Theresa M. Boley

Safety and efficacy of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax

Video-assisted thoracic surgery has been widely used in the treatment of spontaneous pneumothorax despite a paucity of data regarding the relative safety and long-term efficacy for this procedure. We reviewed 113 consecutive patients (68 male and 45 female patients, aged 15 to 92 years, mean 35.1) who underwent 121 video-assisted thoracic surgical procedures during 119 hospitalizations from 1991 through 1993. Recurrent ipsilateral pneumothorax was the most frequent indication for surgery and occurred in 77 patients (65%). The most common method of management was stapling of an identified bleb in the lung, which was undertaken in 105 (87%) patients. No operative deaths occurred. Complications included an air leak lasting longer than 5 days in 10 (8%) patients, two of whom required second procedures for definitive management. No episodes of postoperative bleeding or empyema occurred. The postoperative stay ranged from 1 day to 39 days (median 3 days, average 4.3 days) and 99 patients (84%) were discharged within 5 days. Mean follow-up was 13.1 months and ranged from 1 to 34 months. Eleven patients (10%) were lost to follow-up. Ipsilateral pneumothorax recurred after five of 121 procedures (4.1%). Twelve perioperative parameters (age, gender, race, smoking history, site of pneumothorax, severity of pneumothorax, operative indications, number of blebs, site of blebs, bleb ablation, method of pleurodesis, and prolonged postoperative air leak) were entered into univariate and multivariate analysis to identify significant independent predictors of recurrence. The only independent predictor of recurrence was the failure to identify and ablate a bleb at operation, which resulted in a 23% recurrence rate versus a 1.8% rate in those with ablated blebs (p < 0.001). These data suggest that video-assisted thoracic surgery is a viable alternative to thoracotomy for the treatment of recurrent spontaneous pneumothorax. It results in a short hospital stay, low morbidity, high patient acceptance, and a low rate of recurrence.

Effect of Bovine Pericardial Strips on Air Leak After Stapled Pulmonary Resection

BACKGROUND Surgical procedures for emphysema have been proposed and in many settings resulted in significant improvement in dyspnea and function. The most prevalent surgical problem in all series is prolonged postoperative air leak. METHODS One hundred twenty-three patients undergoing stapled thoracoscopic unilateral lung volume reduction operation were prospectively randomized to receive either no buttressing of their staple lines or buttressing of all staple lines with bovine pericardial strips. RESULTS The two groups were comparable in preoperative risks and in the severity of their emphysema. Postoperative complications were identical in the two groups with respect to pneumonia, empyema, and wound infection; however, there was a significant difference in the duration of postoperative air leaks. Those having the pericardial strips used to buttress their staple lines had chest tubes removed 2.5 days sooner and were discharged from the hospital 2.8 days sooner as a result. The cost data revealed that because of the cost of the pericardial sleeves, the overall hospital charges were almost identical for the two groups (

Heparin-induced thrombocytopenia in open heart surgical patients: Sequelae of late recognition

22,108 bovine,

Tricuspid valve surgery: The past 10 years from the Nationwide Inpatient Sample (NIS) database

22,060 no bovine) in spite of the shortened hospital stay. CONCLUSIONS The use of bovine pericardial sleeves to buttress the staple lines in thoracoscopic unilateral lung volume reduction operation results in a shorter duration of postoperative air leaks. Total hospital charges were comparable in the two groups as the 2.8 days saved in the hospital were offset by the cost of the pericardial sleeves.

Thoracoscopic resection of ectopic parathyroid glands.

Most patients undergoing open heart operations have had exposure to heparin for diagnostic and/or therapeutic procedures. Heparin antibody formation and heparin-induced thrombocytopenia with repeat heparin administration can cause high morbidity and mortality from thrombotic complications, especially when delay in diagnosis occurs. From 1981 to 1991, heparin-induced thrombocytopenia was diagnosed in 82 of 4,261 open heart surgical patients (1.9%). Platelet counts less than 100 x 10(9)/L (100,000/microL) or new or recurring thrombotic events prompted suspicion of heparin-induced thrombocytopenia. Heparin-dependent antibody was diagnosed preoperatively in 12 patients (group I) and postoperatively in 70 patients (group II). Heparin was not given postoperatively in group I patients, and complications in this group were limited to bleeding in 3 patients. There were no thromboembolic events and all patients survived. Group II patients had late recognition of heparin-dependent antibody postoperatively, and heparin exposure was continued for varying periods postoperatively. Thirty-seven group II patients (53%) had bleeding complications and 31 (44%) had thromboembolic complications. These complications led to death in 23 group II patients (33%). Heparin-dependent antibody may occur in patients having open heart operations and is a major cause of morbidity and mortality if not diagnosed early with cessation of heparin therapy.

Elevated hemidiaphragm after cardiac operations: Incidence, prognosis, and relationship to the use of topical ice slush

OBJECTIVES The purpose of this study was to examine the trends in tricuspid valve surgery over time. METHODS We used 10 years (1999-2008) of NIS data to examine the population of patients undergoing tricuspid valve repair or replacement (ICD-9-CM codes 35.14, 35.27, and 35.28). RESULTS We identified 28,726 admissions for tricuspid valve surgery. The total number of tricuspid procedures more than doubled over the 10- year period (1712 cases in 1999 vs 4072 cases in 2008). Although the absolute number of repairs and replacements increased over time, the tricuspid repair rate increased whereas there was a corresponding decrease in tricuspid replacement rate. Isolated tricuspid valve surgery accounted for 20% of the total tricuspid cases, whereas tricuspid surgery as a concomitant procedure to other cardiac operations accounted for the remaining 80%. There was a trend toward increased use of tissue over mechanical valves for tricuspid replacement. Overall hospital mortality was 10.6%. Over time, mortality decreased significantly for both repair and replacement. Concomitant tricuspid replacement was associated with significantly higher hospital mortality than was isolated tricuspid replacement (16.1% vs 10.1%; P = .0001). CONCLUSIONS There has been a dramatic increase in tricuspid interventions over time. This has been associated with an increase in tricuspid repair rates as well as use of bioprostheses for tricuspid replacement. The majority of tricuspid operations are performed concomitantly to other cardiac procedures. Mortality for tricuspid valve surgery remains considerable and significantly higher for replacement than for repair.

Coronary revascularization in the elderly: Determinants of operative mortality

BACKGROUND The vast majority of parathyroid glands in hyperparathyroidism can be resected through a cervical approach. In approximately 2% of the cases, the ectopic gland is in the mediastinum in a location that requires a thoracic approach. METHODS We report 7 such cases that were resected using video-assisted thoracic surgery to avoid the need for an open surgical procedure. RESULTS All glands were successfully identified preoperatively and subsequently resected. Hospital stay averaged less than 3 days with only one minor complication. CONCLUSIONS Ectopic mediastinal parathyroid glands may be safely and accurately resected using video-assisted thoracic surgery to avoid open approaches.

Long Term Survival of Patients Undergoing Mitral Valve Repair and Replacement: A Longitudinal Analysis of Medicare Fee-for-Service Beneficiaries

We have reviewed chest roentgenograms of 745 patients before hospital dismissal after cardiac operations and serially to determine the incidence and prognosis of elevated hemidiaphragm and any relationship to the use of topical ice slush (TIS) in myocardial preservation. All patients had similar myocardial preservation techniques including moderate systemic hypothermia and 4 degrees C saline solution poured over the heart at aortic clamping. During a 12-month period, TIS was added to the saline bath. Two (2.4%) of 84 patients before TIS and 5 (2.5%) of 201 consecutive patients operated on since discontinuing TIS had elevated hemidiaphragm on the predismissal roentgenogram. Of 460 patients in whom TIS was employed, 109 (23.7%) had elevated hemidiaphragm (p less than 0.001). When TIS was employed, elevated hemidiaphragm developed in 72 (26%) of 280 patients without internal mammary artery takedown versus 13 of 33 patients (39.4%) with takedown of the internal mammary artery (p = 0.047). Ninety-nine patients with elevated hemidiaphragm were available for follow-up at 1 month, at which time 79 (79.8%) continued to have elevated diaphragm. At 1 year, 14 (21.9%) of 64 patients had persistent diaphragm elevation. We conclude that TIS predisposes to elevated diaphragm and that the incidence is increased when the internal mammary artery is harvested.

Clinical spectrum of paraesophageal herniation

Over a 13-year period, 668 patients 70 years of age or older underwent isolated primary coronary artery bypass grafting at our institution. There were 472 men and 196 women, ranging from 70 to 90 years of age (median age, 74 years). Hospital mortality was 5.2% (35/668). In patients 70 to 79 years of age, hospital mortality was 4.2% (25/600), whereas in patients 80 years of age or older, mortality was 14.7% (10/68; p < 0.001). Twenty-seven clinical or hemodynamic variables hypothesized as predictors of operative mortality were examined. Mortality was higher in women than in men (9% versus 3.6%; p = 0.006). Those who died were a mean of 3 years older (77 versus 74 years old; p < 0.05) and were more likely to have unstable angina or Canadian class III or IV angina (p < 0.01). Patients requiring urgent operations, preoperative intraaortic balloon assist, intravenous nitroglycerin, or inotropic agents, and those with preoperative hypotension or cardiac arrest were most likely to die in the hospital (p < 0.001). Multivariate logistic regression analysis revealed advancing age, female sex, bypass time, urgency of operation, preoperative cardiac arrest, and unstable angina as primary determinants of mortality (p < 0.05). Although mortality after coronary artery bypass grafting increases with age, the greatest risk of death is in the acutely ill patient with few options for management other than surgical intervention.

Thoracoscopic Operations on Reoperated Chests

Background— Despite the established superiority of mitral repair over replacement, its adoption in the treatment of elderly patients has not been uniform, partly because of a lack of robust long-term survival data. We present the long-term survival of Medicare fee-for-service beneficiaries undergoing mitral valve repair and replacement over a 10-year period. Methods and Results— We used the Medicare database to identify 47 279 fee-for-service beneficiaries ≥65 years of age undergoing primary isolated mitral valve repair or replacement from 2000 to 2009. Operative mortality and long-term survival are presented for repair and replacement. Operative mortality was 3.9% for patients undergoing repair and 8.9% for patients undergoing replacement. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing repair were 90.9%, 77.1%, and 53.6%. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing replacement were 82.6%, 64.7%, and 37.2%. Important predictors of mitral repair included younger age (odds ratio, 1.10; 95% confidence interval, 1.05–1.14), elective admission status (odds ratio, 1.34; 95% confidence interval, 1.27–1.41), and annual mitral procedure volume >40 cases per year (odds ratio, 1.57; 95% confidence interval, 1.36–1.81). Female sex and the presence of comorbidities were associated with a lower likelihood of repair. Conclusions— Mitral valve surgery in the Medicare population carries less risk than previously reported. Given the favorable outcomes of elderly patients undergoing mitral valve surgery, especially mitral valve repair, an approach of earlier identification and surgical referral appears justified regardless of age.Background— Despite the established superiority of mitral repair over replacement, its adoption in the treatment of elderly patients has not been uniform, partly because of a lack of robust long-term survival data. We present the long-term survival of Medicare fee-for-service beneficiaries undergoing mitral valve repair and replacement over a 10-year period. Methods and Results— We used the Medicare database to identify 47 279 fee-for-service beneficiaries ≥65 years of age undergoing primary isolated mitral valve repair or replacement from 2000 to 2009. Operative mortality and long-term survival are presented for repair and replacement. Operative mortality was 3.9% for patients undergoing repair and 8.9% for patients undergoing replacement. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing repair were 90.9%, 77.1%, and 53.6%. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing replacement were 82.6%, 64.7%, and 37.2%. Important predictors of mitral repair included younger age (odds ratio, 1.10; 95% confidence interval, 1.05–1.14), elective admission status (odds ratio, 1.34; 95% confidence interval, 1.27–1.41), and annual mitral procedure volume >40 cases per year (odds ratio, 1.57; 95% confidence interval, 1.36–1.81). Female sex and the presence of comorbidities were associated with a lower likelihood of repair. Conclusions— Mitral valve surgery in the Medicare population carries less risk than previously reported. Given the favorable outcomes of elderly patients undergoing mitral valve surgery, especially mitral valve repair, an approach of earlier identification and surgical referral appears justified regardless of age. # Clinical Perspective {#article-title-17}