Lung Cancer Strategist Program: A novel care delivery model to improve timeliness of diagnosis and treatment in high-risk patients.

INTRODUCTION: The diagnosis and treatment of lung cancer is challenged by complex diagnostic pathways and fragmented care that can lead to care disparities for vulnerable patients. METHODS: A multi-institutional, multidisciplinary conference was convened to address the complexity of lung cancer care particularly in patients at high-risk for treatment delay. The resulting care delivery model, called the Lung Cancer Strategist Program (LCSP), was led by a thoracic-trained advanced practice provider (APP) with emphasis on expedited surgery and early oncologic consultation in the assessment of a newly diagnosed suspicious lung nodule. We performed a retrospective review to evaluate care efficiency and oncologic outcomes in the first 100 LCSP patients compared to 100 concurrent patients managed via routine surgical referral. RESULTS: In the 78 LCSP and 41 routine referral patients managed via nodule surveillance, LCSP patients had a shorter time from suspicious finding to work-up (3 vs. 26 days, p < 0.001) and to surveillance decision (12.5 vs. 39 days, p < 0.001). In the 22 LCSP and 59 routine referral patients treated for intrathoracic malignancy, LCSP patients had fewer hospital visits (4 vs 6, p < 0.001), clinicians seen (1.5 vs. 2, p = 0.08), and diagnostic studies (4 vs 5, p = 0.01) with a shorter time to diagnosis (30.5 vs. 48 days, p = 0.02) and treatment (40.5 vs. 68.5 days, p = 0.02). CONCLUSIONS: Patient triage through a thoracic-trained APP in consultation with surgical, medical, and radiation oncology facilitates rapid assessment of benign versus malignant lesions with reduced time to diagnosis and treatment, even among patients at high-risk for treatment delay.

A geometrically adaptable heart valve replacement.

Congenital heart valve disease has life-threatening consequences that warrant early valve replacement; however, the development of a growth-accommodating prosthetic valve has remained elusive. Thousands of children continue to face multiple high-risk open-heart operations to replace valves that they have outgrown. Here, we demonstrate a biomimetic prosthetic valve that is geometrically adaptable to accommodate somatic growth and structural asymmetries within the heart. Inspired by the human venous valve, whose geometry is optimized to preserve functionality across a wide range of constantly varying volume loads and diameters, our balloon-expandable synthetic bileaflet valve analog exhibits similar adaptability to dimensional and shape changes. Benchtop and acute in vivo experiments validated design functionality, and in vivo survival studies in growing sheep demonstrated that mechanical valve expansion accommodated growth. As illustrated in this work, dynamic size adaptability with preservation of unidirectional flow in prosthetic valves thus offers a paradigm shift in the treatment of heart valve disease.

Mechanical Properties of Autologous Pericardium Change With Fixation Time: Implications for Valve Reconstruction.

Autologous pericardium, fixed in glutaraldehyde, is a common patch material used in heart valve reconstruction. Competence of a reconstructed valve depends on patch dimensions and also on how much the patch deforms when the closed valve is pressurized. In this study, we used biaxial testing to evaluate the deformability of fixed autologous pericardium, and several commercial alternatives, under typical cardiac loads. We found that deformability of fixed autologous pericardium varies predictably with fixation time. This information can be used by surgeons in designing patches for valve repair.

Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals: collateral vessel disease burden and unifocalisation strategies.

IntroductionThe optimal approach to unifocalisation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (pulmonary artery/ventricular septal defect/major aortopulmonary collaterals) remains controversial. Moreover, the impact of collateral vessel disease burden on surgical decision-making and late outcomes remains poorly defined. We investigated our centre's experience in the surgical management of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals.Materials and methodsBetween 1996 and 2015, 84 consecutive patients with pulmonary artery/ventricular septal defect/major aortopulmonary collaterals underwent unifocalisation. In all, 41 patients received single-stage unifocalisation (Group 1) and 43 patients underwent multi-stage repair (Group 2). Preoperative collateral vessel anatomy, branch pulmonary artery reinterventions, ventricular septal defect status, and late right ventricle/left ventricle pressure ratio were evaluated. RESULTS: Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.DiscussionSingle-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.

Valve-sparing repair with intraoperative balloon dilation in tetralogy of Fallot: Midterm results and therapeutic implications.

OBJECTIVES: The significant morbidity of long-term pulmonary regurgitation (PR) has driven the development of pulmonary valve (PV) sparing repair strategies in patients with tetralogy of Fallot (ToF). We assessed mid-term PV function in patients who underwent primary ToF repair with valve-sparing intraoperative balloon dilation (IBD) technique. METHODS: We evaluated 162 consecutive patients with ToF and pulmonary stenosis (ToF-PS) who underwent valve-sparing repair with IBD under 1 year of age. RESULTS: Median age at surgery was 98 days (interquartile range [IQR], 72-126) and median follow-up was 2.5 years (IQR, 0.6-4.9). Median preoperative PV annulus z score was -2.2 (IQR, -2.5 to -1.8). Twenty-five patients (15.4%) required reintervention for residual valvular stenosis. Multivariable analysis demonstrated preoperative annulus z score less than -2.45 (P = .036) and younger age at surgery (P = .001) were independent risk factors for early reintervention for stenosis. Freedom from at least moderate PR was 77%, 61%, and 43% at 1, 3, and 5 years postrepair. Right ventricular dimensions were not significantly different compared with a matched cohort of patients undergoing transannular patch repair at midterm follow-up. CONCLUSIONS: Patients with ToF-PS who undergo valve-sparing repair with IBD develop progressive PR. Compared with transannular patch repair, the extent of RV dilation at midterm follow-up is not significantly different. Patients younger than 3 months of age and those with an annulus z score less than -2.45 experience higher rates of early reintervention for PV stenosis. In these patient subgroups, alternative strategies should be considered. This study suggests valve-sparing repair with IBD does not preserve long-term PV function in patients with ToF-PS.

Liver abnormalities and post-transplant survival in pediatric Fontan patients.

The impact of liver parenchymal abnormalities on survival post-heart transplant remains unknown in pediatric Fontan patients. We assessed pediatric Fontan patients who underwent heart transplant and had documented pretransplant hepatic ultrasound (U/S) studies. Liver U/S findings were classified as normal (Group 1), mildly abnormal (Group 2, hepatomegaly/vascular congestion), or severely abnormal (Group 3, heterogeneous echotexture/nodularity). Among 30 study patients, 8 were classified as Group 1, 14 as Group 2, while 8 met Group 3 criteria. Pretransplant liver biochemistry and synthetic function were similar in all groups. Six Group 3 patients underwent liver biopsy; 4 demonstrated perisinusoidal or centrilobular fibrosis, and 2 had cirrhosis. Overall mortality was 30% (n = 9). Median follow-up was 5 years (range, 0.25-13 years). One-year survival was similar among all 3 groups (P = .37), with a trend toward higher cumulative 5-year survival in Group 1 (100%). The majority of pediatric Fontan patients who underwent heart transplant demonstrated abnormal preoperative liver ultrasound findings. Heterogeneous echotexture or nodularity detected on U/S frequently indicates underlying liver parenchymal abnormalities. The presence of severe liver abnormalities was not associated with higher early mortality post-heart transplant in pediatric Fontan patients; however, late outcomes must be further elucidated.

From Diagnosis to Treatment: Clinical Applications of Nanotechnology in Thoracic Surgery.

Nanotechnology is an emerging field with potential as an adjunct to cancer therapy, particularly thoracic surgery. Therapy can be delivered to tumors in a more targeted fashion, with less systemic toxicity. Nanoparticles may aid in diagnosis, preoperative characterization, and intraoperative localization of thoracic tumors and their lymphatics. Focused research into nanotechnology's ability to deliver both diagnostics and therapeutics has led to the development of nanotheranostics, which promises to improve the treatment of thoracic malignancies through enhanced tumor targeting, controlled drug delivery, and therapeutic monitoring. This article reviews nanoplatforms, their unique properties, and the potential for clinical application in thoracic surgery.

Nanotechnology applications in thoracic surgery.

Nanotechnology is an emerging, rapidly evolving field with the potential to significantly impact care across the full spectrum of cancer therapy. Of note, several recent nanotechnological advances show particular promise to improve outcomes for thoracic surgical patients. A variety of nanotechnologies are described that offer possible solutions to existing challenges encountered in the detection, diagnosis and treatment of lung cancer. Nanotechnology-based imaging platforms have the ability to improve the surgical care of patients with thoracic malignancies through technological advances in intraoperative tumour localization, lymph node mapping and accuracy of tumour resection. Moreover, nanotechnology is poised to revolutionize adjuvant lung cancer therapy. Common chemotherapeutic drugs, such as paclitaxel, docetaxel and doxorubicin, are being formulated using various nanotechnologies to improve drug delivery, whereas nanoparticle (NP)-based imaging technologies can monitor the tumour microenvironment and facilitate molecularly targeted lung cancer therapy. Although early nanotechnology-based delivery systems show promise, the next frontier in lung cancer therapy is the development of 'theranostic' multifunctional NPs capable of integrating diagnosis, drug monitoring, tumour targeting and controlled drug release into various unifying platforms. This article provides an overview of key existing and emerging nanotechnology platforms that may find clinical application in thoracic surgery in the near future.

Impact of pacing on systemic ventricular function in L-transposition of the great arteries.

OBJECTIVE(S): To assess the impact of univentricular versus biventricular pacing (BiVP) on systemic ventricular function in patients with congenitally corrected transposition of the great arteries (ccTGA). METHODS: We performed a retrospective review of all patients with a diagnosis of ccTGA who underwent pacemaker insertion. From 1993 to 2014, 53 patients were identified from the cardiology database and surgical records. RESULTS: Overall mortality was 7.5% (n = 4). One patient required transplantation and 3 late deaths occurred secondary to end-stage heart failure. Median follow-up was 3.7 years (range, 4 days to 22.5 years). Twenty-five (47%) underwent univentricular pacing only, of these, 8 (32%) developed significant systemic ventricular dysfunction. Twenty-eight (53%) received BiVP, 17 (26%) were upgraded from a dual-chamber system, 11 (21%) received primary BiVP. Fourteen (82%) of the 17 undergoing secondary BiVP demonstrated systemic ventricular dysfunction at the time of pacer upgrade, with 7 (50%) demonstrating improved systemic ventricular function after pacemaker upgrade. Overall, 42 (79%) patients underwent univentricular pacing, with 22 (52%) developing significant systemic ventricular dysfunction. In contrast, the 11 (21%) who received primary BiVP had preserved systemic ventricular function at latest follow-up. CONCLUSIONS: Late-onset systemic ventricular dysfunction is a major complication associated with the use of univentricular pacing in patients with ccTGA. All patients with ccTGA who develop heart block should undergo primary biventricular pacing, as this prevents late systemic ventricular dysfunction. Preemptive placement of BiVP leads at the time of anatomical repair or other permanent palliative procedure will facilitate subsequent BiVP should heart block develop.

Evolution of Surgical Approaches in the Management of Congenital Tracheal Stenosis: Single-Center Experience.

BACKGROUND: Congenital tracheal stenosis (CTS) is a serious and rare condition that often presents a complex surgical challenge. We reviewed the evolution of surgical approaches to the management of CTS at a single institution. METHODS: We conducted a retrospective clinical review of all patients who underwent surgical repair of CTS at our institution. From January 1992 to January 2014, a total of 30 patients (median age 92 days; range 3 days-1.7 years) underwent surgery for CTS at our institution. Techniques included slide tracheoplasty (n = 16), tracheal resection (n = 10), pericardial patch tracheoplasty (n = 3), and costal cartilage tracheoplasty (n = 1). Twenty-two (73%) patients had associated intracardiac or great vessel anomalies, including 18 (60%) with left pulmonary artery sling. Five (17%) patients had associated single lung malformation. All procedures were performed via a median sternotomy with cardiopulmonary bypass. RESULTS: Median postoperative length of stay was 25 days (range, 5-431 days). Late airway reintervention was required in seven (26%), including two (15%) infants after slide tracheoplasty, two (22%) posttracheal resection, and two (100%) post pericardial patch tracheoplasty. The one patient who underwent costal cartilage tracheoplasty required multiple reinterventions. Overall mortality was 13% (n = 4), two deaths occurred post slide tracheoplasty, one death occurred after tracheal resection, and one after pericardial patch tracheoplasty, respectively. CONCLUSION: Slide tracheoplasty is the procedure of choice for repair of CTS, while tracheal resection is a viable option for patients with discreet, short-segment stenosis.

Management of Congenital Tracheal Stenosis.

Congenital tracheal stenosis (CTS) is a serious and rare condition. In most cases, stenotic lesions are composed of complete tracheal rings of cartilage.The severity of symptoms correlates with the length of affected trachea, the presence of concomitant respiratory conditions, degree of luminal narrowing,and any bronchial involvement. Critically, CTS is a disorder that can lead to life-threatening respiratory insufficiency in children. Thus, it is a clinical entity that demands timely diagnosis and treatment. This review will firstly discuss the anatomy and pathophysiology of CTS and outline the various clinical presentations associated with the disorder. In addition, methods of diagnosis and treatment strategies will be reviewed, with a focus on contemporary surgical techniques. Finally, postoperative care of patients with CTS will be reviewed, and a contemporary multidisciplinary management approach will be presented.

Paclitaxel-loaded expansile nanoparticles enhance chemotherapeutic drug delivery in mesothelioma 3-dimensional multicellular spheroids.

OBJECTIVES: Intraperitoneal administration of paclitaxel-loaded expansile nanoparticles (Pax-eNPs) significantly improves survival in an in vivo model of malignant mesothelioma compared with conventional drug delivery with the clinically utilized Cremophor EL/ethanol (C/E) excipient. However, in vitro monolayer cell culture experiments do not replicate this superior efficacy, suggesting Pax-eNPs utilize a unique mechanism of drug delivery. Using a mesothelioma spheroid model, we characterized the mechanisms of enhanced tumor cytotoxicity leveraged by Pax-eNPs. METHODS: Human malignant mesothelioma (MSTO-211H) spheroids were co-incubated for 24 hours with Oregon Green-conjugated paclitaxel dissolved in C/E or loaded into eNPs. Oregon Green-paclitaxel uptake was measured as Oregon Green intensity via confocal microscopy and kinetics of tumor cytotoxicity were assessed via propidium iodide staining. Pharmacologic endocytotic inhibitors were used to elucidate mechanisms of eNP uptake into spheroids. RESULTS: Increased drug penetration and a 38-fold higher intraspheroidal drug concentration were observed 24 hours after MSTO-211H spheroids were treated with Oregon Green-conjugated paclitaxel loaded into eNPs compared with Oregon Green-conjugated paclitaxel dissolved in C/E (P < .01). Macropinocytosis was the dominant endocytotic pathway of eNP uptake. Spheroids were more susceptible to paclitaxel when delivered via eNP, exhibiting more than twice the propidium iodine intensity compared with an equivalent paclitaxel-C/E dose. CONCLUSIONS: Compared with monolayer cell culture, the in vitro 3-D tumor spheroid model better reflects the superior in vivo efficacy of Pax-eNPs. Persistent tumor penetration and prolonged intratumoral release are unique mechanisms of Pax-eNP cytotoxicity. 3-D spheroid models are valuable tools for investigating cytotoxic mechanisms and nanoparticle-tumor interactions, particularly given the costs and limitations of in vivo animal studies.

Rare Etiology of Cardiogenic Shock in Children: Anomalous Origin of the Left Coronary Artery from the Opposite Sinus with an Intramural Course.

Anomalous origin of the left coronary artery from the right sinus of Valsalva with an intramural course is a rare but potentially lethal congenital defect. While anomalous origin of the left coronary artery is a well-known cause of sudden cardiac death, it is less well appreciated that this anomaly may manifest in a variety of other clinical presentations, thereby leaving these patients at risk of missed or delayed diagnosis and subsequent poor outcomes. In this report, we describe an adolescent male with an unusual etiology of cardiogenic shock.

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.

Left thoracoscopic sympathectomy for cardiac denervation in patients with life-threatening ventricular arrhythmias.

BACKGROUND: We reported the outcomes of a single-institution experience using video-assisted thoracoscopic left cardiac sympathetic denervation as an adjunctive therapeutic technique in pediatric and young adult patients with life-threatening ventricular arrhythmias. METHODS: We conducted a retrospective clinical review of all patients who underwent left cardiac sympathetic denervation by means of video-assisted thoracoscopic surgery at our institution. From August 2000 to December 2011, 24 patients (13 with long QT syndrome, 9 with catecholaminergic polymorphic ventricular tachycardia, and 2 with idiopathic ventricular tachycardia) were identified from the cardiology database and surgical records. RESULTS: There were no intraoperative complications. The median postoperative length of stay was 2 days (range, 1-32 days). There were no major perioperative complications. Longer-term follow-up was available in 22 of 24 patients at a median follow-up of 28 months (range, 4-131 months). Sixteen (73%) of the 22 patients experienced a marked reduction in their arrhythmia burden, with 12 (55%) becoming completely arrhythmia free after sympathectomy. Six (27%) of the patients were nonresponsive to treatment; each had persistent symptoms at follow-up. CONCLUSIONS: Video-assisted thoracoscopic left cardiac sympathetic denervation can be safely and effectively performed in most patients with life-threatening ventricular arrhythmias. This minimally invasive procedure is a promising adjunctive therapeutic option that achieves a beneficial response in most symptomatic patients. These results support the inclusion of thoracoscopic cardiac sympathetic denervation among the treatment armamentarium in all patients with ventricular arrhythmias refractive to conventional medical therapy.

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.

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.