A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study.

BACKGROUND: Currently, most thoracic surgeons perform surgical pleurodesis for recurrent spontaneous pneumothorax (RSP) by video-assisted thoracic surgery (VATS). However, the superiority of VATS over axillary minithoracotomy is not been established in prospective studies to date. A modified two-port VATS technique and axillary minithoracotomy were prospectively evaluated for possible differences in the short- and long-term outcome for patients. METHODS: In this study, 66 consecutive patients underwent surgical pleurodesis for RSP through either a modified two-port VATS procedure (group A, 33 patients) or axillary minithoracotomy (group B, 33 patients). According to the study design (NCT01192217), the patients were randomly assigned to the two groups, which were similar in terms of age and body mass index. One-lung ventilation time, histology of the available lung parenchyma specimens, early postoperative complications, length of chest tube drainage and hospital stay, recurrence rate, and a score for patient satisfaction with treatment based on the sum of postoperative pain, dependent-arm mobilization, and return to full activity subscores were evaluated. The follow-up period varied from 3 to 53 months (median, 30 months). RESULTS: The one-lung ventilation and operating times were significantly longer (p < 0.001) in group A than in group B. The overall detection of blebs, bulla, or both was 51.5% in group A and 63.8% in group B. The recurrence rate, complication rate, postoperative chest tube drainage duration, postoperative hospital stay, and incidence of chronic pain did not differ between the two groups. The score for patient satisfaction with treatment was significantly higher in group A than in group B (p < 0.001) according the subscores for better dependent-arm mobilization and return to full activity. CONCLUSIONS: Axillary minithoracotomy and VATS are equally effective for the treatment of RSP, although the rate for resection of blebs, bulla, or both is higher with the axillary minithoracotomy procedure. Although VATS is more time consuming, it offers to the patient more satisfaction with treatment.

Atypical atrial myxomas in two asymptomatic patients: a case report.

BACKGROUND: Atypical cardiac myxomas are a rare occurrence and may present with a variety of clinical manifestations depending on the morphology and location. CASE PRESENTATION: Two cases of cardiac myxomas atypically located in asymptomatic patients, diagnosed by transthoracic and transoesophageal echocardiography, are presented. In the first case a myxoma is located under the anterior mitral valve leaflet and in the second case a myxoma is located in the right atrium. CONCLUSION: We emphasize the leading role of transthoracic and transoesophageal echocardiography in the diagnosis of intracavitary cardiac tumours.

C-reactive protein/interleukin-6 ratio as marker of the size of the uncomplicated thoracic aortic aneurysms.

OBJECTIVES: The role of C-reactive protein (CRP) and interleukin-6 (IL-6) as markers in the prognosis of asymptomatic thoracic aortic aneurysm (TAA) patients has not been well established. As such, we evaluated a group of patients for a possible association between serum CRP and IL-6 and aneurysm dimension. METHODS: Serum CRP and IL-6 were determined and aneurysmal size was measured in 26 patients with TAA. RESULTS: The mean (SD) CRP and IL-6 were 0.58 (1.07) and 7.47 (17.78) pg/ml, respectively. Serum CRP, IL-6 and the ratio CRP/IL-6 correlated with the descending aortic aneurysmal dimension (r = 0.426, r = 0.743 and r = 0.328, respectively). A significant correlation was also found between values of the ratio above 0.8 and aneurysmal dimension (both ascending and descending aneurysms) (r = 0.785). Additionally, a significant association between smoking, age group above 69 years and dyslipidemia and aneurysm dimension was established (P = 0.002, P = 0.061 and P = 0.070, respectively). CONCLUSIONS: This report shows that serum CRP, IL-6 levels and the ratio CRP/IL-6 are associated with descending aortic aneurysmal dimensions. Also values of the ratio CRP/IL-6 above 0.8 are associated with aneurysmal dimensions for both ascending and descending aortic aneurysms. It is still early to establish the clinical significance of those findings, and further studies with larger groups of patients with longer follow-up are required in order to truly assess the usefulness of the serum CRP and IL-6 as markers in relation to the progression of the disease.

Coronary ostial stenosis after aortic valve replacement: successful treatment of 2 patients with drug-eluting stents.

Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.

Acute mechanical prosthetic valve thrombosis after initiating oral anticoagulation therapy. Is bridging anticoagulation with heparin required?

Prosthetic valve thrombosis (PVT) represents a serious and potentially lethal complication. It can be attributed more frequently to inadequate anticoagulant therapy. We present a case of acute aortic mechanical valve thrombosis six months after implantation. The patient discontinued oral anticoagulation after being discharged following the primary operation. Two days after reinitiating warfarin as an outpatient, he developed acute valve thrombosis presenting with symptoms and signs of cardiac failure. He was managed with intravenous thrombolysis with a recombinant plasminogen activator which resulted in immediate resolution of thrombus and clinical improvement. A paradox procoagulant effect of warfarin is evident on the first one or two days after initiation of therapy. A 'bridging' protocol with unfractionated or low molecular weight heparin (LMWH) should be considered, according to recently published guidelines, until warfarin reaches therapeutic levels and exerts an antithrombotic effect.

Repair of aortic coarctation in an adult by direct aortoplasty.

Various techniques have been proposed for surgical correction of aortic coarctation in adults. We describe direct aortoplasty repair in a 28-year-old woman with native coarctation. Four-year follow-up with magnetic resonance angiography confirmed a good result. This is a safe and effective technique that provides enlargement of the aortic lumen by avoiding extensive anastomotic suture lines or interposition of prosthetic graft material.

Serum levels of matrix metalloproteinases -1,-2,-3 and -9 in thoracic aortic diseases and acute myocardial ischemia.

BACKGROUND: Matrix metalloproteinases (MMPs) constitute a family of zinc-dependent proteases (endopeptidases) whose catalytic action is the degradation of the extracellular matrix components. In addition, they play the major role in the degradation of collagen and in the process of tissue remodeling. The present clinical study investigated blood serum levels of metalloproteinases- 1, -2, -3 and -9 in patients with acute and chronic aortic dissection, thoracic aortic aneurysm and acute myocardial ischemia compared to healthy individuals. METHODS: The blood serum levels of MMP-1, -2, -3 and -9 were calculated in 31 patients with acute aortic dissection, 18 patients with chronic aortic dissection, 18 patients with aortic aneurysm and in 13 patients with acute myocardial ischemia, as well as in 15 healthy individuals who served as the control group. Serum MMP levels were measured by using an ELISA technique. RESULTS: There were significantly higher levels of MMP-3 in patients with acute myocardial ischemia as compared to acute aortic dissection (17.33 +/- 2.03 ng/ml versus 12.92 +/- 1.01 ng/ml, p < 0.05). Significantly lower levels of MMP-1 were found in healthy controls compared to all groups of patients (1.1 +/- 0.38 ng/ml versus 2.97 +/- 0.68 in acute aortic dissection, 3.09 +/- 0.98 in chronic dissection, 3.16 +/- 0.51 in thoracic aortic aneurysm and 4.58 +/- 1.04 in acute myocardial ischemia, p < 0.05). Higher levels of MMP-1 and MMP-3 were detected on males. There was a positive correlation with increasing age (r = 0.38, p < 0.05). In patients operated for acute type A aortic dissection, the levels of MMP-1, MMP-3 and MMP-9 increased immediately after surgery, while the levels of MMP-2 decrease. At 24 hours postoperatively, levels of MMP -1, -2 and -9 are almost equal to the preoperative ones. CONCLUSION: Measurement of serum MMP levels in thoracic aortic disease and acute myocardial ischemia is a simple and relatively rapid laboratory test that could be used as a biochemical indicator of aortic disease or acute myocardial ischemia, when evaluated in combination with imaging techniques.

Concomitant cholecystectomy and open heart surgery.

PURPOSE: Cholelithiasis may be present concomitantly with cardiac disease. We performed a retrospective study to verify the safety and efficacy of synchronous cholecystectomy and open heart surgery. METHODS: Between 1999 and 2004, we performed synchronous cholecystectomy and open heart surgery in nine patients (group A) and open heart surgery alone in 1248 patients (group B). Open heart surgery was performed with open cholecystectomy (OC) in seven (77.7%) patients and with laparoscopic cholecystectomy (LC) in two (22.2%) patients. One patient with unstable angina and acute cholecystitis underwent simultaneous procedures. The indications for open heart surgery were coronary artery disease in eight (88.8%) patients and severe aortic stenosis in one (11.2%) patient. RESULTS: In group A, the mean number of bypass grafts performed was 2.5 +/- 0.5, the mean operative time was 348.4 min, and patients remained intubated for 25.7 +/- 6.7 h. The mean intensive care unit (ICU) stay was 4.1 +/- 1.6 days and the mean postoperative hospital stay was 19.2 +/- 5.7 days. There was a significant difference between the two groups in these two variables. No intra-abdominal complications or mediastinitis occurred in the immediate postoperative period in the setting of concomitant procedures and the mortality rate was zero. CONCLUSION: Synchronous cholecystectomy and open heart surgery can be performed safely in selected patients.

Successful repair of a huge right coronary artery to a right ventricular fistula: report of a case.

Congenital coronary artery fistulas account for only 0.27%-0.4% of all congenital cardiac defects. We report a case of a right coronary artery (RCA) to a right ventricular(RV) fistula found in 14-year-old girl with clinical signs of heart failure. Echocardiography and cardiac catheterization showed the fistula and a dilated RCA with a diameter of 10 mm. Operative intervention was required, so we performed intracardiac closure of the ventricular fistulous opening under cardiopulmonary bypass (CPB). The patient recovered uneventfully. This method of closure spares the involved coronary artery and is associated with a low risk of recurrence or residual fistula.

Revascularization and mitral valve replacement in a patient with porcelain aorta.

In cases of severe atherosclerosis of the ascending aorta, alterations in the standard surgical technique are mandatory. We report mitral valve replacement and coronary artery bypass grafting in a patient with a severely atherosclerotic aorta. Cardiopulmonary bypass was conducted via an arterial cannula in the femoral artery and two single venous cannulas. Coronary artery bypass grafting was performed using bilateral internal thoracic arteries with beating heart in normothermia. The mitral valve was replaced with a mechanical prosthesis during hypothermic fibrillatory arrest.

Influence of fast-track recovery after coronary artery bypass in the elderly.

We retrospectively analyzed 711 consecutive patients who had isolated coronary artery bypass grafting between January 2000 and December 2004; 572 younger patients (< 70 years) were compared with 139 elderly patients (> or = 70 years). A rapid recovery program based on an anesthetic protocol for early extubation was applied to all patients. The overall hospital mortality rate was 3.3% for the younger group and 4.3% for the elderly group. There were no significant differences in rates of hospital mortality and postoperative complications between the two groups. Early extubation was achieved in significantly more younger (71%) compared to elderly (57%) patients. Rapid recovery with discharge before the 5(th) postoperative day was achieved in 19% of the elderly compared to 48% of the younger patients. Patients in the younger group were discharged from hospital earlier (6.8 +/- 0.3 vs 8.0 +/- 8.5 days). Application of fast-track treatment in an elderly population appears to be a safe and effective approach if used on a selective basis when criteria for early extubation are met.

Totally endoscopic microwave ablation for lone atrial fibrillation: an alternative method of treatment.

Recent studies suggest that pulmonary vein isolation can be an effective method of treatment for atrial fibrillation. This procedure can be performed with minimally invasive, totally endoscopic cardiac surgical techniques. We report our first successful endoscopic isolation of the pulmonary veins in a patient with paroxysmal atrial fibrillation. The procedure consisted of making a box lesion around the pulmonary veins, using a flexible microwave energy delivery probe which was placed endoscopically (video assisted thoracoscopy) through three ports, bilaterally. During a six-month follow up there was no recurrence of atrial fibrillation and the patient's quality of life improved significantly.

Cartilaginous and osseous metaplasia with bone marrow formation in the aortic valve of a patient with giant cell aortitis.

We describe the case of a 40-year-old man who presented with an ascending aortic aneurysm and aortic valve regurgitation. The patient underwent a Bentall surgical procedure. Pathologic findings were consistent with giant cell aortitis with synchronous cartilaginous and osseous metaplasia with bone marrow formation in the degenerated aortic valve. The coexistence of these findings has not been previously reported in the English language literature.