No Abstract Available
Pleural effusion post coronary artery bypass surgery: associations and complications
Background: One of the most frequent complications of coronary artery bypass grafting (CABG) is pleural effusion. Limited previous studies have found post-CABG pleural effusion to be associated with increased length-of-stay and greater morbidity post-CABG. Despite this the associations of this common complication are poorly described. This study sought to identify modifiable risk factors for effusion post-CABG.
Methods: A retrospective cohort study of prospectively collected data assessed patients who underwent CABG over two-years. Data was collected for risk factors and sequelae related to pleural effusion requiring drainage.
Results: A total of 409 patients were included. Average age was 64.9±10.2 years, 330 (80.7%) were male. 59 (14.4%) patients underwent drainage of pleural effusion post-CABG. Effusions were drained on average 9.9±8.4 days post-CABG. Earlier removal of drain tubes and removal near time of extubation were associated with development of pleural effusion. Post-CABG pleural effusion was associated with post-operative renal impairment (P<0.01) and pericardial effusion (P<0.01). Patients with pleural effusion were more likely to require readmission to ICU (P<0.01), reintubation (P=0.03) and readmission to hospital (P=0.03).
Conclusions: Pleural effusion is a common complication of cardiac surgery and is associated with significant morbidity and resource utilization. This study identifies several associated complications that should be considered in the presence of pleural effusion. Modifiable associated factors in the management of drains that may contribute to accumulation of pleural effusion include: early removal of chest drains, higher outputs and removal during or close to mechanical ventilation. Further research is required to assess how adjusting these modifiable factors can decrease rates of effusion post-operatively.
Keywords: Coronary artery bypass graft (CABG); intensive care; intercostal catheter; pericardial effusion; pleural effusion.
Systematic Review of Neoadjuvant Immunotherapy for Patients with Non-Small Cell Lung Cancer
There is a paucity of robust clinical evidence for the role of neoadjuvant immunotherapy in patients with resectable non-small cell lung cancer. The primary aim of the study was to identify the available data on the feasibility, safety and efficacy of neoadjuvant immunotherapy. A systematic review was conducted using electronic databases. Relevant studies were identified according to predefined selection criteria. Five relevant publications on four completed trials were identified. In most studies, >90% of patients were able to undergo surgery within the planned timeframe after neoadjuvant immunotherapy. There was a high incidence of open thoracotomy procedures, either planned or converted from a planned minimally invasive approach. Mortality ranged from 0% – 5%, but none of the reported deaths were considered directly treatment-related. Morbidities were reported according to adverse events related to neoadjuvant systemic therapy, and postoperative surgical complications. Survival outcomes were limited due to short follow-up periods. Major pathologic response ranged from 40.5% – 56.7%, whilst complete pathologic response of the primary tumor ranged from 15% – 33%. Radiological responses were reported according to RECIST criteria and fluorodeoxyglucose-avidity. This systematic review reported safe perioperative outcomes of patients who underwent resection following neoadjuvant immunotherapy. However, there was a relatively high incidence of open thoracotomy procedures, partly due to the technical challenges associated with increased fibrosis and inflammation of tissue, as well as the more advanced stages of disease in patients enrolled in the studies. Future studies should focus on identifying predictors of pathological response
Survival outcomes for surgical resection versus CT-guided percutaneous ablation for stage I non-small cell lung cancer (NSCLC): a systematic review and meta-analysis
Objective: Multiple cohort studies have compared surgical resection with CT-guided percutaneous ablation for patients with stage 1 non-small cell lung cancer (NSCLC); however, the results have been heterogeneous. This systematic review and meta-analysis aims to compare surgery with ablation for stage 1 NSCLC.
Method: A search of five databases was performed from inception to 5 July 2020. Studies were included if overall survival (OS), cancer-specific survival (CSS), and/or disease-free survival (DFS) were compared between patients treated with surgical resection versus ablation (radiofrequency ablation (RFA) or microwave ablation (MWA)) for stage 1 NSCLC. Pooled odds ratios (OR) were calculated.
Results: A total of eight studies were included (total 792 patients: 460 resection and 332 ablation). There were no significant differences in 1- to 5-year OS or CSS between surgery versus ablation. There were significantly better 1- and 2-year DFS for surgery over ablation (OR 2.22, 95% CI 1.14-4.34; OR 2.60, 95% CI 1.21-5.57 respectively), but not 3- to 5-year DFS. Subgroup analysis demonstrated no significant OS difference between lobectomy and MWA, but there were significantly better 1- and 2-year OS with sublobar resection (wedge resection or segmentectomy) versus RFA (OR 2.85, 95% CI 1.33-6.10; OR 4.54, 95% CI 2.51-8.21, respectively). In the two studies which only included patients with stage 1A NSCLC, pooled outcomes demonstrated no significant differences in 1- to 3-year OS or DFS between surgery versus ablation.
Conclusion: Surgical resection of stage 1 NSCLC remains the optimal choice. However, for non-surgical patients with stage 1A, ablation offers promising DFS, CSS, and OS. Future prospective randomized controlled trials are warranted
A series of four transcatheter aortic valve replacement in failed Perceval valves
In recent years, sutureless valves (SV) and rapid deployment valves (RDVs) have become interesting aortic valve substitutes, especially in minimally invasive aortic valve surgery, as they reduce cardio-pulmonary bypass and cross-clamp times. There are two valve types available, the sutureless Perceval and the rapid deployment Intuity valve prosthesis. When these valves fail, besides surgical re-replacement, the valve-in-valve concept has been reported in a small series of case reports. Our own experience includes four cases of failed Perceval valves, in which a balloon-expandable transcatheter valve was implanted in three patients, and a self-expanding transcatheter valve was implanted in a fourth patient. Here, we present these four cases with a focus on the specific valve design of the Perceval valve, as well as on important technical aspects. All cases were performed successfully with clinical improvement. Transcatheter aortic valve replacement (TAVR) as a valve-in-valve concept seems to be a valuable option in selected patients with failed sutureless or RDVs.
Tricuspid valve endocarditis
No abstract available
The “UFO” procedure
The term “UFO” is not a medical term, but helps emphasize the extremely high degree of complexity of a surgical repair that is akin to someone observing an unidentified flying object. It involves replacement of the mitral and aortic valves with reconstruction of the intervalvular fibrous body (IVFB). Specific pathologies that render this operation necessary usually involve the IVFB, which is located between the aortic and mitral valves and constitutes a major portion of the fibrous skeleton of the heart. Patients that most often require such an operation are those with extensive aortic and mitral valve endocarditis with perivalvular extension into the IVFB. Other infrequent situations such as severe aortic and mitral annular calcification involving the IVFB, double valve replacement in patients with extremely small aortic and mitral annuli or double valve reoperations in which no IVFB is available following excision of both valves, necessitating the UFO procedure. The basic surgical principle has been first described as early as 1980. Depending on the extent of excised tissue due to the underlying disease, modifications and additional complex repair techniques have to be adopted. It is of utmost importance to have adequate visibility and exposure. There are certain important structures, which are at a risk of either injury or neglect, that can result in development of life-threatening complications during this operation, which a surgeon should be aware of. A step by step description of the “UFO” procedure can help guide the surgeon to perform this operation safely and efficiently. Although clinical complications are high, they are often related to the underlying disease and not specifically to the procedure itself, if performed perfectly.
Surgical options in infective valve endocarditis with neurological complications
Background: Surgery is a common treatment option for patients with infective endocarditis. We present a large cohort of surgically managed patients with infective endocarditis and evaluate the long-term mortality of those with and without neurological complications.
Methods: We performed a retrospective review of patients surgically managed for infective endocarditis between 1994 and 2017. Demographic and outcome data were collected using a hospital database. Time-to-event analysis was performed with Kaplan-Meier curve and compared statistically with log-rank testing.
Results: At the time of admission, 680 (27.7%) patients with infective endocarditis showed neurological complications. The mean age was 62.6±14.0 years and 70% were male. Two thousand two hundred and sixty-one (92%) patients had left-sided valve endocarditis. Isolated aortic valve endocarditis was present in 59% of patients and 35% of patients had isolated infective endocarditis of the mitral valve. Mean logistic EuroSCORE was 21.2±21.6. Microbiologic cultures were positive in 1,939 patients (79%). The most common bacteria were Staphylococcus aureus (26%). In-hospital mortality in the group of patients with Staphylococcus aureus was significantly higher than in the group infected with other pathogens (18.2% vs. 13.4%, P=0.004). Patients with vegetations ≥1 cm had significantly more systemic embolization (P<0.001). 44% of patients had septic embolization with the most common site being the spleen, followed by the brain. Patients presenting with neurological complications had significantly higher in-hospital and long-term mortality (P<0.0001).
Conclusions: Infective endocarditis patients with neurological complications have a significantly higher risk of mortality than patients without neurological complications. Surgery is an effective treatment in patients presenting with infective endocarditis, and may be undertaken in patients with neurological complications to prevent poorer prognosis.
Diagnostic tools in surgically treated patients with infective valve endocarditis
Background: Infective valve endocarditis (IE) is associated with significant mortality and complication rates. The diagnosis impacts not only the prognosis but also the management of the disease. The aim of this article is to show the findings obtained from the implementation of our most important diagnostic tools and discuss our standard diagnostic process for patients with IE who underwent surgical treatment between 1994 and 2017.
Methods: Between December 1994 and January 2017 a total of 2,458 patients with IE underwent surgery at our institution. We analyzed clinical, microbiological, echocardiographic, and multi slice computer tomographic (MSCT) features in this group.
Results: The most often isolated involved valve was the aortic valve (59%). Prosthetic valve endocarditis (PVE) was present in almost one third of all cases. The most common valve failures were mitral valve insufficiency (MI) and aortic valve insufficiency (AI) (65% and 57% respectively). Almost one half of the aortic insufficiencies were severe. 63% of all vegetations assessed by echocardiography were larger than 1 cm. We detected a septic embolism in 44% of patients and the most common target organ was the spleen (25%). The most common isolated pathogen was Staphylococcus aureus (26%) and affected patients had a significant correlation with in-hospital mortality (P=0.004).
Conclusions: Echocardiography offers valuable information and is the most important diagnostic method in patients with IE. Preoperative MSCT contributes to the entire perioperative decision-making process. Microbiological diagnosis is mandatory in choosing and adjusting antibiotic therapy and also has prognostic value.
The value of an “Endocarditis Team”
Establishment of the Heart Team concept in the field of cardiovascular medicine has resulted in quality improvement in the management of heart valve disease and heart failure. Similarly, the concept of an Endocarditis Team would be important in improving outcomes in patients with infective endocarditis (IE), given it is an uncommon clinical entity with general practitioners and low-volume centers lacking sufficient experience in its management. A multidisciplinary approach can substantially reduce the still unacceptably high morbidity and mortality in patients with IE, as it allows early diagnosis and appropriate comprehensive management. Decision-making within the Endocarditis Team must follow a standard protocol that is based on current clinical guidelines for the management of IE. If surgery is indicated, it is best performed sooner than later in most instances. Communication between referring hospitals and reference centers with an established Endocarditis Team must be smooth and definite protocols for transfer to experienced endocarditis centers with surgical facilities is essential. Follow-up and outpatient care following hospital discharge is crucial due to the possibility of residual infection and risk of development of recurrent endocarditis or heart failure, particularly within the first 2 years. Patient and health-care provider education is the mainstay for the accurate implementation of the Endocarditis Team concept. The following Keynote Lecture offers an overview of the current literature supporting the multidisciplinary management of IE and addresses multiple aspects related to the Endocarditis Team, highlighting its importance and necessity for the comprehensive treatment of this complex disease.
