Asian Cardiovascular and Thoracic Annals recent issues

Video-assisted thoracoscopic patent ductus arteriosus closure in 2,000 patients [ORIGINAL ARTICLE]

Nezafati, Soltani, Mottaghi, Horri, Nezafati — 2011-12-07T00:33:16-08:00

Video-assisted thoracoscopic surgery has proved to be a safe and effective method with low complication and high success rates. From 1997 to 2008, 2,000 consecutive patients with patent ductus arteriosus underwent closure of the ductus with 2 titanium clips via a video-assisted thoracoscopic technique. Complete closure was confirmed using our handmade intraesophageal stethoscope. The mean age was 5.2 years, and mean weight was 9.8 kg. One death was reported 1 month after surgery, due to sepsis during hospitalization for chylothorax treatment. The procedure was converted to an emergency thoracotomy in one case, due to ductal wall rupture. There were 4 late residual shunts treated via thoracotomy. We observed transient laryngeal nerve dysfunction in 14 patients. All patients were reassessed by postoperative echocardiography. The mean procedure (skin-to-skin) time was 10 ± 2 min, and hospitalization was 21 h. This study indicates that video-assisted thoracoscopic closure of patent ductus arteriosus is a safe, simple, and cost-effective method with low complication and high success rates. Furthermore, the cosmetic benefits make it appropriate as an out-patient procedure.

NT-pro-brain natriuretic peptide levels after valve replacement [ORIGINAL ARTICLE]

Elasfar — 2011-12-07T00:33:16-08:00

Elevated plasma N-terminal pro-brain natriuretic peptide levels have been demonstrated in patients with chronic valvular disease. To assess whether changes in N-terminal pro-brain natriuretic peptide levels after mitral, aortic, and double-valve replacement reflect changes in heart failure symptoms, a prospective observational nonrandomized study was undertaken in 24 consecutive patients (mean age, 55.3 ± 16.2 years; 58% male) undergoing mitral and/or aortic valve replacement. Mitral valve replacement was carried out in 12 patients, aortic valve replacement in 8, and combined mitral and aortic valve replacement in 4. N-terminal pro-brain natriuretic peptide measurements, echocardiography, and functional class assessment were performed before and 6 months after surgery. A decrease in N-terminal pro-brain natri-uretic peptide at 6 months postoperatively was significantly associated with decreased left atrial dimension, left ventricular end-diastolic and end-systolic dimensions, increased ejection fraction, and improvement in functional class. Thus we can hypothesize that measurement of N-terminal pro-brain natriuretic peptide might allow early detection of any clinical deterioration as well as assessment of the long-term outcome in valve replacement patients.

Totally endoscopic atrial septal repair using no robotic techniques [ORIGINAL ARTICLE]

Xiangjun, Xufa, Liang — 2011-12-07T00:33:16-08:00

Standard surgical closure of an atrial septal defect via sternotomy is safe and effective. To avoid sternotomy and improve the cosmetic result, minimally invasive cardiac surgery has emerged as an alternative. Robot-assisted totally endoscopic atrial septal defect repair is convincingly superior, but the robotic system is expensive and complicated. We describe a technique of totally endoscopic closed-chest atrial septal defect closure without the aid of a robotic device. Twenty patients underwent totally endoscopic atrial septal defect repair using no robotic techniques between May 2009 and December 2009. No major intraoperative or postoperative complications were observed. One operation was converted to a conventional sternotomy because bleeding from the aortic root could not be controlled. Closure of an atrial septal defect can be performed safely and effectively via an endoscopic approach using no robotic techniques.

Coronary pseudoaneurysm in a non-polymer drug-eluting stent: a rare entity [CASE STUDIES]

Kapoor, Batra, Kumar, Pandey, Agarwal, Sinha — 2011-12-07T00:33:16-08:00

Coronary pseudoaneurysms following implantation of drug-eluting stents, although rare, are not unknown. Nearly all such cases have been reported in patients with sirolimus or paclitaxel polymer-based stents. We describe a case of coronary pseudoaneurysm developing with a non-polymer-based drug-eluting stent in a 50-year-old man who was successfully managed by coronary artery bypass grafting.

An interrupted technique for difficult distal anastomosis during arch surgery [CASE STUDIES]

Follis, Filippone, Montalbano, Centineo, Finazzo, Follis — 2011-12-07T00:33:16-08:00

During aortic arch replacement, construction of the distal anastomosis represents the crucial step because of the time limit of circulatory arrest. If the aneurysmal neck is located at the level of the 5^th thoracic vertebra, it becomes difficult to carry out through a sternotomy approach. We describe a case in which an interrupted suture technique, similar to that used for valve replacement, was employed to maximize the limited exposure and achieve a water-tight anastomosis.

Coagulase-negative staphylococcus endocarditis: staphylococcus lugdunensis [CASE STUDIES]

Sibal, Lin, Jogia — 2011-12-07T00:33:16-08:00

Staphylococcus lugdunensis is an infrequent cause of native valve endocarditis. A case of triple-valve involvement of Staphylococcus lugdunensis with intracardiac fistula formation in a 47-year-old woman was managed successfully with surgery. The importance of early diagnosis and prompt referral for surgical treatment is highlighted.

Ruptured saphenous vein graft aneurysm after aortocoronary bypass grafting [CASE STUDIES]

Satsu, Onoe, Miyashita — 2011-12-07T00:33:16-08:00

Computed tomography demonstrated a giant saphenous vein graft aneurysm that compressed the right atrium of a 72-year-old woman 20 years after undergoing coronary artery bypass grafting. Angiography revealed contrast medium leakage in the mid-portion of the graft aneurysm. Aneurysmectomy was performed without repeat grafting. Postoperative myocardial scintigraphy demonstrated no significant myocardial ischemia. The ischemic effect of non-revascularization should be considered preoperatively because of the difficulties with repeat grafting.

A case of aortoesophageal fistula [CASE STUDIES]

Bakhshandeh, Salehi, Radmehr, Riahi — 2011-12-07T00:33:16-08:00

Aneurysms of the thoracic aorta can have various manifestations, some of which may simulate esophageal diseases, clinically and radiographically. Aortoesophageal fistula is rare and usually fatal. We report a case of aortoesophageal fistula presenting with progressive dysphagia and intermittent episodes of upper gastrointestinal bleeding.

Aneurysm of sinus of Valsalva: uncommon presentation [CASE STUDIES]

Elumalai, Vaidyanathan, Nainar, Balasubramaniam, George — 2011-12-07T00:33:16-08:00

A 28-year-old man presented with acute onset of chest pain. Transthoracic echocardiography confirmed an aneurysm of the sinus of Valsalva dissecting into the interventricular septum. During the next 12 h, the aneurysm enlarged to involve the entire interventricular septum, and the patient developed features of cardiac tamponade. He underwent successful surgical repair.

Thoracoscopic management of spontaneous pneumothorax due to azygos lobe bullae [CASE STUDIES]

Azoury, Sayad — 2011-12-07T00:33:16-08:00

A 22-year-old man presented with recurrent right-sided spontaneous pneumothorax caused by rupture of azygos lobe bullae. Surgical management was successfully completed using a video-assisted thoracoscopic approach. Resection of the bullae harboring azygos lobe and subsequent pleurodesis were performed, sparing the meso-azygos and azygos vein.

Fenestration closure in a calcified ventricular septal defect patch [CASE STUDIES]

Raja, Atamanyuk, Pandey, Kostolny — 2011-12-07T00:33:16-08:00

Ventricular septal defect closure with a fenestrated patch is a recognized rescue maneuver to decrease the risk of right ventricular failure after complete repair in patients with pulmonary atresia. If the fenestration needs surgical closure, severe calcification of the patch may make it extremely difficult. We describe the closure of such a defect in a 6-year-old boy, using a double Dacron patch sandwich.

Adenocarcinoma in pulmonary sequestration [CASE STUDIES]

Lawal, Mikroulis, Eleftheriadis, Karros, Bougioukas, Bougioukas — 2011-12-07T00:33:17-08:00

A 67-year-old male smoker presented with hemoptysis and recurrent pneumonia. Chest computed tomography showed an emphysematous cyst and air-fluid level cavities in the left lower lobe. A left lower lobectomy was performed. The intraoperative finding was intralobar sequestration. Histopathology revealed adenocarcinoma within the sequestrated lobe. Only 8 cases of lung cancer and sequestration have been reported since 1963.

Ruptured pulmonary artery aneurysm: a surgical emergency [CASE STUDIES]

Puri, Kaur, Brar, Singh, Sahoo, Mahant — 2011-12-07T00:33:17-08:00

Idiopathic pulmonary artery aneurysm rupture was diagnosed in a 79-year-old man who presented with a dry cough. He was considered unlikely to tolerate extensive pulmonary artery reconstruction or lung resection; hence, he was salvaged by timely ligation of the distal pulmonary artery at the origin of the aneurysm.

Simple home-made suction device to aid excision of friable atrial myxoma [HOW TO DO IT]

Wong, Wan, Ng, Underwood — 2011-12-07T00:33:17-08:00

Atrial myxoma, especially the papillary subtype, is known to be friable and gelatinous. Manipulation of an atrial myxoma during surgery can be very difficult, and not uncommonly results in fragmention and embolization of part of the tumor. The conventional method using a metallic spoon to manipulate the tumor is widely practiced because alternatives are sparse. We describe a novel home-made suction device to aid the excision of friable atrial myxomas.

Angina in an adolescent [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Maddali, Al-Maskari, Al-delamie — 2011-12-07T00:33:17-08:00

Stridor with recurrent chest infection [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Ahmed, Kureel, Chandra — 2011-12-07T00:33:17-08:00

Pneumopericardium from esophageal-pericardial fistula due to cancer recurrence [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Kasama, Rino, Murakami, Suzuki, Isomatsu, Masuda — 2011-12-07T00:33:17-08:00

Missing floating thrombus in the aorta [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Nakamura, Nakano, Tagusari — 2011-12-07T00:33:17-08:00

Editorial [EDITORIAL]

Kumar — 2011-11-18T08:48:24-08:00

Aortic valve replacement with smaller valve size [ORIGINAL ARTICLE]

Sato, Suenaga, Koga, Kawasaki — 2011-11-18T08:48:24-08:00

The occurrence of prosthesis-patient mismatch after aortic valve replacement with a small valve size was evaluated in 249 patients, focusing on echocardiographic data. Aortic valve pathology included regurgitation in 174 patients and stenosis in 75. Echocardiography was performed in the early and late postoperative periods. A projected effective orifice area index <0.85 cm²·m^–2 was noted in 56 patients; values ≥ 0.85 cm²·m^–2 were found in 128. Postoperative changes in ejection fraction, left ventricular mass regression, and peak transprosthetic gradient were similar in both groups. Small prostheses (≤ 19 mm) were used in 43 patients who had significantly higher postoperative transprosthetic gradients in both the early and late periods, compared to those with larger prostheses. Our findings show that the occurrence of prosthesis-patient mismatch after aortic valve replacement is rare. Left ventricular mass regression occurred in most patients, with acceptable transprosthetic gradients.

Ruptured sinus of Valsalva aneurysm: 10-year Indian surgical experience [ORIGINAL ARTICLE]

Menon, Kottayil, Panicker, Pillai, Karunakaran — 2011-11-18T08:48:24-08:00

Sinus of Valsalva aneurysm is a rare anomaly with a higher incidence in Eastern than Western populations. Recent improvements in diagnostic techniques have resulted in more patients undergoing surgical repair. Uncorrected, the intracardiac shunts and frequently associated cardiac lesions cause a preventable deterioration in heart function. We retrospectively analyzed the data of 33 patients who underwent repair of ruptured sinus of Valsalva aneurysm from May 2000 to January 2010. The aneurysms originated from the right coronary sinus in 24 patients and from the noncoronary sinus in 9, and ruptured into the right ventricle in 21, right atrium in 10, and left ventricle in 2. Operative procedures included simple plication (1), patch repair (32), and aortic valve replacement (10). There were 3 early deaths. The 30 survivors were followed up for 5.4 ± 2.6 years; all had an improvement in functional class, with superior results in those with no aortic regurgitation. Surgical treatment of ruptured sinus of Valsalva aneurysm has an acceptably low operative risk and good long-term symptom-freedom survival. An early aggressive approach is recommended to prevent worsening symptoms and more extensive disease.

Computed tomographic angiography in tetralogy of Fallot [ORIGINAL ARTICLE]

Kasar, Ravikumar, Varghese, Kotecha, Vimala, Kumar — 2011-11-18T08:48:24-08:00

Echocardiography is often inadequate for imaging tetralogy of Fallot, prompting cineangiography. This study prospectively evaluated multidetector computed tomographic angiography for preoperative evaluation of tetralogy of Fallot in 112 consecutive patients. Forty-eight had nonconfluent or hypoplastic pulmonary arteries (mean z-score, –2; range, –11.1–0.13) permitting only palliative or no surgery; 64 had adequate pulmonary artery anatomy (mean z-score, 0.59; range, –2.53–3.4) allowing total repair. The surgical data of 50 patients who underwent total correction were compared with transthoracic echocardiography and multidetector computed tomographic angiography findings. Multidetector computed tomographic angiography tended to reveal unsuspected collaterals and coronary abnormalities besides outlining the right ventricular outflow tract and pulmonary artery branches. The branch pulmonary artery diameter z-score was the most important determinant of surgical strategy, with the worst figures being associated with no surgical options or palliative surgery, and the best figures leading to corrective surgery. The mean radiation dose was 3.45 mSv. Multidetector computed tomographic angiography is a powerful supplement to echocardiography in the preoperative evaluation of tetralogy of Fallot.

Association between body mass index and outcome of coronary artery bypass [ORIGINAL ARTICLE]

Harvey, Haluska, Mundy, Wood, Griffin, Shah — 2011-11-18T08:48:25-08:00

Studies have shown disparate findings regarding body mass index and outcomes after coronary artery bypass. We analyzed body mass index and other clinical variables that might predict morbidity and mortality after primary isolated coronary artery bypass. Data on 4,425 patients (79% men) were reviewed retrospectively. They were classified as underweight (1.6%), normal weight (65%), obese (32%), and morbidly obese (1.4%) according to body mass index <20, 20–29, 30–39, and >40 kg·m^–2, respectively. Multiple logistic regression was used for correlates of 30-day outcome. Cox regression was used for predictors of late outcome in underweight and morbidly obese patients. There were 45 (1%) deaths and 234 (5%) cases of morbidity within 30 days. Independent correlates of 30-day morbidity were smoking, logistic EuroSCORE, blood and blood product transfusions. Correlates of 30-day mortality were logistic EuroSCORE and blood transfusion. The only independent predictor of late death in underweight and morbidly obese patients was preoperative arrhythmia. Body mass index was not a predictor of 30-day morbidity or mortality. The 1-, 3-, and 7-year survival rates were not significantly different between underweight and morbidly obese patients. Body mass index did not affect short-term outcomes after primary coronary artery bypass grafting.

Effect of right ventricular pacing site on QRS Width [ORIGINAL ARTICLE]

Nakamura, Mine, Kanemori, Ohyanagi, Masuyama — 2011-11-18T08:48:25-08:00

To assess the effect of various right ventricular pacing sites on QRS duration, we enrolled 50 patients (mean age, 64 ± 13 years; 36 men); 16 had bradycardia and 34 had tachycardia. The right ventricle was arbitrarily divided into 5 sections: high and low right ventricular outflow tract, mid septum, low septum, and apex. Right ventricular pacing was performed using an electrode catheter at each of the 5 sites. QRS duration was 162 ± 20 ms during high right ventricular outflow tract pacing, 143 ± 17 ms during low right ventricular outflow tract pacing, 151 ± 20 ms during mid-septal pacing, 163 ± 16 ms during low-septal pacing, and 167 ± 18 ms during apical pacing. Paced QRS duration was shorter during low right ventricular outflow tract and mid-septal pacing compared to apical pacing in 34 patients. There was a difference of 10 ms or less in the paced QRS duration between these pacing sites in the other 16 patients. QRS duration was shortest when the septum was paced in the right ventricle. However, QRS duration was similar during pacing in the septum and the apex in 32% of patients.

Pneumocephalus and pneumococcal meningitis after thoracic surgery [CASE STUDIES]

Asner, Chapuis-Taillard, Ris, Gonzalez — 2011-11-18T08:48:25-08:00

A 62-year-old man with adenocarcinoma underwent complete resection with a right upper lobectomy and en-bloc resection of the chest wall, with metallic clips applied to the vertebral nerve roots. A sudden deterioration in neurological status occurred due to pneumocephalus and ascending bacterial meningitis resulting from a subarachnoid-pleural fistula. The neurological status normalized after thoracoplasty and ceftriaxone treatment.

An unusual case of left chest stab wound [CASE STUDIES]

Zebele, Gianoli, Elenbaas, Brink, Van Zundert — 2011-11-18T08:48:25-08:00

A 72-year-old man was admitted with one blade of a huge pair of shears in his left thorax. His hemodynamics deteriorated due to life-threatening vascular lesions. An urgent thoracotomy revealed several injuries to the intercostal vessels and left apical inferior lung lobe. The blade tip was stuck in the posterior chest wall, 2 cm adjacent to the descending aorta. The blade was removed, the lung was sutured, and the patient made a good recovery.

Aortoesophageal fistula after thoracic stent grafting [CASE STUDIES]

Albors, Bahamonde, Sanchis, Boix, Palmero — 2011-11-18T08:48:25-08:00

Aortoesophageal fistula after thoracic stent grafting is rare and usually fatal. A 66-year-old woman developed an aortoesophageal fistula 1 month after endovascular stent grafting of the thoracic aorta for a complicated type B dissection. She had a fatal episode of massive bleeding before she could be treated. The limited treatment options are discussed.

Preoperative embolization of aberrant systemic artery in sequestration of lung [CASE STUDIES]

Saxena, Marshall, Ng, Sinha, Edwards — 2011-11-18T08:48:25-08:00

A 40-year-old man presented with left lower lobe pneumonia that failed to resolve on antibiotic therapy. Computed tomography revealed intralobar sequestration of the left lower lobe supplied by a large artery from the descending aorta. The aberrant artery was embolized using polyvinyl alcohol particles. The sequestered tissue was resected 3 weeks later. Identification and control of the aberrant artery is essential to avoid inadvertent injury and massive hemorrhage.

Ectopic hepatocellular carcinomas developed in the chest wall and skull [CASE STUDIES]

Nenekidis, Anagnostakou, Paralikas, Kokkori, Dedeilias, Zisis — 2011-11-18T08:48:25-08:00

A 68-year-old man presented with a suppurating mass on his skull and a palpable mass on his right upper thoracic wall. Computed tomography revealed a round mass, 70 mm in diameter, invading the right pleural cavity, and a second tumor infiltrating the skull through the left parietal bone. Both masses were resected simultaneously. Histopathology showed that both tumors were hepatocellular carcinomas.

Right atrial thrombus migrating to the superior vena cava during surgery [CASE STUDIES]

van de Gevel, Hamad, Schonberger, van Dantzig, van Straten — 2011-11-18T08:48:25-08:00

Free-floating right heart thrombi are extremely mobile structures that carry a very high mortality rate. We describe a case of pulmonary embolism with a free-floating right heart thrombus that migrated to the superior vena cava during the institution of cardiopulmonary bypass.

Simplified closure of ministernotomy using thermoreactive sternal clips [HOW TO DO IT]

Grapow, Ruter, Melly, Winkler, Eckstein, Matt — 2011-11-18T08:48:25-08:00

An increasing number of aortic valve replacements are performed through a ministernotomy. Due to the small incision and partial fixation of the caudal sternum, the traditional wire closure can be complicated and even harmful to the surrounding tissue. In such cases, we recommend the use of nitinol clips for sternal closure. This technique, which we have used in 48 patients, is simple, safe, and fast, and results in excellent outcomes.

Pulmonary arteriovenous malformation in Osler-Weber-Rendu syndrome [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Chen, Jiang, Chen, Chen — 2011-11-18T08:48:25-08:00

End-systolic murmur due to membranous interventricular septal aneurysm [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Sonmez, Gul, Kayrak — 2011-11-18T08:48:25-08:00

Lung cancer in the native lung after single-lung transplantation [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Ploenes, Passlick — 2011-11-18T08:48:25-08:00

Complete bronchial obstruction without distal lung atelectasis [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Mishra, Mann, Yiu — 2011-11-18T08:48:25-08:00

Pulmonary resection after lung transplantation in cystic fibrosis patients [ORIGINAL ARTICLES]

Souilamas, Saueressig, Boussaud, Amrein, Guillemain, Sonett — 2011-09-01T05:09:22-07:00

Pulmonary resection after lung transplantation in end-stage cystic fibrosis presents unique challenges, and scant literature exists to guide physicians. We retrospectively reviewed 78 transplants for cystic fibrosis performed between 2003 and 2008. Fourteen patients underwent posttransplantation pulmonary resection. We analyzed the indications, surgical procedures, outcomes, and survival. Three pneumonectomies, 4 lobectomies, and 11 wedge resections were carried out. We identified 2 groups based on indication: a diagnostic group, and a therapeutic group of patients in whom the indications were septic native lung in 2, allograft infection in 2, lobar torsion in 2, pulmonary infarction in 2, and size mismatch in 4. The mean intensive care unit and hospital stays were 29 and 50 days, respectively. Four (28.57%) patients died during follow-up, including 2 who underwent pneumonectomy; 10 (71.43%) are still alive. Survival was 43.43 ±8.06 months, and it was not significantly different from that in cystic fibrosis patients who had lung transplantation without pulmonary resection. Pulmonary resection following lung transplantation in cystic fibrosis patients showed acceptable survival and surgical risk, but metachronous pneumonectomy was associated with higher mortality.

Nanofiber-reinforced biological conduit in cardiac surgery: preliminary report [ORIGINAL ARTICLES]

Guhathakurta, Galla, Ramesh, Venugopal, Ramakrishna, Cherian — 2011-09-01T05:09:22-07:00

Several options are available for right ventricular outflow tract reconstruction, including commercially available bovine jugular vein and cryo-preserved homografts. Homograft non-availability and the problems of commercially available conduits led us to develop indigenously processed bovine jugular vein conduits with competent valves. They were made completely acellular and strengthened by non-conventional cross-linking without disturbing the extracellular matrix, which improved the luminal surface characteristics for hemocompatibility. Biocompatibility in vitro and in vivo, along with thermal stability, matrix stability, and mechanical strength have been evaluated. Sixty-nine patients received these conduits for right ventricular outflow tract reconstruction. Seven conduits dilated and 4 required replacement. To counteract dilatation, biodegradable polymeric nanofibers in various combinations and in isolation (collagen, polycaprolactone, polylactic acid) were characterized and used to reinforce the conduit circumferentially. Physical validation by mechanical testing, scanning electron microscopy, and in-vitro cytotoxicity was conducted. Thermal stability, spectroscopy studies of the polymer, and preclinical studies of the coated bovine jugular vein in animals are in progress. The feasibility studies have been completed, and the final polymer selection depends on evaluation of the functional superiority of the coated bovine jugular vein.

Sodium thiopental and mean arterial pressure during cardiopulmonary bypass [ORIGINAL ARTICLES]

Dabbagh, Rajaei, Ahani — 2011-09-01T05:09:22-07:00

Sodium thiopental is known to have a number of cardiovascular effects, but injection into the cardiopulmonary bypass reservoir has not been studied. The effect of sodium thiopental on mean arterial blood pressure during cardiopulmonary bypass was assessed in 150 patients undergoing elective coronary artery bypass grafting. Sodium thiopental 3 mg · kg^–1 was administered via the cardiopulmonary bypass reservoir. Mean arterial pressure was recorded just before drug administration and at 15-sec intervals up to 120 sec afterwards. Compared to the baseline value, mean arterial pressure was significantly higher at 30, 45, 60, and 75 sec after drug administration, and it was significantly lower at 90, 105, and 120 sec. Sodium thiopental, in addition to its effects on myocardial tissue, acts initially as a potent vasopressor, and shortly after, as a potent vasodilator.

N1 non-small-cell lung cancer. A 20-year surgical experience [ORIGINAL ARTICLES]

Casali, Stefani, Morandi — 2011-09-01T05:09:22-07:00

N1 non-small-cell lung cancer has heterogeneous prognosis in relation to node descriptors. There is no agreement on the ideal type of resection. A new classification of N1 descriptors was proposed in the 7^th edition of the TNM staging system. A retrospective study was conducted on 384 patients with T1-T3N1 non-small-cell lung cancer who underwent complete pulmonary resection. The prognostic role of N1 descriptors according to the current and new staging systems and type of resection was investigated. The 5-year survival rate was 46%. Involvement of hilar node stations, multiple stations, and multiple nodes were poor prognostic factors (5-year survival, 33%, 21%, and 30%, respectively), as well as involvement of the hilar zone and multiple zones (5-year survival, 27% and 23%, respectively). Pneumonectomy showed significantly better survival rates compared to lobectomy or bilobectomy (5-year survival, 60% vs. 29%). Multivariate analysis showed that the number of N1 zones and type of resection were independent prognostic factors. Patients with hilar nodal, multiple-level, or multiple-zone involvement had poor prognosis. Standard lobectomy remains the procedure of choice, but in cases of fixed nodes in the hilar zone, sleeve resection or even pneumonectomy should be considered.

Can invasive thymomas be resected by video-assisted thoracoscopic surgery? [ORIGINAL ARTICLES]

Agasthian — 2011-09-01T05:09:22-07:00

Although video-assisted thoracic surgery can be used for well-encapsulated thymomas, its role in invasive thymomas remains controversial. Between 1998 and 2009, 77 patients aged 22–76 years underwent thymomectomy by video-assisted thoracic surgery. Tumors <5 cm without major invasion on preoperative computed tomography were selected. There were 13 invasive thymomas (Masaoka stage III and IV). A modified dissection technique was employed to prevent breaching the tumor capsule and risking tumor seedling. Limited resection of the phrenic nerve, pericardium, perithymic fat, and a wedge of lung was performed en bloc with the tumor. The mean duration of surgery was 138 min. Hospital stay was 3.6 days. Eleven patients had associated myasthenia gravis. There was 1 case of wound infection and no operative mortality. The mean size of the thymomas was 34 mm (range, 23–55 mm). All patients had adjuvant radiotherapy. During follow-up of 4.9 years (range, 1–10 years), there was one local recurrence. With the modified video-assisted thoracic surgery technique, selected invasive thymomas detected during surgery can be removed safely without resorting to sternotomy.

Successful management of descending necrotizing mediastinitis [ORIGINAL ARTICLES]

Wakahara, Tanaka, Maniwa, Nishio, Yoshimura — 2011-09-01T05:09:22-07:00

Descending necrotizing mediastinitis is a critical infection and the mortality rate remains high. Early aggressive surgical drainage and antibiotic therapy are essential for treatment. We evaluated the efficiency of transthoracic drainage using a minimally invasive technique in 11 cases of descending necrotizing mediastinitis between May 2002 and March 2008. We performed a right-side minithoracotomy with thoracoscopic assistance, and the mediastinum was thoroughly drained. The length of hospitalization ranged from 30 to 117 days. The postoperative course was good in all patients, and the outcome was favorable. All patients were discharged without major complications. We recommend employing a minithoracotomy with thoracoscopic assistance for aggressive treatment of descending necrotizing mediastinitis.

Chordal transfer in rheumatic mitral regurgitation: early experience [ORIGINAL ARTICLES]

Lohchab, Laller, Taxak, Johar — 2011-09-01T05:09:22-07:00

Chordal transfer and chordal replacement techniques have been quite successful for repair of anterior mitral leaflet prolapse in degenerative disease, but largely unexplored in rheumatic patients. To extend the scope of valve repair, we assessed the chordal transfer technique for correction of anterior mitral leaflet prolapse in 57 patients with rheumatic mitral regurgitation, who were treated between October 2008 and March 2010. There were 36 women and 21 men with a mean age of 25 ± 7.4 years. Normal chordae and a strip of leaflet tissue were transferred from the posterior leaflet to the free edge of the anterior leaflet; the posterior leaflet was repaired in the same manner as after quadrangular resection. Additional procedures were commissurotomy in 19 patients, aortic valve replacement in 1, tricuspid repair in 5, and cryo maze operations in 21. There was no hospital mortality. One (1.7%) patient had acute renal failure but recovered fully. There was moderate regurgitation in one patient who had undergone simultaneous aortic valve replacement. At a mean follow-up of 6.2 ± 2 months, 56/57 (98.2%) patients were asymptomatic with no significant mitral regurgitation.

Streptokinase for malignant pleural effusions: a randomized controlled study [ORIGINAL ARTICLES]

Okur, Baysungur, Tezel, Ergene, Okur, Halezeroglu — 2011-09-01T05:09:22-07:00

Effective palliative treatment in malignant pleural effusion can only be carried out when the lung is fully expanded after drainage of effusion. We investigated the efficacy of intrapleural fibrinolytics for lysing fibrin deposits and improving lung reexpansion in patients with malignant pleural effusion. We randomly allocated 47 patients with malignant pleural effusion into 2 groups: a fibrinolytic group of 24 were given 3 cycles of 250,000 U intrapleural streptokinase; the control group of 23 received pleural drainage only. Pleurodesis with 5 mg of talc slurry was performed in all patients who had lung reexpansion after drainage. Patient characteristics, pleural drainage, lung expansion assessed by chest radiography, and pleurodesis outcomes were compared between the 2 groups. Patient characteristics were similar in both groups. Lung reexpansion was adequate for performing talc pleurodesis in 96% of patients in the fibrinolytic group and 74% in the control group. In the fibrinolytic group, the mean volume of daily pleural drainage before streptokinase administration was 425 mL, and it increased significantly to 737 mL after streptokinase infusion. Intrapleural administration of streptokinase is advisable for patients with malignant pleural effusion.

A high-volume heart transplantation center in an Islamic country [ORIGINAL ARTICLES]

Canver, Al Buraiki, Saad, Yousafzai, Al Ahmadi, Al Sanei — 2011-09-01T05:09:22-07:00

Cardiac transplants are performed sporadically or not at all in the majority of predominantly Muslim countries in the Middle East. We examined our experience in 76 patients who underwent heart transplantation between January 2005 and May 2010 in our center in Saudi Arabia. Excluded were 50 transplants performed between 1989 and 2004, due to incomplete data. Primary outcomes were complications, 30-day and late mortality rates, and 1-year survival. The heart transplant activity between 2005 and 2010 (15.0 per year) was 4.5-fold higher than that between 1989 and 2004 (3.3 per year). There were 61 (80%) men and 15 (20%) women, with a mean age of 35 years (range, 13–57 years). The mean waiting list time was 64 days (range, 1–262 days), and hospital stay was 30 days (range, 12–166 days). Major complications were infection (10), low-grade rejection (9), reoperation for hemorrhage (8), and sternal dehiscence (2). The 30-day mortality was 7.8% (6/76). Actuarial survival was 87.4% at 1 year and 81.5% at 3 years. A hospital in a Muslim country can increase cardiac transplant activity with excellent 30-day mortality and early survival comparable to that in worldwide counterparts.

Total anomalous pulmonary venous connection beyond infancy [ORIGINAL ARTICLES]

Reddy, Nagarajan, Rani, Prasad, Chakravarthy, Rao, Murthy — 2011-09-01T05:09:22-07:00

Most patients with total anomalous pulmonary venous connection are operated on in infancy, with low mortality and morbidity, but in developing countries, we still encounter patients beyond infancy. We describe our experience in 26 patients aged 1–16 years (mean, 5.01 years), with total anomalous pulmonary venous connection, who underwent correction between June 2007 and December 2009. Eleven patients were >5-years old. Transthoracic echocardiography was diagnostic in all cases. Mean intensive care unit stay was 2.3 ± 0.87 days, and hospital stay was 9.23 ± 2.34 days. There were no early deaths and no major postoperative complications. Follow-up ranged from 10–40 months. Pulmonary artery pressure, as judged by echocardiography, reduced significantly in all patients. Repair of total anomalous pulmonary venous connection beyond infancy can be carried out safely with acceptable results.

Update on the mitral pulmonary autograft [ORIGINAL ARTICLES]

Kabbani, Sabbagh, Kudsi, Nabhani, Jamil — 2011-09-01T05:09:22-07:00

Between July 1997 and August 2004, 92 patients with irreparable mitral valves underwent replacement with a pulmonary autograft. This report brings the follow-up data of these patients up to date. Eighty-eight patients had a successful Ross II operation; 4 were lost to follow-up. The mean follow-up period was 94 months. Transesophageal echocardiography revealed a successful outcome in all 88 patients immediately after the operation. Operative mortality was 4.6%, and late mortality definitely related to the operation was 12.5%. At a mean follow-up of 94 months, freedom from structural valve deterioration (significant mitral stenosis and/or regurgitation) was 93.4%, freedom from reoperation was 92.0%, and freedom from all causes of death was 82.9%. Two autografts were explanted because of endocarditis. Two patients developed significant pulmonary stenosis, one of whom underwent operative repair. These data compare favorably with those of mitral valve replacement using modern bioprostheses. This procedure remains an option for the relatively young patient when life-long anticoagulation is contraindicated or impractical. It is also an option to consider in infants with complex irreparable mitral valve disease.

Epithelioid malignant mesothelioma presenting with features of esophageal tumor [CASE STUDIES]

Khalil, Campbell, Cowen — 2011-09-01T05:09:22-07:00

Intrathoracic epithelioid mesothelioma commonly presents as a diffuse tumor of the pleura. It rarely occurs as a localized tumor that might be surgically resectable. We report a case of one such localized mesothelioma in a 72-year-old woman, which arose from the wall of the esophagus and had all the presenting features of an esophageal tumor.

Late relapse of non-typhoidal salmonella vascular graft infection after 5 years [CASE STUDIES]

Oon, Ong, Robless, Fisher — 2011-09-01T05:09:22-07:00

Salmonella bacteremia can be complicated by mycotic aneurysm with the potential for a catastrophic presentation. Treatment involves prompt surgery with debridement, extraanatomic bypass, and prolonged antibiotic therapy. Any relapse tends to occur within the 1^st year after surgery. We describe a case of Salmonella enteritidis mycotic aneurysm in a 56-year-old man 5 years after the initial presentation, emphasizing the importance of aggressive initial therapy and long-term surveillance.

Pseudocoarctation of the aorta complicated by thoracic aortic aneurysm [CASE STUDIES]

Kimura, Ohtake, Kato, Yashiki, Tomita, Watanabe — 2011-09-01T05:09:22-07:00

Pseudocoarctation is a rare anomaly involving kinking or buckling of the aorta without a pressure gradient across the lesion, considered to be a benign entity warranting no specific intervention. An uncommon case of pseudocoarctation associated with aortic aneurysm formation in 21-year-old woman is described. Pathological findings suggested that the etiology was anomalous development of the aorta in association with pseudocoarctation; therefore, careful follow-up of patients affected by pseudocoarctation is mandatory.

Organ procurement: Spanish transplant procurement management [INVITED REVIEW]

Manyalich, Mestres, Balleste, Paez, Valero, Gomez — 2011-09-01T05:09:22-07:00

Transplantation is an accepted therapeutic option to save or improve the quality of life when organ failure occurs or tissue replacements are needed. However, the lack of organs is the major limitation. The deceased organ procurement organization and professionals provide the solution to this international problem. In this review, we identify the elements involved in the organ procurement management process to analyze the possibility of implementation of deceased organ procurement for a transplantation program. While the donation rates are subject to several negative factors including religious, economic, cultural, and legal issues, the existence of well-trained professionals may considerably increase them. Professional training in organ donation along with the establishment of a solid organizational system has been identified as the crucial factor in developing efficient organ donation and transplantation programs.

Mitral valve prosthesis implanted in atrial wall over huge calcified annulus [HOW TO DO IT]

Gualis, Castano, Gomez-Plana, Martin, de Miguel, de Diego — 2011-09-01T05:09:22-07:00

We describe an alternative technique for mitral valve replacement in patients with severe mitral annular calcification, in whom conventional techniques are not feasible. A new annulus that allows supra-annular prosthetic implantation is created.

A tip for keeping the surgical sutures in order during bronchoplasty [HOW TO DO IT]

Kamiyoshihara, Igai, Nagashima — 2011-09-01T05:09:22-07:00

We describe a device that we use to keep many surgical sutures in order during bronchoplasty. This device is torus-shaped with slits at regular intervals radially, which encircles the surgical field. We tuck the suture material into the slits in the suture runner. Traditionally, they are controlled by the use of many mosquito forceps. We believe that this device is useful, and that our method is simpler than the traditional method.

Acute coronary syndrome due to coronary artery-pulmonary artery fistula [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Elsayed, Govindraj, El-dean, Kuduvalli — 2011-09-01T05:09:22-07:00

Cardiac myxoma examined by 320-detector row computed tomography [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Okamoto, Katsu, Matsumoto — 2011-09-01T05:09:22-07:00

Situs solitus dextrocardia, coarctation, left superior vena cava, sequestration [IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY]

Ng, Wong, Wan, Underwood — 2011-09-01T05:09:22-07:00

Coronary artery bypass in a patient with complex coronary artery anomaly [LETTERS TO THE EDITOR]

Kaleda — 2011-09-01T05:09:22-07:00

Should video-assisted surgery be the first-line approach for bronchogenic cysts? [LETTERS TO THE EDITOR]

Cioffi, de Simone — 2011-09-01T05:09:22-07:00

Chest wall stabilization following mediastinitis [LETTERS TO THE EDITOR]

Lentini, Monaco — 2011-09-01T05:09:22-07:00

Retraction [RETRACTION]

2011-09-01T05:09:22-07:00