A study of variation in therapeutic approach to low-risk differentiated thyroid cancer in the UK.

BACKGROUND: The British Thyroid Association and American Thyroid Association guideline definitions for low-risk differentiated thyroid cancers are susceptible to differing interpretations, resulting in different clinical management in the UK. OBJECTIVE: To explore the national effect of these guidelines on the management of low-risk differentiated thyroid cancers. METHODS: Anonymised questionnaires were sent to multidisciplinary teams performing thyroidectomies in the UK. Risk factors that multidisciplinary teams considered important when managing low-risk differentiated thyroid cancers were established. RESULTS: Most surgeons (71 out of 75; 94.7 per cent) confirmed they were core multidisciplinary team members. More than 80 per cent of respondents performed at least 30 hemi- and/or total thyroidectomies per annum. A majority of multidisciplinary teams (50 out of 75; 66.7 per cent) followed British Thyroid Association guidelines. Risk factors considered important when managing low-risk differentiated thyroid cancers included: type of tumour histology findings (87.8 per cent), tumour size of greater than 4 cm (86.5 per cent), tumour stage T3b (85.1 per cent) and central neck node involvement (85.1 per cent). Extent of thyroid surgery (e.g. hemi- or total thyroidectomy) was highly variable for low-risk differentiated thyroid cancers. CONCLUSION: Management of low-risk differentiated thyroid cancers is highly variable, leading to a heterogeneous patient experience.

Active surveillance for PTMC warranted for the UK population?

BACKGROUND: The incidence of thyroid cancer is increasing globally due to the increase in detection of subclinical, low volume papillary thyroid microcarcinomas (PTMC) (<1 cm). Several international groups have recommended an active surveillance approach for this low-risk disease. In contrast to many other countries, the United Kingdom's (UK's) approach to thyroid nodules is to avoid detection of incidental lesions where appropriate. OBJECTIVE: This study aims to establish the proportion of patients with thyroid cancer in the UK that would benefit from active surveillance. DESIGN, PARTICIPANTS, AND OUTCOME MEASURES: Individuals with PTMC in NHS Lothian from 2009-2020 were reviewed from a local thyroid cancer database. The mode of detection of PTMC and proportion of patients who might benefit from active surveillance were established. RESULTS: From 651 individuals with differentiated thyroid cancer managed over 12-year period, 185 individuals with PTMC were identified (28.4%). The majority of PTMC 151/185 (81.6%) were either diagnosed post-operatively following thyroidectomy for benign disease or with nodal disease. Only 24 individuals with PTMC were identified following palpable thyroid nodule, incidental finding on imaging, and surveillance screening. Therefore, when the indication for surgery was considered, only 24/651 (3.7%) patients were identified pre-operatively and would, therefore, be realistic candidates for active surveillance. CONCLUSION: Less than 4% of patients with thyroid cancer in the UK would be appropriate for active surveillance. Rather than developing programmes to deal with this minority of patients, focus should be maintained on minimising detection of these low-risk cases.

From hormone replacement therapy to regenerative scaffolds: A review of current and novel primary hypothyroidism therapeutics.

Primary hypothyroidism severely impacts the quality of life of patients through a decrease in the production of the thyroid hormones T3 and T4, leading to symptoms affecting cardiovascular, neurological, cognitive, and metabolic function. The incidence rate of primary hypothyroidism is expected to increase in the near future, partially due to increasing survival of patients that have undergone radiotherapy for head and neck cancer, which induces this disease in over half of those treated. The current standard of care encompasses thyroid hormone replacement therapy, traditionally in the form of synthetic T4. However, there is mounting evidence that this is unable to restore thyroid hormone signaling in all tissues due to often persistent symptoms. Additional complications are also present in the form of dosage difficulties, extensive drug interactions and poor patience compliance. The alternative therapeutic approach employed in the past is combination therapy, which consists of administration of both T3 and T4, either synthetic or in the form of desiccated thyroid extract. Here, issues are present regarding the lack of regulation concerning formulation and lack of data regarding safety and efficacy of these treatment methods. Tissue engineering and regenerative medicine have been applied in conjunction with each other to restore function of various tissues. Recently, these techniques have been adapted for thyroid tissue, primarily through the fabrication of regenerative scaffolds. Those currently under investigation are composed of either biopolymers or native decellularized extracellular matrix (dECM) in conjunction with either primary thyrocytes or stem cells which have undergone directed thyroid differentiation. Multiple of these scaffolds have successfully restored an athyroid phenotype in vivo. However, further work is needed until clinical translation can be achieved. This is proposed in the form of exploration and combination of materials used to fabricate these scaffolds, the addition of peptides which can aid restoration of tissue homeostasis and additional in vivo experimentation providing data on safety and efficacy of these implants.

Changes in the management of deep sternal wound infections: a 12-year review.

BACKGROUND: Deep sternal wound infection (DSWI) is a rare but life-threatening complication following cardiac surgery associated with increased morbidity and mortality. Management of these patients has evolved over the years and can include sternal rewiring, mediastinal irrigation, negative-pressure wound therapy (NPWT) dressing or repair with flaps. We reviewed changes in our management of DSWI and outcomes. METHODS: Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, 5472 underwent cardiac surgery at St Vincent's Hospital, Melbourne, and 42 were identified as developing DSWI requiring re-operation between June 2002 and September 2014. Data were collected pertaining to risk factors for DSWI, management strategies and outcomes. Patients were compared from a period prior to NPWT dressing use (June 2002-February 2006, n = 14) and since the NPWT has been used regularly in the management of DSWI (from March 2006, n = 28). Patients were also compared based on the requirement for flap closure of their sternal wound. RESULTS: Because of the widespread use of NPWT dressings, there is a trend towards fewer sternal infections requiring flap closure (25 versus 42.8%) and less post-operative complications after definitive closure (7.1 versus 28.6%). Before and after widespread NPWT use, patients require similar number of re-operations before closure and have no significant differences in time to definitive closure or length of hospital stay. CONCLUSION: The use of NPWT dressings as a bridge to definitive closure may reduce the need for more burdensome flap reconstruction, does not delay definitive reconstruction or prolong hospital stay and may reduce post-reconstruction complications requiring re-operation.

Stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair: the STABILISE concept.

OBJECTIVES: The study objective was to describe the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair technique for aortic dissection repair using proximal descending aortic endografting with distal aortic relamination through bare-metal stent and balloon-induced intimal disruption with immediate intimal reapposition. METHODS: Between April 2007 and September 2011, 11 selected patients (10 male; median age, 50 years) underwent proximal descending aortic endografting plus stent-assisted balloon-induced intimal disruption of the thoracoabdominal aorta to treat complicated aortic dissection (7 type A, 4 acute type B). Patients with type A dissection underwent open surgical intervention plus adjunctive retrograde endovascular repair. Serial computed tomography angiography was used to assess aortic remodeling. RESULTS: There were no intraprocedural complications. Thirty-day incidence of death, stroke, and paralysis/visceral ischemia was 9% (n = 1), 0%, and 0%, respectively. Median follow-up was 18 months (range, 4-54 months). Two patients (18%) required secondary endovascular reintervention. No late adverse events or aortic-related deaths occurred. Complete false lumen obliteration occurred in 90% (n = 10) of patients, with stable maximal diameters in the thoracic (P = .6) and abdominal aortas (celiac trunk: P = .34; renal; P = .6; infrarenal: P = .7) at latest follow-up. CONCLUSIONS: The Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair approach is a feasible endovascular technique that shows promise to achieve complete repair of the dissected aorta by inducing complete false lumen obliteration. The restoration of uniluminal flow in the thoracoabdominal aorta has the potential to improve long-term outcomes. Prospective, multicenter investigations are required to implement this strategy more broadly.

Prophylactic epicardial left ventricular lead implantation for biventricular pacing during operations.

BACKGROUND: Surgical epicardial left ventricular (LV) lead implantation for biventricular pacing has advantages over the transvenous approach in cardiac surgical patients. We investigated the benefit of concomitant prophylactic LV lead implantation during open heart operations and subsequent lead performance after patients with impaired LV function receive a biventricular device. METHODS: Retrospective data of 4,844 patients undergoing cardiac operations through a sternotomy between January 2001 and December 2011 were analyzed. Of these, 380 patients (7.8%) had severe impairment of LV function (contrast left ventriculogram showing grade 4 estimated ejection fraction or echocardiogram showing LV ejection fraction<0.30). LV lead implantation was performed in patients in whom recovery of LV function was unlikely. Lead performance data were collected at follow-up. RESULTS: LV lead implantation occurred in 95 patients (25%), and 29 (30.5%) subsequently received a biventricular device. Of patients with impaired LV function, more patients with prophylactic LV leads underwent biventricular implant than those without LV leads (30.5% vs 1.1%, p<0.0001). The median interval from LV lead implantation to connection to a biventricular device was 30 days (interquartile range, 5.5 to 145 days). At a median follow-up of 437.5 days (interquartile range, 13.8 to 1198 days), the mean pacing threshold (1.25±0.46 vs 1.58±0.66 volts, p=0.069) and impedance (383.81±70.33 vs 448.6±200.1 Ohms, p=0.168) remained stable compared with time of biventricular device connection. CONCLUSIONS: A significant proportion of patients with poor LV function undergoing cardiac operations may benefit from concomitant LV lead implantation. Subsequent lead performance appears satisfactory. Epicardial LV lead placement is easily accomplished during open heart operations and should be considered before the operation.

Prognostic implications of papillary thyroid carcinoma with tall-cell features.

BACKGROUND: The prognostic implications of the diagnosis of a papillary thyroid carcinoma (PTC) with tall-cell features are unknown. METHODS: All PTC patients identified between 1985 and 2005 were analyzed histologically. Classical PTC cases were defined as having <30% tall cells, PTC with tall-cell features (PTC TCF) as 30%-49% tall cells, and tall-cell variant of PTC (TCV) as ≥ 50% tall cells. All classical PTC, PTC TCF, and TCV ≥ 1 cm in size were included. RESULTS: A total of 453 patients satisfied the inclusion criteria (288 classical PTC, 31 PTC TCF, and 134 TCV). Classical PTC patients were younger than their PTC TCF and TCV counterparts (p<0.0002). There was an increase in tumor size from classical PTC to PTC TCF and TCV (p=0.05). Extensive extrathyroid extension and positive margins were more often present in TCV and PTC TCF than in classical PTC (p=0.0001 and p=0.03 respectively). Overall pathologic tumor (pT) stage was more advanced in TCV and PTC TCF than in classical PTC (p<0.0001). Total thyroidectomy and radioactive iodine therapy were more often performed and administered in TCV patients than in their PTC TCF and classical PTC counterparts (p=0.001 and p=0.0001 respectively). Median follow-up was 9.3 years. Ten-year disease-specific survival (DSS) was lower in TCV (96%) and PTC TCF (91%) than in classical PTC (100%; p<0.001). Ten-year distant recurrence-free survival (RFS) was higher in classical PTC (98%) than in PTC TCF (89%) and TCV (96%; p=0.03). In multivariate analysis, the presence of more than five positive nodes and extranodal extension were the only independent prognostic factors of neck and distant RFS respectively. Four (2.4%) of 165 PTC TCF and PTC TCV developed poorly differentiated or anaplastic carcinoma in their recurrence, while none of the 288 classical PTC transformed into higher grades (p=0.017). CONCLUSIONS: PTC TCF and TCV have similar clinicopathologic features that are more aggressive than classical PTC. PTC TCF and TCV have similar DSS and distant RFS but poorer outcomes than classical PTC. PTC TCF are currently being treated like classical PTC, that is, less aggressively than TCV. PTC TCF and TCV TCV have a higher rates of high-grade transformation than classical PTC. Consideration should be given to using a 30% tall-cell threshold to diagnose TCV.

The 'down-under repair' for ischaemic mitral regurgitation.

Current surgical management of restrictive ischaemic mitral regurgitation (IMR) includes mitral valve annuloplasty (MVA) using an undersized ring when the mechanism is secondary to leaflet restriction. In our experience, MVA alone is inadequate to eliminate mitral incompetence in these patients. We report the 'Down-Under Repair' as an adjunctive concept for the treatment of a subset of patients with restrictive IMR and associated inferobasal left ventricular aneurysm. The 'Down-Under Repair' reduces mitral leaflet restriction by approximating the origin of the posterior papillary muscle towards the mitral annulus. Midterm results demonstrated sustained valvular competence and symptomatic improvement.

The association of blood transfusion with mortality after cardiac surgery: cause or confounding? (CME).

BACKGROUND: Bleeding into the chest is a life-threatening complication of cardiac surgery. Blood transfusion has been implicated as an important cause of harm associated with bleeding, based largely on studies demonstrating an independent association between transfusion and mortality. These studies did not, however, consider the possibility that bleeding may in itself be harmful, inasmuch as drains are inefficient at clearing blood from the chest and retained blood may compromise cardiac and lung function. STUDY DESIGN AND METHODS: We undertook a multivariate logistic regression analysis of the risk factors associated with mortality in 2599 consecutive patients undergoing cardiac surgery. Unlike previous studies the risk factors examined included the volume of chest tube drainage at 24 hours. A stratified analysis was also undertaken that compared the adjusted risk of death for patients exposed or not exposed to a postoperative blood transfusion. RESULTS: Blood transfusion was not an independent predictor of mortality (p=0.4). Chest tube drainage was the strongest independent predictor of mortality (p<0.001). In the stratified analysis, chest tube drainage remained an independent predictor of mortality for patients not exposed to a blood transfusion (p<0.01). Furthermore, the risk of death of these patients was no different from patients exposed to a blood transfusion (p=0.7 for interaction). CONCLUSIONS: Our results argue that for patients undergoing cardiac surgery bleeding contributes to mortality through mechanisms unrelated to blood transfusion.

Hybrid proximal surgery plus adjunctive retrograde endovascular repair in acute DeBakey type I dissection: superior outcomes to conventional surgical repair.

OBJECTIVE: The present study compared the outcomes between conventional surgery and the hybrid approach of proximal surgery with adjunctive retrograde descending aortic endografting plus distal bare metal stenting in acute DeBakey type I dissection. METHODS: From 2003 to 2011, 61 patients underwent surgical management for acute type A aortic dissection at our institution. Of these, 37 were DeBakey type I dissections: 18 patients (group 1) received conventional surgical repair alone, and 19 (group 2) underwent conventional hybrid surgery with adjunctive retrograde descending aortic stent grafting plus distal bare metal stenting. RESULTS: The patients' baseline characteristics were comparable, including the incidence of preoperative malperfusion syndromes (P = .23). The intraoperative and postoperative characteristics were similar, except 4 (22%) patients in group 1 (vs 0 in group 2) had ongoing malperfusion postoperatively (P = .04). Overall, hospital mortality was 11% (n = 2) for group 1 versus 5% (n = 1) for group 2. At a mean follow-up of 50 months, 4 (25%) subjects in group 1 required secondary thoracoabdominal aortic reintervention versus none in group 2 (P = .03). CONCLUSIONS: The use of adjunctive retrograde descending aortic endografting plus distal bare metal stenting during acute DeBakey type 1 dissection repair is a feasible method to enhance thoracoabdominal remodeling. This hybrid strategy improves perioperative outcomes and decreases late distal aortic complications compared with conventional surgical repair for acute DeBakey type I dissection. A prospective, multicenter study is warranted to definitively assess this promising new treatment paradigm.

Surgical ventricular restoration procedure: single-center comparison of Surgical Treatment of Ischemic Heart Failure (STICH) versus non-STICH patients.

BACKGROUND: Surgical ventricular restoration (SVR) was conceived to improve hemodynamic and clinical outcomes in ischemic cardiomyopathy. The Surgical Treatment of Ischemic Heart Failure (STICH) trial has conclusively shown no additional benefits of SVR when routinely combined with coronary artery bypass surgery. However, the STICH study did not include a registry arm for SVR-eligible patients who were not randomized. This study describes the SVR experience in a single center when participating in the STICH study, to better understand the role of SVR in current clinical practice. METHODS: All patients receiving SVR between 2002 and 2006 were prospectively followed. Patients were divided into STICH SVR (SSVR) and non-STICH SVR (NSSVR) groups. The SSVR patients received SVR as randomized in STICH. The NSSVR patients were evaluated for eligibility to participate in the STICH trial, and the reasons for not participating were analyzed. Baseline demographics, echocardiographic data, and clinical outcomes were compared. RESULTS: Nine NSSVR patients were compared with 12 SSVR patients. Only 1 NSSVR patient did not fulfill entry criteria into the STICH trial for randomization. The main reason for performing SVR outside of the STICH study was dominant heart failure symptom associated with enlarged left ventricle. The NSSVR group had more anterior wall asynergy (60% vs 45%, p < 0.001), larger preoperative heart volumes (left ventricular end-diastolic volume index 108 mL/m(2) vs 69 mL/m(2), p < 0.05) and larger volume reductions (34% vs 11%, p = 0.06). At 6.5-year follow-up, 83% SSVR and 89% NSSVR patients are alive. CONCLUSIONS: At our institution, patients eligible but not randomized into STICH, had larger preoperative heart volumes and larger volume reduction with SVR. The STICH study may not have included patients most likely to benefit from SVR.

Aortic false lumen thrombosis induction by embolotherapy (AFTER) following endovascular repair of aortic dissection.

PURPOSE: To report the use of a technique (AFTER: aortic false lumen thrombosis induction by embolotherapy) to achieve false lumen (FL) thrombosis and aortic remodeling in patients with residual FL patency after initial endovascular repair of aortic dissection. METHODS: Between January 2003 and January 2010, 31 patients underwent staged total aortic and branch vessel endovascular reconstruction (STABLE) of type A (n = 13) and type B (n = 18) dissection. Of these, 10 patients (5 men; mean age 61 years) who had undergone repair of 4 acute type A, 3 acute type B, and 3 chronic type B dissections demonstrated re-entry tear(s) and FL patency associated with aortic expansion ≥5 mm or flow into a persistently dilated aortic segment. Catheter-directed embolization using coils, glue, or occlusion balloons was performed via a transfemoral approach to the true lumen at a mean of 7 months (range <1 to 26) after initial repair. RESULTS: Technical success was achieved in all patients, with no intraoperative complications. Thirty-day morbidity and mortality was nil. Mean follow-up was 63 months (range 13-96). Reversal or stabilization (<5-mm increase) of thoracoabdominal aortic growth occurred in 9 patients. Complete thrombosis of the thoracic and abdominal FL occurred in 2 patients. In 4, FL occlusion and subsequent thrombosis of the upstream thoracic segment was achieved. Four demonstrated partial FL thrombosis in the thoracic and abdominal aorta. One patient with chronic aneurysmal type B dissection died 4 months post-embolization from aortic rupture. CONCLUSION: The AFTER strategy appears to be a safe and promising adjunctive endovascular approach to treat residual FL patency or aortic enlargement post endovascular repair of aortic dissection. Elimination of FL flow and stabilization of aortic expansion may reduce the risk of late distal aortic complications.

Combined proximal stent grafting plus distal bare metal stenting for management of aortic dissection: Superior to standard endovascular repair?

OBJECTIVES: The present study compared the outcomes between combined proximal descending aortic endografting plus distal bare metal stenting and conventional proximal descending aortic stent-graft repair in patients with type A and type B aortic dissection. METHODS: From January 2003 to December 2010, 63 patients underwent endovascular treatment for acute (type A, 24; type B, 21) and chronic (type B, 18) aortic dissection. Of these, 40 patients underwent proximal descending aortic endografting plus distal bare metal stenting (group 1), and 23 underwent proximal descending stent-graft repair alone (group 2). All patients with type A dissection underwent open surgical intervention plus adjunctive retrograde endovascular repair. RESULTS: The patients were comparable for baseline characteristics and treatment indicators, but more group 1 patients were active smokers (P = .03). The intraoperative characteristics were also similar, although 4 patients, all in group 2, developed malperfusion syndrome postoperatively (P = .02). The overall hospital mortality was 6%. At a mean follow-up of 49 months, 9 group 2 patients (43%) required unplanned secondary intervention compared with 4 in group 1 (11%; P = .007). Reintervention for thoracoabdominal aortic aneurysm or visceral ischemia was performed in 4 patients (19%) from group 2 (P = .03). Late aortic-related deaths occurred in 1 (5 %) and 2 (5%) patients in groups 1 and 2, respectively. CONCLUSIONS: Combined proximal descending aortic endografting plus distal bare metal stenting for aortic dissection provides favorable short-term outcomes and decreases late distal aortic complications compared with conventional endovascular repair. These results support a more widespread application of this approach. A prospective, randomized trial is needed before definite conclusions can be made.

High incidence of insulin resistance and dysglycemia amongst nondiabetic cardiac surgical patients.

BACKGROUND: Undiagnosed glycometabolic dysfunction is prominent amongst nondiabetic cardiac surgical patients, whereas perioperative dysglycemia is associated with adverse outcomes. This study assessed whether the preoperative level of insulin resistance predicts the degree of perioperative dysglycemia in nondiabetic, normoglycemic cardiac surgical patients. METHODS: Twenty-two nondiabetic patients awaiting cardiac operations were assessed for metabolic parameters and whole-body insulin resistance (mean glucose infusion [GINF] rate) using the hyperinsulinemic-euglycemic clamp. Intraoperative and postoperative glucose levels and treatment requirements were analyzed. Linear regression analysis was used to find predictors of baseline, peak intraoperative, and mean postoperative fasting blood glucose (FBG). RESULTS: The mean GINF recorded in nondiabetic, normoglycemic patients was 3.5 ± 1.4 mg/kg/min. The mean peak intraoperative and mean postoperative FBG concentrations were 154.9 ± 34.2 mg/dL (range, 108.1 to 227.0 mg/dL) and 120.7 ± 16.2 mg/dL (range, 100.9 to 154.9 mg/dL), respectively. The GINF correlated inversely with mean peak intraoperative (r = -0.7, p = 0.02) and mean postoperative FBG (r = -0.8, p = 0.01). The GINF did not correlate with preoperative FBG levels (r = 0.3, p = 0.4). Preoperative FBG did not correlate with peak intraoperative (r = 0.4, p = 0.5) or mean postoperative FBG (r = 0.5, p = 0.3). CONCLUSIONS: Nondiabetic, normoglycemic cardiac surgical patients are highly insulin resistant using the hyperinsulinemic-euglycemic clamp. Preoperative insulin resistance, not FBG, is significantly associated with the development of perioperative dysglycemia. Insulin resistance screening may be useful to identify insulin resistance preoperatively and predict the degree of perioperative dysglycemia in cardiac surgical patients but should be performed with a more appropriate and reproducible test.

Combined proximal endografting with distal bare-metal stenting for management of aortic dissection.

BACKGROUND: Established endovascular treatments for aortic dissection often result in incomplete aortic repair, potentially leading to late complications involving the distal aorta. To address the problems of incomplete true lumen reconstitution and late aneurysmal change, we report the midterm results of combined proximal endografting with distal true lumen bare-metal stenting (STABLE: Staged Total Aortic and Branch vesseL Endovascular reconstruction) in Stanford type A and B aortic dissection. METHODS: Between January 2003 and January 2010, 31 patients underwent staged total aortic and branch vessel endovascular reconstruction for management of acute (type A, 13; type B, 11) and chronic (type B, 7) aortic dissection. Proximal endografting was combined with bare-metal Z stent implantation in the distal true lumen. Patients with type A dissection underwent adjunctive treatment at operation. Computed tomography angiography was performed at baseline, 1 year, and annually thereafter to assess aortic remodelling. RESULTS: Primary technical success was 97%. Thirty-day rates of death, stroke, and permanent paraplegia/paresis were 3% (n=1), 0%, and 0%, respectively. Mean follow-up was 57.3 months (range, 5 to 100 months). Overall survival was 60% at 100 months. Aortic-specific survival was 93%. Four patients (13%) underwent device-related reintervention. One (3%) late aortic-related death occurred. Thoracic (p=0.64) and abdominal (p=0.14) aortic dimensions were stable. The true lumen index increased significantly at follow-up. CONCLUSIONS: Staged total aortic and branch vessel endovascular reconstruction is a feasible ancillary endovascular technique to address the problems of distal true lumen collapse, incomplete aortic remodelling, and late aneurysm formation in aortic dissection.