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The internal mammary artery (IMA) is the conduit of choice in coronary revascularization because of its long-term patency. We analyzed the effect of left internal mammary artery (LIMA) harvesting on sternal perfusion. Diameters and velocity parameters of the nonmobilized right internal mammary artery (RIMA) were noninvasively analyzed with duplex ultrasound in 41 patients with LIMA myocardial revascularization pre- (2.6 ± 5 days) and postoperatively (4.9 ± 3.9 months). Data of 41 patients were analyzed; 38 patients underwent all examinations with adequate supraclavicular signals. The proximal RIMA diameter and all velocity parameters increased significantly at follow-up (3.1 ± 0.6 vs. 3.2 ± 0.5 mm, p = 0.03; diastolic peak velocity [DPV] 15 ± 7 vs. 27 ± 9 cm/sec, p < 0.0001; systolic peak velocity [SPV] 90 ± 24 vs. 105 ± 29 cm/sec, p < 0.02). This was more pronounced for the diastolic parameters and for all parameters in the proximal part of the RIMA than in the distal part (DPV 11.9 ± 10.1 vs. 9.5 ± 10.2 cm/sec, p = NS; SPV 14.9 ± 33.9 vs. 7.4 ± 26.0 cm/sec, p = NS). With longer time intervals of follow-up the increase in all diastolic velocity parameters became less pronounced. As demonstrated in the RIMA velocity parameters, patients with skeletonized LIMA grafts (n = 4) had significantly more flow, suggesting hyperemic flow, than patients with pedicled LIMA grafts (n = 34). Only in diastolic velocity integral (DVI) and systolic/diastolic velocity ratio (SDVRA) were there significant differences between diabetics (n = 9) and nondiabetics (n = 29) and only in DVI between female, (n = 8) and male (n = 30) patients. This study indicates that duplex ultrasound is a useful tool for noninvasive RIMA follow-up in LIMA myocardial revascularization. [ABSTRACT FROM AUTHOR]

Objective: To define prognostic parameters for patients with synchronous non-small cell lung cancer (NSCLC).Design: Retrospective study of period from 1970 through 1997.Patients: Patients with a single (n = 2,764) and synchronous NSCLC (n = 85) who underwent pulmonary resection.Methods: All tumors were classified postsurgically, and the tumors of the patients with synchronous lung cancer were staged separately. The most advanced tumor was used for comparison. Actuarial survival time was estimated, and risk factors influencing survival were evaluated. Patients who died within 30 days of surgery were excluded.Measurement and Results: Five-year survival for single NSCLC was 41% and for synchronous lung cancer it was 19%. The relative risk of death for patients with synchronous lung cancer was 1.75, compared to that for patients with single lung cancer. The most advanced tumor in synchronous cancer was a significant predictor of survival (p<0.005). The survival of patients with synchronous lung cancer in which the most advanced tumors were stage I (n = 40) and stage II (n = 27) was not different from that of patients with stage II (n = 834) and stage IIIA (n = 405) single lung cancer, respectively.Conclusion: The poorer survival of patients with synchronous NSCLC is confirmed and quantified. The stage of the most advanced tumor was the best predictor of prognosis. The prognosis of patients with synchronous NSCLC resembles the prognosis of patients with a single lung cancer of a higher stage. Upstaging in synchronous lung cancer is recommended on the basis of these observations. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to verify if gait speed can be an incremental predictor for mortality and/or major morbidity in combination with EuroSCORE II., Methods: A single center prospective study cohort of 150 patients aged 70 years or older and undergoing cardiac surgery between August 2012 and April 2013. Slow gait speed was defined as a time taken to walk 5 meters of ≥6 second. The logistic EuroSCORE and EuroSCORE II were used for risk stratification., Results: The studied group had a mean age of 77.7±5.2 years and mean gait speed was 4.9±1.01 (3.0-8.6) seconds. Slow gait speed was recorded in 21 patients (14%), indicated as frail, the other 129 patients (86%) as active. The logistic EuroSCORE risk (P=0.528), was not significantly different between the two groups. The EuroSCORE II risk, however, was significantly higher (P=0.023) for the frail group. There was no mortality and no statistically significant difference in percentage of major morbidity between the frail (28.6%) versus 17.1% for the active group (P=0.209) and slow gait speed could not be identified as independent predictor. Nevertheless frailty demonstrated an incremental value to improve performance of the logistic EuroSCORE model to predict early mortality and/or major morbidity in this elderly patient population. This was not so for EuroSCORE II., Conclusions: We confirm the incremental value of frailty, evaluated by gait speed, to improve mortality and morbidity prediction of the logistic EuroSCORE model in elderly undergoing cardiac surgery. We could not confirm this for the new EuroSCORE II model.

Aim: The purpose of this study was to evaluate whether women undergoing cardiac surgery are more likely to suffer postoperative complications and mortality than men with respect to baseline and procedural characteristics., Methods: Data of 4030 adult patients undergoing cardiac surgery between January 2007 and June 2012 were retrospectively analyzed; 3075 isolated CABGs (CABG-group) and 955 aortic valve replacements (AVR) whether or not in combination with CABG (VALVE-group) The total study population, had a mean age 69.6 ±10.3 years, and there were 1073/4030 women (26.6%)., Results: Female patients were older (P=0.001), at higher EuroSCORE risk (P=0.001) and have a higher BMI (P=0.001). In the CABG-group female patients receive fewer distal anastomoses (P=0.001) and arterial grafts were less frequently used (P=0.002). In the combined procedures in women less distal anastomoses were applied (P=0.029). Postoperative female CABG patients have a higher hospital mortality (P=0.031) and early mortality (P=0.019). In the VALVE group there is no difference in hospital or early mortality between both genders. Binary logistic regression did not identify female gender as an independent risk factor for hospital- or early mortality in both patient groups., Conclusion: Although female patients undergoing cardiac surgery are older and at higher risk, female gender is not an independent risk factor. The operative procedure and gender related differences in treatment may be important and affect the outcome.

Concerns have been raised about the development of heart failure in patients treated for cancer with angiogenesis inhibitors, such as the tyrosine kinase inhibitor sunitinib. Patients with previous coronary artery disease and hypertension have an increased risk of developing heart failure. Therefore, we studied the effect of sunitinib on the contractility of isolated human atrial trabeculae and the effect on recovery after ischemic stimulation. After informed consent, the atrial appendage of patients undergoing cardiac surgery was harvested and isolated trabeculae were placed in an organ bath with a force transducer. During electrical stimulation, contractile force was measured during normal pacing or after simulated ischemia. Of each patient, one trabecula was perfused with control and one with sunitinib. Contractile force (expressed as percentage of baseline force) declined over time to 57 ± 8 and 73 ± 20% after 150 min of stimulation for solvent- and sunitinib-treated trabeculae, respectively (mean ± SE; n = 8; p > 0.1). After simulated ischemia and reperfusion, contractile force was 40 ± 6% in the control compared to 39 ± 6% in the sunitinib-treated trabeculae during the last final 5 min of reperfusion (n = 12; p > 0.1). Sunitinib at low, but clinically relevant, concentrations does not have a direct effect on function of human atrial cardiomyocytes nor does it attenuate the recovery in contractile force of atrial cardiomyocytes after a period of ischemia. A direct and acute toxic effect on cardiomyocytes does not explain the development of heart failure in patients treated with sunitinib.

Objective: Mechanical ventilation causes cyclic changes in the heart's preload and afterload, thereby influencing the circulation. However, our understanding of the exact physiology of this cardiopulmonary interaction is limited. We aimed to thoroughly determine airway pressure distribution, how this is influenced by tidal volume and chest compliance, and its interaction with the circulation in humans during mechanical ventilation., Design: Intervention study., Setting: ICU of a university hospital., Patients: Twenty mechanically ventilated patients following coronary artery bypass grafting surgery., Intervention: Patients were monitored during controlled mechanical ventilation at tidal volumes of 4, 6, 8, and 10 mL/kg with normal and decreased chest compliance (by elastic binding of the thorax)., Measurements and Main Results: Central venous pressure, airway pressure, pericardial pressure, and pleural pressure; pulse pressure variations, systolic pressure variations, and stroke volume variations; and cardiac output were obtained during controlled mechanical ventilation at tidal volume of 4, 6, 8, and 10 mL/kg with normal and decreased chest compliance. With increasing tidal volume (4, 6, 8, and 10 mL/kg), the change in intrathoracic pressures increased linearly with 0.9 ± 0.2, 0.5 ± 0.3, 0.3 ± 0.1, and 0.3 ± 0.1 mm Hg/mL/kg for airway pressure, pleural pressure, pericardial pressure, and central venous pressure, respectively. At 8 mL/kg, a decrease in chest compliance (from 0.12 ± 0.07 to 0.09 ± 0.03 L/cm H2O) resulted in an increase in change in airway pressure, change in pleural pressure, change in pericardial pressure, and change in central venous pressure of 1.1 ± 0.7, 1.1 ± 0.8, 0.7 ± 0.4, and 0.8 ± 0.4 mm Hg, respectively. Furthermore, increased tidal volume and decreased chest compliance decreased stroke volume and increased arterial pressure variations. Transmural pressure of the superior vena cava decreased during inspiration, whereas the transmural pressure of the right atrium did not change., Conclusions: Increased tidal volume and decreased chest wall compliance both increase the change in intrathoracic pressures and the value of the dynamic indices during mechanical ventilation. Additionally, the transmural pressure of the vena cava is decreased, whereas the transmural pressure of the right atrium is not changed.

Aim: Preoperative carotid screening is common in the prevention of perioperative stroke. The authors describe our experience with selective screening of patients with a recent (<1 year) neurological event. Because many variables are related with the development of perioperative stroke we additionally evaluate the value of a stroke-risk stratification model., Methods: Of 1 442 isolated myocardial revascularizations performed between January 2002 and December 2005, 118 patients had a history of preoperative stroke. Twenty-four patients had a recent stroke. In 5/24 patients duplex revealed significant stenosis of the internal carotid artery, which was treated prophylactically., Results: Eleven patients (0.83%) developed a perioperative stroke. Three patients recovered completely during hospital stay, three died related to their stroke. Of the other 94 patients with a history of stroke, 5 had a stroke, none of them had a significant stenosis of the carotid artery. Of the 1,224 patients without a history of stroke, 6 developed a perioperative stroke. Three of them had a significant carotid artery stenosis, however in two patients stroke deficit was on the ipsilateral side and the third patient had a transient ischemic attack. All eleven patients had a calculated stroke risk of 3 or higher corresponding with a expected risk of at least 0.9%., Conclusions: With the used protocol, in the described patient population, perioperative stroke incidence is low. on the other hand, the complexity of the mechanism of perioperative stroke is confirmed and the use of a stroke-risk stratification model seems us justified for a better identification of patients at risk.

A 38-year-old man developed dysphagia, fever and marked trismus, resulting in an abcess of the parafaryngeal region, soon after the surgical extraction of 2 mandibular molars. Despite systemic antibiotics and surgical drainage, the abcess spread to the mediastinum. Within a short space of time, cervical fasciitis necroticans and descending necrotizing mediastinitis developed. Because of the life-threatening health condition, the patient was admitted to a hospital for further treatment. He underwent surgical exploration of the cervical and sternal region, thoracotomy for mediastinal drainage, debridement, and daily mediastinal rinsing with hydrogen peroxide and betadine iodine. After 5 weeks intensive treatment, the patient could be discharged from the hospital in a fairly good condition of health.

Objective: To correlate supraclavicular ultrasonography at rest and in hyperaemic response with angiographically patent and (distal) 'string sign' left internal mammary artery (LIMA) to left anterior descending (LAD) area grafts., Methods: Fifty-three patients with LIMA to LAD area grafting were prospectively entered in a follow-up study. Arteriography (native and LIMA) was performed at 1.4+/-0.8 years postoperatively and ultrasonography was performed at rest, in hyperaemic response and 2min after hyperaemic response at 1.8+/-0.8 years postoperatively and was compared to arteriography. Ultrasonographic parameters analysed were systolic and diastolic peak velocity, systolic and diastolic velocity integral, diastolic/systolic peak velocity ratio and diastolic/total velocity integral ratio., Results: One patient was excluded because obesity hampered ultrasonography. Arteriography demonstrated functional grafts in 43 patients (group I), sequential distal 'string sign grafts' in 4 patients (group II) and total 'string sign grafts' in 5 patients (group III). Between the groups all ultrasonographic velocities showed a significant linear relation (p

Objective: Comparing the changes in open-heart surgical procedures and hospital mortality in 1992 with 2002., Design and Setting: Retrospective investigation at St Antonius Hospital in Nieuwegein., Method: A comparison of the open-heart surgical procedures, hospital mortality and age distribution of the operated patients was made, using the database of the Department of Cardiothoracic Surgery., Results: The total number of open-heart surgical procedures increased. There were more combined procedures, aortic valve replacements and reconstructions of the thoracic aorta. The total number of reoperations decreased. In 2002 the use of an arterial conduit for coronary bypass procedures reached 94%, and the radial artery was used for the first time. The mean patient age and the hospital mortality were higher in 2002., Conclusion: Comparing cardiovascular surgery in 1992 to 2002 showed an increase in complicated procedures and older age groups of patients. This may be the reason for higher overall mortality. The mean patient age increased considerably from 1992 to 2002, together with the number of combined procedures and aortic valve replacements with biological valve prostheses. These trends give cardiovascular surgery a challenging future, to treat the patient adequately and keeping the mortality and complication rates low.

Objective: The experiences on the treatment of seven consecutive patients with large-cell neuroendocrine carcinoma (LCNEC) were studied, observed over 6 years from 1992. Since LCNEC was recognized as a separate histological entity, only very few series have been reported. Together with the carcinoids (atypical and typical) and the small-cell lung carcinoma (SCLC), it forms the spectrum of neuroendocrine tumors., Methods: Between 1992 and 1997, seven patients who underwent surgical resection were diagnosed as LCNEC postoperatively. Mean age was 65 years (range 54-77 years), five patients were male, all patients were heavy smokers. One patient was staged as IA, four as IB, one as IIIB and one as IV., Results: In five patients, preoperative diagnosis was unknown, in one squamous cell carcinoma and in one adenocarcinoma was suspected. There were four lobectomies, two bilobectomies and one resection of the lingular division with a wedge resection of the upper division of the left upper lobe. Three patients received adjuvant chemotherapy and one, adjuvant radiotherapy. Survival ranged from 7 to 39 months. There are no patients currently alive., Conclusions: LCNEC is a high-grade neuroendocrine tumor with a poor prognosis. In our patients, after surgical resection or multimodality treatment, all have developed widespread metastatic disease with a rapidly fatal course. Due to the rarity of this tumor, the incidence, prognosis and optimal treatment remain to be determined.

This case report describes a patient with severe calcific aortic stenosis who was initially considered inoperable because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved to such an extent that subsequent aortic valve replacement was considered possible and eventually proved to be successful. Balloon aortic valvuloplasty has value as a potential bridge to aortic valve replacement when the risks for surgery are considered to be too high.

Objective: To evaluate the use of left ventricular assist devices (LVAD) as bridge to heart transplantation (HTx) in patients with end-stage heart failure., Method: Between March 1993 and December 2001, 38 patients with refractory end-stage heart failure underwent HeartMate LVAD (Thoratec, Pleasanton Calif.) implantation., Results: A total of 33 of the 38 patients (87%) survived the implantation and perioperative period. There were five perioperative deaths (13%), two due to right ventricular failure, two as a result of bleeding and one probably due to septic shock at the time of LVAD implantation. Three patients (9%) died late in the postoperative period due to septic shock, mechanical failure of the device and a cerebral embolus resulting from LVAD endocarditis, initiated by an acute cholecystitis. Twelve patients (32%) had one or more infectious episodes during long-term assist, of which one patient died. Four patients are still on the device, waiting for a heart transplantation. Twenty-six patients (76%) underwent HTx after 206±129 days of support., Conclusion: These results show the efficacy of LVAD support as a bridge to heart transplantation in patients with end-stage heart failure. Major long-term complications are infections and mechanical failure of the device.

Ventricular tachycardia occurs frequently in patients with mitral valve prolapse. If antiarrhythmic drug therapy fails or mitral valve surgery is indicated, concomitant arrhythmia surgery may be considered. This report describes the first clinical use of an atrial transseptally inserted multielectrode basket catheter, placed across the mitral valve, to guide intraoperative mapping and ablation of monomorphic sustained ventricular tachycardia in association with mitral valve prolapse. Endocardial covering and signal quality of this percutaneous mapping catheter were of good quality, allowing an accurate localization of the site of origin of the tachycardia.

Concomitant severe coronary artery disease and lung malignancies are uncommon. Combining conventional coronary surgery with cardiopulmonary bypass with lung resection is still a controversial issue. Conversely, combining off-pump coronary surgery with right lung resections through a midline sternotomy can be an attractive approach. Off-pump coronary surgery avoids the risks of cardiopulmonary bypass, reduces systemic inflammatory response and does not affect the immune system. We report a series of three patients successfully operated using this approach.

Background: This study was performed to review our experience with postoperative chylothorax and describe our current approach. In addition, we wanted to estimate the impact of video-assisted thoracoscopic surgery (VATS) on our current management policy., Methods: From January 1991 to December 1999, 12 patients developed chylothorax after various thoracic procedures. Their mean age was 61.5 (range 31 to 80 years). The procedures were cardiac, aortic, and pulmonary operations., Results: All patients were initially treated conservatively. In addition, 7 patients needed surgical intervention, including one thoracotomy and six VATS. The site of thoracic duct laceration was identified and treated with VATS in 4 patients. In 2 patients, the leak could not be localized by VATS, and fibrin glue or talcage were applied in the pleural space. All patients were discharged without recurrent chylothorax., Conclusions: VATS is an effective tool in the management of persisting postoperative chylothorax. Its easy use, low cost, and low morbidity rate suggest an earlier use of VATS in the treatment of postoperative chylothorax.

Background: In a number of patients with treated primary non-small cell lung cancer (NSCLC) a second primary tumor will be diagnosed. Our experience with surgery in these patients was analyzed and possible prognostic parameters were defined., Methods: Patients with metachronous NSCLC (n = 127) who underwent resection from 1970 through 1997 were analyzed. All tumors were classified postsurgically. Median interval between the tumors was 3.7 years. Actuarial survival time was estimated and risk factors influencing survival were evaluated., Results: Overall 5-year survival after the first resection was 70% and after the second resection was 26%. Patients with stage IA of the second primary tumor did have a significantly better survival (p < 0.005) as compared with patients with higher staged second primaries. Stage of second primary tumor and age were significant predictors of survival, whereas stage of first tumor, interval between resections, histology, and type of resection were not., Conclusions: Survival of patients with metachronous NSCLC and resection of both tumors is high, but poorer than after resection of the first tumor. Irrespective of the interval, patients with stage IA second primary tumor may benefit more from pulmonary resection.

Closure of the bronchial stump after pneumonectomy can be challenging. Some special situations such as tumor extension, technical pitfalls, or poor tissue quality of the bronchial stump may preclude safe closure of the airway with standard techniques. We describe here a technique of wedge carinal resection that provides the surgeon an alternative whenever the standard closure of the stump is inapplicable. This technique has been successfully used in a series of 4 patients.

Background: A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome., Methods: A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period., Results: Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease., Conclusions: Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.

A surgical technique is described in which a saphenous vein graft is used to reconstruct the jugular vein in horses with facial oedema due to post thrombophlebitic stenosis of the jugular vein. The saphenous vein was harvested from the contralateral limb and implanted in the occluded vein by 2 side-to-end anastomoses. Intra- and post operatively anticoagulative medication was administered. In 2 out of 3 patients the reconstruction resulted in a permanent patent graft and resolution of the facial oedema. In one patient the graft thrombosed.

Background: Bronchopeural fistula after pneumonectomy, with associated empyema, has no standard therapy. The transsternal, transpericardial approach was used in all patients presenting with a large fistula., Methods: From 1974 through 1995, 55 patients underwent transsternal, transpericardial closure of a bronchopleural fistula. Mean age was 62.7 years (range, 33 to 78 years). Malignant disease had been the indication for pneumonectomy in 50 patients and benign lesions in 5 patients. The fistula was right-sided in 41 patients (74.5%), and the bronchial stump was less than 2 cm in 25 (45.5%). Treatment of the concomitant empyema was by closed drainage in 2 patients, by repeated needle aspiration in 17, and by open thoracostomy in 36 patients. Reamputation and closure of the stump was possible in 51 patients; in 4 a primary carinal resection was done., Results: Three patients died within 30 days after operation (5.4%, 70% confidence interval 2.4%-10.7%). Ten patients died late during hospitalization, total hospital mortality, 23.6% (70% confidence interval 17.3% to 31.0%). Recurrent fistula symptoms were caused by a large recurrency in 6 patients (all died), by a small one in 7 (one death due to pulmonary embolism). Mean duration of hospital stay was 56 days (range, 2 to 174 days). At follow-up of 42 patients, there were no recurrent fistulas. All patients with benign lesions are alive and well. Of 37 cancer patients, 29 died, more than half due to malignancy. Risk factors for death included recurrent fistula, short interval between pneumonectomy and onset of fistula, and closing technique. Risk factors for recurrent fistula were a short bronchial stump and the nonuse of an open thoracostomy., Conclusions: Long-term results of transsternal closure are good, but hospital mortality is high. The present treatment of patients with large postpneumonectomy bronchopleural fistula includes early open thoracostomy, improvement of nutritional status, transsternal closure using resorbable sutures, and closure of the pleural space 3 weeks later.

Background: The aim of this study was to identify factors influencing early outcome after surgical treatment of postinfarction ventricular septal rupture. We investigated the influence of proximal or distal rupture location., Methods: Between 1980 and 1992 109 patients were treated surgically for ventricular septal rupture using a standardized technique. A division in time periods was made. The rupture was categorized according to its anterior or posterior site and proximal or distal location., Results: The 30-day mortality rate was 27.5%. Multivariate logistic regression analysis identified preoperative shock (p = 0.0007) and right atrial oxygen saturation less than 60% (p = 0.021) as predictors for early death; the risk for early death declined over the time periods from 50% to 12.8% (p = 0.0007). Proximal ventricular septal rupture location (p = 0.0092) and interval between infarction and ventricular septal rupture less then 1 day (p = 0.034) were risk factors for the occurrence of preoperative shock., Conclusions: Proximal ventricular septal rupture location was the main determinant of preoperative cardiogenic shock, which in turn was the strongest predictor of early mortality. Over the time periods a decrease in early mortality was reached.

Background: Long-term results after bronchial sleeve resection remain controversial, especially in relation to nodal involvement. In a previous report, there were no 10-year survivors among patients with N1 or N2 disease., Methods: From 1960 to 1989, 145 patients underwent bronchial sleeve resection for a bronchogenic tumor. Follow-up was updated until the end of 1994, so the minimum follow-up was 5 years for surviving patients. A univariate analysis and a multivariate analysis were performed., Results: For the whole group, 5-year, 10-year, and 15-year survival rates were 46%, 33%, and 22%, respectively. The median survival time was 53 months. Five-year and 10-year survival rates for the 71 patients with no disease were 62% and 51%, respectively; for the 58 patients with N1 disease, 31% and 10%; and for the 16 patients with N2 disease, 5-year and 7-year survival rates were 31% and 13%. There was a highly significant difference in survival between patients with no and N1 or N2 disease but not between those with N1 and N2 disease. Multivariate analysis showed only nodal stage and patient age to be significant factors in relation to survival., Conclusions: Long-term results after bronchial sleeve resection are influenced chiefly by nodal stage. A significantly lower survival is found in patients with N1 and N2 disease, and most of these patients die of distant metastases.