Right ventricular loop indicating malposition of J-wire introducer for double lumen bicaval Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) cannula

The key to safe placement of a bicaval double lumen cannula for Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) is to visualise correct guide wire placement in the inferior vena cava (IVC), thus aiding subsequent correct advancement of the cannula. Transoesophageal (TOE) and transthoracic (TTE) echocardiography, as well as fluoroscopy, have been described as aiding imaging techniques. We report a case of guide wire malposition into the right ventricle, despite echocardiographic confirmation of guide wire position deep into the IVC. This malposition, if undetected, may have resulted in potential life threatening complications

Ejection fraction - A number to be interpreted with caution!

Cardiogenic shock is frequently seen following acute myocardial infarction complicated by the rupture of interventricular septum and formation of functional ventricular septal defect. Despite significant advances in medical, interventional and surgical management, the mortality in this group of patients remains very high. We present a case of refractory cardiogenic shock following an exclusion bovine pericardial patch repair of post infarction ventricular septal defect, where the residual functional left ventricular cavity size was insufficient to maintain end organ function. This case illustrates the concept of Normal ejection fraction low cardiac output cardiogenic shock , where reporting left ventricular ejection fraction number in isolation can be misleading

A Systematic review and meta-analysis on pulmonary resections by robotic video-assisted thoracic surgery

Background: Pulmonary resection by robotic video-assisted thoracic surgery (RVATS) has been performed for selected patients in specialized centers over the past decade. Despite encouraging results from case-series reports, there remains a lack of robust clinical evidence for this relatively novel surgical technique. The present systematic review aimed to assess the short- and long-term safety and efficacy of RVATS. Methods: Nine relevant and updated studies were identified from 12 institutions using five electronic databases. Endpoints included perioperative morbidity and mortality, conversion rate, operative time, length of hospitalization, intraoperative blood loss, duration of chest drainage, recurrence rate and long-term survival. In addition, cost analyses and quality of life assessments were also systematically evaluated. Comparative outcomes were meta-analyzed when data were available. Results: All institutions used the same master-slave robotic system (da Vinci, Intuitive Surgical, Sunnyvale, California) and most patients underwent lobectomies for early-stage non-small cell lung cancers. Perioperative mortality rates for patients who underwent pulmonary resection by RVATS ranged from 0-3.8%, whilst overall morbidity rates ranged from 10-39%. Two propensity-score analyses compared patients with malignant disease who underwent pulmonary resection by RVATS or thoracotomy, and a meta-analysis was performed to identify a trend towards fewer complications after RVATS. In addition, one cost analysis and one quality of life study reported improved outcomes for RVATS when compared to open thoracotomy. Conclusions: Results of the present systematic review suggest that RVATS is feasible and can be performed safely for selected patients in specialized centers. Perioperative outcomes including postoperative complications were similar to historical accounts of conventional VATS. A steep learning curve for RVATS was identified in a number of institutional reports, which was most evident in the first 20 cases. Future studies should aim to present data with longer follow-up, clearly defined surgical outcomes, and through an intention-to-treat analysis.8 page(s

Reply to the editor

2 page(s

A Meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy

Background: Video-assisted thoracic surgery (VATS) for patients with early-stage non-small cell lung cancer (NSCLC) has been established as a safe and feasible alternative to open thoracotomy. This meta-analysis aims to assess the potential difference between unmatched and propensity score-matched cohorts who underwent VATS versus open thoracotomy in the current literature. Methods: Three relevant studies with unmatched and propensity score-matched patients were identified from six electronic databases to examine perioperative outcomes after VATS lobectomy versus open thoracotomy for patients with early-stage NSCLC. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization. Results: Results indicate that perioperative mortality was significantly lower for VATS compared to open thoracotomy in unmatched patients but no significant difference was detected amongst propensity score-matched patients. Similarly, the incidences of prolonged air leak and sepsis were significantly lower for VATS in the unmatched cohort, but not identified in the propensity score-matched cohort. In both the unmatched and matched groups, patients who underwent VATS were found to have a significantly lower overall perioperative morbidity rate, incidences of pneumonia and atrial arrhythmias, and a shorter duration of hospitalization in comparison to patients who underwent open thoracotomy. Conclusions: The present meta-analysis indicates that VATS lobectomy has superior perioperative outcomes compared to open thoracotomy in both matched and unmatched cohorts. However, the extent of the superiority may have been overestimated in the unmatched patients when compared to propensity score-matched patients. Due to the limited number of studies with available data included in the present meta-analysis, these results are only of observational interest and should be interpreted with caution.8 page(s

Systematic review of trimodality therapy for patients with malignant pleural mesothelioma

Background: Malignant pleural mesothelioma (MPM) is an aggressive form of cancer arising from the pleural mesothelium. Trimodality therapy (TMT) involving extrapleural pneumonectomy with neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy is a recognized treatment option with a curative intent. Despite encouraging results from institutional studies, TMT in the treatment of MPM remains controversial. The present systematic review aims to assess the safety and efficacy of TMT in the current literature. Methods: A systematic review was performed using five electronic databases from 1 January 1985 to 1 October 2012. Studies were selected independently by two reviewers according to predefined selection criteria. The primary endpoint was overall survival. Secondary endpoints included disease-free survival, disease recurrence, perioperative morbidity and length of stay. Results: Sixteen studies were included for quantitative assessment, including one randomized controlled trial and five prospective series. Median overall survival ranged from 12.8-46.9 months. Disease-free survival ranged from 10-16.3 months. Perioperative mortality ranged from 0-12.5%. Overall perioperative morbidity ranged from 50-82.6% and the average length of stay was 9-14 days. Conclusions: Outcomes of patients who underwent TMT in the current literature appeared to be inconsistent. Four prospective series involving a standardised treatment regimen with neoadjuvant chemotherapy indicated encouraging results based on intention-to-treat analysis. However, a small study assessing the feasibility of conducting a randomized controlled trial for TMT versus conservative treatment reported poor short- and long-term outcomes for patients who underwent pneumonectomy. Overall, results of the present systematic review suggest TMT may offer acceptable perioperative outcomes and long-term survival in selected patients treated in specialized centers.10 page(s

Drug-eluting stents versus coronary artery bypass graft surgery in left main coronary artery disease : a meta-analysis of early outcomes from randomized and nonrandomized studies

Objective: The present meta-analysis aimed to compare the short-term safety and efficacy of drug-eluting stents and coronary artery bypass graft surgery for patients with left main coronary artery disease. Methods: Fourteen relevant studies were identified from 5 electronic databases. End points included mortality, stroke, myocardial infarction, repeat revascularization, and major adverse cardiac and cerebrovascular events. Results: Results indicate that all-cause mortality was similar between drug-eluting stents and coronary artery bypass grafting at 30 days and at follow-up beyond 1 year. Likewise, the incidence of myocardial infarction was similar between drug-eluting stents and coronary artery bypass grafting at 12 months and at follow-up beyond 1 year. However, drug-eluting stents were associated with a lower incidence of all-cause mortality at 12 months and a higher incidence of myocardial infarction at 30 days compared with coronary artery bypass grafting. Drug-eluting stents were consistently associated with a higher incidence of repeat revascularization, whereas coronary artery bypass grafting had a higher incidence of stroke. The incidence of major adverse cardiac and cerebrovascular events was similar between the 2 groups at 30 days but higher for drug-eluting stents at 12 months and beyond. Conclusions: Patients treated by drug-eluting stents in randomized controlled trials and observational studies in the current literature are often a preselected subgroup with less complex lesions compared with the overall target population. Results drawn from these studies should be viewed with caution. Coronary artery bypass grafting is associated with a lower incidence of major adverse cardiac and cerebrovascular events at 1 year and beyond, and thus should be regarded as the standard of treatment. However, drug-eluting stents may have a role for selected patients with percutaneously amenable left main disease who are poor surgical candidates.10 page(s

Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer : a meta-analysis of propensity score-matched patients

Objectives This meta-analysis aimed to compare the perioperative outcomes of video-assisted thoracic surgery (VATS) with open thoracotomy for propensity score-matched patients with early-stage non-small cell lung cancer (NSCLC). Methods Four relevant studies with propensity score-matched patients were identified from six electronic databases. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization. Results Results indicate that all-cause perioperative mortality was similar between VATS and open thoracotomy. However, patients who underwent VATS were found to have significantly fewer overall complications, and significantly lower rates of prolonged air leak, pneumonia, atrial arrhythmias and renal failure. In addition, patients who underwent VATS had a significantly shorter length of hospitalization compared with those who underwent open thoracotomy. Conclusions In view of a paucity of high-level clinical evidence in the form of large, well-designed randomized controlled trials, propensity score matching may provide the highest level of evidence to compare VATS with open thoracotomy for patients with NSCLC. The present meta-analysis demonstrated superior perioperative outcomes for patients who underwent VATS, including overall complication rates and duration of hospitalization.6 page(s

Reduction of pericardial adhesions using a bioresorbable membrane

Intrapericardial adhesions form after cardiac surgery and potentially cause morbidity and mortality in reoperations.Reduction in formation of intrapericardial adhesions could theoretically enable technically easier (and possibly safer) cardiac reoperations.This study aimed to evaluate the formation of pericardial adhesions in an animal model and to explore the use of a bioresorbable membrane in potential adhesion reduction