Definitive Palliation Research Articles

Active Machine Learning for Pre-procedural Prediction of Time-Varying Boundary Condition After Fontan Procedure Using Generative Adversarial Networks.

The Fontan procedure is the definitive palliation for pediatric patients born with single ventricles. Surgical planning for the Fontan procedure has emerged as a promising vehicle toward optimizing outcomes, where pre-operative measurements are used prospectively as post-operative boundary conditions for simulation. Nevertheless, actual post-operative measurements can be very different from pre-operative states, which raises questions for the accuracy of surgical planning. The goal of this study is to apply machine leaning techniques to describing pre-operative and post-operative vena caval flow conditions in Fontan patients in order to develop predictions of post-operative boundary conditions to be used in surgical planning. Based on a virtual cohort synthesized by lumped-parameter models, we proposed a novel diversity-aware generative adversarial active learning framework to successfully train predictive deep neural networks on very limited amount of cases that are generally faced by cardiovascular studies. Results of 14 groups of experiments uniquely combining different data query strategies, metrics, and data augmentation options with generative adversarial networks demonstrated that the highest overall prediction accuracy and coefficient of determination were exhibited by the proposed method. This framework serves as a first step toward deep learning for cardiovascular flow prediction/regression with reduced labeling requirements and augmented learning space.

Use of Hybrid Stage I to Stratify Between Single Ventricle Palliation and Biventricular Repair.

Background: Hybrid stage I palliation (HS1P) has been utilized for patients with single ventricle (SV) congenital heart disease (CHD). To date, reports on the use of HS1P for other indications including biventricular (BiV) CHD have been limited. Methods: We performed a single-center retrospective cohort study of patients who underwent HS1P with an anticipated physiologic outcome of BiV repair, or with an undetermined SV versus BiV outcome. Patient characteristics and outcomes from birth through definitive repair or palliation were collected and reported with descriptive statistics. Results: Nineteen patients underwent HS1P with anticipated BiV repair. Extracardiac and intracardiac risk factors (ICRF) were common. Ultimately, 13 (68%) patients underwent BiV repair, 1 (5%) underwent SV palliation, and 5 (26%) died prior to further palliation or repair. Resolution of ICRF tracked with BiV outcome (6/6, 100%), persistence of ICRF tracked with SV outcome or death (3/3, 100%). Twenty patients underwent HS1P with an undetermined outcome. Ultimately, 13 (65%) underwent BiV repair, 6 (30%) underwent SV palliation, and 1 (5%) underwent transplant. There were no deaths. Intracardiac risk factors were present in 15 of 20 patients (75%); BiV repair only occurred when all ICRF resolved (67%). Post-HS1P complications and reinterventions occurred frequently in both groups, through all phases of care. Conclusions: Hybrid stage 1 palliation can be used to defer BiV repair and to delay decision between SV palliation and BiV repair. Resolution of ICRF was associated with ultimate outcome. In this high-risk group, complications are common, and mortality especially in the marginal BiV patient is high.

Transesophageal Echocardiographic Assessment of Single Ventricle Physiology with Interrupted Inferior Vena Cava in a Case of Heterotaxy Syndrome Posted for Kawashima Procedure and Hepatic Vein Rerouting

Transesophageal echocardiography (TEE) is essential in delineating the anatomy, physiology, and perioperative management of single ventricle (SV) lesions. SV lesion is commonly associated with heterotaxy syndrome causing abnormal lateralization of organs across the body’s left-right axis. It is manifested as right atrial or left atrial isomerism. Patients with SV physiology require the Glenn procedure for surgical palliation whereas Fontan operation as definitive intervention. However, in a patient with interrupted inferior vena cava (IVC), the Kawashima procedure is used for definitive palliation. We report a 15-year-old female child diagnosed with SV physiology and interrupted IVC in association with heterotaxy syndrome posted for the Kawashima procedure and hepatic vein rerouting and illustrate the importance of perioperative TEE in delineating the anatomy, decision-making, and confirming the success of repair.

Liver directed therapies in primary and metastatic liver cancer: A rural academic institution experience.

e16188 Background: Liver-directed therapies (LDT) are well established in the treatment of primary and secondary hepatic malignancies and are developed for potentially curative intent, bridging for definitive therapy or palliation. They are used either in isolation usually for hepatocellular carcinoma (HCC) or in combination with systemic chemotherapy and/or surgery. We conducted a retrospective study at our academic institution that serves ethnic minorities and patients with high BMI and multiple major co-morbidities. Methods: All patients who underwent liver-directed therapy at ECU Health Medical Center from the year 2010 to 2020 were included in this study. Total of 196 patients were identified of which 96 met the eligibility criteria. That criteria included all patients who have undergone any type of liver directed therapy in primary and mainly metastatic gastrointestinal liver cancer. We conducted descriptive univariate analysis, cox regression and Kaplan-Meier survival analysis. Results: The study cohort had 63% (n=60) with primary HCC and 38% (n=36) with metastatic liver cancer predominantly colorectal cancer. Median age at diagnosis was 68 yrs. (65.3-69.5), 58% were Caucasian, 38% were black and 2% were other ethnic groups. 68% of the patient were male and 31% were female. ECOG performance status of 1 in 60% of the cohort. 50% of the cohort had 3 major comorbidities other than cirrhosis and hepatitis. Mean body mass index (BMI) was >25 kg/m2. 43% of the patient (n=41) had multiple barriers to care. Patients with primary HCC, 45% had hepatitis C and 48 % had non-viral causes in 60 patients. Child- Pugh A in 67% (n=40), B in 30% (18) and C in 3% (n=3). 70% of non-HCC cohort has colorectal and cholangiocarcinoma. All patient in non-HCC group received chemotherapy and 52% of HCC cohort received systemic therapy. 55% (n= 43) of the patients underwent Y-90 and 55% (n= 53) underwent other types of liver directed therapies, most common being TACE. 62% of the patient underwent 1 treatment and 38% had >2 LDT. Multivariate analysis showed that age (p-value, 0.0229) and type of liver directed therapy ( p-value, 0.0212) are statistically significant in the HCC cohort. In the non-HCC cohort, patients with high BMI (P-value=0.0050) had poor outcome and was statistically significant. Conclusions: Liver directed therapy is a reasonable option for patients with HCC and non-HCC metastatic disease. According to our study, it improves median survival in non-HCC patients. It includes rural population with high BMI, major comorbidities and multiple barriers to care. In this study, 38% of patients were African Americans who are usually underrepresented in majority of studies. Limitations of the study include retrospective nature of the analysis and heterogenous group. In future clinical trials, ethnic minorities should be equally represented to advance health equity and to apply real word data to the populations we serve.

Incidentally enhancing supraclavicular lymphatic convolutes in magnetic resonance angiography in patients with Fontan circulation.

PURPOSE Fontan procedure and its modifications are the preferred approach to definitive palliation in uni- ventricular hearts though often with short-term or long-term complications. It is believed that a dysfunction in lymphatic circulation is responsible for part of the complications. Occasionally, abnormal supraclavicular lymphatic vessel convolutes can be observed in contrast-enhanced magnetic resonance angiography (ceMRA). This study aims to determine the frequency of this phenomenon as well as a possible correlation with the functional status after Fontan procedure. METHODS CeMRA of 37 patients after Fontan surgery was retrospectively screened and grouped for the presence or absence of abnormal lymphatic convolute. An attempt was made to identify differ- ences in the level of dysfunction of the Fontan circulation between the 2 groups. RESULTS In 6 of 37 patients (16%), an abnormal cervical lymphatic convolute was found in the cervical venous angle. The surrogate parameters for a malfunction of the Fontan circulation did not sig- nificantly differ between both groups. CONCLUSION This is the first description of cervical lymphatic vessels in Fontan patients enhancing incidentally in ceMRA, probably due to venous-to-lymphatic reflux. As the likelihood of various complica- tions of Fontan circulation increases with the severity of lymphatic dysfunction, this observation could help to select patients who require closer monitoring or advanced lymphatic imaging.

Fontan-associated liver disease.

Fontan-associated liver disease.

Late Fontan Circulatory Failure. What Drives Systemic Venous Congestion and Low Cardiac Output in Adult Fontan Patients?

The Fontan circulation provides definite palliation for children born with a single anatomical or functional ventricle by diverting systemic venous blood directly to the pulmonary arteries, effectively rendering systemic venous return into portal vessels to the lung. Although this restores pulmonary blood flow and avoids the mixture of oxygenated and deoxygenated blood, it also results in elevated systemic venous pressures and low cardiac output. These are the two hallmarks of any Fontan circulation and the cause of Fontan circulatory failure later in life. We highlight the determinants of systemic venous return, its changed relationship with the pulmonary circulation, how it affects preload, and the changed role of the heart (myocardium, valves, and heart rate). By critically evaluating the components of the Fontan circulation, we hope to give some clues in how to optimize the Fontan circulation and avenues for future research.

Neoadjuvant QUAD Shot as Temporizing Measure Prior to Definitive Surgery for Locally Advanced Oral Cavity Cancer

<h3>Purpose/Objective(s)</h3> The mainstay of treatment for oral cavity cancer is surgery, often with adjuvant therapies if necessary. However, given issues involving prolonged workup or scheduling of surgery, treatment delays are inevitable. We aim to evaluate the utilization of a temporizing hypofractionated course of radiation therapy in the form of a Quad Shot prior to planned surgery for head and neck cancers. <h3>Materials/Methods</h3> Eighteen patients with a primary head and neck malignancy, predominantly locally advanced oral cavity cancers, received radiation therapy in the form of a Quad Shot from June 2016 to July 2021. External beam radiation therapy was delivered to the site of primary disease over 2 days, with 2 fractions per day given at least 6 hours apart. Total dose delivered ranged from 1400cGy to 1500cGy. Out of the 18 patients, 12 (66.7%) went on to receive surgery. The remaining patients either passed away prior to planned surgery or went on to receive definitive chemoradiation or palliation. American Joint Committee on Cancer (AJCC) clinical and pathological stage groups were recorded for each patient. <h3>Results</h3> Out of the 12 patients who received surgery, 1 patient (5.6%) had complete response to the dose of temporizing radiation with no pathological disease seen at surgery. Four patients (22.2%) had a partial response as defined as downstaging on final pathology. No response was seen in 11 patients (61.1%), and 2 patients (11.1%) had progression of disease as defined as upstaging on final pathology. The Quad Shot was overall well tolerated with no recorded adverse effects. Eight patients (44.4%) received adjuvant radiation +/- chemotherapy following surgery. <h3>Conclusion</h3> Discrepancies between clinical staging and pathological staging are common and expected. However, a quarter of our patients experienced downstaging following a temporizing Quad Shot. This raises the question of whether neoadjuvant radiation therapy is a viable option to temporize tumor growth while awaiting a surgery for head and neck cancers.

Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association.

Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.

Dilatable Pulmonary Artery Banding Palliation in Congenital Heart Disease

Surgical pulmonary artery banding (PAB) has been limited in practice because of later requirement for surgical removal or adjustment. The aim of this study is to describe our experience creating a dilatable PAB via transcatheter balloon dilation (TCBD) in congenital heart disease (CHD) patients. Retrospective chart review of adjustable PAB-outline anatomical variants palliated and patient outcomes. Sixteen patients underwent dilatable PAB-median age 52 days (range 4-215) and weight 3.12 kg (1.65-5.8). Seven (44%) of the patients were premature, 11 (69%) had ventricular septal defect(s) with pulmonary over-circulation, four (25%) atrioventricular septal defects, and four (25%) single ventricle physiology. Subsequent to the index procedure: five patients have undergone intracardiac complete repair, six patients remain well palliated with no additional intervention, and four single ventricles await their next palliation. One patient died from necrotizing enterocolitis (unrelated to PAB) and one patient required a pericardiocentesis postoperatively. Five patients underwent TCBD of the PAB without complication-Two had one TCBD, two had two TCBD, and another had three TCBD. The median change in saturation was 14% (complete range 6-22) and PAB diameter 1.7 mm (complete range 1.1-5.2). Median time from PAB to most recent outpatient follow-up was 868 days (interquartile range 190-1,079). Our institution has standardized a PAB technique that allows for transcatheter incremental increases in pulmonary blood flow over time. This methodology has proven safe and effective enough to supplant other institutional techniques of limiting pulmonary blood flow in most patients-allowing for interval growth or even serving as the definitive palliation.

Iatrogenic Oesophageal Perforations in Neoplastic Lesions: Management with Covered Self-Expanding Prostheses

Background:Perforation of the oesophagus is a serious condition. Most of them are iatrogenic and are associated with significant morbidity and mortality, especially with late diagnosis. Aim: To prospectively analyse the results of the endoscopic management of iatrogenic perforations in oesophageal neoplasia, through the immediate insertion of a covered self-expanding prosthesis (CSES). Materials and Methods: Between 01.01.2006 and 12.30.2016, a series of 19 consecutive patients attended the Teaching Unit of Endoscopic Surgery of the Regional de Concepción Hospital, Chile, with the diagnosis of oesophageal neoplasia confirmed by biopsy were prospectively studied. All were subjected to a prior evaluation by the oncology team and subsequently referred for endoscopic palliative management of dysphagia. The average age was 77 ± 9.3 years, 8 (42.1%) were female and 11 (57.9%) were male. In 17 patients (89.5%) the stenosis compromised the oesophagus, in 2 (10.5%) the gastro-oesophageal junction, 16 had a squamous carcinoma (84.2%) and 3 an adenocarcinoma (15.8%). Results: Perforation was diagnosed during the procedure in 18 patients (94.7%) and in 1 (5.3%) 22 hours later. Follow-up was done for a minimum of 90 days or until death. The prostheses were inserted successfully in all cases. The immediate evolution was satisfactory in 12 patients (63.2%). In the rest (36.8%), 18 complications appeared. The most frequent were retrosternal pain, subcutaneous emphysema and fever. The early evolution was satisfactory in 12/19 cases (63.2%). Complication was evidenced in 7 (36.8%), the most frequent was retrosternal pain (36.8%). Fever occurred in 3 (15.8%), pleural effusion in 3 (15.8%) and mediastinitis in 2 of these. The prosthesis was kept in situ as a definitive palliation method for neoplastic dysphagia. In 10 of the 18 cases that survived more than a month, there were late complications (55.6%), none of them associated with the perforation itself. The only death (5.3%) was due to an oesophagus-pleural fistula, associated with an early prosthetic migration. Recovery of the oral intake occurred, on average, at 3.7 days. The hospital stay averaged 9.6 days. Conclusion: The use of CSES for the treatment of iatrogenic oesophageal perforations in the context of neoplasia, is a safe and effective method, with low morbidity, adequate recovery of the oral intake and prompt discharge from hospital.

Long term outcome of single ventricle physiology with pulmonary restriction not undergoing Fontan repair

Abstract Background Patients with univentricular physiology who do not complete the palliation to Fontan are a heterogeneous group with unknown long term outcome. Aims This study aimed at describing the clinical course and long-term survival of patients with SV physiology with restricted pulmonary flow that had not undergone a Fontan type of repair. Methods From the prospectively maintained databases of the adult congenital cardiac units of five tertiary referral centers, data from all SV physiology patients were obtained. Patients completing a Fontan type palliation or developing Eisenmenger physiology and segmental pulmonary hypertension were excluded. Baseline data were recorded on the first visit at adult congenital heart disease (ACHD) unit. The primary end point was death. Results 101 patients (50.5% females) were identified. Mean age at end of follow up was 39.3±11.3 years. Of these, 45 (44.6%) were unoperated (group 1, restricted forward pulmonary flow with or without pulmonary banding), 38 (37.6%) had undergone a cavopulmonary shunt as a definitive palliation (group 2) and 18 (17.8%) had aortopulmonary shunts (group 3). The main diagnosis was double inlet left ventricle (DILV) (N: 52, 51.5%) and most of the ventricle was left (82.2%). The principal reason for not performing a Fontan repair was mean pulmonary artery pressure &amp;gt;18 mmHg. At initial visit at the ACHD unit patients were 32.2±11.1 years of age. 35% of the patients were in NYHA class III-IV, with no differences between groups. However, patients in group 2 had worse oxygen saturation (p=002) and higher haemoglobin (p=0.037). After a mean follow-up of 7.3±4.1 years, mortality was 20.8% (21 patients), being sudden death (7p, 6.9%) the most frequent cause. Patients in group 3 showed worse ventricular function (p=0.0001) and a trend to higher mortality that did not reach statistical significance (HR 2.7, CI 95% 0.91–8.14, P=0.07). Conclusions Patients with single ventricle physiology not undergoing Fontan repair are a population of high risk, with sudden death as main driver of mortality. Patients palliated with aortopulmonary shunts are prone to worse ventricular function and a trend to higher mortality. Funding Acknowledgement Type of funding source: Public hospital(s)

Clinical features and outcomes of adult patients with single ventricle physiology not undergoing Fontan repair

Abstract Background Adult patients with single ventricle (SV) physiology who had not undergone Fontan palliation are uncommon. Little is known about their clinical features and outcomes. Objective This study aims to describe the clinical features, cardiovascular outcomes and long-term survival of patients with SV physiology without Fontan palliation. Methods Data were collected retrospectively from SV physiology patients followed in adult congenital heart disease (ACHD) units of five tertiary referral centers. None of them had Fontan palliation. Baseline data were recorded on the first visit at ACHD unit. Death was considered as main endpoint. Other outcomes such as atrial or ventricular arrhythmias, endocarditis, ICD or pacemaker implantation, admission for heart failure and heart transplant were also collected and analyzed. Association between clinical/analytical baseline variables and death was also evaluated by univariate Cox regression. Results 128 patients were included. On the first visit, mean age was 32.3±10.9 years, being the most common defect double inlet left ventricle (63p, 49.2%). The single ventricle had left morphology in 106 cases (82.8%). At baseline mean heaemglobin was 19.1±2.8 g/dl, mean O2 Sat 83±6.9% and 46 patients (36%) had a NYHA status III or IV. 4 different groups were found: a) Unrestricted pulmonary flow with Eisenmenger physiology (24p, 18.8%); b) Restricted forward pulmonary flow with or without pulmonary banding (46p, 35.9%); c) Aortopulmonary shunts as a source of pulmonary flow (20p, 15.5%) and d) cavopulmonary shunt (Glenn) as a definitive palliation (38p, 29.7%). After 7.3±4.1 years follow-up, mortality was 22.7% (29 patients), being sudden death (9p, 7%) the most frequent cause. Survival rate at 5 and 10 years of follow-up were 85% and 76% respectively (Figure 1). About of the rest of the outcomes, highlighting a high rate of atrial tachycardia (38.3%), admission for heart failure (23.4%), stroke (17.2%), endocarditis (9.4%), pacemaker/ICD implantation (11.8%). Baseline variables associated with higher mortality were: older age (HR=1.1 [1.004–1–087]); NYHA III or IV (HR=5.5 [2.4–12.4]); thrombocytopenia (HR=1.01 [1.001–1.003]); anticoagulant treatment (HR=2.6 [1.7–3.9]); glomerular filtration rate below 60 ml/min (HR=3.77 [1.5–9.6]); QRS width (HR=1.03 [1.01–1.05]); atrial arrhythmias (HR=3.1 [1.5–6.5]); moderate or severe AV valve regurgitation (HR=1.5 [1.15–1.97]) and ventricular ejection fraction (HR=0.94 [0.91-0.97]). Conclusions Adults survivors with SV physiology without Fontan palliation have a high mortality and frequently suffer from serious cardiovascular events. Several clinical (NYHA status, previous atrial arrhythmias, anticoagulant treatment), analytical (renal function, thrombocytopenia), ECG (QRS width) and echocardiography (AV valve regurgitation and EF) factors can identify patients at higher risk of death. Figure 1. Survival curve Funding Acknowledgement Type of funding source: None

Outcome of the Glenn procedure as definitive palliation in single ventricle patients

ObjectivesIn selected single ventricle patients, a Glenn procedure (SV-Glenn) may be considered as definitive palliation. Either the patient is unsuited to progress to a Fontan circulation or a SV-Glenn circulation is preferred. This study aimed at describing the clinical course, and long-term mortality/morbidity of SV-Glenn patients. MethodsAll SV-Glenn patients followed at the University Hospitals Leuven before May 2018 were included. Patients who underwent, or were awaiting, TCPC completion and those who underwent a Glenn in the setting of a biventricular circulation one-and-a-half repair (OAHR), were excluded. ResultsOf 65 Glenn-only patients identified, 21 (32%) had OAHR, whereas 44 (68%) were SV-Glenn patients. Of SV-Glenn patients, 19 died within 6 months after the Glenn procedure. Of 25 SV-Glenn survivors, median age at Glenn was 6.3 (IQR 1.2–29.7) years. Eight were unsuited for TCPC completion; in 17 SV-Glenn was preferred over TCPC completion. Over a median follow-up time of 11 (IQR 3–18) years after the Glenn procedure, 5 (20%) patients died. At latest follow-up 10 (40%) had heart failure, 5 (20%) had atrial and 4 (16%) ventricular arrhythmias, 2 (8%) a thromboembolic event, 7 (28%) required pacemaker implantation, and 2 (8%) had infective endocarditis but none developed cirrhosis or protein-losing enteropathy. Mean saturation at latest follow-up was 87 ± 7%. ConclusionSV-Glenn patients represent a unique and heterogeneous patient population. Outcome was reasonable, although comorbidities, such as heart failure and arrhythmias were not uncommon. In SV-Glenn patients, ‘classic’ complications related to Fontan physiology, such as cirrhosis and protein-losing enteropathy, were absent.

Tailored approach to trans-catheter palliation of critically reduced pulmonary blood supply. Data on long term follow up

The most appropriate treatment of duct dependent pulmonary circulation is still a matter of debate. In particular data on long term results of trans-catheter palliation are still inconclusive. We present the long term outcome of trans-catheter palliation in this group of patients according to the anatomy and to a prespecified algorithm, with particular focus on development of pulmonary tree.We retrospectively analyzed data on patients who had undergone trans-catheter palliation of duct dependant congenital heart disease between 2005 and 2017 in our institution. Arterial duct or right ventricular outflow tract (RVOT) percutaneous transluminal angioplasty (PTA)/stenting were performed according a pre-specified algorithm.47 patients underwent either arterial duct stenting (n = 42) or RVOT PTA/Stenting (n = 5). Median age at catheterization was 13 days (IQR 3–686). Median weight was 3 kg (1.5–4.3). Median follow up was 1127 (6–4396) days. 11 patients out of 47 died (23%). One year, five year and ten year survival were respectively: 82% (95% CI 68–90), 75% (95% CI 60–85) and 60% (95% CI 27–81). At Cox regression analysis, weight at the initial Trans-catheter palliation and univentricular physiology remained independently associated with long term mortality, respectively Hazard ratio 0.3 (95% CI 0.12–0.88, p = 0.03) and Hazard ratio 5 (95% CI 1.3–20.2, p = 0.02). In the overall study cohort 36 patients (76%) needed further intervention, either surgical or trans-catheter, before surgical repair or definitive palliation. Overall, median time to re-intervention was 107 days (2–750). Central pulmonary arteries grew in all patients. Tailored trans-catheter management of congenital heart disease associated with critically reduced pulmonary flow resulted in proper maturation of pulmonary tree allowing surgical repair or definite palliation despite the need for repeated procedures.

ES19.05 Surgical Management of Malignant Pleural Effusion

At first glance, it would seem that the thoracic surgeon has little role to play nowadays in the management of malignant pleural effusion (MPE). Substantial advances have been made in the understanding of the pathophysiology of MPE and its diagnosis. There is broad consensus that pleurodesis should generally be given at the bedside rather than in the operating theatre, while intractable cases can be managed with indwelling catheters. Even where interventions into the chest are required, the advent of ‘medical’ thoracoscopy appears to have diminished the role of surgeons in managing MPE. However, it would be wrong to presume that thoracic surgeons may be completely excluded from the MPE scene. There remain situations were surgery is still required for a definitive diagnosis or effective palliation. Surgeons continue to have more extensive experience with biopsy, drainage, and ‘rapid pleurodesis’ – yielding high rates of success. More importantly, minimally invasive Video-Assisted Thoracic Surgery (VATS) has evolved significantly in recent years. Uniportal VATS is becoming increasingly utilized and is often complemented by technological advances such as non-intubated anesthesia. The latest advances in minimally invasive thoracic surgery have ensured that the high success rate of surgery is now coupled with surprisingly little – if any – functional or physiological ‘cost’ to the patient with MPE. The ‘VATS’ available today is not the same VATS from even a few years ago. This presentation provides an overview of the current surgical options available in the management of MPE. The modern thoracic surgeon remains fully equipped and prepared to contribute to the multi-disciplinary care of patients with this complication. Pleural effusion, thoracoscopy, surgery

Blalock-Taussig shunt versus patent ductus arteriosus stent as first palliation for ductal-dependent pulmonary circulation lesions: A review of the literature.

Infants with ductal-dependent pulmonary blood flow (PBF) often undergo a palliative procedure to provide a stable source of PBF prior to definitive palliation or repair. In the current era, a surgical shunt or ductal stent is used to provide PBF. We aimed to review the current literature comparing ductal stents to surgical shunts. Four small, single-center studies and two larger multicenter studies were identified comparing ductal stent to surgical shunt. Combined, these studies showed ductal stent resulted in similar or improved pulmonary artery growth, fewer complications, shorter length of stay, less diuretic use, and improved survival compared to surgical shunt. Despite inherent minor variability among the studies, ductal stent appears to be associated with more frequent reinterventions. Surgical shunts remain essential to the care of these patients, but ductal stent is a reasonable alternative, and may provide some advantages in select patients with ductal-dependent PBF.

The role of in-vivo optical spectroscopy in assessment of cerebral perfusion in superior cavo-pulmonary shunt (Glenn)

BackgroundBidirectional Glenn shunt is a well-established procedure performed as a part of the single ventricle palliation pathway. It may also provide definitive palliation in certain other patients. However, stroke and neurocognitive dysfunction are common after cardiac surgery with rates of approximately 3–6% and 30–50%, respectively. This study aimed to report and compare early post-operative neurological outcome after on-pump and off pump using temporary cavoatrial shunt in bidirectional Glenn shunt operation using a neurological monitor. MethodsThis prospective comparative non randomized controlled trial included 30 patients undergone Glenn shunt. The study was done at Kasr Alainy Hospitals (Abul Reesh Specialized Pediatric Japanese Hospital) Cairo University, Egypt in the period between October 2015 and October 2017. Patients were divided into two matching and equally-numbered groups: Group A contained 15 patients using cardiopulmonary bypass (CPB); while group B contained 15 patients without using CPB. Cerebral oximetry was done using INVOS. ResultsAs regards operative time it was shorter in group B (p = 0.003), post-operative fits in group A 2 patients (13%), in group B 3 patients (20%), the difference was statistically insignificant (p > 0.05). There was a significant correlation between the area under the curve (AUC) and neurological outcome (p = 0.01). ConclusionsWe suggest that pediatric INVOS system may help to reduce the high rate of brain injuries.

Targeted Increase in Pulmonary Blood Flow in a Bidirectional Glenn Circulation

In patients with a Glenn shunt and unilateral pulmonary vascular abnormalities, supplemental pulmonary blood flow may improve antegrade flow in the target lung and may permit eventual Fontan completion, while mitigating the risks of uncontrolled additional flow to the contralateral lung. We attempted this by inserting a small aortopulmonary shunt into the affected pulmonary artery and banding the central pulmonary artery. We performed a retrospective review of all patients who underwent this procedure from 2000 to 2015. Comparisons of nonparametric variables were performed with the Wilcoxon signed rank test. Twenty patients were followed for a median of 36 months. Vascular abnormalities included recalcitrant unilateral pulmonary arterial (n = 8) or venous (n = 5) obstruction or hypoplasia, combined disease (n = 4), or abundant aortopulmonary collaterals (n = 3). Nine had retrograde flow from the affected lung. The most frequent complications were pleural effusions (n = 4) and shunt thrombosis (n = 4). Postoperatively, all patients demonstrated antegrade flow to the target lung at the earliest postoperative catheterization. Glenn pathway pressures and saturations were unchanged, whereas the shunted pulmonary arterial oxygen saturation and pressure increased by 4% (P = 0.04) and 6mmHg (P = 0.04), respectively. Three patients died; 9 achieved definitive palliation, 4 were deemed to have no improvement, and 4 continue to have a contralaterally shunted Glenn at this time. Targeted additional pulmonary blood flow may be useful for the palliation of single ventricle patients with abnormal pulmonary vasculature. However, morbidity and mortality are common in this high-risk population.

Tunneled pleural catheter use for pleural palliation does not increase infection rate in patients with treatment-related immunosuppression.

Concerns for infections resulting from antineoplastic therapy-associated immunosuppression may deter referral for symptom palliation with a tunneled pleural catheter (TPC) in patients with malignant/para-malignant pleural effusions (MPE/PMPE). While rates of TPC-related infections range from 1 to 21%, those in patients receiving antineoplastic therapy with correlation to immune status has not been established. We aimed to assess TPC-related infection rates in patients on antineoplastic therapy, determine relation to immune system competency, and assess impact on the patient. Patients with a MPE/PMPE undergoing TPC management associated with antineoplastic therapy, from 2008 to 2016, were reviewed and categorized into those with an immunocompromised versus immunocompetent immune status. Of the 150 patients, a TPC-related infection developed in 13 (9%): pleural space in 11 (7%) and superficial in 2 (1%). Ninety-three percent (139/150) were identified to be immunocompromised during their antineoplastic therapy. No difference in TPC-related infections was seen in patients with an immunocompromised (9%, 12/139) versus immunocompetent status (9%, 1/11); p = 0.614. The presence of a catheter-related infection did not negatively impact overall survival over a median follow-up of 144days (interquartile range 41-341); p = 0.740. These results suggest that antineoplastic therapy may not significantly increase the overall risk of TPC-related infections, as the rate remains low and comparable to rates in patients not undergoing antineoplastic therapy. Regardless of immune status, the presence of a catheter-related infection did not negatively impact overall survival. These results should reassure clinicians that the need to initiate antineoplastic therapy should not delay definitive pleural palliation with a TPC.