Contralateral Pneumonectomy 27 Years After Right Single-Lung Transplantation for Emphysema: A Case Report.

BACKGROUND Following single-lung transplantation, native lung inflation can progressively develop in patients with emphysema. CASE REPORT A 74-year-old female patient presented with worsening dyspnea during daily activities. She underwent a right single-lung transplantation for emphysema 27 years ago. Despite recurrent episodes of acute rejection of the grafted lung, the patient had satisfactory recovery of physical fitness during that period and did not report any serious complications or respiratory symptoms. Her recent dyspnea was due to hyperinflation of the native emphysematous lung with mediastinal shift, reduction of venous blood return, and compression of the grafted lung. Although surgical lung volume reduction had resulted in temporary functional improvement 2 years ago, a completion contralateral pneumonectomy was deemed necessary to allow re-expansion of the grafted lung. After anesthesia induction and placement of a double-lumen tube, selective ventilation of the left emphysematous native lung confirmed the absence of gas exchange based on near-zero end-expiratory carbon dioxide fraction. During selective ventilation of the grafted lung, satisfactory gas exchange was achieved and pneumonectomy proceeded uneventfully under minimally-invasive thoracotomy. Immediately after anesthesia emergence and tracheal extubation, the patient experienced respiratory improvement. Continuous thoracic epidural blockade allowed pain-free mobilization and respiratory therapy to facilitate re-expansion of the grafted lung. CONCLUSIONS After single-lung transplantation in COPD patients, native lung hyperinflation is a well-described rare complication. Lung volume reduction including pneumonectomy can be considered a valuable treatment option.

Arterial Wave Reflection and Aortic Valve Stenosis: Diagnostic Challenges and Prognostic Significance.

Introduction: Arterial wave reflection is an important component of the left ventricular afterload, affecting both pressure and flow to the aorta. The aim of the present study was to evaluate the impact of wave reflection on transvalvular pressure gradients (TPG), a key parameter for the evaluation of aortic valve stenosis (AS), as well as its prognostic significance in patients with AS undergoing a transcatheter aortic valve replacement (TAVR). Materials and Methods: The study population consisted of 351 patients with AS (mean age 84 ± 6 years, 43% males) who underwent a complete hemodynamic evaluation before the TAVR. The baseline assessment included right and left heart catheterization, transthoracic echocardiography, and a thorough evaluation of the left ventricular afterload by means of wave separation analysis. The cohort was divided into quartiles according to the transit time of the backward pressure wave (BWTT). Primary endpoint was all-cause mortality at 1 year. Results: Early arrival of the backward pressure wave was related to lower cardiac output (Q1: 3.7 ± 0.9 lt/min vs Q4: 4.4 ± 1.0 lt/min, p < 0.001) and higher aortic systolic blood pressure (Q1: 132 ± 26 mmHg vs Q4: 117 ± 26 mmHg, p < 0.001). TPG was significantly related to the BWTT, patients in the arrival group exhibiting the lowest TPG (mean TPG, Q1: 37.6 ± 12.7 mmHg vs Q4: 44.8 ± 14.7 mmHg, p = 0.005) for the same aortic valve area (AVA) (Q1: 0.58 ± 0.35 cm2 vs 0.61 ± 0.22 cm2, p = 0.303). In multivariate analysis, BWTT remained an independent determinant of mean TPG (beta 0.3, p = 0.002). Moreover, the prevalence of low-flow, low-gradient AS with preserved ejection fraction was higher in patients with early arterial reflection arrival (Q1: 33.3% vs Q4: 14.9%, p = 0.033). Finally, patients with early arrival of the reflected wave (Q1) exhibited higher all-cause mortality at 1 year after the TAVR (unadjusted HR: 2.33, 95% CI: 1.17-4.65, p = 0.016). Conclusion: Early reflected wave arrival to the aortic root is associated with poor prognosis and significant aortic hemodynamic alterations in patients undergoing a TAVR for AS. This is related to a significant decrease in TPG for a given AVA, leading to a possible underestimation of the AS severity.

Prognostic Implications of the Novel Pulmonary Hypertension Definition in Patients with Aortic Stenosis after Transcatheter Valve Replacement.

Introduction: Pulmonary hypertension (PH), traditionally defined as a mean pulmonary artery pressure (PAP) ≥ 25 mmHg, is associated with poor outcomes in patients undergoing a transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Recently, a novel definition for PH has been proposed, placing the cut-off value of mean PAP at 20 mmHg, and introducing pulmonary vascular resistance as an exclusive indicator for the pre-capillary involvement. In light of the novel criteria, whether PH still preserves its prognostic significance remains unknown. Methods: The study population consisted of 380 patients with AS, who underwent a right heart catheterization before TAVR. The cohort was divided according to the presence of PH (n = 174, 45.7%) or not. Patients with PH were further divided into the following groups: (1) Pre-capillary PH ((Pre-capPH), n = 46, 12.1%); (2) Isolated post-capillary PH ((IpcPH), n = 78, 20.5%); (3) Combined pre and post-capillary PH ((CpcPH), n = 82, 21.6%). The primary endpoint was all-cause mortality at 1 year. Results: A total of 246 patients (64.7%) exhibited mean PAP > 20 mmHg. Overall, the presence of PH was associated with higher 1-year mortality rates (hazard ratio (HR) 2.8, 95% CI: 1.4−5.8, p = 0.004). Compared to patients with no PH, Pre-capPH and CpcPH (but not IpcPH) were related to higher 1-year mortality (HR 2.7, 95% CI: 1.0−7.2, p = 0.041 and HR 3.9, 95% CI: 1.8−8.5, p = 0.001, respectively). This remained significant even after the adjustment for baseline comorbidities. Conclusions: Pre-interventional PH according to the novel hemodynamic criteria, is linked with poor outcomes in patients undergoing TAVR for severe AS. However, this is mainly driven by patients with mean PAP ≥ 25 mmHg. Patients with a pre-capillary PH component as defined by increased PVR present an even worse prognosis as compared to patients with isolated post-capillary or no PH who present comparable 1-year mortality rates.

Ventilatory efficiency slope is associated with cardiopulmonary complications after thoracoscopic anatomical lung resection.

OBJECTIVES: The aim of this study was to identify whether steeper V.E/V. CO2 slope was associated with cardiopulmonary complications (CPC) after anatomical resection by video-assisted thoracic surgery. Long-term survival was analysed as secondary outcome. METHODS: We reviewed the files of all consecutive patients who underwent pulmonary anatomical resections by video-assisted thoracic surgery between January 2010 and October 2020 at the Centre for Thoracic Surgery of Western Switzerland. Logistic regression was used to investigate the risk of CPC associated with the V.E/V.CO2 slope and other possible confounders. Survival was analysed with Kaplan-Meier curves. Risk factors associated with survival were analysed with a Cox proportional hazards model. RESULTS: The V.E/V.CO2 slope data were available for 145 patients [F/M: 66/79; mean age (standard deviation): 65.8 (8.9)], which were included in the analysis. Patients underwent anatomical resection [lobectomy (71%) or segmentectomy (29%)] mainly for lung cancer (96%). CPC and all-cause 90-day mortality were 29% and 1%, respectively. The mean (standard deviation) percentage of the predicted V.O2peak was 70% (17). Maximum effort during cardiopulmonary exercise test was reached in only 31% of patients. The V.E/V.CO2 slope (standard deviation) was not different if the maximum effort was reached or not [39 (6) vs 37 (7), P = 0.21]. V.E/V.CO2 slope >35 was associated with an increased risk of CPC (odds ratio 2.9, 95% confidence interval 1.2, 7.2, P = 0.020). V.E/V.CO2 slope >35 was not associated with shorter survival censored for lung cancer-related death. CONCLUSIONS: V . E/V.CO2 slope >35 is significantly associated with postoperative CPC after anatomical resections by video-assisted thoracic surgery. CLINICAL REGISTRATION NUMBER CER-VD (SWITZERLAND): Project ID: 2021-00620.

[Pre-hospital red blood cells transfusions : Logistical aspects]. / Aspects logistiques de la transfusion de concentrés érythrocytaires en milieu préhospitalier.

Pre-hospital red blood cell transfusion is already used in many countries, both in military and civilian settings, and provides a better chance of survival for patients suffering from massive bleeding. However, this is not a current practice in Switzerland. This article aims to study Swiss specificities and provide a turnkey concept for the implementation of red blood cell transfusion in an emergency pre-hospital setting, by road or by air. The transfusion benefits and risks, the logistical aspect and the costs are discussed.

La transfusion de concentrés érythrocytaires (CE) en milieu préhospitalier est déjà réalisée dans de nombreux pays tant dans un contexte militaire que civil et permet d'augmenter les chances de survie des patients souffrant d'hémorragie massive. En Suisse, cette pratique n'est pas courante. Cet article a pour but d'étudier les spécificités suisses et de proposer un concept clé en main pour l'implémentation de la transfusion de CE dans un service de sauvetage médicalisé terrestre ou héliporté. Les bénéfices et les risques de la transfusion, les modalités logistiques et les coûts y sont abordés.

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

Acute effects of transcatheter aortic valve replacement on the ventricular-aortic interaction.

Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis (AS) patients. However, little is known regarding the direct effect of TAVR on the ventricular-aortic interaction. In the present study, we aimed to investigate changes in central hemodynamics after successful TAVR. We retrospectively examined 33 cases of severe AS patients (84 ± 6 yr) who underwent TAVR. Invasive measurements of left ventricular and aortic pressures as well as echocardiographic aortic flow were acquired before and after TAVR (maximum within 5 days). We examined alterations in key features of central pressure and flow waveforms, including the aortic augmentation index (AIx), and performed wave separation analysis. Arterial parameters were determined via parameter-fitting on a two-element Windkessel model. Resolution of AS resulted in direct increase in the aortic systolic pressure and maximal aortic flow (131 ± 22 vs. 157 ± 25 mmHg and 237 ± 49 vs. 302 ± 69 mL/s, P < 0.001 for all), whereas the ejection duration decreased (P < 0.001). We noted a significant decrease in the AIx (from 42 ± 12 to 19 ± 11%, P < 0.001). Of note, the arterial properties remained unchanged. There was a comparable increase in both forward (61 ± 20 vs. 77 ± 20 mmHg, P < 0.001) and backward (35 ± 14 vs. 42 ± 10 mmHg, P = 0.013) pressure wave amplitudes, while their ratio, i.e., the reflection coefficient, was preserved. Our results highlight the impact of TAVR on the ventricular-aortic interaction by affecting the amplitude, shape, and related attributes of the aortic pressure and flow pulse and challenge the interpretation of AIx as a solely vascular measure in AS patients.NEW & NOTEWORTHY Transcatheter aortic valve replacement (TAVR) is linked with an immediate increase in aortic systolic blood pressure and maximal flow, as well as steeper aortic pressure and flow wave upstrokes. After TAVR, the forward wave pumped by the heart is enhanced. Although the arterial properties remain unchanged, the central augmentation index (AIx) is markedly decreased after TAVR. This challenges the interpretation of AIx as a solely vascular measure in patients with aortic valve stenosis.

Preparedness and Reorganization of Care for Coronavirus Disease 2019 Patients in a Swiss ICU: Characteristics and Outcomes of 129 Patients.

OBJECTIVES: In many countries, large numbers of critically ill patients with coronavirus disease 2019 are admitted to the ICUs within a short period of time, overwhelming usual care capacities. Preparedness and reorganization ahead of the wave to increase ICU surge capacity may be associated with favorable outcome. The purpose of this study was to report our experience in terms of ICU organization and anticipation, as well as reporting patient characteristics, treatment, and outcomes. DESIGN: A prospective observational study. SETTING: The division of intensive care at the Geneva University Hospitals (Geneva, Switzerland). PATIENTS: All consecutive adult patients with acute respiratory failure due to coronavirus disease 2019 admitted in the ICU between March 9, 2020, and May 19, 2020, were enrolled. Patients' demographic data, comorbidities, laboratory values, treatments, and clinical outcomes were collected. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The ICU was reorganized into cells of six to eight patients under the care of three physicians and five nurses. Its capacity increased from 30 to 110 beds, fully equipped and staffed, transforming the surgical intermediate care unit, the postoperative care facility, and operating theaters into ICUs. Surge capacity has always exceeded the number of patients hospitalized. Among 129 critically ill patients with severe acute hypoxemic respiratory failure, 96% required invasive mechanical ventilation. A total of 105 patients (81%) were discharged alive and 24 died, corresponding to a mortality of 19%. Patients who died were significantly older, with higher severity scores at admission, had higher levels of d-dimers, plasma creatinine, high-sensitive troponin T, C-reactive protein, and procalcitonin, and required more frequent prone sessions. CONCLUSIONS: A rapid increase in ICU bed capacity, including adequate equipment and staffing, allowed for a large number of critically ill coronavirus disease 2019 patients to be taken care of within a short period of time. Anticipation and preparedness ahead of the wave may account for the low mortality observed in our center. These results highlight the importance of resources management strategy in the context of the ongoing coronavirus disease 2019 pandemic.

Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee.

The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.

Comparison of postoperative complications between segmentectomy and lobectomy by video-assisted thoracic surgery: a multicenter study.

BACKGROUND: Compared to lobectomy by video-assisted thoracic surgery (VATS), segmentectomy by VATS has a potential higher risk of postoperative atelectasis and air leakage. We compared postoperative complications between these two procedures, and analyzed their risk factors. METHODS: We reviewed the records of all patients who underwent anatomical pulmonary resections by VATS from January 2014 to March 2018 in two Swiss university hospitals. All complications were reported. A logistic regression model was used to compare the risks of complications for the two interventions. Adjustment for patient characteristics was performed using a propensity score, and by including risk factors separately. RESULTS: Among 690 patients reviewed, the major indication for lung resection was primary lung cancer (86.4%) followed by metastasis resection (5.8%), benign lesion (3.9%), infection (3.2%) and emphysema (0.7%). Postoperatively, there were 80 instances (33.3%) of complications in 240 segmentectomies, and 171 instances (38.0%) of complications in 450 lobectomies (P = 0.73). After adjustment for the patient's propensity to be treated by segmentectomy rather than lobectomy, the risks of a complication remained comparable for the two techniques (odds ratio for segmentectomy 0.91 (0.61-1.30), p = 0.59). Length of hospital stay and drainage duration were shorter after segmentectomy. On multivariate analysis, an American Society of Anesthesiologists score above 2 and a forced expiratory volume in one second below 80% of predicted value were significantly associated with the occurrence of complications. CONCLUSIONS: The rate of complications and their grade were similar between segmentectomy and lobectomy by VATS.

Determinants of hospital length of stay after transcatheter aortic valve implantation with self-expanding prostheses: a prospective, single centre observational study.

INTRODUCTION: We sought to identify baseline and periprocedural variables affecting hospital length of stay (LoS) in patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: Data on 304 consecutive patients undergoing TAVI at a single centre between August 2008 and December 2017 were collected prospectively. All patients underwent a complete clinical, echocardiographic and laboratory evaluation including a comprehensive frailty assessment at baseline. LoS was defined as the number of in-hospital days after the TAVI procedure during the index hospitalisation until the time the patient left the hospital for home or a rehabilitation clinic. RESULTS: The mean LoS was 10.4 ± 7.1 days (median 8, interquartile range 5–12) with a significant trend towards shorter LoS over time (p <0.001). Patients discharged directly home were more likely to have shorter LoS (p = 0.007). All periprocedural complications were significantly associated with prolonged LoS (p <0.05 for all). Multivariate analysis showed an independent association between LoS and emergency admission (beta 3.24 ± 1.56, p = 0.039), baseline gait speed (beta: 0.39 ± 0.16, p = 0.018), baseline serum C-reactive protein (CRP, beta 0.14 ± 0.04, p = 0.001) and subclavian access (beta 8.27 ± 2 .9, p = 0.005). Gait speed and serum CRP remained significant determinants of LoS even after adjustment for periprocedural complications and patients’ discharge destination. CONCLUSION: Baseline gait speed and serum CRP are significant independent determinants of LoS after TAVI.

A Case of Persistence of Normal Tissue Oxygenation Monitored by Near-Infrared Spectroscopy (NIRS) Values Despite Prolonged Perioperative Cardiac Arrest.

BACKGROUND Patients undergoing cardiac surgery are at risk of adverse perioperative neurological complications. Cerebral oximetry monitoring is increasingly used in these patients to detect intraoperative cerebral hypoxia or ischemic events. Near-infrared spectroscopy (NIRS) uses the near-infrared region of the electromagnetic spectrum for oximetry imaging. A case is reported of the persistence of normal tissue oxygenation monitored by NIRS values despite a prolonged perioperative cardiac arrest. CASE REPORT A 65-year-old man was admitted to the Emergency Department with dysarthria, left facial ptosis, left hemiplegia, and arterial hypotension of 75/50 mmHg. Computed tomography (CT) angiography showed a Stanford type A aortic dissection extending to the right common carotid artery. Shortly after arrival in the operating room, his hemodynamic condition rapidly deteriorated resulting in cardiac arrest. Despite the rapid onset of extracorporeal circulation, adequate systemic blood flow could not be restored. Cerebral NIRS values remained within the normal range (70-80%) from the start of emergency resuscitation, during a prolonged period of extremely low global blood perfusion values, and until all resuscitation ceased. CONCLUSIONS Cerebral oximetry values reflect a balance between cerebral oxygen delivery and consumption. This case demonstrated the persistence of normal tissue oxygenation monitored by NIRS values despite a prolonged perioperative cardiac arrest.

Clinical outcome and risk factors for complications after pulmonary segmentectomy by video-assisted thoracoscopic surgery: results of an initial experience.

BACKGROUND: Pulmonary anatomical segmentectomies are increasingly being done via video-assisted thoracoscopic surgery (VATS). We analyzed clinical outcomes and risk factors for post-operative complications after pulmonary segmentectomy by VATS was introduced in two institutions. METHODS: We retrospectively reviewed records of all patients who underwent anatomical pulmonary segmentectomy by VATS from 2014 to 2016 at the university hospitals of Geneva and Lausanne in Switzerland. RESULTS: One hundred twenty-nine patients (64 men; median age 68 years, range, 29-85 years) underwent anatomical VATS segmentectomy for primary lung tumors (n=100), metastases (n=16) and benign lesions (n=13). The overall 30-day mortality and morbidity rates were 0.8% and 31%, respectively. The reoperation rate was 4.7% [indications: hemothorax 2, prolonged air leak (PAL) 2, segmental torsion 1, empyema 1]. Chest drainage lasted for a median of 2 days (range, 1-33 days) and patients were discharged from the hospital after a median of 6 days (range, 2-37 days). Postoperative complications were mainly associated with chronic obstructive pulmonary disease (COPD) [odds ratio (OR) 2.54 and 95% confidence interval (95% CI), 1.18-5.47], and smoking pack-years >50 units (OR 5.27; 95% CI, 1.68-16.55). Nine patients (9%) presented with distant recurrences. Nodule size >2 cm was associated with decreased disease-free survival (DFS) (P=0.04). There was no association between surgical experience in VATS segmentectomy and DFS or postoperative complications. CONCLUSIONS: Segmentectomies can be safely performed by VATS in an initial experience and result in favorable clinical outcome. COPD and smoking pack-years are associated with an increased risk of complications.

Changes in Hepatic Blood Flow and Liver Function during Closed Abdominal Hyperthermic Intraperitoneal Chemotherapy following Cytoreduction Surgery.

BACKGROUND: The increase in intra-abdominal pressure (IAP) during closed abdominal hyperthermic intraperitoneal chemotherapy (HIPEC) leads to major haemodynamic changes and potential organ dysfunction. We investigated these effects on hepatic blood flow (HBF) and liver function in patients undergoing HIPEC following cytoreductive surgery and fluid management guided by dynamic preload indices. METHODS: In this prospective observational clinical study including 15 consecutive patients, we evaluated HBF by transesophageal echocardiography and liver function by determination of the indocyanine green plasma disappearance rate (ICG-PDR). Friedman's two-way analysis of variance by ranks and Wilcoxon signed-rank test were performed for statistical analysis. RESULTS: During HIPEC, HBF was markedly reduced, resulting in the loss of any pulsatile Doppler flow signal in all but one patient. The ICG-PDR, expressed as median (interquartile 25-75), decreased from 23 (20-30) %/min to 18 (12.5-19) %/min (p < 0.001). Despite a generous crystalloid infusion rate (27 (22-35) ml/kg/h), cardiac index decreased during the increased IAP period, inferior vena cava diameter decreased, stroke volume variation and pulse pressure variation increased, lung compliance dropped, and there was an augmentation in plateau pressure. All changes were significant (p < 0.001) and reversed to baseline values post HIPEC. CONCLUSION: Despite optimizing intravenous fluids during closed abdominal HIPEC, we observed a marked decrease in HBF and liver function. Both effects were transient and limited to the period of HIPEC but could influence the choice between closed or open abdominal cavity procedure for HIPEC and should be considered in similar clinical situations of increased IAP.

Conduction disorders using the Evolut R prosthesis compared with the CoreValve: has anything changed?

Aim: We compared early postprocedural and midterm evolution of atrioventricular and intraventricular conduction disorders following implantation of the new generation Evolut R (ER) prosthesis in comparison with the previous generation CoreValve (CV) system using routinely recorded ECG up to 6-month follow-up. Methods: All consecutive patients treated by transcathether aortic valve implantation (TAVI) using the Medtronic self-expanding devices for symptomatic severe aortic stenosis in a single centre between October 2011 and February 2016 were considered for inclusion. ECGs recorded at baseline, day 1 after TAVI, discharge and 6 months were retrospectively analysed. At each time-point, intrinsic rhythm, PR interval, QRS axis and duration, and atrioventricular and intraventricular conduction were analysed. Atrioventricular and intraventricular conduction following TAVI at discharge and at 6 months were compared intrasubject at the different time intervals and between patients receiving the ER versus the CV prosthesis. Results: Among the 113 patients included in the analysis (51% female, 83.3±6.2 years), 60 (53%) patients received the CV and 53 (47%) patients received the ER. Compared with patients in the CV group, those in the ER group had a lower Society of Thoracic Surgeons score (6.3±3.1vs 4.8±3.6, P=0.02). Patients in the ER group in comparison with those in the CV group more frequently had postprocedural PR interval (57%vs23%, respectively, P=0.004) and QRS prolongation (76%vs50%, P=0.03) at discharge. Incidence of complete atrioventricular block was similar between both groups (9%vs18%, P=0.3) up to 6-month follow-up. No difference in term of new left bundle branch block (LBBB) (34%vs28%, P=0.8) or permanent pacemaker implantation rates (32.1%vs31.7%, P=1.0) was reported. Conclusions: Patients with the ER had greater postprocedural atrioventricular and intraventricular conduction delays than those with the CV at discharge, with however similar incidence of high-degree atrioventricular block, new LBBB and permanent pacemaker implantation up to 6-month follow-up.

Is team-based perception of safety in the operating room associated with self-reported wrong-site surgery? An exploratory cross-sectional survey among physicians.

AIMS: Participation in wrong-site surgery may negatively influence the perception of safety by the health care professionals in the operating room (OR). The objective was to explore if perception of safety in the OR was seen as a team-based or individualist concern and whether having participated in wrong-site surgery was associated with perception of safety. METHOD AND RESULTS: Cross-sectional survey at 2 annual meetings of surgery, in Switzerland, 2010. We used multivariate generalized models to assess the association of perception of safety in the OR (1 item) with self-reported participation in wrong-site surgery-overall, past (more than 3 y ago), or recent (last 3 y) participations-controlling for sociodemographic characteristics and opinion of the surgical safety checklist. One hundred ninety respondents answered the questionnaire (participation rate of 22.6%). Respondents mostly had a team-based, rather than an individualistic, perception of safety in the OR. In multivariate analyses, the influence of ever participation in wrong-site surgery was not significant. However, past participation in wrong-site surgery (more than 3 y ago) was associated with perception of safety as team based, whereas recent participation (last 3 y) was associated-despite not significant at α ≤ 5%-with perception of safety as individualistic. CONCLUSION: In this sample, safety in the OR is most often seen as team based rather than individualistic. Perceiving safety in the OR as team based varies according to recent or past participation in wrong-site surgery. Longitudinal research is needed to assess causality between participation in wrong-site surgery and change in perception of safety.

Hemodynamic challenge to early mobilization after cardiac surgery: A pilot study.

BACKGROUND: Active mobilization is a key component in fast-track surgical strategies. Following major surgery, clinicians are often reluctant to mobilize patients arguing that circulatory homeostasis would be impaired as a result of myocardial stunning, fluid shift, and autonomic dysfunction. AIMS: We examined the feasibility and safety of a mobilization protocol 12-24 h after elective cardiac surgery. SETTING AND DESIGN: This observational study was performed in a tertiary nonacademic cardiovascular Intensive Care Unit. MATERIALS AND METHODS: Over a 6-month period, we prospectively evaluated the hemodynamic response to a two-staged mobilization procedure in 53 consecutive patients. Before, during, and after the mobilization, hemodynamics parameters were recorded, including the central venous oxygen saturation (ScvO 2 ), lactate concentrations, mean arterial pressure (MAP), heart rate (HR), right atrial pressure (RAP), and arterial oxygen saturation (SpO 2 ). Any adverse events were documented. RESULTS: All patients successfully completed the mobilization procedure. Compared with the supine position, mobilization induced significant increases in arterial lactate (34.6% [31.6%, 47.6%], P = 0.0022) along with reduction in RAP (-33% [-21%, -45%], P < 0.0001) and ScvO 2 (-7.4% [-5.9%, -9.9%], P = 0.0002), whereas HR and SpO 2 were unchanged. Eighteen patients (34%) presented a decrease in MAP > 10% and nine of them (17%) required treatment. Hypotensive patients experienced a greater decrease in ScvO 2 (-18 ± 5% vs. -9 ± 4%, P = 0.004) with similar changes in RAP and HR. All hemodynamic parameters, but arterial lactate, recovered baseline values after resuming the horizontal position. CONCLUSIONS: Early mobilization after cardiac surgery appears to be a safe procedure as far as it is performed under close hemodynamic and clinical monitoring in an intensive care setting.

Implementation of the surgical safety checklist in Switzerland and perceptions of its benefits: cross-sectional survey.

OBJECTIVES: To examine the implementation of the Surgical Safety Checklist (SSC) among surgeons and anaesthetists working in Swiss hospitals and clinics and their perceptions of the SSC. METHODS: Cross-sectional survey at the 97th Annual Meeting of the Swiss Society of Surgery, Switzerland, 2010. Opinions of the SSC were assessed with a 6-item questionnaire. RESULTS: 152 respondents answered the questionnaire (participation rate 35.1%). 64.7% respondents acknowledged having a checklist in their hospital or their clinic. Median implementation year was 2009. More than 8 out of 10 respondents reported their team applied the Sign In and the Time Out very often or quasi systematically, whereas almost half of respondents acknowledged the Sign Out was applied never or rarely. The majority of respondents agreed that the checklist improves safety and team communication, and helps to develop a safety culture. However, they were less supportive about the opinion that the checklist facilitates teamwork and eliminates social hierarchy between caregivers. CONCLUSIONS: This survey indicates that the SSC has been largely implemented in many Swiss hospitals and clinics. Both surgeons and anaesthetists perceived the SSC as a valuable tool in improving intraoperative patient safety and communication among health care professionals, with lesser importance in facilitating teamwork (and eliminating hierarchical categories).

Primary malignant achromic melanoma of the lung.

Currently, less than thirty cases of primary malignant melanoma of the lung have been reported in the literature. Thus, strict criteria for diagnosis have been published and include: malignant melanoma associated with bronchial epithelial changes; a solitary lung tumor; no prior history of skin, mucous membrane, intestinal or ocular melanoma; and absence of any other detectable tumor at the time of diagnosis. In this article we present a case of melanoma of the lung without evidence of extra-pulmonary disease.

Late tamponade secondary to aortic root perforation by BioSTAR septal closure device.

We report a patient who presented with pericardial tamponade 9 months after percutaneous closure of a patent foramen ovale using a BioSTAR septal closure device (NMT Medical, Boston, MA). During the operation, bleeding was observed on the posterior aortic root caused by a nonendothelialized strut. The device was explanted, followed by pericardial patch aortoplasty and patch closure of the patent foramen ovale. This report presents a case of late tamponade related to the new-generation bioabsorbable BioSTAR device. Although late complications related with BioSTAR are rare, the presentation may be dramatic. A high index of suspicion and quick intervention is often lifesaving.