LIONS PREY: A New Logistic Scoring System for the Prediction of Malignant Pulmonary Nodules

OBJECTIVES

Classifying radiologic pulmonary lesions as malignant is challenging. Scoring systems like the Mayo model lack precision in predicting the probability of malignancy. We developed the logistic scoring system 'LIONS PREY' (Lung lesION Score PREdicts malignancY), which is superior to existing models in its precision in determining the likelihood of malignancy.

METHODS

We evaluated all patients that were presented to our multidisciplinary team between January 2013 and December 2020. Availability of pathological results after resection or CT-/EBUS-guided sampling was mandatory for study inclusion. Two groups were formed: Group A (malignant nodule; n = 238) and Group B (benign nodule; n = 148). Initially, 22 potential score parameters were derived from the patients' medical histories.

RESULTS

After uni- and multivariate analysis, we identified the following eight parameters that were integrated into a scoring system: (1) age (Group A: 64.5 ± 10.2 years vs. Group B: 61.6 ± 13.8 years; multivariate p-value: 0.054); (2) nodule size (21.8 ± 7.5 mm vs. 18.3 ± 7.9 mm; p = 0.051); (3) spiculation (73.1% vs. 41.9%; p = 0.024); (4) solidity (84.9% vs. 62.8%; p = 0.004); (5) size dynamics (6.4 ± 7.7 mm/3 months vs. 0.2 ± 0.9 mm/3 months; p < 0.0001); (6) smoking history (92.0% vs. 43.9%; p < 0.0001); (7) pack years (35.1 ± 19.1 vs. 21.3 ± 18.8; p = 0.079); and (8) cancer history (34.9% vs. 24.3%; p = 0.052). Our model demonstrated superior precision to that of the Mayo score (p = 0.013) with an overall correct classification of 96.0%, a calibration (observed/expected-ratio) of 1.1, and a discrimination (ROC analysis) of AUC (95% CI) 0.94 (0.92-0.97).

CONCLUSIONS

Focusing on essential parameters, LIONS PREY can be easily and reproducibly applied based on computed tomography (CT) scans. Multidisciplinary team members could use it to facilitate decision making. Patients may find it easier to consent to surgery knowing the likelihood of pulmonary malignancy. The LIONS PREY app is available for free on Android and iOS devices.

Postoperative Tobacco Cessation Improves Quality of Life, Lung Function and Long-Term Survival in Non-Small-Cell Lung Cancer Patients

OBJECTIVES

About 90% of all non-small cell lung cancer (NSCLC) cases are associated with inhalative tabacco smoking. Half of patients continue smoking during lung cancer therapy. We examined the effects of postoperative smoking cessation on lung function, quality of life (QOL) and long-term survival.

MATERIALS AND METHODS

In total, 641 patients, who underwent lobectomy between 2012 and 2019, were identified from our single institutional data base. Postoperatively, patients that actively smoked at the time of operation were offered a structured 'smoking cessation' program. For this retrospective analysis, two patient groups (total n = 90) were selected by pair matching. Group A (n = 60) had no postoperative tobacco smoking. Group B (n = 30) involved postoperative continued smoking. Lung function (FEV1, DLCO) and QOL ('SF-36' questionnaire) were measured 12 months postoperatively. We compared long-term outcomes using Kaplan-Meier curves.

RESULTS

The mean age in group A was 62.6 ± 12.5 years and that in group B was 64.3 ± 9.7 years (p = 0.82); 64% and 62%, respectively, were male (p = 0.46). Preoperative smoking habits were similar ('pack years': group A, 47 ± 31; group B, 49 ± 27; p = 0.87). All relevant baseline characteristics we collected were similar (p > 0.05). One year after lobectomy, FEV1 was reduced by 15% in both groups (p = 0.98). Smoking cessation was significantly associated with improved DLCO (group A: 11 ± 16%; group B: -5 ± 14%; p <0.001) and QOL (vitality (VT): +10 vs. -10, p = 0.017; physical role function (RP): +8 vs. -17, p = 0.012; general health perceptions (GH): +12 vs. -5, p = 0.024). Patients who stopped smoking postoperatively had a significantly superior overall survival (median survival: 89.8 ± 6.8 [95% CI: 76.6-103.1] months vs. 73.9 ± 3.6 [95% CI: 66.9-80.9] months, p = 0.034; 3-year OS rate: 96.2% vs. 81.0%, p = 0.02; 5-year OS rate: 80.0% vs. 64.0%, p = 0.016). The hazard ratio (HR) was 2.31 [95% CI: 1.04-5.13] for postoperative smoking versus tobacco cessation.

CONCLUSION

Postoperative smoking cessation is associated with improved quality of life and lung function testing. Notably, a significant increase in long-term survival rates among non-smoking NSCLC patients was observed. These findings could serve as motivation for patients to successfully complete a non-smoking program.

TTF-1 status in early-stage lung adenocarcinoma is an independent predictor of relapse and survival superior to tumor grading

OBJECTIVES

Thyroid transcription factor 1 (TTF-1) is a well-established independent prognostic factor in lung adenocarcinoma (LUAD), irrespective of stage. This study aims to determine if TTF-1's prognostic impact is solely based on histomorphological differentiation (tumor grading) or if it independently relates to a biologically more aggressive phenotype. We analyzed a large bi-centric LUAD cohort to accurately assess TTF-1's prognostic value in relation to tumor grade.

PATIENTS AND METHODS

We studied 447 patients with resected LUAD from major German lung cancer centers (Berlin and Cologne), correlating TTF-1 status and grading with clinical, pathologic, and molecular data, alongside patient outcomes. TTF-1's impact was evaluated through univariate and multivariate Cox regression. Causal graph analysis was used to identify and account for potential confounders, improving the statistical estimation of TTF-1's predictive power for clinical outcomes.

RESULTS

Univariate analysis revealed TTF-1 positivity associated with significantly longer disease-free survival (DFS) (median log HR -0.83; p = 0.018). Higher tumor grade showed a non-significant association with shorter DFS (median log HR 0.30; p = 0,62 for G1 to G2 and 0.68; p = 0,34 for G2 to G3). In multivariate analysis, TTF-1 positivity resulted in a significantly longer DFS (median log HR -0.65; p = 0.05) independent of all other parameters, including grading. Adjusting for potential confounders as indicated by the causal graph confirmed the superiority of TTF-1 over tumor grading in prognostics power.

CONCLUSIONS

TTF-1 status predicts relapse and survival in LUAD independently of tumor grading. The prognostic power of tumor grading is limited to TTF-1-positive patients, and the effect size of TTF-1 surpasses that of tumor grading. We recommend including TTF1 status as a prognostic factor in the diagnostic guidelines of LUAD.

Case Report: Correlation between pulmonary capillary wedge pressure and left-ventricular diastolic pressure during treatment with veno-arterial extracorporeal membrane oxygenation

Background

Pulmonary capillary wedge pressure (PCWP) is often used as a surrogate for left-ventricular end-diastolic pressure in patients (LVEDP) who are on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support for cardiogenic shock and cardiac arrest. However, the correlation between PCWP and LVEDP is not clear in the setting of V-A ECMO usage. We sought to evaluate this correlation in this case series.

Methods

Patients were referred to our cardiac catheterization laboratory for invasive hemodynamic studies to assess their readiness for VA-ECMO decannulation. All patients underwent simultaneous left and right heart catheterization. Using standard techniques, we measured PCWP and LVEDP simultaneously. Continuous variables were reported as medians with interquartile ranges. The correlation between PCWP and LVEDP was evaluated using simple linear regression and reported as R2.

Results

Four patients underwent invasive hemodynamic studies 4 (2.5, 7) days after VA-ECMO cannulation. All four patients had suffered in-hospital cardiac arrest and had been put on VA-ECMO. At the baseline level of VA-ECMO flow of 4.1 (3.8, 4.4) L/min, the median LVEDP and PCWP were 6 (4, 7.5) mmHg and 12 (6.5, 16) mmHg, respectively. At the lowest level of VA-ECMO flow of 1.9 (1.6, 2.0) L/min, the median LVEDP and PCWP was 13.5 (8.5, 16) mmHg and 15 (13, 18) mmHg, respectively. There was a poor correlation between the simultaneously measured PCWP and LVEDP (R2 = 0.03, p = 0.66).

Conclusions

The PCWP may not correlate well with LVEDP in patients treated with VA-ECMO, particularly at high levels of VA-ECMO support.

The impact of levosimendan on survival and weaning from ECMO after extracorporeal cardiopulmonary resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. After cardiac arrest, the overall ejection fraction is severely impaired; thus, weaning from ECMO is often prolonged or impossible. We hypothesized that early application of levosimendan in these patients facilitates ECMO weaning and survival.

METHODS

From 2016 until 2020, patients who underwent eCPR after cardiac arrest at our institution were analyzed retrospectively and divided into two groups: patients who received levosimendan during ICU stay (n = 24) and those who did not receive levosimendan (n = 84) and analyzed for outcome parameters. Furthermore, we used propensity-score matching and multinomial regression analysis to show the effect of levosimendan on outcome parameters.

RESULTS

Overall, in-hospital mortality was significantly lower in the group which received levosimendan (28% vs. 88%, p ≤ 0.01), and ECMO weaning was more feasible in patients who received levosimendan (88% vs. 20%, p ≤ 0.01). CPR duration until ECMO cannulation was significantly shorter in the levosimendan group (44 + 26 vs. 65 + 28, p = 0.002); interestingly, the rate of mechanical chest compressions before ECMO cannulation was lower in the levosimendan group (50% vs. 69%, p = 0.005).

CONCLUSION

In patients after cardiac arrest treated with eCPR, levosimendan seems to contribute to higher success rates of ECMO weaning, potentially due to a short to mid-term increase in inotropy. Also, the survival after levosimendan application was higher than patients who did not receive levosimendan.

Do skip-N2 metastases significantly impact overall survival and disease-free interval in N2 NSCLC patients? A multicenter analysis

INTRODUCTION

Skip-N2 metastasis (N0N2), thus N2 metastasis in the absence of N1 metastasis, occur in approximately 20-30% of non-small cell lung cancer patients. N0N2 patients have a better prognosis than continuous-N2 metastasis (N1N2) patients following surgery. However, this effect remains controversial.Therefore, we conducted a multicentre study to compare the long-term survival and disease-free interval (DFI) of N1N2- and N0N2 patients.

METHODS

One- and three -year survival rates were measured. Kaplan-Meier curves and a Cox proportional hazards model assessed survival and were used to identify prognostic factors for overall survival. In addition, we performed propensity score matching (PSM) to rule out confounding factors. All patients received adjuvant chemoradiation therapy according to European guidelines.

RESULTS

Between January 2010 and December 2020, 218 stage IIIA/B N2 patients were included in our analysis. The Cox regression analysis revealed that N1N2 significantly influenced the overall survival rate. Before PSM, N1N2 patients showed significantly more metastatic lymph nodes (p < 0.001) and significantly larger tumors (p = 0.05). After PSM, baseline characteristics did not differ between groups. Before and after PSM, N0N2 patients showed significantly better one- (p = 0.01; p = 0.009), -three-year (p < 0.001) and survival rates than N1N2 patients. Furthermore, N0N2 patients showed significantly longer DFI than N1N2 patients before and after PSM (p < 000.1).

CONCLUSION

Prior- and after PSM analysis, N0N2 patients were confirmed to have better survival and DFI than N1N2 patients. Our results demonstrate that stage IIIA/B N2 patients are heterogeneous and would benefit from a more precise subdivision and differential treatment.

The impact of thymectomy in subgroups of Myasthenia gravis patients: a single center longitudinal observation

BACKGROUND

Myasthenia gravis (MG) is a rare neuromuscular disorder. Symptoms can range from ptosis only to life threatening myasthenic crisis. Thymectomy is recommended for anti-acetylcholine receptor-antibody positive patients with early-onset MG. Here, we investigated prognostic factors shaping therapeutic outcomes of thymectomy to improve patient stratification.

METHODS

We retrospectively collected single-center data from a specialized center for MG from all consecutive adult patients that underwent thymectomy from 01/2012 to 12/2020. We selected patients with thymoma-associated and non-thymomatous MG for further investigations. We analyzed the patient collective regarding perioperative parameters in relation to the surgical approach. Furthermore, we investigated the dynamics of the anti-acetylcholine receptor-antibody titers and concurrent immunosuppressive therapies, as well as the therapeutic outcomes in dependence of clinical classifications.

RESULTS

Of 137 patients 94 were included for further analysis. We used a minimally invasive approach in 73 patients, whereas 21 patients underwent sternotomy. A total of 45 patients were classified as early-onset MG (EOMG), 28 as late-onset MG (LOMG) and 21 as thymoma-associated MG (TAMG). The groups differed in terms of age at diagnosis (EOMG: 31.1 ± 12.2 years; LOMG: 59.8 ± 13.7 years; TAMG: 58.6 ± 16.7 years; p < 0.001). Patients with EOMG and TAMG were more often female than patients in the LOMG group (EOMG: 75.6%; LOMG: 42.9%; TAMG: 61.9%; p = 0.018). There were no significant differences in outcome scores (quantitative MG; MG activities of daily living; MG Quality of Live) with a median follow-up of 46 months. However, Complete Stable Remission was achieved significantly more frequently in the EOMG group than in the other two groups (p = 0.031). At the same time, symptoms seem to improve similarly in all three groups (p = 0.25).

CONCLUSION

Our study confirms the benefit of thymectomy in the therapy of MG. Both, the concentration of acetylcholine receptor antibodies and the necessary dosage of cortisone therapy show a continuous regression after thymectomy in the overall cohort. Beyond EOMG, groups of LOMG and thymomatous MG responded to thymectomy as well, but therapy success was less pronounced and delayed compared to the EOMG subgroup. Thymectomy is a mainstay of MG therapy to be considered in all subgroups of MG patients investigated.

Long-term outcomes after minimal right lateral thoracotomy for the resection of cardiac tumors

OBJECTIVES

Cardiac tumors are a rare and heterogeneous entity, with a cumulative incidence of up to 0.02%. This study aimed to investigate one of the largest patient cohorts for long-term outcomes after minimally-invasive cardiac surgery using right-anterior thoracotomy and femoral cardiopulmonary bypass (CPB) cannulation.

METHODS

Between 2009 and 2021, patients who underwent minimally-invasive cardiac tumor removal at our department were included. The diagnosis was confirmed postoperatively by (immune-) histopathological analysis. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed.

RESULTS

Between 2009 and 2021, 183 consecutive patients underwent surgery for a cardiac tumor at our department. Of these, n = 74 (40%) were operated on using a minimally-invasive approach. The majority, n = 73 (98.6%), had a benign cardiac tumor, and 1 (1.4%) had a malignant cardiac tumor. The mean age was 60 ± 14 years, and n = 45 (61%) of patients were female. The largest group of tumors was myxoma (n = 62; 84%). Tumors were predominantly located in the left atrium in 89% (n = 66). CPB-time was 97 ± 36min and aortic cross-clamp time 43 ± 24 min s. The mean hospital stay was 9.7 ± 4.5 days. The perioperative mortality was 0%, and all-cause mortality after ten years was 4.1%.

CONCLUSION

Minimally-invasive tumor excision is feasible and safe, predominantly in benign cardiac tumors, even in combination with concurrent procedures. Patients who require cardiac tumor removal should be evaluated for minimally-invasive cardiac surgery at a specialized center, as it is highly effective and associated with good long-term survival.

A comparative study of four thoracic mortality scores

BACKGROUND

The percentage of patients in resectable stages at initial diagnosis of non-small cell lung cancer (NSCLC) raises due to better screening programs. Therefore, risk prediction models are becoming more critical. Here, we validated and compared four established scoring models, the Thoracoscore, Epithor, Eurloung 2, and the simplified Eurolung 2 (2b), in their ability to predict 30-day mortality.

METHODS

All consecutive patients undergoing anatomical pulmonary resection were included. The performance of the four scoring systems was assessed with Hosmer-Lemeshow goodness-of-fit test (calibration) and receiver operating characteristic (ROC) curves (discrimination). We compared the area under the curve (AUC) of the ROC curves by DeLong's method.

RESULTS

A total of 624 patients underwent surgery for NSCLC at our institution between 2012 and 2018 30-day mortality was 2.2% (14 patients). The AUC for Eurolung 2 and the simplified Eurolung 2 (0.82) were greater than those of the other scoring systems, Epithor (0.71) and Thoracoscore (0.65). In addition, the DeLong analysis showed a significant superiority of Eurolung 2 and Eurolung 2b over the Thoracoscore (p = 0.04); there were no significant differences compared to Epithor.

CONCLUSION

Eurolung 2 and the simplified Eurolung 2 were the favorable scoring systems for predicting 30-day mortality compared to Thoracoscore and Epithor. Therefore, we recommend using Eurolung 2 or the simplified Eurolung 2 for preoperative risk stratification.

Prognostic impact of lymph node spreading pattern in N2 NSCLC patients

BACKGROUND

One-third of non-small cell lung cancer (NSCLC) patients are diagnosed with locally advanced disease. Long-term survival in stage IIIA/B-N2 remains poor; this may also be due to lymph node spreading pattern. Therefore, we compared the overall survival of stage IIIA/B-N2 patients with superior mediastinal lymph nodes (SML) with infracarinal- or inferior mediastinal lymph nodes (IML) and with multilevel disease (MLD).

RESEARCH DESIGN AND METHODS

One-, three-and five-year survival rates were measured. Kaplan-Meier curves and Cox proportional hazards model assessed survival and were used to identify prognostic factors.

RESULTS

We reviewed data of stage IIIA/B-N2 patients (n = 129) who underwent surgery for NSCLC between 2012 and 2020. Patients with SML (n = 62) were compared to ILM (n = 37) and MLD (n = 30). SML patients showed significantly better one- (SML: 95.2% vs. IML: 78.6% vs. MLD: 69.4%, p = 0.03), three- (78.8% vs. 27.7 vs. 13.3%; p = <0.001) and five-year (61.1% vs. 17.1 vs. 3%; p < 0.001) survival rates, than IML and MLD patients. Kaplan-Meier curves showed prolonged overall survival for SML patients (log-rank SML, ILM, MLD p < 0.0001).

CONCLUSIONS

This study showed significantly better long-term survival of SML patients than IML and MLD patients. The long-term survival of ILM and MLD patients was equally poor.

Treatment of acute type A aortic dissection with the Ascyrus Medical Dissection Stent in a consecutive series of 57 cases

OBJECTIVES

The Ascyrus Medical Dissection Stent (AMDS) has been recently introduced as an alternative for total arch replacement in acute aortic dissection type A (AADA). The aim of this study was to evaluate the postoperative outcomes after AMDS treatment in a large contemporary cohort of AADA patients.

METHODS

Data acquisition was performed retrospectively at 2 German aortic centres between 2020 and 2022 and comprised the perioperative parameters and postoperative results of all AADA patients. All patients treated with the AMDS for AADA were included in the study. The primary end point was in-hospital mortality. Secondary end points were defined as early postoperative and AMDS-related complications.

RESULTS

Fifty-seven AADA patients treated by AMDS were included in the study group. The mean age was 64.6 ± 10.8 years and 59.7% (n = 34) were males. The actual in-hospital mortality was considerably lower than the predicted mortality risk by the German registry for acute aortic dissection type A score (16% vs 22%). The median ICU and in-hospital stay were 5 (interquartile range: 3-13) and 12 (interquartile range: 10-22) days, respectively. Postoperative complications comprised acute renal insufficiency (37%) with need for temporary (16%) or permanent dialysis (5%), delirium (26%), re-exploration for bleeding (14%), tracheostomy (14%) and new stroke (4%). A new AMDS-related complication (central stent collapse) was observed in 9% (n = 5) by postoperative computed tomography and chest X-ray. The incidence of complete central AMDS collapse did not impact 30-day mortality.

CONCLUSIONS

The AMDS may be successfully used in AADA with acceptable 30-day mortality in accordance with the German registry for acute aortic dissection type A score. However, careful preoperative evaluation of the patient's individual aortic anatomy regarding potential contraindications and proper device implantation are strongly recommended to avoid complete central AMDS collapse.

Predictors of acute kidney injury in patients after extracorporeal cardiopulmonary resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared with conventional CPR. Data after eCPR for acute kidney injury (AKI) are lacking. We sought to investigate factors predicting AKI in patients who underwent eCPR.

METHODS

From January 2016 until December 2020, patients who underwent eCPR at our institution were retrospectively analyzed and divided into two groups: patients who developed AKI (n = 60) and patients who did not develop AKI (n = 35) and analyzed for outcome parameters.

RESULTS

Overall, 63% of patients suffered AKI after eCPR and 45% of patients who developed AKI needed subsequent dialysis. Patients who developed AKI showed higher values of creatinine (1.1 mg/dL vs 1.5 mg/dL, p ⩽ 0.01), urea (34 mg/dL vs 42 mg/dL, p = 0.04), CK (creatine kinase) (923 U/L vs 1707 U/L, p = 0.07) on admission, and CK after 24 hours of ECMO support (1705 U/L vs 4430 U/L, p = 0.01). ECMO explantation was significantly more often performed in patients who suffered AKI (24% vs 48%, p = 0.01). In-hospital mortality (86% vs 70%; p = 0.07) did not differ significantly.

CONCLUSION

Patients after eCPR are at high risk for AKI, comparable to those after conventional CPR. Baseline urea levels predict the development of AKI during the hospital stay.

Complications associated to wound drainages in tumor spine surgery: a multicenter surveillance study from the German Spine Registry (DWG-Register)

There is an ongoing debate whether a surgical drainage is beneficial to prevent local accumulation of hematoma and to reduce the rate of wound infections, and neurological deficits. Data from the German Spine Society (DWG) registry were filtered for surgically treated spine tumor cases between 2017 and 2021. Cases were categorized into with (Group I) and without (Group II) placement of a surgical drainage. Subgroups were compared for demographic data, type of surgery, experience of the surgeon and postoperative surgical complications. 10,029 cases were included into final analysis (Group I: 3007; Group II: 7022). There was no significant difference between both groups regarding age or gender distribution. Average morbidity of patients was significantly elevated in Group I (p < 0.05) and the rates of invasive surgery were significantly increased in this group (p < 0.001). Overall complication rates were reported with 12.0% (Group I) and 8.5% (Group II). There were significantly more epidural hematoma (p < 0.001) and motor dysfunction (p = 0.049) as well as deep wound infections (p < 0.001) and implant failures (p = 0.02) in Group I. A surgical wound drainage cannot prevent epidural hematoma.

Benign and malignant cardiac masses: long-term outcomes after surgical resection

BACKGROUND

Cardiac tumors represent a rare and heterogenous pathologic entity, with a cumulative incidence of up to 0.02%. This study aimed to investigate one of the largest patient cohorts published for clinical presentation and long-term outcomes after surgical resection.

RESEARCH DESIGN

Between 2009 and 2021, 183 consecutive patients underwent surgery for tumor excision in our center. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed. The diagnosis was confirmed postoperatively by histology and Immunohistochemical investigations. Kaplan-Meier curves assessed survival, and the Cox, proportional hazards model, was used to identify prognostic factors for overall survival.

RESULTS

This series included 183 consecutive patients; most (n=169, 92.3%) were diagnosed with benign cardiac masses. The mean age of patients was 60 ± 16 years, and 48% (n=88) were females. The largest group of tumors is represented by myxoma (n = 98; 54%). The most common malignant tumor was sarcomas (n = 5; 2.7%). The mean hospital stay was 11 ± 6.5 days, and all-cause mortality after ten years was 14%.

CONCLUSION

Surgery represents the gold standard in treating primary cardiac tumors; in benign tumors, it is highly effective and curative, whereas, in malignant tumors, it remains associated with more prolonged survival.

Harmonized procedure coding system for surgical procedures and analysis of surgical site infections (SSI) of five European countries

BACKGROUND

The use of routine data will be essential in future healthcare research. Therefore, harmonizing procedure codes is a first step to facilitate this approach as international research endeavour. An example for the use of routine data on a large scope is the investigation of surgical site infections (SSI). Ongoing surveillance programs evaluate the incidence of SSI on a national or regional basis in a limited number of procedures. For example, analyses by the European Centre for Disease Prevention (ECDC) nine procedures and provides a mapping table for two coding systems (ICD9, National Healthcare Safety Network [NHSN]). However, indicator procedures do not reliably depict overall SSI epidemiology. Thus, a broader analysis of all surgical procedures is desirable. The need for manual translation of country specific procedures codes, however, impedes the use of routine data for such an analysis on an international level. This project aimed to create an international surgical procedure coding systems allowing for automatic translation and categorization of procedures documented in country-specific codes.

METHODS

We included the existing surgical procedure coding systems of five European countries (France, Germany, Italy, Spain, and the United Kingdom [UK]). In an iterative process, country specific codes were grouped in ever more categories until each group represented a coherent unit based on method of surgery, interventions performed, extent and site of the surgical procedure. Next two ID specialist (arbitrated by a third in case of disagreement) independently assigned country-specific codes to the resulting categories. Finally, specialist from each surgical discipline reviewed these assignments for their respective field.

RESULTS

A total number of 153 SALT (Staphylococcus aureus Surgical Site Infection Multinational Epidemiology in Europe) codes from 10 specialties were assigned to 15,432 surgical procedures. Almost 4000 (26%) procedure codes from the SALT coding system were classified as orthopaedic and trauma surgeries, thus this medical field represents the most diverse group within the SALT coding system, followed by abdominal surgical procedures with 2390 (15%) procedure codes.

CONCLUSION

Mapping country-specific codes procedure codes onto to a limited number of coherent, internally and externally validated codes proofed feasible. The resultant SALT procedure code gives the opportunity to harmonize big data sets containing surgical procedures from international centres, and may simplify comparability of future international trial findings.

TRIAL REGISTRATION

The study was registered at clinicaltrials.gov under NCT03353532 on November 27^th, 2017.

Hemangiosis carcinomatosa as an independent risk factor for long-term survival in Non-Small Cell Lung Cancer patients

OBJECTIVES

Recent studies have shown that blood vessel invasion (V1) influences the long-term survival of patients with Non-Small Cell Lung Cancer (NSCLC). The aim of the present study was to emphasize V1 as an independent risk factor. We evaluated the effects of V1 on the survival of NSCLC patients with UICC stages I, II, and III after surgery.

METHODS

This retrospective study includes 747 consecutive patients with NSCLC who underwent anatomic resection and radical lymphadenectomy at our institution between January 2012 and December 2020. V1- were compared to V0-patients (no blood vessel invasion). All patients received adjuvant therapy according to European guidelines when indicated. After excluding patients with detection of lymphangiosis carcinomatosa, tumor-cells at the resection margin, distant metastases and those, that received neoadjuvant therapy, 1-, 3- and 5- year survival rates were assessed by Kaplan-Meier method. To proof V1 as an independent risk factor, a propensity score matched (PSM) analysis was performed regarding age, gender, UICC-stage, lymph-node involvement, and comorbidities.

RESULTS

A total of 461 patients (V0: 440; V1: 21) were included in this analysis. Baseline characteristics did not show any significant difference. Mean age in V0-group was 65.7 ± 10.5 years and 64.1 ± 8.6 years in V1-group (p-value = 0.5). In the V0-group 54.8% were male, whereas in the V1-group this number was 66.7% (p-value = 0.37). Mean survival in V1-group was significantly shorter compared to V0-group (V1: 45.8 ± 9.3 months; V0: 81.1 ± 1.1 months; p-value<0.001). This was confirmed after applying a propensity score matched analysis (V0: 99.9 ± 4.9 months; V1: 45.8 ± 9.3 months; p-value<0.001) - V1 is a prognostic marker independent of UICC stage. The 1-, 3- and 5-year survival rates were significantly shorter for V1-patients (1-year: V0: 100%; V1: 70.6%; p-value = 0.012) (3-year: V0: 95.2%; V1: 46.2%; p-value = 0.002) (5-year: V0: 90.5%; V1: 36.4%; p-value = 0.003).

CONCLUSION

As we have shown with our investigations, V1 has a major impact on long-term survival in NSCLC patients and furthermore, acts as an independent risk factor. Due to our small but specified sample size, our statement should be confirmed by a multicenter study. In the meantime, we suggest making the implementation of the V0/V1 specification mandatory in the tumor classification.

Cardiac tumors-sex-related characteristics and outcomes after surgical resection

OBJECTIVES

Cardiac tumors represent a rare and heterogeneous pathological entity, with a cumulative incidence of up to 0.02%. Gender was previously reported to influence outcomes after tumor surgery. This study aimed to investigate for gender-related differences in outcomes after cardiac surgery.

METHODS

Between 2009 and 2021, 95 male and 88 female patients underwent surgery for tumor extirpation in our center. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed. The diagnosis was confirmed postoperatively by (immune-)histopathological analysis.

RESULTS

There were no significant differences in baseline characteristics and survival. Myxoma was the most common tumor type overall and was more diagnosed in women (n = 36 vs. n = 62, p ≤ 0.001). Sarcoma was the most common malignant tumor type (n = 5). Tumor location at the atrial septum was more likely in women (n = 26 vs. n = 16, p = 0.041), whereas ventricular localization was more common in male patients (n = 20 vs. n = 7, p = 0.001). Minimally invasive tumor extirpation was significantly more often performed in women, and in-hospital stay was shorter in female patients.

CONCLUSION

The localization and dignity of cardiac tumors differ between genders, not affecting survival. Surgical tumor extirpation remains the gold standard of treatment for cardiac tumors in both genders as it is highly effective and associated with good long-term survivorship.

Different pulmonary adenocarcinoma growth patterns significantly affect survival

OBJECTIVE

Adenocarcinoma (AC) is the number one pathological entity of lung cancer with approximately 30-40% of cases. It is known to be heterogeneous and has 5 histopathological growth patterns. We evaluated the long-term survival rates of patients with predominant subtypes.

METHODS

290 patients with AC underwent pulmonary resection between 2012 and 2017 at our institution. We excluded all patients with lymph node involvement and distant metastases. Hence, 163 patients were included for further analysis. Predominant growth pattern was defined if more than 10% of cells showed a growth pattern. 1, 3, and 5-year survival rates were evaluated. Survival was assessed by Kaplan-Meier curves and the Cox proportional hazards model was used to identify prognostic factors for overall survival.

RESULTS

Predominant growth patterns >10% were compared to <10% growth patterns of the same subtype. 1-year, 3-year, and 5-year overall survival rates of patients with predominant solid tumor growth >10% differed significantly from patients with <10% (88.4% vs. 97.6%, p = 0.04; 65.8% vs. 87.4% p = 0.001, 36.4% vs. 65.9% p = 0.01). Survival rates did not differ between >10% papillary and acinar growth compared to <10%. Kaplan-Meier curves showed reduced overall survival for patients with solid tumor growth >10% (log-rank 0.002). Solid tumor growth >10% was an independent prognostic factor for worse long-term survival (Hazard ratio: 3.05, p = 0.01).

CONCLUSION

Our study demonstrates that the presence of a predominant solid pattern in pulmonary adenocarcinoma is a factor for an unfavorable prognosis. This should be kept in mind in daily clinical practice.

Impact of left ventricular unloading using a peripheral Impella®-pump in eCPR patients

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to increasing survival rates in selected patients. Additional left ventricular mechanical unloading, using a transfemoral micro-axial blood pump (Impella® Denver, Massachusetts, USA), might improve patients' outcomes. In this regard, we sought to investigate patients who suffered OHCA (out-of hospital cardiac arrest) or IHCA (in-hospital cardiac arrest) with subsequent eCPR via VA-ECMO (veno-arterial extracorporeal membrane oxygenation) and concomitant Impella® implantation based on survival and feasibility of ECMO weaning.

METHODS

From January 2016 until December 2020, 108 patients underwent eCPR at our institution. Data prior to eCPR and early outcome parameters were analyzed comparing patients who were supported with an additional Impella® (2.5 or CP) (ECMO+Impella®, n = 18) and patients without additional (ECMO, n = 90) support during V-A ECMO therapy. The primary endpoint was in-hospital mortality; secondary endpoints were, among others: ECMO explantation, need for hemodialysis, stroke, and need for blood transfusions.

RESULTS

Low-flow time was significantly lower in the ECMO+Impella group (60 min vs. 55 min, p = .01). All-cause mortality was significantly lower in the ECMO+Impella® group (82% vs. 56%, p = .01). The time of circulatory support was shorter in the ECMO cohort (2.0 ± 1.73 vs. 4.76 ± 2.88 p = .05). ECMO decannulation was significantly more feasible in patients with ECMO+Impella® (72% vs. 32%, p = .01). Patients treated with additional Impella® showed significantly more acute kidney injury with the need for dialysis (72% vs. 18%, p ≤ .01).

CONCLUSION

Concomitant Impella® support might positively influence survival and ECMO weaning in eCPR patients. Treatment-associated complications such as the need for dialysis were more common in this highly selected patient group. Further studies with larger numbers are necessary to evaluate the clinical relevance of concomitant LV-unloading in eCPR patients using an Impella® device.

Outcomes after mechanical versus manual chest compressions in eCPR patients

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (eCPR) is an established treatment option for cardiac arrest. Mechanical reanimation devices are increasingly used but have been associated with complications. This study evaluates typical injury patterns and differences after mechanical versus manual chest compressions among patients undergoing eCPR.

METHODS

From 2016 to 2020, 108 eCPR patients were retrospectively analyzed. Primary endpoints were traumatic, hemorrhagic, or inner organ-related complications, defined as pneumothorax, pulmonary bleeding, major bleeding, gastrointestinal bleeding, gastrointestinal ischemia, cardiac tamponade, aortic dissection, sternal or rib fracture.

RESULTS

70 patients were treated with mechanical CPR (mCPR) and 38 with conventional CPR (cCPR). There were more CPR-related injuries in the mCPR group (55% vs. 83%, p = 0.01), CPR duration was longer (cCPR 40 ± 28 min vs. mCPR 69 ± 25 min, p = 0.01). There was no significant difference in mortality between the groups.

CONCLUSION

Mechanical CPR devices are associated with a higher incidence of traumatic and hemorrhagic injuries in patients undergoing eCPR.

[The value of thymectomy in the treatment of non-thymomatous myasthenia gravis]

The value of thymectomy in the treatment of non-thymomatous myasthenia gravis has been controversially discussed. The relatively low incidence and prevalence of this disease, the inconsistent documentation in various studies and the necessity of a long-term follow-up to assess the therapeutic effects has made the generation of valid data difficult. The publication in 2016 of the MGTX trial in the New England Journal of Medicine delivered the first randomized controlled data in which patients aged 18-65 years with generalized myasthenia gravis and positive for acetylcholine receptor antibodies showed a significant benefit after surgical resection of the thymus via median sternotomy. Despite a lack of validation of the advantages of thymectomy by minimally invasive surgery from randomized controlled studies, this technique seems to positively influence the outcome of certain patient groups in a similar way. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) using subxyphoidal and transcervical access routes showed not only esthetic advantages but also showed no relevant inferiority in the influence on clinical outcomes of myasthenia gravis compared to median sternotomy; however, not only the benefits and the esthetic results show differences but also the advantages in the various subtypes of myasthenia gravis show divergent prospects of success with respect to remission. The clinical spectrum of myasthenia is heterogeneous with respect to the occurrence of antibodies, the body region affected and the age of the patient at first diagnosis. Ultimately, thymectomy is an effective causal treatment of myasthenia gravis.

Gender-related propensity score match analysis of ECMO therapy in postcardiotomy cardiogenic shock in patients after myocardial revascularization

BACKGROUND

Gender is known to influence the pathophysiology and pathogenesis of the coronary vascular disease. Data on gender-related differences in patients with veno-arterial extracorporeal membrane oxygenation due to postcardiotomy cardiogenic shock is lacking in current literature. We aimed to analyze the impact of gender on intraoperative and short-term outcomes of vaECMO patients after coronary surgery and postcardiotomy cardiogenic shock.

METHODS

Between 2006 and 2017, a total of 92 patients with PCS after CABG underwent vaECMO-implantation at our institution. After a 1:1 propensity score match (PSM) for relevant preoperative data, we identified a cohort of 32 patients, 16 males, and 16 females. Periprocedural and short-term outcome data were analyzed with respect to sex differences.

RESULTS

The mean age was 64 ± 11 years, and 79% (n = 73) were male patients. Clinical outcomes showed a 30-day all-cause mortality of 64% (n = 59). After PSM, male patients showed a significantly smaller number of arterial grafts (0.4 ± 0.53 male vs 1.1 ± 0.7 female; p = 0.037). Thirty-day all-cause mortality did not differ between the groups (56% male vs 75% female; p = 0.262). In general, short-term outcome data were comparable without significant differences for the matched groups.

CONCLUSION

Gender has no impact on patients with vaECMO therapy due to PCS in isolated coronary surgery.

Results and outcomes for patients with atrioventricular groove disruption after mitral valve surgery

BACKGROUND

Atrioventricular groove disruption (AVGD) is a rare and severe complication of mitral valve surgery (MVS). Current literature is limited to several case reports and series. Our aim was to analyze outcomes of patients with AVGD after MVS from our tertiary cardiac surgery center.

METHODS

Between June 2010 and January 2019, 18 patients suffering AVGD were identified in our institutional database and included in our retrospective observation. Preoperative, intraoperative and outcome data were analyzed using IBM SPSS Statistics. Late survival was estimated by using the Kaplan-Meier survival analysis.

RESULTS

The mean age of the study population was 76 ± 5 years. Most common indication for MVS was an isolated mitral valve insufficiency (67%). Severe annular calcification was present in four patients (22%). Majority of implanted valves were biological prosthesis (78%). Due to the location, 72% suffered type I rupture. External repair was performed in 94% of all patients. Second look operation in regard of excessive mediastinal hemorrhage was necessary in 67% of patients. Mean hospital stay of the presented collective was 13 ± 11 days with an intra-hospital mortality of 56%. Late follow-up was obtained in eight patients at an average of 3.1 (1.6-5.7) years postoperatively.

CONCLUSION

Mortality rates for AVGD after MVS are high. However, way of managing AVGD depends on the underlying type of rupture and should be evaluated in regard of the myocardial damage. Due to the rare occurrence, registry data might help to address more scientific value concerning therapeutic measures and outcomes of this severe complication.

Perigraft reaction and incorporation of porcine and bovine pericardial patches

OBJECTIVES

Bovine and porcine pericardial patches are frequently used in cardiothoracic and vascular surgery. There are no guidelines recommending the usage of these patches for particular surgical approaches. However, these 2 materials supposedly possess different properties. The clinical advantage of porcine compared with bovine patches remains controversial. In this experimental study, we analysed the incorporation and vascularization of bovine and porcine pericardial patches during the initial phase after implantation.

METHODS

Bovine and porcine pericardial patches were implanted into the dorsal skinfold chamber of C57BL/6 mice (n = 8 per group) to study vascularization and inflammation at the implantation site using repetitive intravital fluorescence microscopy over a 14-day period. At the end of the in vivo experiments, CD-31-positive cells were determined to evaluate the vascularization by immunohistochemistry. Furthermore, cell proliferation and apoptosis were analysed immunohistochemically.

RESULTS

Implanted bovine patches exhibited an enhanced vascularization, as indicated by a significantly higher number of CD-31-positive cells and micro-vessels (23.2 ± 4.3 vs 16.5 ± 5.8 mm-2; P = 0.001). Furthermore, bovine patches showed a slightly but not significantly higher functional capillary density. Both patches induced a moderate leukocytic inflammatory host tissue response, and neither bovine nor porcine patches significantly affected apoptosis and cell proliferation at the implantation site.

CONCLUSIONS

Bovine and porcine pericardial patches are similarly suitable for surgery. Bovine patches exhibited an improved vascularization during the first 14 days after implantation. This may result in a quicker and improved incorporation into the surrounding tissue compared with porcine pericardial patches.

Postoperative long-term survival of non-small cell lung cancer patients with skip-N2 metastases

OBJECTIVE

Radical lymphadenectomy is crucial in operations for non-small cell lung cancer (NSCLC). Usually pN1 and pN2 lymph nodes are affected consecutively (N1N2). Nevertheless, pN2 metastases may also occur in the absence of pN1 as skip-N2 metastases (N0N2). Here we compare the long-term survival of N1N2- and N0N2 patients.

MATERIALS AND METHODS

464 patients underwent surgery for NSCLC at our institution between 2012 and 2017. We retrospectively reviewed data of pN2 stage patients (n = 68). Patients with N1N2 (n = 39) were compared to N0N2 (n = 29) patients. 1-, 3-and 5-year survival rates were measured. Survival was assessed by Kaplan-Meier curves and the cox proportional hazards model was used to identify prognostic factors for overall survival. All patients received adjuvant chemoradiation therapy according to European guidelines.

RESULTS

The baseline characteristics did not differ between groups. We observed no differences in the histology, localization, or gender in our cohort. N0N2 patients showed significantly better 1- (N1N2: 82.4% vs. N0N2 100%; p = 0.001), 3- (14.7% vs. 63.6%; p=<0.001) and 5-year (9.4% vs. 43.8%; p = 0.001) survival rates. Tumor size (Hazard ratio (HR) 1.46, Confidence interval (CI 95%) 1.03-2.04; p = 0.03) and the occurrence of N1N2 (HR 4.26, CI 2.04-8.91; p < 0.0001) were independent prognostic factors for worse long-term survival. The Kaplan-Meier curves showed a reduced overall survival for N1N2 patients (log-rank N1N2, N0N2 p < 0.0001).

CONCLUSION

N1N2 patients have a significantly worse prognosis compared to N0N2 patients. This will aid to classify the heterogeneous pN2-NSCLC patient population more precisely. Further, multimodal therapy should be considered for N1N2 patients.

Rapid Deployment Aortic Valve Replacement with the Perceval S and Intuity Elite

BACKGROUND

 Rapid deployment aortic valve replacement (RDAVR) has emerged as an alternative to conventional aortic valve replacement. This single-center study retrospectively analyzed clinical outcomes and hemodynamic performance of the Perceval S (LivaNova) and Intuity Elite (Edwards LifeSciences) rapid deployment valves (RDVs) in a propensity score matched patient cohort.

METHODS

 A total of 372 consecutive patients with symptomatic aortic valve stenosis underwent RDAVR between 2012 and 2018 at our institution. The Intuity Elite (INT group) and Perceval S (PER group) were implanted in 251 and 121 patients, respectively. After 1:1 propensity score matching for relevant preoperative comorbidities, 107 patient pairs were compared with respect to relevant perioperative data including hemodynamic parameter, postoperative pacemaker implantation, and 30-day all-cause mortality.

RESULTS

 Propensity score matching resulted in balanced characteristics between groups. Cardiopulmonary bypass and aortic cross-clamp time did not differ between groups, but more patients in the INT group received coronary artery bypass grafting compared with the PER group (56 vs. 42%; p = 0.055). Thirty-day mortality (4.7 vs. 2.2%) and need for permanent pacemaker implantation (7 versus 4.4%) were comparable between the INT and PER groups for isolated AVR and also for combined procedures, respectively. Cerebrovascular events showed comparable low rates for both RDVs (INT group [1.9%] vs. PER group [2.8%]). Indexed effective orifice area was higher in the INT group (0.90 vs. 0.82 cm²/m²) and coupled to a lower peak (17 ± 7 vs. 22 ± 8) and mean (10 ± 5 vs. 12 ± 4) pressure gradients compared with the PER group.

CONCLUSIONS

 Our propensity score analysis in AVR patients showed good hemodynamic characteristics with comparable 30-day mortality rate and complications rates for both investigated RDVs.

Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North-Rhine-Westphalia Surgical Myocardial Infarction Registry

Background

Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and ST‐segment–elevation myocardial infarction (STEMI).

Methods and Results

Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score.

Conclusions

Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

Major Bleeding after Surgical Revascularization with Dual Antiplatelet Therapy

OBJECTIVE

Patients with acute coronary syndrome are treated with dual antiplatelet therapy containing acetylsalicylic acid (ASA) and P2Y12 antagonists. In case of urgent coronary artery bypass grafting this might be associated with increasing risks of bleeding complications.

METHODS

Data from 1200 consecutive urgent operations between 2010 and 2018 were obtained from our institutional patient database. For this study off-pump surgery was excluded. The primary composite end point major bleeding consisted of at least one end point: transfusion ≥ 5 packed red blood cells within 24 hours, rethoracotomy due to bleeding, chest tube output >2000 mL within 24 hours. Demographic data, peri-, and postoperative variables and outcomes were compared between patients treated with mono antiplatelet therapy, ASA + clopidogrel (ASA-C) +ticagrelor (ASA-T) or +prasugrel (ASA-P) < 72 hours before surgery. Furthermore, we compared patients with dual antiplatelet therapy with ASA monotherapy.

RESULTS

From 1,086 patients, 475 (44%) received dual antiplatelet therapy. Three-hundred seventy-two received ASA-C (77.7%), 72 ASA-T (15%), and 31 ASA-P (6.5%). Major bleeding (44 vs. 23%, p < 0.0001) was more frequently in patients receiving dual therapy with higher rates of massive drainage loss within 24 hours (23 vs. 11%, p < 0.0001) of mass transfusion (34 vs. 16%, p < 0.0001) and rethoracotomy (10 vs. 5%, p = 0.002) when compared with ASA. In this analysis, ASA-T and ASA-P were not associated with higher bleeding complications compared with ASA-C.

CONCLUSION

Dual antiplatelet therapy is associated with higher rates of major bleeding. Further studies should examine the difference in the prevalence of major bleeding complications in the different dual antiplatelet therapy regimes in patients requiring urgent surgery.

[Chest wall replacement]

The optimal surgical reconstruction of chest wall defects especially in the context of posttraumatic, oncological and congenital etiologies has a large impact on the recovery of the patients. Regardless of the etiology, various complications, such as a generally impaired respiratory physiology in an unstable thorax or decreased pulmonary clearance associated with acute and chronic pulmonary infections, may impair the recovery of affected patients. The postoperative occurrence of an intrathoracic dead space may lead to a difficult to treat empyema. Each thoracic wall defect must be accurately assessed and treated according to size, depth and location on the chest. The complexity of this condition and the resulting complications require the highest degree of surgical care which should be interdisciplinary both preoperatively and postoperatively.

Minimally invasive resection of a giant left atrial myxoma: a case report

Cardiac tumors are a rarity. Most diagnosed primary tumors of the heart are benign, with an incidence ranging between 0.001% and 0.03%. Cardiac myxoma is one of these benign entities. A 44-year-old Caucasian woman who presented with symptoms of a common cold was diagnosed with a massive obstructing myxoma of the left atrium. Despite its large size, the tumor was completely removed using minimally invasive access through right anterior thoracotomy. However, the myxoma was adherent to the left atrial septum and was excised in toto. Pathological examinations confirmed the diagnosis of a primary cardiac myxoma. Total resection of obstructive cardiac myxomas is the therapy of choice, whereas minimally invasive surgical approach might be feasible despite large size and septal localization, but is technically challenging.

Constrictive pericarditis with a life-threatening giant pericardial cyst and pectus excavatum as unusual cause for malign cardiac arrhythmias

Pericardial cysts are rare, abnormal, benign and usually congenital anomalies with an estimated incidence of 1:100.000 and are caused by an incomplete coalescence of foetal lacunae of pericardium development. The size of pericardial cysts varies from 1 to 5 cm and generally do not cause any symptoms. Pectus excavatum is one of the most frequent chest wall abnormalities with a caved-in appearance of the chest and mostly of unknown pathogenesis. We present a rare case of constrictive pericarditis with a huge pericardial cyst (11.6 × 8.7 × 7.1 cm) and pectus excavatum which led to compression of the heart and life-threatening cardiac arrhythmias.

Impact of ascending aortic, hemiarch and arch repair on early and long-term outcomes in patients with Stanford A acute aortic dissection

BACKGROUND:

Stanford A acute aortic dissection (AAD) is a life-threatening emergency associated with major morbidity and mortality. The aim of this study was to compare outcomes of three different surgical approaches in patients with Stanford A AAD.

METHODS:

From January 2006 to March 2015 a total of 240 consecutive patients with diagnosed Stanford A AAD underwent elective, isolated surgical aortic repair in our centre. Patients were divided into three groups according to the extent of surgical repair: isolated replacement of the ascending aorta, hemiarch replacement and total arch replacement. Patients were followed up for up to 9 years. After univariate analysis multinomial logistic regression was performed for subgroup analysis. Baseline characteristics and endpoints as well as long-term survival were analysed.

RESULTS:

There were no statistically significant differences among the three groups in terms of demographics and preoperative baseline and clinical characteristics. Incidence of in-hospital stroke ( p = 0.034), need for reopening due to bleeding ( p = 0.031) and in-hospital mortality ( p = 0.017) increased significantly with the extent of the surgical approach. There was no statistical difference in terms of long-term survival ( p = 0.166) among the three groups. Applying multinomial logistic regression for subgroup analysis significantly higher odds for stroke ( p = 0.023), reopening for bleeding ( p = 0.010) and in-hospital mortality ( p = 0.009) for the arch surgery group in comparison to the ascending aorta surgery group as well as significantly higher odds for stroke ( p = 0.029) for the total arch surgery group in comparison to the hemiarch surgery group were identified.

CONCLUSIONS:

With Stanford A AAD the incidence of perioperative complications increased significantly with the extent of the surgical approach. Subgroup analysis and long-term follow up in patients undergoing isolated ascending or hemiarch surgery showed a lower incidence of cerebrovascular events compared with surgery for total arch replacement.

Impact of age on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection

Objectives:

Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in older patients and requiring immediate surgical repair. The aim of this study was to evaluate early outcome and short- and long-term survival of patients under and above 65 years of age.

Methods:

Two hundred and forty patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015 in our center. After statistical analysis and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up, comprising patients under and above 65 years of age.

Results:

The proportion of patients above 65 years of age suffering from Stanford A AAD was 50% (n=120). The group of patients above 65 years of age compared to the group under 65 years of age showed statistically significant differences in terms of higher odds ratios (OR) for hypertension (p=0.012), peripheral vascular disease (p=0.026) and tachyarrhythmia absoluta (p=0.004). Patients over 65 years of age also showed significantly poorer short- and long-term survival. Our subgroup analysis revealed that male patients (Breslow p=0.001, Log-Rank p=0.001) and patients suffering with hypertension (Breslow p=0.003, Log-Rank p=0.001) were reasonable for these results whereas younger and older female patients showed similar short- and long-term outcome (Breslow p=0.926, Log-Rank p=0.724). After stratifying all patients into 4 age groups (<45; 55-65; 65-75; >75years), short-term survival of the patients appeared to be significantly poorer with increasing age (Breslow p=0.026, Log-Rank p=0.008) whereas long-term survival of patients free from cerebrovascular events (Breslow p=0.0494, Log-Rank p=0.489) remained similar.

Conclusions:

All patients referred to our hospital for repair of Stanford A AAD with higher age had poorer short- and long-term survival, caused by male patients and patients suffering from hypertension, whereas survival of women and survival free from cerebrovascular events of the entire patient cohort was similar, irrespective of age.

Angiosarcoma of the Left Atrium: A Case Report

Background  Primary cardiac tumors are rare, and many diagnosed tumors are benign with an incidence of 0.001% to 0.03%. The primary angiosarcoma is one of the malignant entities.

Discussion  We discuss a case report of a 76-year-old male who underwent a preoperative diagnosis for an upcoming shoulder operation when his cardiologist diagnosed a large cardiac tumor. The patient was referred to our department where he received further diagnostics. The transesophageal echocardiography and the cardiac-magnetic resonance imaging showed a massive tumor with a dimension of 8.6 × 5.6 cm with no signs of malignity.

Method  The operation was performed by standard median sternotomy. The tumor was adherent to the septum and the left atrium, and we were able to remove the specimen in toto. Pathological examinations showed an angiosarcoma with neovascularization and core expression of ERG+ and cytoplasmic expression of CD31+/CD34+, due to the size of the mass. The resection of primary cardiac tumors is mostly the therapy of choice, but in this case concerning an angiosarcoma the prognosis is poor, considering that the angiosarcoma responds very badly to chemotherapy and radiotherapy.