No abstract available
Angiofibromatoid histiosarcoma of the pulmonary artery
We describe the surgical management of a rare pulmonary angiomatoid fibrous histiosarcoma (AFH). A 62-year-old lady presented with shortness of breath and found to have a large left main pulmonary artery defect that was positron emission tomography-avid. Following discussion in a thoracic multidisciplinary team meeting it was deemed unsafe to biopsy considering its intravascular position. The patient proceeded to theatre for a left pneumonectomy. She was successfully discharged home by Day 7. On follow-up the patient is well, and free of malignancy. AFH is an incredibly rare form of sarcoma, and in particular in the thoracic region. We have demonstrated successful oncological resection of a rare intravascular lesion in the pulmonary artery.
Minimally invasive access type related to outcomes of sutureless and rapid deployment valves
Objectives: Minimally invasive surgical techniques with optimal outcomes are of paramount importance. Sutureless and rapid deployment aortic valves are increasingly implanted via minimally invasive approaches. We aimed to analyse the procedural outcomes of a full sternotomy (FS) compared with those of minimally invasive cardiac surgery (MICS) and further assess MICS, namely ministernotomy (MS) and anterior right thoracotomy (ART).
Methods: We selected all isolated aortic valve replacements in the Sutureless and Rapid Deployment Aortic Valve Replacement International Registry (SURD-IR, n = 2257) and performed propensity score matching to compare aortic valve replacement through FS or MICS (n = 508/group) as well as through MS and ART accesses (n = 569/group).
Results: Postoperative mortality was 1.6% in FS and MICS patients who had a mean logistic EuroSCORE of 11%. Cross-clamp and cardiopulmonary bypass (CPB) times were shorter in the FS group than in the MICS group (mean difference 3.2 and 9.2 min; P < 0.001). Patients undergoing FS had a higher rate of acute kidney injury (5.6% vs 2.8%; P = 0.012). Direct comparison of MS and ART revealed longer mean cross-clamp and CPB times (12 and 16.7 min) in the ART group (P < 0.001). The postoperative outcome revealed a higher stroke rate (3.2% vs 1.2%; P = 0.043) as well as a longer postoperative intensive care unit [2 (1-3) vs 1 (1-3) days; P = 0.009] and hospital stay [11 (8-16) vs 8 (7-12) days; P < 0.001] in the MS group than in the ART group.
Conclusions: According to this non-randomized international registry, FS resulted in a higher rate of acute kidney injury. The ART access showed a lower stroke rate than MS and a shorter hospital stay than all other accesses. All these findings may be related to underlying patient risk factors.
Keywords: Aortic valve replacement; Rapid deployment valve; Sutureless and Rapid Deployment Aortic Valve Replacement International Registry; Sutureless valve; The International Valvular Surgery Study Group.
Pneumorrhachis After Thoracoabdominal Aortic Repair
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.
