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Objectives The role of postoperative mediastinal radiotherapy in completely resected non-small cell lung cancer (NSCLC) and pathological N2 disease is controversial. In clinical practice, not all lung cancer patients with histologically confirmed N2 disease and a high risk for local recurrence are able to undergo postoperative concurrent radio/chemotherapy due to their physical condition or postoperative morbidities. Mediastinal radiotherapy is less compromising than a combination of radio/chemotherapy and seems likely to be tolerable for limited patients to achieve better local tumor control. Materials and Methods All patients included in this retrospective analysis were excluded from postoperative adjuvant combination chemo/radiotherapy due to their comorbidity, advanced age, or a complicated postoperative course. Three-dimensional conformal radiotherapy of the mediastinal lymph node stations (mean dose: 50 Gy; range: 50-54 Gy) in patients with R0 resection, additional boost of 10 Gy in patients with R1 or R2 resection, was performed postoperatively. Results A total of 110 patients were included in this analysis. Mean survival was 25.5 ± 19.2 months. The 1-, 3-, and 5-year survival was 75.4, 38.7, and 26.2%, respectively. Postoperative complications and the development of distant metastases did not correlate (p = 0.7). Distant metastases proved to be a significant prognostic factor of survival (p < 0.0001). Local recurrence was seen in a total of three patients (2.7%). Five-year survival of patients developing major postoperative complications was significantly inferior (p = 0.04) to those without postoperative complications. The extent of surgery had a significant impact on survival-5-year survival after lobectomy was significantly longer than after pneumonectomy (p = 0.029). R1 resection had no significant impact on the survival rates (p = 0.67). Discussion Stage III-N2 NSCLC patients with multiple comorbidities or a complicated postoperative course after surgery may benefit from modern mediastinal radiotherapy. Surgery and postoperative mediastinal radiotherapy can achieve local tumor control. Distant metastases have the highest impact on the prognosis. Pneumonectomy, however, should be avoided in stage III NSCLC, when possible., (Georg Thieme Verlag KG Stuttgart · New York.)

Treatment strategies for patients with pulmonary metastases of colorectal carcinoma are continuously evolving. This applies mostly to new systemic therapeutic approaches. For carefully selected patients surgical removal of pulmonary metastases remains an important interdisciplinary therapeutic option and is recommended as first treatment option by the guidelines. Five-year survival rates of up to 60 % are reported following pulmonary metastasectomy. Parenchyma sparing resection has been well established in this setting with low morbidity and mortality. Prognostic factors are, among others, complete resection, thoracic lymph node involvement, the number of metastases and the disease free interval. Although data result mostly from retrospective studies, these factors currently help in patient selection., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Patients with a forced expiratory volume in 1 s (FEV1) below 20% of the predicted normal values (pred.) and either homogeneous emphysema or low diffusing capacity for carbon monoxide (DLCO) have a high risk for adverse events including death when undergoing surgical lung volume reduction., Objectives: We hypothesized that selected patients can benefit from endoscopic lung volume reduction (eLVR) despite a very low FEV1., Methods: This study is a retrospective analysis of consecutive patients with severe airflow obstruction, an FEV1 ≤20% of pred., and low DLCO who were treated by eLVR with endobronchial valves (EBV) between June 2012 and January 2015. Pre- and postinterventional lung function parameters, the 6-min walking test (6-MWT) distance, adverse events, and follow-up were recorded., Results: In 20 patients, there was an overall improvement in lung function with an increase in FEV1 (16.97-21.03% of pred.) and a decrease in residual volume (322-270% of pred.) and total lung capacity (144-129.06% of pred.). The 6-MWT distance improved (from 239 ± 77 to 267± 97 m overall, and from 184 ± 50 to 237 ± 101 m if patients developed an atelectasis of the target lobe). Pneumothorax occurred in 5 of the 20 patients (25%). 30-day mortality was 0%, and all patients survived to discharge., Conclusions: The patients benefitted moderately from EBV treatment despite an initially low FEV1. Some patients improved remarkably. EBV treatment in patients with an FEV1 ≤20% of pred. is generally feasible and safe. The greatest risk is pneumothorax with prolonged chest tube duration., (© 2016 S. Karger AG, Basel.)

Purpose: Histological verification of pulmonary lesions is important to ensure correct treatment. Computed tomographic (CT) transthoracic core biopsy is a well-established procedure for this. Comparison of available studies is difficult though, as technical and patient characteristics vary. Using a standardized biopsy technique, we evaluated our results for CT-guided coaxial core biopsy in a semi-automatic technique., Materials and Methods: Within 2 years, 664 consecutive transpulmonary biopsies were analyzed retrospectively. All interventions were performed using a 17/18G semi-automatic core biopsy system (4 to 8 specimens). The incidence of complications and technical and patient-dependent risk factors were evaluated., Results: Comparing the histology with the final diagnosis, the sensitivity was 96.3%, and the specificity was 100%. 24 procedures were not diagnostic. In all others immunohistological staining was possible. The main complication was pneumothorax (PT, 21.7%), with chest tube insertion in 6% of the procedures (n = 40). Bleeding without therapeutic consequences was seen in 43 patients. There was no patient mortality. The rate of PT with chest tube insertion was 9.6% in emphysema patients and 2.8% without emphysema (p = 0.001). Smokers with emphysema had a 5 times higher risk of developing PT (p = 0.001). Correlation of tumor size or biopsy angle and the risk of PT was not significant. The risk of developing a PT was associated with an increasing intrapulmonary depth of the lesion (p = 0.001)., Conclusion: CT-guided, semiautomatic coaxial core biopsy of the lung is a safe diagnostic procedure. The rate of major complications is low, and the sensitivity and specificity of the procedure are high. Smokers with emphysema are at a significantly higher risk of developing pneumothorax and should be monitored accordingly., Key Points: Using an 18G core biopsy system with 6 specimens will allow immunohistological staining with high sensitivity and specificity. Smokers with emphysema are at a significantly higher risk of developing a pneumothorax., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Pulmonary metastasectomy is widely accepted for different malignant diseases. The role of mediastinal lymph node (LN) dissection in these procedures is discussed controversially. We evaluated our results of LN removal at the time of pulmonary metastasectomy with respect to the frequency of unexpected LN disease., Methods: This was a retrospective analysis of 313 resections performed in 209 patients. Operations were performed in curative intention. Patients with known thoracic LN involvement and those without lymphadenectomy (n = 43) were excluded. Patients were analyzed according the type of LN dissection. Subgroups of different primary cancers were evaluated separately., Results: Sublobar resections were performed in 256 procedures with lymphadenectomy, and 14 patients underwent lobectomy. Patients underwent radical lymphadenectomy (n = 158) or LN sampling (n = 112). The overall incidence of unexpected tumor in LN was 17% (radical lymphadenectomy, 15.8%; sampling, 18.8%). Unexpected LN involvement was found in 17 patients (35.5%) with breast cancer, in 120 (9.2%) with colorectal cancer, and in 53 (20.8%) with renal cell carcinoma. The 5-year survival was 30.2% if LN were tumor negative and 25% if positive (p = 0.19). LN sampling vs radical removal had no significant effect on 5-year survival (23.6% vs 30.9%; p = 0.29)., Conclusions: Dissection of mediastinal LN in resection of lung metastases will reveal unexpected LN involvement in a relevant proportion of patients, in particular in breast and renal cancer. Routine LN dissection appears necessary and may become important for further therapeutic decisions. On the basis of our data, LN sampling seems to be sufficient., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The benefits of surgical therapy of locally advanced non-small cell lung cancer (NSCLC) with infiltration of the superior vena cava (SVC) remains controversial. Here we describe our therapeutic approach and results of our intervention.A retrospective analysis of 22 patients with NSCLC who underwent SVC replacement (n = 17) or reconstruction (n = 5) between 1998 and 2013 was performed. Pneumonectomy was necessary in 16 patients, lobectomy in 8. Preoperative chemotherapy was administered to 3 patients, 16 received postoperative radiation treatment. The clinical course and survival were analyzed.Major postoperative morbidities were found in 13 patients. Graft thrombosis did not occur. Thirty-day mortality was 7 % in pneumonectomy patients and 0 % following lobectomy. Local recurrence was found in 4.5 %, distant metastases developed in 54.5 % of the patients (p = 0.0008). One- and five-year survival probabilities for all patients were 63.6 and 27.9 %. Five-year survival probability was 33 % for patients with SVC reconstruction and 25 % for patients with SVC replacement (p = 0.22). Five-year survival rates after pneumonectomy and lobectomy were 21.4 % and 37.5 %, respectively (p = 0.18).Radical resection involving the SVC in carefully selected patients with NSCLC results in excellent local tumor control. Due to the high rate of distant metastases, application of induction and adjuvant chemotherapy should be carefully assessed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Sleeve lobectomy is an established surgical procedure in patients with lung cancer. Usually the only surgical alternative would be a pneumonectomy. This article describes the perioperative risks and functional results in patients after sleeve lobectomy compared to pneumonectomy and typical lobectomy.There were only minor differences with respect to postoperative morbidity comparing the different procedures but the mortality rate was higher following pneumonectomy. Bronchopleural fistula rates were also similar comparing lobectomy and sleeve lobectomy but elevated following pneumonectomy. Bronchovascular fistulas after sleeve lobectomy are potentially life-threatening. Postoperative pulmonary function tests showed similar values for lobectomy and sleeve lobectomy patients and were considerably better than following pneumonectomy.Whenever possible sleeve lobectomy should take preference over pneumonectomy.

Unlabelled: (18)F-FDG PET is the most accurate noninvasive modality for staging mediastinal lymph nodes in lung cancer. Besides using visual image interpretation, some institutions use standardized uptake value (SUV) measurements in lymph nodes. Mostly, an SUV of 2.5 is used as the cutoff, but this choice was never deduced from respective studies. Receiver operating characteristic (ROC) analyses demonstrated that SUV thresholds of more than 4 resulted in the highest accuracy. But these high cutoffs imply high false-negative rates (FNRs). The aim of our evaluation was to determine an optimal SUV threshold and to compare its diagnostic performance with the results of visual interpretation., Methods: This retrospective study included 95 patients with suspected lung cancer who underwent mediastinoscopy/mediastinal lymphadenectomy after (18)F-FDG PET (90-150 min after 250 MBq of (18)F-FDG). Maximum SUV was measured in 371 lymph node regions biopsied afterward and visually interpreted using a 6-level score (- - - through + + +). Diagnostic performance was assessed by ROC analysis. FNR and false-positive rate (FPR), the sum of both error rates (FNR + FPR), and diagnostic accuracy were plotted against a hypothetical SUV threshold to determine the optimum SUV threshold., Results: SUVs in metastatic lymph nodes were higher (mean +/- SD, 7.1 +/- 4.5; range, 1.4-26.9; n = 70) than in tumor-free lymph node stations (2.4 +/- 1.7; range, 0.6-14.9; n = 301; P < 0.01). Inflammatory lymph nodes exhibited slightly increased SUVs (2.7 +/- 2.0; range, 0.8-14.9; n = 146). The plot of error rates featured a minimum of the sum FNR + FPR for an SUV of 2.5. With increasing SUV threshold, the FPR decreased most prominently up to that value whereas a continuous rise of FNR was noticed. Highest diagnostic accuracy was achieved with an SUV of 4.5. The areas under the ROC curves demonstrated that visual interpretation tends to be more accurate than SUV quantification (visual, 0.930 +/- 0.022; SUV, 0.899 +/- 0.025; P = 0.241). Using an SUV of 2.5 as the threshold, the resulting sensitivity, specificity, and negative predictive value were 89%, 84%, and 96%, respectively., Conclusion: For mediastinal staging, the choice of an SUV of 2.5 as the threshold is justified because FNR + FPR is minimized. The resulting high negative predictive value of 96% allows the omission of mediastinoscopy in patients with negative mediastinal findings on (18)F-FDG PET images. For the experienced observer, visual analysis should be relied on primarily, with calculation of the SUV used, at most, as a secondary aid. For the less experienced observer, the SUV may be of greater value.

Background and Aim of the Study: Valve-preserving aortic replacement has become an accepted option for patients with aortic valve regurgitation and aortic dilatation. The relative role of root remodeling versus valve reimplantation inside a vascular graft has been discussed, albeit controversially. In the present study, an in-vitro model was used to investigate the aortic valve hemodynamics of root remodeling and valve reimplantation; roots with supracommissural aortic replacement served as controls., Methods: Aortic roots with aortoventricular diameter 21 mm were obtained from pigs. Root remodeling was performed using a 22-mm graft (group I, n = 6), or valve reimplantation with a 24-mm graft (group II, n = 7). Control roots were treated by supracommissural aortic replacement (22-mm graft; group III, n = 7). Using an electrohydraulic, computer-controlled pulse duplicator, the valves were tested at flows of 2, 4, 5, 7, and 9 I/min at a heart rate of 70 /min and a mean arterial pressure of 100 mmHg. Parameters assessed included: mean pressure gradient, effective orifice area, valve closure and regurgitant volume, and energy loss due to ejection, valve closure and regurgitation. Data were compared using ANOVA., Results: There were no differences between the three groups in terms of regurgitant volume, energy loss due to valve regurgitation, or valve closure. The aortic valve orifice area was largest and systolic gradient lowest in group I at all flow rates (p < 0.001). Ejection energy loss was lowest in group I at all flow rates (9 l/min: group I, 128 +/- 21 mJ; group II, 399 +/- 46 mJ; group III, 312 +/- 27 mJ; p < 0.001). Valve closure volumes were similar in groups I and III, but significantly lower in group II at all flow rates (p = 0.047)., Conclusion: In this standardized experimental setting, root remodeling--but not valve reimplantation--resulted in physiologic hemodynamic performance of the aortic valve with regard to orifice area, pressure gradient, and systolic energy loss.

Purpose: The differentiation of recurrent lung cancer and post-therapeutic changes remains a problem for radiological imaging, but FDG-PET allows biological characterisation of tissues by visualising glucose metabolism. We evaluated the diagnostic performance and prognostic impact of FDG-PET in cases of suspected relapse of lung cancer., Methods: In 62 consecutive patients, 73 FDG-PET scans were performed for suspected recurrence after surgical therapy of lung cancer. FDG uptake by lesions was measured as the standardised uptake value (SUV). PET results were compared with the final diagnosis established by biopsy or imaging follow-up. SUV and clinical parameters were analysed as prognostic factors with respect to survival., Results: FDG-PET correctly identified 51 of 55 relapses and gave true negative results in 16 of 18 remissions (sensitivity, specificity, accuracy: 93%, 89%, 92%). SUV in recurrent tumour was higher than in benign post-therapeutic changes (10.6+/-5.1 vs 2.1+/-0.6, p<0.001). Median survival was longer for patients with lower FDG uptake in recurrent tumour (SUV<11: 18 months, SUV > or = 11: 9 months, p<0.01). Long-term survival was observed mainly after surgical re-treatment (3-year survival rate 38%), even if no difference in median survival for surgical or non-surgical re-treatment was detected (11 vs 12 months, p=0.0627). For patients subsequently treated by surgery, lower FDG uptake predicted longer median survival (SUV<11: 46 months, SUV> or = 11: 3 months, p<0.001). SUV in recurrent tumour was identified as an independent prognostic factor (p<0.05)., Conclusion: FDG-PET accurately detects recurrent lung cancer. SUV in recurrent tumour is an independent prognostic factor. FDG-PET helps in the selection of patients who will benefit from surgical re-treatment.

We present the case of a 52-year-old male who underwent thoracotomy for resection of a suspected bronchogenic cyst in the right posterior mediastinum. The size of the tumor had increased over years, according to repeated X-rays, and the cyst became symptomatic with obstruction of the right subclavian and jugular veins. To our surprise, histopathology revealed a hydatid cyst.

Background: Pneumonectomy has traditionally been the treatment of choice for central lung tumors. Bronchial sleeve resections are increasingly considered as a reasonable alternative. For tumor involvement of both central airways and pulmonary artery, bronchovascular sleeve resections are possible, but considered to be technically demanding and associated with a higher perioperative risk. In addition, their role as adequate oncologic treatment for lung cancer is unclear. We have compared the early and long-term results of bronchovascular sleeve resection with those of bronchial sleeve resection and pneumonectomy., Methods: We retrospectively analyzed all patients who underwent bronchial sleeve resection (group I, n = 104), bronchovascular sleeve resection (group II, n = 67), and pneumonectomy (group III, n = 63) for central lung cancer in our institution., Results: The groups were comparable regarding demographics and tumor, node, and metastasis (TNM) stage. Early mortality was 1.9% in group I, 1.5% in group II, and 6.3% in group III (p = 0.19). The rate of bronchial complications was 0.96% in group I, 0% in group II, and 7.9% in group III (p = 0.006). Five-year survival was 46.1% in group I, 42.9% in group II, and 30.4% in group III (p = 0.16). Freedom from local recurrence of disease (5 years) was 83.8% in group I, 84.2% in group II, and 88.7% in group III (p = 0.56)., Conclusions: Bronchovascular sleeve resections are as safe as bronchial sleeve resections for the treatment of central lung cancer. Both procedures have comparable early and long-term results, which are similar to those of pneumonectomy. It appears reasonable to apply bronchovascular sleeve resections more liberally.

Objectives: Induction therapy is an important treatment option in locally advanced non-small cell lung cancer. F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) has an important role in initial staging. The aim of this study was to assess the value of FDG-PET in restaging after induction therapy and in analyzing tumor viability, nodal status, distant metastases, and prognosis., Methods: Forty-seven patients with locally advanced non-small cell lung cancer accepted for resection after induction therapy underwent FDG-PET. Images were interpreted visually for mediastinal nodal status and metastatic spread. The FDG accumulation in the tumor site was measured by using the maximum standardized uptake value., Results: Unexpected metastases were detected by means of FDG-PET in 9 patients. Surgical intervention was not performed in 8 patients with confirmed metastases. The rate of unexpected findings increased from complete radiologic remission (0%) over partial remission (9%) to no change (67%). The standardized uptake value was higher in tumors with (n = 26) than in those without (n = 11) histologic proof of viability (6.4 +/- 5.3 vs 2.9 +/- 1.6, P = .006). All patients with standardized uptake values of greater than 5.8 had viable tumors. Sensitivity, specificity, and negative predictive value were 81%, 64%, and 58% for tumor viability and 50%, 88%, and 85% for persistent mediastinal disease. Median survival after resection was greater than 56 months for patients with tumor standardized uptake values of less than 4 and 19 months for patients with standardized uptake values of 4 or greater ( P < .001)., Conclusion: FDG-PET helps in the selection of patients for resection after induction therapy. It can be used to detect unexpected distant metastases, especially after poor response to induction therapy. Its high negative predictive value in mediastinal restaging allows for omission of repeat mediastinoscopy. Tumor standardized uptake value after induction is a prognostic factor.

Background: In patients with bronchogenic carcinoma, mediastinal lymph node staging is essential for determining treatment options. In this retrospective analysis we compared the results of positron emission tomography (PET) using F-18 fluorodeoxyglucose with those of mediastinoscopy in nodal staging for suspected bronchogenic carcinoma., Methods: From March 1997 to June 2001, 102 patients (86 male,16 female, age 62 +/- 9 years) underwent both PET and mediastinoscopy for radiologically suspected mediastinal lymph node disease in bronchogenic carcinoma. Total body emission scans were acquired 90 to 150 minutes after injection of 230 MBq of F-18 fluorodeoxyglucose. Mediastinoscopic evaluation of lymph node stations was performed according to the method of Mountain and Dresler (1R, 1L, 2L, 2R, 4L, 4R,7). Patients were eligible if surgical staging was performed within 6 weeks after the PET scan. RESULTS. Of the 102 patients, benign lesions were diagnosed in 15. In 87 patients malignant disease was proven by histology, and bronchogenic carcinoma was found in 82. Of 469 nodal stations analyzed, malignancy was documented by histology in 84. In PET analysis 79 true-positive and 304 true-negative samples were found. Five lymph node stations were false negative, and 81 samples were false positive. False-positive findings in PET frequently were seen in inflammatory lung disease. The sensitivity of PET was 94.1%, specificity was 79% with a diagnostic accuracy of 81.6%. The positive predictive value of PET was 49.3%, and the negative predictive value was 98.4%., Conclusions: In patients with positive PET scan results histologic verification appears necessary for exact lymph node staging. In view of the negative predictive value mediastinoscopy can be omitted in patients with bronchogenic carcinoma whose PET scan results were negative.

Objective: Valve-preserving root replacement has become an accepted alternative to composite replacement both in dissection and in aneurysmal disease. We retrospectively analysed 5-year results comparing root remodelling and reimplantation procedures., Methods: From October 1995 to January 2001, 119 patients underwent either root remodelling (group A; n = 98; age: 61 +/- 14 years) or valve reimplantation within a vascular graft (group B; n = 21; age: 47 +/- 17 years). In group A, 26 patients were operated for aortic dissection type A and 72 for aortic valve regurgitation and aneurysmal disease. In group B, 8 patients were operated for aortic dissection type A, 13 for aortic valve regurgitation and aneurysm. Concomitant arch surgery was performed in 65 patients (group A: 57; group B: 8)., Results: Time on cardiopulmonary bypass was 121 +/- 30 min in group A, 143 +/- 24 min in group B, and aortic cross-clamp time was 87 +/- 19 min in group A and 113 +/- 24 min in group B. Average duration was therefore longer in group B (p = n.s.) Hospital mortality was 3.1 % in group A and 0 % in group B. Following elective procedures, hospital mortality was 1.1 % in group A. Freedom from aortic regurgitation over grade 2 at 4 years was 86 % in group A and 94.7 % in group B. At 4 years, freedom from proximal reoperation was 97.8 % in group A and 100 % in group B. There was no deterioration of valve function or need for reoperation observed after 1 year in either group., Conclusion: Five-year results are comparable and encouraging for remodelling and reimplantation procedures. If the initial valve function and geometry is adequate, the chance of secondary failure beyond the first year is minimal.

We describe the case of a 58-year-old female patient who underwent redo mitral valve replacement and remained in heart failure. The diagnosis of a left ventricular-right atrial fistula was made. The fistula was closed surgically with a patch of autologous pericardium. The patient improved immediately after the operation and has been asymptomatic since.

Purpose: Aortic valve preservation is a promising alternative to conventional composite replacement of aortic valve and ascending aorta. This approach may have a physiologic benefit compared with valve replacement similar to that seen in mitral valve reconstruction. We investigated aortic valve gradients at rest and during exercise in patients who had undergone valve-preserving aortic replacement and compared them with composite replacement of valve and aorta., Methods: Four groups were studied: nine patients underwent composite valve replacement (group A: valve diameter, 23 to 27 mm), eight patients underwent remodeling of the aortic root (group B), and another nine patients had reimplantation of the aortic valve (group C). Healthy volunteers were studied as a control group (group D). Using continuous-wave Doppler echocardiography, all patients were examined on a bicycle ergometer for aortic valve gradients (0 to 75 W)., Results: There were no differences among the groups with respect to age, body surface, left ventricular end-diastolic diameter, fractional shortening, or left ventricular mass. Maximum resting gradients were significantly elevated in group A compared with groups B, C, and D (group A: 21.3 +/- 7.1 mm Hg; group B: 9.0 +/- 4.5 mm Hg; group C: 8.6 +/- 3.7 mm Hg; group D: 4.9 +/- 1.6 mm Hg; p < 0.05). At 75 W, group A exhibited significantly higher gradients than all other groups (group A: 31.3 +/- 7.5 mm Hg; group B: 13.9 +/- 6.6 mm Hg; group C: 12.8 +/- 3.5 mm Hg; group D: 9. 2 +/- 1.9 mm Hg; p < 0.05). There was no significant difference among the other groups. Both valve-preserving groups had only insignificantly higher gradients than the control group., Conclusion: Our data strongly support the suggestion that preserving the aortic valve restores nearly normal hemodynamic function of the aortic valve. Long-term observations will have to prove the clinical relevance of restoring physiologic aortic valve hemodynamics.

Background: The standard treatment in patients with acute aortic dissection type A (AADA) and aortic regurgitation is either supracommissural aortic or composite replacement of ascending aorta and valve. Valve-preserving surgical procedures provide a promising alternative. We retrospectively analyzed midterm results after these different approaches., Methods: From October 1995 to December 1999, 52 patients (35 men, 17 women) underwent repair of AADA. Patient ages ranged from 30 to 83 years. Composite replacement was chosen for degenerated aortic valves or prior valve replacement (group A; n = 8). With normal root diameter, supracommissural replacement of the ascending aorta was performed (group B; n = 22). For preexisting root dilatation the aortic root was either remodeled (root diameter 30 to 50 mm, group C; n = 17) or the valve reimplanted within a vascular graft (root diameter more than 50 mm, group D; n = 5)., Results: All patients underwent either proximal (n = 46) or total (n = 6) arch replacement under circulatory arrest. Eight patients (15.4%) died (group A: n = 3; group B: n = 3; group C: n = 2). Freedom from aortic regurgitation of grade 2 or more at 2 years was 100% in groups A and D, 90.9% in group C, and 75% following supracommissural replacement. At 2 years freedom from proximal reoperation was 100% in groups A, C, and D and 84.5% in group B., Conclusions: In AADA valve-preserving root replacement leads to improved stability of aortic valve function without an increased operative risk. Midterm results are promising and may show further superiority over supracommissural aortic replacement in the future.

Background: To improve postoperative pulmonary reserve, we have employed parenchyma-sparing resections for central lung tumors irrespective of pulmonary function. The results of lobectomy, pneumonectomy, and sleeve resection were analyzed retrospectively., Methods: From October 1995 to June 1999, 422 typical lung resections were performed for lung cancer. Of these, 301 were lobectomies (group I), 81 were sleeve resections (group II), and 40 were pneumonectomies (group III)., Results: Operative mortality was 2% in group I, 1.2% in group II, and 7.5% in group III (group I and II vs. group III, p<0.03). Mean time of intubation was 1.0+/-4.1 days in group I, 0.9+/-1.3 days in group II, and 3.6+/-11.2 days in group III (groups I and II vs. group III, p<0.01). The incidence of bronchial complications was 1.3% in group I, none in group II, and 7.5% in group III (group I and II vs group III, p<0.001). After 2 years, survival was 64% in group I, 61.9% in group II, and 56.1% in group III (p = NS). Freedom from local disease recurrence was 92.1% in group I, 95.7% in group II, and 90.9% in group III after 2 years (p = NS)., Conclusions: Sleeve resection is a useful surgical option for the treatment of central lung tumors, thus avoiding pneumonectomy with its associated risks. Morbidity, early mortality, long-term survival, and recurrence of disease after sleeve resection are similar to those seen after lobectomy.

Background: Currently, isolated reconstruction of a regurgitant bicuspid aortic valve can be performed with adequate early results. Dilatation of the proximal aorta is known to be associated with this valve anomaly and may be partially responsible for the development of primary regurgitation or secondary failure of valve repair. We have used repair of the bicuspid valve with remodeling of the aortic root as an alternative to insertion of a composite graft., Methods: Between October 1995 and May 1999, 16 patients (12 men, 4 women, aged 35 to 73 years) were seen with a regurgitant bicuspid aortic valve and dilatation of the proximal aorta of more than 50 mm. All patients underwent repair of the valve using either coapting sutures alone (n = 12) or in combination with triangular resection of a median raphe (n = 4). Using a Dacron graft, the aortic root was remodeled and the ascending aorta (n = 16) and proximal arch (n = 4) replaced., Results: No patient died. The postoperative degree of aortic regurgitation was less than grade II in all patients. Valve function has remained stable in all patients between 2 and 43 months postoperatively., Conclusions: Reconstruction of the regurgitant bicuspid valve in the presence of proximal aortic dilatation is feasible with good results by combining the root remodeling technique with valve repair.

In patients with intact sinus node function and atrioventricular block III(o) VDD pacing with a single pass lead may have advantages compared to conventional DDD systems. The purpose of this study was to evaluate the reliability of a new VDD pacemaker with regard to problems encountered with the implantation and the stability of the atrial sensing potential in the postoperative course. 24 patients (10 male, 14 female; age 61 +/- 17 years) underwent implantation of the Intermedics UNITY 292+07 VDD pacemaker. Patients were analyzed postoperatively with respect to stimulation parameters applied. The mean follow-up was 10+/- 3 months. While early on 23 of 24 patients were paced in a VDD mode, one patient was programmed to the vvi mode due to atrial flutter. One patient died early after aortic valve replacement, while another lost his atrial sensing one month postoperatively. Two patients were reprogrammed to the vvi mode because of atrial arrhythmias. The other 20 patients demonstrated stable atrial sensing potential aside from unchanged ventricular stimulation parameters. No infectious or unchanged ventricular stimulation parameters. No infectious or technical problems were observed. From these results it is concluded that VDD pacing may represent an excellent alternative in patients with intact sinus node function and AV block III(o). The atrial sensing was found to be reliable with the additional technical advantage that the single pass lead is less prone to dislocation than the atrial leads in DDD pacing.