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Biomedical subjects

P Macchiarini

Publications and source records attributed to P Macchiarini.

At least 37 records · Page 2Linked to original sources
PubMed1999

Angioscopic video-assisted pulmonary endarterectomy for post-embolic pulmonary hypertension.

OBJECTIVES: To assess whether the use of video-assisted angioscopy would increase the outcome of pulmonary thromboendarterectomy (PTE). METHODS: PTE included a median sternotomy, intrapericardial dissection of the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. It was always performed through two separate arteriotomies on both main intrapericardial pulmonary arteries, into which a rigid 5 mm angioscope connected to a video camera was introduced to increase the visibility and endarterectomies. RESULTS: From January 1996 to July 1998, 68 consecutive patients (35 males and 33 females) aged 54.3 +/- 13.5 years underwent PTE. Patients were in New York Heart Association (NYHA) class II (n = 2), III (n = 43) or IV (n = 23) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 54 +/- 13 mmHg; cardiac output (CO): 3.8 +/- 0.8 l/min, and total pulmonary resistance (TPR): 1207 +/- 416 dyne x s x cm(-5). The cumulated circulatory arrest time was 23 +/- 12 min and postoperative length of ventilatory support 10 +/- 12 days. Nine patients died, for an overall in-hospital mortality of 13.2%. The functional outcome in surviving patients was significantly improved (P < 0.0001) both clinically (NYHA class 3.2 +/- 0.5 vs. 1.3 +/- 0.6) and hemodynamically (PAP (mmHg) 53.1 +/- 13 vs. 30.2 +/- 11.8, CI (l/min per m2) 2.1 +/- 0.5 vs. 2.8 +/- 0.6, TPR (dyne x s x cm(-5)) 1174 +/- 416 vs. 519 +/- 250). CONCLUSIONS: Video-assisted angioscopy improves the quality and degree of pulmonary endarterectomy expanding the indications to include patients with previously inaccessible distal disease.

Adult↗
PubMed1999

Techniques of pneumonectomy. Sleeve pneumonectomy.

Sleeve pneumonectomy is a technically demanding procedure, the indications of which include non-small bronchogenic tumors extending to the tracheobronchial bifurcation without diseased mediastinal nodes. Right sleeve pneumonectomies are best approached through an ipsilateral thoracotomy in the fifth (or fourth) intercostal space. Median sternotomy for left sleeve pneumonectomy gives outstanding exposure to the tracheobronchial bifurcation, and less incisional discomfort and ventilatory restriction than an ipsilateral thoracotomy. If a tracheobronchial anastomosis is under tension, excessive tracheobronchial and mediastinal dissection and perioperative fluid overload are avoided, then the most common and often fatal early (noncardiogenic pulmonary edema) and late (anastomotic dehiscence) complications are significantly lowered. If these guidelines are respected, this operation generates 5-year survival rates exceeding 40%.

Humans↗
PubMed1999

Surgical management of superior sulcus tumors.

Superior sulcus tumor refers to any primary lung cancer presenting with constant pain in the nerve distribution of the eighth cervical, first and second thoracic nerve roots and Horner's syndrome caused by invasion of the stellate ganglion. The pain is steady, severe, and unrelenting, involving the shoulder, the vertebral margin of the scapula and ulnar distribution of the arm to the elbow and finally to the ulnar surface of the forearm, and the small and ring fingers of the hand (Pancoast-Tobias syndrome). Weakness and atrophy of the hand muscles can also occur as the lesions spreads to involve the first and second ribs and vertebrae. Radiologically, there is a small shadow at the extreme apex of the lung with rib and possible vertebral body invasion. Pulmonary symptoms are less frequent because of the peripheral location of the lesions. Since Shaw and Paulson approached superior sulcus tumors in 1961 by using preoperative radiation-therapy (30 to 45 Gy in four weeks including the primary tumor, mediastinum and supraclavicular region) followed by surgical resection, this radiosurgical approach shortly became the standard treatment yielding better disease control and survival than that offered by other treatment modalities. It has now become evident that en bloc resection of the chest wall, involved adjacent structures as well as lobectomy must be considered the standard surgical approach for superior sulcus tumors combined with external radiation (preoperative, postoperative, or both). The goal of the operation is the complete and en bloc resection of the upper lobe in continuity with the invaded ribs, transverse processes, subclavian vessels, T1 nerve root, upper dorsal sympathetic chain and prevertebral muscles.

Arm↗
PubMed1998

Tracheoplasty in congenital tracheal stenosis.

Congenital tracheal stenosis is an uncommon but life-threatening condition whose management is still debated. The rarity of this disease explains the lack of a standard management. Between 1986 and 1996, eight children younger than 1 year were referred to our Institution with a tracheal stenosis. The median age at operation was 3.15 months and the median weight was 4.5 kg. The diagnosis was made after an episode of respiratory distress in all but one and was confirmed by fiberoptic bronchoscopy. The median length of tracheal stenosis was 24.5 mm (Ranges: 4-30 mm). Only one patient was free from associated cardiovascular defect. Tracheal repair was performed under cardiopulmonary bypass in all. In three it was achieved by pericardial augmentation of the stenosed area, in four by resection and end to end anastomosis and in one by sliding tracheoplasty. Concomitant cardiac repair was performed in six. Two patients died after pericardial patch augmentation. In both, death was related to profound hypoxemia due to patch collapse. Two patients developed restenosis after resection and end to end anastomosis. They both had stent placement and one required reoperation and underwent a sliding tracheoplasty. At a median follow-up of 21 months (Ranges: 6-120) all the survivors are doing well and are free from respiratory symptoms. Bronchoscopic evaluation revealed in all a widely patent anastomosis without restenosis. In conclusion, tracheal stenosis in children remains a challenging lesion. Surgical technique, whether resection and end to end anastomosis or sliding tracheoplasty offer better results and should be discussed according to the length of the stenosis. Pericardial plasty should be used with caution.

Anastomosis, Surgical↗
PubMed1998

[Pulmonary thromboendarterectomy with video-angioscopy and circulatory arrest: an alternative to cardiopulmonary transplantation and post-embolism pulmonary artery hypertension].

The best predictor of poor or suboptimum outcome from pulmonary thromboendarterectomy (PTE) is insufficient relief of obstruction, especially in the lower lobes. The aim of this study is to emphasize that the use of video-assisted angioscopy may increase the quality of PTE and thus improve outcome. PTE included a median sternotomy, intrapericardial dissection limited to the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. PTE was always bilateral and performed through two separate arteriotomies of both main intrapericardial pulmonary arteries. A rigid 5 mm angioscope connected to a video camera was introduced through the arteriotomy into the lumen to increase the visibility and perform the video-assisted endarterectomies of all obstructed segmental branches, including normally inaccessible anterior segmental branches. Between January 1996 and December 1997, 48 patients with severe postembolic pulmonary hypertension had PTE. Patients were in New York Heart Association (NYHA) class II (n = 2), III (n = 28) or IV (n = 18) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 53 +/- 13 mmHg, cardiac index 2.16 +/- 0.5 L/min/m2, pulmonary vascular resistances (PVR): 1,152 +/- 414 dyne.s-1.cm-5. Six patients died from alveolar hemorrhage (n = 1), high residual pulmonary pressure and rethrombosis (n = 4) and hypoxic cardiac arrest (n = 1). The functional outcome in surviving patients was as follows: (NYHA) class I (n = 24), II (n = 16) or III (n = 2) with improved hemodynamics: mean pulmonary arterial pressure: 30 +/- 9 mmHg, cardiac index: 2.78 +/- 0.5 L/min/m2, pulmonary vascular resistances (PVR): 484 +/- 159 dynes.s-1.cm-5. Video-assisted angioscopy allows much improved quality and degree of pulmonary endarterectomy. This expands the indications to include patients with previously inaccessible distal disease and candidates for heart-lung transplantation.

Adult↗
PubMed1998

Surgery for invasive primary mediastinal tumors.

BACKGROUND: There have been few reports on results after extended radical resection for primary mediastinal tumors invading neighboring organs. METHODS: A retrospective analysis of 89 patients who underwent total or subtotal resection of a primary mediastinal tumor with resection of at least part of an adjacent structure between 1979 and 1995 was performed. Clinical data were collected from the medical records. RESULTS: There were 35 invasive thymomas, 12 thymic carcinomas, 17 germ cell tumors, 16 lymphomas, 3 neurogenic tumors, 3 thyroid carcinomas, 2 radiation-induced sarcomas, and 1 mediastinal mesothelioma. The tumor was located in the anterior mediastinum in 74% of patients. Residual masses after chemotherapy were excised in 14 patients with germ cell tumor and 8 with lymphoma. A median sternotomy was the most frequently used approach (79% of patients). Total resection was achieved in 79% and significantly improved survival (p < 0.01). Adjacent resected structures included 38 phrenic nerves, 21 superior venae cavae, 16 upper lobes, and 13 innominate veins, in 5 patients, a pneumonectomy was required. The complication rate was 17% and the mortality rate, 6%. With follow-up available for 86 patients, the overall 5-year survival rate was 69% for patients with thymoma, 42% for patients with thymic carcinoma, 48% for patients with germ cell tumor, and 83% for patients with lymphoma. CONCLUSIONS: Malignant mediastinal tumors can be safely resected even if they have invaded other mediastinal structures. Complete resection is important to achieve satisfactory long-term survival. A median sternotomy is an excellent approach, and a preoperative diagnosis by biopsy is desirable. Residual masses after chemotherapy for lymphoma or germ cell tumor should be resected. Extensive resection without a preoperative diagnosis is not indicated.

Adolescent↗
PubMed1998

Evidence of human non-alpha-galactosyl antibodies involved in the hyperacute rejection of pig lungs and their removal by pig organ perfusion.

BACKGROUND: Human natural xenoantibodies represent a major hurdle to the clinical application of pig lungs in transplantation by initiating hyperacute rejection within minutes to hours. OBJECTIVE: The object was to compare pig organ perfusion and specific depletion of anti-alpha-galactosyl xenoantibodies for prevention of hyperacute rejection in the pig to human lung combination. METHODS: Large White pig (20-25 kg) left lungs were removed and continuously ventilated and reperfused ex vivo either with (1) whole human blood previously perfused in situ through pig right lung (group I), liver (group II), or spleen (group III) or with (2) human plasma in vitro immunoabsorbed on columns containing alpha-galactosyl disaccharide (Gal-alpha-(1-3)Gal-beta-(CH2)3NH2; B disaccharide) (group IV). Each study group included 6 animals. RESULTS: The in situ and in vitro preperfusions depleted anti-alpha-galactosyl xenoantibodies and all in situ perfused pig organs showed histologic signs of hyperacute rejection. After the ex vivo reperfusion, group I xenografts had a significantly (P < .001) longer functional and histologic survival than did xenografts in groups II, III, and IV. Human blood reperfusing group I xenografts had a significantly (P < 0.05) lower (1) decline of clotting factors and total circulating immunoglobulins, (2) total and membrane attack complex (C5b,6,7,8,9) complement activation, and (3) hemolysis. By Western blot analysis, the in situ lung preperfusion removed antibodies against non-alpha-galactosyl proteins of low molecular weight that were not eliminated by the alpha-galactosyl column. CONCLUSIONS: Results demonstrate that specific depletion of anti-alpha-galactosyl antibodies alone incompletely protects pig lungs from hyperacute rejection. It is speculated that the more complete prevention of this rejection afforded by pig lung preperfusion relates to the removal of other, non-alpha-galactosyl antibodies.

Acute Disease↗
PubMed1997

Radical resection of radiation-induced sarcoma of the chest wall: report of 15 cases.

BACKGROUND: Surgical management of radiation-induced sarcoma of the chest wall remains difficult because of its impressive local aggressiveness. METHODS: Between 1987 and 1995, 15 patients (median age, 58 years) underwent radical resection of radiation-induced sarcoma of the chest wall. This type of tumor was defined as a metachronous, histologically different neoplasm in the irradiated field of the original tumor. Ten patients had a history of primary breast cancer and 5 patients, Hodgkin's disease. The median delivered radiation dose to the primary tumor area was 45 Gy, and the median interval between radiotherapy and diagnosis of sarcoma was 14 years. Seven tumors were located on the sternum, three on the lateral chest wall, and five in the thoracic outlet. Four total and three partial sternectomies, three lateral chest wall resections and five resections of tumors in the thoracic outlet (three first-rib resections) were performed. Seven patients required stabilization of the chest wall with prosthetic material. Soft tissue reconstruction was carried out with either muscle flaps and skin advancement in 9, musculocutaneous flaps in 4, or skin flaps alone in 2 patients. RESULTS: One patient died 3 months after total sternectomy of respiratory failure. Two patients (13.3%) had a local complication: sepsis after sternectomy in 1 and cutaneous necrosis in 1. Local recurrence occurred in 7 patients after a median interval of 10 months. Two of them died, and 4 underwent a repeat resection, 3 of whom are still alive. Four patients died of systemic recurrence. With a median follow-up of 30 months, overall 5-year survival and 5-year disease-free survival rates were 48% and 27%, respectively. CONCLUSION: Despite poor long-term disease-free survival, radical resection of radiation-induced sarcoma of the chest wall is justified on the basis of low postoperative morbidity and the lack of other available therapies.

Female↗
PubMed1997

Ex vivo lung model of pig-to-human hyperacute xenograft rejection.

OBJECTIVE: Our objective was to study lung hyperacute rejection in the pig-to-human xenotransplantation combination. METHODS: Pig lungs were harvested and continuously ventilated and perfused ex vivo, using a neonatal oxygenating system, with either xenogeneic unmodified human blood (n = 6) or autogeneic pig blood (n = 6). RESULTS: Autoperfused lungs displayed normal hemodynamics, oxygen extraction (arteriovenous oxygen difference), and histologic characteristics throughout the 3-hour study period. By contrast, xenoperfused lungs displayed, within 30 minutes, severe pulmonary hypertension and abolishment of arteriovenous oxygen difference culminating in massive pulmonary edema, hemorrhage, and lung failure after 115 +/- 44.2 minutes of reperfusion. Within 30 minutes, the human blood showed a significant drop of anti-alpha Gal immunoglobulin M and G xenoreactive antibodies (enzyme-linked immunosorbent assay) and complement activity, consumption of clotting factors, and hemolysis; total circulating human immunoglobulins remained substantially normal. Histologically, lungs perfused with human blood were congestive and showed alveolar edema and hemorrhage and multiple fibrin and platelet thrombi obstructing the small pulmonary vessels (arterioles, capillaries, and venules) but not large (segmental or lobar) pulmonary vessels. On immunohistologic examination, deposits of human immunoglobulin M and complement (C1q and C3) proteins were observed on the alveolar capillaries. CONCLUSIONS: This pig-to-human xenograft model suggests that the pig lung perfused with human blood has an early and violent hyperacute rejection that results in irreversible pulmonary dysfunction and failure within approximately 150 minutes of reperfusion.

Acute Disease↗
PubMed1997

Tracheal growth after slide tracheoplasty.

OBJECTIVE: Our goal was to investigate the effects of slide tracheoplasty on tracheal growth in newborn piglets. METHODS: Slide tracheoplasty was performed on normal trachea (n = 6) and a model of tracheal stenosis resembling that seen in infants (n = 6). After division of the trachea at its midportion between the second cartilaginous ring above and the right upper lobe takeoff below (around 23 rings), the proximal and distal segments were incised vertically on opposite anterior and posterior surfaces and reconstructed together. RESULTS: The reconstructed tracheas lengthened and their cross-sectional areas enlarged linearly at a rate of 0.94 cm per month and 1.55 mm2/kg, respectively, as the piglets grew over a 6-month period from 4.7 +/- 0.6 to 64.4 +/- 5.7 kg (+/- standard deviation). Growth was not different between the two studied groups. There was no narrowing or late restenosis. The mean anastomotic cross-sectional area was overall 1.63 +/- 0.28 times larger (range 1.2 to 2.7) than the cross-sectional area of the unreconstructed trachea. When the animals were put to death, all tracheal lumina were completely lined with normal respiratory epithelium and all layers were histologically intact; anastomotic trachealis muscles contracted less (p < 0.001) but relaxed similarly to those muscles lining normal tracheas. Tracheal blood supply was macroscopically and microscopically normal in both groups; however, newborn piglets had an almost twofold increased number of intramural capillary vessels as opposed to adult pigs (p < 0.001). CONCLUSIONS: Results suggest that slide tracheoplasty is not limited by the length of stenosis, provides a permanent enlargement of the cross-sectional airway diameter, does not compromise tracheal vascular supply, and does not impair tracheal growth as somatic growth continues.

Animals↗
PubMed1996

[Intrathoracic goiters. 62 surgically treated patients].

OBJECTIVES: Intrathoracic goitres present as tumors of the upper mediastinum. Malignancy is uncommon, but sudden or progressive development often leads to compression of the trachea. We report here our experience with surgical exeresis. METHODS: From 1980 to 1995, we operated 62 patients with intrathoracic goitre. There were 23 men and 39 women (mean age 63 years). The main manifestations leading to diagnosis were dyspnea (n = 20; 32%) and identification of a mediastinal formation on routine chest x-rays (n = 19; 30%). RESULTS: Antevascular goitre was seen in 24 patients (39%) and retrovascular goitre in 38 (61%). The retrovascular goitres were located anteriorly and laterally to the trachea in 21 patients (34%) and posteriorly in 17 (27%). Simple cervicotomy was used in 57 patients (92%). Manubriotomy (n = 1) and total sternotomy (n = 4) were also required. All intrathoracic goitres removed were benign. Post-operative mortality was nul and morbidity was 11%: 2 cases of hypocalcemia and 2 tracheomalacias including 1 with recurrent nerve palsy and one with hematoma and pulmonary infection. CONCLUSION: Surgical exeresis of intrathoracic goitre is essentially required in case of respiratory distress due to compression of the trachea. Morbidity is low with simple cervicotomy.

Adult↗
PubMed1996

Thymic neuroendocrine carcinoma (carcinoid): a clinicopathologic study of fourteen cases.

The medical records and histologic documents of 14 patients treated at our institution for a thymic carcinoid tumor were reviewed. There were 3 women and 11 men with an age range from 35 to 71 years. One patient had a multiple endocrine neoplasia syndrome; another had a neurofibromatosis. Twelve tumors were revealed by local symptoms and two were asymptomatic. One patient had Cushing's syndrome that appeared secondarily and was related to metastases. Tumors ranged from 6 to 20 cm and had the characteristic histologic appearance of atypical carcinoid tumor. Immunohistochemical evaluations were done. Tumors were positive for cytokeratin (92%), neuroendocrine markers (100%), and p53 oncoprotein (29%). S-100 protein antibody revealed numerous sustentacular cells in one case. Overall survival was 46% and 31% at 3 and 5 years, respectively. However, all patients died of the disease within 109 months as a result of local progression (n = 5), local relapse (n = 3), distant metastases (n = 8), or a combination of these reasons. Median survival was 71, 30, and 5 months for patients who had total resection (n = 4), partial resection (n = 5), or simple biopsy (n = 4), respectively (p = 0.023). In conclusion, thymic carcinoid tumors can be considered thymic neuroendocrine carcinomas because of their malignant behavior and histologic appearance of atypical carcinoid tumors. Complete surgical resection offers the best hope for long-term survival.

Adult↗
PubMed1996

Large bilateral pulmonary artery aneurysms in Behçet's disease: rupture of the contralateral lesion after aneurysmorrhaphy.

An 18-year-old man presented with Behçet's disease and two large bilateral pulmonary artery aneurysms. The day following aneurysmorrhaphy of the right aneurysm, a massive hemoptysis led to death. Postmortem examination disclosed rupture of the left aneurysm in a segmental bronchus. The aneurysms had inflammatory walls and were associated with organized pulmonary arterial thromboses and endomyocardial fibrosis of the right ventricle. Our case report highlights the surgical risk of rupture of associated arterial lesions, certainly related to per- and postoperative pulmonary arterial pressure variations.

Adolescent↗
PubMed1996

Carinal resection for bronchogenic cancer.

Traditionally, high technical morbidity and mortality and uncertain long-term survival have been associated with carinal surgery for bronchogenic carcinoma. However, growing evidence exists that judicious indications, meticulous surgery, and also perioperative management can decrease surgical mortality. Contraindications include patients whose tumors are so extensive that reconstruction would be under tension and those with involved precarinal and paratracheal nodes. Patients with diseased subcarinal nodes might benefit from surgery. Right carinal pneumonectomy is the most common carinal procedure, and the safe limit of resection is approximately 4 cm between the lower trachea and contralateral main bronchus. Small lesions involving the carina only may be resected without pulmonary resection with somewhat greater resectional limits. Right upper lobe tumors involving the carina may also be completely resected by saving the right middle and lower lobes and fashioning a new carina. Fatal early (noncardiogenic pulmonary edema) and late (anastomotic dehiscence or separation) complications after carinal pneumonectomy may be preventable by limiting mediastinal lymphatic dissection and perioperative intravascular fluid overload. A limited tailored thoracoplasty and transposition of the latissimus and serratus muscles into the postpneumonectomy pleural space can mitigate anastomotic complications. If these recommendations are respected, the technical mortality rates of carinal pneumonectomy can equal those observed after conventional pneumonectomy, and 5-year survival rates in excess of 40% can be expected for NO-1 patients. Invasion of the carina by bronchogenic carcinoma should not be considered by itself a surgical contraindication because the potential for cure is not elusive.

Anesthesia, Inhalation↗
PubMed1996

Management of acquired tracheoesophageal fistula.

Acquired, nonmalignant tracheoesophageal fistulae usually result from erosion of the tracheal and esophageal walls by endotracheal or tracheostomy tube cuffs, especially when a rigid nasogastric tube is in place. This has become an infrequent occurrence with the use of high-volume, low-pressure cuffs, but it still represents a life-threatening condition. Spontaneous recovery is exceptional. Most are diagnosed while patients still are mechanically ventilated and, due to the negative effects of positive pressure ventilation on tracheal suture lines, repair should be delayed until patients are weaned. After the patients is weaned from the ventilator, a one-staged anterior approach including esophageal closure, segmental tracheal resection, and primary reconstruction definitely corrects the fistula and removes concurrent tracheal disease and should be preferred to simple division and closure of the fistula.

Anastomosis, Surgical↗