Open redo thymectomy for a large recurrent thymoma in a patient with myasthenia gravis: a case report

Thoracoscopic and robotic approaches are becoming increasingly popular for thymoma surgery. Yet open thymectomy must still be mastered today, as it may be the only viable option in challenging cases. In this study, we report a case of an extended local recurrence of myasthenia gravis associated thymoma and a history of previous sternotomy. The mediastinal mass infiltrated the left upper lobe of the lung, the pericardium, and presumably the aortic arch. Although the standard for thymoma resection at our institution is the robotic approach, we performed primary open redo thymectomy in standby of cardiopulmonary bypass in this case. Intraoperatively, bleeding from the aortic arch occurred, which was promptly controlled due to the open approach and due to immediate availability of cardiopulmonary bypass. The patient was transferred to the normal ward on the first postoperative day, was treated according to fast-track principles and recovered well. The pathology revealed a WHO B2:B1 thymoma with negative resection margins. Thymectomy is recommended as the principal treatment for thymoma and is also advised in the case of recurrence. However, there is no evidence regarding the optimal surgical approach. Our case indicates that in the era of minimally invasive thymectomy, the decision to conduct open surgery is wise when the risk of serious bleeding is anticipated or adherence to oncologic principles is challenged by tumor size or growth pattern.

Left subclavian artery rerouting and selective perfusion management in frozen elephant trunk surgery

INTRODUCTION

The frozen elephant trunk (FET) technique enables combined aortic arch and descending aortic repair. We report our experience with a modified arch replacement technique by rerouting of the left subclavian artery (LSA) and fixation of the FET in Zone 2 or proximally under selective perfusion of all three arch arteries and the downstream aorta.

MATERIAL AND METHODS

From January 2005 to December 2014, 78 of 173 patients operated with the FET technique underwent rerouting of the LSA. Rerouting was performed as aortic-subclavian, aorto-axillary or carotid-subclavia bypass. Hypothermic selective antegrade cerebral perfusion was established for cerebral protection. A separate cardiopulmonary bypass circuit was added for selective LSA and downstream aorta perfusion during the arch repair.

RESULTS

In-hospital mortality, stroke and paraplegia rates were 10%, 8% and 2.5%, respectively. LSA rerouting enabled total arch repair in <60 minutes of selective cerebral perfusion (mean 56 ± 15). No recurrent nerve palsy occurred. The selective perfusion of the downstream aorta led to the reduction of the distal hypothermic circulatory arrest time close to 30 minutes (p < 0.0001).

DISCUSSION

LSA rerouting facilitates arch aortic repair by FET surgery. The selective perfusion of all arch arteries and the downstream aorta during open arch repair reduces the ischemic times and may improve organ protection.

Comparison of mid-term haemodynamic performance between the BioValsalva and the BioIntegral valved conduits after aortic root replacement

OBJECTIVES

We retrospectively compared the haemodynamic performance of the BioValsalva (BV) and BioIntegral (BI) biological aortic-valved conduits in the aortic root position.

METHODS

Between July 2008 and June 2014, a total of 55 patients underwent aortic root replacement using the BV conduit (n = 27) or the BI conduit (n = 28). The primary study endpoints were haemodynamic performance during follow-up, including mean pressure gradients (MPGs) and effective orifice areas (EOAs). Secondary study endpoints were early postoperative outcomes within 30 days and survival.

RESULTS

Both groups did not differ in regard to demographics (BV: median age 71 years, 70.4% female; BI: median age 66 years, 85.7% female, P = 0.15 and P = 0.17) and risk profile (median EuroSCORE-II BV: 3.8 vs 5.3% for BI, P = 0.38). A total of 20% of the total patients (BV 5/27, 18.5% vs BI 6/28, 21.4%) presented with acute type-A aortic dissection. During follow-up, both groups showed no difference in MPGs for all valve sizes [BV, 11.0 mmHg (8.3-14.8 mmHg) vs BI, 11.5 mmHg (9.0-13.0), P = 0.82]. Similar results were achieved for EOAs for all valve sizes [BV, 1.85 cm(2) (1.55-2.21) vs BI, 1.80 cm(2) (1.64-1.83), P = 0.24]. Moreover, there was no statistically significant difference in aortic regurgitation (AR) with none/trace AR in (21/23) 91.3% in BV patients versus (16/21) 76.2% in BI patients (P = 0.23) at follow-up. Both groups showed a high rate of concomitant procedures (BV: 59.3% vs BI: 71.4%, P = 0.40) and emergency indication (BV: 18.5% vs BI: 21.4%, P = 0.79), resulting in an overall 30-day mortality rate of 7.3% (4/55 patients).

CONCLUSIONS

The present small single-centre study is one of the first to evaluate and compare the BioValsalva and BioIntegral biological aortic-valved conduit in the aortic root position. Both conduits showed optimal haemodynamic results with a low incidence of aortic regurgitation.

Urinary [TIMP-2]*[IGFBP7] for early prediction of acute kidney injury after coronary artery bypass surgery

Background

Acute kidney injury (AKI) is a common complication after cardiac surgery. Currently, prediction of AKI with classical tools remains uncertain. Therefore, it was the aim of the present study to evaluate two new urinary biomarkers—insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2) in patients after coronary artery bypass surgery (CABG).

Methods

In a prospective cohort study, 60 consecutive patients undergoing isolated on-pump CABG were enrolled. Urine samples collected every 12 h in the postoperative course were analyzed for the product of TIMP-2 and IGFBP7. Urinary output, serum creatinine and estimated glomerular filtration rate (eGFR) were recorded simultaneously. Primary clinical endpoint was the development of AKI stage 2 or 3 according to the classification of the KDIGO within 48 h after surgery.

Results

48 male and 12 female patients with a mean age of 69.61 ± 8.4 years were included. 19 patients developed an AKI (31.6 %), six patients met the endpoint with AKI 2 or 3 (10 %). Urinary [TIMP-2]*[IGFBP7] increased significantly as early as 4 h after CABG in patients with AKI 2/3 (1.83 ± 2.15 vs. 0.23 ± 0.45, p < 0.05) whereas serum creatinine did not increase until 48 h after surgery. The diagnostic accuracy of [TIMP 2]*[IGFBP7] on day one after surgery for the prediction of AKI 2/3 was significantly better (sensitivity 0.89, specificity 0.81, AUC 0.817, 95 % CI 0.622–1.0 SE 0.099, p = 0.022, cut-off 0.817) than for serum creatinine (AUC 0.359, sensitivity 0.50, specificity of 0.52, cut-off value 1.17 mg/dl) and eGFR.

Conclusion

Urinary [TIMP-2]*[IGFBP7] represents a sensitive and specific biomarker to predict moderate to severe AKI very early after CABG. Analyses from our ongoing larger study are necessary to confirm these findings and probably increase sensitivity and specificity.