Prolonged Non-Steroidal Anti-Inflammatory Drug Exposure After Pleurodesis Increases Pneumothorax Recurrence: A Retrospective Cohort Study.

INTRODUCTION: The use of non-steroidal anti-inflammatory drugs (NSAID) in patients undergoing pleurodesis remains controversial. Although many surgeons are comfortable prescribing NSAIDs post-operatively, some oppose this practice due to concerns of suppressing the inflammatory response and quality of pleurodesis. Only a small body of inconsistent publications exists with respect to guiding therapy in this common clinical scenario. METHODS: A retrospective cohort study was undertaken assessing effect of NSAID exposure on pleurodesis outcomes. An institutional thoracic surgery database was reviewed yielding 147 patients who underwent pleurodesis for pneumothorax between 2010 and 2018. Medical records and imaging were reviewed for patient characteristics, NSAID exposure, recurrent pneumothorax and other adverse events. RESULTS: There was no overall difference between rates of recurrence and procedural failure of pleurodesis (Relative Risk [RR] 1.67 [95% CI 0.74-3.77]). However, NSAID exposure of >48 hours was associated with increased risk of recurrent pneumothorax (RR 2.16 [95% CI 1.05-4.45]). There was no increased rate of other adverse events related to NSAID usage. CONCLUSIONS: NSAID exposure does not increase failure rates or other adverse events following pleurodesis for pneumothorax. However, prolonged NSAID exposure post-pleurodesis may increase procedural failure rates. Further large volume randomised control trials are required.

Predictors of Pacemaker Insertion Post-Sutureless (Perceval) Aortic Valve Implantation.

INTRODUCTION: The use of rapid deployment sutureless aortic valve replacement (AVR) has become a viable alternative to conventional AVR especially in intermediate and high-risk patients. However, sutureless AVR has been associated with increased rates of permanent pacemaker (PPM) implantation compared with conventionally implanted aortic valve prostheses. The aim of this study was to determine predictive factors for complete heart block requiring insertion of a PPM post-AVR with a Perceval S sutureless valve (LivaNova, London, UK). Such knowledge will help to improve patient counselling, selection and management of patients undergoing sutureless AVR. METHODOLOGY: A retrospective cohort study assessed all patients who underwent insertion of the Perceval sutureless aortic valve prosthesis between July 2015 and September 2019. Medical records were reviewed for demographic, preoperative electrocardiograph (ECG), and operative features related to postoperative PPM implantation and follow-up in the electrophysiology clinic. RESULTS: One hundred and thirty (130) patients without pre-existing PPM underwent sutureless AVR (66.9% male, average age 74.4±6.6 years). Fifty-seven (57) underwent concomitant cardiac surgical procedures. Eight (8) patients underwent redo cardiac surgery. Nineteen (19) of the 130 (14.6%) patients required insertion of a PPM during their postoperative course. Factors associated with PPM insertion were right bundle branch block (overall n=15, PPM vs No PPM: 8/19 vs 7/111 [42.1 % vs. 6.31 %; p<0.01]), longer QRS duration 113.32ms±22.24 ms vs 100.52±20.96 ms (p=0.017) and longer PR Interval 185.166±42.38 ms vs 169.23±25.70 ms (p=0.03). CONCLUSION: Insertion of rapid deployment sutureless aortic valves in the setting of pre-existing right bundle branch block, prolonged QRS complex and longer PR intervals is associated with increased risk of postoperative PPM requirement. These factors should be considered when preoperatively counselling and postoperatively managing patients when balloon expandable sutureless valves are used.

Homograft Versus Valves and Valved Conduits for Extensive Aortic Valve Endocarditis with Aortic Root Involvement/Destruction: A Systematic Review and Meta-Analysis.

Aortic valve infective endocarditis is a life-threatening condition. Patients frequently present profoundly unwell and extensive surgery may be required to correct the underlying anatomical deficits and control sepsis. Periannular involvement occurs in more than 10% of patients with aortic valve endocarditis. Complex aortic valve endocarditis has a mortality rate of 10 to 40%. Longstanding surgical dogma suggests homografts represent the optimal replacement option in complex aortic valve endocarditis; however, there is a paucity of evidence and lack of consensus on the optimal replacement choice. A systematic review and meta-analysis was performed utilizing EMBASE, PubMed, and the Cochrane databases to review articles describing homografts versus aortic valve replacement and/or valved conduit graft implantation for complex aortic valve endocarditis. The outcomes of interest were mortality, reinfection, and reoperation. Eleven studies were included in this meta-analysis, contributing 810 episodes of complex aortic valve endocarditis. All included reports were cohort studies. There was no statistically significant difference in overall mortality (risk ratio [RR] 0.99; 95% confidence interval [CI], 0.61-1.59; p = 0.95), reinfection (RR 0.89; 95% CI, 0.45-1.78; p = 0.74), or reoperation (RR 0.91; 95% CI, 0.38-2.14; p = 0.87) between the homograft and valve replacement/valved conduit graft groups. Overall, there was no difference in mortality, reinfection, or reoperation rates between homografts and other valve or valved conduits in management of complex aortic endocarditis. However, there is a paucity of high-quality evidence in the area, and comparison of valve types warrants further investigation.

Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension: a systematic review.

Background: Pulmonary thromboendarterectomy (PTE) is the gold standard treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, the results are poorly quantified outside a few registry reports and several individual centers. Methods: A systematic review was performed searching five electronic databases assessing the outcomes for adult patients undergoing PTE for CTEPH. All articles that reported mortality data were included. Primary outcome measures were early/inpatient mortality; secondary outcomes were survival, pulmonary haemodynamics, morbidity and functional status following PTE for CTEPH. Results were pooled via a meta-analysis of proportions and meta-regression. Results: A total of 5,717 studies were identified, yielding sixty-one relevant papers. Thirty-day mortality ranged from 0.8% to 24.4%, and on meta-analysis was 8.4% [95% confidence interval (CI): 7.2-9.6%]. Mortality was noted to decrease with increasing center volume of PTE cases (P<0.01). Residual pulmonary hypertension was reported in 8.2% to 44.5% of patients. Conclusions: CTEPH is associated with acceptable short-term mortality and an improvement in pulmonary hemodynamics. With increasing volume of experience and ongoing developments over time peri-operative mortality continues to decrease.

Pleural effusion post coronary artery bypass surgery: associations and complications.

BACKGROUND: One of the most frequent complications of coronary artery bypass grafting (CABG) is pleural effusion. Limited previous studies have found post-CABG pleural effusion to be associated with increased length-of-stay and greater morbidity post-CABG. Despite this the associations of this common complication are poorly described. This study sought to identify modifiable risk factors for effusion post-CABG. METHODS: A retrospective cohort study of prospectively collected data assessed patients who underwent CABG over two-years. Data was collected for risk factors and sequelae related to pleural effusion requiring drainage. RESULTS: A total of 409 patients were included. Average age was 64.9±10.2 years, 330 (80.7%) were male. 59 (14.4%) patients underwent drainage of pleural effusion post-CABG. Effusions were drained on average 9.9±8.4 days post-CABG. Earlier removal of drain tubes and removal near time of extubation were associated with development of pleural effusion. Post-CABG pleural effusion was associated with post-operative renal impairment (P<0.01) and pericardial effusion (P<0.01). Patients with pleural effusion were more likely to require readmission to ICU (P<0.01), reintubation (P=0.03) and readmission to hospital (P=0.03). CONCLUSIONS: Pleural effusion is a common complication of cardiac surgery and is associated with significant morbidity and resource utilization. This study identifies several associated complications that should be considered in the presence of pleural effusion. Modifiable associated factors in the management of drains that may contribute to accumulation of pleural effusion include: early removal of chest drains, higher outputs and removal during or close to mechanical ventilation. Further research is required to assess how adjusting these modifiable factors can decrease rates of effusion post-operatively.

Impact of modern media on analgesic requirements during extracorporeal shockwave lithotripsy.

BACKGROUND: In Australia, shockwave lithotripsy (SWL) to treat urinary tract stones is routinely performed with general anaesthesia (GA). We have established a SWL service avoiding GA based outside operating theatres and wish to assess the effectiveness of utilizing modern media on patient satisfaction and analgesic requirements during treatment. METHODS: A randomized three-arm trial was performed. Patients were allocated to either watching videos or listening to music on a tablet device, or to getting no media distraction. A total of 95 patients were recruited in a 1:1:1 fashion. Analgesic requirements were recorded during the procedure and patients were asked to fill out a questionnaire with a visual analogue scale to assess their overall pain and satisfaction with the procedure. RESULTS: Overall pain scores were decreased - the sound media group reported a mean pain score of 3.52 (P = 0.005), the visual group was 3.62 (P = 0.007), compared to 5.45 in the control group. Analgesic requirements were significantly decreased when compared to the control group (P = 0.05). Overall satisfaction with the procedure was improved in the treatment groups, with the sound group having the best result (P = 0.04). CONCLUSION: Modern media can be used as a distraction during SWL in a safe and effective way when treating renal tract stones without GA. Analgesic requirements are decreased significantly, therefore decreasing any potential side-effects and complications. Other departments in Australia should consider using this technique.

Approach to a large rare diaphragmatic hernia in a patient undergoing cardiac surgery.

Hernia of Morgagni is an unusual congenital defect of the sternal portion of the diaphragm. Its concurrence with cardiac surgical pathology is rarely described in the literature. Notwithstanding, huge hernia of Morgagni have been noted to cause serious peri-operative impediment and complications. We report the case of a 50-year-old gentleman with a massive Morgagni hernia that threatened strangulation during cardiopulmonary bypass. We describe the combined surgical approach undertaken to repair this hernia, with an accompanying review of the literature relating to misadventure and management of similar large hernia coinciding with cardiac surgery.

Pseudocyst of the pancreas masquerading as spontaneous pneumomediastinum.

Pseudocyst of the pancreas extending into the thorax represents a rare but potentially catastrophic diagnosis. It can be difficult to both diagnose and manage, with only limited management suggestions within the literature. While pleural effusion is a common complication of pancreatitis, transthoracic extension of a pseudocyst is a rare phenomenon. Herein we discuss a patient with a difficult to recognize extension of pancreatic pseudocyst into the left hemithorax, with unique imaging findings. He had good response to trans-gastric and percutaneous drainage and ultimately proceeded to thoracotomy and decortication. Around this case, the options for investigation and management are discussed.