Asian Cardiovascular and Thoracic Annals current issue

[EDITORIAL] Use of a Biodegradable Annuloplasty Ring for Mitral Valve Repair in Children

Christenson, Kalangos — 2009-06-10

[ORIGINAL ARTICLE] Folic Acid-Based Intervention in Non-ST Elevation Acute Coronary Syndromes

Imasa, Gomez, Nevado — 2009-06-10

Homocysteinemia is a risk factor for cardiovascular diseases. Folic acid combined with vitamins B₆ and B₁₂ is effective in lowering homocysteine levels. This randomized placebo-controlled study was designed to determine the effect of a folic acid-based supplement on secondary prevention of clinical events in non-ST-segment elevation acute coronary syndromes. The study comprised 240 patients with either unstable angina or non-ST-elevation myocardial infarction in the previous 2 weeks who were randomized to a folate group (n =116) or a placebo group (n =124). The folate group received 1 mg folic acid, 400 µg vitamin B₁₂, and 10 mg vitamin B₆ daily. Clinical outcomes within 6 months were assessed. The composite endpoint of death, nonfatal acute coronary syndrome, and serious re-hospitalization was significantly higher in the folate group; serious re-hospitalization alone was significantly higher in this group. Advanced age and diabetes increased susceptibility to the composite outcome. Folic acid-based supplementation is not beneficial and may even be harmful in the secondary prevention of cardiovascular events in patients with unstable angina and non-ST-elevation myocardial infarction. Further studies on the safety of such supplements are suggested. Controlled Clinical Trials Registry no. ISRCTN30249553.

[ORIGINAL ARTICLE] Valve-Sparing Aortic Root Stabilization in Acute Type A Aortic Dissection

Shrestha, Khaladj, Hagl, Haverich — 2009-06-10

Composite replacement is the standard approach for repair of acute type A aortic dissection involving the aortic root. Reimplantation or remodeling procedures have become valve-sparing alternatives. We developed a new and simple technique to stabilize the aortic root. A Dacron graft is attached outside the native aortic cylinder, and incised twice vertically to create openings corresponding to the right and left coronary ostia. Thus the entire graft covers the native aortic root cylinder from the outside, and the native aortic valve and coronary ostia do not need to be reimplanted. From 2002 to 2007, this technique was applied in 14 patients (8 male) with a mean age of 71 years (range, 34–83 years). Four patients died within 30 days; 3 had been hemodynamically unstable with ventilator and inotropic support preoperatively. Echocardiography showed normal function of the preserved aortic valve, without regurgitation, in all patients. This technique is an alternative valve-sparing method for stabilization of the aortic root in patients with acute type A aortic dissection.

[ORIGINAL ARTICLE] Seasonal Variation in Thrombogenicity of Blood: a Word of Caution

Narang, Banerjee, Satsangi, Geelani — 2009-06-10

Thrombogenicity of blood is known to have seasonal variations. The clinical implications of seasonal variations in the anticoagulation profile of patients with mechanical valves was assessed. Data of patients implanted with a mechanical heart valve for more than 3 months were collected at follow-up or on presentation to the emergency department. The mean time from the previous follow-up examination was 3.6 ± 0.3 months. The number of patients with an international normalized ratio >3.5 and the incidence of hemorrhagic events peaked in hottest part of the year (June–July), with 128 cases of prolonged clotting and 43 hemorrhagic events in this period. The number of patients with rapid clotting and the incidence of embolic events peaked in coldest part of the year (December–January), with 120 cases of international normalized ratio <1.5 and 37 embolic events in this period. There was a significant correlation between temperature and thrombogenicity in patients with prosthetic heart valves on long-term anticoagulation.

[ORIGINAL ARTICLE] Outcomes of Mitral Valve Repair for Chronic Ischemic Mitral Regurgitation

Sajja, Mannam, Dandu, Pathuri, Sompalli, Anjaneyulu — 2009-06-10

Mitral regurgitation is a frequent complication of ischemic heart disease. A retrospective study was performed on 127 patients with significant ischemic mitral regurgitation (regurgitant jet area ≥6.0 cm² and/or vena contracta width ≥0.70 cm) who underwent elective mitral valve repair between January 2001 and October 2007. Concomitant myocardial revascularization was carried out in all except one patient, and left ventricular restoration in 8. All patients had ring annuloplasty, with release of posterior mitral leaflet tethering in 21, leaflet resection in 7, chordal transfer in 3, and chordal shortening in 2. There were 4 (3.1%) hospital deaths. Two patients underwent successful mitral valve replacement for repair failure in the immediate postoperative period, and one had an unsuccessful valve replacement at 3 months. During a mean follow-up of 19.65 ± 13.21 months in 121 patients, 111 had trivial or no residual regurgitation, and 10 had mild regurgitation. Mitral valve repair for chronic ischemic mitral regurgitation is a reproducible technique with satisfactory early and mid-term outcomes and freedom from valve-related complications.

[ORIGINAL ARTICLE] Quality of Life After Mechanical vs. Biological Aortic Valve Replacement

Aboud, Breuer, Bossert, Gummert — 2009-06-10

To assess the quality of life after biological and mechanical aortic valve replacement, data of 136 patients were assessed retrospectively after 2 years of follow-up. Bioprostheses were implanted in 53 patients with a mean age of 74 years, and mechanical prostheses were used in 83 with a mean age of 64 years; there were 47 women and 89 men. Quality of life was evaluated using the Short Form 36-Item Health Survey questionnaire. Physical function scores were significantly better in patients with a mechanical prosthesis. Mental health indices were identical in both groups. Younger patients with mechanical valves and older patients with biological valves had significantly better item scores. In all age groups, men tended to have better scores than women, but a significant difference was noted only in the physical functioning index. The quality of life in patients with mechanical and biological valves was similar at 2 years postoperatively.

[ORIGINAL ARTICLE] Exercise Tolerance in Extracardiac Total Cavopulmonary Connection

Yin, Wang, Zhu, Zhang, Wang, Li — 2009-06-10

Cardiopulmonary adaptation during exercise was compared in patients with an extracardiac total cavopulmonary connection and controls with biventricular repair of Fallot’s tetralogy. Heart rate, blood pressure, respiratory frequency, and transcutaneous oxygen saturation increased with treadmill exercise intensity below grade 3 in patients who had undergone extracardiac total cavopulmonary connection. When exercise intensity exceeded grade 4, blood pressure and oxygen saturation decreased continuously, respiratory rate kept increasing, and heart rate showed no significant change. In cases of fenestrated cavopulmonary connection, heart rate peaked at grade 5 exercise intensity, and blood pressure at grade 4; but both peaked at grade 3 in non-fenestrated patients. During all exercise testing, fenestrated patients had a higher respiratory rate but lower oxygen saturation than those without fenestration. Exercise tolerance was below normal after a cavopulmonary connection, but patients still adapted to exercise below grade 3 with appropriate increases in heart rate and respiratory rate. Due to insufficient right heart systems, patients with a cavopulmonary connection showed obvious exercise limitation at exercise intensity grade 3 or more. Total exclusion of the right heart system may also have adverse effects on the sinoatrial node, leading to impaired heart rate regulation.

[INVITED COMMENTARY] Exercise Tolerance in Extracardiac Total Cavopulmonary Connection

Corno — 2009-06-10

[ORIGINAL ARTICLE] Effect of Central Venous Pressure on Spinal Cord Oxygenation

Ulus, Hellberg, Ulus, Karacagil — 2009-06-10

To analyze the effect of central venous pressure on cerebrospinal fluid oxygen tension and intrathecal pressure, multiparameter sensors were introduced into the intrathecal space for continuous monitoring of cerebrospinal fluid Po₂, Pco₂, and intrathecal pressure in 15 pigs. After 20 min of aortic clamping, hypervolemia was established for 20 min, followed by normovolemia. The animals were divided into 3 groups: in group 1, cerebrospinal fluid Po₂ = 0% at some time during crossclamping; in group 2, cerebrospinal fluid Po₂ was <50%; and in group 3, cerebrospinal fluid Po₂ remained ≥ 50%. Mean decreases in cerebrospinal fluid Po₂ during the initial 20 min of crossclamping were 82%, 57%, and 15% in groups 1, 2, and 3, respectively. Following induction of hypervolemia, central venous and cerebrospinal fluid pressures increased simultaneously; this caused a significant decrease in cerebrospinal fluid Po₂ in group 2 only. In this model, aortic clamping did not increase cerebrospinal fluid pressure if central venous pressure was not elevated. The detrimental effect of elevated intrathecal pressure on cerebrospinal fluid oxygenation was seen only in animals with an intermediate degree of spinal cord ischemia. This might have important implications for the prevention of paraplegia during thoracoabdominal aortic replacement.

[ORIGINAL ARTICLE] Off-Pump Coronary Artery Bypass in Severe Left Ventricular Dysfunction

Pande, Agarwal, Kundu, Kale, Chaudhary, Dhir — 2009-06-10

The outcome of multivessel off-pump coronary artery bypass grafting in cases of severe left ventricular dysfunction was studied in 58 consecutive patients with ejection fraction ≤35% who were followed up for a median of 15 months. Patients with ejection fractions ≤25% (group 1) had the largest left ventricular dimensions preoperatively, with gradual increases during follow-up; those with ejection fractions of 26%–35% (group 2) had smaller preoperative ventricular dimensions, with left ventricular regression postoperatively. There was more improvement in ejection fraction in group 2 than group 1 (33% vs. 10%). Mitral regurgitation improved from moderate to mild in group 2; whereas in group 1, mild mitral regurgitation progressed to moderate or severe during follow-up. Ejection fraction was a predictor of more frequent use of intraaortic balloon pumping, longer duration of inotropic use, a higher mean pulmonary artery-to-systemic arterial pressure ratio, and increased postoperative drainage.

[ORIGINAL ARTICLE] Hospital Outcome of Coronary Artery Bypass Grafting and Coronary Endarterectomy

Abid, Farogh, Naqshband, Akhtar, Khan — 2009-06-10

To compare hospital mortality and postoperative complications in patients with severe coronary artery disease undergoing coronary artery bypass grafting with or without coronary endarterectomy, 100 consecutive patients were divided into 2 groups of 50 patients each. Group 1 had coronary endarterectomy, and group 2 had no coronary endarterectomy. There were 87 men and 13 women, with a mean age of 54.79 ±7.8 years; 48% had stable angina. The right coronary artery was endarterectomized in 22 patients, the left anterior descending artery in 21, and the left circumflex in 7. There were no significant differences in outcomes. There was 1 hospital death in each group. Perioperative myocardial infarction occurred in 2 patients in group 1 and 1 in group 2. Endarterectomy is a suitable option to achieve complete revascularization in patients with refractory angina and severe diffuse disease.

[CASE STUDIES] Bilateral Giant Pulmonary Bronchogenic Cysts

Liu, Pan, Wei — 2009-06-10

Bilateral giant tension bronchogenic cysts were detected by computed tomography in a 13-year-old girl who presented with fever and severe cough. One was located in the right upper lobe, the other in the left lower lobe. The cysts, both measuring 10 cm in diameter, were removed in 2 operations 2 months apart.

[CASE STUDIES] Massive Cerebral Air Embolism after Bronchoscopy and Central Line Manipulation

Seeburger, Borger, Merk, Doll, Bittner, Mohr — 2009-06-10

A 50-year-old woman who underwent double-lung transplantation suffered a massive cerebral air embolism with severe neurological impairment and temporary hemodynamic deterioration after surveillance bronchoscopy and central line removal. We hypothesize that this was due to microscopic pulmonary parenchymal injury during bronchoscopy as well as air entrainment during removal of the central venous line, with subsequent transpulmonary passage into the cerebral vessels.

[CASE STUDIES] Diaphragmatic Fenestrations in Catamenial Pneumothorax: a Management Strategy

Rafay, El-Bawab, Kurdi, Al Kattan — 2009-06-10

Video-assisted thoracoscopic exploration of the right hemithorax in a 37-year-old woman with recurrent catamenial pneumothorax revealed multiple diaphragmatic fenestrations. She underwent successful plication of the diaphragm, with no recurrence of pneumothorax after 4 years of follow-up.

[CASE STUDIES] Syncope and Facial Blushing Due to Giant Intrapulmonary Bronchogenic Cyst

Ramos-Izquierdo, Escobar-Campuzano, Llatjos-Sanuy, Moya-Amoros — 2009-06-10

A 43-year-old man presented with dizziness, head instability, and facial reddening, always in relation to body posture and without fever or systemic manifestations. Chest radiography revealed a large cavity with an air-fluid level in the right upper hemithorax. A right upper lobectomy was performed to remove a large bronchogenic cyst. The presentation with cardiac but no respiratory symptoms is uncommon but should be considered in the differential diagnosis of patients with intrathoracic cysts.

[CASE STUDIES] Coarctation of Right Aortic Arch with Left Descending Aorta in an Adult

Hirota, Ishino, Kawada, Sano — 2009-06-10

We report an adult case of right aortic arch coarctation with a left descending aorta. Associated anomalies included dextrocardia, situs inversus, polysplenia, bilateral superior vena cava, and absent inferior vena cava with azygos connection. Extensive mobilization of the azygos vein was needed to obtain a good surgical field, including the left descending aorta via a right thoracotomy, and the lesion was anatomically repaired by resection and end-to-end anastomosis.

[CASE STUDIES] Self-Expanding Bifurcation Stent for Malignant Esophagotracheobronchial Fistula

Lindenmann, Neuboeck, Anegg, Matzi, Maier, Smolle-Juettner — 2009-06-10

A 60-year-old man with esophageal carcinoma in the upper 3rd underwent palliative treatment including photodynamic therapy, brachytherapy, external beam irradiation, and esophageal stenting. He developed a symptomatic malignant esophagotracheo-bronchial fistula that could not be closed by telescope-stenting in the esophagus. Implantation of a self-expanding, covered metal, tracheal bifurcation stent by flexible bronchoscopy resulted in immediate closure of the fistula with an uneventful recovery.

[CASE STUDIES] Left Anterior Descending Coronary Aneurysm

Lloyd, Weiss, Vricella — 2009-06-10

A 19-year-old man presented with gradual onset of retrosternal chest pain and hemodynamic instability. Echocardiography and computed tomography showed substantial anterior and posterior pericardial effusion with tamponade. At surgery, a 3-cm ruptured aneurysm of the left anterior descending coronary artery was identified. It was successfully bypassed using a saphenous vein graft anastomosed to the ascending aorta.

[CASE STUDIES] Pulmonary Angiosarcoma Presenting as Spontaneous Recurrent Hemothorax

Campione, Forte, Luzzi, Comino, Gorla, Terzi — 2009-06-10

An incidental diagnosis of pulmonary angiosarcoma was made after surgical exploration for repeated episodes of bleeding in an 85-year-old woman. Spontaneous hemothorax is uncommon and deserves detailed investigation.

[HOW TO DO IT] Modified Muscle-Sparing High Approach to the Thoracoabdominal Aorta

Belov, Stepanenko, Gens, Savichev, Komarov — 2009-06-10

A modified muscle-sparing high approach to the thoracoabdominal aorta is described, which improves surgical access for thoracoabdominal aortic aneurysm repair. Since 2000, 16 patients with type I and II thoracoabdominal aortic aneurysms have undergone aortic graft replacement using this approach via the 3^rd intercostal space. There were no hospital deaths. Three (18.8%) patients had severe postoperative pain requiring prolonged analgesia. This approach is a good alternative to the standard approach via the 6^th intercostal space.

[INVITED REVIEW] Cellular Cardiomyoplasty: What Have We Learned?

Kao, Browder, Li — 2009-06-10

Restoring blood flow, improving perfusion, reducing clinical symptoms, and augmenting ventricular function are the goals after acute myocardial infarction. Other than cardiac transplantation, no standard clinical procedure is available to restore damaged myocardium. Since we first reported cellular cardiomyoplasty in 1989, successful outcomes have been confirmed by experimental and clinical studies, but definitive long-term efficacy requires large-scale placebo-controlled double-blind randomized trials. On meta-analysis, stem cell-treated groups had significantly improved left ventricular ejection fraction, reduced infarct scar size, and decreased left ventricular end-systolic volume. Fewer myocardial infarctions, deaths, readmissions for heart failure, and repeat revascularizations were additional benefits. Encouraging clinical findings have been reported using satellite or bone marrow stem cells, but understanding of the benefit mechanisms demands additional studies. Adult mammalian ventricular myocardium lacks adequate regeneration capability, and cellular cardiomyoplasty offers a new way to overcome this; the poor retention and engraftment rate and high apoptotic rate of the implanted stem cells limit outcomes. The ideal type and number of cells, optimal timing of cell therapy, and ideal cell delivery method depend on determining the beneficial mechanisms. Cellular cardiomyoplasty has progressed rapidly in the last decade. A critical review may help us to better plan the future direction.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Constrictive Pericarditis with Constrictive Epicarditis

Lindblom, Nyman, Vedin — 2009-06-10

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Left Anomalous Pulmonary Vein Connection: the Role of Magnetic Resonance Imaging

Contrafouris, Chatzis, Giannopoulos, Danias, Sarris — 2009-06-10

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Spontaneous Resolution of Mediastinal Mass of Uncertain Etiology

Narayan, Thomas, Rajnish, Kornaszewska — 2009-06-10

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Computed Tomography Finding Mimicking Aortic Dissection After Cabrol Procedure

Kruser, Osaki, Kohmoto, Chopra — 2009-06-10

[LETTER TO THE EDITOR] The Issue of Entry Closure and Aortic Tailoring in Type B Aortic Dissection

Belov, Stepanenko, Gens, Savichev — 2009-06-10

[LETTER TO THE EDITOR] Bicuspidized Pulmonary Homograft: an Old Technique but Still a Valuable Option

Santini, Telesca, Faggian, Mazzucco — 2009-06-10

[LETTER TO THE EDITOR] The Nephroscope Used for Emergency Therapeutic Bronchoscopy

Chakravarthy, Krishnamoorthy, Rangarajan, Rajeev, Belur — 2009-06-10