Journal: Interactive cardiovascular and thoracic surgery
The objective of this retrospective study was to assess perioperative outcomes, overall survival and freedom from recurrence after induction chemotherapy followed by extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D) in patients with mesothelioma in a propensity score matched analysis.
Professor Archibald Cochrane (1909-1988) is considered to be the originator of the idea of evidence-based medicine in our era. With his landmark book ‘Effectiveness and Efficiency: Random Reflections on Health services’ he managed to inspire and positively influence the medical society with respect to the proper assessment of reliable evidence for the provision of the best medical care. His vision combined with his scientific achievements can be considered as the foundation of the Cochrane Collaboration; named after him in recognition of and gratitude for his pioneering work. We present the highlights of his adventurous and vibrant personal and academic life in an attempt to honour his contribution to shaping modern medical research.
Lung cancer is the leading cause of cancer-related death worldwide. For early stages of the disease, lung resection surgery remains the best treatment with curative intent, but significant morbidity is associated, especially among patients with poor pulmonary function and cardiorespiratory fitness. In those cases, the implementation of a preoperative exercise-based intervention could optimize patient’s functional status before surgery and improve postoperative outcomes and enhance recovery. The aim of this systematic review is to provide the current body of knowledge regarding the effectiveness of a preoperative exercise-based intervention on postoperative and functional outcomes in patients with lung cancer submitted to lung resection surgery. A systematic review of the literature using CINAHL, EMBASE, MEDLINE, Pubmed, PEDro and SCOPUS was undertaken in September 2015 yielding a total of 1656 references. Two independent reviewers performed the assessment of the potentially eligible records against the inclusion criteria and finally, 21 articles were included in the review. Articles were included if they examined the effects of an exercise-based intervention on at least one of the selected outcomes: pulmonary function, (functional) exercise capacity, health-related quality of life (HRQoL) and postoperative outcomes (length of stay and postoperative complications). Fourteen studies were further selected for a meta-analysis to quantify the mean effect of the intervention and generate 95% confidence intervals (CIs) using the Cochrane Review Manager 5.0.25. For two of the outcomes included (exercise capacity and HRQoL), studies showed large heterogeneity and thus, a meta-analysis was considered inappropriate. Pulmonary function (forced vital capacity and forced expiratory volume in 1 s) was significantly enhanced after the intervention [standardized mean difference (SMD) = 0.38; 95% CI 0.14, 0.63 and SMD = 0.27, 95% CI 0.11, 0.42, respectively]. In comparison with the patients in the control groups, patients in the experimental groups spent less days in the hospital (mean difference = -4.83, 95% CI -5.9, -3.76) and had a significantly reduced risk for developing postoperative complications (risk ratios = 0.45; 95% CI 0.28, 0.74). In conclusion, preoperative exercise-based training improves pulmonary function before surgery and reduces in-hospital length of stay and postoperative complications after lung resection surgery for lung cancer.
One of the final treatments for end-stage heart failure is heart transplantation. However, a shortage of donor hearts has created a long waiting list and limited benefits. Our ultimate goal is to create a whole beating heart fabricated on an organ scaffold for human heart transplantation. Here, we successfully performed the first transplantation using a decellularized whole porcine heart with mesenchymal stem cells.
The protective effects of late-phase preconditioning can be triggered by several stimuli. Unfortunately, the transfer from bench to bedside still represents a challenge, as concomitant medication or diseases influence the complex signalling pathways involved. In an established model of primary neonatal rat cardiomyocytes, we analysed the cardioprotective effects of three different stimulating pharmaceuticals of clinical relevance. The effect of additional β-blocker treatment was studied as these were previously shown to negatively influence preconditioning.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘Does the use of bilateral mammary artery grafts compared with the use of a single mammary artery graft offer a long-term survival benefit in patients undergoing coronary artery bypass surgery?’ Altogether 214 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All the included studies were follow-up studies; eight studies used prospective data collection, and five studies collected the study data retrospectively. No randomized controlled trials were found. Nine of the 13 included papers used a propensity-score-matched comparison of the survival of bilateral mammary artery graft [or, bilateral internal thoracic artery (BITA) graft] patients vs single mammary artery graft [or, single internal thoracic artery (SITA) graft] patients. These studies consistently showed an enhanced survival of BITA patients compared with propensity-score-matched SITA patients. Three of the 13 included papers used Cox proportional hazards regression analysis to compare survival of BITA vs SITA patients; one larger study showed better crude survival of BITA patients, but did not identify BITA grafts as independent predictor of enhanced survival. The remaining two studies also did not identify BITA grafts as independent predictor of enhanced survival. One study only presented crude survival estimates of BITA vs SITA patients and therefore was of limited informative value. We conclude that the use of BITA grafts seems to offer a long-term survival benefit compared with a SITA graft for patients undergoing coronary artery bypass grafting surgery. Although randomized evidence is lacking, observational evidence supporting this hypothesis is mounting.
Congenital diseases causing obstruction of the right ventricular outflow tract (RVOT) are common, but the isolated subpulmonary membrane/ring is extremely rare and can be difficult to diagnose precisely, especially in adults. We report a case of surgically resected isolated subpulmonic fibrous ring in a lady with mirror-image dextrocardia and abdominal situs solitus that was misdiagnosed by echocardiography as a subaortic membrane.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘Is porcine or bovine valve better for aortic valve replacement?’ Altogether, 562 papers were found using the reported search, of which 15 represented the best evidence to answer the question. All papers represent either level 1 or 2 evidence. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This best evidence paper includes 9880 patients from 1974-2006 to compare both valve types. All studies compared either all or some of the following outcomes: complication, durability, mortality, functional status and haemodynamic function. Ten of 15 papers assessed the complication profile due to aortic valve replacement in both valve types. Four papers concluded that bovine valves are superior, whereas only one favoured porcine valves. Five papers showed a similar complication profile between both valves. Six of 15 papers commented on valve durability. Both porcine and bovine valve groups have two papers each to support their superiority in valve durability. Two papers demonstrated similar durability in both valves. There are 11 papers comparing the postoperative mortality. We suggest that there is no difference in mortality profile as eight papers showed that both valves had similar mortality profiles. Two papers supported bovine valve and one paper supported porcine valve in this aspect. There were four papers assessing the postoperative functional status, with three papers suggesting that both valve types had similar clinical improvement postoperatively. Eleven papers compared the haemodynamic function. Nine papers were in favour of bovine valves. Two papers demonstrated similar haemodynamic profiles in both valves. In conclusion, the bovine valve is superior in its complication and haemodynamic profiles. Both bovine and porcine valves have comparable results with regard to the mortality, postoperative functional status and valve durability. Significant variability between the valve manufacturers, study designs, study period and patient population in the above studies impose limitations to the comparison of both valves.
Patients undergoing major surgery are at increased risk of developing infections due to resistant organisms, including carbapenem-resistant Klebsiella pneumoniae (CR-Kp). In this study, we assessed risk factors for CR-Kp infections after open heart surgery in a teaching hospital in northern Italy.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: ‘in patients undergoing oesophagectomy, does a minimally invasive approach convey a benefit in hospital length of stay (LOS), when compared to an open approach?’ A total of 647 papers were identified, using an a priori defined search strategy; 24 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and key results are tabulated. Of the studies identified, data from two randomized controlled trials were available. The first randomized study, by Biere et al., compared the use of open thoracotomy and laparotomy versus thoracoscopy and laparoscopy. Those undergoing minimally invasive oesophagectomy (MIO) left hospital on average 3 days earlier than those treated with the open oesophagectomy (OO) technique (P = 0.044). The other randomized trial, by Guo et al., which compared thoracotomy with thoracoscopy and laparoscopy, demonstrated a reduction of 1.8 days in the LOS when employing the MIO technique (P < 0.001). With the addition of the remaining 22 non-randomized studies, comprising 3 prospective and 19 retrospective cohort studies, which are heterogeneous with regard to their design, study populations and outcomes; data are available representing 3173 MIO and 25 691 OO procedures. In total, 13 studies (including the randomized trials) demonstrate a significant reduction in hospital LOS associated with MIO; 10 suggest no significant difference between techniques; and only 1 suggests a significantly greater length of stay associated with MIO. The only two randomized trials comparing MIO and OO demonstrated a reduction in length of stay in the MIO group, without compromising survival or increasing complication rates. All bar one of the non-randomized studies demonstrated either a significant reduction in length of stay with MIO or no difference. The benefit in reduced length of stay was not at the cost of worsened survival or increased complications, and conversion rates in all studies were low.