David Haydock

Physical and Psychological Consequences of Left Cardiac Sympathetic Denervation in Long-QT Syndrome and Catecholaminergic Polymorphic Ventricular Tachycardia

Background—Left cardiac sympathetic denervation reduces risk in long-QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia. Side effects and patient satisfaction have not been systematically analyzed in patients who underwent left cardiac sympathetic denervation. Aims of this study included documenting physical and psychological consequences and patient satisfaction after left cardiac sympathetic denervation in LQTS or catecholaminergic polymorphic ventricular tachycardia. Methods and Results—Patients with LQTS (N=40) and catecholaminergic polymorphic ventricular tachycardia (N=7) underwent video-assisted thoracoscopic left cardiac sympathetic denervation, with a median follow-up of 29 months (range, 1–67 months). Clinical records were reviewed; 44 patients completed a telephone survey. Of 47 patients (53%), 25 were preoperatively symptomatic (15 syncope, 7 near-drowning, and 3 resuscitated sudden death). Indications for left cardiac sympathetic denervation included &bgr;-blocker intolerance (15; 32%) or nonadherence (10; 21%) and disease factors (18; 38%; catecholaminergic polymorphic ventricular tachycardia [6], near-drowning [2], exertional syncope [1], symptoms on therapy [2], LQT3 [1], QTc>520 ms [6]). Other indications were competitive sports participation (2), family history of sudden death (1), and other (1). Median QTc did not change among patients with LQTS (461±60 to 476±54 ms; P=0.49). Side effects were reported by 42 of 44 (95%). Twenty-nine patients (66%) reported dryness on left side, 26 (59%) a Harlequin-type (unilateral) facial flush, 24 (55%) contralateral hyperhidrosis, 17 (39%) differential hand temperatures, 5 (11%) permanent and 4 (9%) transient ptosis, 5 (11%) thermoregulation difficulties, 4 (9%) a sensation of left arm paresthesia, and 3 (7%) sympathetic flight/fright response loss. Majority of the patients were satisfied postoperatively: 38 (86%) were happy with the procedure, 33 (75%) felt safer, 40 (91%) recommended the procedure to others, and 40 (91%) felt happy with their scar appearance. Conclusions—Despite significant morbidity resulting from left cardiac sympathetic denervation, patients with LQTS and CPVT have high levels of postoperative satisfaction.

Subendothelial proteoglycan synthesis and transforming growth factor beta distribution correlate with susceptibility to atherosclerosis.

Coronary bypass vessels, saphenous vein (SV) and internal thoracic artery (ITA), differ in susceptibility to atherosclerosis and medium- to long-term patency. Whereas most ITA remain patent (90% at 10 years), 20% of SV grafts fail in the first year and approximately 45% fail within 10 years. Reasons for these differences are not fully understood. Loss of SV patency may reflect early metabolic events, particularly increased proteoglycan (PG) synthesis which contributes to intimal volume and promotes atherogenesis through retention of atherogenic lipoproteins. We determined, in vitro, the PG metabolic activity of SV, ITA, and human coronary arteries through autoradiographic detection of incorporated [3H]glucosamine. SV had significantly higher levels of PG synthesis than ITA, especially in the subendothelial zone and after time (7 days) in culture. Patterns of synthesis in coronary vessels were similar to SV with high levels of incorporation in the subendothelial zone of thickened intima (> 100 microm). Increased subendothelial labelling in SV was due to increased PG synthesis, not decreased degradation. ITA showed no propensity for upregulation of subendothelial PG synthesis. Immunohistochemistry showed TGF-beta1 and TGF-beta2 localised primarily to the subendothelial zone of SV and coronary arteries. With time in culture immunostaining increased in parallel with increased PG synthesis. Subendothelial TGF-beta1 and TGF-beta2 were absent in ITA. A panspecific TGF-beta neutralising antibody reduced subendothelial PG synthesis in SV and coronary arteries by 50 and 60%, respectively. These results support the idea that vessels susceptible to atherosclerosis show increased accumulation of subendothelial PG mediated by TGF-beta.

Comparison of four contemporary risk models at predicting mortality after aortic valve replacement

OBJECTIVE Risk stratification for aortic valve replacement (AVR) is desirable given the increased demand for intervention and the introduction of transcatheter aortic valve implantation. We compared the prognostic utility of the European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II, Society of Thoracic Surgeons (STS) score, and an Australasian model (Aus-AVR score) for AVR. METHODS We retrospectively calculated the 4 risk scores for patients undergoing isolated AVR at Auckland City Hospital from 2005 to 2012 and assessed their discrimination and calibration for short- and long-term mortality. RESULTS A total of 620 patients were followed up for 3.8 ± 2.4 years, with an operative mortality of 2.9% (n = 18). The mean EuroSCORE, EuroSCORE II, STS score, and Aus-AVR score was 8.7% ± 8.3%, 3.8% ± 4.7%, 2.8% ± 2.7%, and 3.2% ± 4.8%, respectively. The corresponding C-statistics for operative mortality were 0.752 (95% confidence interval [CI], 0.652-0.852), 0.711 (95% CI, 0.607-0.815), 0.716 (95% CI, 0.593-0.837), and 0.684 (95% CI, 0.557-0.811). The corresponding Hosmer-Lemeshow test P and chi-square values for calibration were .007 and 21.1, .125 and 12.6, .753 and 5.0, and .468 and 7.7. The corresponding Brier scores were 0.0348, 0.0278, 0.0276, and 0.0294. Independent predictors of operative mortality included critical preoperative state, atrial fibrillation, extracardiac arteriopathy, and mitral stenosis. The log-rank test P values were all <.001 for mortality during follow-up for all 4 scores, stratified by quintile. CONCLUSIONS All 4 risk scores discriminated operative mortality after isolated AVR. The EuroSCORE had poor calibration, overestimating operative mortality, although the other 3 scores fitted well with contemporary outcomes. The STS score was the best calibrated in the highest quintile of operative risk.

Acute Ischaemic Ventricular Septal Defect—A Formidable Surgical Challenge

BACKGROUND To evaluate our surgical results for Acute Ischaemic Ventricular Septal Defect and suggest practice guidelines. METHODS Retrospective review of data from patient records between 1992 and 2006 for presentation, surgical approaches, morbidity and mortality, statistically analysed to derive guidelines for management. RESULTS We had 36 patients with a mean age of 70.44(+/-6.34) years. Fourteen patients had inferior defects. Twenty-eight patients were in shock (22 on pre-operative IABP). Severe LV and RV dysfunction were present in 18 and 20 patients respectively. At surgery, 17 had infarct resection with patching while 18 had repair with infarct exclusion. Concomitant CABG was performed in 15. One patient was re-operated on for mitral valve replacement and one for recurrent VSD. Recurrent VSD was common (11 patients). Two of these patients underwent percutaneous device closure of whom one died. Prolonged ICU and hospital stay was normal. Early mortality was 52.78% (inferior defects-85.71% and anterior defects-31.82%). Inferior VSD (OR 7.7) and pre-operative shock (OR 6.7), predicted mortality. The subgroup of inferior VSD with shock had mortality equating that with medical management published in literature. CONCLUSIONS Acute Ischaemic VSD is a grim surgical disease marked by residual shunts and high mortality. Patients with inferior defects with shock should be offered surgery only under exceptional circumstances.

Comparison of Risk Scores for Prediction of Complications following Aortic Valve Replacement

BACKGROUND Risk models play an important role in stratification of patients for cardiac surgery, but their prognostic utilities for post-operative complications are rarely studied. We compared the EuroSCORE, EuroSCORE II, Society of Thoracic Surgeons (STS) Score and an Australasian model (Aus-AVR Score) for predicting morbidities after aortic valve replacement (AVR), and also evaluated seven STS complications models in this context. METHODS We retrospectively calculated risk scores for 620 consecutive patients undergoing isolated AVR at Auckland City Hospital during 2005-2012, assessing their discrimination and calibration for post-operative complications. RESULTS Amongst mortality scores, the EuroSCORE was the best at discriminating stroke (c-statistic 0.845); the EuroSCORE II at deep sternal wound infection (c=0.748); and the STS Score at composite morbidity or mortality (c=0.666), renal failure (c=0.634), ventilation>24 hours (c=0.732), return to theatre (c=0.577) and prolonged hospital stay >14 days post-operatively (c=0.707). The individual STS complications models had a marginally higher c-statistic (c=0.634-0.846) for all complications except mediastinitis, and had good calibration (Hosmer-Lemeshow test P-value 0.123-0.915) for all complications. CONCLUSION The STS Score was best overall at discriminating post-operative complications and their composite for AVR. All STS complications models except for deep sternal wound infection had good discrimination and calibration for post-operative complications.

Long-term Survival after Isolated Tricuspid Valve Replacement

BACKGROUND Isolated replacement of the tricuspid valve is rare, and the decision to operate is difficult. This study reviews the in-hospital mortality and long-term survival after tricuspid valve replacement in the absence of concomitant left sided valve surgery. It identifies predictors of poor outcome. METHODS All patients who underwent tricuspid valve replacement between January 1995 and December 2011 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. Logistic regression was used to identify predictors of early and late death. RESULTS Twenty-nine cases were identified. There were six in-hospital deaths (20.6%), and eight late deaths. Ascites was associated with in-hospital death (hazard ratio 16.96; p=0.0052). Higher dose of Frusemide was associated with late mortality (hazard ratio 1.157 per 20mg increase; p=0.0155). Frusemide dose and ascites were both significantly associated with death overall (p<0.01). Survival analysis estimated a 50% probability of surviving to 12.45 years. CONCLUSIONS Isolated tricuspid valve replacement has a high peri-operative risk. Long-term survival in this study was consistent with other reports. Ascites and higher doses of Frusemide were associated with poor outcomes.

Recurrent spontaneous pneumothorax associated with menstrual cycle: Report of three cases of catamenial pneumothorax

Recurrent spontaneous pneumothorax in association with the menstrual cycle was first described by Maurer et al . in 1958 1 and later described as ‘catamenial pneumothorax’ by Lillington et al . in 1972. 2 ‘Catamenial’ is coined from the Greek root meaning monthly. A number of possible causes of this condition have been proposed for this unusual clinical entity and various therapeutic options have also been suggested. We present three cases of catamenial pneumothorax that were treated by thoracic surgery and highlight the difficulties in the diagnosis and treatment of this condition.

Aortic valve replacement in over 70- and over 80-year olds: 5-year cohort study.

Background Demand for aortic valve intervention remains high, and together with the recent introduction of transcatheter aortic valve implantation, this motivates a review of surgical aortic valve replacement in elderly recipients. Methods Consecutive patients over 70 years of age having isolated aortic valve replacement during 2007–11 were retrospectively identified and divided into 70–79 and ≥ 80 years age groups for analyses. Results 62 octogenarians and 121 septuagenarians were eligible. Among octogenarians, a lower proportion were in Canadian Cardiovascular Society angina class 3–4 (3.2% vs. 14.0%, p = 0.022) and fewer had diabetes (11.3% vs. 24.8%, p = 0.034), but a higher proportion had infective endocarditis (6.5% vs. 0%, p = 0.012), and EuroSCORE II was higher (4.9% vs. 3.7%, p < 0.001). Despite this, operative mortality was lower in octogenarians (0% vs. 7.4%, p = 0.029), although hospital stay (11.7 vs. 8.9 days, p = 0.026) was longer. One-, 3-, and 5-year survival rates were 95.2%, 90.1%, and 75.3% for octogenarians and 89.2%, 81.7%, and 70.2% for septuagenarians (p = 0.398). Canadian Cardiovascular Society angina class 3–4 and the presence of other valvular stenosis or regurgitation were independent predictors of mortality. Conclusion Octogenarians had lower operative mortality despite a higher predicted risk preoperatively. Other factors beyond age and EuroSCORE, such as frailty, may be important in deciding whether elderly patients should undergo aortic valve replacement.

Prolonged Survival of Pulmonary Artery Sarcoma After Aggressive Surgical Resection

Pulmonary artery sarcomas are rare tumors with a poor prognosis. Presentation is usually with symptoms of cardiorespiratory dysfunction, and although preoperative diagnosis was unusual historically, modern imaging techniques allow a high degree of confidence, and transvenous catheter biopsy can give confirmation of the diagnosis. This patient survived 6 years after surgical resection of the tumor and left lung with pulmonary artery reconstruction followed by postoperative adjuvant chemotherapy. The prolonged survival supports an aggressive approach in suitable cases.

Propionibacterium acnes biofilm endocarditis requiring radical cardiac debridement and prosthetic valve replacements

transverse colon (Fig. 2). He underwent an uneventful right hemicolectomy and was released home after one week. At follow-up 14 days after his discharge, he was well and had regular bowel movements. Histopathology on the resected specimen showed moderately differentiated mucin producing colorectal adenocarcinoma, invading deeply into the muscularis, with 17 reactive lymph nodes. Colonic intussusception is an uncommon cause of bowel obstruction in adults accounting for only 1–5% of cases. Adult intussusception represents 5% of all cases of intussusception and is distinct from paediatric intussusception in its aetiology and treatment. In children, it is usually primary intussusception or secondary to a benign focus, and pneumatic or hydrostatic (air contrast enema) reduction of the intussusception is usually sufficient to treat the condition in 80% of cases. In contrast, almost 90% of cases in adults are secondary to a pathological condition that serves as a lead point, such as carcinomas, polyps, Meckel’s diverticulum, colonic diverticulum, strictures or benign neoplasms, which are usually diagnosed intraoperatively. Because of a significant risk of associated malignancy estimated at 65% of adult cases, radiological decompression should not be considered. Therefore, the great majority of adult cases of intussusception require definite surgical treatment. References