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Background: Recently, Israel established the first national-level adult cardiac surgery database, which was linked to the Society of Thoracic Surgeons (STS)., Objectives: To validate and compare the STS predicted risk of mortality (PROM) to logistic EuroSCORE I (LESI) and EuroSCORE II (ESII) in Israeli patients undergoing cardiac surgery., Methods: We retrospectively studied 1279 consecutive patients who underwent cardiac surgeries with a calculable PROM. Data were prospectively entered into our database and used to calculate PROM, LESI, and ESII. Scores were normalized and correlated using linear regression and Pearson's test. To examine model calibration, we plotted the total observed versus expected mortality for each score and across five risk-score subgroups. Model discrimination was assessed by measuring the area under the receiver operating curves., Results: The observed 30-day operative mortality was 1.95%. The median (IQ1; IQ3) PROM, LESI, and the ESII scores were 1.45% (0.69; 3.22), 4.54% (2.28; 9.27), and 1.88% (1.18; 3.54), respectively, with observed over expected ratios of 0.63 (95% confidence interval [95%CI] 0.42-0.93), 0.59 (95%CI 0.40-0.87), and 0.24 (95%CI 0.17-0.36), respectively, (STS vs. ESII P = 0.36, STS vs. LESI P = 0.0001). There was good correlation among all scores. All models overestimated mortality. Model discrimination was high and similar for all three scores. Model calibration of the STS, PROM, and ESII were more accurate than the LESI, particularly in higher risk subgroups., Conclusions: All scores overestimated mortality. In Israeli patients, the STS, PROM, and ESII risk-scores were more reliable metrics than LESI, particularly in higher risk patients.

We present the case of a primigravid patient, who developed cardiogenic shock during the early postpartum period in the setting of retained placenta, uterine atony, and hemorrhage. Focused cardiac ultrasound played a central role in identifying the cause of hemodynamic instability. The decision to initiate venoarterial extracorporeal membrane oxygenation was instrumental in the successful outcome for our patient, characterized by a full recovery without major neurological and cardiovascular sequelae.

Background and Aim of the Study: The prosthetic valve of choice in patients with carcinoid valve disease (CVD) remains controversial due to the limited life expectancy of patients with advanced-stage neuroendocrine tumors (NETs) on the one hand, and concerns regarding structural valve deterioration (SVD) on the other hand., Methods: The records of 17 patients (11 females, seven males; mean age 65 ± 11 years; undergoing 18 operations) with primarily right heart failure due to CVD were reviewed. All patients received somatostatin analogs perioperatively. Hospital and follow up data (acquired via direct patient contact and echocardiography) collected included baseline characteristics, procedural details, and clinical outcomes., Results: The primary NET site was the ileum (n = 11), lungs (n = 2) and stomach, colon and appendix (n = 1 each). In one patient the primary tumor location could not be identified. Preoperative urinary levels of 5-hydroxyindole acetic acid (5-HIAA; 61 ± 36 mg/24 h) and serum levels of chromogranin A (2926 ± 4057 ng/ml) were 10- and 50-fold greater than normal, respectively. A total of 23 valves was implanted: five tricuspid valve replacements (TVR; four tissue and one mechanical), TVR and pulmonary valve replacements (PVR; three tissue and one mechanical), and TVR and mitral valve replacements (MVR; one tissue and two mechanical). The 30-day mortality was 11% (n = 2). No patient experienced a carcinoid crisis. The mean follow up was 24 ± 21 months (range: 4-85 months). Four patients (receiving seven valves) developed SVD at 12, 14, 15, and 20 months after surgery, and all of these patients died. The actuarial four-year survival and freedom from SVD were 23 ± 14% and 43 ± 15%, respectively., Conclusions: The data acquired suggested that the main advantage of tissue valve prostheses, namely to avoid lifelong, intense anticoagulation, might be offset by accelerated SVD. The use of mechanical valves should be considered in CVD patients with a large primary tumor mass and persistent high urinary levels of 5-HIAA, and who are unresponsive to therapy.

Background: The left ventricular assist device (LVAD) is used as a bridge to heart transplantation. Currently, these devices are being used for longer periods of time than in previous years for the purpose of bridge to life, thus the need for dental assistance will emerge., Case Description: A female with severe acute congestive heart failure, owing to dilated cardiomyopathy, needed implantation of an LVAD as a bridge to heart transplantation. Six months after insertion of the device she suffered from spontaneous gingival bleeding and sought dental treatment. She presented with several dento-medical problems that required resolution before commencement of dental treatment., Conclusions: Management of a patient with LVAD opens new frontiers for the dental team regarding treatment of the medically severely compromised patient who may present with multiple intervening medical aspects: profound antithrombotic therapy, high risk of device infection, possible magnetic interference with dental instruments, and even assessment of vital signs., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Thoracoabdominal aortic aneurysm repair requires complex surgery. Clamping of the descending aorta during the operation results in organ malperfusion, ischemia, and in some cases, irreversible end-organ damage and death. Several methods for organ preservation during the operation evolved, resulting in decreased post-operative organ malfunction. Re-attachment of intercostal arteries, cerebrospinal fluid drainage, and temporary bypass of the clamped aorta and selective perfusion of the spinal cord, intestine, liver and kidneys are widely used during the operation., Objectives: To determine the impact of implementation of protective measures on the outcome of thoracoabdominal surgery over a decade., Methods: Between March 1993 and March 2003, 11 patients (age 41-80 years, average 60 years) underwent thoracoabdominal aortic aneurysm repair in our hospital. Different methods for organ preservation were used during the operation., Results: The early survival is 91%. One patient suffered from paraplegia and one from mild temporary paraparesis. Two patients died during the follow-up period (at 5 months from pneumonia and at 2 years from aortic arch rupture)., Conclusions: Implementation of all adjuncts to protect the organs dependent on aortic perfusion may eliminate the ischemic consequences of aortic clamping.

Background: New-onset atrial fibrillation after coronary artery bypass grafting is common. Medical therapy includes various antiarrhythmic drugs to control heart rate and restore sinus rhythm. The purpose of this study was to determine the duration of antiarrhythmic therapy after discharge from the hospital., Methods: One hundred twenty-nine patients in whom new atrial fibrillation after coronary artery bypass grafting developed and successfully reverted to sinus rhythm were prospectively randomized at dismissal to receive antiarrhythmic therapy for 1 week (group A; n = 44), 3 weeks (group B; n = 42), or 6 weeks (group C; n = 43). Patients were followed up for an additional 4 weeks after discontinuation of antiarrhythmic therapy for detection of recurrent atrial fibrillation., Results: The incidence of new atrial fibrillation during the study period was 21.2% (256/1206). Among the 129 patients who consented to the study, conversion to sinus rhythm was accomplished with the following medications: amiodarone (group A, 82%; group B, 93%; group C, 88%; P = .29), digoxin (group A, 16%; group B, 7%; group C, 7%; P = .29), beta-blockers (group A, 27%; group B, 19%; group C, 14%; P = .30), calcium channel blockers (group A, 2%; group B, 2%; group C, 0%; P = .60), quinidine (group A, 2%; group B, 2%; group C, 7%; P = .44), and procainamide (group A, 4.5%; group B, 2%; group C, 0%; P = .37). Follow-up was completed in 128 patients (99.2%). There was no significant difference in the recurrence of atrial fibrillation among groups (0%, 2%, and 0% for groups A, B, and C, respectively)., Conclusions: Patients with new atrial fibrillation after coronary artery bypass grafting, converted to normal sinus rhythm before hospital discharge, have a benign course. Antiarrhythmic therapy as short as 1 week may be appropriate in these patients.

Background: Cardiac surgery is being performed with increasing frequency in patients aged 80 years and older., Objectives: To examine the long and short-term results of surgery in this age group., Methods: We retrospectively investigated 202 consecutive patients aged 80 years or older who underwent cardiac surgery between 1991 and 1999, Ninety-six operations (48%) were urgent., Results: The study group comprised 140 men (69%) and 62 women (31%) with a mean age of 82.1 years (range 80-89). Preoperatively, 120 patients (59%) had unstable angina, 37 (18%) had left main coronary artery disease, 22 (11%) had renal failure, 17 (8.5%) had a history of stroke and 13 (6.5%) had previous cardiac surgery. Hospital mortality for the whole group was 7.4%. Postoperative complications included: re-exploration for bleeding in 15 (7.4%), stroke in 8 (4%), sternal wound infection in 3 (1.5%), low cardiac output in 17 (8.4%), new Q wave myocardial infarction in 5 (2.5%), renal failure in 17 (8.5%), and atrial fibrillation in 71 (35%). The actuarial survival for patients discharged from the hospital was 66% at 5 years and 46% at 8 years. The type of surgical procedure was significantly associated with increased early mortality (coronary artery bypass grafting only in 2.9%, CABG + valve in 16.1%, valve only in 16.7%; P = 0.01). Significant predictors (P < 0.05) for late mortality included type of surgical procedure, congestive heart failure, and postoperative low cardiac output., Conclusions: When appropriately applied in selected octogenarians, cardiac surgery can be performed with acceptable mortality and good long-term results.

Background: About 40% of patients with infective endocarditis will require surgical treatment. The guidelines for such treatment were formulated by the American College of Cardiology and American Heart Association in 1998., Objectives: To examine our experience with surgical treatment of infective endocarditis in light of these guidelines., Methods: Surgery was performed in 59 patients with infective endocarditis between 1990 and 1999. The patients' mean age was 48 years (range 13-80). The indications for surgery were hemodynamic instability, uncontrolled infection, and peripheral embolic events. The surgical treatment was based on elimination of infection foci and correction of the hemodynamic derangement. These objectives were met with valve replacement in the majority of patients. Whenever conservative surgery was possible, resection of vegetation and subsequent valve repair were performed and the native valve was preserved., Results: Six patients (10%) died perioperatively from overwhelming sepsis (n = 3), low cardiac output (n = 2) and multiogran failure (n = 1). The mean hospital stay was 15.6 days. Of 59 patients, 47 (80%) underwent valve replacement and in 11 (19%) the surgical treatment was based on valve repair. After 1 year of follow-up there was no re-infection., Conclusion: The new guidelines for surgical treatment of infective endocarditis allow better selection of patients and timing of surgery for this aggressive disease, which consequently decreases the mortality rate. Valve repair is feasible and is preferred whenever possible. According to the new guidelines, patients with neurologic deficit in our series would not have been operated upon, potentially decreasing the operative mortality to 7%.

Background: Fractures of the sternum may be associated with major injuries to thoracic organs, with serious consequences., Objective: To assess the hospital course of patients diagnosed with isolated sternal fracture., Methods: We reviewed 55 medical records of patients who were admitted with isolated sternal fracture to the emergency department during the period January 1990 through August 1999., Results: Fifty-one patients were involved in motor vehicle accidents, and 4 sustained the injury as the result of a fall. Lateral chest X-ray upon admission was diagnostic in the majority of these patients (n = 53). Electrocardiography (n = 52) was abnormal in four patients--old myocardial infarction (n = 1), non-specific ST-T changes (n = 3). Cardiac enzymes (creatine-kinase-MB, n = 42) were pathologically elevated in five patients. Echocardiography, performed in patients with ECG abnormalities and/or elevated myocardial enzymes (n = 7), was normal in these patients as well as in another 18 patients. There were no intensive care unit admissions or arrhythmias during the hospital stay, which ranged from 6 hours to 6 days (mean 2.3 +/- 1.3 days, median 2 days)., Conclusion: Our findings support the view that patients with isolated sternal fracture and no abnormality in ECG and cardiac enzymes during the early hours after injury are expected to have a benign course and can be discharged home from the emergency room within the first 24 hours.

Background: The concomitant occurrence of lung cancer or other thoracic problems requiring surgical treatment in patients with significant coronary artery disease is uncommon., Methods: Three patients underwent revascularization of the anterior descending artery, without cardiopulmonary bypass, with simultaneous pulmonary lobectomy (two patients) or replacement of an obstructed descending aortic graft (one patient)., Results: Postoperative ventilation time was < 3 h, and no morbidity related to the combined procedure occurred during midterm follow-up., Conclusions: This one-stage approach allowed the immediate solution of two intrathoracic comorbidities, reducing expenses and suffering to the patients and minimizing the risk of bleeding or tumor dissemination secondary to extracorporeal circulation-induced coagulopathy and immunosuppression.

Coronary artery disease amenable to percutaneous interventions or coronary artery bypass grafting, and resectable lung cancer are major causes of morbidity and mortality. We present our experience in the treatment of 3 patients (men aged 64 and 66 and a woman of 77) who each had significant coronary artery disease and a resectable lung tumor. They underwent combined coronary artery bypass grafting and pulmonary lobectomy. We conclude from our experience and review of the literature that concomitant surgery in such cases is safe and effective, decreases suffering, and decreases the cost of 2 separate invasive procedures.

The optimal surgical treatment for concomitant carotid and coronary artery disease is controversial. Between 1991 and 1995 we performed 34 procedures for combined disease of the carotid and coronary arteries. The first 8 operations were carotid endarterectomies followed by coronary artery bypass grafting (staged procedure). The next 26 operations were performed during a single anesthesia (combined procedure). The patients were 28 men and 6 women, aged 58-81 years (mean 68). 80% were in functional class III or IV. In 40% ventricular function was moderately or severely reduced. There was an average of 3.6 grafts per patient, and in all except 3 patients the left internal thoracic artery was used as a conduit for coronary artery bypass grafting. 30% had symptomatic carotid stenosis; there was no perioperative mortality. In the staged procedure group, 2 patients had postoperative cardiac complications: in 1 acute coronary insufficiency and acute myocardial infarction in the other. 1 had postoperative, transient, amaurosis fugax. In the combined procedure group, 1 had a myocardial infarction and 1 a minor occipital stroke. During follow-up, 1 patient died 4 months after operation of myocardial infarction, and 1 had a minor stroke. The results suggest that the combined procedure is safe and carries low risk of both mortality and morbidity. Whenever cardiac disease is stable and there is no main coronary artery disease, a staged procedure should be considered. In any other situation we continue to perform the combined procedure.

Lung transplantation is now considered acceptable therapy for end-stage lung disease. Until recently therapy for emphysema was disappointing, but lung transplantation has brought new hope for those terminally ill with the disease. We present our early experience with single-lung transplantation in 5 men and 1 woman with emphysema, 40-61 years old. All recovered following surgery, with remarkable improvement in lung function and functional capacity. They are now 6-20 months post-transplantation, do not need oxygen supplementation and are able to perform their normal daily activities. Shortage of donor organs is the limiting factor for single-lung transplantation in these patients.

Background: University of Wisconsin (intracellular) solution has been shown to offer some distinct benefits of myocardial preservation over Stanford (extracellular) solution, including a more rapid functional recovery, improved adenosine triphosphate preservation, and a tendency for less postoperative inotropic agents. However intracellular solutions with high potassium content have been reported to cause a functional if not structural endothelial injury in laboratory experiments., Methods: Because of this information we retrospectively viewed our follow-up angiographic data for the development of the cardiac allograft vasculopathy in a consecutive series of 195 heart transplant recipients. These patients were treated in identical fashion, with the same immunosuppression regimen, except for the type of cardioplegia used--Stanford solution (group I n = 95) and University of Wisconsin solution (group II n = 100)., Results: With a mean follow-up of 24 months after transplantation, a significant difference was seen in the development of cardiac allograft vasculopathy in group II (22%) versus group I (14%, p < 0.03). Although significant differences were observed with univariate analysis with respect to donor age and ischemic time favoring group I and with multivariate statistical analysis with respect to overall rejections favoring group II, the only significant variable for the difference in the development of allograft vasculopathy was University of Wisconsin cardioplegic solution (p < 0.003). A subgroup of 30 patients previously randomized for a functional study comparing the two cardioplegic agents showed a tendency for statistical significance with a freedom from allograft vasculopathy of 93% in group I, as compared with 83% in group II, after 13 months follow-up (p = 0.09). The overall probability of being free of vasculopathy at 24 months was 86% for group I and 70% for group II., Conclusions: The data support the conclusion that University of Wisconsin intracellular solution is associated with an increased incidence of vasculopathy versus Stanford solution and warrants investigation for modification of this preservation agent in heart transplantation.

The effects of perioperative administration of magnesium sulfate on myocardial function was studied in patients with unstable angina (grade IV) undergoing coronary artery bypass grafting. Myocardial protection consisted of antegrade and retrograde continuous warm blood cardioplegia. Patients were randomly divided into two groups. Group A (50 patients) received intravenous magnesium sulfate (16 mmol) continuously from the time of anesthetic induction to aortic cross-clamping and a second dose (32 mmol) starting after the release of aortic cross-clamp until 24 hours later. Group B (48 patients) did not receive magnesium sulfate and served as control. Left ventricular stroke work index increased in group A from 34 +/- 3 g.m/m2 before operation to 42 +/- 3 g.m/m2, 45 +/- 2 g.m/m2, and 47 +/- 2 g.m/m2, 1, 6, and 12 hours after operation, respectively (p < 0.05 versus preoperative), and in group B from 33 +/- 3 g.m/m2 before operation to 38 +/- 3 g.m/m2, 40 +/- 2 g.m/m2, and 41 +/- 2 g.m/m2, 1, 6, and 12 hours after operation, respectively (p < 0.05). Left ventricular stroke work index was higher in group A 6 (p = 0.06), 12, and 24 hours (p < 0.05) after operation compared with group B. The incidence of ventricular arrhythmias requiring treatment was significantly higher (p < 0.05) in group B: 14 patients versus 1 patient in group A. Postoperative hypertension was more frequent in group B: 16 patients versus 2 patients in group A (p < 0.05). These results indicate that perioperative administration of magnesium sulfate may contribute to better myocardial recovery and fewer ventricular tachyarrhythmias after operation.

The present study was undertaken to determine the value of abnormal late ventricular potentials on signal-averaged electrocardiograms (ECG) in identifying patients at risk of developing ventricular tachycardia or ventricular fibrillation in the early postoperative period after coronary artery bypass grafting. Signal-averaged ECGs were recorded immediately after operation in 72 patients. Abnormal late potentials were defined as the presence of 2 or 3 of the following: (1) root-mean-square amplitude of the last 40 ms of the QRS < 20 microV; (2) duration of the terminal QRS potentials (after 40 microV) > or = 39 ms; and (3) high-frequency QRS duration > 120 ms (in patients with conduction defects, only the first 2 criteria were used). Abnormal late ventricular potentials were present on the immediate postoperative signal-averaged ECG in 26 of the 72 patients (36%). Life-threatening ventricular tachyarrhythmias occurred in 6 patients. Late potentials were present in all 6 patients, but only in 20 of 66 (30%) who did not develop ventricular tachyarrhythmias (p < 0.005) (sensitivity 100%, specificity 70%, predictive accuracy 72%). Of 12 pre- and perioperative variables examined by univariate and multivariate regression analysis, the presence of late potentials on the signal-averaged ECG and low cardiac output postoperatively were found to be independent predictors of life-threatening tachyarrhythmias.

Mitral valve repair in children has the advantage of avoiding mitral valve replacement with its attendant need for anticoagulation and reoperation. Seventy-nine children between the ages of 2 months and 17 years (mean 4.9 years) underwent mitral valve repair between May 1982 and April 1993. There were five patients with mitral stenosis and 74 patients with mitral regurgitation, and 19 children were less than 2 years of age. Patients were divided into anatomic subgroups on the basis of the primary cardiac pathologic condition. Forty-three had severe mitral regurgitation, 21 had moderate mitral regurgitation, and 12 patients with primum atrial-septal defect and 2 patients with univentricular hearts had minimal to moderate mitral regurgitation. Associated cardiac anomalies were present in 68 patients and 85% of the patients required concomitant intracardiac procedures. The methods of mitral valve repair included annuloplasty in 68 (86%), repair of cleft leaflet in 41 (52%), chordal shortening in 9 (11%), triangular leaflet resection in 8 (10%), splitting of papillary muscles with resection of subvalvular apparatus in 7 (9%), and chordal substitution in 1 (1%). The technique of annuloplasty was modified to allow for annular growth. Follow-up was available from 1 to 10 years (mean 4 +/- 2.5 years). There were three early deaths (4%), all occurring as a result of low output cardiac failure in patients with minimal postoperative mitral regurgitation. Three late deaths (4%) occurred in patients with persistent moderate to severe mitral regurgitation and progressive cardiac failure and eight patients (10%) required either rerepair or replacement of the mitral valve. Actuarial survival was 94% at 1 year, 84% at 2 years, and 82% at 5 years, and actuarial freedom from reoperation was 89% at 8 years. All patients received postoperative echocardiography with 82% having minimal to no mitral regurgitation and 98% of long-term surviving patients being free of symptoms. We conclude that mitral valve repair can be done with low early and late mortality. The need for reoperation is relatively low and valve growth has occurred with the use of a modified annuloplasty.

We have developed a technique for autotransfusion of shed mediastinal blood collected in the cardiotomy reservoir. Results in the first 50 consecutive patients in whom the system was employed were studied prospectively (group A) and were compared with those of the last 50 consecutive patients operated on before application of the new method (group B). The mean preoperative hematocrit (about 42%) and the total postoperative bleeding (about 11) were similar in both groups. Only 24 patients (48%) in group A required homologous blood transfusion, versus 43 (86%) in group B (p = 0.0001). This resulted in a 57% saving of blood units in group A (mean, 1.16 +/- 1.49 units per patient versus 2.72 +/- 1.99 in group B, p less than 0.0001). Foreign blood transfusion was thus avoided in 21 of the last 25 patients (84%) of group A. 7 days after operation, the mean hematocrit in group A was 30.9 +/- 4.3, compared with 33.0 +/- 3.8 in group B (p less than 0.001). Hemolytic jaundice occurred in 7 group B patients (14%) but in none in group A (p less than 0.01). A trend towards reduction in other complications was also demonstrated. We conclude that the use of foreign blood transfusions in those undergoing open heart surgery can be reduced significantly by this method, thus avoiding immediate transfusion reactions and minimizing the risks of late complications.