Michael Papiashvilli

Left Ventricular Epicardial Lead Implantation for Resynchronisation Therapy Using a Video-Assisted Thoracoscopic Approach

BACKGROUND Cardiac resynchronisation therapy using a branch of the coronary sinus is the technique of choice for left ventricular (LV) pacing in patients with poor LV function. An alternative option is the surgical implantation of an epicardial LV lead under direct vision. We describe our initial experience with epicardial LV lead implantation. METHODS The records of 10 patients undergoing epicardial LV lead implantation at our institution were retrospectively reviewed. Epicardial leads were implanted on the LV free wall using video-assisted thoracoscopic surgery techniques. RESULTS Ten patients (seven men; three women; mean age 66.9 years) underwent surgery. All 10 patients suffered from congestive heart failure (CHF) and had a mean LV ejection fraction of 25%. All patients failed endocardial LV lead implantation via the coronary sinus because of lack of adequate branches or inability to cannulate the coronary sinus. There were no intraoperative complications, intrahospital or late deaths. The mean hospital stay was 5.2 days. Follow-up showed reversal of ventricular asynchrony and improvement in functional class in all patients. CONCLUSIONS Thoracoscopic epicardial LV lead implantation is a safe and feasible procedure in a population of high risk patients who need resynchronisation therapy after endocardial LV lead placement has failed.

Thoracic Empyema in High-Risk Patients: Conservative Management or Surgery?

We retrospectively analyzed the data of 119 patients who were treated for empyema thoracis from 1999 to 2007. There were 87 men with a mean age of 63.9 years (range, 19–79 years) and 32 women with a mean age 55.2 years (range, 26–78 years). The empyema was right-sided in 73 patients and left-sided in 46. The etiology was parapneumonic in 43.7% of cases, postoperative in 42.0%, posttraumatic in 11.8%, and due to other causes in 2.5%. Eight (6.7%) patients underwent surgery on admission because of unstable clinical status; all 8 survived. Fibrinolysis was used in 111 (93.3%) patients; of these, 88 (73.9%) were successfully treated by intrapleural urokinase instillation, and 23 (19.4%) failed treatment and underwent surgery. All 88 patients who had successful fibrinolytic therapy survived, they accounted for 1.8% of the morbidity. In the 23 patients who underwent surgery after failed treatment, there were 3 deaths, accounting for 2.7% overall mortality and 6.3% morbidity. Treating thoracic empyema in patients with significant comorbidities is challenging. Intrapleural urokinase administration might be beneficial in high-risk patients, but in those without significant comorbidities, early surgery may be considered.

Posterior thoracic esophagostomy as an esophageal sparing procedure

A diverting (posterior) thoracic esophagostomy is a rare, but acceptable, surgical option in some cases. The goal is to save as much esophageal length as possible with a view to future reconstructive surgery. We herein report a 41-year-old woman, in whom a posterior thoracic esophagostomy was successfully created and used for reestablishing further physiological alimentary continuity in a second stage.

Two Cases of an Enormous Single-Lung Metastasis From Synovial Sarcoma

Synovial sarcoma constitutes 8% to 10% of all sarcomas, and most commonly it affects adults in the third to fifth decades of life. This malignancy usually involves the extremities, and although local control by curative resection and adjuvant irradiation has improved, metastases develop in 40% of patients, with lung involvement in the metastatic process in 90% of cases. A single metastasis to the lungs from synovial sarcoma is rare, and a case of a large, single metastasis is even rarer. Herein, we present two cases of patients with an enormous metastatic synovial sarcoma that were successfully removed surgically.

Cervical Mediastinoscopic Lymphadenectomy for Accurate Staging in Lung Cancer

Accurate preoperative staging of the mediastinum is important in the treatment of non-small-cell lung cancer. Enlarged mediastinal lymph nodes on chest computed tomography are positive for malignancy on mediastinoscopy in only half of these patients. After negative mediastinoscopy, some positive nodes are found at thoracotomy. The aim of this study was to attempt to remove all lymph nodes accessible by cervical mediastinoscopic lymphadenectomy and reevaluate the same mediastinal stations at thoracotomy for missed lymph nodes. Between 1999 and 2003, 30 patients with operable non-small-cell lung cancer and enlarged mediastinal lymph nodes (>1 cm in diameter on computed tomography) that were negative on cervical mediastinoscopy underwent pulmonary resection with complete lymph node dissection. The total number of lymph nodes dissected in these 30 patients was 329 (143 at mediastinoscopy and 186 at thoracotomy); the mean numbers of nodes dissected were 4.8 at mediastinoscopy and 6.2 at thoracotomy. Ten (6.5%) residual lymph nodes were detected at thoracotomy in mediastinal stations R4, L4, and 7. The low number of missed lymph nodes demonstrates the accuracy of the technique of cervical mediastinoscopic lymphadenectomy.