Asian Cardiovascular and Thoracic Annals recent issues

[ELECTRONIC CASE STUDIES] Intimal Sarcoma of Aortic Arch Treated with Proton Therapy Following Surgery

Ishigami, Suzuki, Takahashi, Neyatani, Bashar, Kazui — 2008-04-01

Management of a rare case of intimal sarcoma of the aortic arch is reported, which was diagnosed unexpectedly after total arch replacement for pseudoaneurysm. The prognosis for this condition is poor, with death usually within a few months from diagnosis. The newly developed proton-beam radiation therapy was applied to treat a local recurrence of the sarcoma following surgery. Positron-emission tomography/computed tomography revealed complete remission of the lesion.

[ELECTRONIC CASE STUDIES] Mycotic Pseudoaneurysm of the Ascending Aorta at Site of Aortic Cannulation

Gabbieri, Dohmen, Linneweber, Lembcke, von Heymann, Konertz — 2008-04-01

Reoperation for pseudoaneurysm of the ascending aorta presents a surgical challenge. Instituting femorofemoral bypass and establishing hypothermic circulatory arrest is a well-known strategy, although not free from complications. We report a case of mycotic pseudoaneurysm after coronary artery bypass in a 53-year-old man, at the site of previous aortic cannulation, and review the surgical strategies proposed to manage this pathologic entity.

[ELECTRONIC CASE STUDIES] Double Outlet Right Ventricle with Anomalous Left Pulmonary Artery

Bockeria, Makhachev, Sobolev, Plakhova, Gorbachevsky, Zaets — 2008-04-01

We describe a rare case of anomalous origin of the left pulmonary artery from the ascending aorta with concomitant double-outlet right ventricle in a 2-year-old boy. He underwent successful 2-stage surgical treatment with transluminal balloon pulmonary valvuloplasty, followed by complete repair. A follow-up examination at 4 years after the operation showed good results.

[ELECTRONIC CASE STUDIES] Chylous Pericardial Effusion after Aortic Valve Replacement

Chaloob, Brown, Stuklis — 2008-04-01

Chylous pericardial effusion after open-heart surgery is a rare complication. We report a case of chylous pericardial effusion following aortic valve replacement, which presented as cardiac tamponade, and its subsequent management.

[EDITORIAL] From Vision to Mission in Myocardial Restoration

Kofidis, Lee — 2008-04-01

[ORIGINAL CONTRIBUTIONS] Procedural Outcome and Midterm Result of Carotid Stenting in High-Risk Patients

Kojuri, Ostovan, Zamiri, Zolghadr Asli, Bani Hashemi, Borhani Haghighi — 2008-04-01

Carotid endarterectomy is the standard treatment for carotid stenosis, but carotid artery stenting has emerged as a potential alternative. Elective carotid artery stenting was performed in 42 patients aged 42 to 79 years (mean, 67.05 ± 8.67 years) after ultrasonography, computed tomography, magnetic resonance angiography and a neurological evaluation. There was bilateral carotid stenosis in 23 patients (55%), with > 90% stenosis in 18 vessels. All patients had significant associated coronary lesions. An emboli protection device and self-expanding stents were used. One year later, the patients were evaluated by Doppler sonography and selective angiography. Technical success was achieved in all procedures. During follow-up, 1 (2.4%) patient died from myocardial infarction, 1 underwent coronary artery bypass and 14 (40%) had minor complaints including occasional dizziness. No other neurological events were noted. Restenosis was found in one case, but selective angiography ruled out a significant lesion. One patient suffered embolization, but recovered completely within 24 hours. In 7 (17%) patients with type C arch interruption and a tortuous carotid course, stenting was successful and they had no embolization or restenosis. Carotid artery stenting is recommended in high-risk patients.

[ORIGINAL CONTRIBUTIONS] Cardiac Troponin I vs EuroSCORE: Myocardial Infarction and Hospital Mortality

Simon, Capuano, Roscitano, Benedetto, Comito, Sinatra — 2008-04-01

Perioperative myocardial infarction is the most common cause of morbidity and mortality in cardiac surgery. It occurs in 8% to 35% of patients. The primary aim of this prospective study was to determine the level of cardiac troponin I that indicates perioperative myocardial infarction in patients undergoing coronary artery bypass. A secondary goal was to establish the best independent predictor of hospital death. There were 180 consecutive patients undergoing isolated coronary artery bypass surgery enrolled in this study. Values of cardiac troponin I > 12.9 ng·mL^–1 at 8 hours postoperatively predicted perioperative myocardial infarction with a sensitivity of 100% and a specificity of 93.2%. Compared to patients who survived, those who suffered hospital death were significantly older (74 ± 7 vs 63 ± 10 years), had significantly higher levels of cardiac troponin I at 24 hours (9 ± 17 vs 27.3 ± 16 ng·mL^–1) and 48 hours (6.9 ± 19 vs 30.3 ± 24 ng·mL^–1) postoperatively, and a significantly higher EuroSCORE (9 ± 2 vs 4 ± 3). At 8 hours postoperatively, cardiac troponin I led to an earlier diagnosis of perioperative myocardial infarction, while EuroSCORE was the strongest independent predictor of hospital death.

[ORIGINAL CONTRIBUTIONS] Differentiation of Ischemic and Dilated Cardiomyopathy on Electrocardiograms

Aghasadeghi, Aslani — 2008-04-01

Differentiating coronary artery disease with left ventricular dysfunction from dilated cardiomyopathy is important prognostically and therapeutically. To provide a diagnostic algorithm to distinguish these conditions using a standard 12-lead electrocardiogram, all 105 patients with left ventricular ejection fraction < 50% who underwent angiography between January 2004 and December 2006 were studied prospectively. Coronary artery disease was defined as ≥ 50% stenosis of the left main coronary artery or ≥ 70% stenosis of 1 or more of the 3 major epicardial arteries. Normal coronary angiography findings with left ventricular ejection fraction < 50% was defined as dilated cardiomyopathy. The most specific finding for differentiation of these diseases was pathologic Q waves in lead II, aVF, V3 or V4. The most sensitive parameter was a ratio ≥ 5 of R-wave amplitudes in lead V6 and lead III (94% sensitive). The 12-lead electrocardiogram provides a useful noninvasive method for differentiation of dilated cardiomyopathy from coronary artery disease with left ventricular systolic dysfunction.

[ORIGINAL CONTRIBUTIONS] Valvuloplasty in the Treatment of Rheumatic Tricuspid Disease

Pande, Agarwal, Majumdar, Kapoor, Kale, Kundu — 2008-04-01

Organic involvement of the tricuspid valve is uncommon. Valve repair is preferred over replacement as it results in a low gradient across the valve and obviates the risk of prosthesis-related complications. From October 2002 to October 2004, 37 patients who required tricuspid valve repair for organic involvement were included in this study. They were divided into 2 groups depending on the surgical procedure for valve repair: 20 patients in group 1 had tricuspid commissurotomy and De Vega annuloplasty; 17 in group 2 had tricuspid commissurotomy only. There were significant reductions in peak and mean tricuspid gradients and right ventricular systolic pressure in both groups. Annular shortening was similar in both groups (median, 23% in group 1, 21% in group 2), but the ratio of the tricuspid regurgitation jet area to right atrial area was greater in group 2 (median, 0.40 in group 2, 0.19 in group 1). There was no postoperative death. We recommend supporting the tricuspid annulus with annuloplasty in patients with organic tricuspid valve disease and no dilatation of the annulus, if annular shortening is < 30%.

[ORIGINAL CONTRIBUTIONS] Abscess of Residual Lobe After Pulmonary Resection for Lung Cancer

Ligabue, Voltolini, Ghiribelli, Luzzi, Rapicetta, Gotti — 2008-04-01

Abscess of the residual lobe after lobectomy is a rare but potentially lethal complication. Between January 1975 and December 2006, 1,460 patients underwent elective pulmonary lobectomy for non-small-cell lung cancer at our institution. Abscess of the residual lung parenchyma occurred in 5 (0.3%) cases (4 bilobectomies and 1 lobectomy). Postoperative chest radiography showed incomplete expansion and consolidation of residual lung parenchyma. Flexible bronchoscopy revealed persistent bronchial occlusion from purulent secretions and/or bronchial collapse. Computed tomography in 3 patients demonstrated lung abscess foci. Surgical treatment included completion right pneumonectomy in 3 patients and a middle lobectomy in one. Complications after repeat thoracotomy comprised contralateral pneumonia and sepsis in 1 patient. Residual lobar abscess after lobectomy should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy and bronchoscopy. Computed tomography is mandatory for early diagnosis. Surgical resection of the affected lobe is recommended.

[ORIGINAL CONTRIBUTIONS] Survival after Surgery with Cardiopulmonary Bypass in Low Weight Patients

Miyamoto, Sinzobahamvya, Photiadis, Brecher, Asfour — 2008-04-01

To evaluate risk factors for hospital death in patients weighing < 2.5 kg undergoing open-heart surgery, records of 34 consecutive low-weight patients operated on between December 1997 and November 2004 were reviewed. Mean weight was 2.152 ± 0.237 kg (range, 1.600 to 2.460 kg). Biventricular repair was achieved in 28 patients. The most frequent procedures were the arterial switch operation in 9 children, ventricular septal defect closure in 6, repair of total anomalous pulmonary venous connection in 5 and truncus arteriosus repair in 5. There were 8 early deaths. Mortality was strongly associated with the Comprehensive Aristotle Complexity Score: mortality was low (2/27; 7.4%) with a score < 19, and high (6/7; 85.7%) with a score ≥ 19. Higher mortality was encountered after univentricular repair (4/6; 67%). Hyperlactatemia at the end of cardiopulmonary bypass was also associated with poor survival. A Comprehensive Aristotle score < 19 was the strongest predictor of survival in low-weight patients undergoing open-heart surgery. Biventricular repair, when feasible, should be promoted to improve outcome.

[ORIGINAL CONTRIBUTIONS] Management of Malignant Pleural Effusion Associated with Trapped Lung Syndrome

Qureshi, Collinson, Powell, Froeschle, Berrisford — 2008-04-01

Management of recurrent malignant pleural effusion associated with trapped lung syndrome remains problematic. An alternative treatment using a pleural catheter has been advocated. Between August 1999 and August 2002, 127 patients underwent thoracoscopy for malignant pleural effusion. Of these, 52 (41%) with trapped lung were managed by insertion of a pleural catheter. Mean age was 66 years (range, 42–89 years). The most frequent diagnosis was breast cancer. Spontaneous pleurodesis (drainage < 10 mL) occurred in 25 (48%) patients whose catheter was removed after 30 to 255 days (mean, 93.8 days). Symptomatic relief was achieved in 49 (94%) patients. Mean dyspnea score improved significantly from 3.0 to 1.9. Complications comprised catheter blockage, surgical emphysema, cellulitis, and loculated effusion in 2 patients each. Mean length of hospital stay was 3 days (range, 1–16 days). Median survival was 126 days (range, 10–175 days). We conclude that long-term placement of a pleural catheter provides effective palliation for malignant pleural effusion associated with trapped lung syndrome.

[ORIGINAL CONTRIBUTIONS] Potential Role of Adipocytokine Leptin in Acute Coronary Syndrome

Dubey, Zeng, Wang, Liu — 2008-04-01

By activating immune cells or a direct action on the vascular wall, leptin may affect the initiation and progression of atherosclerosis. We investigated whether plasma leptin concentration is associated with coronary artery disease, with particular focus on the relationship between plasma leptin and the development of an acute coronary syndrome. Plasma leptin, interleukin-6 and high-sensitivity C-reactive protein were measured in 34 patients with acute coronary syndrome and 21 with stable angina. Their results were compared with those of 21 normal controls. Plasma leptin levels were significantly higher in the acute coronary syndrome group (13.36 ± 5.02 ng·mL^–1) compared to the stable angina group (8.97 ± 4.06 ng·mL^–1) or normal controls (5.14 ± 2.75 ng·mL^–1). Interleukin-6 and high-sensitivity C-reactive protein were also higher in the acute coronary syndrome group, and leptin correlated positively with interleukin-6 and high-sensitivity C-reactive protein. These findings suggest that plasma leptin levels may be a useful marker of systemic inflammation, and measurement of plasma leptin may be helpful in assessing the risk of developing coronary heart disease.

[ORIGINAL CONTRIBUTIONS] Valve Repair in Rheumatic Heart Disease in Pediatric Age Group

Reddy, Dharmapuram, Swain, Ramdoss, Raghavan, Murthy — 2008-04-01

Valve repair in children is technically demanding but more desirable than valve replacement. From April 2004 to September 2005, 1 boy and 8 girls with rheumatic heart disease, aged 2–13 years (median, 9 years), underwent valve repair for isolated mitral regurgitation in 5, combined mitral and aortic regurgitation in 2, mitral stenosis in 1, and mitral regurgitation associated with atrial septal defect in 1. Chordal shortening in 7, annular plication in 6, commissurotomy in 1, reconstruction of commissural leaflets in 7 were performed for mitral valve disease. Plication and reattachment of the aortic cusps was carried out in 2 patients. Annuloplasty rings were not used. All patients survived the operation, 8 had trivial or mild residual mitral regurgitation, and 1 had trivial aortic regurgitation. Mean left atrial pressure decreased from 14 to 7 mm Hg postoperatively. During follow-up of 3–18 months, all children were asymptomatic and enjoyed normal activity. None required reoperation. In addition to chordal shortening and annular plication, reconstruction of the commissural leaflets is considered the most important aspect of valve repair. It can be achieved without annuloplasty rings, giving good early and midterm results.

[ORIGINAL CONTRIBUTIONS] Endoscopic vs Conventional Vein Harvesting: a Prospective Analysis

Vaidyanathan, Sankar, Cherian — 2008-04-01

Minimally invasive vein harvesting is associated with better leg wound healing and a lower incidence of wound infections. We analyzed our experience in 2 prospectively enrolled groups of non-randomized patients undergoing elective coronary artery bypass grafting. Group 1 was 81 patients who had endoscopic vein harvesting; group 2 was 80 who had conventional open vein harvesting. The time taken for endoscopic harvest (skin incision to skin closure) was significantly less than that for open harvest (51.07 vs 75.94 min). The number of cases to reach a plateau on the learning curve for endoscopic vein harvest was 20 for 2 lengths of vein and 35 for 3 lengths of vein. Significantly more suture repairs per vein were required in group 1 (1.32) than group 2 (0.38). The incidence of wound infection was 1.2% in group 1 vs 8.8% in group 2. Endoscopic vein harvesting is not difficult to learn and it should be preferred over open vein harvest, given its benefits in wound healing.

[ORIGINAL CONTRIBUTIONS] Solitary Benign Fibrous Tumors of the Pleura

Regal, Al Rubaish, Al Ghoneimy, Hammad — 2008-04-01

Solitary benign fibrous tumors of the pleura are very rare. Seven patients (mean age, 52 years) who presented between 1995 and 2005 were studied retrospectively. They had nonspecific chest symptoms and no history of asbestos exposure or smoking. Chest radiography showed a large opacity occupying most of the affected hemithorax, with clear costophrenic angles. Computed tomography of the chest showed a large well-delineated heterogeneous mass directly related to the lateral chest wall. Needle biopsy suggested the benign nature of the lesion. Surgery was performed through a posterolateral thoracotomy. Five tumors arose from visceral pleura, and 2 from parietal pleura. The mean tumor diameter was 7.5 cm (range, 8–14 cm). Complete surgical excision was carried out in all cases. Histopathology and immunohistochemical staining confirmed the benign nature of the tumors. There was no mortality or major complication. The mean follow-up period was 4 years (range, 1–10 years). All patients remained tumor-free during follow-up. Wide local excision, including pulmonary and pleural resection, is recommended as the best therapeutic option.

[ORIGINAL CONTRIBUTIONS] Intramyocardial Angiogenic Cell Precursor Injection for Cardiomyopathy

Arom, Ruengsakulrach, Jotisakulratana — 2008-04-01

Stem cell therapy for heart failure is a rapidly progressing field. The objective of this study was to assess the safety, and short-term results of thoracoscopic direct injection of angiogenic cell precursors into patients with endstage cardiomyopathy. Cells were obtained from the patient’s own blood, avoiding immunological concerns. The number of cells prior to injection was 29.1 ± 18.9 x10⁶. Forty-one patients with cardiomyopathy (mean age, 58.5 ± 14.3 years) underwent stem cell injection; 21 had dilated cardiomyopathy and 20 had ischemic cardiomyopathy. Overall ejection fraction improved significantly by 4.8% ± 7.5% at 149 ± 98 days postoperatively. It increased from 25.9% ± 8.6% to 28.7% ± 9.8% in dilated cardiomyopathy, and from 26.6% ± 5.8% to 33.6% ± 7.8% in ischemic cardiomyopathy. New York Heart Association functional class was significantly better at 2 months in both groups. It was concluded that thoracoscopic intramyocardial angiogenic cell precursor injection is feasible and safe in patients with cardiomyopathy. The early results are good, and phase II trials are in progress.

[CASE STUDIES] Late Presentation of Cor Triatriatum with Persistent Levoatrial Cardinal Vein

Feltri, Crawley, Peart, Pozzi, Corno — 2008-04-01

An asymptomatic 10-year-old boy presented with reduced exercise tolerance and an echocardiographic diagnosis of cor triatriatum. Transthoracic and transesophageal echocardiography failed to reveal the persistent levoatrial cardinal vein discovered at surgery. In patients with late presentation of cor triatriatum with severe mitral inflow obstruction and a small patent foramen ovale, an alternative communication between the posterior collecting chamber and the systemic venous circulation should be sought with alternative imaging techniques.

[CASE STUDIES] Fibrin Sealant for Left Ventricular Rupture after Mitral Valve Replacement

Garcia-Villarreal, Casillas-Covarrubias — 2008-04-01

Despite safer surgical procedures, left ventricular rupture remains a rare but potentially lethal complication of mitral valve replacement. The use of fibrin sealant has substantially improved the outcome of many difficult bleeding episodes after cardiac surgery. We describe a case of left ventricular rupture successfully treated with fibrin sealant combined with external Teflon-pledgeted sutures.

[CASE STUDIES] Angiosarcoma Presenting as Syncope

Nayar, Nayar, Cherian — 2008-04-01

A 31-year-old lady presented with anemia and syncope. Echocardiography revealed massive pericardial effusion with a right atrial mass. Transesophageal echocardiography, computed tomography and magnetic resonance imaging scans confirmed presence of a right atrial mass. Histopathology revealed a high grade angiosarcoma. Complete resection was done and the patient was referred to an oncology unit for further management. After three months the patient had extensive metastasis and succumbed to the disease. This case report highlights the clinical presentation, rapid and aggressive course of cardiac angiosarcomas.

[CASE STUDIES] Hancock Valve Deterioration in Tricuspid Position for Ebstein's Anomaly

Sughimoto, Nakano, Gomi, Nakatani, Nakamura, Sato — 2008-04-01

A 65-year-old woman with a Hancock valve implanted 25 years earlier for Ebstein’s anomaly underwent a successful second tricuspid valve replacement with a Mosaic valve because of significant tricuspid regurgitation. At surgery, it was found that the Hancock valve had a cylinder-shaped hole and had lost its entire structure. Tricuspid valve dysfunction may be tolerated for a long time before surgery is contemplated.

[HOW TO DO IT] Left Heart Pump-Assisted Beating Heart Coronary Surgery in High-Risk Patients

Pepino, Oliviero, Petteruti, di Tommaso, Monaco, Stassano — 2008-04-01

A simple technique of left ventricular assistance, offering the advantages of both cardiopulmonary bypass and off-pump revascularization, was adopted for high-risk patients. It was used in 56 patients with critical left main stenosis and occluded right coronary artery, severely reduced ejection fraction and/or unstable angina. All patients underwent complete and successful myocardial revascularization (3.4 grafts per patient). Weaning from the pump was uncomplicated, and none required conversion to full cardiopulmonary bypass.

[HOW TO DO IT] Easy Technique for Placing Anchoring Sutures for Aortic Root Reimplantation

Ogino, Minatoya, Matsuda, Sasaki — 2008-04-01

In the aortic valve-sparing reimplantation technique, insertion of the anchoring sutures beneath the valve is a crucial but difficult step because the spared aortic cusps obscure the field of view. We present a novel and easy method of placing these anchoring stitches with good exposure of the subvalvular tissue.

[REVIEW PAPER] Current Status of Off-pump Coronary Artery Bypass Surgery

Raja, Dreyfus — 2008-04-01

The expanding indications for angioplasty coupled with the successful short and mid-term results of randomized controlled trials of drug-eluting stents have already had an unquestionable impact on the practice of coronary revascularization operations. However, coronary artery bypass grafting remains a major mode of therapy for coronary artery disease. It is likely that surgery will continue to be preferred for more complex subsets and that surgeons will have to continue to maintain good results in patients with more complex problems. Concerns regarding morbidity associated with conventional surgical myocardial revascularization on cardiopulmonary bypass have led to a resurgence of interest in off-pump bypass surgery during the last decade, with the expectation that it would be safer if cardiopulmonary bypass could be avoided. This review summarizes the impact of off-pump bypass surgery in reducing the morbidity and mortality associated with conventional coronary artery bypass on cardiopulmonary bypass by evaluating the current best-available evidence from randomized controlled trials and meta-analyses comparing off-pump surgery with conventional bypass grafting.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Postinfarction Giant Pseudoaneurysm in the Inferior Wall of the Left Ventricle

Ogawa, Doi, Koushi, Itoh, Nishimura, Yaku — 2008-04-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] A Large Horse Shoe-shaped Leiomyoma of the Thoracic Esophagus

Dahabreh, Dountsis, Vasilikos, Zisis — 2008-04-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Right Ventricular Perforation Induced by Trans Venous Pacing Lead

Sai Krishna, Ramesh Babu, Ram Mohan, Panigrahi, Naresh Kumar — 2008-04-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Bilateral Common Carotid Artery Aneurysm in Takayasu's Arteritis

Tochii, Ando, Yamashita, Hattori, Hoshino, Akita — 2008-04-01

[EDITORIAL] Time to Intervention During Cardiac Interventions. Are We Forgetting a Confounder?

Shuhaiber, Reston — 2008-02-01

[ELECTRONIC CASE STUDIES] Left Ventricular-Right Atrial Communication Complicated by Aortic Regurgitation

Okamura, Nagase, Mitsui, Shibairi — 2008-02-01

We report a case of left ventricular-right atrial communication complicated by aortic valve incompetence in a 29-year-old man. The patient had a history of heart murmur during childhood. There were no clinical signs of infection. We performed plication of the aortic valve and patch closure of the left ventricular-right atrial communication under cardiopulmonary bypass. The patient improved immediately after the operation.

[ORIGINAL CONTRIBUTIONS] Di(2-ethylhexyl) Phthalate Exposure During Cardiopulmonary Bypass

Takahashi, Shibata, Sasaki, Fujii, Bito, Suehiro — 2008-02-01

Di(2-ethylhexyl) phthalate is an excellent plasticizer for polyvinyl chloride but a known endocrine disrupting chemical. To investigate whether tubing containing no diethylhexyl phthalate reduces the overall extraction of this plasticizer during cardiopulmonary bypass, 16 patients undergoing coronary artery bypass grafting were randomly divided into 2 groups of 8 each. Group A had tubing containing diethylhexyl phthalate in the circuit, and group B had no diethylhexyl phthalate in the tubing. The plasma diethylhexyl phthalate level at the end of cardiopulmonary bypass was significantly increased compared to before anesthesia in both groups (group A: 103 ± 60 to 2,094 ± 1,046 ng·mL^–1; group B: 135 ± 60 to 472 ± 141 ng·mL^–1), and it was significantly higher in group A than group B. This study demonstrates that using tubing free from diethylhexyl phthalate significantly reduces the release of this agent during cardiopulmonary bypass, which may minimize exposure to diethylhexyl phthalate.

[ELECTRONIC CASE STUDIES] A Rare Cause of Dissection of Ascending Aorta after Aortic Valve Replacement

Masuda, Murakami, Shishido, Kuinose — 2008-02-01

We present a 78-year-old man who developed Stanford type A aortic dissection seven years after aortic valve replacement. At the previous operation, the diameter of the ascending aorta was 40 mm. Three years later, computed tomography revealed the diameter to have expanded to 50 mm. Four years later, the patient developed aortic dissection with entry at the ascending aorta, and a graft replacement was performed.

[ORIGINAL CONTRIBUTIONS] Neonatal Blalock-Taussig Shunt: Technical Aspects and Postoperative Management

Swain, Dharmapuram, Reddy, Ramdoss, Raghavan, Kona — 2008-02-01

A systemic-pulmonary artery shunt in neonates with decreased pulmonary blood flow is technically demanding. We describe our surgical technique, postoperative management, and results in 19 neonates who underwent a modified Blalock-Taussig shunt between April 2003 and March 2006. Prostaglandin infusion was required in 8 patients who were critically cyanosed, and 5 were on inotropic support preoperatively. A 3.5 or 4.0-mm polytetrafluoroethylene graft was anastomosed with 8/0 polypropylene suture. Postoperatively, systemic pressure was kept slightly higher than normal, and heparin was started early. One patient required revision of the shunt, and one was reexplored for bleeding. There were 2 hospital deaths (mortality, 11%) in patients with preoperative hemodynamic instability. The mean follow-up period was 12 months, with no late postoperative shunt blockage or death. Meticulous surgical technique and judicious use of heparin and inotropic agents improved the outcome and reduced the incidence of shunt blockage and reexploration for bleeding.

[ELECTRONIC CASE STUDIES] Leiomyosarcoma of the Left Atrium

Canadyova, Setina, Smetanova, Mokracek — 2008-02-01

A 41-year-old woman underwent successful excision of a leiomyosarcoma of the left atrium. The preferential left atrial location and frequent myxoid appearance of leiomyosarcoma of the heart make it particularly difficult to distinguish preoperatively from atrial myxoma. Early diagnosis and aggressive surgical intervention with chemotherapy may improve the prognosis.

[ELECTRONIC CASE STUDIES] Unforeseen Scenario in Removal of a Tracheobronchial Foreign Body

Turut, Gulhan, Tastepe — 2008-02-01

Tracheobronchial foreign body aspirations occur most commonly in children but under certain circumstances, are seen in adults. Majority of patients can succesfully be managed via bronchoscopy. However, unexpected complications may develop during the removal procedure. We describe an unusual complication encountered during the removal procedure of an inhaled scarf pin in the trachea of a 23-year old woman. Crucial removal procedure is implicated and awareness of this rare complication is emphasized.

[ORIGINAL CONTRIBUTIONS] Repair of Aortic Coarctation in Adults: the Fate of Hypertension

Hashemzadeh, Hashemzadeh, Kakaei — 2008-02-01

The benefit of coarctation repair on the resolution of systolic hypertension in adults has been questioned. In this retrospective study, hypertension was assessed in 38 adults (22 men, 16 women; mean age, 25.6 ± 6.9 years; range, 16–39 years) who underwent coarctation repair between 1996 and 2006. Thirty patients had preoperative hypertension (mean systolic pressure, 158.3±18.6; range 140–200 mm Hg). At preoperative catheterization, the peak mean systolic gradient across the coarctation was 70.6 ± 21.2 mm Hg (range, 38–120 mm Hg). Operative procedures were resection and end-to-end anastomosis (11 patients), patch aortoplasty (24) and resection with interposition of a Dacron tube graft (3). The patients were followed up for 2–90 months (mean, 37 ± 23 months). Of the 30 patients with preoperative hypertension, 25 (83%) were normotensive at the last follow-up. The mean postoperative systolic blood pressure was significantly lower than the preoperative level. More than half of the patients (58%) were still taking antihypertensive medication. Surgical repair of coarctation of the aorta in adults can lead to regression of systolic hypertension and a decreased requirement for antihypertensive medication.

[ORIGINAL CONTRIBUTIONS] Off-Pump Coronary Artery Bypass Grafting in Left Ventricular Dysfunction

Masoumi, Saidi, Rostami, Sepahi, Roushani — 2008-02-01

Between August 2004 and May 2006, 124 patients undergoing coronary artery bypass grafting with ejection fractions ≤ 35% were randomly assigned to off-pump or conventional procedures. Preoperative characteristics were the same in both groups, except for age and degree of mitral regurgitation. Off-pump coronary artery grafting was carried out using a tissue stabilizer and a single-suture technique; conventional coronary bypass employed cardiopulmonary bypass, moderate hypothermia, and antegrade-retrograde cold blood cardioplegic arrest. There were significantly fewer vessels grafted (3.09 ± 0.41) in the off-pump group than in those who had a conventional procedure (3.42 ± 0.86). The rates of mortality, morbidity, balloon pump support, inotropic usage, gastrointestinal bleeding, renal dysfunction, reintubation, as well as intensive care and hospital stay, were significantly lower in the off-pump group. The incidence of perioperative myocardial infarction did not differ significantly between groups. The results of this study indicate that beating-heart coronary bypass is safe and effective in patients with left ventricular dysfunction.

[ORIGINAL CONTRIBUTIONS] Preoperative Autologous Blood Donation for Cardiac Surgery in Children

Hibino, Nagashima, Sato, Hori, Ishitoya, Tomino — 2008-02-01

Preoperative autologous blood donation has been shown to reduce homologous blood transfusion in cardiac operations, but there have been few reports of its use in children. Of 50 children aged 6 months to 5 years (weight, 6.1–14.8 kg) undergoing primary cardiac surgery for simple anomalies, 23 donated autologous blood before surgery, the other 27 were age and weight-matched controls. Two donations of 10 mL·kg^–1 each were collected via the femoral vein under mild general anesthesia 12 ± 5 and 19 ± 7 days preoperatively. No complications related to autologous blood collection were observed. Homologous blood use was significantly less in the group given autologous blood (4.3%) compared to the control group (44.4%). There was no significant difference in hemoglobin levels between groups before, during or after the operation. Preoperative autologous blood donation appears to be safe and effective in reducing homologous transfusions, even in children weighing less than 15 kg.

[ORIGINAL CONTRIBUTIONS] Long-Term Results of Isolated Tricuspid Valve Replacement

Tokunaga, Masuda, Shiose, Tomita, Morita, Tominaga — 2008-02-01

The long-term outcome of isolated tricuspid valve replacement is unclear because this procedure is rare and usually performed in combination with replacement of other valves. The results of all 31 isolated tricuspid valve replacements carried out in 23 patients in Kyushu University Hospital between 1975 and 2004 were retrospectively reviewed. A bioprosthesis was used in 27 cases and a mechanical valve in 4. There were 2 operative deaths and 4 late deaths. One patient with a mechanical prosthesis needed redo tricuspid valve replacement due to valve thrombosis 6 months after surgery. The mean cardiothoracic ratio and functional class improved significantly postoperatively. At 15 years after tricuspid valve replacement, actuarial survival was 75.6% and freedom from valve-related events was 84.9%. For bioprostheses, freedom from structural valve deterioration at 5, 10 and 15 years was 95.2%, 95.2% and 85.7%, respectively. The long-term results of tricuspid valve replacement are considered satisfactory, and a bioprosthesis can be recommended due to its good outcome and no need for anticoagulation. We should not wait until the development of endstage cardiac impairment before carrying out tricuspid valve surgery.

[ORIGINAL CONTRIBUTIONS] Coronary Artery Fistulas in Pulmonary Atresia and Ventricular Septal Defect

Collison, Dagar, Kaushal, Radhakrishanan, Shrivastava, Iyer — 2008-02-01

Pulmonary atresia with ventricular septal defect is an anomaly with highly variable anatomy. Rarely, a coronary artery-to-pulmonary artery fistula may contribute to pulmonary blood flow. Since 1996, we have treated 4 patients with coronary-pulmonary fistula associated with pulmonary atresia and ventricular septal defect. Two fistulas originated from the left coronary, one from the right coronary, and one from a right-sided solitary coronary system. All terminated in the main pulmonary artery, which was adequate in all cases. The fistulas were managed by direct internal closure. Total intracardiac repair was then accomplished in all patients at the same sitting. There was one death. In children with favorable anatomy, direct closure of the fistula from the pulmonary artery is adequate and allows single-stage intracardiac repair.

[ORIGINAL CONTRIBUTIONS] Is Treatment of Acute Type A Aortic Dissection in Septuagenarians Justifiable?

Shrestha, Khaladj, Haverich, Hagl — 2008-02-01

This study was undertaken to analyze the risk of mortality and neurological complications after treatment of acute type A aortic dissection in septuagenarians. From 1996 through 2002, 24 patients > 70 years underwent surgery for acute type A aortic dissection. Their median age was 75 years (range, 71–82 years), and 15 were male. Eleven (46%) had previous neurological events, 22% presented with hemodynamic instability and aortic rupture was found in 7%. Ten had hypothermic circulatory arrest alone, 3 had it in combination with retrograde cerebral perfusion and 11 had selective antegrade cerebral perfusion as an adjunct. The overall survival rate was 71% (17/24). Temporary neurological dysfunction was found in 3 (12.5%), and permanent neurological dysfunction in 9 (37.5%), leading to death in 3. Comparison of mortality rates and neurological outcome showed a marked tendency towards better outcome in patients who had hypothermic circulatory arrest and selective antegrade cerebral perfusion. Surgery for aortic dissections in the elderly can be performed with acceptable mortality, but there is a high rate of neurological complications. Despite the small number of patients, selective antegrade cerebral perfusion seemed to reduce the incidence of neurological events.

[ORIGINAL CONTRIBUTIONS] Mitral Valve Replacement in Severe Pulmonary Arterial Hypertension

Mubeen, Singh, Agarwal, Pillai, Kapoor, Srivastava — 2008-02-01

The immediate postoperative hemodynamics in 43 patients with severe pulmonary arterial hypertension who underwent mitral valve replacement between January 2000 and September 2001 were studied prospectively. The mean age was 30.6 years. There was mitral stenosis in 19 (44.1%), mitral regurgitation in 9 (20.9%), and mixed lesions in 15 (34.9%). In 36 patients (83.7%, group 1) pulmonary arterial pressure was sub-systemic, with a mean of 58.1 mm Hg and pulmonary vascular resistance of 743.4 dyne·s·cm^–5. Seven patients (16.3%, group 2) had supra-systemic pulmonary arterial pressure of 83.2 mm Hg and pulmonary vascular resistance of 1,529 dyne·s·cm^–5. Lung biopsies were taken from the right lower lobe in 24 patients. Operative mortality was 5.5% in group 1 and 28.5% in group 2. After mitral valve replacement, the pulmonary arterial pressure and vascular resistance decreased significantly in group 1. In group 2, pulmonary arterial pressure decreased significantly but pulmonary vascular resistance remained elevated. Pulmonary vascular changes did not progress beyond grade III (Heath-Edwards’ classification). Mitral valve replacement is safe even in the presence of severe pulmonary arterial hypertension as long as pulmonary arterial pressures are below systemic pressures. Lung biopsy did not help in identifying patients with irreversible pulmonary arterial changes.

[ORIGINAL CONTRIBUTIONS] Endoscopic Radial Artery Harvesting: Patient Satisfaction and Complications

Nishida, Kikuchi, Watanabe, Takata, Ito, Kawachi — 2008-02-01

Endoscopic radial artery harvesting was recently introduced to reduce the morbidity associated with conventional open harvesting and improve cosmetic outcomes. From January 2004 through December 2006, 25 radial arteries were harvested endoscopically from 25 patients using the VasoView endoscopic system. Bilateral radial arteries were harvested from 6 patients by both the endoscopic and open techniques, and postoperative patient satisfaction was assessed using a visual analogue scale. Mean harvesting time was 61.9 ± 16.0 min (range, 44–105 min), and mean harvested conduit length was 16.8 ± 2.0 cm (range, 15–19 cm). Objective dorsal thenar numbness remained in 2 patients (8%); none complained of forearm numbness. All patients expressed marked satisfaction with the endoscopic technique and the small incision. Patient satisfaction was significantly higher with the endoscopic technique than with the open technique (visual analogue scale of 9 vs 5). Postoperative angiography revealed occlusion of a graft that had been anastomosed to a small diagonal branch. The overall graft patency was 96.6%. Endoscopic radial artery harvesting can be performed safely with infrequent complications. This method results in excellent patient satisfaction, particularly regarding the cosmetic outcome.

[ORIGINAL CONTRIBUTIONS] Replacement of Right Coronary Leaflet With Bovine Pericardium

Tao, Zeng — 2008-02-01

Bovine pericardium was used to replace the right coronary leaflet to manage aortic insufficiency resulting from ventricular septal defect in 6 patients aged 15 to 34 years. Aortic insufficiency was severe in 5 patients and moderate in one. In all patients, the ventricular septal defect was repaired before aortic valvuloplasty. They were followed up for 5 to 6 months. No mortality was observed. Three patients had relief of aortic insufficiency, 2 had mild residual aortic insufficiency, and one had minor insufficiency not requiring re-operation. Replacement of the right coronary leaflet with bovine pericardium is a promising technique for young patients. The short-term outcomes are encouraging, but longer follow-up is required to assess the durability and function of bovine pericardium in the aortic position.

[ORIGINAL CONTRIBUTIONS] Isolation of ckit-Positive Cardiosphere-Forming Cells from Human Atrial Biopsy

Aghila Rani, Jayakumar, Srinivas, Nair, Kartha — 2008-02-01

There is increasing interest in developing cell-based therapies to regenerate functional muscle and blood vessels in infarcted dysfunctional myocardium, using stem cells resident in the adult heart. The objective of our study was to identify an easy and cost-effective method for the isolation and expansion of human adult cardiac-resident stem cells. The cells were isolated from right atrial biopsy samples obtained from patients with ischemic heart disease, who were undergoing coronary artery bypass grafting. Two different isolation methods, enzymatic and nonenzymatic, were employed. The cell yield and cluster formation were not significantly different with either of the techniques used for cell isolation. The nonenzymatic method is recommended because of its simplicity and lower cost compared to the enzymatic method.

[CASE STUDIES] Endobronchial Sclerosing Hemangioma: A Rare Presentation of a Parenchymal Tumor

Boudaya, Falcoz, Alifano, Camilleri-Broet, Regnard — 2008-02-01

Endobronchial localization of sclerosing hemangioma is extremely rare. Exact localization of lesion at preoperative work-up allows parenchymal-sparing procedures. We report a case of endobronchial sclerosing hemangioma diagnosed preoperatively and treated by lingular-sparing upper lobectomy with nodal dissection.

[CASE STUDIES] Surgical Closure of Adult Patent Ductus Arteriosus Using a Pursestring Suture

Inaba, Higuchi, Koseni, Osawa, Kinoshita — 2008-02-01

A 52-year-old woman with patent ductus arteriosus underwent transpulmonary surgical closure through a median sternotomy. The procedure was performed under cardiopulmonary bypass with normothermia and a beating heart, using transductal balloon occlusion and a pursestring suture around the orifice of the ductus. The use of a pursestring suture allowed minimization of the risk of balloon breakage, obviated the need for profound hypothermia and circulatory arrest, and greatly increased the technical facility of the procedure.

[CASE STUDIES] Multiple Pulmonary Metastases from Benign Pleomorphic Adenoma

Sit, Chui, Wang, Chiu — 2008-02-01

Metastasizing pleomorphic adenoma is a rare condition of metastasis from a histologically benign salivary gland tumor. We report a case of metastasizing pleomorphic adenoma presenting with multiple bilateral lung metastases, and discuss the clinical aspects of this disease.

[CASE STUDIES] Clear-Cut Complete Rupture of Origin of Right Main Bronchus

Mihos, Potaris, Gakidis, Myrianthefs, Baltopoulos — 2008-02-01

Complete rupture of the main bronchus after blunt thoracic trauma is rare. Most patients with blunt traumatic injury to the trachea or bronchus die before arriving at hospital. A 26-year-old man with complete right main bronchus rupture was successfully treated by urgent surgical intervention and postoperative fiberoptic bronchoscopy for bronchial toilet.

[CASE STUDIES] Endovascular Treatment of Gastroduodenal Artery Aneurysm

Chong, Tan, Htoo — 2008-02-01

Gastroduodenal artery aneurysms are rare. Common causes include blunt trauma, pancreatitis, infection, autoimmune disorders, vascular intervention and surgery. We report 2 patients with gastroduodenal artery aneurysms, the first being an idiopathic true aneurysm and the next, a pseudoaneurysm resulting from pancreatitis. Diagnoses were made by computed tomography scans with successful embolization of both patients. Treatment of gastroduodenal artery aneurysms includes surgery, endovascular techniques or observation. Embolization is a feasible option for gastroduodenal artery aneurysms and pseudoaneurysms.

[HOW TO DO IT] Right Coronary Artery Translocation in Tetralogy of Fallot

Luo, Huang, Tang, Li — 2008-02-01

We describe a simple and cost-effective technique to repair anomalous origin of the right coronary artery from the left coronary artery in tetralogy of Fallot. The proximal right coronary artery is re-implanted into the aorta after it is mobilized and transected. This technique avoids the use of conduits in infants or adults with tetralogy of Fallot and anomalous right coronary arteries, and maintains the growth potential of the translocated native coronary artery.

[HOW TO DO IT] Vettath's Blower and Blower/Mister -- A Simple Device for OPCAB Surgery

Vettath, Vellachamy, Talya, Thazhakuni, Moothencheri, Thomas — 2008-02-01

Since the advent of off-pump coronary artery bypass surgery, a blower/mister has been routinely used in cardiac operation theatres. In our setup, in an attempt to reduce the cost of coronary artery bypass grafting by performing off-pump coronary artery bypass, reusable materials have been routinely used.

[HOW TO DO IT] Conduit from Hypoplastic Right Ventricle to Pulmonary Artery in Tricuspid Atresia

Amanullah, Hasan, Kirk — 2008-02-01

Tricuspid atresia with transposition of the great arteries produces single ventricle physiology. Ultimate goals of neonatal palliative operations are to provide optimum anatomic and physiologic conditions for a Fontan procedure. A modification of the Norwood procedure is reported, with an aorto-pulmonary anatomosis, utilizing the hypoplastic right ventricle as the pulmonary outflow conduit, avoiding a left ventriculotomy and preserving its function with excellent recovery. We believe this technique has not been previously published in the English literature.

[REVIEW PAPER] Coronary Heart Disease Service Framework for Revascularization in Pakistan

Elahi, Khan — 2008-02-01

Many centers across the country have used collaborative techniques to identify problems and come up with innovative solutions. Excellent improvements have been made in every aspect of the patient’s journey through the cardiac surgery services, such as decreased length of stay, reduced clinical variation and costs, and improved outcome. We looked at how the cardiac surgical team at our center is helping to improve services for patients undergoing coronary revascularization. Improvements are not just focused on waiting lists or operating rooms but reflect the wider experience of patients and their families.

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Cardiac Computed Tomography of Aortocoronary Bypass in Type A Aortic Dissection

Weininger, Ritter, Hahn, Beissert — 2008-02-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Hemoptysis Due to Aortic Aneurysm at the Site of Coarctation Repair

Amirghofran, Mollazadeh, Kojuri — 2008-02-01

[IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY] Pleural Chondroma

Eryigit, Baran, Kutlu — 2008-02-01

[ELECTRONIC CASE STUDIES] Acute Fatal Post-CABG Low Dose Amiodarone Lung Toxicity

Argyriou, Hountis, Antonopoulos, Mathioudaki — 2007-11-27

Amiodarone is one of the commonly used anti-arrhythmic agents with well-recognized chronic pulmonary toxicity. We present our experience of a patient with a fatal outcome after coronary artery bypass grafting and a short course of amiodarone treatment with a low total cumulative dose for the treatment of postoperative atrial fibrillation. Necropsy revealed diffuse pulmonary damage due to acute amiodarone lung toxicity.

[ELECTRONIC CASE STUDIES] Off-pump Pericardiectomy Using an Ultrasonic Scalpel and a Heart Positioner

Fukumoto, Yamagishi, Doi, Ogawa, Inoue, Yaku — 2007-11-27

The surgical treatment of constrictive pericarditis often requires extensive pericardial dissection under cardiopulmonary bypass. We performed a pericardiectomy in a patient with constrictive pericarditis without cardiopulmonary bypass, with assistance of a sternal retractor and a suction heart positioner. The severely calcified pericardium, which adhered tightly to the epicardium, was dissected with an ultrasonic scalpel. The operation was completed without blood transfusion. There was no malignant arrhythmia.

[ELECTRONIC CASE STUDIES] Papillary Fibroelastoma of the Left Ventricle: Report of Two Cases

Hino, Miyairi, Kitamura, Miura, Kigawa, Fukuda — 2007-11-27

Papillary fibroelastoma is a relatively rare cardiac tumor. We report two cases of papillary fibroelastoma. The first case involved a 45-year-old woman who presented with rheumatic valves and three tumors developing from the papillary muscle and left ventricle. The second case involved a 68-year-old man who was asymptomatic and whose tumor was detected incidentally on echocardiogram. Both cases were treated surgically. An additional 71 cases of papillary fibroelastoma reported in the medical literature in Japan are reviewed.

[ELECTRONIC CASE STUDIES] Combined Coronary Artery Re-operation and Pulmonary Resection for Hemoptysis

Abe, Kajiyama, Ohara, Asaoka, Toyama, Kobayashi — 2007-11-27

We present a 59-year-old woman who underwent combined pulmonary resection for bronchiectasis with massive, recurrent hemoptysis and redo coronary artery bypass. She had previously been hospitalized four times for massive hemoptysis. She had also undergone coronary artery bypass and had symptomatic severe graft disease. We performed simultaneous right middle lobectomy and redo triple bypass. At surgery, lobectomy was performed before heparinization, then redo bypass was performed using on-pump cardiopulmonary bypass. The postoperative course was uneventful.

[EDITORIAL] The Choice of Valve Prosthesis: Are the Guidelines for Everyone?

Al Halees — 2007-11-27

[ORIGINAL CONTRIBUTIONS] Left Ventricular Hypertrophy and Remodeling after Aortic Valve Replacement

Iyem, Sekuri, Tavli, Buket — 2007-11-27

Left ventricular geometric remodeling and regression of hypertrophy were assessed after aortic valve replacement with a mechanical prosthesis in 37 patients with aortic stenosis and 39 with aortic insufficiency, aged 54.2 ± 14.3 and 52.6 ± 16.6 years, respectively. The follow-up period was 2 years. In patients with aortic insufficiency, ejection fraction increased from 54.4 ± 3.5 preoperatively to 59.6 ± 3.4 after 6 months and 61.7 ± 2.7 after 2 years. In patients with aortic stenosis, ejection fraction increased from 56.6 ± 5.1 preoperatively to 63.9 ± 4.4 after 6 months and 71.7 ± 4.1 after 2 years. Geometric remodeling, regression of hypertrophy, and increased ejection fraction of the left ventricle were similar in both groups at 6 months after surgery, but after 2 years of follow-up, greater improvement was found in patients who had undergone valve replacement for aortic stenosis.

[ORIGINAL CONTRIBUTIONS] Glutamine Improves Myocardial Function Following Ischemia-Reperfusion Injury

Bolotin, Raman, Williams, Bacha, Kocherginsky, Jeevanandam — 2007-11-27

Myocardial ischemia-reperfusion injury is common during cardiac procedures. Glutamine may protect the myocardium by preserving metabolic substrates. Glutamine (0.52 g·kg^–1) or Ringer’s lactate solution (control group) was administered intraperitoneally to 63 Sprague-Dawley rats at 4 or 18 hours prior to experimental ischemia and reperfusion. The hearts were excised and perfused on an isolated working heart model, exposed to global ischemia for 15 min and reperfusion for 1 hour. Left atrial pressure, mean aortic pressure, cardiac flow, coronary flow, and aortic output were measured 15 min before ischemia and every 15 min during reperfusion. There was significantly better cardiac output in the glutamine pretreated groups. Pretreatment at 4 hours before the experiment was superior to pretreatment at 18 hours, with better maintenance of cardiac output and coronary flow. The enhanced protective effect of pretreatment at 4 hours highlights the importance of timing, and suggests a potential clinical benefit.

[ORIGINAL CONTRIBUTIONS] Minimally Invasive Right Posterior Minithoracotomy for Open-Heart Procedures

Mohamed — 2007-11-27

A right posterior minithoracotomy was evaluated in 123 selected patients between November 2002 and August 2006. Their ages ranged from 1.5 to 32 years (mean, 7.8 years) and weights ranged from 12.3 to 61.6 kg (mean, 23.3 kg). Pathology included atrial septal defect in 81 (66%), ventricular septal defect in 16 (13%), and 24 other (mainly valve) defects. All patients had a strictly posterior right minithoracotomy through the 4^th or 5^th right intercostal space, with a 7–9-cm skin incision. There was no mortality or procedure-related morbidity. The mean cardiopulmonary bypass time was 68 min, ischemic time was 47 min, and 47 (38%) patients were extubated on the operating table. The mean hospital stay was 4.3 days and it was < 5 days in 108 (88%) patients. A cosmetically fine scar was achieved in all patients. The right posterior minithoracotomy is a safe, cosmetically superior, and cost-effective approach for selected open-heart procedures.

[ORIGINAL CONTRIBUTIONS] Minimal vs Median Sternotomy for Aortic Valve Replacement

Moustafa, Abdelsamad, Zakaria, Omarah — 2007-11-27

The aim of this study was to compare postoperative outcomes in patients undergoing aortic valve replacement through a ministernotomy or conventional sternotomy. Sixty patients were randomized into 2 groups of 30 each: group 1 had a full sternotomy and group 2 had a ministernotomy. Pain was evaluated on a daily basis, pulmonary function tests were performed perioperatively. The skin incision was shorter in group 2 (7.17 vs 24.50 cm in group 1). There was significantly less mediastinal drainage in group 2 (233 vs 590 mL in 24 hours in group 1). Group 1 patients had more blood transfusions and longer ventilation time. In group 1, 96.7% experienced severe pain, whereas 93.3% in group 2 reported minimal pain. Hospital stay was 17.7 days in group 1 and 8.0 days in group 2. The ministernotomy had a cosmetic advantage, less blood loss and transfusion requirement, greater sternal stability, better respiratory function, and earlier extubation and hospital discharge.

[ORIGINAL CONTRIBUTIONS] Prosthetic Valve Replacement in Adolescents with Rheumatic Heart Disease

Akhtar, Abid, Zafar, Sheikh, Cheema, Khan — 2007-11-27

To assess long-term survival and anticoagulant-related complications after mechanical valve replacement in adolescents with rheumatic heart disease, 88 patients aged ≤ 18 years were prospectively followed up for 10 years (404.2 patient-years). There were 58 (65.9%) boys and 30 (34.1%) girls, with a mean age of 15.4 ± 2.1 years. Mitral regurgitation was detected in 39 (44.3%) patients, and both mitral and aortic regurgitation in 15 (17%). Ball valves were inserted in 52 (59.1%) patients, bileaflet valves in 31 (35.2%), and single-disc valves in 5 (5.7%). There were 4 (4.5%) hospital deaths and 11 late deaths. Patient survival at 30 days, 3 months, 1, 5, and 10 years was 95.5%, 93.2%, 87.5%, 82.9%, and 82.9%, respectively. Mechanical valve thrombosis occurred in 4 patients; it was fatal in 3 of them. Three patients died from stroke. Severe hemorrhage required hospital admission in 4 (4.5%) patients. Mechanical valve replacement in adolescents, with careful follow-up and anticoagulation, has acceptable long-term results.

[ORIGINAL CONTRIBUTIONS] Surgical Experience of Coarctation of the Aorta in Infants and Young Children

Zheng, Liu, Xu, Su, Ding — 2007-11-27

We evaluated the effectiveness of surgical treatment for coarctation of the aorta in infants and young children, based on our experience over 7 years. From March 1999 to December 2005, 168 cases of coarctation of the aorta in patients aged 21 days to 3 years were treated by end-to-end, extended end-to-end, or extended end-to-side ascending aorta and aortic arch anastomosis. The mortality rate was 0.6%. In 138 (82%) patients, the pressure in the lower extremity was higher than in the upper extremity. During 6–24 months of follow-up, hoarseness appeared in 6 patients. Echocardiography revealed stenosis of the end-to-end anastomosis in only 2 patients. We suggest that the best option for surgical treatment of coarctation of the aorta with associated cardiac malformations is a one-stage procedure using a median sternotomy approach. It is better to perform extended end-to-end anastomosis or anastomosis between the distal descending aorta and the left wall of the ascending aorta, or to extend this anastomosis to the transverse arch.

[ORIGINAL CONTRIBUTIONS] Age Deteriorates Palmar Microcirculation Following Radial Artery Harvesting

Knobloch, Tomaszek, Haverich, Vogt — 2007-11-27

The effect of age as a risk factor for deterioration of palmar microcirculation after radial artery harvesting for coronary revascularization is unknown. In 114 patients aged 61.7 ± 6.7 years undergoing radial artery harvesting, superficial and deep tissue oxygen saturation, postcapillary venous filling, and capillary blood flow were determined using a combined laser Doppler spectrophotometry system 25 ± 5 months after surgery. Superficial and deep oxygen saturation at the harvested thenar eminence decreased with age. In the nondonor hand, oxygen saturation declined in the first and second digits. Postcapillary venous filling pressure in both thenars increased with age. It was concluded that neurological complications do not correlate with age. Palmar tissue oxygen saturation, palmar capillary blood flow, and blood velocity decrease, while postcapillary venous filling pressure significantly increases with age. Radial artery harvesting for coronary revascularization does not compromise palmar microcirculation to the same extent as age. A cut-off value of ≤ 67 years was determined by microcirculatory assessment; beyond this, significant deterioration of palmar microcirculation is more likely to occur.

[ORIGINAL CONTRIBUTIONS] Anticoagulation for Prosthetic Heart Valves in Pregnancy. Is There an Answer?

Khamooshi, Kashfi, Hoseini, Tabatabaei, Javadpour, Noohi — 2007-11-27

The aim of this retrospective study was to compare the different anticoagulation regimens used in pregnant women with prosthetic heart valves. We reviewed 196 pregnancies in 110 women from 1974 to 2000. The patients were divided into two groups: group 1 (142 pregnancies) had warfarin throughout pregnancy; and in group 2 (54 pregnancies), warfarin was replaced by subcutaneous heparin during the first trimester and last two weeks of pregnancy. There were no maternal complications in 129 pregnancies in group 1 and 44 in group 2. There were significantly fewer normal births in group 1 (56; 39.4%) compared to group 2 (39; 72.2%). Group 1 had a significantly higher rate of spontaneous abortion (46.5% vs 14.8%), but group 2 had a higher rate of valve thrombosis. In group 1, women with a warfarin requirement < 5 mg had a lower rate of spontaneous abortion. Warfarin is an effective anticoagulant in pregnant women with mechanical valves but it results in significant fetal loss when the dose is > 5 mg. Heparin is a less effective anticoagulant resulting in more maternal complications, but it is more protective of the fetus.

[ORIGINAL CONTRIBUTIONS] Anticoagulation in Pregnancy with Mechanical Heart Valves: 10-Year Experience

Akhtar, Abid, Zafar, Cheema, Khan — 2007-11-27

Anticoagulation in pregnancy was evaluated in 33 women with a mechanical heart valve prosthesis who had 53 pregnancies between 1994 and 2006. Their mean age at valve operation was 24.4 ± 5.4 years, and 22 (67%) had isolated mitral valve disease. Of these patients, 22 had a single pregnancy, 5 had 2 pregnancies, 3 had 3, and 3 had 4. In 43 pregnancies, the patients took warfarin throughout; in the other 10, heparin was used in the first trimester followed by warfarin until the last 15 days. Mean international normalized ratio and warfarin levels before, during, and after pregnancy were similar. Complications occurred in 3 (6%) women who had thrombosed valves: 2 (20%) in the heparin group and 1 (2%) who had warfarin only. Live births resulted from 37 (70%) pregnancies. There were significantly more abortions in the heparin group (6; 60%) than the warfarin group (8; 19%). Hemorrhage requiring transfusion occurred in 2 (5%) patients in the warfarin group. All live births resulted in healthy babies. It was concluded that anticoagulation with warfarin is safe during pregnancy in women with mechanical heart valves.

[ORIGINAL CONTRIBUTIONS] Cardiac Troponin I Concentrations During On-Pump Coronary Artery Surgery

Capuano, Simon, Roscitano, Sclafani, Tonelli, Sinatra — 2007-11-27

Perioperative myocardial infarction remains a frequent complication after coronary artery bypass grafting, and is associated with a poor prognosis. This retrospective study compared cardiac troponin I concentrations after on-pump bypass grafting in 2 groups of patients: 100 operated on using a single-clamp technique to perform anastomoses, and 80 operated on using a double-clamp technique. Postoperative cardiac troponin I levels were not significantly different between groups. It was concluded that the double-clamp technique did not reduce the incidence of myocardial infarction after elective on-pump coronary artery bypass grafting, and use of a single clamp is safe with no adverse effect on postoperative outcome.

[ORIGINAL CONTRIBUTIONS] Learning Curve of Arch-First Technique Analyzed by Cumulative Sum

Song, Tokuda, Hirai, Ueda — 2007-11-27

This study was undertaken to verify efficacy of the arch-first technique in the light of its learning curve. From April 2002 to September 2005, 10 consecutive elective cases of total arch replacement were retrospectively examined. The learning curve of the arch-first technique was constructed using cumulative sum analysis. There were no operative deaths. The mean deep hypothermic circulatory arrest time was 28.4 ± 13.7 min, the lower body ischemic time was 91.3 ± 35.1 min, aortic cross clamp time was 133.2 ± 18.1 min, cardiopulmonary bypass time was 198.8 ± 21.5 min, and operation time was 383 ± 24 min. The durations of deep hypothermic circulatory arrest, bypass, and operation were under the 90% lower alarm line in all 10 cases. The lower body ischemic time and cardiac arrest time were between the 80% upper and lower alert lines. Cumulative sum analysis of total arch replacement using the arch-first technique showed satisfactory rates of improvement in reconstruction of the 3 arch vessels, cardiopulmonary bypass time, and overall mortality.