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Background: Extracorporeal life support (ECLS) has been used in the treatment of accidental hypothermia with hemodynamic instability, with promising outcomes. This systematic review examines ECLS treatment of accidental hypothermia to assess outcomes., Methods: An electronic search was performed to identify articles reporting ECLS use for treatment of accidental hypothermia. Only reports describing patients aged more than 16 years after January 1, 2005, were included. Nineteen studies were identified comprising 47 patients. Demographic information, perioperative variables, and outcomes were extracted for analysis., Results: Median patient age was 48 years (interquartile range (IQR), 29 to 56), and 72.3% (34 of 47) were male. On presentation, median body temperature was 24.6°C (IQR, 22.2° to 26°C), median potassium level 4.3 mmol/L (IQR, 3.4 to 4.6 mmol/L), and median Glasgow Coma Scale score 3 (IQR, 3 to 7). Cardiac arrest occurred in 35 of 47 patients (74.5%). Median time to ECLS initiation from scene was 155 minutes (IQR, 113 to 245). Median ECLS duration was 18 hours (IQR, 4 to 27), with median rewarming rate of 2°C per hour (IQR, 1.5° to 4°). Median intensive care unit stay and hospital length of stay were 8 days (IQR, 2 to 16) and 17 days (IQR, 10 to 36), respectively. Inhospital mortality was 19.1% (9 of 47). Median discharge Glasgow Coma Scale score was 15 (IQR, 15 to 15) with minor long-term cognitive impairments noted in 6 of 47 patients (19.4%). Survival was significantly associated with potassium on presentation (P < .001), initial body temperature (P < .001), and ECLS rewarming rate (P < .001)., Conclusions: Extracorporeal life support is a viable cardiac support option for rewarming patients with accidental hypothermia, and initial potassium level, initial body temperature, and ECLS rewarming rate appear to be significantly associated with survival., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Reoperative mitral valve (MV) surgery through sternotomy can be technically challenging. Limited exposure and injury to the right ventricle or patent grafts (previous coronary artery bypass graft surgery [CABG]) are potential complications upon sternal reentry. The purpose of this study was to examine the results of port access MV surgery through right minithoracotomy in patients with previous cardiac surgery performed through median sternotomy., Methods: From 1998 through July 2007, 651 port access MV procedures were performed. In 107 patients (16.4%), previous cardiac surgery had been performed through midline sternotomy. Mean age was 67.5 +/- 11.2 years, and 60.7% (n = 65) were male. Previous surgery included CABG (n = 45, 42.1%), aortic valve replacement (n = 9, 8.4%), aortic valve replacement/MV repair (n = 2, 1.9%), MV repair (n = 21, 19.6%), MV replacement (n = 5, 4.7%), CABG/MV replacement (n = 1, 0.9%), CABG/MV repair (n = 8, 7.5%), CABG/aortic valve replacement (n = 2, 1.9%), and others (n = 14, 13.1%). New York Heart Association functional classes were I (n = 2, 1.9%), II (n = 28, 26.2%), III (n = 50, 46.7%), and IV (n = 27, 25.2%). The endoaortic balloon was used in 75 patients (70.1%) and the Chitwood clamp in 11 patients (10.2%). In the remaining patients (n = 21, 19.6%), fibrillatory arrest was employed., Results: Mitral valve repair and MV replacement were performed in 60 patients (56.1%) and 47 patients (43.9%), respectively. The 30-day mortality was 4.7% (n = 5). The mean cardiopulmonary bypass and aortic cross-clamp times were 140.8 +/- 43.7 minutes and 77.0 +/- 49.7 minutes, respectively. Complications included 6 reoperations for bleeding (5.6%), 1 stroke (0.9%), and 2 wound infections (1.9%). Conversion to sternotomy was required in 1 patient (0.9%) because of an acute type A dissection secondary to aortic occlusion with Chitwood clamp. The mean hospital stay was 9.6 days. During follow-up, reoperation for failure of MV repair was performed in 4 patients (3.7%)., Conclusions: Reoperative port access MV surgery can be performed with minimal morbidity and mortality. This approach may be the preferred technique for patients who require MV procedures after previous cardiac surgery performed through median sternotomy.

Thoracic paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells and have the capacity to secrete catecholamines. Surgical excision is the optimal treatment of these tumors as they are resistant to chemotherapy and radiation therapy. Although these tumors are most commonly found in the abdomen, 10% of paraganagliomas are located in the thorax, usually in the posterior mediastinum. Occasionally these tumors present in the anterior mediastinum, which can pose a significant surgical challenge due to the proximity of the great vessels and airway. In this report we describe the treatment of an anterior mediastinal pheochromocytoma that presented with tracheal obstruction and required pulmonary artery reconstruction and airway stenting.

Background: Cardiogenic shock secondary to acute myocardial infarction (CS-AMI) is the leading cause of death in all acute coronary syndromes. Experience with the use of left ventricular assist devices (LVADs) in patients with CS-AMI is limited. One of the surgical dilemmas when implanting an LVAD into a patient with an acute anterior wall myocardial infarction is the safety of apical cannulation. We present a decade of experience with the use of LVAD with apical cannulation in patients with CS-AMI., Methods: A retrospective review of the ventricular assist device (VAD) database at the Hospital of the University of Pennsylvania was instituted., Results: From April 1995 to February 2005, 49 patients received LVAD support for CS-AMI (group I). The majority of these patients suffered anterior wall myocardial infarctions. This group of patients was compared with a separate cohort of 61 patients with chronic ischemic cardiomyopathy who received LVAD support (group II). The VAD support successfully bridged 38 (74%) group I patients and 37 (61%) group II patients to heart transplantation. Of the 38 patients transplanted in group I, 33 (87%) were discharged from the hospital. In group II, 36 of the 37 patients transplanted (97%) survived to hospital discharge. The overall in-hospital mortality rates for the series were 33% for group I patients, and 41% for group II patients., Conclusions: Left ventricular assist device support in patients with CS-AMI is a safe and effective therapy which should be incorporated into the standard treatment paradigm for appropriate patients presenting with this lethal disease.

Background: In patients with acute profound cardiogenic circulatory failure unresponsive to conventional resuscitation, we instituted immediate aggressive application of extracorporeal membrane oxygenation (ECMO) to restore circulatory stability. Long-term hemodynamic support was accomplished with an early "bridge" to ventricular assist device (VAD) before definitive treatment with cardiac transplantation., Methods: A respective review of ECMO and VAD data registries was instituted., Results: From May 1996 to July 2000, 23 patients were placed on ECMO support for profound cardiogenic circulatory failure. Eleven patients (47%) were withdrawn from support due to severe neurologic injury or multisystem organ failure. Three patients (13%) were weaned off ECMO with good outcome. Nine patients (39%) were transferred to a VAD. Two patients expired while on VAD support, and 7 of the VAD-supported patients (78%) survived to transplantation. Overall survival was 43%., Conclusions: Emergent ECMO support is a salvage approach for cardiac resuscitation once conventional measures have failed. In neurologically intact patients, the early transfer to a VAD quickly stabilizes hemodynamics, avoids complications, and is essential for long-term circulatory support before definitive treatment with cardiac transplantation.

Background: Mechanical circulatory assist industries have developed ventricular assist devices (VAD) for short-, intermediate-, and long-term use. The purpose of this report is to describe the progress made with the ABIOMED Biventricular System (BVS) 5000 (ABIOMED, Inc, Danvers, MA) short-term VAD., Methods: From June 1994 through August 2000, all cardiogenic shock patients who required short-term mechanical assist were supported with the ABIOMED BVS 5000. Insertion criteria included any condition that may potentially result in cardiac recovery. A formal algorithm for timing of insertion was established to standardize implantation criteria., Results: A total of 45 patients were supported at Hahnemann University Hospital, Philadelphia, PA. There were 26 male and 19 female patients, with a mean age of 57.9 years (range 33 to 80 years). Devices were inserted for postcardiotomy shock in 36 patients (80%) and precardiotomy shock in 9 patients (20%). The average duration of support was 8.3 days (range 1 to 31 days). Overall, there were 22 (49%) patients weaned from support and 14 (31%) discharged from the hospital. For patients in whom the device was implanted in accordance with an established protocol (group A), the wean and discharge rates were 60% and 43%, respectively. The most common morbidities included bleeding and adverse neurologic events., Conclusions: The ABIOMED BVS 5000 VAD continues to be a valuable form of short-term mechanical assist for acute cardiogenic shock. The formation of a uniform VAD insertion algorithm has helped to standardize protocols in management.

The incidence of coronary artery disease in identical twins is unknown. The knowledge of ischemic heart disease in this patient population is represented by case reports. There is considerable controversy regarding the environmental and genetic factors that play a role in the pathogenesis of this disorder. The natural history of coronary artery disease in an asymptomatic twin with a symptomatic counterpart is unclear. We present a case report and literature review of coronary artery disease in identical twins. On the basis of our patient and the information of other patients, asymptomatic twins of symptomatic counterparts require aggressive assessment and management for occult coronary artery disease.

Background: Minimally invasive techniques to harvest the saphenous vein for coronary artery bypass grafting continue to improve and evolve. Smaller cutaneous incisions have been shown to decrease postoperative discomfort and improve healing. We describe a technique involving carbon dioxide insufflation and endoscopic dissection to allow easier and atraumatic dissection., Methods: The VasoView endoscope system (Origin Medsystems, Inc) was used to harvest the saphenous vein for coronary artery bypass grafting in 27 patients. This group was compared with 24 patients having traditional saphenous vein harvesting. Wounds were examined for complications daily. Pain and postoperative mobility were quantified independently by physical therapists., Results: Comparison of patients in the two groups revealed greater edema in the legs with traditional harvesting. Patients with endoscopic removal also had less pain and increased mobility postoperatively. On average, minimally invasive harvesting allowed patients to ambulate to a predischarge goal of 300 ft 2 days earlier., Conclusions: Minimally invasive harvesting of the saphenous vein by insufflation techniques is safe, effective, and atraumatic to the conduit. Discomfort is minimized, promoting earlier and improved ambulation.

Background: Thoracic aortic coarctation accompanied by a second surgically reparable lesion is a rare combination in the adult patient. The simultaneous operative management of both lesions is desirable because of the higher morbidity and mortality that would occur with staged procedures., Methods: We describe the simultaneous operative management in three adult patients with coarctation and a second cardiac lesion. All 3 patients had intrapericardial ascending aorta-descending aorta bypass and concomitant repair of a cardiac lesion. The attendant repairs in the 3 patients, respectively, were aortic valve replacement, orthotopic heart transplantation, and coronary artery bypass grafting., Results: Double arterial cannulation, retrograde cardioplegia, large-bore aorto-aortic bypass grafts, and early use of alpha-agonists to stabilize systemic pressure were all key to ensuring safe conduct of the operation. Each patient had an essentially uneventful postoperative course., Conclusions: Thoracic coarctation and concomitant cardiac pathology can be safely and readily managed with a single-stage approach involving cardiac repair and extraanatomic ascending aorta-descending aorta bypass grafting. A review of the English-language literature of patients managed similarly is included.

Background: Traumatic aorto-right ventricular (Ao-RV) fistulas are rare lesions that result in congestive heart failure if left untreated. Early diagnosis and prompt surgical intervention are required to avoid the natural outcome of cardiac decompensation., Methods: All cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed. The clinical presentation, methods of diagnosis, and treatment strategies were assessed to determine the pathophysiology, natural history, and outcome of surgical intervention., Results: Forty cases of traumatic Ao-RV fistulas were described in the English literature. There were 39 men and 1 woman, with a mean age of 28.3 years (range, 15 to 50 years). Twenty-two (55%) patients had isolated Ao-RV fistulas. Fourteen (35%) had Ao-RV fistulas with aortic insufficiency. Definitive surgical repair was performed in 38 patients. The associated aortic valve injuries were managed with repair techniques or replacement with prosthetic devices. The surgical outcomes in all patients were satisfactory., Conclusions: The pathophysiology and natural history of Ao-RV fistulas involves the development of congestive heart failure. Traumatic aortic insufficiency frequently is associated with this disorder. Early diagnosis and prompt treatment are necessary to avoid the natural outcome of cardiac decompensation. Definitive repair should be performed with the aid of cardiopulmonary bypass during the same hospitalization.

Background: The implantable cardiac defibrillator (ICD) was introduced clinically in 1980 for the management of ventricular arrhythmias., Methods: From January 31, 1989, through May 29, 1996, 329 ICD devices were implanted at Allegheny University Hospital, Hahnemann Division, Philadelphia, Pennsylvania. All device-related infections were examined., Results: Fifteen patients (5%) experienced infection of the generator component of the ICD. There were 14 male and 1 female patients with a mean age of 62 years (range, 38 to 79 years). All infections involved the generator with or without other component involvement. Complete removal of the system was performed in 7 patients, partial removal in 5, and the entire system was left intact in 3. In 4 patients (27%), further procedures were performed to remove additional infection. Three patients (20%) died during the hospital stay., Conclusions: Infection of ICD devices is a devastating event. We favor complete removal of the ICD generator and all the components when possible. Partial removal of the ICD unit (ie, generator only) is reserved for patients in whom the risk of complete removal is too high and infection is confined to the generator only.

Background: Use of the left internal thoracic artery as a bypass graft has been shown to result in better long-term patency and improved survival. In elderly patients, the internal thoracic artery has been used less often for coronary artery bypass grafts because of the belief that greater morbidity and mortality are associated with this procedure. This study was undertaken to test this premise in the octogenarian population., Methods: Over an 8-year period, 474 consecutive patients 80 years of age and greater had coronary artery bypass grafting. The left internal thoracic artery was used in 188 patients (39.7%) (group 1) and saphenous vein grafts only (group 2), in 286 (60.3%). The mean age was 82.6 years (range, 80 to 95 years). There were 312 men (65.8%) and 162 women (34.2%)., Results: Use of the internal thoracic artery as a graft has risen steadily each year, as has the number of patients who are octogenarians. The hospital mortality rate was 7.8%. Patients in group 1 had a mortality rate of 9.0% and patients in group 2, a mortality rate of 7.0%. The mortality rate among survivors at 1 year was 6.7%. Long-term survival was significantly greater in group 1., Conclusions: On the basis of this study, we conclude that the internal thoracic artery is the bypass graft of choice, especially in regard to long-term mortality, and should not be denied to this high-risk group.