Optimal timing of ventricular assist device (VAD) therapy has been discussed mainly among patients with heart failure dependent on inotrope infusion, but little is known about the indication of VAD therapy among less sick ambulatory patients. Considering recent improvement of VAD therapy outcome, now is the best time to discuss the expansion of VAD indication into less sick population. In this review, we will investigate optimal candidates for VAD therapy especially among ambulatory populations on the basis of recent evidence.
Multidisciplinary treatment comprising surgery, chemotherapy, and radiotherapy for resectable esophageal squamous cell carcinoma (ESCC) is widely used with improved prognosis. Transthoracic esophagectomy (TTE) with extended lymph node (LN) dissection, known as three field LN dissection, has been recommended for ESCC using open thoracotomy or the thoracoscopic approach. The Japan Clinical Oncology Group (JCOG) trial (JCOG1409) is investigating the patients’ long term survival using the thoracoscopic approach that has been shown to reduce the incidence of postoperative respiratory complication. For perioperative treatment, neoadjuvant chemotherapy using cisplatin plus 5-fluorouracil (5-FU), has been accepted as the standard of care in Japan based on the JCOG9907 trial. In Western countries, neoadjuvant chemoradiotherapy was shown to prolong overall survival for esophageal cancer, including ESCC. Although surgery has been recognized as an initial curative treatment for esophageal cancer, definitive chemoradiotherapy is an alternative treatment for patients who are unable to undergo thoracotomy or who decline to undergo surgery. This article reviews multidisciplinary treatment advances for ESCC. However, current standard treatments are country dependent and the ongoing trial may help standardize ESCC treatment across various societies.
Purpose: We compared open, video-assisted and robotic-assisted thoracoscopic surgical techniques in the dissection of N1 and N2-level lymph nodes during surgery for lung cancer.
Methods: This retrospective analysis is based on prospectively collected data of patients (excluding those with N2 or N3 diseases, and sleeve resections) undergoing mediastinal lymph node dissection via open (n = 96), video-assisted thoracoscopy (n = 68), and robotic-assisted thoracoscopy (n = 106). The groups are compared according to the number of lymph node stations dissected, the number of lymph nodes dissected, and the number of lymph nodes dissected by stations.
Results: Three techniques had similar results based on the number of the dissected N1 and N2-level lymph node stations. Robotic-assisted thoracoscopic surgery yielded significantly more lymph nodes in total (p = 0.0007), and in the number of dissected N1-level nodes (p <0.0001). All techniques yielded similar number of mediastinal lymph nodes, whereas robotic-assisted thoracic surgery (RATS) yielded more station #11 and #12 lymph nodes compared to the other groups.
Conclusions: In this study, robotic-assisted thoracoscopic surgery has been shown to dissect more lymph nodes at N1 level. However, taking the open approach as standard, we could claim that both currently robotic and video-assisted techniques may provide similar number of dissected N1 and N2-level lymph node stations.
Purpose: We investigated the effectiveness of active renin-angiotensin-aldosterone system (RAAS) control with human atrial natriuretic peptide (hANP) and an angiotensin II receptor blocker (ARB) in patients with chronic kidney disease (CKD) undergoing coronary artery bypass grafting (CABG).
Methods: A total of 286 consecutive patients with CKD undergoing CABG were divided into three groups: Group C (n = 50) receiving placebo, the hANP group (n = 60) receiving hANP, and the active RAAS control therapy (ARC) group (n = 56) receiving hANP plus an ARB. Renal function, brain natriuretic peptide (BNP) and RAAS parameters were analyzed.
Results: After 1 year, renal function parameters were better in the hANP and ARC groups compared with group C, and the dialysis rate was significantly lower (group C: 12%, hANP group: 1.7%, ARC group: 1.8%, p = 0.018) in the hANP and ARC groups. BNP levels were significantly lower in the hANP and ARC groups compared with group C (p = 0.001). There was also a significant difference of aldosterone among the groups (p = 0.023), as well as a significant difference between group C and the ARC group (p = 0.017).
Conclusions: The present study showed that active RAAS control preserved renal function in patients with CKD undergoing CABG. The improved early postoperative outcome with RAAS control may lead to long-term inhibition of cardiovascular events.
Purpose: We evaluated the outcomes of open heart surgery and long-term quality of life for patients 85 years and older.
Methods: We enrolled 46 patients 85 years and older who underwent cardiac and thoracic aortic surgery between May 1999 and November 2012. Long-term assessment was performed for 43 patients; three patients who died in the hospital were excluded. Patient conditions were assessed before surgery, 6 months and 12 months after surgery, and during the late period regarding the need for nursing care, degree of independent living, and living willingness.
Results: Three patients (6.5%) died during hospitalization and 22 (51%) died during the follow-up period. The 1-, 3-, 5-year survival rates were 74%, 49%, and 36%. During the late period, of 21 surviving patients, 18 patients (85%) were living at home. The need for nursing care was comparable before and after surgery. The degree of independent living decreased after surgery. Living willingness was similar before and after surgery.
Conclusion: Among patients 85 years or older who underwent open heart surgery, 85% were living at home. All patients could perform activities of daily living without any assistance while maintaining living willingness.
Francesco Nicolini, Daniela Fortuna, Giovanni Andrea Contini, Davide Pacini, Davide Gabbieri, Rossana De Palma, Tiziano Gherli, RERIC (Registro dell’Emilia Romagna degli Interventi Cardiochirurgici) Investigators
Released: October 20, 2016
[Advance Publication] Released: September 20, 2016
Purpose: The introduction of transcatheter aortic valves has focused attention on the results of conventional aortic valve surgery in high-risk patients. The aim of the study was to evaluate 5-years outcomes in this category of patients in the current surgical era.
Methods: This is an observational retrospective study of 581 high-risk patients undergoing aortic valve replacement from 2008 to 2013, with a mean logistic EuroSCORE of 26.6% ± 14.6%. Data were prospectively collected in a database of Emilia-Romagna region (Italy).
Results: Overall 30-day mortality was 9.3%. Stroke rate was 1.5%. At 1-, 3-, and 5-years overall mortality was 18.2%, 30.4%, and 42.2%, cardiac death rate was 3.9%, 9.2%, and 12.9%, stroke rate 2.5%, 7.7%, and 10.2%, re-operation occurrence 0.2%, 0.9% and 1.3%, and new pacemaker implantation was 2.3%, 5.1% and 7.8%. At multivariate analysis, urgency, hemodynamic instability, LVEF ≤30%, NYHA III-IV, severe chronic obstructive pulmonary disease (COPD), extra-cardiac arteriopathy, cerebrovascular disease, and creatinine >2.0 mg/dL remained independent predictors of 5-year mortality.
Conclusion: The results of the current study add weight to the evidence that traditional aortic valve replacement can be performed in high-risk patients with satisfactory 5-year mortality and morbidity. Our study may help to improve decision-making in this category of high-risk patients with aortic valve disease.
Inflammatory myofibroblastic tumor (IMT) is the most frequent primary lung tumor in children and it may be locally aggressive. The management of a locally advanced pulmonary IMT in an 18 month-old female child is presented.A left pulmonary mass was incidentally found on the computerized tomography (CT) scan of a child with persistent systemic inflammatory syndrome. Biopsy confirmed the diagnosis; after preoperative corticotherapy, left pneumonectomy was performed. The pericardium and left atrium were invaded and resected, requiring pericardial reconstruction. There is no relapse at four years of follow-up.Steroids play a role in tumor size reduction, but marginal resection is the gold standard. Extended approaches are feasible and often required in advanced cases.
Purpose: Cystic adventitial artery disease is an uncommon non-atherosclerotic peripheral vessel disease. Furthermore cystic adventitial disease of the common femoral artery is an extremely rare entity. We report the case of a 54 year-old man complaining of intermittent claudication who was referred to our vascular service.Methods and Results: Doppler ultrasound and multidetector-row computed tomography (CT) with 3-dimensional volume rendering revealed severe stenosis with cystic an adventitial cyst in the common femoral artery. Intra-operative Doppler ultrasound showed the cyst to be multilocular type. Reversed great saphenous vein interposition was successfully placed.Conclusion: Removal of cyst together with artery and interposition using reversed great saphenous vein is the optimal treatment procedure to prevent recurrence.
A 77-year-old woman underwent emergency ascending aortic replacement for type A acute aortic dissection. Fifteen days after the operation, she had motor and sensory disturbances in the lower limbs. Computed tomography revealed multiple aortic thrombi and disrupted blood flow in the right external iliac and left common iliac arteries. She underwent an emergency thrombectomy for acute limb ischemia. Because heparin-induced-thrombocytopenia (HIT) was suspected to have caused the multiple aortic thrombi, we postoperatively changed the anticoagulant therapy from heparin to argatroban. Seventeen days after the first operation, gastrointestinal bleeding developed, and the patient died of mesenteric ischemia caused by HIT. Arterial embolization caused by HIT after cardiovascular surgery is a rare, but fatal event. To avoid fatal complications, early diagnosis and early treatment are essential. Use of a scoring system would probably facilitate early diagnosis.
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