ICVTS - Interactive Feed

Ruptured pseudoaneurysm of the pulmonary artery - rare manifestation of a primary pulmonary artery sarcoma [Cardiac general]

Koch, A., Mechtersheimer, G., Tochtermann, U., Karck, M. — Wed, 14 Oct 2009 06:26:39 PDT

A 64-year-old male developed chest pain while gardening. Aortic dissection and coronary artery disease were excluded but chest computed tomography (CT) scan showed an aneurysmic enlargement of the pulmonary artery and a fluttering structure within. He underwent immediate sternotomy for replacement of the pulmonary artery. Histology showed an intimal sarcoma of both branches of the pulmonary artery. The pulmonary artery was replaced by a T-shaped Gore-Tex-prothesis. Keywords: Pulmonary artery sarcoma; Aneurysm; Pulmonary artery

Mechanical prosthetic mitral valve thrombosis in a first trimester pregnant woman [Cardiopulmonary bypass]

Mon, 12 Oct 2009 05:22:05 PDT

Pregnant women with a mechanical heart prosthesis are at a higher risk of thromboembolic complications. The optimal anticoagulation strategy in this setting remains unclear. When prosthesis thrombosis happens and cardiac surgery must be performed, the risk of fetal mortality is high. Special attention must be paid to improve the placental perfusion during cardiopulmonary bypass (CPB) in order to improve fetal outcomes. A 31-year-old woman, 9 weeks pregnant, was admitted to our institution due to a mitral mechanical prosthesis thrombosis. She had been receiving low molecular weight heparin (LMWH) since pregnancy was detected. She underwent a mitral valve replacement with CPB at 34 °C and a short cardiac arrest time. Both mother and fetus survived. We briefly review the different anticoagulation options during pregnancy and perfusion strategies on CPB to improve fetal outcomes. Keywords: Pregnancy; Mechanical heart valve

Barotraumatic oesophageal perforation with bilateral tension pneumothorax [Esophagus]

Chien, L.-C., Chang, H.-T., Chou, Y.-P. — Mon, 12 Oct 2009 08:46:19 PDT

Barotraumatic oesophageal perforation with bilateral tension pneumothorax is extremely rare and this is a first case reported in the literature. The possibility of the oesophageal perforation due to high-pressure gas flow should be kept in mind and the standard of diagnosis is oesophagography. Keywords: Barotrauma; Oesophageal perforation; Tension pneumothorax; Oesophagography

Perfusion temperature, thyroid hormones and inflammation during pediatric cardiac surgery [Congenital]

Mon, 12 Oct 2009 06:28:42 PDT

Objectives: During cardiopulmonary bypass (CPB) surgery there are several alterations in concentrations of thyroid hormones. Although hypothermia and inflammation have been implicated in the disturbed thyroid axis during CPB, these issues are far from clear. Methods and results: We measured serum/plasma concentrations of thyroid hormones and inflammatory mediators in children with body weight <10 kg, undergoing open heart surgery, randomized to mild (n=15, 32 °C) or moderate (n=15, 25 °C) hypothermia. During CPB there was a marked decrease in triiodothyronine (T3), free thyroxin (FT4) and thyroid-stimulating hormone (TSH), followed by a slight increase after 24 h, but without normalization 48 h after CPB. There was no difference in the thyroid response between the two hypothermia groups. During CPB the maximal changes in plasma levels of interleukin (IL)-6 and the chemokines, regulated on activation normal T cell expressed and secreted (RANTES) and monocyte chemoattractant protein (MCP)-1 were inversely correlated with the maximal changes in serum levels of T3. Conclusion: Our findings in this randomized trial do not support a role for hypothermia as a major cause of altered thyroxin responses in children undergoing CPB. Our finding may also suggest that in addition to IL-6, other inflammatory cytokines such as chemokines should be further investigated for their possible influence on the thyroid axis during CPB. Keywords: CPB; Thyroid hormones; Pediatric; Congenital heart disease; Hypothermia; Inflammatory mediators

Surgical closure of big pulmonary artery-left atrial fistula [Congenital]

Margaryan, R., Arcieri, L., Cantinotti, M., Murzi, B. — Mon, 12 Oct 2009 05:02:28 PDT

Big pulmonary artery-left atrial fistula malformation (PALAF) was diagnosed in a 5-year-old boy. Although transcatheter therapy would be preferred as a treatment of PALAF, the lesion, which was 20 mm in diameter and almost totally shunting the right main pulmonary artery, it was decided to treat by surgical approach. Keywords: Congenital heart disease; Pulmonary artery malformations; Pulmonary artery fistula

Three strikes - don't die of a broken heart [Aortic and aneurysmal (ICVTS only)]

Field, M. L., Sastry, P., Richens, D. — Thu, 08 Oct 2009 06:38:23 PDT

There are multiple layers of complexity in prevention of vehicle related blunt traumatic aortic rupture (BTAR), many of which are enshrined within government policy and car design. We present a 'layers of protection analysis' (LOPA) based loosely on original work by Professor John Doyle, which describes these attempts to 'design out' the risk of BTAR following a vehicle collision. We have modified this approach to include a physiological dimension suggesting that this may be a factor in susceptibility to aortic injury following trauma. Understanding processes involved in BTAR following vehicle collisions is key to designing preventative processes. Keywords: Trauma; Aorta; Layers of protection

Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up [Coronary]

Thu, 08 Oct 2009 05:45:52 PDT

Transfusion of red blood cells (RBC) and other blood products in patients undergoing coronary artery bypass grafting (CABG) is associated with increased mortality and morbidity. We retrospectively analyzed data of patients who underwent an isolated coronary bypass graft operation between January 1998 and December 2007. Mean follow-up was 1696±1026 days, with exclusion of 122 patients lost to follow-up and 80 patients who received more than 10 units of RBC. Of the remaining patients, 8001 (76.7%) received no RBC, 1621 (15.2%) received 1-2 units of RBC, 593 (5.7%) received 3-5 units and 220 (2.1%) received 6-10 units. The number of transfused RBC was a predictor for early but not for late mortality. When compared to expected survival, survival of patients not receiving any blood product was better, while survival of patients receiving more than 3 units of red blood cells was worse. Transfusion of RBC is an independent, dose-dependent risk factor for early mortality after revascularization. Compared to expected survival, receiving no RBC improves patient long-term survival, whereas receiving three or more units of RBC significantly decreases patient survival. Keywords: Revascularization; Blood cells; Survival; Epidemiology; Coronary disease

Surgical management of right coronary artery-coronary sinus fistula causing severe mitral and tricuspid regurgitation [Cardiac general]

El-Watidy, A. M., Ismail, H. H., Calafiore, A. M. — Thu, 08 Oct 2009 00:04:57 PDT

Coronary arteriovenous (AV) fistula is rare congenital anomaly, mostly diagnosed incidentally during routine coronary angiography. We report a symptomatic patient with right coronary artery to coronary sinus (RCA-CS) fistula, complicated by aneurysmal dilatation and thrombosis of the CS, causing severe mitral regurgitation (MR) and tricuspid regurgitation (TR). Keywords: Coronary sinus thrombosis; Coronary arteriovenous fistula; Giant coronary sinus

Warm, beating heart aortic valve replacement in a sickle cell patient [Valves]

Usman, S., Saiful, F. B., DiNatale, J., McGinn, J. T. — Tue, 06 Oct 2009 00:14:42 PDT

Patients with sickle cell abnormalities undergoing surgery are generally considered to be at greater risk for perioperative complications. We present a 25-year-old woman with sickle cell disease (SCD) and severe aortic insufficiency. A minimally invasive, warm, beating heart approach was adopted to try and minimize the risk of sickling due to cardiopulmonary bypass (CPB), low-flow states, cold cardioplegia and aortic cross-clamping. Compared to classical methods, we believe our technique further reduces the risk of systemic and organ hypothermia and thus, sickling. Keywords: Extracorporeal circulation; Minimally invasive surgery; Sickle cell; Valve disease

Excellent functional result in children after correction of anomalous origin of left coronary artery from the pulmonary artery - a population-based complete follow-up study [Congenital]

Ojala, T., Salminen, J., Happonen, J.-M., Pihkala, J., Jokinen, E., Sairanen, H. — Tue, 06 Oct 2009 00:53:04 PDT

Surgical strategy to construct a two-coronary system for a patient with anomalous origin of coronary artery from pulmonary artery (ALCAPA) has evolved with time. Limited long-term follow-up data are available on these children. We report population based follow-up in children operated on for ALCAPA. In total, 29 patients underwent aortic reimplantation of ALCAPA between 1979 and 2006. Twenty (69%) children were repaired with direct aortic implantation, five (17%) with a modified tubular extension technique, and four (14%) patients with an intrapulmonary baffling technique. Early postoperative mortality (<30 days) was 17%. No late mortality (>30 days) was detected. The median length of follow-up was 11 years (range 10 months-27 years). Global left ventricular function by echocardiography (M-mode) was within normal limits (>30%) in all patients one year after operation. Functionally, 80% of patients were classified in class NYHA I, 20% in NYHA II, and 0% in NYHA classes III/IV at the time of the last examination. Excellent results with good long-term outcome can be achieved in infants with ALCAPA using reimplantation techniques. Normalization of cardiac function is expected within the first year in all operative survivors with a patent coronary system. Keywords: ALCAPA; Child; Coronary; Follow-up; Population-based

Stented within a stentless aortic valve. A simple surgical solution for the replacement of a stentless aortic bioprosthesis [Valves]

Panagiotou, M. S., Kogerakis, N. E., Crockett, J. R., Economidou, S. V. — Mon, 05 Oct 2009 09:21:00 PDT

Stentless aortic bioprostheses are designed to offer better hemodynamics, less mechanical stress to the leaflets and as a result less degeneration. Although encouraging results are reported, little evidence has been published regarding reoperations of stentless valves. We are reporting a case of a structural valve dysfunction of an O'Brien-Angell stentless prosthesis, which could not be extracted during reoperation without damaging the aortic root. We are presenting a simple, quick and effective surgical solution, the surgical 'valve within a valve' technique for the avoidance of a redo complex root procedure. Keywords: Aortic valve surgery; Valve disease; Stentless valve

Isolated rib metastases from renal cell carcinoma [Thoracic oncologic]

Mon, 05 Oct 2009 08:49:14 PDT

Osseous metastases of renal cell carcinoma (RCC) are the second more frequent location after lung metastases. They rarely present as isolated location. When isolated, resection may offer five-year survival rates of 30-60%. The purpose of the current study is to focus on a particular subset, the isolated rib metastases (IRM). The files of six patients who underwent radical resection for IRM were reviewed. All had previous radical nephrectomy for clear-cell renal cancer. The mean age of these six men was 55.3 years. Preoperative evaluation included in all patients a conventional chest radiograph and thoracic computed tomography (CT) scanning. Chest wall resections were wide and curative. The mean disease-free interval (DFI) after renal cancer treatment was 25 months. There was no postoperative death. Two patients had synchronous disease. One of them developed two recurrences operated on by large resections. They survived for 77 and 81 months. The overall five and ten-year survival rates were respectively 83 and 66.7%. IRM of RCC are rare and remain not well-known. Surgical wide resection is a safe and effective treatment. Keywords: Chest wall; Thoracic duct; Cancer; Kidney; Osseous metastasis; Renal cancer; Metastasectomy

Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety [Cardiac general]

Papaspyros, S. C., Javangula, K. C., Adluri, R. K. P., O'Regan, D. J. — Fri, 02 Oct 2009 02:01:50 PDT

Error in health services delivery has long been recognised as significant cause of inpatient morbidity and mortality. Root-cause analyses have cited communication failure as one of the contributing factors in adverse events. The formalised fighter pilot mission brief and debrief formed the basis of the National Aeronautics and Space Administration (NASA) crew resource management (CRM) concept produced in 1979. This is a qualitative analysis of our experience with the briefing-debriefing process applied to cardiac theatres. We instituted a policy of formal operating room (OR) briefing and debriefing in all cardiac theatre sessions. The first 118 cases were reviewed. A trouble-free operation was noted in only 28 (23.7%) cases. We experienced multiple problems in 38 (32.2%) cases. A gap was identified in the second order problem solving in relation to instrument repair and maintenance. Theatre team members were interviewed and their comments were subjected to qualitative analysis. The collaborative feeling is that communication has improved. The health industry may benefit from embracing the briefing-debriefing technique as an adjunct to continuous improvement through reflective learning, deliberate practice and immediate feedback. This may be the initial step toward a substantive and sustainable organizational transformation. Keywords: Briefing-debriefing; Crew resource management; Communication; Patient safety; Team attitude

Tracheobronchomalacia treated by inserting a long T-tube into the left main bronchus [Thoracic non-oncologic]

Goto, T., Oyamada, Y., Wakaki, M., Kato, R. — Fri, 02 Oct 2009 01:06:40 PDT

An 88-year-old woman with advanced Parkinson's disease (stage V on the Yahr scale) had difficulty in expectoration and underwent tracheostomy in 1999. In July 2004, granulation tissue was formed in the tracheal lumen at the tip of the tracheostomy tube, and a standard type silicone T-tube was inserted. Thereafter, she was cared for at home, where she was doing well until early March 2009, when a decrease in SaO₂ and difficulty in sputum aspiration were noted. Bronchoscopy showed crescent type tracheobronchomalacia involving the trachea down to the orifice of the left main bronchus. Considering its localization, an intact right main bronchus, a history of tracheostomy tube placement resulting in granulation tissue formation in the lower trachea, and the future need for frequent sputum aspiration, we inserted a long T-tube into the left main bronchus, which is easily replaceable and facilitates sputum aspiration. Right-lung ventilation was maintained through a side aperture made in the long T-tube. After its insertion, her respiratory status stabilized, secretion drainage improved, and she was discharged for treatment at home. Herein, we describe a tracheobronchomalacia patient in whom airway patency was achieved by inserting a long T-tube with a side aperture into the left main bronchus. Keywords: Tracheobronchomalacia; Airway stenosis; T-tube; Bronchoscopy

Clinical usefulness of {alpha}-crystallin antibodies in non-small cell lung cancer patients [Thoracic oncologic]

Cherneva, R., Petrov, D., Georgiev, O., Trifonova, N. — Thu, 01 Oct 2009 10:19:33 PDT

The non-invasive approach of finding biomarkers in peripheral blood of cancer patients makes it useful for clinical application and cancer screening. The aim of the study was to explore the clinical utility of -crystallin antibodies as markers for diagnosis of non-small cell lung cancer (NSCLC) and screening among high-risk groups. -Crystallin antibodies were detected with enzyme-linked immunosorbent assay (ELISA) in 51 NSCLC patients, 38 high-risk chronic obstructive pulmonary disease (COPD) patients and 52 age and sex matched healthy volunteers. -Crystallin IgG antibodies differed significantly between the groups of cancer patients and the healthy volunteers (p<0.001). A cut-off value of 0.317 discerned NSCLC patients with sensitivity 62% and specificity 72% among the control group. The assay was effective in distinguishing the patients with and without lymphogenic metastatic spread of the disease (p=0.045) - sensitivity 60% and specificity 70%. The clinical significance of this marker has a modest implication in lung cancer diagnosis and screening in high-risk groups. Its importance as a prognostic marker or a marker of disease recurrence and lymph node micrometastasis should be further explored. Keywords: -Crystallin antibodies; Non-small cell lung cancer; Biomarker; Lymph node metastasis

Repair of spontaneous right ventricular rupture following sternal dehiscence. A novel technique [Cardiac general]

Efthymiou, C. A., Kay, P. H., Nair, U. R. — Thu, 01 Oct 2009 08:29:29 PDT

Spontaneous rupture of the right ventricle during the early postoperative period is a serious and potentially lethal complication. The inherent friability of the ventricular tissue makes repair difficult since myocardium is frequently weakened by infarction, mediastinitis or trauma caused by an unstable sternum or broken sternal wires. We present a novel yet simple technique for repairing the ruptured anterior wall of the right ventricle in a patient three weeks following coronary artery bypass surgery. Keywords: Ventricle rupture; Trauma; Repair

Heart transplantation using bivalirudin as anticoagulant [Transplantation]

Simsir, S. A., Schwarz, E. R., Czer, L. S.C., Hamburg, S. I. — Thu, 01 Oct 2009 08:09:53 PDT

We present the case of a man with heparin-induced thrombocytopenia (HIT) and acute idiopathic decompensated cardiomyopathy who underwent successful heart transplantation with the use of bivalirudin as anticoagulant. Keywords: Transplantation; Heart; Adult

Effect of 5-azacytidine induction duration on differentiation of human first-trimester fetal mesenchymal stem cells towards cardiomyocyte-like cells [Experimental]

Zhang, Y., Chu, Y., Shen, W., Dou, Z. — Mon, 28 Sep 2009 00:18:41 PDT

The aim of this study is to investigate effects of 5-azacytidine (5-aza) induction duration on differentiation of bone marrow mesenchymal stem cells (MSCs) from human first-trimester abortus (hfMSCs) towards cardiomyocyte-like cells. hfMSCs were stimulated with 10 µmol/l 5-aza for 24 h (group A), 48 h (group B) and 21 days (group C) respectively. During the induction, 30-40% of the cells gradually enlarged, elongated, connected with adjoining cells and formed myotube-like structures, branches and string-bead-like nuclei. Some of the cells congregated into cell clusters or strips. After the induction, numerous myofilaments in the cytoplasm and conjunction of intercalated disc-like structure between adjoining cells were observed. The induced cells expressed mRNAs and proteins of myocardium-specific -actin, sarcomeric β-myocin heavy chain and troponin-T. The positive cell percentages for the three antigens in group C were each significantly higher than those antigens in group A and B (p<0.01) and the cell population doubling time (PDT) of group C was longer than those of group A and B (p<0.01). These indicate that 21-d induction with 10 µmol/l 5-aza slows down proliferation speed of hfMSCs but increases differentiation rate of hfMSCs into cardiomyocyte-like cells if compared with 24-48 h induction. Keywords: Mesenchymal stem cells; Cardiomyocytes; 5-azacytidine; Human first-trimester abortus

Surgical treatment of a rare case of tracheal inflammatory pseudotumor in pediatric age [Thoracic oncologic]

De Palma, A., Loizzi, D., Sollitto, F., Loizzi, M. — Fri, 25 Sep 2009 06:20:17 PDT

Tracheal inflammatory pseudotumor (IPT) is a rare solid lesion with an unpredictable biological course. Treatment can vary and surgical resection may sometimes be necessary, even in pediatric age. We report the case of a 12-year-old male patient who presented to our institution with sudden dyspnoea after some months of wheezing and cough, wrongly considered and treated as asthma. Neck-chest CT-scan and fiberbronchoscopy showed an intraluminal tracheal mass, originating from the left antero-lateral wall at the level of the fifth cartilagineous tracheal ring, involving three rings, that was removed by rigid bronchoscopy. Histopathology revealed a tracheal IPT. Due to rapid tendency to recurrence of the lesion, two more endoscopic recanalizations were performed, but a new recurrence appeared, with CT evidence of transmural involvement of the tracheal wall. Resection of the three involved tracheal rings and termino-terminal tracheal anastomosis were successfully performed through cervicotomy and sternal split. CT-scan and fiberbronchoscopy at seventeen months from surgery show a stable tracheal lumen without signs of recurrence. A tracheal IPT should be suspected in any pediatric patients with tracheal mass and asthmatic symptoms. After radical removal prognosis is generally excellent and recurrences after tracheal resection are rare. Keywords: Tracheal inflammatory pseudotumor; Pediatric age; Surgical resection

Crutch-induced bilateral brachial artery aneurysms [Vascular general (ICVTS only)]

Konishi, T., Ohki, S.-i., Saito, T., Misawa, Y. — Fri, 25 Sep 2009 02:31:46 PDT

A 57-year-old man, who was a chronic axillary crutch user as a result of childhood poliomyelitis, was referred to our hospital because of a sudden onset of right forearm ischemia. The right forearm had no pulse, and three-dimensional computed tomography (3DCT) showed an aneurysm of the right brachial artery associated with arterial occlusion. The thrombosed aneurysm of the brachial artery was resected and the brachial artery was successfully revascularized by interposing a saphenous vein graft. Postoperative 3DCT revealed an asymptomatic left brachial artery aneurysm. His postoperative course was uneventful under warfarin anticoagulation therapy. Keywords: Axillary crutch; Brachial artery aneurysm; Saphenous vein graft; Brachial artery thrombosis; Forearm ischemia

Graft fixation with a side graft holder for sequential and composite graft anastomosis in coronary artery bypass surgery [Coronary]

Shimamura, Y., Hayashi, I. — Fri, 25 Sep 2009 00:09:16 PDT

The purpose of this study was to assess the feasibility and effectiveness of graft fixation with a novel side graft holder for sequential or composite graft anastomosis in coronary artery bypass grafting (CABG). Records of 34 patients who underwent CABG using sequential or composite graft anastomosis technique were reviewed. The device was used on 47 anastomoses (sequential=43; composite graft=4). Excellent fixation and visualization of the graft was obtained in all patients without graft injury. Postoperative angiographic patency rate of distal anastomoses was 95.2% (arterial, 91.2%; venous, 96.7%). All sequential and composite graft anastomoses were patent and without stenosis. One operative death occurred due to low cardiac output after emergent CABG for acute myocardial infarction. No elective patient died during hospitalization. Postoperative complications occurred in 2 patients (ventricular fibrillation, 1; postoperative catheter intervention, 1). No perioperative myocardial infarctions or re-operations occurred. Our clinical experience shows that graft fixation with the device is safe, reliable, and effective for sequential and composite graft anastomosis during CABG. Keywords: Coronary artery bypass grafting; Anastomosis; Surgical instruments

Heparin induced thrombocytopenia in a patient with factor V Leiden following cardiac surgery [Vascular general (ICVTS only)]

Chaubey, S., Davidson, S., Desouza, A. — Fri, 25 Sep 2009 03:09:12 PDT

We report a patient who died as a result of heparin induced thrombocytopenia (HIT) and arterial thromboses following cardiac surgery. The onset was three days after exposure to low molecular weight heparin on the eighth postoperative day. The patient was heterozygous for the factor V Leiden mutation. We have reviewed 15 patients previously diagnosed as HIT on clinical and laboratory criteria and found an incidence of 6.7% (1/15) activated protein C resistance. This second patient had a pulmonary embolus and HIT after only three days exposure to low molecular weight heparin. We postulate that factor V Leiden hastens the onset and magnifies the severity of HIT. Keywords: Heparin induced thrombocytopenia; Factor V Leiden; Complication

Which patient undergoing mitral valve surgery should also have the tricuspid repair? [Valves]

Bianchi, G., Solinas, M., Bevilacqua, S., Glauber, M. — Thu, 24 Sep 2009 07:39:26 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Which patient undergoing mitral valve surgery should also have the tricuspid repair?' Altogether 390 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. While a general agreement exists for tricuspid valve (TV) repair in cases of severe regurgitation and concomitant multivalvular disease requiring surgical intervention, current guidelines provide more vague indications for patients with less severe tricuspid regurgitation (TR). Since this condition has a lower event-free survival rate and the prognosis after symptoms development is dismal, a lower threshold and a more aggressive strategy for intervention is needed. In rheumatic valve disease, mitral valve involvement and disease spreading to TV may be responsible for further regurgitation. Although patients with pulmonary hypertension (PH) may benefit from mitral valve replacement (MVR) or balloon valvotomy, many studies found that preoperative PH does not predict late TR. However, patients with high pulmonary pressure have a lower occurrence of late TR. Tricuspid annular dilation is probably the most important factor for late TR. Once established, it might be irreversible even after resolution of PH as well as absence of 'reverse remodelling'. It has been proposed to treat TR independently from the grade of regurgitation when the annular dimension is over 21 mm/m² or ≥3.5 cm at echo measurement or when the intra-operative TA diameter is more than 70 mm. TV repair should be accomplished in patients with preoperative atrial fibrillation (AF), since it may cause late significant TR development and affect the patient's long-term survival. The presence of a trans-tricuspid pacemaker lead is another known factor for late TR development secondary to adhesions and fibrous retraction. TV repair is probably better than replacement in non-severe organic TV disease. Annuloplasty ring repair has better outcome compared with non-ring based repair techniques; the beneficial effect is also independent of the type of mitral valve surgery performed. Keywords: Left-sided valve surgery; Tricuspid valve repair; Outcome

Can stunned hearts be resuscitated? Evaluation of aspartate/glutamate secondary blood cardioplegia using magnetic resonance spectroscopy [Experimental]

Ghomeshi, H. R., Sun, J., Tian, G., Panos, A., Deslauriers, R., Salerno, T. A. — Thu, 24 Sep 2009 04:23:33 PDT

Objectives: Reperfusion of ischemic hearts with warm, substrate-enriched, blood cardioplegia may alleviate post-ischemic metabolic and functional derangements. This study investigates this possibility using ³¹P magnetic resonance (MR) spectroscopy. Methods: Fifteen blood-perfused Langendorff pig hearts were subjected to 30 min of total, normothermic ischemia. Control hearts (n=8) were reperfused with blood for 40 min. Experimental hearts (n=7) received 20 min of aspartate/glutamate (asp/glu) enriched blood cardioplegic solution, followed by 20 min of normal blood. ³¹P MR spectroscopy was used to observe cellular energetics and intracellular pH (pHi) throughout the experiments. Left-ventricular function and myocardial oxygen consumption were evaluated before and after ischemia. Results: MR spectra showed no improvement in the rate or extent of high-energy phosphate recovery with asp/glu cardioplegia, but showed a transient increase in pHi during cardioplegic reperfusion (p<0.05). This, however, did not affect post-ischemic recovery of high energy metabolites, myocardial function or oxygen consumption. Conclusions: This study raises questions regarding the potential beneficial effects of asp/glu enriched secondary cardioplegic solution on functional or metabolic status of stunned pig hearts. Extrapolation of these results to humans should be viewed with caution. Keywords: Magnetic resonance; Pig heart; Aspartate; Glutamate; Cardioplegia; Myocardial stunning

Controlled antegrade single lung reperfusion during double lung transplant [Pulmonary]

Khalpey, Z., Gilfeather, M., Camp, P. C., Jaklitsch, M. T. — Wed, 23 Sep 2009 06:19:18 PDT

Prompt controlled reperfusion of a pulmonary allograft in a sequential double lung transplant may correct cellular ischemia prior to exposure to full hydrostatic pressures and minimize organ dysfunction. We reviewed the process of a sequential double lung transplant and describe the technique of controlled antegrade graft reperfusion of the initial implant as performed at our institution. Keywords: Lung allograft; Antegrade perfusion; Lung transplant; In-vivo perfusion

Myocyte injury along myofibers in left ventricular remodeling after myocardial infarction [Cardiac general]

Wed, 23 Sep 2009 04:22:09 PDT

Left ventricular (LV) remodeling following myocardial infarction (MI) is considered to contribute to cardiac dysfunction. Though myofiber organization is a key component of cardiac structure, functional and anatomical features of injured myofiber during LV remodeling have not been fully defined. We investigated myocyte injury after acute MI in a mouse model. Mice were subjected to surgical coronary occlusion/reperfusion by left anterior descending coronary artery (LAD) ligation and examined at 1 week and 4 weeks post-MI. Magnetic resonance imaging (MRI) analysis demonstrated a significant decrease in systolic regional wall thickening (WT) in the border and remote zones at 4 weeks post-MI compared to that at 1 week post-MI (-86% in border zone, p<0.05, and -77% in the remote zone, p<0.05). Histological assays demonstrated that a broad fibrotic scar extended from the initial infarct zone to the remote zone along mid-circumferential myofibers. Of particular note was the fact that no fibrosis was found in longitudinal myofibers in the epi- and endo-myocardium. This pattern of the scar formation coincided with the helical ventricular myocardial band (HVMB) model, introduced by Torrent-Guasp. MRI analysis demonstrated that the extension of the fibrotic scar along the band might account for the progression in cardiac dysfunction during LV remodeling. Keywords: Muscle fibers; Ventricular function; Ventricular remodeling; Animals

Air-leak management after upper lobectomy in patients with fused fissure and chronic obstructive pulmonary disease: a pilot trial comparing sealant and standard treatment [Thoracic non-oncologic]

Wed, 23 Sep 2009 00:51:58 PDT

A pilot trial to compare the efficacy of two different procedures to prevent postoperative air-leak in chronic obstructive pulmonary disease (COPD) patients submitted to upper lobectomy for non-small cell lung cancer. Sixty patients with COPD and lung cancer at the upper pulmonary lobes eligible for lobectomy were enrolled and randomly assigned either to standard treatment (ST) with stapling device or to electrocautery dissection and application of a collagen patch coated with human fibrinogen and thrombin (TachoSil®) (experimental treatment (ET)) for the intra-operative completion of their fused fissures. Thirty patients were enrolled in each group during a 3-year period. Preoperative characteristics were similar between the two groups. Statistically significant reduction of air-leak was registered in the ET group when overall incidence of postoperative air-leak (55% vs 96%; P=0.03), postoperative air-leak (mean 1.63±1.96 vs 4.33±4.12 days; P=0.0018), chest drain (mean 3.53±1.59 vs 5.90±3.72 days; P=0.0021) and hospital stay duration (mean 5.87±1.07 vs 7.50±3.20 days; P=0.01) were considered. The use of TachoSil® to prevent postoperative air-leak after interlobar fissure completion in patients with COPD submitted to upper lobectomy seems to be safe and more effective than the standard treatment based on stapling device application. Keywords: Pulmonary lobectomy; Lung tissue sealing; COPD; Stapling devices

The hemiclamshell approach in thoracic surgery: indications and associated morbidity in 50 patients [Thoracic oncologic]

Tue, 22 Sep 2009 07:19:44 PDT

This retrospective study was carried out to evaluate the indications for and outcomes of the hemiclamshell (HCS) approach (longitudinal partial sternotomy with antero-lateral thoracotomy) in patients undergoing mass resection in thoracic surgery. All patients (50) who underwent a HCS procedure in our department, between July 1996 and July 2005, were studied retrospectively, analyzing the indications, morbidity and outcome (pain, neurological or shoulder defects, mortality) at 1 month and 1 year. The main indications were apical tumours (38%), tumours of the cervicothoracic junction (46%) and chest wall (10%), and 'bulky' tumours (6%). One-month mortality was 6%. Two patients suffered from a chylothorax and one from phrenic paralysis. The postoperative analgesic requirements were similar to those after other thoracic surgery approaches. Twelve percent of patients suffered pain at 1 month and 6% at 1 year. Shoulder dysfunction was observed in 10% of patients at 1 month and 6% at 1 year. In conclusion, the HCS surgical approach was associated with an uncomplicated postoperative course. This anterior approach is suitable for apical tumours, tumours of the cervicothoracic junction and 'bulky' lung tumours, providing good access for control of the large vessels and radical mediastinal clearance. Keywords: Cervico-sterno-thoracotomy; Cervicothoracic region; Hemiclamshell; Post-surgical complications; Thoracic surgery; Tumour resection

Primary synovial sarcoma of the lung as an incidental finding [Thoracic oncologic]

Watzka, S. B., Setinek, U., Prosch, H., Mueller, M. R. — Tue, 22 Sep 2009 05:05:21 PDT

Synovial sarcoma of the lung (SSL) is a very rare, but aggressive primary lung tumor. Due to its unusual histological features, it can easily be misdiagnosed, if only small biopsies of the tumor are investigated. Here we review two recent cases of SSL diagnosed and treated in our institution. The first case is a 37-year-old male with a round nodule in the right lower lobe; he underwent a lobectomy. Histologically, the nodule resembled a biphasic tumor. Cytogenetic analysis revealed a translocation t (X; 18), and the diagnosis of primary SSL could be established. The patient is alive and disease-free since 45 months following surgery. The second case is a 41-year-old male with a cystic lesion in the right lower lobe, removed by video-assisted thoracic surgery (VATS) segmentectomy. In the tumor tissue, spindle cell-rich and cystic structures could be found, together with epithelial elements. Because the tumor contained also a translocation t (X; 18), it could be diagnosed as monophasic SSL. The patient is alive and disease-free since 11 months. Since rare diseases of the lung may present as subtle and focal changes, complete removal of suspect pulmonary lesions is always advisable. Keywords: Lung; Neoplastic disease; Mesenchymal tumor; Histology; Chromosomal translocation

Cardiac stunning in the clinic: the full picture [Cardiac general]

Tue, 22 Sep 2009 00:17:41 PDT

Cardiac stunning refers to different dysfunctional levels occurring after an episode of acute ischaemia, despite blood flow is near normal or normal. The phenomenon was initially identified in animal models, where it has been very well characterized. After being established in the experimental setting, it remained unclear, whether a similar syndrome occurs in humans. In addition, it remained controversial, whether stunning was of any clinical relevance as it is spontaneously reversible. Hence, many studies continue to focus on the properties and mechanisms of stunning, although therapies seem more relevant for attenuating and treating myocardial ischemia/reperfusion (I/R) injury, i.e. to bridge until recovery. This article reviews the different facets of cardiac stunning, i.e. myocardial, vascular/microvascular/endothelial, metabolic, neural/neuronal, and electrical stunning. This review also displays where these facets exist and which clinical relevance they might have. Particular attention is directed to the different therapeutic interventions that the various facets of this I/R-induced cardiac injury might require. A final outlook displays possible alternatives to further reduce the detrimental consequences of brief episodes of ischaemia and reperfusion. Keywords: Myocardial; Electrical; Metabolic; Neural; Vascular; Endothelial stunning

Concurrent benign schwannoma of oesophagus and posterior mediastinum [Thoracic oncologic]

Dutta, R., Kumar, A., Jindal, T., Tanveer, N. — Mon, 21 Sep 2009 06:14:57 PDT

A 52-year-old female with recent onset dysphagia and haematemesis was found to have an intramural tumour of the oesophagus. A separate tumour in the posterior mediastinum was also detected. Both the tumours were immunohistochemically and histomorphologically compatible with benign schwannoma. Oesophageal schwannoma is extremely rare and its association with a concurrent schwannoma in posterior mediastinum is not reported earlier in the literature. Keywords: Schwannoma; Oesophagus; Posterior mediastinum; Dysphagia

Early outcomes of video-assisted thoracoscopic resection of thymus in 181 patients with myasthenia gravis: who are the candidates for the next morning discharge? [Thoracic non-oncologic]

Mon, 21 Sep 2009 05:59:46 PDT

The aims of this study are to present the results of videothoracoscopic thymectomy in patients with myasthenia gravis (MG) and to predict the factors affecting the next morning discharge (NMD). This is a retrospective analysis of the prospectively recorded data of 181 consecutive myasthenic patients who underwent videothoracoscopic thymectomy from June 2002 to September 2009. Sixty-one patients (33.7%) were discharged on the next morning. Univariate and multivariate analyses were evaluated to determine the predictors for NMD. Mean calculated variables were: age (29.8 years), duration of symptoms (22.5 months), duration of surgery (51.3 min), postoperative stay (2.1) days, and visual analogue scale (2.1). No mortality occurred. Four patients were required to stay in intensive care unit (ICU) with a mean of 18.6 h. With logistic regression analysis, duration of operation (DoO) was calculated to be the only predictive factor for next morning discharge (p=0.006). Video-assisted thoracoscopic thymectomy (VAT thymectomy) is a safe surgery procedure with a smooth postoperative period for MG. Although a detailed analysis was performed, only DoO was found to be a predictive factor for next morning discharge in MG patients. Keywords: Thoracoscopic thymectomy; Myasthenia gravis; Discharge

A technique of an upper V-type ministernotomy in the second intercostal space [Cardiac general]

Karimov, J. H., Santarelli, F., Murzi, M., Glauber, M. — Mon, 21 Sep 2009 04:38:52 PDT

Since cardiac surgeons found themselves able to offer a less invasive access to heart and great vessels, one of the first techniques to satisfy the tendency of minimizing the surgical trauma during general cardiac surgical procedure was a ministernotomy. In the current paper, we present the technique of V-type ministernotomy in the 2nd intercostal space, which has been employed in our department from June 2007 in 85 consecutive patients (mean age: 58±18 years); those operations consisted of the aortic valve replacement (AVR), surgery of the ascending aorta and epiaortic arterial segment. Keywords: Ministernotomy; Minimally invasive; Aortic valve; Ascending aorta; Debranching

In patients with first-episode primary spontaneous pneumothorax is video-assisted thoracoscopic surgery superior to tube thoracostomy alone in terms of time to resolution of pneumothorax and incidence of recurrence? [Thoracic non-oncologic]

Chambers, A., Scarci, M. — Mon, 21 Sep 2009 01:11:05 PDT

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether video-assisted thoracoscopic surgery (VATS) was justifiable for first-episode primary spontaneous pneumothorax (PSP). Altogether more than 183 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATS has superior outcomes in terms of recurrence rates of pneumothorax (from 0 to 13% according to several studies for VATS vs. 22.8 to 42% for tube thoracostomy alone), duration of chest tube drainage (4.56 vs. 7.6 days) and mean hospital stay (from 2.4 to 7.8 days vs. 6 to 12 days for chest tube drainage) with first-episode PSP compared with conservative treatment. Additionally, even if VATS is associated with an average increased cost of $408, this is mitigated by the reduced length of stay and decreased pneumothorax recurrence, both resulting in a reduction of cost of 42% compared to conservative approach. These findings were not replicated in an article considering primary VATS (PV) vs. secondary VATS (SV) as the best treatment modality for PSP in children. Although the total treatment length of stay was significantly shorter for PV vs. SV (7.1±0.96 vs. 10.5±1.2, P=0.04), morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs. 0/20, P<0.05). In this article the observed recurrence rate was 54%. Performing PV on all patients with PSP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach, therefore, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with SP. Instead, secondary treatment is recommended. Lastly, two articles also examined the rate of recurrence of VATS compared to open thoracotomy (OT). The range was from 0 to 7.7% for OT vs. 10.3 to 13% for VATS, a non-statistical difference. Keywords: Thoracic surgery; Video-assisted; VATS; Primary spontaneous pneumothorax; First-episode pneumothorax

Splenic tear causing a hemoperitoneum after cardiac surgery [Cardiac general]

Ceresa, F., Francio, G., Intili, P. A., Patane, F. — Mon, 21 Sep 2009 00:07:34 PDT

Hemoperitoneum after cardiac surgery is a very rare but life-threatening complication. We have only found a few cases described in the literature, in which the intra-abdominal hemorrhages were caused by liver bleeding, due to direct hepatic trauma or spontaneous hepatic rupture. We describe the first case of hemoperitoneum caused by a spontaneous rupture of the spleen. Keywords: Hemoperitoneum; Cardiopulmonary bypass; Cardiac surgery

Up to twenty-five-year survival after aortic valve replacement with size 19 mm valves [Valves]

Mon, 21 Sep 2009 00:44:34 PDT

Long-term survival was investigated in 202 patients that underwent isolated aortic valve replacement (AVR) with 19 mm valves. There were 171 women with a mean age of 69±9 and 31 men with a mean age of 64±13 years. Patients had a mean body surface area of 1.61±0.13 m². Patient-prosthesis mismatch was moderate in 196 and severe in 6 patients. The mean follow-up for all patients was 78 months. There were 79 late deaths. The actuarial survival rates for all patients were 95±1% at 1 year, 75±2% at 5 years, 56±2% at 10 years, 41±2% at 15 years, 34±3% at 20 years and 34±2% at 25 years. Patients over 70 years old had a lower survival rate (p=0.0001). There were significant differences between ejection fraction (EF) >55% and EF <55% (p=0.0305). AVR with 19 mm valves appeared to provide satisfactory mid-term survival. Age and low EF were risk factors for shorter survival. Keywords: Mid-term survival; Patient-prosthesis mismatch; Small aortic prosthesis

Can chronic neuropathic pain following thoracic surgery be predicted during the post-operative period? [Thoracic oncologic]

Searle, R. D., Simpson, M. P., Simpson, K. H., Milton, R., Bennett, M. I. — Fri, 18 Sep 2009 08:54:37 PDT

Chronic pain following thoracic surgery is common and associated with neuropathic symptoms, however the proportion of patients with neuropathic pain in the immediate postoperative period is unknown. We aimed to determine the proportion of patients who have neuropathic symptoms and signs immediately after, and at 3 months following thoracic surgery. The study was designed as a prospective observational cohort study. We identified patients with pain of predominantly neuropathic origin using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) score in the immediate postoperative period and the self-report LANSS (S-LANSS) version 3 months after surgery. 100 patients undergoing video assisted thoracic surgery (VATS) or thoracotomy completed LANSS scores preoperatively and in the immediate postoperative period. 87% completed 3-month S-LANSS follow-up scores. 8% of patients had positive LANSS scores in the immediate postoperative period; 22% of patients had positive S-LANSS scores 3 months following surgery. There was a significant association between positive scores in the acute and chronic periods (relative risk (RR) 3.5, [95% confidence interval (CI) 1.7-7.2]). Identifying pain of predominantly neuropathic origin in the postoperative period with a simple pain score can help identify those at risk of developing chronic pain with these features following thoracic surgery. Keywords: Acute neuropathic pain; Chronic post-surgical pain; LANSS; Thoracotomy; Thoracic surgery

Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results [Aortic and aneurysmal (ICVTS only)]

Da Rocha, M., Zarka, Z. A., Riambau, V. — Fri, 18 Sep 2009 05:10:40 PDT

Endovascular correction of aorta thoracic pathology in renal transplant patients is a challenge. The aim of this study is to review early and intermediate-term results of endovascular repair of thoracic aorta pathology in patients with functioning previous renal transplant. The records of 81 patients submitted to a thoracic endograft between 2003 and 2008 were reviewed. Five patients with six previous renal transplants were submitted to six thoracic endografting. Two were women. The mean age was 55.4 years old (range 43-75 years). There were two patients with type B aortic dissection, one penetrating ulcer, one aneurysm of the aortic arch and one descending thoracic aorta aneurysm. Three patients underwent hybrid procedures: two total supra-aortic transpositions and one partial transposition of visceral trunks. Three patients presented postoperative complications. There were two cases of pneumonia, one acute limb ischemia and a stroke, with an early death. The mean follow-up was 16.2 months (range 1-40 months). In this period all patients sustained renal function without any related complication. Despite the fact that it is a small series, in our clinical experience, endovascular thoracic aortic surgery can be performed as an alternative to open correction, in high-risk patients with a previous working renal transplant. Keywords: Aneurysm; Endovascular; Aortic aneurysm; Renal transplantation; Renal insuffiency; Hybrid surgery

Feasibility of ablation as an alternative to surgical metastasectomy in patients with unresectable sarcoma pulmonary metastases [Thoracic oncologic]

Ding, J. H., Chua, T. C., Glenn, D., Morris, D. L. — Fri, 18 Sep 2009 01:02:47 PDT

Percutaneous radiofrequency ablation (RFA) is an alternate treatment modality for pulmonary metastasis in non-surgical candidates. Four patients not suitable for surgery underwent percutaneous RFA for pulmonary metastases from leiomyosarcoma. Success of RFA was assessed with computed tomography (CT). The median length from the radiographic diagnosis of metastatic pulmonary disease (CT-scan) from the primary tumor diagnosis was 67.0 months with a range of 15.0-81.0 months. The median disease free interval following RFA was 19.0 months with a range of 4.0-35.0 months. Three of four patients underwent the procedure uneventfully. RFA is a safe and minimally invasive intervention in non-surgical candidates with sarcoma pulmonary metastases. Keywords: Leiomyosarcoma; Pulmonary metastases; Radiofrequency ablation; Sarcoma

An observational study of CoSeal(R) for the prevention of adhesions in pediatric cardiac surgery [Congenital]

Fri, 18 Sep 2009 00:22:48 PDT

We sought to evaluate the utility and safety of CoSeal® surgical sealant (Baxter) for the prevention of cardiac adhesions in children. Seven cardiac surgery centers in Europe recruited consecutive pediatric patients requiring primary sternotomy for staged repair of congenital heart defects. Exclusion criteria included immune system disorder, unplanned reoperation, or reoperation within 3 months of primary repair. CoSeal was sprayed onto the surface of the heart at the end of surgery. Evaluation of adhesions took place at first reoperation. Data on safety, duration of surgery, and ease of CoSeal use were also collected. 79 pediatric patients were recruited between February 2005 and September 2007. Of these, 76 underwent major surgery to repair a wide range of congenital heart defects. 36 patients underwent reoperation >3 months after primary repair, and were included in the efficacy analysis. Mean adhesions score was 8.3 (SD 2.4, range 7-16). Six adverse events (5 serious) were possibly/definitely attributed to CoSeal. CoSeal's ease of use at primary operation was graded by surgeons as 12.1 mm (SD 9.8) on a visual analog scale of 0 ('very easy') to 100 mm ('very difficult'). Results of this prospective uncontrolled trial justify further investigation in a randomized, controlled trial. Keywords: Congenital heart defect; Cardiac surgical procedure; Pericardial adhesions; Repeat sternotomy; Surgical sealant; CoSeal®

Peripheral venous embolized intracardiac foreign body [Cardiac general]

Marcello, P., Garcia-Bordes, L., Mendez Lopez, J. M. — Thu, 17 Sep 2009 04:15:39 PDT

Embolized intracardiac foreign bodies have been previously described in the literature. Those related to iatrogenic procedures, such as catheters and pacemakers electrodes, are the most common. However, traumatic embolization of a metal foreign body is scantily described. We report a case of a peripheral venous embolized intracardiac metal foreign body after traumatic elbow injury. A review of the literature is therefore performed. Intracardiac foreign body removal must be considered when its diameter exceeds 5 mm, its shape is irregular or when symptomatic. Keywords: Foreign body; Embolization; Intracardiac; Peripheral vein

Monitoring of atrial fibrillation burden after surgical ablation: relevancy of end-point criteria after radiofrequency ablation treatment of patients with lone atrial fibrillation [Arrhythmia]

Beukema, R., Beukema, W., Sie, H., Ramdat Misier, A., Delnoy, P. P., Elvan, A. — Thu, 17 Sep 2009 04:56:14 PDT

Studies have shown that continuous rhythm monitoring enables the detection of significantly more atrial fibrillation (AF) episodes than routine follow-up of patients, i.e. based on perception of symptoms or on 24-48 h Holter monitoring. The positive outcome of radiofrequency ablation (RFA) may be easily overestimated, especially in patients with paroxysmal AF. 33 consecutive patients, aged 59.4±8.9 years (range 38-75 years) participated in this study. All patients had documented AF episodes with an AF duration of 9.4±7.1 years (range 1.5-25 years). A new monitoring device, the AF-Alarm was used to more accurately assess the outcome after surgical isolation of pulmonary veins. The AF-Alarm was applied for a duration of 128±42.5 h (range 49-191 h) during a period of 8-15 days. The success rate was 87% based on serial electrocardiograms (ECGs) and 24-48 h Holter monitoring during regular outpatient visits. Combination of ECG, Holter and AF-Alarm data yielded a significantly lower success rate, i.e. at the latest follow-up 69% of the patients were free from AF after surgical ablation (P<0.05). Furthermore, the AF-Alarm device demonstrated a dissociation between symptoms and atrial arrhythmic events and confirmed the occurrence of asymptomatic AF episodes. The most important limitation of the AF-Alarm device was noise detection with oversensing and inappropriate detection of non-existing AF episodes in 9% of patients. Long-term follow-up of the patients seems to be essential as success rates of the initial ablation procedure might vary over time. External recorders like the AF-Alarm may be used as an additional tool to document symptomatic and asymptomatic episodes of atrial arrhythmias in the outpatient setting. Keywords: Atrial fibrillation; RF ablation; Monitoring device

Urgent segmental resection as the primary strategy in management of benign tracheal stenosis. A single center experience in 164 consecutive cases [Thoracic non-oncologic]

Tue, 15 Sep 2009 00:22:30 PDT

The report is a retrospective review of 238 benign tracheal stenoses of various etiologies treated between 1995 and 2008. To show that urgent segmental resection has complication rates similar to elective resection and therefore preoperative dilation is not necessary, we analysed records of patients who underwent either standard segmental resections with anterolateral mediastinal tracheal mobilization, single-suture anastomosis and neck flexion; or insertion of T-tube with oval-shaped horizontal arm. Primary segmental resection was performed in 164 patients (68.9%), including 14 cases with concomitant tracheo-esophageal fistula (TEF). T-tube as an initial treatment suited 74 (31.1%) patients. We encountered 2 partial and 1 complete anastomotic disruptions following subglottic resections treated by T-tube insertion and costal cartilage tracheoplasty or permanent tracheostomy. Restenosis rate in segmental resection was 3.1%. No difference in complication rate between urgent and elective segmental resections was experienced. We treated a small number of patients by endotracheal stent insertion but the results were discouraging. Urgent segmental resection without prior rigid bronchoscopy dilation is our strategy of choice whenever possible. As an alternative to dilation we prefer temporary insertion of modified T-tube. Stand-alone endoluminal dilation and stenting has yet to prove its safety and long-term efficacy. Keywords: Tracheal stenosis; Tracheo-esophageal fistula; Stents; Segmental resection; Free costal cartilage graft

Left paraxiphoidian approach for drainage of pericardial effusions [Thoracic oncologic]

Motas, C., Motas, N., Rus, O., Horvat, T. — Tue, 15 Sep 2009 00:01:27 PDT

Pericardial effusion is one of the frequent complications of malignancies, up to 15-20% of the autopsy specimens showing pericardial or cardiac metastasis. Often the pericardial fluid accumulates in large quantities leading to cardiac tamponade, which can be fatal in the absence of appropriate treatment. The authors present another type of pericardial drainage: the approach is paraxiphoidian, not subxiphoidian or with xiphoid resection. Without xiphoid proces resection, the surgery is better tolerated by patients (frequently the drainage is made under local anaesthesia). In the case of xiphoid preservation, the surgical intervention is easier (no need for hard retraction of this bone). In all the five cases with this access, the postoperative results were very good, with complete evacuation of pericardial effusion. In all the cases, the pericardial biopsy performed under visual control was sufficient for a histological diagnosis and the immunohistochemical tests, if required. Keywords: Subxiphoid pericardial window; Cardiac tamponade; Neoplasic pericardial effusion

Syncope triggered by a giant unruptured sinus of Valsalva aneurysm [Cardiac general]

Matteucci, M. L.S., Rescigno, G., Capestro, F., Torracca, L. — Mon, 14 Sep 2009 23:22:47 PDT

Sinus of Valsalva aneurysms are rare anomalies, most often caused by congenital absence of muscular and elastic tissue in the aortic wall of the sinus. The indication for surgical repair is controversial at the time of diagnosis. As well, the repair technique depends on how many sinuses are dilated, whether the aneurysm is ruptured and whether the aneurysm is symptomatic. We report a case of a single unruptured sinus of Valsalva aneurysm of a 54-year-old woman. Keywords: Sinus of Valsalva; Aneurysm; Repair

Lung function evaluation before surgery in lung cancer patients: how are recent advances put into practice? A survey among members of the European Society of Thoracic Surgeons and of the Thoracic Oncology Section of the European Respiratory Society [Thoracic oncologic]

Mon, 14 Sep 2009 07:06:34 PDT

Keywords: Lung cancer; Lung surgery; Guidelines; Survey

Spontaneous circumferential esophageal dissection in a young man with eosinophilic esophagitis [Esophagus]

Quiroga, J., Prim, J. M. G., Moldes, M., Ledo, R. — Mon, 14 Sep 2009 12:21:33 PDT

Spontaneous esophageal dissection is a rare condition that may happen in patients with eosinophilic esophagitis. Conservative management is an important therapeutic option to be considered. We describe an unusual case of a young man with eosinophilic esophagitis who presented complaining of acute retrosternal pain, fever and vomiting. After a thorough evaluation including CT scan and esophagogram, circumferential esophageal dissection and mediastinal abscess without visible perforation was observed. Abscess resolution and oral nutrition reintroduction was achieved with non-surgical management. Corticoid theraphy was iniciated for esophagitis treatment. Keywords: Eosinophilic esophagitis; Esophageal dissection; Mediastinal abscess

Long term follow up after minimal invasive direct coronary artery bypass grafting procedure: a multifactorial retrospective analysis at 1000 patient-years [Cardiac general]

Fri, 04 Sep 2009 01:09:45 PDT

We provide a multi-factorial long-term follow-up following minimal invasive direct coronary artery bypass grafting (MIDCABG) to evaluate the long-term efficacy. From 1996 onwards, 390 patients underwent MIDCABG (follow-up: 30.0±11.2 months). We analyzed peri-operative and postoperative complications (<30 days) and we obtained early and late angiography. Cumulative follow-up was 1000 patient-years. Early postoperative mortality was 0.8% and myocardial infarction occurred in 1.3% of all patients. Early postoperative angiography (<30 days) was obtained in 238 patients (66.3%) and revealed patency in 97.5% (232/238) including 211 (88.6%) who had no stenosis, 13 with a <50% stenosis (5.5%) and 8 with a >50% stenosis (3.4%), but a patent graft. Only six patients had a total occlusion (2.5%). In the long-term follow-up (completed 74.6%; 291/390 patients), the overall mortality was 5.8%, whereas only 1.7% died due to cardiac reasons. Myocardial infarction occurred in 3.0%, redo CABG was necessary in 1.3%. Seventy-eight patients had late postoperative angiography (>30 days) of those 93.6% (n=73) had a patent graft: 58 had no stenosis (74.4%), 4 had a <50% stenosis (5.1%) and 11 had a >50% stenosis (14.1%), but a patent graft. Only in five patients (6.4%) the anastomosis was occluded. MIDCABG is a safe procedure with long- term anastomotic patency rates comparable with those of open-chest LIMA-left-anterior descending artery (LAD) bypass. Keywords: Minimal invasive; Coronary surgery; Port access; Ischemic heart disease

Splenic injury following diaphragmatic plication: an avoidable life-threatening complication [Thoracic non-oncologic]

Pathak, S., Page, R. D. — Wed, 02 Sep 2009 02:11:26 PDT

We report an unusual complication of left-sided diaphragmatic plication, namely bleeding from the spleen due to tearing of adhesions between the spleen and the abdominal aspect of the diaphragm. We believe that making a small incision in the diaphragm prior to the plication to identify and divide the adhesions could have prevented the complication, and that this manoeuvre should be a standard part of the operation. Keywords: Diaphragm; Paralysis; Plication

Hamartoma of mature cardiac myocytes of the pulmonary infundibulum [Cardiac general]

Galeone, A., Validire, P., Gayet, J.-B., Laborde, F. — Wed, 02 Sep 2009 02:02:01 PDT

We describe the incidental finding and treatment of a very rare and voluminous cardiac tumour located near to the pulmonary infundibulum. The mass was surgically resected and final diagnosis was hamartoma of mature cardiac myocytes. Postoperative course was uneventful and the patient is asymptomatic after six months of follow-up. Keywords: Cardiac tumour; Right ventricle

Influence of major pulmonary resection on postoperative daily ambulatory activity of the patients [Thoracic non-oncologic]

Novoa, N. M., Varela, G., Jimenez, M. F., Aranda, J. L. — Wed, 02 Sep 2009 01:50:00 PDT

To describe and compare the daily ambulatory activity of the patients before and one month after major lung resection. Daily activity was measured using a pedometer (OMROM Walking Style PRO®) given preoperatively in a prospective way to a series of 21 consecutive cases scheduled for lobectomy or pneumonectomy. Analyzed variables were age, pulmonary function, mean number of total and aerobic steps per day, walked distance and mean daily time of aerobic activity. Activity variables were analyzed individually and as a new differential variable DELTA. Wilcoxon and Mann-Whitney nonparametric tests were used for comparison between groups. General series data: 19 male. Age: 63±10.9 years. FEV₁ %: 88.4±22.7. DLCO: 86.2±21.6. Eleven cases had COPD criteria. Type of surgery: 3 pneumonectomy/18 lobectomy. Activity data: all patients showed a global decrease of their activity one month after surgery but, patients in the pneumonectomy group are unable to keep aerobic activity meanwhile patients that undergone lobectomy showed only a 25% reduction in the measured variables. Major pulmonary resection decreases the time and the quality of the daily ambulatory activity of the patients during the first postoperative month. Despite limitations, the chosen pedometer OMRON Walking Style Pro® is an efficient tool to evaluate the perioperative daily ambulatory activity of patients. Keywords: Pedometer; Major lung resection; Daily ambulatory activity; Quality of life

A comparative analysis of saphenous vein conduit harvesting techniques for coronary artery bypass grafting - standard bridging versus the open technique [Cardiopulmonary bypass]

Thu, 20 Aug 2009 00:17:23 PDT

Coronary artery bypass graft (CABG) surgery involves harvesting the great saphenous vein (GSV) using the traditional open technique (TOT). This can be associated with significant leg morbidity and patient dissatisfaction. Alternatively, the standard bridging technique (SBT) is a minimally invasive procedure of vein retrieval that uses smaller frequent incisions along the length of the leg and may reduce postoperative complications. This study was designed to compare the success of SBT in reducing leg morbidity and increasing patient satisfaction. One hundred patients were recruited into the study and computer randomised into two groups of 50 undergoing SBT or TOT. Leg morbidity and patient satisfaction were analysed by assessment of pain scores, wound development and scar formation. Closure and harvesting time were also compared between the two groups. SBT was associated with better wound development (P<0.001) and a significantly higher patient satisfaction (P<0.001). Leg pain was significantly reduced amongst SBT group at rest and with movement (P<0.001). There was also a reduction in saphenous neuropathy with the use of SBT (P<0.001). No difference in closure or harvesting time was demonstrated (P=0.26 and P=0.23, respectively). This study demonstrates that harvesting the GSV by the minimally invasive SBT reduces postoperative leg morbidity and increases patient satisfaction without the need of costly equipment. SBT represents a safe, effective and financially viable technique for vein harvesting. Keywords: Saphenous vein harvesting; Standard bridging technique; Traditional open technique; Prospective comparative study; Coronary artery bypass graft

Effectiveness of sympathetic block by clipping in the treatment of hyperhidrosis and facial blushing [Thoracic non-oncologic]

Fibla, J., Molins, L., Mier, J. M., Vidal, G. — Mon, 10 Aug 2009 00:32:29 PDT

Main cause of dissatisfaction after videothoracoscopic (VATS) sympathectomy in the treatment of hyperhidrosis (HH) and facial blushing (FB) is compensatory sweating (CS). Sympathetic nerve (SN) clipping permits to revert the block effect by removing the clips in case of an intolerable CS. We present our experience with this technique. 61 patients diagnosed for HH and/or FB were operated on VATS SN clipping. Clipping levels varied in function of the sort of disease: FB: T2, palmar HH: T3, axillary HH: T4, palmar-axillary HH: T3-4. Results were evaluated one week, 3 months and 12 months after surgery. 58 of the 61 patients showed improvement of their symptoms (95%). There were minor complications in 3 patients (5.5%). CS was seen in 38/61 (62.2%), being labelled as mild in 33/61 (54%) and severe in 5/61 patients (8.2%), no patient qualified it as intolerable and it was not necessary to remove the clips for CS in any case. SN clipping by VATS is a safe and effective procedure for the management of FB and palmar/axillary HH. Levels of CS are similar or lesser than with the standard sympathicotomy and, if necessary, this technique allows to revert the sympathetic block removing the clips. Keywords: Hyperhidrosis; Facial blushing; Sympathicotomy; Clipping; Compensatory sweating

Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters [Thoracic oncologic]

Efthymiou, C. A., Masoudi, T. I., Thorpe, J. A.C., Papagiannopoulos, K. — Tue, 28 Jul 2009 01:43:19 PDT

Malignant pleural effusions in the presence of trapped lung remain notoriously difficult to treat. Various methods exist ranging from minimally invasive procedures including repeated needle thoracocentesis to the need for a formal surgical procedure such as placement of a pleuroperitoneal shunt and even thoracotomy and decortication. Controversy exists as to what is the optimum treatment for this condition. Any planned treatment should balance the therapeutic benefit provided against convalesce for a disease with a limited life expectancy. Patients should not spend a significant proportion of their remaining life span recovering from palliative procedures. In a series of patients with malignant pleural effusion the medial survival time was 20 weeks, with 30 days and 1 year mortality rates of 12.8% and 83.6% respectively. We describe our five-year experience with the use of indwelling PleurX catheters in patients with malignant pleural effusions in the presence of confirmed trapped lung on radiological or VATS investigation. Patient health related quality of life was investigated by telephone questionnaire. The parameters analysed were symptomatic relief, mobility and ease of management following insertion. 116 patients underwent PleurX catheter insertion by a single operator, 48 questionnaires were completed. Of the 48 cases analysed, improvement in all three quality of life indices was recorded following catheter insertion. Ease of mobility was recorded as moderately satisfied and very satisfied in 50% and 15% of patients, respectively. Symptomatic improvement was found to have been increased with 42% and 6% of patients responding to moderately satisfied and very satisfied, respectively. Ease of management was recorded as slightly satisfied and moderately satisfied in 50% and 33% of patients, respectively, demonstrating a high satisfaction index in patients with chronic progressively debilitating malignancies. Complications were either transient or readily correctable. Pain was the predominant complication occurring in 35% of patients lasting less than 3 days. No patient required catheter removal for resolution of discomfort. Our findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung. The catheters are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliative patients with compromised life expectancy. Keywords: PleurX catheter; Pleural effusion; Decortication; Trapped lung; Palliative care

WITHDRAWN - Radial artery grafts' string-sign - role of graft spasm and competitive flow [Coronary]

Chong, C. F., Moat, N. E., Collins, P. — Fri, 05 Jan 2007 12:40:59 PST

WITHDRAWN - OWING TO AN AUTHORSHIP DISPUTE AND SUBSEQUENT REFUSAL TO SIGN OVER COPYRIGHT, THIS PAPER WAS DEFINITIVELY WITHDRAWN ON 3 JANUARY 2007.