Pre-existing pulmonary fibrosis is associated with adverse outcomes after lung resection.

INTRODUCTION: Pulmonary fibrosis is a risk factor for the development of lung cancer. However, the low incidence of the pathology means that it is not well represented in thoracic surgery risk scoring systems. We aimed to assess whether short and long-term outcomes after lung resection for primary lung cancer were worse in patients with pre-existing pulmonary fibrosis. METHODS: A total of 5029 consecutive patients undergoing lung resection for primary lung cancer between 2012 and 2018 in two UK centres were included. Primary outcomes were 90-day & 1-year mortality, post-operative complications and overall survival. Univariable analyses were used to compare outcomes between patients with and without pre-existing pulmonary fibrosis. RESULTS: In total, 0.7% (n = 33) of patients had a pre-existing diagnosis of pulmonary fibrosis (idiopathic pulmonary fibrosis 48.5%, non-specific interstitial pneumonia 6.1%, unknown 45.5%). Overall, 90-day and 1-year mortality were all significantly higher amongst patients with fibrosis (90-day: 18.2% vs 3.6%, p < 0.001; 1-year: 36.4% vs 10.7%, p < 0.001). The rate of reintubation was significantly higher for patients with fibrosis (9.1% vs 2.9%, p = 0.038) yet there was no difference in post-operative length of stay between groups (fibrosis: 6 days [IQR 4-9 days] vs non-fibrosis: 5 days [IQR 4-8 days], p = 0.675). Overall survival was also significantly reduced for patients with pulmonary fibrosis (log-rank analysis, p < 0.001). CONCLUSIONS: Despite its small size, this study suggests that short and long-term outcomes after lung resection are worse for patients with pre-existing pulmonary fibrosis. Segmental resections could be considered in these patients where oncologically appropriate to minimise peri-operative risk.

Is open window thoracostomy the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed: Is open window thoracostomy (OWT) the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer? Altogether 442 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Empyema following anatomical lung resection (excluding pneumonectomy) is an uncommon complication but one that remains a challenge to treat effectively. Chest tube thoracostomy and intravenous antibiotics remain the initial steps to management, but evidence is lacking with regard to the best ongoing strategy. Conservative options including chest cavity irrigation, postural drainage and vacuum-assisted closure have been attempted with some success, even in the presence of a broncho-pleural fistula. However, the very limited number of patients on which these various management strategies have been trialled on prevents recommendations and clear guidance being given.

Spontaneousrupture of a giant thoracic duct cyst presenting with abdominal pain and a tension chylothorax.

Ruptured thoracic duct cysts are an extremely rare occurrence that may arise spontaneously or due to trauma. Surgical treatment is needed to provide a definitive diagnosis, drain the chylothorax and ligate the thoracic duct to prevent reoccurrence. We report the case of a woman with a ruptured thoracic duct cyst presenting with abdominal pain and subsequent tension chylothorax. To the best of our knowledge, this is the first such reported case.

A systematic review and meta-analysis of mechanical vs biological composite aortic root replacement, early and 1-year results.

OBJECTIVE: Composite aortic root replacement is a standard procedure for various aortic root pathologies. This systematic review was set to identify the postoperative outcomes for composite mechanical root replacement (mCRR) compared to composite biological root replacement (bCRR). METHODS: We systematically reviewed four major databases for all papers assessing outcomes in composite root replacement. Articles selected were chosen by two reviewers. Amongst our inclusion and exclusion criteria, all pediatric populations were excluded as were studies with a cohort less than 50 patients. RESULTS: We identified seven studies that conformed to our inclusion criteria and incorporated 2240 patients. In-hospital mortality was higher but non-significant in the mechanical group (6.1 vs 4.2% respectively). There was no significant difference demonstrated in the risk of in-hospital stroke, late stroke and re-operation in either groups. Additionally, there was no significant difference in: endocarditis, 1-year mortality, 5-year mortality, mean cardiopulmonary or aortic cross-clamp time. CONCLUSIONS: Composite mechanical root offers no superiority to composite biological root. There is a significant increase in the perioperative bleeding amongst composite mechanical root cohort. There is a need for further randomized control trail to assess the efficacy of either methods.

Mitral valve repair or replacement in native valve endocarditis? Systematic review and meta-analysis.

OBJECTIVE: The objective of this study is to review the morbidity and mortality associated with mitral valve repair versus replacement in infective endocarditis patients. METHODS: A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all available data comparing mitral valve repair or replacement in infective endocarditis. Databases were evaluated and assessed to March 2017. Data were analyzed using meta-analytical techniques including odds ratio and mean weighted difference. RESULTS: A total of 8978 patients were analyzed in a total of 14 articles. The average age of the cohort was 53 years. Results revealed a shorter CPB time in the mitral valve (MV) repair compared to replacement group (P = 0.05). Postoperative outcomes (30 days/in hospital events) such as bleeding (P = 0.0047) and recurrence of infective endocarditis (IE) (P = 0.004) were significantly lower in the MV repair group. Beyond 30 days, recurrence of IE was higher in the MV replacement than the repair group (P < 0.0001). Additionally, there were significantly less reoperations in the repair group (P = 0.0021). The MV repair group had significantly better survival at 1 and 5 years postop (P < 0.0001, P < 0.0001). CONCLUSION: This meta-analysis shows that mitral valve repair has good clinical outcomes both in-hospital and at 1 and 5 years of follow-up. Mitral valve repair should be attempted in those patients in whom sufficient valve tissue is present for reconstruction after all infectious tissue has been resected.

Fistula of right internal thoracic artery as a rare cause of chest pain.

Variation in the origin of the internal thoracic arteries has been previously described and reported in the literature; however, there has been no report of an anomalous termination of the right internal thoracic artery into the pulmonary vein persisting and presenting in adult life. We report the case of the right internal thoracic artery originating from the first part of subclavian artery but terminating into the right superior pulmonary vein that presented during the third decade of life.

Hormonal manipulation after surgery for catamenial pneumothorax.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether hormonal manipulation with gonadotrophin-releasing hormone analogues reduces the risk of recurrent catamenial pneumothorax after surgery, compared with surgery alone. Altogether 819 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, date, journal, country of publication, study type, level of evidence, patient group studied, relevant outcomes and results of these papers are tabulated. Of the 7 papers selected, 6 demonstrated a reduction in recurrence of catamenial pneumothorax with the use of gonadotrophin-releasing hormone analogues, whereas in the single paper where surgery alone was performed, no evidence of recurrence was demonstrated. We therefore conclude that, based on very small retrospective observational studies, gonadotrophin-releasing hormone analogues used as an adjunct to surgical intervention may reduce the risk of recurrent pneumothorax, when compared with either no hormonal therapy or oestrogen-progesterone therapy, but should be initiated and supervised by gynaecologists who will be familiar with the therapy and the potential side effects.

Anomalous Right Internal Thoracic Artery Terminating in the Right Superior Pulmonary Vein.

Variation in the origin of the internal thoracic arteries has been previously described and reported in the literature; however, there has been no report of an anomalous termination of the right internal thoracic artery (RITA) in the pulmonary vein persisting and presenting in adult life. We report the case of a right internal thoracic artery originating from the first part of the subclavian artery but terminating in the right superior pulmonary vein that presented during the third decade of life.

Missed aortic valve endocarditis resulting in complete atrioventricular block and redo mechanical valve replacement.

Infective endocarditis is a rare disease associated with high morbidity and mortality. As a result, early diagnosis and prompt antibiotic treatment with or without surgical intervention is crucial in the management of such condition.We report a case of missed infective endocarditis of the aortic valve. The patient underwent mechanical aortic valve replacement, with the native valve being sent for histopathological examination. On re-admission 16 months later, he presented with syncope, shortness of breathing and complete heart block. On review of the histopathology of native aortic valve, endocarditis was identified which had not been acted on. The patient underwent redo aortic valve replacement for severe aortic regurgitation.We highlight the importance of following up histopathological results as well as the need for multidisciplinary treatment of endocarditis with a combination of surgical and antibiotic therapy.

Anomalous origin of the circumflex coronary artery presenting with ventricular fibrillation cardiac arrest.

We report a case of an incidental finding of an anomalous left circumflex coronary artery arising from the right pulmonary artery that effectuated a ventricular fibrillation cardiac arrest in a woman aged 34 years. This rarity was detected during routine work-up to delineate the cause of this arrhythmia. Our patient had a background of double-outlet right ventricle and a ventricular septal defect, which was repaired with a Dacron patch and a left ventricle patch over to the aorta at age 14 months. Angiographic study at the time of her presentation showed anomalous origin of the left circumflex artery originating from the right pulmonary artery; this was discussed in multispecialty team meeting and surgical intervention was recommended; eventually, surgery was performed with reimplantation of the anomalous circumflex artery into the ascending aorta. We highlight the importance of early angiographic studies in patients with known congenital heart defects and emphasise the optimal strategy of treatment.

New-onset atrial fibrillation after anatomic lung resection: predictive factors, treatment and follow-up in a UK thoracic centre.

Objectives: Postoperative atrial fibrillation (POAF) increases morbidity, hospital stay and healthcare expenditure. This study aims to determine the perioperative factors correlating with POAF as well as to evaluate both treatment strategies and AF persistence beyond discharge. Methods: The records of all patients undergoing anatomical lung resection over a 1-year period were retrospectively reviewed. Patients with a history of arrhythmia were excluded. POAF was defined by clinical diagnosis and electrocardiography. Pre- and postoperative demographic and clinical data were collected, and uni- and multivariable regression were performed to determine the factors associated with POAF. Results: POAF occurred in 11.4% (43/377) of patients with a mean of 3.55 days postoperatively and significantly increased hospital stay (6.78 ± 4.42 vs 10.8 ± 5.8 days (P = 0.0014)). No correlation was found with gender, hypertension, ischaemic heart disease, beta-blocker use, alcohol consumption or thyroid dysfunction. However, older age (P = 0.001) and postoperative infection (P < 0.0001; χ2 = 26.03) were found to be significant uni- and multivariable predictors of POAF. Open surgery rather than video assisted thoracoscopic surgery (VATS) (open 26/189 (13.8%); VATS 17/188 (9.0%); P = 0.150) demonstrated a tendency towards increased postoperative AF; however, this was not statistically significant. Four (9.3%) patients remained in AF on discharge, and three required long-term anticoagulation. Three (7%) patients were found to have ongoing AF at 1-month follow-up. Conclusions: Increasing age and postoperative infection are most strongly associated with POAF. Adoption of enhanced recovery protocols, along with more rigorous monitoring and early treatment of postoperative infection may help reduce POAF and its associated morbidity. Rhythm assessment is crucial to identify persistent AF after discharge, and clinicians should be vigilant for recurrence of AF at follow-up.