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[Cardiac general] Robotically-assisted cardiac surgery

Modi, P., Rodriguez, E., Chitwood, W. R. — 2009-06-19

Recognition of the significant advantages of minimizing surgical trauma has resulted in a substantial increase in the number of minimally invasive (MI) cardiac surgical procedures being performed. Synchronously, technological advances in optics, instrumentation and perfusion technology have facilitated routine totally endoscopic robotic cardiac surgery using the da Vinci® telemanipulation system (Intuitive Surgical Inc.). This technology has been applied to many cardiac surgical procedures, in particular, mitral valve repair (MVP) and totally endoscopic coronary artery bypass grafting (TECAB), allowing the surgeon to operate through 5 mm port sites rather than a traditional median sternotomy. In this rapidly evolving field, we review the clinical results of robotic cardiac surgery. Keywords: Surgical procedures; Minimally invasive; Thoracic surgery; Video-assisted; Robotics; Telemedicine/instrumentation

[Valves] Long-term follow-up of elderly patients subjected to aortic valve replacement with mechanical prostheses

Coutinho, G. F., Pancas, R., Antunes, P. E., Antunes, M. J. — 2009-06-19

We propose to analyse the long-term follow-up in patients older than 65 years of age who received a mechanical valve in the aortic position, using death and prosthetic-related complications as endpoints. From April 1988 to December 1995, 144 consecutive patients 65-75 years of age (mean 67.7±2.5) were enrolled. Total duration of follow-up was 1663 patient-years (median 13.0 years) and was complete for 99% of the patients. Thirty-day mortality was 1.4% (n=2). At the end of the study, 77 patients (53.8%) were alive, with ages ranging from 77 to 91 years (mean 82.1±3.2 years). The overall 5-, 10- and 15-year actuarial survival was 87.4%±3.0, 67.7%±4.3 and 58.5%±4.5, respectively. Freedom from stroke was 93.3±3.1%, 84.6±3.3% and 71.7±4.5%, respectively, after identical periods. Freedom from major bleeding was 97.2±1.1%, 90.4±3.5% and 86.4±4.0%, respectively. Freedom from endocarditis was 95.7±2.3%, 95.0±2.1% and 94.4±2.5%, respectively, and freedom from reoperation was 98.0±1.2%, 97.6±1.3%, 96.9±2.4% and 96.4±2.6%, respectively. Freedom from major valve-related events was 87.7±2.6%, 73.9±3.4% and 61.5±4.6%, respectively. Nearly two-thirds of the patients were alive and free from major adverse valve-related events. Hence, we consider implantation of a mechanical prosthesis in elderly patients safe and appropriate, but the choice must be tailored for each specific patient. Keywords: Aortic valve replacement; Elderly; Mechanical prostheses; Bioprostheses

[Cardiac general] Safe use of recombinant activated factor VIIa for recalcitrant postoperative haemorrhage in cardiac surgery

Tatoulis, J., Theodore, S., Meswani, M., Wynne, R., Hon-Yap, C., Powar, N. — 2009-06-18

The aim of this case series is to review the effect of recombinant activated factor VIIa (rFVIIa) on refractory haemorrhage, despite aggressive treatment with conventional blood products and medications at our institution. All patients undergoing cardiac surgery who received rFVIIa as rescue therapy for persistent uncontrollable haemorrhage were studied . We examined coagulation immediately before and after rFVIIa was given; international normalized ratio (INR), activated partial thromboplastin (APTT) fibrinogen and platelet levels, in addition to the use of red cell and non-red cell blood products, morbidity and mortality. Thirty patients (0.6%) received 31 doses of rFVIIa for bleeding refractory to conventional treatment. Twenty received rFVIIa in theatre after primary surgery, 3 after re-exploration and 8 in the intensive care unit (ICU). Hospital mortality was 6.5% (2/30) and there were no documented thromboembolic phenomena. There was significant reduction in red blood cell and product transfusion before and after rFVIIa administration (p<0.001). There was significant correction in coagulation parameters after rFVIIa. Recombinant FVIIa appears to be safe, and is effective in reducing red blood cell and product transfusion requirements and may impact on early and late outcomes in this small complex subgroup of patients. Keywords: Novoseven; Recombinant activated factor seven; Refractory bleeding

[Cardiac general] Collagen-gentamicin implant for prevention of sternal wound infection; long-term follow-up of effectiveness

2009-06-18

In a previous randomized controlled trial (LOGIP trial) the addition of local collagen-gentamicin reduced the incidence of postoperative sternal wound infections (SWI) compared with intravenous prophylaxis only. Consequently the technique with local gentamicin was introduced in clinical routine at the two participating centers. The aim of the present study was to re-evaluate the technique regarding the prophylactic effect against SWI and to detect potential shifts in causative microbiological agents over time. All patients in this prospective two-center study received prophylaxis with application of two collagen-gentamicin sponges between the sternal halves in addition to routine intravenous antibiotics. All patients were followed for 60 days postoperatively. From Jan 2007 to May 2008, 1359 patients were included. The 60-day incidences of any SWI was 3.7% and of deep SWI 1.5% (1.0% mediastinitis). Both superficial and deep SWI were significantly reduced compared with the previous control group (OR= 0.34 for deep SWI, P<0.001). There was no increase in the absolute incidence of aminoglycoside resistant agents. The majority of SWI were caused by coagulase-negative staphylococci (CoNS). The incidence of deep SWI caused by Staphylococcus aureus was 0.07%. The results indicate a maintained effect of the prophylaxis over time without absolute increase in aminoglycoside resistance. (ClinicalTrials.gov NCT00484055). Keywords: Wound infection; Antibiotics; Mediastinitis; Statistics; Regression analysis; Risk factors; Cardiac surgery; Complications

[Esophagus] Thoracoscopic removal of a transesophageal ingested mediastinal foreign body

Ruckbeil, O., Burghardt, J., Gellert, K. — 2009-06-18

Transesophageal migration of a foreign body into the mediastinum in human adults is rare. This event can result in life-threatening situations and is associated with a high mortality rate. Only a few case reports of thoracoscopic removal of a foreign body in adults have been published so far. The authors describe the case of a succesfully performed thoracoscopic approach to remove an ingested needle from the mediastinum posterior of a 69-year-old patient. The authors are discussing why, in similar cases, removal of the foreign body should be performed and they describe the preliminary conditions for this method. A videofile is attached. Keywords: Foreign body; Thoracoscopy; Esophageal perforation/transmigration

[Thoracic non-oncologic] Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience

Demirhan, R., Onan, B., Oz, K., Halezeroglu, S. — 2009-06-18

Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this retrospective study, we present our 10-year experience in the management and clinical outcome of 4205 cases with chest trauma associated with blunt and penetrating injuries in a level I trauma hospital in Turkey. In 66% of the cases, blunt injury mostly related to traffic accidents was the cause of chest trauma. Additional organ injuries were found in 35% (n=1471). Conservative treatment was administered for most patients. Tube thoracostomy was administered in 40% of all cases, whereas thoracotomy was performed in 6% (n=252), of which 209 were early interventions (P=0.001). The morbidity rate in all victims was 25.2%. The mortality rate was 9.3% for all patients and was 6.8% in blunt, 1.4% in penetrating, and 17.7% in associated organ injuries. Mortality and injury severity score (ISS) increased in patients having early surgery (P=0.001). Although most patients could be managed with conservative approaches, early thoracotomy was required in some cases. We believe that urgent hospital admission, early diagnosis, and multidisciplinary approach are very important to improve outcome. Keywords: Chest trauma; Blunt injury; Penetrating injury; Thoracotomy

[Experimental] Pleural electrophysiology variations according to location in pleural cavity

Kouritas, V. K., Hatzoglou, C., Gourgoulianis, K. I., Molyvdas, P. A. — 2009-06-18

The aim of the study was to compare the electrophysiology profile of sheep pleura originated from different locations of the pleural cavity with the respective profile in humans. Sheep specimens obtained from upper and lower lung lobes, 1st-4th and 8th-12th rib, ventral-dorsal diaphragm and mediastinum were mounted between Ussing chambers. Human visceral tissues were obtained from patients subjected to lobectomy. Trans-mesothelial resistance (R_TM) was determined as an indicator of the tissue permeability, while amiloride and ouabain were used as inhibitors of cellular transportation via ion transporters. Control values R_TM were low in lower lobe visceral, caudal costal parietal and diaphragmatic pleura. Amiloride increased R_TM at all locations except upper visceral and mediastinum. Higher R_TM increases were found in caudal parietal and dorsal diaphragmatic samples. Ouabain increased R_TM of lower visceral, caudal parietal and diaphragmatic pleura but not of mediastinal specimens. Observations made in sheep tissue were comparable with human visceral, parietal and mediastinal regions. In conclusion, results suggest heterogeneity of trans-mesothelial permeability among different pleural locations in sheep as was the case for humans. Thoracic surgeons should consider physiology function of each part of pleural cavity before pleural tissue manipulation. Observations made in sheep may be used to understand human physiology. Keywords: Pleura; Sheep; Electrophysiology; Permeability; Ussing

[Thoracic non-oncologic] The etiological factors of recurrence after tracheal resection and reconstruction in post-intubation stenosis

2009-06-16

We assessed several factors which might be responsible for the recurrence of post-intubation airway stenosis in a large group of patients who underwent resection and reconstruction surgery by one surgical team. 494 patients underwent reconstruction of post-intubation airway stenosis during 1995-2006. The case group comprised patients who had developed recurrence, while controls had no recurrence. The diagnosis of the recurrence was made based on the presence of clinical signs or symptoms and bronchoscopic evaluation. The following variables were compared in both groups: age, sex, duration of intubation, reason for intubation, period of time between intubation and surgery, history of previous tracheotomy, previous therapeutic interventions, subglottic involvement, length of resection, presence of unusual tension at the site of anastomosis and anastomotic infection. 52 patients (10.5%) developed recurrence. Lengthy resection, presence of tension at the site of anastomosis, anastomotic infection and subglottic involvement were significantly higher in the case group. Logistic regression model showed that three main predictors are anastomotic infection (OR=3.44), subglottic involvement (OR=2.43), and presence of tension (OR=1.97), respectively. It is concluded that the surgeon can play an important role in avoiding recurrence by decreasing tension, preventing infection, and preserving subglottic structure. Keywords: Tracheal stenosis; Anastomosis; Restenosis

[Coronary] Is urgent coronary artery bypass grafting a safe option in octogenarians? A developing country perspective

Luqman, Z., Ansari, J., Siddiqui, F. J., Sami, S. A. — 2009-06-16

Life expectancy has increased during recent decades leading to a growing number of older population. The objective of this study was to evaluate the outcomes of coronary artery bypass grafting (CABG) in octogenarians and to compare the outcomes of the emergent CABG with elective surgery. Prospectively collected data from 31 consecutive octogenarian patients who underwent CABG between 1 January 2006 and 31 December 2008 were analyzed. Main outcomes of interest included mortality, length of ICU stay, length of hospital stay, priority of surgery, postoperative complications and functional status on follow-up. Fifteen patients were operated on an urgent basis. Patients operated on an urgent basis were in NYHA class III or IV preoperatively (p=0.0016). There were no significant differences in operative and postoperative variables. There were 3 in-hospital deaths and 23 patients (82%) were alive on follow-up and 19 were in functional class I or II. Quality of life assessment was performed using Seattle Angina Questionnaire and patients reported remarkable improvement in quality of life. Overall, 90% patients were not or little disabled in their daily activity. Satisfaction with their current quality of life was reported by 95% of patients. CABG may be performed in octogenarians with remarkable outcomes and improvement in quality of life. Keywords: Octogenarian; Coronary artery bypass grafting; Elderly; Aging

[Thoracic oncologic] Extrapleural pneumonectomy for pyothorax-associated lymphoma

Halezeroglu, S., Akcevin, A. — 2009-06-16

Pyothorax-associated lymphoma (PAL) is a non-Hodgkin's lymphoma that occurs in the pleural cavity of patients with a long-standing history of pyothorax. Here, we report a left pleuropneumonectomy performed for PAL in a 76-year-old male patient with a 60-year history of pyothorax due to tuberculosis. Keywords: Pyothorax-associated lymphoma (PAL); Pleuropneumonectomy; Chronic pyothorax; Tuberculosis; Lung resection

[Coronary] One-stage hybrid procedure: association between awake minimally invasive surgical revascularization and percutaneous coronary intervention

Del Giglio, M., Dell'Amore, A., Zuffi, A., Sokoli, A. — 2009-06-16

Hybrid revascularization provides minimally invasive options for high-risk patients with multivessel coronary artery disease. We used a hybrid approach in two patients. The surgical revascularization with the left internal mammary artery (LIMA) on the left descending coronary artery was performed through an inferior j-shaped mini-sternotomy keeping the patients awake with high-epidural-thoracic anesthesia. At the end of the operation the patients was moved to the angiography laboratory to complete the revascularization with angioplasty. No complications were reported. Keywords: Myocardial infarction; Coronary artery disease; Minimally invasive surgery; Hybrid approach; High epidural thoracic anesthesia

[Aortic and aneurysmal (ICVTS only)] Circulating matrix metalloproteinase-9 concentrations and abdominal aortic aneurysm presence: a meta-analysis

Takagi, H., Manabe, H., Kawai, N., Goto, S.-n., Umemoto, T. — 2009-06-12

To summarize the present evidence for an association between matrix metalloproteinase-9 (MMP-9) and abdominal aortic aneurysm (AAA) presence, we performed a meta-analysis of case-control studies that compared circulating MMP-9 concentrations between patients with AAA and subjects without AAA. MEDLINE database was searched to identify all case-control studies. For each study, data regarding serum or plasma MMP-9 concentrations in both the AAA and control groups were used to generate standardized mean differences (SMDs) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted average of logarithmic SMDs in both fixed- and random-effects models. Our search identified 8 eligible studies including 580 patients with AAA and 258 subjects without AAA. Pooled analysis demonstrated significantly higher circulating MMP-9 concentrations in the AAA group than those in the control group in random-effect models (SMD, 0.70; 95% CI, 0.23-1.17; P=0.004). There was significant study heterogeneity of results (P<0.00001) but no evidence of significant publication bias (P=0.1376). We found that, based on a systematic review and meta-analysis, circulating MMP-9 concentrations are higher in patients with AAA than those in subjects without AAA. Higher circulating MMP-9 concentrations are associated with AAA presence. Keywords: Matrix metalloproteinase 9; Aortic aneurysm; Abdomen; Biological markers

[Valves] Simultaneous mitral valve and lung surgery for complicated endocarditis

Wiedemann, D., Velik-Salchner, C., Laufer, G., Muller, L. — 2009-06-11

A 48-year-old man developed severe sepsis after a chest trauma. The patient suffered from presternal and cervical abscesses, mediastinitis, septic arthritis of the right shoulder, abscesses in the right lung lower lobe and severe infective endocarditis of the mitral valve. After subcutaneous and mediastinal abscess, drainage, hemodynamic stabilization, and control of sepsis, biological mitral valve replacement and concomitant resection of the right lower lobe were performed. Restoration of the shoulder could be performed 22 days later. The patient was discharged after 4 weeks and is well one year after surgery. Keywords: Endocarditis; Sepsis; Cardiac surgery

[Thoracic non-oncologic] Extralobar pulmonary sequestration presenting as hemothorax

Kenji, K., Endo, S., Kanai, Y., Yamamoto, S. — 2009-06-11

Symptomatic extralobar pulmonary sequestration (EPS) is extremely rare. Herein, we report 2 male patients (3 and 16 years of age) with EPS presenting as hemothorax. Thoracotomic resections of the sequestrated lungs were uneventful. Pathologic examinations revealed hemothorax caused by circulatory disorders within the EPSs. Keywords: Extralobar pulmonary sequestration; Infarction; Hemothorax

[Cardiac general] Surgery of left ventricular aneurysm: a propensity score-matched study of outcomes following different repair techniques

Zheng, Z., Fan, H., Feng, W., Zhang, S., Yuan, X., Wang, L., Song, Y., Hu, S. — 2009-06-10

To evaluate early and late outcomes of modified left ventricular reconstruction (VR) and linear repair (LR) of post-infarct left ventricular aneurysm (LVA). A total of 514 patients were consecutively operated on for LVA with modified VR technique in 145 and LR in 352 patients. Using the propensity score-matching method, we selected 202 patients (101 LRs vs 101 VRs) with similar pre- and intra-operative characteristics and compared their clinical outcomes. After matching, the two groups of patients were similar with regard to baseline data. The increment of left ventricular ejection fraction (LVEF) in VR group was more significant than that in LR group. Operative mortality was 2.0% (2.0% LRs vs 2.0% VRs, p=NS). There was a statistically significant difference between LR and VP patients in MACCEs (29.7% LRs vs 13.9% VRs, p<0.001) and hospital readmissions (51.5% LRs vs 30.7% VRs, p<0.001). Overall long-term mortality and cardiac mortality were the same between the two groups (mortality: 11.9% LRs vs 11.9% VRs, p=NS; cardiac mortality: 9.9% LRs vs 8.9% VRs, p=NS). The technique of repairing LVA did not affect the early and later mortality. Keywords: Left ventricular aneurysm; Linear repair; Left ventricular reconstruction; Propensity score

[Thoracic oncologic] Value of positron emission tomography in full-thickness chest wall resections for malignancies

2009-06-10

Preoperative imaging for resection of chest wall malignancies is generally performed by computed tomography (CT). We evaluated the role of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in planning full-thickness chest wall resections for malignancies. We retrospectively included 18 consecutive patients operated from 2004 to 2006 at our institution. Tumor extent was measured by CT and PET, using the two largest perpendicular tumor extensions in the chest wall plane to compute the tumor surface assuming an elliptical shape. Imaging measurements were compared to histopathology assessment of tumor borders. CT assessment consistently overestimated the tumor size as compared to PET (+64% vs. +1%, P<0.001). Moreover, PET was significantly better than CT at defining the size of lesions >24 cm² corresponding to a mean diameter >5.5 cm or an ellipse of >4 cmx7.6 cm (positive predictive value 80% vs. 44% and specificity 93% vs. 64%, respectively). Metabolic PET imaging was superior to CT for defining the extent of chest wall tumors, particularly for tumors with a diameter >5.5 cm. PET can complement CT in planning full-thickness chest wall resection for malignancies, but its true value remains to be determined in larger, prospective studies. Keywords: Chest wall; Positron emission tomography; Computed tomography; Cancer

[Cardiac general] Control charts, Cusum techniques and funnel plots. A review of methods for monitoring performance in healthcare

Noyez, L. — 2009-06-09

Quality control in medicine is generating more and more interest. Industrial concepts of quality control have been refined and transformed to be useful in healthcare monitoring. Whereas medical practitioners first reaction to this new concept of quality control was negative 'we're treating patients, we're not a part of an industrial process', some dramatic cases of inferior medical performance urged the need to adequately monitor healthcare outcomes. To date, several methods have been described, and more and more reports deal with the subject. Most of us, however, are overwhelmed by the new and different tools in use such as Shewhart control charts, cumulative sum charts and funnel plots. This paper will review the methodology of statistical process control and its application in medical practice. Keywords: Quality control; Cardiac surgery; Control charts; Cusum; Funnel plots

[Vascular thoracic] Acute type A aortic dissection. Eighteen years of experience in one center (Hospital 12 de Octubre)

2009-06-05

We review our experience in acute type A aortic dissection analyzing the role of antegrade brain protection. 105 patients underwent surgery for acute type A aortic dissection between March 1990 and October 2008. An open technique with deep hypothermia was used in 81 patients. Deep hypothermia alone was induced in 32 patients; in combination with retrograde cerebral perfusion in 26 patients and in combination with antegrade cerebral perfusion (ACP) in the final 23 patients. The overall hospital mortality rate was 15%. Hospital mortality risk factors were age ≥70 years and preoperative shock (p<0.05). Hospital mortality was reduced to 9% in the last 23 consecutive patients in whom ACP was accomplished (p=0.05). Survival rate after 1, 5, 10 and 15 years of follow-up was 97.6±1.7%, 84.3±4.4%, 60.7±7.5% and 57.1±7.8%, respectively. The only late death risk predictor was the non-use of ACP (p<0.05). Surgery for acute aortic dissection provides excellent results. ACP via the axillary artery improves the prognosis for these patients and should be the brain protection method of choice. Keywords: Aorta; Aortic dissection; Cerebral protection; Surgery complication; Neurologic injury

[Cardiac general] Pulmonary arterial hypertension in rheumatic mitral stenosis: does it affect right ventricular function and outcome after mitral valve replacement?

Pande, S., Agarwal, S. K., Dhir, U., Chaudhary, A., Kumar, S., Agarwal, V. — 2009-06-04

Right ventricular function affects the outcome in valvular heart disease but less is known about the relation between indices of dysfunction and outcome. Seventy patients undergoing mitral valve replacement between April 2007 and April 2008 for predominant rheumatic mitral stenosis were included in the study. Two groups were formed based on right ventricular systolic pressure (RVSP), ≤40 mmHg (group I, n=16) and >41 mmHg (group II, n=54). Right ventricle (RV) function indices were studied by echocardiography. RVSP reduced significantly in group II (p=0.0001) but not in group I. Brain natriuretic peptide (BNP) was raised in all cases and reduced significantly postoperatively. Tricuspid annular plane excursion, myocardial performance index, RV descent and tricuspid valve annular shortening (TV shortening) conformed to RV dysfunction in both the groups, and did not change significantly postoperatively. Regression analysis for outcome revealed TV shortening as the only significant factor (p=0.03). Receiver operating characteristic of TV shortening and adverse outcome showed worse outcome with TV shortening of <11%. RV dysfunction was observed in all cases irrespective of RVSP. TV shortening of <11% was associated with adverse outcome. Postoperative fall in BNP levels may indicate a trend towards recovery. Keywords: Valvular heart disease; Right ventricle; Brain natriuretic peptide

[Valves] Is patient-prosthesis mismatch an independent risk factor for early and mid-term mortality in adult patients undergoing aortic valve replacement?

Urso, S., Sadaba, J. R., Aldamiz-Echevarria, G. — 2009-06-04

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is patient-prosthesis mismatch an independent risk factor for 30-day and mid-term overall mortality in patients undergoing aortic valve replacement (AVR)? Altogether almost 400 papers were found using the reported search, of which 22 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. The majority of the selected articles have focused their analysis on moderate mismatch defined mostly by the presence of an indexed effective orifice area (IEOA)≤0.85 cm²/m². In fact, because of the low incidence of patients with severe mismatch, these were often grouped for the statistical analysis with patients with moderate mismatch. Only 6 studies have analyzed the specific condition of severe mismatch (IEOA<0.65 cm²/m²). Three studies used the IEOA or indexed geometric orifice area (IGOA) as a continuous variable. We conclude that there is no strong evidence that moderate patient-prosthesis mismatch (PPM) (IEOA≤0.85 and >0.65 cm²/m²) is an independent risk factor for 30-day or mid-term overall mortality for adult patients undergoing AVR. An exception could be represented by patients with poor ejection fraction, a condition that can make moderate mismatch a predictor of overall mortality after AVR. On the other hand, severe mismatch is a predictor of overall 30-day or mid-term mortality for patients undergoing AVR independently from the presence of poor ejection fraction. In conclusion our review suggests that the condition of severe PPM should be always avoided, while the presence of moderate mismatch could be tolerated in patients with normal ejection fraction without any impact on overall survival. Keywords: Aortic valve; Heart valve prosthesis; Mortality

[Congenital] Repair of type B interrupted aortic arch using aberrant right subclavian artery

Westaby, S., Agarwal, A., Kadlec, J., Flynn, F. — 2009-06-03

Interrupted type B aortic arch was repaired using aberrant right subclavian artery. In order to gain the full length of this vessel it was mobilised from a left thoracotomy. The aberrant vessel provides autogenous patch material with which to enlarge the ascending aorta and left common carotid artery. Keywords: Interrupted aorta; Subclavian artery

[Thoracic oncologic] Non-functional paraganglioma of the posterior mediastinum

Lin, M.-W., Chang, Y.-L., Lee, Y.-C., Huang, P.-M. — 2009-06-02

Mediastinal paraganglioma is a rare and slow growing neurogenic tumor. Here we described a 49-year-old woman with a non-functional posterior mediastinal paraganglioma. Video-assisted thoracoscopic surgery for tumor excision failed due to massive bleeding. The tumor was excised successfully by lateral thoracotomy with bipolar electrocautery one week after the first operation. Mediastinal paraganglioma remains a surgical challenge due to its hypervascular character and firm adhesion to adjacent mediastinal structure. Since the non-functional posterior mediastinal paraganglioma is often diagnosed after operation, it should be regarded as a differential diagnosis of mediastinal mass, especially if surgeons experience unexpected massive bleeding during operation. Keywords: Paraganglioma; Mediastinal tumor

[Coronary] Spontaneous coronary artery rupture in a young patient: a rare diagnosis for cardiac tamponade

Shrestha, B. M. S., Craig, C. H., Platts, D., Clarke, A. — 2009-06-02

We report a case of spontaneous coronary artery rupture (SCAR) in a 43-year-old male who presented with symptoms of sudden onset of chest pain and hemodynamic collapse. There were no abnormal electrocardiogram changes and serum troponin was not detected. Acute aortic dissection was suspected but urgent contrast computed tomography (CT) showed a large pericardial effusion with cardiac tamponade. This was later confirmed on trans-oesophageal echocardiogram. The SCAR was seen intra-operatively as an isolated perforation of the posterior descending artery. The patient was successfully managed with direct repair under cardiopulmonary bypass. Postoperative multi-detector dual-source 64-slice CT coronary angiography revealed normal coronary arteries with absence of atherosclerotic plaque in all coronary arterial segments. It is concluded that, though rare, a differential diagnosis of SCAR should be considered in cases of acute chest pain with cardiac tamponade in adult patient of all ages. Keywords: Coronary disease; Coronary artery rupture; Cardiac rupture

[Thoracic non-oncologic] Extraction of airway foreign bodies in adults: experience from 1987-2008

2009-06-02

To determine the incidence and the clinical, radiographic, and endoscopic characteristics of adult patients in our area diagnosed with tracheobronchial foreign bodies (FBs), we have performed a descriptive retrospective study analysing rigid and flexible bronchoscopies practised at our department between 1987 and 2008 in patients older than 14 years. Of the 9781 bronchoscopies performed, 32 involved cases of bronchoaspiration of FBs. The mean age of the patients was 43.81 years (SD 21.43); 65.6% were male and 34.4% were female. Acute or recurrent infection was the most frequent clinical presentation. Chest radiographs provided data for diagnosis in 68% of the cases. The most common FBs aspirated were inorganic (pins and plastic devices 21.4%, each). In conclusion, we can say that in our area tracheobronchial aspiration of FBs by adults is not common. The clinical symptoms are highly variable and the foreign bodies are usually lodged in the right bronchial tree. Keywords: Bronchoaspiration; Foreign body; Fibrobronchoscopy; Rigid bronchoscopy

[Thoracic non-oncologic] Bronchoplastic procedure for an unusual condition - Wegener's granulomatosis

Soo, A., Aziz, R., Buckley, M., Young, V. — 2009-06-02

Wegener's granulomatosis (WG) is a systemic vasculitic condition that commonly affects the lung and kidneys. With improvement in medical therapy, airway complications are increasingly encountered and are difficult to manage. Here we present a case whereby a patient presenting with airway complication is successfully treated with surgery. Keywords: Wegener's granulomatosis; Bronchoplastic procedure; Thoracic surgeons

[Cardiac general] Surgical treatment of right atrial myxoma complicated with pulmonary embolism

Canale, L. S., Colafrancecschi, A. S., Botelho, E. S. L., Monteiro, A. J. d. O. — 2009-06-02

Myxomas are the most common type of cardiac benign tumors and most of them are located in the left atrium, followed by the right atrium. Myxomas in the right atrium may rarely embolize to the pulmonary arterial vasculature. We here present the case report of a patient with right atrial myxoma and massive embolism to the pulmonary arteries treated surgically with right atrial mass removal and pulmonary embolectomy. The right atrium mass presented with prolapse through the tricuspid valve causing a stenotic physiology. The left pulmonary artery was completed occluded and the right pulmonary artery was partially obstructed. Surgical tactics included a brief hypothermic circulatory arrest. The patient had an uneventful recovery and stays asymptomatic after 6 months of follow-up. Keywords: Cardiac surgery; Cardiac tumors; Pulmonary embolism

[Coronary] Anatomical and functional assessment of single left internal mammary artery versus arterial T-grafts 12 years after surgery

2009-06-02

We determined whether ultrasonographic left internal mammary artery (LIMA) findings correspond with 64 multislice computed tomography (MSCT) in patients 12 years after coronary artery bypass grafting. We entered thirty-four patients (63.2±9.2 years), sixteen with conventional single LIMA (group I) and eighteen arterial T-grafts (group II), in a cross-sectional study. Patients underwent transthoracic proximal LIMA ultrasonography at rest and during the Azoulay maneuver, transthoracic echocardiography of the left ventricle and 64-MSCT, 11.5±1.4 years postoperatively. MSCT scans showed three string sign LIMA grafts (19%) in group I and three distal string sign LIMA grafts (17%) and sixteen occluded T-graft anastomoses (22%) in group II. LIMA diameters and areas are significantly larger in group II in the origin, 3.5±0.7 vs 2.5±0.5 mm, P=0.00007 and 0.09±0.04 vs 0.05±0.02 cm², P=0.00019 and in the third intercostal space, 3.4±0.7 vs 2.5±0.5 mm, P=0.00009 and 0.09±0.03 vs 0.05±0.02 cm², P=0.000047. Most ultrasonographic LIMA findings do not differ between the groups. Thus, proximal LIMA diameters and areas are significantly larger in T-grafts and ultrasonographic variables equalize between the groups at rest and during the Azoulay maneuver 12 years after surgery. Keywords: Ultrasound; Coronary artery bypass grafting; Follow-up; Computed tomography

[Valves] Minimally invasive Ross procedure through partial upper sternotomy

Franke, U. F.W., Albert, M., Rustenbach, C., Baumbach, H. — 2009-06-01

The Ross procedure has gained increasing interest for therapy of aortic valve pathologies in young adults because of excellent long-term results. This case report describes the first published experiences of the Ross procedure performed through a minimal access in two consecutive patients. The limited access is associated with only a slightly prolonged aortic cross-clamp time. Consequently, the minimal access method does not result in an increased risk for patients. Keywords: Aortic valve replacement; Minimal invasive surgery; Surgical technique

[Cardiac general] Imaging modalities for retrieval of a migrated coil from the left ventricle, after pulmonary arterio-venous malformation embolisation

Pawale, A., Chealikani, G. R., Mitchell, L., Clark, S. — 2009-06-01

We present a case of a 62-year-old lady who was a known case of hereditary haemorrhagic telangectasia (Rendu-Osler-Weber syndrome) and had pulmonary arteriovenous malformations (AVMs). She had multiple embolisations of pulmonary AVMs. During the last embolisation therapy, one of the coils migrated into the heart. This could not be located by transoesophageal echocardiography, however was identified in the left ventricle by computerised tomogram scan. It was removed successfully using cardiopulmonary bypass. Keywords: Arteriovenous malformation; Embolisation; Hereditary haemorrhagic telangectasia

[Coronary] Aprotinin reduces the antiplatelet effect of clopidogrel

2009-05-28

Aprotinin reduces bleeding and transfusion rates in patients undergoing coronary surgery while on clopidogrel. However, safety studies have indicated that aprotinin may have a possible adverse effect related to an increased incidence of thromboembolic events. We therefore studied the adenosinediphosphate (ADP) mediated platelet aggregation before and after administration of aprotinin in patients on clopidogrel. Fifteen clopidogrel-treated patients with acute coronary syndrome undergoing coronary surgery were studied. ADP-mediated platelet aggregation and platelet count ratio (%) were measured before and after a bolus dose [2x10⁶ kallikrein inhibiting units (KIU)] of aprotinin. Aprotinin induced an increased aggregation in eleven of fifteen patients (73%), and a decrease was registered in two patients (13%). The median (25th/75th percentile) ADP-mediated platelet aggregation before and after aprotinin was 84% (76/91) and 94% (86/97, p<0.01). Clopidogrel non-responders with >90% aggregation (n=4) had a median aggregation of 94.5% (91.5/97.5) versus 82% (73/87, p<0.01) in the responders (n=11). The median increase in platelet aggregation after aprotinin was 8% (5/20) in the responders versus 0% (-5.25/3, p<0.01) in the non-responders. Aprotinin increased ADP induced platelet aggregation from 84% to 94% in patients on clopidogrel, which corresponds to a median decrease in relative platelet inhibition of >50%. Keywords: Coronary artery bypass surgery; Pathology/pharmacology/physiology; Blood; Coagulation; Platelets

[Pulmonary] Role of heme oxygenase-1/carbon monoxide system in pulmonary ischemia-reperfusion injury

Wang, W., Wang, F., Shi, L., Jia, X., Lin, L. — 2009-05-28

The aim of this study is to investigate the effect of heme oxygenase-1 (HO-1)/carbon monoxide (CO) system in pulmonary ischemia-reperfusion injury (PIRI) in rabbits. The rabbits were randomly assigned to three groups (n=10, in each), control group (C), PIR group (I-R), PIR+Hemin group (H) and PIR+zinc protoporphyrin IX (ZnPP) group (Z). There were changes to several parameters which included plasma carboxyhemoglobin (COHb), wet to dry ratio of lung tissue weight (W/D), the injured alveoli rate (IAR) and the HO-1 enzymatic activity. Immunohistochemistry (IHC) and in situ hybridization (ISH) for HO-1 was detected in lung. The electron microscopic observation for lung tissue injury was done after PIRI. The plasma content of COHb increased by reperfusion was strengthened by hemin but weakened by ZnPP. The HO-1 activity in lung tissue was upregulated by PIRI, further enhanced by hemin and abolished by ZnPP. Except for the C group, HO-1 was upregulated in all other groups in the pulmonary endothelial cells, some pulmonary vascular smooth muscle cells, extima of vessels and epithelial cells of airway. The injury parameters were highest in the Z group, the second was in the IR group, then the H group and the C group. HO-1/CO system was activated and may be one of the protective signal pathway during PIRI in rabbits. Keywords: Ischemia-reperfusion injury; Lung; Heme oxygenase-1; Carbon monoxide

[Thoracic oncologic] Bronchial stump infiltration after lung cancer surgery. Retrospective study of a series of 2994 patients

Fernandez, E., Lopez de Castro, P., Astudillo, J., Fernandez-Llamazares, J. — 2009-05-26

The incidence of lung cancer has been increasing in developed countries since the mid-1990s. The main objective of this study is to determine if bronquial stump infiltration can affect survival in patients with lung cancer. For this purpose we differentiate between carcinoma 'in situ' and invasive carcinoma. We included patients suffered from non-small cell lung cancer who underwent thoracothomy in order to get cured. The total number of patients was 2994. In this study 80 patients out of the 2994 had bronchial stump affection. 8 patients were excluded thus a total of 72 patients were included, 52 of them had carcinoma 'in situ' and 20 invasive carcinoma. The global survival was 25 months. Patients with carcinoma 'in situ' had a median survival of 25 months as opposed to 21 months in patients with invasive carcinoma. We only found statistical significance when we compared the histology with the type of infiltration of bronchial stump. We did not observe statistical significance in survival between carcinoma 'in situ' and invasive carcinoma bronchial stump infiltration (p=0.094). The only survival predictor variable is the histology (adenocarcinoma), p=0.0001. Keywords: Lung cancer; Stump bronchial affection; Carcinoma in situ

[Thoracic non-oncologic] Headscarf pin tracheobronchial aspiration: a distinct clinical entity

Al-Sarraf, N., Jamal-Eddine, H., Khaja, F., Ayed, A. K. — 2009-05-26

Foreign body (FB) aspiration is commonly seen in children and less commonly in the elderly. However, due to some social and cultural factors, a distinct group of tracheobronchial FB aspiration is increasingly recognized. We sought to assess our experience with such entity. A retrospective review of all cases with veil pin tracheobronchial FB aspiration in a single center over a 13-year period was carried out. There were 35 cases of headscarf tracheobronchial FB aspiration. All were females with mean age of 14 years. All patients experienced coughing and all had positive chest radiography findings. Commonest anatomical location was right main bronchus (32%) followed by left main bronchus (23%). Tracheal pins occurred in 17%. Rigid bronchoscopy was used more often than flexible bronchoscopy (83% vs. 17%, respectively). Repeat bronchoscopy was required in 2 cases (6%). Thoracotomy was required in one patient (3%). There were no complications or hospital deaths. Headscarf pin aspiration is seen in middle-aged women who inappropriately place the pins in their lips prior to securing their veils. Bronchoscopy is the treatment modality of choice and surgery is rarely required. Preventative educational strategies should be implemented to reduce such an avoidable risk. Keywords: Bronchoscopy; Foreign body; Tracheobronchial aspiration

[Vascular general (ICVTS only)] Combined infrainguinal reconstruction and infrapopliteal intraluminal angioplasty for limb salvage in critical limb ischemia

Balaz, P., Rokosny, S., Koznar, B., Adamec, M. — 2009-05-26

The aim of this retrospective study was to assess the success rates of limb salvage, and the primary and secondary patency rates of reconstructions of critical limb ischemia (CLI) patients undergoing combined infrainguinal reconstruction and intraluminal angioplasty of crural arteries. In 2000-2005, infrainguinal reconstruction with concomitant intraluminal angioplasty of crural arteries was performed in 30 patients with CLI, mean age was 63 years (SD=10); according to the Fontaine classification, 28 (93%) patients had stage IV and 2 (7%) stage III ischemia. During mean follow-up of 12.9 (SD=16.9) months, primary 1-year patency of vascular reconstruction was seen in 16 (52.6%) patients of our group. Secondary 1-year patency over the same follow-up period was documented in 17 (56.2%) patients and 1-year limb salvage was obtained in 25 (82.6%) patients. Based on this finding, we consider a combined surgical and endovascular procedure to be the method of choice in limb salvage in patients with critical limb ischemia not allowing for an isolated endovascular procedure. Keywords: Critical limb ischemia; Limb salvage; Combined procedure; Hybrid procedure

[Valves] Pressure-volume loops: feasible for the evaluation of right ventricular function in an experimental model of acute pulmonary regurgitation?

2009-05-26

Pressure-volume loop measurements by cardiac catheterization constitute a highly reliable method for the direct beat-to-beat functional analysis of the heart. We aimed to prove its feasibility for the instantaneous evaluation of right ventricular performance in a novel experimental model of pulmonary regurgitation (PR). Four-month-old sheep (n=18, weighing 35-45 kg) were operated via left anterior thoracotomy. A transannular patch (TAP) was sutured to the right ventricular outflow tract (RVOT). Pulmonary valve annulus was transsected through an incision over the patch without the need for cardiopulmonary bypass. Baseline right ventricular function was obtained by inserting conductance catheters through the pulmonary artery before and immediately after surgical induction of PR. All animals survived. Pressure-volume loop analysis presented immediate significant elevations in pressure and volume loading of the right ventricle. Maximum developed pressure incremented from 26.9±1.1 mmHg to 30.5±0.9 mmHg (P<0.01). End-diastolic volume [62.4±3.4-102.7±8.6 ml (P<0.01)] increased as well. Peak rate of pressure increased during ejection phase, and heart rate rose from 427.1±21.4 mmHg/s to 492.6±24.7 mmHg/s (P<0.01) and from 89.0±3.0 per min to 93.0±3.3 per min (P=0.04), respectively. Right ventricular ejection fraction decreased from 74.1±2.7% to 56.6±3.0% (P<0.01). Our results demonstrate that conductance catheter method is feasible for the evaluation of acute right ventricular volume overload in this new model of PR with TAP augmentation of RVOT. Keywords: Right ventricle; Pulmonary insufficiency; Volume overload; Pressure-volume loops; Conductance catheterization

[Thoracic non-oncologic] The role of thoracoscopy for the diagnosis of hidden diaphragmatic injuries in penetrating thoracoabdominal trauma

2009-05-25

Patients with a thoracoabdominal stab wound may have hidden diaphragmatic injuries that could finally lead to chronic diaphragmatic hernia. In this study we analyzed thirty patients with penetrating thoracoabdominal injuries that were stable hemomodynamically and did not need emergent exploration. They underwent thoracoscopy in order to find a probable diaphragmatic injury from March 2005 to October 2007. The mean age was 26.2 years and the M/F ratio was 5:1. We observed 5 occult diaphragmatic injuries (16.7%) in thoracoscopic evaluations. 3 cases (9.9%) were repaired through thoracoscopic approach while laparatomy was inevitable in 2 (6.6%) patients. Pulmonary parenchymal lacerations were seen in 2 patients (6.6%) which were repaired through thoracoscopy and intra-abdominal injury was seen in 1 patient (3.3%) which was repaired via loparatomy. We performed thoracoabdominal CT-scan 6 months later and chronic diagrammatic hernias were not reported. Diagnostic accuracy of thoracoscopy was 100%. Owing to the high diagnostic accuracy rate, minimal invasiveness and therapeutic potency of thoracoscopy we recommend it to be performed in all clinically stable patients with penetrating thoracoabdominal penetrating injury especially in the 8th intercostal space. Keywords: Thoracoabdominal stab wound; Diaphragmatic injury; Thoracoscopy

[Thoracic oncologic] Clinical significance of preoperative carcinoembryonic antigen level for clinical stage I non-small cell lung cancer: can preoperative carcinoembryonic antigen level predict pathological stage?

Kawachi, R., Nakazato, Y., Takei, H., Koshi-ishi, Y., Goya, T. — 2009-05-20

The purpose of the present study was to retrospectively analyze the clinicopathological characteristics and clarify whether or not the preoperative carcinoembryonic antigen (CEA) level could be used as a decision-making factor as an adjunct to the TNM staging system in patients with clinical stage I non-small cell lung cancer (NSCLC). Between 1993 and 2006, 815 patients who had clinical stage I NSCLC were analyzed retrospectively. The CEA level was defined as being either normal (CEA≤5 ng/ml), high (530 ng/ml) sub-groups. The rate of patients with an elevated CEA level was 33.6%. The 5-year disease-free survival rates for patients with normal, high and very high CEA levels were 76.7%, 60.0% and 31.3% respectively. The survival curve for patients with a normal CEA level almost overlapped that for p-stage I, that for a high CEA level nearly overlapped that for p-stage II, and that for a very high CEA level nearly overlapped that for p-stage III. The present study demonstrated that the preoperative CEA level was a very good predictor of the pathological stage. These findings suggest that the preoperative CEA level may be useful as an adjunct to the TNM staging system. Keywords: Lung cancer; Carcinoembryonic antigen; TNM classification

[Thoracic oncologic] Lichen planus in a case of Good's syndrome (thymoma and immunodeficiency)

Khan, S., Campbell, A., Hunt, C., Sewell, W.A. C. — 2009-05-20

Patients with thymoma are mostly investigated for autoimmunity but a few patients may have underlying immunodeficiency that is referred to as Good's syndrome (GS). Cardiothoracic surgeons must always consider this diagnosis when undertaking thymectomy, as immunoglobulin levels can be easily measured and is readily available. The immunodeficiency in GS can be life-threatening and more importantly, it is not reversed by thymectomy. Collaborative care with an immunologist for these patients is strongly recommended. Keywords: Thymoma; Immunodeficiency; Good's syndrome; Lichen planus

[Thoracic oncologic] Large pedunculated fibrovascular polyp of oesophagus in a young woman

Dutta, R., Kumar, A., Handa, K. K., Dinda, A. K. — 2009-05-20

A 25-year-old female patient with a history of progressive dysphagia of one year duration was detected to have intraluminal polypoidal mass in the oesophagus on barium contrast study and computed tomography. Direct laryngoscopy and flexible endoscopy confirmed the origin from pharyngo-oesophageal junction. Lateral cervical oesophagotomy and excision of a polypoidal mass of 15x6.5x3 cm size was done. Histopathology revealed fibrovascular polyp (FVP) arising from submucosa of oesophagus. FVP is a benign tumour-like condition which can attain an enormous size inside the lumen of the oesophagus. It predisposes the patient to aspiration due to incomplete vocal cord adduction and asphyxia due to possible laryngeal inlet block and thus threatening life. Complete surgical excision through lateral esophagotomy is the standard treatment and provides cure in majority. Keywords: Fibrovascular polyp; Dysphagia; Oesophagus

[Esophagus] A novel surgical technique of repair of posterior wall laceration of thoracic trachea during transhiatal esophagectomy

Gupta, V., Thingnam, S. K.S., Kuthe, S., Verma, G. R. — 2009-05-19

Tracheal injury is a rare, dreaded and potentially fatal complication of transhiatal esophagectomy (THE). The close proximity of major airway to esophagus makes it vulnerable to iatrogenic laceration during mediastinal manipulations. Over a period of five years, three patients with injury to membranous trachea during THE, were managed through the cervical incision. There was laceration of membranous trachea ranging from 3.5 cm to 5 cm in length with minimal loss of tracheal tissue. One of the lacerations was extending up to the right bronchus. All the patients were successfully managed through the cervical incision. The operative repair of trachea lasted for 45-60 min. One patient developed permanent left recurrent laryngeal nerve injury and another had postoperative bronchopneumonia. There was no mortality. Trans-cervical approach is an effective way of repairing thoracic membranous tracheal laceration during THE without any significant increase in the morbidity. Keywords: Esophagectomy; Trachea; Injury; Repair; Technique; Laceration; Trauma; Transhiatal

[Cardiac general] Does obesity affect operative times and perioperative outcome of patients undergoing totally endoscopic coronary artery bypass surgery?

2009-05-19

More and more patients undergoing coronary artery bypass grafting (CABG) are overweight. This patient group suffers from wound healing problems more often than normal-weight patients. Therefore, avoiding sternotomy in obese patients by using an endoscopic technique could be a promising approach. Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. We investigated whether the intra-operative-times or perioperative-outcome after TECAB-procedure are negatively affected by obesity. Patients [n=127, 101 male, 26 female, median age 59 (31-77) years], undergoing arrested-heart TECAB procedure were enrolled. The median body mass index (BMI) in this patient cohort was 26 (19-38). In detail, 27 patients were normal weight (BMI≤25 kg/m²), 67 patients were overweight (BMI 25.1-30 kg/m²), 29 patients were obese (BMI 30.1-33.9 kg/m²) and 4 patients were morbidly obese (BMI≥34 kg/m²). There was no correlation between BMI (1) left internal mammary artery (LIMA) takedown-time [Spearman-rank correlation coefficient (R)=0.02; p=ns], (2) lipectomy and pericardiotomy-time (R=0.042, p=n.s.), (3) total operative-time (R=-0.083: p=ns), (4) cardiopulmonary-bypass-time (R=-0.012; p=ns), (5) aortic-endoocclusion-time (R=-0.055; p=ns), (6) mechanical-ventilation-time (R=0.001, p=ns), (7) length of ICU-stay (R=0.04; p=ns), (8) length of hospital-stay (R=-0.103; p=ns, or (9) occurrence of intra- and/or postoperative adverse events. In overweight, obese but also morbidly obese patients the TECAB procedure did not increase operative times or the rate of intra- or postoperative complications. This patient group, therefore, benefits from this less traumatic version of coronary surgery. Keywords: Obesity; Coronary artery disease; Coronary artery bypass grafting; Endoscopic surgery; Robotic surgery

[Valves] Growth of mitral annulus in the pediatric patient after suture annuloplasty of the entire posterior mitral annulus

Komoda, T., Huebler, M., Berger, F., Hetzer, R. — 2009-05-19

When mitral annuloplasty is performed in small children, room for annular growth should be allowed. However, it has not been reported how the valve develops after mitral annuloplasty of the entire posterior annulus. We report a case showing traces of annular growth at redo surgery. A female patient suffering from mitral valve insufficiency due to annular dilatation underwent modified Paneth plasty with Kay-Wooler commissural plication annuloplasty at the age of 2 years 1 month. In redo surgery 8.4 years after initial repair, enlargement of the commissural portion of the posterior annulus in addition to enlargement of the anterior leaflet and anterior annulus was observed. Modified Paneth plasty reinforceed with a pericardial strip and Kay-Wooler annuloplasty of the posteromedial commissure were performed. Mitral orifice size measured with the Hegar dilator was 18 mm after the re-repair, increasing from 16 mm after the initial repair. Taking into account the normal mitral annulus diameter related to body surface area (BSA) of 16 mm at initial operation and 20 mm at redo surgery, the increase in mitral orifice size from 16 mm to 18 mm in this patient may be regarded as the annular growth in 8.4 years. Keywords: Mitral valve insufficiency; Heart valve disease; Cardiovascular surgical procedures; Re-operation

[Vascular thoracic] Clinical significance of anastomotic leak in ascending aortic replacement for acute aortic dissection

Tanaka, H., Okada, K., Kawanishi, Y., Matsumori, M., Okita, Y. — 2009-05-19

'Anastomotic leak' after ascending aortic replacement for acute aortic dissection, which is determined as direct forward blood flow into the false lumen at the distal anastomosis, prevents the false lumen from being thrombosed. The aim of this study is to determine whether the leak influences on residual aortic growth. Between October 1999 and May 2006, 100 patients presenting for acute type A aortic dissection underwent surgery at our institution. Among the population, 34 patients who underwent ascending aortic replacement and have been followed by computed tomography (CT) for over 6 months were reviewed. On the follow-up computed tomography, maximum diameter of aortic arch and descending aorta were measured and the presence of anastomotic leak was determined. The growth rates of aortic arch and descending aorta in patients diagnosed as having anastomotic leak were greater than patients not having leak (p=0.003, p<0.001, respectively). Initial maximum diameter just after ascending aortic replacement was greater in patients with anastomotic leak than without anastomotic leak in aortic arch and descending aorta (p=0.013, p=0.06). Anastomotic leak after ascending aortic replacement for acute type A aortic dissection contributed to remnant aortic growth. More sophisticated method for reapproximation of dissected aorta should be dictated. Keywords: Aortic dissection; Aorta

[Coronary] The first Latin-American risk stratification system for cardiac surgery: can be used as a graphic pocket-card score

2009-05-19

This study aims to develop the first Latin-American risk model that can be used as a simple, pocket-card graphic score at bedside. The risk model was developed on 2903 patients who underwent cardiac surgery at the Spanish Hospital of Buenos Aires, Argentina, between June 1994 and December 1999. Internal validation was performed on 708 patients between January 2000 and June 2001 at the same center. External validation was performed on 1087 patients between February 2000 and January 2007 at 3 other centers in Argentina. In the development dataset the area under receiver operating characteristics (ROC) curve was 0.73 and the Hosmer-Lemeshow (HL) test was p=0.88. In the internal validation ROC curve was 0.77. In the external validation ROC curve was 0.81 but imperfect calibration was detected because the observed in-hospital mortality (3.96%) was significantly lower than the development dataset (8.20%) (p<0.0001). Recalibration was done in 2007, showing excellent level of agreement betweeen the observed and predicted mortality rates on all patients (p=0.92). This is the first risk model for cardiac surgery developed in a population of Latin-America with both internal and external validation. A simple graphic pocket-card score allows an easy bedside application with acceptable statistic precision. Keywords: Risk stratification; Cardiac surgery; Outcome

[Cardiopulmonary bypass] Impaired cardiac autonomic nervous control after cardiac bypass surgery for congenital heart disease

McGlone, L., Patel, N., Young, D., Danton, M. D. — 2009-05-19

We undertook a study to describe changes in heart rate variability (HRV) postoperatively in children undergoing cardiac bypass surgery for congenital heart disease (CHD). HRV was recorded for a 1-h period preoperatively and a 24-h period postoperatively in 20 children with CHD. We found a highly significant reduction in HRV in both time and frequency domain indices compared to preoperative values which was sustained throughout the 24-h study period. There was a negative correlation between both time and frequency domain HRV measurements and length of cardiac bypass. HRV is reduced postoperatively and correlates with cardiac bypass time. Length of cardiac bypass time may be one mechanism whereby HRV is reduced following surgery. Keywords: Cardiopulmonary bypass; Congenital; Autonomic nervous system; Heart rate

[Thoracic oncologic] Long-term results after resection for soft tissue sarcoma pulmonary metastases

2009-05-18

Isolated pulmonary metastases from soft tissue sarcomas (STS) occur in approximately 20% of the cases. Chemotherapy and surgical resection are the current standard treatment options for these patients. Our goal was to identify any prognostic factors for these patients as well as to estimate their long-term survival rate. We examined a series of twenty-two consecutive patients with pulmonary metastases from STS, treated in our institution from 1996 to 2006. Univariate (log-rank and Cox-regression) analysis was performed to identify any significant prognostic factor. Five-year survival rates were estimated by using Kaplan-Meier methods. Four patients (18.2%) were alive without any disease, twelve patients (54.5%) were dead of disease and we lost all track of six patients (27.3%). Follow-up period ranged from 7 to 75 months. Median follow-up: 14 months, median survival: 19 months. Disease-free interval (DFI) (p=0.005), number of lung nodules (p=0.04) and histology type (p=0.01) were significant prognostic factors at univariate analysis. The overall five-year survival rate was 23.1%. DFI, number of lung nodules at surgery and metastatic histology are significant prognostic factors for patients with resected pulmonary metastases from STS. Keywords: Soft-tissue sarcoma; Lung metastases; Resection; Re-do

[Cardiac general] Floating intra-aortic thrombus presenting as distal arterial embolism

Pousios, D., Velissaris, T., Duggan, S., Tsang, G. M. — 2009-05-18

Floating thrombi in the aorta are a rare finding in the absence of any coagulation abnormality. They often represent a surgical emergency. Our case refers to a 45-year-old woman who presented with acute ischemia of the upper extremity. This was a result of peripheral embolism originating in a floating thrombus in the ascending aorta. A free floating lesion held by a pedicle from the lateral ascending aortic wall was demonstrated using computed tomography and magnetic resonance scans. There was no pre-existing clotting abnormality. Conservative treatment with oral anticoagulation was not successful in removing the lesion. Therefore, a surgical approach was selected through a median sternotomy and cardiopulmonary bypass. Under temporary hypothermic circulatory arrest, the ascending aorta was opened. The lesion was removed along with a rim of aortic wall, circulation was re-established and the aorta was reconnected with use of a synthetic interposition graft. Postoperative course was uneventful. The patient was discharged on oral anticoagulation. Histopathology confirmed the lesion as thrombus. Only a few cases of intra-aortic thrombus without any coagulation abnormality basis are described in literature. Occasionally they present as distal embolism. Treatment should be surgical excision on cardiopulmonary bypass, a procedure performed safely with excellent outcome. Keywords: Ascending aorta; Embolism; Thrombosis; Cardiopulmonary bypass

[Coronary] Prognosis of patients undergoing cardiac surgery and treated with intra-aortic balloon pump counterpulsation prior to surgery: a long-term follow-up study

2009-05-15

The aim of this study was to evaluate short- and long-term outcome in patients undergoing coronary artery bypass grafting (CABG), who received an intra-aortic balloon pump (IABP) prior to surgery. Between January 1990 and June 2004, all patients (ns154) who received an IABP prior to on-pump CABG in our center were included. Patients received the IABP for vital indications (i.e. either unstable angina refractory to medical therapy or cardiogenic shock; group 1: n=99) or for prophylactic reasons (group 2: n=55). A Cox proportional hazards model was used to identify predictors of long-term all-cause mortality. Compared with the EuroSCORE predictive model, observed 30-day mortality in group 1 (15.2%) was slightly higher than predicted (10.3%). A decrease in 30-day mortality occurred in group 2 (median predicted mortality was 7.2% and observed was 0%). Cumulative 1-, 5-, and 6-year survival was 82.8±3.8%, 70.1±4.9%, and 67.3±5.1% for group 1 vs. 98.2±1.8%, 84.0±5.6% and 84.0±5.6% for group 2 (Log-rank: P=0.02). Logistic EuroSCORE (HR 1.03 w1.01-1.05x, P=0.007) was an independent predictor of long-term all-cause mortality. Keywords: Coronary artery bypass grafting; Intra-aortic balloon pump counterpulsation; Logistic EuroSCORE; Long-term survival; Outcome

[Thoracic oncologic] Endobronchial ultrasound-guided transbronchial needle aspiration of undiagnosed intrathoracic lesions

2009-05-15

Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-FNA) is a minimally invasive method used routinely for mediastinal staging of patients with lung cancer. We have used it in 135 consecutive patients with a radiologically suspicious intrathoracic lesion that remained undiagnosed despite bronchoscopy and CT-guided fine-needle aspiration (CT-FNA). There was no operative mortality or surgical complications. In 98 patients with a suspicious lesion in the lung parenchyma, adequate tissue was obtained in 83 patients (85%) and in 37 patients with enlarged lymph nodes or a mediastinal tumor adequate tissue was obtained in 35 cases (95%). However, a final diagnosis was only reached in 45% of the patients and further investigations led to malignancy in 13. We believe that EBUS-FNA represents a good alternative to more invasive diagnostic procedures when conventional methods fail, even though the diagnostic yield is lower compared with mediastinal staging in patients with known lung cancer. In almost half of the cases, EBUS-FNA provides the final diagnosis without exposing the patient to the risk of complications from more invasive procedures. Keywords: Lung cancer; Mediastinum; Diagnostics; Staging; EBUS

[Vascular thoracic] Acute aortic dissection occurring during the butterfly stroke in a 12-year-old boy

Uchida, K., Imoto, K., Yanagi, H., Date, K. — 2009-05-15

A 12-year-old boy had severe chest and back pain of sudden onset while practicing the butterfly stroke in a swimming class. Computed tomography revealed an intimal flap in the descending thoracic aorta with massive right hemothorax. A ruptured type B acute aortic dissection was diagnosed, and then he collapsed. We totally replaced the descending aorta with a woven polyester prosthetic graft during deep hypothermic circulatory arrest. Hemostasis was achieved, but consciousness was not regained after operation, and multiple organ failure occurred. He died on the fifth postoperative day. He and his family had no history of cardiovascular disease. It seems that the swimming provoked a severe Valsalva maneuver, raising blood pressure acutely and thereby leading to dissection. This is then analogous to the propensity for dissection during intense isometic exercise such as weightlifting. Keywords: Acute aortic dissection in children; Butterfly stroke; Swimming

[Valves] Is ministernotomy superior to conventional approach for aortic valve replacement?

Scarci, M., Fallouh, H. B., Young, C., Dunning, J. — 2009-05-15

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is ministernotomy superior to conventional approach for aortic valve replacement (AVR)? Altogether, more than 115 papers were found using the reported search, of which six 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 ministernotomy can be performed safely for AVR, without increased risk of death or other major complication; however, few objective advantages have been shown. Ministernotomy can be offered on the basis of patient choice and cosmesis rather than evident clinical benefit. Keywords: Review; Ministernotomy; Minimally invasive; Aortic valve replacement; Humans

[Assisted circulation] Intra aortic ballon pump insertion through left axillary artery in patients with severe peripheral arterial disease

Zattera, G., Totaro, P., D'Armini, A. M., Vigano, M. — 2009-05-15

Intra aortic balloon pump (IABP) is the mechanical assist device most frequently used in cardiac surgery. Recent demonstration of better outcome following preoperative IABP insertion in high-risk patients has further extended its indication. However, due to an increasing complexity of patients currently referred for cardiac surgery, several patients with potential indication for preoperative andyor postoperative IABP present severe peripheral vascular disease which usually contraindicates IABP insertion. Here we present an alternative technique for IABP insertion in patients with severe peripheral vessel disease. Keywords: Cardiac surgery; Intra aortic balloon pump; Vascular complications

[Thoracic non-oncologic] Thoracic outlet lymphangioma

Marshall, M. B., Oliviera, T. — 2009-05-15

We report a case of a lymphangioma causing thoracic outlet syndrome (TOS) in a young collegiate athelete. This was completely resected with a combined cervical and axillary osteo-muscular sparing approach. Keywords: Lymphangioma; Thoracic outlet syndrome

[Cardiopulmonary bypass] Does use of intraoperative cerebral regional oxygen saturation monitoring during cardiac surgery lead to improved clinical outcomes?

Vohra, H. A., Modi, A., Ohri, S. K. — 2009-05-15

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of cerebral regional oxygen saturation (rSO₂) monitoring during cardiac surgery can lead to improved clinical outcomes. Altogether 488 papers were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. Four prospective and another four retrospective studies involving adult and paediatric patients undergoing various cardiac surgical procedures were selected. These have demonstrated that prolonged intra-operative cerebral desaturations are associated with adverse neurological outcomes and prolonged hospital stay. Further, interventions carried out by thoughtful use of the cerebral oximeter are associated with significant reduction in neurologic injury, major organ morbidity and mortality (MOMM) and duration of hospital stay. Some studies have indicated decreased ventilation and intensive care unit (ICU) stay times as well. Clinical benefit and the lack of use-associated risk of injury at a modest expense support the use of this device routinely in patients undergoing cardiac surgery. Keywords: Cerebral monitoring; Spectroscopy; Heart surgery; Outcome; Evidence-based medicine; Review

[Cardiac general] A pilot randomized study of the neutrophil elastase inhibitor, sivelestat, in patients undergoing cardiac surgery

Abe, T., Usui, A., Oshima, H., Akita, T., Ueda, Y. — 2009-05-15

The primary objective of this study was to determine the feasibility and safety of treatment with Sivelestat in humans to attenuate post-cardiopulmonary bypass lung injury. Twenty patients scheduled to undergo on-pump coronary artery bypass surgery were randomized to receive either 0.3 mg/kg/h intravenous Sivelestat sodium (Sivelestat group; n=10) or isotonic sodium chloride solution (placebo group, n=10), peri-operatively. Postoperative adverse events were recorded until hospital discharge. The alveolar-arterial oxygen gradient (A-aDO₂), intrapulmonary shunt (Qs/Qt) and dynamic lung compliance were determined four times peri-operatively as secondary exploratory outcomes. All patients completed study protocol without discontinuation of intervention. The number of total adverse clinical outcomes, including atrial fibrillation and superficial wound infection, was nine in seven patients in the placebo group and four in four patients in the Sivelestat group (P=0.37). The mean duration of the postoperative hospital stay was shorter in the Sivelestat group (19.0±3.4 vs. 25.6±9.1, P=0.04). The exploratory analysis of relative changes in lung functions showed trends toward attenuation of lung injury in the Sivelestat group in all three pulmonary parameters, though the inter-group difference could be due to chance (P>0.05). It is feasible to administer Sivelestat as a preventive measure against lung dysfunction after cardiopulmonary bypass. Keywords: Cardiopulmonary bypass; Inflammatory response; Coronary artery bypass grafts; Pulmonary function; Peri-operative care

[Valves] Does the use of carbon dioxide field flooding during heart valve surgery prevent postoperative cerebrovascular complications?

Giordano, S., Biancari, F. — 2009-05-15

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether there25 is any benefit with the use of carbon dioxide (CO₂) field flooding techniques in heart valve surgery, in order to reduce postoperative neurological complications. Altogether 202 articles were found using the reported search, and six of them were used to answer the clinical question. All but one trial, were prospective, randomised. Four studies reported a significantly lower intracardiac bubble count in the CO₂ group. A significant reduction of p300 peak latencies in the CO₂ group was observed in one study. Otherwise, neurocognitive test batteries did not reveal any advantages of CO₂ field flooding in two studies. Three studies reported on postoperative cerebrovascular complications and the overall rate of stroke, TIA or prolonged reversible ischemic neurological deficit was 1.2% in the CO₂ group and 2.5% in the control group (Psns). Although the use of CO₂ field flooding has been observed to be associated with a significantly lower count of intracardiac air bubbles, and improved survival in two small studies, so far there is no evidence of a sustained reduction of cerebrovascular complications with the use of this method. Keywords: Evidence-based medicine; Heart valve surgery; Carbon dioxide field flooding; Air embolisation; Stroke