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[Image: see text] Central Picture Legend: Ethical standards for global health initiatives.

Objective: Postoperative wound infection in cardiac surgery remains a subject of significant concern due to associated morbidity, prolonged hospital stay and rise in treatment cost. A conservative management approach to postoperative wound infection with topical dressings and healing by secondary intention is not cost-effective and cosmetic results are less acceptable. We developed our institutional protocol for the treatment of infected postoperative cardiac surgical wounds to reduce hospital stay and improve cosmetic outcome. This study aims to compare our institutional protocol with the conservative management approach. Methods: Adult patients with postoperative superficial or deep sternal and/or leg wound infection were divided into two equal-sized groups and data collected from medical records. Group A was treated according to our institutional protocol of aggressive surgical debridement and delayed primary closure. Group B was treated according to conservative management with topical antiseptic wound dressings and healing by secondary intention. Data were analysed in retrospect with comparative statistics. Results: A total of 30 patients took part in the study. Group A (n=15, seven male, eight female) had a mean age of 55.34±12.84 years. Group B (n=15, eight male, seven female) had a mean age of 56.46±10.21 years. Mean length of hospital stay in Group A and Group B was 5.13±2.06 and 36.67±22.28 days, respectively (pConclusion: In this study, cost and clinical effectiveness of aggressive surgical debridement and delayed primary closure was superior to conservative management with topical antiseptic wound dressings and healing by secondary intention in terms of a shorter hospital stay and better cosmetic outcome.

Human beings have evolved their modes of communication continually through the ages. Over the last decade, social media in their various forms have become the preferred mode among younger generations, and their use has increased among older generations as well. Worldwide users of social media are expected by 2021 to number over 3 billion, which is approximately a third of the world’s population.1 The region with the highest penetration rate of social networks is North America, wherein around 60% of the population has more than one social media account, and 78% of the US population has a social networking profile.2 Social media offer enormous potential benefits for both care providers and patients, as the platform allows for the dissemination and gathering of information and has the innate ability to network globally. In fact, in a recent survey, 70% of surgeons indicated that they believe social media benefited professional development, while 22% preferred social media as their primary modality of networking and communication with colleagues.3 In using social media, care providers, particularly physicians and surgeons, must pay close attention to professionalism, specifically within the framework of professional ethics.

Background We report early results of surgical preparation and subsequent percutaneous Fontan completion strategy for the treatment of single-ventricle defects. Methods Two hundred twenty-seven patients underwent bidirectional cavopulmonary connection (BDCPC) between 2002 and 2007. Thirty-four patients had lateral tunnel created at time of BDCPC, fenestrated with 10 to 14 mm openings with the cardiac superior vena cava end patched to maintain BDCPC physiology. At second stage, Fontan circulation was established by superior vena cava patch perforation, tunnel dilatation, and stenting plus fenestration device closure. Results Thirty-four patients underwent Fontan preparation with BDCPC. Median age was 7.7 months (5 to 51) and 29 patients (85%) had previous palliation. Mean bypass and ischemic times were 141 and 72 minutes, respectively. Median ventilation, intensive care, and hospital stay durations were 1, 5, and 10 days, respectively. There was one early death and two take-downs. Twenty-eight patients underwent Fontan procedure: surgical (n = 3), percutaneous (n = 25). None of the patients who underwent percutaneous Fontan completion required inotropes, chest tube insertion, or mechanical ventilation. Median intensive care and hospital stay durations were 1 and 6 days, respectively. There were no early mortalities after percutaneous Fontan but one late death and one surgical revision. Overall survival after BDCPC with Fontan preparation was 77%. Conclusions Despite longer bypass and ischemic times, Fontan preparation at time of BDCPC is feasible and associated with encouraging early outcomes. Percutaneous Fontan completion is associated with short recovery, low morbidity and excellent early dynamics, and echocardiographic and clinical outcomes. Further follow-up is needed to confirm those favorable results.

Objectives: The Ross procedure is the aortic valve-replacement procedure of choice in children. Nonetheless, late autograft re-operation for dilatation and/or valve regurgitation is of concern. We examined whether preoperative haemodynamic manifestation (e.g., stenosis, regurgitation and mixed aortic valve disease) affected late re-operation risk. Methods: Medical records of 227 children who underwent the Ross procedure (1991—2004) were reviewed. Competing-risks methodology determined time-related prevalence and associated factors for two mutually exclusive end-states after the Ross procedure: (1) death prior to subsequent autograft re-operation and (2) autograft re-operation, with the remainder of patients being alive and free from subsequent autograft re-operation.Results:There were 162 male patients (71%) in this study. Median age at surgery was 12.1 years (range: 1 week—18 years). The haemodynamic aortic valve dysfunction was primarily stenosis (n = 40, 18%), primarily regurgitation (n = 109, 48%) and mixed disease (n = 78, 35%). Underlying pathology was rheumatic fever (n = 104, 46%), congenital heart disease (n = 113, 50%) and endocarditis (n = 8, 3%). Competing-risks analysis showed that, at 10 years following the Ross procedure, 5% of patients had died, 16% had undergone autograft re-operation with aortic valve replacement and 79% were alive and free from autograft reoperation. Ten-year freedom from autograft re-operation for patients with preoperative stenosis, regurgitation and mixed disease was 97%, 69% and 93%, respectively, (p < 0.001 for regurgitation vs others). Risk factors for increased risk of autograft re-operation were rheumatic fever (parameter estimates (PEs): 2.09 0.75, p = 0.006), and earlier year of surgery (PE: 0.20 0.06, p = 0.001). Ten-year freedom from homograft replacement was 81% and was not dependent on haemodynamic manifestation (PE: 0.16 0.38, p = 0.68). Significant factors for homograft replacement included fresh homografts (PE: 2.2 0.63, p = 0.01) and annular enlargement (PE: 1.11 0.3, p = 0.01). Ten-year freedom from cardiac re-operation other than auto-/homograft was 85%, higher in patients with preoperative aortic regurgitation (PE: 1.01 0.42, p = 0.02). Concomitant cardiac surgery was a significant factor for late cardiac re-operation other than auto-/homograft replacement (PE: 1.79 0.39, p < 0.001). Conclusions: The Ross procedure in children is associated with excellent survival. Late autograft re-operation may be required; however, it is more common in children with preoperative aortic regurgitation, especially those with rheumatic fever. Better patient selection in later era has mitigated the risk of autograft re-operation. Continued improved candidate selection, along with modifications in autograft implantation and root/sinotubular stabilisation techniques, may further decrease late autograft failure. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objectives: Although the majority of infants with severe left ventricular outflow tract obstruction (LVOTO) can be managed with balloon or surgical aortic valvotomy, a more complex biventricular repair may be required in a subset of infants with multi-level obstruction, failure of or complication to prior intervention. In the presence of normal left ventricle size and inflow, the Ross procedure is applied in patients with/without ventricular septal defect (VSD), while the Yasui procedure is applied only in those with VSD. We report mid-term outcomes in a single institution. Methods: Thirty-five consecutive infants with severe LVOTO underwent complex biventricular repair using the Ross (n = 21) or Yasui (n = 14) procedure. Outcomes were studied using univariate and multivariable parametric models. Results:The Ross procedure was done at a median age of 88 days (8—353days), in 8/21(38%) neonates.As manyas 12/21 (57%) hadprior catheterand/orsurgicalintervention. Concomitant procedures included arch reconstruction (n = 4/21, 19%) and mitral valve repair (n = 6/21, 29%). In addition, 14/21 (67%) had annular enlargement (modified Ross—Konno). Haemodynamic manifestation was isolated obstruction (n = 10/21, 48%) or mixed obstruction/regurgitation (n = 11/21, 52%). Survival was 81% at 1 month, 70% at 1 year and 63% at 5 years. In multivariable regression models, factors associated with increased risk of mortality included neonatal surgery (p = 0.007), mitral valve repair (p = 0.02), longer cross-clamp time (p = 0.003), and postoperative extracorporeal membrane oxygenator (ECMO) (p = 0.004). Freedom from any cardiac re-operation was 86% at 5 years. The Yasui procedure was done at a median age of 36 days (7—207 days), 6/14 (43%) in neonates. As many as 13/14 procedures (93%) were primary and one procedure followed a prior single-stage Norwood palliation. A total of 10/14 (71%) had critical aortic stenosis and 4/14 (29%) had atresia. All patients had VSD, and 11/14 (79%) required concomitant arch reconstruction. Survival was 79% at 1 month and 5 years while 5-year freedom from re-operation was 57%. Conclusions: Complex biventricular repair can be performed in neonates and infants with severe LVOTO with mid-term survival that is equivalent to that published following balloon or surgical aortic valvotomy. Associated lesions are significant factors that influence outcome and proper patient selection may further improve survival. In neonates with concomitant arch obstruction and VSD, the Yasui operation may be associatedwithlowerearlymortalityrisk.Neonateswithconcomitantmitralvalvepathologymaybebetterservedwithsingleventriclepalliation strategy.

Background— In patients with sickle cell trait or disease, reduced life expectancy and a tendency for complications are believed to negatively affect likelihood of survival after open heart surgery. The aim of this study was to review retrospectively the perioperative results of patients undergoing cardiac surgery at our institution. Methods and Results— Between January 1995 and December 2006, 47 patients with either sickle cell disease or sickle cell trait underwent open heart surgery at our institution. The average age of the 29 male and 18 female patients was 20 years. Patient outcomes were analyzed through the use of the institutional database. Clinical and echocardiographic follow-up was complete in all patients except 3, with a mean follow-up period of 46 months. Current status could be confirmed in 32 patients. The most common operations included the treatment of congenital and valvular heart diseases. There were no coronary artery bypass grafting procedures. Average weight of the patients was 45 kg. Exchange transfusion was performed both preoperatively and during surgery. Mean preoperative hemoglobin S concentration was 30.4±3.2% and decreased to 8.1±2.6% while on pump. Average on-pump hematocrit value was 25.4±3.7%; in the postoperative period, it increased to 32.7±4.9%. Mean cardiopulmonary bypass and cross-clamp times were 95 and 69 minutes, respectively. None of the patients had sickling crisis or acidosis. Postoperative complications included exploration for hemorrhage in 3 patients (6.4%), stroke in 2 patients (4.3%), renal failure in 2 patients (4.3%), and prolonged ventilation in 1 patient (2.1%). Average hospital stay was 8.3 days (range, 4 to 27 days). Early in-hospital death occurred in 1 patient (2.1%); currently, 31 patients (66%) remain alive and free of cardiac symptoms. Conclusion— Heart valve surgery and surgery for congenital heart diseases can be performed safely in patients with sickle cell disease or sickle cell trait with acceptable outcome and survival rates.

Stroke in cardiac patients undergoing surgery is usually attributed to the use of cardiopulmonary bypass. In this report, we present an unusual cause of cerebral dysfunction: a meningioma leading to stroke, following coronary artery bypass grafting in a 62-year-old patient. Diagnosis and treatment options of the pathology are discussed with the guidance of the literature.

Objective:Theidealvalvesubstitutein childrendoesnot exist.Biologicandbioprosthetic valvesdo not requireanticoagulation, howevertheir use is complicated by accelerated degeneration and requirement for reoperation. We examine results following mitral (MVR) or aortic (AVR) replacement with biologic and bioprosthetic valves at our institution. Methods:Medical records of children who underwentAVRor MVR from 1986 to 2006 were reviewed. Median follow-up duration was 10.5 years. Competing-risks methodology determined time-related prevalence and associated factors for three mutually exclusive end states: death, valve reoperation, and survival without subsequent reoperation. Results: One hundred and ten children (age 15.6 2.6 years, 80% females) underwent 123 valve replacements with biologic and bioprosthetic substitutes including 87 MVR and 36 AVR (13 had both). Underlying pathology was mainly rheumatic fever (91%). Thirty-nine patients (35%) had undergone a previous cardiac surgery. Most common mitral substitute was Hancock (73%) and homograft (8%); most common aortic substitute was homograft (41%) and Carpentier—Edwards (39%). Competing-risks analysis showed that 15 years after valve replacement, 16% of patients had died without subsequent reoperation, 66% underwent valve reoperations, and only 18% remained alive without further reoperation. Factors associated with increased reoperation risk included younger age at surgery (p = 0.005), AVR (p = 0.005), male gender (p = 0.02) and homograft use (p = 0.007) especially in the mitral position (p = 0.002). Fifteen-year freedom from endocarditis was 97% while freedom from bleeding and thrombo-embolic complications was 100%. Majority of patients (95%) were in NYHA functional classes I/II at last follow-up. Conclusion: While valve reoperation is inevitable following AVR and MVR with biologic and bioprosthetic substitutes; favorable results such as low valve-related morbidity rate, good long-term survival and functional status encourage their consideration as valid replacement alternatives in selected children especially females. Valve durability is higher in the mitral position and longevity of bioprosthetic valves is greater than that of homografts especially in the mitral position.

Background The Rastelli procedure is the standard surgical treatment of d-transposition of great arteries (d-TGA), ventricular septal defect (VSD), and pulmonary stenosis. Late morbidity is significant due to recurrent left ventricular outflow obstruction (LVOTO), early conduit obstruction, and arrhythmias, with troublesome late mortality. To avoid recurrent LVOTO, we routinely enlarge the VSD and resect the infundibular septum before LV baffling to the aorta. We examined the efficacy of this approach in mitigating recurrent LVOTO risk. Methods Late echocardiographic and time-related clinical results of patients undergoing the Rastelli procedure were examined. Demographics and operative variables affecting outcomes were analyzed. Results The Rastelli cohort comprised 36 patients with d-TGA, VSD, and pulmonary stenosis. Median age at operation was 2.4 years (range, 0.3 to 8.3 years). Pulmonary stenosis was present in 31 and atresia in 5. Twenty-two patients had undergone a previous aortopulmonary shunt, and 6 had an atrial septectomy. No operative or late deaths occurred. Time-related freedom from permanent pacemaker implantation, recurrent LVOTO on echocardiogram, and conduit replacement at 10 years was 82%, 100%, and 49%, respectively. Systolic function was normal in all but 3 patients and 92% were in New York Heart Association functional class I and II. None of the patients had late arrhythmias or required heart transplantation. Conclusions Early and midterm survival after the Rastelli procedure is satisfactory. Aggressive resection of the infundibular septum to enlarge the VSD has mitigated the risk of LVOTO recurrence. Late conduit obstruction remains an important source of morbidity and frequently requires reintervention.

Data from 519 patients older than 65 years with congestive heart failure (CHF) were analyzed after 5 years of clinical follow-up. Two groups were included in the analysis: 321 patients with ejection fractions > or =50% (group with diastolic heart failure) and 198 patients with reduced ejection fraction

Objectives: The study aim was to assess the long-term results (up to 18 years) of mitral balloon valvuloplasty (MBV) and to identify predictors of restenosis and event-free survival. Methods: The immediate and long-term results for 531 consecutive patients (mean age 31 ± 11 years) who underwent successful MBV and were followed up for a mean of 8.5 ± 4.8 years (range: 1.5–18 years) are reported. Results: The mitral valve area (MVA) increased from 0.92 ± 0.17 to 1.95 ± 0.29 cm2 (p < 0.0001). Restenosis was 31 and 19% in patients with mitral echocardiographic score (MES) ≤8. Actuarial freedom from restenosis at 10, 15 and 18 years was 77 ± 2, 46 ± 3 and 18 ± 4% and 86 ± 2, 62 ± 4 and 31 ± 7% for MES ≤8, respectively (p < 0.001). Event-free survival (death, redo MBV, mitral valve replacement, NYHA class III or IV) at 10, 15 and 18 years was 88 ± 1, 53 ± 4, and 21 ± 5% and 93 ± 2, 65 ± 5 and 38 ± 8% for MES ≤8, respectively (p < 0.001). Multivariable Cox regression analysis identified MES >8 (p < 0.0001) and previous surgery (p = 0.043) as predictors of restenosis, and MES >8 (p < 0.0001) and baseline atrial fibrillation (p = 0.03) as predictors of combined events. Conclusion: MBV provides excellent long-term results. The baseline clinical and MES characteristics are predictors of outcome.

Optimal repair of anomalous origin of left coronary artery from pulmonary artery (ALCAPA) relies on the creation of a dual-coronary system. If the anomalous coronary arises at a long distance from the aorta, we use various coronary extension techniques to facilitate tension-free implantation.Thirty patients underwent ALCAPA operations using direct coronary transfer (n = 11) or coronary extension techniques (n = 19). Surgical outcomes were analyzed.Median age and weight were 5.7 months (range, 46 days to 5.45 years) and 5.35 kg (range, 3.3 to 15.9 kg). Five patients had concomitant mitral annuloplasty. Mean cardiopulmonary bypass and ischemic times were 108 +/- 38 and 57 +/- 25 minutes. Two patients required intraoperative revision of the implantation. There were three hospital deaths (10%) and no late deaths. Follow-up echocardiograms demonstrated significant improvement postoperatively vs preoperatively in shortening fraction (35% +/- 2% vs 16% +/- 2%, p0.00001), ejection fraction (64% +/- 3% vs 32% +/- 4%, p0.00001), and mitral regurgitation (11% moderate vs 70% moderate or severe, p = 0.0002). Left ventricular end-diastolic dimension Z-score decreased from 9.1 +/- 0.9 to 1.2 +/- 0.5 (p0.00001). Both techniques were equally effective. Two patients underwent reoperation 1 and 12 years postoperatively (coronary artery bypass grafting, 1; mitral repair with coronary angioplasty, 1). Surviving patients remain asymptomatic (p0.00001).Dual-coronary system can be established in patients with ALCAPA. Coronary extension implantation techniques have acceptable operative mortality and excellent cardiac recovery and late survival. Although the rate of late coronary occlusion is low, continual ventricular or mitral dysfunction should trigger evaluation of persistent coronary compromise.

The purpose of this study was to assess the safety, efficacy, and long-term results (up to 18 years) of mitral balloon valvuloplasty (MBV) in children in comparison to adults.57 children ageor = 18 years (group A) and 474 adult patients (group B) who underwent successful MBV and were followed up for a mean 8.5 +/- 4.8 (range 1.5-18) years were analyzed.Patients in group A had a lower mitral echocardiographic score (echo score), 7.6 +/- 1.3 vs. 8.1 +/- 1 (P = 0.0005); smaller Doppler mitral valve area (MVA), 0.82 +/- 0.16 cm(2) vs. 0.92 +/- 0.17 cm(2) (P0.0001); and higher mitral valve gradient, 15.2 +/- 2.3 mmHg vs. 14.3 +/- 2.1 mmHg (P = 0.0003), than group B. Immediately after MBV, group A had larger MVA whether measured by catheter, 1.99 +/- 0.57 cm(2) vs. 1.8 +/- 0.52 cm(2) (P0.001), or by Doppler, 2.0 +/- 0.27 cm(2) vs. 1.97 +/- 0.28 cm(2) (P0.01), and similar complication rates, compared to group B. After a mean follow-up of 8.5 +/- 4.8 (range 1.5-18 years), restenosis in group A was 26% vs. 31% for group B (P = 0.41). Echo score8 (P = 0.046) was a predictor of restenosis in children and echo score8 (P0.0001) and previous surgery (P = 0.043) were predictors of restenosis in adults. Actuarial freedom from restenosis at 10, 15, and 18 years for groups A and B were 78%+/- 7%, 64%+/- 9%, and 18%+/- 14% and 77%+/- 2%, 43%+/- 4%, and 17%+/- 4%, respectively (P = 0.26). Event-free survival rates at 10, 15, and 18 years were 87%+/- 6%, 62%+/- 1%, and 20%+/- 2% versus 87%+/- 1%, 51%+/- 4%, and 20%+/- 5% for groups A and B, respectively (P = 0.51). Postprocedure MVA2.0 cm(2) (P = 0.043) and previous surgery (P = 0.03) were identified as predictors of events in children. Echo score8 (P0.0001) and prevalvuloplasty AF (P = 0.03) were identified as predictors of events in adults.MBV is safe and effective in children with rheumatic MS. It provides better immediate results than in adults and excellent long-term results that are comparable to those seen in adults.

Background— The formation of angiotensin-(1-7) from either angiotensin (Ang) I or Ang II in failing human hearts is not well understood. Methods and Results— Angiotensinase activity in left and right ventricular membranes from 14 idiopathic dilated cardiomyopathy (IDC), 8 primary pulmonary hypertension (PPH), and 13 nonfailing human hearts was measured with either 125 I-Ang I or 125 I-Ang II as substrate. Ang-(1-7)–forming activity from 125 I-Ang I was inhibited by thiorphan. With 125 I-Ang II as substrate, Ang-(1-7) formation was inhibited by the ACE2-specific inhibitor C16. Western blotting with an anti-ACE2 antibody confirmed the presence of ACE2. Angiotensinase activity with 125 I-Ang I as substrate was increased in failing IDC left ventricles (LVs) compared with nonfailing LVs ( P 125 I-Ang II as substrate was increased in both failing LVs and right ventricles (RVs) of IDC hearts and only in failing RVs of PPH hearts (PPH LV, 51.12±5.25; PPH RV, 89.97±11.21; IDC LV, 139.7±21.96; and IDC RV, 192.7±5.43; NF LV, 32.89±5.38; NF RV 40.49±10.66 fmol/min per milligram ( P P P P Conclusions— Ang-(1-7)–forming activity from both Ang I and Ang II was increased in failing human heart ventricles but was mediated by at least two different angiotensinases. The first, which demonstrated substrate preference for Ang I, was neutral endopeptidase (NEP)-like. The second was ACE2, as demonstrated by Western blotting and inhibition of activity with C16.

To reverse preexisting coronary graft spasm, we investigated the vasodilative effect of the average therapeutic plasma concentration of nitroglycerin (NTG) alone and various calcium antagonists in combination with NTG in human arterial and venous conduits.Vasodilative effects of 2 x 10(-8) mol/L NTG alone and 10(-8) mol/L NTG in combination with 2.2 x 10(-7) mol/L diltiazem, 2.8 x 10(-7) mol/L nifedipine, 10(-7) mol/L verapamil, or 5.6 x 10(-8) mol/L nicardipine were assessed in human radial artery, internal thoracic artery, and saphenous vein segments precontracted with a mixture of ten times the maximum plasma concentrations of endothelin-1 (8.6 x 10(-13) mol/L), angiotensin II (36 x 10(-11) mol/L), 5-hydroxytryptamine (3.4 x 10(-7) mol/L), and norepinephrine (1.7 x 10(-8) mol/L). The studies were done in organ baths.The therapeutic concentration of NTG alone or nifedipine, verapamil, diltiazem, or nicardipine in combination with NTG caused equal relaxation in a particular group of vascular segments (average vasodilation: radial artery, 83% to 95% [p = 0.7608 by analysis of variancel; saphenous vein, 47% to 70% [p = 0.3142]; internal thoracic artery, 54% to 79% [p = 0.27831). These combinations were not equally effective when compared between different groups of vascular segments (vasodilation; radial arteryinternal thoracic arterysaphenous vein [p0.0001 by analysis of variance]). Although not significant, in comparison with NTG alone, NTG in combination with a calcium antagonist caused less vasodilation in any group of vascular segments.Nitroglycerin alone or in combination with nifedipine, verapamil, diltiazem, or nicardipine effectively reverses preexisting vasospasm in coronary artery conduits.

Background . Surgical management of patients presenting for coronary artery bypass grafting with significant bilateral carotid artery stenosis has not been well defined. In this study, our preliminary results of coronary artery bypass grafting with concomitant bilateral carotid endarterectomy have been reviewed. Methods . A retrospective nonrandomized chart review was performed in 33 patients with unstable angina and bilateral carotid artery stenosis, more than 70%, undergoing simultaneous coronary artery bypass grafting and bilateral carotid endarterectomy using an eversion technique. Results . Concomitant coronary artery bypass grafting with bilateral carotid endarterectomy was performed urgently in 24 (73%) and electively in 9 (27%) patients. The average carotid artery cross-clamp and total perfusion times were 14.7 ± 4.9 minutes and 123 ± 29.2 minutes, respectively. The average length of stay in the cardiopulmonary intensive care unit was 4.2 ± 14.2 days and total hospital stay was 16.2 ± 20.5 days. Postoperative in-hospital stay was 14.9 ± 20.3 days. There were no postoperative strokes. Twenty-one (64%) patients were discharged before the tenth postoperative day. Nonfatal postoperative complications occurred in 27% (9 of 33) of patients. The overall 30-day mortality was 6.1% (2 of 33) and that was unrelated to primary cardiac or cerebrovascular events. Conclusions . Favorable outcome supports the justification for performing concomitant coronary artery bypass grafting with bilateral carotid endarterectomies in selected patients.

Background The introduction of cyclosporine has resulted in significant improvement in the survival of cardiac allograft recipients due to decreased mortality from infection and rejection. The original oil-based cyclosporine formulation exhibits variable and unpredictable bioavailability that correlates with an increased incidence of acute and chronic rejection in those patients in whom this is most pronounced. The primary objectives of this prospective, multicenter, randomized, double-blind study in cardiac transplant patients were: to compare the efficacy of cyclosporine microemulsion (CsA-NL) with oil-based cyclosporine (CsA-SM) as measured by cardiac allograft and recipient survival and the incidence and severity of acute rejection episodes; and to assess the safety and tolerability of CsA-NL compared with CsA-SM in this population. This report represents the analysis of results 6 months after transplantation. Methods A total of 380 patients undergoing their first cardiac transplant at 24 centers in the United States, Canada, and Europe were enrolled in this double-blind, randomized trial examining the safety and efficacy of CsA-NL versus CsA-SM. Rejection was diagnosed using endomyocardial biopsy and were graded according to standardized criteria of the International Society of Heart and Lung Transplantation (ISHLT). Clinical parameters were monitored during the study. Survival and freedom from were used for analysis as was Fisher's exact test for comparisons between groups. Results At 6 months after transplantation, allograft and patient survival were the same for both groups. The frequency of ISHLT grade 3A or greater episodes in the two groups was identical. Fewer CsA-NL patients (5.9%) required antilymphocyte antibody (ATG or OKT-3) therapy for rejection compared with the CsA-SM-treated patients (14.1%, P=0.01). Females with ISHLT rejection grade > or = 3A treated with CsA-NL had a 46% lower incidence of rejection compared with the CsA-SM-treated group (31.3% vs. 57.6%, P=0.032). Fewer infections were seen in the CsA-NL. With the exception of baseline and 1 week posttransplant creatinines which were higher in the CsA-NL group, the overall creatinine was not significantly different between the two groups. Conclusions This multicenter, randomized study of cardiac transplant recipients documented less severe rejection (in particular those requiring antibody therapy) and a lower incidence of infection in CsA-NL-treated patients. Results from the female subgroup analysis suggest that the improved bioavailability of CsA-NL might reduce the frequency of rejection episodes in female patients. The use of CsA-NL was not associated with an increased risk of adverse events.

University of Wisconsin solution (UW) has been shown to be an effective preservative for the cardiac allograft. Recently, the high potassium content of UW has been implicated in causing coronary endothelial damage, allegedly contributing to development of cardiac allograft vasculopathy (CAV) and eventually to poorer survival.We examined our experience using UW for preservation of cardiac allografts between 1990 and 1994 (n = 94), and compared these to hearts preserved with the lower potassium-containing Stanford solution used at our center between 1986 and 1990 (n = 65). Indices of graft function, ischemic injury, CAV incidence, CAV severity, and survival were evaluated.The 2 groups were similar in age, gender, diagnosis, donor inotropic support, donor-recipient weight ratio, incidence of acute graft failure, and cytomegalovirus seroconversion. UW-preserved hearts came from older donors (30.5 vs 24.1 years, p.001), and were transplanted into more status 1 recipients (56% vs 22%, p.001), consistent with current trends. Mean ischemic time of UW-preserved hearts was significantly longer (184 vs 155 minutes, p.005) although time required to wean from bypass was less (45.5 vs 73.8 minutes, p.001) and there was a trend towards less inotropic requirement. CPK-MB release was less with UW preservation (63 vs 87 microg/ dL, p = .001). Three years after transplantation, both groups were similar in the incidence of CAV (UW, 27.3%; STNF, 37.5%; p = 0.27), and also the severity of CAV (p = 0.78). Deaths attributed to CAV were equal in each group (UW, 11.4% vs STNF, 10.7%; p = 0.79). Kaplan-Meier survival analysis revealed equivalent survival curves (p = 0.26).We conclude that UW is a safe and effective myocardial preservative, allowing longer ischemic times with equivalent graft function. Our data suggest that when UW is used for cardiac allograft preservation, both CAV and survival are comparable to the experience with other preservatives containing lower concentrations of potassium.

Background . Respiratory complications after successful coronary artery bypass grafting influence the immediate recovery of a patient; however, whether they influence the longevity of a patient is largely unknown. The aim of this study was to examine the effects of preoperative pulmonary risk factors in younger patients and older patients on outcome after coronary artery bypass grafting. Methods . A retrospective chart review was performed on 939 patients who underwent primary coronary artery bypass grafting between July 1987 and November 1996. For better comparison, they were arbitrarily divided by age into two groups: group 1, less than 70 years old (n = 710), and group 2, 70 years old or older (n = 229). The variables collected for each patient included history of chronic obstructive pulmonary disease, active smoking, forced expiratory volume, and ventilatory support for more than 48 hours. These variables were compared with postoperative length of stay in the intensive care unit, length of stay in the hospital, and the midterm survival up to 5 years. The data were analyzed by the use of univariate/multivariate log-rank tests and the method of Kaplan-Meier survival estimates. Results . The presence of chronic obstructive pulmonary disease was associated with increased length of stay in the intensive care unit and in the hospital for both groups. Preoperative forced expiratory volume in 1 second, significantly affected length of stay in the hospital only in the patients less than 70 years old ( p = 0.0001). Delayed extubation beyond 48 hours of ventilatory support resulted in prolonged length of stay in the intensive care unit and in the hospital for patients less than 70 years old ( p = 0.0001, p = 0.0001, respectively) and patients 70 years old or older ( p = 0.0001, p = 0.0001, respectively). The 5-year survival after coronary artery bypass grafting for both groups was significantly influenced by the level of preoperative forced expiratory volume in 1 second ( p = 0.0004, p = 0.0282, respectively). Conclusions . Patients with chronic obstructive pulmonary disease, irrespective of age, stay in the intensive care unit and in the hospital longer after coronary artery bypass grafting. In addition, preoperative forced expiratory volume in 1 second is a significant predictor of 5-year survival in the young and aged individuals undergoing coronary artery bypass grafting.

Background: The literature reports conflicting results for survival after extracorporeal membrane oxygenator support, and survival differs in pediatric and adult patients. We present our institutional experience of adult extracorporeal membrane oxygenator support. Methods: From January 2007 to December 2009, 19 adult patients required extracorporeal membrane oxygenator support after cardiac surgery or catheter interventions. It was provided on an emergency basis to 11 patients, urgently to 5, and electively to 3. Indications included post-cardiotomy cardiogenic shock, post-cardiotomy acute respiratory failure, emergency cardiac resuscitation, and post-percutaneous coronary intervention cardiogenic shock. The mean duration of support was 4 days (range, 1–11 days). Results: Seven (36.84%) patients could be weaned off extracorporeal membrane oxygenator support; one (14.28%) of them survived to hospital discharge and the other 6 (85.71%) died in hospital. Twelve (63.15%) patients could not be weaned off and died while still on extracorporeal membrane oxygenator support. Overall 30-day hospital mortality was 94.73%, and survival to discharge was 5.26%. Conclusion: Our institutional experience of extracorporeal membrane oxygenator support for cardiac indications in adult patients indicates poor survival. It significantly increased costs by delaying imminent death and prolonging stay in the intensive care unit.

The interaction between primary afferent neurons containing neuropeptides and the vascular smooth muscle is incompletely understood. To explore the function of perivascular afferent neurons and to determine whether they produce local effects on vascular smooth muscle cells, we investigated the effects of acute capsaicin and substance P administration in vitro on human internal thoracic arteries (ITA). Vessels were obtained from patients undergoing coronary bypass or from multiorgan transplant donors. Fourteen ITA segments (5 mm wide) were suspended as rings between two stainless-steel stirrups in water-jacketed (37 degrees C) tissue baths under 2.5 to 3 g of basal tension. The tissue baths contained 10 mL physiological salt solution (PSS) of the following composition (mM): NaCl, 119; KCl, 4.7; NaH2PO4, 1.0; MgCl2, 0.5; CaCl2, 2.5; NaHCO3, 25; and glucose, 11; aerated continuously with 95% O2 and 5% CO2. Peptidase inhibitors (phosphoramidon and captopril) were added to PSS to decrease peptide degradation. Mechanical responses were measured isometrically and recorded on a polygraph via isotonic force transducers. Vessels were preconstricted with submaximal concentrations of norepinephrine. After the tension had stabilized, substance P or capsaicin was added cumulatively to the tissue bath. At the end of the experiments, the viability of ITA was verified by its responses to endothelial-dependent (acetylcholine) and endothelial-independent (sodium nitroprusside) vasodilators. In the endothelium-intact ITA segments, substance P produced relaxation of ITA smooth muscle while it induced slight contraction when the ITA was devoid of its endothelium (P = 0.0585). The addition of capsaicin to human ITA primarily produced contractile effects on the developed smooth muscle force. The capsaicin-induced contraction of the ITA smooth muscle was independent of endothelial cell integrity, although contraction was greater in the endothelium-intact ITA segments (P = 0.0165). The acute capsaicin exposure of human ITA revealed that primary afferent neurons containing neuropeptides innervate human ITAs. There is a real potential for perivascular afferent neurons and sensory peptides to influence the ITA smooth muscle function.

Myocardial stunning after heart surgery is associated with increased morbidity and mortality in patients with severe multivessel disease and reduced myocardial function. The purpose of this study was to evaluate the safety, tolerance, and efficacy of adenosine as a cardioprotective agent when added to blood cardioplegia in patients undergoing coronary artery bypass surgery. Sixty-one patients were randomized to standard cold-blood cardioplegia, or cold-blood cardioplegia containing 1 of 5 adenosine doses (100 microM, 500 microM, 1 mM, 2 mM, and 2 mM with a preischemic infusion of 140 microg/kg/min of adenosine). Invasive and noninvasive measurements of ventricular performance and rhythm were obtained preoperatively, prebypass, and then at 1, 2, 4, 8, 16, and 24 hours postbypass. Use of inotropic agents and vasoactive drugs pastoperatively was recorded; blood samples were collected for measurement of nucleoside levels. High-dose adenosine treatment was associated with a 249-fold increase in the plasma adenosine concentration and a 69-fold increase in the combined levels of adenosine, inosine, and hypoxanthine (p0.05). Increasing doses of the adenosine additive were also associated with lower requirements of dopamine (p = 0.003) and nitroglycerine (p = 0.001). The 24-hour average doses for dopamine and nitroglycerine in the placebo group were 28-fold and 2.6-fold greater than their respective high-dose adenosine treatment cohorts. Finally, the placebo- and 100 microM-adenosine group was associated with a lower ejection fraction when compared to patients receiving the intermediate dose or high-dose treatment. These findings are consistent with the hypothesis that adenosine is effective in attenuating myocardial stunning in humans.

Background. Despite the steady increase in the number of elderly patients undergoing coronary artery bypass grafting (CABG), skepticism still exists as to whether this operation is justified in older people with a reduced life expectancy. The purpose of this study was to examine the effects of increasing age on outcome after CABG. Methods. A retrospective chart review was performed on 1,689 consecutive veterans of the United States Armed Forces undergoing isolated primary CABG from January 1972 through December 1994. For better comparison, they were arbitrarily divided by age into three groups: group I, 50 years of age or less (n = 213), group II, between 51 and 70 years of age (n = 1,258), and group III, more than 70 years of age (n = 218). Long-term survival for each group was compared to that of their age-matched population derived from Wisconsin life tables. Results. The preoperative ejection fraction was comparable in all three groups ( p = 0.114). The patients older than 70 years of age had received more grafts per operation than the patients 50 years of age and younger (3.7 versus 3.3) ( p = 0.0001). Although the aortic cross-clamp time was prolonged with advanced age ( p = 0.0002), the cardiopulmonary perfusion time was shortest in elderly patients ( p = 0.0001). The early (30-day) mortality for the entire study population was 1.3%. There was a linear correlation between increasing age and early (30-day) mortality: group I, 0.5% (1/213); group II, 1.0% (13/1,258); and group III, 3.2% (7/218). The overall 10-year actuarial survival for all patients was 67%. The 10-year survival was diminished with increasing age ( p = 0.0001): 74% for group I, 68% for group II, and 47% for group III. Comparative analysis of the three groups with their age-matched counterparts demonstrated an age-related survival after CABG. In group I, reduced survival was evident 4 years after the CABG: the 10-year survival in group I was 74.2%, and the survival of their age-matched population was 93.4% (confidence interval, 67% to 81.9%). In group II a survival difference was obvious 8 years after CABG: 10-year survival of 67.5% versus 75.1% in their age-matched population (confidence interval, 64.8% to 71.6%). In the elderly group of patients, no survival difference was noted: 10-year survival of 42.7% versus 45.9% of the age-matched population (confidence interval, 29.8% to 64.6%). Conclusions. An acceptable early mortality and longterm survival equal to those seen for an age-matched elderly population are sound outcome measures that support the justification of CABG in older patients irrespective of age.

Twiddler's syndrome is a rare complication seen in patients with implanted pacemakers or defibrillators. The condition typically presents with device malfunction and occurs when the patient either consciously or unconsciously twists and rotates the implanted device in its pocket, resulting in torsion and dislodgement of the implanted lead. A case of twiddler's syndrome involving a transvenous defibrillation lead and an abdominally implanted defibrillator is described. This is the first report of this complication with this particular lead. The patient in this report was a middle-aged obese diabetic woman who presented 7 months after defibrillator implantation with device noncapture and intermittent nonsensing. Review of the literature reveals that the majority of patients with this complication are middle-aged obese women with a defibrillator pocket that exceeds the size of the defibrillator. Treatment measures are discussed both for the patient with this complication and for the patient at increased risk for its occurrence.

Background. Despite a nationwide surplus of cardiac transplantation programs, the number of United States armed forces veterans who receive heart transplants has declined over the past several years. This study reviews the efficacy of a partnership between a Veterans Affairs hospital and a university hospital in maximizing the access of veterans to the limited donor heart supply. Methods. As part of a contract-based sharing agreement between the University of Wisconsin Hospital and the William S. Middleton Memorial Veterans Affairs Hospital, 25 veterans underwent orthotopic heart transplantation between October 1993 and April 1995. Care of the patients was provided at the Veterans Affairs Hospital. The transplantation operations were performed at the University of Wisconsin Hospital, and all patients were transferred back to the Veterans Affairs Hospital 5 to 7 days afterward. All patients were men (mean age, 52.1 ± 2.1 years) and were referred from Veterans Affairs hospitals in nine different states. Results. During the 19-month period, the average length of hospital stay for pretransplantation evaluation was 7.0 ± 0.7 days (range, 2 to 15 days). Average status I waiting time was 26.9 ± 3.3 days (range, 5 to 54 days); the average waiting time for status II was 115.1 ± 16 days (range, 15 to 242 days). Posttransplantation length of stay at the Veterans Affairs Hospital was 22 ± 1.8 days (range, 11 to 41 days). Only 1 patient (4%) experienced a lethal postoperative complication. Ten patients (40%) exhibited graft rejection within the first month after transplantation, requiring treatment with augmented immunosuppressive therapy (steroids, orally in 2 patients and intravenously in 8). The overall 30-day mortality rate was 4% (1 patient). The cause of death was acute grade 4 graft rejection 3 weeks after transplantation. Overall patient survival was 96%. Conclusions. A partnership between a Veterans Affairs hospital and a university hospital committed to transplantation can increase Veterans Affairs cardiac transplantation activity, with excellent 30-day mortality and early survival results.

The choice of graft conduit is crucial to the success of coronary artery bypass grafting (CABG) because the patency of a coronary conduit is closely associated with an uneventful postoperative course and a better long-term patient survival. The standard conduits used for CABG are the greater saphenous vein (GSV) and the internal thoracic artery (ITA). An excellent substitute conduit for coronary bypass operations that can be taken "off the shelf" is certainly the dream of every practicing cardiac surgeon. However, virtually every synthetic and biologic alternative to arterial conduits or autologous fresh saphenous vein has proved disappointing. Fortunately, patients with absolutely no autologous conduit alternatives are uncommon. Circumstances exist, however, that often necessitate the use of alternative conduits such as young hyperlipemic patients, absent or unsuitable autologous ITAs and GSV as a result of previous myocardial revascularization, peripheral arterial reconstruction, and varicose vein ligation procedures. This review provides an update on the clinical work done with all coronary conduits available for myocardial surgical revascularization.

In an effort to develop a noninvasive method to evaluate flow characteristics of the internal thoracic artery (ITA) graft after coronary artery bypass grafting, we performed color-flow duplex ultrasound studies of the right and left ITAs of 42 patients before and 5 weeks after bypass grafting. The ITA was visualized with a duplex scanner (5.0-MHz probe) through the first or second intercostal space. We recorded the diameter, peak systolic velocity, and end-diastolic velocity for each patient. Preoperative measurements of the native ITAs were obtained easily in all patients. Postoperatively, the unused right ITA was seen in all patients. Postoperative visualization of the left ITA graft was adequate to make reliable measurements in 40 patients (95%). Postoperative end-diastolic velocities of the unused right ITA and the left ITA graft were markedly higher than the preoperative end-diastolic velocities of the native ITAs (p0.001). Whereas there was a marked increase in the peak systolic velocity of the postoperative unused right ITA (p0.05), the postoperative peak systolic velocity of the left ITA graft was significantly lower than the preoperative value (p0.001). We conclude that postoperative visualization of the left ITA graft is possible with the use of color-flow duplex ultrasound. Ultrasonic surveillance of postoperative ITAs may reveal ITA graft velocity abnormalities before overt graft failure is manifested in the patient who has undergone coronary artery bypass grafting.

Background— Several enzymes that hydrolyze angiotensin I (Ang I) and Ang II to Ang-(1-7) have been identified, but their relative importance in the intact human heart is not known. Methods and Results— Intracoronary (IC) 123 I-Ang I was administered to 4 heart transplantation recipients. Arterial and coronary sinus (CS) samples were taken before and after coadministration of IC enalaprilat. 123 I-Ang metabolites were separated by high-pressure liquid chromatography, and 123 I-Ang-(1-7) and 123 I-Ang II were quantified across the myocardial circulation. 123 I-Ang II formation (as measured by fractional conversion) at steady state was 0.43±0.05 and was reduced to 0.042±0.02 after IC enalaprilat ( P 123 I-Ang-(1-7) was 0.198±0.032 but was reduced to 0.06±0.01 during IC enalaprilat ( P P P Conclusions— Ang-(1-7) was formed in the intact human myocardial circulation and was decreased when Ang II formation was suppressed. These data indicate that the major pathway for Ang-(1-7) generation in the intact human heart was dependent on substrate availability of Ang II. Ang-(1-7)–forming enzymes that demonstrate substrate preference for Ang II are likely to play an important role in the regulation of Ang-(1-7) formation in the intact human heart.

To investigate whether sex hormone receptors exist in the resected non-small-cell lung cancer in human beings and to determine a link between the pulmonary carcinogenesis and the sex receptor status of the lung cancer tissue, we reviewed the case histories of 64 patients who underwent resectional therapy for non-small-cell lung cancer between 1988 and 1990 (38 men and 26 women, mean age 65 years). Mouse monoclonal immunoglobulin G antibodies were used for immunohistochemical detection of estrogen receptors and progesterone receptors in the acetone-fixed specimen. The control group consisted of normal lung tissue from the patients with and without bronchogenic carcinoma and breast cancer tissue from the patients with estrogen and progesterone receptor immunoreactivity. No evidence of estrogen and progesterone receptor immunoreactivity was present in the normal lung tissue. All but two patients had immunoreactivity (97%) for estrogen receptors in the lung cancer tissue ( p p > 0.05). The differences for sex and for histologic subtypes were not statistically significant. Observed actuarial survival at 3 years was 83% for all patients with estrogen receptor immunoreactivity: 94% for women and 75% for men ( p

In general, the right internal thoracic artery (ITA) is used less frequently as a graft than the left ITA in coronary artery bypass grafting. To determine whether there is an anatomic or hemodynamic rationale for the underuse of the right ITA, noninvasive measurements of right and left ITAs were performed in 171 patients before the bypass procedure. Transthoracic visualization of both vessels was accomplished using a color-flow duplex scanner (5.0-MHz probe) through the third intercostal space. The diameter (in millimeters), peak systolic velocity (in centimeters per second), and end-diastolic velocity (in centimeters per second) were measured in all but 2 patients. The mean right ITA diameter was 2.7 +/- 0.6 mm, the mean peak systolic velocity was 100 +/- 29 cm/s, and the mean end-diastolic velocity was 6 +/- 5 cm/s. Diameter and flow velocity measurements for the right and left ITA were similar in all patients (p = not significant). The measured values for both sites were independent of age and sex, or the presence of hypertension or diabetes mellitus (p = not significant). We conclude that no morphologic or physiologic differences exist between the right and left ITAs. The findings from this study indicate that color-flow duplex ultrasound imaging is a safe and reliable noninvasive technique in the preoperative assessment of the anatomic and functional characteristics of the right ITA before coronary artery bypass grafting.

Cardiac transplants are performed sporadically or not at all in the majority of predominantly Muslim countries in the Middle East. We examined our experience in 76 patients who underwent heart transplantation between January 2005 and May 2010 in our center in Saudi Arabia. Excluded were 50 transplants performed between 1989 and 2004, due to incomplete data. Primary outcomes were complications, 30-day and late mortality rates, and 1-year survival. The heart transplant activity between 2005 and 2010 (15.0 per year) was 4.5-fold higher than that between 1989 and 2004 (3.3 per year). There were 61 (80%) men and 15 (20%) women, with a mean age of 35 years (range, 13–57 years). The mean waiting list time was 64 days (range, 1–262 days), and hospital stay was 30 days (range, 12–166 days). Major complications were infection (10), low-grade rejection (9), reoperation for hemorrhage (8), and sternal dehiscence (2). The 30-day mortality was 7.8% (6/76). Actuarial survival was 87.4% at 1 year and 81.5% at 3 years. A hospital in a Muslim country can increase cardiac transplant activity with excellent 30-day mortality and early survival comparable to that in worldwide counterparts.

Triple valve surgery (3VS) is required in some cardiac disorders that simultaneously involve the aortic valve (AV), mitral valve (MV), and tricuspid valve (TCV). Herein are reported details of the authors' experience with 3VS, and their attempts to identify those factors associated with a poor clinical outcome.The medical records of patients who underwent 3VS between 1985 and 2005 were reviewed. A competing-risks methodology was used to determine the time-related prevalence and associated factors for three mutually exclusive end states after 3VS, namely death, valve reoperation, and survival without subsequent valve reoperation.A total of 206 consecutive patients (124 females, 82 males; median age 34 years; range: 12-82 years) underwent 3VS. The most common underlying pathology for all valves was rheumatic, followed by repair failure and prosthesis dysfunction for AV and MV, and functional regurgitation for TCV. In total, 72 patients (35.0%) had undergone prior valve surgery. At 3VS, the MV and AV were usually replaced (70%), whereas the TCV was usually repaired (91%). The operative mortality (prior to hospital discharge) was 11%, and 15-year survival 68%. At 15 years after 3VS, 21% of the patients had died, without subsequent valve reoperation, 50% had undergone valve reoperation, and 30% remained alive without valve reoperation. Baseline factors associated with early mortality after 3VS were older age at operation, TCV replacement, and the use of a mechanical MV during 3VS. A late risk of mortality was associated with poor left ventricular function and renal impairment at the time of the initial 3VS, and MV prosthesis prior to the initial 3VS. Younger age at 3VS and MV repair during the index 3VS were associated with a higher constant risk of valve reoperation, while female gender, MV prosthesis prior to index 3VS, MV replacement with a bioprosthesis during 3VS, and rheumatic TCV disease were associated with an increased late risk of valve reoperation.Both, primary and reoperative 3VS can be performed with acceptable operative mortality and long-term survival. However, patients continue to be at risk of valve reoperation, which steadily increases over time.

Valve replacement in children is problematic, and associated with high anticoagulation-related complications and increased reoperation requirements. Multiple valve replacement may further increase morbidity and worsen outcome. The results are reported of combined aortic valve replacement (AVR) and mitral valve replacement (MVR) in children.The medical records of children who underwent simultaneous AVR and MVR between 1984 and 2004 were reviewed, and the short-term and long-term results and variables affecting outcomes explored. The mean duration of follow up was 9.7 +/- 6.6 years.A total of 84 patients (62 males, 22 females; mean age 15.0 +/- 2.2 years) was identified. The underlying pathology was mainly rheumatic (94%) and endocarditis (4%). Among the patients, 21 (25%) had undergone a prior cardiac surgery. The implanted valves were either mechanical (n = 71) or bioprosthetic (n = 13). The average aortic and mitral valve sizes were 22 mm and 29 mm, respectively. In total, 21 patients had concomitant cardiac surgery, most commonly tricuspid valve repair (n = 18). The mean cardiopulmonary bypass time and ischemic time were 142 +/- 47 min and 107 +/- 33 min, respectively. Survival at 30 days and at one year was 96% and 94%, respectively. The overall 15-year survival was 78% (bioprosthesis 92% versus mechanical 76%; p = 0.4). The 15-year freedom from cardiac reoperation was 59%, and 68% and 75% for mitral and aortic reoperation, respectively. Significant risk factors for reoperation were the use of a bioprosthetic valve (p = 0.003) and female gender (p = 0.03). Freedom rates from endocarditis, thromboembolic and bleeding complications at 15 years were 90%, 92%, and 96%, respectively. Among survivors, 95% were in NYHA class I/II.Children with rheumatic fever and endocarditis may require simultaneous AVR and MVR. Although the operative mortality is acceptable, patients continue to have constant attrition with time, especially those who have received mechanical prostheses. The risk of cardiac reoperation requirement is high in all patients. Despite the greater need for reoperation, bioprosthetic valves could be offered to selected patients, such as females and those who are non-compliant with anticoagulation regimens.

The Ross procedure is a versatile operation that can be applied for aortic valve replacement (AVR) in patients with congenital heart disease (CHD), including small infants and those with complex left ventricular outflow tract (LVOT) obstruction. Herein, the clinical outcome is reported following the Ross procedure in patients with CHD at the authors' institution.The medical records of patients who underwent the Ross procedure for CHD between 1991 and 2007 were reviewed. A competing-risks methodology was used to determine the time-related prevalence and associated factors for three mutually exclusive end states after the Ross procedure, namely death prior to subsequent cardiac reoperation, cardiac reoperation, and survival without subsequent reoperation.A total of 151 patients (98 males, 53 females) was identified. The median age at the time of surgery was 8.6 years (range: 4 days to 33 years). Previously, 103 patients (68%) had undergone cardiac interventions, and 43 (28%) required LVOT enlargement (modified Ross-Konno procedure). A competing-risk analysis showed that, at 10 years after the Ross procedure, 8% of patients had died without subsequent reoperation, 26% underwent cardiac reoperation, and 66% remained alive without further reoperation. The 10-year freedom from autograft and homograft reoperation was 95% and 71%, respectively. Factors associated with early risk of mortality were age1 year and no prior surgical/percutaneous intervention at the time of the Ross procedure. Surgical factors associated with cardiac reoperation were concurrent cardiac surgery and the use of fresh homografts. There were no bleeding or thromboembolic complications, and the 15-year freedom from endocarditis was 95%. Ultimately, 99% of the survivors were in NYHA class I or II.The Ross procedure remains the authors' procedure of choice for AVR in patients with CHD. Outcomes in infants aged1 year may improve with better patient selection and palliative surgical/percutaneous interventions prior to valve replacement. The late survival was excellent and valve-related complications were minimal. The high autograft longevity led to few patients requiring late reoperation for graft replacement.

The incidence and impact of venous thromboembolic complications on pa tient survival following cardiac operations remains unclear. During a five-year period (1984-1988) 4,393 patients underwent open heart surgery; of these, 13 patients had either pulmonary embolus (PE) (5 patients) or deep-vein thrombo sis (DVT) (8 patients). In the PE group, coronary artery bypass grafting was performed in 3 patients, aortic valve replacement in 2. Seven patients had myocardial revascularization and 1 had aortic valve replacement in the DVT group. Postoperative diagnosis was established by means of lung scan (4) or pulmonary angiogram (1) for PE or venous Doppler (4) or contrast venography (4) for DVT. Treatment was supportive with anticoagulation in all patients; 2 underwent interruption of the vena cava. Hospital stay was prolonged in all with an average of thirty-four days. PE accounted for the death of 1 patient. Actuarial survival at five years among the survivors was 92%. This experience suggests that the occurrence of venous thromboembolic events after open heart surgery is rare (overall incidence of 0.3%); however, an awareness of this poten tially lethal complication is still necessary.

We report an unusual clinical presentation of Lyme carditis in a previously healthy 20-year-old black woman without any epidemiologic history of Lyme disease, fulminant in nature, involving a heart valve necessitating emergent mitral valve replacement, and requiring further surgical intervention because of the development of pericardial effusion and tamponade. A dilated right ventricle with normal contractility and severe tricuspid regurgitation with increase in the right atrial size diagnosed later remains under close surveillance.

Objectives: We report results of left atrioventricular valve reoperations (LAVVR) following atri- oventricular septal defect (AVSD) repair and examine variables predictive of outcome. Methods: Multiple demographics and operative variables were analyzed to determine factors affecting survival and reopera- tion. Results: Forty patients following partial (n = 9) or complete (n = 31) AVSD repair underwent 47 LAVVR (1992-2005). Median age was 0.87 years (24 days-7.7 years) at initial AVSD repair and 3.15 years (84 days-13.6 years) at subsequent LAVVR with median interval between AVSD repair and LAVVR of 1.76 years (1 day- 12.9 years). First LAVVR included repair (n = 20) or replacement (n = 20). Operative mortality was 10% and five-year survival was 76 ± 6%. Significant risk factors were complete AVSD (p < 0.001), valve replacement (p < 0.001) for early death, and young age at time of LAVVR (p = 0.03) for late death. Five-year freedom from LAVV re-intervention was 100% for replacement versus 55 ± 13% for repair (p = 0.006). Overall, ejection fraction increased to 61 ± 3% versus 42 ± 2% preoperatively (p < 0.01), and left-ventricle end-diastolic dimension Z-score decreased to 0.05 ± 0.36 versus 3.1 ± 0.3 preoperatively (p < 0.01). Eighty-seven percent of children were in New York Heart Association class I/II at latest follow-up. Conclusions: LAVVR results in significant clinical improvement and lasting recovery in ventricular chamber function and size. Valve repair offers survival advantage and should be aggressively attempted; however, it is only achievable in 50% of cases. Valve replacement is necessary in cases associated with complex LAVV morphology or following repair failure. At intermediate follow-up, patients continue to be at risk of major valve-related morbidity, requirement for re-intervention, and cardiac death. doi: 10.1111/j.1540-8191.2008.00784.x (J Card Surg ****;**:**-**)

The internal mammary artery is the preferred conduit for coronary artery surgery. To determine the role, if any, of preoperative duplex imaging in assessing the suitability of this vessel, preoperative noninvasive measurements of internal mammary artery diameter and blood flow were performed in 243 patients. The left internal mammary artery was insonated through the third intercostal space by use of duplex scanner (5.0 MHz probe) before coronary artery surgery. Internal mammary artery diameter (millimeters), peak systolic velocity (centimeters/second), and mean velocity (centimeters/second) were measured, and internal mammary artery flow was calculated from velocity and cross-sectional area. In 45 of these patients the internal mammary artery diameter also was measured during surgery with a sterile caliper, and blood was collected for 30 seconds from the transected internal mammary artery to measure flow. These findings were compared to the preoperative values. In 243 patients the mean internal mammary artery diameter was 2.34 +/- 0.03 mm, and mean peak systolic blood flow was 226.7 +/- 6.3 ml/min. In the 45 patients in whom intraoperative measurements were obtained, preoperative mean internal mammary artery diameter was 2.39 +/- 0.05 mm and was not significantly different from the intraoperative mean internal mammary artery diameter of 2.36 +/- 0.04 mm. Preoperative peak systolic flow was 231.3 +/- 8.1 ml/min, and mean flow was 110.3 +/- 7.1 ml/min; intraoperative flow measured 136 +/- 3.6 ml/min. Noninvasive determinations correlated with operative findings for internal mammary artery diameter (r = 0.87) (p less than 0.05), peak systolic blood flow (r = 0.70) (p less than 0.05), and mean blood flow (r = 0.60) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral stenosis (MS) with severe pulmonary hypertension (PHT) constitutes a high-risk subset for surgical commissurotomy or valve replacement. Mitral balloon valvuloplasty (MBV) has emerged as the treatment of choice for patients with severe pliable MS. The efficacy of this procedure in patients with severe PHT has not been fully elucidated, notably with regards to the long-term outcome.MBV was successfully performed in 531 consecutive patients. Of these patients, 82 (15%) had severe PHT at baseline (group A), defined as pulmonary artery systolic pressure (PASP) at rest60 mmHg, compared to the remaining 449 patients, who served as controls (group B).Patients with PHT had a higher echo score and were more symptomatic, the majority (52.4%) having moderate to severe tricuspid regurgitation (TR). When comparing PHT with controls, the left atrial pressure was higher (28 +/- 4.9 versus 25.6 +/- 4.6 mmHg; p0.0001), the mean mitral gradient was similar (14.6 +/- 3.8 versus 14.4 +/- 2.1 mmHg; p = 0.30), the baseline mitral valve area (MVA) was smaller (0.72 +/- 0.17 versus 0.86 +/- 0.19 cm2; p0.0001), pulmonary vascular resistance was higher (612 +/- 343 versus 211 +/- 183 dyne/s/cm(-5); p0.0001), and post-procedure MVA was smaller (1.7 +/- 0.44 versus 1.85 +/- 0.54 cm2; p = 0.007). The PASP decreased significantly over 12 months after MBV, from 79 +/- 14 to 36.7 +/- 7.53 mmHg (p0.0001). Freedom from restenosis in PHT patients at 10 and 15 years, respectively, was 66 +/- 6% and 45 +/- 8% versus 78 +/- 2% and 47 +/- 3% in controls (p = 0.0066). Event-free survival at 10 and 15 years, respectively, was 77 +/- 6% and 41 +/- 11% in PHT patients versus 89 +/- 1% and 54 +/- 4% for controls (p = 0.0169). In total, 33 patients (40%) had moderate TR and 10 (12%) had severe TR at baseline. At follow up, only 12 patients had moderate TR and none had severe TR.MBV is a safe and effective technique for treating patients with MS and severe PHT. Although the immediate results were comparable with those in controls, the long-term results proved to be slightly inferior, with a regression of PHT and concomitant severe TR.

Surgical management of patients with concomitant critical cardiac disease and resectable lung lesions is controversial. During a 7-year period (1982 to 1988), 21 patients underwent combined cardiac and pulmonary operations. Patients had cardiac symptoms only; the lung lesions were found on preoperative chest roentgenograms. The pathological diagnosis was established in only 2 of the patients before operation. All underwent concurrent pulmonary resection during cardiac operations requiring extracorporeal circulation. The pulmonary operations included 17 wedge resections and four lobectomies. The final diagnoses in 8 patients with stage I non-small cell lung cancer included epidermoid carcinoma (4), adenocarcinoma (3), and bronchoalveolar carcinoma (1). Postoperatively, 1 patient required a permanent pacemaker and 1 patient died. The actuarial survival at 5 years for all patients who underwent combined procedures was 95%. The 5-year survival for the 8 patients with lung cancer was 88% compared with 100% for those with benign pulmonary pathology (p = 0.172). This experience suggests that combining pulmonary resection with cardiac operations is safe and offers a favorable prognosis to a select group of patients.

Background: The effect of mitral valve morphology (MVM) on the long-term results of mitral balloon valvuloplasty (MBV) is not well established. The aim of the study was to evaluate the impact of MVM on long-term outcome of MBV. Methods : Five hundred and eighteen consecutive patients (mean age, 31 ± 11 years) who underwent successful MBV were followed up for 0.5–16.5 (mean, 6 ± 4.5) years. Patients were divided into two groups according to their mitral echo score (MES) before MBV: group A (n = 340; MES ≤ 8) and group B (n = 178; MES > 8). Results: We report the immediate and long-term clinical and echocardiographic results of the above-mentioned 518 consecutive patients. The mitral valve area was significantly larger in group A than in group B, both immediately after MBV (2.0 ± 0.3 vs. 1.82 ± 0.3 cm2, respectively; P < 0.0001) and also at the last follow-up (1.8 ± 0.33 vs. 1.5 ± 0.33 cm2, respectively; P < 0.0001). Restenosis occurred in 38/340 (11%) in group A vs. 73/178 (41%) in group B (P < 0.0001). Actuarial freedom from restenosis at 5, 10, 15 years were 92 ± 2%, 85 ± 3%, 65 ± 6% for group A vs. 72 ± 4%, 44 ± 5%, 9 ± 6% for group B (P < 0.001). Event-free survival rates at 5, 10, 15 years for group A were 93 ± 1%, 88 ± 2%, 66 ± 6% vs. 82 ± 3%, 59± 6%, 8 ± 7% for group B (P < 0.0001). Stepwise Cox multivariate regression analysis identified MES, preprocedure functional class, and postprocedure mitral valve area ≤ 1.8 cm2, as predictors of restenosis (P < 0.0001, P = 0.014, P = 0.0015, respectively); MES and age as predictors of event-free survival (P < 0.0001, P < 0.0001, respectively). Conclusion: MBV has excellent long-term results in patients with favorable MVM. Favourable MVM is a strong predictor of good long-term outcome. © 2006 Wiley-Liss, Inc.

BACKGROUND The long-term effect of balloon mitral valvuloplasty (BMV) on the incidence of atrial fibrillation (AF) in patients with severe mitral stenosis (MS) remains undetermined. AIMS To assess the effect of successful BMV on the incidence of chronic AF in patients with severe MS, compare the results with historical controls, and identify factors associated with AF in such patients. METHODS Retrospective analysis of 382 consecutive patients with severe MS and in sinus rhythm (SR) who underwent successful BMV (post procedure mitral valve area (MVA) > or =1.5 cm(2), mitral regurgitation (MR) < or =2/4) at our hospital and followed-up for 1-15.6 (mean 5.6 +/- 3.9) years with clinical and echocardiographic examination. RESULTS Thirty-four (8.9%) patients developed AF at follow-up (group A) and 348 patients (group B) remained in SR. At baseline, and in comparison with group B, patients who developed AF (group A) were older, had higher mitral echo score but equal MVA and left atrial (LA) size. The postprocedure MVA was smaller in group A (1.7 +/- 0.3 cm(2)) than in group B (2.0 +/- 0.2 cm(2;) P = 0.002). At follow-up, and in comparison to group B, group A had smaller MVA (1.5 +/- 0.4 cm(2) vs 1.8 +/- 0.4 cm(2) P