Baron L. Hamman

Initial experience in the treatment of thoracic aortic aneurysmal disease with a thoracic aortic endograft at Baylor University Medical Center.

A retrospective review of 27 patients who underwent endovascular repair of thoracic aneurysms and of other thoracic aortic pathology with the thoracic aortic endograft (Gore Medical, Flagstaff, AZ) from June 2005 to July 2007 was performed. The mean follow-up period was 13.5 months (range, 2–25 months). Indications for thoracic endografting included descending thoracic aneurysms (n = 18), thoracoabdominal aneurysms (n = 3), traumatic aortic injuries (n = 3), penetrating aortic ulcers (n = 2), and contained rupture of a type B dissection (n = 1). One patient died during the procedure, for an overall mortality rate of 3.7%. The average length of stay was 8.1 days, with an average stay in the intensive care unit of 4.2 days. If patients with traumatic aortic injuries were excluded, the average overall and intensive care unit length of stay were 5.6 and 1.8 days, respectively. There was one incident of spinal cord ischemia (3.7%). There were five type I or type III endoleaks, three of which required revision (11.1%). In conclusion, thoracic endografting is a safe and viable option for the repair of descending thoracic aneurysms and other aortic pathologies. We have found it to be less invasive, even in conjunction with preoperative debranching procedures, with a shorter recovery time, decreased perioperative morbidity and blood loss, and decreased perioperative mortality compared with standard open repair.

An alternative approach to prescribing sternal precautions after median sternotomy, “Keep Your Move in the Tube”

Traditional sternal precautions, given to sternotomy patients as part of their discharge education, are intended to help prevent sternal wound complications. They vary widely but generally include arbitrary load and time restrictions (lifting no more than a specified weight for up to 12 weeks) and may prohibit common shoulder joint and shoulder girdle movements. Having observed the negative effects of restrictive sternal precautions for many years, our research team performed a series of studies that measured the forces exerted during various common activities and their relationship to the sternum. The results, though informative, led us to realize that the goal of identifying “the” appropriate load restriction to prescribe for sternotomy patients was futile. The alternative approach that we introduce applies standard kinesiological principles and teaches patients how to perform load-bearing movements in a way that avoids excessive stress to the sternum.

Inferior vena cava reconstruction for leiomyosarcoma of Zone I-III requiring complete hepatectomy and bilateral nephrectomy with autotransplantation.

The inferior vena cava (IVC) is the most common site of leiomyosarcomas arising from a vascular origin. Leiomyosarcomas of the IVC are categorized by anatomical location. Zone I refers to the infrarenal portion of the IVC, Zone II from the hepatic veins to the renal veins, and Zone III from the right atrium to the hepatic veins. This is a rare presentation of a Zone I–III leiomyosarcoma. Fifty‐two‐years‐old female with a medical history significant only for HTN was admitted to the hospital with bilateral lower extremity edema and dyspnea. Two‐dimensional echo demonstrated a right atrial thrombus, extending into the IVC. On subsequent CT and MRI, a 15u2009cm mass was noted that began in the right atrium and extended into the IVC, with continuation below the renal veins to above the level of the confluence of the common iliac veins. The patient underwent a complete resection of the mass, replacement of the IVC with Dacron graft, total hepatectomy and bilateral nephrectomy, with liver and kidney autotransplantation. Pathology was consistent with a high grade spindle cell sarcoma of vena cava origin. Patient was readmitted approximately 4 weeks postoperatively to begin adjuvant chemotherapy. This case represents a zone I–III IVC leiomyosarcoma treated with surgical R0 resection. This included a hepatectomy, bilateral nephrectomy, and hepatic and left renal autotransplantation. These complex tumors should be treated with surgical resection, and require a multidisciplinary approach. J. Surg. Oncol. 2015; 112:481–485.

Major Adverse Renal and Cardiac Events After Coronary Angiography and Cardiac Surgery

BACKGROUNDnPatients at high risk for having postprocedural complications may receive iodixanol, an iso-osmolar contrast, during coronary angiography to minimize the risk of renal toxicity. For those who also require cardiac surgery, the wait time between angiography and surgery may be a modifiable factor capable of mitigating poor surgical outcomes; however, there have been inconsistent reports regarding the optimal wait time. We sought to determine the effects of wait time between angiography and cardiac surgery, as well as contrast-induced acute kidney injury on the development of major adverse renal and cardiac events (MARCE).nnnMETHODSnWe merged datasets to identify adults who underwent coronary angiography with iodixanol and subsequent cardiac surgery.nnnRESULTSnOf 965 patients, 126 (13.1%) had contrast-induced acute kidney injury; 133 (13.8%) had MARCE within 30 days and 253 (26.2%) within 1 year of surgery. After adjusting for contrast-induced acute kidney injury, age, and Thakar acute renal failure score, the effect of wait time lost significance for the full cohort, but remained for the subgroup of 654 who had coronary artery bypass graft surgery. Patients undergoing coronary artery bypass graft surgery within 1 day of coronary angiography had an approximate twofold increase in risk of MARCE (30-day hazard ratio 2.13, 95% confidence interval: 1.16 to 3.88, pxa0= 0.014; 1-year hazard ratio 2.07, 95% confidence interval: 1.32 to 3.23, pxa0= 0.002) compared with patients who waited 5 or more days.nnnCONCLUSIONSnPatients who had contrast-induced acute kidney injury and had cardiac surgery within 1 day of angiography had an increased risk of MARCE.

Preoperative visualization of a muscular ventricular septal defect by 64-slice cardiac computed tomography.

A 21-year-old man presented to a primary care physician for a general evaluation. He had a past medical history of a “heart murmur” present since childhood. His only complaint was mild increased fatigability with exertion; he had no dyspnea at rest. Physical examination was remarkable for a 2/6 systolic ejection murmur heard throughout the precordium. A transthoracic echocardiogram showed a muscular ventricular septal defect (VSD) with a mildly dilated right ventricle and an elevated right ventricular systolic pressure of 80 mm Hg. The patient was evaluated for an elective repair of the VSD. Preoperative assessment included a cardiac computed tomography (CT) angiogram (Lightspeed VCT, GE Healthcare) to rule out coronary disease. The CT scan clearly demonstrated the muscular VSD (Figure) and showed normal coronary arteries.

A tribute to John Capehart, MD, “Sooner proud” and 1961 National Spelling Bee champion

Members of the Department of Thoracic and Cardiovascular Surgery, including allied health professionals and staff from transplant services, the anesthesia department, and the operating room, along with everyone at Baylor University Medical Center at Dallas, wish to honor John Capehart, MD, by congratulating him on the 50th anniversary of winning the National Spelling Bee. John was the first Oklahoman to claim this distinction, though his family very nearly dominated the contest for a decade. His brother in 1958 and his sister in 1964 were both finalists at the national competition. n nAnyone who knows John enjoys his witty sense of humor and crisp intellect. The operating room staff has enjoyed interacting with him during a myriad of thoracic, cardiovascular, and transplantation surgical procedures. n nJohns distinction as spelling bee champion has commanded the utmost respect and admiration from his colleagues. The operating room staff regularly consults him regarding word etymology, origin, spelling, and appropriate usage. His uncanny ability to remember names, numbers, dates of birth of fellow surgeons, medical record numbers, as well as dates and details of surgery for transplant patients is unparalleled, and he has mastered a broad range of topics, from military history to sports and other historical events. It is these qualities that make John unique as a splendid and enchanting teller of tales—some of which are actually true.

Severe late (16 years) dysfunction of a bioprosthesis in the mitral valve position without dysfunction of a bioprosthesis in the aortic valve position

A man who was born in 1939 underwent replacement of both mitral and aortic valves with porcine bioprostheses in 1987 (age 48). Thereafter, he was asymptomatic until 2003 (age 64), when he developed signs and symptoms of heart failure. Cardiac catheterization in late 2003 disclosed the following pressures in mm Hg: pulmonary artery, 70/31; right ventricle, 70/18; right atrial mean, 9; pulmonary artery wedge mean, 30, with v waves averaging 54; left ventricle, 108/25; and aorta, 104/65. Left ventricular angiography disclosed a normal-sized left ventricular cavity and severe mitral regurgitation. Aortic root angiogram disclosed trace aortic regurgitation. The preoperative echocardiogram and the operatively excised (late 2003) bioprosthesis, which had been in the mitral valve position, are shown in the Figure. Coronary angiography preoperatively showed insignificant coronary arterial narrowing. n n n nFigure n nEchocardiographic and gross anatomic images of the bioprosthesis in the mitral valve position for 16 years showing severe bioprosthetic regurgitation. (a) A midesophageal 4-chamber view showing 3 distinct defects in the porcine cusps (arrows), (b) A magnified ... n n n nThis case demonstrates that when bioprostheses are placed in both mitral and aortic valve positions during the same operation, the bioprosthesis in the mitral valve tends to degenerate more rapidly than a similar bioprosthesis in the aortic valve (1). The likely reason is that the closing pressure exerted on the mitral bioprosthesis is the left ventricular systolic pressure, whereas the closing pressure exerted on the aortic prosthesis is the aortas diastolic pressure, which in general is about a third lower than the left ventricular peak systolic pressure. In the present patient, the left ventricular peak systolic pressure was 108 mm Hg and the aortas end-diastolic pressure was 65 mm Hg, a 40% difference.