Showing papers in "European Journal of Cardio-Thoracic Surgery in 2014"

2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).

Abstract: Authors/Task Force Members: Franz-Josef Neumann* (ESC Chairperson) (Germany), Miguel Sousa-Uva* (EACTS Chairperson) (Portugal), Anders Ahlsson (Sweden), Fernando Alfonso (Spain), Adrian P. Banning (UK), Umberto Benedetto (UK), Robert A. Byrne (Germany), Jean-Philippe Collet (France), Volkmar Falk (Germany), Stuart J. Head (The Netherlands), Peter Jüni (Canada), Adnan Kastrati (Germany), Akos Koller (Hungary), Steen D. Kristensen (Denmark), Josef Niebauer (Austria), Dimitrios J. Richter (Greece), Petar M. Seferovi c (Serbia), Dirk Sibbing (Germany), Giulio G. Stefanini (Italy), Stephan Windecker (Switzerland), Rashmi Yadav (UK), Michael O. Zembala (Poland) Document Reviewers: William Wijns (ESC Review Co-ordinator) (Ireland), David Glineur (EACTS Review Co-ordinator) (Canada), Victor Aboyans (France), Stephan Achenbach (Germany), Stefan Agewall (Norway), Felicita Andreotti (Italy), Emanuele Barbato (Italy), Andreas Baumbach (UK), James Brophy (Canada), Héctor Bueno (Spain), Patrick A. Calvert (UK), Davide Capodanno (Italy), Piroze M. Davierwala

Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer.

Abstract: Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small-cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a new lymph node map. Some changes in this map have an important impact on mediastinal staging. Moreover, more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography [endobronchial ultrasonography (EBUS)/esophageal ultrasonography (EUS)] with fine-needle aspiration (FNA) is the first choice (when available), since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred to mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumours ≤ 3 cm located in the outer third of the lung. In central tumours or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and FNA or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumours >3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high standardized uptake value. For restaging, invasive techniques providing histological information are advisable. Both endoscopic techniques and surgical procedures are available, but their negative predictive value is lower compared with the results obtained in baseline staging. An integrated strategy using endoscopic staging techniques to prove mediastinal nodal disease and mediastinoscopy to assess nodal response after induction therapy needs further study.

Bioprinting technology and its applications

Abstract: Summary Bioprinting technology has emerged as a powerful tool for building tissue and organ structures in the field of tissue engineering. This technology allows precise placement of cells, biomaterials and biomolecules in spatially predefined locations within confined three-dimensional (3D) structures. Various bioprinting technologies have been developed and utilized for applications in life sciences, ranging from studying cellular mechanisms to constructing tissues and organs for implantation, including heart valve, myocardial tissue, trachea and blood vessels. In this article, we introduce the general principles and limitations of the most widely used bioprinting technologies, including jetting- and extrusion-based systems. Application-based research focused on tissue regeneration is presented, as well as the current challenges that hamper clinical utility of bioprinting technology.

Video-assisted thoracoscopic surgery lobectomy at 20 years: A consensus statement

Abstract: OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) lobectomy has been gradually accepted as an alternative surgical approach to open thoracotomy for selected patients with non-small-cell lung cancer (NSCLC) over the past 20 years. The aim of this project was to standardize the perioperative management of VATS lobectomy patients through expert consensus and to provide insightful guidance to clinical practice. METHODS: A panel of 55 experts on VATS lobectomy was identified by the Scientific Secretariat and the International Scientific Committee of the ‘20th Anniversary of VATS Lobectomy Conference—The Consensus Meeting’. The Delphi methodology consisting of two rounds of voting was implemented to facilitate the development of consensus. Results from the second-round voting formed the basis of the current Consensus Statement. Consensus was defined ap riorias more than 50% agreement among the panel of experts. Clinical practice was deemed ‘recommended’ if 50–74% of the experts reached agreement and ‘highly recommended’ if 75% or more of the experts reached agreement. RESULTS: Fifty VATS lobectomy experts (91%) from 16 countries completed both rounds of standardized questionnaires. No statistically significant differences in the responses between the two rounds of questioning were identified. Consensus was reached on 21 controversial points, outlining the current accepted definition of VATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSION: The present Consensus Statement represents a collective agreement among 50 international experts to establish a standardized practice of VATS lobectomy for the thoracic surgical community after 20 years of clinical experience.

Tumours of the thymus: a cohort study of prognostic factors from the European Society of Thoracic Surgeons database.

Abstract: OBJECTIVES: A retrospective database was developed by the European Society of Thoracic Surgeons, collecting patients submitted to surgery for thymic tumours to analyse clinico-pathological prognostic predictors. METHODS: A total of 2151 incident cases from 35 institutions were collected from 1990 to 2010. Clinical-pathological characteristics were analysed, including age, gender, associated myasthenia gravis stage (Masaoka), World Health Organization histology, type of thymic tumour [thymoma, thymic carcinoma (TC), neuroendocrine thymic tumour (NETT)], type of resection (complete/incomplete), tumour size, adjuvant therapy and recurrence. Primary outcome was overall survival (OS); secondary outcomes were the proportion of incomplete resections, disease-free survival and the cumulative incidence of recurrence (CIR). RESULTS: A total of 2030 patients were analysed for OS (1798 thymomas, 191 TCs and 41 NETTs). Ten-year OS was 0.73 (95% confidence interval 0.69–0.75). Complete resection (R0) was achieved in 88% of the patients. Ten-year CIR was 0.12 (0.10–0.15). Predictors of shorter OS were increased age (P<0–001), stage [III vs I HR 2.66, 1.80–3.92; IV vs I hazard ratio (HR) 4.41, 2.67–7.26], TC (HR 2.39, 1.68–3.40) and NETT (HR 2.59, 1.35–4.99) vs thymomas and incomplete resection (HR 1.74, 1.18–2.57). Risk of recurrence increased with tumour size (P= 0.003), stage (III vs I HR 5.67, 2.80–11.45; IV vs I HR 13.08, 5.70–30.03) and NETT (HR 7.18, 3.48–14.82). Analysis using a propensity score indicates that the administration of adjuvant therapy was beneficial in increasing OS (HR 0.69, 0.49–0.97) in R0 resections. CONCLUSIONS: Masaoka stages III–IV, incomplete resection and non-thymoma histology showed a significant impact in increasing recurrence and in worsening survival. The administration of adjuvant therapy after complete resection is associated with improved survival.

The German Aortic Valve Registry: 1-year results from 13,680 patients with aortic valve disease.

Abstract: OBJECTIVES: The German Aortic Valve Registry (GARY) seeks to provide information on a real-world, all-comers basis for patients undergoing aortic valve interventions. This registry comprises patients undergoing the complete spectrum of transcutaneous and conventional surgical aortic valve interventions. The aim of this study was to use the GARY registry to evaluate conventional and catheter-based aortic valve interventions in several risk groups. METHODS: A total of 13 860 consecutive patients undergoing intervention for aortic valve disease [conventional aortic valve replacement (AVR) or transvascular/transapical TAVR (TV-/TA-TAVR)] were enrolled in 78 German centres in 2011. Baseline, procedural and outcome data, including quality of life, were acquired up to 1 year post-intervention. Vital status at 1 year was known for 98.1% of patients. RESULTS: The 1-year mortality rate was 6.7% for conventional AVR patients (n= 6523) and 11.0% for patients who underwent AVR with coronary artery bypass grafting (n= 3464). The 1-year mortality rate was 20.7 and 28.0% in TV- and TA-TAVR patients, respectively (n= 2695 and 1181). However, if patients were stratified into four risk groups by means of the EuroSCORE and the German AV Score, the highest risk cohorts showed the same mortality at 1 year with either therapy. More than 80% of patients in all groups were in the same or better state of health at 1 year post-intervention and were satisfied with the procedural outcome. CONCLUSIONS: Conventional AVR surgery yields excellent results after 1 year in lower-risk patients. Catheter-based AVR is a good alternative in high-risk and elderly patients.

Bioprinting of artificial blood vessels: current approaches towards a demanding goal

Abstract: Free-form fabrication techniques, often referred to as '3D printing', are currently tested with regard to the processing of biological and biocompatible materials in general and for fabrication of vessel-like structures in particular. Such computer-controlled methods assemble 3D objects by layer-wise deposition or layer-wise cross-linking of materials. They use, for example, nozzle-based deposition of hydrogels and cells, drop-on-demand inkjet-printing of cell suspensions with subsequent cross-linking, layer-by-layer cross-linking of synthetic or biological polymers by selective irradiation with light and even laser-induced deposition of single cells. The need of vessel-like structures has become increasingly crucial for the supply of encapsulated cells for 3D tissue engineering, or even with regard to future application such as vascular grafts. The anticipated potential of providing tubes with tailored branching geometries made of biocompatible or biological materials pushes future visions of patient-specific vascularized tissue substitutions, tissue-engineered blood vessels and bio-based vascular grafts. We review here the early attempts of bringing together innovative free-form manufacturing processes with bio-based and biodegradable materials. The presented studies provide many important proofs of concepts such as the possibility to integrate viable cells into computer-controlled processes and the feasibility of supplying cells in a hydrogel matrix by generation of a network of perfused channels. Several impressive results in the generation of complex shapes and high-aspect-ratio tubular structures demonstrate the potential of additive assembly methods. Yet, it also becomes obvious that there remain major challenges to simultaneously match all material requirements in terms of biological functions (cell function supporting properties), physicochemical functions (mechanical properties of the printed material) and process-related (viscosity, cross-linkability) functions, towards the demanding goal of biofabricating artificial blood vessels.

National perioperative outcomes of pulmonary lobectomy for cancer: the influence of nutritional status.

Abstract: OBJECTIVES Nutritional assessment is not included yet as a major recommendation in lung cancer guidelines. The purpose of this study was thus to assess the influence on surgical outcome of the nutritional status of patients with primary lung cancer undergoing lobectomy. METHODS We queried Epithor, the national clinical database of the French Society of Thoracic and Cardiovascular Surgery, and identified a retrospective cohort of 19 635 patients having undergone lobectomy for a primary lung cancer in the years 2005-11. Their nutritional status was categorized according to the WHO definition: underweight (BMI < 18.5): 857 patients (4.4%), normal (18.5 ≤ BMI < 25): 9391 patients (47.8%), overweight (25 ≤ BMI < 30): 6721 patients (34.2%), obese (BMI ≥ 30): 2666 patients (13.6%). Operative mortality, pulmonary, cardiovascular, infectious and surgical complications rates were collected and analysed for these various BMI groups. RESULTS In the normal-weight category, operative mortality, pulmonary, surgical, cardiovascular and infectious complications rates were 2.7, 14.6, 13.8, 5.5 and 4.1%, respectively. When compared with that of normal BMI patients, adjusted operative mortality was significantly lower in overweight (2.3%; odd ratio (OR): 0.72 [95% confidence interval (CI): 0.59-0.89]; P = 0.002) and obese patients (1.9%, OR: 0.54 [95% CI: 0.40-0.74]; P < 0.001), and significantly higher in underweight patients (4.1%, OR: 1.89 [95% CI: 1.30-2.75]; P = 0.001). Underweight patients experienced significantly more pulmonary (21.1%; P < 0.001), surgical (23.2%; P < 0.001) and infectious (5.1%; P = 0.05) complications (P < 0.0001). Among surgical complications, prolonged air leaks (17.6%; P < 0.001) and bronchial stump dehiscence (1.5%; P = 0.001) were significantly more frequent in underweight patients than in normal BMI patients. Obesity was not associated with increased incidence of postoperative complications, except for arrhythmia (5.6%; P < 0.05), deep venous thrombosis and pulmonary embolism (1.5%; P = 0.005). Moreover, a statistical protective effect of obesity was observed regarding surgical complications (7.1%; P < 0.001). CONCLUSIONS Despite having an increased risk of some postoperative cardiovascular complications, obese patients should undergo surgical standard of care therapy for appropriately stage-specific lung cancer. In underweight patients, in addition to preoperative rehabilitation including a nutritional program, attention should be given to aggressive prophylactic respiratory therapy in the perioperative period, and specific intraoperative actions to prevent prolonged air leaks and bronchial stump dehiscence.

Regional analgesia for video-assisted thoracic surgery: a systematic review.

Abstract: Video-assisted thoracic surgery (VATS) is emerging as the standard surgical procedure for both minor and major oncological lung surgery. Thoracic epidural analgesia (TEA) and paravertebral block (PVB) are established analgesic golden standards for open surgery such as thoracotomy; however, there is no gold standard for regional analgesia for VATS. This systematic review aimed to assess different regional techniques with regard to effect on acute postoperative pain following VATS, with emphasis on VATS lobectomy. The systematic review of PubMed, The Cochrane Library and Embase databases yielded 1542 unique abstracts; 17 articles were included for qualitative assessment, of which three were studies on VATS lobectomy. The analgesic techniques included TEA, multilevel and single PVB, paravertebral catheter, intercostal catheter, interpleural infusion and long thoracic nerve block. Overall, the studies were heterogeneous with small numbers of participants. In comparative studies, TEA and especially PVB showed some effect on pain scores, but were often compared with an inferior analgesic treatment. Other techniques showed no unequivocal results. No clear gold standard for regional analgesia for VATS could be demonstrated, but a guide of factors to include in future studies on regional analgesia for VATS is presented.

Thoracoscopic lobectomy is associated with improved short-term and equivalent oncological outcomes compared with open lobectomy for clinical Stage I non-small-cell lung cancer: A propensity-matched analysis of 963 cases

Abstract: OBJECTIVES: Previous literature has reported lower morbidity for video-assisted thoracoscopic surgery lobectomy (VL) compared with open lobectomy (OL); however, most comparative studies have been retrospective and have failed to compare well-matched patient groups, therefore allowing selection bias to influence results. Furthermore, oncological adequacy of VL has recently been questioned, particularly with respect to lymphadenectomy. This study aimed to evaluate short- and long-term outcomes of a large cohort of consecutive patients with c-stage I non-small-cell lung cancer (NSCLC) that underwent either VL or OL. METHODS: Consecutive patients with c-stage I NSCLC who underwent lobectomy without preoperative therapy were reviewed. Univariable, multivariable and propensity-matched analyses were performed. VL patients who underwent conversion to OL were analysed within the VL group. RESULTS: VL was performed in 307 (32%) patients and OL in 656 (68%). Twenty-two (7%) patients converted from VL to OL. Although there were no differences in overall p-stage grouping, there were fewer patients with pT2 tumours in the VL group (39 vs 48%, P= 0.012) and fewer patients with squamous cell histology (26 vs 18%, P= 0.006). These differences resolved after propensity matching. In unmatched and matched analyses, VL was associated with less overall morbidity, less pulmonary morbidity, fewer atrial arrhythmias, shorter chest tube duration and shorter hospital stay than patients who had OL. Thirty-day in-hospital mortality was 0.3 and 1.4%, for VL and OL groups, respectively (P= NS). In unmatched analysis (log rank), 5-year survival favoured VL (78 vs 68%, P= 0.007); however, after propensity matching there was only a trend towards improved survival with VL (78 vs 73%, P= 0.071). Multivariable Cox regression analysis revealed VL (hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.46–0.92), male sex (HR 1.43, 95% CI 1.10–1.86), Zubrod performance status (HR 3.42, 95% CI 1.26–9.29) and increasing age (HR 1.04, 95% CI 1.03–1.06) to be independent predictors of survival. CONCLUSIONS: Patients with clinical Stage I NSCLC undergoing VL have less perioperative morbidity compared with matched OL controls. Regional lymphadenectomy, nodal upstaging, overall and disease-free survival were similar between VL and OL groups. In experienced centres, VL is an acceptable operation for patients with c-stage I NSCLC.

Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day

Abstract: OBJECTIVES: In fast-track pulmonary resections, we removed chest tubes after video-assisted thoracic surgery (VATS) lobectomy with serous fluid production up to 500 ml/day. Subsequently, we evaluated the frequency of recurrent pleural effusions requiring reintervention. METHODS: Data from 622 consecutive patients undergoing VATS lobectomy from January 2009 to December 2011 were registered prospectively in an institutional database. Data included age, gender, lobe(s) resected, bleeding and duration of surgery. Follow-up was 30 days from discharge. All complications requiring pleurocentesis or reinsertion of a chest tube, and all readmissions were registered. Twenty-three patients were excluded due to missing data, in-hospital mortality and loss to follow-up, leaving 599 for final analysis. Our primary outcome was the number of patients requiring reintervention due to recurrent pleural effusion. Secondary outcomes included time of chest tube removal and time to discharge. The incidence of recurrent pleural effusions requiring reintervention was compared between three groups according to the postoperative day (POD) of chest tube removal (Day 0–1, 2–3 and ≥4, respectively) using Fisher’s exact test. RESULTS: Pleural effusion after chest tube removal required reintervention in 17 patients (2.8%). Of these, 7 needed readmission. Median time from surgery to chest tube removal was 2 days, and median time from surgery to discharge was 4 days. No statistically significant association was found between the incidence of reinterventions due to recurrent pleural effusion and the POD of chest tube removal (P= 0.50). The median time from chest tube removal to discharge was 1 day in all groups. Of the patients who needed reintervention, none had complications regarding this, except one who developed pneumothorax after pleurocentesis. CONCLUSIONS: Our findings suggest that chest tube removal after VATS lobectomy is safe despite volumes of serous fluid production up to 500 ml/day. The proportion of patients who developed pleural effusion necessitating reintervention was low (2.8%), and a complication of the reintervention was seen in only 1 patient.

Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial.

Abstract: OBJECTIVES: Atrial fibrillation (AF) is a significant risk factor for embolic stroke originating from the left atrial appendage (LAA). This is the first report of long-term safety and efficacy data on LAA closure using a novel epicardial LAA clip device in patients undergoing cardiac surgery. METHODS: Forty patients with AF were enrolled in this prospective ‘first-in-man’ trial. The inclusion criterion was elective cardiac surgery in adult patients with AF for which a concomitant ablation procedure was planned. Intraoperative transoesophageal echocardiography (TEE) was used to exclude LAA thrombus at baseline and evaluate LAA perfusion after the procedure, while computed tomography (CT) was used for serial imagery workup at baseline, 3-, 12-, 24- and 36-month follow-up. RESULTS: Early mortality was 10% due to non-device-related reasons, and thus 36 patients were included in the follow-up consisting of 1285 patient-days and mean duration of 3.5±0.5 years. On CT, clips were found to be stable, showing no secondary dislocation 36 months after surgery. No intracardial thrombi were seen, none of the LAA was reperfused and in regard to LAA stump, none of the patients demonstrated a residual neck >1 cm. Apart from one unrelated transient ischaemic attack (TIA) that occurred 2 years after surgery in a patient with carotid plaque, no other strokes and/or neurological events demonstrated in any of the studied patients during follow-up. CONCLUSION :T his is thefirst prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100% effective, safe and durable in the long term. Closure of the LAA by epicardial clipping is applicable to all-comers regardless of LAA morphology. Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation and/or catheter closure. Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention. CLINICAL TRIAL REGISTRATION: The trial is registered at www.ClinicalTrials.gov, reference: NCT00567515.

Segmentectomy or lobectomy for early stage lung cancer: a meta-analysis

Abstract: Summary Early stage lung cancer is routinely treated by lobectomy whenever clinically feasible, whereas the role of segmentectomy is controversial. The purpose of this study was to investigate the benefits of segmentectomy vs lobectomy for early stage lung cancer through a meta-analysis of published data. Eligible studies were identified from MEDLINE through February 2013. The manual selection of relevant studies was based on the summary analysis. We used published hazard ratios (HRs) if available or estimates from the published survival data. Lobectomy was chosen as the reference in all HR calculations. We compared the effect of segmentectomy and lobectomy for Stage I, Stage IA, Stage IAwith tumours larger than 2 cm but smaller than 3 cm in size and Stage IA with tumours of 2 cm or smaller in 22 observational studies. The HRs of overall and cancer-specific survival indicated significant benefits of lobectomy for Stage I, Stage IA and Stage IA with tumours larger than 2 cm but smaller than 3 cm at 1.20 (95% confidence interval [CI] 1.04–1.38; P= 0.011), 1.24 (95% CI 1.08–1.42; P= 0.002) and 1.41 (95% CI 1.14–1.71; P= 0.001), respectively. For tumours 2 cm or smaller, segmentectomy provided an effect equivalent to that of lobectomy (HR 1.05; 95% CI 0.89–1.24; P= 0.550). No significant publication bias was detected in any part of the analysis. These findings should be interpreted in the context of the inherent limitations of meta-analyses of retrospective studies, including the heterogeneity of patient characteristics.

Lung transplantation from initially rejected donors after ex vivo lung reconditioning: the French experience.

Abstract: OBJECTIVES Only 15% of brain death donors are considered suitable for lung transplantation (LTx). The normothermic ex vivo lung perfusion technique is used to potentially increase the availability of high-risk lung donors. We report our experience of LTx with initially rejected donors after ex vivo lung reconditioning (EVLR). METHODS From April 2011 to May 2013, we performed EVLR for 32 pairs of donor lungs deemed unsuitable for transplantation and rejected by the 11 French lung transplant teams. After EVLR, lungs with acceptable function were transplanted. During the same period, 81 double-lung transplantations (DLTx) were used as controls. RESULTS During EVLR, 31 of 32 donor lungs recovered physiological function with a median PO2/FiO2 ratio increasing from 274 (range 162-404) mmHg to 511 (378-668) mmHg at the end of EVLR (P < 0.0001). Thirty-one DLTx were performed. The incidence of primary graft dysfunction 72 h after LTx was 9.5% in the EVLR group and 8.5% in the control group (P = 1). The median time of extubation, intensive care unit and hospital lengths of stay were 1, 9 and 37 days in the EVLR group and 1 (P = 0.17), 6 (P = 0.06) and 28 days (P = 0.09) in the control group, respectively. Thirty-day mortality rates were 3.3% (n = 1) in the EVLR group and 3.7% (n = 3) in the control group (P = 0.69). One-year survival rates were 93% in the EVLR group and 91% in the control group. CONCLUSIONS EVLR is a reliable and repeatable technique that offers a significant increase of available donors. The results of LTx with EVLR lungs are similar to those obtained with conventional donors.

Early results in transplantation of initially rejected donor lungs after ex vivo lung perfusion: a case-control study.

Abstract: OBJECTIVES An increasing number of studies have shown that ex vivo lung perfusion (EVLP) is safe and that rejected donor lungs can be resuscitated and used for lung transplantation (LTx). Early clinical outcomes in patients transplanted with reconditioned lungs at our centre were reviewed and compared with those of contemporary non-EVLP controls. METHODS During 18 months starting January 2011, 11 pairs of donor lungs initially deemed unsuitable for transplantation underwent EVLP. Haemodynamic (pulmonary flow, vascular resistance and artery pressure) and respiratory (peak airway pressure and compliance) parameters were analysed during evaluation. Lungs that improved (n = 11) to meet International Society of Heart and Lung Transplantation criteria were transplanted and compared with patients transplanted with non-EVLP lungs (n = 47) during the same time period. RESULTS Donor lungs were initially rejected due to either inferior PaO2/FiO2 ratio (n = 9), bilateral infiltrate on chest X-ray (n = 1) or ongoing extra corporeal membrane oxygenation (n = 1). The donor lungs improved from a mean PaO2/FiO2 ratio of 27.9 kPa in the donor to a mean of 59.6 kPa at the end of the EVLP (median improvement 28.4 kPa, range 21.0-50.7 kPa). Two single lungs were deemed unsuitable and not used for LTx. Eleven recipients from the regular waiting list underwent either single (n = 3) LTx or double (n = 8) LTx with EVLP-treated lungs. The median time to extubation (12 (range, 3-912) vs 6 (range, 2-1296) h) and median intensive care unit (ICU) stay (152 (range, 40-625) vs 48 (range, 22-1632) h) were longer in the EVLP group (P = 0.05 and P = 0.01, respectively). There were no differences in length of hospital stay (median 28 (range 25-93) vs 28 (18-209), P = 0.21). Two patients in the EVLP group and 6 in the control group had primary graft dysfunction >Grade 1 at 72 h postoperatively. Three patients in the control group died before discharge. All recipients of EVLP lungs were discharged alive from hospital. CONCLUSIONS The use of EVLP seems safe and indicates that lungs otherwise refused for LTx can be recovered and subsequently used for transplantation, although time to extubation and ICU stay were longer for the EVLP group.

Preoperative statin therapy in cardiac surgery: a meta-analysis of 90 000 patients †

Abstract: Summary The objective of this systematic literature review with meta-analysis was to determine the strength of evidence for a preoperative statin on the reduction of adverse postoperative outcomes in patients undergoing cardiac surgery. Randomized controlled (RCT) and observational trials were searched in online databases that reported about the effects of preoperative statin therapy on major adverse clinical outcomes after cardiac surgery. Analysed outcomes included early all-cause mortality, myocardial infarction, atrial fibrillation (AF), stroke and renal failure using a priori-defined criteria. Effect estimates were calculated and are given as odds ratio (OR) with 95% confidence intervals (95% CI) using fixed- or random-effect models. Literature search of all major databases retrieved 2371 studies. After screening, a total of 54 trials were identified (12 RCT, 42 observational) that reported outcomes of 91 491 cardiac surgery patients with (n= 46 614; 51%) or without (n= 44 877; 49%) preoperative statin therapy. Preoperative statin use resulted in a 0.9% absolute risk (2.6 vs 3.5%) and a 31% odds reduction for early all-cause mortality (OR 0.69; 95% CI 0.59–0.81; P< 0.0001). In addition, statin treatment before surgery was associated with a substantial reduction (P< 0.01) in the postoperative end-points AF (OR 0.71; 95% CI 0.61–0.82), new-onset AF (OR 0.68; 95% CI 0.54–0.85), stroke (OR 0.83; 95% CI 0.74–0.93), stay on intensive care unit (weighted mean difference [WMD] �0.14; 95% CI �0.23 to �0.03; P< 0.01) and in-hospital stay (WMD �0.57; 95% CI �0.76 to �0.38; P< 0.01). No statistical differences were found between groups with regard to myocardial infarction or renal failure. In conclusion, the current systematic review strengthens the evidence that preoperative statin therapy extends substantial clinical benefit to early postoperative outcomes in cardiac surgery patients.

Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation.

Abstract: OBJECTIVES Thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation without endotracheal intubation is a promising technique for selected patients, but little is known about its feasibility and safety. METHODS We evaluated 109 patients with lung (105), mediastinal (3) or pleural (1) tumours treated using non-intubated thoracoscopic surgery. Internal, intercostal nerve block was performed at the T3-T8 intercostal level and vagal block was performed adjacent to the vagus nerve at the level of the lower trachea for right-sided operations and at the level of the aortopulmonary window for left-sided operations. Sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. RESULTS Thoracoscopic lobectomy was performed in 43 patients, wedge resection in 50, segmentectomy in 12 and mediastinal or pleural tumour excision in 4. Three patients (2.8%) required conversion to intubated one-lung ventilation because of vigorous mediastinal movement and dense diaphragmatic adhesions. Anaesthetic induction and operation had a median duration of 10.0 and 127.0 min, respectively. Operative complications developed in 13 patients with air leaks for more than 3 days and 1 patient required transfusion of blood products. The median postoperative chest drainage and hospital stay were 2.0 and 4.0 days, respectively. CONCLUSIONS Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation is technically feasible and safe in surgical treatment of lung, mediastinal and pleural tumours in selected patients.

The extracardiac conduit Fontan procedure in Australia and New Zealand: hypoplastic left heart syndrome predicts worse early and late outcomes

Abstract: To identify factors associated with hospital and long-term outcomes in a binational cohort of extracardiac conduit (ECC) Fontan recipients.

Gender-related changes in aortic geometry throughout life †

Abstract: OBJECTIVES: Aortic geometry changes throughout life are not well defined. This investigation delineates aortic geometry across the adult age spectrum and determines the gender-related influence of aging on aortic morphometry. METHODS: Contrast-enhanced computed tomography scans of all aortic segments in 195 subjects (94 women, 101 men, average age 57 ± 20 years) free of vascular disease were analysed. Lengths and diameters of each aortic segment as well as width, height and tortuosity of the thoracic aorta were compared between both genders. RESULTS: Aortic diameters and lengths were larger in men than women (P 70 years old: 3.4 ± 0.3 vs 3.5 ± 0.3 cm, P= 0.241). CONCLUSIONS: Female gender is associated with smaller aortic dimensions, but only at a young age. The dynamics of aortic growth throughout life are greater in women than in men. Gender-related changes in aortic geometry provide a hypothesis for the predominance of aortic dissection in young male patients, which normalizes between genders with increasing age.

Modern temperature management in aortic arch surgery: the dilemma of moderate hypothermia.

Abstract: Arch surgery is undoubtedly among the most technically and strategically challenging endeavours in aortic surgery, requiring thorough understanding not only of cardiovascular physiology, but also in particular, of neurophysiology (cerebral and spinal cord), and is still associated with significant mortality and morbidity. In the late 1980s, when deep hypothermic circulatory arrest (HCA) had gained widespread acceptance as the standard approach for arch surgery, antegrade selective cerebral perfusion (SCP), as an adjunct to deep HCA, began its triumphal march, offering excellent neuroprotection and improved overall outcome. This encouraged the use of antegrade SCP in combination with steadily increasing body core temperatures--a trend culminating in the progressive advocation of moderate-to-mild temperatures up to 35 °C, and even normothermia. The impetus for progressive temperature elevation was the limitation of adverse effects of profound hypothermia and the most welcome side effect of significantly shorter cooling and rewarming periods on cardiopulmonary bypass (CPB), and thereby, potentially, the alleviation of the systemic inflammatory response and, in particular, the risk of severe postoperative bleeding (and other organ dysfunctions). The safe limits of prolonged distal circulatory arrest, particularly with regard to the ischaemic tolerance of the viscera and the spinal cord, have not yet been clearly defined. Adverse outcomes due to inappropriate temperature management (core temperatures too high for the required duration of distal arrest) are probably highly underreported. Complications historically associated with hypothermia, namely excessive bleeding, are possibly overestimated. Trading effective neuroprotection and excellent outcomes for the risk of prolonged 'warm' distal ischaemia might constitute a significant step back, jeopardizing visceral and, in particular, spinal cord integrity, with unpredictable consequences for long-term outcome and quality of life, particularly affecting those in need of more complex surgery or with previous neurological deficits.

Performance of EuroSCORE II in a large US database: implications for transcatheter aortic valve implantation.

Abstract: OBJECTIVES: Validation studies of European system for cardiac operative risk evaluation II (EuroSCORE II) have been limited to European datasets. Therefore, the aims of this study were to assess the performance of EuroSCORE II in a large multicentre US database, and compare it with the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM). In addition, implications for patient selection for transcatheter aortic valve implantation (TAVI) were explored. METHODS: EuroSCORE II and the STS-PROM were calculated for 50588 patients from a multi-institutional statewide database of all cardiac surgeries performed since 2003. Model performance was assessed using the area under the receiver operator curve (AUC), observed vs expected (O:E) ratios and calibration plots. Analyses were performed for isolated coronary artery bypass grafting (CABG) (n=40871), aortic valve replacement (AVR) (n=4107), AVR+CABG (n=3480), mitral valve (MV) replacement (n=1071) and MV repair (n= 1059). RESULTS: The overall in-hospital mortality rate was 2.1%. EuroSCORE II was outperformed by the STS-PROM in the overall cohort with regard to discrimination (AUC=0.77 vs 0.81, respectively; P<0.001) and calibration (O:E=0.68 vs 0.80, respectively). Discrimination for CABG was worse with EuroSCORE II (AUC=0.77 vs STS-PROM: 0.81, P<0.001). Forother procedures discrimination was similar: AVR (AUC=0.71 vs STSPROM: 0.74, P=0.40), AVR +CABG (AUC=0.72 vs STS-PROM: 0.74, P=0.47), MV repair (AUC=0.82 vs STS-PROM: 0.86, P=0.55) andMVr eplacement (AUC=0.78 vs STS-PROM: 0.79, P=0.69). Calibration of EuroSCORE II was worse for CABG (O:E=0.68 vs STS-PROM: 0.80), similar in AVR+CABG (O:E =0.76 vs STS-PROM: 0.70) and MV repair (O:E =0.64 vs STS-PROM: 0.67), while EuroSCORE II may be more accurate in AVR (O:E=0.96 vs STS-PROM: 0.76). Performance of both models improved when only recent cases (after 1 January 2008) were used. Ongoing TAVI trials aimed at patients with an estimated 4–10% risk of mortality are enrolling patients with mean estimated risks of 6.2% (EuroSCORE II) or 6.0% (STS-PROM), and an actual mortality rate of 4.6% (EuroSCORE II) or 4.8% (STS-PROM). CONCLUSIONS: In a large US multicentre database, the STS-PROM performs better than EuroSCORE II for CABG. However, EuroSCORE II is a reasonable alternative in low-risk CABG patients and in those undergoing other cardiac surgical procedures. Clinical trials and physicians that use these scores recruit and treat patients who are at a lower risk than anticipated. This potentially leads to overtreatment with an investigational device. Decision-making should not solely be based on risk scores, but should comprise multidisciplinary heart team discussions.

Predicting systolic anterior motion after mitral valve reconstruction: using intraoperative transoesophageal echocardiography to identify those at greatest risk

Abstract: Objectives We set out to determine if intraoperative pre-bypass transoesophageal echocardiography could assist in predicting which patients are at greatest risk for systolic anterior motion (SAM) after mitral valve repair (MVR). Methods Three hundred and seventy-five consecutive patients who underwent reconstructive MVR surgery for degenerative disease were included. Data were collected using intraoperative echocardiographic images taken prior to the initiation of cardiopulmonary bypass. Based on the physiology of SAM, we postulated that 11 parameters could be potential risk factors for SAM: left ventricular ejection fraction (LVEF), left ventricular end-systolic dimension, left ventricular end-diastolic dimension (LVEDD), basal septal diameter (basal-interventricular septal diameter in diastole (IVDd)), mid-ventricular septal diameter (mid-IVDd), coaptation-septal distance (c-sept), anterior leaflet height, posterior leaflet height, aorto-mitral angle, mitral annular diameter and left atrial diameter. These parameters were measured and recorded by a blinded single operator. Independent predictors of SAM were identified using multiple logistic regression analysis. Results Of the 375 patients, 345 (92%) did not develop SAM (No-SAM group), while 30 (8%) developed intraoperative or postoperative SAM (SAM group). The mean age was 56.8 ± 12.8 and 56.7 ± 13.8 in the No-SAM and SAM groups, respectively. The incidence of fibroelastic deficiency, forme fruste and Barlow's disease was similar in both groups. All patients received a complete annuloplasty ring as part of the repair. There was no statistical difference in the mean ring size used in each group. EF was similar in the No-SAM (56.2% ± 8.1) and SAM (57.0% ± 9.2) P = 0.63) groups. Independent predictors of developing SAM after valve repair were: EDD 15 mm (OR 3.80; P = 0.012) and basal septal diameter ≥ 15 mm (OR 3.63; P = 0.039). Conclusions The risk for SAM can be predicted using intraoperative transoesophageal echocardiography. The combination of a smaller left ventricle, tall posterior leaflet, narrow aorto-mitral angle and enlarged basal septum significantly increases the risk for SAM. Knowing these parameters prior to valve repair can assist the surgeon in adjusting their repair technique to minimize the risk.

New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

Abstract: OBJECTIVES: To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR). METHODS: International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres). RESULTS: Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic path- ology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement (relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92). The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33).

The ascending aorta with bicuspid aortic valve: a phenotypic classification with potential prognostic significance

Abstract: OBJECTIVE: Different methods to classify the anatomical configurations of the aorta with bicuspid aortic valve (BAV) have been proposed. We aimed to test them in terms of descriptive power (i.e. capability to identify different clusters of patients with unique associations of anatomo-clinical features) and possible prognostic significance. METHODS: A consecutive echocardiographic series of 696 BAV patients (mean age 48 ± 16 years, male:female ratio 3:1) was analysed. Three possible schemes for classification of the patterns of aortic dimensions were compared. One defined the aortic shape as ‘N’ (ascending sinotubular junction (STJ)), ‘A’ (ascending > sinuses > STJ) or ‘E’ (sinotubular ≥ sinuses), the second as ‘non-dilated’, ‘ascending phenotype’ (dilated, with ascending > sinuses) or ‘root phenotype’ (dilated, with sinuses > ascending) and the third as normal, ‘type I’ (dilated only at the ascending tract), ‘type II’ (dilated at both ascending and sinus levels) or ‘type III’ (dilated only at the sinuses). We evaluated the correlation with valve morphotypes (right-left fusion, right-non-coronary fusion) and patient characteristics. In a smaller longitudinal study (n= 150), the occurrence of fast growth of the aorta (fifth quintile: ≥1 mm/year) during follow-up (5 ± 3 years) in the various phenotypes was assessed. RESULTS: The three classification methods proved meaningful in terms of association with valve morphotypes: significant associations were found between right-left-coronary BAV and the root phenotype (P 1 mm/year) of the ascending diameter (50% root phenotype patients; P= 0.005). The association with the N type was weaker (P= 0.055); no association was found with types from the other classification scheme (P= 0.42). CONCLUSIONS: When tested on a large population, three previously suggested phenotypic classifications of the BAV aorta proved to categorize patients into significantly different clusters, but only the classification system distinguishing between ascending phenotype and root phenotype showed a potential prognostic value. Phenotypic class of the aorta could be a factor to integrate in future comprehensive models for risk stratification of BAV aortopathy.

Clinical trial of video-assisted thoracoscopic segmentectomy using infrared thoracoscopy with indocyanine green

Abstract: OBJECTIVES: The maintenance of a good surgical view is mandatory in video-assisted thoracoscopic surgery (VATS). For routine segmentectomy, it is necessary to re-inflate the lung in order to identify the intersegmental line. However, such re-inflation can occasionally obstruct the surgical view. Infrared thoracoscopy (IRT) with indocyanine green (ICG) can reveal the intersegmental line based on blood flow differences, without the need for lung re-inflation. The purpose of this study was to confirm the usefulness of IRT with ICG for VATS. METHODS: Between October 2008 and September 2011, 44 consecutive patients underwent segmentectomy at our institution. In 13 patients, VATS segmentectomy using IRT with ICG was employed. Informed consent was obtained from all patients. Computed tomography was performed to identify the dominant pulmonary artery supplying the target segment. The operations were performed using two ports and one mini-thoracotomy (3–6 cm). The dominant arteries were interrupted, and the intersegmental line was identified using IRT with ICG. RESULTS: Identification of the intersegmental line was possible in 11 (84.6%) of the 13 patients. The average age was 70 years, and 6 of the patients were male. The mean operation time was 191 min, and the mean bleeding volume was 64 ml. The operation time and bleeding volume were similar to the values in the other 31 patients who underwent thoracotomy (167 min/115 ml, P= 0.212/0.361, respectively). No complications attributable to IRT with ICG were observed. CONCLUSIONS: VATS segmentectomy using IRT with ICG allows the maintenance of a clear surgical view and identification of the intersegmental line in a high proportion of cases. Therefore, we consider this method to be useful for minimally invasive thoracic surgery.

Pedicled no-touch saphenous vein graft harvest limits vascular smooth muscle cell activation : the PATENT saphenous vein graft study

Abstract: OBJECTIVE: Neointimal hyperplasia secondary to vascular smooth muscle cell (VSMC) activation limits the long-term patency of saphenous vein grafts (SVGs). We compared markers of vascular injury and VSMC activation in SVGs harvested using the pedicled ‘no-touch’ (NT) vs the conventional (CON) technique. METHODS: Patients undergoing coronary artery bypass surgery were enrolled in the PATENT SVG trial (clinicaltrials.gov NCT01488084). Patients were randomly allocated to have SVGs harvested with the NT technique from one leg and the CON method from the other. SVG segments underwent morphometry, histological and electron microscopy assessments and transcript measurements of VSMC activation and differentiation markers. Leg wound functional recovery and harvest site complications were assessed using a quality-of-life questionnaire. RESULTS: A total of 17 patients (65.3±7.3 years) were enrolled. SVGs harvested using the NT vs CON technique exhibited preserved intimal, medial and adventitial architecture. CON harvest was associated with greater medial Kruppel-like factor 4 transcript levels (0.26±0.05 vs 0.11±0.02, P<0.05). CON samples had significantly lower medial serum response factor (0.53±0.11 vs 1.44±0.50, P<0.05) and myocardin (0.59±0.08 vs 1.33±0.33, P<0.05) transcript levels. MicroRNA-145, an inhibitor of VSMC activation and differentiation, was higher in the NT vs CON samples (1.84±1.03 vs 0.50±0.19, P<0.05). Leg assessment scores were worse in the NT legs at 3 months, but similar to CON scores at 12 months. CONCLUSIONS :S VGs harvested using the‘NT’ technique exhibit an early molecular and morphological pattern consistent with decreased VSMC activation compared with CON harvesting. Functional leg recovery was similar in both groups at 12 months. Larger studies are required to corroborate these findings.

Twenty-year durability of the aortic Hancock II bioprosthesis in young patients: is it durable enough?

Abstract: OBJECTIVES: There is a current trend towards the use of bioprosthetic aortic valves in the aortic position in young patients, but there is limited information on durability beyond the first decade. The Hancock II bioprosthesis has been reported to have excellent durability in patients ≥60 years of age. This study examines the long-term durability of the Hancock II bioprosthesis in the aortic position in patients <60 years of age. METHODS: From 1982 to 2008, 304 patients aged 59 years or less underwent aortic valve replacement (AVR) with a Hancock II bioprosthesis at two centres. The mean age was 49.2 ± 9.0 years, and 79% of the patients were male. Valve function was serially assessed by echocardiography. The median follow-up was 14.6 years (maximum 27.5 years). Survival and freedom from adverse events were calculated by using a Kaplan–Meier method. Independent predictors of those events were assessed by using Cox proportional hazards analyses. RESULTS: Survival and freedom from repeat AVR (re-AVR) at 20 years were 57.0 ± 6.1 and 25.4 ± 4.7%, respectively. During the follow-up, 100 patients (33%) underwent re-AVR: 78 for structural valve deterioration (SVD), 11 for endocarditis, 4 for non-structural valve dysfunction and 7 for other reasons. The overall 10-, 15- and 20-year freedom from re-AVR due to SVD were 91.4 ± 2.1, 64.7 ± 4.3 and 29.1 ± 5.3%, respectively. By age group, the 20-year freedom from re-AVR due to SVD amounted to 14.1 ± 8.7% in patients younger than 40 years of age, 21.5 ± 8.5% in patients aged 40–49 and 41.4 ± 8.2% in patients between 50 and 59 (P= 0.04). The independent predictors of re-AVR due to SVD were age [odds ratio (OR): 0.72 per 10 years; 95% confidence interval (CI): 0.58, 0.90; P< 0.01] and prosthesis–patient mismatch (PPM) (effective orifice area index <0.80 cm 2 /m 2 ) (OR: 1.63; 95% CI: 1.01, 2.63; P= 0.045). CONCLUSIONS: The Hancock II bioprosthesis for AVR in patients <60 years of age is associated with excellent durability during the first decade. However, SVD increases dramatically during the second decade and by 20 years, especially in patients aged <50 and/or with PPM. These findings may assist prosthesis selection for patients and their surgeons.

Early clinical outcomes of robot-assisted surgery for anterior mediastinal mass: its superiority over a conventional sternotomy approach evaluated by propensity score matching

Abstract: OBJECTIVES: We performed this study to assess early clinical outcomes of robot-assisted surgery for anterior mediastinal mass by comparing results of the robot group with those of the sternotomy group after propensity score matching. METHODS: Between 2008 and 2012, 145 patients underwent resection of anterior mediastinal mass. Robot-assisted surgery was performed in 37 patients, and conventional surgery by sternotomy in 108 patients. Propensity score matching was done between two groups with variables of age, sex, size of the mass, myasthenia gravis, resection of other organ and pathological diagnosis. Thirty-four patients from the robot group and 34 from the open group were matched, fitting the model. The clinical outcomes of matched groups were compared. RESULTS: In the robot group, mediastinal cyst consisted of 47.1% (16 of 34), thymoma 32.4% (11 of 34), thymic carcinoma 8.8% (3 of 34), thymic hyperplasia 8.8% (3 of 34) and liposarcoma 2.9% (1 of 34). The mean duration of follow-up was 1.11±0.21 and 1.85±0.19 years for the robot and open groups, respectively. There were no mortality or recurrence in both groups during the follow-up. There were no significant differences in operation time, postoperative white blood cell and C-reactive protein increase, maximum visual analogue scale score for pain as well as postoperative intensive care unit care between the two groups. The robot group revealed a lesser number of drains (1.09±0.1 vs 1.41±0.1) and 24-h tube drainage (189.4±20.5 vs 397.6±52.6 ml), lower haemoglobin loss (0.54±0.4 vs 1.35±0.1 g/dl) and haematocrit decrease (1.92±0.5 vs 3.85±0.4%), shorter chest tube days (1.53±0.2 vs 3.06±0.2) and length of hospital stay (2.65±0.2 vs 5.53±0.8) after operation, which were all statistically significant. Although statistically insignificant, there were no postoperative complications in the robot group, but there were 5 (14.7%) in the open group (P=0.063). CONCLUSIONS: In carefully selected patients with relatively smaller sized masses, robot-assisted surgery resulted in excellent early clinical outcomes with lesser tube drainage, lower blood loss, shorter tube days and length of hospital stay without any postoperative complications, compared with the matched open group. Further investigation for long-term clinical outcomes and oncological outcomes is required for a robotic approach. Particularly, long-term follow-up for the local recurrence rate according to the pathological diagnoses is required.

Hybrid thoracoscopic and transvenous catheter ablation of atrial fibrillation

Abstract: The hybrid approach combines an epicardial ablation with a percutaneous endocardial ablation in a single-step or sequential procedure. This study provides an overview of the hybrid procedure for the treatment of stand-alone atrial fibrillation (AF). Papers selected for this review were identified on PubMed and the final selection included nine studies. The total number of patients was 335 (range 15-101). Mean age ranged from 55.2 to 62.9 years. The hybrid approach achieved satisfactory results, with AF-antiarrhythmic drug-free success rates higher than those in isolated procedures. In particular, the bilateral approach with a bipolar device showed a high success rate independently of the AF type and seems to be the better choice for the hybrid procedure. Despite good preliminary results, large, multicentre trials of hybrid AF ablation that target a population of patients with long-standing persistent disease are necessary to establish whether this approach may represent, in the future, a gold-standard treatment for AF.

High-quality 3-dimensional image simulation for pulmonary lobectomy and segmentectomy: results of preoperative assessment of pulmonary vessels and short-term surgical outcomes in consecutive patients undergoing video-assisted thoracic surgery

Abstract: Objectives The aim of this study was to evaluate the effectiveness of 3-dimensional computed tomography (3D-CT) software in short-term surgical outcomes and the assessment of variations of pulmonary vessel branching patterns on performing video-assisted thoracic surgery (VATS). Methods The study included 179 consecutive patients who had undergone VATS anatomical lung resection, of which 172 were lobectomies (96%) and 7 were segmentectomies (4%), from May 2011 through January 2013. There were 124 patients (69%) in whom 3D-CT was performed and 55 patients (31%) who had not undergone 3D-CT. Observed actual pulmonary vessel branching patterns by intraoperative findings or footage were compared with the 3D image findings. Various surgical outcomes, including the occurrence of postoperative complications, in this study defined as those of Grade 2 or above under the Clavien-Dindo classification system, and total operative time, were retrieved from available clinical records. Results Among the 124 patients with preoperative 3D imaging, there were 5 (4%) conversions from VATS to thoracotomy. The incidence rate of patients with postoperative complications was 8% (n = 10), and there were no 30-day or 90-day mortalities. Pulmonary artery (PA) branches were precisely identified for 97.8% (309 of 316) of branches on 3D images, and the sizes of the seven undetected branches (five in the right upper lobe, two in the left upper lobe) ranged from 1 to 2 mm. The 3D images accurately revealed 15 cases (12%) of anomalous or unusual PA branches and 5 cases (4%) of variant pulmonary veins. Multivariate logistic regression analysis of the association with postoperative complications and operative time in 165 lung cancer patients demonstrated that male gender was the only statistically significant independent predictor of complications (risk ratio: 5.432, P = 0.013), and patients without 3D imaging tended to have operative complications (risk ratio: 2.852, P = 0.074), whereas conducting the 3D-CT (risk ratio: 2.282, P = 0.021) as well as intraoperative bleeding amount (risk ratio: 1.005, P = 0.005) had significant association with operative time. Conclusions High-quality 3D-CT images clearly revealed the anatomies of pulmonary vessels, which could play important roles in safe and efficient VATS anatomical resection.