Pulmonary endarterectomy normalizes interventricular dyssynchrony and right ventricular systolic wall stress

Background: Interventricular mechanical dyssynchrony is a characteristic of pulmonary hypertension. We studied the role of right ventricular (RV) wall stress in the recovery of interventricular dyssynchrony, after pulmonary endarterectomy (PEA) in chronic thromboembolic pulmonary hypertension (CTEPH). Methods: In 13 consecutive patients with CTEPH, before and 6 months after pulmonary endarterectomy, cardiovascular magnetic resonance myocardial tagging was applied. For the left ventricular (LV) and RV free walls, the time to peak (Tpeak) of circumferential shortening (strain) was calculated. Pulmonary Artery Pressure (PAP) was measured by right heart catheterization within 48 hours of PEA. Then the RV free wall systolic wall stress was calculated by the Laplace law. Results: After PEA, the left to right free wall delay (L-R delay) in Tpeak strain decreased from 97 +/- 49 ms to -4 +/- 51 ms (P <0.001), which was not different from normal reference values of -35 +/- 10 ms (P = 0.18). The RV wall stress decreased significantly from 15.2 +/- 6.4 kPa to 5.7 +/- 3.4 kPa (P <0.001), which was not different from normal reference values of 5.3 +/- 1.39 kPa (P = 0.78). The reduction of L-R delay in Tpeak was more strongly associated with the reduction in RV wall stress (r = 0.69, P = 0.007) than with the reduction in systolic PAP (r = 0.53, P = 0.07). The reduction of L-R delay in Tpeak was not associated with estimates of the reduction in RV radius (r = 0.37, P = 0.21) or increase in RV systolic wall thickness (r = 0.19, P = 0.53). Conclusion: After PEA for CTEPH, the RV and LV peak strains are resynchronized. The reduction in systolic RV wall stress plays a key role in this resynchronizatio

Pulmonary Arterial Stent Implantation in an Adult with Williams Syndrome

We report a 38-year-old patient who presented with pulmonary hypertension and right ventricular dysfunction due to pulmonary artery stenoses as a manifestation of Williams syndrome, mimicking chronic thromboembolic pulmonary hypertension. The patient was treated with balloon angioplasty and stent implantation. Short-term follow-up showed a good clinical result with excellent patency of the stents but early restenosis of the segments in which only balloon angioplasty was performed. These stenoses were subsequently also treated successfully by stent implantation. Stent patency was observed 3 years after the first procedure

Endoscopic and Percutaneous Preoperative Biliary Drainage in Patients with Suspected Hilar Cholangiocarcinoma

INTRODUCTION: Controversy exists over the preferred technique of preoperative biliary drainage (PBD) in patients with hilar cholangiocarcinoma (HCCA) requiring major liver resection. The current study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) in patients with resectable HCCA. METHODS: One hundred fifteen consecutive patients were explored for HCCA between 2001 and July 2008 and assigned by initial PBD procedure to either EBD or PTBD. RESULTS: Of these patients, 101 (88%) underwent PBD; 90 patients underwent EBD as primary procedure, and 11 PTBD. The technical success rate of initial drainage was 81% in the EBD versus 100% in the PTBD group (P = 0.20). Stent dislocation was similar in the EBD and PTBD groups (23% vs. 20%, P = 0.70). Infectious complications were significantly more common in the endoscopic group (48% vs. 9%, P < 0.05). Patients in the EBD group underwent more drainage procedures (2.8 vs. 1.4, P < 0.01) and had a significantly longer drainage period until laparotomy (mean 15 weeks vs. 11 weeks in the PTBD group; P < 0.05). In 30 patients, EBD was converted to PTBD due to failure of the endoscopic approach. CONCLUSIONS: Preoperative percutaneous drainage could outperform endoscopic stent placement in patients with resectable HCCA, showing fewer infectious complications, using less procedure

Open window thoracostomy: a new therapeutic option using topical negative pressure wound therapy

Open window thoracostomy (OWT) is an invasive treatment option for thoracic empyema that is seldom indicated. These wounds are accompanied with a prolonged hospital stay and significant patient discomfort over an extended period of time. A retrospective report was conducted on patients who underwent OWT at the Academic Medical Center (Amsterdam, The Netherlands) and evaluated if topical negative pressure therapy ([TNP], V.A.C.® Therapy™, KCI Medical BV, Houten, The Netherlands) is a valid treatment option for these wounds. Clinical outcome and applied management methods are analyzed. Between January 1986 and June 2005, 15 patients, with a mean age of 54 years, were treated with OWT. Recently, the authors have used TNP in combination with OWT as a new treatment modality to obtain rapid control over pleural bacterial load and to achieve a well-vascularized wound surface. Good clinical results and a trend toward shorter hospital stays and improved quality of life were seen. Open window thoracostomy as a treatment modality for thoracic empyema is a valid option but only when other means fail or are contraindicated. Treatment of open window thoracostomy in combination with TNP is a safe and adequate therapeutic option for thoracic empyema resulting in improved quality of life and overall shorter hospital sta

Surveillance and epidemiology of surgical site infections after cardiothoracic surgery in The Netherlands, 2002-2007

Surgical site infections after cardiothoracic surgery substantially increase the risk for illness, mortality, and costs. Surveillance of surgical site infections might assist in the prevention of these infections. This study describes the Dutch surveillance methods and results of data collected between 2002 and 2007. Three cardiothoracic procedures were included: coronary artery bypass graft procedures, valve surgery, and a combination of coronary artery bypass graft procedures with concomitant valve surgery. The surgical site infections were divided into sternal and harvest-site infections. Postdischarge surveillance of surgical site infections was mandatory for sternal wounds and elective for harvest-site wounds, with a follow-up period of 42 postoperative days. Multivariate logistic regression was used for risk factor analysis of coronary artery bypass grafts, with adjustment for random variation among hospitals. Eight of the 16 Dutch cardiothoracic centers participated and collected data on 4066 procedures and 183 surgical site infections, revealing a surgical site infection rate of 2.4% for sternal wounds and 3.2% for harvest sites. Sixty-one percent of all surgical site infections were recorded after discharge. For sternal surgical site infections after coronary artery bypass graft procedures, the significant risk factors were rethoracotomy, diabetes, preoperative length of stay, and obesity; for harvest-site infections, the most relevant risk factor was a long time on extracorporeal circulation. Adjusted surgical site infection rates regarding coronary artery bypass graft procedures varied between hospitals from 0.0% to 9.7%. Large differences were found in surgical site infection rates between Dutch hospitals, which indicate room for improvement. The follow-up of patients after hospital discharge reduces underestimation of surgical site infection rate

Poststernotomy mediastinitis: comparison of two treatment modalities

Poststernotomy mediastinitis (PM) is a serious and potentially lethal condition with an overall incidence varying from 0.4-5%. There is little consensus on the ideal management of PM. The aim of this retrospective study was to investigate the effectiveness of topical negative pressure (TNP) therapy vs. traditional closed drainage techniques (CDT) as a treatment modality for PM. We reviewed the data of 10,467 patients who underwent median sternotomy between 1 January 1992 and 31 December 2003. During this period 63 patients were treated for PM. Twenty-nine of these patients were treated with TNP and 34 with conventional CDT. Primary points of interest were: treatment modalities, mortality, surgical site infection recurrence and, duration of therapy and hospital stay. In this series, the total incidence of poststernotomy mediastinitis was 0.6% with high morbidity rates. In the TNP group, lower rates of recurring infection, therapeutic failure and fewer defects at discharge were seen (P <0.05). In conclusion, the results of our series add further data to the knowledge that PM is an important cause of morbidity and mortality. TNP is a safe and adequate treatment modality for treating P

Brain natriuretic peptide as noninvasive marker of the severity of right ventricular dysfunction in chronic thromboembolic pulmonary hypertension

BACKGROUND: Right ventricular (RV) dysfunction is associated with increased morbidity and mortality in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who undergo pulmonary endarterectomy (PEA). We studied whether plasma brain natriuretic peptide (BNP) levels can be used to identify RV dysfunction in CTEPH patients. Therefore, plasma BNP levels were studied in relation to cardiac remodeling and function as determined by cardiac magnetic resonance imaging (MRI). METHODS: Thirty-eight patients with CTEPH (55 +/- 15 years), and ten healthy controls (46 +/- 15 years) were studied. The BNP was determined by an immunoradiometric assay. RESULTS: The CTEPH patients had a mean pulmonary artery pressure of 49 +/- 13 mm Hg, cardiac index 2.1 +/- 0.7 l x min(-1) x m(-2), and pulmonary vascular resistance of 867 +/- 432 dynes x s x cm(-5). In CTEPH patients, compared with controls, right ventricular (RV) remodeling was demonstrated. In the patients, BNP was increased and correlated (all p < 0.0001; Spearman rank test) with MRI parameters of RV remodeling and function: end diastolic (r = 0.71) and end systolic (r = 0.74) volumes, RV mass (r = 0.68), leftward ventricular septal bowing (r = -0.80) and ejection fraction (EF; r = -0.81). By receiver operating curve analysis, BNP levels of 11.5 picomole (pmol)/L and 48.5 pmol/L, respectively, detected RV dysfunction as defined by RVEF less than 0.45 and less than 0.30, respectively, with high sensitivity and specificity. Hemodynamically, BNP levels greater than 48.5 pmol/L identified the most severely affected patients. CONCLUSIONS: In CTEPH patients, BNP levels correlate with RV remodeling and can be used to identify RV dysfunction. Future studies are warranted on the role of BNP to identify "high risk" CTEPH patients and its relation to postoperative hemodynamic outcome, RV failure, and mortalit

Embolization for hemoptysis in chronic thromboembolic pulmonary hypertension: report of two cases and a review of the literature

Hemoptysis is a known complication in patients with bronchial artery hypertrophy due to a variety of chronic pulmonary disorders. Bronchial artery hypertrophy is observed in most patients with chronic thromboembolic pulmonary hypertension (CTEPH), but surprisingly little is known about the incidence of hemoptysis in these patients. In this paper, we report on 2 patients with CTEPH and recurrent severe hemoptysis, who were treated by bronchial artery embolization. One patient recovered and 1 patient died as a consequence of the bleeding. A systematic review revealed 21 studies on the underlying pathology in 1,844 patients with moderate to severe hemoptysis. CTEPH was reported to be the cause of bleeding in 0.1% (n = 2), pulmonary arterial hypertension without chronic thromboembolic disease in 0.2% (n = 4), and acute pulmonary embolism in 0.7% (n = 12) of the patients. In contrast to this, 5 patients (6%) in our own series of 79 CTEPH patients suffered from moderate to severe hemoptysis requiring medical intervention. Severe hemoptysis appears to be an uncommon, but possibly underreported, life-threatening complication in CTEPH patients. As most CTEPH patients require life-long anticoagulants a therapeutic dilemma may ensue. Therefore, we propose that even mild hemoptysis in CTEPH patients warrants prompt evaluation, and treatment by embolization should be offered as first choice in CTEPH patient