Objective: Long-term results after the arterial switch operation have shown that patients may develop aortic insufficiency, and that some even require aortic valve replacement. Methods: A retrospective review of 479 hospital survivors after the arterial switch operation (ASO) was performed. Echocardiographic findings were reviewed and the incidence, as well as the progression, of aortic insufficiency (AI) was investigated. The combined end point of the study was defined as the first documented occurrence of moderate or more aortic insufficiency or the need for aortic valve replacement (AVR). Results: Upon discharge from the hospital 15% of the patients showed an AI of at least grade I, progressing to 20.7% after 1 year. At a mean follow-up time of 9.3 ± 6 years, 249 patients (53%) were free from AI, trivial AI was present 179 patients (38%), mild AI in 34 patients (7.2%) and moderate AI in 7 patients (1.5%). There is a progression of AI with time after ASO (r = 0.26, p < 0.001). A total of 18 patients reached the combined end point, out of which 11 underwent an AVR at a mean time of 11.2 years after ASO. Freedom from the end point was 99.7 ± 0.3%, 97.5 ± 1%, 91.9 ± 2%, 84.6 ± 6% at 5, 10, 15 and 20 years, respectively. The following risk factors were identified by univariate analysis: Taussig-Bing anomaly (p = 0.01), ventricular septal defect (VSD) (p = 0.006), prior pulmonary artery banding (p = 0.004), age over 12 months at time of ASO (p = 0.001) and a postoperative incidence of trivial AI (p < 0.0001). Independent risk factors by multivariate analysis were the presence of a left ventricular outflow tract obstruction (p < 0.0001) and at least a trivial AI at 1 year after the ASO (p < 0.0001). Conclusion: The incidence of trivial or mild AI after the ASO is considerable and a progression over time is evident. However, severe AI and the need for AVR are rare. Patients with VSD or Taussig-Bing anomaly, and those with left ventricular outflow tract obstruction exhibit a higher risk of developing significant aortic insufficiency. Particularly patients who have developed an AI at 1 year after the ASO need to be under close observation.

Background: Minimally invasive operations and percutaneous interventions are well-accepted options in the treatment of congenital heart defects. However, percutaneous interventions may be associated with an increased risk due to limited vascular access or a very tortuous catheter course. In these cases, combining operative and interventional approaches with direct puncture of the heart or the great vessels may facilitate implantation of even large devices. Furthermore, in some situations, cardiopulmonary bypass or circulatory arrest can be omitted when doing a hybrid procedure. Patients: Between January 2000 and April 2007 17 patients were operated in a hybrid fashion. Age ranged from 14 days to 45 years. Operative procedures consisted of implantation of an atrial septal defect occluder via direct puncture of the right atrium (n = 4), closure of a ventricular septal defect via direct puncture of the right ventricle (n = 1), implantation of isthmus stents via the ascending aorta (n = 5), redilation of an isthmus stent (n = 1), redilation of a ductal stent (n = 1), angioplasty of a pulmonary artery stenosis (n = 1), interventional occlusion of an intrahepatic porto-caval shunt (n = 1), stent implantation into the right pulmonary artery (n = 1) and into the right ventricular outflow tract (n = 1) under direct vision as well as atrioseptoplasty combined with a bilateral pulmonary artery banding in one newborn with a single ventricle and very low birth weight (n = 1). Results: The planned intervention could be performed in all cases under the assistance of intraoperative fluoroscopy, transesophageal or epicardial echocardiography, or under direct vision. In all cases, the primary hemodynamic objectives were achieved. Conclusion: In selected patients, the combination of a surgical procedure and a percutaneous intervention may help to reduce both operative and interventional risks. This concept may enable new treatment options, especially in patients with complex congenital heart defects or complex vascular situations.

Objective: Controversy surrounds the optimal method of establishing right ventricle to pulmonary artery continuity in neonates and infants with congenital heart disease. We reviewed our experience with non-valved autologous reconstruction of the right ventricular outflow tract to determine mid-term outcome and risk factors for reintervention. Methods: Between 1998 and 2006, 34 consecutive patients underwent non-valved autologous right ventricular outflow tract reconstruction. The need for postoperative catheter-based intervention or reoperation was assessed using relevant patient and procedure-related variables. Results: Diagnoses included tetralogy of Fallot with anomalous coronary (n = 3), tetralogy of Fallot with pulmonary atresia (n = 10), truncus arteriosus communis (n = 15), and other (n = 6). Median age at surgery was 5 days (1–270 days). Twenty-six (76%) patients were neonates. Median weight was 3.1 kg (1.8–7.3 kg). At a median follow-up of 43 months (1–90 months), 15 (50%) patients underwent reoperation and 7 (23%) underwent catheter-based intervention, with a total of 16 (53%) undergoing either reoperation or catheter-based intervention. Kaplan–Meier freedom from reintervention at 6 months, 1 year, 3 years, and 5 years was 67%, 47%, 47%, and 35% for truncus arteriosus versus 87%, 82%, 68%, and 65% for diagnoses other than truncus arteriosus (p = 0.05). Conclusions: Mid-term outcome following non-valved autologous reconstruction of the right ventricular outflow tract is satisfactory and constitutes a sound alternative to the use of small-diameter conduits in neonates and infants. In our hands, this strategy favors certain anatomic subtypes. Non-truncus patients have significantly lower rates of reintervention. Technical details associated with the anatomical reconstruction of the posterior autologous pathway may play an important role in outcomes.

Objective: Neonatal primary repair has progressively become the treatment of choice for truncus arteriosus with encouraging survival. However, use of valved conduits to reconstruct the right ventricular outflow tract (RVOT) inevitably induces reintervention. This study estimates survival and rate of catheter-interventional and surgical reinterventions. Methods: Thirty-five consecutive neonates who underwent truncus repair with 27 homografts and 8 Contegras from 1987 to 2007 were studied. Interrupted aortic arch (IAA) was associated in nine patients. Actuarial survival and freedom from reintervention were evaluated according to Kaplan–Meier method. Results: Five patients died early after repair. Two died late and one death was related to reintervention. Survival was 91.9% ± 5.4% from postoperative month 2 onwards when IAA was not associated and 41.7% ± 17.3% from month 4 in IAA presence. During a median follow-up of 68 months (range 1–180 months), 42 reinterventions (of which 17 reoperations) were performed in 21 patients. Rate of reintervention was 2.6 per early survivor per 10 years. RVOT obstruction constituted the main indication: branch pulmonary arteries often being involved (n = 25). Uncommon indication was subaortic stenosis (n = 3), aortic arch obstruction (n = 2) and truncal valve regurgitation (n = 2). At year 10, freedom from first, second and third reintervention was 17.9 % ± 8.1%, 46.1% ± 10.6% and 81.9% ± 9.5%, respectively. Sixteen first conduits were explanted. Freedom from first conduit replacement was 87.5% ± 6.8%, 64.1% ± 10.2% and 39.5% ± 10.7% at year 1, 3 and 5, respectively. Homografts enjoyed higher durability than Contegras. Conclusion: Neonatal repair of truncus arteriosus results in high survival, the only risk being IAA association. The rate of reintervention is heavily influenced by stenosis of branch pulmonary arteries.

Objective: The right ventricle in hypoplastic left heart syndrome (HLHS) works at systemic pressure and large volume loading before and after first stage palliation. There is a paucity of information regarding the intrinsic characteristics of the right ventricle in HLHS. We studied extra-cellular matrix composition, myocyte homeostasis and gene expression in right ventricular biopsies obtained from patients with HLHS undergoing neonatal first stage palliation and from patients undergoing neonatal truncus arteriosus repair. Methods: Tissue was evaluated using histological and real-time PCR techniques using the truncus group as a comparative group. Mean difference in outcomes between the HLHS and truncus groups was estimated using linear regression models in unadjusted and age-adjusted analyses. Results: Markers of cell proliferation, apoptosis and fibronectin were significantly higher in the right ventricular myocardium of patients with hypoplastic left heart syndrome compared to truncus arteriosus. Type I collagen content and NKX2.5 expression were significantly lower in HLHS than the truncus group. Conclusion: The neonatal right ventricle in HLHS demonstrates a number of intrinsic differences compared to the right ventricle in truncus arteriosus including relative immaturity of the extra-cellular matrix, inappropriately low transcription factor expression and increased myocyte apoptosis.

Background: Surgical correction of complete atrio-ventricular septal defect (AVSD) achieves satisfactory results with low morbidity and mortality, but may require reoperation. Our recent operative results at mid-term were followed-up. Methods: From June 2000 to December 2007, 81 patients (Down syndrome; n = 60), median age 4.0 months (range 0.7–118.6) and weight 4.7 kg (range 2.2–33), underwent complete AVSD correction. Patch closure for the ventricular septal defect (VSD; n = 69) and atrial septal defect (ASD; n = 42) was performed with left atrio-ventricular valve (LAVV) cleft closure (n = 76) and right atrio-ventricular valve (RAVV) repair (n = 57). Mortality, morbidity, and indications for reoperation were retrospectively studied; the end point ‘time to reoperation’ was analyzed using Kaplan–Meier curves. Follow-up was complete except in two patients and spanned a median of 28 months (range 0.4–6.1 years). Results: In-hospital mortality was 3.7% (n = 3) and one late death occurred. Reoperation was required in 7/79 patients (8.9%) for LAVV insufficiency (n = 4), for a residual ASD (n = 1), for right atrio-ventricular valve insufficiency (n = 1), and for subaortic stenosis (n = 1). At last follow-up, no or only mild LAVV and RAVV insufficiency was present in 81.3% and 92.1% of patients, respectively, and 2/3 of patients were medication-free. Risk factors for reoperation were younger age (<3 months; p = 0.001) and lower weight (<4 kg; p = 0.003), and a trend towards less and later reoperations in Down syndrome (p < 0.2). Conclusions: Surgical correction of AVSD can be achieved with low mortality and need for reoperation, regardless of Down syndrome or not. Immediate postoperative moderate or more residual atrio-ventricular valve insufficiency will eventually require a reoperation, and could be anticipated in patients younger than 3 months and weighing <4 kg.

Objective: Congenital mitral valve regurgitation (MVR) is a rare disease occurring in infancy or childhood. Although congenital MVR has been described in adults, no surgical series has been reported so far. We describe here a 6-year surgical experience of congenital MVR in adults at a single institution. Methods: We reviewed the data of 15 consecutive patients (8 men), aged more than 16 years (median: 38 years; range: 16–70 years) operated on for severe congenital MVR from June 2000 to March 2006. Congenital MVR represented 2.1% of mitral valve surgery performed in adults during the same period. Patients with atrio-ventricular septal defect or atrio-ventricular discordance were excluded. Results: The congenital MVR was preoperatively diagnosed in six (40%) cases. Two (13%) patients had a Williams–Beuren syndrome. The lesions consisted in annular dilation (100%), prolapsed leaflet (87%), chordal abnormalities (80%), papillary muscle abnormalities (40%) or valvular cleft (33%). Mitral valve repair was performed in all cases using Carpentier's techniques. There was no hospital death or late mortality. At last follow-up (median: 60 months; range: 6–83 months), all patients were in NYHA functional class I or II and in a sinus rhythm. On transthoracic echocardiography, 11 (73%) patients had no or trivial MVR. Mild MVR was present in four (27%) patients. No patient was reoperated and endocarditis did not occur. Conclusion: Congenital MVR is rare in adults, often misdiagnosed and accessible to valve repair with excellent mid-term results.

Objective: Saline injection test performed during mitral valvuloplasty is popular; however, discrepancies are sometimes noticed between the ‘naked eye’ findings of regurgitation during the saline injection test and the echocardiographic findings after surgery. These discrepancies may arise due to the geometric differences in the mitral valve-left ventricular complex between the saline-injected left ventricle (LV) and the beating LV. Therefore, to elucidate these differences, we compared the three-dimensional geometries between these two conditions. Methods: Sonomicrometry crystal markers were implanted in seven mongrel dogs at the mitral annulus, edge of the mitral leaflets between scallops, tips of papillary muscles, and LV apex under cardiopulmonary bypass. Geometric data of the LV were acquired during the saline injection test and in the beating heart. Results: The commissural width was greater and the annular height was lesser during the saline injection test than in the beating heart (20.5 ± 5.1 mm vs 17.2 ± 2.2 mm, p < 0.01 and 5.5 ± 1.8 mm vs 7.3 ± 2.2 mm, p < 0.05, respectively), indicating that the saddle-shaped mitral annulus was flattened during the test. Additionally, the middle scallop width and the distance between the papillary tips were greater during the test (14.0 ± 4.2 mm vs 11.3 ± 3.6 mm, p < 0.05 and 22.9 ± 5.9 mm vs 11.6 ± 5.0 mm, p < 0.01, respectively), implying that the middle scallop was stretched by the traction of the chordae. The distance between the papillary tips and the mitral annular plane remained constant in both the conditions (19.3 ± 2.6 mm vs 18.6 ± 6.2 mm, not significant). Conclusions: The saline injection test could aid in determining the length of the reconstructed chordae. However, the test may provide inaccurate data of the mitral-LV dimensions due to the flattened annulus and overstretched leaflets.

Objective: Some have expressed concern that minimal invasive mitral valve (MV) repair may not meet the standard of open surgical techniques. We therefore reviewed our results for minimal invasive MV repair for mitral regurgitation (MR). Material and methods: Between March 1999 and February 2007, a total of 1536 consecutive patients underwent minimal invasive MV surgery for MR at our institution using a right lateral mini-thoracotomy and femoral cannulation for cardiopulmonary bypass. Of these, a total of 1339 (87.2%) patients underwent MV repair and these form the focus of this study. The mean grade of preoperative MR was 3.3 ± 0.6, age was 60.3 ± 12.7 years, ejection fraction was 59.2 ± 15.1% and 819 patients (61.2%) were male. Results: The procedure was successfully performed in all but four patients (0.3%) who required intraoperative conversion to full sternotomy. MV repair techniques consisted of ring annuloplasty with or without chordae-replacement or Carpentier-type leaflet resection. Concomitant procedures consisted of atrial fibrillation ablation in 351 patients (26.2%), tricuspid valve surgery in 80 patients (6.0%), and patent foramen ovale/atrial septal defect closure in 88 patients (6.6%). Mean duration of CPB was 121 ± 38 min and mean aortic cross-clamp time was 70 ± 32 min. Thirty-day mortality was 2.4%. Follow-up was performed in 99% of patients at an average of 28.1 ± 23.9 months postoperatively. The Kaplan–Meier estimate for survival at 5 years was 82.6% (95% CI: 78.9–85.7%) and for freedom from MV reoperation was 96.3% (95% CI: 94.6–97.4%). Conclusions: Minimal invasive MV repair, along with certain concomitant procedures, can be performed in the vast majority of patients with MR. Our large series demonstrates that these procedures can be performed with low perioperative complication rates and very good durability.

Objective: Management of the left atrial appendage (LAA) is considered an important adjunct to ablation in cardiac surgical patients with atrial fibrillation (AF). However, current surgical techniques, both cut-and-sew and stapling, have been associated with incomplete LAA occlusion and complications. Using cardiac magnetic resonance imaging (MRI), we studied the safety and effectiveness of a new device for LAA occlusion in a primate model. Methods: Seven adult baboons underwent off-pump placement of an LAA clip (AtriCure Inc., Westchester, Ohio). LAA occlusion was confirmed intraoperatively by direct incision. All animals had MRI before and after clip placement to assess LAA perfusion, architecture, and overall cardiac function. Pathologic and histological studies were performed at 7, 30 and 180 days. Results: Clip placement was successful in all (n = 7) without any clip related complications. Complete LAA occlusion was demonstrated intraoperatively in all subjects. LAA occlusion was confirmed on pre-sacrifice MRI, and left and right ventricular function were unchanged from preoperative studies; however, clip placement caused small reductions in left ventricular end-diastolic, end-systolic, and stroke volumes. At sacrifice, direct inspection confirmed stable location, persistent LAA exclusion, tissue in-growth and homogenous epithelialization without damage to adjacent structures. Histological analysis revealed a regular in-growth pattern in all studied specimens. Conclusion: We demonstrated a safe, straightforward, persistent and effective method for LAA occlusion with this new LAA clip. MRI effectively demonstrated LAA occlusion and only minor changes in left ventricular volumes.

Background: Preoperative atrial fibrillation (AF) in patients scheduled for elective open-heart surgery is a well-known phenomenon. The cut and sew Maze procedure or variant Maze procedures abolish AF in 45–95% of patients during short- to intermediate-term follow-up. We determined preoperative and postoperative factors predictive of sustained sinus rhythm (SR) and recurrent AF in an elderly cohort of patients with structural heart disease who underwent cardiac surgery. Patients and methods: From November 1995 to November 2003, 285 patients with structural heart disease and permanent AF were scheduled for elective cardiac surgery. All patients underwent a radiofrequency (RF) modified Maze procedure as an adjunct to the open-heart operation. Patients were followed in the outpatient clinic or follow-up data were obtained from attending doctors. Patients are being followed in an ongoing registry; however for the patients who are the subject of this paper follow-up ended November 2006. Preoperative factors predicting recurrent AF postoperatively were assessed, as were factors associated with sustained SR. Results: Two hundred and eighty-five patients (mean age 68.0 ± 9.6 years) underwent a total of 655 open-heart procedures and concomitant RF Maze surgery. In-hospital mortality was 4.6% (13 patients). Mean and median duration of AF were 60.9 ± 68.7 months and 26 months (range 6–396), respectively. Median follow-up was 36.5 months (range 27–114 months). Sustained SR, including atrial rhythm or an atrial-based paced rhythm was present in 59% of patients at 1 year, in 54.4% at 3 years, in 53.4% at 5 years and in 57.1% of patients at the latest follow-up. Stroke was reported in six patients (2.1%). Factors predictive of postoperative AF recurrence were duration of permanent AF, preoperative atrial fibrillation wave and preoperative left atrial (LA) size. Postoperative angiotensin converting enzyme (ACE) inhibitor therapy was associated with SR during follow-up. LA size decreased during follow-up in patients with sustained SR, whereas LA size increased in case of recurrent AF. Conclusions: In this group of elderly patients with permanent AF in the setting of structural heart disease who underwent cardiac surgery and a RF Maze procedure as a concomitant procedure, the duration of AF, preoperative atrial fibrillation wave and preoperative LA size were predictive of recurrent AF, whereas left ventricular ejection fraction, left ventricular diameters and invasive hemodynamic parameters were not. Postoperative ACE inhibitor therapy was associated with sustained SR. Furthermore, sustained SR after RF Maze surgery was associated with decreased LA dimensions.

Objectives: Little is known regarding the mechanisms, the feasibility and the long-term results of re-repair in ‘posterior failure’ of a previous mitral valve repair performed for severe degenerative mitral regurgitation. We report our 16-year experience in redo surgery for late posterior failure of mitral valve repair in degenerative disease. Methods: From 1991 to 2004, 13 consecutive patients (10 males; median age: 65 years) were reoperated for late posterior failure of mitral valve repair. All patients had grade ≥3+ mitral regurgitation. Repair was mainly performed using Carpentier's techniques. Results: Repair failure was due to posterior leaflet prolapse, leaflet retraction or leaflet dehiscence in eight (62%), three (23%) and two (15%) patients, respectively. Repair was performed in nine patients (69%). There was no perioperative death. During follow-up (median: 105 months; range: 40–170 months) one late death occurred in the mitral valve replacement group. One (11%) patient underwent mechanical mitral valve replacement 125 months after re-repair. Congestive heart failure occurred in one patient in each group. At the latest follow-up, all but one patient in the mitral valve repair group were in NYHA functional class I or II and all were in sinus rhythm. Doppler echocardiographic studies of the re-repaired valves (n = 8) showed no or trivial, grade 1+ and grade 2+ residual mitral regurgitation in 6 (75%), 1 and 1 patients, respectively. Mean transmitral gradient was 3 mmHg (2–8 mmHg) and left ventricular ejection fraction was 59% (43–77%). Conclusion: In case of late posterior failure of mitral valve repair for severe degenerative, re-repair is feasible in about 70% of the patients with encouraging results at 10 years.

Objective: Posterior ventricular rupture is a rare and fatal complication of mitral valve surgery. This study is designed to define the risk factors for left ventricular rupture after mitral valve replacement and, especially, to find out if posterior leaflet preservation is protective for posterior ventricular rupture. Methods: Between January 1996 and March 2007, 2560 patients underwent mitral valve replacement operation in our hospital. Risk factors for posterior ventricular rupture were studied with ² and logistic regression analysis. Results: The surgery was complicated with posterior ventricular rupture in 23 (0.8%) of 2560 patients. Nineteen patients (82.6%) were female, four patients (17.4%) were male. Mean age of the patients in this group was 60 ± 10. Mortality rate of the patients with posterior ventricular rupture was 86% (20 patients). Twelve patients with posterior ventricular rupture were at the age of 60 and older. Age of 60 and above was found as a highly significant risk factor for posterior ventricular rupture (OR 4.53, 95% CI 1.98–10.38, p < 0.001). Posterior leaflet was preserved in 513 patients (20%) and posterior ventricular rupture did not occur in these patients. Resection of posterior leaflet was also found as a highly significant risk factor (p = 0.008) for posterior ventricular rupture. Reoperation was performed in 372 patients and posterior ventricular rupture occurred in 7 of them. Reoperation was also found as a significant risk factor (OR 2.563, 95% CI 1.03–6.34, p = 0.042) for posterior ventricular rupture. Conclusions: Extreme annular traction and aggressive decalcification should be avoided during mitral valve resection. Posterior leaflet of the mitral valve should be preserved, especially in the older age group to prevent posterior ventricular rupture.

Objective: Leaflet plication (PL), triangular resection (TR), resuspension with running suture of Gore-Tex (GTx) and extension with autologous pericardial patch (PP) are different techniques to repair aortic leaflet prolapse (LP) for aortic insufficiency (AI). In this study, we report and compare the early and mid-term results of these techniques for aortic valve repair. Methods: From 1996 to 2006, 298 patients underwent elective aortic valve (AV) repair. In 146 of them, prolapse of one (n = 72) or more than one leaflet (n = 74) was found. LP was defined either as a longer or lower leaflet free margin compared to the other leaflet(s) or a relatively low coaptation level of all leaflets. When leaflet tissues were of good quality (thin and pliable), prolapse was treated by GTx (n = 39), PL (n = 25) or GTx + PL (n = 23). When leaflet tissues were of poor quality (thickened, calcified), prolapse was treated by TR or PP (n = 13) or TR or PP + GTx (n = 47). Results: There was no hospital mortality. During the initial hospitalization two patients required reoperation for recurrent AI and one for aorto-right ventricular fistula; of them, two were re-repaired. Median follow-up was 35 months (range 9–136). Three patients needed late reoperation for recurrent AI. At 4 years, overall survival was 99 ± 1% and freedom from reoperation and from recurrent AI (grade >2) was 94 ± 5% and 91 ± 7% respectively. Freedom from recurrent AI was similar in patients having one versus more than one LP repair (88 ± 11% vs 92 ± 8%, p = 0.2) and among the different techniques used to repair leaflet of good quality (PL: 95 ± 8% vs GTx: 83 ± 18% vs PL + GTx: 100%; p = 0.37). When leaflet resection was needed, the addition of GTx significantly reduced the recurrence of AI (TR or PP: 82 ± 18% vs TR or PP + GTx: 97 ± 4%; p = 0.026). Conclusions: Leaflet plication and Gore-Tex resuspension are both effective and durable techniques for aortic leaflet prolapse repair. The addition of Gore-Tex to triangular resection and pericardial patch repair techniques is efficient to reinforce the suture line and to improve the outcome of the repair. Multiple leaflet prolapse is not a prohibitive factor for successful repair even in the absence of a clear reference level such as a normal leaflet, as long as normal anatomical coaptation is achieved.

Objective: The incidence of embolic events and of cerebral malperfusion in aortic dissection type A (AADA) must be viewed in the context of the existence of a number of possible cannulation techniques. Since femoral cannulation is thought to be associated with a higher risk of perfusion of the false lumen and retrograde embolization, techniques establishing antegrade flow may provide a better option. We describe herein our experience with ascending aortic cannulation in this special patient population. Methods: Between November 1999 and February 2006, 122 patients underwent operation for AADA with arterial access via the dissected ascending aorta. The aorta was cannulated at the site of the minimal distances of the dissected layers. Double purse-string sutures were used to support the cannula. Pressure monitoring in both radial arteries as well as bilateral cerebral oxygen saturation measurement helped to identify malperfusion after establishment of cardiopulmonary bypass. Aortic arch as well as aortic root surgery was performed, as dictated by the pathology. Selective antegrade cerebral perfusion and moderate hypothermia were used for brain and body protection. Results: Malperfusion occurred in three patients (2.5%). Hospital mortality was 15% for the entire cohort (18 patients). Permanent neurological dysfunction was detected in 15 patients (12%), whereas temporary neurological dysfunction occurred in 21 (17%). Total arch replacement was performed in 31 patients (25%). Conclusion: Direct cannulation of the ascending aorta is an easy and safe method in patients with AADA. This technique, which also avoids retrograde flow in the downstream aorta, is an alternative to time-consuming axillary artery access.

Background: Total arch replacement necessitating deep hypothermia with circulatory arrest has a greater effect on pulmonary function than other cardiac surgery using cardiopulmonary bypass (CPB). Since April 2004, 100 mg of sivelestat sodium hydrate was administrated by bolus injection into pulp circuit at the initiation of CPB in every case performed total arch replacement. We investigated the hypothesis that prophylactic use of the drug attenuates post-pump pulmonary dysfunction. Methods: A retrospective analysis of 120 consecutive patients who underwent total arch replacement from August 2001 to December 2006 was conducted. Patients were divided into two groups according to the date of surgery, April 2004, when we started sivelestat administration. Group A (n = 60), operated after April 2004, was administrated sivelestat at the initiation of CPB. Group B (n = 60), before April 2004, was not administrated. Time courses of hemodynamic variables were evaluated until 24 h after surgery and those of respiratory variables and inflammatory markers until 48 h after surgery. Results: There were no significant differences in patient age, sex, prevalence of chronic obstructive lung disease, preoperative lung function, time of operation and CPB, minimum temperature, and aprotinin usage. Hospital mortality occurred in two patients in the group B (3.3%) and no patient in group A (0%). Postoperative hemodynamic variables were not different between the two groups. Respiratory index, oxygenation index were significantly better in patients pretreated with sivelestat (respiratory index; p < 0.001, oxygenation index; p < 0.001, respectively). CRP was significantly lower in patients pretreated with sivelestat (p = 0.022). Except for patients who required tracheostomy or re-exploration for bleeding, patients pretreated with sivelestat were extubated significantly shorter (group A: 12.6 ± 10.8 h, group B: 25.5 ± 12.9 h, p = 0.033). No patient with postoperative respiratory failure requiring tracheostomy was noted in sivelestat group. Conclusion: Prophylactic administration of sivelestat at the initiation of CPB results in better postoperative pulmonary function, leading to earlier extubation time. Our study suggests that sivelestat was effective in facilitating postoperative respiratory management in total arch replacement.

Objective: The surgical treatment of recurrent coarctation in adults supposes a redo left thoracotomy with adhesions and high risk of bleeding and injury of adjacent nerves. The rate of paraplegia in these cases may reach 2.6%. Extra-anatomic aortic bypass avoids these complications. We present our results with ascending-to-abdominal aorta extra-anatomic bypass for recurrent aortic coarctation in adults. Methods: Between September 1979 and November 2006 12 patients underwent ascending-to-abdominal aorta bypass. There were 10 males and 2 females. Mean age was 36.2 ± 11.3 (range 21–57) years old. Mean age at primary repair was 14.3 ± 4.2 years old (range 8–21). Operative technique consisted of performing an ascending-to-abdominal aorta bypass via median sternotomy extended into the epigastrium with a supra-umbilical laparotomy through the mid-line abdominal fascia. Concomitant procedures were performed in six patients: three isolated aortic valve replacements (AVR), two ascending aorta graft replacements and one AVR associated with coronary artery bypass graft (CABG). Results: No postoperative mortality was observed. Mean follow-up time was 10.4 ± 9.3 years (range 0.3–27.8). No patients had any graft-related complication or death and all grafts were patent at the end of the follow-up. One patient developed a dilated myocardiopathy, dying at 14 years of follow-up. Four patients had persistence of arterial hypertension controlled with one drug therapy and five patients were asymptomatic. Conclusions: Ascending-to-abdominal aorta extra-anatomic bypass is a safe, effective and less invasive technique for aortic recoarctation in adults with good results at long-term.

Objective: Endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) in combination with selective open surgical revascularization may be an alternative to conventional surgical repair. We analyzed our patient outcomes after elective and emergent endovascular TAAA repair. Methods: Mortality and outcome data from 21 consecutive patients treated with endovascular TAAA repair between 2000 and 2006 were reviewed. An integrated neuroprotective approach was used on all patients. Mortality risk estimates for open surgery (OS) were calculated using the published risk assessment models and compared to our outcomes. Results: Of the 21 patients, 9 had acute presentation: acute pain (9), rupture (6), and malperfusion (1). The celiac axis was overstented in 15. Nine hybrid open surgical procedures were performed: visceral/renal arteries (5), infrarenal aorta (3) and complete arch revascularization (1). Eleven patients had previous aortic surgery. Thirty-day mortality rate was 4.8% (1/21, predicted OS value 8.3%), 1-, 2- and 3-year survival was 80%. One hospital death occurred due to ischemic colitis after inferior mesenteric artery overstenting. No patient with acute presentation died during the initial hospital admission. There was no paraplegia (predicted OS rate 11.46%) and one event of delayed temporary paraparesis 3 weeks after hospital discharge corrected with raising the blood pressure. Other neurologic complications included one minor left pontine stroke with complete resolution, postoperative confusion (1) and saphenous nerve injury (1). No new late endoleaks occurred after initial complete aneurysm exclusion. Five patients underwent early (<30 days) and four patients underwent late endovascular reinterventions for persistent endoleak. An additional reintervention included percutaneous stenting of a superior mesenteric artery stenosis. Actual freedom from late reintervention was 81%, and 76% at 1-, 2 and 3-year follow-up. Late major adverse events included one stent infection leading to multi-organ failure and death. Conclusions: Endovascular treatment of thoracoabdominal aneurysms with selective visceral and renal revascularization is associated with low mortality and can only be effectively performed by a surgeon. High-risk patients and those with acute presentation appear to benefit most from this therapy. Early results up to three years of this therapy are encouraging, but further follow up to validate long-term results is required.

Objective: Postoperative vasoplegic syndrome (PVS) is a potentially lethal condition with increased mortality and other postoperative morbidities. Many previous studies have examined the outcomes associated with on-pump coronary artery bypass grafting (CABG) surgery, little is known about the incidence of PVS after off-pump CABG. Methods: From November 21, 2005 to June 9, 2006, 334 patients underwent isolated on-pump CABG and 362 had off-pump CABG surgery. Perioperative variables were retrospectively compared between on-pump and off-pump CABG surgery using univariate analysis. Significant variables were included into a stepwise regression model to ascertain their independent impact on the incidence of PVS. Results: The incidence of PVS in isolated on-pump CABG was 6.9%; in off-pump CABG was 2.8% (p = 0.01). However, in multivariable models adjusted for confounders, on-pump CABG did not reach statistical significance as a risk factor of PVS (OR = 2.3, 95% CI 0.94–5.78; p = 0.07). In on-pump CABG, preoperative left ventricular EF less than 35% (OR = 3.6; p = 0.02) and increased body mass index (OR = 1.1; p = 0.04) were identified as risk predictors of PVS; whereas elective surgery (OR = 0.2; p = 0.02) and preoperative use of β-blockers (OR = 0.21; p = 0.02) were associated with a decreased rate of PVS. PVS was associated with longer ICU stay (OR = 6.0; p < 0.01), postoperative ventilation (OR = 4.6; p < 0.01), and hospital stay (OR = 2.62; p = 0.03). There was a stronger association between preoperative ACE inhibitors therapy and increased risk of PVS in off-pump CABG surgery (OR = 4.52, 95% CI 0.95–21.67; p = 0.06) than in on-pump CABG surgery (OR = 1.06, 95% CI 0.35–3.19; p = 0.91), but neither of them reaches statistical significance. Conclusions: The incidence of PVS after off-pump CABG surgery was significantly lower than after on-pump CABG surgery.

Background: Off-pump coronary artery bypass surgery (OPCAB) is commonly used as an alternative to conventional on-pump coronary artery revascularization. Historically, sex and age have been shown to adversely affect operative mortality risk as well as long-term survival in conventional surgery. Aims of the study: To evaluate the effect of gender and ageing on long-term mortality following OPCAB surgery. Methods: We have prospectively followed up 1000 consecutive and systematic OPCAB patients operated between September 1996 and April 2003. Average follow-up period was 64 ± 28 months and was complete in 98% of the cohort. Results: There were 223 women (21%) and 777 men (79%). Women were older, 68 ± 10 versus 63 ± 10 years (p < 0.0001) and had higher prevalence of hypertension (p < 0.0001), peripheral vascular disease (PVD) (p = 0.03), recent myocardial infarction (p = 0.04) and a smaller body surface (p < 0.0001). History of congestive heart failure (CHF) (p = 0.001) and unstable angina (p = 0.003) was more frequent in men. Operative mortality was 2.8% in women and 1.4% in men (p = ns). Eight-year survival was 79 ± 2.5% for men and 68 ± 5% for women, (p = 0.02). Cox regression analysis model revealed that age (HR: 2.81; 95% CI: 1.89–4.18), CHF (HR: 2.09; 95% CI: 1.33–3.31), PVD (HR: 1.72; 95% CI: 1.10–2.5), incomplete revascularization (HR: 2.35; 1.37–4.02), multiple internal thoracic artery (MITA) graft/patient (ITA/pt) (HR: 0.61; 95% CI: 0.44–0.84), left ventricular ejection fraction (LVEF) (HR: 0.19; 95% CI: 0.05–0.71) and cerebral vascular disease (HR: 1.50; 95% CI: 1.00–2.24) but not female sex (p = 0.89) were significant predictors of long-term mortality. Above 65 years of age men and women had a comparable overall survival (p = 0.7) whereas fewer than 65 women had a lower survival than men (p = 0.001). Cox regression revealed that LVEF (HR: 0.06; 95% CI: 0.006–0.59), lesser use of MITA graft (HR: 0.45; 95% CI: 0.35–0.79), were significant causes of long-term mortality in the younger cohort. Female gender did not reach statistical significance (p = 0.12). Conclusion: In this series of systematic OPCAB surgery, the lower survival rate observed in younger women was mostly related to a higher prevalence of preoperative comorbidity and a lesser use of MITA grafts than gender itself.

Objective: In coronary artery bypass grafting (CABG), insufficient bypass flow can be a cause of occlusion or string sign of the internal thoracic artery (ITA) graft. A patent saphenous vein (SV) graft from the ascending aorta can reduce the blood flow through the ITA graft, and may affect its long-term patency. In the present study, we examined the impact of the patent SV graft to the left coronary artery on the long-term patency of the ITA to left anterior descending (LAD) artery bypass. Methods: We reviewed the coronary angiograms of 313 patients who had two bypasses to the left coronary artery including 1 in situ ITA to LAD graft between March 1986 and December 2006. Patients who had occlusion of either bypass grafts to the left coronary artery in the early angiography, were excluded. In 64 patients (20.4%), bilateral ITAs were individually anastomosed to the LAD and the second target branch in the left coronary artery (BITA group), while 249 patients (79.6%) had the ITA to LAD bypass and the SV graft to the second target branch in the left coronary artery (ITA/SV group). The mean follow-up period was 6.8 ± 4.9 years. Results: The cumulative patency rate of ITA-LAD bypasses at 10 years was 100% in the BITA group and 81.4% in the ITA/SV group. The ITA to LAD bypass was occluded in 14 (5.6%) patients of the ITA/SV group. In the ITA/SV group, the cumulative graft patency rate of the ITA to LAD bypass in patients who had severe (≥76%) native coronary stenosis between the two anastomotic sites was 98.6% at 5 years, and was significantly higher than that of 82.3% in patients without severe stenosis (p < 0.0001). Conclusions: Long-term patency of the ITA-LAD bypass was affected by the presence of the patent SV graft to the left coronary artery, particularly when the native coronary stenosis between the two anastomotic sites was not severe. Competitive flow from SV graft could play an important role in occlusion of the in-situ arterial graft.

Background: Vasodilator strategies used to treat bypass grafts in the operating theatre, such as nitrates, phosphodiesterase inhibitors and calcium channel antagonists have a broad but short-lived effect against a variety of vasoconstrictor stimuli. Treatments that react irreversibly with proteins modulating vasoconstriction have the advantage that their effects can last well into the postoperative period. In addition systemic effects are avoided as the treatment is localised to the treated graft. This study investigated the use of two clinically applied drugs; fluphenazine (SKF7171A, HCl), an irreversible calmodulin antagonist and minoxidil sulphate, an irreversible potassium channel opener. Treatments were tested against receptor and non-receptor-mediated contraction in the human radial artery. Method: Isometric tension was measured in response to angiotensin II, KCl and vasopressin in 108 radial artery rings (taken from 31 patients undergoing coronary artery bypass grafting). Control responses were compared with rings pretreated with fluphenazine or minoxidil sulphate. Vasopressin responses were also compared in the presence of glyceryl trinitrate or the reversible Rho kinase inhibitor Y27632. Results: Fluphenazine pretreatment significantly suppressed vasoconstriction to all agonists tested. Maximal responses to angiotensin II, vasopressin and KCl were reduced by 42 ± 19%, 35 ± 8% and 48 ± 15% respectively, without any measurable effect on the EC₅₀. Minoxidil sulphate showed no discernable effect. Vasopressin-induced contraction was also reduced by high levels of glyceryl trinitrate (220 µM; 50 µg/ml) or 10 µM Y27632. Conclusions: The irreversible calmodulin antagonist fluphenazine has potential to be developed as an inhibitor of contraction in arterial graft vessels. The involvement of Rho kinase indicates that other vasoconstrictors and surgical stress can sensitize radial artery to vasopressin-induced contraction. Strategies targeting this pathway also have future potential.

Objective: Radial artery harvesting using the less invasive endoscopic technique involves dissection in a narrow tunnel and may cause an injury or induce vasospasm to the conduit. To assess this hypothesis, radial artery segments harvested endoscopically or conventionally were studied for reactivity and integrity. Methods: Rings of radial arteries from 80 CABG patients who had their radial artery harvested either open (n = 40) or endoscopic (n = 40), were attached to a force transducer then subjected to norepinephrine (NE, 10^–6 M), acetylcholine (ACh, 10^–5 M), followed by sodium nitroprusside (SNP, 10^–7 to 10^–5 M) to test endothelial dependant and non-dependant relaxation. Vessels’ integrity was assessed by microscopic staining with hematoxylin–eosin for muscle layers, Masson trichrome for collagen content and von Gieson for elastica layers. Results: Contraction and relaxation in response to NE, ACh and SNP were similar in both techniques. Arterial layers, collagen content and elastic lamina were preserved in all radial rings. Both techniques were found to be equally efficient in physiological and microscopic tests. Conclusions: The similar reactivity and integrity of the radial artery in both techniques should encourage the less invasive endoscopic approach.

Objective: Bone marrow mesenchymal stem cells (MSCs) have the potential to repair the infarcted myocardium and improve cardiac function. However, this approach is limited by its poor viability after transplantation, and controversy still exists over the mechanism by which MSCs contribute to the tissue repair. Methods: The human heme oxygenase-1 (hHO-1) was transfected into cultured MSCs using an adenoviral vector. 1 x 10⁶ Ad-hHO-1-transfected MSCs (HO-1-MSCs) or Ad-Null-transfected MSCs (Null-MSCs) or PBS only (PBS group) were injected intramyocardially into rat hearts 1 h after myocardial infarction. Results: HO-1-MSCs survived in the infarcted myocardium, and expressed hHO-1 mRNA. The expression of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) was significantly enhanced in HO-1-MSCs-treated hearts. At the same time, there were significant reduction of TNF-, IL-1-beta and IL-6 mRNA, and marked increase of IL-10 mRNA in HO-1-MSCs-treated hearts. Moreover, a further downregulation of proapoptotic protein, Bax, and a marked increase in microvessel density were observed in HO-1-MSCs-treated hearts. The infarct size and cardiac performance were also significantly improved in HO-1-MSCs-treated hearts. Conclusion: The combined approach improves MSCs survival and is superior to MSCs injection alone.

Objective: We evaluated the potency of therapeutic angiogenesis using intramyocardial injection of naked DNA expressing two isoforms of hepatocyte growth factor (pCK-HGF-X7) in a porcine myocardial infarction model. Methods: Four weeks after left anterior descending coronary artery ligation, 14 pigs were allocated to pCK-Null (negative control, n = 7) or pCK-HGF-X7 (n = 7) treatment groups. Gated myocardial single photon emission computed tomography was performed 4 and 8 weeks following coronary ligation. The effect of pCK-HGF-X7 on capillary density in the gene-injected myocardium was examined by histological analysis using alkaline phosphatase staining. Results: Segmental myocardial perfusion of the underperfused area (≤70%) from coronary ligation increased in the pCK-HGF-X7 group (p = 0.051), without significant differences in changes over time between the two groups (p = 0.54). Systolic wall thickening (p = 0.001), left ventricular end-diastolic (p = 0.045) and end-systolic volumes (p = 0.009), and left ventricular ejection fraction (p = 0.041) changed in both groups without significant differences in changes over time between the two groups. The increase in the left stoke volume was higher in the pCK-HGF-X7 group than in the pCK-Null group (p = 0.008). Histological analysis showed that capillary density was significantly higher in the pCK-HGF-X7 group than the pCK-Null group (p < 0.001). Conclusion: Intramyocardial injection of pCK-HGF-X7 induced significant angiogenesis at infarct-border zone, and increased the left ventricular stroke volume probably caused by reverse remodeling process.

Objective: The occurrence of intraoperative air leaks is an unavoidable complication during pulmonary surgeries. However, current surgical methods are generally ineffective in closing these visceral pleural defects, resulting in a decreased quality of life for patients. Here, we examined novel tissue engineered cell sheets for the closure of pleural defects in a porcine model. Methods: Skin biopsies were harvested from juvenile swine and tissue sheets composed of dermal fibroblasts were created using ex vivo culture on temperature-responsive dishes. After creating a visceral pleural injury model, the tissue engineered autologous dermal fibroblast sheets were transplanted directly to the defects without the use of sutures or additional adhesive agents, such as fibrin glue. Results: The tissue engineered autologous dermal fibroblast sheets attached directly to the lung surface providing an immediate seal against up to 25 cm H₂O of airway pressure. Four weeks after transplantation, the dermal fibroblast sheets remained present on the pleural surface, providing permanent closure. The dermal fibroblast sheets were also responsive to changes in lung volume due to mechanical ventilation. No recurrences of air leaks were observed throughout the follow-up period. Conclusions: This study presents the development of an effective sealant for visceral pleural defects using autologous cells that have the flexibility to respond to expansion and contraction during respiration.

Objective: Currently, the choice of chest wall prosthesis remains a challenging problem for thoracic and reconstructive surgeons. The purpose of this study is to investigate the feasibility of newly developed biodegradable prostheses. Methods: Two types of chest wall prostheses made from degradable polymer, collagen coated polydioxanone (CCP) mesh and chitin fiber reinforced polycaprolactone (CFRP) strut, were developed and studied. Adult mongrel dogs were subjected to extensive resection and reconstruction of anterior-lateral chest wall, CCP mesh was used in six dogs, the combination of CCP mesh and CFRP strut was used in four dogs, and polypropylene (PP) mesh in two dogs, as contrast. Results: With good integration with tissue, CCP meshes maintained strength in the chest wall for more than 8 weeks and were completely resorbed within 24 weeks, and satisfactory short-term and long-term chest wall stabilization was achieved. The combined use of CCP mesh with CFRP strut provided a firmer chest wall in the early postoperative course. A mild wound infection developed in one animal with CCP mesh but resolved without sequelae, and no added complications were observed with the additional use of CFRP strut. Conclusions: Our experimental study shows that the CCP mesh and CFRP prosthesis were favorable for chest wall repair. The advantages of biodegradable copolymer give them promise as an excellent addition to the available reconstructive techniques currently in use.

Objective: Our aim was to evaluate the efficacy of 3D imaging using multidetector row helical computed tomography (MDCT) in the preoperative assessment of the branching pattern of pulmonary artery (PA) before complete video-assisted thoracoscopic lobectomy (complete VATS lobectomy) for lung cancer. Methods: Forty-nine consecutive patients with clinical stage I lung cancer scheduled for complete VATS lobectomy were evaluated about branching pattern of PA on 16-channel MDCT. Intraoperative finding of the PA branching pattern were compared with the 3D-CT angiography images obtained using MDCT. Results: According to the intraoperative findings, 95.2% (139 of 146) of PA branches were precisely identified on preoperative 3D-CT angiography. All of the seven undetected branches were within 2 mm in diameter. There was not a case that needed conversion to open thoracotomy because of intraoperative bleeding. Conclusion: A 3D-CT angiography using MDCT clearly revealed individual anatomies of pulmonary artery and could play an important role in safely facilitating complete VATS lobectomy procedure. However, we were unable to detect several thin branches with this technique. So, more care should be taken to avoid bleeding from these small vessels.

Objective: Postoperative acute interstitial pneumonia is a subset of post-surgical acute respiratory distress syndrome (ARDS) and is responsible for one third of in-hospital deaths following lung resection in patients with primary lung cancer. We evaluated the usefulness of computed tomography (CT) for detection of interstitial pneumonia (IP) as a risk factor of postoperative ARDS. Methods: Preoperative chest CT of patients who underwent thoracotomy for primary lung cancer was reviewed retrospectively and IP findings in the chest CT were detected. Results: A total of 1148 patients with primary lung cancer underwent thoracotomy. Fifteen patients (1.3%) developed postoperative ARDS. Eleven of these 15 patients died of ARDS. Three of 41 patients who received induction therapy developed postoperative ARDS. Induction therapy was a risk factor of postoperative ARDS (p < 0.01). Eleven out of the 15 patients who developed postoperative ARDS had IP findings (10: localized, 1: diffuse) in their chest CT. Two of three patients who had postoperative ARDS after induction therapy also had IP findings. Chest CTs of 834 patients were retrospectively analyzed; 91 patients (10.9%) had IP-findings (diffuse 1.8%, localized 9.1%). Postoperative ARDS occurred in 8.8% of IP-positive patients, and in 0.4% of IP-negative patients (p < 0.001). Conclusion: Detection of IP by chest CT is useful for the selection of high-risk patients who may have postoperative ARDS following thoracotomy.

Introduction: Surgical resection offers the only realistic chance of permanent cure for pulmonary aspergilloma. This prospective study was designed to evaluate our indications and surgical outcome of pulmonary aspergilloma with analysis of postoperative complications. Patients and methods: Between 2001 and 2008, 42 patients underwent surgical treatment for pulmonary aspergilloma at Zagazig University Hospital. The patients were divided into two groups, group A (simple aspergilloma) n = 12 and group B (complex aspergilloma) n = 30. Results: Group A consisted of eight male and four female patients with a mean age of 43 ± 11.3 years. Group B consisted of 20 male and 10 female patients with a mean age of 46 ± 12 years. The most common presentation and indication for surgery was hemoptysis (83.3%) in both groups. The common underlying lung diseases were tuberculosis (40.4%), bronchiectasis (33.3%) and lung abscess (11.9%). The common surgical procedure performed was lobectomy (85.7%), followed by pneumonectomy (6.7%), segmentectomy (8.3%), cavernoplasty (4.7%) and bilobectomy (6.7%). The postoperative mortality was 3.3% in group B only. Postoperative non-fatal complications occurred in 12 patients (28.5%) in both groups. The complications included prolonged air leak (2.3%), bleeding (4.7%), wound infection (2.3%), empyema (7.1%), bronchopleural fistula (2.3%) and one patient developed chylothorax after lobectomy (2.3%). The mean follow-up period was (25.5 ± 17 months). The survival rate at 5 years was 91.6% and 83.3% in group A and group B respectively and there was no recurrence of disease or hemoptysis. Conclusion: Surgical treatment of pulmonary aspergilloma is the most effective treatment; pulmonary resection is the treatment of choice when indicated and in unstable surgical patients, palliative procedures chosen in bad cardiopulmonary function.

Objective: To identify the optimal debulking procedure in patients with malignant pleural mesothelioma who are not suitable for extrapleural pneumonectomy (EPP). Methods: We reviewed 102 consecutive patients (93 male; 9 female, mean age 63 years) who were not suitable for EPP because of either advanced tumour stage or suboptimal fitness. Patients underwent either a non-radical tumour decortication to obtain lung expansion (group NR) or latterly a radical pleurectomy/decortication to obtain macroscopic tumour clearance (group R). We analysed the comparative perioperative courses and long-term survival. Results: The two groups were similar for age and gender distribution but epithelioid type was more predominant in group R: 78% compared to 55% epithelioid in group NR. Thirty-day mortality was similar (5.9% in group R and 9.8% in the group NR, p = 0.36) but 90-day mortality was significantly higher in the group NR (29.4% vs 9.8% in group R, p = 0.012). More patients in group R received adjuvant chemotherapy (65% vs 28%, p = 0.000) and radiotherapy (65% vs 26%, p = 0.000). Median survival for all cell types was significantly higher in group R (15.3 months vs 7.1 months, p < 0.000). Group R survival rates at 1, 2, 3 and 4 years were 53, 41, 25 and 13%, respectively while for group NR they were 32, 9.6, 2 and 0%, respectively. For epithelioid cell type there was still a significant median survival advantage in group R (25.4 months vs 10.2 months, p < 0.000), but there was no difference for sarcomatoid (9.3 months vs 3.2 months, p = 0.16) or biphasic cell types (9.4 months vs 7 months, p = 0.38). Conclusion: If a patient with epithelioid MPM is fit enough to tolerate a thoracotomy then macroscopic clearance of the tumour is the preferred option as part of a multimodality regime including chemotherapy.

Objective: We sought to assess the clinical implication and prognostic significance of maximum standardised uptake value (SUV_max) of primary non-small cell lung cancer (NSCLC) staged by integrated PET-CT. Methods: A retrospective review was carried out on 176 consecutive patients with histologically proven NSCLC who underwent staging with integrated PET-CT prior to curative intent surgical resection. SUV_max of primary NSCLC were measured and correlated with tumour characteristics, lymph node involvement, surgical stage, type of surgical resection and survival following resection. Results: SUV_max was significantly higher in centrally located tumours, tumours ≥4.0 cm, squamous cell subtype, poorly differentiated tumours, advanced T stage, advanced nodal stage, pleural invasion, and patients requiring complex surgical resection. SUV_max value of 15 was the best discriminative cut-off value for survival generated by log-rank test. When patients were stratified based on this value, those with SUV_max >15 were more likely to have centrally located tumours, squamous cell subtype, advanced T stage, advanced nodal stage, advanced American Joint Committee on Cancer (AJCC) stage, larger tumour size and required more advanced surgical resections than a simple lobectomy. Overall survival was significantly longer for patients with SUV_max ≤15 than those with SUV_max >15. Furthermore, nodal stage specific survival following resection (i.e. non-N2 and N2) were significantly better in patients with SUV_max ≤15 than SUV_max >15. Conclusion: SUV_max correlates with tumour characteristics, surgical stage and prognosis following resection. SUV_max may be a useful preoperative tool, in addition to other known prognostic markers, in allocating patients with potentially poor prognosis preoperatively to neoadjuvant chemotherapy prior to resection in order to improve their overall survival. Prospective and randomised trials are warranted.

Objective: Acute respiratory distress syndrome (ARDS) is a major cause of death following lung resection. At this institution we reported an incidence of 3.2% and a mortality of 72.2% in a review of patients who underwent pulmonary resection from 1991 to 1997 [Kutlu C, Williams E, Evans E, Pastorino U, Goldstraw P. Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 2000;69:376–80]. The current study compares our recent experience with this historical data to assess if improved recognition of ARDS and treatment strategies has had an impact on the incidence and mortality. Methods: We identified and studied all patients who developed ARDS following a lung resection of any magnitude between 2000 and 2005 using the 1994 consensus definition: characteristic chest X-ray or CT, PaO₂/FiO₂ <200 mmHg, pulmonary capillary wedge pressure <18 mmHg and clinical acute onset. Overall incidence and mortality were recorded. Univariate analyses (t-test or ², as appropriate) were carried out to identify correlations between pre-, peri- and postoperative variables and outcomes. Results: We performed 1376 lung resections during the study period. Of these 705 (51.2%) were for lung cancer and 671 (48.8%) for other diseases. Twenty-two patients fulfilled the criteria for ARDS with 10 deaths in this group. The incidence and mortality from ARDS had fallen significantly over the two study periods (incidence from 3.2% to 1.6%, p = 0.01; mortality from 72% to 45%, p = 0.05). Although no significant correlations with incidence and mortality were identified, we found a number of significant trends. In keeping with the ARDS network study recommendations, postoperative tidal volumes were maintained at a lower level when a higher number of pulmonary segments were excised (p = 0.001). Furthermore, consistent with findings in previous studies, the highest incidence and death from ARDS were in pneumonectomy patients (incidence 11.4%; mortality 50%). Although the incidence and mortality from ARDS following pneumonectomy were not significantly different between the two study periods (p = 0.08, p = 0.35), we found that fewer pneumonectomies were performed in the later period (pneumonectomy rate of 6.4% vs 17.4%). Conclusions: The incidence and mortality of ARDS have decreased in our institution. We postulate that this is due to more aggressive strategies to avoid pneumonectomy, greater attention to protective ventilation strategies during surgery and to the improved ICU management of ARDS.

This paper describes a technique for treating severe tricuspid regurgitation due to severe tethering of the tricuspid valve leaflets. The anterior tricuspid leaflet is augmented by use of an autologous pericardial patch, which increases its size, and hence its surface area of coaptation, allowing increased leaflet coaptation to occur with reduced tension within the right ventricle. A Carpentier–Edwards annuloplasty ring is then implanted. We have successfully performed this operation in 15 patients with severe tricuspid regurgitation due to severe leaflet tethering and have achieved complete elimination of tricuspid regurgitation with good coaptation of the tricuspid leaflets. We describe this simple and easily reproducible technique to treat severe tricuspid regurgitation due to tethering of the tricuspid valve leaflets.

Further improvements in the thoracoscopic treatment of spontaneous pneumothorax may reduce the already low invasiveness of the procedure. We have recently experimented with a new device for the coagulation of blebs as an alternative to endostapler resection. Patients with recurrent or persistent spontaneous pneumothorax underwent thoracoscopic treatment. Those with blebs or small bullae were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. Most operations were performed making only two incisions, in some cases under awake epidural anaesthesia. Results are comparable to those of a series of standard thoracoscopic treatments already reported in the literature.

Violent coughing is associated with a multitude of complications including rib fractures and diaphragmatic rupture. In this report we present a case of a 70-year-old male with the rare combination of both complications resulting in herniation of bowel into the left hemithorax and subcutaneously between the separated ribs. Surgical repair was performed via a left thoracotomy, the hernia reduced and the diaphragmatic and chest wall defect repaired primarily with excellent patient recovery and relief of symptoms.

Tracheal diverticulum is a rarely encountered entity which is frequently an incidental finding in the postmortem examination, reported in 1% of patients in an autopsy series. Most cases are asymptomatic, but when symptoms are present they usually have airway symptoms with cough or recurrent respiratory infection. We herein report a case of a tracheal diverticulum, which had cervical dysphagia and sensation of friction.

We present the case of a man who underwent successful heart transplantation with an allograft that was obtained from a donor who had already received heart transplantation.

Double aortic arch is a congenital anomaly that is rarely found in adults. Typically, this is treated in infancy secondary to symptoms. We describe the treatment of an asymptomatic adult male that was diagnosed with double aortic arch during cardiac catheterization.

Iatrogenic injury to the circumflex coronary artery following mitral annuloplasty is a potentially fatal complication. It can be clinically silent or else be responsible for a cardiogenic shock. The diagnosis should be suspected on EKG changes with segmental dysfunction of the lateral wall on the intraoperative echography. The author reports one case whose recognition relied on emergency angiography; the patient was successfully treated by angioplasty and stenting. The management of this complication remains controversial and the various treatment modalities are discussed.