Robotically assisted video-enhanced-endoscopic coronary artery bypass graft surgery.

Since 1988, through fierce industry-driven competition and patients' preference for minimally invasive procedures, widely diffused through the media, laparoscopic cholecystectomy was universally adopted and rapidly became the "gold standard" for symptomatic cholelithiasis. Robotically assisted video enhanced-endoscopic coronary artery bypass surgery (RAVE-CABG) will most likely follow suit with its similar developmental processes for symptomatic coronary artery disease. Since 1998, there are currently two surgical robotic systems that have been used in a clinical setting for endoscopic coronary artery bypass (ECABG): the da Vinci and the ZEUS system.

Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach.

Reoperative left anterior descending artery (LAD) revascularization can be performed through a left anterior small thoracotomy (LAST approach) in patients requiring isolated LAD revascularization. If the left internal mammary artery has been previously used, however, the operation is generally performed either through a median sternotomy or through a full posterolateral thoracotomy for the necessity of connecting the vein graft to the ascending aorta or to the descending thoracic aorta, thus losing the advantages of a minimally invasive approach. In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the left internal mammary artery as the inflow site of a saphenous vein coronary graft to the LAD.

Intervention to improve adherence to ACC/AHA recommended adjunctive medications for the management of patients with an acute myocardial infarction.

Background: The most recent published guidelines regarding management of patients surviving an acute myocardial infarction (AMI) advocate the administration of aspirin (ASA), beta blockers (BB), and angiotensin-converting enzyme inhibitors (ACEi) and discourages the use of calcium-channel blockers (CCB). Previous data collected in our region from the National Registry (NR) showed a dismal compliance with these guidelines. In an attempt to increase physician awareness and to optimize implementation of recommended guidelines, a cardiac and pharmacy steering committee was created.

Myocardial Hematoma Documented by Transthoracic Echocardiography After Sequential Coronary Artery Stenting.

We report the case of a patient who deteriorated suddenly while undergoing endoluminal coronary artery reconstruction with multiple stents to the left anterior descending coronary artery. With the aid of transthoracic echocardiography, a pericardial effusion was noted; however, dissection of the ventricular wall due to a large myocardial hematoma was also identified. Emergency exploration with evacuation of the pericardial blood with coronary artery bypass graft surgery was successfully accomplished.

Photodynamic therapy for chest wall progression from breast carcinoma is an underutilized treatment modality.

Background: Chest wall progression of breast carcinoma after failure of salvage surgery, radiation, and chemohormonal therapy is a quagmire with limited therapeutic options. Because photodynamic therapy (PDT) offers excellent results in cutaneous lesions, PDT may play a role in this indication. However, to the authors' knowledge, published data for this subgroup of patients using the only commercially available photosensitizing agent, Photofrin, often show high treatment morbidity, limiting PDT's usefulness.

Anticoagulation and heart failure.

There are no clear data regarding whether to use warfarin, aspirin, or no therapy in patients with left ventricular systolic dysfunction. Aspirin use is widespread in patients with vascular disease but it can decrease renal blood flow in low output states. Warfarin may be used in patients with advancing heart failure due to the perceived risk of in situ thromboembolism.

Microscopic polyangiitis in a pediatric patient.

Microscopic polyangiitis (MPA), previously called hypersensitivity angiitis, is a systemic necrotizing vasculitis that involves many organ systems including the skin, joints, kidneys, and lungs. Microscopic polyangiitis most commonly affects adults in the fourth and fifth decades of life, with only a few cases reported in children. We describe a pediatric patient with microscopic polyangiitis.

Ischemic Heart Disease.

The goals of treatment of ischemic heart disease are to relieve symptoms, prevent unstable angina or myocardial infarction, and prolong life. Over the past four decades, significant advances in therapy have occurred, initially involving revascularization procedures. Although coronary bypass surgery and percutaneous catheter-based interventions continue to play an important role in therapy, appropriate medical therapy has been shown to have a major impact on the course of the disease and can decrease the need for revascularization.

Exposure and mechanical stabilization in off-pump coronary artery bypass grafting via sternotomy.

Although off-pump coronary artery bypass grafting (CABG) is gaining popularity, obtaining exposure and stabilization of coronary arteries located on the lateral and inferior wall of the heart may be problematic. The aim of this study is to describe strategies and techniques of coronary exposure and mechanical stabilization that may be used to achieve total myocardial revascularization of the beating heart.

Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta.

Endovascular stent graft repair of descending thoracic aortic aneurysms has been recently introduced as an alternative to conventional graft replacement of the diseased aorta. As experience with this new technique accumulates, complications may occur. We herein report the case of a patient in whom we observed distal migration with leak of an endovascular stent graft previously inserted in the descending thoracic aorta, associated with an aortobronchial fistula.

The stress hormone, cortisol, synergizes with HIV-1 gp-120 to induce apoptosis of normal human peripheral blood mononuclear cells.

Both quantitative and qualitative defects in immune functions in patients with AIDS may result from induction of programmed cell death or apoptosis of CD4 T lymphocytes. We postulate that neurohormones may interact with gp-120 that is shed during active HIV infection and cause apoptosis of immunocompetent cells leading to immunopathogenesis of HIV infections. In this study, we investigated the synergistic effect of cortisol plus HIV gp-120 in inducing apoptosis of lymphocytes from normal subjects.

Posterior thoracotomy for reoperative coronary artery bypass grafting without cardiopulmonary bypass: perioperative results.

Background: This retrospective study evaluates morbidity and mortality of reoperative coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) using a posterior thoracotomy to revascularize the lateral aspect of the heart.

Methods: From January 1995 to July 1999, reoperative CABG without CPB was performed on 67 selected patients using a left posterior thoracotomy approach. Preoperative risk factors, postoperative mortality, and major complications were derived from the New York State database.

Use of hyperbaric oxygen chamber in the management of radiation-related complications of the anorectal region: report of two cases and review of the literature.

Purpose: This article was undertaken to present two cases of nonhealing ulcers that occurred after primary radiation therapy and local excision of suspected residual or recurrent anal carcinomas. Both patients responded favorably to hyperbaric chamber treatment. Review of the literature is discussed, including cause, clinical presentation, diagnosis, and options for management of radiation-related complications in the anorectal region and use of hyperbaric oxygen treatment in colorectal surgery.

Use of the "single suture" technique to expose the anterior surface of the heart.

The "single suture" technique, which consists of placing a suture in the oblique sinus of the posterior pericardium and connecting it to a vaginal tape, is commonly adopted in off-pump coronary artery revascularization to obtain elevation of the heart and coronary artery exposure. This report describes the use of this technique to expose the anterior wall of the heart in the setting of ventricular aneurysm repair.

Intramuscular interferon beta-1a therapy initiated during a first demyelinating event in multiple sclerosis. CHAMPS Study Group.

Background: Treatment with interferon beta has been shown to help patients with established multiple sclerosis, but it is not known whether initiating treatment at the time of a first clinical demyelinating event is of value.

Methods: We conducted a randomized, double-blind trial of 383 patients who had a first acute clinical demyelinating event (optic neuritis, incomplete transverse myelitis, or brain-stem or cerebellar syndrome) and evidence of prior subclinical demyelination on magnetic resonance imaging (MRI) of the brain. After initial treatment with corticosteroids, 193 patients were randomly assigned to receive weekly intramuscular injections of 30 microg of interferon beta-1a and 190 were assigned to receive weekly injections of placebo.

Survey of resident training in beating heart operations.

Background: "Off-pump" coronary artery operations are done with increasing frequency in the treatment of coronary artery disease. As a result, residents in thoracic surgery have been confronted with the necessity of gaining experience in this innovative approach to coronary surgery. The aim of this study was to assess the importance of training in minimally invasive coronary revascularization as it was perceived by thoracic surgery residents.

Intermittent infusion of inotropes in the outpatient setting: one-year post treatment analysis.

The course of patients with New York Heart Association (NYHA) class III and IV and refractory heart failure symptoms is characterized by progressive clinical deterioration and frequent hospital readmissions. The value of intermittent intravenous administration of inotropes in managing this group of patients in the outpatient setting has been controversial. In this study, patients with refractory heart failure symptoms were enrolled to assess the impact of a multidisciplinary outpatient program in terms of on hospital admissions, emergency room visits, and interval free of symptoms after administration of inotropes.

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass.

Background: Myocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians.

Methods: Of 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group).

Prevention of bleeding in aortic root surgery.

Bleeding after aortic root replacement with a valved conduit may be problematic and difficult to control. A few technical details that may facilitate hemostasis in aortic root surgery are described.

Role of coronary graft flow measurement during reoperations for early graft failure after off-pump coronary revascularization.

Doppler-based techniques of coronary graft flow measurement are frequently used, especially during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), to exclude graft dysfunction resulting from technical errors. Nevertheless, early graft failure in the immediate postoperative period continues to affect a small percentage of patients who may require emergent reoperation as a result of severe hemodynamic deterioration. In this setting, in which coronary angiography is infrequently an option, expeditious intraoperative assessment of previously constructed coronary grafts may be performed by using the Doppler-based technique Transit Time Flow Measurement (TTFM).

Extended observations on MS patients treated with IM interferon-beta1a (Avonex): implications for modern MS trials and therapeutics.

Extended observations of the pivotal phase III clinical trial of interferon-beta1a (IFNbeta1a; Avonex, Biogen) in relapsing MS patients revealed that: (1) active treatment significantly slowed the accumulation of physical disability over time, reduced clinical exacerbations and MRI brain lesions; (2) clinical efficacy did not depend on disability endpoints; (3) active treatment benefited multiple MRI measures of brain lesions; (4) cerebral atrophy occurred over 2 years in relatively mildly disabled patients; and (5) Avonex could slow the development of atrophy after the first year of treatment. Data from this study were recently used to design a new outcome measure for MS clinical trials (the Multiple Sclerosis Functional Composite), and was also the basis for two ongoing studies of IFNbeta1a: one in patients with monosymptomatic onset of MS and the other in secondary progressive MS.