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Acute pulmonary embolism is a substantial cause of morbidity and death. Although the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines recommend surgical pulmonary embolectomy in patients with acute pulmonary embolism associated with hypotension, there are few reports of 30-day mortality rates. We performed a retrospective review of acute pulmonary embolectomy procedures performed in 96 consecutive patients who had severe, globally hypokinetic right ventricular dysfunction as determined by transthoracic echocardiography. Data on patients who were treated from January 2003 through December 2011 were derived from health system databases of the New York State Cardiac Surgery Reporting System and the Society of Thoracic Surgeons. The data represent procedures performed at 3 tertiary care facilities within a large health system operating in the New York City metropolitan area. The overall 30-day mortality rate was 4.2%. Most patients (68 [73.9%]) were discharged home or to rehabilitation facilities (23 [25%]). Hemodynamically stable patients with severe, globally hypokinetic right ventricular dysfunction had a 30-day mortality rate of 1.4%, with a postoperative mean length of stay of 9.1 days. Comparable findings for hemodynamically unstable patients were 12.5% and 13.4 days, respectively. Acute pulmonary embolectomy can be a viable procedure for patients with severe, globally hypokinetic right ventricular dysfunction, with or without hemodynamic compromise; however, caution is warranted. Our outcomes might be dependent upon institutional capability, experience, surgical ability, and careful patient selection.

Background We designed and tested an innovative transitional care program, involving cardiac surgery nurse practitioners, to improve care continuity after patient discharge home from coronary artery bypass graft (CABG) operations and decrease the composite end point of 30-day readmission and death. Methods A total of 401 consecutive CABG patients were eligible between May 1, 2010, and August 31, 2011, for analysis. Patient data were entered prospectively into The Society of Thoracic Surgeons database and the New York State Cardiac Surgery Reporting System and retrospectively analyzed with Institutional Review Board approval. The “Follow Your Heart” program enrolled 169 patients, and 232 controls received usual care. Univariate and multivariate analyses were used to identify readmission predictors, and propensity score matching was performed with 13 covariates. Results Binary logistic regression analysis identified “Follow Your Heart” as the only independently significant variable in preventing the composite outcome ( p = 0.015). Odds ratios for readmission were 3.11 for dialysis patients, 2.17 for Medicaid recipients, 1.87 for women, 1.86 for non-Caucasians, 1.78 for chronic obstructive pulmonary disease, 1.26 for diabetes, and 1.09 for congestive heart failure. Propensity score matching yielded matches for 156 intervention patients (92%). The intervention showed a significantly lower 30-day readmission/death rate of 3.85% (6 of 156) compared with 11.54% (18 of 156) for the usual care matched group ( p = 0.023). Conclusions A home transition program providing continuity of care, communication hub, and medication management by treating hospital nurse practitioners significantly reduced the 30-day composite end point of readmission/death after CABG. More targeted resource allocation based on odds ratios of readmission may further improve results and be applicable to other patient groups.

Despite the frequent use of surveys to study charitable giving and volunteering, little is known about the quality of the data collected. This article discusses the challenges associated with designing giving and volunteering surveys, suggests strategies for improving measures of giving and volunteering, and shows how they were applied in the design of Canada’s 1997 National Survey of Giving, Volunteering and Participating. Surveys are frequently used to collect data about giving and volunteering; however, the quality of the data is seldom known, and the measurement challenges inherent in such surveys are not well recognized. For example, the inability of respondents to accurately recall past behaviors introduces both random errors and probable downward biases to estimates of giving and volunteering. On the other hand, the tendency of some respondents to provide socially desirable responses may lead to an overreporting of giving and volunteering. The extent to which these two potential sources of bias may offset one another is seldom known and varies from survey to survey according to the particular way in which giving and volunteering are measured. Such threats to the reliability and validity of survey data on giving and volunteering can be minimized by good survey design and the choices that researchers make about such things as the survey method (e.g., telephone, mail, or personal interview), the unit of analysis (individual vs. household), and the types of questions that are used to measure giving and volunteering. In this article, I outline a number of the measurement challenges associated with surveys of giving and volunteering, suggest strategies that can assist in the development of reliable and valid measures of giving and volunteering, and show how these strategies were applied in the design of Canada’s 1997 National Survey of Giving, Volunteering and Participating (NSGVP). The NSGVP was initiated as a collaborative effort by a number of Canadian national voluntary organizations and federal government departments. 1

Background a retrospective chart review of 94 patients with asymptomatic high-grade carotid stenosis undergoing coronary bypass (and valve replacement in some cases) was performed to determine whether significant carotid lesions can be safely ignored in patients undergoing cardiac surgical procedures. These operations were performed during a 2-year period. Patients and methods there were 55 men and 39 women, with an age range of 37–89 years. Seventy-one patients had unilateral high-grade carotid stenosis, 17 patients had bilateral high-grade lesions, and six patients had unilateral high-grade stenosis and contralateral occlusion. Associated medical problems were recorded and short-term follow-up was obtained. Results there was one perioperative stroke and no deaths in this group of patients. Conclusions although these data indicate that high-grade carotid stenoses may be safely ignored during cardiac surgical procedures, a multicentre prospective randomised trial is needed to determine the appropriate treatment of the patient with coexisting carotid and coronary artery disease.

The restrained (air bag and seatbelt) driver of a vehicle involved in a high-speed motor-vehicle accident sustained a tear of the thoracic aorta with no signs of external injury. Air bag deployment may mask significant internal injury, and a high index of suspicion is warranted in such situations.

Rupture of an acute ascending aortic dissection into a surrounding cardiac chamber or pulmonary artery is an uncommon occurrence, and is often only diagnoses post mortem. Although fistulization (aortopulmonary and aorta-right atrial) after acute aortic dissection has been well documented in the literature, acute aortic dissection fistulizing into both the right ventricle and pulmonary artery has not. We report on a 75-year-old woman who presented with an acute ascending aortic dissection with both aortopulmonary and aorta-right ventricular fistulas who underwent repair and had long-term survival.

Cardiac papillary fibroelastoma is a rare primary cardiac tumor that usually involves the heart valves. Multiple fibroelastomas found in a single patient is an even more rare occurrence. We describe the case of a 41-year-old woman who presented with an acute cerebrovascular accident, and was found to have 4 separate fibroelastoma tumors involving the aortic and mitral valves. The role of echocardiography in the diagnosis of this unusual tumor and its therapy is discussed.

Augmented venous drainage improves venous return during minimally invasive cardiac surgery. Two systems to augment drainage are common: in one, a centrifugal pump draws blood from the venous site and pumps it into a venous reservoir. In the other, suction is applied directly to a hard-shell venous reservoir. Both systems overcome the high resistance of the venous cannula when gravity alone is insufficient to provide adequate drainage. Both systems also have shortcomings: in the first approach, the centrifugal pump head can entrap large bubbles, reducing flow and requiring pump stoppage to remove them. Air from the venous line also can be broken up by the centrifugal pump into small bubbles that can pass through the pump head. The direct suction system in the second approach cannot use a closed-bag reservoir, and has the potential to introduce air into the arterial line. We have developed a new venous augmentation system for a closed venous reservoir that provides excellent suction control without the potential to introduce air into the arterial line. Our system replaces the centrifugal pump of the first approach with a roller pump controlled by the Better-Bladder™, a new device with FDA 510(k) clearance for long-term pumping. The Better-Bladder is a length of medical tubing, processed to form a thin-walled, enlarged bladder that is sealed within a clear rigid housing. It acts as an in-line reservoir that provides compliance in the venous line and a noninvasive means to measure blood pressure at the pump inlet. The bladder housing can maintain a negative pressure set by the user that controls the degree of gravity drainage. Tests have shown that the Better-Bladder allows for safe, smooth pump control using a roller pump in the venous line.

A 58-year-old man with left main and right coronary artery disease requiring preoperative intraaortic balloon pumping underwent successful minimally invasive triple coronary bypass through bilateral parasternal incisions. Despite taking immunosuppressive drugs because of a previous liver transplantation, the patient had all-arterial grafts without sternotomy. He was discharged on the fourth postoperative day, returned to work in 4 weeks, and has a negative thallium stress test.

Obesity has been identified as an independent risk factor for cardiovascular disease 1–4 and the occurrence of complications of coronary artery bypass grafting (CABG). 5,6 A study was designed to determine if the risks associated with morbid obesity should alter the indications for CABG, the operative strategy or the postoperative care.

Ninety-six consecutive patients older than 40 years with severe mitral stenosis were retrospectively analyzed to determine the relation of angina pectoris (AP) and coexistent coronary artery disease (CAD). Of the 96 patients, 27 (28%) had angiographically significant CAD, 10 (37%) with AP and 17 (63%) without AP. Of the 96 patients, 21 had AP, 10 (48%) with angiographically significant CAD and 11 (52%) without (CAD). Of 75 patients without AP, 17 (23%) had angiographically significant CAD AP had a specificity of 84% and a sensitivity of 37% in its ability to detect significant CAD. The pulmonary artery systolic, diastolic and mean pressures and the pulmonary vascular resistance did not differ between patients with and those without AP (p greater than 0.05). It is concluded that coexistent CAD is commonly found in patients older than age 40 with severe MS, and is usually clinically silent.

Associated to the field Q ( k 1 / 2 ) Q({k^{1/2}}) ( k k a positive square free integer greater than one), there is a group of transformations of the product of two upper half planes which is analogous to the Hilbert modular group. This group has been shown to have a fundamental domain bounded by a finite number of hypersurfaces. Of particular interest is a subspace of the domain known as the “floor.” This floor is a quotient space of a fiber bundle over the circle which is determined by the field Q ( k 1 / 2 ) Q({k^{1/2}}) . The principal result of this paper is that, conversely, the topological type (indeed the homotopy type) of this fiber bundle determines the field Q ( k 1 / 2 ) Q({k^{1/2}}) which gives rise to it. This is accomplished by computing the homology groups of the fiber space and showing that the integer k k can be determined from these groups.

Seventy-eight patients with isolated, severe aortic regurgitation (AR) were studied retrospectively to determine the prevalence of angiographically significant coronary artery disease (CAD) and its relation to angina pectoris (AP). Angiographically, significant CAD was present in 29 of 78 patients (37%), and 36 patients (46%) had AP. Twenty-one of 36 patients (58%) with AP and 8 of 42 patients (19%) without AP had angiographically significant CAD. AP as a predictor of significant CAD had a sensitivity of 73%, specificity of 69% and a risk ratio of 3:1. The predictive accuracy of detecting CAD in the absence of AP was 81%. The benefit from concomitant coronary artery bypass grafting at the time of aortic valve replacement for AR has not been clearly demonstrated; therefore, routine coronary angiography is still recommended for all AR patients older than 40 years undergoing aortic valve replacement.

The natural history of cyanotic congenital heart disease was described in the 1940s and 1950s from experiences in the United States and other developed nations. [1–3]. Since the advent of palliative procedures (including balloon septostomy), palliative surgery, and corrective surgery, the natural history of cyanotic congenital heart disease has been greatly altered. However, in developing countries around the world, individuals with congenital heart disease still do not receive the benefits of modern therapeutic modalities. In 1980, a program called Lifeline was instituted at North Shore University Hospital, Manhasset, New York. This program was designed to provide care for children with heart disease living in developing countries.

One hundred three patients with isolated, severe aortic stenosis (AS) were retrospectively analyzed to determine the relation of angina pectoris to angiographically significant coronary artery disease (CAD). All patients underwent coronary angiography regardless of the presence or absence of angina. Angina was significantly associated with CAD (p less than 0.002), with a sensitivity of 78% and a specificity of 53%. However, 25% of the patients without angina had angiographically significant CAD, and in these patients there was a 70% prevalence of 1-vessel disease. Patients with isolated, severe AS should undergo coronary angiography to identify coexistent CAD accurately. The absence of angina does not reliably exclude angiographically significant CAD.

While cocaine-induced myocardial infarction has been frequently documented, the differential diagnosis of chest pain should include aortic pathology. The successful management of acute aortic dissection secondary to cocaine abuse has not been previously reported to our knowledge. In a 45-year-old man who presented with typical chest pain and wide mediastinum, the successful management of this disease included early and accurate diagnosis and replacement of the aortic valve as well as the torn portion of the ascending aorta.

Compartment syndrome is a rare and dangerous complication of coronary artery bypass. All reported cases involved the vein donor limb. Once recognized, immediate fasciotomy is necessary to prevent irreversible ischemia and limb loss. Diagnosis requires a high index of suspicion and close observation of the patient, particularly those remaining intubated during the early postoperative period. (J Vasc Surg 2002;36:1069-70.)