Rochelle Wynne

Long-Term Patency of 1108 Radial Arterial-Coronary Angiograms Over 10 Years

BACKGROUND To avoid late vein graft atheroma and failure, we have used arterial grafts extensively in coronary operations. The radial artery (RA) is the conduit of second choice. This study determined the long-term patency of the RA as a coronary graft. METHODS Two independent observers evaluated 1108 consecutive postoperative RA conduit angiograms performed between January 1997 and June 2007 for cardiac symptoms. Mean time to postoperative angiography was 48.3 months (range, 1 to 132 months). An RA graft was considered failed (nonpatent) if there was stenosis exceeding 60%, string sign, or occlusion. Patency was determined over time, by coronary territory grafted and by the degree of native coronary artery stenosis (NCAS). RESULTS At a mean of 48.3 months, 982 of the 1108 RA grafts (89%) were patent. RA patencies for the left anterior descending were 96% (24 of 25), diagonal/intermediate, 90% (121 of 135); circumflex marginal, 89% (499 of 561); right coronary, 83% (38 of 46); posterior descending, 89% (253 of 286); and left ventricular branch/posterolateral, 86% (47 of 55). Patency was 87.5% (56 of 64) for NCAS of less than 60% compared with 89% (926 of 1044; p = 0.89) for NCAS exceeding 60%. Of 318 RAs in place more than 5 years, 294 (92.5%) were patent, and for 107 RAs in place for more than 7 years, 99 were patent (92.5%). Patency was consistent through each year of the decade. Mechanisms of failure did not involve development of atherosclerosis. Patent RA grafts were smooth, with no angiographic evidence of atheroma. CONCLUSIONS Late patencies of RA grafts are excellent and justify continuing use of the RA in coronary operations.

Correlation of Mutation Status and Survival with Predominant Histologic Subtype According to the New IASLC/ATS/ERS Lung Adenocarcinoma Classification in Stage III (N2) Patients

Introduction: We investigated the relationship between predominant subtype, according to the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Lung Adenocarcinoma Classification; mutation status; and patient outcome in stage III (N2) lung adenocarcinoma. Methods: We identified 69 patients with stage III (N2) lung adenocarcinoma operated on with curative intent between 1993 and 2011 who had adequate tumor tissue for molecular analysis and adequate follow-up time for survival analysis. DNA was isolated and tested for mutations using Sequenom’s OncoCarta Panel (v1.0; Sequenom, San Diego, CA). Results: The majority of tumors were acinar (26 of 69 tumors; 38%), solid (24 of 69 tumors; 35%), and micropapillary predominant (13 of 69 tumors; 19%) subtypes. EGFR and KRAS mutations were identified in 17 of 59 tumors (29%) and 13 of 59 tumors (22%), respectively. EGFR mutations occurred most often in acinar (11 of 25 tumors; 44%) and micropapillary predominant tumors (five of 13 tumors; 38%) (p = 0.009), whereas KRAS mutations occurred most often in solid predominant tumors (nine of 21 tumors; 43%) (p = 0.016). Patients with acinar predominant tumors had significantly improved overall survival compared with those with non-acinar predominant tumors (hazard ratio: 0.45; 95% confidence interval: 0.22–0.91; p = 0.026), which remained significant after adjustment for EGFR status, T-stage, sex, and age. Patients with EGFR-mutant micropapillary predominant tumors had similar survival to those with EGFR-mutant acinar predominant tumors. The predominant subtype in the primary tumor was most often seen in the N2 node in micropapillary and solid predominant tumors but not in acinar predominant tumors. Conclusions: The predominant subtype in the primary tumor was associated with overall survival in resected stage III (N2) lung adenocarcinoma and was independent of mutation status. Histologic subtyping provides important prognostic information and potentially molecular correlates.

A Prospective Cohort Study of the Effects of Adjuvant Breast Cancer Chemotherapy on Taste Function, Food Liking, Appetite and Associated Nutritional Outcomes

Background ‘Taste’ changes are commonly reported during chemotherapy. It is unclear to what extent this relates to actual changes in taste function or to changes in appetite and food liking and how these changes affect dietary intake and nutritional status. Patients and methods This prospective, repeated measures cohort study recruited participants from three oncology clinics. Women (n = 52) prescribed adjuvant chemotherapy underwent standardised testing of taste perception, appetite and food liking at six time points to measure change from baseline. Associations between taste and hedonic changes and nutritional outcomes were examined. Results Taste function was significantly reduced early in chemotherapy cycles (p<0.05) but showed recovery by late in the cycle. Ability to correctly identify salty, sour and umami tastants was reduced. Liking of sweet food decreased early and mid-cycle (p<0.01) but not late cycle. Liking of savory food was not significantly affected. Appetite decreased early in the cycle (p<0.001). Reduced taste function was associated with lowest kilojoule intake (r = 0.31; p = 0.008) as was appetite loss with reduced kilojoule (r = 0.34; p = 0.002) and protein intake (r = 0.36; p = 0.001) early in the third chemotherapy cycle. Decreased appetite early in the third and final chemotherapy cycles was associated with a decline in BMI (p = <0.0005) over the study period. Resolution of taste function, food liking and appetite was observed 8 weeks after chemotherapy completion. There was no association between taste change and dry mouth, oral mucositis or nausea. Conclusion The results reveal, for the first time, the cyclical yet transient effects of adjuvant chemotherapy on taste function and the link between taste and hedonic changes, dietary intake and nutritional outcomes. The results should be used to inform reliable pre-chemotherapy education.

The Ross procedure using autologous support of the pulmonary autograft: techniques and late results

OBJECTIVES It is hypothesized that by performing radical aortic root manipulation and then autologous support for the pulmonary autograft in the Ross procedure, this will maintain aortic root size and should, in turn, lead to the demonstrated low incidence of late aortic regurgitation and need for reoperation on the aortic root and valve. METHODS Aortic root size was measured echocardiographically both preoperatively and then at second yearly intervals in 322 consecutive patients who underwent a Ross operation between October 1992 and June 2013 with autologous support of the pulmonary autograft root using the patients own aorta. This technique, a variant of the inclusion cylinder method, has been developed with the aim of minimizing prosthetic materials in the aortic root. RESULTS Measures to reduce aortic root size included annulus reduction in 201 patients (62.4%) and reduction in aortic sinus or sinotubular junction in 159 patients (49.4%). Maximal aortic root diameter postoperatively at 5, 10, and 15 years was 34.0, 34.6, and 34.7 mm, respectively. Eleven reoperations were required during the study period for progressive aortic regurgitation (none for aortic root enlargement), with freedom from reoperation being 96% at both 15 years and 18 years. Preoperative pure aortic regurgitation, aortic annulus, and sinotubular junction enlargement were risk factors for reoperation. CONCLUSIONS This inclusion method of pulmonary autograft implantation leads to minimal increases in aortic root size over time, with no reoperations for aortic root dilatation and a low requirement for aortic valve reoperation. The Ross procedure deserves to remain on the surgical menu for aortic valve replacement.

Total Arterial Revascularization: Achievable and Prognostically Effective—A Multicenter Analysis

BACKGROUND Total arterial revascularization (TAR) is adopted to overcome late vein graft atherosclerosis, and occlusion. Uptake of TAR remains low despite reports suggesting superior survival. Previous studies primarily involved single sites and short-term follow-up. We report the influence of TAR on long-term survival in a large multicenter patient cohort. METHODS We reviewed 63,592 cases from an audited collaborative multicenter database. Of those, 34,181 consecutive patients undergoing first-time isolated coronary artery bypass (CABG) from 2001 to 2012 were studied. The data were linked to the National Death Index. We compared outcomes in patients who underwent TAR (n = 12,271) with outcomes in those who did not (n = 21,910). The influence of TAR on 10-year all-cause late mortality was assessed by propensity score analyses in 6,232 matched pairs. RESULTS The 30-day mortality was 0.8% (96/12,271) for TAR patients and 1.8% (398/21,910) for non-TAR patients (p < 0.001). Late mortality was 7.5% (918/12,271) for TAR patients and 8.9% (1,952/21,910) for non-TAR patients (p < 0.001). The mean follow-up time was 4.9 years. In the propensity-matched cohort, the perioperative mortality was 0.9% (53/6,232) for TAR patients versus 1.2% (76/6,232) for non-TAR patients (p < 0.001). Kaplan-Meier survival in the matched cohort at 1, 5, and 10 years was 97.2%, 91.3%, and 85.4% for TAR patients and 96.5%, 90.1%, and 81.2% for non-TAR patients (p < 0.001). Late mortality was 8.0% (n = 500) for TAR patients and 10.0% (n = 622) for non-TAR patients (p < 0.001). Stratified Cox proportional hazards models showed lower risk for all-cause late mortality in the TAR group (TAR:HR 0.80, 95% confidence interval 0.71 to 0.90, p < 0.001). CONCLUSION TAR is associated with low perioperative mortality and, importantly, improved long-term survival and could be used more liberally.

Surgical Management of Invasive Pulmonary Fungal Infection in Hematology Patients

BACKGROUND The purpose of this study was to analyze our institutional results with pulmonary resection in neutropenic patients with hematologic malignancies and suspected invasive pulmonary fungal infections. METHODS We performed a retrospective medical record review of 25 immunocompromised patients with hematologic malignancies who underwent pulmonary resection between 2000 and 2007. We analyzed preoperative diagnostic technique, degree of pulmonary resection, and postoperative morbidity and mortality to determine whether surgery is a viable treatment option in this subset of patients. RESULTS Twenty-three of 25 patients had a minithoracotomy compared with 2 who had video-assisted thorascopic surgery resection only. Thirteen had wedge resections, 9 had lobectomies, and 3 had segmentectomies. Early surgical morbidity was 2 of 25, involving 1 pneumothorax and 1 empyema. In-hospital mortality was 2, with 1 death primarily related to surgery. Median survival was 342 days, and survival was significantly better in patients with only one lesion. No patient experienced late recurrence of invasive pulmonary fungal infection. Resected pulmonary tissue also provided the best chance for a proven diagnosis in 19 of 25 (76%). CONCLUSIONS This study confirms that pulmonary resection in high-risk immunocompromised patients with suspected invasive fungal infection can be carried out with excellent operative morbidity and mortality.

Safe use of recombinant activated factor VIIa for recalcitrant postoperative haemorrhage in cardiac surgery.

The aim of this case series is to review the effect of recombinant activated factor VIIa (rFVIIa) on refractory haemorrhage, despite aggressive treatment with conventional blood products and medications at our institution. All patients undergoing cardiac surgery who received rFVIIa as rescue therapy for persistent uncontrollable haemorrhage were studied. We examined coagulation immediately before and after rFVIIa was given; international normalized ratio (INR), activated partial thromboplastin (APTT) fibrinogen and platelet levels, in addition to the use of red cell and non-red cell blood products, morbidity and mortality. Thirty patients (0.6%) received 31 doses of rFVIIa for bleeding refractory to conventional treatment. Twenty received rFVIIa in theatre after primary surgery, three after re-exploration and eight in the intensive care unit (ICU). Hospital mortality was 6.5% (2/30) and there were no documented thromboembolic phenomena. There was significant reduction in red blood cell and product transfusion before and after rFVIIa administration (P<0.001). There was significant correction in coagulation parameters after rFVIIa. Recombinant FVIIa appears to be safe, and is effective in reducing red blood cell and product transfusion requirements and may impact on early and late outcomes in this small complex subgroup of patients.

Variable definitions: implications for the prediction of pulmonary complications after adult cardiac surgery

Aim: The aim of this paper was to review the implications that variable definitions have for the prediction of post-operative pulmonary complications after cardiac surgery. Method: A review of the literature from 1980 to 2002. Selected studies demonstrated an original attempt to examine multivariate associations between pre, intra or post-operative antecedents and pulmonary outcomes in patients undergoing coronary artery bypass grafting (CABG). Reports that described the validation of established clinical prediction rules, testing interventions or research conducted in non-human cohorts were excluded from this review. Results: Consistently, variable factor and outcome definitions are combined for the development of multivariate prediction models that subsequently have limited clinical value. Despite being prevalent there are very few attempts to examine post-operative pulmonary complications (PPC) as endpoints in isolation. The trajectory of pulmonary dysfunction that precedes complications in the postoperative context is not clear. As such there is little knowledge of post-operative antecedents to PPC that are invariably excluded from model development. Conclusion: Multivariate clinical prediction rules that incorporate antecedent patient and process factors from the continuum of cardiovascular care for specific pulmonary outcomes are recommended. Models such as these would be useful for practice, policy and quality improvement.

The Ross procedure in adults presenting with bicuspid aortic valve and pure aortic regurgitation: 85% freedom from reoperation at 20 years

OBJECTIVES The Ross procedure has demonstrated excellent results when performed in patients with aortic stenosis or mixed aortic valve disease [aortic stenosis and aortic regurgitation (AR)]. However, due to its reported risk of late reoperation, it is not recommended under current guidelines for patients presenting with bicuspid aortic valve and pure AR. We have analysed our own results in light of this recommendation. METHODS Between 1993 and 2016, 129 consecutive patients with a mean age of 34.7 ± 10.6 years (range 16-64 years) presented with bicuspid aortic valve and pure AR and underwent the Ross procedure. Patients were reviewed annually and had 2nd yearly transthoracic echocardiograms during follow-up. The unit had a liberal reoperation policy where reoperation was performed if patients developed recurrent moderate or greater AR during follow-up. RESULTS There was 1 inpatient death, and 3 late deaths over a mean follow-up duration of 9.6 ± 6.8 years. Late survival at 10 and 20 years post-surgery were 99% [95% confidence interval (CI) 94-100] and 95% (95% CI 85-99), respectively. Eleven patients underwent redo aortic valve replacement (AVR) and 4 patients had redo pulmonary valve replacement. Freedom from reoperation for AVR and more-than-mild AR at 10 and 20 years post-surgery were 89% (95% CI 81-94) and 85% (95% CI 74-92), respectively. Having longer aortic cross-clamp (hazard ratio 1.03, 95% CI 1.00-1.06; P = 0.05) and cardiopulmonary bypass times (hazard ratio 1.02, 95% CI 1.00-1.05; P = 0.05), and having a larger preoperative sinotubular junction diameter (hazard ratio 1.15, 95% CI 1.03-1.30; P = 0.02) were significant predictors of having redo AVR or significant AR at follow-up. CONCLUSIONS With a 20-year freedom from redo AVR and greater-than-mild residual AR of 85%, the utilization of the Ross procedure in bicuspid aortic valve patients with pure AR should be considered.

A single centre point prevalence survey to determine prevalence of indwelling urinary catheter use and nurse-sensitive indicators for the prevention of infection

Abstract Background Catheter-associated urinary tract infection (CAUTI) is the most common hospital-acquired infection. Key factors influencing the development of CAUTI are indwelling urinary catheter (IUC) insertion duration and nursing management for the prevention of this complication. There is very little evidence describing practice patterns associated with IUC management. The aim of this study was to determine the prevalence of IUC use within a major metropolitan tertiary-referral teaching hospital and to explore nurse-sensitive indicators for the prevention of CAUTI in this context. Methods We conducted a point prevalence survey of IUC use by reviewing every inpatient bed ( n = 696) across two sites over a 2-day period in January 2013. Site 1 comprised ( n = 520, 74.7%) acute inpatient beds and Site 2 ( n = 176, 25.3%) aged care and rehabilitation beds within a single organisation. Results At the time of the survey 555 (79.7%) beds were occupied. Few patients ( n = 69, 12.4%) had an IUC in situ and a standard Foleys catheter was used for the majority of patients (62, 92.5%). IUC insertion was more prevalent in women over 70 (20, 71.4%) when compared with men (18, 46.2%; χ 2 4.24, P = 0.04). Fourteen nurse-sensitive indicators were assessed and although all indictors were not present for any single patient, drainage system management appeared to be in accordancewith recommended guidelines.Of the patients with an IUC12 (17.4%) had a urine sample sent in the 24 h preceding the survey and 5 (41.6%) of these samples were positive for bacterial colonisation. Conclusion The prevalence of IUC use in this tertiary teaching hospital was less than that in other centres despite a comparatively older inpatient population in the context of acute care needs. Nurses appear to be proficient in the management of IUC and associated drainage equipment and there is room for interdisciplinary improvement in documentation practices. Future research should test interventions to target appropriate insertion, ongoing need and timely removal of IUC.