Cardiac Hamartoma: A Diagnostic Challenge.

• Cardiac hamartoma is a rare clinical entity with hypertrophied myocytes mixed with fibro-vascular and fatty tissues. • Multi-modality imaging is needed to narrow the differential diagnosis. • Surgical resection can lead to the definitive diagnosis in some cases.

Frequency of severe valvular disease caused by mediastinal radiation among patients undergoing valve surgery in a community-based, regional academic medical center.

Background: Our goal was to define the prevalence of radiation-induced valvular heart (RIVD) disease among patients undergoing cardiac valve surgery in a community-based, regional academic medical center. Mediastinal radiation is a treatment modality for various hematologic and solid malignancies; however, long-term cardiac complications, including radiation-induced valvular heart disease, can occur years after the radiation treatments.

Hypothesis: Mediastinal radiation exposure is an independent risk factor for valvular heart disease often necessitating valve replacement in patients without other risk factors for valve disease.

Left ventricular diverticulum mimicking ventricular pseudoaneurysm in an adult.

True diverticulum of the left ventricle is very rarely seen in adults: the condition typically occurs in children and can be associated with other anatomic defects that involve the thoracoabdominal midline. Left ventricular diverticulum, which is usually asymptomatic and typically discovered incidentally, can pose a substantial challenge to the surgeon.Herein, we report the case of a 46-year-old man who presented with worsening exertional angina and ST-segment elevation in the inferior electrocardiographic leads.

Acute myocardial infarction requiring mechanical bridge to transplantation in a patient with undiagnosed anti-phospholipid antibody syndrome.

We present a young man who sustained an acute myocardial infarction with hemodynamic instability requiring placement of a left ventricular assist device and subsequent cardiac transplantation. Hematologic work-up revealed anti-phospholipid antibody syndrome. To our knowledge this is the first reported case of severe acute heart failure due to anti-phospholipid antibody syndrome in which the patient survived through assist device placement and successful transplantation.

Spontaneous coronary dissection in late pregnancy: a multidisciplinary approach to management.

Spontaneous coronary dissection is a rare but potentially life-threatening condition. It often occurs in late pregnancy and may pose significant risks for the patient and the fetus. Its cause remains uncertain, and established guidelines for management have not been developed.

Influence of different implantation techniques on long-term survival after orthotopic heart transplantation: an echocardiographic study.

Background: Orthotopic heart transplantation (OHT) was initially done by the biatrial technique, although the bicaval technique has recently become more popular. The aim of this study was to compare OHT outcomes when using the bicaval technique vs the biatrial technique.

Methods: A total of 615 patients were transplanted at the Cleveland Clinic Foundation from January 1993 and October 2003 (biatrial technique: n = 293; bicaval technique: n = 322).

Pre-measured artificial chordae for mitral valve repair.

There is growing interest in the application of artificial chordae to correct mitral valve regurgitation caused by prolapse. Application of pre-measured artificial chordae facilitates creation of chordae of appropriate length. Herein we illustrate the technique for creation of pre-measured artificial chordae, documenting neo-chordal length and number in 50 patients with anterior leaflet prolapse, highlighting the need for chordae of more than one length in 14% of patients.

Does right thoracotomy increase the risk of mitral valve reoperation?

Objective: The study objective was to determine whether a right thoracotomy approach increases the risk of mitral valve reoperation.

Methods: Between January of 1993 and January of 2004, 2469 patients with mitral valve disease underwent 2570 reoperations (1508 replacements, 1062 repairs). The approach was median sternotomy in 2444 patients, right thoracotomy in 80 patients, and other in 46 patients.

Regional referral system for patients with acute mechanical support: experience at the Cleveland Clinic Foundation.

Regional referral networks ("hub and spoke") have been created to facilitate the transfer of patients on mechanical circulatory support. Although individual centers report good success, overall outcomes have remained poor. We investigated whether preoperative variables influenced survival and could be used to help select patients best served by referral.

Safety of targeted perioperative mupirocin treatment for preventing infections after cardiac surgery.

Background: Indiscriminate antibiotic use may lead to development of antibiotic resistance. Preoperative mupirocin treatment decreases Staphylococcus aureus carriage and may reduce subsequent surgical site infection, but is unlikely to benefit noncarriers. This study was undertaken to evaluate whether avoiding mupirocin in noncarriers places them at increased risk for subsequent postoperative infection.

Ventricular assist devices and aggressive immunosuppression: looking beyond overall survival.

Background: Patients bridged to heart transplantation with a ventricular assist device (VAD) developed coronary vasculopathy at the same rate as non-bridged patients despite having higher levels of pre-formed antibodies. We hypothesized that allosensitized VAD patients have higher levels of immunosuppression and thus different morbidity and causes of mortality.

Methods: Patients who received a transplant between January 1996 and May 2002 were separated into 2 groups based on the need for VAD support as a bridge to transplantation.

Does use of a right internal thoracic artery increase deep wound infection and risk after previous use of a left internal thoracic artery?

Objective: To determine whether adding right internal thoracic artery to previous left internal thoracic artery bypass at reoperation increases deep sternal wound infection and hospital mortality, particularly in diabetic patients.

Methods: Reoperations (n = 2875; 2381 men) in patients with previous left internal thoracic artery bypass were performed between January 1990 and January 2003; 1939 (67%) had no repeat internal thoracic artery grafting, 923 (32%) received an additional right internal thoracic artery graft, and 13 (0.5%) had bilateral internal thoracic artery grafting with reuse of the left internal thoracic artery.

Influence of patient characteristics and arterial grafts on freedom from coronary reoperation.

Objective: Arteriosclerosis is a progressive disease, and many patients require repeat coronary intervention after coronary artery bypass grafting. We sought to identify patient characteristics and operative factors that predict the need for or bias toward reoperative coronary artery bypass grafting.

Methods: From 1971 to 1998, 48,758 patients underwent primary isolated coronary artery bypass grafting, and 1000 per year were followed every 5 years (n = 26,927).

Transfusion increases the risk of postoperative infection after cardiovascular surgery.

Background: Because of the immunomodulatory effects of transfusion, we attempted to identify factors associated with blood product use and determine the association of transfusion quantity with postoperative infection.

Study Design: We studied total perioperative transfusion of blood products for 15,592 cardiovascular operations performed from July 1998 to May 2003. Infection end points were septicemia/bacteremia (n=351, 2.

Does the arterial cannulation site for circulatory arrest influence stroke risk?

Background: We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest.

Methods: Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses.

Contemporary outcomes of outpatients referred for cardiac transplantation evaluation to a tertiary heart failure center: impact of surgical alternatives.

Background: The growing epidemic of congestive heart failure in the setting of limited donor-organ availability has mandated continued development and increased utilization of medical and surgical alternatives to cardiac transplantation. We sought to assess current disposition and outcomes of patients recently referred for transplant evaluation to a single high-throughput tertiary referral center.

Methods And Results: We performed a retrospective observational review of consecutive patients with advanced heart failure who were assessed initially in an outpatient setting by a heart failure cardiologist, with a view to transplant or nontransplant surgical alternatives between 1995 and 2000.

Experience in prevention of sternal wound infections in nasal carriers of Staphylococcus aureus.

Nosocomial and surgical-site infections are significant burdens to the health care system that account for $5 billion and $1.6 billion each year in the United States, respectively. These infections are associated with significant morbidity and mortality rates, increased length of hospitalization, and increased treatment costs that are often not reimbursed by third-party payers.

Vacuum-assisted venous return reduces blood usage.

Objective: To determine whether vacuum-assisted venous return has clinical advantages over conventional gravity drainage apart from allowing the use of smaller cannulas and shorter tubing.

Methods: A total of 150 valve operations were performed at our institution between February and July 1999 using vacuum-assisted venous return with small venous cannulas connected to short tubing. These were compared with (1) 83 valve operations performed between April 1997 and January 1998 using the initial version of vacuum-assisted venous return, and (2) 124 valve operations performed between January and April of 1997 using conventional gravity drainage.

Emboli capture using the Embol-X intraaortic filter in cardiac surgery: a multicentered randomized trial of 1,289 patients.

Background: Particulate emboli are thought to play a significant role in the development of cardiac surgical complications. Intraaortic filtration of particulate emboli may reduce the burden of this morbidity in cardiac patients.

Methods: A multiinstitutional randomized trial was designed and enrolled 1,289 patients at 22 centers.

Predictive value and cost-effectiveness analysis of a rapid polymerase chain reaction for preoperative detection of nasal carriage of Staphylococcus aureus.

Objective: To determine the accuracy and cost-effectiveness of a polymerase chain reaction (PCR) for detecting nasal carriage of Staphylococcus aureus directly from clinical specimens. CROSS-SECTIONAL STUDY: This occurred in a tertiary-care hospital in Cleveland, Ohio, and included 239 consecutive patients who were scheduled for a cardiothoracic surgical procedure. Conventional cultures and a PCR for S.

Prospective assessment of the predictive value of alpha-glutathione S-transferase for intestinal ischemia.

Nonspecific investigations resulting in treatment delays contribute to the 30 per cent mortality associated with acute mesenteric ischemia (AMI). As preliminary studies indicate that alpha-glutathione S-transferase (alpha-GST) is elevated in AMI we compare the ability of alpha-GST against conventional biochemical tests to predict AMI. There were 58 patients prospectively evaluated for AMI.