The Annals of thoracic surgery
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Randomized Controlled Trial Multicenter Study
Long-term follow-up of high-risk patients in the National Emphysema Treatment Trial.
The National Emphysema Treatment Trial (NETT) was a randomized clinical trial designed to compare lung volume reduction surgery (LVRS) with maximal medical care for patients with severe emphysema. The trial was halted early for a subgroup of patients with severe lung disease. We report longer term follow-up for this high-risk subgroup. ⋯ The NETT was stopped early for high-risk patients with severe lung disease. Longer term follow-up suggests that surgical patients in this high-risk subgroup ultimately achieved comparable outcomes. The high risk of death within 30 days of the surgery may discourage use of the procedure for high-risk patients despite the potential for better long-term outcomes.
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Recent studies using United Network for Organ Sharing data suggest that lung transplantation in patients with high lung allocation scores (LAS) may lead to organ and resource wastage. Therefore, to determine whether a LAS cutoff value should be considered, we evaluated the relation of LAS to waitlist and posttransplant mortality in our center to determine if it could identify patients for whom listing for transplantation may be futile. ⋯ Higher LAS strongly predicts higher mortality on the lung transplantation waitlist, underscoring the value of LAS in prioritizing patients with the highest scores for transplantation. Early posttransplant mortality is modestly higher with higher pretransplant LAS, but the data of our center do not suggest a value above which transplantation should be denied as futile. This suggests that donor organs and resources are not being wasted.
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Postoperative lobar torsion is a rare and life-threatening complication. Several previous cases have been treated with completion lobectomy. We report successful surgical repair of middle lobar torsion after upper lobectomy. ⋯ The surface of the middle lobe appeared congestive, but its surface color, elasticity, and compliance improved 1 h after detorsion. We preserved the middle lobar function and prescribed warfarin for pulmonary vein thrombosis. When preserving a twisted lobe, it is important to consider the damage to the twisted lung, risk of thrombosis, and residual pulmonary function.
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Atrioventricular valve replacement options are limited in infants and small children. The Melody stented bovine jugular vein conduit is being used with increasing frequency for percutaneous pulmonary valve replacement. The Melody valve can be serially dilated over time to accommodate the somatic growth of pediatric patients. We report the initial experience of using the Melody valve as a surgical tricuspid valve replacement in an infant.
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Before clinical manifestation of regurgitation, the tricuspid annulus dilates and flattens when right ventricular dysfunction is potentially reversible. That makes the case for a prophylactic tricuspid annuloplasty even in the absence of significant tricuspid regurgitation. Owing to the appreciation of the favorable prognostic value of tricuspid annuloplasty, the geometry of the normal tricuspid annulus merits critical analysis. ⋯ The tricuspid annulus is a dynamic, multiplanar structure with heterogeneous regional behavior. These characteristics should be taken into account for optimal annuloplasty device design and efficacy.