Baylor University Medical Center's leap to prominence: The 1972 conference "Great Ideas in Surgery".

In 1972, Baylor University Medical Center established the A. Webb Roberts Center for Continuing Education in the Health Sciences. The center included the Beulah Porter Beasley Memorial Auditorium and a 25,000-volume medical library. The author was fortunate enough to attend the 2-day meeting (November 3-4) as a fellow in cardiovascular surgery. The following account is based on his personal recollections but also on the papers published by the participants and bequeathed to him by the late chief of the Department of Surgery, Robert S. Sparkman, MD.

Sir Magdi H. Yacoub, the Leonardo da Vinci of cardiac surgery.

The second half of the 20th century witnessed the emergence and the triumph of cardiac surgery. One of the legends of the period is Sir Magdi H. Yacoub (1935-), pioneer surgeon, scientist, master craftsman, and philanthropist. Yacoub established heart transplantation in the United Kingdom and introduced a variety of new concepts and new operations. His recent work focuses on molecular cardiology. This personal reminiscence highlights his personality, his surgical dexterity, and his many accomplishments and honors.

Connective tissue growth factor (CTGF/CCN2): a protagonist in cardiac allograft vasculopathy development?

BACKGROUND: Connective tissue growth factor (CTGF) has been reported to be upregulated in experimental models of chronic cardiac allograft rejection. We investigated the contribution of CTGF to the development of cardiac allograft vasculopathy (CAV), a surrogate marker for chronic rejection. METHODS: This prospective study included 72 adult heart allograft recipients. Genotyping of the rs6918698 polymorphism was performed by sequence-specific primer polymerase chain reaction (PCR). CTGF protein levels were measured in serum. CTGF messenger RNA (mRNA) from myocardial biopsy specimens was quantified by quantitative real-time PCR. RESULTS: Recipient genotype was associated with the development of CAV (p = 0.014) and the carriers of the C allele (CC and CG genotype) were high-risk recipients for the development of CAV (odds ratio, 3.30; 95% confidence interval, 1.12-9.74; p = 0.044). Serum CTGF protein levels could not be associated with the presence of the C allele but were significantly lower in the patients that had developed CAV (p = 0.038). This was attributed to the addition of everolimus to their immunosuppression scheme. Myocardial relative CTGF mRNA expression was estimated to be approximately twice as much in the CAV patients than in the patients without CAV (p = 0.013). CONCLUSIONS: The important role of CTGF during the development of CAV in heart transplantation was supported by the association of CAV with the recipient CTGF-945 CC/CG genotypes. The CAV patients, who were all receiving everolimus treatment, displayed elevated myocardial CTGF mRNA transcription levels, while everolimus has been observed to reduce serum CTGF protein levels.

Right atrial and septal reconstruction after tumor excision: the single-patch technique.

Surgical excision is the only therapy for benign atrial tumors, if serious complications are to be avoided. We propose a simplified technique whereupon a single autologous pericardial patch is used to not only close the septal defect, but to also reconstruct the right atrium. This new technique allows for wide excision of tumors without reduction of the right atrium, distortion of the tricuspid valve or traction on the atrioventricular node. We propose that this new approach will probably reduce the incidence of postoperative arrhythmias.

Aortic valve replacement: is there an implant size variation across Europe?

BACKGROUND AND AIMS OF THE STUDY: Prompted by anecdotal evidence and observations by surgeons, an investigation was undertaken into the potential differences in implanted aortic valve prosthesis sizes, during aortic valve replacement (AVR) procedures, between northern and southern European countries. METHODS: A multi-institutional, non-randomized, retrospective analysis was conducted among 2,932 patients who underwent AVR surgery at seven tertiary cardiac surgery centers throughout Europe. Demographic and perioperative variables including valve size and type, body surface area (BSA) and early mortality were collected. Group analysis by patient geographic distribution and by annular diameter of the prosthesis utilized was conducted. Patients with a manufacturer's labeled prosthesis size > or = 21 mm were assigned to the 'large' aortic size subset, while those with a prosthesis size < 21 mm were assigned to the 'small' aortic size subset. Effective orifice area indices were calculated for all patients to assess the geographic distribution of patient-prosthesis mismatch. Univariable and multivariable logistic regression analyses adjusting for possible confounding variables were performed. RESULTS: Prostheses with diameter < 21 mm were implanted at almost twice the rate in southern Europe compared to the north (56.4% versus 26.7%, p < 0.01). The mean valve size was also smaller in southern compared to northern European patients (21.6 +/- 2.1 mm versus 23.4 +/- 2.2 mm, p < 0.01). There were no regional differences in the distribution of either gender or BSA. In the multivariable model, south European patients were seven times more likely to receive a smaller-sized aortic valve (OR = 6.5, 95% CI = 4.82-8.83, p < 0.01), and thus the odds of developing patient-prosthesis mismatch were increased two-fold in southern European patients (OR = 1.9, 95% CI = 1.25-2.80, p = 0.02). However, neither geographic distribution nor valve size were significantly associated with operative mortality. CONCLUSION: The study results demonstrated differences in implanted aortic valve size, between the participating northern and southern European countries. Imbalances in the prevalence of rheumatic heart disease, health resource availability and variations in surgical practice throughout Europe might be possible etiological causes.

Effects of inspiratory muscle training on autonomic activity, endothelial vasodilator function, and N-terminal pro-brain natriuretic peptide levels in chronic heart failure.

PURPOSE: To assess the effects of inspiratory muscle training (IMT) on autonomic activity, endothelial function, and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with chronic heart failure. METHODS: Using age- and sex-matched controlled study, 23 patients (mean left ventricular ejection fraction 29 +/- 2%) were assigned to either a high-intensity training group (n = 14), New York Heart Association (NYHA) class II (n = 9)/III (n = 5), or a low-intensity training group (n = 9), NYHA class II (n = 6)/III (n = 3), exercising at 60% and 15% of sustained maximum inspiratory pressure (SPImax), respectively, 3 times per week for 10 weeks. Before and following IMT, patients underwent cardiopulmonary exercise testing and dyspnea evaluation on exertion. Sympathovagal balance was assessed by heart rate variability (HRV) from 24-hour electrocardiogram and endothelial function, using venous occlusion plethysmography. Serum levels of NT-proBNP were determined. RESULTS: High-intensity training group improved maximum inspiratory pressure (PImax, 105.4 +/- 5.3 vs 79.1 +/- 5 cm H2O, P = .001), SPImax (511 +/- 42 vs 308 +/- 28 cm H2O/sec/10, P = .001), peak oxygen consumption (19 +/- 1.2 vs 17.1 +/- 0.7 mL.kgmin, P = .01) and dyspnea (17.6 +/- 0.2 vs 18.1 +/- 0.1, P = .02). Endothelium-dependent vasodilation, HRV, and NT-proBNP levels were not altered. Low-intensity training group increased only the PImax (97.6 +/- 11.3 vs 84.2 +/- 8.7 cm H2O, P = .03). CONCLUSIONS: Improvement in dyspnea and exercise tolerance after IMT were not associated with changes in markers of HRV, endothelial function, and NT-proBNP in patients with mild to moderate chronic heart failure. Further studies on the effects of IMT in advanced heart failure would be worthwhile.

Trans-aortic repair of a sinus of valsalva aneurysm.

Sinus of Valsalva aneurysms are rare and vary in their presentation and approach of surgical repair. We report on a case of isolated right sinus of Valsalva aneurysm that underwent successful excision and patch repair with individual sutures placed through the annulus of the aortic valve.

Immune response to inspiratory muscle training in patients with chronic heart failure.

BACKGROUND: The effects of inspiratory muscle training on plasma cytokines, C-reactive protein and the soluble apoptosis mediators Fas and Fas ligand in chronic heart failure are unknown. DESIGN AND METHODS: Thirty-eight patients with chronic heart failure, age 57+/-2 years, New York Heart Association classification II-III, were assigned to either a high intensity training group (n=15, age 53+/-2 years) exercised at 60% of sustained maximal inspiratory pressure, or a low intensity training group (n=23, age 59+/-2 years), exercised at 15% of sustained maximal inspiratory pressure, three times per week for 10 weeks. Patients in the high intensity training group and low intensity training group were matched for age, sex and New York Heart Association functional class. Plasma levels of tumor necrosis factor (TNF)-alpha, soluble TNF receptor I, interleukin-6, C-reactive protein, soluble apoptosis mediators Fas and Fas ligand were measured at baseline and at post-inspiratory muscle training. Pulmonary function was assessed by spirometry, exercise capacity by a cardiopulmonary exercise test and the 6 min walk test, whereas dyspnea by the Borg scale after the 6 min walk test. RESULTS: High intensity training group improved inspiratory muscle strength (105.1+/-4.9 vs. 79.8+/-4.7 cmH2O, P<0.001), sustained maximal inspiratory pressure (504.5+/-39.7 vs. 312.5+/-26.5 cmH2O/s/10, P<0.001), forced vital capacity (98.9+/-3.9 vs. 96+/-3.3%, P<0.05), peak VO2 (19.4+/-1.2 vs. 17.3+/-0.9 ml/kg per min, P<0.01), 6 min walk test distance (404.3+/-11.9 vs. 378.2+/-10.4 m, P<0.01) and dyspnea (8.0+/-0.4 vs. 9.2+/-0.4, P<0.01). Circulating TNF-alpha, soluble TNF receptor I, interleukin-6, C-reactive protein, soluble apoptosis mediators Fas and Fas ligand were not significantly altered. Low intensity training group increased only the inspiratory muscle strength (90.3+/-5.9 vs. 80.2+/-5 cmH2O, P<0.01). Comparison between groups was significant for soluble TNF receptor I change (high intensity training group, 5.8+/-0.49 vs. 6.1+/-0.42; low intensity training group, 8.4+/-0.6 vs. 7.8+/-0.6, P<0.01). CONCLUSION: A high intensity inspiratory muscle training program resulted in improvement in functional status of chronic heart failure patients compared with low intensity inspiratory muscle training. Improvement in exercise capacity was not associated with an anti-inflammatory effect, although a beneficial influence on soluble TNF receptor I was recorded. Possible reasons include inadequate level of muscle mass exercise and the low pretraining New York Heart Association class.

Preoperative intravenous hydration confers renoprotection in patients with chronic kidney disease undergoing cardiac surgery.

Patients with chronic kidney disease (CKD) are at risk to develop acute renal failure (ARF) after open heart surgery. This complication is associated with high morbidity, mortality, and cost. Because the ability to concentrate urine is lost early in the progression of CKD, renal patients kept on fluid restriction prior to surgery may develop severe dehydration, a situation consistently found to be one of the most critical risk factors for postoperative ARF. Our goal was to investigate whether intravenous hydration for 12 h prior to cardiac surgery could prevent acute renal injury in patients with CKD. This is a prospective study in a tertiary cardiac surgery center. Forty-five patients admitted for elective open heart surgery with moderate-to-severe CKD, as evidenced by a quantified glomerular filtration rate less than 45 mL/min, were assigned using a 2/1 randomization process, to either receive an intravenous infusion of half-isotonic saline (1 mL/kg/h) for 12 h before the operation (hydration group, n = 30, 29 men, 64 + 1.7 years old), or to be simply kept on fluid restriction (control group, n = 15, 14 men, 64.2 + 2.8 years old). Groups were not different in clinical and intraoperative variables associated with postoperative renal injury. ARF developed in 8 of 15 (53%) patients in the control group, but in only 9 of the 30 (30%) patients in the hydration group. Four patients in the control group (27%), but no one in the hydration group, required dialysis after the operation (P < 0.01). Peak creatinine and blood urea nitrogen values were two to three times higher in the control group than in the hydration group. Preoperative intravenous hydration may ameliorate renal damage in patients with moderate-to-severe renal insufficiency undergoing cardiac surgery.

Inspiratory muscle training in a patient with left ventricular assist device.

The use of mechanical assist devices as a 'bridge' to cardiac transplantation, as a "bridge" to recovery, or as a destination therapy in end-stage heart failure, is increasing. Studies of different modes of rehabilitation in this population are lacking. We report the benefits of inspiratory muscle training on the exercise capacity and quality of life in the recipient of a left ventricular assist device.

Effect of long-term calcitonin administration on steroid-induced osteoporosis after cardiac transplantation.

BACKGROUND: Early, rapid bone loss and fractures after cardiac transplantation are well-documented complications of steroid administration; therefore, we undertook this study on the effects of long-term calcitonin on steroid-induced osteoporosis. METHODS: Twenty-three heart transplant recipients on maintenance immunosuppression with cyclosporine, mycophenolate mofetil and prednisone were retrospectively studied. All patients received long-term prophylactic treatment with elemental calcium and vitamin D. Twelve (52.2%) patients also received long-term intranasal salmon calcitonin, whereas 11 (47.8%) received none. Bone mineral density and vertebral fractures were assessed at yearly intervals. Statistical comparisons between each group's bone loss during the first year and in the early (1 to 3 years), intermediate (4 to 6 years) and late (7+ years) post-transplantation periods were done. RESULTS: Lumbar spine bone loss was significant during the early follow-up period in the group not receiving calcitonin (0.744 +/- 0.114 g/cm(2) vs 0.978 +/- 0.094 g/cm(2) [p = 0.002]). The calcitonin group showed bone mineral density (BMD) levels within normal average values throughout the study period. BMD increased in the no-calcitonin group during the intermediate (4 to 6 years) and late (7+ years) follow-up periods, with values approaching normal average and no significant difference between the 2 groups (0.988 +/- 0.184 g/cm(2) vs 0.982 +/- 0.088 g/cm(2) [p = 0.944] and 0.89 +/- 0.09 g/cm(2) vs 1.048 +/- 0.239 g/cm(2) [p = 0.474], respectively). CONCLUSIONS: Prophylactic treatment with intranasal salmon calcitonin prevents rapid bone loss associated with high-dose steroids early after cardiac transplantation. Long-term administration does not seem warranted in re-establishing BMD.

Inspiratory muscle training using an incremental endurance test alleviates dyspnea and improves functional status in patients with chronic heart failure.

BACKGROUND: The benefits of inspiratory muscle training (IMT) in patients with chronic heart failure (CHF) have been inadequately studied. DESIGN AND METHODS: Using a prospective, age and sex-matched controlled study, we investigated 35 patients with moderate to severe CHF (NYHA class II-III and left ventricular ejection fraction 24.4+/-1.3% [mean+/-SEM]). An incremental respiratory endurance test using a fixed respiratory workload was provided by software with an electronic mouth pressure manometer interfaced with a computer. The training group (n=20) exercised at 60% of individual sustained maximal inspiratory pressure (SMIP) and the control group (n=15) at 15% of SMIP. All patients exercised three times weekly for 10 weeks. Pulmonary function, exercise capacity, dyspnea and quality of life were assessed, pre- and post-training. RESULTS: The training group significantly increased both maximum inspiratory pressure (Pimax), (111+/-6.8 versus 83+/-5.7 cmH2O, P<0.001), and SMIP (527822+/-51358 versus 367360+/-41111 cmH2O/sec x 10(-1), P<0.001). Peak VO2 increased after training (17.8+/-1.2 versus 15.4+/-0.9 ml/kg/min, P<0.005), as did the six-minute walking distance (433+/-16 versus 367+/-22 meters, P<0.001). Perceived dyspnea assessed using the Borg scale was reduced for both the treadmill (12.7+/-0.57 versus 14.2+/-0.48, P<0.005) and the walking (9+/-0.48 versus 10.5+/-0.67, P<0.005) exercise tests and the quality of life score was also improved (21.1+/-3.5 versus 25.2+/-4, P<0.01). Resting heart rate was significantly reduced with training (77+/-3.3 versus 80+/-3 beats/min, P<0.05). The control group significantly increased Pimax (86.6+/-6.3 versus 78.4+/-6.9 cmH2O, P<0.05), but decreased SMIP (274972+/-32399 versus 204661+/-37184 cmH2O/sec x 10(1), P<0.005). No other significant effect on exercise capacity, heart rate, dyspnea, or quality of life was observed in this group. CONCLUSION: Inspiratory muscle training using an incremental endurance test, successfully increases both inspiratory strength and endurance, alleviates dyspnea and improves functional status in CHF.