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Background Video-assisted thoracoscopic surgery (VATS) approaches are increasingly used in lung cancer surgery, but little is known about their impact on patients’ health-related quality of life (HRQL). This prospective study measured recovery and HRQL in the year after VATS for non-small cell lung cancer (NSCLC) and explored the feasibility of HRQL data collection in patients undergoing VATS or open lung resection. Patients and Methods Consecutive patients referred for surgical assessment (VATS or open surgery) for proven/suspected NSCLC completed HRQL and fatigue assessments before and 1, 3, 6 and 12 months post-surgery. Mean HRQL scores were calculated for patients who underwent VATS (segmental, wedge or lobectomy resection). Paired t-tests compared mean HRQL between baseline and expected worst (1 month), early (3 months) and longer-term (12 months) recovery time points. Results A total of 92 patients received VATS, and 18 open surgery. Questionnaire response rates were high (pre-surgery 96–100%; follow-up 67–85%). Pre-surgery, VATS patients reported mostly high (good) functional health scores [(European Organisation for Research and Treatment of Cancer) EORTC function scores > 80] and low (mild) symptom scores (EORTC symptom scores Conclusions Lung resection has a considerable detrimental impact on patients’ HRQL that is not fully resolved 12 months post-surgery, despite a VATS approach. Graphic Abstract

Aims Telepathology uses digitised image transfer to allow off-site reporting of histopathology slides. This technology could facilitate the centralisation of pathology services, which may improve their quality and cost-effectiveness. The benefits may be most apparent in frozen section reporting, in which turnaround times (TATs) are vital. We moved from on-site to off-site telepathology reporting of thoracic surgery frozen section specimens in 2016. The aim of this study was to compare TATs before and after this service change. Methods and results All thoracic frozen section specimens analysed 4 months prior and 4 months following the service change were included. Demographics, operation, sample type, time taken from theatre, time received by laboratory, time reported by laboratory, TAT, frozen section diagnosis, final histopathological diagnosis and final TNM staging were recorded. The results were analysed with spss statistical software version 24. In total, there were 65 samples from 59 patients; 34 before the change and 31 after the change. Specimens included 51 lung, six lymph node, three bronchial, three chest wall and two pleural biopsies. Before the change, the median TAT was 25 min [interquartile range (IQR) 20-33 min]. No diagnoses were deferred. No diagnoses were changed on subsequent paraffin analysis. After the change, with the use of digital pathology, the median TAT was 27.5 min (IQR 21.75-38.5 min). This difference was not significant (P = 0.581). Diagnosis was deferred in one case (3.23%). There was one (3.23%) mid-case technical failure resulting in the sample having to be transported by courier, resulting in a TAT of 106 min. No diagnoses were changed on subsequent paraffin analysis. Conclusions There was no significant difference in reporting times between digital technology and an on-site service, although one sample was affected by a technical failure requiring physical transportation of the specimen for analysis. Our study was underpowered to detect differences in accuracy.

The improvement of surgical outcomes has been achieved working under the assumption that they are mainly the result of technical skills. This model, although correct, is not exhaustive and has left out many variables that affect outcomes, of which a number can be grouped under the label of non-technical skills, which is a subset of human factors. Non-technical skills are developed to facilitate a shared mental model between team members, teams and their operational environment. They include situation awareness, decision-making, communication, teamwork, leadership and performance-shaping factors. The importance of these non-technical skills has been highlighted during the investigations of severe accidents in many high-risk industries and healthcare. There is an almost untapped opportunity to improve outcomes focusing on non-technical skills because until recently there has been an under-investment of time and resources in this area compared with technical skills. This theoretical paper supports the adoption of a broader model of human performance as a function of technical and non-technical skills and the cultural and organisational context where these are at play. We also aim to highlight a pathway to increase the investment in nontechnical skills following the most updated evidence.

Background People living with obesity have been among those most disproportionately impacted by the COVID-19 pandemic, highlighting the urgent need for increased provision of bariatric and metabolic surgery (BMS). Objectives To evaluate the possible clinical and economic benefits of BMS compared with nonsurgical treatment options in the UK, considering the broader impact that COVID-19 has on people living with obesity. Setting Single-payer healthcare system (National Health Service, England). Methods A Markov model compared lifetime costs and outcomes of BMS and conventional treatment among patients with body mass index (BMI) ≥ 40 kg/m2, BMI ≥ 35 kg/m2 with obesity-related co-morbidities (Group A), or BMI ≥ 35 kg/m2 with type 2 diabetes (T2D; Group B). Inputs were sourced from clinical audit data and literature sources; direct and indirect costs were considered. Model outputs included costs and quality-adjusted life years (QALYs). Scenario analyses whereby patients experienced COVID-19 infection, BMS was delayed by five years, and BMS patients underwent endoscopy were conducted. Results In both groups, BMS was dominant versus conventional treatment, at a willingness-to-pay threshold of £25,000/QALY. When COVID-19 infections were considered, BMS remained dominant and, across 1000 patients, prevented 117 deaths, 124 hospitalizations, and 161 intensive care unit admissions in Group A, and 64 deaths, 65 hospitalizations, and 90 intensive care unit admissions in Group B. Delaying BMS by 5 years resulted in higher costs and lower QALYs in both groups compared with not delaying treatment. Conclusion Increased provision of BMS would be expected to reduce COVID-19-related morbidity and mortality, as well as obesity-related co-morbidities, ultimately reducing the clinical and economic burden of obesity.

The surgical setting is a highly complex environment where, in ideal conditions, everything should be under control to ensure a positive outcome. However, the existing complexity opens the possibility for multiple failures along the process and many of those failures are related to what is call the non-technical skills of the members of the team. We cannot eradicate human error, but we can try to avoid future mistakes in our daily practice introducing the awareness for providing a high-quality care in which patient safety is crucial. This paper presents an easy approach to concepts and teaching possibilities of those non-technical skills.

IntroductionGabapentin is an antiepileptic drug currently licensed to treat epilepsy and neuropathic pain but has been used off-label to treat acute postoperative pain. The GAP study will compare the effectiveness, cost-effectiveness and safety of gabapentin as an adjunct to standard multimodal analgesia versus placebo for the management of pain after major surgery.Methods and analysisThe GAP study is a multicentre, double-blind, randomised controlled trial in patients aged 18 years and over, undergoing different types of major surgery (cardiac, thoracic or abdominal). Patients will be randomised in a 1:1 ratio to receive either gabapentin (600 mg just before surgery and 600 mg/day for 2 days after surgery) or placebo in addition to usual pain management for each type of surgery. Patients will be followed up daily until hospital discharge and then at 4 weeks and 4 months after surgery. The primary outcome is length of hospital stay following surgery. Secondary outcomes include pain, total opioid use, adverse health events, health related quality of life and costs.Ethics and disseminationThis study has been approved by the Research Ethics Committee . Findings will be shared with participating hospitals and disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and participant newsletters.Trial registration numberISRCTN63614165.

OBJECTIVES As the practice of video-assisted thoracoscopic surgery (VATS) lobectomy gains widespread acceptance, the complexity of procedures attempted increases and the stage of tumour that may be safely approached remains controversial. We examined the impact of nodal involvement with respect to perioperative outcomes after VATS lobectomy. METHODS All patients listed for VATS lobectomy for non-small-cell lung cancer at our institution from 2012 to 2016 were analysed. Bronchoplastic or chest wall resections and tumours over 7 cm were considered a contraindication to a thoracoscopic approach. RESULTS Of the 489 patients identified, 97 (19.8%) patients had pathological nodal involvement. The overall conversion rate was 6.1%, reoperation rate was 5.3% and readmission rate was 5.9%. Median hospital stay was 5 days, 30-day mortality was 0.6% and 90-day mortality was 1.6%. No significant difference was identified between the nodal-negative or -positive groups in terms of preoperative demographics, hospital stay, postoperative complications, conversion rate, reoperation rate or readmission rate. Univariate logistic regression identified gender, Thoracoscore, dyspnoea score, performance status, chronic obstructive pulmonary disease, previous stroke, preoperative lung function and non-adenocarcinoma as predictors of postoperative complications. A multivariate model including nodal status identified Thoracoscore (odds ratio 1.57, 95% confidence interval 1.16-2.18; P

Context As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. Objective To provide guidance on an optimised “train-the-trainer” (TTT) structured educational programme for surgical trainers, in which delegates learn a standardised approach to training candidates in skill acquisition. We aim to describe a TTT course for robotic surgery based on the current published literature and to define the key elements within a TTT course by seeking consensus from an expert committee formed of key opinion leaders in training. Evidence acquisition The project was carried out in phases: a systematic review of the current evidence was conducted, a face-to-face meeting was held in Philadelphia, and then an initial survey was created based on the current literature and expert opinion and sent to the committee. Thirty-two experts in training, including clinicians, academics, and industry, contributed to the Delphi process. The Delphi process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement. Evidence synthesis There was 100% consensus that there was a need for a standardized TTT course in robotic surgery. A consensus was reached in multiple areas, including the following: (1) definitions and terminologies, (2) qualifications to attend, (3) course objectives, (4) precourse considerations, (5) requirement of e-learning, (6) theory and course content, and (7) measurement of outcomes and performance level verification. The resulting formulated curriculum showed good internal consistency among experts, with a Cronbach alpha of 0.90. Conclusions Using the Delphi methodology, we achieved an international consensus among experts to develop and reach content validation for a standardised TTT curriculum for robotic surgery training. This defined content lays the foundation for developing a proficiency-based progression model for trainers in robotic surgery. This TTT curriculum will require further validation. Patient summary As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. There is currently a lack of high-level evidence on how best to train trainers in robot-assisted surgery. We report a consensus view on a standardised “train-the trainer” curriculum focused on robotic surgery. It was formulated by training experts from the USA and Europe, combining current evidence for training with experts’ knowledge of surgical training.

We describe a novel video-assisted thoracic surgery (VATS) anterior approach to lymph node station 7 after VATS left lower lobectomy.

This case report describes a 46-year-old patient with a very unusual pattern of isolated metastasis to an extralobar pulmonary sequestration following orchidectomy for seminoma. The patient underwent uncomplicated video-assisted thoracoscopic resection of the metastasis, involving the whole of the sequestration mass.

OBJECTIVES As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery. METHODS In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds. RESULTS Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners. CONCLUSIONS Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing.

Objectives Uniportal approaches to video-assisted thoracoscopic surgery (VATS) lobectomy have been described in significant series. Few comparison studies between the two techniques exist. The aim was to determine whether the uniportal technique had more favourable postoperative outcomes than the multiport technique. Methods All VATS lobectomies undertaken at a single university hospital during August 2012 to December 2013 were studied. Patients with preoperative opiate use or chronic pain were excluded. Patients were divided into those with uniportal and multiport approaches for analysis. All continuous data were assessed for normality, and analysed with the Mann-Whitney U-tests or t-tests as appropriate. Categorical data were analysed by Fisher's exact or χ(2) test for trend as appropriate. Results One hundred and twenty-nine VATS lobectomies were completed. Six were excluded and data were incomplete for 13, leaving 110 (15 uniportal, 95 multiport) for analysis. The demographics of the two groups were similar. There was no significant difference in the Thoracoscore or American Society of Anesthesiologists grades. The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group, P = 0.84. The median visual analogue pain score in the first 24 h was 0 in the uniportal group and 0 in the multiport group, P = 0.65. There was no difference in the duration of patient-controlled analgesia (P = 0.97), chest drain duration (P = 0.67) or hospital length of stay (P = 0.54). There was no inpatient mortality and no unplanned admission to critical care in either group. Conclusions Uniportal VATS lobectomy is safe, and there is no appreciable negative impact on the hospital stay or morbidity. Patient-reported pain and morphine use in the first 24 h was low with either technique. Larger prospective studies are needed to quantify any benefit to a particular approach for VATS lobectomy.

Objective Innate immune responses to pulmonary resection may be critical in the pathogenesis of important postoperative pulmonary complications and potentially longer-term survival. We sought to compare innate immunity of patients undergoing major pulmonary resection for bronchogenic carcinoma via video-assisted thoracoscopic surgery (VATS) and thoracotomy. Methods Bronchoalveolar lavage was conducted in the contralateral lung before staging bronchoscopy and mediastinoscopy and immediately after lung resection. Blood and exhaled nitric oxide were sampled preoperatively and at 6, 24, and 48 hours postoperatively. Results Forty patients were included (26 VATS and 14 thoracotomy). There was a lower systemic cytokine response from lung resection undertaken by VATS compared with thoracotomy [interleukin 6 (IL-6), analysis of variance (ANOVA) P = 0.026; IL-8, ANOVA P = 0.018; and IL-10, ANOVA P = 0.047]. The VATS patients had higher perioperative serum albumin levels (ANOVA P = 0.001). Lower levels of IL-10 were produced by lipopolysaccharide-stimulated blood monocytes from the VATS patients compared with the thoracotomy patients at 6 hours postoperatively (geometric mean ratio, 1.16; 95% confidence interval, 1.08–1.33; P = 0.011). No statistically significant differences in the neutrophil phagocytic capacity, overall leukocyte count, or differential leukocyte count were found between the surgical groups (ANOVA P > 0.05). No statistically significant differences in bronchoalveolar lavage fluid parameters were found. Exhaled nitric oxide levels fell postoperatively, which reached statistical significance at 48 hours (geometric mean ratio, 1.2; 95% confidence interval, 1.02–1.46; P = 0.029). There were no significant differences found between the surgical groups (ANOVA P = 0.331). Conclusions Overall, a trend toward greater proinflammatory and anti-inflammatory responses is seen with lung resection performed via thoracotomy compared with VATS.

Objectives We evaluated whether single-port video-assisted thoracic surgery is feasible without compromising outcomes, and whether the technique could be reproduced by a trainee. Methods In a 6-month period, 37 operations were performed by single-port video-assisted thoracic surgery. Of the 37 patients, 27 (73%) were male and the mean age was 45.1 ± 21 years. Twenty-three (62%) were operated on by consultants and 14 (38%) by trainees. The procedures included 19 (51.3%) operations for treatment of pneumothoraces, 8 (21.6%) metastasectomies, 7 (18.9%) lung biopsies, 2 (5.4%) empyema débridements, and 1 (2.7%) pleuropericardial window. Results Mean operative time was 51.8 ± 14.7 min. Patient-controlled analgesia infusion was used for 1.3 ± 1 days. Three (8.1%) patients needed an operative reintervention, but there was no intensive treatment unit admission or hospital mortality. Mean postoperative hospital stay was 3.3 ± 2.7 days. On follow-up, all patients had a tissue diagnosis and all lung nodules were R0 resections. Patients operated on by consultants and trainees had similar preoperative profiles and postoperative outcomes, except that those operated on by trainees used patient-controlled analgesia significantly longer (1.8 ± 1.48 vs. 1 ± 0.48 days; p = 0.03). Conclusion Single-port video-assisted thoracic surgery can be performed and reproduced well without compromising outcomes. It is considered aesthetically better and may reduce analgesic requirements, but it might not reduce hospital stay.

Precision medicine, according to the Precision Medicine Initiative, is an emerging medical approach for disease treatment and prevention that takes into account individual variability in genes, environment and lifestyle for each person. This approach is rapidly evolving especially in the field of medical oncology where it has significantly transform cancer care. The ultimate aim of tailoring therapeutic strategies is to maximize the benefit an individual patient harnesses from the specific treatment, while at the same time decreasing the impact of adverse side effects associated with it. Medical oncology is currently leading the way with the ability to identify the specific genetic mutation and allocate the treatment that is most likely benefitting the patients. In thoracic surgery, there is still a gap between our evidence-based guidelines that offer recommendations for groups of patients and the ideal individual approach recommended by the precision medicine. This paper aims to identify areas where it is possible to apply precision medicine to the prevention of postoperative complications after thoracic surgery.

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) lobectomy is associated with improved short-term outcomes compared with thoracotomy. Definition of the hilar structures is crucial to safe VATS lobectomy. Several VATS approaches have been described. We report the effect of three surgeons in our institution undertaking standardized anterior approach (SAA) training on the proportion of isolated lobectomies subsequently completed by VATS. Predictors of successful VATS lobectomy were analysed. METHODS Three consultant surgeons undertook SAA training at two different time points. Two were performing VATS lobectomy prior to SAA training. Training involved a 2-day visit to an established SAA unit. Lobectomies performed by these surgeons between April 2011 and December 2012 (20 months), before and after training, were recorded prospectively. Bilobectomies, sleeve resections, pneumonectomies and chest wall resections were excluded. VATS lobectomy proportions before and after training were compared. Independent predictors of completion by VATS rather than thoracotomy were identified by multivariable logistic regression. RESULTS One hundred and sixty-three isolated lobectomies were performed, 97 of these by VATS (59.5%). The mean age was 68.8 (± 10.5) years. Pathology was lung cancer in 137 (84.0%), other primary malignancy in 10 (6.1%), pulmonary metastases in 8 (4.9%) and benign in 8 (4.9%). The VATS lobectomy rate rose from 22.2% before SAA training to 77.3% after, P < 0.001. The effect was significant for both existing and adopting VATS lobectomy surgeons, P = 0.002 to

Although video-assisted thoracoscopic (VATS) lobectomy offers advantages with regard to pain, respiratory function and mobility, concern is often expressed concerning the cost of stapling devices and increased operative time. We have therefore compared the costs of VATS and open lobectomy in order to assess the overall economic sustainability of a VATS programme.Between January 2004 and December 2006 346 patients underwent pulmonary lobectomy mainly for stage I or II lung cancer (93 VATS lobectomy, 253 thoracotomy). In the VATS group 47% of patients had an upper lobectomy versus 52% in the open group (p=ns). Direct medical costs (disposables, theatre time, high dependency unit stay, hospital stay) were determined and stratified by lobectomy type.Mean theatre cost for a VATS lobectomy was 2533+/-230 euro versus 1280+/-54 euro for a thoracotomy lobectomy (p=0.00001). Mean high dependency unit (HDU) cost was 1713+/-236 euro and 2571+/-80 euro for a VATS and a thoracotomy lobectomy, respectively (p=0.00001). Mean cost of hospital stay for a VATS lobectomy was 3776+/-281 euro versus 4325+/-154 euro for an open one (p=0.00001). The overall cost for a VATS lobectomy was 8023+/-565 euro which was less than an open lobectomy 8178+/-167 euro (p=0.0002). VATS bilobectomy was slightly more expensive than an open one: 8702+/-350 euro versus 8655+/-466 euro but this difference (47 euro) was not significant (p=ns).VATS lobectomy is less expensive than conventional lobectomy. Increased theatre costs (disposables and time) are counteracted by shorter hospital stay. Importantly, the reduced HDU and ward bed stays free resources for other patients.

Background The Ross operation is an alternative to mechanical aortic valve replacement in the young. However, early and late complications after operation have been reported. In order to assess the role of the Ross operation in children and young adults, a 10-year clinical experience was reviewed. Methods Ninety male and 22 female patients, aged 29 ± 10 years (range, 6–49) underwent cross-sectional clinic and echocardiographic examination. Indication for Ross operation was aortic regurgitation in 79 patients, stenosis in 11, and mixed lesion in 22; 82 (73%) had a bicuspid valve. Endpoints of the study were survival and freedom from autograft dilatation, from autograft and homograft dysfunction, and from reoperation. Results There was 1 (1%) hospital and 1 late (1%) death, during an average follow-up of 5.1 ± 1.9 years (range, 0.1–10.6). At 10 years, survival was 98 ± 2%. Late autograft dilatation was identified in 32 (29%) patients and regurgitation in 15 (14%), 7 of whom had autograft dilatation. Ten-year freedom from autograft dilatation was 43 ± 8% and from regurgitation was 75 ± 8%. Multivariate analysis showed younger age ( p = 0.05), preoperative aortic root dilatation ( p = 0.02), root replacement technique ( p = 0.03), and absence of pericardial strip buttressing ( p = 0.04) to be predictive of autograft dilatation. Eleven (10%) patients required reoperation on the autograft (8 prosthetic valve replacement, 3 autograft root repair). Ten-year freedom from reoperation was 72 ± 10% and from replacement of the autograft was 88 ± 5%. Pulmonary homograft obstruction was identified in 6 (5%) patients, requiring homograft replacement in 1. All but 2 (2%) patients were in New York Heart Association class I, with a return to regular school grade or active employment. Conclusions Late outcome for the Ross procedure is excellent in terms of survival and quality of life. Late root dilatation, autograft regurgitation, and homograft stenosis, however, show increasing prevalence with time. Technical modifications of the procedure, yearly aortic root imaging, and early reintervention on the dilated neoaortic root may further enhance the durability of the autologous pulmonary valve.

Objective: To analyze the results of extensive reconstruction of the left anterior descending coronary artery (LAD) by an autologous vein patch, with or without endarterectomy (EA), associated with left internal mammary artery grafting onto the patch. Methods: Between January 1994 and April 2001, among 5871 myocardial revascularizations, 83 patients (1.4%), 77 male (93%), with a mean age ^ SD of 64 ^ 8 years (range 44–84) underwent the above mentioned procedure. Seventy-three of them (88%) were in Canadian Cardiovascular Society (CCS) Class III or IV, and 78 (94%) had a three-vessel disease. Mean preoperative ejection fraction was 58 ^ 12%. Risk factors included hypertension (63%), family history (51%), hyperlipidemia (41%), smoking (38%), diabetes (19%). Mean number of anastomoses/ patient was 3 ^ 0.6. Mean length of vein patch was 2.8 ^ 0.9 cm (range 2–6 cm). A total of 16% of the patients underwent associated LADEA (mean cardiopulmonary bypass time: 132 ^ 21 min; mean aortic crossclamp time: 81 ^ 15 min). Results: There was one hospital death (recurrent MI, 1.2%). Seven patients (8%) had a perioperative myocardial infarction, in three cases in the region supplied by the LAD (none after associated LAD-EA). Mean follow-up period was 47 ^ 20 months (range 5–90) and is 99% complete. There were five late cardiac deaths (6%). A total of 74% survivors have no symptoms, 12% are in CCS Class I–II, and 14% in III–IV. Actuarial freedom from recurrent angina at 3 and 5 years is 77 and 69%, respectively. Follow-up angiograms (49 patients, 60%) revealed a full patent LAD graft in 82% of the cases (GI), versus poor run-off/occluded graft in the remaining 18% (GII). Anginal status was significantly worse in GII patients (P , 0:05). Conclusions: Extended reconstruction of the LAD coronary artery increases surgical risk. The procedure however enhances the probability for a complete revascularization in patients with an unfavourable anatomical substrate, with acceptable mid-term results. q 2002 Elsevier Science B.V. All rights reserved.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) for thymoma has uncertain safety and effectiveness in comparison with transsternal resection. This feasibility study compared short- and mid-term outcomes for patients undergoing these two procedures, highlights weaknesses in current research and makes recommendations for long-term technological evaluations in this field. METHODS: Consecutive thymoma cases between 2004 and 2010 were identified. Patients were divided into two groups according to surgical approach (Group I trans-sternal; Group II VATS) and comparisons were made between groups. The primary outcome was overall survival. Secondary outcomes included operative morbidity and mortality, hospital stay, recurrence rate and disease-free survival. RESULTS: Thirty-nine patients were included (Group I: n=22 vs Group II: n=17). There were no differences between groups at baseline for all measured covariates. No deaths occurred within 30 days of surgery. More patients in Group I developed complications (Group I: n=10 vs Group II: n=3;P=0.093), while hospital stay was shorter in Group II (Group I: 6.4±4.6 days vs Group II: 4.4±1.8 days; P=0.030). Five-year overall survival (Group I: 93.8±6.1% vs Group II: 83.3±11.2%; P=0.425), 5-year disease-free survival (Group I: 71.0±15.3% vs Group II: 83.3±11.2%; P=0.827) and recurrence rates at final follow-up (Group I: n=2 vs Group II: n=1;P=0.363) were similar between the groups. CONCLUSION: VATS thymectomy for thymoma is feasible, safe and has comparable mid-term oncological outcomes to trans-sternal thymectomy. Future research is required to evaluate long-term oncological outcomes of VATS thymectomy for thymoma in national registries and randomized, controlled trials.

Background . To define the long-term results of 331 standard Hancock porcine bioprostheses implanted in the mitral position between 1973 and 1980. Methods . Of 331 patients (225 male patients, 68%), mean age 49 ± 10 years (range 14 to 69 years), 88% were in New York Heart Association functional class III or IV and 77% were in atrial fibrillation. Follow-up time extended more than 20 years (mean 13.9 years, range 0.3 to 24.7 years) for a total of 4,601 patient-years. Results . Overall operative mortality was 6.3%. At 5, 10, 15, and 20 years, the actuarial survival rate of patients were 71% ± 2%, 46% ± 3%, 30% ± 3%, and 22% ± 2%, respectively. Actuarial estimates of freedom from structural valve deterioration were 95% ± 1%, 67% ± 3%, 32% ± 3%, and 14% ± 3%; from reoperation were 96% ± 1%, 72% ± 3%, 36% ± 4%, and 18% ± 4%; from thromboembolism were 89% ± 2%, 82% ± 3%, 74% ± 4%, and 51% ± 2%; and from anticoagulant-related hemorrhage were 98% ± 1%, 96% ± 1%, 91% ± 1%, and 86% ± 4%. Estimates of freedom from all valve-related mortality at 5, 10, 15, and 20 years were 89% ± 2%, 76% ± 3%, 64% ± 4%, and 48% ± 4%. Multivariate analysis showed younger age to be a significant risk factor for reoperation. Age at operation did not correlate with structural valve deterioration. Conclusions . The long-term results with the standard Hancock bioprosthesis implanted in the mitral position appear satisfactory, particularly up to 15 years from implantation. Protection from stroke, anticoagulant hemorrhage, and endocarditis was good.

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) lobectomy has been gradually accepted as an alternative surgical approach to open thoracotomy for selected patients with non-small-cell lung cancer (NSCLC) over the past 20 years. The aim of this project was to standardize the perioperative management of VATS lobectomy patients through expert consensus and to provide insightful guidance to clinical practice. METHODS: A panel of 55 experts on VATS lobectomy was identified by the Scientific Secretariat and the International Scientific Committee of the ‘20th Anniversary of VATS Lobectomy Conference—The Consensus Meeting’. The Delphi methodology consisting of two rounds of voting was implemented to facilitate the development of consensus. Results from the second-round voting formed the basis of the current Consensus Statement. Consensus was defined ap riorias more than 50% agreement among the panel of experts. Clinical practice was deemed ‘recommended’ if 50–74% of the experts reached agreement and ‘highly recommended’ if 75% or more of the experts reached agreement. RESULTS: Fifty VATS lobectomy experts (91%) from 16 countries completed both rounds of standardized questionnaires. No statistically significant differences in the responses between the two rounds of questioning were identified. Consensus was reached on 21 controversial points, outlining the current accepted definition of VATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSION: The present Consensus Statement represents a collective agreement among 50 international experts to establish a standardized practice of VATS lobectomy for the thoracic surgical community after 20 years of clinical experience.

It is beyond the scope of this article to review the advantages of VATS lobectomy, but the data in support of this technique are increasing progressively. There is excellent evidence to support the oncologic equivalence and safety profile as compared with open thoracotomy, and data that demonstrate the reduced pain associated with VATS resection. Also, reduction in immune disturbance provides a tantalizing glimpse of one additional potential modality of benefit for less traumatic surgery. Unfortunately, in the economic world, equivalence, preferably with less cost, is the test applied. Whatever the societal benefit of improved quality of life following surgery, this has no cost benefit attached. From the foregoing discussion one can conclude that VATS lobectomy is no more costly than open resection and does generate additional hospital beds. The authors remain uncertain as to the preferred form of VATS lobectomy but it seems that the reduced trauma of the endoscopic procedure is associated with more benefit in terms of shorter hospitalization albeit at the cost of some increase in operating time. VATS techniques and lobectomy sit comfortably within the structure of any thoracic unit requiring little adjustment to established process. It is likely that ultimately 30% or thereabouts of major pulmonary resection will be undertaken using this technique and that VATS interventions will aid patient assessment regardless of stage or ultimate intended therapy. Competency and responsible use remain paramount considerations.

Background Lobectomy for lung cancer by video-assisted thorascopic surgery (VATS) remains an infrequently performed operation despite numerous publications showing the benefits of successful VATS compared with an open thoracotomy approach. However, concern remains regarding patient safety, notably the need for emergency intraoperative conversion to open thoracotomy leading to potential adverse consequences. We therefore compared the outcomes of converted VATS patients with open thoracotomy controls. Methods Between May 1992 and April 2006, 30 of 286 VATS lobectomies for lung cancer required intraoperative conversion to open thoracotomy. Four patients were of advanced stage and excluded from the study. The remaining patients were matched 2:1 with open thoracotomy controls by age, sex, cancer stage, year, and type of operation. Postoperative complications and pathology were determined from the hospital discharge summary and pathology report. Long-term survival information was obtained from the family doctor or central registry. Results There were no statistically significant differences in postoperative complications between the two groups (p = 0.093). There were no in-hospital deaths in the converted VATS group. Kaplan-Meier survival analysis for cancer-related or unassociated death demonstrated no statistically significant difference (log-rank p = 0.1627). Conclusions Conversion during attempted VATS resection does not prejudice short-term or long-term surgical outcomes. We therefore suggest that VATS lobectomy should be the treatment strategy of choice for stage I and II non-small cell lung cancer in view of the well-established short-term benefits and equivalent survival associated with successful VATS resection.

Background This retrospective analysis assessed the hypothesis that clinical status on admission more than other variables related to surgical or post-operative management may influence in-hospital mortality after surgical treatment of acute type A aortic dissection. Methods Between January 1979 and April 2004, 311 patients, mean age of 59.5±13 years (range, 18 to 88 years), with acute type A aortic dissection were referred for surgery. Logistic regression analysis was applied to demographics, etiological, clinical, and surgical variables, to identify independent predictors of in hospital death. Results In hospital mortality rate was 23%. Univariate analysis showed older age ( p =0.03, OR1.02/yrs), cardiac tamponade ( p =0.001; OR 2.43), hypotension ( p =0.0001; OR 8), myocardial ischemia ( p =0.005; OR 7), acute renal failure ( p =0.0001; OR 4.16), limb ischemia ( p =0.0002; OR 3.3), neurological deficits pre-op ( p =0.0001; OR 8.5), and mesenteric ischemia ( p =0.003) as independent predictors of in-hospital death. Multivariate analysis identified the following presenting variables as predictors of in-hospital death: hypotension ( p =0.003; OR 7.4), myocardial ischemia ( p =0.03; OR 5.8), mesenteric ischemia ( p =0.009), acute renal failure ( p =0.0001; OR 3.9), neurological deficits ( p =0.0001; OR 7.7). In-hospital mortality for the group of patients presenting with at least one of the tested pre-operative complications ( N =158; 51%) was 33% vs 12% ( p =00001). No other variables emerged as significant for in-hospital death. Conclusion In an era of standardized surgical technique, expeditious referral and intervention by lowering preoperative dissection-related complications and co-morbidities might represent the most efficacious tool to improve results.

Objective: Controversy still exists about averting expenditure of health care resources on the growing elderly population. This study evaluates clinical outcome of patients aged 75 years and older operated upon for acute type A aortic dissection. Methods: Between January 1990 and April 2004, of 247 patients undergoing emergency operation for acute type A aortic dissection at our Institution, 40 patients (16%) were aged 75 years and older (mean 78 3 years, range 75—88 years) and represent the study population. On admission, 9 (22.5%) had cardiogenic shock/ hypotension, 20 (50%) cardiac tamponade, 14 (35%) kidney failure, 11 (27.5%) limb ischemia, 3 (7.5%) neurologic deficit, and 1 (2.5%) myocardial ischemia. Surgical procedures included isolated replacement of the ascending aorta in 34 patients (85%), associated with total root replacement in 5 (12.5%), and with aortic valve replacement in 1 (2.5%). Eleven patients (27.5%) underwent aortic arch replacement (hemiarch: n = 8, 20%; total arch: n = 3, 7.5%). Results: In-hospital mortality was 30% (12 patients). Mortality tended to be higher (8/21, 38% vs 4/19, 21%; p = NS) for patients presenting with any one of thefollowing complications: tamponade,shock, brainand/ormyocardial,renal,limbmalperfusion. Actuarial survival at 1, 5, and 7 years was 93 5%, 80 8%, and 80 8%, respectively, and freedom from reoperation 97 2%, 97 2%, and 97 2%, respectively.Actuarialevent-freerateswere94 3%,90 5%,and90 5%.Seventy-fourpercentofsurvivorsareinNYHAFCI, andqualityoflife test (RAND SF-36) revealed a generalized perception of independency and well-being, comparable to an age-matched population. Conclusions: Overall results for emergency repair of acute type A aortic dissection in the elderly justify intervention, particularly in uncomplicated cases. Expeditious referral and intervention by lowering pre-operative dissection-related complications and comorbidities might help to improve results. Survivors show functional status and quality of life similar to contemporary individuals. # 2005 Elsevier B.V. All rights reserved.

In order to compare the long-term outcome of stented vs stentless aortic xenografts, a non-randomized, concurrent case-match trial was conducted on all consecutive patients operated between January 1992 and April 2000.Two hundred and ninety-two patients had stented (group 1) and 376 stentless (group 2) xenograft aortic valve replacement (AVR). Group 1 patients were older (75.0 +/- 4.1 vs 70.4 +/- 6.7 years, p = 0.01), while male gender and aortic stenosis were equally prevalent. NYHA functional class III-IV (85 vs 78%, p = 0.03) and associated procedures (53 vs 41%, p = 0.01) were more common in group 1. The aortic cross-clamping (79.7 +/- 27.8 vs 96.1 +/- 23.3, p = 0.001) and bypass (91.4 +/- 57.5 vs 128.5 +/- 34.0, p = 0.002) times were shorter in group 1. A case-match analysis identified 113 identical patient pairs, on the basis of age, gender, diagnosis, NYHA class, associated cardiac disease, and valve size.The early mortality was higher in group 1 (5.3 vs 2.7%, p = 0.3), though not significantly. During follow-up (37 +/- 30 vs 43 +/- 35 months, p = 0.6), 26 late deaths were recorded (10.3 vs 13.6%, p = 0.4). The 8-year survival was comparable (76 +/- 7 vs 75 +/- 5%, p = 0.2), but freedom from cardiac (77 +/- 7 vs 90 +/- 4%, p = 0.02) and from valve-related death (78 +/- 7 vs 91 +/- 4%, p = 0.02) was higher in group 2. Freedom from structural deterioration (99 +/- 1 vs 98 +/- 2%, p = 0.7) and from reoperation (99 +/- 1 vs 95 +/- 3%, p = 0.2) at 8 years was similar. The late functional status was equally satisfactory (NYHA class I-II 92.7 vs 94.7%, p = 0.06).The survival free from cardiac and valve-related mortality when stentless xenografts for AVR are used is superior to that achieved with stented grafts. Stentless AVR has the potential of conferring selective survival advantages late after operation.

Neonatal fungal valve endocarditis is an uncommon and highly lethal disease. The ideal management strategy is still controversial. Current options include antifungal chemotherapy and surgical intervention, the latter being often limited by risks inherent with valve operations in low body weight infants. We present a case of a premature infant with mutliple Candida tricuspid valve mycetomas. Eradication of infection was achieved by combined liposomal amphotericin therapy and complex tricuspid valve repair. Indications, technical aspects, and outcome of treatment in infants are reviewed.

Inhaled nitric oxide (iNO) is proposed in the management of pulmonary hypertension (PH) in patients undergoing cardiac surgery. Secondary PH related to a long-standing heart valve disease however may be refractory to iNO. Aim of this prospective study was to determine whether the combination of iNO plus dipyridamole (DP), a cyclic guanosine monophosphate-specific phosphodiesterase inhibitor (PDE5), may enhance and/or prolong the response to iNO in adult patients with secondary valve-related PH undergoing cardiac surgery, and attenuate rebound events related to its discontinuation.Responses in 27 patients, 11 male, mean age 72+/-11 years, with PH due to mitral and/or aortic valve disease, were studied in the Intensive Care Unit after cardiac surgery, during sedation and stable hemodynamic conditions. The effect of isolated iNO administration (40 ppm), iNO combined with DP (0.2 mg/kg i.v.), and DP alone (1 mg/kg/24 h) on pulmonary vascular resistance, mean pulmonary artery pressure, cardiac index, mixed venous O2Sat%, and mean arterial pressure were determined.All patients showed at least a 10% decrease in pulmonary vascular resistance vs. baseline after administration of iNO [responders]. Inhaled NO and the combination of iNO/DP produced a reduction of pulmonary vascular resistance and mean pulmonary artery pressure (p0.05). Cardiac index improved with a significant difference between iNO and the association iNO/DP versus baseline (p0.05). This significant hemodynamic improvement versus baseline was maintained during isolated DP administration (p0.05), but not during isolated iNO discontinuation. Mixed venous oxygen saturation showed an overall improvement of 17% (p0.05).Inhaled NO and DP infusion might represent a valuable association in the management of PH secondary to a heart valve disease in patients undergoing cardiac surgery. Their beneficial hemodynamic effects might be particularly valuable in the management of patients with associated right ventricular dysfunction.

Background— The Ross operation is an alternative to mechanical aortic valve replacement in the young. Early dilatation of the pulmonary autograft root exposed to the systemic circulation has been reported. To define the prevalence of, risk factors for, and consequences of late autograft dilatation, outcome in all consecutive patients operated since May 1994 was reviewed. Methods and Results— Ninety one patients, 77 males and 14 females, with at least 1 year of follow-up underwent cross-sectional clinical and echocardiographic examination. Age at operation was 27±10 years (range 6 to 49), and the indication was aortic regurgitation in 54 (59%) patients and bicuspid valve was present in 62 (68%). End-points of the study were freedom from autograft dilatation (root diameter >4 cm or 0.21 cm/m 2 ), from (moderate) autograft regurgitation and from reoperation. Follow-up (4.0±1.9, range 1 to 8 years) autograft root diameters were anulus, 29±4 mm (18–39); sinus of Valsalva, 38±7 mm (24–53); sinotubular junction, 37±6 mm (23–54); and ascending aorta, 37±5 mm (27–54). Late autograft dilatation was identified in 31 (34%) patients and regurgitation in 13 (14%), 7 of whom had autograft dilatation. At 7 years, freedom from dilatation was 42±8%, freedom from regurgitation was 75±8%, and freedom from reoperation was 85±10%. Cox proportional hazard analysis identified younger age ( P =0.05), preoperative sinus of Valsalva ( P =0.02), root replacement technique ( P =0.03), and absence of pericardial buttressing ( P =0.04) as predictive of autograft dilatation, whereas female sex ( P =0.002), follow-up sinus of Valsalva ( P =0.003), and sinotubular junction diameter ( P =0.02) as predictive of autograft regurgitation. Conclusions— Autograft dilatation is common late after the Ross procedure, particularly in younger patients, in those with preoperative aortic aneurysm, and those having root replacement without support of anulus and sinotubular junction. Bicuspid aortic valve is not a risk factor. Significant autograft valve dysfunction affects a minority of patients, but it is more prevalent in those with autograft dilatation.

The study aim was to evaluate our clinical experience with the CarboMedics heart valve prosthesis.Between October 1991 and December 2000, 942 consecutive patients (514 males, 428 females; mean age 58+/-11 years; range: 6-78 years) underwent mechanical valve implantation with the CarboMedics prosthesis. Preoperatively, 47% of patients were in NYHA class III and 22% in class IV; in addition, 134 patients (14.2%) had undergone a previous cardiac operation. Aortic valve replacement (AVR) was performed in 469 patients (49.8%), mitral valve replacement (MVR) in 330 (35.0%), double valve replacement (DVR) in 142 (15.1%), and isolated tricuspid valve replacement (TVR) in one patient. Eighty-eight patients (9.3%) underwent associated myocardial revascularization. Mean cardiopulmonary bypass and aortic cross-clamp times for the entire group were 107+/-39 min and 74+/-24 min, respectively.Overall early mortality was 2.3% (6/469 AVR, 1.2%; 12/330 MVR, 3.6%; 4/142 DVR, 2.8%). Late mortality was 3.1% (n = 29; including 17 cardiac deaths (10 were valve-related). Mean follow up was 66+/-31 months (range: 1-109 months), and was 98% complete yielding a total follow up of 4959 years. Actuarial survival at five years for the entire group was 89.3+/-1.6% (AVR 91.1%, MVR 86.4%, DVR 90.5%). Thromboembolism occurred in 26 patients (2.8%, 0.52%/pt-year) and major hemorrhagic events in 20 (2.1%, 0.4%/pt-year). Nine patients (0.9%) required a reoperation, in three cases (0.3%) after Staphylococcus epidermidis-mediated endocarditis. No structural deterioration occurred. Among 891 survivors, 94% of the patients are currently in NYHA classes I or II (p0.05).This study confirmed the safety and reliability of the CarboMedics mechanical valve prosthesis, even in old age groups. This bileaflet prosthesis showed no structural deterioration, and a low incidence of overall complications.

Background To define the impact of stentless versus stented valve design on survival late after xenograft aortic valve replacement, a retrospective analysis of all consecutive patients operated on between January 1992 and April 2000 was undertaken. Methods Two hundred ninety-two patients had stented (group 1) and 376 stentless (group 2) xenograft aortic valve replacements. Age was older in group 1 (75 ± 4 vs 70 ± 7 years, p = 0.01), whereas male gender and aortic stenosis were equally prevalent. Advanced New York Heart Association class III-IV (85% vs 78%, p = 0.03) and associated procedures (53% vs 41%, p = 0.01) were more common in group 1. Aortic cross-clamp (80 ± 28 vs 96 ± 23 minutes, p = 0.01) and bypass (91 ± 56 vs 129 ± 34 minutes, p = 0.01) times were shorter in group 1. Logistic regression and Cox proportional hazard methods were used to define the role of demographic and operative variables on hospital and late survival, freedom from valve-related mortality, and reintervention. Results Early mortality was higher in group 1 (6.2% vs 2.6%, p = 0.02). Smaller aortic anulus ( p = 0.008), aortic cross-clamp ( p = 0.03), and coronary disease requiring bypass ( p = 0.03) were associated with hospital mortality. During follow-up (37 ± 30 vs 43 ± 35 months, p = NS), 66 late deaths were recorded (12% vs 9%, p = NS). At 8 years, survival (70 ± 5% vs 81 ± 3%, p = 0.01), freedom from cardiac- (85 ± 1% vs 92 ± 3%, p = 0.02), and valve-related death (79 ± 5% vs 95 ± 2%, p = 0.004) were higher in group 2. Freedom from structural deterioration was similar (92 ± 5% vs 93 ± 3%, p = NS), but freedom from reoperation was lower in group 2 (99 ± 1% vs 90 ± 4%, p = 0.009). Multivariate analysis showed female gender ( p = 0.02), age ( p = 0.03), and smaller valve size ( p = 0.05) to be associated with late mortality; age ( p = 0.06) and diagnosis of aortic stenosis ( p = 0.008) with cardiac mortality; longer intensive care unit stay ( p = 0.001) and stented xenografts ( p = 0.05) with valve-related mortality; and younger age ( p = 0.01) and stentless xenograft ( p = 0.05) with reoperation. Conclusions Use of stentless xenografts correlates with better survival and freedom from cardiac- and valve-related mortality than stented valves. However, bias favoring stented valves in older and sicker patients exists. Selective survival advantage of stentless xenograft is confined to valve-related mortality. Stentless valves are more likely to be replaced for dysfunction.

Objective: Bicuspid aortic valve disease has been associated with histologic abnormalities of the aortic root. Recent reports have suggested similar alterations may exist in the pulmonary artery of patients with bicuspid aortic valve. The present study was undertaken to define the histologic condition of the aortic and pulmonary artery root in bicuspid aortic valve disease and the relationship with pulmonary autograft root dilatation after the Ross procedure. Methods: In 17 patients undergoing aortic root replacement with the pulmonary autograft, biopsy specimens of the aortic root and pulmonary artery trunk were collected. Clinical and histologic findings of patients with bicuspid aortic valves were compared with those with tricuspid aortic valves. Results: There were 9 patients (8 male, 1 female) with bicuspid aortic valve (group 1) and 8 (all male) with tricuspid aortic valve (group 2). Mean age was comparable (24.4 ± 9.8 vs 23.6 ± 10.8 years, P =.9). Aortic insufficiency as an indication for operation was more common in group 1 (9/9 vs 5/8, P =.007), whereas preoperative aortic root dilatation was equally prevalent (4/9 vs 1/8, P =.1). Prior aortic valve repair had been performed in 2 patients (1/9 vs 1/8, P =.9). Prevalence of cystic medionecrosis of the aortic wall was similar in the 2 groups (4/9 vs 3/8, P =.6). Cystic medionecrosis of the pulmonary artery trunk was found only in 1 patient with tricuspid aortic valve (0/9 vs 1/8, P =.3). During a mean follow-up of 26.5 ± 12.2 months (32.1 ± 12.7 vs 20.1 ± 7.4 months, P =.04), prevalence of pulmonary autograft root dilatation (greater than 4.0 cm) was equally represented in patients with native bicuspid or tricuspid aortic valve (3/9 vs 2/8, P =.6). Conclusions: Histologic abnormalities of the pulmonary artery root are rare and equally prevalent in young patients with bicuspid and tricuspid aortic valves. On the contrary, root dilatation is relatively common late after autograft root replacement but appears unrelated to bicuspid aortic valve disease or to pre-existing degenerative changes of the pulmonary artery root. J Thorac Cardiovasc Surg 2001;122:74-9

Aortic root remodeling (ARR) has recently been proposed for patients with aortic aneurysms and valve insufficiency (AI). To define factors associated with a favorable functional outcome, a review of the mid-term results with ARR was undertaken.Between March 1994 and October 1997, 17 consecutive patients (11 men, 6 women), aged 57 +/- 11 years (range 35-71), had elective ARR for aortic aneurysm with or without annuloaortic ectasia (13), sinus of Valsalva aneurysm (3), or chronic aortic dissection (1). Moderate or severe AI was present in 11 patients (65%). Preoperative aortic root diameter was 58 +/- 5 mm (range 51-70). ARR involved replacement of all three aortic sinuses and coronary button reimplantation, using grafts with a mean diameter of 28 +/- 2 mm (range 24-30).There was one early death (6%) due to multiple organ failure. Survivors were followed for 16 +/- 12 months (range 1-44). Actuarial 3-year survival was 94% +/- 6%. Discharge echocardiogram showed a decrease in AI in all patients: AI was absent in 11 (69%) and mild in 5 (31%). Recurrence of moderate or severe AI after a mean of 16 +/- 9 months (range 9-28) was noted in 6 patients (37%), 3 of whom had no AI at discharge. Five of 6 patients required aortic valve replacement. Comparison of demographic and operative variables showed that severe preoperative AI (67% vs 20%, p = 0.06), annuloaortic ectasia (100% vs 20%, p = 0.002), and cystic medial necrosis (100% vs 20%, p = 0.002) were significantly more prevalent in patients developing severe AI at follow-up. The 10 patients (63%) with absent AI showed durable competence of the valve and relief from symptoms at follow-up.Despite early restoration of valve competence, AI may recur and progress after ARR at medium-term follow-up in a proportion of patients. The severity of preoperative AI and the nature of aortic root disease may negatively influence the durability of repair. Continued observation of results with ARR appears mandatory to identify the appropriate surgical candidates.

Background . Aortic root replacement (ARR) is a technically demanding procedure that can be performed using a variety of prosthetic devices. Root replacement in the young, but grown-up, patient poses unique problems in terms of the long-term outcome and active lifestyle that must be guaranteed by this operation. To identify the "ideal" substitute for ARR in the young, clinical results in teenagers and young adults ( Methods . Thirty-eight patients younger than 35 years underwent ARR between January 1980 and December 1996. Eighteen patients, aged 30 ± 5 years, had ARR with composite graft (group 1), whereas 20 patients, aged 28 ± 6 years, had ARR with aortic homografts or pulmonary autografts (group 2). Primary indication for the operation was aortic insufficiency with anuloaortic ectasia (12 of 18) in group 1 and aortic insufficiency with or without anuloaortic ectasia (16 of 20) in group 2. Urgent ARR was required in 3 (17%) group 1 patients and 1 (5%) group 2 patient ( p = 0.01). Results . Operative deaths were 2 (11%) in group 1, caused by hemorrhage and low output, and none in group 2. There were 4 (25%) late deaths in group 1, caused by embolism (2), hemorrhage, and myocardial infarction, and 1 (5%) in group 2, caused by arrhythmia. Survival was 81% ± 9%, and 55% ± 18% at 2 and 10 years in group 1 versus 94% ± 5% at 2 years in group 2 ( p = 0.04). Freedom from valve-related events was 93% ± 6% and 62% ± 18% at 2 and 10 years in group 1 versus 100% at 2 years in group 2 ( p = 0.02). Freedom from reoperation in group 1 was 75% ± 22% at 10 years, whereas no reoperations were done in group 2. Seven (58%) group 1 patients versus 1 (5%) group 2 patient were on cardiac medications ( p = 0.001), and 11 (92%) group 1 patients versus no group 2 patients were on warfarin therapy at follow-up. All survivors were back to school or prior employment. Conclusions . Survival early after ARR does not differ depending on the type of prosthesis. Valve-related events are common, and reoperation may be needed late after ARR with composite grafts. Despite limited follow-up with biologic devices, the prevalence of complications with composite grafts makes homograft or autograft ARR preferable in adolescents and young adults.

Background . Aortic root replacement remains a challenging surgical procedure. A variety of techniques and prosthetic devices have thus far been used. In order to assess the performance of the Carboseal (Sultzer Carbomedics, Inc, Austin TX) composite graft, review of the experience with composite root replacement was undertaken. Methods . Between January 1979 and December 1998, 273 patients underwent composite aortic root replacement. One-hundred-six received the Carboseal composite prosthesis (group 1) and 84 other types of composite grafts (group 2). Demographic and operative variables were similar in the 2 patient groups, except for an older mean age in group 1 (58 ± 12 versus 50 ± 12 years, p = 0.001). Results . Operative mortality was lower in group 1 patients (3 of 106, 3% versus 10 of 84, 12%, p = 0.04). Follow-up of survivors was longer in group 2 due to more recent adoption of the Carboseal grafts (93 ± 57 versus 36 ± 23 months, p = 0.01). Late mortality was higher in group 2 (3 of 103, 3% versus 13 of 74, 18%, p = 0.04), with higher prevalence of prosthetic-related complications (2 of 103, 2% versus 12 of 74, 15%, p = 0.002). Reoperation was more prevalent in group 2 (1 of 103, 1% versus 5 of 74, 8%, p = 0.04), and limited to patients having root replacement using the inclusion technique. Functional status of survivors was comparable in the 2 groups (83 of 103, 80% versus 45 of 74, 61% of patients in New York Heart Association class I, p = 0.1). Conclusions . Aortic root replacement using the Carboseal composite graft offers excellent long-term results, with negligible prevalence of prosthetic-related complications. Superior performance compared to other available composite grafts in the present series may be influenced by more recent adoption of the Carboseal conduit and concomitant uniform adoption of coronary button technique.