Incidental findings on routine preoperative noncontrast chest computed tomography and chest radiography prior to cardiac surgery in the multicenter randomized controlled CRICKET study.

OBJECTIVE: To describe the prevalence and consequences of incidental findings when implementing routine noncontrast CT prior to cardiac surgery. METHODS: In the multicenter randomized controlled CRICKET study, 862 adult patients scheduled for cardiac surgery were randomized 1:1 to undergo standard of care (SoC), which included a chest-radiograph, or an additional preoperative noncontrast chest CT-scan (SoC+CT). In this subanalysis, all incidental findings detected on the chest radiograph and CT-scan were analyzed. The influence of smoking status on incidental findings was also evaluated, adjusting for sex, age, and group allocation. RESULTS: Incidental findings were observed in 11.4% (n = 49) of patients in the SoC+CT group and in 3.7% (n = 16) of patients in the SoC-group (p < 0.001). The largest difference was observed in findings requiring follow-up (SoC+CT 7.7% (n = 33) vs SoC 2.3% (n = 10), p < 0.001). Clinically relevant findings changing the surgical approach or requiring specific treatment were observed in 10 patients (1.2%, SoC+CT: 1.6% SoC: 0.7%), including lung cancer in 0.5% of patients (n = 4) and aortic dilatation requiring replacement in 0.2% of patients (n = 2). Incidental findings were more frequent in patients who stopped smoking (OR 1.91, 1.03-3.63) or who actively smoked (OR 3.91, 1.85-8.23). CONCLUSIONS: Routine CT-screening increases the rate of incidental findings, mainly by identifying more pulmonary findings requiring follow-up. Incidental findings are more prevalent in patients with a history of smoking, and preoperative CT might increase the yield of identifying lung cancer in these patients. Incidental findings, but not specifically the use of routine CT, are associated with delay of surgery. KEY POINTS: • Clinically relevant incidental findings are identified more often after a routine preoperative CT-scan, when compared to a standard of care workup, with some findings changing patient management. • Patients with a history of smoking have a higher rate of incidental findings and a lung cancer rate comparable to that of lung cancer screening trials. • We observed no clear delay in the time to surgery when adding routine CT screening.

Non-Small-Cell Lung Cancer Patients with a High Predicted Risk of Irradical Resection: Can Chemoradiotherapy Offer Similar Survival?

PURPOSE: Irradical resection of non-small-cell lung cancer (NSCLC) is a detrimental prognostic factor. Recently, Rasing et al. presented an internationally validated risk score for pre-treatment prediction of irradical resection. We hypothesized that chemoradiation therapy (CRT) could serve as an alternative approach in patients with a high risk score and compared overall survival (OS) outcomes between surgery and CRT. METHODS: Patients from a population-based cohort with stage IIB-III NSCLC between 2015 and 2018 in The Netherlands were selected. Patients with a 'Rasing score' > 4 who underwent surgery were matched with patients who underwent CRT using 1:1 nearest-neighbor propensity score matching. The primary endpoint of OS was compared using a Kaplan-Meier analysis. RESULTS: In total, 2582 CRT and 638 surgery patients were eligible. After matching, 523 well-balanced pairs remained. Median OS in the CRT group was 27.5 months, compared with 45.6 months in the surgery group (HR 1.44, 95% CI 1.23-1.70, p < 0.001). The 114 surgical patients who underwent an R1-2 resection (21.8%) had a worse median OS than the CRT group (20.2 versus 27.5 months, HR 0.77, 95% CI 0.61-0.99, p = 0.039). CONCLUSION: In NSCLC patients at high predicted risk of irradical resection, CRT appears to yield inferior survival compared with surgery. Therefore, choosing CRT instead of surgery cannot solely be based on the Rasing score. Since patients receiving an R1-2 resection do have detrimental outcomes compared with primary CRT, the treatment decision should be based on additional information, such as imaging features, comorbidities, patient preference, and the surgeon's confidence in achieving an R0 resection.

Effect of routine preoperative screening for aortic calcifications using noncontrast computed tomography on stroke rate in cardiac surgery: the randomized controlled CRICKET study.

OBJECTIVES: To evaluate if routine screening for aortic calcification using unenhanced CT lowers the risk of stroke and alters the surgical approach in patients undergoing general cardiac surgery compared with standard of care (SoC). METHODS: In this prospective, multicenter, randomized controlled trial, adult patients scheduled for cardiac surgery from September 2014 to October 2019 were randomized 1:1 into two groups: SoC alone, including chest radiography, vs. SoC plus preoperative noncontrast CT. The primary endpoint was in-hospital perioperative stroke. Secondary endpoints were preoperative change of the surgical approach, in-hospital mortality, and postoperative delirium. The trial was halted halfway for expected futility, as the conditional power analysis showed a chance < 1% of finding the hypothesized effect. RESULTS: A total of 862 patients were evaluated (SoC-group: 433 patients (66 ± 11 years; 74.1% male) vs. SoC + CT-group: 429 patients (66 ± 10 years; 69.9% male)). The perioperative stroke rate (SoC + CT: 2.1%, 9/429 vs. SoC: 1.2%, 5/433, p = 0.27) and rate of changed surgical approach (SoC + CT: 4.0% (17/429) vs. SoC: 2.8% (12/433, p = 0.35) did not differ between groups. In-hospital mortality and postoperative delirium were comparable between groups. In the SoC + CT group, aortic calcification was observed on CT in the ascending aorta in 28% (108/380) and in the aortic arch in 70% (265/379). CONCLUSIONS: Preoperative noncontrast CT in cardiac surgery candidates did not influence the surgical approach nor the incidence of perioperative stroke compared with standard of care. Aortic calcification is a frequent finding on the CT scan in these patients but results in major surgical alterations to prevent stroke in only few patients. KEY POINTS: • Aortic calcification is a frequent finding on noncontrast computed tomography prior to cardiac surgery. • Routine use of noncontrast computed tomography does not often lead to a change of the surgical approach, when compared to standard of care. • No effect was observed on perioperative stroke after cardiac surgery when using routine noncontrast computed tomography screening on top of standard of care.

Alternatives for Vitamin K Antagonists as Thromboprophylaxis for Mechanical Heart Valves and Mechanical Circulatory Support Devices: A Systematic Review.

The holy grail of anticoagulation in patients with intracardiac devices, such as mechanical heart valves (MHVs) and left ventricular assist devices (LVADs), comprises safe prevention of thrombosis without interrupting normal hemostasis. Device-induced thrombosis and anticoagulant-related bleeding problems are dreaded complications that may cause a significantly reduced quality of life and increased morbidity and mortality. Vitamin K antagonists are the current standard for oral anticoagulation therapy in patients with MHVs and LVADs. Even within the therapeutic range, hemorrhage is the primary complication of these drugs, which emphasizes the need for safer anticoagulants for the prevention of device-induced thrombosis. Device-induced thrombosis is a complex multifactorial phenomenon that likely requires anticoagulant therapy targeting multiple pathways. Here, we review the preclinical and clinical data describing the efficacy of a variety of anticoagulants as thromboprophylaxis after implantation of intracardiac devices.

Normal imaging findings after aortic valve implantation on 18F-Fluorodeoxyglucose positron emission tomography with computed tomography.

BACKGROUND: To determine the normal perivalvular 18F-Fluorodeoxyglucose (18F-FDG) uptake on positron emission tomography (PET) with computed tomography (CT) within one year after aortic prosthetic heart valve (PHV) implantation. METHODS: Patients with uncomplicated aortic PHV implantation were prospectively included and underwent 18F-FDG PET/CT at either 5 (± 1) weeks (group 1), 12 (± 2) weeks (group 2) or 52 (± 8) weeks (group 3) after implantation. 18F-FDG uptake around the PHV was scored qualitatively (none/low/intermediate/high) and quantitatively by measuring the maximum Standardized Uptake Value (SUVmax) and target to background ratio (SUVratio). RESULTS: In total, 37 patients (group 1: n = 12, group 2: n = 12, group 3: n = 13) (mean age 66 ± 8 years) were prospectively included. Perivalvular 18F-FDG uptake was low (8/12 (67%)) and intermediate (4/12 (33%)) in group 1, low (7/12 (58%)) and intermediate (5/12 (42%)) in group 2, and low (8/13 (62%)) and intermediate (5/13 (38%)) in group 3 (P = 0.91). SUVmax was 4.1 ± 0.7, 4.6 ± 0.9 and 3.8 ± 0.7 (mean ± SD, P = 0.08), and SUVratio was 2.0 [1.9 to 2.2], 2.0 [1.8 to 2.6], and 1.9 [1.7 to 2.0] (median [IQR], P = 0.81) for groups 1, 2, and 3, respectively. CONCLUSION: Non-infected aortic PHV have similar low to intermediate perivalvular 18F-FDG uptake with similar SUVmax and SUVratio at 5, 12, and 52 weeks after implantation.

Surgically implanted aortic valve bioprostheses deform after implantation: insights from computed tomography.

OBJECTIVE: Little is known about the prevalence and degree of deformation of surgically implanted aortic biological valve prostheses (bio-sAVRs). We assessed bio-sAVR deformation using multidetector-row computed tomography (MDCT). METHODS: Three imaging databases were searched for patients with MDCT performed after bio-sAVR implantation. Minimal and maximal valve ring diameters were obtained in systole and/or diastole, depending on the acquired cardiac phase(s). The eccentricity index (EI) was calculated as a measure of deformation as (1 - (minimal diameter/maximal diameter)) × 100%. EI of < 5% was considered none or trivial deformation, 5-10% mild deformation, and > 10% non-circular. Indications for MDCT and implanted valve type were retrieved. RESULTS: One hundred fifty-two scans of bio-sAVRs were included. One hundred seventeen measurements were performed in systole and 35 in diastole. None or trivial deformation (EI < 5%) was seen in 67/152 (44%) of patients. Mild deformation (EI 5-10%) was seen in 59/152 (39%) and non-circularity was found in 26/152 (17%) of cases. Overall, median EI was 5.5% (IQR 3.4-7.8). In 77 patients, both systolic and diastolic measurements were performed from the same scan. For these scans, the median EI was 6.5% (IQR 3.4-10.2) in systole and 5.1% (IQR3.1-7.6) in diastole, with a significant difference between both groups (p = 0.006). CONCLUSIONS: Surgically implanted aortic biological valve prostheses show mild deformation in 39% of cases and were considered non-circular in 17% of studied valves. KEY POINTS: • Deformation of surgically implanted aortic valve bioprostheses (bio-sAVRs) can be adequately assessed using MDCT. • Bio-sAVRs show at least mild deformation (eccentricity index > 5%) in 56% of studied cases and were considered non-circular (eccentricity index > 10%) in 17% of studied valves. • The higher deformity rate found in bio-sAVRs with (suspected) valve pathology could suggest that geometric deformity may play a role in leaflet malformation and thrombus formation similar to that of transcatheter heart valves.

Iterative reconstruction techniques for computed tomography part 2: initial results in dose reduction and image quality.

OBJECTIVES: To present the results of a systematic literature search aimed at determining to what extent the radiation dose can be reduced with iterative reconstruction (IR) for cardiopulmonary and body imaging with computed tomography (CT) in the clinical setting and what the effects on image quality are with IR versus filtered back-projection (FBP) and to provide recommendations for future research on IR. METHODS: We searched Medline and Embase from January 2006 to January 2012 and included original research papers concerning IR for CT. RESULTS: The systematic search yielded 380 articles. Forty-nine relevant studies were included. These studies concerned: the chest(n = 26), abdomen(n = 16), both chest and abdomen(n = 1), head(n = 4), spine(n = 1), and no specific area (n = 1). IR reduced noise and artefacts, and it improved subjective and objective image quality compared to FBP at the same dose. Conversely, low-dose IR and normal-dose FBP showed similar noise, artefacts, and subjective and objective image quality. Reported dose reductions ranged from 23 to 76 % compared to locally used default FBP settings. However, IR has not yet been investigated for ultra-low-dose acquisitions with clinical diagnosis and accuracy as endpoints. CONCLUSION: Benefits of IR include improved subjective and objective image quality as well as radiation dose reduction while preserving image quality. Future studies need to address the value of IR in ultra-low-dose CT with clinically relevant endpoints. KEY POINTS: • Iterative reconstruction improves image quality of CT images at equal acquisition parameters. • IR preserves image quality compared to normal-dose filtered back-projection. • The reduced radiation dose made possible by IR is advantageous for patients. • IR has not yet been investigated with clinical diagnosis and accuracy as endpoints.

Iterative reconstruction techniques for computed tomography Part 1: technical principles.

OBJECTIVES: To explain the technical principles of and differences between commercially available iterative reconstruction (IR) algorithms for computed tomography (CT) in non-mathematical terms for radiologists and clinicians. METHODS: Technical details of the different proprietary IR techniques were distilled from available scientific articles and manufacturers' white papers and were verified by the manufacturers. Clinical results were obtained from a literature search spanning January 2006 to January 2012, including only original research papers concerning IR for CT. RESULTS: IR for CT iteratively reduces noise and artefacts in either image space or raw data, or both. Reported dose reductions ranged from 23 % to 76 % compared to locally used default filtered back-projection (FBP) settings, with similar noise, artefacts, subjective, and objective image quality. CONCLUSION: IR has the potential to allow reducing the radiation dose while preserving image quality. Disadvantages of IR include blotchy image appearance and longer computational time. Future studies need to address differences between IR algorithms for clinical low-dose CT. KEY POINTS: • Iterative reconstruction technology for CT is presented in non-mathematical terms. • IR reduces noise and artefacts compared to filtered back-projection. • IR can improve image quality in routine-dose CT and lower the radiation dose. • IR's disadvantages include longer computation and blotchy appearance of some images.

Mixed Reality in Modern Surgical and Interventional Practice: Narrative Review of the Literature.

BACKGROUND: Mixed reality (MR) and its potential applications have gained increasing interest within the medical community over the recent years. The ability to integrate virtual objects into a real-world environment within a single video-see-through display is a topic that sparks imagination. Given these characteristics, MR could facilitate preoperative and preinterventional planning, provide intraoperative and intrainterventional guidance, and aid in education and training, thereby improving the skills and merits of surgeons and residents alike. OBJECTIVE: In this narrative review, we provide a broad overview of the different applications of MR within the entire spectrum of surgical and interventional practice and elucidate on potential future directions. METHODS: A targeted literature search within the PubMed, Embase, and Cochrane databases was performed regarding the application of MR within surgical and interventional practice. Studies were included if they met the criteria for technological readiness level 5, and as such, had to be validated in a relevant environment. RESULTS: A total of 57 studies were included and divided into studies regarding preoperative and interventional planning, intraoperative and interventional guidance, as well as training and education. CONCLUSIONS: The overall experience with MR is positive. The main benefits of MR seem to be related to improved efficiency. Limitations primarily seem to be related to constraints associated with head-mounted display. Future directions should be aimed at improving head-mounted display technology as well as incorporation of MR within surgical microscopes, robots, and design of trials to prove superiority.

Acquired blood platelet disorder in patients with end-stage heart failure after implantation of a continuous centrifugal-flow left ventricular assist device: A prospective cohort study.

Background: Continuous-flow left ventricular assist devices (CF-LVADs) are an established therapy for advanced heart failure. Thrombosis and hemorrhage are common complications after CF-LVAD implantation, which may be explained by device-induced platelet activation. Few data on the effect of CF-LVAD implantation on platelets are available to date. Objectives: The aim of this study was to characterize the change in the platelet activation status after CF-LVAD. Methods: Platelet phenotype and reactivity were determined with flow cytometry in 32 adults with end-stage heart failure before and 4 to 6 weeks after CF-LVAD implantation. Sixteen adults with a biological aortic valve prosthesis (AVP) using the same antiplatelet regimen were included to discriminate between the effects of CF-LVAD and the antiplatelet regimen. Plasma markers for platelet activation were determined with enzyme-linked immunosorbent assay. Results: Median (IQR) plasma levels of soluble P-selectin increased from 115.6 (79.1-142.7) ng/mL to 144.5 (100.4-197.5) ng/mL after CF-LVAD implantation (P < .001). Median (IQR) ß-thromboglobulin levels were 60.5 (37.8-81.5) ng/mL before implantation and remained high after LVAD implantation [60.0 (42.0-69.5) ng/mL]. The platelet P-selectin expression after stimulation with ADP (30 and 60 µM) or PAR1-activating peptide (12.5 and 25 µM) was reduced by 17% to 21%, and fibrinogen binding was reduced by 37% to 86%. Platelet responses to agonists were similar in patients with a CF-LVAD and patients with an AVP, except for fibrinogen binding in response to 12.5 µM PAR1-AP, which was lower in patients with a CF-LVAD (P < .001). Conclusions: Combined, these data provide evidence for systemic platelet activation and an acquired platelet disorder after CF-LVAD implantation. This might contribute to the risk of both hemorrhage and thrombosis associated with CF-LVADs.

MarioHeart: Novel In-Vitro Flow Model for Testing Heart Valve Prostheses and Anticoagulant Therapies.

Mechanical heart valve (MHV) prostheses present a risk of thromboembolic complications despite antithrombotic therapy. Further steps in the development of more hemocompatible MHVs and new anticoagulants are impeded due to the lack of adequate in-vitro models. With the development of a novel in-vitro model (MarioHeart), a pulsatile flow similar to the arterial circulation is emulated. The MarioHeart design owns unique features as 1) a single MHV within a torus with low surface/volume ratio, 2) a closed loop system, and 3) a dedicated external control system driving the oscillating rotational motion of the torus. For verification purposes, a blood analog fluid seeded with particles was used to assess fluid velocity and flow rate using a speckle tracking method on high-speed video recordings of the rotating model. The flow rate resembled the physiological flow rate in the aortic root, in both shape and amplitude. Additional in-vitro runs with porcine blood showed thrombi on the MHV associated with the suture ring, which is similar to the in-vivo situation. MarioHeart is a simple design which induces well-defined fluid dynamics resulting in physiologically nonturbulent flow without stasis of the blood. MarioHeart seems suitable for testing the thrombogenicity of MHVs and the potential of new anticoagulants.

Insights in the Prothrombotic Changes After Implantation of a Left Ventricular Assist Device in Patients With End-Stage Heart Failure: A Longitudinal Observational Study.

Thrombus formation is a common complication during left ventricular assist device (LVAD) therapy, despite anticoagulation with vitamin K antagonists (VKA) and a platelet inhibitor. Plasma levels of markers for primary and secondary hemostasis and contact activation were determined before LVAD implantation and 6 and 12 months thereafter in 37 adults with end-stage heart failure. Twelve patients received a HeartMate 3, 7 patients received a HeartWare, and 18 patients received a HeartMate II. At baseline, patients had elevated plasma levels of the platelet protein upon activation, ß-thromboglobulin, and active von Willebrand factor in thrombogenic state (VWFa), which remained high after LVAD implantation. Von Willebrand factor levels and VWF activity were elevated at baseline but normalized 12 months after LVAD implantation. High D -dimer plasma levels, at baseline, remained elevated after 12 months. This was associated with an increase in plasma thrombin-antithrombin-complex levels and plasma levels of contact activation marker-cleaved H-kininogen after LVAD implantation. Considering these results it could be concluded that LVAD patients show significant coagulation activation despite antithrombotic therapy, which could explain why patients are at high risk for LVAD-induced thrombosis. Continuous low-grade systemic platelet activation and contact activation may contribute to prothrombotic effects of LVAD.

Trans-apical versus surgical implantation of autologous ovine tissue-engineered heart valves.

BACKGROUND AND AIM OF THE STUDY: Living tissue-engineered heart valves (TEHVs) based on rapidly degrading scaffolds and autologous cells might overcome the limitations of today's valve substitutes. Following minimally invasive trans-apical implantation into an ovine model, TEHVs showed adequate in-vivo functionality, but a thickening of the leaflets was observed. In order to evaluate the impact of the substantial tissue deformations of TEHVs associated with the crimping procedure during minimally invasive delivery, trans-apical and conventional implantation technologies were compared in an ovine model. METHODS: Trileaflet heart valves (n=11) based on PGA/P4HB-scaffolds, integrated into self-expandable stents, were engineered from autologous ovine vascular-derived cells. After in-vitro culture, the TEHVs were either implanted surgically (n=5), replacing the native pulmonary valve, or delivered trans-apically (n=6) into the orthotopic pulmonary valve position. In-vivo functionality was assessed by echocardiography and by angiography for up to eight weeks. The tissue compositions of the explanted TEHVs and corresponding control valves were analyzed. RESULTS: TEHV implantations were successful in all cases. Independent of the implantation method, the explants demonstrated a comparable layered tissue formation with thickening and deposited fibrous layers. Active remodeling of these layers was evident in the explants, as indicated by vascularization of the walls, invasion of the host cells, and the formation of a luminal endothelial layer on the TEHV leaflets. CONCLUSION: This direct comparison of trans-apical and conventional surgical implantation techniques showed that crimping had no adverse effect on the integrity or functional outcome of TEHVs. This suggests that a thickening of TEHVs in vivo is neither caused by nor enhanced by the crimping procedure, but represents a functional tissue remodeling process.

Application of three-dimensional computed tomography imaging and reconstructive techniques in lung surgery: A mini-review.

Background: Pulmonary surgery is an innovative discipline with increasing demands for minimally invasive techniques in complicated anatomical resections, warranting adequate preoperative imaging of relevant surgical anatomy to ensure safe and radical resection of target lesions. Over the recent years, the emergence of imaging techniques enabling three-dimensional reconstruction has exerted promising influence on pulmonary surgery, facilitating optimal surgical planning and easier identification of the spatial relationship between bronchovascular structures in the individual patient and aiding the safe resection of target pulmonary lesions. The goal of this mini-review is to provide an overview of three-dimensional computed tomography imaging within pulmonary surgery. Methods: The authors performed a targeted qualitative review of the literature to identify current trends and to provide better understanding of three-dimensional reconstruction within the boundaries of pulmonary surgery. Results: Three-dimensional reconstructive techniques can be used for resectability assessment, identification of surgically relevant interindividual anatomic variance and may improve perioperative outcomes. Discussion: Three-dimensional reconstruction using computed tomography imaging improves surgical planning and there is evidence that it results in shorter operative times, less intraoperative blood loss and lower rates of surgical conversion, as it can be applied both pre- and intraoperatively.

Patients' voices in the development of pre-surgical patient education using virtual reality: A qualitative study.

Objective: To identify the information needs and perceptions of patients regarding the application of virtual reality in pre-surgical patient education. Methods: A qualitative study was conducted between March and July 2020. The study population consisted of a purposive sample of patients scheduled for cardiac surgery from a single institution. Semi-structured individual interviews (n=19) were conducted and analysed using thematic analysis. Results: Patient perceptions regarding virtual reality and information needs related to hospitalisation and surgery could be categorised into three themes: Creating familiarity, contents to explore and challenges and preconditions. Conclusions: Virtual reality technology is a promising tool that can enhance conventional patient education to improve understanding and to potentially reduce concerns and anxieties. The virtual reality environment creates an opportunity for patients to be in control of the timing, quantity, depth and frequency of patient education. A virtual reality education tool should not be a substitute for personal contact with the physician. Innovation: Patient information needs were identified profoundly to the further development of a virtual reality intervention. This intervention aims to educate patients prior to elective cardiac surgery.

Frequency of abnormal findings on routine chest radiography before cardiac surgery.

OBJECTIVE: Preoperative chest radiograph screening is widely used before cardiac surgery. The objective of this study was to investigate the frequency of abnormal findings on a routine chest radiograph before cardiac surgery. METHODS: In this retrospective cohort study, 1136 patients were included. Patients were scheduled for cardiac surgery and underwent a preoperative chest radiograph. The primary outcome was the frequency of abnormalities on the chest radiograph. Secondary outcome was the effect of those abnormalities on surgery. RESULTS: One half of the patients (570/1136; 50%) had 1 or more abnormalities on the chest radiograph. Most frequent abnormalities were cardiomegaly, aortic elongation, signs of chronic obstructive pulmonary disease, vertebral fractures or height loss, possible pulmonary or mediastinal mass, pleural effusion, and atelectasis. In 2 patients (2/1136; 0.2%), the chest radiograph led to postponement of surgery, whereas in none of the patients the surgery was cancelled. In 1 patient (1/1136; 0.1%) the surgical approach was altered and in 15 patients (15/1136; 1.3%) further analysis was performed without having an impact on the planned surgical approach. CONCLUSIONS: Although abnormalities are frequently found on preoperative chest radiographs before cardiac surgery, change in clinical management with regard to planned surgery or surgical approach occurs infrequently.

Successful treatment of bronchial stenosis after lung transplantation.

Treatment of stenotic anastomosis after lung transplantation can be challenging. In this case report, we present a case in which 3D computed tomography reconstructions guided the clinical decision towards operative bronchoplasty after which our patient was treated successfully.

Schwannoma of the Recurrent Laryngeal Nerve: A Rare Entity.

Neurogenic tumors are the most common posterior mediastinal tumors in adults. Schwannomas originating from the recurrent laryngeal nerve are rare. The present study describes a 46-year-old man with a tumor in the left superior mediastinum. Because of the narrow relationship with the aorta and the left pulmonary artery, the tumor was excised by left-sided minithoracotomy. The tumor, a schwannoma, originated from and encased the left recurrent laryngeal nerve. Six months after surgery, the patient was free of recurrence without symptoms other than hoarseness. "Additional imaging by magnetic resonance imaging could raise the probability of a neurogenic origin of the mass, eventually leading to collaboration with the neurosurgeon in this case."

Effect of computed tomography before cardiac surgery on surgical strategy, mortality and stroke.

AIM: To investigate whether preoperative chest computed tomography (CT) decreases postoperative mortality and stroke rate in cardiac surgery by detection of calcifications and visualization of postoperative anatomy in redo cardiac surgery which can be used to optimize the surgical approach. METHODS: The PubMed, EMBASE and Cochrane databases were searched and articles concerning preoperative CT in cardiac surgery were included. Articles not reporting mortality, stroke rate or change in surgical approach were excluded. Studies concerning primary cardiac surgery as well as articles concerning redo cardiac surgery were both included. RESULTS: Eighteen studies were included (n=4057 patients) in which 2584 patients received a preoperative CT. Seven articles (n=1754 patients) concerned primary surgery and eleven articles (n=2303 patients) concerned redo cardiac surgery. None of the studies was randomized but 8 studies provided a comparison to a control group. Stroke rate decreased with 77-96% (primary surgery) and 18-100% (redo surgery) in patients receiving a preoperative CT. Mortality decreased up to 66% in studies investigating primary surgery while the effect on mortality in redo surgery varied widely. Change in surgical approach based on CT-findings consisted of choosing a different cannulation site, opting for off-pump surgery and cancellation of surgery. CONCLUSIONS: Current evidence suggests that preoperative CT imaging may lead to decreased stroke and mortality rate in patients undergoing primary cardiac surgery by optimizing surgical approach. In patients undergoing redo cardiac surgery stroke rate is also decreased but the effect on mortality is unclear. However, evidence is weak and included studies were of moderate quality.

Ultra low-dose chest ct with iterative reconstructions as an alternative to conventional chest x-ray prior to heart surgery (CRICKET study): Rationale and design of a multicenter randomized trial.

BACKGROUND: Stroke after cardiac surgery is a severe complication with a persistently high incidence of 1.4 - 9.7%. Postoperative strokes are mainly embolic and can be provoked by manipulation and clamping of the aorta during cardiac surgery, resulting in the mobilization of atherothrombotic material and calcifications from the aortic wall. Computed tomography (CT) can offer preoperative visualization of aortic calcifications with low radiation exposure. We hypothesize that preoperative knowledge regarding the location and extent of aortic calcifications can be used to optimize surgical strategy and decrease postoperative stroke rate. METHODS/DESIGN: The CRICKET study (ultra low-dose chest CT with iterative reconstructions as an alternative to conventional chest x-ray prior to heart surgery) is a prospective multicenter randomized clinical trial to evaluate whether non-contrast chest CT before cardiac surgery can decrease postoperative stroke rate by optimizing surgical strategy. Patients scheduled to undergo cardiac surgery aged 18 years and older are eligible for inclusion. Exclusion criteria are pregnancy, a chest/cardiac CT in the past three months, emergency surgery, concomitant or prior participation in a study with ionizing radiation and unwillingness to be informed about incidental findings. Subjects (n = 1.724) are randomized between routine care, including a chest x-ray, or routine care with an additional low dose chest CT. The primary objective is to investigate whether the postoperative in-hospital stroke rate is reduced in the CT arm compared to the routine care arm of the randomized trial. The secondary outcome measures are altered surgical approach based on CT findings and cost-effectiveness.