Pneumonectomy in a patient with Swyer-James-MacLeod Syndrome

Swyer-James-MacLeod syndrome is a rare disease that results in parenchymal damage believed to be caused by recurrent lung infections in childhood. We report a case of a previously healthy young woman that presented with insidious progression of exertional dyspnea with restrictive lung physiology. Axial imaging demonstrated a hyperinflated emphysematous right lung with lower lobe fibrosis, nodules and air-fluid filled cysts, with a small right pulmonary artery and contralateral shifting of the mediastinum. She underwent right pneumonectomy ultimately resulting in improvement of her symptoms, with surgical pathology indicating extensive emphysema, bronchiectasis, fibrosis with osseous metaplasia, and placental transmogrification of alveolar septa, being consistent with a diagnosis of SJMS

Role and Rationale for Hybrid Coronary Artery Revascularization

The optimal revascularization strategy for patients with multi-vessel coronary artery disease remains controversial. The advent of percutaneous coronary intervention (PCI) has challenged the superiority of coronary artery bypass graft (CABG) surgery for multi-vessel disease. In the late 1990s, an integrated approach, now referred to as “hybrid coronary revascularization” (HCR), was pioneered combining CABG and PCI to offer appropriate patients a less invasive option for revascularization while still capitalizing on the superior patency rates of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery bypass . The operative techniques continue to evolve as well as the timing strategies for intervention and use of anti-platelet therapy. While more research is needed, current data supports hybrid coronary revascularization as a promising technique to optimize outcomes in patients with multi-vessel coronary artery disease

A single center experience with coronary endarterectomy and vein patch reconstruction

Background: To evaluate the medium and late term outcomes of coronary artery bypass grafting with pull-through coronary endarterectomy using a saphenous vein patch for bypass distal anastomosis site. Methods: Retrospective review of all coronary artery bypass graft (CABG) procedures performed from January 1, 2000 through June 30, 2013 with and without concomitant coronary endarterectomy (CE), was carried out at the Veterans Affairs Medical Center in Washington DC. Patients who underwent concomitant valve operations were excluded. Primary outcome was overall survival, with analyses performed examining CE as well as the use of cardiopulmonary bypass. Secondary outcomes included 30-day mortality and post-operative MI. Results: 1255 CABG operations were performed, 10 of which included CE. All CE procedures were performed with saphenous vein patch. 7 involved left anterior descending artery (LAD) CE with left internal mammary artery (LIMA) conduits. The remaining 3 were diagonal branch artery (D1) CE with saphenous vein bypass conduits. 1-year survival was 70%. 5-year survival was 43% out of 7 patients. Conclusions: Pull-through CE with saphenous vein patch is a safe alternative technique for patients with diffuse coronary artery disease. Perioperative events and intermediate outcomes are favorable, although long-term survival is less than patients without CE

Two cases of monoclonal nodular pulmonary amyloidosis and review of the literature

Nodular pulmonary amyloidosis (NPA) is an uncommon pathology of insoluble protein depositing in pulmonary parenchyma. This localized pulmonary form of amyloidosis is most often found to contain combinations of kappa and lambda immunoglobulin light chain and immunoglobulin heavy chain proteins with a polyclonal lymphoplasmacystic infiltrate. Herein we present two cases of NPA of the rarely reported monoclonal (light-chain restricted) form with review of the literature and discussion of the clinical, radiographic, and histologic features of NPA

Experience with miniaturized cardiopulmonary bypass in cardiac surgery: A prospective comparison of the NovoSCI ready system to off-pump and conventional coronary artery bypass grafting

The major source of morbidity following cardiopulmonary bypass (CPB) is the systemic inflammatory response (SIRS response) which leads to multiple derangements in different organ systems. To combat this, miniaturized cardiopulmonary bypass circuits (MCPBC) have been created to lessen the inflammatory response to CPB. Here we examine early outcomes following coronary artery bypass grafting (CABG) using a MCPBC system compared to conventional bypass techniques at a single institution. Methods: 60 consecutive patients undergoing elective CABG were prospectively enrolled. Nine patients underwent coronary artery bypass grafting (CABG) with conventional CPB (cCABG), 33 underwent off-pump CABG (OPCAB), and the remaining 18 patients underwent CABG with a MCPBC system. Demographics and outcomes were compared between groups and statistical analyses applied. Results: No significant difference was observed in mortality between groups, with only one death reported in total. Morbidity was also low, totaling only 6.7%, with none occurring in the MCPBC group. The MCPBC group required less PRBC and total blood product transfusion than the cCABG and OPCABG groups (p = 0.05), but changes in PLT and Hct over time were not different between groups. Conclusions: The MCPBC system was shown to be comparable to conventional bypass and OPCABG in terms of postoperative complications and mortality. Furthermore, the MCPBC system had the advantage of a decreased transfusion requirement. Based on our preliminary observations, this mini-cardiopulmonary bypass circuit provides a safe alternative to conventional bypass techniques

Long-term survival after CABG in diabetics with aggressive risk factor management

Objectives: Diabetes is a well-established risk factor for cardiovascular disease, and diabetics have a threefold increase in risk of death from cardiovascular disease compared to non-diabetics. Following coronary artery bypass grafting, tight glycemic control improves short-term outcomes, however limited data exist for long-term outcomes. Here we examine these outcomes in diabetics using aggressive risk factor management. Methods: A retrospective review of all patients under-going coronary artery bypass between 1991 and 2000 at a single Veterans Affairs Medical Center was undertaken. 973 patients were included, 313 with diabetes and 660 without. Strict glucose control was maintained for all patients. Additional risk factor modification, including anti-platelets medications, statins, and beta blockers were also used. Survival analysis was performed. Results: The diabetic group was at higher risk, with age, BSA, and NYHA class all being greater (p \u3c 0.05). The mean follow-up time was 6.7 ± 3 years. There were 28 deaths/1000 person-years for non-diabetics, and 48 deaths/1000 person-years for diabetics. Survival rates were significantly higher for non-diabetics (72% versus 58% in the diabetic group, p \u3c 0.001). Cox proportional hazard analysis demonstrated mortality risk was 57% higher for diabetic patients (hazard ratio = 1.57; CI: 1.19 - 2.09; p = 0.002). The mortality risk in diabetics with and without prior MI was similar (HR = 0.83; CI: 0.54 - 1.28; p = 0.40). Conclusions: Diabetics undergoing coronary bypass have poorer long-term survival than non-diabetics despite perioperative glycemic control and risk factor modification. The long-term survival decrease in diabetics with history of MI is attenuated with surgical revascularization

An implantable carotid sinus stimulator for drug-resistant hypertension: Surgical technique and short-term outcome from the multicenter phase II Rheos feasibility trial

BackgroundA large number of patients have hypertension that is resistant to currently available pharmacologic therapy. Electrical stimulation of the carotid sinus baroreflex system has been shown to produce significant chronic blood pressure decreases in animals. The phase II Rheos Feasibility Trial was performed to assess the response of patients with multidrug-resistant hypertension to such stimulation.MethodsThe system consists of an implantable pulse generator with bilateral perivascular carotid sinus leads. Implantation is performed bilaterally with patients under narcotic anesthesia (to preserve the reflex for assessment of optimal lead placement). Dose-response testing at 0 to 6 V is assessed before discharge and at monthly intervals thereafter; the device is activated after 1 month’s recovery time. This was a Food and Drug Administration–monitored phase II trial performed at five centers in the United States.ResultsTen patients with resistant hypertension (taking a median of six antihypertensive medications) underwent implantation. All 10 were successful, with no significant morbidity. The mean procedure time was 198 minutes. There were no adverse events attributable to the device. Predischarge dose-response testing revealed consistent (r = .88) reductions in systolic blood pressure of 41 mm Hg (mean fall is from 180-139 mm Hg), with a peak response at 4.8 V (P < .001) and without significant bradycardia or bothersome symptoms.ConclusionsA surgically implantable device for electrical stimulation of the carotid baroreflex system can be placed safely and produces a significant acute decrease in blood pressure without significant side effects

Selective autonomic stimulation of the AV node fat pad to control rapid post-operative atrial arrhythmias.

Junctional ectopic tachycardia (JET) and atrial fibrillation (AF) occur in patients recovering from open-heart surgery (OHS). Pharmacologic treatment is used for the control of post-operative atrial arrhythmias (POAA), but is associated with side effects. There is a need for a reversible, modulated solution to rate control. We propose a non-pharmacologic technique that can modulate AV nodal conduction in a selective fashion. Ten mongrel dogs underwent OHS. Stimulation of the anterior right (AR) and inferior right (IR) fat pad (FP) was done using a 7-pole electrode. The IR was more effective in slowing the ventricular rate (VR) to AF (52 +/- 20 vs. 15 +/- 10%, p = 0.003) and JET (12 +/- 7 vs. 0 +/- 0%, p = 0.02). Selective site stimulation within a FP region could augment the effect of stimulation during AF (57 +/- 20% (maximum effect) vs. 0 +/- 0% (minimum effect),

Rate Control of Atrial Arrhythmias Can Be Achieved by Selective Cardiac Neurostimulation

Introduction: Atrial arrhythmias (AA) occur in up to 40% of patients recovering from open-heart surgery (OHS). Pharmacologic treatment has been the main strategy used for the control of post-operative AA, but is associated with hypotension, pro-arrhythmia and myocardial dysfunction. There is a need for a reversible, modulated solution to rate control. We demonstrated the efficacy of vagal stimulation at inferior right fat pad (FP) to slow the ventricular response (VR) of atrial fibrillation (AF) and junctional ectopic tachycardia (JET). We hypothesized that the VR response to AA could be improved by alterations in 1) the site of stimulation (anterior right FP vs. inferior right FP), 2) site within the two FP regions tested, and 3) whether there was a relationship between stimulation voltage (V) and electrophysiologic effect. Methods: Eight mongrel dogs, age 8.7 ± 3.9 months and weighing 21.5 ± 2.5 kg, underwent open heart surgery replicating Tetralogy of Fallot repair. Stimulation of the anterior right (AR) and inferior right (IR) fat pad was used to control the VR of AF and JET. A 7-pole electrode was sutured to the AR and IR FP and used to deliver stimulation therapy. Tested parameters included: 1) FP site, 2) stimulation pole configuration, and 3) stimulation (1-25) V on the VR to AF and JET. Stimulation frequency was 30 Hz, and pulse width was 0.15 msec. Results: 1). The inferior right FP was more effective in slowing the VR response to AF (-0.43 ± 0.18 vs. -0.18 ± 0.11 %, p =0.03) and JET (-0.16 ± 0.06 vs. 0.0 ±0.0, p =0.06.) 2). Selective site stimulation within a FP region could augment the effect of stimulation during AF (-0.48 ± 0.21 (maximum effect) vs. 0.0 ± 0.0 % (least effect), p=0.01). Stimulation of electrodes 2+3 produced the greatest reduction in HR with a maximum percent VR reduction of 34.8% 3). FP stimulation at increasing V demonstrated a voltage-dependent effect (-0.12 ± 0.19 (low V) vs. -0.63 ± 0.21 (high V) %, p=0.01)