Right mini-parasternotomy may be a good minimally invasive alternative to full sternotomy for cardiac valve operations-a propensity-adjusted analysis.

AIM: Limited realworld data existed for miniparasternotomy approach with good sample size in Asian cohorts and most previous studies were eclipsed by case heterogeneity. The goal of this study was to compare safety and quality outcomes of cardiac noncoronary valve operations by miniparasternotomy and full sternotomy approaches on riskadjusted basis. METHODS: From our hospital database, we retrieved the cases of non-coronary valve operations from 1 January 2005 to 31 December 2012, including re-do, emergent, and combined procedures. Estimated EuroScore-II and propensity score for choosing mini-parasternotomy were adjusted for in the regression models on hospital mortality, complications (pneumonia, stroke, sepsis, etc.), and quality parameters (length of stay, ICU time, ventilator time, etc.). Non-complicated cases, defined as survival to discharge, ventilator use not over one week, and intensive care unit stay not over two weeks, were used for quality parameters. RESULTS: There were 283 miniparasternotomy and 177 full sternotomy cases. EuroScore-II differed significantly (medians 2.1 vs. 4.7, p<0.001). Propensity scores for choosing miniparasternotomy were higher with lower EuroScore-II (OR=0.91 per 1%, p<0.001), aortic regurgitation (OR=2.3, p=0.005), and aortic non-mitral valve disease (OR=3.9, p<0.001). Adjusted for propensity score and EuroScore-II, mini-parasternotomy group had less pneumonia (OR=0.32, p=0.043), less sepsis (OR=0.31, p=0.045), and shorter non-complicated length of stay (coefficient=7.2 (day), p<0.001) than full sternotomy group, whereas Kaplan-Meier survival, non-complicated ICU time, non-complicated ventilator time, and 30-day mortality did not differ significantly. CONCLUSION: The propensity-adjusted analysis demonstrated encouraging safety and quality outcomes for mini-parasternotomy valve operation in carefully selected patients.

Bullet embolisation from the right subclavian vein to the right ventricle: a case report.

Bullet embolism to the heart is an unusual complication of penetrating gunshot injuries. A bullet may reach the heart by direct cardiac penetration or entry into the peripheral venous system with embolisation to the heart, which must be differentiated. This is a report of an unusual case of bullet embolism to the heart that was extracted by direct cardiotomy without cardiopulmonary bypass.

Risk factors for nosocomial infection during extracorporeal membrane oxygenation.

An increasing number of patients receive extracorporeal membrane oxygenation (ECMO) for life support. This study aimed to investigate the incidence and risk factors for nosocomial infection in adult patients receiving ECMO. We reviewed the medical records of adult patients who received ECMO support for more than 72h at Far Eastern Memorial Hospital from 2001 to 2007. ECMO-related nosocomial infections were defined as infections occurring from 24h after ECMO initiation until 48h after ECMO discontinuation. There were 12 episodes of nosocomial infection identified in 10 of the 114 (8.77%) patients on ECMO, including four cases of pneumonia, three cases of bacteraemia, three surgical site infections and two urinary tract infections. The incidence of ECMO-related nosocomial infection was 11.92 per 1000 ECMO-days. The length of ECMO use and intensive care unit (ICU) stay were significantly different between patients with, and without, nosocomial infection (P<0.001). More than 10 days of ECMO use was associated with a significantly higher nosocomial infection rate (P=0.003). Gram-negative bacilli were responsible for 78% of the nosocomial infections. In the univariate analysis, the duration of ICU stay and duration of ECMO use were associated with nosocomial infection. In the multivariate analysis, only the duration of ECMO was independently associated with nosocomial infection (P=0.007). Overall, the only independent risk factor for ECMO-related nosocomial infection identified in this study was prolonged ECMO use.

Rupture of renal artery aneurysm due to Salmonella infection in a patient with systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) are prone to infection. Immunomodulation treatment increases the susceptibility. Salmonella infections in SLE patients may present with various clinical pictures, like pneumonia, septic arthritis, osteomyelitis, peritonitis, abscess and so on. The vascular complications commonly seen in the general population with salmonella infection are rarely encountered in SLE patients. Here we report an SLE patient who presented with spontaneous rupture of salmonella mycotic aneurysm involving the left renal artery. The 54 year-old woman had a stable premorbid condition and had 30 mg prednisolone per day. Acute abdomen and hypotensive shock developed suddenly without warning signs in advance. Image and tissue culture confirmed the diagnosis. The patient had an uneventful recovery. The rare clinical scenario is reported.

Endoscopic harvest of saphenous vein: a lesson learned from 1,348 cases.

BACKGROUND: Endoscopic harvest of saphenous vein is a relatively new technique developed to minimize the wound and postoperative complications. This technique has gained patients' acceptance and become popular in cardiac surgical practices. Because most centers have limited experience with this approach, the authors summarize the clinical profiles of patients undergoing endoscopic vessel harvest (EVH). METHODS: Between March 2001 and August 2006, 1,348 patients (945 men and 403 women) with a mean age of 67.2 years (range, 28-89 years) underwent EVH of saphenous vein for coronary artery bypass surgery, peripheral artery reconstruction, and miscellaneous conditions. The EVH technique was performed using the Vasoview system (Guidant, Menlo Park, CA, USA) under the assistance of carbon dioxide (CO(2)) insufflation. RESULTS: Technical success was achieved in 98.6% of the cases. Two saphenous veins were discarded because of obvious vein injury. The mean harvest time was 45 min: 68 min for the first 50 cases and 23 min for the last 200 cases. Nearly all the patients (98%) had saphenous vein harvested only from the thighs, whereas only 1.5% of the patients had saphenous vein harvested from the legs. Postoperative wound complications were experienced by 61 patients including 25 tract hematomas, 19 wound dehiscences or poor healing, 16 wound infections, and 1 overlying skin necrosis. Overall, 13 subsequent revisions were required for these complications. Detectable air embolisms occurred for 143 patients and numbness in the saphenous nerve territory for 169 patients. CONCLUSION: The findings showed EVH of saphenous vein to be a valid alternative to open saphenectomy, providing excellent surgical results. Therefore, EVH should be considered as the standard of care for saphenous vein harvest.

Successful heterotopic heart transplant after cardiopulmonary bypass rescue of an arrested donor heart.

Global heart transplantation has declined due to the donor shortage. The use of marginal donors has therefore been reintroduced. According to the history of heart transplantation, heterotopic heart transplant has played an important role in the precyclosporine era. In those circumstances, native heart and donor heart worked together to support each other against rejection or progressive heart failure. However, heterotopic transplantation has complicated surgical techniques and requirements for postoperative surveillance. Most training fellows have limited experience with this approach. At present more than 1000 cardiac surgical centers perform heart transplantation, but only 50 centers have experience in performing-heterotopic procedures. Using mechanical circulatory support for the posttransplant period is well developed in most centers. However, using mechanical circulatory support for heart donor with the intention of rescuing the heart has not been reported. Herein, we report a successful heterotopic heart transplantation after rescue with cardiopulmonary bypass of an arrested donor heart.

Hybrid pulmonary artery conduit angioplasty for heterotopic heart transplantation.

Heterotopic heart transplantation is rare in clinical practices. It carries technical difficulty not only during transplantation procedures, but also in the postoperative surveillance. We report two cases of heterotopic heart transplantation, which were complicated by pulmonary artery conduit stenosis within 2 years. We applied a less invasive approach combining cardiovascular surgeons with an interventional cardiologist. Through the donor heart right ventricular outflow tract, we performed balloon angioplasty and stent deployment. An excellent angiographic result with minimal residual pressure gradient was achieved in both patients.

The influence of gender difference on the outcomes of infrainguinal bypass for critical limb ischaemia in Chinese patients.

PURPOSE: to investigate the influence of gender difference on the outcomes of infrainguinal bypass operations performed in Chinese patients with critical limb ischaemia. METHODS: we prospectively studied the results of 191 consecutive infrainguinal bypass operations (98 men, 93 women) for critical lower limb ischaemia in Chinese patients. RESULTS: the women were older than men (median 75 vs 70 years, p=0.001) and cigarette smoking was commoner in men (83% vs 37% p<0.001). The calibre of run-off arteries at the level of distal anastomosis was smaller in women (median 2.5 mm vs 2.0 mm, p=0.03). The 30-day mortality was 3% (five men vs one woman, p=0.09) and early graft failure occurred in 19 patients (12 women vs seven men, p=0.28). At 3 months limb loss occurred in 16 (10 women vs six men, p=0.35) patients. Survival (38% vs 60% at 4 years, p=0.12) was similar in men and women. However, women suffered from poorer primary (33% vs 49% at 3 years, p=0.03) secondary graft patency rates (35% vs 64% at 3 years, p=0.02) than men. Limb survival rate in two groups (75% vs 85% at 4 years, p=0.18) was comparable. CONCLUSION: following infrainguinal bypass for critical limb ischaemia, early results were similar in both gender groups. In the long-term, women patients suffered from significantly higher graft failure rate. However, their long-term survival and limb salvage rate remained comparable to those of men.

Spontaneous intramural hematoma of stomach.

BACKGROUND: Intramural hematoma occurs uncommonly in the gastrointestinal tract and very rarely in the stomach. In case of a spontaneous gastric hematoma, the few previously reported patients all had certain predisposing factors. However, truly spontaneous intramural hematoma of the stomach without an identifiable cause has not been reported before. METHOD: Emergency total gastrectomy was performed in a 49-year-old man with such pathology and the diagnosis was made postoperatively. RESULTS: The patient required further laparotomy on day 10 for drainage and debridement of a subphrenic abscess. He recovered uneventfully from the second operation. After an extensive pathological search, no predisposing factors could be found. The patient remains in good health 18 months after the operations. CONCLUSION: Spontaneous intramural gastric hematoma is extremely rare. But even rarer is when predisposing conditions or lesions are absent.

Correlation of estradiol, parathyroid hormone, interleukin-6, and soluble interleukin-6 receptor during the normal menstrual cycle.

Rodent models suggest that estradiol deficiency promotes bone loss through increasing interleukin-6 (IL-6) activity. However, it is controversial as to whether these findings are applicable to humans. To evaluate estradiol-mediated modulation of IL-6 activity in relation to bone metabolism in humans, we measured serum IL-6, soluble interleukin-6 receptor (sIL-6R), estradiol (E2), progesterone, luteinizing hormone, follicle-stimulating hormone, intact parathyroid hormone (PTH), serum and urine Ca, and bone biochemical markers (serum bone-specific alkaline phosphatase, osteocalcin, and serum and urine deoxypyridinoline [Dpd]) across one menstrual cycle for 211 women. Neither IL-6 nor sIL-6R levels differed between the follicular phase (FP) and the luteal phases (LP). However, IL-6 was negatively correlated with E2 during the FP (p =0.003). Furthermore, IL-6 correlated positively with serum Ca over the entire cycle (p = 0.0091. Serum Ca correlated positively with serum (p = 0.040) and urine (p = 0.006) Dpd. PTH was significantly higher during the FP than in the LP (p = 0.004). PTH was negatively related to E2 (p = 0.002), serum Ca (p < 0.001), and urine Ca (p = 0.036), whereas it was positively correlated with IL-6 (p = 0.027). These data demonstrate that IL-6 and PTH fluctuate with E2, and serum II-6 is associated with PTH levels during the menstrual cycle. However, the role of 11-6 in bone remodeling during the normal menstrual cycle remains to be determined.

Selective estrogen receptor modulators and postmenopausal health.

SERMs are a class of drugs with mixed estrogen agonist/antagonist effects that have great potential at targeting changes seen in the postmenopausal period. Raloxifene is effective in preventing bone loss and may prevent fractures in postmenopausal osteoporosis. It induces changes in lipoprotein concentrations that should be cardioprotective. It has no stimulatory effect on the uterus and is well tolerated. Raloxifene is an attractive alternative to HRT in preventing postmenopausal bone loss, especially for women that are more concerned about the risk of breast cancer or vaginal bleeding. Unanswered questions include raloxifene's effect on fracture incidence, cardiac events, and dementia; long-term safety data are also needed. Its potential role in the primary prevention of breast cancer also needs large, long-term studies. Tamoxifen has been used traditionally as adjuvant therapy for breast cancer, but new data indicate that it is effective in the primary prevention of breast cancer in women at increased risk. Its effects on bone and lipoproteins are attractive complementary effects when used in the subset of women at increased risk for breast cancer. New generations of SERMs are being developed that may have more potent estrogen agonist effects on bone and cardiovascular disease, or more potent antiestrogen effects, especially at the breast. There will likely be a selection of SERMs available, and the choice of SERM for a woman will be tailored to her specific issues and risk profile.

Correlation of serum L-carnitine and dehydro-epiandrosterone sulphate levels with age and sex in healthy adults.

OBJECTIVES: L-carnitine and dehydro-epiandrosterone (DHEA) independently promote mitochondrial energy metabolism. We therefore wondered if an age-related deficiency of L-carnitine or DHEA may account for the declining energy metabolism associated with age. METHODS: we evaluated serum levels of L-carnitine and the sulphated derivative of DHEA (DHEAS) in cross-sectional study of 216 healthy adults, aged 20-95. RESULTS: serum DHEAS levels declined, while total carnitine levels increased with age (P < 0.0001). Total and free carnitine and DHEAS levels were lower in women than men (P < 0.0001). Esterified/free (E/F) carnitine (inversely related to carnitine availability) increased with age in both sexes (P=0.012). CONCLUSION: reduced carnitine availability correlates with the age-related decline of DHEAS levels. These results are consistent with the hypothesis that decreased energy metabolism with age relates to DHEAS levels and carnitine availability.

Carnitine and dehydroepiandrosterone sulfate induce protein synthesis in porcine primary osteoblast-like cells.

Age-related bone loss eventually leads to osteopenia in men and women. The etiology of age-related bone loss is currently unknown; however, decreased osteoblast activity contributes to this phenomenon. In turn, osteoblast proliferation and function is dependent on energy production, thus the loss of energy production that occurs with age may account for the deficient osteoblast activity. Carnitine and dehydroepiandrosterone-sulfate (DHEAS), both of which decline with age, promote energy production through fatty acid metabolism. Thus, we hypothesized that carnitine and DHEAS would increase osteoblast activity in vitro. Accordingly, we measured the effect of carnitine and DHEAS on palmitic acid oxidation as a measure of energy production, and alkaline phosphatase (ALP) activity and collagen type I (COL) as indices of osteoblast function in primary porcine osteoblast-like cell cultures. Carnitine (10(-3) and 10(-1) M) but not DHEAS (10(-9), 10(-8), and 10(-7) M) increased carnitine levels within the cells. Carnitine alone and in combination with DHEAS increased palmitic acid oxidation. Both carnitine and DHEAS alone and in an additive fashion increased ALP activity and COL levels. These results demonstrate that in osteoblast-like cells in vitro, energy production can be increased by carnitine and osteoblast protein production can be increased by both carnitine and DHEAS. These data suggest that carnitine and DHEAS supplementation in the elderly may stimulate osteoblast activity and decrease age-related bone loss.

Changes in bone resorption during the menstrual cycle.

To determine if the cyclic changes of female sex hormones during the menstrual cycle are related to changes in bone formation and resorption, we measured serum bone-specific alkaline phosphatase (BAP) and osteocalcin (OC) and bone resorption markers, serum and urine deoxypyridinoline (Dpyr), three times per week during one menstrual cycle in 20 healthy premenopausal women. Serum estradiol (E2) and progesterone (P) showed characteristic cyclic fluctuations. Serum Dpyr was higher during the follicular phase (FP) than in the luteal phase (p = 0.027). Serum BAP, OC, and urine Dpyr levels did not change substantially across the cycle. Serum Dpyr correlated negatively with serum E2 values measured 6 (p = 0.011) and 8 (p = 0.001) days earlier and with P measured concurrently (p = 0.033) 2 (p = 0.002), 4 (p = 0.003), and 6 (p = 0.014) days earlier. BAP correlated negatively with E2 measured 6 days earlier (p = 0.006). We found no statistically significant correlations of E2 or P with OC or urine Dpyr within women over their cycles. BAP was positively correlated with concurrent serum Dpyr (p = 0.015) during the menstrual cycle. Serum OC levels correlated inversely with age (rs = -0.48, p = 0.036). Women with higher mean urine Dpyr levels had higher mean serum OC levels (rs = 0.49, p = 0.033) and showed a trend toward lower hip bone mineral density (rs = -0.40, p = 0.078). We conclude that the low level of E2 and/or P observed during the FP of the normal menstrual cycle is associated with increased bone resorption. These relationships suggest that normal women experience monthly episodes of increased bone resorption from menarche to menopause.

Arterial lesions in severe lower limb ischaemia: a prospective study of 100 consecutive ischaemic limbs in a Hong Kong Chinese population.

BACKGROUND: The pattern and distribution of arterial lesions in a local Chinese population were studied to assess the feasibility of reconstruction and the possibility of avoiding major amputation of ischaemic limbs. METHOD: Between March 1995 and August 1997, 90 consecutive patients with 100 severely ischaemic lower limbs and their arteriograms were analysed. There were 48 female and 42 male patients with a mean age of 72 years. All the patients were in fair general health, did not have foot pulses and were willing to undergo major arterial reconstruction. Ten patients had bilateral limb ischaemia and 94 of the ischaemic limbs were affected by rest pain with or without ulcer and/or gangrene. The remaining six patients had debilitating claudication. These lesions were classified into low-grade (less than 50% stenosis), high-grade (50-90% stenosis) and critical (> 90% stenosis to occlusion). RESULTS: Critically stenotic or occlusive lesions were present in 16% of aorto-iliac segments; 76% of femoropopliteal arteries; and 82% of trifurcation and infrapopliteal segments. In at least 27 patients one of the two main foot arteries was also severely diseased. The present analysis suggested that 79 of these ischaemic limbs had reconstructable lesions. Sixteen were not suitable for intervention and in five patients the reconstructability was uncertain radiologically. CONCLUSION: Contrary to local belief, the majority of patients in the Chinese community with severe lower limb ischaemia without foot pulses would have technically reconstructable arterial lesions and could benefit from a revascularization procedure.

Laparoscopic resection of a primary retroperitoneal mucinous cystadenoma: report of a case.

Primary retroperitoneal mucinous cystic tumors are extremely rare, and although their histogenesis is still uncertain, several theories have been proposed. Traditionally, transabdominal laparotomy and enucleation of the cyst is the treatment of choice and laparoscopic resection has not previously been reported. This paper presents the case of a 48-year-old woman in whom a primary retroperitoneal cystic mass, 15 x 13 x 9 cm in size, was successfully resected through the laparoscope. Pathological examination revealed a mucinous cystadenoma with borderline malignancy. The patient had a prompt recovery and there was no evidence of recurrence at her 8-month follow-up. However, the prevention of cystic fluid spillage during laparoscopic manipulation is important, especially when the pathology of the retroperitoneal cyst is unclear.

A multidisciplinary approach to salvage the 'unsalvageable' foot.

Extensive tissue loss in a weight-bearing area of the foot almost invariably heralds limb loss. We report on a 74-year-old man with diabetes mellitus who had an ischaemic foot that was affected by prolonged pressure, which resulted in a necrotic heel. After two sessions of debridement, the calcaneum became exposed. Amputation was initially suggested but was refused by the patient. The foot was subsequently salvaged by staged operations. The first operation was a femoro-anterior tibial bypass using an autogenous saphenous vein to revascularise the foot. This was followed by debridement and attachment of a free subscapular flap to cover the defect 2 weeks later by a plastic surgeon. After 85 days of rehabilitation by physiotherapy and education of foot care by a podiatrist, the patient was discharged home and was able to walk with a walking-stick. This multidisciplinary approach

Arterial reconstruction for lower limb ischaemia in Hong Kong Chinese.

BACKGROUND: Lower limb ischaemia due to peripheral arterial disease is uncommon in Chinese people, and few arterial bypass operations have been performed. The management of a consecutive series of patients who were admitted to our department with severe lower limb ischaemis between March 1990 and October 1996 is reported here. METHODS: A total of 91 primary arterial bypass operations were performed for 83 patients (eight patients had bilateral, or two procedures). Of these, 84 operations were for foot salvage and seven operations were for debilitating claudication. There were 80 infra-inguinal bypasses, 10 of which required additional femoro-femoral crossover grafts to improve in-flow. The remaining 11 bypass procedures were performed for aorto-iliac occlusion, which included aortobifemoral bypass (5), axillobifemoral bypass (3) and cross-femoral bypass (3) grafts. There were 46 male and 37 female patients, with a median age of 70 years (36-94). RESULTS: Six patients died (6.6%) postoperatively, all of whom were in the foot salvage group. The overall cumulative foot salvage rate and graft patency was 84 and 56%, respectively, at 5 years. CONCLUSIONS: These results justified the use of the same aggressive approach that was adopted in Western countries for the treatment of peripheral arterial disease, which seemed to be an emerging problem in Hong Kong.