Pulmonary artery reconstruction using an autologous pulmonary vein patch in pulmonary resection.

Pulmonary artery (PA) reconstruction has been accepted to avoid pneumonectomy in locally advanced lung cancer surgery because of its satisfactory outcomes with regard to long-term survival and its low postoperative morbidity and mortality rates. Several techniques of PA reconstruction have been documented. However, the availability of PA reconstruction using an autologous pulmonary vein (PV) patch is unclear. Here, we present a patient who successfully underwent PA reconstruction using an autologous PV patch during resection of a lung adenocarcinoma (cT2aN1M0: stage IIB) in the left upper lobe with hilar extension and left main PA invasion.

Long-segment pulmonary artery resection to avoid pneumonectomy: long-term results after prosthetic replacement.

OBJECTIVES: Resection of a long pulmonary artery (PA) segment infiltrated by tumour and reconstruction by conduit interposition or wide patch is a challenging but feasible option to avoid pneumonectomy. Our goal was to report the long-term results of our experience with this type of operation using various techniques and materials. METHODS: Between 1991 and 2015, 24 patients underwent sleeve resection of a long PA segment or extended resection (>2.5 cm) of 1 aspect of the circumference of the PA associated with lobectomy for centrally located lung cancer. Materials used for conduit reconstruction (20 patients) included pulmonary vein in 12 patients, autologous pericardium in 4, porcine pericardium in 3 and bovine pericardium in 1. Patches used in 4 patients consisted of porcine pericardium (2 patients) and pulmonary vein (2 patients). RESULTS: Twenty-three patients underwent left upper lobectomy without associated bronchoplasty. One patient underwent bronchovascular left upper sleeve lobectomy. The postoperative morbidity rate was 29.1%. No complications related to the reconstructive procedure occurred. There were no postoperative deaths. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography performed every 6 months. Pathological tumour stage ranged from I to IIIA. Five-year overall survival and disease-free survival rates were 69.9% and 52.7%, respectively, at a median follow-up of 41 months. CONCLUSIONS: Resection of the long PA segment followed by conduit or wide patch reconstruction is a feasible, safe and effective option to avoid pneumonectomy. Different biological materials can be used to provide adequate tissue characteristics; the choice is made on a case-by-case basis. Long-term results confirm the oncological reliability of this operation.

Pulmonary artery reconstruction with pulmonary vein conduit for lung cancer: medium-term results.

BACKGROUND: The use of an autologous pulmonary vein (PV) conduit for reconstruction of the pulmonary artery (PA) in lung-sparing resections was first described in 2009, but to date only two case reports appeared and no medium-term and long-term results have been reported, to our knowledge. We present the first case series with medium-term follow-up. METHODS: Between December 2009 and December 2012, 9 patients undergoing PA sleeve resection for centrally located lung cancer received reconstruction by this technique. Three of these patients underwent induction chemotherapy. The venous graft was obtained from the proximal extraparenchymal portion of the superior PV and was sutured to the proximal and distal PA stumps with the standard anastomotic technique. RESULTS: All 9 patients underwent left upper lobectomy with sleeve resection of the PA without associated bronchoplasty. The postoperative morbidity rate was 33% (1 chylothorax, 1 atrial fibrillation, and 1 parenchymal atelectasis). No adverse events related to the reconstructive procedure occurred. There was no postoperative mortality. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography every 6 months. All patients are alive at a mean follow-up time of 32 ± 12.4 months (range, 6 to 42 months). Tumor recurrence has been observed in 2 patients (1 local, 1 systemic). The median survival time is 38 months. The median disease-free survival time is 33 months. CONCLUSIONS: Reconstruction of the PA by a PV graft is a feasible and effective option for parenchymal-sparing resections. The PV conduit shows tissue characteristics similar to those of the arterial wall. This technique is safe and is supported by good medium-term results.

Reconstruction of pulmonary venous conduit with CorMatrix in lung transplant.

Anomalous pulmonary vein anatomy is infrequently encountered during reconstructive lung surgery, especially lung transplantation. Complications of pulmonary venous anastomosis carry high morbidity and mortality. We report a case of anomalous pulmonary vein reconstruction with a decellularized porcine small intestinal submucosa-derived extracellular matrix during bilateral lung transplantation in an 18-year-old woman with cystic fibrosis.

Comparative evaluation of left ventricular mass regression after aortic valve replacement: a prospective randomized analysis.

BACKGROUND: We assessed the hemodynamic performance of various prostheses and the clinical outcomes after aortic valve replacement, in different age groups. METHODS: One-hundred-and-twenty patients with isolated aortic valve stenosis were included in this prospective randomized randomised trial and allocated in three age-groups to receive either pulmonary autograft (PA, n = 20) or mechanical prosthesis (MP, Edwards Mira n = 20) in group 1 (age < 55 years), either stentless bioprosthesis (CE Prima Plus n = 20) or MP (Edwards Mira n = 20) in group 2 (age 55-75 years) and either stentless (CE Prima Plus n = 20) or stented bioprosthesis (CE Perimount n = 20) in group 3 (age > 75). Clinical outcomes and hemodynamic performance were evaluated at discharge, six months and one year. RESULTS: In group 1, patients with PA had significantly lower mean gradients than the MP (2.6 vs. 10.9 mmHg, p = 0.0005) with comparable left ventricular mass regression (LVMR). Morbidity included 1 stroke in the PA population and 1 gastrointestinal bleeding in the MP subgroup. In group 2, mean gradients did not differ significantly between both populations (7.0 vs. 8.9 mmHg, p = 0.81). The rate of LVMR and EF were comparable at 12 months; each group with one mortality. Morbidity included 1 stroke and 1 gastrointestinal bleeding in the stentless and 3 bleeding complications in the MP group. In group 3, mean gradients did not differ significantly (7.8 vs 6.5 mmHg, p = 0.06). Postoperative EF and LVMR were comparable. There were 3 deaths in the stented group and no mortality in the stentless group. Morbidity included 1 endocarditis and 1 stroke in the stentless compared to 1 endocarditis, 1 stroke and one pulmonary embolism in the stented group. CONCLUSIONS: Clinical outcomes justify valve replacement with either valve substitute in the respective age groups. The PA hemodynamically outperformed the MPs. Stentless valves however, did not demonstrate significantly superior hemodynamics or outcomes in comparison to stented bioprosthesis or MPs.

Experience with the autologous pulmonary vein for pulmonary arterioplasty.

OBJECTIVE: Lobectomy with pulmonary artery resection and reconstruction is seldom performed in order to avoid pneumonectomy in selected cases. The aim of this study is to determine how safe and effective the graft reconstruction of the pulmonary artery is, using autologous tissue taken from the pulmonary vein. METHODS: Eight patients with diagnosed non-small-cell lung cancer were treated by lobectomy with pulmonary artery reconstruction with curative intent. All patients could have tolerated pneumonectomy. Patch or conduit angioplasty was performed by using a tailored graft, harvested from the autologous pulmonary vein of the resected lobe. Patients were followed up and the clinical records were analyzed retrospectively. Long-term patency of the reconstructed pulmonary artery was investigated by computed tomographic pulmonary angiogram. RESULTS: No procedure-related complications and no perioperative mortality were observed. No blood transfusion was required. Follow-up varied from 10 to 64 months. No local recurrences were found next to the angioplasty. Ideal long-term patency of the pulmonary artery was demonstrated in all cases. Two patients are alive with evidence of extrathoracic metastatic disease and four patients are apparently healthy. Two patients died of progressive disease. CONCLUSIONS: The use of pulmonary vein tissue as a graft to repair the pulmonary artery is feasible, reproducible, and seems to be oncologically correct. Pulmonary vein tissue can be easily harvested during surgery and offers a high-quality vascular tissue for pulmonary angioplasty.

New technique for pulmonary artery reconstruction.

Bronchial and vascular reconstructive procedures are a technically feasible alternative to pneumonectomy in lung cancer and have the advantage of preserving lung parenchyma function. Sleeve resection and prosthetic reconstruction of the pulmonary artery (PA) have progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery. To spare the lung parenchyma, angioplastic procedures involving removal of a portion of the arterial wall or a circumferential resection with arterial reconstruction have been used. Several techniques of pulmonary arterioplasty have been documented, such as patch reconstruction, end-to-end anastomosis, synthetic prosthesis, biological prosthesis, prosthetic or pericardial conduit. We present the first case reported in the literature of PA reconstruction with a pulmonary vein graft.

Reoperation in a Jehovah's Witness 22 years after aortic allograft reconstruction of the right ventricular outflow tract.

We report the case of a 29-year-old male Jehovah's Witness who presented with hemolysis and right heart failure as a consequence of extreme calcification of an aortic valve-containing allograft and Dacron prosthesis that had been placed 22 years earlier to repair tetralogy of Fallot. Reoperation had been denied by several other centers, because of the patient's refusal to undergo blood transfusion. For 2 weeks preoperatively, we raised the patient's hemoglobin level by treating him with recombinant erythropoietin, oral iron, and folic acid. At surgery, under normothermic cardiopulmonary bypass, we replaced the aortic allograft in the right ventricular outflow tract with a cryopreserved pulmonary allograft, also containing a valve. The postoperative course was uneventful, and the patient was released from the hospital on the 13th postoperative day in excellent condition.

Lung transplantation in a patient with arteriovenous malformations.

Multiple arteriovenous fistulas (AVF) is an infrequent pathology, in which lung transplant is controversial. We report a patient with hereditary hemorrhagic telangiectasia who underwent a single lung transplant with excellent evolution, and three years later (that is, at the time of this paper), she is still alive.

The Ross procedure: Is it the ideal operation for the young with aortic valve disease?

BACKGROUND: Aortic valve prosthesis with adequate hemodynamic performance should allow more complete left ventricular mass regression and normalize left ventricular function. This possibly affects long-term prognosis after aortic valve replacement. OBJECTIVE: Assessment of hemodynamic performance of pulmonary autograft in the aortic position and the regression of left ventricular mass after the Ross procedure. METHODS: Between May 1995 and March 1996, 45 patients with mean age of 27.1 years underwent a Ross procedure. Doppler echocardiography and cardiac catheterization were performed on all patients before hospital discharge to evaluate the hemodynamic performance of auto- and homografts, as well as to evaluate left ventricular mass and function. Fourteen patients with follow-up longer than six months were submitted to dobutamine stress echocardiography to study the hemodynamic performance of auto- and homografts during exercise. RESULTS: Hospital mortality was 6%. After a mean follow-up of 12.8 months (1-23 months) there was one late sudden death. No valve-related event was observed during this period. Immediate and late hemodynamic performance of the pulmonary autografts were normal with an average mean gradient of 1.8 +/- 0.6 mmHg and an average maximum instantaneous gradient of 2.9 +/- 0.9 mmHg. Valvular insufficiency was insignificant. Even during exercise, gradients did not increase significantly with an average mean gradient of 4.3 +/- 2.5 mmHg and an average maximum gradient of 10.4 +/- 6.1 mmHg. Homografts used for right ventricular reconstruction showed excellent immediate hemodynamic performance. However, at late follow-up an increase in flow speed was observed with an average to mean gradient of 10 +/- 7.1 mmHg at rest and 26 +/- 13.2 mmHg during exercise. Left ventricular mass index was normal at rest and during exercise in the majority of patients. CONCLUSION: Given the normal hemodynamic function of pulmonary autografts, the reduction of ventricular mass and normalization of left ventricular function, in addition to the excellent late follow-up of the patients, the Ross procedure is considered the operation of choice for young patients requiring aortic valve replacement.