Cliff P. Connery

Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: A report from the SHOCK Trial Registry

OBJECTIVES We sought to compare the characteristics and outcomes of patients with acute myocardial infarction (MI) and cardiogenic shock (CS) caused by rupture of the ventricular free wall or tamponade versus shock from other causes. BACKGROUND Free-wall rupture is a recognized cause of mortality in patients with acute MI. Some of these patients present subacutely, which provides an opportunity for intervention. Recognition of factors that distinguish them from the overall shock cohort would be beneficial. METHODS The international SHOCK Trial Registry enrolled patients concurrently with the randomized SHOCK Trial. Thirty-six centers consecutively enrolled all patients with suspected CS after MI, regardless of trial eligibility. RESULTS Of the 1,048 patients studied, 28 (2.7%) had free-wall rupture or tamponade. These patients had less pulmonary edema, less diabetes, less prior MI, and less prior congestive heart failure (all p < 0.05). They more often had new Q waves in two or more leads (51.9% vs. 31.5%, p < 0.04), but MI location and time to shock onset after MI did not differ. Of patients with rupture or tamponade, 75% had pericardial effusions. No hemodynamic characteristics identified patients with rupture/tamponade. Most patients with rupture/tamponade had surgery and/or pericardiocentesis (27/28); their in-hospital survival rate was identical to that of the group overall (39.3%). Women and older patients with rupture/tamponade tended to survive intervention less often. CONCLUSIONS Free-wall rupture and tamponade may present as CS after MI, and survival after intervention is similar to that of the overall shock cohort. All patients with CS after MI should have echocardiography in order to detect subacute rupture or tamponade and initiate appropriate interventions.

Early mortality and morbidity of bilateral versus single internal thoracic artery revascularization : Propensity and risk modeling

OBJECTIVES We examined whether bilateral internal thoracic artery (BITA) revascularization is associated with any increased in-hospital mortality and complications compared with single internal thoracic artery (SITA) revascularization. BACKGROUND Despite proven long-term benefits, BITA revascularization has been slow to be adopted because of fear of increased early morbidity. METHODS We evaluated 1,697 consecutive patients undergoing BITA (n = 867) or SITA (n = 830) revascularization. We used propensity score analyses and adjusted risk models to address differences between arms. RESULTS There were 20 (2.3%) deaths in the BITA group versus 26 (3.1%) in the SITA group (odds ratio 0.73, p = 0.30). Propensity analysis identified several parameters that affected the decision to use BITA. Adjusting for propensity score and all potential risk factors, the odds ratio for death with BITA versus SITA was practically 1. Bilateral internal thoracic artery revascularization did not increase the number of in-hospital complications with the possible exception of deep sternal wound infections (11 [1.3%] vs. 3 [0.4%], p = 0.057). In multivariate modeling BITA increased the risk of deep sternal wound infections only in emergent cases and in older patients; the excess risk was negligible among 1,206 patients (71.1% of total) who did not have emergent revascularization and were < or =70 years old (risk difference 0.3%, p = 0.74). There was no difference in length of stay after adjustment for propensity factors (mean 11.3 vs. 11.7 days, p = 0.66). CONCLUSIONS Bilateral internal thoracic artery revascularization grafting confers no increased risk for early death and does not prolong hospital stay. The small increase in the risk of deep sternal wound infections does not affect the majority of patients.

Timely Airway Stenting Improves Survival in Patients With Malignant Central Airway Obstruction

BACKGROUND The survival of patients with malignant central airway obstruction is very limited. Although airway stenting results in significant palliation of symptoms, data regarding improved survival after stenting for advanced thoracic cancer with central airway obstruction are lacking. METHODS Fifty patients received a total of 72 airway stents for malignant central airway obstruction over a two-year period at a single institution. The Medical Research Council (MRC) dyspnea scale and Eastern Cooperative Oncology Group (ECOG) performance status were used to divide patients into a poor performance group (MRC = 5, ECOG = 4) and an intermediate performance group (MRC ≤ 4, ECOG ≤ 3). The SPSS version 16.0 (SPSS Inc, Chicago, IL) and Microsoft Excel (Microsoft, Redmond, WA) were used to analyze the data. Survival curves were constructed using the Kaplan-Meier survival analysis method and a log-rank test was used to compare the survival distributions among different groups. RESULTS Successful patency of the airway was achieved in all patients with no procedure-related mortality. Stenting resulted in significant improvement in MRC and ECOG performance scores (p < 0.01). Significantly improved survival was observed only in patients in the intermediate performance group compared with patients in the poor performance group (p < 0.05). CONCLUSIONS Airway stenting resulted in significant palliation of symptoms in both groups as evaluated by MRC dyspnea scale and ECOG performance status. Compared with historic controls, a significant survival advantage was seen only in the intermediate performance group. We postulate that timely stenting of the airway, before the morbid complications of malignant central airway obstruction have set in, results in improved survival.

Totally endoscopic robotic thymectomy for myasthenia gravis

The current recommendations for treating myasthenia gravis include surgical thymectomy for patients between puberty and 60 years of age. This is a report of a new method for surgical thymectomy using the robotic da Vinci surgical system for a totally endoscopic approach. This new procedure combines the potential advantages of minimally invasive methods with the efficacy of open procedures.

Robot-assisted lobectomy.

Clinical and Technical Description A 48-year-old woman was found to have a 1-cm nodule that had increased in size compared with its size at previous computed tomographic scans. After negative bronchoscopic and mediastinoscopic results, a VATS wedge resection confirmed non–small cell lung cancer. A formal lobectomy was then performed. Incisions for the VATS included a posterior 1-cm incision in the fifth intercostal space, an anterior 1-cm incision in the fifth intercostal space, and a 1-cm incision in the eighth intercostal space. For the lobectomy, the anterior incision was extended to a 6-cm working incision. A 1-cm incision was made anteriorly in the seventh intercostal space, and a 7-mm incision was made in the fourth intercostal space. The entire procedure was performed with the zero-degree scope. The robotic arms were placed in the fourth and eighth intercostal space incisions, the camera was placed in the working incision, and the robotic cart was positioned posteriorly over the right shoulder (Figure 1). The inferior pulmonary ligament was mobilized to the level of the inferior pulmonary vein. Next the hilum was dissected anteriorly, identifying the pulmonary veins. The inferior pulmonary vein was dissected, and a 0-0 silk tie was placed around it. An endovascular stapler was then used to divide the vein. The fissure was dissected, identifying the pulmonary artery to the lower lobe. After complete dissection of the pulmonary artery, the branches to the lower lobe and middle lobe were identified. Lymph nodes on the pulmonary artery were dissected as separate samples. The pulmonary artery was encircled with a 0-0 silk tie, and an endovascular stapler was used to divide the pulmonary artery. Next the bronchus to the lower lobe was dissected and encircled with an umbilical tape. A TA stapler (United States Surgical Corporation, Norwalk, Conn) was used to divide the bronchus. Before cutting the bronchus, the lung was inflated to ensure ventilation of the middle and upper lobes. A branch of the pulmonary artery to the superior segment of the lower lobe was identified and divided with an endovascular stapler. The fissure was completed with an endostapler. The lower lobe was removed in an Endobag tissue retrieval system (Medisco Medical Systems, Swindon, United Kingdom). The bronchus was examined for any evidence of an air leak, and the vessels were examined for any bleeding. The patient had a mediastinoscopy, the results of which were negative, and therefore no further lymph node dissection was performed.

Postoperative and Long-Term Outcome of Patients With Chronic Obstructive Pulmonary Disease Undergoing Coronary Artery Bypass Grafting

BACKGROUND Chronic obstructive pulmonary disease (COPD) has been conventionally associated with increased operative mortality and morbidity after coronary artery bypass grafting. Some studies, however, challenge this association. Moreover, the effect of COPD on long-term survival after coronary artery bypass grafting has not been adequately assessed. Thus, in this clinical setting, both early and late outcome require further examination. METHODS We studied 3,760 consecutive patients who underwent isolated coronary artery bypass grafting between 1992 and 2002. The propensity for COPD was determined by logistic regression analysis, and each patient with COPD was matched with 3 patients without COPD. Matched groups were compared for early outcome and long-term survival (mean follow-up, 7.6 years). Long-term survival data were obtained from the National Death Index. RESULTS There were 550 patients (14.6%) with COPD. Multivariate analysis showed that patients with COPD were older and sicker. However, propensity-matched groups did not differ in terms of hospital mortality or major morbidity, although COPD was associated with a slightly longer hospital stay. In contrast, COPD patients had increased long-term mortality, with a hazard ratio of 1.28 (95% confidence intervals, 1.11 to 1.47; p=0.001). Freedom from all-cause mortality at 7 years after CABG was 65% and 72% in matched patients with and without COPD, respectively (p=0.008). In patients with COPD, the hazard estimate was consistently increased up to 9 years postoperatively. CONCLUSIONS Chronic obstructive pulmonary disease, although not an independent predictor of increased early mortality and morbidity in this series, is a continuing detrimental risk factor for long-term survival.

Mediastinal mass evaluation using advanced robotic techniques

The diagnosis and management of mediastinal masses frequently necessitates biopsy and surgical resection. The use of videothorascopic techniques has broadened the surgeons ability to evaluate and treat such tumors using a minimally invasive approach. We describe herein the use of the da Vinci Robotic Surgical System for evaluating a mediastinal mass in a young woman.

Endoscopic resection of thoracic paravertebral and dumbbell tumors.

OBJECTIVENeurogenic paravertebral tumors are uncommon neoplasms arising from neurogenic elements within the thorax. These tumors may be dumbbell shaped, extending into the spinal canal or exclusively paraspinal. Generally encapsulated, they are located in the posterior mediastinum. In this report, we present our experience in the thoracoscopic resection of these tumors, including surgical technique and potential pitfalls. METHODSA retrospective review of patients undergoing endoscopic surgery for paravertebral tumors was undertaken. Patient demographics, charts, operative reports, and pre- and postoperative images were reviewed. RESULTSBetween 1997 and 2004, 13 patients were treated thoracoscopically for paravertebral tumors in our departments. Our population consisted of four men and nine women. The median age was 44.9 years (range, 29–66 yr). Eight patients presented with pain, dyspnea, cough, and weakness. Five patients had tumors found incidentally. Sizes of the tumors varied from 3 to 9 cm. Final pathology included four neurofibromas, eight schwannomas, and one unclassified granular cell tumor. Gross total resection was achieved endoscopically in all cases. Three patients required a hemilaminectomy for resection of the intraspinal dumbbell component of the tumor during the same operation. The mean operative time was 229.5 minutes. The mean estimated blood loss was 371.1 ml. Postoperative morbidities included one each of tongue swelling, ulnar neuropathy, and intercostal hyperesthesia. The mean hospital stay was 2.8 days. CONCLUSIONParavertebral tumors in the posterior mediastinum are amenable to endoscopic removal, even in hard to reach locations. Tumors with intraspinal extension can be removed concurrently by performing a hemilaminectomy, followed by thoracoscopy, without the need for a thoracotomy.

Robotic intercostal nerve graft for reversal of thoracic sympathectomy: a large animal feasibility model

A subset of patients who undergo video‐assisted thoracoscopic sympathectomy for hyperhydrosis develop post‐procedure compensatory sweating that is perceived as more debilitating than their initial complaints. We propose a novel treatment to reverse sympathectomy by implantation of an intercostal nerve graft using the da Vinci robot.

Successful repair of myocardial free wall rupture after thrombolytic therapy for acute infarction

BACKGROUND Controversy exists regarding the timing of thrombolytic administration and rupture rate. METHODS Hospital records at St. Lukes-Roosevelt Hospital of the 4 study patients were reviewed and compared with those of 41 patients from a group of 537 patients concurrently admitted with a diagnosis of myocardial infarction (MI). RESULTS Four patients experienced ventricular free wall rupture after having a MI between November 17, 1993, and July 28, 1995. All received tissue plasminogen activator. In 1 patient, pericardial effusion associated with a pseudoaneurysm was discovered in the operating room. The 3 others developed clinical pericardial tamponade before surgery. All 4 patients survived and left the hospital on postoperative days 10, 11, 11, and 82, respectively. During this same time period, 537 patients were admitted with MI, 41 of whom died; the studys 4 patients were compared with these 41. CONCLUSIONS These data demonstrate that rupture of the ventricular free wall can occur early after thrombolytic therapy and may have a subacute course. Prompt diagnosis and surgery offer excellent chances of surviving this fatal condition.