Thoracic Surgery:
Lung cancer:
5-year mortality from the time of presentation remains at approximately 85-90%. 80% will be inoperable at presentation, 20% will proceed to attempted resection, of whom 5-10% will be alive 5 years later.
(From BTS Guidelines):
Adenocarcinoma 30-35%
Squamous cell carcinoma ~ 30%
Large cell carcinoma ~ 10-20%
Small cell lung carcinoma ~ 15-25%


Operative Mortality:
Lobectomy 4%
Pneumonectomy 8%

Inoperable at operation: 5-10%
In sq cell lung cancer < 5% show brain metastases (MRI or CT) or bone metastases (bone scan) this percentage is higher in adenocarcinoma and highest in SCLC.
After surgery:
5 year survival rates (NSCLC):
T1-2 N0 50-70%
T1-2 N2 20-30%
T3 N0 45%
T3 N1 37%
T3 N2 0%

< 5% of SCLC are operable.

5 year survival rates superior sulcus (Pancoast tumours): ~ 30%

50% of all lung cancers have extrapulmonary spread at the time of diagnosis.
The average pt with a diagnosis of lung cancer has a 5-year survival of only 10-15%.

Solitary pulmonary nodule (SPN): 35% are malignant. 23% solitary metastases.
Differential diagnosis of SPN: neoplastic, infectious, inflammatory, vascular, traumatic, congenital, rheumatoid nodule, intrapulmonary lymph node, plasma cell granuloma and sarcoidosis.
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Cardiac Surgery:

AVR
Survival After AVR:
a) Early (hospital) death - 3-6% (<5%)
b) Time-related survival:
• 5 years - 75%cts (80-90%)glenn's
• 10 years - 60%
• 15 years - 40%
c) Mode of death
• Early due to CHF, hemorrhage, infection, CVA
• Sudden - 20%
• Device related - 20%

Incidence of rereplacement: 8-17%
Risk of rereplacement: 10%

Etiology of AV disease:
Rheumatic 30-40%
Congenital ~30%
Degeneative ~20-30

Bicuspid AV 0.9-2.0% of normal population.
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MVR:
MVR: Operative mortality: 2.5% for males and 3.9% for females for first time elective cases.
MVR+CABG: Coincident CAD increases operative risk (mortality 6.1% men, 12.2% women).
5-year survival after MVR: 80%.
10 year survival 50 - 87%.
5-year survival(CABG+MVR) 66%
10-year survival(CABG+MVR) 31%
-Freedom from failure at 10 years: 60-78%
-14 years freedom from operation: 27- 43%
Thromboembolism and Bleeding:
- Freedom from thromboembolism at 10 years is similar whether mechanical or bioprosthetic valves are implanted with a rate of 1.6 - 2.9% per patient year.

- between 20-60% of patients have bioprosthetic valve implantation are anticoagulated long term.
- The incidence of anticoagulant-related hemorrhage is between 0.18-2.2 per patient year.
Bleeding is most common in the CNS, GI and GU tracts.
Mechanical Valve Thrombosis and Structural Failure:
Bjork-Shiley valve has a thrombosis rate of 0.28% per patient year.
St. Jude valve has a thrombosis rate between 0.09 and 0.3%
Prosthetic Valve Endocarditis: several series have reported rates of endocarditis of 0.06 to 0.4%, early mortality as high as 75%
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Mitral Stenosis
20-40 years from Rheumatic fever to onset of sypmtoms
Onset of symptoms to disability- 10 years
Atrial fibrillation 30-40% more common in older patients.
10 year survival-- Overall 50-60%
Asymptomatic => 80% (60% no progression of symptoms)
Symptomatic 0-15%
Severe pulmonary hypertension <3%
Older patients with atrial fibrillation 25%
Normal sinus rhythm 46%
Causes of death:
CHF 60-70%
Systemic embolism 20-30%
Pulmonary embolism 10%
Infection 1-5%
Mitral valve prolapse is most common form of valvular heart disease
Affecting 2-6% of population
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Post-infarct VSD
Location: 60% anterior, 40% posterior
Occurrence: 1-2% of MI
Timing: 2-3 days post MI up to 2 weeks
Results or Repair
Survival: 35% early mortality
Functional status: good
Modes of death:
50% CHF, acute 10% sudden death
5% CHF, chronic, intractable.

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Coronary Artery Bypass surgery:
Emergent CAB for hemodynamic instability during acute MI can salvage over 50% of such pts.
•40% of patients studied for symptoms will have significant stenoses in all 3 vessels.
•95% of patients with 1 completely occluded artery will have a significant stenosis in at least one other artery.
•10-20% of patients with significant disease will have L main involvement.
•Diffuse distal disease unsuitable for CAB is uncommon.
Results:
Survival:
•Current hospital mortality is about 3%, most from acute cardiac failure.
•5-year survival is 88%
•10-year survival 75%.
•IMA graft favorably affects the mid- and long-term survival (after 6 years).
•About 25% of all deaths after CAB are unrelated to ischemic heart disease or CAB.
Freedom from angina:
•About 60% of patients are free from symptoms at 10 years.
Freedom from MI:
•Perioperative incidence is 2-5%
•5-year freedom is greater than 95% after CAB
Freedom from sudden death:
•Uncommon after CAB; 97% freedom at 10 years
•Poor preoperative LV function is the most significant risk factor for sudden death postop
Neurologic events:
•Up to 75% of patients may have subtle neurologic deficits in the perioperative period.
•Gross neurologic defects occur in less than 1% of younger patients but up to 5% of patients over age 70.

Graft History
A. Vein grafts:
• 10% close within the first few weeks if antiplatelet therapy is not used.
• 10-year patency is about 50-60%
•B. IMA grafts:
• Intimal hyperplasia also develops; the IMA is highly resistant to atherosclerosis
• 10-year patency is about 90%
• 5-10% develop late stenoses, but most of these do not progress to occlusion.

Reintervention after CAB
• Most interventions are reoperative CAB, although PTCA used in about 25% of cases.
• 90% of patients are free from reoperative at 10 years.
•IMA grafting reduces reoperations and extends time to reoperation.
• Overall risk for reoperative CAB is about twice that of first CAB (~6%).
• 10-year survival after reoperative CAB is about 65% .
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Infective Endocarditis (IE):
0.3-3 per 1000 hospital admissions
Native valve endocarditis (NVE):
predisposing factor in 55-75%
Mortality 20-30%
Prosttic valve endocarditis (PVE): 7-25% of cases of IE
Mortality 23-70%
Early PVE within 60 days of surgery. The limit will change to 12 months.

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Outcome of patents undergoing surgery using circulatory arrest:
•CVA ~ 7%
•Tranient neurological disturbance 20%
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Results After Operation for aortic dissection:
1) Early (hospital) death
• Ascending aorta - 5-10% (up to 30%)
• Arch - 10-25% (up to 50%)
• Descending - 10% (up to 25-60%)
2) 10 year survival - 46%
• 1/3 late death related to residual old false channel or redissection
3) Aneurysm of false channel
• Uncontrolled hypertension - 50%
• Controlled blood pressure - 10-20%
4) Redissection - 10% (Marfan higher)
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CPB
Renal dysfunction: Acute renal insufficiency or renal failure cmplicates 15 % of CPB procedures, 2% require dialysis.

Neurological injury: 0.8 - 5% reported with CVA post CPB, reported mortality reach 20% in this group.
The incidence of cognitive impairment or delirium is 50% in the first week.

Bleeding complications:
The incidence of re-exploration is 4.2% was identified as a strong independent risk factor for mortality, renal failure, prolonged mechanical ventilation, ARDS, sepsis, atrial arrhythmias.
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