Leiomyosarcoma of the thoracic aorta in a patient with hypertrophic cardiomyopathy.

We report a case of leiomyosarcoma of the thoracic aorta in a 49-year-old male patient with history of hypertrophic cardiomyopathy. The only presenting symptom was back pain localized under the left scapula with the frequency and severity of the pain increasing with time. Imaging studies detected the presence of an aortic tumor. The tumor was excised en bloc, and an interposition graft was implanted. The histology showed a fully excised grade 3 leiomyosarcoma. This article discusses features of this rare condition.

Dexamethasone arterializes venous endothelial cells by inducing mitogen-activated protein kinase phosphatase-1: a novel antiinflammatory treatment for vein grafts?

BACKGROUND: Vein grafting in coronary artery surgery is complicated by a high restenosis rate resulting from the development of vascular inflammation, intimal hyperplasia, and accelerated atherosclerosis. In contrast, arterial grafts are relatively resistant to these processes. Vascular inflammation is regulated by signaling intermediaries, including p38 mitogen-activated protein (MAP) kinase, that trigger endothelial cell (EC) expression of chemokines (eg, interleukin-8, monocyte chemotactic protein-1) and other proinflammatory molecules. Here, we have tested the hypothesis that p38 MAP kinase activation in response to arterial shear stress (flow) may occur more readily in venous ECs, leading to greater proinflammatory activation. METHODS AND RESULTS: Comparative reverse-transcriptase polymerase chain reaction and Western blotting revealed that arterial shear stress induced p38-dependent expression of monocyte chemotactic protein-1 and interleukin-8 in porcine jugular vein ECs. In contrast, porcine aortic ECs were protected from shear stress-induced expression of p38-dependent chemokines as a result of rapid induction of MAP kinase phosphatase-1. However, we observed with both cultured porcine jugular vein ECs and perfused veins that venous ECs can be protected by brief treatment with dexamethasone, which induced MAP kinase phosphatase-1 to suppress proinflammatory activation. CONCLUSIONS: Arterial but not venous ECs are protected from proinflammatory activation in response to short-term exposure to high shear stress by the induction of MAP kinase phosphatase-1. Dexamethasone pretreatment arterializes venous ECs by inducing MAP kinase phosphatase-1 and may protect veins from inflammation.

How to manage the left subclavian artery during endovascular stenting for thoracic aortic dissection? An assessment of the evidence.

BACKGROUND: Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue. METHODS: Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, χ(2) tests, and Fisher's exact testing were used for group comparisons. RESULTS: As compared with other outcomes, LSA coverage without revascularization in the presence of aortic dissection is much more likely to be complicated by left arm ischemia (prevalence increased from 0.0% to 4.0% [p = 0.021]), stroke (prevalence increased from 1.4% to 9.0% [p = 0.009]), and endoleak (prevalence increased from 4.0% to 29.3% [p = 0.001]). However, revascularization was not shown to reverse these effects. Longer aortic coverage (≥ 150 mm) was associated with an increased prevalence of spinal cord ischemia (from 1.3% to 12.5% [p = 0.011]) and mortality (from 1.3% to 15.6% [p = 0.003]). CONCLUSION: In patients undergoing endovascular stenting for thoracic aortic dissection, in cases where LSA coverage is necessary, revascularization should be considered before the procedure to avoid complications such as left arm ischemia, stroke, and endoleak, and where feasible, an appropriate preoperative assessment should be carried out.

Evaluation and optimization of fMRI single-subject processing pipelines with NPAIRS and second-level CVA.

In functional magnetic resonance imaging (fMRI) analysis, although the univariate general linear model (GLM) is currently the dominant approach to brain activation detection, there is growing interest in multivariate approaches such as principal component analysis, canonical variate analysis (CVA), independent component analysis and cluster analysis, which have the potential to reveal neural networks and functional connectivity in the brain. To understand the effect of processing options on performance of multivariate model-based fMRI processing pipelines with real fMRI data, we investigated the impact of commonly used fMRI preprocessing steps and optimized the associated multivariate CVA-based, single-subject processing pipelines with the NPAIRS (nonparametric prediction, activation, influence and reproducibility resampling) performance metrics [prediction accuracy and statistical parametric image (SPI) reproducibility] on the Fiswidgets platform. We also compared the single-subject SPIs of univariate GLM with multivariate CVA-based processing pipelines from SPM, FSL.FEAT, NPAIRS.GLM and NPAIRS.CVA software packages (or modules) using a novel second-level CVA. We found that for the block-design data, (a) slice timing correction and global intensity normalization have little consistent impact on the fMRI processing pipeline, but spatial smoothing, temporal detrending or high-pass filtering, and motion correction significantly improved pipeline performance across all subjects; (b) the combined optimization of spatial smoothing, temporal detrending and CVA model parameters on average improved between-subject reproducibility; and (c) the most important pipeline choices include univariate or multivariate statistical models and spatial smoothing. This study suggests that considering options other than simply using GLM with a fixed spatial filter may be of critical importance in determining activation patterns in BOLD fMRI studies.

End-stage vascular access: direct intra-atrial insertion of a dialysis catheter.

Central venous occlusions are a frequent problem in hemodialysis patients. We describe the case of a patient with end-stage vascular access in whom we successfully inserted a direct intra-atrial dialysis line during coronary artery bypass grafting. This technique could be a significant contribution to patients in whom alternative vascular access options are exhausted.

Mini Bypass and Proinflammatory Leukocyte Activation: A Randomized Controlled Trial.

BACKGROUND: Coronary artery bypass grafting (CABG) with conventional cardiopulmonary bypass (CPB) induces systemic inflammation. Miniaturized CPB may attenuate systemic inflammatory activation. The intracellular signaling pathways promoting inflammation in cardiac operations and the relative effects of CPB on these processes are uncertain. In this study, induction of reactive oxygen species (ROS) and activation of nuclear factor (NF)-κB, p38 mitogen-activated protein kinase (MAPK) within leukocytes, and leukocyte accumulation in cantharidin-induced blisters was compared in patients exposed to miniaturized CPB (mCPB) and those who underwent conventional CPB (cCPB). METHODS: Patients undergoing CABG were randomized to receive either cCPB (n = 13) or mCPB (n = 13). Blood samples were collected preoperatively and 5 times after initiating CPB (up to 5 hours) and analyzed by flow cytometry for intracellular markers of activation (ROS, p38-MAPK, and NF-κB phosphorylation). RESULTS: ROS in lymphocytes were elevated in cCPB compared with mCPB (p < 0.01), whereas ROS in granulocytes and monocytes were similar between groups. After initiation of CPB, p38-MAPK was higher in patients receiving cCPB compared with those receiving mCPB (p < 0.05). NF-κB phosphorylation in leukocyte subsets was similar in patients exposed to cCPB and those exposed to mCPB. Leukocyte accumulation in cantharidin-induced blisters, white cell counts, and serum C-reactive protein (CRP) was enhanced in response to cardiac operations, but no differences were observed between mCPB and cCPB groups. Postoperative serum creatinine levels were reduced in the mCPB group compared with the cCPB group (p < 0.05). CONCLUSIONS: Both p38-MAPK activation and ROS were attenuated with the use of mCPB compared with cCPB, providing a potential mechanism for reduced inflammation in association with CPB miniaturization.

NR2 antibody is associated with quality of life in aortic valve replacement.

BACKGROUND: The relationship between the potential brain injury biomarker N-methyl-D-aspartate receptor antibody and quality of life has never been assessed. METHODS: We measured serum N-methyl-D-aspartate receptor antibody levels preoperatively in patients undergoing aortic valve replacement. Quality of life was scored using the Short Form-36 and European Quality of Life 5-Dimensions questionnaires pre- and postoperatively. We analyzed the antibody levels as a continuous variable and as a dichotomous variable with 1.8 ng mL(-1) as the cutoff. RESULTS: Fifty-two patients (15 females) with a mean age of 71 ± 8.4 years were recruited for this study. Forty-eight (92%) patients attended the follow-up visit (405 ± 161 days). No mortality or severe neurological event was recorded. In both quality-of-life instruments, the low antibody level group (n = 35) had significantly better scores than the high antibody level group (n = 17) preoperatively. Postoperatively, the scores for both groups improved; however, the low antibody level group continued to score significantly better in most of the physical and mental health domains (p = 0.04 to <0.001). Multiple regression analyses revealed that antibody level and the 1.8 ng mL(-1) cutoff were independently related to quality of life (pre- and postoperatively). CONCLUSIONS: Higher N-methyl-D-aspartate receptor antibody levels in aortic valve replacement patients are independently related to poorer quality of life pre- and postoperatively.

Monocyte Fc gamma receptor expression in patients undergoing coronary artery bypass grafting.

BACKGROUND: Cardiopulmonary bypass is associated with an inflammatory response with potential deleterious effects. The white cell subpopulation mostly investigated so far is the neutrophil. To date very little has been investigated regarding the role of the monocyte/macrophage. This study focuses on the expression of Fc gamma receptors I, II, and III by monocytes in patients undergoing cardiopulmonary bypass. METHODS: We studied the surface expression of Fc gamma receptors I, II, and III by flow cytometry on gated monocyte subpopulations in the whole blood of adult patients undergoing elective coronary artery bypass grafting. Blood samples were drawn preoperatively and at 15 minutes, 1, 2, 4, 24, 48, and 72 hours, and 6 days postoperatively. A second group of patients undergoing lung resection surgery were studied in a similar fashion. RESULTS: Neither Fc receptor I nor receptor II expression were significantly changed throughout the time points studied. Fc receptor III expression was reduced at 2 and 4 hours (p = 0.016 and 0.002) and increased at 24, 48, and 72 hours after commencement of CPB on a selected subpopulation (15%-35%) of monocytes (p = 0.004, < 0.001, and < 0.001, respectively). This expression returned to preoperative levels by the sixth postoperative day. There were no statistically significant changes in the lung resection group. CONCLUSIONS: Our study demonstrated that cardiopulmonary bypass is associated with a biphasic Fc gamma receptor III expression on a subpopulation of peripheral blood monocytes up to 3 days postoperatively.

Aortic Stiffness Is Related to the Ischemic Brain Injury Biomarker N-Methyl-D-aspartate Receptor Antibody Levels in Aortic Valve Replacement.

Background. Aortic stiffness changes the flow pattern of circulating blood causing microvascular damage to different end-organ tissues, such as brain cells. The relationship between aortic stiffness measured by pulse wave velocity (PWV) and serum ischemic brain injury biomarker N-methyl-D-aspartate receptor antibody (NR2Ab) levels in aortic valve replacement has not been assessed. Methods. Patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS) had their PWV and NR2Ab serum levels measured preoperatively. We analyzed PWV and NR2Ab in two ways: (1) as continuous variables using the actual value and (2) as dichotomous variables (PWV-norm and PWV-high groups) and (NR2Ab-low and NR2Ab-high groups). Results. Fifty-six patients (71 ± 8.4 years) were included in this study. The NR2Ab level (ng/mL) was significantly higher in the PWV-high group (n = 21) than in PWV-norm group (n = 35; median 1.8 ± 1.2 versus 1.2 ± 0.7, resp., P = 0.003). NR2Ab level was positively associated with PWV and negatively associated with male gender. Multiple regression revealed PWV independently related to NR2Ab level, and PWV cut-off was associated with a 7.23 times increase in the likelihood of having high NR2Ab (>1.8 ng/mL). Conclusion. Higher PWV in patients with surgical aortic stenosis is associated with higher levels of the ischemic brain biomarker NR2Ab.

Can lungs be taken for transplantation from donors with a significant smoking history?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Can lungs be taken for transplantation from donors with a significant smoking history?'. Five papers were found using the reported search that represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These studies compared the outcome and survival between patients who receive lungs from smokers with those receiving non-smoker lungs. None of these studies were randomized controlled trials. They retrospectively analysed a cohort of patients undergoing lung transplantation for the past 10 years. These studies showed worse outcomes in the early postoperative period, such as longer intensive care unit stay, longer ventilation time and higher early postoperative mortality, with lungs harvested from smokers. Two studies also demonstrated a worse long-term outcome in recipients of lungs from smokers, whereas the other two showed worse results during the early postoperative period only. These latter two studies reported similar survival rates after 3 months and up to 3 years in recipients receiving smoker vs non-smoker lungs. One study, however, showed a better 5-year survival with smoker lungs compared with non-smokers, although in this study, lungs from heavy smokers showed the worse outcome. Despite the difference in long-term results and outcome reported by these authors, all of these studies unanimously indicate that lungs from smokers should not be rejected, as survival in these patients receiving smoker lungs is still significantly higher in 3 and 5 years compared with that in those who remain on the transplant waiting list. In conclusion, the current evidence in the literature suggests that lungs from smokers can be used for transplantation. Patients should, however, be fully informed of the risks involved with these lungs and the worse outcome compared with those receiving non-smoker lungs.

Are frozen sections of mediastinoscopy samples as effective as formal paraffin assessment of mediastinoscopy samples for a decision on a combined mediastinoscopy plus lobectomy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Are frozen sections of mediastinoscopy samples as effective as formal paraffin assessment of mediastinoscopy samples for a decision on a same-day lobectomy?'. Five papers were found using the reported search that represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These studies compared the efficacy and accuracy of frozen sections (FSs) from mediastinal lymph nodes for staging of patients with lung cancer to determine whether a combined procedure can be planned based on these results and to proceed to thoracotomy and lung resection in cases of negative mediastinal nodes diagnosed by FS. These studies unanimously showed that FS of mediastinal nodes are as accurate as permanent section results and definite histology diagnosis with a sensitivity of >94% and specificity of 100% with no false-positive results. They also confirmed that even in benign lung conditions and other malignancies of the mediastinum, the results of FS are compared with the histology of the node. Based on the current reports, a combined procedure (staging mediastinal nodes by FS and planning for thoracotomy or abandoning thoracotomy) is a safe approach to treat non-small-cell lung cancer (NSCLC). From the patients' point of view, this approach is superior to the staged procedure (mediastinoscopy followed by lung resection at a later date based on the histology of mediastinal nodes) due to single hospitalization and anaesthesia, however whether it is cost effective or not is debatable. It is also labour-intensive and operator-dependent. In conclusion, the current evidence in the literature suggests that a combined procedure of mediastinal node FS followed by lung resection can be a safe alternative to a staged approach to this disease.

Contained rupture of the sinus of valsalva associated with infective endocarditis and untreated congenital ventricular septal defect.

Isolated sinus of Valsalva (SV) aneurysm is a rare condition that may arise in patients with congenital ventricular septal defects (VSD). Small VSDs are often left untreated because of high rate of spontaneous closure. However, complications such as aortic regurgitation and infective endocarditis may occur as complications of small VSDs. We present the case of a 19-year-old man with a history of VSD, who presented with Staphylococcus aureus endocarditis and a contained rupture of the SV into the right ventricle, which was successfully treated. In the light of this case, we believe that even small VSDs should be assessed regularly and treated before such drastic complications occur.

Feasibility and safety of minimized cardiopulmonary bypass in major aortic surgery.

OBJECTIVES: Conventional cardiopulmonary bypass causes haemodilution and is a trigger of systemic inflammatory reactions, coagulopathy and organ failure. Miniaturized cardiopulmonary bypass has been proposed as a way to reduce these deleterious effects of conventional cardiopulmonary bypass and to promote a more physiological state. The use of miniaturized cardiopulmonary bypass has been reported in low-risk patients undergoing valve and coronary artery bypass graft (CABG) surgery. However, little is known about its application in major aortic surgery. METHODS: From February 2007 to September 2010, 49 patients underwent major aortic surgery using the Hammersmith miniaturized cardiopulmonary bypass (ECCO, Sorin). Data were extracted from medical records to characterize preoperative comorbidities (EuroSCORE), perioperative complications and the use of blood products. The same data were collected and described for 328 consecutive patients having similar surgery with conventional cardiopulmonary bypass at the Bristol Heart Institute, our twinned centre, during the same period. RESULTS: The miniaturized cardiopulmonary bypass group had a median EuroSCORE of 8 [inter-quartile range (IQR): 5-11], 13% had preoperative renal dysfunction and 20% of operations were classified as emergency or salvage. Thirty-day mortalities were 6.4; and 69, 67 and 74% had ≥ 1 unit of red cells, fresh frozen plasma (FFP) and platelets transfused, respectively. Eight percent of patients experienced a renal complication, and 8% a neurological complication. The conventional cardiopulmonary bypass group was similar, with a EuroSCORE of 8 (IQR: 6-10); 30-day mortalities were 9.4; and 68, 62 and 74% had ≥ 1 unit of red cells, FFP and platelets transfused, respectively. The proportions experiencing renal and neurological complications were 14 and 5%. CONCLUSIONS: Our experience suggests that miniaturized cardiopulmonary bypass is safe and feasible for use in major aortic cardiac surgery. A randomized trial is needed to evaluate miniaturized cardiopulmonary bypass formally.

Does surgical debulking for advanced stages of thymoma improve survival?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Does surgical debulking for advanced stages of thymoma improve survival?' Altogether, only 17 papers were found using the reported search, of which only 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated; these studies have mainly reported the survival and recurrence rates after total vs subtotal resection of thymic tumours in patients receiving or not receiving adjuvant chemoradiotherapy. These studies confirmed that complete resection is the best prognostic factor in thymomas. With regard to subtotal tumour resection/debulking, we did not find any randomized controlled trials. The evidence on this topic is scarce and these 10 reported were retrospective reviews of the operative, histology and survival data of patients with thymoma who had subtotal vs partial resection for advanced stages of thymoma. Although debulking surgery for thymoma had positively affected survival, in six studies, the difference failed to reach statistical significance. Three of the studies, on the other hand, showed a higher survival rate in thymomas in which maximum debulking was performed and the treatment was followed by high-dose irradiation. None of these studies showed any benefit in debulking surgery for thymic carcinoma. Besides histology and tumour cell-type, other factors influencing survival included the tumour stage and the presence of symptoms such as myasthenia gravis as a warning sign at an early stage. Current evidence in the literature on the survival after debulking surgery for thymoma is contradictory, and most of the studies do not show any survival benefit after debulking for thymoma. However, debulking surgery minimizes the tumour size and area for irradiation postoperatively, hence it can result in less damage to the adjacent tissue during radiotherapy and may be considered for patients in advanced stages of thymoma in whom extensive radiotherapy will be required. In these cases, however, the risks of surgery followed by radiotherapy or radiotherapy alone should carefully be assessed prior to the initiation of treatment.

How to manage the left subclavian artery during endovascular stenting of the thoracic aorta.

We performed a systematic review of the literature to establish whether revascularisation of the left subclavian territory is necessary when this artery is covered by a stent. We retrieved data from 99 studies incorporating 4906 patients. Incidences of left-arm ischaemia (0.0% vs 9.2%, p=0.002) and stroke (4.7% vs 7.2%, p<0.001) were significantly less following revascularisation, although mortality (10.5% vs 3.4%, p=0.032) and endoleak incidence (25.8% vs 12.6%, p=0.008) were increased. No significant differences in spinal-cord ischaemia were seen. Revascularisation may reduce downstream ischaemic complications but can cause significant risk. Indications must be carefully considered on an individual patient basis.

Effect of skeletonization of the internal thoracic artery for coronary revascularization on the incidence of sternal wound infection.

Use of the internal thoracic artery in coronary revascularization confers excellent benefit. We assessed the impact of skeletonization on the incidence of postoperative sternal wound infection in patients undergoing coronary artery bypass grafting. We also investigated whether there is an advantage in using this technique when harvesting both internal thoracic arteries in high-risk groups, such as diabetic patients. Skeletonization was associated with beneficial reduction in the odds ratio of sternal wound infection (odds ratio, 0.41; 95% confidence interval, 0.26 to 0.64). This effect was more evident when analyzing diabetic patients undergoing bilateral internal thoracic artery grafting (odds ratio, 0.19; 95% confidence interval, 0.10 to 0.34).

Evaluation and comparison of GLM- and CVA-based fMRI processing pipelines with Java-based fMRI processing pipeline evaluation system.

Activation patterns identified by fMRI processing pipelines or fMRI software packages are usually determined by the preprocessing options, parameters, and statistical models used. Previous studies that evaluated options of GLM (general linear model)--based fMRI processing pipelines are mainly based on simulated data with receiver operating characteristics (ROC) analysis, but evaluation of such fMRI processing pipelines on real fMRI data is rare. To understand the effect of processing options on performance of GLM-based fMRI processing pipelines with real fMRI data, we investigated the impact of commonly-used fMRI preprocessing steps; optimized the associated GLM-based single-subject processing pipelines; and quantitatively compared univariate GLM (in FSL.FEAT and NPAIRS.GLM) and multivariate CVA (canonical variates analysis) (in NPAIRS.CVA)-based analytic models in single-subject analysis with a recently developed fMRI processing pipeline evaluation system based on prediction accuracy (classification accuracy) and reproducibility performance metrics. For block-design data, we found that with GLM analysis (1) slice timing correction and global intensity normalization have little consistent impact on fMRI processing pipelines, spatial smoothing and high-pass filtering or temporal detrending significantly increases pipeline performance and thus are essential for robust fMRI statistical analysis; (2) combined optimization of spatial smoothing and temporal detrending improves pipeline performance; and (3) in general, the prediction performance of multivariate CVA is higher than that of the univariate GLM, while univariate GLM is more reproducible than multivariate CVA. Because of the different bias-variance trade-offs of univariate and multivariate models, it may be necessary to consider a consensus approach to obtain more accurate activation patterns in fMRI data.

A Java-based fMRI processing pipeline evaluation system for assessment of univariate general linear model and multivariate canonical variate analysis-based pipelines.

As functional magnetic resonance imaging (fMRI) becomes widely used, the demands for evaluation of fMRI processing pipelines and validation of fMRI analysis results is increasing rapidly. The current NPAIRS package, an IDL-based fMRI processing pipeline evaluation framework, lacks system interoperability and the ability to evaluate general linear model (GLM)-based pipelines using prediction metrics. Thus, it can not fully evaluate fMRI analytical software modules such as FSL.FEAT and NPAIRS.GLM. In order to overcome these limitations, a Java-based fMRI processing pipeline evaluation system was developed. It integrated YALE (a machine learning environment) into Fiswidgets (a fMRI software environment) to obtain system interoperability and applied an algorithm to measure GLM prediction accuracy. The results demonstrated that the system can evaluate fMRI processing pipelines with univariate GLM and multivariate canonical variates analysis (CVA)-based models on real fMRI data based on prediction accuracy (classification accuracy) and statistical parametric image (SPI) reproducibility. In addition, a preliminary study was performed where four fMRI processing pipelines with GLM and CVA modules such as FSL.FEAT and NPAIRS.CVA were evaluated with the system. The results indicated that (1) the system can compare different fMRI processing pipelines with heterogeneous models (NPAIRS.GLM, NPAIRS.CVA and FSL.FEAT) and rank their performance by automatic performance scoring, and (2) the rank of pipeline performance is highly dependent on the preprocessing operations. These results suggest that the system will be of value for the comparison, validation, standardization and optimization of functional neuroimaging software packages and fMRI processing pipelines.

Aortic surgery using total miniaturized cardiopulmonary bypass.

PURPOSE: Few centers have attempted aortic surgery using miniaturized cardiopulmonary bypass (MCPB) systems due to concerns of air handling. The extra corporeal circuit optimized (ECCO) total MCPB system uses a venous air removal device and a parallel soft-shell reservoir that allows for venting of the heart. At our institution, total MCPB is used for all coronary artery bypass graft patients. Our objective was to assess the suitability of the ECCO total MCPB system during aortic surgery. DESCRIPTION: Fifty consecutive and unselected aortic procedures using the ECCO system were undertaken. Surgical feasibility, air removal ability, and blood transfusion requirements were audited to determine the efficacy of this technique. EVALUATION: The bypass time was 81.6 +/- 28.0 minutes and the ischemic time was 56.7 +/- 18.9 minutes. Total MCPB handled 1,910 +/- 404 mL of vented blood with 96 venous air removal device activations noted. The blood product transfusion rate was 12%, which was below the surgical transfusion rate for our unit. There were no complications. CONCLUSIONS: Aortic surgery can be undertaken safely and effectively using the ECCO total MCPB system.