Load-dependent extracellular matrix organization in atrioventricular heart valves: differences and similarities.

The extracellular matrix of the atrioventricular (AV) valves' leaflets has a key role in the ability of these valves to properly remodel in response to constantly varying physiological loads. While the loading on mitral and tricuspid valves is significantly different, no information is available on how collagen fibers change their orientation in response to these loads. This study delineates the effect of physiological loading on AV valves' leaflets microstructures using Second Harmonic Generation (SHG) microscopy. Fresh natural porcine tricuspid and mitral valves' leaflets (n = 12/valve type) were cut and prepared for the experiments. Histology and immunohistochemistry were performed to compare the microstructural differences between the valves. The specimens were imaged live during the relaxed, loading, and unloading phases using SHG microscopy. The images were analyzed with Fourier decomposition to mathematically seek changes in collagen fiber orientation. Despite the similarities in both AV valves as seen in the histology and immunohistochemistry data, the microstructural arrangement, especially the collagen fiber distribution and orientation in the stress-free condition, were found to be different. Uniaxial loading was dependent on the arrangement of the fibers in their relaxed mode, which led the fibers to reorient in-line with the load throughout the depth of the mitral leaflet but only to reorient in-line with the load in deeper layers of the tricuspid leaflet. Biaxial loading arranged the fibers in between the two principal axes of the stresses independently from their relaxed states. Unlike previous findings, this study concludes that the AV valves' three-dimensional extracellular fiber arrangement is significantly different in their stress-free and uniaxially loaded states; however, fiber rearrangement in response to the biaxial loading remains similar.

Early Feasibility Study of a Hybrid Tissue-Engineered Mitral Valve in an Ovine Model.

Tissue engineering aims to overcome the current limitations of heart valves by providing a viable alternative using living tissue. Nevertheless, the valves constructed from either decellularized xenogeneic or purely biologic scaffolds are unable to withstand the hemodynamic loads, particularly in the left ventricle. To address this, we have been developing a hybrid tissue-engineered heart valve (H-TEHV) concept consisting of a nondegradable elastomeric scaffold enclosed in a valve-like living tissue constructed from autologous cells. We developed a 21 mm mitral valve scaffold for implantation in an ovine model. Smooth muscle cells/fibroblasts and endothelial cells were extracted, isolated, and expanded from the animal's jugular vein. Next, the scaffold underwent a sequential coating with the sorted cells mixed with collagen type I. The resulting H-TEHV was then implanted into the mitral position of the same sheep through open-heart surgery. Echocardiography scans following the procedure revealed an acceptable valve performance, with no signs of regurgitation. The valve orifice area, measured by planimetry, was 2.9 cm2, the ejection fraction reached 67%, and the mean transmitral pressure gradient was measured at 8.39 mmHg. The animal successfully recovered from anesthesia and was transferred to the vivarium. Upon autopsy, the examination confirmed the integrity of the H-TEHV, with no evidence of tissue dehiscence. The preliminary results from the animal implantation suggest the feasibility of the H-TEHV.

Less-Invasive Aortic Valve Replacement: Trends and Outcomes From The Society of Thoracic Surgeons Database.

BACKGROUND: This study compares outcomes of conventional and less-invasive (LI) approaches for aortic valve replacement (AVR) using The Society of Thoracic Surgeons database. METHODS: Between 2011 and 2017, we identified 122,474 patients undergoing isolated primary AVR. Patients were categorized into 3 groups: (1) full sternotomy (FS) (n = 98,549; 78%), (2) partial sternotomy (PS) (n = 17,306; 15%), and (3) right thoracotomy (RT) (n = 6619; 7%). RESULTS: The rate of LI-AVR increased from 17% in 2011 to 23% in 2016 (P < .001). Femoral cannulation was used in 1.5% of FS, 5.4% of PS, and 71% of RT patients (P < .001). Full sternotomy patients were older and had higher rates of preoperative renal failure, atrial fibrillation, and stroke, and had a higher NYHA function class, lower ejection fraction, and higher STS risk score. Total operative, cardiopulmonary bypass, and cross-clamp time were longest in RT-AVR patients and shortest in those who had FS-AVR. Overall, unadjusted operative mortality was 1.9% (1.05% among low-risk patients) and was not different among the 3 groups (1.97% FS, 1.77% PS, and 1.90% RT; P = .4). The rate of postoperative stroke was 1.2% and was not different among the 3 groups (1.2% FS, 1.3% PS, and 1.1% RT; P = .3). After risk adjustment, these differences remained nonsignificant. After risk adjustment, prolonged ventilation and atrial fibrillation were less common in PS-AVR patients. The adjusted risk for blood transfusion was lower in RT-AVR patients, as was the incidence of renal failure. Femoral cannulation was not associated with increased risk for stroke or mortality after LI-AVR. CONCLUSIONS: Less-invasive AVR is associated with an operative mortality and postoperative stroke rate similar to that of FS. Less-invasive AVRs should serve as a benchmark for comparison between transcatheter aortic valve replacement and surgical AVR in low-risk patients.

Coarctation of the aorta presenting as spontaneous subarachnoid haemorrhage in the absence of cerebral aneurysm: a report of a rare clinical entity.

Subarachnoid haemorrhage (SAH) is a common neurologic event characterised by bleeding into the space immediately surrounding the brain. In non-traumatic SAH, the predominant cause is aneurysmal rupture of the cerebral vasculature. A significant number occur in the absence of vascular anomalies. This report describes a case of a 35-year-old male who presented with a subarachnoid haemorrhage in the absence of intracranial aneurysm. Subsequent workup demonstrated severe proximal hypertension due to congenital aortic coarctation as the cause of this event. This case demonstrates the importance of considering congenital abnormalities when evaluating patients with cerebrovascular events in the absence of common aetiologies.

Arterial supply to sinuatrial and atrioventricular nodes: imaging with multidetector CT.

PURPOSE: To retrospectively evaluate the depiction of anatomic characteristics of the arterial supply to the sinuatrial node (SAN) and the atrioventricular node (AVN) with 64-section computed tomography (CT). MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study; informed consent was not required. Anatomic origin, number, course, and variants of the arteries to the SAN and AVN were examined with coronary multidetector CT in 102 patients (55 men, 47 women; mean age, 57 years +/- 13 [standard deviation]). Known accessory blood supplies to the AVN, including left and right Kugel anastomotic arteries, were investigated. Possible extension of the first septal perforating artery to the AVN was evaluated. Univariate and bivariate statistical data were reported. Means +/- standard deviations, 95% confidence intervals, and percentages were calculated. RESULTS: A single sinuatrial nodal artery originated from the proximal 40 mm of the right coronary artery (RCA) in 67 and from the proximal 35 mm of the left circumflex (LCX) artery in 28 patients. A dual blood supply to the SAN was seen in six patients. The sinuatrial nodal artery was not visualized in one patient. An S-shaped variant was seen in 18% of left sinuatrial nodal arteries and invariably traveled posteriorly in the sulcus between the left superior pulmonary vein and left atrial appendage. The sinuatrial nodal artery approached the nodal tissue by one of three routes-retrocaval (47.5%), precaval (42.6%), or pericaval (9.9%). The AVN was supplied by the RCA in 89 patients, the LCX artery in 11 patients, and by both arteries in two patients. Two left and six right Kugel anastomotic arteries were detected as supplying the AVN area. The first septal perforating artery had no detectable connection to the AVN. CONCLUSION: The arterial blood supply to the SAN and the AVN is variable and can be imaged with multidectector CT. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/2461070030/DC1.

Imaging of patent foramen ovale with 64-section multidetector CT.

PURPOSE: To investigate the feasibility of 64-section multidetector computed tomography (CT) by using CT angiography (a) to demonstrate anatomic detail of the interatrial septum pertinent to the patent foramen ovale (PFO), and (b) to visually detect left-to-right PFO shunts and compare these findings in patients who also underwent transesophageal echocardiography (TEE). MATERIALS AND METHODS: In this institutional review board-approved HIPAA-compliant study, electrocardiographically gated coronary CT angiograms in 264 patients (159 men, 105 women; mean age, 60 years) were reviewed for PFO morphologic features. The length and diameter of the opening of the PFO tunnel, presence of atrial septal aneurysm (ASA), and PFO shunts were evaluated. A left-to-right shunt was assigned a grade according to length of contrast agent jet (grade 1, 1 cm to 2 cm; grade 3, >2 cm). In addition, 23 patients who underwent both modalities were compared (Student t test and linear regression analysis). A difference with P < .05 was significant. RESULTS: A flap valve, seen in 101 (38.3%) patients, was patent at the entry into the right atrium (PFO) in 62 patients (61.4% of patients with flap valve, 23.5% of total patients). A left-to-right shunt was detected in 44 (16.7% of total) patients (grade 1, 61.4%; grade 2, 34.1%; grade 3, 4.5%). No shunt was seen in patients without a flap valve. Mean length of PFO tunnel was 7.1 mm in 44 patients with a shunt and 12.1 mm in 57 patients with a flap valve without a shunt (P < .0001). In patients with a tunnel length of 6 mm or shorter, 92.6% of the shunts were seen. ASA was seen in 11 (4.2%) patients; of these patients, a shunt was seen in seven (63.6%). In 23 patients who underwent CT angiography and TEE, both modalities showed a PFO shunt in seven. CONCLUSION: Multidetector CT provides detailed anatomic information about size, morphologic features, and shunt grade of the PFO. Shorter tunnel length and septal aneurysms are frequently associated with left-to-right shunts in patients with PFO.

MDCT of the S-shaped sinoatrial node artery.

OBJECTIVE: The purpose of this study was to use 64-MDCT to investigate the anatomic characteristics of the S-shaped variant of the sinoatrial node (SAN) artery and to describe the clinical implications of the findings in ablative procedures involving the left atrium. MATERIALS AND METHODS: Coronary CT angiograms of 250 patients (152 men, 98 women; mean age, 60 +/- 12 [SD] years) were retrospectively analyzed for identification of the origin, number, anatomic course, mode of termination, and S-shaped variant of the SAN artery. RESULTS: At least one SAN artery was detected in 244 patients. The S-shaped variant was seen in 35 (14.3%) of these patients. Thirty-four of the variants (30.6% of all left SAN arteries) arose from the proximal to middle portion of the left circumflex artery (mean distance between the ostium of the left circumflex artery and the origin of S-shaped variant, 28.7 +/- 13.1 mm). The other variant (0.7% of all right SAN arteries) originated from the distal right coronary artery. The S-shaped variant was the only artery supplying the SAN in 28 (11.4%) of the patients. In patients with two arteries supplying the SAN, the right SAN artery and the S-shaped variant of the left SAN artery were seen together in seven patients. The S-shaped SAN artery (mean distance from atrial wall, 2.43 +/- 0.992 mm) had a predictable proximal course, lying in the posterior aspect in a groove between the orifices of the left superior pulmonary vein and the left atrial appendage close to the left atrial wall. The terminal segment of the artery approached the nodal tissue posterior to the superior vena cava in 22 patients, anterior to the vena cava in 10 patients, and through branches surrounding the vena cava in two patients. CONCLUSION: The S-shaped variation of the SAN artery is common and has a characteristic anatomic course. MDCT can be used to plan surgical and catheter-based left atrial interventions in which this artery is at risk of injury.

Harvest technique for pedicled transposition of latissimus dorsi muscle: an old trade revisited.

Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of a number of complex intrathoracic pathologies such as bronchopleural fistulas and residual infected pleural spaces. We present a simple step-wise technique for preservation and harvesting of the most common muscle flap employed by thoracic surgeons, namely latissimus dorsi, just prior to performing a standard posterolateral thoracotomy. Since 2004, we have successfully utilized pedicled latissimus muscle as our preferred prophylactic flap against development of postoperative bronchopleural fistulas or recurrent empyemas. This technique should be part of every thoracic surgeon's surgical armamentarium.

Implementation of transcatheter aortic valve replacement in California: Influence on aortic valve surgery.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) procedures were introduced in 2011. Initially, procedures were limited to patients who were not surgical candidates, but subsequently high-risk surgical candidates were considered for TAVR. The influence on aortic valve surgery in California is unknown. METHODS: The California Office of Statewide Health Planning and Development hospitalized patient discharge database was queried for the years 2009 through 2014. isolated surgical aortic valve and aortic valve/coronary artery bypass graft (SAVR) and TAVR procedures were identified by International Classification of Diseases-9th revision clinical modification procedure codes. Seven TAVR programs were introduced in 2011, 12 in 2012, 3 in 2013, and 6 in 2014. SAVR procedure volumes were compared from the 2 years before institution with SAVR volumes during the year(s) after institution of the TAVR program in these 28 hospitals. RESULTS: Overall, surgical volumes increased during the first, second, and third years after implementation of TAVR procedures. Among 7 hospitals with 4-year programs, surgical volumes increased to a maximum of 15.5% during the third year, then began to decrease. The hospital performing the largest number of TAVR procedures showed a marked decrease in SAVR volume by the fourth year, suggesting a shift of SAVR candidates to TAVR. Among all hospitals with 4-year programs, TAVR exceeded SAVR procedures by the fourth year. In California overall, SAVR increased during 2011 through 2013, due primarily to increasing volume of isolated SAVR procedures. Statewide, isolated SAVR increased from a yearly average of 3111 procedures during 2009-2010 to 3592 (+15.5%) in 2013, then decreased slightly in 2014. SAVR plus coronary artery bypass graft procedures decreased during the same time period. CONCLUSIONS: After implementation of TAVR, hospital SAVR volumes increased moderately, then began to decrease by the fourth year, when TAVR volume exceeded SAVR. Surgical candidates may be identified during evaluation for TAVR, resulting in increased SAVR volume. Increasing SAVR volume may also be related to improved patient and provider awareness of aortic valve disease.

Defining operative mortality: Impact on outcome reporting.

OBJECTIVE: Death is an important outcome of procedural interventions. The death rate, or mortality rate, is subject to variability by definition. The Society of Thoracic Surgeons Adult Cardiac Surgery Database definition of "operative" mortality originally included all in-hospital deaths and deaths occurring within 30 days of the procedure. In recent versions of the Society of Thoracic Surgeons Adult Cardiac Surgery Database, "in-hospital" has been modified to include "patients transferred to other acute care facilities," and "deaths within 30 days unless clearly unrelated to the procedure" has been changed to "deaths within 30 days regardless of cause." This study addresses the impact of these redefinitions on outcome reporting. METHODS: The California Office of Statewide Health Planning and Development hospitalized patient discharge database was queried for the year 2009, the most recent year that data files could be linked to the vital statistics death files to include all-cause mortality. Isolated coronary artery bypass grafting, isolated valve, coronary artery bypass grafting valve, and percutaneous coronary intervention procedures were identified by International Classification of Diseases, Ninth Edition, Clinical Modification procedure codes. Percutaneous coronary intervention procedures were further divided into acute coronary syndrome (percutaneous coronary intervention acute coronary syndrome) and all other percutaneous coronary intervention (percutaneous coronary intervention no acute coronary syndrome). Deaths were counted by 5 methods depending on the time and place of occurrence: (1) in-hospital or during the index hospitalization; (2) in-hospital + connected hospitalization, defined as a transfer to another acute care facility on the same day or within 24 hours of discharge; (3) in-hospital + 30 day, death during index hospitalization or within 30 days after the procedure; (4) in-hospital + connected + 30 day readmission, death during index hospitalization, transfer to acute care facility, or deaths during readmission within 30 days; and (5) in-hospital + connected + 30 day. To study the impact of these operative mortality definitions, we examined 5 different methods to track mortality and performed 2 separate analyses. The first analysis did not exclude any patients, and the second analysis excluded any patient who could not be accurately tracked after hospital discharge. RESULTS: In the first analysis with no patients excluded, a total of 17% (117/697) of surgical deaths and 31% (409/1324) of percutaneous coronary intervention deaths were counted after the original hospitalization. The highest percentage of posthospital deaths occurred after elective percutaneous coronary intervention: 45% (135/301). In surgical patients, the highest percentage of posthospital deaths occurred in coronary artery bypass grafting procedures: 20% (57/284). In the second analysis, with untrackable patients excluded, hospital deaths included 12% (161/1324) for percutaneous coronary intervention compared with 4% (30/697) for surgical procedures. CONCLUSIONS: A significant percentage of procedural deaths occur after transfer or discharge from the index hospital. This is especially evident in the percutaneous coronary intervention group. These findings illustrate the importance of the definition of "operative" mortality and the need to ensure accuracy in the reporting of data to voluntary clinical registries, such as the Society of Thoracic Surgeons Adult Cardiac Surgery Database and National Cardiovascular Data Registry.

ALK F1174V mutation confers sensitivity while ALK I1171 mutation confers resistance to alectinib. The importance of serial biopsy post progression.

Many acquired resistant mutations to the anaplastic lymphoma kinase (ALK) gene have been identified during treatment of ALK-rearranged non-small cell lung cancer (NSCLC) patients with crizotinib, ceritinib, and alectinib. These various acquired resistant ALK mutations confer differential sensitivities to various ALK inhibitors and may provide guidance on how to sequence the use of many of the second generation ALK inhibitors. We described a patient who developed an acquired ALK F1174V resistant mutation on progression from crizotinib that responded to alectinib for 18 months but then developed an acquired ALK I1171S mutation to alectinib. Both tumor samples had essentially the same genomic profile by comprehensive genomic profiling otherwise. This is the first patient report that demonstrates ALK F1174V mutation is sensitive to alectinib and further confirms missense acquired ALK I1171 mutation is resistant to alectinib. Sequential tumor re-biopsy for comprehensive genomic profiling (CGP) is important to appreciate the selective pressure during treatment with various ALK inhibitors underpinning the evolution of the disease course of ALK+NSCLC patients while on treatment with the various ALK inhibitors. This approach will likely help inform the optimal sequencing strategy as more ALK inhibitors become available. This case report also validates the importance of developing structurally distinct ALK inhibitors for clinical use to overcome non-cross resistant ALK mutations.

Extended ex vivo myocardial preservation in the beating state using a novel polyethylene glycolated bovine hemoglobin perfusate based solution.

Cardiac preservation for transplantation is generally limited by ischemic hypothermic storage of 4-6 hours. Earlier studies in the authors' laboratory have demonstrated that hypothermic perfusion preservation using a novel oxygen carrying hemoglobin solution may extend preservation times to 8 hours and decrease ischemic injury. The purpose of this study was to compare extended cardiac function after 12 and 24 hours of continuous hypothermic perfusion with a polyethylene glycolated bovine hemoglobin perfusate (PEG-Hb) solution to the clinical standard of hypothermic ischemic preservation. The hearts of 54 anesthetized and intubated New Zealand White rabbits were harvested after cold cardioplegic arrest. Group I (n = 12) hearts were perfused with a PEG-Hb solution at 20 degrees C and 30 mm Hg for 24 hours. Group II (n = 10) hearts were preserved similarly with PEG-Hb for 12 hours. Group III (n = 12) hearts were preserved for 8 hours with PEG-Hb; Group IV (n = 10) were preserved by cold ischemic storage for 4 hours at 4 degrees C; and Group V (n = 10) were tested after fresh extirpation. Left ventricular (LV) function was measured in the nonworking state at 15 minute, 1 hour, and 2 hour intervals after transfer to a standard crystalloid Langendorff circuit. Developed LV pressure at 0.5 ml LV volume was superior in Group II at early time points, yet it was similar in all preserved groups at 2 hours. +dP/dt(max) at 0.5 ml LV volume was consistent at all time points and greater in PEG-Hb preserved groups compared with Group V. -dP/dt(max) at 0.5 ml LV volume was significantly greater in Groups II and III compared with Group V initially (p < 0.05), but all were similar at the end of testing. Continuous perfusion preservation of rabbit hearts for time increments up to 24 hours with this novel PEG-Hb solution at 30 mm Hg and 20 degrees C yields LV function that is similar to 4 hours of ischemic hypothermic storage. Extended cardiac perfusion preservation with this PEG-Hb solution deserves further investigation in large animal transplant models.

Subarachnoid hemorrhage and isolated atresia of the aortic arch.

The case of a 14 year old boy with subarachnoid hemorrhage and atresia of the aorta without patent ductus arteriosus or intracardiac shunt is described. This case calls attention to the possibility of aortic obstruction in adolescents or young adults with hypertensive stroke. The clinical symptoms, radiographic findings, and surgical repair of isolated aortic interruption, including atresia, are discussed.

Cause and effects of decreasing coronary revascularization procedures in California hospitals, 2006 to 2010.

Coronary revascularization procedures decreased markedly in California after the introduction of drug-eluting stents and the initiation of public reporting in 2003, resulting in a large number of low-volume heart programs. California hospital discharge data were analyzed from 2006 to 2010 to study the impact of this change. In-hospital mortality and hospital readmission for major adverse events at 90 days and 365 days were determined for patients who underwent isolated coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) either with acute coronary syndrome (ACS) or PCI without acute coronary syndrome (PCI-noACS). Three terciles were chosen by case volume as follows: high-volume (747 ± 336 [SD]/yr total PCI, 210 ± 130 isolated CABG), intermediate volume (362 ± 47 PCI, 106 ± 27 CABG), and low-volume (211 ± 6 PCI, 53 ± 17 CABG) terciles were studied. PCI-noACS procedures decreased 33% and CABG 20%, whereas PCI-ACS procedures increased slightly. Risk-adjusted in-hospital mortality was slightly better in high-volume compared with low-volume terciles for CABG (2.0% vs 2.6%) and PCI-noACS (0.64% vs 0.85%). There was no difference in major adverse events at 90 days or 365 days among volume terciles within procedure groups, and no change in event rates was noted over the 5-year period. Wide variation in outcomes, associated with low volume, contributed to poor statistical discrimination among providers. In conclusion, lower volume hospitals had similar overall outcomes with wider variation. Conservative treatment strategies apparently contributed to decreased procedure volume. Collaboration among hospitals of similar structure and case volume may be the most appropriate performance improvement model to reduce variability among providers.

Adverse events after coronary revascularization procedures in California 2000 to 2010.

Public reporting of coronary artery bypass grafting (CABG) mortality in California was initiated in 2003. Drug-eluting stents were widely introduced in the same year. Adverse events after percutaneous coronary intervention (PCI) and CABG were analyzed to study the impact of these events. Annual California hospital discharge data were collected from 2000 through 2010. In-hospital mortality and hospital readmission for adverse events <1 year were determined for patients undergoing isolated CABG, PCI for acute coronary syndrome (PCI-ACS), and all other PCIs (PCI-noACS). CABG volume peaked in 2000 and subsequently decreased by 58%; PCI volume peaked in 2005 and subsequently decreased by 20%. After 2003, in-hospital mortality and 1-year mortality for CABG decreased whereas mortality after PCI remained unchanged. Event rates for acute myocardial infarction and stroke varied little over the decade; acute myocardial infarction at 1 year was 2.5% to 2.8% (CABG), 4.5% to 5.4% (PCI-ACS), and 4.6% to 5.8% (PCI-noACS); stroke rate was 1.4% to 1.7% (CABG), 1.2% to 1.6% (PCI-ACS), and 1.0% to 1.2% (PCI-noACS). Reintervention for PCI decreased markedly, from 18.8% to 12.8% (PCI-ACS) and 22.5% to 13.3% (PCI-noACS). Multiple adverse cardiovascular and cerebral events rate at 1 year decreased from 10.8% to 9.4% (CABG), 26.5% to 21.2% (PCI-ACS), and 26.8% to 18.4% (PCI-noACS). Excluding reinterventions, multiple adverse cardiovascular and cerebral events rate at 1 year was 8.3% (CABG), 14.6% (PCI-ACS), and 10.1% (PCI-noACS) in 2010. In conclusion, the volume of coronary interventions in California decreased whereas adverse event rates decreased after the introduction of public reporting and drug-eluting stents. Lower procedure volume combined with improved outcomes resulted in an annual decrease of >6,000 adverse events by the end of the decade.

Postoperative thrombotic thrombocytopenic purpura after open heart operations.

BACKGROUND: Postoperative thrombotic thrombocytopenic purpura (pTTP) after cardiovascular operations has an alarmingly high mortality rate if untreated. Five patients after coronary artery bypass graft (CABG) procedure were diagnosed with pTTP when they were observed to have a persistent thrombocytopenia associated with symptoms of fever, renal insufficiency, thromboembolic events, or altered mental status in conjunction with a microangiopathic hemolytic anemia (MAHA). A guideline for early diagnosis, followed by timely treatment in these cases, is reviewed. METHODS: A retrospective record review of postoperative patients with thrombocytopenia identified 5 patients that met the criteria for pTTP from 2004 to 2008. We examined these 5 cardiovascular surgical patients in terms of clinical presentation, laboratory data, and outcomes. RESULTS: All patients had the combination of an unexplained thrombocytopenia (platelets < 50,000 mm(3)) in conjunction with a MAHA as determined by the presence of schistocytes. Symptoms of neurologic dysfunction and renal insufficiency developed in all patients. Thromboembolic events were noted in 1 patient. All patients underwent plasmapheresis. In 3 patients, response time to clinical recovery and normalization of hematologic laboratory values after plasmapheresis was 3, 4, and 8 days. Two patients did not recover and died. One patient had a clinical and laboratory recovery after 19 days of plasmapheresis; however, after 11 days, thrombocytopenia with MAHA developed and he died on day 53 from complications related to the operation. CONCLUSIONS: Postoperative TTP should be recognized as a possible pathophysiologic mechanism for unexplained postoperative thrombocytopenia and treatment should be initiated once the diagnosis is established.

Coronary venous aneurysm in patients without cardiac arrhythmia as detected by MDCT: an anatomic variant or a pathologic entity.

OBJECTIVES: The aim of this study was to determine the prevalence of coronary venous aneurysm in patients with no history of cardiac arrhythmia using 64-slice multidetector computed tomography. BACKGROUND: Coronary vein aneurysm frequently has been reported in association with cardiac arrhythmias such as ventricular pre-excitation. METHODS: Coronary computed tomography angiograms of 187 patients (108 men, 79 women; mean age +/- SD, 60 +/- 12 years) were analyzed retrospectively for the presence of a focal coronary venous aneurysm. Fusiform aneurysm was defined as a focal dilatation of twice the normal vein. However, any size of diverticular aneurysms was included. Cross-sectional diameters of normal and aneurysmal segments of the posterior interventricular vein, great cardiac vein, and coronary sinus (CS) were measured at mid-diastole, late systole, and atrial systole. The Student t test was used for continuous variables and contingency tables were used for categorical variables. RESULTS: A single aneurysm was found in 19 (10%) patients (fusiform, n =16; diverticular, n = 3). The most common anatomic location was the posterior interventricular vein near the confluence with the CS (n = 14), followed by the great cardiac vein near the junction with the CS (n = 3), and the CS (n = 2). The mean diameter of the aneurysms was 9.3 +/- 1.2 mm (range, 8.1 to 11.4 mm) at mid-diastole and 10.4 +/- 1.4 mm (range, 8.5 to 12.7 mm) at late systole. However, the difference was not statistically significant. All normal CSs and 1 aneurysm arising from the CS showed contraction during atrial systole, which may suggest atrial myocardial coverage of these structures. Patients with a venous aneurysm were significantly older than patients without an aneurysm (67.6 +/- 11 vs. 59 +/- 12 years, respectively; p = 0.006). CONCLUSIONS: Coronary vein aneurysms (especially the fusiform type) were seen in up to 10% of patients with no history of cardiac arrhythmia and can be well visualized on computed tomography angiograms.

Pedicled latissimus dorsi muscle flap: routine use in high-risk thoracic surgery.

Bronchopleural fistula and empyema are serious complications after thoracic surgical procedures, and their prevention is paramount. Herein, we review our experience with routine prophylactic use of the pedicled ipsilateral latissimus dorsi muscle flap. From January 2004 through February 2006, 10 surgically high-risk patients underwent intrathoracic transposition of this muscle flap for reinforcement of bronchial-stump closure or obliteration of empyema cavities. Seven of the patients were chronically immunosuppressed, 5 were severely malnourished (median preoperative serum albumin level, 2.4 g/dL), and 5 had severe underlying obstructive pulmonary disease (median forced expiratory volume in 1 second, 44% of predicted level). Three upper lobectomies and 1 completion pneumonectomy were performed in order to treat massive hemoptysis that was secondary to complex aspergilloma. One patient underwent left pneumonectomy due to ruptured-cavitary primary lung lymphoma. One upper lobectomy was performed because of necrotizing, localized Mycobacterium avium-intracellulare infection. One patient underwent right upper lobectomy and main-stem bronchoplasty for carcinoma after chemoradiation therapy. In 3 patients, the pedicled latissimus dorsi muscle was used to obliterate chronic empyema cavities and to buttress the closure of underlying bronchopleural fistulas. No operative deaths or recurrent empyemas resulted. Two patients retained peri-flap air that required no surgical intervention. We conclude that the use of transposed pedicled latissimus dorsi muscle flap effectively and reliably prevents clinically overt bronchopleural fistula and recurrent empyema. We advocate its routine use in first-time and selected reoperative thoracotomies in patients who are undergoing high-risk lung resection or reparative procedures.

Clinical patterns of surgical endocarditis.

BACKGROUND: This study was aimed at defining clinical and anatomic patterns in cases of surgical endocarditis (SE). METHODS: SE cases done between 1981 and 1997 at our metropolitan county hospital were retrospectively analyzed. RESULTS: A total of 106 consecutive episodes of SE involving 125 valves in 100 patients were studied. SE included 71 aortic, 42 mitral, and 12 tricuspid valves. The etiologies included intravenous drug abuse (IVDA) in 48 (45%) and dental source in 30 (28%). A congenitally deformed valve was present in 19 (18%). Compared to non-IVDA, IVDA episodes of SE were more often superimposed on previously normal valves (38/48 [79%] vs. 30/58 [52%])**, S. aureus infections (17/43 [40%] vs. 9/54 [17%])*, active endocarditis (38/48 [79%] vs. 32/58 [55%])*, and surgically treated on an urgent basis (10/48 [21%] vs. 4/58 [7%])*. Overall, macroemboli occurred in 53 (50%) of SE and was associated with pseudoaneurysm*, preoperative neurologic dysfunction,** and operative death.** The operative mortality (defined by Society of Thoracic Surgeons) for SE was 5/106 (4.7%). Macroembolism,** aortoventricular discontinuity,** abscesses,* pseudoaneurysm,** and preoperative renal failure* were associated with mortality. Prosthetic valve endocarditis was present in 10 of 106 episodes of SE (9.4%). *p < or = 0.05; **p < or = 0.01. CONCLUSION: (1) The aortic valve is most commonly associated with SE, (2) SE of a previously normal valve is more likely to occur with IVDA than other etiologies, (3) macroemboli occur in half of SE and is associated with an increased operative mortality.