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Background Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement. This study examined the outcomes of a technique for left ventricular outflow tract reconstruction using a polyester tube graft, followed by translocation of the aortic valve and coronary arteries. Methods A total of 23 patients with extensive annular erosion resulting from endocarditis or previous aortic valve replacement with or without pseudoaneurysm formation, or occurring after excision of the native valve, underwent suture of a polyester tube graft in the left ventricular outflow tract below the annulus, replacement of the aortic valve and proximal ascending aorta with a composite graft, and reimplantation of the coronary arteries with the use of interposition polyester grafts. The mean age of the patients was 50 years, and 57% were men. Results There were no hospital deaths. The mean duration of follow-up was 6.5 years and extended to 16 years. Actuarial survival at 1, 5, and 10 years was 86.7%, 82.2%, and 62.6%, respectively. Two patients required reoperation for a graft-graft pseudoaneurysm and for degeneration of a porcine bioprosthesis. Echocardiograms obtained at a mean of 75 months postoperatively in 15 of the 23 patients demonstrated normal left ventricular outflow tract dimensions and velocities and a mean effective valve orifice area of 1.07 cm2/m2. All coronary artery grafts were patent on angiography a mean of 40 months postoperatively in 13 patients. Conclusions Extended experience with this technique confirms its safety and effectiveness for patients with extensive destruction of the aortic annulus. It represents a suitable alternative to other currently used techniques.

Background: Brain hyperthermia, accompanying the rewarming phase of cardiopulmonary bypass (CPB), has been involved in the genesis of postoperative brain damage. Blood S100B levels are emerging as a marker of brain distress, and could offer a reliable monitoring tool at different times during and after open heart surgery. Methods: Thirty-two patients undergoing repair of congenital heart disease with CPB and deep hypothermic circulatory arrest (DHCA) were monitored by S100B blood levels and middle cerebral artery Doppler velocimetry pulsatility index (MCA PI) before, during, and after surgical procedure at five predetermined time-points. Results: Both S100B and MCA PI significantly increased, MCA PI values exhibiting a peak at the end of surgery time-point (p > 0.05), while S100B blood levels were increased at the end of CPB (p < 0.05). Multivariate analysis, with S100B levels measured at the end of CPB as dependent variable, showed a positive significant correlation with MCA PI (p # 0.04), with the CPB and the rewarming duration (p # 0.03 and p # 0.009, respectively). Conclusions: The present results show a significant correlation between a biochemical marker of brain damage and an index of increased cerebrovascular resistance, with higher levels during the rewarming CPB phase in pediatric open heart surgery.

BACKGROUND: The Ross operation has been applied to various aortic valve pathologies, particularly when somatic growth is an issue. However, associated cardiac disease and technical problems may limit its use with regard to associated procedures and issues of right ventricular outflow reconstruction. MATERIALS AND METHODS: From December 1992 to March 1998, 24 patients underwent aortic pulmonary autograft implantation. There were 14 males and 10 females, 15+/-10 years of age (mean +/- SD) (range 1 to 50 years), weighing 42.8+/-20 kg (mean +/- SD) (range 8 to 78 kg). Aortic insufficiency was present in 15 (62.5%) patients, stenosis in 8 (33.3%) patients, and valvar stenosis associated with left ventricular outflow tract obstruction in 1 (4.1%) patient. Etiology was rheumatic in 17 patients and congenital in 7. The Ross procedure was accompanied by a partial-Konno left ventricular outflow enlargement in one patient, and mitral valve annuloplasty, mitral commissurotomy, and tricuspid valve replacement in three other patients, respectively. The right ventricular outflow was reconstructed with a valved pulmonary homograft in 14 patients and with a Shelhigh No-React porcine pulmonary conduit in 10 patients. Evaluation was done by New York Heart Association (NYHA) Class and by echocardiography at a follow-up of 22.8+/-24 months (mean +/- SD) (range 3 to 63 months). RESULTS: There were no operative mortalities and no postoperative arrhythmias. One (4.1%) patient required intra-aortic balloon pump (IABP) support for 3 days, one (4.1%) patient died 2 years later of probable arrhythmia, and one (4.1%) patient required mechanical aortic valve replacement 2 years later for severe autograft insufficiency. Left ventricular ejection fraction was unchanged (preoperative 62.4%+/-30%, postoperative 64.2%+/-30% [mean +/- SD], [p = NS]) and no significant gradient was documented by echocardiographic Doppler in the right and left ventricular outflow tracts. The aortic insufficiency scale decreased from a mean of 3.9+/-0.2 to a mean of 1+/-0 (p < 0.01). NYHA Class decreased to I in all patients, from III (10) and II (14). CONCLUSIONS: The pulmonary autograft in the aortic position is suitable for aortic valve replacement in pediatric and adult patients with good medium-term results and in patients with rheumatic etiology, and it provides a desirable solution in the presence of associated pathologies, such as left ventricular tract obstruction or associated multivalvular disease. The development of new means of right ventricular outflow reconstruction must parallel the progress achieved for the left side.

Background We evaluated a one-stage technique for extensive replacement of the thoracic aorta in patients with chronic aortic dissection. Methods Fifty-one patients with chronic expanding thoracic aortic dissections (48 type A, 3 type B with proximal extension) were treated with a single procedure using a bilateral anterior thoracotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-six patients had previous operations: for acute type A aortic dissection (n = 36), aortic valve disease (n = 6), or coronary artery disease (n = 4). The ascending aorta and entire arch were replaced in all patients combined with varying lengths of the descending aorta. Results Hospital mortality was 3.9% (2 patients). Five patients (10%) required reoperation for bleeding. Two patients were discharged on ventilatory support and 2 on dialysis. No patient sustained a stroke, and paraplegia developed in one. The 5- and 7-year survival rates were 79% and 68%. Freedom from reoperation on the thoracic or abdominal aorta was 92% at 5 and 7 years postoperatively. Serial tomograms have documented substantial enlargement of the residual dissected aorta in only 2 patients (reoperated). Conclusions The technique is a safe and suitable alternative to the two-stage (elephant trunk technique) and hybrid procedures for treatment of chronic dissection with aneurysm of the thoracic aorta. It eliminates the risk of rupture in the interval between staged procedures and the risks associated with a second thoracic aortic procedure, and is associated with a low rate of reoperation on the remaining aorta.

Background Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality for the two procedures and death in the interval between, often from aortic rupture. We have used a one-stage approach for operative repair of most, or all, of the thoracic aorta. Methods Sixty-nine patients were treated using a bilateral anterior thoracotomy with transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the arch vessels first to minimize brain ischemia. Forty-two patients had chronic ascending aortic dissections (all but 1 had a previous operation), 24 had degenerative aneurysms, and 3 had chronic descending aortic dissections with proximal extension. The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta. Results In-hospital mortality was 7.2% (5 patients). Morbidity included reoperation for bleeding (13%), mechanical ventilation for more than 72 hours (50%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 9 late deaths unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta for false aneurysm in 1, endocarditis in 1, and progression of disease in 2. Survival at 5 years was 71%. Conclusions The one-stage arch-first technique is a safe and suitable alternative to the two-stage procedure for repair of extensive thoracic aortic disease.

UNLABELLED The aim of this investigation was to verify whether plasma S100B could be a useful tool in identifying which infants subjected to extracorporeal membrane oxygenation (ECMO) might develop intracranial haemorrhage (ICH). A case-control study of eight infants who developed ICH during ECMO was conducted. Plasma samples collected daily after ECMO insertion were assessed for S100B and compared with those obtained from eight infants supported by ECMO who did not develop ICH. Cerebral ultrasound and Doppler velocimetry waveform patterns in the middle cerebral artery (MCA PI) were also recorded at the same time as blood sampling. S100B blood concentrations were significantly higher in the group of infants with ICH 72 h before any signs of haemorrhage could be detected by ultrasound (ICH: 2.91 +/- 0.91 microg/L vs. control: 0.53 +/- 0.15 microg/L), reaching their peak at day 6, when cerebral ultrasound scan patterns were suggestive of intracranial haemorrhage (ICH: 3.50 +/- 1.03 microg/L vs. control: 0.66 +/- 0.27 microg/L) (p < 0.05, for both). The highest S100B levels were observed in the three ICH infants who expired during the ECMO procedure (3.43 microg/L, 4.0 microg/L, 4.12 microg/L, respectively). MCA PI values in the ICH group were also significantly higher, but only 24 h before any ultrasound pattern of bleeding was detected (ICH: 2.31 +/- 0.22 vs control: 1.81 +/- 0.24) (p < 0.05). CONCLUSION This study suggests that blood S100B measurement could be a promising tool for the identification of infants at risk of ICH when imaging assessment and clinical symptoms of haemorrhage might still be silent.

Progressive dilatation of the pulmonary autograft is the principal cause for reoperation following the Ross procedure when the root replacement technique is used. We examined the relation between enlargement of the pulmonary autograft and the development and progression of neo-aortic valve regurgitation, and the long-term clinical follow-up, including the need for reoperation, in patients followed for up to 13 years postoperatively.A Ross procedure was performed on 119 older children and young adults (mean age: 31 years old), using the root replacement technique, between June 1989 and January 2002. Serial echocardiography studies were obtained in 108 patients and analyzed blinded to clinical data. The following variables were measured: diameter of annulus, sinuses of Valsalva, and supravalvular ridge; presence and severity of aortic regurgitation; and valve thickening.The 30 day and late mortality rates were 1.7% and 1.7% (2 patients each). Forty-one patients were followed for more than 5 years, 19 for more than 7 years, and 9 for more than 10 years. There was one thrombotic and no endocarditis events. The 10-year actuarial survival was 96%. Reoperation on the pulmonary autograft or the pulmonary allograft was required in 12 patients. The principal indication for operation on the pulmonary autograft in 11 patients was neo-aortic valve regurgitation (7), aneurysm formation (3), and false aneurysm (1). At 10 years, actuarial freedom from reoperation on the pulmonary autograft was 75%. At last follow-up, 8 of 97 patients without reoperation on the autograft had moderate and none had severe regurgitation of the neo-aortic valve. Independent predictors of progression of neo-aortic valve regurgitation were time from operation, dilatation of the supravalvular ridge, and neo-aortic valve thickening (all p0.0002). Freedom from reoperation in the pulmonary allograft at 10 years was 86%.Long-term follow-up of patients with the Ross procedure using the root replacement technique indicates excellent survival and low thromboembolic and endocarditis risk. The main limitation is the need for reoperation. The prevalence of severe neo-aortic valve regurgitation is low, however there is a progressive increase in regurgitation and in aortic root diameters. Periodic follow-up with echocardiography is recommended because of the continuing risk of progressive regurgitation of the neo-aortic valve and aneurysm formation.

Background Total replacement of the aortic arch is commonly performed with either antegrade perfusion of the brachiocephalic arteries by means of direct cannulation or with an interval of hypothermic circulatory arrest of at least 30 to 40 minutes. We present a technique with a branched graft that uses antegrade brain perfusion without the need for direct cannulation of the brachiocephalic arteries or a separate perfusion circuit, with only a brief period of circulatory arrest of the brain. Methods Twelve patients underwent resection of the aortic arch through either a midline sternotomy (4 patients) or a bilateral anterior thoracotomy (8 patients). The right axillary artery was used for arterial return and for brain perfusion. After establishing hypothermic circulatory arrest, the brachiocephalic arteries were detached from the aorta, flushed, and occluded with clamps. Hypothermic perfusion of the brain was established through the right axillary artery, and the brachiocephalic arteries were sequentially attached to the limbs of a branched aortic graft. Flow to the brain was then established in the antegrade direction through the axillary artery. Results The mean duration of circulatory arrest of the brain at a mean nasopharyngeal temperature of 16°C was 8.8 minutes (range, 6-13 minutes). The subsequent period of hypothermic (20°C-22°C) brain perfusion, during which the 3 branches of the graft were attached to the brachiocephalic arteries, averaged 35 minutes (range, 23-44 minutes). All the patients survived the procedure and were discharged from the hospital. No patient sustained a permanent neurologic deficit. One patient had lethargy for 2 days, with full recovery. Nine of the 12 patients were extubated within 72 hours. Conclusions This technique obviates the need for direct cannulation of the brachiocephalic arteries and for a separate perfusion circuit and requires only a brief period of circulatory arrest of the brain.

Hypothermic cardiopulmonary bypass, usually in combination with an interval of circulatory arrest, was used for the treatment of 211 patients with extensive thoracic or thoracoabdominal aortic disease during a 17-year interval. Profound hypothermia, distal perfusion, and intravenous methylprednisolone and thiopental were used for neuroprotection. No other technique or other adjunctive agents were used. The 30-day mortality rate was 7.1% (15 patients). It was 40% (8 of 20) for patients undergoing emergent operations for aortic rupture or acute dissection and 3.7% (7 of 191) for all other patients (P0.001). Paraplegia occurred in 5 and paraparesis in 1 of the 205 operative survivors whose lower limb function could be assessed postoperatively (2.9%). Of the 121 survivors with thoracoabdominal aortic disease, paraplegia occurred in 1 of 38 patients with Crawford type I disease (2.6%), 2 of 49 with type II (4.1%), and 2 of 34 with type III (5.9%). Paralysis developed in 1 (1.7%) of the 58 patients who underwent aortic dissection. Renal dialysis was required in 6 (2.9%) of the 205 operative survivors, prolonged inotropic support (48 hours) in 23 (11%), reoperation for bleeding in 10 (5%), mechanical ventilation (48 hours) in 50 (24%), and tracheostomy in 21 (10%). Four (1.9%) patients sustained a stroke. Hypothermic cardiopulmonary bypass provides safe and substantial protection against paralysis, and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need for other adjuncts.

Oxygen free radical injury during reperfusion of ischemically stored heart transplants may further impair the ability of the transplanted heart to reuse substrate for recovery. We compared the effects of oxygen free radical scavengers, superoxide dismutase and catalase, either alone or combined with glucose-insulin-potassium, in an improved model of the heterotopically transplanted rat heart. Group 1 hearts (n = 8) received no preservation before transplantation and were transplanted immediately. Hearts in four other groups (n = 8 for each group) underwent cold storage (4° to 6° C) for 3½ hours before transplantation. Five minutes before reperfusion of the transplanted hearts, recipient rats received one of the following intravenous treatments: saline (group 2), glucose-insulin-potassium (group 3), superoxide dismutase/catalase (group 4), and superoxide dismutase/catalase plus glucose-insulin-potassium (group 5). Left ventricular end-diastolic pressure, rate of rise of left ventricular pressure, myocardial blood flow, coronary resistance, and tissue adenosine triphosphate content of the heart transplants were assessed during or at the end of 2 hours of reperfusion. Hearts treated with superoxide dismutase/catalase alone showed improvement of end-diastolic pressure and myocardial blood flow. The use of glucose-insulin-potassium alone did not facilitate the recovery of transplanted hearts. In contrast, the combined use of superoxide dismutase/catalase plus glucose-insulin-potassium resulted in a superior recovery of all functional and hemodynamic parameters. These results indicate that free radical scavengers in the presence of glucose-insulin-potassium significantly improve functional recovery in the setting of heart transplantation. (J T horac C ardiovasc S urg 1992;104:830-7)

This study was designed to evaluate the distribution of cardioplegic solution infused antegradely with simultaneous coronary sinus occlusion. After 1 hr LAD occlusion, sheep were placed on cardiopulmonary bypass. Hearts were arrested with 300 ml of cold cardioplegia and replenished with two additional doses. In group I (n = 10), antegrade cardioplegia (ACP) was given alone; in group II (n = 9), ACP was given in combination with simultaneous coronary sinus occlusion. Microspheres were infused into the cardioplegic line to determine the antegrade distribution of the solution, while a different microsphere was injected into the anterior interventricular vein to detect the venous backflow of the solution. The data showed that myocardium distal to LAD occlusion in group II received more antegrade (0.17 +/- 0.02 versus 0.06 +/- 0.02 ml/g/min, P less than 0.01, in subendocardium; and 0.15 +/- 0.03 versus 0.09 +/- 0.02 ml/g/min, P = NS, in subepicardium) and retrograde (2181 +/- 455 versus 0 counts/g/min, P less than 0.01, in subendocardium; and 2,146 +/- 527 versus 0 counts/g/min, P less than 0.01, in subepicardium) distribution of cardioplegic solution in comparison to group I. We therefore conclude that simultaneous coronary sinus occlusion significantly improves the distribution of antegrade cardioplegic solution to the regionally occluded myocardium by increasing collateral flow as well as venous backflow.

Rejection of the cardiac allograft is often associated with reversible myocardial failure, the mechanism of which is not understood. We have examined this phenomenon in a small animal model that provides the opportunity for multimodality study of the rejection process. Heterotopic cardiac transplantation was performed in the Lewis rat with Lewis X Brown-Norway (allografts) or Lewis (isografts) donors. Without immunosuppression, allografts are completely rejected in 6 to 8 days. At 3 days cardiac grafts were explanted and mounted on a modified Langendorff apparatus for functional measurements or submitted for pathologic examination and biochemical determination of high-energy phosphates. Three-day isografts (n = 9) had minimal histologic changes. Pathologic examination of 3-day allografts (n = 13) showed lymphocytic infiltrate and myocyte necrosis, histologic features for which antirejection treatment is usually given clinically. For grafts subjected to functional studies (n = 11), heart rate, cardiac output, coronary flow, and stroke work were determined at baseline and in response to isoproterenol (3 x 10(-8) mol/ml). Three-day allografts (n = 6) and isografts (n = 5) had similar baseline function. The chronotropic response to isoproterenol was similar in allografts and isografts, but allografts had diminished cardiac output and stroke work after isoproterenol. Adenosine triphosphate levels were normal (41.9 nmol/mg) in 3-day allografts (n = 4). We have evaluated functional, biochemical, and pathologic changes associated with myocardial dysfunction during heterotopic cardiac transplant rejection in a small animal. This model reproducibly demonstrates diminished contractile reserve in 3-day allografts with normal baseline function and high-energy stores but histologically significant rejection.

Background Staged procedures for extensive aneurysmal disease of the thoracic aorta are associated with a substantial cumulative mortality (>20%) that includes hospital mortality for the 2 procedures and death (often from aortic rupture) in the interval between the 2 procedures. We have used a single-stage technique for operative repair of most or all of the thoracic aorta. Methods Forty-six patients with extensive disease of the thoracic aorta were managed with a single-stage procedure by using a bilateral anterior thoracotomy and transverse sternotomy, hypothermic circulatory arrest, and reperfusion of the aortic arch vessels first to minimize brain ischemia. Thirty-one patients with chronic, expanding type A aortic dissections had previous operations for acute type A dissection (n = 22), aortic valve repair or replacement (n = 4), coronary artery bypass grafting (n = 4), or no previous operation (n = 1). The remaining 15 patients had degenerative aneurysms (n = 12) or chronic type B dissections with proximal extension (n = 3). The ascending aorta and aortic arch were replaced in all patients combined with resection of various lengths of descending aorta (proximal one third [n = 19], proximal two thirds to three quarters [n = 22], or all [n = 5]). Coronary artery bypass grafting, valve replacement, or both were performed concomitantly in 19 patients. Results Hospital mortality was 6.5% (3 patients). Morbidity included reoperation for bleeding (17%), mechanical ventilation for more than 72 hours (42%), temporary tracheostomy (13%), and temporary renal dialysis (9%). No patient sustained a stroke. There have been 5 late deaths (3, 18, 34, 51, and 79 months postoperatively) unrelated to the aortic disease. Four patients have undergone successful reoperation on the aorta (false aneurysm [n = 1], endocarditis [n = 1], and progression of disease [n = 2]). Five-year survival was 75%. Conclusion The single-stage, arch-first technique is a safe and suitable alternative to the 2-stage procedure for repair of extensive thoracic aortic disease.

Phentolamine administration during open-heart surgery shortens the cooling and rewarming phases of cardiopulmonary bypass (CPB) and hastens weaning from mechanical ventilation and extubation. Data on the effects of phentolamine on cerebral circulation and function in this setting are lacking. This study reports the cerebral effects of phentolamine using blood S100B protein levels and the middle cerebral artery pulsatility index (MCA PI).Sixty pediatric patients undergoing congenital heart disease repair were randomly assigned to receive either phentolamine 0.2 mg kg(-1) i.v. (n = 30) or placebo (n = 30) before the cooling and rewarming phases of CPB. Samples for S100B measurement were collected at seven predetermined time-points before, during and after surgery. MCA PI values were recorded at the same times as sampling.S100B blood levels were higher in the phentolamine-treated group than in controls after rewarming (3.53 +/- 1.88 vs 1.58 +/- 0.53 microg l(-1); p0.001), remained persistently higher at the end of surgery (2.95 +/- 0.91 vs 0.79 +/- 0.21 microg l(-1); p0.001) and returned to normal ranges 12 h later than in the placebo group (p0.05). MCA PI values were also significantly higher at the end of surgery in the phentolamine-treated group (1.83 +/- 0.50 vs 1.22 +/- 0.34; p0.01). Cooling and rewarming times were shorter in the phentolamine-treated group (p0.01, for all).Despite improved peripheral vasodilatation and perfusion, phentolamine administration in pediatric open-heart surgery is correlated with increased cerebrovascular resistance and brain damage.

Background: Hypotension refractory to maximal doses of alpha-adrenergic drugs after cardiac operations employing cardiopulmonary bypass (CPB) has been referred as “vasoplegic syndrome.” Vasopressin has been used for its therapy with encouraging results. Material and methods: 16 patients (mean age 71, range 47 to 84 years) were treated with intravenous vasopressin (0.1–1 IU/min) for hypotension refractory to maximal doses (>30 μg/kg/min) of norepinephrine after undergoing complex cardiac operations employing CPB. Preoperative ejection fraction was 40.5% (mean, range 20% to 60%), preoperative NYHA class was 3.5 (mean). Hemodynamic measurements were obtained one hour before and one hour after beginning vasopressin infusion; urine output was measured for the 4 hours before and the 4 hours after beginning the infusion. Duration of vasopressin treatment was 58.8 ± 37.3 hours (mean ± SD) . Results: Systolic blood pressure increased from 89.6 ± 7.9 to 119.6 ± 10.5 mmHg (mean ± SD) (p < 0.001) ; systemic vascular resistance increased from 688.0 ± 261.7 to 1043.3 ± 337.1 dyne/s/cm2 (mean ± SD) (p < 0.001) ; cardiac index decreased from 2.69 ± 0.8 to 2.2 ± 0.5 L/min/m2 (mean ± SD) (p < 0.008) ; urine output increased from 36.8 ± 30.4 to 72.8 ± 38.2 mL/h (mean ± SD) (p < 0.001) . Seven patients (44%) survived the hospital stay. Conclusions: High-dose vasopressin is effective in the treatment of the vasoplegic syndrome after cardiac operations employing cardiopulmonary bypass.(J Card Surg 2002;17:485-489)

Background Management of the enlarged, chronically dissected aorta after previous repair of acute ascending aortic dissection or after a previous cardiac operation may present a formidable technical challenge and the optimal method of management is not clearly established. Methods Twenty-one patients with chronic type A aortic dissection (mean age 57 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. Single-stage replacement with perfusion of the aortic arch first to minimize the duration of brain ischemia and a bilateral anterior thoracotomy (clamshell) incision were used. Fourteen patients had undergone previous repair of acute type A dissection. Seven patients had type A dissection after aortic valve replacement (3 patients) or coronary artery bypass (4 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a two-stage repair. The mean interval between the initial and reoperative procedures was 69 months (range, 5 to 249). Results There was 1 (4.8%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Ten patients required assisted ventilation for more than 48 hours. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. There has been 1 late death (mean follow-up 2 years). Conclusions The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.

Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch, the descending thoracic, and the thoracoabdominal aorta. The safety and efficacy of this technique when compared with other adjuncts (ie, simple aortic clamping, partial cardiopulmonary bypass, regional hypothermia) is not clearly established.One hundred and ninety-two patients (age range, 20 to 83 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest (mean, 38 minutes). The technique was used when the location and severity of disease precluded placement of clamps on the proximal aorta (31 patients) or (in 161 patients) when extensive thoracic (47) or thoracoabdominal (114) aortic disease was present, and the risk for development of spinal cord ischemic injury was judged to be increased. Lower intercostal and lumbar arteries were attached separately to the aortic graft in 101 of the 161 patients (63%) who had extensive aortic replacement. No other adjuncts for spinal cord protection were used.The 30-day mortality was 6.8% (13 patients). It was 40% (8 of 20) for patients having emergent operations (acute aortic dissection or rupture) and 2.9% (5 of 172) for all others (p0.001). The 90-day mortality was 12.5% (24 patients). Paraplegia occurred in 4 and paraparesis in 1 (full recovery) of the 186 operative survivors whose lower limb function could be assessed postoperatively (2.7%). Among the 109 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 36 with Crawford extent I, 0 of 42 with extent II, and 2 of 31 with extent III disease. One patient (extent II) developed paraplegia on the 9th postoperative day after a hypotensive episode. None of the 47 patients with aortic dissection developed paralysis. Among the 186 operative survivors, renal dialysis was required in 4 patients (2.2%), prolonged inotropic support in 18 (10%), reoperation for bleeding in 9 (5%), mechanical ventilation (or = 48 hours) in 64 (34%), and tracheostomy in 17 (9%). Four patients (2%) sustained a stroke.Hypothermic cardiopulmonary bypass with circulatory arrest provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.

Objective To establish whether S100B protein may be useful in the early detection of intraventricular hemorrhage in asphyxiated term infants. Design Case-control study. Patients Twenty full-term newborns with intraventricular hemorrhage, 20 asphyxiated infants without intraventricular hemorrhage, and 80 normal newborns. Interventions Routine laboratory variables and neurologic patterns were assessed at birth after 12 and 72 hrs. Ultrasound imaging and middle cerebral artery Doppler velocimetry pulsatility index were recorded at 12 and 72 hrs after birth. S100B protein blood concentrations were determined at 12 hrs. Measurements and main results S100B protein levels were significantly higher in samples collected from newborns who developed intraventricular hemorrhage (1.87 +/- 0.60 microg/L) than from those who did not develop intraventricular hemorrhage (0.72 +/- 0.39 microg/L) or from normal infants (0.66 +/- 0.31 microg/L). Multiple logistic regression analysis showed a significant correlation between circulating S100B protein concentrations and the occurrence of intraventricular hemorrhage. Conclusions This study suggests that elevated S100B protein represents a useful tool for the early detection of intraventricular hemorrhage in the postasphyxia period when clinical examination and cerebral ultrasound might still be silent.

Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch and the descending thoracic and thoracoabdominal aorta. Its safety and efficacy compared with other techniques (eg, simple aortic clamping, partial cardiopulmonary bypass, and regional hypothermia) are not clearly established.One hundred sixty-one patients (ranging from 20 to 83 years old) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass usually with intervals of circulatory arrest (mean interval, 38 minutes).The 30-day mortality rate was 6.2% (10 patients). It was 41% (7 of 17) for patients having emergent operations (rupture or acute dissection) and 2.1% (3 of 144) for all other patients (p0.001). The 90-day mortality rate was 11.8% (19 patients). Paraplegia occurred in 4 and paraparesis in 1 of the 156 operative survivors whose lower limb function could be assessed postoperatively (3.2%). Among the 91 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 33 patients with Crawford type I disease, 0 of 34 with type II disease, and 2 of 24 with type III disease. One patient (type II disease) had development of paraplegia on the tenth postoperative day. None of the 50 patients with aortic dissection experienced paralysis. Renal dialysis was required in 4 (2.5%) of the 157 operative survivors, prolonged inotropic support (48 hours) in 17 (11%), reoperation for bleeding in 8 (5%), mechanical ventilation (48 hours) in 31 (20%), and tracheostomy in 13 (8%). Three patients (1.9%) sustained a stroke.Hypothermic cardiopulmonary bypass provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.

Several late complications jeopardize the clinical performance of recipients of the Fontan operation. The underlying causes have been referred to disturbed flow dynamics in the cavopulmonary connections. Presumably, the large pressure drops occurring in the inferior and superior connections play a pivotal role in the pressure level of the entire circulation, especially in the venous. To address this issue, we retrospectively reviewed catheterization data of six patients with failing Fontan circulation and compared them with those of six patients with functioning Fontan circulation. The impact on the systemic and pulmonary pressure of the increase in the cavopulmonary connection resistances was studied through a steady-state mathematical model of the univentricular closed-loop circulation. In the patients with failing Fontan, pressure in the venae cavae was found to be significantly higher, especially at the inferior cava (19.3 +/- 2.2 versus 12.5 +/- 2.3 mmHg) with the pressure drop at the inferior cavopulmonary connection significantly increased (4.7 +/- 3.1 versus 0.33 +/- 0.82 mmHg). The proposed mathematical model permits us to clearly relate the pressure increase in the venae cavae to an increased resistance in the cavopulmonary connections. Therefore, the present analysis confirms that, to avoid possible congestion of venous circulation, the definitive palliation of univentricular heart should not cause pressure drops at the cavopulmonary connections.

UNLABELLED The aim of this investigation was to study whether kangaroo care could be helpful in full-term infants subjected to cardiac postoperative intensive care during the early post-extubation hours. Kangaroo care was performed at 2-h intervals in the first 12 h after extubation in 5 male infants and assessed by cardiorespiratory parameters. Results showed that, during kangaroo care, heart rate (123 +/- 4 vs 128 +/- 5 bpm), respiratory frequency (43 +/- 3 vs 51 +/- 5 breath pm), transcutaneous carbon dioxide (46 +/- 2 vs 50 +/- 4 mmHg) and central venous pressure (11 +/- 0.8 vs 12 +/- 1.2 mmHg) significantly decreased (p

A technique is presented for treatment of annular erosion using a polyester tube graft that is sutured to the left ventricular outflow tract below the area of erosion. The graft is then everted and sutured to a composite graft. Interposition polyester grafts from the coronary arteries are attached to the composite graft above the valve.

Primary thymomas arising in an intrapulmonary location without an associated mediastinal component are rare entities. The origin of thymomas in this unusual location remains unknown. Knowledge of the natural history and the prognosis of these tumors is also limited because of their rarity.

The need for reoperation remains a principal limitation of the Ross procedure and most commonly includes replacement of the neo-aortic valve. We describe the use of a valve-sparing procedure in a patient with progressive dilatation of the pulmonary autograft and the remaining native ascending aorta and mild regurgitation of the neo-aortic valve.

A 21-year-old white woman, born with a univentricular heart, had undergone staged procedures before Fontan correction. She then began to develop edema, protein-losing enteropathy, and ascites refractory to diuretic therapy. Cardiac angiography showed a patent right Blalock-Taussig shunt, with turbulent cavopulmonary circulation. After undergoing an unsuccessful attempt at coil embolization she then underwent shunt ligation, with resolution of symptoms and normalization of protein levels. This report draws attention to the importance of cavopulmonary laminar flow to prevent the development of protein-losing enteropathy.

Ann Thorac Surg 2002;74:1292 Nicholas T. Kouchoukos, Paolo Masetti and Chris K. Rokkas Single-stage replacement of the thoracic aorta http://ats.ctsnetjournals.org/cgi/content/full/74/4/1292 the World Wide Web at: The online version of this article, along with updated information and services, is located on

The purpose of this study is to investigate whether isolated hearts perfused with cardioplegic solution release inflammatory mediators such as neutrophil chemotactic factors (NCF). Three conditions were tested, including: (1) perfusion of rabbit hearts with crystalloid cardioplegic solution (4°C) saturated with air (95% oxygen) and containing dextrose (i.e. complete system), (2) perfusion of rabbit hearts with non-oxygenated cardioplegic solution, containing dextrose (i.e. minus oxygen system), and (3) perfusion of hearts with cold cardioplegic solution saturated with air in the absence of dextrose (i.e. minus dextrose system). At various time intervals (5 min, 1, 2, 3 and 4 h) samples of circulated perfusate were removed and assayed for the presence of NCF using modified Boyden chambers. Rabbit peritoneal neutrophils were the indicator cells. The standard chemoatractant, f-Met-Leu-Phe (f-MLP) was the positive control. High levels of neutrophil chemotactic activity were detected in perfusate of all above described hearts perfused for 4 h (i.e. 194 ± 22% of f-MLP control—complete system, 126 ± 13%—minus oxygen and 136 ± 10%-minus dextrose). Histological evaluation of these hearts showed evidence of global ischemia. We also detected significant levels of NCF in effluent of hearts perfused for 5 min, 1, 2 and 3 h. Similar to perfused hearts, isolated rabbit hearts incubated for 4 h with non-oxygenated cardioplegic solution (in presence and absence of dextrose) released high levels of NCF (132 ± 18%-intact heart; and 100 ± 6% myocardial segments). Standard checkerboard analysis revealed that the observed activity released from these hearts is chemotatic. Preliminary biochemical characterization of chemotactic factors generated from intact hearts showed that the activity is protease sensitive (76% inhibition—P

Objective We report our experience with a standard surgical technique for treatment of aneurysms associated with Kommerell diverticulum and aberrant subclavian artery. Methods During a 10-year interval, 10 patients with aneurysms of Kommerell diverticulum and aberrant subclavian artery (8 right, 2 left) underwent surgical repair. All 10 patients had aneurysmal degeneration of the adjacent descending thoracic aorta and 7 had aneurysms of the nonaberrant subclavian artery that required treatment. Four of the patients with large Kommerell aneurysms underwent preliminary carotid-to-aberrant subclavian artery bypass and ligation of the subclavian artery proximal to the origin of the vertebral artery. All patients had graft replacement of the subclavian artery and descending thoracic aneurysms through a left thoracotomy using hypothermic cardiopulmonary bypass and circulatory arrest. Continuity of the aberrant subclavian artery was preserved in the 6 patients without prior carotid-to-subclavian artery bypass. Results There were no in-hospital deaths. One patient required reoperation for bleeding, 1 patient developed recurrent laryngeal nerve injury, and 1 patient with delirium had evidence for infarction in the caudate nucleus but recovered completely. There were 4 late deaths from 1.5 to 44 months postoperatively. The remaining 6 patients are well from 8 to 131 months after operation. Conclusions Aneurysms of Kommerell diverticulum and coexisting aneurysms of the adjacent descending thoracic aorta and nonaberrant subclavian artery can be repaired safely with the technique we have utilized.