Sleeve lobectomy is a widely accepted procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study is to assess operative mortality, morbidity, and long-term results of sleeve lobectomies performed for non-small cell lung carcinoma (NSCLC). A retrospective review of 218 patients who underwent sleeve lobectomy for NSCLC between 1981 and 2005 was undertaken. There were 186 (85%) men and 32 women with a mean age of 61.9 years (range, 19-82 years). Eighty patients (36.6%) had a preoperative contraindication to pneumonectomy. Right upper lobectomy was the most common operation (45.4%). Vascular sleeve resection was performed in 28 patients (12.8%) and was commonly associated with left upper lobectomy (n=20; 9.1%; p=0.0001). The histologic type was predominantly squamous cell carcinoma (n=164; 75%), followed by adenocarcinoma (n=46; 21%). Resection was incomplete in nine (4.1%) patients. There were nine operative deaths; the operative mortality and the morbidity rates were 4.1% and 22.9%, respectively. A total of 14 (6.4%) patients presented with bronchial anastomotic complications: two were fatal postoperatively, seven patients required reoperation, three required a stent insertion, and two were managed conservatively. Multivariate analysis showed that compromised patients (p=0.001), current smoking (p=0.01), right sided resections (p=0.003), bilobectomy (p=0.03), squamous cell carcinoma (p=0.03), and presence of N1 or N2 disease (p=0.01) were risk factors for mortality and morbidity. Follow-up was complete in 208 patients (95.4%). Overall 5-year and 10-year survival rates were 53% and 28.6%, respectively. After complete resection, recurrence was local in 10 patients, mediastinal in 20, and distant in 25. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0-N1 vs N2; p=0.01) and the stage of the lung cancer (stage I-II vs III, p=0.02). For patients with NSCLC, sleeve lobectomy achieves local tumor control, even in patients with preoperative contraindication to pneumonectomy and is associated with low mortality and bronchial anastomotic complication rates. Postoperative complications are higher in compromised patients, smokers, N disease, right sided resections, bilobectomies, and squamous cell cancers. The presence of N2 disease and stage III significantly worsen the prognosis.

BACKGROUND: The European Chronic Thromboembolic Pulmonary Hypertension (CTEPH) registry, conducted between 2007 and 2012, reported the major impact of pulmonary endarterectomy (PEA) on the long-term survival of patients with CTEPH. Since then, 2 additional treatments for inoperable CTEPH have become available: balloon pulmonary angioplasty (BPA), and an approved oral drug therapy with the guanylate cyclase stimulator riociguat. The current registry aimed to evaluate the effect of these new therapeutic approaches in a worldwide context. METHODS: Participation in this international global registry included 34 centers in 20 countries. Between February 2015 and September 2016, 1009 newly diagnosed, consecutive patients were included and followed until September 2019. RESULTS: Overall, 605 patients (60%) underwent PEA and 185 (18%) underwent BPA; 76% of the 219 remaining patients not receiving mechanical intervention (ie, neither PEA nor BPA) were treated with pulmonary hypertension drugs. Of patients undergoing PEA and BPA, 38% and 78% also received drugs for pulmonary hypertension, respectively. Median age at diagnosis was higher in the BPA and No PEA/BPA groups than in the PEA group: 66 and 69, respectively, versus 60 years. Pulmonary vascular resistance (PVR) was similar in all groups, with an average of 643 dynes.s.cm ⁻⁵ . During the observation period (>3 years; ≤5.6 years), death was reported in 7%, 11%, and 27% of patients treated by PEA and BPA, and those receiving no mechanical intervention ( P <0.001). In Kaplan-Meier analysis, 3-year survival was 94%, 92%, and 71% in the 3 groups, respectively. PEA 3-year survival improved by 5% from that observed between 2007 and 2012. There was no survival difference in patients receiving vitamin K antagonists and non–vitamin K oral anticoagulants ( P =0.756). In Cox regression, reduced mortality was associated with: PEA and BPA in the global cohort; history of venous thromboembolism and lower PVR in the PEA group; lower right atrial pressure in the BPA group; and use of pulmonary hypertension drugs, oxygen therapy, and lower right atrial pressure, as well as functional class in the group receiving no mechanical intervention. CONCLUSIONS: This second international CTEPH registry reveals important improvement in patient survival since the introduction of BPA and an approved drug for pulmonary hypertension. The type of anticoagulation regimen did not influence survival. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02656238.

Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thrombo-embolic pulmonary hypertension (CTEPH). The aim of this study was to review our initial experience since the implementation of our program. Data were collected prospectively on all patients who underwent PEA between March 2011 and March 2012. Forty-nine patients (20 male, 29 female, mean age 47.7 years) underwent surgery. The preoperative New York Heart Association class distribution showed the majority to be in class III or IV (n = 40). Mortality rate was 14.2% (n = 7) and the morbidity rate was 26.5% (n = 13). After PEA, the durations of mechanical ventilation, intensive care stay and hospital stay before discharge were 49.7 ± 46.1 h, 6.5 ± 5.0 days and 12.9 ± 7.5 days, respectively. The systolic and mean pulmonary artery pressure (PAP) fell significantly from 87.0 ± 26.6 mmHg and 53.8 ± 14.5 before, to 41.5 ± 12.4 mmHg and 28.5 ± 10.5 after surgery (P < 0.001 and P < 0.001, respectively). Pulmonary vascular resistance (PVR) also improved significantly from 808 ± 352.0 to 308 ± 91 dyn•s•cm⁻⁵ (P < 0.001). Univariate analysis showed that preoperative systolic PAP, tricuspid annular plane systolic excursion, right atrial volume, right atrial pressure, forced expiratory volume in 1 s, forced vital capacity, preoperative PVR, postoperative PVR, the duration of circulatory arrest and postoperative use of extracorporeal membrane oxygenation were risk factors for mortality (P < 0.05). According to multivariate analyses, only prolonged mechanical ventilation was selected as predictive risk factor for morbidity (P = 0.005). After a median follow-up of 6.1 months, two patients died due to cerebrovascular disease and one patient needed targeted pulmonary hypertension therapy. The rest of the 39 patients showed marked improvements in their clinical status. Starting a pulmonary endarterectomy program with acceptable mortality and morbidity rates and satisfactory early-term outcomes increases awareness of the CTEPH and surgery. Preoperative factors can primarily predict postoperative outcome after PEA. Identifying the risk factors in order to achieve a good result is important for the success of a PEA program. Therefore all patients diagnosed with CTEPH should be referred for consideration of PEA in a specialized centre.

Postoperative psychiatric disorders (PPDs) may complicate the post-surgical outcome. We analysed the types, incidences, risk factors and outcomes of the PPDs in non-cardiac thoracic surgery patients. All patients (n=100) undergoing major non-cardiac thoracic surgery from January 2004 to March 2005 were investigated prospectively. The diagnosis of PPD was made based on the Diagnosis and Statistical Manual of Mental Disorders. The patients were grouped into two according to the presence (group I) or absence (group II) of PPD. Data on pre-, per- and postoperative factors, and the adverse outcomes were analysed. Eighteen patients (18%) developed PPD, including delirium in 44%, adjustment disorders in 22%, panic attack in 17%, minor depression in 11% and psychosis in 6%. The patients who developed PPD were older (58+/-17 vs 50+/-15 years, p=0.05), had a longer operation time (6+/-1 vs 5+/-2h, p=0.015) and hospital stay (13+/-9 vs 8+/-5 days, p=0.019). The morbidity and mortality rates were not significantly different between the groups (67% vs 46%; 11% vs 1%, respectively). The causative factors in the development of PPD were older age, longer operation time, abnormal serum chemistry values of sodium, potassium, calcium and glucose, hypoalbuminaemia, the presence of the postoperative respiratory distress and infection and blood transfusion (p<0.05). PPDs are associated with adverse outcomes including a longer hospital stay, and increased morbidity and mortality rates. The identification, detection and elimination of these risk factors are recommended.

Background Behçet's syndrome (BS) is a multisystem disorder and is not known as a risk factor for chronic thromboembolic pulmonary hypertension (CTEPH), for which the treatment of choice is pulmonary endarterectomy (PEA). The aim of this study was to review our experience in the surgical treatment of CTEPH in patients with BS. Methods Data were collected prospectively for consecutive patients with BS who underwent PEA over a 6-year period. Results We identified nine patients (seven males, two females, mean age: 34.7 ± 9.9 years) with BS. The mean disease duration before PEA was 88.0 ± 70.2 months. All patients but one received immunosuppressive therapy before the surgery. Exercise-induced dyspnea presented symptoms in six patients. One patient had associated intracardiac thrombosis. PEA was bilateral in five patients, unilateral in three, and lobar in one. No perioperative mortality was observed; however, one patient died four weeks after PEA due to massive hemoptysis. Morbidity was observed in two patients. The systolic pulmonary artery pressure fell significantly from 59.0 ± 22.7 mm Hg to 30.0 ± 6.5 mm Hg after surgery (p = 0.031). Pulmonary vascular resistance also improved significantly from 611.8 ± 300.2 to 234.7 ± 94.9 dyn/s/cm⁵ (p = 0.031). After a median follow-up of 29.4 months, all patients improved to the New York Heart Association (NYHA) functional class I and II. Conclusion Patients with BS may suffer recurrent pulmonary embolism and develop CTEPH. In patients who do not respond to anticoagulation or immunosuppressive therapy, PEA may be a therapeutic option when thrombotic lesions are surgically accessible. Due to the high risk of perioperative mortality, the procedure should be undertaken in centers with experience.

We describe the case of a 60-year-old woman who presented with pulmonary artery sarcoma, a very rare tumor of the cardiovascular system. Her tumor was initially misdiagnosed as chronic pulmonary thromboembolism, and she underwent pulmonary endarterectomy. Early diagnosis of primary pulmonary artery sarcoma is crucial. That alternative should always be considered before settling on a diagnosis of pulmonary embolism. Suspicion should be aroused by the failure of anticoagulant treatment to alleviate pulmonary perfusion abnormalities and systemic symptoms. Surgical resection of the tumor—preferably by pulmonary endarterectomy, followed by reconstruction as needed—is currently the most promising treatment for pulmonary artery sarcoma.