Four decades of experience with carcinoid heart disease: An analysis of 84 patients.

Carcinoid heart disease (CHD) is a serious cardiac condition which is caused by elevated serotonin in the systemic circulation, secreted by neuroendocrine tumours (NET). It mostly affects the right-sided heart valves, where it causes fibrotic disturbances and is associated with worse survival. In this study, we describe a large cohort of patients with CHD and provide an insight into their survival over the past decades. All consecutive patients with a serotonin producing NET and CHD referred to the Netherlands Cancer Institute that presented with CHD or developed CHD during their follow up time were included from 1984 until 2021. Patients were divided into three time periods: 1984-2000, 2000-2010 and 2010-2018. Median N-terminal pro B-type natriuretic protein (NT-proBNP) and serum serotonin levels were stratified according to tricuspid regurgitation severity. Kaplan-Meier curves and log rank test were used for visualisation of survival. Cox regression was used for identification of the characteristics associated with disease specific mortality (DSM). A total of 84 patients with CHD were included of whom 49 (58.3%) were male. Median age at NET diagnosis was 62.3 (range 23.9-81.7) years, and median time to development of CHD was 1.1 (range 0-24.2) years. NT-proBNP was significantly higher when more severe tricuspid regurgitation (TR) was present (p = .027). Median survival from CHD diagnosis for 1984-2000, 2000-2010 and 2010-2018 were 1.3 (confidence interval [CI]: 0.9-1.6), 1.9 (CI: 1.2-2.6) and 3.9 (CI: 1.7-6.2) years (p = .025). Valve replacement surgery (VSR) occurred more frequent in later time periods. VSR (hazard ratio [HR] 0.33, p = .005) and NT-proBNP (HR 1.003, 1.00-1.005, p = .036) were significantly associated with DSM. The prognosis of patients with CHD has improved over the past decades, possibly caused by more VSR. NT-proBNP is a valuable biomarker in patients with CHD. Clinical practice should be aimed at timely diagnosis and intervention of CHD.

Successful treatment of bronchial stenosis after lung transplantation.

Treatment of stenotic anastomosis after lung transplantation can be challenging. In this case report, we present a case in which 3D computed tomography reconstructions guided the clinical decision towards operative bronchoplasty after which our patient was treated successfully.

Effect of computed tomography before cardiac surgery on surgical strategy, mortality and stroke.

AIM: To investigate whether preoperative chest computed tomography (CT) decreases postoperative mortality and stroke rate in cardiac surgery by detection of calcifications and visualization of postoperative anatomy in redo cardiac surgery which can be used to optimize the surgical approach. METHODS: The PubMed, EMBASE and Cochrane databases were searched and articles concerning preoperative CT in cardiac surgery were included. Articles not reporting mortality, stroke rate or change in surgical approach were excluded. Studies concerning primary cardiac surgery as well as articles concerning redo cardiac surgery were both included. RESULTS: Eighteen studies were included (n=4057 patients) in which 2584 patients received a preoperative CT. Seven articles (n=1754 patients) concerned primary surgery and eleven articles (n=2303 patients) concerned redo cardiac surgery. None of the studies was randomized but 8 studies provided a comparison to a control group. Stroke rate decreased with 77-96% (primary surgery) and 18-100% (redo surgery) in patients receiving a preoperative CT. Mortality decreased up to 66% in studies investigating primary surgery while the effect on mortality in redo surgery varied widely. Change in surgical approach based on CT-findings consisted of choosing a different cannulation site, opting for off-pump surgery and cancellation of surgery. CONCLUSIONS: Current evidence suggests that preoperative CT imaging may lead to decreased stroke and mortality rate in patients undergoing primary cardiac surgery by optimizing surgical approach. In patients undergoing redo cardiac surgery stroke rate is also decreased but the effect on mortality is unclear. However, evidence is weak and included studies were of moderate quality.

Crossed wiring closure technique for bilateral transverse thoracosternotomy is associated with less sternal dehiscence after bilateral sequential lung transplantation.

OBJECTIVE: Bilateral transverse thoracosternotomy (clamshell incision) is a widely used approach in bilateral sequential lung transplantation, but the closure technique is associated with sternal dehiscence. This study compares the incidence of sternal dehiscence between the crossed and uncrossed closure techniques. METHODS: In 129 patients who underwent transplantation through a clamshell incision, the sternum was closed using either the crossed or the uncrossed method based on the surgeon's preference. The position of the sternal parts was evaluated on lateral chest radiographs and scored as normal, override, or separation. RESULTS: We observed sternal override in 38 patients and separations in 18 patients. The sternum was closed using the uncrossed method in 79 patients and the crossed method in 50 patients. There were significantly fewer overrides (n = 6, 12.0%) and separations (n = 6, 12.0%) of the sternal parts using the crossed closure technique compared with the uncrossed technique (32 overrides, 41.0%; and 12 separations, 15.1%; P < .001). Reconstructive surgery was only performed in patients with separation of the sternal parts (n = 10). CONCLUSIONS: Using the crossed closure technique for the sternum after bilateral sequential lung transplantation reduces the incidence of sternal dehiscence compared with the uncrossed closure technique and, therefore, reduces the necessity of reconstructive surgery.

Staphylococcus aureus pericardial abscess presenting as a localized bulge of the heart contour.

Purulent pericarditis usually presents as an acute illness with diffuse involvement of the whole pericardium, but can rarely present as a localized effusion. Here, we present a patient with a pericardial abscess caused by Staphylococcus aureus. After surgical drainage of the abscess, the patient made a good recovery. To the best of our knowledge, this is the first case of a pericardial abscess presenting as a localized bulge of the heart contour on the chest X-ray.