pathway and effectively break up the previously mentioned vicious circle. We believe that this ap... more pathway and effectively break up the previously mentioned vicious circle. We believe that this approach has never been reported in literature and should always be kept in mind in these complex vascular obstructions, mainly in low-weight patients. However, only a close follow-up will disclose us the long-term outcome of these vessels, as well as the need of further surgical or percutaneous interventions as the infant grows. Nevertheless, the use of stents potentially re-dilatable up to the adult pulmonary artery size, as was in this patient, should allow additional nonsurgical dilatations whenever the clinical conditions warranted them.
Interactive Cardiovascular and Thoracic Surgery, 2009
A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of cerebral regional oxygen saturation (rSO ) monitoring during cardiac surgery can lead to improved clinical outcomes. Altogether 488 papers 2 were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. Four prospective and another four retrospective studies involving adult and paediatric patients undergoing various cardiac surgical procedures were selected. These have demonstrated that prolonged intra-operative cerebral desaturations are associated with adverse neurological outcomes and prolonged hospital stay. Further, interventions carried out by thoughtful use of the cerebral oximeter are associated with significant reduction in neurologic injury, major organ morbidity and mortality (MOMM) and duration of hospital stay. Some studies have indicated decreased ventilation and intensive care unit (ICU) stay times as well. Clinical benefit and the lack of use-associated risk of injury at a modest expense support the use of this device routinely in patients undergoing cardiac surgery.
Interactive Cardiovascular and Thoracic Surgery, 2010
A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with liver cirrhosis have acceptable outcomes after undergoing cardiac surgery. Altogether 97 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. One prospective and another eight retrospective studies involving adult population of patients with liver cirrhosis undergoing various cardiac surgical procedures were selected. In these studies, the overall mortality was 17.1% and combined mean mortality for Child-Pugh class A, B and C was 5.2%, 35.4% and 70%, respectively. The major morbidity ranged from 20 to 60% in group A and 50 to 100% in the patients with more advanced hepatic disease. Some studies have demonstrated that thrombocytopenia, decreased serum cholinesterase and high preoperative total bilirubin levels are significantly associated with worse clinical outcomes. These studies, although with small samples, collectively demonstrate that patients with Child-Pugh class A cirrhosis tolerated cardiac surgical procedures with a mild increase in mortality and morbidity. However, the risk of mortality in patients with Child-Pugh class B and C or MELD score )13 is extremely high. Nevertheless, even if these patients underwent successful surgery, their long-term survival was significantly poorer and their health status remains compromised even well after cardiac surgery because of persistent liver dysfunction.
Conventional cardiopulmonary bypass can trigger a systemic inflammatory response syndrome similar... more Conventional cardiopulmonary bypass can trigger a systemic inflammatory response syndrome similar to sepsis. Aetiological factors include surgical trauma, reperfusion injury, and, most importantly, contact of the blood with the synthetic surfaces of the heart-lung machine. Recently, a new cardiopulmonary bypass system, mini-extracorporeal circulation (MECC), has been developed and has shown promising early results in terms of reducing this inflammatory response. It has no venous reservoir, a reduced priming volume, and less blood-synthetic interface. This review focuses on the inflammatory and clinical outcomes of using MECC and compares these to conventional cardio-pulmonary bypass (CCPB). MECC has been shown to reduce postoperative cytokines levels and other markers of inflammation. In addition, MECC reduces organ damage, postoperative complications and the need for blood transfusion. MECC is a safe and viable perfusion option and in certain circumstances it is superior to CCPB.
Papillary endothelial hyperplasia (PEH) of the heart is extremely rare. This report describes a c... more Papillary endothelial hyperplasia (PEH) of the heart is extremely rare. This report describes a case of left atrial appendage PEH discovered by intraoperative palpation during mitral valve repair in a 69-year-old woman. The lesion was treated successfully by surgical excision of the left atrial appendage. Immunohistochemistry analysis confirmed the diagnosis and the patient was discharged without any complications.
Abstract Background: The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentles... more Abstract Background: The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentless biological aortic valve suspended within a triple-layered vascular conduit with preformed aortic sinuses of Valsalva. This study compared implantation of the Biovalsalva prosthesis with a “handsewn” composite bioprosthetic graft (CE Perimount bovine bioprosthesis anastomosed to a gelatin-impregnated gelweave Dacron graft). Methods: Between December 2004 and January 2009, 39 patients underwent elective or urgent aortic root replacement (modified Bentall procedure with coronary button reimplantation) using a Biovalsalva (n = 21) or a handsewn bioprosthesis (n = 18) for aortic root dilatation. Results: There was no significant difference in the preoperative variables between the two study groups including age (70.7 ± 1.7 vs. 67.6 ± 2.9 years, p > 0.05). There was no in-hospital mortality. Three patients in each group underwent concomitant aortic hemi-arch replacement. Patients who underwent Biovalsalva implantation had a reduced need for transfusion of blood (1.25 ± 0.32 vs. 3.17 ± 0.71 units, p < 0.05) and fresh frozen plasma (2.78 ± 0.39 vs. 1.85 ± 0.31, p < 0.05), and reduced mediastinal blood loss (416 ± 52 vs. 583 ± 74 mL, p < 0.05) compared to those with a handsewn bioprosthesis. Cardiopulmonary bypass time (141 ± 6 vs. 170 ± 17 minutes, p = NS) and aortic cross-clamp time (113 ± 6 vs. 115 ± 7 minutes, p = NS) were similar. Postoperative echocardiography demonstrated excellent hemodynamic function of the Biovalsalva prosthesis (mean size 25.1 ± 0.4 mm valved conduit) with a peak pressure gradient of 26.2 ± 1.9 mmHg and no or trivial valvular regurgitation. Conclusions: The Biovalsalva prosthesis should be considered for patients requiring a biological aortic root replacement. It offers an “off-the-shelf” preassembled composite biological valve conduit with excellent hemostatic and hemodynamic properties. (J Card Surg 2010;25:321-326)
Interactive Cardiovascular and Thoracic Surgery, 2009
A best evidence topic in thoracic surgery was written according to a structured protocol. The que... more A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgical resection of non-small cell lung cancer (NSCLC) with cerebral metastasis prolongs survival. Altogether 153 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, date, journal, country of publication, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. A vast majority of patients with synchronous presentation underwent cerebral metastasectomy prior to lung resection which led to a rapid regression of neurological symptoms. In these studies, the median survival for the curative intent groups (bifocal therapy"adjuvant treatment) ranged from 19 to 27 months (mean 23.12"3.3 months) and at 1, 2 and 5 years from 56% to 69% (means63.9"5.6%), 28% to 54% (means38.7"11%) and 11% to 24% (means18"5.7%), respectively. In comparison, the median and 1-year survival of the palliative groups were 7.1-12.9 months (means10.3"2.9 months) and 33-39.7% (means35.3"3.8%), respectively. We conclude that in the absence of mediastinal lymph node involvement, surgical resection of NSCLC with complete resection of the brain metastasis improves prognosis. Further, adenocarcinoma, low CEA levels at presentation, response to preoperative chemotherapy before focal treatment and a high Karnofsky performance score (KPS) may have a positive prognostic value.
Summary 2 were found using the reported search, of which eight presented the best evidence to ans... more Summary 2 were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. Four prospective and another four retrospective studies involving adult and paediatric patients undergoing various cardiac surgical procedures were selected. These
A best evidence topic in thoracic surgery was written according to a structured protocol. The que... more A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgical resection of non-small cell lung cancer (NSCLC) with cerebral metastasis prolongs survival. Altogether 153 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, date, journal, country of publication, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. A vast majority of patients with synchronous presentation underwent cerebral metastasectomy prior to lung resection which led to a rapid regression of neurological symptoms. In these studies, the median survival for the curative intent groups (bifocal therapy"adjuvant treatment) ranged from 19 to 27 months (mean 23.12"3.3 months) and at 1, 2 and 5 years from 56% to 69% (means63.9"5.6%), 28% to 54% (means38.7"11%) and 11% to 24% (means18"5.7%), respectively. In comparison, the median and 1-year survival of the palliative groups were 7.1-12.9 months (means10.3"2.9 months) and 33-39.7% (means35.3"3.8%), respectively. We conclude that in the absence of mediastinal lymph node involvement, surgical resection of NSCLC with complete resection of the brain metastasis improves prognosis. Further, adenocarcinoma, low CEA levels at presentation, response to preoperative chemotherapy before focal treatment and a high Karnofsky performance score (KPS) may have a positive prognostic value.
pathway and effectively break up the previously mentioned vicious circle. We believe that this ap... more pathway and effectively break up the previously mentioned vicious circle. We believe that this approach has never been reported in literature and should always be kept in mind in these complex vascular obstructions, mainly in low-weight patients. However, only a close follow-up will disclose us the long-term outcome of these vessels, as well as the need of further surgical or percutaneous interventions as the infant grows. Nevertheless, the use of stents potentially re-dilatable up to the adult pulmonary artery size, as was in this patient, should allow additional nonsurgical dilatations whenever the clinical conditions warranted them.
Interactive Cardiovascular and Thoracic Surgery, 2009
A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of cerebral regional oxygen saturation (rSO ) monitoring during cardiac surgery can lead to improved clinical outcomes. Altogether 488 papers 2 were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. Four prospective and another four retrospective studies involving adult and paediatric patients undergoing various cardiac surgical procedures were selected. These have demonstrated that prolonged intra-operative cerebral desaturations are associated with adverse neurological outcomes and prolonged hospital stay. Further, interventions carried out by thoughtful use of the cerebral oximeter are associated with significant reduction in neurologic injury, major organ morbidity and mortality (MOMM) and duration of hospital stay. Some studies have indicated decreased ventilation and intensive care unit (ICU) stay times as well. Clinical benefit and the lack of use-associated risk of injury at a modest expense support the use of this device routinely in patients undergoing cardiac surgery.
Interactive Cardiovascular and Thoracic Surgery, 2010
A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with liver cirrhosis have acceptable outcomes after undergoing cardiac surgery. Altogether 97 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. One prospective and another eight retrospective studies involving adult population of patients with liver cirrhosis undergoing various cardiac surgical procedures were selected. In these studies, the overall mortality was 17.1% and combined mean mortality for Child-Pugh class A, B and C was 5.2%, 35.4% and 70%, respectively. The major morbidity ranged from 20 to 60% in group A and 50 to 100% in the patients with more advanced hepatic disease. Some studies have demonstrated that thrombocytopenia, decreased serum cholinesterase and high preoperative total bilirubin levels are significantly associated with worse clinical outcomes. These studies, although with small samples, collectively demonstrate that patients with Child-Pugh class A cirrhosis tolerated cardiac surgical procedures with a mild increase in mortality and morbidity. However, the risk of mortality in patients with Child-Pugh class B and C or MELD score )13 is extremely high. Nevertheless, even if these patients underwent successful surgery, their long-term survival was significantly poorer and their health status remains compromised even well after cardiac surgery because of persistent liver dysfunction.
Conventional cardiopulmonary bypass can trigger a systemic inflammatory response syndrome similar... more Conventional cardiopulmonary bypass can trigger a systemic inflammatory response syndrome similar to sepsis. Aetiological factors include surgical trauma, reperfusion injury, and, most importantly, contact of the blood with the synthetic surfaces of the heart-lung machine. Recently, a new cardiopulmonary bypass system, mini-extracorporeal circulation (MECC), has been developed and has shown promising early results in terms of reducing this inflammatory response. It has no venous reservoir, a reduced priming volume, and less blood-synthetic interface. This review focuses on the inflammatory and clinical outcomes of using MECC and compares these to conventional cardio-pulmonary bypass (CCPB). MECC has been shown to reduce postoperative cytokines levels and other markers of inflammation. In addition, MECC reduces organ damage, postoperative complications and the need for blood transfusion. MECC is a safe and viable perfusion option and in certain circumstances it is superior to CCPB.
Papillary endothelial hyperplasia (PEH) of the heart is extremely rare. This report describes a c... more Papillary endothelial hyperplasia (PEH) of the heart is extremely rare. This report describes a case of left atrial appendage PEH discovered by intraoperative palpation during mitral valve repair in a 69-year-old woman. The lesion was treated successfully by surgical excision of the left atrial appendage. Immunohistochemistry analysis confirmed the diagnosis and the patient was discharged without any complications.
Abstract Background: The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentles... more Abstract Background: The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentless biological aortic valve suspended within a triple-layered vascular conduit with preformed aortic sinuses of Valsalva. This study compared implantation of the Biovalsalva prosthesis with a “handsewn” composite bioprosthetic graft (CE Perimount bovine bioprosthesis anastomosed to a gelatin-impregnated gelweave Dacron graft). Methods: Between December 2004 and January 2009, 39 patients underwent elective or urgent aortic root replacement (modified Bentall procedure with coronary button reimplantation) using a Biovalsalva (n = 21) or a handsewn bioprosthesis (n = 18) for aortic root dilatation. Results: There was no significant difference in the preoperative variables between the two study groups including age (70.7 ± 1.7 vs. 67.6 ± 2.9 years, p > 0.05). There was no in-hospital mortality. Three patients in each group underwent concomitant aortic hemi-arch replacement. Patients who underwent Biovalsalva implantation had a reduced need for transfusion of blood (1.25 ± 0.32 vs. 3.17 ± 0.71 units, p < 0.05) and fresh frozen plasma (2.78 ± 0.39 vs. 1.85 ± 0.31, p < 0.05), and reduced mediastinal blood loss (416 ± 52 vs. 583 ± 74 mL, p < 0.05) compared to those with a handsewn bioprosthesis. Cardiopulmonary bypass time (141 ± 6 vs. 170 ± 17 minutes, p = NS) and aortic cross-clamp time (113 ± 6 vs. 115 ± 7 minutes, p = NS) were similar. Postoperative echocardiography demonstrated excellent hemodynamic function of the Biovalsalva prosthesis (mean size 25.1 ± 0.4 mm valved conduit) with a peak pressure gradient of 26.2 ± 1.9 mmHg and no or trivial valvular regurgitation. Conclusions: The Biovalsalva prosthesis should be considered for patients requiring a biological aortic root replacement. It offers an “off-the-shelf” preassembled composite biological valve conduit with excellent hemostatic and hemodynamic properties. (J Card Surg 2010;25:321-326)
Interactive Cardiovascular and Thoracic Surgery, 2009
A best evidence topic in thoracic surgery was written according to a structured protocol. The que... more A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgical resection of non-small cell lung cancer (NSCLC) with cerebral metastasis prolongs survival. Altogether 153 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, date, journal, country of publication, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. A vast majority of patients with synchronous presentation underwent cerebral metastasectomy prior to lung resection which led to a rapid regression of neurological symptoms. In these studies, the median survival for the curative intent groups (bifocal therapy"adjuvant treatment) ranged from 19 to 27 months (mean 23.12"3.3 months) and at 1, 2 and 5 years from 56% to 69% (means63.9"5.6%), 28% to 54% (means38.7"11%) and 11% to 24% (means18"5.7%), respectively. In comparison, the median and 1-year survival of the palliative groups were 7.1-12.9 months (means10.3"2.9 months) and 33-39.7% (means35.3"3.8%), respectively. We conclude that in the absence of mediastinal lymph node involvement, surgical resection of NSCLC with complete resection of the brain metastasis improves prognosis. Further, adenocarcinoma, low CEA levels at presentation, response to preoperative chemotherapy before focal treatment and a high Karnofsky performance score (KPS) may have a positive prognostic value.
Summary 2 were found using the reported search, of which eight presented the best evidence to ans... more Summary 2 were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. Four prospective and another four retrospective studies involving adult and paediatric patients undergoing various cardiac surgical procedures were selected. These
A best evidence topic in thoracic surgery was written according to a structured protocol. The que... more A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgical resection of non-small cell lung cancer (NSCLC) with cerebral metastasis prolongs survival. Altogether 153 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, date, journal, country of publication, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. A vast majority of patients with synchronous presentation underwent cerebral metastasectomy prior to lung resection which led to a rapid regression of neurological symptoms. In these studies, the median survival for the curative intent groups (bifocal therapy"adjuvant treatment) ranged from 19 to 27 months (mean 23.12"3.3 months) and at 1, 2 and 5 years from 56% to 69% (means63.9"5.6%), 28% to 54% (means38.7"11%) and 11% to 24% (means18"5.7%), respectively. In comparison, the median and 1-year survival of the palliative groups were 7.1-12.9 months (means10.3"2.9 months) and 33-39.7% (means35.3"3.8%), respectively. We conclude that in the absence of mediastinal lymph node involvement, surgical resection of NSCLC with complete resection of the brain metastasis improves prognosis. Further, adenocarcinoma, low CEA levels at presentation, response to preoperative chemotherapy before focal treatment and a high Karnofsky performance score (KPS) may have a positive prognostic value.
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