Combined Tracheal Resection and Coronary Artery Bypass With ECMO Support.

In patients with critical tracheal stenosis, extracorporeal membrane oxygenation support provides an additional level of safety over conventional approaches to secure an airway. This brings operations with exquisite complexity into the realm of routine feasibility. Here we describe a case of combined tracheal resection with 4-vessel coronary artery bypass grafting in a patient with critical tracheal stenosis, occluded coronary arteries, and severely reduced ejection fraction. Postoperatively, the patient made an excellent recovery. This case exemplifies a trend where multidisciplinary cooperation, refinements in surgical techniques, and technological advances allow ever more complex cardiothoracic operations to be performed safely.

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease.

Chronic thromboembolic disease is characterised by persistent pulmonary thromboembolic occlusions without pulmonary hypertension. Early surgical treatment with pulmonary endarterectomy may improve symptoms and prevent disease progression. We sought to assess the outcome of pulmonary endarterectomy in symptomatic patients with chronic thromboembolic disease. Patients with symptomatic chronic thromboembolic disease and a mean pulmonary artery pressure <25 mmHg at baseline with right heart catheterisation and treated with pulmonary endarterectomy between January 2000 and July 2013 were identified. Patients were reassessed at 6 months and at 1 year following surgery. A total of 42 patients underwent surgery and the median length of stay in hospital was 11 days. There was no in-hospital mortality but complications occurred in 40% of patients. At 1 year, following surgery, 95% of the patients remained alive. There was a significant symptomatic improvement with 95% of patients in the New York Heart Association functional classes I or II at 6 months. There was a significant improvement in quality of life assessed by the Cambridge pulmonary hypertension outcome review questionnaire. In this carefully selected cohort of chronic thromboembolic disease patients, pulmonary endarterectomy resulted in significant improvement in symptoms and quality of life. Appropriate patient selection is paramount given the known surgical morbidity and mortality, and surgery should only be performed in expert centres.

Use of centrifugal left ventricular assist device as a bridge to candidacy in severe heart failure with secondary pulmonary hypertension.

OBJECTIVES: Raised pulmonary artery pressure (PAP), trans-pulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are risk factors for poor outcomes after heart transplant in patients with secondary pulmonary hypertension (PH) and may contraindicate transplant. Unloading of the left ventricle with an implantable left ventricular assist device (LVAD) may reverse these pulmonary vascular changes. We studied the effect of implanting centrifugal LVADs in a cohort of patients with secondary PH as a bridge to candidacy. METHODS: Pulmonary haemodynamics on patients implanted with centrifugal LVADs at a single unit between May 2005 and December 2010 were retrospectively reviewed. RESULTS: Twenty-nine patients were implanted with centrifugal LVADs (eight HeartWare ventricular assist device (HVAD), HeartWare International, USA and 21 VentrAssist, Ventracor Ltd., Australia). Seventeen were ineligible for transplant by virtue of high TPG/PVR. All the patients were optimized with inotrope/balloon pump followed by LVAD insertion. Four required temporary right VAD support. Thirty-day mortality post-LVAD was 3.4% (1 of 29) with a 1-year survival of 85.7% (24 of 28). Thirteen patients have been transplanted to date: 30-day mortality was 7.7% (1 of 13) and 1-year survival was 91% (10 of 11). Baseline and post-VAD pulmonary haemodynamics were significantly improved: systolic PAP (mmHg), mean PAP, TPG (mmHg) of 57 ± 9.5, 42 ± 4.4 and 14 ± 3.9 reduced to 32 ± 7.5, 18 ± 5.5 and 9 ± 3.3, respectively. PVR reduced from 5 ± 1.5 to 2.1 ± 0.5 Wood units (P < 0.05). CONCLUSIONS: In selected heart failure patients with secondary PH, use of centrifugal LVAD results in significant reductions in PAP, TPG and PVR, which are observed within 1 month, reaching a nadir by 3 months. Such patients bridged to candidacy have post-transplant survival comparable with those having a heart transplant as primary treatment.

A novel technique for pulmonary endarterectomy in the presence of patent coronary artery bypass grafts.

Pulmonary endarterectomy (PEA) is the definitive surgical treatment for chronic thromboembolic pulmonary hypertension, with excellent short- and long-term results. PEA following previous coronary artery bypass graft surgery carries a risk of damage to patent grafts, as well as the risk of inadequate myocardial protection, especially when a patent pedicled internal thoracic artery graft is present. We report a technique where PEA may be safely and successfully accomplished ensuring, adequate clearance of bilateral pulmonary thromboembolic disease via a right pulmonary arteriotomy, avoiding the patent bypass grafts overlying the pulmonary trunk, while ensuring adequate myocardial protection.

Unexplained chronic anemia and leukopenia in lung transplant recipients secondary to parvovirus B19 infection.

Parvovirus B19 (PVB) is a non-enveloped, single-stranded DNA virus of the Parvoviridae family pathogenic to humans. Despite numerous case reports of pure red cell aplasia in lung transplant (LT) recipients after PVB infection, the epidemiology remains poorly outlined. Over a 3-year period, 3 of 54 LT patients with unexplained anemia tested positive for circulating PVB by a nested polymerase chain reaction (PCR) assay. All of these patients presented with anemia and leukopenia, with a favorable long-term prognosis.

Functional and haemodynamic outcome 1 year after pulmonary thromboendarterectomy.

OBJECTIVE: Chronic thromboembolic pulmonary hypertension (CTEPH) results in severe symptoms and impaired survival. Pulmonary thromboendarterectomy (PTE) is considered the gold standard treatment. Many units have reported excellent early results post PTE, but there is less information on whether benefit is sustained. We sought to determine the medium-term functional and haemodynamic outcome for patients following PTE and the longer-term survival after discharge from hospital. METHODS: Data were collected prospectively on all patients who underwent PTE in the UK between 1997 and June 2006. Patients were reassessed at 3 and 12 months after operation. Follow-up over time was assessed using repeated measures ANOVA, the Friedman test or Wilcoxon signed ranks test as appropriate. RESULTS: Two hundred and twenty-nine patients underwent PTE, survived to hospital discharge, and completed follow-up. At 3 months following operation, there was a significant reduction in mean pulmonary artery pressure (47+/-14 to 25+/-14mmHg, p<0.001), a significant increase in cardiac index (1.9+/-0.7 to 2.5+/-0.6l/minm(2), p<0.001) and a significant increase in 6-min walk distance (269+/-123 to 375+/-104m, p<0.001). At 12-month follow-up, the haemodynamic improvements were sustained and there was a further increase in 6-min walk distance (375+/-104 to 392+/-108m, p=0.004). NYHA class was significantly reduced at 3 months, with the improvement sustained at 12 months. Conditional survival following discharge from hospital was 92.5% at 5 years and 88.3% at 10 years. CONCLUSIONS: PTE is a very effective therapy for CTEPH. This is the first report from a continuous national series to fully characterise haemodynamic and functional outcome 1 year after PTE. Patients enjoy continued improvement in haemodynamic status that translates into better exercise capacity, reduced symptoms and excellent survival.

APT070 inhibits complement activation during in vitro cardiopulmonary bypass.

BACKGROUND: The proteins of the complement cascade play an important role in inflammation and the immune response. They have been shown to be activated during cardiopulmonary bypass (CPB), and may be responsible for the inflammatory response to CPB. We looked at the effect of APT070, an anti-complement agent, on human blood during in vitro CPB. MATERIALS AND METHODS: Four hundred millilitres of blood was venesected from healthy human volunteers and heparinised. To the blood was added either APT070 to a concentration of 50 microg/ml (n=5) or vehicle control (n=4). The blood was entered into an in vitro CPB circuit and circulated for 90 min. RESULTS: Our results showed that after 90 min of in vitro bypass APT070 significantly inhibited the activation of compliment as demonstrated by C3a (p=0.03) and sC5b-9 (p=0.01) levels, and reduced neutrophil stimulation as measured by CD11b expression (p=0.04 at 90 min). CONCLUSION: APT070 significantly inhibits complement and neutrophil activation. This result may have considerable implications, especially if it can be shown to decrease the inflammatory sequelae of CPB.

A method for descending thoracic aortic replacement retaining a posterior strip bearing intercostal vessels.

Operations for aneurysms of the descending thoracic aorta are still fraught with danger. Spinal cord injury remains a major cause of morbidity. Many therapeutic strategies have been suggested to reduce the incidence of this devastating complication, including reimplantation of intercostal vessels. However, reimplantation of intercostal vessels, both individually or in groups, is time consuming and compounded by the absence of a reliable means of identifying which vessels actually supply the cord. We present a technique that allowed inclusion of all potentially important descending aortic branching vessels into the repair leading to a favorable outcome in a series of patients.