Objective: To verify the accuracy and precision of the logistic European system for cardiac operative risk evaluation (EuroSCORE) in high-risk cardiac surgery patients and to develop and externally validate a new system of recalibration. Methods: The development series included 4279 high-risk patients who had undergone cardiac operations at the IRCCS Policlinico S. Donato. Performance, accuracy, and precision of the logistic EuroSCORE were assessed in this series, using a deciles-based comparison between expected and observed mortality rates, a receiver operating characteristic analysis, and a Hosmer–Lemeshow test for calibration. Differences between predicted and observed mortality rates were mathematically evaluated to develop an adjusted logistic EuroSCORE. This adjusted risk score was subsequently validated with the same approach on an external series of 1459 high-risk patients who had undergone cardiac operations at the Siena hospital. Results: The adjusted logistic EuroSCORE was based on five different correction factors applied to the crude logistic EuroSCORE depending on its value. At the external validation, this model provided a good performance, with observed mortality rates not significantly different from the expected in 8 out of 10 deciles of risk distribution. The adjusted EuroSCORE had the same moderate balanced accuracy of the crude logistic EuroSCORE (area under the curve: 0.695), with a better precision (Hosmer–Lemeshow calibration test: ²: 3.6, p = 0.891). Conclusions: Recalibration of the logistic EuroSCORE in high-risk patients is needed due to its tendency to overestimate the mortality risk. The application of a variable correction factor results in a better performance, increased precision, with unaltered balanced accuracy.

Objective: We derived a new risk-scoring method by modifying some of the risk factors included in the EuroSCORE algorithm. Methods: This study includes 3613 patients who underwent cardiac surgery at the Vaasa Central Hospital, Finland. The EuroSCORE variables, along with modified age classes (<60 years, 60–69.9 years, 70–79.9 years and ≥80 years), eGFR-based chronic kidney disease classes (classes 1–2, class 3 and classes 4–5) and the number of cardiac procedures, were entered into the regression analysis. Results: An additive risk score was calculated according to the results of logistic regression by adding the risk of the following variables: patients’ age classes (0, 2, 4 and 6 points), female (2 points), pulmonary disease (3 points), extracardiac arteriopathy (2 points), neurological dysfunction (4 points), redo surgery (3 points), critical preoperative status (8 points), left ventricular ejection fraction (>50%: 0; 30–50%: 2 and <30%: 3 points), thoracic aortic surgery (8 points), postinfarct septal rupture (9 points), chronic kidney disease classes (0, 3 and 6 points), number of procedures (1: 0; 2: 2 and 3 or more: 7 points). The modified score had a better area under the receiver operating characteristic curve (additive: 0.867; logistic: 0.873) than the EuroSCORE (additive: 0.835; logistic: 0.840) in predicting 30-day postoperative mortality. The modified score, but not EuroSCORE, correctly estimated the 30-day postoperative mortality. Conclusion: EuroSCORE still performs well in identifying high-risk patients, but significantly overestimates the immediate postoperative mortality. This study shows that the score's accuracy and clinical relevance can be significantly improved by modifying a few of its variables. This institutionally derived risk-scoring method represents a modification and simplification of the EuroSCORE and, likely, it would provide a more realistic estimation of the mortality risk after adult cardiac surgery.

Objective: Transcatheter aortic valve implantation (TAVI) is an alternative treatment for aortic stenosis in selected cases, but requires appropriate vascular access. We report our initial clinical experience with a novel endovascular approach for TAVI. Methods: Between 1 April 2007 and 31 August 2008, 48 patients underwent TAVI at our institution. Of these, eight patients (17%) were deemed to be best served through direct surgical exposure of the left axillary artery rather than a trans-femoral or TA approach. Results: Procedural success was achieved in seven of eight cases. In one patient the axillary artery was too small to accept the 18 French sheath. In the remaining seven, the device was implanted without major complication and with only trivial paravalvular aortic regurgitation. The in-hospital mortality was 0%. The 30-day mortality was 12.5% (one patient). There was one localised dissection at the origin of the vertebral artery. There was one late pericardial effusion and a permanent pacemaker was implanted in five patients. Conclusions: TAVI can be performed through a left axillary artery approach. This is a technically simple procedure and, in this small initial clinical experience, was performed with encouraging results. It is a realistic option in patients in whom neither the trans-femoral or trans-apical approaches are optimal.

Background: Severe peripheral arterial disease may pose a limitation to the applicability of trans-arterial aortic valve implantation in patients who are otherwise candidates. For this reason, transapical aortic valve implantation has been proposed as a possible alternative. Objective: To evaluate the acute safety and performance of a specially designed delivery system, the CoreValve Tranzap^TM delivery catheter, for the transapical implantation of a self-expandable aortic valve prosthesis in a porcine animal model. Methods: Thirteen pigs were implanted with a self-expandable aortic valve bioprosthesis using a 21F catheter delivery system through a transapical approach. The delivery system was evaluated for: (1) the ability to access the implantation site; (2) the ability to precisely position the delivery catheter; (3) control of the delivery of the prosthesis; (4) safe retrieval of the delivery catheter; and (5) the ability to close the apical access site of the heart. Results: Successful implantation was achieved in 100% of the cases. The following points were achieved in all animals: (1) passage of the delivery catheter through an incision in the left ventricular apex; (2) positioning of the delivery catheter on the implantation site; (3) controlled deployment of the aortic valve prosthesis; (4) the safe retrieval of the delivery catheter system; and (5) the adequate closure of the apex of the heart. Conclusion: This study demonstrates the acute safety and feasibility of the CoreValve Tranzap^TM delivery system for the transapical implantation of the CoreValve self-expanding aortic valve bioprosthesis in a porcine animal model.

Objective: Advancing life expectancy with the increased prevalence of aortic valve degenerative disease brings the need for an aortic bioprosthesis with excellent haemodynamic performance and comparable durability. The Mitroflow bioprosthesis has been on the worldwide market, except in the United States, since 1982, while the current model (1991) has only recently gained regulatory approval in the latter country. This study was primarily performed to determine the durability of the current Mitroflow bioprosthesis. Methods: The contemporary Mitroflow bioprosthesis was implanted in 381 patients in three centres. The mean age was 76.4 years (range 53–91 years) and the mean follow-up period was 5.4 ± 3.4 years, a total of 2048.7 years of evaluation. Prosthesis–patient mismatch (PPM) was classified by reference effective orifice area index categories: normal ≥0.85 cm² m^–2 (53.9%), mild 0.84–0.76 cm² m^–2 (33.9%), moderate ≤0.75–0.66 cm² m^–2 (11.7%) and severe ≤0.65 cm² m^–2 (0.5%). Results: The survival, at 10 years, was 39.9 ± 7.9% for 50–69 years, 27.0 ± 3.7% for 70–79 years and 16.6 ± 4.4% for ≥80 years (p = 0.011). There was a trend (p = 0.063) influencing survival for moderate-to-severe PPM. Of the independent predictors influencing survival – moderate-to-severe projected effective orifice area index (pEOAI) (Hazard Ratio (HR) 1.6, p = 0.0142) and left ventricular dysfunction (ejection fraction <35%) (HR 1.9, p = 0.0193) were included. The 10-year freedom from structural valve deterioration (SVD) at explant assessing the same age groups as survival was not different (p = 0.081). The 10-year actual/actuarial freedom from SVD, at explant was for ≥60 years – 94.4 ± 1.4% (85.2 ± 3.9%), for ≥65 years – 94.2 ± 1.4% (85.0 ± 4.0%), for 61–70 years – 97.4 ± 2.6% (95.7 ± 4.3%) and for >70 years – 94.0 ± 1.5% (83.2 ± 4.6%). Conclusions: The Mitroflow external mounted, pericardial aortic bioprosthesis with documented excellent haemodynamics (especially for the small aortic root), demonstrates that prosthesis–patient mismatch in moderate and severe categories can essentially be eliminated, with durability performance comparable to other heterograft (porcine and pericardial) bioprostheses.

Objective: Tricuspid valve replacement (TVR) has a high postoperative mortality, despite recent advances in perioperative care. We report the results of our experience in TVR with an emphasis on early mortality and morbidity and long-term follow-up. Methods: Between October 1994 and August 2007, 80 consecutive TVRs were performed in 78 patients. The mean age was 48 ± 14 (range: 20–70) years. The underlying disease of the patients was classified as rheumatic (n = 54), congenital (n = 12), endocarditis (n = 10) or degenerative (n = 4). Previous cardiac surgery had been performed in 40 patients (50%). Isolated TVR was performed in 24 patients (30%). Results: Hospital mortality occurred in one patient (1.4%). Postoperative morbidities included intra-aortic balloon pump (n = 5), bleeding re-operation (n = 4), delayed sternal closure (n = 3), acute renal failure (n = 3), subdural haematoma (n = 3), extracorporeal membrane oxygenation (n = 1), mediastinitis (n = 1) and pacemaker insertion (n = 4). In 42 patients, ventilator support was needed for more than 72 h. Based on multivariate analysis, age (p < 0.001) and the cardiopulmonary time (p = 0.004) were the identified risk factors. Follow-up was completed in all patients with a mean duration of 56 ± 37 (range: 0–158) months. During the follow-up period, there were seven deaths (8.8%), including five cardiac deaths. The 5- and 8-year survival rates were 95 ± 3% and 79 ± 9% and event-free survival rates were 76 ± 6% and 61 ± 9%, respectively. Based on multivariate analysis, the only identified predictors of late deaths was a postoperative low cardiac output (p = 0.024). Conclusions: TVR can be performed and low operative mortality can be achieved thorough optimal perioperative management in the current era.

Objective: Experimental testing of annuloplasty ring (AR) effects requires a control group if the AR is implanted conventionally. Our goal was to develop a reversible AR insertion method that allows for beating heart assessment with and without an AR, providing the ability to evaluate the effects of an AR in the same animal (internal control). We tested the feasibility of this technique in an in vivo ovine model using four-dimensional (4-D) radiopaque marker tracking. Methods: Before the operation, a rigid AR (Edwards Geoform^®, Edwards Lifesciences, Irvine, CA, USA) was prepared by stitching the middle parts of eight double-armed sutures evenly spaced through the ring fabric using a Spring Eye needle. The resulting loops were ‘locked’ with polypropylene sutures. In addition, two drawstring sutures were attached to the AR. Using cardiopulmonary bypass and cardioplegic arrest, 12 adult sheep had 16 radiopaque markers sewn to the mitral annulus. The AR was implanted by stitching the eight sutures equidistantly in a perpendicular direction through the mitral annulus. The sheep were transferred to the catheterisation laboratory and 4-D marker coordinates were obtained using biplane videofluoroscopy (60 Hz) with the AR inserted (Geo-AR). The locking sutures were then released, the AR was pulled up to the atrial roof using the drawstring sutures and another dataset was acquired (control). Maximum and minimum mitral annular areas (MAA_max, MAA_min) during the cardiac cycle were derived from implanted markers. Data are provided from one representative animal. Results: AR insertion and release were uneventful in all animals. Whereas the mitral annulus was dynamic in the control state (MAA_max: 9.0 cm², MAA_min: 7.8 cm²), mitral annular dynamics were abolished in the Geo-AR case (MAA_max: 6.2 cm², MAA_min: 6.0 cm²). Conclusions: This novel releasable AR implantation method is feasible and permits in vivo assessment of AR effects in the same heart. The new technique should facilitate experimental AR testing and promote the development of ARs based on physical criteria.

Objective: Pulmonary vein isolation (PVI) using ablation energy appears an effective treatment for atrial fibrillation (AF) with a success rate of approximately 80%. However, post-procedural neurological complications still occur in 0.5–10% of all patients undergoing PVI, presumably due to embolism. Therefore, we investigated the occurrence of cerebral micro-embolic signals (MES) as a surrogate marker for the risk of neurological impairment of two different PVI methods: (1) percutaneous endocardial radio-frequency (RF) ablation and (2) thoracoscopic epicardial ablation using RF energy. Methods: Ten patients (eight persistent AF and two paroxysmal AF) underwent a minimally invasive thoracoscopic epicardial (EPI) RF ablation and 10 patients (one persistent AF and nine paroxysmal AF) underwent a percutaneous endocardial (ENDO) isolation. Transcranial Doppler (TCD) was used to detect an MES in the middle cerebral arteries. Results: An average of 5 (±6) MES were detected during epicardial PVI procedure versus 3908 (±2816) MES during percutaneous endocardial PVI procedure. During the ablation application period, respectively, 1 (±1) and 2566 (±2296) cerebral MES were detected. Conclusions: Cerebral micro-emboli during epicardial ablation are almost absent when compared to the thousands of emboli measured during percutaneous endocardial ablation.

Objectives: Considering the role of inflammatory reaction on the pathogenesis of atrial fibrillation (AF), the aim of this study is to investigate perioperative risk factors of AF, as well as to validate the predictive value of high-sensitive C-reactive protein (hsCRP), and transfusion requirement following off-pump coronary bypass surgery (OPCAB) in a prospective and observational trial. Methods: In this cohort, 315 consecutive patients with normal sinus rhythm (NSR) undergoing elective isolated OPCAB are prospectively studied. The patients were classified as either NSR or AF group according to their postoperative rhythm, which was continuously monitored for the first 6 postoperative days. Results: AF developed in 66 patients (19%). Univariate analysis demonstrated old age, pre-existing chronic renal failure, low left ventricle ejection fraction (LVEF <30%), highest hsCRP before the onset of AF, vasopressor and inotropic therapy, packed red blood cells (pRBCs) transfusion and amount of chest tube drainage as predictors of postoperative AF. In a stepwise multivariate analysis of these risk factors, low LVEF (odds ratio: 2.88; 95% confidence interval: 1.07–7.75; p = 0.037), highest hsCRP before the onset of AF (odds ratio: 1.06; 95% confidence interval: 1.01–1.11; p = 0.018), vasopressor therapy (odds ratio: 1.93; 95% confidence interval: 1.04–3.57; p = 0.038) and pRBC transfusion (odds ratio: 5.32; 95% confidence interval: 2.80–10.11; p < 0.001) remained as independent predictors of postoperative AF. Conclusions: Prophylactic strategies aimed at AF reduction may also be considered especially in patients with increased transfusion requirement, which showed highest predictive value for postoperative AF.

Background: Coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC) is the gold standard for surgical coronary re-vascularisation. Recently, minimised extracorporeal circulation system (MECC) has been postulated a safe and advantageous alternative for multi-vessel CABG. Method: Between January 2004 and December 2007, 244 high-risk patients (logistic EuroScore (ES) > 10%) underwent CABG in our institution. ECC was used in 139 (57%) and MECC in 105 (43%) patients. Demographic data including age (MECC: 73.4 ± 7.4 years; ECC: 73.3 ± 6.4 years), ES (MECC: 19.2 ± 9.8%; ECC: 21.4 ± 11.9%), left-ventricular ejection fraction (MECC: 45.6 ± 16.1%; ECC: 43.1 ± 15.3%), diabetes mellitus (MECC: 14.3%; ECC: 15.1%) and COPD (MECC: 6.7%; ECC: 7.9%) did not differ between the two groups. Preoperative end-stage renal failure was an exclusion criterion. The clinical course and serological/haematological parameters in the ECC and MECC patients were compared in a retrospective manner. Results: Although the numbers of distal anastomoses did not differ between the two groups (MECC: 3.0 ± 0.9; ECC: 2.9 ± 0.9), ECC time was significantly shorter in the MECC group (MECC: 96 ± 33 min; ECC: 120 ± 50 min, p < 0.01). Creatinine kinase (CK) levels were significantly lower 6 h after surgery in the MECC group (MECC: 681 ± 1505 U l^–1; ECC: 1086 ± 1338 U l^–1, p < 0.05) and the need of red blood cell transfusion was significantly less after MECC surgery (MECC: 3 [range: 1–6]; ECC: 5 [range: 2–9] p < 0.05). Moreover, 30-day mortality was significantly lower in the MECC group as compared to the ECC group (MECC: 12.4%; ECC: 26.6, p < 0.01). Discussion: MECC is a safe alternative for CABG surgery. A lower 30-day mortality, lower transfusion requirements and less renal and myocardial damage encourage the use of MECC systems, especially in high-risk patients.

Objective: Acute kidney injury (AKI) post-cardiac surgery is associated with mortality rates approaching 20%. The development of effective treatments is hindered by the poor homology between rodent models, the mainstay of research into AKI, and that which occurs in humans. This pilot study aims to characterise post-cardiopulmonary bypass (CPB) AKI in an animal model with potentially greater homology to cardiac surgery patients. Methods and results: Adult pigs, weighing 50–75 kg, underwent 2.5 h of CPB. Pigs undergoing saphenous vein grafting procedures served as controls. Pre-CPB measures of porcine renal function were within normal ranges for adult humans. The effect of CPB on renal function; a 25% reduction in ⁵¹Cr-EDTA clearance (p = 0.068), and a 33% reduction in creatinine clearance (p = 0.043), was similar to those reported in clinical studies. CPB resulted in tubular epithelial injury (median NAG/creatinine ratio 2.6 u mmol^–1 (interquartile range (IQR): 0.81–5.43) post-CPB vs 0.48 u mmol^–1 (IQR: 0.37–0.97) pre-CPB, p = 0.043) as well as glomerular and/or proximal tubular injury (median albumin/creatinine ratio 6.8 mg mmol^–1 (IQR: 5.45–13.06) post-CPB vs 1.10 mg mmol^–1 (IQR: 0.05–2.00) pre-CPB, p = 0.080). Tubular injury scores were significantly higher in kidneys post-CPB (median score 2.0 (IQR: 1.0–2.0) relative to vein graft controls (median score 1.0 (IQR 1.0–1.0), p = 0.019). AKI was associated with endothelial injury and activation, as demonstrated by reduced DBA (dolichos biflorus agglutinin) lectin and increased endothelin-1 and vascular cell adhesion molecule (VCAM) staining. Conclusions: The porcine model of post-CPB AKI shows significant homology to AKI in cardiac surgical patients. It links functional, urinary and histological measures of kidney injury and may offer novel insights into the mechanisms underlying post-CPB AKI.

Objective: The optimal timing for discontinuation of clopidogrel before surgery remains under debate. The purpose of this study is to determine the effect of preoperative clopidogrel administration on postoperative blood loss and the total requirements of homologous blood products after coronary artery bypass grafting (CABG). We also evaluated the perioperative complications. Methods: Consecutive patients (n = 130) undergoing elective CABG were recruited and randomised between 2006 and 2007. In 38 patients (group 1), treatment with clopidogrel was discontinued 5 days prior to surgery, in 40 patients (group 2) 3 days before surgery and in 40 other patients (group 3) clopidogrel was stopped on the day of surgery. Results: Significantly more postoperative blood loss was observed in group 3 compared to group 1 (929 ± 472 ml vs 664 ± 312 ml; p = 0.009). Other group comparisons were not significant. Blood loss after 12 h and at drain removal was also significantly higher in group 3. Patients in group 3 also had higher total requirements of homologous blood products (p = 0.046) and a significantly higher need for fresh frozen plasma (FFP) transfusion (p = 0.034). Univariable regression analyses revealed that continuing clopidogrel till the day of surgery (group 3) was predictive for postoperative blood loss (β = 0.289; p = 0.007) and the total requirements of homologous blood products after surgery (β = 0.280; p = 0.008). These effects remained the same in multivariable analyses. Conclusions: Continuation of clopidogrel until the day of surgery induces significantly more postoperative blood loss and increases significantly the total requirements of homologous blood products and FFP transfusion after surgery. The blood loss and the use of blood products in the group that stopped at 3 days preoperatively were similar to that of the group that stopped at 5 days preoperatively.

Objective: The effectiveness and safety of aprotinin use in cardiac surgery have been questioned. More data reflecting everyday clinical practice from large-scale, unselected populations are needed. We compared the effectiveness and safety of aprotinin in cardiac surgery with those of tranexamic acid in a follow-up study using the population-based Danish health-care databases. Methods: We identified a total of 3535 patients who underwent cardiac surgery at the Aarhus University Hospital, Skejby, between 1 January 2003 and 31 December 2006; of these, 635 patients were treated with aprotinin and 2900 with tranexamic acid. We used propensity score matching to match aprotinin-treated patients with tranexamic-acid-treated patients in a 1:1 ratio, followed by Poisson regression analysis to compute relative risks (RRs). Results: Patients treated with aprotinin had more severe preoperative risk profiles than the tranexamic-acid-treated patients. The rates of postoperative drainage and transfusion of red blood cells were similar in the two groups, whereas the aprotinin group received plasma (adjusted RR = 1.39; 95% confidence interval (CI): 1.15–1.68) and platelets (adjusted RR = 1.47; 95% CI: 1.19–1.81) more frequently than the tranexamic acid group. There were no statistically significant differences in risks of re-operation due to bleeding (adjusted RR = 1.22; 95% CI: 0.84–1.78), 30-day mortality (adjusted RR = 1.03; 95% CI: 0.69–1.54), acute myocardial infarction (adjusted RR = 1.06; 95% CI: 0.69–1.64), stroke (adjusted RR = 1.36; 95% CI: 0.75–2.44) or composite major event (adjusted RR = 1.14; 95% CI: 0.87–1.50) between the two groups. However, patients who received aprotinin had an increased risk of postoperative dialysis (adjusted RR = 1.76; 95% CI: 1.15–2.70). Conclusions: Aprotinin treatment was associated with an increased use of plasma and platelet transfusion and an increased risk for postoperative dialysis, but not with other adverse outcomes, including short-term mortality.

Background: Aprotinin is the only Food and Drug Administration-approved agent to reduce haemorrhage related to cardiac surgery and its safety and efficacy has been extensively studied. Our study sought to compare the efficacy, early and late mortality and major morbidity associated with aprotinin compared with e-aminocaproic acid (EACA) in cardiac surgery operations. Methods: Between January 2002 and December 2006, 2101 patients underwent coronary artery bypass grafting (CABG), valve surgery or CABG and valve surgery in our institution with the use of aprotinin (1898 patients) or EACA (203 patients). Logistic regression and propensity score analysis were used to adjust for imbalances in the patients’ preoperative characteristics. The propensity score-adjusted sample included 570 patients who received aprotinin and 114 who received EACA (1–5 matching). Results: Operative mortality was higher in the aprotinin group in univariate (aprotinin 4.3% vs EACA 1%, p = 0.023) but not propensity score-adjusted multivariate analysis (4% vs 0.9%, p = 0.16). In propensity score-adjusted analysis, aprotinin was also associated with a lower rate of blood transfusion (38.8% vs 50%, p = 0.04), a lower rate of haemorrhage-related re-exploration (3.7% vs 7.9%, p = 0.04) and a higher risk of in-hospital cardiac arrest (3.7% vs 0%, p = 0.03) and a marginally but not statistically significantly higher risk of acute renal failure (6.8% vs 2.6%, p = 0.09). In Cox proportional hazards regression analysis, the risk of late death was higher in the aprotinin compared to EACA group (hazard ratio = 4.33, 95% confidence interval (CI) = 1.60–11.67, p = 0.004). Conclusion: Aprotinin decreases the rate of postoperative blood transfusion and haemorrhage-related re-exploration, but increases the risk of in-hospital cardiac arrest and late mortality after cardiac surgery when compared to EACA. Cumulative evidence suggests that the risk associated with aprotinin may not be worth the haemostatic benefit.

Objective: Leucocyte filtration of salvaged blood has been suggested to prevent patients from receiving activated leucocytes during auto-transfusion in cardiac surgery. This study examines whether leucocyte filtration of salvaged blood affects the red blood cell (RBC) function and whether there is a difference between filtration of the concentrated and diluted blood on RBC function. Methods: Forty patients undergoing cardiac surgery with cardiopulmonary bypass were randomly divided into a group receiving leucocyte filtration of concentrated blood (High-Hct, n = 20) and another group receiving leucocyte filtration of the diluted blood (Low-Hct, n = 20). During operation, all the salvaged blood, as well as the residual blood, from the heart–lung machine was filtered. In the High-Hct group, blood was concentrated with a cell saver prior to filtration, whereas in the Low-Hct group, blood was filtered without concentration. RBC function was represented by RBC aggregation and deformability measured by a laser-assisted optical rotational cell analyser and by the RBC 2,3-diphosphoglycerate (2,3-DPG) and adenosine triphosphate (ATP) contents with conventional biochemical tests. Results: Leucocyte filtration of diluted blood with a low haematocrit (14 ± 4%) did not affect RBC function. However, when the concentrated blood with a high haematocrit (69 ± 12%) was filtered, there was a reduction of ATP content in RBCs after passing through the filter (from 1.45 ± 0.57 µmol g^–1 Hb to 0.92 ± 0.75 µmol g^–1 Hb, p < 0.05). For patients who received the concentrated blood, their in vivo RBC function did not differ from those who received diluted blood. Conclusions: Leucocyte filtration of the diluted salvaged blood during cardiac surgery does not affect RBC function, but it tends to deplete the ATP content of RBCs as the salvaged blood has been concentrated prior to filtration.

Objective: Diaphragmmatic eventration is a relatively uncommon entity with a simple surgical correction technique – plication of the diaphragm. This study aims to assess the clinical and ventilatory impact of this technique. Materials: From April 1988 to February 2007, we operated on 20 patients (12 men) with diaphragmmatic eventration using the postero-lateral approach and correction by radial plication. The mean age of the patients studied was 56.3 ± 15.6 years (range: 13–74 years). A traumatic cause was identified in 13 patients; one patient had a congenital cause and the remainder were of idiopathic origin. Chronic obstructive pulmonary disease and arterial hypertension were present in one-half of the study group, while diabetes mellitus was present in three patients. Dyspnoea was the most common complaint in 75% of the patients, and thoracic pain was present in 25%. The mean forced expiratory volume in 1 s (FEV₁) and vital capacity (VC) were 66.2 ± 15.3% and 70.4 ± 16% of the predicted values, respectively. Results: There was no operative mortality. Apart from a patient with moderate/severe pain and another who had pneumonia, there were no other important perioperative complications. Average drainage time was 3.3 ± 1.6 days (range: 2–7 days). Hospitalisation time was 6.2 ± 1.6 days (5–10 days). Follow-up was complete, for a mean of 59.6 ± 55.1 months (4–206 months). There were three late deaths (one sudden, one stroke and one trauma). Eight of the 17 survivors (47%) are asymptomatic. According to the MRC/ATS grading system, the dyspnoea score was 2.06 ± 0.97 preoperatively and 1.06 ± 1.14 postoperatively (p = 0.007). At follow-up, the FEV₁ was 76.1 ± 20.1% and the VC was 78.4 ± 17.3% (p > 0.1). Two patients had chronic pain. Conclusion: Plication of the diaphragm is a safe and efficient procedure. Most patients experienced significant clinical improvement with enhancement of the FEV₁ and VC. Chronic surgical pain still remains a potential problem with the classical approach.

Objective: Oesophagectomy, whether open or minimal access, is associated with a significant incidence of gastric-conduit-related complications. Previous animal and human studies suggest that ischaemic conditioning of the stomach prior to oesophagectomy improves perfusion of the gastric conduit. We have adopted laparoscopic ligation of the left gastric artery 2 weeks prior to minimally invasive oesophagectomy, having identified a relative high incidence of gastric-tube complications through a cumulative summation (CUSUM) analysis. Methods: This study included 77 consecutive patients who underwent a Total MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric tube formation, cervical anastomosis). The ligation group comprised 22 consecutive patients, excluding those with middle-third squamous tumours or early-stage adenocarcinoma, who underwent ligation 2 weeks prior to MIO at staging laparoscopy. The control group comprised 55 patients who did not undergo ischaemic conditioning in this way. We have defined conduit-related complications as: leak managed conservatively (L); tip necrosis requiring resection and re-anastomosis (TN) and conduit necrosis needing resection and oesophagostomy (CN). The values are reported as medians. The effect of ligation of the left gastric artery was followed with a CUSUM analysis. Results: Ligation was performed 15.5 days pre-operatively (median). There were no complications and the length of hospital stay was 1 day. Although gastric mobilisation at MIO was technically more difficult after ligation, there was no significant difference in operating time (ligation, 407 min; control, 425 min) or blood loss (ligation and control, 500 ml). There was less gastric-conduit morbidity in the ligation group (two of 22, 10%; one L, one CN) compared with the control group (11 of 55, 20%; four L, five TN, two CN), but these differences did not reach statistical significance (p = 0.211 and p = 0.176 Fisher's exact test). The CUSUM analysis showed that during ligation of the left gastric artery, conservatively treated gastric-conduit-related morbidity (leak, resection and re-anastomosis or conduit necrosis) remained within safe limits (10%). Conduit-related-morbidity increased after stopping ligation. Conclusion: In this non-randomised clinical setting, our results suggest that ischaemic conditioning of the stomach prior to MIO is safe. There is a trend to reduced morbidity related to gastric-conduit ischaemia, which was demonstrated by a CUSUM analysis. A randomised trial is needed before ligation of the left gastric artery can be routinely recommended.

Objective: Controversy still persists regarding the ideal length of myotomy to treat oesophageal achalasia. This investigation reports the effects of a short myotomy with an added partial fundoplication for reflux prevention. Methods: From 1997 to 2007, 22 patients (13 men, 9 women, median age: 41 years) with achalasia underwent a 6-cm short myotomy (four oesophagus and two stomach) with a Belsey partial fundoplication by left thoracotomy. Assessments include clinical and radiological evaluation, radionuclide transit studies, manometry, 24-h pH and endoscopy. Results: No morbidity and no mortality occurred. Median follow-up is 54 months (range: 4–139 months). Dysphagia present in all 22 patients left an episodic slow emptying sensation in three patients after operation (p < 0.001). Fresh food regurgitation decreased significantly after the myotomy (17 pre-, four post-regurgitation, p < 0.001). Heartburn present in four patients before the operation was recorded in nine patients postoperatively (p = 0.179). Radiologically, barium stasis decreased significantly from 85% to 30% (p = 0.007). No diverticular formation was seen in the myotomy zone. On the oesophageal scintigram, stasis at 2 min decreased from a median of 60% before the operation to 16% (p < 0.001). The lower oesophageal sphincter (LOS) gradient decreased from 30 to 9.7 mmHg (p < 0.001). LOS relaxation improved from 40% pre- to 93% postoperatively (p = 0.003). Endoscopies and biopsies documented increased mucosal damage after the operation (one preoperative, 13 postoperative; p < 0.001). Conclusions: When treating achalasia, the myotomy, despite being shortened in length, reduces the LOS gradient, relieves obstructive symptoms and improves oesophageal emptying. The LOS relaxation is improved. Complete coverage of the myotomysed zone by the fundus prevents diverticular formation. Oesophageal mucosal damage from reflux is significant despite the partial fundoplication.

Objective: Paravertebral block (PVB) is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. Rib spreading (RS) is an important noxious stimulus considered a major cause of post-thoracotomy pain. Our hypothesis was that a bolus of ropivacaine 0.2% through a paravertebral catheter (PVC) inserted before RS could decrease pain during the first 72 postoperative hours. Methods: The methodology employed was to perform a prospective randomised study of 60 consecutive patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). A catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group, patients were randomised to receive a bolus of 20 ml of ropivacaine 0.2% before rib spreading (pre-RS) or after (post-RS), just before closing the thoracotomy. They postoperatively received 15 ml of ropivacaine 0.2% every 6 h combined with methamizol (every 6 h). Subcutaneous meperidine was employed as a rescue drug. The level of pain was measured with the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as a rescue drug and secondary effects were also recorded. Results: We did not register secondary effects in relation to the PVC (paravertebral or cutaneous bleeding or haematoma, respiratory depression, cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting or pruritus). Seven patients (11.6%) needed meperidine as rescue drug (four pre-RS and three post-RS). The mean VAS values were the following: all cases (n = 60): 4.7 ± 2.0; AT (n = 32): 4.0 ± 2.1; PT (n = 28): 5.6 ± 1.8; pre-RS (n = 30): 4.8 ± 1.9; post-RS (n = 30): 4.6 ± 2.0; AT-pre-RS (n = 16): 4.1 ± 2.0; AT-post-RS (n = 16): 3.9 ± 2.1; PT-pre-RS (n = 14): 5.6 ± 1.6; PT-post-RS (n = 14): 5.4 ± 1.7. Conclusions: Post-thoracotomy analgesia combining PVC and a non-steroidal anti-inflammatory drug is a safe and effective practice. VAS values are acceptable (only 11.6% of patients required meperidine). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.0 vs 5.6; p < 0.01). PVB with ropivacaine before RS got similar VAS values than the block after RS (4.8 vs 4.6; p > 0.05). The moment of the insertion of the PVC does not seem to affect postoperative pain levels.

Objective: Pleurectomy ± bullectomy by video-assisted thoracoscopic surgery (VATS) is an established surgical procedure for pneumothorax. Early ambulation and discharge should be a reasonable goal. This study explores the feasibility of day-case surgery and identifies the obstacles requiring further work to facilitate day-case pneumothorax surgery. Methods: Between June 2007 and May 2008, 16 consecutive patients underwent video-assisted thoracoscopic surgery bullectomy ± pleurectomy (under the care of a single surgeon) with immediate connection to an ambulatory drainage system in the theatre following surgery. Analgesia comprised temporary paravertebral with early conversion to oral opiate ± paracetamol. There were 13 males (81%), average age 23 (range: 17–29) years, and three females (19%), average age 35 (range: 22–46) years. Twelve patients (75%) had left-sided disease, of which nine (56%) underwent elective surgery. All patients had previously suffered at least one primary spontaneous pneumothorax. Patients with probable secondary pneumothorax were excluded from the study. Length of stay (LOS) was compared with a control group of patients conventionally treated prior to the study. Results: In 13 patients (81%), early discharge was achieved 1 (range: 1–2 days) day post-op, whilst connected to an ambulatory drainage system. In three patients, early discharge was not achieved. One of these patients had the chest drain removed prematurely and remained an inpatient for 3 days with aspiration and observation for a small pneumothorax. The two remaining patients required extended inpatient admissions due to postoperative non-surgical complications. In the 13 patients discharged immediately, the time to drain removal (in clinic) was electively 7 days (range: 2–11 days). Two patients required re-admission: one for contralateral spontaneous pneumothorax and another for an ipsilateral basal pneumothorax treated with a drain. Conclusion: We have shown early discharge with ongoing ambulatory drainage following VATS pleurectomy ± bullectomy in patients with primary pneumothorax to be feasible with paravertebral in the theatre and rapid conversion to oral analgesia. Patients managed intercostal drains at home. Limiting factors such as postoperative nausea and pain control usually can be sufficiently managed in the outpatient. Shorter stays may have a beneficial financial result. Long-term follow-up and a quantification of the patients experience is warranted.

Objective: Lung resection for complex aspergilloma (CA) carries high morbidity and mortality and remains controversial in high-risk patients. Cavernostomy followed by muscle-flap plombage has been recommended for patients considered unfit for resection, but subsequent muscle-flap atrophy may be a main cause of failure. We reviewed the place of a limited thoracoplasty in association with that procedure. Methods: Five patients complaining of haemoptysis related to CA were denied lung resection because of bilateral lung destruction (n = 1), and required completion pneumonectomy (previous lobectomy for cancer followed by adjuvant radiation therapy, n = 4). We analysed the data concerning the alternative surgical procedures performed and their immediate and late results. Results: The surgery consisted in cavernostomy, removal of the fungus ball, cavity obliteration with the most directly available muscle flaps (rhomboid muscle n = 2, trapezius and rhomboid n = 2, serratus major and subscapular n = 1). A limited thoracoplasty ranging from 2 to 5 portions of rib (mean resected rib portions n = 3.4) was performed in addition to this procedure. The postoperative course was uneventful. All patients are still alive (mean follow-up 3 years; range: 1–6 years) and faring well without thoracoplasty-related aftereffect, complication related to muscle-flap disuse atrophy nor recurrence of the disease. Conclusion: Cavernostomy followed by muscle transposition has been reported to provide encouraging results. Combining a limited thoracoplasty during the same operation is a simple, safe and well-tolerated procedure regularly achieving good results, and thus deserving consideration.

Objective: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. Methods: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17–82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. Results: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p < 0.0001), postoperative air leak (p = 0.004), operative time (p < 0.0001), hospital stay (p = 0.020) and time to return to work (p < 0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. Conclusions: In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.

Objective: We hypothesised that the agonal phase prior to cardiac death may negatively influence the quality of the pulmonary graft recovered from non-heart-beating donors (NHBDs). Different modes of death were compared in an experimental model. Methods: Non-heparinised pigs were divided into three groups (n = 6 per group). Animals in group I [FIB] were sacrificed by ventricular fibrillation resulting in immediate circulatory arrest. In group II [EXS], animals were exsanguinated (45 ± 11 min). In group III [HYP], hypoxic cardiac arrest (13 ± 3 min) was induced by disconnecting the animal from the ventilator. Blood samples were taken pre-mortem in HYP and EXS for measurement of catecholamine levels. After 1 h of in situ warm ischaemia, unflushed lungs were explanted and stored for 3 h (4 °C). Left lung performance was then tested during 60 min in our ex vivo reperfusion model. Total protein concentration in bronchial lavage fluid was measured at the end of reperfusion. Results: Pre-mortem noradrenalin (mcg l^–1) concentration (baseline: 0.03 ± 0) increased to a higher level in HYP (50 ± 8) vs EXS (15 ± 3); p = 0.0074. PO₂ (mmHg) at 60 min of reperfusion was significantly worse in HYP compared to FIB (445 ± 64 vs 621 ± 25; p < 0.05), but not to EXS (563 ± 51). Pulmonary vascular resistance (dynes s cm^–5) was initially higher in EXS (p < 0.001) and HYP (NS) vs FIB (15824 ± 5052 and 8557 ± 4933 vs 1482 ± 61, respectively) but normalised thereafter. Wet-to-dry weight ratio was higher in HYP compared to FIB (5.2 ± 0.3 vs 4.7 ± 0.2, p = 0.041), but not to EXS (4.9 ± 0.2). Total protein (g l^–1) concentration was higher, although not significant in HYP and EXS vs FIB (18 ± 6 and 13 ± 4 vs 4.5 ± 1.3, respectively). Conclusion: Pre-mortem agonal phase in the NHBD induces a sympathetic storm leading to capillary leak with pulmonary oedema and reduced oxygenation upon reperfusion. Graft quality appears inferior in NHBD lungs when recovered in controlled (HYP) vs uncontrolled (EXS and FIB) setting.

Objective: Single-lung transplantation (SLTX) in patients with previous contralateral pneumonectomy (PN) is a rarely observed situation. Intrathoracic anatomical changes caused by mediastinal shift may complicate the surgical procedure. We collected observations from different transplantation centres to analyse the technical aspects and results. Patients and methods: Between July 1990 and September 2008, 14 patients (seven women and seven men) with previous PN underwent SLTX for end-stage pulmonary failure. Patients were categorised in three groups according to lung disease: cystic fibrosis bronchiectasis (group 1; n = 4), non-cystic fibrosis bronchiectasis (group 2; n = 6) and bronchioloalveolar carcinoma (group 3; n = 4). We reviewed patients’ characteristics according to mediastinal shift, thoracic approach, bypass cannula procedure, perioperative difficulties and immediate and long-term results. Results: Median age was 19.5, 33.5 and 52.5 years in groups 1, 2 and 3, respectively; there were nine left and five right cases of SLTX. Surgery was performed by sternotomy (n = 4), anterolateral thoracotomy (n = 4), clamshell (n = 4) or posterolateral thoracotomy (n = 2). Cannulas for bypass were inserted into femoral (n = 7) or central vessels (n = 5) or both (n = 2). Mediastinal shift did not complicate surgical procedure but rendered cannulation more difficult with ensuing cardiopulmonary bypass dysfunction (n = 3) and early bronchial complications (n = 2). In-hospital mortality rate was 29% (4 out of 14 patients), including two deaths due to perioperative difficulties linked to mediastinal shift. Median global survival was 108 months. Median survival was higher in group 2 (108 months vs 1 month in the other groups) and in case of PN during childhood (n = 6, median survival 108 months corresponding to one death). Conclusions: SLTX after PN is associated with high perioperative morbidity and mortality due to mediastinal shift. Best results are observed in patients undergoing PN for non-cystic fibrosis bronchiectasis and during childhood. Anatomical changes induced by PN must be anticipated to adapt the thoracic approach and cardiopulmonary bypass access.

Trans-apical aortic bioprosthesis implantation is currently evaluated as an alternative technique in high-risk patients. We report the case of a delayed upward displacement of a prosthesis after this procedure. It is hypothesised that the asymmetric calcification of the native valve and the presence of a mitral prosthesis caused the dislocation.

The trans-apical aortic valve implantation (TA-AVI) is an established technique for high-risk patients requiring aortic valve replacement. Traditionally, preoperative (computed tomography (CT) scan, coronary angiogram) and intra-operative imaging (fluoroscopy) for stent-valve positioning and implantation require contrast medium injections. To preserve the renal function in elderly patients suffering from chronic renal insufficiency, a fully echo-guided trans-catheter valve implantation seems to be a reasonable alternative. We report the first successful TA-AVI procedure performed solely under trans-oesophageal echocardiogram control, in the absence of contrast medium injections.