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Cardiac surgery: What the future holds?
Haralabos Parissis
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-93
Abstract: This report identifies the challenges that the specialty is facing, and suggests solutions and strategies for the future.Within the last 50 years, the steps of progress in the medical field are impressive: The 5-year cancer survival rates have risen from 30% to over 60% [1]. Cardiovascular mortality between 1950 and 1990 has decreased by about the same number & HIV/AIDS has been transformed into a chronic disease [1]. Life expectancy for a 45-year-old has increased 9 years since 1950 [2].On the other hand, in the US only, it has been estimated that the number of citizens over the age of 75 is expected to quadruple over the next 50 years [3]; furthermore, IHD is the leading cause of death and in UK accounts for 17.4% of all deaths annually. IHD accounted for approximately one in six male deaths and one in eight female deaths during 2009 [4]. So, although the predictions outline the increased future demand of Cardiothoracic surgery, the specialty has witnessed a notable decrease in applicants over the past decade. In this context, Grover and colleagues [5] reported that the "United States will face a severe shortage of cardiothoracic surgeons within 10 years if entry into the profession keeps declining.'There is a lack of interest amongst young trainees for the cardiothoracic specialty and since 2003 the number of recruiters in the specialty is reducing annually.The reason for this discrepancy is multifaceted.1) Coronary Stent technology has grown larger and has displaced Coronary Artery Bypass surgery globally; In the British Isles, three PCIs are carried out per surgically revascularised case; Furthermore, Intravascular procedures continue to evolve not only with the use of intracoronary stents but also with the introduction of such a technology for the treatment of aortic pathologies and valvular heart disease.Each year patients who undergo cardiac surgery continue to be sicker, older, and at higher risk for complications. As patients get sicker and hear about adva
Forty years literature review of primary lung lymphoma
Haralabos Parissis
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-23
Abstract: By taking into consideration the reported experience, the author discuss the classification, clinical features, histological differential diagnosis, prognostic criteria, therapeutic management and outcome of primary lung parenchyma lymphocytic infiltrates.Primary Lung Lymphoma (PLL) is a rare entity (0.4% of all lymphomas[1] & 3.6% of non- Hodgkins lymphomas[2]) of heterogenous group of patients with some common characteristics: 1) difficult to be diagnosed due to an indolent course (with a tendency to relapse) with a non specific clinical and radiological presentation 2) low diagnostic yield and 3) sometimes difficult to differentiate from pseudo-lymphomas and 4)overall good outcome especially in disease amenable to surgical resection.The main diagnostic criterion for PLL is the absence of extra-pulmonary involvement. That means unilateral or bilateral involvement of the lung with or without hilar or mediastinal lumph node involvement and with or without chest wall involvement [3]. Therefore, in patients with biopsy-proven lymphoma of the lung, PLL is diagnosed if extra-pulmonary involvement is ruled out.In this article we aim to review the literature in order to delineate from the surgeons prospective, the overall experience of the rare entity of PLL and also to bring up to date the variables leading to a favorable outcome following surgery.Pertinent medical literature in the English language was identified through a Medline computerized literature search and a manual search of selected articles using as Key-words: Primary pulmonary Lymphoma, Lung Lymphoma, Pseudolymphoma of the lung, Non-Hodgkin lymphoma of the lung or extranodal lymphoma. The search terms were combined using the Boolean operator term "or" to find all abstracts pertaining to the chosen search terms. These individual terms were then combined using the Boolean operator term "and" to find articles that contained information of all search terms (as per Greenhaligh et al)[4]. The reference lists of ar
Lepirudin as an alternative to "heparin allergy" during cardiopulmonary bypass
Haralabos Parissis
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-44
Abstract: This report indicates that r-hirudin provides effective anticoagulation, however unless ECT is monitoring, post operative hemorrhage is encountered. Therefore this case is unique not only because of its rarity but also by the fact that it presents the caveats encountered when ECT is not available.Traditionally in our effort to maintain optimal cardiopulmonary bypass during cardiac surgery, high dose unfractionated heparin is being used; however there are conditions that the use of heparin is contraindicated. Various thrombin inhibitors could theoretically being used instead, with the favor being Hirudin and lately bivalirudinHirudin is a potent natural direct thrombin inhibitor that is derived from the salivary glands of the medicinal leech, Hirudo medicinalis [1]. It is a 65-amino-acid polypeptide that forms a tight, irreversible 1:1 complex with thrombin (1 molecule of hirudin binds with 1 molecule of thrombin).Hirudin shows both direct anti-Xa activity as well as activation of antithrombin III [2]. It is the most potent and specific thrombin inhibitor known. Uunlike heparin, it is not inactivated by Platelet Factor 4 (PF4), and also can inhibit thrombin bound within the clot [3]. Hirudin is now produced, by using recombinant technology (r-hirudin). Two r-hirudins have been commercially produced (lepirudin and desirudin); however, lepirudin has been more extensively studied and is the focus of this review.Lepirudin is an anti-thrombotic recombinant DNA form of hirudin derived from yeast cells. Each vial of Refludan contains 50 mg of lepirudin. It is normally used in adult patients requiring anticoagulation who have Heparin Induced Thrombocytopenia (HIT) type II [4].Two binding sites are present on the thrombin molecule: the active site that catalyzes the majority of the functions of thrombin, and the -brinogen-binding site that mediates binding of thrombin to -brinogen.Hirudin (lepirudin) binds irreversibly to both the active site and the -brinogen-binding site. T
Carinal surgery: experience of a single center and review of the current literature
Haralabos Parissis, Vincent Young
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-51
Abstract: From February 2000 till January 2007 we have identified 8 cases (1.09%) requiring carinal surgery.Plan of action: Close cooperation with anaesthetics, long flexible ET tube, Right posterolateral thoracotomy, no irrevocable steps until resection guaranteed, mobilization of trachea and main bronchus, division of the trachea & Left main bronchus. Intubate across surgical field. Tailoring for airway size discrepancies, appropriately. Construction of the tracheobronchial anastomosis around the ventilatory tube. Skillfull reintubation, over a long boogie.Mortality: 12.5% due to ARDS (one patient)Morbidity: anastomotic stenosis requiring stent (one patient). Follow-up 52 ± 11 months.Recurrences: 2 patients (both with pathological N2 disease on histology).Success of carinal surgery depends on careful patient selection, team approach and attention to detail. Patients with N2 disease carry the worst prognosis.Until recently the TNM classification staged tumours invading the carina as T4, IIIB. By implication these tumours are inoperable due to local criteria. However a subgroup of those patients can be treated by carinal resection and reconstruction with potential cure. Therefore, there is an argument that this subgroup should the staged as IIIA[1]; especially since this small group of patients consists of a potentially surgical group with favourable outcome and a five years survival up to 40%-45% [2].Indications for carinal resection are reported [3] as: bronchogenic carcinoma (43.2%), other airway neoplasms (44.7%) and benign or inflammatory strictures (11.9%).In this report we are presenting our experience with right side carinal pneumonectomy and carina plasty. The indications, surgical steps and early outcome are reported.Our series of carinal surgery consists of a small number of patients performed by a single surgeon (the senior author of the paper, VY).From February 2000 up till January 2007 we have identified 8 cases (1.09% of all pulmonary resections) of carinal sur
Treatment of pancoast tumors from the surgeons prospective: re-appraisal of the anterior-manubrial sternal approach
Haralabos Parissis, Vincent Young
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-102
Abstract: The Anterior-manubrial sternal approach was described more than a decade ago and although this method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels, its popularity has not reached high levels. We felt that by re-addressing this topic we would stimulate reconsideration of the anterior approach.Pancoast syndrome is due to lesions extending to the superior thoracic inlet. Specific symtomatology mainly due to brachial plexus invasion accounts for the majority of those cases [1-3].Pancoast tumour is a tumour of the apex of the lung with no intervening lung tissue between tumour and chest wall. Subsequently, there is an involvement of structures of the apical chest wall above the level of the second rib. Almost half of the treated cancers are squamous cell carcinomas (45-50%), while the rest are either adenocarcinomas (36-38%) or undifferentiated large-cell carcinomas (11-13%). The tumour rapidly involves the structures of the thoracic inlet & the root of neck. Due to its localization in the apex of the lung, invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, occurs [4]. The classical Pancoast presentation, with shoulder pain radiating to the ulnar side of the arm and the hand, is presented in 55 to 60% of the patients. Pain at the ulnar aspect of the forearm and hand is consistent with T1 involvement; furthermore symptomatology along the intrinsic hand muscles suggests the C8 root or lower trunk tumor deposits. Horners syndrome is reported in up to 30% of the cases.Although those tumours represent a wide range of stage IIB to stage IV disease, [IIB (25-27%), stage IIIA (6-8%), stage IIIB (40-42%) and stage IV (21-23%)] it is the T3, T4, N0-N1 subgroup of this spectrum that could be amenable to surgical intervention [5]. This subgroup of patients (less than 5% of Bronchogenic Carcinomas) however, is difficult to be treated surgically due to the location of
Dangerous drug interactions leading to hemolytic uremic syndrome following lung transplantation
Haralabos Parissis, Kate Gould, John Dark
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-70
Abstract: Two consecutive cases of hemolytic uremic syndrome were diagnosed in our service. In both patients the use of macrolides in patients taking Tacrolimus, resulted in high levels of Tacrolimus.The first patient was a 48 years old female with Bilateral emphysema. She underwent Single Sequential Lung Transplantation. She developed reperfusion injury requiring prolonged stay. Tacrolimus introduced (Day 51). The patient remained well up till 5 months later; Erythromycin commenced for chest infection. High Tacrolimus levels and a clinical diagnosis of HUS were made. She was treated with plasmapheresis successfully.The second case was a 57 years old female with Emphysema & A1 Antithrypsin deficiency. She underwent Right Single Lung Transplantation. A2 rejection with mild Obliterative Bronchiolitis diagnosed 1 year later and she switched to Tacrolimus. She was admitted to her local Hospital two and a half years later with right middle lobe consolidation. The patient commenced on amoxicillin and clarithromycin. Worsening renal indices, high Tacrolimus levels, hemolytic anemia & low Platelets were detected. HUS diagnosed & treated with plasmapheresis.There are 21 cases of HUS following lung transplantation in the literature that may have been induced by high tacrolimus levels. Macrolides in patients taking Cyclosporin or Tacrolimus lead to high levels. Mechanism of action could be glomeruloconstrictor effect with reduced GFR increased production of Endothelin-1 and increased Platelet aggregation.Extensive clinical use has confirmed that tacrolimus is a key option for immunosuppression after transplantation [1-3]. Tacrolimus as primary immunosuppressant for lung transplant recipient is associated with similar survival and reduction in acute rejection episodes compare with cyclosporine [4].Haemolytic uraemic syndrome due to cyclosporin or tacrolimus in a lung transplant population is rare. Up to this year there were only few cases of tacrolimus induced haemolytic uraemic syndrome
Primary leiomyosarcoma of the right atrium: a case report and literature update
Haralabos Parissis, Mohamad Akbar, Vincent Young
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-80
Abstract: A vigorous attempt aiming at tumor clearance followed by adjuvant multimodality therapy along with a tumor surveillance program may improve survival.Primary cardiac malignancies (PCM) are rare. The prevalence of primary cardiac malignancies has been estimated at only 0.001% - 0.28% [1]. Primary cardiac tumors are detected in 1 in a 1000 autopsies and PCM are found in only about 0.0017% of autopsies [2,3]. Metastatic cardiac tumors are a 100-fold more common than primary lesions. The majority of Primary Cardiac tumors are benign (with half of them being myxomas) [4] and approximately 25% of primary cardiac neoplasms are malignant. Among malignant primary cardiac tumors, the most reported are those histopathologically considered as undifferentiated, followed by angiosarcomas with leiomyosarcomas being rare. Due to delayed presentation there is infrequently, a systemic spread at the time of diagnosis. As a result management of this condition is difficult and controversial.We present a case of a 36 year old male who was admitted with recent onset of shortness of breath. CT pulmonary angiogram demonstrated large right sided pulmonary emboli (Figure 1). Moreover, a filling defect was noticed in the right atrium (Figure 2). The defect appeared to be lobulated, irregular, of low attenuation and arising from the free atrial wall. On transthoracic echocardiography (Figure 3) the mass was demonstrated to be extending through the tricuspid valve. A presumptive diagnosis of right atrial myxoma with complicating pulmonary embolism was made. Urgent surgery was arranged. At the time of surgery the right atrial appendage was noted to be very congested and "angry looking". Total cardiopulmonary bypass was established using aortic and bi-caval cannulation. The right atrial cavity was found to be replaced by a friable tumor which had "fronds like" appearance (Figure 4). The mass was extending through the tricuspid valve to the right ventricle. A sample of the tumor was subjected to fro
Traumatic Bilateral Pneumothoraces due to Sternal Wire Migration
Umar Imran Hamid,Scott Gillespie,Colum Lynchehaun,Haralabos Parissis
Case Reports in Medicine , 2012, DOI: 10.1155/2012/438429
Abstract: Sternal wound complications after cardiac surgery are associated with increased morbidity and mortality. Wire migrations associated with sternal dehiscence can lead to catastrophic haemorrhage unless intervened in time. We present a case of sternal wire migration causing bilateral pneumothoraces.
A statistical model that predicts the length from the left subclavian artery to the celiac axis; towards accurate intra aortic balloon sizing
Haralabos Parissis, Alan Soo, Michalis Leotsinidis, Dimitrios Dougenis
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-95
Abstract: Internal aortic lengths and demographic values were collected from a series of 40 cadavers during autopsy. External somatometric measurements were also obtained.There were 23 males and 17 females. The mean age was 73.1+/-13.11 years, weight 56.75+/-12.51 kg and the height 166+/-9.81 cm.Multiple regression analysis revealed the following predictor variables (R2 > 0.70) for estimating the length from LSA to CA: height (standardized coefficient (SRC) = 0.37, p = 0.004), age (SRC = 0.35, p < 0.001), sex (SRC = 0.21, p = 0.088) and the distance from the jugular notch to trans-pyloric plane (SRC = 0.61, p < 0.001).Recommendations: If LSA-CA < 21.9 cm use 34 cc IABP & if LSA-CA > 26.3 cm use 50 cc IABP. However if LSA-CA = 21.9- 26.3 cm use 40 cc, but be aware that it could be "aortic length-balloon membrane length" mismatching.Routinely, IABP size selection is being dictated by the patient's height. Inevitably, this leads to pitfalls. We reported a mathematical model of accurate intraaortic balloon sizing, which is easy to be applied and has a high predictive value.The selection of the intraaortic balloon pump (IABP) in adults has been mainly limited to the use of 40 cc and occasionally 34 cc balloon volume, with a membrane length that varies among manufacturers from 22 to 27.5 cm and an inflated diameter 15 - 18 mm (Table 1).Although in a number of clinical cases the 40 cc volume is sufficient, it shall be noted that an increased balloon volume could potentially contributes to morbidity from vascular events and a reduced balloon volume could decrease the beneficial hemodynamic effects for the heart. There is a causal relashionship between the patient's height and balloon trauma. According to Cox et al [1] the balloon size shall be adjusted depending on the patient's height.The ideal balloon for any patient shall be placed at an ideal position, which equals in length the distance from the left subclavian artery to the celiac axis, 90-95% of the diameter of the descending
Single stage repair of a complex pathology: end stage ischaemic cardiomyopathy, ascending aortic aneurysm and thoracic coarctation
Haralabos Parissis, Bassel Al-Alao, Allan Soo, John Dark
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-152
Abstract: A direct approach to repair thoracic coarctation may entail difficulties in the adult population.Concurrent aortic and cardiac pathology represents a rare entity. This report describes a technique of addressing a complex pathology: a patient with an aortic coarctation, an ascending aortic aneurysm and end stage ischaemic cardiomyopathy.A 58 years old male presented with tachycardia and biventricular failure. Investigations revealed a 9 cm ascending aortic aneurysm containing a dissection flap above a regurgitant bicuspid aortic valve. Despite anti-failure treatment the ejection fraction remained in the range of 15-20%. A CT scan and an MRI (Figure 1) further delineated the ascending aortic aneurysm and revealed an unsuspected but very tight coarctation with good collaterals. A subsequent attempt at coronary angiography failed because of inability to engage the grossly displaced coronary ostia. Very extensive coronary calcification, reaching out to the terminal branches of the major epicardial vessels was however revealed. The conventional procedure would have entailed aortic valve and ascending aortic replacement together with blind CABG and repair of the coarctation. Further episodes of heart failure persuaded us that transplantation was a more acceptable argument. The potential difficulties of grafting only small distal vessels in a patient who already had severe left ventricular dysfunction was a major factor in this decision. The patient was accepted on to the transplant waiting list.Because of his ambulatory nature he remained on the waiting list whilst gradually deteriorating. He was admitted as an emergency with gross congestive heart failure some 11 months after listing. At that time repeat right heart catheter revealed a mean pulmonary artery pressure of 42 with a pulmonary artery papillary wedge of 36 and a cardiac index of less than 2. His creatinine had risen to 137 mm/l. He was admitted to hospital and treated with Dobutamine and Frusemide infusion and
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