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Complex pathology of the distal arch and proximal descending thoracic aorta is usually approached by stent endografting or in situ graft replacement. Oftentimes, these options are not feasible due to unfavorable anatomy, multiple previous procedures, active infection, or presence of concomitant cardiac disease. Thoracic aortic extra-anatomic bypass, as part of an open surgical strategy, is a useful and often the only curative option left for the treatment in these patients. Herein, we describe two cases that illustrate the utility of extra-anatomic thoracic aortic bypass for complex aortic disease.

Despite modern advances in surgical care, triple-valve surgery (TVS) remains a challenge and carries a mortality of 10% to 20%. No validated risk score is available for TVS, and the effect of advanced age is unknown. This study examined our results in the modern era with the aim of identifying perioperative predictors of adverse outcomes.Between 1997 and 2013, 131 patients (mean age, 67.2±13.4 years) underwent TVS at our institution. Sixty-eight patients (51.9%) were aged 70 years and older. The most common etiology for aortic and mitral disease was degenerative (77.1%), rheumatic (10%), and endocarditis or prosthetic-related, or both, in the rest. Tricuspid valve disease was functional in 96%. New York Heart Association functional class III/IV was present in 69.4%, and 24% had had previous cardiac operations. One or more concomitant cardiac procedures were performed in 77 patients (58.8%), including coronary revascularization in 54. All aortic procedures were replacements, 14 patients required a prosthetic root conduit and 7 thoracic aorta replacement. Mitral replacements were used in 55%, repairs in 45%, and 96.2% of tricuspid procedures were repairs. Univariate and multivariate analyses were used to determine predictors of adverse outcomes.The 30-day and hospital mortality was 10.6% (n=14). Major complications occurred in 70 (53.4%). Univariate analysis identified New York Heart Association functional class III/IV (p=0.04), preoperative renal failure requiring dialysis (p=0.04), urgent operation (p=0.04), intraaortic balloon pump placement (p=0.02), and postoperative low cardiac output (p0.0001) as predictors for early death. Proximal aortic operations, urgent operation, and New York Heart Association class IV correlated with increased early mortality (p0.04) in patients aged 70 and older in addition to their decreased overall survival and decreased likelihood of discharge to home. Overall actuarial survival at 1, 5, and 10 years was 84.5%, 75%, and 45%, respectively.TVS remains a surgical challenge in the modern era. Despite a trend of increasing age and surgical risk, the early mortality rate and long-term survival remain respectable. Advanced age is associated with increased perioperative risk, but age per se should not be a contraindication for TVS.

Objective Surgical repair of acute Type A aortic dissection (AADA) is still associated with high in-hospital mortality. We evaluated the impact of perioperative risk factors on early and midterm survival. Methods Retrospective (2002–2011) database analysis at a single institution of 132 consecutive AADA patients (88 male, age 59.8 ± 13.6). All but five patients underwent repair with open distal anastomoses and hypothermic circulatory arrest: aortic valve replacement/root replacement (n = 44, 33.3%) and valve re-suspension/repair (n = 88, 66.7%). Ascending aorta, hemi-arch, and total arch repairs were performed in 11, 113, and eight patients, respectively. Antegrade and retrograde cerebral perfusion were used in all but six patients. Results Overall in-hospital mortality was 17.4% (n = 23). Actuarial survival at one, five, and eight years was 82%, 72%, and 62%, respectively. Perfusion time (cardiopulmonary bypass) (226.5 ± 71.3 vs. 177.5 ± 51.7, p = 0.0002), aortic cross-clamp time (min) (132.8 ± 45.7 vs. 109.8 ± 41.2, p = 0.01), aortic arch (T2) tear (31% vs. 14%, p = 0.03), instability (26% vs. 11%, p = 0.02), postoperative stroke (38% vs. 14%, p = 0.009), and low cardiac output (50% vs. 15%, p = 0.04) all correlated with increased perioperative mortality. A Cox proportional hazard model showed perfusion time (hazard ratio [HR] = 1.01), postoperative stroke (HR = 2.73), age (HR = 1.03), and unstability (HR = 1.8) as significant risk factors (p

Thoracic endovascular aneurysm repair (TEVAR) has been a major advance in the treatment of blunt thoracic aortic injury (BTAI), although many patients still undergo open repair. This study was undertaken to evaluate outcomes with open repair and TEVAR for BTAI.A retrospective review of all patients with BTAI at a single Level I trauma center from 2001 through 2009 was performed. Patients were grouped according to treatment modality, ie, open repair, TEVAR, or medical management. Direct comparison using standard statistical methods was made between patients undergoing open repair and TEVAR since late 2006 when TEVAR began at our institution using standard statistical methods. Outcomes variables included mortality, paraplegia, length of stay, ICU stay, and ventilator requirements.There were 69 patients in the study, with 36 (52.2%) undergoing open repair, 10 receiving TEVAR (14.5%), 10 patients managed medically (14.5%), and 13 (18.8%) who died during triage. Overall mortality in the pre-TEVAR era was 29.6%. Since the introduction of TEVAR, there have been 8 open repairs. Patients undergoing open repair were significantly younger (32 vs 58 years; p = 0.002) and had smaller aortic diameter (18 mm vs 24.5 mm; p0.001) than those undergoing TEVAR. Overall mortality since the introduction of TEVAR has dropped to 12.0% (p = 0.097).TEVAR and open repair should be viewed as complementary rather than competing modalities for the treatment of BTAI. Having both available allows selection of the most appropriate management technique for each patient, with subsequent improvement in outcomes.

Background The diagnosis of thoracic aortic mobile thrombus (TAMT) is rare and is usually made after debilitating embolic events. The optimal treatment strategy is unknown. We report 14 patients with TAMT and aim to better define the role of early (less than 2 weeks) surgical thrombectomy. Methods Between February 1996 and February 2010, we treated 14 patients (9 women; aged 32 to 84 years, mean age 51 years) with TAMT. Hypercoagulable disorders or a strong family history of vascular thrombosis, or both, occurred in 9 patients. Diagnosis was made by transesophageal echocardiogram in 6, computed tomography angiography in 7, and digital subtraction angiography in 1. Embolic locations were extremities (n = 9), cerebral (n = 6), and abdominal (n = 6). Aortic thrombi (n = 17) locations were ascending/arch (n = 7), descending (n = 8), and thoracoabdominal (n = 2). Results All patients were initially treated with heparin and aspirin. Thoracic aortic thrombectomies were performed in 8 patients within 2 weeks of diagnosis: left thoracotomy (n = 5), thoracoabdominal (n = 1), and median sternotomy (n = 2). Left atrial-femoral bypass was used in 5 patients, cardiopulmonary bypass in 2, and no support in 1. Additional procedures were celiac artery (n = 1) and left subclavian artery (n = 2) thrombectomies. Procedures for embolic complications were performed in 7 patients before aortic thrombectomy. Operative mortality was 0%, with no recurrent embolic events after 24 ± 16 months. One patient had thrombectomy of the ascending aorta and medical therapy with warfarin and aspirin for a second concurrent small thrombus in the descending aorta. One patient presented with multiorgan failure and died shortly after admission. Six patients treated medically were discharged on a regimen of oral warfarin and aspirin (14 ± 11 months follow-up), with 2 fatal recurrent embolic events within 6 weeks ( p = 0.09). Conclusions Thoracic aortic mobile thrombus is rare and is commonly associated with morbid thromboembolic events. In our experience, early surgical aortic thrombectomy had a low operative risk and may prevent fatal recurrent embolic events.

Background: Coronary artery remodeling implies structural changes in the vessel wall in response to various pathophysiologic conditions. However, the classification of remodeling is unclear. We hypothesized that the adaptive, positive-outward remodeling is a reactive and compensatory response to the stress. The maladaptive negative-inward constrictive remodeling is a passive atherosclerotic condition in which the vessel becomes stiffer. Methods: Patients with atherosclerotic lesions underwent intravascular ultrasound (IVUS) scans. The size of the vessels distal to and proximal to plaques were analyzed by IVUS. Diabetes was created in mice by an intraperitoneal injection of alloxan (65 mg/kg). To reduce remodeling, mice received ciglitazone, an agonist of peroxisome proliferators activated receptor-g (PPARg) in drinking water. After 8 weeks, atherosclerotic vessels were analyzed for collagen and elastin. Results: IVUS data suggest an adaptive coronary arterial remodeling was a positive compensatory response to various pathologic stimuli; for example, with the deposition of atherosclerotic plaque, coronary arterial segments enlarged to maintain luminal area. This phenomenon was commonly observed during the initial phases of the development of atherosclerosis. However, negative coronary artery remodeling, or a decrease in vessel area with the formation of atherosclerotic plaque, was maladaptive and was associated with smoking, hypertension, hyperhomocysteinemia, diabetes mellitus, and also after percutaneous coronary interventions (restenosis). In diabetic mice, there was increased collagen and decreased elastin contents; however, treatment with ciglitazone ameliorated the decrease in elastin contents. Conclusion: Global enlargement of the coronary vascular tree occurs during pressure and volume overload associated with ventricular hypertrophic states such as athletic conditioning, hypertensive heart disease, and dilated cardiomyopathy. On the other hand, maladaptive coronary arterial remodeling occurs in patients with severe deconditioning, diabetes mellitus, after coronary artery bypass surgery, and in some instances, postintervention.

Background Although improved perioperative outcomes with growth potential of the extracardiac pedicled pericardial Fontan (EPPF) operation have been suggested, no advantage has been demonstrated. Methods We retrospectively reviewed our institutional experience of 54 consecutive patients undergoing EPPF between June 1996 and August 2003. Clinical and echocardiographic follow-up was obtained yearly with a mean follow-up of 2.8 ± 2.0 years. Results There were 29 males, median age 3.3 years (2–6.8). Median cardiopulmonary bypass time was 79 min (39–295). Fibrillatory arrest was used briefly in 9 patients, of which 6 were for fenestration. One Fontan required takedown (1.8%) and there was 1 death (1.8%) from Candida mediastinitis. Median intensive care unit stay, hospital length of stay, and chest tube drainage were 4 days, 12 days, and 8 days, respectively. Arrhythmias occurred in 7 patients. Three (5.6%) of these had preexisting Holter abnormalities requiring permanent pacemaker implantation. Freedom from thromboembolic events, reoperation, and death at 2.8 years after discharge were 96.2%, 98.1%, and 100%, respectively. All patients were New York Heart Association class I-II, with median oxygen saturation of 94 %. Only 5 patients (9.4%) had mild self-restricted activities. Echocardiographic evaluation revealed excellent ventricular function and flow dynamics. Conclusions At midterm follow-up this technique yields outcomes as good as the other Fontan techniques and with further follow-up may prove to be superior. However, at this point no clear advantage has been demonstrated. The low rate of complications and potential for growth are appealing features of this procedure.

Fistulization between the aorta and the right atrium is a rare complication of ascending aortic dissection. Because of the typical haemodynamic unstability, the diagnosis is often made by bedside or intraoperative transoesophageal echocardiography. The treatment is surgical, but with very high mortality. We describe a case of type A aortic dissection complicated with shock and fistulization into the right atrium with the right-to-left shunt through a patent foramen ovale. Surgical repair was successful.

The objective of this study was to compare retrograde with antegrade cerebral protection during acute aortic dissection repair using cerebral oximetry measurements. Fifty consecutive acute ascending aortic dissection repairs were analyzed. Cerebral oximetry data were collected for 41 of 50. Eight patients who had antegrade cerebral protection alone and 29 of 41 had retrograde cerebral protection alone. The per cent change in cerebral oximetry values during deep hypothermic circulatory arrest from baseline and from prearrest values was compared for the two groups using Student t test. The per cent change from baseline for the antegrade patients was: right 13.8 per cent and left -2.5 per cent; the per cent change from baseline for retrograde patients was: right 0.8 per cent and left 0.2 per cent ( P values 0.216 and 0.725, respectively). The per cent change from the prearrest value for the antegrade patients was: right -12 per cent and left -15 per cent; the per cent change from prearrest for retrograde patients was: right -15 per cent and left -16 per cent ( P values 0.514 and 0.956, respectively). No compelling evidence for an advantage to either antegrade or retrograde cerebral perfusion was detected. Further study with a focus on neurologic outcomes is warranted.

Leg wound complications after saphenectomy are frequent after coronary bypass operations and have a detrimental effect on postoperative quality of life and treatment cost. To reduce morbidity, we evaluated a new technique of video-assisted vein harvest.Between March 1996 and October 1996, 50 patients had video-assisted saphenectomy (VAS) and 40 patients had the standard open technique (control group). An additional 13 patients had both procedures (hybrid group). Level of pain, edema, and wound complications were evaluated at discharge and at 2, 4, and 6 weeks postoperatively.The mean operating time for VAS patients was slightly higher than for control (60.6+/-24.7 minutes versus 53.2+/-21.1 minutes; p0.05). The average incision length in VAS patients was 13.8+/-8.8 cm for an average of 3.3 grafts per patient. Three VAS procedures were aborted, two because of time constraints, and one because of bleeding, and a segment of vein was lost to injury. The VAS group had considerably less early postoperative pain than the control group (1.7+/-1.2 versus 4.1+/-1.4 [1 = mild, 10 = severe]; p0.005) and edema was similar for both groups. Patients in the hybrid group reported less pain in the VAS-operated leg. Serious wound infection occurred in 4 patients, with 2 patients in the control group requiring reoperation for drainage and flap reconstruction.Based on this initial experience, VAS harvesting, although initially more time consuming, is a rapidly mastered technique, results in shorter overall incision length, and is associated with considerably less postoperative pain than the standard open technique.

Objective: There is an increasing number of elderly patients presenting with potentially-resectable lung malignancy. The objective of this study is to evaluate the modern perioperative morbidity and mortality in patients undergoing oncologic lung resection and to analyse the trend over a 26-year period in our experience. Methods: Between 1971 and 1996, 1506 patients underwent lung resection for malignancy. We reviewed the 30-day perioperative risk in a group of 385 (25.6%) patients aged 70 years and older operated on for intended cure of lung malignancy. Operations included 293 (77%) lobectomies, 24 pneumonectomies (6%), 16 bilobectomies (4%) and 52 wedge or segmental resections (13%). The pathology was bronchogenic carcinoma in 89% and metastasis or other tumours in 11% of patients. We compared the 30-day perioperative risk between the elderly group (age 70 or greater) and a cohort of 180 patients (control) 69 years and younger. Results: The mortality for all resections in elderly group was 4.2% (16/385) and was 1.6% for the control group. Mortality in the octogenarian group was 2.8%. Female gender correlated with a decreased risk of death, with only two of 16 deaths in females (P , 0.005). Overall morbidity was higher in the study than in control patients (34% vs. 25%, n.s.), although major morbidity was similar in both groups (13.2% vs. 13%). Abnormal pulmonary-function testing and positive cardiac history did not correlate with increase overall or specific risk. Pneumonectomy carried a higher risk for death, with three of 24 deceased (12.5%; P , 0.05). Changes in outcome were analysed over two time periods: the mortality in the early period (1971‐1982), 11.1% (8/72), was significantly elevated above the control group, while mortality in the modern period (1983‐1994) was not, with a rate of 2.6% (8/313). Conclusions: In our series, mortality associated with operative treatment for lung malignancy in the elderly declined, so age alone no longer appears to be a risk factor. Age remains a risk factor for overall, but not major, morbidity. Pneumonectomy should undertaken cautiously in this age group. Based on this data, functional elderly patients should not be denied curative lung resection based on age alone. © 1998 Elsevier Science B.V. All rights reserved

Recent studies have suggested that competitive flow is an important factor in early internal mammary artery (IMA) graft failure. Flow competition from minimally diseased native coronary vessels has been implicated in the failure of IMA grafts, but does not seem to affect saphenous vein grafts (SVG). The objective of this study was to determine the effects of competitive flow on SVG and IMA grafts and to compare the patterns of flow dynamics and pressure on proximal and distal grafts to the left anterior descending (LAD) artery; factors that may be involved in graft failure. Twelve mongrel dogs underwent coronary artery bypass grafting using IMAs and a SVG to an open LAD artery. The right IMA (PIMA) and the SVG were anastomosed in the proximal LAD and the left IMA (DIMA) was anastomosed at a more distal location. The procedure was performed through a left thoracotomy, using an "off pump" technique. Graft flows were measured isolated and in competition. The IMAs and SVG provided flow levels similar to the native LAD when each one was the sole inflow to the LAD. During competitive flow conditions, total and diastolic SVG flows were reduced 54.4 and 50.5%, respectively (P < 0.05). Total and diastolic PIMA and DIMA flows were reduced more drastically (68.6-73.3 and 69.5-68.1%, respectively; P < 0.05). The DIMA had better preservation of diastolic flow compared to PIMA. A delay in the pressure wave was noted in the isolated IMAs, but not in the SVG. This pattern of flow disappeared during competition due to the large, systolic retrograde flow up the IMA grafts. In conclusion, IMAs compared to the SVG are longer and narrower conduits with lower levels of flow during competition. Low levels of flow and oscillating flow (retrograde/ antegrade) may be poorly tolerated by the IMA endothelium and may be factorial to graft failure. These data suggest that a more distal placement of the IMA graft may be protective to the arterial graft under competitive flow conditions.

Surgical repair of acute Type A aortic dissection (AADA) is still associated with high in-hospital mortality. We evaluated the impact of perioperative risk factors on early and midterm survival.Retrospective (2002-2011) database analysis at a single institution of 132 consecutive AADA patients (88 male, age 59.8 ± 13.6). All but five patients underwent repair with open distal anastomoses and hypothermic circulatory arrest: aortic valve replacement/root replacement (n=44, 33.3%) and valve re-suspension/repair (n=88, 66.7%). Ascending aorta, hemi-arch, and total arch repairs were performed in 11, 113, and eight patients, respectively. Antegrade and retrograde cerebral perfusion were used in all but six patients.Overall in-hospital mortality was 17.4% (n=23). Actuarial survival at one, five, and eight years was 82%, 72%, and 62%, respectively. Perfusion time (cardiopulmonary bypass) (226.5 ± 71.3 vs. 177.5 ± 51.7, p=0.0002), aortic cross-clamp time (min) (132.8 ± 45.7 vs. 109.8 ± 41.2, p=0.01), aortic arch (T2) tear (31% vs. 14%, p=0.03), instability (26% vs. 11%, p=0.02), postoperative stroke (38% vs. 14%, p=0.009), and low cardiac output (50% vs. 15%, p=0.04) all correlated with increased perioperative mortality. A Cox proportional hazard model showed perfusion time (hazard ratio [HR]=1.01), postoperative stroke (HR=2.73), age (HR=1.03), and unstability (HR=1.8) as significant risk factors (p0.05) affecting the overall survival.There is a modern trend towards improving overall perioperative outcomes after surgical repair of AADA; however, early mortality and morbidity remain high even in aortic surgery referral centers.

Hyperhomocysteinemia is associated with aortic aneurysm, however, the mechanisms are unclear. We hypothesize that the expression level of genes involved in extracellular matrix (ECM) remodeling, oxidative stress, and enzymes involved in homocysteine metabolism pathway in aortic aneurysm and hyperhomocysteinemia are differentially regulated by DNA methylation. We studied the mRNA levels of MTHFR, SAHH, MMP-1, -9, TIMP-1, -4, peroxiredoxin, NOX-2, -3 (NAPDH oxidase subunits), collagen and elastin in normal and aortic aneurysm tissues from humans and aorta tissue from HHcy (Cystathionine beta synthase heterozygote knockout, CBS+/-) mice treated with high methionine diet. The total RNA was extracted using Trizol method and RT-PCR was performed. Protein expression of MTHFR, H3K9 (trimethyl) and TIMP4 were studied in mice using immunohistochemistry. MTHFR and TIMP4 expression was seen to be increasing in both human aneurysm samples as well as HHcy CBS+/- mice. There was increased expression of MMP9, peroxiredoxin and decreased expression of MMP1, Collagen I and IV was noted in thoracic aortic aneurysm samples. Increased Collagen IV and decreased Collagen I levels were seen in CBS +/- HHcy mice compared to their wild type controls. Since DNA methylation regulates gene expression of enzymes in Hcy metabolism pathway, we also measured the mRNA levels of DNMTs, MBD2 and H3K9. The results suggest an increase in the levels of DNMT1, 3a, MBD2 and H3K9 in CBS +/- aorta compared to their wild type controls. Our findings suggest a possible role of methylation in regulation of expression of genes involved in matrix remodeling and homocysteine metabolism.

Inflammatory aortic aneurysms (IAAs) are rare and located mainly in the infra-renal abdominal aorta. The ascending aorta has been typically spared from this process. We report on two cases of ascending aortic inflammatory aneurysms and describe the available literature on this rare entity. (J Card Surg 2012;27:70-74)

Cardiac arrhythmias, instigated by mechanical and electrical remodeling, are associated with activation of extracellular matrix metalloproteinases (MMPs). However, the connection between intracellular MMPs activation and arrhythmogenesis is not well established. Previously, we determined localization of MMP in the mitochondria using confocal microscopy. We tested the hypothesis that electrical pacing induces the activation of mitochondrial MMP (mtMMP) and is associated with myocyte mechanical dysfunction. Myocytes were isolated and field stimulated at 1 and 4 Hz. Myocyte mechanics and calcium transient was studied using Ion-Optix system. Mitochondrial MMP-9 activation was evaluated using zymography. There was a 25% increase in 1 Hz and 40% increase in 4 Hz stimulation. We observed an increase in mtMMP activation with increase in electrical pacing compared to 0 Hz with a significant increase (p0.05, n=3). Field stimulation at 4 Hz decreased cell re-lengthening. The levels of calcium transient were reduced with increase in contraction frequency. We conclude that electrical stimulation activates mtMMP-9 that is associated with myocyte mechanical dysfunction.

Q fever is a rare systemic infection caused by Coxiella Burnetii. The presentation with endocarditis is insidious, with negative blood cultures, and oftentimes it is not obvious in diagnostic imaging studies until hemodynamic changes or valve destruction is reached [1]. We report a case of Q fever endocarditis involving the tricuspid and aortic valves and a congenital ventricular septal defect. Surgical treatment and distinct aspects of this unusual case are herein described.

A coronary arteriovenous fistula is a rare occurrence. We report a case of a right coronary artery to superior vena cava fistula presenting with myocardial ischemia.

Left circumflex coronary artery anomalies are rare causes of cardiac symptoms, especially in the adult population. Herein we describe a case of a 40-year-old man presenting with stable angina who was found to have aneurysmal formation and fistulization of the left circumflex coronary artery to the coronary sinus. Contrast-enhanced multislice computed tomography was very useful in our case for the diagnosis of such anomalies.

We describe a case of acute cardiac failure in a patient involved in a motor vehicle accident. A diagnosis of acute mitral regurgitation and left atrioventricular disruption was made with transesophageal echocardiography. Successful repair was performed using the mitral valve leaflets to patch the disruption followed by valve replacement.

Background: Neurological impairment is a major cause of morbidity after cardiac surgery and may be associated with occurrence of cerebral microemboli generated during cardiopulmonary bypass (CPB). This study evaluates cerebral dysfunction following coronary artery surgery on-pump and off-pump. Methods: Neurological outcome was evaluated in 322 patients with a coronary artery bypass graft (CABG). Conventional CPB was used (on-pump) in 305 patients and in 17 patients no CPB was used (off-pump). Intraoperatively, a pulsed-wave transcranial Doppler with a 2-MHZ probe measured high-intensity transient signals (HITS) by ultrasonic insonnation of the middle cerebral artery indicating the presence of emboli within the vessel lumen. Transcranial near-infrared spectroscopy measured cerebral venous oxygen saturation for adequate perfusion. Postoperatively, all patients were subjected to the antisaccadic eye movement (ASEM) test, a sensitive indicator of neurocognitive deficits secondary to frontal lobe dysfunction. Results: While there was no significant difference in O2 saturation, the number of microemboli HITS generated was significantly higher in the on-pump group than the off-pump group. In the off-pump group, 16 (94%) of 17 patients had perfect scores on the ASEM test, while only 108 (35.4%) of 305 patients achieved a perfect score in the on-pump group (p < 0.01). Furthermore, while all patients in the off-pump group achieved at least 90%, 28% (86/305) in the on-pump group scored “zero” on the ASEM test. Conclusion: Cerebral dysfunction as evidenced by ASEM errors is common following coronary bypass on-pump, but rare with off-pump bypass surgery. Cerebral microemboli generated during CPB may account for this difference. (J Card Surg 1998;13:27–31

Type A aortic dissection is a high risk surgical emergency. Its occurrence during pregnancy represents an extremely high risk for death and sequelae for both the mother and the fetus. Surgical treatment in the form of cesarean delivery and aortic repair using hypothermia and circulatory arrest is mandatory in most patients. We report the case of a 29-year-old Marfan female with an acute type A aortic dissection at 34 weeks of a twin pregnancy. She underwent cesarean delivery of male twins followed by repair of the ascending aorta and proximal arch using deep hypothermia and circulatory arrest. The mother and twin babies survived without sequelae and are alive at two years.

Background . Minimally invasive coronary artery bypass grafting has become an increasingly accepted therapy for selected patients with single-vessel coronary artery disease. Reported morbidity has focused on anastomotic problems, but the occurrence of serious wound complications after these procedures has not been well documented. Methods . We reviewed our institutional experience with 35 patients to look for the incidence of serious wound complications. Results . Three patients had serious wound problems after minithoracotomy for coronary artery bypass graft procedures. This represents an overall 9% wound morbidity rate and a 100% rate in the obese women. Conclusions . Wound complications at the incision site after minithoracotomy coronary artery bypass graft procedures seem to occur distinctly in obese women with redundant breasts.

Introduction: Under certain conditions (small internal mammary artery (IMA) or large runoff), double grafting of the left anterior descending (LAD) artery system is necessary to avoid the ominous consequences of myocardial hypoperfusion. Previous studies have shown that a saphenous vein (SVG) adjacent to an IMA graft leads to failure of the IMA. This study compares IMA flow patterns when adjacent (B1 cm) and separated (3‐4 cm) from a SVG placed on a proximally occluded LAD. Methods :A SVG and right IMA (PIMA) to proximal LAD (2.5‐3 mm) coronary bypass were performed in 12 mongrel dogs. The left IMA (DIMA) was anastomosed to the distal LAD (1.5 mm). All anastomoses were carried out without cardiopulmonary bypass. The native LAD was occluded proximally to the PIMA anastomosis, and all graft flows were measured in competitive and non-competitive flow conditions. Results: Isolated graft to LAD flows were similar for the three conduits. There was a drop in flow in both the PIMA and DIMA when placed in competition with the SVG (10.19 3.0 vs. 19.19 4.6 ml:min; PB 0.05). The total drop in flow was significantly greater in the PIMA (67.6 vs. 39.9%; PB 0.05). Diastolic flow was better preserved in the distal IMA graft (19.695.6 vs. 10.293.0 ml:min; PB0.05). The patterns of flow were much different during competition and there was significant retrograde systolic flow in all PIMA grafts while there was no (n 5) or minimal retrograde flow (n 7) in the DIMA grafts. Conclusion: An IMA graft, when adjacent to a SVG, sustains a significant decrease in both total and diastolic flows and develops an oscillating pattern of flow in early systole (retrograde then antegrade). Placing the IMA more distally on the LAD improves flow and decreases retrograde flow. In clinical situations requiring double grafting on the LAD, distance between grafts may be an important factor in maintaining IMA patency. © 1998 Elsevier Science B.V.

Surgeons have traditionally relied on ring preparations to predict how arterial bypass conduits will behave in the postoperative circulation. Objective: This study compared pharmacologic [norepinephrine (NE) challenge] and physiologic [arterial preload] responses of gastroepiploic (GEA) and internal thoracic (ITA) arteries in a standard static ring preparation and a dynamic perfusion system. Methods: Six GEAs (1.0-1.5 mm dia.) and six ITAs (1.5-2.0 mm dia.) 11 cm long were harvested from adult pigs and mounted on a computer controlled perfusion system. Inflow pressure was set at 80 mmHg and outflow resistance was adjusted to simulate high (80-90 ml/min) and low (15-20 ml/min) flow demands. NE response (10 -9 -10 -5 M) was measured under low flow conditions and at high flow conditions when distal arterial pressure (load) was reduced. NE response (10 -9 -10 -5 M) was also evaluated in arterial rings (ITA N = 6, GEA N = 6) with tensions adjusted to simulate the loads occurring at low flow (80 mmHg) and high flow (60 mmHg) situations. Results: In the static ring preparation, NE response [ED 50 ] was similar for both GEA and ITA and was not affected by load. The dynamic preparation demonstrated that the GEAs were significantly more responsive to NE than the ITAs [ED50 high flow: ITA 6.1 ± 0.3**, GEA 7.2 ± 0.3***: *P < 0.05 versus baseline, **P < 0.05 versus low flow values, ***P < 0.05 versus ITA]. Furthermore, in the dynamic preparation, NE response was profoundly affected by reduced load which occurs under high flow conditions [7.18±0.3 versus 6.1±0.3 under high flow and 5.8±0.1 versus no response under low flow conditions]. Conclusion: Static ring preparations do not discern differences between ITA and GEA susceptibility to spasm and fail to detect the effect of load. The dynamic preparation demonstrated significant differences between the GEA and ITA potential to spasm which is consistent with widespread clinical experience. Furthermore a dynamic preparation is highly sensitive to reduced load which occurs under high flow conditions. Although it is more demanding, the dynamic preparation provides superior information to the surgeon in predicting the behavior of arterial bypass grafts.

Objective: Competitive flow from patent native coronary vessels is implicated in the failure of internal thoracic artery (ITA) grafts, but it is not thought to affect saphenous vein graft (SVG) patency. This study examines instantaneous pressure and flow dynamics in left ITA and SVG grafts in competition with a patent left anterior descending (LAD) artery. Methods: SVG (3.0‐4.0 mm) and ITA (1.5‐2.0 mm) to proximal LAD (2.5‐3.0 mm) coronary bypass was performed in 10 mongrel dogs. Flow and pressure were measured in the occluded (No Competition) and opened (Competition) ITA, SVG and LAD. Results: The ITA and SVG, when each was the sole inflow to the LAD, provided similar flow as the native LAD. During competitive flow, total LAD flow was preserved and flow in the ITA and SVG were reduced (8.209 1.25 and 10.009 1.73 ml:min; PB 0.005). SVG diastolic flow was reduced to 11.5292.17 ml:min (55.5%); PB0.003. Flow in the SVG remained predominantly antegrade. In contrast, ITA diastolic flow was reduced more drastically, to 5.379 1.25 ml:min (80.7%); PB 0.0001. When the ITA was the only inflow to the LAD, there was delay in the LAD pressure wave. This delay disappears during competition due to the large, systolic retrograde flow up the ITA. Conclusion: The ITA, compared to the SVG, is a longer and narrower conduit with lower levels of flow during competition. Due to a delay in the pressure wave, the ITA flow is retrograde during early systole. Low levels of flow, with a markedly decreased diastolic phase, and the oscillating pattern in systole (retrograde:antegrade) may be poorly tolerated by the ITA endothelium and lead to graft deterioration. © 1997 Elsevier Science B.V.

The anterior fourth interspace minithoracotomy is our current choice for exposure of the anterior myocardial wall for minimally invasive coronary bypass grafting procedures. This approach provides direct access to the left anterior descending coronary artery for anastomosis, and good exposure of the midsegment of the internal thoracic artery. We describe the use of instrumentation that facilitates the harvest of the left internal thoracic artery under direct vision. The use of this retractor system, which elevates the third and fourth and depresses the second and first ribs, permits better visualization of the internal thoracic artery and allows for proximal internal thoracic artery harvest without rib resection.

Background. Anterior wall myocardial revascularization through a left anterior minithoracotomy is an increasingly accepted procedure. Technical failure at the anastomotic site, promoting persistent or recurrent angina, is known to occur and may be underrecognized. This report summarizes the incidence of technical failure in an initial clinical experience and describes potential causes of early postoperative complications. Methods. Between December 1995 and May 1996, 15 patients underwent left internal mammary artery-to-left anterior descending artery revascularization without extracorporeal circulation. The surgical indication was single-vessel coronary disease in all patients. We exposed the left anterior descending artery target site through a 10-cm left anterior fourth space thoracotomy. The fourth costal cartilage was resected and the left internal mammary artery was harvested under direct visualization. Two 4-0 polypropylene sutures snared in tourniquets proximal and distal to the anastomotic site were used to obtain a bloodless field and stabilization of the left anterior descending artery. Results. All patients had procedures initially deemed successful based on disappearance of angina or postoperative transthoracic Doppler examination of the internal mammary artery 3 to 5 days postoperatively. However, 3 patients presented with recurrent angina at 2, 6, and 8 weeks. Angiography or direct visualization at operation demonstrated the technical complication (stenosis at the anastomotic site in 2 and snare injury in the native vessel in 1). Two patients required reoperation. Conclusions. Initial results with minimally invasive coronary bypass grafting have generated great enthusiasm worldwide, but there is no consensus on how the procedure should be performed. These results suggest that a nonstabilized anastomosis results in an unacceptable failure rate. Furthermore, sutures encircling the left anterior descending artery should not be used for vessel stabilization as injury of the artery may occur.

Background . Octogenarians often present with potentially resectable bronchogenic carcinoma. Older reports noting prohibitive mortality and recent surveys documenting continued substantial risk raise concerns about the applicability of operation in this age group. Methods . We reviewed the short-term and long-term results of pulmonary resection for intended cure of lung cancer in patients 80 years and older operated on from 1980 through 1995. Our surgical philosophy favored lobectomy over lesser resection and generally avoided pneumonectomy in the elderly. Results . Fifty-four octogenarians underwent resection: 43 lobectomies, 2 extended lobectomies, 2 bilobectomies, 3 segmentectomies, 3 wedge excisions, and 1 pneumonectomy. There were two perioperative deaths (3.7%). The overall nonfatal complication rate was 42%, with a major complication rate of 11%. Postoperative stay decreased from 8.1 days overall to 6.3 days in the last 3 years. Only 3 patients required temporary convalescent care after discharge. Actuarial survival at 1, 3, and 5 years was 86%, 62%, and 43%, respectively, for all discharged patients (n = 52) and 97%, 78%, and 57% for stage I cases (n = 39). Patients with tumors beyond stage I fared poorly. Conclusions . Advanced age per se is neither a contraindication to curative resection nor a routine indication for nonanatomic operations in healthy octogenarians with stage I lung cancer. With proper selection, acute risk should be low. Pneumonectomy, extended resection, and operation for stage II or III disease should be considered only in exceptional cases.

A transanal alternative to open surgery is described for opening strictured colorectal anastomoses with an EndoGIA® stapler.

The occurrence of a flow "steal phenomenon" from a large branch of the internal mammary artery (IMA) is rare and its pathogenesis is still controversial. We describe a case of a patent large anomalous left IMA branch which produced recurrent angina 3 years post MIDCAB. Transcatheter coil obliteration of the vessel produced symptomatic relief. However, six months later, chest pains recurred in association with unwinding of the coil and recannulization of the collateral vessel. Successful ligation of the culprit branch using a VATS approach is presented.