Machine learning to predict myocardial injury and death after non-cardiac surgery.

Myocardial injury due to ischaemia within 30 days of non-cardiac surgery is prognostically relevant. We aimed to determine the discrimination, calibration, accuracy, sensitivity and specificity of single-layer and multiple-layer neural networks for myocardial injury and death within 30 postoperative days. We analysed data from 24,589 participants in the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation study. Validation was performed on a randomly selected subset of the study population. Discrimination for myocardial injury by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.70 (0.69-0.72) vs. 0.71 (0.70-0.73) with variables available before surgical referral, p < 0.001; 0.73 (0.72-0.75) vs. 0.75 (0.74-0.76) with additional variables available on admission, but before surgery, p < 0.001; and 0.76 (0.75-0.77) vs. 0.77 (0.76-0.78) with the addition of subsequent variables, p < 0.001. Discrimination for death by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.71 (0.66-0.76) vs. 0.74 (0.71-0.77) with variables available before surgical referral, p = 0.04; 0.78 (0.73-0.82) vs. 0.83 (0.79-0.86) with additional variables available on admission but before surgery, p = 0.01; and 0.87 (0.83-0.89) vs. 0.87 (0.85-0.90) with the addition of subsequent variables, p = 0.52. The accuracy of the multiple-layer model for myocardial injury and death with all variables was 70% and 89%, respectively.

Perioperative myocardial injury in patients receiving cardiac output-guided haemodynamic therapy: a substudy of the OPTIMISE Trial.

BACKGROUND: Evidence suggests that cardiac output-guided haemodynamic therapy algorithms improve outcomes after high-risk surgery, but there is some concern that this could promote acute myocardial injury. We evaluated the incidence of myocardial injury in a perioperative goal-directed therapy trial. METHODS: Patients undergoing major gastrointestinal surgery (n=723) were randomly assigned to cardiac output-guided haemodynamic therapy (intervention group) or usual care as part of the OPTIMISE trial. At four participating sites, 288 patients were enrolled in a biomarker substudy. Serum high-sensitivity cardiac troponin I (TnI) concentration and N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration were measured before and at 24 and 72 h after surgery. RESULTS: Median preoperative TnI and NT-ProBNP concentrations were 4.3 ng litre(-1) and 144 pg ml(-1), respectively. After surgery, 67 (46%) patients in the intervention group and 68 (48%) patients receiving usual care had TnI concentrations above the 99th centile upper reference limit (P=0.82). Peak serum TnI concentration was similar in the intervention and usual care groups (median [interquartile range]: 10.0 [5.3-21.5] vs 7.8 [5.0-21.8] ng litre(-1); P=0.85), and no differences were observed in serum TnI concentrations over 72 h (repeated-measures anova, P=0.51). Likewise, there were no differences in peak NT-proBNP concentration between intervention and usual care groups (645 [362-1169] vs 659 [381-1028] pg ml(-1); P=0.86) or in serial NT-proBNP concentrations over 72 h (P=0.20). CONCLUSIONS: Myocardial injury is common among patients undergoing major gastrointestinal surgery. In this study, the frequency was not affected by cardiac output-guided fluid and low-dose inotropic therapy.

Comprehensive validation of early diagnostic algorithms for myocardial infarction in the emergency department.

OBJECTIVE: To comprehensively evaluate diagnostic algorithms for myocardial infarction using a high-sensitivity cardiac troponin I (hs-cTnI) assay. PATIENTS AND METHODS: We prospectively enrolled patients with suspected myocardial infarction without ST-segment elevation from nine emergency departments in Japan. The diagnostic algorithms evaluated: (i) based on hs-cTnI alone, such as the European Society of Cardiology (ESC) 0/1-h or 0/2-h and High-STEACS pathways; or (ii) used medical history and physical findings, such as the ADAPT, EDACS, HEART, and GRACE pathways. We evaluated the negative predictive value (NPV), sensitivity as safety measures, and proportion of patients classified as low or high-risk as an efficiency measure for a primary outcome of type 1 myocardial infarction or cardiac death within 30 days. RESULTS: We included 437 patients, and the hs-cTnI was collected at 0 and 1 hours in 407 patients and at 0 and 2 hours in 394. The primary outcome occurred in 8.1% (33/407) and 6.9% (27/394) of patients, respectively. All the algorithms classified low-risk patients without missing those with the primary outcome, except for the GRACE pathway. The hs-cTnI-based algorithms classified more patients as low-risk: the ESC 0/1-h 45.7%; the ESC 0/2-h 50.5%; the High-STEACS pathway 68.5%, than those using history and physical findings (15-30%). The High-STEACS pathway ruled out more patients (20.5%) by hs-cTnI measurement at 0 hours than the ESC 0/1-h and 0/2-h algorithms (7.4%). CONCLUSIONS: The hs-cTnI algorithms, especially the High-STEACS pathway, had excellent safety performance for the early diagnosis of myocardial infarction and offered the greatest improvement in efficiency.

Cardiovascular effects of particulate air pollution exposure: time course and underlying mechanisms.

Air pollution is now recognized as an important independent risk factor for cardiovascular morbidity and mortality and may be responsible for up to 3 million premature deaths each year worldwide. The mechanisms underlying the observed effects are poorly understood but are likely to be multifactorial. Here, we review the acute and chronic effects of air pollution exposure on the cardiovascular system and discuss how these effects may explain the observed increases in cardiovascular morbidity and mortality.

Predictors of UK healthcare worker burnout during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic is putting health professionals under increasing pressure. This population is already acknowledged to be at risk of burnout. AIM: We aim to provide a 'snapshot' of the levels of burnout, anxiety, depression and distress among healthcare workers during the COVID-19 pandemic. METHODS: We distributed an online survey via social media in June 2020 open to any UK healthcare worker. The primary outcome measure was symptoms of burnout measured using the Copenhagen Burnout Inventory. Secondary outcomes of depression, anxiety, distress and subjective measures of stress were also recorded. Multivariate logistic regression analysis was performed to identify factors associated with burnout, depression, anxiety and distress. RESULTS: A total of 539 persons responded to the survey; 90% female and 53% nurses. Participants with moderate-to-severe burnout were younger (49% vs. 33% under 40 years, P = 0.004), more likely to have pre-existing comorbidities (21% vs. 12%, P = 0.031), twice as likely to have been redeployed from their usual role (22% vs. 11%; P = 0.042), or to work in an area dedicated to COVID-19 patients (50% vs. 32%, P < 0.001) and were almost 4 times more likely to have previous depression (24% vs. 7%; P = 0.012). CONCLUSION: Independent predictors of burnout were being younger, redeployment, exposure to patients with COVID-19, being female and a history of depression. Evaluation of existing psychological support interventions is required with targeted approaches to ensure support is available to those most at risk.

Dynamic Changes in High-Sensitivity Cardiac Troponin I in Response to Anthracycline-Based Chemotherapy.

AIMS: Treatment advances have improved cancer-related outcomes and shifted interest towards minimising long-term iatrogenic complications, particularly chemotherapy-related cardiotoxicity. High-sensitivity cardiac troponin I (hs-cTnI) assays accurately quantify very low concentrations of plasma troponin and enable early detection of cardiomyocyte injury prior to the development of myocardial dysfunction. The profile of hs-cTnI in response to anthracycline-based treatment has not previously been described. MATERIALS AND METHODS: This was a multicentre prospective observational cohort study. Female patients with newly diagnosed invasive breast cancer scheduled to receive anthracycline-based (epirubicin) chemotherapy were recruited. Blood sampling was carried out before and 24 h after each cycle. Hs-cTnI concentrations were measured using the Abbott ARCHITECTSTAT assay. RESULTS: We recruited 78 women with a median (interquartile range) age of 52 (49-61) years. The median baseline troponin concentration was 1 (1-4) ng/l and the median cumulative epirubicin dose was 394 (300-405) mg/m2. Following an initial 33% fall 24 h after anthracycline dosing (P < 0.001), hs-cTnI concentrations increased by a median of 50% (P < 0.001) with each successive treatment cycle. In total, 45 patients had troponin measured immediately before the sixth treatment cycle, 21 (46.6%) of whom had hs-cTnI concentrations ≥16 ng/l, indicating myocardial injury. Plasma hs-cTnI concentrations before the second treatment cycle were a strong predictor of subsequent myocardial injury. CONCLUSIONS: Cardiotoxicity arising from anthracycline therapy is detectable in the earliest stages of breast cancer treatment and is cumulative with each treatment cycle. This injury is most reliably determined from blood sampling carried out before rather than after each treatment cycle.

Influence of menstrual cycle on circulating endothelial progenitor cells.

BACKGROUND: Endothelial progenitor cells (EPCs) are circulating mononuclear cells that participate in angiogenesis. The aim of this study was to determine the influence of the menstrual cycle on the number and function of EPCs, and to investigate their relationship with circulating concentrations of sex steroids and inflammatory mediators. METHODS: Ten healthy nulliparous, premenopausal, non-smoking women with regular menses were studied over a single menstrual cycle. Venepuncture was performed in the menstrual, follicular, peri-ovulatory and luteal phases. EPCs were quantified by flow cytometry (CD133(+)CD34(+)KDR(+) phenotype) and the colony-forming unit (CFU-EPC) functional assay. Circulating concentrations of estradiol, progesterone and inflammatory mediators (TNF-alpha, IL-6, sICAM-1 and VEGF) were measured by immunoassays. RESULTS: The numbers of CD133(+)CD34(+)KDR(+) cells were higher in the follicular phase (0.99 +/- 0.3 x 10(6) cells/l) compared with the peri-ovulatory phase (0.29 +/- 0.1 x 10(6) cells/l; P < 0.05). In contrast, the numbers of CFU-EPCs did not vary over the menstrual cycle. There were no correlations between EPCs and concentrations of either circulating sex steroids or inflammatory mediators. CONCLUSIONS: CD133(+)CD34(+)KDR(+) cells but not CFU-EPCs vary during the menstrual cycle. Our findings suggest a potential role for circulating EPCs in the normal cycle of physiological angiogenesis and repair of the uterine endometrium that is independent of circulating sex steroids or inflammatory mediators.

Continuous positive airway pressure improves vascular function in obstructive sleep apnoea/hypopnoea syndrome: a randomised controlled trial.

BACKGROUND: The obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is associated with hypertension and increased cardiovascular risk, particularly when accompanied by marked nocturnal hypoxaemia. The mechanisms of these associations are unclear. We hypothesised that OSAHS combined with severe nocturnal hypoxaemia causes impaired vascular function that can be reversed by continuous positive airways pressure (CPAP) therapy. METHODS: We compared vascular function in two groups of patients with OSAHS: 27 with more than 20 4% desaturations/h (desaturator group) and 19 with no 4% and less than five 3% desaturations/h (non-desaturator group). In a randomised, double blind, placebo controlled, crossover trial, the effect of 6 weeks of CPAP therapy on vascular function was determined in the desaturator group. In all studies, vascular function was assessed invasively by forearm venous occlusion plethysmography during intra-arterial infusion of endothelium dependent (acetylcholine 5-20 microg/min and substance P 2-8 pmol/min) and independent (sodium nitroprusside 2-8 microg/min) vasodilators. RESULTS: Compared with the non-desaturator group, patients with OSAHS and desaturations had reduced vasodilatation to all agonists (p = 0.007 for all). The apnoea/hypopnoea index and desaturation frequency were inversely related to peak vasodilatation with acetylcholine (r = -0.44, p = 0.002 and r = -0.43, p = 0.003) and sodium nitroprusside (r = -0.42, p = 0.009 and r = -0.37, p = 0.02). In comparison with placebo, CPAP therapy improved forearm blood flow to all vasodilators (p = 0.01). CONCLUSIONS: Patients with OSAHS and frequent nocturnal desaturations have impaired endothelial dependent and endothelial independent vasodilatation that is proportional to hypoxaemia and is improved by CPAP therapy. Impaired vascular function establishes an underlying mechanism for the adverse cardiovascular consequences of OSAHS.

Increased arterial stiffness in patients with chronic obstructive pulmonary disease: a mechanism for increased cardiovascular risk.

RATIONALE: Chronic obstructive pulmonary disease (COPD) is associated with a 2-3-fold increase in the risk of ischaemic heart disease, stroke and sudden death. The mechanisms responsible for this association are not clear and appear to be independent of smoking history. OBJECTIVE: We test the hypothesis that patients with COPD have increased arterial stiffness and blood pressure in comparison with age and smoking matched controls. METHODS: In a prospective case control study, we recruited 102 patients with COPD and 103 healthy controls matched for age and smoking status. Patients were assessed by clinical history and spirometry, with arterial stiffness and blood pressure determined using radial artery applanation tonometry and sphygmomanometry. RESULTS: Patients with COPD had increased arterial stiffness compared with matched controls, with elevated augmentation pressure (17 (1) vs 14 (1) mm Hg; p = 0.005) and a reduced time to wave reflection (131 (1) vs 137 (2) ms; p = 0.004). These differences were associated with increases in both diastolic (82 (1) vs 78 (1) mm Hg; p = 0.005) and systolic blood pressure (147 (2) vs 132 (2) mm Hg; p<0.001). Serum C reactive protein concentrations were threefold higher in patients (6.1 (0.9) vs 2.3 (0.4) mg/l; p = 0.001). Data are presented as mean (SEM). CONCLUSIONS: Patients with COPD have increased arterial stiffness and blood pressure in comparison with controls matched for age and smoking status. We speculate that increased systemic inflammation and vascular dysfunction could potentially explain the excess cardiovascular morbidity and mortality associated with COPD.

Radial artery vasomotor function following transradial cardiac catheterisation.

AIMS: To determine the reproducibility of flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) in the assessment of radial artery vasomotor function, and to examine the effect of transradial catheterisation on radial artery injury and recovery. METHODS: Radial artery FMD and NMD were examined in 20 volunteers and 20 patients on four occasions (two visits at least 24 hours apart, with two assessments at each visit). In a further 10 patients, radial artery FMD was assessed in the catheterised arm prior to, at 24 hours and 3 months following cardiac catheterisation. RESULTS: There were no differences in baseline radial artery diameter (2.7±0.4 mm vs 2.7±0.4 mm), FMD (13.4±6.4 vs 12.89±5.5%) or NMD (13.6±3.8% vs 10.1±4.3%) between healthy volunteers and patients (p>0.05 for all comparisons). Mean differences for within and between day FMD were 2.53% (95% CIs -15.5% to 20.5%) and -4.3% (-18.3% to 9.7%) in patients. Compared to baseline, radial artery FMD was impaired at 24 hours (8.7±4.1% vs 3.9±2.9%, p=0.015) but not 3 months (8.7±4.1% vs 6.2±4.4, p=0.34) following transradial catheterisation. CONCLUSIONS: Radial FMD is impaired early after transradial catheterisation but appears to recover by 3 months. While test-retest variability was demonstrated, our findings suggest that transradial access for cardiac catheterisation may afford a potential model of vascular injury and repair in vivo in man.

Renal artery stenosis and polycystic kidney disease.

A patient had unilateral renal artery stenosis and, at the same time, bilateral polycystic kidney disease. The renal venous renin ratio of 151:40, together with a high peripheral plasma renin activity, indicated that the hypertension was partially caused by renopressor mechanism. Correction of the obstructive lesion permitted a better control of hypertension with antihypertensive drugs, and the peripheral and renal venous renin activity returned to normal. The success in detecting one pathogenic mechanism responsible for arterial hypertension should not deter further diagnostic efforts.

Measurement of atrial septal defect during cardiac catheterization. Experimental and clinical results.

The size of experimental and clinical secundum atrial septal defects may be accurately measured during cardiac catheterization. The position of the defects in the septum and their distance from the aortic and mitral valves may also be ascertained. A balloon catheter inflated with radiopaque dye is used for the measurement. The volume of dye in the balloon has been correlated with its maximal diameter. Thus, a no. 8-10 French catheter filled with 10 ml of diatrizoate (50 percent) has a diameter of approximately 25 mm and a no. 8-22 French catheter filled with 40 ml of diatrizoate a diameter of approximately 43 mm. Persistent arrhythmias or other adverse effects of the procedure were not observed. There was a high correlation between balloon-measured atrial septal defects and those measured at necropsy in the animals or at operation in the patients. These measurements aid in determining whether an ostium secundum defect is of proper size and location to be closed transvenously and may also prove valuable in physiologic studies of atrial septal defects or other cardiac anomalies.

Preparation of the internal mammary artery graft. Which is the best method?

Early reports questioned the adequacy of flow of the internal mammary artery when used routinely as a bypass graft. "Adequate" mammary artery flow is now contested only in certain situations, that is, left ventricular hypertrophy, acute myocardial infarction, and reoperations. To compare the methods of mammary pedicle graft preparations with free mammary artery flow, we studied 31 patients who had the left internal mammary artery harvested for elective coronary artery bypass grafting. Group I comprised 14 patients whose mean body surface area was 1.91 m2. Systolic, diastolic, and mean arterial blood pressures, left atrial pressure, and heart rate were recorded and stabilized during flow measurements. Free flow of the internal mammary artery was measured before any pharmacologic manipulation and ranged from 5 to 44 ml/min (mean 18 ml/min). The grafts were sprayed and wrapped in sponges soaked in diluted papaverine solution (60 mg in 40 ml normal saline) for an average of 21 minutes. Free flow ranged from 10 to 108 ml/min (mean 51 ml/min). Intraluminal papaverine of the same dilution was then injected with hydrostatic dilatation. Immediate internal mammary artery flows rose from 150 to 333 ml/min (mean 229 ml/min). Group II comprised 17 patients who had internal mammary artery takedown under the exact conditions used in group I. Mean body surface area was 1.89 m2. Mammary artery pedicles were injected with diluted papaverine throughout their lengths with size 25 needles. After an average of 19.5 minutes, free flow ranged from 28 to 132 ml/min (mean 69 ml/min). Intraluminal diluted papaverine was then administered as in group I, and flows increased from 144 to 280 ml/min (mean 198 ml/min). The distal internal mammary arteries in both groups were 1.75 to 2.5 mm in internal diameter at the site of arteriotomy for flow measurement. This study shows that all mammary arteries are in spasm immediately after harvest and that flow is inadequate before any pharmacologic intervention. Although extraluminal vasodilators will increase free mammary artery flow, intraluminal papaverine followed by hydrostatic dilatation raises free flow to maximal capacity. Subsequent graft spasm has not been observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Massive air embolism during cardiopulmonary bypass. Causes, prevention, and management.

Massive air embolism during cardiopulmonary bypass is a frightening complication requiring immediate response and carrying strong medicolegal implications. From July, 1971, to July, 1979, there were eight instances of massive air embolism during 3,620 cardiopulmonary bypass operations. Five such accidents from other institutions are included in this report. Causes were (1) inattention to reservoir level, (2) reversal of pump head tubing or direction of pump head rotation, (3) unexpected resumption of heartbeat, (4) inadequate steps to remove air after cardiotomy, (5) high-flow suction deep in a pulmonary artery, (6) defective oxygenator, (7) use of a pressurized cardiotomy reservoir, and (8) inadvertent detachment of oxygenator during bypass. Prevention includes a systematic check of pump suckers and perfusion lines before bypass, a sensing device on the oxygenator reservoir, secure fixation of the oxygenator and avoidance of traffic around pump equipment, immediate cessation of pump and inspection for abnormal noise, use of standard maneuvers to remove air from the heart, and carotid compression with resumption of heartbeat. Immediate management of massive air embolism consists of placing the patient in a deep Trendelenburg position and making a large stab wound in the ascending aorta for retrograde drainage from the cerebrovascular bed. Temporary retrograde perfusion through the superior vena cava (SVC) may also be used. Subsequent steps are hypothermia with the resumption of cardiopulmonary bypass, elevation of blood pressure, steroids, ventilation with 100% oxygen, and deep barbiturate anesthesia. Among the 13 patients, there were four instantaneous deaths. Cerebral injury which resolved within a 2 month period occurred in three patients. The remainder had no neurologic sequelae. Nonfatal cerebral air injury may be associated with prolonged convalescence yet complete recovery, as compared to embolism from debris or clot, which offers a poorer prognosis.

Atherosclerosis of the ascending aorta and coronary artery bypass. Pathology, clinical correlates, and operative management.

Analysis of 1735 patients who underwent coronary artery bypass grafting from January 1981 through December 1988 revealed 152 (8.8%) patients with mild (4.5%), moderate (2.2%), or severe (2.0%) atherosclerosis of the ascending aorta. Three distinct pathologic patterns were found. The prevalence of stroke in patients with the severe type of aortic disease prompted development of a new operative technique that has been used in 16 patients. It involves a "no-touch" technique of the ascending aorta whereupon the proximal saphenous vein anastomoses are performed end to side to internal mammary artery grafts. Ages ranged from 49 to 80 years (mean 68.9). The 16 patients had 62 distal artery and vein anastomoses and 26 proximal saphenous vein-internal mammary end-to-side anastomoses. Internal mammary artery free flows ranged from 130 to 420 ml/min. Two hospital deaths were unrelated to the technique. There have been no strokes or recurrences of angina. An inordinately high incidence of main left coronary disease (50%), significant carotid disease (79%), and abdominal aortic occlusive or aneurysm disease (93%) was discovered. Ascending aortic atherosclerosis must be suspected in all coronary bypass patients with associated significant carotid, abdominal aortic, and main left coronary artery disease, aortic wall irregularity on ascending aortic angiography, adhesions between the ascending aorta and its adventitia, pale appearance of the ascending aorta, and minimal bleeding of an aortic cannulation stab wound. A "no-touch" technique that avoids any manipulation of the ascending aorta and that uses the internal mammary arteries as the sole source of blood supply for coronary bypass is an effective method to prevent aortic clamp injury, "trash heart," or stroke from severe ascending aortic disease. Preoperative angiographic visualization of the ascending aorta of all patients undergoing coronary artery bypass is mandatory.

Valvulotomy of valves in the saphenous vein graft before coronary artery bypass.

Occasionally, repeat angiograms disclose turbulence, with or without clot formation, at the valve sites in saphenous veins used as coronary artery bypass grafts. A simple valvulotomy may be used to split these valves to allow a more even flow and to avoid the valve recess where air may be trapped or thrombus formed. A potential cause for perioperative infarction or graft failure may thus be avoided.

Nonoperative closure of left-to-right shunts.

Efforts to close left-to-right shunts at Ochsner Medical Institutions have been directed toward atrial septal defects (ASD) and patent ductus arteriosus (PDA). PDA's were constructed in dogs by interposing a segment of jugular vein between the aorta and main pulmonary artery. Five dogs in which the PDA was closed by a plug device inserted through the femoral vessels were put to death at 6 to 12 months. Histologic sections showed good fibrous ingrowth with endothelial covering on the aorta and pulmonary artery sides. There were no migrations redidual shunts. At cardiac catherterization, 18 patients had ASD's sized and located as to position in the septum. The sized ranged from 13 to greater than 30 mm. in diameter. The ASD sizes in patients who underwent standard operative closure were compared to the measurements at catheterization, and the variation was insignificant. In 5 patients, centrally positioned secundum ASD's were closed with double umbrella devices, 25 to 35 mm. in diameter. Anatomic contraindications for umbrella closure include ASD's greater than 30mm. in diameter, anomalous pulmonary venous connection, common atrium, inferiorly or superioly located secrumdum ASD, and sinus venosus ASD. Follow-up studies from 6 to 12 months on 5 patients with umbrella closure have revealed no hemolysis, arrhythmias, thromboembolism, migration, or other untoward effects.

Clinical comparison between patients with saphenous vein and internal mammary artery as a coronary graft.

From January, 1971, through May, 1978, the records of 1,239 patients who had comparable patterns of coronary artery bypasses were retrieved for study from the Ochsner computerized data bank. Seven hundred twenty-six patients had saphenous vein grafts (SVG) alone and 513 patients had internal mammary artery (IMA) grafts alone or in combination with SVG. Patients with IMA grafts had significantly improved survival over patients with SVGs, but after exclusion of biasing subgroups the improved survival was not reliably different (p = 0.1684). The percentages of patients who had unrelieved angina after operation were similar (5.0% versus 4.8%); the rates of nonfatal myocardial infarction and of postoperative congestive heart failure were also similar. When the recently done SVG bypasses were compared to those done before mid-1975, we found that unrelieved angina rates and nonfatal myocardial infarction rates were significantly improved in the recent group. We conclude that use of the SVG is indicated in some clinical situations and use of the IMA graft in others. Therefore, cardiovascular surgeons should be proficient in using both grafts.

Delayed pulmonary complications of ventricular aneurysm repair. Report of two cases and review of the literature.

Two patients referred to Ochsner Foundation Hospital after ventricular aneurysm repair had the delayed pulmonary complications of massive hemoptysis and bronchiectasis. Only three cases of infected ventricular aneurysm repair have been reported previously. The felt buttress used in aneurysm repair may be the seat of indolent infection or it may erode into pulmonary tissue with secondary infection. For anatomic reasons the lingular segment of the lung appears to be at increased risk of involvement. Symptoms led to the correct diagnosis in one case at 7 months and in the other at 3 years after the original operation. Infection may be prevented by appropriate measures. However, should such a catastrophe occur, aggressive surgical therapy with removal of all foreign material is mandatory.

Management of an infected Hancock prosthesis after repair of truncus arteriosus.

This report described a case in which purulent mediastinitis involving a Hancock prosthesis developed after repair of truncus arteriosus in a 6-year-old boy. The graft and surrounding area became sterilized after having been irrigated with povidone-iodine and antibiotic solutions for 6 weeks. At his most recent visit, the child was completely active and asymptomatic.