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Lobar Torsion following Bilateral Lung Transplantation
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Abstracts
Conclusion: BST is a safe procedure for all appropriate patients in ICU.
Initial Centre Experience with the St. Jude Trifecta Aortic Valve Prosthesis and Cor-Knot Suture Fixation Device
References
Karan Sian *, Stuart Sugito, Sheila Li, Ajay Ayengar, Ross Mejia, Peng Seah
[1] Terra RM, Fernandez A, Helbert B, et al. Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation. Clinics 2007;62(4):427–32. [2] Silvester W, Knight S, Seevanayagam S, et al. Percutaneous versus surgical tracheostomy: a randomized controlled study with long-term follow-up. Crit Care Med 2006;34(8):2145–52.
http://dx.doi.org/10.1016/j.hlc.2015.12.072 60-Day Survival Rate under Treatment of Acute Type A Aortic Dissection by Transapical Aortic Cannulation Technique Surakarn Saraithong *, Phunlerd Piyaraj, Shin Yamamoto, Oshima Susumu Phramongkutklao Hospital, Bangkok, Thailand Introduction: Acute type A aortic dissection has several techniques of cardiopulmonary bypass (CPB) for aortic cannulation. The most important for all aortic cannulation sites is perfusing into the true lumen. Objective: This article aims to show a technique and results of 60-day survival rate under treatment of Acute type A aortic dissection by tranapical aortic cannulation technique. Materials and Methods: The study investigated data covering 12 years of surgery experience involving Acute type A acute aortic dissection by transapical aortic cannulation technique at Kawasaki Saiwai Hospital, Kawasaki, Japan. Statistical Analysis: Cox proportional hazard regression was employed to analyse risk ratio, and Kaplan Meier curve was used to estimate the survival time Results: The study population (N=309) was investigated for survival analysis. The person-time was 6363.50 person/ months. We found that, the deaths event totalled 29 persons (9.38%). The mortality rate was 4.55/1000 person/months (95% confidence interval = 3.17-6.56/1000 person-month). Conclusion: Risk factors influencing the survival rate in Acute type A aortic dissection included sex, coronary artery disease (CAD), preoperative deterioration, total arch replacement, CPB technique using only DHCA (Deep Hypothermic Circulatory Arrest), DHCA with RCP (Retrograde Cerebral Perfusion) and DHCA with SCP (Antegrade Selective Cerebral Perfusion). The ascending aortic diameter and proximal descending aorta diameter, increased the death rate by 11% and 18% respectively. When the diameter increased every 1 mm, and when the operation time increased every 1 minute, the death rate was increased by 1%. Keywords: Acute Type A Aortic Dissection; Tranapical Aortic Cannulation Technique; Deep Hypothermic Circulatory Arrest. http://dx.doi.org/10.1016/j.hlc.2015.12.073
John Hunter Hospital, Newcastle, NSW, Australia Objectives: The recently introduced Trifecta valve (St. Jude Medical Inc., St. Paul, MN, USA) is a tri-leaflet stented pericardial valve made for use in the supra-annular aortic position. The Cor-Knot (LSI Solutions, Victor, NY, USA) is a suture fixation device designed for remote equivocal suture tensioning and quick fixation. The present study aims to evaluate our preliminary experiences with this new valve and suture fixation device. Methods: Twenty-nine patients underwent aortic valve replacement (AVR) with the Trifecta valve between November 2013 and July 2015. Cor-Knot was used to secure the aortic valve in 11 (40%) patients. All data, intraoperative, and postoperative was prospectively gathered. Echocardiography was performed prior to discharge from hospital. Mean Euro SCORE II was 2.53%. Seven (23%) were female. Mean age was 72.0 +/- 7.07 (range 61-83 years). Fifteen (52%) patients underwent combined procedures. Results: Concomitant procedures included: mitral valve replacement (2), coronary artery bypass grafting (10) and redo AVR (4). In-hospital mortality at 30 days was 1 (3%). Mean gradients were 10, 9, 9, and 7 mm Hg for the 21, 23, 25 and 27 mm valve size, respectively. Cor-Knot demonstrated a mean reduction in total cardio pulmonary bypass and cross-clamp times of 18.7 and 14.5 minutes respectively. Statistical significance however could not be shown. No paravalvular leak or significant aortic regurgitation was demonstrated before discharge. Conclusions: Initial clinical experience and early haemodynamics of the Trifecta valve are promising. Further studies with larger patient cohorts will be required to demonstrate any benefit of the Cor-Knot device in reducing bypass and cross-clamp times. http://dx.doi.org/10.1016/j.hlc.2015.12.074 Lobar Torsion following Bilateral Lung Transplantation Georgina Stephens *, Krishna Bhagwat, Adrian Pick, David McGiffin The Alfred Hospital, Melbourne, VIC, Australia Purpose: To review all cases of lobar torsion following lung transplantation in the literature, with the addition of a further case occurring at The Alfred Hospital. Methodology: A review of the available literature was undertaken to find all reports of lobar torsion following lung transplantation. Cases were examined to determine predisposing factors leading to torsion, clinical presentation, management and prognosis. Results: Ten cases, including our own, have been published. Eight of the cases occurred within the first 5
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Abstracts
postoperative days, the remaining two cases occurring at postoperative days 8 and eleven. There is a higher reported incidence of torsion of left lobes compared to right lobes (7 verses 3). Predisposing factors proposed were size discrepancy between the donor lung and the thoracic cavity (1 case), presence of a complete fissure in the donor lung (3 cases), or a combination of these two factors (2 cases). Four cases did not identify a predisposing factor. Two cases were successfully managed with detorsion of the affected lobe. Six cases underwent lobectomy and one case of incomplete torsion was successfully conservatively managed. Conclusion: All the reported cases illustrate surgeons and transplant physicians should be aware of this rare complication of lung transplantation. A high degree of suspicion is required in the postoperative lung transplant recipient who experiences acute respiratory insufficiency. Lobectomy is indicated when the lobe is nonviable. Simple detorsion may be tried even in cases of late diagnosis. We recommend checking anatomical structures carefully before thoracotomy closure, especially during a second thoracotomy for haemostasis, and when the graft has a complete fissure. http://dx.doi.org/10.1016/j.hlc.2015.12.075 Pericardial Constriction Post-Lung Transplant Georgina Stephens *, Dr Krishna Bhagwat, A/Prof Silvana Marasco, Prof David McGiffin The Alfred Hospital, Melbourne, VIC, Australia Purpose: To review all cases of pericardial constriction following lung transplantation in the literature, with the addition of two further cases occurring at The Alfred Hospital. Methodology: A literature review was undertaken to find all reports of pericardial constriction following lung transplantation. Cases were examined to determine demographic details of patients, presenting symptoms and signs, underlying pathology resulting in transplantation, whether pericardiotomy occurred during transplantation, management, pathological findings and outcomes. Results: Nine cases of pericardial constriction post-lung transplantation have been reported. All cases presented with symptoms and signs of biventricular failure. Pericardiotomy at time of transplant was reported in six cases, but not mentioned in the remaining three. All cases underwent pericardiectomy. Seven cases commented on pathological findings of the pericardium. Six cases reported pericardial fibrosis. One case identified fungal infection, which was the only case with a proven aetiology for pericardial constriction. Follow-up was reported in 8 cases. Six patients returned to baseline function or were reported to be doing well post-pericardiectomy. Two patients passed away during follow-up, but not directly related to pericardial constriction. Conclusion: Pericardial constriction lung transplantation is a rare but now well-described entity, with no identified aetiology in the absence of infection. A high index of suspicion for pericardial constriction should be held in lung transplant patients who present with evidence of cardiac failure, if
more common pathologies have been excluded. Pericardiectomy is the only option for definitive management. http://dx.doi.org/10.1016/j.hlc.2015.12.076 Informed Consent: Impact of full disclosure on public reporting of surgeon specific outcome data Elizabeth Suthers *, Sonia Chanchlani, Ben Dunne, Christopher Merry Fiona Stanley Hospital, Perth, WA, Australia Purpose: To examine the history and case law surrounding informed consent with a focus on Australian law and the implications for surgeon specific outcome data. Methodology: A literature review of relevant case law, significant judgments, and legal precedents was undertaken. Results: Under the influence of common law (the doctrine of precedent), Australian medico-legal practices have evolved over time. Litigation to define informed consent first occurred in 1767 England, Slater vs Baker and Stapleton, which determined that a patient has the right to be informed of what will happen to him. The case of Schloendorff v Society of New York Hospital (1994) determined that the patient has autonomy: the right to make decisions regarding themselves. Until the 1990s, Australia’s attitude toward informed consent followed that of England taking into consideration the Bolem principle, summarised as the legal requirement of duty of care towards the patient, with the standard of care being determined by a reasonable body of medical practitioners. The major change came with the judgment of Rogers v Whitaker in 1992, which overturned the Bolem principle as inapplicable in Australian law, instead determining that the patient must be provided with all the relevant information, as it applies to the individual patient and not as deemed relevant by a reasonable body of medical practitioners. Conclusion: With the current legal requirements that the patient must be provided with all relevant information, as it applies to the individual patient and not as deemed relevant by the treating clinician, this could progress to making public reporting of surgeon specific outcome data a legal requirement. http://dx.doi.org/10.1016/j.hlc.2015.12.077 Cardiac Surgery in Octogenerians: Single centre experience Sujeeth Suvarna *, Konstantinos Pechlivanidis, Delia Clune, Alexandru Cornea, Edel Costigan, Niamh Dunne, Maria Hayes, Beata Kis, Helen O’Connell, Mary O’Gorman Blackrock Clinic, Dublin, Ireland Purpose: As the relative proportion of older persons is increasing in Ireland more octogenarians are being referred for cardiac surgery. The aim of our study is to analyse our experience concerning the immediate postoperative outcomes in this sub-group of elderly population.
Abstracts
Conclusion: BST is a safe procedure for all appropriate patients in ICU.
Initial Centre Experience with the St. Jude Trifecta Aortic Valve Prosthesis and Cor-Knot Suture Fixation Device
References
Karan Sian *, Stuart Sugito, Sheila Li, Ajay Ayengar, Ross Mejia, Peng Seah
[1] Terra RM, Fernandez A, Helbert B, et al. Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation. Clinics 2007;62(4):427–32. [2] Silvester W, Knight S, Seevanayagam S, et al. Percutaneous versus surgical tracheostomy: a randomized controlled study with long-term follow-up. Crit Care Med 2006;34(8):2145–52.
http://dx.doi.org/10.1016/j.hlc.2015.12.072 60-Day Survival Rate under Treatment of Acute Type A Aortic Dissection by Transapical Aortic Cannulation Technique Surakarn Saraithong *, Phunlerd Piyaraj, Shin Yamamoto, Oshima Susumu Phramongkutklao Hospital, Bangkok, Thailand Introduction: Acute type A aortic dissection has several techniques of cardiopulmonary bypass (CPB) for aortic cannulation. The most important for all aortic cannulation sites is perfusing into the true lumen. Objective: This article aims to show a technique and results of 60-day survival rate under treatment of Acute type A aortic dissection by tranapical aortic cannulation technique. Materials and Methods: The study investigated data covering 12 years of surgery experience involving Acute type A acute aortic dissection by transapical aortic cannulation technique at Kawasaki Saiwai Hospital, Kawasaki, Japan. Statistical Analysis: Cox proportional hazard regression was employed to analyse risk ratio, and Kaplan Meier curve was used to estimate the survival time Results: The study population (N=309) was investigated for survival analysis. The person-time was 6363.50 person/ months. We found that, the deaths event totalled 29 persons (9.38%). The mortality rate was 4.55/1000 person/months (95% confidence interval = 3.17-6.56/1000 person-month). Conclusion: Risk factors influencing the survival rate in Acute type A aortic dissection included sex, coronary artery disease (CAD), preoperative deterioration, total arch replacement, CPB technique using only DHCA (Deep Hypothermic Circulatory Arrest), DHCA with RCP (Retrograde Cerebral Perfusion) and DHCA with SCP (Antegrade Selective Cerebral Perfusion). The ascending aortic diameter and proximal descending aorta diameter, increased the death rate by 11% and 18% respectively. When the diameter increased every 1 mm, and when the operation time increased every 1 minute, the death rate was increased by 1%. Keywords: Acute Type A Aortic Dissection; Tranapical Aortic Cannulation Technique; Deep Hypothermic Circulatory Arrest. http://dx.doi.org/10.1016/j.hlc.2015.12.073
John Hunter Hospital, Newcastle, NSW, Australia Objectives: The recently introduced Trifecta valve (St. Jude Medical Inc., St. Paul, MN, USA) is a tri-leaflet stented pericardial valve made for use in the supra-annular aortic position. The Cor-Knot (LSI Solutions, Victor, NY, USA) is a suture fixation device designed for remote equivocal suture tensioning and quick fixation. The present study aims to evaluate our preliminary experiences with this new valve and suture fixation device. Methods: Twenty-nine patients underwent aortic valve replacement (AVR) with the Trifecta valve between November 2013 and July 2015. Cor-Knot was used to secure the aortic valve in 11 (40%) patients. All data, intraoperative, and postoperative was prospectively gathered. Echocardiography was performed prior to discharge from hospital. Mean Euro SCORE II was 2.53%. Seven (23%) were female. Mean age was 72.0 +/- 7.07 (range 61-83 years). Fifteen (52%) patients underwent combined procedures. Results: Concomitant procedures included: mitral valve replacement (2), coronary artery bypass grafting (10) and redo AVR (4). In-hospital mortality at 30 days was 1 (3%). Mean gradients were 10, 9, 9, and 7 mm Hg for the 21, 23, 25 and 27 mm valve size, respectively. Cor-Knot demonstrated a mean reduction in total cardio pulmonary bypass and cross-clamp times of 18.7 and 14.5 minutes respectively. Statistical significance however could not be shown. No paravalvular leak or significant aortic regurgitation was demonstrated before discharge. Conclusions: Initial clinical experience and early haemodynamics of the Trifecta valve are promising. Further studies with larger patient cohorts will be required to demonstrate any benefit of the Cor-Knot device in reducing bypass and cross-clamp times. http://dx.doi.org/10.1016/j.hlc.2015.12.074 Lobar Torsion following Bilateral Lung Transplantation Georgina Stephens *, Krishna Bhagwat, Adrian Pick, David McGiffin The Alfred Hospital, Melbourne, VIC, Australia Purpose: To review all cases of lobar torsion following lung transplantation in the literature, with the addition of a further case occurring at The Alfred Hospital. Methodology: A review of the available literature was undertaken to find all reports of lobar torsion following lung transplantation. Cases were examined to determine predisposing factors leading to torsion, clinical presentation, management and prognosis. Results: Ten cases, including our own, have been published. Eight of the cases occurred within the first 5
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Abstracts
postoperative days, the remaining two cases occurring at postoperative days 8 and eleven. There is a higher reported incidence of torsion of left lobes compared to right lobes (7 verses 3). Predisposing factors proposed were size discrepancy between the donor lung and the thoracic cavity (1 case), presence of a complete fissure in the donor lung (3 cases), or a combination of these two factors (2 cases). Four cases did not identify a predisposing factor. Two cases were successfully managed with detorsion of the affected lobe. Six cases underwent lobectomy and one case of incomplete torsion was successfully conservatively managed. Conclusion: All the reported cases illustrate surgeons and transplant physicians should be aware of this rare complication of lung transplantation. A high degree of suspicion is required in the postoperative lung transplant recipient who experiences acute respiratory insufficiency. Lobectomy is indicated when the lobe is nonviable. Simple detorsion may be tried even in cases of late diagnosis. We recommend checking anatomical structures carefully before thoracotomy closure, especially during a second thoracotomy for haemostasis, and when the graft has a complete fissure. http://dx.doi.org/10.1016/j.hlc.2015.12.075 Pericardial Constriction Post-Lung Transplant Georgina Stephens *, Dr Krishna Bhagwat, A/Prof Silvana Marasco, Prof David McGiffin The Alfred Hospital, Melbourne, VIC, Australia Purpose: To review all cases of pericardial constriction following lung transplantation in the literature, with the addition of two further cases occurring at The Alfred Hospital. Methodology: A literature review was undertaken to find all reports of pericardial constriction following lung transplantation. Cases were examined to determine demographic details of patients, presenting symptoms and signs, underlying pathology resulting in transplantation, whether pericardiotomy occurred during transplantation, management, pathological findings and outcomes. Results: Nine cases of pericardial constriction post-lung transplantation have been reported. All cases presented with symptoms and signs of biventricular failure. Pericardiotomy at time of transplant was reported in six cases, but not mentioned in the remaining three. All cases underwent pericardiectomy. Seven cases commented on pathological findings of the pericardium. Six cases reported pericardial fibrosis. One case identified fungal infection, which was the only case with a proven aetiology for pericardial constriction. Follow-up was reported in 8 cases. Six patients returned to baseline function or were reported to be doing well post-pericardiectomy. Two patients passed away during follow-up, but not directly related to pericardial constriction. Conclusion: Pericardial constriction lung transplantation is a rare but now well-described entity, with no identified aetiology in the absence of infection. A high index of suspicion for pericardial constriction should be held in lung transplant patients who present with evidence of cardiac failure, if
more common pathologies have been excluded. Pericardiectomy is the only option for definitive management. http://dx.doi.org/10.1016/j.hlc.2015.12.076 Informed Consent: Impact of full disclosure on public reporting of surgeon specific outcome data Elizabeth Suthers *, Sonia Chanchlani, Ben Dunne, Christopher Merry Fiona Stanley Hospital, Perth, WA, Australia Purpose: To examine the history and case law surrounding informed consent with a focus on Australian law and the implications for surgeon specific outcome data. Methodology: A literature review of relevant case law, significant judgments, and legal precedents was undertaken. Results: Under the influence of common law (the doctrine of precedent), Australian medico-legal practices have evolved over time. Litigation to define informed consent first occurred in 1767 England, Slater vs Baker and Stapleton, which determined that a patient has the right to be informed of what will happen to him. The case of Schloendorff v Society of New York Hospital (1994) determined that the patient has autonomy: the right to make decisions regarding themselves. Until the 1990s, Australia’s attitude toward informed consent followed that of England taking into consideration the Bolem principle, summarised as the legal requirement of duty of care towards the patient, with the standard of care being determined by a reasonable body of medical practitioners. The major change came with the judgment of Rogers v Whitaker in 1992, which overturned the Bolem principle as inapplicable in Australian law, instead determining that the patient must be provided with all the relevant information, as it applies to the individual patient and not as deemed relevant by a reasonable body of medical practitioners. Conclusion: With the current legal requirements that the patient must be provided with all relevant information, as it applies to the individual patient and not as deemed relevant by the treating clinician, this could progress to making public reporting of surgeon specific outcome data a legal requirement. http://dx.doi.org/10.1016/j.hlc.2015.12.077 Cardiac Surgery in Octogenerians: Single centre experience Sujeeth Suvarna *, Konstantinos Pechlivanidis, Delia Clune, Alexandru Cornea, Edel Costigan, Niamh Dunne, Maria Hayes, Beata Kis, Helen O’Connell, Mary O’Gorman Blackrock Clinic, Dublin, Ireland Purpose: As the relative proportion of older persons is increasing in Ireland more octogenarians are being referred for cardiac surgery. The aim of our study is to analyse our experience concerning the immediate postoperative outcomes in this sub-group of elderly population.