Defective NOTCH signaling drives increased vascular smooth muscle cell apoptosis and contractile differentiation in bicuspid aortic valve aortopathy: A review of the evidence and future directions.

Bicuspid aortic valve (BAV) disease remains the most common congenital cardiac disease and is associated with an increased risk of potentially fatal aortopathy including aortic aneurysm and dissection. Mutations in the NOTCH1 gene are one of only a few genetic anomalies identified in BAV disease; however evidence for defective NOTCH signaling, and its involvement in the characteristic histological changes of VSMC apoptosis and differentiation in ascending aortae of BAV patients is lacking. This review scrutinizes the evidence for the interactions of NOTCH signaling, cellular differentiation and apoptosis in the context of aortic VSMCs and provides focus for future research efforts in the diagnosis of BAV aortopathy and prevention of catastrophic complications through NOTCH signaling manipulation.

Endoscopic ultrasound in esophageal carcinoma: comparison with multislice computed tomography and importance in the clinical decision making process.

AIM: As resective surgery for oesophageal carcinoma is only appropriate for a selected cohort of patients, preoperative staging plays an important role in the management of these patients. This study assessed the accuracy of endoscopic ultrasound (EUS) staging in comparison with computerised tomography (CT) staging and the impact of EUS in management of patients with oesophageal carcinoma undergoing gastro-esophagectomy. METHODS: Ninety-six consecutive patients with oesophageal carcinoma underwent preoperative staging with multislice CT and EUS. Of these, 50 patients underwent gastro-esophagectomy, allowing preoperative staging data from these imaging modalities to be compared to postoperative histopathological staging, classified according to the TNM system. Management plans for these patients made without use of EUS were then compared to those following EUS staging. RESULTS: The overall accuracy rate of EUS for T staging was 64%, showing good agreement with postoperative histopathological staging of the resected specimen (weighted k=0.42, 95%CI= 0.32-0.52). In terms of clinical decision making, the T stage accuracy rose to 90% when differentiating T1 from T2/3 lesions. In terms of N staging, the overall accuracy was 72% (weighted k=0.44, 95% CI=0.34-0.54). In comparison, N staging by CT was significantly less accurate (62% vs 72%, P<0.01, chi squared) and showed poor agreement with postoperative histopathological nodal staging (weighted k=0.24, 95%CI =0.11-0.37). Importantly, in 56% of patients, staging information obtained from EUS instigated change in management compared to that configured without EUS. CONCLUSION: EUS enhances preoperative staging of oesophageal cancer and is important in preoperative clinical decision making process, especially with increasing use of neoadjuvant chemotherapy.

Synchronous thymoma and lung carcinoma resected via median sternotomy with VATS guidance.

Synchronous tumours of the thymus and lung are rare. We describe the case of a 57-year-old gentleman, who presented with a large type AB thymoma in the superior anterior mediastinum and a primary bronchogenic adenocarcinoma in the right upper lobe. In view of this, he underwent surgical resection of the thymoma directly through amedian sternotomy and right upper lobectomy via the median sternotomy with video assisted thoracoscopic guidance.

Aortic root replacement in cardiac dextroversion.

Adult cardiac surgery in patients with malrotation of the heart is rare. A 60 year-old lady, with known cardiac dextroversion, presented with dyspnoea and pre-syncopal attacks. Echocardiographical and radiological investigation confirmed the dextroversion, with clockwise rotation of the heart through its longitudinal axis. This resulted in the right ventricular outflow tract and pulmonary artery being wrapped anteriorly around the aorta, with posterior displacement of the right atrium. The presence of a heavily calcified, bicuspid aortic valve and dilated ascending aorta was also demonstrated. At surgery, venous cannulation was established by rotating the heart anticlockwise and access to the aortic valve gained with a more superior oblique aortotomy. In the presence of a dilated ascending aorta with a calcified, bicuspid aortic valve, the aortic root was replaced with a valved conduit. To the authors' knowledge, this is the first report of an aortic root replacement in a patient with cardiac dextroversion.

Emergency intensive care admission following elective thoracic surgery.

AIM: The aim of this study was to analyse the outcomes of patients admitted to the intensive care unit (ICU) following initial recovery after elective thoracic surgery. METHODS: The case notes of all patients who underwent elective thoracic surgery over a one-year period were reviewed. Patients who were admitted to ICU following an initial recovery on the ward were identified and their postoperative course analysed. The clinical and demographic characteristics of these patients were recorded and their outcomes analysed. RESULTS: A total of 20 patients were admitted to ICU of whom 13 (65%) were admitted for respiratory complication, 5 with sepsis and 2 with cardiovascular instability. Sixteen (80%) patients required CPAP or BIPAP, of whom only 7 (35%) required mechanical ventilation. Renal support was required in 7 patients, with 2 (10%) requiring haemofiltration. ICU survival was 15 patients (75%), whilst overall three-month survival post ICU admission was 65%. Requirement for renal support was the only predictor of mortality on univariate and multivariate analysis. CONCLUSIONS: Salvage ICU admission following elective thoracic surgery is associated with significant mortality, however the outcome is far from hopeless. The majority of patients can be managed without recourse to mechanical ventilation or haemofiltration. The need for renal support is, however, a significant adverse prognostic indicator.

Left atrial phaeochromocytoma.

Phaeochromocytomas of the heart are very rare. This report describes the case of a 69 year old woman presenting with persistent hypertension and a left atrial phaeochromocytoma diagnosed by 131I-metaiodobenzylguanidine scintigraphy scanning. She was successfully treated by surgical excision with the aid of cardiopulmonary bypass and perioperative alpha and beta adrenergic blockade.