P2540Sex-specific differences in the clinical presentation, surgical complications, and course of chronic thromboembolic pulmonary hypertension

Background

Women are more susceptible to develop several forms of pulmonary hypertension, but they may have better survival rates than men. Sparse data are available concerning sex-specific differences in chronic thromboembolic pulmonary hypertension (CTEPH).

Purpose and methods

We investigated sex-specific differences in the clinical presentation of CTEPH, functional parameters, exposure to pulmonary endarterectomy (PEA), and survival.

Results

Women constituted half of the study population (N=679 treatment-naïve patients from the European CTEPH registry) and were characterized by a lower prevalence of some cardiovascular risk factors (e.g. prior acute coronary syndrome, smoking habit, chronic obstructive pulmonary disease), but more prevalent obesity, cancer, and thyroid diseases. Median age was 62 (IQR 50–73) years in women and 63 (IQR 53–70) in men. Women underwent PEA less often than men (54% vs 65%; Figure 1, Panel A) and were exposed to fewer additional cardiac procedures, notably coronary artery bypass graft surgery (0.5% vs. 9.5%). The prevalence of specific reasons for not being operated, including the patient's refusal and the proportion of proximal vs. distal lesions, did not differ between sexes. A total of 57 (17.0%) deaths in women and 70 (20.7%) in men were recorded over long-term follow-up. Female sex was positively associated with long-term survival (adjusted Hazard Ratio 0.66; 95% Confidence Interval 0.46–0.94). Short-term mortality was identical in the two groups (Figure 1, Panel B).

Conclusions

Women with CTEPH had a lower prevalence of cardiovascular risk factors and underwent PEA less frequently than men, who, in turn, were more often exposed to additional major cardiac surgery procedures. Women had more favorable long-term survival.

Acknowledgement/Funding

The CTEPH registry is supported by a research grant from Actelion Pharmaceuticals Ltd.

[Surgical treatment of pulmonary arterial hypertension]

INTRODUCTION

Pulmonary arterial hypertension (PAH) is a severe disease that has undergone a dramatic improvement in therapeutic management over the past 20 years. Among the new therapeutic options, surgery has the potential to dramatically improve or, in some cases, cure PAH.

BACKGROUND

Surgical treatment of PAH includes pulmonary endarterectomy which can cure PAH when the cause is obstruction of the pulmonary arteries by fibrous tissue resulting from pulmonary embolism, by tumours as angiosarcomas, and echinococcus cysts. Transplantation is required in end-stage PAH after failure of medical treatment. Atrial septostomy and Potts procedure are palliative surgical procedures that can delay transplantation.

VIEWPOINT

Extracorporeal cardiopulmonary support is the latest surgical improvement, not only as a bridge to transplantation in end-stage PAH but also during recovery after transplantation or pulmonary endarterectomy.

CONCLUSIONS

Surgery is part of the therapeutic management of PAH. Dialogue between physicians and surgeons is a prerequisite for any reasoned therapeutic decision.

Surgical treatment of celiac artery aneurysm associated with median arcuate ligament

Celiac artery aneurysms are rare but potentially fatal because of the risk of rupture. Atherosclerosis and fibrous dysplasia are the two most common etiologies. Median arcuate ligament compression of the celiac artery is common but usually asymptomatic. We report three cases of post-stenotic celiac artery aneurysm with median arcuate ligament compression admitted to our hospital over the past two years. Although the incidence is rare with only 8 cases reported in the literature, a median arcuate ligament may have a role in the development of celiac artery aneurysms and its presence can influence the surgical strategy.

Comparative use of perioperative chemotherapy (CT) in non-small cell lung cancer (NSCLC) between 2004 and 2007

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Background: Adjuvant (ADJ) platinum-based CT has become a new standard of care for patients (pts) with resected stage II and III NSCLC, and is discussed in selected stage IB pts. Impact of positive randomized trials which showed significant survival improvement (first published in 2004) on the use of ADJ CT has been poorly studied to date. Methods: A retrospective study of consecutive pts with NSCLC who underwent curative surgery during the first half of year 2004 and 2007 in the surgical center Marie Lannelongue (France) was conducted. Logistic regression models were employed to identify cofactors associated with the use of ADJ CT (excluding stage IV). Odds ratio (OR) > 1 corresponds to a more frequent use than in reference group. Results: A total of 240 pts (116 in 2004, 124 in 2007) underwent curative surgery for NSCLC (11% IA; 30% IB; 27% II; 27% III; 5% IV). Among all pts, 12 % received neoADJ CT (less in 2007, 8% vs 16% p=.04), 35% ADJ (4% both). Reasons for not receiving ADJ CT included stage I (34%), death (11%), comorbidities (10%), poor performance status (10%), advanced age (8%), post-operative complications (7%), patient refusal (3%). More ADJ CT was prescribed in 2007 (41% vs 30% in 2004, p=.009). Overall, 45% of pts with stage II-III received ADJ CT in 2004 versus 69% did so in 2007. In multivariate analysis (194 pts), ADJ CT was associated with the year of inclusion (OR=2.67 p=.009), stage (stage II, OR=6.77, stage III, OR=16.85; p<.0001), serious medical history (OR=.41 p=.01) and salvage surgery (OR=.26 p=.03). Cisplatin was the preferred platinum compound in 76% of neoADJ regimens (mostly cisplatin-docetaxel), and 70% of ADJ CT (mostly cisplatin-vinorelbine). Conclusions: The presentation and publication of “positive” ADJ CT trials had significantly increased prescription of ADJ CT in pts with stage II-III NSCLC. Nevertheless 31% of the stage II-III did not received CT mostly because of comorbidities, highlighting the need of a personalized CT.

No significant financial relationships to disclose.

Bone morphogenetic protein signalling in heritable versus idiopathic pulmonary hypertension

Mutations in the gene encoding bone morphogenetic protein (BMP) receptor type 2 (BMPR-2) have been reported in pulmonary arterial hypertension (PAH), but their functional relevance remains incompletely understood. BMP receptor expression was evaluated in human lungs and in cultured pulmonary artery smooth muscle cells (PASMCs) isolated from 19 idiopathic PAH patients and nine heritable PAH patients with demonstrated BMPR-2 mutations. BMP4-treated PASMCs were assessed for Smad and p38 mitogen-activated protein kinase (MAPK) signalling associated with mitosis and apoptosis. Lung tissue and PASMCs from heritable PAH patients presented with decreased BMPR-2 expression and variable increases in BMPR-1A and BMPR-1B expression, while a less important decreased BMPR-2 expression was observed in PASMCs from idiopathic PAH patients. Heritable PAH PASMCs showed no increased phosphorylation of Smad1/5/8 in the presence of BMP4, which actually activated the p38MAPK pathway. Individual responses varied from one mutation to another. PASMCs from PAH patients presented with an in vitro proliferative pattern, which could be inhibited by BMP4 in idiopathic PAH but not in heritable PAH. PASMCs from idiopathic PAH and more so from heritable PAH presented an inhibition of BMP4-induced apoptosis. Most heterogeneous BMPR-2 mutations are associated with defective Smad signalling compensated for by an activation of p38MAPK signalling, accounting for PASMC proliferation and deficient apoptosis.

[Diagnosis and care of postembolic pulmonary hypertension: the role of the pneumologist]

The prognosis of postembolic pulmonary hypertension, a rare and serious disease, has been transformed with the curative intervention of pulmonary endarteriectomy. The screening is based on two key non invasive examinations, the cardiac ultrasound and ventilation-perfusion scintigraphy. The confirmation of the diagnosis and the determination of the best therapeutic options then relies on the expertise of the national reference centre, based on the haemodynamics and the morphological data provided by pulmonary angiography and spiral computerised tomography. Although the technique of endarteriectomy is fully validated, a drug approach is in the assessment process, both in the inoperable forms or when confronted with persistent postsurgical pulmonary hypertension.

[Invasion of the pulmonary artery by an undifferentiated carcinoma]

INTRODUCTION

The diagnosis of chronic obstruction of the pulmonary artery is difficult. We present the case of a woman with an invasive, undifferentiated carcinoma of the pulmonary artery.

CASE REPORT

A 61 year old woman complained of increasing dyspnoea. This was evaluated by computed tomography which showed a defect in the main pulmonary artery. There was no clinical or radiological improvement following anticoagulant treatment for two months. A repeat CT scan showed a persisting intravascular defect and the diagnoses considered included post-embolic pulmonary arterial hypertension and angiosarcoma. A surgical biopsy was performed and pericardial and aortic tumour nodules were found during the operation. The pathological examination revealed undifferentiated carcinoma. Further investigations failed to reveal the primary site.

CONCLUSION

Invasion of the pulmonary artery by angiosarcoma or other tumour is part of the differential diagnosis of chronic thromboembolic disease. The diagnosis rests on histology obtained by an intravascular or surgical procedure. Complete surgical excision may be possible in angiosarcoma but it was impossible in our patient. The patient died despite two courses of chemotherapy and targeted therapy with erlotinib.

Pulmonary hypertension associated with myeloproliferative disorders: a retrospective study of ten cases

BACKGROUND

Pulmonary hypertension (PH) is a severe hemodynamic disorder in which the pulmonary artery pressure is persistently elevated, leading to right-sided heart failure. Some studies have suggested an association between PH and myeloproliferative diseases (MPD).

OBJECTIVES

This study describes clinical, hematological and hemodynamic characteristics of PH associated with MPD.

METHODS

We retrospectively reviewed 10 cases of PH associated with MPD: polycythemia vera (8 patients) and essential thrombocythemia (2 patients), followed between 1993 and 2002. The baseline evaluation was established by right-sided heart catheterization, ventilation/perfusion lung scan and pulmonary angiography if required.

RESULTS

Six patients had confirmed chronic thromboembolic pulmonary hypertension (CTEPH) and 4 had pulmonary arterial hypertension (PAH) associated with MPD without other risk factors for PAH. The hemodynamic characteristics of CTEPH and PAH associated with MPD were similar. The diagnosis of CTEPH was concomitant to that of MPD in all cases (5 polycythemia vera and 1 essential thrombocythemia). The PAH associated with MPD occurred later in the evolution of the MPD (3 polycythemia vera and 1 essential thrombocythemia) with a median of 162 months after the diagnosis of MPD, and it was associated with myeloid metaplasia (p < 0.01).

CONCLUSION

We describe 2 distinct forms of PH in the context of MPD: CTEPH, which is diagnosed at an early stage of the MPD, and PAH, which occurs later in the course of the MPD and is associated with myeloid metaplasia. Progressively increasing dyspnea in a patient with an MPD warrants further investigation to rule out PAH and CTEPH, while a diagnosis of CTEPH warrants ruling out MPD.

Hypertension pulmonaire postembolique

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease characterized by the persistence of thromboemboli obstructing the pulmonary arteries as an organized tissue. The consequence is an increase in pulmonary vascular resistance resulting in pulmonary hypertension (PH) and progressive right heart failure.

BACKGROUND

It is difficult to recognize the postembolic nature of PH because there is no known history of thromboembolic disease in more than 50% of cases. Diagnosis is based on the presence of mismatched segmental defects in the ventilation-perfusion scanning. When CTEPH is suspected, pulmonary angiography and high-resolution CT scan are required to establish the diagnosis and to assess the operability. Pulmonary angiography is always performed in conjunction with a diagnostic right heart catheterization, which is required to confirm the diagnosis of PH and to determine the degree of hemodynamic impairement. If there is a good correlation between the pulmonary vascular resistance and the anatomical obstruction, pulmonary endarterectomy (PEA) must be proposed. Otherwise, vasodilator and antiproliferative treatments and lung transplantation represent interesting alternatives.

VIEWPOINT AND CONCLUSION

PEA remains the treatment of choice for eligible patients. Nevertheless, there is a need to conduct randomized trials to assess the efficacy of novel medical therapies in some situations: (1) in inoperable CTEPH due to distal lesions, (2) before PEA (therapeutic bridge) in patients who are considered "high risk" due to extremely poor hemodynamics, (3) in patients with persistent pulmonary hypertension after surgery.

Surgical Management of Mediastinal Goiters: When Is a Sternotomy Required?

OBJECTIVE

Mediastinal goiters are frequently diagnosed, particularly in the elderly population. However, factors associated with an increased risk of median sternotomy have not been analyzed systematically.

METHODS

Between 1980 and 2004, a total of 185 patients underwent surgery for mediastinal goiters in our institution. There were 126 women and 59 men with a median age of 68 years (range 24 to 94 years). The goiters were left-sided in 77 patients, right-sided in 69 patients, and bilateral in 39 patients.

RESULTS

Clinical presentation was mainly dyspnea (37 %), palpation of a cervical mass (35 %), superior vena cava syndrome (5 %), dysphagia (4 %) and dysphonia (4 %). Goiters measured between 5 and 23 cm (median 10 cm) and were prevascular (38 %), retrovascular and paratracheal (33 %), and retrotracheal (27 %). Aberrant intrathoracic goiters were observed in 4 patients (2 %). The large majority of goiters could be removed transcervically, regardless of the location and extension of the goiters. A sternotomy was required in 13 patients (6 %), mainly because of recurrent goiter ( P = 0.1), ectopic goiter ( P < 0.001), or invasive carcinoma ( P < 0.001). Superior vena cava syndrome, emergent airway compression, dysphagia, retrotracheal goiter, or crossover goiters were not found to be associated with an increased risk of sternotomy. One patient (0.5 %) died postoperatively from massive intraoperative carcinomatous pulmonary emboli. Histology demonstrated a thyroid carcinoma in 18 patients (10 %).

CONCLUSIONS

Surgery for mediastinal goiters should always be considered, even in elderly patients because of the high risk of tracheal compression and the low morbidity of the surgery. Most mediastinal goiters are benign and can be removed through a cervical approach. Sternotomy should only be performed in cases of previous cervical thyroidectomy, invasive carcinoma, or ectopic goiter.

Traitement chirurgical de la maladie thromboembolique pulmonaire chronique

Chronic thromboembolic pulmonary hypertension is a condition that has long remained in the shadows, a kind of orphan disease, because of the lack of any curative treatment. The renewal of interest by pulmonary specialists, cardiologists and thoracic surgeon is due to the development over the past 20 years of major new treatments: lung transplantation, continuous prostacyclin infusion, and pulmonary endarterectomy, in chronological order. Most patients with postembolic pulmonary arterial hypertension (PEPAH) in a sufficiently proximal location can benefit from curative surgical treatment by bilateral endarterectomy of the pulmonary arteries. This complex surgery, performed under deep hypothermic circulatory arrest, clears out the pulmonary vascular bed down through its subsegmental branches and results in a frank reduction in pulmonary vascular resistance and normalization of cardiopulmonary function. It is a curative procedure with a perioperative mortality rate less than 7% and a definitive result, unlike pulmonary and cardiopulmonary transplantation, which have a postoperative mortality rate of 20% and a 5-year survival rate of 50%. It is difficult to recognize the postembolic nature of pulmonary hypertension because there is no known history of venous thrombosis or embolic phenomena in more than 50% of cases. Diagnosis is based on the presence of mismatched segmental defects in the radioisotopic ventilation-perfusion scanning. To be accessible to endarterectomy, lesions must involve the main, lobar, or segmental arteries. When conducted by experienced operators according to specific protocols, pulmonary (frontal and lateral views of each lung) and multislice CT angiography optimize assessment of the lesion site. When the pulmonary vascular resistance evaluated by catheterization is correlated with the anatomical obstruction visible on the images, pulmonary endarterectomy has a mortality rate below 4% and offers the patient a substantial chance to regain normal cardiorespiratory function. In cases of pulmonary arterial hypertension due to older embolisms, major arteriolitis occurs in the nonobstructed areas and aggravates the pulmonary hypertension, which may become suprasystemic. The endarterectomy mortality rate is then higher, and in specific cases justifies preoperative medical treatment. Pulmonary or cardiopulmonary transplantation is indicated in this disease only when the lesions are too distal and thus inaccessible to endarterectomy.

Splenectomy and chronic thromboembolic pulmonary hypertension

BACKGROUND

An increased prevalence of splenectomy has been reported in patients with idiopathic pulmonary arterial hypertension. Examination of small pulmonary arteries from these subjects has revealed multiple thrombotic lesions, suggesting that thrombosis may contribute to this condition. Based on these findings, we hypothesised that splenectomy could be a risk factor for chronic thromboembolic pulmonary hypertension (CTEPH), a condition defined by the absence of thrombus resolution after acute pulmonary embolism that causes sustained obstruction of the pulmonary arteries and subsequent pulmonary hypertension.

METHODS

The medical history, clinical characteristics, thrombotic risk factors and haemodynamics of 257 patients referred for CTEPH between 1989 and 1999 were reviewed. In a case-control study the prevalence of splenectomy in patients with CTEPH was compared with that of patients evaluated during the same period for idiopathic pulmonary hypertension (n=276) or for lung transplantation in other chronic pulmonary conditions (n=180).

RESULTS

In patients with CTEPH, 8.6% (95% CI 5.2 to 12.0) had a history of splenectomy compared with 2.5% (95% CI 0.7 to 4.4) and 0.56% (95% CI 0 to 1.6) in cases of idiopathic pulmonary arterial hypertension and other chronic pulmonary conditions, respectively (p<0.01).

CONCLUSION

Splenectomy may be a risk factor for chronic thromboembolic pulmonary hypertension.

Chest wall resection for invasive lung carcinoma, soft tissue sarcoma, and other types of malignancy. Pathologic aspects in a series of 107 patients

With improvements in surgical techniques for resection and reconstruction of the chest wall, pathologists are confronted with complicated surgical specimens. There are no currently available guidelines specifically dedicated to the handling of these specimens. Extended resections of lung carcinoma chest wall invasions may change the clinical value of some TNM subsets. We reviewed a series of 107 consecutive malignant tumors involving the chest wall and resected in our institution during a 3-year period. The 107 patients included 39 females and 68 males aged 6 to 80 years (mean, 53 years). Ninety-eight cases (92%) were en bloc resection. There were 55 invasions by lung carcinomas including 19 Pancoast tumors. With the current TNM classification, five lung carcinomas, treated with vertebral body resection because of vertebral foramina invasion, were T3. Four lung carcinomas were N3 or M1 only because of supraclavicular or chest wall lymph node invasion. Other tumors included 20 primary soft-tissue tumors, 13 primary skeletal tumors, 12 metastases, four local invasions by breast tumors, and three miscellaneous lesions. Resected structures included one to six ribs (mean, 2.6; n = 89), thoracic inlet (n = 24), three or four vertebral bodies (n = 13), sternum (n = 17), clavicles (n = 15), shoulder blade (n = 4), upper limb (n = 2), skin (n = 29), lung (n = 64), diaphragm (n = 2), and mediastinum (n = 2). Ten cases were incomplete resections including five because of vertebral body or vertebral foramina tumor invasion. The study of surgical specimens resulting from resection of malignant tumors of the chest wall is complicated because of the variety of both tumor histologic types and involved anatomic structures. Specimen radiograms have a great informative value. Assessment of surgical margins, especially vertebral foramina, is imperative. In lung carcinomas invading the chest wall, we suggest that vertebral foramina invasion could be classified T4 and that the prognostic value of chest wall lymph nodes isolated invasions should be assessed for a possible N1 classification.

Chronic thromboembolic pulmonary hypertension

Pulmonary arterial hypertension is a severe disease that has been ignored for a long time. However, over the past 20 yrs chest physicians, cardiologists and thoracic surgeons have shown increasing interest in this disease because of the development of new therapies, that have improved both the outcome and quality of life of patients, including pulmonary transplantation and prostacyclin therapy. Chronic thromboembolic pulmonary arterial hypertension (CTEPH) can be cured surgically through a complex surgical procedure: the pulmonary thromboendarterectomy. Pulmonary thromboendarterectomy is performed under hypothermia and total circulatory arrest. Due to clinically evident acute-pulmonary embolism episodes being absent in > 50% of patients, the diagnosis of CTEPH can be difficult. Lung scintiscan showing segmental mismatched perfusion defects is the best diagnostic tool to detect CTEPH. Pulmonary angiography confirms the diagnosis and determines the feasibility of endarterectomy according to the location of the disease, proximal versus distal. The technique of angiography must be perfect with the whole arterial tree captured on the same picture for each lung. The lesions must start at the level of the pulmonary artery trunk, or at the level of the lobar arteries, in order to find a plan for the endarterectomy. When the haemodynamic gravity corresponds to the degree of obliteration, pulmonary thromboendarterectomy can be performed with minimal perioperative mortality, providing definitive, excellent functional results in almost all cases.

[Surgical treatment of post-embolism pulmonary hypertension]

Pulmonary hypertension is a serous condition which, after a long history as an orphan disease, has raised renewed interest due to the development of efficacious therapeutic options including lung transplantation and continuous infusion of prostacycline. Bilateral endarteriectomy of the pulmonary arteries is another possibility for post-embolism pulmonary hypertension. The procedure is complex and must be performed in conditions of cardiac arrest and deep hypothermia but, unlike transplantation, provides definitive cure. Recognizing the post-embolic nature of pulmonary hypertension is not simple because old episodes of venous thrombosis or embolus migration are not found in 50% of patients. Segmentary defects on the perfusion scintigraphy contrasting with the homogeneous respiratory scintigraphy is the primary diagnostic feature. Lesions must be located in a main trunk or at the origin of lobular or segmentary branches to be accessible to endarteriectomy. An antero-posterior and lateral angiogram of each lung and a multiple-array helicoidal angioscan performed with a precise protocol by an experienced team are needed to identify the localization of the lesions. If the pulmonary resistance determined at right catheterism is correlated with anatomic obstruction, the risk of mortality of pulmonary endarteriectomy is low, offering patients a significant chance for normal or nearly normal cardiorespiratory function.

Analysis of CD4+CD25+ cell population in the thymus from myasthenia gravis patients

The present study is aimed at exploring the regulatory CD4(+)CD25(+) T cells in the thymus from myasthenia gravis (MG) patients. In early-onset MG, the thymus is hyperplastic and contains autoreactive activated T cells. Preliminary studies indicate that these CD4(+)CD25(+) cells include activated autoreactive T cells. Studies to characterize the phenotype and suppressive capacity of these cells will be discussed.

[Catamenial pneumothorax. Failure of videothorascopic treatment]

INTRODUCTION

Catamenial pneumothorax occurs in women during the menses. It is frequently associated with diaphragmatic fenestrations or episodes of pleural endometriosis.

OBSERVATION

We report the case of a patients who had presented 25 episodes of right pneumothorax despite treatment with videothorascopy initiated after the 10th episode. These episodes coincided with menstruation. Diagnosis of catamenial pneumothorax was evoked and thoracic surgery was indicated. Exploration of the pleural fossa did not reveal symphysis but 7 diaphragmatic orifices, which were sutured before conducting mechanical pleurodesis. No relapse of pneumothorax was reported following surgery.

COMMENTS

Around one hundred cases of catamenial pneumothorax have been reported in the literature. They represent 2.8 to 5.6% of spontaneous pneumothroax in women. Diagnosis is evoked on the occurrence of recurrent pneumothorax appearing 24 to 72 hours after the onset of menstruation. The pathogeny is uncertain and several mechanisms are frequently evoked. In the prevention of relapses, treatment consists in closing the diaphragmatic orifices with thoracotomy, resection of eventual bubbles, and pleural symphysis. Videothorascopy does not appear adapted to treatment.

Late intracaval and intracardiac leiomyomatosis following hysterectomy for benign myomas treated by surgery and GnRH agonist

BACKGROUND

The aim of this study was to report an exceptional case of a patient presenting with intracaval and intracardiac leiomyomatosis treated by combined surgical and medical treatment.

CASE

A 48-year-old presented with intracaval and intracardiac leiomyomatosis (IL) discovered 6 years following a total hysterectomy with ovarian conservation for myomas. Surgical resection of the pelvic myomas and intracaval leiomyomatosis was performed during the same surgical procedure. Given the presence of a small tumor residuum in the pelvic cavity, postoperative medical treatment based on a gonadotropin-releasing hormone (GnRH) agonist was delivered for 1 year. The patient was followed-up using clinical examination and systematic CT scan. Ten months following the end of medical treatment, she is still in good health and the pelvic residuum has stabilized.

CONCLUSIONS

Patients with pelvic tumor combined with IL could be treated using a one-stage surgical procedure. In cases of incomplete surgical resection, medical treatment based on GnRH agonist could be successfully delivered.

Serotonin transporter overexpression is responsible for pulmonary artery smooth muscle hyperplasia in primary pulmonary hypertension

Hyperplasia of pulmonary artery smooth muscle cells (PA-SMCs) is a hallmark pathological feature of primary pulmonary hypertension (PPH). Here we found that PA-SMCs from patients with PPH grow faster than PA-SMCs from controls when stimulated by serotonin or serum and that these effects are due to increased expression of the serotonin transporter (5-HTT), which mediates internalization of indoleamine. In the presence of 5-HTT inhibitors, the growth stimulatory effects of serum and serotonin were markedly reduced and the difference between growth of PA-SMCs from patients and controls was no longer observed. As compared with controls, the expression of 5-HTT was increased in cultured PA-SMCs as well as in platelets and lungs from patients with PPH where it predominated in the media of thickened pulmonary arteries and in onion-bulb lesions. The L-allelic variant of the 5HTT gene promoter, which is associated with 5-HTT overexpression and increased PA-SMC growth, was present in homozygous form in 65% of patients but in only 27% of controls. We conclude that 5-HTT activity plays a key role in the pathogenesis of PA-SMC proliferation in PPH and that a 5HTT polymorphism confers susceptibility to PPH.

Partial cricoidectomy with primary thyrotracheal anastomosis for postintubation subglottic stenosis

OBJECTIVE

We describe a Pearson-type technique and evaluate its results for postintubation subglottic stenosis.

METHODS

Forty-five patients underwent a partial cricoidectomy with primary thyrotracheal anastomosis, and 5 underwent simultaneous repair of a tracheoesophageal fistula as well. Twenty-four (53%) patients were referred to us after initial conservative (n = 21) or operative (n = 3) management. There were 27 cuff lesions, 7 stomal lesions, and 11 at both levels. The upper limit of the stenosis was 1.5 cm (range, 1-2.5 cm) below the cords, and the subglottic diameter was reduced by 60% in 38 (84%) of the patients. The length of airway resection ranged from 2 to 6 cm (median, 3 cm). Despite 23 thyrohyoid or suprahyoid releases, 8 anastomoses were under tension.

RESULTS

Thirty-seven (82%) patients were extubated after the operation (n = 30) or within 24 hours (n = 7). Six patients required postoperative airway stenting (median, 5.5 days). Early (<30 days) complications occurred in 18 (41%) patients, mainly as transient airway and voice complaints, aspiration, and dysphagia. One (2%) patient died of myocardial infarction. Late morbidities were 2 failures occurring as bilateral recurrent nerve paralysis and restenosis requiring definitive tracheostomy. Patients had excellent or good anatomic (n = 42 [96%]), functional (n = 41 [93%]), or both types of long-lasting results, with no stenotic relapse.

CONCLUSIONS

Partial cricoidectomy with primary thyrotracheal anastomosis can be applied in patients with postintubation stenosis extending up to 1 cm below the cords and measuring up to 6 cm in length with excellent-to-good definitive results. The association with a tracheoesophageal fistula does not contraindicate surgical repair.

Use of embryonic human trachea grown in nude mice to patch-repair congenital tracheal stenosis

BACKGROUND

Long congenital tracheal stenosis is a life-threatening condition, and the available surgical treatments do not give satisfactory long-term results.

METHODS

Human embryonic tracheas were implanted in the abdominal cavities of nude mice until their differentiation was completed. These differentiated tracheas were used to patch-repair surgically induced tracheal stenosis in piglets. The human, mouse, or pig origin, of all the cells in the two successive xenotransplants in the nude mouse and the pig, was determined on tissue sections by in situ hybridization with species-specific DNA probes.

RESULTS

The transplanted pigs thrived and reached normal adulthood, irrespective of the administration of immunosuppressive treatment. The human tracheal tissue developed in nude mice conserved human structures, with the exception of feeding capillaries, which were of mouse origin. The tracheal patch in the adult healthy pigs comprised only pig cells organized into a fibrous scar, which was covered by normal pig epithelium.

CONCLUSIONS

Results suggest that human embryonic trachea grown in nude mice can be successfully used as patch tracheoplasty for long congenital tracheal stenosis without conventional immunosuppression.

Factors affecting long-term survival after en-bloc resection of lung cancer invading the chest wall

OBJECTIVE

Several reports emphasize the importance of en-bloc resection as the optimal surgical treatment of lung cancer with chest wall invasion. We investigated possible factors which could affect long-term survival following radical resection of these tumors.

METHODS

Between 1981 and 1998, 100 patients (90 male; ten female), with a median age of 60 years (36-84), underwent radical en-bloc resection of non-small cell lung cancer (NSCLC) with chest wall involvement. Patients with superior sulcus tumors invading the thoracic inlet were excluded from this series. There were 43 squamous and 57 non-squamous tumors. The median number of resected ribs was three (1-5). Lung resection included 73 lobectomies, two bilobectomies, 18 pneumonectomies and seven segmentectomies. Chest wall resection also extended to the sternum in one patient, the transverse process in one, the costotransverse foramen and hemivertebrae in two. All patients had a complete resection. Sixty-three patients received postoperative radiotherapy and 12 received chemotherapy. Histological data, including differentiation and depth of chest wall invasion, were carefully reviewed. The effect of various factors on survival were studied.

RESULTS

There were four in-hospital deaths. Lymph node involvement was negative on surgical specimens in 65 patients, and 28 patients had positive N1 nodes; the final histology revealed seven N2 diseases. Chest wall invasion was limited to the parietal pleura in 29 patients and included intercostal muscles, bones and extrathoracic muscles in 67, 24 and seven cases, respectively. The overall 2-year survival rate was 41%. The 5-year survival for patients with N0, N1 and N2 disease was 22, 9 and 0%, respectively. A local recurrence occurred in 13 patients, with four having a new resection and 45 patients developing systemic metastases. The nodal status (N0-1 vs. N2; P=0. 026) and the number of resected ribs(<2 vs. >2; P=0.03) were survival predictors in univariate analysis. By multivariate analysis, the two independent factors affecting long-term survival were the histological differentiation (well vs. poorly differentiated; P=0. 01) and the depth of chest wall invasion (parietal pleura vs. others; P=0.024).

CONCLUSIONS

Histological differentiation and depth of chest wall involvement were the main factors affecting long-term survival in this series. The role of induction chemotherapy for tumors with poor prognosis should be investigated.

Endothelial nitric oxide synthase function in pig lung after chronic pulmonary artery obstruction

Because long-term pulmonary artery (PA) obstruction is associated with expansion of the systemic blood supply to the lung, chronic ischemia may not occur, and endothelium nitric oxide synthase (eNOS) function may be preserved in postobstructive pulmonary arteries. To test this hypothesis, we studied piglets 2 d or 5 wk after left PA ligation or a sham operation. We measured left lung ATP and lactate lung concentrations; calcium-dependent and calcium-independent NOS activities and eNOS protein; and left PA relaxations in response to acetylcholine, calcium ionophore, and sodium nitroprusside. Decreases in ATP and increases in lactate concentrations were significantly attenuated after 5 wk PA occlusion (p < 0.05 versus sham and 2-d ligation). Compared with sham and 2-d PA occlusion, calcium-dependent NOS activity and eNOS protein were lower in the long-term PA occlusion group. Calcium-independent NOS activity was unchanged. Acetylcholine and calcium ionophore relaxations were impaired after 5 wk, whereas only acetylcholine relaxation was impaired after 2-d PA occlusion. Relaxation to sodium nitroprusside remained unchanged. In conclusion, despite relative conservation of lung energy metabolism, prolonged PA occlusion decreased eNOS function and protein in postobstructive pulmonary arteries.