Comparative Analysis of Therapeutic Strategies in Post-Cardiotomy Cardiogenic Shock: Insight into a High-Volume Cardiac Surgery Center

Background: Post-cardiotomy cardiogenic shock (PCCS), which is defined as severe low cardiac output syndrome after cardiac surgery, has a mortality rate of up to 90%. No study has yet been performed to compare patients with PCCS treated by conservative means to patients receiving additional mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (ECMO). Methods: A single-center retrospective analysis from January 2018 to June 2022 was performed. Results: Out of 7028 patients who underwent cardiac surgery during this time period, 220 patients (3%) developed PCCS. The patients were stratified according to their severity of shock based on the Stage Classification Expert Consensus (SCAI) group. Known risk factors for shock-related mortality, including the vasoactive-inotropic score (VIS) and plasma lactate levels, were assessed at structured intervals. In patients treated additionally with ECMO (n = 73), the in-hospital mortality rate was 60%, compared to an in-hospital mortality rate of 85% in patients treated by conservative means (non-ECMO; n = 52). In 18/73 (25%) ECMO patients, the plasma lactate level normalized within 48 h, compared to 2/52 (4%) in non-ECMO patients. The morbidity of non-ECMO patients compared to ECMO patients included a need for dialysis (42% vs. 60%), myocardial infarction (19% vs. 27%), and cerebrovascular accident (17% vs. 12%). Conclusions: In conclusion, the additional use of ECMO in PCCS holds promise for enhancing outcomes in these critically ill patients, more rapid improvement of end-organ perfusion, and the normalization of plasma lactate levels.

Transcatheter closure of postsurgical aortic pseudoaneurysms guided by three-dimensional image reconstruction: a single-centre experience

BACKGROUND

Postsurgical thoracic aortic pseudoaneurysms (PTAPs) are a potentially lethal complication after cardiac or aortic surgery. Surgical management can pose a challenge with high in-hospital mortality rates. Transcatheter closure is a less-invasive alternative treatment option for selected patients, although current experience is limited.

AIMS

We aimed to evaluate procedural and imaging outcomes of our first 11 cases of transcatheter PTAP closure with the use of closure devices.

METHODS

Patients with a high operative risk who underwent transcatheter PTAP closure at our centre from 2019 to 2021 were retrospectively included. Suitability was evaluated on preprocedural computed tomography (CT) scans and three-dimensional (3D) reconstructions. All procedures were performed in the catheterisation laboratory. Intraprocedural aortography and postprocedural CT scans with 3D reconstructions were used to evaluate PTAP occlusion.

RESULTS

Eleven consecutive patients with a high operative risk and a history of cardiac/aortic surgery who underwent transcatheter PTAP closure were included. PTAPs were predominantly located at the proximal or distal anastomosis of a supracoronary ascending aortic vascular graft or Bentall prosthesis (82%). Implanted closure devices included Amplatzer Valvular Plug III (82%), Amplatzer septal occluder (9%) and Occlutech atrial septal defect occluder (9%). No periprocedural complications occurred. After device deployment, residual flow was absent on aortography in 64% and minimal residual flow was present in 36% of patients. Subtotal or total occlusion of the PTAP on follow-up CT ranged between 45% and 73%.

CONCLUSIONS

Although subtotal or total occlusion of the PTAP was found at follow-up in only 45-73% of cases, transcatheter PTAP closure guided by preprocedural 3D reconstructions can offer a valuable minimally invasive primary treatment option for patients who otherwise would face a high-risk reoperation.

Endovascular Repair of Complicated Type B Aortic Intramural Haematoma: A Single Centre Long Term Experience

OBJECTIVE

To evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) in the treatment of patients with complicated type B aortic intramural haematoma (IMH).

METHODS

A retrospective observational study of patients treated between January 2002 and December 2017 was performed. Complicated type B IMH was defined as persistent pain, rapid dilatation, presence of ulcer-like projections (ULPs), haemothorax, and other signs of (impending) rupture. Thirty day results and long term follow up outcomes were reported.

RESULTS

Thirty-nine patients were included for analysis (mean age 68 ± 8 years, 36% male). The thirty day mortality rate was 5%, stroke rate 10%, and re-intervention rate 3%. The median follow up duration was 49 months (25th - 75th percentile: 2 - 96 months). At 10 years, estimated freedom from all cause mortality was 66 ± 9%. During follow up, nine re-interventions were performed, leading to a 10 year estimated freedom from re-intervention rate of 72 ± 8%. Estimated freedom from aortic growth at 10 years was 85 ± 9%.

CONCLUSION

Complicated type B IMH can be treated effectively by TEVAR, thus preventing death from aortic rupture. However, severe early post-operative complications, most importantly stroke, are of concern. Long term outcomes are excellent, although re-interventions are not uncommon, either for progression of proximal or distal aortic disease or due to stent graft related complications.

Surgical bypass from the left common carotid artery to the left subclavian artery: Supraclavicular approach

To create an optimal landing zone (zone 2) in the aortic arch for concomitant or subsequent thoracic endovascular aortic repair of aortic diseases (aneurysm, dissection), surgeons frequently need to debranch the supra-aortic vessels. In this video tutorial, we present an alternative to our 2 other video tutorials for surgical debranching of the left subclavian artery (link; link). Depending on patient-specific characteristics, surgical preference and local experience, the surgeon chooses the approach. Here we show how to safely perform a supraclavicular left common carotid artery-to-left subclavian artery bypass.

Surgical bypass from the left common carotid artery to the left subclavian artery: Central approach

To create an optimal landing zone (zone 2) in the aortic arch for concomitant or subsequent thoracic endovascular aortic repair of aortic diseases (aneurysm, dissection), surgeons frequently need to debranch the supra-aortic vessels. We present a surgical debranching of the left subclavian artery by performing a centrally located bypass from the left common carotid artery to the left subclavian artery.

Surgical bypass from the left common carotid artery to the left subclavian artery: Infraclavicular approach

To create an optimal landing zone (zone 2) in the aortic arch for concomitant or subsequent thoracic endovascular aortic repair of aortic diseases (aneurysm, dissection), surgeons frequently need to debranch the supra-aortic vessels. We present in this video tutorial an alternative to our video tutorial for surgical debranching of the left subclavian artery in which we used a central approach. When the proximal left subclavian artery is dissected or shows dense adhesions around its proximal, centrally located section, it can be helpful to stretch this bypass to the infraclavicular part of the left subclavian artery.

A New Methodology to Determine Apposition, Dilatation, and Position of Endografts in the Descending Thoracic Aorta After Thoracic Endovascular Aortic Repair

Purpose: To validate computed tomography angiography (CTA)–applied software to assess apposition, dilatation, and position of endografts in the proximal and distal landing zones after thoracic endovascular aortic repair (TEVAR) of thoracic aortic aneurysm. Materials and Methods: Twenty-two patients (median age 75.5 years; 11 men) with a degenerative descending thoracic aortic aneurysm treated with TEVAR with at least one postoperative CTA were selected from a single center’s database. New CTA-applied software was used to determine the available apposition surface in the proximal and distal landing zones, apposition of the endograft fabric with the aortic wall, shortest apposition length, endograft inflow and outflow diameters, shortest distance between the left subclavian artery and the proximal endograft fabric, and shortest distance between the celiac trunk and the distal endograft fabric on each CTA. Interobserver variability for these parameters was assessed with the repeatability coefficient and the intraclass correlation coefficient. Results: Excellent interobserver agreement was found for all measurements. Interobserver variability of surface and shortest apposition length calculations was larger for the distal site compared with the proximal site, with a mean difference of 10% vs 2% of the mean available apposition surface, 12% vs 5% of the endograft apposition surface, and 16% vs 8% of the shortest apposition length, respectively. Inflow and outflow diameters of the endograft showed low variability, with a mean difference of 0.1 mm with 95% of the interobserver difference within 1.8 mm. Mean interobserver differences of the proximal and distal shortest fabric distances were 1.0 and 0.9 mm (both 2% of the mean lengths). Conclusion: Assessment of apposition, dilatation, and position of the proximal and distal parts of an endograft in the descending thoracic aorta is feasible after TEVAR with the new software. Interobserver agreement for all measured parameters was excellent for the proximal and distal landing zones. The new method allows detection of subtle changes during follow-up. However, a larger study is needed to quantify how parameters change over time in complicated and uncomplicated TEVAR cases and to define the real added value of the new methodology.

[Surgery in patients with centrally-situated non-small cell lung carcinoma: lung-parenchymal sparing procedure versus pneumonectomy]

OBJECTIVE

To examine if lung-parenchymal sparing resection ('sleeve' resection) is a safe and oncologically responsible alternative to pneumonectomy in patients with central tumours. Further, to evaluate in how far this technique is being used in the Netherlands.

DESIGN

Retrospective cohort study.

METHOD

Patients undergoing either lung-parenchymal sparing procedure or pneumonectomy for centrally situated non-small cell lung carcinoma (NSCLC) between January 1995 and January 2010 were included. Early mortality, perioperative complications, survival and disease-free survival in both groups were compared. Survival was calculated using the Kaplan-Meier method.

RESULTS

A total 78 patients underwent sleeve resection and 89 pneumonectomy. Early mortality (during admission or within 30 days of operation) in the sleeve-resection group was 1.3% (1 patient), and 9.0% (8) (p = 0.038) in the pneumonectomy group. In the sleeve-resection group 6.4% (5) developed a bronchopleural fistula; in the pneumonectomy group this was 4.5% (4) (p=0.735). Median survival in the sleeve-resection group was 90 months, and 1- and 5-year-survival were 88 (SD: 4) and 61% (SD: 6), respectively. Median survival in the pneumonectomy group was 17 months, with a 1- and 5-year survival of 63 (SD: 5) and 24% (SD: 5), respectively. The difference in survival was significant (p <0.001; hazard ratio: 3.27; 95% CI: 2.11-5.08). The effect of TNM stage was not statistically significant in addition to operation (p = 0.079) and TNM stage was not a clear confounder: even after analysis the hazard ratio was 2.74. In the sleeve-resection group, after 5 years disease-free survival was 62% (SD: 7). In the pneumonectomy group, this was 34% (SD: 7) (p = 0.05).

CONCLUSION

Patients with centrally-situated NSCLC who undergo a lung-parenchymal sparing procedure have lower mortality and better survival than patients who undergo pneumonectomy.

Staging for locally advanced pancreatic cancer

AIM

To address the role of a dedicated radiologist and high quality CT scanning in staging of patients referred with suspected locally advanced pancreatic cancer. Furthermore, the value of laparoscopy in detecting CT-occult metastases in these patients was assessed.

METHODS

In a prospective cohort study, 116 patients with suspected unresectable pancreatic cancer referred from peripheral hospitals (107) or our own gastroenterology department (9) were analysed. CT scans from referral centres were reviewed and in case of locally advanced disease or uncertain metastatic disease, patients underwent a laparoscopy to detect CT-occult metastases. Patients without metastases were offered 5-FU based chemoradiotherapy.

RESULTS

After reviewing 107 abdominal CT scans from referral centres, 73 (68%) scans had to be repeated due to unacceptable quality. Locally advanced disease was confirmed in 59 (55%) patients and metastatic disease was found in 24 patients (22%). During laparoscopy, metastases were found in 24/68 (35%) patients with locally advanced disease on CT scan and metastases were confirmed in 3/5 (60%) with suspected metastases. Overall, only 46/116 (40%) patients with suspected unresectable disease appeared to have locally advanced pancreatic cancer after adequate staging including laparoscopy in our centre.

CONCLUSION

Correct staging is difficult in patients with suspected locally advanced pancreatic cancer and should preferably be performed in centres with technically advanced equipment and experienced radiologists. Laparoscopy should be offered to patients before locoregional therapy.

Long-term survival after radical resection for pancreatic head and ampullary cancer: a potential role for the EGF-R

BACKGROUND/AIM

Pancreatic cancer has a dismal prognosis. Ampullary cancer (defined as cancer of the ampulla of Vater or the distal common bile duct) has a better prognosis and is thought to be a biologically different tumor. The aim of this study was to find factors that could predict survival after radical (R-0) resection for pancreatic head and ampullary cancers.

METHODS

We analyzed clinical and pathological data from 93 patients who underwent a true R-0 resection for pancreatic head or ampullary cancer. Furthermore, we performed a tissue microarray protein expression analysis for several growth factor receptors and oncogenes: HER-2, EGF-R, ER, PR, C-myc, p53, p16, RB-1, and chromogranin A as a neuroendocrine differentiation marker.

RESULTS

Median survival (14 vs. 42 months) and time to recurrence (16 vs. 42 months) were significantly longer for ampullary than for pancreatic head cancers. Preoperative pain, perineural invasion, lymph node metastasis, and tumor differentiation grade are indicators of a poor survival. No differences in protein expression were found between groups, except for EGF-R which was expressed more in pancreatic head cancers (p = 0.026).

CONCLUSIONS

Outcomes for ampullary cancers are better than for pancreatic head cancers. This different biological behavior can possibly be explained by differences in EGF-R expression.

Adjuvant 5-FU-based chemoradiotherapy for patients undergoing R-1/R-2 resections for pancreatic cancer

BACKGROUND

Pancreatic cancer is the fifth leading cause of cancer-related death worldwide. Among patients treated with surgery alone, liver metastasis occurs in up to 50%, peritoneal recurrence in 25%, and local recurrence occurs in 50-80% of all patients who underwent resection. Even after a macroscopically curative resection, tumour cells might be observed by microscopy at one or more edges of the resected specimen in 20-51% (R-1) which might account for the high local recurrence.

AIM OF THE STUDY

An analysis was performed in 54 patients who underwent an irradical resection (R-1 and R-2) for pancreatic cancer. 33 patients were treated with chemoradiotherapy. To evaluate the effect of therapy on survival and recurrence, this group was retrospectively compared to a group of 21 patients that did not receive chemoradiotherapy.

METHODS

Radiotherapy consisted of 50 Gy external upper abdomen radiation in two courses of 3 weeks, concomitant with intravenous 5-FU 25 mg/kg/24 h continuously on the first 4 days of each treatment course. Follow-up was performed mainly by CT scanning and occasionally by US and was completed for all but 1 patient.

RESULTS

The treatment protocol was completed in all patients without complications. Local recurrence was found in 6 (18%) patients in the group of patients who received adjuvant therapy versus 16 (48%) patients in the group that did not receive adjuvant therapy (p = 0.001). The median survival time for the treated group was 12.8 vs. 13.7 months in the group that did not receive chemoradiotherapy (p = 0.9). Three (9%) patients are still alive 140, 88 and 70 months after receiving surgery and adjuvant treatment.

CONCLUSION

Adjuvant chemoradiotherapy clearly gives a significant better local control. However, treatment with 5-FU and radiotherapy does not improve survival due to distant metastases. This therapy probably prolongs survival in only a few patients. More effective treatment methods have to be designed to prevent metastatic disease and improve survival.

Locally advanced pancreatic cancer treated with radiation and 5-fluorouracil: a first step to neoadjuvant treatment?

AIM OF THE STUDY

In two institutions, a retrospective analysis was performed on patients with histologically proven locally advanced pancreatic cancer without distant metastases. The aim of this analysis is to assess whether chemoradiotherapy provides survival benefit for patients with locally advanced pancreatic cancer.

METHODS

Forty-five patients from the Erasmus Medical Centre (Erasmus MC), Rotterdam, received 5-fluorouracil (5-FU) and radiotherapy and, 38 patients from the Academic Medical Centre Amsterdam (AMC) were offered the best supportive care. Radiotherapy consisted of 50 Gy external upper abdomen radiation in two courses, concomitant with intravenous 5-FU 25 mg/kg/ 24 h continuously on the first 4 days of each treatment course.

RESULTS

The treatment protocol was completed in 38 of 45 patients (84%) without complications. Radiological response was evaluated in 38 patients. Ten patients (26%) showed a partial response, stable disease was seen in 6 (16%) patients and progressive disease in 22 (58%) patients. A second-look operation was performed in 8 of 10 patients (72%) showing a radiological response, in 3 patients the tumour could be resected. Median overall survival time for the Erasmus MC group (n = 45) was 9.8 months compared to 7.6 months when the best supportive care was given (AMC group, p = 0.04).

CONCLUSION

Although overall survival remains poor, treatment with 5-FU and radiotherapy might benefit some patients with locally advanced pancreatic cancer.

Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors

OBJECTIVE

A prospective randomized multicenter study was performed to assess whether the results of pylorus-preserving pancreaticoduodenectomy (PPPD) equal those of the standard Whipple (SW) operation, especially with respect to duration of surgery, blood loss, hospital stay, delayed gastric emptying (DGE), and survival.

SUMMARY BACKGROUND DATA

PPPD has been associated with a higher incidence of delayed gastric emptying, resulting in a prolonged period of postoperative nasogastric suctioning. Another criticism of the pylorus-preserving pancreaticoduodenectomy for patients with a malignancy is the radicalness of the resection. On the other hand, PPPD might be associated with a shorter operation time and less blood loss.

METHODS

A prospective randomized multicenter study was performed in a nonselected series of 170 consecutive patients. All patients with suspicion of pancreatic or periampullary tumor were included and randomized for a SW or a PPPD resection. Data concerning patients' demographics, intraoperative and histologic findings, as well as postoperative mortality, morbidity, and follow-up up to 115 months after discharge, were analyzed.

RESULTS

There were no significant differences noted in age, sex distribution, tumor localization, and staging. There were no differences in median blood loss and duration of operation between the 2 techniques. DGE was observed equally in the 2 groups. There was only a marginal difference in postoperative weight loss in favor of the standard Whipple procedure. Overall operative mortality was 5.3%. Tumor positive resection margins were found for 12 patients of the SW group and 19 patients of the PPPD group (P < 0.23). Long-term follow-up showed no significant statistical differences in survival between the 2 groups (P < 0.90).

CONCLUSIONS

The SW and PPPD operations were associated with comparable operation time, blood loss, hospital stay, mortality, morbidity, and incidence of DGE. The overall long-term and disease-free survival was comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma.

Survival after surgical management of pancreatic adenocarcinoma: does curative and radical surgery truly exist?

Surgery for pancreatic cancer offers a low success rate but it provides the only likelihood of cure. Modern series show that, in experienced hands, the standard Whipple procedure is associated with a 5-year survival of 10%-20%, with a perioperative mortality rate of less than 5%. Most patients, however, will develop recurrent disease within 2 years after curative treatment. This occurs, usually, either at the site of resection or in the liver. This suggests the presence of micrometastases at the time of operation. Negative lymph nodes are the strongest predictor for long-term survival. Other predictors for a favourable outcome are tumour size, radical surgery and a histopathologically well-differentiated tumour. Adjuvant therapy has, so far, shown only modest results, with 5FU chemotherapy, to date, the only proven agent able to increase survival. Nowadays, the choice of therapy should be based on histopathological assessment of the tumour. Knowledge of the molecular basis of pancreatic cancer has led to various discoveries concerning its character and type. Well-known examples of genetic mutations in adenocarcinoma of the pancreas are k-ras, p53, p16, DPC4. Use of molecular diagnostics and markers in the assessment of tumour biology may, in future, reveal important subtypes of this type of tumour and may possibly predict the response to adjuvant therapy. Defining the subtypes of pancreatic cancer will, hopefully, lead to target-specific, less toxic and finally more effective therapies. Long-term survival is observed in only a very small group of patients, contradicting the published actuarial survival rates of 10%-45%. Assessment of clinical benefit from surgery and adjuvant therapy should, therefore, not only be based on actuarial survival but also on progression-free survival, actual survival, median survival and quality of life (QOL) indicators. Survival in surgical series is usually calculated by actuarial methods. If there is no information on the total number of patients and the number of actual survivors, and no clear definition of the subset of patients, actuarial survival curves can prove to be misleading. Proper assessment of QOL after surgery and adjuvant therapy is of the utmost importance, as improvements in survival rates have, so far, proved to be disappointing.

Flow profiles in the left anterior descending and the right coronary artery assessed by MR velocity quantification: effects of through-plane and in-plane motion of the heart

PURPOSE

The purpose of this work was to compare the temporal profiles of volume flow in the left anterior descending artery (LAD) and the right coronary artery (RCA) and to assess the effect of through-plane and in-plane myocardial motion.

METHOD

In eight healthy volunteers, MR phase-difference velocity quantification was applied with prospective ECG triggering, pixel size of 1.16 x 0.98 mm2 (LAD) or 1.25 x 0.98 mm2 (RCA), velocity sensitivity of 40 cm/s, and data acquisition time window of 64 ms for LAD (3 ky lines per heartbeat) and 24 ms for RCA. In-plane motion was measured from the magnitude images.

RESULTS

In the LAD, systolic peak and mean flow values were 0.94+/-0.28 and 0.30 +/-0.22 ml/s, respectively. Diastolic peak and mean flows were 2.42+/-0.56 and 1.38+/-0.43 ml/s. The systolic to diastolic ratio was 0.37+/-0.12 for peak flow and 0.22+/-0.15 for mean flow. Mean flow through the cardiac cycle was 59.1+/-15.0 ml/min. In the RCA, systolic peak and mean flow values were 1.96+/-0.69 and 0.74+/-0.31 ml/s, respectively. Diastolic peak and mean flows were 1.80+/-0.53 and 0.83+/-0.20 ml/s. The systolic to diastolic ratio was 0.97+/-0.58 for peak flow and 0.85+/-0.39 for mean flow. Mean flow through the cardiac cycle was 38.4+/-10.8 ml/min. The in-plane velocity of the coronary artery cross-section was 6.4+/-1.8 cm/s for the LAD and 14.9 +/-4.0 cm/s for the RCA (given by peak values in diastole).

CONCLUSION

It is confirmed noninvasively with MR that the LAD shows a predominantly diastolic flow, whereas the RCA shows about equal flow values in systole and diastole. Through-plane motion correction is required for assessing the true flow patterns. The in-plane velocities of the coronary artery cross-sections imply a maximum data acquisition time window, estimated at 58 ms for the LAD and at 23 ms for the RCA.