Bilateral internal mammary artery grafting: Comparison between different surgical techniques

BACKGROUND

Increasing evidence continues to demonstrate a survival advantage for bilateral internal mammary artery (BIMA) over single internal mammary artery (SIMA) for coronary artery bypass grafting (CABG). However, there are still doubts about which surgical strategy is the best one to use with BIMA grafting. This study aims to compare immediate and mid-term outcomes with BIMA CABG, using different surgical techniques, through transit-time flow measurement (TTFM) and clinical follow-up.

METHODS

In this retrospective study, there were included 170 consecutive patients who underwent CABG between February 2011 and June 2014 in one single center. Patients were 95.9% men with a mean age of 58.8±8.6 years (range 35-78). The global cohort was then divided in subgroups: the in situ / composite "Y" graft subgroups and the off-pump / on-pump subgroups. TTFM assessment was used in 100% of the grafts. Mid-term follow-up was complete in 100% of patients.

RESULTS

In 57.6% of patients, BIMA were used in situ: right internal thoracic artery (RIMA) to left anterior descending artery (LAD) and left internal thoracic artery (LIMA) to circumflex (Cx) branches and in 42.4% of patients, RIMA was anastomosed to LIMA in a "Y" shape: LIMA to LAD and RIMA to Cx branches. RIMA/LIMA-LAD and RIMA/LIMA-OM grafts mean flow and mean pulsatility index were 35.4 ml/min and 2.6, and 29.6ml/min and 2.6, respectively. There were no differences on in situ or "Y" shape grafts regarding pulsatility index. There were also no differences regarding pulsatility index and morbidity between surgeries performed off or on-pump. In a mean follow-up time of 18.8 months, 97.6% of patients had complete angina relief and there was no mortality.

CONCLUSIONS

CABG surgery with BIMA grafting can be safely performed, even in patients with multiple risk factors, without compromising grafts quality, regardless the surgical technique.

Transapical aortic valve and mitral valve in ring prosthesis implantation - a new advance in transcatheter procedures

Transcatheter valve implantation offers a new treatment modality to those patients whose general condition makes conventional surgery very risky. However, the transcatheter option has only been available for the aortic valve. We describe a case of a successful implantation of two Edwards SAPIEN(®) 26 and 29 mm transapical valves, respectively, in aortic and mitral positions, on a 74-year-old patient with severe aortic and mitral stenosis. The procedure progressed uneventfully. Predischarge echocardiogram showed a peak aortic gradient of 20 mmHg, mild periprosthetic regurgitation, peak and mean mitral gradients of 12 and 4, respectively, and moderate (II/IV) periprosthetic regurgitation. Indications for transapical valve implantation will rapidly increase in the near future. It is essential to individualize the treatment be applied for each patient, in order to optimize the success of the procedure.

Intermittent mechanical prosthesis blockage mimicking acute coronary syndrome

Valve blockage is one of the most serious complications of a mechanical prosthesis. Its annual incidence ranges from < 0.5% to 4.5% per patient/year. The diagnosis is not always done in time, as the clinical presentation is highly variable. In order to better understand the spectrum of clinical presentation of this complication, this paper presents the clinical case of a 64 year-old woman, whose personal medical history included aortic valve replacement with a monoleaflet Medtronic Hall® (Medtronic Inc, Minneapolis, MN) 21 mm, transferred from a peripheral hospital with the diagnosis of acute coronary syndrome of the anterolateral wall, with ST-segment depression and intermittent cardiogenic shock. The authors reviewed also the blockage mechanisms and its implications on the diagnosis and management of this potentially lethal condition.

Surgical treatment of non-small cell lung cancer in octogenarians - safety and prognosis

BACKGROUND

Reluctance to recommend surgery for the elderly is partly based on the expectation that the rate of complications and mortality is higher in this group of patients and on the impression that the life expectancy of an octogenarian with lung cancer is limited by death from natural causes.

METHODS

Between 2007-2011, we operated on 57 patients over 80 years who underwent thoracotomy with curative intent for lung cancer. Mean age was 82.2 years, 17 were female and 40 male. The presence of preoperative comorbidities in this group of patients was significant: chronic lung disease - 22.8%, cardiovascular disease - 38.6% and a history of other malignancy - 17.5%. However, their respiratory function was very acceptable with an average FVC of 93.6% and an average FEV1 of 83.2%. The predominant location of tumor (mean size of 3.0±1.7 cm) was upper lobes (63.2%) and cytological diagnosis was established preoperatively in 61.4% of cases. Preoperative staging was complemented by positron emission tomography in 42.1% of cases and in 12.2% with mediastinoscopy.

RESULTS

We performed 35 lobectomies (61.4%), 4 bilobectomies (7.0%), 9 wedge resections (15.8%) and 5 pneumonectomies (8.8%). All surgeries were performed through lateral thoracotomy. In 4 patients (7.0%), anatomic resection was aborted intraoperative due to unexpected metastatic disease and/or unresectable mass discovered during exploratory thoracotomy. Lymph node dissection was complete in 57.8%. Final pathology analysis showed: adenocarcinoma in 50.9% of cases, squamous cell carcinoma in 14.0% and carcinoid tumour in 14.0%. Final staging was T1 (24.4%), T2 (26.7%), T3-4 (11.1%), N0 (35.5%), N1-2 (4.4%), G1 (8.9%), G2 (28.9%), G3 (8.9%). Mean hospital stay was 10.7±8.1 days. Main surgical complications recorded were: prolonged air leak (15.8%), atelectasis requiring bronchoscopy (7.0%) and persistent air chamber on chest roentgenography (10.5%). We observed an overall operative mortality of one case - 1.8%, which was an 80 year-old patient submitted to a pneumonectomy.

CONCLUSIONS

In conclusion, octogenarians should not be denied surgery exclusively due to age. Surgeons should base their decision first on the stage of the disease, and then on an accurate assessment of the general clinical conditions. Pneumonectomy and extended operations should generally be avoided.

Surgery for thoracic empyema: personal experience and current highlights

Thoracic empyema remains challenging for thoracic surgeons. The principles of empyema treatment are early diagnosis and early treatment. Decision-making involves a triad consisting of the etiology of empyema, general condition of the patient and stage of disease. For acute empyema, early surgical intervention, such as video-assisted thoracoscopic debridement, is recommended when conventional chest tube drainage has failed. Radical treatments of chronic empyema include 1 removal of the empyema space (decortication with or without lung resection) and 2 obliteration of the pleural space with muscle flaps or omentum flaps, or by thoracoplasty. Decortication is the procedure of choice for patients with re-expandable underlying lung. For patients who are not eligible for the above-mentioned radical treatment, open-window thoracostomy can be considered. The current attitudes show that the present concepts are based mainly on expert opinion. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualized approaches can be recommended based on institutional practice and local protocols.

Non-cystic fibrosis bronchiectasis

Bronchiectasis is characterized by irreversible widening of the medium-sized airways, with inflammation, chronic bacterial infection and destruction of the bronchial walls. Exercise or inspiratory muscle training may improve quality of life and exercise endurance in people with non-cystic fibrosis bronchiectasis. Prolonged-use antibiotics improve clinical response rates, but may not reduce exacerbation rates or lung function. Surgery is often considered for people with extreme damage to one or two lobes of the lung who are at risk for severe infection or bleeding. In this review, the authors will focus on non-cystic fibrosis bronchiectasis, pointing out the differences in management when compared with the cystic fibrosis context, with special emphasis on surgical management.

[Complications in patients undergoing thoracotomy for lung carcinoma]

Lung cancer is a common fatal disease, and fewer than 20% of all lung cancer patients are candidates for a curative resection. Major concerns, however, are the mortality and morbidity rates for pulmonary resection which remain significant.Despite the improvements in surgical techniques and perioperative patient management, postoperative cardiopulmonary complications still occur in 20%-30% of lung cancer surgical patients. Patients undergoing thoracotomy for lung carcinoma present a uniquely high risk group for pulmonary complications in particular. Histories of heavy smoking, chronic lung disease, coexisting medical conditions, and the nature of the procedure contribute. The spectrum of pulmonary complications may range from atelectasis and pneumonia to acute lung injury, with the most severe form being acute respiratory distress syndrome. This review was undertaken to evaluate and discuss major complications in patients undergoing thoracotomy for lung cancer.

[Thoracoscopic sympathectomy for hyperhidrosis]

BACKGROUND

Primary hyperhidrosis affects between 1 and 3% of the population. It is a problem of sympathetic deregulation which is characterized by profuse sweating on the palmar surface of the hands, armpits, groin and feet. The therapeutic options for the management of hyperhidrosis have traditionally been non-operative. However, there are several studies demonstrating that primary hyperhidrosis is best treated by endoscopic thoracic sympathectomy.

METHODS

This article presents a review of existing approaches and techniques of thoracoscopic sympathectomy for treatment of hyperhidrosis as well as the author's summary and preferences.

RESULTS

Thoracoscopic sympathectomy is now the standard procedure chosen for the treatment of severe hyperhidrosis. It is safe and successful in almost 98% of cases and only 1-2% of patients experience recurrence. All patients develop some degree of compensatory sweating after surgery. In most this is mild and tolerable; however, in 3-5% of patients it is severe and intolerable. The patients should be made aware that the most satisfied patients are those with preoperative palmar or palmar- axillary hyperhidrosis.

DISCUSSION

The best segment interrupted for the treatment of primary hyperhidrosis, is still controversial. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary and only axillary hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis.

Differential effects of Mandevilla velutina compounds on paw oedema induced by phospholipase A2 and phospholipase C

This study compares the effect of Mandevilla velutina compounds with some anti-inflammatory drugs against phospholipase A2- and phospholipase C-induced rat hindpaw oedema. Injection of phospholipase A2 (Naja naja, 2.5-20 U/paw) and phospholipase C (Clostridium perfringens, 0.03-0.05 U/paw) caused a dose-and-time-related increase in paw oedema. Compounds MV 8608 (55 mumol/kg) and MV 8612 (32 mumol/kg, i.p.) inhibited phospholipase A2-induced paw oedema without interfering with phospholipase C-induced oedema. Local injection of both M. velutina compounds also partially attenuated the oedema evoked by phospholipases A2 and C. Dexamethasone (1.3 mumol/kg, p.o.) suppressed only phospholipase A2-induced paw oedema, while indomethacin (11 mumol/kg, p.o.) attenuated only the early phase of phospholipase C-induced oedema. By contrast, phenidone (616 mumol/kg, i.p.) inhibited only phospholipase C-induced oedema, while cyproheptadine (31 mumol/kg) and pyrilamine (100 mumol/kg, p.o.) inhibited only phospholipase A2 oedema. Treatment of animals with compound 48/80 markedly suppressed phospholipase A2-induced paw oedema and to a lesser degree the oedema caused by phospholipase C. Our results indicate that there are marked differences regarding the mechanisms underlying the paw oedema responses caused by phospholipase A2 and phospholipase C. In addition, our data show that M. velutina compounds cause potent and long-lasting inhibition of the pro-inflammatory action of phospholipase A2, an effect which may account for their reported anti-inflammatory activities.