Routine Mediastinal Drainage Fluid Culture for Early Diagnosis of Poststernotomy Mediastinitis.

BACKGROUND: Early diagnosis of poststernotomy mediastinitis (PSM) is challenging. Since 2016, we have routinely performed mediastinal drainage fluid culture (MDFC) in patients undergoing sternotomy. This study aimed to determine the utility of MDFC for early diagnosis of PSM. METHODS: Between November 2016 and April 2020, we conducted MDFC in 1,012 patients on the third postoperative day and prospectively observed for PSM occurrence for 3 months. If bacteria were identified, additional MDFC or blood culture was performed to reduce the possibility of false positives. Based on MDFC results, the decision for early treatment for PSM was at the attending physician's discretion. RESULTS: Bacteria were identified in MDFC of 29 patients, eight of whom subsequently developed PSM. Among 983 patients with negative MDFC, only 15 developed PSM. In multivariate analysis, previous sternotomy history and positive MDFC were predictors of PSM. Positive MDFC was regarded as true positive if (1) PSM occurred subsequently, and/or (2) the same bacteria were identified in additional MDFC/blood culture. Non-occurrence of PSM in the absence of antibiotic treatment was regarded as false-positive MDFC. The sensitivity, specificity, and positive and negative predictive values of routine MDFC for diagnosis of mediastinal infection were 46.4, 99.0, 56.5, and 98.5%, respectively. When categorizing cases with positive MDFC based on the identified bacteria, the positive predictive value was highest (76.9%) when Staphylococci were identified. CONCLUSION: Routine MDFC after sternotomy can facilitate early diagnosis of PSM. Early treatment for PSM may be indicated in patients in whom Staphylococci are identified in the MDFC.

Nosocomial Infection in Adult Patients Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation.

Data on the frequency of nosocomial infections during extracorporeal membrane oxygenation (ECMO) in adult populations remain scarce. We investigated the risk factors for nosocomial infections in adult patients undergoing venoarterial ECMO (VA-ECMO) support. From January 2011 to December 2015, a total of 259 patients underwent ECMO. Of these, patients aged 17 years or less and patients undergoing ECMO for less than 48 hours were excluded. Of these, 61 patients diagnosed with cardiogenic shock were evaluated. Mean patient age was 60.6 ± 14.3 years and 21 (34.4%) patients were female. The mean preoperative Sequential Organ Failure Assessment (SOFA) score was 8.6 ± 2.2. The mean duration of ECMO support was 6.8 ± 7.4 days. The rates of successful ECMO weaning and survival to discharge were 44.3% and 31.1%, respectively. There were 18 nosocomial infections in 14 (23.0%) patients. These included respiratory tract infections in 9 cases and bloodstream infections in a further 9. In multivariate analysis, independent predictors of infection during ECMO were the preoperative creatinine level (hazard ratio [HR], 2.176; 95% confidence interval [CI], 1.065-4.447; P = 0.033) and the duration of ECMO support (HR, 1.400; 95% CI, 1.081-1.815; P = 0.011). A higher preoperative creatinine level and an extended duration of ECMO support are risk factors for infection. Therefore, to avoid the development of nosocomial infections, strategies to shorten the length of ECMO support should be applied whenever possible.

Coronary Sinus Ostial Atresia Presenting as Infective Endocarditis in a Previously Healthy Young Woman.

Coronary sinus ostial atresia is a rare disease. Most patients are usually asymptomatic and diagnosed incidentally during surgery or at autopsy. We report a case of coronary sinus ostial atresia with unroofed coronary sinus syndrome in a previously healthy woman who presented with infective endocarditis.

Reliable femoral chronic total occlusion model using a thin biodegradable polymer coated copper stent in a porcine model.

Chronic total occlusions (CTOs) are common in patients with peripheral arterial disease (PAD). This study aimed to examine the feasibility and reliability of a CTO induced by a thin biodegradable polymer (polyglycolic acid) coated copper stent in a porcine femoral artery. Novel thin biodegradable polymer coated copper stents (9 mm long) were crimped on an angioplasty balloon (4.5 mm diameter × 12 mm length) and inserted into the femoral artery. Histopathologic analysis was performed 35 days after stenting. In five of six stented femoral arteries, severe in-stent restenosis and total occlusion with collateral circulation were observed without adverse effects such as acute stent thrombosis, leg necrosis, or death at 5 weeks. Fibrous tissue deposition, small vascular channels, calcification, and inflammatory cells were observed in hematoxylin-eosin, Carstair's, and von Kossa tissue stains; these characteristics were similar to pathological findings associated with CTOs in humans. The neointima volume measured by micro-computed tomography was 93.9 ± 4.04 % in the stented femoral arteries. CTOs were reliably induced by novel thin biodegradable polymer coated copper stents in porcine femoral arteries. Successful induction of CTOs may provide a practical understanding of their formation and application of an interventional device for CTO treatment.

Cardioprotective effect of fimasartan, a new angiotensin receptor blocker, in a porcine model of acute myocardial infarction.

Cardioprotective effect of fimasartan, a new angiotensin receptor blocker (ARB), was evaluated in a porcine model of acute myocardial infarction (MI). Fifty swine were randomized to group 1 (sham, n=10), group 2 (no angiotensin-converting enzyme inhibitor [ACEI] or ARB, n=10), group 3 (perindopril 2 mg daily, n=10), group 4 (valsartan 40 mg daily, n=10), or group 5 (fimasartan 30 mg daily, n=10). Acute MI was induced by occlusion of the left anterior descending artery for 50 min. Echocardiography, single photon emission computed tomography (SPECT), and F-18 fluorodeoxyglucose cardiac positron emission tomography (PET) were performed at baseline, 1 week, and 4 weeks. Iodine-123 meta-iodobenzylguanidine (MIBG) scan was done at 6 weeks for visualization of cardiac sympathetic activity. Left ventricular function and volumes at 4 weeks were similar between the 5 groups. No difference was observed in groups 2 to 5 in SPECT perfusion defect, matched and mismatched segments between SPECT and PET at 1 week and 4 weeks. MIBG scan showed similar uptake between the 5 groups. Pathologic analysis showed similar infarct size in groups 2 to 5. Infarct size reduction was not observed with use of fimasartan as well as other ACEI and ARB in a porcine model of acute MI.

Immunological Analysis of Postoperative Delirium after Thoracic Aortic Surgery.

Background: Delirium is a recognized neurological complication following cardiac surgery and is associated with adverse clinical outcomes, including elevated mortality and prolonged hospitalization. While several clinical risk factors for post-cardiac surgery delirium have been identified, the pathophysiology related to the immune response remains unexamined. This study was conducted to investigate the immunological factors contributing to delirium in patients after thoracic aortic surgery. Methods: We retrospectively evaluated 43 consecutive patients who underwent thoracic aortic surgery between July 2017 and June 2018. These patients were categorized into 2 groups: those with delirium and those without it. All clinical characteristics were compared between groups. Blood samples were collected and tested on the day of admission, as well as on postoperative days 1, 3, 7, and 30. Levels of helper T cells (CD4), cytotoxic T cells (CD8), B cells (CD19), natural killer cells (CD56+CD16++), and monocytes (CD14+CD16-) were measured using flow cytometry. Results: The median patient age was 71 years (interquartile range, 56.7 to 79.0 years), and 21 of the patients (48.8%) were male. Preoperatively, most immune cell counts did not differ significantly between groups. However, the patients with delirium exhibited significantly higher levels of interleukin-6 and lower levels of tumor necrosis factor-alpha (TNF-α) than those without delirium (p<0.05). Multivariate analysis revealed that lower TNF-α levels were associated with an increased risk of postoperative delirium (p<0.05). Conclusion: Postoperative delirium may be linked to perioperative changes in immune cells and preoperative cytokine levels. Additional research is required to elucidate the pathophysiological mechanisms underlying delirium.

Malignant Solitary Fibrous Tumor of the Mediastinum with Multiple Recurrences and a Rare Metastasis to the Thyroid Gland: A Case Report.

Solitary fibrous tumors (SFTs) are rare neoplasms arising from mesenchymal cells. Although most SFTs are benign, rare cases of metastasis have been reported at various sites. Complete surgical resection is the mainstay of treatment for both primary and recurrent or metastatic SFTs. Herein, we present a case of an SFT initially identified in the anterior mediastinum that later developed multiple metastases, even to the thyroid gland. The patient underwent repeated surgical resection and is currently being followed up in an outpatient setting.

Long-Term Outcomes of the Maze Procedure Combined with Endoatriectomy for Patients with Calcified Left Atria.

PURPOSE: Left atrial calcification (LAC) is found in long-lasting rheumatic valvular disease and is almost always accompanied by atrial fibrillation (AF). In the presence of LAC, endoatriectomy is required when performing the maze procedure. However, the technical feasibility of endoatriectomy and the long-term outcomes of the maze procedure in patients with LAC are uncertain. METHODS: The medical records of 18 consecutive patients who underwent combined endoatriectomy and maze procedure were analyzed retrospectively. RESULTS: Accompanying operations were mitral valve replacement (n = 16) and commissurotomy (n = 2). There was 1 operative death from sepsis following mediastinitis. When patients were divided into "broad" (n = 11) and "limited" (n = 7) groups, with the extent of LAC either greater or less than half of the left atrium, respectively, there was no intergroup difference in postoperative complications. During follow-up (median, 11.4 years), AF recurred in 11 patients. At the last follow-up visits, electrocardiography revealed significantly fewer patients in the broad group maintaining sinus rhythm (1/11 vs 4/6, P = 0.03). The 10-year AF recurrence-free survival rates were 13.9% and 66.7% in the broad and limited groups, respectively (P = 0.01). CONCLUSIONS: The maze procedure combined with endoatriectomy seems technically feasible with acceptable long-term rhythm outcomes if the LAC extent is limited.

Intracardiac Thymoma with Superior Vena Cava and Left Brachiocephalic Vein Extension: A Case Report.

Thymomas are common anterior mediastinal tumors with a relatively favorable prognosis compared to that of other types of thoracic malignancies. However, thymomas that invade surrounding structures, such as the heart or vena cava, have been infrequently reported, and intracardiac thymomas are exceedingly rare. Treatment of invasive thymoma is difficult because the high rate of incomplete resection results in a high rate of recurrence. Herein, we present a rare case of a thymoma that originated in the right atrium and extended into the superior vena cava and brachiocephalic vein.

Surgical Experience with Descending Necrotizing Mediastinitis: A Retrospective Analysis at a Single Center.

Background: We analyzed our experience with descending necrotizing mediastinitis (DNM) treatment and investigated the efficacy of video-assisted thoracoscopic surgery (VATS) for mediastinal drainage. Methods: This retrospective analysis included patients who underwent surgical drainage for DNM at our hospital from 2005 to 2020. We analyzed patients' baseline characteristics, surgical data, and perioperative outcomes and compared them according to the mediastinal drainage approach among patients with type II DNM. Results: Twenty-five patients (male-to-female ratio, 18:7) with a mean age of 54.0±12.9 years were enrolled in this study. The most common infection sources were pharyngeal infections (60%). Most patients had significantly increased white blood cell counts, elevated C-reactive protein levels, and decreased albumin levels on admission. The most common DNM type was type IIB (n=16, 64%), while 5 and 4 patients had types I and IIA, respectively. For mediastinal drainage, the transcervical approach was used in 15 patients and the transthoracic approach (VATS) in 10 patients. The mean length of hospital stay was 26.5±23.8 days, and the postoperative morbidity and in-hospital mortality rates were 24% and 12%, respectively. No statistically significant differences were found among patients with type II DNM between the transcervical and VATS groups. However, the VATS group showed shorter mean antibiotic therapy duration, drainage duration, and hospital stay length than the transcervical group. Conclusion: DNM manifested as severe infection requiring long-term inpatient treatment, with a mortality rate of 12%. Thus, active treatment with a multidisciplinary approach is crucial, and mediastinal drainage using VATS is considered relatively safe and effective.

Aortic Valve Replacement by Subannular Endomyocardial Implantation of Valve Prosthesis in Behçet's Disease.

The novel anastomosis technique, "subannular endomyocardial implantation of valve prosthesis (SEIV)," focuses on excluding aortic annular tissue from suture line to avoid vascular inflammation in Behçet's disease (BD). We aimed to validate that SEIV could prevent prosthetic valve detachment (PVD) after aortic valve replacement (AVR) in BD patients and retrospectively analyzed the medical records of five BD patients who underwent AVR. There was no operative death. Two complete atrioventricular blocks occurred; in one of them, a permanent pacemaker (PPM) was inserted before discharge. The other one was discharged without a PPM; however, he died suddenly 32 days postoperatively. The median follow-up period was 3.3 years. There was a case of PVD with newly developed Valsalva sinus aneurysm requiring the Bentall operation at 3.6 years postoperatively. In conclusion, SEIV might prevent PVD in BD patients who underwent AVR. However, aortic root pathology related to BD activity and resulting PVD may occur later.

Successful treatment with femoro-femoral venovenous extracorporeal membrane oxygenation in traumatic tracheal injury: a case report.

BACKGROUND: Traumatic tracheal injury is a rare type of trauma. In this type of injury, catastrophes may occur owing to a failure to secure the patient's airway. Extracorporeal membrane oxygenation (ECMO) is rescue therapy available for the treatment of urgent cardiorespiratory distress until the patient's vital signs have stabilized. The various applications of ECMO configurations have expanded the scope for this therapy. CASE PRESENTATION: We describe the case of a 66-year-old man with tracheal rupture with thyroid cartilage fracture due to cultivator handle who was treated with veno-venous ECMO. This case reflects the role and limitations of veno-venous ECMO, in which patient survival was possible with a bi-femoral configuration while also ensuring a clear airway. CONCLUSION: We shared our experience with bi-femoral veno-venous ECMO as a therapeutic option to contribute to choosing an appropriate approach. Based on our review of the literature, the present case was an uncommon report of survival after tracheal rupture due to trauma without other complications.

Open surgical treatment of subclavian artery pseudoaneurysm after endovascular repair: a case report.

BACKGROUND: Subclavian artery aneurysms are rare but may cause life-threatening complications. Surgical repair has been performed as a treatment of choice, but recently, with the development of endovascular treatment, many endovascular repairs have been performed to prevent surgical complications. CASE PRESENTATION: A patient undergoing endovascular repair with a subclavian artery aneurysm was diagnosed with a type II endoleak with an enlarged aneurysmal sac. Surgical repair was performed to remove the aneurysmal sac compressing the adjacent organs. CONCLUSIONS: The highly mobile subclavian artery has abundant collaterals. Therefore, regular follow-up is essential for endovascular repair. Surgical repair is effective when adjacent organs are compressed by the aneurysm sac.

Unusual cause of acute right ventricular dysfunction: rapid progression of superior vena cava aneurysm complicated by thrombosis and pulmonary thromboembolism.

Aneurysms of the major thoracic veins are rare. They are usually asymptomatic and thus treated conservatively. We report an extremely rare case of rapidly progressing superior vena cava (SVC) aneurysm complicated by thrombosis and acute pulmonary thromboembolism (PTE) with right ventricular dysfunction. Thrombolytic therapy for hemodynamically significant acute PTE was harmful to the patient in the present case, because it induced further thrombosis and mobilization of the thrombi within the aneurysm, subsequently causing de novo PTE. Surgical aneurysmectomy combined with pulmonary artery embolectomy would be a treatment of choice in patients with SVC aneurysm complicated by acute PTE.

Thoracoscopic pulmonary metastasectomy in metastatic colorectal cancer: Surgical outcomes and prognostic factors.

BACKGROUND: This study aimed to confirm the effectiveness of thoracoscopic metastasectomy for colorectal cancer (CRC) and determine its prognostic factors. METHODS: Of the 181 patients who underwent video-assisted thoracoscopic surgery (VATS) for pulmonary metastases from CRC between 2011 and 2017, 173 were retrospectively reviewed. Surgical outcomes, long-term survival, and the factors affecting the prognosis were analyzed. RESULTS: The patients in the study were predominantly male (n = 104, 60.1%), and the median age was 65 years (range, 25-83 years). The median follow-up time was 46 months (range, 0-114 months). The surgical procedures were 156 wedge resections, five segmentectomies, and 12 lobectomies. Conversion to thoracotomy was required in nine patients. The postoperative complication rate was 2.9%, and the in-hospital mortality rate was 1.2%. The overall 1-, 3-, and 5-year survival rates were 94.8%, 70.6%, and 51.8%, respectively. Univariate analysis showed that the prognostic factors for survival were age (p = 0.027), pathological stage of CRC (p = 0.019), prior extrathoracic metastasis (p = 0.005), preoperative carcinoembryonic antigen level (p = 0.020), number of pulmonary metastases (p = 0.011), and disease-free interval (p = 0.026). In the multivariate analysis, two factors were related to prognosis: age (hazard ratio [HR], 1.881; 95% confidence interval [CI]; 1.189-2.976; p = 0.007) and prior extrathoracic metastasis (HR, 2.170; 95% CI; 1.269-3.711; p = 0.005). CONCLUSIONS: VATS for pulmonary metastasectomy for CRC can be performed relatively safely, and our results regarding long-term survival are comparable with those of other studies. In this study, older age (≥70 years) and prior extrathoracic metastasis were independent prognostic factors of poor prognosis.

Complete Genome Sequence of Weissella cibaria Strain BM2, Isolated from Korean Kimchi.

Weissella cibaria appears to have broad-spectrum health benefits. Here, we report the genome sequence of Weissella cibaria strain BM2, which was isolated from homemade kimchi; it consists of one circular chromosome of 2,462,443 bp and one plasmid of 11,067 bp. A total of 2,337 coding sequences were predicted, including 2,117 protein-coding sequences and a G+C content of 45.06%.

Laparoscopic repair of hiatal hernia.

BACKGROUND: Laparoscopic hiatal hernia repair is a complex surgery typically performed by general abdominal surgeons because it typically involves an abdominal approach. Here, we report our experiences on laparoscopic repair of hiatal hernia as thoracic surgeons. METHODS: Based on our experience of minimally invasive esophageal surgery (MIES) for esophageal cancer, we began performing laparoscopic repair of hiatal hernia in 2009. We analyzed the surgery-related data and postoperative outcomes of 18 consecutive patients we operated on from 2009 to 2017. RESULTS: There were 1 male and 17 female patients with a median age of 73 years (range, 37-81 years). Ten of 14 symptomatic patients experienced reflux symptoms, such as heartburn. Four patients had a history of prior abdominal surgery. Hiatal hernia types I, II, III, and IV were observed in 3, 9, 5, and 1 patients, respectively. Two (11.1%) laparoscopic procedures required conversion. Modified Collis gastroplasty was used as an esophageal lengthening procedure in 5 patients (27.8%). Mean operation time was 213.8±70.1 minutes and mean hospital stay was 6.2±1.5 days. There were no postoperative complications. At the last follow-up, 15 patients (83.3%) were asymptomatic; however, 3 (16.7%) complained of reflux or dysphagia. Recurrent hiatal hernia was detected on an esophagogram in only 1 patient at 3.5 years after laparoscopic surgery. CONCLUSIONS: Laparoscopic repair of hiatal hernia is a feasible technique with a satisfactory surgical outcome. Importantly, it can be performed by thoracic surgeons who are experienced in the laparoscopic approach.

Erratum: Predictive Value of Procalcitonin for Infection and Survival in Adult Cardiogenic Shock Patients Treated with Extracorporeal Membrane Oxygenation.

[This corrects the article on p. 48 in vol. 54, PMID: 29399566.].