Customized Two-Dimensional Computed Tomography-Guided Preoperative Pectus Bar Shaping.

INTRODUCTION: Successful minimally invasive repair of pectus excavatum relies on a pectus bar that closely conforms to the desired shape of the sternum and ribs to produce optimal elevation and remodeling. However, the present method of empirical intraoperative bar shaping is tedious and risks trauma to surrounding structures. To overcome this, we devised a technique using a life-sized computed tomography (CT) printout of the patient's chest wall to guide preoperative bar bending. METHODS: A 5-cm-wide polymethylmethacrylate block placed on the sternum as the patient underwent chest CT was used as a marker to guide scaling of an axial screenshot of the patient's chest to life-size. This life-size image was printed and the planned correction of the patient's chest wall was traced onto it. The pectus bar was bent according to this template. Patient demographics, Haller index, surgical indications, operative technique, complications, aesthetic and functional improvements, and overall satisfaction were assessed. RESULTS: Thirty patients (4 women) underwent primary minimally invasive repair of pectus excavatum with a single pectus bar shaped preoperatively over an 8-year period. The average age and Haller index was 20.6 years and 5.4, respectively. The mean operative time was 66.4 minutes. Satisfactory sternal elevation was attained with a single attempt at bar insertion in all cases. Two patients had pneumothoraxes that resolved without intervention. The mean follow-up period was 50.1 months. There were no cases of bar migration or recurrence of deformity after bar removal. On a 5-point Likert scale, all patients indicated an improvement in aesthetic appearance (4.6), and patients with physical symptoms (10) reported an improvement in function (4.4). The overall satisfaction score was 4.7. CONCLUSIONS: This technique of CT-guided preoperative pectus bar shaping is straightforward, eliminates the need for intraoperative revisions to bar shape, and achieves effective correction of the pectus excavatum deformity. All patients were satisfied with the aesthetic, functional, and overall outcomes.

Trachea Reconstruction with Single-Stage Composite Flaps in a Rabbit Model.

BACKGROUND: Trachea reconstruction requires creation of a functional lining, semirigid support, and vascularity. We aimed to design composite flaps with these three components in a rabbit model. METHODS: Circumferential (n = 9) and partial anterior (n = 8) tracheal defects were created in rabbits. A circumferential defect was reconstructed with a tubed ear flap incorporating cartilage for support and skin for lining. This was pedicled on the posterior auricular vessels and tunneled into the neck to bridge the defect. In the second experiment, a longitudinal anterior trachea defect was patched with a pedicled rib cartilage and intercostal muscle flap based on the internal mammary vessels. The vascularized fascia over the intercostal muscles replaced the lining while the cartilage provided support. Postoperatively, the rabbits were monitored clinically and endoscopically. The tracheal constructs were examined histologically after the animals were sacrificed. RESULTS: Rabbits with circumferential defects reconstructed with the ear flap survived up to 6 months. Histology demonstrated vascularized cartilage with good integration of the flap with native trachea. However, hair growth and skin desquamation resulted in airway obstruction in the long term. In the second experiment, all the rabbits survived without respiratory distress, and the intercostal muscle fascia was completely covered by native respiratory epithelium. CONCLUSION: We described two experimental techniques using autologous composite flaps for single-stage trachea reconstruction in a rabbit model. Skin was a poor lining replacement, whereas vascularized muscle fascia became covered with respiratory epithelium. A rib cartilage and muscle flap could potentially be used for reconstruction of partial defects in humans.

Prevalence of Healthcare-Associated Infections and Antimicrobial Use Among Adult Inpatients in Singapore Acute-Care Hospitals: Results From the First National Point Prevalence Survey.

BACKGROUND: We conducted a national point prevalence survey (PPS) to determine the prevalence of healthcare-associated infections (HAIs) and antimicrobial use (AMU) in Singapore acute-care hospitals. METHODS: Trained personnel collected HAI, AMU, and baseline hospital- and patient-level data of adult inpatients from 13 private and public acute-care hospitals between July 2015 and February 2016, using the PPS methodology developed by the European Centre for Disease Prevention and Control. Factors independently associated with HAIs were determined using multivariable regression. RESULTS: Of the 5415 patients surveyed, there were 646 patients (11.9%; 95% confidence interval [CI], 11.1%-12.8%) with 727 distinct HAIs, of which 331 (45.5%) were culture positive. The most common HAIs were unspecified clinical sepsis (25.5%) and pneumonia (24.8%). Staphylococcus aureus (12.9%) and Pseudomonas aeruginosa (11.5%) were the most common pathogens implicated in HAIs. Carbapenem nonsusceptibility rates were highest in Acinetobacter species (71.9%) and P. aeruginosa (23.6%). Male sex, increasing age, surgery during current hospitalization, and presence of central venous or urinary catheters were independently associated with HAIs. A total of 2762 (51.0%; 95% CI, 49.7%-52.3%) patients were on 3611 systemic antimicrobial agents; 462 (12.8%) were prescribed for surgical prophylaxis and 2997 (83.0%) were prescribed for treatment. Amoxicillin/clavulanate was the most frequently prescribed (24.6%) antimicrobial agent. CONCLUSIONS: This survey suggested a high prevalence of HAIs and AMU in Singapore's acute-care hospitals. While further research is necessary to understand the causes and costs of HAIs and AMU in Singapore, repeated PPSs over the next decade will be useful to gauge progress at controlling HAIs and AMU.

Novel Use of Thalidomide in Recurrent Gastrointestinal Tract Bleeding in Patients with Left Ventricular Assist Devices: A Case Series.

BACKGROUND: Bleeding is an important and common complication of left ventricular assist devices (LVADs). One of the common causes of gastrointestinal bleeding is arteriovenous malformations. However, the source of bleeding is often hard to identify. Thalidomide is efficacious in treatment of gastrointestinal (GI) bleeding in non-LVAD patients. We report our experience of the use of thalidomide in the treatment of GI bleeding in four patients with LVAD. METHOD AND RESULTS: Four patients who had recurrent GI bleeding from May 2009 to December 2014 were started on thalidomide. All of them responded to treatment and had no further gastrointestinal bleeding while on thalidomide. One patient developed constipation, requiring thalidomide to be stopped. Another patient developed symptomatic neuropathy, that resolved with reduction of dosage. CONCLUSION: Thalidomide appears safe and efficacious in LVAD patients with recurrent gastrointestinal bleeding.

Therapeutic Hypothermia May Improve Neurological Outcomes in Extracorporeal Life Support for Adult Cardiac Arrest.

BACKGROUND: Limited data exists on patients receiving therapeutic hypothermia during extracorporeal life support (ECLS). We investigated outcomes and prognostic factors in these patients. METHODS: A retrospective review was conducted for 225 consecutive adult patients treated with ECLS between July 2003 and January 2016. Extracorporeal life support was initiated for refractory cardiac arrest (>10 mins) in 79 patients (35.1%). Patient demographics, ECLS-related complications, in-hospital mortality and neurological outcomes were analysed. RESULTS: The mean age was 49.9±12.4 years. Sixty-two patients (78.5%) were male. The mean duration of CPR and ECLS were respectively, 32.0±23.3 mins and 5.4±4.0 days. Therapeutic hypothermia (34oC) was maintained for 24hours in 14 patients (17.7%). Thirty-five patients (44.3%) were weaned off ECLS. Twenty-one patients (26.6%) survived to hospital discharge with 16 (20.3%) recovering good neurological function. Compared to ECLS at normothermia, neurologically favourable survival was higher in the hypothermia group (42.9% vs 15.4%, p=0.020). Multivariable analysis identified a non-shockable rhythm [odds ratio (OR) 5.1, confidence interval (CI) 1.5-16.8], ischaemic hepatitis (OR 6.2, CI 1.1-33.6) and hypoxic ischaemic encephalopathy (OR 5.1, CI 1.5-17.1) as predictors of in-hospital mortality. Therapeutic hypothermia (OR 4.9, CI 1.2-20.4) and acute renal failure (OR 0.19, CI 0.05-0.70) were predictors of neurologically favourable survival. CONCLUSIONS: In this report of patients treated with ECLS, in-hospital survival and survival with good neurological performance were 26.6% and 20.3% respectively. A non-shockable rhythm, ischaemic hepatitis and hypoxic ischaemic encephalopathy were predictors of in-hospital mortality. Therapeutic hypothermia during ECLS was associated with improved neurological outcomes.

Banking of cryopreserved iliac artery and vein homografts: clinical uses in transplantation.

Iliac artery and vein homografts are critical for revascularization in living-donor liver transplantation. Since 2010, National Cardiovascular Homograft Bank and National University Hospital have collaborated in the pioneer endeavor of banking iliac vessel homografts for such surgeries in Singapore. This article aims to demonstrate that the processing, decontamination and cryopreservation techniques that our bank follow, help preserve iliac vessel homografts for a longer duration as compared to homografts preserved using short-term preservation techniques. This paper reports the first 4 years of post-operative outcome for recipients as a preliminary report for a longer-term outcome study. Criteria for donor assessment, techniques of iliac vessel homograft recovery, processing, decontamination, cryopreservation and storage according to the American Association of Tissue Banks standards are also described. From 2010 until 2013, we discovered of the iliac vessel homografts processed, 17 (94.4 %) were suitable for clinical use. Nine iliac artery grafts (64 %) and one iliac vein graft (14 %) were implanted. Irrespective of vessel type, homografts <90 mm in length were of little use. Of the nine current iliac vessel homograft recipients, eight patients (89 %) had living-donor liver transplantation and one patient (11 %) had reconstruction of the right internal carotid artery after resection of an aneurysm. Our preliminary results supports existing literatures that suggest cryopreserved iliac vessel homografts can be successfully used for revascularization in liver transplantation and reconstruction of carotid artery. Encouraging short-term post-operative patient outcomes have been achieved, with no report of adverse event attributed to implanted homografts. We believe that our processing, decontamination and cryopreservation techniques have helped preserve the homografts for longer duration as compared to homografts preserved using short-term preservation techniques.

iPSC-derived human mesenchymal stem cells improve myocardial strain of infarcted myocardium.

We investigated global and regional effects of myocardial transplantation of human induced pluripotent stem cell (iPSC)-derived mesenchymal stem cells (iMSCs) in infarcted myocardium. Acute myocardial infarction (MI) was induced by ligation of left coronary artery of severe combined immunodeficient mice before 2 × 10(5) iMSCs or cell-free saline were injected into peri-infarcted anterior free wall. Sham-operated animals received no injection. Global and regional myocardial function was assessed serially at 1-week and 8-week by segmental strain analysis by using two dimensional (2D) speckle tracking echocardiography. Early myocardial remodelling was observed at 1-week and persisted to 8-week with global contractility of ejection fraction and fractional area change in saline- (32.96 ± 14.23%; 21.50 ± 10.07%) and iMSC-injected (32.95 ± 10.31%; 21.00 ± 7.11%) groups significantly depressed as compared to sham control (51.17 ± 11.69%, P < 0.05; 34.86 ± 9.82%, P < 0.05). However, myocardial dilatation was observed in saline-injected animals (4.40 ± 0.62 mm, P < 0.05), but not iMSCs (4.29 ± 0.57 mm), when compared to sham control (3.74 ± 0.32 mm). Furthermore, strain analysis showed significant improved basal anterior wall strain (28.86 ± 8.16%, P < 0.05) in the iMSC group, but not saline-injected (15.81 ± 13.92%), when compared to sham control (22.18 ± 4.13%). This was corroborated by multi-segments deterioration of radial strain only in saline-injected (21.50 ± 5.31%, P < 0.05), but not iMSC (25.67 ± 12.53%), when compared to sham control (34.88 ± 5.77%). Improvements of the myocardial strain coincided with the presence of interconnecting telocytes in interstitial space of the infarcted anterior segment of the heart. Our results show that localized injection of iMSCs alleviates ventricular remodelling, sustains global and regional myocardial strain by paracrine-driven effect on neoangiogenesis and myocardial deformation/compliance via parenchymal and interstitial cell interactions in the infarcted myocardium.

Use of left ventricular assist device (HeartMate II): a Singapore experience.

Recent advances in medical and device therapies in heart failure have improved the survival of patients with heart failure. However, due to the limited availability of suitable heart donors, left ventricular assist devices (LVADs) have become an important tool as a bridge-to-heart transplantation for patients with refractory heart failure in Singapore. We report our experience with the HeartMate II (HMII) LVAD (Thoratec Corporation, Pleasanton, CA, USA) as a bridge-to-heart transplant in our center from 2009 to 2012. This was a retrospective review of 23 consecutive patients who underwent HMII LVAD implantation in our center between May 2009 and December 2012. All patients were classified as Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels 1 to 3 and underwent LVAD implantation as a bridge-to-heart transplant. There were 17 male and 6 female patients. The mean age was 43.6 years old (range 14 to 64). The etiologies of heart failure included ischemic heart disease [8], idiopathic dilated cardiomyopathy [11], viral myocarditis [2], and chemotherapy-induced cardiomyopathy [2]. Nine patients were INTERMACS level 1, 12 patients level 2, and two patients level 3. All patients successfully underwent HMII LVAD implantation. There was no mortality within the first 30 postoperative days. Postoperative complications included stroke with full neurological recovery (21.7%), mediastinal infection (21.7%), cardiac tamponade or mediastinal collection requiring reopening of the chest (39.1%), cardiac arrhythmia (13.0%), and pump thrombosis with pump replacement (4.3%). All patients were discharged from hospital after LVAD implantation. Three patients experienced driveline infections during outpatient follow-up. There were 19 readmissions due to the following conditions: sub-therapeutic anticoagulation (13.0%), gastrointestinal bleeding (13.0%), suspected pump thrombosis (13.0%), transient ischemic attack (8.7%), arrhythmia (8.7%), congestive cardiac failure due to severe aortic regurgitation (8.7%), right ventricular failure (4.3%), rhabdomyolysis (4.3%), and hematuria (4.3%). Post-LVAD implantation, 20 patients were functionally New York Heart Association (NYHA) class I, while 3 reported NYHA III symptoms. Three patients were successfully bridged to heart transplantation. One patient was successfully explanted 11 months after LVAD implantation. There were two mortalities during the follow-up period. The average duration of LVAD support was 522 days (range 47 to 1316 days). The HeartMate II LVAD has proven to be effective in our Asian population. Driveline infection rate remains low even in the tropical hot, humid climate in Singapore. With more patients ending up on extended periods of LVAD support, increased emphasis in the detection and management of long-term complications of ventricular assist devices will be needed.

Homograft banking in Singapore: two years of cardiovascular tissue banking in Southeast Asia.

Established in 2008, the National Cardiovascular Homograft Bank (NCHB) has been instrumental in creating an available supply of cardiovascular tissues for implantation in Singapore. This article introduces its collaboration with Singapore General Hospital Skin Bank Unit. The procedure of homograft recovery, processing, cryopreservation and quality assurance are presented. Since its establishment, the NCHB has followed the guidelines set by the Ministry of Health Singapore and the American Association of Tissue Banks. A total of 57 homografts had been recovered and 40 homografts were determined to be suitable for clinical use. The most significant reasons for non-clinical use are positive microbiological culture or unsuitable graft condition. Crucial findings prompted reviews and implementation of new procedures to improve the safety of homograft recipients. These include (1) a change in antibiotic decontamination regime from penicillin and streptomycin to amikacin and vancomycin after a review and (2) mandating histopathogical examination since the discovery of cardiac sarcoidosis in a previously undiagnosed donor. Further, the NCHB also routinely performs dengue virus screening, for donors suspected of dengue infection. Cultural factors which affect the donation rate are also briefly explored. By 2010, 31 homografts had been implanted into recipients with congenital or acquired heart valve conditions. More than half of these recipients were children. Post-operative outcomes had been encouraging, with no report of adverse events attributed to implanted homografts.

Two-year outcome of ventricular assist device via a modified left atrium to aorta approach in cardiac amyloidosis.

Cardiac amyloidosis is a debilitating disease associated with poor long-term survival. Medical or palliative treatment is the usual course of therapy, but patients are often intolerant of conventional heart failure treatment. The current standard of care of sequential heart and bone marrow transplant is usually not feasible for ill or frail patients or in countries with limited organ donors or without transplant programmes. Left ventricular assist devices (LVAD) are not usually offered to these patients due to high peri-operative risks and risks of suction events with the LVAD in a small left ventricle. We report the 2 year outcome and discuss the challenges faced in the management of our patient with end-stage heart failure due to cardiac amyloidosis, who was successfully supported with an LVAD using a modified left atrium to aorta implantation technique.

Prognostic Factors for Survival After Extracorporeal Membrane Oxygenation for Cardiogenic Shock.

The aim of this study is to examine factors that can predict mortality in patients that have veno-arterial extracorporeal membrane oxygenation (VA-ECMO) instituted for cardiogenic shock. A single-center, retrospective study of 127 patients who underwent VA-ECMO for cardiogenic shock between January 2003 and December 2017 was conducted. Eighty-three (65%) patients survived to weaning or bridging therapy. Complications on VA-ECMO include: hemorrhage (40%), stroke (14%), requirement for dialysis (42%), and limb ischemia (24%). Univariate analysis revealed shorter ECMO duration, higher body mass index, preimplantation creatinine > 100 mmol/l, lower preimplantation serum albumin, and the development of stroke or limb ischemia on ECMO to be significantly associated with mortality while on ECMO. Multivariate analysis by logistic regression found shorter ECMO duration and lower preimplantation serum albumin to be significantly associated with mortality. VA-ECMO is an effective strategy in treating patients with cardiogenic shock and provides a reasonable chance of survival to weaning or bridging to other therapy. Preimplantation hypoalbuminemia, preimplantation serum creatinine > 100 mmol/l, and the development of stroke and limb ischemia while on VA-ECMO are strongly associated with mortality.

Treatment of recalcitrant air leaks: the combined latissimus dorsi-serratus anterior flap.

Pleural space problems after lung resection and persistent air leaks are among the commonest challenges posed to thoracic surgeons. Surgical repair of air leaks are indicated when conventional tube thoracostomy has failed to solve the problem. We would like to propose the novel application of the combined latissimus dorsi-serratus anterior transposition flap for selected cases of air leaks that are recalcitrant to conventional treatment. We discuss its indications and the surgical technique. Five patients underwent the procedure between 2004 and 2007. They were male patients aged between 32 and 70 years. Four patients had alveolar-pleural fistulas resulting in persistent air leaks while the fifth patient had, in addition, a space problem following lung volume reduction surgery. All patients had prolonged treatment with chest drains without success. With the patient in a lateral decubitus position, a lazy-S incision was used to expose the entire latissimus dorsi and the proximal slips of the serratus anterior muscles. They were raised as pedicled flaps and transferred in tandem. The latissimus dorsi was introduced into the pleural cavity via a thoracic window and used to reinforce the fistula repair. The serratus anterior muscle closed the rib window. In all cases, the lungs reexpanded and chest drains were removed within 5 days post surgery. There were no recurrent air leaks at 1-year follow-up with all patients. Conservative treatment in all our patients was unsuccessful. The dual flap technique has the advantage of allowing normal ventilation while providing a seal over the alveolar-pleural fistula. The muscle bulk of the latissimus dorsi fills the pleural dead space and the serratus anterior muscle seals the axilla preventing subcutaneous emphysema. There was minimal morbidity associated with the use of this dual muscle flap technique. This technique is an effective treatment option for recalcitrant air leaks.

Restrictive mitral valve annuloplasty for chronic ischaemic mitral regurgitation: outcomes of flexible versus semi-rigid rings.

BACKGROUND: Restrictive mitral annuloplasty is the mainstay of surgical correction of chronic ischaemic mitral regurgitation (CIMR). Long-term data on the various types of annuloplasty rings is limited. The aim of this study was to investigate the clinical and echocardiographic outcomes of restrictive mitral annuloplasty in patients with CIMR, comparing the use of flexible versus semi-rigid annuloplasty rings. METHODS: A retrospective review was conducted for 133 patients with CIMR who underwent restrictive mitral annuloplasty at our institution between 1999 and 2015. Patient demographics and postoperative outcomes were analyzed. RESULTS: Mean age was 61.9±9.2 years and 103 patients (77.4%) were male. All patients underwent coronary artery bypass grafting, with a mean of 3.3±0.8 grafts. Flexible rings was implanted in 39 patients (29.3%, group F) and semi-rigid rings in 94 (70.7%, group R). Preoperative New York Heart Association class was III/IV in 104 patients (78.2%). Mean preoperative left ventricular ejection fraction was 28.8%±10.2%. Preoperative mitral regurgitation was moderate in 51 patients (38.3%) and severe in 82 (61.7%). In-hospital mortality occurred in 11 patients (8.3%). Overall survival at 1, 5 and 10 years were, respectively, 86.4%, 69.7% and 45.9%. At 10 years, overall survival (group F 53.1%, group R 40.0%, P=0.330) and freedom from moderate to severe MR (group F 53.1%, group R 53.8%, P=0.725) did not differ significantly. Freedom from hospitalization for heart failure was 59.3%. Left ventricular reverse remodelling, defined as a reduction of left ventricular end-systolic volume index >15%, occurred more commonly in Group R (51.1%) compared to Group F (23.1%), P=0.003. CONCLUSIONS: Restrictive mitral annuloplasty was associated with an operative mortality of 8.3%. Heart failure symptoms and significant MR recur in approximately 40% of patients after 10 years. Survival remained suboptimal and was not influenced by the type of annuloplasty ring.

Elucidating the genomic architecture of Asian EGFR-mutant lung adenocarcinoma through multi-region exome sequencing.

EGFR-mutant lung adenocarcinomas (LUAD) display diverse clinical trajectories and are characterized by rapid but short-lived responses to EGFR tyrosine kinase inhibitors (TKIs). Through sequencing of 79 spatially distinct regions from 16 early stage tumors, we show that despite low mutation burdens, EGFR-mutant Asian LUADs unexpectedly exhibit a complex genomic landscape with frequent and early whole-genome doubling, aneuploidy, and high clonal diversity. Multiple truncal alterations, including TP53 mutations and loss of CDKN2A and RB1, converge on cell cycle dysregulation, with late sector-specific high-amplitude amplifications and deletions that potentially beget drug resistant clones. We highlight the association between genomic architecture and clinical phenotypes, such as co-occurring truncal drivers and primary TKI resistance. Through comparative analysis with published smoking-related LUAD, we postulate that the high intra-tumor heterogeneity observed in Asian EGFR-mutant LUAD may be contributed by an early dominant driver, genomic instability, and low background mutation rates.

Pulmonary sclerosing pneumocytoma with mediastinal lymph node metastasis.

Pulmonary sclerosing pneumocytoma is a rare tumour with 23 cases reported to have metastasis to lymph nodes, but to date, only 6 had involved mediastinal nodal stations. Our patient was a 40-year-old Asian female with a 2.5 cm nodule in her right lower lobe. Positron-emission tomography suggested no nodal disease; but after resection, the intra-lobular, hilar and subcarinal nodes were all found to be involved. As prognosis of this rare disease is uncertain, we aim to report our findings against available literature and similar cases.

Primary pulmonary sarcomatoid carcinoma with intracardiac extension.

Primary pulmonary sarcomatoid carcinoma is rare. It is generally regarded as an aggressive tumor. We report, to our best knowledge, the first case of pulmonary sarcomatoid carcinoma with extensive intracardiac spread. This case illustrated the misleading clinical features of this condition. Previous literature is also reviewed.

A rare case of unilateral severe bullous emphysema in a 32-year-old female.

Congenital bullous emphysema is defined as large bullae involving at least one-third of a hemithorax. We describe the case of a 32-year-old female who presented with increasing shortness of breath. Radiological investigations revealed severe emphysema with hyperexpansion of the right lung and a mediastinal shift to the left. A lung perfusion scan showed reduced perfusion in the right lung. The patient underwent a right pneumonectomy with a diagnosis of congenital bullous emphysema. She was doing well 6 years later.

Ciliated muconodular papillary tumor: a solitary peripheral lung nodule in a teenage girl.

Papillary tumors of the peripheral lung containing ciliated cells and extracellular mucin include solitary peripheral ciliated glandular papilloma, ciliated muconodular papillary tumor, and well-differentiated papillary adenocarcinoma with cilia formation. We report the case of a 19-year-old woman who was a nonsmoker and presented with an incidental small peripheral lung nodule. The resection specimen showed a soft grayish nodule. Histologic examination further revealed a relatively circumscribed mucinous nodule featuring a tubulopapillary tumor composed of ciliated columnar cells and goblet cells, accompanied with abundant extracellular mucin. No lepidic growth pattern was evident. The tumor cells were immunoreactive for cytokeratin 7, thyroid transcription factor-1, and carcinoembryonic antigen, whereas p63 and cytokeratin 5/6 highlighted the presence of basal cells. Next-generation sequencing did not identify any genetic alterations in targeted regions and mutational hotspots of a panel of 22 genes commonly implicated in lung and colon cancers. Taken together, our case was most likely a ciliated muconodular papillary tumor.

Contained Rupture in HeartMate II Outflow Graft Bend Relief Disconnection.

Thoratec recalled their HeartMate II ventricular assist device in March 2012 after some problems related to disconnection of the bend relief. Abrasion on the pump outflow graft caused by a disconnected bend relief is rare. We report the case of a 49-year-old man in whom a disconnected bend relief caused a puncture in the outflow graft, resulting in a contained hematoma, requiring outflow graft replacement.