Pulmonary valve replacement after repaired Tetralogy of Fallot

In this review article, we describe pulmonary valve replacement (PVR) late after repaired Tetralogy of Fallot (TOF). Since the introduction of surgical intervention for patients with TOF in 1945, surgical management of TOF has dramatically improved early survival with mortality rates, less than 2–3%. However, the majority of these patients continue to experience residual right ventricular outflow tract pathology, most commonly pulmonary valve regurgitation (PR). The patients are generally asymptomatic during childhood and adolescence and, however, are at risk for severe PR later which can result in exercise intolerance, heart failure, arrhythmias, and sudden death. While it has been shown that PVR improves symptoms and functional status in these patients, the optimal timing and indications for PVR after repaired TOF are still debated. This article reviews the current state of management for the patient with PR after repaired TOF.     

Pulmonary artery sling: results with median sternotomy, cardiopulmonary bypass, and reimplantation

Background. The classic surgical approach to pulmonary artery (PA) sling has been through a left thoracotomy with division of the left PA and reimplantation into the main PA anterior to the trachea. Another approach is anterior left PA translocation with distal tracheal resection. Since 1985, we have repaired PA sling with a median sternotomy approach, cardiopulmonary bypass, and division and reimplantation of the left PA into the main PA with simultaneous repair of associated tracheal stenosis. The purpose of this review is to determine the outcome of that strategy.

Methods. From 1985 to 1998, 16 infants had surgical treatment of PA sling, 14 had left PA division and reimplantation into the MPA, 2 patients had repair using the translocation technique. Mean age at repair was 6.9 months, median age was 4 months. All infants, except 1 with an absent right lung, were operated on at the time of diagnosis. All had rigid bronchoscopy, which revealed associated complete tracheal rings in 12 patients. Seven patients had tracheal repair with pericardial tracheoplasty, 4 had repair using a tracheal autograft technique, and 2 had a distal tracheal resection (one for tracheomalacia). Of the 2 patients having the translocation technique, 1 had a severely hypoplastic right lung and the other had complete absence of the right lung.

Results. There has been no operative mortality. Hospital stay ranged from 5 to 188 days (mean 36 ± 42 days). There was 1 late death 7 months postoperatively from respiratory complications of pericardial tracheoplasty. All left pulmonary arteries are patent and blood flow to the left lung by nuclear scan (n = 10) ranges from 24% to 46% (mean 35% ± 9%).

Conclusion. The strategy of median sternotomy, cardiopulmonary bypass, and left PA division and reimplantation into the main PA with simultaneous tracheal repair has resulted in a low operative mortality and excellent patency of the left pulmonary artery. Results with repair of the commonly associated complete tracheal rings has recently improved with the use of the free tracheal autograft technique.     

Pulmonary carcinoid tumors--ten years experience

Pulmonary carcinoid tumors are rare, accounting for as many as 2% of all pulmonary neoplasms and for 10% of carcinoid tumors overall. Previously classified as bronchial adenomas, actually are classified as neuroendocrine tumors. They have a subclassification into typical classed as low-grade malignant neoplasm and atypical more aggressive, with more potential to cause local invasion. In this paper, the authors report a retrospective study of 25 patients, who had the diagnosis of pulmonary carcinoid tumors and had been operated between January of 1994 and August of 2004. We conclude that this tumors must be considered malignant in the surgical approach.     

肺转移瘤的诊断与外科治疗

目的探讨肺转移瘤的诊断、手术指征、切除方式及影响预后的因素,以提高患者的生存率。方法125例肺转移瘤患者均行手术治疗,共行肺转移瘤切除术138次,其中行一次手术116例,二次手术5例,三次手术4例。手术方式为肺部分切除66次,肺段切除2次,肺叶切除53次,肺叶加部分胸壁扩大切除2次,全肺切除3次,肿瘤剜除12次;行开胸手术130次,电视胸腔镜手术（VATS）8次。结果本组患者中原发肿瘤为上皮组织来源的94例,肉瘤类26例,其它种类5例。全组患者无围术期死亡,随访122例,随访时间1～10年,1年、3年和5年生存率分别为90．4％、53．3％和34．8％;其中结、直肠癌、肾癌和软组织肉瘤的预后较好,5年生存率分别为43．8％、37．5％和33．3％。105例肺转移瘤完全切除患者的5年生存率为38．9％,20例不完全切除患者为16．7％。89例行常规肺门及纵隔淋巴结摘除患者仅有12例术后病理证实有淋巴结转移,无淋巴结转移患者和有淋巴结转移患者的5年生存率分别为41．5％和14．3％。结论对诊断明确、符合标准的肺转移瘤患者行积极的手术治疗可取得满意的效果,手术径路以后外侧小切口为主,能否完全切除肿瘤和肺门纵隔淋巴结的转移状况是影响预后的重要因素。     

Massive Pulmonary Hemorrhage: Surgical Approach as Choice of Treatment

Massive pulmonary hemorrhage is still a life-threating problem with high mortality. The surgical versus medical approach to this condition was compared in 146 patients who were treated over a ten-year period. Our evidence shows that early operation is the only choice of treatment.     

Pulmonary hypertension in mitral valve disease: 56 surgical patients reviewed.

A total of 392 patients have undergone prosthetic valve surgery including the mitral valve over a four-year period (1972-76). Of these patients 56 (14%) had a pulmonary artery systolic pressure of 70 mmHg or more during preoperative cardiac catheterisation and the hospital mortality of this group was 5.4%. Similarly, the hospital mortality of the remaining 336 patients with a pulmonary artery pressure below 70 mmHg was 5.4%. The presence of pulmonary hypertension in patients with valve disease including the mitral valve does not therefore indicate that the risk of dying in hospital as a consequence of corrective surgery is increased. The absence of a raised hospital mortality in this recent series may be attributed to improved surgical techniques and materials, while the use of droperidol and pentolinium which may reduce pulmonary vascular resistance as well as systemic resistance during surgery could be contributory.     

Pulmonary metastasectomy of renal cell carcinoma: Local experience

Objective: Up until now, the prognosis of a patient with disseminated renal cell carcinoma is poor with 5‐year survival less than 2%. In a small subset of patients with isolated pulmonary metastasis, long‐term survival after pulmonary metastasectomy has been reported to be acceptable. The purpose of the present study was to evaluate the result of pulmonary metastasectomy in a local cardiothoracic surgical centre. Methods: Patients who had renal cell carcinoma and pulmonary metastasectomy for isolated pulmonary metastasectomy were recruited for the study. Their survival was analysed. Results: Between 1992 and 2004, 13 patients underwent 15 operative procedures for pulmonary metastases from renal cell carcinoma. The median follow up was 39.8 months (from 4.6 to 127.5 months). The five‐year survival after pulmonary metastasectomy was 48.3% and median survival was 25.4 months. There was no postoperative mortality. Pulmonary recurrence was the commonest recurrent site after pulmonary metastasectomy. Conclusion: Pulmonary metastasectomy for renal cell carcinoma is a safe and effective procedure. And, as the lung is the commonest site of first recurrence after pulmonary metastasectomy, the present study on the control of these occult metastases is necessary.     

Pulmonary thromboendarterectomy.

Pulmonary thromboendarterectomy (PTE) provides a curative alternative to the otherwise fatal condition of chronic thromboembolic pulmonary hypertension (CTEPH). However, the condition is under-diagnosed due to a lack of awareness. An acceptable operative mortality of around 10% and long-term survival exceeding medical therapy or transplantation makes PTE a favourable choice for the treatment of CTEPH. Outcome is further optimised if the disease is diagnosed early and patients referred to specialised centres. An increase in the number of surgical procedures will also contribute to lower the mortality associated with this condition.     

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Ten years experience in Denmark

OBJECTIVES: To evaluate survival and functional outcome in patients treated by pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension in Denmark. DESIGN: Follow-up of the first 50 patients operated at Aarhus University Hospital, Denmark. RESULTS: Fifty patients underwent PEA in the period from 1994 to mid 2004. Prior to surgery all patients were in World Health Organization (WHO) function class III (n=33) or IV (n=17). The mean pulmonary artery pressure was 50 mmHg (range 25-76), cardiac index 1.8 l min(-1)m(-2) (range 0.8-2.8) and pulmonary vascular resistance 819 dyn s cm(-5) (range 241-3,067). In-hospital mortality was 12/50 (24%). Surgical mortality was highest in the early period. Since year 2000 in-hospital deaths occurred in only 2 among 23 patients (9%). Leading causes of death were persistent pulmonary hypertension and bleeding. Three patients died during long-term follow-up with a median observation time of 3 years. The overall 5 year survival rate was 74%. At 3 months follow-up 90% of the patients (34/38) had improved one or more WHO functional classes and the systolic pulmonary artery pressure estimated by Doppler echocardiography had decreased from 80 mmHg (range 49-115) to 43 mmHg (range 14-95). CONCLUSION: Pulmonary endarterectomy has been successfully implemented in Denmark. The perioperative mortality was reduced over time to 9% during the past 5 years. Functional outcome and long-term survival were excellent stressing the importance of surgical treatment for chronic thromboembolic pulmonary hypertension.     

肺转移瘤的外科治疗（附40例报告）

报告外科治疗肺转移瘤４０例，其中肉瘤肺转移１３例，癌肺转移２７例，无手术死亡。术后１、３、５、７和１０年生存率分别为８９．５％、３８．９％、２８．６％、１６．６％和７．６％。肉瘤和癌肺转移瘤切除后５年生存率分别为２５．０％和３１．３％。作者对手术适应证、手术方法和影响预后的因素进行了讨论。主张对肺转移瘤不论是孤立性或单侧多发性，还是双侧肺转移瘤均应积极争取外科治疗。在临床上估计可以切除且及早切除肺转移瘤可能获得较好治疗效果时，就不必去考虑转移瘤的倍增时间（ＴＤＴ）和无瘤间期（ＤＦＩ）。     

Pulmonary aspergilloma: results of surgical treatment. Report of a series of 206 cases

STUDY AIM: The aim of this retrospective study was to report the results of the surgical treatment in 188 patients operated on for pulmonary aspergilloma in a series of 206 patients observed in Morocco. PATIENTS AND METHOD: From 1982 to 1998, 206 patients were treated for pulmonary aspergilloma in the same hospital; 188 were operated on and surgery was contraindicated in the other patients with general or respiratory failure. Hemoptysis was the main symptom, present in 190 patients (92%). Surgery was performed on principle with 108 lobectomies, 38 segmentectomies, 18 lobectomies and segmentectomies, 21 pleuropneumonectomies and 3 thoracoplasties. RESULTS: Postoperative complications occurred in 36% of the patients including: pyothorax (n = 15), hemothorax (n = 10), rehabitation defects (n = 17) and respiratory failure (n = 10). Reoperation was necessary in 6 patients. Postoperative mortality rate was 6.4% (12 patients including 5 treated by pleuro-pneumonectomy). CONCLUSION: The surgical treatment, in spite of its high morbidity, has to be proposed to all patients with pulmonary aspergilloma, even in asymptomatic patients when there is no surgical contraindication. Pleuropneumonectomy is a very high risk procedure and its indications must be restricted. Thoracoscopy was rarely performed in this series.     

原发性肺腺癌及其外科疗效（附115例报告）

１９８３年６月至１９９１年１２月，手术治疗原发性肺腺癌１１５例，占同期肺癌手术２７．３％。术后１、３、５年生存率分别为６７．０％、３５．４％、２１．８％，无手术死亡。本病发生率日趋上升，误诊率高达６７．８％；根治性手术是重要治疗手段，但不能控制潜在性微转移灶。作者就其独特临床特点、影响疗效因素、Ｎ_２淋巴结清除以及全身综合治疗等有关问题进行讨论。     

Pulmonary resection for multi-drug resistant tuberculosis

OBJECTIVES: Mycobacterium tuberculosis continues to be a major cause of morbidity and mortality throughout the world. Complacency by the medical profession and by patients has caused a new strain of Mycobacterium tuberculosis to emerge that is highly resistant to current antibiotics. The possibility of a new worldwide epidemic of drug-resistant Mycobacterium tuberculosis is of concern. Optimal therapy for patients infected with multi-drug resistant tuberculosis often requires surgical intervention to eradicate the infection. We report on our experience with pulmonary resection for multi-drug resistant tuberculosis. METHODS: During a 17-year period, 172 patients underwent 180 pulmonary resections. All patients had multi-drug resistant tuberculosis and had a minimum of 3 months of medical therapy before surgery. Muscle flaps were frequently used to avoid residual space and bronchial stump problems. RESULTS: During the study period, 98 lobectomies and 82 pneumonectomies were performed. Eight patients underwent multiple procedures. Operative mortality was 3.3% (6/180). Three patients died of respiratory failure, 2 patients died of a cerebrovascular accident, and 1 patient had a myocardial infarction. Late mortality was 6.8% (11/166). Significant morbidity was 12% (20/166). One half (91) of the patients had positive sputum at the time of surgery. After the operation, the sputum remained positive in only 4 (2%) patients. Mean length of follow-up was 7.6 years (range 4-204 months). CONCLUSIONS: Surgery remains an important adjunct to medical therapy for the treatment of multi-drug resistant Mycobacterium tuberculosis. In the setting of localized disease, persistent sputum positivity, or patient intolerance of medical therapy, pulmonary resection should be undertaken. Pulmonary resection for multi-drug resistant tuberculosis can be performed with acceptable operative morbidity and mortality.     

Pulmonary Embolectomy: Recommendation for Early Surgical Intervention

Abstract Background: Acute pulmonary embolism (PE) is a life‐threatening disease which often results in death if not diagnosed early and treated aggressively. Despite all efforts at improving outcomes, there is no consensus on the management of acute severe PE. Methods: From May 2000 to June 2009, 16 consecutive patients underwent surgical pulmonary embolectomy at our institution. Mean age was 45 ± 17 years (range, 14 to 76) with nine (56%) males and seven (43%) females. Preoperatively, all cases were classified as massive PE; seven (43%) patients were in hemodynamic collapse and emergently underwent operation while receiving cardiopulmonary resuscitation. Results: There were nine (56%) urgent/emergent and seven (44%) salvage patients undergoing surgical pulmonary embolectomy. Of nine nonsalvage patients, seven (77%) patients presented with moderate to severe right ventricular (RV) dilation/dysfunction. Mean cardiopulmonary bypass time was 43 ± 41 minutes (range, 9 to 161). Mean follow‐up duration was 48 ± 38 months (range: 0.3 to 109), with seven in‐hospital deaths (43%): mortality was 11% (1/9) in emergent operations and 85% (6/7) in salvage operations. Conclusions: Surgical pulmonary embolectomy should be considered early in the management of hemodynamically stable patients with PE who show evidence of RV dilation and/or failure, as it is associated with satisfactory outcomes. Conversely, pulmonary embolectomy has dismal results under salvage conditions. Revision of current guidelines for the surgical management of this condition may be warranted . (J Card Surg 2010;25:261‐266)     

Pulmonary complications after surgical treatment of lung cancer in octogenarians

Objective: The purpose of this study was to analyze the risks associated with pulmonary resection for primary non-small cell lung cancer in octogenarians to help better management in these patients. Methods: We reviewed the outcome in our 35 patients aged 80 years and older who underwent pulmonary resection between 1981 and 1998. Results: The 5-year survival rate was 39.8%. The operative mortality rate was 0% and the morbidity 60%. There were ten major pulmonary complications, including respiratory insufficiency following bacterial pneumonia and sputum retention. Preoperative arterial pO₂ was significantly lower, A-aDO₂ was significantly higher, and operation time were significantly longer in patients with pulmonary complications after surgical treatment than in patients without complications (P<0.05). Conclusions: Surgical treatment was not contraindicated for octogenarians with lung cancer. However, a relatively preoperative low arterial pO₂, high A-aDO₂, and long operation time may be risk factors for postoperative pulmonary complications in such patients. Surgeons must assess the preoperative data prudently to determine appropriate surgical strategy.     

Thoracoscopic Surgery for Pulmonary Tuberculosis

Tuberculosis historically was a major impetus for the development of thoracic surgery, and it remains a serious health problem of global proportion. Thoracoscopy was first introduced at the turn of this century for closed chest adhesiolysis as an adjunct to collapse therapy for treatment of tuberculosis. This indication became obsolete with the discovery of streptomycin during the 1940s; and for a long time since then thoracoscopy was used only sporadically for the diagnosis of pleural disease. However, over the last few years, modern video-assisted thoracoscopic surgery (VATS) has provided a new approach to the management of pulmonary tuberculosis. Over the last 5 years we have used VATS for diagnosis or treatment (or both) of 62 patients with pulmonary tuberculosis, including 20 pleural biopsies, 8 decortications, 17 wedge lung resections, 8 drainages of empyema, and 9 lobectomies. There was no surgical mortality, and complications were few. We conclude that VATS provides a safe, effective diagnostic modality (pleural biopsy, wedge resections) and therapeutic modality (decortications, drainage of empyema) for selected patients with pulmonary tuberculosis.     

Pulmonary atresia with intact ventricular septum: is neonatal repair advisable?

The optimal management of pulmonary atresia with an intact ventricular septum in the neonate remains controversial. The introduction of balloon septostomy and prostaglandin has significantly reduced early mortality but early surgical intervention is necessary to obtain a more adequate pulmonary blood flow. Fourteen neonates with pulmonary atresia and an intact ventricular septum were admitted to the Wessex Cardiothoracic Unit, Southampton from 1979 to 1986. Thirteen patients underwent cardiac catheterization. Cardiac catheterization data and right ventricular angiograms were reviewed retrospectively. Four patients with tripartite ventricles underwent total repair. The others received various palliative operations (valvotomy + modified Blalock-Taussig shunt or modified Blalock-Taussig shunt alone). Retrospective analysis of the angiograms indicated that right ventricular morphology alone is not a satisfactory criterion for surgical management. We have been able to demonstrate that there is a good correlation between the diameter of the tricuspid valve and the diameter of the infundibulum and that successful neonatal repair is possible when the tricuspid valve diameter is above 80% of the normal value for weight and when the tricuspid valve diameter to infundibular diameter ratio (TV/Inf ratio) is 2.2 or less. In patients with a tripartite ventricle but inadequate TV diameter and TV/Inf ratio, a closed pulmonary valvotomy with a modified Blalock-Taussig shunt remains the treatment of choice.     

Right pulmonary artery to left atrium communication

This is a collective review of 59 published cases of right pulmonary artery to left atrium communication in the English-language literature. In this article, we review the literature on the clinical presentation, anatomic variations, diagnostic features, and management considerations of previously reported cases. Two-dimensional echocardiography and cardiac catheterization including selective angiography provided the necessary diagnostic information and defined the anatomy before surgery in all patients. Various management options including medical, surgical, and transcatheter closure have been reported. The lesions have been classified into four types (I, II, III, and IV) that have a bearing on the appropriate surgical approach and techniques of repair that are discussed in the text. Use of extracorporeal circulation may be considered in selected instances. The operative mortality rate during the earlier era (1950 to 1979) was high, at 22%. More recently, the mortality rate has approached zero. An individualized surgical approach depending on the type of surgical connections is recommended.     

完全型肺静脉异位引流外科死亡的因素分析

完全型肺静脉异位引流（total anomalous pulmonary venous connection,TAPVC）是少数需行急诊手术的先天性心脏病之一,该病较高的围术期死亡率导致其成为先天性心脏病外科治疗的一大难题。近年来对于完全型肺静脉异位引流死亡因素的研究日益增多,并取得较大进展。其中手术年代、解剖分型、低年龄、低体重、长时间体外循环及肺静脉梗阻为较为公认的死亡因素。本文综述了近几年来国内外有关完全型肺静脉异位引流死亡因素分析的研究进展,以便能够更深入了解其机制,尽可能降低其死亡率,提高临床治疗效果。     

Bidirectional Cavopulmonary Shunt in Patients With Anomalies of Systemic and Pulmonary Venous Drainage

Background. Bidirectional cavopulmonary shunt and Fontan repair are now commonly performed in patients with a variety of forms of complex single ventricle, including those with anomalies of systemic or pulmonary venous return. These anomalies are ideally dealt with during bidirectional cavopulmonary shunt, thereby minimizing the complexity of the eventual Fontan procedure.

Methods. Between March 1990 and December 1995, 36 patients with anomalous systemic or pulmonary venous drainage underwent bidirectional cavopulmonary shunt. A combination of anomalous systemic and pulmonary venous drainage was present in 12 patients, whereas 19 patients had anomalous drainage only from the systemic circulation and 5 patients had isolated anomalies of pulmonary venous return. Visceral heterotaxy syndrome was diagnosed in 18 patients. The median age at operation was 11 months, and bidirectional cavopulmonary shunt was the first surgical procedure performed in 10 of these patients. Techniques of repair are described.

Results. There were two early deaths and one bidirectional cavopulmonary shunt was taken down, for mortality and failure rates not significantly different than those for all patients undergoing bidirectional cavopulmonary shunt during this time period (n = 117). At a mean follow-up of 19.9 months, there have been three late deaths and 11 patients have undergone Fontan completion. Actuarial survival was 87% at 1 year and 81% at 3 years. Among all patients undergoing bidirectional cavopulmonary shunt during this time period, neither heterotaxy syndrome nor anomalies of systemic or pulmonary venous return were significantly associated with decreased survival or poor outcome.

Conclusions. Bidirectional cavopulmonary shunt can be performed in patients with anomalous systemic or pulmonary venous drainage, including those with visceral heterotaxy syndrome, with morbidity and mortality rates that do not differ significantly from those achieved in all patients undergoing bidirectional cavopulmonary shunt. In this report, we describe our experience with this group of patients, primarily focusing on outcomes and technical issues that pertain to the use of bidirectional cavopulmonary shunt as a preparatory procedure for the extracardiac conduit Fontan operation.