Nonbacterial Thrombotic Endocarditis Presenting with Leg Pain and a Left Atrial Mass Lesion.

Systemic lupus erythematosus (SLE) is a major cause of nonbacterial thrombotic endocarditis (NBTE) associated with intracardiac sterile vegetations. It is rare for vegetations to present as an atrial tumor. This report describes a 48-year-old female with SLE and antiphospholipid syndrome complicated by recurrent thrombosis on anticoagulation. A large left atrial mass lesion was detected on echocardiography during a work-up for leg burning. Infective endocarditis could not be confirmed, and hence left atrial mass lesion was the most likely diagnosis. The patient was managed surgically and the pathology report revealed fibrin networks in a pattern similar to that of thrombosis, characteristic of NBTE.

The radial artery: Results and technical considerations.

BACKGROUND: The radial artery (RA) is a frequently used conduit for coronary artery bypass graft (CABG). We review the results of the use of the RA in CABG patients and discuss the unique technical considerations when using this conduit. METHODS: A literature search was performed in PubMed through December 2017 on the comparative efficacy of the RA to other conduits and technical considerations for the use of the RA in CABG surgery. RESULTS: When compared to the saphenous vein graft, the RA proved to be superior in graft patency in multiple randomized clinical trials. The RA was associated with better clinical outcomes in observational studies. The debate over the second best arterial conduit remains unresolved between the RA and the right internal thoracic artery. Preoperative evaluation of the patient's coronary anatomy and the quality of the RA is imperative to achieve the best clinical outcome with RA grafting. CONCLUSION: With careful preoperative planning and attention to technical details, the RA is an excellent choice as the second conduit for CABG surgery.

A 20-Year Experience With Resection of Primary Cardiac Tumors and Metastatic Tumors of the Heart.

BACKGROUND: Cardiac tumors are uncommon, occurring in less than 1% of the population, and are comprised of numerous tumor types. Management of certain tumors types such as sarcoma have evolved and improved in the recent era. We evaluate the outcomes of patients who underwent resection of benign or malignant cardiac tumors with a focused review of cardiac sarcomas. METHODS: Institutional data were reviewed from 1997 to 2017, and 180 patients who underwent tumor resection were identified. Outcomes and survival were examined based on tumor type. RESULTS: Two-thirds of patients (119 of 180) had benign tumors. Of 61 malignant tumors, 23 were sarcomas, 24 were cavoatrial tumors, and 8 were T4 lung tumors. In the sarcoma group, operative mortality was 2 of 23 (9.1%). Neoadjuvant therapy was administered to 8 of 23 patients (34.8%) with R0 resection achieved in 5 of 8 patients (62.5%). R0 resection was successful in 7 of 15 patients (46.7%) without neoadjuvant therapy. Mean survival with neoadjuvant therapy was 2.76 ± 3.85 years versus 1.28 ± 1.31 years without neoadjuvant therapy (p = 0.428). Mean survival with R0 resection was 2.79 ± 4.23 years compared with 1.64 ± 1.63 years without (p = 0.407). In the T4 lung tumor group, operative mortality was zero and R0 resection was achieved in 6 of 8 (75%). The cavoatrial tumors were mostly renal cell carcinoma resected with a mortality of 4.5%. CONCLUSIONS: Cardiac tumors are comprised of diverse tumor types. Indications for, and benefits of, resecting benign tumors and many malignant tumor types are clear, and operative outcomes are generally good. Cardiac sarcomas benefit from neoadjuvant therapy, which improves the rate of complete resection, thus improving survival.

High-dose versus low-dose opioid anesthesia in adult cardiac surgery: A meta-analysis.

STUDY OBJECTIVE: We performed a systematic comparison of high-dose and low-dose opioid anesthesia in cardiac surgery. DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING: Operating room. PATIENTS: 1400 adult patients undergoing cardiac surgery using general anesthesia. INTERVENTIONS: All RCTs comparing the effects of various doses of intravenous opioids (morphine, fentanyl, sufentanil, and remifentanil) during adult cardiac surgery using general anesthesia published until May 2018 (full-text English articles reporting data from human subjects) were included. MEASUREMENTS: Primary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes were ventilation time, use of vasopressors, perioperative myocardial infarction, perioperative stroke, and hospital LOS. MAIN RESULTS: Eighteen articles were included (1400 patients). There was no difference in ICU LOS between studies using high or low dose of opioids (both short-acting and long-acting) (standard mean difference [SMD]-0.02, 95%CI: -0.15-0.11, P = 0.74). Similarly, there was no difference in secondary outcomes of ventilation time (SMD-0.27, 95%CI: -0.63-0.09, P = 0.14), use of vasopressors (OR 0.61, 95%CI: 0.29-1.30, P = 0.20), myocardial infarction (risk difference 0.00, 95% CI: -0.02-0.03, P = 0.70), stroke (RD 0.00, 95% CI: -0.01-0.01, P = 0.92) and hospital LOS (SMD 0.03, 95% CI: -0.26-0.33, P = 0.84). At meta-regression, there was no effect of age, gender, or type of opioid on the difference between groups. CONCLUSIONS: Our data suggest that low-dose opioids, both short acting and long acting, are safe and effective to use in adult cardiac surgery patients, independent of the clinical characteristics of the patients and the type of opioid used. In view of the current opioid epidemic, low-dose opioid anesthesia should be considered for cardiac surgery patients.

Single Versus Multi-Incisional Video-Assisted Thoracic Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Video-Assisted Thoracic Surgery (VATS) is conventionally performed through multiple small incisions (C-VATS). Recent studies have reported encouraging results with the single-incision VATS (S-VATS) over the conventional technique. However, these studies were either small in size, unfocused, nonuniform, retrospective, lacking follow-up information, or focused on pain. We aim to validate previously reported results in a single large meta-analysis, including only the best evidence studies available. METHODS: Systematic review of the PubMed archive was conducted to include only full English articles with Newcastle Ottawa Scale score ≥7. The primary outcome was the complications rate while secondary outcomes were operative time, resected lymph nodes (LNs), chest tube duration, estimated blood loss, length of postoperative stay (LOS), and postoperative pain on day 1 after surgery. Odds ratio and standard mean difference were used as effect estimates. Random model and leave-one-out analysis were used. RESULTS: A total of 39 studies were included with 4635 patients (1686 S-VATS versus 2949 C-VATS). S-VATS has resulted in significantly less postoperative pain (P < .001), blood loss (P = .006), LOS (P < .001), and chest tube duration (P < .001). In lung cancer patients, the number of retrieved LNs was similar to that of C-VATS (P > .05). Subgroup comparison of the rate of complications between lung resections versus other intrathoracic procedures, lung cancer versus pneumothorax, and lung cancer versus other lung-only lesions did not show any significant differences between the groups. CONCLUSION: Performing S-VATS technique has shown superior postoperative outcomes over the C-VATS technique in the treatment of thoracic disorders. Substantial benefit was confirmed in terms of less postoperative pain, blood loss, drainage time, and postoperative hospital stay.

Bilateral internal thoracic artery use in coronary bypass surgery: is there a benefit?

PURPOSE: Over the past three decades, there have been a plethora of retrospective observational data and meta-analyses which support the hypothesis of improved clinical outcomes using bilateral internal thoracic arteries (BITA) when compared to saphenous vein grafts (SVGs). However, recently published results have brought this thinking into doubt. We discuss the existing literature on the subject and attempt to clarify the appropriate use of BITA in coronary artery bypass surgery (CABG). METHODS: A review of all existing meta-analyses on BITA was conducted to better understand the utility of BITA in CABG. A review of the largest randomized controlled trials on the subject was then compared to the observational data. RESULTS: In all existing meta-analyses, BITA shows a significant advantage over the use of a single internal thoracic artery (SITA) with SVGs. The two largest randomized controlled trials evaluating BITA failed to show a survival advantage and brought into question the complications associated with BITA. CONCLUSIONS: At present, the use of multiple arterial grafts remains a reasonable choice, particularly in young patients, provided that their use does not increase the operative risk. Further evidence currently being collected may lend a definitive answer in the near future.

Unmeasured Confounders in Observational Studies Comparing Bilateral Versus Single Internal Thoracic Artery for Coronary Artery Bypass Grafting: A Meta-Analysis.

BACKGROUND: Observational studies suggest a survival advantage with bilateral single internal thoracic artery (BITA) versus single internal thoracic artery grafting for coronary surgery, whereas this conclusion is not supported by randomized trials. We hypothesized that this inconsistency is attributed to unmeasured confounders intrinsic to observational studies. To test our hypothesis, we performed a meta-analysis of the observational literature comparing BITA and single internal thoracic artery, deriving incident rate ratio for mortality at end of follow-up and at 1 year. We postulated that BITA would not affect 1-year survival based on the natural history of coronary artery bypass occlusion, so that a difference between groups at 1 year could not be attributed to the intervention. METHODS AND RESULTS: We searched MEDLINE and Pubmed to identify all observational studies comparing the outcome of BITA versus single internal thoracic artery. One-year and long-term mortality for BITA and single internal thoracic artery were compared in the propensity-score-matched (PSM) series, that is, the form of observational evidence less prone to confounders. Thirty-eight observational studies (174 205 total patients) were selected for final comparison. In the 12 propensity-score-matched series (34 019 patients), the mortality reduction for BITA was similar at 1 year and at the end of follow-up (incident rate ratio, 0.70; 95% confidence interval, 0.60-0.82 versus 0.77; 95% confidence interval, 0.70-0.85; P for subgroup difference=0.43). CONCLUSIONS: Unmeasured confounders, rather than biological superiority, may explain the survival advantage of BITA in observational series.

Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies.

BACKGROUND: The effect of high transfusion ratios of fresh frozen plasma (FFP): packed red blood cell (RBC) on mortality is still controversial. Observational evidence contradicts a recent randomized controlled trial regarding mortality benefit. This is an updated meta-analysis, including a non-trauma cohort. METHODS: Patients were grouped into high vs. low based on FFP:RBC ratio. Primary outcomes were 24-h and 30-day/in-hospital mortality. Secondary outcomes were acute respiratory distress syndrome and acute lung injury rates. Random model and leave-one-out-analyses were used. RESULTS: In 36 studies, lower ratio showed poorer 24-h and 30-day survival (p < 0.001). In trauma and non-trauma settings, a lower ratio was associated with worse 24-h and 30-day mortality (P < 0.001). A ratio of 1:1.5 provided the largest 24-h and 30-day survival benefit (p < 0.001). The ratio was not associated with ARDS or ALI. CONCLUSIONS: High FFP:RBC ratio confers survival benefits in trauma and non-trauma settings, with the highest survival benefit at 1:1.5.

Totally endoscopic coronary artery bypass surgery: A meta-analysis of the current evidence.

BACKGROUND: Totally endoscopic coronary artery bypass (TECAB) has emerged as an alternative to other minimally invasive techniques. However, limited TECAB results are available to date. The purpose of this systematic review is to examine the existing literature to give an objective estimate of the outcomes of TECAB using a meta-analytical approach. METHODS: A comprehensive online review was performed in Ovid MEDLINE®, Ovid EMBASE and The Cochrane Library from 2000 to July 2017. Eligible studies included single arm TECAB studies as well as comparative studies (TECAB vs minimally invasive direct coronary artery bypass (MIDCAB)). Pooled event rates and odds ratios (ORs) for operative mortality, perioperative myocardial infarction (MI), perioperative stroke, graft patency and repeat revascularization were estimated. Single arm and pairwise comparisons were performed. RESULTS: Seventeen single arm TECAB articles (3721 patients, weighted mean follow-up 3.3years) were included. The pooled event rate was 0.80% (95%CI: 0.60-1.2%) for operative mortality, 2.28% (95%CI: 1.7-3%) for perioperative MI, 1.50% (95%CI: 1.1-2.0%) for perioperative stroke, 2.99% (95%CI: 1.6-5.4%) for repeat revascularization and 94.8% (95%CI: 89.3-97.5%) for early graft patency (weighted mean follow-up 10.1months). On pairwise meta-analysis 376 patients (263 TECAB and 113 MIDCAB) were included. No difference in operative mortality (OR=0.25, 95%CI: 0.02-2.83), perioperative MI (OR=3.09, 95%CI: 0.37-26.12) or perioperative stroke (OR=1.33, 95%CI: 0.17-10.26) was found between the two techniques. CONCLUSIONS: TECAB has an acceptably low operative risk and a good early patency rate. The incidence of perioperative MI requires further investigation. The dearth of data comparing TECAB to open approaches compels the need for future comparative trials.

Current Solutions for Long-Segment Tracheal Reconstruction.

This article is a continuation of previous reviews about the appropriate method for long-segment tracheal reconstruction. We attempted to cover the most recent, successful and promising results of the different solutions for reconstruction that are rather innovative and suitable for imminent clinical application. Latest efforts to minimize the limitations associated with each method have been covered as well. In summary, autologous and allogenic tissue reconstruction of the trachea have been successful methods for reconstruction experimentally and clinically. Autologous tissues were best utilized clinically to enhance revascularization, whether as a definitive airway or as an adjunct to allografts or tissue-engineered trachea (TET). Allogenic tissue transplantation is, currently, the most suitable for clinical application, especially after elimination of the need for immunosuppressive therapy with unlimited supply of tissues. Similar results have been reported in many studies that used TET. However, clinical application of this method was limited to use as a salvage treatment in a few studies with promising results. These results still need to be solidified by further clinical and long-term follow-up reports. Combining different methods of reconstruction was often required to establish a physiological rather than an anatomical trachea and have shown superior outcomes.

Posterior Left pericardiotomy for the prevention of postoperative Atrial fibrillation after Cardiac Surgery (PALACS): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. POAF is associated with increased morbidity and hospital costs. We herein describe the protocol for a randomized controlled trial to determine if performing a posterior left pericardiotomy prevents POAF after cardiac surgery. METHODS/DESIGN: All patients submitted to cardiac surgery at our institution will be screened for inclusion into the study. The study will consist of two parallel arms with random allocation between groups to either receive a posterior left pericardiotomy or serve as a control. Masking will be done in a single-blinded fashion to the patient. Patients will be continuously monitored postoperatively for the occurrence of atrial fibrillation until discharge. At the follow-up clinic visit (15-30 days after surgery), the primary endpoint (atrial fibrillation) and other secondary endpoints, such as pleural or pericardial effusion, will be assessed. A total sample size of 350 subjects will be recruited. DISCUSSION: POAF is associated with increased morbidity, prolonged hospital stay, and increased costs after cardiac surgery. Several strategies aimed at reducing the incidence of POAF have been investigated, including beta-blockers, amiodarone, and statins, all with suboptimal results. Posterior left pericardiotomy has been associated with a reduction of POAF in previous series. However, these studies had limited sample sizes and suboptimal methodology, so that the efficacy of posterior pericardiotomy in preventing POAF remains to be definitively proven. Our randomized trial aims to determine the effect of a posterior left pericardiotomy on the incidence of POAF. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02875405 , protocol record 1502015867. Registered on July 2016.