Prior Thoracic Surgery Research Articles

Clinical utility of echocardiography in internal medicine: a narrative review

Echocardiography has emerged as an invaluable tool in internal medicine, providing real-time, non-invasive evaluation of cardiac structure and function. Its clinical utility spans a wide range of applications, including the diagnosis and management of heart failure, valvular heart diseases, and cardiomyopathies, as well as systemic conditions like sepsis and chronic kidney disease. The ability to perform bedside echocardiography has made it particularly useful in critical care settings, allowing for rapid assessment of cardiac function in hemodynamically unstable patients. Echocardiography also plays a key role in guiding therapeutic interventions, from fluid management to valvular repair and replacement procedures. Despite its many advantages, echocardiography is not without limitations. Image quality may be compromised in patients with obesity, lung disease, or prior thoracic surgery, necessitating alternative imaging modalities like cardiac magnetic resonance imaging or computed tomography. Operator expertise is another critical factor influencing diagnostic accuracy, underscoring the importance of proper training. Recent advancements, including artificial intelligence integration and portable devices, are expected to further expand the role of echocardiography, making it more accessible in diverse clinical settings. This narrative review highlights the broad clinical utility of echocardiography in internal medicine, its challenges, and the future directions that promise to enhance its role in patient care.

1588: Lung SBRT in patients with prior thoracic surgery and/or radiotherapy and impaired lung function

1588: Lung SBRT in patients with prior thoracic surgery and/or radiotherapy and impaired lung function

Metastatic intradural primary spinal osteosarcoma: illustrative case.

Osteosarcomas are a common primary bone neoplasm among adolescents but represent 0.2% of all malignancies with an incidence of two to four cases per million persons annually worldwide. Although known to have significant metastatic potential, its rare incidence, treatment resistance, and poor prognosis have rendered it a poorly understood and infrequently documented pathology. Herein the authors present the first documented case of lumbosacral intradural metastasis of a primary osteosarcoma in a young patient, possibly via intradural dissemination following pinhole durotomy in a prior thoracic surgery. Osteosarcomas remain a difficult pathology to treat, particularly upon metastatic dissemination. The utility of adjuvant radiotherapy after resection of an osteosarcoma is increasingly evident in the reduction of local recurrence. In the context of intraoperative pinhole durotomies in resections of high-grade lesions, due consideration should be given to whole-spine radiation, although this remains an evidence-free zone.

Analysing predictors of surgical site infections in patients undergoing emergency surgery for traumatic pulmonary haemorrhage.

Identifying predictors for surgical site infections (SSIs) after emergency surgical treatment for traumatic pulmonary haemorrhage (TPH) is crucial for improving patient outcomes. This study aims to ascertain these predictors. In this comprehensive retrospective study, conducted from January 2020 to December 2023 at our institution, 75 patients were analysed, including a case group of 25 patients with SSIs and a control group of 50 without SSIs post-TPH surgery. Inclusion criteria focused on patients aged 18 and above undergoing thoracotomy or minimally invasive thoracic surgery for TPH. Exclusion criteria included compromised immune systems, chronic pulmonary diseases, prior thoracic surgery or active infections at admission. We assessed several predictors: anaemia; operation time over 2 h; hospital stay over 5 days; intraoperative blood loss exceeding 500 mL; body mass index (BMI) ≥25 kg/m2; age ≥ 50 years; use of surgical drains; the presence of open wounds; diabetes mellitus and non-prophylactic antibiotic use. Statistical analysis involved univariate and multivariate logistic regression, using SPSS Version 27.0. Univariate analysis revealed significant associations between SSIs and surgical drain placement, diabetes mellitus, open wounds and non-prophylactic antibiotic use (p < 0.01). Multivariate analysis confirmed these factors as significant predictors of SSIs, with notable odds ratios. Other variables like anaemia, extended hospital stay, excessive intraoperative blood loss, older age and higher BMI did not significantly predict SSIs. Significant predictors for SSIs following TPH surgery include surgical drain placement, diabetes mellitus, open wounds and non-prophylactic antibiotic use. Identifying and managing these risks is crucial in clinical practice to reduce SSIs incidence and improve patient outcomes.

Natural History of Lung Hernias

Background: Lung herniation has been described in case reports or series. There are scare data in the form of original research studies to systematically evaluate this condition. Objective: Our aim was to evaluate lung hernias with a focus on their natural history. Methods: This is a retrospective study at our institution of patients who were found to have lung herniation on imaging between September 2010 and November 2022. Electronic medical record review was performed to extract clinical information regarding patients. Computed tomographic imaging was used to evaluate hernia size and size progression over time with a median follow-up time of 3.8 years. Results: Thirty-eight patients were eligible for analysis. Majority of patients were overweight or obese (31/38), smokers (31/38), had prior thoracic surgery (30/38), and were asymptomatic (33/38). Twenty of 38 patients had stability in hernia size, 12 of 38 patients had hernia size progression, and 6 of 38 patients showed hernia size regression. Younger age was found to be predictive of hernia size progression with age of 60 years being the cut-off for its prediction. Conclusion: Lung hernias typically either remain stable in size or show size progression. Younger age (60 years cut-off) was found to be predictive of size progression. This is the largest systematic investigation at a medical institution to the best of our knowledge of lung hernias which used computed tomographic imaging to follow up lung hernias. Further information could be given to patients with this condition and to clinicians for potential management guidance.

Comparison of outcome after stereotactic ablative radiotherapy of patients with metachronous lung versus primary lung cancer

BackgroundEarly-stage lung cancer, primarily treated with surgery, often occur in poor surgical candidates (impaired respiratory function, prior thoracic surgery, severe comorbidities). Stereotactic ablative radiotherapy (SABR) is a non-invasive alternative that provides comparable local control. This technique is particularly relevant for surgically resectable metachronous lung cancer, in patients unable to undergo surgery.. The objective of this study is to evaluate the clinical outcome of patients treated with SABR for stage I metachronous lung cancer (MLC) versus stage I primary lung cancer (PLC).Patients and methods137 patients treated with SABR for stage I non-small cell lung cancer were retrospectively reviewed, of which 28 (20.4%) were MLC and 109 (79.6%) were PLC. Cohorts were evaluated for differences in overall survival (OS), progression-free survival (PFS), metastasis-free survival, local control (LC), and toxicity.ResultsAfter SABR, patients treated for MLC have comparable median age (76.6 vs 78.6, p = 0.2), 3-year LC (83.6% vs. 72.6%, p = 0.2), PFS (68.7% vs. 50.9%, p = 0.9), and OS (78.6% vs. 52.1%, p = 0.9) as PLC, along with similar rates of total (54.1% vs. 42.9%, p = 0.6) and grade 3 + toxicity (3.7% vs. 3.6%, p = 0.9). Previous treatment of MLC patients was either surgery (21/28, 75%) or SABR (7/28, 25%). The median follow-up was 53 months.ConclusionSABR is a safe and effective approach for localized metachronous lung cancer.

Utilization and Outcomes of Observation for Spontaneous Pneumothorax at an Integrated Health System

IntroductionThough limited, recent evidence supports observation rather than intervention for spontaneous pneumothorax management. We sought to compare the utilization and outcomes between observation and intervention for patients with primary and secondary spontaneous pneumothoraces. MethodsA retrospective cohort study of all adults presenting to Kaiser Permanente Northern California emergency rooms with spontaneous pneumothorax from 2016 to 2020 was performed. Those with prior pneumothoraces, tension physiology, bilateral pneumothoraces, effusions, and prior thoracic procedures or surgery on the affected side were excluded. Groups included observation versus intervention. Baseline clinicodemographic variables and outcomes were compared. Treatment was considered successful if further interventions were not required for pneumothorax resolution. Wilcoxon rank-sum tests, chi-square tests, Fischer exact tests, and multivariable logistic regression models were performed. ResultsOf the 386 patients with primary spontaneous pneumothorax, age, race/ethnicity, body mass index, smoking status, and the Charlson comorbidity index were not different between treatment groups. Of 86 patients with secondary spontaneous pneumothorax, age, gender, and smoking status were not different between treatment groups. Among patients with primary pneumothoraces, 83 underwent observation while 303 underwent intervention. The success rate was 92.8% for observation and 60.4% for intervention (P < 0.0001). Among patients with secondary pneumothoraces, 15 underwent observation while 71 underwent intervention, with a successful rate of 73.3% for observation and 32.4% for intervention (P = 0.003). ConclusionsGiven the high success rates for observation of both small and moderate primary and secondary pneumothoraces, observation should be considered for clinically stable patients. Observation may be the superior choice for decreasing morbidity and healthcare costs.

PERIOPERATIVE SMALL LUNG NODULE LOCALIZATION FOR MINIMALLY INVASIVE THORACIC SURGERY WITH AN ELECTROMAGNETIC NAVIGATIONAL SYSTEM

PERIOPERATIVE SMALL LUNG NODULE LOCALIZATION FOR MINIMALLY INVASIVE THORACIC SURGERY WITH AN ELECTROMAGNETIC NAVIGATIONAL SYSTEM

Cautionary tales in the use of magnets for the treatment of long gap esophageal atresia

BackgroundThe use of magnets for the treatment of long gap esophageal atresia or “magnamosis” is associated with increased incidence of anastomotic strictures; however, little has been reported on other complications that may provide insight into refining selection criteria for appropriate use. MethodsA single institution, retrospective review identified three cases referred for treatment after attempted magnamosis with significant complications. Their presentation, imaging, management, and outcomes were reviewed. ResultsAll three patients had prior cervical or thoracic surgery to close a tracheoesophageal fistula prior to magnamosis, creating scar tissue that can prevent magnet induced esophageal movement, leading to either magnets not attracting enough or erosion into surrounding structures. Two patients had a reported four centimeter esophageal gap prior to attempted magnamosis, both failing to achieve esophageal anastomosis, suggesting that these gaps were either measured on tension with variability in gap measurement technique, or that the esophageal segments were fixed in position from scar tissue and unable to elongate. One patient had severe tracheobronchomalacia requiring tracheostomy, with improvement in his airway after eventual tracheobronchopexies, highlighting that magnamosis does not address comorbidities often associated with this patient population. ConclusionsWe propose the following inclusion criteria and considerations for magnamosis: an esophageal gap truly less than four centimeters off tension with standardized measurement across centers, cautious use with a history of prior thoracic or cervical esophageal surgery, no associated tracheobronchomalacia or great vessel anomaly that would benefit from concurrent repair, and ideally to be used in centers equipped to manage potential complications. Level of evidenceLevel IV treatment study.

Robotic-Assisted Navigation Bronchoscopy as a Paradigm Shift in Peripheral Lung Access.

The sensitivity of suspicious lung nodules biopsied by currently available techniques is suboptimal. Robotic-assisted navigation bronchoscopy (RANB) is a novel method for biopsying lung nodules. Our study objective was to determine the sensitivity for malignancy and overall diagnostic accuracy for RANB when combined with cone beam CT (CBCT) for secondary confirmation. 52 consecutive patients were prospectively enrolled. Demographic data, nodule characteristics, procedural information, and follow-up results were obtained. Mean patient age was 66, with the majority Caucasian (73%) females (65%) with a similar number of never (46%) and former (46%) smokers. 15 patients had a history of cancer and 3 had a prior thoracic surgery. 59 total nodules were included as 7 patients had two nodules biopsied. Mean nodule diameter was < 2cm in all dimension with the majority solid (41, 70%) and located in the upper lobes (left: 22, 37%; right: 17, 29%). Bronchus sign was absent (32, 54%) or present (27, 46%) in a similar number. All nodules were successfully reached with nine (15%) requiring minor directional changes after initial cone beam CT. A tissue diagnosis was obtained in 83% (49/59) of biopsied nodules, with malignancy (31, 65%) most common. Including all biopsy results and follow-up imaging, we obtained an 84% (31/37) procedural sensitivity for malignancy and an overall 86% (51/59) diagnostic yield. RANB with CBCT increases sensitivity for malignancy and diagnostic accuracy of lung nodule biopsies. Combining these modalities has the potential to shift the diagnostic approach to pulmonary nodules.

Occlusion of the Celiac Artery during Endovascular Thoracoabdominal Aortic Aneurysm Repair Is associated with Increased Perioperative Morbidity and Mortality

Some studies suggest that celiac artery coverage during elective endovascular thoracoabdominal aortic aneurysm (TAAA) repair is safe given sufficient collateralization of visceral organ perfusion from the superior mesenteric artery. However, there is concern that celiac artery coverage may lead to increased risk of foregut or spinal cord ischemia with an attendant increased risk of mortality. We sought to investigate rates of bowel ischemia, spinal cord ischemia, and 30-day mortality associated with celiac artery coverage during TEVAR and complex EVAR. The Society for Vascular Surgery Vascular Quality Initiative database was queried for TEVAR and complex EVAR cases from 2012 to 2018. Inclusion criteria included TAAA pathology and endograft extension to aortic zone 6. Patients with aortic rupture, trauma, prior thoracic aortic surgery, known preoperative occlusion of the left subclavian superior mesenteric, or celiac arteries were excluded. Cases with intraoperative celiac artery occlusion (CAO) were compared retrospectively to cases with celiac artery preservation (CAP). Primary outcomes included 30-day mortality and a composite end point of 30-day mortality, spinal cord ischemia (transient or permanent lower extremity neurologic deficit), and bowel ischemia (colonoscopic evidence of ischemia, bloody stools in a patient who dies prior to colonoscopy or laparotomy, or other documented clinical diagnosis). Univariable comparisons were performed using chi-squared tests and Student's t-tests, as appropriate. Multivariable logistic regression analyses were employed to identify independent predictors of outcome. There were 628 cases identified for inclusion in the study. Patients undergoing CAO (n=44) were more likely to be female or to have higher rates of preoperative spinal drain use, American Society of Anesthesiologists score ≥3, low preop hemoglobin, and/or symptomatic presentation, but fewer mean number of aortic zones covered. CAO was associated with higher 30-day mortality (5 of 44, 11%) compared to CAP (23 of 584, 4%), P=0.039. The composite end point occurred at a significantly greater proportion for those who had CAO (10 of 44, 23%) compared to CAP (53 of 584, 9%, P=0.008), driven by higher rates of 30-day mortality and bowel ischemia (9% vs. 2%, P=0.026). By multivariate analysis, CAO was predictive of 30-day mortality (odds ratio [OR]=3.9, 95% confidence interval [CI]=1.1-13.8, P=0.04) and the composite endpoint (OR=3.0, 95% CI=1.1-8.5, P=0.03). Increasing procedure time was also associated with 30-day mortality (OR=1.4, 95% CI=1.1-1.7, P<0.001) and the composite end point (OR=1.4, 95% CI=1.1-1.6, P<0.001). For those treated for TAAAs, CAO was independently predictive of increased 30-day mortality and a composite end point of perioperative mortality, spinal cord ischemia, and bowel ischemia. When treating patients with extensive aortic aneurysmal disease, physicians should attempt to preserve the celiac artery, by revascularization or avoiding ostium coverage, whenever feasible.

Preoperative Heparin for Lung Cancer Resection Increases Risk of Reoperation for Bleeding

Lung cancer patients are at risk for venous thromboembolism (VTE). Preoperative heparin administration may increase the risk of bleeding requiring reoperation. The purpose of this study was to evaluate preoperative heparin's effect on reoperation for bleeding. A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer from January 2006 to April 2018. Preoperative heparin was administered at the discretion of the attending surgeon. Comparisons were performed between preoperative subcutaneous heparin (5000 U) and no heparin groups. A total of 3325 lung resections were reviewed, 1.4% (n = 48) required reoperation for bleeding. VTE occurred in 1.1% (n = 38). Four hundred sixty-four patients (14.0%) did not receive preoperative heparin. The preoperative heparin group had increased rates of prior thoracic surgery (5.1% [n = 146] vs 1.7% [n = 8], P < 0.001), minimally invasive approach (40.2% [n = 1150] vs 10.6% [n = 49], P < 0.001), and sublobar resections (17.7% [n = 506] vs 10.6% [n = 49], P < 0.001). There were no differences in blood loss/transfusions. Reoperation for bleeding was significantly increased in the preoperative heparin group (1.6% [n = 47] vs 0.2% [n = 1], P = 0.017). There were no differences in VTE (1.5% [n = 7] vs 1.1% [n = 31], P = 0.424). On logistic regression, preoperative heparin was independently associated with increased reoperation for bleeding (odds ratio 8.13, P = 0.039); however, preoperative heparin was not independently associated with VTE. Preoperative heparin was associated with increased reoperation for bleeding. VTE rates are low after pulmonary resection for lung cancer and are not decreased by preoperative heparin. Preoperative heparin use should be determined by risk factor stratification for VTE and reoperation for bleeding in patients undergoing lung cancer resection.

PS01.242: HIATAL HERNIA AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Hiatal hernias (HH) are a known, yet poorly studied, post-surgical complication of esophagectomy. The aim of this study was to analyze in a retrospective fashion the MIE experience at our institution, in order to individuate factors associated with post-surgical HH development. Methods We reviewed data from MIE performed at University of Colorado from July 2013 to July 2017. Our most common approach of choice is Ivor Lewis MIE with circular stapled end to side anastomosis. We divided our patient population in two groups: those who developed a HH at any time post operatively and those who did not. We compared pre-, intra- and post-operative clinical variables of interest in the two groups using Pearson chi-squared and Fisher's exact test for binomial variables and Two-sample Wilcoxon rank-sum (Mann-Whitney) test for continuous variables. Results 91 patients underwent MIE in the study period: 11 developed HH in a time frame ranging from one week to two years post operatively. 8 patients had a HH involving one or more intra-abdominal organs other than the stomach; 3 patients had a HH interesting mostly the tubulized stomach. 7 patients required a reoperation. There were no statistically significant differences in the prevalence of pre-operative comorbidities between the two groups. Patient who developed a HH were significantly less likely to have had prior abdominal or thoracic surgery (Pr = 0.039). As expected, they were also significantly more likely to require a reoperation (Pr = 0.000). There were no statistically significant differences in intra-operative variables between the two groups, including operative time and anastomotic technique, nor where there differences in incidence of post operative complications other than HH. We did observe a trend towards higher rate of preoperative chemotherapy and radiation in the HH group. Of note, we did attempt to prevent HH by means of tacking abdominal organs to the abdominal wall, however this did not prove to significantly decrease HH incidence. Conclusion HH occurs in a non-negligible percentage of patients undergoing MIE. Lack of prior surgery appears to be significantly associated with HH, perhaps due to lesser adhesion burden acting as a mean of organ fixation. Disclosure All authors have declared no conflicts of interest.

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis.

Aortic stenosis (AS) is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement (SAVR) has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged. Transcatheter aortic valve replacement (TAVR) is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety (e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing). The impact of comorbidities (pulmonary hypertension, arterial hypertension and obesity paradox), the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category (extremely high, high, intermediate and low risk) are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.

Stereotactic body radiation therapy for non-small cell lung cancer patients with prior history of thoracic surgery and/or radiation therapy: the influence of smoking, size, and central location on risk of complications

PurposeThe purpose of this retrospective cohort study was to evaluate the effect of tumor location and other major factors on the risk of complications from stereotactic body radiation therapy (SBRT) in non-small cell lung cancer (NSCLC) patients with a history of thoracic surgery and/or radiation therapy.MethodsMedical records of patients with recurrent or second primary NSCLC treated with SBRT between 2005 and 2015 were reviewed. All patients had prior thoracic surgery and/or radiation therapy and were treated with image-guided, robotic SBRT. Time to local failure and toxicity was evaluated by using cumulative incidence and competing risk regression analysis. Overall survival was estimated using the Kaplan-Meier method.ResultsFifty-six patients with 74 tumors treated with SBRT were included for analysis. Of the 74 tumors, 19 (26%) were centrally located within 2 cm of the proximal bronchial tree. At a median follow-up of 27 months (range = 5–129), the 2-year cumulative incidence of LF was 13% for peripheral tumors and 16% for central tumors (p = 0.95). Neither prior thoracic surgery nor radiation therapy was associated with increased LF or toxicity. Among the 56 patients, eight (14%), three (5%), and one (2%) experienced grade 2, 3, and 4 complications following SBRT. Patients with a ≥ 50 pack-year smoking history were more likely to develop ≥ grade 2 toxicity (HR 5.3; 95% CI 1.4–19.9, p = 0.01). Central tumor location was associated with higher risk of toxicity (HR 3.4; 95% CI 1.1–10.5, p = 0.04) as was planning tumor volume > 30 mL (HR 4.3; 95% CI 1.1–16.3, p = 0.047). In a multivariable model, central location remained significant after adjusting for smoking history and planning tumor volume.ConclusionsAfter prior thoracic surgery and/or radiation, SBRT retreatment for NSCLC provided durable local control and was well tolerated in most patients. Patients with a history of previously operated and/or radiated lung cancer with new central tumors, PTV volume > 30 mL, or smoking history ≥ 50 pack-years were at higher risk of complications from SBRT.

Analysis of the risk factors for postoperative cervical anastomotic leakage after McKeown's esophagectomy

Objective: To analyze risk factors of anastomotic leakage after McKeown'sesophagectomy. Methods: The clinical data of 635 esophageal cancer patients, who underwent McKeown's esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences from January 2012 to December 2015, were retrospectively analyzed. The risk factors of cervical anastomotic leakage were identified through analysis of medical history, surgical procedure, tumor characteristics and vascular calcification. Results: Among all the 635 patients, anastomotic leakage occurred in 111 (17.5%)patients. Univariate analysis showed that the American Society of Anesthesiologists (ASA) risk class, prior thoracic surgery, upper digestive tract ulcer, COPD, hypertension, peripheral vascular disease, renal insufficiency, FEV1% predicted, DLCO% predicted, duration of surgery and calcification of descending aorta, celiac trunk and left postceliac arteries were associated with a statistically significant increase in risk of cervical anastomotic leakage (P<0.05 for all). Logistic regression analysis showed that ASA risk class, peripheral vascular disease, renal insufficiency and calcification of descending aorta and celiac trunk were independent risk factors of cervical anastomotic leakage after McKeown's esophagectomy (P<0.05 for all). Conclusions: ASA risk class, peripheral vascular disease, renal insufficiency, calcification of descending aorta and celiac trunk are independent risk factors of cervical esophageal anastomotic leakage after McKeown's esophagectomy.

The Society of Thoracic Surgeons Lung Cancer Resection Risk Model: Higher Quality Data and Superior Outcomes

The Society of Thoracic Surgeons (STS) creates risk-adjustment models for common cardiothoracic operations for quality improvement purposes. Our aim was to update the lung cancer resection risk model utilizing the STS General Thoracic Surgery Database (GTSD) with a larger and more contemporary cohort. We queried the STS GTSD for all surgical resections of lung cancers from January 1, 2012, through December 31, 2014. Logistic regression was used to create three risk models for adverse events: operative mortality, major morbidity, and composite mortality and major morbidity. In all, 27,844 lung cancer resections were performed at 231 centers; 62% (n= 17,153) were performed by thoracoscopy. The mortality rate was 1.4% (n= 401), major morbidity rate was 9.1% (n= 2,545), and the composite rate was 9.5% (n= 2,654). Predictors of mortality included age, being male, forced expiratory volume in 1 second, body mass index, cerebrovascular disease, steroids, coronary artery disease, peripheral vascular disease, renal dysfunction, Zubrod score, American Society of Anesthesiologists rating, thoracotomy approach, induction therapy, reoperation, tumor stage, and greater extent of resection (all p < 0.05). For major morbidity and the composite measure, cigarette smoking becomes a risk factor whereas stage, renal dysfunction, congestive heart failure, and cerebrovascular disease lose significance. Operative mortality and complication rates are low for lung cancer resection among surgeons participating in the GTSD. Risk factors from the prior lung cancer resection model are refined, and new risk factors such as prior thoracic surgery are identified. The GTSD risk models continue to evolve as more centers report and data are audited for quality assurance.

Acoustical detection of coronary stenosis: a double-blinded angiographic comparison in a clinically relevant cohort

Background: Hemodynamically significant coronary stenosis generates local blood flow turbulence. In a prior study, we demonstrated feasibility of acoustical detection (AD) to identify this turbulence using a specialized microphone that detects acoustical pressure waves from the chest wall and analyzes signals using a modified form of fast Fourier transform (FFT). We have expanded our study to include analysis in the setting of clinically relevant variables including age, sex, body mass index (BMI), hemoglobin (Hgb), and left ventricular ejection fraction (EF). We hypothesize that this AD modality will remain validated in a clinically relevant cohort of patients, including those with potential confounding variables. Methods: We prospectively studied 199 consecutive patients who underwent elective coronary angiography. Patients with history of valvular disease or prior thoracic surgery of any kind were excluded. AD data were collected prior to angiography at predetermined anterior thoracic auscultation sites. An experienced cardiologist blinded to clinical and acoustic data recorded the maximal percent diameter stenosis in each of 16 coronary segments. Acoustic data were analyzed by an acoustical engineer blinded to clinical and angiographic data. AD analysis results were graded as "Normal" or "Diseased." Results: All pts had analyzable acoustic recordings. Prevalence of significant CAD (>50% stenosis in any segment) at angiography was 51.8% (n=106; 22%, 19%, 9% with 1, 2, 3-vessel disease). Four patients had a total occlusion of a single vessel and no other significant disease. The sensitivity and specificity for AD of a coronary stenosis >50% in any vessel were 0.64 and 0.75 (NPV 0.66 and PPV 0.73). AD had maximal accuracy in detecting a >50% stenosis with an area under the ROC curve of 0.69 (p<0.0001). When coronary stenosis was defined as 70% rather than 50%, the sensitivity and specificity of AD were 0.65 and 0.69. When pts with isolated total occlusions were excluded, the area under the ROC curve was essentially unchanged (0.67). Multivariable logistic regression of age, sex, BMI, Hgb, and EF demonstrated no significant correlation. Conclusion: These data support our hypothesis that AD remains a validated screening modality to detect coronary stenosis independent of theorized confounding mechanical and flow-related variables. The reduced economic cost, potential widespread use, and lack of risk altogether make this method a practical and potentially transformative technology to detect significant coronary stenosis in a clinically relevant patient population.

No Increased Risk of Spinal Cord Ischemia in Delayed AAA Repair Following Thoracic Aortic Surgery

To examine the results of open or endovascular abdominal aortic aneurysm (AAA) repair following prior open or endovascular thoracic aortic surgery. A retrospective review of all patients who underwent AAA repair in a delayed fashion following prior thoracic aortic surgery at a single university hospital between 1999 and 2011 was performed. Thirteen patients underwent AAA repair following prior thoracic aortic repair. Mean age was 68.9 ± 6.9 years and 77% (n = 10) were male. Three patients experienced transient delayed-onset spinal cord ischemia (SCI) following initial thoracic surgery. Mean time interval between initial thoracic aortic surgery and subsequent AAA repair was 2.0 ± 1.8 years. Overall rate of SCI and 30-day mortality after delayed AAA repair was 0%. This series does not demonstrate any evidence of increased risk of perioperative mortality or SCI in patients undergoing delayed AAA repair after prior thoracic aortic surgery.

Hybrid thoracic endovascular aortic repair via right anterior minithoracotomy

Hybrid thoracic endovascular aortic repair (TEVAR) has expanded the surgical management of complex thoracic aneurysms. Aortic arch debranching generally requires a sternotomy. We describe our experience performing a right anterior minithoracotomy for hybrid TEVAR. During a 3-year period, 7 patients (aged 76 ± 15 years; 57% were male) with aortic arch aneurysms underwent hybrid TEVAR via a right anterior minithoracotomy. Of all with prior thoracic or abdominal aortic surgery, 4 had a prior sternotomy. All patients included in this series had an American Society of Anesthesiology score of 4 or greater. Repairs were performed via a 5-cm incision at the third to fourth intercostal space to access the ascending arch. A Satinsky clamp on the ascending aorta facilitated bypass with the 10-mm arm of a bifurcated 10/12-mm graft to the innominate artery or right common carotid artery (12-mm arm: endoprosthesis conduit). The remaining arch vessels were bypassed as needed; subsequently, a thoracic stent graft was deployed by the 12- or 14-mm arm. Primary technical success was 86% (6 patients); 1 patient required conversion to sternotomy secondary to bleeding. Complications included cerebrovascular accident in 2 patients (28%) and respiratory failure in 2 patients (28%). The average length of stay was 12 days with no wound infection. One death occurred during the 30-day period. Right anterior minithoracotomy is a compelling, less invasive technique for hybrid TEVAR. Further experience will be necessary to completely evaluate the merits of this approach.