Supportive pericardial suspension for surgical airway management of tracheobronchomalacia in unilateral pulmonary agenesis

Unilateral pulmonary agenesis, a rare developmental defect of the lung, is often accompanied by tracheobronchial stenosis or malacia due to displacement, distortion, and compression of the surrounding great vessels. We present two cases of unilateral pulmonary agenesis complicated by tracheobronchial problems that were successfully managed surgically with supportive pericardial suspension.Keywords: pericardial suspension, tracheobronchomalacia, unilateral pulmonary agenesi

Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel

AbstractObjectives: The safety and reliability of a method of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, CVG, Cincinnati, Ohio) were evaluated. Methods: The mural branches of the internal thoracic artery were cut by means of 3 methods, differentiated by distance from the site of application of the Harmonic Scalpel blade to the internal thoracic artery. A total of 15 branches were cut from the internal thoracic artery at (0 mm) the origin (group I) or at 1 mm (group II) or 2 mm (group III) distal to the origin. Tissue preparations were examined for successful vessel closure and severity of tissue damage. The length of stump (L) and the length of tissue damage from the stump (D) were determined by a computer image analysis system, and pressure testing was performed to evaluate the physical strength of vessel closure. Results: In group I, 8 of the 15 branches exhibited discontinuity of the vascular wall structure, probably because of insufficient sealing of the divided section, and 12 of the 15 branches exhibited tissue denaturation on the internal thoracic artery wall adjacent to areas of origin, which was probably caused by the heat transferred from the branches during the process of coagulation. In groups II and III, continuity of wall structure of stumps suggestive of stable closure of branches was confirmed. The lengths of tissue damage from the stump (D) were 0.96, 0.58, and 0.63 mm in groups I, II, and III, respectively, and the lengths of intact area (L – D) in the corresponding groups were –0.78, 0.61, and 1.51 mm. The negative figure in group I indicates the presence of tissue damage in the internal thoracic artery itself. By contrast, in groups II and III the internal thoracic arteries were intact, with a safety margin of greater than 0.5 mm. On physiologic evaluation of vessel closure, 2 of the 24 (8.3%) branches burst under a pressure lower than 350 mm Hg because of insufficient vessel coagulation, but the remaining 22 branches (91.7%) remained intact under pressures up to 350 mm Hg. Conclusion: The internal thoracic artery skeletonization method with an ultrasonic scalpel (Harmonic Scalpel: output level 2) appears to be a safe and reliable method of skeletonized internal thoracic artery harvesting when branches are sectioned at least 1 mm distal to their origin at a sufficiently slow speed. (J Thorac Cardiovasc Surg 2000;120:1142-7

Amiodarona causa vasodilatação dependente do endotélio em artérias coronárias caninas Amiodarone causes endothelium-dependent vasodilation in canine coronary arteries

OBJETIVO: Avaliar os efeitos vasodilatadores da amiodarona em artérias coronárias caninas empregando soluções de amiodarona dissolvida em polisorbato 80 ou em água. MÉTODOS: Anéis de artéria coronária, com e sem o endotélio íntegro, foram imersos em solução de krebs e conectadas a um transdutor para aferição de força isométrica promovida por contração vascular. As artérias foram expostas a concentrações crescentes de polisorbato 80, amiodarona dissolvida em água, amiodarona dissolvida em polisorbato 80 e uma apresentação comercial da amiodarona (Cordarone®). Os experimentos foram conduzidos na presença e na ausência dos seguintes bloqueadores enzimáticos: apenas indometacina, Nômega-nitro-L-arginina associada à indometacina e apenas Nômega-nitro-L-arginina. RESULTADOS: O polisorbato 80 causou pequeno relaxamento não dependente do endotélio. O Cordarone®, a amiodarona dissolvida em água e em polisorbato 80 promoveram relaxamento dependente do endotélio, que foi de maior magnitude para a amiodarona dissolvida em polisorbato e para o Cordarone®. Apenas a associação de indometacina com a Nômega-nitro-L-arginina foi capaz de abolir o relaxamento dependente do endotélio provocado pela amiodarona dissolvida em polisorbato 80. CONCLUSÃO: Os resultados obtidos indicam que a vasodilatação promovida pela amiodarona em artérias coronárias caninas é causada principalmente pela estimulação da liberação de óxido nítrico e fatores endoteliais relaxantes dependentes das ciclo-oxigenases.<br>OBJECTIVE: To assess the vasodilating effects of amiodarone on canine coronary arteries by using solutions of amiodarone dissolved in polysorbate 80 or water. METHODS: Rings of coronary arteries, with or without intact endothelium, were immersed in Krebs solution and connected to a transducer for measuring the isometric force promoted by a vascular contraction. The arteries were exposed to increasing concentrations of polysorbate 80, amiodarone dissolved in water, amiodarone dissolved in polysorbate 80, and a commercial presentation of amiodarone (Cordarone). The experiments were conducted in the presence of the following enzymatic blockers: only indomethacin, Nw-nitro-L-arginine associated with indomethacin, and only Nw-nitro-L-arginine. RESULTS: Polysorbate 80 caused a small degree of nonendothelium-dependent relaxation. Cordarone, amiodarone dissolved in water, and amiodarone dissolved in polysorbate 80 caused endothelium-dependent relaxation, which was greater for amiodarone dissolved in polysorbate and for Cordarone. Only the association of indomethacin and Nw-nitro-L-arginine could eliminate the endothelium-dependent relaxation caused by amiodarone dissolved in polysorbate 80. CONCLUSION: The results obtained indicate that vasodilation promoted by amiodarone in canine coronary arteries is mainly caused by stimulation of the release of nitric oxide and cyclooxygenase-dependent relaxing endothelial factors

Risk factor of pneumonitis on dose-volume relationship for chemoradiotherapy with durvalumab: Multi-institutional research in Japan

Objectives: To estimate appropriate dose-volume parameters for avoidance of pneumonitis in use of chemoradiotherapy and durvalumab for treatment of lung cancer. Materials and methods: Patients with non-small cell lung cancer treated with concurrent chemoradiotherapy followed by durvalumab at 9 centers were enrolled in the study. Three-dimensional radiotherapy, intensity modulated radiotherapy, and proton beam therapy were used. The frequency and severity of pneumonitis and the dose-volume relationship for normal lung were evaluated. Univariable and multivariable analyses were conducted to identify risk factors. A covariate adjusted hazard ratio was then estimated for the percentages of normal lung volume irradiated at ≥ X Gy (Vx) (X = 5–40) and lung volume non-irradiated at ≥ X Gy (X = 5–40), with the covariates selected in the variable selection. Cumulative incidence functions and covariate adjusted hazard ratios were also estimated for dichotomized variables, with estimated cut-off points. Results: A total of 91 patients were enrolled in the study. The median time from the start of radiotherapy to development of pneumonitis was 4.1 months. Pneumonitis was observed in 80 patients (88%), including grade 2 or severe pneumonitis in 31 (34%) and ≥ grade 3 pneumonitis in 11 (12%). Pneumonitis was inside the irradiation field in 73 of the 80 patients (91%). The selected factors for ≥ grade 2 pneumonitis were V20, and primary site (upper lobe) in multivariable analysis. The cut off value of V20 was 18.99%, and there was a significant difference between V20 of < 18.77 and ≥ 18.77. Conclusion: Though there are some limitation of this study, the basic concept of concurrent chemoradiotherapy with an emphasis on V20 remains unchanged in use of durvalumab. However, we recommend reduction of V20 to as small a value as possible in use of this therapy