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Background: In a prospective, randomized trial involving 263 patients who would be incompletely revascularized by coronary artery bypass grafting (CABG) alone, CABG plus transmyocardial revascularization (CABG/TMR) provided an early mortality benefit with similar angina relief compared with CABG alone at 1 year. We evaluated the long-term outcome of patients randomized to CABG/TMR or CABG alone., Methods: Thirteen centers that enrolled 83% (218/263) of the patients in the original trial participated in this longitudinal study. Between 1996 and 1998, these centers randomized 218 patients who would be incompletely revascularized by CABG alone because of diffusely diseased target vessels to either holmium:yttrium-aluminum-garnet (holmium:YAG) CABG/TMR (n = 110) or CABG alone (n = 108). Baseline demographics and operative characteristics were similar between groups. Follow-up (mean 5.0 +/- 1.7 years) included survival and blinded angina class assessment., Results: At this 5-year follow-up both groups experienced significant angina improvement from baseline, however, the CABG/TMR group had a lower mean angina score (0.4 +/- 0.7 vs 0.7 +/- 1.1, p = 0.05), a significantly lower proportion of patients with severe angina (class III/IV: 0% [0/68] vs 10% [6/60], p = 0.009), and a trend towards greater number of angina-free patients (78% [53/68] vs 63% [38/60], p = 0.08), compared with CABG alone patients. Kaplan-Meier survival at 6 years was similar between CABG/TMR and CABG alone patients (76% vs 80%, p = 0.90)., Conclusions: Five-year follow-up of prospectively randomized patients who would be incompletely revascularized because of diffuse coronary artery disease indicates that the addition of TMR to conventional CABG provides superior angina relief compared to CABG alone.

Seven patients with complex thoracic aortic aneurysms were operated on using profound hypothermia and circulatory arrest through a left thoracotomy. Three patients had false aneurysms, 2 had large aneurysms precluding access for proximal control, 1 patient had had previous hemiarch replacement, and 1 patient had a thoracoabdominal aneurysm. All patients were cooled on partial cardiopulmonary bypass until the electroencephalogram was isoelectric (approximately 15 degrees C rectal temperature). Circulatory arrest times ranged from 7 to 56 minutes (median, 34 minutes). There was one death due to cardiac failure, and paraplegia developed in 1 patient. The 6 survivors are otherwise well at a median of 12 months postoperatively. Hypothermia and circulatory arrest is an invaluable technique for the treatment of complex aortic aneurysms requiring left thoracotomy for resection. The techniques employed are described and the indications for their use are discussed.

An alternative technique of handling the aortic cannulation site blowout is described. The cannulation site is excluded with a side-biting clamp. The area is excised. Pericardial patch is sewn in to cover the defect.

These studies demonstrate that immune monitoring and individualized modulation of recipient immune reactivity using a quality-controlled preparation of rabbit antithymocyte globulin can improve results of cardiac transplantation. The most valuable assay in individualizing drug doses was the serial measurement of T-cell levels using a complete lymphocyte profile technique and monitoring with phytohemagglutinin to rule out false low T-cell levels. Using this system, the incidence and severity of early rejections were markedly reduced and no grafts were lost to rejection in the first month. The recent first-year graft survival has been about 60%, an improvement largely related to a reduction in early rejection and infection. This technique of immunosuppression appears quite promising for improving the results of future cardiac transplantations.

Seventeen consecutive patients underwent pull-through esophagectomy using blunt dissection from laparotomy and cervical incisions for carcinoma of the esophagus. Fifteen patients had a middle-third lesion while 2 patients had a distal-third lesion. The gastrointestinal tract was reconstructed using primary gastroesophagostomy in 15 patients and colon interposition in 2. Both the colon and stomach were placed through the posterior mediastinum. The surgical technique and results are described in detail. There were two major complications. One patient died of massive gastric hemorrhage on the eighth postoperative day in spite of emergency operation. Another patient sustained a tear of the membranous trachea at the time of blunt dissection. This was repaired through a right thoracotomy without difficulty. Esophagectomy using blunt dissection offered excellent palliation and resulted in little morbidity in our series. The shortened operating time, minimal blood loss, total lack of postoperative chest pain, minimal pulmonary complications, and the benefit of a cervical anastomosis are several advantages compared with the present surgical approaches.

The case of a patient with a chronic, posttraumatic descending thoracic aortic aneurysm and a large diaphragmatic hernia is presented. We repaired the diaphragm with Prolene mesh and externally grafted the aneurysm. To our knowledge, simultaneous repair of these two chronic injuries has not been reported. The merits of external grafting of aortic aneurysms are discussed.