A review of bat hibernacula across the western United States: Implications for white-nose syndrome surveillance and management.

Efforts to conserve bats in the western United States have long been impeded by a lack of information on their winter whereabouts, particularly bats in the genus Myotis. The recent arrival of white-nose syndrome in western North America has increased the urgency to characterize winter roost habitats in this region. We compiled 4,549 winter bat survey records from 2,888 unique structures across 11 western states. Myotis bats were reported from 18.5% of structures with 95% of aggregations composed of ≤10 individuals. Only 11 structures contained ≥100 Myotis individuals and 6 contained ≥500 individuals. Townsend's big-eared bat (Corynorhinus townsendii) were reported from 38% of structures, with 72% of aggregations composed of ≤10 individuals. Aggregations of ≥100 Townsend's big-eared bats were observed at 41 different caves or mines across 9 states. We used zero-inflated negative binomial regression to explore biogeographic patterns of winter roost counts. Myotis counts were greater in caves than mines, in more recent years, and in more easterly longitudes, northerly latitudes, higher elevations, and in areas with higher surface temperatures and lower precipitation. Townsend's big-eared bat counts were greater in caves, during more recent years, and in more westerly longitudes. Karst topography was associated with higher Townsend's big-eared bat counts but did not appear to influence Myotis counts. We found stable or slightly-increasing trends over time in counts for both Myotis and Townsend's big-eared bats from 82 hibernacula surveyed ≥5 winters since 1990. Highly-dispersed winter roosting of Myotis in the western USA complicates efforts to monitor population trends and impacts of disease. However, our results reveal opportunities to monitor winter population status of Townsend's big-eared bats across this region.

Adult surgical experience with Loeys-Dietz syndrome.

BACKGROUND: Loeys-Dietz syndrome (LDS) results from mutations in receptors for the cytokine transforming growth factor-ß leading to aggressive aortic pathology sometimes accompanied by specific phenotypic features including bifid uvula, hypertelorism, cleft palate, and generalized arterial tortuosity. We reviewed our adult surgical experience with LDS in order to validate current recommendations regarding management of this newly described disease. METHODS: All adult (≥ 18 years old) patients with LDS undergoing surgical treatment at a single referral institution from September 1999 to May 2013 were retrospectively reviewed. RESULTS: Eleven adult LDS patients were identified by clinical criteria and genotyping. Seven (64%) experienced acute type A dissection at some point in their lives. All eventually required aortic root replacement, and 73% required multiple vascular surgical interventions. Over a mean follow-up of 65 ± 49 months, 2.8 cardiovascular procedures per patient were performed. In patients with type A dissection, a mean of 3.4 operations were performed versus 1.8 operations for patients without dissection. Total aortic replacement was required in 5 patients (45%) and 2 (18%) required neurosurgical intervention for cerebrovascular pathology. There was 1 late death from infectious complications, and no deaths from vascular catastrophe. CONCLUSIONS: These results confirm the aggressive nature of LDS aortic pathology. However, the improved survival compared with earlier LDS reports suggest that aggressive treatment strategies may alter outcomes and improve the natural history of this syndrome.

Discrepant visual speech facilitates covert selective listening in "cocktail party" conditions.

The presence of congruent visual speech information facilitates the identification of auditory speech, while the addition of incongruent visual speech information often impairs accuracy. This latter arrangement occurs naturally when one is being directly addressed in conversation but listens to a different speaker. Under these conditions, performance may diminish since: (a) one is bereft of the facilitative effects of the corresponding lip motion and (b) one becomes subject to visual distortion by incongruent visual speech; by contrast, speech intelligibility may be improved due to (c) bimodal localization of the central unattended stimulus. Participants were exposed to centrally presented visual and auditory speech while attending to a peripheral speech stream. In some trials, the lip movements of the central visual stimulus matched the unattended speech stream; in others, the lip movements matched the attended peripheral speech. Accuracy for the peripheral stimulus was nearly one standard deviation greater with incongruent visual information, compared to the congruent condition which provided bimodal pattern recognition cues. Likely, the bimodal localization of the central stimulus further differentiated the stimuli and thus facilitated intelligibility. Results are discussed with regard to similar findings in an investigation of the ventriloquist effect, and the relative strength of localization and speech cues in covert listening.

Insincere utterances and gaze: eye contact during sarcastic statements.

Anecdotal evidence suggests that speakers often gaze away from their listeners during sarcastic utterances; however, this question has not been directly addressed empirically. This study systematically compared gaze-direction of speakers in dyadic conversation when uttering sincere and sarcastic statements. 18 naïve participants were required to recite a series of contradictory statements on a single topic to a naive listener, while at the same time conveying their actual opinion about this topic. This latter task could only be accomplished through prosodic or nonverbal communication by indicating sincerity or insincerity (sarcasm) for the various statements and allowed examination of gaze across the two conditions for each participant. Subsequent analysis of the videotaped interaction indicated that, during the time for the actual utterance, sarcastic utterances were accompanied by greater gaze aversion than were sincere utterances. This effect occurred for 15 of 18 participants (3 men, 15 women; M age = 19.8, SD = 1.0) who had volunteered for a small credit in an Introductory Psychology course. Results are discussed in terms of nonverbal communication and possible miscommunication which may apply given cultural differences in use of nonverbal cues.

Inspiring medical students to pursue surgical careers: outcomes from our cardiothoracic surgery research program.

BACKGROUND: The past several years have witnessed a dramatic decline in the number of general surgery residents pursuing cardiothoracic surgery residency training. We believe that attracting individuals to pursue surgical careers should begin during the formative years of medical education. We implemented a program to introduce first-year medical students to cardiothoracic surgery and laboratory research. METHODS: In 2003, we began a program providing an introduction to cardiothoracic laboratory research and surgery for medical students. Students are competitively selected for our three-part 8-week summer program. First, students are paired with a cardiothoracic surgery attending for shadowing in clinic and the operating room. Second, students actively participate in large-animal operations in the laboratory. Finally, students complete a clinical research project under the direction of a laboratory resident and faculty mentor. These projects are the students' own. They are responsible for presenting their findings to the division of cardiac surgery at the end of the program. RESULTS: Since 2003, 18 students have completed the program. Each one has completed a project, collectively resulting in 39 peer-reviewed manuscripts. One student has published 28 peer-reviewed manuscripts. Of 10 students eligible for residency, 8 have applied in general surgery or surgical subspecialty (3 general, 2 plastic, 2 cardiothoracic, and 1 neurosurgery). CONCLUSIONS: Implementing a program to introduce medical students to clinical and laboratory surgery has been successful, as measured by academic productivity. Eighty percent of eligible students entered a surgical field. Programs like these serve to stimulate interest in our specialty.

Aortic root replacement in 372 Marfan patients: evolution of operative repair over 30 years.

BACKGROUND: We reviewed the evolution of practice and late results of aortic root replacement (ARR) in Marfan syndrome patients at our institution. METHODS: A retrospective clinical review of Marfan patients undergoing ARR at our institution was performed. Follow-up data were obtained from hospital and office records and from telephone contact with patients or their physicians. RESULTS: Between September 1976 and September 2006, 372 Marfan syndrome patients underwent ARR: 269 had a Bentall composite graft, 85 had valve-sparing ARR, 16 had ARR with homografts, and 2 had ARR with porcine xenografts. In the first 24 years of the study, 85% received a Bentall graft; during the last 8 years, 61% had a valve-sparing procedure. There was no operative or hospital mortality among the 327 patients who underwent elective repair; there were 2 deaths among the 45 patients (4.4%) who underwent emergent or urgent operative repair. There were 74 late deaths (70 Bentalls, 2 homograft, and 2 valve-sparing ARRs). The most frequent causes of late death were dissection or rupture of the residual aorta (10 of 74) and arrhythmia (9 of 74). Of the 85 patients who had a valve-sparing procedure, 40 had a David II remodeling operation; there was 1 late death in this group, and 5 patients required late aortic valve replacement for aortic insufficiency. A David I reimplantation procedure using the De Paulis Valsalva graft has been used exclusively since May 2002. All 44 patients in this last group have 0 to 1+ aortic insufficiency. CONCLUSIONS: Prophylactic surgical replacement of the ascending aorta in patients with Marfan syndrome has low operative risk and can prevent aortic catastrophe in most patients. Valve-sparing procedures, particularly using the reimplantation technique with the Valsalva graft, show promise but have not yet proven as durable as the Bentall.

Long-acting oral phosphodiesterase inhibition preconditions against reperfusion injury in an experimental lung transplantation model.

OBJECTIVES: Ischemia-reperfusion injury remains a devastating complication of lung transplantation. Phosphodiesterase inhibitors have been shown to precondition tissues against ischemia-reperfusion injury. Little is known, however, about the utility of phosphodiesterase inhibition in reperfusion injury after lung transplantation. We evaluated the long-acting phosphodiesterase-5 inhibitor, tadalafil, in an ex vivo lung transplant model. METHODS: New Zealand White rabbits (4 kg), were given oral tadalafil (n = 11) 24 hours before lung harvest and compared with rabbits given oral vehicle alone (n = 11). Lungs were recovered with Perfadex solution (Vitrolife, Kungsbacka, Sweden) and cold stored for 18 hours. After storage, lung blocks were reperfused with donor rabbit blood in an ex vivo apparatus. Pulmonary artery pressures were recorded with serial arterial and venous blood gas sampling and animals served as their own controls. Phosphodiesterase-5 and protein kinase G tissue activity assays confirmed drug effects. Luminol chemiluminescence assay was used to measure reactive oxygen species and levels of endothelial and inducible nitric oxide synthase were measured. RESULTS: Extended cold storage, followed by reperfusion produced a consistent reproducible decrease in oxygenation and increase in pulmonary pressure. Tadalafil-treated animals exhibited greater Pao(2) throughout the course of reperfusion (P = .001) Mean pulmonary artery pressure was lower in tadalafil-treated animals (22 vs 40 mm Hg; P = .04). Phosphodiesterase-5 activity was decreased (143 +/- 8 vs 205 +/- 32 mP; P < .001) with protein kinase G activity increased (25 +/- 12 vs 12 +/- 2.4 fU/microg; P = .01) in the experimental group confirming that oral pretreatment resulted in active phosphodiesterase inhibition in the lung tissue. Reactive oxygen species (as measured by luminol activity) were decreased in tadalafil-treated animals (7.8 +/- 1.5 vs 10.2 +/- 1.2 relative light units; P = .003). CONCLUSIONS: Our experimental model demonstrates that oral donor pretreatment with a long-acting phosphodiesterase inhibitor is an effective strategy for improving pulmonary performance after reperfusion. Importantly, phosphodiesterase enzymes and their downstream effectors may play a critical role in reperfusion injury after lung transplantation.

EuroSCORE predicts short- and mid-term mortality in combined aortic valve replacement and coronary artery bypass patients.

BACKGROUND AND AIM OF THE STUDY: European system for cardiac operative risk evaluation (EuroSCORE) has been studied for its effectiveness in predicting operative mortality, and more recently, long-term mortality in a wide variety of cardiac surgical procedures. Combined coronary artery bypass and aortic valve replacement (AVR-CABG) carries increased perioperative risk, and tends to have higher-risk patients. Performance of the EuroSCORE system in patients undergoing concomitant AVR-CABG has not been well established. Thus, we aimed to analyze the accuracy of both additive and logistic EuroSCOREs in predicting operative and mid-term mortality. METHODS: We retrospectively reviewed and calculated EuroSCOREs for all patients who underwent AVR-CABG between January 2000 and December 2004. Patients who had previous cardiac surgery and those undergoing any concomitant procedures were excluded. Areas under the receiver operator curves (ROC) were determined to assess EuroSCORE's accuracy in predicting operative mortality. Kaplan-Meier analysis and Cox regression were used to determine mid-term survival, freedom from repeat revascularization, and predictors of these outcomes. RESULTS: There were 233 patients who met study criteria. Mean follow-up period was 2.2 +/- 1.7 years with one patient lost to follow-up. Mean additive and logistic EuroSCOREs were 8.77 and 16.1, respectively, with an observed mortality of 9.44%. The area under the ROC curves for additive EuroSCORE was 0.76 and for logistic EuroSCORE was 0.75. Regression analysis revealed additive EuroSCORE, but not logistic EuroSCORE, to be predictive of mid-term mortality. CONCLUSIONS: Both additive and logistic EuroSCOREs were accurate in predicting operative morality. Only additive EuroSCORE was predictive of mid-term mortality in AVR-CABG patients. EuroSCORE remains a good and well-validated risk stratification model applicable to patients who undergo concomitant AVR-CABG.

Surgical ventricular restoration versus cardiac transplantation: a comparison of cost, outcomes, and survival.

BACKGROUND: Cardiac transplantation is the accepted standard treatment for end-stage heart disease but is donor limited. Surgical ventricular remodeling is an established treatment for patients with ischemic cardiomyopathy. We sought to compare charges, outcomes, and survival in patients undergoing surgical ventricular restoration (SVR) versus cardiac transplantation (CTx). METHODS AND RESULTS: We retrospectively analyzed hospital charges, length of stay (LOS), and survival for 69 SVR and 53 CTx patients at our institution between January 2002 and June 2005. We also compared New York Heart Association (NYHA) status and Kaplan-Meier survival of our SVR patients with CTx patients with ischemic cardiomyopathy from the International Society of Heart & Lung Transplantation (ISHLT) registry. Median total LOS (12 days vs. 17 days, P = .01) and median postoperative LOS (10 days vs. 15 days, P = .02) were shorter for SVR patients than our CTx patients. Median total hospital charges ($45,506 vs. $137,679, P < .0001) and median total drug charges ($2,625 vs. $15,930, P < .0001) were lower for SVR patients. Significant improvements in ejection fraction were seen after both SVR (27% vs. 37%; P < .0001) and CTx (14% vs. 62%, P < .0001). Furthermore, 91% (49/54) of surviving SVR patients, 98% (44/45) of surviving CTx patients, and 91% of ISHLT CTx patients improved to NYHA Class I/II at follow-up. Survival did not differ between groups. CONCLUSIONS: SVR patients demonstrate cost-effective clinical improvements that lead to good overall survival. SVR is an excellent surgical option for CHF patients who are not transplant candidates, and should be considered for ischemic cardiomyopathy patients who qualify for transplantation. This strategy may help relieve donor shortage and improve allocation of donor organs.

Ziconotide: an update and review.

BACKGROUND: Ziconotide is the only N-type calcium channel blocker approved by the US FDA for the treatment of chronic pain. The approved indication is for the management of severe chronic pain in patients for whom intrathecal therapy is warranted and who are intolerant of or refractory to other treatments such as systemic analgesics, adjunctive therapies or intrathecal morphine. OBJECTIVE: The purpose of this article was to review the available safety, efficacy and dosing information for ziconotide. METHODS: The sources searched for literature from 1980 to January 2008 included Pub Med, MEDLINE and PREMEDLINE using the words ziconotide, conotoxins and pain. RESULTS/CONCLUSION: Ziconotide is administered intrathecally by infusion pump to block nociceptive signal transmission in the spinal cord. It is a synthetic neuroactive peptide equivalent to the omega conotoxin MVIIA, a constituent of the venom of the fish-hunting marine snail Conus magus. It is highly potent, has a steep dose-response curve, a slow onset of action and a narrow margin of safety and responses to dose adjustments are slow. Patients receiving ziconotide should be under the care of physicians experienced in the management of intrathecal infusion therapy for pain control and should have convenient access to medical facilities.

Aortic root operations for Marfan syndrome: a comparison of the Bentall and valve-sparing procedures.

BACKGROUND: We compared results of the Bentall procedure with valve-sparing aortic root replacement (VSRR) for aortic root aneurysm in Marfan syndrome. METHODS: Marfan syndrome patients who had the Bentall procedure or VSRR at our institution between April 1997 and September 2006 were identified. Follow-up information was obtained from hospital charts and contact with patients or their physicians. Kaplan-Meier survival and propensity score analyses were performed. RESULTS: One hundred forty Marfan syndrome patients had either the Bentall procedure (n = 56) or VSRR (n = 84; 40 remodeling and 44 reimplantation). Bentall patients were older than VSRR patients (38 versus 29 years; p = 0.0001) and had more aortic dissections (16% versus 1%; p = 0.0012); more urgent/emergent surgery (20% versus 2%; p = 0.0008); larger preoperative sinus diameter (5.7 versus 5.1 cm; p = 0.0004); and more preoperative 3+/4+ aortic insufficiency (59% versus 10%; p < 0.0001). There were no operative deaths. Postoperatively, 9% Bentall patients (5 of 56) and 1% of VSRR patients (1 of 84) suffered thromboembolic events (p = 0.03). Two percent (1 of 56) of Bentall patients required reoperation on the aortic root versus 6% of VSRR patients (5 of 84; p = 0.40). Eight-year freedom from aortic valve replacement was 90% for VSRR patients. Eight-year survival was 90% for Bentall and 100% for VSRR patients (p = 0.01). Propensity-adjusted regression showed that the Bentall procedure did not predict mortality (p = 1.00) and did not protect from reoperation (odds ratio = 0.28; 95% confidence interval: 0.01 to 4.33; p = 0.36). CONCLUSIONS: The Bentall procedure and VSRR have similar operative results in Marfan syndrome. The procedures are distinguished by higher rates of thromboembolism among Bentall patients and higher rates of reoperation among VSRR patients. Lower late survival among Bentall patients probably reflects the preferential use of the Bentall procedure for higher risk patients.

Impact of septal myocardial infarction on outcomes after surgical ventricular restoration.

BACKGROUND: Surgical ventricular restoration (SVR) is classically performed in heart failure patients with anteroseptal infarction. It is unknown how the extent of septal myocardial infarction (SMI) affects prognosis. We reviewed our experience to evaluate the impact of the extent of SMI on outcomes after SVR. METHODS: We retrospectively reviewed SVR patients from January 2002 to December 2005. Patients were stratified based on the extent of SMI assessed by magnetic resonance imaging and intraoperative findings; SMI was graded as less than 50%, 50% to 74%, and 75% or greater of the length or height, or both, of the septum. Follow-up was 100%. RESULTS: Seventy-eight patients underwent SVR. Twenty-eight patients had less than 50%, 30 patients had 50% to 74%, and 20 patients had 75% or greater involvement of the length or height, or both, of the septum. Patients with 75% or greater involvement had a significantly lower ejection fraction and larger left ventricular volumes preoperatively by magnetic resonance imaging. All patients with 75% or greater involvement were New York Heart Association (NYHA) class III/IV preoperatively, and 50% (10 of 20) had significant mitral regurgitation requiring a concomitant mitral valve procedure. Operative mortality was similar between groups. Cardiac function improved and was similar among the three groups postoperatively. The PR intervals on electrocardiography were similar among the three groups, but did show trends toward longer duration for those with more extensive SMI. Preoperative mean QRS duration was significantly longer for patients with 75% or greater SMI. Three-year Kaplan-Meier survival was also similar among groups; 75% or greater involvement was not a predictor of mortality on Cox regression (odds ratio = 1.4; 95% confidence interval: 0.3 to 7.0; p = 0.6). Three quarters (15 of 20) of patients with 75% or greater involvement of the septum improved to NYHA class I/II at follow-up. CONCLUSIONS: This study has evaluated the impact of the extent of SMI on SVR outcomes. These data demonstrate similar survival and significant functional and clinical improvement after SVR regardless of the extent of SMI.

Two thousand Blalock-Taussig shunts: a six-decade experience.

BACKGROUND: The Blalock-Taussig shunt (BTS) remains valuable for palliation of congenital heart disease, but its role has evolved. We reviewed our total institutional experience with BTS to examine changes in its use and outcomes. METHODS: A retrospective review was performed of all patients undergoing BTS at our institution from November 1944 to May 2006. Hospital records and autopsy records were evaluated to determine patient demographics, diagnoses, operative data, hospital complications, and long-term outcomes. RESULTS: During the last 62 years, 2,016 BTS were performed by 28 surgeons on 1,880 patients from 35 countries. Classic BTS were performed in 75% (1,503 of 2,016 BTS). Diagnosis was tetralogy of Fallot in 72% (1,294 of 1,802), although diagnoses were imprecise in the early part of the series. Overall operative mortality was 14% (227 of 1,574). On follow-up, 32% of tetralogy of Fallot patients (411 of 1,294 patients) underwent subsequent total correction at our institution, and an additional 116 patients for whom follow-up was available had total correction of tetralogy of Fallot at other institutions, a combined total correction of tetralogy of Fallot rate of 41%. Of patients with complex congenital heart defects, 26% (106 of 404 patients) had subsequent cavopulmonary connection or atrial or arterial switch procedures. A comparison of the first and second halves of the series revealed several trends: decreasing mean annual number of BTS (66/year versus 9/year, respectively), decreasing operative mortality (16% versus 9%), and increasing proportion of single-ventricle diagnoses (5% versus 34%). CONCLUSIONS: Evolution of the BTS has seen a decrease in overall use, particularly in tetralogy of Fallot, but greater application to single-ventricle cardiac lesions and improved operative survival.

Influence of pretransplant panel-reactive antibody on outcomes in 8,160 heart transplant recipients in recent era.

BACKGROUND: Panel-reactive antibody (PRA) screening to detect HLA antibodies is an important part of evaluation for potential heart transplant recipients. We sought to determine how different levels of PRA affect outcomes in heart transplantation. METHODS: A retrospective cohort study of using data reported to the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) registry from January 1, 2000, to December 31, 2004, was performed. The association between PRA at transplant and primary end points, allograft and patient survival, as well as a secondary end point, rejection within 1 year, was analyzed. RESULTS: Pretransplant PRA was reported for 8,160 (79.4%) of the 10,279 first heart transplant recipients during the study period. Panel-reactive antibody was 0% in 6,481 (79.4%) patients (group 1), 1% to 10% in 930 (11.4%) patients (group 2), 11% to 25% in 309 (3.8%) patients (group 3), and greater than 25% in 440 (5.4%) patients (group 4). Actuarial survival was significantly different among the four groups by Kaplan-Meier method (p < 0.001). Furthermore, using PRA cutoffs of 0%, 10%, or 25%, the group with lower PRA had significantly better patient and allograft survival. Cox proportional hazard modeling revealed increasing PRA as a significant predictor of mortality (p < 0.001). However, when each group (2, 3, and 4) was compared with group 1 (PRA 0%), only group 4 (PRA > 25%) had worse survival on multivariate analysis. Patients with PRA greater than 25% confirmed by the flow cytometric technique had the worst overall survival. Rejection rate within 1 year after transplantation also significantly increased with increasing PRA. Propensity-matched patients demonstrated similar results. CONCLUSIONS: This large series of patients from the United Network for Organ Sharing database has demonstrated that elevated PRA remains a significant risk factor in a recent cohort of heart transplant recipients. Patients with PRA greater than 25% are at a particularly high risk.

Global VOR gain adaptation during near fixation to foveal targets.

Long-term rotational vestibulo-ocular (VOR) adaptation occurs during systematic dysmetria between visual and vestibular afferents, adjusting eye-rotation angular velocity to re-establish retinal stability of the visual field. Due to translational motion of the eyes during head rotation, VOR gain is higher when fixating near objects. The current study measures VOR in humans before and after 6 min of exposure to a foveal near-target during sinusoidal whole-body rotation at 0.45 Hz. All of six participants showed post-exposure increases in open-loop VOR gain after fixating near targets, demonstrating a mean modulation increase of open-loop VOR gain from 0.86 before adaptation to 1.2 after adaptation. We discuss a number of theoretical and applied implications.

Outcomes following surgical ventricular restoration for patients with clinically advanced congestive heart failure (New York Heart Association Class IV).

BACKGROUND: It has been well documented that survival in patients with advanced congestive heart failure (CHF) receiving medical therapy is worse with advancing stages of disease (New York Heart Association [NYHA] IV versus NYHA III). However, such comparisons are rare in the surgical treatments for CHF. Surgical ventricular restoration (SVR) is an accepted therapy for patients with ischemic cardiomyopathy after anterior wall myocardial infarction. We evaluated the impact of advanced stage of CHF (NYHA IV) on survival after SVR. METHODS AND RESULTS: A retrospective review was conducted of SVR patients at our institution between January 2002 and December 2005. Seventy-eight patients underwent SVR during the study period; 34 patients were NYHA IV and 44 patients were NYHA II/III before surgery. NYHA IV patients had significantly worse preoperative ejection fraction (EF), left ventricular end systolic volume index (LVESVI), and stroke volume index (SVI). Both groups demonstrated significant improvement in EF and LVESVI after SVR, and there were no differences between the groups with regard to postoperative EF, LVESVI, or SVI. There were 3 operative deaths in each group (P = 1.00). Sixty-five percent (P < .0001) of NYHA IV patients and 82% (P < .0001) of NYHA II/III patients improved to NYHA class I or II at follow-up. NYHA IV patients trended toward reduced Kaplan-Meier survival at 32 months (68% versus 88%, P = .08), although NYHA IV was not a significant predictor of mortality. CONCLUSIONS: NYHA IV patients demonstrate similar improvements in cardiac function with acceptable, although decreased, survival after SVR when compared with those with less severe clinical disease. These outcomes are superior to those reported for medical management, indicating that patients with clinically advanced CHF who are appropriate candidates should be considered for SVR irrespective of preoperative NYHA class.

Impact of lateral wall myocardial infarction on outcomes after surgical ventricular restoration.

BACKGROUND: Surgical ventricular restoration (SVR) attempts to reverse negative ventricular remodeling after anterior myocardial infarction (MI). However, the impact of lateral wall MI (LMI) on SVR outcomes is unknown. METHODS: We retrospectively reviewed SVR patients between January 2002 and December 2005. Patients were grouped into those with and without LMI. Lateral wall myocardial infarction patients were further subdivided into those with anterior-lateral and anterior-inferior-lateral MI. Extent of LMI was assessed intraoperatively as less than 25%, 25% to 49%, 50% to 75%, and more than 75% of the lateral wall. Follow-up was 100%. RESULTS: Seventy-eight patients underwent SVR; all had anterior MI. Forty-one percent (32 of 78) had LMI; 19% (6 of 32) had anterior-lateral MI; and 81% (26 of 32) had anterior-inferior-lateral MI. The remaining 59% (46 of 78) comprised the no-LMI group. Among LMI patients, 6% (2 of 32) had more than 75% involvement of the lateral wall. Lateral wall myocardial infarction patients were more likely to be New York Heart Association (NYHA) class IV preoperatively. There were 2 operative deaths in the LMI group. Surgical ventricular restoration significantly improved ejection fraction and end-systolic volume index for patients with and without LMI. Sixty-three percent of patients (20 of 32) with LMI and 83% of patients (38 of 46) without LMI improved to NYHA class I/II at follow-up. Three-year Kaplan-Meier survival for LMI patients was 67%, which trended toward a decreased survival versus patients without LMI (85%; p = 0.18). Three-year Kaplan-Meier survival for anterior-lateral MI patients was 100%, and for anterior-inferior-lateral MI patients, it was 60%. Lateral wall myocardial infarction involving >50% of the lateral wall was a significant predictor of mortality (odds ratio = 8.3, 95% confidence interval: 1.3 to 54.1, p = 0.03). CONCLUSIONS: Cardiac function is improved after SVR for patients with and without LMI. However, anterior-inferior-lateral MI and LMI involving 50% or more of the lateral wall may predict mortality. Our results should prompt further investigation to determine the role of SVR for patients with LMI.

Outcomes following surgical ventricular restoration in elderly patients with congestive heart failure.

Despite the well described benefits of surgical ventricular restoration (SVR) for patients with ischemic cardiomyopathy, the effects of advanced age on outcomes following this procedure have not been well documented. The authors compared outcomes in 69 consecutive patients 65 years and older (n=27) and younger than 65 years (n=42) to determine the utility of SVR in an elderly population with end-stage heart failure. Patients 65 years and older demonstrated significant improvements in ejection fraction (P=.01) and left ventricular end-systolic volume index (P=.07) following SVR, which were similar to the improvements seen in patients younger than 65 years. Sixty percent (15 of 25) of patients 65 years and older in preoperative New York Heart Association class III/IV improved to class I/II at follow-up (P<.0001). Actuarial survival was 68.8% at 2.5 years. Like their younger counterparts, elderly patients demonstrate significant improvements in ventricular function and NYHA class with acceptable survival following SVR.

Subclavian flap aortoplasty: still a safe, reproducible, and effective treatment for infant coarctation.

OBJECTIVE: Subclavian flap repair of infant coarctation has been criticized and in many centers abandoned in favor of resection with end-to-end anastomosis. The goal of this study was to examine intermediate and long-term results of infant subclavian flap aortoplasty, which has been the preferred technique at our institution over the last two decades. METHODS: Our patient database identified all infants (age<1 year) who underwent repair of isthmic coarctation via thoracotomy between January 1984 and December 2004. Procedure details and late results were collected by retrospective review of hospital and clinic data. Follow-up was 95.8% complete at a mean of 6.7 years. RESULTS: Between January 1984 and December 2004, 119 infants underwent isolated subclavian flap repair of coarctation. Mean age and weight at operation were 35+/-52 days (range 1-269 days) and 3.5+/-1.3kg (range 0.7-9.3kg), respectively. Concomitant pulmonary artery banding was performed in 22% (26/119). In-hospital mortality was 4% (5/119) and cumulative late mortality was 6% (7/114) of patients with long-term follow-up. Actuarial survival at 1, 5, and 10 years was 91, 85, and 85%, respectively. Overall re-intervention rate for re-stenosis was 11% (12/114); 10 patients (9%) underwent balloon angioplasty while 3 patients (3%) required operative revision. All re-stenoses occurred in the descending aorta, and all occurred in patients who had undergone neonatal repair. At late follow-up, there were no significant neurologic events (left recurrent laryngeal nerve injury, stellate ganglion dysfunction, or paraplegia), no clinically significant ischemic arm complications, and no flap aneurysms. CONCLUSIONS: Subclavian flap aortoplasty remains our procedure of choice for isthmic coarctation, as it is a simple, technically straightforward technique with a low incidence of re-stenosis and serious early and late morbidity. Furthermore, subclavian flap re-stenoses are easily treated with percutaneous intervention and seldom require surgical re-intervention via thoracotomy.

Aortic valve replacement and concomitant coronary artery bypass: assessing the impact of multiple grafts.

BACKGROUND: The impact of multivessel coronary artery disease and multivessel coronary artery bypass grafting on outcomes after combined aortic valve replacement and coronary artery bypass grafting (AVR-CABG) has not been sufficiently evaluated. METHODS: We retrospectively reviewed all patients who underwent AVR-CABG at our institution between January 2000 and December 2004. Patients with any previous or concomitant procedures were excluded. The Kaplan-Meier method was used to calculate survival and freedom from postoperative repeat revascularization. Predictors of mortality were determined by Cox regression analysis. RESULTS: The study cohort consisted of 233 AVR-CABG patients. Mean follow-up was 2.2 +/- 1.7 years with one patient lost to follow-up. Preoperative clinical characteristics were well-matched between patients who received one (n = 86), two (n = 81), or three or four (n = 66) bypass grafts. Operative mortality was 9.3%, 11.1%, and 7.6%, respectively (p = 0.76). Patients in all groups demonstrated significant improvement in New York Heart Association (NYHA) status (p < 0.01). Freedom from postoperative repeat revascularization for all patients after five years was 96.8% and did not differ among groups (p = 0.93). Five-year survival for each group was 63.6%, 72.4%, and 63.9%, respectively (p = 0.91). Emergent operation, ejection fraction less than 0.30, operative age greater than 65 years, NYHA class III/IV, and chronic obstructive pulmonary disease were significant predictors of mortality. The number of stenosed vessels, the number of bypass grafts, incomplete revascularization, and the presence of aortic stenosis or aortic insufficiency did not predict mortality. CONCLUSIONS: For patients undergoing AVR-CABG, the number of bypass grafts does not adversely affect survival. Rather, a patient's preoperative risk factors are a better predictor of outcome.