SLL-PEEP Ventilation to Improve Exposure in Minimally Invasive Right Anterolateral Minithoracotomy Aortic Valve Replacement.

OBJECTIVE: An accepted landmark to assess feasibility of surgical aortic valve replacement (SAVR) via right anterolateral minithoracotomy (RALT) is the aortic-midpoint to right-sternal-edge distance. We aimed to evaluate single left lung positive-end-expiratory-pressure (SLL-PEEP) ventilation inducing an intraoperative rightward shift of the ascending aorta to improve exposure. METHODS: Nineteen patients with aortic stenosis undergoing SAVR via RALT were prospectively analyzed. SLL-PEEP ventilation (20,395 cmH2O) via a double-lumen endotracheal tube was applied immediately before transthoracic aortic cross-clamping, thereby inducing rightward shift of the ascending aorta to enhance exposure. We analyzed preoperative computed tomography (CT) reconstructions and intraoperative video recordings. Primary endpoint was extent of rightward shift induced by SLL-PEEP ventilation; secondary endpoints were procedure times and safety events. RESULTS: Mean age was 61 ± 14.8 years and 6 of 19 (31.6%) were female. Mean EuroSCORE II was 0.81% ± 0.04%, STS-PROM was 1.13% ± 0.74%, and mean aortic rightward shift induced by SLL-PEEP ventilation was 10.32 ± 4.14 mm (4 to 17 mm; P = 0.003). Median shift in the group considered suitable for the RALT approach by preoperative CT-scan evaluation was 14.2 mm (IQR 11) and in the less suitable group 11.5 mm (IQR 5). Mean procedure time was 167 ± 28.9 min, CPB time was 105.7 ± 18.4 min, and cross-clamp time was 64.5 ± 13 min. Fifteen patients (79%) received SAVR via RALT with implantation of a bioprosthesis, whereas a rapid-deployment-prosthesis was used in 4 patients (21%). Ten of 19 (53%) patients who were classified as less suitable preoperatively received SAVR via RALT after SLL-PEEP ventilation. No strokes were observed. CONCLUSIONS: The SLL-PEEP ventilation maneuver during SAVR via RALT significantly enhances aortic exposure. There were no safety events associated with this maneuver and we were able to demonstrate significant rightward aortic shift in every single patient.

Minimally invasive surgical aortic valve replacement: The RALT approach.

Less-invasive techniques for cardiothoracic surgical procedures are designed to limit surgical trauma, but the technical requirements and preoperative planning are more demanding than those for conventional sternotomy. Patient selection, interdisciplinary collaboration, and surgical skills are key factors for procedural success. Aortic valve replacement is frequently performed through an upper hemisternotomy, but the right anterior minithoracotomy represents an even less traumatic, technical advancement. Preoperative assessment of the ascending aorta in relation to the sternum is mandatory to select patients and the intercostal access site. This description of the surgical technique focuses on the specific procedural details including the obligatory planning with computed tomography and our cannulation strategy. We also sought to define the anatomical ascending aorta-sternal relationship, as it is of utmost importance in preoperative computed tomographic planning.

Retrospective 1-year outcome follow-up in 200 patients supported with HeartMate 3 and HeartWare left ventricular assist devices in a single centre.

OBJECTIVES: Various trials have assessed the outcome and reliability of the HeartWare HVAD (HW) and HeartMate 3 (HM3) left ventricular assist devices. A direct comparison of clinical outcomes and of the complication profile of these 2 left ventricular assist devices is lacking. We present a retrospective analysis of patients supported with HM3 and HW as a left ventricular assist device. METHODS: Preoperative data, complications and outcomes including a 1-year follow-up of patients supported with the HM3 and HW in a single centre were retrospectively analysed. Both pumps were implanted on- or off-pump, employing standard and minimally invasive techniques. For logistic reasons, the 2 device types were implanted in an alternating manner, thereby reducing the systematic bias for pump selection. We considered this to be an appropriate approach, as no differences in respect of survival or the complication profile of the two device types have been demonstrated. Anticoagulation was similar in patients with both pumps according to our anticoagulation protocol, with a target international normalized ratio of 2.5-3.0, a home monitoring system and blood pressure management with a mean arterial target pressure of 70-80 mmHg. RESULTS: Between October 2015 and April 2017, 100 patients underwent implantation of the HW and 100 patients underwent implantation of the HM3. The median time on the device was 0.98 years (range 0-2.23 years). The median age was 58.5 (51-65) versus 57 (49-64) years (P = 0.456); the number of male patients was 87 versus 88 (P = 0.831). Of the HW patients, 73% were rated as having an INTERMACS level I or II, compared to 57% of the HM3 patients (P = 0.018). There were no further differences in preoperative data. A total of 14 patients had pre-, intra- or post-pump blood flow obstruction in the HW group versus 4 in the HM3 group [hazard ratio (HR) 2.5 (0.7-8.8), P = 0.103]. There were no differences regarding gastrointestinal bleeding [HR 1.25 (0.56-2.64), P = 0.624] or driveline infection (0.68 vs 0.8 events per patient-year, P = 0.0789). The incidence of ischaemic stroke was similar in both groups [HR 0.72 (0.25-2.09), P = 0.550]. Cerebral bleeding was more frequent in patients supported with HW [HR 6.79 (1.43-32.20), P = 0.016]. The incidence of cerebrovascular accidents, on the other hand, was similar in both groups [HR 1.85 (0.83-4.19), P = 0.13]. The incidence of haemocompatibility-related adverse events, however, was significantly higher in the HW group (113 points corresponding to 1.28 events per patient-year versus 69 points corresponding to 0.7 events per patient-year, P < 0.001). The 1-year survival was similar in both groups [62.2%, 95% confidence interval (CI) (0.53-0.73) vs 66.7%, 95% CI (0.58­0.767) [corrected]. CONCLUSIONS: Our data show that the complication profile differs between the 2 pumps, but that early survival is comparable.

Cytogenetic studies in acute leukemia patients relapsing after allogeneic stem cell transplantation.

We analyzed karyotype stability in 22 patients with acute leukemia at relapse or disease progression after allogeneic stem cell transplantation (allo-SCT). Karyotypes before and at relapse after allo-SCT were different in 15 patients (68%), the most frequent type being clonal evolution either alone or combined with clonal devolution (13 patients). Patients with and without a karyotype change did not differ significantly in overall survival (OS) (median, 399 vs. 452 days; P = 0.889) and survival after relapse (median, 120 vs. 370 days; P = 0.923). However, acquisition of additional structural chromosome 1 abnormalities at relapse after allo-SCT occurred more frequently than expected and was associated with reduced OS (median, 125 vs. 478 days; P = 0.008) and shorter survival after relapse (median, 37 vs. 370 days; P = 0.002). We identified a previously undescribed clonal evolution involving t(15;17) without PML-RARA rearrangement in an AML patient. We conclude that a karyotype change is common at relapse after allo-SCT in acute leukemia patients. Moreover, our data suggest that additional structural chromosome 1 abnormalities are overrepresented at relapse after allo-SCT in these patients and, in contrast to a karyotype change per se, are associated with reduced OS and shorter survival after relapse.

Technical feasibility of 2D-3D coregistration for visualization of self-expandable microstents to facilitate coil embolization of broad-based intracranial aneurysms: an in vitro study.

INTRODUCTION: The use of self-expandable microstents for treatment of broad-based intracranial aneurysms is widely spread. However, poor fluoroscopic visibility of the stents remains disadvantageous during the coiling procedure. Flat detector angiographic computed tomography (ACT) provides high resolution imaging of microstents even though integration of this imaging modality in the neurointerventional workflow has not been widely reported. METHODS: An acrylic glass model was used to simulate the situation of a broad-based sidewall aneurysm. After insertion of a self-expandable microstent, ACT was performed. The resulting 3D dataset of the Microstent was subsequently projected into a conventional 2D fluoroscopic roadmap. This 3D visualization of the stent supported the coil embolization procedure of the in vitro aneurysm. RESULTS: In vitro 2D-3D coregistration with integration of 3D ACT data of a self-expandable microstent in a conventional 2D roadmap is feasible. CONCLUSIONS: Unsatisfying stent visibility constrains clinical cases with complex parent vessel anatomy and challenging aneurysm geometry; hence, this technique potentially may be useful in such cases. In our opinion, the clinical feasibility and utility of this new technique should be verified in a clinical aneurysm embolization study series using 2D-3D coregistration.

Proton magnetic resonance spectroscopy in pituitary macroadenomas: preliminary results.

OBJECT: The aim of this study was to correlate proton MR (1H-MR) spectroscopy data with histopathological and surgical findings of proliferation and hemorrhage in pituitary macroadenomas. METHODS: Quantitative 1H-MR spectroscopy was performed on a 1.5-T unit in 37 patients with pituitary macroadenomas. A point-resolved spectroscopy sequence (TR 2000 msec, TE 135 msec) with 128 averages and chemical shift selective pulses for water suppression was used. Voxel dimensions were adapted to ensure that the volume of interest was fully located within the lesion and to obtain optimal homogeneity of the magnetic field. In addition, water-unsuppressed spectra (16 averages) were acquired from the same volume of interest for eddy current correction, absolute quantification of metabolite signals, and determination of full width at half maximum of the unsuppressed water peak (FWHM water). Metabolite concentrations of choline-containing compounds (Cho) were computed using the LCModel program and correlated with MIB-1 as a proliferative cell index from a tissue specimen. RESULTS: In 16 patients harboring macroadenomas without hemorrhage, there was a strong positive linear correlation between metabolite concentrations of Cho and the MIB-1 proliferative cell index (R = 0.819, p < 0.001). The metabolite concentrations of Cho ranged from 1.8 to 5.2 mM, and the FWHM water was 4.4-11.7 Hz. Eleven patients had a hemorrhagic adenoma and showed no assignable metabolite concentration of Cho, and the FWHM water was 13.4-24.4 Hz. In 10 patients the size of the lesion was too small (< 20 mm in 2 directions) for the acquisition of MR spectroscopy data. CONCLUSIONS: Quantitative 1H-MR spectroscopy provided important information on the proliferative potential and hemorrhaging of pituitary macroadenomas. These data may be useful for noninvasive structural monitoring of pituitary macroadenomas. Differences in the FWHM water could be explained by iron ions of hemosiderin, which lead to worsened homogeneity of the magnetic field.