Antifibrotic effects of vitamin D3 on human lung fibroblasts derived from patients with idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal interstitial lung disease. Up to now, no treatment can stop the progression of IPF. Vitamin D3 (VD) reduces experimental lung fibrosis in murine models and depletion of vitamin D3 might be associated with the reduced survival of patients with IPF. In this context, we determined if VD can prevent the pro-fibrotic functions of human lung fibroblasts (HLFs) isolated from patients with IPF. IPF and control HLFs were derived from surgical lung biopsies collected from patients with IPF or with primary lung cancer, respectively. VD (3-100 nM) markedly reduced the basal and PDGF-induced proliferation of HLFs. VD also altered cell cycle by increasing the percentage of IPF HLFs arrested in the G0/G1 phase, and by downregulating the expression of various cell cycle regulatory proteins. In addition, VD barely prevented the TGF-ß1-induced differentiation in HLFs. At 100 nM, VD slightly reduced the expression of the pro-fibrotic marker α-smooth muscle actin, and had no effect on fibronectin and collagen-1 expression. In contrast, 100 nM VD strongly inhibited the aerobic glycolytic metabolism induced by TGF- ß1. Finally, VD reduced both the secretion of lactate, the levels of lactate deshydrogenase mRNA and the activity of intracellular LDH in IPF HLFs. In conclusion, our study shows that VD reduced pro-fibrotic functions of HLFs. These findings suggest that it might be interesting to assess the potential clinical benefits of vitamin D supplementation in patients with IPF, especially on lung function decline.

Anti-fibrotic effects of nintedanib on lung fibroblasts derived from patients with Progressive Fibrosing Interstitial Lung Diseases (PF-ILDs).

The tyrosine kinase inhibitor nintedanib has been recently approved for the treatment of Interstitial Lung Diseases (ILDs) that manifest a progressive fibrosis phenotype other than Idiopathic pulmonary Fibrosis (IPF). Nintedanib reduces the development of lung fibrosis in various animal models resembling features of PF-ILD and in vitro, it inhibits the fibrosing phenotype of human lung fibroblasts (HLFs) isolated from patients with IPF. To get insight on the cellular and molecular mechanisms that drive the clinical efficiency of nintedanib in patients with non-IPF PF-ILD, we investigated its effects on the fibrosing functions of HLFs derived from patients with PF-hypersensitivity pneumonitis (PF-HP, n = 7), PF-sarcoidosis (n = 5) and pleuroparenchymal fibroelastosis (PPFE, n = 4). HLFs were treated with nintedanib (10 nM-1 µM) and then stimulated with PDGF-BB (25-50 ng/ml) or TGF-ß1 (1 ng/ml) for 24-72 h to assess proliferation and migration or differentiation. At nanomolar concentrations, nintedanib reduced the levels of PDGF receptor and ERK1/2 phosphorylation, the proliferation and the migration of PF-HP, PF-sarcoidosis and PPFE HLFs stimulated with PDGF-BB. Moreover, nintedanib also attenuates the myofibroblastic differentiation driven by TGF-ß1 but only when it is used at 1 µM. The drug reduced the phosphorylation of SMAD2/3 and decreased the induction of collagen, fibronectin and α-smooth muscle actin expression induced by TGF-ß1. In conclusion, our results demonstrate that nintedanib counteracts fundamental fibrosing functions of lung fibroblasts derived from patients with PF-HP, PF-sarcoidosis and PPFE, at concentrations previously reported to inhibit control and IPF HLFs. Such effects may contribute to its clinical benefit in patients suffering from these irreversible ILDs.

Impact of robotic-assisted and video-assisted sympathetic nerve reconstruction on quality of life for severe compensatory hyperhidrosis after thoracic sympathectomy.

OBJECTIVES: Severe compensatory hyperhidrosis (CH) is a disabling complication following thoracic sympathectomy. Our study was to establish valid patient selection criteria and determine outcomes of nerve reconstructive surgery. Furthermore, we assessed the clinical feasibility and safety of a robotic-assisted approach compared to video-assisted thoracoscopic surgery. METHODS: Adults with severe CH following bilateral sympathectomy for primary hyperhidrosis were enrolled. We performed 2 questionnaires: the Hyperhidrosis Disease Severity Scale and the Dermatology Life Quality Index before and 6 months after nerve reconstructive surgery. A one-time evaluation of healthy volunteers (controls) was undertaken to validate the quality of life measures. RESULTS: Fourteen patients (mean age 34.1 ± 11.5 years) underwent sympathetic nerve reconstruction. None of the patients had a recurrence of primary hyperhidrosis. Improvement in quality of life was reported in 50% of patients. Both mean Hyperhidrosis Disease Severity Scale and mean Dermatology Life Quality Index were significantly reduced compared to preoperative assessments. In 10 patients, a video-assisted approach and in 4 patients robotic assistance was utilized. There was no significant difference in outcomes between approaches. CONCLUSIONS: Somatic-autonomic nerve reconstructive surgery offers a reversal in the debilitating symptoms in some patients with severe CH. Proper patient selection, preoperative counselling and management of expectation are of paramount importance. Robot-assisted thoracic surgery is an alternative method to conventional video-assisted surgery. Our study provides a practical approach and benchmark for future clinical practice and research.

Measurement and Analysis of Lobar Lung Deformation After a Change of Patient Position During Video-Assisted Thoracoscopic Surgery.

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical technique for the diagnosis and treatment of early-stage lung cancer. During VATS, large lung deformation occurs as a result of a change of patient position and a pneumothorax (lung deflation), which hinders the intraoperative localization of pulmonary nodules. Modeling lung deformation during VATS for surgical navigation is desirable, but the mechanisms causing such deformation are yet not well-understood. In this study, we estimate, quantify and analyze the lung deformation occurring after a change of patient position during VATS. We used deformable image registration to estimate the lung deformation between a preoperative CT (in supine position) and an intraoperative CBCT (in lateral decubitus position) of six VATS clinical cases. We accounted for sliding motion between lobes and against the thoracic wall and obtained consistently low average target registration errors (under 1 mm). We observed large lung displacement (up to 40 mm); considerable sliding motion between lobes and against the thoracic wall (up to 30 mm); and localized volume changes indicating deformation. These findings demonstrate the complexity of the change of patient position phenomenon, which should necessarily be taken into account to model lung deformation for intraoperative guidance during VATS.

Arsenic trioxide inhibits the functions of lung fibroblasts derived from patients with idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a chronic and fatal interstitial lung disease. Currently, no treatment can block or reverse the development of lung fibrosis in patients suffering from IPF. Recent studies indicate that arsenic trioxide (ATO), a safe, effective anti-cancer pro-oxidant drug, prevents the differentiation of normal human lung fibroblasts (NHLFs) in vitro and reduces experimental pulmonary fibrosis in vivo. In this context, we investigated the anti-fibrotic effects of ATO on the main fibrosis functions of human lung fibroblasts (HLFs) isolated from patients with IPF. IPF and non-IPF (control) HLFs were incubated with 0.01-1 µM ATO and stimulated with pro-fibrotic factors (PDGF-BB or TGF-ß1). We measured their rates of proliferation, migration and differentiation and the cell stress response triggered by ATO. ATO did not affect cell viability but strongly inhibited the proliferation and migration of PDGF-BB-stimulated IPF and control HLFs. ATO also prevented myofibroblastic differentiation, as assessed by the expression of α-smooth muscle actin (α-SMA) and collagen-1, and the phosphorylation of SMAD2/3 in TGF-ß1-stimulated HLFs. These antifibrotic effects were associated with increased expression of the transcription factor NRF2 and its target genes NQO1 and HMOX1. Genetic silencing of NRF2 inhibited the ATO-induced cell stress response but did not prevent the ATO-dependent inhibition of α-SMA expression in TGF-ß1-stimulated HLFs. The results demonstrate that ATO, at concentrations similar to exposure in blood plasma of ATO-treated cancer patients, counteracted pro-fibrotic activities of HLFs from IPF patients. We propose to consider ATO for clinical exploration to define the therapeutic potential in patients with IPF.

The illusion of a chest wall tumor: a case-report of sternal tuberculosis.

The incidence rate of tuberculosis in developed countries is low. The most common presentation of this disease is its pulmonary form but with the increasing use of immunosuppressive drugs, extra-pulmonary tuberculosis is re-emerging. Nevertheless, sternal bone involvement is uncommon. We report the case of an eighty-three-year-old man who presented a painful sternal mass which progressed towards cutaneous ulceration. The first diagnostic hypothesis was neoplasia. The pathological and microbiological diagnosis of tuberculosis was achieved after surgical biopsy. The patient received treatment against tuberculosis for nine months enabling recovery without surgery. This case illustrates the importance of having a diagnosis prior to any kind of treatment facing any voluminous parietal thoracic lesions.  This diagnosis is made possible by surgical samples and interdisciplinary teamwork. This case underlines that tuberculosis remains a differential diagnosis that must be evoked in case of unusual bone mass.

A hybrid, image-based and biomechanics-based registration approach to markerless intraoperative nodule localization during video-assisted thoracoscopic surgery.

The resection of small, low-dense or deep lung nodules during video-assisted thoracoscopic surgery (VATS) is surgically challenging. Nodule localization methods in clinical practice typically rely on the preoperative placement of markers, which may lead to clinical complications. We propose a markerless lung nodule localization framework for VATS based on a hybrid method combining intraoperative cone-beam CT (CBCT) imaging, free-form deformation image registration, and a poroelastic lung model with allowance for air evacuation. The difficult problem of estimating intraoperative lung deformations is decomposed into two more tractable sub-problems: (i) estimating the deformation due the change of patient pose from preoperative CT (supine) to intraoperative CBCT (lateral decubitus); and (ii) estimating the pneumothorax deformation, i.e. a collapse of the lung within the thoracic cage. We were able to demonstrate the feasibility of our localization framework with a retrospective validation study on 5 VATS clinical cases. Average initial errors in the range of 22 to 38 mm were reduced to the range of 4 to 14 mm, corresponding to an error correction in the range of 63 to 85%. To our knowledge, this is the first markerless lung deformation compensation method dedicated to VATS and validated on actual clinical data.

Early and long-term results of hypothermic circulatory arrest in aortic surgery: a 20-year single-centre experience.

AIMS: The aim of this study was to document the postoperative outcomes of patients who underwent hypothermic circulatory arrest (HCA), the evolution of HCA management over time and to identify the risks factor for early mortality and postoperative stroke. METHODS: Four hundred and twenty-four patients who underwent aortic surgery with HCA at our institution between January 1995 and June 2016 were consecutively included. RESULTS: The main indications were degenerative aneurysm (254; 59.9%) and acute type A aortic dissection (146; 34.4%). Interventions were performed under deep (18.4 ±â€Š0.9°C; n = 350; 82.5%) or moderate (23.9 ±â€Š1.9°C; n = 74; 17.5%) hypothermia. Antegrade cerebral perfusion (ACP) was employed in 86 (20.3%) cases. The use of moderate hypothermia significantly increased from 2011, to become the preferred strategy in 2016. The in-hospital mortality was 12.5% and the postoperative stroke rate was 7.1%. Kaplan--Meier 5-year survival was 65.7%. Nonelective timing [odds ratio (OR) 4.05; P < 0.001], stroke (OR 3.77' P = 0.032), renal failure (OR 2.49; P = 0.023), redo surgery (2.42; P = 0.049) and CPB time (OR 1.05; P = 0.03) were independent risk factors for in-hospital mortality in multivariate analysis. Femoral cannulation was the only independent risk factor for stroke (OR 3.97; P = 0.002). The level of hypothermia and the use of ACP were not associated with either in-hospital mortality or postoperative stroke. CONCLUSION: HCA might be widely considered to achieve a radical treatment of the aortic disease, provided that hypothermia is maintained below the 24°C safety threshold and ACP is used for HCA exceeding 30 min, to ensure optimal brain, spinal cord and visceral organs protection.

Adult cardiac surgery during COVID-19 lockdown: Impact on activity and outcomes in a high-volume centre.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak had a direct impact on adult cardiac surgery activity, which systematically necessitates a postoperative stay in intensive care. AIM: To study the effect of the COVID-19 lockdown on cardiac surgery activity and outcomes, by making a comparison with the corresponding period in 2019. METHODS: This prospective observational cohort study compared adult cardiac surgery activity in our high-volume referral university hospital from 9 March to 10 May 2020 versus 9 March to 10 May 2019. Data were collected in our local certified database and a national database sponsored by the French society of thoracic and cardiovascular surgery. The primary study endpoints were operative mortality and postoperative complications. RESULTS: With 105 interventions in 2020, our activity dropped by 57% compared with the same period in 2019. Patients were at higher risk, with a significantly higher EuroSCORE II score (3.8±4.5% vs. 2.0±1.8%; P<0.001) and higher rates of active endocarditis (7.6% vs. 2.9%; P=0.047) and recent myocardial infarction (9.5% vs. 0%; P<0.001). The weight and priority of the interventions were significantly different in 2020 (P=0.019 and P<0.001, respectively). The rate of acute aortic syndromes was also significantly higher in 2020 (P<0.001). Operative mortality was higher during the lockdown period (5.7% vs. 1.7%; P=0.038). The postoperative course was more complicated in 2020, with more postoperative bleeding (P=0.003), mechanical circulatory support (P=0.032) and prolonged mechanical ventilation (P=0.005). Only two patients (1.8%) developed a positive status for severe acute respiratory syndrome coronavirus 2 after discharge. CONCLUSIONS: Adult cardiac surgery was heavily affected by the COVID-19 lockdown. A further modulation plan is necessary to improve outcomes and reduce postponed operations to decrease operative mortality and morbidity.

Thoracic splenosis: Case report of a symptomatic case.

Thoracic splenosis is the autotransplantation of splenic tissue in the left thoracic cavity as a result of a splenic injury. This rare pathology is usually asymptomatic and may be discovered on incidental imaging, but the diagnosis often requires invasive procedures such as surgery in order to eliminate a neoplasic origin. We report a rare symptomatic case of a 39-year-old man presenting with chest pain and multiple nodules revealed on a computed tomography scan. The patient underwent a surgical exploration and the pathological studies concluded to a thoracic splenosis. Indeed, the previous medical history of the patient revealed a left thoraco-abdominal traumatism during childhood. The aim of this paper is to emphasize that the diagnosis can now be performed using only imaging techniques such as technetium-99 sulfur colloid or labelled heat-denatured red blood cell scintigraphy to avoid unnecessary invasive procedures including thoracotomy.

Early and late outcomes of aortic surgery under hypothermic circulatory arrest in the elderly: a single center study.

BACKGROUND: With the progressive aging of the population, aortic surgeons are caring for an increasing number of elderly patients. The objective of this study was to analyze early and late outcomes of aortic surgery with hypothermic circulatory arrest in patients aged 70 and above at our institution. METHODS: We performed a retrospective cohort study including every patient aged 70 years or older who underwent aortic surgery with hypothermic circulatory arrest between January 1995 and June 2016 at our institution. Operative results were compared with the contemporary younger counterparts aged <70 years. In-hospital mortality and postoperative stroke were primary outcomes of interest. The main secondary outcomes included acute renal failure, reoperation for bleeding, and spinal cord injury. RESULTS: In the study population, the in-hospital mortality was 16.8% (21/125). Ten (8.0%) patients presented postoperative stroke, and 6 had temporary neurologic disturbance (4.8%). Spinal cord injury occurred in 1 (0.8%) patient. For elective interventions and type A aortic dissections, the in-hospital mortality and stroke rates were 4.6% (3/65) and 7.7% (5/65), 26.8% (11/41) and 12.2% (5/41), respectively. The proportion of non-elective interventions, including type A aortic dissection, and the type of neuroprotective strategy were similar in septuagenarians and younger patients. Patients aged ≥70 had significant shorter cardiopulmonary bypass, myocardial ischemia, and circulatory arrest durations, compared to their younger counterparts. The in-hospital mortality of septuagenarians and younger patients were similar for elective surgery (4.6% vs. 4.7%, P=0.900) and aortic dissections (26.8% vs. 15.1%, P=0.107). There was no statistically significant difference between the two age groups regarding postoperative stroke, spinal cord injury, renal failure requiring dialysis or reintervention for bleeding. Estimated 1-, 3-, and 5-year survival was 78.0%, 70.6%, and 65.7%, respectively. The 5-year survival for elective surgery was 74.9% and 56.0% for non-elective procedures. CONCLUSIONS: Aortic surgery with circulatory arrest in the elderly demonstrated favorable early and late results when compared with younger individuals, with an acceptable operative risk even under emergency conditions, and should not be denied only because of the chronological age of the patients.

Conventional aortic valve replacement in 2005 elderly patients: a 32-year experience.

OBJECTIVES: Considering the good immediate results reported for transcatheter aortic valve implantation in high-risk patients, the role of conventional aortic valve replacement (AVR) is being questioned, especially in elderly patients. The aim of this study was to evaluate our long-term results of conventional AVR in octogenarians. METHODS: A total of 2005 patients aged ≥80 years underwent AVR for aortic stenosis in our institution between 1978 and 2011. Of these, 1009 (50%) patients had an associated extracardiac comorbidity and 650 (32%) patients had coronary lesions. Valve replacement was the sole procedure in 1515 (76%) patients, and 396 (19%) patients had concomitant coronary artery bypass grafting. Data were collected at the time of surgery in our database, and regularly updated by mailed questionnaires and telephone contact. RESULTS: Early mortality of isolated AVR was 5.5% for the last 10 years of the series. Significant risk factors were chronic obstructive pulmonary disease, chronic renal failure, advanced cardiac disease [left or right ventricular failure, New York Heart Association (NYHA) Class IV and atrial fibrillation] and coronary disease. Long-term follow-up was 99.5% complete (9 patients lost to follow-up), totalling 8849 patient-years. Nine hundred and one patients died at late follow-up with a median survival of 7.1 years, with 7 patients becoming centenarian. Apart from older age, main late causes of death were cardiovascular (20.5%), neurological deficit (10.2%) and cancer (10.2%). Actuarial survival was 83%, 62.5% and 25% at 2, 5 and 10 years, respectively. This survival compares favourably with that of a French-matched population. Above all, 90% of late survivors reported functional improvement. Univariable and multivariable analysis identified risk factors of late death as male gender, associated comorbidity, renal failure, advanced cardiac disease, atrial fibrillation and impaired ventricular function. Coronary lesions, associated cardiac surgery and small diameter prostheses (19 or 21 mm) did not impair long-term survival. CONCLUSIONS: AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides an excellent quality of life and restores life expectancy. Percutaneous valve implantation is to be considered, in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis for the majority of patients.

Post-menopausal pulmonary leiomyoma metastasis: an unexpected finding.

Benign metastasizing leiomyoma (BML) is a rare entity characterized by proliferation of extra-uterine smooth muscle tumors. BML has both malignant behavior and benign characteristics. Here, we present a case of pulmonary BML occurring in a 70-year-old woman treated by surgery.

Combined thoracic and hepatobiliary surgery for iatrogenic bronchobiliary fistula.

Bronchobiliary fistula is a rare pathology mainly caused by hepatic tumors, bile duct obstruction, or hepatic hydatid disease. A 70-year-old man developed a bronchobiliary fistula after biliary stenting. After failure of conservative treatment including endoscopic retrograde biliary drainage, he underwent a combined operation with a two-level approach. Both a thoracotomy and laparotomy were performed, allowing pulmonary resection, diaphragmatic repair, and bile duct reconstruction during the same operation. Postoperative follow-up at one year showed optimal healing of the fistula.

Clinical outcomes in patients after extracorporeal membrane oxygenation support for post-cardiotomy cardiogenic shock: a single-centre experience of 92 cases.

OBJECTIVES: Post-cardiotomy cardiogenic shock is a major concern in cardiac surgery. We reviewed our experience of extracorporeal membrane oxygenation (ECMO) as temporary circulatory support in post-cardiotomy cardiogenic shock. METHODS: Between January 2005 and December 2014, adult patients implanted with ECMO after cardiac surgical procedures were included. Indications for ECMO were failure to be withdrawn from cardiopulmonary bypass or refractory cardiogenic shock occurring during postoperative Days 1 and 2. Patients' characteristics and outcomes were prospectively collected in a local ECMO database. RESULTS: Ninety-two patients, median age of 63 years (17-83 years), were supported by ECMO following valvular surgery (66%), acute aortic dissection (10%) and coronary artery bypass grafting (9%). A total of 37% were combined surgical procedures, 24% were redo procedures and 33% were emergent procedures. The median duration of ECMO support was 6 days (1-28 days). The weaning rate from mechanical support was 48%. Overall 1-month and 6-month survival rates were, respectively, 42% and 39%. Survivors were younger (57 vs 63 years old, P = 0.02) and had a higher preoperative left ventricular ejection fraction (52.5 vs 44.1%, P = 0.017). There was a trend for lower serum creatinine levels and total bilirubin rates in the survivors' group 24 h after initiation of ECMO (respectively, 162 vs 212 µmol/l, P = 0.06; 25.3 vs 54.2 mg/dl, P = 0.08). Valvular surgery and peak lactic acid serum level were associated with poor outcomes. The mean health-related quality of life EuroQoL scale was 68 ± 16/100 at 2 years. CONCLUSIONS: Refractory cardiogenic shock requiring ECMO was most frequently observed after redo valvular surgery in the present study. The overall 6-month survival rate was 39% after ECMO support for post-cardiotomy cardiogenic shock with acceptable health-related quality of life. Improved kidney and liver functions after 24 h of support were associated with favourable outcomes.

Infective Endocarditis With Paravalvular Extension: 35-Year Experience.

BACKGROUND: We investigated our surgical strategy and clinical results in patients from active infective endocarditis (AIE) complicated by paravalvular involvement to determine the risk factors of early and late death and reoperation. METHODS: From October 1979 to December 2014, 955 patients underwent operations for AIE; among them 207 had AIE with paravalvular extension. The patients were a mean age of 59.9 ± 15.4 years, and 162 (78%) were male. Of these patients, 137 (66%) had isolated aortic valve endocarditis, and 138 (67%) had native valve endocarditis. Follow-up was 99% complete. RESULTS: The operative mortality of the cohort was 16% (n = 34). Abnormal communication, mechanical valve implantation, and renal failure were independent predictors of 30-day death. Survival at 1, 5, 10, and 15 years was 90.3% ± 2.3%, 62.4% ± 3.7%, 49.3% ± 4.1%, and 37.9% ± 4.4%, respectively. Streptococcus endocarditis (all species), complex annular repair, and preoperative heart failure were independent predictors of long-term death. A reoperation was required in 29 patients (14%). Streptococcus pneumoniae endocarditis was the only independent predictor of early reoperation (within 30 days after the operation or during the same hospitalization). Freedom from reoperation at 1, 5, 10, and 15 years was 91.9% ± 2.2%, 89.6% ± 2.6%, 89.6% ± 2.6%, and 87.0% ± 3.5%, respectively. Independent predictors of late reoperation were urgent/emergency operation, prosthetic valve endocarditis, and complex annular repair. CONCLUSIONS: AIE complicated by paravalvular involvement remains a surgical challenge. Valve replacement (particularly using bioprosthesis) associated with ad hoc reconstruction seems to be a reliable option and showed very encouraging results in this context.

Combined Coronary Revascularization: Single-Center 10-Year Experience.

OBJECTIVE: This study aimed to assess the long-term outcome of combined coronary revascularization. METHODS: Between January 2000 and September 2010, 106 consecutive patients underwent combined coronary revascularization, either the same day or staged within 90 days. Percutaneous coronary intervention was always performed before coronary artery bypass grafting. We identified three groups as follows: one-stop combined coronary revascularization (n = 20), percutaneous coronary intervention for acute coronary syndrome before subsequent surgery (n = 39), and percutaneous coronary intervention for stable coronary artery disease before subsequent surgery (n = 47). Off-pump technique was used in all cases. RESULTS: A total of 107 angioplasties were realized (drug-eluting stents, 21; bare metal stents, 114; balloon angioplasty, 4). Percutaneous coronary intervention was mostly performed in the right coronary artery or branches (85%). The mean (SD) number of grafts was 1.9 (0.6), among them 1.8 (0.7) with arterial grafts. A total of 87.7% of the patients underwent exclusive arterial revascularization. There was one reexploration for bleeding and no in-hospital death. Eleven patients died in the follow-up. Repeat percutaneous coronary intervention was necessary for six patients and repeat surgery for one patient. The mean (SD) follow-up was 6.1 (2.7) years. Complete follow-up was obtained in 96.2% of the patients. Freedom from ischemic events (all-cause deaths, angina, acute coronary syndrome, myocardial infarction) was 86.3% (3.7%) at 5 years and 79.7% (5.2%) at 8 years (no difference between groups). Freedom from major adverse cardiac or cerebrovascular events was 88.8% (3.4%) at 5 years and 75.7% (5.2%) at 8 years (no difference between groups). CONCLUSIONS: Combined coronary revascularization increases the use of arterial grafts, with good long-term outcome.

Small pulmonary nodule localization with cone beam computed tomography during video-assisted thoracic surgery: a feasibility study.

OBJECTIVES: To describe a non-invasive guidance procedure, using intraoperative cone beam computed tomography (CBCT) and augmented fluoroscopy to guide lung resection during video-assisted thoracic surgery (VATS). METHODS: Patients with solitary or multiple lung nodules between 5 and 20 mm in size were included. Under general anaesthesia, a moderate pneumothorax allowing the CBCT acquisition was first performed. Then a segmentation of the lesion was performed on a 3D reconstruction. A projection of this 3D reconstruction was then integrated into the digital workspace and automatically registered into the fluoroscopic images, creating an augmented fluoroscopy. The procedure was continued under classic video-thoracoscopic vision taking account of the augmented fluoroscopy to locate the targeted nodule. RESULTS: Eight patients were included (mean age 61 ± 11.7 years): 7 patients had an isolated lesion and 1 patient had two lesions (mean size 13.2 ± 5.1 mm). Their mean depth to the pleura was 21.4 ± 10.7 mm. Four patients underwent a wedge resection associated with lymph node resection. Two patients had an initial wedge resection followed by a complementary lobectomy associated with lymph node resection (primary lung tumour). One patient had a wedge resection in the upper lobe and a lobectomy of the inferior lobe associated with lymph node resection. One patient underwent a conversion and a bilobectomy due to vascular injury. The mean global operating time was 100.6 ± 36.7 min. All the nodules have been identified on the CBCT acquisitions. The segmentation of the lesion has been performed in all cases. We have been able to detect all the nodules and to successfully perform the resection in all cases owing to the augmented fluoroscopy. The mean fluoroscopic time was 134.2 ± 55.0 s. The mean imaging time, between the incision and the final nodule localization, was 11.8 ± 3.8 min. CONCLUSIONS: This paper is the first describing a clinical application of CBCT performed during thoracic surgery. Associated with augmented reality, it offers a significant progress in VATS resection of subpalpable lung nodules. This preliminary experience highlights the potential of the proposed CBCT approach to improve the perception of targeted small tumours during VATS.