Is internal mammary artery graft beneficial in emergent coronary artery bypass surgery? A Society of Thoracic Surgeons national database analysis.

BACKGROUND: Often, only saphenous vein grafts (SVGs) are used in emergent coronary artery bypass graft (CABG) procedures to provide quicker myocardial revascularization despite its lower long-term patency relative to the internal mammary artery (IMA) grafts. We examined differences between IMA and non-IMA graft recipients in emergent CABGs and its impact on in-hospital outcomes. METHODS: Retrospective review of Society of Thoracic Surgeon National Database was done to identify patients age ≥18 years undergoing primary emergent isolated CABG between 2013 and 2016. Emergent salvage, non-LAD disease, subclavian stenosis and revascularization with other arterial grafts were excluded. The study population was divided in two groups: IMA and non-IMA groups. Demographics, preoperative, intraoperative factors and postoperative outcomes were analyzed between the groups. RESULTS: Of 18,280 emergent CABGs during the study period, 16281 had IMA used and 1999 had only vein grafts. The IMA group was younger, more likely to be male, had lower creatinine and higher ejection fraction. The non-IMA and IMA groups were then propensity risk matched with ratio of 1:2 which showed significantly higher in-hospital mortality in the non-IMA group (15% vs. 7%, P<0.0001). The non-IMA groups also had higher rates bleeding (5% vs. 3%, P<0.01), renal failure (10% vs.6%, P<0.0001) and prolonged vent (44% vs. 30%, P<0.0001). CONCLUSIONS: IMA grafts in primary isolated emergent CABGs are associated with significantly lower rates of in-hospital mortality. Even for emergent CABG there may be a clinical benefit in using IMA grafts rather than SVGs only.

Innovative and Contemporary Interventions of Diaphragmatic Disorders.

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

The Development of Pulmonary Hypertension Results in Decreased Post-Transplant Survival.

The effects of pulmonary hypertension (PAH) on survival after heart transplantation are debated, especially for patients with left ventricular assist devices (LVAD). The United Network of Organ Sharing database was retrospectively queried from January 2005 to June 2015 to identify adult patients who underwent heart transplantation. Four groups were defined: patients without PAH, persistent PAH, resolved PAH, and developed PAH between listing and transplant. A total of 15,914 patients underwent heart transplant of which 4,662 (29%) were implanted with an LVAD. Of the total population, 10,872 (68%) had PAH at time of listing and 9,661 (61%) had PAH at time of transplant. Long-term survival was significantly worse for patients with an LVAD than for those without who had PAH at time of transplant (p = 0.010). Kaplan-Meier analysis showed a trend of worse long-term survival for patients with an LVAD who developed PAH by the time of transplant but improved survival for patients with resolved PAH while on LVAD therapy (p = 0.052). PAH at time of transplant results in worse long-term survival for patients with an LVAD. Furthermore, the development of PAH while on LVAD therapy may negatively impact long-term post-transplant survival, while resolution of PAH improves long-term survival.

Hybrid Endovascular Aortic Arch Reconstruction for Acute Aortic Dissection: An Endovascular Bridge Technique for Complex Anatomy.

Acute type A aortic dissections starting at the arch pose a challenge for cardiac surgeons. Open surgical repair requires deep hypothermic circulatory arrest for arch reconstruction and is associated with significant morbidity and mortality. Hybrid aortic repair techniques, with open arch debranching and thoracic endovascular aortic repair, have been employed in high-risk cases and challenging aortic pathology. Herein, we present a case of a 33-year-old African American male with a history of open thoracoabdominal aortic reconstruction and femoral-femoral artery bypass for a type B dissection who subsequently presented with new-onset chest pain and was found to have a retrograde type A dissection of a bovine arch with multiple dissection flaps and possible contrast extravasation on chest computed tomography. Endovascular reconstruction of the aortic arch using a hybrid technique was utilized and proved to be feasible and further should be considered when complex anatomy limits traditional surgical options.

Single Versus Double Lung Retransplantation Does Not Affect Survival Based on Previous Transplant Type.

BACKGROUND: Survival following retransplantation with a single lung is worse than after double lung transplant. We sought to characterize survival of patients who underwent lung retransplantation based on the type of their initial transplant, single or double. METHODS: The United Network for Organ Sharing database was queried for adult patients who underwent lung retransplantation from 2005 onward. Patients were excluded if they underwent more than one retransplantation. The patient population was divided into 4 groups based on first followed by second transplant type, respectively: single then single, double then single, double then double, and single then double. Descriptive analysis and Kaplan-Meier survival analysis were performed. A p value less than 0.05 was considered significant. RESULTS: A total of 410 patients underwent retransplantation in the study time period. Overall mean survival for all patients who underwent retransplantation was 1,213 days. Kaplan-Meier survival analysis demonstrated no difference in graft survival between the 4 study groups (p = 0.146). CONCLUSIONS: There was no significant difference in graft survival between recipients of retransplant with single or double lungs when stratified by previous transplant type. These results suggest that when retransplantation is performed, single lung retransplantation should be considered, regardless of previous transplant type, in an effort to maximize organ resources.

Sunshine Heart C-Pulse: device for NYHA Class III and ambulatory Class IV heart failure.

Advanced heart failure (HF) patients not meeting criteria for ventricular assist device or heart transplant with life-limiting symptoms are limited to medical and resynchronization therapy. The Sunshine Heart C-Pulse, based on intra-aortic balloon pump physiology, provides implantable, on-demand, extra-aortic counterpulsation, which reduces afterload and improves cardiac perfusion in New York Heart Association Class III and ambulatory Class IV HF. The C-Pulse reduces New York Heart Association Class, improves 6-min walk distances, inotrope requirements and HF symptom questionnaires. Advantages include shorter operative times without cardiopulmonary bypass, no reported strokes or thrombosis and no need for anticoagulation. Driveline exit site infections, inability to provide full circulatory support and poor function with intractable arrhythmias remain concerns. Current randomized controlled studies will evaluate long-term efficacy and safety compared with medical and resynchronization therapy.

Normalization of Exhaled Carbonyl Compounds After Lung Cancer Resection.

BACKGROUND: Quantitative analysis of specific exhaled carbonyl compounds (ECCs) has shown promise for the detection of lung cancer. The purpose of this study is to demonstrate the normalization of ECCs in patients after lung cancer resection. METHODS: Patients from a single center gave consent and were enrolled in the study from 2011 onward. Breath analysis was performed on lung cancer patients before and after surgical resection of their tumors. One liter of breath from a single exhalation was collected and evacuated over a silicon microchip. Carbonyls were captured by oximation reaction and analyzed by mass spectrometry. Concentrations of four cancer-specific ECCs were measured and compared by using the Wilcoxon test. A given cancer marker was considered elevated at 1.5 or more standard deviations greater than the mean of the control population. RESULTS: There were 34 cancer patients with paired samples and 187 control subjects. The median values after resection were significantly lower for all four ECCs and were equivalent to the control patient values for three of the four ECCs. CONCLUSIONS: The analysis of ECCs demonstrates reduction to the level of control patients after surgical resection for lung cancer. This technology has the potential to be a useful tool to detect disease after lung cancer resection. Continued follow-up will determine whether subsequent elevation of ECCs is indicative of recurrent disease.

Donor Oversizing Results in Improved Survival in Patients with Left Ventricular Assist Device.

Donor to recipient undersizing can result in diminished graft survival. The United Network for Organ Sharing database was retrospectively queried from January 2008 to December 2013 to identify adult patients who underwent heart transplantation. This population was divided into those without and with a left ventricular assist device (LVAD) at the time of transplant. Both groups were further subdivided into three groups: donor:recipient body mass index (BMI) ratio <0.8 (undersized), ≥0.8 and ≤1.2 (matched), and >1.2 (oversized). Kaplan-Meier analysis was used to compare graft survival. Cox regression analysis was used to identify factors affecting graft survival time. There was no difference in mean graft survival between undersized, matched, and oversized groups in patients without an LVAD (p = 0.634). Mean graft survival was significantly worse for undersized patients with an LVAD when compared with matched and oversized patients (p = 0.032). Cox regression revealed age, creatinine, waitlist time, United Network for Organ Sharing status, BMI ratio, and total bilirubin as significant factors affecting graft survival time. A donor to recipient BMI ratio of ≥1.2 results in significantly improved long-term graft survival for patients with an LVAD at the time of heart transplantation compared with patients with a BMI ratio of <1.2. An oversized organ should be considered for patients supported with an LVAD.

Left ventricular assist devices: current controversies and future directions.

Advanced heart failure is a growing epidemic that leads to significant suffering and economic losses. The development of left ventricular assist devices (LVADs) has led to improved quality of life and long-term survival for patients diagnosed with this devastating condition. This review briefly summarizes the short history and clinical outcomes of LVADs and focuses on the current controversies and issues facing LVAD therapy. Finally, the future directions for the role of LVADs in the treatment of end-stage heart failure are discussed.

High sensitivity for lung cancer detection using analysis of exhaled carbonyl compounds.

OBJECTIVE: Several volatile carbonyl compounds in exhaled breath have been identified as cancer-specific markers. The potential for these markers to serve as a screening test for lung cancer is reported. METHODS: Patients with computed tomography-detected intrathoracic lesions and healthy control participants were enrolled from 2011 onward. One liter of breath was collected from a single exhalation from each participant. The contents were evacuated over a silicon microchip, captured by oximation reaction, and analyzed by mass spectrometry. Concentrations of 2-butanone, 3-hydroxy-2-butanone, 2-hydroxyacetaldehyde, and 4-hydroxyhexanal were measured. The overall population was divided into 3 groups: those with lung cancer, benign disease, and healthy controls. An elevated cancer marker was defined as ≥1.5 SDs above the mean concentration of the control population. One or more elevated cancer markers constituted a positive breath test. RESULTS: In all, 156 subjects had lung cancer, 65 had benign disease, and 194 were healthy controls. A total of 103 (66.0%) lung cancer patients were early stage (stage 0, I, and II). For ≥1 elevated cancer marker, breath analysis showed a sensitivity of 93.6%, and a specificity of 85.6% for lung cancer patients. Additionally, 83.7% of stage I tumors ≤2 cm were detected; whereas only 14% of the control population tested positive. In a comparison of cancer to benign disease, specificity was proportional to the number of elevated cancer markers present. CONCLUSIONS: Screening using a low-dose CT scan is associated with high cost, repeated radiation exposure, and low accrual. The high sensitivity, convenience, and low cost of breath analysis for carbonyl cancer markers suggests that it has the potential to become a primary screening modality for lung cancer.

Double lung transplants have significantly improved survival compared with single lung transplants in high lung allocation score patients.

BACKGROUND: Historically, double lung transplantation survival rates are higher than those of single lung transplantation, but in critically ill patients a single lung transplant, with less associated operative morbidity, could afford a better outcome. This article evaluates how survival is affected in patients who have a high lung allocation score (LAS) and receive a single versus a double lung transplant. METHODS: The UNOS Thoracic Transplant Database for lung transplants from January 2005 to June 2012 was used for analysis. Propensity matching was used to minimize differences between the high and low LAS groups and between single and double lung transplants in the high LAS group. RESULTS: Within this database, there were 8,778 patients, of whom 8,050 had an LAS less than 75 and 728 had an LAS greater than or equal to 75. Kaplan-Meier survival curves stratified by high and low LAS, and by single versus double lung transplants, showed a marked decrease in survival (p<0.001) in those with a high LAS who received a single lung transplant when compared with those with a high LAS who received a double lung transplant. This was a much greater difference in survival than was present in the low LAS patient population. CONCLUSIONS: Despite a higher operative morbidity, patients who had a high LAS did substantially better in terms of survival if two lungs were transplanted rather than only one, with a larger difference in survival than for patients with a lower LAS.