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Pectus excavatum is a common chest wall deformity with inward deviation of sternum and accompanying ribs. The depression can cause symptomatic cardiac compression, although the cardiopulmonary impact remains controversial. We present 2 cases of cardiac transplantation followed by modified minimally invasive pectus excavatum repair due to the hemodynamic consequences of the pectus deformity.

Background The objectives of this study were to describe opioid prescribing after hospitalization for elective cardiac operation, to identify factors associated with increased opioid prescriptions, and to develop procedure-specific opioid prescribing guidelines. Methods We analyzed data from all adults (≥18 years) undergoing elective cardiac operation for acquired heart disease from July 2014 to March 2017 at 3 affiliated hospitals. Opioid prescription data were abstracted and converted to morphine milligram equivalents (MME). Multivariable logistic regression was performed with the outcome of top-quartile prescriptions. Results There were 4145 study patients after exclusion of preoperative opioid users (10.5%). Mean ± SD patient age was 63.9 ± 13.2 years, and 68.4% (n = 2835) were male. The operation was the first in 87.3% (3617); the most common operative approach was sternotomy in 91.0% (n = 3773), followed by robot-assisted operation in 4.6% (n = 192). The majority of patients, 72.7%, received an opioid prescription at hospital dismissal, with a median opioid prescription of 200 MME (interquartile range 0 to 375 MME; range 0 to 6400 MME). This varied by hospital, with medians of 150, 450, and 600 MME (P Conclusions Significant variation in opioid prescribing practices after cardiac operation was observed. The primary driver was hospital-centric as opposed to patient specific. Opioid prescribing guidelines were established to standardize posthospital pain management.

Interfacility transport of a critically ill patient with acute respiratory distress syndrome (ARDS) may be necessary for a higher level of care or initiation of extracorporeal membrane oxygenation (ECMO). During the COVID-19 pandemic, ECMO has been used for patients with severe ARDS with successful results. Transporting a patient after ECMO cannulation by the receiving facility brings forth logistic challenges, including availability of adequate personal protective equipment for the transport team and hospital capacity management issues. We report our designated ECMO transport team's experience of 5 patients with COVID-19-associated severe ARDS after cannulation at the referring facility. Focusing on transport-associated logistics, creation of checklists, and collaboration with emergency medical services partners is necessary for safe and good outcomes for patients while maintaining team safety.

We present a case of refractory acute hypoxemic respiratory failure due to influenza B pneumonia with concomitant large intra-atrial shunt (IAS) and severe pulmonary regurgitation in a patient with Saethre-Chotzen syndrome with prior pulmonary homograft placement. Our patient's hypoxemia improved with inhaled nitric oxide as an adjunct to mechanical ventilation without requiring extracorporeal membrane oxygenation, and eventually a percutaneous closure with a 30 mm CardioSeal patent foramen ovale closure device was accomplished. However, his peri-procedural hospital course was complicated by occluder device migration, which was retrieved with eventual surgical closure of the PFO. Nitric oxide has not demonstrated any statistically significant effect on mortality and only reported to transiently improved oxygenation in patients with hypoxemic respiratory failure. Our case demonstrates that inhaled nitric oxide may have a role in acute hypoxemic respiratory failure in a case with significant cardiac and pulmonary shunts.

As a bridge to heart transplantation or destination treatment, implantation of the Heartmate 3 (HM3) left ventricular assist device is a viable option for patients with end-stage congestive heart failure. The recent Momentum 3 trial has shown favorable outcomes compared with Heartmate 2. We report the first case of aortic root thrombus occurring early after HM3 implantation as a bridge to heart transplantation. Our case suggests that bridging with an Impella 5.0 preceding HM3 implantation could potentially predispose patients to aortic root thrombus after HM3 implantation, due to Impella-related injury to the aortic valve and aortic root stasis after durable LVAD support.

Objectives Left ventricular (LV) septal hypertrophy in aortic stenosis raises diagnostic and therapeutic questions. However, the etiology and clinical consequences of this finding have not been well studied. The aim of this study was to perform a morphologic evaluation of the LV in aortic stenosis and to investigate the contributing factors and consequences of septal hypertrophy. Methods Patients with moderate or severe aortic stenosis were prospectively enrolled. Patients with previous myocardial infarction, wall motion abnormalities, at least moderate valvular regurgitation, known cardiomyopathy, an LV ejection fraction of less than 50%, and age younger than 65 years were excluded. Results Forty-one patients underwent a final analysis. Septal hypertrophy (LV septal wall thickness ≥15 mm) was confirmed in 21 of 41 patients. The septal hypertrophy group had higher peak aortic valve velocity, a higher diabetes mellitus rate, and a higher rate and longer duration of hypertension than those without septal hypertrophy. The peak aortic valve velocity (odds ratio, 7.1; 95% confidence interval, 1.4–37.1) and diabetes mellitus (odds ratio, 7.4; 95% confidence interval, 1.2–46.2) were the significant factors associated with septal hypertrophy by multivariate analysis. Intraventricular conduction disturbance on electrocardiography was more frequent in the septal hypertrophy group (P = .021). Conclusions Left ventricular septal hypertrophy was commonly observed in elderly patients with aortic stenosis, and a higher aortic valve velocity, hypertension, and diabetes mellitus were associated factors. Intraventricular conduction disturbance occurred more often in patients with septal hypertrophy than those without, which implies the pathophysiologic consequence. Further studies are needed to determine the impact of septal hypertrophy and intraventricular conduction disturbance on the prognosis of patients after aortic valve interventions.

We aimed to develop a risk prediction model using a machine learning to predict survival and graft failure (GF) 5 years after orthotopic heart transplant (OHT). Using the International Society of Heart and Lung Transplant (ISHLT) registry data, we analyzed 15,236 patients who underwent OHT from January 2005 to December 2009. 342 variables were extracted and used to develop a risk prediction model utilizing a gradient-boosted machine (GBM) model to predict the risk of GF and mortality 5 years after hospital discharge. After excluding variables missing at least 50% of the observations and variables with near zero variance, 87 variables were included in the GBM model. Ten fold cross-validation repeated 5 times was used to estimate the model’s external performance and optimize the hyperparameters simultaneously. Area under the receiver operator characteristic curve (AUC) for the GBM model was calculated for survival and GF 5 years post-OHT. The median duration of follow-up was 5 years. The mortality and GF 5 years post-OHT were 27.3% (n = 4161) and 28.1% (n = 4276), respectively. The AUC to predict 5-year mortality and GF is 0.717 (95% CI 0.696–0.737) and 0.716 (95% CI 0.696–0.736), respectively. Length of stay, recipient and donor age, recipient and donor body mass index, and ischemic time had the highest relative influence in predicting 5-year mortality and graft failure. The GBM model has a good accuracy to predict 5-year mortality and graft failure post-OHT.

Purpose In patients with NYHA Class IV heart failure, renal disease may limit candidacy for heart transplantation. Combined heart-kidney transplantation has been effective in patients with multi-organ failure, thereby improving long-term cardiac graft function and overall patient survival. Donors with acute kidney injury (AKI) may limit available organs for transplantation. We aimed to report our experience using donor kidneys with AKI in combined heart-kidney transplantation. Methods From 2005-2020, a single institutional retrospective chart review of patients undergoing combined heart-kidney transplants was performed. The United Network for Organ Sharing (UNOS) database was used to collect data. Statistical analysis was done using a two-sample T-test and comparison of means test. Results were stratified by age, sex, post-operative length of stay (LOS), episodes of rejection, post-operative CRRT, post-operative delay in renal graft function, and cardiac function. Results 35 patients received combined heart-kidney transplants. Average age was 59.37 years. Average follow-up was 50.58 months. In our patient pool, 77.2% were male and 22.8% were female. 5 patients received kidneys from donors who had AKI, of which 1 had delayed graft function (20%). 14 patients who received donor kidneys without AKI had delayed graft function (43.3%) (p=0.88). Average LOS was not statistically different. Current eGFR was not statistically different. 3 patient deaths were not related to graft rejection. See Table 1. Conclusion This study demonstrates that combined heart-kidney transplantation can be done safely and effectively using donor kidneys with AKI. Our analysis shows no difference in post-operative delayed graft function of the kidney with AKI, LOS, and renal/cardiac function. Although our experience suggests safe use of donor kidneys with AKI, larger studies are necessary to define the short and long-term outcomes of combined heart-kidney transplantation with AKI donors.

Purpose Orthotopic heart transplantation (OHT) is a life-saving procedure for advanced end-stage heart failure patients. Given the conservative allocation policy and mismatch of donors and wait-listed patients, the prediction of post OHT outcomes including survival and graft failure (GF) can help optimize organ allocation. We aimed to develop a risk prediction model using machine learning algorithm to predict survival and GF 5 years after OHT. Methods Using International society of heart and lung transplant (ISHLT) registry data, we retrospectively analyzed 15236 patients who underwent OHT from January 2005 through December 2009. 342 variables including pre/ post OHT, discharge and follow up information were extracted and used to develop a risk prediction model utilizing a gradient boosted classification tree algorithm (GBM) to predict the risk of graft failure and mortality 5 yrs. after hospital discharge. Variables with missing observations were handled internally by the GBM algorithm. A 10 fold cross-validation repeated 5 times was used to estimate the model's external performance. Receiver operator curve (ROC) for GBM model was calculated to predict survival and GF 5 years post OHT. Results The mean duration of follow up of 4.7 years (median 5 years). The mortality and graft failure 5 years post- OHT was 27.3% (n = 4161) & 28 %( n=4276) respectively. The area under ROC (AUC) to predict 5 yr. mortality and GF are 0.717 (95% CI 0.696- 0.737) & 0.661 (95% CI 0.640-0.683) respectively. Length of stay, recipient and donor age, recipient body mass index and ischemic time had the highest weight in predicting 5-year mortality and graft failure. The subgroup of patients with age>60yrs had a higher AUC for both the models. Conclusion The GBM model has an excellent accuracy in predicting 5 yr.-mortality and graft failure in patients undergoing OHT.

Abdominal complications following cardiopulmonary bypass (CPB) procedures may have mortality rates as high as 25%. Advanced procedures such as ventricular assist devices, artificial hearts and cardiac transplantation are being increasingly employed, changing the complexity of interventions. This study was undertaken to examine the changing trends in complications and the impact of cardiac surgery on emergency general surgery (EGS) coverage.A retrospective review was conducted of all CPB procedures admitted to our ICU between Jan. 2007 and Mar. 2010. The procedures included coronary bypass (CABG), valve, combination (including adult congenital) and advanced heart failure (AHF) procedures. The records were reviewed to obtain demographics, need for EGS consult/procedure and outcomes.Mean age of the patients was 66 ± 8.5 years, 71% were male. There were 945 CPB procedures performed on 914 patients during this study period. Over 39 months, 23 EGS consults were obtained, resulting in 10 operations and one hospital death (10% operative mortality). CABG and valve procedures had minimal impact on EGS workload while complex cardiac and AHF procedures accounted for significantly more EGS consultations (p0.005) and operations (p0.005). The majority of consultations were for small bowel obstruction/ileus (n = 4, 17%), cholecystitis (n = 3, 13%) and to rule out ischemia (n = 2, 9%)In the era of modern critical care and cardiac surgery, advanced technology has increased the volume of complex CPB procedures increasing the EGS workload. Emergency general surgeons working in institutions that perform advanced procedures should be aware of the potential for general surgical complications perioperatively and the resultant nuances that are associated with operative management in this patient population.

Valve surgery is very different from coronary artery bypass grafting (CABG). Over the natural history of valvular heart disease (VHD), the physiologic characteristics change markedly and, in the operating room, physiologic and hemodynamic conditions are quite variable and are readily influenced by anesthetic interventions. For some types of valve lesions it can be relatively difficult to predict preoperatively how the heart will respond to the altered loading conditions associated with valve repair or replacement. It is essential to understand the natural history of each of the major adult-acquired valve defects and how the pathophysiologic conditions evolve. Surgical decision making regarding valve repair or replacement must also be understood, because a valve operated on at the appropriate stage of its natural history will have a good and more predictable outcome than one operated on at a late stage, when the perioperative result can be quite poor. Because pathophysiologic conditions are dynamic and differ significantly among valve lesions, understanding the physiology and natural

Invasive mucormycosis infections occur in less than 1% of recipients of orthotopic heart transplants. Given the angioinvasive nature of these infections, the mortality rate is high. Little literature exists regarding the presentation and management of these infections. We present a case of a patient who developed an infection after orthotopic heart transplant, describe the successful multidisciplinary management surrounding his care, and review the available literature regarding mucormycosis infections in heart transplant recipients.

Left ventricular (LV) septal hypertrophy in aortic stenosis raises diagnostic and therapeutic questions. However, the etiology and clinical consequences of this finding have not been well studied. The aim of this study was to perform a morphologic evaluation of the LV in aortic stenosis and to investigate the contributing factors and consequences of septal hypertrophy.Patients with moderate or severe aortic stenosis were prospectively enrolled. Patients with previous myocardial infarction, wall motion abnormalities, at least moderate valvular regurgitation, known cardiomyopathy, an LV ejection fraction of less than 50%, and age younger than 65 years were excluded.Forty-one patients underwent a final analysis. Septal hypertrophy (LV septal wall thickness ≥15 mm) was confirmed in 21 of 41 patients. The septal hypertrophy group had higher peak aortic valve velocity, a higher diabetes mellitus rate, and a higher rate and longer duration of hypertension than those without septal hypertrophy. The peak aortic valve velocity (odds ratio, 7.1; 95% confidence interval, 1.4-37.1) and diabetes mellitus (odds ratio, 7.4; 95% confidence interval, 1.2-46.2) were the significant factors associated with septal hypertrophy by multivariate analysis. Intraventricular conduction disturbance on electrocardiography was more frequent in the septal hypertrophy group (P = .021).Left ventricular septal hypertrophy was commonly observed in elderly patients with aortic stenosis, and a higher aortic valve velocity, hypertension, and diabetes mellitus were associated factors. Intraventricular conduction disturbance occurred more often in patients with septal hypertrophy than those without, which implies the pathophysiologic consequence. Further studies are needed to determine the impact of septal hypertrophy and intraventricular conduction disturbance on the prognosis of patients after aortic valve interventions.

Emergent mechanical support with transfer of patients in acute cardiopulmonary shock to specialty centers for definitive management is often required at non-transplant centers. An alternative approach to the traditional "hub and spoke" model is presented. A team of health care specialists from our hospital is deployed to the community hospital for stabilization, possible implantation, and transfer of patients to our tertiary care facility. Patient assessment can be made with intervention, allowing stabilization and safe transfer by our team to our institution. This method provides tertiary level care at the referring hospital and may improve survival for a sub-set of patients in the community hospital setting.

Background:Conventional transvenous approaches for implantable cardioverter defibrillator (ICD) lead placement are not possible in some patients with limited venous access or severe tricuspid valve dysfunction. Methods:We retrospectively identified six patients who underwent ICD placement or revision requiring nontraditional alternative surgical lead placement at our institution between November 2006 and August 2008. The baseline and operative patient characteristic data were accumulated and reviewed. Results:All the patients (mean age 71 ± 3.4 years) underwent nontraditional surgical placement of epicardial ICD leads and traditional placement of ventricular epicardial bipolar pacing/sensing leads. Five patients had the distal lead tip fixed to the anterior epicardium of the right ventricular outflow tract, which was then looped under and around the ventricles, forming a “sling,” and tunneled to a left subclavicular pocket. One patient had a single unipolar subcutaneous array lead fashioned into a “loop” and placed under the inferior aspect of the ventricles. The average procedure time was 311 ± 115 minutes with a mean defibrillatory threshold (DFT) of ≤ 22 + 3 J. Post-procedure hospitalization was 9.3 ± 4.4 days and no device-related complications were encountered. Mean device follow-up of 451 + 330 days showed normal function and two appropriate successful ICD discharges. Conclusion:Nontraditional alternative surgical methods for the placement of ICD systems in adult patients with limited venous access or TV dysfunction can achieve results similar to those of conventionally placed endovascular leads with limited complications and comparable DFTs in short-term follow-up. (PACE 2010; 33:217–225)

Background Indications for placement of implantable cardioverter-defibrillators (ICD) and pacemakers have expanded, and traditional transvenous implantation may not be feasible in patients with aberrant anatomy or venous obstruction. In these settings, successful lead placement has required innovative surgical approaches. A case series of successful placement of these systems in challenging patients is presented. Methods A 2-year retrospective study of patients undergoing placement of minimally invasive epicardial pacing leads or ICD coils was performed. Results Eleven patients underwent minimally invasive surgical placement of leads or coils. None were converted to open sternotomy. One required extension to minianterior thoracotomy. Causes of intravenous placement failure included aberrant anatomy with failure to access coronary sinus in 9 and venous occlusion in 2. Four patients had previous operations through a median sternotomy. Procedures included left video-assisted thoracoscopic (VATS) placement of a left ventricular epicardial lead in 8, left VATS conversion to minianterior thoracotomy left ventricular epicardial lead placement in 1, left VATS placement of ICD coil in 1, subxiphoid placement of a right ventricular epicardial lead in 1, subxiphoid ICD coil in 2, and subcutaneous ICD coil placement in 3. Mean hospitalization was 4.6 days. Postoperative hypotension and pulmonary edema occurred in 27% of patients. No patients died. Conclusions Conventional transvenous lead implantation may be difficult or impossible in some patients with aberrant or occluded venous access. Novel surgical approaches with the use of minimally invasive procedures can establish optimally functional pacing and ICD systems without sternotomy and low associated morbidity.

Therapeutic radiotherapy rarely causes sarcoma, and this occurs years after completion of the intended treatment. In treating breast carcinoma, careful planning in the application of modern radiotherapeutic techniques usually can shield the heart and pericardium. We report a rare case of angiosarcoma of the pericardium, which presented in a 41-year-old woman as constrictive pericarditis 8 years after irradiation for cancer of the left breast. To our knowledge, this is only the 2nd report of angiosarcoma of the pericardium after radiotherapy.

Prosthetic valve endocarditis is an uncommon manifestation of infection with Bartonella species. Herein, we report a case of Bartonella henselae endocarditis involving prosthetic mitral and aortic valves. The patient had a favorable outcome with combined medical and surgical therapy. Concomitant crescentic glomerulonephritis led to an initial mistaken diagnosis of Wegener's granulomatosis.

Circulatory assist devices are an increasingly common method of treating patients with refractory cardiogenic shock. We describe a patient who was a heart transplant candidate with biventricular failure who underwent CardioWest total artificial heart-temporary (SynCardia Inc, Tucson, AZ) implantation with extracorporeal membrane oxygenation to manage the patient's subsequent respiratory failure. After respiratory and hemodynamic stabilization, the CardioWest total artificial heart-temporary served as a successful 62-day bridge-to-heart transplantation.

A 59-year-old woman presented for evaluation of palpitations, orthopnoea, and dyspnoea on exertion. On examination, the patient was found to have an apical holosystolic murmur suggestive of mitral regurgitation. She had no history of rheumatic heart disease but had experienced migraine headaches for which she started taking methysergide when she was 51 years old. She stopped using the methysergide at age 53, when …

The intrinsic and extrinsic activation pathways of the hemostatic system converge when prothrombin is converted to thrombin. The ability to generate an adequate thrombin burst is the most central aspect of the coagulation cascade. The thrombin-generating potential in patients following cardiopulmonary bypass (CPB) may be indicative of their hemostatic status. In this report, thrombography, a unique technique for directly measuring the potential of patients' blood samples to generate adequate thrombin bursts, is used to characterize the coagulopathic profile in post-CPB patients. Post-CPB hemostasis is typically achieved with protamine reversal of heparin anticoagulation and occasionally supplemented with blood product component transfusions. In this pilot study, platelet poor plasma samples were derived from 11 primary cardiac surgery patients at five time points: prior to CPB, immediately post-protamine, upon arrival to the intensive care unit (ICU), 3 hours post-ICU admission, and 24 hours after ICU arrival. Thrombography revealed that the Endogenous Thrombin Potential (ETP) was not different between [Baseline] and [PostProtamine] but proceeded to deteriorate in the immediate postoperative period. At the [3HourPostICU] time point, the ETP was significantly lower than the [Baseline] values, 1233 +/- 591 versus 595 +/- 379 nM.min (mean +/- SD; n=9, p.005), despite continued adequacy of hemostasis. ETPs returned to baseline values the day after surgery. Transfusions received, conventional blood coagulation testing results, and blood loss volumes are also presented. Despite adequate hemostasis, thrombography reveals an underlying coagulopathic process that could put some cardiac surgical patients at risk for postoperative bleeding. Thrombography is a novel technique that could be developed into a useful tool for perfusionists and physicians to identify coagulopathies and optimize blood management following CPB.

In most cases, acute mitral valve regurgitation in the setting of infective endocarditis is caused by the destruction of either the mitral valve leaflets or the chordal apparatus. A 54-year-old woman had development of respiratory failure due to pulmonary oedema from severe acute mitral valve regurgitation in the setting of acute bacterial endocarditis. She was found to have a ruptured anterolateral papillary muscle from occlusion of the circumflex artery by embolic vegetations arising from the aortic valve. Although this occurrence is uncommon, an embolic phenomenon resulting in myocardial infarction and subsequent rupture of papillary muscle must be considered as a cause of acute severe mitral valve regurgitation.

Fulminant myocarditis with rapid onset of symptoms and hemodynamic compromise is a rare indication for mechanical support. Because of the potentially reversible nature of this illness, advanced mechanical circulatory support is warranted to achieve recovery or as a bridge to transplantation. Circulatory device options currently available allow for a phased implementation of support modalities in a manner that reduces costs and patient risk. We present a patient with fulminant myocarditis where extracorporeal membrane oxygenation (ECMO) support escalated to short-term Levitronix CentriMag (Levitronix, Waltham, MA) biventricular assist devices (BiVADs). These in turn were exchanged, without major surgery, to long-term paracorporeal VADs (Thoratec, Pleasanton, CA). After rehabilitation and nearly total recovery, the patient was weaned from mechanical circulatory support after 104 cumulative days.

End-stage renal failure is often considered a relative contraindication for total artificial heart implantation due to the increased risk of mortality after transplantation. We report the successful treatment of a patient having heart and renal failure with the CardioWest (SynCardia Inc, Tucson, AZ) total artificial heart for bridge-to-cardiac transplantation of a heart and kidney.

Coccidioidal pericarditis, an uncommonly diagnosed entity, may evolve to a constrictive process. Constrictive coccidioidal pericarditis requires pericardiectomy and antifungal therapy. In the elderly, pericardiectomy may be complicated by coagulopathy and septic shock. Despite potential toxicity, use of antifungal therapy early postoperatively offers the best chance for survival.

Background Atrial fibrillation after pulmonary resection increases morbidity and costs. To evaluate the efficacy of low-dose oral amiodarone (LDOA) as prophylaxis for atrial fibrillation after pulmonary resection, we reviewed all patients 60 years or older having pulmonary resections by thoracotomy in a 30-month period. Methods We identified 31 patients who received prophylactic LDOA (200 mg by mouth every 8 hours) while hospitalized and 52 patients who received no prophylactic treatment. The groups were comparable for sex, age, comorbidities, and surgical procedure. Results Twenty of 83 patients (24%) had postoperative atrial fibrillation: 17 of 52 patients (33%) without prophylaxis and 3 of 31 (9.7%) with prophylaxis (odds ratio, 0.221; 95% confidence interval, 0.059 to 0.829; p = 0.0253). The median total hospital charge was $30,800 (range, $20,400–$96,900) for 50 patients without prophylaxis and $26,700 (range, $11,000–$55,900) for 31 patients with prophylaxis (p = not significant). Patients receiving LDOA had lower accumulated charges per day of hospital stay (p = 0.0011). Conclusions LDOA prophylaxis significantly reduces the incidence of atrial fibrillation after pulmonary resection. Its use in this population may be cost-effective. Results of this pilot study provide a rationale for a prospective randomized trial.

A 41-year-old man with non-ischaemic dilated cardiomyopathy and morbid obesity was hospitalized with shortness of breath, abdominal pain, and haematochezia. At the age of 39 years, he underwent a left ventricular assist device (LVAD) placement (HeartMate II; Thoratec Corporation, Pleasanton, CA) for destination therapy and tricuspid valve annuloplasty. Initial evaluation revealed ischaemic colitis, elevated left heart filling pressures, and severe haemolysis. LVAD readings were not definitive but suggested a thrombus. Colour flow Doppler transesophageal echocardiography (TEE) demonstrated a normal flow in the left ventricular inflow ( Panel A ; see Supplementary data online, Movie S1 ) and outflow …

Pectus excavatum (PE) deformity is present in the majority of Marfan patients. Many have not had PE repair and present as adults with aortic and valve pathology requiring operative intervention. We present our preliminary report of simultaneous cardiac surgery and repair of the chest wall deformity. Utilizing this modified minimally invasive excavatum repair provided quick, safe repairs with good cosmetic results.

Although complement activation during cardiopulmonary bypass (CPB) is well documented, its pathogenic role in postperfusion organ injury is unproven. In this study, soluble human complement receptor type 1 (sCR1), a potent inhibitor of complement activation, was used to determine the contribution of complement activation to pulmonary injury in a porcine model of CPB. In vitro experiments demonstrated that sCR1 inhibits both classic and alternative complement pathways in the pig. Seven control piglets and 6 piglets treated with sCR1 (12 mg/kg intravenously) underwent 2 hours of hypothermic (28 degrees C) CPB followed by 2 hours of observation. In control piglets, total hemolytic complement activity and functional activities of C3 and C5 declined to 61.3%, 67.8%, and 61.4% of prebypass values, respectively, after 2 hours of CPB. Plasma from animals treated with sCR1 had virtually no hemolytic activity (total hemolytic complement activity < 5% of baseline), demonstrating effective complement inhibition. Similar degrees of neutropenia developed in the two groups during CPB, and there was no difference in post-CPB lung tissue myeloperoxidase level. Two hours after CPB, pulmonary vascular resistance increased 338% in control piglets but only 147% in piglets pretreated with sCR1 (p < 0.05); the alveolar-arterial gradient was not significantly different between controls (331 +/- 52 mm Hg) and piglets receiving sCR1 (290 +/- 85 mm Hg). Histologic examination revealed similar degrees of pulmonary edema in both groups. These data constitute direct evidence that complement activation plays a pathogenic role in lung injury after CPB.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective analysis of the records of 60 patients who underwent pericardiectomy over a 10-year period (1980 to 1990) at The Johns Hopkins Hospital was performed. Indications for operation were effusive disease in 24 patients and constriction in 36 patients. Six patients (10%) with pericardial effusion had pain as the primary symptom necessitating intervention. The operative approach for pericardiectomy was median sternotomy in 52 patients (4 patients required cardiopulmonary bypass) and left anterior thoracotomy in 8 patients. Nine patients (5 with constriction and 4 with effusion) with a prior limited pericardial procedure required formal pericardiectomy. The operative mortality rate for pericardial effusion and constriction was 4.2% and 5.6%, respectively. Follow-up (median follow-up, 56.9 +/- 38.2 months) was obtained on 56 patients (93.3%). Actuarial survival at 1 year, 5 years, and 10 years for all patients was 82.1% +/- 5.1%, 71.7% +/- 6.7%, and 59.8% +/- 12.2%, respectively. A Cox proportional hazards regression analysis was performed using 20 clinical variables. A history of malignancy, previous pericardial procedure, and preoperative New York Heart Association class IV were found to be predictors of poor survival. All patients who underwent operation primarily for effusion with associated pain are alive and have improved functional capacity without steroid use. We conclude that pericardiectomy can be performed with low mortality and can result in good long-term survival and improved functional capacity. Patients who are seen primarily with pain refractory to steroid therapy can be relieved of symptoms with operation.

IntroductionThe Nuss procedure for pectus excavatum (PE) repair has been successfully performed in Marfan syndrome (MFS) patients however there is concern for future risk of aortic dilation/rupture and need for emergent access with support bars in place.Case presentationWe present a 45 year-old male with MFS that required descending aortic replacement shortly after modified Nuss repair.DiscussionThe majority of MFS patients have severe PE and repair with the Nuss procedure is not uncommon. The risk for life threatening aortic dilation, dissection, or rupture in such patients is a concern when utilizing this technique. Our work has been reported in line with the CARE criteria.ConclusionNuss repair should be considered in MFS patients with technique modifications and careful consideration of future risk of aortic dilation and rupture.