Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial-MIST-3.

Rationale: Assessing the early use of video-assisted thoracoscopic surgery (VATS) or intrapleural enzyme therapy (IET) in pleural infection requires a phase III randomized controlled trial (RCT). Objectives: To establish the feasibility of randomization in a surgery-versus-nonsurgery trial as well as the key outcome measures that are important to identify relevant patient-centered outcomes in a subsequent RCT. Methods: The MIST-3 (third Multicenter Intrapleural Sepsis Trial) was a prospective multicenter RCT involving eight U.K. centers combining on-site and off-site surgical services. The study enrolled all patients with a confirmed diagnosis of pleural infection and randomized those with ongoing pleural sepsis after an initial period (as long as 24 h) of standard care to one of three treatment arms: continued standard care, early IET, or a surgical opinion with regard to early VATS. The primary outcome was feasibility based on >50% of eligible patients being successfully randomized, >95% of randomized participants retained to discharge, and >80% of randomized participants retained to 2 weeks of follow-up. The analysis was performed per intention to treat. Measurements and Main Results: Of 97 eligible patients, 60 (62%) were randomized, with 100% retained to discharge and 84% retained to 2 weeks. Baseline demographic, clinical, and microbiological characteristics of the patients were similar across groups. Median times to intervention were 1.0 and 3.5 days in the IET and surgery groups, respectively (P = 0.02). Despite the difference in time to intervention, length of stay (from randomization to discharge) was similar in both intervention arms (7 d) compared with standard care (10 d) (P = 0.70). There were no significant intergroup differences in 2-month readmission and further intervention, although the study was not adequately powered for this outcome. Compared with VATS, IET demonstrated a larger improvement in mean EuroQol five-dimension health utility index (five-level edition) from baseline (0.35) to 2 months (0.83) (P = 0.023). One serious adverse event was reported in the VATS arm. Conclusions: This is the first multicenter RCT of early IET versus early surgery in pleural infection. Despite the logistical challenges posed by the coronavirus disease (COVID-19) pandemic, the study met its predefined feasibility criteria, demonstrated potential shortening of length of stay with early surgery, and signals toward earlier resolution of pain and a shortened recovery with IET. The study findings suggest that a definitive phase III study is feasible but highlights important considerations and significant modifications to the design that would be required to adequately assess optimal initial management in pleural infection.The trial was registered on ISRCTN (number 18,192,121).

Post-medistinoscopy chylopericardium.

Isolated Chylopericardium (without chylothorax) is a rare clinical disorder that may happen idiopathically or secondary to trauma, radiotherapy, lymphatic anomalies, infections or mediastinal neoplasm. We present a case of middle-aged male with no past medical history of note prior to developing heavy sweating, loss of weight and cough. A series of investigations were done including chest computed tomography which showed enlarged mediastinal lymph nodes leading to uncomplicated mediastinoscopy and lymph node biopsy. Six days after being discharged, he developed dyspnoea and chest pain. Echocardiography revealed massive pericardial effusion. Pericardiocentesis was done and surprisingly revealed milky white chylous fluid. The patient was then successfully managed without the need for further intervention.

Single crossclamp: Safe training tool for coronary artery bypass grafting.

OBJECTIVE: The single-crossclamp technique for coronary artery bypass grafting is recognized to reduce manipulation of the ascending aorta, and thereby improve neurological outcomes. However, there is a perceived disadvantage of long cardiopulmonary bypass and crossclamp times. Our objective was to evaluate outcomes with this technique and determine whether it is safe for training. METHODS: Patients undergoing coronary artery bypass between October 2005 and February 2014 with use of the single-crossclamp method were divided into 2 groups: a consultant group (n = 1024), and a trainee group (n = 504), depending on the primary surgeon. Their outcomes were compared. RESULTS: The consultants operated on more nonelective patients who had a higher risk profile (mean additive EuroSCORE I 4.05 vs. 3.80, p = 0.085; logistic EuroSCORE I 4.36 vs. 3.64, p = 0.002). There were 9 (0.9%) deaths in the consultant group and 5 (1%) in the trainee group. The mean number of grafts in the consultant group was greater, but the crossclamp time was similar and cardiopulmonary bypass time was shorter. There were 4 (0.4%) cerebrovascular events in the consultant group and 3 (0.6%) in the trainee group. Postoperative stay was shorter in the trainee group (7.19 vs. 7.97 days, p = 0.033). Other complication rates were similar. CONCLUSIONS: The technique has excellent outcomes, especially neurological, and is safe for training junior surgeons.

Salvage therapy with topical antifungal for Aspergillus fumigatus empyema complicating extrapleural pneumonectomy.

We describe an unusual case of Aspergillus fumigatus empyema and bronchopleural fistulae after extrapleural pneumonectomy (EPP) and chemoradiotherapy (CRT), which was treated successfully under salvage conditions with debridement, an innovative topical antifungal application and supplemented systemic antifungal therapy and which went on for a definitive surgical procedure. Combinations of CRT and EPP have been recommended in a select group of patients with malignant mesothelioma. Irrespective of the combination, EPP is associated with mortality in the range of 4-15% and a complication rate as high as 62%.

A prospective audit of endoscopic vein harvesting for coronary artery bypass surgery.

INTRODUCTION: The objectives of this study were to: (i) assess the feasibility of minimally invasive endoscopic harvesting of the long saphenous vein or radial artery for use as conduit during coronary artery bypass surgery in the NHS setting; and (ii) investigate the results of endoscopic vein harvesting with regards to postoperative complications, ability to mobilise, and patient satisfaction. PATIENTS AND METHODS: In this prospective audit, 25 consecutive patients, aged 52-90 years, undergoing either coronary artery bypass grafting alone or together with valve surgery or atrial fibrillation ablation were studied. All data were entered in purpose-designed proforma. Pre-operative risk factors including increasing age, diabetes, peripheral vascular disease, obesity, renal impairment, tobacco consumption and steroid use were documented. Time taken for harvest and conversion to traditional open vein harvest, quality of harvested vein in terms of number of repairs and vein damage were recorded. Postoperatively, we recorded harvest site wound complications, number of days to mobilise and total hospital stay. Pain score and patient satisfaction were also assessed. RESULTS: There was one death due to myocardial infarction; another patient had postoperative cerebrovascular accident. A total of 43 lengths of grafts were harvested, 41 were long saphenous vein and two radial artery. Vein harvest time reduced significantly from a maximum of 94 min to 34 min for two lengths of long saphenous vein. Three patients required conversion from endoscopic vein harvesting to open vein harvest. The only postoperative complication directly related to endoscopic harvesting was bruising along the tunnel created by the passage of the instruments. None of the patients had any wound complication; none required antibiotics or wound debridement. Mean time to mobilise was 3.4 days. All patients who underwent successful endoscopic vein harvesting expressed satisfaction with regards to postoperative pain and cosmetic result. CONCLUSIONS: Competence and ability to harvest conduit in an acceptable time frame are obtainable after a relatively low number of cases. The procedure is associated with a low number of postoperative complications and very high patient satisfaction.

A simple reproducible method of preventing lobar torsion.

Torsion of remaining lobes after pulmonary resection is a potentially serious complication with high reported morbidity and mortality. A range of additional procedures has been described, we have used a simple, effective, quick and easy to reproduce minor procedure to prevents torsion.

Do coronary artery bypass grafts using cephalic veins have a satisfactory patency?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether using the cephalic vein from the arm for coronary artery bypass grafts achieves an adequate patency rate. Only 219 papers were identified on Medline using the reported search and hand-searching of reference lists. Fourteen papers represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. The patency rate seems to be in the order of 50% at around three years for cephalic veins used for coronary bypass grafting, and this was variable. In addition, we identified only 181 cephalic veins used for coronary bypass grafting in the literature from seven papers. In lower extremity bypass procedures over 900 uses of the cephalic vein have been documented but again patency seems to be around 50% at three to five years. Arterialisation of the vein using an arteriovenous fistula, or angioscopy, have both been used as an attempt to improve patency. In addition, a large proportion of the reported cephalic veins for coronary grafting were used for sequential bypass grafting which may have affected patency rates. Thus, in summary, the patency of the cephalic vein used for coronary artery bypass grafting is around 50% at three years.

Truncus arteriosus communis: early and midterm results of early primary repair.

BACKGROUND: Repair of truncus arteriosus communis (TAC) in the neonatal and early infant period has become standard practice in many centers. We report our experience on early primary repair of TAC, with a focus on early and midterm results. METHODS: From July 1993 to December 2005, 29 patients with median age 28 days (range, 11 to 127), and median body weight 3.1 kg (range, 2.6 to 5.9 kg), underwent primary repair of TAC. The anatomical type of TAC was as follows: A1-2, 27; A3, 0; and A4, 2. Right ventricular outflow tract was reconstructed with an aortic (n = 7) or pulmonary homograft (n = 8), or a bovine (n = 11) or porcine valved xenograft (n = 3). Follow-up was complete for all patients. RESULTS: Hospital mortality was 3.4% (1 death due to respiratory infection). At a mean follow-up of 74 months (range, 2 to 149), 1 patient died suddenly 2 months after surgery (6-year actuarial survival 93%). Of the 27 midterm survivors, 14 (52%) underwent 30 interventional procedures including percutaneous balloon dilation with or without stenting for right ventricular outflow tract or branch pulmonary artery obstruction. Eight of them were reoperated on for right ventricle-to-pulmonary artery conduit replacement (n = 8, 23%), and aortic valve regurgitation (n = 1, 3.4%). The overall freedom from any reintervention at 6 years was 50%. Aortic valve regurgitation was trace in 15 patients, mild in 8, moderate in 4. All midterm survivors but 1 (26 of 27) had good ventricular function. CONCLUSIONS: Truncus arteriosus communis repair can be performed early with very low perioperative mortality and satisfactory midterm morbidity; the latter is mainly attributed to right ventricular outflow tract reconstruction. Interventional cardiac catheterization delays inevitable conduit replacement.

Intra-aortic balloon pumping in children undergoing cardiac surgery: an update of the Liverpool experience.

OBJECTIVE: Intra-aortic balloon pumping in children remains a rarity. We report our experience in supporting pediatric cardiac surgical patients with intra-aortic balloon pumping. METHODS: We reviewed the cases of 24 children supported with intra-aortic balloon pumping after cardiac surgery in our institution from 1994 through 2003. RESULTS: Mean age at the time of the operation was 5.0 +/- 5.6 years (range, 7 days-17.5 years). Ten patients were infants less than 6 months old. Mean weight was 18.9 +/- 18.1 kg (range, 3.5-58.7 kg). Indications for intra-aortic balloon pump deployment were postoperative hemodynamic deterioration (n = 11, 8 survivors), failure to wean off cardiopu(n = 7, 5 survivors), and prophylaxis before weaning off cardiopulmonary bypass (n = 6, 5 survivors). The balloon was inserted through the ascending aorta in infants and through the femoral artery in children. Eighteen children (7 infants) were weaned off the intra-aortic balloon pump successfully (intra-aortic balloon pump survival, 75%). Mean duration of intra-aortic balloon pump support was 121.3 +/- 140.60 hours (range, 8-670 hours). There were 3 post-intra-aortic balloon pump in-hospital deaths (survival to hospital discharge, 62.5%). Severe intra-aortic balloon pump-related complications were mesenteric ischemia in 1 patient and lower limb ischemia requiring intra-aortic balloon pump removal in 1 patient. At a mean follow-up of 85 +/- 31 months (range, 18-124 months), all 15 long-term survivors were alive and well. CONCLUSIONS: Use of an intra-aortic balloon pump is an effective modality of cardiac support in properly selected pediatric cardiac surgical patients with refractory low cardiac output. It can be safely used in small infants and neonates. In selected cases with known left ventricular dysfunction, there is a place for prophylactic use of an intra-aortic balloon pump.

Should patients post-cardiac surgery be given low molecular weight heparin for deep vein thrombosis prophylaxis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of prophylactic postoperative low molecular weight heparin (LMWH) or unfractionated heparin after cardiac surgery would significantly reduce morbidity by reducing the incidence of deep vein thromboses (DVTs) and pulmonary emboli (PEs). Altogether 390 papers were identified on Medline. Relevant major guidelines were also searched together with their reference lists. Sixteen papers represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that the benefit of heparin prophylaxis for the prevention of DVTs and PEs is well established in non-cardiac surgery with reductions in the incidence of DVTs reported to be of the order of 50-70% in orthopaedic, general and obstetric surgery and in general medicine. No studies have yet been performed in cardiac surgery, but contrary to the view that DVTs are rare, in fact the incidence of DVT post-cardiac surgery is up to 15-20% and the incidence of PE is around 0.5 to 4% although many of these occur after discharge and many may be difficult to detect clinically. This is similar to the incidence of patients undergoing high risk general surgery. There is no evidence that heparin prophylaxis started the day after surgery increases the risk of pericardial effusions and the risk of bleeding complications is estimated to be 4%. Thus, we recommend that all patients post-cardiac surgery be commenced on heparin prophylaxis the day after their surgery and continue this up to discharge even if mobile. The particular regime should be guided by the ACCP recommendations for prophylaxis in high risk general surgical patients.

Sutureless fixation of temporary pacing wire.

A simple sutureless technique of fixing ordinary straight insulated temporary pacing wire is described by creating a floret of the insulation of the wire. It can be easily accomplished and reproduced.

Total extracardiac cavopulmonary connection: an alternative technique of fenestration.

Fenestrating an extracardiac conduit used for total cavopulmonary connection normally requires an additional incision on the right-sided atrium and is time consuming. Herein we describe an alternative technique that may be used to facilitate this process, which consists of creating the fenestration by using part of the atrial incision resulting from the disconnection of the inferior vena cava from the right atrium. The advantages of this technique are avoidance of an extra incision and suture line on the atrium, and the ease of construction. This may be especially useful in patients with heterotaxy syndromes with mesocardia or dextrocardia, in whom the atrial mass is displaced posteriorly and can be difficult to reach. Closure of the fenestration can be easily performed at a later stage in the cardiac catheterization laboratory by using a septal occluding device.

Contegra bovine jugular vein right ventricle to pulmonary artery conduit in Ross procedure.

BACKGROUND: In the Ross procedure a valved conduit, most commonly pulmonary or aortic homograft, is used in place of autotransplanted pulmonary valve. Increasing demand and diminishing supply of homografts has resulted in a search for alternatives. A biological conduit from the valved segment of bovine jugular vein (Contegra) has been used successfully as an alternative. METHODS: Early clinical and echocardiographic results were analyzed retrospectively for 20 patients (median age 14.4 years) who underwent a Ross procedure with Contegra as right ventricle to pulmonary artery conduit between November and June 2003 (during the last 31 months). RESULTS: There was no operative mortality and late mortality or morbidity during the mean follow-up of 13.8 +/- 9.1 months (range 1 to 31 months). No patient required reoperation. The median gradient at discharge was 16 +/- 4.5 mm Hg, which remained unchanged at last follow-up. No deterioration in conduit or conduit valve function was noted. CONCLUSIONS: This new bovine jugular vein conduit can be a viable alternative to a homograft in the Ross procedure. The early clinical and hemodynamic results are encouraging. Ease of availability and favorable handling and technical characteristics make it more attractive than a homograft. Xenograft origin of this conduit necessitates close follow-up for assessment of durability and longer-term results.