[Beating heart surgical treatment of atrio-esophageal fistula after radiofrequency ablation of atrial fibrillation]. / Trattamento chirurgico a cuore battente di una fistola atrio-esofagea post-ablazione tramite radiofrequenza di fibrillazione atriale.

Atrio-esophageal fistula (AEF) is a rare (0.02-0.1%) complication of radiofrequency ablation for atrial fibrillation and is associated with high mortality. It typically presents between 2 and 6 weeks after catheter ablation. AEF was reported to be the second complication as cause of death after radiofrequency ablation with a mortality rate of 71%. Common clinical features of AEF include dysphagia, nausea, heartburn, hematemesis or melena, high fever, sepsis, pericardial or pleural effusions, mediastinitis, seizures, and stroke. Once the diagnosis of AEF is made, early surgical repair is mandatory. Herein, we report a case of a AEF treated surgically without extracorporeal circulation.

High PD-L1/IDO-2 and PD-L2/IDO-1 Co-Expression Levels Are Associated with Worse Overall Survival in Resected Non-Small Cell Lung Cancer Patients.

Programmed death ligand 1 (PD-L1) expression is a predictive biomarker of the success of PD-1/PD-L1 inhibitor therapy for patients with advanced non-small cell lung cancer (NSCLC) but its role as a prognostic marker for early-stage resectable NSCLC remains unclear. We studied gene expression levels of immune-related genes PD-1, PD-L1, PD-L2, IDO-1, IDO-2 and INFγ in tumor tissue of surgically resected NSCLC and correlated the finding with clinicopathological features and patient outcomes. A total of 191 consecutive early-stage NSCLC patients who underwent curative pulmonary resection were studied. The mRNA expression levels of immune-related genes were evaluated by quantitative reverse transcription polymerase chain reaction (qRT-PCR) using RT2 Profiler PCR Arrays (Qiagen). PD-1, PD-L2 and IDO-2 gene expression levels were significantly higher in patients with squamous histology (p = 0.001, p = 0.021 and p < 0.001; respectively). PD-1, PD-L1 and IDO-2 gene expression levels were significantly higher in patients with higher stage (p = 0.005, p = 0.048 and p = 0.002, respectively). The univariate analysis for recurrence-free survival (RFS) and overall survival (OS) showed that patients with higher levels of three-genes (PD-L1/PD-L2/INFγ) (hazard ratio (HR)) 1.90 (95% confidence interval (CI), 1.13-3.21), p = 0.015) were associated with a worse RFS, while patients with higher levels of both genes (PD-L1/IDO-2) or (PD-L2/IDO-1) were associated with a worse OS (HR 1.63 95% CI, 1.06-2.51, p = 0.024; HR 1.54 95% CI, 1.02-2.33, p = 0.04; respectively). The multivariate interaction model adjusted for histology and stage confirmed that higher levels of three genes (PD-L1/PD-L2/INFγ) were significantly associated with worse RFS (HR 1.98, p = 0.031) and higher levels of both genes (PD-L1/IDO-2) and (PD-L2/IDO-1) with worse OS (HR 1.98, p = 0.042, HR 1.92, p = 0.022). PD-L1/IDO-2 and PD-L2/IDO-1 co-expression high levels are independent negative prognostic factors for survival in early NSCLC. These features may have important implications for future immune-checkpoint therapeutic approaches.

Microalbuminuria assessment after thoracic surgery: Early identification of complication risks.

INTRODUCTION: Microalbuminuria (MA) is considered a reflection of systemic capillary leak and an early marker of acute stress reaction to the surgical insult, proportional to the severity of the initiating condition and predictive of the individual response to surgical stress. OBJECTIVES: We conducted a prospective study to assess for the variation of MA within 4 days after thoracic surgery. We correlated observed MA levels with both their respective PaO2 /FiO2 respiratory ratio and the onset of postoperative complications. METHODS: This single-centre study enrolled 255 consecutive patients having an American Society of Anaesthesiologists (ASA) score ≤ 3. The mean age was 62 years with 67% male. All patients were scheduled for elective pulmonary resection. MA was measured in urine samples as the albumin-to-creatinine ratio (A/C), prior to, at and after extubation up to 96 hours. PaO2 /FiO2 was measured at extubation and on the first postoperative day. RESULTS: Overall, preoperative A/C levels resulted normal, with a significant average increase at extubation which peaked 6 hours later (P < 0.001). Larger postoperative A/C increases were observed in patients who developed postoperative complications, compared to those without these complications (P < 0.019). Moreover, patients undergoing major open pulmonary resections had larger postoperative A/C increases, compared to those undergoing minor video-assisted thoracic surgery resections (P < 0.006). At the time of extubation, A/C was inversely related to the PaO2 /FiO2 ratio (r = -0.25; P = 0.038). Peak A/C > 61 mg/g (P = 0.0003) was associated with postoperative cardio-pulmonary complications (OR 3.85; P = 0.003). CONCLUSION: Within 6 hours after extubation, MA assessment may be a rapid and relatively inexpensive method for better predicting perioperative risk in an ASA score ≤ 3 population.

Pericardiectomy for constrictive pericarditis.

Chronic constrictive pericarditis results from inflammation and fibrosis of the pericardium. This situation eventually leads to impairment of diastolic filling and right heart failure. Once the diagnosis is made, because the disease is basically irreversible, a pericardiectomy is the mandatory treatment. The standard surgical treatment has been extensively described. The goal of this video tutorial is to render a visual explanation of the described techniques and to provide tips to help make the procedure easier to perform. The standard technique is performed through a median sternotomy, preferably without cardiopulmonary bypass if feasible. The procedure includes the complete removal of the anterior pericardium from phrenic nerve to phrenic nerve and the removal of the diaphragmatic pericardium and of part of the pericardium posterior to both phrenic nerves. Before starting the actual pericardiectomy procedure, it is useful to separate the pericardial rigid shell from the pleurae and from the diaphragm; this step allows the operator to see both phrenic nerves clearly and to give clear boundaries between the pericardium and the diaphragm, which are not often as clear as desirable due to fat, edema, inflammation, and scarring. Once a portion of the pericardium has been detached from the myocardium, it can be excised, making the portion yet to be removed more visible.