A meta-analysis assessing the benefits of concomitant pleural tent procedure after upper lobectomy.

A meta-analysis comparing outcomes of upper lobectomies with or without pleural tenting was performed. Five trials comprising 396 patients were selected. There was significantly reduced duration of hospital stay, chest drain use, and air leak in the pleural tenting group compared with the group without the pleural tent. There was also a significant reduction in number of patients with prolonged air leak more than 7 days in pleural tenting group. No other difference was noted in other outcomes such as total drainage, operative time, or hospital costs. In patients at high-risk of air leak, we advocate concomitant use of the pleural tent after upper lobectomies.

A meta-analysis comparing muscle-sparing and posterolateral thoracotomy.

We compared outcomes of posterolateral thoracotomy vs muscle-sparing thoracotomy after open thoracic operations. Twelve trials were included, comprising 571 patients in the muscle-sparing thoracotomy group and 512 patients in the posterolateral thoracotomy group. There was significantly improved shoulder internal rotation (weighted mean difference, -1.28; 95% confidence interval, -2.45 to -0.11; p = 0.03) and pain scores on day 7 (weighted mean difference, -0.76; 95% confidence interval, -1.26 to -0.27; p = 0.002) but higher seroma rates (odds ratio, 8.26; 95% confidence interval, 2.16 to 31.56; p = 0.002) in the muscle-sparing thoracotomy group compared with the posterolateral thoracotomy group. We advocate using muscle-sparing thoracotomy, especially on patients dependant on quicker recovery of shoulder function.

Right ventricular metastasis of transitional cell carcinoma of the renal pelvis: successful single stage surgical treatment.

A 58-year-old female presented with symptoms mimicking infective endocarditis and was diagnosed with a right ventricular metastasis from a transitional cell carcinoma (TCC) of the left renal pelvis. The patient was treated with concurrent removal of the cardiac tumour and radical left nephrectomy followed by adjuvant gemcitabine-cisplatin chemotherapy. To our knowledge, this is the 14th report of cardiac metastases from TCC and the only case where one-stage surgical management of primary and cardiac metastases from TCC has been successfully completed.

A prospective clinical study of cerebral microemboli and neuropsychological outcome comparing vent-line and auto-venting arterial line filters: both filters are equally safe.

INTRODUCTION: Microemboli are the main implicated cause of neuropsychological (NP) impairment after cardiac surgery. This prospective clinical trial compared the effect of an auto-venting arterial line filter on intraoperative cerebral microemboli and NP outcome compared to an arterial line filter with a vent line, in patients undergoing elective coronary artery bypass graft (CABG) surgery. METHODS: One hundred and ten patients received either an Avecor Affinity (n =73) or Pall AV-6 (n =37) control filter. Cerebral microemboli during cardiopulmonary bypass were recorded by transcranial Doppler monitoring of the right middle cerebral artery. Evidence of cerebral impairment was obtained by comparing patients' performance in a NP test battery (nine tests) administered 6-8 weeks postoperatively with their preoperative scores. RESULTS: During cardiopulmonary bypass, the median number and range of microemboli were 67 (5-846) and 55 (2-773) for the Avecor and AV-6 groups, respectively (p = 0.47). There was no difference in NP outcome. CONCLUSION: There is no difference in the filtering ability of vent-line and auto-vent filters as assessed by cerebral microemboli. This, together with the similar NP outcome, suggests that both types of filter are equally safe for clinical use.

Leucocyte-depleting arterial line filtration does not reduce myocardial injury assessed by Troponin T during routine coronary artery bypass grafting using crossclamp fibrillation.

INTRODUCTION: Leucocyte filtration can reduce inflammation and end-organ damage. The aim of this study was to test the cardioprotective effect of systemic leucocyte filtration during cardiopulmonary bypass (CPB) for coronary revascularization. METHODS: Sixty patients scheduled for elective coronary artery bypass grafting were prospectively randomised to receive either a test leucocyte-depleting (LD) filter or a control standard arterial line filter in the CPB circuit. Myocardial injury was determined by serum Troponin T concentration up to 72 h postoperatively. In addition, perioperative neutrophil counts, serum elastase and electrocardio-grams (ECGs) were evaluated. RESULTS: There was a peak of Troponin T release at 6 h in both groups. There was no difference between LD or control group Troponin T at any time point. No difference in neutrophil count was found. A greater rise in neutrophil elastase occurred in the LD group during CPB and 10 min post CPB (376 and 496 versus 108 and 228 mcg/L, p<0.001). CONCLUSIONS: LD arterial line filters did not confer any cardioprotective effect as measured by Troponin T in elective coronary revascularization cases.

A single-center experience of the Sorin Bicarbon heart valve prosthesis: long-term clinical, hematological and hemodynamic results.

BACKGROUND AND AIM OF THE STUDY: The Sorin Bicarbon (SB) bileaflet valve, available since 1990, has a good clinical safety profile. The study aim was to assess the long-term clinical results following implantation, plus hemodynamic and hematological aspects of the valve. METHODS: A total of 195 SB prostheses (100 aortic, 67 mitral, 14 double valve replacements) was implanted in 181 patients (108 males, 73 females) since 1991. RESULTS: Mean age at implantation was 60.5 +/- 10.8 years. Actuarial analysis at 9.0 years showed an overall survival of 63.9 +/- 5.5%; 28.2% of deaths were early (n = 11), and 71.8% late (n = 28). Freedom from thrombosis was 99.4 +/- 0.6% (one early event, successfully reoperated on), and from embolic events was 86.3 +/- 4.7%. Freedom from endocarditis and hemorrhagic complications were respectively 98.1 +/- 1.1% and 98.6 +/- 0.9%. No occurrence of hemolysis was reported. Freedom from non-structural valve dysfunction was 98.7 +/- 0.9%, and from reoperation was 96.1 +/- 1.6%. Hemodynamic evaluation by echocardiography and hematological testing was performed at 7.0 +/- 1.3 years (range 5-9 years) in a subset of 31 patients (20 males, 11 females). Mean valve size was 23.9 mm for aortic mitral. Echocardiography showed that aortic valves had a mean effective orifice area (EOA) of 2.26 +/- 1.28 cm2, with peak and mean pressure gradients of 23.6 +/- 14.6 and 12.9 +/- 8.1 mmHg, respectively. The mean EOA of mitral valve prostheses was 2.67 +/- 0.66 cm2, with peak and mean pressure gradients of 12.2 +/- 4.5 and 3.8 +/- 1.6 mmHg, respectively. Overall mean hemoglobin was 13.4 +/- 1.35 g/dl, and serum lactate dehydrogenase 630 +/- 13 IU/l. Serum haptoglobin was detectable in one patient only, and the mean reticulocyte count was 1.24 +/- 0.51%. CONCLUSION: In the present authors' experience, the Sorin Bicarbon prosthesis has low complication rates and maintains an excellent hemodynamic function over time. Hemolytic potential is insignificant with this valve.

The effect of leucocyte-depleting arterial line filters on cerebral microemboli and neuropsychological outcome following coronary artery bypass surgery.

OBJECTIVES: A randomised clinical trial sought evidence as to whether leucocyte-depleting (LD) arterial line filters added a further degree of neuroprotection in patients undergoing elective coronary artery bypass graft (CABG) surgery. METHODS: One hundred and ninety-two patients were randomised to the use of a Pall Leukoguard-6 LD filter or either an Avecor Affinity or Pall Autovent-6 control filter. Cerebral microemboli during surgery were recorded by transcranial Doppler (TCD) monitor over the right middle cerebral artery. Evidence of cerebral impairment was obtained by comparing patients' performance in a neuropsychological (NP) test battery (nine tests) administered 6-8 weeks post-operatively with their pre-operative scores. RESULTS: The groups proved well balanced in pre-operative variables. During cardiopulmonary bypass (CPB) the median number and range of microemboli was 15 (3-180) in the LD group compared to 67 (5-846) and 55 (2-773) for the Avecor and AV6 groups, respectively (P<0.0001). One hundred and sixty-two patients completed all the NP tests. The LD group showed better post-operative performance in all but one of the nine tests although the difference in a total change score just failed to reach significance (P=0.07 one-tailed t-test). CONCLUSIONS: LD filtration during CABG reduced the number of cerebral microemboli recorded by TCD and showed a strong trend towards improving NP performance post-operatively. These findings suggest that the use of such filters in CABG surgery may offer increased neuroprotection.