Risk analysis for thoracoscopic lung volume reduction: a multi-institutional experience

OBJECTIVE

Most reports of thoracoscopic lung volume reduction (TLVR) are relatively small and early experiences from a single institution, factors which limit both the statistical validity and the applicability to the population at large. In order to address these shortcomings we undertook an analysis of the TLVR experience at five separate institutions to assess operative morbidity and identify predictors of mortality.

METHODS

Questionnaires were sent to four groups of surgical investigators at five institutions actively performing TLVR. Data was requested regarding preoperative, operative and postoperative parameters. Twenty-five potential predictors of mortality were analyzed and seven proved to be at least marginally significant (P<0.10). These parameters were entered into a stepwise logistic regression analysis to identify independent predictors.

RESULTS

The 682 patients (415 males, 267 females, mean age 64.0 years) underwent unilateral (410) or bilateral (272) TLVRs. Overall, operative mortality was 6% with half of the deaths resulting from respiratory causes. The remaining patients were discharged to home (88%), a rehabilitation facility (4%) or a ventilator facility (2%). There were 25 perioperative factors chosen representing clinically important indices such as spirometry, oxygenation, functional status, clinical and demographic variables. Univariate analysis identified seven variables as predictors of mortality (P<0.10) and these were entered into a stepwise logistic regression analysis. Only age, 6-min walk, gender (male 8%, female 3% mortality) and the procedure performed (unilateral 4.6%, bilateral 8%) were independent predictors while preoperative steroid therapy, preoperative oxygen administration, and time since smoking cessation dropped out of the model. The specific institution, learning curve (early vs. late experience), type of lung disease, spirometric indices and predicted maximum VO(2) were not significant predictors.

CONCLUSION

This experience suggests that unilateral and bilateral lung volume reduction procedure can be performed with acceptable morbidity and mortality. Although age, gender, exercise capacity and the procedure performed are all independent predictors of mortality, the risk of operative death did not appear excessive in this fragile patient subset.

Acute type A aortic dissection: retrograde perfusion with left superior vena cava

Retrograde cerebral perfusion with hypothermic circulatory arrest confers additional cerebral protection during repair of type A aortic dissection. We present a 42-year-old man with acute type A aortic dissection and a persistent, left superior vena cava. Cannulation of the right and left superior vena cava is used for retrograde perfusion of both hemispheres with bilateral monitoring of electroencephalogram and somatosensory-evoked potentials during and after the hypothermic circulatory arrest interval.

Comparison of clinical results for unilateral and bilateral thoracoscopic lung volume reduction

BACKGROUND

It is widely believed that bilateral thoracoscopic lung volume reduction (BTLVR) yields superior results when compared with unilateral thoracoscopic lung volume reduction (UTLVR) with regard to spirometry, functional capacity, oxygenation and quality of life results.

METHODS

To address these issues, we compared the results of patients undergoing UTLVR (N = 338 patients) and BTLVR (N = 344 patients) from 1993 to 1998 at five institutions. Follow-up data were available on 671 patients (98.4%) between 6 and 12 months after surgery, and a patient self-assessment was obtained at a mean of 24 months.

RESULTS

It was found that BTLVR provides superior improvement in measured postoperative percent change in FEV1 (L) (UTLVR 23.3% +/- 55.3 vs BTLVR 33% +/- 41, p = 0.04), FVC(L) (10.5% +/- 31.6 vs 20.3% +/- 34.3, p = 0.002) and RV(L) (-13% +/- -22 vs -22% +/- 17.9, p = 0.015). BTLVR also provides a slight improvement over UTLVR in patient's perception regarding improved quality of life (UTLVR 79% vs BTLVR 88%, p = 0.03) and dyspnea relief (71% vs 61%, p = 0.03). There was no difference in mean changes in PO2 (mm Hg) (UTLV 4.5 +/- 12.3 vs BTLVR 4.9 +/- 13.3, p = NS), 6-minute walk (UTLVR 26% +/- 66.1 vs BTLVR 31% +/- 59.6, p = NS) or decreased oxygen utilization (UTLVR 78% vs BTLVR 74%, p = NS).

CONCLUSIONS

These data suggest that both UTLVR and BTLVR yield significant improvement, but the results of BTLVR seem to be superior with regard to spirometry, lung volumes, and quality of life.

Structural determinants of aortic regurgitation in type A dissection and the role of valvular resuspension as determined by intraoperative transesophageal echocardiography

Disruption of the aortic root by dissection often produces significant aortic regurgitation (AR). Resuspension of the native valve usually reestablishes competence. The mechanisms of this complex process are poorly understood. We used intraoperative transesophageal echocardiography to characterize the in vivo aortic root structure of type A aortic dissection and the changes brought about by native valve resuspension. Intraoperative transesophageal echocardiograms were obtained from 34 patients with type A dissection and aortic resuspension between January 1990 and April 1997. The severity of AR, aortic root diameter, circumference of the aortic annulus, percentage of the annulus dissected, and presence of leaflet prolapse were assessed in multiple planes. Preoperatively, AR of varying degree was present in 25 patients (73%). Multivariate analysis revealed that preoperative AR was most related to percentage of the annulus dissected (p<0.0001) and less related to root diameter (p<0.01). Leaflet prolapse was predicted by percent aortic annulus dissected (p <0.0001). After resuspension, annular dissection and leaflet prolapse were no longer present. Postoperative AR was significantly decreased from preoperative AR (p<0.0001) and was considered trace to mild. Although postoperative root diameter and annular circumference decreased (p<0.001), individual reductions in AR did not correlate with individual changes in root diameter or annular circumference. The degree of dissection of the valve annulus is the most significant determinant of leaflet prolapse and AR severity. Overall size of the aortic root also contributes to AR. Surgical resuspension significantly decreases root size, but its primary benefit is restoration of the structural integrity of the aortic annulus.

Fatal hyperammonemia after orthotopic lung transplantation

BACKGROUND

A case of fatal hyperammonemia complicating orthotopic lung transplantation was previously reported.

OBJECTIVE

To describe the incidence, clinical features, and treatment of hyperammonemia associated with orthotopic lung transplantation.

DESIGN

Retrospective cohort analysis.

SETTING

Academic medical center and lung transplantation center in Philadelphia, Pennsylvania.

PATIENTS

145 sequential adult patients who underwent orthotopic lung transplantation.

MEASUREMENTS

Plasma ammonium levels.

RESULTS

Six of the 145 patients who had had orthotopic lung transplantation developed hyperammonemia, all within the first 26 days after transplantation. The 30-day post-transplantation mortality rate was 67% for patients with hyperammonemia compared with 17% for those without hyperammonemia (P = 0.01). Development of major gastrointestinal complications (P = 0.03), use of total parenteral nutrition (P < 0.001), and lung transplantation for primary pulmonary hypertension (P = 0.045) were associated with hyperammonemia.

CONCLUSIONS

Hyperammonemia is a potentially fatal event occurring after orthotopic lung transplantation. It is associated with high nitrogen load, concurrent medical stressors, primary pulmonary hypertension, and hepatic glutamine synthetase deficiency.

Long-term survival after thoracoscopic lung volume reduction: a multiinstitutional review

BACKGROUND

It has been suggested that bilateral thoracoscopic lung volume reduction (BTLVR) yields significantly better long-term survival than unilateral thoracoscopic lung volume reduction (UTLVR).

METHODS

All perioperative data were collected at the time of the procedure. Follow-up data were obtained during office visits or by telephone.

RESULTS

A total of 673 patients underwent thoracoscopic LVR: 343 had either simultaneous or staged BTLVR and 330, UTLVR. As of July 1998, follow-up was available on 667 (99%) of the 673 patients with a mean follow-up of 24.3 months. The patients in the BTLVR group were significantly younger (62.6+/-8.0 years versus 65.4+/-8.1 years; p < 0.0001), had a higher preoperative arterial oxygen tension (69.7+/-12 mm Hg versus 65.3+/-11 mm Hg; p < 0.0001), and had a superior preoperative 6-minute walk performance (279.9+/-93.6 m [933+/-312 feet] versus 244.5+/-101.4 m [815+/-338 feet] p < 0.0001). There was no difference in the operative mortality rate between the two groups (UTLVR, 5.1%, and BTLVR, 7%). Actuarial survival rates for the UTLVR group at 1 year, 2 years, and 3 years were 86%, 75%, and 69%, respectively versus 90%, 81%, and 74%, respectively, for the BTLVR group (p = not significant).

CONCLUSIONS

Contrary to previous reports, survival after BTLVR was not superior to that after UTLVR even though the former group appeared to have a lower risk preoperatively because of younger age, higher arterial oxygen tension, more advantageous anatomy, and better functional status. Despite thoracoscopic LVR, the actuarial mortality rate approached 30% at 3 years, and this calls into question whether this procedure offers any survival advantage to patients with end-stage emphysema.

Emergency repair of thoracoabdominal aortic aneurysms with immediate presentation

OBJECTIVE

The objective of this report was the study of the clinical outcome of emergently repaired thoracoabdominal aortic aneurysms (TAAAs).

METHODS

We retrospectively reviewed our experience with TAAA repairs from 1990 to 1998. During this interval, 110 TAAA procedures were performed, 33 (30%) of which were for immediate presentations. The chi(2) test and regression analysis were used for the analysis of mortality, paraplegia, and renal failure (hemodialysis) rates and of factors that predict these complications, respectively.

RESULTS

There were no significant differences between the elective and immediate presentations with respect to the use of adjunctive procedures (lumbar drain, hypothermia, and bypass grafting). The overall mortality rate was 13%. There were no statistically significant differences between the 30-day mortality rates or the complication rates in elective versus immediate presentations. Subgroup analysis results showed a significantly higher in-hospital mortality rate in type II TAAA with immediate presentation and free rupture presentation as compared with the overall mortality rate (50% vs 13%, P <.05, and 67% vs 13%, P <.01, respectively). Multiple regression analysis results identified the use of bypass grafting (atrial-femoral or cardiopulmonary) and lumbar drain and shorter bypass grafting time as significant predictors of decreased overall mortality (P <.05). The mortality rates were not significantly different among aneurysm types and were not significantly decreased with the use of hypothermia. Paraplegia (5%) and renal failure (9%) rates were not predicted with aneurysm type, immediate versus elective presentation, or the adjunctive use of hypothermia, lumbar drain, or bypass grafting.

CONCLUSION

The emergency repair of TAAA with immediate presentation can be performed with mortality and morbidity rates that approach those of elective presentations, except in the setting of free rupture or symptomatic type II TAAA. Adjunctive circulatory management techniques and lumbar drains may reduce mortality in TAAA repair.

Oxygen delivery during retrograde cerebral perfusion in humans

Retrograde cerebral perfusion (RCP) potentially delivers metabolic substrate to the brain during surgery using hypothermic circulatory arrest (HCA). Serial measurements of O2 extraction ratio (OER), PCO2, and pH from the RCP inflow and outflow were used to determine the time course for O2 delivery in 28 adults undergoing aortic reconstruction using HCA with RCP. HCA was instituted after systemic cooling on cardiopulmonary bypass for 3 min after the electroencephalogram became isoelectric. RCP with oxygenated blood at 10 degrees C was administered at an internal jugular venous pressure of 20-25 mm Hg. Serial analyses of blood oxygen, carbon dioxide, pH, and hemoglobin concentration were made in samples from the RCP inflow (superior vena cava) and outflow (innominate and left carotid arteries) at different times after institution of RCP. Nineteen patients had no strokes, five patients had preoperative strokes, and four patients had intraoperative strokes. In the group of patients without strokes, HCA with RCP was initiated at a mean nasopharyngeal temperature of 14.3 degrees C with mean RCP flow rate of 220 mL/min, which lasted 19-70 min. OER increased over time to a maximal detected value of 0.66 and increased to 0.5 of its maximal detected value 15 min after initiation of HCA. The RCP inflow-outflow gradient for PCO2 (slope 0.73 mm Hg/min; P < 0.001) and pH (slope 0.007 U/min; P < 0.001) changed linearly over time after initiation of HCA. In the group of patients with preoperative or intraoperative strokes, the OER and the RCP inflow-outflow gradient for PCO2 changed significantly more slowly over time after HCA compared with the group of patients without strokes. During RCP, continued CO2 production and increased O2 extraction over time across the cerebral vascular bed suggest the presence of viable, but possibly ischemic tissue. Reduced cerebral metabolism in infarcted brain regions may explain the decreased rate of O2 extraction during RCP in patients with strokes.

IMPLICATIONS

Examining the time course of oxygen extraction, carbon dioxide production, and pH changes from the retrograde cerebral perfusate provided a means to assess metabolic activity during hypothermic circulatory arrest.

Comparison of open and thoracoscopic bilateral volume reduction surgery: complications analysis

BACKGROUND

The effectiveness of lung volume reduction for the treatment of patients with emphysema is well established, but data about the surgical approach, the postoperative management, and complications are limited. We report a comparison of patients undergoing bilateral lung volume reduction (BLVRS) via median sternotomy and thoracoscopic techniques with emphasis on hospital course and complications.

METHODS

All patients undergoing BLVRS at Hospital of University of Pennsylvania were analyzed for mortality and morbidity, using a combination of prospective data analysis and retrospective chart review.

RESULTS

Patients undergoing BLVRS via median sternotomy were older than those undergoing video-assisted thoracoscopic surgery (VATS) procedures (63.9+/-6.89 vs 59.3+/-9.4 years, p = 0.005). Operating time was longer for the VATS procedure (147 versus 129 minutes, p = 0.006) while estimated blood less was greater for median sternotomy (209 versus 82 L, p = 0.0000017). Significant differences were found in intensive care unit stay, days intubated, life-threatening complications, respiratory complications, requirement for tracheostomy, and death that favored VATS BLVRS. When only later cohorts of patients were compared, more life-threatening complications and deaths were found in patients undergoing BLVRS by median sternotomy. There were no differences between early and late median sternotomy BLVRS patients. Twenty-six percent of the lethal complications in median sternotomy BLVRS patients were bowel perforations, equally divided between duodenal ulcers and colons.

CONCLUSIONS

Managing patients after BLVRS remains complex. Bilateral video-assisted volume reduction offers equivalent functional outcome with potentially decreased morbidity and mortality. Gastrointestinal perforations can complicate the management of these patients.

Mediastinoscopic subtotal removal of mediastinal cysts

STUDY OBJECTIVE

Evaluate the use of mediastinoscopy in the surgical diagnosis and treatment of mediastinal cystic masses in adults.

DESIGN

Case reports and literature review.

SETTING

Academic department of surgery.

PATIENTS

Three consecutive adults with mediastinal masses identified on plain radiographs and CT.

INTERVENTIONS

Operative mediastinoscopy.

MEASUREMENTS AND RESULTS

All patients were successfully treated with removal of cyst wall, establishment of diagnosis, and same-day hospital discharge.

CONCLUSIONS

Simple mediastinoscopic removal of mediastinal cysts offers the same potential for diagnosis and treatment as more conventional methods, with a potential for less morbid and more cost-effective care.

Primary graft failure following lung transplantation

STUDY OBJECTIVES

To determine the incidence of primary graft failure (PGF) following lung transplantation, assess possible risk factors, and characterize its effect on outcomes.

METHODS

Retrospective review of 100 consecutive patients undergoing lung transplantation at the University of Pennsylvania Medical Center. Fifteen patients meeting diagnostic criteria for PGF (PGF+ group) were compared with 85 patients without this complication (PGF- group).

RESULTS

The incidence of PGF was 15%. There was no significant difference in age, sex, underlying pulmonary disease, preoperative pulmonary artery systolic pressure, type of transplant, allograft ischemic times, use of cardiopulmonary bypass, or use of postoperative prostaglandin E1 infusion between the PGF+ and PGF- groups. Induction therapy with antilymphocyte globulin was used less frequently in the PGF+ group (p<0.005). Duration of mechanical ventilatory support was 36+/-43 days vs 4+/-6 days for the PGF+ and PGF- groups, respectively (p<0.0001). Hospital stay was significantly longer in the PGF+ group, averaging 75+/-105 days, compared with 27+/-38 days in the PGF group (p<0.005). One-year actuarial survival for the PGF+ group was only 40% compared with 69% for the PGF- group (p<0.005). Five of the six PGF+ survivors were ambulatory by 1 year; three were completely independent while two continued to require assistance with activities of daily living. Six-minute walk test distance among the ambulatory patients averaged 883+/-463 feet (range, 200 to 1,223 feet) compared with 1513+/-424 feet for the PGF- group (p<0.005). Among the subset of survivors who underwent single lung transplantation for COPD, the mean percent predicted FEV1 at 1 year was 43% for the PGF+ group and 55% for the PGF- groups, but this difference was not statistically significant.

CONCLUSIONS

PGF is a devastating postoperative complication, occurring in 15% of patients in the current series, and it is associated with a high mortality rate, lengthy hospitalization, and protracted and often compromised recovery among survivors.

Neurophysiologic effects of retrograde cerebral perfusion used for aortic reconstruction

OBJECTIVE

The results of neurophysiologic monitoring using somatosensory evoked potentials (SSEPs) and electroencephalography (EEG) were analyzed to determine if retrograde cerebral perfusion (RCP) supported central nervous system electrical function during surgery that required temporary interruption of antegrade cerebral perfusion (IACP).

DESIGN

A prospective, observational study.

SETTING

A university hospital.

PARTICIPANTS

Fifteen adult patients who underwent aortic reconstruction using RCP and three patients who underwent thoracic aortic operations using hypothermic circulatory arrest without RCP.

INTERVENTIONS

SSEPs and EEG were monitored continuously throughout the operation. Regression analysis was performed to determine the factors that affected the rate of decrease in SSEP amplitudes during IACP and the time required for SSEP and EEG activity to recover after antegrade cerebral perfusion (ACP) was restored.

MEASUREMENTS AND MAIN RESULTS

The amplitude of SSEPs that were elicited decreased over time after IACP. The mean +/- standard deviation (SD) time required for the brachial plexus (Erb's point), cervicomedullary junction (N13), and brainstem (N18) SSEPs to decrease to 0.5 of their original amplitude after IACP were 30 +/- 2, 19 +/- 2, and 16 +/- 2 minutes, respectively. The rate of decrease in the N18 SSEP amplitude after IACP correlated positively to the fraction of no-flow time (p = 0.01).

CONCLUSION

RCP attenuated the rate of decay in SSEP amplitudes during IACP. This suggested that RCP had a measurable physiologic effect on central nervous system function and may increase the time that ACP can be safely interrupted.

Severe acute extrinsic airway compression by mediastinal tumor successfully managed with extracorporeal membrane oxygenation

The successful use of femoral venoarterial extracorporeal membrane oxygenation to support an adult patient with extrinsic airway compression secondary to a large mediastinal tumor is presented. Extracorporeal membrane oxygenation was continued until a combination of chemotherapy and radiation therapy allowed sufficient tumor shrinkage to permit decannulation. This method should be considered and available before manipulation of the airway in similar patients.

Comparison of short-term functional outcomes following unilateral and bilateral lung volume reduction surgery

STUDY OBJECTIVES

To compare short-term functional outcomes following unilateral and bilateral lung volume reduction surgery (LVRS) performed in patients with advanced emphysema.

METHODS

LVRS was performed unilaterally in 32 patients and bilaterally in 119 patients. Pulmonary function testing and 6-min walk test (6MWT) were performed preoperatively and repeated at 3 to 6 months postoperatively.

RESULTS

Bilateral LVRS was associated with increased in-hospital mortality (10% vs 0%, p<0.05) and a higher incidence of postoperative respiratory failure (12.6% vs 0%; p<0.05) compared with unilateral LVRS. There was no significant difference in duration of air leaks between unilateral and bilateral groups, but the mean hospital stay was significantly longer following bilateral LVRS (21.1+/-32.0 days vs 14.2+/-14.0 days; p<0.05). Preoperatively, there was no significant difference between the unilateral and bilateral groups with respect to FEV1, FVC, residual volume, or 6MWT distance. However, for all of these parameters, the magnitude of improvement was significantly greater following bilateral LVRS. Notably, the magnitude of improvement in each parameter following unilateral LVRS exceeded half that following bilateral LVRS, suggesting that functional outcomes after the unilateral procedure were disproportionate to the amount of tissue resected. Serial functional assessment of seven patients undergoing staged unilateral procedures (two unilateral procedures separated in time by at least 3 months) demonstrated somewhat unpredictable responses; failure to achieve a favorable response to the initial procedure did not necessarily portend a similar outcome with the contralateral side, and vise versa.

CONCLUSIONS

Bilateral LVRS produces a greater magnitude of short-term functional improvement than does the unilateral procedure and should be considered the procedure of choice for most patients. Unilateral LVRS should be reserved for patients in whom factors contraindicating entrance into one hemithorax exist.

Resection of a pulmonary malignancy invading the intrapericardial inferior vena cava

Resection of extensive lung cancers invading thoracic vascular structures (T4 lesions) can yield long-term survival provided the margins and nodes are free of tumor. We report the resection of the suprahepatic inferior vena cava for direct tumor involvement by a pulmonary malignancy. The resection was performed without bypass, and the cava was subsequently reconstructed with a 22-mm-diameter Dacron graft. Patency was documented on postoperative magnetic resonance angiograms. The patient was discharged home on postoperative day 10 without complications and remains well 8 months after the operation. Potentially curative resections and reconstructions of suprahepatic inferior vena cava involved with pulmonary malignancies are possible and can be done without cardiopulmonary bypass.

Effect of volume reduction on lung transplant timing and selection for chronic obstructive pulmonary disease

BACKGROUND

End-stage chronic obstructive pulmonary disease has traditionally been treated with lung transplantation. For 2 years, our lung transplantation program has placed patients with appropriate criteria for lung transplantation and volume reduction into a prospective management algorithm. These patients are offered the lung volume reduction option as a "bridge" to "extend" the eventual time to transplantation. We examine the results of this pilot program.

METHODS

From October 11, 1993, to April 17, 1997, 31 patients were evaluated for lung transplantation who also had physiologic criteria for volume reduction (forced expiratory volume in 1 second < or = 25%; residual volume > 200%; significant ventilation/perfusion heterogeneity). All patients completed 6 weeks of pulmonary rehabilitation and then had baseline pulmonary function and 6-minute walk tests. These patients were then offered volume reduction as a "bridge" and were simultaneously listed for transplantation. Postoperatively, these 31 patients were then divided into two groups: Those with satisfactory results at 4 to 6 months after volume reduction and those with unsatisfactory results. Volume reduction was performed through a video thoracic approach in 87% of the patients and bilateral median sternotomy in the remaining 13%. The condition of the patients was monitored after the operation with repeated pulmonary function tests and 6-minute walk tests at 3-month intervals.

RESULTS

Twenty-four of 31 patients (77.4%) had primary success (at 4 to 6 months) results after lung volume reduction and 7 patients (22.6%) had primary failure, including 1 patient who died in the perioperative period (3.2%). Four patients (16.7%) from the primary success cohort had significant deterioration in their pulmonary function during intermediate-term follow-up and were then reconsidered for lung transplantation. Two of them have subsequently undergone transplantation with good postoperative pulmonary function results. Interestingly, three patients had alpha 1-antitrypsin deficiency; two had a poor outcome of lung volume reduction and primary failure.

CONCLUSIONS

Lung volume reduction in these patients is safe. Seventy-seven percent of otherwise suitable candidates for lung transplantation achieved initial good results from volume reduction and were deactivated from the list (placed on status 7). Most patients entering our prospective management algorithm have either significantly delayed or completely avoided lung transplantation after volume reduction. Lung volume reduction has substantially affected the practice, timing, and selection of patients for lung transplantation. Our waiting list now has a reduced percentage of patients with a diagnosis of chronic obstructive pulmonary disease compared with 3 years ago. Our experience suggests that lung volume reduction may be limited as a "bridge" in alpha 1-antitrypsin deficiency.

Aortic dissection in a patient receiving chemotherapy for Hodgkin's disease--a case report

Cancer chemotherapy is associated with a wide range of vascular toxicities, which may be related to endothelial cell damage by these agents. The authors describe a patient with Hodgkin's disease who developed an atypical aortic dissection while receiving MOPP/ABV chemotherapy (nitrogen mustard, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, and vinblastine). They would place aortic dissection on the list of potential vascular complications associated with antineoplastic agents.

Anterior axillary muscle-sparing thoracotomy for lung transplantation

We have been using an anterior axillary muscle-sparing thoracotomy to perform single-lung transplantation in patients with chronic obstructive pulmonary disease. The incision allows excellent exposure and may lead to improved chest wall and shoulder girdle mechanics, which may allow for a faster recovery. This incision has become our preferred approach in patients with chronic obstructive pulmonary disease requiring single-lung transplantation who have not had a previous ipsilateral thoracic operation.

Loss of alpha-v integrin expression and recurrence in node-negative lung carcinoma

BACKGROUND

Despite "curative" resection, metastases develop in many patients with node-negative (N0) non-small cell lung carcinoma. Alternative biologic markers for this tumor would be useful. Integrins are cell adhesion molecules that are thought to be important in tumor progression, and expression of these molecules previously has been shown to be altered in non-small cell lung carcinoma. We evaluated alterations in integrin expression and clinical outcome.

METHODS

Immunohistochemical staining of tumor specimens was performed, and clinical data were reviewed retrospectively.

RESULTS

Data were complete for 42 patients. Half of all patients (21/42) and 9 of 26 patients with negative nodes experienced tumor recurrence during follow-up. Neither histologic type nor tumor differentiation status correlated with recurrence. However, loss of the alpha v integrin subunit was associated significantly with recurrence in the N0 group. Seventy-five percent of patients with negative nodes who exhibited recurrence lost alpha v expression, compared with only 10% of patients with negative nodes who did not exhibit recurrence (p = 0.012). Alterations of other integrin subunits did not correlate significantly with prognostic follow-up variables.

CONCLUSIONS

Loss of alpha v expression may serve as a marker for patients with node-negative non-small cell lung carcinoma who are at high risk for recurrence, potentially directing additional therapies.

Retrograde cerebral perfusion (RCP) in aortic arch surgery: efficacy and possible mechanisms of brain protection

Retrograde cerebral perfusion (RCP) was first introduced to treat air embolism during cardiopulmonary bypass (CPB). Its use was reintroduced to extend the safety of hypothermic circulatory arrest (HCA) during operations involving an open aortic arch. RCP seems to prevent cerebral rewarming during HCA. Both clinical and animal data suggest that RCP provides between 10% and 30% of baseline cerebral blood flow when administered through the superior vena cava (SVC) at jugular pressures of 20 to 25 mm Hg. RCP flows producing jugular venous pressures higher than 30 mm Hg may cause cerebral edema. Cerebral blood flow generated by RCP is able to sustain some cerebral metabolic activity, yet is not able to fully meet cerebral energy demands even at temperatures of 12 degrees to 18 degrees C. RCP may further prevent embolic events during aortic arch surgery when administered at moderate jugular vein pressures (< 40 mm Hg). Clinical results suggest that RCP, when applied during aortic arch reconstruction, may extend the safe HCA period and improve morbidity and mortality, especially when HCA times are more than 60 minutes. RCP applied in patients and severe carotid and brachiocephalic occlusive disease may be ineffective, and caution is in order when RCP times are greater than 90 minutes.

Bilateral versus single lung transplantation for chronic obstructive pulmonary disease

OBJECTIVE

Traditionally, despite ventilation/perfusion mismatch, single lung transplantation has been the mainstay for end-stage chronic obstructive pulmonary disease. We tested the hypothesis that bilateral sequential lung transplantation has better short- and intermediate-term results than single lung transplantation for chronic obstructive pulmonary disease.

METHODS

One hundred twenty-six consecutive lung transplants have been performed from November 1991 to March 1996. Seventy-six have been for chronic obstructive pulmonary disease. The diagnosis of this disease includes emphysema (80.3%), alpha 1-antitrypsin deficiency (9.2%), lymphangioleiomyomatosis (7.9%), and obliterative bronchiolitis (2.6%). Twenty-nine transplants have been bilateral and 47 have been single. Mean age was 55.3 for patients having single lung transplantation and 48.8 for those having bilateral lung transplantation (p = 0.001). The distribution of the diagnoses was similar between the two groups. At 6 months, there were 29 survivors of single lung transplantation and 20 survivors of bilateral lung transplantation, with complete data for evaluation. Pulmonary function tests and 6-minute walk tests were evaluated at a mean of 15.4 and 12.8 months after transplantation, respectively.

RESULTS

Sixty-day mortality was 21.3% for single lung transplantation versus only 3.45% for bilateral lung transplantation (p = 0.03). Additionally, Kaplan-Meier analysis revealed 1- and 2-year survivals of 71.1% and 63.3% for single lung transplantation versus 90% and 90% for bilateral lung transplantation, respectively. Multiple major morbidities were analyzed. Primary graft failure was significantly reduced in the bilateral group (p = 0.049). Both 6-minute walk tests and forced expiratory volume in 1 second were improved from baseline by both single and bilateral lung transplantation (p = 0.001).

CONCLUSIONS

Bilateral lung transplantation improves forced expiratory volume in 1 second and 6-minute walk tests significantly over single lung transplantation (p < 0.0001). Both perioperative mortality and Kaplan-Meier survival (to 3 years) are significantly improved when bilateral rather than single lung transplantation is used for chronic obstructive pulmonary disease in our series (p < 0.05). This is probably the result of significantly reduced primary graft failure.

Bilateral lung volume reduction surgery for advanced emphysema. A comparison of median sternotomy and thoracoscopic approaches

STUDY OBJECTIVES

To compare short-term outcomes following bilateral lung volume reduction surgery performed by median sternotomy (MS) and video-assisted thoracoscopic surgery (VATS).

METHODS

Bilateral lung volume reduction surgery was performed by MS in 80 patients and by VATS in 40. All patients underwent preoperative assessment with pulmonary function testing, arterial blood gas determination, and 6-min walk test (6MWT). Pulmonary function testing and 6MWT were repeated at 3 to 6 months postoperatively.

RESULTS

The mean age of the VATS group was lower than that of the MS group (59.3 +/- 9.4 vs 62.4 +/- 6.9 years; p = 0.001), but there were no differences in baseline functional parameters of disease severity (FEV1, FVC, residual volume [RV], arterial PCO2, or 6MWT). All patients in both groups were extubated at the completion of surgery, but 17.5% of patients in the MS group and 2.5% in the VATS group (p = 0.02) subsequently required reintubation at some point during the postoperative course. Thirty-day operative mortality was 4.2% for the MS group and 2.5% for the VATS group (p = not significant). However, total in-hospital mortality was 13.8% for the MS group, while it remained 2.5% for the VATS group (p = 0.05). Mortality was largely confined to patients 65 years of age or older. There was no significant difference in duration of air leaks or length of hospital stay between the two groups. Functional outcomes achieved with the two techniques were similar. Specifically, there was no difference between the two groups in mean postoperative FEV1, FVC, RV, or 6MWT, or in the magnitude of change in these parameters over preoperative values.

CONCLUSIONS

Bilateral lung volume reduction surgery performed by either MS and VATS approaches leads to similar improvements in pulmonary function and exercise tolerance. VATS is associated with a significantly lower incidence of respiratory failure and a trend toward decreased in-hospital mortality and may be the preferred technique, particularly for high-risk patients.

Circulatory management with retrograde cerebral perfusion for acute type A aortic dissection

BACKGROUND

Cerebral circulation during urgent repair of acute type A aortic dissection has traditionally been managed with cardiopulmonary bypass and aortic cross clamping proximal to the innominate artery or by the use of hypothermic circulatory arrest (HCA). The more recently introduced retrograde cerebral perfusion (RCP) may confer additional cerebral protection during elective aortic arch reconstruction. The purpose of this study was to demonstrate the efficacy of RCP in the urgent repair of acute type A aortic dissection.

METHODS AND RESULTS

We evaluated 60 consecutive patients who underwent repair of acute type A aortic dissection over a 6-year period. Patients were grouped according to intraoperative circulatory management strategies. Group 1 consisted of 41 patients operated on early in the series who were managed by cardiopulmonary bypass and standard aortic cross clamping (n = 21) with conversion to HCA (n = 20) if the intimal tear extended into the aortic arch. Since 1993, 19 patients, who make up group 2, were managed with routine open distal anastomosis and HCA with RCP. Data were analyzed for clinically evident, radiographically confirmed cerebrovascular accidents and 60-day mortality and evaluated by chi 2 analysis. Stroke and mortality rates of patients managed with either cardiopulmonary bypass or HCA were 26.3% and 29.3%, respectively. Patients undergoing RCP experienced statistically significant reductions in rates of confirmed cerebrovascular accidents (0%, P = .015) and mortality (5.3%, P = .04).

CONCLUSIONS

We conclude that the introduction of circulatory management using RCP with HCA during urgent operative repair of acute type A aortic dissection has significantly improved both stroke and mortality rates.

Detection of stroke during cardiac operations with somatosensory evoked responses

OBJECTIVES

The objectives of this study were to determine if monitoring of intraoperative somatosensory evoked potentials could be used to detect stroke during cardiac operations and to establish indicators of cerebral ischemia based on changes in these potentials.

METHODS

Twenty-five patients undergoing cardiac operations underwent preoperative and postoperative neurologic examinations as well as intraoperative recording of somatosensory evoked potentials. Detailed analysis of the waveforms of these potentials was performed.

RESULTS

Two of the 25 patients had intraoperative strokes. These patients and only these patients had changes in their somatosensory evoked potentials during the operation suggesting cerebral ischemia. The unilateral disappearance of the cortical somatosensory evoked potential waves correlated significantly with the clinical outcome of stroke (p < 0.004). Ischemic changes were detected in real time and were related to the removal of the aortic crossclamp in one patient and to the initiation of cardiopulmonary bypass in the other.

CONCLUSIONS

Somatosensory evoked potentials can detect intraoperative stroke during cardiac operations. Acute, unilateral decreases in amplitude of the cortical potential are more useful than changes in latency in detecting intraoperative stroke.

Triiodothyronine optimizes sheep ventriculoarterial coupling for work efficiency

BACKGROUND

Triiodothyronine (T3) administration after cardiopulmonary bypass has been shown to significantly improve cardiac performance. The present study was undertaken to elucidate the effects of T3, when administered as an intravenous bolus, on both cardiac energetics and stroke work-oxygen utilization (EW/LVVO2) efficiency.

METHODS

In both unstressed and stressed hearts, energetics were evaluated at baseline and 2 hours after intervention in an in vivo sheep preparation. In the first group (n = 5) sheep received saline vehicle. In the second group (n = 9) sheep received an intravenous bolus of 1.2 micrograms/kg of T3. In the third group (n = 7) sheep received a 2-hour intravenous infusion of dobutamine at a rate of 5 micrograms/kg/min.

RESULTS

In the unstressed heart, T3 improved cardiac function at no cost in oxygen consumption by decreasing afterload and hence improved EW/LVVO2 efficiency. In contrast, dobutamine improved unstressed cardiac function by increasing contractility at the cost of increased oxygen consumption and thus decreased EW/LVVO2 efficiency. Triiodothyronine optimized ventriculoarterial coupling for efficiency, but dobutamine optimized coupling for maximal work. In the stressed heart, T3 again improved EW/LVVO2 efficiency, but dobutamine had the opposite effect.

CONCLUSIONS

The bolus administration of T3 improves unstressed cardiac performance through optimization of ventriculoarterial coupling for EW/LVVO2 efficiency, primarily through vasodilation. Triiodothyronine also increases efficiency in the stressed heart. This study supports the use of T3 in cardiac operations to improve cardiac performance with no cost in oxygen consumption characteristic of inotropic agents.