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Background: Understanding the spatial and temporal drainage patterns of the pleural space could have profound impact on the treatment of lung cancer and mesothelioma. The purpose of this study was to identify the in vivo pattern of drainage from the pleural space to prognostic lymph node stations., Methods: Fifty-six rats underwent pleural space injection of a novel lymph tracer composed of recombinant human serum albumin (HSA) covalently conjugated to the near-infrared (NIR) fluorophore IRDye78 via an amide bond (HSA-78). Nodal uptake was imaged at 10, 20, 30, and 60 minutes and 4, 12, and 24 hours after injection with a custom system that simultaneously acquires color video, NIR fluorescence of HSA-78, and a merged picture of the two. Six pigs underwent the same procedure with imaging at 30 minutes, 1 hour, and 24 hours., Results: In both the rat model and the pig model, HSA-78 drained from the pleural space to superior mediastinal lymph nodes first, followed by other intrathoracic and then extrathoracic lymph nodes over the course of 24 hours., Conclusion: NIR fluorescence imaging in two species shows that the superior mediastinal lymph nodes are the first to drain the pleural space. Over the course of 24 hours, the pleural space also communicates with other intrathoracic and then extrathoracic lymph nodes. This study also demonstrates an intraoperative method for identifying nodes communicating with the pleural space, with potential utility in the staging and/or resection of lung cancer and mesothelioma.

The use of near-infrared or infrared photons is a promising approach for biomedical imaging in living tissue. This technology often requires exogenous contrast agents with combinations of hydrodynamic diameter, absorption, quantum yield and stability that are not possible with conventional organic fluorophores. Here we show that the fluorescence emission of type II quantum dots can be tuned into the near infrared while preserving absorption cross-section, and that a polydentate phosphine coating renders them soluble, disperse and stable in serum. We then demonstrate that these quantum dots allow a major cancer surgery, sentinel lymph node mapping, to be performed in large animals under complete image guidance. Injection of only 400 pmol of near-infrared quantum dots permits sentinel lymph nodes 1 cm deep to be imaged easily in real time using excitation fluence rates of only 5 mW/cm(2). Taken together, the chemical, optical and in vivo data presented in this study demonstrate the potential of near-infrared quantum dots for biomedical imaging.

The evolution of the surgical therapy of mitral valve disease emanates from original statements by British cardiologists in 1902 and anecdotal individual surgical cases in 1923 and 1925. Considerable amounts of experimental investigation during these years and after World War II in 1948 finally resulted in the widespread use of closed mitral commissurotomy, a successful therapy for noncalcified mitral stenosis. The history of mitral valve surgery then rapidly progressed with a variety of prosthetic and bioprosthetic valve devices, ultimately, to a considerable number of successful valve repair operations with prosthetic ring annuloplasty. The authors conclude with a discussion of the current status of minimally invasive mitral valve surgery, both by direct vision and robotic assistance. The entire evolution of thought and technique of mitral valve surgery is summarized in this paper from 1902-2002.

Robotic takedown of the left internal mammary artery and direct off-pump anastomosis to the left anterior descending artery through small thoracotomy incisions can be done safely with minimal morbidity and is associated with decreased blood loss, decreased ventilatory requirements, less intensive care unit stay, and less overall length of stay. It should be considered as an alternative to percutaneous angioplasty and stenting for those with isolated left anterior descending artery disease.

Objective: Valvular tissue and aorta calcify at different rates when placed as fresh homografts or cryopreserved allografts. Furthermore, differences between valvular endothelial cells and aortic endothelial cells are not well appreciated. We established primary cultures of valve and aortic endothelial cells derived from swine and tested transcriptional and proliferative differences on various extracellular matrices., Methods: Transcriptional profiling was performed on primary cultures of porcine valve and aortic endothelial cells. We extracted total RNA from both cell types and created cDNA libraries. We scored for 847 genes important in signal transduction pathways, and measured their expression on valve and aortic endothelial cells. To determine if there were functional differences between aortic and valvular cells, their growth rate was determined by cell counting on various extracellular matrices., Results: Of 847 genes investigated, 69 (8.1%) were transcriptionally active on aortic endothelial cells and 89 (10.5%) on valve endothelial cells. Common to both cell types were 55 genes, which represents 79.7% (55/69) of activated genes on aortic endothelial cells and 61.8% (55/89) of those in valve endothelial cells. Remarkable features of the analysis included Ephrin ligand and receptor specificity for cell type, a potential fibroblast growth factor autocrine loop in both cell types, as well as upregulation of the platelet-derived growth factor receptor in valvular cells. Aortic endothelial cells were noteworthy of upregulation of vascular endothelial cell growth factor-B and vascular cell adhesion molecule. Proliferation analysis revealed that valve endothelial cells grew more rapidly (12-fold over control) than aortic endothelial cells (3-fold over control). Furthermore, valve endothelial cells proliferated most rapidly on gelatin or collagen, whereas aortic endothelial cells were most proliferative on lysine or laminin., Conclusions: Valve and aortic endothelial cells have different transcriptional and proliferative profiles. The knowledge of these differences may be an exploitable strategy in the future rational design of artificially engineered valve surfaces and in the study of the valve antigenicity, immunogenicity and structural failure.

Background: Coronary artery hemostasis during offpump coronary artery bypass (OPCAB) may be achieved with extraluminal coronary occlusion or intraluminal coronary shunting. We sought to determine with a normal porcine beating-heart model whether coronary shunting preserves regional myocardial perfusion and function compared with coronary occlusion., Methods: Six pigs (50-60 kg) underwent sternotomy and instrumentation. Two pairs of ultrasonic crystals were placed in the distribution of t h e left anterior descending (LAD) and left circumflex (LCx) arteries for measurement of fractional change in area (FCA), an index of regional contractility. Regional myocardial blood flow (RMBF) was determined with radiolabeled microspheres. Data were recorded for each animal at baseline and after LAD arteriotomy and vascular control with (1) a 1.5-mm intraluminal shunt, (2) proximal occlusion, and (3) proximal and distal occlusion., Results: One pig experienced ventricular fibrillation during LAD manipulation and was excluded from the study. Data were summarized for the remaining 5 animals. Coronary shunting maintained RMBF and function (FCA) compared with baseline. Proximal occlusion led to 50% (P =.05) and 47% (P =.04) decreases in RMBF and FCA, respectively, in the LAD region. Proximal and distal occlusion led to 55% (P =.03) and 51% (P = 02) decreases in RMBF and FCA, respectively, in the LAD region. There were no significant changes in RMBF or FCA in the LCx (control) region., Conclusion: Intraluminal coronary shunting is capable of preserving distal myocardial perfusion and function in a normal porcine heart. Coronary occlusion, in contrast, significantly reduces regional perfusion and function. More frequent use of intracoronary shunting may facilitate OPCAB by minimizing ischemia and hemodynamic compromise.

Background: Cardiac positioning during off-pump coronary artery bypass (OPCAB) using deep pericardial sutures (DPS) typically results in some degree of hemodynamic compromise. We sought to determine whether cardiac positioning using an apical suction device was hemodynamically superior to DPS., Methods: Five healthy pigs underwent sternotomy and instrumentation to measure right atrial (RA) pressure, left ventricular (LV) pressure and volume, and aortic pressure and flow. These variables were recorded at baseline, with simple attachment of the apical suction device (Xpose Access Device, Guidant, Inc.), and during exposure of the posterior descending artery (PDA) and obtuse marginal (OM) branches of the left circumflex artery using DPS and the apical suction device., Results: Application of the apical suction device to the beating heart in neutral anatomic position did not result in any statistically significant change in hemodynamics compared to baseline except for a small decrease in RA pressure. DPS positioning resulted in statistically significant compromise in nearly all measured hemodynamic parameters, including cardiac output (-21% PDA, -30% OM), mean arterial pressure (-18% PDA, -26% OM), and stroke work (-31% PDA, -38% OM). In addition, LV end-diastolic pressure decreased (-59% PDA, -51% OM) while RA pressure increased (+17% PDA, +16% OM). Similar target exposure using the apical suction device resulted in near-baseline hemodynamics. The only statistically significant changes were a modest decrease in cardiac output (-18% OM) and RA pressure (-11% PDA)., Conclusion: DPS positioning significantly compromises hemodynamics due to reduced LV filling. The apical suction device provides good exposure with less hemodynamic compromise.