 inhibitors do not compromise platelets in healthy volunteers, many clinicians remain hesitant to administer them perioperatively without definitive evidence of intact platelet function during anesthesia and surgery., Methods: In 20 patients scheduled for lower abdominal and pelvic surgery, 5 mL of blood were obtained for baseline platelet aggregometry. One hour prior to surgery, patients received an oral solution of either rofecoxib (ROF) 50 mg or placebo (PLAC) by randomized, double-blinded assignment. Approximately one hour after onset of anesthesia, an intraoperative blood sample was obtained. Baseline and postdrug samples were centrifuged to generate platelet-rich plasma, which was challenged with adenosine diphosphate (ADP) and arachidonic acid (AA). Aggregometry was performed with and without incubation with aspirin. The data in each subject were normalized to baseline aggregation in response to AA alone and ADP alone. Intergroup differences were assessed using paired t test; P < 0.05 was considered significant., Results: Consistent with known effects of anesthesia on platelet function, both groups had approximately 25% intraoperative declines in aggregation in response to ADP (P = NS for PLAC vs ROF) and even greater declines in response to AA (P = NS for PLAC vs ROF). Aspirin eliminated aggregation in response to AA in both groups (P = NS), and it caused similar declines in PLAC and ROF groups during exposure to ADP (P = NS)., Conclusion: This study provides strong evidence that ROF does not compromise platelet aggregation during anesthesia and surgery; nor does it interfere with the platelet inhibitory effect of aspirin.