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Background Minimally invasive surgery, stereotactic radiotherapy, and radiofrequency ablation are commonly proposed in the case of pulmonary colorectal-metastasis as alternatives to conventional open surgery. Preoperative imaging assessment by computed tomography (CT) scan and fluorodeoxyglucose positron emission tomography (FDG-PET) are critical to guide oncologic radical treatment. Our aim was to investigate the accuracy of CT and FDG-PET for the evaluation of the number of pulmonary colorectal metastases and thoracic lymph nodal involvement (LNI). Methods Patients who underwent lung surgical resection for pulmonary colorectal metastases from 2004 to 2014 were analyzed. Concordance between histology, CT scan, and FDG-PET findings were assessed. Results Data of 521 patients were analyzed. Of those, FDG-PET was performed in 435 (83.5%). A moderate agreement between both CT scan (kappa index: 0.42) and FDG-PET (kappa index: 0.42) findings and the histologically proven number of metastases was observed. The number of histologically proven metastases was correctly discriminated in 61.7% of cases with CT scan and in 61.8% of cases with FDG-PET. Multiple metastases were discovered in 20.9% of clinical single metastasis cases with CT scan, and in 24.4% of those cases with FDG-PET. One hundred fifty patients (29.1%) presented with pathologic LNI. A poor agreement was observed between LNI and CT scan findings (kappa index: 0.02), and a weak agreement was observed concerning LNI and FDG-PET findings (kappa index: 0.39). Conclusions Computed tomography and FDG-PET have limitations if the objective is to detect all malignant nodules and to discriminate the LNI in cases of pulmonary metastases of colorectal cancer. [ABSTRACT FROM AUTHOR]

Background Postpneumonectomy acute respiratory distress syndrome (ppARDS) is a life-threatening condition with a disastrous prognosis. This study assessed the efficacy of venovenous extracorporeal membrane oxygenation (VV-ECMO) in adult patients with unresponsive severe ppARDS. Methods We retrospectively reviewed data of all patients treated with VV-ECMO for ppARDS from January 2009 to December 2015. We calculated the Sequential Organ Failure Assessment score before ECMO insertion and monitored the subsequent mechanical ventilation settings. The primary end point was hospital survival. The secondary end point was the ability to achieve a protective ventilatory strategy allowing lung recovery on ECMO. Results VV-ECMO was indicated in 8 ppARDS patients for refractory hypoxemia (median partial pressure of arterial oxygen/fraction of inspired oxygen: 68 [range, 60 to 75] mm Hg). Median Sequential Organ Failure Assessment before ECMO was 15 (range, 12 to 17), predicting a mortality rate greater than 80%. Median duration of ECMO was 9.5 (range, 5 to 16) days. Tidal volumes and plateau pressures both decreased on ECMO (pre-ECMO tidal volume: 412 [range, 250 to 450 mL] vs ECMO tidal volume: 277 [range, 105 to 367 mL], p = 0.0156; pre-ECMO plateau pressure: 34 [range, 32 to 40] cm H 2 O vs ECMO plateau pressure: 24.5 [range, 23.3 to 27.3] cm H 2 O, p = 0.0195). ECMO could be weaned in 7 patients (87.5%). Hospital survival was 50%. Conclusions Hospital survival was better than predicted before ECMO insertion. In severe and refractory ppARDS, VV-ECMO allows lung recovery and therefore increased survival. [ABSTRACT FROM AUTHOR]

Background Clinical guidelines are created to reduce variation in care practices, with the goal of improving patient outcomes. There is currently no international consensus on best practices for pulmonary resection. Our aim was to evaluate variation in treatment patterns and outcomes for pulmonary resection by comparing The Society of Thoracic Surgeons (STS) and the European Society of Thoracic Surgery (ESTS) general thoracic surgery databases (GTSDs). Methods An international collaboration was established between the STS and ESTS GTSD task forces. Patients who underwent pulmonary resection between 2010 and 2013 were identified from the 2 databases. Data on patient demographics, disease characteristics, treatment strategies, morbidity, and mortality were compared. Results There were 78,212 lung resections captured in the STS (n = 47,539) and ESTS databases (n = 30,673). Patients from the STS database were more likely to be of the female sex, have no pathologic N2 disease, have had previous cardiothoracic operations, and have received preoperative thoracic irradiation compared with patients from the ESTS database. In addition, patients from the STS database were more likely to have undergone a thoracoscopic operation and have received a sublobar resection. Although there was an increased risk of reintubation, atrial arrhythmias, and return to the operating room in the STS patients, the mean hospital length of stay was shorter than in patients from the ESTS database, regardless of operation performed. Thirty-day mortality was higher in the STS patients for wedge resection ( p < 0.001) but lower for lobectomy ( p < 0.001) and pneumonectomy ( p < 0.001) compared with the ESTS patients. Conclusions Differences exists in patient population, procedures performed, and outcomes for pulmonary resections between the STS and ESTS databases, suggesting an opportunity for quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Background Bronchopleural fistula (BPF) remains a rare but fatal complication of thoracic surgery. The aim of this study was to develop and validate a predictive model of BPF after pulmonary resection and to identify patients at high risk for BPF. Methods From January 2005 to December 2012, 34,000 patients underwent major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) and were entered into the French National database Epithor. The primary outcome was the occurrence of postoperative BPF at 30 days. The logistic regression model was built using a backward stepwise variable selection. Results Bronchopleural fistula occurred in 318 patients (0.94%); its prevalence was 0.5% for lobectomy (n = 139), 2.2% for bilobectomy (n = 39), and 3% for pneumonectomy (n = 140). The mortality rate was 25.9% for lobectomy (n = 36), 16.7% for bilobectomy (n = 6), and 20% for pneumonectomy (n = 28). In the final model, nine variables were selected: sex, body mass index, dyspnea score, number of comorbidities per patient, bilobectomy, pneumonectomy, emergency surgery, sleeve resection, and the side of the resection. In the development data set, the C-index was 0.8 (95% confidence interval: 0.78 to 0.82). This model was well calibrated because the Hosmer-Lemeshow test was not significant (χ 2 = 10.5, p = 0.23). We then calculated the logistic regression coefficient to build the predictive score for BPF. Conclusions This strong model could be easily used by surgeons to identify patient at high risk for BPF. This score needs to be confirmed prospectively in an independent cohort. [ABSTRACT FROM AUTHOR]

We report a case of partial anomalous pulmonary venous return from the left upper lobe in a donor lung discovered during lung transplantation. The upper lobe vein could be implanted successfully into the donor atrial cuff to restore physiologic venous drainage. The abnormality was retrospectively identified on the donor’s chest computed tomographic scan. Cardiac magnetic resonance imaging performed in the recipient 6 months after transplantation demonstrated patent left pulmonary venous drainage. This is the third reported case of partial anomalous pulmonary venous return in a donor lung, but the first description of direct ex vivo suture into the donor cuff. [ABSTRACT FROM AUTHOR]

Background Few randomized controlled trials have been published on outcomes after treatment of spontaneous pneumothorax. The objective of this study was to assess recurrence, pulmonary complications, prolonged air leak, and hospital duration of stay in patients undergoing videothoracoscopic surgery (VATS) or thoracotomy for spontaneous pneumothorax. Methods From January 2005 to December 2012, 7,396 patients underwent operations for spontaneous pneumothorax and were entered into the French national database. The propensity score, which is the conditional probability of assignment to a particular treatment given a vector of observed covariates, was used for the analysis. Three statistical analyses were performed: matching, subclassification, and the inverse probability of treatment weighting. The primary end point was recurrence, defined as a pneumothorax requiring a chest tube or new operation. The secondary end point was pulmonary complications, prolonged air leak, and hospital duration of stay. Results VATS was performed in 6,419 patients and thoracotomy in 997 patients. Pleurodesis was performed by abrasion or pleurectomy in 5,873 patients (79%) and by using a chemical agent in 1,523 patients (21%). The median time to recurrence was 3 months (range, 1 to 76 months). The recurrence rate was higher in the VATS group regardless of the statistical analysis that was used: 2.1 for unmatched samples, 2.5 for matched samples, 2.3 for subclassification, and 1.7 for the inverse probability of treatment weighting. VATS significantly reduced the hospital duration of stay by 1 day but did not significantly reduce pulmonary complications or prolonged air leak. Conclusions VATS reduced the hospital duration of stay, but the risk of recurrence was higher. This information should be delivered to patients before pneumothorax operations. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to better characterize prolonged air leak (PAL), defined as an air leak longer than 7 days, and to develop and validate a predictive model of this complication after pulmonary resection. Methods: All lung resections entered in Epithor, the French national thoracic database (French Society of Thoracic and Cardiovascular Surgery), were analyzed. Data collected between 2004 and 2008 (n = 24,113) were used to build the model using backward stepwise variable selection, and the 2009 data (n = 6,813) were used for external validation. The primary outcome was PAL. Results of the predictive model were used to propose a score: the index of PAL (IPAL). Results: Prevalence of PAL after pulmonary resection was 6.9% (n = 1,655) in the development data set. In the final model, 9 variables were selected: gender, body mass index, dyspnea score, presence of pleural adhesions, lobectomy or segmentectomy, bilobectomy, bulla resection, pulmonary volume reduction, and location on upper lobe. In the development data set, the C-index was 0.71 (95% confidence interval [CI], 0.70 to 0.72). At external validation, the C-index was 0.69 (95% CI, 0.66 to 0.72) and the calibration slope (ie, the agreement between observed outcomes and predictions) was 0.874 (<1). A score chart based on these analyses has been proposed. The formula to calculate the IPAL is the following: gender (F = 0; M = 4) - (body mass index-24) + 2 × dyspnea score + pleural adhesion (no = 0; yes = 4) + pulmonary resection (wedge = 0; lobectomy or segmentectomy = 7; bilobectomy = 11; bulla resection = 2; volume reduction = 14) + location (lower or middle lobe = 0; upper = 4). Conclusions: Surgeons can easily use the well-validated model to determine intraoperative preventive measures of PAL. [ABSTRACT FROM AUTHOR]

Background: The aim of this prospective study, based on the iterative completion of the 36-item short form health survey questionnaire (SF36) after open heart surgery, was twofold: to evaluate the changes in quality of life (QOL) scores (over time and by gender, and also in comparison with scores from a normal population) and to identify possible gender differences in two-year cardiac functional status. Methods: From July 2000 to July 2002, 590 elective patients were included in this study. Baseline and follow-up QOL surveys were obtained for 439 patients (307 males and 132 females). The QOL scores were compared by gender, by analysis of variance, and by the Student t test. Factors influencing two-year cardiac functional status were determined by logistic regression. Results: The comparison of baseline and follow-up scores showed a significant improvement (a sharp increase between baseline and year one, then stabilization) in all dimensions of the SF36, two years after surgery in all patients. However, QOL was significantly lower in women than in men in all but two dimensions; at baseline and during follow-up. When compared with the normal population, men and women over 75 had a similar QOL. The best independent predictive factor of two-year cardiac functional status in women was the physical component summary score and in men, the mental component summary score. Conclusions: The benefit of open heart surgery at two-year follow-up is equivalent in both genders in terms of QOL, although women had lower baseline QOL scores. [Copyright &y& Elsevier]

Background: The choice of myocardial revascularization strategy for the right coronary artery (RCA) in patients with multivessel disease and chronic stable angina remains controversial. Our aim was to determine the better strategy—hybrid, combining bypass of the left coronary network and percutaneous coronary intervention of the RCA, or exclusively surgical—and if the latter, the best conduit. Methods: We used decision analysis, a modeling technique, to compare two RCA revascularization strategies: surgical grafting and percutaneous coronary intervention. A review of the English language literature determined the variables for each strategy. All possible outcomes of each strategy were analyzed to determine the baseline strategy yielding the highest expected effectiveness. Sensitivity analysis determined the most relevant elements in the model and indicated threshold values. Results: Arterial grafting of the RCA led to the highest expected effectiveness, respectively 6% and 7% higher than that of percutaneous coronary intervention and the saphenous graft procedure. Of the arteries available—the radial, right gastroepiploic, and right internal thoracic artery—the most effective was the right internal thoracic artery, pedicled for the proximal part of the RCA and free connected as a Y or a T to the pedicled left internal thoracic artery for the distal part of the RCA. Sensitivity analysis showed surgery to be the appropriate strategy when the expected 1-year patency rate of the arterial graft exceeded 80%. Conclusions: This analysis shows arterial grafting of the RCA to have better outcomes than percutaneous coronary intervention, and the right internal thoracic artery to be the best conduit. [Copyright &y& Elsevier]

Background: This prospective randomized study aimed to compare beating and arrested heart revascularization in patients undergoing first elective coronary artery bypass graft, with cardiac troponin I release used to evaluate myocardial injury.Methods: Seventy patients were randomly assigned to a beating or arrested heart revascularization group. Cardiac troponin I concentrations were measured in serial venous blood samples drawn preoperatively in both groups: after aortic unclamping at 6, 9, 12, and 24 hours in the arrested heart group and after the last anastomosis at 6, 9, 12, and 24 hours in the beating heart group. Analysis of covariance with repeated measures was performed to test the effect of group and time on cardiac troponin I concentration.Results: The total amount of cardiac troponin I released was higher in the arrested heart revascularization group than in the beating heart revascularization group (8.25 ± 6.16 vs 3.18 ± 4.75 μg, p < 0.0001). Cardiac troponin I concentrations were significantly higher in the arrested heart group at hours 6, 9, 12, and 24 than in the beating heart group (p < 0.0001).Conclusions: The lower release of cardiac troponin I in the beating heart revascularization group indicates that conventional coronary artery bypass graft with cardioplegic arrest causes more damage to the heart than off-pump myocardial revascularization. [Copyright &y& Elsevier]

: BackgroundOptimal management for patients presenting a second episode of spontaneous pneumothorax remains controversial. The aim of this study was to compare two possible treatment strategies, video-assisted thoracic surgery (VATS) and conservative management, in order to assess which of the two was better adapted for the treatment of the second episode of spontaneous pneumothorax.: MethodsThe authors propose a decision analytic model including a cost-effectiveness study to compare two clinical strategies: VATS (reference strategy) and conservative management (alternative strategy). Data were obtained from a Medline search for English language articles and cost estimates were derived from the financial and public health departments of our hospital. The model was analyzed to determine the baseline strategy leading to the highest expected effectiveness and the lowest expected cost.: ResultsConservative management offered a slight advantage in expected effectiveness value (99.99 vs 99.93 for VATS). VATS produced the lowest expected cost (€4347 vs €7536 for conservative management). The incremental cost-effectiveness ratio was €57,750. Within the ranges tested, the sensitivity analysis presented consistent results in terms of effectiveness and advocated conservative management as the best strategy. In terms of cost, with the exception of length of stay, the sensitivity analysis was insensitive in estimating the different probabilities, and favored VATS over conservative management.: ConclusionsIn the management of the second episode of spontaneous pneumothorax, VATS offers substantial savings in cost for only a slight decrease in effectiveness, when compared with conservative management. [Copyright &y& Elsevier]

: BackgroundCardiac troponin I (CTnI) has been shown to be a marker of myocardial injury. The aim of this prospective, randomized study was to compare intermittent antegrade warm cardioplegia with tepid blood cardioplegia in patients undergoing first elective coronary artery bypass graft, using CTnI release as the criterion for evaluating the adequacy of myocardial protection.: MethodsSeventy patients were randomly assigned to one of two cardioplegia groups. CTnI concentrations were measured in serial venous blood samples drawn immediately before cardiopulmonary bypass and after aortic unclamping at 6, 9, 12, and 24 hours. Analysis of covariance with repeated measures was performed to test the effect of the type of cardioplegia and time on CTnI concentration.: ResultsThe total amount of CTnI released (8.23 ± 20.5 μg in the warm group and 3.19 ± 2.4 μg in the tepid group) was not statistically different (p = 0.23). The CTnI concentration did not differ for any sample in either of the two groups when adjusted on ejection fraction and the number of preoperative myocardial infarctions (p = 0.06). No patient in the tepid group versus 4 patients in the warm group showed CTnI evidence of perioperative myocardial infarction (p = 0.12).: ConclusionsOur study showed no preference for warm or tepid cardioplegia in terms of myocardial protection, either for clinical or biological data. [Copyright &y& Elsevier]

Background. Quality of life (QOL) instruments help to integrate the patient’s view into clinical practice and into the evaluation of new therapeutic strategies. The aim of the present study was to determine which of two generic QOL instruments, the Nottingham Health Profile (NHP) or the Short Form Health Survey (SF36), was the more suitable for use in cardiac surgery.Methods. The NHP and the SF36 were compared before and 5 weeks after surgery. Comparison was conducted in two stages: (1) the acceptability and psychometric properties of the tools were measured, and (2) the short-time evolution of angina pectoris and dyspnea status were assessed with the QOL.Results. A total of 322 patients were included and 299 patients completed preoperative and postoperative questionnaires. Acceptability was similar for both questionnaires. Internal consistency, ceiling effect, sensitivity to change, as well as the assessment of the evolution of angina pectoris and dyspnea were better for the SF36 than for the NHP.Conclusions. The SF36 seems more suitable than the NHP for evaluating QOL in cardiac surgery. [Copyright &y& Elsevier]

Clamshell (bilateral anterolateral thoracotomy combined to transverse sternotomy) is an invasive surgical approach that is helpful in particular situations, especially bilateral lung transplantation. The closure technique remains challenging because clamshell incision can end with override, separation, or sternal pseudarthrosis complications. We describe the use of new absorbable sternal pins to stabilize the sternal closure and to help avoid additional sternal complications. [ABSTRACT FROM AUTHOR]

Bronchioloalveolar carcinoma is a rare, but well-known disease that symptomatically worsens with intrapulmonary shunting and consequent hypoxemia. Surgical resection of the involved area offers relief from disabling hypoxemia and may improve survival. We present 3 patients with intrapulmonary shunting. [Copyright &y& Elsevier]

We present a new pattern for tailoring the “π” graft that uses the advantages of the mammary loop technique. The two internal thoracic mammary arteries are skeletonized. The free right mammary artery is anastomosed end-to-side to the proximal part of the in situ left mammary artery to make a “Y” graft. The distal end of the left mammary artery is anastomosed end-to-side to the middle portion of the right one to form a loop with the two arteries. The loop is severed at the appropriate level at the time of the coronary anastomosis to form a “π” graft. This technique allows a more rational use of the length of the two mammary arteries, because the branch leading to the left anterior descending artery is measured and cut precisely at the time of the anastomosis. [Copyright &y& Elsevier]

We present a technique that permits the grafting of two vessels with the left internal thoracic artery when a sequential graft cannot be performed. The left internal mammary artery is anastomosed to itself resulting in a loop that will be cut open at the time of the coronary anastomosis. [Copyright &y& Elsevier]

Cryopreserved monobloc aorto-mitral homograft implantation to treat complex recurrent endocarditis involving the intervalvular fibrous body and both aortic and mitral orifices, as previously described, remains a technically demanding procedure. We report two cases of recurrent destructive aorto-mitral endocarditis treated by a monobloc aorto-mitral homograft implantation with encouraging results. [Copyright &y& Elsevier]

We present a new pattern for tailoring the "pi" graft that uses the advantages of the mammary loop technique. The two internal thoracic mammary arteries are skeletonized. The free right mammary artery is anastomosed end-to-side to the proximal part of the in situ left mammary artery to make a "Y" graft. The distal end of the left mammary artery is anastomosed end-to-side to the middle portion of the right one to form a loop with the two arteries. The loop is severed at the appropriate level at the time of the coronary anastomosis to form a "pi" graft. This technique allows a more rational use of the length of the two mammary arteries, because the branch leading to the left anterior descending artery is measured and cut precisely at the time of the anastomosis.

Background: The aim of this prospective study, based on the completion of the short form health survey questionnaire (SF36) before and 1-year after open heart surgery, was threefold: to evaluate the changes in quality of life (QOL) after open heart surgery, to determine the factors influencing QOL, and to assess the relation between preoperative QOL and 1-year cardiac functional status., Methods: Logistic regression was used to determine factors that influence patients' QOL scores and their 1-year cardiac functional status. Different groups were constituted in terms of 1-year cardiac functional status by means of an arborescent classification., Results: Comparison of preoperative and postoperative mean scores in the 293 patients included in the study revealed an improvement in all but three dimensions of the SF36 scale. Quality of life improved after operation in an average of 50% of patients. The most frequently found independent predictors of impairment after surgery were NYHA functional class III or IV and angina class III or IV. At 1 year, 64% of patients had satisfactory cardiac functional status. Independent predictive factors of 1-year cardiac functional status were: physical functioning, pain, general health problems, and coronary artery bypass graft. The arborescent classification indicated that the probability of having a "satisfactory" 1-year cardiac functional status was greater than 75% for patients with at least one preoperative QOL dimension above 75 on the scale., Conclusions: Preoperative QOL determined by the SF36 is predictive of 1-year cardiac functional status. Coronary artery bypass patients do not recover as well as patients having undergone heart valve surgery.