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Background: Statistical risk models for durable left ventricular assist device (LVAD) implantation inform candidate selection, quality improvement, and evaluation of provider performance. This study developed a 90-day mortality risk model using The Society of Thoracic Surgeons National Intermacs Database (STS Intermacs)., Methods: STS Intermacs was queried for primary durable LVAD implants from January 2019 to September 2023. Multivariable logistic regression was used to derive a model based on preimplant risk factors by using derivation (2019-2021 implants) and validation (2022-2023 implants) cohorts. Model performance (derivation and validation cohorts) was assessed using C-statistics, Brier scores, and calibration plots. A refined model (all patients) was generated to calculate observed-to-expected (O/E; 95% CI) ratios for each center., Results: The study population consisted of 11,342 patients from 2019 to 2023 who were sequentially divided in time into derivation (n = 6775) and validation (n = 4567) cohorts. Ninety-day mortality was 8.0% (9.2% in the derivation cohort vs 7.4% in the validation cohort; P = .001). Logistic regression applied to derivation and validation cohorts produced similar discrimination (area under the curve [AUC], 0.714 [95% CI, 0.69-0.74]; and AUC, 0.707; [95% CI, 0.67-0.72], respectively) and calibration (Brier score, .08 vs .07), with overestimation of risk among patients with a predicted risk >0.4. The O/E analysis identified 22 (12.5%) centers with worse than expected mortality with a 95% CI >1.0 and 14 centers (8.0%) with better than expected mortality with a 95% CI <1.0 (all P < .05)., Conclusions: The STS Intermacs risk model demonstrated satisfactory discrimination and calibration. This tool may be used to inform candidate selection, facilitate quality improvement, and assess provider performance., Competing Interests: Disclosures Francis D. Pagani has served as a noncompensated ad hoc scientific advisor for Abbott, BrioHealth Solutions, Berlin Heals, FineHeart, and Medtronic; has served as a noncompensated medical monitor for Abiomed; has served as a member of the Data Safety Monitoring Board for Carmat; and has received travel support from BrioHealth Solutions. Aditi Nayak has served on the clinical advisory board of Pumpinheart; and has reported consulting for Alira Health. Jeffrey Teuteberg has reported consulting for Abbott, Broadview Ventures, and Medtronic; has served on the advisory board for Abiomed, Care Dx, Medtronic, and Takeda; and has served as a speaker for CareDx, Medtronic, and Paragonix. Palak Shah has reported consulting for Procyrion, Merck, Natera, Ortho Clinical Diagnostics, Tosoh Biosciences, and JVP Labs. J. David Vega has reported membership on the Clinical Events Committee for BrioHealth INNOVATE IDE clinical trial. Josef Stehlik has reported consulting for Medtronic, Natera, and TransMedics. All other authors declare that they have no conflicts of interest., (Copyright © 2025 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The timing of operative revascularization for patients with concomitant carotid artery stenosis and coronary artery disease remains controversial. We examined the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to evaluate the association of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with postoperative outcomes., Methods: All patients undergoing CABG with known carotid stenosis of >80% were identified from 2011 to 2016. Individuals were stratified by use of cardiopulmonary bypass and whether a concomitant CEA was performed at the time of CABG. Multivariate logistic regression was used to model the probability of combined CABG and CEA. The resulting propensity scores were used to match individuals on the basis of clinical and operative characteristics to evaluate primary (30-day mortality and in-hospital transient ischemic attack and stroke) and secondary (STS morbidity composite events and length of stay) end points, with P < .05 required to declare statistical significance., Results: After propensity score matching, 994 off-pump CABG patients (497 CABG only and 497 CABG-CEA) and 5952 on-pump CABG patients (2976 CABG only and 2976 CABG-CEA) were identified. For patients who received on-pump operations, those undergoing CABG-CEA had no observed difference in rate of in-hospital stroke (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.72-1.21; P = .6), higher incidence of STS morbidity composite events (OR, 1.15, 95% CI, 1.01-1.31; P = .03), longer length of stay (7.0 [interquartile range, 5.0-9.0] days vs 6.0 [interquartile range, 5.0-9.0] days; P < .005), and no observed difference in 30-day mortality (OR, 1.28; 95% CI, 0.97-1.69; P = .08) compared with those undergoing CABG only. For off-pump procedures, CABG-CEA patients had no observed difference in rate of in-hospital stroke (OR, 0.80; 95% CI, 0.37-1.69; P = .56) compared with those undergoing CABG only., Conclusions: Whereas the differences are relatively small, these data suggest that a combined CABG-CEA approach is unlikely to provide significant stroke reduction benefit compared with CABG only. However, comparison with staged approaches merits further investigation., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: When transcatheter aortic valve replacement (TAVR) cannot be carried out through transfemoral access, alternative access TAVR is indicated. The purpose of this study was to explore inhospital and 1-year outcomes of patients undergoing alternative access TAVR through the transapical (TA) or transaortic (TAo) techniques in the United States., Methods: Clinical records of 4,953 patients undergoing TA (n = 4,085) or TAo (n = 868) TAVR from 2011 to 2014 in The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy Registry were linked to Centers for Medicare and Medicaid Services hospital claims. Inhospital and 1-year clinical outcomes were stratified by operative risk; and the risk-adjusted association between access route and mortality, stroke, and heart failure repeat hospitalization was explored., Results: Mean age for all patients was 82.8 ± 6.8 years. The median STS predicted risk of mortality was significantly higher among patients undergoing TAo (8.8 versus 7.4, p < 0.001). When compared with TA, TAo was associated with an increased risk of unadjusted 30-day mortality (10.3% versus 8.8%) and 1-year mortality (30.3% versus 25.6%, p = 0.006). There were no significant differences between TAo and TA for inhospital stroke rate (2.2%), major vascular complications (0.3%), and 1-year heart failure rehospitalizations (15.7%). Examination of high-risk and inoperable subgroups showed that 1-year mortality was significantly higher for TAo patients classified as inoperable (p = 0.012)., Conclusions: Patients undergoing TAo TAVR are older, more likely female, and have significantly higher STS predicted risk of mortality scores than patients operated on by TA access. There were no risk-adjusted differences between TA and TAo access in mortality, stroke, or readmission rates as long as 1 year after TAVR., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Public report cards and confidential, collaborative peer education represent distinctly different approaches to cardiac surgery quality assessment and improvement. This review discusses the controversies regarding their methodology and relative effectiveness. Report cards have been the more commonly used approach, typically as a result of state legislation. They are based on the presumption that publication of outcomes effectively motivates providers, and that market forces will reward higher quality. Numerous studies have challenged the validity of these hypotheses. Furthermore, although states with report cards have reported significant decreases in risk-adjusted mortality, it is unclear whether this improvement resulted from public disclosure or, rather, from the development of internal quality programs by hospitals. An additional confounding factor is the nationwide decline in heart surgery mortality, including states without quality monitoring. Finally, report cards may engender negative behaviors such as high-risk case avoidance and "gaming" of the reporting system, especially if individual surgeon results are published. The alternative approach, continuous quality improvement, may provide an opportunity to enhance performance and reduce interprovider variability while avoiding the unintended negative consequences of report cards. This collaborative method, which uses exchange visits between programs and determination of best practice, has been highly effective in northern New England and in the Veterans Affairs Administration. However, despite their potential advantages, quality programs based solely on confidential continuous quality improvement do not address the issue of public accountability. For this reason, some states may continue to mandate report cards. In such instances, it is imperative that appropriate statistical techniques and report formats are used, and that professional organizations simultaneously implement continuous quality improvement programs. The statistical methodology underlying current report cards is flawed, and does not justify the degree of accuracy presented to the public. All existing risk-adjustment methods have substantial inherent imprecision, and this is compounded when the results of such patient-level models are aggregated and used inappropriately to assess provider performance. Specific problems include sample size differences, clustering of observations, multiple comparisons, and failure to account for the random component of interprovider variability. We advocate the use of hierarchical or multilevel statistical models to address these concerns, as well as report formats that emphasize the statistical uncertainty of the results.

Background: Of all aortic operations, thoracoabdominal aortic repairs have the highest risk of spinal cord neurologic injury, manifest by lower limb paraplegia or paraparesis. Cerebrospinal fluid drainage combined with intrathecal papaverine (CSFDr + IP) may reduce the risk and severity of neurologic injury. The objective of this study was to evaluate the effect of CSFDr + IP to prevent neurologic injury after high-risk thoracoabdominal aneurysm repairs., Methods: We screened 64 patients before operation with descending thoracic or thoracoabdominal aneurysms for possible inclusion in a prospective, randomized study. Thirty-three patients with high-risk type I and II thoracoabdominal aneurysms met inclusion criteria and 17 were randomly assigned to CSFDr + IP and 16 to the control group. The study was terminated early after interim analysis revealed a significant difference., Results: Of 64 patients screened, 2 patients died after operation (3.1%, 2/64); both were in the randomized study (6%, 2/33), and neither had a neurologic injury. Neurologic injury developed in 2 CSFDr + IP patients and 7 control patients (p = 0.0392). Control patients also had lower postoperative motor strength scores (p = 0.0340). On multivariate analysis, risk factors for neurologic injury included (p < 0.05) longer cross-clamp time, failure to actively cool with bypass, and postoperative hypotension, whereas CSFDr + IP was protective. Logistic regression showed that CSFDr + IP and active cooling significantly reduced the risk of injury and that the two combined modalities were additive. Of 64 patients screened, only 2 (3%) had a permanent neurologic deficit preventing ambulation., Conclusions: For high-risk thoracoabdominal aneurysms, CSFDr + IP was effective in reducing the incidence and severity of neurologic injury. Active cooling may be further additive to CSFDr + IP protection, although this needs to be confirmed in a larger study.

Background: Neural networks are nonparametric, robust, pattern recognition techniques that can be used to model complex relationships., Methods: The applicability of multilayer perceptron neural networks (MLP) to coronary artery bypass grafting risk prediction was assessed using The Society of Thoracic Surgeons database of 80,606 patients who underwent coronary artery bypass grafting in 1993. The results of traditional logistic regression and Bayesian analysis were compared with single-layer (no hidden layer), two-layer (one hidden layer), and three-layer (two hidden layer) MLP neural networks. These networks were trained using stochastic gradient descent with early stopping. All prediction models used the same variables and were evaluated by training on 40,480 patients and cross-validation testing on a separate group of 40,126 patients. Techniques were also developed to calculate effective odds ratios for MLP networks and to generate confidence intervals for MLP risk predictions using an auxiliary "confidence MLP.", Results: Receiver operating characteristic curve areas for predicting mortality were approximately 76% for all classifiers, including neural networks. Calibration (accuracy of posterior probability prediction) was slightly better with a two-member committee classifier that averaged the outputs of a MLP network and a logistic regression model. Unlike the individual methods, the committee classifier did not overestimate or underestimate risk for high-risk patients., Conclusions: A committee classifier combining the best neural network and logistic regression provided the best model calibration, but the receiver operating characteristic curve area was only 76% irrespective of which predictive model was used.

Background: The role of noninvasive carotid artery screening in relation to other clinical variables in identifying patients at increased risk of stroke after coronary artery bypass grafting was examined., Methods: Preoperative, intraoperative, and postoperative clinical data were prospectively collected for 1,835 consecutive patients undergoing first-time isolated coronary artery bypass grafting between March 1990 and July 1995, 1,279 of whom had screening carotid ultrasonography. All patients with postoperative neurologic events were identified and reviewed in detail. Average patient age was 65.3 years (range, 33 to 92 years), and 9.3% (171 patients) had a prior permanent stroke or transient ischemic attack. Hospital and 30-day mortality was 2.2% (41 patients). Forty-five patients (2.5%) had a transient or permanent postoperative neurologic event. The data were analyzed by stepwise logistic regression to determine the independent predictors of both significant carotid stenosis and stroke., Results: On multivariate analysis, the clinical predictors of significant carotid stenosis were age (p < 0.0001), diabetes (p = 0.0123), female sex (p = 0.0026), left main coronary stenosis greater than 60% (p < 0.0001), prior stroke or transient ischemic attack (p = 0.0008), peripheral vascular disease (p = 0.0001), prior vascular operation (p = 0.0068), and smoking (p < 0.0001). When all variables were evaluated for those patients who underwent noninvasive carotid artery screening, the independent predictors of postoperative neurologic event were prior stroke or transient ischemic attack (p < 0.0001), peripheral vascular disease (p = 0.0037), postinfarction angina pectoris (p = 0.0319), postoperative atrial fibrillation (p = 0.0014), carotid stenosis greater than 50% (p = 0.0029), cardiopulmonary bypass time (p = 0.0006), significant aortic atherosclerosis (p = 0.0054), postoperative amrinone or epinephrine use (p = 0.0054), and left ventricular ejection fraction less than 0.30 (p = 0.0744)., Conclusions: The etiology of postoperative stroke is multifactorial. Selective use of carotid ultrasonography is of value in identifying patients who are at greater risk of postoperative stroke independent of other variables and should be considered before coronary artery bypass grafting, particularly in patients with a history of neurologic event or peripheral vascular disease.

Background: Although originally developed for use in manufacturing statistical quality control techniques may be applicable to other frequently performed, standardized processes., Methods: We employed statistical quality control charts (X- s, p, and u) to analyze perioperative morbidity and mortality and length of stay in 1,131 nonemergent, isolated, primary coronary bypass operations conducted within a 17-quarter time period., Results: The incidence of the most common adverse outcomes, including death, myocardial infarction, stroke, and atrial fibrillation, appeared to follow the laws of statistical fluctuation and were in statistical control. Postoperative bleeding, leg-wound infection, and the summation of total and major complications were out of statistical control in the early quarters of the study period but showed progressive improvement, as did postoperative length of stay., Conclusions: The incidence of morbidity and mortality after primary, isolated, nonemergent coronary bypass operations may be described by standard models of statistical fluctuation. Statistical quality control may be a valuable method to analyze the variability of these adverse postoperative events over time, with the ultimate goal of reducing that variability and producing better outcomes.

Background: The overall incidence of anterior ischemic optic neuropathy after open heart operations at the Lahey Clinic is less than 0.5%. However, during the 2-year period, March 1, 1990, to March 1, 1992, an increased incidence (8 of 602 patients or 1.3%) of this complication was observed., Methods: A rigorous analysis was conducted of all 602 patients who underwent operation during this period., Results: No preoperative risk factors were identified. The development of anterior ischemic optic neuropathy was associated with prolonged cardiopulmonary bypass time, low hematocrit levels, excessive perioperative body weight gain, and the use of epinephrine and amrinone. Other hypothetical risk factors include systemic hypothermia, anemia, increased intraocular pressure, and microembolization. Treatment options include the use of corticosteroid medications, reduction of intraocular pressure, and optic nerve fenestration, although recent evidence and our experience indicate that the fenestration procedure is of no benefit., Conclusions: Because all methods of treatment have had limited success, efforts to prevent this complication are of paramount importance.

Background: A calcified porcelain aorta may complicate aortic valve insertion and require an alternative, more complex method for valve replacement. The reason for this is that sutures cannot be inserted through the calcific plates in the annulus and ascending aorta., Methods: In 6 patients with an average age of 73.8 years (range, 65 to 81 years), we performed the simpler procedure of aortic endarterectomy of the calcific plates with the aortic valve replacement. We realized that there may be an increased risk of postoperative complications, particularly stroke. The calcific plates were fractured to allow debridement of the calcium. In addition, an end-arterectomy was performed of the left main coronary ostium in 2 patients, and 5 patients also had coronary artery bypass grafting performed., Results: All 6 patients underwent successful operations without major complications. On follow-up, echocardiography or computed tomographic scans in 3 patients have not shown dilation of the ascending aorta., Conclusion: Endarterectomy of the aorta may be an option in the management of patients with calcification of the aorta.

Papillary fibroelastomas are rare cardiac tumors, but they are the most common primary tumor of the heart valves. These lesions occur on any of the valves or endothelial surfaces of the heart and may be detected by echocardiography, cardiac catheterization, during open heart operation for other conditions, or at autopsy. Because of their potential for cerebral and coronary embolization, even small papillary fibroelastomas should be excised.

A 68-year-old patient presented with an extensive aortic aneurysm extending from the aortic valve to the aortic bifurcation associated with severe continuous pain, dysphagia, and hoarseness. Because of the risk of impending rupture and an "elephant trunk" procedure not being an option, the entire aorta from the aortic valve to the aortic bifurcation was replaced during one operation using deep hypothermia with circulatory arrest and retrograde perfusion of the brain through the jugular veins. Seven months after the operation the patient walks more than 3 km a day and lives a normal life. The operative repair is presented.

Between January 1970 and October 1992, 119 patients underwent 126 repairs of a paraesophageal hiatal hernia at the Lahey Clinic. Seven patients with a recurrent hernia required reoperation. Of the procedures, 19 (15%) included an antireflux procedure because of severe reflux symptoms and objective evidence of reflux demonstrated by grade 2 esophagitis on endoscopy, manometric evidence of a hypotensive lower esophageal sphincter pressure (< or = 10 mm Hg), positive results on 24-hour pH monitoring, or all three methods. Follow-up ranged from 6 months to 18 years with a median of 61.5 months, and the results of 115 operations were analyzed. Symptomatic results were good to excellent after 96 (83.5%) of these 115 operations. Thirteen symptomatic paraesophageal hernias recurred in 12 patients (one recurrence per 58 patient-years of follow-up). Severe reflux symptoms accompanied by endoscopic evidence of esophagitis developed in 2 patients who had not undergone an antireflux procedure at the time of repair of the hernia. We conclude that an antireflux procedure is rarely required in patients undergoing repair of a paraesophageal hiatal hernia and should be employed only when objective evidence of reflux is seen preoperatively.

Pulmonary edema is an uncommon but serious complication associated with major resection of the lung, usually after pneumonectomy. The pathophysiology of this condition is not completely understood, but recent experimental and clinical data suggest that this condition results from a combination of increased filtration gradient across the pulmonary microcirculation together with hyperpermeability. Overzealous perioperative infusions of fluid have been implicated in clinical cases. We present the reports of 2 patients with postpneumonectomy pulmonary edema we recently encountered and a review of the literature to provide diagnostic and therapeutic guidelines in dealing with this serious complication.

Intrathoracic extramedullary hematopoiesis rarely involves the pleura and is usually asymptomatic. We report a 73-year-old woman with myelofibrosis who had pleural involvement with extramedullary hematopoietic tissue that produced a massive hemothorax. Before the diagnosis of extramedullary hematopoietic tissue was established, sclerosis with tetracycline was attempted, which accelerated pleural bleeding and required surgical evacuation. The bleeding was ultimately controlled by low-dose radiation therapy.

Administration of retrograde cardioplegia is hampered by the presence of a persistent left superior vena cava, which results in excessive runoff of solution into the persistent left superior vena cava and the right atrium. Technical modifications are described that permitted aortic valve replacement to be performed in a patient with persistent left superior vena cava using only retrograde cardioplegia.

Pulmonary venous infarction, although rare, can develop in patients with the various pathologic conditions outlined. The triad of cough, dyspnea, and hemoptysis should raise clinical suspicion. The venous phase of pulmonary arteriography is the best way to document pulmonary venous obstruction, although MR imaging may also prove useful in the future. Treatment of patients with pulmonary venous infarction should be determined on the basis of the obstructing pathologic findings. Antibiotic therapy is important, as evidenced by the early experimental experience with this condition. It may be the only treatment available to patients with idiopathic fibrosing mediastinitis. Pulmonary resection, however, can be accomplished when a localized obstructing lesion is identified.

This type of pulmonary venous infarction has not been previously reported, namely: pulmonary vein obstruction from squamous cell carcinoma. Furthermore, this case is unique in that the characteristic pathologic vascular changes observed with pulmonary venous infarction were contrasted with a noninfarcted upper lobe that was removed from the same patient one year later.

The automatic cardioverter defibrillator generator is a relatively large unit, which has most often been implanted in a subcutaneous pocket. In a consecutive series of 120 primary implantations, we employed a subrectus fascia pocket that has resulted in a cosmetically superior result with a 0.8% incidence of system infection. The technique of subfascial implantation is described.

The management of patients with uncomplicated bronchogenic cysts has evolved over the last decade with the development of more precise diagnostic techniques and a better understanding of the variable natural history of these lesions. Although an aggressive surgical approach is still indicated for infants and children, it is acceptable to treat asymptomatic bronchogenic cysts in adults in a conservative manner. Observation alone may be indicated for small, classic, asymptomatic cysts. The use of mediastinoscopy or percutaneous or transbronchial needle techniques for carinal or paratracheal cysts offers the option of fluid aspiration or wall biopsy, thus avoiding thoracotomy. An air-fluid level in the cyst, the presence of malignant cells in the aspirate or biopsy, the development of symptoms, or enlargement or recurrence of the cyst on follow-up examination mandates complete surgical removal at thoracotomy. This is also indicated for intraparenchymal bronchogenic cysts, which are more prone to bronchial communication and infectious complications and for which the distinction from a carcinoma with a cystic component may be difficult.

alpha 2-Antiplasmin deficiency is a serious coagulation disorder that results in unrestrained fibrinolytic activity. Clinically, it is manifested by instability of the fibrin hemostatic plug and prolonged or delayed bleeding, which is more serious in patients who are homozygous for this trait. A patient scheduled for aortic valve replacement and coronary bypass presented with a history of repeated episodes of postoperative bleeding. Hemostatic laboratory evaluation revealed that the patient had the heterozygous form of alpha 2-antiplasmin deficiency with a serum concentration of 52 percent (normal, greater than 65 percent of the activity of pooled plasma). He underwent preoperative plasmapheresis with administration of 3,000 ml of fresh frozen plasma, which resulted in an increase in the preoperative level of alpha 2-antiplasmin to 78 percent. Although postoperative blood loss was greater than normal, it was easily managed. Preoperative identification of this rare coagulation abnormality permitted appropriate treatment and probably prevented a postoperative death from hemorrhage.

Regression of Barrett's epithelium after antireflux operations remains a controversial topic. We evaluated the effect of antireflux procedures in patients with Barrett's esophagus on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Of the 241 patients with Barrett's esophagus treated at the Lahey Clinic from 1973 to 1989, 37 patients underwent an antireflux operation. Regression was defined as histological evidence of regenerating squamous mucosa that completely or partially replaced the columnar epithelium. Improvement in lower esophageal sphincter pressure to 12 mm Hg or greater occurred in 19 of 26 patients (73%) who had perioperative manometry. Symptomatic relief of esophagitis occurred in 34 of 37 patients (92%). Four patients had partial regression with regenerating squamous mucosa juxtaposed with areas of columnar epithelium. Carcinoma developed in 3 of 37 patients (8.1%). One patient had recurrence of severe symptoms of reflux esophagitis before development of carcinoma. Patients with Barrett's esophagus who have undergone a successful antireflux operation with symptomatic relief and evidence of improvement in lower esophageal sphincter pressures rarely show regression of Barrett's mucosa and may still be at risk for development of carcinoma. Therefore, the indications for antireflux operation in Barrett's esophagus should remain the same as for other patients with gastroesophageal reflux, but yearly endoscopic and histological surveillance should be continued postoperatively.

Carcinoma of the adrenal cortex may occasionally extend through the inferior vena cava to the right atrium without actually invading the vascular endothelium. Surgical resection may result in excellent palliation and the potential for prolonged survival when no other signs of advanced disease are present. Extrapolating from our experience with renal cell carcinoma extending to the right atrium, we resected a similar adrenocortical carcinoma using hypothermic circulatory arrest.

We reviewed our concurrent experience with percutaneous insertion versus surgical placement of the intraaortic balloon pump over a two-year period both to compare morbidity and to provide guidelines for the choice of method in particular patient groups and clinical settings. The effects on morbidity of sex, age, emergency placement, coexisting peripheral vascular disease, and duration of counterpulsation were determined. Sex was a highly significant factor, with low complication rates (3/29 or 10.3%) for percutaneous insertion in men and an inordinately high morbidity (12/17 or 70.6%) in women (Fisher exact test: p = 4.611 X 10(-5)). This difference may be due to the smaller size of the femoral artery in women. We conclude that percutaneous insertion is the preferred technique for most men but that direct exposure of the femoral artery should be employed in women. Given the serious morbidity encountered with each technique, there is no justification to broaden the indications for intraaortic balloon counterpulsation.

Occasionally, severe coronary insufficiency necessitates the placement of an intraaortic balloon pump in a patient with a preexisting synthetic aortofemoral bypass graft. Our experience with two such patients suggests that insertion of the intraaortic balloon through a limb of the aortofemoral graft is a safe and effective technique.

A rare and often fatal condition, total obstruction of the left main coronary artery has been treated with increasing success in both acute and chronic clinical settings. Seventeen patients with acute occlusion have been reported in the literature. All were discovered at the time of acute periinfarction catheterization and were treated aggressively with intracoronary thrombolysis, percutaneous transluminal angioplasty, emergency bypass surgery, or a combination of techniques. Chronic total occlusion of the left main coronary artery has been reported in 59 patients, including 3 at our institution. These patients present with chronic but increasingly severe angina. A right dominant coronary anatomy is always found, usually with well-developed right-to-left collaterals. The results of surgical revascularization in our 3 patients and in 45 others described in the literature support the safety and efficacy of this approach.

Symptomatic visual deficits occurred in 4 patients in a series of 700 open heart operations performed by one of us (D.M.S.). The causes of these deficits were retinal emboli, occipital lobe infarction, and anterior ischemic optic neuropathy. The pathophysiology and clinical presentation of these complications are discussed, and previous reports of postoperative visual complications are reviewed.

Long-term survival after treatment of Pancoast tumors has been limited in most series to those patients without positive lymph nodes or residual tumor. In our series of 18 consecutive patients treated with preoperative irradiation and resection, 14 underwent supplemental postoperative radiotherapy because of positive lymph nodes, tumor at the resection margin, or both. No hospital deaths occurred. Eight patients subsequently died, 6 because of metastatic disease; only 2 deaths were secondary to local recurrence. Ten patients are alive at 6 months to 13 years after resection, and 9 of the 10 have no evidence of tumor recurrence. The overall five-year observed survival (Kaplan-Meier) for the entire series was 56.1 +/- 12.7% (+/- standard error). Although the number of patients is small, the addition of postoperative radiotherapy for those with unfavorable operative findings resulted in long-term survival comparable to that of patients with negative nodes and margins.

Extrathoracic esophagectomy for carcinoma is an acceptable substitute for transthoracic resection if it can be shown to have comparable or superior safety and no adverse effect on long-term survival. To test this hypothesis, we employed extrathoracic esophagectomy in 30 consecutive patients with carcinoma of the esophagus from January, 1978, to July, 1984. During this period, 65 comparable patients underwent transthoracic resection through a left thoracotomy for lower esophageal lesions or a right thoracotomy and laparotomy for upper thoracic lesions. Only patients with carcinoma limited to the gastric cardia were excluded from the study. Overall morbidity was higher in the extrathoracic than in the transthoracic group (13 of 30 or 43.3% versus 15 of 65 or 23.1%; p = 0.05), but the differences in hospital mortality (4 of 65 or 6.2% for the transthoracic group versus 4 of 30 or 13.3% for the extrathoracic group) and duration of hospital stay (17.4 +/- 11.7 days for the transthoracic group versus 20.5 +/- 13.4 days for the extrathoracic group) were not statistically significant. Considering all patients who either died or sustained a postoperative complication, we found significant differences favoring transthoracic resection in those subgroups of patients who were able to undergo primary reconstruction at the time of resection (12 of 57 or 21.1% versus 15 of 28 or 53.6%; p = 0.004), those with advanced Stage III lesions (11 of 47 or 23.4% versus 12 of 20 or 60%; p = 0.006), those with tumor of the lower esophagus (8 of 35 or 22.9% versus 6 of 10 or 60%; p = 0.04), and those with tumor that could be resected through a left thoracotomy (2 of 18 or 11.1% versus 17 of 30 or 56.7%; p = 0.002). Actuarial survival curves for all transthoracic and extrathoracic resections and separate analysis for Stage I and Stage III tumors revealed no statistically significant differences between these two techniques.

Because of their tendency to progressively enlarge with compression of adjacent structures, as well as the small chance of malignancy, most intrathoracic goiters should be excised surgically. Most anterior substernal goiters and some ipsilateral posterior mediastinal goiters can be removed safely through a cervical incision. Large posterior mediastinal goiters, contralateral retrotracheal or retroesophageal posterior mediastinal goiters, and isolated mediastinal goiters with no significant cervical connection are best removed through a combined cervical and thoracic approach. The Lahey Clinic experience with three patients with posterior mediastinal goiter is described.