Gianfranco Campalani

Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature

BACKGROUND The issue of performing simultaneous pulmonary resection and cardiac surgery in patients with coexisting lung carcinoma and ischaemic heart disease remains controversial. We report our experience and review the literature. METHODS Thirteen patients (male ten, female three; mean age 65 years) underwent simultaneous cardiac surgery and pulmonary resection. Lung pathology consisted of primary lung carcinoma (n = 10), benign disease (n = 2) and carcinoid (n = 1). Lung resections included pneumonectomy (n = 3), lobectomy (n = 4), segmentectomy (n = 1) and local excision (n = 5). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 11, aortic valve replacement in one and mitral valve repair with CABG in one patient. In all but one case the lung resection was performed prior to heparinization and cardiopulmonary bypass (CPB). In two patients, with suitable coronary anatomy, myocardial revascularization without CPB was performed to reduce morbidity. RESULTS There was no hospital mortality. Postoperative blood loss and ventilation requirements were reduced in the patients who were operated on without CPB. Prolonged ventilatory support was required in two cases. All patients with benign pathology are alive. In the lung cancer group there have been five late deaths: disseminated metastatic disease (n = 3), anticoagulant related haemorrhage (n = 1) and broncho-pleural fistula (n = 1). Of the remaining five patients four are alive and disease free 7-23 months post-operatively; one patient has recurrent disease 40 months post-operatively. CONCLUSIONS Simultaneous pulmonary resection and cardiac surgery is associated with acceptable operative morbidity and mortality. In patients with lung carcinoma long-term survival was determined by tumour stage. The avoidance of CPB may be advantageous by decreasing blood loss and ventilation requirements.

Transcaval Migration of an Acupuncture Needle from the Abdominal Cavity to the Heart

Abstract  We report the case of a patient who was noted to have inserted an acupuncture needle into his abdomen. The needle migrated to the heart and was removed from the right ventricle using cardiopulmonary bypass. (J Card Surg 2010;25:654‐656)

An unusual iatrogenic cause of right coronary air embolism

A 62-year-old woman undergoing redo mitral valve replacement was noted to have persistent intracardiac air following standard deairing procedures. Transesophageal echocardiography (TEE) identified air bubbles entering the left atrium from the right superior pulmonary vein. Exploration of the pleural cavity revealed a fistula between the pulmonary parenchyma and the right superior pulmonary vein caused by the atriotomy closure suture transfixing the edge of the lung, which was repaired with immediate disappearance of the air emboli. This demonstrates that transesophageal echocardiography is an invaluable aid to ensuring complete deairing after open heart procedures.

Have improvements in myocardial protection influenced a surgeon's choice of coronary artery bypass surgery?

The aim of this study is to determine whether improvements in myocardial protection strategy have influenced the surgeons choice of coronary artery bypass surgery. Between February 2002 and April 2009, a total of 662 patients underwent coronary artery bypass surgery under the provision of a single consultant surgeon. Operative mortality was defined as in-hospital death and comparison was made based on both the observed and expected mortalities as derived from the logistic EuroSCORE. Of the 662 patients who underwent cardiac surgery, 155 had off-pump whilst 507 had conventional coronary artery bypass surgery. The observed mortalities improved over the years in line with the improvements in myocardial protection strategy despite the increasing risk as predicted by the logistic EuroSCORE, with a reduction in the ratio of observed to expected mortalities of 1.2 in the off-pump group to 0.4 in the conventional group who had better myocardial protection. This has lead to a change in practice being predominantly off-pump at the beginning to that of conventional surgery in the later part of the study. As the case mix of patients gets worse with the increasing severity of multi-vessel disease and poor ventricular function, myocardial protection becomes crucial to the surgeons preoperative assessment.