As the baby boom generation ages, the number of people with heart failure is expected to rise exponentially. A rapid increase in the demand for heart transplants will result in an increased use of left ventricular assist devices. This case illustrates the challenges facing transplant teams in evaluating elderly heart failure patients as candidates for assist devices. The critical elements of a psychosocial assessment are described.
]]>Concerns exist in the field of transcatheter aortic valve implantation regarding the treatment of patients with mechanical mitral valve for possible interference between the percutaneous aortic valve and the mechanical mitral prosthesis. We report our experience with percutaneous aortic valve implantation in 4 patients with severe aortic stenosis, previously operated on for mitral valve replacement with a mechanical prosthesis. All patients underwent uneventful percutaneous retrograde CoreValve implantation (CoreValve Inc, Irvine, CA). No deformation of the nitinol tubing of the prostheses (ie, neither distortion nor malfunction of the mechanical valve in the mitral position) occurred in any of the patients. All patients are alive and asymptomatic at a mean follow-up of 171 days.
]]>Chylopericardium is a rare disorder that can be secondary to thoracic duct injury. Consequences include nutritional, metabolic, and immunologic abnormalities, as well as cardiac complications, such as pericarditis and cardiac tamponade. We present a case of chylopericardium presenting as cardiac tamponade after a median sternotomy for mechanical aortic valve replacement.
]]>A 21-year-old man with pulmonary fibrosis and a 27-year-old woman with idiopathic pulmonary hypertension, who were in pulmonary hypertensive crisis, were successfully treated by using venoarterial extracorporeal membrane oxygenation, followed by living-donor lobar lung transplantation. In both of the patients, bridging time of extracorporeal membrane oxygenation to lung transplantation was 2 days, and both could be weaned from cardiopulmonary support immediately after transplantation in the operating room. No major complications were seen, including primary graft dysfunction. The cardiopulmonary functions of these patients markedly improved after living-donor lobar lung transplantation.
]]>A rare but important constellation of musculoskeletal and cutaneous symptoms, including synovitis, acne, pustulosis, hyperostosis, and osteitis, has recently been designated the SAPHO syndrome. The exact etiology is unknown, although various infectious agents have been proposed. The most common site of osteoarticular involvement is the sternoclavicular joint, and therefore, recognition of this syndrome and appropriate workup and management is crucial in the differential diagnosis of an anterior chest wall mass.
]]>Heterogeneity in microvascular perfusion is associated with impaired tissue oxygenation. We hypothesized that cardiac surgery with or without cardiopulmonary bypass (CPB) could induce microvascular alterations.
We used an orthogonal polarization spectral imaging technique to evaluate the sublingual microcirculation in patients undergoing cardiac surgery with (n = 9) or without (n = 6) CPB. We also included, as a control group, 7 patients undergoing thyroidectomy with the same anesthetic procedure. Hemodynamic and microcirculatory variables were obtained the day before surgery, after induction of anesthesia, during CPB, on admission to the intensive care unit or the recovery room, and 6 and 24 hours after the end of the surgical procedure. Data are presented as median (25th to 75th percentile).
No differences in hemodynamic variables were observed between the two cardiac surgery groups. The proportion of perfused vessels was similar in all three groups at baseline (89% [87% to 90%]), and decreased similarly after induction of anesthesia to 71% (69% to 74%). It decreased further during CPB to 53% (50% to 56%). On admission to the intensive care unit or recovery room, alterations were more severe in CPB than in off-pump patients (60% [59% to 62%] versus 64% [61% to 65%]; p = 0.03), whereas they had already normalized in thyroidectomy patients (89% [86% to 90%]; p = 0.0005 versus cardiac surgery). In both cardiac surgery groups these microcirculatory alterations decreased with time, but persisted at 24 hours. The severity of microvascular alterations correlated with peak lactate levels after cardiac surgery (y = 11.5 – 0.15x; r 2 = 0.65; p < 0.05).
Microcirculatory alterations are observed in cardiac surgery patients whether or not CPB is used. Anesthesia contributes to these alterations, but its effects are transient.
Previous reports have supported the use of bilateral internal thoracic arteries to revascularize the left coronary circulation. If this becomes standardized practice, the optimal conduit for the right coronary system remains to be established. Our objective is to compare the performance of the radial artery versus the saphenous vein when used to graft the right coronary artery or its branches during an 8-year period after primary coronary artery bypass graft surgery.
The Radial Artery Patency and Clinical Outcomes study is a randomized controlled trial comparing radial artery, saphenous vein, and free right internal thoracic artery. Of the 621 patients enrolled in the study, 465 patients received a graft to the right coronary artery or its branches. The retrospectively compiled database was used to establish patency rates and clinical events among these patients.
Absolute graft patency rates were as follows: radial artery, 86.9% of 68 (95% confidence interval, 76.6% to 93.1%); and saphenous vein, 81.2% of 197 (95% confidence interval, 75.1% to 86.1%). Noninferiority tests show that absolute radial patency to saphenous patency is at least 0.9526 (p = 0.025). Kaplan-Meier estimates of angiographic outcomes show no significant difference (log rank p = 0.22). Cardiac events in the right coronary territory occurred in the radial artery group (1.79%) versus the saphenous vein group (4.93%; p = 0.26). Overall mortality was 8.03% in the radial artery group versus 12.5% in the saphenous vein group (p = 0.23).
The radial artery patency is at least comparable to that of the saphenous vein when grafted to the right coronary artery or its branches. The paucity of clinical events in both grafts is notable. Selection of best conduit may therefore be made according to other factors.
True lung injury is among the leading causes of transfusion-related mortality. Pulmonary morbidity after cardiac surgery has been related to damaging effects of cardiopulmonary bypass and transfusion, but is confounded by cardiac-related events that may not reflect true lung injury. Thus, cardiac surgery poses unique challenges to criteria-specific diagnosis of transfusion-related acute lung injury (TRALI). Our objective was to determine the prevalence of pulmonary morbidity related to transfusion and whether TRALI consensus-criteria are applicable to cardiac surgery.
A total of 16,847 patients underwent on-pump, coronary artery bypass grafting (CABG), valve, or CABG-valve surgery from September 1998 to February 1, 2006. We performed four propensity-score-matching analyses with logistic regression on probability of receiving a transfusion: total hospital red blood cell (RBC) and fresh frozen plasma (FFP) transfusion and intraoperative RBC and FFP transfusion. Outcomes included traditional cardiac-surgery-defined pulmonary morbidity and ratio of arterial partial pressure of oxygen to fractional inspired oxygen concentration (Pa
Patients receiving RBC transfusion had more risk-adjusted pulmonary complications: respiratory distress 4.8% vs 1.5%, p < 0.001; respiratory failure 2.2% vs 0.39%, p < 0.0001; longer intubation times, 9.9 hours vs 7.5 hours, p < 0.0001; acute respiratory distress syndrome, 0.64% vs 0.21%, p = 0.015; and reintubation, 5.6% vs 1.3%, p < 0.0001. The FFP was similarly related to more pulmonary complications after surgery. By TRALI criteria, the majority manifested "lung injury" (Pa
Transfusion is associated with many measures of postoperative pulmonary morbidity. Yet the Pa
Late improvements in myocardial perfusion and thickening after off-pump revascularization were evaluated during a 5-year follow-up by myocardial single photon emission computed tomography.
Between 2001 and 2003, 68 patients who underwent off-pump coronary artery bypass grafting using bilateral internal thoracic artery
Postoperative reversibility scores improved significantly at 3 months (p < 0.001) and further at 5 years (p = 0.030). Postoperative Z values improved significantly at 3 months (p < 0.001), between 1 year and 5 years (p = 0.006), and further at 5 years (p = 0.004). In the mixed models, there were no significant differences in reversibility scores and Z values between groups Y and I at any point.
Reversibility scores and thickening gradually improved during 5 years after off-pump revascularization using bilateral internal thoracic arteries. No significant differences were observed between
Decreased cognitive function associated with coronary artery bypass graft surgery is common. These deficits may be similar to the cognitive dysfunction seen in the spectrum of mild cognitive impairment to Alzheimer's disease, which are believed to result from the accumulation of amyloid beta (Aβ) peptide in the brain. We measured cognition both before and after coronary artery bypass graft surgery and assayed Aβ levels to investigate whether the cognitive dysfunction of cardiac surgery was associated with Aβ levels.
The plasma of 332 patients, who had undergone neuropsychological testing before and 3 and 12 months after coronary artery bypass graft surgery, was analyzed for Aβ42 and Aβ40. Patients were classified as having preexisting cognitive impairment if cognitive function was decreased in two or more tests compared with a healthy control group, and postoperative cognitive dysfunction was defined as a decline in two or more tests compared with the group mean baseline score.
Preexisting cognitive impairment was present in 117 patients (35.2%), and postoperative cognitive dysfunction was present in 40 (12%) at 3 months and 41 (13%) at 12 months after surgery. Both plasma Aβ42 and Aβ40 levels assessed before the surgery were significantly lower in patients who later had postoperative cognitive dysfunction at 3 months.
Decreased preoperative plasma levels of Aβ42 and Aβ40 in patients who exhibit postoperative cognitive dysfunction at 3 months suggest that postoperative cognitive dysfunction at this time may share a common mechanism with mild cognitive impairment and Alzheimer's disease. This process may be exacerbated by anesthesia.
Emergent coronary artery bypass graft surgery (CABG) for acute myocardial infarction is associated with an increased operative risk. For estimation of mortality risk, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) is appropriate up to a medium risk score (<6 points). To predict mortality risk more accurately in cases of higher EuroSCORE, additional cardiac data can be helpful.
Over a 3-year period, patient data including acute myocardial infarction and emergent CABG were retrospectively reviewed. Univariate and multivariate analysis for in-hospital mortality was performed. The EuroSCORE analysis and follow-up was investigated.
Overall in-hospital mortality was 18.3%. Preoperative cardiac related predictors for in-hospital mortality were cardiogenic shock (p < 0.001), very poor left ventricular function (p = 0.001), and ST-segment elevation (p = 0.012). In multivariate regression analysis, age, cardiogenic shock, and pulmonary hypertension were independent preoperative risk factors. According to the EuroSCORE, we could define three statistically different groups: intermediate-risk, high-risk, and very high risk, with an observed mortality of 3.3%, 20.0%, and 63.2%, respectively. The EuroSCORE correlates with but overestimates the mortality risk. In subgroup analysis, the creatine kinase-myocardial band/hour ratio for the intermediate-risk group and ST-segment elevation for the high-risk group were additional cardiac risk factors.
Patients with an acute myocardial infarction and emergency aortocoronary CABG have an elevated operative risk. Logistic EuroSCORE overestimates the mortality rate. Three different risk groups can be defined, in which creatine kinase-MB/h-ratio and ST-segment elevation can more accurately predict operative risk.
We assessed the efficacy of aggressive lipid controlling therapy (ALCT), which maintains low-density lipoprotein cholesterol (LDL-C) below to 80 mg/dL and LDL/high-density lipoprotein cholesterol (HDL-C) ratio less than 1.5 for preventing postcoronary bypass (CABG) saphenous vein graft (SVG) diseases by using intracoronary angioscopy.
Twenty-one patients after CABG were divided into two groups: group I consisted of 10 patients whose serum LDL-C level and LDL/HDL could be controlled less than 80 mg/dL and 1.5, respectively, by rosuvastatin for about one year; group II consisted of 11 patients whose LDL-C level and LDL/HDL have been higher than 100 mg/dL and 2.5, respectively, regardless of having medication of pravastatin. Twenty-seven SVGs were assessed by intravascular ultrasound (IVUS) and angioscopy on postoperative 12 to 16 months.
The serum LDL-C level (I: 64.1 vs II: 130.2 mg/dL) and LDL/HDL (I: 1.36 vs II: 2.64), and high sensitive C-reactive protein (I: 0.045 ± 0.100 vs II: 0.116 ± 0.020 mg/dL) were significantly lower in group I. In group II, IVUS detected eccentric plaques in 11 (78.6%) of 14 SVGs. Furthermore the angioscope showed yellow plaque in all 14 SVGs (100%) and 11 (78.6%) of them had thrombi. On the other hand, in group I, all 13 SVGs had no eccentric, yellow plaques or thrombi and the intima was entirely clear white.
Prophylactic treatment for yellow plaque and thrombus formation are extremely important in the development of early and late SVG disease. Aggressive lipid controlling therapy is quite attractive to avoid post CABG SVG disease and may be effective to maintain the long-term graft patency.
Dermabond (Ethicon UK, Edinburgh, United Kingdom) is a topical skin adhesive used for surgical wound closure, with purported advantages over conventional sutures on cosmetic outcomes, cost benefits, and operative times. This study compared results of skin closure using Dermabond and subcuticular sutures after coronary artery bypass grafting (CABG).
The study prospectively enrolled and randomized 106 patients who underwent CABG. The groups received closure with Dermabond skin glue or subcuticular sutures (n = 53 each) after saphenous vein harvesting using the bridging technique. Wound closure time for the two methods was recorded. Cosmetic appearance was assessed using the Hollander, the Vancouver, and the visual analog scale. Patient satisfaction was recorded before discharge and at week 6.
There were no significant differences in the total operative time between the two groups (p = 0.43). Closure time was significantly shorter in the Dermabond group (p = 0.017). Patients in the Dermabond group also reported superior cosmetic outcome at weeks 1 (p < 0.001) and 6 (p = 0.001) and improved patient satisfaction (p < 0.001).
Dermabond has demonstrated superiority over traditional subcuticular skin sutures in terms of closure time, cosmetic appearance, and patient satisfaction. This technique provides a novel method of wound closure after CABG.
This study aimed to identify the impact of diabetes mellitus and related comorbidities on long-term survival of heart failure patients who had undergone surgical ventricular restoration. Surgical ventricular restoration is an optional therapeutic strategy for patients with ischemic dilated cardiomyopathy. Reported prognostic predictors for late morbidity and mortality are predominantly related to cardiac conditions, whereas the prognostic impact of comorbidities still needs to be defined.
A total of 329 patients (234 nondiabetic and 95 diabetic) who survived the surgical ventricular restoration operation were admitted to this study. Cardiac mortality follow-up data were collected. Actuarial survival curves were calculated for the two groups; differences between groups and the impact of other comorbidities were established using a log-rank test and a Cox regression analysis.
The mean follow-up time was 44 months. Diabetic patients had a significantly worse survival rate: at 5 years, their survival rate was 81%, versus 89% for nondiabetic patients (p = 0.019). Other comorbidities significantly associated with the survival rate were chronic renal failure, New York Heart Association class, and liver dysfunction. Diabetic patients without comorbidities had a survival rate similar to that of nondiabetic patients. Diabetic patients with at least one comorbidity had a significantly worse outcome. Diabetic patients with chronic renal failure had a 5-year survival rate of 40%, versus 85% for nondiabetic patients (p = 0.002).
Noncomplicated diabetes has no negative impact on long-term survival after surgical ventricular restoration. Conversely, complicated diabetes, namely the presence of chronic renal failure, carries a long-term cardiac mortality risk that is four times higher than the risk for nondiabetic patients.
Bridge to heart transplantation with a left ventricular assist device (LVAD) can be a promising therapy for patients who are not effectively stabilized with conservative measures. However, referral for LVAD therapy may be limited secondary to reports of poor outcomes when mechanical circulatory support is required before transplantation.
A retrospective review was undertaken to evaluate outcomes in United Network of Organ Sharing (UNOS) status 1 heart transplant recipients who were bridged to transplant with an implantable LVAD or with intravenous inotropes only from 1994 to 2007. Preoperative characteristics, posttransplant survival, and postoperative complications were compared between 86 patients with an implantable LVAD and 173 patients bridged with intravenous inotropes only.
The patients had similar baseline characteristics and pretransplant hemodynamics. Hemodynamics in the LVAD group, as measured by cardiac index, pulmonary vascular resistance, central venous pressure, and pulmonary capillary wedge pressure, significantly improved during mechanical support. Short-term and long-term posttransplant survival and the incidence of posttransplant infectious complications and rejection episodes during the first year was similar. The incidence of posttransplant renal dysfunction was higher in patients bridged with inotropes.
Patients bridged to transplant with a LVAD represent a subset of UNOS status 1 patients who deteriorated on intravenous inotropic therapy. Bridging to heart transplantation with an implantable LVAD provides comparable outcomes to similar status 1 patients who were stabilized on inotropic infusions only. In contrast with International Society of Heart and Lung Transplantation data, no increase in posttransplant morbidity or mortality occurred in LVAD-bridged patients.
The role of a percutaneous ventricular assist device (VAD) for left heart support in the management of patients in cardiogenic shock is not well defined.
All patients who received LV support using the percutaneous TandemHeart (percTH) ventricular support device (Cardiac Assist, Pittsburgh, PA) were retrospectively reviewed. Indications for insertion included bridge to decision (BTD) or "salvage" and bridge to transplant (BTT).
Between April 2005 and December 2008, 22 percTH devices were successfully implanted in patients (13 men) with isolated left heart failure. Mean duration of support was 6.8 ± 9.4 days (median, 4; maximum, 45 days). Of patients requiring percTH support for at least 3 days, mean pump flows were 3.77 ± 1.10, 4.22 ± 0.69, and 4.04 ± 0.41 L/min on at days 1, 2, and 3. Mean serum aspartate aminotransferase levels were 455 ± 994 mg/dL before percTH, 551 ± 1046 mg/dL at day 1, and 231 ± 225 mg/dL at day 3 after percTH. No mechanical device failure, device-related infections, or cerebrovascular accidents occurred. Ten of 11 BTT patients were successfully bridged. Support was withdrawn in 7 of 11 BTD patients. The percTHs were successfully explanted in 4 BTD patients: 1 as recovery, 1 direct to transplant, and 2 to VAD.
The percTH was reliable, with no mechanical device failures and minimal associated adverse events. We support the use of the percTH in the BTD mode, allowing time for a more complete evaluation of neurologic and end-organ status without the added expense and morbidity of a long-term VAD.
We sought to determine whether transcatheter aortic valve implantation is a reasonable treatment option in patients with a very or extremely high risk for conventional aortic valve replacement, presenting with a logistic EuroSCORE greater than 30% or a Society of Thoracic Surgeons score greater than 15%.
Between May 2005 and November 2008, 39 of 85 transcatheter aortic valve implantation patients with a very high risk for aortic valve replacement underwent either transfemoral (n = 15) or transapical (n = 24) transcatheter aortic valve implantation with a mean estimated logistic EuroSCORE of 44.2% ± 12.6% (mean ± standard deviation) and a Society of Thoracic Surgeons score of 17.9% ± 6.1%. Transcatheter aortic valve implantation was performed in a hybrid operative theater using the Cribier-Edwards or Edwards SAPIEN prosthesis.
Valve implantation was successful in 97% of the patients. Operative mortality was 2.6%, and mortality at 30 days was 17.9%. After valve implantation, hemodynamic improvement was assessed by decreased mean pressure gradient (p < 0.001) and increased aortic valve area (p < 0.001), accompanied by improved New York Heart Association functional status (p < 0.01). Actuarial survival was 74.4% at 3 months, 74.4% at 6 months, and 64.1% at 12 months of follow-up. Echocardiography revealed aortic regurgitation in 58% of the patients during hospital stay, 43% at 6 months of follow-up, and 40% at 12 months of follow-up, but no structural valve deterioration could be observed during the complete follow-up period.
Transcatheter aortic valve implantation in patients with severe aortic stenosis and a very high risk for aortic valve replacement is feasible and may be a reasonable treatment option in these patients.
Mechanical strain may affect aortic valve cusp, leading to an altered extracellular matrix ultrastructure and eventually aortic stenosis. The aim of this study was to evaluate the affect of these potential relationships on human tissue.
Extracellular matrix protein disposition was analyzed on human aortic valve cusp retrieved from 31 patients during routine aortic valve replacement surgery. Samples were immediately fixed in 2-hydroxyethyl methacrylate. Immunohistology and Western blot analysis were used to quantify decorin, tenascin-C, biglycan, alkaline-phosphatase, osteocalcin, and osteopontin content. Fibroblast function was analyzed on interstitial cells derived from aortic valve cups from patients undergoing aortic valve replacement. Cells were grown to confluency in modified Eagle's medium supplemented with 10% fetal calf serum under sterile conditions. Thereafter, mechanical strain was applied for 72 hours and 60 cycles per minute. Elongation of as much as 10% in comparison with no elongation (control group) was applied. All results were correlated to hemodynamic variables.
Decorin and biglycan were mostly located at the inflow aspects of the cusp, tenascin-C in the central layer, and osteopontin, osteocalcin, and alkaline phosphatase were concentrated near the cell populations surrounding calcified areas. The intensity of this protein expression was significantly related to the pressure gradient. Expression levels were twice to five times higher than normal in patients with a preoperative pressure gradient of more than 100 mm Hg. On fibroblasts subjected to mechanical strain, a similar significant increase in the expression for decorin, biglycan, alkaline-phosphatase, tenascin-C, osteocalcin, and osteopontin was found by immunohistology. Western blot analysis confirmed significantly enhanced expressions of two and eight times the normal levels.
A specific pattern of extracellular matrix protein expression was found in relation to mechanical strain on human aortic valve cusp tissue and in mechanically stimulated human valvular fibroblasts. This new insight into the process of aortic valve degeneration may be important for further therapeutic approaches to ameliorate the progression or even the initiation of potential aortic valve stenosis.
Differences in the mechanical properties of aortic tissues and replacement materials can have unwanted hemodynamic effects leading to graft failure. The aim of this experimental study was to compare the mechanical properties of different graft-patch materials used in aortic arch reconstruction with those of healthy and dilated human ascending aortas (AAs).
Four square samples were taken from 30 healthy (n = 120) and 14 dilated (n = 56) AA rings and from 34 human pericardial sections (fresh [n = 68] and Carpentiers solution fixed [n = 68]). In addition, square samples from commercial bovine pericardium (n = 14) were also compared with woven Dacron grafts (n = 24) and tested biaxially. Stress-strain curves (0% to 30%) were generated using a biaxial tensile tester to quantify the anisotropic properties and stiffness of the materials at 37°C.
We found significant differences in stiffness and anisotropy among all material types. Fresh and fixed human pericardia, bovine pericardium, and Dacron were 9.5, 7.1, 16.4, and 18.4 times stiffer than dilated AAs, which was 1.3 times stiffer than healthy AAs under physiologic stretch. Only dilated and healthy AAs showed an increase in anisotropic properties with increasing strain.
The significant differences in the mechanical properties among all materials we found are intended to increase the awareness of these differences in materials used in aortic reconstruction surgery. This finding suggests that improvements are needed in prosthetic material design to better mimic native tissue.
The Sorin Memo 3D (Sorin Biomedica Cardio S.r.L., Saluggia, Italy) is a new, complete semirigid annuloplasty ring. Clinical use, outcomes, and echocardiographic results are reported as an evaluation of its safety and efficacy in the treatment of mitral valve regurgitation (MVR).
This device was assessed in 63 patients (63.5% men; mean age, 70.2 ± 10.3 years) who underwent MVR operations between January 2007 and June 2008. Functional classification was normal leaflet motion (type I; 1.6%), leaflet prolapse (type II; 66.7%), and restricted leaflet motion (type III; 31.7%). Valve disease was degenerative (68.25%), ischemic (25.4%), and nonischemic dilated cardiomyopathy (6.35%).
Early mortality (≤30 days) was 3.3% (2 patients). Late mortality (11.2 ± 5.1 months) was 4.9% (3 patients). No deaths were device-related. Thromboembolic stroke occurred in 3.3% and endocarditis in 1.6%. Freedom from reoperation was 98.4%. At 6 months, MVR was grade 0/1 in 93.7% and grade 2+ in 6.4%. Left end-diastolic ventricular diameters decreased significantly from 59.3 ± 6.9 mm preoperatively to 50.6 ± 12.2 mm at 6 months, pulmonary arterial pressure decreased from 44.8 ± 7.1 mm Hg to 38.4 ± 5.5 mm Hg, and left ventricular ejection fraction increased significantly from 0.469 ± 0.129 to 0.582 ± 0.106. New York Heart Association functional class was I in 81% and II in 13.8%.
Early results indicate the Sorin Memo 3D ring safely and effectively minimizes secondary MVR resulting from all causes and preserves mitral annular flexibility and function at follow-up.
The three-dimensional saddle shape of the mitral annulus is well characterized in animals and humans, but the impact of annular nonplanarity on valve function or mechanics is poorly understood. In this study, we investigated the impact of the saddle shaped mitral annulus on the mechanics of the P2 segment of the posterior mitral leaflet.
Eight porcine mitral valves (n = 8) were studied in an in-vitro left heart simulator with an adjustable annulus that could be changed from flat to different degrees of saddle. Miniature markers were placed on the atrial face of the posterior leaflet, and leaflet strains at 0%, 10%, and 20% saddle were measured using dual-camera stereophotogrammetry. Averaged areal strain and the principal strain components are reported.
Peak areal strain magnitude decreased significantly from flat to 20% saddle annulus, with a 78% reduction in the measured strain over the entire P2 region. In the radial direction (annulus free edge), a 44.4% reduction in strain was measured, whereas in the circumferential direction (commissure-commissure), a 34% reduction was measured from flat to 20% saddle.
Nonplanar shape of the mitral annulus significantly reduced the mechanical strains on the posterior leaflet during systolic valve closure. Reduction in strain in both the radial and circumferential directions may reduce loading on the suture lines and potentially improve repair durability, and also inhibit progression of valve degeneration in patients with myxomatous valve disease.
Hypothermic circulatory arrest (HCA) and antegrade selective cerebral perfusion (ASCP) are utilized for cerebral protection during aortic surgery. However, no consensus exists regarding optimal ASCP-temperature showing a tendency toward higher values during the last years. This study investigates regional changes of cerebral blood flow (CBF) during ASCP at two temperatures.
In this blinded study, 20 pigs (35 to 37 kg) were randomized to two groups. Animals were cooled to 10 minutes of HCA followed by 60 minutes of ASCP. Afterward the animals were perfused at 25°C and 30°C according to the study group. Fluorescent microspheres were injected at seven time points during the experiment to calculate total and regional CBF. Hemodynamics, cerebrovascular resistance (CVR) and cerebral metabolic rate of oxygen (CMRO2) were assessed. Tissue samples from the cortex, cerebellum, hippocampus, and pons were taken for microsphere count.
The CBF and CMRO2 decreased significantly (p < 0.002) during cooling in both groups; it was significantly higher throughout ASCP in the 30°C versus the 25°C group (p = 0.0001). These findings were similar among all brain regions, certainly at different levels. The CBF increased significantly (p = 0.002) during the early period of ASCP for analyzed regions and decreased significantly (p = 0.034) below baseline after 60 minutes of ASCP, reaching critical levels in the hippocampus and neocortex. The hippocampus turned out to have the lowest CBF, while the pons showed the highest CBF. Thirty minutes and more ASCP provides less CBF compared with baseline values at both temperatures.
Antegrade selective cerebral perfusion improves CBF in all regions of the brain for a limited time. Our study characterizes the brain specific hierarchy of blood flow during ASCP. These dynamics are highly relevant for clinical strategies of perfusion.
The mortality and morbidity rates are high after cardiac surgery in hemodialysis (HD)-dependent patients. To improve their outcomes, optimal perioperative managements should be discussed.
A retrospective analysis of 245 HD patients who underwent cardiac surgery between 1994 and 2007 was conducted. The basic management strategies were (1) low-potassium HD for 2 days before surgery, (2) only hemofiltration during cardiopulmonary bypass, and (3) start of regular intermittent HD on the first postoperative day. Continuous venovenous hemodiafiltration was applied only for patients with hemodynamic instability.
The causes of renal failure included diabetic (n = 89, 36%), glomerulonephritis (n = 49, 20%), and unknown (n = 75, 31%). The history of HD was 9.7 ± 7.6 years. The operative procedures included coronary (n = 135), valve (n = 103), and others. The amount of intraoperative ultrafiltration was 6,123 ± 324 mL during cardiopulmonary bypass for 197 ± 67 minutes. Two hundred eight patients (85%) were managed with only intermittent HD, whereas 36 patients (15%) needed continuous venovenous hemodiafiltration. The use of continuous venovenous hemodiafiltration significantly declined during the year (26% before 2003 and 3% after 2003; p < 0.001). The amount of fluid removal on the first postoperative day was 1,297 ± 81 mL. The hospital mortality was 9.7% with the causes including infection (n = 11), cardiac events (n = 6), gastrointestinal events (n = 5), and stroke (n = 2). A multivariate logistic regression analysis revealed that selection of intermittent HD or continuous venovenous hemodiafiltration was not related to the hospital mortality.
Simplified management only with intermittent HD can be safely performed in most HD-dependent patients undergoing cardiac surgery.
Topical hemostatic agents composed of a gelatin-based matrix and thrombin have been reported to be effective, in addition to traditional means, in terminating bleeding during cardiac operations. We compared a hemostatic matrix sealant agent (FloSeal; Baxter Inc, Deerfield, IL) with alternative topical hemostatic agents in a mixed cohort of elective cardiac and thoracic aortic operations.
Following sample size calculation, in a prospective randomized study design, 209 patients were treated with FloSeal matrix sealant (FloSeal group) and 206 patients received alternative agents as topical hemostatic materials (comparison group). FloSeal is composed of a self-expandable gelatin matrix component and purified bovine thrombin. Comparisons included hemostatic patches or sponges composed of either oxidized regenerated cellulose or purified porcine skin gelatin. Study endpoints were the following: rate of successful intraoperative hemostasis (identified by cessation of bleeding) and time required for hemostasis; overall postoperative bleeding; rate of transfusion of blood products; rate of surgical revision for bleeding; postoperative morbidity; and intensive care unit stay.
Statistically higher rates of successful hemostasis and shorter time-to-hemostasis were observed in the FloSeal group (p < 0.001 both). Time-to-event analysis confirmed this finding (p = 0.0025). Postoperative bleeding and rate of transfusion of blood products were statistically decreased in the FloSeal group (p < 0.001 both). Rates of revision for bleeding and of minor complications were not statistically different among groups in the overall cohort, but were significantly lesser in the FloSeal group if only patients with overt intraoperative bleeding are considered (p = 0.04 both). The advantages observed in the FloSeal group were not offset in patients undergoing systemic hypothermia.
The topical hemostatic agent used in the FloSeal group is effective in terminating intraoperative bleeding as an adjunct to traditional surgical methods for stopping bleeding. Its judicious use is associated with lesser need for transfusion of blood products and rate of revision for bleeding. Its cost-utility profile should be addressed in dedicated trials.
The low incidence of aortic aneurysm among children and young adults limits information about etiology, surgical indications, procedures of choice, and operative results.
From 2003 to 2008, 35 patients aged 7 to 35 years (mean 21) underwent replacement of the ascending aorta for 19 ascending aortic aneurysms and 16 aortic root aneurysms. Underlying diseases included 10 congenital aortic stenoses, 10 bicuspid aortic valves, 8 congenital heart diseases, 6 Marfan syndromes, and 1 aortitis.
Indications for surgery were maximal diameter of 200% of normal for isolated aneurysms, and 160% of normal in case of associated aortic valve dysfunction or symptoms. Operative procedures included 27 ascending aortic replacements with or without aortic valve replacement (including 22 conduits) and 8 valve-sparing operations, performed in 6 patients with Marfan syndrome and 2 with congenital heart diseases. There was 1 in-hospital death. Thirty-four patients survived the operation and are in New York Heart Association functional class II or less at a maximum of 5 years of follow-up. All patients are free from reoperation, but 1 patient had a thromboembolic event. Aortic valve function is good in all 8 patients after the valve-sparing operation.
Ascending aortic aneurysm in children and young adults was surgically treated with excellent midterm outcome. A diameter of 200% of normal was the indication for surgery; however, in case of associated lesions, smaller diameters should be considered for surgery. Conduit implantation is the gold standard. Valve-sparing operation can be performed in selected patients with encouraging results.
Homografts (HGs) are considered the gold standard for pulmonary valve replacement. However, to avoid further operations, the use of mechanical valves (MVs) might be considered, especially in patients who had had multiple prior operations or require an additional MV in another position.
Data of 19 patients with MVs were compared with 19 patients with HGs, matched for age, sex, and follow-up time. Development of gradient and regurgitation were analyzed using hierarchical multilevel modeling. Mean follow-up time was 5.8 ± 2.6 years.
The initial pressure gradient was significantly lower in HGs compared with MVs (11.7 mm Hg vs 19.2 mm Hg, p = 0.006), but the annual increase was significantly higher in HGs compared with MVs (4.0 mm Hg/year vs 1.1 mm Hg/year, p = 0.008). The initial regurgitation grade was significantly higher in HGs compared with MVs (0.81 vs 0.37, p < 0.001), and the annual increase was also significantly higher in HGs compared with MVs (0.09 grade/year vs –0.01 grade/year, p < 0.001). Reintervention was required in 3 HGs (stenosis), and in 2 MVs (thrombosis after irregular anticoagulation, dysfunction due to ingrowth of tissue). Freedom from reintervention was not significantly different between both groups (p = 0.32).
The hemodynamic performances of MVs are superior to HGs because gradient and regurgitation develop significantly slower. However, this does not lead to lower reintervention rates. Because reoperations of MVs can be prevented by appropriate surgical technique and strict anticoagulation, MVs should be considered for the pulmonary position, especially in patients who require anticoagulation treatment for additional MVs or rhythm disturbances.
An increasing number of surgeons prefer to place a conduit from the right ventricle to the pulmonary artery at the time of the Norwood stage I procedure. Proximal conduit stenoses have led us to modify this technique by using ring-enforced polytetrafluoroethylene conduits.
Angiograms of 24 patients with conventional conduits (CC) and 28 patients with ring-enforced conduits (RC) before partial bidirectional cavopulmonary anastomosis were analyzed. The degree of conduit stenosis on three different levels—proximal anastomosis, substernal part of the conduit, and distal anastomosis—was compared between the two groups.
In the RC group, the extent of conduit stenosis at the level of proximal anastomosis and within the substernal proximal third of the conduit was minimized (23% ± 22% vs 45% ± 22%, p = 0.001, and 7% ± 6% vs 49% ± 26%, p < 0.001, respectively). At the level of the anastomosis with the pulmonary arteries, results were similar in the RC group (24% ± 14%) vs CC group (31% ± 15%, p = 0.103). Significantly fewer patients in the RS group required urgent intervention (dilatation ± stenting) or early stage II operation (1 vs 6 patients, p = 0.034).
The use of a ring-enforced polytetrafluoroethylene conduit between the right ventricle and the pulmonary artery in Norwood stage I palliation effectively prevents substernal compression and reduces interstage morbidity.
Pericarditis requiring pericardiectomy is uncommon in the pediatric population. The aim of this study is to characterize our experience with this subset of patients.
Between February 1978 and May 2008 pericardiectomy was performed on 27 pediatric patients (25 male). The indication for surgery was inflammatory pericarditis in 16 and constrictive pericarditis in 11. Mean age was 16.7 years (range, 3 to 21 years). Chest pain was the most common presenting complaint. Median duration of symptoms prior to operation was 1 year. Most patients had aggressive pharmacologic treatment prior to operation. Before pericardiectomy, 10 patients were hospitalized for treatment of symptoms, 15 underwent pericardiocentesis, and 3 had a prior partial pericardiectomy.
Twenty-one patients underwent complete pericardiectomy, 3 a biventricular pericardiectomy, and 3 a completion pericardiectomy. Pathologic histology of all specimens was positive for pericarditis. Pericardial cultures were obtained in 13 cases with bacteria retrieved from only 2 specimens. Median length of stay was 7 days, and the majority had an uneventful postoperative course. The one early mortality was due to acute hepatic failure in a patient with radiation-induced heart disease, 155 days after operation. After median follow-up of 1 year, complete resolution of symptoms was achieved in 89% of patients.
In properly selected pediatric patients, complete pericardiectomy can be performed with good outcomes. Although the etiology of pericardial irritation is frequently elusive, resolution of symptoms can be expected in most patients. Confronted with medically refractory pericarditis, earlier consideration for pericardiectomy may be warranted.
The presence of postoperative residual perimembranous ventricular septal defect (PmVSD) is relatively uncommon. However, reoperation might be associated with an increased surgical risk. Transcatheter device closure is an alternative strategy for management of postoperative residual defects.
Between July 2002 and November 2008, transcatheter closure of postoperative residual PmVSDs was attempted in 26 patients (11 male, 15 female). Symmetric and asymmetric PmVSD occluders were used.
The diameter of residual defects was from 3 mm to 10 mm (mean 6.3 ± 2.3 mm) on transthoracic echocardiography. In 24 of 26 patients, the residual defects were successfully closed. No direct residual defect was found on left ventriculography after the procedure. Total occlusion rate was 62% (15 of 24) at completion of the procedure, rising to 71% (19 of 24) at one week and 96% (23 of 24) during the follow-up. Twenty patients had only one device implanted, whereas 4 patients had two devices implanted. The waist size of occluders used ranged from 5 mm to 12 mm (mean 8.6 ± 2.5 mm). One patient presented with complete atrioventricular block 3 days after the procedure and recovered 2 weeks later. Hemolysis occurred in 3 patients after the procedure within 12 hours. These patients recovered 4 weeks, 4 days, and 8 days later, respectively. During follow-up, the devices were in a stable position with optimal shapes. No late complications were observed.
Transcatheter closure of postoperative residual PmVSDs is possible without the need for reoperation. The early and midterm prognosis of patients with transcatheter closure is good.
The role of surgical lung resection in the management of severe hemoptysis has evolved after advances in interventional radiology. We sought to describe the indications for surgical lung resection in such patients and to identify predictive factors of postoperative complications.
This study is a retrospective analysis (May 1995 to July 2006) of consecutive patients referred to the intensive care unit of a tertiary hospital for severe hemoptysis who underwent surgical lung resection.
Among 813 patients referred for severe hemoptysis, 111 underwent surgical lung resection. Interventional radiology had been first attempted in 87 patients (78%); 68 underwent surgery because of a failed procedure (n = 28) or bleeding persistence or recurrence within 72 hours despite a completed procedure (n = 40); 19 patients underwent surgery after bleeding control. The remaining 24 patients (22%) were directly referred to the surgeon (5 for emergency surgery). Overall, surgery was performed in emergency (n = 48), scheduled after bleeding control (n = 48), or planned after discharge (n = 15). The main indications for surgery were mycetoma, cancer, bronchiectasis, and active tuberculosis. Surgery for mycetoma (odds ratio, 9.4; 95% confidence interval, 2.8 to 32), emergency surgery (odds ratio, 5.3; 95% confidence interval, 1.8 to 16), and pneumonectomy (odds ratio, 4.7; 95% confidence interval, 1.2 to 18) independently predicted complications. Fifteen patients died in the intensive care unit, of whom 14 underwent emergency surgery. Chronic alcoholism (odds ratio, 4.6; 95% confidence interval, 1.1 to 19), the need for mechanical ventilation or vasoactive drugs on admission (odds ratio, 8.2; 95% confidence interval, 1.9 to 35), and blood transfusion before surgery (odds ratio, 8; 95% confidence interval, 1.5 to 42) predicted mortality.
Attempting at controlling bleeding with first-line nonsurgical approaches appears necessary to optimize the operative conditions and improve outcome of patients with severe hemoptysis.
While general thoracic surgical procedures are performed by several different surgical subspecialties, debate remains as to whether surgeon specialty impacts outcomes.
The Nationwide Inpatient Sample (NIS) was queried for procedure codes for pneumonectomy, lobectomy, limited lung resection, and decortication. We constructed multivariate logistic regression models to calculate odds of hospital mortality or length-of-stay (LOS) greater than 14 days (a marker of morbidity), adjusted for age, sex, patient comorbidities, hospital setting, and surgeon specialty. A surgeon was considered general thoracic if they performed greater than 75% general thoracic operations and less than 10% cardiac operations, Cardiac if greater than 10% cardiac operations, and general surgeon if less than 75% general thoracic and less than 10% cardiac operations. A second set of models additionally adjusted for procedure-specific hospital and surgeon volume.
From 1996 to 2005, the NIS estimates 41,808 pneumonectomies, 321,767 lobectomies, 75,200 limited lung resections, and 149,318 decortications were performed in the United States. For all procedures studied, general thoracic surgeons had significantly decreased odds-of-death and LOS greater than 14 days compared with general surgeons. Cardiac surgeons had significantly decreased LOS greater than 14 days for all operations and decreased odds-of-death for decortications, lobectomy, and limited lung resection compared with general surgeons. When further adjusted for surgeon volume, most differences in odds-of-death were no longer present; however, significantly decreased LOS greater than 14 days largely persisted for both general thoracic and cardiac surgeons.
The majority of general thoracic surgical operations in the United States are performed by surgeons not specializing in thoracic surgery. Both general thoracic surgeons and cardiac surgeons achieve better outcomes than general surgeons. Differences in mortality may be more dependent on surgeon volume than subspecialty. Differences in morbidity are significantly impacted by surgeon specialty and volume.
The objective of this study was to evaluate the operative mortality, morbidity, and long-term survival of sleeve lobectomy for non–small cell lung cancer and low-grade neoplasms. We evaluated the effects of neoadjuvant therapy on the bronchial anastomotic complication rate and determined whether sleeve lobectomy performed in patients with N1 disease resulted in decreased overall survival.
This study is a retrospective review of 196 patients who underwent sleeve lobectomy. One hundred twenty-five patients had non–small cell lung cancer. There were 117 men (59.7%) and 79 women (40.3%) with a mean age of 54 years. Sixteen patients (13%) received neoadjuvant therapy. Fifty-six patients with N1 disease underwent sleeve lobectomy.
There were 4 (2.0%) postoperative deaths. The postoperative morbidity rate was 36.7%. Four patients (2.0%) experienced bronchopleural fistulas. Multivariate analysis demonstrated that age older than 70 years (p = 0.02) and the diagnosis of non–small cell lung cancer (p = 0.0002) were risk factors for postoperative complications. Multivariate analysis also demonstrated that neoadjuvant therapy predicted anastomotic complications (p = 0.01). For non–small cell lung cancer patients, the 5-year survival rate was 44%. The 5-year survival rates for patients with pathologic N0 disease and N1 disease were 52.6% versus 39.3%, respectively (p = 0.205).
Sleeve lobectomy can be performed with minimal bronchial anastomotic complications and low postoperative mortality. In our study, neoadjuvant therapy for non–small cell lung cancer adversely influenced the rate of anastomotic complications. Performing sleeve lobectomy for patients with N1 disease was not associated with decreased overall survival rates.
The therapeutic strategies for non-small cell lung carcinoma (NSCLC) with N1 and N2 disease differ remarkably. Debate exists about the definition of the borderline between N1 and N2 stations. This study evaluated the prognostic effect of N1 disease, especially focused on the significance of the main bronchial node (No. 10) vs N2 disease.
The records of 1601 patients who underwent complete pulmonary resection for NSCLC were reviewed to examine the clinical features of lymph nodal involvement.
There were 1086 patients (67.8%) with pN0 disease, 202 (12.6%) with pN1, and 274 (17.1%) with pN2 disease; overall 5-year survival rates were 74.7%, 56.1% and 28.9%, respectively (p < 0.001). Overall 5-year survival rates were 60.2% in hilar N1 and 49.6% in intralobar N1. Overall 5-year survival rates were 58.6% in N1 without node 10 and 35.1% in N1 with node 10. A significant difference was observed between N0 and N1 without node 10 (p < 0.001), and N1 without node 10 and N1 with node 10 (p = 0.033); however, the difference between N1 with node 10 and N2 was not significant. The status of node 10 involvement was an independent prognostic factor of pN1 patients, as well as age and gender.
Patients with node 10-positive N1 disease have an unfavorable prognosis, and the disease behaves like N2 disease. The definition of clear borderline between N1 and N2 is mandatory to achieve a uniform classification map. This study offers further information for clinical and therapeutic purposes.
We retrospectively analyzed risk factors for late bronchopleural fistula after non-small cell lung cancer (NSCLC) surgery and compared with those for early bronchopleural fistula.
In all, 6,239 patients with NSCLC who underwent surgery were studied, and clinical risk factors were examined by univariate and multivariate analysis. This study included 23 patients (0.38%) with late bronchopleural fistula and 43 patients (0.65%) with early bronchopleural fistula among all 6,239 patients. Follow-up data were recorded until December 2005 or until death. Statistical significance was calculated using the log rank test.
By univariate analysis, patients with radiotherapy after operation, pneumonia after operation, pneumonectomy, and advanced age were related to higher risk of bronchopleural fistula. In the multiple logistic regression models, both pneumonia and operative procedure were among the independent risk factors of early and late bronchopleural fistula. Early bronchopleural fistula was observed primarily in the aged. Late bronchopleural fistula was associated with postoperative radiotherapy. The average intervals of bronchopleural fistula between pneumonectomy and lobectomy were significantly different. Compared with the mortality rate of late bronchopleural fistula (0%), the mortality rate of early bronchopleural fistula (11.6%) was significantly higher.
There are both similarities and differences between the risk factors for early and late bronchopleural fistula. We should analyze the different reasons for the occurrence of bronchopleural fistula, and adopt different preventive measures. Different follow-up should be provided for the different operations.
Surgical resection is the standard of care for patients with resectable non-small cell lung cancer or selected patients with pulmonary metastases. Stereotactic radiosurgery may offer an alternative option for high-risk patients who are not surgical candidates. We report our initial experience with stereotactic radiosurgery in the treatment of lung neoplasm in 100 consecutive patients.
Patients who were medically inoperable were offered stereotactic radiosurgery. Thoracic surgeons evaluated all patients, placed fiducials, and performed treatment planning in collaboration with radiation oncologists. Initially, a median dose of 20 Gy prescribed to the 80% isodose line was administered in a single fraction, and this was subsequently increased to a total of 60 Gy in three fractions. The primary end point evaluated was overall survival.
We treated 100 patients (median age, 70 years; 51 men, 49 women) with stereotactic radiosurgery: 46 (46%) with primary lung neoplasm, 35 (35%) with recurrent cancer, and 19 (19%) with pulmonary metastases. The median follow-up was 20 months. The median overall survival was 24 months. Local recurrence occurred in 25 patients. The probability of 2-year overall survival was 50% for the entire group, 44% for primary lung cancer, 41% for recurrent cancer, and 84% for metastatic cancer.
Our initial experience indicates that stereotactic radiosurgery has reasonable results in these high-risk patients. Resection continues to remain the standard treatment; however, stereotactic radiosurgery may offer an alternative in high-risk patients. Further prospective studies with different dose schema are needed to evaluate the efficacy of stereotactic radiosurgery.
Surgical resection is the standard of care for patients with resectable non–small cell lung cancer or selected patients with pulmonary metastases. However, for high-risk patients radiofrequency ablation (RFA) may offer an alternative option. The objective of this study was to evaluate computed tomography–guided RFA for high-risk patients and report our initial experience in 100 consecutive patients by a thoracic surgical service.
Medically inoperable patients were offered RFA. Thoracic surgeons evaluated and performed RFA under computed tomography guidance. Patients were followed in the thoracic surgery clinic. The primary end point evaluated was overall survival.
One hundred patients underwent image-guided RFA for lung neoplasm (40 men, 60 women; median age, 73.5 years; range, 26 to 95 years). Forty-six patients (46%) with primary lung neoplasm, 25 patients (25%) with recurrent cancer, and 29 patients (29%) with pulmonary metastases underwent RFA. The mean follow-up for alive patients was 17 months. The median overall survival for the entire group of patients was 23 months. The probabilities of 2-year overall survival for the entire group, primary lung cancer patients, recurrent cancer patients, and metastatic cancer patients were 49% (95% confidence interval, 37 to 60), 50% (95% confidence interval, 33 to 65), 55% (95% confidence interval, 25 to 77), and 41% (95% confidence interval, 19 to 62), respectively.
Our experience indicates that image-guided RFA done by the thoracic surgeons is feasible and safe in high-risk patients with lung neoplasm with reasonable results in patients who are not fit for surgery. Thoracic surgeons can perform RFA safely, and should continue to investigate this new image-guided modality that may offer an alternative option in medically inoperable patients.
Lung donation after cardiac death (DCD) can enlarge the donor pool. Single-center reports have shown comparable outcomes after lung transplantation using conventional donors versus DCD in small numbers of patients.
We performed a retrospective review of DCD experience at a single lung transplant program using a prospective database.
Between January 2003 and April 2008, 293 lung transplantations were performed, including 11 bilateral transplantations (3.7%) using DCD lungs. Similar criteria were used to assess donor quality. The hospital mortality for DCD recipients was 2 of 11 (18%) and overall mortality was 4 of 11 (36%) by 18 months of follow-up. Seven DCD patients (64%) are alive with a median follow-up of 32 months. The DCD group was comparable to the control group in age and ischemic times. The 4 deaths, when compared with 7 DCD survivors, had longer ischemic time (293 minutes versus 232 minutes) and a higher incidence of nonlocal donors (3 of 4 versus 1 of 7).
At our center, early outcomes after DCD lung transplantations are somewhat inferior to those of series from other centers but approach national averages for conventional lung transplantation. Thus, DCD lung transplantation has the potential to increase the donor pool but must be offered cautiously.
Whether single lung transplantation (SLT) or bilateral lung transplantation (BLT) is optimal for patients with severe idiopathic pulmonary fibrosis (IPF) is unknown. We examine a large multi-institutional cohort of high-risk IPF patients to address this question.
We retrospectively reviewed United Network for Organ Sharing data to identify 1,256 lung transplant (LTx) recipients with IPF between 2005 and 2007. Risk of 30-day, 90-day, and 1-year mortality for SLT versus BLT was examined across levels of the lung allocation score (LAS [both continuous with incorporation of interaction terms and categorized by LAS quartiles]). Multivariable analysis was conducted through Cox proportional hazards regression.
Lung allocation score quartiles were as follows: quartile 1, 29.8 to 37.8, n = 315; quartile 2, 37.9 to 42.4, n = 313; quartile 3, 42.5 to 51.9, n = 314; and quartile 4, 52.0 to 94.1, n = 314. Overall, 21.1% more patients received BLT in the highest LAS quartile (59.5%) than in the lowest LAS quartile (38.4%, p < 0.05). In patients at highest risk, BLT was associated with a 14.4% decrease in mortality at 1 year after LTx. This survival benefit was confirmed on univariate analysis (hazard ratio 1.90 [95% confidence interval: 1.16 to 3.13], p = 0.01) and multivariable analysis (hazard ratio 2.09 [95% confidence interval: 1.07 to 4.10], p = 0.03) as well as in sensitivity analyses incorporating pulmonary hypertension and maximizing follow-up. There were no differences in the risk of death with SLT at 30 or 90 days after LTx in any quartile on unadjusted or multivariable adjusted analysis.
We provide an initial examination of survival by procedure type and LAS score for LTx recipients with IPF. Bilateral LTx appears to offer advantages over SLT for high-risk patients.
Pectus repair in adults can be challenging. Standard repair has been the modified Ravitch procedure. More recently the minimally invasive Nuss procedure, used exclusively in children, has been introduced for correction of pectus deformities in adults. There is a paucity of data on which procedure is most appropriate for adults and even less information on the most appropriate operation for pectus recurrence in adults. The purpose of this study is to determine if any specific patient characteristic exists that places patients at an increased risk for recurrence and describe our management of recurrent pectus defects in adults.
We retrospectively reviewed the records of all patients (>16 years of age) who underwent primary or recurrent repair of pectus deformities from April 1999 through December 2006.
Forty-eight patients, 37 (77%) men and 11 women, underwent pectus repair with a median age of 28 years (range, 16 to 54 years). Indication for initial repair was pectus excavatum in 39 (81%) and pectus carinatum in 9. The primary procedure was a modified Ravitch repair in 40 patients and a Nuss procedure in 8. Thirteen patients (27%) underwent reoperation for recurrence; 8 (62%) patients had undergone a previous Nuss procedure and 5 had a modified Ravitch repair. All reoperative patients had a primary pectus index (PI) greater than 4.0, while 8 (62%) also had an asymmetrical defect. All failed Nuss procedure patients underwent a modified Ravitch repair for correction, while the recurrent open repair patients required complex reconstructions. Results were good or excellent in greater than 90% of patients undergoing a reoperative procedure.
Adults with severe pectus deformities (PI > 4.0) and asymmetric defects are at a greater risk of recurrence after a Nuss procedure. These patients may better be served with a modified Ravitch repair initially. Reoperation for failed pectus repair in adults can be performed safely with outstanding results.
Solitary (localized) fibrous tumors of the pleura (SFTP) are rare slow-growing neoplasms that generally have a favorable prognosis. The aim of this paper is to evaluate the predictors of outcome in a series of 110 patients with SFTP.
The records of 110 patients (63 men; mean age 56.4 years; range, 17 to 79) surgically treated for SFTP from July 1990 to February 2008, were evaluated for demographics, operative procedure, histopathology, morbidity, mortality, postoperative chemotherapy or radiotherapy, and long-term follow-up.
Operative mortality was 0.9% (1 of 110) and the overall morbidity was 10.9% (12 of 110). The main surgical approach was video-assisted thoracoscopic surgery (69 procedures with a conversion rate of 14.5%); 40 patients underwent thoracotomy and 1 had sternotomy. The visceral pleura was the site of origin in 95 tumors, the parietal pleura in 13, the mediastinal pleura in 2 cases. Sixty-three tumors were pedunculated, 35 were sessile, and 12 were inverted fibroma. Tumors were pathologically benign in 95 cases (86.4%), and malignant in 15 (13.6%). Symptomatic patients presented with malignant tumors more often than asymptomatic (19.1% versus 9.5%). Overall 10-year survival rate was 97.5%. The overall disease-free survival rate was 90.8% (95.7% in benign cases and 67.1% in malignant cases; p < 0.05). Eight patients presented with recurrence of disease, 4 cases of which were malignant and 4 were benign.
Solitary fibrous tumor of the pleura is a rare disease that includes both benign and malignant variants.The outcome is mostly benign, with an overall 10-year survival rate of 97.5%. Pathologically benign lesions show a better disease-free survival rate than malignant lesions (95.7% versus 67.1%; p < 0.05). Surgery is the gold standard of treatment as neither radiotherapy nor chemotherapy proved to be effective.
Although thymectomy is a standard practice of care in patients with myasthenia gravis, the best approach to thymic resection remains controversial. This study was conducted to assess the effect of maximal resection on neurologic outcome and identify predictors of disease remission.
Data of 78 myasthenic patients who underwent modified maximal thymectomy during a 17-year period were retrospectively analyzed. The primary study end point was the achievement of complete remission. Separate analysis was performed for thymoma and nonthymoma patients regarding the factors predicting the neurologic outcome.
No patients died perioperatively. Surgical morbidity was 7.7%. The rate of postoperative myasthenic crisis was 3.8%. Thymoma and nonthymoma patients experienced comparable complete stable remission prediction (74.5% vs 85.7% at 15 years; p = 0.632). The absence of steroids in the preoperative medical treatment was statistically related to the prediction for complete stable remission in both thymoma (95% confidence interval [CI], 2.687 to 339.182, p = 0.006) and nonthymoma patients (95% CI, 1.607 to 19.183; p = 0.007) in multivariate analysis. In thymomatous myasthenia gravis, there was a statistically significant association between disease remission and the World Health Organization (WHO) histologic classification (95% CI, 0.262 to 0.827; p = 0.009).
Maximal resections are recommended in myasthenic patients. Disease severity represents the prime determinant of the neurologic outcome after thymectomy. The neurologic outcome in patients after thymectomy may be statistically associated with the WHO classification subtypes but not necessarily with the aggressiveness of these tumors.
The purpose of this retrospective study was to investigate the feasibility of colon interposition procedures after esophagectomy with extended lymphadenectomy.
Between 1990 and 2008, 95 consecutive patients underwent colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer in our Institution. We reviewed clinical data and long-term survival, and also investigated the association between anastomotic leakage and clinicopathologic findings.
We applied three-field lymphadenectomy to 71 patients and two-field to 24 patients, by a right thoracotomy. Ninety-two patients underwent reconstruction by a retrosternal route, and a posterior mediastinal route was applied to only three patients. We performed hand-sewn anastomosis in the neck in all cases. Three patients required microvascular surgery. Sixty-one patients (64%) experienced postoperative morbidity, most commonly pulmonary complications. Anastomotic leakage occurred in 12 patients (13%). No colon conduit necrosis was detected. Overall mortality, including hospital mortality, was 5.3%. Dysphagia (39%) and diarrhea (38%) were common and stricture was low (6%) after discharge. The overall 5-year survival rate was 43%. During the latter period (1998 to 2008), when ileocolon grafts evolved as the primary choice for interposition, the rate of leakage decreased from 17% (1990 to 1997) to 5.4%. No mortality was recorded during the latter period.
Results from this study demonstrate that colon interposition after esophagectomy with extended lymphadenectomy is feasible and can have a favorable outcome.
Improvements in enabling technology have facilitated minimal access techniques to the surgical ablation of atrial fibrillation. A variety of lesion sets (usually targeting only the left atrium) have been used in attempts to ablate atrial fibrillation. We describe a new epicardial approach to apply a set of left atrial lesions, which are electrophysiologically equivalent to all the left atrial lesions of the Cox maze III while using minimal access techniques.
Using minimal access techniques, we have isolated the pulmonary veins and made connecting lesions on the dome of the left atrium to create a set of lesions electrophysiologically equivalent to all the left atrial lesions of the Cox maze III. Intraoperative electrophysiological evaluation is used to insure complete isolation across each lesion line.
Using these minimal access procedures, we have obtained a complete block across all lesion lines in all patients.
These techniques have made it possible to perform the full Cox maze III left atrial lesion set with minimal access techniques.
Calcium phosphate cements control bleeding and are safe to use in osteoporotic sternums during open heart surgery. We looked at the clinical and radiographic effects of this agent on bone healing.
Since March 2006, 18 patients had calcium phosphate cement inserted in their sternal tables at heart surgery. They were followed-up by office visits and chest computed tomographic (CT) scans. All preoperative and postoperative CT chest scans were evaluated for cement absorption, bone replacement, and bone density.
Five preoperative and 41 postoperative CT chest scans were available for evaluation. Median interval from surgery to CT scan was 531 days (range, 3 to 966 days). At follow-up there were neither clinical dehiscences nor nonunions of the sternums. Calcium phosphate cement appears to reabsorb quickly, but not completely. Five patients with pre-surgical CT chest scans demonstrated an average, improved bone density of 281.66 Hounsfield units at follow-up (p = 0.006).
In each patient, cement was replaced by new bone, and there is evidence that more bone is present as a result of cement use.
In this case we illustrate our experience with transapical minimal invasive aortic valve replacement in a patient who previously underwent mitral valve replacement. The implantation did not interfere with the existing prosthesis and could even be used as a further landmark, helping height positioning of the aortic valve.
]]>Rupture of cardiac valves as a consequence of nonpenetrating cardiac trauma is an uncommon phenomenon. We report the case of a 24-year-old patient with a "two-stage" traumatic rupture of the anterolateral papillary muscle of the mitral valve, after a blunt chest trauma, who successfully underwent emergency mitral valve replacement.
]]>In Jehovah's Witness patients, the use of red blood cells, platelets, and fresh frozen plasma is not optional. Various blood conservation techniques are available, but complex cardiac surgery remains a major challenge. The feasibility of fractions of "primary components" has not been fully considered in published case reports. For Jehovah's Witness patients who preoperatively give consent, factor IX concentrates may be acceptable for hemostatic therapy. We hereby describe a combination of "secondary components" to prevent excessive bleeding in a Jehovah's Witness patient undergoing complex replacement of the aortic arch.
]]>Cogan's syndrome is a rare systemic disease which occurs predominantly in children and young adults. It was originally described as the combination of interstitial keratitis and audiovestibular disturbance. The nonspecific symptoms of the patients can be associated with numerous of systemic manifestations and, most characteristic, cardiovascular involvement. It affects large vessels (Takayasu-like) and medium size (polyarteritis nodosa-like) vessels. Here a case of extensive thoracoabdominal aortic replacement in a 28-year-old woman with Cogan's syndrome due to the symptomatic aortic aneurysm is described.
]]>Aortic thrombosis has been described in the medical literature as a rare and catastrophic complication of abdominal aortic aneurysms. However, it has only been reported once in cardiac surgical settings. We report a unique case of thrombosis of an abdominal aortic aneurysms during the course of cardiac surgery, in a fully anticoagulated patient on cardiopulmonary bypass. Prompt diagnosis and immediate surgical management were critical for a successful outcome.
]]>Cardiovascular syphilis has become a medical curiosity with the advent of widespread use of penicillin for the treatment of early syphilis. We report a case of a 37-year-old man who presented with sudden onset breathlessness that worsened insidiously for 1 year. Diagnosis of syphilitic aortopulmonary fistula was confirmed by aortography, contrast computed tomography, and histopathology. The patient underwent successful surgical correction. A high level of suspicion and awareness is needed for the diagnosis of this now rare disease. This entity is only amenable to surgical correction, even as existing surgical techniques need constant improvisation and individualization to each patient.
]]>Pulmonary vein stenosis is a known complication of radiofrequency ablation; its incidence ranges from 8% to 50%. However, complete occlusion of unilateral pulmonary veins is uncommon. We report a case with radiofrequency ablation that was complicated by complete occlusion of pulmonary veins along with fibrosing mediastinitis, which we believe has not been previously reported.
]]>Circulatory assist devices are an increasingly common method of treating patients with refractory cardiogenic shock. We describe a patient who was a heart transplant candidate with biventricular failure who underwent CardioWest total artificial heart-temporary (SynCardia Inc, Tucson, AZ) implantation with extracorporeal membrane oxygenation to manage the patient's subsequent respiratory failure. After respiratory and hemodynamic stabilization, the CardioWest total artificial heart-temporary served as a successful 62-day bridge-to-heart transplantation.
]]>We describe the case of a 23-month-old girl with combined immunodeficiency syndrome and a left ventricular aneurysm. Due to the size of the aneurysm and development of an intramural thrombus, repair was performed after confirmation of bone marrow transplant engraftment. Endoventricular circular patch plasty (Dor procedure) was performed, with excellent outcome and normalization of ventricular geometry and function.
]]>We present a case with a rare combination of tetralogy of Fallot with an absent pulmonary valve, and a single coronary artery with a major fistula to the main pulmonary artery. Myocardial ischemia developed in response to increasing shunt flow through the coronary fistula, resulting in heart failure. We ligated the coronary fistula and plicated the anterior wall of the dilated pulmonary arteries during the neonatal period. Complete repair through a transatrial-transpulmonary approach was performed at the age of 17 months. The postoperative course was excellent and the patient maintained a stable hemodynamic and respiratory state with no evidence of myocardial ischemia.
]]>Duplication of mitral valve is a very rare anomaly. It is characterized by two independent mitral valve apparatuses (leaflets and annulus) and subvalvular apparatuses (chordae and papillary muscles) that function well by themselves. In this report, we present duplicate mitral valve with parachute chordal attachment and mitral stenosis in an infant. The patient was successfully treated with the reconstruction of the larger valve without any intervention to the smaller one.
]]>Isolated subclavial artery is a rare congenital anomaly. Herein we discuss a patient with isolated left subclavian artery and bilateral patent arterial ducts who underwent sucessful repair. We also describe the detailed anatomy of both recurrent nerves in this condition and embryology of the anomaly.
]]>We present a case of right heart failure after left pneumonectomy as a result of an isolated, contralateral partial anomalous pulmonary venous return. We successfully treated this with percutaneous atrioseptostomy. For unstable patients with postoperative acute heart failure from an undetected partial anomalous pulmonary venous return, this minimally invasive procedure represents a useful primary option while allowing secondary conventional surgery if required.
]]>Complications of the residual pleural space after pulmonary resection have been reported to be between 5% and 40% depending on the type of resection, and they increase morbidity, mortality, hospital stays, and costs. The therapeutic use of autologous prepared platelet leukocyte-enriched gel is a relatively new technology for the stimulation and acceleration of soft tissue and bone healing. This gel can be applied to a diversity of tissue. We describe the case of a successful application through a chest tube of platelet leukocyte gel to treat an infected residual pleural space that developed after pulmonary lobectomy for lung cancer.
]]>Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.
]]>The incidence of cystic lesions of anterior mediastinum is low, which is responsible for approximately 10% of anterior mediastinal tumors. We presented a special case of primary anterior mediastinal tumor with both prominent cystic change and extreme high carbohydrate antigen 19-9 level of cystic fluid here. From the finding of this case report, we suggested that the diagnosis of cystic anterior mediastinal tumors should include both cystic seminoma and mature cystic teratoma.
]]>Lipoblastoma is a rare benign mesenchymal tumor of embryonal fat that occurs almost exclusively in infants and children less than age 3. It is a benign tumor with a high recurrence rate. We present a case of mediastinal lipoblastoma in a 21-month-old girl who presented with respiratory infection and progressive dyspnea. Complete surgical excision of the mass was achieved through a lateral thoracotomy. Her postoperative course was uneventful and the histopathologic examination proved that the mass was a lipoblastoma. We emphasize that this rare mediastinal tumor should be included in the differential diagnosis of infants having a mediastinal mass.
]]>Synovial sarcoma constitutes 8% to 10% of all sarcomas, and most commonly it affects adults in the third to fifth decades of life. This malignancy usually involves the extremities, and although local control by curative resection and adjuvant irradiation has improved, metastases develop in 40% of patients, with lung involvement in the metastatic process in 90% of cases. A single metastasis to the lungs from synovial sarcoma is rare, and a case of a large, single metastasis is even rarer. Herein, we present two cases of patients with an enormous metastatic synovial sarcoma that were successfully removed surgically.
]]>A bronchogastric fistula is a very rare complication of transthoracic esophagectomy. We report a case of bronchogastric fistula after transthoracic esophagectomy caused by dehiscence of the staple line in the gastric tube, with subsequent erosion into the right main bronchus. The patient was managed successfully in two surgical stages. First, the bronchial defect was repaired using a polyglactin mesh covered by a serratus anterior muscle flap. Two months later, the esophagogastric continuity was restored with colon interposition.
]]>The esophageal stent is used extensively for a malignant stricture, and many complications have been reported. We present a case of esophageal cancer with surgical esophageal stenting. Spinal epidural abscess occurred postoperatively, and we believe that the pathogenesis may be related to the esophageal stent.
]]>Bleeding is one of the most devastating complications of the Bentall procedure. We describe a simple, modified composite valve Dacron (DuPont, Wilmington, DE) graft to prevent bleeding from the proximal anastomosis between the graft and aortic annulus. The composite graft was modified by adding a short skirt of Dacron tube to a standard composite graft root. After the proximal end of the modified composite graft was implanted in the aortic annulus, the short skirt of Dacron tube was sewed to the remaining native aortic wall to wrap the proximal graft and aortic annular anastomosis. Our initial application of the modified composite graft demonstrated that this modified composite graft is an easy and effective way to prevent bleeding from the proximal anastomosis after the Bentall procedure.
]]>We present our technique for reconstruction of aortic valve, mitral valve, and aortomitral curtain in double-valve endocarditis with involvement of intervalvular fibrous body.
]]>Pulmonary venous pathway obstruction is a late complication of the atrial switch operation for transposition of the great arteries. Gaining peripheral access to the pulmonary venous baffle obstruction to treat the obstruction with stent deployment is difficult if not impossible. We present three patients in which we used hybrid procedures in the operating room to relieve the pulmonary venous pathway obstructions.
]]>We describe a novel method for closure of the bronchus intermedius, after right lower lobectomy, using a flap derived from the lower lobe apical segmental bronchus. We have successfully used this technique in an endobronchial carcinoid tumor occurring in a young man. It allowed middle lobe preservation despite a very proximal tumor position within the basal trunk bronchus. Adequate tumor margins were confirmed by on-table frozen section examination. This technique may have particular use in carcinoids or benign tumors.
]]>Progenitor cell therapy is a promising treatment for ischemic heart disease. Early clinical trials of autologous bone marrow-derived progenitor cell therapy for acute and chronic myocardial ischemia showed modest functional improvements after cell delivery; however, the duration of these benefits remains unclear. Ongoing investigations continue to enhance our understanding of the mechanisms by which progenitor and stem cells function and how their survival and cardioprotective abilities can be improved. This review discusses: (1) relevant progenitor and stem cells in myocardial regenerative therapy, (2) routes of cell delivery to ischemic myocardium, (3) clinical trials investigating bone marrow-derived progenitor cell therapy for myocardial ischemia, and (4) future directions of the field.
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