The potential of bioresorbable vascular scaffold (BVS) technology has been demonstrated in first-in-man studies with up to 5-year follow-up. This study sought to investigate the 1-year outcomes of ...the BVS, for the treatment of chronic total occlusions (CTOs), using various imaging techniques. Thirty-five true CTO lesions treated with BVS were included in this prospective study. Scaffolds were deployed after mandatory predilation and intravascular ultrasound analysis. Optical coherence tomography was performed after BVS implantation and at 10 to 12 months. Multislice computed tomography was performed at baseline and at 6 to 8 months. Mean patient age was 61 ± 10 years. The most frequent vessel treated was the right coronary artery (46%). Lesions were classified as intermediate (49%) or difficult/very difficult (26%) according to the Japanese CTO complexity score. Predilation was performed in 100% of lesions, using cutting balloons in 71% of these. The total scaffold length implanted per lesion was of 52 ± 23 mm. All scaffolds were delivered and deployed successfully. Postdilation was undertaken in 63%. By multislice computed tomography at 6 months, we observed 2 cases of asymptomatic scaffold restenosis, subsequently confirmed by angiography. At 12 months, no scaffold thrombosis or major adverse cardiac events were reported. The optical coherence tomography at follow-up showed that 94% of struts were well apposed and covered (5% of uncovered struts and 1% of nonapposed struts), and only 0.6% of struts were nonapposed and uncovered. In conclusion, 1-year results suggest that BVS for CTO is associated with excellent clinical and imaging outcomes. Accurate percutaneous coronary BVS technique might have enabled these promising results.
Prolonged air leak (PAL) remains a frequent complication after lung resection. Perioperative preventative strategies have been tested, but their efficacy is often difficult to interpret due to ...heterogeneous inclusion criteria. The objective of this study was to develop and validate a practical score to stratify the risk of PAL after lobectomy.
Six hundred fifty-eight consecutive patients were submitted to pulmonary lobectomy (2000 to 2008) in center A and were used to develop the risk-adjusted score predicting the incidence of PAL (> 5 days). Exclusion criteria were chest wall resection and postoperative assisted mechanical ventilation. No sealants, pleural tent, or buttressing material were used. To build the aggregate score numeric variables were categorized by receiver operating curve analysis. Variables were screened by univariate analysis and then used in stepwise logistic regression analysis (validated by bootstrap). The scoring system was developed by proportional weighing of the significant predictor estimates and was validated on patients operated on in a different center (center B).
The incidence of PAL in the derivation set was 13% (87 of 658 cases). Predictive variables and their scores were the following: age greater than 65 years (1 point); presence of pleural adhesions (1 point); forced expiratory volume in one second less than 80% (1.5 points); and body mass index less than 25.5 kg/m(2) (2 points). Patients were grouped into 4 risk classes according to their aggregate scores, which were significantly associated with incremental risk of PAL in the validation set of 233 patients.
The developed scoring system reliably predicts incremental risk of PAL after pulmonary lobectomy. Its use may help in identifying those high-risk patients in whom to adopt intraoperative prophylactic strategies; in developing inclusion criteria for future randomized clinical trials on new technologies aimed at reducing or preventing air leak; and for patient counseling.
When to Remove a Chest Tube Novoa, Nuria M; Jiménez, Marcelo F; Varela, Gonzalo
Thoracic surgery clinics,
02/2017, Letnik:
27, Številka:
1
Journal Article
Recenzirano
Despite the increasing knowledge about the pleural physiology after lung resection, most practices around chest tube removal are dictated by personal preferences and experience. This article ...discusses recently published data on the topic and suggests opportunities for further investigation and future improvements.
The revised cardiac risk index (RCRI) has been proposed as a tool for cardiac risk stratification before lung resection. However, the RCRI was originally developed from a generic surgical population ...including a small group of thoracic patients. The objective of this study was to recalibrate the RCRI in candidates for major lung resections to provide a more specific instrument for cardiac risk stratification.
One thousand six hundred ninety-six patients who underwent lobectomy (1,426) or pneumonectomy (270) in two centers between the years of 2000 and 2008 were analyzed. Stepwise logistic regression and bootstrap analyses were used to recalibrate the six variables comprising the RCRI. The outcome variable was occurrence of major cardiac complications (cardiac arrest, complete heart block, acute myocardial infarction, pulmonary edema, or cardiac death during admission). Only those variables with a probability of less than 0.1 in more than 50% of bootstrap samples were retained in the final model and proportionally weighted according to their regression estimates.
The incidence of major cardiac morbidity was 3.3% (57 patients). Four of the six variables present in the RCRI were reliably associated with major cardiac complications: cerebrovascular disease (1.5 points), cardiac ischemia (1.5 points), renal disease (1 point), and pneumonectomy (1.5 points). Patients were grouped into four classes according to their recalibrated RCRI, predicting an incremental risk of cardiac morbidity (p < 0.0001). Compared with the traditional RCRI, the recalibrated score had a higher discrimination (c indexes, 0.72 versus 0.62; p = 0.004).
The recalibrated RCRI can be reliably used as a first-line screening instrument during cardiologic risk stratification for selecting those patients needing further cardiologic testing from those who can proceed with pulmonary evaluation without any further cardiac tests.
Abstract We report on a 49-year-old man who presented to the emergency department with progressive angina. Echocardiography displayed severe aortic regurgitation and aortic valve thickening. The ...suspected diagnosis was acute aortic syndrome. Cardiac computed tomography showed circumferential thickening of the aortic wall and left main coronary artery ostial stenosis. Histologic examination showed diffuse aortic inflammation. No damage of any other organ or vascular structure was reported, and the final diagnosis was nonspecific aortitis. Differential diagnosis, prognosis, and therapeutic strategies are discussed.
The objective of this investigation is to evaluate whether the Thoracic Revised Cardiac Risk Index (ThRCRI) is an independent prognostic factor after lung resection for early-stage lung cancer.
...Observational analysis performed on 1,370 patients (from 2000 to 2011) undergoing anatomic lung resection for pathologic stage I non-small cell lung cancer in three thoracic surgery units. Survival was calculated by the Kaplan-Meier method. The association between survival and several clinical variables was determined by Cox multivariate analysis.
Median follow-up was 77 months. Patients were assigned to risk classes according to their ThRCRI score: class A (score, 0 to 1), 1,062 patients; class B (score, 1.5 to 2.5), 284 patients; class C (score, >2.5), 24 patients. Patients in class A had a longer 5-year overall survival (66%) compared w those in classes B (53%) and C (35%; log-rank test, p < 0.0001). The ThRCRI remained an independent prognostic factor after Cox regression analysis (hazard ratio, 1.2; p = 0.001) along with age (hazard ratio, 1.03; p < 0.0001), pT stage (hazard ratio, 1.6; p < 0.0001), and forced expiratory volume in 1 second (hazard ratio, 0.98; p < 0.0001). Five-year cancer-specific survival was longer in patients with ThRCRI class A (77%) compared with classes B (75%) and C (55%; log-rank test, p = 0.05). Mortality from cardiac events occurring during follow-up was 1.5% in class A, 7% in class B, and 13% in class C (p < 0.0001).
The ThRCRI is a useful prognostic score in patients undergoing resection for early-stage lung cancer. Patients with a score greater than 2.5 should be counseled about their increased risk of major perioperative cardiac events and their expected decreased long-term survival.
Recently published papers have shown that lobectomy improves lung function in selected patients with chronic obstructive pulmonary disease (COPD) months after surgery, but little information can be ...found discussing the effect of lobectomy on pulmonary function in the immediate period after surgery in these cases. The aim of this multicenter prospective study is to evaluate whether preoperative COPD influences the decrease of forced expiratory volume in 1 second the day after surgery.
One hundred eighty-five patients undergoing nonextensive lobectomy were included. Selection criteria and perioperative management were homogeneous; all procedures were performed by muscle-sparing or video-assisted thoracoscopic surgical approach. Multivariate regression analysis was performed to identify whether COPD index (calculated by adding the percent preoperative forced expiratory volume in 1 second to the preoperative ratio of forced expiratory volume in 1 second to forced vital capacity, both values taken in decimal form) had an independent and reliable association with the decrease in forced expiratory volume in 1 second observed on the first postoperative day corrected for the effect of other preoperative and operative factors. The regression analysis was then validated by bootstrap analysis.
Thirty-day mortality of the series was 1.1% (2 patients) and cardio-respiratory morbidity 20% (37 patients). Patients with lower preoperative pulmonary volumes had lower postoperative decrease of the pulmonary function (Pearson correlation coefficient, 0.28; p < 0.001). At linear regression, COPD index (p = 0.008), modality of analgesia (p < 0.0001), pain score (p = 0.01), the percentage of functioning parenchyma removed during operation (p = 0.006), and the presence of coronary artery disease (p = 0.03) had independent and reliable influence on the dependent variable (p < 0.001 and 0.003, respectively).
Preoperative COPD degree (measured as COPD index) has a direct independent correlation with the decrease in postoperative forced expiratory volume in 1 second the day after surgery.
Ambulatory treatment of pleural problems such as pneumothorax and malignant pleural effusions has been extensively described and is commonly used. On the contrary, outpatient management of chest ...tubes after lung resection is less frequently performed. Because prolonged air leak after lobectomy is a common problem, early discharge of these patients under pleural drainage can avoid many hospital days without compromising the quality of care. In this article, general rules for outpatient chest tube management are described and available portable devices are reviewed.
Objectives The goal of this study was to define the frequency of stent gaps by 64-detector computed tomographic angiography (CTA) and their relation to in-stent restenosis (ISR), stent fracture (SF), ...and overlap failure (OF). Background SF defined by catheter angiography or intravascular ultrasound has been implicated in ISR. Methods A total of 292 consecutive patients, with 613 stents, who underwent CTA were evaluated for stent gaps associated with decreased Hounsfield units. Correlations with catheter coronary angiography (CCA) were available in 143 patients with 384 stents. Results Stent gaps were noted in 16.9% by CTA and 1.0% by CCA. ISR by CCA was noted in 46.1% of the stent gaps (p < 0.001) as determined by CCA, and stent gaps by CTA accounted for 27.8% of the total ISR (p < 0.001). In univariate analysis, stent diameter ≥3 mm was the only CCA characteristic significantly associated with stent gaps (p = 0.002), but was not a significant predictor by multivariate analysis. Bifurcation stents, underlying calcification, stent type, location, post-dilation, and overlapping stents were not observed to be predisposing factors. Excessive tortuosity and lack of conformability were not associated with stent gaps; however, their frequency was insufficient to permit meaningful analysis. Conclusions Stent gap by CTA: 1) is associated with 28% of ISR, and ISR is found in 46% of stent gaps; 2) is associated with ≥3-mm stents by univariate (p = 0.002) but not by multivariate analysis; 3) is infrequently noted on catheter angiography; and 4) most likely represents SF in the setting of a single stent, and may represent SF or OF in overlapping stents.
An Exceptional Cause of Acute Right Heart Failure Carreras-Mora, Jose; Duran-Cambra, Albert; Vilades-Medel, David ...
JACC. Case reports,
March 2020, 2020-03-00, 2020-03-01, Letnik:
2, Številka:
3
Journal Article
Recenzirano
Odprti dostop
We describe a patient with of acute right ventricular dysfunction secondary to right ventricular isolated Takotsubo syndrome (TTS). The importance of appropriate differential diagnosis for acute ...right ventricular dysfunction differential diagnosis of acute right ventricular dysfunction and the differences in diagnosis and management of right ventricular TTS and typical left ventricular TTS are highlighted. (Level of Difficulty: Intermediate.)
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This study describes a case of acute right ventricular dysfunction secondary to right ventricular isolated Takotsubo syndrome (TTS). The importance…
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