Search

This study sought to characterize the current US experience of aortic prosthetic valve endocarditis (PVE) compared with native valve endocarditis (NVE).The Society of Thoracic Surgeons Database was queried for entries of active aortic infective endocarditis (IE). Two analyses were performed: (1) trends of surgical volume and operative mortality (2011-2019); and (2) descriptive and risk-adjusted comparisons between PVE and NVE (2014-2019) using multivariable logistic regression.From 2011 to 2019, there was a yearly increase in the proportion of PVE (20.9% to 25.9%; P.001) with a concurrent decrease in operative mortality (PVE, 22.5% to 10.4%; P.001; NVE, 10.9% to 8.5%; P.001). From 2014 to 2019, active aortic IE was identified in 9768 patients (NVE, 6842; PVE, 2926). Aortic root abscess (50.1% vs 25.2%; P.001), aortic root replacement (50.1% vs 12.8%; P.001), homograft implantation (27.2% vs 4.1%; P.001), and operative mortality (12.2% vs 6.4%; P.001) were higher in PVE. After risk adjustment, PVE (odds ratio [OR], 1.5; 95% CI,1.16-1.94; P.01), aortic root replacement (OR, 1.49; 95% CI,1.15-1.92; P.001), Staphylococcus aureus (OR, 1.5; 95% CI,1.23-1.82; P.001), and unplanned revascularization (OR, 5.83; 95% CI,4.12-8.23; P.001) or mitral valve surgery (OR, 2.29; 95% CI,1.5-3.51; P.001) correlated with a higher operative mortality, whereas prosthesis type (P = .68) was not an independent predictor.IE in the United States has risen over the past decade. However, operative mortality has decreased for both PVE and NVE. PVE, extension of IE requiring aortic root replacement, and additional unplanned surgical interventions carry an elevated mortality risk. Prosthesis selection did not affect operative mortality.

The axillary artery is a reliable inflow vessel when addressing pathology of the aortic root and aortic arch that may preclude standard central cannulation strategies. This narrative review examines the use of the axillary artery in cardiac surgery. Anatomy, indications for use, cannulation strategies, and potential complications will be discussed.A comprehensive review of the current literature was performed using PubMed, Cochrane Review, and authoritative committee guidelines. A narrative review incorporating current available evidence was undertaken.Use of the axillary artery in select cardiac surgical cases is reliable, reproducible, and may be preferable in certain cases involving ascending aortic pathology, reoperative surgery, porcelain aorta, access for transcatheter valve therapies, and peripheral mechanical circulatory support.

In patients undergoing high-risk cardiac surgery, the uncertainty of outcome may complicate the decision process to intervene. To augment decision-making, a machine learning approach was used to determine weighted personalized factors contributing to mortality.American College of Surgeons National Surgical Quality Improvement Program was queried for cardiac surgery patients with predicted mortality ≥10% between 2012 and 2019. Multiple machine learning models were investigated, with significant predictors ultimately used in gradient boosting machine (GBM) modeling. GBM-trained data were then used for local interpretable model-agnostic explanations (LIME) modeling to provide individual patient-specific mortality prediction.A total of 194 patient deaths among 1291 high-risk cardiac surgeries were included. GBM performance was superior to other model approaches. The top five factors contributing to mortality in LIME modeling were preoperative dialysis, emergent cases, Hispanic ethnicity, steroid use, and ventilator dependence. LIME results individualized patient factors with model probability and explanation of fit.The application of machine learning techniques provides individualized predicted mortality and identifies contributing factors in high-risk cardiac surgery. Employment of this modeling to the Society of Thoracic Surgeons database may provide individualized risk factors contributing to mortality.

BACKGROUND: Reductive annuloplasty repair of ischemic mitral regurgitation (IMR) is associated with high rates of recurrent MR, which may be improved with etiology-specific annuloplasty rings. METHODS: From October 2005 to May 2015, 128 consecutive patients underwent repair of IMR with the GeoForm ring. Clinical data was extracted from our local Society of Thoracic Surgeons database and electronic medical records. Mortality data was obtained from the Michigan State Social Security Death Index. RESULTS: The average age of patients was 65±11 years with mean pre-op left ventricular ejection fraction (LVEF) of 30%±10% and MR grade of 3.1±0.9 (0–4+). Thirty-day mortality was 4.7%, rate of renal failure 7.9%, rate of atrial fibrillation 27.3%, and no strokes were observed. Of the surviving patients, 89% (109/122) had a follow-up echocardiogram beyond 1 month with a mean echocardiographic follow-up of 59±39 months. LVEF improved from 30%±10% to 38%±14%, P

Refusal of blood product transfusion presents a unique challenge in patients requiring major cardiac surgery. We present a case of a 45-year-old African American female Jehovah's Witness with a history of aortic dissection who presented to the emergency department with worsening back pain. Imaging revealed aneurysmal dilatation of her known Stanford type A dissection measuring 10.9 cm. A staged carotid-subclavian bypass followed by aortic valve, ascending aorta, and aortic arch replacement with debranching was performed using a bloodless strategy.

A 71-year-old woman was admitted with acute hypoxic and hypercapnic respiratory failure and cardiogenic shock, secondary to acute on chronic biventricular systolic and diastolic congestive heart failure and severe aortic and mitral valve stenosis. She further presented with pulmonary hypertension and moderate-to-severe tricuspid regurgitation requiring high and increasing doses of vasopressors. The patient was percutaneously cannulated for venoarterial extracorporeal membrane oxygenation (VA-ECMO) and stabilized on ECMO, with a urine output of 17.3 L within the following 8 days. Balloon valvuloplasty and/or transcatheter aortic valve replacement were discussed but ruled out by the multidisciplinary team considering the mitral valve could not be fully addressed. Though lung function was not fully optimized, a window of opportunity was identified and used for double valve replacement on day 8 of VA-ECMO support. After a 24-hour vasoplegic period, the patient was extubated to continuous positive airway pressure and further transitioned to nasal cannula, following which she recovered well.

Neuroendocrine tumours are rare neoplasms typically arising in the gastrointestinal tract that may result in carcinoid syndrome and/or acquired valvular dysfunction. Herein, we present a unique case of a 68-year-old asymptomatic woman with a primary left ventricular neuroendocrine tumour.

Background The Cox Maze-IV procedure (CMP-IV) has replaced the Cox Maze-III procedure as the most common approach for the surgical treatment of atrial fibrillation (AF). The Food and Drug Administration-regulated AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation (ABLATE) trial sought to demonstrate the safety and efficacy of the CMP-IV performed with the Synergy ablation system (AtriCure, Inc, Cincinnati, OH). Methods Fifty-five patients (aged 70.5 ± 9.3 years), 92.7% of whom had nonparoxysmal AF, underwent CMP-IV to terminate AF during a concomitant cardiac surgical procedure. Lesions were created using the AtriCure Synergy bipolar radiofrequency ablation system. All patients were seen for follow-up visits after 30 days, 3 months, and 6 months, with 24-hour Holter monitoring at 6 months. Late evaluation was performed by 48-hour Holter monitoring at an average of 21 months. Results The primary efficacy endpoint, absence of AF (30 seconds or less) at 6-month follow-up off antiarrhythmic medications (Heart Rhythm Society definition), indicated 76% (38 of 50) were AF free (95% confidence interval: 62.6% to 85.7%). The primary safety endpoint, the rate of major adverse events within 30 days, was 9.1% (5 of 55; 95% confidence interval: 3.9% to 19.6%), with 3.6% mortality (2 of 55). Secondary efficacy endpoints included being AF free with antiarrhythmic drugs (6 months, 84%; 21 months, 75%), successful pulmonary vein isolation (100%), and AF burden at 6 and 21 months. The results, together with those for the secondary safety endpoint (6-month major adverse events), demonstrated that the Synergy system performs comparably to the cut-and-sew Cox Maze-III procedure. Conclusions The CMP-IV using the AtriCure Synergy system was safe and effective for cardiac surgical patients who had persistent and longstanding persistent AF.

Fungal aortic graft infections are unusual and have been reported primarily in the abdominal aortic position. Ascending aortic graft infections secondary to Candida species have been reported rarely and invariably localized to the confines of the aortic graft. We present an interesting case of an ascending aortic graft infection with Candida albicans, with evidence of invasion of the sternum and overlying soft tissues.

OBJECTIVES Pulmonary hypertension (PHT) is associated with tricuspid annular dilatation, but the effect of acute increase of pulmonary pressure on three-dimensional (3D) tricuspid annular dynamics and shape is unknown. Better understanding of tricuspid annular dynamics may lead to improved and more durable surgical reparative techniques. METHODS In nine open-chest anaesthetized sheep nine sonomicrometry crystals were implanted on the right ventricle while on cardiopulmonary bypass. Additional nine crystals were implanted around the tricuspid annulus (TA) with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Two additional equidistant crystals were implanted between each commissure, creating three segments for every region. Pressure transducers were placed in the left ventricular (LV), right ventricular (RV) and right atrium. PHT was induced by acute pulmonary artery constriction with a pneumatic occluder. Sonomicrometry and echocardiographic data were collected before and after induction of PHT. TA area, regional and total perimeter, and 3D annular geometry were calculated from 3D crystal coordinates. Regional annular contraction was defined as the percentage difference between maximal and minimal region length during the cardiac cycle. RESULTS PHT increased RV pressure from 31 ± 9 mmHg to 46 ± 13 mmHg (P = 0.001) and decreased left ventricular (LV) pressure from 111 ± 24 mmHg to 78 ± 36 mmHg (P = 0.018). There was no significant tricuspid regurgitation observed with PHT. During PHT, the TA area increased by 12 ± 13% from 641 ± 139 mm(2) to 721 ± 177 mm(2) (P = 0.037). The total perimeter increased from 103 ± 11 mm to 109 ± 13 mm (P = 0.02). All annular regions dilated significantly with PHT with 8 ± 10, 5 ± 5 and 5 ± 5% increase in anterior, posterior and septal annular length, respectively (P < 0.05). PHT reduced regional annular contraction in the anterior region only (17 ± 7 vs 14 ± 8%; P = 0.02). The TA had a complex 3D saddle geometry and the shape of the annulus was altered during PHT only in the antero-posterior region. CONCLUSIONS The changes in tricuspid annular conformation, contractility and its 3D geometry observed during acute ovine PHT may help in the design of new pathology-specific tricuspid annular rings.

BackgroundReductive ring annuloplasty represents the current standard surgical therapy for ischemic mitral regurgitation (IMR); however, the clinical results have been suboptimal. Etiology-specific prostheses such as the GeoForm annuloplasty ring have been designed to better address the annular and subvalvular perturbations associated with IMR. However, clinical experience is limited, and mid-term results are lacking.MethodsWe reviewed the clinical outcomes of 86 patients who had undergone implantation of a GeoForm ring at our center from 2005 to 2011. Perioperative mortality and clinical parameters were derived from The Society of Thoracic Surgeons database. Follow-up survival was assessed using the Social Security Death Index. Surviving patients were interviewed by telephone for valve-specific follow-up data and to complete the Medical Outcomes Study, short-form, 36-item, quality-of-life questionnaire.ResultsThe mean grade of IMR preoperatively was 3.1 ± 0.8 (range, 1-4+), 0.2 ± 0.4 in the immediate postoperative period, and 0.7 ± 0.7 at the last mean follow-up point of 41 months; only 2 patients developed ≥2+ IMR during the follow-up period, for a 5-year freedom from recurrent 2+ IMR of 86%. The mean left ventricular end-diastolic and end-systolic diameters decreased from before to after surgery from 6.0 ± 0.0 cm to 5.3 ± 09 cm and 5.0 ± 0.9 cm to 4.3 ± 1.1 cm, respectively (P

Background To compare the perioperative and long term survival after aortic valve replacement using stentless versus stented valves in a large cohort of patients grouped using propensity score matching. Methods From 1991 to 2012, 4,563 patients underwent aortic valve replacement with stentless and stented valves at our institution. Propensity score matching identified 444 pairs using 13 independent variables: incidence of operation, smoking status, renal failure, hypertension, diabetes, peripheral vascular disease, cerebrovascular disease, chronic lung disease, ejection fraction, gender, age, valve status, and use of coronary artery bypass graft. Data were collected from our Society of Thoracic Surgeons database and the Social Security Death Index. Groups were compared using univariate and Kaplan-Meier analysis. Results The two groups demonstrated no significant differences for the 13 matching variables and the majority of 30-day outcomes (p > 0.05). The stented valve group showed a higher incidence of postoperative bleeding (3.6% vs 1.1%, p = 0.015), but a lower incidence of stroke (0.9% vs. 2.9%, p = 0.028). One, five, and 10-year survival was 95.0, 80.7, and 52.8% for stented and 93.2, 80.5, and 51.3% for stentless valves. Overall survival did not differ significantly between the two groups (p = 0.641). Conclusions Stentless and stented valves had identical 30-day outcomes except for a higher postoperative incidence of bleeding and a lower incidence of stroke in the stented group. There was no significant difference in long term survival between valve types. Both valves may be used for aortic valve replacement with low morbidity and excellent long term survival.

Objective The superior hemodynamics and excellent long-term clinical performance of stentless xenografts are well described. However, the early and midterm clinical outcomes of stentless valves in patients with acute type A dissection are widely unknown. The current study evaluated the early and midterm clinical outcomes of stentless bioprosthesis for repair of acute type A aortic dissection. Methods Between May 2005 and December 2009, 24 of 80 patients underwent root replacement using the Medtronic Freestyle xenograft (Medtronic Inc, Minneapolis, Minn) at the Meijer Heart Center. Prospective data collection was used for retrospective review. Univariate comparisons of preoperative, intraoperative, and postoperative variables were performed between patients who underwent stentless root bioprosthesis for the correction of acute type A aortic dissection (n = 24). Results The mean age of patients was 57 years, with 15 patients aged less than 65 years. Axillary and femoral artery cannulation were used in 16 patients (67%) and 7 patients (29%), respectively. Median crossclamp and cardiopulmonary bypass times were 198 minutes (92-480 minutes) and 288 minutes (109-588 minutes), respectively. Median circulatory arrest time was 28 minutes (24-50 minutes). Operative mortality rate was 25%. Actuarial 5-year survival was 62.5%. No patients required redo aortic root replacement. Conclusions Stentless valve implantation can be accomplished with satisfactory early and midterm clinical outcomes and is a valuable option in patients with acute aortic dissection who require root replacement.

Background The clinical characteristics, management, and outcomes of patients who had intraoperative aortic dissection (IAD) have not been thoroughly investigated. This study compared early and late clinical outcomes in patients with IAD vs spontaneous (non-IAD) acute type A aortic dissection. Methods Between January 1, 2000, and July 1, 2008, 251 patients from 4 academic medical centers underwent repair of acute type A aortic dissection; of those, 11 had IAD. The mean age was 72 ± 9 years for patients experiencing IAD and 59 ± 13 years for those with non-IAD ( p = 0.001). Patients with IAD were more likely to have coronary artery disease ( p = 0.003) and a history of arrhythmia ( p = 0.038). Rates for major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Results Operative mortality was not adversely influenced by IAD (27% IAD vs 17% non-IAD, p = 0.42). There were no differences in the rates of reoperation for bleeding (10% IAD vs 20% non-IAD, p = 0.69), stroke (18% IAD vs 18% non-IAD, p ≥ 0.99), or acute renal failure (9% IAD vs 22% non-IAD, p = 0.47) between the two groups. Actuarial 5-year survival was 64% for IAD patients vs 73% for non-IAD patients ( p = 0.33). Conclusions IAD does not adversely influence early outcomes and actuarial 5-year survival of patients with type A dissection.

Background Long cross clamp times have been associated with poor clinical outcomes, yet some patients require extremely long ischemic times to repair complex surgical problems. The purpose of this study was to examine short and mid-term survival and to identify risk factors for mortality and morbidity in patients with cross clamp times greater than or equal to 300 min. Methods Review of our institution’s Society of Thoracic Surgeons database identified 202 patients who underwent surgical procedures necessitating aortic cross clamp times 300 min or greater between 2001 and 2012. Short-term (30-day) clinical outcomes were derived from this database and survival was assessed utilizing the Social Security Death Index. Univariate and multivariate analyses were used to determine the relationship between independent variables and mortality and postoperative outcomes. Results The average age of the patients was 69.5 ± 10.6 (mean ± standard deviation) years and the mean ejection fraction was 52 ± 12 %. 70.3 % of patients were male. Mean cross clamp time was 346 ± 45 min, and total bypass time was 421 ± 70 min. Thirty-day mortality was 12.4 %. The incidence of bleeding and stroke were 6.4 % and 4.0 % respectively. Prolonged ventilation occurred in 26.7 % of patients, and incidence of renal failure was 10.4 %. One, three, five, and seven year survival of the patients who survived the first 30 days post-surgery was 91.9 %, 83.2 %, 75.6 % and 65.7 % respectively. Proportional hazards analysis determined that the statistically significant hazard ratios for mid-term mortality for female gender, age, and prolonged postoperative ventilation were 2.11, 1.04 and 2.72, respectively (p

Objectives Left ventricular assist device (LVAD) implantation may alter right ventricular shape and function and lead to tricuspid regurgitation. This in turn has been reported to be a determinant of right ventricular (RV) failure after LVAD implantation, but the effect of mechanical left ventricular (LV) unloading on the tricuspid annulus is unknown. The aim of the study was to provide insight into the effect of LVAD support on tricuspid annular geometry and dynamics that may help to optimize LV unloading with the least deleterious effect on the right-sided geometry. Methods In seven open-chest anaesthetized sheep, nine sonomicrometry crystals were implanted on the right ventricle. Additional nine crystals were implanted around the tricuspid annulus, with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Left ventricular unloading was achieved by connecting a cannula in the left atrium and the aorta to a continuous-flow pump. The pump was used for 15 min at a full flow of 3.8 ± 0.3 l/min. Epicardial echocardiography was used to assess the degree of tricuspid insufficiency. Haemodynamic, echocardiographic and sonomicrometry data were collected before and during full unloading. Tricuspid annular area, and the regional and total perimeter were calculated from crystal coordinates, while 3D annular geometry was expressed as the orthogonal distance of each annular crystal to the least squares plane of all annular crystals. Results There was no significant tricuspid regurgitation observed either before or during LV unloading. Right ventricular free wall to septum diameter increased significantly at end-diastole during unloading from 23.6 ± 5.8 to 26.3 ± 6.5 mm (P = 0.009), but the right ventricular volume, tricuspid annular area and total perimeter did not change from baseline. However, the septal part of the annulus significantly decreased its maximal length (38.6 ± 8.1 to 37.9 ± 8.2 mm, P = 0.03). Annular contraction was not altered. The tricuspid annulus had a complex 3D saddle-shaped geometry that was unaffected during experimental conditions. Conclusions In healthy sheep hearts, left ventricular unloading increased septal-free wall RV diameter and reduced the length of the septal annulus, without altering the motion or geometry of the tricuspid annulus. Acute left ventricular unloading alone in healthy sheep was not sufficient to significantly perturb tricuspid annular dynamics and result in tricuspid insufficiency.

Aortic valve replacement with stentless xenografts has become routine since their introduction in the early 1990s. Although concerns of structural valve deterioration and long-term durability have been voiced, the reports on the causes or pathology associated with early valve failure have been sparse. We report two unusual cases of failure leading to patient death within the first year after implantation of the aortic valve and root with the Freestyle prostheses (Medtronic Inc, Minneapolis, MN). We suggest an early immunologic reaction to the xenograft, leading to a fatal inflammatory process, as a mechanism for unusual early valve failure in these patients.

Deep sternal infections secondary to bony instability and malunion, can result in mediastinitis. Previous authors have described the use of prophylactic rigid plate fixation in high-risk patients. The purpose of our study is to review the use of prophylactic sternal platting with pectoralis advancement flaps in high-risk patients with a history of chest irradiation. Fourteen patients (July 2003-September 2008) with a history of chest irradiation who underwent a median sternotomy followed by prophylactic rigid plate fixation of the sternum were reviewed. Breast cancer was the most common etiology of chest irradiation (n=11, 78%). The average EuroSCORE was 24.06% with 72% of patients having a preoperative New York Heart Association (NYHA) class≥III. There were no episodes of sternal non-union, mediastinitis or death. Follow-up was 100% with a 0% 30-day and a 7.1% one-year mortality rate (non-cardiac). A comparison between mean preoperative left ventricular ejection fraction (LVEF) (49.6%) and postoperative LVEF (59.7%) was statistically significant (P

A partir de un centro individual se presentan los resultados de la experiencia con la correccion aortica endovascular de patologias de la aorta toracica que confirman su utilidad en pacientes con comorbilidades sustanciales. Se efectuo una revision retrospectiva de todos los pacientes sometidos a correccion de patologias de la aorta toracica, de forma endovascular o abierta, desde 2002. Las principales variables analizadas incluyeron la presentacion clinica, demografia, factores de riesgo preoperatorio, informes operatorios y resultados clinicos. El grupo endovascular incluyo a 37 pacientes (22 hombres), mientras que el grupo de cirugia abierta incluyo a 19 pacientes (ocho hombres). Fueron tratados con caracter urgente por un traumatismo o rotura ocho pacientes por grupo (22% y 42%, respectivamente; p = 0,11). Los pacientes tratados con tecnicas endovasculares eran significativamente mas ancianos y con mas procesos comorbidos (p

Les resultats du traitement endovasculaire de l'aorte thoracique dans notre institution sont presentes et confirment qu'il est sur chez les patients presentant des comorbidites significatives. Une revue retrospective de tous les patients ayant eu une reparation endovasculaire ou ouverte de l'aorte thoracique dans notre institution depuis 2002 a ete effectuee. Les principaux criteres de jugement incluaient la presentation clinique, les donnees demographiques, les facteurs de risque pre-operatoires, les details operatoires et les resultats cliniques. Le groupe endovasculaire comprenait 37 patients (22 hommes), tandis que le groupe opere de maniere conventionnelle incluait 19 patients (huit hommes). Huit patients de chaque groupe ont ete traites en urgence d'un traumatisme ou d'une rupture (22% et 42% respectivement, p = 0,11). Les patients du groupe endovasculaire etaient significativement plus vieux et porteurs de davantage de comorbidites (p

To assess the incremental value of the left-side-down decubitus view in radiographic evaluation of ileocolic intussusception.The institutional review board approved this retrospective investigation with waiver of informed consent. Between February 24, 2002, and January 25, 2007, 304 studies (300 patients; mean age, 1.3 years; range, 0.1-3.9 years) met the following inclusion criteria: kidney ureter bladder (KUB) and decubitus views obtained, with subsequent proof of diagnosis. Using a consensus approach, two pediatric radiologists evaluated KUB and decubitus views for four variables: (a) discrete mass and (b) small-bowel obstruction (positive criteria); (c) air or stool in ascending colon and (d) cecal air or stool (negative criteria). On the basis of these criteria, each study was graded as negative, positive, or indeterminate for intussusception. Diagnostically determinate studies and the ability to visualize or exclude intussusception were calculated to determine sensitivity and specificity. The difference between proportions was calculated, along with 95% confidence intervals. Agreement between the supine KUB view and supine KUB plus left-side-down decubitus views was tested with the McNemar test.Intussusception was present in 58 of 304 studies (19%). Adding the decubitus view to the KUB view increased the number of determinate studies from 110 of 304 (36.2%) to 205 of 304 (67.4%) (difference, 31.2 percentage points; P.001). Intussusception was correctly identified with KUB view alone in 35 of 58 studies (60.3%); this value increased to 43 of 58 (74.1%) with KUB plus decubitus views (P = .0215). Intussusception was correctly excluded with the KUB view alone in 63 of 246 studies (25.6%); this increased to 143 of 246 studies (58.1%) with addition of the decubitus view (P.0001).The addition of decubitus views increased the number of diagnostically determinate studies and increased the ability to diagnose or exclude intussusception. The authors believe that a left-side-down decubitus view should be included in the initial evaluation of patients suspected of having intussusception, particularly when the supine view is diagnostically indeterminate.

Paravalvular leak following a mitral valve replacement is a complication seen in approximately 1 of 10 replacements. The corrective method has traditionally been reoperation. Septal occluder devices are more commonly being utilized as an alternative percutaneous correction method. We report the use of septal occluder devices in the repair of mitral paravalvular leak in two patients at severely high EuroSCORE II mortality risk. In both patients, the occluder devices became unstable, leading to a recurrence of severe paravalvular leak.

Paragonimiasis is an important cause of pulmonary disease worldwide. It results from an infection with Paragonimus, a parasite that reproduces through a complex life cycle involving snails, crustaceans, and mammals. Humans acquire the disease by ingesting uncooked freshwater crab or crayfish. Paragonimus species are distributed globally, and the disease is well known in endemic regions of Asia where culturally based methods of food preparation foster human transmission. Paragonimus also exists in regions of the United States but has been a rare cause of pulmonary disease. We report a case of a previously healthy young man who developed a dense empyema from Paragonimus kellicotti that ultimately required thoracotomy and praziquantel to eradicate his infection.

Background Transcatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown. Methods The Society of Thoracic Surgeons (STS) Database at our center enrolled 3,735 patients after AVR since 1997. In this time interval, we identified 61 patients 80 years and older who underwent AVR for severe AS or failed aortic bioprosthesis after having prior cardiac surgery. All clinical parameters were derived from the STS database. Follow-up mortality was assessed using the Social Security Death Index. Results The average age of the patients was 83 ± 2 years, 77% were male, and 75% underwent an isolated coronary artery bypass graft (CABG) as their first cardiac procedure. The mean ejection fraction was 0.53 ± 0.13. The CABG was performed concurrently in 49% of patients at the time of redo sternotomy and AVR. Stented bioprosthesis was implanted in 61% of patients and stentless in 39%. Perioperative mortality was 1.6% (1 of 61). One, 3, 5, and 7 year survival rates were 85%, 69%, 63%, and 43%, respectively. Patients with AVR only had similar survival to patients who underwent concomitant AVR and CABG. Type of aortic prosthesis did not influence postoperative survival. Conclusions In selected patients over the age of 80 with history of prior cardiac surgery, AVR can be performed safely with very good mid-term outcomes. Age alone should not be exclusion criteria for surgical AVR in octogenarians with prior cardiac surgery.

Results are presented from our single-institutional experience with thoracic endovascular aortic repair to confirm that it is safe in patients with significant comorbidities. A retrospective review of all patients undergoing endovascular or open thoracic aortic repair at our institution since 2002 was performed. Main outcome measures included clinical presentation, demographics, preoperative risk factors, operative details, and clinical outcomes. The endovascular group included 37 patients (22 males), whereas the open group included 19 patients (eight males). Eight patients per group were treated emergently for trauma or rupture (22% and 42%, respectively; p=0.11). Endovascular patients were significantly older with more comorbid conditions (p0.05). However, the overall perioperative complication rate was similar in the two groups (32.4% and 31.6%, respectively). Postoperative renal failure occurred only in four open patients (21.1% vs. 0%, p0.05). Operative time, ventilator days, and total length of stay were also greater for open patients (p0.05). There was one death in the endovascular group and three in the open group (2.7% and 15.8%, respectively; p=0.07). Endovascular patients had shorter operative time and length of stay, fewer ventilator days and intensive care unit days, and fewer transfusions. Although the endovascular patients were significantly older with more comorbidities, the complication rate was similar to the open group. Also, there was a trend toward lower mortality in the endovascular group (p=0.07). Endovascular repair is the procedure of choice for treating the descending thoracic aorta in high-risk patients even in the emergent setting.

Reconstruction of sternal nonunion following surgical resection can be difficult. Presented here is a case of sternal salvage with rigid fixation in the face of a massive aortic pseudoaneurysm. Plating is a safe and efficient technique that provides bone approximation and results in long term rigid sternal fixation. This case report highlights the history and biomechanical theory and examines the safety and clinical outcomes of sternal reconstruction with plating fixation.

OBJECTIVES: Pulmonary hypertension (PHT) is associated with tricuspid annular dilatation, but the effect of acute increase of pulmonary pressure on three-dimensional (3D) tricuspid annular dynamics and shape is unknown. Better understanding of tricuspid annular dynamics may lead to improved and more durable surgical reparative techniques. METHODS: In nine open-chest anaesthetized sheep nine sonomicrometry crystals were implanted on the right ventricle while on cardiopulmonary bypass. Additional nine crystals were implanted around the tricuspid annulus (TA) with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Two additional equidistant crystals were implanted between each commissure, creating three segments for every region. Pressure transducers were placed in the left ventricular (LV), right ventricular (RV) and right atrium. PHT was induced by acute pulmonary artery constriction with a pneumatic occluder. Sonomicrometry and echocardiographic data were collected before and after induction of PHT. TA area, regional and total perimeter, and 3D annular geometry were calculated from 3D crystal coordinates. Regional annular contraction was defined as the percentage difference between maximal and minimal region length during the cardiac cycle. RESULTS: PHT increased RV pressure from 31 ± 9 mmHg to 46 ± 13 mmHg (P= 0.001) and decreased left ventricular (LV) pressure from 111 ± 24 mmHg to 78 ± 36 mmHg (P= 0.018). There was no significant tricuspid regurgitation observed with PHT. During PHT, the TA area increased by 12±13% from 641±139 mm 2 to 721±177 mm 2 (P=0.037). The total perimeter increased from 103±11 mm to 109±13 mm (P= 0.02). All annular regions dilated significantly with PHT with 8 ± 10, 5 ± 5 and 5 ± 5% increase in anterior, posterior and septal annular length, respectively (P< 0.05). PHT reduced regional annular contraction in the anterior region only (17 ± 7 vs 14 ± 8%; P= 0.02). The TA had a complex 3D saddle geometry and the shape of the annulus was altered during PHT only in the antero-posterior region. CONCLUSIONS: The changes in tricuspid annular conformation, contractility and its 3D geometry observed during acute ovine PHT may help in the design of new pathology-specific tricuspid annular rings.

INTRODUCTION: Crigler-Najjar syndrome, type I, is a disease characterized by complete absence of hepatic bilurbin glucuronidation. The congenital indirect hyperbilrubinemia is due to an autosomal recessive deficiency of the enzyme, uridine diphosphate glucuronosyl transferase (UDPGT). The inbred homozygous Gunn rat is also deficient in UDPGT, exhibits unconjugated hyperbilirubinemia, and is an excellent animal model of the Crigler-Najjar syndrome. This study was performed to test the ability of transplanted intestine from normal Wistar rat donors to correct the deficiency in hepatic bilirubin conjugation. MATERIALS AND METHODS: In phase 1, Gunn rats underwent 40-cm heterotopic small-bowel transplants from either Wistar (experimental) or Gunn (control) rats. In phase 2, 15- to 20-cm Wistar-to-Gunn jejunal transplants were placed either heterotopically or orthotopically (in intestinal continuity). All rats were treated with cyclosporin A (CsA), 5 mg/kg per day. Serum bilirubin levels were determined spectrophotometrically at weekly intervals posttransplantation. In phase 2, UDPGT activity was quantitated at 0, 2, 4, and 8 weeks using known quantities of bilirubin as substrate. RESULTs: Total bilirubin levels decreased significantly in the 40-cm heterotopic transplant recipient rats. From the initial values of 7.12±0.59 mg/dL, levels reached the nadir of 4.23±0.27 mg/dL. A parallel drop in serum levels of indirect bilirubin was noted (5.04±0.54 mg/dL to 2.74±0.23 mg/dL). After 6 weeks, bilirubin levels began to rise toward pretransplant values. In contrast, there was no significant change in bilirubin levels in the control Gunn-to-Gunn rats. Fifteen- to 20-cm heterotopic Wistar-to-Gunn transplants caused a qualitatively similar drop in total and indirect bilirubin levels. Orthotopic (in continuity) Wistar-to-Gunn transplants lowered serum bilirubin levels more rapidly, and the effect was sustained throughout the 8-week study period. By 1 week posttransplantation, total bilirubin levels dropped from 5.11±0.48 mg/dL to 2.41±0.16 mg/dL (P

Purpose The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use. Materials and Methods Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 μ g (LD) and 249 μ g (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups. Results There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% ( κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 [0-180.6] vs 0.6 [0-73.2] hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition. Conclusion The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage.

Objective Up to 90% of embolic strokes that occur in patients with atrial fibrillation originate from the left atrial appendage. Exclusion of the left atrial appendage during cardiac surgery may decrease the future risk of stroke, especially in patients with atrial fibrillation or at high risk for developing atrial fibrillation. We report the initial results of a multicenter Food and Drug Administration trial to assess the safety and efficacy of a novel left atrial appendage exclusion clip. Methods Patients undergoing elective cardiac surgery via median sternotomy with atrial fibrillation or a Congestive Heart Failure, Hypertension, Age > 75 Years, Diabetes Mellitus, Stroke score greater than 2 were eligible for concomitant AtriClip (Atricure Inc, Westchester, Ohio) device insertion. Device insertion (35, 40, 45, and 50 mm) was performed at any point after sternotomy on or off cardiopulmonary bypass. Safety was assessed at 30 days, and efficacy of left atrial appendage exclusion was assessed at operation (by transesophageal echocardiography) and 3-month follow-up (by computed tomography angiography or transesophageal echocardiography). Results A total of 71 patients (mean age, 73 years) undergoing open cardiac surgery at 7 US centers were enrolled in the study. The left atrial appendage in 1 patient was too small and did not meet eligibility criteria; the remaining 70 patients had successful placement of an AtriClip device. Intraprocedural successful left atrial appendage exclusion was confirmed in 67 of 70 patients (95.7%). Although significant adverse events occurred in 34 of 70 patients (48.6%), there were no adverse events related to the device and no perioperative mortality. At 3-month follow-up, 1 patient died and 65 of 70 patients (92.9%) were available for assessment. Of the patients who underwent imaging, 60 of 61 patients (98.4%) had successful left atrial appendage exclusion by computed tomography angiography or transesophageal echocardiography imaging. Conclusions In this small study, safe and atraumatic exclusion of the left atrial appendage can be performed during open cardiac surgery with the AtriClip device with greater than 95% success and appears to be durable in the short term by imaging. Long-term studies are needed to evaluate the efficacy in the prevention of stroke.

We chose bilateral PAB to minimize risks of complete repair of multiple VSDs in the neonatal period and to reduce potential complications of neoaortic valve insufficiency or root dilation. Palliation can improve physiology, cause some VSDs to close or become restrictive, allow easier technical repair of remaining VSDs, and limit aortic valve insufficiency and root dilation. Recently, the use of Amplatzer septal occluder devices (St Jude Medical, Inc, St Paul, Minn) has been described in older children with multiple VSDs; however, there have been no reports involving neonates. The staged approach described here may be a viable low-risk alternative for patients with TGA and multiple midmuscular and apical VSDs.