Theo J. Klinkenberg

Bone marrow dysfunction in chronic heart failure patients

To investigate whether chronic heart failure (CHF) is associated with a general dysfunction of the haematopoietic compartment.

Pulmonary oligometastases: Metastasectomy or stereotactic ablative radiotherapy?

BACKGROUND AND PURPOSE Stereotactic ablative radiotherapy (SABR; or stereotactic body radiotherapy, SBRT) emerges as treatment option for pulmonary oligometastatic disease (OMD), but there are no studies comparing SABR with pulmonary metastasectomy (PME). We analysed consecutive patients referred via a university-hospital based multidisciplinary team. MATERIAL AND METHODS Patients were offered PME as first choice and SABR in case they were considered to be less suitable surgical candidates. Overall survival was the primary endpoint. Secondary endpoints were progression-free-survival, local control of treated metastases, and freedom-from-failure of a local-only treatment strategy without systemic therapy. RESULTS From 2007 until 2010, 110 patients were treated and analysed (PME, n=68; SABR, n=42). Median follow-up time was 43 months (minimally, 25). Estimated overall survival rates at one, three, and five years were 87%, 62%, and 41% for PME, and 98%, 60%, and 49% for SABR, respectively (logrank-test, p=0.43). Local control at two years was 94% for SABR and 90% for PME. Progression-free survival was 17% at three years, but 43% of the patients still had not failed a local-only treatment strategy. CONCLUSIONS Although SABR was second choice after PME, survival after PME was not better than after SABR. Prospective comparative studies are clearly required to define the role of both, SABR and PME in OMD.

Feasibility and outcome of epicardial pulmonary vein isolation for lone atrial fibrillation using minimal invasive surgery and high intensity focused ultrasound

AIMS Transvenous pulmonary vein isolation (PVI) is the cornerstone of non-pharmacological rhythm control therapy in symptomatic atrial fibrillation (AF). Success and complications rates are, however, still not optimal. New techniques and energy sources are therefore being developed. METHODS AND RESULTS Fifteen patients with lone AF refractory for antiarrhythmic drugs (AADs) underwent PVI by minimal invasive epicardial off-pump monolateral right-sided video-assisted thoracic surgery (VATS) using the UltraCinch with high-intensity focused ultrasound (HIFU). Primary endpoint was successful ablation defined as absence of AF or atrial flutter/tachycardia after 6 months assessed by complaints, 12 lead electrocardiogram, and 96 h Holter monitoring. Secondary endpoints were ablation success at the end of follow-up irrespective of AADs use or re-ablation and complications related to the procedure. Mean age was 47 +/- 10 years and 14 (93%) were male. Eleven (73%) had paroxysmal, and 4 (27%) patients had persistent AF. Median AF history was 5 (1-12) years. At 6 months, six (40%) patients had sinus rhythm after one epicardial PVI (four on AADs). After 1.3 +/- 0.6 years, four (27%) patients had sinus rhythm after one epicardial PVI (two on AADs) and in six (40%) patients endocardial radiofrequency re-ablation was performed, which was successful in three patients (20%). Two patients (13%) were planned for re-ablation. Three others (20%) refused re-ablation. Two major complications occurred (one late tamponade and one bleeding during surgery, necessitating sternotomy). CONCLUSION Epicardial PVI using monolateral right-sided VATS with the UltraCinch delivering HIFU is feasible, but is associated with substantial complications. Furthermore, the success rate was low. More research is therefore warranted to assess optimal ablation techniques and energy sources to perform PVI.

Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature

Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.

Drug concentration in lung tissue in multidrug-resistant tuberculosis

To the Editor: Multidrug-resistant tuberculosis (MDR-TB) is emerging worldwide, with 3.7% of new cases and 20% of previously treated tuberculosis (TB) cases having MDR-TB. Unfortunately, second-line TB drugs, used for MDR-TB treatment, are less effective than first-line drugs [1]. Sputum culture rather than sputum smear microscopy is recommended to monitor treatment response [1]. Therapeutic drug monitoring (TDM), which may help optimise efficacy and minimise side-effects with the potential to safeguard intestinal absorption of drugs [2], is currently not recommended in World Health Organization (WHO) treatment guidelines [1]. Although TDM yields information on serum drug concentrations, penetration of second-line TB drugs into diseased tissues such as destroyed lung tissue has, to our knowledge, not been addressed in studies [3]. Herein, we report simultaneous blood and tissue concentrations of second-line TB drugs in lung tissue destroyed by MDR-TB. A 13-year-old Somalian, HIV sero-negative female, residing in the Netherlands since 2010, was admitted to our TB Unit (TB Center Beatrixoord, University Medical Center Groningen, Groningen, the Netherlands) in September 2011 with a 3-month history of cough, fever, chest pain and unintentional 14 kg weight loss. TB contacts were denied and she had not received a bacilli Calmette–Guerin vaccination. Apart from almost absent breathe sounds and dullness to percussion over the left lung field her physical examination was normal. Chest radiography showed infiltrates in the left lung, particularly in the left upper lobe. Sputum microscopy revealed acid-fast bacilli, and she was started on TB treatment with isoniazid, rifampicin, pyrazinamide and ethambutol. 2 weeks later, molecular diagnostic tests revealed mutations in both the katG and rpoB genes. MDR-TB was now considered and she was transferred to our hospital (University …

Single-port one-stage bilateral thoracoscopic sympathicotomy for severe hyperhidrosis: prospective analysis of a standardized approach

BackgroundPrimary palmar and/or axillary focal hyperhidrosis is a frequent disorder characterized by excessive sweating beyond physiological needs, often leading to a substantial impairment of quality of life. Over the years several minimally invasive surgical treatments have been described, however results vary, and due to a lack of uniform surgical approach, technique and nomenclature are often difficult to compare. In this prospective study we sought to evaluate the safety and effectiveness of our standardized technique of single-port, one-stage bilateral thoracoscopic sympathicotomy.MethodsOn a prospective basis a hundred consecutive patients with severe or intolerable primary hyperhidrosis underwent one-stage bilateral single-port thoracoscopic sympathicotomy. Primary outcome was measured in pre- vs. post-operative Hyperhidrosis Disease Severity Scale scores. Location and extend of compensatory hyperhidrosis, and satisfaction with the procedure were registered.ResultsA significant reduction in mean Hyperhidrosis Disease Severity Scale score (3.69 ± 0.47 preoperatively vs. 1.06 ± 0.34 postoperatively) (p < 0.001) was observed. In 97 (97%) out of the 100 enrolled patients a >80% reduction in sweat production was achieved. Compensatory hyperhidrosis was seen in 27 patients (27%). It was rated as mild by 21 patients (78%) and as moderate by 6 (22%) of these patients. No severe compensatory hyperhidrosis was reported. Major complications, such as intraoperative bleeding, infections, and Horner’s syndrome were not observed.ConclusionsHighly selective sympathicotomy at well-defined levels with a one-stage bilateral single-port transaxillary thoracoscopic approach is a save procedure, with excellent and reproducible immediate results in the treatment of primary palmar and/or axillary hyperhidrosis.

Mitral valve repair for post-myocardial infarction papillary muscle rupture.

OBJECTIVES Papillary muscle rupture (PMR) is a rare, but serious mechanical complication of myocardial infarction (MI). Although mitral valve replacement is usually the preferred treatment for this condition, mitral valve repair may offer an improved outcome. In this study, we sought to determine the outcome of mitral valve repair for post-MI PMR and to provide a systematic review of the literature on this topic. METHODS Between January 1990 and December 2010, 9 consecutive patients (mean age 63.5 ± 14.2 years) underwent mitral valve repair for partial post-MI PMR. Clinical data, echocardiographic data, catheterization data and surgical reports were reviewed. Follow-up was obtained in December of 2012 and it was complete; the mean follow-up was 8.7 ± 6.1 (range 0.2-18.8 years). RESULTS Intraoperative and in-hospital mortality were 0%. Intraoperative repair failure rate was 11.1% (n = 1). Freedom from Grade 3+ or 4+ mitral regurgitation and from reoperation at 1, 5, 10 and 15 years was 87.5 ± 11.7%. Estimated 1-, 5-, 10- and 15-year survival rates were 100, 83.3 ± 15.2, 66.7 ± 19.2 and 44.4 ± 22.2%, respectively. There were 3 late deaths, and 2 were cardiac-related. All late survivors were in New York Heart Association Class I or II. No predictors of long-term survival could be identified. CONCLUSIONS Mitral valve repair for partial or incomplete post-MI PMR is reliable and provides good short- and long-term results, provided established repair techniques are used and adjacent tissue is not friable. PMR type and adjacent tissue quality ultimately determine the feasibility and durability of repair.

CT-guided percutaneous hookwire localization increases the efficacy and safety of VATS for pulmonary nodules

The diagnosis of pulmonary nodules of unknown origin is challenging, and such nodules are not always suitable for transthoracic needle biopsy. With the advent of video assisted thoracic surgery (VATS) and CT‐guided percutaneous hookwire localization (CT‐PHL) we hypothesized that the combination of these two procedures will improve early diagnosis.

Long-term Outcome of Surgery or Stereotactic Radiotherapy for Lung Oligometastases

ABSTRACT Local treatment for pulmonary oligometastases (one to five lesions) using metastasectomy or stereotactic ablative radiotherapy (SABR) was investigated in a cohort that received multidisciplinary tumor board–based treatment decisions. The first choice of treatment was surgery; SABR was recommended in cases of adverse clinical factors. Propensity score–adjusted and unadjusted overall survival was the primary end point; local control and time to failure of a local‐only treatment strategy were also analyzed. With a minimum follow‐up time of 5.8 years, the 5‐year overall survival rate was 41% for surgery (n = 68) and 45% for SABR (n = 42). Again not different for the two modalities, 40% of patients were free from failure of a local‐only treatment strategy, and 20% were free from any progression at 5 years. The 5‐year local control rate was 83% for SABR and 81% for surgery. Despite treatment selection clearly disadvantaging SABR against surgery, even unadjusted outcome was not better when pulmonary oligometastases were surgically removed rather than irradiated.

A staged approach for a lung-liver transplant patient using ex vivo reconditioned lungs first followed by an urgent liver transplantation

Combined lung–liver transplantation is a logistically challenging procedure hampered by shortage of organ donors. We describe the case of a young patient with end‐stage lung disease due to of cystic fibrosis and liver cirrhosis who needed combined lung–liver transplantation. The long waiting for this caused an interesting clinical dilemma. We decided to change our policy in this situation by listing him only for the lung transplantation and to apply for a high urgent liver transplantation if the liver failed after the lung transplantation. This strategy enabled us to use lungs treated with ex vivo lung perfusion (EVLP) from an unsuitable donor after circulatory death. After conditioning for 4 h via EVLP, the pO2 was 59.7 kPa. The lungs were transplanted successfully. He developed an acute‐on‐chronic liver failure for which he received a successful liver transplantation 19 days after the lung transplantation.