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Background Appropriate collection of quality of life (QOL) measurements for left ventricular assist device (LVAD) patients is challenging. Patient-Reported Outcomes Measurement Information System (PROMIS) is a popular tool that has been validated across multiple disciplines, but its applicability to the LVAD population remains unknown. Methods This single-center, retrospective review included LVAD patients that completed a PROMIS assessment and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) survey at clinical encounters postoperatively. Patients completed computer adaptive PROMIS assessments for physical function, pain interference and depression. All PROMIS domains are designed to follow a normal distribution (mean T-score 50, standard deviation 10) in the general population. Assessments were aggregated over time and correlation between the KCCQ-12 summary score and each PROMIS domain was assessed individually. Results A total of 178 LVAD patients were included in the study. The median time between LVAD implantation and PRO collection was 16.5 [interquartile range, 7.9-37.8] months. Patients typically had worse physical function (T-score 38.8 [33.6-44.2]) but comparable pain (51.1 [38.7-59.2]) and depression (49.9 [41.7-57.5]) as the general population. The KCCQ-12 was more strongly correlated to PROMIS physical function (Spearman’s ρ = 0.746) than pain (ρ = -0.539) or depression (ρ = -0.591). Conclusions PROMIS provides a robust QOL data collection system that can be implemented in a clinical setting without imposing a significant burden. Using this more holistic system may allow for better patient-centered care in order to address QOL limitations imposed by LVAD support that are not directly related to heart failure symptoms.

Background Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) undoubtedly saves many lives, but it is associated with a high degree of patient morbidity, mortality, and resource use. This study aimed to develop a machine learning algorithm to augment clinical decision making related to VA-ECMO. Methods Patients supported by VA-ECMO at a single institution from May 2011 to October 2018 were retrospectively reviewed. Laboratory values from only the initial 48 hours of VA-ECMO support were used. Data were split into 70% for training, 15% for validation, and 15% withheld for testing. Feature importance was estimated, and dimensionality reduction techniques were used. A deep neural network was trained to predict survival to discharge, and the final model was assessed using the independent testing cohort. Model performance was compared with that of the SAVE (Survival After Veno-arterial ECMO) score by using a receiver operator characteristic curve. Results Of the 282 eligible adult patients who were undergoing VA-ECMO, 117 (41%) survived to discharge. A total of 1.96 million laboratory values were extracted from the electronic medical record, from which 270 different summary variables were derived for each patient. The most important variables in predicting the primary outcome included lactate, age, total bilirubin, and creatinine. For the testing cohort, the final model achieved 82% overall accuracy and a greater area under the curve than the SAVE score (0.92 vs 0.65; P = .01) in predicting survival to discharge. Conclusions This proof of concept study demonstrates the potential for machine learning models to augment clinical decision making for patients undergoing VA-ECMO. Further development with multi-institutional data is warranted.

The rate of heart failure and subsequent placement of left ventricular assistive devices (LVADs) has been increasing. The extra-anatomic placement of the LVAD and outflow graft presents a challenging problem for repair when complications arise. The present report describes a case of a 63-year-old man who had presented with acute pseudoaneurysm of the outflow graft of his recently placed LVAD. Percutaneous access of the left subclavian artery and percutaneous, transthoracic access of the outflow graft was obtained to allow for sheath placement and stent deployment within the outflow graft. The patient underwent successful endovascular repair of the defect without complications.

Background Despite limited evidence, systemic anticoagulation is the current standard of care for patients supported on venoarterial-extracorporeal membrane oxygenation (VA-ECMO). We hypothesized that not anticoagulating patients on VA-ECMO would decrease complications. Methods We retrospectively reviewed adult patients supported on VA-ECMO at our institution. Patients were stratified based on anticoagulation strategy. The primary outcome was a composite of hemorrhagic and thrombotic complications. Secondary outcomes included blood product use, incidence of heparin-induced thrombocytopenia (HIT), hospital length of stay, and in-hospital mortality. Results From May 2011 through January 2018, there were 203 eligible patients supported on VA-ECMO, 35% (75 patients) were not anticoagulated. Overall complication rates were significantly lower for the no anticoagulation group (57% versus 76%; P = .007) including a trend toward fewer hemorrhagic complications (53% versus 63%; P = .178) without increased risk of thrombosis (13% versus 21%; P = .147). The anticoagulated group required more transfusions of packed red blood cells (12.8 versus 1.09; P = .002) and platelets (3.0 versus 1.3; P = .009) and showed a higher incidence of HIT (8% versus 0%; P = .015). No difference was found in overall mortality (72% versus 62%; P = .165). Conclusions The absence of routine systemic anticoagulation for patients supported on VA-ECMO is not associated with higher mortality, pump failure, or thrombotic complications. Patients had a lower requirement for blood product transfusions, and there was no incidence of HIT. Patients supported on VA-ECMO without other indications for anticoagulation can be treated without systemic anticoagulation during their VA-ECMO course.

OBJECTIVES History of prior cardiac surgery has traditionally been considered a risk factor for subsequent cardiac procedures. The aim of this study was to investigate the outcomes of patients implanted with a left ventricular assist device via redo sternotomy. METHODS Prospectively collected data were reviewed for all patients implanted with a continuous-flow left ventricular assist device at a single institution from December 2006 through June 2018. Patients were separated into 2 cohorts: those with a history of prior cardiac surgery (redo sternotomy) and those undergoing primary sternotomy at the time of left ventricular assist device implantation. The primary outcome was overall survival. RESULTS Of the 321 patients included in the study, 77 (24%) were implanted via redo sternotomy and 244 (76%) via primary sternotomy. The redo sternotomy cohort was generally older (59 ± 10 vs 57 ± 12 years, P = 0.050) and had a higher incidence of ischaemic disease (70% vs 49%, P = 0.002). The Kaplan–Meier survival analysis demonstrated that overall survival was not significantly different between the redo sternotomy and primary sternotomy groups (6-month survival: 86% vs 92%; 5-year survival: 53% vs 51%; log-rank P = 0.590 for overall difference during follow-up). The propensity score analysis consistently showed that redo sternotomy was not significantly associated with mortality risk (hazard ratio 1.19, 95% confidence interval 0.73–1.93; P = 0.488). Redo sternotomy patients were more likely to require rehospitalization during their first year postoperatively (P = 0.020) and spent less time out of the hospital during the first year (P = 0.046). CONCLUSIONS The redo sternotomy cohort represents a more technically challenging patient population, but overall survival similar to that of primary sternotomy patients can be achieved.

Short‐to‐shield (STS) is a potential complication for left ventricular assist device (LVAD) patients supported by the HeartMate II (HMII) pump. This phenomenon occurs when a damaged internal wire within the driveline makes contact with the surrounding sheath, resulting in insufficient power delivery to the motor when connected to a grounded power base unit (PBU). An ungrounded cable can be used to negate these effects, but the long‐term safety of this treatment strategy is unknown. In this case series, we present our institutional experience treating 17 STS patients with an ungrounded cable. In total, we present 4922 patient‐days (13.4 patient‐years) of ungrounded cable support after primary STS treatment. There were no deaths or complications related to STS. These data suggest that the long‐term use of an ungrounded cable is a reasonable treatment option for patients who cannot or do not wish to undergo pump exchange or splice repair., Patients that experience short‐to‐shield can be safely managed with an ungrounded cable long‐term with careful monitoring.

Background: Advancements in left ventricular assist device (LVAD) technology have improved long-term survival for properly selected patients with advanced heart failure. However, the subset of patients in critical cardiogenic shock remain difficult to treat with persistently high patient morbidity and mortality. The goal of this study is to describe our institutional experience utilizing extracorporeal membrane oxygenation (ECMO) as a bridge to LVAD for patients in cardiogenic shock comparing the less invasive complete sternal-sparing (CSS) surgical technique to median sternotomy. Methods: Data was collected as a single center retrospective review of patients implanted with a continuous-flow LVAD directly off ECMO from 2012 to 2018. Patients were stratified by LVAD surgical technique. The primary outcome was survival to discharge. Secondary outcomes included postoperative complications, resource utilization and survival at 6-months. Results: Of the 37 patients implanted directly off ECMO, 26 (70%) patients were implanted via median sternotomy and 11 (30%) patients by the CSS approach. Median time on ECMO support was 8 days (range, 2–29 days). Preoperative characteristics were similar between groups. Survival to discharge was 78% overall (73% vs . 91% CSS, P=0.391). The CSS cohort had fewer postoperative complications, including fewer transfusions (P=0.044) and trend towards less right ventricular (RV) failure (62% vs . 27% CSS, P=0.079). Both cohorts required similar median length of stay (LOS) in the intensive care unit (ICU) (11 vs . 12 days, P=0.695) and similar overall hospital LOS (34 vs . 22 days, P=0.242). Overall survival was 74% at six months (68% vs . 89% CSS, P=0.386). Conclusions: VA ECMO can be used effectively as a bridge-to-LVAD for patients in cardiogenic shock. The less invasive CSS approach demonstrates potential advantages to median sternotomy. Further study is needed to better understand the benefits of less invasive surgical techniques.

Background: This study investigates the use of modern machine learning (ML) techniques to improve prediction of survival after orthotopic heart transplantation (OHT). Methods: Retrospective study of adult patients undergoing primary, isolated OHT between 2000-2019 as identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was one-year post-transplant survival. Patients were randomly divided into training (80%) and validation (20%) sets. Dimensionality reduction and data re-sampling were employed during training. Multiple machine learning algorithms were combined into a final ensemble ML model. Discriminatory capability was assessed using area under receiver-operating-characteristic curve (AUROC), net reclassification index (NRI), and decision curve analysis (DCA). Results: A total of 33,657 OHT patients were evaluated. One-year mortality was 11% (n=3,738). In the validation cohort, the AUROC of singular logistic regression was 0.649 (95% CI 0.628-0.670) compared to 0.691 (95% CI 0.671-0.711) with random forest, 0.691 (95% CI 0.671-0.712) with deep neural network, and 0.653 (95% CI 0.632-0.674) with Adaboost. A final ensemble ML model was created that demonstrated the greatest improvement in AUROC: 0.764 (95% CI 0.745-0.782) (p

Background Left ventricular assist device (LVAD) therapy has been the standard of care for selected patients with advance heart failure. Even though considerable strides have been achieved with the introduction of the newest centrifugal pump, therapy is still burdened with significant perioperative complications. Smaller devices, along with improved techniques and instruments, have encouraged the adoption of minimally invasive cardiac surgery (MICS) techniques for LVAD implantation to improve perioperative outcomes. Methods We describe a technique for complete sternal-sparing (CSS) HeartMate 3 (Abbott Laboratories, Abbott Park, IL) left ventricular assist device (LVAD) implantation using bilateral thoracotomies and discuss early clinical outcomes of the first ten consecutive patients who underwent CSS implantation of the HeartMate 3 LVAD at our institution. Results The median length of stay in the intensive care unit was 3.5 days. No patients required reexploration for postoperative bleeding. There was no incidence of right ventricle failure, stroke, renal failure, hepatic failure, or myocardial infarction. The median length of hospitalization after LVAD implantation was 14.5 days (interquartile range, 12 to 17 days). Conclusions Our early outcomes suggest that the CSS approach may reduce the incidence of right ventricular failure, bleeding, intubation time, and intensive care unit length of stay. Further studies are needed to fully elucidate the advantages of CSS LVAD implantation compared with median sternotomy.

Background Anomalous left coronary artery from the pulmonary artery is a rare congenital abnormality that requires surgical correction. Case summary We describe the case of a 33-year-old female with a history of anomalous left coronary artery of the pulmonary artery who presents with exertional angina. She underwent a Takeuchi repair that was complicated by a baffle leak. She was successfully treated with left internal mammary artery-left anterior descending (LAD) bypass grafting and percutaneous baffle leak closure. Discussion The Takeuchi procedure involves the creation of an aortopulmonary window and an intrapulmonary tunnel that ‘baffles’ the aorta to the ostium of the anomalous left coronary artery. The most common late complication of the Takeuchi procedure is the presence of a baffle leak. Percutaneous baffle leak occlusion via vascular plug and coronary bypass of the LAD can successfully treat a baffle leak with excellent short-term follow-up.

Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several potential benefits. We hypothesized that the CSS approach for HeartMate 3 (HM3) LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). We retrospectively reviewed patients who were implanted with a commercial HM3 at our institution from September 2017 to August 2018. The Activity Measure for Post-Acute Care short forms and Functional Independence Measure scores were used to assess the patient’s physical limitations postoperatively. A total of 43 patients were included in the study: 27 (63%) CSS patients and 16 (37%) FS patients. At postoperative day 3, the CSS cohort demonstrated improved mobility based on Activity Measure for Post-Acute Care scores compared to the FS group; 40% of the CSS cohort versus 67% of the FS cohort remained 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the Functional Independence Measure sit-to-stand metric with 78% of the CSS cohort achieving modified or complete independence by postoperative day 15 compared to only 21% of the FS patients. These early data suggest that the CSS approach for HM3 LVAD implantation improves postoperative mobility and functional independence compared to FS.

Objective Early reports of less invasive techniques for left ventricular assist device (LVAD) implantation have demonstrated promising results. We sought to investigate the safety and feasibility of implementing the complete sternal-sparing (CSS) approach for LVAD implantation in patients with a history of prior cardiac operation. Methods This was a retrospective review of prospectively collected data for all patients implanted with a fully magnetically levitated LVAD from April 2017 through December 2018. Patients were dichotomized based on surgical approach: CSS or full median sternotomy (FS). Perioperative complications and overall survival were compared between cohorts. Results Of the 29 eligible patients, 15 (52%) were implanted via the CSS approach and 14 (48%) via FS. Preoperative characteristics were similar between cohorts. Overall survival to discharge was 93% for CSS compared to 71% for FS ( P = 0.169). The CSS cohort demonstrated fewer postoperative complications, including fewer cases of severe right ventricular failure ( P = 0.006) and less blood product utilization ( P = 0.015). Median hospital length of stay was significantly shorter for the CSS cohort (median 13 vs 32.5 days, P = 0.016). Neither cohort had any 30-day readmissions. Conclusions Early data suggest that the CSS technique is a safe and effective technique for patients with a history of prior sternotomy. Further studies are needed to validate this single-center experience.

Little is known about the temporal trends and outcomes for extra-corporeal membrane oxygenation (ECMO) in patients with high-risk pulmonary embolism (PE) in the United States. We queried the National Inpatient Sample (NIS) database from 2005 to 2013 to identify patients admitted with high-risk PE. Our objective was to determine trends for ECMO use in patients with high-risk PE. We also assessed in-hospital outcomes among patients with high-risk PE receiving ECMO. We evaluated 77,809 hospitalizations for high-risk PE. There was an upward trend in the utilization of ECMO from 0.07% in 2005 to 1.1% in 2013 ( p = 0.015). ECMO was utilized more in urban teaching hospitals and large hospitals. ECMO use was associated with lower mortality in patients with massive PE ( p < 0.001). In-hospital mortality for patients receiving ECMO was 61.6%, with no change over the observational period ( p = 0.68). Our investigation revealed several independent predictors of increased mortality in patients with high-risk PE using ECMO as hemodynamic support, including: age, female sex, obesity, congestive heart failure, and chronic pulmonary disease. ECMO, therefore, as a rescue strategy or bridge to definitive treatment, may be effective in the management of high-risk PE when selecting patients with favorable clinical characteristics.

Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary bypass that provides life-saving support to critically ill patients whose illness is progressing despite maximal conventional support. Use in adults is expanding, however neurological injuries are common. Currently, the existing brain imaging tools are a snapshot in time and require high-risk patient transport. Here we assess the feasibility of measuring diffuse correlation spectroscopy, transcranial Doppler ultrasound, electroencephalography, and auditory brainstem responses at the bedside, and developing a cerebral autoregulation metric. We report preliminary results from two patients, demonstrating feasibility and laying the foundation for future studies monitoring neurological health during ECMO.

Background: The role of antiplatelet agents in the modulation of arterial disease is well described, but a paucity of data exists regarding their role in chronic venous insufficiency (CVI). We hypothesize that platelet responses to various antiplatelet agents are altered when comparing platelet function within refluxing and non-refluxing vein segments. Additionally, changes in platelet phenotype may alter vein wall biology. Methods: Isolated platelets were obtained simultaneously from the patient antecubital vein (ACV) and a refluxing greater saphenous vein (GSV) during surgical phlebectomy and compared to platelets from healthy individuals. Non-refluxing GSV was harvested for coronary bypass. Platelet surface receptor activation was assessed through P2Y12 (clopidogrel), PAR1 (vorapaxar), and thromboxane (aspirin) pathways by flow cytometry for p-selectin. Immunoblotting assessed CD41 (platelet) and CD45 (WBC) within the wall of vein samples. Results: Platelets from refluxing GSV showed a significant increase in reactivity via all platelet signaling pathways, especially P2Y12 and thromboxane when compared to platelets from the ACV in the same patient. Conversely, platelets collected from the ACV in CVI patients showed a significant decrease in reactivity to all agonists compared to ACV in healthy individuals without CVI. Most notably, GSV from a patient with CVI had a reduction in CD41 content, but a seven-fold increase in the CD45:CD41 ratio, compared to GSV from healthy people (Figure). Conclusions: Platelet activation by these clinically relevant pathways is enhanced locally in the refluxing GSV, yet systemic, circulating platelets isolated from CVI patients are 2-3-fold less active than systemic platelets from healthy people. Our data suggest that reflux may locally alter the circulating platelet phenotype and in turn also have a role in remodeling the vein wall.

A 74-year-old man with a past medical history of diabetes mellitus, hypertension, severe aortic stenosis, coronary artery disease status post-coronary artery bypass surgery with left internal mammary artery, vein graft, and aortic valve replacement with a Rapid Deployment Edwards 23-mm Intuity Elite

Background Management of existing aortic insufficiency (AI) and mechanical aortic valves in patients undergoing left ventricular assist device (LVAD) implantation remains controversial. Surgical options to address these issues include closure, repair or replacement of the valve. Methods Continuous-flow LVAD/biventricular VAD patients entered into the INTERMACS database between June 2006 and December 2012 were included ( n = 5,344) in this analysis. Outcomes were compared between patients who underwent aortic valve (AV) closure ( n = 125), repair ( n = 95) and replacement ( n = 85). Results Among patients who underwent an AV procedure, actuarial survival was significantly reduced for AV closures (63.2%) compared with AV repairs (76.8%) and replacements (71.8%) ( p = 0.0003). Differences were greater between groups when only INTERMACS Level 1 or 2 patients were analyzed ( p = 0.003). After multivariate adjustment, AV closure remained a significant risk factor for mortality (hazard ratio=1.87, 95% confidence interval 1.39 to 2.53, p p Conclusions AV closure was associated with increased mortality when compared with repair or replacement in patients with AI who underwent LVAD insertion. The reasons for this association require further investigation. This is the largest study to date to examine concomitant AV procedures in patients undergoing LVAD insertion.

This study evaluated clinical outcomes associated with erythropoiesis stimulating agent (ESA) use in left ventricular assist devices (LVAD)-supported patients.Use of ESAs in patients with LVADs may minimize blood transfusions and decrease allosensitization. ESAs increase thrombotic events, which is concerning because LVADs are sensitive to pump thrombosis (PT).We retrospectively reviewed 221 patients at our center who received a HeartMate II (Thoratec Corp., Pleasanton, California) LVAD between January 1, 2009 and June 6, 2013. Patients were divided into those who received ESAs during index admission (n = 121) and those who did not (n = 100). Suspected PT was defined as evidence of thrombus in the LVAD or severe hemolysis (lactate dehydrogenase1,000 mg/dl or plasma-free hemoglobin40 mg/dl). Outcomes were compared between cohorts using inverse probability-weighted analyses.During a mean follow-up of 14.2 ± 11.9 months, suspected PT occurred in 37 patients (ESA 23%, no ESA 12%; p =0.03). The ESA cohort received ESAs 13.9 ± 60.9 days after LVAD implantation. At 180 days, event-free rates for suspected PT were ESA 78.6% versus no ESA 94.5% (p 0.001). ESA use had higher rates of suspected PT (hazard ratio [HR]: 2.35; 95% confidence interval [CI]: 1.38 to 4.00; p = 0.002). For every 100-unit increase in cumulative ESA dosage, the hazard of suspected PT increased by 10% (HR: 1.10; 95% CI: 1.04 to 1.16; p 0.001). After inverse probability weighting, ESA use was associated with a significantly higher rate of all-cause mortality (HR: 1.62; 95% CI: 1.12 to 2.33; p = 0.01).ESA use in LVAD patients is associated with higher rates of suspected PT.

Cardiomyopathy (CM) is generally treated with generic heart failure medications, namely diuretics, beta blockers and afterload reduction. Extracorporeal membrane oxygenation (ECMO) can be used in patients with cardiogenic shock (CS) who do not respond to conventional therapy. A 32 year old female

It is clearly established that morbidity and mortality from congestive heart failure (CHF) is related to the irreversible progression of left ventricular (LV) dysfunction. Regardless of the etiology of CHF, the associated deterioration in LV diastolic compliance and systolic function results in impaired ventricular filling and decreased tissue perfusion leading to the progression of the symptoms of fatigue, dyspnea on exertion and peripheral edema [1]. The management options for CHF range from medical therapy, to conventional surgical procedures aimed at alleviating the cause of CHF, to cardiac augmentation procedures and total cardiac transplantation [1]. With the introduction of more effective antiarrhythmic agents and afterload reducing agents to the drug armamentarium, the currently available pharmacologic therapy for CHF is of proven, but limited, efficacy in reducing symptoms and long-term mortality [2]. A Survival Trial of Amiodarone Therapy in Congestive Heart Failure (STAT-CHF trial) found no difference in survival among heart failure patients with asymptomatic ventricular arrhythmias who received amiodarone therapy or placebo [3]. The conventional surgical options for the management of CHF are directed at the underlying pathophysiology of the disease; Coronary artery bypass grafting (CABG), mitral valve repair or replacement and LV aneurysm resection or remodeling are all attempts to reverse or slow down the progressive LV dilatation and failure. The Duke Cardiovascular Disease Databank followed more than 1400 patients with CHF and compared CABG to medical therapy [4]. The study reported favorable event-free survival for CABG over medical therapy after 30 days to over 10 years. The 10-year adjusted survival in the CABG cohort was 42 compared with only 13% for nonsurgically treated patients [4]. In patients with ischemic or nonischemic CHF, the associated or functional mitral regurgitation (MR) worsens both symptoms and prognosis. In these instances, surgical approaches including mitral valve repair with an annuloplasty ring and valve replacement with preservation of the subvalvular apparatus may alleviate these symptoms or delay their progression.

Objectives Cardiogenic shock from refractory right ventricular (RV) failure during left ventricular assist device placement is associated with high morbidity and mortality. The addition of extracorporeal membrane oxygenation to RV mechanical assistance may help RV recovery and lead to improved outcomes. Methods We retrospectively reviewed all implanted continuous-flow left ventricular assist devices from April 2009 to June 2013. RV mechanical support was utilized for RV failure defined as haemodynamic instability despite vasopressors, pulmonary vascular dilators and inotropic therapy. RV assist devices were utilized with and without in-line membrane oxygenation. Results During the study period, 267 continuous-flow left ventricular assist devices were implanted. RV mechanical support was utilized in 27 (10%) patients; 12 (46%) had the addition of in-line extracorporeal membrane oxygenation. The mean age of patients with a right ventricular assist device with membrane oxygenation was lower than that in patients with a right ventricular assist device alone (45.6 ± 15.9 vs 64.6 ± 6.5, P = 0.001). Support was weaned in 66% (10 of 15) of patients with right ventricular assist device (RVAD) alone vs 83% (10 of 12) of those with RVAD with membrane oxygenation (P = 0.42). The RVAD was removed after 10.4 ± 9.4 vs 5 ± 2.99 days for patients with a RVAD with membrane oxygenation (P = 0.1). Patients with RVAD with membrane oxygenation had a 30-day mortality rate of 8 vs 47% for those with RVAD alone (P = 0.04). The survival rate after discharge was 86, 63 and 54% at 3, 6 and 12 months for both groups combined. Conclusions Patients with a RVAD with membrane oxygenation support for acute RV failure after continuous-flow left ventricular assist device implantation had a lower 30-day mortality than those with a RVAD alone. Patients who survive to discharge have a reasonable 1-year survival. Combining membrane oxygenation with RVAD support appears to offer a short-term survival benefit in patients with RV failure after continuous-flow left ventricular assist device implantation.

The purpose of this study was to investigate the relationship between right atrial (RA) reservoir and conduit function and to determine how hemodynamic changes influence this relationship and its impact on cardiac output. In 11 open-chest sheep, RA reservoir and conduit function were quantified as RA inflow with the tricuspid valve closed versus open, respectively. Conduit function was separated into early (before A wave) and late (after A wave) components. The effects of inotropic stimulation, partial pulmonary artery occlusion, and pericardiotomy were tested. At baseline with the pericardium intact, reservoir function accounted for 0.56 (SD 0.13) of RA inflow, early conduit for 0.29 (SD 0.07), and late conduit (during RA contraction) for 0.16 (SD 0.11). Inotropic stimulation decreased conduit function and increased reservoir function, but these effects did not reach statistical significance. With partial pulmonary artery occlusion, early conduit function fell to 0.20 (SD 0.11) ( P < 0.04), and the conduit-to-reservoir ratio decreased by 41% ( P < 0.03). Similarly, after pericardiotomy, early conduit function fell to 0.14 (SD 0.09) ( P < 0.004), reservoir function increased to 0.72 (SD 0.08) ( P < 0.04), and, consequently, the early conduit-to-reservoir ratio decreased by 63% ( P < 0.006). Cardiac output was inversely related to the conduit-to-reservoir ratio ( r = 0.39, P < 0.001). This study demonstrated that the right atrium adjusts its ability to act more as a reservoir than a conduit in a dynamic manner. The RA conduit-to-reservoir ratio was directly related to the right ventricular pressure-RA pressure gradient at the time of maximum RA volume, with increased ventricular pressures favoring conduit function, but it was inversely related to cardiac output, with an increase in the reservoir contribution favoring improved cardiac output.

Background The Cox-Maze III remains the gold standard for the surgical treatment of atrial fibrillation. However, the "cut-and-sew" technique is time consuming and technically challenging. The pulmonary veins are the source of ectopy in the majority of patients with atrial fibrillation. The safety and efficacy of bipolar radiofrequency to electrically isolate the pulmonary veins was evaluated in a prospective multi-center trial. Methods Beginning in January 2002, 30 patients at three medical centers underwent pulmonary vein isolation using bipolar radiofrequency and were followed for 6 months. Twenty-four of the patients also underwent a modified Cox-Maze III. Electrical isolation of the pulmonary veins was confirmed with intraoperative pacing. Pulmonary vein patency was assessed by magnetic resonance imaging or three-dimensional computed tomography in 15 patients at 1 month. Results Mean age was 60.9 ± 11.7 years. Nineteen patients had paroxysmal atrial fibrillation. All pulmonary veins were isolated in every patient. The left pulmonary veins underwent 3.0 ± 1.4 applications for a total of 26.4 ± 10.5 seconds. The right pulmonary veins underwent 2.8 ± 1.1 applications for a total of 26.3 ± 12.6 seconds. There was no operative mortality. At 1 month, imaging revealed no evidence of pulmonary vein stenosis. At 6 months, 96% of patients were in normal sinus rhythm. Conclusions The use of bipolar radiofrequency for electrical isolation of pulmonary veins and to replace other Cox-Maze III incisions is safe and effective at controlling atrial fibrillation. This emerging technology may shorten and simplify the surgical management of atrial fibrillation.

ObjectiveThe Cox maze III procedure has excellent long-term efficacy in curing atrial fibrillation. It has not been widely practiced because it is technically challenging and requires prolonged cardiopulmonary bypass. The aim of this study was to examine a simplified Cox maze III procedure that uses bipolar radiofrequency energy as an ablative source.MethodsBeginning January 2002, a total of 40 consecutive patients underwent a modified Cox maze III procedure with bipolar radiofrequency energy. Nineteen had a lone maze procedure and 21 had a maze procedure plus a concomitant operation. One month after the operation, the first 8 patients were investigated with high-resolution magnetic resonance imaging. Patients were followed up monthly with clinical examination and electrocardiography.ResultsThere was no operative deaths. The crossclamp times were 47 ± 26 minutes for the modified lone Cox maze III procedure and 92 ± 37 minutes for the Cox maze III procedure plus concomitant procedures. These were significantly shorter than our previous times for the traditional Cox maze III procedure (93 ± 34 minutes and 122 ± 37 minutes, respectively, P < .05). Follow-up magnetic resonance imaging showed no evidence of pulmonary vein stenosis, and atrial contractility was preserved in all patients. There were no late strokes. At 6-month follow-up, 91% of patients (21/23) were in sinus rhythm.ConclusionsBipolar radiofrequency ablation can be used to replace the surgical incisions of the Cox maze procedure. This energy source did not result in pulmonary vein stenosis. The modification of the Cox maze III procedure to use bipolar radiofrequency ablation simplified and shortened this procedure without sacrificing short-term efficacy.

Background For the last decade, the Cox maze III procedure has been available for the treatment of atrial fibrillation. It is unknown whether the operation has similar efficacy in patients with lone atrial fibrillation compared with that in patients with atrial fibrillation associated with coronary, valve, or congenital heart disease. This study examined the long-term outcome of patients who underwent this procedure either as a lone operation or as a concomitant procedure. Methods From 1988 to 2001, 198 patients underwent a Cox maze III procedure; 112 were lone operations, and 86 were concomitant procedures. Major complications included renal failure, reoperation for bleeding, mediastinitis, stroke, and balloon pump insertion. Follow-up was performed by means of mail and telephone questionnaires with both the patients and their cardiologists. All patients who had any history of arrhythmia or who were taking medication had their rhythm documented by means of electrocardiography. Results The lone operation group was significantly younger (51.3 ± 10.5 vs 58.8 ± 9.9 years) and had a higher male/female ratio (4:1 vs 2:1). There was no difference in operative mortality between groups (1.8% vs 1.2%). At a follow-up of 5.4 ± 2.9 years, 96.6% (172/178) of all patients were free of atrial fibrillation. There was no difference between the lone operation and concomitant procedure groups (95.9% vs 97.5%). Conclusion The Cox maze III procedure has equivalent operative risk and long-term efficacy in patients undergoing both lone operations and concomitant procedures. The Cox maze III procedure remains the standard against which alternative procedures for atrial fibrillation must be judged.

Background A significant number of patients presenting for coronary revascularization have chronic atrial fibrillation. Although the Cox maze III procedure is the gold standard for the surgical treatment of this arrhythmia, few of these patients undergo atrial fibrillation operations at the time of their coronary bypass grafting. This study examined the long-term outcome of patients with ischemic heart disease who underwent the Cox maze procedure at our institution. Methods From 1990 to 2002, 47 patients undergoing operations for ischemic heart disease underwent a concomitant Cox maze III procedure. All patients underwent coronary bypass grafting, and 7 (15%) patients underwent coronary bypass grafting plus a mitral valve repair. Follow-up was performed by means of mail and telephone questionnaires with both the patients and their cardiologists. All patients who had any history of arrhythmia or who were taking medications had their rhythm documented by electrocardiogram. Results The mean age of these patients was 62 ± 8 years, with a marked male predominance (45 men and 2 women). Twenty-eight (60%) of the patients had paroxysmal atrial fibrillation, and the remainder had persistent arrhythmias. The mean duration of atrial fibrillation was 7.6 ± 6.5 years. The operative mortality in this series was 2%. Nine (19%) patients required postoperative pacemakers. At last follow-up (mean of 5.7 ± 3.3 years), 98% of patients were free of atrial fibrillation. Conclusion The Cox maze III procedure has a low operative mortality and excellent long-term efficacy in patients with ischemic heart disease. These data suggest a more widespread use of this procedure in these patients.

Background: Recently, there has been renewed interest in the development of minimally invasive procedures to treat atrial fibrillation. Unipolar radiofrequency catheters are plagued by poor results, in part because of their inability to produce transmural lesions. This study tested the ability of bipolar radiofrequency energy to create chronic transmural lesions on the beating heart that isolated atrial myocardium. Methods: Five sheep underwent a right thoracotomy. Baseline pacing was performed from the following targeted areas: right atrial appendage, superior vena cava, inferior vena cava, and right pulmonary veins. A cuff of atrial myocardium around the targeted tissue was clamped between the 2 arms of the device. Radiofrequency energy was delivered at 750 mA and continued until the tissue conductance between the electrodes reached a stable minimum level. After ablation, pacing was used to document tissue isolation. The animals survived for 30 days. Results: Twenty circumferential lesions were produced at the initial operation. The mean ablation time was 9.3 ± 4.0 seconds, and the mean peak temperature was 48.4°C ± 6.4°C. All lesions acutely and chronically isolated the targeted tissue. Trichrome staining showed that all lesions were transmural. There were no instances of pulmonary vein stenosis or thrombosis. Conclusions: Bipolar radiofrequency energy can produce permanent transmural linear lesions on the beating heart. Online measurement of tissue conductance reliably predicted lesion transmurality. This new technology may enable surgeons to perform a curative minimally invasive operation for atrial fibrillation on the beating heart. J Thorac Cardiovasc Surg 2002;124:708-13

Objective: The purpose of this study was to evaluate the effect of target vessel characteristics on radial artery patency when used as a composite T graft. Methods: Between October 1993 and March 2001, 1022 patients underwent coronary bypass with the internal thoracic artery–radial artery composite T graft. Of these, angiography has been performed on 109 patients at a mean 27.1 months (range, 2-70 months) postoperatively for symptoms of ischemia. By means of Cox proportional hazard models, the relationships between anastomotic patency and target vessel location, proximal stenosis, target diameter, and quality were assessed. Results: A total of 231 radial artery anastomoses were evaluated. The mean stenosis for patent anastomoses was 82% compared with 71% for occluded anastomoses (P

Background . This multicenter prospective trial was designed to assess the safety and efficacy of using a robotically-assisted microsurgical system to create endoscopic coronary anastomoses. Methods . Thirty-two patients scheduled for elective primary coronary surgery underwent endoscopic anastomosis of the left internal thoracic artery (LITA) to the left anterior descending (LAD) artery. Three thoracic ports (two for instruments and one for a camera) were placed, and a robotic system was used to perform the LITA–LAD graft. Conventional techniques were used to perform the other grafts. Thirty-one patients underwent median sternotomy and 1 patient underwent a limited anterior thoracotomy. Results . Graft flow was measured in the operating room and averaged 37 ± 19 mL/min. Mean anastomosis time was 24 ± 9 minutes. There were three intraoperative revisions (9%). Two were for inadequate flow and one for an inadvertent injury. Each of these grafts was successfully revised by hand. There were no technical failures of the robotic system. Average postoperative length of stay was 5.5 ± 2.7 days. There were three reoperations for bleeding, but none of these were related to the LAD anastomosis. Two months following the operation, selective angiography revealed a graft patency of 93%. The patients have been followed for 16 ± 4 months. Conclusions . This initial prospective multicenter trial documents the feasibility of robotically-assisted coronary bypass grafting. Further trials are warranted to establish the safety and efficacy of this new technology.

During the past 10 years, surgeons have begun to explore strategies to decrease the invasiveness of cardiac surgery. Great strides have been made in the development of beating heart surgery, which eliminates cardiopulmonary bypass. 1 Techniques also have been developed to decrease the size of the incision, and some procedures can now be performed through small thoracotomies 2 and limited sternotomies. The next step in the evolution of minimally invasive cardiac surgery would be the development of a completely endoscopic procedure. 3 The explosion of arthroscopic and laparoscopic techniques during the past several decades has revolutionized orthopedic and general surgery. However, endoscopic techniques have had little impact on microsurgical disciples, such as cardiac surgery. There are several reasons for this shortcoming. Traditional endoscopic instruments are not well suited for microsurgery 4 because of their length and the fulcrum effect. The length of the instruments magnifies even the smallest surgical tremor, making microsurgery difficult if not impossible. The fulcrum effect makes it difficult to judge precisely the deflection of the instrument tip for a prescribed movement of the instrument handle. Moreover, the nonintuitive movement of endoscopic tools (i.e., the instrument tip moving opposite to the handle) is problematic for fine microscopic suturing. Traditional endoscopic visualization also is a hurdle to the performance of microsurgery. There is a lack of depth perception on the video image, and the hand-held endoscopic camera often yields an unsteady picture in highly magnified surgical fields. With recent advancements in computers 5 and robotic systems, it was hypothesized that robotics would prove to be an enabling technology for endoscopic cardiac surgery. 6,7 This study reports the 1-year follow-up of the first prospective, nonrandomized trial in North America of endoscopic coronary artery bypass grafting (ECABG). The Zeus Robotic Surgical System (Computer Motion, Inc., Goleta, CA) was used in this trial. This system consisted of a surgeon console (Fig. 1), a computer control system, and three robotic arms (Fig. 2). The surgeon remained seated in a chair in front of the console, which consisted of a video monitor, two instrument handles, and a computer control system. The instrument handles were identical to traditional Castro-Viejo microsurgical needle drivers. As the surgeon moved the handles, his or her motions were mechanically relayed to a computer control system and digitized. Once the software processed the digital information (tremor filtration, motion scaling), the commands were relayed in real time to the two robotic arms. These arms, attached to the operating table, precisely controlled the instrument tips, which entered the patient through 5-mm ports. A third robotic arm held the endoscopic camera and was controlled by simple voice commands. Figure 1. The Zeus Robotic Surgical System. The surgical console consists of a video monitor and two customized instrument handles. The surgeon grasps the handles and his or her movement is mechanically relayed to a computer control system, which digitizes ... Figure 2. The robotic arms are attached to the operating table and precisely control two instrument tips that are positioned within the patient through 5-mm ports. A third voice-controlled arm is used to manipulate the endoscope. Before beginning clinical studies, our group used the Zeus system to successfully complete coronary artery anastomoses in both cadaveric and live animals. 8,9 This single-center prospective clinical trial was approved by the Food & Drug Administration to evaluate the safety and efficacy of robotically assisted ECABG. All patients enrolled in this trial underwent robotically assisted anastomosis of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). All other grafts were sewn by hand in a traditional fashion. It was mandated that the procedures had to be performed on the stopped heart with cardiopulmonary bypass and cardioplegic arrest. The primary study end points were graft patency at 8 weeks and the incidence of device-related complications. The 12-month follow-up end points included major adverse cardiac events and recurrent angina.

ObjectiveTo assess the effect of extremity vascular complications (EVCs, including ischemia or vessel trauma) on the outcomes of patients receiving cardiac support devices (CSDs, including ventricular assist device [VAD] and extracorporeal membrane oxygenation [ECMO]).MethodsInstitutional Review Board-approved, retrospective review of a prospectively maintained database of all temporary and permanent CSD recipients from 7/1/10 to 6/30/12. Patient demographics, procedural data, and outcomes were analyzed. The primary endpoint was all-cause mortality at 30-days post-CSD initiation.ResultsOf 208 patients who received CSDs, 31 (14.9%) experienced EVC: 13 (8.9%) of the 146 permanent VADs, 10 (26.3%) of the 38 temporary VADs, and 8 (33.3%) of the 24 ECMO patients. The 30-day mortality for CSD-EVC patients was not significantly higher than that of the CSD patients who did not experience EVC for permanent VAD (15.4% vs 4.5%; P = .15) and ECMO patients (50.0% vs 68.75%; P = 1.00), but was significantly higher for temporary VAD patients (80.0% vs 35.7%; P = .03). Within the CSD-EVC cohort, patients who received a temporary VAD had a significantly higher 30-day mortality and decision to withdraw care after EVC compared with those who received a permanent VAD (P = .01 and P < .01, respectively). Looking beyond the 30-day window, EVC was associated with higher mortality rates in the permanent VAD population (53.8% vs 25.6%; P = .025) but not the temporary VAD or ECMO groups.ConclusionsIn temporary VAD recipients, EVCs result in higher 30-day mortality, more frequent withdrawal of care, and shortened survival time relative to the global temporary VAD group. EVC in permanent VAD recipients did not affect early (30-day) mortality rates, but strongly predicted a higher cumulative mortality risk for the 2-year study period. Overall ECMO mortality rates were high, and not significantly impacted by the occurrence of EVC. The nature of the EVC (cannulation site complication vs embolic injury) did not impact mortality. This data provides quality improvement targets for VAD programs.

Warm cardioplegic induction improves the ischemically "stressed" adult heart. However, it is rarely used in infants, despite the fact that many newborn hearts are stressed by other factors such as hypoxia. The need for amino acids as well as their mechanism of action has also not been studied.We first assessed the role of cardioplegic induction temperature in 10 nonhypoxic neonatal piglets undergoing 70 minutes of multidose blood cardioplegic arrest. Five piglets (group 1) received a cold (4 degrees C) induction, and 5 (group 2) a warm (37 degrees C) induction. Twenty-six other piglets underwent ventilator hypoxia (fraction of inspired oxygen, 8% to 10%) for 60 minutes before cardiopulmonary bypass (stress). Six piglets (group 3) then underwent 70 minutes of cardiopulmonary bypass without ischemia (hypoxia controls), and 20 underwent 70 minutes of cardioplegic arrest. Five of these (group 4) received cold cardioplegic induction, and 15 received warm induction; in 5 of these (group 5), the warm cardioplegic solution contained amino acids, in 5 others (group 6), it was unsupplemented, and in the remaining 5 (group 7), nitroglycerin was added to determine the role of vasodilation. Myocardial function was assessed by pressure-volume loops (expressed as a percent of control), and coronary vascular resistance was measured with cardioplegic infusions.In nonhypoxic (normal) piglets, cold (group 1) and warm (group 2) induction completely preserved systolic function (end-systolic elastance, 100% versus 104%) and preload recruitable stroke work (100% versus 102%), with minimal increase in diastolic compliance (162% versus 156%). Hypoxia-reoxygenation alone (group 3) depressed systolic function (end-systolic elastance, 51%+/-2%) and preload recruitable stroke work (54%+/-3%), and raised diastolic stiffness (260%+/-15%). The detrimental effects of reoxygenation persisted (unchanged from reoxygenation alone) with cold induction (group 4) or warm induction without amino acids (groups 6 and 7). In contrast, warm induction with amino acids (group 5) restored systolic function (end-systolic elastance, 105%+/-3%; p0.001 versus groups 3, 4, 6, and 7) and preload recruitable stroke work (103%+/-2%; p0.001 versus groups 3, 4, 6, and 7), and decreased diastolic stiffness (154%+/-7%; p0.001 versus groups 3, 4, 6, and 7). However, there was no difference in myocardial oxygen consumption in hypoxic hearts receiving a warm induction (6.9 versus 6.5 versus 7.3 mL/g per 5 minutes) (groups 5, 6, 7), and coronary vascular resistance was lowest with nitroglycerin (group 7).Cardioplegic induction can be given either warm or cold in nonhypoxic neonatal hearts. In contrast, only warm induction with amino acids repairs the hypoxic injury, but the primary mechanism of action is not related to increased metabolic activity or vasodilation.

The field of robotic thoracic surgery has exploded in the last five years. Robotic technology allows the surgeon to perform complex operations with smaller incisions. As robotic systems become smaller, more efficient and the surgeons gain more experience, the results will continue to improve. The goal is less trauma to the patient which will decrease hospital stay, complications and lower health care costs, while allowing faster healing and productivity.

Background This study compared Cox-Maze IV (CMIV) outcomes for the treatment of atrial fibrillation (AF) in patients with lone AF vs those with AF and mitral valve (MV) disease. Methods Since 2002, 200 patients have undergone a CMIV procedure for lone AF (n = 101) or concomitantly with MV operations (n = 99). Preoperative, perioperative, and late outcomes between these groups were compared. Data were collected prospectively and reported at 3, 6, and 12 months. Results Lone AF patients had AF of longer duration; patients with AF and MV disease were older, with larger left atria and worse New York Heart Association classification ( p p > 0.05, respectively) was similar between both groups. Perioperative atrial tachyarrhythmias were more prevalent in patients with concomitant MV operations (57% vs 41%, p = 0.03); however, freedom from AF and antiarrhythmics was similar for both groups at 12 months (76% and 77%). The only predictor for atrial tachyarrhythmia recurrence or arrhythmic drug dependence was failure to isolate the posterior left atrium ( p Conclusions Patients with AF and MV disease have distinct comorbidities compared with patients with lone AF. However, the CMIV is safe and effective in both groups and should be considered for patients with AF undergoing MV operations. Patients with MV disease had more atrial tachyarrhythmias at 3 months, but freedom from AF and antiarrhythmics was similar to patients with lone AF at 1 year. The posterior left atrium should be isolated in every patient, because this was the only predictor for failure of the CMIV for either group.

OBJECTIVE: Management of patients with concomitant carotid and coronary artery disease has been controversial. Divergent strategies have been employed, including simultaneous carotid endarterectomy and coronary bypass (SCC) versus various staged procedures. While no strict comparison group is available, this study defines current outcomes of SCC, as compared qualitatively to two reference categories. METHODS: Utilizing the STS database from 2003 to 2007, patients having SCC were compared to cerebrovascular disease patients undergoing coronary bypass with prior carotid endarterectomy (Ref Gp I), and those with carotid Doppler stenosis >75% and no carotid intervention (Ref Gp II). Logistic regression analysis adjusted for differences in baseline characteristics, and operative mortality (OM) and a composite of neurological complications (NC) were assessed. RESULTS: Of 747,932 patients undergoing isolated CABG with/without CEA, 108,271 (14.4 %) had cerebrovascular disease. In this group, 5,732 (5.3%) underwent SCC. The SCC group had more males and less severe coronary disease (both p ). CONCLUSION: Although no proper control group exists for comparison, SCC as recently performed in North America carries a high risk, as compared to any of the reference groups. Suboptimal results associated with the SCC strategy suggest a need for quality improvement and research on the optimal management of patients with simultaneous carotid and coronary disease.

Background Complex use of arterial conduits has resurrected concerns about the adequacy of conduit flow. The T-graft is the extreme example of this trend. Our purpose was to identify the limitation of single source inflow and to compare flow capacity with completion coronary flow. Methods Between February 1999 and November 2001, 372 patients underwent total arterial revascularization with the T-graft alone. Intraoperative flows were recorded for each limb of the T-graft before and after distal anastomoses in 204 patients. Independent predictors of T-graft flow were identified by multivariate analysis. Results Free flow for the radial arterial (RA) limb was 161 ± 81 mL/min, the internal thoracic artery (ITA) limb 137 ± 57 mL/min (combined 298 ± 101 mL/min) versus simultaneous limb flow of 226 ± 84 mL/min giving a flow restriction of 24% ± 14%. Completion coronary flow was 88 ± 49 mL/min for the RA, 60 ± 45 mL/min for the ITA, and 140 ± 70 mL/min for both limbs simultaneously to give a flow reserve (vs simultaneous free flow) of 160% or 1.6. Independent predictors of completion RA limb flow are RA proximal diameter ( p = 0.005), number of anastomoses ( p = 0.018), and target stenosis ( p = 0.005). Conclusions A flow reserve of 1.6 compares favorably with an ITA flow reserve of 1.8 at 1-month postoperatively and 1.8 for both the ITA T-graft and the ITA/RA T-graft at 1-week postoperatively as reported by others. Proximal RA diameter and competitive coronary flow influence completion T-graft flow. These data quantitate the limitation of single source inflow of the T-graft configuration and support its continued use.

Background Pinacidil solutions have been shown to have significant cardioprotective effects. Pinacidil activates both sarcolemmal and mitochondrial potassium-adenosine triphosphate (K ATP ) channels. This study was undertaken to compare pinacidil solution with University of Wisconsin (UW) solution and to determine if the protective effect of pinacidil involved mitochondrial or sarcolemmal K ATP channels. Methods Thirty-two rabbit hearts received one of four preservation solutions in a Langendorff apparatus: (1) UW; (2) a solution containing 0.5 mmol/L pinacidil; (3) pinacidil with Hoechst-Marion-Roussel 1098 (HMR-1098), a sarcolemmal channel blocker; and (4) pinacidil with 5-hydroxydecanote, a mitochondrial channel blocker. Left ventricular pressure-volume curves were generated by an intraventricular balloon. All hearts were placed in cold storage for 8 hours, followed by 60 minutes of reperfusion. Results Postischemic developed pressure was better preserved by pinacidil than by UW. This cardioprotective effect was eliminated by 5-hydroxydecanote and diminished by HMR-1098. Diastolic compliance was better preserved by pinacidil when compared with UW. This protection was abolished by the addition of 5-hydroxydecanote and moderately decreased by HMR-1098. Conclusions Our results support the superiority of pinacidil over UW after 8 hours of storage. The cardioprotective role of pinacidil is mediated primarily by the mitochondrial K ATP channel.

The radial artery (RA) can be used as either an aortocoronary (RA-Ao) or composite graft (T graft). Optimum use for the RA has yet to be established. We compared RA patency with these two techniques.Between October 1993 and June 2001, 1505 patients underwent coronary artery bypass grafting using the RA as either a composite (n = 1022) or RA-Ao graft (n = 483). Angiograms performed on 203 (13.5%) patients with signs or symptoms of ischemia at an average of 26.1 +/- 18.5 months postoperatively were reviewed.Patients with RA-Ao grafts had a greater incidence of postoperative angiography versus patients with composite grafts (19% versus 11%; p0.01). Patients receiving T grafts had a greater number of anastomoses per patient (4.1 +/- 0.6 versus 3.0 +/- 1.0; p0.01) and a higher incidence of total arterial revascularization (100% versus 41%; p0.01). Regardless of grafting strategy, patency was significantly worse for targets of the right coronary artery (58% T graft; 67% RA-Ao; p0.01 for both) and for targets with less than or equal to 70% stenosis (59% T graft; 57% RA-Ao; p0.01 for both). The site of proximal anastomosis failed to effect RA patency (relative risk, 1.2; 95% confidence interval, 0.7 to 1.8; p = 0.50).The site of the proximal anastomosis does not appear to influence patency. Both RA-Ao and composite conduits are sensitive to target location and stenosis. Advantages of composite grafting include greater conduit length and minimizing aortic manipulation at the expense of increased complexity and the potential for hypoperfusion. These factors should be considered when choosing an RA grafting strategy.

Background Alternative energy sources have been proposed for the transvenous and surgical treatment of atrial fibrillation. This study examined the physiologic consequences of a novel energy source, bipolar radiofrequency energy, in a chronic animal model in order to determine its ability to produce transmural lesions on the beating heart. Methods Five dogs underwent baseline pacing from the following target areas: right and left atrial appendage, superior and inferior vena cavae, and right and left pulmonary veins. A cuff of atrial myocardium, proximal to the target tissue was clamped and ablated between the arms of the bipolar radiofrequency energy device. Tissue conductance was used as a transmural indicator. After ablation, the pacing protocol was repeated. Baseline and postablation pulmonary vein flows were measured. Animals were survived for 30 days, and permanent electrical isolation was evaluated by pacing, epicardial mapping, and histology. Results Mean ablation time was 5.0 ± 1.8 seconds and mean peak tissue temperature was 46.7°C ± 2.8°C. All lesions (30/30) acutely and permanently isolated atrial tissue. There was no change in pulmonary vein flow. Mapping studies with pacing of atrial tissue on both sides of the lesion confirmed isolation. Histology demonstrated that all lesions were linear, continuous, and transmural with no thrombus formation or stenosis. Conclusions Bipolar radiofrequency energy rapidly produced permanent transmural linear lesions on the beating heart. Measurement of tissue conductance reliably predicted transmural lesions. This new technology may enable the development of a less invasive, surgical approach to atrial fibrillation.

Background Paraplegia or paraparesis after otherwise successful thoracic or thoracoabdominal aortic reconstruction is a devastating complication for patient and physician. Interventions for its prevention have focused primarily on the intraoperative period. We have recently noted a significant incidence of delayed-onset neurologic deficit. Methods We reviewed our most recent 5-year experience with thoracic and thoracoabdominal reconstruction to examine the incidence of and potential contributors to delayed paraplegia or paraparesis. Results Between June 1996 and June 2001, 60 patients (29 men, 31 women) underwent repair of isolated thoracic (n = 26) or thoracoabdominal aortic aneurysm (Crawford I, n=7; Crawford II, n=14; Crawford III, n=12; Crawford IV, n=1) by the cardiac and vascular surgical services collaboratively. Repair was performed endovascularly in 6, and open with either circulatory arrest in 12, partial left heart bypass in 37, or partial femorofemoral bypass in 5. Operative mortality was 9.3% (5 of 54 patients) for open repair and 0% for endovascular repair. Paraplegia or paraparesis occurred in 6 (10%) patients of which 83.3% (5 of 6) were delayed in onset. All patients with delayed paraplegia or paraparesis had degenerative aneurysms of Crawford extent II (n = 3) or III (n = 2), had intraoperative left heart bypass, and had perioperative spinal drainage. Delayed paraplegia or paraparesis occurred up to 27 days postoperatively, and was associated with a documented episode of hypotension in 60% (3 of 5) of patients. Conclusions Improvements in intraoperative management may have reduced immediate paraplegia or paraparesis among vulnerable patients only to leave them at risk of delayed-onset deficit. Postoperative care, including assiduous attention to avoidance of even transient hypotension, must be tailored to this patient population.

ObjectiveThe introduction of new technologies has shifted some resident index procedures to nonsurgical specialists. We examined the operative case volume of thoracic surgery residents during the last 6 years to objectively identify changes and trends.MethodsProgram and resident data from 2002 to 2007 were entered into a database and analyzed. Program match information was obtained from the National Resident Matching Program. Resident operative experience and board examination results were obtained from the American Board of Thoracic Surgery.ResultsA total of 795 residents qualified for the written American Board of Thoracic Surgery examination; 627 residents graduated from 2-year programs, and 168 residents graduated from 3-year programs. The total number of resident cases was higher in 3-year programs compared with 2-year programs in all 10 index categories studied (P < .01). The total volume of cases has not significantly increased in 2-year programs. The volume of coronary artery bypass graft surgeries decreased in every resident program model studied. The volume of general thoracic cases increased in all program models. Two-year, 2-resident programs had the lowest volume in 5 of the 10 categories, reaching significance in 3 categories. The written board pass rate was lower among 2-year programs than among 3-year programs (86% vs 95%, respectively, P = .003).ConclusionTraining programs have so far weathered the storm by maintaining index volume with a new case mix, but significant trends in revascularization procedures are concerning. This study indicates a significant advantage in case volume and board pass rates among 3-year programs. Thoracic residency programs should be reorganized so that the number of residents does not exceed the capacity of the program to provide a meaningful experience.