Intraoperative PTH Monitoring in Normohormonal Primary Hyperparathyroidism

Background: A subset of patients with primary hyperparathyroidism present with inappropriately normal PTH levels despite elevated serum calcium, called normohormonal primary hyperparathyroidism (NHPHP). This disease variant presents a clinical dilemma regarding intraoperative parathyroid hormone (IOPTH) monitoring during parathyroidectomy when using the standard criteria of a ≥ 50% reduction in IOPTH from baseline to determine surgical success. This study aimed to determine what percent reduction in post-excision IOPTH from baseline in NHPHP patients would yield a high cure rate similar to that of classic primary hyperparathyroidism. Methods: This was a single surgeon, single institution retrospective cohort study of patients that underwent parathyroidectomy between July 2013 and February 2020. Demographic, preoperative, intraoperative, and postoperative metrics were collected. Patients with NHPHP were compared to those with classic primary hyperparathyroidism. Results: 496 patients were included in the study. 66 (13.3%) were of the normohormonal variant based on preoperative intact PTH levels and 28 (5.6%) based on baseline IOPTH levels. The cure rates in the normohormonal groups were not significantly different from their classic counterparts: 98.4% and 100.0% vs 97.1% and 97.1%, p = 1.000. The median percent decline in post-excision IOPTH from baseline that achieved cure in the normohormonal groups were 82.8% and 80.4% compared to their respective controls of 87.3% and 87.1%, p = 0.017 and p=0.001. Conclusion: A ≥ 75% decline in 15-minute post-excision IOPTH level from baseline can be used as a more stringent criterion for achieving high rates of cure in patients with NHPHP that undergo parathyroidectomy

Extra-Anatomic Redo of MIDCAB and OPCAB: An Early Experience.

BACKGROUND: Eighteen patients with unstable angina underwent repeat myocardial revascularization without cardiopulmonary bypass using saphenous vein grafts from either the left (13) or right (2) axillary arteries or the descending thoracic aorta (3). Patients\u27 ages ranged from 53 to 85 years. Left ventricular ejection fractions ranged from 15% to 60%. METHODS: In 14 patients, the heart was exposed through an anterior thoracotomy, a minimally invasive direct coronary artery bypass (MIDCAB) technique. In 3 patients a left posterolateral thoractomy (lateral MIDCAB) was performed. One patient underwent repeat sternotomy (off-pump coronary artery bypass: OPCAB). In MIDCAB and lateral MIDCAB patients, the target vessel was a coronary artery in 8 patients and a previously placed vein graft in the remaining 9 patients. One patient underwent repeat sternotomy, and 3 coronary arteries were bypassed with a complex vein graft attached to the left axillary artery. Two patients died of mesenteric ischemia on the 2nd and 7th postoperative day. The remainder of patients were discharged from the hospital free of angina. Early graft patency was demonstrated by noninvasive vascular laboratory testing and/or angiography in the 13 survivors in whom the axillary artery had been the site of the proximal anastomosis. RESULTS: Follow-up ranged from 1 to 25 months. No other patients have died, and none have undergone additional surgical or catheter-based procedures. Three patients have developed recurrent angina, and in 4 patients the extra-anatomic bypass grafts have apparently become occluded. CONCLUSION: Extra-anatomic, off-pump bypass from the axillary artery or descending thoracic aorta to one or more coronary arteries can be performed safely in seriously ill patients requiring a repeat bypass procedure. The early results, regarding relief of angina, are encouraging