Journal of Cardiothoracic Surgery - Latest Articles

Primary Pulmonary Adenocarcinoma Mimicking Papillary Thyroid Carcinoma

Ya-Zhen Zhu — 2013-05-17T00:00:00Z

We herein reported a primary pulmonary papillary carcinoma with colloid-like luminal content in the glandular cavity and classic nuclear features such as pseudo-inclusions, intranuclear grooves in the tumor cell nuclei and ground glass nuclei which closely mimics papillary thyroid carcinoma. Meanwhile, lymph node in the left pulmonary hilum was involved and showed similar features to the primary pulmonary papillary carcinoma. This specific histopathological presentation caused a diagnostic dilemma.The patient didn't show previous concomitant or subsequent evidence of a thyroid tumor. Immunohistochemistry further confirmed pulmonary origin and excluded a metastasis from the thyroid, as it was thyroglobulin negative, thyroid transcription factor 1 and surfactant apoprotein A positive, which was consistent with the imageology and history.Based on the above features, the diagnosis of primary pulmonary papillary carcinoma was confirmed. Understanding the existence of papillary thyroid carcinoma-like pulmonary papillary carcinoma will avoid misdiagnosis or unnecessary clinical and radiologic investigations in future.

Multiple anomalous left pulmonary venous connections detected with transthoracic echocardiography

Tzu-Lin Wang — 2013-05-17T00:00:00Z

Partial anomalous pulmonary venous connection is a rare congenital anomaly in which one or more pulmonary veins are connected to the venous circulation. The condition is frequently misdiagnosed, and usually identified by transesophageal echocardiography or invasive cardiac catheterization. We present the case of a 26-year-old female with new onset dyspnea on exertion who was diagnosed with the left superior and inferior pulmonary veins draining into the innominate vein via a vertical vein by two and three-dimensional transthoracic echocardiography and multidetector computed tomographic angiography.

Splenectomy increases the survival time of heart allograft via developing immune tolerance

Jinguo Zhu — 2013-05-16T00:00:00Z

Background: The spleen is an active lymphoid organ. The effect of splenectomy on the immune response remains unclear. This study investigated whether splenectomy can induce immune tolerance and has a beneficial role in cardiac allograft. Methods: Wistar rats were used for heart donors. The Sprague--Dawley (SD) rats designated as the recipients of heart transplantation (HT) were randomly assigned into four groups: sham, splenectomy, HT, splenectomy + HT. The survival of transplanted hearts was assessed by daily checking of abdominal palpation. At various time points after transplantation, the transplanted hearts were collected and histologically examined; the level of CD4+CD25+ T regulatory lymphocytes (Tregs) and rate of lymphocyte apoptosis (annexin-v+ PI+ cells) in the blood were analyzed by using flow cytometric method. Results: 1) Splenectomy significantly prolonged the mean survival time of heart allografts (7 +/- 1.1 days and 27 +/- 1.5 days for HT and splenectomy + HT, respectively; n = 12-14/group, HT vs. splenectomy + HT, p < 0.001); 2) Splenectomy delayed pathological changes (inflammatory cell infiltration, myocardial damage) of the transplanted hearts in splenectomy + HT rats; 3) The level of CD4+CD25+ Tregs in the blood of splenectomized rats was significantly increased within 7 days (2.4 +/- 0.5%, 4.9 +/- 1.3% and 5.3 +/- 1.0% for sham, splenectomy and splenectomy + HT, respectively; n = 15/group, sham vs. splenectomy or splenectomy + HT, p < 0.05) after splenectomy surgery and gradually decreased to baseline level; 4) Splenectomy increased the rate of lymphocyte apoptosis (day 7: 0.3 +/- 0.05%, 3.9 +/- 0.9% and 4.1 +/- 0.9% for sham, splenectomy and splenectomy + HT, respectively; n = 15/group, sham vs. splenectomy or splenectomy + HT, p < 0.05) in a pattern similar to the change of the CD4+CD25+ Tregs in the blood. Conclusions: Splenectomy inhibits the development of pathology and prolongs the survival time of cardiac allograft. The responsible mechanism is associated with induction of immune tolerance via elevating CD4+CD25+ Tregs and increasing lymphocyte apoptosis.

The utility of surgical lung biopsy in cancer patients with acute respiratory distress syndrome

Chih-Hao Chang — 2013-05-16T00:00:00Z

Background: This retrospective study evaluated the utility and safety of surgical lung biopsy (SLB) in cancer patients with acute respiratory distress syndrome (ARDS). Methods: All cases of critically ill patients with cancer and diagnosed with ARDS who underwent SLB in a tertiary care hospital from January 2002 to July 2009 were reviewed. Clinical data including patient baseline characteristics, surgical complications, pathological findings, treatment alterations, and survival outcomes were retrospectively collected and analyzed. Results: A total of 16 critically ill patients with cancer diagnosed with ARDS who underwent SLB were enrolled. The meantime from ARDS onset to SLB was 3.0 +/- 1.5 days. All SLB specimens offered a pathological diagnosis, and specific diagnoses were made in 9 of 16 patients. Biopsy findings resulted in a change in therapy in 11 of 16 patients. Overall, the SLB surgical complication rate was 19% (3/16). SLB did not directly cause the observed operative mortality. The ICU mortality rate was 38% (6/16). Patients who switched therapies after SLB had a trend toward decreased mortality than patients without a change in therapy (27% versus 60%; P = 0.299). Conclusions: In selected critically ill cancer patients with ARDS, SLB had a high diagnostic yield rate and an acceptable surgical complication rate.

Epidural analgesia is not superior to systemic postoperative analgesia with regard to preventing chronic or neuropathic pain after thoracotomy

Sandra Kampe — 2013-05-13T00:00:00Z

Background: To assess prospectively the incidence of chronic and neuropathic pain in patients undergoing anteroaxillary thoracotomy with postoperative epidural analgesia or controlled-release oxycodone pain regimen. Methods: 77 patients who underwent anteroaxillary thoracotomy were enrolled in our observational study. 40 patients received postoperatively a standardized oral analgesic protocol with controlled-release oxycodone and IV non opioid (CRO Group), and 37 patients received epidural analgesia with ropivacaine 0.1% + 1 mug/ml sufentanil (EDA Group) and IV non opioid. The painDETECT questionnaire was completed from the patients with one of the authors (JL) on the 7th postoperative day and six months postoperatively. Results: The data of 60 patients were eligible for statistical analysis, 28 patients in the CRO Group and 32 patients in the EDA Group. 17 patients did not reach the 6-months follow-up interval (12 drop outs in the CRO Group and 5 drop outs in the EDA Group).79% percent of patients in the CRO Group and 74% percent of patients in the EDA Group had a numeric rating scale score (NRS) = 0 after 6 months. 22% percent of patients in the CRO Group and 16% percent of patients in the EDA Group experienced a NRS 1--3 6-months postoperatively. No patient in the CRO Group and 9% percent of patients in the EDA Group had 6-months postoperatively a NRS 4--6. Neither in the CRO Group nor in the EDA Group we could detect a neuropathic pain 6 months postoperatively corresponding to a painDETECT score > 18. Overall, with regard to NRS, there was no statistical difference between the two groups (p = 0.13). 90% percent of patients in the CRO Group and 90% percent of patients in the EDA Group showed 6-months postoperatively a painDETECT score < 13 (definitely no neuropathic pain), and 9% percent in the EDA Group and 11% in the CRO Group had a 6-months painDETECt score 13--18 (p = not significant). Conclusion: These pilot data indicate that epidural analgesia is not superior to systemic postoperative analgesia with regard to preventing chronic or neuropathic pain after thoracotomy.

Preoperative risk stratification models fail to predict hospital cost of cardiac surgery patients

Akmal Badreldin — 2013-05-09T00:00:00Z

Background: Preoperative risk stratification models have previously been suggested to predict cardiac surgery unit costs. However, there is a lack of consistency in their reliability in this field. In this study we aim to test the correlation between the values of six commonly known preoperative scoring systems and evaluate their reliability at predicting unit costs of cardiac surgery patients. Methods: Over a period of 14 months all consecutive adult patients undergoing cardiac surgery on cardiopulmonary bypass were prospectively classified using six preoperative scoring models (EuroSCORE, Parsonnet, Ontario, French, Pons and CABDEAL). Transplantation patients were the only patients we excluded. Total hospital costs for each patient were calculated independently on a daily basis using the bottom up method. The full unit costs were calculated including preoperative diagnostic tests, operating room cost, disposable materials, drugs, blood components as well as costs for personnel and fixed hospital costs. The correlation between hospital cost and the six models was determined by linear regression analysis. Both Spearman's and Pearson's correlation coefficients were calculated from the regression lines. An analysis of residuals was performed to determine the quality of the regression. Results: A total of 887 patients were operated on for CABG (n = 608), valve (n = 142), CABG plus valve (n = 100), thoracic aorta (n = 33) and ventricular assist devices (n = 4). Mean age of the patients was 68.3+/-9.9 years, 27.6% were female. 30-day mortality rate was 4.1%. Correlation between the six models and hospital cost was weak (Pearson's: r < 0.30; Spearman's: r < 0.40). Conclusion: The risk stratification models in this study are not reliable at predicting total costs of cardiac surgical patients. We therefore do not recommend their use for this purpose.

Modified hypothermic circulatory arrest for emergent repair of acute aortic dissection type a: a single-center experience

Hong Qian — 2013-05-09T00:00:00Z

Background: Deep hypothermic circulatory arrest (DHCA) with antegrade cerebral perfusion has been historically preferred for organ protection during surgical repair of the acute aortic dissection type A. However, in the past decades, different perfusion-specific strategies with a growing trend to increase the body temperature at circulatory arrest emerged. In this study, we retrospectively analyzed the clinical results of our modified protocol for cardiopulmonary bypass and hypothermia management. Methods: Between February 2007 and September 2012, 54 consecutive patients suffering from acute aortic dissection type A underwent emergent surgery. All patients received hypothermic circulatory arrest in combination with antegrade cerebral perfusion. The patients were divided into two subsets according to the degree of hypothermia and perfusion strategies: namely the DHCA group and the group of modified hypothermic circulatory arrest (MHCA). Results: The overall 30-day mortality was 27.8% and was not significantly different between groups (DHCA, 33.3%, MHCA, 19%; p=0.253). The requirement for blood product transfusion in MHCA patients was significantly less as as compared with the patients in the DHCA group. No difference occurred in the incidence of temporary neurologic dysfunction, dialysis-dependent renal failure, or reexploration for bleeding between two groups of patients. The use of MHCA was identified as a protective factor against the postoperative composite complications (OR, 0.78; CI, 0.52 to 0.98; p=0.04) and the prolonged intensive care unit stay (OR, 0.8; 95% CI, 0.56 to 0.98; p=0.04). Conclusions: Moderate hypothermia in combination with selective brain perfusion and systemic retrograde perfusion is associated with adequate cerebral and visceral protection, reduced postoperative complications and shortened intensive care unit stay in our series. This modified perfusion strategy may help in improving perioperative outcomes in this particular group of patients.

Epicardial unipolar radiofrequency ablation for left ventricular aneurysm related ventricular arrhythmia

Yang Yu — 2013-05-07T00:00:00Z

We report a case of a 62-year-old Chinese man with typical triple-vessel lesions and apical left ventricular aneurysm accompanied with ventricular tachycardia. Off-pump coronary artery bypass (OPCAB) grafting was performed in combination with epicardial unipolar radiofrequency ablation and linear closure of left ventricular aneurysm. The patient recovered well without postoperative complications. Holter monitoring showed no recurrence of the ventricular arrhythmia and the attack frequency of arrhythmia decreased significantly. The patient has been angina-free for 25 months since the operation and shows increasing exercise tolerance. Thus, left ventricular aneurysm plication combined with epicardial unipolar radiofrequency ablation during OPCAB may be beneficial for patients with ventricular aneurysm and preoperative malignant ventricular arrhythmia.

The presence of old pulmonary tuberculosis is an independent prognostic factor for squamous cell lung cancer survival

Yiming Zhou — 2013-05-06T00:00:00Z

Background: Pulmonary tuberculosis (TB) is associated with an increased risk of lung cancer. Our study investigated whether the coexistence of an old pulmonary TB lesion is an independent prognostic factor for lung cancer survival in Chinese non-small cell lung cancer patients. Methods: We performed a retrospective review of 782 non-small cell lung cancer patients who underwent surgical resection as their primary treatment in 2006 and were followed for 5 years. The associations between lung cancer survival and the presence of old pulmonary TB lesions were assessed using Cox's proportional hazard regression analysis adjusted for WHO performance status (PS), age, sex, smoking-status, tumor stage, and surgical approach. Results: Sixty-four of the patients had old pulmonary TB lesions. The median survival of squamous cell carcinoma patients with TB was significantly shorter than that of patients without TB (1.7 vs. 3.4 years, p < 0.01). The presence of an old pulmonary TB lesion is an independent predictor of poor survival with a hazard ratio (HR) of 1.72 (95% CI, 1.12--2.64) in the subgroup of squamous cell carcinoma patients studied. Conclusion: The presence of an old pulmonary TB lesion may be an important prognostic factor for predicting the survival of squamous cell carcinoma patients.

Expandable external support device to improve Saphenous Vein Graft Patency after CABG

Yanai Ben-Gal — 2013-05-06T00:00:00Z

Objectives: Low patency rates of saphenous vein grafts remain a major predicament in surgical revascularization. We examined a novel expandable external support device designed to mitigate causative factors for early and late graft failure. Methods: For this study, fourteen adult sheep underwent cardiac revascularization using two vein grafts for each; one to the LAD and the other to the obtuse marginal artery. One graft was supported with the device while the other served as a control. Target vessel was alternated between consecutive cases. The animals underwent immediate and late angiography and were then sacrificed for histopathologic evaluation. Results: Of the fourteen animals studied, three died peri-operatively (unrelated to device implanted), and ten survived the follow-up period. Among surviving animals, three grafts were thrombosed and one was occluded, all in the control group (p = 0.043). Quantitative angiographic evaluation revealed no difference between groups in immediate level of graft uniformity, with a coefficient-of-variance (CV%) of 7.39 in control versus 5.07 in the supported grafts, p = 0.082. At 12 weeks, there was a significant non-uniformity in the control grafts versus the supported grafts (CV = 22.12 versus 3.01, p < 0.002). In histopathologic evaluation, mean intimal area of the supported grafts was significantly lower than in the control grafts (11.2 mm^2 versus 23.1 mm^2 p < 0.02). Conclusions: The expandable SVG external support system was found to be efficacious in reducing SVG's non-uniform dilatation and neointimal formation in an animal model early after CABG. This novel technology may have the potential to improve SVG patency rates after surgical myocardial revascularization.