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Spontaneous coronary artery dissection (SCAD) is a rare and potentially deadly disease without a clear and universal treatment. Medical as well as mechanical interventions, including percutaneous and coronary bypass surgery, have been used. We present two dissimilar cases of SCAD that required markedly different treatments reflecting the variety in clinical presentation and outcome. A brief review of the literature is included., (© 2011 Wiley Periodicals, Inc.)

Neuroendocrine tumors (NETs) of the thorax, including bronchial and thymic neuroendocrine NETs, are often referred to as NETs of the foregut. The incidence and prevalence of NETs are increasing in the United States as demonstrated in the Surveillance, Epidemiology, and End Results from 1973 to 2004 (J Clin Oncol. 2008;26[18]:3063-3072). Although the majority of bronchial and thymic NETs are sporadic, approximately 5% to 10% can be associated with hereditary syndrome, multiple endocrine neoplasms type 1 (Nat Rev Cancer. 2005;5[5]:367-375). Diagnosis is made by tissue pathology, allowing for characterization and classification of the NET. Radiologic evaluation is performed to determine the extent of disease involvement. Clinical symptoms from hormonal overproduction or from paraneoplastic processes are medically managed to improve patients' quality of life. Locoregional disease can be curative with surgery; however, distant or metastatic disease is rarely curable. Therapeutic options for metastatic/advanced NETs of the thorax are mainly to palliate symptoms. Final treatment recommendations for patients with either bronchial or thymic NETs should be individualized, weighing the risks and benefits of therapy.

Partial anomalous pulmonary venous connection with infradiaphragmatic drainage into the inferior vena cava (scimitar syndrome) constitutes a rare diagnosis in adults. Diagnosis is suggested by plain chest roentgenogram and confirmed by computed tomography angiography or magnetic resonance imaging. Reported operations for scimitar syndrome are complex, often requiring circulatory arrest. Reoperation for pulmonary vein stenosis is a troubling complication. We report an effective simplified operation for use in adults., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The public reporting of hospital quality and safety data is a growing phenomenon. Yet there are few reports of the effects of publicly reported data on individual organizations, particularly when the data show worse than expected performance. In this article, our hospital's response to having a mortality rate from coronary artery bypass graft surgery that was significantly higher than other programs in the Commonwealth of Massachusetts is reported. The data caused suspension of elective cardiac surgery at the institution, and an independent review of the program was undertaken. The effects of the suspension and publication of mortality data on quality and patient safety, the residency training program in cardiothoracic surgery, and the financial performance of the hospital are described. Several lessons were learned that may be of value to other health care organizations that experience a public crisis in clinical quality.

Carcinoid tumors of the lung are rare neuroendocrine tumors that make up approximately 1 to 2% of all lung neoplasms. These tumors overexpress somatostatin receptors, and somatostatin analog therapy has become standard in the treatment of carcinoid tumors. In addition, radiolabeled somatostatin analogs have been used to diagnose and treat these lesions. We describe the case of a patient with a right lung mass diagnosed as a carcinoid tumor. The patient underwent complete resection of this tumor with the assistance of intraoperative detection with a handheld gamma probe after the administration of the radiolabeled somatostatin analog (111)In-pentetreotide. This approach allowed us not only to detect the tumor easily, but to scan the bed of the tumor after resection and to re-excise an area of increased radioisotope uptake that corresponded to the presence of residual tumor. We believe this to be the first reported case of bronchial carcinoid resected with the assistance of intraoperative gamma detection after the administration of a radiolabeled somatostatin analog. This technology allowed us to achieve a complete surgical resection with no residual tumor detected either pathologically or by somatostatin scanning.

Background: Malignant mesothelioma is an uncommon but lethal cancer of increasing incidence, particularly among patients with a history of exposure to asbestos. Although numerous treatments have been employed, including chemotherapy, radiation therapy, surgical resection, and combinations of the above, no satisfactory treatment yet exists, and affected patients will die of this disease, usually within 12 months. Gene-based therapies constitute a new approach that offers hope of improved control of these tumors while being associated with less morbidity than conventional chemotherapeutic or surgical regimens. We demonstrated that PA1-STK cells home in vivo to mesothelioma deposits, a phenomenon that is required for optimal exertion of this therapeutic concept., Methods: Gene-modified ovarian cancer cells expressing the thymidine-kinase gene (PA1-STK) were radiolabeled with 99Tc and infused into the pleural space of 4 patients with malignant pleural mesothelioma, then scanned to determine distribution of the cells., Results: PA1-STK cells recognized and adhered preferentially to mesothelioma lining the chest wall., Conclusions: Cell-based "suicide gene" therapy utilizing the "bystander effect" with the gene-modified ovarian cancer cell line PA1-STK is feasible in human pleural mesothelioma. We have shown that this trafficking and homing of the therapeutic cells to the intrapleural tumor sites, a requirement for success with this novel therapeutic concept, is also valid in humans.

Background: The surgical approach to tetralogy of Fallot (TOF) continues to evolve and now many centers favor early repair for TOF., Methods: Our experience includes 82 consecutive patients less than 1 year old with TOF (n = 74) and TOF with pulmonary atresia (n = 8) who were operated on between January 1992 and March 1998. Mean age at repair was 5.2 +/- 1.2 months and mean weight was 4.5 +/- 0.4 kg. Seven patients (anomalous left anterior descending artery [n = 1], pulmonary atresia with hypoplastic pulmonary arteries [n = 6]), underwent palliative procedures in the neonatal period followed by complete repair. Forty-nine patients (59%) were symptomatic (severe cyanosis or hypoxic spells), and 33 patients (41%) were asymptomatic. A combined transatrial-transpulmonary approach was employed in 28 patients (34%), and transannular patch or conduit for reconstruction of the right ventricular outflow tract (RVOT) was required in 54 patients (66%). The mean Nakata index was 160 +/- 25 mm2/m2., Results: There were no hospital deaths. Mean post-repair peak right ventricular/systemic pressure ratio was 0.48 +/- 0.1. There were no late deaths or reoperations during a mean follow-up of 23 +/- 5 months. All patients are currently asymptomatic and in New York Heart Association class 1. Postoperative evaluation by two-dimensional and Doppler echocardiography or cardiac catheterization showed minimal pulmonary artery stenosis with a mean pressure gradient of 15 +/- 6 mm Hg across the RVOT., Conclusions: Our experience suggests that early repair of TOF can yield excellent results and initial palliation does not preclude early complete repair.

Fatty acids represent an essential source of fuel for the heart and play an important role in the mechanical, electrical, and synthetic activities of cardiac cells. Under pathological conditions, such as ischemia followed by reperfusion, the myocardium is exposed to very high levels of fatty acids, in particular the monounsaturated fatty acid, oleic acid. Elevated plasma fatty acids have been linked to an increased risk for cardiac arrhythmias. In other species, fatty acids have been shown to modulate several cardiac ion channels, most notably potassium channels. Virtually nothing is known about the actions of oleic acid on potassium channels in human heart. We therefore characterized the effects of oleic acid on the transient outward current, sustained current, and inwardly rectifying current, some of the major potassium channels present in human atrium, using the whole-cell patch clamp method. Exposure of cells to oleic acid (5 microM) reduced the transient outward potassium current to 3.7 +/- 0.8 pA/pF (n = 4) compared with 7.0 +/- 0.7 pA/pF (n = 4) (P <. 05) for cells not exposed. In contrast, oleic acid had little effect on either the sustained current (4.3 +/- 0.3 pA/pF, n = 4 for oleic acid versus 4.8 +/- 0.5, n = 5 for control) present after the decay of the transient outward current or on the amplitude of IK1 measured at -100 mV (1.4 +/- 0.4 pA/pF, n = 4 for oleic acid versus 1.3 +/- 0. 4 pA/pF, n = 6 for control). In addition, oleic acid significantly slowed the rate of recovery of the transient outward current, which is predicted to result in a use-dependent reduction in current amplitude in the beating heart. These results suggest a possible contributing role for oleic acid block of the transient outward current in the pathological consequences of myocardial ischemia.

Clinical studies have suggested that quinidine is less effective when used for the treatment of atrial arrhythmias in pediatric patients compared with its clinical effectiveness in the adult patient population. Age-related changes in the cardiac actions of quinidine on action potential duration and interaction with potassium channels in several mammalian species also have been reported. We investigated the effects of postnatal development on quinidine's interaction with major repolarizing currents (Ito, IKur, Ins, and IK1) in human atrial myocytes, using the whole-cell configuration of the voltage-clamp technique. Our results indicate that there are age-related changes in both the IC50 for quinidine blockade of Ito, as well as the mechanism of quinidine unblocking. In contrast, quinidine was found to inhibit both adult and pediatric IK1 and IKur in an age-independent manner, whereas the nonselective cation current (Ins), which contributes to the sustained outward current (Isus), was insensitive to quinidine. The results from this study help to clarify the electrophysiological mechanism by which quinidine elicits its antiarrhythmic effect in the pediatric and adult human population.

Transesophageal echocardiographic studies were used to monitor the presence of air bubbles in the heart after open heart operations. After cardiac valvular procedures all 22 patients managed with careful deairing procedures had persistence of air bubbles for at least 30 minutes and usually for 45 minutes. In 56 patients with CO2 field flooding, all foam disappeared in less than 1 minute in 48 patients and the remaining 8 had complete disappearance in 1 to 24 minutes. These observations demonstrate the ineffectiveness of the usual deairing maneuvers and the effectiveness of CO2 field flooding in displacing air.

We describe a simple method of remodeling an ascending aorta that has dilated in response to a stenotic aortic valve. It provides excellent exposure for valve replacement and avoids the use of substantial prosthetic material in effecting a secure, facile closure.

During evaluation of a man for claudication, abnormal chest roentgenographic results were found. Computed tomography documented a 6.5-cm aneurysm of an aberrant retroesophageal right subclavian artery. Interruption of the right subclavian artery with an end-to-side subclavian-carotid anastomosis was performed via a right supraclavicular incision, followed immediately by left transthoracic interruption of the origin of the right subclavian artery using a heparin-bonded shunt. This approach avoids previously reported embolic complications while preserving brachial blood flow and providing safe access to the aorta.

Between April 1, 1988 and April 1, 1993, 88 patients underwent thoracoscopic procedures for diagnosis or treatment or both of diseases which had previously been approached by standard thoracotomy in our practice. Fifty-three (60.2%) were men and 35 (39.8%) women. The median age was 63, range 19 to 88 years. Although the indications for operation generally fell into one of five categories, the ultimate diagnoses established by the procedure spanned a wide array of chest pathology. Morbidity and mortality remained low and length of stay in hospital was favorable in comparison with a subset of patients with malignant pleural disease who underwent thoracotomy for diagnosis. Thoracoscopy, or video-assisted thoracic surgery (VATS), is a procedure which compares favorably with traditional thoracotomy in selected patients and its horizons as a diagnostic and therapeutic tool continue to expand.

Twenty-five low birth weight, premature neonates who were refractory to aggressive medical management underwent ligation of symptomatic patent ductus arteriosus. The mean birth weight was 1,007 g and the mean gestational age 29 weeks. Six patients (24 percent) died before discharge, two from continued cardiorespiratory failure. Echocardiography showed significant improvement in left atrial and left ventricular dimensions after ligation. In the premature neonate with respiratory distress and congestive heart failure refractory to aggressive medical management, surgical ligation may be accomplished with an acceptable hospital mortality in very low birth weight infants.

During the past 75 years much progress has occurred in the field of vascular surgery. During this period, contributions from clinical surgeons have stimulated new scientific discoveries which have led to further clinical applications in a mutually perpetuating cycle of surgical advancement. One of the major achievements has been the use of the venous autograft employed as an arterial substitute. First used by Goyanes in 1906 to replace a popliteal aneurysm, a venous autograft was first successfully employed in the United States by Bernheim in 1915. The stepwise development of this aspect of modern vascular surgery is presented, and the role of other related contributions in making its use feasible is reviewed.

In a study comparing indium-111 platelet scintigraphy and two-dimensional echocardiography as methods of identifying left ventricular thrombi, the results obtained with both techniques were verified at surgery or autopsy in 53 patients--34 with left ventricular aneurysms, and 19 with mitral-valve disease. Left ventricular thrombi were found at surgery or autopsy in 14 of the patients with aneurysms and in none of those with mitral-valve disease. Thirteen of 53 echocardiograms (25 per cent) were technically inadequate and excluded from the analysis. In the group with aneurysms, the sensitivity of scintigraphy in detecting thrombi was 71 per cent, and that of echocardiography was 77 per cent. The specificity of scintigraphy was 100 per cent, and that of echocardiography was 93 per cent. We conclude that indium-111 platelet scintigraphy and two-dimensional echocardiography have useful and complementary roles in the detection of left ventricular thrombi. Both these noninvasive techniques can be used to monitor therapy.

This report defines the incidence of variations in the renal vascular pedicle in a group of patients with normal renal function as determined by standard laboratory criteria. The study group consisted of 166 patients undergoing renal arteriography as potential renal allograft donors. Ninety-seven patients were male and 69 were female. Ages ranged from 18-54 years, median age being 37 years. All patients underwent preliminary screening tests including blood chemistries, creatinine clearance, urinalysis, culture and excretory urography. If these studies were normal, renal arteriography was performed utilizing flush aortogram and, in 20% of cases, selective renal arteriography. The most common anomaly was the presence of multiple renal arteries supplying the same kidney, occurring in 32% of cases. Prehilar segmental branching was the second most common variation, occurring in 17% of patients. Other variations included fetal lobulation (4%), significant stenosis at origin of the renal artery (2%), fibromuscular dysplasia (2%), microaneurysms (0.5%), true aneurysms (1%) and dromedary hump (0.5%). Less than one-half of the patients demonstrated the simplest vascular pedicle, namely, single artery and vein bilaterally. The incidence of anatomical variations in the renal vascular pedicle is greater than attributed to normal subjects in previous reports. Anomalies determine the choice of kidney in renal allografting and may disqualify a potential donor, even in the face of ostensibly normal renal function. Routine arteriography should be considered a standard prerequisite in the evaluation of potential living related renal donors.

Technical advances in cardiac surgery have made accessible previously remote regions within the heart and great vessels; nevertheless, limitations in the ability to locate intramyocardial foreign bodies with precision utilizing conventional radiographic techniques, together with the frequent inability to palpate a foreign body located within the walls of the heart chambers, has dampened early enthusiasm for their removal. Despite this, the recognized complications associated with nonoperative management continue to militate for an aggressive approach. The following case illustrates the use of operative high-frequency ultrasonography in the exact localization of an intramyocardial foreign body. The precision thus afforded minimizes operative time, confines the size of the necessary ventriculotomy, and greatly facilitates successful removal.

Despite numerous clinical reports of coronary artery fistulas, there have been no laboratory models. A circumflex coronary-pulmonary artery fistula was constructed with a vein graft in 11 adult foxhounds. A temporary intravascular shunt obviated the need for cardiopulmonary bypass. Measurements of aortic flow, arterial pressure, left ventricular pressure and its derivative, heart rate, and flow in the proximal coronary, distal coronary, and fistula were made with the fistula open and closed in 9 animals. Mean fistula flow was 89 c.c. per minute, representing a 1.1:1 left-to-right shunt. Mean proximal coronary flow increased 211 per cent, and there was a relative steal of 26 per cent of distal coronary flow with the fistula functioning. Phasic flow patterns showed continuous systolic and diastolic flow in the proximal coronary artery and fistula. Despite the striking changes in coronary flow patterns, there was no significant effect on measured left ventricular function. Futher uses for this model and variations of it aresuggested.

Right ventricular failure following cardiac surgery must be rapidly diagnosed and treated to minimize injury to the heart. Switching from aortic to pulmonary artery perfusion during cardiopulmonary bypass is a method of rapidly testing the adequacy of right ventricular function and supporting the ventricle if necessary. A centrifugal pump has been used for long-term support for two cases managed in this manner.

In 16 patients requiring coronary artery bypass grafting (10 control and 6 streptokinase patients), we compared the preoperative, operative, and postoperative cardiovascular parameters. Streptokinase patients had an acute myocardial infarction and attempted reperfusion with streptokinase before coronary artery bypass grafting. One patient failed to recannalize with streptokinase and one patient had reocclusion after withdrawal of heparin necessitating coronary artery bypass grafting. Examination of hemodynamic parameters revealed a lower preoperative mean blood pressure and an elevated pulmonary artery wedge pressure in streptokinase patients. The elevated pulmonary artery wedge pressure persisted through the postoperative period of observation. These results indicate that only minor differences exist between control and streptokinase patients. Emergency and elective coronary artery bypass grafting can be safely performed in patients treated with streptokinase for acute myocardial infarction without associated cardiogenic shock.

A case of left atrial myxoma is reported in which tumor tissue was found to contain high levels of vasoactive intestinal polypeptide. This finding further supports the concept that myxomas are true neoplasms and may explain some of the poorly understood clinical manifestations of this tumor.