Acute respiratory distress secondary to posterior mediastinal goiter: a case report

Large posterior mediastinal goiters are extremely rare. Progressive enlargement and possible compression of adjacent structures, as well as malignant potential necessitate that these goiters should be surgically excised. A review of mediastinal tumors, specifically intra-thoracic goiters is presented along with a case report of acute respiratory compromise secondary to tracheal compression by a large posterior goiter

Endovascular repair of thoracic aortic pseudoaneurysms and patch aneurysms

Pseudoaneurysms and patch aneurysms are life-threatening late complications after thoracoabdominal aortic aneurysm (TAAA) repair. We treated four patients who presented with a pseudoaneurysm or patch aneurysm involving the descending thoracic portion of a previously implanted TAAA graft. In each patient, stent grafts were placed within the existing graft to cover the aneurysm endoluminally. All patients recovered without major complications, and computed tomography performed after a mean follow-up of 51.5 ± 19.7 months showed that the repairs remained intact

Outcomes of concomitant aortic valve replacement and coronary artery bypass grafting at teaching hospitals versus nonteaching hospitals

ObjectiveHospitals with a high volume and academic status produce better patient outcomes than other hospitals after complex surgical procedures. Risk models show that concomitant aortic valve replacement and coronary artery bypass grafting pose a greater risk than isolated coronary artery bypass grafting or aortic valve replacement. We examined the relationship of hospital teaching status and the presence of a thoracic surgery residency program with aortic valve replacement/coronary artery bypass grafting outcomes.MethodsBy using the Nationwide Inpatient Sample database, we identified patients who underwent concomitant aortic valve replacement/coronary artery bypass grafting from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates.ResultsThe 3 groups of patients did not differ significantly in their baseline characteristics. Patients who underwent aortic valve replacement/coronary artery bypass grafting had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio 1.58; 95% confidence interval, 1.39–1.80; P < .0001) and teaching hospitals without a thoracic surgery residency program (odds ratio 1.42; 95% confidence interval, 1.26–1.60; P < .0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (odds ratio 0.95; 95% confidence interval, 0.87–1.04; P = .25) or teaching hospitals without a thoracic surgery residency program (odds ratio 1.00; 95% confidence interval, 0.92–1.08; P = .98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality).ConclusionPatients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program

Homograft use in reoperative aortic root and proximal aortic surgery for endocarditis: A 12-year experience in high-risk patients

ObjectivesWe examined the early and midterm outcomes of homograft use in reoperative aortic root and proximal aortic surgery for endocarditis and estimated the associated risk of postoperative reinfection.MethodsFrom January 2001 to January 2014, 355 consecutive patients underwent reoperation of the proximal thoracic aorta. Thirty-nine patients (10.9%; mean age, 55.4 ± 13.3 years) presented with active endocarditis; 30 (76.9%) had prosthetic aortic root infection with or without concomitant ascending and arch graft infection, and 9 (23.1%) had proximal ascending aortic graft infection with or without aortic valve involvement. Sixteen patients (41.0%) had genetically triggered thoracic aortic disease. Twelve patients (30.8%) had more than 1 prior sternotomy (mean, 2.4 ± 0.6).ResultsValved homografts were used to replace the aortic root in 29 patients (74.4%); nonvalved homografts were used to replace the ascending aorta in 10 patients (25.6%). Twenty-five patients (64.1%) required concomitant proximal arch replacement with a homograft, and 2 patients (5.1%) required a total arch homograft. Median cardiopulmonary bypass, cardiac ischemia, and circulatory arrest times were 186 (137-253) minutes, 113 (59-151) minutes, and 28 (16-81) minutes. Operative mortality was 10.3% (n = 4). The rate of permanent stroke was 2.6% (n = 1); 3 additional patients had transient neurologic events. One patient (1/35, 2.9%) returned with aortic valve stenosis 10 years after the homograft operation. During the follow-up period (median, 2.5 years; range, 1 month to 12.3 years), no reinfection was reported, and survival was 65.7%.ConclusionsThis is one of the largest North American single-center series of homograft use in reoperations on the proximal thoracic aorta to treat active endocarditis. In this high-risk population, homograft tissue can be used with acceptable early and midterm survival and a low risk of reinfection. When necessary, homograft tissue may be extended into the distal ascending and transverse aortic arch, with excellent results. These patients require long-term surveillance for both infection and implant durability

Surgical revascularization for acute coronary syndromes: a narrative review

Acute coronary syndrome (ACS) comprises a spectrum of disease that includes unstable angina, non-ST-elevation myocardial infarction, and ST-elevation myocardial infarction. Clinical management of patients with ACS has greatly evolved over the last two decades, but ACS remains an important cause of morbidity and mortality in patients with coronary artery disease. This narrative review describes the indication, timing, and approaches to surgical revascularization in the context of ACS. In particular, the review discusses and compares the utilization of off-pump coronary artery bypass grafting (CABG) vs. conventional on-pump CABG. Other surgical interventions, such as totally endoscopic coronary artery bypass and hybrid coronary revascularization, are also reviewed