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Left ventricular outflow tract (LVOT) obstruction in obstructive hypertrophic cardiomyopathy (HCM) is caused by a constellation of abnormalities. This study reviewed outcomes of a comprehensive approach to correct these abnormalities during surgery. This was a single-institution study of patients with HCM who underwent septal myectomy from 2016 to 2023. Their New York Heart Association functional classification and most recent echocardiogram that estimated LVOT gradient and mitral valve function were tracked. The study included 103 patients with a mean age of 54 years (interquartile range, 40-67 years) and common comorbidities: hypertension (50%) and atrial fibrillation (25%). On average, the preprocedure resting echocardiogram showed an LVOT gradient of 36.4 mm Hg and moderate or severe mitral regurgitation in 50.5% of patients. All patients underwent septal myectomy, and associated abnormalities contributing to LVOT obstruction were addressed. Elongation of the anterior leaflet of the mitral valve was typically treated with papillary muscle realignment (72%). Aberrant papillary muscle heads and elongated secondary chordae tendineae contributing to systolic anterior motion were resected (66%). Myocardial bands, including apicoseptal bands contributing to LVOT obstruction, were resected (68%). With an average follow-up of 4 years, 91% of patients were considered to be in New York Heart Association functional class I or II. Long-term echocardiographic follow-up showed a mean peak LVOT gradient of 11 mm Hg (interquartile range, 4-13 mm Hg). Only 1 patient had more than mild mitral regurgitation. A comprehensive surgical approach to HCM that addresses the entire constellation of abnormalities associated with HCM, including mitral valve anterior leaflet elongation, aberrant or displaced mitral valve subvalvular apparatus, and myocardial bands, leads to outstanding midterm outcomes. [ABSTRACT FROM AUTHOR]

Hypertrophic obstructive cardiomyopathy is a genetic disorder treated with septal reduction therapy, either alcohol septal ablation or septal myectomy (SM). Historically older patients have been presumed to be poor candidates for SM and thus referred directly for alcohol septal ablation in some centers. We reviewed our experience with SM in older patients. We identified 100 patients at our institution who underwent SM for hypertrophic obstructive cardiomyopathy from 2015 to 2020. Demographic and clinical characteristics and outcomes of patients 65 years or older were compared with patients younger than 65. Sixty-five patients were in the <65 group and 35 patients in the ≥65 group. Both groups had similar preoperative peak stress left ventricular outflow tract gradients (129 mm Hg vs 110 mm Hg, P <.001). Most patients in both groups had moderate to severe mitral regurgitation on preoperative stress echocardiography. The elderly group was more likely to have coronary artery bypass graft as a concomitant procedure (37% vs 8%, P <.001). Only 1 death occurred in the series secondary to a pulmonary embolism. At the 30-day follow-up on stress echocardiography, peak stress gradients were normal in both groups (21 and 20 mm Hg, respectively; P <.001), and 88% of all patients had trace to mild mitral regurgitation. Properly selected older patients can safely undergo SM with excellent outcomes similar to younger patients. Relief of left ventricular outflow tract obstruction and correction of mitral regurgitation are reliably achieved in both groups. Advanced age should not be a strict criteria for selecting septal reduction therapy approach. [ABSTRACT FROM AUTHOR]

Although patients with various types of heritable aortopathy often require distal aortic repair, data are limited regarding the most extensive operations—open thoracoabdominal aortic aneurysm (TAAA) repairs. The objective of this multicenter registry study was to characterize TAAA repairs in a large cohort of patients with different heritable aortic diseases. From the 3699 patients enrolled at 8 participating centers in the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) Registry, we identified 155 open TAAA repairs in 142 unique patients. We examined data related to clinical characteristics, surgical techniques, and outcomes. The primary diagnoses included Marfan syndrome (n = 76; 54%), familial thoracic aortic aneurysm and dissections (n = 31; 22%), and Loeys-Dietz syndrome (n = 10; 7%). Most repairs were performed for aneurysms associated with aortic dissection (n = 110; 71%). The most common repairs involved the entire descending thoracic aorta with distal extension (21% Crawford extent I and 36% extent II). Adjuncts used during repair varied substantially. The operative mortality rate was 1.3%. Other complications included paraplegia (4%), acute renal failure (5%), and vocal cord paralysis (21%). Reoperation after TAAA repair was required in a subset of cases for early bleeding (n = 15; 10%) and late repair failure (n = 7; 5%). Open TAAA repairs are necessary in a variety of heritable aortic diseases. These patients often require extensive surgical repair, and a variety of adjunctive techniques are utilized. The risk of repair failure and the need for reoperation in a subset of patients support the need for vigilant long-term surveillance after repair. [ABSTRACT FROM AUTHOR]

Background Septal myectomy has been the mainstay of the surgical treatment of obstructive hypertrophic cardiomyopathy (HCM); however, recently there is growing appreciation for associated mitral valve abnormalities that contribute to left ventricular outflow tract (LVOT) obstruction. In this study, we describe our experience with combined papillary muscle realignment (PMR) and septal myectomy for the treatment of obstructive HCM. Methods We identified 44 patients undergoing surgery for obstructive HCM whose anatomy was amenable to combined PMR and septal myectomy at our institution over a 20-month period. All patients underwent resting and stress echocardiography preoperatively and postoperatively. Demographic, clinical, and imaging data were prospectively collected in a cardiac surgery database. Results Patient age ranged broadly, with mean age of 54 (range, 18 to 76) years. Preoperatively, 70% of patients were New York Heart Association functional class III or IV, the mean stress LVOT gradient was 144 mm Hg, and severe mitral regurgitation (MR) with stress was seen in 81%. Additional procedures included division of myocardial bands (50%) and chordae (43%) and resection of accessory papillary muscles (25%). Following the procedure, mean resting and stress gradients were reduced to normal (12 and 27 mm Hg, respectively; p < 0.0001). No patient had severe MR and only 3 (6.8%) had moderate MR ( p < 0.0001). Mean length of stay was 6 days and there were no mortalities. Conclusions Septal myectomy combined with PMR is a safe, highly effective, and reproducible procedure that reliably relieves LVOT obstruction and corrects MR without the need for mitral valve repair or replacement. [ABSTRACT FROM AUTHOR]

Background The optimal management of tricuspid regurgitation (TR) in patients undergoing left ventricular assist device (LVAD) implantation is controversial. This study was undertaken to determine the impact of tricuspid valve repair (TVR) at the time of LVAD implantation on survival. Methods The Interagency Registry for Mechanically Assisted Circulatory Support was used to analyze the outcomes of patients undergoing LVAD implantation as destination therapy with or without concomitant TVR. Results Among 2,527 patients undergoing implant of a continuous flow LVAD as destination therapy during the study period, 989 (39%) had moderate or severe TR. The management of TR was not uniform among these patients. Patients with moderate and severe TR underwent TVR in 16.7% and 35.3% of cases, respectively. Moderate and severe TR at the time of LVAD implantation were associated with poorer survival over the entire follow-up period ( p = 0.009). Interestingly, TVR at the time of LVAD implantation did not confer improved survival, even among patients with preimplant moderate or severe TR. A potential explanation for this finding is that patients with preimplant moderate or severe TR who underwent LVAD implant with concomitant TVR commonly experienced recurrent, late TR (21% to 27%). Conclusions Tricuspid valve repair is performed commonly at the time of LVAD implant despite the fact that it does not confer a clear survival benefit. For many patients, LVAD implant alone relieves preimplant TR as effectively as LVAD implant with TVR. Further study is necessary to determine what factors lead to recurrence of late TR in LVAD patients both with and without TVR. [ABSTRACT FROM AUTHOR]

Background: Perioperative red blood cell transfusion is associated with adverse outcomes after cardiac operations. Although restrictive transfusion protocols have been developed, their safety and efficacy are not well demonstrated, and considerable variation in transfusion practice persists. We report our experience with a restrictive transfusion protocol. Methods: We analyzed the outcomes in 409 patients undergoing cardiac operations enrolled in a trial conducted at 30 centers worldwide. Blood products were administered on the basis of a transfusion algorithm applied across all centers, with a restrictive transfusion trigger of hemoglobin less than or equal to 6 g/dL. Transfusion was acceptable but not mandatory for hemoglobin 6 to 8 g/dL. For hemoglobin 8 to 10 g/dL, transfusion was acceptable only with evidence for end-organ ischemia. Results: The patient population was moderately complex, with 20.5% having combined procedures and 29.6% having nonelective operations. The mean EuroSCORE for the population was 4.3, which predicted a substantial incidence of morbidity and mortality. Actual outcomes were excellent, with observed mortality of 0.49% and rates of cerebrovascular accident, myocardial infarction, and acute renal failure 1.2%, 6.1%, and 0.98%, respectively. The frequency of red blood cell transfusion was 33.7%, which varied significantly by center. Most transfusions (71.9%) were administered for hemoglobin 6 to 8 g/dL; 21.4% were administered for hemoglobin 8 to 10 g/dL with evidence for end-organ ischemia; 65.0% of patients avoided allogeneic transfusion altogether. Conclusions: A restrictive transfusion protocol can be safely applied in the care of moderate-risk patients undergoing cardiac operations. This strategy has significant potential to reduce transfusion and resource utilization in these patients, standardize transfusion practices across institutions, and increase the safety of cardiac operations. [Copyright &y& Elsevier]

Background. Improved outcomes as well as lack of donor hearts have increased the use of ventricular assist devices (VADs), rather than inotropic support, for bridging to transplantation. Recognizing that organ allocation in the highest status patients remains controversial, we sought to compare outcomes of patients with VADs and those receiving advanced medical therapy. Methods. The United Network of Organ Sharing (UNOS) database was used to compare survival on the waiting list and posttransplantation survival in status 1A heart transplantation patients receiving VADs or highdose/dual inotropic therapy or an intraaortic balloon pump( IABP), or both. Adjusted survival was calculated using Cox's proportional hazard model. Results. Adjusted 1-year posttransplantation mortality was higher among patients with VADs compared with patients receiving inotropic agents alone (hazard ratio [HR], 1.48; p < 0.05). Survival remained better for patients receiving inotropic agents alone in the post-2008 era (HR, 1.36; p = 0.03) and among those with isolated left-sided support (HR, 1.33; p = 0.008). When patients who received IABPs were added and analyzed after 2008, the left ventricular assist device (LVAD) group had similar survival (HR, 1.2; p = 0.3). Survival on the waiting list, however, was superior among patients with LVADs (HR, 0.56; p < 0.05). In a therapy transition analysis, failure of inotropic agents and the need for LVAD support was a consistent marker for significantly worse mortality (HR, 1.7; p < 0.05). Conclusions. Although posttransplantation survival is better for patients who are bridged to transplantation with inotropic treatment only, the cost of failure of inotropic agents is significant, with a nearly doubled mortality for those who later require VAD support. Survival on the waiting list appears to be improved among patients receiving VAD support. Careful selection of the appropriate bridging strategy continues to be a significant clinical challenge. [ABSTRACT FROM AUTHOR]

Background: Heart transplant (HTx) recipients reach transplantation through increasing numbers of support pathways, including transition from one pathway to another. Outcomes of patients successfully bridged with various support pathways are unknown. We sought to identify mechanical circulatory support pathways that maximize survival after HTx. Methods: A supplemented United Network Organ Sharing Dataset tracked status 1 HTx outcomes from 2000 to 2010. Recipients were grouped based on support pathway before HTx, including those transitioning from one pathway to another. Multivariable factors for time-related death were sought using Cox proportional hazard regression models. Results: We identified 13,250 status 1 HTx recipients. Initial support pathways were inotropes (n = 7,607), left ventricular assist device (LVAD [n = 4,034]), intraaortic balloon pump (n = 729), biventricular assist device (n = 521), extracorporeal membrane oxygenation (ECMO [n = 316]), and right ventricular assist device (n = 43). Multivariable analysis demonstrated that LVAD use conferred a survival advantage (hazard ratio [HR] 0.71; p < 0.001), whereas all other support pathways, including inotropes (HR 1.1; p = 0.02), right ventricular assist device (HR 1.9; p = 0.01), and ECMO (HR 2.2; p < 0.001) increased the risk of post-HTx death. Support pathway transition (both escalation and reduction) occurred in 2,175 patients. Patients who transitioned from either ECMO or biventricular assist device support at listing to LVAD-only support at HTx had improved post-HTx survival that was comparable to patients who had LVAD-only therapy throughout their course ( p = 0.74). Conclusions: The LVAD supported HTx recipients have better posttransplant survival than patients after all other mechanical support pathways. Survival after HTx is optimized when ECMO or biventricular assist device support can be transitioned to LVAD-only support. Our findings should aid clinical decision making and inform organ allocation policy development intended to maximize societal benefits of HTx. [Copyright &y& Elsevier]

Background: Prevalence of univentricular (1V) anatomy over time and whether 1V anatomy is associated with early death after heart transplant (HTx) among recipients with adult congenital heart disease (ACHD) is unknown. We investigated changes in case-mix over time, 1V vs biventricular (2V) status, and the effect of 1V anatomy on death after HTx among ACHD recipients. Methods: The Nationwide Inpatient Sample (NIS) was used to identify ACHD HTx recipients in the United States aged 14 years or older from 1993 to 2007, divided into era 1 (1993 to 2000) and era 2 (2001 to 2007). In-hospital death was compared among recipients with 1V and 2V anatomy. Multivariable determinants associated with an increased risk of in-hospital death were sought with logistic regression models. Results: From a national estimate of 509 ACHD recipients, 143 were 1V and 366 were 2V. Overall, 1V in-hospital mortality (23%) was higher than for 2V (8%; p < 0.001) and remained associated with in-hospital death after adjustment for other factors (odds ratio, 3.9; 95% confidence interval, 1.29 to 11.74; p = 0.02). All 1V diagnoses had higher mortality than all 2V diagnoses. Despite minor fluctuations, the proportion of 1V patients did not increase over time (era 1, 36%; era 2, 30%; p = 0.46). Conclusions: Overall case-mix of ACHD recipients (1V vs 2V) has not changed over time. Initial 1V anatomy increases post-HTx death among ACHD recipients, whereas 2V patients have mortality rates similar to non-CHD recipients. National and international transplant registries should include specific CHD diagnoses because this factor plays such a large role in determining early outcomes. [ABSTRACT FROM AUTHOR]

Background: For patients with thoracic aortic aneurysms (TAA), aortic size on imaging is widely used to guide clinical decision making. This study examined the impact of methodological variance on aortic quantification. Methods: We studied enrollees in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions. Aortic size on computed tomography was quantified by 2 linear methods; cross-sectional dimensions in axial (AX) and double oblique (DO) plane. Calculated area was compared to planimetry. Established cutoffs (area/height >10 cm2/m, diameter ≥ 5cm) for prophylactic TAA repair were used to compare surgical eligibility by each method. Results: Fifty subjects were studied. Aortic size differed between AX and DO at all locations (p ≤ 0.001), with magnitude greatest at the sinotubular junction (4.8 ± 1.1 vs 4.0 ± 1.0 cm, p < 0.001). The difference between AX and DO correlated with aortic angular displacement (r = 0.37, p < 0.01), which was threefold larger at the sinotubular junction (37 ± 12 degrees) than the ascending aorta (12 ± 5 degrees; p < 0.001). At all locations, aortic area calculated using DO yielded smaller differences with planimetry than AX (p < 0.05). DO and planimetry yielded equal prevalence (24%) of subjects eligible for prophylactic TAA repair based on area-height cutoff, whereas AX prevalence was higher (44%; p = 0.006). Using a linear cutoff, AX yielded over a twofold greater prevalence of surgically eligible subjects (56%) than did DO (24%; p < 0.001). Conclusions: Established linear methods for aortic measurement yield different results that impact surgical eligibility. DO yielded improved agreement with planimetry and differed with AX in proportion to aortic geometric obliquity. Findings support DO measurements for imaging evaluation of subjects with TAA. [ABSTRACT FROM AUTHOR]

Background: Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. Methods: The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical ‘OR’ connector—Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical ‘AND’ connector. Results: In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. Conclusions: Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations. [Copyright &y& Elsevier]

Background: Maintenance of appropriate capillary blood glucose in cardiovascular surgery patients has been associated with improved outcomes, including lower mortality. Interpatient variability in insulin resistance can make management difficult, leading to unexpected episodes of hypoglycemia and hyperglycemia. To improve postoperative glucose control at our institution, a patient-specific insulin-resistance–guided (IRG) protocol was developed. Methods: Prospective data were gathered on 100 consecutive cardiovascular surgery patients managed with our standard insulin infusion protocol and 100 patients managed using the IRG protocol. Clinical characteristics and glycemic indices were analyzed for the two groups. Primary endpoints included (1) percentage of time spent in the target range, (2) number of hypoglycemic and hyperglycemic episodes, (3) time to achievement of target blood glucose, and (4) the total daily dose of insulin required. Results: The IRG protocol resulted in significant improvements, including increased percentage of time spent in the normoglycemic range (82.5% versus 65.8%, p < 0.001), reduced rate of hypoglycemic episodes (0.12 versus 0.99, p < 0.01), reduced rate of hyperglycemic episodes (capillary blood glucose >126 mg/dL: 4.8 versus 8.2, p < 0.01), and a reduced time to the first measurement in the target range. Total daily dose of insulin was mildly increased, but failed to reach statistical significance (92.48 versus 82.64 units, p = 0.32). Conclusions: Use of the IRG protocol led to improved glycemic indices while reducing episodes of hypoglycemia in both diabetic and nondiabetic patients. The ability to adjust a patient''s insulin dosing based upon factors related to their insulin resistance results in improved blood glucose control and safety in cardiovascular surgery patients. [Copyright &y& Elsevier]

Background: Genetic disorders are an important cause of thoracic aortic aneurysms (TAAs) in young patients. Despite advances in the treatment of genetically triggered TAAs, the optimal syndrome-specific treatment approach remains undefined. We used data from the National Institutes of Health–funded, multicenter National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) to characterize the contemporary surgical treatment of patients with genetically triggered TAAs. Methods: GenTAC''s aim is to collect longitudinal clinical data and banked biospecimens from 2800 patients with genetically triggered TAAs. We analyzed data from the 606 patients (mean age, 37.5 years) enrolled in GenTAC to date whose clinical data were available. Results: The patients'' primary diagnoses included Marfan syndrome (35.8%), bicuspid aortic valve with aneurysm (29.2%), and familial TAAs and dissections (10.7%). Of these, 56.4% had undergone at least one operation; the most common indications were aneurysm (85.7%), valve dysfunction (65.8%), and dissection (25.4%). Surgical procedures included replacement of the aortic root (50.6%), ascending aorta (64.8%), aortic arch (27.9%), and descending or thoracoabdominal aorta (12.4%). Syndrome-specific differences in age, indications for operation, and procedure type were identified. Conclusions: Patients with genetically transmitted TAAs evaluated in tertiary care centers frequently undergo surgical repair. Aneurysm repairs most commonly involve the aortic root and ascending aorta; distal repairs are less common. Like TAAs themselves, complications of TAAs, including dissection and aortic valve dysfunction, are important indications for intervention. Future studies will focus on syndrome- and gene-specific phenotypes, biomarkers, treatments, and outcomes to improve the treatment of patients with TAAs. [Copyright &y& Elsevier]

Background: Hormonal status is a potentially important cause for gender differences in outcomes after cardiovascular operations. Estrogen withdrawal states may potentiate ischemia–reperfusion injury by impairing endothelial cell function and increasing inflammatory cytokine levels. We hypothesized that gender influences mortality after mitral valve operations and that it varies with age, especially during periods of declining ovarian function. Methods: We studied 24,977 patients (49% women) in The Society of Thoracic Surgeons National Database who underwent isolated mitral valve repair or replacement from 2002 to 2005. Age-related gender differences in mortality after mitral valve operation were compared by risk-adjusted analysis. Results: Gender and age had a pronounced impact on hospital mortality. Women aged 40 to 49 and 50 to 59 had significantly greater hospital mortality than risk-matched men. The adjusted female/male odds ratio for hospital mortality in the group aged 40 to 49 was 2.56 (95% confidence interval, 1.31 to 5.01) but progressively decreased in the four subsequent age groups. This pattern was statistically significant (p = 0.028 and p = 0.018 for 40 to 49 vs 70 to 79 and 80 to 89, respectively) and represents a declining relative mortality risk for women of advanced age. Conclusions: In patients aged 40 to 59 years, the mortality of mitral valve operation is approximately 2.5 times higher in women compared with men with similar risk factors. This survival disadvantage diminishes with further aging. Changes in ovarian function may be an important cause for this gender–age interaction and are a potential target for novel hormone-based therapies. [Copyright &y& Elsevier]

Background: Intractable hemorrhage after complex cardiovascular operations is a serious and potentially lethal complication. We report our experience with the use of activated recombinant factor VIIa (rFVIIa) as rescue therapy for patients with refractory postoperative hemorrhage. Methods: From April 2002 through December 2003, 9 patients received rFVIIa for intractable hemorrhage after cardiovascular surgery. Patients underwent aortic surgery (2), coronary artery bypass graft surgery (4), double valve operations (2), and mitral valve replacement (1). Four of these procedures were reoperations. Intraoperative aprotinin was used in all patients. All patients underwent standard heparinization (300 IU/kg) before cardiopulmonary bypass and reversal with protamine. Results: Five patients underwent reexploration for mediastinal hemorrhage before treatment; 2 were reexplored twice. The average transfusion requirement before rFVIIa administration was 9 U of blood, 7 U of plasma, 22 U of platelets, and 19 U of cryoprecipitate. rFVIIa was administered as an intravenous bolus at 68 to 120 μg/kg. Mean time of administration from the first operation was 10.9 ± 7.2 hours. At the time of activated rFVIIa administration, chest tube drainage averaged 640 mL/h. In all patients, chest tube drainage was dramatically reduced to less than 100 mL/h within 5 hours after drug delivery. None of the patients required reexploration after treatment. There were no postoperative neurologic or cardiovascular complications. Conclusions: When used as rescue therapy for intractable hemorrhage after cardiovascular surgery, rFVIIa may be effective in promoting hemostasis, preventing reexploration, and reducing transfusion requirements. [Copyright &y& Elsevier]

Background. Infection of the sternoclavicular joint is unusual, and treatment of this entity has not been standardized. We sought to characterize the current presentation and optimal management of this disease.Methods. We retrospectively reviewed the records of the last 7 patients undergoing operation for suppurative infections of the sternoclavicular joint at this institution. Patients were interviewed regarding upper extremity function after formal joint resection.Results. Predisposing factors were common and included diabetes mellitus (n = 2), clavicular fracture (n = 1), human immunodeficiency virus infection (n = 1), immunosuppression (n = 1), and pustular skin disease (n = 1). All patients presented with local symptoms including clavicular mass and tenderness. Diagnosis and evaluation were facilitated by cross-sectional imaging. Organisms isolated included Staphylococcus aureus, group G streptococcus, and Proteus and Propionibacterium species. Antibiotic therapy and simple drainage and debridement were generally ineffective, leading to recurrence of infection in 5 of 6 patients treated initially in this manner. Six patients were treated with resection of the sternoclavicular joint and involved portions of first or second ribs with soft tissue coverage by advancement flap from the ipsilateral pectoralis major muscle. Response to this therapy was excellent, with cure in all patients, no wound complications, and excellent upper extremity function at long-term follow-up.Conclusions. Aggressive surgical management including resection of the sternoclavicular joint and involved ribs with pectoralis flap closure would appear to be the preferred treatment for all but the most minor infections of the sternoclavicular joint. This approach has minimal impact on upper extremity function. [Copyright &y& Elsevier]

A need persists for implantable devices that provide support for the failing right ventricle. The anatomy of the right ventricle presents unique challenges at the time of right ventricular assist device implant. We describe a technique for right ventricular outflow tract cannulation that minimizes the risk of right ventricular assist device inflow cannula obstruction and right ventricular compression. [ABSTRACT FROM AUTHOR]

Pseudoxanthoma elasticum (PXE) is a rare, inherited connective tissue disorder with numerous systemic manifestations that include premature coronary artery disease. Coronary artery bypass grafting (CABG) is known to be beneficial in patients with PXE-related coronary artery disease. In these patients, however, the suitability of arterial conduits, including the internal mammary artery, has been controversial. We present a patient with PXE-related coronary artery disease who has had long-term patency of a left internal mammary artery (LIMA) graft after an off-pump CABG procedure in which LIMA and bilateral radial artery conduits were used. [Copyright &y& Elsevier]

Extraskeletal osteosarcoma is a rare malignancy that has not been previously reported to arise from the diaphragm. We describe the case of a 47-year-old woman who had a large thoracic mass found at operation to be an extraskeletal osteosarcoma arising from the diaphragm. The tumor was completely resected en bloc with a margin of surrounding diaphragm, which necessitated a diaphragmatic reconstruction. The literature concerning this rare tumor is reviewed. [Copyright &y& Elsevier]

Background: Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007., Methods: The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector., Results: In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management., Conclusions: Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)