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Objective The commercially available C-Port distal anastomotic device (Food and Drug Administration cleared in 2007) is an automated miniature vascular stapler that performs the coronary anastomosis. This prospective multicenter registry sought to evaluate midterm patency using this device compared with hand-sewn grafts. Methods Patients receiving at least one C-Port anastomosis during coronary artery bypass grafting surgery were enrolled at eight sites. Of the 117 patients enrolled, 78 patients (67%) with 104 C-Port vein grafts completed the study to patency assessment via computed tomography angiography. Clinical follow-up and index graft patency (Gated 64-slice computed tomography scan) were performed at least 12 months postoperatively. The primary efficacy endpoint was patency compared with the peer-reviewed results from the PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT IV) trial. Results The patient population was consistent with the PREVENT IV placebo cohort. The mortality at 12 months was 0.85% (1/117). The major cardiac morbidity rate was 3.4% (4/117). The C-Port vein graft occlusion rate was 16.3% (17/104) compared with 26.6% (597/2242) in the PREVENT IV trial ( P = 0.011). Within this study, C-Port graft occlusion rates were not significantly different from the hand-sewn grafts ( P = 0.821). Conclusions The C-Port device is safe and effective in creating the distal anastomosis with equivalent patency rates to hand-sewn grafts at 12 months. When compared with hand-sewn anastomoses from a recent large prospective trial, the C-Port device demonstrated a statistically significant reduction in midterm graft occlusion. Further studies are required to evaluate its effect in less invasive coronary surgery.

In this article we discuss two cases that highlight possible complications of cardiac device implantation. In particular, our first case involves a patient who, during implantable cardioverter defibrillator (ICD) implantation, sustained injuries to her subclavian artery and vein and subsequently developed a self-resolving neuropraxia of the brachial plexus. In our second case, the patient, also during ICD implantation, had his left cephalic vein nicked during cutdown. Post-op he then developed a hematoma-induced left brachial plexus injury that also eventually self-resolved. A literature search has not shown other incidences of iatrogenic brachial plexus injuries from ICD implantation as described.

Sestamibi Localization of a Parathyroid Adenoma in the Presence of a Thymoma: a Case Report and Review of the Literature Preoperative localization in the surgical management of primary hyperparathyroidism is complicated by widely variable parathyroid gland anatomy, coexisting thyroid pathology, incidence of supernumerary and ectopic parathyroid glands, and limitations of targeted imaging studies. Technetium 99mTcsestamibi scans have decreased accuracy, sensitivity and specificity in the presence of multi-gland parathyroid disease. A number of reports suggest that thymomas, which also show increased sestamibi uptake, are potential sources of false positives on 99mTc-sestamibi scans. Herein, we describe a thymoma in association with a parathyroid adenoma complicating localization of hyperfunctional parathyroid tissue. We review the literature of concurrent pathology between parathyroid adenomas and thymomas paying particular attention to how these cases present on preoperative 99mTcsestamibi scans.

Robot-Assisted Mediastinal Parathyroidectomy: Collaboration Between Otolaryngology and Thoracic Surgery There are only a few cases in the literature describing roboticassisted mediastinal parathyroidectomy. Herein, we present the largest cohort of patients (N=7) treated with roboticassisted mediastinal parathyroidectomy. All patients showed biochemical resolution of disease and no major complications were encountered. In our experience, robotic-assisted mediastinal parathyroidectomy is safe and effective in patients with primary hyperparathyroidism when performed in collaboration by experienced and robotically trained thoracic and head and neck surgeons.

We present a case where defibrillation threshold was dangerously elevated to the point that the patient had no safety margin, and his implantable cardioverter-defibrillator generator was discovered to have migrated. Generator migration reduces the distance between the can and the coil, effectively creating a smaller bipolar current and sparing the left ventricle from the current needed for defibrillation. This case underscores the importance of securing the generator in place, as this patient would have been spared multiple shocks and an invasive medical procedure had his generator been better secured.

In coronary artery bypass grafting (CABG) surgery, there is uncertainty about whether the radial artery affects quality of life or costs relative to the saphenous vein. This study compared the cost and quality of life for patients randomized to either radial artery or saphenous vein grafts.We analyzed the duration and cost of the index surgery and costs and quality of life (Seattle Angina Questionnaire and Health Utility Index) at 1 year for 726 participants.The 2 treatment groups had similar baseline characteristics. Using the radial artery added approximately 31 minutes to the surgery (from skin incision to skin closure; P.001) compared with a saphenous vein graft. There were no significant differences in terms of costs and quality of life after the index hospitalization or at 1 year.Coronary artery bypass grafting with the radial artery lasts approximately 31 minutes longer than with the saphenous vein. However, costs and the quality of life were not statistically different.

Survival after the rupture of the both mitral and tricuspid valves in blunt thoracic trauma is uncommon and requires prompt diagnosis and treatment. We present a case in which transesophageal echocardiography performed in the operating room by the anesthesiologist identified the etiology of hemodynamic instability and facilitated successful emergency replacement of both valves.

This study examined factors determining efficacy of intracavitary cardioversion of atrial tachyarrhythmias in closed chest, anesthetized dogs with talc pericarditis. Electrode catheters were positioned transvenously with the cathode in the right atrial appendage. In Group 1 dogs (n = 6), three anode sites (superior and inferior venae cavae ostia and mid-right atrium) were tested with graded energy shocks to determine the lowest effective cardioversion energy at each anode position. In Group 2 dogs (n = 9), multiple cardioversion attempts with energy levels of 0.01 to 5.0 J were used to evaluate reproducibility of energy thresholds. In Group 3 dogs (n = 6) without talc-induced pericarditis, atrial pathologic study was done after five intracavitary shocks (0.5 or 5.0 J). In Group 1, cardioversion was achieved with 0.75 J or less with no significant difference in minimal effective cardioversion energies among the three anode positions tested. In Group 2, 98 (26%) of 372 cardioversion attempts were successful. Intra-animal minimal effective cardioversion energies varied widely, and timing of shocks relative to atrial electrograms did not influence efficacy. Complications were infrequent and included delayed sinus rhythm recovery, transient atrioventricular block and ventricular fibrillation. Ventricular fibrillation occurred in 9 (2.4%) of 372 shocks, and was associated with higher delivered energies (6 of 9 with greater than or equal to 1.0 J) and with shocks delivered 116 to 180 ms after onset of the QRS complex. In Group 3, two dogs had no histologic damage, three dogs had multiple small foci of subendocardial necrosis and in one dog these foci coalesced to involve half the atrial wall thickness. Thus, low energy cardioversion of atrial tachyarrhythmias is feasible using intracavitary electrodes. Synchronization of energy delivery to the QRS complex is important to minimize risk of ventricular fibrillation.

Among 97 specimens of ascending aorta from adults with clinical coronary disease, the prevalence of atherosclerotic plaques greater than 8 mm in diameter was 38%. The right side of the ascending aorta was more commonly involved than the left; the sites least commonly involved were the right-posterior, upper right-anterior, and lower posterior locations. Of specimens with plaques at the orifice of the innominate artery, 80% also had plaques in the ascending aorta, and 73% of specimens with plaques at the orifice of the left subclavian artery had plaques in the ascending aorta.

Preexcitation of the atria during reciprocating tachycardia (RT) by a premature ventricular complex occurring when the His bundle is refractory provides direct evidence of the presence of accessory atrioventricular (AV) connection. The impact of ventricular stimulation site and RT cycle length on inducibility of atrial preexcitation was assessed in 38 patients with RT utilizing a single accessory AV connection (right free wall in 5 patients, left free wall in 21 and posterior septal/paraseptal in 12). Extrastimuli were inserted at right ventricular (RV) apical, left ventricular (LV) septal and LV free wall sites. Inducibility of and magnitude of atrial preexcitation increased as stimulation site approached accessory AV connection site. Thus, for RV free wall connections, RV extrastimuli preexcited the atria in 5 of 5 patients, LV septal in 1 of 5 and LV free wall in 0 of 4. For LV free wall accessory connections, RV extrastimuli preexcited the atria in only 3 of 21 patients, compared with 12 of 17 with LV septal and 20 of 21 with LV free wall stimulation. Additionally, the magnitude of atrial preexcitation achieved was related to RT cycle length, diminishing as cycle length shortened. Finally, in a few instances both RV apical and LV free wall extrastimuli failed to elicit preexcitation in patients with a posterior septal connection. Thus, ventricular pacing site and RT cycle length contribute importantly to induction of atrial preexcitation by ventricular extrastimulation technique and should be considered during evaluation of patients with RT in whom accessory AV connections may be present.

Flecainide acetate, an investigational class 1 antiarrhythmic agent, undergoes biotransformation in man with production of 2 major metabolites: meta-O-dealkylated flecainide (S-24623) and the meta-O-dealkylated lactam of flecainide (S-26191). This study compared the effects of flecainide, S-24623 and S-26191 on cardiac electrophysiologic characteristics in the anesthetized dog. Each dog received 2 dose levels of 1 of the 3 test compounds after control measurements. Flecainide (2 and 4 mg/kg in 8 dogs), S-24623 (4 and 8 mg/kg in 8 dogs) and S-26191 (4 and 10 mg/kg in 7 dogs) were administered intravenously in dilute solution. Of the 3 compounds, only flecainide significantly prolonged sinus cycle length (p less than 0.01). However, both flecainide and S-24623 significantly prolonged minimum atrial paced cycle length with 1:1 atrioventricular conduction, atrioventricular nodal effective and functional refractory periods, and right ventricular effective refractory period. Metabolite S-26191 exhibited qualitatively similar but much weaker electrophysiologic actions. The maximal electrophysiologic effects of flecainide and S-24623 were approximately equivalent, but the metabolite was about one-half as potent on a milligram-permilligram basis, and lacked marked effects on infranodal (HV interval) conduction. S-26191 was less than one-tenth as potent as flecainide. Therefore, since both flecainide metabolites occur primarily in the conjugated form in plasma (i.e., free metabolite concentrations are low), it is unlikely that these compounds either potentiate flecainide's antiarrhythmic action or increase susceptibility to drug toxicity in the clinical setting.

Advances in both cardiac surgery and the technology of recording and displaying electrical signals from biologic tissues have contributed to the evolution of intraoperative electrophysiologic evaluation in patients with preexcitation syndromes. As early as 1930, Barker [1] demonstrated the feasibility of epicardial electrogram recordings in the human heart and reported activation times at ventricular epicardial sites in a patient with a chronically open chest wound (Figure 25-1). In 1967, Durrer and Roos [2] obtained activation times determined from unipolar ventricular electrograms and demonstrated very early excitation at the lateral aspect of the base of the right ventricle in a patient with atrial septal defect and Wolff-Parkinson-White (WPW) syndrome. In that same year Burchell et al. [3] utilized ventricular activation times to evaluate ventricular excitation during sinus rhythm, and atrial activation times to evaluate atrial excitation during tachycardia in a patient with atrial septal defect and WPW syndrome. Even though the attempt to interrupt the accessory connection in this patient was unsuccessful, demonstration of the proximity of the site of early ventricular activation during prexcitation to the early site of atrial activation during tachycardia was important in establishing and defining the role of intraoperative electrophysiologic recordings in localizing the site of surgical exploration or accessory connetion ablation (Figure 25-2). In 1968, a report from Duke University described the successful surgical ablation of an accessory connection [4]; the localization of the accessory connection was determined from the ventricular epicardial excitation sequence (isochrone map).