Peyman Sardari Nia

Quality of life evolution after lung cancer surgery in septuagenarians: a prospective study §

OBJECTIVE To prospectively evaluate quality of life (QoL) evolution after lung cancer surgery in a cohort of septuagenarians with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and LC13. METHODS Between January 2003 and December 2006, QoL was prospectively recorded in 60 consecutive septuagenarians undergoing lung cancer surgery. Forty-nine lobectomies and 11 pneumonectomies were performed. Questionnaires were administered before surgery and 1, 3, 6 and 12 months postoperatively (MPO) with response rates of 100%, 83%, 87%, 90% and 77%, respectively. RESULTS After lobectomy, QoL scores returned to baseline 3-6 months after surgery, with the exception of a persistent decrease in physical functioning and an increase in dyspnea within the 12 months follow-up. In the 12 months follow-up period after pneumonectomy, there was no return to baseline in physical, role and social functioning. After pneumonectomy, most quality of life scores returned to baseline at 1-month follow-up, with the exception of dyspnea and general pain, which returned to baseline at 3 and 6 months, respectively. Comparing both resections, significant differences in evolution of physical functioning (6MPO p=0.045), role functioning (3MPO p=0.035), social functioning (6MPO p=0.006, 12MPO p=0.001) and general pain (6MPO p=0.037) were reported in favor of lobectomy. CONCLUSIONS The present study documented QoL evolution profiles of septuagenarians after pulmonary surgery. The results indicate that both resections have a major impact on elderly patients, especially physical functioning and dyspnea status. If both resections are compared, lobectomy patients have a more favorable evolution in QoL subscales compared to pneumonectomy.

Prognostic value of a biologic classification of non-small-cell lung cancer into the growth patterns along with other clinical, pathological and immunohistochemical factors

OBJECTIVES Classification of non-small-cell lung cancer (NSCLC) into growth patterns is based on the following question: What does the tumour do with normal lung parenchyma? There are only three possible ways according to which a tumour can behave: (1) preservation of lung tissue and use of its microenvironment for further growth, (2) destruction of lung tissue and formation of new microenvironment for continued expansion and (3) preservation of lung tissue and formation of new microenvironment (modulation). The aim of the current study is to test the prognostic value of growth-pattern classification along with other clinical, pathological and immunohistochemical factors. METHODS Clinicopathological factors of 239 patients operated for NSCLC were retrospectively reviewed. Preoperative smoking status was determined based on two prospectively independent questionnaires. Co-morbidity was determined based on Charlson co-morbidity index (CCI). Haematoxylin-eosin tissue sections were analysed for the determination of tumour growth patterns, histological types, grading, necrosis and desmoplasia. Tumour cell proliferation, endothelial cell proliferation and microvessel density were determined based on double immunostaining with CD34 and Ki67 antibodies. Follow-up data were updated in 2008. RESULTS According to the growth-pattern classification, 161 patients (67.4%) had a destructive, 33 (13.8%) a papillary and 45 (18.8%) an alveolar growth pattern. Multiple Cox regression analysis showed that older age (p<0.001), lymph node metastasis (p<0.001), growth-pattern classification (p=0.036) and current smokers (p=0.027) were independent prognostic factors for overall survival. Similar results were obtained for disease-specific and disease-free survival. Papillary (hazard ratio=1.658 and confidence interval=1.001-2.748, p=0.050) and alveolar (hazard ratio=2.056 and confidence interval=1.305-3.237, p=0.002) growth patterns were independent predictors of early recurrence. CONCLUSIONS Growth-pattern classification remains a significant prognostic factor in NSCLC providing a possible explanation for survival differences in the same disease stage.

A multidimensional dynamic quantification tool for the mitral valve.

OBJECTIVES The mitral valve (MV) is a complex three-dimensional (3D) intracardiac structure. 3D transthoracic and transoesophageal echocardiography are used to evaluate and describe the changes in the mitral valve apparatus due to degenerative or functional mitral regurgitation. These techniques are, however, not accurate enough to capture the dynamic changes during the cardiac cycle. We describe a novel multistage modelling (MSM) technique, using three-dimensional transoesophageal echocardiography (3D TOE), to visualize and quantify the MV during all the phases of the cardiac cycle. METHODS Using 3D TOE, sets of images were obtained from 32 individuals who were undergoing surgery for other reasons and who did not have MV disease. These images were divided into six steps whereby every step represented one cardiac cycle. The image sets were then cropped and sliced at the level of MV, then imported and segmented by the open source software (3D Slicer) to create 3D mathematical models. The models were synchronized with patients ECGs and then reunited and exported as multiphase dynamic models. The models were analysed in two steps: (i) direct step-by-step visual inspections of the MV from various angles and (ii) direct measurements of anteroposterior, intercommissural, anterolateral-posteromedial diameters, anterolateral angles and anteroposterior angles in systole and diastole at different levels. RESULTS The segmentation results in 32 × 6 high-quality cropped MV. The division of models into six steps allows quantification and tracking of MV movement. Reunion of the models leads to creation of a full real-time simulation of the MV during the cardiac cycle. Synchronization of the models with ECG enables accurate simulation. Measurements of the diameters showed: median intercommissural diameters were increased with 10% from mid-systole to mid-diastole [31.9 mm (28.9-34.9), 34.8 mm (31.2-38.2), respectively, P-value <0.001]. This was also observed for anteroposterior diameters [33.8 mm (29.8-35.2), 37.1 mm (31.8-38.5), respectively, P-value <0.001]. Anterolateral-posteromedial diameter did not change significantly in both phases [43.7 mm (36.3-48.9), 43.5 mm (35.5-47.5), respectively]. Intercommissural and anteroposterior diameters were approximately the same in systole [31.9 mm (28.9-34.9) and 32.5 mm (29.8-35.2)] and diastole [34.8 mm (31.2-38.2) and 35.2 mm (31.8-38.5)]. Measurements of anteroposterior angle at the anterolateral junction showed that this angle was accentuated acutely in diastole rather in systole [115° (104-129), 126° (113-137), respectively, P-value <0.001]. It was the same when measuring the anterolateral angle [105° (97-113), 119° (106-130), respectively, P-value <0.001]. CONCLUSIONS The novel MSM technique allows precise quantification of shape changes in MV, which may help in better understanding the normal MV physiology, facilitate the diagnosis of MV pathologies and lead to numerical simulation of MV flow and displacement. It can also help cardiac surgeons and cardiologists gain a better understanding of the MV and assist them in obtaining a reliable orientation in order to choose optimal treatment strategies and plan surgical interventions. The measurement of the new anterolateral angle allowed better quantification of mitral annulus angulation and could be considered as new parameter that may help in future development of a new generation of mitral rings.

Comparing the endo-aortic balloon and the external aortic clamp in minimally invasive mitral valve surgery

OBJECTIVES The aim of this study was to assess the differences in perioperative outcomes and complications between the endo-aortic balloon (EAB) and the external aortic clamp (EAC) during primary elective minimally invasive mitral valve surgery (MIMVS) in a single referral centre by one surgeon. Primary outcomes were cardiopulmonary bypass time (CPB), cross-clamp time (CX) and occurrence of postoperative cerebrovascular accidents (CVAs). Secondary outcomes were other perioperative parameters and complications. METHODS We retrospectively analysed 340 consecutive patients who underwent MIMVS for mitral regurgitation (MR), mitral stenosis or combined regurgitation/stenosis between November 2010 and March 2014 in a single referral centre. In total, 221 patients who underwent an isolated mitral valve repair or isolated mitral valve replacement or repair/replacement combined with an atrial fibrillation (AF)-ablation procedure were included. Patients who had previous cardiac surgery or concomitant tricuspid valve surgery, myxoma or atrial septal defect closure surgery were excluded. RESULTS A total of 57 patients (Group A) underwent MIMVS using the EAC and 164 patients (Group B) were operated using an EAB. Preoperative variables showed a significant difference in poor left ventricular function (LVF, P = 0.18) and moderate LVF (P = 0.019). No significant differences were found in CPB-time, cross-clamp time or postoperative CVA. Furthermore, no significant differences were found in complications, 30-day mortality or postoperative echocardiographical MR gradation. Hospital stay, however, was prolonged in Group A (P = 0.001) and maximum troponin T levels were significantly lower in Group B (P = 0.014). In Group B however, 10 procedures were converted (6%) from EAB to EAC. CONCLUSIONS There is no difference in use between the EAB and the EAC in terms of CPB-time and cross-clamp time, complications or MR gradation at discharge. Use of the EAC showed significantly higher postoperative levels of troponin T, implying more myocardial damage, compared with the EAB. In 6% of the cases however, patients were converted from the EAB to the EAC.

Preoperative planning with three-dimensional reconstruction of patient's anatomy, rapid prototyping and simulation for endoscopic mitral valve repair

Objectives Mitral valve repair performed by an experienced surgeon is superior to mitral valve replacement for degenerative mitral valve disease; however, many surgeons are still deterred from adapting this procedure because of a steep learning curve. Simulation-based training and planning could improve the surgical performance and reduce the learning curve. The aim of this study was to develop a patient-specific simulation for mitral valve repair and provide a proof of concept of personalized medicine in a patient prospectively planned for mitral valve surgery. Methods A 65-year old male with severe symptomatic mitral valve regurgitation was referred to our mitral valve heart team. On the basis of three-dimensional (3D) transoesophageal echocardiography and computed tomography, 3D reconstructions of the patients anatomy were constructed. By navigating through these reconstructions, the repair options and surgical access were chosen (minimally invasive repair). Using rapid prototyping and negative mould fabrication, we developed a process to cast a patient-specific mitral valve silicone replica for preoperative repair in a high-fidelity simulator. Results Mitral valve and negative mould were printed in systole to capture the pathology when the valve closes. A patient-specific mitral valve silicone replica was casted and mounted in the simulator. All repair techniques could be performed in the simulator to choose the best repair strategy. As the valve was printed in systole, no special testing other than adjusting the coaptation area was required. Subsequently, the patient was operated, mitral valve pathology was validated and repair was successfully done as in the simulation. Conclusions The patient-specific simulation and planning could be applied for surgical training, starting the (minimally invasive) mitral valve repair programme, planning of complex cases and the evaluation of new interventional techniques. The personalized medicine could be a possible pathway towards enhancing reproducibility, patients safety and effectiveness of a complex surgical procedure.

Preoperative planning of left-sided valve surgery with 3D computed tomography reconstruction models: sternotomy or a minimally invasive approach?

OBJECTIVES With the emergence of a new concept aimed at individualization of patient care, the focus will shift from whether a minimally invasive procedure is better than conventional treatment, to the question of which patients will benefit most from which technique? The superiority of minimally invasive valve surgery (MIVS) has not yet been proved. We believe that through better patient selection advantages of this technique can become more pronounced. In our current study, we evaluate the feasibility of 3D computed tomography (CT) imaging reconstruction in the preoperative planning of patients referred for MIVS. METHODS We retrospectively analysed all consecutive patients who were referred for minimally invasive mitral valve surgery (MIMVS) and minimally invasive aortic valve replacement (MIAVR) to a single surgeon in a tertiary referral centre for MIVS between March 2014 and 2015. Prospective preoperative planning was done for all patients and was based on evaluations by a multidisciplinary heart-team, an echocardiography, conventional CT images and 3D CT reconstruction models. RESULTS A total of 39 patients were included in our study; 16 for mitral valve surgery (MVS) and 23 patients for aortic valve replacement (AVR). Eleven patients (69%) within the MVS group underwent MIMVS. Five patients (31%) underwent conventional MVS. Findings leading to exclusion for MIMVS were a tortuous or slender femoro-iliac tract, calcification of the aortic bifurcation, aortic elongation and pericardial calcifications. Furthermore, 2 patients had a change of operative strategy based on preoperative planning. Seventeen (74%) patients in the AVR group underwent MIAVR. Six patients (26%) underwent conventional AVR. Indications for conventional AVR instead of MIAVR were an elongated ascending aorta, ascending aortic calcification and ascending aortic dilatation. One patient (6%) in the MIAVR group was converted to a sternotomy due to excessive intraoperative bleeding. Two mortalities were reported during conventional MVS. There were no mortalities reported in the MIMVS, MIAVR or conventional AVR group. CONCLUSIONS Preoperative planning of minimally invasive left-sided valve surgery with 3D CT reconstruction models is a useful and feasible method to determine operative strategy and exclude patients ineligible for a minimally invasive approach, thus potentially preventing complications.

Novel multi-dimensional modelling for surgical planning of acute aortic dissection type A based on computed tomography scan

OBJECTIVES Acute type A aortic dissection (TAAD) is a life-threatening emergency and requires immediate surgical intervention. We propose a novel finite element multi-dimensional modelling (FE-MDM) technique to identify aortic tears preoperatively to aid surgical preplanning. METHODS Thirty-two patients with TAAD were included in this retrospective study. Computed tomography (CT) scans were imported using the segmentation software and reconstruction resulted in modelling of single TAAD components: aortic wall, false lumen, true lumen, gap in the flap and blood in both lumens. CT scans were processed by interpreters who were blinded to the clinical data and then were compared with operative findings. The models were assessed and compared regarding localization and size of the entry tear with the intraoperative findings. Image set data were retrieved from CT scans. RESULTS Surgical inspection confirmed the localization of the tear obtained by the model in all patients with a 100% chance prediction (P < 0.0001) in all patients. With the simulation of the guided-cannulation, it was possible to place the cannula in the ascending aorta in 100% of patients (P < 0.0001 vs surgery). Using the virtual volume model, the chance of inserting into the false lumen was 0% (P < 0.0001). There was a strong correlation between the virtual volume model and cannulation in the true lumen (r = 0.88, P < 0.0001). CONCLUSIONS The FE-MDM technique of aortic dissection is helpful in identifying the site of the tear and may be considered as an additional tool in surgical preplanning. It may also enhance the efficiency of deep hypothermic circulatory arrest in patients with single entry sites in the ascending aorta and it may facilitate direct cannulation of the ascending aorta.

Aortic elongation part II: the risk of acute type A aortic dissection

Objectives Prophylactic surgery for prevention of acute type A aortic dissection (ATAAD) is reserved for patients with an ascending aortic aneurysm ≥55 mm. Identification of additional risk predictors is warranted since over 70% of patients presenting with ATAAD have a non-dilated aorta or an aneurysm that would not have met the diameter criterion for preventative surgery. Aim of the study was to evaluate ascending aortic elongation as a risk factor for ATAAD and to compare aortic lengths between ATAAD patients and healthy controls. Methods Aortic lengths and diameters of ATAAD patients were measured on three-dimensional modelled computed tomography and adjusted to predissection dimensions in this cross-sectional single-centre study. Logistic regression was used to evaluate the relation between ATAAD and aortic dimensions. Lengths of different aortic segments were compared with a healthy control group using propensity score matching. Results Two-hundred and fifty patients were included in the study (ATAAD, n=40; controls, n=210). Ascending aortic length and diameter proved to be independent predictors for ATAAD (OR=5.3, CI 2.5 to 11.4, p<0.001 and OR=8.6, CI 2.4 to 31.0, p=0.001). Eighty patients were matched based on propensity scores (ATAAD n=40, controls n=40). The ascending aorta was longer and more dilated in ATAAD patients compared with healthy controls (78.6±8.8 mm vs 68.9±7.2 mm, p<0.001, 34.4 mm ±3.2. vs 39.4 mm ±5.7, p<0.001, respectively). No differences were found in lengths of the aortic arch and descending aorta. Conclusions Ascending aortic length could serve as an independent predictor for ATAAD. Future studies addressing indications for prophylactic surgery should also investigate aortic length.

Aortic elongation part I: the normal aortic ageing process

Objectives Differentiation between normal and abnormal features of vascular ageing is crucial, as the latter is associated with adverse outcomes. The normal aortic ageing process is accompanied by gradual luminal dilatation and reduction of vessel compliance. However, the influence of age on longitudinal aortic dimensions and geometry has not been well studied. This study aims to describe the normal evolution of aortic length and shape throughout life. Methods A total of 210 consecutive patients were prospectively enrolled in this cross-sectional single-centre study. All subjects underwent CT on a third-generation dual-source CT scanner. Morphometric measurements, including measurements of segmental length and tortuosity, were performed on three-dimensional models of the thoracic aorta. Results The length of the thoracic aorta was significantly related to age (r=0.54) and increased by 59 mm (males) or 66 mm (females) between the ages of 20 and 80 years. Elongation was most pronounced in the proximal descending aorta, which showed an almost 2.5-fold length increase during life. The lengthening of the thoracic aorta was accompanied by a marked change of its geometry: whereas the aortic apex was located between the branch vessels in younger patients, it shifted to a more distalward position in the elderly. Conclusions The normal ageing process is accompanied by gradual aortic elongation and a notable change of aortic geometry. Part II of this two-part article investigates the hypothesis that excessive elongation could play a role in the occurrence of acute aortic dissection.

Value of Multidimensional Modeling in Planning Surgery for a Dissecting Ventricular Septal Hematoma Following Aortic Valve Sparing Root Reimplantation

We report a technique of multidimensional modeling (MDM) used to assist in the planning of a repair of a dissecting ventricular septal hematoma (DVSH) following a David procedure. doi: 10.1111/jocs.12757 (J Card Surg 2016;31:390–393)