Papillary muscle rupture following routine aortic valve replacement.

A 56-year-old man who underwent routine aortic valve replacement (AVR) for aortic insufficiency suffered a presumed embolic event to a small vessel supplying the posteromedial papillary muscle. This led to papillary muscle rupture, and severe, acute mitral regurgitation requiring emergent mitral valve replacement 6 days postoperatively. Small-vessel coronary embolization outside the setting of infection/endocarditis leading to infarction and papillary muscle rupture following elective AVR has not been previously described in the literature.

Natural history of the proximal aorta in patients with descending thoracic aortic disease.

OBJECTIVE: This study investigated the growth and behavior of the ascending aorta in patients with descending thoracic aortic disease. METHODS: We examined 200 patients with descending thoracic aortic disease including acute type B dissection (n = 95), chronic type B dissection (n = 38), intramural hematoma (n = 23), and thoracoabdominal aortic aneurysms (n = 44). Images from computed tomography and magnetic resonance imaging were evaluated after three-dimensional reconstruction to examine the growth rate in those with >1 year of imaging follow-up (n = 108). Survival data were derived from all 200 patients in this study. RESULTS: Average proximal aortic dimensions at the index image were relatively small, measuring 3.65 ± 0.51 cm in the root, 3.67 ± 0.48 cm in the ascending aorta, and 3.50 ± 0.44 cm in the proximal arch. Average growth rate was low for the aortic root, ascending aorta, and proximal arch at 0.36 ± 0.64 mm/y, 0.26 ± 0.44 mm/y, and 0.25 ± 0.44 mm/y, respectively. There was no difference in baseline proximal aortic dimensions and growth rate between the four subgroups. An index aortic diameter ≥4.1 cm grew faster than those <4.1 cm at the ascending aorta (P = .028) and proximal arch (P = .019). There was no difference in aortic growth rates at the aortic root (P = .887). After the index scan, five patients underwent six ascending aortic replacement procedures, leading to a 3% ascending aortic intervention rate. Overall median life expectancy was 86.15 years. CONCLUSIONS: Native ascending aortic growth in patients with descending thoracic aortic disease is slow. We suggest regular follow-up for index ascending aorta ≥4.1 cm because of its larger initial size and more rapid growth.

Acute retrograde type A aortic dissection: morphologic analysis and clinical implications.

BACKGROUND: This study compares the morphology and outcomes of acute retrograde type A dissections (RTADs) with acute antegrade type A dissections (ATADs), and acute type B dissections. MATERIALS AND METHODS: From 2000 to 2016, there were 12 acute RTADs, 96 ATADs, and 92 type B dissections with available imaging. Dissections were characterized using computerized tomography angiography images. We examined clinical features, tear characteristics, and various morphologic measurements. RESULTS: Compared with acute type B dissections, RTAD primary tears were more common in the distal arch (75% versus 43%, P = 0.04), and the false-to-true lumen contrast intensity ratio at the mid-descending thoracic aorta was lower (0.46 versus 0.71, P = 0.020). RTAD had less false lumen decompression because there were fewer aortic branch vessels distal to the subclavian that were perfused through the false lumen (0.40 versus 2.19, P < 0.001). Compared with ATAD, RTAD had less root involvement where root true-to-total lumen area ratio was higher (0.88 versus 0.76, P = 0.081). Furthermore, RTAD had a lower false-to-true lumen contrast intensity ratio at the root (0.25 versus 0.57, P < 0.05), ascending aorta (0.25 versus 0.72, P < 0.001), and proximal arch (0.39 versus 0.67, P < 0.05). RTAD were more likely to undergo aortic valve resuspension (100% versus 74%, P = 0.044). CONCLUSIONS: RTAD tends to occur when primary tears occur in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared with ATAD, RTAD has less root involvement, and successful aortic valve resuspension is more likely.

The presence or severity of pulmonary hypertension does not affect outcomes for single-lung transplantation.

Advanced lung disease (ALD) that requires lung transplantation (LTX) is frequently associated with pulmonary hypertension (PH). Whether the presence of PH significantly affects the outcomes following single-lung transplantation (SLT) remains controversial. Therefore, we retrospectively examined the outcomes of 279 consecutive SLT recipients transplanted at our centre, and the patients were split into four groups based on their mean pulmonary artery pressure values. Outcomes, including long-term survival and primary graft dysfunction, did not differ significantly for patients with versus without PH, even when PH was severe. We suggest that SLT can be performed safely in patients with ALD-associated PH.

The Mitral Monobloc: A Simplification for Intervalvular Fibrous Body Reconstruction in Endocarditis.

The only viable option in prosthetic valve endocarditis with extensive abscess of the aorto-mitral curtain is radical debridement and reconstruction of the intravalvular fibrous body. This report details a simplified intravalvular fibrous body reconstruction technique.

Outcomes of surgical aortic valve replacement for mixed aortic valve disease.

BACKGROUND: Mixed aortic valve disease (MAVD) is associated with a poorer natural history compared with isolated lesions. However, clinical and echocardiographic outcomes for aortic valve replacement (AVR) in mixed disease are less well understood. METHODS: Retrospective review of AVRs (n=1,011) from 2000-2016. Isolated AVR, AVR + coronary bypass, and AVR + limited ascending aortic replacement were included. Predominant aortic stenosis (AS) group was stratified into group 1 (n=660) with concomitant mild or less aortic insufficiency (AI), and group 2 (n=197) with accompanying moderate or greater AI. Predominant AI group was stratified using the same schema for concomitant AS into groups 3 (n=143) and 4 (n=53). Median follow-up was 3.1 and 4.4 years respectively for AS and AI groups. RESULTS: For the predominant AS group (n=857) preoperatively, group 2 had a larger preoperative left ventricular end diastolic diameter (LVESD) (51.0±8.4 vs. 48.6±7.2, P=0.02) and lower preoperative left ventricular ejection fraction (LVEF) (57.6% vs. 60.2%, P=0.043). No differences in left ventricular (LV) dimensions, LV or right ventricular (RV) function was evident at follow up (P>0.05). After propensity matching for age, operation, and comorbidities, there was no difference in survival (P=0.19). After propensity matching for the predominant AI group (n=196), survival was lower for group 4 compared to 3 (P=0.02). There were no differences in LV dimensions, LV or RV function preoperatively or on follow-up (P>0.05). CONCLUSIONS: Predominant AS associated with higher AI grades had larger LV dimensions and worse LV function preoperatively. These differences resolve after AVR with equivalent survival. However, predominant AI with more severe AS had reduced survival despite AVR.

Coronary bypass in left ventricular dysfunction and differential cardiac recovery.

Background We aimed to examine the efficacy of surgical revascularization with respect to improvement in ventricular function and survival in patients with ischemic cardiomyopathy and poor left ventricular function. Methods We retrospectively analyzed the data of 429 patients (median age 64.6 years, 81.1% male) with ejection fractions <40% undergoing isolated primary coronary artery bypass grafting from 2000 to 2016. Techniques included on-pump cardioplegic arrest ( n = 312), off-pump ( n = 75), and on-pump beating heart ( n = 42). Propensity matching was performed to compare the cardioplegic arrest group ( n = 114) with the combined off-pump and beating heart groups ( n = 114). Results Postoperatively, ejection fraction increased by 10.1% ± 13.1% (from 31.4% ± 7.1% to 41.6% ± 13.6%; p < 0.001) and mitral regurgitation grade improved ( p < 0.001) but right ventricular function on echocardiographic assessment worsened over time ( p = 0.04). No difference in ejection fraction improvement was seen in the time periods <1 (9.8% ± 11.2%), 1-5 (11.6% ± 14.5%), and >5 (8.8% ± 14.2%) years ( p = 0.442). Following propensity matching, there was no significant difference between the combined off-pump/beating heart and cardioplegic arrest groups with respect to survival or postoperative complications. Conclusions Patients with moderate to severe left ventricular dysfunction experience long-term improvement in left ventricular ejection fraction after coronary artery bypass. However, right ventricular function often continues to decline, contributing to persistent or worsening heart failure symptoms and late mortality. No difference in survival was seen between the 2 techniques.

Coronary Events in Patients Presenting for Repair of Acute Type A Aortic Dissection.

BACKGROUND: Preoperative coronary angiography is often not performed in acute Type A dissection. We examined differences in the incidence of pre-existing coronary disease and subsequent coronary events between patients undergoing acute Type A dissection repair and patients undergoing elective proximal aortic aneurysm repair. METHODS: From 2000 to 2015, there were 154 acute Type A dissection repairs and 457 elective proximal aortic aneurysm repairs. We performed a retrospective review to evaluate preoperative coronary disease and postoperative coronary interventions such as percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG). RESULTS: A total of 31 (20%) dissection patients and 123 (27%) elective surgery patients had preoperative evidence of coronary artery disease (p = 0.094). All elective surgery patients but only six (4%) dissection patients had preoperative coronary catheterization. More CABGs were performed in the elective surgery group (19%) than in the dissection group (3%, p < 0.001). There were no differences in the incidence of prior PCI, CABG, or myocardial infarction between groups. Following dissection repair, four patients required coronary interventions. Of these, two (1.3%) experienced chest pain and underwent PCI at 4.7 and 4.3 months postoperatively, respectively, and another two experienced symptoms and required PCI at 5 and 7 years, respectively. The 30-day and 14-year mortality rates after dissection repair were 13% and 24%, respectively. Although the dissection group had poorer survival than the elective surgery group (p < 0.001), there was no difference in conditional survival after aortic-related deaths over the first year were censored (p = 0.104). CONCLUSIONS: Given the low incidence of missed significant coronary disease (1.3%), it is reasonable to perform Type A dissection repair without coronary angiography.

Cluster analysis of acute ascending aortic dissection provides novel insight into mechanisms of distal progression.

BACKGROUND: Whether primary tear size impacts extent of type A dissection is unclear. Using statistical groupings based on dissection morphology, we examined its relationship to primary tear area. METHODS: We retrospectively reviewed 108 patients who underwent acute ascending dissection repair from 2000-2016. Dissection morphology was characterized using 3-dimensional (3D) reconstructions of computed tomography (CT) scan images. Two-step cluster analysis was performed to group the dissections by examining the true lumen area as a fraction of the total aortic area at various levels. RESULTS: Cluster analysis defined two distinct categories. This first grouping corresponds to DeBakey type I (n=71, 65.7%) with a dissection extending from the ascending aorta to the aortic bifurcation. The second grouping conforms more closely to DeBakey type II dissection (n=37, 34.3%). It differs however from the classic type II definition as the dissection may extend up to the distal arch from the ascending aorta. Compared to type I, this "extended" DeBakey type II had no malperfusion (P<0.05), a larger primary tear area (6.6 vs. 3.7 cm2, P=0.009), and a greater burden of atherosclerotic coronary artery disease (P<0.05). A smaller aortic valve annulus (P=0.025) and a smaller root false lumen area (P=0.017) may explain less aortic valve insufficiency (P<0.05) in extended type II dissections. No differences in complications or survival were seen. CONCLUSIONS: In this series, limited distal extension of DeBakey type II dissections appears to be related to a larger primary tear area and greater atherosclerotic disease burden. It is also associated with less malperfusion and aortic valve insufficiency.

Lung transplantation for high-risk patients with idiopathic pulmonary fibrosis.

BACKGROUND: Survival for patients with idiopathic pulmonary fibrosis (IPF) and high lung allocation score (LAS) values may be significantly reduced in comparison to those with lower LAS values. OBJECTIVES: To evaluate outcomes for high-risk IPF patients as defined by LAS values ≥46 (N=42) versus recipients with LAS values <46 (N=89). METHODS: We retrospectively reviewed records of 131 consecutive patients with IPF who received lung transplants at our institution between 1999 and 2013. RESULTS: The mean LAS was significantly higher (59.5, interquartile range 43.9-75.9 vs. 39.3, interquartile range 37.7-44.3; p<0.01) for the high-risk cohort. The higher LAS cohort had significantly lower percent predicted forced vital capacity (FVC) versus recipients with LAS <46 (41.3±14.1% vs. 53.2±16.2%; p<0.01) and required more supplemental oxygen (7±5 vs. 4±2 L/min, p<0.01) prior to transplant versus recipients with LAS <46. Although the incidence of early post-LTX pulmonary complications was increased for the higher LAS group versus recipients with LAS <46, 30-day mortality and actuarial survival did not differ between the two cohorts. CONCLUSIONS: Although lung transplantation in patients with IPF and high LAS values is associated with increased risk of early post-transplant complications, long-term post-transplant survival for our high-LAS cohort was equivalent to that for the lower LAS recipients.

Prevention of early sudden circulatory collapse after the Norwood operation.

BACKGROUND: After modifications in our perioperative management protocol, we have observed a decrease in sudden circulatory collapse after the Norwood operation. The current study examines early outcomes after the Norwood operation in our unit in an attempt to identify variables that may have altered the risk of unexpected circulatory collapse. METHODS AND RESULTS: We studied 105 consecutive neonates who underwent a Norwood operation in our institution. Our treatment protocol has changed in the past 3 years to include the use of alpha-blockade with phenoxybenzamine (POB) for systemic afterload reduction and selective cerebral perfusion. Forty-eight infants had selective cerebral perfusion. Forty-two infants received POB. Sixty patients had hypoplastic left heart syndrome. There was no difference in age, diagnosis, number of neonates with weight <2.5 kg, aortic size diameter <2 mm, highest preoperative lactate level, and shunt size indexed to body weight among patients with or without use of POB. Twenty-five infants had circulatory collapse during the first 72 hours. Twelve of them could be explained by technical issues. Thirteen others who appeared clinically stable had early sudden circulatory collapse without an apparent cause. Sixteen out of 25 neonates died. Of those with technical problems, 8 out of 12 died. Based on the hazard function, 3 incremental risk factors for early circulatory collapse were technical issue at operation (P<0.001), longer cross-clamp time (P<0.007), and no use of POB (P<0.002). For a technically successful operation, freedom from circulatory collapse at 72 hours is 95% with the use of POB versus 69% without (P<0.002). Diagnosis, aortic size, atrioventricular valve function, birth weight, age at operation, and total circulatory arrest time and were not predictive of early sudden circulatory collapse. CONCLUSIONS: Recent changes in our treatment protocol have resulted in a decrease incidence of sudden circulatory collapse after the Norwood operation. Optimal surgical technique is the most important predictor of early survival. The use of aggressive afterload reduction with POB reduced the risk of early sudden arrest.

Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes.

OBJECTIVE: This study was undertaken to evaluate the late outcomes of reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement. METHODS: Seventy-six consecutive patients underwent reconstruction of the intervalvular fibrous body with replacement of the mitral and aortic valves. There were 35 men and 41 women whose mean age was 58 +/- 12 years. Additional procedures were circumferential reconstruction of the mitral annulus in 27 patients, tricuspid valve repair in 21, coronary artery bypass in 15, and aortic root replacement in 4. Indications for the operation were active infective endocarditis with abscess in 15 patients, extensive calcification of the mitral annulus and interventricular fibrous body in 24, lack of fibrous tissue to secure a prosthetic valve in 17, and treatment or prevention of patient-prosthesis mismatch in 20. Fifty-five patients had undergone one or more previous valve operations, and 52 (68%) were in functional class IV. The mean follow-up was 47 +/- 47 months, and it was complete. RESULTS: There were 8 (10%) operative and 18 (24%) late deaths. The 10-year survival was 50% +/- 9%. There were 15 reoperations in 12 patients: 7 for prosthetic valve endocarditis (5 early, 2 late), 7 for patch or valve dehiscence (3 early, 4 late), and 1 for structural valve deterioration. All but 2 reoperations were re-reconstruction of the intervalvular fibrous body and double valve replacement. The 10-year freedom from reoperation was 73% +/- 7%. CONCLUSION: Reconstruction of the intervalvular fibrous body during double valve replacement is a technically challenging operation, but it is useful in patients with complex valve pathology for whom no alternative procedure is available.

Biventricular repair in children with atrioventricular septal defects and a small right ventricle: anatomic and surgical considerations.

OBJECTIVE: We sought to characterize morphology and to evaluate a strategy of using biventricular repair in patients with a small right ventricle and an unbalanced atrioventricular septal defect. METHODS: Thirty-eight children with a small right ventricle and an atrioventricular septal defect underwent operative therapy. Thirty-two had biventricular repair, and 6 had single-ventricle palliation. A small right ventricle was defined on the basis of echocardiographic measurements expressed as the atrioventricular valve index (ie, right atrioventricular valve/left atrioventricular valve area) and as the ratio of right ventricular to left ventricular length. Validation of measurements in patients with a small right ventricle and an atrioventricular septal defect was achieved by comparison with balanced case-matched control subjects with atrioventricular septal defects. RESULTS: Children with a small right ventricle and an atrioventricular septal defect had a lower atrioventricular valve index (mean, 0.41 +/- 0.1 vs 0.52 +/- 0.1 [control], P < .0001) and lower right ventricular/left ventricular length ratio (0.78 +/- 0.1 vs 0.99 +/- 0.17 [control], P < .0001). Children with a small right ventricle undergoing single-ventricle palliation had the smallest right ventricular dimensions. There were 4 operative deaths. Three patients with a small right ventricle and an atrioventricular septal defect who underwent biventricular repair and had an atrioventricular valve index of less than 0.50 required early reoperation for right ventricular inadequacy. A restrictive atrial fenestration was created in 11 infants. Survival at 10 years was 87% for patients undergoing biventricular repair versus 100% for control subjects (P = .042). CONCLUSIONS: Extending the use of biventricular repair in properly selected patients with a small right ventricle and an atrioventricular septal defect is feasible. An atrial fenestration improves the physiologic tolerance to repair in selected patients. The use of biventricular repair in children with atrioventricular valve indexes of less than 0.50 requires caution.

Interdigitating arch reconstruction eliminates recurrent coarctation after the Norwood procedure.

BACKGROUND: We sought to determine whether evolving techniques of aortic arch reconstruction used during the Norwood procedure decreased the incidence of postoperative aortic arch obstruction. METHODS: Our technique for aortic arch reconstruction in patients undergoing the Norwood procedure has evolved from using an allograft patch (classic group, n = 26) to primary connection of the pulmonary artery and arch (autologous group, n = 20). More recently, we have used a novel technique involving coarctation excision, an extended end-to-end anastomosis on the back of the arch, and a counterincision on the anterior descending aorta to sew in an allograft patch for total arch reconstruction (interdigitating group, n = 33). Cardiac catheterizations performed before stage II palliation were reviewed for aortic diameters at multiple levels in 79 infants (median age, 4.2 months). Aortic arch obstruction was defined as a ratio between the diameters of the arch anastomosis and the descending aorta (coarctation index) of less than 0.7. RESULTS: Overall, 15 (19%) children had aortic arch obstruction. All 15 required aortic intervention (balloon angioplasty, n = 12; surgical patch angioplasty, n = 2; both, n = 1). Aortic arch obstruction rates for the classic, autologous, and interdigitating groups were 46% (n = 12), 15% (n = 3), and 0%, respectively ( P > .001). CONCLUSION: Reconstruction of the aortic arch with excision of ductal and coarctation tissue is associated with lower aortic arch obstruction rates in patients undergoing the Norwood procedure. Arch reconstruction with a novel interdigitating technique decreases the incidence of aortic arch obstruction.

Conventional and sutureless techniques for management of the pulmonary veins: Evolution of indications from postrepair pulmonary vein stenosis to primary pulmonary vein anomalies.

OBJECTIVE: We have previously reported a limited but favorable experience with a novel sutureless technique for surgical management of postoperative pulmonary vein stenosis occurring after repair of total anomalous pulmonary venous drainage. Because this technique requires integrity of the retrocardiac space for hemostasis, extension of the technique to the primary repair of pulmonary vein anomalies requires evaluation. This analysis reviews our experience with the sutureless technique in patients with postrepair pulmonary vein stenosis, as well as our extension of the technique into primary repair of pulmonary vein anomalies. METHODS: Retrospective univariable-multivariable analysis of all pulmonary vein stenosis procedures and sutureless pulmonary vein procedures over a 20-year period was performed. Cox proportional hazards modeling was used to identify variables associated with freedom from reoperation or death. RESULTS: Sixty patients underwent 73 procedures, with pulmonary vein stenosis present in 65 procedures. The sutureless technique was used in 40 procedures. Freedom from reoperation or death at 5 years after the initial procedure was 49%. Unadjusted freedom from reoperation or death was greater with the sutureless technique for patients with postrepair pulmonary vein stenosis ( P = .04). By using multivariable analysis, a higher pulmonary vein stenosis score was associated with greater risk of reoperation or death. After adjustment, the sutureless repair was associated with a nonsignificant trend toward greater freedom from reoperation or death ( P = .12). Despite the absence of retrocardiac adhesions, operative mortality was not increased with the sutureless technique ( P = .64). Techniques to control bleeding (intrapleural hilar reapproximation) and improve exposure (inferior vena cava division) were identified. CONCLUSION: The sutureless technique for postrepair pulmonary vein stenosis is associated with encouraging midterm results. Extension of the indications for the technique to primary repair appears safe with the development of simple intraoperative maneuvers.

Acute fibrinous and organising pneumonia following lung transplantation is associated with severe allograft dysfunction and poor outcome: a case series.

Acute fibrinous and organising pneumonia (AFOP) is a histopathologic variant of acute lung injury that has been associated with infection and inflammatory disorders and has been reported as a complication of lung transplantation. A retrospective chart review was performed for all patients transplanted at the University of Wisconsin Hospital and Clinics from January 1995 to December 2013 (n = 561). We identified 6 recipients whose clinical course was complicated by AFOP. All recipients were found to have AFOP on lung biopsy or at post-mortem examination, and 5 of the 6 patients suffered progressive allograft dysfunction that led to fatal outcome. Only 1 of the 6 patients stabilised with augmented immunosuppression and had subsequent improvement and stabilisation of allograft function. We could not clearly identify any specific cause of AFOP, such as drug toxicity or infection. Lung transplantation can be complicated by lung injury with an AFOP pattern on histopathologic examination of lung biopsy specimens. The presence of an AFOP pattern was associated with irreversible decline in lung function that was refractory to therapeutic interventions in 5 of our 6 cases and was associated with severe allograft dysfunction and death in these 5 individuals. AFOP should be considered as a potential diagnosis when lung transplant recipients develop progressive decline in lung function that is consistent with a clinical diagnosis of chronic lung allograft dysfunction.

Lung transplantation from donation after cardiocirculatory death: a systematic review and meta-analysis.

BACKGROUND: Lung transplantation (LTx) can extend life expectancy and enhance the quality of life for select patients with end-stage lung disease. In the setting of donor lung shortage and waiting list mortality, the interest in donation after cardiocirculatory death (DCD) is increasing. We performed a systematic review and meta-analysis to compare outcomes between DCD and conventional donation after brain death (DBD). METHODS: PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and ClinicalTrials.gov were searched. We identified original research studies with 1-year post-transplant survival data involving >5 DCD transplants. We performed meta-analyses examining 1-year survival, primary graft dysfunction, and acute rejection after LTx. RESULTS: We identified 519 citations; 11 observational cohort studies met our inclusion criteria for systematic review, and 6 met our inclusion criteria for meta-analysis. There were no differences found in 1-year mortality after LTx between DCD and DBD cohorts in individual studies or in the meta-analysis (DCD [n = 271] vs DBD [n = 2,369], relative risk [RR] 0.88, 95% confidence interval [CI] 0.59-1.31, p = 0.52, I(2) = 0%). There was also no difference between DCD and DBD in a pooled analysis of 5 studies reporting on primary graft dysfunction (RR 1.09, 95% CI 0.68-1.73, p = 0.7, I(2) = 0%) and 4 studies reporting on acute rejection (RR 0.72, 95% CI 0.49-1.05, p = 0.09, I(2) = 0%). CONCLUSIONS: Survival after LTx from DCD is comparable to survival after LTx from DBD in observational cohort studies. DCD appears to be a safe and effective method to expand the donor pool.

Practical use of alpha blockade strategy in the management of hypoplastic left heart syndrome following stage one palliation with a Blalock-Taussig shunt.

Alpha blockade with phenoxybenzamine has been used in the postoperative management after the Norwood operation. The principle of this approach is the increase in systemic cardiac output by maximal dilation of the systemic circulation. This effect results in a more stable parallel circulation through prevention of fluctuations in systemic vascular resistance in the early postoperative period. We have incorporated this approach in our postoperative management protocol and have observed a decrease in sudden cardiac collapse. This article describes the practical use of alpha blockade strategy, its clinical application, and the most common clinical scenarios observed during the initial hours following stage one palliation with a Blalock-Taussig shunt for hypoplastic left heart syndrome in our cardiac surgery unit.

Acuity adaptable patient care unit system shortens length of stay and improves outcomes in adult cardiac surgery: University of Wisconsin experience.

OBJECTIVES: The Acuity Adaptable Patient Care (AAC) unit system allows all beds within a nursing unit to negate the need for transfer with changes in patient status. The unit is specialty specific to all levels of patient care. This system was implemented in March 2006 for cardiothoracic surgery at our institution. The purpose of this study was to evaluate the impact of the AAC system on the outcomes after adult cardiac surgery. METHODS: We retrospectively reviewed 2930 consecutive patients who underwent major adult cardiac procedures between January 2003 and December 2010. The cohorts were divided into the pre-AAC group (January 2003 to February 2006, n = 1029) and the AAC group (March 2006 to December 2010, n = 1901). Patient demographics and postoperative outcomes were assessed. RESULTS: The proportion of coronary artery bypass grafting was significantly lower (pre-AAC vs AAC: 43 vs 35%, P < 0.01), while those of aortic procedure (4 vs 11%, P < 0.01) and mechanical assist device insertion (3 vs 5%, P = 0.02) were higher in the AAC group. After the implementation of the AAC system, the incidence of all complications defined by the Society of Thoracic Surgeons (STS) database (49 vs 34%, P < 0.01), the median length of intensive care unit (ICU) stay (49 [interquartile range (IQR), 27-99] vs 26 [19-45] h, P < 0.01), that of hospital stay (6 [4-10] vs 5 [4-7] days, P < 0.01) and the readmission rate of ICU (5 vs 2% P < 0.01) were significantly decreased. Significant reductions in hospital mortality and the rate of hospital readmission <30 days were not observed. CONCLUSIONS: The implementation of the AAC system has improved the outcomes after major cardiac procedures. The incidence of postoperative complications and length of stay have all decreased significantly without increasing readmission rate. AAC creates a system of fluid care with specialty-trained nursing and other ancillary support that expedites discharge and improves overall patient outcomes.

Lung transplant for interstitial lung disease: outcomes before and after implementation of the united network for organ sharing lung allocation scoring system.

OBJECTIVES: This study was undertaken to evaluate whether the adoption of the united network for organ sharing lung allocation score (LAS) was associated with significant changes in lung transplantation (LTX) outcomes for patients with interstitial lung disease (ILD) who underwent LTX at the University of Wisconsin Hospital and Clinics. METHODS: Outcomes for 107 consecutive patients with various forms of ILD who underwent LTX between January 1993 and March 2009 were examined. Patients transplanted following the implementation of the LAS system (LAS, n = 56) were compared with those transplanted prior to LAS implementation (pre-LAS, n = 51) for whom LAS scores were calculated. RESULTS: Patients with idiopathic pulmonary fibrosis (IPF) comprised the majority of patients with ILD. Recipients transplanted after the implementation of the LAS were significantly older (pre-LAS: 50.4 vs. LAS: 56.7 years, P < 0.01), required more supplemental oxygen (3 vs. 5 l/min, P < 0.01) and displayed lower cardiac index values (3.1 vs. 2.6 l/m(2), P < 0.01). The estimated LAS was significantly increased from 38.3 (pre-LAS) to 43.3 (LAS), P < 0.01. However, waiting time decreased from 266 to 78 days (P < 0.01). The rate of bilateral vs. single LTX was lower (35 vs. 16%, P = 0.02) for the post-LAS group. Cold ischaemic time was shorter in the post-LAS group (434 vs. 299 min, P < 0.01), and the length of hospital stay decreased from 24 to 11 days (P < 0.01). Hospital mortality (11 vs. 7%, P = 0.51) and post-transplant survival did not differ between the groups. CONCLUSIONS: Post-transplant outcomes for patients with ILD or the subset of recipients with IPF were not adversely affected by the implementation of the LAS.