Introduction: Patients who have mitral valve (MV) disease with associated pulmonary hypertension (PH) may develop acute rises in pulmonary vascular resistance (PVR) perioperatively.Such pulmonary hypertensive crises may significantly increase perioperative morbidity and mortality. Although there is limited experience with agents to reduce the PVR, their use may be associated with systemic hypotension.Aim: To evaluate the safety and haemodynamic effects of intravenous (IV) sildenafil perioperatively, in patients with PH and MV disease undergoing cardiac surgery.Method: Nine patients, two males and seven females, age range 64 to 81 (median 76) years, with PH, mean pulmonary artery pressure range 30 to 56 (median 43) mmHg, associated with MV disease, who had MV surgery, received IV sildenafil (1mg/ml) at a rate of 1mg/kg for one hour in the immediate post operative period.Pulmonary and systemic haemodynamic measurements were recorded at ten-minute intervals.Results: A statistically significant reduction (p=0.006) in PVR was observed.There was a trend towards improvement in the cardiac index (CI), although it did not reach statistical significance (p=0.059).Mean systemic arterial pressure remained stable and no detrimental effect on other haemodynamic parameters was noted.Discussion: Our study suggests that perioperative use of IV sildenafil is safe and not associated with systemic hypotension.We observed a favourable response in PVR and a trend towards improvement in CI.We suggest that IV sildenafil should be considered for selected patients with MV disease and PH who require MV surgery.

Right heart catheterization (RHC) is important in the evaluation of pulmonary hypertension, but is not without risk.

Covered metallic endobronchial stents are increasingly used in the management of diverse large airway pathology and once deployed they are considered permanent. Long-term complications of stent fracture and airway granulation tissue formation may necessitate stent removal. We describe successful endoscopic removal of the Ultraflex expandable tracheal metallic stents (Microvasive; Boston Scientific, Natick, MA) in 5 patients at 105, 84, 50, 38, and 21 months after deployment, with excellent tracheal healing and clearance of granulation tissue noted at 6 weeks after removal in each patient.

We read with interest the recent literature review submitted by te Raa et al regarding treatment options in massive pulmonary embolism during pregnancy [ [1] te Raa D.G. Ribbert L.S.M. Snijder R.J. Biesma D.H. Treatment options in massive pulmonary embolism during pregnancy; A case-report and review of literature. Thromb Res. 2009 May; 124: 1-5 Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar ]. As highlighted venous thromboembolism is a leading cause of maternal mortality in the UK [ [2] Why Mothers Die 2000-2002. in: Lewis G. Sixth Report of the Confidential Enquiries into Maternal Death. RCOG Press, London2004 Google Scholar ]. Treatment options for pregnant patients that develop pulmonary embolism are often considered high risk with possible effects to both mother and foetus. We describe our total experience of thrombolysis for the treatment of massive PE in pregnancy over the last 5 years.

Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours. (Ann Thorac Surg 2009; 88: 1691-2) (C) 2009 by The Society of Thoracic Surgeons

Background: Sildenafil is of benefit to selected patients with pulmonary hypertension due to parenchymal lung or cardiac disease. We present data from patients with secondary pulmonary hypertension, comparing their right heart catheter results and six minute walking distance to time on treatment.Methods: 25 patients with symptomatic secondary pulmonary hypertension received sildenafil 50 mg tds in a 5-year period. Underlying causes were chronic inoperable thromboembolic disease (11), COPD (6). interstitial lung disease (5) and valvular heart disease (3). Their cardio-pulmonary haemodynamics were measured with right heart catheterization prior to treatment, post-treatment at 2, 6 and 12 months and subsequently depending upon clinical need. Six-minute walk distance was also measured.Results: Patient age range was 40 to 83 (median 70.5) years. Time of treatment to latest right heart catheter was 2 to 60 (median 17) months and 8 to 61 (median 34) months to clinic follow-up or death. There was a significant reduction in six-minute walk distance from baseline to long term (>12 months) follow-up (p = 0.002). Pulmonary vascular resistance was significantly reduced from baseline to 12 months (p = 0.049). The mean pulmonary arterial (PA) pressure was significantly reduced at long-term follow-up (p = 0.009). 20 patients had an improved PA pressure with treatment. In those with a worsening PA pressure, two had an improvement in cardiac output and six minute walk distance, two had stable cardiac output at 20 and 21 months, and one had measurements taken during a significant illness. Three patients, who had a reduction in PA pressure, subsequently died of progression of underlying illness at 8 months, from myocardial infarction at 34 months, and from aspergillus pneumonia at 59 months.Conclusion: Long-term use of sildenafil in patients with secondary forms of pulmonary hypertension is associated with a sustained improvement in cardio-pulmonary haemodynamics. Lack of improvement may be attributed to other factors apart from treatment failure, such as underlying disease progression or unrelated concurrent illness at time of assessment. (C) 2009 Elsevier Inc. All rights reserved.

Background: Sildenafil may be of benefit for selected patients with pulmonary hypertension associated with parenchymal lung and cardiac diseases. However the medium term benefits of this treatment for such patients is unclear.Patients and methods: 16 consecutive patients with secondary pulmonary hypertension who had been on maximal appropriate therapy received Sildenafil 50 mg tds following assessment which included right heart catheter, 2D echocardiography and six minute walk test. Right heart catheterisation, 2D echocardiography and six minute walk test were performed after eight weeks treatment, at 12 months and at six monthly intervals thereafter. Baseline medications were continued.Results: 16 patients with pulmonary hypertension associated with inoperable chronic pulmonary thromboembolism (6 patients), valvular heart disease (4), chronic obstructive pulmonary disease (3), idiopathic pulmonary fibrosis (2), and obstructive sleep apnoea (1) were studied. The age range was 42 to 8 1 (median 68) years and the period of follow up was 12 to 51 (median 22) months. Six minute walk increased significantly, p = 0.002, from baseline to long term follow up. The improvement in 14 patients ranged from 14 in to 300 in with a percentage increase of 5% to 567% increase. In one patient there was no change and in one patient the six minute walk test fell as a consequence of progression of known arthritis. The mean pulmonary artery pressure was significantly reduced at long term follow up (p = 0008). The pulmonary vascular resistance (PVR) fell in eleven patients, this reduction ranged from 0.2 woods units to 8.7 woods units (mean reduction 3.3 woods units). The percentage reduction in PVR ranged from 7% to 71% with a mean reduction of 43%. In five patients the pulmonary vascular resistance increased. 2D echocardiography showed a sustained improvement in right ventricular function in 11 patients. There were no deaths during follow up.Conclusion: Sildenafil may have a role for selected patients with pulmonary hypertension associated with cardiac and pulmonary diseases. The medication seems well tolerated and for some patients is effective within 8 weeks and results in a sustained long term improvement in haemodynamics and exercise capacity. (C) 2007 Published by Elsevier Inc.

Madden, B.1; Crerar-Gilbert, A.1; Sheth, A.1; Draper, A.1; O'Brien, M.1 Author Information

Pneumothorax is a relatively common condition that is usually managed either conservatively, by chest tube drainage or, if a refractory air leak persists, then with cardiothoracic intervention. However, there is a small group of patients with a persistent air leak in whom surgical intervention is felt to be inappropriate. This study looks at a novel management strategy in a patient presenting with this scenario. A male with underlying bullous lung disease presented with a right pneumothorax. Complete re-expansion was not achieved, despite chest tube drainage and suction. Cardiothoracic intervention was felt to be inappropriate and the air leak persisted despite prolonged conservative management. Ventilation scintigraphy was therefore used to localise the air leak prior to targeted radiotherapy in an attempt to seal the leak via radiation-induced fibrosis. Three weeks after the first fraction of radiotherapy, the air leak ceased. In complex cases of pneumothorax with persistent air leak where cardiothoracic intervention is deemed inappropriate, identification of the air leak site and localised radiotherapy could be considered.