Successful high‐risk percutaneous coronary intervention with the use of minimal extracorporeal circulation system

Minimal extracorporeal circulation (MECC) represents a contemporary system which integrates several advances in cardiopulmonary bypass technology in a single circuit. We challenged the efficacy of the MECC system to support the circulation in elective high‐risk percutaneous coronary intervention (PCI). A 78‐year‐old patient with complex coronary disease who would have been otherwise rejected for interventional therapy underwent PCI with rotablation on MECC support. The MECC system provided hemodynamic support at a flow of 1.8 L min^?1 m^?2 while perfusion pressure was kept at a minimum of 70 mm Hg. This allowed for successful angioplasty of the left main stem and a chronically occluded right coronary artery, which otherwise produced significant hemodynamic compromise. This case illustrates that mechanical circulatory support with the MECC system could provide a stable environment and a “safety net” for carrying out complex percutaneous coronary intervention in high‐risk patients. © 2012 Wiley Periodicals, Inc.     

Chirurgische Therapie der fulminanten Lungenembolie

Zusammenfassung Die fulminante Lungenembolie wird nur noch selten chirurgisch behandelt. Die Operation wird als „Ultima-Ratio“-Therapie insbesondere bei Patienten mit kardiopulmonaler Reanimation angesehen. Vor dem Hintergrund eines erheblichen Anteils von Patienten mit residualer Obstruktion nach Lysetherapie mit der Gefahr der Entwicklung einer chronischen pulmonalen Hypertonie und besserer Risikostratifizierung haben einzelne Zentren wieder mehr Patienten einer offenen chirurgischen Embolektomie zugeführt. Hier sind Überlebensraten bis 89% in der perioperativen Phase erzielt worden. Möglich war dies durch Operationen am schlagenden, normothermen Herzen unter Verwendung spezieller Instrumente, wie sie bei der Pulmonalisthrombendarteriektomie Verwendung finden. Die Bestätigung dieser guten Ergebnisse bei noch hämodynamisch stabilen Patienten mit mäßiger bis starker Einschränkung der rechtsventrikulären Funktion durch die Autoren und andere rechtfertigt den Einsatz dieses Verfahrens an Kliniken mit angeschlossener Herzchirurgie in einer früheren Phase, in welcher der Patient noch nicht reanimationspflichtig ist. Die Durchführung einer kontrollierten, randomisierten Studie zur Erfassung des tatsächlichen Stellenwerts im Vergleich zur Lysetherapie wäre wünschenswert im Sinne einer bestmöglichen Therapie für den Patienten. Abstract Surgical embolectomy for massive pulmonary embolism (PE) has become a rare procedure. Often, it is viewed as a last-chance option for patients undergoing cardiopulmonary resuscitation after massive PE. Thus thrombolytic therapy has become the treatment of choice. However, a significant proportion of patients suffers from residual obstruction after thrombolytic therapy and faces the development of chronic pulmonary hypertension. Therefore, some centers have regained interest in surgical embolectomy after improved risk stratification and reported very good results. Perioperative survival rates up to 89% have been reported. This was accomplished by surgery on the ECC-(extracorporeal circulation-)supported, beating, normothermic heart and utilization of special instruments. These encouraging results have been confirmed by the authors and others in patients with stable systemic hemodynamics but moderate to severe right ventricular dysfunction. The more widespread use of surgical embolectomy seems warranted. A randomized, controlled trial is overdue to determine the benefits of this therapy in stable patients compared with thrombolytic therapy if “best-practice” therapy is to be achieved for the patients’ benefit.     

Clinical course and surgical long-term outcome in geriatric patients with non-small cell carcinoma

Summary Background Recent studies indicate that chronological age is not a contraindication to pulmonary resection in elderly with lung cancer but other data are lacking. The purpose of this study was to determine clinical patterns and trends of surgical outcome, short- and long-term survival in elderly patients with surgery for non-small cell lung carcinoma (NSCLC). Methods A retrospective cohort of 273 elderly patients aged over 70 years with NSCLC who underwent curative resection from 1986 to 2001 was followed-up for outcomes. Analysis was performedwith respect to preoperative conditions, surgery, histology, mortality, postoperative course, complications, and length of survival during the observation period. Results Mean age was 73.2±3.1 years old (maximum, 88 years), and 31 (11.3%) patients were 80 years old or older, consisting of 170 (62.2%) males, with a mean follow-up of 31 months. There were 115 (42.3%) squamous carcinomas, 83 (30.5%) adenocarcinomas, 11 (4.1%) bronchioalveolar carcinomas, 47 (17.4%) large cell carcinomas, 8 (2.8%) mixed type and 9 (2.9%) miscellaneous malignant neoplasms.Most patients (n=237) received standard procedures: 151 lobectomies, 49 bilobectomies, 42 pneumonectomies, 9 sleeve resections and 22 wedge resections. Atotal of 36 patients underwent extended resections for tumors involving, the chest wall (n=25), mediastinum (n=7) and pericardium (n=4). Thirty-day mortality was 5.4% (n=15) with 25.9% developing pulmonary and 5.3% major cardiovascular complications. Multivariate analysis showed that extended procedures (p=0.0001), male gender (p=0.0001), low FEV₁ (p=0.02) and age (p=0.02) were independent predictors of early mortality. Overall survival rates at 5, 10, and 15 years were 35.6%, 10.5%, and 2.5%, respectively. Multivariate analysis showed that advanced disease stage (p=0.00012), low FEV₁ (p=0.003). previous cardiac disease (p=0.01), and hypertension (p=0.03) were independent predictors which influenced survival. Conclusions Properly selected patients even greater than or equal to 80 year old with NSCLC can be resected safely with favourable acceptable long-termsurvival. Careful attention to preoperative clinical staging is important since elderly beyond early staged disease fare poorly. Surgery is justified for the treatment of stage I–II lung cancer. Substantial long-term survival rates may also be achieved in stage IIIA patients in the absence of a macroscopically N2 disease. Standard lobectomy is the procedure of choice, extended resections should only be carried out in highly selected patients.