Interactive CardioVascular and Thoracic Surgery current issue

[Editorial - Pulmonary] The use of sealants in modern thoracic surgery: a survey

2009-06-22

[Work in progress report - Cardiac general] Transpulmonary versus continuous thermodilution cardiac output after valvular and coronary artery surgery

Breukers, R.-M. B.G.E., Groeneveld, A.B. J., de Wilde, R. B.P., Jansen, J. R.C. — 2009-06-22

Residual left-sided valvular insufficiencies after valvular surgery may confound transpulmonary thermodilution cardiac output (COtp). We compared the technique with the continuous right-sided thermodilution technique (CCO) after valvular surgery (n=8) and coronary artery surgery (n=8). Patients with pulmonary and femoral artery catheters in the intensive care unit (ICU) were included. After valvular surgery, there was minimal aortic insufficiency in four patients and minimal to moderate mitral valve insufficiency in six. Five fluid loading steps (250 ml) were done in each patient. CCO and COtp were measured prior to and 15 min after each step. The cardiac output was lower after valvular than coronary artery surgery but responses to fluid loading steps were similar among surgery types and techniques. After valvular and coronary artery surgery, cardiac output was lower prior to responses than in non-responses to fluids, by either technique. After valvular surgery, COtp and CCO correlated (r=0.64, P<0.001, n=48) but fluid-induced changes did not. After coronary artery surgery, COtp and CCO correlated (r=0.81, P<0.001) and changes also did (r=0.55, P<0.001). At fluid-induced CCO increases <20%, the r for changes in cardiac output measured by both techniques was similar after valvular and coronary artery surgery. Thus, COtp and CCO were of similar value in predicting and monitoring fluid responses after both surgery types. This argues against left-sided valvular insufficiencies confounding COtp.

[Work in progress report - Cardiopulmonary bypass] Video-assisted right atrial surgery with a single two-stage femoral venous cannula

Murzi, M., Kallushi, E., Solinas, M., Glauber, M. — 2009-06-22

In the present paper, we report our experience with a single two-stage femoral venous cannula, ideated to drain simultaneously both the superior and the inferior vena cava during minimally invasive cardiac surgery. This cannula has been used in 79 patients (mean age 66.2±11.3 years; mean body surface area 1.9±0.2 m²) who underwent limited access mitral and tricuspid valve surgery at our institution. In our experience, this cannula permits to obtain a safe venous drainage (mean arterial flow 4.7±0.6 l/min, 104±13.3% of the theoretical flow) and it allows for a correct functioning of the pump even when the right atrium is opened. In redo cases (17 patients) the procedure was conducted without snaring the caval veins. In all cases, insertion and positioning of the venous cannula was easily obtained and no patients required a conversion to an alternative perfusion strategy. In conclusion, during minimally invasive procedures requiring opening the right atrium, venous return can be safely accomplished with this two-stage femoral venous cannula. The use of this cannula permits the avoidance of the risk associated with the insertion of a second venous cannula and, in so doing, significantly simplifies the procedure.

[Institutional report - Thoracic non-oncologic] Comparing bipolar electrothermal device and endostapler in endoscopic lung wedge resection

Kovacs, O., Szanto, Z., Krasznai, G., Herr, G. — 2009-06-22

Video-assisted thoracoscopy (VATS) is gaining on thoracic surgery, having newly developed devices next to endostaplers for haemostatic and airtight sealing of lung parenchyma. Though the bipolar electrothermal Ligasure has good results for pulmonary wedge resection, its literature is small in numbers. Authors compared Ligasure and endostapler for pulmonary wedge resection of solitary pulmonary nodules (SPN). Authors performed a retrospective analysis of 44 consecutive patients. The indication of operation was non-verified SPN in all cases. They carried out pulmonary wedge resection for 22 patients with Ligasure–Atlas and 22 patients with ETS Flex endostapler via VATS. Authors examined the gender, average age (62 vs. 49 years), mean hospital stay (6.6 vs. 6.8 days), average operation time (55 vs. 50 min), number of complications (2 vs. 1), average drainage time (2.8 vs. 2.7 days), average fluid loss (190 vs. 160 ml), and instrumental costs ( 367 vs. 756) of both groups. They accomplished the histological analysis of the coagulated lung parenchyma as well. According to the results, the Ligasure–Atlas is eligible for pulmonary wedge resection. The method is safe, easy to use, having minimal rate of complications. It can moderate costs of operation, compared to endostaplers.

[Institutional report - Experimental] A randomised controlled trial comparing Mediwrap(R) heat retention and forced air warming for maintaining normothermia in thoracic surgery

Rathinam, S., Annam, V., Steyn, R., Raghuraman, G. — 2009-06-22

Hypothermia is one of the common complications in the perioperative period. Currently, normothermia is maintained with forced air warming (FAW) or passive heat retention methods. We compared the efficacy of the Mediwrap^® blanket with FAW in maintaining normothermia during intra-operative period in thoracic surgery in a prospective randomised controlled trial on 30 patients. Core temperature was measured at 30-min intervals in the perioperative period and the time taken to attain baseline in the postoperative periods in the two groups was compared. There was no difference in core temperatures between the groups during pre- and intra-operative period, with mean±S.D. final core temperatures of 36.2±0.6 °C with Mediwrap^® and 36±0.9 °C with the FAW blanket. However, the postoperative core temperatures were significantly higher in the Mediwrap^® group. The time required to reach baseline temperature was lower in the Mediwrap^® group with a mean±S.D. of 66±66 min as compared to 161±108 min in the FAW group. The Mediwrap^® blanket is as effective as the FAW blanket in maintaining core body temperature during thoracotomy when applied thirty minutes before the surgery.

[Institutional report - Experimental] Single high-dose intramyocardial administration of erythropoietin promotes early intracardiac proliferation, proves safety and restores cardiac performance after myocardial infarction in rats

2009-06-22

Various studies demonstrate erythropoietin (EPO) as a cardioprotective growth hormone. Recent findings reveal EPO in addition might induce proliferation cascades inside myocardium. We aimed to evaluate whether a single high-dose intramyocardial EPO administration safely elevates early intracardiac cell proliferation after myocardial infarction (MI). Following permanent MI in rats EPO (3000 U/kg) in MI EPO-treatment group (n=99) or saline in MI control group (n=95) was injected along the infarction border. Intramyocardial EPO injection activated the genes of cyclin D1 and cell division cycle 2 kinase (cdc2) at 24 h after MI (n=6, P<0.05) evaluated by real time-PCR. The number of Ki-67⁺ intracardiac cells analyzed following immunohistochemistry was significantly enhanced by 45% in the peri-infarction zone at 48 h after EPO treatment (n=6, P<0.001). Capillary density was significantly enhanced by 17% as early as seven days (n=6, P<0.001). After six weeks, left ventricular performance assessed by conductance catheters was restored under baseline and dobutamine induced stress conditions (n=11–14, P<0.05). No thrombus formation was observed in the heart and in distant organs. No deleterious systemic adverse effects were apparent. Single high-dose intramyocardial EPO delivery proved safety and promoted early intracardiac cell proliferation, which might in part have contributed to an attenuated myocardial functional decline.

[Institutional report - Cardiac general] Effect of melatonin in the prevention of postoperative pericardial adhesion formation

Saeidi, M., Sobhani, R., Movahedi, M., Alsaeidi, S., Eshraghi Samani, R. — 2009-06-22

To evaluate the efficacy of melatonin in preventing postoperative pericardial adhesions, 12 single breed dogs were randomized equally into experimental (melatonin) and control groups. After ketamine anesthesia, a vertical midsternal incision was done and the parietal pericardium of the inferior site of the heart was opened vertically. To promote adhesion formation, abrasions were created on both parietal and visceral pericardial surfaces in an area of 2 cm² with two vertically reciprocal movements of dry gauze. In the melatonin group, 5% ethanol plus 10 mg/kg melatonin in 10 ml NaCl and, in control group, 10 ml NaCl dilution vehicle containing 5% ethanol was instilled intra-pericardium on to the abrasion sites. After a 6-week recovery period, the animals were evaluated for grading of adhesion formation by an examiner blinded to the groups. The extent of adhesions was graded from 0 (no adhesion) to 3 (total involvement of the traumatized area). The results showed that adhesion scores were significantly lower in melatonin group (1.00±0.63) compared with controls (2.66±0.51); P=0.001. We conclude that melatonin administration effectively reduced postoperative pericardial adhesions in dogs. The use of melatonin in the prevention of pericardial adhesion formation in human subjects warrants further investigations.

[Institutional report - Valves] Minimally invasive mitral valve surgery through right thoracotomy in patients with patent coronary artery bypass grafts

2009-06-22

We report our institutional experience, with 25 consecutive patients with patent coronary artery bypass grafts (71.8±12.7 years), who underwent video-assisted minithoracotomic approach for mitral valve surgery. The surgical technique includes: right minithoracotomy, femoral cannulation and hypothermic ventricular fibrillation. Mean preoperative EuroSCORE was 10.2±2.4 and mean ejection fraction was 45±9%. Operative mortality was 4% (1/25). No patient required a conversion to sternotomy. Procedures performed were: mitral valve repair in 15 patients (60%), replacement in 10 (40%) and associated tricuspid repair in seven (28%). Mean blood transfusion was 1.2 package/patient. No cardiological, neurological, vascular and wound complications were observed. Postoperative major morbidity includes: severe pulmonary dysfunction in two patients (8%) and acute renal failure in one (4%). Mean ICU and hospital stay were 3.4±2.9 and 10.6±7.9 days. Echocardiographic follow-up (22.8±14.9 months) revealed trace or mild mitral valve regurgitation in all the mitral repair patients. When interrogated, all the surviving patients preferred the minithoracotomic approach rather than the sternotomy. In conclusion, minimally invasive right thoracotomy can be safely performed in patients with functioning coronary bypass grafts requiring mitral valve operation. Low blood transfusion, the avoidance of deep wound infection and the high patient satisfaction are the main advantages of this approach.

[Institutional report - Congenital] Brain natriuretic peptide is removed by continuous veno-venous hemofiltration in pediatric patients

Ricci, Z., Garisto, C., Morelli, S., Di Chiara, L., Ronco, C., Picardo, S. — 2009-06-22

We wanted to evaluate if brain natriuretic peptide (BNP) is cleared during continuous veno-venous hemofiltration (CVVH) sessions in children with congenital heart disease. A prospective observational single-center study was conducted in a post-cardiac surgery intensive care unit of the city children's hospital. Ten children requiring CVVH for acute kidney injury following cardiac surgery were enrolled. Seven of them were undergoing postoperative extracorporeal membrane oxygenation. BNP clearance was evaluated by the difference between pre-filter and post-filter BNP blood amount indexed to pre-filter BNP concentration. All CVVH treatments were performed with 0.6 m² polyacrylonitrile filter, in predilution setting, at a dose of 80 ml/kg/h. Troponin I and myoglobin levels were also measured and CVVH clearances of these markers calculated for comparison with BNP. A significant decrease in post-filter compared with pre-filter levels of BNP was shown in all 10 cases (P<0.01). Median BNP clearance was 35.6 (29–39.3) ml/min. Troponin I and myoglobin levels did not show any significant drop between pre- and post-filter values (P>0.05) and their clearance was significantly lower than BNP (P: 0.0004). A daily analysis of BNP levels showed a significant decrease of its blood concentration. BNP levels were significantly reduced after three and four days from CVVH start (P<0.05). During 80 ml/kg/h CVVH, utilizing polyacrylonitrile membranes, BNP is efficiently cleared from blood in a small cohort of pediatric post-cardiosurgical patients. In this situation, BNP absolute blood levels may be unpredictable.

[eComment] eComment: Brain natriuretic peptide is removed by continuous veno-venous hemofiltration in pediatric patients

Bockeria, L. A., Yarustovsky, M. — 2009-06-22

[Institutional report - Cardiopulmonary bypass] Comparison of minimally invasive closed circuit versus standard extracorporeal circulation for aortic valve replacement: a randomized study

2009-06-22

To evaluate the clinical results of aortic valve replacement performed with a miniaturized closed circuit extracorporeal circulation (MECC) system and to compare it to standard cardiopulmonary bypass (CPB). One hundred and twenty consecutive patients undergoing isolated aortic valve replacement were randomly assigned to either a miniaturized closed circuit CPB with the maquet-cardiopulmonary MECC System© (study group, n=60) or to a standard CPB (control group, n=60). Demographic characteristic and operative data were similar in the two groups. No hospital death occurred in either group and no difference in intensive care unit (ICU) stay and in-hospital stay was observed. Patients in the study group showed lower chest tube drainage (212±62 ml vs. 420±219 ml, P<0.05) and lower need for blood products (6.1% vs. 40.4%, P<0.05) than patients in the control group. Platelet count at ICU arrival was significantly higher in the study group (139±40x10 ⁹/l vs. 164±75x10 ⁹/l, P=0.05). Peak postoperative troponin I release was significantly lower in the MECC group (3.81±2.7 ng/dl vs. 6.6±6.8 ng/dl, P<0.05). In this randomized study the MECC system has demonstrated best postoperative clinical results in terms of need for transfusion, platelets consumption and myocardial damage as compared to standard CPB.

[Institutional report - Thoracic oncologic] Chromosomal deletion in patients with malignant pleural mesothelioma

Neragi-Miandoab, S., Sugarbaker, D. J. — 2009-06-22

Malignant pleural mesothelioma (MPM) is associated with frequent deletions of specific chromosomal regions within 1p, 3p, 6q, 9p, 13q, 15q, and 22q. In this retrospective review of our patients with MPM, the tumor tissue of 40 patients (31 male and 9 female) was evaluated for chromosomal deletions and was karyotyped. Chromosomal deletions in regions 1p, 3p, 6p, 9p, 6q, 9q, 22q were observed in 22 of 40 patients (55%). Of this group of 22 patients, 15 (68%) demonstrated deletions in chromosome 6; 12 (54%) exhibited deletions in chromosome 22q; and 13 (59%) had deletions in chromosome 9p. Asbestos exposure was found in only 13 of the 22 patients (59%) with chromosomal deletions. There was no correlation between asbestos exposure and chromosomal deletion (95% CI –0.38–0.23, P=0.63). Chromosomal deletion did not correlate with age (95% CI –0.45–0.14, P=0.29). The majority of patients with chromosomal deletions had epithelial histology (17 of 22 patients; 77%), which was not statistically significant (95% CI –0.14–0.46, P=0.27). Chromosomal deletion is common in tumor tissue of MPM and the inactivation of tumor suppressor genes (TSGs) residing in these chromosomes may contribute to mesothelial cell tumorigenesis.

[Institutional report - Thoracic non-oncologic] Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients

Al-Refaie, R. E., Awad, E., Mokbel, E. M. — 2009-06-22

A retrospective study aimed to analyze our experience in 46 patients with blunt traumatic diaphragmatic rupture (BTDR) admitted to our tertiary hospital from 1995 to 2007. Charts, chest roentgenograms (CXR), and computed tomography (CT) scans were carefully reviewed. The mean age was 36.5±10.1 years, 36 (78.3%) were males. The etiology was a traffic accident in 36 (78.3%) patients. BTDR was left-sided in 34 (73.9%) and right-sided in 12 (26.1%) patients. CXR was diagnostic in 26 (56.5%) and CT in 12 (26.1%) patients. Associated injuries included lung 12 (26.1%), liver 10 (21.7%), spleen 24 (52.2%) and bowel 2 (4.2%) patients. BTDR was approached through thoracotomy 26 (56.5%), laparotomy 16 (34.8%), and combined approach 4 (8.7%) patients. The repair was primarily with interrupted non-absorbable sutures in 42 (91.3%) and by prosthetic mesh in four patients. Complications developed in 20 patients. Mortality was observed in 2 (4.3%) patients. We concluded that BTDR is a common lesion in young adult males on the left side caused by a traffic accident. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis. Associated injuries represent the main prognostic factor affecting morbidity and mortality. Thoracotomy and primary repair is adequate surgical treatment.

[eComment] eComment: A practical approach for imaging of diaphragmatic injury

Edwin, F. — 2009-06-22

[Institutional report - Congenital] Do we need fenestration when performing two-staged total cavopulmonary connection using an extracardiac conduit?

2009-06-22

Between August 1999 and December 2007, 72 consecutive patients with single ventricle physiology underwent a modified Fontan procedure after a bidirectional Glenn shunt using an extracardiac polytetrafluoroethylene conduit without fenestration. Nitric oxide gas inhalation was commenced just after cardiopulmonary bypass together with intravenous phosphodiesterase III inhibitor administration. After oral intake was started, pulmonary vascular dilators such as beraprost, sildenafil, bosentan were given orally according to amount of chest drainage and patient's condition. After discharge, oxygen therapy at home was continued for three months. No hospital death occurred after surgery. All patients were followed by our institute and follow-up period was 44.2±26 (36–106.8) months. One late death occurred during this follow-up period after re-operation. Cardiac catheterization after the Fontan completion showed transpulmonary gradient of 5.9±2.4 mmHg, systemic output of 3.4±2.1 l/min m². Arterial oxygen saturation (SaO₂) at the latest outpatient visit was 94.4±3.8%. According to our clinical experience with two-staged total cavopulmonary connection using an extracardiac conduit without fenestration, fenestration in the Fontan circuit is not necessary when performing the Fontan completion. Two-staged extracardiac total cavopulmonary connection without fenestration can be satisfactorily completed with the aid of pulmonary vasodilation therapy.

[eComment] eComment: Re: Do we need fenestration when performing two-staged total cavopulmonary connection using an extracardiac conduit?

Bockeria, L. A., Movsesian, R. R. — 2009-06-22

[Institutional report - Cardiac general] The effect of using microplegia on perioperative morbidity and mortality in elderly patients undergoing cardiac surgery

2009-06-22

Old age is a significant risk factor for perioperative morbidity and mortality following cardiac surgery and optimal myocardial protection strategy should be sought in this group of patients. We, therefore, reviewed the data on 295 consecutive patients older than 75 years who underwent any cardiac surgical procedure. Microplegia was used in 144 patients compared to 151 patients who had the standard 4:1 blood cardioplegia. Logistic regression analysis was used for propensity matching to balance the differences between the two groups. The microplegia group included more females and sicker patients as indicated by higher Parsonnet scores. There were differences in the pump time, aortic cross-clamp time, procedure type and surgeons between the two groups. These differences were balanced using the propensity matching. In-hospital mortality, acute renal injury and confusion were higher in the microplegia group (17%, 34%, 35%, respectively) compared to the standard 4:1 cardioplegia group (9%, 23%, 24%, respectively) (P=0.04, 0.04, 0.04, respectively). These differences were not statistically significant after propensity matching. These results demonstrate that the use of microplegia is safe in patients older than 75 years who are undergoing cardiac surgery and results in similar in-hospital morbidity and mortality to the standard 4:1 blood cardioplegia.

[Institutional report - Aortic and aneurysmal] Mid-term results of thoracic endovascular aortic repair in surgical high-risk patients

2009-06-22

Between May 2001 and June 2008, the outcome and morphological changes in thoracic aortic lesions of 20 surgical high-risk patients who underwent TEVAR were evaluated. Aortic lesions included 8 (40%) type B dissections, 5 (25%) atherosclerotic aneurysms, 4 (20%) penetrating ulcers and 3 (15%) traumatic aortic ruptures. All patients were classified as American Society of Anaesthesiologists class IV and obtained high scores in both the logistic European System for Cardiac Operative Risk Evaluation, median of 14.5% (range 8.1–65.7%), and the STS Parsonet 95 scoring system, median of 14 (range 10–52). Endovascular stent-graft deployment was technically successful in all cases. No surgical conversion occurred. Early mortality was observed in two patients. Clinical and imaging follow-up was available in all patients at a median time of 28 months (range 4–89 months). Overall actuarial survival was 90% at one and five years and 60% at seven years. Mean diameter of the descending aorta decreased from 51.1±13 mm to 45.3±8 mm (P=0.032). Mean reduction in dimension of aneurysms was 10.7±8 mm. Endovascular thoracic aorta repair will probably benefit more patients with multiple comorbidities that limit their life expectancy than patients with a lower profile.

[Institutional report - Esophagus] A surgeon's case volume of oesophagectomy for cancer does not influence patient outcome in a high volume hospital

2009-06-22

The aim of this study is to assess if individual case volume of oesophageal resections influences the operative mortality rate in a high volume hospital. Between June 1994 and June 2006, 252 total thoracic oesophageal resections (75% male, mean age 63 years) were performed by five surgeons in tertiary referral centre. Operative approach was standardised in all cases and consisted of left thoracolaparotomy, resection of all intrathoracic and abdominal oesophagus and left cervical incision for anastomosis. Operative mortality, defined as in-hospital death irrespective of length of stay, was compared among consultants and also trainees. A total of 207 operations were performed by five consultants with nine deaths (4.3%) compared to two deaths after 45 operations by 17 trainees (4.4%) [Fisher's exact test, P=0.61 (CI=0.84–1.26)]. Individual case volume for consultants ranged from 5 to 10.5 cases/years [²-test, P=0.34 (CI=0.89–1.29)] with 0–5.4% mortality rate [²-test, P=0.24 (CI=0.96–1.19)]. Overall hospital volume ranged from 17 to 57 cases/years. This study confirms that surgeons with appropriate training in oesophageal resection may get good results despite lower individual case volumes when a standardised approach is taken in an institution with a high case volume.

[Institutional report - Thoracic oncologic] The maximum standardized uptake values on positron emission tomography to predict the Noguchi classification and invasiveness in clinical stage IA adenocarcinoma measuring 2 cm or less in size

2009-06-22

This study investigated whether the standardized uptake value (SUV) of the tumor correlated with the Noguchi classification and tumor invasiveness in patients with clinical stage IA adenocarcinoma ≤2 cm in size. Fifty-four patients that underwent a curative surgical resection for clinical stage IA adenocarcinoma ≤2 cm from April 2005 to December 2008 had integrated positron emission tomography (PET) – computed tomography (CT) with ¹⁸F-fluorodeoxyglucose (FDG) as part of the preoperative workup. The relationships between the maximum SUV (SUV_max) and Noguchi classification, pathological results of intratumoral lymphatic or vascular invasion of tumor cells, and pleural invasion were examined. In comparison to tumors with an SUV_max>1.0, tumors with an SUV_max≤1.0 were more frequently classified as Noguchi type A or B (P<0.0001). Tumors with an SUV_max>1.0 had more intratumoral lymphatic or vascular invasion of tumor cells and pleural invasion (P=0.0005 and P=0.0002). These results suggest that an SUV_max is an important predictor for the Noguchi classification and tumor invasiveness in patients with clinical stage IA adenocarcinoma ≤2 cm in size.

[Institutional report - Thoracic non-oncologic] Long-term functional results after surgical treatment of parapneumonic thoracic empyema

Casali, C., Susanna Storelli, E., Di Prima, E., Morandi, U. — 2009-06-22

Retrospective evaluation of long-term functional results of surgical treatment of chronic pleural empyema. Two different surgical procedures (debridement vs. decortication) and approaches (VATS vs. thoracotomy) were analyzed. Three end-points were considered: short-term surgical results, short- and long-term radiological results, clinico-functional long-term results. Fifty-one debridement (52% VATS, 48% thoracotomy) and 68 decortication were performed. Postoperative mortality and morbidity were 1.5% and 24%, respectively. Older age (>70 years old) had worse postoperative morbidity (P=0.048). Video-assisted thoracic surgery (VATS) debridement had lower postoperative hospital stay (P=0.006) and shorter duration of chest drainage (P=0.006). The infectious process was resolved in all patients. All patients presented a postoperative radiological improvement, 63 patients (60%) with a complete pulmonary re-expansion. Sixty patients (58%) referred a complete respiratory recovery. VATS debridement had a greater improvement in subjective dyspnea degree (P=0.041). The long-term spirometric evaluation was normal in 58 patients (56%). Age >70 years old resulted the only variable associated to poor long-term results (FEV₁% <60% and/or MRC grade ≥2) at multivariate analysis. Surgical treatment of pleural empyema achieves excellent long-term respiratory outcomes. VATS is associated to less postoperative mortality and shorter postoperative hospital stay. In elderly patients, postoperative morbidity could be higher and long-term functional improvement less warranted.

[eComment] eComment: Is video-assisted thoracoscopic surgery really superior to open decortication for empyema thoracis?

Edwin, F., Frimpong-Boateng, K. — 2009-06-22

[Institutional report - Thoracic oncologic] The maximum standardized 18F-fluorodeoxyglucose uptake on positron emission tomography predicts lymph node metastasis and invasiveness in clinical stage IA non-small cell lung cancer

2009-06-22

In patients with clinical stage IA non-small cell lung cancer (NSCLC), we investigated whether the maximum standardized uptake value (SUV_max) of ¹⁸F-fluorodeoxyglucose (FDG) by the tumor correlated with lymph node metastasis, intratumoral lymphatic and vascular invasion of tumor cells, and pleural invasion. From April 2005 to November 2008, 58 patients underwent a lobectomy with systematic hilar and mediastinal lymph node dissection for clinical stage IA NSCLC. All patients had integrated FDG-positron emission tomography (PET)/computed tomography (CT) performed in our center as part of the preoperative workup within one month of resection. The relationships between the SUV_max and pathologic results of lymph node metastasis, intratumoral lymphatic and vascular invasion of tumor cells, and pleural invasion were examined. Compared with tumors with an SUV_max≤2.0, tumors with an SUV_max>2.0 had more frequent lymph node metastasis, intratumoral lymphatic and vascular invasion of tumor cells and pleural invasion (all P<0.05). Our results suggest that in patients with clinical stage IA NSCLC, SUV_max is an important predictor of tumor invasiveness.

[Institutional report - Congenital] Outcome after reoperation for atrioventricular septal defect repair

2009-06-22

Results of surgical repair of atrioventricular septal defect (AVSD), both partial (PAVSD) and complete (CAVSD), have improved. However, reoperation is not uncommon. This report describes our experience in 59 patients who underwent reoperation after AVSD repair, between 1977 and 2008. Thirty-one patients had a PAVSD, 28 had a CAVSD. Mean interval between initial repair and reoperation was 10±11 years (PAVSD vs. CAVSD: 13±12 vs. 6±9 years, P=0.063). Reoperations were required for left atrioventricular valve regurgitation (LAVVR) in 53 patients (combined with right atrioventricular valve regurgitation in 10, atrial septal defect (ASD) in 11, ventricular septal defect (VSD) in 7, left ventricular outflow tract (LVOT) obstruction in 1, and aortic valve stenosis in 1), ASD in 3, and LVOT obstruction in 3. Valve repair was performed in 45 patients and replacement in 8. Repair techniques of the left-sided atrioventricular valve (LAVV) included cleft closure in 44 patients, commissuroplasty in 19, and annuloplasty in 1. Freedom from additional reoperation was 85%, and 80% at 5 and 15 years. Hospital mortality was 3%. Overall survival was 91%, and 86% after 5 and 15 years. The most common indication to undergo reoperation is LAVVR. Reoperation is safe and in the majority of cases, a durable repair of the LAVV can still be achieved.

[eComment] eComment: Discrete subaortic stenosis following repair of atrioventricular septal defects

Edwin, F., Tettey, M. M., Entsua-Mensah, K., Frimpong-Boateng, K. — 2009-06-22

[Institutional report - Coronary] Prevention of perioperative atrial fibrillation with betablockers in coronary surgery: betaxolol versus metoprolol

2009-06-22

In this study, we tried to compare the efficacy and safety of betaxolol vs. metoprolol immediately postoperatively in coronary artery bypass grafting (CABG) patients and to determine whether prophylaxy for atrial fibrillation (AF) with betaxolol could reduce hospitalization and economic costs after cardiac surgery. Our trial was open-label, randomized, multicentric enrolling 1352 coronary surgery patients randomized to receive betaxolol or metoprolol. The primary endpoints were the composites of 30-day mortality, in-hospital AF (safety endpoints), duration of hospitalization and immobilization, quality of life, and the above endpoint plus in-hospital embolic event, bradycardia, gastrointestinal symptoms, sleep disturbances, cold extremities (efficacy plus safety endpoint). At the end of the study the incidence and probability of early postoperative AF with betaxolol was lower than with metoprolol in coronary surgery (P<0.0001). In the two study groups minor side effects were similar and no major complication was reported (P<0.001). Patient compliance was good and the general condition improved due to shortened hospitalization and immobilization with subsequent improvement in the psychological status, less arrhythmias and lack of significant side effects. In conclusion, because of its efficacy and safety, betaxolol was superior to metoprolol for the prevention of the early postoperative AF in coronary surgery.

[Institutional report - Valves] Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts

2009-06-22

As the population ages, an increasing number of patients with patent coronary grafts will require subsequent aortic valve replacement. Major operative problems include those associated with re-entry and, in particular, damage of the patent grafts. Between January 2007 and October 2008, 10 patients who had previous coronary bypass surgery underwent aortic valve replacement through upper j-shaped mini re-sternotomy. In all patients the previous grafts were patent. The operation was performed with normothermic cardiopulmonary bypass without dissection and temporary closure of the arterial and venous coronary bypass grafts. The mean age was 73.2±13.6 years. The patients had a mean of 2.8±0.6 bypass grafts. There were no intraoperative complications due to redo ministernotomy and at no time conversion to full re-sternotomy was necessary. No damage to the previous grafts was reported and the incidence of perioperative myocardial infarction was 0%. One patient required a pacemaker implantation for atrio-ventricular block. The in-hospital mortality was 0%. Aortic valve replacement in previous coronary bypass grafting can be performed safely with a mini re-sternotomy. This approach avoids extensive dissection, decreasing the risk of injuries to heart chambers and previous patent coronary grafts with low morbidity and mortality.

[eComment] eComment: Mini resternotomy for aortic valve replacement in patients with patent bypass

Murzi, M., Kallushi, E., Solinas, M., Glauber, M. — 2009-06-22

[eComment] eComment: Aortic valve replacement in patients with patent coronary grafts: how to do it?

Botta, L., Martinelli, L. — 2009-06-22

[Institutional report - Cardiac general] Aprotinin increases mortality as compared with tranexamic acid in cardiac surgery: a meta-analysis of randomized head-to-head trials

Takagi, H., Manabe, H., Kawai, N., Goto, S.-n., Umemoto, T. — 2009-06-22

To determine whether aprotinin increases mortality as compared with tranexamic acid in cardiac surgery, we performed a meta-analysis of randomized head-to-head trials. All prospective randomized head-to-head trials of aprotinin vs. tranexamic acid enrolling patients undergoing cardiac surgery were identified using a web-based search engine (PubMed). For each study, data regarding mortality in both the aprotinin and tranexamic acid groups were used to generate risk ratios (RRs) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted averages of logarithmic RRs in random-effects models. Our search identified nine trials (eight trials included in the previous meta-analysis and the blood conservation using antifibrinolytics in a randomized trial [BART] study). Seven trials were composed of low-risk patients (n=1291) and two trials consisted of low-risk patients (n=1628). Pooled analysis of the nine trials demonstrated a statistically significant 45% increase in mortality with aprotinin relative to tranexamic acid therapy (RR, 1.45; 95% CI, 1.00 [1.0002]–2.11; P=0.05 [0.0499]). The present meta-analysis of updated all randomized head-to-head trials, the best evidence, demonstrated a statistically significant increase in mortality with aprotinin relative to tranexamic acid therapy in cardiac surgery.

[eComment] eComment: A comparison of the safety of aprotinin and tranexamic acid in cardiac surgery

Koniari, I., Apostolakis, E., Martha, M. — 2009-06-22

[Institutional report - Thoracic oncologic] Prognostic significance of pleural lavage cytology after thoracotomy and before closure of the chest in lung cancer

2009-06-22

Some reports have described pleural lavage cytology (PLC) to be a prognostic factor for non-small cell lung cancer (NSCLC) patients. However, there have only been a few reports describing the findings both immediately after thoracotomy (PLC after thoracotomy) and before the closure of the chest (PLC before closure). From April 2002 to April 2008, both PLC after thoracotomy and PLC before closure were performed in 296 consecutive patients who underwent resections for NSCLC. PLC after thoracotomy was positive in 14 patients. The survival rate in the PLC after thoracotomy positive cases was significantly poorer than in PLC after thoracotomy negative cases (P=0.047). In contrast, there were 26 PLC before closure positive cases. The survival rate in the PLC before closure positive cases was significantly poorer than in the PLC before closure negative cases (P<0.0001). Multivariate analyses revealed that PLC after thoracotomy is not an independent prognostic factor in our study. However, PLC before closure was an independent prognostic factor based on multivariate analyses. We conclude that PLC before closure was found to be a better prognostic factor than PLC after thoracotomy for NSCLC patients.

[ESCVS article - Vascular general] Nitric oxide: link between endothelial dysfunction and inflammation in patients with peripheral arterial disease of the lower limbs

2009-06-22

Objectives: To analyse the role of nitric oxide (NO) in peripheral arterial disease (PAD) and its association with inflammation and brachial artery flow-mediated dilation (BAFMD) as an estimation of endothelial dysfunction. Material and methods: Cross-sectional study of 82 patients with ischaemia (50 with Fontaine stage II and 32 with Fontaine stage III–IV) in whom BAFMD, hsCRP and nitrite levels in plasma were determined by colorimetric assay using the Griess reaction. They were compared with a control group of healthy subjects (n=41) with ABI >0.9, under 30 years of age. Results: No significant differences were found between the different stages of ischaemia in relation to risk factors or concomitant treatments. The patients with PAD had significantly higher NO levels in plasma than the control group (23.92±23.27 µM vs. 12.77±11.12 µM, P=0.001). However, no statistically significant differences were observed in the NO levels between the two groups of patients with PAD (25.24±24.47 µM vs. 21.86±19.86 µM, P=0.38). Neither were differences found between the two in BAFMD (4.7±4.2 vs. 4.3±2.8, P=0.1). The hsCRP values were statistically higher in PAD stage III–IV (8.2±13.5 vs. 29.2±33.2, P=0.0001). Conclusions: The presence of elevated NO values in PAD, in conjunction with elevated CRP levels, reinforces the theory that atherosclerosis has an inflammatory nature. Its lack of correlation with the clinical severity, also occurring in BAFMD, lends weight to the hypothesis that endothelial dysfunction is an event which takes place in the first stages of the disease.

[ESCVS article - Aortic and aneurysmal] Reimplantation valve-sparing aortic root replacement with the Valsalva graft: what have we learnt after 100 cases?

2009-06-22

Objectives: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and mid-term results. The success of this operation primarily depends on preserving the highly sophisticated dynamic function of the aortic valve by recreating an anatomical three-dimensional configuration similar to the normal aortic root, thus minimizing the mechanical stress and strain on the cusps. Over the years several techniques have been proposed to reproduce the sinuses of Valsalva. We reviewed our experience with aortic valve reimplantation by means of a modified Dacron graft that incorporates sinuses of Valsalva, in a series of 100 consecutive patients. Methods: During a 60-month period, 100 patients with aortic root aneurysm underwent aortic valve reimplantation using the Gelweave Valsalva^TM prosthesis. There were 74 males and the mean age was 60±12 years (range 28–83 years). Five patients had the Marfan's syndrome, 15 had a bicuspid aortic valve. Cusp repair was performed in five patients. The mean follow-up time was 28.6 months (range 1–60). Transesophageal echocardiogram was performed at the end of each procedure to assess the aortic valve in terms of competence, dynamic motion and level of coaptation within the graft. Results: There was one hospital death and two late deaths. Overall survival at 60 months was 91.7±5.1%. Five patients developed severe aortic incompetence (AI) during follow-up requiring aortic valve replacement (AVR). The 60 months freedom from re-operation due to AI was 90.9±4.4%. One patient had moderate AI at latest echocardiographic study. The 60 months freedom from AI>2+ was 91.6±7.9%. Cox regression identified cusp's repair as independent risk factor (P=0.001) for late reimplantation failure (AVR or AI>2+). There were no episodes of endocarditis and the majority of the patients (88%) were in New York Heart Association functional class I. Conclusions: The aortic valve reimplantation with the Gelweave Valsalva^TM prosthesis provided satisfactory mid-term results. An accurate assessment of the level of coaptation of the aortic cusps in respect to the lower rim of the Dacron graft by means of intraoperative transesophageal echocardiogram at the end of each procedure is mandatory in order to avoid early reimplantation failure. Cusp's repair may play an important role in the development of late AI. However, long-term results are needed in order to define the durability of this technique.

[Negative results - Pulmonary] Sudden hemothorax following lobectomy caused by staple

Motoyama, H., Yamashina, A., Chihara, K. — 2009-06-22

A 74-year-old female with lung cancer underwent a right lower lobectomy by video-assisted thoracic surgery (VATS), and suddenly developed hemothorax soon after discharge. The bleeding point was an intercostal artery which faced a stump of the right lower vein divided by a stapler. Operative finding suggested that it was caused by an incidental injury of the artery by a staple.

[Best evidence topic - Cardiac general] Does preoperative computed tomography reduce the risks associated with re-do cardiac surgery?

Khan, N. U., Yonan, N. — 2009-06-22

A best evidence topic was written according to the structured protocol. The question addressed was whether preoperative computed tomography (CT) scan reduces the risk associated with re-do cardiac surgery. A Medline search revealed 412 papers, of which seven were deemed relevant to the topic. We conclude that preoperative CT angiography using ECG-gated multi-detector scan enables excellent anatomical details of heart, aorta and previous grafts, and highlights high-risk cases due to adherent grafts or ventricle or aortic atherosclerosis. This allows for better risk stratification and change of surgical strategy to reduce the potential risk in patients coming for re-do cardiac surgery. According to published reports, high-risk CT-scan findings in these patients caused clinicians to cancel surgery in up to 13% of cases, while preventive surgical strategies including non-midline approach, peripheral vascular exposure or establishing cardiopulmonary bypass prior to re-sternotomy have been reported in over two-thirds of patients with significant reduction in the operative risk. The risk of damage to vital structures, including previous grafts, heart or larger vessels is generally reported fewer than 10%, with evidence of significantly lower incidence of intra-operative injuries in patients who had prior CT-scans compared to those who did not. Hence, adequate preoperative imaging using ECG-gated multi-slice CT is essential for optimum planning of re-do cardiac surgery.

[Case report - Cardiac general] Treatment of high-output coronary artery fistula by off-pump coronary artery bypass grafting and ligation of fistula

Mahesh, B., Navaratnarajah, M., Mensah, K., Amrani, M. — 2009-06-22

Coronary artery fistulas (CAF) are uncommon entities often associated with myocardial ischemia and high output failure. Surgical options include ligation of the fistula, with/without simultaneous coronary artery bypass grafting (CABG). We report a case of left main coronary artery (LMCA) fistula to the coronary sinus (CS), which was associated with high-output bi-ventricular failure, and moderate mitral (MR) and tricuspid regurgitation (TR), related to the volume overload and annular dilatation. This was tackled elegantly by off-pump CABG to protect the territories supplied by the LMCA, followed by ligation of the fistula. This resulted in resolution of the MR and TR. Intraoperative transesophageal echocardiogram (TEE) greatly facilitated the surgical treatment, by identifying the origin and the draining points for the fistula, and aided in the quantification of MR and TR, which had regressed sufficiently at the end of the procedure and did not require surgical correction. This article outlines the importance of multi-disciplinary treatment approach for this complex condition.

[Case report - Cardiac general] Unusual presentation of primary cardiac lymphoma

Bagwan, I. N., Desai, S., Wotherspoon, A., Sheppard, M. N. — 2009-06-22

Cardiac lymphomas are rare neoplasms and account for a minor proportion of primary cardiac malignancies. Secondary involvement of the heart and pericardium by systemic lymphoma is well documented, but primary lymphomas of heart and pericardium are extremely rare, accounting for ~2% of all primary cardiac tumours. Most cases are diagnosed at autopsy, but nowadays, with modern imaging technologies, early diagnosis and treatment is possible. Here, we present two unique incidental presentations of primary cardiac lymphomas (PCL), one in an atrial myxoma and other involving a valvular homograft and discuss the potential pitfalls and prognosis of this rare entity.

[Case report - Pulmonary] Haemo-pneumothorax and haemoptysis in a patient with suspected Ehlers-Danlos syndrome

Purohit, N., Marsland, D., Roberts, N., Townsend, E. — 2009-06-22

We present a case of recurrent haemo-pneumothorax in a young female patient with previously undiagnosed Ehlers–Danlos syndrome (EDS). The patient presented with a spontaneous haemo-pneumothorax not associated with menstruation. Following further subsequent episodes, left lower lobectomy was performed. In the past, the patient had suffered recurrent atraumatic bilateral patella dislocations which were never fully investigated. Histology of the lung tissue revealed features suggestive of EDS. Haemothorax is a rare complication of type IV EDS. There are very few reported cases of pulmonary presentation of EDS type IV.

[Case report - Thoracic non-oncologic] Delayed cardiac tamponade following posttraumatic diaphragmatic hernia without an intrapericardial component

Makhija, Z., Shaygi, B., Deshpande, R., Marrinan, M. — 2009-06-22

We describe a case of posttraumatic diaphragmatic laceration with unusual late sequelae of presentation. Ventilatory and gastrointestinal compromises are known complications of such herniae; but delayed cardiac tamponade without an intrapericardial component of such a hernia has not been reported so far.

[eComment] eComment: Chilaiditis syndrome leading to tamponade

Siniorakis, E., Kirvassilis, G., Exadaktylos, N., Karidis, K. — 2009-06-22

[Case report - Assisted circulation] Safety and efficacy of transbrachial intra-aortic balloon pumping with the use of 7-Fr catheters in patients undergoing coronary bypass surgery

Rubino, A. S., Onorati, F., Serraino, F., Renzulli, A. — 2009-06-22

We report the cases of five consecutive patients undergoing coronary artery bypass grafting (CABG) who required a transbrachial approach for 7-Fr catheter intra-aortic balloon pumping (IABP) insertion because of unsuitable femoral arteries. No adverse outcomes occurred in any patient during a mean 72 h of IABP support. Our experience with 7-Fr catheters appears to confirm previous reports of the safety and efficacy of transbrachial IABP assistance and suggests that such support can be provided safely for an extended duration with the use of these smaller catheters.

[Case report - Valves] On-pump beating heart mitral valve repair in patients with patent bypass grafts and severe ischemic cardiomyopathy

Atoui, R., Bittira, B., Morin, J. E., Cecere, R. — 2009-06-22

Re-operative mitral valve surgery in patients with poor ventricular function can be challenging especially in the presence of patent bypass grafts. We report the case of 11 patients with severe ischemic cardiomyopathy who underwent reoperative mitral valve repair through a limited right thoracotomy approach, on a non-fibrillating beating heart. All patients had their valves successfully repaired with no operative mortality and minimal morbidity. The technical aspects of the procedure are discussed, and the pertinent literature reviewed.

[Case report - Aortic and aneurysmal] Aortic dissection due to sildenafil abuse

Tiryakioglu, S. K., Tiryakioglu, O., Turan, T., Kumbay, E. — 2009-06-22

This report deals with a 28-year-old male patient, admitted with a type A aortic dissection, potentially related to the use of sildenafil. In the literature, we found only two other potentially sildenafil-related cases of aortic dissections, one type A and one type B. In our patient, a bicuspid aortic valve and an ascending aortic aneurysm were other underlying anomalies that could have led to the aortic dissection.

[eComment] eComment: Acute aortic dissection in children and young adults - the role of sildenafil

Edwin, F., Tettey, M. M., Frimpong-Boateng, K. — 2009-06-22

[Case report - Thoracic non-oncologic] Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocyst

Chang, Y.-C., Chen, C.-W. — 2009-06-22

Acute mediastinitis is a life-threatening disease. Common etiologies include surgical infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. Mediastinitis caused by pancreatic disease is rare. The most common thoracic complication of pancreatic disease is reactive pleural effusion. We report a case of acute mediastinitis and bilateral empyema thoracis arising from a pancreatic pseudocyst. We utilized thoracoscopy to drain the mediastinum without drainage of the intra-abdominal cyst. The patient recovered well after operation.

[eComment] eComment: Optimal exposure for debridement of necrotizing mediastinitis and bilateral empyema thoracis

Edwin, F., Tettey, M. M., Tamatey, M., Frimpong-Boateng, K. — 2009-06-22