We report the unusual case of a 72-year-old woman with a primary presentation of right heart failure in the setting of recently diagnosed Ebstein's anomaly with concomitant atrial fibrillation (AF). The patient had New York Heart Association (NYHA) class III dyspnea for 12 months, with refractory right heart failure prior to undergoing surgical management in the form of a tricuspid annuloplasty ring and plication of the atrialized ventricle. The patient had an uneventful postoperative recovery and enjoyed an improvement in her exercise tolerance (NYHA class I) with minimal echocardiographic evidence of tricuspid regurgitation (TR) at the latest follow-up.
]]>A successful closure of an aneurysmal aorto-right ventricular tunnel (ARVT) in a 16-year-old male patient is reported here. An attempt at device closure had failed in this patient. Diagnosis was confirmed by Doppler echocardiography, 3-dimensional computed tomography, and cardiac catheterization. Surgical closure with a Dacron patch (W.L. Gore & Associates, Flagstaff, AZ) at the aortic end and direct closure at the ventricular end was done successfully with the patient under mild hypothermia. The postoperative echocardiogram showed a competent aortic valve with a closed ARVT.
]]>Percutaneous procedures and endovascular prostheses are becoming increasingly frequent, replacing classic interventions, and new complications are now appearing. We report the case of a liver transplant patient with a stenosis in the anastomosis of the suprahepatic veins to inferior vena cava, treated by self-expanding prosthesis, who developed an aorto–right atrial fistula and an atrial septal defect. Open heart surgery was performed to correct the defects. Transthoracic echocardiogram 1 year later revealed no evidence of residual shunt.
]]>We present a case of primitive neuroectodermal tumor of the left atrium with involvement of the coronary sinus. The initial presentation was of cardiac tamponade resulting from the size of the tumor. There was no evidence of tumor elsewhere, and after complete resection and without adjuvant chemotherapy the patient is well at 2-year follow-up. There has been no evidence of tumor recurrence. This is a rare reported case of resection of a cardiac primitive neuroectodermal tumor without adjuvant chemotherapy. Other cases in the literature have been treated by orthoptic transplantation and resection with chemotherapy.
]]>In this study, we show the use of three-dimensional printing models for preoperative planning of transcatheter valve replacement in a patient with an extreme porcelain aorta. A 70-year-old man with severe aortic stenosis and a porcelain aorta was referred to our center for transcatheter aortic valve replacement. Unfortunately, the patient died after the procedure because of a potential ischemic event. Therefore, we decided to fabricate three-dimensional models to evaluate the potential effects of these constructs for previous surgical planning and simulation of the transcatheter valve replacement.
]]>We report a rare case of an intrathymic primary intrathoracic goiter. The patient with newly diagnosed breast carcinoma was also known to have a distinct large anterior mediastinal mass. This was removed via a median sternotomy, after a thorascopic biopsy had been performed in the past but a diagnosis had not been reached. A discussion relating to the extremely rare occurrence of intrathymic ectopic thyroid tissue and the surgical treatment of primary intrathoracic goiters is included.
]]>Three-dimensional computed tomography angiography (3D-CTA) is valuable for preoperative simulations for lung cancer. However, when using 3D-CTA alone, it is difficult to identify tumor safety margins, especially for a segmentectomy. We report 2 cases of primary lung cancer for which we performed segmentectomy based on preoperative simulations by 3D-CTA with virtual 3D safety margins. We found this technique easy to use for simulations and useful for safely performing segmentectomy for small tumors in lung cancer.
]]>The optimal cannulation site in repair of DeBakey type I aortic dissection is controversial, and malperfusion during cardiopulmonary bypass is facilitated by retrograde flow. We propose the use of a long arterial cannula through the femoral artery to achieve a proximal antegrade perfusion. The tip of the cannula is placed in the true lumen of the distal aortic arch through the common femoral artery (Seldinger technique and transesophageal echography guidance). In 9 patients, there was one case of operative mortality (cardiac death), and no cases of perioperative stroke, bowel ischemia, severe renal failure, or local complications. Proximal perfusion can achieved rapidly and through an easily accessible site.
]]>Previous reports demonstrate that 1-year survival is severely compromised in patients with severe primary graft dysfunction (PGD) after lung transplantation. We examined if advances in extracorporeal membrane oxygenation (ECMO) support, including polymethylpentene oxygenators and reliance on venovenous (VV) ECMO have improved outcomes in patients with severe PGD after lung transplantation.
The analysis included data prospectively collected on all single-lung or double-lung transplants between November 2001 and December 2009. Heart-lung transplants were excluded. Comparisons were made between recipients who did and did not require ECMO for PGD after transplant.
Since November 2001, when VV ECMO became the routine treatment for severe PGD after transplant at our center, 28 of 498 patients (6%) have required VV ECMO support. Successful weaning occurred in 27 of 28 (96%). Support was withdrawn for 1 patient with irreversible neurologic injury. Survival was substantially better than in previous reports: 30 days, 82%; 1 year, 64%; and 5 years, 49%. Freedom from bronchiolitis obliterans syndrome was 88% in the ECMO survivors at 3 years, but maximum allograft function was considerably worse than in transplant recipients not requiring ECMO (peak forced expiratory volume in 1 second: 58% in ECMO vs 83% in non-ECMO, p = 0.001).
Advances in ECMO technology, particularly VV ECMO, have greatly improved the ability to support patients with severe PGD after lung transplantation. VV ECMO is an important tool in the armamentarium of any lung transplant program to optimize patient outcomes; however, strategies to improve lung allograft function in patients experiencing severe PGD are still needed.
This study evaluated hospital operative volume of video-assisted thoracoscopic surgery (VATS) lobectomy in primary lung cancer as a predictor of short-term outcomes after pulmonary lobectomy on a national scale. Some previous analyses comparing VATS vs open lobectomy outcomes have been limited by inaccuracies in patient cohort identification.
The 2008 Healthcare Utilization Project-Nationwide Inpatient Sample database was culled using the International Classification of Diseases (9th Clinical Modification) procedure codes specifically distinguishing VATS vs open lobectomies (32.41 and 32.49, respectively) available only after October 2007. High hospital VATS volume was defined as 95th percentile or higher (> 20 VATS/year). Univariable and multivariable analyses were used to identify independent predictors of the following outcome measures: 30-day in-hospital morbidity and mortality, hospital length of stay (LOS), and hospital costs.
We identified 6,292 primary lung cancer patients undergoing pulmonary lobectomy, including 1,523 undergoing VATS (24%). Compared with open, VATS patients had fewer complications (38% vs 44%, p < 0.001) and median LOS (5 vs 7 days; p < 0.001). In multivariable analysis, VATS was an independent predictor of fewer total complications (odds ratio, 0.83; p = 0.004) and shorter LOS (2.3 ± 0.3-day difference, p < 0.001). Patients undergoing VATS at high-volume VATS hospitals had shorter median LOS (4 vs 6 days, p = 0.001) compared with low-volume VATS hospitals. Multivariable analysis showed high hospital VATS volume independently predicted shorter LOS (0.9 ± 0.4-day difference, p = 0.001).
In a national database, VATS lobectomy was associated with fewer complications and shorter LOS than open lobectomy in primary lung cancer patients. Among patients undergoing VATS, high hospital volume was also associated with shorter LOS.
Segmentectomy provides an anatomic, parenchymal-sparing strategy for patients with limited lung function. Recently, interest has been renewed in segmentectomy for the treatment of early stage lung cancer.
We reviewed the medical records of all patients undergoing segmentectomy from January 1999 through December 2004. Survival curves were estimated using the Kaplan-Meier method.
There were 113 consecutive patients (58 men, 55 women); median age was 72.5 years (range, 30 to 94 years). Median forced expiratory volume in 1 second was 1.53 L (range, 0.5 L to 3.27 L). Median diffusion capacity of lung for carbon monoxide was 69% predicted (range, 23% to 129%). Significant comorbidities were present in 62 patients (55%). There was no perioperative mortality. Major morbidity occurred in 28 patients (25%). Mean tumor size was 2.1 cm. Resection margins were negative in all cases. Ninety-two patients (81%) were stage I. Overall 5-year survival was 79% for stage IA patients. Current smoking, diffusion capacity of lung for carbon monoxide less than 69%, tumor size greater than 2 cm, N2 disease, and advanced histology grade were associated with decreased survival by univariate analysis. In a multivariate model, only tumor size greater than 2 cm remained significant. Tumor recurrence was observed in 39 patients (35%): local in 17 patients (15%) and distant only in 22 (20%). For stage IA patients with T1a lesions, local recurrence was 5% and distant recurrence was 13%. Five-year recurrence-free survival of these patients was 69%.
Pulmonary segmentectomy can be performed safely in selected patients with preoperative reduced lung function and comorbidities. For stage IA disease, survival approximates that seen after lobectomy, with similar local recurrence rates for patients with T1a tumors.
The prognostic significance of hilar structures invasion, which remains undefined for non-small cell lung cancer (NSCLC), may have potential application for cancer staging. Tumor extension along the bronchus and pulmonary vessels was examined for survival significance.
In all, 213 pathologically proved central-type stage I NSCLC cases were enrolled. Four study groups were assigned based on the extent of resections: standard lobectomy (group L, n = 32), bronchoplastic procedures (group B, n = 94), standard lobectomy combined with pulmonary angioplasty (group A, n = 48), and bronchial sleeve resection combined with pulmonary artery angioplasty (group BA, n = 39). Univariate and multivariate analysis were performed by the Kaplan-Meier method and the Cox regression model.
There were 2 postoperative deaths (pulmonary embolism and serious pulmonary infection). Complications were noted in 39 patients (18.3%). Among these patients, the overall 5-year survival rate was 60.2% ± 0.05%, with a median survival time of 75.0 ± 7.5 months. The 5-year survival rates of subgroups were 79.5%, 59.7%, 59.0%, and 47.9%, respectively for groups L, B, A, and BA. Univariate analysis indicated tumor size, bronchial invasion, arterial involvement, and type of operation as closely associated with long-term survival. Multivariate analysis indicated that type of operation and tumor size were the most prominent prognostic factors of 5-year survival.
Proximal tumor extension into bronchus, invasions into extrapericardial pulmonary vessels, and tumor size were the most important risk factors for 5-year survival with central-type stage I NSCLC. Tumor extension in the hilum was highly related to prognosis and might provide pertinent information to accurately define a tumor ("T") subclass.
Cyclooxygenase-2 (COX-2) is constitutively overexpressed in a variety of epithelial malignancies and is usually associated with a poor prognosis. Fluorodeoxyglucose positron emission tomography (FDG-PET) has become an important tool for the diagnosis and staging of non–small-cell lung cancer. The maximal standardized uptake values (SUVmax) of primary tumors on FDG-PET have been shown to be correlated with some clinicopathologic factors. In this study, we investigated the prediction of intratumoral COX-2 expression by FDG-PET in cases of lung adenocarcinoma.
We conducted a retrospective review of the data of 60 patients with lung adenocarcinoma measuring less than 3 cm in diameter. Immunohistochemical staining for COX-2 and other biological factors that might influence cancer progression was performed, and the correlations of the selective tumor marker expression with the SUVmax were evaluated.
A significant correlation was observed between the SUVmax and the expressions of COX-2, Ki-67, and vascular endothelial growth factor (VEGF). Multiple stepwise regression analysis revealed significant relationships between the SUVmax and the expression of COX-2 (p < 0.001) and Ki-67 (p = 0.016). Of the 2, COX-2 expression was the stronger determinant of the SUVmax, which increased in proportion to the score for COX-2 expression. The recurrence-free survival of patients with elevated COX-2 expression was significantly worse than that of patients not showing COX-2 expression.
The expression of COX-2 in primary tumors is as strongly correlated with a worse clinical outcome as is increased FDG uptake in cases of lung adenocarcinoma. These findings indicate that the SUVmax of primary tumors might reflect the biological malignant potential in lung adenocarcinomas.
The purpose of this study was to assess the effect of human immunodeficiency virus (HIV) infection on postoperative survival among non-small cell lung cancer (NSCLC) patients.
A retrospective cohort study compared 22 HIV-infected lung cancer patients to 2,430 lung cancer patients with HIV-unspecified status who underwent resection at Johns Hopkins Hospital from 1985 to 2009. Subcohort comparative analyses were performed using individual matching methods.
Thirty-day mortality rates did not differ between HIV-infected and HIV-unspecified patients. Survival rates for HIV-infected lung cancer patients were significantly shorter than for HIV-unspecified patients (median, 26 versus 48 months; p = 0.001). After adjustment, the relative hazard of mortality among HIV-infected NSCLC patients was more than threefold that of HIV-unspecified patients (adjusted hazard ratio, 3.08; 95% confidence interval: 1.85 to 5.13). When additional surgical characteristics were modeled in a matched subcohort, the association remained statistically significant (adjusted hazard ratio, 2.31; 95% confidence interval: 1.11 to 4.81). Moreover, HIV-infected lung cancer patients with CD4 counts less than 200 cells/mm3 had shortened median survival compared with patients whose CD4 counts were 200 cells/mm3 or greater (8 versus 40 months; p = 0.031). Postoperative pulmonary and infectious complications were also elevated in the HIV-infected group (p = 0.001 and p < 0.001, respectively). After surgery, median time to cancer progression was shorter among HIV-infected patients (20.4 months) versus HIV-unspecified patients (p = 0.061).
The HIV-infected NSCLC patients have more postoperative complications, rapid progression to disease recurrence, and poorer postoperative survival. Optimizing immune status before surgery and careful patient selection based on diffusion capacity of lung for carbon monoxide may improve patient outcomes.
Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications.
Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results.
In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n = 13, and herpesvirus simplex, n = 1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p = 0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications.
When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications.
Subcarinal node metastasis is common in patients with esophageal cancer. Some scholars have suggested that subcarinal nodes might not need to be sampled or dissected in patients with superficial squamous cell carcinoma of the thoracic esophagus. This research investigated the frequency of subcarinal node metastasis in patients with esophageal squamous cell carcinoma, identified the factors correlated to subcarinal node metastasis, and evaluated the clinical relevance of subcarinal node metastasis in thoracic esophageal squamous cell carcinoma.
We retrospectively analyzed the clinical data of 1,812 consecutive patients with thoracic esophageal squamous cell carcinoma who underwent esophagectomy in the Cancer Center of Sun Yat-sen University. The surgical procedures included the left transthoracic procedure, Ivor-Lewis approach, and the cervical-thoracoabdominal procedure.
The frequency of subcarinal node metastasis was 10.0%. The univariate and multivariate analysis showed that longer tumor length, higher pathologic T stage, lower histologic grade, and positive lymph node metastases of other groups were associated with a higher frequency of subcarinal node metastasis (all p < 0.05). Patients with solitary subcarinal node metastasis had a significantly lower 5-year cumulative survival rate than those with solitary paraesophageal node metastasis (25.3% vs 39.6%, p < 0.05).
Longer tumor length, higher pathologic T stage, lower histologic grade, and positive lymph node metastases of other groups are associated with a higher frequency of subcarinal node metastasis. Subcarinal node metastasis indicates worse prognosis of patients with thoracic esophageal squamous cell carcinoma compared with paraesophageal node metastasis.
It remains unclear if patients with clinical stage T2 N0 (cT2 N0) esophageal cancer should be offered induction therapy vs surgical intervention alone.
This was a retrospective cohort study of cT2 N0 patients undergoing induction therapy, followed by surgical resection, or resection alone, at the Johns Hopkins Hospital from 1989 to 2009. Kaplan-Meier analysis was used to compare all-cause mortality in cT2 N0 patients who had resection alone vs those who had induction chemoradiation therapy, followed by resection.
A study cohort of 69 patients was identified and divided into two groups: 55 patients (79.7%) received induction therapy and 14 (20.3%) did not. No statistically significant difference in 5-year survival rate was observed for the two groups: 49.5% for the resection-only group and 53.8% for the induction group. More than 50% of cT2 N0 patients were understaged.
For cT2 N0 esophageal cancer patients, the benefit of neoadjuvant therapy is still unclear. Induction therapy for cT2 N0 did not translate into a statistically significant improvement in survival. However, due to the significant understaging of T2 N0 patients, we recommend neoadjuvant therapy to all cT2N0 patients before operation.
The objective of this report is to discuss the efficacy of in situ replacement for treating mycotic aneurysm, particularly using rifampicin-bonded grafts and omental pedicle grafts, on the basis of our 7 years of experience.
Between December 2003 and December 2010, we performed surgical treatments in 23 patients (for the thoracic aorta in 6 patients, for the thoracoabdominal aorta in 8 patients, and for the abdominal aorta in 9 patients; 7 emergency, 10 urgent, and 6 elective operations) with mycotic aneurysm by using rifampicin-bonded grafting and omental pedicle grafting.
One patient died in hospital because of local recurrent infection. One patient required an additional operation on another aortic site, and 3 patients had spinal cord injuries (2 transient and 1 permanent). Overall survival at 5 years was 95%, and the rate of freedom from aortic events at 5 years was 86%.
In situ replacement using rifampicin-bonded grafting and omental pedicle grafting is effective for treating mycotic aneurysms of the thoracic and abdominal aorta.
The modified Bentall procedure remains a gold standard of aortic root surgery. We present in this study the early and late outcomes of a particular modification using 2 separated grafts for the coronary reimplantation.
From 1995 to 2009, 153 patients aged 57 ± 12 (mean ± standard deviation [SD]) underwent elective (n = 113) or urgent (n = 40) aortic root replacement with a composite mechanical valve conduit reconstruction using 2 short, separated 8-mm Dacron grafts for the coronary reimplantation and were retrospectively reviewed.
Aortic disease etiologies were annuloaortic ectasia (n = 108), type A aortic dissection (n = 38), aortic false aneurysm, or Valsalva aneurysm evolution after previous cardiac surgery (n = 7). The overall early mortality was 8.5% (20% for urgent procedure and 4.4% for elective procedure). For the whole group, actuarial survival at 5 and 10 years was 86.3% ± 2.78 and 73.7% ± 4.23, respectively. Among the 23 late deaths, 9 were valve-related deaths (stroke, n = 3; endocarditis, n = 1; unknown, n = 5). During the follow-up, linearized rates of major bleeding, thromboembolism, and endocarditic evolution were, respectively, 1.3 %/patient-years, 0.42 %/patient-years, and 0.22 %/patient-years. One patient presented a nonseptic false aneurysm of the right coronary anastomosis and no structural valve dysfunction has been diagnosed. In total, only 2 patients required an aortic root reoperation.
The modified Bentall procedure using 2 separated grafts for the coronary reimplantation is a feasible, safe, easy, and reproducible operative technique for aortic root surgery.
Aortic dissection is an evolving process that may require one or several reoperations after its initial repair. We conducted a study to evaluate risk factors and define the incidence and locations of reoperations after surgical correction of acute type A aortic dissection (AAD).
Between 1998 and 2008, 250 consecutive patients (mean age 62.5 ± 12.4 years) underwent surgery for AAD at our institution. Replacement of the ascending aorta was done in 173 cases, composite graft replacement in 61 cases, separate aortic valve and ascending aorta replacement in 2 cases, and arch replacement required by distal repair in 14 cases. Mean follow-up time was 4.7 ± 5.6 years.
Freedom from reoperation was 99%, 82%, and 79% at 1, 5, and 10 years, respectively. Twenty-five patients required 25 reoperations at a mean interval of 4.7 years after initial surgery for the correction of AAD. Reoperations included 21 procedures on the proximal aorta (ascending aorta, aortic root, or valve) and 4 procedures on the distal aorta (arch or descending aorta). Cox regression analysis identified the use of gelatin-resorcinol-formaldehyde (GRF) glue (p = 0.0270), and nonreplacement of the aortic root at the time of initial AAD repair (p = 0.0004), as a significant risk factor for proximal reoperation, and a patent false lumen (p = 0.0107) as a significant risk factor for distal reoperation.
A patent false lumen, the use of GRF glue, and aortic root preservation at initial operation influence the risk for surgical correction in patients undergoing surgery for AAD. These patients need long-term follow-up.
Congenital bicuspid aortic valves (BAVs) result from fusion of 2 valve cusps, resulting in left-noncoronary (L-N), right-left (R-L), and right-noncoronary (R-N) morphologic presentations. BAVs predispose to ascending thoracic aortic aneurysms (ATAAs). This study hypothesized that ATAAs with each BAV morphologic group possess unique signatures of matrix metalloproteinases (MMPs) and endogenous tissue inhibitors of metalloproteinases (TIMPs).
Ascending thoracic aortic aneurysm tissue from 46 patients with BAVs was examined for MMP/TIMP abundance, and global MMP activity was compared with normal aortic specimens (n = 15). Proteolytic balance was calculated as the ratio of MMP abundance to a composite TIMP score. Results were stratified by valve morphologic group (L-N [n = 6], R-L [n = 31], and R-N [n = 9]).
The BAV specimens (p < 0.05 versus normal aorta, 100%) displayed elevated global MMP activity (273% ± 63%), MMP-9 (263% ± 47%), and decreased MMP-7 (56% ± 10%), MMP-8 (58% ± 11%), TIMP-1 (63% ± 7%), and TIMP-4 (38% ± 3%). The R-L group showed increased global MMP activity (286% ± 89%) and MMP-9 (267% ± 55%) with reduced MMP-7 (45% ± 7%), MMP-8 (68% ± 15%), TIMP-1 (58% ± 7%), and TIMP-4 (35% ± 3%). The L-N group showed elevated global MMP activity (284% ± 71%) and decreased MMP-8 (37% ± 17%) and TIMP-4 (48% ± 14) activity. In the R-N group, MMP-7 (46% ± 13%) and MMP-8 (36% ± 17%) and TIMP-1 (59% ± 10%) and TIMP-4 (42% ± 5%) were decreased. The R-L group demonstrated an increased proteolytic balance for MMP-1, MMP-9, and MMP-12 relative to L-N and R-N.
Each BAV morphologic group possesses a unique signature of MMPs and TIMPs. MMP/TIMP score ratios suggest that the R-L group may be more aggressive, justifying earlier surgical intervention.
This article investigates patient radiation doses during implantation of thoracic stent-graft. Aortic stengraft implantation can be disturbed by many factors, which, in turn, lead to prolongation of the procedure time and, as a consequence, increase the radiation dose.
Measurements of radiation length (fluoroscopy and exposure), air kerma (AK) in grays, and dose–area product in grays · square centimeters were conducted simultaneously in 100 patients. The patients were analyzed retrospectively, regarding their body mass index (BMI), type of aneurysms, number of stent-graft parts, angulation of aorta, and coverage of the left subclavian artery.
Mean total dose–area product value for this kind of treatment was 361 Gy · cm2. This was caused by the fact that total mean AK was high for the cohort analyzed and reached 797 mGy. For 23 patients total AK was between 1 and 2 Gy, and for 3 it exceeded 2 Gy. In the remaining group, the maximal radiation dose was very high and exceeded 3 Gy. The total AK of patients with BMI within the range of 25 to 29.9 kg/m2 and with BMI greater than 30 kg/m2 significantly increased in comparison with the group of patients with BMI between 18 and 24.9 kg/m2 (p = 0.00005 and 0.000001, respectively). During the study, a good correlation between AK and fluoroscopy time (r = 0.6) and for AK (or dose–area product) and exposure time (r = 0.66 or 0.81, respectively) was observed.
The main factors contributing to a high radiation dose being acquired by patients during thoracic stent-graft were BMI greater than 25 kg/m2, number of parts of the stent-graft, and angulation of the neck of aneurysm exceeding 60 degrees.
Thoracic endovascular aneurysm repair (TEVAR) has been rapidly introduced as a primary treatment modality for thoracic aortic diseases with limited data available on midterm to late-term outcomes.
A retrospective single institution study comparing hospital and midterm outcomes and costs for TEVAR versus open elective repair of descending thoracic aneurysms was conducted. Fifty-seven patients were included between 2005 and 2007 (TEVAR = 28; open = 29) and were followed until May 2010.
Patients in the TEVAR group were older (73.2 versus 62.3 years; p < 0.001). Hospital mortality was higher in the open repair group (10.3% versus 3.6%; p = 0.611). There was no statistical difference in stroke, paraparesis or paralysis, sepsis, or renal failure; however, a composite major adverse event variable showed a higher complication with open repair versus TEVAR (37.9% versus 14.3%; p = 0.043). Mean follow-up was 42.6 months for open repair versus 26.9 for TEVAR (p = 0.002). Kaplan-Meier survival analysis showed the initial survival benefit for TEVAR was lost in less than 6 months; however, the difference did not reach statistical significance during follow-up (log-rank test p = 0.232). Mean surveillance imaging costs for a TEVAR patient were $1,800.38 higher than for an open patient at 2 years. Compliance of TEVAR patients with follow-up imaging was 78%, 64%, 50%, and 42% at 1, 6, 12, and 24 months, respectively, and was even lower in those not registered in device trials.
Patients in the TEVAR group had favorable early outcomes; however, midterm survival was reduced secondary to comorbidities. This study raises concern for the ongoing costs of surveillance imaging in TEVAR as well as patient compliance with follow-up.
Endocarditis affecting the aortic valve, with abscess formation and root destruction, remains a challenge to treat. Aortic root homografts have been advocated because of a perceived lower risk of infective complications than with other root replacement grafts. However, the theoretical advantage of homografts has not been re-evaluated in the modern era. This report is based on an examination of our results for all aortic root replacements in complex, active endocarditis affecting the aortic valve.
From 2000 to 2010, 134 patients (70.9% male; mean age 58.3 ± 14.8 years) at our institution underwent aortic root replacement for active endocarditis. Ninety of the patients (67.2%) had a previously implanted prosthetic aortic valve. Our findings for these patients included one or more of the following: abscess (n = 110, 82.1%), valve vegetation (n = 98, 73.1%), and pseudoaneurysm or rupture or both (n = 62, 46.3%). We retrospectively reviewed data for the patients from hospital records and the social security data base.
A mechanical composite graft (MC) was used in 43 of the patients (32.1%), a non-homograft biologic valve conduit (BC) in 55 patients (41.0%), and a homograft (HG) valve in 36 patients (26.9%). There was no significant difference among the groups in the incidence of major complications or in-hospital mortality. During a mean follow-up of 32.1 ± 29.4 months, the rates of readmission, reinfection, and reoperation were similar for the three groups. The mean 5-year survival in the study was 58 ± 9% for the MC group, 62 ± 7% for the BC group, and 58 ± 9% for the HG group, respectively (p = 0.48).
Aortic root replacement in the presence of complex active infection is associated with significant morbidity and mortality. We report that the rates of major complications and late mortality were similar among MC, BC, and HG groups in our study.
The risk of death and complications of infective endocarditis (IE) treated medically has to be balanced against those from surgery in constructing a therapeutic approach. Recent literature has drawn conflicting conclusions on the benefit of surgery for IE. We reviewed patients treated surgically for IE at the Cleveland Clinic from 2003 to 2007 to examine their outcomes.
A retrospective review of consecutive patients who underwent surgery for native and prosthetic valve endocarditis between January 1, 2003, and December 31, 2007, was conducted. Surgical outcomes were reviewed to include survival and postoperative complications. Survival was evaluated at end of hospital stay, 30 days, 1 year, and at last follow-up.
Four hundred twenty-eight patients underwent surgery for IE during the study period: 248 (58%) had native valve endocarditis and 180 (42%) had prosthetic valve endocarditis. Overall 90% of patients survived to hospital discharge. When compared with patients with native valve infection, patients with prosthetic infection had significantly higher 30-day mortality (13% versus 5.6%; p < 0.01), but long-term survival was not significantly different (35% versus 29%; p = 0.19). Patients with IE caused by Staphylococcus aureus had significantly higher hospital mortality (15% versus 8.4%; p < 0.05), 6-month mortality (23% versus 15%; p = 0.05), and 1-year mortality (28% versus 18%; p = 0.02) compared with non–S aureus IE.
Surgical treatment of IE was associated with 90% hospital survival. Outcomes within the 30 days were better for native valve than for prosthetic valve endocarditis. Long-term outcomes were similar. Finally, S aureus was associated with significantly higher mortality compared with other pathogens.
The choice of prosthesis for aortic valve replacement in young and middle-aged patients remains challenging owing to the accelerated degeneration of bioprostheses in these age groups and the risks of thromboembolism and bleeding with mechanical valves. Theoretically, the living pulmonary autograft (Ross operation) would be advantageous. Long-term results of the various Ross techniques are needed for defining the value of this surgical concept.
Of a total of 576 subcoronary Ross patients operated on between June 1994 and June 2011, we report on 203 consecutive subcoronary patients (mean age, 47.2 ± 13.6 years, 155 male, 2,491 patient-years) with a follow-up of at least 10 years (mean, 12.3 ± 2.9 years).
Early and late mortality were 0.98% (n = 2) and 11.4% (n = 23). Valve-related mortality was 2.5% (n = 5). Survival did not differ from that of the general German population. Freedom from autograft or allograft reoperation was 92.2% at 10 years and 87.1% at 15 years. Five major bleeding (0.20%/patient-year) and 11 thromboembolic events (0.44%/patient-year) occurred in 5 and 10 patients, respectively. Neither a systematic increase in aortic regurgitation nor an increase in root dimensions with time could be observed. In the vast majority of patients, valvular hemodynamics at latest echocardiographic follow-up were excellent.
Long-term results of the original subcoronary Ross operation reveal normal survival, excellent hemodynamics, low risk of thromboembolism or bleeding, and small risk for reoperation. These results favor the pulmonary autograft concept in young and middle-aged patients in experienced centers and may serve to better define its role in surgical treatment of aortic valve disease in these patients.
Aortic root replacement with a mechanical valve prosthesis is a widely accepted surgical technique. This study aims to evaluate short-term and long-term outcomes of this approach and to identify predictors of 30-day mortality.
We retrospectively analyzed a consecutive series of 528 patients (mean age, 54 ± 13 years) who underwent aortic root replacement for aneurysm (83%), acute type A dissection (15%), or endocarditis (2%) in the period between 1974 and 2008. The mean time of follow-up was 9.0 ± 7.0 years (range, 0 to 36 years). Concomitant aortic surgery was performed in 71%, coronary revascularization in 18%, and mitral valve surgery in 3%. Selective antegrade cerebral perfusion was applied in 25% and deep hypothermic circulatory arrest in 28% of patients.
Overall 30-day mortality was 3.2% to 2.5% for elective surgery and 6.5% for urgent surgery. Morbidity included resternotomy for bleeding or tamponade (19%), pacemaker implantation (3.6%), myocardial infarction (4.0%), and neurologic damage (4.2%). Multivariate analysis revealed myocardial infarction (p < 0.001) and the lack of glue use (p = 0.018) as independent predictors of 30-day mortality. Subanalysis of the selective antegrade cerebral perfusion patients and the deep hypothermic circulatory arrest patients revealed infarction (p = 0.005) and coronary artery disease (p = 0.45) for selective antegrade cerebral perfusion and wrapping (p = 0.035) for deep hypothermic circulatory arrest as independent risk factors. The survival rate was 87%, 73%, and 29% after 5, 10, and 25 years, respectively.
Aortic root replacement with a mechanical valve prosthesis can be performed safely with low mortality and acceptable morbidity. Perioperative myocardial infarction is the strongest independent risk factor of 30-day mortality.
This study evaluated the long-term clinical performance of the Mosaic bioprosthesis (Medtronic Inc, Minneapolis, MN) after aortic valve replacement.
From 1995 to 2008, 178 patients (48 women; mean age, 74 ± 6 years) had aortic valve replacement. Mean functional class was 2.3 ± 0.5, and 157 patients (88%) were in sinus rhythm. Prosthetic sizes were 23 mm in 98 patients and 25 mm in 66. Follow-up was completed in December 2009 with a cumulative duration of 1,015 patient/years (mean, 5.7 ± 3.5 years, maximum, 13.7 years).
Early mortality was 4%, none being valve-related; of 38 late deaths 7 were valve-related. Actuarial survival at 13 years was 48% ± 8%. Mean functional class of current survivors was 1.2 ± 0.6. Six embolic episodes occurred and four cases of endocarditis, with respective actuarial freedom of 92% ± 5% for embolism and 97% ± 2% for endocarditis at 13 years. Four patients required reoperations for endocarditis and 2 for structural deterioration. Actuarial freedom from structural deterioration and from reoperation for all causes was 89% ± 7% and 86% ± 7% at 13 years, with an actuarial freedom from prosthesis-related deaths of 86% ± 5%. Results of echocardiographic evaluation at 1 year were mean peak gradient, 20 ± 6 mm Hg and mean effective orifice area index, 1.07 ± 0.21 cm2/m2 for size 23 mm and 22 ± 6 mm Hg and 1.11 ± 0.26 cm2/m2for size 25 mm; at 10 years, mean peak gradient and mean effective orifice area index were 28 ± 13 mm Hg and 1.01 ± 0.19 cm2/m2 for size 23 mm and 26 ± 8 mm Hg and 1.08 ± 0.18 cm2/m2for size 25 mm.
The Mosaic bioprosthesis showed good overall performance, with low incidence of structural valve deterioration and hemodynamic stability in the long-term. Expected increased durability of this device should be verified at longer follow-up intervals.
Knowledge of the dynamic changes of the aortic valve (AV) annulus may aid in the sizing and design of transcatheter valve prostheses. We assessed AV annulus distention in patients without AV disease and with severe AV stenosis (AS) using computed tomography (CT).
Electrocardiogram-gated multislice CT scans of 15 patients without AV disease (age 53 ± 12 years) and 20 patients with severe AS (age 81 ± 6 years) were analyzed. Images in plane with the AV annulus were reconstructed for every 10% to 12.5% of the cardiac cycle. With the use of dedicated software the annulus was segmented. In all phases of the cardiac cycle the area was measured, as were the maximum radius (Rmax) and minimum radius (Rmin) of an ellipse fitted around the segmented lumen. The asymmetry ratio was defined as Rmax/Rmin. Direct comparison of both groups was not possible because age and scan protocols were confounding factors.
The mean change of the area, Rmax, and Rmin was 122 ± 33 mm2, 1.8 ± 0.7 mm, and 2.4 ± 0.5 mm in the patients with nondiseased annulus and 98 ± 52 mm2, 1.4 ± 0.7 mm, and 1.9 ± 0.8 mm in those with AS. The mean asymmetry ratio was 1.3 ± 0.1, indicating an elliptic annulus. Both the asymmetry ratio and the area changed significantly over the cardiac cycle (p < 0.001).
With the use of CT and postprocessing software, significant area and radius changes during the cardiac cycle were demonstrated in both the nondiseased annulus and the stenotic annulus. This finding may help selection of the optimal size in patients undergoing AV implantation and also aid in prosthesis design.
We prospectively applied the Surgical Treatment of Ischemic Cardiomyopathy trial entry criteria to an observational database to determine whether coronary artery bypass grafting (CABG) decreases mortality compared with medical therapy (MED) for patients with coronary artery disease and depressed left ventricular ejection fraction.
This was a retrospective, observational, cohort study of prospectively collected data from the Duke Databank for Cardiovascular Disease. Long-term mortality was the main outcome measure. Between January 1, 1995, and July 31, 2009, 86,874 patients underwent cardiac catheterization for suspected ischemic heart disease and were evaluated for inclusion in the analysis.
A total of 2,624 patients were found to have left ventricular ejection fraction less than 0.35, coronary artery disease amenable to CABG, and no left main stenosis of greater than 50%. After exclusions including ongoing Canadian Cardiovascular Society class III angina and acute myocardial infarction, 763 patients were included for propensity score analysis, including 624 who received MED and 139 who underwent CABG. Adjusted mortality curves were constructed for those patients in the three quintiles most likely to receive CABG. The curves diverged early, with risk-adjusted mortality rates at 5 years of 46% for MED versus 29% for CABG, and the survival benefit of CABG over MED continued through 10 years of follow-up (hazard ratio, 0.63; 95% confidence interval, 0.45 to 0.88).
Among a propensity-matched, risk-adjusted, observational cohort of patients with coronary artery disease, left ventricular ejection fraction less than 0.35, and no left main disease of greater than 50%, CABG is associated with a survival advantage over MED through 10 years of follow-up.
The purpose of the present study was to compare outcome in propensity score-matched patients, aged 70 years or greater, undergoing isolated off-pump coronary bypass surgery using a bilateral (BITA) or single (SITA) skeletonized internal thoracic artery.
Of 912 consecutive patients undergoing isolated coronary bypass grafting (906 using the off-pump technique without emergent conversion to cardiopulmonary bypass), the 491 aged 70 years or greater undergoing off-pump skeletonized single (n = 247) or bilateral (n = 244) skeletonized internal thoracic artery grafting were retrospectively analyzed after excluding the 6 who were transferred to our hospital after receiving percutaneous cardiopulmonary bypass, the 72 who had only 1 target in the left coronary area, and the 343 aged less than 70 years. A total of 217 pairs were matched using propensity scores calculated from 9 preoperative factors (0.69).
The rate of postoperative complications was similar between the groups. The 5-year estimated survival free from overall death and cardiac event, respectively, in the BITA group versus the SITA group were 86.4% ± 3.2% versus 73.5% ± 3.9% (p = 0.01) and 93.2% ± 2.7% versus 87.5% ± 3.0% (p = 0.01). In multivariate Cox models, bilateral internal thoracic artery grafting was significantly associated with a lower risk of overall death (hazard ratio 0.56; 95% confidence interval 0.31 to 0.99; p = 0.04) and cardiac event (hazard ratio 0.36; 95% confidence interval 0.15 to 0.88; p = 0.03).
In elderly patients, off-pump in situ left-sided bilateral skeletonized internal thoracic artery grafting is associated with lower risk of overall death and cardiac event than single internal thoracic artery grafting and carries no increased operative risk.
Metabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting.
A total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up.
A total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p = 0.04), cardiac arrhythmias (35.3% versus 25.2%; p < 0.0001), renal failure (12% versus 8.7%; p = 0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p < 0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensity-adjusted Cox proportional-hazards regression were age (p = 0.0008), preoperative left ventricular ejection fraction (p = 0.001), preoperative renal failure (p = 0.001), and MetS (p = 0.006). Higher C-reactive protein levels were found preoperatively (8.6 ± 2.3 versus 5.14 ± 3.1 mg/L; p < 0.0001) and both early (71.2 ± 9 versus 49.6 ± 8.7 mg/L; p < 0.0001) and late (7.4 ± 2.7 versus 4.8 ± 2.5mg/L; p < 0.0001) after surgery.
The main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy.
Refractory vascular spasm (RVS) concomitantly involving the entire coronary artery system and grafted conduits after coronary artery bypass grafting (CABG) surgery is a rare, but dreadful event. No consensus exists in terms of appropriate management.
Between 1986 and 2009, 5,762 patients underwent isolated CABG at our institution, and 7 patients experienced RVS involving the coronary arteries and implanted conduits. Mean age was 65.6 years and 3 were female. All patients received from 3 to 5 distal anastomoses, including use of the left internal mammary artery. During the same time period, 18 patients experienced perioperative vasospasm of a single coronary artery or of a grafted conduit.
All diffuse RVS events occurred between 3 and 8 hours after surgery. All patients had diffuse ischemic-like electrocardiographic changes, and 5 patients rapidly developed cardiogenic shock in the intensive care unit. Angiography was quickly performed in all patients and showed diffuse RVS involving either the native coronary arteries or the anastomosed arterial and venous conduits. The first 5 patients of this series died in the catheterization lab due to rapidly evolving refractory cardiogenic shock and unresponsive cardiac arrest, despite intraaortic counterpulsation and aggressive pharmacologic interventions (selective vasodilators and systemic inotropes). In the last 2 patients, extracorporeal membrane oxygenation was quickly instituted (1 in the catheterization lab, 1 in the operating room) and RVS could be successfully managed with complete resolution of ongoing vasospasm. In the single vascular spasm, there was only 1 death for refractory cardiac arrest, whereas all the other patients were successfully treated with direct infusion of vasodilators.
Diffuse RVS after CABG is a rare but lethal condition. Our experience, although limited, indicates that in such cases an aggressive treatment, that is, prompt extracorporeal membrane oxygenation institution and controlled cardiocirculatory assistance, represents the preferred solution to face such a dramatic event and may save patient lives.
Coronary artery disease is the single leading cause of death in the United States. Commonly it is treated with coronary bypass grafting using the saphenous vein (SV) or internal mammary artery (IMA) as a conduit. Unfortunately, the SV has much lower patency rates compared with the IMA. Several hypotheses exist as to why occlusion occurs more commonly in SV grafts than in IMA grafts. However detailed studies in this area have been limited. This study investigates the effects of pressure distention on inflammation in SV conduit used in coronary artery bypass grafting (CABG).
Saphenous vein distention pressure was measured intraoperatively during 48 CABG procedures. A segment of SV was excised from the conduit before distention. Because the vein was used for coronary artery grafting, sequential pieces were archived for evaluation. Real-time polymerase chain reaction (RT-PCR) and immunohistochemical analyses were performed to investigate a change in the expression of biomarkers.
Upregulation of various biomarkers occurred. These biomarkers included scavenger receptors A and B (SR-A, SR-B), toll-like receptors 2 and 4 (TLR2, TLR4), platelet endothelial cell adhesion molecule (PECAM), vascular cell adhesion molecule (VCAM), and intercellular cell adhesion molecule (ICAM) in segments of SV that were subjected to distention. Immunohistochemical results mirrored RT-PCR findings. A significant correlation was observed between biomarkers and pressure values.
These studies demonstrate that markers of inflammation are upregulated in response to SV distention. The data suggest that the pressure used in graft preparation procedures should be regulated to avoid inflammation and its potential to induce graft failure.
Controversy exists about whether preoperative angiotensin-converting enzyme inhibitor (ACEi) therapy is associated with adverse outcomes after coronary artery bypass grafting (CABG).
We analyzed the outcomes of consecutive patients who underwent isolated CABG between 1998 and 2007 at a single institution. We used multivariable models to examine the association between preoperative ACEi therapy and in-hospital and long-term outcomes.
Of the 5946 patients undergoing isolated CABG during the study period, 3,262 (54.9%) were treated with an ACEi preoperatively and 2,684 (45.1%) were not. Median follow-up was 3.8 years. Patients treated with an ACEi preoperatively were more likely to have diabetes, hypertension, an ejection fraction of less than 40%, and recent myocardial infarction (all p < 0.0001). They were less likely to have pre-existing renal failure (p = 0.004) or require an urgent or emergent CABG (p = 0.03). Postoperative use of an inotrope (26% vs 20%, p < 0.0001) or intra-aortic balloon pump (1.8% vs 1.1%, p = 0.03) was more frequent in patients treated preoperatively with an ACEi; however, preoperative ACEi use was not an independent predictor of in-hospital mortality (odds ratio [OR], 1.1; p = 0.76), prolonged length of stay in the intensive care unit (OR, 0.9; p = 0.09), or new-onset renal failure (OR, 0.7; p = 0.09). Furthermore, preoperative use of an ACEi had no independent association with long-term survival (p = 0.54) or freedom from acute coronary syndrome (p = 0.07). However, it was associated with an increased risk of readmission for heart failure over time (hazard ratio, 1.2; p = 0.007).
We found no association between preoperative ACEi therapy and adverse in-hospital outcomes or long-term survival after CABG. Preoperative ACEi therapy appears to be safe in patients undergoing CABG.
Advances in critical care medicine have allowed for improved care of patients requiring prolonged intensive care unit length of stay (prICULOS) after cardiac operations, yet little is known regarding their eventual outcomes. The purpose of this study was to examine short- and long-term outcomes in patients undergoing cardiac operations with prICULOS.
All cases of coronary artery bypass grafting (CABG), aortic valve, mitral valve, and combined CABG/valve surgical procedures performed at a single institution from July 2002 to July 2007 were identified. All-cause mortality in patients discharged alive from the hospital was determined until December 2007 through linkage with the Social Security Death Index. Patients who experienced intraoperative death or those with missing or invalid social security numbers were excluded. The definition of prICULOS was total ICULOS greater than 7 days.
A total of 3,478 patients met inclusion criteria. One hundred thirty-seven of three thousand four hundred seventy-eight patients (3.9%) experienced prICULOS. These patients were more likely to be older than 70 years (55.5% versus 30.5%; p < 0.0001) and to have had recent myocardial infarction (28.5% versus 20.1%; p = 0.02), previous cardiac operation (18.3% versus 6.9%; p < 0.0001), and emergent status (9.5% versus 1.6%; p < 0.0001). They experienced greater in-hospital mortality (37.2% versus 1.7%; p < 0.0001) and those who were discharged alive had worse long-term survival (log-rank, p < 0.0001). After risk adjustment, prICULOS emerged as a significant predictor of in-hospital death (odds ratio [OR] 20.9; 95% confidence interval [CI], 12.9–33.7) and decreased long-term survival (hazard ratio [HR] 2.9; 95% CI, 2.0–4.3).
Patients with prICULOS after cardiac operations have worse overall outcomes. These data may be used to inform these patients and their families of realistic expectations regarding their clinical course.
Acute kidney injury (AKI) duration after cardiac surgery is associated with poor survival in a dose-dependent manner. However, it is not known what perioperative risk factors contribute to prolonged AKI and delayed recovery. We sought to identify perioperative risk factors that predict duration of AKI, a complication that effects short and long-term survival.
We studied 4,987 consecutive cardiac surgery patients from 2002 through 2007. Acute kidney injury was defined as a 0.3 or greater (mg/dL) or 50% or greater increase in serum creatinine from baseline. Duration of AKI was defined by the number of days AKI was present. Stepwise multivariable negative binomial regression analysis was conducted using perioperative risk factors for AKI duration. The c-index was estimated by Kendall's tau.
Acute kidney injury developed in 39% of patients with a median duration of AKI at 3 days and ranged from 1 to 108 days. Patients without AKI had a duration of 0 days. Independent predictors of AKI duration included baseline patient and disease characteristics, and operative and postoperative factors. Prediction for mean duration of AKI was developed using coefficients from the regression model and externally validated the model on 1,219 cardiac surgery patients in a separate cardiac surgery cohort (Translational Research Investigating Biomarker Endpoints-AKI). The c-index was 0.65 (p < 0.001) for the derivation cohort and 0.62 (p < 0.001) for the validation cohort.
We identified and externally validated perioperative predictors of AKI duration. These risk factors will be useful to evaluate a patient's risk for the tempo of recovery from AKI after cardiac surgery and subsequent short and long-term survival. The levels of awareness created by working with these risk factors have implications regarding positive changes in processes of care that have the potential to decrease the incidence and mitigate AKI.
Urinary L-type fatty acid-binding protein (L-FABP) has not been evaluated for adult post-cardiac surgery acute kidney injury (AKI) to date. This study was undertaken to evaluate a biomarker panel consisting of urinary L-FABP and N-acetyl-β-D-glucosaminidase (NAG), a more established urinary marker of kidney injury, for AKI diagnosis in adult post-cardiac surgery patients.
This study prospectively evaluated 77 adult patients who underwent cardiac surgery at 2 general hospitals. Urinary L-FABP and NAG were measured before surgery, at intensive care unit arrival after surgery (0 hours), 4, and 12 hours after arrival. The AKI was diagnosed by the Acute Kidney Injury Network criteria.
Of 77 patients, 28 patients (36.4%) developed AKI after surgery. Urinary L-FABP and NAG were significantly increased. However, receiver operating characteristic (ROC) analysis revealed that the biomarkers' performance was statistically significant but limited for clinical translation (area under the curve of ROC [AUC-ROC] for L-FABP at 4 hours 0.72 and NAG 0.75). Urinary L-FABP showed high sensitivity and NAG detected AKI with high specificity. Therefore, we combined these 2 biomarkers, which revealed that this combination panel can detect AKI with higher accuracy than either biomarker measurement alone (AUC-ROC 0.81). Moreover, this biomarker panel improved AKI risk prediction significantly compared with predictions made using the clinical model alone.
When urinary L-FABP and NAG are combined, they can detect AKI adequately, even in a heterogeneous population of adult post-cardiac surgery AKI. Combining 2 markers with different sensitivity and specificity presents a reasonable strategy to improve the diagnostic performance of biomarkers.
The development of acute kidney injury (AKI) after adult cardiac surgery is associated with increased morbidity and mortality. Our aim was to assess the risk factors for postoperative AKI and whether the addition of perioperative management variables can improve AKI prediction.
We studied 3,219 patients operated from January 2006 to December 2009. The AKI was defined as proposed by the Acute Kidney Injury Network. Patient preoperative characteristics, as well as intraoperative, cardiopulmonary bypass (CPB), and postoperative management variables, were evaluated for association with AKI with logistic regression analysis. The model including all variables was assessed first, then separate models including only preoperative variables followed by the sequential addition of intraoperative, CPB, and postoperative management variables were tested; receiver operating characteristic analysis was used to evaluate and compare models' discriminatory power.
The AKI occurred in 288 of 3,219 patients (8.9%). Logistic regression analysis identified 15 predictors of AKI; 4 were preoperative (age, diabetes, smoking, and serum creatinine), 4 intraoperative (inotropes, erythrocytes transfusion, cross-clamp time, and need of a new pump run), 2 CPB-related (urine output and furosemide administration during CPB), and 5 postoperative (erythrocytes transfusion, administration of vasoconstrictors, inotropes, diuretics, and antiarrhythmics). Model-discrimination performance improved from an area under the curve of 0.830 (95% confidence interval 0.807 to 0.854) for the model including only preoperative variables to an area under the curve of 0.904 (95% confidence interval 0.886 to 0.921) for the model including all variables (p < 0.001).
Several factors influence AKI development after cardiac surgery and perioperative patient management significantly affects AKI occurrence. Predictive models can be sensibly improved by the addition of these variables.
Thoracic residency program enrollment continues to decline. While job market and decreasing reimbursements are often cited as the main reasons, length of and format of training may also be significant.
The Medical College of Wisconsin established an Accreditation Council for Graduate Medical Education-approved 6-year integrated thoracic training program. The number and characteristics of applicants to the 6-year program were then compared with previous applicants applying to the traditional 2-year program.
Applicants to the 6-year integrated program scored higher on the United States Medical Licensing Examination part 1 and part 2 than previous applicants to the traditional2-year program. The 6-year applicants also were more published and a greater percentage of them held other advanced degrees.
Institution of a 6-year integrated thoracic surgery training program at the Medical College of Wisconsin led to a significant increase in number of applications. Additionally, the 6-year applicants appeared to be more academically accomplished than previous applicants to the traditional 2-year program. While early in the experience, it appears that interest in thoracic surgery is high among medical students and institution of a 6-year program has the potential to once again attract the "best and the brightest" to this specialty.
The risk of reoperation on the autograft and homograft is the major long-term drawback of the Ross procedure. The incidence and clinical implications of reoperations after the Ross procedure are reported.
Between March 1992 and February 2010, 336 consecutive patients had a Ross procedure (mean follow-up, 6.2 ± 4.9 years). Autograft implant technique was freestanding root replacement in 269 patients, subcoronary implantation in 52 patients and a modified root replacement with the autograft included in a Valsalva tube graft in 15.
Subsequently, 38 patients (11.3%) underwent reoperations, for autograft dilatation in 23 and a significant autograft insufficiency in 9, at 9.6 ± 3.7 years and 2.6 ± 3.9 years, respectively. Aortic and pulmonary infective endocarditis occurred in 3 patients. Three patients underwent a non valve-related cardiac reoperation. Three patients received a transcatheter pulmonary valve implantation after 12.2 ± 1.7 years. At 15 years, freedoms for autograft and homograft explantation (with 95% confidence interval) were 83.3% (77.4%- to 9.2%) and 92.8% (87.6% to 97.9%), respectively. Native aortic valve regurgitation, indexed aortic annulus diameter exceeding 1.35 cm/m2 and autograft diameter were risk factors for dilated autograft reoperation (hazard ratio, 3.23 [95% confidence interval, 1.19 to 8.81], p = 0.02; 3.83 [0.9 to 16.33], p = 0.07 and 1.2 per mm [1.01 to 1.41], p = 0.03), respectively.
Autograft dilatation was the leading cause of reoperation in patients who underwent root replacement. Long-term follow-up is mandatory to determine whether modifications of the operative technique could limit autograft dilatation.
Surgical results for functional univentricular heart with total anomalous pulmonary venous connection (TAPVC) have been unsatisfactory to date.
During a 25-year period until December 2009, 207 TAPVC patients underwent surgical repair at our institute, including 56 with a univentricular heart. The 10-year survival rate was 51.1% with univentricular heart and 84.7% with biventricular heart (p < 0.0001; log-rank, 27.6). Surgical outcomes and risk factors for early and late death after TAPVC repair in univentricular hearts were retrospectively analyzed.
Patients were aged 3.8 ± 4.3 years and weighed 12.3 ± 10.7 kg at operation. Preoperative diagnoses included heterotaxy syndrome in 55, asplenia in 48, preoperative pulmonary venous obstruction in 35, and pulmonary atresia in 20. TAPVC was classified as I in 22, II in 26, III in 5, and IV in 3. Concomitant procedures included Fontan procedure in 29, bidirectional Glenn procedure in 5, systemic–pulmonary shunt in 11, and pulmonary artery banding in 5. There were 17 hospital deaths and 11 late deaths. Fontan completion was undertaken in 31 (55.3%). Postoperative pulmonary venous obstruction was found in 15. Multivariate analysis identified TAPVC III and IV and pulmonary atresia as risk factors for hospital death. Univariate analysis identified postoperative pulmonary venous obstruction and concomitant systemic–pulmonary shunt as risk factors for hospital and late death.
TAPVC III, IV, and pulmonary atresia are risk factors for early postoperative death. Intensive intervention, including perioperative management and operation, is required in these complex patients.
Single ventricle hearts can be surgically palliated by a series of operations culminating in the Fontan procedure, which establishes a total cavopulmonary connection. The second-stage procedure creates a physiologic connection between the superior vena cava and the pulmonary artery.
From 1998 to 2010, 557 patients with single ventricle heart disease underwent second-stage surgical palliation. This cohort was retrospectively analyzed to assess patient outcome by a number of anatomic, physiologic, and procedural factors. The analysis excluded patients undergoing hybrid first-stage procedures.
The median age at operation was 165 days (range, 59 days to 49 years). The most common anatomic subtypes were hypoplastic left heart syndrome (52%), tricuspid atresia (12%), unbalanced atrioventricular septal defect (10%), double inlet left ventricle (9%), or other (17%). Left ventricular hypoplasia was present in 70%. A hemi-Fontan procedure was done in 89%, and 11% received a bidirectional Glenn. Concomitant atrioventricular valve repair was necessary in 9%. Early mortality was 4.7%, and 5.9% died after discharge but before Fontan. No early or late deaths occurred in patients with tricuspid atresia and double inlet left ventricle. Multivariate analysis demonstrated ventricular dysfunction, atrioventricular valve regurgitation, and unbalanced atrioventricular septal defect were significant adverse risk factors for survival to Fontan.
Second-stage palliation can be performed at low risk for patients with left ventricular dominance, but significant risk remains for patients with left ventricular hypoplasia and unbalanced atrioventricular septal defect. Atrioventricular valve insufficiency is a persistent problem that has not been neutralized by repair strategies.
Right-side heart function is essentially externalized during extracardiac total cavopulmonary connection. The Fontan procedure has a certain impact on pulmonary hemoperfusion and may explain various postsurgical complications. In this study, alterations of pulmonary perfusion in patients undergoing the Fontan procedure were analyzed at the 5-year postoperative mark by radionuclide imaging and angiocardiography, and results of both methods were compared.
For 43 post-Fontan patients, perfusion ratios of each lung segment were calculated based on radionuclide imaging data. The pulmonary vascular resistance and pulmonary artery index of each patient were also calculated from right angiocardiographic measurements.
The radionuclide count and advantage perfusion ratio of right lung at follow-up did not differ significantly from early postoperative values (t = 0.38, p > 0.05; t = 1.12, p > 0.05), and superior/inferior vena cava perfusion ratios were stable (t = 0.88, p > 0.05; t = 0.74, p > 0.05). The superior/inferior segment perfusion ratio of the whole lung declined significantly (t = 2.54, p < 0.05), while that of the dorsal lung segment rose significantly (t = 2.16, p < 0.05). Compared with early postoperative status, the pulmonary arterial index of patients at follow-up were significantly increased (t = 2.41, p < 0.05), while small pulmonary vascular resistances declined significantly (t = 2.08, p < 0.05; t = 2.69, p < 0.05), and arterial oxygen saturation levels were unaltered (t = 1.12, p > 0.05). The early angiographic and radionuclide perfusion studies of 5 patients did not match.
After the Fontan procedure, hypostatic redistribution of pulmonary blood flow is characteristic. The weak pulse of blood, in the absence of ventricular ejection, can promote pulmonary vascular changes, but at later (intermediate) follow-up, the decline in vascular resistance that results carries no benefit in terms of blood perfusion or oxygenation. Microcirculatory arteriovenous shunting is the likely cause. In this study of functional pulmonary hemoperfusion, radionuclide imaging was deemed superior to angiocardiography.
This report reviews our 40-year experience with pediatric mitral valve replacement (MVR) with respect to mortality, valve-related morbidity, and reoperation risk factors.
From 1970 to 2010, 97 patients have undergone a total of 136 MVRs. Median age was 8 years (2 weeks to 18 years), 41 patients (42%) were less than 5 years, and 16 were infants (17%). Etiology was congenital in 65 patients (67%), rheumatic in 27 (28%), and endocarditis in 5 (5%). Regurgitation was the predominant lesion in 67 patients (69%), stenosis in 23 (24%), and mixed in 7 (7%) patients. Mechanical valves (ball, n = 11; or bileaflet disc, n = 66) and xenografts (porcine, n = 14; bovine, n = 2) were used in 93 initial MVR patients. Since 2002, 5 children have undergone Ross MVR with a pulmonary autograft in 3 and an aortic homograft in 2.
Hospital mortality was 6% (6 of 97). There were 23 late deaths and 5 patients have required cardiac transplantation. Thirty-five year actuarial survival was 71%. Age less than 2 years, MVR prior to 1980, atrioventricular septal defect, univentricular heart, and additional left side obstructions were significant predictors of death. Mean follow-up was 12.8 ± 10.1 years (range, 2 months to 38 years). Seventeen patients with mechanical valves experienced systemic emboli in 9 (10%), valve thrombosis in 5 (6%), and bleeding requiring transfusion in 3 (3%) patients. Thirty-two patients required reoperations (35%) from 3 months to 14 years (mean, 6.5 ± 4.4 years) after initial MVR. Actuarial freedom from reoperation at 35 years was 63%. Variables associated with mitral re-replacement were younger age, small weight, valve diameter less than 23 mm, MVR prior to 1980, and type of implanted valves (xenograft, single-leaflet disk, ball-caged, or human valves).
Pediatric MVR can be performed with low initial mortality but should be reserved for medical and reconstruction failure because reoperation, valve-related complications, and late mortality are high. Bileaflet prostheses larger than 23 mm have the lowest reoperation risk. Ross MVR may offer select patients a durable tissue valve without lifelong anticoagulation and its associated complications.
Permanent cardiac pacing is not often done in children, and when done is usually accomplished through epicardial pacing. We reviewed a 12-year experience with the implantation of epicardial pacemakers by our clinical group.
Fifty-three patients who underwent their first implantation of an epicardial pacemaker before the age of 18 years and between 1997 and 2009 were included in our study. The mean age of the patients at the time of first pacemaker implantation was 5.7 ± 4.8 years. Indications for pacemaker implantation included postoperative or congenital atrioventricular block and sinus node dysfunction. The patients underwent 105 operations for the replacement of pacemaker pulse generators and 75 operations for the replacement of pacemaker leads. The most commonly used generator mode was the rate-responsive accelerometer-based (DDDR) mode, which was used in 40.9% of the patients. We used more non-steroid-eluting leads (70.1%) than steroid-eluting leads (29.1%).
The overall duration of follow-up in the study was 8.0 ± 4.5 years (range, 2.1 months to approximately 17.0 years). Freedom from the need for generator replacement was 98.0%, 60.7%, and 11.1% at 1, 5, and 8 years, respectively. A tendency toward early generator exhaustion was observed among younger patients (p = 0.058). The generator mode used for pacing did not significantly affect generator longevity. Freedom from the need for lead replacement was 98.3%, 83.8%, and 63.6% at 1, 5, and 10 years, respectively. The mean longevity of the leads used in the study was 10.8 ± 0.8 years. Neither patient age at the time of lead implantation nor type of lead significantly affected lead longevity.
Lead longevity was sufficiently long and did not vary significantly according to type of lead. Generator longevity was not affected by lead type, generator mode, or patient age at the time of pacemaker implantation.
The purpose of this study was to evaluate the hemostatic efficacy and feasibility of direct injection of fibrin sealant into the sternal marrow cavity in senior patients undergoing on-pump coronary artery bypass grafting (CABG).
A total of 82 senior patients undergoing on-pump CABG were randomized to the bone wax group (n = 40) or the fibrin sealant group (n = 42) for the period July 2010 to January 2011.
The fibrin sealant–treated group had less chest drainage in the first 24 hours (186.67 ± 49.53 versus 333.75 ± 60.49 mL), less total chest drainage (326.19 ± 67.24 versus 516 ± 88.46 mL), less packed red blood cell (PRBC) administration (3.6 ± 1.25 versus 7.4 ± 2.13 U), less fresh frozen plasma (FFP) administration (5.52 ± 1.64 versus 8.95 ± 1.77 U), shorter intubation time (40.36 ± 8.62 versus 46.25 ± 10.46 hours), and shorter hospital stay (10.45 ± 1.17 versus 11.03 ± 1.37 days) compared with the bone wax group. No significant difference in the incidence of postoperative complications was found.
Direct injection of fibrin sealant into the sternal marrow cavity significantly reduces the amount of postoperative blood loss and offers an attractive new treatment alternative for senior patients undergoing on-pump CABG.
Coronary ostial stenosis is usually treated by conventional coronary artery bypass graft surgery. Although patch angioplasty is a widely accepted alternative surgical treatment, it has been reported sporadically. We encountered bilateral ostial stenosis with Takayasu disease. This report describes successful patch angioplasty using glutaraldehyde-treated autologous pericardium of bilateral coronary ostial stenosis owing to Takayasu disease.
]]>A 78-year-old gentleman with a diagnosis of symptomatic severe xenograft aortic stenosis with multiple comorbidities was referred for transcatheter aortic valve implantation, that is, a "valve-in-valve" procedure. Transcatheter aortic valve implantation was performed by transapical approach using a balloon-expandable bioprosthesis. During valve deployment, the prosthesis moved toward the left ventricle and a second balloon-expandable valve was implanted within the first one—a "valve-in-valve-in-valve" to avoid further ventricular embolization of the first bioprosthesis. Echocardiography at hospital discharge showed a residual mean transvalvular gradient of 17 mm Hg and trivial paravalvular aortic regurgitation. At 1 year follow-up, the patient was in New York Heart Association functional class II.
]]>A 35-year-old woman presented with an aortobronchial fistula after polyester graft replacement of coarctation of the descending thoracic aortic. Treatment of the fistula included antibiotic therapy and stent graft placement. Life-threatening sepsis developed in the postoperative period. Subsequent treatment required excision of the infected graft complex with extra-anatomic reconstruction of the thoracic aorta. The patient had a very stormy postoperative course and required heroic measures, including mechanical circulatory support, to achieve survival. The present case demonstrates failure of endovascular therapy of an aortobronchial fistula. The case should serve as a cautious reminder that the underlying cause for infection remains even after apparent successful endovascular therapy.
]]>A 63-year-old male patient with a type B aortic dissection after the use of tadalafil, a phosphodiesterase type 5 inhibitor, is presented. The possible role of a novel predisposing factor—sexual activity combined with tadalafil—is reviewed. This report and three other cases add a new dimension to the known predisposing factors such as chronic systemic hypertension, hereditary connective tissue diseases– and congenital aortic valve diseases. However, the precise role of phosphodiesterase type 5 inhibitors in the pathophysiology of aortic dissection remains unknown.
]]>Few publications address cardiac surgery in the presence of meningioma. Individual complications include transient visual loss from a suprasellar meningioma, hemiparesis after mitral valve replacement with recovery after resection, and non-fatal hemorrhage into a posterior fossa meningioma. The largest report of 16 patients with known meningiomas over 11 years suggested a benign course, with no new neurologic symptoms and no required resection of a meningioma over an average follow-up of 31 months. In 2 cases we report a presumed posterior fossa meningioma led to fatal outcome after cardiac surgery performed on bypass. Possible causes and future considerations are discussed.
]]>It has been suggested previously that rebound hypercoagulability may be responsible for morbidity and mortality following clopidogrel cessation in adults with acute coronary syndrome. We report a case of acute occlusion of a modified Blalock-Taussig shunt in an infant after clopidogrel discontinuation.
]]>We report a modification of the Starnes technique for palliating severe tricuspid regurgitation associated with a dysplastic right ventricle in a neonate, using a fenestrated pericardial patch allowing for unidirectional flow. The patient eventually underwent a successful Glenn shunt construction with a persistent reduction in right ventricle size at 1 year follow-up.
]]>Conventional surgery for revision of right ventricular outflow tract conduits is complex and demanding. Percutaneous implantation of pulmonary valves may not be feasible in all cases. We describe a safe, alternative hybrid transapical approach from the right ventricle that avoids the extensive dissection and potential complications of revision surgery.
]]>A 64-year-old man with a history of esophageal adenocarcinoma status postneoadjuvant therapy underwent esophagogastrectomy. Postoperatively he was found with increasing dyspnea and oxygen requirements. Computed tomography of the chest showed retrocardiac herniation of atelectatic lung into the contralateral hemithorax.
]]>A patient with blunt trauma and traumatic bronchial rupture and lung collapse had prominent symptoms of platypnea-orthodeoxia syndrome. These symptoms were relieved by bronchial repair. The syndrome is rarely seen and is usually associated with a patent foramen ovale or atrial septal defect. The syndrome has not been described previously in association with traumatic bronchial rupture.
]]>Spontaneous rupture of a mediastinal germ cell tumor, while rare, is always accompanied by bleeding. In this report, we describe a case of a primary mediastinal mixed germ cell tumor that presented with bilateral massive hemothorax and hemorrhagic shock. An urgent thoracotomy, which was performed to control bleeding, confirmed bilateral hemothorax secondary to a ruptured mediastinal tumor. Pathologic diagnosis revealed the mediastinal tumor to be mixed choriocarcinoma and immature teratoma, with lung metastatic choriocarcinoma. The patient recovered well from the operation and received salvage chemotherapy. Two years after diagnosis, the patient remains in remission with no evidence of disease.
]]>We present a case of a 58-year-old man who experienced Bronchiolitis obliterans organizing pneumonia after a 3-month exposure to polyester powder paint. Mineralogical analysis by transmission electron microscopy of a pulmonary sample and the polyester powder paint he was exposed to showed the presence of titanium dioxide nanoparticles in both. We suggest that exposure to titanium dioxide nanoparticles should be added to the etiology of Bronchiolitis obliterans organizing pneumonia.
]]>Primary tracheal tumors are rare. Approximately 1% of them are leiomyoma. Given the rarity of these lesions, optimal management has not been defined. Bronchoscopic, local surgical excision and partial tracheal resection have all been described. One report of recurrence after resection has been published. The incidence of recurrence following local excision is unknown. We report a case of an incidental tracheal leiomyoma diagnosed and treated with a combined approach.
]]>The HeartWare left ventricular assist device (LVAD) is a new addition to the family of second-generation continuous-flow LVADs. The miniaturized dimensions of the HeartWare LVAD provide the opportunity for its safe implantation through nonsternotomy incisions. We present our technique for HeartWare LVAD implantation through bilateral anterior thoracotomy incisions. This technique has proved to be safe and reproducible, with good clinical outcome.
]]>Pulmonary regurgitation developing late after tetralogy of Fallot repair is now recognized as a serious threat to the long-term welfare of these patients. This article summarizes our experience with 5 patients who underwent reoperations for treatment of severe pulmonary regurgitation after transannular patch repair of tetralogy of Fallot. In each case, the intraoperative findings revealed anatomy favorable for valve repair and enabled preservation of the native pulmonary valves.
]]>We describe our surgical technique to manage a small aortic annulus during aortic valve replacement. Starting with the posterior annular enlargement incision described by Manouguian, a stentless porcine aortic root, with excision of the left and right porcine coronary segments and conservation of the mural wall (Freestyle MS design, Medtronic, Minneapolis, MN ), was used. The Freestyle bioprosthesis enlarges the aortic annulus using a direct suture of the valve on the enlarged annulus, and the aorta is closed by a direct suture of the mural wall of the bioprosthesis. Therefore, the aortic annulus enlargement is made only using the aortic bioprosthesis, without other material.
]]>Significant hemodynamic alterations often occur during off-pump coronary artery bypass operations. Historically, left main coronary artery stenosis has been excluded from off-pump coronary artery bypass operations because of this concern. Many articles in recent times support off-pump operations in left main coronary artery (LMCA) stenosis. We describe here a safe and effective method to reduce the incidence of hemodynamic changes during beating heart surgery in patients with LMCA stenosis.
]]>Mitral valve repair is considered the procedure of choice for correcting mitral regurgitation in myxomatous disease, providing long-term results that are superior to those with valve replacement. The use of artificial chordae to replace elongated or ruptured chordae responsible for mitral valve prolapse and severe mitral regurgitation has been the subject of extensive experimental work to define feasibility, reproducibility, and effectiveness of this procedure. Artificial chordae made of autologous or xenograft pericardium have been replaced by chordae made of expanded polytetrafluoroethylene (PTFE), a material with the unique property of becoming covered by host fibrosa and endothelium. The use of artificial chordae made of PTFE has been validated clinically over the past 2 decades and has been an increasing component of the surgical armamentarium for mitral valve repair. This article reviews the history, details of the relevant surgical techniques, long-term results, and fate of artificial chordae in mitral reconstructive surgery.
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