Comparative clinical experience of subcostal VATS versus conventional uniportal lateral VATS approach.

INTRODUCTION: The present study reports the first clinical experience with subcostal uniportal VATS (suVATS) compared with the conventional lateral uniportal VATS (luVATS) approach. PATIENTS AND METHODS: All patients who underwent suVATS between January 2019 and April 2020 were included. Patients who had undergone luVATS for similar indications were included as the control group. The data were prospectively and retrospectively analysed. RESULTS: The suVATS group included 38 patients with a mean age of 61 (30-83) years. The luVATS group included 33 patients (mean age, 69 years; range: 46-89 years). An intercostal block was performed intraoperatively in the luVATS group. Local infiltration under anaesthesia was performed around the incision in the suVATS group. The duration of the surgery was significantly longer in the suVATS group. However, the chest tube treatment and hospital stay duration were significantly shorter in the suVATS group. The routinely recorded Visual Analogue Scale scores on the first post-operative day and the day of discharge were significantly lower in the suVATS group. CONCLUSION: Subcostal uniportal VATS enables a shorter drainage treatment duration and hospital stay and significantly reduces post-operative pain. Thus, a faster patient recovery can be achieved.

Clinical Outcome in Patients with Nosocomial COVID-19 Infection After Thoracic Surgery.

In the present study, we retrospectively evaluated outcomes in 8 patients (mean age 67 ± 7, range 55-77 years; male/female 7/1) who acquired nosocomial COVID-19 infection postoperatively out of the 39 adults who underwent elective thoracic surgery in November 2020. All patients were tested negative for COVID-19 on admission. The mortality rate in the eight patients was 25%. The surviving six patients were discharged in a good clinical condition. Fatal outcomes were due to the development of severe and unrelenting acute respiratory distress syndrome (ARDS) and were associated with preoperatively reduced serum albumin (<3 g/dL), an open surgical approach, oxygen saturation <90% at the time of COVID-19 diagnosis, and the real-time PCR cycle threshold (Ct) value <20. A high mortality rate indicates a need for systematic and frequent COVID-19 screening in patients scheduled for elective thoracic surgery and the use of minimally invasive procedures whenever feasible.

Long-term follow-up of patients supported with the HeartWare left ventricular assist system.

The aim of the present study is to report our long-term experience with the HeartWare Ventricular Assist System (HVAD). Between July 2009 and February 2018, a total of 103 patients (mean age 50.0 ± 14.4, range 28-74 years; 22 females) received HVAD implantation in a single center institution. A total of 26 (25.4%) patients were in cardiogenic shock preoperatively and received extracorporeal life support (ECLS) prior to HVAD implantation. The aim of left ventricular assist device (LVAD) implantation was bridge to transplantation (BT) in 59 (57.3%), destination therapy (DT) in 28 (27.2%), and bridge to decision in 16 (15.5%). There were 211.1 total patient years of support. Mean survival was 2.05 ± 2.14 years. Kaplan-Meier analysis showed an overall survival rate of 69.7%, 56.7%, 46.0%, and 25.0% at 1, 2, 4, and 8 years, respectively. A total of 23 patients (22.3%) died during the hospital stay. Of them 65.2% (15 patients) were preoperatively in cardiogenic shock (INTERMACS 1). Sub-analysis of the BT patients showed a mean survival of 2.45 ± 2.29 years with a survival rate of 85.1%, 75.1%, 67.2%, and 44.8% at 1, 2, 4, and 8 years, respectively. Among them, 20 patients received heart transplantation on follow-up. Mean survival of DT patients was 2.18 ± 1.91 years with a survival rate of 67.9%, 49.0%, and 25.1% at 1, 2, and 4 years, respectively. At latest follow-up in September 2018, 26 patients (25.24%) were still on LVAD. A total of five patients completed 6 years on LVAD, of them two were supported over 8 years. The most common adverse event reported was gastrointestinal bleeding requiring rehospitalization (0.161 EPPY). A total of 19 patients reported disabling stroke. Pump thrombosis was diagnosed in six patients (5.8%) (0.02 EPPY), of them four patients underwent pump exchange. To the best of our knowledge, this is the longest experience with HVAD reported so far. Patients supported with an HVAD show a satisfactory long-term survival. Further multicenter evaluations are needed to confirm these single-center results.

Lung volume reduction surgery: from National Emphysema Treatment Trial to non-intubated awake video-assisted thoracoscopic surgery.

Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.