Frank A. Baciewicz

Anticoagulation with bivalirudin during cardiopulmonary bypass in cardiac surgery

Heparin is the standard agent used for systemic anticoagulation during cardiopulmonary bypass in cardiac operations. Alternatives are needed when patients with heparin-induced thrombocytopenia type II are encountered. We present a patient with a clinical picture of heparin-induced thrombocytopenia type II who was effectively anticoagulated with bivalirudin, a direct thrombin inhibitor, during cardiopulmonary bypass for a cardiac operation.

Power output of pericardium-lined skeletal muscle ventricles, left ventricular apex to aorta configuration: Up to eight months in circulation

OBJECTIVE The purpose of this experiment was to evaluate the potential for a skeletal muscle ventricle connected to the circulation between the left ventricle and the aorta to provide effective, long-term cardiac assist. METHODS Skeletal muscle ventricles were constructed from the latissimus muscle in 10 dogs. After conditioning, the skeletal muscle ventricles were connected to the left ventricle and the aorta with 2 valved conduits. The skeletal muscle ventricle was programmed to contract during diastole. RESULTS At time of implantation, skeletal muscle ventricles stimulated at 33 Hz and in a 1:2 ratio with the heart significantly decreased left ventricular work by 56% (P <.01) and at 50 Hz by 65% (P <.01). At a 1:2 ratio, the power output of the skeletal muscle ventricles was 59% of left ventricular power output at 33 Hz (P <. 01) and 93% at 50 Hz (P <.01). Animals survived 7, 11, 16, 17, 72, 99, 115, 214, and 249 days. Three deaths were directly related to the skeletal muscle ventricle. One animal is alive at 228 days. In the animal that survived 249 days, skeletal muscle ventricle power output at 8 months with a 33 Hz stimulation frequency and a 1:2 contraction ratio was 57% of left ventricular power output and 82% at 50 Hz. At a 1:1 ratio, skeletal muscle ventricle power output was 97% and 173% of the left ventricle at 33 and 50 Hz, respectively. CONCLUSIONS Left ventricular assist with a skeletal muscle ventricle connected between the left ventricle and the aorta is the most hemodynamically effective configuration we have tested and can maintain significant power output up to 8 months.

Women at increased risk for cardiac toxicity following chemoradiation therapy for esophageal carcinoma

PURPOSE The purpose of this study was to identify factors associated with cardiac toxicity in patients treated with chemoradiation therapy (CRT) for esophageal carcinoma. METHODS AND MATERIALS One hundred twenty-seven patients with adenocarcinoma or squamous cell carcinoma of the esophagus treated from July 2002 to June 2011 at 2 academic institutions with preoperative or definitive CRT were retrospectively reviewed. Association of cardiac toxicity with a number of variables was investigated, including heart disease, cardiac bypass and angioplasty, diabetes, insulin use, smoking, chemotherapy regimen, and tumor location. T test assessed risk of cardiac toxicity secondary to age. Dose volume histograms (DVH) were evaluated for percentage of heart volume receiving >20, 30, 40, and 50 Gy (V20-V50). The Fisher exact test analyzed for an association between dose volume parameters and cardiac toxicity. RESULTS Patient population included 100 men and 27 women with a mean age of 64 years. Median follow-up was 12.7 months (range, 0.3-99.6 months). Any cardiac toxicity occurred in 28 patients, the majority of which were pericardial effusion (23/28). Odds ratio for toxicity in women was 4.15 (95% confidence interval [CI], 1.63-10.50; P = .0017) and time to cardiac toxicity by sex was significant (P = .0003). Patients above the median cutoff for V20, V30, and V40 had increased odds of developing cardiac toxicity (P = .03, .008, .002). There was 4.0 increased odds of developing cardiac toxicity with V40 >57% (95% CI, 1.5-10.3, P = .002). On multivariable logistic regression analysis, sex was the only variable associated with any cardiac toxicity and pericardial effusion (P = .0016, P = .0038). None of the other investigated variables were associated with increased risk of cardiac toxicity. CONCLUSIONS Female patients and dose greater than the median for V20-V40 were associated with the development of cardiac toxicity, specifically pericardial effusion. These data suggest exercising increased care when designing radiation fields in women undergoing CRT for esophageal carcinoma, as pericardial effusion may be a long-term complication.

Repair type I aortic dissection in a patient with human immunodeficiency virus infection.

A 57-year-old man with human immunodeficiency virus (HIV) infection was evaluated in October 1997 with complaints of weakness of the right lower extremity. A chest computerized axial tomographic scan revealed a type I aortic dissection. He underwent surgical repair including resuspension of the aortic valve and placement of a 32-mm interposition graft between the aortic root and the transverse arch. Postoperatively he required abdominal aorta fenestration and stenting for ischemia of the left lower extremity. Follow-up magnetic resonance imaging 3(1)/(2) years postoperatively showed a normal-sized ascending and transverse aorta and the residual dissection in the descending thoracic and abdominal aorta. The thoracic and abdominal aorta diameters have remained stable. Select patients with type I aortic dissection and HIV infection are candidates for surgical repair.

Gastric conduit revision postesophagectomy: Management for a rare complication

Objective: Severe postesophagectomy gastric conduit dysfunction refractory to standard endoscopic intervention is rare, with few published reports discussing timing, technique, or results of reoperation. This case series examines assessment and management of severe conduit dysfunction and details techniques for conduit revision. Methods: We retrospectively reviewed patients who underwent esophagectomy between September 2008 and October 2015 and studied patients who underwent conduit revision. Results: More than 400 patients underwent Ivor Lewis or transhiatal esophagectomies during this 7‐year period. Eight patients underwent reoperation for conduit revision. The strategy for initial anastomosis and management of the pylorus were variable. Symptoms included dysphagia, delayed emptying, aspiration, and weight loss. Evaluation and management included esophagram, computed tomography, repeated esophagoscopy with pyloric intervention, and selective anastomotic dilation. Two patients also had associated paraconduit hiatal hernias. Average time to reoperation was 3.8 years (range 2 weeks to 6.5 years). All revisions were performed through a thoracotomy with either laparoscopy or laparotomy. Revisions were completed in 7 patients. Average length of stay was 9.9 days (range 4‐21). Average follow up was 10.1 months (range 1‐36). The completed revisions led to restoration of a regular diet with improved patient satisfaction. Conclusions: Severe gastric conduit dysfunction after esophagectomy is rare. Symptoms, esophagram findings, and response to interventional esophagoscopy guide the decision to revise the conduit. Principles of conduit revision include reducing paraconduit hernias, reducing redundant conduit, tubularizing a dilated conduit, and ensuring adequate gastric drainage. Selective revision was performed with minimal morbidity and durable improvement in subjective symptoms of dysphagia and reflux.

Preoperative pulmonary rehabilitation for marginal-function lung cancer patients

Background This study aimed to evaluate the impact of preoperative pulmonary rehabilitation in lung cancer patients undergoing pulmonary resection surgery with marginal lung function. Methods Short-term outcomes of 42 patients with forced expiratory volume in 1 s < 1.6 L who underwent lung resection between 01/2006 and 12/2010 were reviewed retrospectively. They were divided into group A (no preoperative pulmonary rehabilitation) and group B (receiving pulmonary rehabilitation). In group B, a second set of pulmonary function tests was obtained. Results There were no significant differences in terms of sex, age, race, pathologic stage, operative procedure, or smoking years. Mean forced expiratory volume in 1 s and diffusing capacity for carbon monoxide in group A was 1.40 ± 0.22 L and 10.28 ± 2.64 g∙dL−1 vs. 1.39 ± 0.13 L and 10.75 ± 2.08 g∙dL−1 in group B. Group B showed significant improvement in forced expiratory volume in 1 s from 1.39 ± 0.13 to 1.55 ± 0.06 L (p = 0.02). Mean intensive care unit stay was 6 ± 5 days in group A vs. 9 ± 9 days in group B (p = 0.22). Mean hospital stay was 10 ± 4 days in group A vs. 14 ± 9 days in group B (p = 0.31). There was no significant difference in morbidity or mortality between groups. Conclusion Preoperative pulmonary rehabilitation can significantly improve forced expiratory volume in 1 s in some marginal patients undergoing lung cancer resection. However, it does not improve length of stay, morbidity, or mortality.

Anomalous Aortic Origin of the Right Coronary Artery

mitral valve repair. Nonetheless, mitral regurgitation recurrence is more than 7 times higher after repair. Will this trade-off result in lower survival in the long term? We will have to wait for Acker and colleagues’ follow-up results. For whom should we reserve these highly demanding technical procedures of mitral valve repair? Young patients in whom we can avoid placing a mechanical valve are the main beneficiaries of mitral valve repair. These patients should be referred to highly experienced mitral valve centers to decrease the risk of mitral regurgitation recurrence. Until now, the surgeon who replaced the mitral valve instead of repairing it left the operating room unsatisfied with himself or herself. This feeling of low self-esteem might be over.

Split Latissimus Dorsi Muscle Flap Repair of Acquired, Nonmalignant, Intrathoracic Tracheoesophageal and Bronchoesophageal Fistulas

The development of a fistula between the tracheobronchial tree and oesophagus due to nonmalignant causes is uncommon. Division of the fistula with muscle flap interposition eliminates contact between the tracheobronchial segment and the oesophagus, theoretically decreasing the chance of recurrence as well as providing a robust blood supply to aid in healing. The split latissimus dorsi muscle flap is a well-suited flap for such repairs because of the ability to simultaneously cover two separate apertures (tracheobronchial and oesophageal). The authors describe the split latissimus dorsi muscle flap with step-by-step technique for repair of intrathoracic aerodigestive fistulas.

Two-suture technique for pulmonary artery anastomosis in orthotopic heart transplantation

Distortion of the pulmonary artery anastomosis due to the size mismatch between the recipients pulmonary trunk and the donors pulmonary artery was the cause of acute right ventricular failure after cardiac transplantation. The problem was corrected with a two-suture technique, which has been used subsequently.

When should the elephant (frozen elephant trunk) enter the room (aorta)

From the Cardiothoracic Surgery Section, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Mich. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication April 24, 2017; accepted for publication May 5, 2017; available ahead of print June 27, 2017. Address for reprints: Frank A. Baciewicz, Jr, MD, Harper Hospital, 3990 John R St, Detroit, MI 48201 (E-mail: fbaciewi@dmc.org). J Thorac Cardiovasc Surg 2017;154:1190-1 0022-5223/