Peter Brady

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.

The use of ultra-low-dose aprotinin to reduce blood loss in cardiac surgery

One hundred patients due to undergo primary cardiac surgery were prospectively randomized to receive aprotinin or placebo. In the aprotinin group, 250,000 kallikrein inhibitory units (KIU) of aprotinin were added to the cardiopulmonary bypass prime solution. A further 250,000 KIU of aprotinin were infused intravenously over 30 minutes immediately before the start of cardiopulmonary bypass. The control group received 0.9% saline in equal volumes at identical times. The study was designed to have a 90% chance of demonstrating a 30% reduction in blood loss. No significant differences were found between the two groups. The median blood loss in the aprotinin group was 750 mL (interquartile range 556 to 1025 mL, 95% confidence interval 600 to 800 mL). In the control group, the median blood loss was also 750 mL (interquartile range 500 to 988 mL, 95% confidence interval 625 to 925 mL). In the aprotinin group, 12 patients received postoperative autotransfusion of shed mediastinal blood of median volume of 665 mL (interquartile range 500 to 925 mL, 95% confidence interval 450 to 1000 mL). In the control group, 14 patients received postoperative autotransfusion of mediastinal blood of median volume of 663 mL (interquartile range 600 to 800 mL, 95% confidence interval 600 to 700 mL). Five patients in the aprotinin group and seven patients in the control group required postoperative homologous blood transfusion. Reassessment of inclusion criteria showed a 19% reduction in blood loss in patients undergoing only aortocoronary bypass receiving aprotinin compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Initial experience with the balloon expandable Edwards-SAPIEN Transcatheter Heart Valve in Australia and New Zealand: The SOURCE ANZ registry: Outcomes at 30 days and one year

BACKGROUND We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edwards SAPIEN™ Transcatheter Heart Valve (THV) in the Australian and New Zealand (ANZ) clinical environment. METHODS This single arm registry of select patients treated in eight centres, represent the initial experience within ANZ with the balloon expandable Edwards SAPIEN THV delivered by transfemoral (TF) and transapical (TA) access. RESULTS The total enrolment for the study was 132 patients, 63 patients treated by TF, 56 by TA, and 2 patients were withdrawn from the study. The mean ages: 83.7 (TF) and 81.7 (TA), female: 34.3% (TF) and 61.3% (TA), logistic EuroSCORE: 26.8% (TF) and 28.8% (TA), and with procedural success (successful implant without conversion to surgery or death): 92.4% (TF) and 87.1% (TA) (p=0.32). Outcomes were not significantly different between TF and TA implants. These included one year mortality of 13.6% (TF) and 21.7% (TA) (p=0.24), MACCE: 16.7% (TF) and 28.3% (TA) (p=0.12), pacemaker: 4.6% (TF) and 8.3% (TA) (p=0.39), and VARC major vascular complication of 4.6% (TF) and 5.0% (TA) (p=0.91). CONCLUSION TAVI in the ANZ clinical environment has demonstrated excellent outcomes for both the TA and TF approaches in highly selected patients. These results are consistent with those demonstrated in European, Canadian registries and the pivotal US clinical trials. ACTRN12611001026910.

Adverse Reactions to Plasma Volume Expanders

SummaryPlasma volume expanders are effective in the restoration of blood volume. All the available plasma volume expanders may rarely induce anaphylactoid reactions, although such reactions are extremely uncommon in shocked patients. The reactions are caused by different mechanisms depending on the solution, and there is little evidence that IgE antibodies are involved. In addition to these reactions, effects on haemostasis and renal function may occur, and the persistence of hydroxyethyl starch in the body has led to concern about its potential role as a carcinogen, although there is no evidence to suggest that this has occurred.

The use of extracorporeal membrane oxygenation therapy in the delayed surgical repair of a tracheal injury.

Acute tracheal injury secondary to intubation can present with varying degrees of severity. Onset of symptoms occur hours or even days after the initial injury. A 34-year-old woman required surgery for a large tracheal tear after emergency intubation. The inability to adequately ventilate combined with secondary aspiration injury required that the patient be placed on extracorporeal membrane oxygenation before undergoing surgery. This case demonstrates the use of extracorporeal membrane oxygenation to manage a patient awaiting surgery for severe tracheal tears.

Ventricular remodeling after cardiomyoplasty in heart failure sheep: passive and dynamic effects

BACKGROUND Recent reports claim that cardiomyoplasty (CMP) has a girdling effect on the left ventricle, to prevent dilatation and functional deterioration, but the mechanism of its long-term effects on the native heart is not known. We compared the relative role of CMPs active squeezing and passive girdling in chronically failing hearts. METHODS After induction of stable heart failure (left ventricular ejection fraction = 27% +/- 7%) by staged coronary microembolization, CMP was performed in 11 of 18 sheep. After 8 weeks pacing training of the latissimus dorsi muscle (LDM), cardiac assist was begun with 1:2 synchronous bursts in 6 sheep (d-CMP, n = 6), and the LDM in the passive group (p-CMP, n = 5) remained unstimulated. Four (base line) and 30 weeks after induction of heart failure, the pressure-volume relationship was derived. RESULTS After 30 weeks in d-CMP the slope (Emax) of the end-systolic pressure-volume relationship increased by 66% +/- 55% (p < 0.05) and external work efficiency by 48% +/- 41% (p < 0.01). In the passive CMP and control groups, slope and external work efficiency were unchanged. Conversely, left ventricular end-diastolic volume decreased (-14% +/- 12%, p < 0.05) in the dynamic CMP group compared with a static course in the passive CMP group (3% +/- 10%, p > 0.05) and an increase (18% +/- 15%, p < 0.05) in controls. CONCLUSIONS Dynamic CMP improved native hearts contractility and external work efficiency. In addition, whereas passive CMP has simply a girdling effect, dynamic CMP also induces reverse left ventricular chamber remodeling.

Technical Improvements in the Repair of Acute Postinfarction Ventricular Septal Rupture

Postinfarction ventricular septal rupture (VSR) is a high‐risk complication following myocardial infarction (MI). Surgical treatment has evolved to improve an otherwise poor prognosis. Certain subsets of patients remain a formidable challenge. The presence of cardiogenic shock has consistently been found to have the highest risk. Over a 10‐year period, our technique of repair has evolved from established procedures to one we believe confers superior results. Endocardial patching to viable myocardium reinforced with an epicardial patch not only corrects the shunt but maintains ventricular geometry and avoids tension on friable muscle. We report on a series of nine consecutive patients in cardiogenic shock. The operative mortality was 22%, none due to low cardiac output syndrome, shunt recurrence, or bleeding. All patients have been followed with transesophageal echocardiography at a mean period of 14 months (range 3–31 months). One patient is in New York Heart Association (NYHA) Class I, four are in NYHA Class II, and two in NYHA Class III.

HeartPatch implanted direct cardiac compression: effect on coronary flow and flow patterns in acute heart failure sheep.

A novel HeartPatch direct cardiac compression (DCC) device has been shown to effectively restore circulatory parameters in sheep with acute heart failure (HF). Its effect on the coronary circulation and myocardial perfusion, however, remains uncertain. The effect of DCC assist on coronary artery blood flow (CABF) and its patterns in acute HF sheep were examined in this study. Ten sheep (51 ± 6 kg) were implanted with a heart patch on each of the left ventricular and right ventricular free walls 1 week before study. Stable HF [cardiac output (CO) at 51 ± 8% of baseline] induced by intravenous esmolol resulted in CABF decreasing to 53 ± 16% of baseline (p < 0.001). DCC device activation did not alter CABF (54 ± 15% of baseline, N.S.) but was accompanied by increases in both peak antegrade and retrograde flow velocity (161 ± 75%, p < 0.001 and 413 ± 377%, p < 0.001). A shift in the proportion of flow occurring in diastole (%DF) also was observed: baseline, 81 ± 9%; HF, 82 ± 6%; DCC assist, 121 ± 16% (p < 0.001). Despite significant changes in coronary artery flow pattern resulting from DCC of the failing heart, total antegrade coronary flow was maintained. These findings suggest that myocardial perfusion is not compromised by DCC.

Tracheo-oesophageal fistula following a fall

A previously healthy 22-year-old man was admitted to hospital after falling 3 m from a balcony onto concrete while intoxicated. There was no reported loss of consciousness but the patient was amnesic of the event. On examination in the emergency department his Glasgow coma score (GCS) was initially 12/15 and was agitated. He was haemodynamically stable. Examination revealed subcutaneous emphysema of his neck. He had a graze across the interscapular region of the back. The remainder of the examination was unremarkable. Due to agitation and decreased level of consciousness he was intubated. A computed tomography (CT) scan of the chest revealed pneumomediastinum, a haematoma to the right side of the oesophagus in the superior mediastinum and a small left sided pneumothorax. CT of the head and abdomen were normal. The patient’s injuries at the time were assessed as (i) closed head injury (ii) small left-sided pneumothorax and (iii) suspicion of oesophageal and/or trachea perforation. The patient was admitted to the intensive care unit and intubated for 24 h. Post-extubation he was neurologically stable. On day 2 a barium swallow was performed and showed extraluminal contrast to the left of the oesophagus just above the carina, consistent with an oesophageal rupture. Swallowing the barium caused him to have a coughing attack. Total parenteral nutrition (TPN) was commenced and the patient was advised to not swallow his saliva. Prophylactic intravenous ampicillin, gentamicin and metronidazole were started. On day 4 the patient developed a cough producing yellowish, blood-stained sputum. A chest X-ray performed on day 6 revealed bilateral pleural effusions. A repeat CT of the chest on day 8 revealed persisting bilateral pleural effusions with a reduction in mediastinal gas. A non-ionic contrast swallow was performed on day 13 and showed passage of contrast from the upper oesophagus into the right main bronchus which showed the presence of a tracheooesophageal fistula (see Fig. 1). A bronchoscopy was performed on day 15 and this showed a 3-cm laceration in the posterior membranous trachea with excessive saliva freely entering the tracheal lumen. The patient underwent repair of the TOF on day 18. Through a right thoracotomy incision in the fourth intercostal space a 3-cm tear in the anterior oesophagus was found. This was communicating with a 5-mm perforation in the posterior membranous trachea 2 cm above the carina. Primary repair of both holes was undertaken. A pericardial flap was interposed between the trachea and oesophagus and then fibrin glue was applied. Antibiotics were ceased 24 h postoperatively. A repeat gastrograffin swallow performed on day 6 after operation showed contrast passing freely between a persisting TOF into the right bronchus. This was managed conservatively by maintaining him

The heart string: a simple, inexpensive exposure of the heart during coronary artery operations.

A method of heart retraction during coronary artery bypass operations is described. The technique improves exposure of the coronary arteries, especially of the circumflex and posterior descending coronary branches during grafting. In addition, it is simple, safe, and inexpensive. Furthermore, this technique can be applied for off-pump coronary artery bypass surgery.