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30 Prophylactic Cardiac andVascular Surgery Procedures
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Fig. 30.3 Shamblin stage III carotid body tumor located at left carotid artery bifurcation
The proximity to cranial nerves (VII, IX, X, XI, XII) also causes a surgical challenge. Surgical categorization for carotid body tumors was sug­gested by Shamblin etal. [9]. Shamblin stage I tumors are rather small with insignicant inva­sion to the carotid artery. Surgical excision can be performed easily without disturbing the arterial structures. Stage II tumors are relatively bigger, but arterial adhesions can be separated. Shamblin stage III tumors are very big and more densely adherent to the vessels and nerves. These tumors usually need to be resected with arterial ligation and reconstruction. Most of tumors course asymptomatically in early stages. Diagnosis can be made with Duplex ultrasound scanning, CT angiography, MR angiography or carotid arteri­ography (Fig.30.3). Surgery must be considered as soon as possible even in the asymptomatic patients to prevent the invasion of vascular and neural structures.
30.4 Valvular Heart Diseases
30.4.1 Aortic Valve Stenosis
The main etiologies for the condition of aortic stenosis are congenital, degenerative and rheu­matic origins. The patients remain asymptomatic
361
Fig. 30.4 Operative view of severe aortic stenosis
for a long period of time. Frequently seen symp­toms are angina pectoris, syncope and congestive heart failure. When symptoms arise, there is a risk of sudden death. Around 50% of patients with severe aortic stenosis are asymptomatic when diagnosed. The decision of aortic valve replacement in such patients is still on debate [
10, 11]. The degree of aortic valve calcication,
appearance of symptoms, increase in the gradient and worsening of the left ventricular (LV) func­tion should be observed closely. The goal must be the timely intervention of aortic valve replace­ment to preserve the cardiac function, stop addi­tional damage and prevent mortality.
Asymptomatic patients with severe aortic ste-
nosis and LV systolic dysfunction require opera-
12, 13]. In asymptomatic patients with
tion [ preserved LV systolic function, aortic valve replacement should be considered if there is another cardiac intervention planned. An early operation should be scheduled in case of aortic valve area of 0.75cm2 or an increase in transval­vular gradient during exercise (Fig. 30.4). Patients with coronary artery disease and moder­ate aortic stenosis with a mean transaortic gradi­ent of more than 40 mmHg require combined procedures with coronary bypass and valve replacement [14].
Over the last decades, transcatheter aortic valve replacement has gained signicant popularity, and the encouraging outcomes led the
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increase of transcatheter procedures [15]. Despite developments, recommended technique for asymptomatic severe aortic stenosis is still the surgical aortic valve replacement.
Evaluation of whether the transcatheter aortic valve replacement should be done in patients with asymptomatic aortic stenosis, a prospective randomized controlled multicenter trial, was started in 2017. The evaluation of transcatheter aortic valve replacement compared to surveil­lance for patients with asymptomatic severe aor­tic stenosis (EARLY TAVR) trial evaluates whether there is benet from transcatheter aortic valve replacement before patients become symp­tomatic (such as dyspnea, dizziness, fainting or angina pectoris). Similar studies may provide a direct guideline about the management of asymp­tomatic severe aortic stenosis.
30.4.2 Aortic Valve Regurgitation
Patients with aortic insufciency are usually symptom-free for a long time. However, the increase in left ventricle diameter continues grad­ually as the disease progresses. In most patients, degree of aortic regurgitation increases slowly. In this way, it causes left ventricle to adapt the pres­sure changes by increasing its end-diastolic vol­ume and resulting eccentric hypertrophy in the LV wall.
Progressive aortic insufciency eventually results in ventricular dysfunction, cardiomegaly and decrease of LV ejection fraction. When patients become symptomatic, expected mortal­ity would not be more than 4years. Aortic valve replacement should be planned before the ven­tricular functions begin to deteriorate and decrease the ejection fraction.
According to AHA/ACC and ESC/EACTS guidelines, aortic valve replacement is recom­mended in asymptomatic patients with chronic severe regurgitation and LV ejection fraction less than 50% [12, 16].
Aortic valve replacement should be consid­ered in asymptomatic patients with chronic severe regurgitation and LV ejection fraction greater than 50% in the presence of severe LV
dilatation (LV end-systolic diameter >50 mm). Absence of symptoms with severe aortic regurgi­tation with normal LV systolic function and pro­gressive severe LV dilation (LV end-diastolic diameter >65mm) is another reasonable indica­tion of surgery.
30.4.3 Mitral Valve Regurgitation
Mitral regurgitation is the most common valvular pathology in the North America and the second most common in Europe, necessitating surgical correction. It can be due to primary abnormalities of mitral valve (mitral annulus, anterior and pos­terior mitral valve leaets, chorda tendinea) or secondary to LV dysfunction (functional or isch­emic) (Fig. 30.5). Chronic mitral regurgitation causes LV enlargement and deterioration in the LV functions [17].
The severity of mitral valve pathology is esti­mated according to echocardiographic ndings. Patients with severe, chronic mitral regurgitation may remain symptom-free for a long time. When compensatory mechanisms fail, symptoms of heart failure start to arise.
In patients with asymptomatic mitral regurgi­tation, on medical therapy, 5-year mortality is above 20% [18]. However, mitral valve surgery is associated with higher survival rates. In asymp­tomatic patients with preserved cardiac func­tions, severe mitral regurgitation will cause need
Fig. 30.5 Rupture of chorda tendinea is among common causes of mitral regurgitation
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of a surgical intervention within less than 10years.
Mitral valve surgery is indicated in asymp­tomatic patients with LV dysfunction (LV ejec­tion fraction <60% and/or LV end-systolic dimension >40mm). Mitral valve reconstruction is advised in asymptomatic patients with chronic severe primary mitral regurgitation due to ail leaet and preserved LV systolic function, sig­nicant LA dilatation and presence of sinus rhythm.
In asymptomatic patients, mitral valve repair is reasonable if new onset atrial brillation or resting pulmonary hypertension exists (systolic pulmonary pressure at rest >50mmHg) [13, 19]. Long-term survival of the patients treated with the nonsurgical approach was considerably lower compared with the group of patients who were treated with early surgical approach [20]. Especially in experienced hands, mitral valve repair has good success rates, with low-operative mortality. If the pathology is an isolated posterior mitral valve prolapse, success rates are even higher.
30.4.5 Tricuspid Valve Regurgitation
Tricuspid regurgitation is mostly seen as a sec­ondary to right ventricular dysfunction with increased volume and pressure load. Besides, left-sided pathologies can also cause tricuspid regurgitation by putting pressure loads on the right side of the heart, leading to the right ven­tricular and tricuspid annular dilatation. Increased right atrial pressures may cause hepatic conges­tion, ascites and pretibial edema. Most of the conditions, leaets of the valve are anatomically normal [21].
The timing of the surgical intervention is criti­cal. In severe primary tricuspid regurgitation, if the progressive right ventricular enlargement or deterioration of the right ventricular function is detected, surgical intervention should be carried out in asymptomatic patients. A delay in surgical timing may cause permanent right ventricular dysfunctions, leading to suboptimal surgical out­comes. As a surgical technique, tricuspid valve repair with ring annuloplasty is considered supe­rior to valve replacement (Fig.30.6) [22].
30.4.4 Mitral Valve Stenosis
The most common cause of mitral stenosis is acute rheumatic fever. Despite being less com­mon, degenerative or congenital etiology is also seen.
In mitral valve stenosis, patients with moder­ate to severe stenosis (mitral valve area <1.5cm require for percutaneous or surgical therapy. Percutaneous mitral commissurotomy is consid­ered as the appropriate choice in most symptom­atic patients in the presence of appropriate anatomy. In asymptomatic patients, surgery is restricted to those at higher risk for cardiac com­plications (systemic embolism or hemodynamic decompensation) who have contraindications for percutaneous mitral commissurotomy (i.e., left atrial thrombus) and to those having low risk for surgery. For the most part, surgical method is the replacement of the mitral valve.
2
)
30.4.6 Tricuspid Valve Stenosis
Among other valvular pathologies, tricuspid ste­nosis is rarely seen. Most of the time, it is accom­panied by another mitral valve disorder,
Fig. 30.6 Tricuspid ring annuloplasty for severe tricus­pid regurgitation
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particularly in patients with rheumatic heart dis­ease. Some other etiologic factors are congenital, right atrial tumors, endomyocardial brosis and carcinoid syndrome [23].
30.5 Cardiac Tumors
Cardiac tumors can be seen either primarily or secondarily. Primary cardiac tumors are classi­ed as benign and malignant tumors. Approximately, 3/4 of primary tumors are benign. Almost half of the benign tumors are atrial myxomas, and about 75% of the malignant tumors are sarcomas [24]. The most common primary tumor in children is known as the rhabdomyosarcoma.
30.5.1 Myxoma
Myxoma is the most common primary cardiac tumor in adults. Most of them originates from the left atrium, secondly from the right atrium [25]. Most popular clinical pictures are intracardiac obstruction (mostly mitral orice) with conges­tive heart failure, peripheral embolization, fever, fatigue or weight loss [26]. Surgical resection is the only effective option for patients with cardiac myxoma and should be accomplished as soon as possible before deadly complications occur (Fig.30.7).
In few patients, myxoma can be diagnosed incidentally on routine echocardiography with­out any symptoms and signs associated with it. The medical history may not reveal any event of cerebrovascular infarct, syncope or shortness of breath, suggestive of obstruction or embolism. It is realistic to decide an urgent surgery in asymp­tomatic atrial myxoma. During the operation, careful attention should be made to avoid manip­ulation of the heart to prevent arise emboli from myxoma. The tumor should be excised com­pletely. Most of the patients continue living their normal lives without symptoms. Despite the recurrence very rare, repeated echocardiographic evaluation is useful to detect development of a repeated myxoma.
30.5.2 Papillary Fibroelastoma
Papillary broelastoma of the heart valve is the second most common cardiac tumor (approxi­mately <10% of all), which is usually diagnosed in postmortem examination. With the increased use of echocardiography, papillary broelastoma can be diagnosed incidentally on routine cardiac examination. Despite the benign nature, high incidence of systemic embolization and obstruc­tive complications (i.e., coronary ostial compli­cations) warrants surgical resection in large tumors [27].
Fig. 30.7 Surgical excision of huge left atrial myxoma
30.5.3 Rhabdomyoma
Rhabdomyoma is the most common cardiac tumor in children and often seen in newborn. More than half of the cases are associated with tuberous sclerosis. It can be located in both of the ventricles and often tends to be multiple [28]. Obstruction of valvular orice or intraventricular chamber and resulting heart failure is the main, most common complication. If patient is asymp­tomatic and is not diagnosed with tuberous scle­rosis, prompt surgical intervention must be applied during the rst year of life. When symp­toms arise, it can be understood that the tumor is
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usually disseminated, and the rate of surgical success is unfortunately very low.
30.6 Other Cardiac Diseases
30.6.1 Cardiac Hydatid Cyst
Hydatid cyst is an endemic parasitic infection, typically seen in rural areas. However, parasitic infection of the cardiac structures by Echinococcus granulosus is not common [29]. The diagnosis can be challenging, since the signs can be unpre­dictable. The clinical course can vary from asymptomatic to sudden death, depending on the part of the affected body and the dimension of the cyst. First rule of the diagnosis is to anticipate the cardiac hydatidosis, especially in endemic regions. The mostly involved part of the heart is the LV myocardium [30].
It can be diagnosed incidentally by routine diagnostic tools, such as chest X-ray, ECG, echo­cardiography or computed tomography. The most recommended treatment of cardiac hydatid cyst is total excision and plication of cyst cavity (Fig.30.8). Surgical intervention should be per­formed, including asymptomatic patients, as soon as possible, since the follow up with medi­cal therapy cannot prevent rupture of the cyst and its catastrophic complications (rupture, tampon­ade, systemic anaphylaxis, embolization, low cardiac output syndrome).
30.7 Aortic Diseases
30.7.1 Aortic Dissection
Basic denition of aortic dissection, mainly due to hypertension and aortic wall structural anoma­lies, is the separation of tunica media from tunica intima caused by a tear in the aortic wall and mis­direction of blood ow toward the tear. Natural course of the disease depends on the localization. For Stanford type B aortic dissections, which start from the aortic zone distal to the left subcla­vian artery, surgery is limited to certain circum­stances, such as malperfusion, acute dilatation and rupture; whereas, Stanford type A aortic dis­section, which starts from the ascending aorta, always requires an emergent operation [31]. Dissections involving ascending aorta are at high risk for rupture, cardiac tamponade, acute aortic valve insufciency, acute myocardial infarction and malperfusion when left unoperated. Indicatively, half of these patients die within the rst 48h and 80% in the rst week [32]. Patients usually present with acute severe chest pain or back pain, and sometimes the symptoms of mal­perfusion, can be present. Rarely, the patients may remain asymptomatic, surviving the acute phase, which lead to chronic aortic dissection and related aneurysms. Surgery should be performed, especially aneurysms with increased diameters to prevent rupture, and eventually, the death.
30.7.2 Proximal Aortic Aneurysms
Some pathologies of the proximal aorta can have an asymptomatic clinical course. Among these, main group includes aneurysms of the ascending aorta and arcus aorta. Majority has a silent course, which results in sudden death due to rupture and cardiac tamponade. The most important factor for prediction of the rupture risk is the diameter of the aneurysm. Rupture risk begins when diam­eter reaches 5cm and above. It becomes apparent with the diameters over 5.5–6cm and above [33].
Fig. 30.8 Surgical removal of left ventricular hydatid cyst
Chronic obstructive pulmonary disease, smok-
ing, uncontrolled hypertension, renal failure and
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aba
Fig. 30.9 (a) Operative views of ascending aortic aneurysm. (b) Surgical repair of ascending aortic aneurysm with Dacron graft and coronary ostial implantation
b
aortic structural diseases (i.e., Marfan syndrome) are the other risk factors for rupture [34].
Patients may experience chest pain or dyspnea due to concomitant aortic valve pathologies or may remain asymptomatic. Patients should be followed up according to the ascending aortic diameter, which when reaches to certain levels, should be operated immediately to prevent rup­ture, even an asymptomatic clinical course is present. The current gold standard treatment for ascending aorta and arcus pathologies is the open surgical approach (Fig.30.9a, b). However, there are limited series studies with endovascular techniques.
30.7.3 Distal Aortic Aneurysms
Thoracoabdominal aortic aneurysms form an important part of distal aortic aneurysms. These pathologies are complex and challenging for sur­geons. These patients tend to have multiple risk factors, operative mortality and morbidity.
These aneurysms may originate anywhere in the descending aorta distal to the left subclavian artery and involve different levels of abdominal. From surgical point of view, it may be necessary to open both thorax and abdomen (Fig.30.10). As the aneurysm involves more structures on differ­ent levels of the aorta, more intercostal, lumbar and visceral branches arise from the aneurysm, and duration of operation extends, risking of isch­emic injury of relevant tissue and organs.
While investigating natural course of distal aortic aneurysms, it is shown that 2-year survival rate of the patients who are treated medically was only at 24% [35]. These are the patients who were followed up with medical treatment due to various impediments for the surgery. Mostly, the patients die from the rupture of the aneurysm sac and hemorrhagic shock that follows. In a recent trial, critical threshold for rupture was found to be 6cm for thoracoabdominal aortic aneurysms and 6.5 cm for descending aortic aneurysms. However, dissection may occur in smaller diameters [36].
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Fig. 30.10 Thoracoabdominal aortic aneurysm repair via thoracoabdominal incision
Abdominal aortic aneurysms are the most common type of aortic aneurysms. For asymp­tomatic patients, surgical repair is the standard approach to prevent rupture. Elective abdominal aortic surgery is recommended when the risk of rupture exceeds the risk of surgical intervention. Generally, the risk of aneurysm rupture surpasses the risk related with surgical repair when aneu­rysm diameter becomes 5.5 cm and above. Surgical repair of asymptomatic abdominal aor­tic aneurysm is frequently indicated when diam­eter exceeds 5.5cm [37]. Currently, there are two techniques for abdominal aortic aneurysm repair. These are open repair and the abdominal endo­vascular aneurysm repair (EVAR) (Fig.30.11).
Similar to type B dissections and descending aortic aneurysms, endovascular repair superseded open surgery in abdominal aortic aneurysms. Randomized trials showed the EVAR superiority over open surgery, especially in the early outcomes. Furthermore, blood loss, cardiopulmonary compli­cation rates, hospital stay and periprocedural risk are lower with EVAR technique than open surgery [38]. However, there is no difference for long-term complications, long- term survival rates between EVAR and open surgical approach [39].
367
Fig. 30.11 Operative view of abdominal aortic aneurysm
30.7.4 Femoral andPopliteal Artery Aneurysm
Femoral aneurysms are usually pseudoaneu­rysms, whereas the popliteal aneurysms are gen­erally degenerative true aneurysms. The femoropopliteal aneurysm should be investigated in patients with aneurysm in the aortoiliac seg­ment. The association of femoral aneurysm with abdominal aneurysms has been reported as 50–90%, and in popliteal aneurysm around 30–50%. Femoral true aneurysms are generally having an asymptomatic clinical course. As the aneurysm sac grows, the symptoms may arise. Leg ischemia due to embolism and symptoms of compression can be seen. Obstructive symptoms, including compression of the nerves, adjacent venous obstruction and thromboembolism, can induce ischemic symptoms. Large and thrombus­containing asymptomatic popliteal and femoral aneurysms should be treated surgically or inter­ventionally to prevent further ischemic complications.
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30.7.5 Popliteal Entrapment Syndrome
Popliteal entrapment syndrome involves an abnormal relationship between the popliteal artery and the medial head of the gastrocnemius muscle [40]. The sudden onset of symptoms is more commonly seen than slow progressing claudication. Symptoms usually can arise as a result of a heavy exercise. Some patients remain asymptomatic until an acute occlusion of the popliteal artery develops or until thromboem­bolic complications arise due to post-stenotic dilatation. Muscle resection and relief the decom­pression of the popliteal artery provides the nec­essary healing.
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Prophylactic Chest Surgery Procedures
31
İrfanYalçınkaya andMahmutTalhaDoğruyol
31.1 Introduction
Prophylactic surgery is generally used to describe the process of minimizing the risk of cancer by surgically removing a tissue or organ with the potential to develop a tumor. Thus, the surgical intervention to benign or premalignant lesions with the potential to develop malignancy or exci­sion of a pathological structure before it gets complicated also falls into this category. Prophylactic surgery, commonly used for heredi­tary breast or ovarian cancer, is not an unfamiliar denition for thoracic surgery. This surgery option has been used for many years in bulla with the potential to complicate into a pneumothorax or tuberculosis sequelae, which may become complicated. The list can be further expanded with congenital malformations or excision of a premalignant lesion with the potential to develop malignancy within the thorax. The present study aimed to discuss the prophylactic surgical proce­dures regarding chest surgery. Prophylactic sur­gical procedures in the eld of chest surgery can
İ. Yalçınkaya (*) Department of Thoracic Surgery, Health Science University, Süreyyapaşa Chest Disease and Chest Surgery, Research and Training Hospital, İstanbul, Turkey e-mail: irfan.yalcinkaya@saglik.gov.tr
M. T. Doğruyol Department of Thoracic Surgery, Manisa City Hospital, Manisa, Turkey e-mail: talha.dogruyol@saglik.gov.tr
be classied into two categories: benign patholo­gies and precancerous pathologies.
31.2 Benign Pathologies
In general, the morbidity and mortality of an elective surgical procedure are always lower than those of emergency surgery. Therefore, surgical interventions, planned for pathologies likely to be complicated, have been generally accepted among thoracic surgeons, as these interventions can be lifesaving. The prophylactic surgery indi­cations for benign pathologies that are reported in the literature are mentioned under this title. Thus, prophylactic surgery application is reported in several special benign conditions.
31.2.1 Pneumothorax
Surgery is indicated if a complication, such as prolonged air leak or hemothorax, develops in the rst episode of pneumothorax. However, occupa­tional risks, such as aircraft personnel or divers, being in isolated areas away from medical insti­tutions, and psychological reasons, indicate pro­phylactic surgery [1]. If no surgery is performed, the chance of recurrence is up to 75% within 5years after the rst episode; however, this rate increases to 83% after the second episode [1, 2]. It is reported in the literature that 10–20% recur­rence is possible in those who undergo only
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_31
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