Rocco J. Lafaro

Pretreatment of Human Myocardium with Adenosine During Open Heart Surgery

Background: Depressed myocardial performance after cardiac surgery can be contributed to ischemic reperfusion injury (IRI) incurred during and following the cardiopulmonary bypass (CPB). Myocardial preconditioning (PC) achieved by brief ischemia and subsequent reperfusion appears to be a clinically useful method of improved cardiac protection during surgery involving CPB by retarding IRI. Based on animal studies, activation of cardiac adenosine (ADO) receptors prior to the prolonged ischemic period appears to mimic this PC phenomenon. Aims and Methods: We investigated whether the human myocardial PC can be mimicked with ADO in the setting of the coronary artery bypass graft (CABG). The specific proposed objective of this study was to determine whether ADO infusion just prior to starting the CPB can improve post‐CPB myocardial hemodynamics. Patients undergoing elective CABG with poor ventricular function (ejection fraction ± 30%), and with at least three‐vessel disease were selected for this study (n = 7 ADO, and n = 7 control). Results: Our results show that ADO infusion (250–350 μg/kg ± 10 min) just prior to CPB resulted in an immediately improved postbypass cardiac index (Cl) in the OR (Cl increase of 41.5%± 11.1% for ADO vs 9.7%± 6.0% for control, p < 0.05). Forty hours postoperatively in the intensive care unit, ADO patients had improved Cl (3.3 ± 0.2 L/min per m2 for ADO, vs 2.6 ± 0.1 L/min per m2 for control, p < 0.05), stroke volume index (35 ± 3 mL/m2 per beat for ADO, vs 26 ± 4 L/min per m2 for control, p < 0.05). ADO patients maintained lowered resting heart rate (90 ± 6 for ADO, vs 108 ± 4 for control, p < 0.05) 40 hours after the surgery. ADO patients also released significantly less CPK during the first 24 hours of the postoperative period. Conclusion: Based on these measurements, ADO pretreated patients had improved ventricular performance postoperatively. It also appears that ADO pretreatment results in lowered postoperative myocardial energy demand and less myocellular injury during CPB. To our knowledge, this is the first study to demonstrate that human myocardium can be hemodynamically improved with ADO pretreatment, and may be protected against IRI incurred during and following the CPB. We believe that a cardiac surgeon may now have the unique opportunity to confer myocardial protection during and after a cardiac surgical procedure.

Malignant renal tumor with extension to the inferior vena cava

BACKGROUND Management of malignant renal tumors involving the inferior vena cava (IVC) depends on tumor extension within the cava. METHODS Of 295 patients treated for renal cancer, propagation of tumor mass through the renal vein to IVC was seen in 22 (7%) patients. Cephalad extension of the tumor was suprarenal: infrahepatic in 12, retrohepatic in 6, and within the right atrium in 4 patients. All patients had radical nephrectomy, cavotomy, and complete resection of tumors except 1 with diffuse peritoneal metastasis. RESULTS Twenty-one patients had curative resections. No operative deaths and no instances of pulmonary embolism or exsanguination occurred. Seventeen patients were alive at 2 years and 12 at 5 years, resulting in 77% and 55% survival rates, respectively. CONCLUSIONS An aggressive approach for vena cava involvement from malignant renal neoplasms resulted in prevention of tumor embolus, minimization of blood loss, and maintenance of venous return to the heart.

Heterogeneity of TERT promoter mutations status in squamous cell carcinomas of different anatomical sites

Squamous cell carcinoma (SCC) can arise from different anatomical sites including the skin, head and neck, lung, esophagus, genital area, and so on. Despite the same histopathologic features and immunohistochemistry profile, the SCCs of different body sites can show tremendous differences in their presenting symptoms, risk factor associations, natural history, prognosis, and response to treatment. This may reflect the fact that SCCs are heterogenous and likely have unique molecular characteristics at different anatomical sites. Recurrent somatic mutations in the TERT promoter region were first reported in human melanomas. Subsequently, other tumors including cutaneous SCC were found to demonstrate high frequencies of the same mutations. However, the incidences of TERT promoter mutation in noncutaneous SCCs have not been systemically studied. We investigated the TERT promoter mutation status among SCCs from different sites. We collected 84 cases of SCC from the skin (27), head and neck (12), lung (25), and cervix (10), as well as 10 cases of urothelial carcinoma with squamous differentiation (UC-SqD). We found that the frequencies of TERT promoter mutation among SCC of different sits are quite heterogenous: ~70% in skin SCC and UC-SqD, 16.67% in head and neck SCC, and 0% in lung and cervix SCC. These results may support the hypothesis of different carcinogenesis mechanisms of SCC in different sites. It also indicates that TERT promoter mutation could be a biomarker for distinguishing skin SCC or UC-SqD vs pulmonary SCC.

Immediate structural valve deterioration of 27-mm Carpentier-Edwards aortic pericardial bioprosthesis

We describe two cases of immediate structural valve deterioration of the 27-mm Carpentier-Edwards pericardial valve. Tissue characteristics of bovine pericardium and the possible mechanism of failure are discussed.

Recurrence of Renal Cell Carcinoma with Extensive Vena Caval Thrombus Three Years after Radical Nephrectomy

A 70-year-old man, who had undergone a radical nephrectomy for localized renal cell carcinoma (RCC) three years ago, was recently evaluated for shortness of breath. During his work-up, a transesophageal echocardiogram and magnetic resonance imaging indicated an extensive vena caval thrombus originating from the renal vein stump. Successful vena caval thrombectomy with cardiopulmonary bypass confirmed that the thrombus was comprised of RCC. This is a rare type of RCC recurrence with an unusual timing (3 years after a nephrectomy), alerting the importance of strict follow-up on all patients even after complete surgical excision of all suspected tumors.

Atherosclerotic pseudoaneurysm of the ascending aorta

Pseudoaneurysms in the ascending aorta most commonly occur as a complication of surgical procedures at this site. They have also been reported in association with trauma, infection, aortitis, and other disorders. Pseudoaneurysm formation in the descending aorta or arch may occur as a result of penetrating ulcers in the presence of severe atherosclerotic plaque. Pseudoaneurysm as a result of atherosclerotic disease has only rarely been noted in the ascending aorta, where complex plaque is less common. We report here the finding with transesophageal echocardiography of a pseudoaneurysm in the ascending aorta as a result of atherosclerotic disease and penetrating ulcer.

Cardiac cavernous hemangioma mimicking pericardial cyst: Atypical echocardiographic appearance of a rare cardiac tumor

Cavernous hemangioma is a rare tumor with infrequent cardiac involvement. Preoperative or antemortem diagnosis may be difficult. Several prior case reports have described echocardiographic findings of cavernous hemangioma. We report here a 50-year-old white female patient with this tumor. Transesophageal echocardiography detected a mass with an echocardiographic appearance not previously described for cavernous hemangioma. The tumor appeared as a large echolucent unilocular cystic mass, leading to an erroneous preoperative diagnosis of pericardial cyst. This previously unreported finding should be recognized by echocardiographers in the evaluation of cardiac masses.

Neural Network Prediction of ICU Length of Stay Following Cardiac Surgery Based on Pre-Incision Variables

Background Advanced predictive analytical techniques are being increasingly applied to clinical risk assessment. This study compared a neural network model to several other models in predicting the length of stay (LOS) in the cardiac surgical intensive care unit (ICU) based on pre-incision patient characteristics. Methods Thirty six variables collected from 185 cardiac surgical patients were analyzed for contribution to ICU LOS. The Automatic Linear Modeling (ALM) module of IBM-SPSS software identified 8 factors with statistically significant associations with ICU LOS; these factors were also analyzed with the Artificial Neural Network (ANN) module of the same software. The weighted contributions of each factor (“trained” data) were then applied to data for a “new” patient to predict ICU LOS for that individual. Results Factors identified in the ALM model were: use of an intra-aortic balloon pump; O2 delivery index; age; use of positive cardiac inotropic agents; hematocrit; serum creatinine ≥ 1.3 mg/deciliter; gender; arterial pCO2. The r2 value for ALM prediction of ICU LOS in the initial (training) model was 0.356, p <0.0001. Cross validation in prediction of a “new” patient yielded r2 = 0.200, p <0.0001. The same 8 factors analyzed with ANN yielded a training prediction r2 of 0.535 (p <0.0001) and a cross validation prediction r2 of 0.410, p <0.0001. Two additional predictive algorithms were studied, but they had lower prediction accuracies. Our validated neural network model identified the upper quartile of ICU LOS with an odds ratio of 9.8(p <0.0001). Conclusions ANN demonstrated a 2-fold greater accuracy than ALM in prediction of observed ICU LOS. This greater accuracy would be presumed to result from the capacity of ANN to capture nonlinear effects and higher order interactions. Predictive modeling may be of value in early anticipation of risks of post-operative morbidity and utilization of ICU facilities.

Giant myxoma causing heart failure symptoms

Summary Background: Myxomas arising from the eustachian valve are exceedingly rare. Case Report: A 72-year-old Jamaican-Chinese woman was evaluated for worsening dyspnea. The 2-dimensional and real time 3-dimensional transesophageal echocardiogram showed a 75 mm length × 44 mm width, multilobulated, mobile mass arising from the eustachian valve occupying the entire right atrial and right ventricular cavities extending into the coronary sinus, right ventricular outflow tract, and proximal inferior vena cava. The patient underwent successful resection of the mass and replacement of the tricuspid valve. Histopathologic examination confirmed the diagnosis of atrial myxoma. Conclusions: This is the largest myxoma found on a Eustachian valve.

Extracardiac Fontan Operation Through a Right Thoracotomy

An extracardiac Fontan operation through a right thoracotomy incision is an alternative approach in children who have an ascending aorta that is in close proximity to the sternum, as in aortic atresia or transposed great vessels, and in those who have had prior mediastinitis.