Meta-analysis of extracorporeal membrane oxygenation in combination with intra-aortic balloon pump vs. extracorporeal membrane oxygenation only in patients with cardiogenic shock due to acute myocardial infarction

BackgroundIncidence and mortality of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) remain high despite substantial therapy improvements in acute percutaneous coronary intervention over the last decades. Unloading the left ventricle in patients with Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be performed by using an intra-aortic balloon pumps’ (IABP) afterload reduction, which might be especially beneficial in AMI patients with CS.ObjectiveThe objective of this meta-analysis was to assess the effect of VA-ECMO + IABP vs. VA-ECMO treatment on the mortality of patients with CS due to AMI.MethodsA systematic literature search was performed using EMBASE, COCHRANE, and MEDLINE databases. Studies comparing the effect of VA-ECMO + IABP vs. VA-ECMO on mortality of patients with AMI were included. Meta-analyses were performed to analyze the effect of the chosen treatment on 30-day/in-hospital mortality.ResultsTwelve studies were identified by the literature search, including a total of 5,063 patients, 81.5% were male and the mean age was 65.9 years. One thousand one hundred and thirty-six patients received treatment with VA-ECMO in combination with IABP and 2,964 patients received VA-ECMO treatment only. The performed meta-analysis showed decreased mortality at 30-days/in-hospital after VA-ECMO + IABP compared to VA-ECMO only for patients with cardiogenic shock after AMI (OR 0.36, 95% CI 0.30–0.44, P≤0.001). Combination of VA-ECMO + IABP was associated with higher rates of weaning success (OR 0.29, 95% CI 0.16–0.53, P < 0.001) without an increase of vascular access complications (OR 0.85, 95% CI 0.35–2.08, P = 0.72).ConclusionIn this meta-analysis, combination therapy of VA-ECMO + IABP was superior to VA-ECMO only therapy in patients with CS due to AMI. In the absence of randomized data, these results are hypothesis generating only

Is manual palpation of the lung necessary in patients undergoing pulmonary metastasectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether manual palpation of the lung is necessary in patients undergoing pulmonary metastasectomy. In total, 56 articles were found using the described search strategy. After screening these articles and their references, 18 publications represented the best evidence to answer the clinical question. No randomized controlled trial addressing the three-part question was available. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers were tabulated. The studies reported on 1472 patients with different primary cancers. The patients underwent more than 1630 pulmonary metastasectomies between 1990 and 2014 after the treatment of primary cancer. Almost three quarters of patients underwent open procedures like thoracotomy or sternotomy. Most frequently, helical CT with a slice thickness ranging between 1 and 10 mm was used for preoperative imaging. The sensitivity in detecting pulmonary nodules ranged from 34 to 97%. The corresponding sensitivity rates for PET-CT were 66-67.5 and 75% for high-resolution CT. The positive predictive value for lesions detected by helical CT varied from 47 to 96%. Helical CT reached a specificity between 54 and 93% in detecting pulmonary nodules. The surgeons identified more nodules by meticulous palpation than helical CT. It is noteworthy that up to 48.5% of these palpated nodules were benign lesions (false-positive). Patients with smaller imaged nodules, multiple imaged nodules or primary mesenchymal tumour are more likely to have occult pulmonary nodules. We conclude that not all palpable pulmonary nodules can be imaged preoperatively. Thoracotomy allows the manual palpation of the ipsilateral hemithorax and might be superior to video-assisted thoracic surgery regarding radical resection. However, not all palpable nodules are malignant, and the impact of non-resected pulmonary metastases on patient survival is not clearly evaluated

Is manual palpation of the lung necessary in patients undergoing pulmonary metastasectomy?: Table 1:

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether manual palpation of the lung is necessary in patients undergoing pulmonary metastasectomy. In total, 56 articles were found using the described search strategy. After screening these articles and their references, 18 publications represented the best evidence to answer the clinical question. No randomized controlled trial addressing the three-part question was available. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers were tabulated. The studies reported on 1472 patients with different primary cancers. The patients underwent more than 1630 pulmonary metastasectomies between 1990 and 2014 after the treatment of primary cancer. Almost three quarters of patients underwent open procedures like thoracotomy or sternotomy. Most frequently, helical CT with a slice thickness ranging between 1 and 10 mm was used for preoperative imaging. The sensitivity in detecting pulmonary nodules ranged from 34 to 97%. The corresponding sensitivity rates for PET–CT were 66–67.5 and 75% for high-resolution CT. The positive predictive value for lesions detected by helical CT varied from 47 to 96%. Helical CT reached a specificity between 54 and 93% in detecting pulmonary nodules. The surgeons identified more nodules by meticulous palpation than helical CT. It is noteworthy that up to 48.5% of these palpated nodules were benign lesions (false-positive). Patients with smaller imaged nodules, multiple imaged nodules or primary mesenchymal tumour are more likely to have occult pulmonary nodules. We conclude that not all palpable pulmonary nodules can be imaged preoperatively. Thoracotomy allows the manual palpation of the ipsilateral hemithorax and might be superior to video-assisted thoracic surgery regarding radical resection. However, not all palpable nodules are malignant, and the impact of non-resected pulmonary metastases on patient survival is not clearly evaluated

Surgery for Pulmonary Metastases in Patients with Advanced Soft Tissue and Osteosarcomas

Background Advanced soft tissue or osteosarcoma is often associated with lung metastases. Curative pulmonary metastasectomy is appropriate for patients with successfully resected primary cancer who show no evidence of extrapulmonary metastases, with proven functional operability and completely resectable metastases. Material and Methods Systematic literature research and qualitative analysis of studies on patients undergoing lung metastasectomy after resection of primary sarcoma published since 01.01.2010. We assessed operative findings, survival data and prognostic factors. Results Pulmonary metastasectomy results in a median post-metastasectomy survival of 8.76 to 69.9 months. Five year survival rates after metastasectomy vary between 21.7 and 56.8%. The patients' prognosis depends particularly on complete resection of all suspected metastases. Intrapulmonary recurrence could be treated by repeated resection, but this procedure requires careful decision for indication. Re-metastasectomy might result in a favourable outcome in selected cases. Conclusion Pulmonary metastasectomy should be considered as treatment of choice in selected patients with isolated lung metastases from osteosarcoma. Optimal indication might lead to an advantage in patients with metastasectomy of isolated lung metastases from soft tissue

Lung Metastasectomy for Pulmonary Metastatic Breast Carcinoma

Breast carcinoma with pulmonary metastasis can be treated locally or systemically. Following primary tumour resection patients with isolated, completely resectable pulmonary nodules and definite functional operability can be offered lung metastasis resection. Following metastasectomy a median survival of 32 to 96.6 months can be achieved with corresponding five-year survival rates between 30.8 and 54.4%. The procedure is associated with a mortality rate of 0 to 3%. The most important independent prognostic factor for long-term survival is complete resection of all lung lesions. The configuration and pattern of metastasis as well as disease-free interval, hormone and HER2/neu receptor status also appear to influence prognosis, but are of lesser importance. Intrapulmonary recurrence of metastases may, after careful selection on a case-by-case basis, also be treated operatively. In some cases this is associated with a favourable long-term prognosis. Pulmonary metastasectomy should be the treatment of choice for selected patients with metastatic breast carcinoma

Meta-Analysis of Stroke and Mortality Rates in Patients Undergoing Valve-in-Valve Transcatheter Aortic Valve Replacement

Background During the past decade, the use of transcatheter aortic valve replacement (TAVR) was extended beyond treatment-naive patients and implemented for treatment of degenerated surgical bioprosthetic valves. Selection criteria for either valve-in-valve (viv) TAVR or redo surgical aortic valve replacement are not well established, and decision making on the operative approach still remains challenging for the interdisciplinary heart team. Methods and Results This review was intended to analyze all studies on viv-TAVR focusing on short- and mid-term stroke and mortality rates compared with redo surgical aortic valve replacement or native TAVR procedures. A structured literature search and review process led to 1667 potentially relevant studies on July 1, 2020. Finally, 23 studies fulfilled the inclusion criteria for qualitative analysis. All references were case series either with or without propensity score matching and registry analyses. Quantitative synthesis of data from 8509 patients revealed that viv-TAVR is associated with mean 30-day stroke and mortality rates of 2.2% and 4.2%, respectively. Pooled data analysis showed no significant differences in 30-day stroke rate, 30-day mortality, and 1-year mortality between viv-TAVR and comparator treatment (native TAVR [n=11 804 patients] or redo surgical aortic valve replacement [n=498 patients]). Conclusions This review is the first one comparing the risk for stroke and mortality rates in viv-TAVR procedures with native TAVR approach and contributes substantial data for the clinical routine. Moreover, this systematic review is the most comprehensive analysis on ischemic cerebrovascular events and early mortality in patients undergoing viv-TAVR. In this era with increasing numbers of bioprosthetic valves used in younger patients, viv-TAVR is a suitable option for the treatment of degenerated bioprostheses

Bisphosphonates for advanced prostate cancer

Background The prevalence and incidence of pain and skeletal complications of metastatic bone disease such as pathologic fractures, spinal cord compression and hypercalcemia is high and an important contributor to morbidity, poor performance status and decreased quality of life. Moreover, pathologic fractures are associated with increased risk of death in people with disseminated malignancies. Therefore, prevention of pain and fractures are important goals in men with prostate cancer at risk for skeletal complications. Objectives To assess the effects of bisphosphonates in men with bone metastases from prostate cancer. Search methods We identified studies by electronic search of bibliographic databases including the Cochrane Controlled Trials Register and MEDLINE on 13 July 2017 and trial registries. We handsearched the Proceedings of American Society of Clinical Oncology (to July 2017) and reference lists of all eligible trials identified. This is an update of a review last published in 2006. Selection criteria We included randomized controlled studies comparing the effectiveness of bisphosphonates in men with bone metastases from prostate cancer. Data collection and analysis Two review authors independently extracted data and assessed the quality of trials. We defined the proportion of participants with pain response as the primary end point; secondary outcomes were skeletal-related events, mortality, quality of life, adverse events, analgesic consumption and disease progression. We assessed the quality of the evidence for the main outcomes using the GRADE approach. Main results We included 18 trials reporting on 4843 participants comparing the effect of bisphosphonate administration to control regimens. Primary outcome: there was no clear difference in the proportion of participants with pain response (RR 1.15, 95% CI 0.93 to 1.43; P = 0.20; I-2 = 0%; 3 trials; 876 participants; low quality evidence). In absolute terms, bisphosphonates resulted in a pain response in 40 more participants per 1000 (19 fewer to 114 more). Secondary outcomes: bisphosphonates probably reduced the incidence of skeletal-related events in participants with prostate cancer metastatic to bone (RR 0.87, 95% CI 0.81 to 0.94; P = 0.27; I-2 = 19%; 9 trials; 3153 participants; moderate quality evidence). In absolute terms, bisphosphonates resulted in 58 fewer SREs per 1000 (85 fewer to 27 fewer). We found no clinically relevant differences in mortality (RR 0.97, 95% CI 0.91 to 1.04; P = 0.43; I-2 = 1%; 9 trials; 2450 participants; moderate quality evidence). In absolute terms, bisphosphonates resulted in 16 fewer deaths per 1000 (47 fewer to 21 more). Outcome definition of quality of life and themeasurement tools varied greatly across trials and we were unable to extract any quantitative data for meta-analysis. Bisphosphonates probably increased the number of participants affected by nausea (RR 1.19, 95% CI 1.00 to 1.41; P = 0.05; I-2 = 0%; 9 trials; 3008 participants; moderate quality evidence). In absolute terms, bisphosphonates resulted in seven more cases of nausea per 1000 (0 fewer to 14 more). Bisphosphonates probably increased the number of renal adverse events (RR 1.65, 95% CI 1.11 to 2.46; P = 0.01; I-2 = 0%; 7 trials; 1794 participants; moderate quality evidence). In absolute terms, bisphosphonates resulted in 22 more renal adverse events per 1000 (4 more to 50 more). We found no clear difference in the number of participants with osteonecrosis of the jaw between groups (RR 1.92, 95% CI 0.75 to 4.90; P = 0.17; I-2 = 0%; 5 trials; 1626 participants; very low quality evidence). In absolute terms, bisphosphonates resulted in seven more cases with osteonecrosis of the jaw per 1000 (2 fewer to 29 more). We observed no clinically relevant difference in the proportion of participants with decreased analgesic consumption (RR 1.19, 95% CI 0.87 to 1.63; P = 0.28; I-2 = 37%; 4 trials; 416 participants). Statistical analysis revealed that bisphosphonates probably reduced the number of participants with disease progression (RR 0.94, 95% CI 0.90 to 0.98; P = 0.006; I-2 = 0%; 7 trials; 2115 participants; moderate quality evidence). In absolute terms, bisphosphonates resulted in 36 fewer cases of disease progression per 1000 (71 fewer to 7 fewer). Findings of our predefined subgroup and sensitivity analyses were no different from those of the primary analyses. Authors' conclusions Based on low quality evidence, there may be no clinically relevant difference in the proportion of men with pain response between bisphosphonates and control regimens inmenwith bonemetastases fromprostate cancer. Bisphosphonates probably decrease the number of skeletal-related events and disease progression. These benefits need to be weighed against the increased risk of renal impairment and nausea in men receiving bisphosphonates. Future studies should explicitly evaluate patient important outcomes such as quality of life and pain by using standardized and comparable assessment tools

Surgical therapy for pulmonary metastases from malignant melanoma

Results of previous studies question the benefits of pulmonary surgery in patients with pulmonary metastases from malignant melanoma. A systematic literature search and analysis of articles published since 1 January 2000 was carried out to investigate the advantages of metastasectomy and alternative forms of therapy. Patients reached a median survival time of 17-40 months and 5-year survival rates between 18% and 39.4% after metastasectomy. Intrathoracic recurrence occurred in 30 % of patients but could be successfully treated with re-operations in some cases. Various monoclonal antibodies are currently available and achieve a median survival time of up to 17 months. Pulmonary metastasectomy is the treatment of choice in selected patients; however, in the future the benefits should be revalidated in comparison with pharmaceuticals of the current generation

Lung Metastasectomy in Pulmonary Metastatic Colorectal Carcinoma

Background Patients with colorectal cancer are often affected by liver and lung metastases. Besides systemic therapies, lung metastasectomy is a suitable treatment option after complete resection of primary colorectal carcinoma and even concomitant liver metastases. Material and Methods We have performed a systematical literature research of all studies published after 01.01.2010. Studies reporting on at least 100 patients undergoing lung metastasectomy after 01.01.2000 have been included in our final analysis. Operative data, survival data and prognostic factors have been extracted. Results Eleven study cohorts reporting on 2,891 patients could be included in the final analysis. Complete resection could be achieved in most cases and thoracic surgeons preferred subsegmental resections. Pathological examination revealed thoracic lymph node involvement in 2.3 to 18.2% of patients. The postoperative mortality varied from 0 to 0.5%. The median follow up ranged between 27.5 and 65.1 months. Pulmonary metastasectomy resulted in 5-year survival rates of 53 to 75.5% and 5-year progression-free survival rates of 33 to 50.9%. Intrathoracic recurrence occurred in 25.2 to 42.9% of patients with complete resection and five-year survival rates ranged from 49 to 75.5% after repeat pulmonary metastasectomy. Analysis of prognostic factors revealed that number, size and distribution of lung metastases are minor important prognostic factors. Moreover, current data suggest disadvantageous post-metastasectomy survival for patients with elevated pre-metastasectomy serum CEA level or intrathoracic lymph node metastases in comparison with the control groups. Nevertheless, even in these patients, lung metastasectomy might be a beneficial procedure. Conclusions In patients with colorectal cancer and resectable isolated lung or combined liver and lung metastases pulmonary resection should be the treatment of choice. Pulmonary metastasectomy should be combined with thoracic lymph node resection to remove potential lymph node metastases. Repeat metastasectomy should be offered to patients suffering from isolated intrathoracic recurrence