David Marshman

The International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society grading system has limited prognostic significance in advanced resected pulmonary adenocarcinoma

Introduction: The International Association for the Study of Lung Cancer, the American Thoracic Society and the European Respiratory Society (IASLC/ATS/ERS) system which subclassifies lung adenocarcinoma into five distinct types has been widely adopted. We assessed the prognostic value of subclassifying adenocarcinoma in this way in consecutive patients undergoing surgery. Methods: All patients at our institution undergoing surgery for lung carcinoma between 2000 and 2010 were identified. The original pathology slides were independently reviewed and reclassified according to the 2011 IASLC/ATS/ERS grading and the American Joint Committee on Cancer (AJCC) 7th edition 2009 staging systems. Results: We identified 270 patients including 152 with adenocarcinoma histology with long-term follow-up. Using the Kaplan–Meier method, the calculated 5 year survival for each of the adenocarcinoma categories were papillary-predominant 80%, lepidic-predominant 71%, micropapillary-predominant 55%, acinar-predominant 43%, solid-predominant 39% and invasive mucinous adenocarcinoma 38%. The AJCC stage was a very strong predictor of survival (p < 0.001). The IASLC/ATS/ERS subclassification of adenocarcinoma demonstrated a trend as a prognostic marker but failed to reach statistical significance in univariate or multivariate analysis. Conclusion: Although the IASLC/ATS/ERS classification has been validated by several studies in stage I tumours, further studies of larger cohorts will be required to show prognostic value in unselected lung carcinoma undergoing surgery with curative intent.

Self-monitoring for atrial fibrillation recurrence in the discharge period post-cardiac surgery using an iPhone electrocardiogram.

OBJECTIVES Postoperative atrial fibrillation (POAF) occurs in 25-40% of patients following cardiac surgery, and is associated with a significant increased risk of stroke and mortality. Routine surveillance is not performed post-discharge; however, recurrence of POAF can occur in up to 30% of patients discharged in sinus rhythm. This study aimed to determine the feasibility of patients self-monitoring with an iPhone handheld electrocardiogram (iECG) to identify recurrence of POAF in the post-discharge period following cardiac surgery. METHODS Patients with POAF following cardiac surgery were eligible for participation if they had no prior history of atrial fibrillation (AF) and were discharged home in stable sinus rhythm. Participants were provided with an iECG and asked to record a 30-s iECG, four times per day for 4 weeks post-discharge. iECGs were automatically transmitted to a secure server, and reviewed for the presence of AF by the research team and a validated algorithm. All participants also received brief education on AF. RESULTS Forty-two participants completed the intervention (mean age 69 ± 9 years, 80% male). Self-monitoring for POAF recurrence using an iECG was feasible and acceptable, and participants felt empowered. Self-monitoring identified 24% (95% confidence interval, 12-39%) with an AF recurrence within 17 days of hospital discharge. These participants were significantly younger than those without AF recurrence (64 ± 7 vs 70 ± 10 years; P = 0.025), and had a significantly lower CHA2DS2-VASc score (2.3 ± 1.2 vs 3.7 ± 2.3; P = 0.007). However, 80% were at high enough stroke risk to warrant consideration of anticoagulation, i.e. CHA2DS2-VASc score ≥2. Only 30% of recurrences were associated with palpitations. Participation also improved AF knowledge from 6.4 ± 1.8 to 7.3 ± 1.8 (P = 0.02), of a total score of 10. CONCLUSIONS Providing patients with an iECG is a non-invasive, inexpensive, convenient and feasible way to monitor for AF recurrence in post-cardiac surgery patients. It also provides a mechanism to provide knowledge about the condition and also potentially reduce anxiety. The success of patients using this technology also has implications for extending the use of iECG self-monitoring to other patient groups such as those undergoing antiarrhythmic interventions for AF.

Circumferential intimal tear in type A aortic dissection with intimo-intimal intussusception into left ventricle and left main coronary artery occlusion

From the Departments of Cardiothoracic Surgery and Cardiology, Royal North Shore Hospital, University of Sydney, Sydney, Australia. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication March 29, 2012; accepted for publication May 7, 2012; available ahead of print June 7, 2012. Address for reprints: Sepehr Seyed Lajevardi, MBBS, Department of Cardiothoracic Surgery, Royal North Shore Hospital, Pacific Highway, St Leonards NSW 2065, Sydney, Australia (E-mail: sepehrlaj@gmail.com). J Thorac Cardiovasc Surg 2012;144:e21-3 0022-5223/

Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: a study protocol

36.00 Crown Copyright 2012 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.05.010

Malignant Cardiac Tamponade from Non-Small Cell Lung Cancer: Case Series from the Era of Molecular Targeted Therapy

Introduction Postoperative atrial fibrillation (AF) occurs in 30–40% of patients after cardiac surgery. Identification of recurrent postoperative AF is required to initiate evidence-based management to reduce the risk of subsequent stroke. However, as AF is often asymptomatic, recurrences may not be detected after discharge. This study determines feasibility and impact of a self-surveillance programme to identify recurrence of postoperative AF in the month of posthospital discharge. Methods and analysis This is a feasibility study, using a cross-sectional study design, of self-screening for AF using a hand-held single-lead iPhone electrocardiograph device (iECG). Participants will be recruited from the cardiothoracic surgery wards of the Royal North Shore Hospital and North Shore Private Hospital, Sydney, Australia. Cardiac surgery patients admitted in sinus rhythm and experiencing a transient episode of postoperative AF will be eligible for recruitment. Participants will be taught to take daily ECG recordings for 1 month posthospital discharge using the iECG and will be provided education regarding AF, including symptoms and health risks. The primary outcome is the feasibility of patient self-monitoring for AF recurrence using an iECG. Secondary outcomes include proportion of patients identified with recurrent AF; estimation of stroke risk and patient knowledge. Process outcomes and qualitative data related to acceptability of patients use of the iECG and sustainability of the screening programme beyond the trial setting will also be collected. Ethics and dissemination Primary ethics approval was received on 25 February 2014 from Northern Sydney Local Health District Human Resource Ethics Committee, and on 17 July 2014 from North Shore Private Hospital Ethics Committee. Results will be disseminated via forums including, but not limited to, peer-reviewed publications and presentation at national and international conferences. Trial registration number ACTRN12614000383662.

Long Term Outcomes Following Freestyle Stentless Aortic Bioprosthesis Implantation: An Australian Experience.

Cardiac tamponade complicating malignant pericardial effusion from non-small cell lung cancer (NSCLC) is generally associated with extremely poor prognosis. With improved systemic chemotherapy and molecular targeted therapy for NSCLC in recent years, the prognosis of such patients and the value of invasive cardiothoracic surgery in this setting have not been adequately examined. We report outcomes from a contemporary case series of eight patients who presented with malignant cardiac tamponade due to NSCLC to an Australian academic medical institution over an 18 months period. Two cases of cardiac tamponade were de novo presentations of NSCLC and six cases were presentations following previous therapy for NSCLC. The median survival was 4.5 months with a range between 9 days to alive beyond 17 months. The two longest survivors are still receiving active therapy at 17 and 15 months after invasive surgical pericardial window respectively. One survivor had a histological subtype of large cell neuroendocrine carcinoma and the other received targeted therapy for epidermal growth factor receptor mutation. These results support the consideration of active surgical palliation to treating this oncological emergency complicating NSCLC, including the use of urgent drainage, surgical creation of pericardial window followed by appropriate systemic therapy in suitably fit patients.

Surviving Right Atrial Rupture From Blunt Thoracic Trauma After Pericardiectomy

BACKGROUND The Freestyle stentless bioprosthesis (FSB) has been demonstrated to be a durable prosthesis in the aortic position. We present data following Freestyle implantation for up to 10 years post-operatively and compare this with previously published results. METHODS A retrospective cohort analysis of 237 patients following FSB implantation occurred at five Australian hospitals. Follow-up data included clinical and echocardiographic outcomes. RESULTS The cohort was 81.4% male with age 63.2±13.0 years and was followed for a mean of 2.4±2.3 years (range 0-10.9 years, total 569 patient-years). The FSB was implanted as a full aortic root replacement in 87.8% patients. The 30-day all cause mortality was 4.2% (2.0% for elective surgery). Cumulative survival at one, five and 10 years was 91.7±1.9%, 82.8±3.8% and 56.5±10.5%, respectively. Freedom from re-intervention at one, five and 10 years was 99.5±0.5%, 91.6±3.7% and 72.3±10.5%, respectively. At latest echocardiographic review (mean 2.3±2.1 years post-operatively), 92.6% had trivial or no aortic regurgitation. Predictors of post-operative mortality included active endocarditis, acute aortic dissection and peripheral vascular disease. CONCLUSIONS We report acceptable short and long term outcomes following FSB implantation in a cohort of comparatively younger patients with thoracic aortic disease. The durability of this bioprosthesis in the younger population remains to be confirmed.

Repair of a Mycotic Coronary Artery Aneurysm with an Intact Prosthetic Aortic Valve.

Right atrial rupture secondary to blunt trauma is exceedingly rare. We present a case report of blunt chest trauma and right atrial rupture in a patient with a background of pericardiectomy that were successfully managed surgically. Right atrial rupture must be considered as a differential diagnosis in patients with blunt chest trauma. In patients with previous pericardiectomy, this injury may manifest with massive hemothorax, and insertion of a chest drain should be performed with extreme caution. In our experience, urgent exploratory thoracotomy and repair of the defect are the mainstays of acute management.

Anaortic Techniques Reduce Neurological Morbidity After Off-Pump Coronary Artery Bypass Surgery

We describe the case of a 75-year-old man with a mycotic right coronary artery aneurysm without evidence of prosthetic valve endocarditis. Eight years previously he had undergone coronary artery bypass surgery and aortic valve replacement. He presented with methicillin resistant staphylococcus aureus septicaemia after a prolonged hospital admission. Further investigation revealed a large mycotic right coronary artery aneurysm prompting urgent surgical repair. This case, of a mycotic coronary artery aneurysm in an atherosclerotic native coronary artery, is an extremely rare entity, which is further complicated by the presence of a prosthetic aortic valve.