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.

Objective: Trans-catheter aortic valve implantation is an alternative treatment option for patients facing high risk for aortic valve replacement. Currently, the results of trans-apical trans-catheter procedures performed outside controlled trials are unknown. Methods: The Edwards SAPIEN^TM Aortic Bioprosthesis European Outcome (SOURCE) Registry collects data of patients treated at European centres during the first year following commercialisation of the Edwards SAPIEN^TM bioprosthesis. Only data from centres that could provide 100% of their consecutively treated patients (n = 32) were included in the study population. This article provides the 30-day outcome data involving the trans-apical patients, including univariate and multivariate risk analyses for postoperative 30-day mortality. Results: The interim results are based on a total number of 575 procedures performed between January 2008 and 31 January 2009. Mean age at implant was 80.7 years, and patients had a mean logistic EuroSCORE of 29.1%. Baseline characteristics included coronary artery disease 56%, prior coronary intervention 27.1%, prior coronary bypass grafting 26.9%, concomitant mitral valve disease 32.8%, porcelain aorta 11.5%, peripheral vascular disease 27.5%, prior stroke 6.3% and pulmonary disease 29.4%. Successful valve deployment was observed in 92.7% with a 3.5% conversion rate to open surgery, incidence of coronary obstruction of 0.7% and valve embolisation of 0.5%. The incidence of aortic regurgitation in excess of 2+ was 2.3% immediately following the procedure. The incidence of major postoperative complications included bleeding requiring re-operation 2.1%, dialysis 7.1%, pacemaker implantation 7.3%, stroke 2.6%, major vascular complications 2.4% and myocardial infarction 0.7%. The total 30-day mortality was 10.3%. Logistic EuroSCORE ≥30% and missing ejection fraction were found to be the only independent predictors for 30-day mortality. Conclusions: These results demonstrate that although trans-apical trans-catheter aortic valve implantation is a complex surgical technique, the learning curve can be minimised by appropriate training programmes. Very high logistic EuroSCOREs predict inferior survival and make it likely that in this subgroup of patients there may be some who, despite having had a successful trans-catheter aortic valve implantation procedure, do not benefit in the midterm.

Objectives: We reviewed our surgery registry, to identify predictive risk factors for operative results, and to analyse the long-term survival outcome in octogenarians operated for primary isolated aortic valve replacement (AVR). Methods: A total of 124 consecutive octogenarians underwent open AVR from January 1990 to December 2005. Combined procedures and redo surgery were excluded. Selected variables were studied as risk factors for hospital mortality and early neurological events. A follow-up (FU; mean FU time: 77 months) was obtained (90% complete), and Kaplan–Meier plots were used to determine survival rates. Results: The mean age was 82 ± 2.2 (range: 80–90 years; 63% females). Of the group, four patients (3%) required urgent procedures, 10 (8%) had a previous myocardial infarction, six (5%) had a previous coronary angioplasty and stenting, 13 patients (10%) suffered from angina and 59 (48%) were in the New York Heart Association (NYHA) class III–IV. We identified 114 (92%) degenerative stenosis, six (5%) post-rheumatic stenosis and four (3%) active endocarditis. The predicted mortality calculated by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.6 ± 5.7%, and the observed hospital mortality was 5.6%. Causes of death included severe cardiac failure (four patients), multi-organ failure (two) and sepsis (one). Complications were transitory neurological events in three patients (2%), short-term haemodialysis in three (2%), atrial fibrillation in 60 (48%) and six patients were re-operated for bleeding. Atrio-ventricular block, myocardial infarction or permanent stroke was not detected. The age at surgery and the postoperative renal failure were predictors for hospital mortality (p value <0.05), whereas we did not find predictors for neurological events. The mean FU time was 77 months (6.5 years) and the mean age of surviving patients was 87 ± 4 years (81–95 years). The actuarial survival estimates at 5 and 10 years were 88% and 50%, respectively. Conclusions: Our experience shows good short-term results after primary isolated standard AVR in patients more than 80 years of age. The FU suggests that aortic valve surgery in octogenarians guarantees satisfactory long-term survival rates and a good quality of life, free from cardiac re-operations. In the era of catheter-based aortic valve implantation, open-heart surgery for AVR remains the standard of care for healthy octogenarians.

Objective: A bicuspid aortic valve (BAV) may be associated with an aortopathy affecting clinical outcome. Our aim was to assess long-term outcome and analyse if progressive aortic dilatation occurs with time in patients with BAV disease who underwent stentless valve replacement. Methods: Demographic, operative and clinical data were retrospectively reviewed. Patients were classified according to whether their native aortic valve was identified as tricuspid (TC) or bicuspid (BC) at the time of AVR. Serial transthoracic echocardiography was used to measure changes in ascending aortic diameter over time. Propensity adjustment and multivariate regression were used. Events over time were assessed using the Kaplan–Meier method, and the determinants of events were assessed with the Cox proportional-hazards model. Results: Between January 1991 and January 2001, 215 patients underwent AVR. They had a serial follow-up echocardiography performed for a mean of 6.1 ± 4.3 years postoperatively. Ninety patients (41%) had a BAV, and the BC group was younger (BC 62 ± 15 years vs TC 71 ± 12 years; p = 0.002). We found no difference in the increase in ascending aortic diameter over follow-up (BC 0.1 ± 0.5 cm vs TC 0.0 ± 0.5 cm; p = 0.34). BC morphology was not an independent predictor of increased overall mortality (propensity-adjusted hazard ratio: 0.79; 95% confidence interval (CI): 0.42–1.44; p = 0.44) or increased risk of reoperation (propensity adjusted hazard ration: 1.84; 95% CI: 0.88–3.36; p = 0.11). Conclusion: Stentless AVR is protective against progressive aortic aneurysmal disease and confers excellent clinical outcomes in patients with BAV and normal preoperative ascending aortic diameter.

Objective: The Hancock II (HII) is a second-generation porcine bioprosthesis introduced into clinical use in 1982. This study aimed to evaluate very long-term outcomes for the HII valve in a large patient population. Methods: Between May 1983 and November 1993, 517 consecutive patients (pts) (309 male, mean age: 64 ± 9 years) underwent valve replacement (VR) surgery with HII, with 302 (58.4%) in the aortic VR (AVR) and 215 (41.6%) in the mitral VR (MVR) position, respectively. At implant, 106 pts (20.5%) were <60 years of age (G1), while 411 (79.5%) were ≥60 years of age (G2). The 25-year follow-up was complete for all pts at a median of 12 years (range: 0–25). Results: Long-term death occurred in 208 AVR and in 165 MVR pts. Survival at 15 and 20 years was 39.5% and 23.3% in AVR pts and 39.0% and 15.8% in MVR pts. At 25 years the survival of MVR pts was 13.7% (four pts at risk). Late freedom from re-operation was 85.5% and 79.3% at 15 and 20 years in the AVR pts and 73.3% and 52.8% in the MVR pts, respectively. In the AVR population, 20-year freedom from re-operation was 52.2% in G1 pts and 86.8% in G2 pts (p < 0.0001), while in the MVR population it was 41.4% in G1 pts and 61.9% in G2 pts (p = 0.201), respectively. Conclusions: These results confirm the excellent long-term performance of the HII bioprosthesis.

Objectives: Multiplicity of aortic valve repair or sparing techniques results in a lack of standardisation, limiting widespread adoption of such procedures. To treat dilated diameters at the aortic annular base and sinotubular junction while maintaining root dynamics, we propose a standardised and physiological repair approach to the surgical management of aortic root aneurysms, consisting of root remodelling, cusp re-suspension and subvalvular aortic ring annuloplasty. Methods: From May 2003 to September 2009, 144 unselected patients with aortic root aneurysms underwent remodelling with external subvalvular ring annuloplasty in 13 centres (21 surgeons). Preoperative aortic insufficiency (AI) ≥grade 2 was present in 63.9% (92), Marfan syndrome in 12.5% (18) and bicuspid valve in 22.9% (33). Cusp repair was performed in 40.3% (58) patients. Results: Valve repair was successful in all but two cases. Repair of cusp prolapse was necessary in 58 patients, significantly more frequent in bicuspid (24/33, 72.7%) than in tricuspid (34/111, 30.6%) valves (p < 0.05). Operative mortality was 2.8% (four). Subvalvular ring implantation produced a significant annular base reduction from 27.6 ± 2.5 mm to 20.5 ± 2.6 mm (p < 0.01) without significant mean trans-valvular gradient (7.2 ± 1.7 mmHg). During follow-up (median 2.2 years (0.75–4.4, maximum 6.25 years)), five patients died while eight required a re-operation. Six were operated on during our early experience. Strategy for cusp re-suspension evolved over three operative periods, with a significant increase in the rate of cusp repair. From May 2003 to December 2006: eye balling evaluation (15/67 (22.4%)); from January 2007 to August 2008: alignment of cusp free edges (17/38 (44.7%)); and from September 2008 to September 2009: a two-step standardised repair consisting of alignment of cusp free edges and effective height re-suspension (26/39 (66.7%) p < 0.05). Freedom from AI ≥ grade 2 was 91.3% (115) at the end of follow-up. Conclusions: Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with satisfactory preliminary results. The ongoing CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root) will compare this standardised repair technique using an expansible aortic ring to mechanical valve replacement.

Objective: This study was undertaken to evaluate transit-time flow (TTF) as a tool to detect technical errors in arterial bypass grafts intra-operatively and predict outcomes. Methods: TTF's three parameters, pulsatility index (PI, index of resistance), flow (cc min^–1) and diastolic filling (DF, proportion of diastole with coronary flow), were measured in 990/1000 (99%) of arterial grafts in 336 consecutive patients, prospectively enrolled in a database. Grafts were revised when TTF findings supported the otherwise suspected graft malfunction. If no other signs/suspicion of graft malfunction existed (normal electrocardiogram (EKG), stable haemodynamics and unchanged ventricular function on trans-oesophageal echocardiography (TEE)), and the PI was >5, grafts were not revised. Major adverse cardiac events (MACEs: recurrent angina, perioperative myocardial infarction, postoperative angioplasty, re-operation and/or perioperative death) were related to TTF measurements. Results: The average number of grafts per patient was 3.02, of which 99% were arterial. Satisfactory grafts were achieved in 916/990 (93%) of the grafts, with flows from 34 to 61 cc min^–1, PI ≤5 and DF of 62–85%. Fourteen conduits, 20 grafts (2%) suspected to be problematic, were revised. Patients were divided into two groups: 277 (82%) with at least one graft with PI ≤5 and 59 (18%) with a PI >5. MACE occurred in 25 (7.4%) patients — 15/277 patients with a PI ≤5 (5.4%) and 10/59 with a PI >5 (17%, p = 0.005). Mortality following non-emergent surgery was significantly higher in patients with a PI >5 (5/54, 9%) than in patients with a PI ≤5 (5/250, 2%, p = 0.02). Flow and DF were not predictive of outcomes. Conclusion: A high PI predicts technically inadequate arterial grafts during surgery — even if all other intra-operative assessments indicate good grafts; it also predicts outcomes, particularly mortality.

Objectives: The objective of this study was to assess changes in left ventricular (LV) volume, function and regional myocardial wall stress in non-infarcted segments following restrictive mitral annuloplasty (RMA) in patients with ischaemic cardiomyopathy (ICM) and severe functional mitral regurgitation (MR). Patients and methods: Twenty-two patients with ICM (ejection fraction <35%) and severe MR were investigated before and 3 months after RMA using cine-angiographic multidetector row computed tomography (cine-MDCT). For comparative purposes, 38 normal subjects were also studied. Cine-MDCT LV images were reconstructed in a cardiac cycle and regional circumferential wall stress (end-systolic stress (ESS)) was evaluated from the LV end-systolic image using Janz's method. The ESS was determined in six basal and six mid-LV segments of the ventricle based on AHA/ASE criteria. Five apical infarcted segments were not analysed. Mean circumferential fibre shortening (CFS) in both basal and mid-LV regions was determined as a parameter of regional systolic performance. Results: Left ventricular end-diastolic volume (index) (LVEDVI) and left ventricular end-systolic volume (index) (LVESVI) decreased significantly and left ventricular ejection fraction (LVEF) increased after surgery. Neither end-systolic nor end-diastolic sphericity index changed significantly after surgery. Regional ESS significantly decreased in both basal and mid-LV regions after surgery. There was a significant inverse correlation between the change in average value of regional ESS and magnitude of increase in mean CFS of the mid-LV region (r = –0.67, p = 0.0018). Postoperative reduction in ESS in the mid-LV region was also correlated with improvement in global EF (r = –0.72, p < 0.01). Conclusion: The present cine-MDCT may be useful for assessing regional myocardial stress in patients with ICM. We found that RMA could reduce both end-diastolic and end-systolic volume leading to reduction in regional systolic wall stress, which resulted in improved ejection performance of non-infarcted myocardium in patients with functional MR and ICM.

Objective: Nontransplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. Anterior restoration for anterior akinesis has shown favourable outcome. Posterior restoration and surgical results are also discussed. Methods: At the Hayama Heart Center in Japan, between 2005 and 2009, posterior restoration for DCM was performed in 36 patients (10 with ischaemic and 26 with nonischaemic, including muscular dystrophy in three). There were 32 men and four women with a mean age of 53 years. The mean preoperative ejection fraction was 23% and the preoperative New York Heart Association (NYHA) classification was class III in 16 patients and class IV in 20 with eight emergent operations. To identify the posterior lesion before operation, speckle-tracking echocardiography was used, with a Vivid 7 ultrasound machine. The short-axis images from the middle level of the left ventricle (LV) were obtained to assess myocardial segmental viability. Based on the results of speckle-tracking echocardiography, posterior restoration was performed in patients with postero-lateral akinesis and septal kinesis. After the cardioplegic arrest, mitral plasty or coronary artery bypass grafting (CABG) was performed and the posterior LV muscle between bilateral papillary muscles was partially resected under beating heart. The LV apex was preserved and cryoablation was applied between the cut edge and the mitral annulus. All the patients were followed with cardiac echocardiography. Results: In addition to LV restoration, mitral plasty was successfully performed in all the patients. Concomitant CABG was performed in seven, tricuspid surgery in 11 and cardiac resynchronisation therapy (CRT) in eight. Perioperative intra-aortic balloon pumping (IABP) was used in six and there was no hospital mortality, including eight emergent operations. After the operation, 29 patients (80.6%) improved their functional class into class I or II. In the late follow-up, there were two cardiac deaths and one noncardiac death and the 4-year survival rate was 85.8%. Conclusions: The site selection with speckle-tracking echocardiography demonstrated the accurate akinetic lesion of the posterior LV wall. The posterior restoration with preservation of bilateral papillary muscles and LV apex based on the site selection improved operative and mid-term results in the selected patients with DCM.

Objective: The gold standard test in the diagnosis of heart transplant rejection is right ventricular (RV) myocardial biopsy, which is an invasive, time-consuming, expensive method. In an effort to find a reliable method to minimise the sequential use of myocardial biopsy, we assessed the main echocardiographic indices for the detection of allograft rejection. Materials and methods: Fifty myocardial specimens were examined in this prospective study, which assessed the prominent echocardiographic parameters propounded by previous studies as indicators of rejection. Prior to biopsy, all the patients underwent preoperative transthoracic echocardiography. The accuracy of the echocardiographic indices was compared with that of myocardial biopsy indices as the gold standard. At three myocardial segments, namely, RV base, interventricular septal (Sep) base and lateral left ventricular (Lat) base, peak systolic strain (RV-S, Lat-S and Sep-S) was measured. In addition, time to systole (TS) was measured at the same three segments, yielding the three variables of RV-TS, Sep-TS and Lat-TS. Results: Our logistic regression model revealed that the four factors of Lat-S (%), Sep-TS (ms), posterior wall thickness (PWT; mm) and left ventricular mass index (LVMI; g m^–2) could denote heart transplant rejection. We devised a new index, the echo rejection score, using the following formula: [(PWT + LVMI) – (Lat-S + Sep-TS)]. This new formula has an area under a curve of 0.932 and a cut-off point of 0; it yields a sensitivity of 100.0%, specificity of 71.0%, positive predictive value of 67.9% and a negative predictive value of 100.0%. If the echo rejection score is >0, there is a 67.9% possibility that a cardiac transplant patient is presenting with allograft rejection, while a score ≤0 denotes a 100% improbability of rejection. Conclusion: Our proposed method for screening patients at risk of acute cardiac rejection with echo rejection score showed a good sensitivity in detection of graft rejection. However, further study is required to determine if it can be used as an adjunct to the myocardial biopsy.

Objectives: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in subarachnoid haemorrhage, brainstem death (BSD) and heart failure. We examined the relationship between NT-proBNP and cardiac functional status after BSD and left ventricular (LV) BNP precursor gene expression. Methods: We assayed NT-proBNP in the serum of potential heart donors investigated with pulmonary artery flotation catheters, transthoracic echocardiography and cardiac troponin (cTn) I and T. After 6.9 h of optimisation, haemodynamic studies were repeated to determine haemodynamic functional suitability for transplantation. Median (interquartile range (IQR)) NT-proBNP levels are reported according to initially measured dichotomised pulmonary capillary wedge pressure (PCWP), cardiac index (CI), indexed cardiac power output (CPOi), left ventricular ejection fraction (LVEF), wall motion score (WMS), extravascular lung water index (EVLWI), cTnT and cTnI and end-management functional suitability. LV biopsies were snap-frozen, mRNA extracted and reverse-transcribed, allowing performance of Taqman real-time polymerase chain reaction assays of mRNA–BNP precursor. Results: There were 79 subjects. Median NT-proBNP was 121 pg ml^–1 (range 5–4139) and levels correlated with time from coning (p < 0.01, r = –0.379). Higher NT-proBNP was found in donors with PCWP >14 mmHg; 504 (120–1544) versus 101 (38–285); p = 0.01; CI <2.4 l min^–1 m^–2 410 (123–1511) versus 95 (37–264); p = 0.001; CPOi <0.5 W m^–2 256 (78–694) versus 105 (37–315); p = 0.02; LVEF <50% 231 (75–499) versus 72 (36–177); p = 0.04; WMS >2; 343 (80–673) versus 99 (37–236); p = 0.01; cTnT >0.1 µg ml^–1 499 (127–967) versus 80 (36–173); p < 0.001 and cTnI >1 mg ml^–1 410 (97–684) versus 88 (36–190); p < 0.01 and in hearts functionally unsuitable at end-optimisation; 189 (74–522) versus 85 (39–243); p = 0.02. Hearts functionally suitable for transplantation expressed significantly less mRNA encoding for BNP precursor (0.19-fold; p = 0.01). Conclusion: During or after BSD, NT-proBNP is released and the heart is a likely source. Higher NT-proBNP levels are associated with donor heart dysfunction and a failure to achieve haemodynamic functional suitability criteria. This supports the hypothesis that biomarkers, including NT-proBNP, may be useful in donor heart assessment.

Objectives: Early diagnosis of rejection after heart transplantation is mandatory, since even mild rejection can rapidly progress to more severe rejection. However, the identification of patients at high risk of acute cellular rejection and their non-invasive diagnosis remains a challenge. To identify patients with a high risk of acute cellular rejection during the first post-transplantation year. Methods: A retrospective study of 114 consecutive patients submitted to first heart transplantation (between November 2003 and January 2008). The International Society for Heart and Lung Transplantation (ISHLT) grading system was used for the classification of endomyocardial biopsies. Patients were divided into two groups: group A (non-rejecting) – 90 patients who had no significant rejection episodes (ISHLT grade <2R); and group B (rejecting) – included 24 patients with moderate or severe rejection episodes (grade ≥2R) during a 1-year post-transplantation follow-up. The Kaplan–Meier method was used for cumulative survival analysis with the Breslow test for assessing statistical differences between curves. Results: The group B patients tended to have more ischaemic aetiology (42% vs 26%, p = 0.13) and lower baseline triglycerides (99.1 ± 34.2 vs 117.9 ± 63.6 mg dl^–1, p = 0.17), tended to receive less cardiac allografts from donors of the same ABO blood type (83% vs 92%, p = 0.25) and to have longer cardiopulmonary bypass times (108 ± 64 min vs 94 ± 26 min, p = 0.12). Significantly, they had more hyperuricaemia (71% vs 43%, p = 0.02) and longer mechanical ventilation times (19.2 ± 17.9 h vs 14.3 ± 5.3 h, p = 0.031). During follow-up, the group B patients tended to have more severe infections (46% vs 31%, p = 0.16), to be more frequently Quilty-positive (50% vs 30%, p = 0.073) and to have a higher 1-year mortality (8% vs 2%, p = 0.18). Uric acid levels higher than 7.2 mg dl^–1 were identified as the optimal cut-off value to predict acute rejection after heart transplantation (with a sensitivity of 71%, a specificity of 62% and an area under the curve of 0.64). Conclusions: Our work suggests that hyperuricaemia may be a marker of acute cellular rejection that could be another tool helping to identify acute rejection during the follow-up of cardiac-transplanted patients.

Objectives: Lung organ scarcity has led to more generous acceptance of organs under the idea of extended-donor criteria. However, long-term effects have to be monitored to redefine present practice. In this study, we investigated the impact of donor age over 55 years in lung transplantation. Methods: In this retrospective study, 186 consecutive double-lung transplantation procedures from January 2000 to December 2008 were evaluated. A total of 19 recipients received lungs from donors aged 55 years or older (range 55–69 years) (group A) and 167 received lungs from younger donors (range 8–54) (group B). In-hospital mortality, intensive care unit (ICU) stay, rejection episodes, lung function and survival up to 5 years were evaluated. Results: In-hospital mortality was similar in both groups (group A: 10.5%; group B: 13.7%). Postoperative ICU stay was 19 ± 33 days versus 17 ± 34 days (A vs B). Rejection episodes as well as postoperative lung function up to 5 years, and overall cumulative 5-year survival (group A: 52.4%; group B: 50.9%) did not reach statistical significance. However, a trend of increased bronchiolitis obliterans syndrome (BOS) prevalence and reduced lung function was noted. Cause of death showed no differences in both groups. Conclusions: Donor age ≥55 years does not compromise immediate and long-term results after lung transplantation, although long-term observation of patients receiving such an organ suggests earlier lung dysfunction. Due to the rising need of organs, lungs from donors aged 55 or older have to be considered for transplantation. However, the acceptance should be based on donor lung evaluation and individual recipient needs. Long-term outcomes over 5 years need to be further investigated.

Objectives: Bronchoscopic balloon dilatation (BBD) has become a valuable tool in the treatment of tracheobronchial stenosis (TBS). The objective of this study was to assess the short- and long-term effects of BBD. Methods: A retrospective study that included all patients with confirmed, symptomatic stenosis, who underwent BBD between 2002 and 2008. A total of 92 BBD procedures were performed in 35 patients at our institute. Lung function studies were recorded for all patients before, immediately after and 1 month following the BBD. Long-term follow-up was for a mean of 33 ± 4 months. Results: All patients had initial success, including increased airway dimensions and symptom relief. No complications were noted related to BBD. Forced expiratory volume after one second (FEV₁) was significantly increased after BBD (10.5%, p = 0.03). These effects persisted for at least 1 month. Long-term follow-up, however, demonstrated the need for stent placement in 25 of 35 patients (71%), 210 ± 91 days after BBD. Ten of 35 patients died 456 ± 119 days after BBD due to progression of primary disease; all deaths were unrelated to the BBD procedures. Conclusions: BBD is a safe method that offers immediate symptomatic relief in both tracheal and bronchial stenosis. However, BBD is a temporary measure, as many patients will require definitive or additional treatment with laser or stent placement.

Objective: The present study aims to evaluate age-related change of postoperative pain after the Nuss procedure by referring to clinical cases, and to elucidate the biomechanical aetiology of the change by using the finite element method. Methods: Twelve paediatric patients (paediatric group: 9.4 ± 2.3 years old) and 13 adult patients (adult group: 26.3 ± 5.5 years old) who received the Nuss procedure for pectus excavatum were included in the study. On the second postoperative day, the patients were asked to indicate regions on the thorax where they felt the greatest pain. The locations of these regions were compared between the two groups. In addition, stress-distribution patterns were examined using finite element models produced by simulating the thoraces of the patients. The stress-distribution patterns were compared between the two groups. Results: The patients of the paediatric group and adult group tend to have pain on the anterior and posterior regions of the thorax, respectively. The finite element study revealed that paediatric thoraces and adult thoraces develop intensified stresses in the anterior region and the posterior region, respectively. Conclusion: Postoperative pain tends to occur in the anterior part of the thorax for paediatric patients and in the posterior part of the thorax for adult patients, reflecting the stress distributions of these two distinct patient populations.

Objectives: The decision to proceed to simple underwater seal drainage or to apply active suction to the underwater seal following pulmonary operation is a controversial one. For the sake of selecting the alternative to reduce postoperative air leakage, we performed a meta-analysis of randomised controlled trials (RCTs) to determine the benefit of suction or non-suction following lung surgery on patient outcomes. Methods: RCTs published in English from 1999 to 2009 were included. A fixed-effect model was developed for postoperative pneumothorax cases. A random-effects model was developed for quantitative data synthesis, including prolonged air-leak cases, duration of air leakage, time for the removal of chest tubes and hospital stay. Results: Odds ratio (95% confidence interval (CI)), expressed as suction versus non-suction, was 0.11 (0.03–0.49) for postoperative pneumothorax cases; relative risk was 1.48 (0.82–2.70) for prolonged air-leakage cases; weighted mean difference was 1.16 (–0.63 to 2.94) for the duration of air leakage, 0.96 (–0.12 to 2.05) for the time for removal of chest tubes and 2.19 (0.61–4.98) for the hospital stay. Conclusion: There is no necessity to use suction in most cases, since it cannot decrease the incidence of prolonged air leak. However, suction can reduce the occurrence of postoperative pneumothorax resulting from early air leak. As a result, the early use of postoperative suction might be crucial to specific patients to whom early elimination of residual space is very important.

Objectives: Rupture of the oesophagus is a surgical emergency with significant morbidity and mortality. We present our experience in managing such patients in a tertiary care cardiothoracic unit. Methods: We conducted a retrospective clinical review of patients who were admitted following rupture of the oesophagus over a period of 6 years (2002–2008). Results: In our unit, there were 27 admissions following isolated rupture of the oesophagus, of which 18 were males and nine were females. The median age was 65 years (range 22–87). Twenty-four (89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic. Primary surgical repair was done in 21 (77%) patients, a two-stage repair in 8% and conservative management in 16.6%. Mean hospital stay was 31 days (range 13–80 days). Overall, in-hospital mortality was five out of 27 patients (18.5%). Time from onset of symptoms to diagnosis of oesophageal perforation was early (<24 h) in 17 (63%) patients and late (>24 h) in the remaining 10 (37%) patients. In four out of the five non-survivors, there was a >24-h delay in diagnosis. The mortality rate among patients with a delayed diagnosis was 40% compared to 6.2% among those who were diagnosed in <24 h (p = 0.047). Conclusions: Our review confirms that an early diagnosis and management (‘golden 24 h’) are crucial for successful outcome in patients with rupture of the oesophagus. We reiterate the importance of critical care support, particularly in the early stages of management. For early detection, the primary and secondary care sectors need to be better educated.

Objective: Oesophageal gastrointestinal stromal tumours (GISTs) are extremely rare. The preoperative diagnosis is complicated by lack of specificity and the clinical features of patients with oesophageal GISTs need to be fully studied. Methods: We have reviewed retrospectively the medical records of those patients who are treated surgically for oesophageal GISTs in our two hospitals. Results: Eight oesophageal GISTs were identified among the 63 oesophageal mesenchymal tumours in our two hospitals in the past 30 years. Of the eight patients, the male:female ratio was 5:3; the median age of the patients was 57 years (range 49–71 years). Dysphagia was the most common symptom, and all cases were diagnosed postoperatively. The tumours were resected by enucleation or oesophagectomy. The median follow-up was 59 months, ranging from 14 to 202 months, with four of the patients succumbing to the disease, among them two with recurrence and another two with metastasis. Conclusions: Our study indicates that oesophageal GIST is rather rare, and it has relatively high recurrence and mortality rates, especially for patients with large tumours (larger than 9 cm). At present, surgical resection and postoperative diagnosis remain the mainstay for treatment of patients with oesophageal GISTs in China.

In this article, a new technique for turn-over jejunal graft without kinking of its mesenteric vessels is described. Graft necrosis occurred on a left colon oesophageal reconstruction performed for a 56-year-old-woman. A salvage oesophageal reconstruction was performed by a long-segment, supercharged, pedicled anisoperistaltic ileum. Regurgitations were permanent in spite of medical treatment. Segmental reverse of ileum loops was used to turn over the direction of peristaltism without mesenteric twisting. The technique has never been described previously.

Robot-assisted lobectomy has been reported elsewhere as a feasible technique for lobectomy. We report a modification of the previously reported technique using a complete port-access approach without utility thoracotomy.

Introduction: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This article compares the experiences of patients with lung cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy care conference (TMC). Methods: The records of patients with a non-small-cell lung cancer at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation prior to the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy and adherence to national treatment guidelines. The summary data of patients treated before and after the TMC were initiated, and then compared. Results: Between 2001 and 2007, 535 patients were treated prior to the initiation of the TMC and 687 patients within the TMC. The number of patients receiving a complete staging evaluation (79%/93%: p < 0.0001), multidisciplinary evaluation prior to therapy (62%/96%: p < 0.0001) and adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines (81%/97%: p < 0.0001) all increased significantly while mean days from diagnosis to treatment significantly decreased (29/17: p < 0.0001) following the initiation of a TMC. Conclusion: A multidisciplinary thoracic malignancy conference increased the percentage of patients receiving complete staging, a multidisciplinary evaluation and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with non-small-cell lung cancer benefit from being evaluated in a prospective, multidisciplinary care conference.

Objective: Lung cancer resection in breathless patients with severe chronic obstructive pulmonary disease (COPD) remains controversial. Whilst open lobectomy remains the gold standard, alternative approaches have been described. We undertook a retrospective, observational study to compare the outcomes of a tailored strategy combining video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy against open lobectomy in these patients. Method: Clinical outcomes were studied in 84 consecutive patients (male:female ratio was 56:28, mean age 69.0 years, median preoperative-forced expiratory volume in 1 s (FEV₁) 41%) with a predicted-postoperative FEV₁ ≤40% (median 32.8% and range 14–40%) who underwent anatomical lung resection for lung cancer. The control group consisted of 35 patients who underwent open lobectomy. The study group comprised 27 patients who underwent anatomical segmentectomy, 18 who underwent VATS lobectomy and four who underwent VATS segmentectomy. Results: There were no significant inter-group differences in age (p = 0.87), gender (p = 0.49), preoperative FEV₁ (p = 0.30) or cardiac co-morbidities (p = 0.78). There were more upper lobe resections in the control group (51% vs 94%, p < 0.0001). Tumour size tended to be smaller in the study group (p = 0.052). There were also more incidences of stage I cancers in the study group (90% vs 71%, p = 0.043). The median length of hospital stay was shorter in the study group (8 vs 12 days, p = 0.054). There was no significant difference in either in-hospital mortality (8% vs 14%, p = 0.48) or recurrence rate (26% vs 20%, p = 0.60). However, unadjusted survival was significantly longer in the study group (median survival 54 months vs 20 months, 5-year survival 42% vs 18%, p = 0.03). The survival benefit of this group remained significant in multivariate analyses (adjusted survival hazard ratio (HR) 2.39, 95% confidence interval (CI): 1.30–4.39, p = 0.005). A subgroup analysis on only uncomplicated stage I cancers found a similarly worse outcome in the control group (p = 0.002). After segregating surgical approach and the extent of resection, the VATS approach was identified as the critical factor conferring survival advantage to the study group (hazard ratio (HR) 2.78, 95% CI: 1.21–6.37, p = 0.016). Conclusions: Despite a tailored approach to patients with severe pulmonary dysfunction, there was still significant disparity in survival between groups. Patients who underwent open lobectomy have a worse outcome despite adjusting for confounders. This survival benefit was driven by thoracotomy avoidance through VATS resection. The use of operative techniques to reduce chest-wall dysfunction should be considered in the breathless patient.

Objective: Surgical resection is the treatment of choice to cure patients with non-small-cell lung cancer (NSCLC); nevertheless, the assessment of the lower limit of surgical tolerance remains difficult. Ventilatory inefficiency (measured as the ventilation to CO₂ production ratio ( slope) is a survival predictor in pulmonary hypertension (PH) and chronic heart failure (CHF) and is considered a marker of PH in chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the role of slope as preoperative mortality and morbidity predictor in COPD patients submitted to lung resection for NSCLC and considered operable according to current standards. Methods: A retrospective analysis was performed in 145 consecutive COPD patients with lung cancer (128 males and 17 females), with a mean age of 64 years (range: 41–82 years) who were referred for preoperatory evaluation. Because of bronchial obstruction or reduced pulmonary diffusion capacity for carbon monoxide (D _L,CO), all these patients were considered operable only after a cardiopulmonary exercise test showed a preserved cardiopulmonary function. Results: A total of 98 lobectomies, eight bilobectomies and 39 pneumonectomies (13 left and 26 right) were performed. Twenty-one patients (14.5%) suffered severe cardio-respiratory complications; 15/106 patients (14.2%) after lobectomy/bilobectomy and 6/39 (15.4%) after pneumonectomy. Five patients (3.4%) died within 30 days after surgery (3/106 after lobectomy/bilobectomy (2.8%) and 2/39 after pneumonectomy (5.1%)). Considering all functional parameters before surgery and the postoperative predicted values, a logistic regression analysis individuated the slope as the only independent mortality predictor (odds ratio (OR): 1.24 z = 2.77; p < 0.007). The was instead the best predictor for the occurrence of severe cardiopulmonary postoperative complications (OR: 0.05, z = –2.39, p < 0.02). Conclusions: In COPD patients, a high slope before lung resection is an independent mortality predictor even in the presence of an acceptable cardiopulmonary performance. COPD patients with high slope before surgery must be carefully screened to exclude pulmonary hypertension, especially before surgical procedures with large parenchymal exeresis.

Objective: Survival after resections for non-small cell lung cancer remains poor. Recurrent lung cancer remains common. Due to the common risk factor of smoking, cardiovascular deaths occur in the absence of recurrent lung cancer in up to 15% of patients. Aspirin has been proven to reduce cardiovascular mortality as a secondary prophylactic agent, but not as a primary agent. Aspirin being a COX-2 inhibitor has been shown to reduce the chance of metastasis in adenocarcinoma but not squamous carcinoma. We sought to investigate the effect of long-term aspirin therapy on survival post potentially curative surgery. Methods: We analysed a prospective thoracic surgical database, from time period 2003 to date. Patients who were on aspirin pre-operatively, N = 412 were compared to non users, N = 1353. Patient long-term outcome was assessed utilising the national strategic tracking service that operates in the United Kingdom. Cox proportional hazards analysis was used to determine significant factors affecting survival. Results: 100% survival follow up was achieved. Regular users of aspirin had >5% increased survival, which was significant, p = 0.05, despite having a higher cardiovascular risk profile. Mode of death data was not available. Conclusions: Adjuvant aspirin post resection for potentially curative non-small cell lung cancer significantly increases survival. The mechanism of increased survival needs further investigation and is the basis for the trial: Adjuvant Aspirin for Non-Small cell Lung Cancer – The Big A Trial. www.TheBigATrial.co.uk.

Objectives: The increasing age of the population has raised the importance of determining the minimally required surgical treatment for elderly lung cancer patients. Despite a number of previous studies, the therapeutic impact of a radical mediastinal lymphadenectomy (RLA) associated with a pulmonary resection for lung cancer remains controversial. Herein, we investigated the impact of lymph node dissection on the overall survival for elderly lung cancer patients and assessed whether the non-performance of an RLA could be justified in the surgical treatment for these elderly patients. Methods: We analysed the data for 160 patients aged 70 years and older (113 males, 47 females) who underwent curative-intent surgery for non-small-cell lung cancer. They were divided into two groups, according to the method used for the intra-operative mediastinal lymph node dissection, the radical systematic lymphadenectomy (RLA, n = 76) and the non-radical lymphadenectomy (NLA, n = 94) groups. A Cox proportional hazards model and the Kaplan–Meier method were used for the survival analyses. Propensity-based analyses were also used to reduce the effect of non-randomisation and possible bias in indication of treatment between the two groups. Results: RLAs had no protective effect on mortality; the hazard ratio for the RLA group in comparison to the NLA group was 0.97 (95% confidence interval (CI): 0.32–2.89) in the multivariate analysis and 1.43 (95% CI: 0.42–4.91) in the propensity-based stratifying analysis. The 3-year survival probability was 81.3% (95% CI: 67.1–89.8) for the NLA group, which was marginally better than that of the RLA group (77.5% (95% CI: 63.3–86.8)). There was no significant difference in the overall survival between the two groups (p = 0.26). The 3-year survival probability of the NLA group at each quartile of the propensity score also tended to be better than that of the RLA group, which did not show any significant difference. Conclusions: There was no survival benefit shown for RLA associated with pulmonary resections in the present cohort, even in the propensity-based analyses. Although some reports recommend a systematic mediastinal lymphadenectomy for proper staging and better survival, a pulmonary resection with non-performance of radical lymphadenectomy could be an acceptable surgical treatment for the increasing number of elderly lung cancer patients.

Objectives: Epidermal growth factor receptor (EGFR)-targeted therapies are a valid therapeutic option for advanced non-small-cell lung cancer (NSCLC), but unequivocally recognised predictive factors for therapeutic response are lacking. However, intrinsic resistance might occur due to loss of EGFR expression during the course of the disease or its treatment. Methods: Paraffin-embedded tissue from cases with metastatic NSCLC obtained at autopsy was retrieved from our archive. Specimens of primary tumour (n = 39; 64% adenocarcinoma) and of all corresponding metastases (n = 70) were immunohistochemically stained for EGFR expression. Two observers independently scored staining intensity and evaluated the percentage of positively stained cells. Identical staining intensity and ≤10% difference in number of stained cells were defined as perfect concordance; and one-increment difference in staining intensity and less than 30% difference in number of stained cells were defined as good concordance. Results: Twenty-seven out of 39 primary tumours (69%) were EGFR-positive on immunohistochemistry (IHC), with 12/27 (44%) of positive tumours exhibiting intense or moderate EGFR expression. The median number of EGFR-expressing cells in primary tumours was 50% (range 0–100%). Overall Spearman's rank correlations for staining intensity and percentage of positively stained cells between primary tumours and paired metastases were 0.78 (p < 0.001) and 0.60 (p < 0.001), respectively. Perfect concordance was observed in 51% (20/39) and good concordance in 18% (7/39) of corresponding pairs, respectively, whereas 9/12 metastases showing discordant staining with their corresponding primary tumours had lacked EGFR expression. Conclusions: In most NSCLCs, EGFR status of primary tumours correlates with EGFR status of corresponding metastases. Hence, loss of EGFR expression is unlikely during disease progression, local or non-EGFR-targeting systemic treatment.

Objectives: We analysed our experience in primary malignant chest-wall tumours (PMCWTs) with an emphasis on a new reconstruction technique and on survival. Methods: From 1998 to 2008, 41 patients (23 (56%) male, mean age 48 years) with PMCWT were operated in our unit: chondrosarcoma n = 25; osteosarcoma n = 8; Ewing's sarcoma n = 2; other n = 6. We performed nine sternectomies and 32 lateral chest-wall resections (median number of ribs resected = 3.5). Resections were extended to the lung (n = 2), diaphragm (n = 3), vertebral body (n = 3), scapula (n = 1) and upper limb (n = 1). Stability was obtained by a prosthetic material, rigid and non-rigid and a muscular flap. As non-rigid material, we mostly used a polytetrafluoroethylene patch (n = 24). In the past 2 years, two patients (one total sternectomy and one wide anterior chest-wall resection) were reconstructed with a rigid system composed of mouldable titanium connecting bars and rib clips (Strasbourg Thoracic Osteosyntheses System – STRATOS, MedXpert GMbH, Heitersheim, Germany). A muscular flap was added in 12 patients (29.3%). Results: There was no perioperative mortality or significant morbidity and all patients were extubated within first 24 h. At a mean follow-up of 60.5 months (range 4–130 months), the overall 5- and 10-year survival was 61% and 47%, respectively. In the chondrosarcoma group, 5- and 10-year survival was 80%. Conclusions: Wide resection with tumour-free margins is necessary in PMCWT to minimise local recurrence and to contribute to long-term survival. The STRATOS system, developed for chest-wall replacement, allows a firm reconstruction, simple to handle and to fix, avoiding instability or paradoxical movement also in wide chest-wall resections.

Objective: Prolonged deep hypothermic circulatory arrest (DHCA) adversely affects outcome and quality of life in thoracic aortic surgery. Several techniques of antegrade cerebral perfusion are routinely used: bilateral selective antegrade cerebral protection (SACP) by introducing catheters in the innominate and left carotid artery, unilateral perfusion through the right axillary antegrade cerebral perfusion (RAACP) or a combination of right axillary perfusion with an additional catheter in the left carotid artery (RAACCP), resulting also in bilateral perfusion. The aim of the present study was to analyse the impact of the different approaches on the quality of life (QoL). Methods: The data of 292 patients who underwent surgery of the thoracic aorta using DHCA at our hospital between January 2004 and December 2007 have been analysed and a follow-up was performed focussing on QoL, assessed with the Short Form-36 Health Survey Questionnaire (SF-36). Results were analysed according to the type of cerebral perfusion and the duration of DHCA. Results: Patients’ characteristics were similar in all groups. Of the total, 3.4% patients underwent DHCA (average 8.3 ± 6.4 min) without ACP, 45.9% underwent SACP (average DHCA of 15.6 ± 7.1 min), 40.4% had RAACP (average DHCA of 28.1 ± 11.6 min) and 9.4% bilateral perfusion (RAACCP) (average DHCA of 43.1 ± 16.7 min). The average follow-up was 23.2 ± 15.1 months. QoL was preserved in all groups. For DHCA above 40 min, bilateral ACP provides superior midterm QoL than unilateral RAACP (average SF-36 95.1 ± 44.4 vs 87.6 ± 31.3; p = 0.072). Conclusions: When midterm QoL is assessed, bilateral SACP provides the best cerebral protection for prolonged DHCA (>40 min).

Objective: The aim of this retrospective study was to analyse results and risk factors of death after the repair of the interrupted aortic arch, and to compare results obtained with the use of deep hypothermic circulatory arrest versus isolated cerebral perfusion. Methods: The primary repair of the interrupted aortic arch and associated heart lesions was performed in 50 consecutive patients. The median age was 5 days and the mean weight was 3.1 ± 0.6 kg. The interrupted aortic arch was of type A in 12 (24%) patients, type B in 37 (74%) and type C in one (2%) patient. Ventricular septal defect was present in 48 (96%) patients, subaortic stenosis in 15 (30%), truncus arteriosus in 14 (28%), transposition of the great arteries in two (4%), aortopulmonary window in two (4%) and double-outlet right ventricle in one (2%). The surgery consisted of reconstruction of the aortic arch by direct anastomosis and repair of associated heart lesions. In 25 (50%) patients, aortic arch reconstruction was performed using hypothermic circulatory arrest (group I) and in 25 by isolated cerebral perfusion (group II). The duration of cardiopulmonary bypass, aortic cross-clamping and circulatory arrest or isolated cerebral perfusion was 191 ± 46 min, 90 ± 24 min and 40 ± 14 min, respectively, in group I; and 194 ± 39 min, 74 ± 20 min and 31 ± 6 min, respectively, in group II. Results: There were 10 (20%) deaths in this series, eight (32%) in group I and two (8%) in group II. Out of 12 patients operated before 1995, seven (58%) patients died; and out of 38 patients operated between 1995 and 2009, three (8%) patients died (p = 0.008). By Cox multifactorial analysis, the earlier date of operation represented the only risk factor of death (p = 0.037). Twelve (71%) survivors in group I and five (22%) survivors in group II required re-intervention, most often for subaortic stenosis, aortic arch obstruction or conduit obstruction. All patients remain in the New York Heart Association (NYHA) class I or II at median 12.6 years in group I, and 1.7 years in group II, respectively, after surgery. Conclusions: Interrupted aortic arch can be repaired in neonates with a mortality of 5–10%. The results depend on experience. Isolated cerebral perfusion was joined with decreased mortality but it did not influence the occurrence of neurological complications.

Objective: To determine outcomes of patients undergoing a bidirectional cavo-pulmonary shunt (BCPS) in the Fontan era. Methods: From 1990 to 2000, 212 patients underwent a BCPS in a single institution at a mean age of 2.6 ± 5 years. Results: Hospital mortality was 6% (13 patients). Five patients were lost to follow-up (3%). After a mean of 9 ± 4 years, 15 patients had not yet been referred for Fontan surgery and their status was deemed satisfactory (11 11/2 ventricle repair, three BCPS and one patient converted to a bi-ventricular repair). Out of the remaining 179 patients who could potentially have reached a Fontan status, 141 had undergone the procedure and seven were awaiting Fontan completion. The expected completion rate of Fontan surgery after BCPS was 83% (148/179). Thirteen patients died and heart transplantation was necessitated in nine patients. Nine were deemed unsuitable for Fontan surgery for cardiac (seven), respiratory (one) or neurologic (one) reasons. After BCPS, the only predictors of late failure (death, heart transplantation or NYHA class III–IV) were not reaching Fontan status and the presence of bilateral superior vena cava (SVC). Ten-year survival was 99% (95% confidence interval (CI): 95–99%) for Fontan patients and 67% (95%CI: 50–80%) for those left with a BCPS. Conclusion: In the present era, staging with BCPS represents a selection process in the Fontan pathway. Almost a fifth of the patients will not reach Fontan status. Outstanding results after Fontan surgery may hide a high attrition rate between BCPS and Fontan.

Objective: A lateral tunnel-total cavopulmonary connection (LT-TCPC) using a right atrial (RA) free wall is the first choice of treatment for patients with a small body weight in this institute. Whether the growth of the LT is appropriate or not according to the growth of the body remains controversial. In addition, the optimal initial diameter of an LT is unknown. The purpose of this study was to verify the growth of the LT. Methods: Ninety-one patients of a total of 267 TCPC cases underwent an LT-TCPC at less than 5 years of age in this institute between March 1991 and June 2008. The data on 47 of the 91 patients, which were available to investigate the LT growth, were retrospectively reviewed. The mean age at LT-TCPC was 37 ± 11 months (16–57 months). The mean body weight at TCPC was 12.4 ± 2.4 kg (7.6–20.0 kg). The initial LT diameter was determined with Hegar's sizer of the estimated half-pulmonary arterial (PA) diameter, which is a diameter that results in half of the dimension of the normal pulmonary valve. The measured maximum LT diameter (mm) divided by the estimated half-PA diameter (mm) was considered as the LT index. The size of the LT was evaluated using either echocardiography or angiography. Results: The mean follow-up period was 7.4 ± 3.5 years (1.6–13.5 years). The LT index was initially 2.0 ± 0.7 (1.3–4.5), 2.0 ± 0.4 (1.3–3.2) at 1 year after operation, 2.1 ± 0.5 (1.5–3.2) at 5 years after operation, 1.9 ± 0.4 (1.5–2.8) at 10 years after operation and 2.1 ± 0.5 (1.6–2.5) at 13 years after operation, respectively. Conclusions: LT growth suitable for the body growth can be expected. Although there was some variation in the initial LT diameter, the LT index tended to converge at 2.0 with growth.

Objective: Sildenafil is a strong pulmonary vasodilator that increases the intracellular cyclic guanosine monophosphate concentration through inhibition of phosphodiesterase-5. We assessed the benefit of oral sildenafil for persistent pulmonary hypertension early after congenital cardiac surgery in paediatric patients. Methods: Sildenafil was administered at a starting dose of 0.5 mg kg^–1 following admission to the intensive care unit. With careful monitoring of haemodynamics, the dose was increased stepwise by 0.5 mg kg^–1 every 4–6 h up to a maximum of 2 mg kg^–1. After successful weaning from a ventilator and from other vasodilators, sildenafil was gradually discontinued over the next 5–7 days. Results: A retrospective review of medical records showed an age distribution of <1 month (n = 26), ≥1 – <6 months (n = 36), ≥6 – <12 months (n = 19), 1–3 years (n = 8), 4–9 years (n = 9) and >10 years (n = 2) at the time of surgery. The surgeries were performed for ventricular septal defect closure (n = 17), arterial switch (n = 30), truncus arteriosus repair (n = 10), complete atrioventricular septal defect repair (n = 12), total anomalous venous drainage repair (n = 9), and other open-heart surgery (n = 22). The aforementioned concomitant inhaled nitrous oxide treatment was performed in 66 patients. Pulmonary arterial pressure decreased in 28, was unchanged in five and elevated in one patient out of the total of 34 cases for which data from continuous pressure monitoring were available. Bosentan was added in three cases with persistent symptoms due to pulmonary hypertension despite sildenafil treatment. After sildenafil administration, modest oxygen desaturation occurred in seven cases, but no ‘rebound’ pulmonary hypertension occurred. There were no significant adverse events during sildenafil treatment. Conclusions: Our results suggest that oral sildenafil is a safe and effective alternate for persistent pulmonary hypertension following congenital heart surgery in children.

Objective: The longevity of valved right ventricle to pulmonary artery (RV-PA) conduits is limited due to calcification and degeneration of non-viable structures. Xenografts are commonly used because of the restricted availability of cryopreserved homografts. Tissue-engineered (de-cellularised) pulmonary valves (TEPVs) were thought to be a valuable alternative to cryopreserved pulmonary homografts due to postoperative seeding with viable autologous vascular endothelial cells. Methods: From July 2007 to December 2008, xenogenous TEPV (Matrix P plus©) were implanted in 16 patients in the right ventricular outflow tract for different indications, related to congenital heart disease. Mean age at operation was 14 ± 11 years, including three patients younger than 1 year. The median conduit size was 22 mm (range: 13–26 mm). Results: The early and late survival rates were 100%. At a median follow-up of 10 months (range: 2–17 months), six patients (38%) had to be re-operated upon due to obstructed grafts. Five of these patients were older than 13 years (range: 13–26 years); one patient was younger than 1 year. On echocardiography before re-operation, mean systolic gradient in the main PA was 66 ± 18 mmHg. In explanted conduits, we found a predominantly peripheral conduit narrowing without leaflet calcification. Histological examination revealed stenosis formation, due to inflammatory infiltration and severely fibrogenic pseudo-intimal reaction. Conclusions: On the basis of our short-term results, the Matrix P plus© de-cellularised tissue-engineered pulmonary valve cannot be regarded as an ideal conduit for right ventricular outflow tract reconstruction, as the widespread use of these grafts may increase the possibility of frequent early conduit failures.

Objective: To assess the effects of preoperative administration of allopurinol in patients undergoing open-heart surgery (OHS) for valvular heart diseases. Methods: In this prospective randomised double-blind study, 50 consecutive patients undergoing OHS for valvular heart disease were randomised into two groups of 25 patients each: (a) control group received placebo and (b) test group received allopurinol prior to surgery. Serum troponin T and creatine phosphokinase-MB (CPK-MB) isoenzymes were measured prior to the induction of anaesthesia, at the time of aortic cross-clamp release and 24 h following termination of cardiopulmonary bypass. Postoperatively assessed parameters were inotropic score, rhythm, and duration of mechanical ventilation and occurrence of a low cardiac output state. Results: Significant differences were observed with respect to inotropic score: median 5 ((0–25) vs 0 (0–25) p = 0.027) and mean 6.44 ± 6.145 versus 3.4 ± 5.54, mean duration of mechanical ventilation (11.1 ± 4.9 vs 7.5 ± 2.5 h, p = 0.002, hospital stay (6.35 ± 1.43 vs 5.04 ± 0.611, p = 0.001) and maintenance of normal sinus rhythm (NSR) (18 vs 25, p = 0.004) between the control groups versus the test group, respectively. There were no significant differences in the levels and trends of troponin T and CPK-MB between the two groups. Conclusion: The administration of allopurinol prior to OHS for valvular heart diseases is associated with increased conversion and maintenance to normal sinus rhythm, reduced inotropic score and a reduction in the duration of mechanical ventilation and hospital stay. There was, however, no significant difference in the blood levels of CPK-MB and troponin T and a large sample size is required to assess this further.

Objective: Minimised perfusion circuits (MPCs) are expected to reduce the side effects of conventional cardiopulmonary bypass (CCPB); however, conclusive data from sufficiently powered clinical trials are lacking. The purpose of this study was to evaluate the safety and efficacy of the ROCsafeRX^TM minimised perfusion circuit. Methods: A randomised, controlled, multicentre clinical trial comparing both perfusion circuits in patients subjected to elective coronary artery bypass and/or aortic valve replacement is described. The primary end points of safety, defined as procedure success without device-related complications, and secondary end point of efficacy, including reduction of transfusion requirement and incidence of atrial fibrillation, are analysed. Results: To date, 291 patients have been enrolled and randomised (146 MPC vs 145 CCPB). With the exception of a significantly higher male population in the MPC group (83.6% vs 71.0%, p = 0.01), both groups were well matched for demographic data and type of surgery. There were no device-related complications but a hard-shell reservoir had to be integrated in one MPC because of a tear in the right atrium that was managed uneventfully. Total transfusion requirement (329 ± 599 ml vs 783 ± 1638 ml, p ≤ 0.001) and erythrocyte transfusion (181 ± 341 ml vs 434 ± 798 ml, p ≤ 0.001) were significantly reduced in the MPC group. The incidence of atrial fibrillation was significantly lower in the MPC group (7.1% vs 19.5%, p ≤ 0.01), while freedom of major adverse events showed no significant difference. Conclusions: Lack of device-related complications combined with a significant reduction in postoperative atrial fibrillation and transfusion requirements have shown the ROCsafeRX^TM MPC to be both safe and efficient for large-scale use in cardiac patients. Additional data are expected to confirm these initial findings.

Objective: Aprotinin is frequently used to reduce blood loss during cardiac surgery; however, it also causes renal injury. Since aprotinin reduces nitric oxide (NO) and prostaglandin I₂ (PGI₂), and both cause vasodilation and inhibit activation of neutrophils and platelets, their reduction may be responsible for the injury. This study was to determine whether the combination of aprotinin with NO and prostaglandin E₁ (PGE₁, an analogue of PGI₂) can attenuate renal injury associated with aprotinin during cardiopulmonary bypass (CPB). Methods: Thirty mongrel dogs were equally divided into five groups, with each group receiving CPB and aprotinin, NO, PGE₁, a combination of the three or no treatment (control). Serum creatinine and creatinine clearance were determined. To elucidate the mechanism, neutrophil, platelet and thrombin activations were also assessed. Results: After CPB, serum creatinine increased and creatinine clearance decreased in all dogs. These changes were similar among the NO, PGE₁, aprotinin and control groups, but were significantly smaller in the combination group. Similarly, myeloperoxidase activities in tissues, CD11b expression, plasma elastase, prothrombin fragment (PTF) 1 + 2 and platelet activation factor were lower, whereas neutrophil and platelet counts were higher in the combination group than in the other groups (P < 0.05). Conclusions: Aprotinin combined with NO and PGE₁ produced synergistic protective effects and improved renal function, due partly to inhibition of platelet and neutrophil activation and suppression of thrombin formation.

Objectives: The purpose of this study was to develop a specific postoperative score in intensive care unit (ICU) cardiac surgical patients for the assessment of organ dysfunction and survival. To prove the reliability of the new scoring system, we compared its performance to existing ICU scores. Methods: This prospective study consisted of all consecutive adult patients admitted after cardiac surgery to our ICU over a period of 5.5 years. Variables were evaluated using the patients of the first year who stayed in ICU for at least 24 h. The reproducibility was then tested in two validation sets using all patients. Performance was assessed with the Hosmer–Lemeshow (HL) goodness-of-fit test and receiver operating characteristic (ROC) curves and compared with the Acute Physiology and Chronic Health Evaluation (APACHE II) and Multiple Organ Dysfunction Score (MODS). The outcome measure was defined as 30-day mortality. Results: A total of 6007 patients were admitted to the ICU after cardiac surgery. Mean HL values for the new score were 5.8 (APACHE II, 11.3; MODS, 9.7) for the construction set, 7.2 (APACHE II, 8.0; MODS, 4.5) for the validation set I and 4.9 for the validation set II. The mean area under the ROC curve was 0.91 (APACHE II, 0.86; MODS, 0.84) for the new score in the construction set, 0.88 (APACHE II, 0.84; MODS, 0.84) in the validation set I and 0.92 in the validation set II. Conclusions: Most of general ICU scoring systems use extensive data collection and focus on the first day of ICU stay. Despite this fact, general scores do not perform well in the prediction of outcome in cardiac surgical patients. Our new 10-variable risk index performs very well, with calibration and discrimination very high, better than general severity systems, and it is an appropriate tool for daily risk stratification in ICU cardiac surgery patients. Thus, it may serve as an expert system for diagnosing organ failure and predicting mortality in ICU cardiac surgical patients.

Objective: Negative pressure wound therapy (NPWT) is a recently introduced treatment modality for post-sternotomy mediastinitis. The aim of this study was to compare the mortality rate, the sternal re-infection rate and the length of hospital stay in patients with post-sternotomy mediastinitis after NPWT and conventional treatment. Methods: We retrospectively analysed 118 patients with post-sternotomy mediastinitis after cardiac surgery. One group of 69 patients was treated with NPWT and the other group of 49 patients with conventional therapy. Results: There were no major differences between the two groups concerning preoperative data (EuroScore) or primary cardiac surgery (mainly coronary artery bypass grafting). NPWT therapy was found to reduce mortality rate (P = 0.005) and sternal re-infection rate (P = 0.008) compared with conventional treatment and tended to lead to a shorter length of hospital stay (P = 0.08). Conclusions: NPWT for post-sternotomy mediastinitis demonstrates encouraging clinical results with a reduction of the mortality rate and the sternal re-infection rate compared with conventional treatment. The results support NPWT as the first-line treatment for deep sternal wound infections.