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BACKGROUND Unroofing of anomalous coronary artery originating from the opposite sinus of Valsalva has become the procedure of choice for this congenital lesion, with surgery performed in children as young as two years old. An increasing number of this anomaly is diagnosed in infancy with no clear indication whether surgical repair should be done in this age group. This paper reviews our experience with this anomaly, and focuses on its surgical management in infants. METHODS Between April 2002 and February 2007, eight patients underwent surgical repair of anomalous coronary artery arising from the opposite sinus of Valsalva and coursing between the aorta and pulmonary artery. Patients' age varied from two months to 28 years with a mean of 11.7 +/- 11.1 years. SURGICAL TECHNIQUE Surgical repair involved unroofing the intramural segment of the anomalous coronary artery using cardiopulmonary bypass. RESULTS Two patients were younger than one year (Group A), and six patients were older than one year (group B). The mean intensive care unit stay was 2.5 +/- 0.7 days for Group A and 2.8 +/- 1.9 for Group B. The mean hospital stay was 4 +/- 1.4 days for Group A and 4.3 +/- 2.4 days for Group B. There was no mortality and no complications. The mean follow-up period is 14 +/- 15.7 months with a range of one to 39 months. At the time of the last follow-up, all patients were asymptomatic in New York Heart Association class I and follow-up echocardiography on six of eight patients showed wide open coronary ostium. CONCLUSION Unroofing the anomalous coronary artery arising from the opposite sinus of valsalva can be done in infants with minimal morbidity and mortality. Longer follow-up is needed to assess long-term results.

Warfarin and heparin have formed the mainstay in the prophylaxis of deep vein thrombosis (DVT), stroke prevention in atrial fibrillation, and treatment of thromboembolic disease (TED). However, these choices are hampered by difficult administration, interactions with other medications, side effect profile, and limited indications for treatment. Anti-factor Xa (anti-Xa) inhibitors have already entered the drug market with the drug Fondaparinux being the first anti- Xa inhibitor to be approved for use in the U.S. by the Food and Drug Administration (FDA), and other drugs such as idraparinux being currently in development. A new class of medications, known as direct thrombin inhibitors (DTI), includes the parental agents lepirudin, argatroban and bivalirudin which have been approved by the FDA and the oral agents ximelagatran, melagatran and dabigatran. The latter three drugs which are oral DTIs may soon replace warfarin and heparin as the preferred medications for DVT prophylaxis and for reducing the relative risk of stroke. These drugs do not rely on blocking serine proteases nor do they require a co-factor (antithrombin III) like unfractionated heparin (UFH) or low molecular weight heparin (LMWH). DTIs are rapid in onset, easy to administer, do not interact with other medications or foods, have limited side effects, and can be administered in a fixed dose. The DTI ximelagatran has already been approved in several European and Asian countries, and over a dozen randomized clinical trials have been conducted demonstrating its performance to be on par with warfarin. However, approval by the FDA in the U.S. remains pending in view of reported incidences of elevations in hepatic enzymes that are currently under evaluation. This review examines the role of DTIs in the prevention and treatment of TED and the recent patents reported in the literature.

Patients with pulmonary insufficiency due to scleroderma have long been considered suboptimal candidates for lung transplantation. This has been supported by small single-center experiences that did not reflect the entire U.S. experience. We sought to evaluate the outcome of patients with scleroderma who underwent lung transplantation. We conducted a retrospective review of 47 patients with scleroderma who underwent lung transplantation at 23 U.S. centers between 1987 and 2004 and were reported to the United Network for Organ Sharing. Women constituted 57% of the patients. The mean age was 46 years. Twenty-seven patients received single lung transplants (57%), and the remaining received double lung transplants. The mean cold ischemia time was 4.1 hours. There were 7 early deaths (or =30 days) and 17 late deaths (30 days). The causes of early death were primary graft failure and a cardiac event in two patients each and bacterial infection and stroke in one patient each. Late mortality was due to infection in seven patients, respiratory failure in three, malignancy in two, and multisystem organ failure, rejection, pulmonary hypertension, and a cardiac event in one patient each. The causes of early and late death were not recorded for two patients. One patient received a second transplant owing to graft failure of the first. Twenty-three patients (49%) were alive at a mean follow-up of 24 months. The Kaplan-Meier 1- and 3-year survival rates were 67.6% and 45.9% respectively, which are not significantly different from those of 10,070 patients given transplants for other lung conditions during the same period (75.5% and 58.8% respectively, P = 0.25). Donor gender, recipient's age, and type of transplant did not affect survival. In carefully selected patients with scleroderma who have end-stage lung disease, lung transplantation is a valid life-saving therapeutic option. Available data suggest acceptable short-term morbidity and mortality and a long-term survival similar to that of patients given transplants for other lung conditions.

Purpose Lung transplantation has been increasingly used as a treatment modality for patients with pulmonary lymphangioleiomyomatosis (LAM). In this study, we evaluated the outcome of patients with LAM who underwent lung transplantation with the aim of making some recommendations regarding patient management. Methods We conducted a retrospective review of 79 patients who underwent primary lung transplantation for end-stage pulmonary LAM at 31 US transplant centers between January 1987 and December 2002 and were reported to the United Network for Organ Sharing (UNOS). Results All patients were women with a mean age of 41.1 years (range, 24–65 years). Thirty-four patients (43%) received single-lung transplants. Bilateral lung transplantation was performed in 45 patients (57%). The mean cold ischemia time was 4.7 hours. There were 2 intra-operative deaths. The 30-day mortality was 5% (4 patients). The causes of early death were primary graft failure in 2 patients, hyperacute rejection in 1 patient, and a cardiac event in 1 patient. Twenty late deaths (>30 days post-transplant) occurred. Of those, 5 were from multisystem organ failure, 5 from pulmonary complications, and 2 from fungal infection. Rejection and bronchiolitis obliterans accounted for 2 deaths each. The cause of death was a cardiac event in 1 patient and was not recorded in the remaining 3. Four patients were re-transplanted. Fifty-five patients (70%) were alive at a mean follow-up of 37 months (range 0–128 months). The actuarial Kaplan-Meier survival was 85.75% at 1 year, 76.35% at 3 years, and 64.91% at 5-years. Log-rank analysis showed a statistically significant difference in the survival rate of LAM patients compared with a historical group of patients who had transplantation for all lung conditions during the same period (45.12%, p = 0.0012). Transplant era, type of transplant, donor gender, ischemia time of more than 4 hours, age more than 40 years, and donor/recipient cytomegalovirus did not impact survival. Conclusions Lung transplantation is a valuable therapeutic option for patients with end-stage pulmonary LAM. Transplantation offers survival rates that are equivalent to or better than those of patients who received a lung transplant for other indications.

Postoperative bleeding is a common complication following cardiothoracic surgical procedures requiring cardiopulmonary bypass (CPB). Serious bleeding complications requiring the administration of blood products, hemostatic drugs, and even repeat surgery are associated with considerable morbidity, mortality, and resource consumption. Therapy with recombinant activated factor VII (rFVIIa) may be an effective treatment strategy for patients with refractory bleeding. We report the successful use of rFVIIa for the treatment of intractable postoperative bleeding following aortic aneurysm repair in two patients with Marfan syndrome. In both patients, surgical reexploration was avoided, and the patients' clinical status was stabilized after the administration of rFVIIa. In one patient, hemostasis was rapidly achieved within minutes, whereas hemostasis occurred gradually over several hours in the second patient. Including our personal experience with the two cases, the use of rFVIIa has been reported in 20 patients who required CPB for cardiothoracic surgical procedures. Hemostasis was achieved in all patients. In 14 patients (70%), rapid hemostasis was achieved following a single dose of rFVIIa (mean dose, 57 microg/kg). In the remaining six patients, gradual hemostasis was achieved after a mean of 3.4 doses (mean cumulative dose, 225 microg/kg). Two patients (10%) were believed to have experienced thromboembolic complications after the administration of rFVIIa (one was fatal), and, in another patient, intracoronary thrombosis was suspected but was not confirmed. In patients experiencing postoperative bleeding complications that are refractory to treatment with blood products, hemostatic agents, and/or repeat surgery, the use of rFVIIa may be considered.

Mechanical complications of acute myocardial infarction are estimated to account for 25,000 fatalities yearly in the United States. The diagnosis necessitates a high degree of clinical suspicion. Once recognized, prompt surgical intervention is necessary because if left untreated the condition frequently causes a fatal outcome. The main determinants of survival are the preoperative hemodynamic status of the patient, the presence of multisystem failure at presentation, and concomitant revascularization during repair of the defect. Because ischemic heart disease remains the leading cause of death in such patients following repair, coronary artery bypass should be considered and, whenever possible, performed in conjunction with repair of the postinfarct mechanical complication.

A localized thrombus involving the ascending aorta and arch rarely occurs in the absence of an underlying etiology such as chest trauma, atherosclerosis, a hypercoagulable state or instrumentation. A review of the literature between 1966 - 2003 yielded 38 reported cases of localized aortic arch thrombi, 21 of which were treated by surgical excision of the thrombus using different approaches. In this communication, we describe this clinical entity, with its diagnosis and management. The technical details that are important to ensure the safe conduct of the procedure are discussed.

Multiple randomized trials support the treatment of patients with multivessel coronary artery disease (CAD) and relatively normal left ventricular (LV) ejection fraction (EF) by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). However, there has been a paucity of trials in the recent literature that have compared the outcomes of patients with multivessel CAD and low EF who undergo PCI or CABG. This review examines some of the clinical trials and series in this subgroup of patients and also compares the outcome of patients undergoing either procedure in the absence and presence of LV dysfunction. These trials and series support the notion that PCI can be successfully performed in patients with low EF with relatively low mortality, but that CABG is associated with greater freedom from repeat revascularization and from angina or congestive heart failure symptoms. In addition, most of the data published thus far indicate a long-term survival advantage among patients with ventricular dysfunction who have undergone CABG. Further studies, including randomized trials incorporating the evolving techniques of CABG and the recent advances in PCI, will be needed to assess the proper role and outcome of these two interventions.

Primary neuroendocrine tumors of the thymus are highly aggressive tumors that rarely occur. A little more than 200 cases have been reported, many of which were single case reports. Only a few articles contained modest series from single centers for analysis. A review of 157 cases collected from the major series reported to-date show a clinical pattern with male preponderance (male:female ratio, 3:1) and a mean age of 54 years. Most patients presented with symptoms and signs of local compression. Almost 50% of these tumors were functionally active and were associated with endocrinopathies. Several histologic variants have been described, all with similar ultrastructural features. The biologic behavior of these tumors shows a direct relation to the degree of differentiation. Whenever possible, surgical resection is the treatment of choice as adjuvant therapy is controversial and has been used with variable success. Potential therapies exploit the presence of somatostatin receptors on a variety of these tumors. Use of radiolabeled Octreotide for radionuclide therapy has yielded tumor inhibition in animal models and may have clinical application. Fifty-one percent of the patients survived 3 years, 27% survived 5 years, and less than 10% survived beyond 10 years. Histologic grade, tumor extension, and early detection are the most important factors affecting survival. Other prognostic factors that impact outcome include presence of endocrinopathy, incomplete resectability, nodal status, and presence of distant metastasis.

Coronary artery bypass grafting has been utilized as a beneficial treatment for myocardial ischemic disease for over three decades. Failure of coronary artery venous grafts occurs at a substantial rate and has a large impact on two main endpoints, survival and quality of life. An exhaustive amount of basic research has been generated to delineate possible mechanisms responsible for graft failure and modalities to prevent its occurrence. Although pharmacotherapy exists, insufficient translation has emerged from the bench to the operating room. In this article, we review the literature regarding the current mechanisms and mediators including growth factors, nitric oxide and genetics leading to saphenous vein graft occlusion. The review addresses the current state of affairs and modes for prevention of vein graft failure perioperatively and newer technologies that may help ameliorate this problem in the future.

Mechanical obstruction of the distal esophagus by a fetus-in-fetu is an extremely rare condition that has not been previously reported. We present the case of a 27-year-old man who presented with dysphagia caused by fetus-in-fetu contained within a retroperitoneal cystic cavity. The tumor, noticed since childhood, did not cause any symptoms until a year before presentation when symptoms of dysphagia developed. We propose including this entity in the differential diagnosis of a retroperitoneal mass.

We hypothesized that diastolic counter-pulsation using aortomyoplasty will increase coronary blood flow.In dogs (n = 6, 20 to 25 kg), the left latissimus dorsi muscle was isolated, wrapped around the descending thoracic aorta, and conditioned by chronic electrical stimulation. Heart failure was induced by rapid ventricular pacing. In a terminal study, left ventricular and aortic pressures, and blood flow in the left anterior descending coronary artery and descending aorta were measured. The endocardial-viability ratio was calculated.Aortomyoplasty increased mean diastolic aortic pressure (70 +/- 5 to 75 +/- 5 mm Hg, p0.05) and reduced peak left ventricular pressure (86 +/- 4 to 84 +/- 4 mm Hg, p0.05), leading to a 16% increase in endocardial-viability ratio (1.29 +/- 0.05 to 1.49 +/- 0.05, p0.05). Coronary blood flow was increased by 15% (8.2 +/- 1.5 to 9.4 +/- 1.6 mL/min, p0.05). During muscle contraction, 2.7 +/- 0.5 mL was ejected from the wrapped aortic segment.These data demonstrate that aortomyoplasty provides successful diastolic counterpulsation after muscle conditioning and heart failure.

Early extubation and fast-track management protocols on younger, low-risk patients result in shorter hospital stays and decreased costs. The impact of such protocols on elderly patients undergoing coronary artery bypass graft (CABG) surgery is not presently known.A matched retrospective cohort study.A university teaching hospital.Six hundred ninety-eight consecutive patients undergoing isolated CABG between January 1995 and September 1996.Three hundred seventy-seven patients underwent early extubation, defined as extubation within 8 hours of arrival in the intensive care unit. They were divided into groups of patients 70 years of age and younger (n = 263) and patients older than 70 years of age (n = 114).The mean length of stay (LOS) for all patients extubated within 8 hours or less was 5.5 days versus 8.4 days for patients who underwent later extubation (p0.0001). The percentage of patients undergoing early extubation was greater for the younger cohort (59% v 48%; p0.003) compared with the older cohort of patients. Analysis of demographics showed the older patients to have a greater incidence of peripheral vascular disease, congestive heart failure, and prior strokes (p0.05). Although the intensive care unit LOS was similar, postoperative LOS was 5.3 +/- 1.8 days for the younger patients versus 6.1 +/- 2.6 days for the older patients (p = 0.001). The overall surgical mortality rate was 2.6% (18/698), and there were no deaths among patients undergoing early extubation. Reintubation rate was negligible in both groups of patients.This study confirms the safety and efficacy of early extubation among elderly patients undergoing CABG. Elderly patients have more comorbid conditions, yet a significant number can be extubated early, with resultant shortened LOSs.

J Thorac Cardiovasc Surg Massad Sean Garrean, Cimenga Tshibaka, Ziad Hanhan, Alexander S. Geha and Malek G. fistula after coronary artery bypass operations Coronary-pulmonary steal caused by internal thoracic artery-pulmonary artery http://jtcs.ctsnetjournals.org/cgi/content/full/130/2/569 located on the World Wide Web at: The online version of this article, along with updated information and services, is

A review of the published world experience with heart transplantation for iron overload cardiomyopathy (IOC) between 1967 and 2003 as well as review of unpublished cases from the database of the United Network for Organ Sharing since 1992, identified a total of 16 patients (14 men and 2 women). Mean age was 31 years (range, 14-63 years). IOC etiology was hemochromatosis in 11 patients (69%), thalassemia major in 4 (25%), and Diamond-Blackfan anemia in 1 (6%). The 30-day mortality was 12%. Three patients (19%) died within 1 year of the transplant, all of infectious complications. An additional patient died at 7.14 years (unknown cause). The actuarial Kaplan-Meier 1-, 3-, and 5-year survival rates were 81% for all 3 time intervals. The actuarial 10-year survival was 41%.

Background: To determine the influence of left ventricular function on the long-term survival of patients with coronary artery disease and lethal ventricular arrhythmias, who undergo concomitant coronary artery bypass grafting (CABG) and implantable cardiovertor defibrillator (ICD) implantation, we studied survival in 54 consecutive patients who underwent CABG and ICD implantation. Methods: Group I consisted of 35 patients with left ventricular ejection fraction (LVEF) ± 35% (mean 25.3 ± 5.6) and Group II consisted of 19 patients with LVEF > 35% (mean 47.5 ± 6.6). The two groups were similar with regards to age, gender, clinical presentation, induced arrhythmias, and the number of grafts placed at the time of surgery. Results: Two in-hospital deaths (3.7%) occurred, both in Group I. During follow-up (42.5 ± 21.8 months), there were 10 deaths in Group I (1 noncardiac, 1 sudden, and 8 heart failure), and 1 death in Group II (heart failure) (p < 0.04). Conclusions: Concomitant CABG and ICD implantation can be performed with an acceptable in-hospital mortality, even in patients with poor left ventricular function. Although freedom from sudden cardiac death remains excellent, overall long-term survival is limited by refractory heart failure, especially in those patients with left ventricular dysfunction at the time of surgery.

During the 7-year period from August 1986 to December 1993, 242 patients with malignant ventricular arrhythmias underwent 242 ICD implantations and 50 subcutaneous generator changes. Wound infections developed in 5 patients (1.7%): in 3 cases, after primary implantation (3/242 [1.2%]); and in 2 following a generator change (2/50 [4.0%]). This difference was not statistically significant. Infection developed at the generator pocket and became clinically manifest between 6 weeks and 40 months, postoperatively. Our treatment approach with the first patient consisted of simple debridement of the pocket and reimplantation of the existing generator. This led to recurrence, and the generator was safely explanted. In the remaining four patients, our approach has been that of local treatment, with wide debridement of the pocket, and placement of a closed irrigation system with continuous irrigation with a bacitracin, polymyxin, neomycin solution, and culture-specific antibiotic therapy. We have successfully controlled the infection and salvaged the generator with this approach in all four patients, who are all alive and well at a mean follow-up of 25.0 +/- 17.3 months with no recurrence. The good results obtained in these patients suggest that the concept of total explanation of the infected ICD should be reassessed.

Sustained atrial fibrillation is very common after cardiac surgical procedures. We hypothesized that atrial defibrillation could be accomplished consistently and safely by means of low-energy shocks delivered by temporary stainless steel wire electrodes placed at the time of the operation. Sterile pericarditis was created in five mongrel dogs (20.9 ± 2.1 kg), and pairs of standard temporary stainless steel wire electrodes were placed on the right atrial appendage, on Bachmann's bundle, and on the right ventricular apex for pacing, sensing, and recording. Temporary stainless steel wire electrodes, insulated except for the distal 6 cm and used to deliver defibrillation shocks, were placed adjacent to both atrial free walls and secured to the pericardium. All electrodes were brought out through the skin, and the sternotomy was closed. Dogs were tested in the conscious state on postoperative day 2. Sustained atrial fibrillation was induced by rapid atrial pacing. A customized software program was used to control the defibrillator, which delivered R wave–synchronous biphasic shocks to the atria through the temporary defibrillation electrodes. The shock intensity began at 50 volts and was increased by 10-volt increments until atrial fibrillation was terminated. Atrial fibrillation was terminated in all dogs at 112 ± 7 volts, with an energy of 0.42 ± 0.07 joule and an impedance of 67.8 ± 4 ohms (all values mean ± standard error of the mean). The mean percent success for atrial defibrillation at this minimal threshold was 49%. Thus at low-threshold voltages atrial fibrillation could be terminated with every other shock. A 25% increase in the minimal threshold voltage improved the conversion rate to 73% (mean energy 0.66 ± 0.19 joule and mean impedance of 67 ± 3.8 ohms). No complications were detected with the use of the electrodes or after their removal on the seventh postoperative day. One instance of electrode migration on the right atrial free wall was detected by roentgenography, but this did not adversely affect atrial defibrillation threshold. No ventricular arrhythmias or hemodynamic complications were noted during shock delivery. We conclude that successful conversion of atrial fibrillation to sinus rhythm can be achieved consistently with shock energies below 0.5 joule delivered with temporary epicardial defibrillation wire electrodes in this canine pericarditis model. These results suggest that this approach to the management of sustained atrial tachyarrhythmias has considerable promise in the management of atrial fibrillation in patients who have had cardiac operations. (J THORAC CARDIOVASC SURG 1996;111:392-8)

Objectives.This study sought to determine whether temporary epicardial wire electrodes can be used safely and effectively to defibrillate the atria with low energy shocks in the absence of anesthesia.Background.Atrial fibrillation after open heart surgery is a significant clinical problem.Methods.Twelve dogs with sterile pericarditis were studied. In the first group (6 dogs, bilateral thoracotomy group), a wire electrode, insulated except for the distal 6 cm, was placed on the epicardial free wall of each atrium. Each end of the bare wire was then sutured to the parietal pericardium. In the second group (6 dogs, median sternotomy group), the wire electrodes were kept in place by a double loop of Prolene placed around the distal tip of the bare wire and sewn to the overlying parietal pericardium. In the bilateral thoracotomy group, atrial defibrillation thresholds (defined as 10% successful defibrillation of 20 shocks at a given delivered energy) were obtained in anesthetized dogs using the wire electrodes with the chest closed and open and using two transvenously placed catheters with coil electrodes in the distal 6 cm (one in the coronary sinus and the other in the right atrial appendage) with the chest open. In the median sternotomy group, thresholds were obtained in minimally sedated animals without reopening the chest. A 25% increase above threshold shock was also used to determine a new percent success. After 4 days, the wire electrodes were removed by pulling on the external ends. At the time of removal, blood pressure and heart rate were monitored for 30 min, after which dogs were killed and their hearts sent for histopathologic study. For all dogs, chest radiographs were obtained postoperatively and on study days.Results.Atrial defibrillation using the wire electrodes was successful in all dogs at a mean (±SE) voltage of 112 ± 9 V, with an energy level of 0.46 ± 0.07 J and an impedance of 59.3 ± 5 ohms. The mean percent success at the atrial defibrillation threshold was 36 ± 5%. The 25% increase in defibrillation voltage improved the mean percent success to 73% (mean energy 0.66 ± 0.19 J). No clinical or hemodynamic complications were observed during shock delivery, and no ventricular arrhythmias were induced during the shocks. No complications followed wire electrode removal. Histopathologic analysis showed no structural damage.Conclusions.The atrial defibrillation threshold obtained using temporary epicardial wire electrodes for atrial defibrillation is < 1 J in dogs. Atrial defibrillation using temporary epicardial wire electrodes can be performed safely, quickly and reliably without the need for anesthesia or antiarrhythmic agents. The wire electrodes can be removed without adverse hemodynamic or structural consequences. These data provide a basis for testing atrial defibrillation using epicardial wire electrodes in patients after open heart surgery.

Background. Primary tissue failure is the most frequent indication for reoperation in patients with a mitral bioprosthetic valve (MBPV). Complete excision of the bioprosthesis is time-consuming and may be complicated by cardiac rupture at the atrioventricular junction or the posterior left ventricular wall where a strut is embedded, injury to the circumflex coronary artery, or late perivalvular leak. A new approach to avoid these complications by excision of only the bioprosthetic tissue and attachment of a St. Jude valve (SJV) to the intact stent has been developed and evaluated. Methods. The results of replacement of failed MBPV with SJV in 71 consecutive patients between September 1992 and December 1994 were analyzed; 57 patients had the valve replaced after complete excision and 14 with stent preservation. The demographic and clinical profiles of the two groups were similar. Results. Among patients undergoing complete excision of the MBPV, operative mortality was 14% (8 of 57), with 12 late deaths and a 5-year survival of 75% and three late perivalvular dehiscences requiring another operation. No operative deaths occurred in the intact stent group and one late death (cancer), and all the remaining patients are doing well without perivalvular leaks or other complications. Conclusions. Leaving the MBPV stent intact eliminates the need for extensive dissection, thus shortening and simplifying the procedure and diminishing its attendant mortality and morbidity. It offers a safe and logical approach to replacement of a degenerated MBPV with a SJV of comparable size.

During the 7-year period from August 1986 to July 1993, 203 patients with malignant ventricular arrhythmias underwent 203 implantable cardioverter-defibrillator (ICD system) implantations at the University Hospitals of Cleveland. Sixty-four patients had significant coronary artery stenoses amenable to myocardial revascularization and thus, at the time of the operation for ICD placement, also underwent coronary artery bypass graft. A retrospective analysis of the course of these 64 patients was carried out to determine the effect of two different treatment strategies on the outcome and cost of therapy. Thirty-six patients (group 1) underwent concomitant implantation of the ICD leads, patches and generator at the time of myocardial revascularization; 28 patients (group 2) underwent a two-stage strategy of initial placement of the ICD leads and patches at the time of myocardial revascularization followed by postoperative electrophysiologic testing to determine the persistent need for generator implantation. Of this latter group, 16 patients still had inducible sustained ventricular tachycardia during postoperative electrophysiologic testing and underwent generator implantation; 12 patients did not receive an ICD generator. The overall 30-day mortality rate was 4.7%. Two patients died in group 1 for a mortality rate of 5.5% and one died in group 2 for a mortality rate of 3.6%. The mean(s.d.) length of stay was 22.8(9.6) days at a mean(s.d.) cost of $93 000(33 000) for group 1 and 24.5(9.6) days at a mean cost of $82 900(30 000) for group 2 (P = n.s.). The mean(s.d.) postoperative length of stay was 13.7(7.8) days for group 1 and 15.4(6.5) days for group 2 (P = n.s.). Other complications occurred in 23% of surviving patients in group 1 and 29% of surviving patients in group 2 (P = n.s.). Mean follow-up was 33 months for group 1 and 23 months for group 2. At the end of 2 years, 78% of patients in group 1 and 86% in group 2 were alive (P = n.s.). It is concluded that concomitant coronary artery bypass grafting and ICD implantation does not result in significantly shorter hospitalization or lower costs. A staged approach appears equally economical, particularly as some patients are spared the cost of the initial ICD generator, the subsequent periodic generator replacements and the mandatory ICD follow-up. This has important implications when the use of non-thoracotomy devices becomes widespread.

the immediate postoperative period, a complication thought to be due to a noncompressive thoracic myelopathy, possibly caused by spinal cord ischemia. Clinical summary. A 52-year-old man with a history of diabetes mellitus, hypertension, and obesity was admitted to the University of Illinois Hospital 3 months after esophageal resection for carcinoma of the mid-esophagus performed elsewhere. The patient had a history of severe reflux esophagitis complicated by esophageal stricture and Barrett esophagus. He had been treated in the past with several dilatations. Because of symptoms of weight loss and dysphagia to solid food, he underwent an esophagogastroduodenoscopy that showed a sessile ulcerative lesion in the mid-esophagus. Biopsy specimens of that lesion showed a poorly differentiated adenocarcinoma. Subsequently, the patient underwent a subtotal esophagectomy and an intrathoracic esophagogastrostomy performed through a right lateral thoracotomy (Ivor Lewis approach). No perigasParaplegia after esophageal resection for carcinoma of the esophagus is rare. A review of the world literature since 1966 showed that only 4 such cases have been reported.1-3 We add a fifth case, that of a patient who was referred to our institution for follow-up after resection of adenocarcinoma of the PARAPLEGIA AFTER ESOPHAGECTOMY: WHO ARE THE PATIENTS AT RISK?

The CarboMedics Top Hat supraannular aortic valve provides an orifice-to-annulus ratio of 1:1 in most patients, and enhances patient outcomes. This study compared the midterm echocardiographic parameters of 52 patients undergoing aortic valve replacement with a Top Hat valve with those in other studies of Top Hat or CarboMedics intraannular valves. Echocardiography was performed 6–48 months after surgery with Top Hat sizes 21-27. Parameters evaluated included mean gradient, peak gradient, effective orifice area, and effective orifice area index. Preoperative and postoperative echocardiographic measurements were compared in 38 patients with aortic valve stenosis. Hemodynamic data were comparable to those of other studies, but the Top Hat prosthesis implanted was significantly larger (by a mean of 3.29 mm) than the valve size indicated using an intraannular valve sizer in 48 patients. Mean effective orifice area improved significantly from 0.73 cm2 preoperatively to 2.04 cm2 postoperatively. In patients with preoperative aortic valve stenosis, postoperative mean peak gradient was significantly reduced. The larger orifice-to-annulus ratio of the Top Hat valve improved hemodynamic parameters assessed by echocardiography up to 4 years postoperatively, with a lower transvalvular gradient, hence decreased left ventricular workload.

Introduction of the automatic implantable cardioverter defibrillator (AICD) has dramatically affected the surgical treatment of malignant ventricular tachyarrhythmias. The authors continue to perform electrophysiologically directed subendocardial resection (SER) of left ventricular (LV) scars in selected patients, and we revascularize (CABG) those patients undergoing AICD implantation who have significant myocardial ischemia. In an attempt to define the optimal role of each procedure, this report analyzes our 8-year experience with 348 consecutive patients treated surgically for these arrhythmias (SER since 1983 and AICD since 1986). All patients undergoing SER had organized ventricular tachycardia (VT) as a result of myocardial infarction, and most had LV aneurysms; of those undergoing AICD or AICD/CABG, 60% had VT, 15% had ventricular fibrillation, and 25% had both or were noninducible. The thirty-day mortality rate was 1.5% (3/197) for AICD, 5.4% (5/93) for AICD/CABG, and 8.6% (5/58) for SER; these mortality figures are not significant different. Late deaths in all groups were predominantly due to congestive heart failure, and actuarial survival as well as freedom from sudden death was similar between the groups at 4 years. Recurrent VT occurred in 167 of 282 (59%) of long-term survivors of AICD or AICD/CABG during follow-up and in nine of 53 (17%) of those with SER. Forty-eight per cent of survivors of AICD or AICD/CABG required antiarrhythmic medications, whereas only 11% of those with SER required antiarrhythmics. Long-term survival in each group is much higher than that reported for comparable patients with severe LV dysfunction treated medically. In those patients with organized VT and LV aneurysm who are judged able to survive the procedure, SER offers a high likelihood of cure rather than simple prevention of sudden death.

BACKGROUND In animals, parasympathetic nerve fibers that innervate the sinoatrial node can be selectively stimulated to increase atrial cycle length. These nerve fibers course through an epicardial fat pad at the margin of the right superior pulmonary vein, the superior vena cava, and the right atrium. We hypothesized that similar nerves exist and can be selectively stimulated in humans. METHODS AND RESULTS Microscopic examination of fat pads excised from the margin of the right superior pulmonary vein, the superior vena cava, and the right atrium during two human autopsies revealed the presence of nerve fibers and ganglia. We electrically stimulated this epicardial fat pad in 16 patients during cardiac surgery. The fat pads were stimulated with continuous-pulse trains for 15 seconds via a hand-held bipolar electrode using constant current (10-15 mA), constant pulse width (0.02-0.05 msec), and at 6.6, 10, 20, 25, and 30 Hz. The mean atrial cycle length +/- 1 SEM increased from 734 +/- 34 msec at baseline to a maximum of 823 +/- 61 msec at 6.6 Hz, 1,167 +/- 125 msec at 10 Hz, 1,734 +/- 281 msec at 20 Hz, 2,993 +/- 661 msec at 25 Hz, and 2,461 +/- 668 msec at 30 Hz during nerve stimulation. Linear regression analysis showed that the response of atrial cycle length to sinoatrial parasympathetic nerve stimulation was frequency dependent. The maximum response and complete decay of the response occurred within 4-8 seconds of initiation or termination of sinoatrial parasympathetic nerve stimulation. Atrioventricular conduction time and the PR interval did not change during sinoatrial parasympathetic nerve stimulation, even when the atria were paced at the baseline heart rate. CONCLUSIONS Electrical stimulation of parasympathetic nerve fibers in a fat pad near the sinoatrial node increased atrial cycle length without affecting atrioventricular nodal conduction. This is the first study in which such nerve fibers that innervate the sinoatrial node have been selectively stimulated in humans.

BACKGROUND A reliable, noninvasive procedure to determine the location of accessory atrioventricular connections in patients with Wolff-Parkinson-White syndrome would add an important diagnostic tool to the clinical armamentarium. METHODS AND RESULTS Body surface potential mapping (BSPM) using 180 electrodes in various-sized vests and displayed as a calibrated color map was used to determine the ventricular insertion site of the accessory atrioventricular (AV) connections in 34 patients with Wolff-Parkinson-White syndrome. Attempts were made to determine the 17 ventricular insertion sites described by Guiraudon et al. All 34 patients had an electrophysiologic study (EPS) at cardiac catheterization, and 18 had surgery so the ventricular insertion sites could be accurately located using EPS at surgery. A number of physiologic observations were also made with BSPM. CONCLUSIONS The following conclusions were drawn: 1) BSPM using QRS analysis accurately predicts the ventricular insertion site of accessory AV connections in the presence of a delta wave in the electrocardiogram; 2) the ventricular insertion sites of accessory AV connections determined by BSPM and by EPS at surgery were identical or within one mapping site (1.5 cm or less) in all but four of 18 cases; three of the four exceptions had more than one accessory AV connection, and the other had a very broad ventricular insertion; 3) BSPM and EPS locations of the accessory AV connections correlated very well in the 34 cases despite the fact that BSPM determines the ventricular insertion site and EPS determines the atrial insertion site of the accessory AV connection; 4) as suggested by the three cases of multiple accessory AV connections, EPS and BSPM may be complementary since BSPM identified one pathway and EPS identified the other (in the case with a broad ventricular insertion, BSPM and EPS demonstrated different proportions of that insertion); 5) BSPM using ST-T analysis is very much less accurate in predicting the ventricular insertion site of accessory AV connections unless there is marked preexcitation; 6) standard electrocardiography using the Gallagher grid methodology (but with no attempt at stimulating maximal preexcitation) was not as accurate as QRS analysis of BSPM in predicting the ventricular insertion site of the accessory AV connection; however, exact comparison is hampered by the different number and size of the Gallagher and Guiraudon insertion sites; 7) BSPM using QRS analysis appears to be very accurate in predicting right ventricular versus left ventricular posteroseptal accessory AV connections; 8) typical epicardial right ventricular breakthrough, indicative of conduction via the specialized AV conduction system, occurs in all patients with left ventricular free wall accessory AV connections; 9) epicardial right ventricular breakthrough was not observed in cases with right ventricular free wall or anteroseptal accessory AV connections; 10) epicardial right ventricular breakthrough can occur in the presence of posteroseptal accessory AV connections, whether right or left ventricular; and 11) the delay in epicardial right ventricular breakthrough in cases with left ventricular insertion may provide a marker to estimate the degree of ventricular preexcitation.

Atrial fibrillation (AF) affects several million patients worldwide and is associated with a number of heart conditions, particularly coronary artery disease, rheumatic heart disease, hypertension, and congestive heart failure. The treatment of AF and its complications is quite costly. Atrial fibrillation usually results from multiple macro-re-entrant circuits in the left atrium. Very frequently, particularly in association with mitral valve disease, these circuits arise from the area of the junction of the pulmonary venous endothelium and the left atrial endocardium. Pharmacological therapy is at best 50% effective. Therapeutic options for AF include antiarrhythmic drugs, cardioversion, atrioventricular (A-V) node block, pacemaker insertion, and ablative surgery. In 1987, Cox developed an effective surgical procedure to achieve ablation. Current ablative procedures include the classic cut-and-sew Maze operation or a modification of it, namely through catheter ablation, namely, cryoablation, radiofrequency ablation (dry or irrigated), and other forms of ablation (e.g., laser, microwave). These procedures will be described, along with the indications, advantages and disadvantages of each. Special emphasis on the alternative means to cutting and sewing to achieve appropriate effective atrial scars will be stressed, and our experience with these approaches in 50 patients with AF and associated cardiac lesions and their outcomes is presented.

The CarboMedics Top Hat supra-annular aortic valve allows a one-size (and often two-size) increase over the standard intra-annular valve. This advantage should minimize the risk of patient-prosthesis mismatch, where the effective prosthetic valve orifice area is less than that of a normal valve. It is suggested that the ability to implant Top Hat valves having greater size, relative to standard intra-annular valves, may currently be under-utilized. Further, there has been some concern that Top Hat implantation can cause obstruction of the coronary ostia. This study evaluates the authors' clinical experience with Top Hat supra-annular aortic valve size selection, and the technical aspects of implantation.Between January 1999 and October 2005, a total of 251 consecutive patients underwent 252 aortic valve replacements with Top Hat supra-annular mechanical prostheses (CarboMedics, Inc., Arvada, CO, USA) at two institutions. Size frequency distribution was compared to published series, and to the manufacturer's US registry. The ventriculoaortic junction (VAJ) size was available in 234 patients, and compared to the size of the Top Hat valve implanted.Valves implanted were 2 mm larger than the VAJ in 56% of patients (130/234), 3 mm larger in 1.7% (4/234), and 4 mm larger in 42% (98/234). Numbers of 19-mm and 21-mm valves were less (p0.001) in the present series (22%) than in published series (52%) and the US registry (46%). No patient required unplanned coronary bypass, and 30-day mortality was 2.0% (5/251), indicating a good safety profile for the valves implanted in this series.The general distribution of implant sizes in the US indicates that cardiac surgeons may be under-sizing the Top Hat supra-annular aortic valve during aortic valve replacement, thereby missing the full advantage of its unique design for lowering the transvalvular gradient and, consequently, left ventricular workload, leading to a reversal of left ventricular hypertrophy.

Synovial sarcomas that primarily arise from the heart and pericardium are extremely rare, especially the ones involving both sides of the heart. To date, few cases have been reviewed in the literature. Our patient was a 36-year-old man who presented with primary biatrial synovial sarcoma that also involved the tricuspid annulus, heart valves, and interatrial septum. The tumor was debulked to relieve the atrioventricular obstruction. Molecular analysis confirmed the diagnosis of synovial sarcoma with positive t (X;18) SYT-SSX gene fusion. The patient is currently receiving chemotherapy. From our review of the 20 cases thus far reported in the English-language medical literature, the tumor more frequently affects young male patients, and carries a poor prognosis. Early detection is difficult because of the aggressive nature of the tumor. Like other sarcomas, wide surgical resection remains the mainstay of therapy. Adjuvant radiation therapy for local recurrence and chemotherapy for control of systemic disease may have some beneficial effect on overall survival, but the benefit is likely limited.

Valve dysfunction is not an uncommon occurrence following heart transplantation but when present can be managed medically with diuretics and vasodilator therapy. If medical therapy fails, these patients are considered for retransplantation. Due to the scarcity of donor hearts, efforts aimed at limiting the pool of cardiac retransplantation candidates are being focused lately on preservation of cardiac allograft function by conventional operations in lieu of a retransplant. A review of the literature for patients who underwent valve operations following their heart transplants yielded 26 cases. Four of these had isolated mitral valve procedures, 18 had tricuspid procedures, two had combined mitral and tricuspid operations and two had aortic valve replacements. In this communication, we present a case of severe aortic insufficiency developing 7 yr after heart transplantation and leading to progressive clinical deterioration and NYHA class IV heart failure symptoms. The aortic valve was replaced with a 21-mm Carbo Medics supra-annular mechanical prosthesis (CarboMedics Inc.). She had a favorable postoperative course and remains well 7 months after her operation. Surgical correction of valvular lesions is warranted if the function of the previously transplanted heart is reasonably preserved.

Diabetes mellitus is associated with a distinct cardiomyopathy. Whether cardiac myofilament function is altered in human diabetes mellitus is unknown. Myocardial biopsies were obtained from seven diabetic patients and five control, nondiabetic patients undergoing coronary artery bypass surgery. Myofilament function was assessed by determination of the developed force-Ca2+ concentration relation in skinned cardiac cells from flash-frozen human biopsies. Separate control experiments revealed that flash freezing of biopsy specimens did not affect myofilament function. All patients in the diabetes mellitus cohort were classified as Type 2 diabetes mellitus patients, and most showed signs of diastolic dysfunction. Diabetes mellitus was associated with depressed myofilament function, that is, decreased Ca2+ sensitivity (29%, P < 0.05 vs. control) and a trend toward reduction of maximum Ca2+-saturated force (29%, P = 0.08 vs. control). The slope of the force-Ca2+ concentration relation (Hill coefficient) was not affected by diabetes, however. We conclude that human diabetes mellitus is associated with decreased cardiac myofilament function. Depressed cardiac myofilament Ca2+ responsiveness may underlie the decreased ventricular function characteristic of human diabetic cardiomyopathy.

Background We retrospectively reviewed the United Network for Organ Sharing (UNOS) database to assess the survival of patients with amyloidosis who were treated by heart transplantation. Methods Over a 15-year period, 69 patients had received orthotopic heart transplants and were entered into the database with the diagnosis of amyloidosis. The cohort consisted of 38 men and 31 women. Mean age was 51 years. Results There were 5 operative deaths and 29 late deaths at a mean follow-up of 40 months. Nine patients died of amyloid-related complications, and one developed graft vasculopathy and was retransplanted. Conclusions Survival was influenced by recipient's sex (1-year survival 84% for men vs 64% for women, p = 0.003) but not by transplant era, ischemia time, or UNOS status.

Purpose: Ischemic injury of the saphenous vein graft (SVG) during temporary storage prior to implantation in coronary bypass grafting (CABG) is believed to contribute to SVG thrombosis and stenosis. We aimed to show that; cellular apoptosis in endothelial and smooth muscle cells of the SVG is amplified by the short-term preservation, and that pyruvate-based preservation reduces the degree of cellular apoptosis as compared to other media. Methods: 5-cm SVG segments were taken from 14 patients undergoing CABG. Each 5-cm segment was then subdivided into five 1-cm units (totalling 70 units). For each patient, the first of the five subunits became the control and was immediately examined for apoptosis. These units did not undergo storage. The other four segments were stored at 20°C for 1-hour in one of the following solutions: Normal saline, Euro-Collins (EC), University of Wisconsin solution (UWS) or a 10mM pyruvate solution. Apoptotic cells were detected by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL assay) and the Student’s t-test was used for comparison. To minimize variability, each patient served as his/her own control. Results: Mean (SEM) number of TUNEL positive cells was similar in segments preserved with pyruvate when compared to Controls (4.00 ± 0.47% versus 4.03 ± 0.40%). When these compared by Student’s t-test, there was no significant difference in the number of apoptotic cells among 10/14 patients (71%). Pyruvate preserved segments had significantly less apoptosis (p < 0.05) in 10/14 patients (71%) when compared to normal saline, in 7/14 patients (50%) when compared to EC, and in 3/14 patients when compared to UWS. Conclusions: Procurement of SVGs is associated with a measurable degree of cellular apoptosis and cellular apoptosis is amplified by the short-term preservation. However, pyruvate preserved SVGs had less cell damage when compared to those preserved in other media and where similar to controls.

A new surgical approach to augment the pumping ability of failed hearts is known as aortomyoplasty-a technique in which the latissimus dorsi muscle is wrapped around the aorta and stimulated during cardiac diastole to provide chronic diastolic counterpulsation. The authors hypothesized that the manner in which the latissimus dorsi muscle is wrapped around the aorta will determine the amount of augmentation during counterpulsation. In dogs (n=9), they measured the cardiovascular effects of different muscle wrap techniques. Their results suggest that muscle wrap orientation determines the amount of augmentation during aortomyoplasty, and a new muscle wrap technique provides greater augmentation than wrap techniques previously reported.

An unusual case of a penetrating intracardiac injury is described in a 16-year-old boy who presented with a retained 14-cm segment of an ice pick that went unnoticed by the patient for 4 days. The ice pick had lacerated the anterior papillary muscle of the left ventricle causing avulsion of its tip and prolapse of the anterior leaflet of the mitral valve resulting in severe mitral regurgitation. The urgency for surgical correction of the traumatic mitral valve injury at the time of extraction of the intracardiac foreign body through a single-stage approach versus a two-stage approach is discussed.

Background . The most common indication for reoperation in patients with a bioprosthetic valve is primary tissue failure. Explantation of the bioprosthesis is time consuming, and for a mitral valve, may be complicated by cardiac rupture at the atrioventricular junction or the posterior left ventricular wall where a strut is imbedded, injury to the circumflex artery, and late perivalvular leak; for an aortic valve, annular disruption and perivalvular leak may complicate explantation. A new approach to simplify these procedures and avoid these complications, by excising only the bioprosthetic tissue and attaching a bileaflet mechanical valve to the intact stent, was developed in 1991 and was evaluated over a 9-year period in 50 patients who had had one (34), two (10), three (4), or four (2) previous open cardiac operations. Methods . Since 1991, we have replaced degenerated mitral bioprostheses in 34 patients (25 to 84 years of age; 12 male, 22 female) by preserving the stent and suturing a St. Jude or Carbomedics bileaflet valve to the atrial side of the bioprosthetic cuff; the mitral valve was exposed through a median sternotomy in 21 patients and through a right anterolateral thoracotomy in 13. Using a similar approach, starting in 1995, 16 additional patients (55 to 73 years of age; 11 male, 5 female) with degenerated aortic bioprostheses had the aortic valve replaced by excising the bioprosthetic tissue and amputating the struts, then suturing a Carbomedics valve to the aortic side of the bioprosthetic cuff. This allows the use of a bileaflet valve similar in size to the bioprosthesis with exact matching of the orifices. Results . Bypass time averaged 61 ± 14 minutes and aortic cross-clamp time 43 ± 12 minutes. There has been no operative mortality. Three late deaths occurred at 9, 37, and 58 months, and were not valve related. No gradients of hemodynamic significance have been detected on transesophageal echocardiographic follow-up. Conclusions . Leaving the bioprosthetic cuff intact eliminates the need for extensive dissection, thus shortening and simplifying the procedure and diminishing its attendant mortality and morbidity. This valve-on-valve approach also allows replacement of a degenerated bioprosthesis with a bileaflet valve of comparable size rather than a smaller one jammed into the orifice of the bioprosthetic stent, thus avoiding undue trauma to the bileaflet valve and maintaining excellent hemodynamic function.

Background. Recent advances in techniques of cardiopulmonary bypass permitted hypothermic circulatory arrest (HCA) using groin cannulation with the chest closed (CC-HCA) and without direct access to the heart. Herein we describe our experience with this technique for complex intracranial aneurysms. Methods. Between 1992 and 1999, 16 patients (4 men and 12 women) with a mean age of 52 years (range 32 to 61 years) with complex intracranial aneurysms underwent resection or clipping of their aneurysms at our institution using the technique of CC-HCA and groin cannulation. Groin access was obtained with 16F to 19F arterial and 18F to 20F venous cannulas placing the tips at the aortoiliac and atriocaval junctions, respectively. Patients were cooled to a nasopharyngeal temperature of 16°C. Results. Mean circulatory arrest time was 32 minutes. No patient required conversion to standard sternotomy and central cannulation. There were no intraoperative deaths. The 30-day hospital mortality was 2 of 16 patients (12%). Of the 14 surviving patients (88%), 1 developed bilateral third nerve palsy and another left hemiparesis that improved on follow-up. Both were discharged to an extended care facility and continued to do well at home after discharge. Two patients developed deep venous thrombosis postoperatively and required anticoagulation. All patients continued to do well at a mean follow-up of 42 months. Conclusions. The less invasive technique of CC-HCA through groin cannulation avoids complications associated with a sternotomy, is safe and is associated with little morbidity, reduced operative time, and early hospital discharge and rehabilitation.

To ascertain whether early extubation and fast-track treatment protocols are feasible in elderly patients, we analyzed 487 consecutive patients who had isolated coronary artery bypass grafting between January 1995 and June 1997, constituting the experience of a single surgeon.Management consistently applied to all patients emphasized early extubation protocol, tepid cardioplegia and normothermic bypass to reduce pump times, early mobilization and chest tube removal, and protocol treatment of atrial fibrillation. Elderly patients at least 70 years old (n = 176, mean age 75 years) were compared with younger patients (n = 311, mean age 58 years).The hospital mortality rate was 0.8% (4 of 487 patients), and there was no difference in the operative mortality rate of the older cohort versus the younger cohort (0.6% versus 0.9%; p0.05). Older patients had a higher incidence of peripheral vascular disease, congestive heart failure, prior strokes, renal failure, and cerebrovascular disease (p0.05). Early extubation was achieved in 71% of younger patients versus 57% of older cohort (95% confidence interval, 14%+/-9%; p = 0.002). Older patients had significantly higher incidence of postoperative atrial fibrillation (27% versus 14%; 95% CI, 13%+/-7%; p0.001), a factor responsible for shorter length of stay among younger patients (5.6+/-2.8 days versus 7.2+/-3.7 days; 95% CI, 1.6+/-0.3 days; p0.001). Nonetheless discharge before the fifth postoperative day was achieved in 34% of the elderly patients.Although elderly patients have a higher acuity of illness, critical pathways for accelerated discharge are safe and feasible in most elderly patients.

Bronchiectasis may occur with various congenital and acquired immunodeficiency diseases. The association of bronchiectasis and the X-linked lymphoproliferative disease (XLP), also known as Duncan's disease is unknown. We describe the case of a 39-year-old man with XLP, the oldest surviving, who developed chronic bronchiectasis with hemoptysis and required a pneumonectomy to control his symptoms.

Sinoatrial Parasympathetic Innervation. Introduction: The response to sinoatrial parasympathetic nerve stimulation (shortened atrial refractoriness) was used to determine the atrial distribution of these nerve fibers in humans. We hypothesized that, in humans, parasympathetic nerves that innervate the sinoatrial node also innervate the right atrium and that the greatest density of innervation is near the sinoatrial nodal fat pad. Methods and Results: Temporary epicardial wire electrodes were sutured in pairs in the sinoatrial nodal fat pad, high right atrium, and right ventricle by direct visualization during coronary artery bypass surgery in nine patients. Appropriate electrode placement was confirmed by electrically stimulating the fat pad in the operating room to prolong sinus cycle length by 50%. Experiments were performed in the electrophysiology laboratory 1 to 5 days after surgery. Programmed atrial stimulation was performed via an endocardial electrode catheter advanced to the right atrium. The catheter tip electrode was moved in 1-cm concentric zones around the epicardial wires by fluoroscopic guidance. Atrial refractoriness was determined in the presence and absence of sinoatrial parasympathetic nerve stimulation at each cutheter site. In 8 of 9 patients, parasympathetic nerve stimulation reproducibly prolonged sinus cycle length by 50%. There was no effect on AV nodal conduction (no prolongation of PR interval) and no change in AV nodal refractoriness. Atrial effective refractory periods reproducibly shortened in response to parasympathetic nerve stimulation in 1-cm zones up to 3 cm surrounding the fat pad, by a mean (± SEM) of 26.6 ± 4.3 msec (zone 1), 11.4 ± 1.8 msec (zone 2), and 10.0 ± 2.5 msec (zone 3), respectively (P = 0.0001). At distances > 3 cm from the fat pad, the effective refractory period did not shorten. Conclusion: Stimulation of parasympathetic nerves that innervate the sinoatrial node shortened atrial refractoriness in humans.

Background . The clinical results of implantable cardioverter-defibrillator (ICD) implantation in the elderly have received limited documentation. As the longevity of the U.S. population has increased, so has the need for ICD implantation in the elderly. We evaluated the efficacy and outcome of ICD implantation in elderly patients (>70 years) compared with younger patients. Methods . The case records of all consecutive patients who underwent ICD implantation at our institution between 1986 and 1994 were reviewed. Of a total of 238 patients, 78 patients were 70 years of age or older and 160 patients were younger than 70 years of age. Results . The mean age of the younger group was 58 years and that of the elderly group was 74 years. There were no statistical differences in the presence of coronary artery disease, left ventricular systolic function, the inducibility of arrhythmias, or the history of sudden cardiac death. The hospital morbidity rate was similar in both groups (6.9% in the younger group and 7.7% in the elderly group; p = not significant). The operative mortality rate was 1.9% for the younger group and 1.3% for the elderly group ( p = not significant). At a mean follow-up of 33 ± 26 months, Kaplan-Meier survival curves demonstrated similar survival rates, with 93%, 82%, and 65% of the patients alive at 1, 3, and 6 years, respectively. Conclusions . Implantable cardioverter-defibrillator implantation was equally effective in the treatment of patients older than 70 years as in younger patients. No differences in theoretic survival or morbidity were observed.

A premise of cardiac risk stratification is that the added risk of coronary artery bypass grafting (CABG) is offset by the improved safety of subsequent vascular reconstruction (VR). We questioned if elective CABG is patients with severe peripheral vascular disease (PVD) is a relatively high-risk procedure. A cohort study of 680 elective CABG patients from January 1993 to December 1994 was performed using three mutually exclusive outcomes of complication-free survival, morbidity, and mortality. Patient characteristic, operative, and outcome data were prospectively collected. Retrospective review determined that 58 patients had either a standard indication for or a history of VR. Overall CABG mortality was 2.5%, with statistically similar but relatively higher rates for PVD as compared to non-PVD patients. In contrast, major morbidity occurred at rates 3.6-fold higher in PVD patients (39.7%) than in disease-free patients (16.7%) after adjustment for the effects of patient and operative variables (odds ratio [OR] 3.67, 95% confidence interval [CI] 1.93-6.99). CABG morbidity in the PVD patient was most likely in those patients with aortoiliac (OR 9.51, CI 3.20-28.27) and aortic aneurysmal (OR 5.24, CI1.28-21.41 ) disease types. CABG in PVD patients is associated with significant major morbidity. Such morbidity may preclude or alter the timing of subsequent VR. (Ann Vasc Surg 1997; 11:612-619.)

Background. Although early extubation after coronary bypass surgery has been shown to reduce length of stay, a systematic cost analysis of its economic benefit has not been reported, and previous studies have used hospital charges that are typically confused with actual costs. Methods. A consecutive series of 690 patients undergoing coronary bypass surgery during a 24-month period were studied to determine the effect of early extubation, defined as removal of the endotracheal tube within 8 hours of arrival to the intensive care unit, on length of stay and hospital costs. Patients in group 2 (n = 362) who underwent coronary bypass surgery in 1995, subsequent to the initiation of an early extubation protocol, were compared with those in group I (n = 328) operated on in 1994, before implementation of early extubation. To reflect true hospital resource consumption, only costs (not charges) directly related to patient health care (variable direct cost) were analyzed. Results. Baseline characteristics such as age, gender, previous myocardial infarctions, section fraction, reoperations, diabetes, and left main stenosis were similar in both groups. Operative mortality for the entire group was 3.3% and did not differ between the two groups ; the incidence of serious morbidity was 10.9% for the entire group. Early extubation was accomplished in 38% of patients in group 2 versus 3% in group 1 (p < 0.001), and postoperative length of stay declined from 9.4 days to 7.7 days (p < 0.01). This was accompanied by a significant (p = 0.001) reduction in variable direct cost per case. Conclusions. Early extubation after coronary bypass surgery is an effective strategy of reducing length of stay and does not appear to impact on either morbidity or mortality. An additional benefit is significant cost savings realized through accelerated recovery and control of resource use.

Hemangiomas, benign tumors of vascular origin, compromise less than 3% of all nonmalignant esophageal neoplasms. Because of their infrequent occurrence, such vascular tumors may be mistaken for more common benign tumors of the esophagus. We report the successful surgical management of an esophageal arteriovenous malformation presenting with clinical, radiographic, and endoscopic features resembling those of a leiomyoma.

Heterotopic implantation of the pulmonary venous confluence into the left atrial appendage during left lung transplantation is a reasonable alternative technique to reestablish venous drainage when exposure of the native left pulmonary veno-atrial connection may be problematic. We used this approach in a 39-year-old woman with chronic bronchiectasis who underwent bilateral sequential lung transplantation through a clam-shell approach. Dense hilar scarring and a small left atrial size made exposure of the native left pulmonary veno-atrial connection difficult.