Khaled Abdelhady

Improved Survival Associated with Neoadjuvant Chemoradiation in Patients with Clinical Stage IIIA(N2) Non–Small-Cell Lung Cancer

Introduction: Optimal management of clinical stage IIIA-N2 non–small-cell lung cancer (NSCLC) is controversial. This study examines whether neoadjuvant chemoradiation plus surgery improves survival rates when compared with other recommended treatment strategies. Methods: Adult patients from the National Cancer Database, with clinical stage IIIA-N2 disease definitively treated between 1998 and 2004 at American College of Surgeons Commission on Cancer accredited facilities, were included in the study. Treatment was defined as neoadjuvant chemoradiation plus either lobectomy (NeoCRT+L) or pneumonectomy (NeoCRT+P), lobectomy plus adjuvant therapy (L+AT), pneumonectomy plus adjuvant therapy (P+AT), and concurrent chemoradiation (CRT). Median follow-up and overall survival (OS) were defined from date of diagnosis to last contact. Five-year OS was estimated using Kaplan–Meier methods. Cox proportional hazard regression was used to estimate hazard ratios and 95% confidence intervals (CIs), adjusting for sociodemographic, clinical, and facility characteristics. Results: Median follow-up was 11.8 months for 11,242 eligible patients. Five-year OS was 33.5%, 20.7%, 20.3%, 13.35%, and 10.9% for NeoCRT+L, NeoCRT+P, L+AT, P+AT, and CRT, respectively (p < 0.0001). On multivariable analysis, the estimated hazard ratio was 0.51 (CI: 0.45–0.58) for NeoCRT+L; 0.77 (0.63–0.95) for NeoCRT+P; 0.66 (0.59–0.75) for L+AT; 0.69 (0.54–0.88) for P+AT; and 1.0 (reference) for the CRT group. Comorbidity did not attenuate the relationship between treatment and survival. Conclusion: This large study demonstrates that patients with clinical stage IIIA-N2 NSCLC, who underwent neoadjuvant chemoradiation followed by lobectomy, were associated with an improved survival.

Recent Developments in Antithrombotic Therapy: Will Sodium Warfarin Be a Drug of the Past?

Warfarin and heparin have formed the mainstay in the prophylaxis of deep vein thrombosis (DVT), stroke prevention in atrial fibrillation, and treatment of thromboembolic disease (TED). However, these choices are hampered by difficult administration, interactions with other medications, side effect profile, and limited indications for treatment. Anti-factor Xa (anti-Xa) inhibitors have already entered the drug market with the drug Fondaparinux being the first anti-Xa inhibitor to be approved for use in the U.S. by the Food and Drug Administration (FDA), and other drugs such as idraparinux being currently in development. A new class of medications, known as direct thrombin inhibitors (DTI), includes the parental agents lepirudin, argatroban and bivalirudin which have been approved by the FDA and the oral agents ximelagatran, melagatran and dabigatran. The latter three drugs which are oral DTIs may soon replace warfarin and heparin as the preferred medications for DVT prophylaxis and for reducing the relative risk of stroke. These drugs do not rely on blocking serine proteases nor do they require a co-factor (antithrombin III) like unfractionated heparin (UFH) or low molecular weight heparin (LMWH). DTIs are rapid in onset, easy to administer, do not interact with other medications or foods, have limited side effects, and can be administered in a fixed dose. The DTI ximelagatran has already been approved in several European and Asian countries, and over a dozen randomized clinical trials have been conducted demonstrating its performance to be on par with warfarin. However, approval by the FDA in the U.S. remains pending in view of reported incidences of elevations in hepatic enzymes that are currently under evaluation. This review examines the role of DTIs in the prevention and treatment of TED and the recent patents reported in the literature.

Current Status of the Surgical Treatment of Atrial Fibrillation

Atrial fibrillation (AF) affects several million patients worldwide and is associated with a number of heart conditions, particularly coronary artery disease, rheumatic heart disease, hypertension, and congestive heart failure. The treatment of AF and its complications is quite costly. Atrial fibrillation usually results from multiple macro-re-entrant circuits in the left atrium. Very frequently, particularly in association with mitral valve disease, these circuits arise from the area of the junction of the pulmonary venous endothelium and the left atrial endocardium. Pharmacological therapy is at best 50% effective. Therapeutic options for AF include antiarrhythmic drugs, cardioversion, atrioventricular (A-V) node block, pacemaker insertion, and ablative surgery. In 1987, Cox developed an effective surgical procedure to achieve ablation. Current ablative procedures include the classic cut-and-sew Maze operation or a modification of it, namely through catheter ablation, namely, cryoablation, radiofrequency ablation (dry or irrigated), and other forms of ablation (e.g., laser, microwave). These procedures will be described, along with the indications, advantages and disadvantages of each. Special emphasis on the alternative means to cutting and sewing to achieve appropriate effective atrial scars will be stressed, and our experience with these approaches in 50 patients with AF and associated cardiac lesions and their outcomes is presented.

Utilization of Cardiothoracic Surgeons for Operative Penetrating Thoracic Trauma and Its Impact on Clinical Outcomes

BACKGROUND Large series reporting outcomes for penetrating thoracic trauma have identified injury pattern and injury severity scoring as predictors of poor outcome. However, the impact of surgical expertise on patient outcomes has not been previously investigated. We sought to determine how often board-certified cardiothoracic surgeons are utilized for operative thoracic trauma and whether this has an effect on patient outcomes. METHODS A level I trauma center registry was queried between 2003 and 2011. Records of patients undergoing surgery as a result of penetrating thoracic trauma were retrospectively reviewed. Patient demographics, injuries, injury severity, utilization of a cardiothoracic surgical operative consult and outcomes were recorded. Patients operated on by cardiothoracic surgeons were compared with patients operated on by trauma surgeons using stepwise multivariate analyses to determine the factors associated with utilization of cardiothoracic surgeons for operative thoracic trauma and survival. RESULTS Cardiothoracic surgeons were used in 73.0% of cases (162 of 222) over the study period. The use of cardiothoracic surgeons increased incrementally both overall (38.5% to 73.9%), and for emergent/urgent cases (31.8% to 73.3%). When comparing patients undergoing operation on an emergent/urgent basis by cardiothoracic versus trauma surgeons, there was no significant difference with regard to demographics, mechanism of injury, injury severity scoring, or surgical morbidity. Stepwise logistic regression showed the presence of a cardiothoracic surgeon to be independently associated with survival (odds ratio 4.70; p = 0.019). CONCLUSIONS Use of cardiothoracic surgeons for operative thoracic trauma increased over the study period. Outcomes for severely injured patients with elevated chest injury scores or decreased revised trauma scores may be improved with appropriate operative consultation with a board-certified cardiothoracic surgeon.

Diagnosis and management of primary effusion lymphoma in the immunocompetent and immunocompromised hosts.

Primary effusion lymphoma (PEL) is an uncommon non-Hodgkin lymphoma associated with human herpes virus-8 (HHV-8) that grows mainly in serous body cavities. The most common presentation of PEL is that of a young immunocompromised male with shortness of breath, as the pleural cavity is most commonly affected. Diagnosis is primarily based on fluid cytology in which PEL cells display variable morphology and a null lymphocyte immunophenotype; however, evidence of HHV-8 infection within the neoplastic cell is essential. Patients have commonly been treated with systemic multidrug chemotherapy and antiretroviral therapy if they were HIV positive or were immunocompromised for other reasons. In the immunocompetent patient, there have been no agreed-upon pathways for management of this condition. Progression of disease is common and median survival is approximately 6 months. Novel intrapleural treatments with antiviral agents such as intracavity cidofovir have shown to be effective in controlling local disease, and ongoing clinical trials may provide some promise in the treatment for this condition.

Red Blood Cell Distribution Width as a Biomarker for Need for Coronary Artery Bypass Graft Surgery and Its Clinical Outcome

currently unclear. However, the cholesterol content of erythrocyte membranes (CEM) which has been associated with clinical instability in CAD has also been linked to red blood cell size and shape [4] . It is believed that the increased CEM levels among red blood cells, a novel biomarker of clinical instability in CAD, may facilitate our understanding of why RDW is associated with increased morbidity and mortality in cardiovascular disease. In their current study, Ephrem and Kanei [1] hypothesize that RDW levels at the time of hospital admission are directly associated with recourse to CABG in patients with UA and NSTEMI. Among the 503 subjects included in their retrospective analysis, RDW was directly and independently associated with recourse to CABG versus a nonsurgical approach such as pharmacological management or PCI. The authors conclude that, with establishing such an association, RDW should be considered in the stratification of patients presenting with UA or NSTEMI. In their study, the charts of the 503 patients who had unstable angina (UA or NSTEMI) were retrospectively reviewed by the authors over a 12-month period between January 1, 2007, and December 30, 2007. Of those, 270 (53%) had medical therapy, 180 (36%) had PCI, and 53 (11%) had CABG. The decision of CABG was made at the discretion of the treating surgeon who had knowledge of the RDW from the outset. Based on that, one cannot but In this issue of Cardiology, Ephrem and Kanei [1] report on an observational cross-sectional study in which they examined the association of red blood cell distribution width (RDW) and the need for coronary artery bypass graft (CABG) surgery and CABG mortality in patients with unstable angina (UA) and non-ST segment myocardial infarction (NSTEMI). RDW is a measure of heterogeneity in erythrocyte size that is used in the differential diagnosis of microcytic anemia. RDW has been evaluated in previous studies, some of which were cited in the paper by Ephrem and Kanei [1] , as a biomarker for cardiovascular disease. Higher levels of RDW have been associated with increased mortality among patients with heart failure, myocardial infarction, and coronary artery disease (CAD). RDW has also been recently demonstrated to be a prognostic marker of death, myocardial infarction, and unplanned revascularization in a broad population undergoing percutaneous coronary intervention (PCI) [2] . Higher RDW values have also been found to be associated with poor functional outcome and mortality after acute cerebral infarction, leading the investigators to propose using RDW as a biomarker for the prediction of long-term outcomes in patients with acute cerebral infarction [3] . The biological mechanisms underlying the association of higher RDW with cardiovascular mortality risk are Received: August 3, 2012 Accepted: August 3, 2012 Published online: October 24, 2012

Endovascular Treatment of Aortic Aneurysms: Techniques and Clinical Update

Open repair of abdominal and thoracic aortic aneurysms continues to be associated with considerable morbidity and mortality. Endovascular repair of abdominal and thoracic aortic aneurysms has evolved over the past few years and has significantly reduced the morbidity of aortic aneurysm repair compared with the standard open surgical procedures. Several devices have been approved for clinical use for this purpose. This has allowed the treatment of patients who are otherwise at high risk for open repair. This review paper aims to (1) describe the general principles of use for endovascular devices and review the radiographic features and clinical trials for the devices in current use, (2) present the results of the clinical trials that led to the approval and marketing of the current devices, and (3) review new techniques and approaches for the treatment of aortic aneurysms.

Left Atrial and Carotid Body Paraganglioma

We report a rare case of left atrial paraganglioma with a synchronous carotid body paraganglioma in a 30-year-old man with succinate dehydrogenase B gene mutation. The patient initially presented with a neck mass and palpitations. Laboratory test results showed elevated catecholamine levels. A cardiac paraganglioma was identified by computed tomography, meta-iodobenzylguanidine scintigraphy, and magnetic resonance imaging. Surgical resection of both paragangliomas were performed on two separate occasions. Serum and urine catecholamine levels returned to normal range. On follow-up, there was no recurrence of the cardiac paraganglioma. Radiotherapy was subsequently initiated for recurrence in the carotid body paraganglioma.

Primary Pulmonary Vein Leiomyosarcoma With Left Atrial Extension

Leiomyosarcoma (LMS) is a mesenchymal tumor originating from the smooth muscle cells. LMS of the great vessels accounts for 60% of cases, with inferior vena cava being the most common site. Pulmonary vein LMS is an extremely rare subset that was first reported in 1939. LMS is an aggressive tumor, making surgical resection the treatment of choice. Herein, we present a rare case of pulmonary vein LMS extending into the left atrium, which was resected.

Metastatic right atrial hepatoma

A 73-year-old female presented with shortness of breath and was found to have amultilobulated mass floating within the right atrium on transesophageal echocardiogram (TEE) (Fig. 1). An abdominal ultrasound revealed a 5.6 × 6.2-cm hepatic mass in the dome of the right lobe (Fig. 2). Because of the concern for tumor emboli, the patient underwent resection of the right atrial mass on cardiopulmonary bypass in the arrested heart with bi-caval cannulation. Following a right atriotomy, the mass was found attached to the inferior vena cava at the atrio-caval junction, and did not involve the atrial wall, septum, or the tricuspid valve (Fig. 3). The mass was completely resected (Fig. 4). Histopathological examination revealed a metastatic hepatocellular carcinomawith negative tumormargins. The patient was being evaluated for chemoembolization of the hepatoma but eventually succumbed 3 weeks after surgery from complications related to hepatorenal syndrome. Seventeen similar cases have been reported of which eight had metastatectomy with only three patients alive at 21 months. The remaining nine patients who did not undergo resection succumbed within 6 months from the time of the diagnosis.