Interactive CardioVascular and Thoracic Surgery current issue

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 (ESTS) and of the Thoracic Oncology Section of the European Respiratory Society (ERS) [Editorial - Thoracic oncologic]

Tue, 17 Nov 2009 10:56:35 PST

Controlled antegrade single lung reperfusion during double lung transplant [New ideas - Pulmonary]

Khalpey, Z., Gilfeather, M. S., Camp, P. C., Jaklitsch, M. T. — Tue, 17 Nov 2009 10:56:35 PST

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.

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

Novoa, N., Varela, G., Jimenez, M. F., Aranda, J. L. — Tue, 17 Nov 2009 10:56:35 PST

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.

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

Shimamura, Y., Hayashi, I. — Tue, 17 Nov 2009 10:56:35 PST

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 two 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.

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

Zhang, Y., Chu, Y., Shen, W., Dou, Z. — Tue, 17 Nov 2009 10:56:35 PST

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 messenger ribonucleic acids (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.

Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results [Work in progress report - Aortic and aneurysmal]

Da Rocha, M., Zarka, Z. A., Riambau, V. A. — Tue, 17 Nov 2009 10:56:35 PST

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 (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.

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

Tue, 17 Nov 2009 10:56:35 PST

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 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.

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

Beukema, R., Beukema, W. P., Sie, H. T., Misier, A. R., Delnoy, P. P., Elvan, A. — Tue, 17 Nov 2009 10:56:35 PST

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. Thirty-three 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.

eComment: Monitoring of atrial fibrillation burden after surgical ablation [eComment]

Bockeria, L., Revishvili, A. Sh., Dzhordzhikiya, T. R. — Tue, 17 Nov 2009 10:56:35 PST

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

Efthymiou, C. A., Masudi, T., Charles Thorpe, J. A., Papagiannopoulos, K. — Tue, 17 Nov 2009 10:56:35 PST

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. One hundred and sixteen 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 <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.

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

Tue, 17 Nov 2009 10:56:35 PST

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 one month and one 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 one month and 6% at one year. Shoulder dysfunction was observed in 10% of patients at one month and 6% at one 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.

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

Fibla, J. J., Molins, L., Manuel Mier, J., Vidal, G. — Tue, 17 Nov 2009 10:56:35 PST

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. Sixty-one patients diagnosed for HH and/or FB were operated on VATS SN clipping. Clipping levels varied in function for the sort of disease: FB: T2, palmar HH: T3, axillary HH: T4, palmar-axillary HH: T3-4. Results were evaluated 1 week, 3 months and 12 months after surgery. Fifty-eight of the 61 patients showed improvement of their symptoms (95%). There were minor complications in three 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.

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

Tue, 17 Nov 2009 10:56:36 PST

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 three-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 ST based on stapling device application.

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

Tue, 17 Nov 2009 10:56:36 PST

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 three 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. Seventy-nine 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. Thirty-six patients underwent reoperation >3 months after primary repair, and were included in the efficacy analysis. Mean adhesions score was 8.3 (standard deviation [S.D.] 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 (S.D. 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.

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

Tue, 17 Nov 2009 10:56:36 PST

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 two partial and one 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.

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

Tue, 17 Nov 2009 10:56:36 PST

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.

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

Tue, 17 Nov 2009 10:56:36 PST

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 NMD (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 NMD in MG patients.

Can chronic neuropathic pain following thoracic surgery be predicted during the postoperative period? [Institutional report - Thoracic oncologic]

Searle, R. D., Simpson, M. P., Simpson, K. H., Milton, R., Bennett, M. I. — Tue, 17 Nov 2009 10:56:36 PST

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 three 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 three months after surgery. One hundred patients undergoing video assisted thoracic surgery (VATS) or thoracotomy completed LANSS scores preoperatively and in the immediate postoperative period. Eighty-seven percent completed three months S-LANSS follow-up scores. Eight percent of patients had positive LANSS scores in the immediate postoperative period; 22% of patients had positive S-LANSS scores three 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.

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? [Best evidence topic - Thoracic non-oncologic]

Chambers, A., Scarci, M. — Tue, 17 Nov 2009 10:56:36 PST

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 183 papers were found using the reported search, of which nine 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 (CTD) (4.56 vs.7.6 days) and mean hospital stay (from 2.4 to 7.8 days vs. 6 to 12 days for CTD) 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 spontaneous pneumothorax (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.

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

Bianchi, G., Solinas, M., Bevilacqua, S., Glauber, M. — Tue, 17 Nov 2009 10:56:36 PST

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 tricuspid annulus (TA) diameter is >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.

eComment: Which functional tricuspid regurgitation should be surgically corrected? [eComment]

Bockeria, L. A., Skopin, I. I., Tsiskaridze, I. M. — Tue, 17 Nov 2009 10:56:36 PST

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

Karimov, J. H., Santarelli, F., Murzi, M., Glauber, M. — Tue, 17 Nov 2009 10:56:36 PST

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.

Heparin induced thrombocytopenia in a patient with factor V Leiden following cardiac surgery [Case report - Vascular general]

Chaubey, S., Davidson, S. J., DeSouza, A. C. — Tue, 17 Nov 2009 10:56:36 PST

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.

eComment: Heparin-induced thrombocytopenia [eComment]

Bockeria, L., Samsonova, N., Klimovich, L. — Tue, 17 Nov 2009 10:56:36 PST

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

Watzka, S. B., Setinek, U., Prosch, H., Muller, M. R. — Tue, 17 Nov 2009 10:56:36 PST

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.

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

Galeone, A., Validire, P., Gayet, J.-B., Laborde, F. — Tue, 17 Nov 2009 10:56:36 PST

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.

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

Dutta, R., Kumar, A., Jindal, T., Tanveer, N. — Tue, 17 Nov 2009 10:56:36 PST

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.

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

De Palma, A., Loizzi, D., Sollitto, F., Loizzi, M. — Tue, 17 Nov 2009 10:56:36 PST

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 5th 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 17 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.

Crutch-induced bilateral brachial artery aneurysms [Case report - Vascular general]

Konishi, T., Ohki, S.-i., Saito, T., Misawa, Y. — Tue, 17 Nov 2009 10:56:36 PST

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.

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

Quiroga, J., Prim, J. M. G., Moldes, M., Ledo, R. — Tue, 17 Nov 2009 10:56:36 PST

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 therapy was initiated for esophagitis treatment.

Peripheral venous embolized intracardiac foreign body [Case report - Cardiac general]

Marcello, P., Garcia-Bordes, L., Mendez Lopez, J. M. — Tue, 17 Nov 2009 10:56:36 PST

Embolized intracardiac foreign bodies have been previously described in the literature. Those related to iatrogenic procedures, such as catheters and pacemaker 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.

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

Pathak, S., Page, R. D. — Tue, 17 Nov 2009 10:56:36 PST

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.

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

Matteucci, M. L.S., Rescigno, G., Capestro, F., Torracca, L. — Tue, 17 Nov 2009 10:56:36 PST

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.

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

Ceresa, F., Francio, G., Aldo Intili, P., Patane, F. — Tue, 17 Nov 2009 10:56:36 PST

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.

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

Ding, J. H., Chua, T. C., Glenn, D., Morris, D. L. — Tue, 17 Nov 2009 10:56:36 PST

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.