Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Jan 2020
Combined Endosonographic Mediastinal Lymph Node Staging in Positron Emission Tomography and Computed Tomography Node-Negative Non-Small-Cell Lung Cancer in High-Risk Patients.
Positron emission tomography (PET) with computed tomography (CT) is routinely utilized to investigate lymph node (LN) metastases in non-small-cell lung cancer. However, it is less sensitive in normal-sized LNs. This study was performed in order to define the prevalence of mediastinal LN metastases discovered on combined endosonography by endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration in patients with a radiologically normal mediastinum. ⋯ Thirteen (61%) had occult N2 disease and 2 (9%) had adrenal involvement. None of the upstaged patients had N1 LN involvement on PET-CT or CT scan. Combined endosonographic lymph node staging should be considered in the pretreatment staging of high-risk patients with non-small-cell lung cancer in the presence of radiologically normal mediastinal lymph nodes due to the significant rate of radiologically occult lymph node metastases.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2019
Comparative StudyThe Clinical Significance of Cerebral Microbleeds in Infective Endocarditis Patients.
We assessed the clinical features of cerebral microbleeds (CMBs) and their association with clinical outcomes in active infective endocarditis patients. From January 2009 to June 2015, 132 active IE patients diagnosed per the modified Duke's criteria were retrospectively reviewed. Brain magnetic resonance imaging was performed in 102 patients, and 74 patients whose image data were available to assess CMBs were enrolled. ⋯ Cox regression analysis adjusting age and operative risk did not show that CMB was a significant risk factor for all-cause death and major adverse event. Patients with CMB were older than those without, and microbleeds were associated with antiplatelet therapy, staphylococcal infection, and prosthetic valve endocarditis. However, the mid-term clinical outcomes of patients with CMB and those without were comparable.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2019
Ninety-Day Readmissions of Bundled Valve Patients: Implications for Healthcare Policy.
Medicare's Bundle Payment for Care Improvement (BPCI) Model 2 groups reimbursement for valve surgery into 90-day episodes of care, which include operative costs, inpatient stay, physician fees, postacute care, and readmissions up to 90 days postprocedure. We analyzed our BPCI patients' 90-day outcomes to understand the late financial risks and implications of the bundle payment system for valve patients. All BPCI valve patients from October 2013 (start of risk-sharing phase) to December 2015 were included. ⋯ Bundled claims for a 90-day episode of care are significantly increased in patients with readmissions. TAVR patients represent a high-risk group for late readmission, possibly a reflection of their chronic disease processes. Being able to identify patients at highest risk for 90-day readmission and the associated claims will be valuable as we enter into risk-bearing episodes of care agreements with Medicare.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2019
Comparative StudyDifferential Effects of Normoxic and Hyperoxic Reperfusion on Global Myocardial Ischemia-Reperfusion Injury.
The objectives were to investigate if after hypoxia or ischemia, normoxic reperfusion is associated with less oxidant stress (OS), inflammation, and myocardial injury than hyperoxic reperfusion. In this study, cardiomyocytes (H9c2 cells) were cultured in hypoxia, followed by reoxygenation in normoxia or hyperoxia. Cardiomyocyte OS, inflammation, and apoptosis were measured. ⋯ In contrast, LV +dP/dt was relatively well preserved under normoxic reperfusion conditions (to 70 ± 14% after 2-hour reperfusion), and was associated with an attenuated myocardial OS, inflammatory, apoptotic, and injury response compared to the hyperoxia group (eg, cTn-I: 5.9 ± 1.5 vs 20.2 ± 7.6 ng/mL, respectively, P < 0.0001). Overall, in both in vitro and in vivo experiments, normoxic reperfusion/reoxygenation was associated with less robust OS, inflammation, apoptosis, and myocardial injury compared with hyperoxic reperfusion/reoxygenation. These results suggest that hyperoxia should be avoided to minimize myocardial OS, inflammation, and ventricular dysfunction after CPB.