Factors affecting early and long-term outcomes after completion pneumonectomy

Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n = 19; local recurrence, n = 17; or metastasis, n = 11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p = 0.005), coronary artery disease (p = 0.03), removal of the right lung (p = 0.02), advanced age (p = 0.02), and renal failure (p < 0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p = 0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p = 0.04) and mechanical stump closure (p = 0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.     

Pulmonary Resection for Lung Trauma

Background. Pulmonary resection is rarely required for trauma, and its mortality is reportedly high.

Methods. A 10-year retrospective review of pulmonary resections for trauma was done.

Results. Of 2,455 patients with chest trauma, 183 (7.4%) underwent thoracotomy and 32 (1.3%) required pulmonary resection. Mean age was 28.4 years and mean injury severity score was 24.5. Mechanism of injury was stab wound in 14 patients, gunshot wound in 6, and blunt trauma in 12. Blunt trauma patients had a higher injury severity score (29.6) than penetrating trauma patients (21.4), but this was not significant (p < 0.07). Indications for thoracotomy were hemorrhage in 24 patients, airway disruption in 4, and other indications in 4. Operations consisted of wedge resection (19 patients), lobectomy (9), and pneumonectomy (4). Four (12.5%) patients (pneumonectomy, 2; lobectomy, 1; wedge, 1) died. Mortality for pneumonectomy was 50%, but this was not significantly higher than for lesser resections. Blunt trauma had a higher mortality (33%) than penetrating trauma (0%) (p < 0.02). Nonsurvivors had higher injury severity scores (44.2) than survivors (21.6) (p < 0.001).

Conclusions. Pulmonary resection is infrequently required for lung injury. Overall mortality is lower than previously reported, but pneumonectomy has a high mortality. Blunt trauma has a higher mortality than penetrating trauma. Injury severity scores are higher for nonsurvivors than survivors; this shows the importance of associated injuries on outcome.     

Reperfusion injury significantly impacts clinical outcome after pulmonary transplantation

Background. Reperfusion injury after pulmonary transplantation can contribute significantly to postoperative pulmonary dysfunction. We hypothesized that posttransplantation reperfusion injury would result in an increase in both in-hospital mortality and morbidity. We also hypothesized that the incidence of reperfusion injury would be dependent upon the cause of recipient lung disease and the interval of donor allograft ischemia.

Methods. We performed a retrospective study of all lung transplant recipients at our institution from June 1990 until June 1998. One hundred patients received 120 organs during this time period. We compared two groups of patients in this study: those experiencing a significant reperfusion injury (22%) and those who did not (78%).

Results. In-hospital mortality was significantly greater in patients experiencing reperfusion injury (40.9% versus 11.7%, p < 0.02). Posttransplantation reperfusion injury also resulted in prolonged ventilation (393.5 versus 56.8 hours, p < 0.001) and an increased length of stay in both the intensive care unit (22.2 versus 10.5 days, p < 0.01) and in the hospital (48.8 versus 25.6 days, p < 0.03). The incidence of reperfusion injury could not be attributed to length of donor organ ischemia (221.5 versus 252.9 minutes, p < 0.20). The clinical impact of reperfusion injury was significantly greater in patients undergoing transplantation for preexisting pulmonary hypertension (6/14) than those with chronic obstructive pulmonary disease or emphysema alone (6/54) (42.9% versus 11.1%, p < 0.012).

Conclusions. Clinically significant pulmonary reperfusion injury increased in-hospital mortality and morbidity resulting in prolonged ventilation, length of stay in the intensive care unit, and cost of hospitalization. The incidence of reperfusion injury was not dependent upon the duration of donor organ ischemia but increased with the presence of preoperative pulmonary hypertension. These findings suggest that recipient pathophysiology and donor allograft quality may play important roles in determining the incidence of reperfusion injury.     

Outcome with high blood lactate levels during cardiopulmonary bypass in adult cardiac operation

Background. High blood lactate levels during cardiopulmonary bypass (CPB) are associated with tissue hypoperfusion and may contribute to postoperative complications or death. The objective of this study was to determine an association between blood lactate levels during CPB and perioperative morbidity and mortality.

Methods. We reviewed 1,376 patients who underwent cardiac operation with CPB. Patients with abnormal preoperative blood lactate levels were excluded (n = 101). Blood lactate concentration during CPB, clinical data, and perioperative events were recorded.

Results. Peak blood lactate levels of 4.0 mmol/L or higher during CPB were present in 227 patients (18.0%). Postoperative mortality was higher in this group than in the patients who had peak blood lactate levels of less than 4.0 mmol/L during CPB (11.0% versus 1.4%; p < 0.001, relative risk [RR] = 9.0). Postoperative hemodynamic instability occurred in 29.5% of patients with elevated levels of lactate during CPB compared with 10.9% of patients with lower lactate levels (p < 0.001, RR = 3.4). Overall, major postoperative complications occurred in 43.2% and 21.8% of patients in each group, respectively (p < 0.001, RR = 2.7). Logistic regression analysis revealed that peak blood lactate levels of 4.0 mmol/L or higher during CPB were strongly associated with postoperative mortality (p = 0.0001) and morbidity (p = 0.013).

Conclusions. Blood lactate concentration of 4.0 mmol/L or higher during CPB identifies a subgroup of patients with increased risk of postoperative morbidity and mortality.     

Long-term outcomes and risk factor analysis after pneumonectomy for active and sequela forms of pulmonary tuberculosis.

OBJECTIVE: The prevalence of pulmonary tuberculosis remains high in several areas of the world, and pneumonectomy is often necessary to treat the disease. We retrospectively analyzed the morbidities, mortalities, and long-term outcomes after pneumonectomy for the treatment of active tuberculosis or its sequelae. MATERIALS AND METHODS: Between 1981 and 2001, 94 patients underwent either pneumonectomy or pleuropneumonectomy for the treatment of tuberculosis. The patients included 44 males and 50 females and the mean age was 40 (16-68) years. The pathology included destroyed lung in 80, main bronchus stenosis in ten, and both lesions in four. Surgical procedures performed were pneumonectomy in 47, pleuropneumonectomy in 43, and completion pneumonectomy in four. RESULTS: One patient died postoperatively due to empyema. Twenty-three complications occurred in 20 patients: empyema in 15 (including seven bronchopleural fistulae), wound infections in five, and other complications in three. Univariate analysis revealed the presence of empyema, pleuropneumonectomy, prolonged operation time, old age, and intraoperative contamination as risk factors of postpneumonectomy empyema; it also showed that low preoperative FEV(1) and postoperative persistent positive sputum AFB were risk factors of bronchopleural fistula. In multivariate analysis, old age and low preoperative FEV(1) were risk factors of empyema while low preoperative FEV(1), positive sputum acid-fast bacilli, and the presence of aspergilloma were risk factors of bronchopleural fistula. There were 12 late deaths. Actuarial 5- and 10-year survival rates were 94+/-3% and 87+/-4%, respectively. CONCLUSION: Pneumonectomy could be performed with acceptable mortality and morbidity, and could achieve satisfactory long-term survival for the treatment of tuberculosis. In patients with risk factors, special care is recommended to prevent postoperative empyema or bronchopleural fistula.     

Anatomical risk factors for mortality and cardiac morbidity after arterial switch operation

Background. The arterial switch operation (ASO) is the treatment of choice for transposition of the great arteries.

Methods. Anatomical risk factors on mortality and morbidity were analyzed retrospectively in 312 patients who underwent ASO between 1982 and 1997.

Results. Survival was 95%, 92%, and 92% after 30 days, 5, and 10 years, respectively. Operative survival improved after 1990 to 97% (p < 0.001). Risk factors for operative mortality were complex anatomy (p = 0.018), coronary anomalies (p = 0.008), and prolonged bypass time (p < 0.001). Determinants of late mortality were coronary distribution (p = 0.03), position of the great arteries (p = 0.0095), bypass time (p = 0.047), and aortic coarctation (p = 0.046). After a follow-up of 3.6 ± 2.7 years (0.1 to 14.9 years), 98% had good left ventricle function, 94% were in sinus rhythm, 2.4% had moderate to severe pulmonary stenosis, 0.3% had significant aortic regurgitation, and 1% had coronary stenosis. Freedom from reoperation was 100%, 96%, and 94% after 1, 5, and 10 years, respectively. No preoperative anatomic parameter correlated with long-term morbidity.

Conclusions. ASO can be performed with low operative mortality (< 5%) and long-term morbidity. Malformations associated with complex transposition of the great arteries influence early and late mortality.     

Partial versus full sternotomy for aortic valve replacement

Background. Recent trends suggest that smaller incisions reduce postoperative morbidity. This study tests the hypothesis that a partial upper sternotomy improves patient outcome for aortic valve replacement.

Methods. A group of 50 patients who underwent aortic valve surgery through a partial upper sternotomy (group I) were compared to 50 patients who underwent aortic valve replacement through a median sternotomy during the same time period (group II). The mean age (60 ± 2 versus 63 ± 2 years; mean ± SEM) and preoperative ejection fractions (53 ± 2 versus 54 ± 2) were similar. Operations were performed with central cannulation, and antegrade/retrograde blood cardioplegia.

Results. There was one death in each group. No differences were found in aortic occlusion time, mediastinal drainage, transfusion incidence, narcotic requirement, length of stay, or cost. The incidence of pleural and pericardial effusions was increased (18.4% versus 3.9%, p < 0.03), and the need for postoperative inotropic support was higher (38.7% versus 19.6%, p < 0.03) in the partial sternotomy group.

Conclusions. Aortic valve replacement can be performed through a partial sternotomy with results comparable to full sternotomy. The partial sternotomy offers a cosmetic benefit, but does not significantly reduce postoperative pain, length of stay, or cost.     

Open-lung biopsy guides therapy in children

Background. Open-lung biopsy is uncommon in children. Modern indications and outcomes are unknown.

Methods. This is a retrospective review of 64 open-lung biopsies (58 patients) from 1976 to 1996. Open-lung biopsies were used to grade vasculopathy in 8 patients (12% of 64) with pulmonary hypertension and in 10 patients (16% of 64) with combined pulmonary hypertension and lung parenchymal disease. Forty-six biopsies (72%) were obtained to diagnose parenchymal disease. Comparisons were made between biopsies performed from 1976 to 1989 and from 1990 to 1996.

Results. In the period 1990 to 1996, there were significantly more infants (p = 0.03), comorbid disease (p = 0.009), extracorporeal membrane oxygenation support (p < 10⁻⁴), and ventilator dependence (p = 0.05) and significantly less immunocompromise (p = 0.04). A definitive diagnosis was made in 43 of 64 cases (67%) and altered workup in 63 of 64 cases (98%). No correlation existed between Heath-Edwards grade of microangiopathy and catheterization data. Definitive diagnosis was most strongly associated with a nonimmunocompromised patient (p < 10⁻⁴). Although only one death (1.5%) was related to open-lung biopsy, the procedure was associated with a 30% inhospital mortality rate and an 11% morbidity rate. Of the 19 deaths, 1 patient died from the procedure, 13 died from their diseases, and 5 had support withdrawn. Death was associated with preoperative ventilator dependence (p < 10⁻⁴) and extracorporeal membrane oxygenation (p = 0.007).

Conclusions. Pediatric open-lung biopsy commonly alters the diagnostic workup (98%). It is recommended for children who have been supported for 2 weeks by extracorporeal membrane oxygenation and for those with combined pulmonary hypertension and parenchymal lung disease. It is less useful in immunocompromised children.     

Oropharyngeal dysphagia after cardiac operations

Background. As many as 15% of hospitalized patients have oropharyngeal dysphagia. The incidence and causes of postoperative oropharyngeal dysphagia (OD) in patients having cardiac operations are poorly documented and the best treatment is uncertain. We undertook a study to evaluate OD in patients having cardiac operations.

Methods. As part of a quality improvement project, all patients operated on in 1998 and 1999 were monitored for the signs or symptoms of OD. Patients with OD had diagnostic and therapeutic interventions to limit adverse outcomes. At the end of the 2-year evaluation period, patient risk factors, diagnoses, results of interventions, and outcomes were measured.

Results. Thirty-one out of 1,042, patients (3%) had OD. OD is more common in older patients (p < 0.0001) with diabetes (p = 0.02), renal insufficiency (p = 0.012), hyperlipidemia (p = 0.046), and preoperative congestive heart failure (p < 0.0001), and in those having noncoronary artery bypass procedures (p < 0.0001). One patient with OD died from respiratory arrest, presumably secondary to aspiration. Modified barium swallow (MBS) identified oral dysphagia in 2 patients, pharyngeal dysphagia in 7 patients, and both oral and pharyngeal dysphagia in 17 patients. One patient had a structural defect (cervical osteophyte) causing dysphagia and 4 patients had no identifiable cause of dysphagia on MBS. Postoperative neurologic complications are more common in patients with OD. Ten of 31 patients (32%) with OD had some new neurologic complication after operation compared with 36 of 1,011 (3.5%) who had a postoperative neurologic problem without OD. In 19 patients with OD no cause for swallowing difficulty was identified. Specifically, no metabolic, myopathic, or infectious abnormalities were identified in any patient with OD. Hospital charges were significantly increased in patients with OD ($69,320 versus $36,087, p < 0.0001). Therapy consisting of modification of eating behavior and swallowing technique and in some severe cases enteral or parenteral feeding was successful in all patients except 1, but 4 patients required more than 4 months of supportive care before return to oral feeding was possible.

Conclusions. OD is associated with increased cost and morbidity. Older patients with diabetes, preoperative heart failure, and renal insufficiency are at increased risk for OD. Early recognition and intervention is likely to result in satisfactory outcome but may be associated with a protracted postoperative course.     

Coronary revascularization with or without cardiopulmonary bypass in patients with preoperative nondialysis-dependent renal insufficiency

Background. Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing conventional coronary artery bypass grafting. Off-pump coronary artery bypass operations have been shown to reduce renal dysfunction in patients with normal renal function, but the effect of this technique in patients with preoperative nondialysis-dependent renal insufficiency is unknown.

Methods. From June 1996 to December 1999, data of 3,250 consecutive patients undergoing coronary artery bypass grafting were prospectively entered into the Patient Analysis & Tracking Systems (PATS, Dendrite Clinical Systems, London, UK). Two hundred and fifty-three patients with preoperative serum creatinine more than 150 μmol/L were identified (202 patients on-pump, 51 patients off-pump), and clinical outcomes were analyzed. Serum creatinine and urea, in-hospital mortality, and morbidity were compared between groups. The association of perioperative factors with acute renal failure was investigated by multiple logistic regression analysis.

Results. Preoperative characteristics were similar between the groups. Mean number of grafts was 2.9 ± 0.8 and 2.3 ± 0.8 in the on-pump and off-pump groups, respectively (p < 0.0001). Comparison between groups showed a significantly higher incidence of stroke, inotropic requirement, blood loss, and transfusion of red packed cell and platelets in the on-pump group (all p < 0.05). Postoperative serum creatinine and urea were higher in the on-pump group with a significant difference at 12 hours postoperatively (p < 0.05). Logistic regression analysis identified cardiopulmonary bypass, serum creatinine level 60 hours postoperatively, inotropic requirement, need for intraaortic balloon pump, transfusion of red packed cell, and hours of ventilation as predictors of postoperative acute renal failure.

Conclusions. This study suggests that off-pump coronary artery bypass operations reduce in-hospital morbidity and the likelihood of acute renal failure in patients with preoperative nondialysis-dependent renal insufficiency undergoing myocardial revascularization.     

The efficacy of intraoperative internal intercostal nerve block during video-assisted thoracic surgery on postoperative pain

Background. Video-assisted thoracic surgery (VATS) is widely used for many thoracic surgical procedures. Postoperative pain is less after VATS than after conventional thoracic surgery, but is still significant. The objective of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.

Methods. Thirty-two patients underwent VATS bilateral sympathectomy for the treatment of hyperhidrosis. The patients were randomly divided into two groups with similar demographic and preoperative physiologic parameters. Group A (n = 16) was submitted to thoracoscopic, internal intercostal nerve blocks performed at T2, T3, and T4 intercostal levels using 3 cc of 0.5% bupivacain in each intercostal space. The injections were performed bilaterally, immediately after the sympathectomy, through the same port. Group B (n = 16) underwent bilateral thoracic sympathectomy without the block. During the immediate postoperative period, heart rate, blood pressure, respiratory rate, pain score, and analgesic requirements were monitored every 30 minutes.

Results. No morbidity was recorded in association with the thoracoscopic, internal intercostal nerve block. The mean heart rates (77 ± 6 vs 89 ± 12 beats per minute, p < 0.001), respiratory rates (15 ± 2 vs 18 ± 3 respirations per minute, p < 0.01), pain score (1.9 ± 0.6 vs 2.7 ± 0.5, p < 0.01), and postoperative analgesic requirements (20 ± 18 vs 50 ± 21 mg pethidine HCL, p < 0.001) were significantly lower in group A. There was no significant difference in blood pressures.

Conclusions. Thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements.     

Neopterin: a prognostic variable in operations for lung cancer

Background. We studied the prognostic value of preoperatively measured neopterin to predict survival of lung cancer patients. Neopterin is produced and secreted by interferon-γ-stimulated monocytic cells. High urinary neopterin concentrations are found in patients with viral infections, allograft rejection episodes, and some malignant diseases. In various tumor types high urinary neopterin concentrations are associated with a worse prognosis.

Methods. Preoperative neopterin levels of 110 patients (29 women, 81 men) with lung cancer including 7 patients with small cell lung cancer were measured and related to the time of survival after operation. Patients with clinically suspected stage IIIB lung cancer were not operated and therefore not enrolled in this study. Infectious diseases were not apparent at the time of preoperative urine sampling. Median postoperative follow-up period was 17.4 months.

Results. In a univariate analysis, patients with a preoperative neopterin concentration of more than 212 μmol/mol creatinine (4th quartile) were determined to have a significantly lower survival probability. In a multivariate analysis, a neopterin concentration of more than 212 μmol/mol creatinine (p < 0.01) and T-stage status (p < 0.005) were determined to be significantly predictive variables for worse survival prognosis.

Conclusions. Preoperative neopterin proved to be a reliable prognostic factor for survival. Immunology may provide an accurate assessment of tumor aggression and its clinical behavior. In this sense, neopterin can serve as an immunologically based estimation of malignant outgrowth. In patients who are operable by clinical tumor stage but have a high risk for operation, elevated preoperative neopterin may help in the decision for a nonoperative treatment.     

Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema

Background. We evaluated a technique of video-assisted thoracoscopic (VAT) decortication of the visceral cortex to reexpand entrapped lung in cases of chronic postpneumonic pleural empyema.

Methods. A prospective cohort study of 48 consecutive patients with multiloculated postpneumonic pleural empyema in whom visceral pleural decortication was required was studied. The effect of VAT decortication on perioperative outcome and factors affecting its success were assessed.

Results. Before the introduction of VAT decortication 12 patients were treated by thoracotomy (group T). In the subsequent 36 patients VAT decortication was attempted with success in 21 (group VS) but lung expansion was not observed in 15 patients (group VF) who required thoracotomy. There was no difference in the age or sex distribution of the 3 groups. Operating time was significantly longer in group T than group VS, mean difference 30.3 minutes (p = 0.001) and postoperative hospital stay was longer in group T than group VS, mean difference 2.9 days (p = 0.004). The success of VAT decortication was not related to either the delay between onset of symptoms or hospital admission and surgery; indeed the operating time decreased with increasing preoperative delay. However, success was related to increasing operative experience (p = 0.001).

Conclusions. VAT decortication is a feasible new technique to achieve lung reexpansion in chronic postpneumonic pleural empyema and has perioperative benefits over thoracotomy.     

Reversibility of Cardiac Dysfunction After Valve Replacement in Elderly Patients With Severe Aortic Stenosis

Background. The role of aortic valve replacement for aortic stenosis has not been fully defined in terms of the postoperative reversibility of cardiac dysfunction and pulmonary hypertension in elderly patients.

Methods. Cardiac function, assessed by radioisotope ventriculography and catheterization data, was evaluated before and after operation, and their results were compared between preoperative and postoperative data in each group of younger patients (<69 years, group I, n = 29) and elderly patients (≥70 years, group II, n = 21).

Results. One month postoperatively the peak ejection rate determined by radioisotope ventriculography improved significantly in comparison with the preoperative value in elderly patients (preoperatively, 228 ± 38 versus postoperatively, 319 ± 116% end-diastolic volume per second, p < 0.05), although their preoperative peak ejection rate was severely depressed. The postoperative peak filling rate of the elderly group was not completely reversible to almost normal value, whereas that of the younger group was completely reversible. Early diastolic peak filling rate (one-third peak filling rate) was not reversible in both two groups. Pulmonary hypertension in the elderly patients was reversible to postoperative almost normal pulmonary artery pressure despite the severity of aortic stenosis (systolic pulmonary artery pressure preoperatively, 37 ± 16 mm Hg versus postoperatively, 25 ± 5 mm Hg, p < 0.02; diastolic pulmonary artery pressure preoperatively, 15 ± 6 mm Hg versus postoperatively, 10 ± 4 mm Hg, p < 0.05).

Conclusions. Both cardiac dysfunction, reflected by reduction of peak ejection rate, and pulmonary hypertension in elderly patients with severe aortic stenosis were reversed, reaching almost normal values 1 month after operation.     

Intermittent Antegrade Tepid Versus Cold Blood Cardioplegia in Elective Myocardial Revascularization

Background. The ideal temperature for blood cardioplegia administration remains controversial.

Methods. Fifty-two patients who required elective myocardial revascularization were prospectively randomized to receive intermittent antegrade tepid (29°C; group T, 25 patients) or cold (4°C; group C, 27 patients) blood cardioplegia.

Results. The two cohorts were similar with respect to all preoperative and intraoperative variables. The mean septal temperature was higher in group T (T, 29.6° ± 1.1°C versus 17.5° ± 3.0°C; p < 0.0001). After reperfusion, group T exhibited significantly greater lactate and acid release despite similar levels of oxygen extraction (p < 0.05). The creatine kinase-MB isoenzyme release was significantly lower in group T (764 ± 89 versus 1,120 ± 141 U · h/L; p < 0.04). Hearts protected with tepid cardioplegia demonstrated significantly increased ejection fraction with volume loading, improvement in left ventricular function at 12 hours, and decreased need for postoperative inotropic support (p < 0.05). The frequency of ventricular defibrillation after cross-clamp removal was lower in this cohort (p < 0.05). There were no hospital deaths, and both groups had similar postoperative courses.

Conclusions. Intermittent antegrade tepid blood cardioplegia is a safe and efficacious method of myocardial protection and demonstrates advantages when compared with cold blood cardioplegia in elective myocardial revascularization.     

Risk analysis in patients bridged to transplantation

Background. Efforts to predict mortality in bridge to cardiac transplant patients have concentrated on pre-ventricular assist device (VAD) status. To more fully identify factors influencing survival to transplant, we reviewed the preoperative and postoperative VAD courses of 105 bridge to transplant patients.

Methods. Sixty-four parameters (34 pre-VAD, 30 post-VAD), including hemodynamics, complications, and evaluations of major organ function were examined and analyzed.

Results. Thirty-three patients (31%) died on VADs and 72 were transplanted. There were two posttransplant operative deaths (3%). By univariate analysis 23 of 64 factors were significant. These 23 factors were entered into a stepwise logistic regression analysis to identify predictors of survival to transplant. Four factors, including pre-VAD intubation (p < 0.005), cardiopulmonary bypass (CPB) time during VAD insertion (p < 0.0001), mean pulmonary artery pressure (first postoperative day after VAD) (p < 0.0002), and highest post-VAD creatinine (p < 0.01) were independent predictors of transplantation.

Conclusions. Other than the need for intubation, pre-VAD variables were of little value in predicting survival to transplant. Problems during VAD insertion (long CPB time) and post-VAD renal insufficiency were independent predictors. Severe complications that developed during the interval of VAD support, including cerebrovascular accident, bleeding and infection, were surprisingly not predictors for transplantation.     

Pleuropneumonectomy for pulmonary tuberculosis and chronic tuberculous empyema

Surgical intervention is often necessary to treat either the active pulmonary tuberculosis or its sequelae such as destroyed lung, tuberculous empyema, and bronchial stenosis. Pleuropneumonectomy, which has been reported to be associated with high mortality and morbidity, is performed when the pleural space is completely obliterated due to previous inflammation or when preoperative empyema is complicated. In this article we report 3 patients receiving pleuropneumonectomy for pulmonary tuberculosis or chronic tuberculous empyema in recent 3 years. The mean operation time is 5 hours and 56 minutes, and the mean volume of intraoperative bleeding amounted to 1,417 ml. Autologous blood transfusion was prepared for all 3 patients and transfused them during the operation. No mortality, but postoperative complications were seen in 2 patients (67%) with a history of diabetes mellitus. They were sternum infection and bronchopleural fistula, which were successfully treated conservatively. Diabetes mellitus is thought to be a major risk factor for not only tuberculous disease itself, but also postoperative morbidity. As for surgical techniques, wide skin incision with multiple thoracotomy is necessary to keep a good operative field, and special care must be taken for great vessels and nerves at extrapleural dissection. We conclude that pleuropneumonectomy is relatively risky but effective surgical procedure for adequately selected patients with destroyed lung and tuberculous empyema.     

Mitral commissurotomy, a technique outdated? Long-term follow-up over a period of 35 years

Background. The objective of this study was to evaluate long-term survival, valve-related complications as well as prognostic factors for early and late outcome after open and closed mitral commissurotomy covering a follow-up period of 35 years.

Methods. From 1955 to 1977, 183 patients with mitral stenosis underwent mitral commissurotomy at our institution. Closed valvotomy was performed on 143 patients (group A) and open valvotomy on 40 patients (group B).

Results. Survival rates after 10, 20, and 30 years were 89%, 67.8%, and 49.1% in group A and 91.7%, 66.7%, and 45.9% in group B (p = not significant). The risk of late death increased significantly with an advanced preoperative New York Heart Association functional class, atrial fibrillation, higher age at operation, pre- or postoperative mitral regurgitation, and leaflet calcification. Forty-four patients in group A and 5 patients in group B required reoperation (p < 0.05). Independent predictors for reoperation in a multivariate analysis were a remaining postoperative mitral stenosis or regurgitation. A total of 68 patients showed valve-related complications. The linearized rate of valve-related morbidity and mortality was 2.1% per patient-years in group A versus 1.1% per patient-years in B (p < 0.01).

Conclusions. Long-term survival for open and closed commissurotomy are excellent, showing no difference between the groups. However, both the incidence of reoperation as well as valve-related morbidity and mortality were significantly lower after open commissurotomy. In well-selected patients with pure mitral stenosis and no leaflet calcification, open commissurotomy still remains a valid surgical option.     

Prognostic significance of neuroendocrine differentiation in adenocarcinoma of the lung

Background. The relative incidence of adenocarcinoma of the lung is increasing and some patients with lung carcinoma, detected at an early stage, still develop recurrent disease despite complete resection of the tumor. Recently, neuroendocrine differentiation in large cell carcinoma of the lung has been reported to be of prognostic significance. Therefore, we have evaluated the prognostic significance of neuroendocrine differentiation in adenocarcinoma of the lung.

Methods. A total of 90 resected specimens of adenocarcinoma of the lung measuring 3 cm or less (T1 N0 M0 or T2 N0 M0) were reviewed histologically and immunohistochemical staining was performed to determine the degree of neuroendocrine differentiation.

Results. Seven adenocarcinomas exhibited neuroendocrine differentiation in 10% or more of tumor cells. The disease-free survival rate for these patients was significantly lower than that of patients with tumors exhibiting neuroendocrine differentiation in less than 10% of tumor cells or with absent neuroendocrine differentiation (p < 0.0005). Other conventional pathologic factors such as vascular invasion (p < 0.0005), lymphatic invasion (p < 0.05), and pleural involvement (p < 0.05) were also of prognostic significance. In multivariate analysis, the presence of 10% or more neuroendocrine marker-positive tumor cells, vascular invasion, and lymphatic invasion were found to be significantly adverse prognostic factors (p = 0.0162, p = 0.0111, and p = 0.0173, respectively).

Conclusions. Neuroendocrine differentiation of tumor cells is a prognostic factor in lung adenocarcinoma. It is suggested that the identification of neuroendocrine differentiation as well as vascular invasion by tumor in small peripheral adenocarcinoma of the lung may predict the prognosis of these patients.     

Screening Carotid Ultrasonography and Risk Factors for Stroke in Coronary Artery Surgery Patients

Background. The role of noninvasive carotid artery screening in relation to other clinical variables in identifying patients at increased risk of stroke after coronary artery bypass grafting was examined.

Methods. Preoperative, intraoperative, and postoperative clinical data were prospectively collected for 1,835 consecutive patients undergoing first-time isolated coronary artery bypass grafting between March 1990 and July 1995, 1,279 of whom had screening carotid ultrasonography. All patients with postoperative neurologic events were identified and reviewed in detail. Average patient age was 65.3 years (range, 33 to 92 years), and 9.3% (171 patients) had a prior permanent stroke or transient ischemic attack. Hospital and 30-day mortality was 2.2% (41 patients). Forty-five patients (2.5%) had a transient or permanent postoperative neurologic event. The data were analyzed by stepwise logistic regression to determine the independent predictors of both significant carotid stenosis and stroke.

Results. On multivariate analysis, the clinical predictors of significant carotid stenosis were age (p < 0.0001), diabetes (p = 0.0123), female sex (p = 0.0026), left main coronary stenosis greater than 60% (p < 0.0001), prior stroke or transient ischemic attack (p = 0.0008), peripheral vascular disease (p = 0.0001), prior vascular operation (p = 0.0068), and smoking (p < 0.0001). When all variables were evaluated for those patients who underwent noninvasive carotid artery screening, the independent predictors of postoperative neurologic event were prior stroke or transient ischemic attack (p < 0.0001), peripheral vascular disease (p = 0.0037), postinfarction angina pectoris (p = 0.0319), postoperative atrial fibrillation (p = 0.0014), carotid stenosis greater than 50% (p = 0.0029), cardiopulmonary bypass time (p = 0.0006), significant aortic atherosclerosis (p = 0.0054), postoperative amrinone or epinephrine use (p = 0.0054), and left ventricular ejection fraction less than 0.30 (p = 0.0744).

Conclusions. The etiology of postoperative stroke is multifactorial. Selective use of carotid ultrasonography is of value in identifying patients who are at greater risk of postoperative stroke independent of other variables and should be considered before coronary artery bypass grafting, particularly in patients with a history of neurologic event or peripheral vascular disease.