William C. Feng

Preoperative chemotherapy and radiation therapy for stage IIIa carcinoma of the lung

Thirty-six patients with stage IIIa histologically proven non-small cell carcinoma (T3 N2 or T2 N2) underwent concomitant radiation therapy and chemotherapy before pulmonary resection. The therapy consisted of two cycles of continuous infusion of cis-platinum, 25 mg.m-2.day-1 (days 1 through 4) every 4 weeks and concomitant irradiation, 55 Gy, of the tumor and mediastinum. Two to 3 weeks after treatment, the patients were reevaluated for thoracotomy and pulmonary resection. Five patients were found to have unresectable lesions. Thirty-one patients had complete resection, 27 by radical pneumonectomy and 4 by radical lobectomy, giving a resectability rate of 86%. Complete sterilization of lung tumor and mediastinal nodes proven histologically was achieved in 10 patients (28%) and 17 patients (47%). The 3-year survival rate is 61.7% for patients who had resection. Median follow-up is 27 months (range, 6 to 61 months). The preliminary study indicates that preoperative cis-platinum and concomitant radiation therapy is tolerated, appears to increase resectability, and may improve survival in patients with stage IIIa lung cancer.

Nineteen-Millimeter Aortic St. Jude Medical Heart Valve Prosthesis: Up to Sixteen Years’ Follow-up

UNLABELLED BACKGROUND; Prosthetic valve replacement in a small aortic root without annulus enlargement raises concern about its long-term benefits. METHODS Between July 1979 and June 1994, 104 (18%) of 593 patients underwent aortic valve replacement using the 19-mm St. Jude Medical heart valve prosthesis. There were 93 women and 11 men, with a mean age of 66.2 +/- 10.6 years. Forty-four patients (42%) were 70 or more years old. The mean body surface area was 1.61 +/- 0.16 m2 (range, 1.2 to 2.1 m2). Forty-nine patients (47%) underwent concomitant procedures; 23 patients (22%) required coronary artery bypass grafts and 25 patients (24%), mitral valve replacement. Ninety-eight patients (94%) presented in New York Heart Association class III and IV. RESULTS The operative mortality was 7.6% (8 patients). Follow-up was 100% with a mean of 5.48 +/- 3.73 years (range, 1 to 16 years) and a total of 708 patient-years. There were 18 late deaths, with a mortality of 2.5% patient-years. The incidence of thromboembolism was 0.4% patient-years (3 patients) and anticoagulant-related morbidity was 0.85% patient-years (6 patients). Long-term survival in the two groups with a body surface area of less than 1.7 m2 and 1.7 m2 or more was not statistically different (p = 0.30). The univariate analysis with body surface area as a predictor of mortality showed that a larger body surface area had no effect on the long-term mortality (chi2 p value = 0.36). Survival for 5 and 10 years with the 95% confidence interval was 80.6% +/- 8.3% and 61.6% +/- 15%. Freedom from thromboembolism was 96.3% +/- 4.2% and anticoagulant-related hemorrhage was 91.8% +/- 6.8% at the end of 16 years. Cox proportional hazards model, with time-dependent covariates, showed that events of thromboembolism, anticoagulant-related hemorrhage, and myocardial infarction during follow-up increased the risk of late death (risk ratio, 9.5, 10.3, and 32.8, respectively). The age at operation was an independent risk factor, with decreased survival with age 70 or more years (p = 0.0002). However, body surface area (p = 0.97) and concomitant cardiac procedures (p = 0.86) were not statistically significant predictors of death. CONCLUSIONS The long-term performance of the 19-mm St. Jude Medical heart valve prosthesis in the small aortic root is satisfactory irrespective of the body surface area, and it is a viable alternative for such patients.

St. Jude medical cardiac valves in small aortic roots: Follow-up to sixteen years ☆ ☆☆

Prosthetic aortic valve replacement in the small aortic root raises concerns of its long-term effects. Between 1978 and 1994, 270 patients received only small aortic prostheses (< or = 21 mm). There were 117 men (43.3%) and 153 women (56.7%) with a mean age of 64.3 +/- 11.6 years (range 19 to 87 years). The body surface areas ranged from 1.2 to 2.26 m2 (mean 1.71 +/- 0.27 m2). Ninety-one percent of patients had New York Heart Association class III or IV symptoms and 33% underwent concomitant coronary artery bypass grafting. The operative mortality rate was 3.3% (9 deaths) and follow-up (100%) extended from 1 to 16 years (mean 6.2 +/- 3.9 years) with cumulative survival of 1676 patient-years. There were 55 late deaths (3.28% per patient-year). The linearized rates of morbidity reported as percent per patient-year were as follows: structural failure, 0%; paravalvular leak, 0.12%; prosthetic endocarditis, 0.24%; anticoagulant-related morbidity, 1.24%; and thromboembolism, 1.10%. In 89% of the survivors New York Heart Association functional performance had improved to class II or I. The actuarial survival with 95% confidence intervals at 5, 10, and 16 years was 86.9% (82.5%, 91.3%), 68.6% (60.6%, 76.6%), and 53.6% (36.6%, 70.6%), respectively. Freedom from late valve-related events (95% confidence intervals) at 10 and 16 years was as follows: thromboembolism, 91.2% (86.6%, 95.8%) and 78.3% (62.6%, 94%); anticoagulant-related morbidity, 89.1% (83.8%, 94.4%) and 81.0% (65.1%, 96.9%); and prosthetic endocarditis, 98.8% (97.5%, 100%) and 98.8% (97.5%, 100%), respectively. Multivariate analysis revealed age at operation, myocardial infarction, and endocarditis affected the long-term survival. The risk of sudden death irrespective of body surface area and valve size was not statistically different. Thus the long-term performance of the St. Jude Medical valve in small aortic roots is satisfactory.

Swan-Ganz catheter-induced massive hemoptysis and pulmonary artery false aneurysm

Swan-Ganz catheter-induced massive hemoptysis and later pulmonary artery false aneurysm occurred in a patient with prosthetic mitral regurgitation. This patient was successfully managed by double-lumen endotracheal intubation, control of pulmonary hypertension, reversal of anticoagulation, mitral valve re-replacement, and transcatheter embolization. The pertinent literature is reviewed.

Monitoring End-tidal Carbon Dioxide During Weaning from Cardiopulmonary Bypass in Patients Without Significant Lung Disease

End-tidal carbon dioxide tension (Petco2) changes with fluctuations in cardiac output (CO). We compared Petco2 to pulmonary artery blood flow (PAQt) during weaning from cardiopulmonary bypass (CPB) in normothermic patients without significant pulmonary disease. Fifteen consecutive adult cardiac surgical patients were prospectively studied during and shortly after weaning from CPB. Before separation from CPB, Petco2 and PAQt were measured, the latter by transesophageal Doppler echocardiography. At the time of measurements patients were normothermic, and ventilated at 6 breaths/min with tidal volumes of 10 mL/kg. After separation from CPB, thermodilution cardiac output (TDCO) was measured in addition to PAQt and Petco2. Regression and bias analyses were used to compare Petco2, PAQt, and TDCO. Seventy measurements were recorded; 31 before separation from CPB and 39 after separation from CPB. A good correlation was seen between PAQt and Petco2 (r = 0.88) and between TDCO and PAQt (r = 0.93; mean bias 0.03 L/min; sd 0.52 L/min). The regression analysis of PAQt on Petco2 showed greater variability at Petco2 levels > 34 mm Hg (n = 22; r = 0.14). Increases in Petco2 plateaued at this level, although PAQt continued to increase. When Petco2 was more than 30 mm Hg, all PAQt and TDCO values were >4.0 L/min (>2.0 L/min/m2). When Petco2 exceeded 34 mm Hg, all values of PAQt, and 28/29 values of TDCO were more than 5 L/min (>2.5 L/min/m2). One patient had TDCO of 4.69 L/min (2.39 L/min/m2). In normothermic patients without significant pulmonary disease, Petco2 is a useful index of PAQt during separation from CPB. Under the clinical settings in this study, a Petco2 greater than 30 mm Hg was invariably associated with a CO more than 4.0 L/min or a cardiac index >2.0 L/min/m2. Implications In normothermic patients without pulmonary disease, acute changes in Petco2 during separation from cardiopulmonary bypass were reflective of changes in pulmonary artery blood flow. Specific Petco2 values were predictive of cardiac output values under the clinical conditions of the study.

Midterm outcomes of patients undergoing aortic valve replacement after previous coronary artery bypass grafting

OBJECTIVES Redo cardiac surgery for aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG) is technically challenging and carries a high incidence of peri-operative complications. However, experience in the field continues to evolve generating reproducible, and increasingly safer results. We anticipate an increased future role for catheter-based valve procedures and review our operative results to maintain current surgical outcomes for comparison. METHODS A retrospective review was conducted from 1996 through 2010 of patients undergoing AVR as a re-operation after previous CABG. Data were obtained through query of the Society of Thoracic Surgeons (STS) database and chart review. Patient outcomes were compared with STS-predicted risk scores. RESULTS One hundred and thirty-two patients met inclusion criteria (male 83%, female 17%). Average age was 76 (± 7). Thirty-seven patients (28%) required concomitant CABG. Average ejection fraction was 45 (± 14). Comorbid conditions included: diabetes 37% (49/132), hypertension 87% (115/132), NYHA class III/IV 83% (110/132), smoking 51% (67/132), chronic obstructive pulmonary disease 21% (27/132), history of myocardial infarction 61% (80/132), renal failure 16% (21/132) and peripheral arterial disease 38% (50/132).Operative (30-day + hospital) mortality was 6.1% (8/132; 95% CI = 2.9-12.0%), and 30-day mortality was 3.8% (5/132; 95% CI = 1.4-9.1%). One, three and five-year survival rates were 86, 74 and 62%, respectively. Complication rates were as follows: re-operation for bleeding 2.3% (3/132), permanent stroke 0.8% (1/132), prolonged ventilator requirement 18.2% (24/132), deep sternal wound infection 0% (0/132; CI = 0.0-3.5%) and renal failure 9.1% (12/132; none required dialysis). The mean STS-predicted mortality risk score was 7.8% for 111 (applicable) patients for whom actual operative (30-day + hospital) mortality was 3.6%. CONCLUSIONS Low initial operative mortality suggests that surgery is safe and reproducible. However, older age and multiple comorbidities in this patient population may significantly influence late outcomes. The data reported in this study: (i) support open surgical technique as a safe, reliable approach for redo AVR in patients who have undergone previous CABG, and (ii) add to the large body of evidence suggesting that STS scores overestimate risk.

Impaired contractile response of human peripheral arterioles to thromboxane A-2 after cardiopulmonary bypass.

BACKGROUND We studied the contractile response of human peripheral microvasculature to thromboxane A-2 (TXA-2) before and after cardiopulmonary bypass (CPB), with and without the blockade of TXA-2 receptors, or the inhibition of phospholipase C (PLC), phospholipase A-2 (PLA-2) or protein kinase C (PKC)-α. We also examined the protein/gene expression and localization of TXA-2 receptors, TXA-2 synthase, PLC, and other TXA-2-related proteins. METHODS Skeletal muscle arterioles (90-180 μm in diameter) were harvested pre- and post-CPB from patients (n = 28) undergoing cardiac surgery. RESULTS The post-CPB contractile response of skeletal muscle arterioles to TXA-2 analog U-46619 was impaired compared with pre-CPB (P < .05). The presence of TXA-2 receptor antagonist SQ-29548 (10(-6)mol/L) prevented the contractile response to U-46619 (P < .05). Pretreatment with the PLC inhibitor U-73122 (10(-6)mol/L) significantly inhibited the U-46619-induced contractile response (P < .01). Administration of the PLA-2 inhibitor quinacrine (10(-6)mol/L) or PKC-α inhibitor safingol (2 × 10(-5)mol/L), however, failed to affect U-46619-induced contraction. Total protein levels and gene expression of TXA-2 receptors, and TXA-2 synthase of skeletal muscle, were not altered post-CPB. Confocal microscopy showed no differences in the expression of PLCβ-3 in the microcirculation. PLCβ-3 was localized to both smooth muscle and endothelium. CONCLUSION CPB decreases the contractile response of human peripheral arterioles to TXA-2 soon after cardiac surgery. This response may be in part responsible for the decrease in vascular tone, and accompanying hypotension sometimes observed after cardiac operations utilizing CPB.

Long-term survival after use of internal thoracic artery in octogenarians is gender related

OBJECTIVE The goal of this study is to assess the benefits of a left internal thoracic artery as a bypass conduit in octogenarians undergoing elective coronary artery bypass grafting. We hypothesize that there is no survival advantage and that outcome may be gender related. METHODS In a retrospective analysis of 1141 octogenarians (aged >80 years) undergoing isolated coronary artery bypass grafting from 1996 to 2012, patients were divided into 2 groups: Group I (coronary artery bypass grafting-left internal thoracic artery) included 870 patients (339 female/531 male), and group II (coronary artery bypass grafting-saphenous vein graft) included 271 patients (131 female/140 male). RESULTS The overall 30-day mortality was 5.7%: 4.3% in group I and 7.0% in group II (P = .1). Group II had a lower trend of any postoperative complication (P = .05) and pneumonia (P = .05). When analyzed by gender, there were no discernable differences in long-term survival for male patients in group I (65% at 5 years and 29% at 10 years) versus male patients in group II (65% at 5 years and 31% at 10 years) (P = .2). However, survival was significantly greater for female patients in group I (70% at 5 years and 35% at 10 years) versus female patients in group II (63% at 5 years and 21% at 19 years) (P = .01). Multiple logistic and Cox regression analysis showed that left internal thoracic artery use is associated with improved survival in female patients (hazard ratio [HR], 0.72; confidence interval [CI], 0.56-0.93) but not in male patients (HR, 1.14; CI, 0.9-1.4). Advanced age was associated with an increased risk of mortality (HR, 1.08 per year; CI, 1.05-1.1). Both patient age (P = .01) and Society of Thoracic Surgeons-predicted 30-day mortality (P = .03) remain in the final model for 30-day mortality. The benefit of the left internal thoracic artery after coronary artery bypass grafting in octogenarians may be gender related. CONCLUSIONS This study shows that the benefit of the left internal thoracic artery in the octogenarian population undergoing coronary artery bypass grafting may be gender related. For elderly female patients, the use of the left internal thoracic artery as a bypass conduit was associated with better long-term survival, whereas no significant difference was found among the male population. The use of the left internal thoracic artery was associated with a greater postoperative pulmonary morbidity for the study population as a whole. The present study does not refute the benefit of the left internal thoracic artery-left anterior descending graft, but instead distinguishes a subset who might benefit more.

Redo Sternotomy for Cardiac Reoperations Using Peripheral Heparin-Bonded Cardiopulmonary Bypass Circuits Without Systemic Heparinization: Technique and Results

OBJECTIVE Cardiac reoperations are challenging and time-consuming and incur a high incidence of perioperative complications because of injuries to cardiac structures, bleeding, and hemodynamic instability. Some centers are using extracorporeal circulation with heparinization at the time of resternotomy, but it leads to prolonged anticoagulation, platelet dysfunction, fibrinolysis, coagulopathy, and morbidity. The authors routinely perform resternotomy in complex surgery with the support of heparinless cardiopulmonary bypass with heparin-bonded circuits (HBCs). The authors describe their technique, indication, and results. METHODS The femoral artery or axillary artery and femoral veins are cannulated before sternotomy, and cardiopulmonary bypass is instituted using an HBC without systemic heparinization. Systemic heparin (200-300 U/kg) is administered when all structures are isolated before aortic cross-clamping (activated coagulation time >400 seconds). RESULTS Between 1996 and 2008, 336 patients underwent redo sternotomy using the HBC for complex cardiac procedures, with 29 deaths (8.6% deaths within 30 days). Only 5 (1.5%) of 336 patients sustained injury to the right ventricle, aorta, bypass grafts, or ventricular fibrillation during re-entry without hemodynamic deterioration; and underwent uneventful repair and outcomes. There was no online HBC thrombosis. CONCLUSIONS This study shows that HBC without systemic heparinization during resternotomy can be used safely in complex redo cardiac surgery. The heart is completely decompressed during the resternotomy, allowing easy dissection, less likely injury to vital structures, and less bleeding without compromising the hemodynamics.

Tricuspid regurgitation with postinfarction ventricular septal defect

Severe tricuspid regurgitation became apparent in 2 patients who had acute inferior myocardial infarction after repair of a ventricular septal defect. Subsequent tricuspid valve insertion was performed successfully in 1 patient. The pertinent literature is reviewed.