Quality assessment of robot assisted thoracic surgical resection of non-small cell lung cancer: nodal upstaging and mediastinal recurrence.

BACKGROUND: Robot assisted thoracic surgery (RATS) is the minimally invasive surgical technique of choice for treatment of patients with non-small cell lung cancer (NSCLC), at the Isala Hospital. The aim of this study is to compare clinical and pathological staging results and mediastinal recurrence after RATS for anatomical resections of lung cancer as surrogate markers for quality of mediastinal lymph node dissection (MLND). METHODS: This single institute retrospective study was conducted in patients who underwent RATS for NSCLC. Excluded were patients with a history of concurrent malignant disease, with other previous neoplasms, with small cell lung cancer (SCLC) and patients in whom the robotic technique was converted to thoracotomy, prior to lymph node dissection. Data were obtained from the hospital database. The difference between clinical and pathological staging was expressed as upstaging and downstaging. Computed Tomography scanning was used for follow-up, and diagnosis of mediastinal recurrence. RESULTS: From November 2011 to May 2016, 227 patients underwent RATS at Isala Hospital Zwolle, the Netherlands. Of those, 130 (mean age, 69.5±9.3 years) met the eligibility criteria. Preoperative mediastinal lymph node staging was done by endoscopic ultrasound/endobronchial ultrasound, by positron emission tomography (PET) or mediastinoscopy. In 14 patients (10.8%) unforeseen N2 disease was found, 6 patients (4.6%) were upstaged from cN0 to pN2 and 8 patients (6.2%) were upstaged from cN1 to pN2. Mediastinal recurrence was detected in 7 patients (5.4%) during a median follow-up of 54 months (range, 1.5-102 months). CONCLUSIONS: In patients with NSCLC, who underwent anatomical resection by means of RATS, an unforeseen N2 disease rate of 10.8% was demonstrated and a mediastinal recurrence rate of 5.4%. It is concluded that robotic surgery provides an accurate lymph node dissection.

Fifteen years' experience with the use of artificial chords for valve reconstruction in children.

OBJECTIVES: To retrospectively review our experience with artificial chords in mitral and tricuspid reconstructive surgery in children. METHODS: All consecutive paediatric (<18 years) patients who underwent mitral or tricuspid valve reconstruction with the use of artificial chords in our centre in the past 15 years were retrospectively analysed. RESULTS: Thirty-nine patients (age 3 days to 17 years) underwent reconstruction of the mitral (n = 27) or tricuspid (n = 12) valve using artificial chords. Mean number of chords was 3.5 ± 1.7. In 26 of 27 mitral valve patients, chords were placed on the anterior leaflet, in one on the posterior leaflet. In 10 of the 12 tricupid valve, patients chords were placed on the anterior leaflet and in 2 on the septal leaflet. All mitral patients underwent annuloplasty (10 bilateral Wooler-Kay and 17 rigid ring annuloplasty). Ten of the 12 tricuspid patients underwent annuloplasty (1 rigid ring and 9 commissural plication). Follow-up was after 8.7 ± 5.5 years. There was no early or late mortality. The actuarial freedom from reoperation rates at 1, 5 and 10 years were 95%, 91% and 81%, respectively. No reoperations occurred in the tricuspid group. In the mitral group, there were 2 early failures and 3 late reoperations due to mitral stenosis. Restricted leaflet motion probably caused by the artificial chords was seen in only 1 patient. CONCLUSIONS: Our data show that long-term durability of mitral and tricuspid valve reconstruction using artificial chords in children is good. Despite patient growth, restricted leaflet motion by the artificial chords does not seem to form a major problem.

Persistent sinus venosus valve requiring surgery in children.

OBJECTIVE: To review our experience with cardiac surgery due to remnants of the sinus venosus valve. DESIGN: We performed a retrospective evaluation of patients records during the period from 1980 to 2007. RESULTS: Three patients underwent surgical removal of the redundancy of the right sinus venosus valve. CONCLUSION: Remnants of the embryologic sinus venosus valve may present by various entities. Cardiac surgery should be performed only in patients with continuing symptoms attributed to a persistent sinus venosus valve.

Artificial chordae for pediatric mitral and tricuspid valve repair.

OBJECTIVE: To evaluate pediatric atrioventricular valve repair with artificial chordae. METHODS: Between February 2001 and January 2006, artificial chords were used in 21 children with severe mitral or tricuspid valve regurgitation. Patients with AVSD were excluded. Median age was 84 (1-194) months. Five patients had isolated tricuspid valve anomalies, 16 had mitral valve anomalies (associated tricuspid annular dilatation in 4). Tricuspid neochordae were placed to anterior (three patients) and septal (two patients) leaflets. Mitral neochordae were placed to anterior (15 patients) and posterior (1 patient) leaflets. Additional ring annuloplasties were performed in 12 (mitral 11, tricuspid 1), as well as 2 de Vega tricuspid annuloplasties. Patch insertion was used in acute endocarditis (tricuspid one). All echocardiographic studies were reviewed and analyzed by a single cardiologist. RESULTS: No mortality occurred. Follow-up was complete (mean 28+/-18 months). Two patients were reoperated, one for mitral ring dehiscence and one for recurring mitral valve insufficiency. Both valves were replaced by mechanical valve prosthesis. At last follow-up tricuspid insufficiency was mild (three) or moderate (two). Moderate insufficiency occurred due to remaining restriction of the septal leaflet after repair in endocarditis (one) and remaining prolapse of the anterior leaflet (one). Mitral insufficiency was absent (five), mild (seven), or moderate (two). Moderate insufficiency was caused by recurrent anterior leaflet shortening after valve repair in rheumatic valve disease (two). Valve restriction caused by artificial chordae was not found. CONCLUSIONS: Mitral and tricuspid valve repair with artificial chordae in children demonstrated acceptable results. Despite patient growth, valvular restriction by the artificial chordae was not observed ad mid-term follow-up.

Repair of ruptured tendinous chords in the newborn with flail tricuspid valve and functional pulmonary atresia.

Isolated congenital tricuspid valve regurgitation in a neonate was associated with heart failure and functional pulmonary atresia. Surgical repair of the ruptured chordae with the use of polytetrafluoroethylene artificial tendinous cords restored normal hemodynamics.