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Aims We aim to evaluate the clinical relevance and the prognostic value of arterial and venous renal Doppler in acute decompensated precapillary pulmonary hypertension (PH). Methods and results The renal resistance index (RRI) and the Doppler-derived renal venous stasis index (RVSI) were monitored at admission and on Day 3 in a prospective cohort of precapillary PH patients managed in intensive care unit for acute right heart failure (RHF). The primary composite endpoint included death, circulatory assistance, urgent transplantation, or rehospitalization for acute RHF within 90 days following inclusion. Ninety-one patients were enrolled (58% female, age 58 ± 16 years). The primary endpoint event occurred in 32 patients (33%). In univariate logistic regression analysis, variables associated with RRI higher than the median value were non-variable parameters (age and history of hypertension), congestion (right atrial pressure and renal pulse pressure), cardiac function [tricuspid annular plane systolic excursion (TAPSE) and left ventricular outflow tract- velocity time integral], systemic pressures and NT-proBNP. Variables associated with RVSI higher than the median value were congestion (high central venous pressure, right atrial pressure, and renal pulse pressure), right cardiac function (TAPSE), severe tricuspid regurgitation, and systemic pressures. Inotropic support was more frequently required in patients with high RRI (P = 0.01) or high RVSI (P = 0.003) at the time of admission. At Day 3, a RRI value <0.9 was associated with a better prognosis after adjusting to the estimated glomerular filtration rate. Conclusion Renal Doppler provides additional information to assess the severity of patients admitted to the intensive care unit for acute decompensated precapillary PH. [ABSTRACT FROM AUTHOR]

The article discusses the challenges and potential solutions for total tracheal replacement. Four main solutions are currently being investigated: composite autologous tissues construct, decellularized aortic allograft, 2 steps chimeric tracheal allograft, and complete bioengineered construct. The authors describe their own technique using a forearm free flap armed with custom-carved costal cartilage grafts, but acknowledge that their construct lacks respiratory ciliated epithelium lining. They commend another innovative technique using a tubulated internal mammary perforator flap combined with the Ravitch procedure, but highlight the need for further research to address unresolved questions and demonstrate the effectiveness of these techniques. [Extracted from the article]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Direct involvement of the superior vena cava (SVC) by non-small cell lung cancer (NSCLC) requires en-bloc tumour resection with complete vascular clamping and prosthetic replacement. We report the outcomes of this highly demanding procedure in the largest patient cohort to date. METHODS We searched our institution's database for patients who underwent complete en-bloc resection of NSCLC invading the SVC followed by prosthetic SVC replacement, between 1980 and 2018. Patients with cN2, cN3 or distant metastases were not eligible. RESULTS We identified 48 patients (38 males, 10 females; mean age of 57 years; tumour size, 1.9–17 cm). Neoadjuvant therapy was administered to 17 and adjuvant therapy to 31 patients. R0 resection was achieved in 41 (85%) patients; lymph node involvement was pN0 in 8, pN1 in 23, pN2 in 14 and pN3 in 3 patients. Five patients died within 30 days of surgery. Right pneumonectomy was significantly associated with postoperative death (P  =   0.02). Postoperative complications developed in 13 other patients. No neurologic events related to SVC clamping occurred. Graft thrombosis developed in 2 patients. Median survival was 24 months; 3-, 5- and 10-year survival rates were 45%, 40% and 35%, respectively; and corresponding disease-free survival rates were 37%, 37% and 30%, respectively. By univariable analysis, only margin-free (R0) resection was associated with better survival (P  =   0.02). CONCLUSIONS In highly selected patients with NSCLC involving the SVC, mortality is acceptable after complete en-bloc resection and prosthetic replacement done in an expert centre. SVC involvement should not preclude consideration of curative resection in selected patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES Extracorporeal membrane oxygenation (ECMO) has become the standard of cardiopulmonary support during a sequential double lung transplant for pulmonary hypertension. Whether central or peripheral cannulation is the best strategy for these patients remains unknown. Our goal was to determine which is the best strategy by comparing 2 populations of patients. METHODS We performed a single-centre retrospective study based on an institutional prospective lung transplant database. RESULTS Between January 2011 and November 2016, 103 patients underwent double lung transplant for pulmonary hypertension. We compared 54 patients who had central ECMO (cECMO group) to 49 patients who had peripheral ECMO (pECMO group). The pECMO group had significantly more bridged patients who received emergency transplants (31% vs 6%, P  = 0.001). The incidence of Grade 3 primary graft dysfunction requiring ECMO (14% vs 11%, P  = not significant) and of in-hospital mortality (11% vs 14%, P  = not significant) was similar between the groups. Groin infections (16% vs 4%, P  = 0.031), deep vein thrombosis (27% vs 11%, P  = 0.044) and lower limb ischaemia (12% vs 2%, P  = 0.031) occurred significantly more often in the pECMO group. The number of chest reopenings for bleeding or infection was similar between the groups. The 3-month, 1-year and 5-year survival rates did not differ between the groups (P  = 0.94). CONCLUSIONS Central or peripheral ECMO produced similar results during double lung transplant for pulmonary hypertension in terms of in-hospital deaths and long-term survival rates. Central ECMO provided satisfactory results without major bleeding provided the patient was weaned from ECMO at the end of the procedure. Despite the rate of groin and lower limb complications, peripheral cannulation remained the preferred solution to bridge the patient to transplant or for postoperative support. [ABSTRACT FROM AUTHOR]

OBJECTIVES The management of malignant tumours invading the inferior vena cava (IVC) generally requires a high-risk surgery with low long-term benefits. Surgical treatment with resection and/or embolectomy of the IVC may, however, be beneficial in selected patients. We describe our experience with regard to patient selection, operative technique and outcomes through a standardized and simplified approach. METHODS Between 1996 and 2012, 37 patients underwent extended resection of malignant tumours invading the IVC. Tumour infiltration was located at the hepatic and suprahepatic segment in 23 patients (62%), the renal segment in 6 (16%), and the infrarenal segment in 8 (24%). Fourteen patients (38%) had right heart involvement, of whom 5 had a tumour thrombus located in the pulmonary arteries (PA). RESULTS All the patients underwent a median laparotomy. A sternotomy with full liver mobilization was performed for tumours involving the PA, or the retrohepatic or supradiaphragmatic IVC. Cardiopulmonary bypass was performed in 15 patients (41%), with deep hypothermic circulatory arrest (DHCA) in 5 (14%). The 30-day mortality rate was 5.4%. The 1-, 5- and 10-year survival rates were 68.1, 45.7 and 40%, respectively, with a median survival of 18 months. Incomplete resection (R1 or R2) was the only parameter found to have a significant negative effect on survival (P = 0.003). CONCLUSIONS Radical resection of malignant tumours invading the IVC is feasible in carefully selected patients and may require CPB with or without DHCA. Morbidity and mortality are low and the survival rates acceptable, particularly in patients with complete resection of the tumour. [ABSTRACT FROM PUBLISHER]

OBJECTIVES Local breast cancer recurrence is often viewed as an early sign of rapidly progressive metastatic disease for which chest wall resection (CWR) can provide no benefits. We retrospectively reviewed our experience with full-thickness CWR to determine whether long-term outcomes warranted this aggressive procedure. METHODS Between 2001 and 2012, 33 women (mean age, 50.7 years; range, 33–72 years) underwent en-bloc CWR with curative intent. Mean disease-free interval from initial tumour resection was 90.5 months (range, 2–252 months). Resection included skin, muscle and an average of 2.7 ribs (range, 1–8 ribs) and was extended to the sternum (n = 21), subclavian vessels (n = 9), lung (n = 8), pericardium (n = 8), phrenic nerve (n = 2) or T1 nerve root (n = 1). Complete R0 resection was achieved in 31 (94%) patients. Chest wall reconstruction was performed in 28 patients, with polytetrafluoroethylene mesh (n = 17) or titanium ribs (n = 11). A musculocutaneous flap was used in 17 (52%) patients. RESULTS Postoperative morbidity was 36%, with no deaths. Median follow-up was 33 months (range, 3–96 months). Median survival was 69 months and 1-, 3- and 5-year survival rates were 100, 81 and 63%, respectively. Recurrence developed in 13 patients, including 12 with distant metastases. Disease-free survival rates were 77, 57 and 50% after 1, 3 and 5 years, respectively. By univariate analysis, only resection extended to intrathoracic structures was associated with better survival (P = 0.033). CONCLUSIONS En-bloc full-thickness CWR eventually extended to adjacent structures provides acceptable morbidity and excellent long-term survival and should be considered the treatment of choice in locally recurrent breast cancer. [ABSTRACT FROM AUTHOR]

OBJECTIVES The study aimed to determine the optimal surgical procedure to treat pulmonary artery sarcomas responsible for pulmonary hypertension. METHODS Between 1997 and 2010, 31 patients were treated surgically for pulmonary artery sarcomas. Sixteen patients were male; the mean age was 56 years (range, 26–78 years). Common symptoms were characteristic of acute or chronic pulmonary thromboembolic disease. Also, 21 patients experienced mild to severe pulmonary hypertension, with a mean total peripheral resistance of 473 dyn s cm−5. Clinical presentation and preoperative work-up confirmed the suspicion of pulmonary artery sarcoma in 18 patients. The required surgical procedures included the following: pulmonary endarterectomy in 25 patients (combined with a right pneumonectomy in five and with a replacement of the main pulmonary artery by a homograft reconstruction in one), pneumonectomy only in five (three right and two left), with the use of cardiopulmonary bypass in three cases. In one patient, the right pulmonary artery only was replaced on cardiopulmonary bypass. RESULTS Final pathology showed 26 high-grade and five intermediate-grade sarcomas. The 30-day mortality was 13% (four patients). Repeat pulmonary resection was required in two patients due to recurrent disease. Moreover, 18 patients received adjuvant therapy. Mean follow-up was 19 months (range, 1–99 months); of the 11 patients alive at follow-up, four were noted to have recurrent disease. The 1-, 3- and 5- year survival was 63, 29 and 22%, respectively. CONCLUSIONS The prognosis of this very infrequent disease remains poor. Bilateral pulmonary endarterectomy may yield significant survival rates because it provides completeness of resection without sacrificing the pulmonary vascular bed. [ABSTRACT FROM AUTHOR]

OBJECTIVES The postoperative course following sternectomy for cancer carries significant morbidity due to paradoxical breathing, pulmonary infections and infectious complications. The purpose of this report is to evaluate the outcomes in patients undergoing sternal reconstruction using an innovative titanium rib bridge system (STRATOS). METHODS From 2008 to 2011, 24 patients underwent sternectomy with a titanium rib bridge system reconstruction. Soft coverage tissue was performed concurrently using a prosthetic mesh and pedicled or free flaps. Postoperative data were collected prospectively. RESULTS The median age was 56 (31–85 years). The indications for sternal resection were primary sarcoma (n = 4), metastasis (n = 15) and radiation-induced sarcoma (n = 5). Twenty-one subtotal and three total sternectomies were performed. Resection margins included the anterior rib (n = 13, mean: 2/patient), clavicles (n = 9), breast (n = 4), superior vena cava (n = 1), pericardium (n = 5), phrenic nerve (n = 4), lung (n = 6) and diaphragm (n = 1). The stability of the chest wall typically required an average of two titanium bars and rib clips per patient. There was no perioperative mortality. Twenty-three patients were extubated within the first 24 h. The mean intensive care unit and hospital stay was 3.5 and 14 days, respectively. Wound infection did occur in one patient but did not require the removal of the titanium rib system. The postoperative forced expiratory volume in 1 s did not differ significantly from the preoperative status (P = 0.07). CONCLUSIONS After sternectomy for cancer, reconstruction with a titanium rib bridge system has low morbidity and permits a rapid return to baseline pulmonary mechanics. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Whether double-lung transplantation (DLT) or heart–lung transplantation (HLT) is the best option in patients with pulmonary hypertension (PH) remains unclear. At our institution, patients with severe right ventricular dysfunction or congenital systemic-to-pulmonary shunt (CSPS) are preferentially treated with HLT. We sought to determine whether the outcomes warrant continuing this policy. Methods: We retrospectively reviewed cases of DLT (n =67) or HLT (n =152) performed for end-stage PH between 1986 and 2008 at our institution. According to the new clinical classification of PH, 147 patients were group I (pulmonary arterial hypertension group, of which 30 had CSPS), 24 were group III (PH associated with lung disease and/or hypoxaemia), 20 were group IV (chronic thrombo-embolic PH) and 20 were group V (sarcoidosis or histiocytosis X). Results: Compared with the HLT group, the DLT group had less severe disease as reflected by a higher preoperative cardiac index (2.5±0.8 vs 2.0±0.4; P =0.0006), lower New York Heart Association (NYHA) functional class (3.4±0.4 vs 3.8±0.5; P <0.0001), lower rates of kidney failure (31% vs 66%; P <0.0001) and liver failure (13% vs 38%; P =0.0003) and less need for preoperative inotropic support (10% vs 25%; P =0.014). Nevertheless, survival after 1, 5, 10 and 15 years was not significantly different between the two groups (HLT group: 70%, 50%, 39% and 26%; and DLT group: 79%, 52%, 43% and 30%; respectively; P =0.932). Freedom from obliterative bronchiolitis-related death was significantly greater in the HLT group (100% at 1 year, 84% at 5 years and 74% at 10 years; compared with 98%, 70%, and 59%, respectively, in the DLT group; P =0.035). Conclusions: In patients with end-stage PH, good long-term survival rates were obtained using either DLT or HLT. However, these results were achieved with preferential use of HLT in patients with right heart failure or CSPS. Obliterative bronchiolitis-related death was less common with HLT than with DLT. [Copyright &y& Elsevier]

OBJECTIVES Locally advanced thymoma can often involve the phrenic nerve (PN) due to its location on the mediastinal pleura. However, en bloc resection including the PN may cause severe postoperative complications, especially in myasthenia gravis patients. The aim of the study was to determine whether a PN involved could be spared during thymoma resection. METHODS A retrospective study was conducted on patients who underwent resection of Masaoka Stage III and IV thymomas adherent, on digital palpation, to at least one PN in our institution between 1998 and 2012. An en bloc resection of the tumour with the invaded PN was performed unless patients with no preoperative PN paralysis had: both PN involved, compromised preoperative lung function, severe myasthenia gravis, severe comorbidities or minimal PN involvement (PN adherent to the edge of the tumour). All patients received postoperative radiation therapy. RESULTS There were 114 patients with a mean age of 57 years (range, 28–84). PN was spared in 73 patients (64%) and removed in 41 (36%). Sixty-five patients had Masaoka Stage III (57%) and 49 had Stage IV (43%); these were similar between both groups. On permanent histology, 6 (15%) of the resected PN were not involved, whereas a permanent postoperative PN palsy was found in 4 (5.4%) patients where the PN was spared. Postoperative mortality and morbidity were 0 and 15% in the spared group and 2.4 and 9.7% in the resected group, respectively (P = 0.56). Recurrence rate was significantly higher in the spared group (39.5 vs 19.5%; P = 0.02) but the 5-year disease-free survival rates (53.6 vs 66.8%, P = 0.14) and overall 5-year survival (85 vs 88%, P = 0.6) were not significantly different between the spared- and resected-PN groups, respectively. CONCLUSIONS Sparing the PN during thymoma resection achieved good long-term and disease-free survivals in high-risk patients comparable with en bloc PN resection. However, it carried a higher risk of recurrence despite adjuvant radiation therapy. [ABSTRACT FROM AUTHOR]

OBJECTIVE Platinum-based chemotherapy followed by surgical resection of residual masses has become the standard treatment of patients with primary mediastinal non-seminomatous germ cell tumours (NSGCTs). Persistent serum tumour marker (STM) elevation after chemotherapy usually indicates a poor prognosis. We retrospectively assessed surgical outcomes in patients with high STM levels after chemotherapy for primary mediastinal NSGCT. METHODS Between 1983 and 2010, residual tumour excision was performed in 21 patients, 20 men and one woman with a median age of 30 years (range: 19–49 years), with primary mediastinal NSGCTs and high STM levels after platinum-based chemotherapy, followed by second-line chemotherapy in 11 patients. RESULTS Alpha-fetoprotein was elevated in all 21 patients and β-human chorionic gonadotropin in three patients. Permanent histology demonstrated viable germ cell tumour (n = 13), teratoma (n = 3) or necrosis (n = 5). After surgery, the STM levels returned to normal in 11 patients. Eight patients are alive with a median follow-up of 98 months. The 5-year survival rate was 36% and was not significantly affected by the use of preoperative second-line chemotherapy. At univariate analysis, only postoperative STM elevation and residual viable tumour, indicating incomplete resection, were significantly associated with lower survival (P = 0.018 and P = 0.04, respectively). CONCLUSION In patients with primary mediastinal NSGCTs and elevated post-chemotherapy STMs, surgery is warranted when complete resection is deemed feasible. In specialized oncology centres, this aggressive approach can provide a cure in some patients. [ABSTRACT FROM PUBLISHER]

Abstract: Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n =19; local recurrence, n =17; or metastasis, n =11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p =0.005), coronary artery disease (p =0.03), removal of the right lung (p =0.02), advanced age (p =0.02), and renal failure (p <0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p =0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p =0.04) and mechanical stump closure (p =0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival. [Copyright &y& Elsevier]

Abstract: Objective: Because pleuropneumonectomy is associated with a high mortality rate, its indication for the treatment of Masaoka stage IVa thymoma is debated. We reviewed retrospectively our single-center experience in order to determine if the benefits warrant the risk of such procedure. Methods: Between 1970 and 2009, 17 patients (12 men and 5 women) with a mean age of 44 years (range, 25–62 years) underwent a pleuropneumonectomy for a Masaoka stage IVa thymoma in our institution. Eight patients had recurrent thymoma after a mean postoperative period of 47±28 months, and nine patients presented de novo with stage IVa disease. A multimodality treatment including chemotherapy, radiotherapy, or both was performed in 14 (82%) patients. Results: Eight patients (47%) experienced a major postoperative complication, including four broncho-pleural fistulae (23%). There were no operative deaths and the 30-day mortality was 17.6% (3/17). But two patients died at 2 and 3 months, increasing the postoperative mortality to 29.4% (5/17). Complete resection was achieved in 11 (65%) patients. By univariate analysis, myasthenia gravis was the only risk factor for broncho-pleural fistulae. With a median survival of 76 months and median follow-up of 59 months (range, 1–262 months), 5-year and 10-year survivals were 60% and 30%, respectively. During follow-up, a recurrence occurred in two patients at 26 and 87 months, respectively, which was treated medically without success. Conclusions: Pleuropneumonectomy for Masaoka stage IVa thymoma is associated with a high morbid-mortality rate. However, included in a multimodality strategy and in highly selected patients this procedure may provide good long-term survival. [Copyright &y& Elsevier]