Revistas

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Early and long-term results of pectoralis muscle flap reconstruction versus sternal rewiring following failed sternal closure [THORACIC]
OBJECTIVES
The aim of the study was to compare early and long-term results of pectoralis muscle flap reconstruction with those of sternal rewiring following failed sternal closure. Primary outcomes of the study were survival and failure rate. Respiratory function, chronic pain and quality of life were also evaluated.
METHODS
In a propensity-score matching analysis, of 94 patients who underwent sternal reconstruction, 40 were selected; 20 underwent sternal reconstruction with bilateral pectoralis muscle flaps (Group 1) and 20 underwent sternal rewiring (Group 2). Survival and failure rates were evaluated by in-hospital records and at follow-up. Respiratory function measures, including vital capacity (VC), were evaluated both by spirometry and computed tomography (CT) volumetry. Chronic pain was evaluated by the visual analogue pain scale.
RESULTS
At 85 ± 24 months of follow-up, survival and procedure failure were 95 and 90% in Group 1 and 60 and 55% in Group 2, respectively (P < 0.01, for both comparisons). Based on CT-scan volumetry, in Group 1, severe non-union and hemisternal paradoxical movement occurred less frequently (2 vs 7, P = 0.01). At spirometry assessment, postoperative VC was greater in Group 1 (3220 ± 290 vs 3070 ± 290 ml, P = 0.04). The same trend was detected by CT-scan in-expiratory measures (4034 ± 1800 vs 3182 ± 862 mm³, P < 0.05). Correspondingly, in Group 1, less patients presented in NYHA Class III (P < 0.05), and both chronic persistent pain score and physical health quality-of-life score were significantly better in the same group.
CONCLUSIONS
In our study, muscle flap reconstruction guaranteed better early and late-term results as shown by lower rates of mortality, procedure failure and hemisternum stability. Moreover, Group 1 patients had greater postoperative VC, lower NYHA class and better quality of life. These results suggest that, in patients with multiple bone fracture, the rewiring approach does not promote physiological bone consolidation, whereas the muscle flap reconstruction can assure more physiological ventilatory dynamics.
Effect of radiofrequency ablation and comparison with surgical sympathectomy in palmar hyperhidrosis [THORACIC]
OBJECTIVES
Hyperhidrosis is a the disorder of excessive sweating in certain regions of the body. It is usually treated with surgical sympathectomy. Radiofrequency therapy has been successfully used for sympatholysis. We tested the primary hypothesis that radiofrequency therapy is independently associated with decreased palmar hyperhidrosis and compared results for patients receiving this treatment with patients who underwent surgical sympathectomy.
METHODS
We included all the patients undergoing treatment for hyperhidrosis between March 2010 and April 2012. Patients who underwent either surgical sympathectomy or radiofrequency ablation for palmar hyperhidrosis were included and analysed. The outcomes studied included complications, success of the procedure, patient satisfaction with their procedure and compensatory hyperhidrosis.
RESULTS
There were 94 patients who met our criteria, of whom 46 (49%) had surgical sympathectomy and 48 (51%) had radiofrequency ablation performed. Radiofrequency had a success rate of 75% in treating hyperhidrosis, but this was found to be statistically lower than for surgical sympathectomy (95%; P < 0.01). The groups were similar regarding patient satisfaction (P = 0.26) and compensatory hyperhidrosis (P = 0.78).
CONCLUSIONS
This is the first clinical study to evaluate the role of radiofrequency ablation and compare it with the surgical treatment option for palmar hyperhidrosis. Radiofrequency ablation significantly decreased hyperhidrosis, but it had a lower success rate than surgical sympathectomy.
Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae [THORACIC]
OBJECTIVES
Tracheo-oesophageal fistula (TOF) is a rare, life-threatening condition. We report our results of surgical treatment and evaluation of the outcome of acquired non-malignant TOF.
METHODS
Twenty-five patients (aged 49 ± 21 years) with TOF were operated on between 2001 and 2011. Tracheo-oesophageal fistula was due to prolonged intubation/tracheostomy (84%), was secondary to other surgery (8%) or trauma (4%) or was idiopathic (4%). The tracheal defect was 2.4 ± 1.3 cm long and was associated with tracheal stenosis in seven (28%) patients. Surgical treatment consisted of direct suturing of the oesophageal defect in two layers (or end-to-end oesophageal resection and anastomosis in one case) associated with tracheal suturing (n = 15; 60%), tracheal resection and anastomosis (n = 8; 32%) or covering of a large tracheal defect by an intercostal muscle flap or by a resorbable patch with muscle apposition (n = 2; 8%). The surgical approach was cervicotomy (n = 14; 56%), cervicotomy plus median sternotomy or split (n = 6; 24%), thoracotomy (n = 4; 16%) or cervicotomy plus sternal spit plus thoracotomy (n = 1; 4%). In 18 (72%) cases a muscular flap was used and in six (24%) a protective tracheostomy was performed.
RESULTS
No perioperative deaths occurred. Morbidity occurred in eight (32%) patients; none of them required a second surgical look. At median follow-up of 41 months, the outcome was excellent or good for 22 patients (88%), two (8%) are still dependent on jejunostomy and tracheostomy for neurological diseases and one (4%) is under mechanical ventilation for end-stage respiratory failure.
CONCLUSIONS
Surgical treatment of TOF is associated with good results in terms of control of acute symptoms and long-term outcome, particularly concerning oral intake and spontaneous breathing.
Subjective impairment after cardiac surgeries: the relevance of postoperative cognitive decline in daily living [ADULT CARDIAC]
OBJECTIVES
Postoperative cognitive decline (POCD) is a frequent complication after cardiac surgeries. It remains unclear how relevant this decline in psychometric results is for daily life. The aim of the study was to assess cognitive failures, as seen by patients and close relatives, on a quantitative level.
METHODS
In addition to an extensive neuropsychological test battery, we interviewed 82 patients with a modified version of the self-assessment cognitive failure questionnaire (s-CFQ) and 62 close relatives (mostly spouses) with the CFQ-for-others version (f-CFQ) before and 3 months after aortic valve replacement. The questionnaires evaluate the frequency of failures in daily living related to memory, attention, action and perception.
RESULTS
POCD occurred in all tests that had been applied to assess declarative memory functions; the mean performance dropped from baseline in these tests (P-values ranging from 0.033 and <0.001). The s-CFQ did not differ between baseline and postoperative assessment [baseline: mean 37.60, standard deviation (SD) 14.38; post: mean 36.22, SD 12.29] (t_{(0.05, 76)} = 1.17; P = 0.246). However, the assessment by others was worse in the f-CFQ after surgery (baseline: mean 8.02, SD 4.51; post: mean 9.58, SD 6.11) (t_{(0.05, 61)} = 2.61; P = 0.012). All changes were observed in questions related to memory and attention failures only. Higher (worse) rates in f-CFQ change scores correlated with neuropsychological change scores, namely in pictorial memory (mistakes) (r = 0.35; P = 0.003) and word fluency (correct answers) (r = –0.29; P = 0.014). Additionally, those patients with worse f-CFQ change scores (>1 SD) from baseline had clearly worse outcomes in word fluency (t_{(0.05, 60)} = 2.53; P = 0.007) and non-verbal learning (t_{(0.05, 60)} = 2.66; P = 0.005). The effects remained significant when controlled for depression/anxiety scores.
CONCLUSIONS
The result demonstrates that cognitive side-effects could have a perceivable impact on daily living functions. However, slight deficits are more realized by others than by the patients themselves. Correlations between ratings by others and psychometric cognitive measures indicate that assessment by others is more reliable than self-assessment.
Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients [ADULT CARDIAC]
OBJECTIVES
Recent studies have suggested an increased risk of stroke in patients undergoing minimally invasive mitral-valve surgery with retrograde perfusion when compared with antegrade perfusion. The aim of the present study was therefore to evaluate the impact on early outcome of retrograde arterial perfusion (RAP) strategy vs antegrade arterial perfusion strategy in a consecutive large cohort of patients who underwent minimally invasive mitral-valve surgery through a right minithoracotomy.
METHODS
Between 2003 and 2012, 1280 consecutive patients underwent first-time minimally invasive mitral-valve surgery at our institution. A total of 167 (13%) of these patients received a retrograde perfusion, while 1113 (87%) received antegrade perfusion. Logistic analysis was used to evaluate outcomes and risk factors for stroke. Treatment selection bias was controlled by constructing a propensity score from core patient characteristics. The propensity score was the probability of receiving retrograde perfusion and was included along with the comparison variable in the multivariable analyses of outcome.
RESULTS
The overall frequency of in-hospital mortality was 1.1% (14/1280) and postoperative stroke was 1.6% (21/1280). After adjusting for the propensity score, RAP was associated with a higher incidence of stroke (5 vs 1%; P = 0.002), postoperative delirium (14 vs 5%, P = 0.001) and aortic dissection (1.7 vs 0%; P = 0.01). Multivariable regression analysis revealed that the use of retrograde perfusion was an independent risk factor for stroke [odds ratio (OR) 4.28; P = 0.02] and postoperative delirium (OR 3.51; P = 0.001).
CONCLUSIONS
Minimally invasive mitral valve procedure can be performed with low morbidity and mortality. The use of retrograde perfusion is associated with a higher incidence of neurological complications and aortic dissection when compared with antegrade perfusion. Central aortic cannulation allows the avoidance of complications associated with retrograde perfusion while extending the suitability of minimally invasive mitral procedures also to those patients who have an absolute contraindication to femoral artery cannulation.
Can the edge-to-edge technique provide durable results when used to rescue patients with suboptimal conventional mitral repair? [ADULT CARDIAC]
OBJECTIVES
The ‘edge-to-edge’ technique (EE) can be used as a bailout procedure in case of a suboptimal result of conventional mitral valve (MV) repair. The aim of this study was to assess the long-term outcomes of this technique used as a rescue procedure.
METHODS
From 1998 to 2011, of 3861 patients submitted to conventional MV repair for pure mitral regurgitation (MR), 43 (1.1%) underwent a rescue edge-to-edge repair for significant residual MR at the intraoperative hydrodynamic test or at the intraoperative transoesophageal echocardiography. Residual MR was due to residual prolapse in 30 (69.7%) patients, systolic anterior motion in 12 (27.9%) and post-endocarditis leaflet erosion in 1 (2.3%). According to the location of the regurgitant jet, the edge-to-edge suture was performed centrally (60.5%) or in correspondence with the anterior or posterior commissure (39.5%). The original repair was left in place.
RESULTS
There were no hospital deaths. Additional cross-clamp time was 15.2 ± 5.6 min. At hospital discharge, all patients showed no or mild MR and no mitral stenosis. Clinical and echocardiographic follow-up was 97.6% complete (median length 5.7 years, up to 14.6 years). At 10 years, actuarial survival was 89 ± 7.4% and freedom from cardiac death 100%. Freedom from reoperation and freedom from MR ≥3+ at 10 years were both 96.9 ± 2.9%. At the last echocardiogram, MR was absent or mild in 37 patients (88%), moderate in 4 (9.5%) and severe in 1 (2.4%). No predictors for recurrence of MR ≥2+ were identified. The mean MV area and gradient were 2.8 ± 0.6 cm² and 2.7 ± 0.9 mmHg. NYHA I–II was documented in all cases.
CONCLUSIONS
A ‘rescue’ EE can be a rapid and effective option in case of suboptimal result of ‘conventional’ MV repair. Long-term durability of the repair is not compromised.
Focus on the unique mechanisms involved in thoracic aortic aneurysm formation in bicuspid aortic valve versus tricuspid aortic valve patients: clinical implications of a pilot study [AORTIC SURGERY]
OBJECTIVES
The involvement of different factors in the onset of thoracic aortic aneurysm (TAA) in patients with a bicuspid aortic valve (BAV) vs those with a tricuspid aortic valve (TAV) is well recognized. However, the molecular, genetic and cellular mechanisms driving TAA remain unclear. The aim of this study was to identify the different mechanisms involved in TAA development in patients with BAV vs TAV.
METHODS
Aorta specimens and DNA samples were collected from 24 BAV (18 men and 6 women; mean age: 54.2 ± 14.39 years) and 110 TAV (79 men and 31 women, mean age: 66 ± 9.8 years) patients. A control group of 128 subjects (61 men and 67 woman, mean age: 61.1 ± 5.8 years) was also enrolled. Histopathological and immunoistochemical analyses were performed, as well as genotyping of 10 polymorphisms.
RESULTS
In BAV-associated ascending aortas, significant severe plurifocal apoptosis of smooth muscle cells and matrix metalloproteinase-9 (MMP-9) amounts were detected. In contrast, TAV-associated ascending aortas were characterized by a significant severity of elastic fragmentation, cystic medial necrosis, medial fibrosis and inflammation. In addition, in BAV cases, the –1562TMMP-9 and –735TMMP-2 alleles represent independent risk factors for TAA. The effects of these genotypes combined with hypertension and smoking in BAV cases result in an increase in both the apoptosis (P = 0.0001) and levels of MMP-9 (P = 0.001). In TAV cases, the D angiotensin-converting enzyme and +896A Toll-like receptor-4 alleles seem to be the predictive factors for TAA risk. They, combined with hypertension and age, significantly increase both the microscopic lesions and inflammation.
CONCLUSIONS
Our data seem to suggest that TAA in BAV and TAV patients arises from different molecular, cellular and genetic mechanisms. They might help to identify the potential molecular and genetic biomarkers that are useful to detect BAV subjects at high TAA risk, to monitor and treat them differently from those with TAV, with approaches such as the complete removal of the ascending aorta, including the aortic root with or without dilatation.
Right papillary muscle sling: proof of concept and pilot clinical experience [BASIC SCIENCE]
OBJECTIVES
Left-sided intraventricular remodelling by papillary muscle approximation associated with annuloplasty of the mitral valve improved outcomes for severe functional mitral regurgitation compared with annuloplasty alone. We conceived of, and studied, a papillary muscle sling on the right side of the heart associated with annuloplasty, seeking to reduce tricuspid valve tethering and right ventricular volumes and to preserve ventricular function.
METHODS
An experimental model on ex vivo porcine hearts established the anatomical feasibility of the procedure. A first-in-man clinical series of 5 patients (3 men) with a mean age of 63.3 years (51–73) had mean right ventricular volumes of 320 ml (280–350) and 200 ml (155–250) in diastole and systole, respectively, and an ejection fraction of 30% (25–40). The mean pulmonary artery pressure was 60 mmHg (55–70), and all had Grade IV/IV tricuspid regurgitation (TR).
RESULTS
There was no operative mortality. Post-repair, magnetic resonance imaging and echocardiographic studies showed mean right ventricle volumes of 165 ml (155–180) and 124 ml (110–140) in diastole and systole, respectively, and an ejection fraction of 28% (25–35) (P = 0.03). TR was <2, gradient across tricuspid valve was ≤4 mmHg and there was no right ventricular outflow tract obstruction. All patients were in New York Heart Association Class ≤2.
CONCLUSION
Intraventricular remodelling with a papillary muscle sling is safe and feasible on the right heart. Short-term follow-up shows that it ameliorates clinical functional status and improves valve competency through reduced tension and tethering of tricuspid leaflets.
Early lung retrieval from traumatic brain-dead donors does not compromise outcomes following lung transplantation [TRANSPLANTATION AND MECHANICAL CIRCULATORY SUPPORT]
OBJECTIVES
To determine whether lung retrieval from traumatic donors performed within 24 h of brain death has a negative impact on early graft function and survival after lung transplantation (LT), when compared with those retrieved after 24 h.
METHODS
Review of lung transplants performed from traumatic donors over a 17-year period. Recipients were distributed into two groups: transplants from traumatic donor lungs retrieved within 24 h of brain death (Group A), and transplants from traumatic donor lungs retrieved after 24 h of brain death (Group B). Demographic data of donors and recipients, early graft function, perioperative complications and mortality were compared between both groups.
RESULTS
Among 356 lung transplants performed at our institution, 132 were from traumatic donors (70% male, 30% female). Group A: 73 (55%); Group B: 59 (45%). There were 53 single, 77 double, and 2 combined LT. Indications were emphysema in 41 (31%), pulmonary fibrosis in 31 (23%), cystic fibrosis in 38 (29%), bronchiectasis in 9 (7%) and other indications in 13 patients (10%). Donor and recipient demographic data, need or cardiopulmonary bypass, postoperative complications and Intensive Care Unit and hospital stay did not differ between groups. Primary graft dysfunction (A vs B): 9 (16%) vs 13 (26%) P = 0.17. PaO₂/FiO₂ 24 h post-transplant (A vs B): 303 mmHg vs 288 mmHg (P = 0.57). Number of acute rejection episodes (A vs B): 0.93 vs 1.49 (P = 0.01). Postoperative intubation time (A vs B): 99 vs 100 h (P = 0.99). 30-day mortality (A vs B): 7 (10%) vs 2 (3.5%) (P = 0.13). Freedom from bronchiolitis obliterans syndrome (A vs B): 82, 72, 37, 22 vs 78, 68, 42, 15%, at 3, 5, 10 and 15 years, respectively (P = 0.889). Survival (A vs B): 65, 54, 46, 42 and 27 vs 60, 50, 45, 43 and 29% at 3, 5, 7, 10 and 15 years, respectively (P = 0.937).
CONCLUSIONS
In our experience, early lung retrieval after brain death from traumatic donors does not adversely affect early and long-term outcomes after LT.
Giant oesophageal polyp prolapse [IMAGES IN CARDIO-THORACIC SURGERY]
Aortic valve surgery and an anomalous origin of the intramural right coronary artery from the ascending aorta [IMAGES IN CARDIO-THORACIC SURGERY]
A huge mediastinal space-occupying lesion [IMAGES IN CARDIO-THORACIC SURGERY]
Is it better to shine a light, or rather to curse the darkness? Cerebral near-infrared spectroscopy and cardiac surgery [EDITORIALS]
Total aortic arch replacement in 2013: where do we go from here? [EDITORIALS]
Acute pulmonary embolectomy [REVIEW]

Acute pulmonary embolism (PE) is a common condition frequently associated with a high mortality worldwide. It can be classified into non-massive, sub-massive and massive, based on the degree of haemodynamic compromise. Surgical pulmonary embolectomy, despite having been in existence for over 100 years, is generally regarded as an option of last resort, with expectedly high mortality rates. Recent advances in diagnosis and recognition of key qualitative predictors of mortality, such as right ventricular stress on echocardiography, have enabled the re-exploration of surgical pulmonary embolectomy for use in patients prior to the development of significant circulatory collapse, with promising results. We aim to review the literature and discuss the indications, perioperative workup and outcomes of surgical pulmonary embolectomy in the management of acute PE.
Currently, children with congenital heart disease are not limited in their submaximal exercise performance [CONGENITAL]
OBJECTIVES
In several former studies, adolescents and adults with congenital heart disease (CHD) had a reduced exercise capacity even with defects considered to be simple. Currently, children might get better medical management and less restrictions concerning an active lifestyle or sports activities. The exercise performance of this new generation of children with CHD has to be evaluated.
METHODS
In the year 2010, 88 children (12.7 years, 52 males), 11–14 years old, with various CHD performed a cardiopulmonary exercise test in our institution. These children were matched for age and gender with healthy subjects who underwent the same procedure at a school survey.
RESULTS
In comparison with healthy controls, children with CHD had a diminished peak oxygen uptake (CHD: 35.5 ml/min/kg vs controls: 42.4 ml/min/kg; P < 0.001) corresponding to 87.1% (CHD) and 99.5% (Controls) of the reference value, respectively. Peak oxygen uptake decreased with the severity of the heart defect (r = –0.410; P < 0.001). However, there was no difference in oxygen uptake at the ventilatory threshold (CHD: 20.6 ml/min/kg vs controls: 21.5 ml/min/kg; P = 0.68).
CONCLUSIONS
Currently, children with CHD are not limited in their submaximal exercise performance. However, there is still a reduction in peak oxygen uptake.
The neoaortic root in children with transposition of the great arteries after an arterial switch operation [CONGENITAL]
OBJECTIVES
Neoaortic root changes in children with transposition of the great arteries (TGA) are reportedly risk factors for the development of neoaortic regurgitation (NeoAR). The aims of this study were to assess the neoaortic root diameter and relative proportion in children with TGA after surgical correction and to identify possible correlations with the development of neoaortic insufficiency.
METHODS
Of the 611 children who had the arterial switch operation performed in the Cardiology Department of the Polish Mother's Memorial Hospital, 172 consecutive patients were qualified for this study. The inclusion criteria were: anatomical correction performed during the neonatal period, more than 10 years of postoperative observation and at least two full echocardiographic examinations.
RESULTS
NeoAR increased during postoperative follow-up and at the end of the observation period, 76% of the patients had NeoAR (27%-trace, 42%-mild, 7%-moderate and 0.6%-severe). Among the analysed risk factors for NeoAR development, the significant ones were arterial valve discrepancy (OR = 2.05; 95% CI: 1.04–4.02; P = 0.031) and the non-facing commissures (OR = 4.05; 95% CI: 1.34–11.9; P = 0.01). The neoaortic root diameter was not statistically significantly correlated with the presence of NeoAR or with the heart defects associated with transposition. The neoaortic root was initially, on average, 37% (z-score = 1.58) bigger than the aortic root in healthy children. This disproportion increased during the follow-up evaluations to 57% (z-score = 2.09).
CONCLUSIONS
The neoaortic root in children after the arterial switch procedure develops differently from that in healthy children, but this is not evidently related to NeoAR development or associated heart defects.
Editorial Comment: Re: The neoaortic root in children with transposition of the great arteries after an arterial switch operation [CONGENITAL]
Cardiac magnetic resonance imaging for perioperative evaluation of sternal eversion for pectus excavatum [THORACIC]
OBJECTIVES
Pectus excavatum is associated with varying degrees of exercise intolerance and symptomatology. Various forms of evaluation have been inconsistent in identifying objective data for correlation with symptoms. Cardiac magnetic resonance (CMR) imaging provides a promising method for delineating the anatomical and physiological components of pectus excavatum as well as measuring the results of surgical repair.
METHODS
Six patients with symptomatic pectus excavatum underwent preoperative evaluation with CMR. All patients had successful, uncomplicated repair of pectus excavatum using the sternal eversion technique. At the first postoperative visit, all patients underwent postoperative evaluation with CMR. Pre- and postoperative CMR measurements were compared for each patient.
RESULTS
Preoperative CMR demonstrated evidence of anatomical and dynamical compression of the heart in all patients. After surgery, all patients showed improvement on postoperative CMR. Five of the 6 (83%) patients had complete relief of right ventricular compression, and 5 of the 6 (83%) patients had relief of left atrial compression. The degree of antero-posterior chest wall narrowing was also markedly improved, with an average postoperative vs preoperative Haller index of 3.2 (range, 2.7–3.8) vs 5.0 (range, 4.0–5.9).
CONCLUSIONS
After surgical correction of pectus excavatum with the sternal eversion technique, CMR demonstrates improvement in both anatomical chest wall contour and cardiac performance. Sternal eversion provides the most complete anatomical correction and greatest relief of internal cardiac compression. We recommend CMR as the definitive modality for evaluation of patients with pectus excavatum, as this modality shows that the primary underlying physiological abnormality in pectus excavatum is cardiac compression.
Editorial Comment: Is it possible to detect postoperative improvements in cardiac function through magnetic resonance imaging in patients with pectus excavatum--at rest? [THORACIC]
Risk factors influencing the pleural drainage volume after transthoracic oesophagectomy [THORACIC]
OBJECTIVES
The objective of this study was to clarify the factors influencing pleural drainage volume after transthoracic oesophagectomy and to determine criteria for the selection of patients who would benefit from the early removal of chest drains.
METHODS
Clinicopathological characteristics of 155 patients who underwent transthoracic oesophagectomy were prospectively collected, and the daily drainage volume of each patient was retrospectively reviewed. Potential risk factors were compared between the high-output group (n = 39) and low-output group (n = 116), which were dichotomized using the 75th percentile of total pleural drainage volume of the total study population. Multivariate logistic regression analyses were used to identify independent risk factors.
RESULTS
The median duration of drainage was 10 days, with a median total drainage volume of 2258 ml. Of 27 potential risk factors influencing the drainage volume, creatinine clearance (P = 0.04), operative approach (P = 0.03) and thoracic duct removal (P = 0.01) were significantly associated with the total pleural drainage volume. The removal of the thoracic duct (P = 0.02; odds ratio, 4.02; 95% confidence interval 1.20–13.41) and lower creatinine clearance (P = 0.04; odds ratio, 1.02; 95% confidence interval 1.00–1.04) was independent risk factors for increased pleural drainage volume after transthoracic oesophagectomy.
CONCLUSIONS
The early removal of chest drains may be possible in patients without these risk factors.
Is video-assisted lobectomy for non-small-cell lung cancer oncologically equivalent to open lobectomy? [THORACIC]
OBJECTIVES
The purpose of this study was to compare overall and disease-free survival after VATS and open lobectomy for clinical Stage I and II non-small-cell lung cancer (NSCLC).
METHODS
A retrospective review of a prospective database of all patients undergoing VATS or open lobectomy for clinical Stage I or II NSCLC between 2002 and 2010 was performed. Postoperative outcomes, disease-free survival and overall survival were compared between the two groups after optimum 1:1 propensity matching for age, gender, tumour histology and pathological stage.
RESULTS
Over an 8-year period, 608 patients underwent lobectomy for NCSLC by VATS (n = 196, 32%) or open technique (n = 412, 68%). After matching, there were 190 patients in each group. Adenocarcinoma was found in 80% (open: 149, VATS: 152) and 55% of tumours were T1 (open: 108, VATS: 105). Pathological N1 disease was found in 21 and 19 patients in the open and VATS group, respectively. Disease-free 5-year survival was 69.1% for the open group vs 69.7% for VATS (P = 0.94). Cancer-specific 5-year survival was 82.9% for the open group vs 76.7% for VATS (P = 0.170). Five-year overall survival was 73% in the open group vs 64% in the VATS group (P = 0.17). Operative mortality and postoperative complications were not significantly different between groups.
CONCLUSIONS
Overall survival and disease-free survival are not significantly different when compared between VATS lobectomy and open lobectomy. VATS resection appears to provide an adequate oncological operation for patients with operable clinical Stage I and II NSCLC.
Significance of tumour vessel invasion in determining the morphology of isolated tumour cells in the pulmonary vein in non-small-cell lung cancer [THORACIC]
OBJECTIVES
The existence of clustered isolated tumour cells (ITCs) in the pulmonary vein (PV) of the lungs of patients with lung cancer has been reported to be a prognostic factor. However, the clinical–pathological characteristics related to their presence in the PV remain unclear.
METHODS
We analysed the surgical results and clinical–pathological findings of 130 patients who underwent surgery for non-small-cell lung cancer in regard to blood vessel invasion (BVI), serum carcinoembryonic antigen (CEA) level, maximum standardized uptake value (SUV-max), size of the solid region in computed tomography findings and pathological stage according to an ITC type, i.e. no tumour (N), singular tumour cells (S) and clustered tumour cells (C).
RESULTS
ITCs were detected in 96 (74%) of the patients, with C observed in 43, S in 53 and N in 34. Recurrence was seen in 33 (26%) cases, 21 of which were classified as C, 9 as S and 3 as N. The disease-free survival rate was significantly worse in C cases when compared with the others (P < 0.01). The rate of C was high in cases with high serum CEA, advanced p-staging and positive BVI ratio. Furthermore, BVI positive and ITC morphology were strongly related (BVI positive; 79 in C, 40 in S, 9% in N; P < 0.01).
CONCLUSIONS
Clustered ITCs were shown to be a prognostic indicator and strongly related to BVI. Our results suggest that determination of BVI has prognostic value, as clustered ITCs with metastatic potential are disseminated from the invaded vein.
Clinicopathological features of thymic carcinomas and the impact of histopathological agreement on prognostical studies [THORACIC]
OBJECTIVES
Thymic carcinomas have wide ranges of reported survival. Interobserver agreement on diagnosis might affect prognostical studies. Clinicopathological features of thymic carcinomas were compared with thymic epithelial neoplasms in which pathologists disagreed upon.
METHODS
Patients treated with thymic epithelial neoplasms were reviewed. Three thoracic pathologists independently classified all cases according to the World Health Organization classification. The study group comprised cases in which all pathologists agreed independently on thymic carcinomas. A disagreement group included cases in which pathologists disagreed upon the diagnosis. Tumours were staged according to the modified Masaoka and tumour-node metastasis (TNM) stages. Time-to-death was estimated with the Kaplan–Meier method. Survival outcomes were assessed with the Cox proportional-hazards regression.
RESULTS
In the study group, 25 of 29 patients presented with symptoms but no autoimmune diseases. Masaoka stage III (18 of 29) and TNM stage III (13 of 24) were most common. Complete tumour resection was achieved in 17 of 29. Four patients had metastasis at diagnosis, and 12 developed metastasis/recurrence post-treatment. The estimated 5-year survival was 35.6%, and recurrence/metastasis-free survival was 34.2%. Overall survival was associated with weight loss (P = 0.02) and metastasis/recurrence with morphology (P = 0.009). In the disagreement group, most disagreements occurred between type B3 thymomas and carcinomas (21 of 29). Twenty-four of the 29 patients presented with symptoms, including autoimmune disorders (12 of 29). Masaoka stage III (10 of 29) and TNM stage IV (10 of 17) were most common. Twenty-one of the 29 underwent complete tumour resection. The estimated 5-year survival was 64.9%. Two patients had metastasis at diagnosis and eight developed metastasis/recurrence post-treatment. The study group had significantly more patients with chest pain and additional treatment than the disagreement group (P = 0.005 and 0.044, respectively). The disagreement group had more patients with myasthenia gravis and a higher TNM stage (P = 0.0003 and 0.025, respectively). The risks of death and recurrence/metastasis were significantly higher in the study group than the disagreement group [P = 0.025, hazard ratio (HR) = 2.44 and P = 0.012, HR = 3.23, respectively].
CONCLUSIONS
Thymic carcinomas were diagnosed at high stages and the overall prognosis appeared relatively poor. Autoimmune disease was not a manifestation of thymic carcinomas. Weight loss was associated with survival. The disagreement group in contrast had more patients with autoimmune syndrome and, despite a higher stage, had a better survival, suggesting that interobserver variability in the histopathological classification of thymic carcinomas vs thymomas leads to prognostical variability.
Near-infrared spectroscopy for neuromonitoring of unilateral cerebral perfusion [ADULT CARDIAC]
OBJECTIVES
There is neither consensus regarding which methods of neuromonitoring are adequate and reliable for assessing cerebral cross-perfusion during unilateral cerebral perfusion (UCP) nor are any threshold values defined. The aim of the study was to evaluate the usefulness of near-infrared spectroscopy (NIRS) for the neuromonitoring of right-sided UCP, which is increasingly used for cerebral protection as a consequence of the recent rise in supra-aortic cannulation methods.
METHODS
For the purpose of the study, 122 patients (mean age 67 ± 12 years) who underwent open aortic arch surgery between August 2007 and July 2011 using right-sided UCP with a duration time exceeding 20 min were evaluated. The neuromonitoring consisted of NIRS and pressure measurement in both radial arteries in all patients. Forty-four (36%) patients suffered acute aortic dissection (3 having cerebral malperfusion), and 89 (73%) underwent total or subtotal arch replacement. Logistic regression analysis was used to model neurological adverse outcome (permanent and temporary neurological dysfunctions) as a function of cerebral oxygen saturation and other covariates.
RESULTS
During UCP (mean duration 38 ± 18 min) performed at a constant blood temperature of 28°C, the mean brain oxygen saturation dropped on the non-direct perfused side from 66 to 61% on average, corresponding to 92% of the baseline. In only 1 patient, an insufficient cross-over perfusion was presumed due to an intense drop of the saturation to 15% and was treated by employment of bilateral perfusion. In all remaining patients, the drop was not below 40% and/or 70% of the baseline. In the adjusted analysis, acute aortic dissection could be found as an independent predictor of an adverse neurological outcome (5 permanent, all in acute dissections, and 9 temporary dysfunctions), while there was no association between the occurrence of adverse neurological outcome and the values of regional cerebral oxygen saturation during UCP.
CONCLUSIONS
NIRS seems to be a reliable instrument to recognize a relevant disruption of cerebral cross-perfusion during UCP. A drop of brain oxygen saturation to 40% and/or 70% of the baseline can be considered a threshold value for sufficient cerebral cross-perfusion, at least under the flow and temperature management presented.
Editorial Comment: Uni- or bilateral antegrade cerebral perfusion: that is the question! [ADULT CARDIAC]
Dynamic trends in cardiac surgery: why the logistic EuroSCORE is no longer suitable for contemporary cardiac surgery and implications for future risk models [ADULT CARDIAC]
OBJECTIVES
Progressive loss of calibration of the original EuroSCORE models has necessitated the introduction of the EuroSCORE II model. Poor model calibration has important implications for clinical decision-making and risk adjustment of governance analyses. The objective of this study was to explore the reasons for the calibration drift of the logistic EuroSCORE.
METHODS
Data from the Society for Cardiothoracic Surgery in Great Britain and Ireland database were analysed for procedures performed at all National Health Service and some private hospitals in England and Wales between April 2001 and March 2011. The primary outcome was in-hospital mortality. EuroSCORE risk factors, overall model calibration and discrimination were assessed over time.
RESULTS
A total of 317 292 procedures were included. Over the study period, mean age at surgery increased from 64.6 to 67.2 years. The proportion of procedures that were isolated coronary artery bypass grafts decreased from 67.5 to 51.2%. In-hospital mortality fell from 4.1 to 2.8%, but the mean logistic EuroSCORE increased from 5.6 to 7.6%. The logistic EuroSCORE remained a good discriminant throughout the study period (area under the receiver-operating characteristic curve between 0.79 and 0.85), but calibration (observed-to-expected mortality ratio) fell from 0.76 to 0.37. Inadequate adjustment for decreasing baseline risk affected calibration considerably.
DISCUSSIONS
Patient risk factors and case-mix in adult cardiac surgery change dynamically over time. Models like the EuroSCORE that are developed using a ‘snapshot’ of data in time do not account for this and can subsequently lose calibration. It is therefore important to regularly revalidate clinical prediction models.
Editorial Comment: Dynamic trends in cardiac surgery require dynamic models [ADULT CARDIAC]
Acetylsalicylic acid treatment until surgery reduces oxidative stress and inflammation in patients undergoing coronary artery bypass grafting [ADULT CARDIAC]
OBJECTIVES
Acetylsalicylic acid (ASA) is a cornerstone in the treatment of coronary artery disease (CAD) due to its antiplatelet effect. Cessation of aspirin before coronary artery bypass grafting (CABG) is often recommended to avoid bleeding, but the practice is controversial because it is suggested to worsen the underlying CAD. The aims of the present prospective, randomized study were to assess if ASA administration until the day before CABG decreases the oxidative load through a reduction of inflammation and myocardial damage, compared with patients with preoperative discontinuation of ASA.
METHODS
Twenty patients scheduled for CABG were randomly assigned to either routine ASA-treatment (160 mg daily) until the time of surgery (ASA), or to ASA-withdrawal 7 days before surgery (No-ASA). Blood-samples were taken from a radial artery and coronary sinus, during and after surgery and analysed for 8-iso-prostaglandin (PG) F_2α; a major F₂-isoprostane, high-sensitivity C-reactive protein (hs-CRP), cytokines and troponin T. Left ventricle Tru-Cut biopsies were taken from viable myocardium close to the left anterior descending artery just after connection to cardiopulmonary bypass, and before cardioplegia were established for gene analysis (Illumina HT-12) and immunohistochemistry (CD45).
RESULTS
8-Iso-PGF_2α at baseline (t₁) were 111 (277) pmol/l and 221 (490) pmol/l for ASA and No-ASA, respectively (P = 0.065). Area under the curve showed a significantly lower level in plasma concentration of 8-iso-PGF_2α and hsCRP in the ASA group compared with the No-ASA group with (158 pM vs 297 pM, P = 0.035) and hsCRP (8.4 mg/l vs 10.1 mg/l, P = 0.013). All cytokines increased during surgery, but no significant differences between the two groups were observed. Nine genes (10 transcripts) were found with a false discovery rate (FDR) <0.1 between the ASA and No-ASA groups.
CONCLUSIONS
Continued ASA treatment until the time of CABG reduced oxidative and inflammatory responses. Also, a likely beneficial effect upon myocardial injury was noticed. Although none of the genes known to be involved in oxidative stress or inflammation took a different expression in myocardial tissue, the genetic analysis showed interesting differences in the mRNA level. Further research in this field is necessary to understand the role of the genes.
Editorial Comment: Reduction of oxidative stress: a new indication for acetylsalicylic acid in coronary artery bypass surgery [ADULT CARDIAC]
Red cell distribution width and coronary artery bypass surgery [ADULT CARDIAC]
OBJECTIVES
The red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with coronary artery disease with or without heart failure. We sought to investigate the role of RDW in patients undergoing isolated coronary artery bypass graft surgery (CABG).
METHODS
Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Univariate and multivariate analysis was performed for in hospital mortality, long-term survival, length of hospital stay, length of intensive care unit stay and creatinine kinase muscle–brain (CKMB) release.
RESULTS
Overall mortality was 2.1% for all cases, N = 8615. Median follow up was 5.8 years. Univariate analysis demonstrated that the RDW has a significant effect on CKMB release, P = 0.001, in-hospital mortality, P < 0.0001, and long-term survival, P < 0.0001, but no significant effect on the ITU length of stay, P = 0.9, or hospital length of stay, P = 0.2. Multivariate analysis revealed that the RDW was a significant factor determining in-hospital mortality and long-term survival, but had no significant effect on CKMB release, ITU or hospital length of stay. Confounding factor analysis revealed that in the absence of anaemia, the RDW was still a significant factor determining in-hospital mortality and long-term survival.
CONCLUSIONS
The RDW is a significant factor determining in-hospital mortality and long-term survival in patients undergoing isolated CABG. The mechanism of association requires further study.
Cryopreserved human allografts (homografts) for the management of graft infections in the ascending aortic position extending to the arch [AORTIC SURGERY]
OBJECTIVES
The management of infected Dacron grafts in the ascending aortic position involving the aortic arch and aortic root remains a technical challenge. Total replacement of the infected graft material with cryopreserved homografts appears to be an effective treatment strategy for these patients.
METHODS
Seventeen consecutive patients were operated on for infection of their ascending aortic graft where the aortic arch was also involved 26 ± 33 months after initial surgery, in 70%, for type A aortic dissection (12 acute aortic dissection type A and 1 chronic aortic dissection type A). The aortic root was additionally affected in 14 patients. Computed tomography and echocardiography follow-up was performed in all patients.
RESULTS
Hospital mortality was 24% (n = 4). Cardiopulmonary bypass and aortic cross-clamp times were 288 ± 128 and 165 ± 78 min, respectively. In 14 patients, the aortic root was replaced. Hypothermic circulatory arrest was necessary in all patients (41 ± 25 min) with additional cold selective antegrade cerebral perfusion in 14 (41 ± 30 min). During follow-up, 1 patient died due to a cerebral haemorrhage at 3 months and another at 4 years, of pulmonary embolism. Two patients were successfully reoperated on for degeneration of the aortic valve at 16 and 94 months; 1 patient had an early degeneration of the homograft and needed re-replacement with a homograft. In 2 other patients, a stent graft had to be placed to cover the distal anastomosis between the homograft and native aorta. In all others, recent follow-up revealed no degeneration of the implanted homografts.
CONCLUSIONS
Surgery for infected Dacron grafts in the ascending aortic position with involvement of the arch can be performed with an acceptable perioperative mortality. In case of degeneration of the valve, reoperations can be performed with good results in experienced hands. Therefore, we consider the concept of complete explantation of all infected material and replacement with homografts a successful treatment strategy. Nevertheless, close follow-up of the patients is mandatory so as not to miss any degeneration or reinfection of the implanted grafts.
Editorial Comment: Re: Cryopreserved human allografts (homografts) for the management of graft infections in the ascending aortic position extending to the arch [AORTIC SURGERY]
Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms [AORTIC SURGERY]
OBJECTIVES
Postoperative infection control is one of the most important issues for infected aortic aneurysms, and the methods of preventing recurrent infection remain controversial. We previously reported that omental flaps could prevent or reduce the occurrence of infection after implanting an artificial aortic graft. However, the long-term outcomes of this strategy are unknown. We used imaging modalities to evaluate whether wrapping prosthetic grafts with omentum prevents postoperative graft infection over the long-term.
METHODS
We surgically treated 521 patients with thoracic aortic aneurysm (TAA) at our hospital between July 1995 and May 2012. Of these, 22 (3.9%) (male, n = 17; mean age, 68.2 ± 11.4 years) had infectious TAA. All infectious aneurysms were resected, all patients received in-situ grafts and 16 grafts were wrapped with omentum. We followed up all survivors annually using computed tomography. We also used angiography to investigate blood circulation in omental flaps over the long-term.
RESULTS
Five patients died in-hospital (operative mortality, 26.3%). The operative mortality rates of patients with and without omental wrapping were 12.5 and 50.0%, respectively (P = 0.06, NS), and the 5-year event-free survival rates were 84.6 and 33.3% (P = 0.025), respectively. Omental flaps around prosthetic grafts and their blood circulation were well-preserved over the long-term.
CONCLUSIONS
Wrapping implanted artificial aortic grafts with omental flaps could prevent or reduce the occurrence of subsequent infection. Furthermore, blood circulation in the flaps must be well-preserved to improve the long-term outcomes.
Detection of thoracic aortic prosthetic graft infection with 18F-fluorodeoxyglucose positron emission tomography/computed tomography [AORTIC SURGERY]
OBJECTIVES
To investigate the diagnostic value of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in detecting thoracic aortic prosthetic graft infection.
METHODS
Nine patients with clinically suspected thoracic aortic graft infection underwent FDG-PET/CT scanning. In these patients, the diagnoses could not be confirmed using conventional modalities. The patients' clinical courses were retrospectively reviewed.
RESULTS
On the basis of surgical, microbiological and clinical follow-up findings, the aortic grafts were considered infected in 4 patients and not infected in 5. All 4 patients with graft infection (root: 2 cases, arch: 1 case and descending: 1 case) eventually underwent in situ re-replacement. Two of the 4 patients also had abdominal grafts; however, only the thoracic grafts were replaced because uptake was low around the abdominal grafts. The maximal standardized uptake value (SUV_max) in the perigraft area was higher in the infected group than in the non-infected group (11.4 ± 4.5 vs 6.9 ± 6.4), although the difference was not statistically significant. According to the receiver operating characteristic analysis, SUV_max >8 appeared to be the cut-off value in distinguishing the two groups (sensitivity: 1.0 and specificity: 0.8).
CONCLUSIONS
FDG-PET/CT is useful for confirming the presence of graft infection by detecting high uptake around grafts and excluding other causes of inflammation. An SUV_max value greater than 8 around a graft suggests the presence of graft infection. In addition, FDG-PET/CT can be used to clarify the precise extent of infection. This is especially useful if multiple separated prosthetic grafts have been implanted.
A new and simple classification for sinus of Valsalva aneurysms and the corresponding surgical procedure [AORTIC SURGERY]
OBJECTIVES
The classification system of Sakakibara and Konno for sinus of Valsalva aneurysm (SVA) is highly complex and seldom utilized in clinical practice. In this study, we propose a new and simple classification system; we suggest a novel approach that utilizes four distinct types of SVAs.
METHODS
We retrospectively studied 257 cases of SVAs in which surgical repair was performed between October 1996 and December 2009 and divided these cases into four types: I, rupture or protrusion into the right atrium; II, rupture or protrusion into the right atrium or right ventricle near or at the tricuspid annulus; III, rupture or protrusion into the right ventricular outflow tract under pulmonary valve and IV, others. The surgical results of the different approaches in each respective type were compared as follows: cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, intensive care unit time and postoperative stay time.
RESULTS
In all the patients, there was no early postoperative death; all the patients recovered and were discharged as expected. There were no significant differences in intensive care unit time and postoperative stay time among different approaches in each type (P > 0.05). Two hundred and thirty-eight (92.61%) patients were followed up.
CONCLUSIONS
Surgical repair of SVAs exhibited good long-term results. Our classification of SVA could be potentially helpful for surgical practice. For Type I, the right atrium approach is advised; for Type II, the transaortic approach with a right atrium incision is advised; for Type III, the transaortic approach with pulmonary incision is advised while for Type IV, repair according to the respective situation is advisable.
Ischaemic preconditioning prevents the liver inflammatory response to lung ischaemia/reperfusion in a swine lung autotransplant model [BASIC SCIENCE]
OBJECTIVES
Lung ischaemia/reperfusion (IR) induces a systemic inflammatory response that causes damage to remote organs. The liver is particularly sensitive to circulating inflammatory mediators that occur after IR of remote organs. Recently, remote ischaemic preconditioning has been proposed as a surgical tool to protect several organs from IR. The present study was designed to investigate a possible protective effect of lung ischaemic preconditioning (IP) against the liver inflammatory response to lung IR.
METHODS
Two groups [IP and control (CON)] of 10 Large White pigs underwent lung autotransplants (left pneumonectomy, ex situ cranial lobectomy and caudal lobe reimplantation). Before pneumonectomy was performed in the study group, IP was induced with two 5-min cycles of left pulmonary arterial occlusion and a 5-min interval of reperfusion between the two occlusions. Five animals underwent sham surgery. Liver biopsies were obtained during surgery at (i) prepneumonectomy, (ii) prereperfusion, (iii) 10 min after reperfusion of the implanted lobe and (iv) 30 min after reperfusion. The expression of tumor necrosis factor-α (TNF-α), interleukin (IL)-1, IL-10 and inducible form of nitric oxide synthase (iNOS) was analysed by western blotting. The expression of mRNA for TNF-α, IL1, IL-10, monocyte chemoattractant protein-1 (MCP-1), nuclear factor kappa beta and iNOS was analysed by reverse transcription–polymerase chain reaction. Caspase-3 activity was determined by enzyme-linked immunosorbent assay. Non-parametric tests were used to compare differences between and within groups.
RESULTS
Lung IR markedly increased expression of TNF-α (P = 0.0051) and IL-1 (P = 0.0051) and caspase-3 activity (P = 0.0043) in the CON group compared with the prepneumonectomy levels. A decrease of IL-10 mRNA expression was observed in the CON group after lung reperfusion. In the IP group, TNF-α (P = 0.0011) and IL-1 (P = 0.0001) expression and caspase-3 activity (P < 0.0009) were lower after reperfusion than in the CON group. IP caused reversion of the observed decrease of IL-10 mRNA expression (P = 0.016) induced in liver tissue by lung IR. Lung IR markedly increased the expression of mRNA MCP-1 after 10 min (P = 0.0051) and 30 min (P = 0.0051) of reperfusion. These increases were not observed in the IP or sham groups.
CONCLUSIONS
IP prevented liver injury induced by lung IR through the reduction of proinflammatory cytokines and hepatocyte apoptosis.
Adenosine injection prior to cardioplegia enhances preservation of senescent hearts in rat heterotopic heart transplantation [BASIC SCIENCE]
OBJECTIVES
Advanced donor age is one of the risk factors for graft failure and is the leading cause of early death after heart transplantation. Better myocardial preservation methods should reduce graft failure. The purpose of this study was to determine if adenosine, which is known to enhance cardioplegic protection, enhances myocardial preservation during heart transplantation using older donors.
METHODS
We used a rat heterotopic heart transplantation model with Lewis rats that were at least 60 weeks old as donors. We injected saline (control) or adenosine (0.1 or 0.2 mg/kg) before cardioplegia, perfused with cold Celsior and stored the hearts in Celsior for 6 h at 4°C. The grafts were transplanted into syngenic, 12–16-week old recipients, and blood and tissue were collected 3 h after reperfusion.
RESULTS
Bolus injection of adenosine led to faster mechanical arrest after perfusion with Celsior and faster reanimation after reperfusion compared with controls. Adenosine treatment significantly reduced myocardial injury, as indicated by serum troponin I and creatine phosphokinase levels. The mRNAs for inflammatory cytokines were markedly increased in the control grafts, but were less upregulated in the grafts treated with adenosine. The grafts treated with adenosine also exhibited less mitochondrial damage, fewer infiltrating cells and a higher adenosine triphosphate content.
CONCLUSIONS
Adenosine injection prior to perfusion of cardioplegia significantly reduced cold ischaemia/reperfusion injury in cardiac grafts from older donors and improved the stores of cellular energy after reperfusion. This procurement protocol may be clinically feasible and should be considered in the clinical setting, particularly for older donors.
Editorial Comment: Adenosine in heart transplants: have we finally found the good indication? [BASIC SCIENCE]
Development of cardiac support bioprostheses for ventricular restoration and myocardial regeneration [BASIC SCIENCE]
OBJECTIVES
Ventricular constraint devices made of polyester and nitinol have been used to treat heart failure patients. Long-term follow-up has not demonstrated significant benefits, probably due to the lack of effects on myocardial tissue and to the risk of diastolic dysfunction. The goal of this experimental study is to improve ventricular constraint therapy by associating stem cell intrainfarct implantation and a cell-seeded collagen scaffold as an interface between the constraint device and the epicardium.
METHODS
In a sheep ischaemic model, three study groups were created: Group 1: coronary occlusion without treatment (control group). Group 2: postinfarct ventricular constraint using a polyester device (Acorn CorCap). Group 3: postinfarct treatment with stem cells associated with collagen matrix and the polyester device. Autologous adipose mesenchymal stem cells cultured in hypoxic conditions were injected into the infarct and seeded into the collagen matrix.
RESULTS
At 3 months, echocardiography showed the limitation of left ventricular end-diastolic volume in animals both treated with constraint devices alone and associated with stem cells/collagen. In Group 3 (stem cell + collagen treatment), significant improvements were found in ejection fraction (EF) and diastolic function evaluated by Doppler-derived mitral deceleration time. In this group, histology showed a reduction of infarct size, with focuses of angiogenesis and minimal fibrosis interface between CorCap and the epicardium due to the interposition of the collagen matrix.
CONCLUSIONS
Myocardial infarction treated with stem cells associated with a collagen matrix and ventricular constraint device improves systolic and diastolic function, reducing adverse remodelling and fibrosis. The application of bioactive molecules and the recent development of nanobiotechnologies should open the door for the creation of a new semi-degradable ventricular support bioprosthesis, capable of controlled stability or degradation in response to physiological conditions of the left or right heart.
Long-term outcomes of bilateral lobar lung transplantation [TRANSPLANTATION AND MECHANICAL CIRCULATORY SUPPORT]
OBJECTIVES
Lobar lung transplantation is an option that provides the possibility of transplanting an urgent listed recipient of small size with a size-mismatched donor lung by surgically reducing the size of the donor lung. We report our short- and long-term results with bilateral lobar lung transplantation (BLLT) and compare it with the long-term outcomes of our cohort.
METHODS
Retrospective analyses of 75 lung transplant recipients who received downsized lungs with a special focus on 23 recipients with BLLT performed since January 2000. Postoperative surgical complications, lung function tests, late complications and survival were analyzed. The decision to perform lobar transplantation was considered during allocation and finally decided prior to implantation.
RESULTS
Cystic fibrosis was the most common indication (43.5%) followed by pulmonary fibrosis (35%). Median age at transplantation was 41 (range 13–66) years. Fifteen were females. Nineteen of the transplantations (83%) were done with extracorporeal membrane oxygenation (ECMO) support; 3 of them were already on ECMO prior to transplantation. There was no 30-day or in-hospital mortality. No bronchial complications occurred. The most common early complication was haematothorax (39%), which required surgical intervention. The rate of postoperative atrial arrhythmias was 30%. Forced expiratory volumes in 1 s (% predicted) at 1 and 2 years were 76 ± 23 and 76 ± 22, respectively (mean ± standard deviation). By 2-year follow-up, bronchiolitis obliterans syndrome was documented in 3 patients with a median follow-up of 1457 days. Overall survivals at 1 and 5 years were 82 ± 8 and 64 ± 11%, respectively and were comparable with those of 219 other recipients who received bilateral lung transplantation during the same period (log rank test, P = 0.56).
CONCLUSIONS
This study demonstrates that BLLT has short- and long-term outcomes comparable with those of standard bilateral lung transplantation. The limitation of lung transplantation due to size-mismatch, particularly in smaller recipients, could be overcome by utilizing lobar lung transplantation.
Editorial Comment: Merits of cadaveric lobar lung transplantation [TRANSPLANTATION AND MECHANICAL CIRCULATORY SUPPORT]
Measurement of extravascular lung water following human brain death: implications for lung donor assessment and transplantation [TRANSPLANTATION AND MECHANICAL CIRCULATORY SUPPORT]
OBJECTIVES
The measurement of extravascular lung water could aid the assessment and guide the management of potential lung donors following brain death. We therefore sought to validate a single indicator thermodilution extravascular lung water index (EVLWI-T) measurement using gravimetry and to assess the impact and clinical correlates of elevated EVLWI-T in potential lung donors and transplant recipients.
METHODS
In a prospective study, we measured serial EVLWI-T and haemodynamic and oxygenation data in 60 potential lung donors. To validate the EVLWI-T measurement, we measured in vivo thermodilution EVLWI (EVLWI-T) and gravimetric ex vivo EVLWI (EVLWI-G) in donor lungs rejected for transplant using the Holcroft and Trunkey modification of Pearce's method. We assessed the clinical correlates of elevated lung water and measured interleukin-8 and hepatocyte growth factor in bronchoalveolar lavage (BAL) fluid.
RESULTS
The mean EVLWI-T (n = 60) was 9.7 (4.5) ml kg^–1, being >7–10 ml kg^–1 in 23/60 and >10 ml kg^–1 in 16/60 potential donors. Donor lungs with EVLWI >10 ml kg^–1 were more likely to be receiving norepinephrine (P = 0.04), have higher pulmonary capillary wedge pressures (P = 0.008), be unsuitable for transplantation (P = 0.007) and, if transplanted, have worse survival (P = 0.04). Lungs submitted to gravimetric analysis [n = 20 in 11 donors (9 double and 2 single)] had EVWLI-T of 10.8 (2.7) and EVLWI-G was 10.1 (2.5). There was a strong correlation between EVLW-T and EVLW-G (r = 0.7; P = 0.014), but EVLWI-T over-predicted the EVLWI-G by ~1 ml kg^–1 (EVLW-T = 1.05 x EVLW-G). Cytokine levels in BAL fluid were elevated.
CONCLUSIONS
Elevated lung water is found in >50% of potential lung donors, predicts lung suitability for transplant and may adversely affect recipient outcome. Although EVLWI-T intrinsically overestimates gravimetric lung water, its measurement may aid the assessment of organ suitability. Lung water accumulation and the proinflammatory response may both be targets for modifying therapy.
Implantation of rotary blood pumps into 115 patients: a single-centre experience [TRANSPLANTATION AND MECHANICAL CIRCULATORY SUPPORT]
OBJECTIVES
From 2004 to 2009, rotary blood pumps were implanted for heart failure as a bridge to transplant or destination therapy in 101 male and 14 female patients at our institution. We report on our experiences of these patients with a follow-up of 132 patient years.
METHODS
Seventy-four HeartMate II axial flow pumps and 41 HeartWare centrifugal pumps were implanted in patients with non-ischaemic (n = 70) or ischaemic cardiomyopathy (n = 45). The mean age of the patients was 50 ± 13 years. All patients were on inotropic support prior to implantation. Extracorporeal membrane oxygenation was used as a bridging procedure in 21 cases.
RESULTS
The perioperative mortality was 14%. Hospital discharge occurred on average after 46 ± 33 days. Twenty-two patients of this cohort received a heart transplant 492 ± 342 days after implantation of the device. Two patients died after heart transplantation. A 1-year survival of 73% and a 2-year survival of 69% were recorded, despite a low incidence of transplant procedures. The longest support time was 1686 days.
CONCLUSIONS
Modern left ventricular assist device technology can be used successfully for heart failure. The scarcity of donor hearts leads to prolonged periods on the device, and chronic ventricular assist device therapy has become a reality, although bridge to transplant was intended; therefore, sufficient support services for outpatient care of these patients are required.
Use of centrifugal left ventricular assist device as a bridge to candidacy in severe heart failure with secondary pulmonary hypertension [TRANSPLANTATION AND MECHANICAL CIRCULATORY SUPPORT]
OBJECTIVES
Raised pulmonary artery pressure (PAP), trans-pulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are risk factors for poor outcomes after heart transplant in patients with secondary pulmonary hypertension (PH) and may contraindicate transplant. Unloading of the left ventricle with an implantable left ventricular assist device (LVAD) may reverse these pulmonary vascular changes. We studied the effect of implanting centrifugal LVADs in a cohort of patients with secondary PH as a bridge to candidacy.
METHODS
Pulmonary haemodynamics on patients implanted with centrifugal LVADs at a single unit between May 2005 and December 2010 were retrospectively reviewed.
RESULTS
Twenty-nine patients were implanted with centrifugal LVADs (eight HeartWare ventricular assist device (HVAD), HeartWare International, USA and 21 VentrAssist, Ventracor Ltd., Australia). Seventeen were ineligible for transplant by virtue of high TPG/PVR. All the patients were optimized with inotrope/balloon pump followed by LVAD insertion. Four required temporary right VAD support. Thirty-day mortality post-LVAD was 3.4% (1 of 29) with a 1-year survival of 85.7% (24 of 28). Thirteen patients have been transplanted to date: 30-day mortality was 7.7% (1 of 13) and 1-year survival was 91% (10 of 11). Baseline and post-VAD pulmonary haemodynamics were significantly improved: systolic PAP (mmHg), mean PAP, TPG (mmHg) of 57 ± 9.5, 42 ± 4.4 and 14 ± 3.9 reduced to 32 ± 7.5, 18 ± 5.5 and 9 ± 3.3, respectively. PVR reduced from 5 ± 1.5 to 2.1 ± 0.5 Wood units (P < 0.05).
CONCLUSIONS
In selected heart failure patients with secondary PH, use of centrifugal LVAD results in significant reductions in PAP, TPG and PVR, which are observed within 1 month, reaching a nadir by 3 months. Such patients bridged to candidacy have post-transplant survival comparable with those having a heart transplant as primary treatment.
Editorial Comment: Ventricular assist devices for advanced heart failure: evidence that cannot be ignored [TRANSPLANTATION AND MECHANICAL CIRCULATORY SUPPORT]
Outcomes of swing-back aortic arch repair in arterial switch and Norwood operations [SURGICAL TECHNIQUE]

The outcomes of the swing-back technique for aortic arch repair during the arterial switch and Norwood operations are not well reported. Between May 2004 and January 2011, we performed this technique during the arterial switch and Norwood operations in 2 and 4 patients, respectively. The median (range) patient age and body weight were 17 (12–147) days and 3.4 (2.2–6.1) kg, respectively. All patients survived the procedures. The median follow-up duration was 4 (1–8) years. One patient showed recoarctation in the early postoperative period, which was successfully repaired by a single-catheter intervention. The latest median pressure gradient across the neoaortic arch was 0 (0–6) mmHg. Neoaortic valve regurgitation was found to be minimal by echocardiography. During the follow-up period, the Fontan operation was performed in all the patients who underwent the Norwood operation. These results suggest that the swing-back technique yields satisfactory mid-term outcomes.
An alternative approach to explantation and exchange of the HeartWare left ventricular assist device [SURGICAL TECHNIQUE]
OBJECTIVES
Left ventricular assist device (LVAD) explantation and exchange is a relatively infrequent but potentially complex procedure. Patients requiring such procedures have multisystem suboptimal physiological reserve due to end-stage heart failure and are prone to complications. Less-invasive procedures are believed to facilitate postoperative recovery and early mobilization. We describe an alternative approach to explantation and exchange of the HeartWare LVAD through left thoracotomy.
METHODS
Six patients (M = 4, F = 2, mean age = 49.16 years) underwent device explant/exchange or initial implant (explant = 2, exchange = 3, initial implant = 1) through left thoracotomy utilizing cardiopulmonary bypass and induced ventricular fibrillation (VF). The mean bypass time and mean VF arrest time were 82 and 3 min, respectively. A new outflow graft was anastomosed to the previous outflow graft in 3 cases of device exchange and to the descending aorta in 1 case of initial implant.
RESULTS
One patient died in the intensive care unit due to unrelated causes (gram-negative sepsis) after device exchange. All others were discharged alive and currently remain on follow-up. The mean length of hospital stay was 40.66 days.
CONCLUSIONS
On-pump approach through single thoracotomy incision is safe and equally suitable for device explant, exchange and initial implant. However, structural heart defects requiring surgical correction and the requirement of simultaneous right ventricular assist device are the limitations of this approach.
Surgical adhesive may cause false positives in integrated positron emission tomography and computed tomography after lung cancer resection [CASE REPORTS]

Surgical adhesives are frequently used after pulmonary resection to prevent or reduce pulmonary air leakages, since leakages may cause complications delaying the removal of chest drainage tubes and prolonging in-hospital stay. In this paper, we present 2 patients who underwent curative-intent pulmonary resection for non-small-cell lung carcinoma, in which the biological adhesive BioGlue^® was used. Follow-up fluoro-2-deoxy-d-glucose positron emission tomography/computed tomographic (FDG-PET/CT) imaging revealed hypermetabolic pulmonary nodular lesions. Subsequent surgical exploration showed that the lesions were foreign body reactions to the bioadhesive. To our knowledge, this is the first study to examine false-positive follow-up FDG-PET/CT scans caused by the use of BioGlue^® in pulmonary resection procedures.
Photodynamic therapy for bronchial carcinoid tumours: complete response over a 10-year follow-up [CASE REPORTS]

A 63-year old woman diagnosed in September 2001 with a typical bronchial carcinoid of the left upper lobe bronchus extending into the left main stem bronchus is presented. The patient was unsuitable for standard surgical treatment, and the topography was not amenable for a parenchyma-saving bronchoplastic procedure. Two cycles of bronchoscopic photodynamic therapy (PDT) were undertaken at 6 monthly intervals. The patient has now been followed up regularly for over 10 years without signs of recurrence bronchoscopically or radiologically. To our knowledge, this is the first case of a carcinoid tumour treated solely by PDT.
Spontaneous aortic rupture early postpartum without trauma or connective tissue disorder [CASE REPORTS]

Rupture of the thoracic aorta is a rare but recognized complication following pregnancy. The common causes of thoracic aortic rupture in the peripartum period are trauma, dissecting aneurysms and saccular aneurysms secondary to systemic connective tissue disease. We report a case of non-traumatic spontaneous aortic rupture in a patient without trauma or systemic connective tissue disease 1 day postpartum, which was successfully managed by surgical repair of the thoracic aorta.
Aortobronchial fistula in the presence of a midgraft hole after endovascular repair of thoracic aortic aneurysms [CASE REPORTS]

Aortobronchial fistulas (ABF) are infrequent and require urgent diagnosis, often relying on a bundle of arguments. Thoracic endovascular aortic repair (TEVAR) is a possible therapeutic approach that needs close surveillance because its durability in such situations remains uncertain. We report a case of haemoptysis related to an aortobronchial fistula recurring 6 years after TEVAR, with an intraoperative finding of a midgraft hole. The patient underwent open repair with in situ aortic replacement with an aortic cryopreserved homograft.
Successful surgical removal of an intravenous leiomyoma extending to the right atrium 4 years after hysterectomy [IMAGES IN CARDIO-THORACIC SURGERY]
Pseudoaneurysm of the ascending aorta [IMAGES IN CARDIO-THORACIC SURGERY]
A ductal aneurysm rapidly developing into coarctation of the aorta [IMAGES IN CARDIO-THORACIC SURGERY]
Catastrophic ascending aortic graft thrombosis [IMAGES IN CARDIO-THORACIC SURGERY]
A simple technique for marking the aortic annulus during the implantation of a stentless aortic bioprosthesis [IMAGES IN CARDIO-THORACIC SURGERY]
Gas in the superior mesenteric artery: severe malperfusion and bowel necrosis caused by acute aortic dissection [IMAGES IN CARDIO-THORACIC SURGERY]
Prognostic significance of microvascular invasion and microlymphatic permeation in non-small-cell lung cancer [LETTERS TO THE EDITOR]
Reply to Wang et al. [LETTERS TO THE EDITOR]
Ground glass opacity and T-factor in staging lung adenocarcinoma [LETTERS TO THE EDITOR]
Reply to Baisi et al. [LETTERS TO THE EDITOR]
Clopidogrel and aspirin administration management prior to coronary artery surgery requires an individual approach [LETTERS TO THE EDITOR]
Minimally invasive mitral valve surgery: still possible when aortic clamping is judged unsafe [LETTERS TO THE EDITOR]
Reply to Saleh et al. [LETTERS TO THE EDITOR]
Repair versus replacement of the aortic valve for the treatment of active infective endocarditis: is Sorin Solo the aortic bioprosthesis Columbus's egg? [LETTERS TO THE EDITOR]
Reply to Totaro and Zattera [LETTERS TO THE EDITOR]