Sharon Worcester

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

Annual mammography in women aged 40 to 59 years was no more effective than was physical examination or usual care for reducing breast cancer mortality when adjuvant therapy for breast cancer is readily available, according to 25-year findings from the Canadian National Breast Screening Study.

During a 5-year screening period beginning in 1980, 666 invasive breast cancers were detected in 44,925 women randomized to receive annual mammography and annual physical breast examinations, and 524 were detected in 44,910 women randomized to receive a single physical breast examination followed by usual care in the community. Of these, 180 and 171 in the mammography and control arms, respectively, died of breast cancer during up to 25 years of follow-up (mean of 22 years), Dr. Anthony B. Miller of the University of Toronto, and his colleagues reported.

The 25-year cumulative mortality from breast cancer detected during the screening period was similar between the women in the mammography arm and the control arm (hazard ratio, 1.05), the investigators reported Feb. 11 in BMJ.

After the screening period, an additional 2,584 breast cancers were detected in the mammography arm and 2,609 in the control arm during the follow-up period. Overall, 1,005 women died from breast cancer during follow-up, including 351 who were diagnosed during the screening period.

Of the breast cancers detected in the mammography arm during the initial screening period, 484 were screen detected, 176 were interval cancers, and 6 were lacking data. The mean size of cancers diagnosed in the mammography arm was 1.91 cm vs. 2.10 cm in the control arm, they said.

"In the mammography arm, 30.6% of cancers were node positive and 68.2% were palpable. In the control arm, 32.4% of the cancers were node positive and all were palpable ...on average, palpable cancer were larger than cancers that were detected only by mammography (2.1 cm v 1.4 cm) and were more likely to be node positive (34.7% vs. 16.5%)," the investigators wrote (BMJ 2014 Feb.11;348 [doi:10.1136/bmj.g366]).

Although 25-year survival was better for those with tumors less than 2 cm vs. greater than 2 cm, those with breast cancer detected in the mammography vs. the control arm, and for those in the mammography arm with nonpalpable vs. palpable tumors (HR, 0.46, 0.79, and 0.58, respectively), the overall 25-year cumulative mortality from breast cancer was similar between women in the mammography arm and control arm, (HR, 0.99), the investigators wrote.

The findings were nearly identical for those aged 40-49 years, and those aged 50-59 years, the investigators noted.

Notably, at the end of the screening period, an excess of 142 breast cancers were detected in the mammography group, compared with the control group, and at 15 years, that excess remained at 106, implying that 22% of the screen-detected invasive cancers in the mammography arm were overdiagnosed, meaning that the cancer might not otherwise have become clinically apparent during the patient’s lifetime.

"This represents one overdiagnosed breast cancer for every 424 women who received mammography screening in the trial. Assuming that nearly all overdiagnosed cancers in the Canadian National Breast Screening Study were nonpalpable, 50% of mammogram detected, nonpalpable cancers were overdiagnosed," they said.

The Canadian National Breast Screening Study was supported by the various Canadian health agencies and advocacy groups. Dr. Miller was supported in part by a national health scientist award from Health and Welfare Canada.

Annual mammography in women aged 40 to 59 years was no more effective than was physical examination or usual care for reducing breast cancer mortality when adjuvant therapy for breast cancer is readily available, according to 25-year findings from the Canadian National Breast Screening Study.

During a 5-year screening period beginning in 1980, 666 invasive breast cancers were detected in 44,925 women randomized to receive annual mammography and annual physical breast examinations, and 524 were detected in 44,910 women randomized to receive a single physical breast examination followed by usual care in the community. Of these, 180 and 171 in the mammography and control arms, respectively, died of breast cancer during up to 25 years of follow-up (mean of 22 years), Dr. Anthony B. Miller of the University of Toronto, and his colleagues reported.

The 25-year cumulative mortality from breast cancer detected during the screening period was similar between the women in the mammography arm and the control arm (hazard ratio, 1.05), the investigators reported Feb. 11 in BMJ.

After the screening period, an additional 2,584 breast cancers were detected in the mammography arm and 2,609 in the control arm during the follow-up period. Overall, 1,005 women died from breast cancer during follow-up, including 351 who were diagnosed during the screening period.

Of the breast cancers detected in the mammography arm during the initial screening period, 484 were screen detected, 176 were interval cancers, and 6 were lacking data. The mean size of cancers diagnosed in the mammography arm was 1.91 cm vs. 2.10 cm in the control arm, they said.

"In the mammography arm, 30.6% of cancers were node positive and 68.2% were palpable. In the control arm, 32.4% of the cancers were node positive and all were palpable ...on average, palpable cancer were larger than cancers that were detected only by mammography (2.1 cm v 1.4 cm) and were more likely to be node positive (34.7% vs. 16.5%)," the investigators wrote (BMJ 2014 Feb.11;348 [doi:10.1136/bmj.g366]).

Although 25-year survival was better for those with tumors less than 2 cm vs. greater than 2 cm, those with breast cancer detected in the mammography vs. the control arm, and for those in the mammography arm with nonpalpable vs. palpable tumors (HR, 0.46, 0.79, and 0.58, respectively), the overall 25-year cumulative mortality from breast cancer was similar between women in the mammography arm and control arm, (HR, 0.99), the investigators wrote.

The findings were nearly identical for those aged 40-49 years, and those aged 50-59 years, the investigators noted.

Notably, at the end of the screening period, an excess of 142 breast cancers were detected in the mammography group, compared with the control group, and at 15 years, that excess remained at 106, implying that 22% of the screen-detected invasive cancers in the mammography arm were overdiagnosed, meaning that the cancer might not otherwise have become clinically apparent during the patient’s lifetime.

"This represents one overdiagnosed breast cancer for every 424 women who received mammography screening in the trial. Assuming that nearly all overdiagnosed cancers in the Canadian National Breast Screening Study were nonpalpable, 50% of mammogram detected, nonpalpable cancers were overdiagnosed," they said.

The Canadian National Breast Screening Study was supported by the various Canadian health agencies and advocacy groups. Dr. Miller was supported in part by a national health scientist award from Health and Welfare Canada.

Annual mammography in women aged 40 to 59 years was no more effective than was physical examination or usual care for reducing breast cancer mortality when adjuvant therapy for breast cancer is readily available, according to 25-year findings from the Canadian National Breast Screening Study.

During a 5-year screening period beginning in 1980, 666 invasive breast cancers were detected in 44,925 women randomized to receive annual mammography and annual physical breast examinations, and 524 were detected in 44,910 women randomized to receive a single physical breast examination followed by usual care in the community. Of these, 180 and 171 in the mammography and control arms, respectively, died of breast cancer during up to 25 years of follow-up (mean of 22 years), Dr. Anthony B. Miller of the University of Toronto, and his colleagues reported.

The 25-year cumulative mortality from breast cancer detected during the screening period was similar between the women in the mammography arm and the control arm (hazard ratio, 1.05), the investigators reported Feb. 11 in BMJ.

After the screening period, an additional 2,584 breast cancers were detected in the mammography arm and 2,609 in the control arm during the follow-up period. Overall, 1,005 women died from breast cancer during follow-up, including 351 who were diagnosed during the screening period.

Of the breast cancers detected in the mammography arm during the initial screening period, 484 were screen detected, 176 were interval cancers, and 6 were lacking data. The mean size of cancers diagnosed in the mammography arm was 1.91 cm vs. 2.10 cm in the control arm, they said.

"In the mammography arm, 30.6% of cancers were node positive and 68.2% were palpable. In the control arm, 32.4% of the cancers were node positive and all were palpable ...on average, palpable cancer were larger than cancers that were detected only by mammography (2.1 cm v 1.4 cm) and were more likely to be node positive (34.7% vs. 16.5%)," the investigators wrote (BMJ 2014 Feb.11;348 [doi:10.1136/bmj.g366]).

Although 25-year survival was better for those with tumors less than 2 cm vs. greater than 2 cm, those with breast cancer detected in the mammography vs. the control arm, and for those in the mammography arm with nonpalpable vs. palpable tumors (HR, 0.46, 0.79, and 0.58, respectively), the overall 25-year cumulative mortality from breast cancer was similar between women in the mammography arm and control arm, (HR, 0.99), the investigators wrote.

The findings were nearly identical for those aged 40-49 years, and those aged 50-59 years, the investigators noted.

Notably, at the end of the screening period, an excess of 142 breast cancers were detected in the mammography group, compared with the control group, and at 15 years, that excess remained at 106, implying that 22% of the screen-detected invasive cancers in the mammography arm were overdiagnosed, meaning that the cancer might not otherwise have become clinically apparent during the patient’s lifetime.

"This represents one overdiagnosed breast cancer for every 424 women who received mammography screening in the trial. Assuming that nearly all overdiagnosed cancers in the Canadian National Breast Screening Study were nonpalpable, 50% of mammogram detected, nonpalpable cancers were overdiagnosed," they said.

The Canadian National Breast Screening Study was supported by the various Canadian health agencies and advocacy groups. Dr. Miller was supported in part by a national health scientist award from Health and Welfare Canada.

ORLANDO – Age and increased lung allocation score are among factors associated with risk of lung retransplantation, according to an analysis of data from the United Network for Organ Sharing.

Of 24,194 consecutive patients who underwent lung transplantation between 1987 and 2012 and who were included in the nationwide registry, 941 (3.9%) underwent retransplantation. Age over 40 years, increased lung allocation score, increased percentage decline in forced ventilatory capacity (FVC), and readmission to the intensive care unit each were associated with retransplantation (odds ratios, 2.26, 0.98, 0.99, and 2.27, respectively), Dr. J. Awori Hayanga reported at the annual meeting of the Society of Thoracic Surgeons.

The current findings could allow for better prediction of graft failure and the need for retransplantation, and could help guide immunosuppression protocols and donor selection, he said. This is important, because although the overall volume of retransplantation remains less than 5%, the number of such procedures is steadily increasing, with up to 100 now performed each year.

"Following the introduction of the lung allocation score, the waiting time decreased, and the volume, perhaps predictably, increased by almost 60% with this increased emphasis on clinical acuity. The relative paucity of donors nevertheless engenders a considerable amount of scrutiny," Dr. Hayanga said. "Contention exists between the utilitarian view, where allocation prioritizes recipients in most need, versus the egalitarian view that seeks to provide equal opportunity to all those in need," he explained.

While this ethical argument is "tempered somewhat by steadily improving outcomes," retransplantations still remain inferior to primary transplantations, carrying a 30% overall increased risk of death. Prior to this study, the risk factors for retransplantation were poorly characterized in the literature.

The study also showed that donor factors associated with retransplantation included smoking history and body mass index less than 18.5 kg/m² (OR, 1.47 and 1.68, respectively). One transplant-related factor – increased graft ischemic time – was also associated with retransplantation (OR, 0.91), said Dr. Hayanga of the University of Pittsburgh.

Lung transplantation is a well-established therapeutic option for end-stage lung disease, but long-term outcomes are largely determined by chronic allograft failure – a diagnosis which constitutes "the most justifiable, evidence-driven indication for retransplantation," he said. Survival among patients who undergo retransplantation for this indication have nearly equivalent survival to those with a first transplant, he noted.

Conversely, "there are multiple observations in the literature of the dismal outcomes observed following retransplantation for primary graft failure and airway complications," he noted.

"We seek now to build and validate a risk scoring model to help predict the risk for chronic graft failures and for retransplantation, to enrich the dialogue, to improve immunosuppressive and selection protocols, and ultimately to provide evidence-based prognostic data," he said.

This study was funded by the Ruben J. Williams Foundation. Dr. Hayanga reported having no other disclosures.

ORLANDO – Age and increased lung allocation score are among factors associated with risk of lung retransplantation, according to an analysis of data from the United Network for Organ Sharing.

Of 24,194 consecutive patients who underwent lung transplantation between 1987 and 2012 and who were included in the nationwide registry, 941 (3.9%) underwent retransplantation. Age over 40 years, increased lung allocation score, increased percentage decline in forced ventilatory capacity (FVC), and readmission to the intensive care unit each were associated with retransplantation (odds ratios, 2.26, 0.98, 0.99, and 2.27, respectively), Dr. J. Awori Hayanga reported at the annual meeting of the Society of Thoracic Surgeons.

The current findings could allow for better prediction of graft failure and the need for retransplantation, and could help guide immunosuppression protocols and donor selection, he said. This is important, because although the overall volume of retransplantation remains less than 5%, the number of such procedures is steadily increasing, with up to 100 now performed each year.

"Following the introduction of the lung allocation score, the waiting time decreased, and the volume, perhaps predictably, increased by almost 60% with this increased emphasis on clinical acuity. The relative paucity of donors nevertheless engenders a considerable amount of scrutiny," Dr. Hayanga said. "Contention exists between the utilitarian view, where allocation prioritizes recipients in most need, versus the egalitarian view that seeks to provide equal opportunity to all those in need," he explained.

While this ethical argument is "tempered somewhat by steadily improving outcomes," retransplantations still remain inferior to primary transplantations, carrying a 30% overall increased risk of death. Prior to this study, the risk factors for retransplantation were poorly characterized in the literature.

The study also showed that donor factors associated with retransplantation included smoking history and body mass index less than 18.5 kg/m² (OR, 1.47 and 1.68, respectively). One transplant-related factor – increased graft ischemic time – was also associated with retransplantation (OR, 0.91), said Dr. Hayanga of the University of Pittsburgh.

Lung transplantation is a well-established therapeutic option for end-stage lung disease, but long-term outcomes are largely determined by chronic allograft failure – a diagnosis which constitutes "the most justifiable, evidence-driven indication for retransplantation," he said. Survival among patients who undergo retransplantation for this indication have nearly equivalent survival to those with a first transplant, he noted.

Conversely, "there are multiple observations in the literature of the dismal outcomes observed following retransplantation for primary graft failure and airway complications," he noted.

"We seek now to build and validate a risk scoring model to help predict the risk for chronic graft failures and for retransplantation, to enrich the dialogue, to improve immunosuppressive and selection protocols, and ultimately to provide evidence-based prognostic data," he said.

This study was funded by the Ruben J. Williams Foundation. Dr. Hayanga reported having no other disclosures.

ORLANDO – Age and increased lung allocation score are among factors associated with risk of lung retransplantation, according to an analysis of data from the United Network for Organ Sharing.

Of 24,194 consecutive patients who underwent lung transplantation between 1987 and 2012 and who were included in the nationwide registry, 941 (3.9%) underwent retransplantation. Age over 40 years, increased lung allocation score, increased percentage decline in forced ventilatory capacity (FVC), and readmission to the intensive care unit each were associated with retransplantation (odds ratios, 2.26, 0.98, 0.99, and 2.27, respectively), Dr. J. Awori Hayanga reported at the annual meeting of the Society of Thoracic Surgeons.

The current findings could allow for better prediction of graft failure and the need for retransplantation, and could help guide immunosuppression protocols and donor selection, he said. This is important, because although the overall volume of retransplantation remains less than 5%, the number of such procedures is steadily increasing, with up to 100 now performed each year.

"Following the introduction of the lung allocation score, the waiting time decreased, and the volume, perhaps predictably, increased by almost 60% with this increased emphasis on clinical acuity. The relative paucity of donors nevertheless engenders a considerable amount of scrutiny," Dr. Hayanga said. "Contention exists between the utilitarian view, where allocation prioritizes recipients in most need, versus the egalitarian view that seeks to provide equal opportunity to all those in need," he explained.

While this ethical argument is "tempered somewhat by steadily improving outcomes," retransplantations still remain inferior to primary transplantations, carrying a 30% overall increased risk of death. Prior to this study, the risk factors for retransplantation were poorly characterized in the literature.

The study also showed that donor factors associated with retransplantation included smoking history and body mass index less than 18.5 kg/m² (OR, 1.47 and 1.68, respectively). One transplant-related factor – increased graft ischemic time – was also associated with retransplantation (OR, 0.91), said Dr. Hayanga of the University of Pittsburgh.

Lung transplantation is a well-established therapeutic option for end-stage lung disease, but long-term outcomes are largely determined by chronic allograft failure – a diagnosis which constitutes "the most justifiable, evidence-driven indication for retransplantation," he said. Survival among patients who undergo retransplantation for this indication have nearly equivalent survival to those with a first transplant, he noted.

Conversely, "there are multiple observations in the literature of the dismal outcomes observed following retransplantation for primary graft failure and airway complications," he noted.

"We seek now to build and validate a risk scoring model to help predict the risk for chronic graft failures and for retransplantation, to enrich the dialogue, to improve immunosuppressive and selection protocols, and ultimately to provide evidence-based prognostic data," he said.

This study was funded by the Ruben J. Williams Foundation. Dr. Hayanga reported having no other disclosures.

ORLANDO – Survival following repeat lung transplantation is similar to survival following initial lung transplantation when performed at least 90 days after the initial transplant, according to a review of data from the United Network for Organ Sharing registry.

However, survival in those retransplanted within 90 days of the primary transplant is severely diminished, Asishana A. Osho, a fourth-year medical student at Duke University, Durham, N.C., reported at the annual meeting of the Society of Thoracic Surgeons.

The outcomes of 9,270 primary lung transplant cases and 456 retransplant cases performed since implementation of the lung allocation score (LAS) show that overall 5-year survival was significantly better in the primary transplant patients (hazard ratio, 1.69). However, after 1:1 propensity matching, 5-year survival was similar for 429 primary transplant and 429 retransplant patients (HR, 1.01), and between 392 primary transplant patients and 392 matched late (after 90 days) retransplant patients (HR, 1.23).

Conversely, 5-year survival was significantly reduced for 51 early (within 90 days) retransplant patients, compared with 51 matched primary transplant patients (HR, 1.38), Mr. Osho said.

Patients included in the study were participants in the UNOS registry. The median age of those in the primary transplant group was 58 years, compared with 62 years for the early retransplantation group and 47 for the late retransplantation group. The median LAS were 38.9, 88.3, and 45.8 for the groups, respectively.

Bilateral transplantation was performed in 66.5% of cases.

The findings provide new information about the effects of retransplantation timing and have potential implications for clinical decision making, Mr. Osho said.

The frequency of lung retransplantation has increased over the past several years, probably because of the implementation of the LAS, and this increase has also been accompanied by an increase in survival among those undergoing a repeat transplantation, as is apparent when comparing survival curves before and after 2005, he noted.

The current results, however, show that the survival is diminished with early retransplantation. Patients also generally did worse if they were treated in the ICU before transplant, if they had a single vs. double lung transplant, or if they received the transplant for primary graft dysfunction vs. for bronchiolitis obliterans.

The diminished survival among those undergoing early retransplantation may be related to the stress of having two major procedures in close proximity, Mr. Osho said.

"An additional consideration is that patients who do poorly shortly after the first transplant may have certain traits that predispose them to doing poorly with subsequent procedures," he said.

Though limited by the fact that only patients who ultimately received lungs were included, and by the retrospective design (a factor somewhat mitigated by the use of propensity matching), the findings identify factors, including admission status, type of treatment, and transplant diagnosis that clinicians should be cognizant of before performing retransplantation, and they suggest that the utility of early repeat transplantation requires further examination, he concluded.

Mr. Osho reporting having no disclosures.

ORLANDO – Survival following repeat lung transplantation is similar to survival following initial lung transplantation when performed at least 90 days after the initial transplant, according to a review of data from the United Network for Organ Sharing registry.

However, survival in those retransplanted within 90 days of the primary transplant is severely diminished, Asishana A. Osho, a fourth-year medical student at Duke University, Durham, N.C., reported at the annual meeting of the Society of Thoracic Surgeons.

The outcomes of 9,270 primary lung transplant cases and 456 retransplant cases performed since implementation of the lung allocation score (LAS) show that overall 5-year survival was significantly better in the primary transplant patients (hazard ratio, 1.69). However, after 1:1 propensity matching, 5-year survival was similar for 429 primary transplant and 429 retransplant patients (HR, 1.01), and between 392 primary transplant patients and 392 matched late (after 90 days) retransplant patients (HR, 1.23).

Conversely, 5-year survival was significantly reduced for 51 early (within 90 days) retransplant patients, compared with 51 matched primary transplant patients (HR, 1.38), Mr. Osho said.

Patients included in the study were participants in the UNOS registry. The median age of those in the primary transplant group was 58 years, compared with 62 years for the early retransplantation group and 47 for the late retransplantation group. The median LAS were 38.9, 88.3, and 45.8 for the groups, respectively.

Bilateral transplantation was performed in 66.5% of cases.

The findings provide new information about the effects of retransplantation timing and have potential implications for clinical decision making, Mr. Osho said.

The frequency of lung retransplantation has increased over the past several years, probably because of the implementation of the LAS, and this increase has also been accompanied by an increase in survival among those undergoing a repeat transplantation, as is apparent when comparing survival curves before and after 2005, he noted.

The current results, however, show that the survival is diminished with early retransplantation. Patients also generally did worse if they were treated in the ICU before transplant, if they had a single vs. double lung transplant, or if they received the transplant for primary graft dysfunction vs. for bronchiolitis obliterans.

The diminished survival among those undergoing early retransplantation may be related to the stress of having two major procedures in close proximity, Mr. Osho said.

"An additional consideration is that patients who do poorly shortly after the first transplant may have certain traits that predispose them to doing poorly with subsequent procedures," he said.

Though limited by the fact that only patients who ultimately received lungs were included, and by the retrospective design (a factor somewhat mitigated by the use of propensity matching), the findings identify factors, including admission status, type of treatment, and transplant diagnosis that clinicians should be cognizant of before performing retransplantation, and they suggest that the utility of early repeat transplantation requires further examination, he concluded.

Mr. Osho reporting having no disclosures.

ORLANDO – Survival following repeat lung transplantation is similar to survival following initial lung transplantation when performed at least 90 days after the initial transplant, according to a review of data from the United Network for Organ Sharing registry.

However, survival in those retransplanted within 90 days of the primary transplant is severely diminished, Asishana A. Osho, a fourth-year medical student at Duke University, Durham, N.C., reported at the annual meeting of the Society of Thoracic Surgeons.

The outcomes of 9,270 primary lung transplant cases and 456 retransplant cases performed since implementation of the lung allocation score (LAS) show that overall 5-year survival was significantly better in the primary transplant patients (hazard ratio, 1.69). However, after 1:1 propensity matching, 5-year survival was similar for 429 primary transplant and 429 retransplant patients (HR, 1.01), and between 392 primary transplant patients and 392 matched late (after 90 days) retransplant patients (HR, 1.23).

Conversely, 5-year survival was significantly reduced for 51 early (within 90 days) retransplant patients, compared with 51 matched primary transplant patients (HR, 1.38), Mr. Osho said.

Patients included in the study were participants in the UNOS registry. The median age of those in the primary transplant group was 58 years, compared with 62 years for the early retransplantation group and 47 for the late retransplantation group. The median LAS were 38.9, 88.3, and 45.8 for the groups, respectively.

Bilateral transplantation was performed in 66.5% of cases.

The findings provide new information about the effects of retransplantation timing and have potential implications for clinical decision making, Mr. Osho said.

The frequency of lung retransplantation has increased over the past several years, probably because of the implementation of the LAS, and this increase has also been accompanied by an increase in survival among those undergoing a repeat transplantation, as is apparent when comparing survival curves before and after 2005, he noted.

The current results, however, show that the survival is diminished with early retransplantation. Patients also generally did worse if they were treated in the ICU before transplant, if they had a single vs. double lung transplant, or if they received the transplant for primary graft dysfunction vs. for bronchiolitis obliterans.

The diminished survival among those undergoing early retransplantation may be related to the stress of having two major procedures in close proximity, Mr. Osho said.

"An additional consideration is that patients who do poorly shortly after the first transplant may have certain traits that predispose them to doing poorly with subsequent procedures," he said.

Though limited by the fact that only patients who ultimately received lungs were included, and by the retrospective design (a factor somewhat mitigated by the use of propensity matching), the findings identify factors, including admission status, type of treatment, and transplant diagnosis that clinicians should be cognizant of before performing retransplantation, and they suggest that the utility of early repeat transplantation requires further examination, he concluded.

Mr. Osho reporting having no disclosures.

ORLANDO – Tumor response nodes obtained from patients who undergo esophagectomy for early-stage adenocarcinoma provide valuable prognostic information, according to Dr. Dylan Nieman.

Such nodes – lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells – may mark the prior spread of tumor, and should be counted as positive, Dr. Nieman of the University of Rochester (N.Y.) said at the annual meeting of the Society of Thoracic Surgeons.

The current practice of ignoring these nodes likely results in systematic pathologic understaging, he explained.

In 90 patients who underwent esophagectomy after neoadjuvant therapy for esophageal adenocarcinoma, the median number of nodes found per resection specimen was 18. A total of 100 tumor response nodes without viable malignant cells were identified in 38 (42%) of the patients.

The majority of the patients with treatment response nodes had only one node detected, Dr. Nieman said.

The median survival for the entire cohort was 55.6 months, and the 5-year survival was 35%. The median survival of patients with evidence of treatment response nodes was poorer, but not significantly different from those without treatment response nodes (45.9 vs. 55.6 months), he noted.

"However, for a subset of 62 patients classified as having limited or no nodal involvement – that is, AJCC N0 or N1 – the presence of treatment response nodes was associated with significantly poorer survival. This effect remained when adjusting for patient age and [American Joint Committee on Cancer] stage (hazard ratio, 2.7)," he said.

In a subset of 46 patients with pathologic AJCC stage 2B or less, the presence of treatment response nodes was still associated with poorer survival, even after adjustment for age and AJCC stage.

"To look at this a different way, if tumor response nodes were to be counted as positive, the nodal status of 29 of these patients would be upstaged. This includes 18 of 39 patients, or 46%, who were classified as node negative, and 8 of 23 patients, or 34%, who were classified as N1 by AJCC pathological assessment," he said.

The recategorization of those 29 patients resulted in better survival for the entire group, but particularly for those in the lowest-stage group, he noted.

When investigators modeled stage-adjusted survival, the counting of tumor response nodes as positive offered a better model fit, compared with following the current practice of ignoring tumor response nodes, he explained.

Patients included in the study were identified from a prospectively collected clinical database of esophagectomy patients, and were treated with neoadjuvant therapy for esophageal adenocarcinoma between 2006 and 2011. Most (82 of 90) were men. The patients had a mean age of 62 years, and were followed for a median of 27 months. Forty patients received preoperative chemotherapy, and 50 received preoperative chemoradiation.

In all cases, pathologic resection margins were negative.

On pathologic review, the majority had T3 tumors. More than 40% were staged as node negative, and more than two-thirds were staged with N0 or N1 disease.

"Prior to neoadjuvant therapy, all of these patients were clinically staged stage 2 or stage 3, but at the time of resection after neoadjuvant therapy, by AJCC staging, 24% of the patients were stage 0 or 1, 27% were stage 2, and almost half were stage 3," he said.

The findings are notable, because the current AJCC pathologic staging for esophageal adenocarcinoma is derived from the experience of patients undergoing esophagectomy alone. This approach has unclear relevance in patients who receive multimodality therapy, which has supplanted primary surgery as the standard of care for locoregionally advanced esophageal adenocarcinoma, he said.

"Future efforts at revising the staging system for esophageal adenocarcinoma should consider treatment response lymph nodes. ... We currently have pathological staging models that are of limited usefulness for our neoadjuvantly treated population. Perhaps consideration of these nodes can help improve that," he concluded.

Dr. Nieman reported having no financial disclosures.

tsnews@frontlinemedcom.com

ORLANDO – Tumor response nodes obtained from patients who undergo esophagectomy for early-stage adenocarcinoma provide valuable prognostic information, according to Dr. Dylan Nieman.

Such nodes – lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells – may mark the prior spread of tumor, and should be counted as positive, Dr. Nieman of the University of Rochester (N.Y.) said at the annual meeting of the Society of Thoracic Surgeons.

The current practice of ignoring these nodes likely results in systematic pathologic understaging, he explained.

In 90 patients who underwent esophagectomy after neoadjuvant therapy for esophageal adenocarcinoma, the median number of nodes found per resection specimen was 18. A total of 100 tumor response nodes without viable malignant cells were identified in 38 (42%) of the patients.

The majority of the patients with treatment response nodes had only one node detected, Dr. Nieman said.

The median survival for the entire cohort was 55.6 months, and the 5-year survival was 35%. The median survival of patients with evidence of treatment response nodes was poorer, but not significantly different from those without treatment response nodes (45.9 vs. 55.6 months), he noted.

"However, for a subset of 62 patients classified as having limited or no nodal involvement – that is, AJCC N0 or N1 – the presence of treatment response nodes was associated with significantly poorer survival. This effect remained when adjusting for patient age and [American Joint Committee on Cancer] stage (hazard ratio, 2.7)," he said.

In a subset of 46 patients with pathologic AJCC stage 2B or less, the presence of treatment response nodes was still associated with poorer survival, even after adjustment for age and AJCC stage.

"To look at this a different way, if tumor response nodes were to be counted as positive, the nodal status of 29 of these patients would be upstaged. This includes 18 of 39 patients, or 46%, who were classified as node negative, and 8 of 23 patients, or 34%, who were classified as N1 by AJCC pathological assessment," he said.

The recategorization of those 29 patients resulted in better survival for the entire group, but particularly for those in the lowest-stage group, he noted.

When investigators modeled stage-adjusted survival, the counting of tumor response nodes as positive offered a better model fit, compared with following the current practice of ignoring tumor response nodes, he explained.

Patients included in the study were identified from a prospectively collected clinical database of esophagectomy patients, and were treated with neoadjuvant therapy for esophageal adenocarcinoma between 2006 and 2011. Most (82 of 90) were men. The patients had a mean age of 62 years, and were followed for a median of 27 months. Forty patients received preoperative chemotherapy, and 50 received preoperative chemoradiation.

In all cases, pathologic resection margins were negative.

On pathologic review, the majority had T3 tumors. More than 40% were staged as node negative, and more than two-thirds were staged with N0 or N1 disease.

"Prior to neoadjuvant therapy, all of these patients were clinically staged stage 2 or stage 3, but at the time of resection after neoadjuvant therapy, by AJCC staging, 24% of the patients were stage 0 or 1, 27% were stage 2, and almost half were stage 3," he said.

The findings are notable, because the current AJCC pathologic staging for esophageal adenocarcinoma is derived from the experience of patients undergoing esophagectomy alone. This approach has unclear relevance in patients who receive multimodality therapy, which has supplanted primary surgery as the standard of care for locoregionally advanced esophageal adenocarcinoma, he said.

"Future efforts at revising the staging system for esophageal adenocarcinoma should consider treatment response lymph nodes. ... We currently have pathological staging models that are of limited usefulness for our neoadjuvantly treated population. Perhaps consideration of these nodes can help improve that," he concluded.

Dr. Nieman reported having no financial disclosures.

tsnews@frontlinemedcom.com

ORLANDO – Tumor response nodes obtained from patients who undergo esophagectomy for early-stage adenocarcinoma provide valuable prognostic information, according to Dr. Dylan Nieman.

Such nodes – lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells – may mark the prior spread of tumor, and should be counted as positive, Dr. Nieman of the University of Rochester (N.Y.) said at the annual meeting of the Society of Thoracic Surgeons.

The current practice of ignoring these nodes likely results in systematic pathologic understaging, he explained.

In 90 patients who underwent esophagectomy after neoadjuvant therapy for esophageal adenocarcinoma, the median number of nodes found per resection specimen was 18. A total of 100 tumor response nodes without viable malignant cells were identified in 38 (42%) of the patients.

The majority of the patients with treatment response nodes had only one node detected, Dr. Nieman said.

The median survival for the entire cohort was 55.6 months, and the 5-year survival was 35%. The median survival of patients with evidence of treatment response nodes was poorer, but not significantly different from those without treatment response nodes (45.9 vs. 55.6 months), he noted.

"However, for a subset of 62 patients classified as having limited or no nodal involvement – that is, AJCC N0 or N1 – the presence of treatment response nodes was associated with significantly poorer survival. This effect remained when adjusting for patient age and [American Joint Committee on Cancer] stage (hazard ratio, 2.7)," he said.

In a subset of 46 patients with pathologic AJCC stage 2B or less, the presence of treatment response nodes was still associated with poorer survival, even after adjustment for age and AJCC stage.

"To look at this a different way, if tumor response nodes were to be counted as positive, the nodal status of 29 of these patients would be upstaged. This includes 18 of 39 patients, or 46%, who were classified as node negative, and 8 of 23 patients, or 34%, who were classified as N1 by AJCC pathological assessment," he said.

The recategorization of those 29 patients resulted in better survival for the entire group, but particularly for those in the lowest-stage group, he noted.

When investigators modeled stage-adjusted survival, the counting of tumor response nodes as positive offered a better model fit, compared with following the current practice of ignoring tumor response nodes, he explained.

Patients included in the study were identified from a prospectively collected clinical database of esophagectomy patients, and were treated with neoadjuvant therapy for esophageal adenocarcinoma between 2006 and 2011. Most (82 of 90) were men. The patients had a mean age of 62 years, and were followed for a median of 27 months. Forty patients received preoperative chemotherapy, and 50 received preoperative chemoradiation.

In all cases, pathologic resection margins were negative.

On pathologic review, the majority had T3 tumors. More than 40% were staged as node negative, and more than two-thirds were staged with N0 or N1 disease.

"Prior to neoadjuvant therapy, all of these patients were clinically staged stage 2 or stage 3, but at the time of resection after neoadjuvant therapy, by AJCC staging, 24% of the patients were stage 0 or 1, 27% were stage 2, and almost half were stage 3," he said.

The findings are notable, because the current AJCC pathologic staging for esophageal adenocarcinoma is derived from the experience of patients undergoing esophagectomy alone. This approach has unclear relevance in patients who receive multimodality therapy, which has supplanted primary surgery as the standard of care for locoregionally advanced esophageal adenocarcinoma, he said.

"Future efforts at revising the staging system for esophageal adenocarcinoma should consider treatment response lymph nodes. ... We currently have pathological staging models that are of limited usefulness for our neoadjuvantly treated population. Perhaps consideration of these nodes can help improve that," he concluded.

Dr. Nieman reported having no financial disclosures.

tsnews@frontlinemedcom.com

ORLANDO – Tumor response nodes obtained from patients who undergo esophagectomy for early-stage adenocarcinoma provide valuable prognostic information, according to Dr. Dylan Nieman.

Such nodes – lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells – may mark the prior spread of tumor, and should be counted as positive, Dr. Nieman of the University of Rochester (N.Y.) said at the annual meeting of the Society of Thoracic Surgeons.

The current practice of ignoring these nodes likely results in systematic pathologic understaging, he explained.

In 90 patients who underwent esophagectomy after neoadjuvant therapy for esophageal adenocarcinoma, the median number of nodes found per resection specimen was 18. A total of 100 tumor response nodes without viable malignant cells were identified in 38 (42%) of the patients.

The majority of the patients with treatment response nodes had only one node detected, Dr. Nieman said.

The median survival for the entire cohort was 55.6 months, and the 5-year survival was 35%. The median survival of patients with evidence of treatment response nodes was poorer, but not significantly different from those without treatment response nodes (45.9 vs. 55.6 months), he noted.

"However, for a subset of 62 patients classified as having limited or no nodal involvement – that is, AJCC N0 or N1 – the presence of treatment response nodes was associated with significantly poorer survival. This effect remained when adjusting for patient age and [American Joint Committee on Cancer] stage (hazard ratio, 2.7)," he said.

In a subset of 46 patients with pathologic AJCC stage 2B or less, the presence of treatment response nodes was still associated with poorer survival, even after adjustment for age and AJCC stage.

"To look at this a different way, if tumor response nodes were to be counted as positive, the nodal status of 29 of these patients would be upstaged. This includes 18 of 39 patients, or 46%, who were classified as node negative, and 8 of 23 patients, or 34%, who were classified as N1 by AJCC pathological assessment," he said.

The recategorization of those 29 patients resulted in better survival for the entire group, but particularly for those in the lowest-stage group, he noted.

When investigators modeled stage-adjusted survival, the counting of tumor response nodes as positive offered a better model fit, compared with following the current practice of ignoring tumor response nodes, he explained.

Patients included in the study were identified from a prospectively collected clinical database of esophagectomy patients, and were treated with neoadjuvant therapy for esophageal adenocarcinoma between 2006 and 2011. Most (82 of 90) were men. The patients had a mean age of 62 years, and were followed for a median of 27 months. Forty patients received preoperative chemotherapy, and 50 received preoperative chemoradiation.

In all cases, pathologic resection margins were negative.

On pathologic review, the majority had T3 tumors. More than 40% were staged as node negative, and more than two-thirds were staged with N0 or N1 disease.

"Prior to neoadjuvant therapy, all of these patients were clinically staged stage 2 or stage 3, but at the time of resection after neoadjuvant therapy, by AJCC staging, 24% of the patients were stage 0 or 1, 27% were stage 2, and almost half were stage 3," he said.

The findings are notable, because the current AJCC pathologic staging for esophageal adenocarcinoma is derived from the experience of patients undergoing esophagectomy alone. This approach has unclear relevance in patients who receive multimodality therapy, which has supplanted primary surgery as the standard of care for locoregionally advanced esophageal adenocarcinoma, he said.

"Future efforts at revising the staging system for esophageal adenocarcinoma should consider treatment response lymph nodes. ... We currently have pathological staging models that are of limited usefulness for our neoadjuvantly treated population. Perhaps consideration of these nodes can help improve that," he concluded.

Dr. Nieman reported having no financial disclosures.

ORLANDO – Tumor response nodes obtained from patients who undergo esophagectomy for early-stage adenocarcinoma provide valuable prognostic information, according to Dr. Dylan Nieman.

Such nodes – lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells – may mark the prior spread of tumor, and should be counted as positive, Dr. Nieman of the University of Rochester (N.Y.) said at the annual meeting of the Society of Thoracic Surgeons.

The current practice of ignoring these nodes likely results in systematic pathologic understaging, he explained.

In 90 patients who underwent esophagectomy after neoadjuvant therapy for esophageal adenocarcinoma, the median number of nodes found per resection specimen was 18. A total of 100 tumor response nodes without viable malignant cells were identified in 38 (42%) of the patients.

The majority of the patients with treatment response nodes had only one node detected, Dr. Nieman said.

The median survival for the entire cohort was 55.6 months, and the 5-year survival was 35%. The median survival of patients with evidence of treatment response nodes was poorer, but not significantly different from those without treatment response nodes (45.9 vs. 55.6 months), he noted.

"However, for a subset of 62 patients classified as having limited or no nodal involvement – that is, AJCC N0 or N1 – the presence of treatment response nodes was associated with significantly poorer survival. This effect remained when adjusting for patient age and [American Joint Committee on Cancer] stage (hazard ratio, 2.7)," he said.

In a subset of 46 patients with pathologic AJCC stage 2B or less, the presence of treatment response nodes was still associated with poorer survival, even after adjustment for age and AJCC stage.

"To look at this a different way, if tumor response nodes were to be counted as positive, the nodal status of 29 of these patients would be upstaged. This includes 18 of 39 patients, or 46%, who were classified as node negative, and 8 of 23 patients, or 34%, who were classified as N1 by AJCC pathological assessment," he said.

The recategorization of those 29 patients resulted in better survival for the entire group, but particularly for those in the lowest-stage group, he noted.

When investigators modeled stage-adjusted survival, the counting of tumor response nodes as positive offered a better model fit, compared with following the current practice of ignoring tumor response nodes, he explained.

Patients included in the study were identified from a prospectively collected clinical database of esophagectomy patients, and were treated with neoadjuvant therapy for esophageal adenocarcinoma between 2006 and 2011. Most (82 of 90) were men. The patients had a mean age of 62 years, and were followed for a median of 27 months. Forty patients received preoperative chemotherapy, and 50 received preoperative chemoradiation.

In all cases, pathologic resection margins were negative.

On pathologic review, the majority had T3 tumors. More than 40% were staged as node negative, and more than two-thirds were staged with N0 or N1 disease.

"Prior to neoadjuvant therapy, all of these patients were clinically staged stage 2 or stage 3, but at the time of resection after neoadjuvant therapy, by AJCC staging, 24% of the patients were stage 0 or 1, 27% were stage 2, and almost half were stage 3," he said.

The findings are notable, because the current AJCC pathologic staging for esophageal adenocarcinoma is derived from the experience of patients undergoing esophagectomy alone. This approach has unclear relevance in patients who receive multimodality therapy, which has supplanted primary surgery as the standard of care for locoregionally advanced esophageal adenocarcinoma, he said.

"Future efforts at revising the staging system for esophageal adenocarcinoma should consider treatment response lymph nodes. ... We currently have pathological staging models that are of limited usefulness for our neoadjuvantly treated population. Perhaps consideration of these nodes can help improve that," he concluded.

Dr. Nieman reported having no financial disclosures.

ORLANDO – Tumor response nodes obtained from patients who undergo esophagectomy for early-stage adenocarcinoma provide valuable prognostic information, according to Dr. Dylan Nieman.

Such nodes – lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells – may mark the prior spread of tumor, and should be counted as positive, Dr. Nieman of the University of Rochester (N.Y.) said at the annual meeting of the Society of Thoracic Surgeons.

The current practice of ignoring these nodes likely results in systematic pathologic understaging, he explained.

In 90 patients who underwent esophagectomy after neoadjuvant therapy for esophageal adenocarcinoma, the median number of nodes found per resection specimen was 18. A total of 100 tumor response nodes without viable malignant cells were identified in 38 (42%) of the patients.

The majority of the patients with treatment response nodes had only one node detected, Dr. Nieman said.

The median survival for the entire cohort was 55.6 months, and the 5-year survival was 35%. The median survival of patients with evidence of treatment response nodes was poorer, but not significantly different from those without treatment response nodes (45.9 vs. 55.6 months), he noted.

"However, for a subset of 62 patients classified as having limited or no nodal involvement – that is, AJCC N0 or N1 – the presence of treatment response nodes was associated with significantly poorer survival. This effect remained when adjusting for patient age and [American Joint Committee on Cancer] stage (hazard ratio, 2.7)," he said.

In a subset of 46 patients with pathologic AJCC stage 2B or less, the presence of treatment response nodes was still associated with poorer survival, even after adjustment for age and AJCC stage.

"To look at this a different way, if tumor response nodes were to be counted as positive, the nodal status of 29 of these patients would be upstaged. This includes 18 of 39 patients, or 46%, who were classified as node negative, and 8 of 23 patients, or 34%, who were classified as N1 by AJCC pathological assessment," he said.

The recategorization of those 29 patients resulted in better survival for the entire group, but particularly for those in the lowest-stage group, he noted.

When investigators modeled stage-adjusted survival, the counting of tumor response nodes as positive offered a better model fit, compared with following the current practice of ignoring tumor response nodes, he explained.

Patients included in the study were identified from a prospectively collected clinical database of esophagectomy patients, and were treated with neoadjuvant therapy for esophageal adenocarcinoma between 2006 and 2011. Most (82 of 90) were men. The patients had a mean age of 62 years, and were followed for a median of 27 months. Forty patients received preoperative chemotherapy, and 50 received preoperative chemoradiation.

In all cases, pathologic resection margins were negative.

On pathologic review, the majority had T3 tumors. More than 40% were staged as node negative, and more than two-thirds were staged with N0 or N1 disease.

"Prior to neoadjuvant therapy, all of these patients were clinically staged stage 2 or stage 3, but at the time of resection after neoadjuvant therapy, by AJCC staging, 24% of the patients were stage 0 or 1, 27% were stage 2, and almost half were stage 3," he said.

The findings are notable, because the current AJCC pathologic staging for esophageal adenocarcinoma is derived from the experience of patients undergoing esophagectomy alone. This approach has unclear relevance in patients who receive multimodality therapy, which has supplanted primary surgery as the standard of care for locoregionally advanced esophageal adenocarcinoma, he said.

"Future efforts at revising the staging system for esophageal adenocarcinoma should consider treatment response lymph nodes. ... We currently have pathological staging models that are of limited usefulness for our neoadjuvantly treated population. Perhaps consideration of these nodes can help improve that," he concluded.

Dr. Nieman reported having no financial disclosures.

Smartphone platform–based teledermatology was reliable for the initial triage of inpatient dermatology consultations in a prospective study at an academic medical center.

Teledermatology has demonstrated effectiveness in outpatient settings, but its use for inpatient settings, where dermatology consultive services may be limited or lacking, has not been well explored, wrote John S. Barbieri and his colleagues at the of the University of Pennsylvania, Philadelphia. Their findings were published online Feb. 12 in JAMA Dermatology.

In this study of 50 adult inpatients for whom a dermatology consultation was requested, an in-person dermatologist determined that 66% of consultations could have been triaged to the next day or later and that 18% could have been triaged to outpatient care after hospital discharge. Two independent teledermatologists each said 60% could be triaged to the next day or later. One said 12% could be deferred to outpatient care and the other said 8% could be deferred.

The in-person dermatologist and the teledermatologists agreed 90% of the time regarding whether the patient needed a same-day consultation. When a teledermatologist did not recommend that the patient be seen the same day, there nevertheless was complete diagnostic agreement for 60% of cases and partial diagnostic agreement for 40% of cases reported.

Furthermore, if the in-person dermatologist recommended a biopsy, the teledermatologists agreed, on average, in 95% of cases, the investigators said (JAMA Dermatol. 2014 Feb. 12 [doi:10.1001/jamadermatol.2013.9517]).

For triage, concordance between the in-person dermatologist and the teledermatologists was moderate, and inter-rater reliability between the two teledermatologists was moderate. For biopsy, concordance between the in-person dermatologist and the teledermatologists was fair to moderate, and inter-rater reliability between the two teledermatologists was substantial.

The degree of diagnostic agreement in this study was consistent with that reported in the literature, Mr. Barbieri and his associates noted.

The teledermatologists reported that they would "feel comfortable managing this patient with teledermatology alone" in 58% and 90% of cases, respectively.

"Our findings suggest that teledermatology is reliable for the initial triage of inpatient dermatologic consultation at an academic medical center. ... In addition to being reliable, teledermatology may also increase efficiency when used to triage inpatient consultations," the investigators wrote, explaining that the teledermatologists’ ability to safely triage 60% of consultations to the next day or later would create an opportunity to batch consultations together.

For an outpatient dermatologist serving as a part-time consultant for a hospital, batching consultations would optimize time spent at the hospital, they pointed out.

The teledermatologists also were able to safely triage another 10% of patients, on average, to outpatient care, eliminating the need for them to be seen in the hospital, Mr. Barbieri and his coworkers said.

The findings also suggest that some patients can be managed by teledermatology alone.

Study subjects were consenting adult patients who were hospitalized for any indication. The dermatology consultations for the patients were requested between Sept. 1, 2012, and April 31, 2013.

The patients received a standard complete inpatient consultation, which involved a same-day consultation with the in-person dermatologist. For the purposes of the study, the dermatologist recorded a triage decision based on when he believed the patient could have been seen, whether a biopsy was needed, and up to three possible diagnoses under consideration.

Additionally, a teledermatology consultation was submitted by a blinded, trained medical student using the AccessDerm smartphone platform from Vignet, and the consultation was evaluated by two independent experienced teledermatologists who recorded the same information recorded by the in-person dermatologist.

The limitations of this study included the location choice of an academic medical center, where patients may present with more complex and acute illnesses, compared with patients at a community hospital. Also, the use of standardized templates did not allow for multiple lesions to be evaluated separately. These limitations could actually be expected to increase the difficulty of the teledermatology consultations, so the findings "may represent a lower bound to the reliability of teledermatology for the triage of inpatient dermatologic consultations," the investigators noted.

Future studies should assess whether the results can be generalized to a community hospital setting, Mr. Barbieri and his associates said.

One of the study authors, Ryan Littman-Quinn, reported receiving 25% of his salary from Vignet for consultation on unrelated projects.

Smartphone platform–based teledermatology was reliable for the initial triage of inpatient dermatology consultations in a prospective study at an academic medical center.

Teledermatology has demonstrated effectiveness in outpatient settings, but its use for inpatient settings, where dermatology consultive services may be limited or lacking, has not been well explored, wrote John S. Barbieri and his colleagues at the of the University of Pennsylvania, Philadelphia. Their findings were published online Feb. 12 in JAMA Dermatology.

In this study of 50 adult inpatients for whom a dermatology consultation was requested, an in-person dermatologist determined that 66% of consultations could have been triaged to the next day or later and that 18% could have been triaged to outpatient care after hospital discharge. Two independent teledermatologists each said 60% could be triaged to the next day or later. One said 12% could be deferred to outpatient care and the other said 8% could be deferred.

The in-person dermatologist and the teledermatologists agreed 90% of the time regarding whether the patient needed a same-day consultation. When a teledermatologist did not recommend that the patient be seen the same day, there nevertheless was complete diagnostic agreement for 60% of cases and partial diagnostic agreement for 40% of cases reported.

Furthermore, if the in-person dermatologist recommended a biopsy, the teledermatologists agreed, on average, in 95% of cases, the investigators said (JAMA Dermatol. 2014 Feb. 12 [doi:10.1001/jamadermatol.2013.9517]).

For triage, concordance between the in-person dermatologist and the teledermatologists was moderate, and inter-rater reliability between the two teledermatologists was moderate. For biopsy, concordance between the in-person dermatologist and the teledermatologists was fair to moderate, and inter-rater reliability between the two teledermatologists was substantial.

The degree of diagnostic agreement in this study was consistent with that reported in the literature, Mr. Barbieri and his associates noted.

The teledermatologists reported that they would "feel comfortable managing this patient with teledermatology alone" in 58% and 90% of cases, respectively.

"Our findings suggest that teledermatology is reliable for the initial triage of inpatient dermatologic consultation at an academic medical center. ... In addition to being reliable, teledermatology may also increase efficiency when used to triage inpatient consultations," the investigators wrote, explaining that the teledermatologists’ ability to safely triage 60% of consultations to the next day or later would create an opportunity to batch consultations together.

For an outpatient dermatologist serving as a part-time consultant for a hospital, batching consultations would optimize time spent at the hospital, they pointed out.

The teledermatologists also were able to safely triage another 10% of patients, on average, to outpatient care, eliminating the need for them to be seen in the hospital, Mr. Barbieri and his coworkers said.

The findings also suggest that some patients can be managed by teledermatology alone.

Study subjects were consenting adult patients who were hospitalized for any indication. The dermatology consultations for the patients were requested between Sept. 1, 2012, and April 31, 2013.

The patients received a standard complete inpatient consultation, which involved a same-day consultation with the in-person dermatologist. For the purposes of the study, the dermatologist recorded a triage decision based on when he believed the patient could have been seen, whether a biopsy was needed, and up to three possible diagnoses under consideration.

Additionally, a teledermatology consultation was submitted by a blinded, trained medical student using the AccessDerm smartphone platform from Vignet, and the consultation was evaluated by two independent experienced teledermatologists who recorded the same information recorded by the in-person dermatologist.

The limitations of this study included the location choice of an academic medical center, where patients may present with more complex and acute illnesses, compared with patients at a community hospital. Also, the use of standardized templates did not allow for multiple lesions to be evaluated separately. These limitations could actually be expected to increase the difficulty of the teledermatology consultations, so the findings "may represent a lower bound to the reliability of teledermatology for the triage of inpatient dermatologic consultations," the investigators noted.

Future studies should assess whether the results can be generalized to a community hospital setting, Mr. Barbieri and his associates said.

One of the study authors, Ryan Littman-Quinn, reported receiving 25% of his salary from Vignet for consultation on unrelated projects.

Smartphone platform–based teledermatology was reliable for the initial triage of inpatient dermatology consultations in a prospective study at an academic medical center.

Teledermatology has demonstrated effectiveness in outpatient settings, but its use for inpatient settings, where dermatology consultive services may be limited or lacking, has not been well explored, wrote John S. Barbieri and his colleagues at the of the University of Pennsylvania, Philadelphia. Their findings were published online Feb. 12 in JAMA Dermatology.

In this study of 50 adult inpatients for whom a dermatology consultation was requested, an in-person dermatologist determined that 66% of consultations could have been triaged to the next day or later and that 18% could have been triaged to outpatient care after hospital discharge. Two independent teledermatologists each said 60% could be triaged to the next day or later. One said 12% could be deferred to outpatient care and the other said 8% could be deferred.

The in-person dermatologist and the teledermatologists agreed 90% of the time regarding whether the patient needed a same-day consultation. When a teledermatologist did not recommend that the patient be seen the same day, there nevertheless was complete diagnostic agreement for 60% of cases and partial diagnostic agreement for 40% of cases reported.

Furthermore, if the in-person dermatologist recommended a biopsy, the teledermatologists agreed, on average, in 95% of cases, the investigators said (JAMA Dermatol. 2014 Feb. 12 [doi:10.1001/jamadermatol.2013.9517]).

For triage, concordance between the in-person dermatologist and the teledermatologists was moderate, and inter-rater reliability between the two teledermatologists was moderate. For biopsy, concordance between the in-person dermatologist and the teledermatologists was fair to moderate, and inter-rater reliability between the two teledermatologists was substantial.

The degree of diagnostic agreement in this study was consistent with that reported in the literature, Mr. Barbieri and his associates noted.

The teledermatologists reported that they would "feel comfortable managing this patient with teledermatology alone" in 58% and 90% of cases, respectively.

"Our findings suggest that teledermatology is reliable for the initial triage of inpatient dermatologic consultation at an academic medical center. ... In addition to being reliable, teledermatology may also increase efficiency when used to triage inpatient consultations," the investigators wrote, explaining that the teledermatologists’ ability to safely triage 60% of consultations to the next day or later would create an opportunity to batch consultations together.

For an outpatient dermatologist serving as a part-time consultant for a hospital, batching consultations would optimize time spent at the hospital, they pointed out.

The teledermatologists also were able to safely triage another 10% of patients, on average, to outpatient care, eliminating the need for them to be seen in the hospital, Mr. Barbieri and his coworkers said.

The findings also suggest that some patients can be managed by teledermatology alone.

Study subjects were consenting adult patients who were hospitalized for any indication. The dermatology consultations for the patients were requested between Sept. 1, 2012, and April 31, 2013.

The patients received a standard complete inpatient consultation, which involved a same-day consultation with the in-person dermatologist. For the purposes of the study, the dermatologist recorded a triage decision based on when he believed the patient could have been seen, whether a biopsy was needed, and up to three possible diagnoses under consideration.

Additionally, a teledermatology consultation was submitted by a blinded, trained medical student using the AccessDerm smartphone platform from Vignet, and the consultation was evaluated by two independent experienced teledermatologists who recorded the same information recorded by the in-person dermatologist.

The limitations of this study included the location choice of an academic medical center, where patients may present with more complex and acute illnesses, compared with patients at a community hospital. Also, the use of standardized templates did not allow for multiple lesions to be evaluated separately. These limitations could actually be expected to increase the difficulty of the teledermatology consultations, so the findings "may represent a lower bound to the reliability of teledermatology for the triage of inpatient dermatologic consultations," the investigators noted.

Future studies should assess whether the results can be generalized to a community hospital setting, Mr. Barbieri and his associates said.

One of the study authors, Ryan Littman-Quinn, reported receiving 25% of his salary from Vignet for consultation on unrelated projects.

ORLANDO – The use of autologous platelet-rich plasma following cardiac surgery was associated with a significantly reduced incidence of sternal wound complications – and with a 50% reduction in the costs associated with such complications – in a study of 2,000 patients.

The findings suggest that routine use of platelet-rich plasma (PRP) should be considered for all patients undergoing sternotomy for cardiac surgical procedures, Dr. Amit N. Patel said at the annual meeting of the Society of Thoracic Surgeons.

Over a 7-year period, an initial 1,000 patients undergoing open cardiac operations requiring sternotomy received standard-of-care sternal closure, including preoperative antibiotic treatment and protocol-driven glycemic management. The second 1,000 patients received the same standard-of-care sternal closure plus PRP, which was applied to the sternum at the time of closure.

Compared with the control group, the patients who received PRP had a significantly reduced incidence of deep sternal wound infections (0.6% vs. 2.0%) and superficial wound drainage (2.0% vs. 8.0%), as well as a lower readmission rate (0.8% vs. 4.0%), said Dr. Patel of the University of Utah, Salt Lake City.

On multivariate analysis, the use of PRP was an independent predictor of a reduced incidence of deep sternal wound infection, he reported.

Furthermore, the total cost associated with caring for wound complications was reduced by about 50% in the PRP group ($593,791 vs. $1,256,960), he added.

The treatment and control groups were similar with respect to age, weight, diabetes, renal dysfunction, smoking status, and steroid use. However, the treatment group had more ventricular assist device implantations and open aortic operations. No complications associated with the use of PRP were reported.

Given the increased morbidity, mortality and costs associated with sternal wound complications following cardiac surgery, the findings have important implications for improving outcomes, Dr. Patel said, noting that the findings support those of several prior studies demonstrating that autologous platelet-rich plasma promotes successful wound healing through improved ossification.

"The problem is, how do you prepare it, how do you apply it, and how do you use it reproducibly?" he said.

In the current study, the Magellan Platelet Separator System was used, and it provided such reproducibility – at a cost of $385 per application, he noted.

Though limited by the single-center, nonrandomized, and nonblinded nature of the study, the findings are bolstered by the large sample size and the fact that the study was conducted at a tertiary referral center, he said.

"The overall potential of PRP in this large sample size was very positive," he concluded.

Dr. Patel reported having no disclosures.

ORLANDO – The use of autologous platelet-rich plasma following cardiac surgery was associated with a significantly reduced incidence of sternal wound complications – and with a 50% reduction in the costs associated with such complications – in a study of 2,000 patients.

The findings suggest that routine use of platelet-rich plasma (PRP) should be considered for all patients undergoing sternotomy for cardiac surgical procedures, Dr. Amit N. Patel said at the annual meeting of the Society of Thoracic Surgeons.

Over a 7-year period, an initial 1,000 patients undergoing open cardiac operations requiring sternotomy received standard-of-care sternal closure, including preoperative antibiotic treatment and protocol-driven glycemic management. The second 1,000 patients received the same standard-of-care sternal closure plus PRP, which was applied to the sternum at the time of closure.

Compared with the control group, the patients who received PRP had a significantly reduced incidence of deep sternal wound infections (0.6% vs. 2.0%) and superficial wound drainage (2.0% vs. 8.0%), as well as a lower readmission rate (0.8% vs. 4.0%), said Dr. Patel of the University of Utah, Salt Lake City.

On multivariate analysis, the use of PRP was an independent predictor of a reduced incidence of deep sternal wound infection, he reported.

Furthermore, the total cost associated with caring for wound complications was reduced by about 50% in the PRP group ($593,791 vs. $1,256,960), he added.

The treatment and control groups were similar with respect to age, weight, diabetes, renal dysfunction, smoking status, and steroid use. However, the treatment group had more ventricular assist device implantations and open aortic operations. No complications associated with the use of PRP were reported.

Given the increased morbidity, mortality and costs associated with sternal wound complications following cardiac surgery, the findings have important implications for improving outcomes, Dr. Patel said, noting that the findings support those of several prior studies demonstrating that autologous platelet-rich plasma promotes successful wound healing through improved ossification.

"The problem is, how do you prepare it, how do you apply it, and how do you use it reproducibly?" he said.

In the current study, the Magellan Platelet Separator System was used, and it provided such reproducibility – at a cost of $385 per application, he noted.

Though limited by the single-center, nonrandomized, and nonblinded nature of the study, the findings are bolstered by the large sample size and the fact that the study was conducted at a tertiary referral center, he said.

"The overall potential of PRP in this large sample size was very positive," he concluded.

Dr. Patel reported having no disclosures.

ORLANDO – The use of autologous platelet-rich plasma following cardiac surgery was associated with a significantly reduced incidence of sternal wound complications – and with a 50% reduction in the costs associated with such complications – in a study of 2,000 patients.

The findings suggest that routine use of platelet-rich plasma (PRP) should be considered for all patients undergoing sternotomy for cardiac surgical procedures, Dr. Amit N. Patel said at the annual meeting of the Society of Thoracic Surgeons.

Over a 7-year period, an initial 1,000 patients undergoing open cardiac operations requiring sternotomy received standard-of-care sternal closure, including preoperative antibiotic treatment and protocol-driven glycemic management. The second 1,000 patients received the same standard-of-care sternal closure plus PRP, which was applied to the sternum at the time of closure.

Compared with the control group, the patients who received PRP had a significantly reduced incidence of deep sternal wound infections (0.6% vs. 2.0%) and superficial wound drainage (2.0% vs. 8.0%), as well as a lower readmission rate (0.8% vs. 4.0%), said Dr. Patel of the University of Utah, Salt Lake City.

On multivariate analysis, the use of PRP was an independent predictor of a reduced incidence of deep sternal wound infection, he reported.

Furthermore, the total cost associated with caring for wound complications was reduced by about 50% in the PRP group ($593,791 vs. $1,256,960), he added.

The treatment and control groups were similar with respect to age, weight, diabetes, renal dysfunction, smoking status, and steroid use. However, the treatment group had more ventricular assist device implantations and open aortic operations. No complications associated with the use of PRP were reported.

Given the increased morbidity, mortality and costs associated with sternal wound complications following cardiac surgery, the findings have important implications for improving outcomes, Dr. Patel said, noting that the findings support those of several prior studies demonstrating that autologous platelet-rich plasma promotes successful wound healing through improved ossification.

"The problem is, how do you prepare it, how do you apply it, and how do you use it reproducibly?" he said.

In the current study, the Magellan Platelet Separator System was used, and it provided such reproducibility – at a cost of $385 per application, he noted.

Though limited by the single-center, nonrandomized, and nonblinded nature of the study, the findings are bolstered by the large sample size and the fact that the study was conducted at a tertiary referral center, he said.

"The overall potential of PRP in this large sample size was very positive," he concluded.

Dr. Patel reported having no disclosures.

ORLANDO – A novel combination of aortic root remodeling and aortic valve bicuspidization helped prevent the need for surgery in young adult patients with unicuspid aortic valve anatomy and root dilatation, according to Dr. Diana Aicher.

Though unicuspid aortic valve (UAV) anatomy is rare, about 60% of affected patients require aortic valve surgery before 20 years of age owing to aneurysm of the aortic root. Aortic root remodeling and aortic valve bicuspidization allow for good aortic valve hemodynamic function, and in most patients with aortic regurgitation due to UAV and root aneurysm, the surgical procedure obviates the need for aortic valve replacement, Dr. Aicher reported at the annual meeting of the Society of Thoracic Surgeons.

Of 25 patients with aortic regurgitation due to UAV and aortic root dilatation who underwent the procedure between August 2001 and August 2012, 84% were free from reoperation and 91% were free from aortic valve replacement at 5 years of follow-up, said Dr. Aicher of Uniklinikum des Saarlandes, Homburg, Germany.

Intraoperative echocardiography revealed minimal (stage 1) aortic regurgitation in 8% of patients and no aortic regurgitation in 92% of patients. The systolic peak gradient was 14 mm Hg.

No early or late deaths occurred following surgery, and there was no bleeding or thromboembolism. One patient developed endocarditis during follow-up, which was treated with antibiotics and reoperation for aortic regurgitation 2 months later, Dr. Aicher noted.

Three other patients required reoperation; two had relevant recurrent aortic regurgitation due to suture dehiscence and were reoperated on between 16 and 32 months after the initial procedure. One patient received a biological aortic valve replacement.

Patients included in the study were adults aged 21-65 years (mean age, 37.5 years). All were followed echographically at 3, 6, and 12 months, and then at yearly intervals for up to 141 months (mean, 42 months).

The findings suggest that in patients with UAV who develop aortic root aneurysm, a combination of valve bicuspidization – a procedure developed by Dr. Aicher and her team several years ago – and root remodeling can be used to treat both defects with a satisfactory result, she said.

The procedure involves resection of the dilated aortic root tissue, leaving two tongues at 180-degree orientation for the commissures. A new commissure is then created opposite the normal one, and cusp tissue is augmented by autologous pericardial patches. Dilation of the basal ring was corrected by suture annuloplasty in 16 patients.

The findings indicate that "in the presence of UAV and aortic root dilatation, the concept of valve bicuspidization and root remodeling can be applied with satisfactory hemodynamic results. Additional stabilization of the atrioventricular junction by a circumferential annuloplasty is an important complement to the repair strategy," Dr. Aicher said.

"Our repair strategy is an alternative to the current standard of care," she concluded.

Dr. Aicher reported having no disclosures.

ORLANDO – A novel combination of aortic root remodeling and aortic valve bicuspidization helped prevent the need for surgery in young adult patients with unicuspid aortic valve anatomy and root dilatation, according to Dr. Diana Aicher.

Though unicuspid aortic valve (UAV) anatomy is rare, about 60% of affected patients require aortic valve surgery before 20 years of age owing to aneurysm of the aortic root. Aortic root remodeling and aortic valve bicuspidization allow for good aortic valve hemodynamic function, and in most patients with aortic regurgitation due to UAV and root aneurysm, the surgical procedure obviates the need for aortic valve replacement, Dr. Aicher reported at the annual meeting of the Society of Thoracic Surgeons.

Of 25 patients with aortic regurgitation due to UAV and aortic root dilatation who underwent the procedure between August 2001 and August 2012, 84% were free from reoperation and 91% were free from aortic valve replacement at 5 years of follow-up, said Dr. Aicher of Uniklinikum des Saarlandes, Homburg, Germany.

Intraoperative echocardiography revealed minimal (stage 1) aortic regurgitation in 8% of patients and no aortic regurgitation in 92% of patients. The systolic peak gradient was 14 mm Hg.

No early or late deaths occurred following surgery, and there was no bleeding or thromboembolism. One patient developed endocarditis during follow-up, which was treated with antibiotics and reoperation for aortic regurgitation 2 months later, Dr. Aicher noted.

Three other patients required reoperation; two had relevant recurrent aortic regurgitation due to suture dehiscence and were reoperated on between 16 and 32 months after the initial procedure. One patient received a biological aortic valve replacement.

Patients included in the study were adults aged 21-65 years (mean age, 37.5 years). All were followed echographically at 3, 6, and 12 months, and then at yearly intervals for up to 141 months (mean, 42 months).

The findings suggest that in patients with UAV who develop aortic root aneurysm, a combination of valve bicuspidization – a procedure developed by Dr. Aicher and her team several years ago – and root remodeling can be used to treat both defects with a satisfactory result, she said.

The procedure involves resection of the dilated aortic root tissue, leaving two tongues at 180-degree orientation for the commissures. A new commissure is then created opposite the normal one, and cusp tissue is augmented by autologous pericardial patches. Dilation of the basal ring was corrected by suture annuloplasty in 16 patients.

The findings indicate that "in the presence of UAV and aortic root dilatation, the concept of valve bicuspidization and root remodeling can be applied with satisfactory hemodynamic results. Additional stabilization of the atrioventricular junction by a circumferential annuloplasty is an important complement to the repair strategy," Dr. Aicher said.

"Our repair strategy is an alternative to the current standard of care," she concluded.

Dr. Aicher reported having no disclosures.

ORLANDO – A novel combination of aortic root remodeling and aortic valve bicuspidization helped prevent the need for surgery in young adult patients with unicuspid aortic valve anatomy and root dilatation, according to Dr. Diana Aicher.

Though unicuspid aortic valve (UAV) anatomy is rare, about 60% of affected patients require aortic valve surgery before 20 years of age owing to aneurysm of the aortic root. Aortic root remodeling and aortic valve bicuspidization allow for good aortic valve hemodynamic function, and in most patients with aortic regurgitation due to UAV and root aneurysm, the surgical procedure obviates the need for aortic valve replacement, Dr. Aicher reported at the annual meeting of the Society of Thoracic Surgeons.

Of 25 patients with aortic regurgitation due to UAV and aortic root dilatation who underwent the procedure between August 2001 and August 2012, 84% were free from reoperation and 91% were free from aortic valve replacement at 5 years of follow-up, said Dr. Aicher of Uniklinikum des Saarlandes, Homburg, Germany.

Intraoperative echocardiography revealed minimal (stage 1) aortic regurgitation in 8% of patients and no aortic regurgitation in 92% of patients. The systolic peak gradient was 14 mm Hg.

No early or late deaths occurred following surgery, and there was no bleeding or thromboembolism. One patient developed endocarditis during follow-up, which was treated with antibiotics and reoperation for aortic regurgitation 2 months later, Dr. Aicher noted.

Three other patients required reoperation; two had relevant recurrent aortic regurgitation due to suture dehiscence and were reoperated on between 16 and 32 months after the initial procedure. One patient received a biological aortic valve replacement.

Patients included in the study were adults aged 21-65 years (mean age, 37.5 years). All were followed echographically at 3, 6, and 12 months, and then at yearly intervals for up to 141 months (mean, 42 months).

The findings suggest that in patients with UAV who develop aortic root aneurysm, a combination of valve bicuspidization – a procedure developed by Dr. Aicher and her team several years ago – and root remodeling can be used to treat both defects with a satisfactory result, she said.

The procedure involves resection of the dilated aortic root tissue, leaving two tongues at 180-degree orientation for the commissures. A new commissure is then created opposite the normal one, and cusp tissue is augmented by autologous pericardial patches. Dilation of the basal ring was corrected by suture annuloplasty in 16 patients.

The findings indicate that "in the presence of UAV and aortic root dilatation, the concept of valve bicuspidization and root remodeling can be applied with satisfactory hemodynamic results. Additional stabilization of the atrioventricular junction by a circumferential annuloplasty is an important complement to the repair strategy," Dr. Aicher said.

"Our repair strategy is an alternative to the current standard of care," she concluded.

Dr. Aicher reported having no disclosures.