Perioperative Coronavirus Vaccination - Timing and Implications: A Guidance Document

Cardiothoracic surgical patients are at risk of increased coronavirus disease severity. Several important factors influence the administration of the coronavirus disease vaccine in the perioperative period. This guidance statement outlines current information regarding vaccine types, summarizes recommendations regarding appropriate timing of administration, and provides information regarding side effects in the perioperative period for cardiac and thoracic surgical patients.

Large Right Coronary Artery Aneurysm

Complications of aneurysm include thrombosis and distal embolization, rupture, and vasospasm. The natural history and prognosis remain obscure. Controversies persist regarding the use of surgical or medical management.

Preoperative pulmonary rehabilitation for marginal-function lung cancer patients

Background This study aimed to evaluate the impact of preoperative pulmonary rehabilitation in lung cancer patients undergoing pulmonary resection surgery with marginal lung function. Methods Short-term outcomes of 42 patients with forced expiratory volume in 1 s < 1.6 L who underwent lung resection between 01/2006 and 12/2010 were reviewed retrospectively. They were divided into group A (no preoperative pulmonary rehabilitation) and group B (receiving pulmonary rehabilitation). In group B, a second set of pulmonary function tests was obtained. Results There were no significant differences in terms of sex, age, race, pathologic stage, operative procedure, or smoking years. Mean forced expiratory volume in 1 s and diffusing capacity for carbon monoxide in group A was 1.40 ± 0.22 L and 10.28 ± 2.64 g∙dL^-1 vs. 1.39 ± 0.13 L and 10.75 ± 2.08 g∙dL^-1 in group B. Group B showed significant improvement in forced expiratory volume in 1 s from 1.39 ± 0.13 to 1.55 ± 0.06 L ( p = 0.02). Mean intensive care unit stay was 6 ± 5 days in group A vs. 9 ± 9 days in group B ( p = 0.22). Mean hospital stay was 10 ± 4 days in group A vs. 14 ± 9 days in group B ( p = 0.31). There was no significant difference in morbidity or mortality between groups. Conclusion Preoperative pulmonary rehabilitation can significantly improve forced expiratory volume in 1 s in some marginal patients undergoing lung cancer resection. However, it does not improve length of stay, morbidity, or mortality.

Modification of Cabrol Patch for Control of Aortic Root Bleeding

Rate of bleeding following aortic root replacement is reported in upto 24% of cases. Bleeding significant enough to require re-operation is reported in upto 4% of cases. We performed a modification of Cabrol patch to control bleeding from complicated aortic root replacement procedure. We used a perigraft - right-atrial fistula technique to control bleeding from aortic root area using a bovine pericardial patch. Patient had an uneventful hospital course and was discharged on postoperative day 14.

Split latissimus dorsi muscle flap repair of acquired, nonmalignant, intrathoracic tracheoesophageal and bronchoesophageal fistulas

The development of a fistula between the tracheobronchial tree and oesophagus due to nonmalignant causes is uncommon. Division of the fistula with muscle flap interposition eliminates contact between the tracheobronchial segment and the oesophagus, theoretically decreasing the chance of recurrence as well as providing a robust blood supply to aid in healing. The split latissimus dorsi muscle flap is a well-suited flap for such repairs because of the ability to simultaneously cover two separate apertures (tracheobronchial and oesophageal). The authors describe the split latissimus dorsi muscle flap with step-by-step technique for repair of intrathoracic aerodigestive fistulas.

Successful use of fondaparinux for bridging early after aortic and mitral mechanical heart valve replacement

OBJECTIVE

To report a case of successful use of fondaparinux for bridging early after aortic and mitral mechanical heart valve replacement (MHVR).

CASE SUMMARY

A 71-year-old female underwent aortic and mitral valve replacements with St. Jude medical bileaflet prostheses, as well as DeVega tricuspid annuloplasty and coronary artery bypass graft. Anticoagulation was initially withheld following the procedure because of thrombocytopenia, large amount of chest tube drainage (~1 L/day), and concerns regarding postoperative bleeding. The thrombocytopenia (baseline platelet count 183 x 10(3)/μL; postoperative platelet count 44 × 10(3)/μL) was thought to be a consequence of the cardiopulmonary bypass; there was a low probability of heparin-induced thrombocytopenia. However, the care team preferred to avoid heparin products and initiated fondaparinux 7.5 mg subcutaneously once daily on postoperative day 8 once the patient's platelet count had recovered to >100 x 10(3)/μL. The treatment was bridged to warfarin on postoperative day 13 and the patient was discharged home after receiving 8 days of fondaparinux. Throughout the patient's hospitalization and upon follow-up on postoperative day 31, there were no signs or symptoms of thromboembolic events or bleeding.

DISCUSSION

Unfractionated heparin and low-molecular-weight heparins are the standard of care for bridging to warfarin in patients with MHVR. The use of fondaparinux following MHVR has not been studied in randomized controlled trials. In vitro studies support the effectiveness of fondaparinux in preventing thrombus formation on mechanical heart valves. However, the only data available in humans as of December 2011 are 3 case reports. Two of these case reports described the successful use of fondaparinux for anticoagulation in a patient with an aortic valve replacement. In the third case report, the patient had an aortic and mitral valve replacement. Our case report is novel because it describes the use of fondaparinux early after MHVR, which is the most critical time period for effective thromboprophylaxis.

CONCLUSIONS

The use of fondaparinux for postoperative bridging in our patient early after combined aortic and mitral MHVR was effective. However, until studies evaluate the efficacy and safety of fondaparinux in patients with MHVR, its use should be considered only when heparin products are contraindicated.

Sternoclavicular osteomyelitis: a new complication of misplaced tracheostomy tube

We report a patient who presented with erythema and swelling over the chest and neck several days after the placement of a tracheostomy tube. Sternoclavicular osteomyelitis and anterior mediastinal abscess occurred, as complications of inadvertent pretracheal tracheostomy tube placement, which were treated with right sternoclavicular resection and mediastinal drainage.

Potentially curable lung cancer patients not offered operation

BACKGROUND

Recent reports have noted the decreased resection rate in early stage lung cancer. Our surgical population includes 25% second surgical opinion (SSO) patients not offered surgical intervention after initial evaluation at other institutions. This study assesses the reasons those patients were initially rejected for operation at other institutions and determines the outcome of operative intervention.

METHODS

This report is an analysis of 103 consecutive patients undergoing lung operation for cancer by a single surgeon from June 2006 through June 2008. This included 26 patients (25%) in the SSO group and 77 patients (75%) seen initially at our cancer center (control).

RESULTS

Reasons for initial rejection in the SSO group were the following: (1) anatomically unresectable (14 patients); (2) radiologic contraindication (11 patients); (3) multiple lesions (6 patients); (4) inadequate pulmonary reserve (5 patients); (5) significant medical comorbidities (2 patients); (6) advanced age (2 patients); (7) patient misunderstandings (2 patients); (8) prior high dose radiation (1 patient); (9) negative diagnostic study (1 patient) and negative exploratory thoracotomy (1 patient). Age and comorbidities were similar for both groups. The planned resection was completed in 25 of 26 patients. Two SSO patients (8%) and nine control patients (11%) had positive N2 nodes. Length of stay was identical and the single death was in a control patient.

CONCLUSIONS

An SSO after initial rejection for resection of lung cancer is highly desirable. The short-term outcomes in these SSO patients screened at a multidisciplinary lung cancer center are comparable with patients offered resection after initial evaluation at a large multidisciplinary cancer center.