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Objective: Radial artery harvesting using the less invasive endoscopic technique involves dissection in a narrow tunnel and may cause an injury or induce vasospasm to the conduit. To assess this hypothesis, radial artery segments harvested endoscopically or conventionally were studied for reactivity and integrity. Methods: Rings of radial arteries from 80 CABG patients who had their radial artery harvested either open (n = 40) or endoscopic (n = 40), were attached to a force transducer then subjected to norepinephrine (NE, 10 � 6 M), acetylcholine (ACh, 10 � 5 M), followed by sodium nitroprusside (SNP, 10 � 7 to 10 � 5 M) to test endothelial dependant and non-dependant relaxation. Vessels’ integrity was assessed by microscopic staining with hematoxylin—eosin for muscle layers, Masson trichrome for collagen content and von Gieson for elastica layers. Results: Contraction and relaxation in response to NE, ACh and SNP were similar in both techniques. Arterial layers, collagen content and elastic lamina were preserved in all radial rings. Both techniques were found to be equally efficient in physiological and microscopic tests. Conclusions: The similar reactivity and integrity of the radial artery in both techniques should encourage the less invasive endoscopic approach. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Oral analgesia after "fast-track" cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.One hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I) per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II) per os every 12 hr and placebo twice daily. Acetaminophen 500 mg per os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mg per os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.Baseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.Peroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/ acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.

There are known clinical and laboratory predictors for stroke and death following CABG. The aim of this study was to determine if transthoracic echocardiographic findings prior to CABG have additional predictive value for occurrence of perioperative cerebrovascular accident (CVA) and death. The files of patients who underwent CABG between January 2002 and November 2004, with perioperative echocardiographic assessment were reviewed. Echocardiographic variables examined included LV size, function and hypertrophy, mitral annulus calcification (MAC) and aortic valve calcification (AVC). Patients in whom post-CABG stroke or death was documented were compared with those without these endpoints. Of the 572 patients who met the study criteria, 33 (5.8%) had a neurological event and 26 (4.5%) died, four after a major stroke. One hundred and sixty-seven patients had MAC and 228 AVC. On multivariate analysis, risk factors for stroke were previous stroke (OR=2.91 CI 1.179-7.24; P

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

Objectives: Release of thromboxane (Tx) A2 by platelets may be one of multiple factors that are responsible for lung injury after cardiopulmonary bypass, leading to pulmonary vasoconstriction and impaired oxygenation. In experimental models, the inhibition of Tx receptor or its production improved lung function. The use of aspirin, which is used widely in the treatment of ischemic heart disease because of its antiplatelet activity, is usually discontinued a week before the patient undergoes the operation to restore normal platelet hemostatic function. The purpose of this study was to determine the relationship between the time of cessation of aspirin before coronary artery bypass surgery, and postoperative oxygenation and bleeding. Design: A prospective clinical study comparing the effect of aspirin on postoperative oxygenation in patients who had been treated or had not been treated with aspirin. Setting: Tx levels in the pericardial fluid, oxygenation, and bleeding were compared between the two groups. Patients: Thirty-two patients with coronary artery disease who were undergoing coronary artery bypass grafting. Fourteen of these patients received aspirin until the day of the operation, whereas 18 patients stopped receiving aspirin at least 1 week before undergoing the operation. Main results: Mean ( SD) Tx levels in the pericardial fluid were significantly lower in the aspirin group (117 47 pg/mL) compared to those in the control group (1,306 2,048 pg/mL; p 0.02). The duration of ventilation after the operation was significantly longer in the nonaspirin group (9.6 5.6 h vs 3.8 1.4 h, respectively; p 0.0004). PO2 reached a higher level while patients breathed 100% O2 in the aspirin group (235 54 mm Hg vs 176 27 mm Hg, respectively; p 0.001). The mean amount of bleeding during the first 24 h after surgery was increased in the aspirin group (710 202 mL) compared with the nonaspirin group (539 143 mL; p 0.01), but these patients did not require more transfusions. Conclusions: The administration of aspirin until the operation may improve oxygenation with only a slight increase in bleeding. This improvement is probably mediated by antiplatelet activity and Tx inhibition by aspirin. (CHEST 2005; 127:1622–1626)

Background: The number of patients awaiting heart transplantation is increasing in proportion to the waiting period for a donor. Studies have shown that coenzyme Q10 (CoQ10) has a beneficial effect on patients with heart failure. Hypothesis: The purpose of the present double-blind, placebo-controlled, randomized study was to assess the effect of CoQ10 on patients with end-stage heart failure and to determine if CoQ10 can improve the pharmacological bridge to heart transplantation. Methods: A prospective double-blind design was used. Thirty-two patients with end-stage heart failure awaiting heart transplantation were randomly allocated to receive either 60 mg U/day of Ultrasome™---CoQ10 (special preparation to increase intestinal absorption) or placebo for 3 months. All patients continued their regular medication regimen. Assessments included anamnesis with an extended questionnaire based partially on the Minnesota Living with Heart Failure Questionnaire, 6-min walk test, blood tests for atrial natriuretic factor (ANF) and tumor necrosis factor (TNF), and echocardiography. Results: Twenty-seven patients completed the study. The study group showed significant improvement in the 6-min walk test and a decrease in dyspnea, New York Heart Association (NYHA) classification, nocturia, and fatigue. No significant changes were noted after 3 months of treatment in echocardiography parameters (dimensions and contractility of cardiac chambers) or ANF and TNF blood levels. Conclusion: The administration of CoQ10 to heart transplant candidates led to a significant improvement in functional status, clinical symptoms, and quality of life. However, there were no objective changes in echo measurements or ANF and TNF blood levels. Coenzyme Q10 may serve as an optional addition to the pharmacologic armamentarium of patients with end-stage heart failure. The apparent discrepancy between significant clinical improvement and unchanged cardiac status requires further investigation.

Previous investigations have shown the effectiveness of sustained intra- or extravascular administration of vascular endothelial growth factor (VEGF) in chronic myocardial ischemia in improvement of left ventricular function. The present investigations were undertaken in order to evaluate efficacy of a single bolus or local intracoronary delivery.Yorkshire pigs underwent placement of a left circumflex artery ameroid occluder. Three weeks later the animals were randomized to treatment with VEGF (20 micrograms) accomplished by local intracoronary delivery system (InfusaSleeve, n = 10), intracoronary bolus infusion (n = 7) or by epicardial implantation of an osmotic delivery system (n = 7). An additional group of animals received intracoronary administration of saline and served as a control (n = 9). Three weeks after initiation of therapy, the animals were evaluated with regard to myocardial perfusion and global as well as regional ventricular function.All three VEGF treatment groups but not the control animals demonstrated a significant increase in the left-to-left (but not right-to-left) collateral index, myocardial blood flow (pre-therapy LCX vs. LAD (average of all groups): 0.76 +/- 0.35 vs. 0.96 +/- 0.38 ml*min-1*g-1, p = 0.03; post-therapy: LCX vs. LAD: 1.16 +/- 0.39 vs. 1.15 +/- 0.28 ml*min-1*g-1, p = NS) and coronary vasodilatory reserve 3 weeks after growth factor administration. The observed increase in VEGF-induced perfusion correlated with improvement in regional ventricular function in all VEGF-treated groups (pre-therapy vs. post-therapy: i.c. VEGF 20 +/- 5.1 vs. 33 +/- 4.8; local VEGF 16 +/- 2.8 vs. 33.6; pump VEGF 17 +/- 3.8 vs. 34 +/- 4.9 p0.05 for all) but not control animals (21 +/- 3.3 vs. 27 +/- 5.8, p = NS).Single intracoronary delivery (intravascular bolus or local delivery) of VEGF is effective in stimulating physiologically significant angiogenesis in porcine model of chronic myocardial ischemia.

Background Cardioplegia is known to affect coronary vascular reactivity. We examined the effects of intermittent cold and continuous warm blood cardioplegia on β-adrenoceptor–mediated, adenosine triphosphate–sensitive K + (K + ATP )–channel–mediated, and endothelium-dependent relaxation and on the myogenic tone of coronary arterioles. Methods Pigs were placed on cardiopulmonary bypass. Hearts were arrested for 1 hour with a cold blood cardioplegic solution administered intermittently (n=12; iCB-CP) or with a warm blood cardioplegic solution delivered continuously (n=12; cWB-CP). Selected hearts (n=6 in each group) were then reperfused for 1 hour. In vitro relaxation responses of precontracted microvessels (50 to 160μm) were studied in a pressurized no-flow state. Results Relaxation in response to isoproterenol (β-adrenergic agonist) was similar after iCB-CP and cWB-CP, whereas forskolin (adenylate cyclase activator)–induced relaxation was impaired more after iCB-CP than after cWB-CP. After reperfusion the respective responses were similar. Both iCB-CP and cWB-CP preserved receptor-mediated, endothelium-dependent relaxation in response to adenosine, 5 * -diphosphate; non–receptor-mediated endothelium-dependent relaxation in response to A23187; endothelium-independent cyclic guanosine monophosphate–mediated relaxation in response to sodium nitroprusside, and K + ATP -channel–mediated relaxation. Relaxations in response to 8-bromo-cyclic guanosine monophosphate (a cyclic guanosine monophosphate–dependent protein kinase activator) and to 8-bromo-cyclic adenosine monophosphate (a cyclic adenosine monophosphate–dependent protein kinase activator) were impaired after iCB-CP alone and after reperfusion, whereas the respective responses were not affected after cWB-CP. Myogenic tone was decreased similarly after iCB-CP and cWB-CP but was not further altered after reperfusion. Cardiac function was similar after iCB-CP and cWB-CP. Conclusions These results suggest that cWB-CP is similar to iCB-CP in its ability to preserve endothelium-dependent relaxation and K + ATP -channel function. The superior preservation of β-adrenergic-cyclic adenosine monophosphate–mediated coronary responses after cWB-CP is brief and associated with minimal improvement of myocardial function and myogenic tone.

Background. Cardiopulmonary bypass (CPB) is associated with alterations in the regulation of organ perfusion and vascular permeability. The purpose of this study was to examine the effects of hypothermic CPB on the regulation of the skeletal muscle microcirculation and the modulating influence of the priming solution. Methods. Sheep were placed on hypothermic CPB with a prime of either Pentastarch hydroxylethyl starch (HS) solution (n = 7), a solution in which HS is conjugated with deferoxamine (n = 7), or Ringer's lactate solution (n = 7). Sheep were placed on hypothermic CPB (27°C) for 90 minutes while the heart was protected with cold blood cardioplegia. Sheep were then separated from CPB and perfused for an additional 3 hours off CPB. Hemodynamics and total water content were measured. Results. In vitro relaxation responses of gracilis muscle arterioles (70 to 180 μm) to the endothelium-dependent agent acetylcholine, the endothelium-independent cyclic GMP-mediated vasodilator sodium nitroprusside, the β-adrenergic agonist isoproterenol, and the adenylate cyclase activator forskolin were studied. No statistically significant hemodynamic differences were observed between groups. However, weight gain was significantly less when the priming solution was HS or HS-deferoxamine compared to when Ringer's lactate was used. Skeletal muscle arteriolar relaxations to the endothelium-dependent vasodilator acetylcholine and the βadrenergic agonist isoproterenol were impaired after CPB in the HS and Ringer's lactate groups. Acetylcholine response was preserved in the HS-deferoxamine group, whereas the response to isoproterenol remained impaired. The responses to sodium nitroprusside and forskolin were similar in all groups. Conclusions. Skeletal muscle microvascular endothelium-dependent relaxation and β-adrenergic relaxation are reduced after CPB using either a crystalloid or HS prime. Skeletal muscle microvascular endothelial dysfunction may be attributable to oxygen-derived free radical-mediated injury, whereas altered β-adrenergic regulation is attributable to mechanisms other than the generation of oxygen-derived free radicals during CPB.

We compared the effect of hypermagnesium and hyperkalemic crystalloid cardioplegia on beta-adrenoceptor-mediated and endothelium-dependent relaxation and myogenic responses of coronary arterioles. Pigs were placed on cardiopulmonary bypass. Hearts were arrested with cold hypermagnesium (25 mM Mg2+, hyper-Mg, n = 12) or hyperkalemic (25 mM K+, hyper-K, n = 12) crystalloid cardioplegia for 1 hr. Hearts of selected pigs (n = 6 in each group) were then reperfused for 1 hr. In vitro relaxation responses of acetylcholine-pre-contracted arterioles were studied in a pressurized no-flow state with video-microscopy. Relaxation of pre-contracted coronary microvessels (70-150 microns) to isoproterenol (beta-adrenergic agonist) and forskolin (adenylate cyclase activator) was preserved after cardioplegia using a hyper-Mg solution. In contrast, responses were impaired to isoproterenol [P0.01 (two-factor ANOVA) vs. controls, n = 6] and forskolin (P0.01) after hyper-K cardioplegia. After 1 hr of reperfusion, relaxation responses to isoproterenol and forskolin were partially recovered. Hyper-Mg cardioplegia and post-cardioplegic reperfusion did not affect receptor-mediated endothelium-dependent relaxation to ADP, non-receptor-mediated endothelium-dependent relaxation to A23187, and endothelium-independent relaxation to nitroprusside. However, responses to ADP (P0.01) and A23187 (P0.05) were selectively impaired after hyper-K cardioplegia. Myogenic contraction was impaired after either hyper-Mg or hyper-K cardioplegia. Left ventricular systolic pressure, coronary blood flow, and +dP/dt were similar after hyper-Mg or hyper-K cardioplegia. These results suggest that hyper-Mg cardioplegia is superior to hyper-K cardioplegia in terms of preserving beta-adrenoceptor-mediated and endothelium-dependent regulation of the coronary microcirculation, yet it has minimal if any additional beneficial effect on preserving myogenic responses or myocardial contractile function.

The aim of the study was to examine the safety and effectiveness of the Harmonic Scalpel® for reducing spasm caused by thermal injury during radial artery harvesting. The study sample included 100 candidates undergoing coronary artery bypass grafting. In half the patients, radial artery harvesting was performed using the ultrasonic Harmonic Scalpel equipped with coagulating curved shears and a 14 cm scissor-grip handle and in the other half, hemostatic clips, scissors, and minimal electrocautery were employed. Comparison of outcome between the groups showed that radial artery harvesting with the Harmonic Scalpel was associated with a shorter harvesting time, lower frequency of spasm, larger internal diameter of the radial artery graft, and a significantly reduced need for clips to control bleeding than the standard method. In addition, there were no cases of hematoma or superficial wound infection in the arm, and no postoperative reduction in soft touch sensation or objective pin-prick sensation. In conclusion, the Harmonic Scalpel provides excellent control of bleeding without the need for potentially damaging electrocautery, and with a markedly decreased use of hemostatic clips. Harvesting time is also shorter. The minimized thermal injury decreases the rate of radial artery spasm. Further studies using additional objective measures are currently underway to confirm these findings.

A 48-year-old man undergoing orthotopic heart transplantation for ischemic cardiomyopathy developed severe right heart failure. Severe intractable bleeding complicated implantation of a right ventricular assist device. Treatment with 9.6 mg of recombinant activated factor VII stopped the bleeding, and the patient could be transferred to the intensive care unit. This is the first reported case of the successful use of recombinant activated factor VII to control bleeding with subsequent right ventricular assist device function.

The effect of periadventitial administration of acidic fibroblast growth factor (FGF) on coronary microvascular reactivity and blood flow was examined in the collateral-dependent and normally perfused myocardium.Ameroid constrictors were placed on the proximal left circumflex (LCx) coronary artery in 14 pigs. In seven pigs acidic FGF (10 micrograms) was administered into the perivascular space of the proximal LCx artery by using an ethylene vinyl acetate copolymer slow release device. After 7 to 9 weeks coronary arterial microvessels (70 to 150 microns) were studied in a pressurized (40 mm Hg) no-flow state with video microscopy.Relaxation mediated by beta-adrenoceptors and induced by isoproterenol (p0.05), and endothelium-dependent relaxation induced by adenosine 5' diphosphate (ADP) (p0.05) of isolated microvessels from the collateral-dependent LCx region were markedly reduced compared with the respective responses of vessels from the normally perfused left anterior descending (LAD) artery region. Relaxation induced by the adenylate cyclase activator forskolin and the guanylate cyclase activator sodium nitroprusside were unaltered. Chronic treatment with acidic FGF normalized responses to isoproterenol (p0.001 versus nontreated LCx) and ADP (p0.001 versus nontreated LCx) in the collateral-dependent LCx region, whereas responses to forskolin and sodium nitroprusside were not changed. Blood flow in the collateral-dependent LCx region (0.49 +/- 0.24 ml/min/gm) was less than that in the normally perfused LAD region (0.80 +/- 0.24 ml/min/gm, p0.05). Treatment with acidic FGF improved perfusion in the LCx region (0.80 +/- 0.06 ml/min/gm, p0.05) but did not significantly affect blood flow in the LAD territory (0.89 +/- 0.09 ml/min/gm).The periadventitial delivery of acidic FGF normalizes vasomotor regulation by beta-adrenergic and endothelium-dependent mechanisms and improves myocardial perfusion to the collateral-dependent myocardium. This may have implications regarding the treatment of patients with severe coronary artery disease who are not ameneable to conventional methods of revascularization.

Patients who undergo cardiopulmonary bypass frequently have neuropsychologic dysfunction. This study was undertaken to determine whether altered cerebral perfusion and vascular responses may in part lead to these neuropsychologic changes. Pigs were placed on normothermic cardiopulmonary bypass for 2 hours. Basal cerebral blood flow and in vivo responses to administration by internal carotid artery of neuronally released vasoactive substances were evaluated before and 5 to 15 minutes after termination of cardiopulmonary bypass. Another group of pigs were placed on cardiopulmonary bypass for 2 hours and then perfused off bypass for 1 additional hour. In vitro responses of cerebral arterial microvessels (100 to 175 μm) from both groups were examined in a pressurized (40 mm Hg) no-flow state with videomicroscopy. Vessels from uninstrumented pigs served as control preparations for in vitro studies. Cerebrovascular resistance and cerebral perfusion were maintained constant during cardiopulmonary bypass and after separation from bypass. The internal carotid artery infusion of acetylcholine (cholinergic agonist) caused increased internal carotid artery blood flow before cardiopulmonary bypass but decreased blood flow after cardiopulmonary bypass. After 2 hours of cardiopulmonary bypass, the increase in internal carotid artery blood flow induced by isoproterenol (a β-adrenoceptor agonist) was reduced, whereas the response to sodium nitroprusside (a guanylate cyclase activator) was unchanged. In vitro acetylcholine-induced microvascular vasodilation was converted to a contractile response and isoproterenol elicited less relaxation after 2 hours of cardiopulmonary bypass. One hour of cerebral perfusion after cardiopulmonary bypass caused a further reduction in isoproterenol-induced relaxation but had no further effect on the cholinergically mediated response. In vitro relaxation responses to sodium nitroprusside and forskolin (an adenylate cyclase activator) were similar in all experimental groups, suggesting that second-messenger mechanisms remain intact after normothermic cardiopulmonary bypass. In conclusion, basal cerebrovascular resistance and internal carotid artery blood flow are maintained if the systemic circulation and pressure are supported with fluid administration after cardiopulmonary bypass. Agonist-induced vasodilation of cerebral microvessels to cholinergic and β-adrenoceptor stimulation are selectively impaired after normothermic cardiopulmonary bypass, whereas second-messenger mechanisms remain intact. (J Thorac Cardiovasc Surg 1996;112:450-61)

Acute massive pulmonary embolism is associated with a high mortality rate. Prompt diagnosis and treatment are mandatory for a successful outcome. Although thrombolysis is effective, it is associated with a high rate of bleeding complications. This report describes the use of emergent pulmonary embolectomy as an effective and aggressive therapeutic approach to a massive saddle pulmonary embolism in a 66-year-old woman. With the application of specific surgical techniques and good interdisciplinary cooperation, pulmonary embolectomy may serve as more than a last resort for the management of this clinically unstable and dangerous condition.

Background. Nonimmune long-term travelers to sub-Saharan Africa are at a high risk of contracting malaria. Most previous studies described risk factors and spatial distribution only in short-term travelers. This study describes the epidemiology and spatial distribution of malaria cases among expatriate healthcare workers in Equatorial Guinea. Methods. We conducted a cohort study evaluating the risk factors for malaria among healthcare personnel working in a hospital in Bata, Equatorial Guinea. Demographic data were recorded for all workers, and the spatial distribution of malaria cases within the hospital perimeters was determined. Results. During 2008 noncomplicated falciparum malaria was diagnosed in 13/102 workers (12.75%). On univariate analysis, the factors negatively associated with the risk of contracting malaria were living above the first floor and being older than 30 years. This association remained significant in multivariate analysis [hazard ratio (HR) = 0.24, 95% confidence interval [CI] = 0.06–0.91 for subjects living above the first floor and HR = 0.14, 95% CI = 0.04–0.52 for subjects above 30 years old]. Males and smokers had increased risk of contracting malaria on univariate analysis. However, this association was not significant in multivariate analysis (HR = 3.37, 95% CI = 0.87–13.1 and HR = 3.12, 95% CI = 0.83–11.75, for univariate and multivariate analysis, respectively). Low compliance with malaria prevention guidelines was observed in the study cohort. Conclusions. Living on the ground floor of apartment buildings in sub-Saharan Africa, as opposed to living on the top floors, confers an increased risk of acquiring malaria in long-term travelers with low compliance to prophylaxis. These findings should be discussed in advance with people intending to stay in sub-Saharan Africa for an extended period of time. The association between belonging to a younger age group and an increased risk of acquiring malaria, and the marginally significant increased risk of malaria in males and smokers, can probably be explained by increased exposure to malaria vectors. The compliance of healthcare workers with malaria prophylaxis is extremely low, as was previously described for other long-term residents.

Postoperative mortality after coronary artery bypass grafting (CABG) surgery is traditionally considered to be influenced by gender. However, the data are conflicting and it is not clear whether gender is a true independent risk factor for death in this setting. We analyzed our database to determine whether gender is an independent risk factor for death after CABG.A retrospective analysis of 1 758 isolated first-time coronary artery bypass graft patients treated between 2003 and 2005 was conducted in the Department of Cardiothoracic Surgery of Rabin Medical Center, a major tertiary facility in Israel.The female patients had a distinctly different pre- and intraoperative profile compared with the male patients, and significantly higher postoperative mortality (p0.05). On a propensity scoring of 359 matched pairs, the risk factors for death were found to be severe left ventricular dysfunction, chronic obstructive pulmonary disease, and use of an intra-aortic balloon pump (p0.05). The addition of intraoperative data to the model yielded only cardiopulmonary bypass time and use of an intra-aortic balloon pump as risk factors for death (p0.05). Validation with the bootstrap technique revealed that strong predictors of death (50 % of the sample) were cardiopulmonary bypass time, use of an intra-aortic balloon pump, and, to a lesser extent, chronic obstructive pulmonary disease. Female gender was not found to be an independent risk factor for death after coronary artery bypass graft.Female gender is apparently not an independent risk factor for coronary artery bypass graft mortality in this patient group.

Intravenous leiomyomatosis is a rare, benign neoplasm of the uterine, affecting adult women. We report two cases in whom intravenous leiomyomatosis extended through the inferior vena cava into the right heart chambers and the pulmonary artery. Both patients underwent staged operation with excision of the cardiac and primary tumour. The differential diagnosis of a right atrial mass in middle-aged women should include intravenous leiomyomatosis.

Objective Open-heart surgery carries a high risk for hemodialysis patients. This study focuses on the short and long-term outcomes of hemodialysis patients undergoing heart surgery. Design The study was carried out as a retrospective analysis in the Department of Cardiothoracic Surgery in a large university-affiliated hospital. Patients 115 hemodialysis patients underwent cardiac surgery in our department between 1 July 1996 and 31 July 2006. 67.5 % (77 patients) underwent isolated coronary artery bypass grafting (CABG), 13.2 % (15 patients) underwent isolated aortic valve replacement (AVR) and 20.2 % (23 patients) underwent mitral valve surgery or combined valve and coronary artery bypass grafting or multiple valve surgery. Methods The relationship between several variables (age, sex, hypertension, diabetes, and previous myocardial infarction, type of disease, preoperative ejection fraction, and congestive heart failure) and operative (30 days) mortality and late survival was analyzed. Results The overall 30-day mortality was 18.3 % (21 patients). It was 13 % (10/77 patients) for the isolated CABG group and 13.3 % (2/15) for the isolated AVR group. Patients undergoing combined valve and coronary surgery or multiple valve surgery had a higher perioperative mortality of 39.1 % (9/23) compared to the isolated CABG and isolated AVR patients. Perioperative death was also higher in patients with moderate and severe LV dysfunction, and in patients with diabetes. The duration of dialysis periods was not related to perioperative death. Mean follow-up was 26.4 +/- 29.7 months (0.1 to 104 months). Actuarial survival at 1 year and 5 years was 76 % and 55 % for isolated CABG, 59 % and 21 % for isolated AVR, and 44 % and 33 % for all other cases, respectively (log rank P = 0.001). Conclusion Patients on dialysis have a high risk of perioperative mortality and poor long-term survival rates. Mortality is higher and survival is worse after combined CABG and valve-related procedures or multiple valve surgery than after isolated CABG and AVR.

The differences in hand functionality after harvesting the radial artery for coronary artery bypass grafting (CABG) in an endoscopic technique relative to open technique are unclear. One hundred and sixty-four patients who had CABG and their non dominant hand radial artery was harvested either in an open technique (n = 92) or in an endoscopic technique (n = 72) in a period of 9.8 ± 3.5 months after the operation were studied. Surgical technique was surgeon specific. Patients were asked either five questions (endoscopic group), or six questions (open group), to assess how radial artery harvesting affected them. Significantly more patients in the open group experienced significant limitations in their work and regular daily activities (12% versus 0%, p = 0.02), social activities (13% versus 0%, p = 0.005), and experienced significant pain (8% versus 0%, p = 0.04) compared with the endoscopic group. More patients in the open group complained that their arm incision disturb them (24% versus 10%, p = 0.01). Forty-two patients (46%) in the open group would prefer smaller incision. A “limitation score” variable was created from the first four questions to reflect overall functionality. Severe limitation was present in 3% of the open group versus 0% in the endoscopic group (p = 0.04). Female sex and open harvesting technique were found to be independently associated with higher limitation score. After a mean of 9.8 months after surgery, patients reports good overall upper-limb function. However, more patients in the open technique had significant disabilities and dissatisfaction.

Recent years have witnessed important progress in the use of minimally invasive robotic-enhanced surgical systems in cardiac and general thoracic interventions. We report the first-ever successful use of the Zeus robotic surgical system (Computer Motion, Inc, Goleta, CA) for the excision of an anterior mediastinal mass. Proper positioning of the thoracic ports for the robotic arms to permit a wide range of movement, is the key to the application of the system for intrathoracic cage operations. Other advantages of the system include three-dimensional voice controlled imaging, low-heat surgical field, and good exposure of the structures.

Background: The number of patients awaiting heart transplantation is increasing in proportion to the waiting period for a donor. Studies have shown that coenzyme Q10 (CoQ10) has a beneficial effect on patients with heart failure. Hypothesis: The purpose of the present double‐blind, placebo‐controlled, randomized study was to assess the effect of CoQ10 on patients with end‐stage heart failure and to determine if CoQ10 can improve the pharmacological bridge to heart transplantation. Methods: A prospective double‐blind design was used. Thirty‐two patients with end‐stage heart failure awaiting heart transplantation were randomly allocated to receive either 60 mg U/day of Ultrasome™‐‐‐CoQ10 (special preparation to increase intestinal absorption) or placebo for 3 months. All patients continued their regular medication regimen. Assessments included anamnesis with an extended questionnaire based partially on the Minnesota Living with Heart Failure Questionnaire, 6‐min walk test, blood tests for atrial natriuretic factor (ANF) and tumor necrosis factor (TNF), and echocardiography. Results: Twenty‐seven patients completed the study. The study group showed significant improvement in the 6‐min walk test and a decrease in dyspnea, New York Heart Association (NYHA) classification, nocturia, and fatigue. No significant changes were noted after 3 months of treatment in echocardiography parameters (dimensions and contractility of cardiac chambers) or ANF and TNF blood levels. Conclusion: The administration of CoQ10 to heart transplant candidates led to a significant improvement in functional status, clinical symptoms, and quality of life. However, there were no objective changes in echo measurements or ANF and TNF blood levels. Coenzyme Q10 may serve as an optional addition to the pharmacologic armamentarium of patients with end‐stage heart failure. The apparent discrepancy between significant clinical improvement and unchanged cardiac status requires further investigation.

Early extubation after isolated coronary artery bypass surgery was assessed retrospectively in 545 of 779 patients treated by the same surgical team over one year. All underwent extubation within 10 hr of arrival at the cardiothoracic intensive care unit: 343 in < 6 hr and 202 in 6–10 hr. Operative mortality was 2.2%. Group comparisons revealed that patients who had earlier extubation were younger (61 vs. 66 years; p < 0.001), more likely to be male (72.5% vs. 61.3%; p < 0.05), with a shorter aortic crossclamp time (49.2 ± 15.0 vs. 53.3 ± 14.0 min; p < 0.05), cardiopulmonary bypass time (65 ± 18.4 vs. 72.2 ± 19.2 min; p < 0.05), intensive care unit stay (18.8 ± 5.6 vs. 22.4 ± 3.2 hr; p < 0.05) and postoperative hospital stay (5.2 ± 2.2 vs. 6.0 ± 2.4 days; p = 0.01). Extubation < 6 hr after cardiopulmonary bypass may accelerate recovery. The finding of no significant differences in clinical parameters between the groups suggests that efforts to further reduce the time to extubation might be worthwhile.

Left ventricle pseudoaneurysm is an infrequent complication of myocardial infarction, and is most commonly localized in the inferoposterior left ventricular segments. We describe a patient post anterior myocardial infarction, who presented with pulmonary edema and a large pseudoaneurysm of the anterolateral wall with involvement of the anterolateral papillary muscle, resulting in severe mitral regurgitation. The patient underwent successful operation and is currently well.

Papillary fibroelastoma (PFE) is a rare and histologically benign tumor, but it may have malignant propensity for life-threatening complications. Herein are described four cases of PFE which reflect the clinical diversity of this lesion. The diagnostic and surgical approach utilized is also briefly reviewed.The files of four patients with cardiac valvular PFE treated at the authors' center between January 2002 and November 2003 were reviewed. The diagnosis was strongly suggested by echocardiography. Tumors were noted in aortic (n = 2), mitral (n = 1) and tricuspid (n = 1) sites. Indications for surgery were myocardial infarction (both aortic tumors), previous stroke (mitral tumor), and preventive (tricuspid tumor).Surgical excision with a conservative, valve-sparing approach was performed in all cases. For the first aortic tumor, the aortic valve was reconstructed with a patch of autologous pericardium. None of the patients had evidence of valvular regurgitation after excision on intraoperative transesophageal echocardiography, and all had an uneventful recovery. There were no cases of recurrence or regurgitation on follow up echocardiography.PFE is an uncommon but increasingly recognized cause of embolic phenomena. Prompt identification allows for surgical excision, which seems to be curative, safe and well-tolerated. A conservative valve-sparing approach is recommended because of the absence of recurrence after total excision.

Background Video-assisted thoracoscopy with the creation of a pericardial window is a noninvasive method of pericardial drainage. It also allows an excellent view of both the pleural cavity and pericardium and the precise selection of biopsy sites. We review our 3-year experience with this technique. Methods Between January 2001 and February 2004, 18 patients (10 men, 8 women; mean age 57 years) with echocardiographically diagnosed pericardial effusion underwent video-assisted thoracoscopy at our center. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operating time was 46 minutes. A right thoracic approach was used in 16 patients and a left thoracic approach in 2. Results Microbiology and virology cultures of the pericardial fluid were negative. Histologic findings were compatible with tuberculosis in 2 cases and granulocytic sarcoma, infiltrating breast carcinoma, and infiltrating nonsmall cell carcinoma in 1 case each. In the remaining patients, the histologic diagnosis was chronic or subacute nonspecific pericarditis. Talc pleurodesis was performed in 3 patients for concomitant malignant pleural effusion. In 4 patients, the pericardial effusion occurred secondary to cardiac surgery; 3 were receiving anticoagulants after valve replacement, and 1 had a heart transplant. There were no complications of the thoracoscopy technique. Conclusions Video-assisted thoracoscopic fenestration is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures. Concomitant pleural and pulmonary disorders may be managed simultaneously.

Objective: The internal thoracic artery has become the conduit of choice for coronary artery bypass grafting. To avoid spasm of the artery, and increases in its diameter and flow, various vasodilators have been used either intraluminally or by topical application by different surgeons. In order to define the best vasodilating agent for preparation of the internal thoracic artery, a randomized double-blind placebocontrolled clinical study was performed in a group of patients submitted for elective coronary artery bypass grafting. Methods and results: Eighty (80) consecutive patients submitted for elective first time coronary artery bypass grafting were randomly subdivided into five treatment groups. Free flow of the left internal thoracic artery was measured using an electromagnetic flow meter. The first measurement was performed shortly after the internal thoracic artery was dissected from the chest wall and the second just prior to performing distal anastomosis to the left anterior descending coronary artery. During the time interval between the two measurements the internal thoracic artery was immersed in a special applicator tube containing 20 ml solution of one of the following drugs: papaverin 2 mg/ml, nitroglycerin 1 mg/ml, verapamil 0.5 mg/ml, nitroprusside 0.5 mg/ml, normal saline 0.9%. Results: No statistically significant differences were found between the groups in respect to age, body surface area, bypass time, cross clamping time, and time interval between the two flow measurements. Mean arterial pressure at the time of the first and second internal thoracic artery flow measurements did not show statistically significant differences either within or between the groups. In all five groups, the free flow of the internal thoracic artery increased significantly with time. However, no statistically significant differences were shown between the five groups with respect to second flow (Pa 0:2). Conclusions: Within the limits of our study design, we suggest that preparation of the LITA by topical vasodilator drugs using a special applicator tube does not result in a significantly superior free flow than placebo. q 1999 Elsevier Science B.V. All rights reserved.

Objective.The lung injury regularly associated with cardiopulmonary bypass (CPB) may be linked to gut mucosal dysfunction occurring as the result of mucosal ischemia associated with nonpulsatile CPB. To examine this possibility we postulated that the weak-β2 agonist dopexamine would improve gut mucosal blood flow, thereby decreasing gut and lung dysfunction seen after CPB in sheep. Methods.Anesthetized sheep had 2 h of hypothermic (24°C), nonpulsatile CPB, and 60 min of cold, blood cardioplegic arrest. After warming they were separated from CPB for 2 h of reperfusion. Before and during CPB, dopexamine at 2 μg/kg/min (n= 7) or saline (n= 7) were infused in a blinded fashion. Hemodynamic parameters were measured. Biatrial thromboxane B2levels were obtained. Mesenteric arterial flow (QSMA), mucosal flow (Qmuc), FD-4 clearance (ClFD-4), and tonometric pHiwere measured at baseline and 30-min intervals on, and after, CPB. Results.After CPB, similar reductions in MAP were seen (P< 0.05 vs. baseline), but heart rate and the mean pulmonary vascular resistance were significantly increased in the dopexamine animals (P< 0.05 vs. placebo). Plasma thromboxane was similarly increased in both groups after CPB (P< 0.05 vs. baseline), returning to baseline 1 h after CPB. TheQsmawas not altered, but a statistically significant decrease inQmucand pHioccurred in both groups (P< 0.05 vs. baseline). In both groups FD-4 clearance reached a peak 30 min after CPB (P< 0.05; dopexamine vs. baseline). After 2 h neither of these changes returned to control levels. Conclusions.In this ovine model, gut mucosal ischemia and increased permeability occur with hypothermic CPB, but dopexamine administration during CPB, compared to placebo, neither ameliorates these intestinal derangements nor reduces post-CPB lung pathophysiology.

A number of heparin-binding growth factors, including basic (bFGF) and acidic (aFGF) fibroblast growth factors have been shown to promote angiogenesis in vivo. In this study, we employed a sustained-release polymer extravascular delivery system to evaluate the angiogenic efficacy of a novel form of genetically modified aFGF in the setting of chronic myocardial ischemia. Fifteen Yorkshire pigs subjected to Ameroid occluder placement on the left circumflex (LCX) artery were treated with perivascularly administered aFGF in ethylene vinyl acetate (EVAc) polymer (10 μg, n = 7) or EVAc alone (controls, n = 8). Seven to nine weeks later, after coronary angiography to document Ameroid-induced coronary occlusion, all animals underwent studies of coronary flow and global and regional left ventricular function. Microsphere-determined coronary flow in the Ameroid-compromised territory was significantly increased in aFGF-treated compared with control animals, and this improvement in perfusion was maintained during ventricular pacing. Left ventricular function studies demonstrated improved global and regional function in aFGF-treated animals. We conclude that local perivascular delivery of genetically modified aFGF results in significant improvement in myocardial flow and regional and global left ventricular function.

Cardiopulmonary bypass (CPB) is associated with a generalized defect in the intrinsic control of vascular smooth muscle. To determine if myogenic reactivity of skeletal muscle arterioles was altered by CPB, sheep (n = 7) were placed on hypothermic CPB (27 degrees C) for 90 min and hearts were arrested by cold blood cardioplegia ([K+] = 25 mM) for 60 min. Arterioles (70-180 microns) were isolated from the gracilis muscle before (control) and 15 min after CPB. In vitro arteriolar responses were studied with video-microscopy. Myogenic reactivity was examined to stepwise increases in intraluminal pressure from 10 to 100 mm Hg. Mean arterial pressure was decreased from 80 +/- 15 prior to CPB to 55 +/- 4 mm Hg (P0.01) 15 min after CPB. Myogenic contraction was observed in control vessels and was markedly attenuated by the protein kinase C inhibitor staurosporine (P0.01). CPB decreased myogenic contraction and shifted the pressure-diameter relation upward, suggesting a decrease in the intrinsic tone (both P0.05 vs control). CPB reduced contractile responses to the alpha 1-adrenoceptor agonist phenylephrine from -43 +/- 7% to -23 +/- 5% (P0.01) and the protein kinase C activator 12-deoxyphorbol 13-isobutyrate 20-acetate (phorbol ester) from -64 +/- 6% to -38 +/- 16% (P0.01). CPB-associated decrease in myogenic reactivity of skeletal muscle arterioles is likely due to alterations in protein kinase C and/or downstream signal transduction. This may account in part for reduction in systemic vascular resistance and hypotension associated with CPB.

Background The purpose of the current investigation was to determine and compare the direct effect of isoflurane on normal resistance coronary arteries and similarly sized coronary arteries in collateral-dependent (CD) circulation. A differential vasomotor effect of isoflurane might contribute to flow redistribution, either adverse or favorable, between normal and CD regions. Methods The authors used a swine model of chronic coronary occlusion. Six weeks after ameroid occluder placement around the left circumflex artery, the heart was removed. Myocardial blood flow, measured in vivo before the removal, was lower during rapid atrial pacing in the CD region than in the normally perfused region. These in vivo studies established the existence and location of CD circulation. Subepicardial microvessels, measuring approximately 100 microns, were dissected from both the CD region and the normal region. Either with or without preconstriction of the vessels with the thromboxane analogue U46619 1 microM, direct vasomotor effect of isoflurane was examined in vitro by video microscopy. In addition, vasomotor responses to endothelin-1, the endothelium-dependent dilator adenosine 5' diphosphate, and the endothelium-independent dilator sodium nitroprusside were compared between CD and normal resistance vessels. Results Isoflurane caused greater concentration-dependent constriction of the normal vessels than of the CD vessels (P < 0.05); this constrictive effect was masked by preconstriction of the vessels. Vasodilation of ADP was less in CD vessels than in normal vessels (P < 0.001), but vasodilation to sodium nitroprusside was not significantly different (P = 0.45). Vasoconstriction to endothelin-1 was greater in CD vessels than in normal vessels (P < 0.01). Conclusions The vasoconstrictive effect of isoflurane normally observed in coronary resistance vessels is impaired in resistance vessels that supply a CD area. The basis of this may be related to endothelial dysfunction.

Background. The purpose of this study was to determine whether cerebral cortical microvascular responses to platelet-derived vasoactive substances are altered after normothermic cardiopulmonary bypass (CPB), and whether these alterations are modified by moderate hypothermia. Methods. Pigs were placed on normothermic CPB (37°C) for 2 hours and then perfused off CPB with normothermic blood for either 15 minutes (n = 8) or 60 minutes (n = 6). Another group was placed on moderately hypothermic CPB (25°C) for 2 hours and then perfused off CPB at 37°C for 15 minutes (n = 6). Alpha-stat pH management was used. In vitro responses of isolated cortical cerebral arterioles (90 to 170 μ m internal diameter) to platelet-derived vasoactive substances were examined in a pressurized no-flow state with video-microscopy. Microvessels from noninstrumented pigs (n = 14) were used as controls for in vitro studies. Results. Cerebrovascular resistance and internal carotid artery blood flow were similar 15 minutes after CPB in both normothermic and hypothermic groups. However, relaxations of microvessels to adenosine 5′ diphosphate or serotonin were reduced in vessels from both groups. One hour of after CPB cerebral perfusion did not change this pattern of altered vascular reactivity. Hypothermia caused a partial but significant reduction in impairment of responses to adenosine 5′ diphosphate and serotonin. Microvascular relaxation to the endothelium-independent agent sodium nitroprusside and contraction to a thromboxane A 2 analog were similar in all experimental groups, suggesting normal vascular smooth muscle responsiveness. Conclusions. This study demonstrates that normothermic extracorporeal circulation reduces endothelium-dependent relaxation responses to products of platelet activation in the cerebral microcirculation. Moderate hypothermia attenuates the CPB-induced impairment of endothelium-dependent relaxation, but has no effect on baseline cerebral blood flow after rewarming.

Recombinant activated factor VII (rFVIIa) (NovoSeven®; Novo Nordisk, Denmark) was developed primarily for the treatment of bleeding episodes in hemophilic patients. Little information is available on the use of rFVIIa in other situations, such as intractable postsurgical or post-traumatic bleeding. In the field of cardiac surgery, only a very few cases of treatment with rFVIIa are described. Because of the difficulty in performing randomized trials in this setting, information based on case studies is very valuable.