Olivier Baron

Closure of the bronchial stump by manual suture and incidence of bronchopleural fistula in a series of 209 pneumonectomies for lung cancer

OBJECTIVE Bronchopleural fistula after pneumonectomy is a very serious complication, occurring in 1-4% of cases, regardless of the bronchial stump closure technique adopted. The objective of this study was to report a bronchial stump closure technique in pneumonectomy by manual suture (polypropylene running suture) and to study the incidence of bronchopleural fistula. METHODS Between January 1988 and December 1997, 209 patients (186 men and 23 women, mean age = 60.5 years) were operated by the same operator. The indication for surgery was lung cancer in all cases. RESULTS The incidence of bronchopleural fistula was 2.4%; four fistulas during the first postoperative month and another occurred at 6 months; four were located on the left side and one was situated on the right. The bronchial stulnp was covered in only two of these five cases; 40% died of this complication. Neoadjuvant treatment (chemotherapy and/or radiotherapy) was found to increase the risk of development of bronchopleural fistula (40% vs. 7.2%) and this difference was statistically significant (P = 0.046). CONCLUSIONS Manual closure of the bronchial stump by running suture, performed on an open bronchus, is a reliable technique with a low incidence of bronchopleural fistula. Those results could be further improved by systematically covering the right and the left bronchial stumps.

Early Structural Valve Deterioration of Mitroflow Aortic Bioprosthesis Mode, Incidence, and Impact on Outcome in a Large Cohort of Patients

Background— Structural valve deterioration (SVD) is a major flaw of bioprostheses. Early SVD has been suspected in the last models of Mitroflow bioprosthesis. We sought to assess the incidence, mode, and impact of SVD on outcome in a large series of Mitroflow aortic valve replacement. Methods and Results— Six hundred seventeen consecutive patients (aged 76.1±6.3 years) underwent aortic valve replacement with a Mitroflow prosthesis (models 12A/LX) between 2002 and 2007. By echocardiography, 39 patients developed early SVD (1.66% per patient-year), with stenosis as the main mode (n=36). Mean delay to SVD was only 3.8±1.4 years, and 5-year SVD-free survival was 91.6% (95% confidence interval [CI], 88.7–94.7) for the whole cohort and 79.8% (95% CI, 71.2–89.4) and 94.0% (95% CI, 90.3–97.8) for 19- and 21-mm sizes, respectively. Among the 39 patients with SVD, 13 patients (33%) had an accelerated SVD once the mean gradient exceeded 30 mm Hg. Valve-related death was 46.2% in this SVD subgroup. Five-year overall survival was 69.6% (95% CI, 65.7–73.9). In multivariable analysis, SVD was the strongest correlate of overall mortality (hazard ratio=7.7; 95% CI, 4.4–13.6). Conclusions— Early SVD is frequent in Mitroflow bioprosthesis (models 12A/LX), especially for small sizes (19 and 21 mm), and reduces overall survival. An unpredictable accelerated pattern of SVD constitutes a life-threatening condition. In view of the large number of Mitroflow valves implanted worldwide, one can expect an epidemic of SVD and valve-related deaths, which represents a major public health issue, especially in the elderly. Hence, a close follow-up with yearly echocardiography after Mitroflow implantation is advisable. An urgent reoperation should be discussed in patients with severe SVD even though they are still asymptomatic.Background— Structural valve deterioration (SVD) is a major flaw of bioprostheses. Early SVD has been suspected in the last models of Mitroflow bioprosthesis. We sought to assess the incidence, mode, and impact of SVD on outcome in a large series of Mitroflow aortic valve replacement. Methods and Results— Six hundred seventeen consecutive patients (aged 76.1±6.3 years) underwent aortic valve replacement with a Mitroflow prosthesis (models 12A/LX) between 2002 and 2007. By echocardiography, 39 patients developed early SVD (1.66% per patient-year), with stenosis as the main mode (n=36). Mean delay to SVD was only 3.8±1.4 years, and 5-year SVD-free survival was 91.6% (95% confidence interval [CI], 88.7–94.7) for the whole cohort and 79.8% (95% CI, 71.2–89.4) and 94.0% (95% CI, 90.3–97.8) for 19- and 21-mm sizes, respectively. Among the 39 patients with SVD, 13 patients (33%) had an accelerated SVD once the mean gradient exceeded 30 mm Hg. Valve-related death was 46.2% in this SVD subgroup. Five-year overall survival was 69.6% (95% CI, 65.7–73.9). In multivariable analysis, SVD was the strongest correlate of overall mortality (hazard ratio=7.7; 95% CI, 4.4–13.6). Conclusions— Early SVD is frequent in Mitroflow bioprosthesis (models 12A/LX), especially for small sizes (19 and 21 mm), and reduces overall survival. An unpredictable accelerated pattern of SVD constitutes a life-threatening condition. In view of the large number of Mitroflow valves implanted worldwide, one can expect an epidemic of SVD and valve-related deaths, which represents a major public health issue, especially in the elderly. Hence, a close follow-up with yearly echocardiography after Mitroflow implantation is advisable. An urgent reoperation should be discussed in patients with severe SVD even though they are still asymptomatic. # CLINICAL PERSPECTIVE {#article-title-37}

Prospective preoperative mediastinal lymph node staging by integrated positron emission tomography—computerised tomography in patients with non-small-cell lung cancer §

OBJECTIVE Mediastinal lymph node staging determines the treatment strategy for non-small-cell lung cancer. This study aims to evaluate prospectively the accuracy of preoperative integrated 18-fluoro-2-deoxy-D-glucose positron emission tomography-computerised tomography ((18)FDG PET-CT) for mediastinal lymph node staging. METHODS Preoperative integrated (18)FDG PET-CT was used to analyse mediastinal lymph nodes in patients with non-small-cell lung cancer. Nodal stations were identified according to the American Thoracic Society mapping system. Lymph nodes with a standardised uptake value (SUVmax) >3 were considered to be positive. The mediastinal lymph nodes were harvested during lung resection and the results of integrated (18)FDG PET-CT were compared to the mediastinal lymph node histology results. RESULTS A total of 51 patients were enrolled in this study. The mean interval between integrated (18)FDG PET-CT and surgery was 31+/-15.8 days (range: 2-78 days). The mean mediastinal lymph node harvested and station number per patient during surgery were 11.8+/-5.6 (range: 2-27) and 3.8+/-1 (range: 2-6), respectively. The incidence of N2 pathological disease was 19.6%. The integrated (18)FDG PET-CT sensitivity and specificity were 40+/-30% and 85+/-11%, respectively. The positive and negative predictive values were 40+/-30% and 85+/-11%, respectively. False-positive results (six patients) were mainly due to inflammatory lymph nodes. False-negative results (six patients) were mainly due to infra-centimetrical, malignant lymph node invasion. CONCLUSION The sensitivity of integrated (18)FDG PET-CT for mediastinal lymph node staging in patients selected for surgery is low. When positive mediastinal lymph nodes are detected, invasive mediastinal staging must be performed. On the other hand, the specificity is high: patients with negative integrated (18)FDG PET-CT can be operated upon without invasive mediastinal staging.

Outcome of Heart Transplants 15 to 20 Years Ago : Graft Survival, Post-transplant Morbidity, and Risk Factors for Mortality

OBJECTIVES The study was conducted to determine the long-term outcome of patients who underwent heart transplantation 15 to 20 years ago, in the cyclosporine era, and identify risk factors for death. METHODS A retrospective analysis was done of 148 patients who had undergone heart transplantation between 1985 and 1991 at a single center. Operative technique and immunosuppressive treatment were comparable in all patients. RESULTS Actuarial survival rates were 75% (n = 111), 58% (n = 86), and 42% (n = 62) at 5, 10, and 15 years, respectively. The mean follow-up period was 12.1 +/- 5.6 years for patients who survived more than 3 months after transplantation (n = 131). The major causes of death were malignancy (35.8%) and cardiac allograft vasculopathy (24.7%). No death related to acute rejection was reported after the first month of transplantation. Graft coronary artery disease was detected on angiography in 66 (50.3%), and 7 (5.3%) had retransplantation. Malignancies developed in 131 patients (48.1%), including skin cancers in 31 (23.6%), solid tumors in 26 (19.8%), and hematologic malignancies in 14 (10.6%). Severe renal function requiring dialysis or renal transplantation developed in 27 patients (20.6%). By multivariable analysis, the only pre-transplant risk factor found to affect long-term survival was a history of cigarette use (p < 0.0004). CONCLUSIONS Long-term survival at 15 years after cardiac transplantation remains excellent in the cyclosporine era. Controlling acute allograft rejection can be achieved but seems to carry a high rate of cancers and renal dysfunction. History of cigarette use affects significantly long-term survival in our study.

Myocardial preservation using Celsior solution in cardiac transplantation: early results and 5-year follow-up of a multicenter prospective study of 70 cardiac transplantations.

BACKGROUND Several storage methods using a wide variety of extracellular or intracellular solutions applied either as continuous perfusion, intermittent perfusion, or simple immersion of the heart have been commonly used. We have performed a prospective randomized multicenter study of 70 cardiac transplantation recipients to evaluate the Celsior solution for cardiac preservation. METHODS Seventy consecutive patients were included in this trial and received a cardiac graft arrested and preserved with Celsior. The first follow-up period was 1 month. The mean age of the recipients was 49 years (range, 28 to 66 years), and 81.7% were male. The main disease was nonobstructive cardiomyopathy (64.3%). The age range of donors was between 14 and 56 years with a mean of 33 years. The majority of grafts (73%) were stored in 1 L of Celsior. A midterm follow-up at 5 years was performed and was 100% complete. RESULTS The operative mortality (<30-day) rate was 6 of 70 (8.6%). Sixty-three patients (90%) had at least satisfactory hemodynamic measurements on day 2. The first postoperative echocardiograms showed good myocardial performance for 90% of the grafts. Actuarial survival rate at 5 years was 75% +/- 5.1%. CONCLUSIONS The use of Celsior in cardiac transplantation was safe and very effective. This solution proved very valuable in at-risk patients.

Surgical resection of pulmonary metastases from colorectal carcinoma : Five-year survival and main prognostic factors

Between 1986 and 1994, 19 patients underwent pulmonary resection for metastatic colorectal carcinoma. The mean interval between colon resection and appearance of pulmonary metastasis was 41 +/- 21 months. All the patients had no more than two metastases. Wedge resection alone or associated with lobectomy was performed in four patients, lobectomy in ten, and pneumonectomy in five. One patient died within the month after surgery. Mean follow-up was 35 +/- 26 months. The 5-year survival rate was 38.7%. Repeat thoracotomy for recurrent metastases was performed in one patient. The disease-free interval, the size of metastases, the type of pulmonary resection, and the location and the stage of primary cancer had no apparent influence on survival, but the survival rate at 4 years was 25% for patients with high carcinoembryonic antigen (CEA) level versus 80% for those with low CEA level. We conclude that, at least when the number of metastases is less than two, resection of colorectal lung metastasis is safe and effective.

CardioWest (Jarvik) Total Artificial Heart: A Single-Center Experience With 42 Patients

BACKGROUND When implanted in patients with biventricular failure, the CardioWest total artificial heart has asserted itself over time as a reliable bridge-to-transplant device that as yet is used by only a few international teams. The aim of this single-center retrospective study is to assess both the comorbidity and survival of patients awaiting heart transplants while receiving circulatory support with a CardioWest total artificial heart. METHODS From 1990 to December 2006, 42 patients received a CardioWest total artificial heart at our center. Mean age at the time of implantation was 45.7 +/- 9.5 years, and 40 patients (95%) were men. Idiopathic or dilated cardiomyopathy was diagnosed in 45.2% (n = 19) of the patients and ischemic cardiomyopathy in 42.8% (n = 18). Average body surface area was 1.9 +/- 0.22 m(2). RESULTS Duration of support was 1 to 292 days (mean, 101 +/- 86 days). Twelve patients died (28.5%) while receiving device support, and 30 patients (71.5%) underwent transplantation. Actuarial survival rates for the transplanted patients were 90% (n = 25), 81% (n = 14), and 76% (n = 10) at 1, 5, and 10 years, respectively. Causes of death during device support included multiorgan failure in 6 (50%), sepsis in 2, acute respiratory distress syndrome in 2, alveolar hemorrhage in 1, and other cause in 1. There were no device malfunctions that led to patient death. Adverse events included stroke in 3 patients (7%) and infections in 35 patients (85%) during support. CONCLUSIONS The CardioWest total artificial heart is an excellent bridge-to-transplant device for patients with biventricular failure. Our study demonstrates excellent safety, reliability, and efficiency. Exceptional outcome after transplantation underlines its capacity to aid in end-organ recovery.

Mitral valve replacement with the St. Jude medical prosthesis: a 15-year follow-up

BACKGROUND A retrospective study was conducted to analyze the results of St. Jude Medical mitral valve replacement. METHODS From January 1979 to December 1989, 870 patients (54% women, 46% men; mean age, 55.8 +/- 6.2 years) underwent mitral valve replacement with the St. Jude Medical prosthesis. Of these operations 616 were isolated mitral valve replacements and 254 were double valve replacements. Coronary artery bypass grafting was performed concomitantly in 55 patients (6.3%). RESULTS Overall, early mortality was 5.05%, with 4.2% for the isolated mitral valve procedure and 7.08% for the double valve replacement. Follow-up at 15 years was complete in 859 patients (98.74%). Mean follow-up time was 93.5 months, for a total of 6,436 years. Actuarial survival at 15 years was 59.5% +/- 5%, 60.5% +/- 6%, and 56.9% +/- 9%, for the entire group, the isolated mitral valve and double valve procedures, respectively. Multivariate analysis identified age, sex, hospital stay, and preoperative mitral regurgitation as independent prognosis factors for overall mortality. Of 606 patients alive at the latest follow-up, the New York Heart Association class improved significantly (from 67% class III/IV before the operation to 88% class I/II after the operation). All patients received warfarin to maintain an international normalized ratio between 3.5 and 4. The linearized rates (% per patient-year) of thrombosis, thromboembolism, and major hemorrhage were, respectively, 0.21, 0.75, and 0.94 for the entire group; 0.18, 0.67, and 0.88 for the isolated mitral valve operation; and 0.15, 0.92, and 1.08 for the double valve replacement. For the entire group the freedom from thrombosis and thromboembolism at 15 years was 98.1% +/- 1% and 88% +/- 4%, respectively. No case of structural dysfunction occurred. The freedom from paravalvular leak and endocarditis at 15 years was 95.3% +/- 2% and 97.3% +/- 2.4%, respectively. The probability of remaining free from reoperation at 15 years was therefore 95.6% +/- 2.5%. CONCLUSIONS These results confirm that the St. Jude Medical valve is a reliable prosthesis with very low thrombosis and thromboembolism rates, allowing the use of a low dose of anticoagulation with an international normalized ratio of about 3.

Resection of hepatic and pulmonary metastases in patients with colorectal cancer.

The resection of liver and lung metastases is now regarded as valid therapy, although the surgical procedure of both metastatic sites has not been clearly defined. Nine consecutive patients who underwent resection of both liver and lung metastases from colorectal cancer (5 Dukes’ stage B, 3 C, 1 D) between 1986 and 1999 were studied retrospectively. A total of 19 resections were performed: 8 hepatectomies, 2 liver wedge resections, and 9 lung lobectomies. No operative or hospital deaths occurred, and mean postoperative hospital stay per procedure was 12 days. Mean survival after resection of the primary colorectal tumor was 66.3 (range: 26–96) months. The median interval was 24.2 (range: 2–39) months from resection of the liver metastasis and 30.4 (range: 3–45) months from resection of the lung metastasis. At the last follow-up, 6 patients were still alive, 4 of whom were free of recurrence 59, 69, 74, and 76 months, respectively, after resections. Three patients died with metastases. Aggressive treatment of liver and lung secondaries from colorectal cancer was performed without hospital mortality and acceptable morbidity. Longer survival times warrant the use of this alternative therapy for selected patients. In association with new effective chemotherapies, it will be possible to select patients who will benefit from surgery.

Bivalvular mechanical Mitral-Aortic valve replacement in 254 patients: Long-Term results—a 22-year follow-up

BACKGROUND We have retrospectively studied 254 patients who underwent a bivalvular mechanical mitral-aortic replacement in the cardiovascular and thoracic surgery unit of Nantes from 1979 to 1989. The follow-up was 22 years (1979 to 2001). The last patient was operated on 12 years before the end of the follow-up. METHODS All mitral prostheses were St. Jude Medical (SJM) bileaflet valves, and the aortic prostheses were 124 monodisc Björk-Shiley valves, 3 Sorin prostheses, and 127 St. Jude Medical bileaflet prostheses. The mean age was 56.8 +/- 8.5 years with a sex ratio equal to 1. Rheumatism as the etiology predominated with 79.5%. Ninety-seven percent of the patients were followed for a total of 2,779 patient-years and a mean of 11.7 years. RESULTS Operative mortality was 7.08%. Freedom from overall mortality and valve-related mortality at 22 years were 45.7% +/- 3.6% and 73.1% +/- 3%, respectively. The linearized rates of thromboembolic and hemorrhagic events were 1.07% and 0.9% per patient-year, respectively. Multivariate analysis showed age (p < 0.002), sex (p < 0.01), and degenerative etiology (p = 0.04) as independent factors of late mortality, and age, sex, degenerative disease, and tricuspid pathology were related to valve-related mortality. CONCLUSIONS This study shows good results after mechanical mitral-aortic replacement in terms of survival rate and quality of life in surviving patients, and outlines the factors influencing long-term results as compared with isolated mitral valve replacement.