Coagulopathy in patients with acute pulmonary embolism: a pilot study of whole blood coagulation and markers of endothelial damage.

Whole blood coagulation and markers of endothelial damage were studied in patients with acute pulmonary embolism (PE), and evaluated in relation to PE severity. Twenty-five patients were enrolled prospectively each having viscoelastical analysis of whole blood done using thrombelastography (TEG) and Multiplate aggregometry. Fourteen of these patients were investigated for endothelial damage by ELISA measurements of Syndecan-1 (endothelial glycocalyx degradation), soluble endothelial Selectin (endothelial cell activation), soluble Thrombomodulin (endothelial cell injury) and Histone Complexed DNA fragments (endothelial cytotoxic histones). The mean values of TEG and Multiplate parameters were all within the reference levels, but a significant difference between patients with high and intermediate risk PE was observed for Ly30 (lytic activity) 1.5% [0-10] vs. 0.2% [0-2.2] p = .04, and ADP (platelet reactivity) 92 U [20-145] vs. 59 U [20-111] p = .03. A similar difference was indicated for functional fibrinogen 21 mm [17-29] vs. 18 mm [3-23] p = .05. Analysis of endothelial markers identified a significant difference in circulating levels between high and intermediate risk PE patients for Syndecan-1 118.6 ng/mL [76-133] vs. 36.3 ng/mL [11.8-102.9] p = .008. In conclusion, patients with acute PE had normal whole blood coagulation, but high risk PE patients had signs of increased activity of the haemostatic system and significantly increased level of endothelial glycocalyx degradation.

Transit-time flow measurement as a predictor of coronary bypass graft failure at one year angiographic follow-up.

BACKGROUND: Transit-time flow measurement (TTFM) is a commonly used intraoperative method for evaluation of coronary artery bypass graft (CABG) anastomoses. This study was undertaken to determine whether TTFM can also be used to predict graft patency at one year postsurgery. METHODS: Three hundred forty-five CABG patients with intraoperative graft flow measurements and one year angiographic follow-up were analyzed. Graft failure was defined as more than 50% stenosis including the "string sign." Logistic regression analysis was used to analyze the risk of graft failure after one year based on graft vessel type, anastomatic configuration, and coronary artery size. RESULTS: Nine hundred eighty-two coronary anastomoses were performed of which 12% had signs of graft failure at one year angiographic follow-up. In internal mammary arteries (IMAs), analysis showed a 4% decrease in graft failure odds for every 1 mL/min increase in TTFM (OR = 0.96, CI = [0.93; 0.99], p = 0.005). ROC analysis showed good discriminative ability for TTFM alone AUC = 69.5% in IMA grafts. For single-vein grafts the decrease in graft failure odds was 2% for every 1 mL/min increase in TTFM (OR = 0.98; CI = [0.97; 1.00], p = 0.059) and AUC of 59.9%. There were no significant relationships between TTFM and graft failure in other graft types or graft configurations. CONCLUSION: The TTFM method has good discriminative ability for assessing the risk of graft failure in certain graft types within the first year after CABG surgery and is a valuable instrument for intraoperative quality assessment of bypass grafts.

Transient internal mammary artery graft stenosis on early angiography: navigating pitfalls in hybrid myocardial revascularization.

OBJECTIVES: Left internal mammary artery (LIMA) graft stenoses detected at early coronary angiography may be reversible and consequently prompt unnecessary graft revision. We aim to investigate the frequency, natural course, and clinical significance of internal mammary artery graft stenosis upon early angiography in patients undergoing hybrid myocardial revascularization. METHODS: In this retrospective sub-study of the Coronary Hybrid Revascularization Study, we compared graft appearance, ie, stenosis degree and flow, on early (in-hospital) and scheduled follow-up coronary angiography after 1 year. We assessed the change in graft patency using the Fitzgibbon classification (grade A: unimpaired runoff; grade B > 50% stenosis; grade O: occlusion), as well as graft association with adverse events (death, myocardial infarction, stroke, and repeat revascularization) at up to 5-year follow-up. RESULTS: We report clinical follow-up data for all 131 patients included in the Coronary Hybrid Revascularization Study. Change in graft patency was analyzed in 86 patients with satisfactory visualization of the LIMA graft on early and follow-up coronary angiography. All LIMA grafts were patent at discharge and follow-up. Twenty-seven of 37 (73%) grade B graft stenoses at early angiography resolved to grade A during follow-up of median 12 months (range, 8-83 months) after surgery. Angiographically significant graft stenoses at early coronary angiography were not associated with adverse clinical outcome up to 5-year follow-up. CONCLUSIONS: Our results suggest that the majority of clinically silent LIMA graft stenoses resolve during follow-up and are not associated with adverse clinical outcomes.

Reliable and valid assessment of performance in thoracoscopy.

BACKGROUND: As we move toward competency-based education in medicine, we have lagged in developing competency-based evaluation methods. In the era of minimally invasive surgery, there is a need for a reliable and valid tool dedicated to measure competence in video-assisted thoracoscopic surgery. The purpose of this study is to create such an assessment tool, and to explore its reliability and validity. METHODS: An expert group of physicians created an assessment tool consisting of 10 items rated on a five-point rating scale. The following factors were included: economy and confidence of movement, respect for tissue, precision of operative technique, creation and placement of ports, localization of pathologic tissue, use of staplers, retrieval of tissue in bag and placement of chest tube. Fifty consecutive thoracoscopic wedge resections were recorded and assessed blindly and independently by two experts using the tool. RESULTS: Four residents, four fellows and five consultants performed 1-10 (median 4) operations each. The fellows performed significantly better than the residents (P = 0.03; effect size, ES = 0.72). The consultants scored 11% higher than the fellows, but this difference was not significant (P = 0.10, ES = 0.64). The inter-rater reliability was acceptable (Cronbach's alpha 0.71). CONCLUSIONS: This tool for assessing performance in thoracoscopy is reliable and valid. It can provide unbiased feedback to trainees, and can be used to evaluate new teaching curricula, i.e. simulation-based training. Furthermore, it has potential to aid in certification of new thoracic surgeons.

Surgical treatment of acute pulmonary embolism--a 12-year retrospective analysis.

OBJECTIVES: Surgical embolectomy for acute pulmonary embolism (PE) is considered to be a high risk procedure and therefore a last treatment option. We wanted to evaluate the procedures role in modern treatment of acute PE. DESIGN: All data on patients treated with surgical embolectomy for acute PE were retrieved from our clinical database. The mortality was extracted from the Danish mortality register. RESULTS: From October 1998 to July 2010, 33 patients underwent surgical embolectomy. All procedures were done through a median sternotomy and extracorporeal circulation. Twenty-six patients were diagnosed with a high risk PE and 7 with an intermediate risk PE and intracardial pathology. Six patients had been insufficiently treated with thrombolysis. Thirteen patients had contraindication for thrombolysis. Six patients were brought to the operating theatre in cardiogenic shock, 8 needed ventilator support, and 1 was in cardiac arrest. The postoperative 30-day mortality was 6% and during the 12-year follow-up the cumulative survival was 80% with 4 late deaths. CONCLUSION: Surgical pulmonary embolectomy can be performed with low mortality although the treated patients belong to the most compromised part of the PE population. The results support surgical embolectomy as a vital part of the treatment algorithm for acute PE.

Outcomes of isolated tricuspid valve surgery in contemporary practice.

OBJECTIVES: Isolated tricuspid valve (TV) surgery is rarely performed and has been associated with high mortality and morbidity. The aim of this study was to describe the clinical outcome and functional capacity following isolated TV surgery in contemporary practice. METHODS: We conducted a retrospective cohort study including all patients who underwent isolated TV surgery at our institution from 2013 to 2019. Our cohort was identified using the Western Denmark Heart Registry. Postoperative outcomes were evaluated using patients' medical records. The clinical and echocardiographic status was reported for patients who survived beyond 1 year. RESULTS: We included 43 patients [mean age 65.2 ± 13.8, median European System for Cardiac Operative Risk Evaluation II 1.8 (interquartile range 2.0)]. Twelve (27.9%) had prior cardiac surgery. Up to 90-day follow-up, no patient died and major morbidity was limited to 4 patients (9.3%) requiring pacemaker implantation and 1 patient requiring 2 reoperations. Within 1 year, 4 patients (9.3%) died. Nine patients (20.1%) required single readmission for cardiac reasons during the median follow-up of 38.4 months (interquartile range 30.9 months). All patients who survived beyond 1 year (n = 39) completed clinical follow-up. At follow-up, 38/39 (97.4%) patients were New York Heart Association I or II compared to 12/39 (30.8%) preoperatively (P = 0.001). The presence of oedema and intensity of diuretic treatment were significantly reduced (P = 0.005 and P = 0.008, respectively). Echocardiographic follow-up showed significant improvement of TV dysfunction in all patients. CONCLUSIONS: Our results suggest that isolated TV surgery can be performed safely and greatly improve patients' functional status. Our findings support the importance of optimal surgical timing and patient selection.

[Trikuspidalklapinsufficiens].

Tricuspid regurgitation (TR) has in recent literature been described as an independently progressive disorder associated with a poor prognosis. Studies have emphasized the importance of a more proactive approach in treating TR in order to prevent progression of right ventricular dysfunction and ultimately right heart failure. These findings have renewed interest in surgical treatment for isolated TR whilst also fueling rapid advancements in transcatheter therapies, as argued in this review.

Tricuspid annular plane systolic excursion is significantly reduced during uncomplicated coronary artery bypass surgery: A prospective observational study.

OBJECTIVES: Longitudinal shortening constitutes most of the right ventricle (RV) contraction in the normal heart. However, after even uncomplicated cardiac surgery with preserved RV function a significant and sustained decrease in longitudinal contraction expressed as a reduction in tricuspid annular plane systolic excursion (TAPSE) has been observed. Why and exactly when this happens remains unsettled. The aim of this study was to evaluate the magnitude and timing of changes in TAPSE in relation to sternotomy, pericardial opening, cardiopulmonary bypass (CPB), and chest closure. METHODS: Fifty patients with normal preoperative ejection fraction and no valvulopathy, who underwent coronary artery bypass grafting with the use of CPB, were included. TAPSE was assessed using transthoracic echocardiography (TTE) at baseline and immediately after chest closure. Transesophageal echocardiography was performed at the following time points: after (1) anesthesia induction and transthoracic echocardiography; (2) sternotomy; (3) pericardiotomy; (4) completion of CPB; and (5) chest closure. RESULTS: TAPSE was significantly reduced to approximately half of its initial value in all patients (from 22 [95% confidence interval, 21-23 mm] after anesthesia induction to 9 [95% confidence interval, 8-10 mm] after chest closure). No change was seen after pericardiotomy. The most prominent reduction (30%-40%) was observed after weaning from CPB. An additional significant decrease of 13% to 16% was seen after chest closure. CONCLUSIONS: TAPSE was consistently reduced to approximately half of its initial value after uncomplicated coronary artery bypass grafting surgery. The reduction happened mainly after weaning from CPB, possibly reflecting conformational change of the RV.

Acute Pulmonary Embolism in a National Danish Cohort: Increasing Incidence and Decreasing Mortality.

This study reports the incidence, clinical profile and mortality for acute pulmonary embolism (PE) patients in the Danish population in four eras from 2004 to 2014. Patients admitted with first-time acute PE from 2004 through 2014 were identified from national patient registries classified according to the International Classification of Diseases, 10th edition, World Health Organization. A total of 30,275 patients from a population of 4,301,673 adult residents aged 18 years or older were diagnosed with first-time acute PE, corresponding to an incidence of 64 (95% confidence interval: 61-66) per 100,000 adult residents per year. Throughout the study period, PE incidence increased from 45 to 83 per 100,000 adult residents. Age at disease onset also increased during the study period, rising from 67.1 to 68.0 (p = 0.002). Cancer was the most frequent concomitant diagnosis, with an incidence of 15.9%. Thoracic computed tomography and referral to specialized cardiac centres increased significantly throughout the study period. The 30- and 90-day mortality rates decreased between 2004 and 2014 from 17 to 11% and from 23 to 18% (p < 0.00), respectively. The 5-year mortality risk was reduced when comparing Era IV (2012-2014) with Era I (2004-2005), with a hazard ratio of 0.93 (p = 0.01). In Denmark, the annual incidence of acute PE has increased during the past decade from 45 to 83 per 100,000 adults with a significant decrease in both short- and long-term mortalities. In recent years, patients were more likely to be investigated with modern diagnostics and referred to cardiac centres for specialized treatment.

Surgical embolectomy compared to thrombolysis in acute pulmonary embolism: morbidity and mortality.

OBJECTIVES: The aim of this study was to investigate the long-term outcome after acute high- and intermediate-risk pulmonary embolism (PE) treated with surgical embolectomy or thrombolysis. METHODS: Prospective follow-up including assessment of 30-day and 5-year mortality. Clinical evaluation including ventilation/perfusion scintigraphy by single-photon emission computed tomography in combination with X-ray computed tomography, measurement of pulmonary diffusion impairment, spirometry and echocardiography. RESULTS: A total of 136 patients (64 with high-risk and 72 with intermediate-risk PE) were included, 80 participated in the clinical follow-up, 16 were alive but declined follow-up and 40 were deceased. For high-risk PE patients the median time to clinical follow-up was 31 months [8­133]. No significant difference was observed in 30-day (Plog-rank = 0.16) or 5-year (Plog-rank = 0.53) mortality between patients treated with surgical embolectomy or thrombolysis. Ventilation/perfusion mismatch identified residual emboli in 4 patients (31%) treated with surgical embolectomy compared to 16 (76%) treated with thrombolysis (P = 0.009). Pulmonary diffusion impairment was identified in 4 patients (31%) treated with surgical embolectomy in comparison to 15 (71%) treated with thrombolysis (P = 0.02). In intermediate-risk PE patients, no significant difference in mortality (Plog-rank = 0.51 and 0.86), diffusion impairment or ventilation/perfusion mismatch was found between patients treated with surgical embolectomy or thrombolysis. CONCLUSIONS: Surgical embolectomy for acute high-risk PE has similar mortality, but better outcome on pulmonary end-points when compared to thrombolysis. Patients with high-risk PE could benefit from being referred to a centre with both specialized cardiology and cardiothoracic surgery for interdisciplinary evaluation of optimal treatment strategy.

[Patients with acute critical pulmonary embolism should be evaluated and treated in a centre with medical and surgical possibilities]. / Patienter med svær akut lungeemboli bør visiteres til centre med thoraxkirurgisk ekspertise.

Acute pulmonary embolism (PE) is a common and potential lifethreatening condition. Nevertheless the advancements in the patient visitation and treatment algorithms have been few and the mortality unchanged high. Acute high risk PE, which is the most serious subtype, is primary treated with trombolysis. This treatment is not always possible or sufficient. Recent studies have shown that surgical embolectomy is a relevant treatment offer with low mortalities of 6-8%. Patients with acute critical PE should be evaluated and treated in a multidisciplinary centre with medical and surgical possibilities.

Simulation-based training for thoracoscopy.

INTRODUCTION: An increasing proportion of thoracic procedures are performed using video-assisted thoracic surgery. This minimally invasive technique places special demands on the surgeons. Using simulation-based training on artificial models or animals has been proposed to overcome the initial part of the learning curve. This study aimed to investigate the effect of simulation-based training and to compare self-guided and educator-guided training. METHODS: The study included a surgeon group (n = 10) and 30 randomized novices in 3 groups. A control group (n = 10) and the group of surgeons (n = 10) were tested with no previous simulator training. A self-guided training group (n = 10) and an educator-guided training group (n = 10) trained for 3 hours on 3 scenarios of increasing fidelity and difficulty before taking a standardized test consisting of performing a wedge resection on a porcine lung, which was recorded and assessed blindly and independently by 2 thoracoscopic experts using a modified version of a validated assessment tool. RESULTS: Interrater reliability was acceptable (Spearman ρ = 0.73, P < 0.001). The control group and the self-guided training group performed significantly worse than the experienced surgeons (P = 0.012 and P = 0.010, respectively). There was no significant difference between the educator-guided training group and the experienced surgeons (P = 0.271). CONCLUSIONS: This randomized study concerning simulation-based training for thoracoscopy showed that 3 hours of intensive simulator training with a dedicated educator enables novices to perform an acceptable wedge resection in a simple, simulated model. Although not significant, it seemed that having an educator present during training had a beneficiary effect. Transfer studies are required for further conclusions.

[Recurring pneumothorax due to traumatic rupture of the diaphragm]. / Recidiverende pneumothorax på grund af traumatisk diafragmalæsion.

We present a case where a patient is diagnosed with a traumatic right-sided diaphragmatic rupture ten years after the trauma, after eight incidences of pneumothorax and two thoracoscopic operations. Ten years before the current case, the female patient was the victim of a blunt thoraco-abdominal trauma. In the following years, she had recurrent right-sided pneumothorax and no effect of thoracoscopic surgery. In connection with the third thoracoscopic operation, a right-sided diaphragm lesion was discovered. We believe that part of the syndrome catamenial pneumothorax, where air is thought to pass through the cervix, could explain her condition.