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Objective To present a case that demonstrates the evolution of a pheochromocytoma over a several-year period and to emphasize the importance of a thorough work-up for pheochromocytoma in patients with neurofibromatosis type 1 (NF1) and hypertension. Methods We review the long-term clinical, biochemical, and imaging findings in a man with a complex medical history of hypertension, NF1, and cardiomyopathy. Results A 44-year-old man, with a well-documented history of headaches, hypertension, and NF1, was referred for evaluation of a right adrenal enlargement. He had developed cardiomyopathy and undergone an evaluation for cardiac transplantation. Initial computed tomography revealed subtle asymmetry in the upper right adrenal gland. Biochemical studies for pheochromocytoma yielded equivocal findings, with a 1.5-fold elevation in the urinary norepinephrine and near-normal urinary metanephrine level. Because 131I-metaiodobenzylguanidine imaging showed no tracer uptake in the area of the right adrenal gland, the patient was thought not to have a pheochromocytoma. The patient eventually underwent cardiac transplantation and did well. On reassessment 3 1/2 years later, he was found to have a larger right adrenal mass. The second endocrine evaluation demonstrated substantial elevation in the urinary metanephrine level, and the patient underwent laparoscopic right adrenalectomy to remove the tumor (3.5 by 3.0 by 2.5 cm), which proved to be a pheochromocytoma. Conclusion This case shows that a pheochromocytoma can be difficult to diagnose and can evolve to become a large, biochemically active tumor. It is imperative that patients with an adrenal tumor undergo periodic reevaluation to ensure that the tumor remains stable in size. If the tumor enlarges, further biochemical testing is warranted.

Objective The REMATCH trial compared the use of left ventricular assist devices with optimal medical management for patients with end-stage heart failure. When the trial met its primary end point criteria in July 2001, left ventricular assist device therapy was shown to significantly improve survival and quality of life. With extended follow-up, 2 critical questions emerge: (1) Did these benefits persist, and (2) did outcomes improve over the course of the trial, given the evolving nature of the technology? Methods We analyzed survival in this randomized trial by using the product-limit method of Kaplan and Meier. Changes in the benefits of therapy were analyzed by examining the effect of the enrollment period. Results The survival rates for patients receiving left ventricular assist devices (n = 68) versus patients receiving optimal medical management (n = 61) were 52% versus 28% at 1 year and 29% versus 13% at 2 years ( P = .008, log-rank test). As of July 2003, 11 patients were alive on left ventricular assist device support out of a total 16 survivors (including 3 patients receiving optimal medical management who crossed over to left ventricular assist device therapy). There was a significant improvement in survival for left ventricular assist device–supported patients who enrolled during the second half of the trial compared with the first half ( P = .03). The Minnesota Living with Heart Failure scores improved significantly over the course of the trial. Conclusion The extended follow-up confirms the initial observation that left ventricular assist device therapy renders significant survival and quality-of-life benefits compared with optimal medical management for patients with end-stage heart failure. Furthermore, we observed an improvement in the survival of patients receiving left ventricular assist devices over the course of the trial, suggesting the effect of greater clinical experience.

Background Left ventricular assist device (LVAD) failure and malfunction rates are critical gauges for establishing LVADs as a long-term therapy for end-stage heart failure patients. These device performance measures, however, have been inadequately characterized in the bridge-to-transplantation literature. Methods REMATCH is a randomized trial that compares optimal medical management with LVAD implantation for patients with end-stage heart failure. An independent committee adjudicated patient outcomes. The primary endpoint—survival—was analyzed by intention to treat using the log-rank statistic. Frequency of event occurrence was analyzed by Poisson regression. The time to first event was analyzed by the product limit method. Device performance was disaggregated into confirmed malfunctions and system failures. The latter were events in which patients could not be rescued with backup circulatory support measures. Results The 1-year survival rate was 52% (95% confidence limit [CL]; 40%–63%) for LVAD patients versus 28% (95% CL; 17%–39%) for medical patients and the 2-year survival rate was 29% (95% CL; 19%–40%) for LVAD patients versus 13% (95% CL; 5%–22%) for medical patients. System failure was 0.13 per patient per year and the confirmed LVAD malfunction rate was 0.90. Freedom from device replacement was 87% at 1 year and 37% at 2 years. Conclusions Despite the observed rates of device malfunction and replacement, LVAD implantation confers clinically significant improvement with regard to survival as compared with medical management. Device modifications and innovations for infection management exhibit great promise of improving device performance in the near future.

Background . Most of our patients with coronary artery disease have undergone bypass exclusively with purely internal thoracic artery grafts (PITA). Our goal has been to lengthen the time a patient benefits from coronary bypass operations. The present report describes an 8.5-year study of outcomes including mortality and the need for reintervention in patients who have undergone bypass with PITA. Methods . We studied 897 patients who underwent PITA with a total of 3,784 internal thoracic artery (ITA) grafts (4.2 grafts per patient). Connecting ITA to ITA along with sequential anastomosis made the procedure possible. Results . Early mortality for the group was 2.3%. Freedom from death was 86% and freedom from reintervention was 94% at 5 years after the operation. Conclusions . The acceptable early and late mortality and the 94% freedom from reintervention as long as 8.5 years after operation in this group of patients inspire us to continue choosing PITA for patients with three-vessel coronary artery disease.

CTLA-4 is an immunoregulatory receptor expressed on the surface of activated T and B lymphocytes. The counterreceptors for CTLA-4 are the B7 family molecules. We describe alternatively spliced mRNAs expressed in hematolymphoid tissues of humans, mice, and rats that lack the transmembrane domain coded by exon 3 of the CTLA-4 gene. These alternate transcripts were detected by RT-PCR in B cells and resting T cells of both the CD4 and the CD8 phenotype. Activation of human blood mononuclear cells with PHA or anti-CD3 + anti-CD28 monoclonal antibodies appears to effect a decrease in the amount of the alternative transcript relative to the full-length transcript. Recombinant sCTLA-4 is a B7-binding protein and has immunomodulatory effects as measured by inhibition of the mixed leukocyte response. Human serum contains immunoreactive material consistent with a native soluble form of CTLA-4.

Background . Safe transition from cardiopulmonary bypass to the HeartMate left ventricular assist device without periods of low output, air emboli, or injury to the right ventricle is vital to its successful implantation. A right atrial-to-left ventricular shunt has been developed to purge quickly and completely all air from the system and prevent its reentry, as well as to assist the right ventricle during the transition from cardiopulmonary bypass to the HeartMate. Methods . From January 1994 through July 1996, we used an extracorporeal membrane oxygenation right atrial-to-left ventricular shunt during 17 HeartMate implantations in 16 patients. The shunt consists of the existing right atrial two-stage cannula, the bypass circuit, and a separate aortic line that fills the left ventricle using a 21F cannula in the lateral ventricular wall. Air is monitored in the heart and aorta using transesophageal echocardiography. Results . Ten of the 16 patients are living and 8 have undergone transplantation. Two patients are still using the device and are awaiting transplantation. None of the patients have experienced postoperative neurologic events suggestive of air emboli. Conclusions . The extracorporeal membrane oxygenation right atrial-to-left ventricular shunt is simple and inexpensive to construct. It provides for a smoother and safer transition from cardiopulmonary bypass to the HeartMate left ventricular assist device.

We compared the survival outcomes, left ventricular assist device (LVAD)-related hospitalization, stroke, infection, panel reactive antibody, and blood product use data among 13 Novacor and 51 HeartMate system recipients. Stroke was significantly higher in Novacor patients, as was blood product use at the time of heart transplantation, likely due to long-term anti-coagulation, while the LVAD-related hospitalization and infections did not differ between the 2 groups. A positive panel reactive antibody was seen more among the HeartMate patients, but did not have a significant clinical impact and may not represent a true allosensitization.

Selection of the bypass graft that the patient has demonstrated will remain patent and free from critical atherosclerosis is a most important part of coronary artery bypass reoperations. Sixteen patients in whom a patent left internal thoracic artery—left anterior descending coronary artery bypass graft and obstructed or closed saphenous vein grafts to other coronary arteries were visualized underwent reoperation. To reach the inadequately perfused circumflex and right coronary arteries, the right internal thoracic artery was anastomosed to the left internal thoracic artery as a T graft and then was attached to the circumflex and right coronary artery branches. All patients survived the procedure and are free from angina. There were no perioperative myocardial infarctions, and there was no suggestion of hypoperfusion by the grafts. We believe this technique may reduce the incidence of graft failure in patients undergoing reoperative coronary artery bypass grafting.

the risk of CAV in subjects treated with CNI/AZA (HR-2.33, CI -1.06-5.0, p 0.035; n 160) but not in CNI/MMF (HR -1.49, CI 0.26-7.71, p 0.64; n 59) or in sirolimus (as primary immunosuppressant) treated subjects (HR 0.13, CI 0.001-2.55, p 0.13, n 33). In multivariate analysis 6-month TRS (HR 2.84, CI1.44-6.91, p 0.02) and 6-month MRS (HR-2.66, CI-0.99-6.95, p 0.05) remained significant predictors of increased risk for CAV onset. Twelve and 24 months rejection scores were not risk factors for the onset of CAV. By Kaplan-Meier analysis 6month TRS 0.3 was associated with a significantly shorter time to CAV onset (p 0.018). There was no association between TRS and MRS and 3D IVUS criteria but 38% of this group were treated with sirolimus and 69% with MMF. Conclusions: Increased episodes of rejection in the first 6 months in subjects treated with CNI and AZA increases risk of CAV. Lack of association between rejection score and CAV, assessed agiographically and by 3D IVUS in patients treated with MMF and sirolimus suggests that this combination of immunosuppressive agents may result in improvement in the long-term outcome of CAV.

The results of isolated mitral valve replacement with the Bjork-Shiley disc prosthesis from 1970 to 1973 were compared with those obtained with the cloth-covered Starr-Edwards valve (Models 6300 and 6310) between 1968 and 1971. The patients in both series were followed from 6 to 42 months postoperatively. Hospital mortality rate with the disc prosthesis was 3.6 per cent as opposed to 23.8 per cent with the ball valve, but this difference might be due mainly to the improvement in intraoperative and postoperative care initiated after the ball-valve series was concluded. Fewer late deaths (6.6 versus 15 per cent), thromboembolic complications (4.7 versus 9 per cent), and a better quality of life among survivors were observed with the disc prosthesis, although there was no statistical significance. Prosthetic infection occurred in eight (12 per cent) of the ball valves and only in one (0.9 per cent) of the disc valves (p

Subendocardial flow was measured as a temperature differential between the epicardium and the subendocardium during cardiopulmonary bypass by a measured bolus of cold blood of known temperature injected into the aortic root. The probes, with 0.1 second time response, were accurately placed in the subendocardium and the subepicardium, equidistant from the nearest coronary vessel. The least change recorded was 0.015° C. Direct-current operational amplifier offset the basal temperature, which was measured by a separate probe and maintained constant by small variations from the heat exchanger. Subendocardial and subepicardial flows were recorded in 20 dogs at constant aortic root pressures in the empty, beating and the empty, fibrillating heart. The effects of varying the aortic root pressures on the subendocardial and subepicardial flow ratios were studied in the empty, beating and empty, fibrillating heart. At all pressures studied, the endocardial-epicardial ratio was significantly lower for the empty, fibrillating than for the empty, beating heart (p

A case report of a traumatic tear of the aortic arch with a successful surgical repair is presented. The surgical techniques used in the management of this unusual injury are described, and the principles of cerebral perfusion are discussed.

Initially, the internal mammary artery (IMA) was implanted into the myocardium, and 10 years later it was anastomosed directly to coronary arteries. Our experience with the IMA started with single attached grafts. To reduce injury to the pedicle and improve anastomotic accuracy, magnification, microsurgical techniques, and cardioplegia were introduced. After establishing excellent long-term patency of the IMA and knowing of the high incidence of obstruction in saphenous vein grafts 7 to 10 years after operation, we hypothesized that multiple IMA coronary anastomoses could improve the long-term results of coronary artery bypass grafting. Bilateral IMA, sequential IMA, and IMA Y-grafts were used to increase the number of mammary coronary anastomoses to 3.1 per patient. Early clinical results and patency evaluations are encouraging. In our experience, the IMA has evolved from being implanted into the myocardium, to a single bypass graft to the left anterior descending coronary artery, and finally to being the bypass conduit of choice supplying blood to three or more obstructed coronary arteries or their branches.

To improve (he early and late benefits from coronary artery bypass grafting, we have expanded the use of the internal mammary artery by bypassing three or more coronary arteries with mammary grafts. Experience with higher power magnification and the use of the single internal mammary artery are necessary prerequisites of this procedure. The first 100 patients who had three or more mammary artery–coronary artery anastomoses are reviewed. Eighty-six patients received three mammary-coronary anastomoses, 13 received four, and one received six. An average of 3.2 internal mammary artery grafts and 1.7 saphenous vein grafts per patient were placed. Twenty-five of 27 mammary grafts were open on postoperative graft visualization. There were no early deaths and only one patient died late of complications of gangrene of the lower extremities. None of the patients had significant left ventricular failure and only three had perioperative myocardial infarctions. None of the patients complain of angina and 58 of 59 postoperative stress tests were normal. This procedure should significantly reduce the late closure of bypass grafts and the complications thereof, including the need for reoperation.

Long-term patency of the internal mammary artery graft surpasses that of all other bypass conduits. The use of multiple internal mammary artery grafts should improve the long-term results following coronary artery bypass grafting. Technical factors used in mobilizing, preparing, and anastomosing the internal mammary artery are discussed in this article. Fifty-three patients received sequential attached left internal mammary artery grafts from April, 1982, to August, 1983. In 6 of these patients, the right internal mammary artery was anastomosed to a circumflex marginal branch. There were no operative deaths or instances of low cardiac output. One patient suffered anastomotic narrowing that possibly could have been prevented by excision of excess tissue from the internal mammary artery pedicle. Multiple internal mammary artery grafting should have a profound influence on the results of coronary artery bypass grafting.

Percutaneous transluminal coronary angioplasty (PTCA) has been used to treat patients with prior coronary artery bypass grafting who have stenosis of a saphenous vein graft and/or a native artery. During 53 months, 61 patients underwent 105 angioplasty attempts. Eighty lesions (76%) were successfully dilated in 46 of 61 patients (75 %). Success in a patient was determined by a ≥20% decrease in the percent diameter stenoses coupled with an improved clinical response; 52 patients had one prior CABG and nine patients had two or more prior CABGs. Multivessel disease was present in 56 patients (92%). A vein graft stenosis was successfully dilated in 26 of 33 cases (79%)—19 of 25 (76%) at an anastomotic site and seven of eight (88 %) in the graft body. An arterial stenosis was successfully dilated in 37 of 52 cases (71%)—18 of 22 (82%) in the left anterior descending, 13 of 22 (59%) in the circumflex, 21 of 26 (81 %) in the right coronary, and two (100%) in the left main coronary artery. There is no statistically significant difference in the incidence of success in dilating a vein graft or native artery. Complications included: one emergency CABG (1.6%), three myocardial infarctions (4.9%), and two deaths (3.3%). There were 15 unsuccessful PTCAs: Ten patients had elective CABG, one had emergency CABG, two received medical treatment, and two died. Forty-six patients are being followed-up: Twenty-eight (61 %) continue to do clinically well, seven (15%) had another PTCA and remain well and 10 (16%) had elective CABG because of restenosis and/or disease progression. There was one late death and one late myocardial infarction. Thus, 35 patients (57%) had continued clinical success without the need for repeat CABG; 89% had no angina or improved angina, and 90% had improved exercise treadmill results. PTCA is technically feasible in selected patients with prior CABG and can achieve a clinical response with an acceptable complication rate when compared to repeat CABG.

A new temporary pacemaker electrode, which leaves no exposed areas of wire when implanted, has been designed for use in postoperative cardiac surgical patients. The device, tested in 28 patients who underwent open-heart surgery, has significantly reduced the increase in myocardial threshold to pacing that occurs with the commonly used electrode. Sensing of the electrical signal has been excellent for demand pacing. We feel that this new electrode represents an improvement in the management of patients with postoperative arrhythmias.

A series of 142 adult patients undergoing open-heart surgery were studied. All known blood-conservativing methods were utilized in an attempt to use as little blood as possible. Hemodilution, autologous transfusion, prevention of wasting of blood, and management of postoperative anemia were the measures employed. An average of 2.66 units of blood were given per patient during the entire hospital stay. Twenty patients were not given any blood at all. The patients were removed from cardiopulmonary bypass without difficulty when the hematocrit reading was in the high teens or low twenties. Later in the postoperative period the patients seemed to progress without difficulty with hematocrit readings of 22 to 25 percent.

The internal mammary artery (IMA) was used as a graft in 298 patients undergoing coronary bypass procedures. Two patients died during the operative period and 2 others died one year later. Most of the survivors are free of angina. Of the IMAs restudied 9 to 24 months postoperatively, 95% were patent. This group included nearly all the patients having angina after operation. There are some situations in which the IMA may have inadequate flow in comparison to the vein graft. These results suggest the IMA is an excellent graft in most coronary bypass procedures.

A total of 205 adults with a variety of congenital heart lesions underwent operation for total correction of their defects. Operative and long-term mortality were 3 and 4 percent, respectively. There has been only one operative death in the past five years (85 patients). While most defects were repaired with good hemodynamic and symptomatic improvement, the three lesions associated with the worst results were cyanotic tetralogy of Fallot, severe pulmonic stenosis complicated by atrial septal defect, and ostium primum atrial septal defect. Myocardial failure due to end-stage myocardial fibrosis was the major cause of operative mortality. Myocardial fibrosis and irreversible pulmonary changes seemed to be the two factors limiting operative correction. An aggressive operative approach seems justified based on this study.

Data from three large groups of patients undergoing aorta-to-coronary artery saphenous vein bypass grafting with follow-up angiograms between 0 and 32 months and postoperative clinical evaluation for up to 46 months enable us to say there is an early saphenous vein closure rate of 9%. These closures are probably related to technical judgment difficulties and lend themselves to improvement in results. The documented late closure rate in 92 patients followed a mean of 31.7 months was 13%. This is a rate of one late closure per 171 patient-months. Of the 92 patients, 80 had some effective vein graft functioning in this follow-up period. Histological evaluation has revealed subintimal fibrous hyperplasia to be the predominant factor involved in late closure of the vein bypass. Its manifestations are variable, and the multifactorial etiology is as yet unclear. Since 5% of vein grafts have some significant subintimal fibrous hyperplasia at the time of insertion, only close follow-up with correlation of operative, angiographic, and histological data will provide the answers to the question of etiology of late vein graft closure. Studies on the effect of trauma, vascularity, and nutrition of vein grafts are necessary. The answer to this problem will be necessary to set the coronary vein bypass procedure on a firm footing in the treatment of coronary artery disease.

The results of combined valve replacement and coronary artery bypass in 13 patients are presented. The importance of preoperative coronary visualization in all adult patients undergoing valve replacement is emphasized. The techniques by which we have been able to carry out perfusion of the coronary arteries in these patients with coronary atherosclerosis is also demonstrated. The combined attack on both these problems should, with increasing skill, improve the results in patients with combined valve and coronary artery disease.

Ideally, autotransfusion after cardiac surgical procedures should offer the protection of underwater-seal drainage and involve additional cost to the patients only if their blood is reinfused. A technique of returning the patient's postoperatively drained blood that employs these features and that we have found to be safe, simple, and cost-effective is presented.

Three patients undergoing coronary artery bypass operation at this institution over a two-month period were found to have significant atherosclerotic disease involving the internal mammary artery. All 3 patients were relatively young men with hypertension and severe three-vessel coronary involvement. Continuing experience with the internal mammary artery plus subsequent extensive postmortem dissections have supported our impression that atherosclerosis involving the internal mammary artery is much more prevalent than previously implied. Techniques for evaluating this vessel both preoperatively and intraoperatively are discussed.

The transverse sinus route for bypassing high marginal circumflex coronary arteries facilitates the operation and obviates potential kinking sites at the left atrial appendage and pericardial reflection over the pulmonary veins. The vein bypass emerges from the transverse sinus and closely parallels the marginal circumflex coronary vessels.

Cardiac tamponade after open heart surgery is a life-threatening situation that must be diagnosed and treated as quickly as possible. The causes, diagnosis and management of this problem are discussed. Six cases are presented.