A Unique Hybrid Approach to Complex Re-Do Aortic Root Surgery.

BACKGROUND: We present the case of a 23-year-old male with ventriculo-aortic dehiscence and a retrosternal false aneurysm communicating to the left ventricular outflow tract (LVOT) and ascending aorta. His history included aortic valve replacement (AVR) and mitral valve (MV) repair remotely, followed by two further operations for endocarditis and aortic root abscess. METHODS: The risk associated with the redo surgery required detailed planning and innovative techniques to allow it to be performed safely. These included femoral cannulation for cardiopulmonary bypass, venting the left ventricular apex via a small left anterior thoracotomy, use of a CODA® (COOK Medical, Bloomington USA) balloon to occlude the distal ascending aorta (placed via left brachial artery) and finally, the use of a PROPLEGE® (Edwards Lifesciences, Irvine, USA) retrograde cardioplegia cannula (placed via right internal jugular vein).

Targeted Bleeding Management Reduces the Requirements for Blood Component Therapy in Lung Transplant Recipients.

OBJECTIVE: Lung transplantation is associated with high rates of bleeding and frequent blood transfusion. The authors aimed to determine if point-of-care coagulation testing (POCCT) reduced transfusion requirements. DESIGN, SETTINGS, AND PARTICIPANTS: A before-and-after cohort analysis conducted at a single tertiary referral center. Ninety-three sequential adult patients between January 2010 and January 2014 undergoing isolated lung transplant without preoperative extracorporeal support were analyzed. INTERVENTION: ROTEM and multi-plate POCCT were introduced on July 1, 2012, with an associated algorithm based on the results. MEASUREMENTS AND MAIN RESULTS: Statistically significant decreases in the proportion of patients receiving PRBCs (87% v 65%; p = 0.015), FFP (72% v 30%; p<0.0001) and platelets (70% v 37%; p = 0.002) were found after the intervention. There were small decreases in median chest tube blood loss at 2 hours (300 mLs v 215 mLs; p = 0.03) and 4 hours (440 mLs v 350 mLs; p = 0.050) but not at 12 hours postoperatively. There were no changes in reoperation for bleeding (9% v 4%; p = 0.158) or in-hospital mortality (6% v 2%; p = 0.617). The cost of blood products administered decreased from a median of $3,935.00 to $991.00 (p<0.001). CONCLUSIONS: Use of POCCT in lung-transplant surgery is associated with significant reductions in blood product use and cost. There were no detectable changes in outcome aside from a small decrease in early postoperative bleeding.

Lung resection for multidrug-resistant tuberculosis.

The emergence of multidrug-resistant tuberculosis poses a serious challenge to traditional drug therapy. In view of the relapse rate of up to 50% following medical management, there has been renewed interest in the role of surgery for this problem. We report our experience with lung resection for this condition. Over a 5-year period, resection was performed in 23 patients who were diagnosed with multidrug resistance after completing a course of standard chemotherapy and at least 3 months of second-line therapy. Pneumonectomy was performed in 17 patients and lobectomy in 6. There was no operative or postoperative mortality. Major complications developed in 4 patients (17.4%): 2 had post-pneumonectomy empyema and 2 underwent rethoracotomy for bleeding. Ten patients were sputum positive preoperatively, and only 1 remained positive after surgery. The patients were put on appropriate chemotherapy and followed up for 18 months. The cure rate was 95.6%. Pulmonary resection can be considered as an important adjunct to medical therapy in carefully selected patients: those who have localized disease with adequate pulmonary reserve, or who have multiple previous relapses, or whose sputum remains positive after 4 to 6 months of appropriate medical treatment. Surgery offers high cure rates with acceptable morbidity and mortality.