Genetic Risk, Adherence to a Healthy Lifestyle, and Ischemic Heart Disease.

PURPOSE OF REVIEW: The purpose of this review is to investigate and discuss two aspects of coronary artery disease (CAD)-genetic risk and therapeutic lifestyle change (TLC)-both of which have key importance for patients and their care but which actually receive inadequate attention. RECENT FINDINGS: Genetic risk has generally been relegated to a broad association with the presence of one or more inherited cardiovascular (CV) risk factors such as hypercholesterolemia, family history of atherosclerosis, hypertension, and diabetes mellitus. However, the future of genetic risk is an understanding of specific genes, a genetic risk score, specific genetic loci known as selective nucleotide polymorphisms (SNPs), specific alleles, and microribonucleic acids (miRNAs). Healthy lifestyle is fashionably referred to as TLC and encompasses physical fitness, exercise, behavioral modification, diet, and stress reduction. In the past decade, aggressive treatment of cholesterol with statins has received the major emphasis for CV risk reduction. Genetics, of course, can only be modified by factors that influence epigenetics, and TLC could have an effect on genetics by this mechanism. On the other hand, each individual component of TLC has been shown to contribute to a reduction of CV risk. Although aggressive pharmaceutical approaches are now in vogue, whatever TLC can contribute, depending on the degree of individual patient adherence, should never be forgotten.

Management Strategies for Noncardiac Surgery Following a Coronary Artery Event.

PURPOSE OF REVIEW: Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? RECENT FINDINGS: High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180 days with CV risk decreased by a statin and an ACEI or an ARB.

Video-Assisted Thoracoscopic versus Open Lobectomy: Costs and Outcomes.

OBJECTIVES: Video-assisted thoracoscopic (VATS) lobectomy is considered a promising surgical therapy for the diagnosis and treatment of non-small-cell lung carcinoma. The issue of whether VATS is superior to open thoracotomy remains controversial, however. We sought to determine whether the use of VATS lobectomy for diagnosing and treating non-small-cell lung carcinoma would improve patient outcomes at our institution. METHODS: A retrospective review of electronic and paper medical charts identified 109 consecutive operations for all patients undergoing thoracotomy or VATS lobectomy performed at the University of Kentucky Chandler Medical Center for fiscal years 2013 and 2014. Variables of interest included operative procedure (thoracotomy vs VATS) and operative findings (pathologic stage, operative time, postoperative length of stay [LOS], time spent in the intensive care unit, postoperative complications, direct cost). RESULTS: The demographic characteristics of the patients of both groups were similar in terms of sex (64.6% vs 44.3% male) and age (62.4 vs 61.6 years), but not stage, which was higher in the thoracotomy group. The overall operative procedure time (170.6 vs 196.3 minutes), postoperative LOS (5.7 vs 5.5 days), number of lymph nodes sampled (6.2 vs 7.0), and time spent in the intensive care unit (2.1 vs 2.4 days) did not vary between both groups. The average cost per procedure did not vary significantly-$14,003.61 compared with $15,588.11 for thoracotomy and VATS, respectively. CONCLUSIONS: In our study, the VATS group was associated with no reduction in postoperative LOS and a nonsignificant reduction in the amount of time spent in the intensive care unit. Postoperative perception of pain did not vary between either group. Pain perception did, however, correlate strongly with time from operation. Cost did not vary significantly between both groups, with VATS being equivalent to thoracotomy in terms of cost at our institution. In our experience, VATS is an effective, minimally invasive, and safe approach for the resection of lung nodules.

Coenzyme Q-10 in Human Health: Supporting Evidence?

Coenzyme Q-10 (CoQ10) is a widely used alternative medication or dietary supplement and one of its roles is as an antioxidant. It naturally functions as a coenzyme and component of oxidative phosphorylation in mitochondria. Decreased levels have been demonstrated in diseased myocardium and in Parkinson disease. Farnesyl pyrophosphate is a critical intermediate for CoQ10 synthesis and blockage of this step may be important in statin myopathy. Deficiency of CoQ10 also has been associated with encephalomyopathy, severe infantile multisystemic disease, cerebellar ataxia, nephrotic syndrome, and isolated myopathy. Although supplementation with CoQ10 has been reported to be beneficial in treating hypertension, congestive heart failure, statin myopathy, and problems associated with chemotherapy for cancer treatement, this use of CoQ10 as a supplement has not been confirmed in randomized controlled clinical trials. Nevertheless, it appears to be a safe supplementary medication where usage in selected clinical situations may not be inappropriate. This review is an attempt to actualize the available information on CoQ10 and define its potential benefit and appropriate usage.

Modern management of thoracic empyema.

OBJECTIVES: Historically, surgical management of empyema was performed predominantly via open thoracotomy; however, during the past decade the use of video-assisted thoracoscopic surgery (VATS) as an alternative has increased. This study retrospectively compared the outcomes and management of patients with empyema at the University of Kentucky Medical Center who had undergone VATS versus those receiving open thoracotomy to determine whether VATS decortication provided comparable results. METHODS: Adult patients who had undergone open thoracotomy or VATS decortication for empyema between 2005 and 2009 at the University of Kentucky were identified by querying the hospital's cardiothoracic surgery database. Patients were sorted by procedure on an intent-to-treat basis. Comorbid conditions, preoperative course, operative outcomes, and postoperative outcomes were compared. Quantitative data were analyzed with either an unpaired t test or the Mann-Whitney U test. Qualitative data were analyzed using the Fisher exact test. RESULTS: Fifty-three patients were identified, 18 of whom underwent VATS and 35 underwent open thoracotomy. Eight of the 18 VATS procedures (44.4%) were converted to open thoracotomy. Patients undergoing VATS had a significantly shorter median length of stay (11 vs 18 days, respectively; P = 0.044), chest tube duration (6 vs 12 days, respectively; P < 0.001), operative blood loss (55.6 vs 344 mL, respectively; P = 0.003), and fewer postoperative respiratory failures (0% vs 22.9%, respectively; P = 0.0451). The two groups did not differ significantly in overall morbidity, reoperation, mortality, or preoperative comorbidities. CONCLUSIONS: In adults, VATS offers results comparable to those of open thoracotomy, and lengths of stay, chest tube durations, and postoperative outcomes are superior. Although the conversion rate of VATS to open thoracotomy at our institution was high (38.1%) compared with studies at other institutions, the data still indicate that VATS is both a safe and reliable alternative to open thoracotomy.

A Brief Historical Perspective on Pulmonary Embolism.

Pulmonary embolism is a major cause of mortality worldwide. In this historical perspective, we aim to provide an overview of the rich medical history surrounding pulmonary embolism. We highlight Virchow's first steps toward understanding the pathophysiology in the 1800s. We see how those insights inspired early attempts at intervention such as surgical pulmonary embolectomy and caval ligation. Those early interventions were refined and ultimately led to the development of inferior vena cava filters, the earliest clinical applications of anticoagulation, and even apparently disparate medical advances such as the successful development of cardiopulmonary bypass. We also see how the diagnosis of pulmonary embolism has evolved from rudimentary monitoring of vitals and symptoms to the development of evermore sophisticated tests such as contrast tomography angiography and echocardiography. Finally, we discuss current approaches to diagnosis, classification, and myriad treatments including anticoagulation, thrombolysis, catheter-directed interventions, surgical embolectomy, and extracorporeal membrane oxygenation guided by Pulmonary Embolism Response Teams.

Popliteal artery aneurysm repair-A single center experience.

BACKGROUND: Popliteal artery aneurysms (PAAs) are relatively rare but are one of the most common peripheral arterial aneurysms. Open popliteal artery aneurysm repair (OPAR) has been the standard, but technological advancements have made endovascular popliteal artery aneurysm repair (EPAR) a promising alternative. The aim of this study is to compare EPAR and OPAR efficacy and outcomes over a 10-year period. METHODS: This study retrospectively reviewed 72 patient charts who were diagnosed with PAA or popliteal artery pseudoaneurysm and underwent EPAR or OPAR from 1 January 2010 to 31 December 2019. Endovascular popliteal artery aneurysm repair was used in 37 cases and OPAR in 35 cases. RESULTS: Graft patency <30 days postoperative was 100% in both EPAR and OPAR groups. Graft patency >90 days postoperative was 72.73% in the EPAR group and 82.35% in the OPAR group (p = 0.477). Graft patency >2 years postoperative was 81.25% in the EPAR group and 86.67% in the OPAR group (p = 0.682). Freedom from reoperation 30-day postoperative was 78.38% in the EPAR group and 80% in the OPAR group (p = 0.865). Freedom from amputation 30-day postoperative was 91.43% in the EPAR group and 94.29% in the OPAR group (p = 0.263). The 30-day survival rate was 94.59% in the EPAR group and 100% in the OPAR group. CONCLUSIONS: Endovascular repair represents a promising alternative for PAA repair. Our results demonstrate that EPAR has similar outcomes for asymptomatic, acutely symptomatic, and chronic symptomatic patients. Technological advancements of stent properties and refinement of surgical techniques may further improve endovascular techniques.

Computed Tomography (CT)-Guided Needle Biopsy of Lung Lesions: A Single Center Experience.

(1) Objective: Lung cancer is one of the leading causes of cancer death among men and women across the globe. The accurate and timely diagnosis of lung lesions is of paramount importance for prognosis. This single-center study is the first to assess the diagnostic yield and complication rate of a computed tomography (CT)-guided needle biopsy of pulmonary parenchymal and pleural nodules in an academic training center in the United States. (2) Methods: This is a retrospective study approved by IRB. Patients who underwent CT-guided needle biopsy between 2016 and 2020 were reviewed. A CT-guided needle biopsy involving mediastinal lesions was excluded, focusing only on lung parenchymal and pleural lesions. A CT-guided needle biopsy aborted at any point during the procedure was also excluded from this study. (3) Results: 1063 patients were included in this study; 532 were males, and 531 were females. Lesion size ranged from 0.26 cm to 9.2 cm. 1040 patients received diagnoses, among which 772 had a specific diagnosis, and 268 had nonspecific inflammatory or non-malignant diagnoses. Twenty-three cases were non-diagnostic. Among the patients with specific diagnoses, 691 were malignant, 5 were hamartomas, 30 were fungal infections, 6 were acid-fast-positive organisms, and 40 were unspecified atypical cells. Of the patients that had a malignant diagnosis, 317 were adenocarcinoma, 197 were squamous cell carcinoma, 26 were a neuroendocrine tumor, 45 were non-small cell carcinoma (undifferentiated), 17 were small cell carcinoma, and 89 were other metastatic malignancies to the lung. Various common complications, including pneumothorax (337), hemorrhage (128), and hemoptysis (17), were observed, and 42 of the cases required chest tube intervention; others were treated with observation. Other rare complications observed included hemothorax (4) and oxygen desaturation (2), and there was no death in this series. (4) Conclusions: CT-guided needle biopsy is a reliable diagnostic modality for patients with lung parenchymal and pleural nodules, and it can effectively distinguish between benign and cancerous lesions before invasive procedures such as video-assisted thoracoscopy (VATs) or thoracotomy are planned. Our study showed a higher rate of pneumothorax and pulmonary hemorrhage compared to the rates established in guidelines, attributable to the varying experience level in a busy training academic center.

Intraoperative blood transfusion of one or two units of packed red blood cells is associated with a fivefold risk of stroke in patients undergoing elective carotid endarterectomy.

OBJECTIVE: Transfused blood can disrupt the coagulation cascade. We postulated that packed red blood cell (PRBC) transfusion may be associated with thromboembolic phenomena. We used propensity matching to examine the relationship between intraoperative PRBC transfusion and stroke during carotid endarterectomy (CEA). METHODS: We selected CEA procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005-2009. We excluded bilateral, redo, and emergent procedures. We used multivariate logistic regression to identify independent risk factors for stroke. We then calculated a transfusion propensity score to match patients who received one or two units of transfused PRBC intraoperatively with patients of similar risk profiles who had not been transfused. RESULTS: Our criteria resulted in 12,786 elective CEA patients. Of these, 82 (0.6%) received a one- to two-unit intraoperative transfusion. Thirty-day stroke rates were 1.4% (179/12,704) in the nontransfused group and 6.1% (5/82) in the transfused group (Fisher exact test, P = .007). In forward stepwise multivariable regression of risk factors, only hemiplegia, stroke history, and transient ischemic attacks were predictive of 30-day stroke. We used these same variables to calculate transfusion propensity. We matched 80 transfused patients with 160 controls, thus, creating two groups with very similar risk profiles differing only by their transfusion status. In the matched groups, there was a fivefold increase in the risk of stroke in transfused patients (Fisher exact test, P = .043) CONCLUSIONS: Intraoperative transfusion of one to two units of PRBCs is associated with a fivefold increase in stroke risk. This holds true after consideration of stroke risk variables and operative duration as a surrogate for technical difficulty. The increased risk may be related to several effects of transfused blood on the coagulation inflammation cascade.

Mediastinoscopy: trends and practice patterns in the United States.

OBJECTIVES: Historically, mediastinoscopy has been the gold standard for the staging of lung cancer. A practice gap exists as the result of a variation in knowledge concerning current trends and practice patterns of mediastinoscopy usage. In addition, there are regional variations in practice-based learning and patient care. Lessons learned during surgeries performed on patients with lung cancer and other advances such as positron emission tomography and endobronchial ultrasound could be universally applied to improve surgeons' management of patient care. The purpose of this study was to assess contemporary practices in the staging of lung cancer. METHODS: We queried the Society of Thoracic Surgeons National Database for data regarding mediastinoscopy usage, yield, and variation, both by year and region. RESULTS: Cases with mediastinoscopy, as a percentage of all cases performed in the database, have significantly decreased from 14.6% in 2006 to 11.4% in 2010 (P < 0.001). The 5-year median rate of mediastinoscopy in lung cancer patients at 163 centers was 15.3% (interquartile range 5.2%-31.7%), indicating significant variation among centers. The overall median center rate also decreased over time from 21.4% (2006) to 10.0% (2010). CONCLUSIONS: With advances in minimally invasive procedures and imaging, mediastinoscopy usage has declined significantly. Our findings are likely to be relevant to both clinical practice and practice guidelines.

Surgical treatment of lung cancer in octogenarians.

BACKGROUND: As the population ages, octogenarians are becoming the fastest growing patient demographic for non-small-cell lung cancer. We examined lobectomies and 30-day outcomes in this group compared with younger patients to gain insight into the optimal treatment for this challenging group. METHODS: We analyzed data from the American College of Surgeons National Quality Improvement Program for patients with lung cancer undergoing lobectomy during calendar years 2005-2010. We compared clinical risk factors, intraoperative factors, and 30-day operative mortality and major morbidity in octogenarians versus younger patients undergoing either open traditional thoracotomy (OPEN) or video-assisted (VATS) pulmonary lobar resection. RESULTS: Of 2171 patients who had lobar resections for lung cancer, 245 (11%) were octogenarians. Six hundred eight lobectomies (28.0%) were VATS procedures and 1563 (72.0%) were OPEN procedures. The VATS rate increased as patient age increased (34% VATS for octogenarians vs 27% for patients younger than 80 years; P = 0.01). Thoracic surgeons performed VATS with greater frequency compared with general surgeons, especially in octogenarians (41% VATS for thoracic surgeons vs 29% for general surgeons; P < 0.001). Univariate analysis suggests significantly increased major morbidity (pulmonary, renal, and sepsis), but not operative mortality in octogenarians; however, multivariate predictors of major morbidity include OPEN procedures, preoperative decreased functional status, history of chronic obstructive pulmonary disease, preoperative sepsis, prior radiation, diabetes, and dyspnea on exertion (all P < 0.05), but they do not include advanced age. CONCLUSIONS: Comorbidities predict most increased morbidity in octogenarians, and advanced age per se is not an important multivariate predictor of postoperative morbidity or mortality. The frequency of VATS lobectomy increased with increasing patient age, and VATS predisposes to decreased morbidity in octogenarians.

Noninvasive optical evaluation of spontaneous low frequency oscillations in cerebral hemodynamics.

Spontaneous low frequency oscillations (LFOs) around 0.1 Hz have been observed in mean arterial pressure (MAP) and cerebral blood flow velocity (CBFV). Previous studies have shown that cerebral autoregulation in major arteries can be assessed by quantification of the phase shift between LFOs of MAP and CBFV. However, many cerebral diseases are associated with abnormal microvasculature and tissue dysfunction in brain, and quantification of these abnormalities requires direct measurement of cerebral tissue hemodynamics. This pilot study used a novel hybrid near-infrared diffuse optical instrument to noninvasively and simultaneously detect LFOs of cerebral blood flow (CBF) and cerebral oxygenation (i.e., oxygenated/deoxygenated/total hemoglobin concentration: [HbO(2)]/[Hb]/THC) in human prefrontal cortex. Using the hybrid instrument and a finger plethysmograph, the dynamic changes of CBF, [HbO(2)], [Hb], THC and MAP were concurrently measured in 15 healthy subjects at rest, during 70° head-up-tilting (HUT) and during enforced breathing at 0.1 Hz. The LFOs were extracted from the measured variables using power spectral analysis, and the phase shifts and coherences of LFOs between MAP and each of the measured hemodynamic variables were calculated from the corresponding transfer functions. Levels of coherence (>0.4) were used to judge the success of LFO measurements. We found that CBF, [HbO(2)] and THC were reliable hemodynamic parameters in detecting LFOs and HUT was the most robust and stable protocol for quantifying phase shifts of hemodynamic LFOs. Comparing with other relevant studies, similar success rates for detecting cerebral LFOs have been achieved in our study. The phase shifts of LFOs in CBF were also close to those in CBFV reported by other groups, although the results in cerebral oxygenation measurements during enforced breathing varied across studies. Future study will investigate cerebral LFOs in patients with cerebral impairment and evaluate their cerebral autoregulation capabilities and neurocognitive functions via the quantification of LFO phase shifts.

A prospective randomized study comparing fibrin sealant to manual compression for the treatment of anastomotic suture-hole bleeding in expanded polytetrafluoroethylene grafts.

OBJECTIVE: The ideal hemostatic agent for treatment of suture-line bleeding at vascular anastomoses has not yet been established. This study evaluated whether the use of a fibrin sealant containing 500 IU/mL thrombin and synthetic aprotinin (FS; marketed in the United States under the name TISSEEL) is beneficial for treatment of challenging suture-line bleeding at vascular anastomoses of expanded polytetrafluoroethylene (ePTFE) grafts, including those further complicated by concomitant antiplatelet therapies. METHODS: Over a 1-year period ending in 2010, ePTFE graft prostheses, including arterio-arterial bypasses and arteriovenous shunts, were placed in 140 patients who experienced suture-line bleeding that required treatment after completion of anastomotic suturing. Across 24 US study sites, 70 patients were randomized and treated with FS and 70 with manual compression (control). The primary end point was the proportion of patients who achieved hemostasis at the study suture line at 4 minutes after start of application of FS or positioning of surgical gauze pads onto the study suture line. RESULTS: There was a statistically significant difference in the comparison of hemostasis rates at the study suture line at 4 minutes between FS (62.9%) and control (31.4%) patients (P < .0001), which was the primary end point. Similarly, hemostasis rates in the subgroup of patients on antiplatelet therapies were 64.7% (FS group) and 28.2% (control group). When analyzed by bleeding severity, the hemostatic advantage of FS over control at 4 minutes was similar (27.8% absolute improvement for moderate bleeding vs 32.8% for severe bleeding). Logistic regression analysis (accounting for gender, age, intervention type, bleeding severity, blood pressure, heparin coating of ePTFE graft, and antiplatelet therapies) found a statistically significant treatment effect in the odds ratio (OR) of meeting the primary end point between treatment groups (OR, 6.73; P < .0001), as well as statistically significant effects for intervention type (OR, 0.25; P = .0055) and bleeding severity (OR, 2.59; P = .0209). The safety profile of FS was excellent as indicated by the lack of any related serious adverse events. CONCLUSIONS: The findings from this phase 3 study confirmed that FS is safe and its efficacy is superior to manual compression for hemostasis in patients with peripheral vascular ePTFE grafts. The data also suggest that FS promotes hemostasis independently of the patient's own coagulation system, as shown in a representative population of patients with vascular disease under single- or dual-antiplatelet therapies.

A randomized, double-blind trial comparing continuous thoracic epidural bupivacaine with and without opioid in contrast to a continuous paravertebral infusion of bupivacaine for post-thoracotomy pain.

OBJECTIVE: To compare the results of continuous epidural bupivacaine analgesia with and without hydromorphone to continuous paravertebral analgesia with bupivcaine in patients with post-thoracotomy pain. DESIGN: A prospective, randomized, double-blinded trial. SETTING: A teaching hospital. PARTICIPANTS: Patients at a tertiary care teaching hospital undergoing throracotomy for lung cancer. INTERVENTIONS: Subjects were assigned randomly to receive a continuous thoracic epidural or paravertebral infusion. Patients in the epidural group were randomized to receive either bupivacaine alone or in combination with hydromorphone. Visual analog scores as well as incentive spirometery results were obtained before and after thoracotomy. METHODS AND MAIN RESULTS: Seventy-five consecutive patients presenting for thoracotomy were enrolled in this institutional review board-approved study. On the morning of surgery, subjects were randomized to either an epidural group receiving bupvicaine with and without hydromorphone or a paravertebral catheter-infused bupvicaine. Postoperative visual analog scores and incentive spirometry data were measured in the postanesthesia care unit, the evening of the first operative day, and daily thereafter until postoperative day 4. Analgesia on all postoperative days was superior in the thoracic epidural group receiving bupivacaine plus hydromorphone. Analgesia was similar in the epidural and continuous paravertebral groups receiving bupivacaine alone. No significant improvement was noted by combining the continuous infusion of bupivacaine via the paravertebral and epidural routes. Incentive spirometry goals were best achieved in the epidural bupivacaine and hydromorphone group and equal in the group receiving bupivacaine alone either via epidural or continuous paravertebral infusion. CONCLUSIONS: The current study provided data that fill gaps in the current literature in 3 important areas. First, this study found that thoracic epidural analgesia (TEA) with bupivacaine and a hydrophilic opioid, hydromorphone, may provide enhanced analgesia over TEA or continuous paravertebral infusion (CPI) with bupivacaine alone. Second, in the bupivacaine-alone group, the increased basal rates required to achieve analgesia resulted in hypotension more frequently than in the bupivacaine/hydromorphone combination group, underscoring the benefit of the synergistic activity. Finally, in agreement with previous retrospective studies, the current data suggest that CPI of local anesthetic appears to provide acceptable analgesia for post-thoracotomy pain.

Pneumonectomy for non-small cell lung cancer: outcomes analysis.

OBJECTIVE: The purpose of this study was to investigate the morbidity and mortality of 100 consecutive patients with pneumonectomy for non-small cell lung cancer at the University of Kentucky. METHODS: We retrospectively reviewed the medical records of 100 consecutive pneumonectomy patients, 1998-2009. RESULTS: The median age of patients was 59 years, with a range of 27 to 79 years. Sixty-eight patients (68%) were men. Fifty-four patients (54%) received left pneumonectomy. Major postoperative complication rate was 39%, with atrial fibrillation being the most common complication, occurring in 26 patients. The overall postoperative mortality rate was 11% (11/100 patients). The mortality rate among right pneumonectomy patients was 17.4% (8/46 patients) compared with 5.6% (3/54 patients) for left pneumonectomy. The postoperative mortality rate among patients receiving neoadjuvant therapy was 14.3% (4/28 patients). In addition, among patients who received neoadjuvant therapy, the mortality rate for right and left pneumonectomy was 21.4% (3/14 patients) and 7.1% (1/14 patients), respectively. The mortality rate among patients older than 70 years at the time of pneumonectomy was 18.2% (2/11 patients). CONCLUSIONS: With a postoperative mortality rate of 11% and a major postoperative complication rate of 39%, pneumonectomy for non-small cell lung cancer is associated with high morbidity and mortality. The factors associated with the increased mortality rate include right pneumonectomy, patient age older than 70 years at the time of procedure, and neoadjuvant therapy before pneumonectomy.

Diagnosis and Management of Aortic Valvular Disease in the Elderly.

Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.

Use of fibrin sealant as a hemostatic agent in expanded polytetrafluoroethylene graft placement surgery.

BACKGROUND: The low thrombogenicity, porosity, and limited elasticity of expanded polytetrafluoroethylene (ePTFE) vascular grafts, although beneficial, may exacerbate the problem of suture-line bleeding at vascular anastomoses and consequently lead to increased operating times. The overall objective of this prospective, randomized, controlled, subject-blinded, multicenter phase 2 study was to evaluate the efficacy and safety of a fibrin sealant containing 500 IU/mL thrombin and synthetic aprotinin (FS; marketed in the United States under the name TISSEEL) for hemostasis in subjects undergoing vascular surgery and receiving prosthetic ePTFE vascular grafts. METHODS: FS was compared with manual compression with surgical gauze pads, a standard of care for hemostasis in vascular surgery. Two FS polymerization/setting times (60 and 120 seconds) were investigated to evaluate influence on the efficacy results. Patients undergoing ePTFE graft placement surgery (N = 73) who experienced bleeding that required treatment after surgical hemostasis were randomized to be treated with FS with clamps opened at 60 seconds (FS-60; N = 26), with FS with clamps opened at 120 seconds (FS-120; N = 24), or with manual compression with surgical gauze pads (control; N = 23). The proportion of subjects achieving hemostasis at 4 minutes (primary endpoint) as well as at 6 and 10 minutes (secondary endpoints) in the three treatment groups was analyzed using logistic regression analysis, taking into account gender, age, type of intervention, severity of bleeding, systolic blood pressure, diastolic blood pressure, heparin coating of the ePTFE graft, and platelet inhibitors. RESULTS: There were substantial differences in the proportion of subjects who achieved hemostasis at the study suture line at 4 minutes from treatment application between FS-120 (62.5%) and control (34.8%) groups (a 79.6% relative improvement). Logistic regression analyses found a statistically significant treatment effect at the 10% level in the odds ratio (OR) of achieving hemostasis at 4 minutes between the FS-120 and control groups (OR = 3.98, p = 0.0991). Furthermore, it has been shown that the perioperative administration of platelet inhibitors significantly influences (OR = 3.89, p = 0.0607) hemostasis rates at the primary endpoint. No statistically significant treatment effects were found for the other factors. Logistic regression analyses performed on the secondary endpoints demonstrated a significant treatment effect of achieving hemostasis at 6 minutes (OR = 9.92, p = 0.0225) and at 10 minutes (OR = 6.70, p = 0.0708) between the FS-120 and control groups. Statistically significant effects in the logistic regression analyses were found at the 10% level in the OR of achieving hemostasis at 6 and 10 minutes, respectively, for the following factors: FS-120 versus control group (OR = 9.92; p = 0.0225 and OR = 6.70; p = 0.0708, respectively), type of intervention (OR = 0.3; p = 0.0775 and OR = 0.25; p = 0.0402, respectively), and heparin coating of the ePTFE prosthesis (OR = 4.83; p = 0.0413 and OR = 3.65; p = 0.0911, respectively). FS was safe and well-tolerated, as indicated by the lack of any related serious adverse events. CONCLUSION: The findings from this phase 2 study support the strong safety profile of FS and suggest that it is an efficacious hemostatic agent in ePTFE graft placement surgery, as well as a useful tool in peripheral vascular surgery applications.

Antiplatelet drugs: mechanisms and risks of bleeding following cardiac operations.

Preoperative antiplatelet drug use is common in patients undergoing coronary artery bypass grafting (CABG). The impact of these drugs on bleeding and blood transfusion varies. We hypothesize that review of available evidence regarding drug-related bleeding risk, underlying mechanisms of platelet dysfunction, and variations in patient response to antiplatelet drugs will aid surgeons as they assess preoperative risk and attempt to limit perioperative bleeding. The purpose of this review is to (1) examine the role that antiplatelet drugs play in excessive postoperative blood transfusion, (2) identify possible mechanisms to explain patient response to antiplatelet drugs, and (3) formulate a strategy to limit excessive blood product usage in these patients. We reviewed available published evidence regarding bleeding risk in patients taking preoperative antiplatelet drugs. In addition, we summarized our previous research into mechanisms of antiplatelet drug-related platelet dysfunction. Aspirin users have a slight but significant increase in blood product usage after CABG (0.5 U of nonautologous blood per treated patient). Platelet adenosine diphosphate (ADP) receptor inhibitors are more potent antiplatelet drugs than aspirin but have a half-life similar to aspirin, around 5 to 10 days. The American Heart Association/American College of Cardiology and the Society of Thoracic Surgeons guidelines recommend discontinuation, if possible, of ADP inhibitors 5 to 7 days before operation because of excessive bleeding risk, whereas aspirin should be continued during the entire perioperative period in most patients. Individual variability in response to aspirin and other antiplatelet drugs is common with both hyper- and hyporesponsiveness seen in 5 to 25% of patients. Use of preoperative antiplatelet drugs is a risk factor for increased perioperative bleeding and blood transfusion. Point-of-care tests can identify patients at high risk for perioperative bleeding and blood transfusion, although these tests have limitations. Available evidence suggests that multiple blood conservation techniques benefit high-risk patients taking antiplatelet drugs before operation. Guidelines for patients who take aspirin and/or thienopyridines before cardiac procedures include some or all of the following: (1) preoperative identification of high-risk patients using point-of-care testing; (2) withdrawal of aspirin or other antiplatelet drugs for a few days and delay of operation in patients at high risk for bleeding if clinical circumstances permit; (3) selective perioperative use of evidence-based blood conservation interventions (e.g., short-course erythropoietin, off-pump procedures, and use of intraoperative blood conservation techniques), especially in high-risk patients; and (4) platelet transfusions if clinical bleeding occurs.

Managing Cardiovascular Risk Factors without Medications: What is the Evidence?

In this era of potent medications and interventional cardiovascular (CV) procedures, the importance of beginning with and including Therapeutic Lifestyle Changes (TLC) is frequently forgotten. A major goal of this review article is to show and emphasize that modification of CV risk with nonmedication approaches makes an essential contribution to CV risk reduction. Available information on TLC and modifiable CV risk factors was reviewed and assessed. Modifiable major CV risk factors include diabetes mellitus, hypertension, hyperlipidemia, tobacco abuse, obesity, stress, and a sedentary lifestyle. Age as a major CV risk factor is, of course, not susceptible to modification. A contribution to the control of CV risk factors can occur without the start of medications and there is proof of benefit for beginning with a non-pharmacological approach. TLC can benefit all of the major modifiable CV risk factors and there is good evidence for the additional benefit of supervised and group TLC. TLC includes physical activity, diet, and smoking cessation. Evidence for the benefits of TLC in reducing CV disease events is well established. However, medications must be added in those patients with higher CV risk to obtain maximum cholesterol reduction (lower is better for the low-density lipoprotein cholesterol) and good blood pressure control. The benefit of TLC is frequently forgotten in this era of potent medications and invasive procedures. The benefits of diet and physical activity are emphasized with supporting data. Many motivated patients can prolong their lives significantly by dedication to TLC. Therapeutic Lifestyle Change (TLC) especially encompasses increased physical activity, a healthy diet, and smoking cessation. There is extensive proof for the benefit of TLC in contributing to cardiovascular (CV) disease prevention. CV diseases have strong metabolic and inflammatory components, both of which can be improved by TLC.

The relationship between mortality and preexisting cardiac disease in 5,971 trauma patients.

BACKGROUND: We observed significant morbidity and mortality in patients with preexisting cardiac disease who suffer severe traumatic injuries. We wondered about the types of injury seen and about the cardiac risks factors that predispose to worse outcomes in these patients. Our hypothesis is that significant cardiac comorbidity is associated with adverse trauma outcomes. METHODS: We reviewed 10,144 trauma admissions to the University of Kentucky during a 5-year period (2002-2007) in patients 21 years or older. The types and extent of injuries were characterized, and risk factors for poor outcome were assessed. Propensity analysis assessed variable interaction and adjusted for important multivariate cardiovascular risk factors. RESULTS: Of the 10,144 adult trauma patients, there was adequate cardiovascular history before emergency treatment in 5,971 patients (58.9%). Of the 700 trauma deaths, 236 (33.7%) had adequate medical history to allow accurate assessment of cardiovascular disease. Significant multivariate predictors of trauma-related death included older age (odds ratio [OR] = 0.938), injury severity score (OR = 0.893 per unit score), major burn (OR = 5.907), assault with a weapon (OR = 3.205), systolic blood pressure divided by Glasgow coma score (OR = 0.958 per score unit), and female (OR = 1.629). In the cohort of 236 deaths with adequate medical history, severe head and chest injuries caused death in 187 patients (79.2%). Significant propensity-adjusted cardiovascular risks of trauma death included preinjury warfarin use (OR = 2.309, p = 0.001), congestive heart failure (CHF) (OR = 2.060, p = 0.011), and preinjury beta-blocker use (OR = 2.62, p = 0.001). The highest mortality rates occurred in patients with combinations of these cardiovascular risk factors. For example, patients on warfarin with CHF had a 26.3% mortality rate, whereas patients on warfarin and beta-blocker had a 27.3% mortality rate. CONCLUSIONS: Preinjury cardiac risk factors, especially preinjury warfarin, beta-blocker use, and CHF, are independent multivariate predictors of mortality in patients suffering significant trauma. Although head and chest injuries are the most frequent causes of death, patients with more than one preinjury cardiac risk factor have 5 to 10 times the mortality risk compared with those without cardiac risks.