Faculty Bibliography

Patients with severe coronavirus disease 2019 from infection with severe acute respiratory syndrome coronavirus 2 mount a profound inflammatory response and are predisposed to thrombotic complications. Pulmonary vein thrombosis is a rare disease process resulting in pulmonary congestion, infarction, and potential mortality. This report describes a patient with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation for hypoxic respiratory failure who developed hemorrhagic infarction of the right lower lobe. During emergency exploration the patient was found to have a right inferior vein thrombosis and marked lobar hemorrhage mandating lobectomy.

BACKGROUND:Coronavirus disease 2019 (Covid-19) remains a worldwide pandemic with a high mortality rate among patients requiring mechanical ventilation. The limited data that exists regarding the utility of extracorporeal membrane oxygenation (ECMO) in these critically ill patients shows poor overall outcomes. This paper describes our institutional practice regarding the application and management of ECMO support for patients with Covid-19 and reports promising early outcomes. METHODS:>60 mmHg with no life-limiting comorbidities. Patients were cannulated at bedside and were managed with protective lung ventilation, early tracheostomy, bronchoscopies and proning as clinically indicated. RESULTS:Of 321 patients intubated for Covid-19, 77 (24%) patients were evaluated for ECMO support with 27 (8.4%) patients placed on ECMO. All patients were placed on veno-venous ECMO. Current survival is 96.3%, with only one mortality to date in over 350 days of total ECMO support. Thirteen patients (48.1%) remain on ECMO support, while 13 patients (48.1%) have been successfully decannulated. Seven patients (25.9%) have been discharged from the hospital. Six patients (22.2%) remain in the hospital of which four are on room-air. No healthcare workers that participated in ECMO cannulation developed symptoms of or tested positive for Covid-19. CONCLUSIONS:The early outcomes presented here suggest that the judicious use of ECMO support in severe Covid-19 may be clinically beneficial.

While lung cancer remains the most common cause of cancer-related mortality in the United States, surgery for curative intent continues to be a mainstay of therapy. The robotic platform for pulmonary resection for non-small cell lung cancer (NSCLC) has been utilized for more than a decade now. With respect to more localized resections, such as wedge resection or lobectomy, considerable data exist demonstrating shorter length of stay, decreased postoperative pain, improved lymph node dissection, and overall lower complication rate. There are a multitude of technical advantages the robotic approach offers, such as improved optics, natural movement of the operator's hands to control the instruments, and precise identification of tissue planes leading to a more ergonomic and safe dissection. Due to the advantages, the scope of robotic resections is expanding. In this review, we will look at the existing data on extended robotic pulmonary resections, specifically post-induction therapy resection, sleeve lobectomy, and pneumonectomy. Additionally, this review will examine the indications for these more complex resections, as well as review the data and outcomes from other institutions' experience with performing them. Lastly, we will share the strategy and outlook of our own institution with respect to these three types of extended pulmonary resections. Though some controversy remains regarding the use and safety of robotic surgery in these complex pulmonary resections, we hope to shed some light on the existing evidence and evaluate the efficacy and safety for patients with NSCLC.

Management of patients with lung cancer continues to be challenging during the COVID-19 pandemic, due to the increased risk of complications in this subset of patients. During the COVID-19 surge in New York City, New York University Langone Health adopted triage strategies to help with care for lung cancer patients, with good surgical outcomes and no transmission of COVID-19 to patients or healthcare workers. Here, we will review current recommendations regarding screening and management of lung cancer patients during both a non-surge phase and surge phase of COVID-19.

The Coronavirus Disease 2019 (COVID-19) pandemic remains a disruptive force upon the health care system, with particular import for thoracic surgery given the pulmonary pathophysiology and disease implications of the virus. The rapid and severe onset of disease required expedient innovation and change in patient management and novel approaches to care delivery and nimbleness of workforce. In this review, we detail our approaches to patients with COVID-19, including those that required surgical intervention, our expedited and novel approach to bronchoscopy and tracheostomy, and our expansion of telehealth. The pandemic has created a unique opportunity to reflect on our delivery of care in thoracic surgery and apply lessons learned during this time to "rethink" how to optimize resources and deliver excellent and cutting-edge patient care.

Objective: Homograft aortic root replacement provides an excellent hemodynamic restoration of valve function for prosthetic aortic valve endocarditis, but is susceptible to degeneration and calcification. The optimal surgical intervention for valvular disease after homograft root replacement is controversial due to the high risk of morbidity and mortality with reintervention.
Method(s): This video demonstrates a case of redo sternotomy with mechanical aortic valve replacement (AVR) in a patient post 2 previous AVRs and a porcelain homograft. A 38-year-old female presented in heart failure from prosthetic valve endocarditis, with a history of systemic lupus erythematosus, complicated by end-stage renal failure requiring dialysis and lupus anticoagulant.
Result(s): The patient had severe prosthetic aortic insufficiency, severe mitral regurgitation, and severe tricuspid regurgitation. A third-time redo sternotomy was performed. A mechanical sized #17 valve was placed in the aortic position and a #23 sized mechanical valve was placed in the mitral position. A bovine patch aortoplasty of the aorta was required after the calcified wall shattered into fragments upon transection with a patch of bovine pericardium. Postoperative echo revealed preserved left ventricular and right ventricular function with good function of the mechanical aortic and mitral valves.
Conclusion(s): Mechanical AVR, without replacement of the aortic root, is a feasible and potentially effective method of reestablishing a functional aortic valve in a patient with a severely calcified aortic homograft

Robotic thoracic surgery continues to gain momentum and is emerging as the optimal method for minimally invasive thoracic surgery. As a rapidly advancing field, continued review of the surgical and anesthetic concerns unique to robotic thoracic operations is necessary to maintain safe and efficient practice. In this review, we discuss the intraoperative concerns as they pertain to pulmonary, esophageal, and mediastinal thoracic robotic operations.