Thoracic Bleeding Research Articles

Double trouble: Co-infection of Angiostrongylus vasorum and Dirofilaria immitis in golden jackal (Canis aureus) in Friuli Venezia Giulia, Italy

This study reports the first co-infection of Angiostrongylus vasorum and Dirofilaria immitis, two nematodes affecting canid cardiopulmonary systems, in golden jackals (Canis aureus) in Italy. Data on golden jackal carcasses, recovered in Friuli Venezia Giulia (Italy) from 2020 to 2023, were recorded using InfoFaunaFVG wildlife monitoring network. Out of 60 necropsied golden jackals, 24 tested positive for either pathogen, with 3 animals displaying co-infection. Pathological findings included verminous pneumonia, abdominal and thoracic bleeding, and adult individuals in the heart and pulmonary arteries. The recent expansion of the golden jackal in northern Italy may favour the establishment and spread of these nematodes, posing challenges for disease containment and surveillance. Given the increasing prevalence of angiostrongylosis and cardiopulmonary dirofilariosis in Europe, health monitoring of wild canids is essential to reduce their potential impact.

Application of uniportal video-assisted thoracoscopic surgery in the treatment of tuberculous destroyed lung

Objective: To examine the efficacy of uniportal video-assisted thoracoscopic surgery in the treatment of tuberculous destroyed lung. Methods: This is a retrospective case series study. The clinical data of 33 patients with tuberculous destroyed lung who had received uniportal video-assisted thoracoscopic pulmonary resection from June 2020 to May 2022 in Department of Surgery, Wuhan Pulmonary Hospital were retrospectively analyzed. There were 13 males and 20 females, aged (47.5±16.2) years (range: 19 to 68 years). The course of the disease was from 15 days to 8 years. All 33 cases had pleural adhesions, including 30 cases with total pleural adhesions and atresia. There were 21 cases of calcification of the thoracic lymph node, 17 cases of aspergillus infection, 4 cases of drug-resistant tuberculosis. The surgical incision was located at the midline of the fifth intercostal axilla, length 4 to 5 cm. The principle of separating pleural adhesions was easy first and difficult later, and then appropriate procedures were selected to resect the diseased lung based on the exploration situation. There were 12 cases that underwent superior lobectomy, 11 cases that underwent superior lobectomy and dorsal segmentectomy, 3 cases that underwent inferior lobectomy, 3 cases that underwent pneumonectomy, 2 cases that underwent middle and inferior lobectomy, and 1 case that underwent superior lobectomy, dorsal segmentectomy and basal segment wedgectomy. The surgical techniques, perioperative evaluation and treatment, management of complications, and the outcome were summarized. Results: Six cases were converted to thoracoscope assisted small incision or thoracotomy. For 27 cases who successfully underwent uniportal VATS, the operation time was (238.7±76.8) minutes (range: 60 to 420 minutes), the intraoperative bleeding was (400.4±315.9) ml (range: 50 to 1 200 ml). The duration of postoperative drainage was (12.7±8.3) days (range: 3 to 42 days). The postoperative hospital stay was (15.2±7.9) days (range: 6 to 43 days). Persistent postoperative pulmonary leakage occurred in 12 cases. There were 2 cases of active thoracic bleeding, one of which was cured with conservative treatment. The other case underwent secondary operation. One case of bronchopleural fistula was cured after continuous thoracic drainage to control infection and implantation of one-way bronchial valve through a fiberoptic bronchoscope. Conclusion: For selected patients with tuberculous destroyed lung, choosing the reasonable surgical procedures and techniques, the uniportal VATS could reduce surgical trauma.

Spontaneous haemopneumothorax: A rare illness with unusual presentation and aetiology

Background: In the acute context, spontaneous haemopneumothorax is a life-threatening condition that can occur without any radiological abnormalities and may be caused by thoracic vascular aberrancy. Case presentation: We discuss the case of a healthy 24-year-old man who visited our emergency department complaining of left sided chest pain and shortness of breath. He had previously visited a tertiary care facility’s emergency department for the same complaint the same day and had been released following a normal CXR and blood tests. His repeat x-ray chest revealed hemopneumothorax in our department. His CT scan further revealed ruptured aberrant blood vessel which was medial to the left subclavian artery. Conclusion: This example illustrates the importance of maintaining a high index of suspicion when evaluating patients who present with chest pain and shortness of breath. There must be a repeat patient examination and x-ray chest for patients who experience prolonged chest discomfort, despite normal first investigations. If the patient’s repeat x-ray’s indicate hemopneumothorax, this should leave one to ponder the likelihood that thoracic bleeding could result from vascular aberrancy as a cause.

Spontaneous hemopneumothorax: a rare illness with unusual presentation and etiology

Background: In the acute context, spontaneous hemopneumothorax is a potentially life-threatening condition that can occur without any radiological abnormalities and may be caused by thoracic vascular aberrancy. Case Presentation: We discuss the case of a healthy 24-year-old man who visited our emergency department (ED) complaining of left-sided chest pain and shortness of breath. He had previously visited a tertiary care facility’s ED for the same complaint the same day and had been released following normal chest X-ray (CXR) and blood tests. His repeat CXR revealed hemopneumothorax in our department. His computed tomography scan further revealed a ruptured aberrant blood vessel which was medial to the left subclavian artery. Conclusion: This example case report illustrates the importance of maintaining a high index of suspicion for the probability of haemo or pneumothorax when evaluating patients who present with chest pain and shortness of breath. There must be a repeat patient examination and CXR for patients who experience prolonged chest discomfort, despite normal initial investigations. If the patient’s repeat X-rays indicate hemopneumothorax, this should leave one to ponder the likelihood that thoracic bleeding could result from vascular aberrancy.

254. TODAY’S ISSUES IN ROBOT-ASSISTED ESOPHAGECTOMY

Abstract Recently, effectiveness of robot-assisted minimally invasive esophagectomy (RAMIE) has been reported however, there are some issues specific to RAMIE which may lead to major complications. The issues include 1) interference with the right shoulder, 2) compression of vertebral bodies and blood vessels, 3) energy devices, and 4) education to young surgeons. In this study, we evaluated the short-term outcome of RAMIE in our department, and show the ideas for improving those issues. For 1), the assistant gives instructions to the surgeon, and uses a protector on right shoulder. In 2), port arrangement depending on the cases and switching the camera port is useful. 3) Because those devices are still under developing, careful procedure is required while using energy device, 4) Double console and extra thoracoscopic camera is useful in operating under the education. We conducted a comparative study of 81 cases of RAMIE performed at our institution from 2014 to January 2022 and 392 cases of prone thoracoscopic esophagectomy performed at about the same time, to evaluate the short-term outcomes including complications. RAMIE showed an increase in thoracic operation time (median 286 min vs 260 min), but amount of thoracic bleeding tended to be smaller (median 13 mL vs 19 mL). Recurrent laryngeal nerve palsy (G1) was about 40%, and pneumonia was about 18%, which was about the same. One case encountered to in-hospital death from RAMIE group by aspiration pneumonia and one cardiac tamponade by thoracoscopic surgery, respectively, Also, there was no difference in short-term outcomes between experienced and non-experienced surgeons, except operation time. It is difficult to educate young surgeons who cannot afford to pay attention to the surroundings because there is a possibility that the surrounding organs will be damaged without resistance. Therefore, experienced surgeon should observe and understand the situation using double console or an additional scope. Also, many other knacks and tricks are important to reduce the complications arises from robotic surgery.

411. MAJOR INTRAOPERATIVE COMPLICATIONS IN MINIMALLY INVASIVE ESOPHAGECTOMIES

Abstract Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma, with equal oncological results as open surgery. The number of MIEs in Europe are increasing. Postoperative complications have been recently reviewed by a multicenter study that benchmarked MIE outcomes. There are no studies, to date, regarding major intraoperative complications during MIE and their effect on patient survival. Data was gathered retrospectively from 10 European centers with a minimum MIE experience of 3 years and more than 20 procedures annually. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal- and GE junction cancers operated between 2003–2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, major anesthesiologic complications including intubation injuries, arrhythmias, pulmonary embolism and myocardial infarction. We also included minor intraoperative events that led to additional repair or resection of vascular structures or airways. Amongst 2862 MIE cases we identified 99 patients with 103 intraoperative complications. Of the 34 different complications the most common were vascular lesions during laparoscopy (n = 40). There were 20 splenic artery and -capsular injuries, 11 requiring splenectomy. Four losses of conduit due to gastroepiploic artery injury and five colon injuries were reported. Six tracheobronchial lesions needed repair, and 12 patients had significant lung parenchyma injuries. During thoracoscopy nine of the 13 cases with bleeding were converted and an additional 5 patients required postoperatively emergency re-intervention for thoracic bleeding. There were 2 on-table deaths. 10 of the 99 patients died in-hospital. This study offers a good overview of the wide range of possible intraoperative complications. Knowing the pitfalls can help trainees, and experienced surgeons, avoid common complications. Unfortunately, this study does not offer us incidence, which would require a prospective trial. On-table deaths are exceedingly rare. There is a possible underreporting of complications, an issue not avoided by implementing specific surveying criteria. Surgical registries need to capture intraoperative complications better in the future.

Acute haemothorax and pleuropulmonary blastoma: Two extremely rare complications of extralobar pulmonary sequestration

Extralobar bronchopulmonary sequestration (eBPS) is a congenital lung malformation characterized by non-functional lung tissue with no connection with the bronchial tree, receiving systemic blood supply and covered by its own visceral pleura. It is mostly asymptomatic, however it can rarely get complicated with infections and neoplastic degeneration. Its management is still debated: many authors suggest observation for asymptomatic cases and intervention only in case of symptoms, others advocate surgery even in asymptomatic patients. Pleuropulmonary blastoma (PPB) is a rare malignant sarcomatous neoplasm, representing the most common primary lung malignancy in children. Typically, PPB is associated with congenital pulmonary airway malformation (CPAM). eBPS is rarely associated with PPB. We report a case of a previously healthy three-year-old boy presented to our emergency room with massive hemothorax after a low-energy chest trauma. Imaging revealed active thoracic bleeding by an anomalous artery arising from the celiac tripod, and an irregular mass in the lower right hemithorax. After performing biopsy, pathologic examination revealed a PPB. The patient underwent four cycles of chemotherapy before surgery. The operative findings revealed a right supradiaphragmatic extralobar mass, with no communication with the bronchial tree, strictly adherent to the right middle lobe. After mass excision, histological analysis confirmed the diagnosis of PPB type 2. The patient underwent postoperative chemotherapy. No recurrence nor metastasis were noted during the current follow-up. DICER-1 research revealed biallelic mutation on the tumor and on the surrounding normal tissue. We reviewed the literature concerning PPB and BPS. Based on these data, we would recommend intervention even in case of asymptomatic eBPS.

Impact of a Modified Bicaval Anastomoses Technique on Outcome After Orthotopic Heart Transplantation

<h3>Purpose</h3> Implantation techniques for orthotopic heart transplantation (HTx) have evolved during the centuries. By now, bicaval anastomosis are preferred compared to biatrial as they are reported to cause less pacemaker implantation, however they can increase duration of warm ischemia. Recently new approaches of modified bicaval techniques in order to minimize warm ischemia are gaining popularity in the literature. <h3>Methods</h3> Between 2010 and 2021 n=218 patients underwent HTx in our department. The recipients were retrospectively reviewed and divided regarding their anastomoses technique. Anastomoses were sutured either in biatrial, bicaval or in a modified bicaval manner with suturing of the superior cava vein and A. pulmonalis anastomosis after removing the aortic cross-clamp during the reperfusion. <h3>Results</h3> The majority of patients were transplanted in bicaval (n=179), followed by biatrial (n=34) and modified bicaval technique (n=5). Warm ischemia was 66±15 min for bicaval, 62±11 min for biatrial but only 42±8 min for modified bicaval technique (p<0.01). Bonferroni correction revealed no significant differences between bicaval and biatrial (p=0.18) but between both bicaval and modified bicaval (p<0.01) and biatrial and modified bicaval technique (p=0.05). Incidence of severe primary graft dysfunction was comparable between bicaval (29.9 %) and biatrial (27.3 %) anastomosis. In contrast, in patients with modified bicaval technique primary graft dysfunction did not occur. The same effect was observed for perioperative neurological events as well as thoracic bleeding. In addition, stay on intensive care unit was significantly shorter for modified bicaval patients (p=0.02). Incidence of postoperative pacemaker implantation was 16.7 % for biatrial compared to 3.2 % for bicaval and 0 % for modified bicaval technique (p=0.03). <h3>Conclusion</h3> While incidence of postoperative need for pacemaker implantation was increased in patients with biatrial anastomoses, there was no significant difference regarding warm ischemia and perioperative adverse events compared to bicaval technique. Although the results for modified bicaval technique are only preliminary by now, we were able to report promising results with significant shorter duration of warm ischemia and decreased perioperative complications indicating an optimized anastomoses technique for HTx.

Removal of Electrophysiological Devices in the Context of Heart Transplantation: Comparison of Combined and Staged Extraction Procedures

During heart transplantation (HTx), tip of the leads of cardiac implantable electrophysiological devices (CIEPD) has to be cut when resecting the heart. Timing of the removal of the remaining device and leads is still discussed controversially. Between 2010 and 2021, n = 201 patients underwent HTx, of those n = 124 (61.7%) carried a present CIEPD. These patients were divided on the basis of the time of complete device removal (combined procedure with HTx, n = 40 or staged procedure, n = 84). CIEPD was removed 11.4 ± 6.7 days after the initial HTx in staged patients. Dwelling time, number of leads as well as incidence of retained components (combined: 8.1%, staged: 7.7%, p = 1.00) were comparable between both groups. While postoperative incidence of infections (p = 0.52), neurological events (p = 0.47), and acute kidney injury (p = 0.44) did not differ, staged patients suffered more often from primary graft dysfunction with temporary mechanical assistance (combined: 20.0%, staged: 40.5%, p = 0.03). Consecutively, stay on intensive care unit (p = 0.02) was prolonged and transfusions of red blood cells (p = 0.15) and plasma (p = 0.06) as well as re-thoracotomy for thoracic bleeding complications (p = 0.10) were numerically increased in this group. However, we did not observe any differences in postoperative survival. Presence of CIEPD is common in HTx patients. However, the extraction strategy of CIEPD most likely did not affect postoperative morbidity and mortality except primary graft dysfunction. Especially, retained components, blood transfusions, and infective complications are not correlated to the timing of CIEPD removal.

Impact of pretransplant left ventricular assist device support duration on outcome after heart transplantation.

OBJECTIVESHeart transplantation after left ventricular assist device (LVAD) implantation remains challenging. It is still unclear whether its support duration impacts the outcome after transplantation. METHODSAll patients undergoing heart transplantation between 2010 and 2021 at a single department after previous left ventricular assistance were retrospectively reviewed and divided into 4 different study groups with regard to the duration of LVAD support to examine the impact on the postoperative morbidity and mortality.RESULTSA total of n = 198 patients were included and assigned to the 4 study groups (group 1: <90 days, n = 14; group 2: 90 days to 1 year, n = 31; group 3: 1–2 years, n = 29; group 4: >2 years, n = 24). Although there were no differences between the 4 groups concerning relevant mismatch between the recipients and donors, the incidence of primary graft dysfunction was numerically increased in patients with the shortest support duration, and also those patients with >1 year of support (group 1: 35.7%, group 2: 25.8%, group 3: 41.4%, group 4: 37.5%, P = 0.63). The incidence of acute graft rejection was by trend increased in patients of group 1 (group 1: 28.6%, group 2: 3.3%, group 3: 7.1%, group 4: 12.5%, P = 0.06). Duration of LVAD support did not impact on perioperative adverse events (infections, P = 0.79; acute kidney injury, P = 0.85; neurological events, P = 0.74; thoracic bleeding, P = 0.61), neither on postoperative survival (1-year survival: group 1: 78.6%, group 2: 66.7%, group 3: 80.0%, group 4: 72.7%, P = 0.74).CONCLUSIONWe cannot identify a significant impact of the duration of pretransplant LVAD support on postoperative outcome; therefore, we cannot recommend a certain timeframe for transplantation of LVAD patients.

Traumatic Hemothorax Caused by Thoracic Wall and Intrathoracic Injuries: Clinical Outcomes of Transcatheter Systemic Artery Embolization.

PurposeWe aimed to assess the clinical efficacy of transcatheter arterial embolization (TAE) for treating hemothorax caused by chest trauma.Materials and MethodsBetween 2015 and 2019, 68 patients (56 male; mean age, 58.2 years) were transferred to our interventional unit for selective TAE to treat thoracic bleeding. We retrospectively investigated their demographics, angiographic findings, embolization techniques, technical and clinical success rates, and complications.ResultsBleeding occurred mostly from the intercostal arteries (50%) and the internal mammary arteries (29.5%). Except one patient, TAE achieved technical success, defined as the immediate cessation of bleeding, in all the other patients. Four patients successfully underwent repeated TAE for delayed bleeding or increasing hematoma after the initial TAE. The clinical success rate, defined as no need for thoracotomy for hemostasis after TAE, was 92.6%. Five patients underwent post-embolization thoracotomy for hemostasis. No patient developed major TAE-related complications, such as cerebral infarction or quadriplegia.ConclusionTAE is a safe, effective and minimally invasive method for controlling thoracic wall and intrathoracic systemic arterial hemorrhage after thoracic trauma. TAE may be considered for patients with hemothorax without other concomitant injuries which require emergency surgery, or those who undergoing emergency TAE for abdominal or pelvic hemostasis.

Resuscitative endovascular balloon occlusion of the aorta for thoracic trauma in the setting of platelet dysfunction: A translational swine study.

In patients with noncompressible torso hemorrhage, antiplatelet medications may lead to worse outcomes. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may potentially stabilize these patients, but currently, major thoracic bleeding is a contraindication. The goal of this study was to determine if REBOA use for shock with major thoracic bleeding has worse outcomes in the setting of platelet dysfunction (PD). Forty-one male Yorkshire swine (60-80 kg) underwent a 30% hemorrhage and then were randomized to three thoracic injuries, with and without zone 1 REBOA occlusion: pulmonary parenchymal injury (PI), thoracic venous injury (VI), or subclavian artery injury (AI). All animals were given aspirin to produce PD. Following hemorrhage, thoracic injuries were induced (T0) and allowed to bleed freely. Resuscitative endovascular balloon occlusion of the aorta groups had zone 1 occlusion, with deflation at T30. All groups received whole blood resuscitation at T30 and were euthanized at T90. Survival, total blood loss, hemodynamics, and arterial blood gas parameters were analyzed. The PD-VI-REBOA group had 87.5% survival where PD-VI survival was 28.6%. No difference in survival was seen in the PI or AI groups. The PD-VI-REBOA group had total blood loss of 575.0 ± 339.1 mL, which was less than the PD-VI group (1,086.0 ± 532.1 mL). There was no difference in total thoracic blood loss in the PI and AI groups with the addition of REBOA. All groups showed an equivalent decrease in HCO3 and base excess and increase in lactate at the end of the 30-minute prehospital phase. In this study, zone 1 REBOA improved survival and decreased blood loss with major VI, where no differences were seen in parenchymal and subclavian artery injuries. For thoracic bleeding without surgical capability, outcomes may be improved with REBOA, and these findings challenge current guidelines stating the contraindication of REBOA use in this setting.

Resuscitative endovascular balloon occlusion of the aorta for thoracic trauma: A translational swine study.

Forty-eight male Yorkshire swine (60-80 kg) underwent 30% hemorrhage and were randomized to three thoracic injuries, with and without zone 1 REBOA occlusion: pulmonary parenchymal injury, thoracic venous injury, or subclavian artery injury. Following hemorrhage, thoracic injuries were induced (time of major thoracic injury) and allowed to bleed freely. The REBOA groups had zone 1 occlusion after the thoracic injury, with deflation at the end of prehospital. All groups had whole blood resuscitation at the end of prehospital and were euthanized at end of the hospital care phase. Survival, total blood loss, mean arterial pressure, end-tidal CO2, and arterial blood gas parameters were analyzed. Statistical significance was determined by t tests and two-way repeated-measures analysis of variance. The use of REBOA improved the hemodynamics in all three injury patterns, with no differences observed in the outcomes of short-term survival and thoracic blood loss between the REBOA and non-REBOA groups. All groups showed equivalent changes in markers of shock (pH, HCO3, and base excess) prior to resuscitation. In this animal study of hemorrhage and major thoracic bleeding, the addition of zone 1 REBOA did not significantly affect short-term survival or blood loss, while providing hemodynamic stabilization. Therefore, in noncompressible thoracic bleeding, without immediate surgical capability, long-term outcomes may be improved with REBOA, and thoracic hemorrhage should not be considered contraindications to REBOA use.

Application of esophageal wire traction in lymph node dissection during three-hole thoracoscopic McKeown esophagectomy

Introduction The quality of left recurrent laryngeal nerve lymph node dissection is critical in esophageal cancer. We investigated whether esophageal wire traction in three-hole thoracoscopic esophagectomy can improve the same. Material and methods We retrospectively analyzed the data of 98 patients who underwent thoracoscopic esophagectomy in our center from January 2018 to July 2018: 36 patients with esophageal wire traction and 62 patients without traction (control group). The clearance time for left recurrent laryngeal nerve lymph nodes, thoracic bleeding volume, number of left recurrent laryngeal nerve lymph nodes, and complications were recorded. Results The observation group had a shorter clearance time for the left recurrent laryngeal nerve lymph nodes (15.8 ± 6.9 min vs. 20.00 ± 6.2 min), less thoracic bleeding (55.8 ± 30.2 mL vs. 70.7 ± 30.3 mL), and higher number of dissected left recurrent laryngeal lymph nodes (3.3 ± 1.4 vs. 2.5 ± 1.1) than the control group. There was no significant difference in the incidence of anastomotic leakage, pulmonary infection, arrhythmia, chylothorax, and nerve injury. Conclusions Esophageal wire traction shortens the clearance time for the left recurrent laryngeal nerve lymph nodes, reduces thoracic bleeding, and improves the quality of left recurrent laryngeal nerve lymph node dissection in three-hole thoracoscopic esophagectomy.

Using chest drain outputs for the blunt trauma patient to guide thoracotomy. A review of literature.

The current Advanced Trauma Life Support guidelines state that immediate output from a chest drain (also referred to as a tube thoracostomy) of >=1500mL or ongoing blood loss of >=200mL hourly for 2-4 hours are indications for thoracotomy, with the rationale being that the rate of ongoing haemorrhage requires open surgical intervention. This figures aims to be pragmatic and easy to follow, particularly for the stressful trauma environment, but oversimplifies thoracic bleeding for the critically injured patient. It does not consider the mechanism of injury (blunt or penetrating), the patient’s medical co-morbidities including medications, nor the presence of extra-thoracic injury. Furthermore, patients who have significant tissue injury or ongoing bleeding may potentially be coagulopathic and focussed efforts need to be on haemostatic resuscitation before open surgery is entertained. Blunt injured patients can typically have complicated injury patterns, resulting in bleeding from multiple sites, so it is not surprising that outcomes after thoracotomy are poor. This review article aims to summarise the literature regarding thoracotomy after high chest drain output in the setting of blunt trauma. We excluded papers focussing on resuscitative thoracotomies in peri-arrest patients.

Uniportal video-assisted thoracoscopic surgery for the treatment of thoracic emergencies.

While video-assisted thoracoscopic surgery (VATS) is well accepted in the management of thoracic emergencies, uniportal VATS has not yet been studied for this indication. This paper reports the results of the treatment of chest trauma patients by uniportal VATS in a single center with extensive experience in uniportal VATS. In this prospective study all patients who underwent uniportal VATS for thoracic surgical emergency cases, between 06/2012 and 09/2017, were included and the data were reviewed retrospectively. Six hundred forty-two uniportal VATS procedures were performed. Among those, 12 emergency cases could be identified. The indication was a hemothorax with active bleeding in all cases and the uniportal VATS approach was carried out after carefully evaluating all clinical factors and risks related to such a special setting. The location, extent and severity of the injuries were diagnosed and treated intraoperatively. The conversion rate was zero. The mean surgical time was 106.25 minutes [63-240], the chest tube was removed after 6.75 days in average (range, 1-25). All patients were transferred to the post anesthesia care unit (PACU) or intensive care unit (ICU) for at least one night (range, 1-25). The mean postoperative hospital stay was 10.67 days [4-26]. In expert hands, uniportal VATS approach seems to be a safe and feasible procedure for both, the diagnostics and management of emergency cases, such as active thoracic bleeding in cardiopulmonary stable patients.

In reply Trauma pneumonectomy for major thoracic bleeding

In reply Trauma pneumonectomy for major thoracic bleeding

Thoracic Bleeding Complications in Patients With Venovenous Extracorporeal Membrane Oxygenation

Patients with respiratory failure are treated more frequently with venovenous extracorporeal membrane oxygenation (vv-ECMO). These patients are atrisk for bleeding due to complex multifactorial coagulation disorders resulting from the extracorporeal circulation. A retrospective analysis was conducted of prospectively collected data on all patients requiring vv-ECMO between December 2010 and December 2016. End points were the incidence, consequence, and in-hospital mortality of patients with thoracic bleeding complications. The study included 418 patients (aged 50 ± 16.5 years) requiring vv-ECMO. In 23.2% (n= 97) of patients, relevant hemorrhage was documented. Thoracic bleeding developed in 40 patients (41.2%), followed by diffuse (21.6%), cerebral (14.4%), gastrointestinal (6.2%), cannulation site (6.2%), and other bleeding locations. Thoracic bleeding complications occurred spontaneously (40%), postoperatively (37.5%), after interventions (20%), and after trauma (2.5%). A thoracic operation was performed in 60% (n= 24) of these patients, and a repeated operation due to bleeding was necessary in 45.8%. Mean ECMO duration (18.6 ± 16.8 days; p= 0.035) and hospital length of stay (58 ± 50 days; p= 0.002) were significantly longer than that in patients without bleeding. In-hospital mortality was significantly higher in patients with thoracic bleeding complications (52.5%) than in patients without bleeding complications (32.7%; p= 0.013). Thoracic bleeding complications were observed in 9.6% of patients and represented the most frequent bleeding complication during vv-ECMO treatment. Almost 60% of patients required surgical revision, and nearly half of these patients underwent a repeated operation. Because mortality is high in these patients, vv-ECMO should be performed in only centers experienced with thoracic surgery.

Abstract No. 667 Transcatheter arterial embolization for traumatic thoracic bleeding: 4-year experiences in a single trauma center

We aimed to assess the safety and efficacy of transcatheter arterial embolization (TAE) for thoracic arterial hemorrhage following chest trauma. From November 2013 to May 2017, 35 patients were referred to our interventional unit for thoracic arterial bleeding following chest trauma, based on clinical decisions and computed tomography (CT) images. A total of 35 patients (male:female ratio, 26:9; mean age, 52.9 years) who underwent selective TAE of thoracic hemorrhage-culprit arteries were included in this study. Technical and clinical success, complications, and 30-day mortality rate were analyzed. In 35 patients who underwent TAE, the main bleeding arteries were intercostal artery (n=23), internal mammary artery (n=11) superior and/or lateral thoracic artery (n=3), and bronchial artery (n=3). N-butyl-2-cyanoacrylate (NBCA) (n=21), gelatin sponge particles (n=7), microcoils (n=2), and combinations of NBCA, microcoils, or gelatin sponge particles (n=10) were used as embolic agents. Initial technical success was achieved in all 27 patients, with immediate cessation of bleeding. Eight patients showed rebleeding 1-2 days later and underwent repeated TAE with successful result. Clinical success rate was 85.7% (30/35), and five patients underwent thoracotomy for controlling residual bleed. There were no TAE-related major complications such as infarction or quadriplegia. The 30-day mortality rate was 5.7% (2/35). Our clinical experience suggests that TAE used to control thoracic arterial bleeding following chest trauma is safe and effective as a minimally invasive treatment alternative to surgery.

Successful support of biventricular heart failure patients by new EXCOR® Adult pumps with bileaflet valves: a prospective study.

The Berlin Heart EXCOR® Adult biventricular assist device (BiVAD) is an approved mechanical circulatory support for patients with end-stage biventricular heart failure. In this prospective post-market clinical follow-up study, we present the first clinical experience of the new EXCOR® Adult pump with bileaflet (BL) valves in Europe. After CE-mark approval in August 2014, a total of 12 patients were enrolled with a mean age of 44years ± 11 (range 21-58years). The majority of patients (n = 11) were in INTERMACS level 1 or 2. Eight patients had a median pre-operative extracorporeal life support (ECLS) of 6days (range 1-37days). Primary end point was survival, either to heart transplantation (HTx), recovery or alive at 12months on device, whichever occurred first. Secondary end point was the number of adverse events throughout EXCOR® BiVAD support. Median support time up to last follow-up on EXCOR® BiVAD device was 248days (range 57-381days) and patient survival at 1year was 92%. Half of the EXCOR® BiVAD patients (n = 6) were transplanted and five patients were still on support at 1year post-implantation. Complications during EXCOR® BiVAD support were thoracic bleeding, exit site infection and ischemic cerebrovascular incidents in three cases, respectively. The new EXCOR® Adult pump with BL provides pulsatile high cardiac output with excellent outcome and successful bridging to HTx, particularly in critically ill patients with INTERMACS level 1 or 2at the time of implantation.