Syed S. Qadri

An unusual presentation of pedunculated thrombus in the distal arch of the aorta after splenectomy for B-cell lymphoma

A 59-year-old woman who was asymptomatic after a splenectomy for B-cell lymphoma was found to have a pedunculated mass filling 50% of the aortic lumen within the distal aortic arch on a routine follow-up computed tomographic scan of the chest (A/cover image, and B). She was referred to us with a differential diagnosis of tumor originating from the aortic wall. On transesophageal echocardiogram it seemed to be a solid mass rather than a floating thrombus. With suspicion of malignancy, it was decided to remove the mass surgically. Left thoracotomy was performed, and a 4-cm mass originating from the inner aspect of the distal aortic arch just above the remnant of the ductus arteriosus was excised on partial left heart bypass (C). The histology report showed a cylinder of pale hemorrhagic tissue, 4.0 1.0 0.8 cm, consisting of fibrin thrombus with a few atypical lymphoid cells present at one edge. However, this was insufficient for a firm diagnosis of malignancy. After surgery she received anticoagulant medication for 6 months. She remains well, with no evidence of recurrent thrombus after 3 years of follow-up. Nonaneurysmal aortic arch lesions are a frequent and a stillunderestimated source of stroke and peripheral embolization (in 10% of patients, the source of peripheral embolism cannot be identified). A floating thrombus in an apparently normal aortic arch is considered a life-threatening condition. Although rare, this diagnosis must not be overlooked in the search for etiology of recurrent and disseminated peripheral ischemic events, because of the significant morbidity and mortality related to a delayed diagnosis. Coagulopathies, atherosclerosis, trauma, malignancy, pregnancy, and previous aortic surgery are a few common causes of thrombus formation in this rare condition. There are various treatment options available, such as anticoagulation, balloon thrombectomy, stenting, and surgery. All these therapeutic modalities have their limitations; nonsurgical treatment involves high risk of embolism (reported as a 73% incidence of embolic events for highly mobile aortic thrombi as compared with 12% for immobile ones), ischemia, and stroke, whereas surgery has been reported with high mortality and morbidity. Complicated vascular surgical procedures have been performed for definitive treatment. Primary tumors of the aorta are rare, and only a few cases are reported in the literature; as a result of our suspicion of tumor, we aimed to remove the lesion in a controlled manner under bypass, because no standard approach

The differential effects of systemic vasoconstrictors on human pulmonary artery tension

OBJECTIVES Acute pulmonary hypertension following cardiac surgery can have a significant effect on postoperative morbidity and mortality. However, limited data are available on the efficacy and potency of clinically used systemic vasopressors on the pulmonary vasculature. The aim of this study was to use human pulmonary artery to characterize the pharmacological effects of clinically used vasopressors on the human pulmonary vasculature. METHODS Fifty-seven pulmonary artery rings of internal diameter 2-4 mm and 2 mm long, mounted in a multiwire myograph system, were used to measure changes in isometric tension. We constructed concentration response curves by cumulative addition to the myograph chambers of KCl, noradrenaline (NA), adrenaline (AD), vasopressin, endothelin-1 (ET-1) and prostaglandin F2a (PGF2a). RESULTS AD, NA, ET-1, PGF2a and KCl caused dose-dependent vasoconstriction in the pulmonary artery samples (EC50 246 nM [95% confidence interval, CI, 153-394 nM], 150 nM [95% CI 51-447 nM], 1.46 nM [95% CI 0.69-3.1 nM], 6.35 µM [95% CI 3.58-11.2 µM] and 17.24 mM [95% CI 12.43-24.07 mM], respectively), whereas vasopressin had no significant effect. The order of efficacy was KCl = PGF2a > AD > NA > ET-1 and the order of potency was ET-1 T-AD = NA > PGF2a > KCl. CONCLUSIONS This study demonstrated the efficacy and potency of clinically used vasopressors and endogenous vasopressors on human pulmonary vascular tone. PGF2a and KCl equally caused maximal amounts of constriction, whereas ET-1 had less effect and vasopressin had no effect. These effects may need to be taken into account in the clinical setting because they might result in the development of pulmonary hypertension.

Short- and long-term outcomes of pneumonectomy in a tertiary center.

Background Surgery is the most important therapeutic modality for lung cancer. Surgical outcomes are normally reported as 30-day or 90-day mortality or 5-year survival; 10-year survival is rarely mentioned in national data or international studies. Methods Three hundred and six patients (79% male) underwent pneumonectomy, mainly for lung cancer, from January 1998 to February 2013. Their short- and long-term outcomes up to September 2014 were analyzed retrospectively. The mean age was 64 years (range 22–82 years) and 24% were aged ≥70 years. Thoracoscore was used to calculate the risk of hospital mortality. Results Operative mortality was 4.5% whereas predicted mortality was 8%. The operative mortality for cancer patients was 3.3%; the national mortality for lung cancer is 6.5%. Only 2 patients died in hospital after a pneumonectomy in the last 5 years. Half of the patients who died in hospital were ≥70 years old; 29% (4 patients) died after urgent operations for nonmalignant disease. Overall 5- and 10-year survival was 32% and 20%. Median and mean survival was 26 and 57 months, respectively. Long-term survival was better in females aged <70 years, in left pneumonectomy patients, and in those with squamous cell lung cancer. Conclusion Our mortality for pneumonectomy was 50% less than the national mortality rate and significantly lower than that predicted by the Thoracoscore for lung cancer. This confirms that pneumonectomy is still an effective modality for the treatment of lung cancer, with low operative mortality and good long-term survival, especially in younger patients.

Characterization of optimal resting tension in human pulmonary arteries

AIM To determine the optimum resting tension (ORT) for in vitro human pulmonary artery (PA) ring preparations. METHODS Pulmonary arteries were dissected from disease free sections of the resected lung in the operating theatre and tissue samples were directly sent to the laboratory in Krebs-Henseleit solution (Krebs). The pulmonary arteries were then cut into 2 mm long rings. PA rings were mounted in 25 mL organ baths or 8 mL myograph chambers containing Krebs compound (37 °C, bubbled with 21% O2: 5% CO2) to measure changes in isometric tension. The resting tension was set at 1-gram force (gf) with vessels being left static to equilibrate for duration of one hour. Baseline contractile reactions to 40 mmol/L KCl were obtained from a resting tension of 1 gf. Contractile reactions to 40 mmol/L KCl were then obtained from stepwise increases in resting tension (1.2, 1.4, 1.6, 1.8 and 2.0 gf). RESULTS Twenty PA rings of internal diameter between 2-4 mm were prepared from 4 patients. In human PA rings incrementing the tension during rest stance by 0.6 gf, up to 1.6 gf significantly augmented the 40 mmol/L KCl stimulated tension. Further enhancement of active tension by 0.4 gf, up to 2.0 gf mitigate the 40 mmol/L KCl stimulated reaction. Both Myograph and the organ bath demonstrated identical conclusions, supporting that the radial optimal resting tension for human PA ring was 1.61 g. CONCLUSION The radial optimal resting tension in our experiment is 1.61 gf (15.78 mN) for human PA rings.

Colorectal Cancer Presenting as Single Pulmonary Hilar Lymph Node Metastasis

Colorectal carcinoma is the second biggest cancer responsible for mortality. Lung metastasis is the commonest, following the liver. It is not uncommon to perform pulmonary metastasectomy and identify mediastinal metastasis. Previous studies have identified incidental lymph node involvement following routine mediastinal lymph node clearance in 20–50% of cases. However, solitary intrathoracic lymph node metastasis is exceedingly rare. Even when present, it is usually metachronous. In our case, we present an exceedingly rare case whereby the intrathoracic lymph node metastasis is solitary, not accompanying pulmonary disease and with no liver metastasis. We also review the evidence for mediastinal lymphadenectomy in the literature.

P246 The in vitro effect of commonly used vasodilators on human pulmonary artery

Introduction Acute pulmonary hypertension following cardiac surgery can have a significant effect on post-operative morbidity and mortality. The phosphodiesterase inhibitor sildenafil and the nitric oxide donor Sodium-Nitroprusside (SNP) are commonly used to treat pulmonary hypertension. The aim of this study was to characterise the pharmacological effects of clinically used vasodilators on the human pulmonary vasculature in comparison to the endogenous pulmonary vasodilators Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP). Methods Research ethics committee approval was obtained for the use of human tissue for this study. Patients undergoing lung resection were consented for their resected lung tissue to be included in the study. Patients under the age of 18 and who cannot give informed consent were excluded from the study and twelve patients were enrolled in this study. Pulmonary arteries were dissected from disease free areas of lung resection and 35 PA rings of internal diameter 2–4 mm and 2 mm long were prepared. PA rings were mounted in a multiwire myograph system containing Krebs-Henseleit solution (aerated with 21% O2: 5% CO2 at 37oC) for measuring changes in isometric tension. A basal tension of 1.61 g was applied and the rings left to equilibrate for 60 min. After equilibration rings were pre-constricted to 11.21 µM PGF2α (EC80) then concentration response curves were constructed to Sildenafil, SNP, ANP and BNP by cumulative addition to the myograph chambers. The Integrity of the endothelium was confirmed with 1 μM Acetylcholine and smooth muscle viability was confirmed by exposure to potassium chloride. Results ANP was the most potent and effective vasodilator whereas BNP had little effect. SNP was marginally less potent and effective than ANP and the maximum effect of sildenafil was about 50% that of ANP. The EC50 for ANP, BNP, Sildenafil and SNP were 1.105 nM, 28.78 nM, 1.06 uM and 22.6 nM respectively. Conclusion This study demonstrated the differential effect of commonly used agonists on pulmonary vascular reactivity and this is the first comparison of these agents in human pulmonary arterial tissue. These effects may need to be considered in the clinical setting. Abstract P246 Figure 1 Combined concentration response curse to ANP (n = 8), BNP (n = 7), Sildenafil (n = 12) and SNP (n = 8), n = number of PA rings used. The EC50 of ANP, BNP, Sildenafil and SNP were 1.1 nM, 28.78 nM and 22.6 nM respectively

Extrapleural Pneumonectomy A Blessing or a Curse in the Management of Pleural Malignant Mesothelioma

Background: Malignant pleural mesothelioma is a rare but complicated disease associated with very poor prognosis, despite all forms of treatment and almost 100% mortality after diagnosis. Objectives: The use of extrapleural pneumonectomy (EPP) in the management of malignant mesothelioma has become controversial recently and appears to be a dying modality. This retrospective study aimed to review and compare our results with available literature. Methods: Consecutive patients were reviewed from March 1999 to April 2011 who underwent EPP for malignant mesothelioma. Shortand long-term outcomes were analyzed retrospectively until February 2013. Results: There were 30 consecutive patients who underwent EPP in 13 years. The majority of them were male (29 patients) with a mean age of 61 years (34-71 years). There was no in-hospital or 30-day mortality in this cohort, although Thoracoscore predicted 7.9% risk of in-hospital mortality. The overall median survival was 20 + 24 months, which prolonged to 47.5 + 24 months in patients who received trimodality treatment. Thirty-one percent of patients survived ≥ 4 years and 2 patients are still alive at 6 and 7 years postoperatively. Survival was significantly longer in epitheloid versus biphasic mesothelioma, right versus left pneumonectomy, age below 65 years, and with no N2 disease. Survival at 6, 12, and 18 months was 80%, 65%, and 55% in comparison with 65%, 52%, and 34%, respectively, in the Mesothelioma and Radical Surgery trial. Conclusions: Epitheloid mesothelioma, right pneumonectomy, negative extrapleural lymph nodes, and age below 65 years are associated with prolonged survival. Extrapleural pneumonectomy has a role in the management of malignant mesothelioma in selected patients by experienced surgeons.

WITHDRAWN: Is there life after the Mesothelioma and Radical Surgery trial? Does extrapleural pneumonectomy still have a role in the management of pleural mesothelioma? A 13-year, single-center experience

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Giant aneurysm of saphenous vein graft to right coronary artery

FIGURE 2. Another view of the computed tomographic scan showing the A 64-year-old white man presented with hemoptysis. He underwent coronary artery bypass grafting (CABG) in 1982, followed by a redo-CABG in 1992, which involved a venous graft to his right coronary artery. A chest radiograph revealed a large shadow on the right border of the heart. This was thought to be a lung tumor, because he is a smoker. Chest computed tomography (CT) revealed that it was a large aneurysm of the saphenous vein graft to the right coronary artery (Figures 1 and 2). The graft was patent, with a large lumen and a large clot in the aneurysmal portion, compressing the right atrium but not causing symptoms, possibly because of its insidious and slow progress. The hemoptysis was the result of an infective process in the left upper lobe of the lung, which resolved with antibiotics. True aneurysms of aortocoronary saphenous vein grafts are a relatively rare complication of bypass surgery. Complications of thrombosis, embolization, or rupture are potentially fatal and, therefore, require immediate surgical intervention. However, our patient had multiple comor-