Outcomes of pericardiectomy for constrictive pericarditis following mediastinal irradiation.

BACKGROUND: Pericardiectomy for postradiation constrictive pericarditis has been reported to generally have unfavorable outcomes. This study sought to evaluate surgical outcomes in a large cohort of patients undergoing pericardiectomy for radiation-associated pericardial constriction. METHODS: A retrospective analysis of all patients (≥18 years) who underwent pericardiectomy for a diagnosis of constrictive pericarditis with a prior history of mediastinal irradiation from June 2002 to June 2019 was conducted. There were 100 patients (mean age 57.2 ± 10.1 years, 49% females) who met the inclusion criteria. Records were reviewed to look at the surgical approach, the extent of resection, early mortality, and late survival. RESULTS: The overall operative mortality was 10.1% (n = 10). The rate of operative mortality decreased over the study period; however, the test of the trend was not statistically significant (p = .062). Hodgkin's disease was the most common malignancy (64%) for which mediastinal radiation had been received. Only 27% of patients had an isolated pericardiectomy, and concomitant pericardiectomy and valve surgery were performed in 46% of patients. Radical resection was performed in 50% of patients, whereas 47% of patients underwent subtotal resection. Prolonged ventilation (26%), atrial fibrillation (21%), and pleural effusion (16%) were the most common postoperative complications. The overall 1, 5-, and 10-years survival was 73.6%, 53.4%, and 32.1%, respectively. Increasing age (hazard ratio, 1.044, 95% confidence interval 1.017-1.073) appeared to have a significant negative effect on overall survival in the univariate model. CONCLUSION: Pericardiectomy performed for radiation-associated constrictive pericarditis has poor long-term outcomes. The early mortality, though high (~10%), has been showing a decreasing trend in the test of time.

Impact of postoperative complications after cardiac surgery on long-term survival.

PURPOSE: The impact of postoperative complications on long-term survival is not well characterized. We sought to study the prevalence of postoperative complications after cardiac surgery and their impact on long-term survival. METHODS: Operative survivors (n = 26,221) who underwent coronary artery bypass grafting (CABG) (n = 13,054, 49.8%), valve surgery (n = 8667, 33.1%) or combined CABG and valve surgery (n = 4500, 17.2%) from 1993 to 2019 were included in the study. Records were reviewed for postoperative complications and long-term survival. Propensity-match analysis was performed between patients who did and did not have a postoperative complication. The associations between postoperative complications and survival were assessed using a Cox-proportional model. RESULTS: Complications occurred in 17,463 (66.6%) of 26,221 operative survivors. A total of 17 postoperative complications were analyzed. Postoperative blood product use was the commonest (n = 12,397, 47.3%), followed by atrial fibrillation (n = 8399, 32.0%), prolonged ventilation (n = 2336, 8.9%), renal failure (n = 870, 3.3%), reoperation for bleeding (n = 859, 3.3%) and pacemaker/ICD insertion (n = 795, 3.0%). Stroke (hazard ratio [HR]: 1.55; 95% confidence interval [CI]: 1.36-1.77), renal failure (HR: 1.45; 95% CI: 1.33-1.58) and pneumonia (HR: 1.23; 95% CI: 1.11-1.36) had the strongest impact on long-term survival. Long-term survival decreased as the number of postoperative complications increased. CONCLUSIONS: Postoperative complications after cardiac surgery significantly impact outcomes that extend beyond the postoperative period. Stroke, renal failure, and pneumonia are particularly associated with poor long-term survival.

Gender representation among speaking and leader roles at European cardio-thoracic surgical annual meetings.

OBJECTIVES: Our goal was to evaluate gender representation among session leaders and abstract presenters at European cardio-thoracic surgical annual meetings. METHODS: We did a descriptive study of the gender distribution among session leaders and abstract presenters at 2 European cardio-thoracic international meetings from 2017 to 2022. Data from publicly available programmes were used to generate a list of session leaders and abstract presenters. The primary outcome was to evaluate the proportion of female sessions leaders at the annual meetings. Descriptive analyses were performed including the Cochran-Armitage trend test for linear trend of proportions. RESULTS: A total of 1025 sessions of 11 annual meetings of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Thoracic Surgeons were examined. A total of 397 (13.2%) out of 3007 total session leaders and 955 (15.2%) out of 6251 abstract presenters were female. From 2017 to 2022, the proportions of both female session leaders and abstract presenters trended significantly [10.4% to 21.9% (P < 0.001) and 13.7% to 18.3% (P < 0.001), respectively]. The EACTS female members and female meeting attendees significantly increased from 2017 to 2022 [11.1% to 15.9% (P < 0.001) and 23.7% to 26.9% (P < 0.001)], respectively. Most of the women attendees at the EACTS and the European Society of Thoracic Surgeons meetings who were session leaders and speakers came from Germany, Italy, the United Kingdom and the United States. CONCLUSIONS: Women are under-represented compared to men in leadership and speaking roles at European cardio-thoracic surgical annual meetings. In the past few years, an encouraging positive trend over time for female leadership roles has been noted; as a result, the proportion of female society members is represented at the annual meetings. However, a substantial gender gap still exists in leading roles of meeting attendees.

Ten-Year Experience with Endomyocardial Biopsy after Orthotopic Heart Transplantation: Comparison between Trans-Jugular and Trans-Femoral Approach.

BACKGROUND: Endomyocardial biopsy (EMB) is considered the gold standard for monitoring allograft rejection after heart transplantation. EMB is an invasive procedure that may be performed via a trans-jugular or a trans-femoral approach with a complication rate reported as less than 6%. The aim of this study was to evaluate the complication rate after EMBs in heart recipients and to compare the results of EMBs performed via a trans-jugular or a trans-femoral approach. METHODS: Medical records of heart recipients undergoing EMBs between January 2012 and December 2022 were retrospectively reviewed. EMB-related complications were classified as major (death, pericardial effusion, hemopericardium, cardiac tamponade requiring a pericardiocentesis or an urgent cardiac surgery, ventricular arrythmias, permanent atrio-ventricular block requiring permanent pacing, hemothorax, pneumothorax and retroperitoneal bleeding) and minor (de novo tricuspid regurgitation, arrhythmias, coronary artery fistula, vascular access site complications). RESULTS: A total of 1698 EMBs were performed during the study period at our institution in 212 heart recipients. There were 927 (55%) EMBs performed through a trans-jugular approach (TJ group) and 771 (45%) EMBs performed through a trans-femoral approach (TF group). A total of 60 (3.5%) complications were recorded, including nine (0.5%) major complications (six cardiac tamponades, two pneumothorax and one retroperitoneal bleeding) and 51 (3%) minor complications (seven coronary fistulae, five de novo tricuspid regurgitation, four supraventricular arrythmias and thirty-five vascular access site complications). No difference was found in total (38 [4%] vs. 22 [3%]; p = 0.16) and major (6 [1%} vs. 3 [0.4%]; p = 0.65) complications (32 [3%] vs. 19 [2%]; p = 0.23) between the TJ group and the TF group. No difference was found in male sex, age at time of EMB and time from HT between complicated and not complicated EMBs. CONCLUSIONS: EMBs represent a safe procedure with a low risk of complications. In our experience, EMBs performed via a trans-jugular approach are as safe as the trans-femoral approach.

Validation of RayStation Monte Carlo dose calculation algorithm for multiple LINACs.

PURPOSE: A photon Monte Carlo (MC) model was commissioned for flattened (FF) and flattening filter free (FFF) 6 MV beam energy. The accuracy of this model, as a single model to be used for three beam matched LINACs, was evaluated. METHODS: Multiple models were created in RayStation v.10A for three linacs equipped with Elekta "Agility" collimator. A clinically commissioned collapsed cone (CC) algorithm (GoldCC), a MC model automatically created from the CC algorithm without further optimization (CCtoMC) and an optimized MC model (GoldMC) were compared with measurements. The validation of the model was performed by following the recommendations of IAEA TRS 430 and comprised of basic validation in a water tank, validation in a heterogeneous phantom and validation of complex IMRT/VMAT paradigms using gamma analysis of calculated and measured dose maps in a 2D-Array. RESULTS: Dose calculation with the GoldMC model resulted in a confidence level of 3% for point measurements in water tank and heterogeneous phantom for measurements performed in all three linacs. The same confidence level resulted for GoldCC model. Dose maps presented an agreement for all models on par to each other with γ criteria 2%/2mm. CONCLUSIONS: The GoldMC model showed a good agreement with measured data and is determined to be accurate for clinical use for all three linacs in this study.

Special Issue "New Perspectives in Cardiovascular Surgery".

In recent decades, cardiovascular surgery has been making great strides in the field of medicine [...].

Mitral Valve Repair vs Replacement in Patients with Previous Mediastinal Irradiation.

Long-term outcomes of mitral valve surgery after mediastinal radiation therapy (MRT) are not well characterized. We analyzed long-term survival in patients who underwent mitral valve repair or replacement after MRT. From 2001 to 2018, 148 patients underwent mitral valve surgery at our institution after MRT for cancer. The association between surgery group and survival was assessed using Cox proportional hazards modeling, with propensity score adjustment to control for clinical and operative differences between groups. Mitral valve was repaired in 48 (32.4%) and replaced in 100 (67.6%) patients. The groups (repair vs replacement) were similar in age (62.0 vs 57.1 years, p = 0.10), gender (female n = 38, 79.2% vs n = 65, 65%, p = 0.08), chronic lung disease (n = 12, 25.0% vs n = 37, 37.0%, p = 0.19), congestive heart failure (n = 13, 27.1% vs n = 38, 38.4%, p = 0.20), but differed in atrial fibrillation (n = 17, 35.4% vs n = 13, 13.0%, p = 0.002), first cardiovascular surgery (n = 34, 70.8% vs n = 47, 47.0%, p = 0.006), and time since MRT (median 12, 7-27 years, vs 30, 19-37 years, p < 0.001). Long term survival was no different between groups in the unadjusted (p = 0.835) and propensity-adjusted (p = 0.645) analysis, and inferior to the expected survival of an age- and sex-matched population. Mediastinal irradiation negatively impacts survival in patients who undergo mitral valve surgery. The traditional advantage of mitral valve repair over replacement on long-term survival was not seen in patients with radiation associated mitral valve disease.

Calcified Left Ventricular Pseudoaneurysm of the Base of the Heart.

Cardiac pseudoaneurysms of noninfectious or nonischemic etiology are rare. This case report illustrates the surgical management of a patient with a large postsurgical calcified pseudoaneurysm located in the base of the heart that was disrupting the continuity between the aortic and mitral annulus.

Safety and Early Oncologic Outcomes of Lung Resection in Patients with Isolated Pulmonary Recurrent Prostate Cancer: A Single-center Experience.

The introduction of novel imaging approaches for recurrent prostate cancer (PC) has paved the way for the use of nonsystemic approaches in patients with recurrent disease. While use of surgery or radiotherapy is standard for men with nodal or bone recurrence only, there are no significant data on the possible curative role of surgery for pulmonary metastases. We aimed to assess the efficacy of lung resection in patients with isolated pulmonary recurrence after radical prostatectomy (RP) for clinically localized PC. Overall, nine patients with biochemical recurrence after RP and either single (n=4) or multiple (n=5) pulmonary uptake spots on fluorodeoxyglugose, choline, or prostate-specific membrane antigen positron emission tomography/computed tomography underwent a total of 20 lung resections between 2011 and 2017 at our institution. No postoperative complications occurred. After lung resection, seven of the nine patients experienced a biochemical response (defined as prostate-specific antigen <0.2ng/ml at 40d after surgery). All patients except for one were free of clinical recurrence (CR) at median follow-up of 23mo. One patient experienced CR and received androgen deprivation therapy at the time of bone recurrence. Although larger prospective studies are needed, our series demonstrates that surgical resection of isolated pulmonary metastases is safe and effective in selected PC patients with recurrent disease.

Evaluation of the effectiveness of novel single-intervention adaptive radiotherapy strategies based on daily dose accumulation.

Parotid gland (PG) shrinkage and neck volume reduction during radiotherapy of head and neck (H&N) cancer patients is a clinical issue that has prompted interest in adaptive radiotherapy (ART). This study focuses on the difference between planned dose and delivered dose and the possible effects of an efficient replanning strategy during the course of treatment. Six patients with H&N cancer treated by tomotherapy were retrospectively enrolled. Thirty daily dose distributions (DMVCT) were calculated on pretreatment megavoltage computed tomography (MVCT) scans. Deformable Image Registration which matched daily MVCT with treatment planning kilovoltage computed tomography was performed. Using the resulting deformation vector field, all daily DMVCT were deformed to the planning kilovoltage computed tomography and resulting doses were accumulated voxel per voxel. Cumulative DMVCT was compared to planned dose distribution performing γ-analysis (2 mm, 2% of 2.2 Gy). Two single-intervention ART strategies were executed on the 18th fraction whose previous data had suggested to be a suitable timepoint for a single replanning intervention: (1) replanning on the original target and deformed organ at risks (OARs) (a "safer" approach regarding tumor coverage) and (2) replanning on both deformed target and deformed OARs. DMVCT showed differences between planned and delivered doses (3D-γ 2mm/2%-passing rate = 85 ± 1%, p < 0.001). Voxel by voxel dose accumulation showed an increase in average dose of warped PG of 3.0 Gy ± 3.3 Gy. With ART the average dose of warped PG decreased by 3.2 Gy ± 1.7 Gy in comparison to delivered dose without replanning when both target and OARs were deformed. Average dose of warped PG decreased by 2.0 Gy ± 1.4 Gy when only OARs were deformed. Anatomical variations lead to increased doses to PGs. Efficient single-intervention ART-strategies with replanning on the 18th MVCT result a reduced PG dose. A strategy with deformation of both target and OAR resulted in the lowest PG dose, while formally maintaining PTV coverage. Deformation of only OAR nevertheless reduces PG dose and has less uncertainties regarding PTV coverage.