Showing papers in "Interactive Cardiovascular and Thoracic Surgery in 2012"
TL;DR: The embryonic and foetal development of the ribs and the sternum is highlighted following the understanding that the origin of these deformities is given by the disruption in the maturation of the parasternal region.
Abstract: Pectus excavatum and pectus carinatum represent the most frequent chest wall deformations. However, the pathogenesis is still poorly understood and research results remain inconsistent. To focus on the recent state of knowledge, we summarize and critically discuss the pathological concepts based on the history of these entities, beginning with the first description in the sixteenth century. Based on the early clinical descriptions, we review and discuss the different pathogenetic hypotheses. To open new perspectives for the potential pathomechanisms, the embryonic and foetal development of the ribs and the sternum is highlighted following the understanding that the origin of these deformities is given by the disruption in the maturation of the parasternal region. In the second, different therapeutical techniques are highlighted and based on the pathogenetic hypotheses and the embryological knowledge potential new biomaterial-based perspectives with interesting insights for tissue engineering-based treatment options are presented.
162 citations
TL;DR: It is concluded that radio-guided surgery is a preferable method that showed high accuracy with minimal complications and operator dependence in detecting subcentimetre PNs when compared with other techniques such as ultrasonography, finger palpation, fluoroscopic, hook-wire, spiral-wire and microcoil localization.
Abstract: A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing video-assisted thoracoscopic surgery (VATS) excision, what is the best way to locate a subcentimetre solitary pulmonary nodule (PN) in order to achieve successful excision?' Altogether, 107 papers were found using the reported search, of which 19 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The hook-wire technique showed a varied success rate ranging from 58 to 97.6% and a relatively higher failure rate due to wire dislodgement. The most common complication of this method was pneumothorax. CT-guided spiral-wire localization displayed a success rate of 86% with the added advantage of providing more stability than the hook-wire technique and permitting manipulation. Radio-guided localization techniques and fluoroscopic-aided methods using contrast media displayed consistently high sensitivities with few complications. The radio-guided technique had the benefit of allowing a longer time-period between the staining of the nodule and the operation. Ultrasonography showed sensitivities ranging from 92.6 to 100%; however, it is highly operator-dependent. Finger palpation was shown to achieve suboptimal results and should be avoided. We concluded that radio-guided surgery is a preferable method. It showed high accuracy with minimal complications and operator dependence in detecting subcentimetre PNs when compared with other techniques such as ultrasonography, finger palpation, fluoroscopic, hook-wire, spiral-wire and microcoil localization.
109 citations
TL;DR: A multidisciplinary, optimized, multimodal pre- and postoperative programme should be instituted, trying to improve the outcome of patients who had a non-traumatic lower limb amputation in a university hospital.
Abstract: The aim of this retrospective study was to evaluate factors potentially influencing short- and long-term mortality in patients who had a non-traumatic lower limb amputation in a university hospital. A consecutive series of 93 amputations (16% toe/foot, 33% trans-tibial, 9% through knee and 42% trans-femoral) were studied. Their mean age was 75.8 years; 21 (23%) were admitted from a nursing home and 87 (92%) were amputated due to a vascular disease and/or diabetes. Thirty days and 1-year mortality were 30 and 54%, respectively. Cox regression analysis demonstrated that the 30-day mortality was associated with older age (P = 0.01), and the number of co-morbidities (P = 0.04), when adjusted for gender, previous amputations, cause of and amputation level, and residential status. Thus, a patient with 4 or 5 co-morbidities (n = 20) was seven times more likely to die within 30 days, compared with a patient with 1 co-morbidity (n = 16). Further, the risk of not surviving increased with 7% per each additional year the patient got older. Of concern, almost one-third of patients died within 1 month. This may be unavoidable, but a multidisciplinary, optimized, multimodal pre- and postoperative programme should be instituted, trying to improve the outcome.
89 citations
TL;DR: The use of intravenous or oral iron supplementation proved ineffective in correcting anaemia after cardiopulmonary bypass and did not reduce blood transfusion requirements.
Abstract: OBJECTIVES: Anaemia is a frequent complication after cardiopulmonary bypass surgery. Iron therapy has been variably employed by medical centres over the years. In our study we test o test the clinical effectiveness of intravenous and oral iron supplementation in correcting anaemia, and its impact on blood transfusion requirements, in patients undergoing cardiopulmonary bypass surgery. METHODS: A double-blind, randomized, placebo-controlled clinical trial with three parallel groups of patients. Group I (n= 54): intravenous iron(III)-hydroxide sucrose complex, three doses of 100 mg/24 h during pre- and postoperative hospitalization and 1 pill/24 h of oral placebo in the same period and during 1 month after discharge. Group II (n= 53): oral ferrous fumarate iron 1 pill/24 h pre- and postoperatively and during 1 month after discharge, and intravenous placebo while hospitalized. Group III (n= 52): oral and intravenous placebo pre- and postoperatively, following the same protocol. Data were collected preoperatively, at theatre, at intensive care unit admission, before hospital discharge and 1 month later. RESULTS: (1) Baseline clinical and demographic characteristics and surgical procedures were similar in the three groups; (2) no intergroup differences were found in haemoglobin and haematocrit during the postoperative period; (3) the intravenous iron group showed higher serum ferritin levels at hospital discharge (1321 ± 495 ng/ml; P< 0.001) and 1 month later (610 ± 387; P< 0.001) compared with the other groups and (4) we did not observe statistical differences in blood transfusion requirements between the three groups. CONCLUSIONS: The use of intravenous or oral iron supplementation proved ineffective in correcting anaemia after cardiopulmonary bypass and did not reduce blood transfusion requirements. [Current Controlled Trials number: NCT01078818 (oral and intravenous iron in patients postoperative cardiovascular surgery under EC)].
89 citations
TL;DR: Investigation of adult patients undergoing redo-mitral valve replacement (redo-MVR) at an institution showed that overall survival was associated with the LVEF < 50% (P < 0.001), concomitant AVR (P<0.001) and urgent surgery (P = 0.03).
Abstract: The aim of this study was to investigate the overall outcome of adult patients undergoing redo-mitral valve replacement (redo-MVR) at our institution. Forty-nine patients (24 males) underwent redo-MVR with either bioprosthetic (n = 24) or mechanical valves (n = 25) between January 2000 and 2010. Median age of patients was 63 years (range 21-80 years), and the mean additive EuroSCORE was 12 ± 4. Median time to re-operation was 8.2 ± 6.6 years for first time redo-MVR and 6.4 ± 5.6 years for second-time redo-MVR. Indications included prosthetic endocarditis (n = 22), para-prosthetic leak (n = 12), structural valve degeneration (n = 8), prosthetic valve thrombosis (n = 6) and malignancy (n = 1). The mean follow-up was 47.5 ± 37.0 months (range 0.1-112.3 months). In-hospital mortality was 12% (n = 6). Mean hospital stay was 17 ± 11 days (range 8-50 days). Actuarial survival at 1 and 5 years was 81 ± 5% and 72 ± 6%, respectively. Three patients required re-intervention: two for prosthetic valve endocarditis and one for para-prosthetic leak. Multivariate analysis showed that overall survival was associated with the LVEF < 50% (P < 0.001), concomitant AVR (P < 0.001) and urgent surgery (P = 0.03).
88 citations
TL;DR: It is concluded that there is a substantial alteration of the prothrombotic profile in patients with axial-flow LVADs and abnormalities appeared to be reversible with the removal of the device and are likely to be responsible for the high incidence of non-surgical bleeding episodes reported.
Abstract: A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is an optimal antithrombotic management for patients supported with axial-flow left ventricular assist devices (LVADs). Altogether, more than 758 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These included seven prospective and three retrospective cohort studies with a total of 538 patients with axial-flow left ventricular assist device (LVAD) (HeartMate II, Jarvik 2000, INCOR, Thoratec assist device) implanted across the world as destination therapy or bridge to transplantation. We conclude that there is a substantial alteration of the prothrombotic profile in patients with axial-flow LVADs. These abnormalities appeared to be reversible with the removal of the device and are likely to be responsible for the high incidence of non-surgical bleeding episodes reported. Warfarin seems to offer a lower thromboembolic risk compared with unfractioned heparin or low molecular weight heparin. There are reports that suggest that managing axial-flow LVAD without anticoagulation, after major bleeding complications, is possible but in all probability, these papers are subject to publication bias as poor outcomes are unlikely to have been reported. All patients with axial-flow LVAD, showed severely impaired platelet function at point of care tests. The use of warfarin (INR target 2.5), in association with aspirin at 100 mg/day, or with point-of-care tests titrated antiplatelet therapy to inhibit 70%, seems to have the best bleeding-thrombosis, and in many cases a very small dose of aspirin of 25 mg twice a day and a dose of clopidogrel of 35 mg/day, were sufficient to achieve a reduction of the maximum aggregation to less than 30%. Finally, we would like to emphasize that such recommendations are addressed only to patients with axial-flow LVAD.
84 citations
TL;DR: Epicardial LAA clip occlusion leads to the acute electrical isolation of the LAA and may not only provide stroke prevention but also reduce the recurrence of AF.
Abstract: OBJECTIVES: The exclusion of the left atrial appendage (LAA) has been used to reduce the risk of stroke associated with atrial fibrillation (AF). While LAA exclusion has been associated with a reduced risk of stroke, the effect on the electrical activity of the LAA (a potential source of AF) remains unknown. As such, we sought to demonstrate whether surgical epicardial clip occlusion leads to the electrical isolation of the LAA. METHODS: From December 2010 until August 2011, 10 patients with paroxysmal AF underwent off-pump coronary artery bypass surgery with bilateral pulmonary vein isolation and an LAA clip occlusion with a new epicardial clip. Before and after the clip was placed, pacing manoeuvres were performed to assess the electrical exit and entry blocks from the LAA. RESULTS: All clips were applied successfully. The mean procedure time for the clip application was 4 ± 1 min. No complications occurred related to clip application. Prior to the pericardial closure, 18 ± 3 min after the clip placement, the LAA stimulation and pacing manoeuvres demonstrated complete electrical isolation of the LAA in all cases. CONCLUSIONS: Epicardial LAA clip occlusion leads to the acute electrical isolation of the LAA and may not only provide stroke prevention but also reduce the recurrence of AF.
82 citations
TL;DR: Administration of low-dose of PCC significantly decreased postoperative bleeding after CPB, and variations of prothrombin time, activated partial thromboplastin time and platelets with time were not different according to the treatment groups.
Abstract: OBJECTIVES: Prothrombin complex concentrates (PCCs) are sometimes used as ‘off label’ for excessive bleeding after cardiopulmonary bypass (CPB). The main objective of this study was to retrospectively evaluate the clinical and biological efficacy of PCC in this setting. METHODS: We reviewed the charts of all patients who had undergone cardiac surgery under CPB in our institution for 2 years. Patients treated for active bleeding with haemostatic therapy were identified. Chest tube blood loss was quantified postoperatively in the first 24 h. Coagulation parameters were recorded at intensive care unit admission and in the patient’s first 24 h. Thromboembolic complications were also ascertained. RESULTS: Seventy-seven patients out of the 677 studied (11.4%) were included: PCC was solely administered in 24 patients (group I), fresh frozen plasma in 26 (group II) and both in 27 (group III). The mean dose of PCC was 10.0 UI/kg ± 3.5 for group I vs 14.1 UI/kg ± 11.2 for group III (P = 0.09). Initial blood loss in the first hour was different between the three groups (P = 0.05): 224 ± 131 ml for group I, 369 ± 296 ml for group II and 434 ± 398 ml for group III. Only group I vs group III presented a significant difference (P= 0.02). Variations of blood loss over time were no different according to the treatment groups (P= 0.12). Reductions in blood loss expressed in percentage showed no difference between the three groups after 2 h: 54.5% (68.6–30.8) for group I; 45.0% (81.6–22.2) for group II; 57.6 (76.0–2.1) for group III; (P = 0.89). Re-exploration for bleeding involved 1 patient in group I (4%), 2 in group II (8%) and 10 in group III (37%) (P= 0.002). Except for fibrinogen, variations of prothrombin time, activated partial thromboplastin time and platelets with time were not different according to the treatment groups. Cerebral infarction occurred in one patient in group II.
77 citations
TL;DR: On this best evidence, intra- and postoperative maintenance fluid is recommended to be administered at 1-2 ml/kg/h and that a positive fluid balance of 1.5 l should not be exceeded in the perioperative period with caution being exercised with regard to the adequacy of oxygen delivery.
Abstract: A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether a conservative fluid management strategy in the perioperative management of lung resection patients is associated with a reduced incidence of postoperative acute lung injury (PALI) and/or acute respiratory distress syndrome (ARDS) in the recovery period. Sixty-seven papers were found using the reported search, of which 13 level III and 1 level IV evidence studies represented the best evidence to answer the question. Two retrospective case-control studies demonstrated a direct association between liberal fluid intake and the incidence of PALI/ARDS following lung resection on multivariate analysis (MVA) with odds ratios (ORs) of 1.42 (95% CI 1.09-4.32, P = 0.011) and 2.91 (1.9-7.4, P = 0.001). In non-PALI/ARDS cases, the mean intraoperative fluid infusion volume was significantly less [1.22 l (1.17-1.26) vs 1.68 l (1.46-1.9) P = 0.005], the fluid balance over the first 24 postoperative hours was significantly less [1.52 l positive (1.44-1.60) vs 2.0 l positive (1.6-2.4) P = 0.026] and cumulated intra- and postoperative fluid infusion was significantly less [2.0 ml/kg/h (1.7-2.3) vs 2.6 ml/kg/h (2.3-2.9) P = 0.003]. These data show that the difference between fluid regimes associated with an increased incidence of PALI/ARDS (i.e. 'liberal') and those which are not (i.e. 'conservative') is narrow but significant. However, this does not prove a causative role for liberal fluid in the multifactorial development of PALI/ARDS. On this best evidence, we recommend intra- and postoperative maintenance fluid to be administered at 1-2 ml/kg/h and that a positive fluid balance of 1.5 l should not be exceeded in the perioperative period with caution being exercised with regard to the adequacy of oxygen delivery. If the fluid balance exceeds this threshold, a high index of suspicion for PALI/ARDS should be adopted and escalation of the level of care should be considered. If a patient develops signs of hypoperfusion after these thresholds are exceeded, inotropic/vasopressor support should be considered.
76 citations
TL;DR: Significant risk factors for reoperation for bleeding after cardiac surgery was low ejection fraction, high EuroSCORE, procedures other than isolated CABG, elongated time on ECC, low body mass index, diabetes mellitus and preoperatively elevated s-creatinine.
Abstract: At Odense University Hospital (OUH), 5–9% of all unselected cardiac surgical patients undergo reoperation due to excessive bleeding. The reoperated patients have an approximately three times greater mortality than non-reoperated. To reduce the rate of reoperations and mortality due to postoperative bleeding, we aim to identify risk factors that predict reoperation. A total of 1452 consecutive patients undergoing cardiac surgery using extracorporeal circulation (ECC) between November 2005 and December 2008 at OUH were analysed. Statistical tests were used to identify risk factors for reoperation. We performed a case-note review on propensity-matched patients to assess the outcome of reoperation for bleeding regarding morbidity and mortality. In total, 101 patients (7.0%) underwent surgical re-exploration due to excessive postoperative bleeding. Significant risk factors for reoperation for bleeding after cardiac surgery was low ejection fraction, high EuroSCORE, procedures other than isolated CABG, elongated time on ECC, low body mass index, diabetes mellitus and preoperatively elevated s-creatinine. Reoperated patients significantly had a greater increase in postoperative s-creatinine and higher mortality. Surviving reoperated patients significantly had a lower EuroSCORE and a shorter time on ECC compared with non-survivors. The average time to re-exploration was 155 min longer for non-survivors when compared with survivors.
72 citations
TL;DR: More trials conforming to the characteristics of low-risk-of-bias studies and enrolling a larger and well-defined population of patients are needed to better clarify the effect of GDT in the specific setting of cardiovascular surgery.
Abstract: In cardiovascular surgery, reduced organ perfusion and oxygen delivery contribute to increased postoperative morbidity and prolonged intensive care unit stay. Goal-directed therapy (GDT), a perioperative haemodynamic strategy aiming to increase cardiac output, is helpful in preventing postoperative complications, but studies in the context of cardiovascular surgery have produced conflicting results. The purpose of the present meta-analysis is to determine the effects of perioperative haemodynamic goal-directed therapy on mortality and morbidity in cardiac and vascular surgery. MEDLINE, EMBASE, The Cochrane Library and the DARE databases were searched until July 2011. Randomized controlled trials reporting on adult cardiac or vascular surgical patients managed with perioperative GDT or according to routine haemodynamic practice were included. Primary outcome measures were mortality and morbidity. Data synthesis was obtained by using odds ratio (OR) with 95% confidence interval (CI) by a random effects model. An OR <1 favoured GDT. Statistical heterogeneity was assessed by Q and I(2) statistics. Eleven articles (five cardiac surgery and six vascular procedures), enrolling a total sample of 1179 patients, were included in the analysis. As compared with routine haemodynamic practice, perioperative GDT did not reduce mortality in either cardiac or vascular surgery (pooled OR 0.87; 95% CI 0.37-2.02; statistical power 64%). GDT significantly reduced the number of cardiac patients with complications (OR 0.34; 95% CI 0.18-0.63; P = 0.0006), but no effect was observed in vascular patients (OR, 0.84; 95% CI 0.45-1.56; P = 0.58). Perioperative GDT prevents postoperative complications in cardiac surgery patients, while it has no effect in vascular surgery. The different characteristics and comorbidities of the population enrolled could explain these conflicting results. More trials conforming to the characteristics of low-risk-of-bias studies and enrolling a larger and well-defined population of patients are needed to better clarify the effect of GDT in the specific setting of cardiovascular surgery.
TL;DR: The results showed that the single-stage approach with combined elective PCI and TAVI is feasible and safe and has become the primary choice for treatment of high-risk patients with severe aortic valve stenosis and CAD.
Abstract: There is no established strategy of how and when to treat coronary artery disease (CAD) in patients referred for transcatheter aortic valve implantation (TAVI). Simultaneous, single-stage treatment of both pathologies is a possible solution. We report our initial results of simultaneously performed transapical TAVI and elective percutaneous coronary interventions (PCI) in high-risk patients with severe aortic valve stenosis. Between April 2008 and July 2011, a total of 419 patients underwent transapical TAVI. Combined elective PCI and TAVI were performed in 46 (11%) patients. Only the most significant coronary lesion or lesions were treated. Technical success of the combined approach was 100%. The mean count of implanted stents per patient was 1.6 ± 1.0 (range, 1–5 stents). The 30-day mortality rates in the PCI and TAVI group was 4.3%. Survival at 12, 24 and 36 months of the PCI and TAVI group 87.1 ± 5.5, 69.7 ± 10.3 and 69.7 ± 10.3%, respectively. The results showed that the single-stage approach with combined elective PCI and TAVI is feasible and safe. It has become our primary choice for treatment of high-risk patients with severe aortic valve stenosis and CAD.
TL;DR: Titanium devices (clips and bars; screws and plates) are effective and safe for repair of rib fractures and large chest wall defect reconstruction with minimal complications and good long-term results.
Abstract: OBJECTIVES: To describe our experience with two new titanium-based devices for chest wall reconstruction and stabilization. METHODS: A Retrospective analysis of 18 consecutive patients (multiple rib fractures n= 9, iatrogenic rib fracture n= 2, lung herniation n= 2, chest wall tumour n= 5) who underwent surgery for rib fractures or chest wall tumours requiring chest wall resection and reconstruction between October 2010 and March 2012 was conducted. Chest wall defects and rib fractures were fixed with titanium clips and bars or titanium plates and screws through a posterolateral thoracotomy. RESULTS: There were 12 males, and the median age was 61 years. There were no postoperative deaths. The only postoperative complication observed was a pleural effusion requiring drainage in one patient who had titanium clips for the fixation of multiple traumatic rib fractures. Median length of stay of the drain and median length of hospital stay were 3 days (range 1–6) and 4 days (range 2–42 days), respectively. The average follow-up period of operatively managed patients was 6 months, (range 2–14 months). Two cases of hardware failure occurred in two patients treated for a lung hernia with large chest wall defects involving the anterior costal margin with either devices. CONCLUSIONS: Titanium devices (clips and bars; screws and plates) are effective and safe for repair of rib fractures and large chest wall defect reconstruction with minimal complications and good long-term results.
TL;DR: Radiofrequency ablation (RFA) and stereotactic ablative radiotherapy (SABR) offer a clear survival benefit compared with conventional radiotherapy in the treatment of early stage non-small cell lung cancer (NSCLC) in medically inoperable patients.
Abstract: A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'is radiofrequency ablation more effective than stereotactic ablative radiotherapy in patients with early stage medically inoperable non-small cell lung cancer?' Altogether, over 219 papers were found, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Radiofrequency ablation (RFA) and stereotactic ablative radiotherapy (SABR) offer a clear survival benefit compared with conventional radiotherapy in the treatment of early stage non-small cell lung cancer (NSCLC) in medically inoperable patients. Overall survival at 1 year (68.2-95% vs. 81-85.7%) and 3 years (36-87.5% vs. 42.7-56%) was similar between patients treated with RFA and SABR. However, 5-year survival was higher in SABR (47%) than RFA (20.1-27%). Local progression rates were lower in patients treated with SABR (3.5-14.5% vs. 23.7-43%). Both treatments were associated with complications. Pneumothorax (19.1-63%) was the most common complication following RFA. Fatigue (31-32.6%), pneumonitis (2.1-12.5%) and chest wall pain (3.1-12%) were common following SABR. Although tumours ≤ 5 cm in size can be effectively treated with RFA, results are better for tumours ≤ 3 cm. One study documented increased recurrence rates with larger tumours and advanced disease stage following RFA. Another study found increasing age, tumour size, previous systemic chemotherapy, previous external beam radiotherapy and emphysema increased the risk of toxicity following SABR and suggested that risk factors should be used to stratify patients. RFA can be performed in one session, whereas SABR is more effective if larger doses of radiation are given over two to three fractions. RFA is not recommended for centrally based tumours. Patients with small apical tumours, posteriorly positioned tumours, peripheral tumours and tumours close to the scapula where it may be difficult to position an active electrode are more optimally treated with SABR. Treatment for early stage inoperable NSCLC should be tailored to individual patients, and under certain circumstances, a combined approach may be beneficial.
TL;DR: A successful surgical excision was performed of the right gCAA, tightening of the left anterior descending artery aneurysm and concomitant coronary artery bypass grafting and a pathological examination confirmed advanced atherosclerosis.
Abstract: Giant coronary artery aneurysms (gCAAs) with a diameter exceeding 5 cm are extremely rare. The pathomechanisms and therapeutical measures in such cases have been controversial topics of discussion. Twenty-seven patients with gCAAs exceeding 5 cm in size described in the literature were evaluated. A case with multiple gCAAs at our department was included in the analysis. Apart from atherosclerosis of all coronary arteries, a large (1.5 2.5 cm) left anterior descending coronary artery aneurysm (CAA) and a gCAA (10.6 9.2 cm) originating from the right coronary artery, the latter causing recurrent myocardial ischaemia with the occlusion of the peripheral right coronary artery and compressing the right cardiac cavities, were the pathological findings in our 43-year old male patient. gCAAs predominantly develop at the proximal right coronary artery. The majority of these aneurysms develop secondary to atherosclerotic lesions in young patients. We performed a successful surgical excision of the right gCAA, tightening of the left anterior descending artery aneurysm and concomitant coronary artery bypass grafting. A pathological examination confirmed advanced atherosclerosis. Microbiological examinations could find no signs of infectious causes. CAAs bear a significant risk of severe complications and have a high risk of mortality. A more aggressive surgical approach should be recommended.
TL;DR: It is concluded that NPWT should be considered as a first-line treatment for most DSWIs, and significantly reduces the risk of early re-infections in patients with DSWI.
Abstract: RESULTS: The DSWI rate was 1.8% and did not change during the study period. Demographics were similar for both groups, except for peripheral arterial disease which was less common in the NPWT group. Coagulase-negative staphylococci were also more common (as the only pathogen identified) in the NPWT group (70% vs 30%, P= 0.01). The median length of hospital stay was 43 days in both groups and the sternum could be closed with delayed primary closure in all except 2 patients, one in each group. Eight patients in the CvT group required surgical revision for re-infections, including debridement and rewiring, when compared with 1 patient in the NPWT group (P= 0.02). Furthermore, 6 patients in the CvT group developed late chronic infections of the sternum requiring surgical revision, compared with one in the NPWT group (P= 0.10). The 30-day mortality was not significantly different between groups (4% vs 0%, P> 0.1) and the same was true for 1-year mortality (17% vs 0%, P= 0.11). CONCLUSIONS: NPWT significantly reduces the risk of early re-infections in patients with DSWI. There was a lower rate of late chronic sternal infections and lower mortality in the NPWT group, but the difference was not statistically significant. We conclude that NPWT should be considered as a first-line treatment for most DSWIs.
TL;DR: Short-term remote preconditioning improves haemodynamics and does not reduce myocardial injury after coronary artery bypass surgery, and further study of high-risk patients may be needed to fully evaluate the clinical effect of RIPC.
Abstract: Remote ischaemic preconditioning (RIPC) gained attention as a possibility to reduce myocardial injury after a subsequent sustained episode of myocardial ischaemia. This prospective randomized study was carried out to assess whether RIPC reduces myocardial injury in coronary artery bypass grafting patients. Eighty patients were assigned to remote preconditioning or control treatment. Ischaemic preconditioning was induced by three 5-min cycles of upper limb ischaemia and reperfusion after anaesthesia induction. Haemodynamic and markers of myocardial damage were analysed preoperatively and over 48 h postoperatively. The cardiac index was higher immediately after remote preconditioning in the main group. There were no differences in other haemodynamic, troponin I and creatine kinase-MB concentrations at any time point between groups. Thus, short-term remote preconditioning improves haemodynamics and does not reduce myocardial injury after coronary artery bypass surgery. Further study of high-risk patients may be needed to fully evaluate the clinical effect of RIPC.
TL;DR: With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.
Abstract: The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.
TL;DR: Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardIAL ischaemia due to early graft failure.
Abstract: Perioperative graft failure following coronary artery bypass grafting (CABG) may result in acute myocardial ischaemia. Whether acute percutaneous coronary intervention, emergency reoperation or conservative intensive care treatment should be used is currently unknown. Between 2003 and 2009, 39 of the 5598 patients who underwent isolated CABG surgery underwent early postoperative coronary angiography for suspected myocardial ischaemia. Following angiography, two groups were identified: patients who underwent immediately reintervention (group 1); and those treated conservatively (group 2). Primary study endpoints were mortality and postoperative myocardial infarct size. Postoperative coronary angiography revealed early perioperative bypass graft failure in 32 of 39 patients. Acute percutaneous coronary intervention was performed in 15 patients, redo-CABG in 4 patients and conservative treatment in 13 patients. The number of failing bypass grafts were significantly higher in group 1 compared with group 2 (P=0.0251). A trend toward lower post-procedural peak cardiac troponin T and creatinine phosphokinase serum levels in group 1 was observed (163.0 vs. 206.0 and 4.35 vs. 5.53, respectively) (P=0.0662 and 0.1648). Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardial ischaemia due to early graft failure.
TL;DR: PMV after coronary bypass is associated with a reduction in early and mid-term survival, and Kaplan-Meier survival curves showed reduced survival among PMV patients with an improved survival in the tracheostomy subgroup.
Abstract: OBJECTIVES Despite the seriousness of prolonged mechanical ventilation (PMV) as a postoperative complication, previously proposed risk prediction models were met with limited success. The purpose of this study was to identify perioperative variables associated with PMV in elective primary coronary bypass surgery. PMV was defined as the need for intubation and mechanical ventilation for >72 h, after completion of the operation. METHODS Between April 1997 and September 2010, 10 ,977 consecutive patients were retrospectively reviewed. A series of two multivariate logistic regression analyses were carried out to identify preoperative predictors of prolonged ventilation and the impact of operative variables. RESULTS PMV occurred in 215 (1.96%) patients; 119 (55.3%) of these underwent tracheostomy. At multivariate analysis, predictors included NYHA higher than class II (odds ratio [OR], 1.77; 95% confidence intervals [CI], 1.34-2.34), renal dialysis (OR, 5.5; 95% CI, 2.08-14.65), age at operation (OR, 1.04; 95% CI, 1.02-1.06), reduced FEV(1) (OR, 0.99; 95% CI, 0.98-0.99), body mass index >35 kg/m(2) (OR, 1.73; 95% CI, 1.14-2.63). On serial logistic regression analyses, operative variables added little to the discriminatory power of the model. Kaplan-Meier survival curves showed reduced survival among PMV patients (P < 0.001) with an improved survival in the tracheostomy subgroup. CONCLUSIONS PMV after coronary bypass is associated with a reduction in early and mid-term survival. Risk modelling for PMV remains problematic even when examining a more homogenous lower risk group.
TL;DR: Risk factors associated with higher in-hospital mortality after re-exploration for bleeding and tamponade include delayed resternotomy, higher levels of lactate and lower levels of haematocrit before revision and other well-known risk factors such as older age, more complex cardiac procedures, redo operations, longer cardiopulmonary bypass, renal failure and diabetes mellitus.
Abstract: The aim of this study was to determine the outcome of patients who had a chest resternotomy and to identify risk factors for higher in-hospital mortality after re-exploration for bleeding and/or tamponade after cardiac operations. We present our experience of an acceptably low re-exploration rate after cardiac surgery, and the outcomes of those re-explored. This was a retrospective analysis of medical records of all patients who had a chest re-exploration for the control of bleeding and cardiac tamponade over a 7-year period (2000-06), at the Cardiothoracic Centre of the Hospital Ceske Budějovice, Czech Republic. Between 2000 and 2006, 152 patients (3.4% of the total heart operations) underwent re-exploration after heart surgery. One hundred and seven (70.4%) were re-explored for bleeding, 36 (23.7%) for possible tamponade and nine (5.9%) for both. An identifiable source of bleeding was found in 72.4% patients. Risk factors associated with higher in-hospital mortality after re-exploration for bleeding and tamponade include delayed resternotomy, higher levels of lactate and lower levels of haematocrit before revision and other well-known risk factors such as older age, more complex cardiac procedures, redo operations, longer cardiopulmonary bypass, renal failure and diabetes mellitus. Patients who need re-exploration are at a higher risk of complications, morbidity and mortality if the time until re-exploration is prolonged.
TL;DR: Current evidence suggests that there are no contraindications-given the absence of negative impact on survival-for the use of MDs for the transplant of a proposed standard receiver, but caution is necessary in order to avoid organ shortage, despite these encouraging results.
Abstract: Summary A best evidence topic was constructed according to a structured protocol. The question addressed was whether the presence of extended criteria donors influences the early and long-term results in patients referred for lung transplantation. Of the 30 papers found using a report search, 14 presented the best evidence to answer the clinical question. The authors, journal, date, country of publication, study type, group studied, relevant outcomes and results of these papers are given. In total, we recorded 10 retrospective studies that considered all the donor criteria for comparing marginal donors (MDs) and standard donors. On the one hand, six of them showed no difference between the two groups in terms of early and long-term results. On the other hand, four studies demonstrated a negative impact of MDs on various early outcomes (mortality, primary graft dysfunction, duration of mechanical ventilation, length of stay in intensive care unit), whereas no significant negative influence on survival has ever been described when screening MD results. More precisely, when analysing the role of individual factors of marginality, as done in two of the 14 studies, a significant negative impact was observed for a low level of PaO2 at the time of harvesting, positive bronchoscopy and smoking history. More specifically, the first two criteria have been validated by several authors, both in multicentre and cohort studies. Finally, the importance of avoiding the donation of the lung from an MD to a high-risk recipient emerged, whereas the association with single or bilateral transplants remains more controversial. Hence, current evidence suggests that there are no contraindications—given the absence of negative impact on survival—for the use of MDs for the transplant of a proposed standard receiver. However, given the low level of evidence of published studies, caution is necessary in order to avoid organ shortage, despite these encouraging results.
TL;DR: In conclusion, lobectomy is still recommended for younger patients with adequate cardiopulmonary function, although limited resection carries a decreased rate of complications and shorter hospital stays, it may also carry a higher rate of loco-regional recurrences.
Abstract: A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: is limited pulmonary resection equivalent to lobectomy in terms of morbidity, long-term survival and locoregional recurrence in patients with stage I non-small-cell lung cancer (NSCLC)? A total of 166 papers were found using the reported search; of which, 16 papers, including one meta-analysis and one randomized control trial (RCT), represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. With regards to 5-year survival rates, the evidence is conflicting: a 2005 meta-analysis and six other retrospective or prospective nonrandomized analyses did not find any statistically significant difference when comparing lobectomy with limited resection. However, three studies found evidence of a decreased overall survival with limited resection, including the only randomized control trial, which showed a 50% increase in the cancer-related death rate (P = 0.09), and a 30% increase in the overall death rate in patients undergoing limited resection (P = 0.08). Age, tumour size and specific type of limited resection were also factors influencing the survival rates. Four studies, including the RCT, found increased locoregional recurrence rates with limited resection. There is also evidence that wedge resections, compared with segmentectomies, lead to lower survival and higher recurrence rates. In conclusion, lobectomy is still recommended for younger patients with adequate cardiopulmonary function. Although limited resection carries a decreased rate of complications and shorter hospital stays, it may also carry a higher rate of loco-regional recurrences. However, limited resection may be comparable for patients >71 years of age, and those with small peripheral tumours.
TL;DR: The bronchial stent was successfully removed in all patients without sequelae 71-123 days after its implantation and has proved to be an effective, safe and fast method to treat even large PPBPFs.
Abstract: The aim of the study was to assess the feasibility, efficacy and safety of the use of a conical self-expandable stent for the treatment of post-pneumonectomy bronchopleural fistula (PPBPF). Between April 2008 and November 2010, six patients underwent treatment for the PPBPF by the introduction of a tracheobronchial conical fully covered self-expandable nitinol stent with the aim of excluding the bronchial dehiscence from the airflow. We secured the prosthesis to the tracheal mucosa with titanium helical fasteners tacks. Five patients presented with a bronchial fistula larger than 5 mm following right (4) or left (1) pneumonectomy. One patient had an anastomotic dehiscence after right tracheal sleeve pneumonectomy. A chest tube showed the absence of empyema in all cases. Immediate resolution of the bronchial air leak was obtained in all the patients. Permanent closure of the bronchial dehiscence without recurrence was achieved in all the patients at a mean follow-up time of 13 months (range 3–32). The bronchial stent was successfully removed in all patients without sequelae 71–123 days after its implantation. The use of the conical self-expandable Silmet ® stent has proved to be
TL;DR: It is concluded that despite heparin-bonded and newer third-generation heparIn-polymer-b Bonded cardiopulmonary bypass circuits having a greater cost per person, their improved clinical outcomes and biocompatibility in patients undergoing cardiac surgery make them a preferable option to standard non-hepar in-bonding circuits.
Abstract: A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Is a fully heparin bonded cardiopulmonary bypass circuit superior to a standard cardiopulmonary bypass circuit?’ Altogether more than 792 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated (Table 1). The studies analysed show that perfusion with heparin-coated and heparin-polymer-coated bypass does not increase the risk of adverse effects but reduces blood loss, re-operation rates, ventilation time, length of intensive care unit (ICU) and hospital stay and is also associated with improved biocompatibility, as evidenced by platelet preservation, reduced leucocyte and complement activation, and proinflammatory cytokine production. The various coated circuits have comparable biocompatibility as evaluated by a range of inflammatory markers and clinical outcomes. Three studies documented a significant decrease in post-operative blood loss (P = 0.001–0.54) and a meta-analysis found that perfusion with a heparin-bonded circuit resulted in a reduction in blood transfusion requirements (20%), ventilation time (P 250) resulted in the greatest clinical benefit and improvement in inflammation. One study documented significant platelet preservation with the use of third-generation heparin-polymer-bonded circuits (P ≤ 0.05). We conclude that despite heparin-bonded and newer third-generation heparin-polymer-bonded cardiopulmonary bypass circuits having a greater cost per person, their improved clinical outcomes and biocompatibility in patients undergoing cardiac surgery make them a preferable option to standard non-heparin-bonded circuits.
TL;DR: It is concluded that preoperative diagnosis and early diagnosis of MH by using laparotomy and thoracotomy is useful for safe and effective repair and that resection of the hernia sac and insertion of a mesh are not necessary.
Abstract: OBJECTIVES: Morgagni hernia (MH) is an uncommon type of diaphragmatic hernia. This study aimed to summarize clinically relevant data with respect to MHs in adults. METHODS: We performed a retrospective chart review of patients who underwent surgical repair of foramen due to MH at our hospitals between 1996 and 2010. Data were collected on patient demographics, presenting symptoms, modes of diagnosis, surgical procedures, surgery outcomes, recurrence of hernia and follow-up of the patients. RESULTS: We included 36 patients with the mean age of 50.2 years. Of these 66.7% (n= 24) were female. Thirty-one patients had MH on the right side and 1 patient had bilateral MH. Most of the patients experienced abdominal symptoms. 72.2% of patients underwent laparotomy (n= 26, 72.2%), (n= 6, 16.7%) thoracotomy (n= 6, 16.7%), and a thoraco-abdominal approach (n= 4, 11.1%). Resection of the hernia sac and insertion of a mesh were not done in any patients. No recurrence occurred. CONCLUSIONS: We conclude that preoperative diagnosis and early diagnosis of MH by using laparotomy and thoracotomy is useful for safe and effective repair. Also we suggest that resection of the hernia sac and insertion of a mesh are not necessary.
TL;DR: A new research approach is proposed by involving specially trained sniffer dogs into research strategies by making use of their ability to identify LC in the breath sample of patients.
Abstract: Lung cancer (LC) continues to represent a heavy burden for health care systems worldwide. Epidemiological studies predict that its role will increase in the near future. While patient prognosis is strongly associated with tumour stage and early detection of disease, no screening test exists so far. It has been suggested that electronic sensor devices, commonly referred to as ‘electronic noses’, may be applicable to identify cancer-specific volatile organic compounds in the breath of patients and therefore may represent promising screening technologies. However, three decades of research did not bring forward a clinically applicable device. Here, we propose a new research approach by involving specially trained sniffer dogs into research strategies by making use of their ability to identify LC in the breath sample of patients.
TL;DR: Stationary cycling provides a well-tolerated and clinically effective alternative to walking in the early postoperative period after coronary artery bypass graft surgery.
Abstract: OBJECTIVES: The purpose of this study was to compare the effectiveness of moderate-intensity stationary cycling and walking exercise programmes in the early postoperative period after first-time coronary artery bypass graft surgery. METHODS: In this prospective trial, 64 patients (57 men, 7 women, mean age = 66 ± 9 years) performed twice daily, moderate-intensity exercise sessions, of 10-min duration, from postoperative day 3 until discharge from hospital. Patients were randomly assigned to stationary cycling or walking exercise intervention groups. Preoperative and discharge functional exercise capacity and health-related quality of life were assessed using 6-min walk and cycle assessments and the SF-36 version 2.0 questionnaire. Compliance with exercise was calculated as the proportion of scheduled exercise sessions completed. RESULTS: There were no significant differences between intervention groups at hospital discharge for 6-min walk distance (cyclists: 402 ± 93 m vs walkers: 417 ± 86 m, P= 0.803), 6-min cycle work (cyclists: 15.0 ± 6.4 kJ vs walkers: 14.0 ± 6.3 kJ, P= 0.798) or healthrelated quality of life. There was no significant difference between intervention groups for postoperative length of hospital stay (P= 0.335). Compliance rates for intervention groups were cyclists: 185/246 (75%) scheduled exercise sessions completed vs walkers: 199/242 (82%) scheduled exercise sessions completed (P= 0.162). CONCLUSIONS: Stationary cycling provides a well-tolerated and clinically effective alternative to walking in the early postoperative period after coronary artery bypass graft surgery. The optimal frequency, intensity and duration of exercise in the early postoperative period require further investigation. (Clinical trials register: Australian New Zealand Clinical Trials Registry; identification number: ACTRN12608000359336; http://www.anzctr.org.au/trial_view.aspx?ID=82978).
TL;DR: radical hybrid VATS segmentectomy including atypical resection of (sub)segments is a useful option for clinical stage-I NSCLC and the exact identification of anatomical intersegmental plane followed by dissection using electrocautery is critical from oncological and functional perspectives.
Abstract: We analysed the results of radical segmentectomy achieved through a hybrid video-assisted thoracic surgery (VATS) approach that used both direct vision and television monitor visualization at a median follow-up of over 5 years Between April 2004 and October 2010, 102 consecutive patients able to tolerate lobectomy to treat clinical T1N0M0 non-small cell lung cancer (NSCLC) underwent hybrid VATS segmentectomy in which we used electrocautery without a stapler to divide the intersegmental plane detected by selective jet ventilation in addition to the path of the intersegmental veins Curative resection was achieved in all patients The median surgical duration and blood loss during the surgery were 129 min (range, 60–275 min) and 50 ml (range, 10–350 ml), respectively The complication rate was 98% (10/102) with the most frequent being prolonged air leak, and there was no case of in-hospital death or 30-day mortality post procedure Five and seven patients developed locoregional and distant recurrences, respectively The overall and disease-free 5-year survival rates were 898% and 847%, respectively Radical hybrid VATS segmentectomy including atypical resection of (sub)segments is a useful option for clinical stage-I NSCLC The exact identification of anatomical intersegmental plane followed by dissection using electrocautery is critical from oncological and functional perspectives
TL;DR: Although the early and late outcomes are encouraging, a structured strategy should be developed and further experience is needed to ensure TAVI in patients who are in cardiogenic shock is feasible.
Abstract: Transcatheter aortic valve implantation (TAVI) has been introduced to treat patients at high risk for conventional surgery; however, cardiogenic shock is considered a contraindication for TAVI. The aim of the present study was to evaluate early and intermediate mortality of patients in cardiogenic shock undergoing TAVI as a rescue procedure. Patients in cardiogenic shock underwent transapical TAVI with Edwards SAPIEN (Edwards Lifesciences, Irvine, CA, USA) prosthetic valves. Preoperative, perioperative and 1-year follow-up data were analysed. Analysis included 358 patients. Preoperative cardiogenic shock was present in 21 (5.9%) patients. EuroSCORE (cardiogenic shock 73.1 ± 18.9% vs. non-cardiogenic shock 36.0 ± 18.7%; P < 0.0001) and Society of Thoracic Surgeons score (cardiogenic shock 50.8 ± 28.1% vs. non-cardiogenic shock 16.7 ± 12.2%; P < 0.0001) were significantly higher in the cardiogenic shock group, and left ventricular ejection fraction (cardiogenic shock 26.0 ± 13.1% vs. no-cardiogenic shock 51.4 ± 13.0%; P < 0.0001) was significantly lower. Thirty-day mortality was significantly higher in the cardiogenic shock group (cardiogenic shock 19% vs. non-cardiogenic shock 5%; P = 0.02) and 1-year survival significantly lower (cardiogenic shock 46% vs. no-cardiogenic shock 83%; P < 0.0001). At Cox regression, EuroSCORE was the sole determinant for follow-up mortality (odds ratio = 1.02; P = 0.04). TAVI in patients who are in cardiogenic shock is feasible. Although the early and late outcomes are encouraging, a structured strategy should be developed and further experience is needed.