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The incidence of thyroid cancer is increasing globally due to the increase in detection of subclinical, low volume papillary thyroid microcarcinomas (PTMC) (1 cm). Several international groups have recommended an active surveillance approach for this low-risk disease. In contrast to many other countries, the United Kingdom's (UK's) approach to thyroid nodules is to avoid detection of incidental lesions where appropriate.This study aims to establish the proportion of patients with thyroid cancer in the UK that would benefit from active surveillance.Individuals with PTMC in NHS Lothian from 2009-2020 were reviewed from a local thyroid cancer database. The mode of detection of PTMC and proportion of patients who might benefit from active surveillance were established.From 651 individuals with differentiated thyroid cancer managed over 12-year period, 185 individuals with PTMC were identified (28.4%). The majority of PTMC 151/185 (81.6%) were either diagnosed post-operatively following thyroidectomy for benign disease or with nodal disease. Only 24 individuals with PTMC were identified following palpable thyroid nodule, incidental finding on imaging, and surveillance screening. Therefore, when the indication for surgery was considered, only 24/651 (3.7%) patients were identified pre-operatively and would, therefore, be realistic candidates for active surveillance.Less than 4% of patients with thyroid cancer in the UK would be appropriate for active surveillance. Rather than developing programmes to deal with this minority of patients, focus should be maintained on minimising detection of these low-risk cases.

Background Deep sternal wound infection (DSWI) is a rare but life-threatening complication following cardiac surgery associated with increased morbidity and mortality. Management of these patients has evolved over the years and can include sternal rewiring, mediastinal irrigation, negative-pressure wound therapy (NPWT) dressing or repair with flaps. We reviewed changes in our management of DSWI and outcomes. Methods Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, 5472 underwent cardiac surgery at St Vincent's Hospital, Melbourne, and 42 were identified as developing DSWI requiring re-operation between June 2002 and September 2014. Data were collected pertaining to risk factors for DSWI, management strategies and outcomes. Patients were compared from a period prior to NPWT dressing use (June 2002–February 2006, n = 14) and since the NPWT has been used regularly in the management of DSWI (from March 2006, n = 28). Patients were also compared based on the requirement for flap closure of their sternal wound. Results Because of the widespread use of NPWT dressings, there is a trend towards fewer sternal infections requiring flap closure (25 versus 42.8%) and less post-operative complications after definitive closure (7.1 versus 28.6%). Before and after widespread NPWT use, patients require similar number of re-operations before closure and have no significant differences in time to definitive closure or length of hospital stay. Conclusion The use of NPWT dressings as a bridge to definitive closure may reduce the need for more burdensome flap reconstruction, does not delay definitive reconstruction or prolong hospital stay and may reduce post-reconstruction complications requiring re-operation.

The epidemiology of infective endocarditis is changing due to a number of factors, including more frequent and varied antibiotic use, the emergence of resistant microorganisms, and an increase in the implantation of cardiovascular devices. This review outlines and consolidates the most recent guidelines, including the 2007 and 2010 AHA/ACC guidelines and scientific statements for the prevention and management of infective endocarditis and for the management of cardiovascular device infections. The evidence-based guidelines, including the 2009 HRS consensus document, for the treatment of patients with cardiovascular device-related infections are also reviewed. Only patients with prosthetic valves, patients with prior endocarditis, cardiac transplant patients with a valvulopathy, and certain congenital heart disease patients now require endocarditis prophylaxis. There is an increasing incidence of cardiovascular device-related infections due to the higher frequency of implanted devices and higher morbidity and mortality rates in older patients.

Current surgical management of restrictive ischaemic mitral regurgitation (IMR) includes mitral valve annuloplasty (MVA) using an undersized ring when the mechanism is secondary to leaflet restriction. In our experience, MVA alone is inadequate to eliminate mitral incompetence in these patients. We report the 'Down-Under Repair' as an adjunctive concept for the treatment of a subset of patients with restrictive IMR and associated inferobasal left ventricular aneurysm. The 'Down-Under Repair' reduces mitral leaflet restriction by approximating the origin of the posterior papillary muscle towards the mitral annulus. Midterm results demonstrated sustained valvular competence and symptomatic improvement.

Surgical ventricular restoration (SVR) was conceived to improve hemodynamic and clinical outcomes in ischemic cardiomyopathy. The Surgical Treatment of Ischemic Heart Failure (STICH) trial has conclusively shown no additional benefits of SVR when routinely combined with coronary artery bypass surgery. However, the STICH study did not include a registry arm for SVR-eligible patients who were not randomized. This study describes the SVR experience in a single center when participating in the STICH study, to better understand the role of SVR in current clinical practice.All patients receiving SVR between 2002 and 2006 were prospectively followed. Patients were divided into STICH SVR (SSVR) and non-STICH SVR (NSSVR) groups. The SSVR patients received SVR as randomized in STICH. The NSSVR patients were evaluated for eligibility to participate in the STICH trial, and the reasons for not participating were analyzed. Baseline demographics, echocardiographic data, and clinical outcomes were compared.Nine NSSVR patients were compared with 12 SSVR patients. Only 1 NSSVR patient did not fulfill entry criteria into the STICH trial for randomization. The main reason for performing SVR outside of the STICH study was dominant heart failure symptom associated with enlarged left ventricle. The NSSVR group had more anterior wall asynergy (60% vs 45%, p0.001), larger preoperative heart volumes (left ventricular end-diastolic volume index 108 mL/m(2) vs 69 mL/m(2), p0.05) and larger volume reductions (34% vs 11%, p = 0.06). At 6.5-year follow-up, 83% SSVR and 89% NSSVR patients are alive.At our institution, patients eligible but not randomized into STICH, had larger preoperative heart volumes and larger volume reduction with SVR. The STICH study may not have included patients most likely to benefit from SVR.

Objective The present study compared the outcomes between conventional surgery and the hybrid approach of proximal surgery with adjunctive retrograde descending aortic endografting plus distal bare metal stenting in acute DeBakey type I dissection. Methods From 2003 to 2011, 61 patients underwent surgical management for acute type A aortic dissection at our institution. Of these, 37 were DeBakey type I dissections: 18 patients (group 1) received conventional surgical repair alone, and 19 (group 2) underwent conventional hybrid surgery with adjunctive retrograde descending aortic stent grafting plus distal bare metal stenting. Results The patients' baseline characteristics were comparable, including the incidence of preoperative malperfusion syndromes ( P = .23). The intraoperative and postoperative characteristics were similar, except 4 (22%) patients in group 1 (vs 0 in group 2) had ongoing malperfusion postoperatively ( P = .04). Overall, hospital mortality was 11% (n = 2) for group 1 versus 5% (n = 1) for group 2. At a mean follow-up of 50 months, 4 (25%) subjects in group 1 required secondary thoracoabdominal aortic reintervention versus none in group 2 ( P = .03). Conclusions The use of adjunctive retrograde descending aortic endografting plus distal bare metal stenting during acute DeBakey type 1 dissection repair is a feasible method to enhance thoracoabdominal remodeling. This hybrid strategy improves perioperative outcomes and decreases late distal aortic complications compared with conventional surgical repair for acute DeBakey type I dissection. A prospective, multicenter study is warranted to definitively assess this promising new treatment paradigm.

Background Undiagnosed glycometabolic dysfunction is prominent amongst nondiabetic cardiac surgical patients, whereas perioperative dysglycemia is associated with adverse outcomes. This study assessed whether the preoperative level of insulin resistance predicts the degree of perioperative dysglycemia in nondiabetic, normoglycemic cardiac surgical patients. Methods Twenty-two nondiabetic patients awaiting cardiac operations were assessed for metabolic parameters and whole-body insulin resistance (mean glucose infusion [GINF] rate) using the hyperinsulinemic-euglycemic clamp. Intraoperative and postoperative glucose levels and treatment requirements were analyzed. Linear regression analysis was used to find predictors of baseline, peak intraoperative, and mean postoperative fasting blood glucose (FBG). Results The mean GINF recorded in nondiabetic, normoglycemic patients was 3.5 ± 1.4 mg/kg/min. The mean peak intraoperative and mean postoperative FBG concentrations were 154.9 ± 34.2 mg/dL (range, 108.1 to 227.0 mg/dL) and 120.7 ± 16.2 mg/dL (range, 100.9 to 154.9 mg/dL), respectively. The GINF correlated inversely with mean peak intraoperative (r = −0.7, p = 0.02) and mean postoperative FBG ( r = −0.8, p = 0.01). The GINF did not correlate with preoperative FBG levels ( r = 0.3, p = 0.4). Preoperative FBG did not correlate with peak intraoperative ( r = 0.4, p = 0.5) or mean postoperative FBG ( r = 0.5, p = 0.3). Conclusions Nondiabetic, normoglycemic cardiac surgical patients are highly insulin resistant using the hyperinsulinemic-euglycemic clamp. Preoperative insulin resistance, not FBG, is significantly associated with the development of perioperative dysglycemia. Insulin resistance screening may be useful to identify insulin resistance preoperatively and predict the degree of perioperative dysglycemia in cardiac surgical patients but should be performed with a more appropriate and reproducible test.

BACKGROUND: Bleeding into the chest is a life-threatening complication of cardiac surgery. Blood transfusion has been implicated as an important cause of harm associated with bleeding, based largely on studies demonstrating an independent association between transfusion and mortality. These studies did not, however, consider the possibility that bleeding may in itself be harmful, inasmuch as drains are inefficient at clearing blood from the chest and retained blood may compromise cardiac and lung function. STUDY DESIGN AND METHODS: We undertook a multivariate logistic regression analysis of the risk factors associated with mortality in 2599 consecutive patients undergoing cardiac surgery. Unlike previous studies the risk factors examined included the volume of chest tube drainage at 24 hours. A stratified analysis was also undertaken that compared the adjusted risk of death for patients exposed or not exposed to a postoperative blood transfusion. RESULTS: Blood transfusion was not an independent predictor of mortality (p = 0.4). Chest tube drainage was the strongest independent predictor of mortality (p

Background Established endovascular treatments for aortic dissection often result in incomplete aortic repair, potentially leading to late complications involving the distal aorta. To address the problems of incomplete true lumen reconstitution and late aneurysmal change, we report the midterm results of combined proximal endografting with distal true lumen bare-metal stenting (STABLE: Staged Total Aortic and Branch vesseL Endovascular reconstruction) in Stanford type A and B aortic dissection. Methods Between January 2003 and January 2010, 31 patients underwent staged total aortic and branch vessel endovascular reconstruction for management of acute (type A, 13; type B, 11) and chronic (type B, 7) aortic dissection. Proximal endografting was combined with bare-metal Z stent implantation in the distal true lumen. Patients with type A dissection underwent adjunctive treatment at operation. Computed tomography angiography was performed at baseline, 1 year, and annually thereafter to assess aortic remodelling. Results Primary technical success was 97%. Thirty-day rates of death, stroke, and permanent paraplegia/paresis were 3% (n = 1), 0%, and 0%, respectively. Mean follow-up was 57.3 months (range, 5 to 100 months). Overall survival was 60% at 100 months. Aortic-specific survival was 93%. Four patients (13%) underwent device-related reintervention. One (3%) late aortic-related death occurred. Thoracic ( p = 0.64) and abdominal ( p = 0.14) aortic dimensions were stable. The true lumen index increased significantly at follow-up. Conclusions Staged total aortic and branch vessel endovascular reconstruction is a feasible ancillary endovascular technique to address the problems of distal true lumen collapse, incomplete aortic remodelling, and late aneurysm formation in aortic dissection.

Background and Purpose— This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke. Methods— Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria ( Tables 1 and 2 ). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. Conclusion— Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.

The causes of cryopreserved allograft heart valve degeneration are poorly understood. We investigated HLA mismatch and other factors implicated in allograft valve degeneration. For this study we recruited 110 adult recipients of allograft heart valves who underwent surgery between June 1998 and March 2003 in the state of Victoria, Australia. Recipients and donors were HLA typed using serological and molecular methods. Valve function at most recent echocardiographic follow-up was examined for an association with the following variables using univariate and multivariate methods: HLA-A,-B, and -DR donor-recipient mismatch; HLA class I mismatch; total HLA mismatch; valve ischemic time; recipient age; donor age; ABO blood group donor-recipient match; and allograft size. Mean recipient age was 45 years (18-75 years), 75% were men. Seventy-four pulmonary (62 Ross procedure) and 36 aortic allografts were examined. Median valve ischemic time was 31 hours, range 20-48 hours. Echocardiographic follow-up was complete at a mean of 41 (+/-18) months, range 6-85 months. At univariate analysis longer ischemic time and younger recipient age were associated with valve dysfunction. HLA-A, -B, or DR mismatch, HLA class I mismatch, total HLA mismatch, donor age, ABO mismatch, and allograft size were not associated with valve dysfunction. Only younger recipient age remained significant at multivariate analysis. In conclusion, longer ischemic times and younger patient age predicted valve dysfunction at a mean of 3 years follow-up. Recipient age remained the strongest predictor of valve dysfunction. These results indicate that allograft ischemic times should be minimized.

Background A 40-year-old man presented with acute chest and back pain, hypertension and anuria. Two years previously he had been diagnosed with acute uncomplicated type B aortic dissection. Following conservative management, with aggressive antihypertensive therapy and analgesia, he was monitored with 6-monthly surveillance CT scans. These demonstrated a complicated type B dissection with renal and iliac malperfusion. Investigations Multislice CT, transthoracic and transesophageal echocardiography, digital subtraction aortography. Diagnosis Acute-on-chronic type B aortic dissection, complicated by aneurysmal dilatation of the thoracic aorta and visceral malperfusion. Management Antihypertensive therapy; staged thoracoabdominal and branch vessel endoluminal repair (STABLE procedure), with stabilization of the dissection and rescue of renal function; CT imaging surveillance to monitor for any further complications.

A 42-year-old male was admitted with persistent atypical chest pain following a motorcycle accident six months previously. A pseudoaneurysm, diagnosed by transthoracic echocardiography and computed tomography, was excised and the right coronary artery underwent bypass grafting. Language: en

Dissection of the interventricular septum (IVS) is an extremely rare entity. An institutional echocardiographic database was retrospectively reviewed; 13 patients with a diagnosis of IVS dissection were found and confirmed by cardiac surgery. The purposes of the study were: to determine the value of transthoracic echocardiography (TTE) in establishing the diagnosis of IVS dissection, and to detail the TTE features of IVS dissection. Thirteen patients with IVS dissection diagnosed by TTE, 8 males and 5 females were taken from 789,114 TTE studies performed between 1985 and 2014. All underwent cardiac surgery during which their diagnosis was confirmed. The etiology, location, 2-dimensional morphology, and color Doppler findings of IVS dissection were noted. The right sinus of Valsalva (SOV) was involved in 11 of the 13 patients. In 5 patients, a single aneurysm of the right SOV was seen dissecting into the IVS. One patient with a combination of a bicuspid aortic valve and a right SOV aneurysm dissected into the IVS. In 4 patients, aortic valve infective endocarditis resulted in IVS dissection. In 1 patient, mechanical aortic valve prosthetic replacement was complicated by annular detachment and a severe paravalvular leak causing IVS dissection. In all 11 patients, TTE showed a dissecting cystic-like mass in the IVS from the base to the mid-septum or confined to the septal base. The path of the dissection in these 11 patients was traced to the right SOV and communications between the IVS dissection and the aortic root were identified. In the remaining 2 patients, IVS dissection followed septal rupture due to a myocardial infarction, and communication was seen between the IVS dissection and the right ventricle. The study showed that most of the dissections of the IVS commence in the right SOV, due to either congenital anomalies or infective endocarditis, or following aortic valve replacement or myocardial infarction. The TTE characteristic of IVS dissection is a cystic-like mass seen in the IVS.

In recent decades, there has been an appropriate focus on ensuring gender equity in the quantity and quality of evidence to guide female-specific, optimal management strategies for suspected and known ischemic heart disease (IHD). The evolving evidence supports a multifactorial pathophysiology of coronary atherosclerosis that includes obstructive coronary artery disease (CAD) and dysfunction of the coronary microvasculature and endothelium, and therefore, the term IHD best encompasses this varied pathophysiology in women. An overwhelming body of evidence has documented undertreatment and undertesting of women, leading to higher case fatality rates and increased morbid complications among women.1–3 Accordingly, to increase our knowledge base, women were given the status of a priority population, which resulted in federal policy to include proportional representation of females in clinical trials and registries.4 The past decade provided abundant evidence to guide clinical decision making regarding diagnostic testing for suspected IHD. In 2005, the American Heart Association (AHA) published an evidence synthesis on the use of CAD imaging for the evaluation of symptomatic women with suspected myocardial ischemia.5 Numerous reports have since provided additional high-quality evidence, including data on coronary computed tomographic angiography (CCTA) and cardiac magnetic resonance imaging (CMR), which in 2005 were considered research techniques.5 The present statement provides an update to the 2005 document and synthesizes contemporary evidence on appropriate symptomatic female candidates for diagnostic testing, as well as sex-specific data on the diagnostic and prognostic accuracy for exercise treadmill testing (ETT) with electrocardiography, stress echocardiography, stress myocardial perfusion imaging (MPI) with single-photon emission computed tomography (SPECT) or positron emission tomography (PET), stress CMR, and CCTA.5 Within this document, quality evidence is synthesized, and important gaps in knowledge about the assessment of IHD risk in women are identified. The 2005 document included sections on the evaluation of asymptomatic …

A patient with a history of rheumatic mitral valve disease and valve replacement in childhood presented with severe, persistent dyspnea. During an electrophyisiologic procedure, she was discovered to have a fistula from the left ventricle to the coronary sinus. She had severe pulmonary hypertension and elevated filling pressures, with a significant left-to-right shunt. Percutaneous closure of the fistula was performed using two vascular plugs. Subsequently the patient's hemodynamics improved and her symptoms subsided. Here, we describe the case and review the literature.

Department of Cardiology, St. Vincent’s Hospital Melbourne, Victoria Parade, Fitzroy, Victoria, Australia 3065 Consultant Cardiologist, Department of Cardiology, St. Vincent’s Hospital Melbourne, Victoria Parade, Fitzroy, Victoria, Australia 3065 Consultant Cardiothoracic Surgeon, Department of Cardiothoracic Surgery, St. Vincent’s Hospital Melbourne, Victoria Parade, Fitzroy, Victoria, Australia 3065 Associate Professor, Director of Cardiology, St. Vincent’s Hospital Melbourne, Victoria Parade, Fitzroy, Victoria, Australia 3065

axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects. J Thorac Cardiovasc Surg. 2005;130:277-81. 3. Schreiber C, Bleiziffer S, Kostolny M, Horer J, Eicken A, Holper K, et al. Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients. Ann Thorac Surg. 2005;80:673-6. 4. Bleiziffer S, Schreiber C, Burgkart R, Regenfelder F, Kostolny M, Libera P, et al. The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis. J Thorac Cardiovasc Surg. 2004;127:1474-80. 5. Nicholson IA, Bichell DP, Bacha EA, del Nido PJ. Minimal sternotomy approach for congenital heart operations. Ann Thorac Surg. 2001;71: 469-72.

Bleeding into the chest is a life-threatening complication of cardiac surgery. Blood transfusion has been implicated as an important cause of harm associated with bleeding, based largely on studies demonstrating an independent association between transfusion and mortality. These studies did not, however, consider the possibility that bleeding may in itself be harmful, inasmuch as drains are inefficient at clearing blood from the chest and retained blood may compromise cardiac and lung function.We undertook a multivariate logistic regression analysis of the risk factors associated with mortality in 2599 consecutive patients undergoing cardiac surgery. Unlike previous studies the risk factors examined included the volume of chest tube drainage at 24 hours. A stratified analysis was also undertaken that compared the adjusted risk of death for patients exposed or not exposed to a postoperative blood transfusion.Blood transfusion was not an independent predictor of mortality (p=0.4). Chest tube drainage was the strongest independent predictor of mortality (p0.001). In the stratified analysis, chest tube drainage remained an independent predictor of mortality for patients not exposed to a blood transfusion (p0.01). Furthermore, the risk of death of these patients was no different from patients exposed to a blood transfusion (p=0.7 for interaction).Our results argue that for patients undergoing cardiac surgery bleeding contributes to mortality through mechanisms unrelated to blood transfusion.

Purpose To report the use of a technique (AFTER: aortic false lumen thrombosis induction by embolotherapy) to achieve false lumen (FL) thrombosis and aortic remodeling in patients with residual FL patency after initial endovascular repair of aortic dissection. Methods Between January 2003 and January 2010, 31 patients underwent staged total aortic and branch vesselendovascular reconstruction (STABLE) of type A (n = 13) and type B (n = 18) dissection. Of these, 10 patients (5 men; mean age 61 years) who had undergone repair of 4 acute type A, 3 acute type B, and 3 chronic type B dissections demonstrated re-entry tear(s) and FL patency associated with aortic expansion ≥5 mm or flow into a persistently dilated aortic segment. Catheter-directed embolization using coils, glue, or occlusion balloons was performed via a transfemoral approach to the true lumen at a mean of 7 months (range < 1 to 26) after initial repair. Results Technical success was achieved in all patients, with no intraoperative complications. Thirty-day morbidity and mortality was nil. Mean follow-up was 63 months (range 13–96). Reversal or stabilization ( < 5-mm increase) of thoracoabdominal aortic growth occurred in 9 patients. Complete thrombosis of the thoracic and abdominal FL occurred in 2 patients. In 4, FL occlusion and subsequent thrombosis of the upstream thoracic segment was achieved. Four demonstrated partial FL thrombosis in the thoracic and abdominal aorta. One patient with chronic aneurysmal type B dissection died 4 months post-embolization from aortic rupture. Conclusion The AFTER strategy appears to be a safe and promising adjunctive endovascular approach to treat residual FL patency or aortic enlargement post endovascular repair of aortic dissection. Elimination of FL flow and stabilization of aortic expansion may reduce the risk of late distal aortic complications.

As the cause of allograft heart valve degeneration is poorly understood, the study aim was to investigate the host antibody response to allograft valve implantation.Sera were obtained from 92 recipients of allograft heart valves (61 pulmonary, 31 aortic). Sera were tested for anti-HLA class I antibodies by ELISA and complement-dependent cytotoxicity (CDC) methods, and anti-HLA class II antibodies by ELISA. Specificities of recipient anti-HLA class I antibodies were defined by standard CDC testing against a panel of T lymphocytes from 80 blood donors. Donor valve HLA typing was performed on stored donor DNA samples using molecular methods. The presence of donor-specific anti-HLA class I antibodies was hence defined in recipient sera. The presence of anti-HLA antibodies and donor-specific anti-HLA class I antibodies were correlated with function of allograft valves at the most recent echocardiographic follow up.At a mean of 3.0 years (range: 0.3-5.4 years) after allograft implantation, 96% (87/92) and 82% (75/92) of patients were positive for anti-HLA class I and II antibodies, respectively, by ELISA testing. Some 68% (61/90) of patients were positive for anti-HLA class I antibody (PRA5%) by CDC testing. PRA levels decreased with greater postoperative interval (r = -0.31, p = 0.003). In 68 recipients where donor HLA type was defined, 54% (37/68) of patients had antibodies specific to at least one donor HLA class I antigen. In 87 patients with a recent echocardiographic examination available for analysis (at a mean of 3.5 +/- 1.6 years postoperatively), there was no association between valve dysfunction and antibody status.Anti-HLA class I and II antibodies were detected by ELISA methods in most patients after allograft implantation extending to 5.4 years. The clinical significance of these findings is unclear, as no correlation was found between the prevalence of anti-HLA antibody and echocardiographic parameters of valve dysfunction at a mean of 3.5 years follow up.

Background and Purpose— This guideline provides an overview of the evidence on various established and potential stroke risk factors and provides recommendations for the reduction of stroke risk. Methods— Writing group members were nominated by the committee chair on the basis of each writer’s previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee. The writers used systematic literature reviews (covering the time period since the last review published in 2001 up to January 2005), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations based on standard American Heart Association criteria. All members of the writing group had numerous opportunities to comment in writing on the recommendations and approved the final version of this document. The guideline underwent extensive peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— Schemes for assessing a person’s risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to their potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic factors. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. Conclusion— Extensive evidence is available identifying a variety of specific factors that increase the risk of a first stroke and providing strategies for reducing that risk.

The Cox-Maze III procedure remains the yardstick by which all treatments for atrial fibrillation are measured. This procedure is not widely adopted because of its perceived technical complexity, invasiveness and longer procedural time. Efforts have been made by various investigators to reproduce Dr Cox's results using alternative lesion sets and energy sources. Bipolar radiofrequency (BPRF) ablation avoids the morbidity of cut-and-sew lesions, reduces procedural time and increases the likelihood of transmurality and continuity of lesions created compared to unipolar devices. Initial results are encouraging. We present our surgical technique and early experience using BPRF modification of the Cox-Maze III procedure using the Medtronic Cardioblate ® BP system.

Removal of intracardiac air during valvular surgery should be accomplished in the most effective manner. We conducted a prospective randomized controlled trial to compare mechanical de-airing and carbon dioxide (CO2) field flooding in 18 patients undergoing elective valvular surgery. Transoesophageal echocardiography was used to record intracardiac bubbles, and this was assessed postoperatively by two independent echocardio-graphers blinded to treatment group. Both assessors graded the bubble count higher in the mechanical de-airing group compared with the CO2 flooding group, and there was good agreement between assessors. CO2 field flooding is more effective than mechanical de-airing in removing intracardiac bubbles following valvular surgery.

Wednesday 10 August – Scientific Session 9/1130–1145 Evolution in the Techniques andOutcomes of Aortic Arch Surgery: A 22 Year Single Centre Experience Reece A. Davies 2,4,∗, Deborah Black2, Richmond W. Jeremy2,3, Paul G. Bannon1,2,4, Matthew S. Bayfield1,4, P. Nicholas Hendel 1,2,4, Clifford F. Hughes1,2,4, Michael K. Wilson1,4, Michael P. Vallely 1,2,4 1 Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia 2 Faculty of Medicine, The University of Sydney, Australia 3 Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia 4 The Baird Institute for Heart and Lung Surgical Research, Sydney, Australia Introduction: Aortic arch replacement is a complicated and high risk procedure used mainly in the treatment of aneurysms and dissections of the aortic arch. There have been many advances over recent years [1,2]. Published mortality rates in modern series vary between 6 and 16% [1,3]. We review the changes in our unit’s techniques and outcomes and attempt to identify predictors of an adverse outcome over the past 22 years. Methods: Data were collated from databases and medical records for all patients who underwent aortic arch replacement surgery from January 1989 toDecember 2010. T ( t t m

Fig. 1. (a) CT chest at the time revealed a brachiocephalic trunk aneurysm extending from the origin of the arch of the aorta all the way up to the thoracic inlet area measuring in excess of 8 cm 7 cm 6 cm with evidence of surrounding thrombus and multiple lymph nodes in the preand peri-carinal area with the largest measuring 2.0 cm. (b) The trachea and oesophagus were compressed by the aneurysm and displaced to the left side (Fig. 2). This explained the hoarseness of voice and dysphagia for liquids and solid food in patient. The two working diagnoses were an underlying vasculitic process or a pre-existing aneurysm that became secondarily infected and rapidly expanded as per patient’s blood and urine that grew E. coli.

Objectives The study objective was to describe the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair technique for aortic dissection repair using proximal descending aortic endografting with distal aortic relamination through bare-metal stent and balloon-induced intimal disruption with immediate intimal reapposition. Methods Between April 2007 and September 2011, 11 selected patients (10 male; median age, 50 years) underwent proximal descending aortic endografting plus stent-assisted balloon-induced intimal disruption of the thoracoabdominal aorta to treat complicated aortic dissection (7 type A, 4 acute type B). Patients with type A dissection underwent open surgical intervention plus adjunctive retrograde endovascular repair. Serial computed tomography angiography was used to assess aortic remodeling. Results There were no intraprocedural complications. Thirty-day incidence of death, stroke, and paralysis/visceral ischemia was 9% (n = 1), 0%, and 0%, respectively. Median follow-up was 18 months (range, 4-54 months). Two patients (18%) required secondary endovascular reintervention. No late adverse events or aortic-related deaths occurred. Complete false lumen obliteration occurred in 90% (n = 10) of patients, with stable maximal diameters in the thoracic ( P = .6) and abdominal aortas (celiac trunk: P = .34; renal; P = .6; infrarenal: P = .7) at latest follow-up. Conclusions The Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair approach is a feasible endovascular technique that shows promise to achieve complete repair of the dissected aorta by inducing complete false lumen obliteration. The restoration of uniluminal flow in the thoracoabdominal aorta has the potential to improve long-term outcomes. Prospective, multicenter investigations are required to implement this strategy more broadly.