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Journal and News Scan
A stimulating editorial triggered by tri-species autopsy work on angiodysplasia potentially attributable to continuous-flow LVAD. Dr Birks discusses the findings and appears open to the suggestion that LVAD per se is a cause of gastrointestinal angiodysplasia and thence bleeding, as opposed to the anticoagulation for LVAD.
Researchers used a nanomaterial sensor array and pattern recognition statistical techniques to evaluate exhaled breath samples from patients with suspicious lesions on imaging. A total of 119 patients were included, of whom 30 had benign lesions. In cancer patients, the accuracy of discriminating EGFR mutations from wild-type EGFR was 83%. The accuracy of differentiating early stage cancer from benign disease was 87%.
The authors demonstrated substantial concordance between sequencing of 39 genes in a liquid assay and routine diagnostic testing in tissue in 82 patients. Agreement was 98%, and the primary reason for failure was low levels of circulating DNA in the plasma. Sensitivity was 70%, and specificity was 100%. The system offers accurate identification of driver mutations in plasma of patients with NSCLC.
In this Masters of Cardiothoracic Surgery, Meier and colleagues outline their approach to transmitral myectomy and surgical management of systolic anterior motion in a case vignette of a 45-year-old male with hypertrophic cardiomyopathy. The technique combines a transmitral left ventricular myectomy and a resuspension of the anterior mitral leaflet with a partial, flexible annuloplasty. The perils and pitfalls of this technique are presented in this article, which is accompanied by a narrated video with operative footage.
A Brazilian woman ran a road race in Rio de Janiero, powered by the transplanted heart of a German Olympian that she had received only a year earlier.
A suspicious shadow showed up on the x-ray of a UK man’s lung, but surprisingly and luckily turned out to be a toy traffic cone he had swallowed as a child.
The September issue of The Surgeons’ Lounge delves into myths and facts about blood transfusion.
Drugs and Devices
The European Medicines Agency gave a positive opinion to a once-a-day triple-drug inhaler for COPD made by GlaxoSmithKline.
Research, Trials, and Funding
Oral intubation might be a better choice than nasal intubation for anesthesia in children over 6 months old undergoing cardiac surgery.
Researchers at Boston Children’s Hospital in Massachusetts are developing a device to better monitor tissue oxygen levels as a way to predict impending cardiac failure.
Paci and colleagues investigated the effect that multimodal enhanced recovery pathways (ERP) have on the costs of lung resection. The authors’ analysis evaluated the socioeconomic impact of ERPs including postdischarge health care system utilization and caregiver burden, in addition to institutional costs.
The authors analyzed their prospective hospital TAVR register to assess whether the addition of serum albumin as a marker of frailty would improve the ability of the STS and EuroSCORE-2 scores to predict mortality. TAVR patients were divided into 4 groups based on median serum albumin and median STS and EuroSCORE-2 values.
Result: A model including albumin in addition to either conventional score improved the prediction of mortality with either score by more than 40%.
Conclusion: Using scores that include serum albumin as a marker of frailty can improve the prediction of mortality in patients undergoing TAVR.
While it is being increasingly understood that frailty in the older adult patient undergoing cardiac surgery is associated with an increased rate of postoperative mortality, it is still unclear if the addition of frailty measures to existing risk-assessment tools contributes to an improved prediction of long-term disabilty. In a prospective observational cohort analysis of 188 older adult patients undergoing cardiac surgery, Lytwyn and colleagues have sought to determine if a measurement of frailty (using either the Modified Fried Criteria, the Short Physical Performance Battery or the Clinical Frailty Scale) was effective in predicting one-year functional survival (defined as being alive at 1 year with a health-related quality of life score greater than 60 on the EuroQol-Visual Analogue Scale). The authors observed a 2-3 fold worse one-year functional survival in frail cardiac surgery patients, and the addition of any measure to the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) was associated with improved predictive value of negative outcomes.
Within the field of Enhanced Recovery after Thoracic and Cardiac Surgery (ERATS and ERACS, respectively), appropriate fluid administration that avoids the detrimental effects of tissue edema on organ function and wound healing is a potentially important modifier of postoperative outcomes. This use of specific hemodynamic and other targets to provide goals of administered fluids (i.e. goal-directed therapy or GDT) has been suggested as an effective means to provide sufficient volume to facilitate cardiac flow while minimizing the potential harms of excessive fluid resuscitation. The literature to this point, however, has been inconsistent in demonstrating improvements in clinical outcomes. Bednarczyk and colleagues have undertaken an important and well-constructed SR/MA to determine if acute volume resuscitation using an objective measure of fluid responsiveness (stroke volume variation, pulse pressure variation, and stroke volume change with passive leg raise/fluid challenge) is associated with improved outcomes. In this analysis, the authors have concluded that the use of GDT guided assessments of fluid responsiveness was associated with reduced mortality, ICU length of stay, and time on mechanical ventilation. Further high quality clinical investigation in the cardiac critical care environment is warranted.
Microlobectomy is a novel form of VATS lobectomy.
This paper documents the experience of its use in England, at the Mayo clinic, in Copenhagen, in Edinburgh, Wales, and in Texas.
The rules of microlobectomy are that you must perform no incisions greater than 5 mm in the intercostal spaces, but the ports mirror your usual multiport approach. You use a subxiphoid incision to remove the lobe and perform the stapling, and there are hints and tips to make this easier at www.microlobectomy.com.
Let us know what you think. Something new or just a mix of well tried and tested approaches?
Twenty-two percent of patients went home day one and 42% day two so if nothing else it shows that well-performed minimally invasive lobectomy results in very early discharges with good short-term outcomes.