Reproducibility of left atrial ablation with high-intensity focused ultrasound energy in a calf model

ObjectiveAchieving transmural tissue ablation might be necessary for successful treatment of atrial fibrillation. The purpose of this study was to evaluate the reproducibility of transmural left atrial ablation using a high-intensity focused ultrasound energy system in a calf model.MethodsNine heparinized bovines underwent a beating-heart left atrial ablation with a single application of the high-intensity focused ultrasound device. All animals were acutely killed, and the left atrium was fixed in formalin. Protocolized histological sections (5 μm) were obtained throughout each lesion and prepared with Masson trichrome and hematoxylin and eosin staining. Measurements were performed on a total of 359 slides from the 9 lesions. In addition, fresh left atrial tissues from 18 unused human donor hearts that did not meet the criteria for cardiac transplantation were measured at the site where the high-intensity focused ultrasound device is normally applied.ResultsCalf left atrial thickness ranged between 2.5 and 20.1 mm, with a mean of 9.10 mm. High-intensity focused ultrasound ablation consistently produced a 100% transmural lesion in left atrial thickness up to 6 mm. In addition, a transmural lesion was observed in 91% of tissues that were up to 10 mm thick and in 85% that were up to 15 mm thick. Human left atrial thickness ranged between 1.2 to 6 mm, with a mean of 3.7 mm.ConclusionsCalf left atrial thickness in this study was greater than human left atrial thickness. Human left atrial thickness is generally less than 6 mm, and in this range high-intensity focused ultrasound ablation achieved 100% transmurality. These histological results might correlate with a high success rate of atrial fibrillation ablation by using the high-intensity focused ultrasound system

A 9 cm robotic thymectomy and pericardial repair case report

In the modern surgical era, improved technology has allowed for the increasing use of the robotic platform for thymoma resection. Historically, tumors >5 cm were deemed inappropriate for minimally invasive approaches; thoracic surgeons, however, have become adept with performing increasingly complex thymectomies using minimally invasive techniques. Excision of large thymomas using the robotic platform is no longer considered a rare event, however few publications have described the use of minimally invasive surgery for excision of the pericardium with mesh reconstruction. We present a case of an asymptomatic, incidentally discovered 9 cm thymoma involving the pericardium and right lung upper lobe that was resected via bilateral robotic-assisted thymectomy with wedge resection and pericardial resection with mesh reconstruction. The case highlights the use of the robotic platform to avoid a conversion to open thymectomy. The patient was discharged home on postoperative day 3 with minimal pain and narcotic requirement. We aim to contribute to the existing literature supporting the use of the robotic platform during complex thymectomy. The associated video presentation serves as a visual instructional guide for the thymoma resection, with the right upper lobe and pericardium and the pericardial reconstruction. This minimally invasive technique has been associated with shorter hospital stay, reduced pain and faster recovery

Hemoptysis is frequently fatal if blood comes directly from the aorta commentary

Physicians throughout the world, across various specialties, are faced with diagnostic challenges of appropriately identifying the source of hemotosysis, which could range from a simple treatable infection, to the more ominous massive hemorrhage from the aorta requiring emergency, life saving surgery. Aortobronchopulmonary fistula, which is an abnormal communication between the thoracic aorta and the pulmonary tree, is an uncommon but often lethal condition if not promptly surgically intervened. Over the decades, the underlying cause has shifted, from primarily due to an aortic infection, such as tuberculosis, to now secondarily as a result of endovascular repair of the intrathoracic aorta. The best treatment modality, whether open surgical repair, endovascular management, or hybrid approach continues to be debated given the high operative morbidity and mortality of open repair and need to address the pulmonary communication, with optimal management still undetermined

Pulmonary Function Tests Do Not Predict Pulmonary Complications After Thoracoscopic Lobectomy

Pulmonary function tests predict respiratory complications and mortality after lung resection through thoracotomy. We sought to determine the impact of pulmonary function tests upon complications after thoracoscopic lobectomy. A model for morbidity, including published preoperative risk factors and surgical approach, was developed by multivariable logistic regression. All patients who underwent lobectomy for primary lung cancer between December 1999 and October 2007 with preoperative forced expiratory volume in 1 second (FEV 1) or diffusion capacity to carbon monoxide (D lco) 60% or less predicted were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Pulmonary complications were defined as atelectasis requiring bronchoscopy, pneumonia, reintubation, and tracheostomy. During the study period, 340 patients (median age 67) with D lco or FEV 1 60% or less (mean % predicted FEV 1, 55 ± 1; mean % predicted D lco, 61 ± 1) underwent lobectomy (173 thoracoscopy, 167 thoracotomy). Operative mortality was 5% (17 patients) and overall morbidity was 48% (164 patients). At least one pulmonary complication occurred in 57 patients (17%). Significant predictors of pulmonary complications by multivariable analysis for all patients included D lco (odds ratio 1.03, p = 0.003), FEV 1 (odds ratio 1.04, p = 0.003), and thoracotomy as surgical approach (odds ratio 3.46, p = 0.0007). When patients were analyzed according to operative approach, D lco and FEV 1 remained significant predictors of pulmonary morbidity for patients undergoing thoracotomy but not thoracoscopy. In patients with impaired pulmonary function, preoperative pulmonary function tests are predictors of pulmonary complications when lobectomy for lung cancer is performed through thoracotomy but not through thoracoscopy

Achieving opioid-free discharge following robotic thoracic surgery: A single institution experience

Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control and have been associated with decreased opioid requirements. We investigated the impact of continual ERATS refinement on the incidence of opioid free discharge. We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naïve robotic thoracoscopic procedures. Demographics, operative outcomes, postoperative opioid dispensed (morphine milligram equivalent – MME), opioid discharge status were collected. Our primary outcome of interest was factors associated with opioid free discharge; our secondary objective was to determine the incidence of new persistent opioid users. 466 patients from our optimized ERATS protocol were included,309 (66%) were discharged without opioids. However, 157(11%) of patients discharged without opioids required a prescription post discharge. Conversely, 7/157 patients (11%), never filled their opioid prescriptions given at discharges. Factors associated with opioid-free discharges were non-anatomic resections, mediastinal procedures, minimal pain and lack of opioid usage on the day of discharge. More importantly, 3.2% of opioid-free discharge patients became new persistent opioid users versus 10.8% of patients filling opioid prescriptions after discharges (p=0.0013). Finally, only 2.3% of opioid-naïve patients of the entire cohort became chronic opioid users, there was no difference in the incidence of chronic use by opioid discharge status. Optimized opioid sparing ERATS protocols are highly effective in reducing opioid prescription on the day of discharge. We observed a very low rate of new persistent or chronic opioid use in our cohort, further highlighting the role ERATS protocols in combating the opioid epidemic

Large mediastinal schwannoma with great vessel encroachment requiring vascular reconstruction: a case report

The most common posterior mediastinal masses are neurogenic tumors such as peripheral nerve sheath tumors (PNST). Schwannomas, a subtype of PNST, are most often benign, well encapsulated tumors of neural crest cell origin, and are frequently incidentally found, ranging in size from small asymptomatic mediastinal tumors to large masses. Rarely, large schwannomas are discovered when symptoms develop due to compression or involvement of nearby structures leading to an array of possible sequela which can include, but not limited to, persistent cough, hemoptysis, and dysphagia. Management decisions are based off of tumor size, location, concern for underlying malignant pathology, and potential for complications related to tumor invasion of vital anatomical structures. A majority of the schwannomas undergo surgical resection, though a subset of small, asymptomatic, benign tumors on imaging or pathology may be managed with surveillance. This case report describes a large posterior mediastinal schwannoma adherent to the posterior aortic arch and encasing the left subclavian and vertebral arteries. Surgical resection required vascular resection of a segment of the left subclavian artery and graft reconstruction using polytetrafluoroethylene (PTFE). This report further highlights the importance of preoperative planning with consideration of a multidisciplinary approach in preparation for resection of large, complex posterior mediastinal masses

The essential role of non-steroidal anti-inflammatory drugs in pain control following robotic thoracoscopic lung resections

Background: Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control. We investigated the effect of non-steroidal analgesic drugs (NSAIDs) on pain control by comparing patient levels and opioid requirements after robotic pulmonary resections.Methods: We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naive robotic thoracoscopic pulmonary resections. All patients received postoperative NSAIDs unless contraindicated or at the discretion of the attending surgeons. Our original protocol (ERATS-V1) was modified to optimize opioid-sparing effect without affecting pain control (ERATS-V2). Demographics, operative outcomes, and postoperative opioid dispensed [morphine milligram equivalent (MME)] were collected.Results: A total of 491 patients (147 ERATS-V1; 344 ERATS-V2) were included in this study. There was no difference in patient characteristics or operative outcomes between ERATS cohorts. Protocol optimization was associated with a 2-to 10-fold reduction of postoperative opioid use without compromising pain control. In ERATS-V1 cohort, there was no difference in pain levels and opioid requirements with NSAID usage. In ERATS-V2 cohort, while pain levels were similar, higher in-hospital opioid consumption was observed in no-NSAID subgroup [MME: 20.5 (IQR, 4.8-40.5) vs. 12.0 (IQR, 2.0-32.2), P=0.0096, schedule II: 14.2 (IQR, 3.0-36.4) vs. 6.8 (IQR, 1.4-24.0), P=0.012] as well as total postoperative schedule II opioid requirement [17.8 (IQR, 3.0-43.5) vs. 8.8 (IQR, 1.5-30), P=0.032].Conclusions: The opioid-sparing effect of NSAIDs was observed only in optimized ERATS patients. Modifications of our pre-existing ERATS was associated with a significant reduction of opioid consumption without affecting pain levels. This revealed the role of NSAIDs in postoperative pain management otherwise masked by excessive opioids use