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We describe a novel technical modification for reoperative aortic valve replacement in destructive recurrent prosthetic aortic valve endocarditis. We encountered complex anatomy in a previously operated aortic root wherein the aortic annulus and the right coronary sinus of Valsalva were destroyed. This precluded secure suture placement. We modified a composite mechanical Valsalva conduit to create a separate sinus of Valsalva left in continuity with the mechanical valve. This approach allowed us to exclude the infected right sinus of Valsalva and the corresponding aortic annulus.
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We present a unique case of aggressive symptomatic constrictive pericarditis within one month following off pump coronary artery bypass grafting surgery. The patient had a medical history of Hodgkin's lymphoma treated with radiotherapy and chemotherapy 20 years ago. Investigations confirmed constrictive pericardium with patent grafts and good biventricular function. Pericardiectomy was successful with remarkable recovery of symptoms.
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A 79-year-old male with a history of syncope attack was found to have a mass in the interventricular septum. The tumor was surgically removed, and the histological diagnosis was ectopic thyroid tissue. The outcome of the surgery was expected to be successful, however, the patient died from multiorgan failure.
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Enfermedad de la Arteria Coronaria , Tabique Interventricular , Masculino , Humanos , Anciano , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Tabique Interventricular/diagnóstico por imagen , Tabique Interventricular/cirugíaRESUMEN
We report a case of spontaneous hemothorax after aortic valve replacement in a 72-year-old female resulting from rupture of a pleural adhesion leading to hemodynamic instability. doi: 10.1111/jocs.12729 (J Card Surg 2016;31:211-213).
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Implantación de Prótesis de Válvulas Cardíacas , Hemotórax/etiología , Hemotórax/cirugía , Enfermedades Pleurales/complicaciones , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Anciano , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Femenino , Hemodinámica , Hemotórax/diagnóstico por imagen , Humanos , Complicaciones Posoperatorias/diagnóstico por imagen , Rotura Espontánea , Adherencias Tisulares/complicaciones , Resultado del TratamientoAsunto(s)
Aneurisma Coronario/etiología , Aneurisma Coronario/cirugía , Vena Safena/trasplante , Anciano , Angiografía Coronaria , Puente de Arteria Coronaria , Vasos Coronarios/cirugía , Humanos , Imagenología Tridimensional , Masculino , Arterias Mamarias/trasplante , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
There are few reports regarding endovascular treatment in thoracic surgical patients. Here, we describe the cases of 2 patients who received adjuvant endovascular therapy prior to surgery. One presented with recurrent chest infection. Computed tomography revealed systemic blood supply to an intralobar sequestration. The other presented with an avulsion injury to the internal mammary vein. Coil embolization was employed in both patients with subsequent uncomplicated surgery. Endovascular intervention may stop active bleeding in the chest and reduce the risk of operative hemorrhage in selected thoracic surgical patients.
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Secuestro Broncopulmonar/cirugía , Secuestro Broncopulmonar/terapia , Embolización Terapéutica/métodos , Procedimientos Quirúrgicos Torácicos , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/terapia , Adulto , Secuestro Broncopulmonar/diagnóstico por imagen , Femenino , Hemorragia/complicaciones , Hemorragia/diagnóstico por imagen , Hemorragia/terapia , Humanos , Masculino , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Heridas no Penetrantes/diagnóstico por imagenRESUMEN
Castleman's disease is a benign lymphoproliferative disease characterised by hyperplasia of lymphoid follicles. It can affect any lymph nodes in the body. Here we describe a caucasian patient who presented with six months history of shortness of breath with CT scan confirming an 8 cm segment of consolidated lung in left hilum. PET scan revealed a mass measuring 68x80x55 mm extending from the left hilum out into the left upper lobe containing area of calcification with SUV max 4.8. The differential diagnosis included atypical sequestration, hamartoma and primary lung malignancy. The patient underwent left video assisted enucleation of the lesion. The histology confirmed the diagnosis of Castleman's disease.
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Enfermedad de Castleman/diagnóstico , Enfermedades Pulmonares/diagnóstico , Adulto , Enfermedad de Castleman/diagnóstico por imagen , Enfermedad de Castleman/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Enfermedades Pulmonares/diagnóstico por imagen , Enfermedades Pulmonares/cirugía , Ganglios Linfáticos/patología , Tomografía de Emisión de Positrones , Tomografía Computarizada por Rayos XRESUMEN
A 42-year old woman presented with rheumatoid arthritis, dyspnoea and a congenital foregut cyst referred by a rheumatologist for thoracic surgery. The cyst was removed by video-assisted thoracoscopic surgery. The patient developed acute haemoptysis in the immediate postoperative period, which necessitated pulmonary resection due to infracted right lower lobe. This case report highlights the complication related to an unusual anatomy of a congenital foregut cyst.
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Quiste Broncogénico , Infarto Pulmonar , Adulto , Quiste Broncogénico/complicaciones , Quiste Broncogénico/diagnóstico por imagen , Quiste Broncogénico/patología , Quiste Broncogénico/cirugía , Femenino , Humanos , Complicaciones Posoperatorias/cirugía , Infarto Pulmonar/etiología , Infarto Pulmonar/cirugía , Cirugía Torácica Asistida por Video , Tomografía Computarizada por Rayos XRESUMEN
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether endobronchial valves improve outcomes in patients with severe emphysema. Eighty-seven papers were found using the reported search, of which seven 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. Endobronchial Valve for Emphysema Palliation Trial demonstrated that endobronchial valve increased forced expiratory volume in one second by 4.3% (95% confidence interval 1.4-7.2) and decreased by 2.5% in the control group (95% confidence interval -5.4 to 0.4) at a 6-month interval. This benefit is more marked in patients who do not have collateral ventilation into the area of lung being isolated as mapped by bronchoscopic physiological mapping (Chartis) or by computed tomography imaging documenting intact fissures. This evidence is reflected in the Endobronchial Valve for Emphysema Palliation Trial. Patients treated with endobronchial valve with high heterogeneity and complete fissures had greater improvement in forced expiratory volume in one second at 6- and 12-month intervals. We conclude that endobronchial valve placement improves lung function, exercise capacity and quality of life in selected patients with emphysematous diseases.
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Pulmón/cirugía , Implantación de Prótesis/instrumentación , Enfisema Pulmonar/cirugía , Benchmarking , Broncoscopía , Medicina Basada en la Evidencia , Tolerancia al Ejercicio , Volumen Espiratorio Forzado , Humanos , Pulmón/fisiopatología , Diseño de Prótesis , Enfisema Pulmonar/diagnóstico , Enfisema Pulmonar/fisiopatología , Enfisema Pulmonar/psicología , Calidad de Vida , Recuperación de la Función , Índice de Severidad de la Enfermedad , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Synthetic materials have traditionally been used for tissue reconstruction in thoracic surgery. New biomaterials have been tested in other areas of surgery with good results. The aim of our study is to evaluate our initial experience using prostheses in extended thoracic surgery. METHODS: A review was performed of all patients who underwent extended surgical procedures requiring soft tissue reconstruction with bioprosthetic materials after thoracic surgery from August 2009 to August 2011. A total of 44 consecutive patients were included. Operations involved radical pleurectomy and decortication for mesothelioma (n = 29), extended operations for thoracic malignancies (n = 8), surgery for trauma or perforated organs or complications (n = 6), and for benign infectious causes (n = 1). RESULTS: A total of 76 patches were used in 44 patients (median of 2; range 1 to 3 per patient). Median hospital stay was 13 (range 5 to 149) days. Three patients died during the postoperative period (6.8%); pulmonary embolism 5 days after intrapericardial pneumonectomy with chest wall reconstruction, fatal pneumonia 26 days after radical pleurectomy and decortication for mesothelioma, and bronchopleural fistula 11 days after pneumonectomy with diaphragm and atrium excision for lung cancer after initial chemoradiotherapy. No other surgical exploration or removal of patches has been required for infection. CONCLUSIONS: Our initial experience of using bioprosthetic patches for soft tissue reconstruction in thoracic surgery has proven satisfactory with overall acceptable results. The infection rates are low even when a proportion of procedures were performed under contaminated environments. Biologic prosthesis should be part of the surgical options to reconstruct soft tissues in thoracic surgery.
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Bioprótesis , Procedimientos de Cirugía Plástica/métodos , Pared Torácica/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Torácicos/métodosRESUMEN
Thymoma, a common anterior mediastinal tumour, may present with paraneoplastic neurological symptoms. The presence of neuronal anti-Hu paraneoplastic antibodies in thymoma patients is very rare. Here, we describe a patient who presented with symptoms of a sensory peripheral neuropathy in the presence of onconeural antibodies cross-reactive with Hu antigen, in whom an underlying thymoma was diagnosed. Subsequent minimally invasive thymomectomy improved her neurological symptoms significantly.
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Anticuerpos Antineoplásicos/inmunología , Proteínas del Tejido Nervioso/inmunología , Polineuropatía Paraneoplásica/inmunología , Timoma/complicaciones , Neoplasias del Timo/complicaciones , Anciano de 80 o más Años , Diagnóstico Diferencial , Femenino , Humanos , Polineuropatía Paraneoplásica/diagnóstico , Polineuropatía Paraneoplásica/etiología , Timoma/diagnóstico , Timoma/inmunología , Neoplasias del Timo/diagnóstico , Neoplasias del Timo/inmunología , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVES: Atrial tachyarrhythmias occur in up to 25% of patients after major thoracic surgery. We examined risk factors for new-onset atrial fibrillation (AF) following oesophagectomy in an attempt to guide prophylactic use of anti-arrhythmic strategies. METHODS: Data were extracted from a database of patients who underwent oesophagectomy between 1991 and 2009. Patients with pre-operative arrhythmias were excluded leaving 997 patients for further analysis. Univariate and multivariate logistic regression analyses were performed to identify factors predicting AF, and receiver operating characteristic curves were generated from a model using these predictors. Statistical significance was reflected in a P-value of <0.05. RESULTS: Patients who developed AF (n = 209; 20.96%) were older (median age 70.54 years vs. 66.9 years; P < 0.01) and included 141 males (67.4%) (P = 0.11). Patients with AF were noted to have a higher in-hospital mortality rate (n = 17; 8.1% vs. n = 34; 4.8%) (P = 0.04) and a longer stay in hospital (14 days vs. 12 days; P < 0.01). Multivariate analysis identified advanced age and neo-adjuvant chemotherapy to be independent predictors of the risk of developing AF. Assessment of discriminative ability of a predictive model revealed a c-statistic of just 0.62. CONCLUSIONS: Despite the identification of age and neo-adjuvant chemotherapy as predictors of AF, the moderate discriminative ability of predictive modelling does not support the use of prophylactic anti-arrhythmic drugs. However, the high incidence of AF after major thoracic surgery makes it necessary to understand its underlying mechanisms better before prophylactic strategies are considered.
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Fibrilación Atrial/etiología , Fibrilación Atrial/mortalidad , Neoplasias Esofágicas/tratamiento farmacológico , Neoplasias Esofágicas/cirugía , Esofagectomía/efectos adversos , Terapia Neoadyuvante/efectos adversos , Factores de Edad , Anciano , Análisis de Varianza , Antineoplásicos/efectos adversos , Antineoplásicos/uso terapéutico , Fibrilación Atrial/fisiopatología , Bases de Datos Factuales , Neoplasias Esofágicas/patología , Esofagectomía/métodos , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Terapia Neoadyuvante/métodos , Estadificación de Neoplasias , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/métodos , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Resultado del Tratamiento , Reino UnidoRESUMEN
We investigate the suitability of the two existing risk stratification systems available for predicting mortality in a cohort of patients undergoing lung resection under a single surgeon. Data from the 290 consecutive patients who underwent pulmonary resection between January 2008 and January 2011 were extracted from a prospective clinical data base. In-hospital mortality risk scores are calculated for every patient by using Thoracoscore and ESOS.01 and were compared with actual in-hospital mortality. The receiver operating characteristic (ROC) curve was used to establish how well the systems rank for predicting patient mortality. Actual in-hospital mortality was 3.1% (n = 9). Thoracoscore and ESOS values (mean ± SEM) were 4.93 ± 0.32 and 4.08 ± 0.41, respectively. The area under the ROC curve values for ESOS and Thoracoscore were 0.8 and 0.6, respectively. ESOS was reasonably accurate at predicting the overall mortality (sensitivity 88% and specificity 67%), whereas Thoracoscore was a weaker predictor of mortality (sensitivity 67% and specificity 53%). The ESOS score had better predictive values in our patient population and might be easier to calculate. Because of their low specificity, the use of these scores should be limited to the assessment of outcomes of surgical cohorts, but they are not designed to predict risks for individual patients.
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Modelos Estadísticos , Neumonectomía/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Inglaterra , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Neumonectomía/efectos adversos , Valor Predictivo de las Pruebas , Curva ROC , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Pectus excavatum (PE) is the most common chest wall deformity in adolescent life. Nuss procedure is a well-established technique for the repair of PE. The indication for correction is mainly medical aesthetic. Advantages of Nuss over conventional methods include reduced length of hospital stay, smaller incisions, and absence of need for osteochondrectomies. Here, we describe our experience with this procedure. MATERIALS AND METHODS: This was a retrospective study of patients who underwent Nuss procedure by a single surgeon between 2006 and 2010 in a regional center. Indications for surgery included the following: Progressive deformity and psychological stress. All patients underwent chest X-ray and pulmonary function testing. A standard Nuss procedure was performed using a single bar. Patients' satisfaction was assessed by a questionnaire and follow-up clinic letters. Satisfaction with body image was scored on a scale of 1-10. RESULTS: Eleven patients with PE underwent correction by Nuss procedure. Mean age of the patient was 19 years (range: 15-30). The average hospital stay was 7 days (range: 4-23 days). There was no mortality and no episodes of wound infection. In the immediate post-operative period, three patients (12.5%) were noted to have poor pain control. The post-operative course was uneventful in all cases except one patient who developed lung collapse, pleural effusion, and bar dislocation. Hundred percent of patients were satisfied with the scar. Seven patients scored 7 out of 10 on satisfaction with body image and two patients scored 6 or less. None of the patients complained of chronic pain. CONCLUSION: Nuss procedure is an effective method for the correction of PE. Most patients were satisfied with the outcome and none experienced chronic pain.
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BACKGROUND: We have demonstrated that diabetic human myocardium cannot be protected by ischemic preconditioning (IP) and identified a dysfunction of the mitochondria as the cause of the defect. Here we have investigated whether modulation of the nitric oxide (NO) metabolism can overcome the unresponsiveness of the diabetic myocardium to cardioprotection. METHODS: Myocardial slices (30-40 mg) obtained from the right atrial appendage of patients with diabetes undergoing elective cardiac surgery were randomized to the following protocol (n=6/group): NO donor SNAP (100 µM), nonselective nitric oxide synthase (NOS) inhibitor L-NAME (100 µM), and selective neuronal NOS (nNOS) inhibitor TRIM (100 µM) for 20 min prior to 90 min ischemia followed by 120 min reoxygenation (37°C). Some preparations were subjected to ischemic/reoxygenation alone or to IP (5 min ischemia/5 min reoxygenation) to act as control. Tissue injury was assessed by creatine kinase (CK) released (IU/mg wet wt), and cell necrosis and apoptosis by propidium iodide and TUNEL (% of aerobic control). RESULTS: IP did not decrease CK release, cell necrosis or apoptosis in diabetic myocardium. However, NO donor SNAP, the nonspecific NOS inhibitor L-NAME, and the specific nNOS inhibitor TRIM significantly reduced CK leakage, cell necrosis, and apoptosis in diabetic myocardium. CONCLUSIONS: These results demonstrate that both the provision of exogenous NO and the suppression of endogenous NO production result in potent protection of diabetic human myocardium overcoming the unresponsiveness of these tissues to cardioprotective therapies.
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Apéndice Atrial/efectos de los fármacos , Diabetes Mellitus Tipo 2/complicaciones , Isquemia Miocárdica/tratamiento farmacológico , NG-Nitroarginina Metil Éster/farmacología , Donantes de Óxido Nítrico/farmacología , Óxido Nítrico/metabolismo , Apoptosis/efectos de los fármacos , Apéndice Atrial/metabolismo , Apéndice Atrial/patología , Cardiotónicos/farmacología , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/patología , Inhibidores Enzimáticos/farmacología , Humanos , Precondicionamiento Isquémico Miocárdico , Mitocondrias/metabolismo , Isquemia Miocárdica/metabolismo , Isquemia Miocárdica/patología , Miocardio/metabolismo , Miocardio/patología , Necrosis , Óxido Nítrico Sintasa/antagonistas & inhibidores , Técnicas de Cultivo de Órganos , Distribución Aleatoria , S-Nitroso-N-Acetilpenicilamina/farmacologíaRESUMEN
BACKGROUND: Refractory post cardiopulmonary bypass (CPB) bleeding continues to cause concern for cardiac surgeons and intensivists. Massive postoperative hemorrhage following CPB is multifactorial and not fully understood, and it is also associated with increased mortality and morbidity. Activated recombinant factor VII (rFVIIa) has emerged as possible salvage medication in refractory post cardiac surgical bleeding. This observational study sought to identify the pattern of use of rFVIIa in cardiac surgery, its effectiveness, and risk. METHODS: This study involved a retrospective case review of medical records of ten patients undergoing a variety of cardiac surgery procedures and who developed life-threatening bleeding during surgery or after surgery despite conventional medical therapy, including transfusion of blood and blood products, and received rFVIIa at a regional center between August 2007 and April 2009. RESULTS: All ten patients received two consecutive doses of rFVIIa (average dose 65 µg/kg) at a 2-hour interval. Eight patients were re-explored due to massive postoperative bleeding or cardiac tamponade before receiving rFVIIa. Surgical sources of bleeding were not identified in any cases. A second re-exploration was carried out in two cases. Two patients (20%) died in ITU from problems not related to bleeding and thromboembolism. Blood loss was significantly reduced after administration of rFVIIa. Blood loss 6 hours prior to treatment was 1758.5 ± 163.9 mL and blood loss in the 6-hour period post treatment was 405.6 ± 50.5 mL (P < 0.05). Blood and blood products used in the 6-hour period before and after administration of rFVIIa were 19.6 ± 1.5U and 4.4 ± 0.6U, respectively (P < 0.05). No adverse reactions or thrombotic complications related to rFVIIa were noted. CONCLUSION: In our limited study, use of rFVIIa in refractory post surgical bleeding was significantly reduced blood loss and use of blood and blood products. We concluded that rFVIIa can be used satisfactorily and safely as a rescue therapy in the management of post cardiac surgical bleeding.
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BACKGROUND: Nitric oxide (NO) is cardioprotective and a mediator of ischemic preconditioning (IP). Endothelial nitric oxide synthase (eNOS) is protective against myocardial ischemic injury and a component of IP but the role and location of neuronal nitric oxide synthase (nNOS) remains unclear. Therefore, the aims of these studies were to: (i) investigate the role of nNOS in ischemia/reoxygenation-induced injury and IP, (ii) determine whether its effect is species-dependent, and (iii) elucidate the relationship of nNOS with mitoKATP channels and p38MAPK, two key components of IP transduction pathway. RESULTS: Ventricular myocardial slices from rats and wild and nNOS knockout mice, and right atrial myocardial slices from human were subjected to 90 min ischemia and 120 min reoxygenation (37 degrees C). Specimens were randomized to receive various treatments (n = 6/group). Both the provision of exogenous NO and the inhibition of endogenous NO production significantly reduced tissue injury (creatine kinase release, cell necrosis and apoptosis), an effect that was species-independent. The cardioprotection seen with nNOS inhibition was as potent as that of IP, however, in nNOS knockout mice the cardioprotective effect of non-selective NOS (L-NAME) and selective nNOS inhibition and also that of IP was blocked while the benefit of exogenous NO remained intact. Additional studies revealed that the cardioprotection afforded by exogenous NO and by inhibition of nNOS were unaffected by the mitoKATP channel blocker 5-HD, although it was abrogated by p38MAPK blocker SB203580. CONCLUSIONS: nNOS plays a dual role in ischemia/reoxygenation in that its presence is necessary to afford cardioprotection by IP and its inhibition reduces myocardial ischemic injury. The role of nNOS is species-independent and exerted downstream of the mitoKATP channels and upstream of p38MAPK.