Early and long-term outcomes of re-sternotomy for aortic valve replacement with patent coronary artery grafts.

OBJECTIVE: The aim was to evaluate early and long-term outcomes of re-sternotomy for aortic valve replacement (AVR) with previous patent coronary artery grafts. METHODS: Data for re-sternotomy for AVRs (group 1 isolated AVR, group 2 AVR with concomitant procedure) were collected (2000-2019). Logistic regression analysis was performed to identify predictors of in-hospital mortality and postoperative composite outcome (in-hospital death, transient ischemic attack/stroke, renal failure requiring new hemofiltration, deep sternal wound infection, re-exploration for bleeding/tamponade and length of stay >30 days). Survival curves were compared using log-rank test Cox proportion hazards model was used for predictors of long-term survival. RESULTS: Total 178 patients were included (groups 1-90 patients, group 2-88 patients). Mean age was 75 ± 4 years and mean log EuroSCORE was 17 ± 12% (15 ± 8% - group 1 vs. 19 ± 14% - group 2, p = 0.06). Mean follow-up was 6.3 ± 4.4 years. Cardiovascular injury occurred in 12%. Left internal mammary artery was most commonly injured. In-hospital mortality was 7.8% (5% - group 1 vs. 10.2% - group 2, p = 0.247). NYHA class III-IV, perioperative intra-aortic balloon pump and cardiovascular injury were independent predictors of in-hospital mortality (hazard ratio: 13.33, 95% confidence interval: 2.04-83.33, p = 0.007). Survival was significantly worse with cardiovascular injury at re-sternotomy up to 5 years (46% vs. 67%, p = 0.025) and postoperative complications (p = 0.023). Survival was significantly lower than age-matched first-time AVR and UK population. CONCLUSIONS: Long-term survival is significantly impaired by cardiovascular injury and perioperative complications of re-sternotomy.

Image-guided combined ablation and resection in thoracic surgery for the treatment of multiple pulmonary metastases: A preliminary case series.

OBJECTIVES: To demonstrate the feasibility and preliminary outcomes of a novel hybrid technique combining percutaneous microwave ablation and wire-assisted wedge resection for patients with multiple pulmonary metastases using intraoperative imaging. METHODS: We describe our technique and present a retrospective case series of 4 patients undergoing iCART at our institution between August 2018 and January 2020. Procedures were performed in a hybrid operating suite using the ARTIS Pheno cone beam computerized tomography scanner (Siemens Healthineers, Erlangen, German). Patient information included past history of malignancy as well as lesion size, depth, location, and histology result. Surgical complications and length of stay were also recorded. RESULTS: Five procedures were performed on 4 patients during the study period. One patient underwent bilateral procedures 4 weeks apart. All patients underwent at least 1 ablation and 1 wedge resection during the combined procedure. Patient ages ranged from 40 to 66 years and the majority (75%) were men. All had a past history of cancer. Lesions were treated in every lobe. Size and depth ranged from 6 to 24 mm and 21 to 33 mm, respectively, for ablated nodules and 5 to 27 mm and 0 to 22 mm, respectively, for the wedge resected nodules. Three procedures were completed uniportal and operative time ranged from 51 to 210 minutes. All cases sustained <10 mL blood loss. There were 2 intraoperative pneumothorax, 1 prevented successful completion of the ablation. One patient required a prolonged period of postoperative physiotherapy and was discharged on day 6. The other patients were discharged on postoperative day 2 or 3. All 5 histology specimens confirmed metastatic disease. CONCLUSIONS: Our hybrid approach provides a minimally invasive and comprehensive personalized therapy for patients with multiple pulmonary metastases under a single general anesthetic. It provides histology-based diagnosis whilst minimizing lung tissue loss and eliminating the need for transfer from radiology to operating theatre. Emergence of ablation as a treatment for stage 1 non-small cell lung cancer and the expansion of lung cancer screening may widen the application of iCART in the future.

Tropheryma whipplei endocarditis.

Tropheryma whipplei is a bacterium that causes a rare infection called Whipple's disease and can cause devastating effects if left untreated. It is important to recognize that patients with this infection may present with atypical symptoms and are often apyrexial with normal inflammatory markers. Moreover, routine blood cultures often do not isolate these bacteria in conventional growth media. Therefore, it requires a high level of clinical suspicion to make this diagnosis. Here, we present two cases of Tropheryma whipplei aortic valve endocarditis, with atypical presentation and similar unusual but striking echocardiographic images.

Practical prescribing of intravenous unfractionated heparin.

Intravenous unfractionated heparin is sometimes poorly managed in NHS hospitals. This article investigates why this is so and reviews the evidence for optimal unfractionated heparin prescribing, using it to make some suggestions as to how doctors can improve this.

Magnetic resonance imaging of ferumoxide-labeled mesenchymal stem cells seeded on collagen scaffolds-relevance to tissue engineering.

Mesenchymal stem cells (MSCs) are a promising candidate cell for tissue engineering. Magnetic resonance imaging (MRI) has been proven effective in visualizing iron-labeled stem cells; however, the efficiency of this approach for visualization of cells seeded on scaffolds intended for use as tissue-engineered heart valves has not been assessed. MSCs were labeled by incubating for 48 h with ferumoxide and poly-L-lysine as transfecting agent. Any detrimental effect of iron labeling on cell viability, proliferation, and differentiation was examined using appropriate functional assays. Change in the nuclear magnetic relaxation properties of labeled cells was determined using in vitro relaxometry of cells seeded in 3-dimensional collagen gels. Images of labeled and non-labeled cells seeded onto 1% type I bovine collagen scaffolds were obtained using MRI. The presence of intracellular iron in labeled cells was demonstrated using Prussian blue staining, confocal microscopy, and electron microscopy. Cell viability, proliferation, and differentiation were comparable in labeled and non-labeled cells. The T2 relaxation time was 40% to 50% shorter in ferumoxide-labeled cells. Labeled cells seeded on scaffolds appeared as areas of reduced signal intensity in T2 weighted images. Ferumoxide labeling persisted and remained effective even on scans performed 4 weeks after the labeling procedure. Ferumoxide labeling of human MSCs seeded on collagen scaffolds is an effective, non-toxic technique for visualization of these cells using MRI. This technique appears promising for cell tracking in future tissue-engineering applications.