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Background: Atrial fibrillation (AF) can be treated using a maze procedure during planned cardiac surgery, but the effect on clinical patient outcomes, and the cost-effectiveness compared with surgery alone, are uncertain., Objectives: To determine whether or not the maze procedure is safe, improves clinical and patient outcomes and is cost-effective for the NHS in patients with AF., Design: Multicentre, Phase III, pragmatic, double-blind, parallel-arm randomised controlled trial. Patients were randomised on a 1 : 1 basis using random permuted blocks, stratified for surgeon and planned procedure., Setting: Eleven acute NHS specialist cardiac surgical centres., Participants: Patients aged ≥ 18 years, scheduled for elective or in-house urgent cardiac surgery, with a documented history (> 3 months) of AF., Interventions: Routine cardiac surgery with or without an adjunct maze procedure administered by an AF ablation device., Main Outcome Measures: The primary outcomes were return to sinus rhythm (SR) at 12 months and quality-adjusted life-years (QALYs) over 2 years after randomisation. Secondary outcomes included return to SR at 2 years, overall and stroke-free survival, drug use, quality of life (QoL), cost-effectiveness and safety., Results: Between 25 February 2009 and 6 March 2014, 352 patients were randomised to the control ( n  = 176) or experimental ( n  = 176) arms. The odds ratio (OR) for return to SR at 12 months was 2.06 [95% confidence interval (CI) 1.20 to 3.54; p  = 0.0091]. The mean difference (95% CI) in QALYs at 2 years between the two trial arms (maze/control) was -0.025 (95% CI 0.129 to 0.078; p  = 0.6319). The OR for SR at 2 years was 3.24 (95% CI 1.76 to 5.96). The number of patients requiring anticoagulant drug use was significantly lower in the maze arm from 6 months after the procedure. There were no significant differences between the two arms in operative or overall survival, stroke-free survival, need for cardioversion or permanent pacemaker implants, New York Heart Association Functional Classification (for heart failure), EuroQol-5 Dimensions, three-level version score and Short Form questionnaire-36 items score at any time point. Sixty per cent of patients in each trial arm had a serious adverse event ( p  = 1.000); most events were mild, but 71 patients (42.5%) in the maze arm and 84 patients (45.5%) in the control arm had moderately severe events; 31 patients (18.6%) in the maze arm and 38 patients (20.5%) in the control arm had severe events. The mean additional cost of the maze procedure was £3533 (95% CI £1321 to £5746); the mean difference in QALYs was -0.022 (95% CI -0.1231 to 0.0791). The maze procedure was not cost-effective at £30,000 per QALY over 2 years in any analysis. In a small substudy, the active left atrial ejection fraction was smaller than that of the control patients (mean difference of -8.03, 95% CI -12.43 to -3.62), but within the predefined clinically equivalent range., Limitations: Low recruitment, early release of trial summaries and intermittent resource-use collection may have introduced bias and imprecise estimates., Conclusions: Ablation can be practised safely in routine NHS cardiac surgical settings and increases return to SR rates, but not survival or QoL up to 2 years after surgery. Lower anticoagulant drug use and recovery of left atrial function support anticoagulant drug withdrawal provided that good atrial function is confirmed., Further Work: Continued follow-up and long-term clinical effectiveness and cost-effectiveness analysis. Comparison of ablation methods., Trial Registration: Current Controlled Trials ISRCTN82731440., Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 19. See the NIHR Journals Library website for further project information., Competing Interests: Samer Nashef received personal expenses from AtriCure, Inc. (Amsterdam, the Netherlands) for contributing to educational courses for surgeons interested in learning the maze procedure, independently of this study. AtriCure, Inc. is one of several manufacturers of atrial fibrillation ablation devices, the technology of which was used in atrial fibrillation surgery in this study.

Objectives: The U.K. Transcatheter Aortic Valve Implantation Registry reported 30-day and 1-year mortality rates of 7.1% and 21.4%, respectively, for patients who underwent transcatheter aortic valve replacement (TAVR) in the United Kingdom between 2007 and 2009. The study aim was to report long-term outcomes in this same cohort of patients., Background: There are few data on outcomes beyond 3 years after TAVR in any notable number of patients., Methods: Data from all TAVR procedures performed in the United Kingdom between January 2007 and December 2009 were prospectively collected. All-cause mortality status was reported in March 2014. Mortality tracking was achieved in 97.7% patients., Results: The minimal time from replacement to census was 4.1 years, and the maximal time was 7.0 years. The 3- and 5-year survival rates were 61.2% and 45.5%, respectively. Independent predictors of 3-year mortality were renal dysfunction (hazard ratio [HR]: 1.65), atrial fibrillation (HR: 1.36), logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥18.5 (HR: 1.33), respiratory dysfunction (HR: 1.28), and ventricular dysfunction (left ventricular ejection fraction <30%) (HR: 1.53). Coronary artery disease (HR: 1.28) and age (HR: 1.03) were additional independent predictors of mortality at 5 years. Stroke within 30 days of TAVR was the only independent procedural predictor of mortality at 3 and 5 years (HR: 2.17 at 3 years). Device type, access route, and paravalvular leak did not independently predict long-term outcome., Conclusions: In the large U.K. Transcatheter Aortic Valve Implantation Registry, long-term outcomes after TAVR are favorable with 3- and 5-year survival rates of 61.2% and 45.5%, respectively. Long-term survival after TAVR is largely determined by intrinsic patient factors. Other than stroke, procedural variables, including paravalvular aortic leak, did not appear to be independent predictors of long-term survival., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We assessed trends in the performance of transcatheter aortic valve implantation in the United Kingdom from the first case in 2007 to the end of 2012. We analyzed changes in case mix, complications, outcomes to 6 years, and predictors of mortality., Methods and Results: Annual cohorts were examined. Mortality outcomes were analyzed in the 92% of patients from England and Wales for whom independent mortality tracking was available. A total of 3980 transcatheter aortic valve implantation procedures were performed. In successive years, there was an increase in frequency of impaired left ventricular function, but there was no change in Logistic EuroSCORE. Overall 30-day mortality was 6.3%; it was highest in the first cohort (2007-2008), after which there were no further significant changes. One-year survival was 81.7%, falling to 37.3% at 6 years. Discharge by day 5 rose from 16.7% in 2007 and 2008 to 28% in 2012. The only multivariate preprocedural predictor of 30-day mortality was Logistic EuroSCORE ≥40. During long-term follow-up, multivariate predictors of mortality were preprocedural atrial fibrillation, chronic obstructive pulmonary disease, creatinine >200 μmol/L, diabetes mellitus, and coronary artery disease. The strongest independent procedural predictor of long-term mortality was periprocedural stroke (hazard ratio=3.00; P<0.0001). Nonfemoral access and postprocedural aortic regurgitation were also significant predictors of adverse outcome., Conclusions: We analyzed transcatheter aortic valve implantation in an entire country, with follow-up over 6 years. Although clinical profiles of enrolled patients remained unchanged, longer-term outcomes improved, and patients were discharged earlier. Periprocedural stroke, nonfemoral access, and postprocedural aortic regurgitation are predictors of adverse outcome, along with intrinsic patient risk factors., (© 2015 American Heart Association, Inc.)

Objectives: Lung volume reduction surgery (LVRS) for advanced emphysema is well established, with strong evidence from the National Emphysema Treatment Trial. However, there is still reluctance to offer the procedure, and many have looked for alternative, unproven treatments. The multidisciplinary approach has been well established in treatment of lung cancer and, more recently, in coronary artery surgery. We reviewed our practice to validate the role of our multidisciplinary team approach in our LVRS programme., Methods: Our multidisciplinary approach employs respiratory physicians, radiologists and surgeons involved in case selection, who meet on a regular basis. Cases are selected on the basis of clinical presentation, imaging (radionuclide lung perfusion and computerized tomography) and respiratory physiology. Retrospective analysis of prospectively collected data on 633 patients referred for lung volume reduction surgery between July 1995 and July 2013., Results: Six hundred and thirty-three patients (422 male) were referred for LVRS, of whom 253 [178 male; median age 61 years (range 37-79 years)] underwent 292 LVRS procedures.There were 268 video-assisted thoracoscopic surgical procedures, of which 13 were one-stage bilateral procedures and 37 required a staged second side. Overall median hospital stay was 13 (4-197) days, during which 11 patients died. Prolonged hospital stay was associated with increasing age and with duration of air leak, which in turn was associated with diffusion capacity and forced expiratory volume in 1 s., Conclusions: The outcomes of a successful LVRS programme are not only dependent on good surgical technique and post-operative care. Case selection and work-up by a dedicated multidisciplinary approach for emphysema patients plays an invaluable and integral part in an LVRS programme., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The aim of the current study was to identify predictors of paraprosthetic aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and examine its influence on short/medium-term mortality using the UK TAVI Registry. TAVI is an effective treatment for high-risk patients with severe symptomatic aortic stenosis (AS), but paraprosthetic AR has been associated with increased in-hospital and mid-term mortality., Methods: Between January 2007 and December 2011, 2584 TAVI procedures were performed in the UK. Patients undergoing 'valve-in-valve' procedures, patients with aortic regurgitation as the primary pathology and with no recorded severity of AR were excluded from this analysis (n=144). In total, therefore, 2440 patients were included. Balloon-expandable and self-expanding devices were implanted in 52.7 and 47.2%, respectively, using either transfemoral (67.7%) or non-transfemoral, surgical access (32.3%)., Results: Postprocedural AR was observed in 68%, mild AR in 57% and moderate-severe in 10%. A large aortic annulus, high preprocedural transaortic gradient, and use of self-expanding valve were independent predictors of moderate-severe AR. Moderate-severe (but not mild) AR was associated with increased mortality, and this relationship appeared significant for the balloon-expandable but not the self-expanding device., Conclusions: Our data suggest that a large aortic annulus, high preprocedural transaortic gradient, and use of the self-expanding valve predict moderate-severe AR after TAVI. Such a degree of AR is associated with a significantly worse outcome with the balloon-expandable, but not with the self-expanding valve. Further studies are needed to verify this and explore potential mechanisms., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We describe a case of 64-year-old female patient with ventricular tachycardia intractable to medical treatment and acute heart failure following myocardial infarction. Emergency surgical ventricular reconstruction and subendocardial resection was undertaken. We discuss the option of surgical intervention in this difficult and unusual clinical scenario.

Aims: Transcatheter aortic valve replacement (TAVR) is established as a treatment strategy for patients with end-stage aortic stenosis, many of whom are suffering from severe pulmonary hypertension (PH). In cardiac surgery patients, PH is associated with less symptomatic improvement and increased late mortality. This study elucidates the impact of PH on outcome after TAVR., Methods and Results: Pre and 90 days post-TAVR, pulmonary artery systolic pressure (PASP) was determined non-invasively by echocardiography in 353 patients undergoing TAVR. PH was classified as absent (<30 mmHg), mild-to-moderate (30-60 mmHg), and severe (>60 mmHg). Three hundred and fifty-three patients at high surgical risk, indicated by a logistic EuroSCORE of 26.6±16.5%, underwent TAVR. The severity of PH before TAVR was related to outcome with two-year mortality rates of 13.9%, 27.3%, and 48.4% for PASP <30 mmHg, 30-60 mmHg, and >60 mmHg, respectively (p=0.001). In patients with baseline PASP >60 mmHg, PASP decreased from 65.6±7.6 mmHg to 49.5±14.0 mmHg (p<0.001) at 90 days after TAVR. Patients with persistent severe PH had a worse prognosis than patients with a decrease of PASP below 60 mmHg (two-year mortality rate: 50.0% vs. 18.6%; p=0.001)., Conclusions: Severe pulmonary hypertension predicts adverse outcome after TAVR. Reduction of PASP after the procedure is associated with favourable prognosis.

Objectives: The aim of this study was to evaluate the performance of the aortic regurgitation (AR) index as a new hemodynamic parameter in an independent transcatheter aortic valve implantation (TAVI) cohort and validate its application., Background: Increasing evidence associates more-than-mild periprosthetic aortic regurgitation (periAR) with increased mortality and morbidity; therefore precise evaluation of periAR after TAVI is essential. The AR index has been proposed recently as a simple and reproducible indicator for the severity of periAR and predictor of associated mortality., Methods: The severity of periAR was evaluated by echocardiography, angiography, and periprocedural measurement of the dimensionless AR index = ([diastolic blood pressure - left ventricular end-diastolic pressure]/systolic blood pressure) × 100. A cutoff value of 25 was used to identify patients at risk., Results: One hundred twenty-two patients underwent TAVI by use of either the Medtronic CoreValve (Medtronic, Minneapolis, Minnesota) (79.5%) or the Edwards-SAPIEN bioprosthesis (Edwards Lifesciences, Irvine, California) (20.5%). The AR index decreased stepwise from 29.4 ± 6.3 in patients without periAR (n = 26) to 28.0 ± 8.5 with mild periAR (n = 76), 19.6 ± 7.6 with moderate periAR (n = 18), and 7.6 ± 2.6 with severe periAR (n = 2) (p < 0.001). Patients with AR index <25 had a significantly increased 1-year mortality rate compared with patients with AR index ≥ 25 (42.3% vs. 14.3%; p < 0.001). Even in patients with none/mild periAR, the 1-year mortality risk could be further stratified by an AR index <25 (31.3% vs. 14.3%; p = 0.04)., Conclusions: The validity of the AR index could be confirmed in this independent TAVI cohort and provided prognostic information that was complementary to the severity of AR., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective was to define the characteristics of a real-world patient population treated with transcatheter aortic valve implantation (TAVI), regardless of technology or access route, and to evaluate their clinical outcome over the mid to long term., Background: Although a substantial body of data exists in relation to early clinical outcomes after TAVI, there are few data on outcomes beyond 1 year in any notable number of patients., Methods: The U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry was established to report outcomes of all TAVI procedures performed within the United Kingdom. Data were collected prospectively on 870 patients undergoing 877 TAVI procedures up until December 31, 2009. Mortality tracking was achieved in 100% of patients with mortality status reported as of December 2010., Results: Survival at 30 days was 92.9%, and it was 78.6% and 73.7% at 1 year and 2 years, respectively. There was a marked attrition in survival between 30 days and 1 year. In a univariate model, survival was significantly adversely affected by renal dysfunction, the presence of coronary artery disease, and a nontransfemoral approach; whereas left ventricular function (ejection fraction <30%), the presence of moderate/severe aortic regurgitation, and chronic obstructive pulmonary disease remained the only independent predictors of mortality in the multivariate model., Conclusions: Midterm to long-term survival after TAVI was encouraging in this high-risk patient population, although a substantial proportion of patients died within the first year., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

We sought to determine the significance of incomplete stent frame expansion after transcatheter aortic valve implantation with the Medtronic-CoreValve device. Incomplete coronary stent expansion is a well-described phenomenon. Transcatheter valves are mounted on stents; however, the incidence of incomplete stent expansion after transcatheter aortic valve implantation, its sequelae and predictors are poorly elucidated. The 18Fr CoreValve revalving system was used to treat anatomically and clinically suitable patients with severe calcific aortic stenosis. The postdeployment stent dimensions were measured on fluoroscopic images at multiple levels of the stent frame. Incomplete expansion at each was defined as <100% expected and complete expansion as ≥100%. These parameters were correlated to the hemodynamic and clinical end points. A total of 50 consecutive patients underwent transcatheter aortic valve implantation with the Medtronic-CoreValve at a single center from January 2007 to December 2008. For the inflow portion, incomplete expansion was seen in 54% of patients and was unrelated to the aortic valve area, peak or mean aortic valve gradients, or measures of aortic regurgitation, although it was paradoxically associated with a lower incidence of prosthesis-patient mismatch. Incomplete expansion of the constrained portion was seen in 62% of the patients and displayed a trend toward a greater incidence of aortic regurgitation grade 2 or greater, although this was rare. Incomplete expansion of the Medtronic CoreValve stent frame is common. For the most part, valvular hemodynamic function was satisfactory, regardless of the degree of expansion of the stent frame that carries it and a strategy of reluctant postdilation in the context of incomplete stent frame expansion was supported., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The intra aortic balloon pump (IABP) is a mechanical assist device which improves cardiac function. The device has a well-established place in algorithms for managing low cardiac output following cardiac surgery. There is increasing evidence that certain cardiac surgery patients benefit from a period of preoperative augmentation with the intra aortic balloon pump., Objectives: To determine the effect of the preoperative intra aortic balloon pump on mortality and morbidity in a number of different patients groups undergoing coronary artery bypass grafting., Search Strategy: The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2009), MEDLINE (2000 to August 2009), EMBASE (1998 to August 2009), BIOSIS previews (1969 to August 2009) and ISI Proceedings (1990 to August 2009) were searched. References and ongoing registers of studies were checked. No language restrictions were applied., Selection Criteria: Randomised controlled trials (RCTs) of any size or length were included., Data Collection and Analysis: Papers were assessed for inclusion by two authors independently and differences were settled by consensus with a third author. Date are presented in the form of odds ratios (OR) and 95% confidence intervals (CI)., Main Results: Six trials were included (five on-pump and one off-pump). This update adds the results of one further trial. Data from a total of 255 patients were included in the meta-analysis of mortality outcomes; all on-pump. Generally, the patients were considered as "high risk" and 132 were treated preoperatively with IABP and 123 served as controls. There were four hospital deaths in the intervention arm and 23 in the non-intervention arm (OR 0.18, 95% CI 0.08 to 0.41; P<0.0001). In a subgroup analysis, low cardiac index (<2.0 L/min/m(2)) was noted in 21 out of 105 patients in the treatment arm and 59 patients out of 88 in the non-treatment arm (OR 0.14, 95% CI: 0.08 to 0.25; P<0.00001). An off-pump versus on-pump analysis was not possible due to the limited number of off-pump studies. However a single well-conducted RCT suggested favourable effect of the preoperative IABP in off-pump patients., Authors' Conclusions: Evidence suggests that preoperative IABP may have a beneficial effect on mortality and morbidity in specific high risk patient groups undergoing coronary artery bypass grafting, however there are many problems with the quality, validity and generalisability of the trials. However, the available evidence is not robust enough to extend the use of IABP to truly elective, high risk patients. Defining more precisely which patient groups may benefit would be the challenge for the future.

Objectives: This study sought to assess the proportion of patients anatomically suitable for transcatheter aortic valve implantation by multiple access approaches., Background: The devices currently in mainstream use for transcatheter treatment of severe aortic stenosis are those of Edwards (Edwards Lifesciences, Nyon, Switzerland) and Medtronic CoreValve (M-C) (Luxembourg City, Luxembourg). The range of patients that these can presently treat requires elucidation to guide the necessary evolution of these technologies and increase their scope of therapy., Methods: A consecutive series of patients were assessed with transthoracic or transesophageal echocardiography and invasive angiography to assess anatomical suitability by different approaches. The transfemoral access requirements for Edwards and M-C (Edwards currently 22- and 24-F, soon to be 18- and 19-F; M-C 18-F) as well as the aortic valve annular criteria (18 to 25 mm and 20 to 27 mm, respectively) were incorporated in this assessment. Patients unsuitable for the transfemoral approach were considered for Edwards transapical and M-C transaxillary and direct ascending aortic access. Patients suitable for these devices and access approaches were identified., Results: Data were analyzed for 100 consecutive patients. Edwards suitability was 28% for Edwards-Sapien transfemoral, 78% for Edwards Novaflex transfemoral, and 88% for Edwards-Sapien transapical. Medtronic CoreValve suitability was 84% for transfemoral and 89% using additional transaxillary and direct aortic approaches. Of the 12 patients unsuitable for Edwards-based procedures, 8 were suitable for M-C. Of the 11 patients unsuitable for M-C-based techniques, 8 were suitable for Edwards. Only 3% were anatomically unsuitable for all approaches., Conclusions: In this series, 97% of patients were anatomically suitable for a complementary approach to treatment., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Prosthesis-patient mismatch (P-PM) is an important determinant of morbidity and mortality following open aortic valve replacement. The aims of this study were to report its incidence and determinants following transcatheter aortic valve implantation (TAVI) with the Corevalve bioprosthesis, which have-thus far-not been described., Methods and Results: Patients with severe calcific aortic stenosis received TAVI with the Corevalve bioprosthesis via transfemoral route. Following TAVI, moderate P-PM was defined as indexed aortic valve effective orifice area (AVAi) < or =0.85 cm(2)/m(2) and severe P-PM as AVAi < or =0.65 cm(2)/m(2). Clinical, echocardiographic, and procedural factors relating to P-PM were studied. Optimal device position was defined on fluoroscopy as final position of the proximal aspect of the Corevalve stent frame 5-10 mm below the native aortic annulus. Between January 2007 and January 2009, 50 consecutive patients underwent TAVI in a single centre with the Corevalve bioprosthesis. Mean age was 82.8 years (SD 5.9; 70-93) and 48% were male. P-PM occurred in 16 of 50 cases (32%). Optimal position was achieved in 50% of cases. P-PM was unrelated to age, annulus size, LVOT size, Corevalve size, aortic angulation, ejection fraction, and sex. It was inversely correlated to optimal position (Spearman rho r = -0.34, P = 0.015). Those with optimal positioning had a 16% incidence of P-PM relative to 48% of those with suboptimal positioning (Pearson chi(2) P = 0.015)., Conclusion: The incidence of P-PM following TAVI with the Corevalve bioprosthesis is compared favourably with that seen after AVR with conventional open stented bioprostheses and its occurrence is influenced by device positioning.

Previous studies have suggested that South Asian (SA) ethnicity is a predictor of poorer outcome after coronary artery bypass grafting (CABG). Our aim was to identify potential reasons for the higher postoperative mortality in SA patients and investigate all these reasons. All individuals undergoing isolated CABG in a tertiary cardiac centre from April 2002 to September 2007. In total, there were 2897 subjects (2623 white subjects; 274 SA subjects) who were included in an observational study showing the effect of ethnicity on the medium-term survival following CABG. Survival at 30 days and survival up to five years (median 2.7 years) were measured. SA subjects undergoing CABG were younger (62+/-9 vs. 66+/-9 years, P<0.001), less obese [body mass index (BMI) 26+/-4 vs. 28+/-4 kg/m(2), P<0.001] and had a higher prevalence of diabetes mellitus (58% vs. 33%, P<0.001) compared with white subjects. Thirty-day mortality was higher in SA subjects (2.6% vs. 1.0%, P=0.02). Non-diabetic SA had similar 30-day mortality, five-year survival and life expectancy compared to non-diabetic white subjects. In contrast, diabetic SA had a higher 30-day mortality (3.8% vs. 1.4%, P=0.01) and worse life expectancy compared to diabetic white subjects. The higher early postoperative mortality observed in SA patients is related to higher incidence of diabetes among them. SA diabetics have a significantly higher postoperative mortality and worse overall life expectancy. Ethnicity per se is not an independent predictor of short- or medium-term survival after CABG.

Aims: The optimal clinical protocol to detect fractures of transcatheter aortic valves is unknown. To the best of our knowledge, there are no published reports describing stent or frame fractures following transcatheter aortic valve implantation. The purpose of this study is two-fold: (1) to determine the optimal fluoroscopic protocol to identify potential fractures of the Medtronic CoreValve frame; and (2) to implement this protocol in the analysis of the fluoroscopic films of patients implanted with the CoreValve device with 1-year minimum follow-up., Methods and Results: Considering the resolution of fluoroscopy (approximately 0.2 mm), we used a 0.2 mm diamond-cutter to create a single fracture in a single strut of two CoreValve frames. An intact CoreValve prosthesis was used as control. These prostheses were subsequently implanted in post-mortem heart specimens. A protocol involving still frames and rotational (left-right and cranial-caudal) fluoroscopic imaging was then applied to the heart specimens. The experimentally induced fractures were detectable on the rotational cine runs (left-right and cranial-caudal); in some of the fixed acquisition sequences, however, the fractures were undetectable. The fluoroscopic protocol was retrospectively applied to the films of 58 patients who underwent implantation with the CoreValve System between October 2005 and August 2008 and had at least 1-year follow-up. The mean and median follow-up times were 22 months and 24 months, respectively (range 12 to 36 months). Rotational cine films (only left-right lateral) were available in 39 patients (60%). No frame fractures of the CoreValve frame were identified., Conclusions: Rotational cine runs in the left-right and cranial-caudal directions should be mandatory in the clinical assessment of the structural integrity of the CoreValve frame. No frame fractures were identified in 58 patients implanted with the Medtronic CoreValve device with 2-year mean follow-up.

Background: There is considerable controversy regarding the optimal management of patients undergoing cardiac surgery who are found to have an asymptomatic, unilateral carotid artery stenosis. Prior to 2004, the policy of this Unit was to perform a synchronous cardiac and carotid revascularisation. After January 2004, the policy was changed and patients underwent their cardiac procedure without carotid revascularisation. The aim of this study was to audit the incidence of stroke in the peri-operative period following this change in practice., Methods: Five-year audit of the 30-day risk of stroke after 61 consecutive open cardiac procedures in patients with unilateral, asymptomatic 70-99% (NASCET) stenoses who did not undergo prophylactic carotid endarterectomy., Results: 61 cardiac procedures; coronary artery bypass grafting (CABG)=44, valve replacement=6, CABG+valve replacement=9, CABG+repair of left ventricular aneurysm=2 were undertaken and the 30-day outcomes audited. There were three deaths (4.9%), all due to myocardial infarction. No strokes occurred in any patient in the 30-day post-operative period., Conclusion: These results challenge the opinion that the presence of a unilateral, asymptomatic carotid stenosis in patients undergoing open cardiac surgery is associated with an increased risk of peri-operative stroke, sufficient to warrant routine prophylactic carotid revascularisation.

Introduction: Changes in atrioventricular (AV) conduction and need for permanent pacemaker (PPM) are a recognized complication after open aortic valve replacement. We hypothesized that the need for PPM after CoreValve (Corevalve Inc, Irvine, CA) can be predicted with a combination of baseline variables., Methods: In patients undergoing transcatheter aortic valve implantation, potential clinical, electrocardiographic and echocardiographic predictors of permanent pacing requirement were studied., Results: Between January 2007 and March 2008, 34 patients with severe symptomatic aortic stenosis were recruited in a single center. Mean age was 84.4 years (SD 5.4, range 71-93). Of 34 cases paced at baseline, 3 (8.8%) were excluded from this analysis, as was the single periprocedural mortality. Of the remaining 30, 10 underwent permanent pacemaker implantation during the same admission (33.3%). PPM was for prolonged high-grade AV block in 4 cases, episodic high-grade AV block in 5, and sinus node disease in 1. Need for pacemaker was correlated to left axis deviation at baseline (P = .004, r = 0.508) and left bundle-branch block with left axis deviation (P = .002, r = 0.548). It was related to diastolic interventricular septal dimension on transthoracic echocardiography >17 mm (P = .045, r = 0.39) and the baseline thickness of the native noncoronary cusp (P = .002, r = 0.655). A susceptibility model was generated, and if at least one of (1) left bundle-branch block with left axis deviation, (2) interventricular septal dimension >17 mm, or (3) noncoronary cusp thickness >8 mm was present, the likelihood of PPM could be predicted with 75% sensitivity and 100% specificity and a receiver operating characteristic curve area of 0.93 +/- 0.055 (P < .001)., Conclusions: After transcatheter aortic valve implantation with CoreValve, permanent pacing was performed in around a third of patients and we present preliminary concepts towards a predictive model for this phenomenon.

The association between gastrointestinal (GI) bleeding due to angiodysplasia of the large intestine and calcific aortic stenosis (AS) has been a matter of debate. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. von Willebrand factor is the strongest possible link between aortic stenosis and bleeding associated with GI angiodysplasia. Physicians should be aware of this entity when dealing with elderly patients presenting either with GI bleeding or with AS. A high index of suspicion and appropriate diagnostic procedures followed by prompt treatment could be life saving. Several questions related to the pathogenesis and optimal management remain unanswered. Aortic valve replacement appears to offer the best hope of long-term resolution of the bleeding, and should be considered in most cases. The association between chronic gastrointestinal bleeding in elderly patients and aortic stenosis becomes more relevant with the advent of transcatheter aortic valve implantation which can be offered even to elderly patients with comorbidities which could make conventional surgery impossible.

Background/aims: Severe aortic stenosis (AS) is associated with hypertrophy of the left ventricle (LVH), which is linked to adverse clinical outcomes. To date, the effects of the novel technology of percutaneous aortic valve replacement (PAVR) on LVH in severe AS have not been described. We sought to test the hypothesis that PAVR would result in regression of LVH associated with severe AS., Methods: Patients were recruited as part of a single-arm, prospective, safety, feasibility and clinical outcome study of the third-generation CoreValve percutaneous aortic bioprosthesis. To assess hypertrophy at baseline and at 1 month, the parasternal long-axis view in end-diastole was used to assess interventricular septal dimension and left ventricular posterior wall dimension., Results: 15 patients were studied. There were significant periprocedural reductions in peak (76.6 +/- 28.1 mmHg to 16.3 +/- 7.5 mmHg; p < 0.001) and mean (45.3 +/- 18.4 mmHg to 8.2 +/- 3.7 mmHg; p = 0.001) transvalvular gradients and increases in calculated aortic valve areas (0.73 +/- 0.19 cm2 to 1.5 +/- 0.3 cm2). Septal wall thickness regressed by 13% from 1.54 +/- 0.30 cm at baseline to 1.35 +/- 0.27 cm at 1 month (for difference; p = 0.002)., Conclusion: We demonstrate an early regression of septal hypertrophy after PAVR for severe AS which is comparable to that seen at 1 year after conventional surgical aortic valve replacement.

Percutaneous aortic valve replacement (PAVR) offers considerable promise in treating high risk patients with aortic valve disease. Two devices are currently clinically available for transfemoral delivery: the Edwards-Sapien balloon-expandable bioprosthesis and the Corevalve self-expanding bioprosthesis, both of which require careful sizing of the peripheral vasculature. Through a case based discussion, we illustrate that these limits of PAVR technology can be stretched in cases of extraordinary clinical need. We demonstrate that, following a learning curve of "optimal cases," successful PAVR is also possible in diffusely diseased peripheries of borderline small size or with focal aortoiliofemoral disease amenable to a separate intervention beforehand., ((c) 2008 Wiley-Liss, Inc.)

Background: To study the feasibility and efficacy of video-assisted thoracoscopic (VAT) placement of the left ventricular pacing lead for cardiac resynchronization therapy (CRT) where the conventional transvenous coronary sinus approach has failed., Methods: Seventeen patients underwent the VAT procedure. Indications for CRT were ischemic cardiomyopathy in six patients and nonischemic cardiomyopathy in 11. The procedure was performed under general anesthesia with single-lung ventilation. Three 2-cm incisions were used on the left chest wall to place the screw-in lead near the obtuse marginal arteries high on the lateral wall of the left ventricle (LV)., Results: The VATS approach was successful in 13/17 (76%) patients. Median procedure time was 75 minutes (range 55-135). A learning curve was observed that appeared to plateau at 75 minutes procedure time after four cases. Median length of hospital stay was 2 days (range 2-8) with one patient requiring intensive care. Satisfactory thresholds and impedances of 2.3 +/- 0.9 V/0.5 ms and 560 ohms, respectively, were achieved at mean follow-up of 226 days. All patients reported symptomatic benefit with reduction in New York Heart Association score from III preoperatively to II postoperatively., Conclusions: VAT placement of the epicardial pacing lead is feasible, safe, and efficacious. It should be considered in cases where the transvenous route has failed or as an alternative in prolonged or hazardous transvenous procedures.

Monitoring of mixed venous oxygen saturation (SvO(2)) is currently performed using invasive fibre-optic catheters. This procedure is not without risk as complications may arise from catheterization. This paper describes an alternative, non-invasive method of monitoring peripheral venous oxygen saturation (SxvO(2)) which, although it cannot replace pulmonary artery catheters, can serve as an adjunct/early warning indicator of when there is an imbalance in oxygen supply and demand. The technique requires the generation of an artificial venous pulse at the finger, thereby causing modulation of the venous blood volume within the digit. The blood volume changes are monitored using an optical sensor. Just as pulse oximetry utilizes the natural arterial pulse to perform a spectrophotometric analysis of the peripheral blood in order to estimate the arterial blood oxygen saturation, the proposed venous oximetry technique uses the artificially generated venous pulse to estimate SxvO(2). A prototype device was tested in a pilot study with patients undergoing heart surgery. Data from this study support the notion that the method is capable of tracking haemodynamic changes and suggests the technique is worthy of further development and evaluation.

Background: The intra aortic balloon pump (IABP) is a mechanical assist device which improves cardiac function. The device has a well-established place in algorithms for managing low cardiac output following cardiac surgery. There is increasing evidence that certain cardiac surgery patients benefit from a period of preoperative augmentation with the intra aortic balloon pump., Objectives: To determine the effect of the preoperative intra aortic balloon pump on mortality and morbidity in a number of different patients groups undergoing coronary artery bypass grafting., Search Strategy: Searches were performed of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1 2005), MEDLINE (2000-2005) and EMBASE (1998-2005). No language restrictions were applied., Selection Criteria: Randomised or controlled trials of any size or length were included., Data Collection and Analysis: Papers were assessed for inclusion by two reviewers independently. Differences were settled by consensus with a third reviewer. Data were extracted and entered into RevMan 4.1, through which a meta-analysis of the data was performed., Main Results: Five randomised controlled trials were identified from a total of 765 studies (4 on-pump and 1 off-pump). Data from a total of 193 patients were included in the meta-analysis; all on-pump. Generally, the patients were designated as "high risk" . 105 patients were treated preoperatively with IABP and 88 patients served as controls. There were three hospital deaths in the intervention arm and 18 in the non-intervention arm (odds ratio (OR) 0.16; 95% confidence intervals (CI): 0.06 to 0.4; P<0.0001). Low cardiac index (<2.0 L/min/m2) was noted in 21 out of 105 patients in the treatment arm and 59 patients out of 88 in the non-treatment arm (OR 0.14; 95% CI: 0.08 to 0.25; P<0.00001). A large proportion of the control group had an IABP inserted postoperatively for low cardiac index (52 out of 88). An off-pump versus on-pump analysis was not possible due to the limited number of off-pump studies. However a single well-conducted randomised controlled trial suggested favourable effect of the preoperative IABP in off-pump patients., Authors' Conclusions: Available evidence suggests the preoperative intra aortic balloon pump may have a beneficial effect on mortality and morbidity in specific high risk patient groups undergoing coronary artery bypass grafting, however, the randomised evidence is from a number of small trials, with a high proportion of unstable patients, recruited at a single institution.

Objective: To describe the clinical and echocardiographic outcome after mitral valve (MV) repair for active culture positive infective MV endocarditis., Patients and Methods: Between 1996 and 2004, 36 patients (mean (SD) age 53 (18) years) with positive blood culture up to three weeks before surgery (or positive culture of material removed at operation) and intraoperative evidence of endocarditis underwent MV repair. Staphylococci and streptococci were the most common pathogens. All patients had moderate or severe mitral regurgitation (MR). Mean New York Heart Association (NYHA) class was 2.3 (1.0). Follow up was complete (mean 38 (19) months)., Results: Operative mortality was 2.8% (one patient). At follow up, endocarditis has not recurred. One patient developed severe recurrent MR and underwent valve replacement and one patient had moderate MR. There were two late deaths, both non-cardiac. Kaplan-Meier five year freedom from recurrent moderate to severe MR, freedom from repeat operation, and survival were 94 (4)%, 97 (3)%, and 93 (5)%, respectively. At the most recent review the mean NYHA class was 1.17 (0.3) (p < 0.0001). At the latest echocardiographic evaluation, left atrial diameters, left ventricular end diastolic diameter, and MV diameter were significantly reduced (p < 0.05) compared with preoperative values., Conclusions: MV repair for active culture positive endocarditis is associated with low operative mortality and provides satisfactory freedom from recurrent infection, freedom from repeat operation, and survival. Hence, every effort should be made to repair infected MVs and valves should be replaced only when repair is not possible.

Background: Our centre in 1995 reported 26% of vascular complications in cardiac surgical patients treated with intra-aortic balloon pump (IABP). However, during the last decade there have been improvements in IABP technology and insertion techniques. We aimed to evaluate the impact of these changes on the incidence of IABP-related complications in cardiac surgery., Methods: Demographics, indications, technique and complication rate in 186 consecutive patients treated with IABP from January 1994 to December 1998 (Group I) were compared with 323 consecutive patients treated with IABP from January 1999 to December 2003 (Group II) at our regional cardiothoracic centre. Data was variably expressed as mean with or without range and either standard deviation or range. Statistical significance was accepted at P<0.05., Results: There were 121 (65%) and 194 (60%) males in Group I and II, respectively. The mean age was 66+/-12.1 (17-88) years and the mean duration of IAPB use was 43.5h (range 3-144 h). Overall complication rate was 10% in Group I and 2% in Group II whereas vascular complications accounted for 3% in Group-I and 1% in Group-II. Logistic regression analysis demonstrated cardiogenic shock being strongly correlated to in-hospital mortality (OR 4.68; P=0.004) followed by older age (OR 3.12; P=0.034) and ejection fraction <35% (OR 1.78; P=0.03)., Conclusion: The study demonstrated a significant decrease in the IABP-related complications even though complexity of cases referred for surgery has increased. Henceforth, the risk of 1% vascular complications should play little influence on decision-making regarding the use of IABP.

Venox is a propriety Venous Oximetry system, capable of measuring peripheral venous oximetry. In this ongoing study, Venox is being compared against mixed central venous oximetry during human cardiac surgery, with Fibre optic reflectance spectrophotometry being used as the gold standard, placed in the pulmonary artery. A background review of the Pulse oximetry, current venous oximetry techniques and the potential advantage of the VENOX system are discussed. Lessons learnt, Preliminary results, and future plans are included in discussion.

Off-pump coronary artery bypass surgery has been adopted enthusiastically worldwide. However, despite more than 6 years' experience and refinement, many surgeons use it only sporadically and some hardly at all. This reluctance persists despite support for the procedure because of the lack of properly designed risk models and/or randomized studies. Although it has not been overwhelmingly shown that off-pump surgery is superior to the conventional on-pump procedure, the technique has its place in our specialty. It has been shown to be better for noncritical end points in selected patients in the hands of selected surgeons. That there are differences in surgical skill among surgeons is something we all know but rarely discuss in public. Until now, disparities in skill have been most salient with uncommon and extraordinarily challenging operations. Perhaps the off-pump procedure should be regarded as the "challenging" aspect of coronary artery bypass surgery, and self-restraint may need to remain in force if we are to continue to achieve the highest level of clinical excellence.

Objective: To study variations in use of intra-aortic balloon counterpulsation (IABC) and their impact on complications by comparing aspects of its use in a Regional Cardiothoracic Centre with an international database., Methods and Results: Indications, technique and complication rate in 764 consecutive patients treated with IABC from January 1998 to November 2001 (Group I) at the Regional Cardiothoracic Centre were compared with 24,555 consecutive patients from the international ("Benchmark") database (Group II). Patients in Groups I and II were of similar mean age (65.5 vs. 65.6 years) and predominantly males (77.1% vs. 66.9%). IABC-related complications were significantly less in Group I vs. Group II (3.93% vs. 7.04%, p<0.001), probably due to the increased use of smaller French size balloons (8f in Group I: 73.3% vs. Group II: 28.8%, p<0.001) and significantly less use of femoral artery sheaths (Group I: 91.2% vs. Group II: 20.4%, p<0.001) as well as less concomitant use of potent anti-thrombotic therapy (4.2% vs. 21.7%). By comparison to the international database only a minority of our patients were transferred in specifically for insertion of IABC (Group I: 1.3% vs. Group II: 22.8%, p<0.001) suggesting under-recognition of the potential value of IABC in haemodynamically compromised patients., Conclusion: In comparison to an international database, complications were significantly less after IABC at the regional cardiothoracic centre. There were far fewer patients referred specifically for IABC use. Indications, choice of appropriate device, technique of deployment and concomitant use of anti-platelet therapy varies and perhaps needs to be standardised internationally. Regular audit of any such large database is vital to ensure dissemination of potentially important messages it contains.

Objectives: To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD)., Design: Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility., Setting: Four tertiary cardiothoracic surgery centres in England., Participants: Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel., Interventions: Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB., Main Outcome Measures: The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs., Results: A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively., Conclusions: The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.

A 34-yr-old male suffered multiple trauma in a road traffic accident. He required right thoracotomy and laparotomy to control exanguinating haemorrhage, and received 93 u blood and blood products. Intraoperatively, he developed severe systemic inflammatory response syndrome (SIRS) with coagulopathy and respiratory failure. At the end of the procedure, the mean arterial pressure (MAP) was 40 mm Hg, arterial blood gas analysis showed a pH of 6.9, Pa(CO(2)) 12 kPa, and Pa(O(2)) 4.5 kPa, and his core temperature was 29 degrees C. There was established disseminated intravascular coagulation. The decision was made to stabilize the patient on veno-venous extracorporeal membrane oxygenation (ECMO) only 10 h after the accident, in spite of the high risk of haemorrhage. The patient was stabilized within 60 min and transferred to the intensive care unit. He was weaned off ECMO after 51 h. He had no haemorrhagic complications, spent 3 weeks in the intensive care unit, and has made a good recovery.

Objective: Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs., Methods: Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months., Results: The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval., Conclusion: We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.

Objective: Mesenteric ischaemia is an uncommon (<1%) but serious complication of cardiac surgery associated with a mortality >50%. Predictors of this complication are not well defined, and diagnosis can be difficult and prompt surgical intervention can be lifesaving., Methods and Results: In a retrospective case-note analysis from May 1994 through to May 2000, we identified mesenteric ischaemia in 39 of 5349 consecutive patients (0.07%) undergoing cardiac surgery with cardiopulmonary bypass. By logistic multivariate analysis, we have identified six possible predictors of intestinal ischaemia: duration of cross-clamp, use of significant inotropic support, intra-aortic balloon counterpulsation for low cardiac output, need for blood transfusions, triple vessel disease and peripheral vascular disease. In all patients a combination of four predictors were present. Patients who survived this complication had surgical intervention earlier (6.4+/-3.8 h) than those who did not (16.9+/-10 h)., Conclusions: The diagnosis and prompt treatment of mesenteric ischaemia post cardiac surgery requires a high degree of awareness. These predictors may be useful in alerting medical staff to the possibility of gastro-intestinal ischaemic complications after cardiac surgery particularly that early surgical intervention reduces mortality.

Background: Valve durability has been a major concern with bioprostheses, and the Tissuemed (Aspire) porcine bioprosthesis was designed to provide a solution to structural valve failure. Because bioprostheses tend to fail by 8 years, the aim of our study was to determine its midterm durability and performance., Methods: We reviewed 506 prostheses that were implanted in 493 patients (287 men; mean age 73 +/- 6 years) between 1991 and 1999. Preoperatively 316 (68%) patients were in New York Heart Association class III or IV. There were 417 (85%) aortic, 61 (12%) mitral, 13 (2.6%) aortic and mitral, and two (0.4%) tricuspid procedures. Concomitant procedures were performed in 163 (33%) patients. Follow-up was complete in 488 (98.9%) patients with a total cumulative follow-up of 1,402 patient-years., Results: The 30-day mortality in this elderly population was 10% (95% confidence interval, 8 to 13), with no early valve-related deaths. Patients' survival at 8 years was 46% +/- 7%. This was influenced by the following factors: (1) the patient's age, being worse for those 70 years or older (p = 0.005); (2) those in New York Heart Association functional class III and IV (p = 0.004); (3) those in atrial fibrillation before the operation (p = 0.006); (4) those with poor left ventricular function (p = 0.009); and (5) those who had a previous cardiac operation (p = 0.003). Valve-related complications (expressed as percent per patient-year) were thromboembolism at 0.9%/patient-year; major hemorrhage at 1.4%/patient-year; bacterial endocarditis at 0.4%/patient-year; nonstructural dysfunction at 0.2%/patient-year, and reoperation at 0.2%/patient-year. At 8 years, freedom from thromboembolism was 93% +/- 7%, major hemorrhage, 90% +/- 4%, nonstructural dysfunction, 99% +/- 1%, structural valve failure, 100%, and reoperation, 99% +/- 1%. At follow-up, 98% of survivors were in New York Heart Association class I or II., Conclusions: Our study suggests that at 8 years, the Tissuemed (Aspire) porcine bioprosthesis is durable and has satisfactory performance with low complication rates.

Background: Allen's test is widely used to assess the ulnar collateral blood supply of the hand before radial artery harvest for coronary bypass surgery. This study was performed to determine the optimum cut-off point for a positive Allen's test and the clinical reliability of Allen's test in this role., Methods: Patients undergoing coronary artery bypass surgery were examined by independent observers using both Allen's test and a Doppler ultrasound test of the ulnar collateral circulation., Results: We examined 93 hands in 47 patients; mean age was 63.6 years. Receiver operating characteristic analysis found that at a conventional cut-off of 6 seconds on Allen's test had a sensitivity of 54.5%, specificity of 91.7%, and diagnostic accuracy of 78.5%. At a cut-off of 5 seconds diagnostic accuracy was maximal (79.6%), with sensitivity of 75.8% and specificity of 81.7%; 100% sensitivity occurred at a cut-off of 3 seconds, with specificity of 27% and diagnostic accuracy of 52%., Conclusions: At no cut-off point does Allen's test perform satisfactorily as a discriminatory test. It should be replaced by more objective tests, such as Doppler ultrasound.

Background: The purpose of our research was to evaluate the functional recovery and homeostasis of myocardium during simultaneous continuous retrograde and antegrade cardioplegia versus continuous retrograde cardioplegia., Methods: Forty patients who underwent elective coronary artery bypass grafting (CABG) were prospectively assigned to two clinically matched groups and analyzed in respect to cardioplegia protocol. Group I consisted of 24 patients who received continuous retrograde blood cardioplegia; Group II consisted of 16 patients who received simultaneous continuous ante- and retrograde cardioplegia. Hydrogen ion release, carbon dioxide, lactate concentration oxygen content, and oxygen extraction were measured from coronary sinus effluent and from the arterial line before and after cross-clamping of the aorta. Median changes of these parameters were reported. Cardiac output was measured and left and right ventricle stroke works were calculated. Incidence of low cardiac output, ventricular fibrillation, raised cardiac enzymes, and ischemic changes on electrocardiogram (ECG) were noted., Results: In the simultaneous group, oxygen content and oxygen extraction recovered well after cross-clamping. The same parameters did not recover to the same extent in the retrograde group. These changes were notable between groups. Hydrogen ion, carbon dioxide, and lactate releases were comparable between groups. Trend toward better recovery of left ventricle stroke work index was encountered in the simultaneous group., Conclusions: Viability of myocardium measured with oxygen utilization and functional recovery is better preserved with simultaneous antegrade and retrograde cardioplegia. However, there is no difference in anaerobic metabolism markers. Thus simultaneous ante- and retrograde cardioplegia is probably advantageous over retrograde alone.

Background: The incidence of malignant mesothelioma is increasing. There is the perception that survival is worse in the UK than in other countries. However, it is important to compare survival in different series based on accurate prognostic data. The European Organisation for Research and Treatment of Cancer (EORTC) and the Cancer and Leukaemia Group B (CALGB) have recently published prognostic scoring systems. We have assessed the prognostic variables, validated the EORTC and CALGB prognostic groups, and evaluated survival in a series of 142 patients., Methods: Case notes of 142 consecutive patients presenting in Leicester since 1988 were reviewed. Univariate analysis of prognostic variables was performed using a Cox proportional hazards regression model. Statistically significant variables were analysed further in a forward, stepwise multivariate model. EORTC and CALGB prognostic groups were derived, Kaplan-Meier survival curves plotted, and survival rates were calculated from life tables., Results: Significant poor prognostic factors in univariate analysis included male sex, older age, weight loss, chest pain, poor performance status, low haemoglobin, leukocytosis, thrombocytosis, and non-epithelial cell type (p<0.05). The prognostic significance of cell type, haemoglobin, white cell count, performance status, and sex were retained in the multivariate model. Overall median survival was 5.9 (range 0-34.3) months. One and two year survival rates were 21.3% (95% CI 13.9 to 28.7) and 3. 5% (0 to 8.5), respectively. Median, one, and two year survival data within prognostic groups in Leicester were equivalent to the EORTC and CALGB series. Survival curves were successfully stratified by the prognostic groups., Conclusions: This study validates the EORTC and CALGB prognostic scoring systems which should be used both in the assessment of survival data of series in different countries and in the stratification of patients into randomised clinical studies.

Objective: To identify predictors of early and late outcome among 117 consecutive patients who underwent postinfarction ventricular septal defect (VSD) repair over a period of 12 years., Methods: A retrospective analysis of clinical data was performed. Mean age was 65.5+/-7.8. There were 43 females. Full data were obtained in 110 patients. Of these, 76 patients presented with anterior and 34 with posterior VSD. Thirty-three patients were operated in cardiogenic shock. Mean time between myocardial infarction (MI) and VSD development was 5.6+/-7.8 days (median 4) and from VSD to surgery 9. 0+/-28.1 (median 2). Sixty-six patients had intraaortic balloon pump (IABP) inserted, and 15 were ventilated preoperatively. Logistic regression and Cox regression were used for multivariate analysis., Results: Thirty days mortality was 37%. Among 110 patients, in whom complete analysis was possible, 38 died within 30 days (35%). Mortality in the posterior VSD group was 35% and in the anterior VSD group 34% (NS). In 44 patients (40%) a residual shunt was found on postoperative echocardiography. This required reoperation in 13 patients (four deaths). Cardiogenic shock prior to surgery adversely influenced early survival - odds ratio (OR) 5.7 (confidence interval (CI) 2.1-16.0) (P=0.0008). Deterioration of haemodynamic status in between admission and surgery was stronger predictor of mortality than shock on admission - OR 6.0 (CI 1.6-22.6) (P=0.008) vs. 3.1 (CI 1.0-9.3) (P=0.049). A longer time between MI and surgery favoured survival - OR 0.1 (CI 0.03-0.4) (P=0.002). The time period from the infarct to the septal rupture, but not from the rupture to surgery, appeared to be a significant predictor of survival - OR 0.2 (CI 0. 05-0.6) (P=0.008). Five years survival was 46+/-5%. Preoperative cardiogenic shock affected late survival - OR 2.7 (CI 1.5-4.9) (P=0. 001). Of 72 patients who survived 30 postoperative days, 12 (17%) were in New York Heart Association (NYHA) class III or IV and five (6.9%) in Canadian Cardiovascular Soceity (CCS) class III or IV at the last follow-up., Conclusions: Preoperative cardiogenic shock and early postinfarction septal rupture carry a grave prognosis. Achieving haemodynamic stability prior to surgery may be beneficial but prolonged attempts to improve patients' cardiovascular state are hazardous.

Aims: This retrospective study investigated whether the supraventricular arrhythmias (SVA) observed during cardiac surgery are limited to or persist beyond the postoperative period, their clinical consequences and whether they are influenced by preoperative and postoperative factors., Methods: A total of 375 patients undergoing elective bypass graft surgery over a 15-month period by three surgeons were included. All patients had their preoperative medications continued to the day of surgery and prophylactic anti-arrhythmic medications were not used in any of the cases. Standard anaesthetic techniques were used. Rhythm disturbances were diagnosed by ECG. The arrhythmias were treated medically or by cardioversion. All patients were followed up for 6 months., Results: Postoperative SVA occurred in 25% of patients. The commonest arrhythmia was atrial fibrillation (89.4%), followed by atrial flutter (6.4%) and supraventricular tachycardia (4.2%). In 89. 8% of the cases, the arrhythmias occurred within the first four postoperative days with a maximum incidence on the second day (27. 7%). Atrial fibrillation was still present in 50% of patients at hospital discharge and in 39% at 6 months follow up. Patients with arrhythmias had a prolonged hospital stay (7.7+/-2.6 vs. 6.0+/-2.6 days; P<0.05). There was no hospital mortality in the study and the incidence of postoperative stroke was equal in the sinus rhythm and arrhythmia patients (1.1%). SVA were more frequent when cardioplegia was used to protect the heart (32%) than with intermittent ischaemia (9%; P<0.001). At 6 months follow up, the patients receiving cardioplegia also had a higher prevalence of atrial fibrillation than those operated with intermittent ischaemia (41% vs. 22%; P<0. 05). The incidence of SVA and persistence of atrial fibrillation was unrelated to other preoperative and intraoperative factors., Conclusion: Postoperative supraventricular arrhythmias have a long-lasting effect on cardiac rhythm: patients with SVA have a high probability of remaining in atrial fibrillation at hospital discharge and 6 months after surgery. The occurrence of atrial fibrillation seems to be influenced by the type of myocardial protection used but this does not appear to exert harmful effects.

Purpose: To describe a case of endovascular graft exclusion of an innominate artery pseudoaneurysm arising from blunt trauma., Methods and Results: A 21-year-old patient was admitted following a major road accident. Computed tomography (CT) and aortography on admission disclosed an isolated innominate artery pseudoaneurysm. The lesion was stable, so an elective endoluminal repair was undertaken once the patient was treated for his other injuries. The right carotid artery was exposed and controlled, and the aneurysm was excluded by transluminal implantation of a customized stent-graft consisting of predilated polytetrafluoroethylene graft material covering a balloon-expandable Palmaz stent. A CT scan at 1 month and duplex scans at 6-month intervals documented good stent-graft positioning and aneurysm exclusion over a period of 18 months., Conclusions: This case illustrates the potential durability of endoluminal repair of innominate artery lesions and highlights the potential role of this minimally invasive alternative to surgery in these clinical situations.

Background: To evaluate the homeostasis of myocardium during simultaneous continuous retrograde and antegrade cardioplegia vs retrograde continuous cardioplegia., Methods: 40 patients who underwent elective operation of coronary arteries bypass grafting were randomly assigned to 2 groups: group one consisted of 24 patients who received retrograde continuous blood cardioplegia; group two consisted of 16 patients who received simultaneous continuous ante/retrograde cardioplegia. The following measurements were taken: acidosis, oxygen content, oxygen extraction and oxygen consumption; they were taken before and after cross-clamp releasing from coronary sinus effluent and from arterial line. Incidence of low cardiac output, ventricular fibrillation, raised cardiac enzymes and ischemic changes on ECG was noted., Results: In simultaneous group such parameters as acidosis, oxygen content, oxygen extraction and myocardial oxygen consumption recovered after cross-clamping and changes of their values were respectively: 0.0005, 0.87 ml/100 ml, 0.098 and 1.4 ml/min. The same parameters didn't recovered in retrograde group and changes were respectively: 0.05 - p=0.2; 3.7 ml/100 ml - p=0.006, 0.29 p=0.006 and 7.4 ml/min - p=0.03. These changes were significant between groups., Conclusions: Metabolic viability of myocardium measured with oxygen utilisation is better preserved with simultaneous antegrade and retrograde cardioplegia.

Background: The skeletonization of internal thoracic artery is postulated to improve graft length, early blood flow, sternal blood supply, and postoperative respiratory function. Concern exists that skeletonization may injure internal thoracic artery, precluding good results of surgery. Reports on endothelial function of skeletonized internal thoracic artery are lacking., Methods: A prospective assessment of early clinical outcomes of 357 consecutive patients undergoing coronary artery bypass grafting was performed: 287 patients with nonskeletonized and 70 with skeletonized left internal thoracic artery (LITA). The lengths of LITA and of its discarded distal segment, as well as free LITA blood flow, were measured. The dose-effect relationship for relaxation to acetylcholine was studied in the organ bath., Results: Apart from a higher incidence of breaching the pleura with nonskeletonized LITA the clinical outcomes were comparable. The length of skeletonized LITA was 17.8+/-1.14 cm versus 20.3+/-0.52 cm skeletonized (p = 0.11). The length of discarded LITA was shorter in nonskeletonized artery (0.8+/-0.28 cm versus 2.6+/-0.49 cm; p = 0.022). The free LITA blood flow was 66.3+/-7.42 mL/min in nonskeletonized vessel versus 100.3+/-14.84 mL/min in skeletonized (p = 0.048). The acetylcholine-induced relaxation was similar in both groups (maximal relaxation, 80.7%+/-5.95% in nonskeletonized versus 72.9%+/-9.11% in skeletonized; not significant; negative logarithm of half-maximal effect, 7.43+/-0.18 versus 7.1+/-0.10, respectively; p = 0.063)., Conclusions: Skeletonization does not damage the endothelial function of the LITA. Higher free blood flow and available LITA length should encourage the use of skeletonized LITA in clinical practice.

Two patients developed a ventriculo-pulmonary fistula several years after original resection of a left ventricular aneurysm. Both presented with chronic mild haemoptysis. In the first case mild haemoptysis lasted nearly 19 months, and despite a battery of non invasive and invasive investigations, diagnosis was ultimately made via exploratory thoracotomy. In the second case mild haemoptysis lasted four months and finally manifested as a large haemoptysis. Diagnosis was made preoperatively using echocardiography. We recommend the use of echocardiography when haemoptysis occurs in a patient with a previous history of ventricular aneurysm repair.

Objective: Recent development in minimally invasive coronary surgery prompted us to carry out prospective evaluation of patients undergoing coronary artery bypass grafting through left anterior small thoracotomy., Methods: Between April 1996 and February 1997, 15 patients (age 32-70, 12 male) were operated on. The left internal thoracic artery (LITA) basal flow was assessed by means of transcutaneous Duplex ultrasound scanning with pulsed waved Doppler. Eight patients were studied in the immediate postoperative period (2-4 days) and seven patients (1-7 months) following revascularisation. In addition to that, nine patients underwent coronary angiography., Results: LITA graft flows were quantifiable in all 15 patients. In two patients there was a significant reduction in both time-averaged velocity and total flow. The subsequent coronary angiogram revealed severe (>50%) stenosis of LITA graft in both patients. One of these patients had a reversible obstruction documented by Duplex scanning and coronary angiography. Systolic measures did not differ between normal (13) and stenosed grafts (2), but diastolic time-averaged velocity (indicating coronary run-off) and total flow appeared lower in the latter., Conclusions: LITA flow following left anterior small thoracotomy surgery can be evaluated non-invasively. Measurement of diastolic flow (i.e. coronary perfusion rather than internal thoracic branch run-off) and total flow is useful in estimating graft function.