A rare presentation of anomalous origin of left coronary artery from the pulmonary artery in a young adult

Anomalous origin of left coronary artery from the pulmonary artery (ALCAPA) is a very rare congenital cardiac disorder with an incidence of about 1 in 300000 live births. The majority of patients are symptomatic in early infancy with symptoms of intractable heart failure. Only very few patients survive to adulthood with minimal symptoms. A young female was referred to us in view of breathlessness, clinical examination didn抰 show any signs except a grade 2 systolic murmur in the pulmonary area. The patient underwent 2D echocardiography evaluation which revealed suspicion of ALCAPA and was confirmed using coronary angiography. The patient underwent surgical closure of ALCAPA along with left internal mammary artery (LIMA) to left anterior descending (LAD) anastomosis, postoperative period was uneventful, on routine follow-up the patient is doing well with resolution of dyspnea. ALCAPA is a very rare disorder and most of it is diagnosed in infancy and not many surviving beyond infancy, high degree of suspicion of ALCAPA is needed for young patients presenting with symptoms of angina, heart failure.

Clinical application and strategy of total-arterial coronary artery bypass grafting / 中国胸心血管外科临床杂志

@#Since the advent of coronary artery bypass grafting (CABG), the selection of bypass conduits has always been one of the most controversial topics in this field. Arterial conduits have received extensive attention due to their excellent biological features and high patency. In recent years, the application of arterial grafting and total arterial grafting in China keeps increasing in recent years, but there is still a gap compared to the Europe and America. Previous clinical studies have indicated the benefits of the total arterial grafting in terms of patency and long-term outcomes, but the advantage of multiple arterial grafting over other procedures is still in need to be confirmed with high-quality randomized controlled trials. This article reviews the clinical application and strategy of total-arterial CABG, aiming to provide objective reference for future clinical research and application.

Assessment of the internal mammary artery using ultrasound in patients with coronary artery disease before coronary artery bypass grafting / 中国胸心血管外科临床杂志

@#Objective    To investigate the feasibility and effectiveness of using ultrasound to evaluate the internal mammary artery (IMA) and explore the related factors affecting the quality of IMA. Methods    From July 2020 to January 2021, for patients who underwent coronary artery bypass grafting at the Department of Cardiovascular Surgery, Fuwai Hospital, ultrasound was applied to measure bilateral IMA at the parasternal second intercostal space. There were 62 males and 18 females with an average age of 59.9±8.3 years. The clinical data of the patients were recorded and analyzed. Results    A total of 160 IMA were measured. The IMA was detected in 99.4% (159/160), and the one that was not measured was proved to be occluded by enhanced CT. A total of 157 (98.1%) IMA intima were smooth, 2 (1.3%) were found to have uneven intimal thickening and less smooth, and only 1 (0.6%) was occluded. The intravascular diameter, peak systolic flow rate, peak diastolic flow rate, and blood flow rate of the left second intercostal IMA were 1.9±0.3 mm, 66.8±17.7 cm/s, 6.4 (0.0, 9.7) cm/s, 19.7±9.4 mL/min; and those of the right one were 2.1±0.3 mm, 69.7±18.5 cm/s, 6.0 (0.0, 9.2) cm/s and 22.8±11.5 mL/min, respectively. IMA vessel diameter and blood flow were greater on the right than those on the left side in the same individual (P<0.01). In univariate analysis, sex and body surface area were the factors that influenced the size of the IMA vessel among different individuals, and by linear regression analysis, the size of the IMA vessel was only related to body surface area among different individuals. On univariate analysis, diabetes mellitus was the only factor affecting IMA blood flow, with a mean reduction in blood flow of 18.4% (left) and 21.7% (right) in the diabetic group (P<0.05). Conclusion    Preoperative evaluation of the IMA using ultrasound over the parasternal second intercostal space is easy, noninvasive, and has a high success rate. The internal diameter of the IMA is positively correlated with body surface area, and blood flow is significantly reduced in patients with diabetes.

Effects of the deep inspiration breath-hold technique on cardiac dosimetry in internal mammary node irradiation with intensity-modulated radiation therapy for postoperative left breast cancer / 中华放射医学与防护杂志

Objective:To explore the effects of the deep inspiration breath-hold (DIBH) technique on cardiac dosimetry in internal mammary node irradiation with intensity-modulated radiation therapy (IMN-IMRT) for postoperative left breast cancer.Methods:Totally 23 left breast cancer patients in the First Affiliated Hospital of Bengbu Medical College from Octorber 2021 to July 2022 receiving postoperative IMN-IMRT were enrolled in this study. The changes in dosimetric parameters for their heart and left anterior descending coronary artery (LAD) in the DIBH mode were observed, and the potential factors affecting DIBH effects were analyzed.Results:Compared with the free breath (FB) mode, the DIBH mode manifested a heart volume decrease by 18% ( t = 10.47, P < 0.001), a left lung volume increase by 42% ( t = -14.55, P < 0.001), and significantly reduced dosimetric parameters ( Dmean, Dmax, V5- V30) for the heart and LAD, exhibiting statistically significant differences ( t=-13.38 to -3.30, P<0.05). As indicated by the Pearson correlation analysis, the relative ratio of cardiac dose reduction was positively correlated with that of left lung expansion ( r = 0.82, P < 0.001) and negatively correlated with the patient′age ( r = -0.56, P = 0.005). Conclusions:DIBH can effectively reduce the heart and LAD radiation doses in IMN-IMRT for postoperative left breast cancer and that the patient's age, and the DIBH effects might be affected by the vital capacity.

Single-center usage of right internal mammary artery in coronary artery bypass grafting / 中华胸心血管外科杂志

Objective:To report the use of right internal mammary artery (RIMA) in coronary artery bypass grafting (CABG) in our center, summarize the purpose and configuration of RIMA graft in CABG.Methods:All clinical data of coronary artery bypass grafting patients in our center performed in the past 6 years were collected and analyzed retrospectively. Those patients were divided into RIMA group and non-RIMA group according to the use of RIMA. Propensity score matching had been performed before these data was compared. Surgical technique of use of RIMA was summarized.Results:1 537 CABG had been performed from January 1st, 2016 to October 31st, 2021 in our center. Of which, 128 cases were allocated to RIMA group. After propensity score matching having been performed, there was no difference in baseline data between the RIMA group and the non-RIMA group (128 cases), and the RIMA group had more grafts and arterial grafts than the non-RIMA group. The postoperative drainage volume in the RIMA group was more than that of the non-RIMA group. However, there was no statistical significance in difference of transfusion between two groups. Also, there was no difference in postoperative mechanical ventilation time, ICU time and length of stay postoperatively. The postoperative complications were similar between two groups. Postoperative patency rate of the RIMA graft was as high as 95.2%. The target vessels of RIMA included left anterior descending branch (45 cases), diagonal branch (19 cases), intermediate branch (12 cases). obtuse marginal or circumflex branch (16 cases), posterior descending branch (5 cases) and right coronary trunk (18 cases). 41 RIMA used as free grafts, 87 used as in situ grafts, of which 19 RIMA need lengthened by other graft vessels.Conclusion:The patency rate of RIMA graft is high and the application of RIMA do not increase the surgical risk significantly. However, there are versatile contour of RIMA grafts. It can be used as artery graft in selected patients.

Cardiac dosimetry analysis and quality of life evaluation of internal breast lymph node irradiation in postoperative left breast cancer / 国际肿瘤学杂志

Objective:To analyze the cardiac dosimetry of lymph node irradiation in the internal breast region after left-sided breast cancer surgery and to assess its impact on patients' quality of life.Methods:The clinical data of 108 patients who underwent inverse intensity modulated radiotherapy (IMRT) after left-sided breast cancer surgery in Cancer Hospital of Nantong University from May 2019 to May 2021 were collected and retrospectively analyzed, and divided into a study group (with internal breast, 55 cases) and a control group (without internal breast, 53 cases) according to whether the postoperative radiotherapy included lymph node irradiation in the internal breast region. The dosimetric indexes of planned target area (PTV) , cardiac tolerance, serum myocardial injury markers and quality of life before and after radiotherapy were compared between the two groups.Results:In terms of PTV dosimetry, the conformality index (CI) of the study group and the control group were 0.73±0.07 and 0.75±0.08, the homogeneity index (HI) were 0.17±0.03 and 0.17±0.02, the D max were (55.69±1.02) Gy and (55.46±1.13) Gy, the D mean were (50.54±0.23) Gy and (50.48±0.21) Gy respectively, there were no statistically significant differences ( t=1.38, P=0.169; t<0.01, P>0.999; t=1.11, P=0.269; t=1.41, P=0.160) . In terms of cardiac receptivity, the D mean of the two groups were (5.93 ± 0.32) Gy, (5.64 ± 0.30) Gy, V 40 were (0.47 ± 0.10) %, (0.41 ± 0.11) %, and V 30 were (2.48 ± 0.51) %, (2.06 ± 0.49) % respectively, and there were statistically significant differences ( t=4.86, P<0.001; t=2.97, P=0.004; t=4.36, P<0.001) . The levels of serum troponin Ⅰ (cTnⅠ) before radiotherapy in the study group and the control group were (0.09±0.02) ng/ml and (0.09±0.01) ng/ml, creatine kinase isoenzyme MB (CK-MB) were (0.27±0.08) U/L and (0.25±0.08) U/L, myoglobin (MYo) were (3.84±1.02) μg/L and (3.69±0.97) μg/L, and brain natriuretic peptide (BNP) were (172.35±16.24) pg/ml and (169.81±15.93) pg/ml respectively, there were no statistically significant differences ( t<0.01, P>0.999; t=1.30, P=0.197; t=0.78, P=0.436; t=0.82, P=0.414) . One month after radiotherapy, the levels of serum cTnⅠ in the two groups were (0.09±0.03) ng/ml and (0.09±0.02) ng/ml, CK-MB were (0.29±0.09) U/L and (0.28±0.08) U/L, MYo were (4.06±1.08) μg/L and (4.01±1.03) μg/L, and BNP were (175.13±17.09) pg/ml, (172.47±16.28) pg/ml respectively, there were no statistically significant differences ( t<0.01, P>0.999; t=0.61, P=0.544; t=0.25, P=0.806; t=0.83, P=0.410) . The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) scores before radiotherapy in the study and the control groups were (60.24±5.13) points and (61.19±5.46) points, (74.12±7.20) points and (75.35±7.88) points at 1 month after radiotherapy, (77.53±7.14) points and (78.95±7.08) points at 6 months after radiotherapy, and (75.02±6.93) points and (76.68±6.74) points at 1 year after radiotherapy respectively, there were no statistically significant differences ( t=0.93, P=0.353; t=0.85, P=0.399; t=1.04, P=0.302; t=1.26, P=0.210) . The EORTC QLQ-C30 scores at 1 month, 6 months, and 1 year after radiotherapy were higher than those before radiotherapy in the two groups, and there were statistically significant differences (all P<0.001) . Conclusion:IMRT containing lymph node irradiation in the internal breast region after left breast cancer surgery brings a certain degree of increased cardiac dose, but it is feasible to control it within a certain range and does not affect the patients' cardiac function or quality of life in the short term.

Análise comparativa das doses cardíacas recebidas por pacientes com câncer de mama esquerda planejadas com duas formas alternativas de delineamento do CTV da cadeia mamária interna / Comparative analysis of heart doses received by patients with left breast cancer planned with two alternative internal mamary delineation CTVs

Propósito. Com a publicação, na última década, do resultado de grandes estudos demonstrando a correlação entre a dose de radiação recebida no coração e o aumento de eventos cardíacos adverso. Nosso estudo investiga a possibilidade de reduzir a dose cardíaca de radiação sem utilizar os protocolos ideais de inspiração profunda (DIBH). Metodologia. Analisamos os parâmetros dosimétricos referentes a 43 pacientes recebidas no departamento de radioterapia da Santa Casa de Maceió tratadas com radioterapia adjuvante em mama ou plastrão esquerdos incluindo fossa e cadeia mamária interna (MI). Todas as pacientes foram submetidas a duas tomografias e planejamentos distintos, com e sem inspiração profunda (DIBH), em um protocolo simplificado adequado para a realidade do Sistema Único de Saúde (SUS). Foram analisados os efeitos dosimétricos sobre o volume alvo, o coração, o pulmão esquerdo com o DIBH simplificado e com formas alternativas de delineamento da cadeia mamária interna. Resultados. Em nosso estudo, o protocolo de DIBH simplificado demonstrou uma redução da dose média cardíaca mesmo em pacientes incluindo radiação nodal regional ampla (692 cGy vs 502 cGy - p < 0,0001). As doses médias no ventrículo esquerdo (VE) (1222 cGy vs 857 cGy ­ p < 0,0001), na artéria coronária anterior descendente (LAD) (3739 cGy vs 3345 cGy ­ p = 0,0001) e outros parâmetros como o V25% do coração (12,4% vs 7,7% - p < 0,0001) também se mostraram reduzidas. Os delineamentos alternativos da cadeia mamária interna (MI) não produziram alterações significantes nas doses cardíacas ou pulmonares. O melhor parâmetro para predizer o benefício do DIBH foi a expansibilidade do pulmão esquerdo (r = 0,6 - p < 0,0001), sendo que os pacientes com relação entre o pulmão normal e o inspirado menor que 1,3-1,4 não obtiveram benefício significativo. Doses pulmonares também tiveram melhora estatisticamente significativa com o DIBH (média 1448 cGy vs 1294 cGy ­ p < 0,0001; V20 32,6% vs 28,2% - p <0,0001; V5 48,7% vs 45,4% - p < 0,0005), Conclusão. Nosso estudo indica que um protocolo simplificado de DIBH pode ser uma alternativa para beneficiar pacientes selecionados que necessitam reduzir a dose cárdica de radiação em tratamentos e mama esquerda e drenagens regionais em serviços de radioterapia de alta demanda e recursos limitados

Purpose. In the last decade, seminars studies demonstrated the correlation between radiation doses received in the heart with the incidence of cardiac disease, such as acute coronary events. This aroused the interest in new techniques to reduce this problem. Numerous studies have already shown that Deep Inspiration Breath Hold (DIBH) may be the best option for reducing cardiac dose. However, the vast majority of these investigations were carried out in a different scenario from the one found in our reality. Our study investigated the feasibility of reducing the cardiac dose without using an ideal DIBH protocol, which are difficult to implement in services with high demand and low economic support. Methods. The dosimetric parameters of 43 patients from the radiotherapy department of Santa Casa de Maceió were analyzed. All patients were treated with adjuvant radiotherapy to the left breast, including supraclavicular fossa and internal mammary chain (IM). The patients underwent two different CT scans and planning, with and without DIBH, in a simplified protocol suitable for the reality of tour public health system (Free Breath Hold; no respiratory training; selection of only the patients with greater benefit). The dosimetric impact on the heart, its substructures and the left lung were studied with the simplified DIBH and with alternative forms of delineation to the IM. Results. The simplified DIBH protocol demonstrated, in our study, a reduction in mean cardiac dose for patients including wide regional nodal radiation (692 cGy vs 502 cGy - p < 0.0001). The doses for the Left ventricular (1222 cGy vs 857 cGy ­ p < 0.0001), the Left anterior-descending coronary (3739 cGy vs 3345 cGy ­ p = 0.0001) and other parameters such as heart V25% (12.4% vs 7, 7% - p < 0.0001) were also reduced. The doses to the heart did not achieve statistically significant reduction with alternative delineation of the MI CTV. The best parameter predicting the benefit of DIBH was the left lung expansion (r = 0.6 - p < 0.0001), with patients with a ratio lower than 1.3-1,4 having no significant benefit. Pulmonary doses also showed a statistically significant improvement with DIBH (Dmed 1448 cGy vs 1294 cGy ­ p < 0.0001; V20 32.6% vs 28.2% - p <0.0001; V5 48.7% vs 45, 4% - p < 0.0005), but the reductions were small, as was the increase in pulmonary dose when the MI CTV is outlined to joining the supraclavicular fossa. Conclusion. Our study indicates that a simplified DIBH protocol may serve as an option to benefit selected patients with locally advanced breast cancer treated in departments with high occupation of the Linacs and low capacity for investment in new technology

Risk assessment of internal mammary lymph node metastasis and choice of irradiation of internal mammary lymphatic drainage area in breast cancer patients with negative internal breast lymph nodes on imaging / 中华肿瘤杂志

Objective: To explore the independent risk factors of internal mammary lymph nodes (IMN) metastasis and the risk assessment method of IMN metastasis preoperatively in breast cancer patients with negative IMN in imaging examination, and guide the radiotherapy of IMN in patients with different risk stratification of IMN metastasis. Methods: The clinical and pathological data of 301 breast cancer patients who underwent internal mammary sentinel node biopsy(IM-SLNB) and/or IMN dissection in Shandong Cancer Hospital with negative IMN on CT and/or MRI from January 2010 to October 2019 were analyzed retrospectively. The independent risk factors were analyzed by univariate and multivariate logistic regression, and the independent risk factors of IMN metastasis were used to risk stratification. Results: Among the 301 patients, 43 patients had IMN metastasis, and the rate of IMN metastasis was 14.3%. Univariate analysis showed that vascular tumor thrombus, progesterone receptor (PR) expression, T stage and N stage were associated with IMN metastasis. Multivariate logistic regression analysis showed that tumor located in medial quadrant, positive PR and axillary lymph node metastasis were independent risk factors for IMN metastasis. The risk of IMN metastasis was assessed according to the independent risk factors of the patients: low-risk group is including 0 risk factor, medium-risk group is including 1 risk factor, and high-risk group is including 2-3 risk factors. According to this evaluation criteria, 301 patients with breast cancer were divided into low-risk group (with 0 risk factors), medium-risk group (with 1 risk factor) and high-risk group (with 2-3 risk factors). The IMN metastasis rates were 0 (0/34), 4.3% (6/140) and 29.1% (37/127), respectively. Conclusions: The risk stratification of IMN metastasis according to three independent risk factors of IMN metastasis including tumor located in medial quadrant, positive PR and axillary lymph node metastasis in breast cancer patients can guide the radiotherapy of IMN in newly diagnosed breast cancer patients. For N1 patients, radiotherapy of IMN is strongly recommended when the primary tumor is located in the medial quadrant and/or PR positive.

Graft flow analysis of application of bilateral internal mammary artery with different configurations in coronary artery bypass grafting / 中华胸心血管外科杂志

Objective:To analyze the influence of application of bilateral internal mammary artery(BIMA) with different configurations in coronary artery bypass grafting(CABG).Methods:From January 2018 to December 2020, 82 patients underwent CABG using BIMA were included, with 75 males and 7 females, aged(56.9±9.8) years old. According to the target of coronary artery of BIMA, patients were divided into two groups, 23 patients(group B) who underwent the traditional operation(RIMA to the right coronary artery), and 59 patients(group L) whose RIMA were grafted to the left ventricular arteries. Also the patients were divided into two groups according to the RIMA used either in situ(group I, 57 cases) or free(group F, 25 cases). Compare the grafts flow between groups. The CTA angiography of coronary artery was completed to evaluate the grafts patency before discharge.Results:There was 1 early operative death(1.22%). The mean flow(MF) of RIMA was significantly higher in group B( P=0.013). The pulsatility index(PI) of LIMA was significantly lower and the MF of RIMA and BIMA was higher(all P<0.05), fewer patients with LIMA-MF less than 15 ml/min( P=0.023)in the group I. CTA angiography before discharge showed that only 1 RIMA to right coronary artery was occlusion. Conclusion:It is better to use BIMA in situ in CABG, RIMA used in right coronary artery can receive more satisfactory graft flow. BIMA has good patency in early stage, therefore is the ideal and stable coronary bypass graft.

Predictive Factors and Prognostic Value of Pathologic Complete Response of Internal Mammary Lymph Nodes in Breast Cancer After Neoadjuvant Chemotherapy / 肿瘤防治研究

Objective To explore the prognostic factors of the pathological complete response of internal mammary lymph node (ipCR) after neoadjuvant chemotherapy and its effect on breast cancer prognosis. Methods We retrospectively analyzed the clinical data of 70 patients with primary breast cancer with internal mammary lymph node metastasis who received neoadjuvant chemotherapy. Patients were divided into the ipCR group and non-ipCR group based on their postoperative pathology. χ2 test, Fisher, and Logistic regression were used for univariate and multivariate analysis. Meanwhile, the Kaplan-Meier curve and Cox regression were used for prognostic analysis. Results Of 70 patients, 31 obtained ipCR (44.3%). Univariate analysis showed that the expression levels of apCR, HR, and HER2 status were related to ipCR (P < 0.05). Multivariate analysis showed that age, apCR, and HER2 status were independent predictors of ipCR (P < 0.05). The average DFS of ipCR group was better than non-ipCR group (96.0 vs. 67.1 months, P < 0.05). The risk of recurrence and metastasis was 87% lower in the ipCR group than in the non-ipCR group (HR=0.13, 95%CI: 0.04-0.44, P < 0.01). ipCR, Ki67 expression level, and breast pCR (bpCR) were independent factors affecting patients' prognosis. Conclusion There is a correlation between clinico pathological factors and ipCR after neoadjuvant chemotherapy. ipCR can be used to predict the prognosis of patients with internal mammary lymph node metastasis.

Efficacy comparison between Milrinone and Papaverine on the spasm of internal mammary artery during off-pump coronary artery bypass grafting / 中华胸心血管外科杂志

Objective:To compare the efficacy of Milrinone and Papaverine in relieving the spasm of internal mammary artery (LIMA) during off-pump coronary artery bypass grafting (OPCABG).Methods:Between April 2018 to December 2018, 200 patients who suffered obvious angina pectoris and three-vessel disease documented by coronary angiography, undergoing OPCABG at Beijing Anzhen Hospital, Capital Medical University were recruited in this study, including 103 males and 97 females, aged 46-74 years, with an average of (59.12±0.49) years old. For all patients, the LIMA was anastomosed to left anterior descending artery(LAD). According to different methods relieving LIMA spasm, all patients randomly divided into 4 groups (n=50): Papaverine surface infiltration group (group Ⅰ), Papaverine injection group (group Ⅱ), Milrinone surface infiltration group (group Ⅲ) and Milrinone injection group (group Ⅳ). The blood flow (ml/min) of the free LIMA, the blood flow of the LIMA-LAD after bypass, anastomotic time of obtuse marginal artery, the use of vasoactive drugs, the outcomes of perioperative period and 1 year after operation were compared in the four groups.Results:There was no significant difference between group Ⅲ and group Ⅰ in the blood flow of free LIMA and LIMA-LAD[(45.50±1.43)ml/min vs. (47.42±1.61)ml/min、(28.60±0.89)ml/min vs. (28.40±0.96)ml/min, all P>0.05]. The blood flow of free LIMA and the LIMA-LAD in group Ⅱ were significantly higher than those in group Ⅰ[(60.36±1.28)ml/min vs. (47.42±1.61)ml/min, (42.40±1.25)ml/min vs. (28.40±0.96)ml/min, all P<0.05]. The blood flow of free LIMA and LIMA-LAD in group Ⅳ were significantly higher than those in group Ⅲ[(70.86±2.00) ml/min vs. (45.50±1.43) ml/min, (59.46±1.25) ml/min vs. (28.60±0.89) ml/min, all P<0.05]. The blood flow of free LIMA and LIMA-LAD in group Ⅳ were significantly higher than those in group Ⅱ[(70.86±2.00) ml/min vs. (60.36±1.28) ml/min, (59.46±1.25) ml/min vs. (42.40±1.25)ml/min, all P<0.05]. The anastomotic time of obtuse marginal artery[(7.14±0.72)min vs. (8.30±0.93)min, (8.10±0.89)min, (8.14±0.90)min, P<0.05], the dopamine dose[(3.76±0.40)μg·kg -1·min -1 vs. (5.02±0.52)μg·kg -1·min -1, (4.84±0.48)μg·kg -1·min -1, (4.90±0.49)μg·kg -1·min -1,P<0.05] and the esmolol usage (32% vs. 60%, 58%, 58%, P<0.05) during the operation in group Ⅳ were significantly reduced compared with the other three groups. The V3 ST depression on the postoperative first day[(0.34±0.18)mv vs. (0.71±0.22)mv, (0.68±0.20)mv, (0.69±0.22) mv, P<0.05], and the TNI on the postoperative third day[(0.24±0.08)ng/ml vs. (0.56±0.15)ng/ml, (0.54±0.11)ng/ml, (0.53±0.12) ng/ml, P<0.05] were significantly lower in group Ⅳ than those in the other three groups. However, there was no significant difference about the first-year patency of LIMA-LAD among four groups. Conclusion:For relieving spasm of LIMA, the Milrinone injection was better than that of Papaverine, which could shorten the anastomotic time of obtuse marginal artery, maintain intraoperative hemodynamics stability, reduce myocardial damage during OPCABG.

obot-assisted bilateral internal mammary arteries harvesting for off-pump coronary artery bypass grafting with 5 grafts by minimally invasive small incision: A case report / 中国胸心血管外科临床杂志

@#Objective    To introduce the method and preliminary experience of robot-assisted bilateral internal mammary arteries (BIMA) harvesting for off-pump coronary artery bypass grafting (OPCAB) with 5 grafts via left anterolateral minithoracotomy. Methods    BIMA were harvested using the da Vinci robotic surgical system, and the right internal mammary artery (RIMA) was pulled out of the thoracic cavity through right second intercostal space. Intercepting the distal part of the RIMA for the BIMA composite Lima-Rima Y graft and anastomosing the great saphenous vein with remaining RIMA end to end. The Y graft anastomosed with left anterior descending (LAD) branch and diagonal branches (DIAG), artery-vein graft sequentially anastomosed with blunt round branch, left ventricular posterior branch and posterior descending branch. Results    The operation succeeded without hemodynamic instability and intra aortic balloon pump (IABP) implantation or cardiopulmonary bypass. The blood flow of Y graft was 24 mL/min, and the blood flow of artery-vein graft was 30 mL/min. Ventilator assistance time was 35 hours, ICU staying time was 62 hours, and postoperative myocardial enzymes increased temporarily. Postoperative coronary CTA showed that all the grafts were patency, and cardiac ultrasound indicated that the heart function was normal. The patient cured and discharged from hospital 7 days after operation. Conclusion    Robot-assisted bilateral internal mammary artery harvesting for OPCAB with 5 grafts via left anterolateral minithoracotomy is feasible, which can achieve complete revascularization.

Analysis of influencing factors of graft stenosis after left internal mammary artery-left anterior descending coronary artery bypass grafting / 国际外科学杂志

Objective:To explore the influencing factors of postoperative graft stenosis in patients undergoing left internal mammary artery-left anterior descending branch (LIMA-LAD) coronary artery bypass graft (CABG) surgery.Methods:A retrospective analysis of the clinical data of 86 patients who were admitted to the Second Affiliated Hospital of Hainan Medical College and received coronary angiography after CABG surgery from July 2019 to December 2020 due to recurrent chest tightness, chest pain and other symptoms. According to the degree of stenosis of the LIMA-LAD graft, the patients were divided into stenosis group ( n=25) and non-stenosis group ( n=61). The graft stenosis of patients in the stenosis group was ≥50%, and the graft stenosis of patients in the non-stenotic group was less than 50%. The general information, past medical history, CABG intraoperative data, current visit data and biochemical indicators of the two groups were compared. Measurement data were expressed as mean±standard deviation ( Mean± SD), comparison between groups was by t-test; count data comparison between groups was by Chi-square test. Logistic regression analysis was used to screen out the influencing factors of graft stenosis after CABG. Use the rms package in the R 4.0.2 software to build a nomogram prediction model. Using receiver operating characteristic (ROC) curve to evaluate the discriminative degree of the model. Use the calibration curve and deviation correction C-index to evaluate the nomogram prediction model. Use X-tile software to obtain the cutoff value of the nomogram model integral, use Kaplan-Meier method to draw the survival curve, and use Log-rank to test. Results:Logistic regression analysis showed that smoking, hypertension, pre-CABG left anterior descending branch (LAD) stenosis <75%, pre-CABG left internal mammary artery (LIMA) blood flow, and coronary angiography diffuse lesions are independent risk factors that affect LIMA-LAD graft stenosis after CABG ( P<0.05). The C-index value predicted by the nomogram model was 0.879 (95% CI: 0.818-0.955, P<0.001). The area under the ROC curve was 0.712 (95% CI: 0.594-0.801, P<0.001), with good discrimination. The calibration curve shows that the accuracy of the model prediction was good. Through the X-tile software screening to obtain the model score cutoff value, the patients were divided into low-risk group (≤54 points), medium-risk group (>54 points and ≤112 points), and high-risk group (>112 points). The results of survival analysis showed that the incidence of postoperative graft stenosis in the three groups was 20.9%, 50.0% and 80.0%, respectively. Conclusions:Smoking, hypertension, LAD stenosis before CABG <75%, LIMA blood flow before CABG, and coronary angiography diffuse lessions are independent risk factors that affect LIMA-LAD graft stenosis after CABG. The construction of a nomogram prediction model can provide a reference for evaluating the patency of the LIMA-LAD graft vessel before CABG operation, and reduce the probability of LIMA-LAD graft vessel stenosis after CABG operation.

Skeletonized bilateral internal mammary artery harvesting with harmonic scalpel in coronary artery bypass grafting / 中国胸心血管外科临床杂志

@#Objective    To summarize the use of harmonic scalpel to harvest bilateral internal mammary artery in coronary artery bypass grafting (CABG). Methods    The clinical data of 54 patients of bilateral skeletonized internal mammary artery harvesting for CABG in our hospital from January 2016 to May 2020 were analyzed retrospectively. There were 51 males and 3 females with a mean age of 62.37±9.56 years. Results    All patients went through the procedure unevently and discharged from hospital. The number of grafts was 4.07±0.85 per patient, the operation time was 267.21±47.00 min, mechanical ventilation time was 342.43±132.17 min and hospital stay was 12.21±4.43 d. Conclusion    It is safe and effective to use harmonic scalpel to harvest skeletonized bilateral internal mammary artery in CABG.

A dosimetric analysis of incidental radiation to the internal mammary nodes with a three-field chest wall technique

@#<p style="text-align: justify;"><strong>Objectives:</strong> The authors' aim was to conduct a dosimetric analysis of the incidental radiation dose to the internal mammary node (IMN) region using a three-field chest wall technique (TFCWT).</p><p style="text-align: justify;"><strong>Methods:</strong> This retrospective study utilized 3D-conformal radiotherapy plans of 50 postmastectomy patients (25 left-sided and 25 rightsided). All plans used the TFCWT, composed of narrowed tangents matched medially to an AP electron field, and prescribed a total dose of 50 Gy in 28 fractions. The IMNs were not intentionally treated in all included plans.</p><p style="text-align: justify;"><strong>Results:</strong> The mean dose to the IMN-planning target volume (IMN-PTV) was 45.1 Gy (26.4 - 55.6, SD 6.5). Minimum doses received by 95% and 90% of the IMN-PTV were 29.3 Gy (8 - 49, SD 10.0) and 34.0 Gy (10.0 - 52.0, SD 8.6), respectively. The percent volume of IMN-PTV receiving 100%, 95%, 90%, and 80% were 47.4% (3 - 94, SD 21.6), 55.6% (6 - 97, SD 22.4), 61.92% (7 - 98, SD 22.2), and 72.61% (18-100, SD 20.2), respectively. The average ipsilateral lung V20 Gy (with supraclavicular fields) was 25.0% (16 - 29, SD 3.4), and the average heart mean dose was 2.5 Gy (0.5 - 7.9, SD 1.58).</p><p style="text-align: justify;"><strong>Conclusion:</strong> Although the results suggest increased IMN radiation doses with the TFCWT when compared historically to standard tangents, the incidental doses are comparatively less than that traditionally prescribed to the IMNs in high-risk patients. It is unknown whether this incidental IMN dose confers any clinical benefit.</p>

Efficacy of prophylactic irradiation of internal mammary lymph nodes in breast cancer: a Meta-analysis / 中华放射肿瘤学杂志

Objective:To evaluate the effect of prophylactic irradiation of internal mammary lymph nodes in patients with breast cancer in this Meta-analysis.Methods:CNKI, Wanfang Medical network, CBM, PubMed, EMBASE and Web of Science were searched by computer. The controlled clinical studies comparing whether or not internal mammary lymph node irradiation as an intervention were included and the quality of the included literature was evaluated according to Newcastle-Ottawa Scale (NOS). RevMan 5.3 software and Stata 14 software were used for Meta-analysis.Results:A total of 11 original articles were included, and 13 181 patients were included for Meta-analysis. There was no statistically significant difference in the overall survival (OS) between patients with and without internal mammary lymph node irradiation ( P=0.490). The subgroup analysis using the date of treatment and the degree of risk in the enrolled population as criteria showed that 5-year OS was significantly increased after internal mammary area irradiation in high-risk stage Ⅱ-Ⅲ patients (N+ , T 3-T 4 stage) with the date of treatment of after 2000( P=0.003, 0.006). Compared with patients without internal mammary area irradiation, internal mammary irradiation significantly increased the 5-year disease-free survival (DFS)( P<0.001). Conclusion:Under the modern radiotherapy technology, internal mammary lymph node irradiation improves the DFS of patients, and may bring OS benefits to high-risk stage Ⅱ-Ⅲ breast cancer patients (N+ , T 3-T 4 stage).

Dosimetric evaluation, acute toxicity and short-term efficacy of postmastectomy hypofractionated internal mammary chain irradiation with electrons / 中华放射肿瘤学杂志

Objective:To investigate the dosimetric characteristics, acute toxicity and short-term efficacy of postmastectomy hypofractionated internal mammary (IM) chain irradiation with electrons in patients with high-risk breast cancer.Methods:A total of 155 patients with breast cancer who underwent modified mastectomy between November 2018 and January 2020 were selected. Among them, 137(88.4%) patients were classified as stage Ⅲ and 18(11.6%) as stage Ⅱ. All patients received standard chemotherapy, endocrine therapy and anti-Her2 targeted therapy. CTV im was divided into three subregions: CTV im1, CTV im2 and CTV im3, which represented the first, second and third intercostal IM, respectively. The planning target volume of subraclavicular region (PTV sc) was delineated. CTV cw and CTV im were irradiated with 6-15 MeV electron at 43.5 Gy in 15 fractions over 3 weeks. Moreover, PTV sc was irradiated with 6 MV X-ray at 43.5 Gy in 15 fractions over 3 weeks using two-dimensional radiotherapy (2DRT) or three-dimensional radiotherapy (3DRT). The dosimetric characteristics of CTV im, PTV sc, lung, heart, left anterior descending coronary artery (LAD) and right coronary artery (RA) were evaluated, and the acute toxicity and short-term efficacy were analyzed. Results:The mean dose (D mean) of CTV im was (43.3±2.6) Gy, D 95% was (30.5±8.3) Gy, V 90% was (85.0±10.5)% and V 80% was (91.0±7.4)%, respectively. The corresponding parameters of CTV im1 were significantly lower than those of CTV im2 and CTV im3(all P<0.001). Body mass index exerted no significant effect on IM dose ( P>0.05). Compared with 2DRT, 3DRT for SC significantly increased theD mean of CTV im[(43.4±2.6) Gy vs.(41.4±2.3) Gy, P=0.021], and the hot spot within PTV sc[V 110%: (26.7±17.5) cm 3vs.(12.5±8.4) cm 3, P=0.018; V 120%: (6.1±5.3) cm 3vs.(2.0±2.6) cm 3, P=0.023]. TheD mean of the ipsilateral lung was (9.8±1.9) Gy, and V 20Gy was (19.7±4.7)%. TheD mean of heart was (3.3±1.7) Gy in the whole group, (4.7±1.4) Gy for the left-sided breast cancer and (2.6±1.2) Gy for the right-sided breast cancer, respectively. TheD mean of LAD for the left-sided breast cancer was (13.9±4.9) Gy. TheD mean of RA for the right-sided breast cancer was (7.5±3.7) Gy. The incidence rates of ≥ grade 2 acute radiation dermatitis, esophagitis and pneumonitis were 19.3%, 4.5% and 2.6%, respectively. With a median follow-up time of 20.5 months (range: 9.9-41.8 months), 2 cases of chest wall recurrence, 2 regional lymph node recurrence, 6 distant metastases and 1 death were reported. Conclusions:When hypofractionated internal mammary chain is irradiated by electrons after mastectomy, the doses to the lung, heart and coronary artery are low, and the acute toxicities are mild. However, the dose to CTV im1 is inadequate. Although short-term efficacy is high, long-term follow-up is warranted.

Comparison of different delineation methods of clinical target volume of internal mammary lymph node for patients after internal mammary lymph node dissection / 中华放射肿瘤学杂志

Objective:To compare the differences of postoperative clinical target volume of internal mammary lymph node (CTV ImlN) by different delineation methods, and to explore the reasonable method of CTV ImlN delineation after internal mammary lymph node dissection (ImlND). Methods:A total of 20 breast cancer patients who had undergone modified radical mastectomy (MRM) with ImlND on the affected side and had complete preoperative and postoperative CT images were selected. The CTV (CTV pr-I, CTV pr-a) of both sides of ImlN were delineated on preoperative CT images according to RTOG guideline. On postoperative CT images, three different methods including deformation image registration (DIR) method, visual contrast method and precise measurement method, were employed to delineate the postoperative CTV ImlN of the affected side. The targets were named as CTV DIR, CTV V and CTV M, respectively. The central displacement, target volume, degree of inclusion (DI) and conformity index (CI) of CTV pr-a, CTV V, CTV M and CTV DIR were compared. Results:The central displacement of CTV V, CTV M and CTV DIR from CTV pr-a was 2.17 cm, 1.44 cm and 1.25 cm, respectively. The target volume of CTV pr-a, CTV pr-I, CTV V, CTV M and CTV DIR was 2.10 cm 3, 2.17 cm 3, 2.04 cm 3, 1.88 cm 3 and 2.07 cm 3 respectively. There was no significant difference in the target volume (all P>0.05). The CI values of CTV V-CTV pr-a and CTV M-CTV pr-a were both 0.16, and that of CTV DIR-CTV pr-a was 0.43. The CI value of CTV DIR was significantly higher than those of CTV V and CTV M (both P<0.01). The DI values of CTV V-CTV pr-a, CTV M-CTV pr-a and CTV DIR-CTV pr-a were 0.26, 0.24 and 0.58, respectively. The DI value of CTV DIR was significantly higher than those of CTV V and CTV M (both P<0.01). Conclusions:It is difficult to accurately delineate the CTV ImlN for patients after ImlND. However, the spatial position fitness of the target region delineated by DIR method is better than those by visual contrast and precise measurement methods.

Disección de la arteria mamaria interna en cirugía cardíaca: Una historia no siempre bien contada / Internal mammary artery harvesting in cardiac surgery: an often mistold story

RESUMEN La arteria mamaria interna es el hemoducto de elección para injertar en la arteria coronaria descendente anterior. Un enorme cuerpo de evidencia demuestra que los resultados de la cirugía de revascularización miocárdica en el corto y largo plazo dependen de determinados factores relacionados con la preparación de la arteria, como su flujo y el grado de vascularización esternal residual. Por ese motivo, en las últimas décadas el procedimiento de disección de la arteria mamaria interna ha recibido tanta atención como la técnica de construcción de los injertos. Sin embargo, la historia de su origen y posterior evolución no ha sido siempre adecuadamente contada y muchas imprecisiones se han trasmitido a lo largo de los años.

ABSTRACT The left internal mammary artery is the conduit of choice for left anterior descending coronary artery grafting. A huge body of evidence shows that the short and long-term outcomes of coronary artery bypass grafting depend on specific factors related to the preparation of the artery, namely, its blood flow and residual sternal vascularization degree. Accordingly, the internal mammary artery harvesting has received as much attention as the grafting construction technique in recent decades. However, the story of its origins and subsequent progress has not always been properly told as many inaccuracies have been passed on over the years.

Research progress of sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer / 国际外科学杂志

The feasibility and safety of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) for breast cancer are still controversial in clinical practice. SLNB after NAC is feasible and safe for patients with clinically node-negative (cN0) breast cancer, while those with clinically node-positive (cN+ ) should be carefully considered. In addition to methylene blue and 99mTc-sulfur colloid tracing, some other tracing methods have been proposed in clinical studies, such as carbon nanoparticles and indocyanine green fluorescence tracing. The axillary lymph node (ALN) state of SLNB patients after NAC was associated with molecular subtyping, response to chemotherapy, residual breast tumor size, etc. Therefore, a number of factors should be considered to determine whether ALN dissection is needed. The false negative rate of SLNB after NAC can be reduced by some measures such as placing clips prior to surgery and preoperative tattooing with sterile black carbon suspension. Besides ALN, internal mammary lymph nodes is another route for breast cancer metastasis. As a low-invasive diagnostic technique, internal mammary sentinel lymph node biopsy can complete lymph node staging and pathological staging to guide treatment. This review attempts to introduce the research progress of SLNB after NAC from multiple aspects such as feasibility and safety, tracer methods, assessment of ALN status and methods to reduce false negative rate.