Objective: This study aimed to obtain an upper estimate of any survival benefit conferred by resection in patients with a diagnosis of malignant pleural mesothelioma. Methods: We analysed published data concerning survival from diagnosis among four groups of patients with mesothelioma, identified by ascending level of intervention: (A) no surgery; (B) thoracotomy but no resection; (C) resection but no adjuvant treatment; and (D) resection as part of multimodality treatment. Mean survival was estimated for each of these four groups. Mean survival was also estimated for all those having resection (groups C and D) and for all those not having a resection (groups A and B). Results: Mean survival was 16.8, 17.8 and 17 months for those having no surgery, thoracotomy alone and resection with no adjuvant treatment respectively (groups A, B and C) and 32.9 months for those having multimodality treatment (group D). Mean survival was 25.6 months in those who had resection and 17.1 months in those that did not. The survival advantage of any management that included surgical resection was estimated as being no more than 9 months. This is the most optimistic estimate and requires all observed differences in survival to be attributed to the effect of treatment and none to selection for treatment. Furthermore, within this upper estimate is included any benefit from other components of multimodality treatment. Conclusions: Given the burden of morbidity of resection in the management of pleural mesothelioma, this most optimistic estimate of the magnitude of any survival benefit should be taken into account in any policy decision, in clinical trial proposals and in strategies adopted by clinical teams.

Objectives: The expression of cyclooxygenase-2 (COX-2) and cell-cycle proteins (p21 and p27) proves useful in predicting prognosis and orientating therapy in many malignant tumours. Malignant pleural mesothelioma is an uncommon and lethal cancer for which there are limited treatment options. In this study, we evaluated the impact on prognosis and the influence on therapeutic strategy of immunohistochemical expression of COX-2, p21 and p27 in specimens from patients treated for malignant pleural mesothelioma. Methods: We retrospectively reviewed immunohistochemical expression of COX-2, p21 and p27 dichotomised into high and low expression from specimens of 77 consecutive patients undergoing biopsy-plus-pleurodesis (n = 6), pleurectomy–decortication (n = 44) or extrapleural pneumonectomy (n = 27) operations for malignant pleural mesothelioma between 1987 and 2007. Histology was of epithelioid (n = 50), biphasic (n = 17) and sarcomatoid (n = 10) subtypes. Tumour node metastasis (TNM)-stage was I (n = 21), II (n = 36) and III (n = 20). Therapies used were sole adjuvant radiotherapy (n = 17), adjuvant radio-chemotherapy (n = 56) and neo-adjuvant chemotherapy plus adjuvant radiotherapy (n = 4). From 2005 on, preoperative maximal standard uptake value (SUV_MAX) was also measured by fluorodeoxyglucose positron-emission-tomography. Significance was investigated by Kaplan–Meier survival and Cox regression analysis. Results: The median survival was 10 months. Survival was negatively influenced by histology (epithelioid vs biphasic vs sarcomatoid) (p = 0.009), positive macroscopic resection margins (p = 0.016), metastatic mediastinal lymph nodes (p = 0.016), high COX-2 (p = 0.0001) expression, low p21 (p = 0.0001) expression and low p27 (p = 0.001) expression. Conversely, neither the type of surgery (biopsy-plus-pleurodesis vs pleurectomy-decortication vs extrapleural pneumonectomy), nor preoperative SUV_MAX (≥6.0 vs <6.0), or combined therapies (sole radiotherapy vs adjuvant radio-chemotherapy vs neo-adjuvant chemotherapy plus adjuvant radiotherapy) reached a significant level of difference. Cox regression analysis showed that only immunohistochemical triple combination of high COX-2 and low p21 and p27 expression influenced survival (p = 0.0001, hazard ratio 4.7, 95% confidence intervals 3–11) regardless of type of treatment. Conclusions: At Cox regression analysis, a combination of high COX-2 and low p21 and p27 expression resulted in the only negative prognosticator of malignant pleural mesothelioma. With this combination, less aggressive surgical options might be preferred.

Objective: Increased immunoreactivity of integrin-linked kinase (ILK) in the primary tumour is an adverse prognostic factor in a variety of preclinical and clinical models of human cancer. Here, we investigate the relationship between ILK immunoreactivity in primary non-small-cell lung cancer (NSCLC) and the survival after curative lung resection. Methods: Tumour specimens of 138 radically operated NSCLC patients have been retrieved from the pathology archive, mounted in tissue microarrays and immunostained against ILK. The immunoreactivity against ILK has been graded in a semi-quantitative manner (negative or 1–3 positive) by two observers blinded to any patient data, and correlated to the survival data. Results: In total, 88 of 138 tumours (64%) showed an ILK immunoreactivity, which varied significantly between various histological subtypes as it ranged from 46% (squamous cell carcinoma (SCC)) to 79% (adenocarcinoma) (p = 0.019). The 5-year cancer-related survival of ILK-positive SCC patients was at 42 ± 10% versus 72 ± 9% significantly shorter than in ILK-negative patients (p = 0.011). In addition, the recurrence-free survival (RFS) of ILK-positive SCC patients was also significantly shorter than of ILK-negative patients (38 ± 10% vs 60 ± 10%) (p = 0.005). In multivariate analysis, ILK expression was a significant prognostic factor for RFS in squamous cell carcinoma (p = 0.018), but not in adenocarcinoma or in the rare histology group. Conclusions: Primary NSCLC tumours show a variable ILK immunoreactivity, dependent on the histological subtype. In SCC, ILK immunoreactivity is a significantly adverse prognostic factor.

Objective: Lymph node metastasis is a characteristic of malignant cancers and is observed more frequently in oesophageal cancer than in other digestive tract cancers, making it one of the most important prognostic factors. Vascular endothelial growth factors C (VEGF-C) and D (VEGF-D) are important lymphangiogenic factors in human cancers and lymphangiogenesis is associated with lymph node metastasis. The aim of the study was to determine the correlation between pre-treatment serum levels of VEGF-C (sVEGF-C) and VEGF-D (sVEGF-D) and clinicopathologic features in patients with oesophageal cancer. Methods: Serum VEGF-C and sVEGF-D were measured by enzyme-linked immunoadsorbent assay (ELISA) on 149 patients with oesophageal cancer, 29 patients with benign oesophageal diseases and 30 healthy controls. Results: Serum VEGF-C and sVEGF-D levels were significantly higher in patients with oesophageal carcinoma than in the control group (p < 0.001 and p = 0.001, respectively) or in the benign oesophageal diseases group (p = 0.04 and p = 0.03, respectively). Subgroup analysis showed that lymph node metastasis (p = 0.001), stage (p = 0.001), tumour depth (p = 0.006), resectability (p = 0.002), tumour size (p = 0.01), distant metastases (p = 0.01) and histological grading (p = 0.04) were correlated with an elevated level of sVEGF-C. Elevated levels of sVEGF-D were associated with tumour depth (p = 0.002), stage (p = 0.01) and lymph node metastasis (p = 0.02). Among the patients (n = 83) who underwent potentially curative surgery, the overall survival time (p = 0.008) was shorter for patients with a high level (>8667 pg ml^–1) of sVEGF-C than for those with a low level (<8667 pg ml^–1), when the cut-off value was determined on the basis of the median value in oesophageal cancer patients. On univariate regression analysis, tumour size, tumour depth, stage, lymph node metastases, distant metastases, resectability and sVEGF-C were found to be significant prognostic factors. Conclusions: These results suggest that pre-treatment levels of sVEGF-C and sVEGF-D reflect lymph node metastases and advanced stage of oesophageal cancer. Serum VEGF-C may be useful in predicting poor outcome for patients undergoing a potentially curative oesophagectomy.

Objective: Immunosuppression therapy in lung transplantation (LTX) remains unsatisfactory due to a high incidence of infection and frequent acute rejection (AR), leading to early onset of the bronchiolitis obliterans syndrome (BOS). The long-term success of LTX is limited by BOS, associated with marked morbidity and mortality. The strongest risk factor for BOS is frequent AR. Decreasing frequent AR episodes might lead to improved long-term survival following LTX. Methods: Despite the introduction of many novel agents, the basis of currently applied protocols remains a calcineurin inhibitor, that is, cyclosporine/tacrolimus (TAC). Eighty-two lung recipients received oral-only administered immunosuppression with oral TAC, mycophenolate mofetil (MMF) and intravenous (IV) methylprednisolone as introduction 2 h prior to skin incision. Intra-operatively, patients received additional methylprednisolone prior to unclamping the pulmonary arteries. Postoperatively oral TAC/MMF and prednisolone were continued and trough levels closely monitored (target 8–12 ng ml^–1). Pulmonary function tests were performed frequently and daily after discharge by means of a self-measuring device (daily forced expiratory volume in 1 s (FEV₁)) as the major part of a close follow-up and monitoring programme. Trans-bronchial biopsies were rarely performed. Patient data were collected prospectively and stored in transplantation registries. LTX survival was analysed according to the Kaplan–Meier method. Results: The follow-up of the LTX patients through frequent ambulatory care unit visits and close monitoring of the immunosuppressive regimen and the medication response was 100% complete. The mean duration of observation per patient was 1.8 ± 1.7 years (median 1.4, range: 0.0–6.4 years) and this study included 176.5 patient-related years of follow-up. The 1-, 3- and 5-year survival following LTX was 70%, 60% and 55%, respectively. Eight patients (10%) underwent high-dose intravenous (IV) bolus methylprednisolone treatment and taper for AR. Two additional patients developed BOS more than 4 years following LTX. The AR- and BOS-related mortality was 0% within the 7-year interval of LTX. Alterations in FEV₁ were associated with significant anastomotic airway and infectious complications, requiring frequent bronchoscopic interventions, stenting and laser therapy as well as frequent IV antibiotic treatment. The 30-day and in-hospital mortality of 19.5% was markedly related to primary graft failure and viral infection. Long-term survival was limited predominantly by cytomegalovirus (CMV) infection and sepsis. Conclusions: Our results suggest that a standard immunosuppressive regimen of TAC and MMF orally administered and introduced prior to skin incision for LTX surgery and maintained long-term might reduce the incidence of acute and chronic rejection. Viral infections and not BOS seemed to be the limiting factor of long-term survival.

Objective: Whether double-lung transplantation (DLT) or heart–lung transplantation (HLT) is the best option in patients with pulmonary hypertension (PH) remains unclear. At our institution, patients with severe right ventricular dysfunction or congenital systemic-to-pulmonary shunt (CSPS) are preferentially treated with HLT. We sought to determine whether the outcomes warrant continuing this policy. Methods: We retrospectively reviewed cases of DLT (n = 67) or HLT (n = 152) performed for end-stage PH between 1986 and 2008 at our institution. According to the new clinical classification of PH, 147 patients were group I (pulmonary arterial hypertension group, of which 30 had CSPS), 24 were group III (PH associated with lung disease and/or hypoxaemia), 20 were group IV (chronic thrombo-embolic PH) and 20 were group V (sarcoidosis or histiocytosis X). Results: Compared with the HLT group, the DLT group had less severe disease as reflected by a higher preoperative cardiac index (2.5 ± 0.8 vs 2.0 ± 0.4; P = 0.0006), lower New York Heart Association (NYHA) functional class (3.4 ± 0.4 vs 3.8 ± 0.5; P < 0.0001), lower rates of kidney failure (31% vs 66%; P < 0.0001) and liver failure (13% vs 38%; P = 0.0003) and less need for preoperative inotropic support (10% vs 25%; P = 0.014). Nevertheless, survival after 1, 5, 10 and 15 years was not significantly different between the two groups (HLT group: 70%, 50%, 39% and 26%; and DLT group: 79%, 52%, 43% and 30%; respectively; P = 0.932). Freedom from obliterative bronchiolitis-related death was significantly greater in the HLT group (100% at 1 year, 84% at 5 years and 74% at 10 years; compared with 98%, 70%, and 59%, respectively, in the DLT group; P = 0.035). Conclusions: In patients with end-stage PH, good long-term survival rates were obtained using either DLT or HLT. However, these results were achieved with preferential use of HLT in patients with right heart failure or CSPS. Obliterative bronchiolitis-related death was less common with HLT than with DLT.

Objectives: Acute uncomplicated Stanford type B aortic dissection (TBAD) is optimally managed with medical treatment. However, surgery and thoracic endovascular aortic repair (TEVAR) are occasionally indicated, particularly when end-organ ischaemia develops. This study assesses the perioperative and long-term outcomes of medical, interventional and surgical management of acute TBAD. Methods: A total of 135 consecutive patients with acute TBAD treated at our institution between 2000 and 2008 were analysed. Of these patients, 84 were treated medically (group A, median age: 65 years, interquartile range (IQR): 34–90), 46 patients received TEVAR (group B, median age: 65, IQR: 23–83) and five patients underwent open surgical management (group C, median age: 60 years, IQR: 44–69). Clinical data and information on complications, re-intervention and acute and long-term mortality were retrospectively collected and examined. Follow-up was made on 98% of patients with a median time span of 1107 days (IQR: 870–1343). Results: There were no significant differences in age, gender, body mass index or co-morbidities among the three treatment groups. Group B patients had the highest rate of ruptures (n = 7) and impending ruptures (n = 19). Indications for surgery in group C were impending rupture with malperfusion (n = 1), rupture (n = 2) and refractory pain (n = 2). The maximal diameter of dissection was significantly higher in group C (mean: 52.6 mm, IQR: 36–82, p < 0.05) than in group B (mean: 42.0 mm, IQR: 20–74) and group A (mean: 40.6, IQR: 23–66). The 30-day and 5-year mortality rates, respectively, were 8.5% and 27.9% for group A, 20.0% and 43.7% for group B (p = 0.018 for group A) and 20.0% for both time points for group C patients. The rate of re-intervention was significantly higher in group A (A: 22/84, 26.2% vs B: 8/46, 17.4%; p = 0.049, and group C: 1/5, 20%). The rate of major complications (e.g., stroke, paraplegia and/or vascular problems) did not differ among groups. Conclusions: Medical, interventional and surgical management for acute TBAD result in acceptable survival rates. Although stent implantation and surgery were reserved for patients with complications of TBAD in the current study, results were good for both treatment modalities. Randomised prospective trials should be performed to determine whether conservative, TEVAR or surgical management is most advantageous for complicated acute TBAD patients.

Objectives: Antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) for ascending/transverse arch repair is used for cerebral protection. This study evaluates ACP in combination with retrograde cerebral perfusion (RCP) during extended HCA and compares it to RCP-only. Methods: Between January 2005 and April 2007, we performed 64 consecutive arch repairs requiring extended HCA (>40 min). RCP-only was used with 34 patients and ACP with brief RCP (‘integrated’) was used with 30 patients. Mean HCA time was 51 ± 13 min. Mean RCP-only time was 47 ± 9.6 min; in the integrated group, mean ACP time was 42 ± 14.4 min with an added RCP time of 10.8 ± 7.6 min. For the entire cohort, 95% (61/64) underwent total arch repair, and 67% (43/64) had elephant trunk reconstruction. Variables predictive of mortality and neurological outcomes were analysed prospectively, but technique selection was non-randomised. Results: Preoperative and operative variables did not differ between the RCP-only and the integrated groups except for aortic valve replacement, which was more frequently performed in the integrated group (33% (10/30) vs 12% (4/34), P = 0.05), and preoperative renal dysfunction, which was more frequent in the RCP group (26% (9/34) vs 7% (2/30), P = 0.04). No significant difference was observed in outcomes between the groups; however, the integrated group had higher mortality, stroke and temporary neurological deficit than RCP-only. Conclusions: The observed trends in actual outcomes were a cause for concern. ACP combined with a short period of RCP did not provide better outcomes than RCP-only. The use of RCP remains warranted in our experience.

Objective: The treatment of thoraco-abdominal aortic aneurysms (TAAAs) is extremely laborious, due to the surgical complexity of this condition. In particular, postoperative spinal paraplegia poses a severe complication that significantly lowers patient's quality of life. In 1997, we devised a hybrid procedure consisting of extended endovascular aortic repair (EVAR) and visceral reconstruction. In this article, we report the long-term results obtained from this procedure. Methods: We conducted 1106 endovascular aortic repairs between 1997 and 2008. Among these, we selected 86 cases of TAAA. The mean patient age was 71.6 years. Preoperative complications included 19 cases of stroke, 22 cases of coronary artery disease (CAD) and 16 cases of chronic obstructive pulmonary disease (COPD). Cerebrospinal fluid drainage was initiated during the operation. We performed bypasses from the aortic bifurcation to abdominal visceral arteries, and deployed stent grafts to exclude the entire TAAA. Results: Operative time averaged 386 min. We lost two patients and encountered only one case of graft occlusion. Two patients had acute renal failure, but neither required a tracheostomy. Furthermore, no patients exhibited paraplegia or delayed paraplegia. We observed endoleaks in nine cases, and shrunken aneurysms in 73 cases. Long-term results included survival rates of 94.8%, 85.8%, 80.2% and 66.6% at 2, 5, 8 and 10 years, respectively. Only two patients died from aortic events. Rates of freedom from aortic events were 90.7%, 80.6%, 70.8% and 70.8% at 2, 5, 8 and 10 years, respectively. Conclusions: The hybrid TAAA-repair protocol yielded satisfactory results. Although thorough follow-up is required for visceral bypass, this procedure could become the standard for TAAAs.

Objective: Primary adult aortic coarctation (PAAC) is an unusual cause of hypertension. The standard of care includes surgical repair, which can be associated with considerable morbidity and operative risk. Although balloon angioplasty has been successfully used in paediatric and adolescent patients with coarctation, little information exists regarding the endovascular repair of PAAC. This study examines the procedural safety and efficacy of endovascular repair of PAAC along with midterm outcomes. Methods: Between January 2000 and July 2008, 16 patients underwent endovascular repair of PAAC. All patients were hypertensive with 13 patients (81.3%) receiving medical therapy. Symptoms included chest pain (n = 11, 69%), progressive fatigue (n = 5, 31%), exercise intolerance (n = 4, 25%) and shortness of breath (n = 3, 19%). Associated cardiac concerns included depressed ejection fraction (n = 6, 38%), pulmonary hypertension (n = 5, 31%), ascending aortic dilatation (n = 5, 31%) and bicuspid aortic valve (n = 4, 25%). Endovascular repair was achieved using a percutaneous femoral approach. Balloon angioplasty of the coarctation was performed prior to treatment using a balloon-expandable uncovered stent. Aortic diameters were assessed using intravascular ultrasound. Pre- and post-procedure pressure gradients were measured and success was determined as a residual pressure gradient across the treated aorta of less than 20 mmHg. Results: The male:female (M:F) ratio was 9:7 with a mean age of 39.7 years. Procedural success was 100%. Mean pre-procedural aortic diameter was 8.4 mm (3–14 mm) and mean post-procedural aortic diameter was 16.3 mm (10–20 mm) (p = 0.04). The mean pre-procedural pressure gradient was 48.3 mmHg (25–100 mmHg) and the mean post-procedural pressure gradient was 0.5 mmHg (0–15 mmHg) (p = 0.05). Twelve patients received one stent, two patients received two stents, one patient received three stents and one other patient received a thoracic stent graft. The rate of paraplegia was 0% with no blood transfusions, strokes or deaths. Follow-up ranged from 12 to 72 months (mean = 22.8 months). One patient required re-intervention with an additional stent 14 months following the initial procedure and all the patients remain symptom-free. Conclusion: Endovascular repair of PAAC is safe and effective and compares favourably with open surgical repair. Midterm follow-up suggests that the treatment is durable and may be an alternative to surgical repair. Although this is the largest endovascular treatment series for PAAC reported to date, additional study and follow-up are needed.

Objective: The objective of this study was to evaluate the long-term outcome of total repair for tetralogy of Fallot. Methods: Between April 1986 and December 2007, a total of 734 patients underwent total repair for tetralogy of Fallot. There were 444 males and 290 females. The median age and weight were 17.2 months (0.4–329.6 months) and 9.5 kg (2.6–53.5 kg). The median follow-up duration was 150.2 months (1.9–356.2 months). Results: There were 27 early deaths (3.7%) and 13 late deaths. A longer cardiopulmonary bypass time and the use of total circulatory arrest were risk factors for early death. The overall survival rate was 94.8%, 92.8% and 92.8% at 10, 20 and 25 years, respectively. The presence of pulmonary atresia was a risk factor for long-term survival. Re-operation or re-intervention was required in 224 patients (31.7%). The most common causes of re-operation or re-intervention were pulmonary regurgitation in 109 patients and branch pulmonary artery stenosis in 127 patients. Freedom from re-operation or re-intervention rate was 81.5%, 68.9% and 46.6% at 5, 10 and 20 years, respectively. Reconstruction of the right ventricular outflow tract with other than non-trans-annular repair and branch pulmonary arterioplasty at the time of total repair were the risk factors for late re-operation or re-intervention. The use of a monocusp patch was not associated with early mortality or re-operation. At the latest follow-up, most patients were in the New York Heart Association functional class 1 or 2. Conclusions: The long-term outcome of total repair for tetralogy of Fallot was satisfactory. A longer cardiopulmonary bypass time and the use of deep hypothermic circulatory arrest were associated with early mortality. The patients with pulmonary atresia have poorer late survival. Preservation of the pulmonary annulus can reduce the re-operation rate. A small pulmonary artery that requires augmentation may increase the risk of re-operation. The use of a monocusp in patients who underwent trans-annular repair has no benefit for early survival, the postoperative recovery and avoidance of re-operation. Age was not a risk factor for early mortality and re-operation.

Objectives: The optimal pulmonary valved conduit for infants and small children remains controversial. This report compares the initial insertion outcome of small caliber bovine jugular vein (BJV) (12–14 mm) with pulmonary homografts (PHs) (10–15 mm) in patients under age 2. Methods: From December 1998 to August 2009, 84 children (mean age 8.4 ± 8.5 months) received BJV (n = 51) or PH (n = 32) conduits. Mean Z score for BJV was 2.2 (range: –0.8 to 3.3) and for PH 2.1 (range: 0.8–4.2; P = 0.2). The two cohorts were similar with respect to age, BSA, conduit indication, bypass and cross-clamp time. Graft dysfunction is defined as right ventricular outflow tract obstruction with peak echo-Doppler gradient >40 mmHg and/or grade III/IV conduit valve regurgitation. Graft failure is defined as need for conduit replacement or need for catheter or surgical re-intervention. Follow-up was greater in number in homografts (BJV, 4.4 ± 3.0 years vs PH, 5.9 ± 3.6 years; P = 0.05). Results: Early and late mortality were similar (BJV, 80%; PH 88%; P = 0.55). No death was graft related. Freedom from dysfunction was improved at 5 and 10 years with BJV (BJV, 90% at 85% vs PH, 71% and 24% P < 0.05). Conduit failure trended higher in the PH cohort at 5 and 10 years (BJV, 85% and 67% vs PH, 75% and 45%; P = 0.06). Freedom from explantation was significantly better for BJV patients (BJV, 85% vs PH, 47% P < 0.001. Freedom from distal conduit stenosis was similar (BJV, 52% vs PH, 44% P = 0.36). Conclusions: This study suggests that the early performance of small BJV may be more advantageous than homografts. A BJV conduit is an appropriate first choice for conduit replacement in patients less than 2 years of age.

Objective: Failure of the pulmonary autograft following the Ross Procedure is mainly due to dilatation and/or cusp prolapse causing insufficiency. We analysed the result of pulmonary autograft valve sparing and repair, using techniques developed for native aortic root and valve. Methods: Of a total of 275 patients who underwent Ross operation between 1991 and 2009, 31 needed autograft re-operation. Of the 28 patients re-operated in our centre, 26 (93%) had autograft valve preservation and they represent the study cohort. At the initial Ross procedure, root remplacement technique was performed in 20 patients and autograft inclusion technique was performed in 6. Mean redo interval was 9.3 ± 3.5 years and mean age at redo was 44 ± 13 years. Indications for re-operations were neo-aorta dilatation (n = 12; 46%), autograft insufficiency (n = 4; 15%) and dilatation with autograft insufficiency (n = 10; 40%). Neo-aorta dilatation was repaired using valve-sparing root replacement (n = 12, 46%) or ascending aorta replacement (n = 10; 40%). Cusp prolapse was repaired by commissural re-suspension (n = 1), free margin plication (n = 10) or re-suspension with polytetrafluoroethylene (PTFE; n = 6). Cusp repair was performed in isolation (n = 4) or in association with sparing (n = 5) or ascending aorta replacement (n = 4). Results: There was no in-hospital mortality. Two patients having undergone isolated cusp repair needed valve replacement for recurrent insufficiency after 5 days and 8 years postoperatively. At follow-up (100% complete, median: 27 months) all patients were alive, in New York Heart Association (NYHA) class I (n = 22; 84%) or II (n = 4; 16%). No autograft regurgitation was present in nine patients (five sparing and four ascending aorta replacement); grade I insufficiency was present in 11 (six sparing and five ascending aorta replacement), grade 2 in two (one sparing and one isolated cusp repair) and grade 3 in two (one ascending aorta replacement and one isolated cusp repair). At 3 years, overall freedom from autograft insufficiency ≥grade 3 was 80%. Conclusion: Preservation of the pulmonary autograft valve can be safely performed in selected patients. At midterm, repair of neo-aorta dilatation using valve-sparing root replacement or ascending aorta replacement showed acceptable results. In contrast, results of cusp repair for isolated autograft insufficiency were unsatisfactory.

Objectives: The Ross operation in the setting of a bicuspid aortic valve (BAV) remains controversial. Using data from the German Ross Registry, we sought to investigate the effect of the presence of a BAV on autograft function and diameters over time after the Ross operation compared with the presence of a tricuspid aortic valve (TAV). Methods: A total of 1277 patients (mean age 42.2 ± 15.3 years) with intra-operatively documented aortic valve morphology during the Ross operation were analysed in the present study (sub-coronary technique, n = 648, root replacement technique, n = 629 patients). A BAV was present in 70.9% of patients. Clinical and echocardiographic follow-up was performed preoperatively and at pre-specified intervals (mean follow-up 5.7 ± 3.8 years, 6806 patient-years). Hierarchical multilevel modelling techniques were used for the statistical analysis of serial measurements and comparisons among groups. Results: Initial neo-aortic regurgitation was lower in the BAV group (0.52 vs 0.62 aortic insufficiency (AI) grades, p = 0.008), whereas the annual increase of it did not differ among groups. In both surgical techniques, no significant development of neo-aortic regurgitation (<0.02 AI grades per year) could be detected. Initial aortic annulus and sinus dimensions did not differ in the presence of a BAV. However, BAV patients developed a higher degree of annulus and sinus dilatation over time (0.20 mm per year vs 0.06 mm per year, p = 0.003; 0.24 vs 0.11 mm per year, p = 0.013). This effect persisted when allowing for the two different surgical techniques. Baseline sinotubular junction (STJ) diameters did not differ among groups and annual increase thereof was similar (29.15 mm vs 28.9 mm, p = 0.69; 0.44 mm vs 0.35 mm, p = 0.15). Conclusions: For the observed time period, postoperative neo-aortic regurgitation after the Ross procedure did not differ between patients with a BAV or a TAV. Root dimensions, although clinically not relevant, increased in both valve entities supporting surgical reinforcement strategies. We cannot consider a BAV as a contraindication for the Ross operation.

Objectives: To define the effects of annuloplasty rings (ARs) on the dynamic motion of anterior mitral leaflet (AML) and posterior mitral leaflet (PML). Methods: Fifty-eight adult, Dorsett-hybrid, male sheep (49 ± 5 kg) had radiopaque markers inserted: eight around the mitral annulus, four along the central meridian (from edge to annulus) of the AML (#A₁–#A₄) and one on the PML edge (#P₁). True-sized Edwards Cosgrove (COS, n = 12), St Jude RSAR (St. Jude Medical, St. Paul, MN, USA) (n = 12), Carpentier–Edwards Physio (PHYSIO, n = 12), Edwards IMR ETlogix (ETL, n = 10) or Edwards GeoForm (GEO, n = 12) ARs were implanted in a releasable fashion. Under acute open-chest conditions, 4D marker coordinates were obtained using biplane videofluoroscopy with the respective AR inserted (COS, RSAR, PHYSIO, ETL and GEO) and after release (COS-Control, RSAR-Control, PHYSIO-Control, ETL-Control and GEO-Control). AML and PML excursions were calculated as the difference between minimum and maximum angles between the central mitral annular septal-lateral chord and the AML edge markers ( _1exc– _4exc) and PML edge marker (β _1exc) during the cardiac cycle. Results: Relative to Control, (1) RSAR, PHYSIO, ETL and GEO increased excursion of the AML annular ( _4exc: 13 ± 6° vs 16 ± 7°*, 16 ± 7° vs 23 ± 10°*, 12 ± 4° vs 18 ± 9°*, 15 ± 1° vs 20 ± 9°*, respectively) and belly region ( _2exc: 41 ± 10° vs 45 ± 10°*, 42 ± 8° vs 45 ± 6°, n.s., 33 ± 13° vs 42 ± 14°*, 39 ± 6° vs 44 ± 6°*, respectively, _3exc: 24 ± 9° vs 29 ± 11°*, 28 ± 10° vs 33 ± 10°*, 16 ± 9° vs 21 ± 12°*, 25 ± 7° vs 29 ± 9°*, respectively), but not of the AML edge ( _1exc: 42 ± 8° vs 44 ± 8°, 43 ± 8° vs 41 ± 6°, 42 ± 11 vs 46 ± 10°, 39 ± 9° vs 38 ± 8°, respectively, all n.s.). COS did not affect AML excursion ( _1exc: 40 ± 8° vs 37 ± 8°, _2exc: 43 ± 9° vs 41 ± 9°, _3exc: 27 ± 11° vs 27 ± 10°, _4exc: 18 ± 8° vs 17 ± 7°, all n.s.). (2) PML excursion (β _1exc) was reduced with GEO (53 ± 5° vs 43 ± 6°*), but unchanged with COS, RSAR, PHYSIO or ETL (53 ± 13° vs 52 ± 15°, 50 ± 13° vs 49 ± 10°, 55 ± 5° vs 55 ± 7°, 52 ± 8° vs 58 ± 6°, respectively, all n.s); * = p < 0.05. Conclusions: RSAR, PHYSIO, ETL and GEO rings, but not COS, increase AML excursion of the AML annular and belly region, suggesting higher anterior mitral leaflet bending stresses with rigid rings, which potentially could be deleterious with respect to repair durability. The decreased PML excursion observed with GEO could impair left ventricular filling. Clinical studies are needed to validate these findings in patients.

Objective: To date, transfemoral and trans-apical valved stent implantation techniques are limited to the replacement of pulmonary and aortic valves in a strictly selected group of patients. The current study was designed to assess the short-term follow-up using a mitral valved stent in off-pump technique. Methods: A self-expanding, repositionable mitral valved stent was created for trans-apical implantation. Five pigs underwent successful trans-catheter implantation. Data were gathered to assess the animals’ haemodynamical stability after stent implantation (n = 5), 6 h (n = 5) and 1 week (n = 4). The valved stent function was assessed by trans-oesophageal echocardiography and ventriculogram. Cardiac computed tomography (CT) was used to evaluate positioning of the new implant. Results: Precise valved stent deployment and accurate subsequent adjustment of its intra-annular position allowed for reduction of paravalvular leakage in all animals. The deployment time ranged from 122 to 271 s and blood loss from 65 to 245 cc. Accurate positioning was established in all but one animal. The average mean transvalvular gradient and mean gradient across left ventricular outflow tract (LVOT) recorded immediately after deployment, 6 h and 1 week were 1.9 ± 0.9 mmHg, 3.5 ± 1.6 mmHg, 4.1 ± 02.3 mmHg and 1.4 ± 01.3 mmHg, 1.5 ± 0.7 mmHg 1.9 ± 0.7 mmHg, respectively. Mild regurgitation was present after valved stent deployment in one out of five animals after 1 h, one out of five animals at 6 h, and two out of four animals at 1 week. All animals exhibited normal haemodynamics after mitral valved stent implantation and maintained stability for the period of monitoring (6 h). One animal died of unrecognised imperfect valved stent positioning after 1 day. In the subsequent animals, valved stent migration, embolisation, systolic anterior movement or LVOT obstruction was not observed after 1 week follow-up. Conclusions: The new mitral valved stent can be deployed in a reproducible manner to achieve reliable stent stability, minimal gradients across the LVOT and adequate valved stent function in short-term follow-up.

Objective: Percutaneous catheter pulmonary vein isolation (PVI) has been the preferred choice for invasive treatment of symptomatic, drug-refractory lone atrial fibrillation (AF). Incomplete ablation lines, procedure-related morbidity and long-term success remain, however, a problem. A minimally invasive surgical approach can provide an attractive and secure alternative. Surgery offers an epicardial, bipolar approach under direct vision, but the invasiveness of surgery remains a problem. Therefore, we developed a completely thoracoscopic procedure. The objective of this study was to assess the feasibility, safety and effectiveness of a completely thoracoscopic surgical procedure to cure lone AF. Methods: Bilateral ‘video-assisted thoracoscopy’ was performed to isolate the bilateral pairs of pulmonary veins using bipolar RF-energy, to ablate the ganglionic plexus (GP) and to amputate the left atrial appendage. Preoperative, in-hospital and follow-up data were collected for our first 30 patients. Results: AF was paroxysmal in 63%, persistent in 27% and permanent in 10% of cases. The mean (±SD) left atrial diameter was 42.1 ± 7.4 mm and the mean duration of AF was 79.0 ± 63.9 months. Freedom from AF was obtained in 77% of the patients during a mean follow-up of 11.6 months. Forty-three percent of the patients had previously undergone a percutaneous PVI and were all free from AF during follow-up. Mean operation time was 137.4 ± 24.7 min. All patients were extubated in the operating room and left the recovery room within 12 h. The mean hospital stay was 5.1 ± 1.8 days. Two patients ultimately underwent a median sternotomy. No CVAs or pacemaker implantation were identified and none of the patients died. Conclusion: We report our initial experience of a completely thoracoscopic PVI with GP-ablation and amputation of the left atrial appendage and demonstrate that the procedure is feasible, safe and effective for the treatment of lone AF.

Objective: Although the left atrial appendage (LAA) is excised to prevent thrombosis in the maze procedure, it remains unclear whether LAA is retained in expectation of LAA booster function. Therefore, we quantitatively assessed LAA size and function after the maze procedure in patients with chronic atrial fibrillation (AF) and mitral valve disease (MVD), and compared with those in patients with sinus rhythm after coronary artery bypass grafting (CABG). Methods: We studied 23 patients (maze group: 65.0 ± 9.2 (SD) years) undergoing the maze procedure for chronic AF and mitral valve surgery and 16 patients having sinus rhythm after CABG (CABG group: 66.5 ± 9.3 years). The maze procedure was conducted by radiofrequency (RF) ablation and LAA was preserved in all cases. Left atrium (LA) and LAA volume and booster function were quantitatively evaluated by multidetector computed tomography (MDCT) at 11.7 ± 10.4 months (maze group) and 16.8 ± 19.9 months (CABG group) after the surgery. Results: In all 23 patients of the maze group, sinus rhythm was well restored. LAA was clearly visualised without thrombi in all 39 patients. The maximal LA volume in the maze group was 128.8 ± 54.6 ml, being larger than 105.3 ± 36.1 ml in the CABG group. LA ejection fraction (EF) in the maze group was 16.1 ± 7.0%, being significantly lower than 26.8 ± 8.7% in the CABG group. Meanwhile, the maximal LAA volume in the maze group was significantly larger (16.9 ± 7.3 ml vs 8.4 ± 4.7 ml), but LAA EF (34.1 ± 12.8% vs 36.1 ± 7.4%) was comparable in the two groups. Conclusion: LAA largely contributes to LA booster function, particularly in the maze group, because LA booster function is deteriorated in this group of patients.

Objective: The impact of pre-existing atrial fibrillation on the long-term outcome in patients after off-pump coronary revascularisation is not well known. This study aims to determine the independent effects of preoperative atrial fibrillation on the early and late outcomes of off-pump coronary artery bypass surgery. Methods: A total of 513 patients undergoing isolated coronary artery bypass surgery using off-pump approach between 2000 and 2005 were studied. Twenty-six of them (5.1%) had preoperative atrial fibrillation (15 had paroxysmal atrial fibrillation and 11 had persistent or permanent atrial fibrillation) and the other 487 patients were in normal sinus rhythm. Early and late outcomes were compared retrospectively between patients with preoperative atrial fibrillation and patients in sinus rhythm. The median follow-up period for the entire study population was 3.3 ± 2.7 years. Results: The baseline characteristics of the patients with preoperative atrial fibrillation were generally similar to those of patients in sinus rhythm. However, the patients with atrial fibrillation had a significantly lower left ventricular ejection fraction compared with those in sinus rhythm (50 ± 15 vs 56 ± 12%, p = 0.03). The mean age of the atrial fibrillation group was almost 3 years more than that of the sinus rhythm group. Operative mortality was similar in patients with atrial fibrillation (3.8%) and those in sinus rhythm (1.0%). Ten patients developed cerebral infarction within 7 days after surgery, including one patient (3.8%) from the atrial fibrillation group and nine patients (1.8%) from the sinus rhythm group. Long-term survival was significantly decreased in the atrial fibrillation group (5-year survival: 70 ± 9.6% vs 87 ± 1.8%; p = 0.0018). Freedom from cerebral complications was also significantly decreased in the atrial fibrillation group (5-year survival: 85 ± 8.3% vs 95 ± 1.2%; p = 0.0009), but there were no differences in cardiac death and major cardiac adverse events. On Cox proportional hazards regression analysis, preoperative atrial fibrillation was a significant adverse predictor for survival (hazard ratio = 3.0, 95% confidence intervals (CIs) 1.3–6.9; p = 0.009) and independent predictor of late cerebral infarction (hazard ratio = 6.2, 95% CIs 2.0–19.3; p = 0.0002). Conclusions: Uncorrected preoperative atrial fibrillation is strongly associated with poor long-term survival and increased late cerebral complications after off-pump coronary artery bypass surgery. Concomitant atrial fibrillation surgery should be considered to improve the long-term results of surgical revascularisation.

Objectives: There are still doubts on the effect of preoperative atrial fibrillation (AF) on early and late mortality after coronary artery bypass grafting (CABG). This retrospective study demonstrates the effects of preoperative AF on the short-term and long-term survival after CABG. Methods: We retrospectively analysed the data of 10 626 patients who underwent CABG between January 1998 and December 2007. The data of 221 patients with a history of preoperative AF (2.5%) and 8631 patients with preoperative sinus rhythm were eligible for analysis. Survival of these patient groups was compared to survival of age- and sex-matched groups of the Dutch general population. Results: Mean follow-up duration was 4.6 ± 2.9 years. Multivariate logistic regression analysis showed preoperative AF to be an independent risk factor for early mortality after CABG, with an odds ratio of 2.06 (95% confidence interval (CI): 1.08–3.95; P = 0.029). Multivariate Cox proportional hazard analysis revealed that preoperative AF is an independent risk factor for late mortality after CABG, with a hazard ratio (HR) of 1.67 (95% CI: 1.21–2.31; P = 0.002). Using propensity score matching, AF was also an independent risk factor for late mortality after CABG, with an HR of 2.77 (95% CI: 1.6–4.79; P < 0.001). In comparison with the general Dutch population, patients with preoperative AF who undergo CABG have a worse long-term survival, while patients with preoperative sinus rhythm experience a better survival. Conclusions: Preoperative AF is an independent risk factor for early and late mortality after first-time elective CABG.

Objective: Our unit has used off-pump coronary artery bypass (OPCAB) surgery since 1998, and has consequently developed teaching methods for surgical trainees. This study aimed to compare the medium-term results of OPCAB performed by experts or supervised trainees. Methods: We retrospectively analysed the data relating to 1333 OPCAB operations performed between January 1998 and January 2006 (mean patient age: 65.3 ± 13; M/F ratio: 2.9), and compared the medium-term outcomes of the 977 (73.3%) carried out by three expert surgeons (group A) with the remaining 356 (26.7%) carried out by four supervised trainees (group B). Results: There were no preoperative differences in patient age, gender, angina class, operative priority, extent of coronary artery disease, the presence of a recent myocardial infarction or left main stenosis or European System for Cardiac Operative Risk Evaluation (EuroSCORE) between the two groups. Thirty-day mortality was 1% in group A and 0.6% in group B (p = 0.43), and 4-year actuarial survival, respectively, 97.4 ± 1.1% and 94.3 ± 4.1% (p = 0.41); the freedom from new re-vascularisation rates in the two groups were, respectively, 96 ± 0.7% and 95.3 ± 1.4% (p = 0.3). Conclusions: The results of this study reflect our unit's long experience of OPCAB surgery and that its successful re-engineering towards the systematic use of OPCAB was feasible. They also show that, in this context, teaching OPCAB surgery is safe in a non-selected cohort of patients, and that the medium-term outcomes of the patients operated on by trainee or expert surgeons are similar.