Colonization with multi-drug-resistant organisms negatively impacts survival in patients with non-small cell lung cancer.

OBJECTIVES: Multidrug-resistant organisms (MDRO) are considered an emerging threat worldwide. Data covering the clinical impact of MDRO colonization in patients with solid malignancies, however, is widely missing. We sought to determine the impact of MDRO colonization in patients who have been diagnosed with Non-small cell lung cancer (NSCLC) who are at known high-risk for invasive infections. MATERIALS AND METHODS: Patients who were screened for MDRO colonization within a 90-day period after NSCLC diagnosis of all stages were included in this single-center retrospective study. RESULTS: Two hundred and ninety-five patients were included of whom 24 patients (8.1%) were screened positive for MDRO colonization (MDROpos) at first diagnosis. Enterobacterales were by far the most frequent MDRO detected with a proportion of 79.2% (19/24). MDRO colonization was present across all disease stages and more present in patients with concomitant diabetes mellitus. Median overall survival was significantly inferior in the MDROpos study group with a median OS of 7.8 months (95% CI, 0.0-19.9 months) compared to a median OS of 23.9 months (95% CI, 17.6-30.1 months) in the MDROneg group in univariate (p = 0.036) and multivariate analysis (P = 0.02). Exploratory analyses suggest a higher rate of non-cancer-related-mortality in MDROpos patients compared to MDROneg patients (p = 0.002) with an increased rate of fatal infections in MDROpos patients (p = 0.0002). CONCLUSIONS: MDRO colonization is an independent risk factor for inferior OS in patients diagnosed with NSCLC due to a higher rate of fatal infections. Empirical antibiotic treatment approaches should cover formerly detected MDR commensals in cases of (suspected) invasive infections.

The value of different 18F-FDG PET/CT baseline parameters in risk stratification of stage I surgical NSCLC patients.

OBJECTIVE: Administration of postoperative chemotherapy to patients with completely resected stage I NSCLC is still a matter of debate. The aim of the present study was to evaluate the value of different baseline 18F-FDG PET parameters in identifying surgical stage I NSCLC patients who are at high risk of recurrence, and thus are indicated for further postoperative treatment. METHODS: This is a retrospective study, which included 49 patients (28 males, 21 females) with the median age of 69 years (range 28-84), who had pathologically proven stage I NSCLC. All patients underwent 18F-FDG PET/CT at baseline followed by complete surgical resection of the tumor (R0). Baseline SUVmax, MTV and TLG were measured. Patients' follow-up records were retrospectively reviewed, and DFS (disease-free survival) was assessed. For each parameter, the most accurate cut-off value for the prediction of recurrence was calculated using the ROC curve analysis and the Youden index. DFS was evaluated for patients above and below the calculated cut-off value using the Kaplan-Meier method and the difference in survival between the two groups was estimated using the log-rank test. RESULTS: Median observation time of the patients after surgery was 28.7 months (range 3.5-58.8 months). 9 patients developed recurrence. The calculated cut-off values for SUVmax, MTV and TLG were 6, 6.6 and 33.6, respectively. Using these cut-offs, the observed sensitivity for SUVmax, MTV and TLG for prediction of recurrence was 100%, 89% and 89%, respectively, while the observed specificity was 43%, 73% and 65%, respectively. The difference in survival between patients below and above the cut-off value was statistically significant in all three studied parameters. The highest AUC was observed for MTV (AUC = 0.825, p = 0.003), followed by TLG (AUC = 0.789, p = 0.007), and lastly SUVmax (AUC = 0.719, p = 0.041). ROC curve analysis showed that volumetric parameters had better predictive performance than SUVmax as regards recurrence. CONCLUSION: PET-derived parameters at baseline were predictive of recurrence in stage I surgical NSCLC patients. Moreover, the metabolic volume of the tumor was the most significant parameter for this purpose among the studied indices.

Late Clinical Presentation of Inferior Vena Cava Deviation into the Left Atrium Following Atrial Septal Defect Repair in the Childhood.

A 19-year-old woman underwent ASD closure with patch in the childhood. Fifteen years later, she presented with severe cyanosis and dyspnea on exertion. Clinical diagnostics revealed a dislocation of the patch resulting in a right-to-left shunt (RLS) that was compensated in the past years by a recurrent ASD allowing a left-to-right shunt (LRS). The existing balance between interatrial shunts vanished by the growth of the patient leading to the clinical deterioration. After successful redo surgery, the patient was discharged home 8 days postoperatively.

Treatment Planning Considerations for Robotic Guided Cardiac Radiosurgery for Atrial Fibrillation.

PURPOSE: Robotic guided stereotactic radiosurgery has recently been investigated for the treatment of atrial fibrillation (AF). Before moving into human treatments, multiple implications for treatment planning given a potential target tracking approach have to be considered. MATERIALS & METHODS: Theoretical AF radiosurgery treatment plans for twenty-four patients were generated for baseline comparison. Eighteen patients were investigated under ideal tracking conditions, twelve patients under regional dose rate (RDR = applied dose over a certain time window) optimized conditions (beam delivery sequence sorting according to regional beam targeting), four patients under ultrasound tracking conditions (beam block of the ultrasound probe) and four patients with temporary single fiducial tracking conditions (differential surrogate-to-target respiratory and cardiac motion). RESULTS: With currently known guidelines on dose limitations of critical structures, treatment planning for AF radiosurgery with 25 Gy under ideal tracking conditions with a 3 mm safety margin may only be feasible in less than 40% of the patients due to the unfavorable esophagus and bronchial tree location relative to the left atrial antrum (target area). Beam delivery sequence sorting showed a large increase in RDR coverage (% of voxels having a larger dose rate for a given time window) of 10.8-92.4% (median, 38.0%) for a 40-50 min time window, which may be significant for non-malignant targets. For ultrasound tracking, blocking beams through the ultrasound probe was found to have no visible impact on plan quality given previous optimal ultrasound window estimation for the planning CT. For fiducial tracking in the right atrial septum, the differential motion may reduce target coverage by up to -24.9% which could be reduced to a median of -0.8% (maximum, -12.0%) by using 4D dose optimization. The cardiac motion was also found to have an impact on the dose distribution, at the anterior left atrial wall; however, the results need to be verified. CONCLUSION: Robotic AF radiosurgery with 25 Gy may be feasible in a subgroup of patients under ideal tracking conditions. Ultrasound tracking was found to have the lowest impact on treatment planning and given its real-time imaging capability should be considered for AF robotic radiosurgery. Nevertheless, advanced treatment planning using RDR or 4D respiratory and cardiac dose optimization may be still advised despite using ideal tracking methods.

In vitro assessment of prosthesis type and pressure recovery characteristics: Doppler echocardiography overestimation of bileaflet mechanical and bioprosthetic aortic valve gradients.

OBJECTIVE: Pressure recovery results in Doppler gradients greater than catheter gradients and is well established in association with bileaflet mechanical aortic valves. Because pressure recovery is influenced by orifice geometry, it might manifest differently with various valve prostheses. If true, then the reliability of Doppler echocardiography for the estimation of aortic valve gradients might be different with different prostheses. The purpose of the present study was to test, in an in vitro setting, the degree to which pressure recovery results in Doppler overestimation of gradients for three commonly used aortic valve prostheses. METHODS: Carpentier Edwards Perimount, Medtronic Mosaic, and St. Jude Medical bileaflet prostheses were tested under various flow conditions in a pulsatile mock flow loop with a normal aorta size. Mean pressure gradient was assessed with transducers 1 cm and 10 cm distal to the valve and with Doppler echocardiography. Pressure recovery was defined as the difference between the Doppler gradient and a 10-cm gradient. The percentage of the maximum pressure gradient composed of pressure recovery and the percentage of pressure recovery complete 1 cm distal to the valve were calculated. RESULTS: There was substantial pressure recovery for all valves in all flow states. Pressure recovery was responsible for 50% or more of the Doppler gradients for almost all conditions and was more than 70% complete within 1 cm for almost all conditions. Multivariate analysis found that flow and valve area (but not valve type) were predictors of pressure recovery; that flow was the major predictor of the percentage of Doppler gradient composed of pressure recovery (with minor contributions from the aorta size and prosthesis type); and that valve type and aorta size were the major predictors of the percentage of pressure recovery complete at 1 cm. CONCLUSIONS: In an in vitro model with a normal aorta size, substantial pressure recovery occurred with all three aortic valve prostheses. Although statistically significant differences were found between valve types in the percentage of pressure recovery and percentage of pressure recovery complete at 1 cm, the differences were small and clinically unimportant. Clinically, among patients with an ascending aorta diameter less than 3.0 cm, Doppler echocardiography likely substantially overestimates aortic valve mean gradient, regardless of prosthesis type.

Primary complete repair of partial double aortic arch and Kommerell diverticulum.

Tracheal and esophageal stenosis caused by double aortic arch and Kommerell diverticulum is a rare but important pathologic entity in adult patients. Clinical symptoms are caused by esophageal or tracheal stenosis, or both. The present article describes a surgical method of complete repair with division of the rudimentary left arch, resection of the diverticulum, and transposition of the left subclavian artery. This method was transferred from pediatric patients and led to excellent clinical results in 2 consecutive adult patients compared with the previous technique with division of the left arch alone.

Long-term follow-up after steroid-eluting epicardial pacemaker implantation in young children: a single centre experience.

AIMS: The purpose of this paper is the retrospective investigation of the clinical outcome and modes of failure leading to reoperation, as well as the report of the long-term results, in a group of young children who underwent epicardial pacemaker implantation. METHODS AND RESULTS: Between 2000 and 2008, 45 young children underwent epicardial pacemaker implantation at 3.2 +/- 2.5 years of age for congenital (n = 27) or post-operative (n = 18) atrioventricular block. The follow-up time was 5.7 years +/- 5 months (range: 6 months to 7.3 years). Five lead malfunction events (11%) were detected during the follow-up time, three of which were due to ventricular lead fracture. All revisions could be performed without complications, and all revised pacemakers showed stable pacing and sensing parameters during long-term follow-up. The actuarial freedom from reoperation at 6 years was 88.8 +/- 2%. Median epicardial ventricular and atrial pacing thresholds were stable and excellent at the latest follow-up, with means of 1.1 +/- 0.5 V and 0.7 +/- 0.8 V, respectively. CONCLUSION: In our patient cohort of 45 young children, epicardial pacing was associated with a satisfactory clinical outcome and acceptable long-term results. The major cause of reoperation in our series was lead fracture. Reoperations were performed at a low risk.

An unusual presentation of a sarcoidosis that mimicked lymphatic metastatize non small cell lung carcinoma in positron emission tomography: a case report.

In the last decade, several sophisticated and accurate imaging methods such as positron emission tomography have been developed in order to evaluate malignant potential in enlarged mediastinal lymph nodes. This case illustrates an unusual presentation of sarcoidosis that mimicked lymphatic metastases of non small cell lung carcinoma. The reported high specificity and sensitivity of positron emission tomography-Computer Tomography regarding mediastinal staging could lead in same cases of false positives to a delaying of stage adapted therapy of non small cell lung carcinoma, showing that despite the recent advances of imaging techniques, such as positron emission tomography-computer tomography, several limitations of this imaging technique are still existing.

Surgical left ventricular remodeling leads to better long-term survival and exercise tolerance than coronary artery bypass grafting alone in patients with moderate ischemic cardiomyopathy.

OBJECTIVES: Optimal treatment strategies for patients with ischemic cardiomyopathy and moderately reduced left ventricular function remain controversial. We assessed the early and midterm outcomes after surgical revascularization alone versus revascularization and additional left ventricular remodeling in these patients. METHODS: Between 2000 and 2003, 285 consecutive patients with coronary artery disease and moderately impaired left ventricular function (ejection fraction 30%-40%) were surgically treated with coronary artery bypass grafting alone (group 1, n = 165) or open left ventricular remodeling in addition to revascularization (group 2, n = 120). Preoperatively, the New York Heart Association class, left ventricular ejection fraction, and end-diastolic diameter were comparable. Early and midterm outcomes, hemodynamic performance, and quality of life assessed by Minnesota Quality of Life Questionnaire were evaluated during a mean follow-up period of 70 months. RESULTS: Group 2 patients demonstrated significantly longer ventilation times, higher blood loss, and need for blood transfusion but had significantly lower operative mortality (4.5% compared with 8.5% in group 1). Seven-year follow-up demonstrated survival of 74.3% +/- 8.1% in group 1 versus 84.2% +/- 5.4% in group 2 (P < .05). Follow-up examinations revealed greater improvement of functional class in group 1 with mean 1.7 +/- 0.7 versus 2.03 +/- 0.8 in group 2 (P < .05). Cardiac-related hospital readmissions were comparable (3.8% vs 4.1%, P = .73). CONCLUSIONS: Patients with ischemic cardiomyopathy, in whom surgical ventricular remodeling was possible and performed, experienced more perioperative complications but had superior early and midterm outcome regarding survival, functional class, and quality of life.

Permanent biventricular ICD-implantation in a heart failure second re-do-CABG patient: a case report.

Biventricular pacing has been suggested in end-stage heart failure. We present a 59-year-old patient undergoing second re-do CABG (coronary artery bypass graft) and carotid artery endarterectomy. Ejection fraction was 15%, QRS-width 175 ms. Following the carotid and CABG procedure, an implanted single-chamber ICD (implantable cardioverter defibrillator) was upgraded to permanent biventricular DDD pacing by implantation of one epicardial left ventricular and one epicardial atrial electrode. At follow-up two months postoperatively ejection fraction had significantly improved to 45%, the patient underwent stress test with adequate load and reported a good quality of life.

Hydrodynamic comparison of biological prostheses during progressive valve calcification in a simulated exercise situation. An in vitro study.

OBJECTIVE: Despite continuous development of anticalcification treatment for biological valve prostheses, calcification remains one major cause of structural failure. The following study investigates hemodynamics and changes in opening and closing kinematics in progressively calcified porcine and pericardial valves in a simulated exercise situation. MATERIALS AND METHODS: Five pericardial (Edwards Perimount Magna) and five porcine (Medtronic Mosaic Ultra) aortic valve bioprostheses (23 mm) were investigated in an artificial circulation system (150 beats/min, cardiac output 8l/min). Leaflet kinematics were visualized with a high-speed camera (3000 frames/s). Valves were exposed to a calcifying solution for 6 weeks. Repeated testing was performed every week. All prostheses underwent X-ray and photographic examination including measurement of calcium content for evaluation of progressive calcification. RESULTS: In the exercise situation pericardial valves demonstrated lower pressure gradients initially compared to the porcine valves (8.5+/-1.4 vs 11+/-1.6 mmHg), but significantly higher closing volume (5.3+/-1.2 ml vs 1.2+/-0.2 ml of stroke volume) leading to an equal total energy. Neither valve type demonstrated a significant increase in gradient or closing volume compared to the normal output situation. Opening and closing times were longer for pericardial valves after 6 weeks (opening time 42+/-10 ms vs 28+/-10 ms, closing time 84+/-12 vs 52+/-10 ms after 6 weeks). Pericardial valves calcified faster and more severely leading to an increase in gradients and closure volume. CONCLUSIONS: In the exercise situation pericardial valves demonstrated superior systolic function compared to porcine valves. Therefore pericardial valves have some advantage in active patients due to the lower gradients. Total energy loss remained constant during progressive calcification for both valves. Leaflet opening and closing is faster in porcine valves; clinical impact of these findings is not known. Diastolic performance is also important and should always be tested also in vivo.

Hemodynamic evaluation of aortic regurgitation by magnetic resonance imaging.

Magnetic resonance imaging was compared with echocardiography and angiography in determining the regurgitant volume in patients with aortic regurgitation. Forty patients were examined at 1.5 T. The regurgitant jet was located using a gradient-echo sequence. Cine measurements were performed to calculate left ventricular function. For flow evaluation, a velocity-encoded breath-hold phase-difference magnetic resonance sequence was used. The degree of aortic regurgitation assessed by magnetic resonance imaging agreed with that of angiography in 28 of 40 (70%) patients, and with the echocardiography result in 80%. Correlation between calculated stroke volume by magnetic resonance cine and flow measurements was very good (r > 0.9). Magnetic resonance imaging enables quick and reliable quantitative assessment of aortic regurgitant volume, and it might be the optimal technique for multiple follow-up studies and assessment of left ventricular function, leading to better evaluation of disease severity and optimization of the timing of valve surgery.

Hemodynamic performance of fresh and calcified aortic valve prostheses in critical low stroke volume.

BACKGROUND AND AIM OF THE STUDY: Heart failure is common following aortic valve replacement, and optimal prosthesis function is crucial in this critical clinical setting. The study aim was to investigate the hemodynamic performance and leaflet kinematics of fresh and calcified biological aortic valves in a simulated low stroke volume situation. METHODS: Edwards Perimount Magna (PM) and Medtronic Mosaic Ultra (MU) valves were investigated in an artificial circulation system (130 beats/min, stroke volume 19 ml), and the results compared to normal output (70 beats/min, stroke volume 70 ml). Leaflet kinematics were visualized using a high-speed camera. All valves were exposed to a calcifying solution for six weeks. RESULTS: In the low- and normal-output situation, the PM valve initially demonstrated lower pressure gradients compared to the MU valve (low output 2.4 +/- 0.16 versus 3.4 +/- 0.19 mmHg), but showed a significantly higher closing volume (up to 19% of stroke volume) leading to an increased total energy loss. Regurgitation for the PM valve was explained by progressively longer opening and closing times. The PM valve calcified faster and more severely, leading to increasing gradients and closure volume. CONCLUSION: In the low stroke volume situation pericardial valves demonstrated superior systolic performance, but inferior diastolic performance, leading to a higher total energy loss compared to porcine valves. This finding may have clinical relevance in heart-failure patients.

Venoarterial extracorporeal membrane oxygenation for treatment of cardiogenic shock: clinical experiences in 45 adult patients.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation is an established treatment option in patients with cardiogenic shock. This report reviews our 3-year experience with this support system with respect to early and midterm outcome, as well as predictors of survival. METHODS: From January 2003 until November 2006, 45 (0.8%) of 5750 patients undergoing cardiac surgery procedures required the following: temporary extracorporeal membrane oxygenation support coronary artery bypass grafting, n = 20; implantation of a left ventricular assist device, n = 5; heart transplantation, n = 1; heart and lung transplantation, n = 1; coronary artery bypass grafting plus repair of postinfarction ventricular septal defect, n = 3; coronary artery bypass grafting plus mitral valve repair, n = 5; aortic valve replacement, n = 2; coronary artery bypass grafting plus aortic valve replacement, n = 3; and other procedures, n = 5. Extracorporeal membrane oxygenation implantation was performed through the femoral vessels or axillary artery or through the right atrium and ascending aorta. Additional intra-aortic balloon pumps were used in 30 patients. RESULTS: Average patient age was 60.1 +/- 13.6 years. There were 35 male patients. Average duration of extracorporeal membrane oxygenation was 6.4 +/- 4.5 days. Twenty-five patients could be successfully weaned from extracorporeal membrane oxygenation. The 30-day mortality was 53% (24/45 patients). The in-hospital mortality was 71% (32/45 patients). Thirteen (29%) patients could be successfully discharged. After a follow-up period of up to 3 years, 10 (22%) patients were still alive. CONCLUSIONS: Extracorporeal membrane oxygenation offers sufficient cardiopulmonary support in adults with similar hospital and midterm survival rates to those of other mechanical support systems. Early indication, alternative peripheral cannulation techniques, and reduced anticoagulation to avoid perioperative bleeding could improve our results with increasing experience.

Antegrade cerebral perfusion for acute type A aortic dissection in 120 consecutive patients.

BACKGROUND: Treatment of acute type A aortic dissection remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurologic morbidity and mortality. The following study investigates clinical results after modification of perfusion technique for cardiopulmonary bypass as well as temperature management. METHODS: Between January 2000 and August 2006, 120 consecutive patients underwent repair of acute type A dissection. Selective antegrade cerebral perfusion through the right subclavian artery combined with mild systemic hypothermia (30 degrees C) was used in all patients. RESULTS: Mean cardiopulmonary bypass time was 144 +/- 53 minutes, and mean myocardial ischemic time was 98 +/- 49 minutes. Isolated cerebral perfusion was performed for 25 +/- 12 minutes. Mean core temperature amounted to 30.1 degrees +/- 2.2 degrees C. Chest tube drainage during the first 24 hours was 525 +/- 220 mL. Mean ventilation time was 54 +/- 22 hours. Elevation of serum lactate levels at 1, 12, and 24 hours postoperatively rose to 22 +/- 14, 18 +/- 11, and 19 +/- 8 mg/dL respectively. We observed new postoperative permanent neurologic deficits in 5 patients (4.2%) and TND in 3 patients (2.5%). The 30-day mortality rate was 5% (n = 6). After a mean follow-up period of 2.8 years, 104 patients (87%) were still alive. CONCLUSIONS: Antegrade cerebral perfusion in combination with mild hypothermia offered sufficient neurologic protection in our patient cohort, provided adequate distal organ protection, and reduced perioperative complications in surgery for type A dissection. This perfusion strategy may help in reducing perioperative complications in this particular patient population.

Impact of different pacing modes on left ventricular contractility following cardiopulmonary bypass.

BACKGROUND: Acute left ventricular (LV) dysfunction after cardiopulmonary bypass (CBP) is a serious complication in cardiac surgery. The aim of this study was to investigate the effect of different epicardial pacing modes on LV contractility and changes of myocardial oxygen extraction (MVO(2)) following CPB in an animal model. The utility of conductance catheter measurement versus left ventricular outflow tract mean systolic acceleration (LVOT(Acc)) for quantification of LV function was evaluated. METHODS: Fourteen piglets underwent median sternotomy and CPB for 90 minutes, myocardial ischemia for 60 minutes, and reperfusion for 30 minutes. Different pacing modes were obtained before and after CPB to investigate changes in LV function. LV Function was quantified by end-systolic-pressure-volume relationships (ESPVR) as measured by the conductance catheter method and by LVOT(Acc) obtained from transepicardial echocardiographic studies. RESULTS: LV contractility improved significantly by biventricular and atrial pacing compared with natural sinus rhythm (SR). MVO(2) remained stable or even decreased with biventricular pacing after surgery compared with SR. Right ventricular pacing resulted in poor LV-function with a rise of MVO(2). LVOT(Acc) showed a strong correlation to invasively measured ESPVR. CONCLUSION: Postoperative biventricular pacing was associated with an improved LV contractility without rise of MVO(2) compared with SR and atrial pacing. At termination of CPB, this appears to facilitate the management of LV failure and potentially may reduce the need for inotropic support, additionally protecting myocardial metabolism. The echocardiographic assessment of LVOT(Acc) was a simple and reliable as well as effective method to quantify LV contractility and showed a good correlation with the more invasive conductance catheter.

Opening and closing kinematics of fresh and calcified aortic valve prostheses: an in vitro study.

OBJECTIVES: In vitro testing of biologic valves has been performed using only fresh but treated valves suitable for patient implantation. The present study investigates changes in hemodynamic performance and leaflet kinematics in progressively calcified porcine and pericardial aortic valve prostheses. METHODS: Edwards Perimount Magna (Edwards Lifesciences, Irvine, Calif) (n = 5) and Medtronic Mosaic Ultra (Medtronic Inc, Minneapolis, Minn) (n = 5) heart valves (23 mm) were investigated in an artificial circulation system (70 beats/min, cardiac output 5 L/min). Leaflet kinematics were visualized with a high-speed camera (3000 frames/sec). Valves were then exposed to a calcium-phosphate solution at a constant pulse rate of 300 beats/min for a total of 6 weeks. Repeated testing was performed after 1, 2, 3, 4, and 6 weeks of calcification. The calcification process might not be similar to in vivo performance. RESULTS: Initially, the Perimount Magna valves demonstrated lower pressure gradients compared with the Mosaic Ultra valves (9.7 +/- 0.36 mm Hg vs 14.0 +/- 1.16 mm Hg), but they showed higher closing volume and leakage flow. Total energy loss was equivalent after 1 week of calcification. Perimount Magna valves calcified significantly faster and more severely, leading to an increase in gradients and closure volume. Leaflet kinematics showed progressively longer opening and closing times for the pericardial valves (closing time Perimount Magna 135 +/- 11 msec vs Mosaic Ultra 85 +/- 9 msec after 6 weeks). CONCLUSIONS: On the basis of visual inspection, despite the new ThermaFix (Edwards Lifesciences) tissue treatment, the Perimount Magna pericardial valves calcified in vitro faster and more severely than did the Mosaic Ultra porcine valves, which demonstrated a more constant performance throughout the calcification process. Leaflet kinematics showed a progressive prolongation of opening and closing times for pericardial valves, leading to higher closing volume.