Robotic navigational bronchoscopy in a thoracic surgery practice: Leveraging technology in the management of pulmonary nodules

Objectives

Robotic navigational bronchoscopy is increasingly used to improve diagnostic yield for pulmonary nodules compared with the 50% to 60% obtained by standard bronchoscopy; however, safety and efficacy data are limited to small series. The aim of this study was to evaluate diagnostic yield and clinical outcomes in a large multisurgeon single-center cohort.

Methods

All patients who underwent robotic navigational bronchoscopy and biopsy from September 2020 to October 2022 were identified from a prospective institutional registry. The primary outcome was diagnostic yield. The secondary outcome was diagnostic yield for molecular testing.

Results

A total of 503 nodules were biopsied during the study period. Median nodule size was 2.1 cm. Overall diagnostic yield was 87.9%. Factors associated with increased diagnostic yield were decreased time from date of planning computed tomography to procedure date (odds ratio, 0.98; 95% CI, 0.96-0.99; P = .04) and greater nodule size (odds ratio, 1.03; 95% CI, 1.01-1.07; P = .02) per 0.1-cm increment. Molecular analysis was sent in 101 patients and was sufficient in 90% of cases. Complications occurred in 22 (5%) patients, including 13 (3.1%) with pneumothoraxes (7 patients requiring a chest drain), and 5 (1.2%) patients had bleeding requiring intraprocedural bronchial intervention. A total of 41 patients were consented for biopsy and resection during a single anesthetic event. Four of these cases were stopped at robotic navigational bronchoscopy due to an alternative diagnosis. Mean length of stay was 3.4 ± 1.1 days. There were no major complications.

Conclusions

This study suggests robotic navigational bronchoscopy has a high diagnostic yield and obtains adequate tissue for molecular analysis critical for selection of targeted therapies. With careful patient selection robotic navigational bronchoscopy can be combined with surgery to treat lung cancer as a single procedure with low complication rates.

Highly Sensitive Non-Invasive Early Lung Cancer Detection Utilizing DNA Methylation Topology in Sputum-Derived Epithelial Cells

Objective

Sputum is a source of exfoliated respiratory epithelial cells transformed early in lung carcinogenesis. Malignant cells are hypomethylated and contain less genomic 5-methylcytosine (5mC). Validating a test that recognizes and quantifies aberrantly hypomethylated cells in sputum, we assessed its potential as a screening tool for detecting early-stage non-small cell lung cancer.

Methods

Cells extracted from sputum were immunofluorescence labeled with an anti-5-methylcytosine antibody and counterstained with 4',6-diamidino-2-phenylindole (DAPI) delineating global nuclear DNA (gDNA). Via confocal scanning and 3-dimensional image analysis, fluorescence 5mC and DAPI signals were measured in segmented cell nuclei, and a 5mC/DAPI co-distribution map was generated for each imaged cell. Cells were classified as hypomethylated based on 5mC load and 5mC/DAPI co-distribution. The proportion of hypomethylated epithelial cells in the sputum determines whether a patient has lung cancer.

Results

A total of 88 subjects were enrolled: 12 healthy subjects; 34 high-risk subjects with benign chronic lung disorders (10 with chronic obstructive pulmonary disease, 24 with idiopathic pulmonary fibrosis), and 43 subjects with non-small cell lung cancer (27 with stage I-II and 16 with stage III-IV). The test identified early-stage non-small cell lung cancer and distinguished it from the high-risk group with 95.8% (95% confidence interval, 78.9-99.9) sensitivity and 41.2% (95% confidence interval, 24.6-59.3) specificity applying only 5mC, 95.8% (95% confidence interval, 78.9-99.9) sensitivity and 26.5% (95% confidence interval, 12.9-44.4) specificity using solely 5mC/DAPI index, and 100% (95% confidence interval, 98.7-100) sensitivity and 26.1% (95% confidence interval, 26.2-27.8) specificity with the combined parameters.

Conclusions

We tested and validated a novel, noninvasive, highly sensitive screening test for non-small cell lung cancer. With the use of sputum, our test may impact lung cancer screening, evaluation of pulmonary nodules, and cancer surveillance algorithms.

Senescence of Alveolar Type 2 Cells Drives Progressive Pulmonary Fibrosis

Rationale: Idiopathic pulmonary fibrosis (IPF) is an insidious and fatal interstitial lung disease associated with declining pulmonary function. Accelerated aging, loss of epithelial progenitor cell function and/or numbers, and cellular senescence are implicated in the pathogenies of IPF.Objectives: We sought to investigate the role of alveolar type 2 (AT2) cellular senescence in initiation and/or progression of pulmonary fibrosis and therapeutic potential of targeting senescence-related pathways and senescent cells.Methods: Epithelial cells of 9 control donor proximal and distal lung tissues and 11 IPF fibrotic lung tissues were profiled by single-cell RNA sequencing to assesses the contribution of epithelial cells to the senescent cell fraction for IPF. A novel mouse model of conditional AT2 cell senescence was generated to study the role of cellular senescence in pulmonary fibrosis.Measurements and Main Results: We show that AT2 cells isolated from IPF lung tissue exhibit characteristic transcriptomic features of cellular senescence. We used conditional loss of Sin3a in adult mouse AT2 cells to initiate a program of p53-dependent cellular senescence, AT2 cell depletion, and spontaneous, progressive pulmonary fibrosis. We establish that senescence rather than loss of AT2 cells promotes progressive fibrosis and show that either genetic or pharmacologic interventions targeting p53 activation or senescence block fibrogenesis.Conclusions: Senescence of AT2 cells is sufficient to drive progressive pulmonary fibrosis. Early attenuation of senescence-related pathways and elimination of senescent cells are promising therapeutic approaches to prevent pulmonary fibrosis.

Outcomes of patients with advanced non-small cell lung cancer and airway obstruction treated with photodynamic therapy and non-photodynamic therapy ablation modalities

Background

Non-small cell lung cancer (NSCLC) patients with central airway obstruction (CAO) may have better survival on systemic therapy if the airway patency is successfully restored by bronchoscopic interventions. It remains unclear which therapeutic bronchoscopic modality [laser, stenting, external beam radiation, brachytherapy and photodynamic therapy (PDT)] used for restoring airway patency positively affects outcomes in these patients. We analyzed the effectiveness of PDT in terms of mortality, and time to subsequent treatments in patients with stage III and IV NSCLC.

Methods

Study used Surveillance, Epidemiology, and End Results (SEER) Medicare linked data. We categorized NSCLC patients diagnosed between 2000 and 2011 and with stage III and IV, into three treatment groups: PDT + radiation ± chemotherapy, non-PDT ablation therapy + radiation ± chemotherapy, and radiation + chemotherapy. We analyzed all-cause and cause-specific mortality using Cox proportional hazard models with an inverse probability weighted propensity score adjustment. Time to subsequent treatment was analyzed using GLM model.

Results

For the PDT group, hazard for all-cause and cause-specific mortality was comparable to the radiation + chemotherapy group (HR =1.03, 95% CI: 0.73-1.45; and HR =1.04, 95% CI: 0.71-1.51, respectively). The non-PDT ablation group had higher hazard for all-cause (HR =1.22, 95% CI: 1.13-1.33) and cause-specific mortality (HR =1.10, 95% CI: 1.01-1.20), compared to the radiation + chemotherapy group. The PDT group had longer time to follow-up treatment, compared to non-PDT ablation group.

Conclusions

In our exploratory study of stage III and IV NSCLC patients with CAO, addition of PDT demonstrated hazard of mortality comparable to radiation + chemotherapy group. However, addition of non-PDT ablation showed higher mortality compared to the radiation + chemotherapy group. Future studies should investigate the efficacy and effectiveness of multimodal therapy including radiation, chemo, immunotherapy and bronchoscopic interventions.

Disparities in Compliance With National Guidelines for the Treatment of Malignant Pleural Mesothelioma

BACKGROUND

Current guidelines support cancer-directed surgery, chemotherapy, or active surveillance for clinical stages 1 to 3 of epithelial malignant pleural mesothelioma (MPM). Definitive chemotherapy is recommended for sarcomatoid/biphasic histologies. Our objective is to assess compliance with recommendations, measuring their impact on overall survival.

METHODS

The National Cancer Database participant user file (2004 to 2014) was queried for patients diagnosed with MPM clinical stages 1 to 3. Multivariable logistic regression model identified factors independently associated with guideline compliance. Kaplan-Meier analysis and Cox proportional hazards were used for overall survival comparison with histologic subgroup analysis.

RESULTS

A total of 3419 patients with clinical stages 1 to 3 met criteria for analysis and comprised epithelial (68.5%), sarcomatoid (17.2%), and biphasic subtypes (14.3%). Cancer-directed surgery was significantly underutilized in epithelial MPM, with 29.3% having no treatment. On multivariable analysis, insurance status and facility type were the strongest predictors of guideline compliance. High-volume hospitals were the most compliant with guidelines (odds ratio 3.58, 95% confidence interval (CI), 2.34 to 5.49, P < .001). Median survival estimates for no treatment, chemotherapy alone, surgery plus chemotherapy, and trimodal therapy were 10.2, 15.4, 21.1, and 21.7 months, respectively (log rank P < .001). In epithelial MPM, a significant increase in overall survival was observed in surgery plus chemotherapy (hazard ratio 0.62, 95% CI, 0.53 to 0.73, P < .001) and trimodality (hazard ratio 0.61, 95% CI, 0.49 to 0.76, P < .001; reference: no treatment).

CONCLUSIONS

There is a suboptimal compliance with national guidelines for the treatment of MPM, particularly in low-volume nonacademic settings. Adherence to recommended surgery-based multimodal therapy is associated with an overall survival improvement.

Predictors of Failure to Rescue After Esophagectomy

BACKGROUND

Failure to rescue (FTR), defined as death after a major complication, is a metric increasingly being used to assess quality of care. Risk factors associated with FTR after esophagectomy have not been previously studied.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent esophagectomy with gastric conduit between 2010 and 2014. Patients with at least one major postoperative complication were grouped according to inhospital mortality (FTR group) and survival to discharge (SUR group). A stepwise logistic regression model was used to identify predictors of FTR.

RESULTS

A total of 1,730 patients comprised the study group, with 102 (5.9%) in the FTR group and 1,628 (94.1%) in the SUR group. The FTR patients were older (69.0 versus 64.0 years, p < 0.0001) compared with the SUR patients. There were no differences in sex, body mass index, preoperative weight loss, smoking status, operation type, or surgeon specialty between the two groups. Age greater than 75 years (adjusted odds ratio 2.68, p < 0.0001), black race (adjusted odds ratio 2.75, p = 0.001), American Society of Anesthesiologists class 4 or 5 (adjusted odds ratio 1.82, p = 0.02), and the occurrence of pneumonia, respiratory failure, acute renal failure, sepsis, or acute myocardial infarction were predictive of FTR based on multivariable logistic regression.

CONCLUSIONS

Nearly 6% of patients who have a major complication after esophagectomy do not survive to discharge. Age greater than 75 years, black race, American Society of Anesthesiologists class 4 or 5, and complications related to major infection or organ failure predict FTR. Further research is necessary to investigate how these factors affect survival after complications in order to improve rescue efforts.

Current status of research and treatment for non-small cell lung cancer in never-smoking females

Lung cancer is the leading cause of cancer-related deaths worldwide with over 1 million deaths each year. The overall prognosis of lung cancer patients remains unsatisfactory, with a 5-year overall survival rate of less than 15%. Although most lung cancers are a result of smoking, approximately 25% of lung cancer cases worldwide are not attributable to tobacco use. Notably, more than half of the lung cancer cases in women occur in non-smokers. Among non-small-cell lung cancer (NSCLC) cases, cigarette-smokers have a greater association with squamous cell carcinoma than adenocarcinoma, which is more common in non-smokers. These findings imply that specific molecular and pathological features may associate with lung adenocarcinoma arising in non-smoker female patients. Over the past decade, whole genome sequencing and other '-omics' technologies led to the discovery of pathogenic mutations that drive tumor cell formation. These technological developments may enable tailored patient treatments throughout the course of their disease, potentially leading to improved patient outcomes. Some clinical and laboratory studies have shown success outcomes using epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKI) in patients with EGFR mutations and ALK rearrangements, respectively. In fact, these 2 mutations are predominantly present in female non-smokers with adenocarcinoma. Immunotherapy has also recently emerged as a major therapeutic modality in NSCLC. In this review, we summarize the current understanding of NSCLC biology and new therapeutic molecular targets, focusing on the pathogenesis of non-smoker female NSCLC patients.

Survival Difference in Patients with Malignant Pleural Effusions Treated with Pleural Catheter or Talc Pleurodesis

Malignant pleural effusions (MPE) are commonly managed with either pleural catheter (PC) or talc pleurodesis (TP). The aim of this study was to compare survival in MPE patients treated with either PC or TP. A retrospective review of our cancer center database was performed. Patients with metastatic cancer and MPE were analyzed. Demographic and clinical data were tabulated and compared. A total of 238 patients with MPE treated by either PC or TP were included. Of these, 79 patients comprised the PC group and 159 the TP group. PC had a higher incidence of advanced disease (stage III or IV) at initial diagnosis compared with TP (70.9% vs 57.2%, P = 0.05). TP had a longer postprocedure length of stay compared with PC (7.1 vs 5.0 days, P = 0.02); however, overall length of stay was similar (9.7 vs 11.1 days, P = 0.34). Read-missions were significantly lower in TP (11.9% vs 22.8%, P = 0.04). Mean survival was higher in TP compared with PC (18.7 vs 4.1 months, P < 0.001). Patients with metastatic cancer and MPE treated with TP had significantly higher survival compared with PC. This is likely related to a greater disease burden in PC, as 70 per cent of patients in this group had stage III or IV disease on initial presentation.

Survival Difference in Patients with Malignant Pleural Effusions Treated with Pleural Catheter or Talc Pleurodesis

Malignant pleural effusions (MPE) are commonly managed with either pleural catheter (PC) or talc pleurodesis (TP). The aim of this study was to compare survival in MPE patients treated with either PC or TP. A retrospective review of our cancer center database was performed. Patients with metastatic cancer and MPE were analyzed. Demographic and clinical data were tabulated and compared. A total of 238 patients with MPE treated by either PC or TP were included. Of these, 79 patients comprised the PC group and 159 the TP group. PC had a higher incidence of advanced disease (stage III or IV) at initial diagnosis compared with TP (70.9% vs 57.2%, P = 0.05). TP had a longer postprocedure length of stay compared with PC (7.1 vs 5.0 days, P = 0.02); however, overall length of stay was similar (9.7 vs 11.1 days, P = 0.34). Readmissions were significantly lower in TP (11.9% vs 22.8%, P = 0.04). Mean survival was higher in TP compared with PC (18.7 vs 4.1 months, P < 0.001). Patients with metastatic cancer and MPE treated with TP had significantly higher survival compared with PC. This is likely related to a greater disease burden in PC, as 70 per cent of patients in this group had stage III or IV disease on initial presentation.

Gastroesophageal Reflux Reported on Esophagram Does Not Correlate with pH Monitoring and High-resolution Esophageal Manometry

Gastroesophageal reflux disease (GERD) is commonly reported on esophagram (UGI) studies. The correlation of findings suggestive of GERD on UGI with pH monitoring and high-resolution esophageal manometry (HRM) studies is unclear. We investigate the correlation between reflux on UGI with the findings on pH studies and HRM. Subjects completed a symptom questionnaire before their scheduled study. Data from pH and HRM studies were compared with findings of the UGI. Sixty-five patients were evaluated. Reflux was reported on UGI in 19 of 65 (29.2%). Thirty-six patients had both UGI and pH studies; 22 of 36 (61.1%) had reflux on pH studies. UGI had a false-negative finding in 11 of 20 (55%) with no radiographic evidence of reflux. There was a false-positive finding in five of 16 (31.2%) patients on UGI. There was concordance in 11 of 36 (30.5%). Sixty-three patients had both UGI and HRM; there was positive concordance in eight of 63 (12.7%). Using pH monitoring as the gold standard for GERD, sensitivity was 0.50, specificity 0.64, positive predictive value 0.68, and negative predictive value 0.45 for reflux on UGI. The correlation between reflux reported on UGI and 24-hour pH monitoring is poor. Esophagram (UGI) should be reserved for defining structural defects in the esophagus and not reflux.

Gastroesophageal reflux reported on esophagram does not correlate with pH monitoring and high-resolution esophageal manometry

Gastroesophageal reflux disease (GERD) is commonly reported on esophagram (UGI) studies. The correlation of findings suggestive of GERD on UGI with pH monitoring and high-resolution esophageal manometry (HRM) studies is unclear. We investigate the correlation between reflux on UGI with the findings on pH studies and HRM. Subjects completed a symptom questionnaire before their scheduled study. Data from pH and HRM studies were compared with findings of the UGI. Sixty-five patients were evaluated. Reflux was reported on UGI in 19 of 65 (29.2%). Thirty-six patients had both UGI and pH studies; 22 of 36 (61.1%) had reflux on pH studies. UGI had a false-negative finding in 11 of 20 (55%) with no radiographic evidence of reflux. There was a false-positive finding in five of 16 (31.2%) patients on UGI. There was concordance in 11 of 36 (30.5%). Sixty-three patients had both UGI and HRM; there was positive concordance in eight of 63 (12.7%). Using pH monitoring as the gold standard for GERD, sensitivity was 0.50, specificity 0.64, positive predictive value 0.68, and negative predictive value 0.45 for reflux on UGI. The correlation between reflux reported on UGI and 24-hour pH monitoring is poor. Esophagram (UGI) should be reserved for defining structural defects in the esophagus and not reflux.

Benefits of video-assisted thoracoscopic surgery in the treatment of non-small-cell lung cancer

SUMMARY Anatomic lung resection remains the gold standard in the treatment of lung cancer. The traditional approach has been an open thoracotomy with anatomic lobectomy. The approach to the operation has continued to evolve, transitioning from large thoracotomy incisions to smaller muscle sparing incisions to video-assisted thoracic surgery. This article reviews the studies and evidence in support of the potential benefits afforded by the video-assisted thoracic surgery approach in the treatment of lung cancer.

Exercise performance comparison of bicaval and biatrial orthotopic heart transplant recipients

BACKGROUND

The standard biatrial technique for orthotopic heart transplantation uses a large atrial anastomosis to connect the donor and recipient atria. A modified technique involves bicaval and pulmonary venous anastomoses and is believed to preserve the anatomic configuration and physiological function of the atria. Bicaval heart transplantation reduces postoperative valvular regurgitation and is associated with a lower incidence of pacemaker insertion.

OBJECTIVE

The aim of this study was to compare postoperative functional capacity and exercise performance in patients with bicaval and biatrial orthotopic heart transplantation.

METHODS

Patients were selected for the study if they did not have any of the following: obstructive coronary artery disease (>50% stenosis), severe mitral or tricuspid regurgitation, signs of rejection (grade≥1B-1R) on endomyocardial biopsy during the prior year, respiratory impairment, a permanent pacemaker, orthopedic or muscular impediments, or lived more than 150 miles from the medical center. A total of 27 patients qualified. In 15 patients who received a biatrial heart transplant and 12 patients with a bicaval heart transplant, a stationary bicycle exercise test was performed. Ventilatory gas exchange and maximum oxygen consumption measurements were measured.

RESULTS

Recipient and donor characteristics, including body surface area, donor/recipient weight mismatch, immunosuppressive regimen, and self-reported weekly exercise activity, did not differ between the biatrial and bicaval groups (P=not significant [NS]). At peak exercise, similar heart rate, workload, oxygen consumption, carbon dioxide production, ventilation, functional capacity, and exercise duration were found between the 2 groups (P=NS). Patients in the biatrial group were studied later than patients in the bicaval group (6.54±0.71 vs 4.68±0.28 years; P<.001).

CONCLUSION

There were no significant differences in the exercise capacity between patients with biatrial versus bicaval techniques for orthotopic heart transplantation. Factors other than the atrial connection (such as cardiac denervation, immunosuppressive drug effect, or physical deconditioning) may be more important determinants of subnormal exercise capacity after heart transplantation. Nevertheless, the reduction in morbidity and postoperative complications and the simplicity in the bicaval technique suggest that bicaval heart transplantation offers advantages when compared with the standard biatrial technique.

Chromosomal abnormalities and novel disease-related regions in progression from Barrett's esophagus to esophageal adenocarcinoma

Barrett's esophagus (BE) is a metaplastic condition caused by chronic gastroesophageal reflux which represents an early step in the development of esophageal adenocarcinoma (EAC). Single-nucleotide polymorphism microarray (SNP-chip) analysis is a novel, precise, high-throughput approach to examine genomic alterations in neoplasia. Using 250K SNP-chips, we examined the neoplastic progression of BE to EAC, studying 11 matched sample sets: 6 sets of normal esophagus (NE), BE and EAC, 4 of NE and BE and 1 of NE and EAC. Six (60%) of 10 total BE samples and 4 (57%) of 7 total EAC samples exhibited 1 or more genomic abnormalities comprising deletions, duplications, amplifications and copy-number-neutral loss of heterozygosity (CNN-LOH). Several shared abnormalities were identified, including chromosome 9p CNN-LOH [2 BE samples (20%)], deletion of CDKN2A [4 BE samples (40%)] and amplification of 17q12-21.2 involving the ERBB2, RARA and TOP2A genes [3.1 Mb, 2 EAC (29%)]. Interestingly, 1 BE sample contained a homozygous deletion spanning 9p22.3-p22.2 (1.2 Mb): this region harbors only 1 known gene, basonuclin 2 (BNC2). Real-time PCR analysis confirmed the deletion of this gene and decreased the expression of BNC2 mRNA in the BE sample. Furthermore, transfection and stable expression of BNC2 caused growth arrest of OE33 EAC cells, suggesting that BNC2 functions as a tumor suppressor gene in the esophagus and that deletion of this gene occurs during the development of EAC. Thus, this SNP-chip analysis has identified several early cytogenetic events and novel candidate cancer-related genes that are potentially involved in the evolution of BE to EAC.

Ischemic mitral regurgitation: revascularization alone versus revascularization and mitral valve repair

BACKGROUND

In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair.

METHODS

We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group.

RESULTS

No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 +/- 0.14 versus 0.44 +/- 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p < 0.01). The combined surgical group had a greater reduction in IMR grade (2.7 +/- 0.1 grades versus 0.2 +/- 0.1 grade), a lower postoperative IMR grade (0.9 +/- 0.1 versus 2.3 +/- 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p < 0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% +/- 5% versus 41% +/- 7%, p = 0.53). Independently predictive of higher early mortality (< or = 30 days) by Cox analysis were longer pump time (p < 0.001) and older age (p < 0.02). Predictive of late mortality (> 30 days) were older age (p < 0.001), fewer bypass grafts (p < 0.01), and lower ejection fraction (p < 0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure.

CONCLUSIONS

In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients.

Total Circulatory Arrest for the Replacement of the Descending and Thoracoabdominal Aorta

HYPOTHESIS

Hypothermic total circulatory arrest (TCA) in the resection and replacement of the thoracoabdominal and descending thoracic aorta is safe, will significantly decrease the incidence of postoperative renal failure, and should be preferentially performed over left heart bypass (LHB).

DESIGN

Retrospective review case series.

SETTING

Large, private, urban teaching hospital.

PATIENTS

All adult patients with aortic disease that involved the distal aortic arch, the descending thoracic aorta, or the thoracoabdominal aorta who underwent resection and graft replacement of the diseased segment via LHB or TCA at our institution from 1989 to 2001 are included in this study. A total of 59 patients were evaluated: 10 had descending thoracic aneurysms, 20 had thoracoabdominal aneurysms, 22 had chronic type B dissections, 4 had acute type B dissections, and 3 had adult coarctations.

INTERVENTIONS

In 1989 to 1994, LHB was primarily used; in 1994 to 2001, TCA was primarily used.

MAIN OUTCOME MEASURES

Renal failure, 30-day operative mortality, paraplegia, and any other morbidities.

RESULTS

A significant decrease occurred in the incidence of postoperative renal failure from 15% (3/20) in patients who underwent LHB to 0% (0/39) in patients who underwent TCA (P = .04). Furthermore, a significant decrease occurred in the 30-day operative mortality, which decreased from 20% (4/20) in patients who underwent LHB to 5% (2/39) in patients who underwent TCA (P = .04). Postoperative paraplegia decreased from 5% (1/20) in patients who underwent LHB to 2.6% (1/39) in patients who underwent TCA (P > .99).

CONCLUSIONS

Our use of TCA in the resection and replacement of the diseased thoracoabdominal and descending thoracic aorta has produced excellent results. Our patients have experienced no postoperative renal failure and a low 30-day operative mortality. The use of TCA in this patient population is a viable option for surgeons comfortable with the technique.

Surgeons should provide minimally invasive approaches for the treatment of congenital heart disease

The basis for pursuing techniques for less invasive surgery on children with congenital heart disease is to reduce the known long-term morbidities of thoracotomy and sternotomy. In addition, rapid return to normal activities, reduced length of stay, and better pain control may be achieved. Several congenital lesions have been successfully treated with innovative minimally invasive techniques; however, further technique and technology development is required to accomplish repair of the more complex defects safely and effectively.

A novel sub-population of bone marrow-derived myocardial stem cells: potential autologous cell therapy in myocardial infarction

BACKGROUND

Several studies have identified beta2-microglobulin-negative (beta2M(-)) cells as a potential stem cell fraction in the bone marrow of rats and humans. We studied the ability of bone marrow-derived beta2M(-) cells to differentiate into cardiomyocytes and reconstitute the myocardium in a model of myocardial infarction.

METHODS

beta2M(-) cells were purified from bone marrow of Lewis rats using a magnetic activated cell-sorting technique. beta2M(-) cells, 2.5 x 10(6) cells in 100 microl of phosphate-buffered saline (PBS), were transplanted 7 days after infarction into a transmural myocardial scar induced by cryoinjury in Lewis rats (n = 9). Control Group 1(n = 10) received a 100-microl injection of PBS, and Control Group 2 (n = 15) received no injection. The beta2M(-) cells were labeled before transplantation, using the membrane fluorescent intercalated dye, PKH26. Repopulation was examined at 6 and 8 weeks after transplantation. Differentiation of beta2M(-) cells into cardiac myocytes was determined by the colocalization of troponin and PKH26 to the same cell, utilizing immunohistochemistry, ultraviolet photomicroscopy and fluorescence microscopy on 6-microm serial sections. Area of engraftment within the scar was calculated by planimetry.

RESULTS

The treatment group had multiple islands of de novo-formed myocardium within the fibrous matrix of the transmural scar (mean area 35 +/- 4.2% of scar area at 6 and 8 weeks). These cells colocalized cardiac-specific troponin and PKH26. Using these techniques, no myocardial islands were seen in the control groups. Before transplantation, beta2M(-) cells were troponin-negative.

CONCLUSIONS

This study demonstrates that beta2M(-) cells represent a novel sub-population of bone marrow-derived stem cells capable of successful and substantial engraftment in areas of transmural myocardial scar, with de novo formation of cardiac myocytes. The functional significance of this observation is being studied.

Inhibition of graft coronary arteriosclerosis after heart transplantation

Graft coronary arteriosclerosis (GCA) is the leading cause of long-term mortality after heart transplantation (HTx). The goal of this study was to demonstrate that inhibition of immunemediated injury by cyclosporine (CsA) protects the allograft from GCA. ACI-to-Lewis rat allografts were disparate in major and nonmajor histocompatibility loci. Isografts (Lewis-Lewis) were controls. Treatment groups received either olive oil or CsA at 2.5, 5, 10, or 20 mg/kg/day for 3 months. Histology (elastin) and immunohistochemistry using monoclonal antibodies to CD4, CD8, CD45R, RT1B, CD11b/c, CD25, and alpha-actin was performed to examine the epicardial and intramyocardial coronary arteries. Computerized image morphometry was utilized to measure intimal and medial thickness and area. Rats receiving olive oil or CsA at 2.5 mg/kg/day had severe rejection and no graft survival. CsA at 5 mg/kg/day resulted in less severe rejection with significant intimal and medial proliferation (P < 0.001). CsA at 10-20 mg/kg/day paralleled Lewis-Lewis isograft outcomes and inhibited arteriosclerotic vascular changes in the allograft (P < 0.001). Perivascular T-helper cells and macrophages were a characteristic finding with low-dose CsA but rare with higher CsA doses. In this new model of accelerated GCA in rats, immune-mediated antigen-dependent vasculopathy as a result of inadequate immunosuppresion is fundamental in the development of GCA, which appeared equally in epicardial arteries and intramyocardial arterioles. CsA prevents GCA in a dose-dependent fashion in the rat allograft.

Biventricular support in patients with profound cardiogenic shock: a single center experience

Options for managing heart failure patients with cardiogenic shock refractory to inotropic and intra-aortic balloon pump (IABP) therapy are limited. Ventricular assist devices (VADs) can bridge these patients to heart transplantation. However, controversy exists over whether extracorporeal membrane oxygenation (ECMO) before VAD placement is beneficial. We report our use of biventricular assist devices (BiVADs) as a direct bridge to transplant. Since July 1999, 19 Thoratec BiVADs were implanted for heart failure unresponsive to medical therapy. Patient ages ranged from 20 to 67 years. Causes of heart failure included idiopathic 32%, ischemic 26%, postcardiotomy 21%, and other 21%. All patients were in cardiogenic shock, and three were receiving cardiopulmonary resuscitation (CPR) before implant. Preimplant conditions included IABP 89%, mechanical ventilation 68%, three or more inotropes 84%, hyperbilirubinemia 59%, acute renal failure 63%, and hemodialysis 16%. Fifty-nine percent of patients bridged successfully to transplantation, with 90% posttransplant survival. Duration of BiVAD support ranged from 0 to 91 days, with two patients currently on support awaiting transplantation. Complications included bleeding requiring reoperation 26%, stroke 11%, infection (any positive culture) 68%, and cannula site infection 5%. The Thoratec BiVAD can successfully be used as a direct bridge to transplantation in heart failure patients with cardiogenic shock.

Decompressive craniectomy in trauma patients with severe brain injury

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.

Decompressive Craniectomy in Trauma Patients with Severe Brain Injury

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.