Annals of thoracic surgery short reports最新文献

Background

Right ventricular (RV) failure after heart transplantation (HT) is common in those with pretransplantation elevated pulmonary vascular resistance (PVR). Mechanical circulatory support has been used as a bridge to recovery, with mixed outcomes. We describe a patient with failed single-ventricle palliation in whom severe RV failure developed after HT. We review the current literature and outline our post-HT strategy.

Methods

An infant with trisomy 21, severely unbalanced right dominant atrioventricular septal defect, and hypoplastic aortic arch was palliated with a hybrid procedure. At 6 months of age, cardiac catheterization measured PVR index of 5.47 Wood units × m² on maximal medical therapy. The patient was deemed unsuitable for second-stage palliation and underwent HT at 18 months of age. Despite preemptive medical therapies, acute RV failure developed, necessitating extracorporeal membrane oxygenation. He was quickly converted to main pulmonary artery to left atrial cannulation. Unloaded RV function normalized; he was weaned from support and discharged home 5 weeks after HT.

Results

Failure of medical therapy in RV failure after HT requires escalation to mechanical circulatory support. We review the literature on RV failure and support after HT. We also describe a novel cannulation strategy to provide a reliable way to directly reduce RV afterload, to allow physiologic training of the right ventricle to a higher PVR, and to maintain normal left ventricular coupling and loading.

Conclusions

In pediatric patients with elevated PVR undergoing HT, advanced therapies can be used effectively to treat acute RV failure. Unique cannulation strategies may play a role in improving survival of similar patients.

Background

Paravertebral block (PVB) is effective in controlling postoperative pain after video-assisted thoracoscopic surgery (VATS) lobectomy but is subject to a high rate of failure because of incorrect site of injection. We compared methylene blue PVB with thoracic epidural anesthesia (TEA) for postoperative pain after VATS lobectomy.

Methods

We conducted a prospective randomized trial of patients undergoing VATS lobectomy; 120 patients were randomly assigned to the PVB or TEA group. The end points were postoperative pain at 1 hour, 12 hours, 24 hours, and 48 hours; time to perform TEA and PVB; opioid consumption; and postoperative outcomes.

Results

PVB was associated with reduction of local anesthesia time (P < .0001). In 2 cases, methylene blue showed that the block was not well performed; thus, it was repeated. No significant differences were found in postoperative pain, opioid consumption, and postoperative outcomes.

Conclusions

PVB with methylene blue is as effective as TEA for controlling postoperative pain. Methylene blue use could help reduce PVB failure.

The endocardial anchoring technique is a novel modification of total anomalous pulmonary venous return repair that involves creation of an L-shaped flap of the pulmonary venous confluence, subsequently anchoring it to the endocardium. A wide and smooth pathway can be expected from the theoretical advantages of this technique, namely, a smooth inner surface of the anchored flap and traction force to extend the orifice of the connection. An application of this technique for a rare variant of supracardiac total anomalous pulmonary venous return suggests its potential to be an alternative to the conventional repair, especially in patients with a curved pulmonary venous confluence.

Background

Lidocaine in del Nido cardioplegia solution prolongs the refractory period of cardiomyocytes, yielding a longer arrest per dose. Serum lidocaine concentrations >8 mg/L are associated with seizure and cardiotoxicity. We evaluated serum lidocaine concentrations in patients receiving del Nido solution during cardiac surgery.

Methods

Forty consecutive patients undergoing cardiac surgical procedures with del Nido cardioplegia were selected for serum lidocaine concentration measurements determined immediately after aortic cross-clamp removal. Variables included weight, body surface area, operation, cardiopulmonary bypass time, aortic cross-clamp time, and total volume of del Nido solution. The primary outcome was serum lidocaine concentration relative to total volume of del Nido solution. Descriptive statistics and Pearson correlations were computed.

Results

Median weight was 78.3 kg (range, 43-132.4 kg), and mean body surface area was 1.9 ± 0.2 m². Operations included coronary artery bypass grafting (n = 26 [65%]), a combination procedure (n = 5 [12.5%]), isolated mitral valve repair or replacement (n = 4 [10%]), isolated aortic valve replacement (n = 3 [7.5%]), and aortic repair or replacement (n = 2 [5%]). Median total volume of del Nido solution was 1870 mL (range, 800-5800 mL). Mean serum lidocaine concentration was 2.2 ± 0.6 mg/L. Serum lidocaine concentration was weakly correlated with del Nido solution volume (R² = 0.21). The highest total volume of del Nido solution (5800 mL) did not yield the highest serum lidocaine concentration of 3.5 mg/L.

Conclusions

Serum lidocaine concentration during cardiac surgical procedures weakly correlates with the volume of del Nido solution used and does not reach toxic levels even at high doses of del Nido solution. The results of this study may help alleviate concerns for lidocaine toxicity with high doses of del Nido solution.

A 33-year-old woman who had previously undergone mitral valve repair for native valve endocarditis presented with a submitral left ventricular pseudoaneurysm, with related mitral valve dysfunction. The operative approach to this complex pathophysiologic process is presented.

Background

Lung cancer is the leading cause of cancer-related death. Although lung cancer screening has been shown to reduce mortality, only a small fraction of eligible people receive screening. This study briefly educated screening-eligible individuals about lung cancer risk, prevention, and screening recommendations. We then evaluated race and gender as predictors of willingness to be screened once participants were educated.

Methods

An online lung cancer screening learning module was created and distributed to convenience samples of screening-eligible White Americans (n = 173) and Black Americans (n = 52) between November 2022 and February 2023. Participants viewed short modules about lung cancer risks and screening. Thereafter, participants rated their willingness to consider future screening using theory of planned behavior measurement frameworks (attitudes, norms, perceived control, and intentions to screen), with higher scores indicating greater willingness. Participant demographics were recorded.

Results

Black Americans reported higher perceived control over obtaining screening than White Americans (t₂₂₃ = −3.10; P < .001; d = 1.28). We observed no other racial differences in willingness as Black Americans and White Americans reported similar attitudes, normative beliefs, and intentions. Women also showed more positive attitudes and greater intention to be screened than men did (t₂₂₃ = −2.42; P = .02; d = 1.66).

Conclusions

Once informed about lung cancer risks, prevention, and screening recommendations, Black Americans may be as willing as White Americans to undergo screening, highlighting potential causal factors other than willingness for existing racial disparities in lung cancer screening uptake. Gender differences in willingness highlight a potential need for gender-targeted outreach and communication.