General Thoracic and Cardiovascular Surgery

A case of type A acute aortic dissection with a common carotid trunk Abstract We present a rare case of common carotid artery with acute type A aortic dissection. A 72-year-old woman underwent emergent aortic arch repair using Antegrade selective cerebral protection. Bottom-tapped cannulae were inserted into three orifices of arch vessels, however, regional cerebral oxygen saturation decreased after rewarming. We found that arch branches were in order from front to back, right subclavian artery, common carotid trunk, and left subcravian artery. The patient complicated stroke in the right middle cerebral artery.

Intraoperative displacement of a Perceval sutureless prosthesis Abstract We describe a patient with mitral incompetence and aortic stenosis who underwent mitral valve repair and aortic valve replacement using a Perceval sutureless bioprosthesis. After weaning from cardiopulmonary bypass, repeated mitral valve repair was required due to residual mitral regurgitation. During this procedure, the aortic prosthesis was displaced, most likely by undue inadvertent traction on the atrial retractor, requiring its removal and reinsertion. When employing a sutureless valve gentle manipulation of the heart is mandatory to avoid possible adverse events as that herein described. Should this happen, the Perceval valve can be easily removed and repositioned.

Living-donor lung transplantation after surgical repair of transposition of the great arteries Abstract Pediatric pulmonary hypertension after surgery for congenital heart disease is a significant complication. We present a case of living-donor lung transplantation for a 12-year-old girl with pulmonary hypertension after surgical repair of transposition of great arteries. Despite repairing the transposition of great arteries, her growth was severely restricted because of progressive pulmonary hypertension; thus, lung transplantation was discussed. Standard bilateral lobar transplantation seemed unfeasible due to oversized grafts, so we performed a single lobar transplantation. Unexpectedly, she developed complications and died 3 months postoperatively despite another emergent lobar transplantation. We discussed the challenges and potential solutions regarding lobar size mismatching.

It is time to consider incorporating sarcopenia assessment in the surgical management of non-small-cell lung cancer

Novel harvesting technique of no-touch saphenous vein graft using THUNDERBEAT Abstract The no-touch technique of saphenous vein involves harvesting the vein as a pedicled graft and avoidance of direct contact with the vein or excessive high-pressure expansion. This technique provides long-term graft patency as that of internal mammary artery; however, the wound complications could be greater than conventional skeletonized technique. To solve the problem of leg wound trouble and to harvest the vein simpler, we have developed a novel harvesting technique using a newly developed energy device, THUNDERBEAT. This technique has the ability of efficacious tissue dissection, safer sealing of branches, and less wound complications without thermal damage to the graft. This strategy was successfully used in 35 patients.

Case report of cardiac herniation after sleeve pneumonectomy with superior vena cava reconstruction Abstract Cardiac herniation is a complication that occurs after intrapericardial pneumonectomy. It is life-threatening unless promptly diagnosed and surgery performed. We report a case of cardiac herniation after right intrapericardial pneumonectomy following radiotherapy for lung cancer. The patient developed cardiac herniation with sudden hypotension following a switch to the spine position. An immediate switch to the lateral decubitus position improved the cardiocirculatory dynamics, and surgical patch closure was performed. The circulation dynamics was unstable for several hours after surgery with elevated enzyme levels, which improved 2 days later. Immediate thoracotomy before irreversible myocardial damage resulted in a successful outcome. The risk of cardiac herniation should always be considered after intrapericardial pneumonectomy.

Preoperative biopsy does not affect postoperative outcomes of resectable non-small cell lung cancer Abstract Objectives Preoperative diagnostic interventions such as transbronchial biopsy and/or computed tomography-guided biopsy inevitably disrupt the lung structures and may disseminate tumour cells into the airway, vessels, or pleural cavity. Therefore, these procedures may affect the postoperative outcomes. Thus, we aimed to compare the survival outcomes in patients diagnosed by transbronchial biopsy vs computed tomography-guided biopsy vs lung resection. Methods In a single-institution retrospective analysis, data from consecutive patients with cTanyN0M0 lung cancer, who underwent surgery between January 2006 and December 2012, were extracted by chart review. The overall and recurrence-free survivals of patients diagnosed by transbronchial biopsy, computed tomography-guided biopsy, and lung resection were compared using the univariate and multivariate Cox proportional hazard models. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. Results Transbronchial biopsy and/or computed tomography-guided biopsy were performed for larger and more advanced tumours, than lung resection (intra- or postoperative-diagnosis group). At crude analysis, transbronchial biopsy group and computed tomography-guided biopsy group showed higher probability of pleural dissemination, and worse prognosis than the lung resection group. At multivariate analysis, the diagnostic methods were not identified as independent risk factors of pleural dissemination, overall survival, or recurrence-free survival. Conclusions Preoperative diagnostic interventions did not affect the relapse risk and prognosis, in this study cohort. Thus, preoperative diagnostic intervention is recommended if deemed necessary.

Lung transplantation via cardiopulmonary bypass: excellent survival outcomes from extended criteria donors Abstract Objectives The role of intraoperative cardiopulmonary bypass (CPB) in lung transplant (LTx) surgery is controversial. CPB enables slow pulmonary reperfusion and initial ventilation with low oxygen concentrations, both theoretically protective of transplanted lungs. In this study, we explored clinical outcomes following extended criteria donor LTx surgery implementing a thoroughly protective allograft reperfusion strategy using CPB. Methods Thirty-nine consecutive adult patients who underwent bilateral LTx with elective CPB and protective allograft reperfusion were reviewed. Bilaterally implanted lungs were reperfused simultaneously, via slow CPB flow reduction and initial ventilation with 21% oxygen and nitric oxide, followed by a brief modified ultrafiltration. During weaning from CPB, mean pulmonary arterial pressure was strictly maintained at 10–15 mmHg by controlling CPB and pulmonary flow. The clinical outcomes in 23 patients who received lungs from extended criteria donors (ECD group) were elucidated and compared to 16 patients undergoing LTx from standard criteria donors (SCD group). Results No life-threatening deterioration was observed to graft functionality during the first 72 h after LTx in the ECD group; however, only one patient required post-transplant extracorporeal membrane oxygenation. In three of 23 ECD LTx patients (12%), surgical revision for bleeding was required. Survival outcomes for the ECD group were favorable, with 100% survival at 6-months, 87.0% at 1-year, and 80.7% at 5-years. Outcomes in the ECD group were comparable to those in the SCD group. Conclusions Despite a certain extent of risk associated with full-dose heparinization, use of CPB does not undermine survival outcomes after ECD LTx surgery if protective allograft reperfusion is securely performed.

Transfer of a minimally invasive mitral valve repair program from a high-volume center to a very low volume center: how many cases are necessary to maintain acceptable results? Abstract Objective To investigate whether minimally invasive mitral valve repair (MIMVR) can be transferred from a high-volume center into a very small volume center and to clarify how many cases are necessary for maintenance of this program, early outcomes of MIMVR in Asahikawa Medical University were compared with those results in patients operated by a single surgeon in Duesseldorf University Hospital. Methods Sixty-five patients who underwent MIMVR in Asahikawa Medical University (group A) between May 2014 and July 2018 and 134 patients who underwent MIMVR in Duesseldorf University Hospital (group D) between September 2009 and January 2014 by a surgeon who started MIMVS later in Asahikawa were retrospectively analyzed. Results In group D, there were more patients with ischemic mitral valve regurgitation and with annular calcification than in group A. Survival rate at 6 months and 1 year was 98.5% and 98.5% in group A and 92.9% and 91.3% in group D, respectively. EuroSCORE II was significantly higher in patients dead within 30 days and within the first year. Conclusions The present study demonstrated that MIMVR programs can be transferred with acceptable early results into very low volume centers, if the team is developed by surgeons who are well trained and experienced in MIMVR. Moreover, the present study suggested that case number for maintenance of acceptable results may be obviously less than the previous recognition that this kind of specialized surgery could be maintained with at least 50 cases annually. However, meticulous preparations for surgery are essential for satisfactory surgical outcomes.

Malperfusion in type A aortic dissection: results of emergency central aortic repair Abstract Background Although outcomes of acute type A aortic dissection (ATAAD) have improved, malperfusion remains associated with high morbidity and mortality rates, and its optimal therapeutic treatment is unknown. Emergency central repair has been performed as our first-line approach for malperfusion. Here, we analyzed outcomes of ATAAD with malperfusion and reassessed emergency central repair. Methods In total, 1026 ATAAD patients underwent emergency surgery within 48 h of symptom onset, of whom 318 (30.9%) patients complicated with any preoperative malperfusion were included. Pathophysiology of malperfusion and surgical outcomes were analyzed. Results The in-hospital mortality rate was 12.9% for patients with malperfusion and 4.8% for patients without malperfusion (p < 0.0001). Coronary malperfusion was complicated in 7.5% of patients (% dead per group, 19.5%), mesenteric malperfusion in 3.6% (24.3%), renal malperfusion in 8.8% (14.4%), lower leg malperfusion in 12.6% (13.7%), brain malperfusion in 9.7% (12.0%), and spinal malperfusion in 1.1% (18.2%). Mortality rates varied substantially according to the number of affected organ systems (none, 4.8%; one system, 10.4%; two systems, 14.5%; three systems, 30.0%, and four systems; 30.3%; p < 0.0001). In malperfused patients, logistic regression analysis revealed that obesity (body mass index > 30 kg/m2), preoperative shock (systolic blood pressure < 80 mmHg), and visceral ischemia were independent predictors for hospital death. Conclusions Malperfusion of more organ systems and mesenteric malperfusion resulted in unfavorable prognosis, and effects of central repair were limited in such severe/complex malperfusion. To further improve outcomes of ATAAD with malperfusion, emergency reperfusion of affected organs followed by central repair might be considered.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com